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Fluoroscopically Guided Epidural
Injections of the Cervical and
Lumbar Spine1
Euddeum Shim, MD
Joon Woo Lee, MD, PhD
Eugene Lee, MD, PhD
Joong Mo Ahn, MD, PhD
Yusuhn Kang, MD, PhD
Heung Sik Kang, MD, PhD
Abbreviations: AP = anteroposterior, ESI =
epidural steroid injection
RadioGraphics 2017; 37:537–561
Published online 10.1148/rg.2017160043
Content Codes:
1
From the Department of Radiology, Seoul Na-
tional University Bundang Hospital, 82 Gumi-
ro, 173 Beon-gil, Bundang-gu, Seongnam-
si, Gyeonggi-do 13620, Republic of Korea.
Received March 6, 2016; revision requested
April 22 and received July 14; accepted July 29.
For this journal-based SA-CME activity, the au-
thors, editor, and reviewers have disclosed no rel-
evant relationships. Address correspondence
to J.W.L. (e-mail: joonwoo2@gmail.com).
J.W.L. supported by a Seoul National Univer-
sity Bundang Hospital (SNUBH) research fund
grant (02-2010-034).
©
RSNA, 2016
SA-CME LEARNING OBJECTIVES
After completing this journal-based SA-CME
activity, participants will be able to:
■■List common indications for epidural
steroid injections.
■■Describe the contrast agent shadow
seen on “true” epidurograms according
to the type of injection method used.
■■Identify the contrast agent shadow seen
on “false” epidurograms, which indicates
that additional drugs should not be in-
jected until the needle is repositioned.
See www.rsna.org/education/search/RG.
An earlier incorrect version of this
article appeared online. This article
was corrected on December 22, 2016.
537
NEUROLOGIC/HEAD AND NECK IMAGING
Advances in imaging and the development of injection techniques
have enabled spinal intervention to become an important tool in
managing chronic spinal pain. Epidural steroid injection (ESI) is
one of the most widely used spinal interventions; it directly deliv-
ers drugs into the epidural space to relieve pain originating from
degenerative spine disorders—central canal stenoses and neural
foraminal stenoses—or disk herniations. Knowledge of the normal
anatomy of the epidural space is essential to perform an effective
and safe ESI and to recognize possible complications. Although
computed tomographic (CT) or combined CT-fluoroscopic guid-
ance has been increasingly used in ESI, conventional fluoroscopic
guidance is generally performed. In ESI, drugs are delivered into
the epidural space by interlaminar or transforaminal routes in the
cervical spine or by interlaminar, transforaminal, or caudal routes
in the lumbar spine. Epidurography is usually performed before
drug delivery to verify the proper position of the needle in the epi-
dural space. A small amount of contrast agent is injected with fluo-
roscopic guidance. Familiarity with the findings on a typical “true”
epidurogram (demonstrating correct needle placement in the
epidural space) permits proper performance of ESI. Findings on
“false” epidurograms (demonstrating incorrect needle placement)
include muscular staining and evidence of intravascular injection,
inadvertent facet joint injection, dural puncture, subdural injection,
and intraneural or intradiscal injection.
©
RSNA, 2016 • radiographics.rsna.org
Introduction
Chronic spinal pain is not a life-threatening condition but can cause
profound disabilities in physical and psychologic health (1). With
the increase in life expectancies, treatment of chronic spinal pain
has become a major issue. In a study of the burden of diseases in
the United States from 1990 to 2010, low back pain and neck pain
ranked first and fourth, respectively, as diseases or injuries with the
highest number of years patients lived with a disability (2). Because
of the growing prevalence of spinal pain and technical advances in
treatment, nonsurgical interventions for spinal pain have rapidly
increased (3). Epidural steroid injection (ESI) delivers drugs directly
into the epidural space under fluoroscopic, computed tomographic
(CT), or combined CT-fluoroscopic guidance and relieves pain
originating from degenerative spine disorders or disk herniations for
a relatively short time. Despite considerable controversy about the
efficacy of ESI, the outcomes of which do not differ from those of
a reference treatment (eg, injection of saline or analgesics such as
bupivacaine) and which brings only immediate to short-term (<3
months) improvement of pain and function, ESI has become one of
the most commonly used interventions for spinal pain (3–6). In the
United States, 9505 per 100 000 Medicare beneficiaries underwent
538 March-April 2017
TEACHING POINTS
■■ General indications for ESI include herniated disk disease with
or without radicular pain, spinal stenosis, axial low back pain,
and post–lumbar surgery syndrome.
■■ With an interlaminar ESI, a single line and a well-defined or
smudged convexity along the spinolaminar line on the lat-
eral view suggest that the needle tip is positioned correctly in
the epidural space. On the AP view, contrast agent dispersion
with drug injection may outline exiting spinal nerves.
■■ With a transforaminal ESI, if the needle tip is in the true epi-
dural space, a test dose of contrast agent will flow upward
(occasionally downward) along the medial margin of the
pedicles and along the exiting nerve.
■■ With an intradural injection, contrast material rapidly dispers-
es and accumulates at the ventral portion of the spinal canal,
forming a cerebrospinal fluid–contrast agent level (dorsal ce-
rebrospinal fluid and ventral contrast material) because of the
patient’s prone position. The AP view demonstrates a sym-
metric distribution of contrast material, similar to that seen at
myelography.
■■ At imaging, intraepineural injection manifests as two thin lines
resembling a so-called tram track, with a subtle feathery ap-
pearance inside the nerve root and sharp outlines.
interventions for spinal pain in 2013, and about
one-half of those patients underwent epidural
procedures; the remainder underwent other types
of pain interventions, including facet joint inter-
ventions, sacroiliac joint blocks, other types of
nerve blocks, and discography and disk decom-
pression (3).
Several meta-analyses have shown that, for
managing chronic spinal pain, ESI has been rated
as good to fair on the U.S. Preventive Services
Task Force grading system and as level II or III of
evidence-based practice on the American Soci-
ety of Interventional Pain Physicians grading of
evidence system (7–9). These ratings are made
on the basis of evidence obtained from at least
one randomized controlled trial or one relevant
high-quality nonrandomized trial. However,
some researchers have concluded that there is no
evidence for the efficacy of ESI in management
of chronic spinal pain except in cases of radicular
pain associated with disk herniation (5,6). This
inconsistency could be due to the complexity of
chronic spinal pain and the variability in patient
selection, injection techniques, and outcome as-
sessment (6).
From 2000 to 2013, an average of 2.7% of
interventions performed on patients who were
Medicare beneficiaries with spinal pain were
performed by a radiologist (3). During the same
period, the total number of interventional ser-
vices increased by 236%, and the annual average
growth in the number of interventions performed
by radiologists for spinal pain was 8.7% (3). Ra-
diologists have several advantages when perform-
radiographics.rsna.org
ing spinal interventions. They are familiar with
various imaging modalities and excel at inferring
three-dimensional structures on two-dimensional
fluoroscopic images, which means that they are
quick to learn spinal intervention techniques and
can perform them more accurately than other
specialists.
This article reviews the anatomy of the spinal
epidural space, suggests methods for selecting the
proper ESI approach according to different clini-
cal or imaging features, and describes the techni-
cal details of ESI and its complications.
Anatomy for ESI
The epidural space is the space located inside the
vertebral spinal canal and outside the dural sac,
and it extends from the foramen magnum to the
sacral hiatus (Fig 1). Regardless of the vertebral
body level (cervical or lumbar spine), the epidural
space is bordered by the ligamentum flavum and
periosteum posteriorly, the posterior longitudi-
nal ligament and vertebral body anteriorly, and
the pedicles and intervertebral foramina laterally
(10). The epidural space commonly contains fat,
abundant venous plexus, spinal branches of the
segmental arteries, and lymph vessels (Figs 1, 2).
Fat is the major component of the epidural space
and is the key factor in ESI because it allows
injected lipophilic medication to stay in the epi-
dural space for a long period and the action to be
sustained (11). The nerve roots from the spinal
cord pass through the epidural space before they
exit the spinal canal through the intervertebral
foramina.
The subdural space is considered not a true
space but an acquired space developed at the
interface of the dura mater and arachnoid mater
(12,13). It is discussed further in the section on
“Subdural Injection.”
Cervical Epidural Space
The epidural space is smallest at the cervical
level. The anteroposterior (AP) diameter of the
posterior cervical epidural space is 1–2 mm.
However, the posterior cervical epidural space
increases to 3–4 mm when the patient’s neck is
flexed (14).
Although the cervical and lumbar spinal
epidural spaces have the same basic contents and
are bordered by similar structures, their detailed
anatomy is somewhat different. Epidural fat is
not evenly distributed and is nearly absent at the
cervical level, unlike in the lumbar region (11).
The neural foramina in particular are aligned
according to an axis oriented 45° forward, and
the pedicles and transverse processes are directed
laterally and backward toward the vertebral body
(15). Two vertebral arteries from both subclavian
RG • Volume 37 Number 2 Shim et al 539

Figures 1, 2. (1) Cross-sectional anatomy of the cervical and lumbar spine. The epidural space is the space inside the
vertebral spinal canal and outside the dura mater. The subdural space is a potential space between the dura mater and
arachnoid mater. (a, b) Axial T2-weighted magnetic resonance (MR) images with color overlays show the cervical (a)
and lumbar (b) spine. The radiculomedullary artery (arrow and red circle in b) traverses the intervertebral foramen ante-
riorly. Blue dashed lines = arachnoid mater, blue solid areas = posterior longitudinal ligament (at the ventral aspect) and
ligamentum flavum (LF) (at the dorsal aspect), green solid areas in a = epidural venous plexus (EVP), H = posterior epidural
space, tan areas = epidural fat (EF), white dotted lines = pia mater, VA = vertebral artery, white solid lines = dura mater.
(c) Sagittal T1-weighted MR image shows the lumbosacral spine. * = sacral hiatus, blue dashed line = arachnoid mater,
tan areas = epidural fat, white line = dura mater. (2) Model of normal anatomy of the intervertebral foramen shows the
following structures: a, aorta; b, lumbar artery; c, radiculomedullary artery (artery of Adamkiewicz); d, anterior spinal
artery; e, spinal cord; f, nerve root; g, ascending lumbar vein; h, lumbar vein; i, anterior internal vertebral venous plexus.

arteries pass through the transverse foramina,
which are holes in the transverse processes just
in front of the spinal ganglion (Fig 1a). The close
anatomic relationship of the vertebral arteries
and the cervical neural foramina is implicated in
cases of direct trauma to the vertebral artery or
cerebral and cerebellar infarction during a cervi-
cal transforaminal injection (16).
The radiculomedullary arteries, which give
rise to an anterior spinal artery, are a main con-
cern when performing ESI. In the 6th week to
4th month of prenatal development, almost all of
the segmental arteries regress their cord supply,
which leaves four to eight radiculomedullary ar-
teries and 10–20 radiculopial arteries (supplying
the pial network of the spinal cord and posterior
spinal arteries) along the spine (17). The regres-
sion is prominent in the caudal segments of the
spinal cord (17). Because a few radiculomedul-
lary arteries are responsible for the blood supply
540 March-April 2017
to the spinal cord, insult to or drug injection into
a radiculomedullary artery at ESI may cause
critical complications. At the level of the cervical
spine, the upper cervical spinal cord is mainly
supplied by the anterior spinal artery from the
vertebral arteries (15). The anterior spinal artery
is reinforced by a few radiculomedullary arteries
when it follows along the ventral median fissure
of the spinal cord (18). The origin of these vessels
in the cervical regions is more variable than in
the thoracolumbar region (18). The midcervical
spinal cord is fed by two to three anterior radicu-
lomedullary arteries from the vertebral arteries or
the ascending cervical artery (which branches off
from the thyrocervical trunk), and the lower cer-
vical and upper thoracic spinal cord is supplied
by an anterior radiculomedullary artery from the
deep cervical artery (which branches off from the
costocervical trunk) (15). Although these ves-
sels tend to compose a collateral network that
provides compensatory flow to the spinal cord,
the radiculomedullary artery may be penetrated
in cervical transforaminal injections, which could
induce cord infarction (19–21).
Lumbar Epidural Space
The AP diameter of the posterior lumbar epi-
dural space is 5–6 mm at the L2–L3 level, and it
enlarges progressively toward the lower lumbar
and sacral level (14). The lumbar epidural space
also widens when the patient’s back is flexed.
The intervertebral foramen of the lumbar spine
is defined superiorly and inferiorly by the pedicles
of the vertebrae above and below, anteriorly by the
two adjacent vertebral bodies and disk, and pos-
teriorly by the facet joint and ligamentum flavum
(Fig 2). The pedicles of the lumbar spine extend
from the vertebral body straight back to border the
intervertebral foramen (10).
The sacral hiatus is an inverted U-shaped
defect in the posterior wall of the spinal canal,
formed by a failed fusion of the bilateral laminae
at the S5 level (10). Its apex tends to be slightly
above the distal third of S4, and its lateral mar-
gins are formed by the two sacral cornua (22).
The hiatus is covered by the sacrococcygeal
membrane, the subcutaneous fat layer, and skin
(22). In the sacral epidural space, advancing the
needle cranially beyond the S3 level carries risk
for dural puncture because the dural sac usually
extends caudally to the S2 level (Fig 1c).
For the blood supply to the nerve roots and
spinal cord in the lumbar spine, the intercostal
and lumbar arteries arising from the aorta branch
off from radicular arteries (for nerve roots),
radiculopial arteries (which mainly supply the
posterior spinal artery), and radiculomedullary
arteries (which supply the anterior spinal artery).
radiographics.rsna.org
These arteries enter the spinal canal by pass-
ing through the upper anterior quadrant of the
intervertebral foramen (15,23) (Figs 1b, 2). The
artery of Adamkiewicz (great segmental medul-
lary artery), which is the dominant radiculomed-
ullary artery, is responsible for supplying blood to
a long segment of the spinal cord from the lower
thoracic to the conus medullaris level. It supplies
the anterior two-thirds of the spinal cord when
seen in cross section (14). Although the artery
of Adamkiewicz displays considerable anatomic
variation, it frequently branches off from the lum-
bar or intercostal arteries and passes through the
intervertebral foramen between T6 and L2 (more
commonly at the T9–L2 level), and it is rarely
reported between L3 and S2 (24). It rarely comes
from the lower lumbar level. The artery of Adam-
kiewicz is located on the left side of the body in
two-thirds of the population (24). According to
Atluri et al (25), 10 of 18 cases of paraplegia after
lumbar transforaminal ESI occurred after the
left-sided approach, and in seven of nine cases,
the needle tip location was approached in the
superior part of the foramen. Murthy et al (23)
reported that 110 of 113 (97.3%) arteries of Ad-
amkiewicz were located in the superior half of the
intervertebral foramen. These anatomic findings
should be considered when performing ESI.
Indications, Choice of
Approach, and Contraindications
It is essential to confirm whether a patient’s char-
acteristics of pain are concordant with findings
at MR imaging or CT before ESI is performed.
Radicular pain associated with disk herniation
or foraminal stenosis usually follows the affected
nerve root distribution, which could result in mo-
tor weakness as well as sensory changes (Table 1)
(Fig 3). Spinal stenosis causes neurogenic claudi-
cation and sciatica, which improve with forward
flexion, whereas axial low back pain is aggravated
with forward flexion (27). General indications for
ESI include herniated disk disease with or with-
out radicular pain, spinal stenosis, axial low back
pain, and post–lumbar surgery syndrome.
The injection methods used at our institu-
tion, which are selected according to the cause of
pain, are described in Table 2. In a patient with
disk herniation, ESI has shown short-term (<6
months) effectiveness in many studies, and strong
evidence has demonstrated consistent findings
among multiple high-quality randomized con-
trolled trials (28,29). Although ESI is effective in
managing lumbar disk herniation regardless of
the approach used (interlaminar, caudal, or trans-
foraminal), the preferred approach differs accord-
ing to the zone of the herniated disk (30,31). The
basic principle is to select the approach closest to
RG • Volume 37 Number 2 Shim et al 541

Table 1: Sensory and Motor Weakness according to Affected Nerve Root

Affected
Nerve Root Area of Pain Motor Weakness
Lumbar level
L1 Inguinal ...
L2 Anteromedial thigh Hip flexion and adduction, some knee
extension
L3 Anterior thigh and knee Knee extension, hip flexion and adduction
L4 Anteromedial calf Hip extension, flexion, and adduction
L5 Lateral leg and medial foot Foot dorsiflexion, toe extension and flexion
S1 Posterior thigh and calf, heel, and lateral foot Plantar flexion, toe flexion, knee flexion
Cervical level
C2 Back of head and upper neck (occipital neuralgia) …
C3 Supraclavicular fossa at the midclavicular line …
C4 Above clavicle, over the acromioclavicular joint …
C5 Lateral upper arm to elbow Elbow flexion
C6 Lateral forearm, first and second fingers Wrist extension
C7 Third finger, center of palm Elbow extension
C8 Medial forearm, fourth and fifth fingers Finger flexion
Source.—Reference 26.

Figure 3. Left L2–L3 transforaminal ESI performed with single-plane fluoroscopy in a patient with disk injury who experienced a
tingling sensation in the left anteromedial thigh. (a) Sagittal T2-weighted MR image shows a left L2–L3 foraminal herniated disk with
superior migration (arrow) causing left L2 nerve root compression at the foramen, a finding that corresponds to the patient’s left
anteromedial thigh pain. (b) AP fluoroscopic image obtained with the patient in the prone position shows a horizontal line (arrows)
in the disk space. (c) On an 80° oblique fluoroscopic image, the needle tip is too ventrally located. Arrows = contrast material along
the disk, dotted line = bone landmark.

the source of the pain. For a lateralized herni-
ated disk at the lumbar level, we tend to prefer
a preganglionic transforaminal injection over a
paramidline interlaminar injection (30,31). On
the basis of the laterality of symptoms, unilateral
radiculopathy by the herniated disk could be
treated with an ipsilateral transforaminal injec-
tion. However, in the cervical spine, an inter-
laminar midline or paramidline injection is the
option of choice, irrespective of disease categories
or laterality of symptoms, because (a) an inter-
laminar approach is safer and more comfortable
for patients, and (b) a cervical transforaminal
injection has potential risk for serious complica-
tions, including cerebellar and spinal cord infarc-
tion (32,33). Choi et al (33) demonstrated that
542 March-April 2017 radiographics.rsna.org

Table 2: Suggested ESI Method by Disease Category and Location

Herniated intervertebral disk disease, with or without radicular pain
Central zone
   Cervical spine: interlaminar midline ESI
   Upper lumbar spine: interlaminar midline ESI
   Lower lumbar spine: caudal ESI or interlaminar midline ESI (interchangeable)
Paracentral (right or left central) and/or subarticular zones
   Cervical spine: first choice is interlaminar paramidline ESI; second choice is transforaminal ESI
   Lumbar spine: first choice is transforaminal ESI (ganglionic if there is inferior migration of the disk;
   preganglionic if no migration); second choice is interlaminar paramidline ESI
Foraminal or extraforaminal zones
   Cervical spine: first choice is interlaminar paramidline ESI; second choice is transforaminal ESI
   Lumbar spine: transforaminal ESI
Spinal stenosis
Central canal stenosis only
   Cervical spine: interlaminar midline ESI
   Upper lumbar spine: first choice is interlaminar midline ESI; second choice is caudal ESI
   Lower lumbar spine: first choice is caudal ESI; second choice is interlaminar midline ESI
Neural foraminal stenosis only
   Cervical spine: first choice is interlaminar paramidline ESI; second choice is transforaminal ESI
   Lumbar spine: first choice is multilevel transforaminal ESI; second choice is interlaminar paramidline ESI
Central canal stenosis with neural foraminal stenosis (multilevel)
   Cervical spine: first choice is interlaminar midline ESI; second choice is transforaminal ESI
   Lumbar spine: first choice is caudal ESI; second choice is interlaminar paramidline ESI; third choice is
  transforaminal ESI
Axial low back pain
First choice is interlaminar midline ESI
Postoperative spine
Adjacent segmental degeneration in the cranial level of the surgical site
   Disk degeneration, spinal stenosis: interlaminar midline ESI
   Facet joint arthritis, segmental instability, olisthesis: bilateral facet joint injections
Adjacent segmental degeneration in the caudal level of the surgical site
   Disk degeneration, spinal stenosis: interlaminar midline ESI
   Facet joint arthritis, segmental instability, olisthesis: bilateral facet joint injections
Postlaminectomy adhesion
   First choice is caudal ESI (with hyaluronidase); second choice is transforaminal ESI with facet joint injections
Note.—The injection methods are suggested according to our experience and are not absolute. Patient symp-
toms and physical examination findings should always be considered in the choice of injection method.

inadvertent vascular uptake and patient discom-
fort during procedures were significantly lower
in the group in which the interlaminar approach
was used than in the transforaminal approach
group, and there was no statistically significant
difference in symptom improvement between
the two groups. A previous study by Lee et al
(32) showed that a cervical paramidline injection
is extremely effective in patients with cervical
radiculopathy.
Whereas there is robust evidence for ESI ef-
ficacy in treatment of radicular pain associated
with disk herniation, considerable controversy
surrounds the use of ESI in patients with spinal
stenosis, nonradicular discogenic back pain, or
postoperative spinal pain (5,6,34). For patients
with lumbar spinal stenosis, the North Ameri-
can Spine Society has suggested interlaminar
injections to provide short-term (2 weeks to 6
months) symptom relief in patients with neu-
rogenic claudication or radiculopathy; however,
there is conflicting evidence concerning their
long-term (>1 year) efficacy (35). A well-con-
trolled study by Friedly et al (36) showed that
both a steroid-lidocaine injection group and a
lidocaine-alone injection group experienced im-
provement of pain and function compared with
the baseline score in patients with lumbar spinal
RG • Volume 37 Number 2
stenosis. In the study, the degree of improvement
was slightly higher in the steroid-lidocaine group
than in the lidocaine-alone group at 3 weeks
but was not different at 6 weeks (36). Although
there is no high-quality ESI trial focused on
degenerative neural foraminal stenosis alone, a
small group of studies showed the effectiveness
of transforaminal injection in patients with neural
foraminal stenosis (37). For patients with axial
low back pain, Lee et al (38) proposed a thera-
peutic trial of interlaminar ESI before discogra-
phy when discogenic back pain is suspected.
In the postoperative spine, altered biome-
chanical stresses cause facet loading, increased
mobility, and increased intradiscal pressure,
especially in structures neighboring a fused seg-
ment (39). Degeneration that develops above or
below a fused spinal segment is called adjacent
segment disease. The term has a broad meaning
that includes disk degeneration, disk herniation,
olisthesis, instability, hypertrophic facet joint
arthritis, stenosis, and scoliosis (39). In patients
with adjacent segment disease, epidural or facet
joint injections could be considered as a con-
servative treatment option. The choice of injec-
tion method is likely to depend on the type of
adjacent segment disease. If the main problem
is instability, olisthesis, or facet joint arthritis, a
facet joint injection would be favored. Epidural
fibrosis (or adhesion) is widely accepted to be
a main cause of post–lumbar surgery syndrome
(40). High-quality randomized controlled trials
have reported the effectiveness of caudal injec-
tions in managing post–lumbar surgery syndrome
(40,41). The addition of hyaluronidase to the
injectate tends to provide longer-term pain relief in
patients with post–lumbar surgery syndrome (41).
When considering ESI, several preexisting
conditions should be checked to avoid compli-
cations. These conditions include coagulopathy
or concurrent anticoagulation therapy, systemic
infection, local skin infection at the puncture site,
hypersensitivity to administered agents, and preg-
nancy. According to a consensus statement by the
Society of Interventional Radiology (42), ESI is
classified as a category 2 procedure, which means
there is a moderate risk for bleeding (between a
low–bleeding-risk procedure, in which bleeding
is easily detected and controllable, and a signifi-
cant–bleeding-risk procedure, in which bleeding is
difficult to detect or control). For category 2 pro-
cedures, the international normalized ratio (INR)
and platelet count should be adjusted to less than
1.5 and more than 50 000/µL, respectively (42). If
a patient is taking anticoagulants, the medication
should be withheld in consultation with the pre-
scribing physician. Warfarin should be withheld 5
days before ESI, and the patient’s INR should be
Shim et al 543
rechecked before the procedure. Low–molecular-
weight heparin therapy should be stopped 24
hours before ESI, whereas heparin does not need
to be withheld because it is a short-acting agent
(the half-life of heparin is 23 minutes to 2.48
hours). Other medications that must be withheld
include fondaparinux (Arixtra; GlaxoSmithKline,
London, England [withhold 2–5 days before
the procedure]), clopidogrel (Plavix; Handok,
Seoul, Republic of Korea [withhold 5 days]), and
ticlopidine (Ticlid; Roche, Basel, Switzerland
[withhold 5 days]). Nonsteroidal anti-inflamma-
tory drugs, including aspirin, do not have to be
stopped before ESI (43). In patients with a bleed-
ing tendency, facet joint injections that do not
directly puncture the epidural space can be used
as an alternative to reduce the risk for epidural
hemorrhage (44). Hwang et al (44) assumed that
indirect spread of medication through the poten-
tial horizontal pathways and facet capsule rupture
during injection might be associated with effective
responses to facet joint injections in patients with
spinal stenosis.
When infection is clinically suspected (because
of fever, chills, or severe myalgia), inflamma-
tory markers (erythrocyte sedimentation rate
or C-reactive protein) and the white blood cell
count should be checked before the procedure.
Infectious spondylitis is an absolute contraindica-
tion for ESI. Relative contraindications include
uncontrolled diabetes mellitus, congestive heart
failure, and an immunosuppressed state.
Administered Medications
Steroids and local anesthesia are generally used in
combination for anti-inflammatory and analgesic
effects. It is theorized that the lipophilic charac-
teristic of the steroid permits sustained release
from the abundant epidural fat, which is where
the steroid is injected (45). Cells exposed to the
steroid synthesize a phospholipase A2–inhibitory
glycoprotein (termed lipomodulin) and inhibit the
inflammatory pathway; phospholipase A2, which
is an inflammatory enzyme, converts membrane
phospholipids into arachidonic acid and subse-
quently controls lipoxygenase, leading to the for-
mation of leukotrienes. On the molecular level, the
steroid induces anti-inflammatory coding genes
such as lipocortin, interleukin-1 receptor antago-
nist, and secretory leukocyte protease inhibitor
(46). The steroid also reduces nerve swelling and
upregulates the transcription of anti-inflammatory
genes, in contrast to local analgesics, which are re-
sponsible for immediate pain relief (45). The effect
of steroids remains the subject of dispute. Some
studies have shown that epidural injection of either
saline or analgesics (a placebo injection) alone did
not differ significantly from steroid injection in
544 March-April 2017
the level of pain relief (47,48). A well-controlled,
double-blind, randomized trial (36) showed that
a steroid-injected group reported slightly greater
improvement in pain and functional outcome at 3
weeks after injection and greater satisfaction with
their treatment; however, there was no difference
at 6 weeks between this group and the placebo-
injected group. Thus, steroid injection may be
superior to placebo injection in the immediate (<3
weeks) period (6,36).
Although the steroid is administered by local
injection, it has variable systemic adverse effects,
which include antidepressive effect, suppres-
sion of the hypothalamus-pituitary-adrenal axis,
Cushing syndrome, osteoporosis, weight gain,
hypertension, insomnia, mood swings, psycho-
sis, headache, hiccups, flushing, gastrointestinal
symptoms, and menstrual disturbances (36). It
also causes fluid retention and hyperglycemia.
Interventional radiologists who contemplate use
of ESI in patients with congestive heart failure or
diabetes mellitus should proceed cautiously and
consider alternative therapeutic measures.
Transient elevation of the white blood cell
count after ESI is an unfamiliar phenomenon
(49). We have experienced some cases that
showed elevation of the white blood cell count
without infection after ESI. Corticosteroids
stimulate the release of mature neutrophils from
the bone marrow to the peripheral blood (50).
This could occur within a few days after injection
but is distinguished from neutrophilia associated
with postprocedural infection by rapid normaliza-
tion (usually 1 day after injection) and absence
of increased band-form neutrophils (immature
neutrophils) (49).
Particulate Steroid Injection
The choice of steroid formula is a recent issue in
ESI. Particulate steroids, including triamcinolone
acetonide, prednisolone acetate, methylpred-
nisolone acetate, and betamethasone acetate,
may be responsible for spinal cord infarction or
cerebellar infarction after ESI, presumably due to
particle embolization (16,24,51,52). Particulate
steroids are thought to work as emboli if there is
inadvertent puncture of small arteries that supply
the spinal cord or brain. Against that background,
the U.S. Food and Drug Administration warned
in 2014 that injection of all types of corticoste-
roids into the epidural space of the spine could
be harmful and required label changes for corti-
costeroids used in ESI (53). However, dexameth-
asone sodium phosphate, which is nonparticulate,
is considered safe (54). In 2015, the U.S. Food
and Drug Administration Safe Use Initiative co-
ordinated meetings of a multidisciplinary working
group, which published consensus recommenda-
radiographics.rsna.org
tions and a viewpoint article on ESI safeguards
(54,55). The recommendations included prohi-
bition of particulate steroids in cervical transfo-
raminal ESI (55). In lumbar transforaminal ESI,
a nonparticulate steroid should be used for the
initial injection, but there are situations in which
particulate steroids could be used (55). Although
early studies suggested that particulate steroids
were superior to nonparticulate steroids in the
duration of pain relief, recent studies suggest
inconsistent results regarding a longer duration of
pain relief for particulate steroids (56–58).
Fluoroscopic Equipment, Patient
Preparation, and Medication Dosages
Although CT guidance or combined CT-fluo-
roscopic guidance is increasingly used for ESI,
conventional fluoroscopic guidance is generally
used (59). The fluoroscopic equipment used for
ESI should allow the target anatomy to be viewed
in multiple projections; therefore, equipment with
a C-arm configuration should be used (14). Al-
though a single-plane C-arm system is sufficient
to perform ESI, biplane fluoroscopy is superior
because of the ability to view the target anatomy
in two projections at once, which reduces proce-
dural time (14).
The equipment and drug dosages used at our
institution are summarized in Table 3. Ten mil-
ligrams of dexamethasone are injected for each
ESI. The North American Spine Society recom-
mends that each ESI session is limited to 15 mg
of dexamethasone and that no more than three
ESIs are performed in a 6-month period (45).
Use of a pressure extension line is recommended
so that once a needle has been placed, it can no
longer be touched and possibly dislodged (60).
The skin must be sterilized with betadine-
soaked cotton balls after marking the puncture
site. Preparation of the skin starts from the center
of the injection site and works outward toward
the periphery. A widening circular motion is used
to make a painted circle with a 5–10-cm radius.
Cervical Epidural Injection
For a cervical interlaminar ESI, the patient is in
the prone position, is requested to bend his or
her neck forward to widen the interspinous space,
and is assisted by two pillows, one placed under
the shoulder and one placed under the fore-
head (a large pillow under the shoulder makes
neck flexion easy, and a small pillow under the
forehead is for patient comfort). Both arms are
tucked in caudally so that the patient’s shoulders
do not obscure the lower cervical space.
The cervical neural foramina are aligned
according to an axis oriented 45° forward. A
cervical transforaminal ESI (with the exception
RG • Volume 37 Number 2 Shim et al 545

Table 3: Equipment and Drug Dosages Used for Cervical, Lumbar, and Caudal ESIs at Our Institution

Cervical Lumbar

Parameter Transforaminal Interlaminar Transforaminal Interlaminar Caudal

Equipment 25-gauge needle 22-gauge needle 22-gauge needle 22-gauge figure 22-gauge needle
(1) (1) (1) needle (1) (1)
2-mL syringe (1) 2-mL syringe (1) 2-mL syringe (1) 2-mL syringe (1) 5-mL syringe (2)
1-mL lock syringe 5-mL syringe (1) 5-mL syringe (1) 5-mL syringe (1) 1-mL lock syringe
for test contrast 1-mL lock syringe 1-mL lock syringe 1-mL lock syringe for test contrast
agent injection for test contrast for test contrast for test contrast agent injection
(1) agent injection agent injection agent injection (1)
Pressure extension (1) (1) (1) Pressure extension
line Pressure extension Pressure extension Pressure extension line
line line line
Drugs Steroid: 10 mg (2 Steroid: 10 mg (2 Steroid: 10 mg (2 Steroid: 10 mg (2 Steroid: 10 mg (2
mL) of dexa- mL) of dexa- mL) of dexa- mL) of dexa- mL) of dexa-
methasone (5 methasone (5 methasone (5 methasone (5 methasone (5
mg/mL) mg/mL) mg/mL) mg/mL) + 0.5 mg/mL) + 3
Local anesthetic: mL saline mL saline
3.75 mg (0.5 Local anesthetic: Local anesthetic:
mL) of ropiva- 7.5 mg (1 mL) 3.75 mg (0.5
caine hydro- of ropivacaine mL) of ropiva-
chloride (7.5 hydrochloride caine hydro-
mg/mL) + 1 (7.5 mg/mL) + chloride (7.5
mL saline 2 mL saline mg/mL) + 4.5
mL saline
Note.—Numbers in parentheses indicate quantity needed.

of injection to the C1 and C2 nerve roots) is
performed with the patient in the supine position.
The patient is requested to turn his or her face to
the side opposite the injection. C1 and C2 nerve
root injection is performed with the patient in
the prone position (see the section on “C2 Nerve
Root Block”).
Lumbar Epidural Injection
For an interlaminar or caudal injection, the patient
lies prone on the fluoroscopy table. For lumbar
and caudal ESIs, a large pillow is placed under the
patient’s abdomen to help the lower back flex and
to decrease lumbar lordosis, resulting in a widened
interspinous space. A lumbar transforaminal ESI
is performed in the same position as for a lumbar
interlaminar ESI.
Trajectory and Techniques for ESI
Manipulating a Beveled Needle
The needles used for ESI have an asymmetric
beveled tip. The bevel face should be directed
180° from the desired needle trajectory because it
tends to bend in the direction opposite the bevel.
Remembering the direction of the bevel tip and
face will help the radiologist to delicately ma-
nipulate the needle. The use of a beveled needle
is especially recommended for caudal injection.
Because the posterior aspect of the epidural space
in the sacrum contains fewer vascular and neural
structures, the bevel face should be turned to the
anterior side of the epidural space to avoid vascu-
lar and neural structures.
Cervical Interlaminar Injection
The posterior cervical epidural space widens
with neck flexion (14). For a cervical interlami-
nar ESI, the level of the injection and the skin
puncture site should be confirmed on AP and
lateral views of the cervical spine. A cervical
interlaminar injection is usually performed by
using the C6–C7 or C7–T1 interlaminar spaces,
where the epidural fat is more adequate (14).
Because the cervical epidural space has less fat
than the lumbar epidural space, special precau-
tions are required to avoid inadvertent dural
puncture. Although the C7–T1 interlaminar
space is wider, our institution prefers to admin-
ister injections by using the C6–C7 interlaminar
approach because the shoulders can obscure the
lower cervical spine on lateral projections. It is
unclear whether a lower cervical injection site is
effective for upper cervical pathologic conditions
because most cervical degenerative disk disease
occurs in the lower cervical segments. Previous
546 March-April 2017 radiographics.rsna.org

Figure 4. Cervical interlaminar injection performed with single-plane fluoroscopy in a patient in the prone position. (a, b) Needle
trajectory for a cervical interlaminar injection. (a) AP view with caudal angulation of the current tube shows the interlaminar space of
C6–C7 en face (J). Dotted lines = bone landmarks, double-headed arrow = interlaminar space (ILS) of C5–C6, SP = spinous process.
(b) On a lateral view, the spinolaminar line (dashed line) is well identified. Arrow and H = interlaminar space (ILS), DS = disk space,
IAP = inferior articular process, IVF = intervertebral foramen, SAP = superior articular process, SP = spinous process, VB = vertebral
body. (c, d) Lateral “true” epidurograms obtained with a test injection of contrast agent show correct needle placement. A semilunar
convexity (arrows in c) and a thin line of contrast agent along the spinolaminar line (dashed line) are seen. (e) AP view shows contrast
agent dispersion (arrows) that outlines exiting nerve roots.

studies (61,62) that evaluated the distribution
of administered material showed that injectate
diffuses superiorly to the C2–C4 level, such that
a lower cervical injection may effectively treat
upper cervical lesions.
Regarding the volume of injectate, Lee et al
(61) recommended that a total amount of 5 mL
(which includes the test dose of contrast agent) is
sufficient to distribute the medication efficiently.
Goel and Pollan (62) proposed that a 2–4-mL
injection without a test dose of contrast agent
would be sufficient to cover the cervical epidural
space. On the basis of these studies and our expe-
riences, we use a total volume of 2–3 mL for cer-
vical interlaminar ESI (Table 3). After confirming
the puncture site on AP and lateral views of the
cervical spine (Fig 4a, 4b), it is recommended
that the skin puncture be started with use of the
AP view, with caudal angulation of the cur-
rent tube to see the interlaminar space en face.
The needle is then advanced just ventral to the
spinolaminar line with use of the lateral view. The
cervical epidural space is only 1–2 mm in width.
It is important to be cautious and to use a small
test dose of contrast agent injected intermittently
while the needle is traversing the spinolaminar
line. When the needle tip arrives at the true epi-
dural space, just ventral to the spinolaminar line,
RG • Volume 37 Number 2 Shim et al 547

Figure 5. Cervical transforaminal injection performed with single-plane fluoroscopy in two patients in the supine position (a–d in
same patient; e in another patient). (a) Step 1: On an oblique image, the needle entry site is confirmed by contact with the superior
articular process of the lower cervical spinal segment. (b) Step 2: On an oblique image, the needle is advanced parallel to the beam
of the current tube. The intervertebral foramen (IVF) is outlined by the top dotted line, and the lower dotted lines indicate bone
landmarks. FJ = facet joint, IAP = inferior articular process, SAP = superior articular process. (c) Step 3: On a posteroanterior image,
the final needle advancement should not pass the midline (solid white line) of the lateral mass. Dotted lines = margins of the lateral
masses. (d, e) Posteroanterior images show contrast agent flowing upward along the medial margin of the pedicles (oval in d and
dotted arrow in e) and the exiting nerve root (solid arrows).

contrast agent flows dorsally along the spinolami-
nar line. With an interlaminar ESI, a single line
and a well-defined or smudged convexity along
the spinolaminar line on the lateral view sug-
gest that the needle tip is positioned correctly in
the epidural space (Fig 4c, 4d). On the AP view,
contrast agent dispersion with drug injection may
outline exiting spinal nerves (Fig 4e).
Cervical Transforaminal Injection
The cervical neural foramina are aligned accord-
ing to an axis oriented 45° forward; therefore, a
cervical transforaminal injection must be per-
formed by using an oblique anterior approach
with the patient in the supine position (15). The
level of targeting of the intervertebral foramen
must be confirmed first (Fig 5a). The obliquity
of the current tube, approximately 45° toward
the symptomatic side, allows the intervertebral
foramina to enlarge. After tilting the current tube
to the angle at which the foramen is the most en-
larged, a needle is advanced parallel to the C-arm
beam, targeting the dorsal and posterior aspect of
the foramen, with contact to the superior articu-
lar process of the lower cervical spinal segment
(Fig 5b). Then, returning to the AP view, the
needle tip is cautiously advanced further, to the
lateral third of the lateral mass (not beyond the
548 March-April 2017 radiographics.rsna.org

Figure 6. Lumbar interlaminar injection performed with single-plane fluoroscopy in a patient in the prone position. (a, b) Lateral
“true” epidurograms show correct needle placement. (a) The needle tip is placed just ventral to the spinolaminar line (dotted ar-
rows), and contrast agent forms a vertical semilunar shape (solid arrows). (b) When the ligamentum flavum is thick, the needle tip
may enter deep into the spinolaminar line (dotted arrows) to enter the true epidural space (solid arrows). Dashed line = interverte-
bral foramen (IVF), DS = disk space, ILS = interlaminar space, SP = spinous process, VB = vertebral body. (c) AP view shows a thick
asymmetric contrast agent deposit that fades out at the periphery. Contrast agent sometimes flows out into a neural foramen (solid
arrows). Double-headed arrow = interlaminar space (ILS).

midline of the lateral mass on the AP view) (Fig
5c). These approaches avoid unintended punc-
ture of the vertebral artery and dural sleeve of
the nerve roots. With a tranforaminal ESI, if the
needle tip is in the true epidural space, a test dose
of contrast agent will flow upward (occasion-
ally downward) along the medial margin of the
pedicles and along the exiting nerve (Fig 5d, 5e).
Lumbar Interlaminar Injection
The pedicles of the lumbar spine extend back-
ward to border the intervertebral foramen;
therefore, interlaminar and transforaminal
epidural injections are feasible by using the poste-
rior approach in a patient who is in the prone
position (10). Technically, the basic approach
is the same as for a cervical interlaminar ESI.
The patient’s back should be flexed to widen
the epidural space. After checking the level on
the AP view, the current tube should be rotated
caudally to open up the interlaminar space en
face. Skin puncture is performed with use of the
AP view at the center of the interlaminar space
along the midline (Fig 6c), after which the needle
is advanced just ventral to the spinolaminar line
(the base of the spinous process) seen on the
lateral view (Fig 6a). To confirm arrival at the
epidural space, a test dose of contrast agent is
injected (0.1–0.3 mL). In the paramidline ap-
proach, the tip of the needle may traverse the
spinolaminar line too deeply, and the test dose
of contrast agent may not show the true shape of
the epidural space. When this is the case, the AP
view must be rechecked to confirm if the needle
has escaped too laterally. When the ligamen-
tum flavum is thick, the tip of the needle may
enter deep into the spinolaminar line (Fig 6b).
The paramidline approach is preferred when a
midline approach is difficult, as in cases with os-
sification of the supraspinous ligament or Baas-
trup disease. The loss of resistance as the needle
traverses the ligamentum flavum, which indicates
that the needle is in the epidural space, can be
unreliable, compared with use of test injections of
contrast material (55,63–65). A test injection of
contrast material would result in a vertical semi-
lunar-shaped contrast agent deposit along the
spinolaminar line on the lateral view and a thick
ipsilateral contrast agent shadow along the medial
margin of the upper and lower pedicles and the
exciting nerve sheath on the AP view (Fig 6a–6c).
In a lumbar interlaminar ESI, the administered
fluid typically can travel one or two levels in both
the caudad and cephalad directions.
Lumbar Transforaminal Injection
For a lumbar transforaminal injection, the cur-
rent tube is tilted cranially or caudally until the
superior endplate appears as a straight line, and
the tube is then rotated ipsilaterally at an oblique
angle (10°–30°), which reveals a typical “Scotty
dog” appearance composed of the posterior ele-
RG • Volume 37 Number 2 Shim et al 549

Figure 7. Lumbar transforaminal injection performed with single-plane fluoroscopy in two patients in the prone position (a–c in
same patient). (a) Oblique radiograph of the lumbar spine shows the “Scotty dog” appearance (dotted lines) of the posterior element
of the vertebrae. × = subpedicular approach, + = retroneural approach, IAP = inferior articular process, SAP = superior articular process,
TP = transverse process. (b) Lateral single-plane fluoroscopic image shows the proper location of the needle tip in the subpedicular
(×) and posterolateral (retroneural) (+) approaches. The needle is placed to the retroneural space. White lines = imaginary outline
of the ganglion and nerve roots. (c) AP image shows the subpedicular approach. Contrast agent flows along the medial margin of
the pedicle (arrow), and lobulations (arrowheads) are seen outside the foramen. The needle tip should not be advanced beyond the
midpedicular line (6-o’clock position on the clock face). Dotted outline = pedicle (P). (d, e) AP (d) and lateral (e) images in a different
patient show the retroneural approach. The needle tip (circle in e) is placed at the lower portion of the neural foramen, and injected
contrast agent is seen spreading into the intraneural and retroneural epidural spaces. Dotted line in e = intervertebral foramen (IVF).

ment of the vertebrae. For a lumbar transforami-
nal ESI, which approaches the epidural space
through the intervertebral foramina, a classic ap-
proach (subpedicular, supraneural) and a postero-
lateral approach (retroneural) are possible (Fig 7a,
7b) (66,67). In the classic subpedicular approach,
a “safe triangle” in the anterior-superior third of
the neural foramen is identified for targeting just
below the chin of the “Scotty dog” (the inferior
lateral aspect of the pedicle) (Fig 7a, 7c). By us-
ing this approach, drugs can be delivered into the
anterior epidural space, which is usually a location
closest to neural compression by a herniated disk,
and the needle tip tends to be placed at the lateral
half of the foramen as seen on the AP view, with
minimal risk for dural puncture (68,69). However,
the “safe triangle” currently is considered to be a
misnomer because radiculomedullary arteries are
located almost in the triangle (23,70). In the pos-
terolateral (ie, retroneural) approach, the needle
targets posterior to the nerve root (retroneural)
just after penetrating the circumneural sheath and
delivers drugs from the posterolateral corner of the
epidural space to the lesion (Fig 7a, 7b, 7d, 7e).
The advantages of the posterolateral approach are
less chance of nerve root irritation and less chance
550 March-April 2017
Figure 8. Caudal injection performed with single-plane fluoroscopy in a patient in the prone position. (a, b) AP (a) and lateral (b)
images show the needle advancing through the sacral hiatus (circle in a and oval in b). (c) “True” epidurogram with correct place-
ment of the needle tip (circle) shows findings that resemble a Christmas tree.
of vascular injury (71). For the posterolateral
(retroneural) approach, the needle is inserted just
lateral to the superior articular process or the pars
interarticularis on a 10°–30° oblique view. On the
lateral view, the needle tip is advanced with inter-
mittent injection of contrast agent until contrast
agent spreads between the circumneural sheath
and the nerve root. The needle tip should not
be advanced into the anterior third of the neural
foramen on the lateral view, and it should not be
advanced beyond the midpedicular line (6-o’clock
position) on the AP view (Fig 7b, 7c). If patients
report pain because of nerve irritation during
needle advancement, the needle should be with-
drawn to avoid intraepineural injection. A test dose
of contrast agent that has been correctly injected
into the epidural space draws shadows along the
medial margin of the upper and lower pedicles
and the exiting nerve sheath on the AP view, and
contrast agent sometimes appears as lobulations
along the nerve sheath (Fig 7c, 7d).
Caudal Injection
Caudal ESI is a commonly used epidural injec-
tion technique to deliver drugs through the sacral
hiatus to the lower lumbar spine. At our institu-
tion, caudal ESI is preferred in patients with
multiple central canal stenoses that affect more
than two levels. It is also useful in patients with
severe central canal stenosis or those with a post-
operative spine in which the posterior epidural fat
is effaced and insufficient for placing a needle at
radiographics.rsna.org
CT or MR imaging. For the procedure, the sacral
hiatus should be checked on both the AP and
lateral views. After the entry site is confirmed, the
needle is advanced into the sacral epidural space
along the posterior margin on the lateral view (Fig
8a, 8b). Because the dural sac terminates at the S2
level, the needle tip should not go up beyond the
S3 level, to avoid dural puncture (Fig 8c). A few
studies of the level of vertebral segments covered
by caudal ESI have suggested that a total volume
of 20 mL of injectate is required to reach the
L3–L4 level (72,73). At our institution, we use a
volume of about 10–15 mL for caudal ESI (10 mg
[2 mL] of dexamethasone [concentration, 5 mg/
mL], 3.75 mg [0.5 mL] of ropivacaine hydrochlo-
ride [7.5 mg/mL], and 7.5 mL of saline; if more
volume needs to be injected, saline is added) (Ta-
ble 3). This volume is somewhat less than in the
aforementioned studies because of concern that a
large volume of injectate may increase the pressure
in the epidural space. An increase of epidural pres-
sure can result in compression of neural structures
and increased intracranial pressure. Contrast
agent filling in the true epidural space looks like a
Christmas tree on the AP view (Fig 8c).
Pitfalls: False ESI
Staining of Paravertebral
Muscles and Ligaments
Beginners tend to advance the needle carefully
and repetitively when injecting the test dose of
RG • Volume 37 Number 2 Shim et al 551

Figure 9. Contrast agent staining of paravertebral muscle and soft

tissue. (a) Lateral single-plane fluoroscopic image of the lumbar spine
shows an irregular cloud-shaped accumulation of contrast agent (open
arrow) posterior to the spinolaminar line. Solid arrows = true epidural
space staining. (b, c) Psoas muscle staining. (b) AP single-plane fluoro-
scopic image of the lumbar spine shows psoas muscle staining (arrows)
that mimics the exiting nerve root shadow. (c) Axial T2-weighted MR im-
age of the lumbar spine shows the close relationship between the psoas
muscle (dark pink area) and the nerve root (yellow oval).

contrast agent. Contrast staining of the para-
vertebral soft tissue, ligaments, or muscles in
the course of needle advancement is frequently
encountered. This paravertebral muscular or liga-
mentous staining appears parallel to the course
of the muscle fiber or ligament. The so-called
false staining is usually located posterior to the
spinolaminar line; therefore, it is easy to distin-
guish from true epidural space staining (Fig 9a).
However, because muscular or ligamentous stain-
ing diffuses slowly after injection, repetitive con-
trast agent injections can conceal the needle tip
and even the staining of the true epidural space.
In this case, further advancement of the needle
carries risk for dural puncture, and it is recom-
mended to reposition the needle one level caudad
or cephalad. If the needle tip is advanced too an-
teriorly and laterally during a lumbar transforam-
inal injection, the psoas muscle can be stained
with contrast agent (Fig 9b, 9c). Because of the
obliquity of the psoas muscle fibers, the stain-
ing can mimic the true contrast agent shadow of
an exiting nerve root, but it will lack the upward
flow along the medial margin of the pedicle and
lobulations along the nerve. The needle should be
repositioned in the medial direction.
Intravascular Injection
Intravascular injection is a common pitfall in
epidural injections. Nahm et al (74) reported that
intravascular injections were observed in 20.6%
of cervical injections and 6.1% of lumbar injec-
tions in a prospective study of 2145 transforami-
nal ESIs at fluoroscopy. Intravascular contrast
agent flows in a configuration of curvilinear or
thin straight lines and disappears at the moment
of injection without accumulation (Fig 10). If
intravascular flow is observed, the needle is with-
drawn sufficiently and repositioned, targeting dif-
ferent locations. Nevertheless, when vascular flow
constantly appears, the method of approach must
be modified; for example, from a midline approach
to a paramidline approach or vice versa. Although
inadvertent arterial flow is thought to dissipate
more rapidly compared with intravenous injection,
it is difficult to distinguish arterial from venous
injections (74). Most intravascular injections are
venous and may decrease the effectiveness of the
552 March-April 2017 radiographics.rsna.org

Figure 10. Intravascular injection during a cer-

vical transforaminal injection performed with sin-
gle-plane fluoroscopy in a patient in the supine
position. (a, b) Posteroanterior images show a
linear contrast agent shadow (arrow in a) and
contrast agent flow that is still noted (arrow in
b) when contrast agent is injected after slight ad-
vancement of the needle tip. (c) Posteroanterior
image shows that the contrast agent shadow has
rapidly dissipated and is no longer seen (oval).

ESI and enhance the systemic effect of the drugs
(75). As mentioned earlier, inadvertent arterial
injection of a particulate steroid was thought to
be responsible for spinal cord infarction in ESI.
The artery of Adamkiewicz (the largest radiculo-
medullary artery that supplies the anterior spinal
artery) frequently branches from the lumbar or
intercostal arteries at the T9–L2 level but rarely
comes from the lower lumbar level. Because it
passes through the upper half of the neural fora-
men anteriorly, a posterolateral (retroneural) ap-
proach with injection of a nonparticulate steroid
is recommended (23,24,67). Most reported
spinal cord infarctions occurred during transfo-
raminal injections, but two cases occurred during
lumbar interlaminar ESIs, and one was during
a lumbar facet joint injection (51,76,77). These
lumbar interlaminar ESIs and facet joint injec-
tions were performed on the postoperative spine,
which indicates that a change in arterial supply
in the postoperative spine with scar tissue forma-
tion may have played a predominant role in cord
infarction (51,77).
Inadvertent Facet Joint Injection
Huang and Palmer (78) reported the incidence of
inadvertent lumbar facet joint injection as 1.2%
during interlaminar ESI (8 out of 686). Inadver-
tent facet joint injection can be seen without direct
puncture of the articulation of the facet joint (Fig
11a, 11b). There are anatomic considerations that
could explain this phenomenon. The facet joint
capsule is a thin fibrous layer enveloping the joint,
which has varying degrees of medial extension into
the ligamentum flavum or between the ligamentum
flavum and the lamina at the anterior aspects of the
facet joint capsule. This potential extradural space
refers to the retrodural space of Okada that lies
dorsal to the ligamentum flavum (79). When a con-
trast agent shadow indicative of facet joint injection
appears during an interlaminar approach, it means
that the needle tip is just posterior to the ligamen-
tum flavum, near the epidural space. Therefore,
minimal advancement with a test dose of contrast
agent would demonstrate the true epidural space
(Fig 11b, 11c). Other considerations of inadvertent
facet joint injection include horizontal communi-
RG • Volume 37 Number 2 Shim et al 553

Figure 11. Inadvertent facet joint injection seen at single-plane fluoroscopy

in two patients. (a–c) C5–C6 interlaminar injection in a 37-year-old patient
in the prone position. (a) AP image shows that despite a midline injection
approach (not directly penetrating the facet joint), the right facet articulation
is revealed as a U-shaped line (arrow). (b) On a lateral image, contrast agent
reveals a sigmoid facet joint line (arrowheads). (c) Epidurogram obtained
as the needle tip was minimally advanced without repositioning shows the
true epidural space along the spinolaminar line (arrows). (d) AP arthrogram
obtained in a different patient during a lumbar interlaminar injection shows
a W-shaped area of contrast agent (arrowheads) in the facet joints, which
indicates communication between the bilateral facet joints through the in-
terspinous bursa (arrow).

cation between bilateral facet joints through the
interspinous bursa (Baastrup disease) and through
other channels such as a pars interarticularis frac-
ture (spondylolysis) (Fig 11d) (80). Contrast agent
in facet joints demonstrates an oblique sigmoid line
along the articulation on the lateral view, and a J- or
U-shape (W-shape with horizontal communica-
tion) on the AP view (Fig 11).
Dural Puncture
Dural puncture in epidural injection is a common
and critical condition with a reported incidence
of up to 5% (81). Complications of dural punc-
ture include post–dural puncture headache, par-
esthesia, intracranial hemorrhage, cauda equina
syndrome, aseptic meningitis, and arachnoiditis
(82,83). Rodriguez et al (83) demonstrated
that the incidence of postprocedural headache
for fluoroscopically guided dural puncture was
2.2%. Post–dural puncture headache is caused by
cerebrospinal fluid leakage through the puncture
site, which results in low intracranial pressure.
It usually develops within 5 days after dural
puncture and typically manifests as a postural
headache that worsens within 15 minutes of sit-
ting or standing and improves within 15 minutes
after lying down (84). It may be accompanied by
neck stiffness, tinnitus, or photophobia (84). For
management of post–dural puncture headache,
hydration, oral nonopioid analgesics, and bed
rest are frequently used (85). An epidural blood
patch is a relatively easy and effective option to
treat post–dural puncture headache by sealing
the puncture site with 10–20 mL of autologous
blood (85). The epidural blood patch method is
identical to an epidural interlaminar injection and
differs only in that autologous blood rather than
a steroid mixture is injected. A prophylactic epi-
dural blood patch may be considered in patients
with multiple dural punctures during a procedure
or a previous history of post–dural puncture
headache (86–88).
With an intradural injection, contrast material
rapidly disperses and accumulates at the ventral
portion of the spinal canal, forming a cerebro-
spinal fluid–contrast agent level (dorsal cerebro-
spinal fluid and ventral contrast agent) because
of the patient’s prone position (Fig 12a). The AP
554 March-April 2017 radiographics.rsna.org

Figure 12. Dural puncture in two patients. (a, b) L4–L5 interlaminar injection performed with single-plane fluoroscopy in a 34-year-
old woman. (a) Lateral image shows the needle tip (circle) deeply advanced into the spinolaminar line. Test contrast agent accu-
mulates at both the posterior epidural space (arrows) and the ventral surface of the thecal sac. Contrast agent accumulation at the
ventral surface of the spinal canal forms a cerebrospinal fluid–contrast agent level (arrowheads) and indicates dural puncture. (b) AP
image shows that contrast agent is symmetrically accumulated in the central portion of the spinal canal (arrowheads) but is faint.
(c–e) Perineural cysts in a patient with a previous L4–L5 hemilaminectomy. (c) Lateral radiograph of the lumbar spine shows a large
radiolucent lesion (arrows). (d) Sagittal T2-weighted MR image of the lumbar spine shows correlative large S2–S3 perineural cysts
(arrows), findings that were missed on this image. (e) AP C-arm–guided fluoroscopic image shows well-defined intrathecal contrast
agent (arrowheads) and perineural cysts (arrows), even though the needle tip is placed at the S4 level.

view demonstrates a symmetric distribution of
contrast agent, similar to that seen at myelogra-
phy (Fig 12b, 12e). Recognizing dural puncture
by administration of test contrast agent is impor-
tant. If drugs are injected into the dural sac, there
may be disastrous consequences. There are a few
reports of aseptic meningitis and arachnoiditis
induced by intrathecal steroid injection, which
are thought to be associated with the steroid dose
and multiple injections (82,89). Unintended
intradural injection of local anesthetics acts as
an intrathecal anesthesia equivalent. The median
effective dose of ropivacaine, referred to as the
minimum local anesthetic dose, for attaining a
T12 bilateral sensory block within 20 minutes
after injection was found in one study to be 8.41
mg in intrathecal anesthesia for lower limb sur-
gery (90). At our institution, 3.75 mg (0.5 mL)
of ropivacaine is used for lumbar transforaminal
ESI, 7.5 mg (1 mL) is used for lumbar interlami-
nar ESI, and 3.75 mg (0.5 mL) is used for caudal
ESI. Intradural injection of local anesthetics into
the high spinal cord level can cause fatal compli-
cations such as respiratory failure; thus, local an-
esthetics must be excluded from cervical epidural
injection. If dural puncture is recognized by using
RG • Volume 37 Number 2
test contrast agent administration, medications
that exclude anesthetics could be injected after
the needle is repositioned.
It is important to evaluate the level of termina-
tion of the dural sac and the possible presence of
large perineural cysts at preprocedural imaging
(Fig 12c, 12d). Although the dural sac usually
terminates at the S2 level, it rarely extends to the
upper S3 level (91). Perineural cysts referred to
as Tarlov cysts are cystic dilatations of meninges
around the posterior spinal nerve roots or dorsal
root ganglions (82,89). Although they have been
found to occur anywhere in the spine, they most
often affect the S2 and S3 nerve roots and could
enlarge the sacral canal or foramen extending
below the S3 level (92,93). They are likely to
freely communicate with the arachnoid space. If a
large perineural cyst is penetrated but overlooked
at ESI, iatrogenic transient spinal anesthesia and
other complications associated with dural punc-
ture by the injected drugs could occur.
Subdural Injection
The subdural space is a space between the dura
mater and arachnoid mater (Fig 2). Unlike previ-
ous assumptions that the subdural space may
be a natural potential space, recent studies have
revealed that the subdural space is not a true cav-
ity but an acquired one induced by traction force
(12,13). At microscopic examination, multiple
neurothelial cell layers were noted between the
dura lamina and the arachnoid lamina, and the
inner layers of the dura mater were separated
from the outer layers of the arachnoid membrane
in some areas, whereas in other areas, they were
attached (13). These characteristics of the dura–
arachnoid interface cause various contrast agent
shadows after subdural injection. Such shadows
could exhibit a tubular blotchy appearance, which
could represent entrapped contrast material be-
Shim et al 555
Figure 13. Subdural contrast agent
injection in a 74-year-old man. (a) AP
single-plane fluoroscopic image shows a
tubular blotchy contrast agent shadow
that spreads up and down and separates
the dura mater and arachnoid mater (ar-
rowheads). The inner margins of the con-
trast agent shadow demarcate the exiting
nerve root sleeve (lower arrows) and are
focally interrupted (upper arrow). (b) Ax-
ial CT image at the L3 vertebral body level
shows a contrast agent globule entrapped
at the interface of the dura mater and
arachnoid mater. The posterior epidural
fat space is displaced to the right (arrows)
by the contrast globule. (Case courtesy of
Ja-Young Choi, Seoul National University,
Seoul, Republic of Korea.)
tween the dura–arachnoid interface (Fig 13) (94).
Subdural contrast agent often spreads up and
down the dural sheath, manifesting with fine verti-
cal parallel lines that demarcate the inner surface
of the dura (94). The lines could be occasionally
interrupted by the exiting nerve root sleeve (94)
(Fig 13a). The incidence of unintentional subdural
injection ranges from 0.1% to 0.8% in epidural
block cases (13). If subdural contrast agent filling
is observed, the needle should be repositioned to
avoid the same site. Drugs should not be injected,
especially anesthetics, which may cause respiratory
depression or cardiovascular depression such as
bradycardia, hypotension, and even cardiac arrest,
although recovery usually occurs within a few
hours (95).
Nerve Injury
The neurologic manifestations of nerve injection
injury range from minor but severe transient pain
to severe transient sensory neurologic deficit and,
rarely, permanent neurologic deficit (96,97). The
risk for nerve fascicle injury tends to be higher in
nerves with a high neural (nerve fascicles) to non-
neural tissue (epineurium and connective tissue
among fascicles) ratio, including the spinal nerve
roots. When the ratio is higher, fascicles are more
easily disrupted (98). Lee et al (99) reported that
1.83% of patients treated with cervical or lum-
bar transforaminal ESI complained of transient
neurologic deficits, which were more frequent in
cervical procedures than in lumbar procedures.
If patients feel searing pain along the dermatome
at the level of the transforaminal injection, the
needle should be promptly withdrawn sufficiently
and repositioned. During cervical transforaminal
ESI, if the patient complains of severe ipsilateral
radiating pain, even if the needle is placed far from
the neural foramen, the needle could be in contact
with the nerve root one level above, in part of the
556 March-April 2017 radiographics.rsna.org

Figure 14. Nerve injury during a right C5–

C6 transforaminal injection performed with
single-plane fluoroscopy in a 50-year-old
man. Fluoroscopic image shows two sharp
thin lines with a feathery filling and “tram
track” appearance (open arrows) along the
C5 nerve root, suggesting an intraepineural
injection. After the needle was repositioned,
a true epidural contrast agent shadow (solid
arrows) is seen through the C5–C6 foramen.

brachial plexus (Fig 14). In this case, repositioning
of the needle is recommended.
Although not all intraepineural (intraneu-
ral) injections lead to neurologic complications,
intraepineural injections are considered a ma-
jor risk factor for nerve damage (100,101). In
addition, extraepineural injection is reportedly
more effective than intraepineural injection in the
management of lumbar radiculopathy (102). At
imaging, intraepineural injection manifests as two
thin lines resembling a so-called tram track, with
a subtle feathery appearance inside the nerve
root and sharp outlines (Fig 14) (71). With an
intraepineural injection, the patient would have
severe radiating pain along the nerve territory.
Regarding intraneurally injected drugs, lidocaine
was found to produce hyperalgesia and much de-
position of inflammatory cells in the dorsal root
ganglion of rats (103). Such hyperalgesia and
inflammation would occur in patients in whom
lidocaine is injected into the spinal nerve roots.
Therefore, even if a test dose of contrast agent
is injected into the nerve root, administration of
additional drugs must be avoided.
Disk Injury
The incidence of intradiscal injection ranges
from 0.002% (six in 2412 patients) to 2.4% (six
in 251 patients) (104,105). Inadvertent intradis-
cal injections mostly occur during transforami-
nal ESI, and ipsilateral foraminal stenosis and
far-lateral disk herniation are considered to be
contributing factors (104,106,107) (Fig 3a). The
most serious complication of inadvertent disk
injection is chemical inflammatory discitis, which
also carries risk for accelerating disk degenera-
tion (108). Disk injury is likely to happen when
the needle advances too ventrally (Fig 3c). The
horizontal flow into the disk should be perceived,
and the needle should be repositioned dorsally
(Fig 3b, 3c). Preprocedural intravenous antibiot-
ics have been used as in the recommendation for
discography, but postprocedural antibiotics are
barely used (109). Although, to our knowledge,
no study has yet been conducted on the use of
antibiotics after disk injury during ESI, on the
basis of discography cases, antibiotics would be
the preferred treatment in such cases.
Special Indications
C2 Nerve Root Block
A C2 nerve root block is rarely required for
diagnostic or therapeutic purposes in patients
with cervicogenic headache or occipital neuralgia.
Cervicogenic headache is a headache syndrome
arising from degeneration of the cervical spine,
which is innervated by the C1–C3 nerve root
branches (110). The characteristics of cervicogenic
pain include unilaterality without side shift (unlike
symptoms of migraine), pain provocation with
neck movement, sustained backward tilting of the
head, external pressure on the occipital or higher
cervical region of the symptomatic side, limited
movement of the neck, and nonradicular ipsilateral
shoulder pain (110). The International Association
for the Study of Pain considered pain reduction
after a C2 nerve root block a characteristic of cer-
vicogenic headache (111). Occipital neuralgia is a
specific type of headache, of which 90% of cases
are isolated to the sensory territories of the greater
occipital nerve and 10% to the lesser occipital
nerve (112). Studies (113) have indicated that C2
or C3 nerve root blocks resulted in pain reduc-
tion in the relatively short term. Technically, a C2
nerve root block can be performed with fluoros-
copy if the structural anatomy is well known. The
patient is positioned prone and asked to flex the
RG • Volume 37 Number 2 Shim et al 557

Figure 15. C2 nerve root block. (a) Axial T2-weighted MR image with color overlay shows the safe zone (green
arrow) in the lateral third of the C1–C2 articulation for a C2 nerve root block. The dorsal nerve root (DNR) has a
small bulge (yellow ovals) called the dorsal root ganglion (DRG). The ventral nerve root (VNR) and dorsal nerve
root fuse and form a spinal nerve. Red circles = vertebral arteries (VA), white lines = C1 lateral masses. (b) Sagit-
tal T2-weighted MR image shows the C1–C2 neural foramen. In the sagittal plane, the C2 dorsal root ganglion
(yellow circle) is positioned in the anterior half of the C1 posterior neural arch. Dashed line = imaginary line of
the C1 posterior neural arch, yellow line = spinal nerve. (c, d) C2 nerve root block performed with single-plane
fluoroscopy in an 82-year-old woman with occipital neuralgia. (c) AP image with the patient in the prone posi-
tion shows contrast agent flowing along the C2 nerve root (arrows). The dotted lines outline the C1 right lateral
mass. (d) Lateral image shows the needle tip at the midline of the C1 posterior neural arch (dashed line). Fuzzy
contrast agent flow is seen at the C1–C2 neural foramen.

neck, and the skin is meticulously sterilized above
the hairline. The “safe zone” is the lateral third of
the space between two lines visualized along the
medial and lateral margins of the C1 lateral mass
(Fig 15a, 15c). To avoid vertebral artery puncture,
the needle tip should never go beyond the lateral
margin of the lateral mass. To avoid C2 dorsal
root ganglion injury, the needle should stay within
the lateral third of the lateral mass. After proper
targeting and advancement, the needle is advanced
to arrive at the midline of the level of the C1 pos-
terior neural arch as seen on the lateral view (Fig
15b, 15d). At our institution, we administer 10 mg
(2 mL) of dexamethasone by using a 5-mL syringe
and a 25-gauge spinal needle.
Postoperative Spine
Because lumbar interlaminar ESI is not appli-
cable in the postoperative spine, which has an
effaced epidural space, lumbar transforaminal
ESI may be considered. Because the postopera-
tive spine (primarily a spine that has undergone
decompressive procedures) lacks the original
relevant bone anatomy (ie, the spinous processes,
laminae, and parts of the facet joints have been
removed), epidural injection could be difficult.
To overcome these anatomic changes, one needs
to imagine the original anatomy with reference
to the remaining structures above or beneath. It
is helpful to recall the fact that screws traverse
pedicles (Fig 16b). Facet joints fused with bone
chips could form a large bony mass around the
original facet joint, a situation in which a larger
oblique angle than usual is required to secure the
needle route (Fig 16). Caudal injection is another
option for the postoperative spine. However,
there may be inadequate spread of the injectate
because of scar tissue (114,115).
558 March-April 2017
Figure 16. Anatomy for left L4–L5 transforaminal injection in a patient who had undergone L2–L4 posterior instru-
mentation, laminectomy, and intra-articular facet fusion. (a) Coronal reconstructed CT image shows large bone chips
(arrow). (b) Oblique fluoroscopic image shows that the large bone chips (arrows) interrupt the trajectory for a transfo-
raminal injection. Dotted lines = imagined original anatomy on the basis of the pedicle screws and remaining spinous
processes.
Conclusion
Cervical and lumbar ESIs are well-established
effective treatment options that will be performed
more frequently in the future because of the
increase in the number of elderly people with
chronic spinal pain. Given the rapid increase in the
use of spinal interventions, it is important for radi-
ologists to know the common indications for epi-
dural injections and to understand the dedicated
anatomy and procedures. Informing themselves
and honing their skills, distinguishing findings of
accurate needle placement from those of incorrect
needle placement, and recognizing possible com-
plications will help radiologists remain up to date
and qualified to perform spinal interventions.
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