Lumbar Epidural Steroid Injection Approaches: A Practical Overview for Trainees

Lumbar epidural steroid injections (ESIs) are a commonly performed interventional procedure in the treatment of acute and chronic pain related spinal disorders. The three primary approaches to the epidural space include interlaminar, transforaminal, and caudal techniques, each with unique technical considerations, advantages, and limitations. The interlaminar approach allows broad epidural spread and is frequently utilized for multilevel pathology. The transforaminal approach enables more targeted delivery of medication near the affected nerve root, allowing for greater local drug concentration while also providing potential diagnostic value in identifying symptomatic nerve roots. The caudal approach provides a technically useful alternative in patients with prior lumbar surgery, scoliosis, or altered spinal anatomy and is associated with a favorable safety profile. This concise review summarizes the key teaching points of each lumbar ESI technique and provides representative fluoroscopic images to highlight the characteristic procedural views commonly encountered in clinical practice.