Lumbar Interlaminar Epidural Steroid Injections: A Survey of Physician Techniques and Practice Variability

Background and/or Objectives: Interlaminar epidural steroid injections (ESIs) are widely used for chronic spinal pain caused by disc herniation and degenerative stenosis, primarily to reduce inflammation and improve function. The interlaminar approach enables broad medication distribution across multiple nerve roots. However, technical variations may influence efficacy and complication rates. This study examines interventional pain physician practice patterns, assessing technique differences, their clinical impact, and potential for standardization.

Design: A nationwide, anonymous cross-sectional survey was conducted to examine the practice styles of interventional pain physicians performing interlaminar ESIs. A broad array of topics were covered but this analysis focuses on LOR technique, epidural access methods, and contrast spread patterns in lumbar ESIs.

Setting : A survey link was distributed via email and social media to academic physicians in ACGME-approved fellowship training programs and practicing interventional pain physicians across academic, hospital-based, and private practice settings.

Participants : 96 interventional pain physicians who perform ESIs were surveyed. By physician specialty, 75.0% were anesthesiologists, 18.8% were physiatrists, 4.2% were neurologists, 1.0% were radiologists, and 1.0% were emergency medicine physicians. By practice setting, 52.6% were academic-based employees, 20.0% were private practice employees, 19.0% were hospital-based employees, and 8.4% were private practice owners or partners.

Interventions: N/A

Main Outcome Measures: Outcomes included proportions of preferred LOR technique (saline versus air), use of ipsilateral versus paramedian access, and consistency of bilateral contrast spread during midline ESIs.

Results: Among 92 respondents, 53.3% use LOR to saline, while 42.4% use LOR to air. When accessing the epidural space, 80.4% prefer an ipsilateral approach to the side of pathology, and 24.2% prefer a paramedian approach. For midline ESIs, only 4.4% consistently achieve bilateral contrast spread.

Conclusions: Despite widespread use, significant variability exists in ESI technique. While consensus guidelines offer safety recommendations, standardization remains limited. Identifying common practices can help refine techniques and optimize patient outcomes.