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Skeletal Radiol. 2013 Dec;42(12):1683-92. doi: 10.1007/s00256-013-1713-5. Epub 2013 Aug 31.

Access routes and reported decision criteria for lumbar epidural drug injections: a systematic literature review.

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Department of Radiology, University Hospital Zurich, Ramistrasse 100, CH 8091, Zurich, Switzerland,



To review lumbar epidural drug injection routes in relation to current practice and the reported criteria used for selecting a given approach.


This was a HIPPA-compliant study. Employing a systematic search strategy, the MEDLINE and EMBASE databank as well as the Cochrane Library were searched for studies on epidural drug injections. The following data were noted: access route, level of injection, use of image guidance, and types and doses of injected drugs. Justifications for the use of a particular route were also noted. Data were presented using descriptive statistics.


A total of 1,211 scientific studies were identified, of which 91 were finally included (7.5%). The interlaminar access route was used in 44 of 91 studies (48.4%), the transforaminal in 37 of 91 studies (40.7%), and the caudal pathway in 26 of 91 studies (28.6%). The caudal pathway was favored in the older studies whereas the transforaminal route was favored in recent studies. Decision criteria related to correct needle placement, concentration of injected drug at lesion site, technical complexity, costs, and potential complications. Injection was usually performed on the level of the lesion using local anesthetics (71 of 91 studies, 78.0%), steroids (all studies) and image guidance (71 of 91 studies, 78%).


The most commonly used access routes for epidural drug injection are the interlaminar and transforaminal pathways at the level of the pathology. Transforaminal routes are being performed with increasing frequency in recent years.

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