Understanding the Landscape of Lumbar Epidural Steroid Injections: A Review of Interlaminar, Transforaminal, and Caudal Approaches.

Purpose of the Review: Lumbar epidural steroid injections (ESIs) have been used for decades for managing lumbosacral pain, particularly in patients with radiculopathy and chronic low back pain. Despite frequent use, there remains debate regarding their overall effectiveness, fueled by variability in physician technique and differing opinions on the optimal approach. This narrative review examines the three primary methods of lumbar ESI administration-transforaminal, interlaminar, and caudal-to evaluate their respective advantages, limitations, and clinical applications. Summary: Each ESI technique offers unique benefits and potential risks. The transforaminal approach provides targeted delivery to affected nerve roots but is associated with higher risks of complications such as nerve injury or vascular compromise. The interlaminar approach allows broader spread of injectate with a lower technical complexity but may lack precision in targeting the specific source of pain. The caudal approach, typically reserved for patients with altered spinal anatomy or prior lumbar surgery, offers the safest trajectory but often the least precise medication delivery. Outcomes with ESIs are highly variable, which contributes to the ongoing debate about their role in lumbosacral pain management. Conclusion: Understanding the technical differences, risk profiles, and clinical indications of each lumbar ESI approach can help guide treatment planning and optimize outcomes. By tailoring the injection technique to the individual patient's anatomy and clinical presentation, physicians may improve both the efficacy and safety of epidural steroid injections in the treatment of lumbosacral pain.