Objective: This study compared the effectiveness of transforaminal epidural steroid injection (TFESI) alone with that of combined transforaminal and caudal epidural steroid injection (CESI) in multi-level lumbar disc disease, which does not require surgery and does not respond to conservative treatment. Materials and Methods: A total of 99 patients, who were administered TFESI alone or in combination with CESI for radicular pain between November 2018 and August 2019, were analysed retrospectively. Results: The visual analogue scale (VAS) and the Oswestry Disability index (ODI) scores of the patients were evaluated in the pre-injection and post-injection periods in the 3rd week, 3rd month and 6th month. Both the ODI and VAS scores were significantly lower in the early and late post-injection periods than in the pre-injection period in both groups. Combined TFESI and CESI for multi-level lumbar disc disease provided significant improvement in pain management and functional capacity compared with TFESI alone. Conclusion: Combined transforaminal and CESIs should be considered in patients with multi-level lumbar disc disease, which is difficult to manage.


Bush K, Cowan N, Katz DE, Gishen P. The natural history of sciatica associated with disc pathology. A prospective study with clinical and independent radiologic follow-up. Spine. 1992;17:1205-12.

Colonna PC, Friedenberg ZB. The disc syndrome; results of the conservative care of patients with positive myelograms. J Bone Joint Surg Am. 1949;31:614-8.

Carey TS, Garrett JM, Jackman AM. Beyond the good prognosis. Examination of an inception cohort of patients with chronic low back pain. Spine. 2000;25:115-20.

Saal JA, Saal JS. Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy. An outcome study. Spine. 1989;14:431-7.

Saal JA, Saal JS, Herzog RJ. The natural history of lumbar intervertebral disc extrusions treated nonoperatively. Spine. 1990;15:683-6.

Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990;72:403-8.

Schwarzenbach O, Rohrbach N, Berlemann U. Segment-by-segment stabilization for degenerative disc disease: a hybrid technique. Eur Spine J. 2010;19:1010-20.

Benyamin RM, Manchikanti L, Parr AT, Dawan S, Sing V, Falcoet EJE, et al. The effectiveness of lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain. Pain Physician. 2012;15:E363-404.

Ghahreman A, Ferch R, Bogduk N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Med. 2010;11:1149-68.

Jeong HS, Lee JW, Kim SH, Myung JS, Kim JH, Kang HS. Effectiveness of transforaminal epidural steroid injection by using a preganglionic approach: a prospective randomized controlled study. Radiology. 2007;245:584-90.

Lutz GE, Vad VB, Wisneski RJ. Fluoroscopic transforaminal lumbar epidural steroids: an outcome study. Arch Phys Med Rehabil. 1998;79:1362-6.

Manchikanti L, Boswell MV, Singh V, Ramsin M Benyamin, Bert Fellows, Salahadin Abdi, et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. 2009;12:699-802.

Riew KD, Yin Y, Gilula L, Bridwell KH, Lenke LG, Lauryssen C, et al. The effect of nerve-root injections on the need for operative treatment of lumbar radicular pain. A prospective, randomized, controlled, double-blind study. J Bone Joint Surg Am. 2000;82:1589-93.

Lee JW, Kim SH, Choi JY, Yeom JS, Kim KJ, Chung SK, et al. Transforaminal epidural steroid injection for lumbosacral radiculopathy: preganglionic versus conventional approach. Korean J Radiol. 2006;7:139-44.

Lee JW, Kim SH, Lee IS, Choi JA, Choi JY, Hong SH, et al. Therapeutic effect and outcome predictors of sciatica treated using transforaminal epidural steroid injection. AJR Am J Roentgenol. 2006;187:1427-31.

Boos N, Aebi M (Eds.). Spinal Disorders. Springer-Verlag Berlin Heidelberg, Berlin 2008.

Leven D, Passias PG, Errico TJ, Lafage V, Bianco K, Lee A, et al. Risk factors for reoperation in patients treated surgically for intervertebral disc herniation: A subanalysis of eight-year SPORT data. J Bone Joint Surg Am. 2015;97:1316-25.

Wang Q, Liu J, Shi Y, Chen Y, Yu H, Ma J, et al. Short-term effects of a dynamic neutralization system (Dynesys) for multi-segmental lumbar disc herniation. Eur Spine J. 2016;25:1409-16.

Beyaz SG. Comparison of transforaminal and interlaminar epidural steroid injections for the treatment of chronic lumbar pain. Braz J Anesthesiol. 2017;67:21-7.

Manchikanti L, Buenaventura RM, Manchikanti KN, Ruan X, Gupta S, Smith HS, et al. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician. 2012;15:E199-245.

Ogoke BA. Caudal epidural steroid injections. Pain Physician. 2000;3:305-12.

Pountos I, Panteli M, Walters G, Bush D, Giannoudis PV. Safety of epidural corticosteroid injections. Drugs in R&D. 2015;16:19-34.

Collighan N, Gupta S. Epidural steroids. Continuing Education in Anaesthesia, Critical Care & Pain. 2010;10:1-5.

Hashemi M, Dadkhah P, Taheri M, Ghasemi M, Hosseinpour A. Lumbar transforaminal epidural steroid injection in patients with lumbar radicular pain; outcome results of 2-year follow-up. Bull Emerg Trauma. 2019;7:144-9.

Vad VB, Bhat AL, Lutz GE, Cammisa F. Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study. Spine. 2002;27:11-5.

Roberts ST, Willick SE, Rho ME, Rittenberg JD. Efficacy of lumbosacral transforaminal epidural steroid injections: a systematic review. PM R. 2009;1:657-68.

Bush K, Hillier S. A controlled study of caudal epidural injections of triamcinolone plus procaine for the management of intractable sciatica. Spine. 1991;16:572-5.

Khanna V. Caudal epidural steroid injections-a mini review. Spine. 2017, doi: 10.19080/oajnn.2017.03.555606

Murakibhavi VG, Khemka AG. Caudal epidural steroid injection: a randomized controlled trial. Evid Based Spine Care J. 2011;2:19-26.

Singh V, Manchikanti L. Role of caudal epidural injections in the management of chronic low back pain. Pain Physician. 2002;5:133-48.

Kircelli A, Cansever T, Yılmaz C. The influence of adjunctive caudal epidural steroid injection on the therapeutic effect of transforaminal epidural steroid injection. Neurol India. 2018;66:90-5.

Manchikanti L, Singh V, Pampati V, Falco FJ, Hirsch JA. Comparison of the efficacy of caudal, interlaminar, and transforaminal epidural injections in managing lumbar disc herniation: is one method superior to the other? Korean J Pain. 2015;28:11-21.

Ökmen K, Ökmen BM. The efficacy of interlaminar epidural steroid administration in multilevel intervertebral disc disease with chronic low back pain: a randomized, blinded, prospective study. Spine J. 2017;17:168-74.

Singh JR, Cardozo E, Christolias GC. The clinical efficacy for two-level transforaminal epidural steroid injections. PMR. 2017;9:377-82.

Buenaventura RM, Datta S, Abdi S, Smith HS. Systematic review of therapeutic lumbar transforaminal epidural steroid injections. Pain Physician. 2009;12:233-51.

Gharibo CG, Fakhry M, Diwan S, Kaye AD. Conus medullaris infarction after a right L4 transforaminal epidural steroid injection using dexamethasone. Pain Physician. 2016;19:E1211-4.

Goodman BS, Posecion LW, Mallempati S, Bayazitoglu M. Complications and pitfalls of lumbar interlaminar and transforaminal epidural injections. Curr Rev Musculoskelet Med. 2008;1:212-22.

Makkar JK, Singh PM, Jain D, Goudra B. Particulate vs non-particulate steroids for transforaminal epidural steroid injections: Systematic review and meta-analysis of the current literature. Pain Physician. 2016;19:327-40.

Glaser SE, Shah RV. Root cause analysis of paraplegia following transforaminal epidural steroid injections: the ‘unsafe’ triangle. Pain Physician. 2010;13:237-44.

Manchikanti L, Cash KA, Pampati V, Damron KS, McManus CD. Evaluation of lumbar transforaminal epidural injections with needle placement and contrast flow patterns: a prospective, descriptive report. Pain Physician. 2004;7:217-23.

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