Targeted Treatment for Lumbar Disc Herniation (Transforaminal Epidural Injection)

Transforaminal epidural injection (targeted injection treatment) is an imaging-guided injection of medication directly into the affected area to reduce inflammation, swelling and associated pain around the nerve root in patients with pain radiating down the leg (radicular pain) due to lumbar disc herniation. Completed in 15–20 minutes under local anaesthesia, it is an interventional pain treatment used in non-surgical management of lumbar disc herniation, with demonstrated short-term effectiveness for leg pain.

What Is a Transforaminal Epidural Injection (Targeted Treatment), and How Is It Performed?

It is a scientific treatment method used effectively in non-surgical management of lumbar disc herniation. A lumbar disc herniation causes severe pain by pressing on sensitive nerve roots within the spinal canal. In an epidural injection, this area is reached with a special needle/cannula under advanced imaging guidance, and medication chosen according to the patient’s clinical condition (primarily local anaesthetic and steroid, with additional drugs in some patients) is administered into the epidural space. The main aims of this treatment are:

• Reducing Inflammation: It helps reduce the swelling and inflammation that create pressure around the nerve root. The treatment aims to reduce pain caused by this inflammation.
• Effect on Tissue Adhesions: It contributes to releasing tissue adhesions in the area.

Procedure and Duration

• Preparation: No extensive preparation period is required before the procedure.
• Comfort: It is performed entirely under local anaesthesia, although mild sedation may also be given if needed.
• Duration: The procedure takes an average of 15–20 minutes.
• Discharge: Our patients are discharged following a short period of clinical observation, approximately 30–60 minutes after the procedure.

Can Targeted Treatment Avoid Lumbar Disc Surgery? (Success Rates)

Yes, when patients are appropriately selected, targeted treatment (transforaminal epidural steroid injection) reduces the need for surgery. In a study of patients already selected for surgery, 71% of those receiving the injection no longer required an operation, compared with 33% in the local-anaesthetic-only group [1]. Of those who avoided surgery, 81% still had not undergone an operation five years later [2].

Scientific studies demonstrate this treatment’s effectiveness for herniation-related leg pain at the strongest level of evidence [3, 4]. According to a current guideline review, epidural steroid injections reduce pain and limitations in mobility in the short term. Evidence for long-term effects is more limited [5, 7].

What Are the Risks and Side Effects of Targeted Treatment?

The rate of serious complications is low when targeted treatment is performed by specialist physicians under imaging (fluoroscopic) guidance using appropriate safety protocols. A study covering 16,638 procedures observed no serious complications such as permanent nerve damage, bleeding or infection [6]. Side effects are usually mild and temporary; the most common are a transient feeling of faintness due to a fall in blood pressure (vasovagal reaction, 1.2%), temporary steroid-related insomnia, facial flushing or headache (2.6%), and a temporary increase in pain (2.1%) [6]. Serious neurological complications have also been reported with transforaminal epidural injections, although rarely [4].

Which Herniations and Patients Can Be Treated with Targeted Injection?

Transforaminal epidural injection is one of the options that may be considered for patients with lumbar disc herniation who do not need emergency surgery, particularly for radicular pain radiating into the leg. Suitability is not determined by herniation size alone: the distribution of symptoms, neurological examination, MRI findings, level and location of the herniation, and whether a condition requiring surgery is present are assessed together. Nucleoplasty, another interventional pain procedure used for lumbar disc herniation, has more limited applications; disc structure and degree of herniation are determining factors. Beyond disc herniation, the procedure may be considered to relieve symptoms in some patients with spinal canal narrowing (lumbar spinal stenosis) who have not yet reached the threshold for surgery; however, evidence in these patients is weaker than for disc herniation [4, 7]. Epidural injections do not remove bone or tissue thickening in the spinal canal; the aim is symptom relief by reducing inflammation of nerve roots compressed within the narrowed canal.

Which Patients Are Not Suitable for Epidural Injection?

This treatment is unsuitable in the following circumstances:

• Active infection
• Uncontrolled bleeding risk
• Use of certain blood-thinning drugs (anticoagulants/antiplatelets)
• Severe uncontrolled metabolic conditions
• A history of serious allergy to the medications used

Epidural Injection Techniques

Three different techniques are used according to the patient’s anatomy, the location of the herniation and the extent of the condition:

1. Transforaminal Epidural Injection

This is the technique known as targeted injection. It is delivered only into the small, confined area containing the herniation and nerve compression, making it a frequently preferred approach for radicular pain due to disc herniation. Favourable results may be obtained particularly in recent-onset acute radicular pain. (You can watch our related animation at the top of this page.)

2. Interlaminar Epidural Injection

This is a widely used conventional technique with established safety. It is more often preferred in extensive spinal canal narrowing (spinal stenosis) involving multiple spinal levels and in cases of multiple lumbar disc herniations.

3. Caudal Epidural Injection

This is another technique used for lumbar disc herniations affecting the lowest spinal levels (near the tailbone) and symptoms of canal narrowing in that region.

🩺 Physician’s Insight & Clinical Experience

As a spine surgeon who frequently performs interventional pain treatments, I have used this method in thousands of patients and can say this: epidural injection is a safe and highly effective treatment I use before surgery in patients who do not require emergency surgery. I treat a large proportion of my patients with this method without needing to operate. I assess each patient’s radiological and clinical findings together and develop the treatment plan accordingly. I perform the procedure in the operating theatre under fluoroscopic (X-ray) guidance. I choose the epidural injection technique according to the location of the herniation and the distribution of symptoms, and sometimes combine these three techniques.

We shared this experience in four clinical studies published in Turkish Neurosurgery that I co-authored and in which I performed all injections. These studies examined the results of transforaminal injections for differently located, extruded and recurrent lumbar disc herniations in series ranging from 305 to 1,632 patients [8, 9, 10, 11]. The studies are clinical series without control groups and with 12-week follow-up.

My patients’ main concerns are “cortisone use” and the “risk of paralysis”. Delivering the medication directly to the target under imaging guidance and watching the procedure live on screen minimises the risk of serious complications.

Frequently Asked Questions

What Is Targeted Treatment, and How Is It Performed?

It is a 15–20-minute interventional procedure in which a combination of medications (steroid and local anaesthetic) is injected under imaging guidance directly into the area where the herniated disc presses on the nerve.

What Is the Success Rate of Targeted Treatment?

In a small study of patients already selected for surgery, 71% of those receiving a cortisone-containing injection no longer needed surgery, compared with 33% in the local-anaesthetic-only group. Of those who avoided surgery, 81% remained without surgery five years later [1, 2].

Does Targeted Treatment Have Risks or Side Effects?

Yes, like any interventional procedure, it can have side effects; however, serious complications are rare when performed under fluoroscopic guidance with guideline-compliant technique. A large series of 16,638 procedures found no serious complications (permanent nerve damage, bleeding or infection). The most common effects were self-limiting, such as temporary faintness (vasovagal reaction, 1.2%) and a transient steroid response (2.6%) [6]; serious neurological complications have also been reported in the literature, although rarely [4].

How Many Days Does It Take for Targeted Treatment to Work?

In our clinical experience, the effect usually begins on day 3–4 after the procedure and becomes noticeable in most patients within the first 10 days. There may be short-lived relief immediately afterwards due to the local anaesthetic; this is temporary, and pain may persist until the main effect begins.

Does Targeted Treatment Completely Eliminate the Herniation?

No. The main purpose of an epidural injection is not to physically remove the herniated tissue but to reduce inflammation and pain around the nerve root. Some lumbar disc herniations may shrink spontaneously over time.

Which Medications Are Used in Targeted Treatment?

The main components are a local anaesthetic and a corticosteroid. The local anaesthetic helps reduce pain quickly, while the corticosteroid aims to reduce inflammation around the nerve root. Depending on the patient’s clinical condition, the physician may also choose additional medications (such as hyaluronidase or hypertonic NaCl); the medication composition and dose are individualised.

How Many Sessions Are Needed?

Most patients receive a single session; rarely, treatment may be repeated up to 3 sessions.

Does Targeted Treatment Provide a Lasting Solution?

For many patients, yes: most patients who avoided surgery have been shown to remain without surgery five years later [2]. Whatever method is used, lifestyle changes such as weight control and muscle strengthening are important for maintaining the result.

Is There a Risk of Paralysis with Targeted Treatment?

The risk of paralysis is very low. A large safety series found no permanent nerve damage [6]; because rare serious neurological complications have been reported in the literature, the risk is not entirely zero [4].

Can Targeted Treatment Be Used for Ruptured Lumbar Disc Herniations?

Yes, if there is no condition requiring emergency surgery. A clinical study of 305 patients with ruptured (extruded) lumbar disc herniation, co-authored by M. Levent Deniz, MD, who performed the injections, found the injection more effective in patients with a shorter duration of symptoms [10].

Is the Procedure Painful?

Because the procedure is performed under local anaesthesia, pain is generally mild and brief. The needle-entry area is first numbed with local anaesthetic; patients may feel a prick or pressure when the needle enters. Mild sedation (a relaxed, sleepy state) can also be used if needed for comfort.

Is Increased Pain After Targeted Treatment Normal?

Yes, the volume of medication entering the confined injection space can temporarily increase pressure on the nerve. Although this may increase pain during the first 24–48 hours, the sensation gives way to marked relief as the medications begin to work.

How Much Does Targeted Treatment Cost?

As treatment costs vary according to the patient and hospital conditions, a definite fee can only be determined after examination and review of imaging.

Which Specialist Performs Targeted Treatment in Istanbul?

One of the physicians performing targeted treatment in Istanbul is M. Levent Deniz, MD, a specialist in brain, nerve and spine surgery. He has administered epidural injections to thousands of patients; four clinical studies in which he performed all the injections were published in Turkish Neurosurgery [8, 9, 10, 11].

How Many Days Should I Rest After Treatment, and When Can I Return to Work?

In our clinical practice, two days of rest after the procedure is sufficient for most patients, who can usually return to work on the third day. For people doing heavy physical work, this period may be extended on the physician’s advice.

References

1. Riew KD, Yin Y, Gilula L, 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(11):1589-1593. PMID: 11097449. PubMed
2. Riew KD, Park JB, Cho YS, et al. Nerve root blocks in the treatment of lumbar radicular pain. A minimum five-year follow-up. J Bone Joint Surg Am. 2006;88(8):1722-1725. PMID: 16882893. PubMed
3. Ghahreman A, Ferch R, Bogduk N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Med. 2010;11(8):1149-1168. PMID: 20704666. PubMed
4. Manchikanti L, Knezevic NN, Navani A, et al. Transforaminal Epidural Steroid Injections: A Systematic Review and Meta-Analysis of Efficacy and Safety. Pain Physician. 2021;24(S1):S209-S232. PMID: 33492919. PubMed
5. American Academy of Neurology Guidelines Subcommittee. Epidural Steroids for Cervical and Lumbar Radicular Pain and Spinal Stenosis Systematic Review Summary: Report of the AAN Guidelines Subcommittee. Neurology. 2025. PMID: 39938000. PubMed
6. El-Yahchouchi CA, Plastaras CT, Maus TP, et al. Adverse Event Rates Associated with Transforaminal and Interlaminar Epidural Steroid Injections: A Multi-Institutional Study. Pain Med. 2016;17(2):239-247. PMID: 26593277. PubMed
7. Chou R, Hashimoto R, Friedly J, et al. Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis. Ann Intern Med. 2015;163(5):373-381. PMID: 26302454. PubMed
8. Adilay U, Guclu B, Deniz L, et al. Comparison of the Effect of Single Lumbar Transforaminal Epidural Steroid Injections for the Treatment of L4-5 and L5-S1 Paramedian Disc Herniation. Turk Neurosurg. 2019;29(2):279-284. PMID: 30649822. PubMed
9. Guclu B, Deniz L, Yuce Y, et al. Transforaminal Epidural Steroid Injection in the Treatment of Pain in Foraminal and Paramedian Lumbar Disc Herniations. Turk Neurosurg. 2020;30(3):394-399. PMID: 32020569. PubMed
10. Guclu B, Deniz L, Katar S, et al. Optimal Timing and Outcome of Transforaminal Epidural Steroid Injection for the Management of Radicular Pain due to Extruded Lumbar Disc Herniation. Turk Neurosurg. 2023;33(3):509-513. PMID: 36951037. PubMed
11. Adilay U, Deniz L, Sari MF, et al. Comparison of Single Lumbar Transforaminal Epidural Steroid Injections for Treatment of Early and Late Recurrent Lumbar Disc Herniation. Turk Neurosurg. 2024;34(4):660-665. PMID: 38874245. PubMed

• 👨‍⚕️ Author and medical reviewer of this content: M. Levent Deniz, MD – Brain, Nerve and Spine Surgeon
• ⚠️ Medical Disclaimer: This page is for information only; consult your doctor for diagnosis and treatment.