Targeted Treatment for Lumbar Disc Herniation (Transforaminal Epidural Injection)

Transcript translated from Turkish (video audio remains in Turkish)

Hello everyone, I am Dr. Mehmet Levent Deniz, a specialist in brain, nerve and spine surgery. I will explain the transforaminal epidural injection, also known as a targeted injection, that I use in non-surgical treatment of lumbar disc herniations.

A transforaminal epidural injection is one of the epidural injection techniques and is the most effective of these for lumbar disc herniations. The procedure is performed under imaging guidance and local anaesthesia. After local anaesthesia, a spinal needle is guided with fluoroscopy to the area where the nerve is compressed. A small amount of contrast medium is given, and the needle position is checked on X-ray. A combination of a steroid, local anaesthetic, hyaluronidase and hypertonic sodium chloride is then injected. The aim is to reduce swelling and inflammation in the area, release any adhesions and shrink the herniated disc tissue in order to relieve the pressure causing pain.

The procedure takes 10 to 15 minutes. Patients are discharged after about 30 minutes of observation.

I wish you all pain-free and happy days. Stay well.

What Is Targeted Treatment for Lumbar Disc Herniation?

Targeted treatment (transforaminal epidural injection) is a non-surgical interventional pain treatment in which medication is injected around the nerve root under imaging guidance. A lumbar disc herniation causes severe pain by pressing on sensitive nerve roots within the spinal canal.

How Does Targeted Treatment for Lumbar Disc Herniation Work?

Targeted treatment relieves pain by reducing swelling and inflammation around the nerve root.

• 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.

How Is Targeted Treatment for Lumbar Disc Herniation Performed?

During the procedure, a special needle or cannula is guided to the nerve-root area using advanced imaging. Medication selected according to the patient’s clinical condition (primarily a local anaesthetic and steroid, with additional drugs in some patients) is administered into the epidural space.

• 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 risk of targeted treatment is low: a study covering 16,638 procedures observed no serious complications such as permanent nerve damage, bleeding or infection [6]. The rate of serious complications is low when specialist physicians perform the procedure under imaging (fluoroscopic) guidance using appropriate safety protocols. 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 used for patients with lumbar disc herniation who do not need emergency surgery, particularly for 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 algology procedure (interventional pain treatment) 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?

Patients with active infection, uncontrolled bleeding risk, severe uncontrolled metabolic conditions or a history of serious allergy to the medications used, or those taking certain blood-thinning medicines (anticoagulants or antiplatelets), are not suitable for this treatment.

Epidural Injection Techniques

Three techniques—transforaminal, interlaminar and caudal—are used according to the patient’s anatomy, the location of the herniation and the distribution of symptoms.

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, classic technique of proven reliability. It is more often preferred in extensive spinal canal narrowing (spinal stenosis) involving multiple spinal levels and in cases of multiple lumbar disc herniations.

Transcript translated from Turkish (video audio remains in Turkish)

An interlaminar epidural injection is an epidural injection technique preferred for patients with multiple lumbar disc herniations or spinal canal stenosis.

The procedure is performed under imaging guidance and local anaesthesia. After local anaesthesia, an epidural cannula is guided into the epidural space using fluoroscopy. A small amount of contrast medium is injected into the epidural space, and the needle position is checked on X-ray. A combination of a steroid, local anaesthetic, hyaluronidase and hypertonic sodium chloride is then injected. The aim is to reduce swelling and inflammation in the area, release any adhesions and shrink the herniated disc tissue in order to relieve the pressure causing pain.

The procedure takes 10 to 15 minutes. Patients are discharged after about 30 minutes of observation.

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.

Transcript translated from Turkish (video audio remains in Turkish)

A caudal epidural injection is an epidural injection technique preferred for patients with spinal canal stenosis and disc herniation affecting the lower levels.

The procedure is performed under imaging guidance and local anaesthesia. After local anaesthesia, an epidural needle is guided into the epidural space using fluoroscopy. A small amount of contrast medium is injected into the epidural space, and the needle position is checked on X-ray. A combination of a steroid, local anaesthetic, hyaluronidase and hypertonic sodium chloride is then injected. The aim is to reduce swelling and inflammation in the area, release any adhesions and shrink the herniated disc tissue in order to relieve the pressure causing pain.

The procedure takes 10 to 15 minutes. Patients are discharged after about 30 minutes of observation.

🩺 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 quite 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.

How Long Does Targeted Treatment for Lumbar Disc Herniation Take?

The procedure takes about 15–20 minutes.

How Long Will I Stay in Hospital After Targeted Treatment?

Patients are discharged after approximately 30–60 minutes of clinical observation following the procedure.

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].

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

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).

Is the Cortisone Used in Targeted Treatment Harmful?

The risk is low: because cortisone is delivered directly to a small area around the nerve root, very little enters the rest of the body. Temporary steroid-related effects such as insomnia, facial flushing or headache occur infrequently (2.6%) and resolve on their own [6]. Conditions such as diabetes are assessed before the procedure.

How Many Sessions Are Performed?

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?

Patients feel a mild prick or pressure; pain is generally mild and brief because the procedure is performed under local anaesthesia. 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.

Is Targeted Treatment Available in Public Hospitals?

Yes. Targeted treatment (epidural injection) is available in the algology (interventional pain treatment) and neurosurgery departments of some public and university hospitals. Availability and appointment procedures vary by hospital.

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 neurosurgery. 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].

What Should I Do After Targeted Treatment, and When Can I Return to Work?

Patients are discharged after approximately 30–60 minutes of clinical observation. For most patients, two days of rest after the procedure is sufficient, and they can 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 – Neurosurgery Specialist
• ⚠️ Medical Disclaimer: This page is for information only; consult your doctor for diagnosis and treatment.