TECHNIQUE: Under fluoroscopy, needle entry site and pathway are drawn according to the spinal anatomy. The needle is advanced toward the lateral recess and the needle tip is placed medially to the medial border of the pedicle under anteroposterior view and posteriorly to the posterior border of the upper endplate under lateral view. After checking optimal contrast spread, steroids and local anesthetics are injected.
CASE ILLUSTRATION: An 86-year-old woman who suffered from lower back pain with radiculopathy received interventional treatment. Comparing the "traditional" supraneural approach with the FLLR approach, the difference in contrast enhancement to lateral recess is clearly shown.
DISCUSSION: Compared to the pre-existing approaches, the FLLR approach may provide better ventral epidural and lateral recess enhancement. Furthermore, with the advanced needle tip, the injectate may enhance not only the at-level nerve root but also the nerve root of adjacent level during their existence in a single injection. With blunt needle usage, no nerve root injury or dura puncture was noted so far.
CONCLUSION: FLLR TFESI is a modified fluoroscopic technique targeted on lateral recess and anterior epidural space. However, subsequent trials are needed to confirm its efficacy in pain reduction and the rate of complications.