text: PROCEDURE:,  Left L5 transforaminal epidural steroid injection with 40 mg of Kenalog under fluoroscopic guidance.,INDICATIONS:  ,The patient is a 78-year-old female with back pain referring into the left side.  She has had a couple of epidurals in the past, both of which led to only short-term improvement with intralaminar and caudal placements.  Therefore, transforaminal approach was selected for today's procedure.,Risks and benefits were discussed with the patient.  She agreed to accept the risks and signed informed consent to proceed.,PROCEDURE DETAILS:,  The patient was placed prone on the table.  The skin was thoroughly cleansed with betadine swabs x3 and wiped off with a sterile gauze.  The subcutaneous intramuscular and interligamentous region was anesthetized with buffered 1% lidocaine.,A 5-inch, 22-gauge spinal needle was directed under intermittent fluoroscopic guidance using an oblique approach at the opening of the L5 nerve root.  Once bony contact was made, a lateral was obtained and showed the needle tip to be against the posterior spinal body in the anterior epidural space.  Then an AP view was obtained which showed the needle tip to be below the 6 o'clock position of the pedicle.,EPIDUROGRAM: , Omnipaque 300, 1 mL, was placed through the foraminal opening of the L5 nerve root on the left.  This did show dye spread pattern which was narrowed consistent with foraminal stenosis.  The dye did traverse the foraminal opening and was seen spreading around the pedicle into the anterior epidural space.  It was also spreading peripherally along the L5 nerve root.,The patient tolerated the procedure well.  She did feel that the needle tip was placed at the epicenter of her pain, and this was improved with the placement of the anesthetic.,I will see the patient back in the office in the next few weeks to monitor response of the injection.pain management, transforaminal approach, epidural steroid injection, nerve root, needle tip, kenalog, transforaminal, fluoroscopic, guidance, foraminal, injection