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•*1. Overview of Cervical Epidural Steroid Injection Approaches**
Cervical epidural steroid injections are performed via two principal techniques: interlaminar (ILESI) and transforaminal (TFESI). ILESI involves accessing the posterior epidural space through the interlaminar window, typically at the level of pathology, while TFESI targets the ventral epidural space adjacent to the affected nerve root via the neural foramen.[1-2] Both approaches are indicated for the management of cervical radiculopathy and, in some cases, axial neck pain due to disc herniation or spinal stenosis.[3-4]
•*2. Comparative Efficacy**
Current evidence from meta-analyses and randomized controlled trials demonstrates no significant difference in short- or long-term pain or disability outcomes between ILESI and TFESI for cervical radiculopathy.[3-7] While some studies report marginally greater early pain reduction with one approach (e.g., TFESI at 1 month, ILESI at 3 months), these differences are not consistent or sustained, and overall results are equivocal.[5][8-9] The American Academy of Neurology and the American Society of Anesthesiologists/American Society of Regional Anesthesia and Pain Medicine guidelines both state that neither approach is clearly superior for pain or functional outcomes.[4][10] Both techniques yield clinically meaningful improvements in a substantial proportion of patients, with responder rates for ≥50% pain reduction and ≥30% improvement in disability scores being similar at 6–12 months.[5][9]
•*3. Comparative Safety**
Large database analyses and guideline reviews indicate that overall neurologic complication rates are rare and similar for both ILESI and TFESI.[4][11-13] However, TFESI is associated with a higher odds of nerve root injury (OR 1.69) and a lower odds of epidural hematoma (OR 0.60) compared to ILESI.[11] Catastrophic complications such as paralysis or stroke are exceedingly rare but have been reported for both approaches, with TFESI carrying unique risks related to inadvertent intra-arterial injection due to proximity to vertebral and radicular arteries.[4][14] The use of non-particulate corticosteroids (e.g., dexamethasone) and strict image guidance is strongly recommended to mitigate these risks.[2][14] For ILESI, serious complications (e.g., dural puncture, spinal cord injury) are also rare and not increased at higher cervical levels when performed with appropriate technique.[12]
•*4. Clinical Decision-Making Considerations**
Selection of injection approach should be individualized, taking into account patient anatomy, pathology, and risk profile.[1][14] For example, TFESI may be preferred for unilateral radicular pain due to foraminal stenosis, while ILESI may be favored for central disc herniation or axial pain.[1][6] Guidelines from the American Academy of Neurology recommend tailoring the approach to the clinical scenario, with careful attention to procedural safety.[4] Advanced imaging and procedural techniques are essential for both approaches to optimize efficacy and minimize complications.[2][14]
•*5. Limitations and Gaps in Evidence**
The available literature is limited by heterogeneity in study design, small sample sizes, and a paucity of high-powered, cervical-specific randomized controlled trials.[3-4][13] Most studies are underpowered to detect rare but serious adverse events, and there is inconsistency in outcome measures and follow-up duration. Further research is needed to clarify optimal patient selection and refine procedural safety.
In summary, there is no significant difference in safety or efficacy between cervical interlaminar and transforaminal epidural steroid injection for radicular pain, according to current evidence and major guidelines. The choice of approach should be individualized, with strict adherence to safety protocols and consideration of patient-specific factors.
1.
Epidural Steroid Injections.
William J, Roehmer C, Mansy L, Kennedy DJ.
Physical Medicine and Rehabilitation Clinics of North America. 2022;33(2):215-231. doi:10.1016/j.pmr.2022.01.009.
2.
The Anatomy, Technique, Safety, and Efficacy of Image-Guided Epidural Access.
Maus T.
Radiologic Clinics of North America. 2024;62(2):199-215. doi:10.1016/j.rcl.2023.09.006.
3.
Comparison of Clinical Efficacy of Transforaminal and Interlaminar Epidural Steroid Injection in Radicular Pain Due to Cervical Diseases: A Systematic Review and Meta-Analysis.
Lee JH, Lee Y, Park HS, Lee JH.
Pain Physician. 2022;25(9):E1351-E1366.
4.
Epidural Steroids for Cervical and Lumbar Radicular Pain and Spinal Stenosis Systematic Review Summary: Report of the AAN Guidelines Subcommittee.
Armon C, Narayanaswami P, Potrebic S, et al.
Neurology. 2025;104(5):e213361. doi:10.1212/WNL.0000000000213361.
New Research
5.
One-Year Results From a Randomized Comparative Trial of Targeted Steroid Injection via Epidural Catheter Versus Standard Transforaminal Epidural Injection for the Treatment of Unilateral Cervical Radicular Pain.
Conger A, Kendall RW, Sperry BP, et al.
Regional Anesthesia and Pain Medicine. 2021;46(9):813-819. doi:10.1136/rapm-2021-102514.
6.
Comparison of Clinical Efficacy Between Interlaminar and Transforaminal Epidural Injection in Patients With Axial Pain Due to Cervical Disc Herniation.
Lee JH, Lee SH.
Medicine. 2016;95(4):e2568. doi:10.1097/MD.0000000000002568.
7.
Comparison of Contrast Flow and Clinical Effectiveness Between a Modified Paramedian Interlaminar Approach and Transforaminal Approach in Cervical Epidural Steroid Injection.
Choi E, Nahm FS, Lee PB.
British Journal of Anaesthesia. 2015;115(5):768-74. doi:10.1093/bja/aev342.
8.
Comparative Effectiveness of Parasagittal Interlaminar and Transforaminal Cervical Epidural Steroid Injection in Patients With Cervical Radicular Pain: A Randomized Clinical Trial.
Sim JH, Park H, Kim Y, et al.
Pain Physician. 2021;24(2):117-125.
9.
A Randomized Comparative Trial of Targeted Steroid Injection via Epidural Catheter vs Standard Transforaminal Epidural Injection for the Treatment of Unilateral Cervical Radicular Pain: Six-Month Results.
McCormick ZL, Conger A, Sperry BP, et al.
Pain Medicine (Malden, Mass.). 2020;21(10):2077-2089. doi:10.1093/pm/pnaa242.
10.
Practice Guidelines for Chronic Pain Management: An Updated Report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine.
Anesthesiology. 2010;112(4):810-33. doi:10.1097/ALN.0b013e3181c43103.
Practice Guideline
11.
Comparable Overall Risk of Neurologic Adverse Events Following Cervicothoracic Interlaminar and Transforaminal Epidural Injections: An Analysis of 1.29 Million Patients.
Seddio AE, McNamara KF, Gouzoulis MJ, et al.
Spine. 2024;:00007632-990000000-00809. doi:10.1097/BRS.0000000000005181.
New Research
12.
Safety of Interlaminar Cervical Epidural Injections: Experience With 12,168 Procedures in a Single Pain Clinic.
Schultz DM, Hagedorn JM, Abd-Elsayed A, Stayner S.
Pain Physician. 2022;25(1):49-58.
13.
Cervical Transforaminal Epidural Steroid Injections for Radicular Pain : A Systematic Review.
Borton ZM, Oakley BJ, Clamp JA, Birch NC, Bateman AH.
The Bone & Joint Journal. 2022;104-B(5):567-574. doi:10.1302/0301-620X.104B5.BJJ-2021-1816.R1.
14.
Risks and Benefits of Cervical Transforaminal Epidural Steroid Injections: A Comprehensive Review.
Hasoon J, Brown A, Moauro A, Viswanath O, Abd-Elsayed A.
Current Pain and Headache Reports. 2025;29(1):72. doi:10.1007/s11916-025-01385-0.
New Research
Cervical epidural steroid injections are performed via two principal techniques: interlaminar (ILESI) and transforaminal (TFESI). ILESI involves accessing the posterior epidural space through the interlaminar window, typically at the level of pathology, while TFESI targets the ventral epidural space adjacent to the affected nerve root via the neural foramen.[1-2] Both approaches are indicated for the management of cervical radiculopathy and, in some cases, axial neck pain due to disc herniation or spinal stenosis.[3-4]
•*2. Comparative Efficacy**
Current evidence from meta-analyses and randomized controlled trials demonstrates no significant difference in short- or long-term pain or disability outcomes between ILESI and TFESI for cervical radiculopathy.[3-7] While some studies report marginally greater early pain reduction with one approach (e.g., TFESI at 1 month, ILESI at 3 months), these differences are not consistent or sustained, and overall results are equivocal.[5][8-9] The American Academy of Neurology and the American Society of Anesthesiologists/American Society of Regional Anesthesia and Pain Medicine guidelines both state that neither approach is clearly superior for pain or functional outcomes.[4][10] Both techniques yield clinically meaningful improvements in a substantial proportion of patients, with responder rates for ≥50% pain reduction and ≥30% improvement in disability scores being similar at 6–12 months.[5][9]
•*3. Comparative Safety**
Large database analyses and guideline reviews indicate that overall neurologic complication rates are rare and similar for both ILESI and TFESI.[4][11-13] However, TFESI is associated with a higher odds of nerve root injury (OR 1.69) and a lower odds of epidural hematoma (OR 0.60) compared to ILESI.[11] Catastrophic complications such as paralysis or stroke are exceedingly rare but have been reported for both approaches, with TFESI carrying unique risks related to inadvertent intra-arterial injection due to proximity to vertebral and radicular arteries.[4][14] The use of non-particulate corticosteroids (e.g., dexamethasone) and strict image guidance is strongly recommended to mitigate these risks.[2][14] For ILESI, serious complications (e.g., dural puncture, spinal cord injury) are also rare and not increased at higher cervical levels when performed with appropriate technique.[12]
•*4. Clinical Decision-Making Considerations**
Selection of injection approach should be individualized, taking into account patient anatomy, pathology, and risk profile.[1][14] For example, TFESI may be preferred for unilateral radicular pain due to foraminal stenosis, while ILESI may be favored for central disc herniation or axial pain.[1][6] Guidelines from the American Academy of Neurology recommend tailoring the approach to the clinical scenario, with careful attention to procedural safety.[4] Advanced imaging and procedural techniques are essential for both approaches to optimize efficacy and minimize complications.[2][14]
•*5. Limitations and Gaps in Evidence**
The available literature is limited by heterogeneity in study design, small sample sizes, and a paucity of high-powered, cervical-specific randomized controlled trials.[3-4][13] Most studies are underpowered to detect rare but serious adverse events, and there is inconsistency in outcome measures and follow-up duration. Further research is needed to clarify optimal patient selection and refine procedural safety.
In summary, there is no significant difference in safety or efficacy between cervical interlaminar and transforaminal epidural steroid injection for radicular pain, according to current evidence and major guidelines. The choice of approach should be individualized, with strict adherence to safety protocols and consideration of patient-specific factors.
1.
Epidural Steroid Injections.
William J, Roehmer C, Mansy L, Kennedy DJ.
Physical Medicine and Rehabilitation Clinics of North America. 2022;33(2):215-231. doi:10.1016/j.pmr.2022.01.009.
2.
The Anatomy, Technique, Safety, and Efficacy of Image-Guided Epidural Access.
Maus T.
Radiologic Clinics of North America. 2024;62(2):199-215. doi:10.1016/j.rcl.2023.09.006.
3.
Comparison of Clinical Efficacy of Transforaminal and Interlaminar Epidural Steroid Injection in Radicular Pain Due to Cervical Diseases: A Systematic Review and Meta-Analysis.
Lee JH, Lee Y, Park HS, Lee JH.
Pain Physician. 2022;25(9):E1351-E1366.
4.
Epidural Steroids for Cervical and Lumbar Radicular Pain and Spinal Stenosis Systematic Review Summary: Report of the AAN Guidelines Subcommittee.
Armon C, Narayanaswami P, Potrebic S, et al.
Neurology. 2025;104(5):e213361. doi:10.1212/WNL.0000000000213361.
New Research
5.
One-Year Results From a Randomized Comparative Trial of Targeted Steroid Injection via Epidural Catheter Versus Standard Transforaminal Epidural Injection for the Treatment of Unilateral Cervical Radicular Pain.
Conger A, Kendall RW, Sperry BP, et al.
Regional Anesthesia and Pain Medicine. 2021;46(9):813-819. doi:10.1136/rapm-2021-102514.
6.
Comparison of Clinical Efficacy Between Interlaminar and Transforaminal Epidural Injection in Patients With Axial Pain Due to Cervical Disc Herniation.
Lee JH, Lee SH.
Medicine. 2016;95(4):e2568. doi:10.1097/MD.0000000000002568.
7.
Comparison of Contrast Flow and Clinical Effectiveness Between a Modified Paramedian Interlaminar Approach and Transforaminal Approach in Cervical Epidural Steroid Injection.
Choi E, Nahm FS, Lee PB.
British Journal of Anaesthesia. 2015;115(5):768-74. doi:10.1093/bja/aev342.
8.
Comparative Effectiveness of Parasagittal Interlaminar and Transforaminal Cervical Epidural Steroid Injection in Patients With Cervical Radicular Pain: A Randomized Clinical Trial.
Sim JH, Park H, Kim Y, et al.
Pain Physician. 2021;24(2):117-125.
9.
A Randomized Comparative Trial of Targeted Steroid Injection via Epidural Catheter vs Standard Transforaminal Epidural Injection for the Treatment of Unilateral Cervical Radicular Pain: Six-Month Results.
McCormick ZL, Conger A, Sperry BP, et al.
Pain Medicine (Malden, Mass.). 2020;21(10):2077-2089. doi:10.1093/pm/pnaa242.
10.
Practice Guidelines for Chronic Pain Management: An Updated Report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine.
Anesthesiology. 2010;112(4):810-33. doi:10.1097/ALN.0b013e3181c43103.
Practice Guideline
11.
Comparable Overall Risk of Neurologic Adverse Events Following Cervicothoracic Interlaminar and Transforaminal Epidural Injections: An Analysis of 1.29 Million Patients.
Seddio AE, McNamara KF, Gouzoulis MJ, et al.
Spine. 2024;:00007632-990000000-00809. doi:10.1097/BRS.0000000000005181.
New Research
12.
Safety of Interlaminar Cervical Epidural Injections: Experience With 12,168 Procedures in a Single Pain Clinic.
Schultz DM, Hagedorn JM, Abd-Elsayed A, Stayner S.
Pain Physician. 2022;25(1):49-58.
13.
Cervical Transforaminal Epidural Steroid Injections for Radicular Pain : A Systematic Review.
Borton ZM, Oakley BJ, Clamp JA, Birch NC, Bateman AH.
The Bone & Joint Journal. 2022;104-B(5):567-574. doi:10.1302/0301-620X.104B5.BJJ-2021-1816.R1.
14.
Risks and Benefits of Cervical Transforaminal Epidural Steroid Injections: A Comprehensive Review.
Hasoon J, Brown A, Moauro A, Viswanath O, Abd-Elsayed A.
Current Pain and Headache Reports. 2025;29(1):72. doi:10.1007/s11916-025-01385-0.
New Research
