Practice Patterns of Physicians Who Perform Lumbar Interlaminar Epidural Steroid Injections: A Technical Survey

Introduction: Interlaminar epidural steroid injections (ESIs) are widely used for chronic spinal pain caused by disc herniation and degenerative stenosis. The interlaminar approach allows for broad medication distribution across multiple nerve roots. However, technical variations, including loss-of-resistance (LOR) technique and injection site selection, may influence efficacy and complication rates. This study examines practice patterns among interventional pain physicians, assessing technique variations and their clinical impact while exploring opportunities for standardization. Methods: A questionnaire was distributed to interventional pain physicians from a range of specialties and practice settings who perform ESIs. Practice parameters of lumbar ESIs were surveyed including loss-of-resistance (LOR) technique, methods of accessing the epidural space via the interlaminar approach, and contrast spread patterns when using the midline approach. Results: Among 92 respondents, 53.3% use LOR to saline, while 42.4% use LOR to air. When accessing the epidural space, 80.4% prefer an ipsilateral approach to the side of pain or pathology. Use of a paramedian approach showed wide variation, with 24.2% reporting "always", 33.0% "most of the time", 30.8% "sometimes", and 12.1% "rarely". For midline approaches, only 4.4% of physicians reported always achieving bilateral contrast spread. The majority noted achieving it "most of the time" (54.4%) or "sometimes" (36.7%). A minority indicated they rarely (2.2%) or never (2.2%) achieve bilateral spread when performing midline ILESIs. Conclusion: Despite widespread use, significant variability exists in ESI technique. While consensus guidelines offer safety recommendations, standardization remains limited. Identifying common practices can help refine techniques and improve patient outcomes.