Lumbar Epidural Steroid Injection (LESI) Competency Certification — Questions and Answers

Question 1: Which symptom should prompt the physician to schedule urgent follow-up (within 24-48 hours) rather than routine follow-up after LESI?

Mild headache resolved with rest and hydration
Temporary numbness in the injected dermatome lasting 2 hours
Mild soreness at injection site
New onset bowel or bladder dysfunction after the procedure (Correct answer)

Correct answer: New onset bowel or bladder dysfunction after the procedure

New bowel or bladder dysfunction after ESI may signal cauda equina compromise from an epidural hematoma or abscess, requiring urgent evaluation rather than watchful waiting.

Question 2: Radiation dose reduction during fluoroscopic LESI can be achieved by all of the following EXCEPT:

Using last-image hold rather than live fluoroscopy for static checks
Collimating the beam to the area of interest
Increasing distance between the image intensifier and the patient (Correct answer)
Using pulsed fluoroscopy rather than continuous

Correct answer: Increasing distance between the image intensifier and the patient

Increasing the distance between the image intensifier and the patient actually increases radiation dose to the patient; the intensifier should be kept as close to the patient as possible to minimize dose.

Question 3: Rapid disappearance of contrast on fluoroscopy during ESI, without epidural spread pattern, indicates:

Air in the epidural space
Intravascular injection — injection should be stopped immediately (Correct answer)
Intrathecal injection
Correct epidural placement

Correct answer: Intravascular injection — injection should be stopped immediately

Rapid vascular washout of contrast (disappearing within seconds without epidural spread) indicates intravascular needle placement; the procedure must be stopped, the needle repositioned, and contrast re-injected to confirm epidural placement.

Question 4: A patient fails to achieve any meaningful pain relief after two well-placed, image-guided LESI procedures. What is the most reasonable next step?

Continue injections indefinitely until some benefit is achieved
Reassess the diagnosis and consider alternative pain generators or surgical consultation (Correct answer)
Prescribe long-term bed rest
Perform a third injection with higher steroid dose

Correct answer: Reassess the diagnosis and consider alternative pain generators or surgical consultation

Failure to respond to two appropriately performed ESIs suggests the diagnosis may be incorrect or that surgical correction of a structural problem is needed; referral for reassessment and surgical consultation is appropriate.

Question 5: The duration of radicular symptoms most predictive of a successful response to LESI is:

Acute symptoms less than 3-4 weeks
Sub-acute radiculopathy (3-12 months) (Correct answer)
Pain present since childhood
Chronic pain lasting more than 5 years

Correct answer: Sub-acute radiculopathy (3-12 months)

Patients with sub-acute radiculopathy (3 weeks to 12 months) tend to show the best response to ESI, as sufficient neural inflammation is present but irreversible fibrosis has not yet developed.

Question 6: When LESI is used as a bridge therapy, the primary intent is to:

Replace the need for all other treatments
Provide permanent opioid-free pain management
Reduce inflammation and pain sufficiently to allow the patient to engage in conservative rehabilitation while natural history takes its course (Correct answer)
Cure the underlying structural pathology

Correct answer: Reduce inflammation and pain sufficiently to allow the patient to engage in conservative rehabilitation while natural history takes its course

As bridge therapy, LESI aims to reduce acute inflammatory pain enough for the patient to engage in physical therapy and allow the natural healing process (e.g., disc resorption) to proceed without requiring surgery.

Question 7: After an ESI, when is the optimal time to assess whether the injection was clinically effective?

Only after three injections in a series
12 months after injection
2-4 weeks after injection (allowing full steroid effect) (Correct answer)
Immediately upon leaving the procedure room

Correct answer: 2-4 weeks after injection (allowing full steroid effect)

The full anti-inflammatory effect of epidural corticosteroids takes 1-2 weeks to develop; re-evaluation at 2-4 weeks provides the best assessment of clinical benefit.

Question 8: The Spine Patient Outcomes Research Trial (SPORT) found that, at two-year follow-up, patients with lumbar disc herniation who received ESI compared to those who did not showed:

Dramatically superior long-term outcomes with ESI
ESI completely prevented the need for surgery in all patients
Similar outcomes to non-ESI patients, with ESI primarily offering short-term benefit (Correct answer)
ESI patients had significantly worse surgical outcomes

Correct answer: Similar outcomes to non-ESI patients, with ESI primarily offering short-term benefit

SPORT and other long-term studies show that at 2 years, outcomes for disc herniation patients who received ESI and those who did not are similar, confirming that ESI primarily provides short-term symptom relief rather than altering long-term natural history.

Question 9: Which condition is an ABSOLUTE contraindication to lumbar ESI?

Patient age over 80 years
Active systemic infection or local infection at the injection site (Correct answer)
Poorly controlled diabetes
Mild coagulopathy (INR 1.2)

Correct answer: Active systemic infection or local infection at the injection site

Active systemic infection or local skin infection at the injection site is an absolute contraindication to ESI because introducing a needle creates a pathway for infectious organisms to reach the epidural space.

Question 10: The lateral fluoroscopic view during interlaminar LESI is used primarily to confirm:

Needle depth (anterior-posterior positioning in the spinal canal) (Correct answer)
Absence of spondylolisthesis
Bilateral spread of contrast
Level identification

Correct answer: Needle depth (anterior-posterior positioning in the spinal canal)

The lateral view confirms that the needle tip is at the appropriate depth within the posterior epidural space and has not advanced too far anteriorly toward the intrathecal space or nerve roots.

Question 11: Which functional outcome measure, assessing disability from low back pain, is frequently used alongside pain scores in ESI outcome studies?

PHQ-9 depression screening
Modified Rankin Scale
Oswestry Disability Index (ODI) (Correct answer)
Glasgow Coma Scale

Correct answer: Oswestry Disability Index (ODI)

The Oswestry Disability Index is a validated, 10-item questionnaire measuring the impact of low back pain on daily activities and is widely used in ESI outcome research.

Question 12: A patient with uncontrolled coagulopathy (platelet count 40,000/μL) requires LESI. The appropriate action is:

Proceed with smaller needle gauge
Postpone until platelet count is optimized above acceptable threshold (typically 70,000-100,000/μL) (Correct answer)
Use ultrasound guidance only
Administer the injection at a higher lumbar level

Correct answer: Postpone until platelet count is optimized above acceptable threshold (typically 70,000-100,000/μL)

A platelet count below 70,000-100,000/μL significantly increases hemorrhagic risk; ASRA guidelines recommend optimizing platelet count before proceeding with neuraxial procedures.

Question 13: What is the primary neurotransmitter of the parasympathetic nervous system?

Acetylcholine (Correct answer)
Norepinephrine
Glutamate
Dopamine

Correct answer: Acetylcholine

Acetylcholine is the primary neurotransmitter of the parasympathetic nervous system. It is responsible for transmitting signals between nerve cells and plays a crucial role in regulating various bodily functions, such as digestion, heart rate, and relaxation. Acetylcholine acts as a chemical messenger, binding to receptors on target cells and initiating a response. It is released by parasympathetic neurons and helps in promoting rest and digestion, as opposed to the fight-or-flight response mediated by norepinephrine.

Question 14: The caudal epidural approach accesses the epidural space through which anatomical opening?

The interlaminar space at L5-S1
The posterior sacral foramina at S2-S4
The S1 neural foramen
The sacral hiatus at the base of the sacrum (Correct answer)

Correct answer: The sacral hiatus at the base of the sacrum

The sacral hiatus is a midline opening at the inferior end of the sacral canal formed by non-fusion of the S4-S5 laminae and is the entry point for the caudal approach.

Question 15: How long should patients typically be observed in recovery after an LESI before discharge?

Overnight admission
5-10 minutes
2-4 hours
15-30 minutes (Correct answer)

Correct answer: 15-30 minutes

Patients are typically observed for 15-30 minutes post-ESI to monitor for immediate complications such as vasovagal reactions, allergic responses, or unexpected motor block from local anesthetic.

Question 16: What is the recommended treatment for a confirmed postdural puncture headache that fails conservative management?

High-dose oral corticosteroids
Epidural blood patch (Correct answer)
Surgical dural repair
Repeat lumbar puncture

Correct answer: Epidural blood patch

An autologous epidural blood patch — injection of 15-20 mL of the patient's own blood into the epidural space — is the gold-standard treatment for PDPH that does not resolve with conservative measures.

Question 17: Which imaging modality is used for LESI guidance when fluoroscopy is contraindicated (e.g., pregnancy)?

Blind landmark technique
Ultrasound guidance (Correct answer)
CT guidance
MRI-guided injection

Correct answer: Ultrasound guidance

Ultrasound guidance avoids ionizing radiation and can be used for lumbar ESI when fluoroscopy is contraindicated, particularly in pregnancy, using real-time visualization of the ligamentum flavum and epidural space.

Question 18: A patient who received LESI reports complete resolution of radicular symptoms at one month. What is the most appropriate management?

Order repeat MRI to confirm disc resolution
Continue monitoring, encourage physical therapy, and avoid repeat injection if not needed (Correct answer)
Schedule surgical consultation for definitive treatment
Schedule immediately for a second injection prophylactically

Correct answer: Continue monitoring, encourage physical therapy, and avoid repeat injection if not needed

If symptoms have resolved after ESI, repeat injection is not indicated; the patient should pursue physical therapy and lifestyle modification to maintain the benefit and prevent recurrence.

Question 19: Which symptom after LESI should prompt immediate emergency evaluation for cauda equina syndrome?

Mild headache when standing
Bilateral leg weakness, saddle anesthesia, and bowel/bladder dysfunction (Correct answer)
Transient leg weakness for 2 hours
Mild soreness at the injection site

Correct answer: Bilateral leg weakness, saddle anesthesia, and bowel/bladder dysfunction

Bilateral leg weakness, saddle anesthesia, and bowel or bladder dysfunction suggest cauda equina syndrome, a neurological emergency requiring urgent imaging and possible surgical decompression.

Question 20: In which clinical scenario is LESI best supported by evidence as providing meaningful benefit?

Acute disc herniation with radiculopathy of less than 3 months duration (Correct answer)
Degenerative disc disease without neural compression
Lumbar spondylosis without canal stenosis
Chronic axial low back pain without radiculopathy lasting more than 2 years

Correct answer: Acute disc herniation with radiculopathy of less than 3 months duration

The strongest evidence supports LESI for acute radiculopathy from disc herniation of shorter duration, where the inflammatory component is active and corticosteroids can provide meaningful short-term benefit.

Question 21: Which fluoroscopic view is most useful for identifying the sacral hiatus before performing a caudal epidural injection?

Lateral view (Correct answer)
Caudal tilt AP view
Ipsilateral oblique view
Anteroposterior (AP) view

Correct answer: Lateral view

The lateral view clearly delineates the sacral hiatus, the sacrococcygeal junction, and the depth of the sacral canal, guiding correct needle angulation and depth.

Question 22: In transforaminal LESI under fluoroscopy, the oblique view is used to identify which landmark for needle placement?

The 'Scotty dog' silhouette to target the superior foramen (eye of the Scotty dog) (Correct answer)
The disc space
The spinous process
The sacral hiatus

Correct answer: The 'Scotty dog' silhouette to target the superior foramen (eye of the Scotty dog)

The oblique fluoroscopic view creates the 'Scotty dog' silhouette of the lumbar vertebra; the eye of the dog represents the pedicle, and the needle is targeted to the 6 o'clock position below the pedicle (superior foramen).

Question 23: In the event of a vasovagal reaction during LESI, the first-line treatment is:

Terminate the procedure and discharge immediately
Intravenous epinephrine 0.3 mg
Place patient supine, elevate legs, and administer IV fluids and atropine if bradycardic (Correct answer)
Administer oral antihistamines

Correct answer: Place patient supine, elevate legs, and administer IV fluids and atropine if bradycardic

Vasovagal reactions are managed by placing the patient supine with legs elevated to restore venous return, and IV atropine is given for symptomatic bradycardia.

Question 24: Digital subtraction angiography (DSA) during transforaminal LESI offers what advantage over standard fluoroscopy?

It shows disc morphology in real time
It measures epidural spread volume
It enhances detection of intravascular contrast uptake by subtracting the bony background (Correct answer)
It identifies the conus medullaris level

Correct answer: It enhances detection of intravascular contrast uptake by subtracting the bony background

DSA subtracts the static bony fluoroscopic image, leaving only contrast flow visible, which makes small volumes of intravascular contrast uptake far more detectable than with standard fluoroscopy.

Question 25: A patient with an implanted spinal cord stimulator (SCS) at L1 requires LESI at L4-L5. What is the primary concern?

Contrast dye reacting with the SCS
Local anesthetic deactivating the stimulator permanently
Steroid interaction with the implant battery
Needle trauma to the SCS lead and risk of epidural hematoma at the SCS site (Correct answer)

Correct answer: Needle trauma to the SCS lead and risk of epidural hematoma at the SCS site

The primary concern is physical trauma to the SCS lead during needle placement and the risk of epidural hematoma formation at the implant site, which can cause device malfunction or neurological injury.

Question 26: The dorsal root ganglion (DRG) of a lumbar nerve root is typically located where within the neural foramen?

At the lateral exit of the foramen
In the middle of the foramen (Correct answer)
Medial (just outside the thecal sac)
Outside the foramen entirely

Correct answer: In the middle of the foramen

The dorsal root ganglion is typically positioned in the mid-portion of the neural foramen, making it susceptible to compression by foraminal stenosis.

Question 27: A patient on warfarin for atrial fibrillation needs ESI. How long should warfarin typically be held before the procedure?

12 hours
24 hours
4-5 days (Correct answer)
7-10 days

Correct answer: 4-5 days

Warfarin should be held for 4-5 days prior to ESI to allow normalization of the INR, with confirmation of INR ≤1.5 before proceeding.

Question 28: Which consent element is most critical and unique to ESI compared to routine surgical procedures?

Consent for general anesthesia
Disclosure that corticosteroids are used off-label for epidural administration per FDA requirements (Correct answer)
Disclosure of the facility's infection rate statistics
Consent for blood transfusion

Correct answer: Disclosure that corticosteroids are used off-label for epidural administration per FDA requirements

The FDA mandates that patients be informed that corticosteroids are not FDA-approved for epidural injection (off-label use), making this disclosure a critical and unique consent element for ESI.

Question 29: A 'Christmas tree' pattern of contrast spread on fluoroscopy during interlaminar LESI indicates:

Appropriate epidural spread along nerve roots (Correct answer)
Subdural injection
Intrathecal injection
Intravascular injection

Correct answer: Appropriate epidural spread along nerve roots

Epidural contrast spread radiating along multiple nerve root sleeves in a symmetrical pattern resembling a Christmas tree confirms proper epidural placement of the needle.

Question 30: Why is live (real-time) fluoroscopy preferred over intermittent static images during contrast injection for LESI?

Static images cause more patient discomfort
Live fluoroscopy uses less contrast
Real-time imaging immediately detects dynamic intravascular contrast flow that would be missed on a single static image (Correct answer)
Static images give higher radiation dose

Correct answer: Real-time imaging immediately detects dynamic intravascular contrast flow that would be missed on a single static image

Intravascular contrast uptake is a dynamic event — contrast flows away rapidly; real-time fluoroscopy allows the physician to see this flow pattern as it happens, whereas a single static image taken afterward may appear normal.

Question 31: A patient allergic to iodinated contrast media who requires fluoroscopic LESI should be:

Pre-medicated with corticosteroids and antihistamines before contrast use, or procedure performed under ultrasound guidance (Correct answer)
Given double the steroid dose to compensate
Denied the procedure entirely
Scheduled for MRI-guided injection only

Correct answer: Pre-medicated with corticosteroids and antihistamines before contrast use, or procedure performed under ultrasound guidance

Patients with contrast allergy can undergo ESI after standard allergy pre-medication protocol (corticosteroids and antihistamines), or alternative guidance methods such as ultrasound can be used to avoid contrast.

Question 32: Post-procedural instructions for LESI patients should include which specific warning sign to monitor?

Avoid all physical activity for 30 days
Report any signs of infection: progressive back pain, fever, or neurological worsening (Correct answer)
Normal saline intake for 48 hours
Wear a lumbar brace for 2 weeks

Correct answer: Report any signs of infection: progressive back pain, fever, or neurological worsening

Patients must be explicitly instructed to report progressive back pain, fever, or new/worsening neurological deficits, as these can signal epidural abscess or hematoma requiring emergency intervention.

Question 33: When performing a transforaminal LESI at the L4-5 level, which nerve root is primarily targeted?

L4 nerve root exiting below the L4 pedicle through the L4-5 foramen (Correct answer)
L3 nerve root exiting below the L3 pedicle
L5 nerve root exiting below the L5 pedicle
S1 nerve root at the S1 foramen

Correct answer: L4 nerve root exiting below the L4 pedicle through the L4-5 foramen

The L4 nerve root exits through the L4-5 foramen below the L4 pedicle; a transforaminal injection at this level targets the L4 root sleeve and the adjacent ventral epidural space.

Question 34: According to ASRA guidelines, what INR threshold generally requires postponement of ESI?

INR > 1.2
INR > 1.5 (Correct answer)
INR > 3.0
INR > 2.0

Correct answer: INR > 1.5

ASRA guidelines generally recommend an INR of 1.5 or less before proceeding with neuraxial injections to minimize bleeding risk.

Question 35: The 'loss of resistance' technique during ESI uses which substance to confirm epidural entry?

Air or preservative-free normal saline (Correct answer)
Iodinated contrast only
Gadolinium
Steroid injectate itself

Correct answer: Air or preservative-free normal saline

The loss of resistance technique uses air or preservative-free saline in a syringe; the plunger meets resistance in the ligamentum flavum and suddenly loses resistance as the needle enters the epidural space.

Question 36: What is the FDA's current regulatory status of corticosteroid use for epidural injection?

Off-label use — not approved for epidural administration (Correct answer)
Banned for epidural use since 2014
Approved only for caudal route
Fully FDA-approved with specific epidural indication

Correct answer: Off-label use — not approved for epidural administration

No corticosteroid is currently FDA-approved for epidural administration; their use via this route is off-label, and the FDA requires a warning label about this.

Question 37: Which symptom pattern suggests that a patient is NOT an appropriate candidate for ESI as a primary treatment?

Cauda equina syndrome with acute bowel and bladder dysfunction (Correct answer)
Radicular pain with disc herniation on MRI
Unilateral leg pain radiating below the knee with dermatomal distribution
Moderate neurological deficits that have been stable for 3 months

Correct answer: Cauda equina syndrome with acute bowel and bladder dysfunction

Acute cauda equina syndrome is a surgical emergency requiring urgent decompression — ESI would cause harmful delay and is contraindicated as primary management.

Question 38: Which needle gauge is most commonly used for transforaminal lumbar epidural steroid injections?

25-27 gauge
20-22 gauge (Correct answer)
30-32 gauge
16-18 gauge

Correct answer: 20-22 gauge

A 22-gauge (sometimes 20-gauge) spinal needle provides sufficient lumen for contrast and steroid injection while minimizing tissue trauma and risk of vascular injury in the foraminal region.

Question 39: Which anatomical variant can obstruct midline spread of injectate in the lumbar epidural space?

Spondylolisthesis
Ligamentum flavum hypertrophy
Epidural septum or plica mediana dorsalis (Correct answer)
Facet joint effusion

Correct answer: Epidural septum or plica mediana dorsalis

The plica mediana dorsalis (posterior epidural midline septum) is an anatomical variant that can restrict midline spread of epidural injectate.

Question 40: Which comorbidity requires informing the patient that ESI may cause a prolonged elevation of blood pressure?

All of the above require this counseling (Correct answer)
Hypertension
Chronic kidney disease
Hypothyroidism

Correct answer: All of the above require this counseling

Hypertensive patients should be counseled that systemic steroid absorption can transiently elevate blood pressure, requiring monitoring and possible antihypertensive adjustment after ESI.

Question 41: Before performing LESI, a patient should be screened for allergy to which class of medications?

NSAIDs
Opioid analgesics
Local anesthetics, corticosteroids, and iodinated contrast (Correct answer)
Penicillin antibiotics

Correct answer: Local anesthetics, corticosteroids, and iodinated contrast

Pre-procedure allergy screening should include local anesthetics, corticosteroids, and iodinated contrast agents, as all three are typically used during an ESI procedure.

Question 42: Which pre-procedural check is most important for reducing the risk of wrong-level injection during fluoroscopic LESI?

Pre-procedure nerve conduction study
Pre-procedure MRI review to identify target level and count vertebral levels under fluoroscopy (Correct answer)
Pre-procedure CBC blood count
Pre-procedure urinalysis

Correct answer: Pre-procedure MRI review to identify target level and count vertebral levels under fluoroscopy

Reviewing pre-procedure MRI and carefully counting vertebral levels under live fluoroscopy (often using bony landmarks like the sacrum) ensures accurate level targeting and prevents wrong-level injection.

Question 43: The typical dose of triamcinolone acetonide used per interlaminar LESI is:

200-400 mg
5-10 mg
20-40 mg (Correct answer)
80-120 mg

Correct answer: 20-40 mg

Triamcinolone acetonide is typically used at 20-40 mg per lumbar epidural steroid injection, balancing efficacy with minimizing systemic steroid effects.

Question 44: What is the appropriate response if a patient calls 48 hours post-ESI reporting worsening back pain and a fever of 101.5°F?

Advise ice application and reassure that this is normal steroid flare
Reschedule for a repeat injection in one week
Prescribe oral antibiotics over the phone and reassure
Direct immediately to emergency department for urgent evaluation to exclude epidural abscess (Correct answer)

Correct answer: Direct immediately to emergency department for urgent evaluation to exclude epidural abscess

Back pain with fever after ESI must be treated as epidural abscess until proven otherwise; urgent emergency evaluation with MRI is required because delays can result in permanent paralysis.

Question 45: Which psychiatric medication requires special consideration before LESI due to potential for severe hypertensive crisis with epinephrine-containing test doses?

Benzodiazepines
Monoamine oxidase inhibitors (MAOIs) (Correct answer)
Tricyclic antidepressants
Selective serotonin reuptake inhibitors (SSRIs)

Correct answer: Monoamine oxidase inhibitors (MAOIs)

MAOIs inhibit the metabolism of catecholamines; use of epinephrine-containing solutions in patients on MAOIs can trigger a severe hypertensive crisis.

Question 46: The epidural fat in the lumbar region serves which primary function relevant to LESI?

Supplies blood to the spinal cord
Acts as a medium through which injectate spreads (Correct answer)
Prevents cerebrospinal fluid leakage
Provides structural support to the vertebral column

Correct answer: Acts as a medium through which injectate spreads

Epidural fat fills the space around neural structures and serves as the medium through which injected corticosteroids and local anesthetics diffuse toward inflamed nerve roots.

Question 47: The subdural space (between the dura and arachnoid) is an uncommon injection site. Which contrast pattern distinguishes subdural from epidural injection?

Subdural shows rapid vascular wash-out
Subdural shows unilateral foraminal spread only
Subdural shows a 'lenticular' or crescent-shaped contrast pattern without nerve root sheath filling (Correct answer)
Subdural shows a myelographic pattern identical to intrathecal

Correct answer: Subdural shows a 'lenticular' or crescent-shaped contrast pattern without nerve root sheath filling

Subdural injection produces a characteristic lenticular (lens-shaped) or crescent-shaped contrast spread that does not fill nerve root sheaths and does not produce the myelographic pattern of intrathecal injection.

Question 48: In fluoroscopic interlaminar LESI, the AP (anteroposterior) view is used primarily to:

Confirm absence of intravascular injection
Assess disc morphology
Measure epidural space depth
Verify midline or paramedian needle position between the laminae (Correct answer)

Correct answer: Verify midline or paramedian needle position between the laminae

The AP fluoroscopic view confirms that the needle tip is positioned midline or paramedian between the target laminae before advancing to the epidural space.

Question 49: A disc herniation at L5-S1 most commonly compresses which nerve root?

S1 nerve root (Correct answer)
S2 nerve root
L5 nerve root
L4 nerve root

Correct answer: S1 nerve root

A paracentral or posterolateral disc herniation at L5-S1 typically compresses the traversing S1 nerve root.

Question 50: Fluoroscopic guidance for LESI is recommended over blind (landmark-based) injections primarily because:

It eliminates all risk of complications
Insurance requires fluoroscopy for reimbursement only
It confirms accurate needle placement and reduces the rate of inaccurate injections from approximately 30-40% to near zero (Correct answer)
It is faster than the blind technique

Correct answer: It confirms accurate needle placement and reduces the rate of inaccurate injections from approximately 30-40% to near zero

Studies show that blind epidural injections have inaccurate placement rates of 30-40%; real-time fluoroscopy with contrast confirmation reduces inaccurate placement rates to near zero.

Question 51: LESI is generally most effective for which type of pain generator?

Radicular pain from nerve root compression or inflammation (Correct answer)
Sacroiliac joint pain
Myofascial pain syndrome
Axial low back pain from facet arthropathy

Correct answer: Radicular pain from nerve root compression or inflammation

ESI is best supported for radicular pain (sciatica) caused by nerve root inflammation or compression from disc herniation or foraminal stenosis, rather than non-radicular axial back pain.

Question 52: The patients body is rotated at ___________ degrees for the AP Oblique Projections

40
45 (Correct answer)
25
35

Correct answer: 45

The patient's body is rotated at 45 degrees for the AP Oblique Projections. This specific angle allows for a better visualization of certain anatomical structures or organs that may be obscured in other projections. By rotating the body at 45 degrees, it provides a different perspective and helps to highlight specific areas of interest for diagnostic purposes.

Question 53: The Knees are flexed during the AP Lumbar Spine to flatten the natural ________________________ curve of the spine.

Dorsal
Lordotic (Correct answer)
Transverse
Kyphotic

Correct answer: Lordotic

During the AP Lumbar Spine, the knees are flexed to flatten the natural lordotic curve of the spine. The lordotic curve refers to the inward curve of the lower back. By flexing the knees, it helps to reduce the curvature of the lower back and create a more flattened position for the lumbar spine during the imaging procedure. This positioning allows for better visualization and assessment of the lumbar vertebrae and their alignment.

Question 54: In performing transforaminal LESI under fluoroscopy, after achieving oblique 'Scotty dog' view and placing the needle at the target, which view should be obtained NEXT to check needle depth?

Caudal tilt view
Lateral view (Correct answer)
AP (anteroposterior) view
Cranial tilt view

Correct answer: Lateral view

After the oblique view guides the needle to the foramen, a lateral fluoroscopic view is obtained to assess the depth (anterior-posterior position) of the needle tip within the foramen before injecting contrast.

Question 55: Which is the correct sequence of imaging steps for a safe transforaminal LESI?

Oblique view for foraminal targeting → lateral view for depth → AP view for final position → contrast injection → steroid injection if pattern correct (Correct answer)
Inject steroid → check AP view → inject contrast
Steroid injection → contrast injection → AP view check
AP view only → steroid injection

Correct answer: Oblique view for foraminal targeting → lateral view for depth → AP view for final position → contrast injection → steroid injection if pattern correct

Safe transforaminal LESI follows a stepwise imaging sequence: oblique for targeting, lateral for depth, AP for final position, contrast injection to confirm non-vascular epidural spread, then steroid injection only after a correct pattern is confirmed.

Question 56: The ligamentum flavum, which is traversed during interlaminar LESI, is composed primarily of which tissue?

Hyaline cartilage
Dense irregular collagen
Elastic fibrocartilage
Yellow elastic fibers (Correct answer)

Correct answer: Yellow elastic fibers

The ligamentum flavum ('yellow ligament') is composed predominantly of yellow elastic fibers, giving it its characteristic color and elasticity.

Question 57: A posterior epidural spread pattern without filling of nerve root sheaths on fluoroscopy after interlaminar injection suggests which problem?

Intravascular injection
Needle tip in the posterior epidural fat only without adequate anterior spread toward the nerve root (Correct answer)
Intrathecal injection
Subdural injection

Correct answer: Needle tip in the posterior epidural fat only without adequate anterior spread toward the nerve root

Posterior-only contrast spread without anterior flow toward nerve root sleeves suggests the needle may be too posterior, limiting injectate access to the target anterior epidural space where nerve roots are located.

Question 58: Which outcome measure is most commonly used to assess pain relief following LESI in clinical practice?

Numerical Rating Scale (NRS) or Visual Analog Scale (VAS) for pain intensity (Correct answer)
Serum inflammatory marker (CRP) levels
EMG/nerve conduction studies
Oswestry Disability Index (ODI) only

Correct answer: Numerical Rating Scale (NRS) or Visual Analog Scale (VAS) for pain intensity

The NRS (0-10) and VAS are the standard patient-reported outcome measures for tracking pain intensity before and after ESI in both clinical practice and research settings.

Question 59: Well defined, projecting from the junctions of the pedicles and laminae.

Spinous Processes
Transverse Process
Articular Processes (Correct answer)
Mamillary Processes

Correct answer: Articular Processes

Articular processes are well defined and project from the junctions of the pedicles and laminae. These processes are found in the vertebrae and play a crucial role in the movement and stability of the spine. They form joints with adjacent vertebrae, allowing for flexion, extension, rotation and lateral bending of the spine. The description provided matches the characteristics of articular processes, making it the correct answer.

Question 60: When performing a caudal epidural injection, the 'pop' or loss of resistance typically occurs as the needle passes through which structure?

The posterior longitudinal ligament of the lower sacrum
The posterior sacral ligament overlying the sacrum
The sacrococcygeal ligament connecting the coccyx to the sacrum
The sacrococcygeal membrane covering the sacral hiatus (Correct answer)

Correct answer: The sacrococcygeal membrane covering the sacral hiatus

The sacrococcygeal membrane (homologue of the ligamentum flavum) covers the sacral hiatus; piercing it produces the characteristic 'pop' signaling entry into the sacral epidural canal.

Question 61: Which is the most feared catastrophic complication of transforaminal lumbar ESI?

Infection and epidural abscess
Postdural puncture headache
Epidural hematoma
Spinal cord infarction causing paraplegia (Correct answer)

Correct answer: Spinal cord infarction causing paraplegia

Spinal cord infarction due to inadvertent intra-arterial injection of particulate steroid into a radiculomedullary artery is the most feared catastrophic complication of transforaminal LESI.

Lumbar Epidural Steroid Injection (LESI) Competency Certification

A procedural competency certification assessing physician knowledge and skill in performing fluoroscopy-guided lumbar epidural steroid injections, covering spinal anatomy, imaging guidance, patient selection, and post-procedure management.

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35 min

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70%

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