title: Access routes and reported decision criteria for lumbar epidural drug injections: a systematic literature review.
abstract: OBJECTIVE
  To review lumbar epidural drug injection routes in relation to current practice and the reported criteria used for selecting a given approach.
  
  
  METHODS
  This was a HIPPA-compliant study. Employing a systematic search strategy, the MEDLINE and EMBASE databank as well as the Cochrane Library were searched for studies on epidural drug injections. The following data were noted: access route, level of injection, use of image guidance, and types and doses of injected drugs. Justifications for the use of a particular route were also noted. Data were presented using descriptive statistics.
  
  
  RESULTS
  A total of 1,211 scientific studies were identified, of which 91 were finally included (7.5%). The interlaminar access route was used in 44 of 91 studies (48.4%), the transforaminal in 37 of 91 studies (40.7%), and the caudal pathway in 26 of 91 studies (28.6%). The caudal pathway was favored in the older studies whereas the transforaminal route was favored in recent studies. Decision criteria related to correct needle placement, concentration of injected drug at lesion site, technical complexity, costs, and potential complications. Injection was usually performed on the level of the lesion using local anesthetics (71 of 91 studies, 78.0%), steroids (all studies) and image guidance (71 of 91 studies, 78%).
  
  
  CONCLUSIONS
  The most commonly used access routes for epidural drug injection are the interlaminar and transforaminal pathways at the level of the pathology. Transforaminal routes are being performed with increasing frequency in recent years.
authors.affiliation: Department of Radiology, University Hospital Zurich, Ramistrasse 100, CH 8091, Zurich, Switzerland, gustav@andreisek.de.
authors.forename: Gustav
authors.initials: G
authors.lastname: Andreisek
authors.forename: Maja
authors.initials: M
authors.lastname: Jenni
authors.forename: Dominic
authors.initials: D
authors.lastname: Klingler
authors.forename: Maria
authors.initials: M
authors.lastname: Wertli
authors.forename: Marina
authors.initials: M
authors.lastname: Elliott
authors.forename: Erika J
authors.initials: EJ
authors.lastname: Ulbrich
authors.forename: Sebastian
authors.initials: S
authors.lastname: Winklhofer
authors.forename: Johann
authors.initials: J
authors.lastname: Steurer
mesh_terms: D000779:Anesthetics, Local / Q000008:administration & dosage*; D001416:Back Pain / Q000453:epidemiology / Q000517:prevention & control*; D003657:Decision Making; D006801:Humans; D007268:Injections, Epidural / Q000379:methods* / Q000706:statistics & numerical data*; D038622:Internationality; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D015995:Prevalence; D013256:Steroids / Q000008:administration & dosage*
chemical_list: D000779:Anesthetics, Local; D013256:Steroids