Transforaminal injection technical series, part 6 Lt L5 TF & bilateral flavo 4/5 54800

Lumbar left L5 TF and bilateral flavo 4 5 54800
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Welcome to today's session! Our focus will be a technical walkthrough on implementing the lumbar subpedicular approach for transforaminal injections alongside bilateral facet joint injections, primarily for patients experiencing chronic unilateral radicular pain. It's crucial to note that the purpose of the facet joint injections isn't to alleviate facet joint pain per se but to relieve symptoms associated with stenosis. Therefore, I refer to this procedure as a 'Flavo' injection. I adopted this term from the flavotomy.

This exploration will be supplemented with a technical video for a hands-on understanding.


Meet my patient, a 65-year-old male who has been under my care for approximately three years. He first consulted with me after experiencing left lower back pain radiating downwards, which began a year before his initial visit. He typically schedules appointments every seven to nine months, each time presenting with similar symptoms.
Let's review his spinal MRI, conducted three years ago when he first reported pain.
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Before we describe the MRI grading details of our patient, kindly take a moment to review the table that elucidates how radiologists categorize disc degeneration from grades 1 to 5. It's better to understand that in Grade 5, the MRI will showcase a homogeneous low signal intensity with the nucleus and annulus appearing indistinguishable from one another.

T1-weighted sagittal images reveal significant findings. The mid-sagittal image displays advanced degeneration, grade 5, at the L2-3, L4-5, and L5-S1 intervertebral discs, with grade 4 degeneration noted at the L3-4 disc. A closer examination of the left parasagittal sectional image uncovers severe foraminal stenosis at L4-5, accompanied by subchondral low signal intensity and moderate foraminal stenosis at L5-S1. Meanwhile, the right parasagittal sectional image highlights mild foraminal stenosis.

Turning our attention to T2-weighted sagittal images, the mid-sagittal sectional discloses diffuse high-signal intensity in the bone marrow of L2, L4, and L5 vertebral bodies. Additionally, there's notable high signal intensity within the L4-5 and L5-S1 discs. Another key observation is the pronounced proliferation of fat within the anterior epidural space, spanning from the L4 body level down to the S1 level, leading to a narrowed thecal sac.
The left parasagittal and far lateral images further unveil high-signal intensity within the bone marrow of L4 and L5 bodies and the L5 pedicle. Significant foraminal stenosis at L4-5 and moderate foraminal stenosis observed at L5-S1 are evident.

Upon reviewing the axial T2-weighted image at the L4-5 disc level, it's apparent that there is an increase in both anterior and lateral epidural fat. Combined with a thickened ligamentum flavum, it results in crowded nerve rootlets. Additionally, there's observable diffuse disc bulging and grade D severe central stenosis at the L4-5 level.


Additionally, please familiarize yourself with the MRI grading systems for central and foraminal stenosis. Typically, central stenosis grading is based on axial T2 weighted images, while foraminal stenosis is conventionally assessed using sagittal scans. However, in instances where it's permissible, I opt for oblique sagittal scan images to guide the evaluation of foraminal stenosis.


Clinical Impression: The patient presents with Grade D severe central stenosis at the L4-5 level. Concurrently, severe foraminal stenosis at left L4-5 and moderate foraminal stenosis observed at left L5-S1. Bone marrow edema is also evident within the L2, L4, and L5 vertebral bodies and the left L5 pedicle.

For his treatment, I use a cocktail of:
Botox (40 to 50 units)
Triamcinolone (30mg)
40% Dextrose combined with optimal local anesthetics.
The total volume of this mixture is approximately 3.5 ml. I inject 1.5 ml into the foraminal space, and for each facet joint injection, I administer 1 ml into each facet.

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