• Jaspal R Singh, Eliana Cardozo, and George C Christolias.
• Department of Rehabilitation Medicine, New York Presbyterian- Weill Cornell Medical Center, 525 E 68th Street, Baker 16, New York, NY 10065(∗). Electronic address: Dr@RickySinghMD.com.
• PM R. 2017 Apr 1; 9 (4): 377-382.

BackgroundEpidural steroid injections have been used in combination with other modalities for the treatment of lumbar radicular pain. The literature has shown that 1-level lumbar fluoroscopically guided transforaminal epidural steroid injections (TFESIs) are effective in decreasing pain and morbidity; however, the efficacy of 2-level TFESIs has not been investigated, although they are performed by many practitioners in the treatment of lumbar radicular pain.ObjectivesTo assess the clinical effectiveness of 2-level TFESIs in patients with unilateral, single-level lumbar radicular pain. In addition, a subgroup analysis was performed based on disk herniation location.Study DesignRetrospective cohort.SettingOutpatient physiatry pain practice.PatientsA total of 721 patients were included in this study having undergone a two-level transforaminal epidural steroid injection.MethodsThe study group included patients who underwent a 2-level lumbar TFESI. Patients presented for lumbar radicular pain as the result of disk herniation with or without radiculopathy and were scheduled to receive a lumbar TFESI at L3 or below. Of this group, only those that underwent a 2-level TFESIs were included in the study, and data analysis was carried out on this group.Main Outcome MeasuresSubjects were assessed with a pain numerical rating scale (NRS 0-10) and Oswestry Disability Index (ODI) before TFESI and at 2-week and 2-month follow-up. Responders were defined as greater that 50% reduction in NRS or greater than 40% reduction in ODI.ResultsA total of 57.7% of patients were responders in terms of NRS (P < .05, confidence interval 53.6%-61.9%) and 51.7% responded in ODI at 2-month follow-up (P < .05 [confidence interval 47.5%-55.9%]). In addition, patients with complete pain relief (defined as 0/10 on NRS) were noted at both 2-week (n = 239, 33%) and 2-month (n = 130, 18%) follow-up. In subgroup analysis, the paracentral/subarticular disk group had an increased number of responders, 66.0% in NRS and 64.0% in ODI at 2-month follow-up (P < .05).ConclusionsTwo-level TFESIs are effective in the management of radicular pain, but more research is needed to evaluate the utility of this treatment compared with single-level TFESI. Our study showed a greater improvement in pain and function as a result of 2-level TFESIs in the setting of paracentral/subarticular disk herniations.Level Of EvidenceIV.Copyright © 2017 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.

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