Epidural Steroid Injections NYC — Fluoroscopic-Guided Spinal Injections at New York Bone & Joint

Introduction

An epidural steroid injection (ESI) is one of the most widely used and, when properly selected and precisely administered, most effective non-surgical treatments for back and leg pain caused by spinal nerve compression. The corticosteroid delivered into the epidural space reduces the inflammation that’s amplifying the pain signal from a compressed nerve root, providing meaningful relief that allows patients to complete physical therapy and, in many cases, avoid surgery altogether. [1] [2]

The critical variables are diagnosis, approach, and accuracy. The diagnosis determines whether an ESI is the right treatment. The approach (whether interlaminar, transforaminal, or caudal) determines where the medication is delivered. And the accuracy of needle placement, confirmed with fluoroscopic imaging and contrast dye, determines whether the medication reaches the intended target. At New York Bone & Joint, all three are addressed before the needle is placed.

Dr. Efime Popovitz performs epidural steroid injections under fluoroscopic guidance as the standard for all spinal procedures at New York Bone & Joint. His dual board certification in Anesthesiology and Pain Medicine and fellowship training at Yale School of Medicine provide the anatomical depth and procedural precision that ESI outcomes require. His evaluation of every patient begins with the two questions that should precede every injection: is this the right treatment for this specific patient, and can I place it where it will actually work?

What is an Epidural Steroid Injection and What Does It Do?

The epidural space is a narrow corridor running the length of the spine between the bony spinal canal and the dura, the protective covering of the spinal cord and nerve roots. When nerve roots are compressed by a herniated disc, narrowed by spinal stenosis, or inflamed by degenerative changes, they generate the pain, numbness, and weakness that patients experience in the back, legs, or arms.

An epidural steroid injection delivers corticosteroid medication directly into this epidural space, reducing the local inflammatory response around the affected nerve roots. The result is a reduction in the inflammation that’s amplifying the nerve’s pain signal, not a correction of the structural problem causing the compression. This is the most important distinction to understand before proceeding: an ESI treats the inflammatory component of nerve root pain. It doesn’t repair a herniated disc, widen a stenotic canal, or stabilize a degenerative spine. [2]

For many patients, that distinction matters less than it sounds. When a disc herniation compresses a nerve root, the inflammatory response around that nerve is often responsible for the majority of the pain. Reducing it can produce dramatic relief while the disc, which has lost its blood supply at the point of herniation, begins to resorb over weeks to months. An ESI that quiets the nerve for 8 to 12 weeks, combined with structured physical therapy, can be the intervention that allows the natural healing process to complete.

“Every patient I see before a spinal injection gets the same explanation: the injection addresses inflammation, not anatomy. If your pain is coming primarily from nerve root inflammation around a herniated disc, you may get significant relief. If it’s coming primarily from mechanical instability, severe canal narrowing that leaves no room for the nerve regardless of inflammation, or a structural problem that requires surgical correction? The injection will tell us that, too. A diagnostic ESI that provides only partial or brief relief is still valuable clinical information. It tells us where the problem isn’t, which helps us find where it is.” — Dr. Efime Popovitz

The Three Approaches: Interlaminar, Transforaminal, and Caudal

Epidural steroid injections are not a single technique. Three distinct approaches are used at New York Bone & Joint, each with different anatomical targets, indications, and advantages. The choice of approach is based on the patient’s diagnosis, the level of pathology, the symptoms’ distribution, and what the imaging shows.

“The choice between interlaminar and transforaminal is one of the most consequential decisions in spinal injection practice. Transforaminal delivery places the medication directly at the site of nerve root compression. It’s the most targeted approach and, for single-level unilateral radiculopathy with clear imaging correlation, typically produces the best outcomes. But it requires more precise needle placement and fluoroscopic confirmation. Interlaminar is more forgiving anatomically and covers more territory, but the medication distribution is less predictable. I choose based on the clinical picture, imaging, and patient’s symptom pattern rather than on what’s technically easier.” — Dr. Efime Popovitz

Conditions and Indications

Epidural steroid injections are indicated for specific conditions involving nerve root inflammation or compression along the spinal axis. The following are the primary indications treated at New York Bone & Joint: [1] [2]

Why Fluoroscopic Guidance is Non-Negotiable at New York Bone & Joint

Landmark-guided spinal injections, placed using surface anatomy and palpation without imaging confirmation, produce less reliable outcomes than fluoroscopically guided injections. Studies consistently show that fluoroscopic guidance significantly improves needle placement accuracy and clinical outcomes compared to blind technique for most spinal targets. [6]

At New York Bone & Joint, fluoroscopic guidance is the standard for all epidural steroid injections. Here’s what it means for your procedure:

• Real-time imaging: Fluoroscopy provides live X-ray imaging throughout the procedure, allowing precise needle advancement to the target with continuous visualization of the needle tip position.
• Contrast confirmation: Before any medication is injected, contrast dye is introduced through the needle. The spread of contrast on fluoroscopy confirms that the needle is correctly positioned within the epidural space and that medication will reach the intended target. If the contrast doesn’t spread as expected, the needle is repositioned before injection.
• Vascular safety: Contrast under live fluoroscopy reveals inadvertent vascular placement, a safety check that can’t be performed with a blind injection. Intravascular injection of corticosteroid carries rare but serious neurological risks. [8] Fluoroscopic confirmation eliminates this risk.
• Documentation: Fluoroscopic images are part of the procedure record, providing a verifiable record of needle placement for every injection.

“Patients sometimes ask me whether the fluoroscopy is necessary or whether it adds to the procedure cost. My answer is the same every time: accurate placement is the single most important variable in whether your injection works. The fluoroscopy isn’t optional equipment. It’s how I know the medication is going where it needs to go.” — Dr. Efime Popovitz

What to Expect: Before, During, and After

Before the Procedure

Dr. Efime Popovitz will review your symptoms, examine the relevant spinal levels, and confirm the appropriate indication and approach based on your imaging and clinical picture. If you don’t have recent MRI, we will arrange it before scheduling the injection. You will receive pre-procedure instructions including any medication adjustments (particularly blood thinners), fasting requirements if sedation is used, and transportation arrangements. Most patients don’t require sedation for an ESI, but it’s available for anxious or complex cases.

During the Procedure

The procedure takes 20–30 minutes. You’ll lie on the fluoroscopy table in a position that optimizes access to the target level. The skin is cleaned and a local anesthetic is injected to numb the entry point. The spinal needle is then advanced under fluoroscopic guidance. Contrast dye is injected to confirm epidural placement. The corticosteroid is then delivered. You may feel pressure during the procedure and, in some cases, transient reproduction of your symptoms as the needle approaches the nerve root. This is normal and brief.

After the Procedure

Most patients go home within 30 minutes of the procedure’s completion. You may experience a temporary increase in back or leg pain for 24–48 hours as the local anesthetic wears off before the steroid takes effect. Pain relief typically begins within 3–5 days. We recommend avoiding strenuous activity for 24 hours. Most patients return to desk work the same day or the next day.

Risks and Considerations

Epidural steroid injections have an excellent safety record when performed by an experienced physician under fluoroscopic guidance. The following risks should be understood: [2] [8]

• Post-procedure soreness: Temporary pain at the injection site or brief increase in symptoms for 24–48 hours is common and resolves without intervention.
• Steroid effects: Temporary blood glucose elevation (important for diabetic patients to monitor), transient facial flushing, and rarely, systemic steroid effects. Your physician will advise based on your medical profile.
• Headache (dural puncture): If the needle inadvertently enters the dural space (a wet tap), a positional headache can result. This is uncommon with experienced practitioners and fluoroscopic guidance, and is managed conservatively or with a blood patch if persistent.
• Infection: Rare with standard sterile technique. Less than 1 in 10,000 procedures.
• Rare neurological complications: Epidural hematoma, abscess, or spinal cord injury are exceedingly rare but require immediate recognition and management. Fluoroscopic guidance and contrast confirmation significantly reduce the risk of inadvertent vascular injection. [8]
• Incomplete or short-lived relief: Not every patient responds to every ESI. If two well-placed injections at the correct level don’t provide meaningful relief, the diagnosis should be re-evaluated. Continued injection without a treatment response is not a strategy.

At your consultation, Dr. Efime Popovitz will review the specific risks relevant to your procedure, medical history, and medications.

Why Choose New York Bone & Joint for Epidural Steroid Injections?

References

1. American Academy of Orthopaedic Surgeons. Epidural Steroid Injections. OrthoInfo. orthoinfo.aaos.org/en/treatment/spinal-injections
2. Cohen SP et al. Epidural steroid injections: a comprehensive evidence-based review. Pain. 2013. pubmed.ncbi.nlm.nih.gov/23598728
3. Abdi S et al. Epidural steroids in the management of chronic spinal pain: a systematic review. Pain Physician. 2007. pubmed.ncbi.nlm.nih.gov/17256030
4. Manchikanti L et al. Epidural injections for lumbar radiculopathy and spinal stenosis. Pain Physician. 2015. pubmed.ncbi.nlm.nih.gov/27008296
5. Soin A et al. Lumbar Epidural Steroid Injections for Chronic Spinal Pain: A Clinical Review of Efficacy and Evidence. Cureus. 2025. pubmed.ncbi.nlm.nih.gov/41487815
6. Shen PC et al. Comparison of ultrasound- vs. landmark-guided injections for musculoskeletal pain: an umbrella review. J Rehabil Med. 2024. pubmed.ncbi.nlm.nih.gov/39185547
7. Chang-Chien GC et al. Transforaminal versus interlaminar approaches to epidural steroid injections. Pain Physician. 2014. pubmed.ncbi.nlm.nih.gov/25054401
8. Horlocker TT et al. Anticoagulation and neuraxial procedures: practice advisory. ASRA. 2018. asra.com/guidelines-articles
9. Friedly JL et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. JAMA. 2014. pubmed.ncbi.nlm.nih.gov/24988555
10. American Academy of Orthopaedic Surgeons. Herniated Disk in the Lower Back. OrthoInfo. orthoinfo.aaos.org/en/diseases–conditions/herniated-disk-in-the-lower-back