Original Article

Residents’ Learning Curve of Lumbar

Transforaminal Epidural Steroid Injections
Holger Joswig1 Sarah Roberta Haile2 Gerhard Hildebrandt1 Martin Nikolaus Stienen3

1 Department of Neurosurgery, Cantonal Hospital St. Gallen, Address for correspondence Holger Joswig, MD, Department of
St. Gallen, Switzerland Neurosurgery, Cantonal Hospital St. Gallen - Rorschacher Str. 95,
2 Epidemiology, Biostatistics and Prevention Institute, University of St. Gallen 9007, Switzerland
Zurich, Zurich, Switzerland
3 Service de Neurochirurgie, Hôpitaux Universitaires de Genève,
Genève, Switzerland

J Neurol Surg A

Abstract Background and Study Aims There is a paucity of literature on beginners’ training and
on its connection with patient safety for transforaminal epidural steroid injections

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(TFESIs). This study retrospectively assessed the learning curves and associated
complications of neurosurgery residents never previously exposed to TFESI and
compared them with experienced board-certified faculty neurosurgeons (BCFNs).
Material and Methods Procedure time in minutes, dose-area product (DAP) in
cGy
cm2, periprocedural observations, and complications in 354 TFESIs for radicular
pain secondary to lumbar disk herniation or lumbar spinal stenosis were extracted
from operative notes and the electronic infiltration logbook in the per-injection
format. Learning curves for 238 residents and 116 BCFN TFESIs in terms of procedure
time and DAP were estimated using monotone regression.
Keywords Results Residents’ TFESI procedure time and DAP reached BCFN level (4.7 minutes and
► learning curve 140.2 Gy
cm2) after 67 and 68 cases, respectively. Residents’ TFESIs were unsuccessful
► lumbar disk in 1.7%, mostly for severe obesity and hypertrophied facet joints, but no severe
herniation complications were noted. Obesity, however, did not result in increased procedure
► lumbar spinal times or radiation exposure in general. Residents were faster and required less
stenosis fluoroscopy in TFESI of the upper lumbar nerve roots than for L5 or S1 in particular.
► resident training Conclusion The residents’ learning curve for TFESIs in terms of procedure time and
► transforaminal radiation exposure can be overcome safely after < 70 TFESIs. An outcome analysis
epidural steroid correlating to the interventionalist’s training level would be worth investigating in
injection future studies.

Introduction approach under imaging guidance. Despite the fact that TFESI
has been used for many decades, the pathophysiologic
In the care of patients with radiculopathy secondary to a mechanism behind it and the efficacy of this procedure
lumbar disk herniation or lumbar spinal stenosis, treating remain a source of controversy. In light of reported severe
physicians increasingly rely on a trial of transforaminal complications, safety precautions have been recommended.1
epidural steroid injections (TFESIs). A combination of a local Most studies today, including those of our institution,2 are
anesthetic and glucocorticoid is usually applied epidurally to performed by interventionalists with long-standing experi-
the affected nerve root via a transforaminal or interlaminar ence in TFESI. However, patient care in teaching hospitals is

received © Georg Thieme Verlag KG DOI http://dx.doi.org/

July 13, 2016 Stuttgart · New York 10.1055/s-0037-1599056.
accepted after revision ISSN 2193-6315.
November 14, 2016
Learning Curve for Lumbar TFESIs Joswig et al.

provided by physicians with varying degrees of experience. the skin. Procedure time was recorded at the point the Chiba
In a previous report, the involvement of musculoskeletal and needle (ECOJEKT 23G, 15 cm length, HS Hospital Service,
neuroradiology fellows in TFESI did not prolong fluoroscopy Aprilia, Italy) was poked through the skin. Under single-shot
time and/or increase the radiation dose.3 But how do be- fluoroscopy guidance, the needle was advanced to the base of
ginners do in TFESI? We describe the learning curves and the subjacent pedicle (so-called safe triangle8). For the S1
associated complications of four neurosurgery residents root, the needle was inserted into the craniomedial aspect of
never previously exposed to TFESI and compare them with the first sacral foramen. To control depth and check for the
experienced board-certified faculty neurosurgeons (BCFNs). correct needle position, the image intensifier, which was
handled by operating room personnel on verbal command of
the interventionalist, had to be rotated from AP to lateral and
Material and Methods
back if required. After negative flashback/aspiration, 1 to
Training Program 5 mL contrast agent iopamidol 300 mg/mL (Iopamiro 300,
According to our institution’s structured training program Bracco Suisse, Manno, Switzerland) were applied under
(►Supplementary Table 1), neurosurgery residents are in- continuous fluoroscopy to ensure periradicular spread and
troduced to lumbar TFESIs at the end of their postgraduate rule out intravascular needle tip placement (►Fig. 1).
year (PGY)-1, first by observing at least 10 TFESIs. After A mixture of 2 to 3 mL of 40 mg/mL triamcinolone (Kena-
positive appraisal of the BCFN in charge, they are allowed cort-A 40, Dermapharm, Hünenberg, Switzerland) and 0.5%
to perform TFESI under supervision. When deemed fit to bupivacaine (Bupivacaine hydrochloride, Sintetica, Mendri-

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safely perform TFESI, they proceed on their own, although a sio, Switzerland) was administered in the ratio 1:5. Ideally,
backup BCFN is always available in case of unforeseen patients experienced a transient triggering of leg pain or
problems. reported tingling sensations down the leg during the injec-
tion of the drugs. Operation time ended with needle with-
Injection Technique drawal. Throughout the procedure, the DAP in cGy
cm2 was
All TFESI procedures by residents and BCFNs were performed recorded.
in the same manner under fluoroscopy guidance (Siemens
Arcadis Varic, Munich, Germany). The transforaminal tech- Study Groups
nique, which was previously shown to be equally2,4,5 or even The resident TFESI group included all consecutive patients
more effective5–7 than the interlaminar technique, was used who received TFESIs by four neurosurgery residents starting
in all patients. The patient was in the prone position and the with their first case during their training. They were
lumbosacral region disinfected with isopropyl and propyl compared with TFESIs performed by four BCFNs with special
alcohol with 2-phenylphenol (Kodan Forte, Schülke & Mayr, focus on spine surgery and long experience with TFESIs
Zurich, Switzerland) and draped in a sterile manner. The during the same time interval.
correct level was determined with anteroposterior (AP)
fluoroscopy. For TFESI, we never use local anesthesia for Data Collection
The operative notes and infiltration room electronic logbook
were reviewed retrospectively. Procedure time in minutes
and the dose-area product (DAP) in cGy
cm2 were used to
create learning curves. Patient demographic data (age, gen-
der, weight, and height) were extracted from the patient
charts. Diagnosis, procedure-related details (nerve root level,
side), and procedural observations were recorded. The latter
included flashback/aspiration of blood or cerebrospinal fluid
(CSF), contrast-confirmed intravascular needle tip place-
ment, whether the patient reported a transient triggering
of leg pain, tingling sensations, and so on, during the injec-
tion, as well as procedural complications and TFESI failures.
In order to not exclude any patients who received TFESI for
multiple nerve roots in the same session, procedure time and
DAP were converted into the per-injection format as done by
Smuck et al.9

Statistical Considerations
Dependent variables were TFESI time in minutes, DAP in
cGy
cm2, and intraoperative observations. Independent
Fig. 1 Lateral fluoroscopy of a left L5 transforaminal epidural steroid
variables were resident status of the physician, nerve root
injection using a mixture of 0.5% bupivacaine and 40 mg/mL triam-
cinolone. Periradicular spread is ensured and intravascular needle tip level, and the patient’s body mass index (BMI) in kg/m2. An
placement ruled out by prior application of iopamidol 300 mg/mL additional analysis was done on the residents’ PGY. Relation-
under continuous fluoroscopy. ships were first visualized graphically and analyzed for

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 Learning Curve for Lumbar TFESIs Joswig et al.

Table 1 Case baseline characteristics (per-injection format)a

Resident TFESI BCFN TFESI p value

Age, y 57.1 16.4 62.1 15.3 0.009
Gender 0.084
Male 134 56.3% 54 46.6%
Female 104 43.7% 62 53.4%
Body proportions
Weight, kg 77.7 12.7 79.7 15.2 0.221
Height, cm 172.1 9.3 170.7 9.6 0.364
Body mass index, kg/m2 26.3 4.4 27.4 5.4 0.142
Indication for TFESI < 0.001
Lumbar disk herniation 176 73.9% 36 31.0%
Lumbar spinal stenosis 62 26.1% 80 69.0%
Nerve root 0.040

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L1 1 0.4% 1 0.9%
L2 6 2.5% 3 2.6%
L3 26 10.9% 13 11.2%
L4 37 15.6% 33 28.5%
L5 108 45.4% 50 43.1%
S1 60 25.2% 16 13.8%
Side 0.047
Right 119 50.0% 71 61.2%
Left 119 50.0% 45 38.8%
Total n ¼ 238 100% n ¼ 116 100%

Abbreviations: BCFN, board-certified faculty neurosurgeon; TFESI, transforaminal epidural steroid injection.
a
A total of 238 and 116 TFESIs were performed by neurosurgery residents and BCFNs, respectively.
Note: Categorical variables are presented as count and percentage, nominal variables as mean and standard deviation.

trends. Independent variables were then dichotomized into residents performed 238 TFESIs (resident 1, 82; resident 2,
resident versus BCFN, upper (L1–L4) and lower nerve roots 81; resident 3, 38; and resident 4, 37). In total, 182 TFESIs
(L5–S1), obese (BMI  30 kg/m2) versus nonobese were performed by residents in their junior stage (76.5%;
(BMI < 30 kg/m2), and whether the respective resident PGY 1–3) and 56 TFESIs by residents in their senior stage of
was at the beginning (junior level, PGY 1–3) or at the end training (23.5%; PGY 4–6). At the beginning, they were
of his or her training (senior level, PGY 4–6). Analysis of supervised for an average of 5.3 cases (range: 2–9). Through-
continuous variables (TFESI time and DAP) was performed out the rest of their learning curve, BCFNs were called in for
using rank sum tests. Analysis of categorical variables (pro- help in nine instances (4.1%). During the same time interval,
cedural observations and complications) was done using 116 TFESIs were performed by four BCFNs. A total of 77
logistic regression with the results presented as odds ratio patients (21.8%) were considered obese, and one third of all
(OR) with 95% confidence intervals (CIs). Because there were TFESIs was performed for nerve roots L1–L4 (120 [33.9%]),
baseline differences between patients treated by residents whereas two thirds targeted L5 or S1 (234 [66.1%]). Baseline
and BCFNs (►Table 1), an additional multivariate logistic characteristics were balanced for most parameters except for
regression model was built. The software used for the patient age, indication, and nerve root level.
statistical analysis was Stata v.14 (StataCorp, College Station,
Texas, United States). The learning curves were estimated Learning Curve and TFESI Time
using monotone regression available with the isoreg func- Procedure time was < 10 minutes by the 10th and approx-
tion in R (v.3.2.2)10 as previously reported.11,12 imated BCFN level (4.7 minutes) by the 67th TFESI
(►Figs. 2A and 3A). TFESI time was significantly longer
for those performed by junior compared with senior
Results
residents (8.50  3.94 minutes versus 5.71  2.39 mi-
►Tables 1 and 2 provide baseline characteristics, procedural nutes; p < 0.0001; ►Fig. 3B). Mean TFESI time for the
variables, and observations in the per-injection format. Four upper lumbar nerve roots (L1–L4; 6.26  3.74 minutes)

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Learning Curve for Lumbar TFESIs Joswig et al.

Table 2 Procedural variables and observations (per-injection format)a

Resident TFESI BCFN TFESI p value

TFESI time, min 7.8 3.8 4.7 1.5 < 0.001
DAP, Gy
cm2 268.1 321.0 140.2 133.7 0.087
Periprocedural observations 0.028
Nothing special 223 93.7% 115 99.1%
Yes 15 6.3% 1 0.9%
CSF aspiration 3 1.3% – –
Flashback/Blood aspiration 4 1.7% 1 0.9%
Intravascular needle tip placement 8 3.3% – –
Provocation during injection < 0.001
Yes 144 60.5% 97 83.6%
No 94 39.5% 19 16.4%
Treatment 0.307

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Successful 234 98.3% 116 100%
Unsuccessful 4 1.7% – 0%
Total n ¼ 238 100% n ¼ 116 100%

Abbreviations: BCFN, board-certified faculty neurosurgeon; CSF, cerebrospinal fluid; DAP, dose-area product; TFESI, transforaminal epidural steroid
injection.
a
Total of 238 and 116 fluoroscopy-guided lumbar TFESIs performed by neurosurgery residents and BCFNs, respectively.
Note: Categorical variables are presented as count and percentage, nominal variables as mean and standard deviation.

was significantly shorter than for the lower nerve roots L5 obesity in one case and for reasons not further specified in
or S1 (7.12  3.44 minutes; p ¼ 0.0006; ►Fig. 3C). TFESI another case. In one resident case, the injectate had to be
was similarly long in nonobese (6.97  3.56 minutes) and administered 1.5 cm lateral to the neuroforamen due to
obese patients (6.31  3.54 minutes; p ¼ 0.0756). obesity, but for statistical analysis this TFESI was considered
successful. A change to an extra-long needle in one obese
Learning Curve and DAP patient and four facet joint obstacles were reported in the
There was missing data for DAP in 94 of 238 (39.5%) residents BCFN group, but all these cases could be completed and were
and 38 of 116 (32.8%) BCFN TFESIs. In terms of DAP, the considered successful TFESIs.
largest improvement was observed by the 20th TFESI, when No severe complications occurred in any of the groups. A
DAP had reduced from 569 at baseline to 213 cGy
cm2 total of 16 procedural observations were made of which 15
(►Fig. 2B). After that, there was a long plateau until around occurred during resident TFESIs. In univariate analysis, res-
the 68th TFESI when average DAP reduced to 135 cGy
cm2 idents were more likely to observe flashback/aspiration of
and reached the BCFN mean DAP of 140.2 Gy
cm2. blood or CSF or contrast-confirmed intravascular needle tip
In general, residents tended to use more radiation than placement (OR: 7.18; 95% CI, 0.93–55.34; p ¼ 0.058). Once
BCFNs (268.1 versus 140.2 Gy
cm2; p ¼ 0.087; ►Fig. 3D), corrected for baseline group differences including age, gen-
and there was a strong tendency for more radiation der, underlying diagnosis, segment, and side, the effect
exposure caused by junior residents (306.87  357.33 became more pronounced and statistically significant (OR:
Gy
cm2) compared with senior residents 10.25; 95% CI, 1.24–84.38; p ¼ 0.030). Within the group of
(160.09  140.63 Gy
cm2; p ¼ 0.067; ►Fig. 3E). From residents, junior status was no predictor of a procedural
both figures it becomes evident that the range of used observation (OR: 1.32; 95% CI, 0.39–4.39; p ¼ 0.648). Like-
radiation was large. In general, more radiation was needed wise, neither obesity (OR: 0.89; 95% CI, 0.25–3.25;
for levels L5 and S1 (281.49  336.70 Gy
cm2) compared p ¼ 0.867) nor TFESI for nerve roots L5 or S1 (OR: 1.03;
with the upper lumbar levels (153.49  143.16 Gy
cm2; 95% CI, 0.34–3.07; p ¼ 0.962) were significant predictors of
p ¼ 0.0441; ►Fig. 3F). Obese patients were equally procedural observations.
exposed to radiation (249.35  216.03 Gy
cm2) as non-
obese patients (243.17  315.11 Gy
cm2; p ¼ 0.2228).
Discussion
Difficulties, Complications, and Procedural In this first report on TFESI beginners, we demonstrate that
Observations the learning curve in terms of procedure time and DAP is
Four resident TFESIs failed (1.7%) due to the inability to pass a overcome in < 70 cases when these variables approximate
hypertrophied facet joint with the needle in two cases, expert (BCFN) level. Significant improvement can already be

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 Learning Curve for Lumbar TFESIs Joswig et al.

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Fig. 2 Procedure time (A) in minutes (min) and (B) dose-area product (DAP) in cGy
cm2 of 238 transforaminal epidural steroid injections (TFESIs)
in the per-injection format performed by four neurosurgery residents. Black dots represent failed resident TFESIs. Procedure time was < 10
minutes by the 10th, and DAP dropped below 213 cGy
cm 2 from 569 at baseline by the 20th TFESI. Mean board-certified faculty neurosurgeon
(BCFN) procedure time (4.7 min) and DAP (140.2 Gy
cm2 ) in 116 TFESIs depicted by the horizontal dashed lines was reached by the 67th and 68th
TFESI, respectively. The dotted lines represent the middle 95% of the BCFN procedure time and DAP. Note that there was missing data for DAP in
94 of 238 (39.5%) resident and 38 of 116 (32.8%) BCFN TFESIs.

seen after 10 to 20 cases, shortly after residents performed problems to visualize the S1 foramen using fluoroscopy might
TFESI without supervision. Because no severe complications all be explanations. It is recommended that junior residents
occurred and difficulties encountered in TFESI led to unsuc- perform their first 20 TFESIs on upper lumbar nerve roots in
cessful ESI in a few cases only, the present data suggest that slim patients.
patient safety is warranted while trainees build up experi- Pain provocation during injection indicates direct drug
ence with this technique. The current work lines up with a application in the proximity of the nerve root and could be
series of previous reports assessing the safety of neurosur- regarded as proxy of a technically successful TFESI, and this
gery resident training surgery.11,13–16 was more often achieved by BCFNs than by residents. How-
Considering potential long-term consequences of radia- ever, the residents’ negative pain provocation rate of 39.5%
tion exposure, DAP should be kept at a minimum. Because compares with what is reported in the literature.8
DAP was significantly higher at the beginning of the learning Concerning procedural observations, the records of CSF
curve with a strong trend toward a higher DAP within the and blood aspiration, flashback, and intravascular needle tip
group of residents with junior status, a longer resident placement were less frequent in BCFN notes. For reporting
supervision to train a goal-directed use of fluoroscopy would these kinds of observations during TFESI, however, we have
be ideal. Our data suggest that an acceptable reduction in no hospital standard, and we cannot exclude retrospective
DAP can be achieved by the 20th case. However, continuous bias. Intravascular penetration caused by residents was
resident supervision for so-called simple procedures such as generally low and might be explained by the fact that
TFESI can be difficult in busy neurosurgery routines. Intro- inexperienced interventionalists are known to be less accu-
ductory seminars on lumbar spine procedures17 could po- rate in interpreting contrast dispersal patterns.18 Thus the
tentially shorten the learning curve. absolute rate of these observations could in fact be higher.
Severe obesity and hypertrophied facet joints resulted in
some unsuccessful resident TFESIs. These conditions therefore Limitations
prove unsuitable for beginners in TFESI, although according to In addition to the shortcomings of the retrospective design
our data, obesity did not result in increased procedure times9 already mentioned, data for DAP were missing in 37.3% of
and radiation exposure3,9 as previously reported. The data cases. More fluoroscopy parameters such as a record on
further support our personal experience that TFESI of the fluoroscopy time or the total number of shots could have
upper lumbar nerve roots is easier to perform than TFESI for L5 helped to better describe the residents’ learning curve.
or S1 in particular; as for the former, residents were faster and Unfortunately, these parameters could not be retrieved
required less fluoroscopy. More degeneration of hypertro- from our records. Although procedure time itself does
phied facet joints of the lumbosacral segments, the iliac crest not necessarily relate to proficiency,19 it has been used
interfering with the transforaminal trajectory of L5 ESI, and before in assessments of learning curves12 and represents a

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Learning Curve for Lumbar TFESIs Joswig et al.

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Fig. 3 Procedure time in minutes (min) and dose-area product (DAP) in cGy
cm2 for transforaminal epidural steroid injections (TFESIs)
performed by four neurosurgery residents (n ¼ 238) and board-certified faculty neurosurgeons (BCFN; n ¼ 116). (A) Resident versus BCFN
procedure times. (B) Junior versus senior residents’ procedure times (8.50  3.94 min versus 5.71  2.39 min; p < 0.0001. (C) Upper versus
lower lumbar nerve roots and S1 procedure time (L1–L4; 6.26  3.74 min versus 7.12  3.44; p ¼ 0.0006. (D) Resident versus BCFN DAP (268.1
versus 140.2 Gy
cm2 ; p ¼ 0.087. (E) Junior versus senior residents DAP (306.87  357.33 Gy
cm2 versus 160.09  140.63 Gy
cm2 ; p ¼ 0.067.
(F) Upper versus lower lumbar nerve roots and S1 DAP (153.49  143.16 Gy
cm 2; p ¼ 0.0441 versus 281.49  336.70 Gy
cm 2). The figures
display the mean with the 25th to 75th percentile (box), the upper and lower adjacent values (whiskers), and outliers (dots). Note that there were
missing data for DAP in 94 of 238 (39.5%) resident and 38 of 116 (32.8%) BCFN TFESIs. PGY, postgraduate year.

fair surrogate marker for the following reasons: Needle complications were encountered during 238 TFESIs per-
repositioning is done blindly most of the time, and bony formed by residents, and the rate of unsuccessful attempts
obstacles such as hypertrophied facet joints and iliac crests was 1.7%. At the moment the question whether patients’
are overcome by feeling a loss of resistance. At the begin- outcomes are influenced by the interventionalist’s training
ning of the learning curve, the needle had to be completely level as well remains unanswered.
withdrawn and the image intensifier readjusted to choose
a new entry point (parameters that could also be assessed
in future studies); this extra procedure time is not well Acknowledgments
reflected by fluoroscopy time. Further spinal injections of We thank our senior neurosurgeons for the teaching of
facet and sacroiliac joints performed by participating res- TFESI and our operating room personnel for their skilled
idents in a similar manner to TFESI certainly shortened the assistance. We also thank Carolin Hock for proofreading
learning curve. Lastly, comparisons of patients’ clinical the manuscript.
outcomes after TFESI performed by residents and BCFNs
are missing in the present report because they could not
be retrieved well enough retrospectively, and some infil-
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