Low back pain is the second most common disease, following heart diseases, that causes labor loss. Therefore, studies are conducted not only on diagnosis-based treatment, but also on methods that maximize the comfort of life.

Low back pain and associating radicular symptoms (pains that refer to foot) are one of the most serious medical and socioeconomic problems in the present day. Low back pain occurs in 80-85% of adults before the age of 50 years. While 90% of patients with acute low back pain recover completely within several weeks, low back pain persists longer than 4 to 6 weeks only in 10% of patients. For long-standing pains, one should considered lumbar disc hernia, tumor, facet joint pain, hip joint disorders, lumbar spondylolisthesis and psychological problems.

The first step of conservative treatment includes exercises that aim relieving the pain and passive methods that include resting and avoidance from lifting heavy objects. For medication treatment, pain killers and anti-edema agents as well as muscle relaxants provide significant help. A long-term measure is loss of weight. The condition persists in a group of patients and neither surgery nor medication treatment is sufficient whatsoever the diagnosis is. The major one of those conditions is lumbar hernia.


In practice, lumbar hernia is the most common cause of the low back pain. The cartilage disc located between two vertebras ruptures and bulges into the spinal canal and compresses the nerves that innervate legs. The result is a low back pain followed by foot pain. For lumbar hernia cases that are easily diagnosed with MRI, there is no definitely curative medicine. Steroid agents may relieve some complaints, but steroid agents in injection or pill form cannot be substantially delivered to cartilages, as there is no vascularization in the torn cartilage.  Cartilage tears to the lateral side by 30%. Transforaminal steroid injection provides good outcomes in those patients. In this method, steroids are directly instilled to the diseased site and exert effects.

Transforaminal epidural steroid injection is, therefore, an important option that is considered among methods preferred for patients with no response to the medical treatment. Moreover, it is also a good method for infectious neural root diseases, such as Herpes Zoster and edema and inflammation secondary to tumoral invasion in cancer patients as well as neuralgic pain, spinal canal stenosis, scoliosis, lumbar spondylolisthesis and low back pain persisting after lumbar hernia surgery.

It is an advantageous method, as it can be applied under local anesthesia in a short time (3 to 5 minutes) on a special surgical table using a special imaging device at operating room conditions and the patient can be discharged to home 1 hour after the injection. Although the term “steroid agent” fears patients, it causes no side effect as it is used at very small concentrations, excluding some very rare conditions. Patients can engage in routine work life following 1-day resting at home.


Facet joint is a real joint between upper and lower articular processes of one vertebra and the other adjacent vertebra and it is located at the posterior part of the spinal column. Facet joints ensure strength and anterior and posterior bending and twisting motions. The joint is covered by a thin, superficial cartilage and wrapped by a capsule; the joint space is filled by synovial fluid (the fluid that nourishes the cartilage and prevents friction between two osseous surface when the spine moves).

There are two principle causes of facet joint injection.

1.              Diagnosis: Determining cause of the pain.

2.               Treatment: Treating the abnormality determined.

 A problem in facet joint (such as inflammation, irritation, swelling or arthritis) may cause low back pain. Pains that refer to foot may mimic the lumbar hernia.  Low back pains in advanced age are largely caused by facet joint disorders. Diagnostic tests may point to the abnormality in the facet joint and reveal out that the facet joint is the cause of the pain. It is characterized by aggravation at night and during immobility. If it is determined that the true cause of the low back pain is facet joints and if a small dose of local anesthetic agent administered to the facet joint relieves or eliminates the pain, it points to the fact that the pain is caused by the facet joint.  This procedure is diagnostic use of facet joint injection.

If it is definitely determined that the facet joint is the cause of the pain, therapeutic injection of anesthetic agents and steroid agents may ensure long-standing relief of the pain.

Both procedures are applied in a short time (5 minutes) in the operating theater using a special X-ray device and the patient is discharged to home after the procedure.

- Transforaminal injection and facet joint block are alternative methods that are reserved for persistent low back pain.

- Better outcomes are obtained, if the treatment is supported by anti-edema medicines.

- The gold recommendation includes concomitant weight loss and exercises that strengthen abdominal muscles.

 Levent Akduygu, M.D.

Neurosurgeon, Türkiye Hastanesi