Enhanced Delivery of Transforaminal Epidural Steroid Injection (TFESI) for Radiculopathy Associated with Acute Lumbar Disc Prolapse Through Physiotherapist-led Assessment, Consent, and Direct Listing.

CONTEXT: Invasive treatments for lumbar radiculopathy with persistent symptoms and concordant disc prolapse include a transforaminal epidural steroid injection (TFESI) and microdiscectomy. Evidence supports TFESI as a potential first-line alternative to surgery. Our expedited nerve root block service (ERBS) reduced progression to surgery; however, waiting times remained suboptimal.

OBJECTIVES

We evaluated a streamlined pathway incorporating physiotherapy-led consent and direct TFESI listing.

METHODS

This retrospective observational study evaluated a pathway modification in which the pre-procedure specialist consultation was removed. Two Musculoskeletal Clinical Assessment Service (MCAS) physiotherapists were trained to assess suitability, obtain consent, and list patients directly for TFESI, with consultant validation conducted virtually. The primary outcomes were the median waiting time from MCAS consent to TFESI and the change in waiting time compared with the previous pathway. Secondary outcomes were the proportion of listings validated, patient-reported response to TFESI, progression to surgery, and the association between TFESI response and disc pathology.

RESULTS

A total of 129 patients provided consent (mean age, 47.3 ± 12.7 years; 95% confidence interval (CI), 45.1 - 49.5; 63.6% female), with 100% validation. The median waiting time from MCAS consent to TFESI was 50 days (range, 2 - 262 days), representing a 37-day reduction (43%) compared with the previous pathway. A positive TFESI response occurred in 83% of patients, and 14% required microdiscectomy. Response rates were similar for disc protrusion (84%) and extrusion (81%).

CONCLUSIONS

A physiotherapy-led ERBS pathway was associated with reduced waiting times and no identified safety concerns, while maintaining a low conversion rate to surgery.