We have just read the study titled “Comparison of the efficacy of transforaminal epidural steroid injection technique with and without contrast in lumbar radiculopathy: prospective longitudinal cohort study,” but we were surprised [1]. Since intravascular penetration is common during epidural steroid injection. Even though drawback technique, using real-time fluoroscopy with contrast agent is not possible to detect more than 30% of intravascular penetration [2,3]. You may get close to the nerve root or epidural area with the method that you describe, but how did you determine that there was no vascular penetration? To what extent does drawback technique protect you from spinal complications?

Serious complications due to particulate steroids have been reported in spinal procedures. Additionally, particulate steroids are recommended to be used only in selected situations [4]. Although you did not use contrast in the study and you used particulate steroids. Would not this pose a significant risk to patients?

Finally, while even minor complication rates are around 2% [5], you state that you have not seen any complications in your study. Could you consider this as biases?

To promote our understanding of your excellent research, we look forward to hearing from you regarding our submission. It will also be a good response for our colleagues who perform these procedures.