Background: Among the many diagnostic and therapeutic interventions available for the
management of chronic pain, epidural steroid injections are one of the most commonly used
modalities. The explosive growth of this technique is relevant in light of the high cost of
health care in the United States and abroad, the previous literature assessing the effectiveness
of epidural injections has been sparse with highly variable outcomes based on technique,
outcome measures, patient selection, and methodology. However, the recent assessment of
fluoroscopically directed epidural injections has shown improved evidence with proper inclusion
criteria, methodology, and outcome measures.
The exponential growth of epidural injections is illustrated in multiple reports. The present report
is an update of the analysis of the growth of epidural injections in the Medicare population from
2000 to 2011 in the United States.
Study Design: Analysis of utilization patterns of epidural procedures in the Medicare
population in the United States from 2000 to 2011.
Objectives: The primary purpose of this assessment was to evaluate the use of all types of
epidural injections (i.e., caudal, interlaminar, and transforaminal in the lumbar, cervical, and
thoracic regions) with an assessment of specialty and regional characteristics.
Methods: This assessment was performed utilizing the Centers for Medicare and Medicaid
Services (CMS) Physician/Supplier Procedure Summary (PSPS) Master data from 2000 to 2011.
Results: Epidural injections in Medicare beneficiaries increased significantly from 2000 to
2011. Overall, epidural injections increased 130% per 100,000 Medicare beneficiaries with an
annual increase of 7.5%. The increases per 100,000 Medicare recipients were 123% for cervical/
thoracic interlaminar epidural injections; 25% for lumbar/sacral interlaminar, or caudal epidural
injections; 142% for cervical/thoracic transforaminal epidural injections; and 665% for lumbar/
sacral transforaminal epidural injections. The use of epidurals increased 224% in the radiologic
specialties (interventional radiology and diagnostic radiology) and 145% in psychiatric settings,
whereas and physical medicine and rehabilitation physicians’ use of epidurals increased 520%.
Limitations: Study limitations include lack of inclusion of Medicare Advantage patients. In
addition, the statewide data is based on claims which may include the contiguous or other
states.
Conclusions: Epidural injections in Medicare recipients increased significantly. The growth was
significant for some specialties (radiology, physical medicine and rehabilitation, and psychiatry)
and for certain procedures (lumbosacral transforaminal epidural injections).
Key words: Spinal pain, interventional pain management, epidural injections, caudal epidural,
lumbar epidural, cervical epidural, cervical transforaminal, lumbar transforaminal
Academic Physical Medicine and Rehabilitation Acute Care Consultations