Trends in the Treatment in Low Back Pain

Janna Friedly, MD MPH – Rehabilitation Medicine

Summary: Epidural steroid injections (ESIs) for lumbosacral radiculopathy and axial spine pain syndromes are frequently used as an alternative to more invasive surgical treatments. ESIs are recognized as an accepted treatment for lumbosacral radiculopathy among PM&R specialists and are being performed with increasing frequency. However, no studies have adequately explored the practice pattern variations and the impact of ESIs on health care utilization and costs associated with low back pain. This project represents a systematic evaluation of the lumbar ESI practice pattern variations in the United States. The primary goals of this project are to characterize the use of ESIs for various low back pain syndromes, to understand practice pattern variations both geographically and by specialty over time and to determine the impact of ESIs on health care costs and subsequent health care utilization for low back pain syndromes. This project will make use of existing administrative claims data, thus focusing primarily on macro-level trends. These analyses are particularly important because they will help to clarify factors associated with changes in ESI rates and will assess the impact of recent practice advances. Understanding rates and trends in the use of ESIs may help to identify medical practices requiring more consistent therapeutic approaches as well as key areas for further research efforts.

Specific aim 1: To characterize trends and variations in patterns of lumbar epidural steroid injection (ESI) use. Are rates of lumbar epidural steroid injections increasing over time in the United States? Are there geographic variations in lumbar ESI rates nationwide and within small geographic service areas? Are there variations in techniques commonly practiced including the use of fluoroscopy (vs. blind approach) and the anatomical approach employed? Which diagnoses are ESIs being used to treat? Are there practice variations in which diagnosis ESIs are used to treat? Is there variation in the chronicity of symptoms for which ESIs are used, the total number of ESIs performed per patient and the concomitant use of other therapies such as physical therapy and/or chiropractic services? Are PM&R specialists as compared to other specialists performing a higher percentage of the lumbar ESIs over time?

Specific aim 2: To determine the impact of epidural steroid injections on subsequent costs and usage for the treatment of lumbosacral radiculopathy and other axial spine pain syndromes. Are ESIs associated with lower subsequent health care utilization and costs for low back pain? What are the inflation-adjusted costs per injection over time? What is the total health care expenditure for ESIs? Are there differences in rates of subsequent lumbar surgery in patients who have been treated with epidural steroid injections for radiculopathy.