An Updated Analysis of Utilization of Epidural
Procedures in Managing Chronic Pain in the
Medicare Population from 2000 to 2018
Authors: Manchikanti Laxmaiah 
Published: March 2021

Background: With increasing costs of health care in the United States, attention is focused on
expensive conditions. Musculoskeletal disorders with low back and neck pain account for the
third highest amount of various disease categories. Minimally invasive interventional techniques
for managing spinal pain, including epidural injections, have been considered to be growing
rapidly. However, recent analyses of utilization of interventional techniques from 2000 to 2018 has
shown a decline of 2.6% and a decline of 21% from 2009 to 2018 for epidural and adhesiolysis
procedures.
Objectives: The objectives of this analysis of epidural procedures from 2000 to 2018 are to
provide an update on utilization of epidural injections in managing chronic pain in the fee-forservice (FFS) Medicare population, with a comparative analysis of 2000 to 2009 and 2009 to 2018.
Study Design: Utilization patterns and variables of epidural injections in managing chronic
spinal pain from 2000 to 2009 and from 2009 to 2018 in the FFS Medicare population in the
United States.
Methods: This analysis was performed by utilizing master data from CMS, physician/supplier
procedure summary from 2000 to 2018. The analysis was performed by the assessment of
utilization patterns using guidance from Strengthening the Reporting of Observational Studies in
Epidemiology (STROBE).
Results: Overall, epidural procedures declined at a rate of 20.7% per 100,000 Medicare enrollees
in FFS Medicare in the United States from 2009 to 2018, with an annual decline of 2.5%. However,
from 2000 to 2009, there was an increase of 89.2%, with an annual increase of 7.3%. This analysis
showed a decline in all categories, with an annual decrease of 4.7% for lumbar interlaminar and
caudal epidural injections, 4.7% decline for cervical/thoracic transforaminal epidural injections,
1.1% decline for lumbar/sacral transforaminal epidural injections, and finally 0.4% decline for
cervical/thoracic interlaminar epidural injections. Overall declines from 2009 to 2018 were highest
for cervical and thoracic transforaminal injections with 35.1%, followed by lumbar interlaminar
and caudal epidural injections of 34.9%, followed by 9.4% for lumbar/sacral transforaminal
epidurals, and 3.5% for cervical and thoracic interlaminar epidurals.
Limitations: This analysis was limited by noninclusion of Medicare Advantage plans, which
constitutes almost 30% of the Medicare population. In addition, utilization data for individual
states continues to be sparse and may not be accurate or representative of the population.
Conclusions: The declining utilization of epidural injections in all categories with an annual of
2.5% and overall decrease of 20.7% from 2009 to 2018 compared with annual increases of 7.3%
and overall increase of 89.2% from 2000 to 2009 shows a slow decline of utilization of all epidural
injections.
Key words: Chronic spinal pain, interlaminar epidural injections, caudal epidural injections,
transforaminal epidural injections, utilization patterns