Long-Term Outcomes of Epidurals with Lidocaine With or Without Steroids for Lumbar Disc Herniation and Spinal Stenosis: A Meta-Analysis

BACKGROUND

Previous meta-analyses examined only the short-term differences between lidocaine and steroids vs lidocaine alone in treating lumbar degenerative diseases. Long-term outcomes (1-2 years) in patients with lumbar disc herniation (LDH) and lumbar central spinal stenosis (LCSS) have not yet been systematically evaluated.

OBJECTIVE

The objective of our study was to assess quantitatively the difference in efficacy at 1 to 2 years between lidocaine alone vs lidocaine and steroids for the management of LDH or LCSS.

STUDY DESIGN

We conducted a meta-analysis.

METHODS

PubMed, EMBASE, and the Cochrane library were electronically searched up to July 22, 2016, for randomized controlled trials comparing lidocaine alone vs in combination with steroids for the treatment of LDH and LCSS. Effective pain relief (EPR), Numeric Rating Scale (NRS-11), Oswestry Disability Index (ODI), opioid intake (OI), and total employed increased rate (TEIR) were the endpoints. Risk ratios (RRs) or weighted mean difference (WMD) with 95% confidence intervals (CIs) were calculated, and the pooled analysis was conducted using RevMan 5.2.

RESULTS

Seven trials were included. EPR was not significantly different at 1 and 2 years, with RR = 1.08 (95% CI, 0.90-1.30; P = .39) and RR = 1.04 (95% CI, 0.92-1.18; P = .51), respectively, in patients treated with lidocaine alone vs in combination with steroids. The NRS-11 was also similar at 1 and 2 years. ODI and OI were not significantly different at 1 and 2 years. A similar TEIR effect was also observed for the 2 treatments.

LIMITATIONS

This meta-analysis relied on a small sample size of trials. Significant heterogeneity among studies was observed. Several significant differences in terms of age of the patients were reported in one included trial.

CONCLUSION

This meta-analysis confirmed the similar effects associated with lidocaine alone vs in combination with steroids for the management of LDH and LCSS. Studies with longer follow-up periods are still recommended.

KEY WORDS

Effective pain relief, lidocaine, long-term, lumbar central spinal stenosis, lumbar disc herniation, Numeric Rating Scale, opioid intake, Oswestry Disability Index, steroids, total employed increased rate.

An Updated Analysis of Utilization of Epidural Procedures in Managing Chronic Pain in the Medicare Population from 2000 to 2018

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-for-service (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.

Retrospective cohort study of usage patterns of epidural injections for spinal pain in the US fee-for-service Medicare population from 2000 to 2014

OBJECTIVE

To assess the usage patterns of epidural injections for chronic spinal pain in the fee-for-service (FFS) Medicare population from 2000 to 2014 in the USA.

DESIGN

A retrospective cohort.

METHODS

The descriptive analysis of the administrative database from Centers for Medicare and Medicaid Services (CMS) Physician/Supplier Procedure Summary (PSPS) master data from 2000 to 2014 was performed. The guidance from Strengthening the Reporting of Observational studies in Epidemiology (STROBE) was applied. Analysis included multiple variables based on the procedures, specialties and geography.

RESULTS

Overall epidural injections increased 99% per 100 000 Medicare beneficiaries with an annual increase of 5% from 2000 to 2014. Lumbar interlaminar and caudal epidural injections constituted 36.2% of all epidural injections, with an overall decrease of 2% and an annual decrease of 0.2% per 100 000 Medicare beneficiaries. However, lumbosacral transforaminal epidural injections increased 609% with an annual increase of 15% from 2000 to 2014 per 100 000 Medicare population.

CONCLUSIONS

Usage of epidural injections increased from 2000 to 2014, with a decline thereafter. However, an escalating growth has been seen for lumbosacral transforaminal epidural injections despite numerous reports of complications and regulations to curb the usage of transforaminal epidural injections.

Percutaneous adhesiolysis procedures in the medicare population: analysis of utilization and growth patterns from 2000 to 2011

BACKGROUND

Multiple reviews have shown that interventional techniques for chronic pain have increased dramatically over the years. Of these interventional techniques, both sacroiliac joint injections and facet joint interventions showed explosive growth, followed by epidural procedures. Percutaneous adhesiolysis procedures have not been assessed for their utilization patterns separately from epidural injections.

STUDY DESIGN

An analysis of the utilization patterns of percutaneous adhesiolysis procedures in managing chronic low back pain in the Medicare population from 2000 to 2011.

OBJECTIVE

To assess the utilization and growth patterns of percutaneous adhesiolysis in managing chronic low back pain.

METHODS

The study was performed utilizing the Centers for Medicare and Medicaid Services (CMS) Physician Supplier Procedure Summary Master of Fee-For-Service (FFS) Data from 2000 to 2011.

RESULTS

Percutaneous adhesiolysis procedures increased 47% with an annual growth rate of 3.6% in the FFS Medicare population from 2000 to 2011. These growth rates are significantly lower than the growth rates for sacroiliac joint injections (331%), facet joint interventions (308%), and epidural injections (130%), but substantially lower than lumbar transforaminal injections (665%) and lumbar facet joint neurolysis (544%).

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.

CONCLUSION

Percutaneous adhesiolysis utilization increased moderately in Medicare beneficiaries from 2000 to 2011. Overall, there was an increase of 47% in the utilization of adhesiolysis procedures per 100,000 Medicare beneficiaries, with an annual geometric average increase of 3.6%.

Analysis of the growth of epidural injections and costs in the Medicare population: a comparative evaluation of 1997, 2002, and 2006 data

BACKGROUND

Interventional techniques for the treatment of spinal techniques are commonly used and are increasing exponentially. Epidural injections and facet joint interventions are the 2 most commonly utilized procedures in interventional pain management. The current literature regarding the effectiveness of epidural injections is sparse with highly variable outcomes based on the technique, outcome measures, patient selection, and methodology. Multiple reports have illustrated the exponential growth of lumbosacral injections with significant geographic variations in the administration of epidural injections in Medicare patients. However, an analysis of the growth of epidural injections and costs in the Medicare population has not been performed with recent data and has not been looked at from an interventional pain management perspective.

STUDY DESIGN

Analysis of epidural injection growth and costs in Medicare's population 1997, 2002, and 2006.

OBJECTIVES

The primary purpose of this study was to evaluate the use of all types of epidural injections (i.e. caudal, interlaminar, and transforaminal in lumbar, cervical and thoracic regions), and other epidural procedures, including epidural adhesiolysis. In addition, the purpose was to identify trends in the number of procedures, reimbursement, specialty involvement, fluoroscopy use, and indications from 1997 to 2006.

METHODS

The Centers for Medicare and Medicaid Services (CMS) 5% national sample carrier claim record data from 1997, 2002, and 2006 was utilized.

OUTCOMES ASSESSMENT

Outcome measures included Medicare beneficiaries' characteristics receiving epidural injections, epidural injections by place of service, type of specialty, reimbursement characteristics, and other variables.

RESULTS

Epidural injections increased significantly in Medicare beneficiaries from 1997 to 2006. Patients receiving epidurals increased by 106.3%; visits per 100,000 population increased 102.7%. Hospital outpatient department (HOPD) payments increased significantly; ASC average payments decreased; overall payments increased. The increase in procedures performed by general physicians outpaced that of interventional pain management (IPM) physicians.

LIMITATIONS

Study limitations include no Medicare Advantage patients; potential documentation, coding, and billing errors.

CONCLUSIONS

Epidural injections grew significantly. This growth appears to coincide with chronic low back pain growth and other treatments for low back pain. Since many procedures are performed without fluoroscopy, continued growth and inappropriate provision of services might reduce access.