1. 2024;27;E983-E994A 24% Decline in the Utilization of Epidural Procedure Visits for Chronic Spinal Pain Management in the Medicare Population from 2019 to 2022: Updated Analysis of the Effect of Multiple Factors
   Health Policy Research
   Laxmaiah Manchikanti, MD, Mahendra R. Sanapati, MD, Vidyasagar Pampati, MSc, Alan D. Kaye, MD, PhD, Alaa Abd-Elsayed, MD, Amol Soin, MD, Devi E. Nampiaparampil, MD, Nebojsa Nick Knezevic, MD, PhD, Christopher G. Gharibo, MD, and Joshua A. Hirsch, MD.

BACKGROUND: The analysis of epidural procedure utilization has revealed several notable trends over recent years. Utilization increased significantly until 2004, then rose minimally until 2011, followed by gradual declines up to 2019 in the Medicare population. The COVID-19 pandemic led to a marked 19% decline in usage from 2019 to 2020. Additionally, recent studies of interventional pain management techniques showed a 28.9% reduction in use from 2019 to 2022, leading to an average annual decline of 10.9%.

OBJECTIVE: The present investigation aims to provide an updated evaluation of epidural procedure usage for chronic pain management in the U.S. Medicare population.

STUDY DESIGN: A retrospective cohort study examining utilization patterns and variables for epidural injections in the fee-for-service (FFS) Medicare population in the U.S. from 2000 to 2022.

METHODS: Data was obtained from the Centers for Medicare & Medicaid Services (CMS) master database, specifically using the physician/supplier procedure summary for 2000–2022. Episodes or procedure visits were defined as one per region using primary codes only, while services included all procedure levels and any add-on codes.

RESULTS: Between 2000 and 2010, epidural episodes rose by 6.7% annually but then declined by 3% each year from 2010 to 2019. The COVID-19 pandemic led to a 19.3% reduction in procedures from 2019 to 2020, followed by a partial recovery of 5.5% in 2021, then another 10.9% drop in 2022. During 2019–2022, lumbar interlaminar and caudal procedures decreased by 26.9%, while cervical/thoracic interlaminar procedures declined by 24.2%. By 2022, transforaminal procedures surpassed interlaminar procedures, reversing the trend from 2000.

LIMITATIONS: This analysis includes data only through 2022 and is limited to the FFS Medicare population; it does not account for Medicare Advantage Plan enrollees, who made up nearly half of Medicare participants by 2022. Additionally, the study is subject to limitations inherent in retrospective claims data analysis.

CONCLUSION: This two-decade analysis indicates significant shifts in epidural procedure utilization, with steady increases until 2010, followed by a general decline affected by COVID-19 and other contributing factors. An approximate 24% decline in epidural procedure visits for chronic spinal pain management was noted from 2019 to 2022.

KEY WORDS: Chronic spinal pain, interventional techniques, interlaminar epidural injections, caudal epidural injections, transforaminal epidural injections, utilization patterns, COVID-19 pandemic, economic decline, Affordable Care Act (ACA)