Epidural steroid injection overuse

Epidural Steroid Injection Overuse: Measuring the Terrain First

Epidural steroid injection overuse is a pattern of repeat procedures with no measured reason or result behind them. The correction is a documented metabolic, cognitive and balance baseline taken before the next procedure and taken again after it.

Utilization data record how often the needle is used and nothing about the patient it was used on. A baseline measured before the next procedure is the outcome field the claims never had.

Epidural steroid injection overuse is almost never visible in one chart. It appears in aggregate: in traditional Medicare the transforaminal epidural rose 579 percent between 2000 and 2010, and in commercial claims patients averaged 4.46 spinal procedures in the twelve months after their first. Chapter 12 of The Pained Brain, by Dr. Gurpreet Singh Padda, MD, MBA, MHP, and Dr. KrisJay Fucanan, MD, defends the procedure as a bridge and rejects it as a destination. For a practice, the variable that separates the two is measurable: whether anything about the patient’s terrain was documented before the next procedure and documented again after it.

Why can’t claims data show epidural steroid injection overuse?

The utilization literature shares a limitation that matters more than its magnitude: none of it carries an indication or an outcome. In a cohort of 196,332 commercially insured patients, the busiest tenth of providers performed 36.6 percent of spinal procedures, nine times the lowest tenth. After a first lumbar medial branch ablation in 44,936 patients, repeats accumulated to 45.7 percent by seven years. Across 4,108,121 patients with a lumbar degenerative diagnosis, the annual injection rate held near 10 percent, and states that injected more also operated more. Since 2019 the direction has reversed, with interventional techniques down 16.8 percent in traditional Medicare through 2024.

Both trends are uninterpretable at the patient level. A repeat ablation after genuine relief can be guideline-consistent, and claims cannot tell a planned repeat from a failure; a decline cannot tell better selection from reduced access. The same fix answers both: record a measured state of the patient that can be compared over time.

What drives repeat spinal procedures?

In a study of 31 physician organizations affiliated with 22 health systems, volume formed the base incentive for 93.3 percent of specialist incentive plans and for 83.9 percent in primary care, with quality metrics carrying a minor share of the weighting. Practices tend to cite a different driver. Surveyed, 2,106 physicians estimated a median 20.6 percent of care is unnecessary and named malpractice fear most often. Yet when 36 hospitalists rated 4,215 of their own orders, 28 percent carried some defensive motive, and those claiming the most defensive orders did not order more than their peers. Habit, referral patterns and training carry part of the pattern too, which is exactly why structure, not exhortation, has to change the default.

Epidural steroid injection overuse: what the repeat-procedure chart omits

The composite patient in the chapter arrives for his ninth epidural with imaging, a nerve study and a surgical opinion on file, and no fasting insulin, diet history or sleep history. The medication burden that accompanies that pattern is well described. Excessive polypharmacy, ten or more agents, reached 25.9 percent in a Quebec chronic pain cohort. Of 20,422 discharges of older polypharmacy inpatients, an opioid combined with a hypnotic appeared in 24.5 percent of those with chronic noncancer pain. In nursing homes, roughly one resident in twenty started on a gabapentinoid had a loop diuretic added within three months.

The two biological drivers the procedure pathway leaves unmeasured are metaflammation with insulin resistance and the iatrogenic load of the regimen itself. Neither appears in a utilization count, and both can be measured in an ordinary clinic.

A measured baseline before the next procedure

Measura [Cardiometabolic and Autonomic Health Analysis] is a testing service; it measures, does not treat, and returns results to the ordering physician. For a patient on a repeat-procedure pathway, a documented baseline might include:

• Laboratory panels for metabolic markers, with fasting insulin specified on the order
• Bioimpedance body composition, so muscle and fat compartments are tracked rather than weight
• Cognitive assessment with vestibular and balance testing when the regimen combines opioids, hypnotics or gabapentinoids, tied into the practice’s fall-prevention workflow
• Heart rate variability or broader autonomic testing when the history points toward autonomic involvement

Standing orders make the baseline reproducible instead of dependent on who staffs the clinic that day. The annual wellness visit is a natural anchor, and structured results feed the documentation that MIPS and HEDIS reporting rely on.

How does remeasurement show whether a plan worked?

The clearest demonstration that terrain moves comes from outside pain. The DiRECT trial began from the premise that type 2 diabetes requires lifelong treatment and randomized primary care practices to a structured weight-management program. Remission ran 46 against 4 percent at one year and 36 against 3 at two, with antidiabetic drugs still prescribed in 40 against 84 percent. The response was graded by weight lost: 57 percent remission at 10 to 15 kilograms and 86 percent at 15 or more. That gradient is what a practice can only see if weight, composition and metabolic markers were measured at the start.

The pain data are smaller and honest. Multidisciplinary rehabilitation improves pain by about half a point on a ten-point scale over usual care. Its larger contribution is dependency: in 1,457 patients in a three-week program, 86.74 percent of opioid users were weaned with no difference in improvement by admission dose, though 30.70 percent resumed within a year. Across 86 samples and 15,616 patients, self-efficacy predicted impairment, distress and pain prospectively, which argues for showing patients their own measured change.

Why the process reforms missed

Choosing Wisely was followed by a 4 percent relative reduction in low-value back imaging, and a value-based primary care program left back imaging at 13.8 percent in both arms. Both targeted the order, not the patient. Continuity is the counterexample: annual physician face time per person in the United States is 60.4 minutes, while 18 of 22 studies linked greater continuity with lower mortality, and among 4,552,978 Norwegians more than fifteen years with one physician carried an odds ratio for death of 0.75. Decision aids made a values-matched choice 1.75 times as likely. Measurement, continuity and a shared decision are one workflow. The preceding topic in the series is screening for cluster headache, the next is image guidance, and every study cited is in the Chapter 12 technical companion.

Frequently asked questions

References

• Abbott, Z. I., Nair, K. V., Allen, R. R., & Akuthota, V. R. (2012). Utilization characteristics of spinal interventions. The Spine Journal, 12(1), 35–43. https://doi.org/10.1016/j.spinee.2011.10.005
• Starr, J. B., Gold, L. S., McCormick, Z., Suri, P., & Friedly, J. (2019). Repeat procedures and prescription opioid use after lumbar medial branch nerve radiofrequency ablation in commercially insured patients. The Spine Journal, 20(3), 344–351. https://doi.org/10.1016/j.spinee.2019.10.005
• Reid, R. O., Tom, A. K., Ross, R. M., Duffy, E. L., & Damberg, C. L. (2022). Physician Compensation Arrangements and Financial Performance Incentives in US Health Systems. JAMA Health Forum, 3(1), e214634. https://doi.org/10.1001/jamahealthforum.2021.4634
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• Lean, M. E.; Leslie, W. S.; Barnes, A. C.; Brosnahan, N.; Thom, G.; McCombie, L.; Peters, C.; Zhyzhneuskaya, S.; Al-Mrabeh, A.; Hollingsworth, K. G.; Rodrigues, A. M.; Rehackova, L.; Adamson, A. J.; Sniehotta, F. F.; Mathers, J. C.; Ross, H. M.; McIlvenna, Y.; Stefanetti, R.; Trenell, M.; … Taylor, R. (2018). Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet, 391(10120), 541–551. https://doi.org/10.1016/S0140-6736(17)33102-1
• Huffman, K. L.; Rush, T. E.; Fan, Y.; Sweis, G. W.; Vij, B.; Covington, E. C.; Scheman, J.; Mathews, M. (2017). Sustained improvements in pain, mood, function and opioid use post interdisciplinary pain rehabilitation in patients weaned from high and low dose chronic opioid therapy. Pain, 158(7), 1380–1394. https://doi.org/10.1097/j.pain.0000000000000907
• Jackson, T., Wang, Y., Wang, Y., & Fan, H. (2014). Self-efficacy and chronic pain outcomes: a meta-analytic review. The Journal of Pain, 15(8), 800–814. https://doi.org/10.1016/j.jpain.2014.05.002
• Sandvik, H., Hetlevik, Ø., Blinkenberg, J., & Hunskaar, S. (2022). Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway. British Journal of General Practice, 72(715), e84–e90. https://doi.org/10.3399/BJGP.2021.0340
• Stacey, D., Lewis, K. B., Smith, M., Carley, M., Volk, R., Douglas, E. E., Pacheco-Brousseau, L., Finderup, J., Gunderson, J., Barry, M. J., Bennett, C. L., Bravo, P., Steffensen, K., Gogovor, A., Graham, I. D., Kelly, S. E., Légaré, F., Sondergaard, H., Thomson, R., … Trevena, L. (2024). Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews, 1(1), CD001431. https://doi.org/10.1002/14651858.CD001431.pub6

Related reading

• Screening for Cluster Headache in Primary Care: A Three-Item Workflow
• Before the Diagnostic Nerve Block: What the Referring Chart Needs
• Laboratory Panels

Medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP, medical director of Measura. Last reviewed September 12, 2026.