Reducing Reliance on Epidural Steroid Injections Through Evidence-Based De-Implementation
Key Takeaways:
- Epidural spinal injections (ESIs) are the procedural treatment for chronic low back pain, but care risks and limited long-term benefits make them a good candidate for de-implementation.
- Current financial incentives and inequitable access contribute to the prolonged use of ESIs for patients with chronic low back pain. Reforming payment models and patient access are crucial for redirecting care toward more effective therapies.
- Researchers describe a 4-step process to de-implementing ESIs that involves analyzing treatment data, engaging patients, providers, payers, and policymakers, designing de-implementation strategies, and then measuring results.
Despite documented evidence of inadequate long-term benefits, ESIs prevail as the most common form of treatment for patients with chronic low back pain. Their continued popularity highlights the necessity of normalizing de-implementation strategies in health care to remove and restrict ineffective and potentially harmful treatments.
Researchers examined ESIs as a viable candidate for de-implementation and outlined various de-implementation strategies using a 4-step process.
Spinal Injections as a Low-Value Therapy
For patients with non-specific chronic low back pain, ESIs have not been found to provide meaningful long-term relief or to improve physical function.
Additionally, reliance on ESIs comes with a multitude of risks. ESIs can cause dural puncture, infection, and nerve damage. Over exposure has been associated with bone demineralization, increased fracture risk, and adrenal suppression. Furthermore, reliance on spinal injections can lead to the reduction of active, evidence-based therapies designed to improve pain relief and physical function for chronic low back pain.
De-Implementing Spinal Injections
De-implementation requires deliberate, systemic strategies aimed at restricting and removing low-value treatments. Viable alternatives must be presented as suitable replacements for the therapy being de-implemented. Alternatives to ESIs include physical therapy, chiropractic care, massage, acupuncture, and mind-body therapies such as yoga and tai chi.
Barriers to de-implementation revolve around financial incentives and access. Payment and reimbursement structures favor procedural treatments, even if the efficacy of those treatments is limited. Additionally, disparities in access lead to underserved populations choosing the more available option.
According to the researchers, interdisciplinary, proactive efforts are needed to reduce these barriers and promote alternatives to ESIs. A restructured payment system that prioritizes population management and patient-centered care will incentivize providers and payers to redirect care toward more effective treatments.
The authors outlined a 4-step guideline to de-implementing ESIs:
- Step 1: Measure Current Practice Patterns
- Step 2: Engage Stakeholders and Identify Drivers of ESI Use
- Step 3: Design a De-Implementation Strategy
- Step 4: Monitor Impact and Effects of Strategy
According to the authors, “Prioritizing de-implementation alongside implementation creates space for treatments that deliver the greatest benefit and reinforces an ethical commitment to providing care that is effective, equitable, and worthy of patient trust.”
Reference
Ballengee LA, Lentz TA, Goertz C, McStay F, Morken I, George SZ. De-implementing spinal injections in pursuit of value-based care: rethinking pain relief. J Pain. 2026:106245. doi:10.1016/j.jpain.2026.106245
