1. 2026;29;1-16Updated Analysis of Declining Utilization Rate of 13% Epidural Procedures for Chronic Spinal Pain Management in the Traditional Medicare Population from 2019 to 2024
   Health Policy Research
   Laxmaiah Manchikanti, MD, Mahendra Sanapati, MD, Vidyasagar Pampati, MSc, Alan D. Kaye, MD, PhD, Nebojsa Nick Knezevic, MD, PhD, Annu Navani, MD, Devi Nampiaparampil, MD, and Joshua A. Hirsch, MD.

BACKGROUND: Recent analysis of epidural procedure utilization has demonstrated significant shifts over the past 25 years. Utilization increased substantially until 2004, continued with modest growth through 2011, and then gradually declined through 2019 among the Medicare population. Influences from the COVID-19 pandemic, the Affordable Care Act (ACA), and economic pressures have continued to contribute to declining utilization patterns.

OBJECTIVE: The present investigation provides an updated evaluation of epidural procedure utilization for chronic pain management in the U.S. Medicare population, focusing on the time periods of 2000 to 2010, 2010 to 2019, and 2019 to 2024. 

STUDY DESIGN: A retrospective cohort study evaluating utilization patterns and variables for epidural injections in the fee-for-service (FFS) traditional Medicare population in the U.S. from 2000 to 2024.

METHODS: A retrospective longitudinal analysis of Medicare Part B data from 2000 through 2024 was completed. Epidural injection services included cervical/thoracic and lumbar/caudal interlaminar injections, and cervical/thoracic and lumbar/sacral transforaminal injections, identified using procedure codes in the study database. A procedure or service represented all interventions performed during a treatment episode, incorporating add-on codes and bilateral services. Episodes were defined as one unit regardless of bilateral or additional services, reflecting the number of times patients received treatment. Utilization was assessed through counts, rates per 100,000 beneficiaries, geometric mean changes, and percent changes across key intervals (2000–2010, 2010–2019, 2019–2024). Trends by provider’s specialty and place of service were also evaluated.

RESULTS: From 2000 to 2010, services, episodes, and rates per 100,000 beneficiaries increased 144.3%, 126.1%, and 103%. From 2010 to 2019, this pattern shifted to declining utilization, with reductions of 9.5% in services, 0.4% in episodes, and 9% in rates per 100,000. From 2019 to 2024, procedural rates declined 13%, episodes declined 22.6%, and episode rates declined 11.9%, corresponding to average annual reductions of 2.8%, 4.3%, and 2.6%.
Comparative analysis showed that from 2000 to 2010, interlaminar epidural rates increased 43.8%, whereas transforaminal epidural rates increased 579.1%. From 2010 to 2019, interlaminar rates declined 18.4%, while transforaminal rates increased 5%. From 2019 to 2024, interlaminar rates declined 14.6% compared to 8.7% for transforaminal procedures. By 2024, interventional pain specialists performed over 92% of all epidural injections, while other specialties showed decreasing participation. A continued shift toward office settings and ambulatory surgery centers (ASCs) was also observed.

LIMITATIONS: The study includes data only through 2024 and is limited to the FFS Medicare population, excluding Medicare Advantage beneficiaries who accounted for 54% of Medicare enrollment by 2024. Limitations inherent to retrospective claims data also apply. 

CONCLUSION: Epidural injection utilization has shifted substantially over the last 25 years, driven by changes in clinical practice, regulatory and economic influences, and pandemic-related disruptions. The increasing concentration of procedure utilization among interventional pain specialists, together with the continued expansion of transforaminal techniques, underscores the progressive specialization and refinement of interventional pain management within the Medicare population.

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)