When it comes to healthcare, as a primary care physician, I follow the news closely. When Medicare saw there was an overutilization of spinal procedures, the response was to pay closer attention to claims submitted. They also cut reimbursement for these procedures. Shouldn’t the same policies be instituted for private insurance? In the meantime, should I advise my patients to skip spinal injections recommended by other physicians when research doesn’t show this treatment is effective?

Spinal injections are used for people with back pain that has not improved with conservative care. Such injections include epidural steroid injections, nerve blocks, radiofrequency neurotomy (heat nerves to stop pain transmission), sacroiliac injections, and discography (injecting dye into the disc to look for disc protrusion or herniation).

There is a concern about this pattern of overuse because as you point out, research does NOT support this treatment as an effective way to manage back pain. And in the case of spinal injection treatment, more is not better. In other words, if the first three injections didn’t help, further injection therapy isn’t likely to benefit the patient either.

In studies of Medicare and VA patients, the majority of spinal injection procedures were being done by a small number of medical specialists. Anesthesiologists, neurologists, and physicians at specialty pain clinics were the ones most likely to be giving these injections.

And the top 10 per cent of providers were responsible for one-third of all spinal injections. Similar patterns of overuse were found in a recent study at the University of Colorado School of Medicine by using data entered into a central database for privately insured adults

The authors of that particular study pointed out it is important to remember that all high utilization doesn’t necessarily mean overuse. There may simply be some physicians who are so skilled at this treatment that patients do get better. They spread the word and before you know it, more patients are going to the same physicians. But there is a way to find out if this is really what is happening.

And this study sheds light on the subject. By showing who is doing how many procedures and then evaluating the results, it is possible to see whether improved outcomes are the result of clinical expertise. It looks more like a certain group of physicians are using spinal injections to treat more people than should be included (based on evidence of who is a good candidate for this procedure). It is also possible (though not proven yet) that these same providers are accepting less than optimal results. And profit can certainly be a strong motivator for some physicians.

What can be done about this pattern of overutilization of spinal injection procedures? Guidelines for the responsible use of injection spine procedures must be published based on high-quality evidence. Such guidelines would give physicians a standard by which to guide treatment decisions. Insurance companies could also use the guidelines to base reimbursement on.

That sounds simple enough but what may be excessive for one patient may be just right for another. Some insurance companies have set limits and restrictions (e.g., only covering four injections in a six month period).

Until major guiding organizations such as the North American Spine Society can give more than suggestions for the use of spinal injections, perhaps treatment should be guided by practice consensus (best opinions of current experts based on current evidence).