Epidural Spinal Injection Safety, Coverage Guidelines by Multisociety Partnership

Between 1994 and 2001, the number of lumbar epidural spinal injections and facet joint interventions rose sharply among the Medicare population.

At the 33^rd annual meeting of the American Academy of Pain Medicine (AAPM), Virtaj Singh, MD, clinical faculty at the University of Washington, gave the opening lecture titled “Multisociety Pain Work Group: How Societies Work Together to Make a Difference.”¹ During his presentation, Dr Singh sought to highlight the successes of the Multi-Society Pain Work Group (MPW) that resulted in Medicare modifying its approach to coverage.

Between 1994 and 2001, the number of lumbar epidural spinal injections and facet joint interventions rose sharply among the Medicare population, with increases of 271% and 231%, respectively.² As the increases were deemed unsustainable for Medicare, the agency tasked field experts from several stakeholder societies to formulate consensus recommendations for these procedures.

As a result of this assignment, the MPW was initiated. Participating societies included the American Academy of Neurological Surgeons, AAPM, as well as radiology and anesthesiology societies. Despite being from different backgrounds, these groups reached consensus between 2013 and 2014, and established recommendations for cervical and lumbar epidural steroid injections (ESIs) and facet joint interventions. Medicare has now adopted these guidelines in 45 out of 50 states, and many of the prime insurers have followed suit.

This led Medicare to seek help from the MPW in order to establish safety guidelines for those procedures, which at the time were associated with increased risk of infection and spinal cord injury. In 2014, the MPW came together and developed 17 recommendations for safety.³ Although those recommendations are now adopted, they remain, in Dr Singh’s opinion, controversial. The recommendations stipulate that cervical and lumbar interlaminar ESIs be performed with image guidance, and that cervical and lumbar transforaminal ESIs be conducted under real-time fluoroscopy or digital subtraction angiography. In addition, cervical interlaminar ESIs should not be at a level higher than C6-C7, as the epidural space is much smaller in that region. Another recommendation that Dr Singh deemed of particular importance specifies that cervical transforaminal ESIs should never be done with particulate steroids, which are believed to have led to spinal cord injuries. Instead, nonparticulate steroids (eg, dexamethasone) should be used. Safety guidelines were also established to reduce the risk of infection associated with ESIs: procedures should be performed with extension tubing, face masks to avoid oral flora from getting into the epidural space and causing infection, and sterile gloves. In addition, the avoidance of moderate to heavy sedation during these procedures is advised so as to allow patients to communicate adverse reactions during the procedure.

While the MPW was shown to effectively advocate for both patients and clinicians, Dr Singh concluded, “ If physicians and societies are not proactive, we may not have a seat at the table when these decisions are being made…we need to be at the table and never assume that somebody else is going to do the work to advocate for us.”

References

1. Singh V. Multisociety Pain Work Group (MPW): how societies work together to make a difference. Presented at: American Academy of Pain Medicine 33rd Annual Meeting; March 16-19, 2017; Orlando, Florida.
2. Manchikanti L, Boswell MV, Giordano J, Friedly J, Chan L, Deyo R. Increases in lumbosacral injections in the Medicare population: 1994 to 2001. Spine2007;32:1754-1760.
3. Manchikanti L, Falco FJ. Safeguards to prevent neurologic complications after epidural steroid injections: analysis of evidence and lack of applicability of controversial policies. Pain Physician. 2015;18(2):E129-138.