Trends in lumbar epidural injection selection: A survey of practitioner preferences and practice patterns

Ryan Triglia , Andrew Walrond , Jesse Wagner , Paul M. Kitei , Jeffrey Boyd , Jeremy I. Simon
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Abstract

Background

Lumbar radiculopathy is estimated to affect approximately 3–5 % of the population. Among the leading causes of radiculopathy are degenerative or congenital spinal stenosis and lumbar disc herniations, which can contribute to compression and narrowing in various regions of the spine including the neural foramen, subarticular recess, or central canal. When patients do not respond to typical conservative treatment such as medications and physical therapy, epidural steroid injections can be considered as a next step in management. There are three approaches available for accessing the lumbar epidural space: caudal, interlaminar, and transforaminal. There is no clear consensus regarding the selected approach for an epidural injection based on a patient's history, physical examination, and imaging findings, however.

Objective

The purpose of this study was to explore how factors such as primary residency training, fellowship training, practice setting, adherence to IPSIS guidelines, geographic location, and years of experience may influence epidural approach preferences.

Methods

A survey was created utilizing the Survey Monkey™ platform which was then administered by the International Pain and Spine Intervention Society (IPSIS) to all active members via email. The survey consisted of seven questions asking for demographic information including residency specialty, fellowship training, if the fellowship emphasized IPSIS guidelines, years in practice, country of practice, and practice setting. There were questions that described hypothetical clinical scenarios that provided the respondent with the pain distribution and the associated pertinent magnetic resonance imaging (MRI) findings. For each scenario, the responder was given options for type of therapeutic injection the practitioner would choose. The final two questions then asked which steroid the responder would utilize for an interlaminar and transforaminal epidural steroid injection. The survey was open for completion during a three-month period. A total of 202 IPSIS members responded, with an average of 196 responses to each question with a completion rate of 74 %.

Results

Most respondents completed residency in Physical Medicine and Rehabilitation (63.1 %) or Anesthesiology (29.9 %), with 67.7 % reporting fellowship training aligned with IPSIS guidelines. The most common fellowship type was ACGME-accredited pain (38.6 %), and respondents were primarily based in the U.S. (84.8 %), practicing in private multi-specialty groups (35.5 %). Experience levels were well distributed, with most in either early (<5 years, 32.1 %) or late-career (>15 years, 34.7 %) stages. Across all six clinical scenarios, the transforaminal supraneural approach was most frequently selected, especially at L4-L5 and L5-S1. Respondents selecting the most common techniques were primarily PM&R-trained and fellowship-trained in ACGME pain programs using IPSIS-guided approaches, with a balanced distribution across years in practice. Dexamethasone was the most frequently used steroid for both interlaminar (35.1 %) and transforaminal (71.1 %) epidural injections. Providers selecting dexamethasone were again predominantly PM&R-trained, IPSIS-guided, and either early or late career.

Conclusion

Symptom distribution, particularly radicular pain, strongly influenced the choice of transforaminal supraneural injections, underscoring the primacy of clinical presentation over imaging alone. The predominant use of dexamethasone reflects a broader shift toward safety-oriented protocols. Overall, provider training and practice setting were more predictive of decision-making than clinical scenario complexity, highlighting the need for continued education across all provider types.
腰椎硬膜外注射选择的趋势:从业者偏好和实践模式的调查
腰椎神经根病估计影响大约3 - 5%的人群。神经根病的主要原因是退行性或先天性椎管狭窄和腰椎间盘突出,这可能导致脊柱各区域的压迫和狭窄,包括神经孔、关节下隐窝或中央椎管。当患者对典型的保守治疗如药物和物理治疗没有反应时,可以考虑硬膜外类固醇注射作为下一步的管理。有三种入路可用于进入腰椎硬膜外腔:尾侧入路、椎间入路和椎间入路。然而,基于患者的病史、体格检查和影像学表现,对于硬膜外注射的选择方法尚无明确的共识。目的本研究的目的是探讨主要住院医师培训、奖学金培训、实践环境、遵守IPSIS指南、地理位置和经验年数等因素如何影响硬膜外入路偏好。方法利用survey Monkey™平台进行调查,由国际疼痛和脊柱干预协会(IPSIS)通过电子邮件向所有活跃会员进行管理。该调查包括7个人口统计信息问题,包括住院医师专业、奖学金培训、奖学金是否强调IPSIS指南、实践年限、实践国家和实践环境。有一些问题描述了假想的临床场景,为被调查者提供了疼痛分布和相关的磁共振成像(MRI)结果。对于每一种情况,应答者都可以选择医生会选择的治疗注射类型。最后两个问题询问应答者将使用哪种类固醇进行椎间和经椎间孔硬膜外类固醇注射。这项调查将在三个月内完成。共有202名IPSIS成员回应,平均每个问题有196份回复,完成率为74%。结果大多数受访者完成了物理医学和康复(63.1%)或麻醉学(29.9%)的住院医师培训,其中67.7%的受访者报告了与IPSIS指南一致的奖学金培训。最常见的奖学金类型是acgme认证的疼痛(38.6%),受访者主要来自美国(84.8%),在私人多专业团体中执业(35.5%)。经验水平分布均匀,大多数在早期(5年,32.1%)或后期(15年,34.7%)阶段。在所有六种临床情况中,最常选择经椎间孔神经上入路,特别是L4-L5和L5-S1入路。选择最常见技术的受访者主要是在使用ipiss指导方法的ACGME疼痛项目中接受过PM&; r培训和奖学金培训,在实践中具有平衡分布。地塞米松是椎间(35.1%)和经椎间孔(71.1%)硬膜外注射中最常用的类固醇。选择地塞米松的服务提供者主要还是接受过pm&r培训,ipsis指导,或者是职业生涯的早期或晚期。结论症状分布,尤其是神经根性疼痛,强烈影响椎间孔神经上注射的选择,强调临床表现比影像学更重要。地塞米松的主要应用反映了更广泛的转向以安全为导向的方案。总的来说,医生培训和实践环境比临床情景复杂性更能预测决策,这突出了所有医生类型继续教育的必要性。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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