Facet Injections, Prior Authorization, and the Future of Image-Guided Spinal Pain Management

Imaged-guided spinal injections have long been used to treat chronic neck, back, and radicular pain. As a neuroradiologist who has performed thousands of these injections, I believe they are an excellent treatment option for many patients. However, I am concerned that recent reimbursement changes to some spinal injections may have unforeseen consequences on the entire field of spinal pain management.

Why? Image-guided injections are targeted therapies. The radiologists, anesthesiologists, and pain medicine physicians who perform such injections use preprocedural and intraprocedural imaging to administer medicine in precise anatomic locations. This targeted approach offers pain reduction without the considerable risks and adverse effects of opioids. Nevertheless, the injections are designed to be performed in specific clinical contexts.

Take intra-articular facet injections. Administration of steroids into facet joints is meant for patients who have discomfort localized to the neck or back and with facet osteoarthritis in the corresponding region, especially if associated with evidence of acute joint inflammation.¹ In my practice, most patients fit this mold neatly. Others do not. Those that do not fit the mold often have vague symptoms or describe pain that is either widespread or does not conform to a clear underlying diagnosis.

To be fair to our ordering providers, the management of chronic pain is incredibly difficult and often lacks satisfactory answers from modern medicine. Patients with ill-defined pain are especially challenging because few viable treatments exist. Furthermore, most providers feel tremendous pressure to offer patients some form of treatment, rather than sending them out the door with nothing. In that setting, intra-articular facet injections represent a reasonable option that is both low-risk and potentially beneficial. Still, the result can be frustrating for radiologists. Too often, intra-articular facet injections feel like a “may as well try it” order for patients with ill-defined symptoms.

Also, consider the downstream effects. On an individual basis, performing intra-articular facet injections on patients with diffuse or ill-defined pain may cause little harm. On a greater scale, however, ineffectual injections can have a profound impact on the success rates of image-guided procedures. With time, the data supporting image-guided facet injections will weaken as it is confounded by an inappropriately large and frustratingly nonspecific pool of participants.

In fact, this confounding may have already occurred. Studies have historically produced mixed results regarding the efficacy of intra-articular spinal steroid injections. Some authors, including Mazmudar et al,² believe that these results reflect the heterogeneity of the studies performed. It seems equally likely, however, that patient heterogeneity is the culprit.

Regardless of the reason, a major change recently occurred that may upend image-guided spinal pain management. In 2023, the Centers for Medicare and Medicaid Services (CMS) began requiring prior authorization for facet joint injections, presumably as a cost-saving measure. Such requirements are predictably unpopular. For physicians and patients alike, prior authorizations represent a major roadblock in the prescription of targeted pain management.

Here is the crux of the issue. The enormous pool of patients with both chronic axial low back pain and nonspecific pain has not disappeared, nor has the pressure on the pain management physicians to offer treatment options for these patients. Instead, it is possible that the new requirement of the CMS has simply led to a change in pain management. Anecdotally, I have seen a substantial uptick in the number of inappropriate transforaminal injection requests, both for patients with chronic axial low back pain and the patients with nonspecific, ill-defined symptoms. In short, transforaminal injections feel like they are becoming the new “may as well try it”.

If my instincts are correct, and if what I have witnessed reflects a broader national trend, this requirement could have a substantial negative impact on the future of image-guided transforaminal injections. As the pool of patients undergoing transforaminal injections swells and as the specificity of these injections decreases, the data supporting such procedures will undoubtedly appear weaker.

I passionately believe in the efficacy of appropriately ordered and competently performed image-guided spinal injections. For the good of our patients, it is up to us to protect the integrity of these procedures. This protection will require an ongoing, multifaceted approach from our community, in which together we: 1) ensure that future studies assessing spinal injection efficacy adhere to stringent inclusion criteria, 2) educate both ordering providers and patients on when spinal injections should and should not be requested, and 3) have active political voices and advocating for reimbursement policies that do not compromise patient care.

• Received April 19, 2024.
• Accepted after revision May 17, 2024.

• © 2024 by American Journal of Neuroradiology