De-implementing Spinal Injections in Pursuit of Value-Based Care: Rethinking Pain Relief

Lindsay A Ballengee; Trevor A Lentz; Christine Goertz; Frank McStay; Inga Morken; Steven Z George

doi:10.1016/j.jpain.2026.106245

De-implementing Spinal Injections in Pursuit of Value-Based Care: Rethinking Pain Relief

J Pain. 2026 Feb 25:106245. doi: 10.1016/j.jpain.2026.106245. Online ahead of print.

Authors

Lindsay A Ballengee¹, Trevor A Lentz², Christine Goertz³, Frank McStay⁴, Inga Morken⁴, Steven Z George⁵

Affiliations

¹ Duke University School of Medicine, Department of Population Health Sciences, 215 Morris Street, Durham, NC 27701, USA; Duke University School of Medicine, Department of Orthopaedic Surgery, 311 Trent Drive, Durham, NC 27710, USA; Duke Clinical Research Institute, 300 W. Morgan Street, Durham, NC 27701, USA. Electronic address: Lindsay.Ballengee@duke.edu.
² Duke University School of Medicine, Department of Population Health Sciences, 215 Morris Street, Durham, NC 27701, USA; Duke University School of Medicine, Department of Orthopaedic Surgery, 311 Trent Drive, Durham, NC 27710, USA; Duke Clinical Research Institute, 300 W. Morgan Street, Durham, NC 27701, USA; Duke Margolis Institute for Health Policy, 230 Science Drive, Durham, NC 27708, USA.
³ Duke University School of Medicine, Department of Orthopaedic Surgery, 311 Trent Drive, Durham, NC 27710, USA; Duke Clinical Research Institute, 300 W. Morgan Street, Durham, NC 27701, USA; Duke Margolis Institute for Health Policy, 230 Science Drive, Durham, NC 27708, USA.
⁴ Duke Margolis Institute for Health Policy, 230 Science Drive, Durham, NC 27708, USA.
⁵ Duke University School of Medicine, Department of Population Health Sciences, 215 Morris Street, Durham, NC 27701, USA; Duke University School of Medicine, Department of Orthopaedic Surgery, 311 Trent Drive, Durham, NC 27710, USA; Duke Clinical Research Institute, 300 W. Morgan Street, Durham, NC 27701, USA.

Abstract

Despite guideline recommendations to the contrary, patients experiencing low back pain are commonly exposed to low-value care. Spinal injections for chronic low back pain are a key example of this disconnect. Their persistence highlights the broader challenge of removing low-value practices in pain care. Low-value interventions rarely fade with the introduction of new treatments; rather, their continued use reflects entrenched reimbursement incentives, provider training norms, and patient expectations. This Focus Article applies implementation science concepts to examine spinal injections as an obvious candidate for de-implementation away from existing practice patterns. Evidence of limited effectiveness and risks is summarized, alongside multilevel determinants that sustain ongoing use at the provider, patient, organizational, and system levels. A range of strategies is mapped to guide change and a four-step roadmap is presented to operationalize these concepts. Embedding de-implementation of spinal injections alongside implementation efforts for other pain management options reframes change as an intentional redesign of care delivery rather than a withdrawal of treatment. By redirecting resources away from ineffective procedures and toward evidence-based alternatives, de-implementation offers a proactive pathway to improve outcomes, enhance equity, reduce waste, and strengthen patient trust in pain management. PERSPECTIVE: This article applies an implementation science lens to spinal injections for chronic low back pain. By outlining barriers, strategies, and describing a practical roadmap, it reframes de-implementation as a proactive quality improvement approach that offers other viable treatment options while redirecting resources towards higher value treatment options for pain management.

Keywords: Chronic low back pain; De-implementation; Epidural steroid injections; Low-value care; Value-based care.

Grants and funding

UH3 AT009790/AT/NCCIH NIH HHS/United States