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De-implementing Spinal Injections in Pursuit of Value-Based Care: Rethinking Pain Relief.
Lindsay A Ballengee1, Trevor A Lentz2, Christine Goertz3
1Duke 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.
The Journal of Pain
|February 27, 2026
Summary
Spinal injections for chronic low back pain are often low-value care. De-implementation strategies are needed to shift resources toward evidence-based pain management, improving outcomes and patient trust.
Area of Science:
- Implementation Science
- Health Services Research
- Pain Management
Background:
- Low back pain patients frequently receive low-value care, such as spinal injections, despite guidelines.
- The persistence of low-value interventions is driven by financial incentives, provider norms, and patient expectations.
- This disconnect highlights a significant challenge in reforming pain management practices.
Purpose of the Study:
- To apply implementation science concepts to the de-implementation of spinal injections for chronic low back pain.
- To examine the multilevel determinants sustaining the use of spinal injections.
- To present strategies and a roadmap for de-implementation.
Main Methods:
- Review of evidence on spinal injection effectiveness and risks.
- Analysis of multilevel determinants (provider, patient, organizational, system) of continued use.
- Application of implementation science frameworks to de-implementation.
Main Results:
- Spinal injections for chronic low back pain demonstrate limited effectiveness and carry risks.
- Multilevel factors contribute to the entrenched use of these low-value procedures.
- A four-step roadmap and various strategies are proposed for de-implementation.
Conclusions:
- De-implementation of spinal injections is a necessary step toward optimizing pain care.
- Reframing de-implementation as redesigning care, not withdrawing treatment, facilitates change.
- Redirecting resources from ineffective injections to evidence-based alternatives improves outcomes, equity, and trust.
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