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Related Concept Videos

Local Anesthetics: Clinical Application as Spinal Anesthesia01:11

Local Anesthetics: Clinical Application as Spinal Anesthesia

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Spinal anesthetics are given during lower abdomen and limb surgeries to block sensory and motor neurons. They are administered in the mid to low lumbar regions, primarily acting on the cauda equina's nerve roots. The blockade level depends on the local anesthetic (LA) concentration. Usually, low LA concentrations are sufficient to block sensory fibers, while only high LA concentrations block motor fibers. Other factors like injection volume and speed, the patient's posture, and the drug...
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Related Experiment Video

Updated: Apr 27, 2026

Surgical Technique for Spinal Cord Delivery of Therapies: Demonstration of Procedure in Gottingen Minipigs
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Rationing by assumption: De-implementation of spinal injections requires rigorous comparative evidence.

Robert W Hurley1, Zachary L McCormick2, Steven P Cohen3

  • 1Departments of Anesthesiology, Translational Neuroscience, and Public Health, Pain Outcomes Lab, Wake Forest University School of Medicine, Winston Salem, NC, United States.

The Journal of Pain
|April 25, 2026
PubMed
Summary

De-implementing epidural steroid injections for chronic low back pain faces limitations. Critical analysis suggests current proposals lack rigorous evidence and may restrict patient access to cost-effective treatments.

Keywords:
Chronic low back painCognitive behavioral therapyCost-effectivenessDe-implementationEpidural steroid injectionsImplementation science

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Area of Science:

  • Health Services Research
  • Implementation Science
  • Pain Management

Background:

  • Epidural steroid injections (ESIs) are used for chronic low back pain (CLBP).
  • Implementation science frameworks aim to guide de-implementation of medical interventions.
  • A recent proposal targets ESI de-implementation for CLBP.

Purpose of the Study:

  • Critically evaluate the proposed framework for de-implementing ESIs for CLBP.
  • Identify limitations in the target population definition, evidence base, and comparative analyses.
  • Argue for rigorous comparative evidence before de-implementation.

Main Methods:

  • Commentary and critical analysis of a proposed implementation science framework.
  • Review of the evidentiary basis, including clinical practice guidelines and cost-utility analyses.
  • Examination of methodological rigor and symmetrical application of de-implementation standards.

Main Results:

  • The proposal inadequately defines the target population ('non-specific' CLBP).
  • The primary evidence source is under review for retraction due to methodological flaws.
  • Proposed alternative therapies have modest effect sizes and face a lower evidentiary standard.
  • Cost-utility analyses do not consistently favor de-implementation over ESIs.
  • Incentive analysis for de-implementation is not symmetrically applied.

Conclusions:

  • De-implementing ESIs requires head-to-head comparative effectiveness and cost-effectiveness data.
  • Current proposals risk restricting access to a potentially cost-effective therapy.
  • De-implementation must meet the same rigorous evidentiary standards as implementation.