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was lidocaine followed by a corticosteroid chosen at the discretion of the treating physician (methylprednisolone, betamethasone, triamcinolone or dexamethasone). Main Outcome Measures: Morning serum cortisol levels (a marker of hypothalamic pituitary axis suppression) obtained at 3 weeks post injection; predictive variables included age, gender, body mass index, smoking history, race, diabetes, depression, baseline opioid use and type of corticosteroid administered. Results: Patients receiving corticosteroids plus lidocaine experienced a mean 14.4% reduction in cortisol levels at week 3 compared to baseline vs. an 8.2% increase for those receiving lidocaine alone (P¼.002). Compared to patients treated with lidocaine alone injections, patients who received methylprednisolone and triamcinolone had an average three-week cortisol reduction of 41.0% (P¼.005) and 41.6% (P<.001) from baseline. Three-week change in cortisol was not statistically different among patients treated with betamethasone [1.8% reduction P¼.801]) or dexamethasone (23.3%, P¼.114) relative to those receiving lidocaine alone injections. Steroid-moderated differences in three-week cortisol change did not otherwise differ by demographic or patient-level baseline characteristics. Conclusions: Risk of cortisol suppression was not associated with any demographic or patient-level baseline characteristics. Use of methylprednisolone or triamcinolone in epidural corticosteroid injections for spinal stenosis was associated with significantly higher risk of cortisol suppression at three weeks than use of betamethasone or dexamethasone. These findings of systemic effects are consistent with the known longer duration of effect and higher hydrocortisone equivalency of methylprednisolone and triamcinolone as compared to betamethasone and dexamethasone. Objective: To determine the utilization of spinal interventional techniques by physician specialty and the modalities of physical therapy in the management of degenerative spondylolisthesis in Medicare beneficiaries. Design: Retrospective observational study of the Medicare population.Setting: This study utilized the 5% national sample of Medicare carrier claims from 2000 through 2011.Participants: A cohort of beneficiaries with a new ICD-9 diagnosis code for degenerative lumbar spondylolisthesis was identified. Beneficiaries with a concurrent diagnosis of lumbar trauma, infection or malignancy were excluded. Current procedural terminology codes for lumbar interventional techniques and physical therapy were used to identify the expenditures each year by specialty on this cohort. Interventions: Not Applicable. Main Outcome Measures: Rate of Surgery. Results: A total of 95,647 individuals with a new diagnosis of degenerative spondylolisthesis were included in the analysis. Over 40% of beneficiaries included in this analysis underwent at least one injection, approximately one third (37%) participated in physical therapy, one in five (21%) underwent spinal surgery, and one third (36%) did not utilize any of these inter...

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