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Do Lumbar Epidural Steroid Injections Increase Infections After Lumbar Spine Surgery?

Epidural steroid injections (ESIs) have been demonstrated to successfully decrease pain in patients who have radiculopathy from disc herniations and stenosis.[1-2] ESIs are available as a form of conservative treatment that offer potential in either avoiding or postponing surgical intervention. However, in cases in which patients do not have pain relief after epidural steroid injections, how long should surgeons wait before they can operate on the patient without an increased risk of a postoperative infection? Some authors have recommended waiting more than 3 months before spine surgery, a concept further promoted by evidence in joint arthroplasty.[3-4] However, in a patients with pain refractory to ESI or with more rapid neurological deterioration, waiting an indeterminate period may not be the best option.[5] Thus, determining an appropriate time to wait after epidural steroid injections would be helpful for spine surgeons. In this article, I review the current literature on the increased risk of infections in patients who have had lumbar spine surgery after ESI.

Infection Rates After ESI

Some studies have reported increased infection rates in patients who have spine surgery after an epidural steroid injection. For example, Kreitz et al performed a retrospective review on 15,011 patients who had spine surgery.[6] Among the patient population, 5108 underwent fusion and 9903 had a decompression only. The infection rate was 1.95% for fusion patients and 0.98% in patients who had only decompression. The authors concluded that there was an increased risk of infection in patients who had a fusion but no increased risk in patients with decompression only. Although the authors noted an association between preoperative epidural steroid injections and fusion, BMI, and Charlson Comorbidity Index, there was no association between age and sex.

In another study, Singla et al performed a database search on patients who received ESI prior to surgery.[7] The authors noted an increased infection rate in patients who had a lumbar spinal fusion performed within 3 months after ESI, but they did not find an increased infection rate if the injection was performed more than 3 months prior to surgery. Yang et al performed a database search in the PearlDiver database.[8] The authors evaluated infection rates in patients who had single-level lumbar decompression after ESI. The authors noted that having a lumbar decompression within 3 months after ESI may be associated with an increased rate of infection. As a result, these authors recommended delaying surgery for 3 months after an ESI. Li et al performed a retrospective review of patients who had a lumbar fusion after ESI and found a statistically significant difference in patients who had an ESI 1 month prior to surgery.[9] Meanwhile, Donnely et al performed a database search on patients who had ESIs prior to lumbar decompression and found a statistically significant difference in patients who had an epidural steroid injection up to 6 months prior to surgery.[10]

Despite these reports, several papers have reported no association between infection rates and epidural steroid injections prior to surgery. In a study by Hartveldt et al, the medical records of 56,311 patients who had spine surgery were reviewed. Of these patients, 11,945 had an epidural steroid injection within 90 days of surgery, and 134 (2.5%) developed a postoperative infection.[11] The authors did not see an increased rate of infection in patients who had epidural steroid injections prior to surgery at any time points (within 30 days, 30-90 days, and greater than 90 days). Seavey et al performed a retrospective review on 6535 patients in the Military Heath Systems Repository and found no significant variation between an ESI cohort and a control cohort with regard to infection rates.[12] This finding was further validated by a similar study by Pisano et al.13

Conclusion

Overall, while conflicting data are present, current literature recommends delaying surgical intervention for at least 3 months after ESI in cases of lumbar fusion or increased patient comorbidity burden. However, some situations, such as increased progression of neurological deficits, may require surgeons to more critically discuss risks versus benefits with patients prior to surgical intervention.

References

1. Fekete T, Woernle C, Mannion AF, et al. The effect of epidural steroid injection on postoperative outcome in patients from the lumbar spinal stenosis outcome study. Spine. 2015;40(16):1303–1310.

2. Kaufmann TJ, Geske JR, Murthy NS, et al. Clinical effectiveness of single lumbar transforaminal epidural steroid injections. Pain Med. 2013;14(8):1126–1133.

3. Kreitz TM, Mangan J, Schroeder GD, et al. Do preoperative epidural steroid injections increase the risk of infection after lumbar spine surgery? Spine. 2021;46(3):E197.

4. Desai A, Ramankutty S, Board T, Raut V. Does intraarticular steroid infiltration increase the rate of infection in subsequent total knee replacements? Knee. 2009;16(4):262–264.

5. Støttrup CC, Andresen AK, Carreon L, Andersen MØ. Increasing reoperation rates and inferior outcome with prolonged symptom duration in lumbar disc herniation surgery: a prospective cohort study. Spine J. 2019;19(9):1463–1469.

6. Kreitz TM, Mangan J, Schroeder GD, et al. Do preoperative epidural steroid injections increase the risk of infection after lumbar spine surgery? Spine. 2021;46(3):E197.

7. Singla A, Yang S, Werner BC, et al. The impact of preoperative epidural injections on postoperative infection in lumbar fusion surgery. J Neurosurg Spine. 2017;26(5):645–649

8. Yang S, Werner BC, Cancienne JM, et al. Preoperative epidural injections are associated with increased risk of infection after single-level lumbar decompression. Spine J. 2016;16(2):191–196.

9. Li P, Hou X, Gao L, Zheng X. Infection risk of lumbar epidural injection in the operating theatre prior to lumbar fusion surgery. J Pain Res. 2020;13:2181–2186.

10. Donnally CJ, Rush AJ, Rivera S, et al. An epidural steroid injection in the 6 months preceding a lumbar decom - pression without fusion predisposes patients to post-operative infections. J Spine Surg. 2018;4(3):529–533.

11. Hartveldt S, Janssen SJ, Wood KB, et al. Is There an association of epidural corticosteroid injection with postoperative surgical site infection after surgery for lumbar degenerative spine disease? Spine. 2016;41(19):1542–1547.

12. Seavey JG, Balazs GC, Steelman T, Helgeson M, Gwinn DE, Wagner SC. The effect of preoperative lumbar epidural corticosteroid injection on postoperative infection rate in patients undergoing single-level lumbar decompression. Spine J. 2017;17(9):1209–1214.

13. Pisano AJ, Seavey JG, Steelman TJ, Fredericks DR, Helgeson MD, Wagner SC. The effect of lumbar corticosteroid injections on postoperative infection in lumbar arthrodesis surgery. J Clin Neurosci. 2020;71:66–69.

Yu-Po Lee, MD

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