Do Epidural Steroid Injections Affect Outcomes and Costs in Cervical Degenerative Disease? A Retrospective MarketScan Database Analysis

Abstract

Study Design Retrospective cohort study. Objective To investigate the effect of preoperative epidural steroid injection (ESI) on quality outcomes and costs in patients undergoing surgery for cervical degenerative disease. Methods We queried the MarketScan database, a national administrative claims dataset, to identify patients who underwent cervical degenerative surgery from 2007 to 2016. Patients under 18 and patients with history of tumor or trauma were excluded. Patients were stratified by ESI use at 3, 6, 12, 18, and 24 or more months preoperative. Propensity score matched controls for these groups were obtained. Baseline demographics, postoperative complications, reoperations, readmissions, and costs were compared via univariate and multivariate analysis. Results 97 117 patients underwent cervical degenerative surgery, of which 29 963 (30.7%) had ESI use at any time preoperatively. Overall, 90-day complication rate was not significantly different between groups. The ESI cohorts had shorter length of stay, but higher 90-day readmission and reoperation rates. ESI use was associated with higher total payments through the 2-year follow-up period. Among patients who received preoperative ESI, male sex, history of cancer, obesity, PVD, rheumatoid arthritis, nonsmokers, cervical myelopathy, BMP use, anterior approach, 90-day complication, 90-day reoperation, and 90-day readmission were independently associated with increased 90-day total cost. Conclusion ESI can offer pain relief in some patients refractory to other conservative management techniques, but those who eventually undergo surgery have greater healthcare resource utilization. Certain characteristics can predispose patients who receive preoperative ESI to incur higher healthcare costs.

Preoperative Epidural Steroid Injections and Postoperative Infections After Lumbar or Cervical Spine Surgery: A Systematic Review and Meta-Analysis

“… 22 , 24 , 27 , 29 , 30 , 31 For the cervical spine group, 2 retrospective studies met inclusion and exclusion criteria. 5 , 32 One study used a proprietary Medicare claims database (PearlDriver) 5 and POIs for anterior and posterior fusions were reported separately, and another study used a proprietary nationally representative database (MarketScan) 32 and POIs for anterior and posterior fusions were combined.

Figure 1 Preferred reporting items for systematic reviews and meta-analyzes flow chart for the study selection process.

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“… Infection requiring reoperation within 30 d Method for identifying and performing ESI not specified Comparison group not matched Consultancy, fees, grants, and stock ownership reported Cohort only included patients that completed a preoperative and month 3 postoperative self-report assessment of functionality Lumbar Spine Minimally Invasive Discectomy Ozturk et al, 30 2018 Retrospective review at a single academic institution Single-level lumbar microdiscectomy 2011-2015 30-d and 90-d postoperative infection identified by retrospective review Fluoroscopically guided TFESI 18 received single-level ESI, 13 received 2-level and 1 received 3-level ESI Comparison group randomly selected but not matched to ESI group No funding or conflicts of interest reported Study cohort of 64 selected from a group of 2461 patients, 32 excluded for medical or surgical reasons Shakya et al, 31 2022 Retrospective study at a single tertiary care spine center Single-level minimally invasive microtubular lumbar discectomy 2017-2020 6-mo postoperative infection identified by chart review Single TFESI performed within 1 y of surgery Comparison group not matched No funding or conflicts of interest reported Time period of postoperative infection in TFESI group not specified beyond 1-y before surgery Cervical Spine Anterior and Posterior Fusion Cancienne et al, 5 2016 Proprietary Medicare claims database (PearlDriver) searched using CPT and ICD-9 codes 2005-2012 Anterior cervical discectomy and fusion, posterior cervical fusion 90-d postoperative infection defined using ICD-9 and CPT codes Transforaminal or interlaminar ESI Matched comparison group No funding reported. Personal fees, royalties reported Infection rates for anterior and posterior fusion reported separately Wadhwa et al, 32 2021 Proprietary nationally representative database (MarketScan) searched using ICD-9 and CPT codes 2007-2016 Anterior cervical discectomy and fusion, posterior cervical fusion, 1-level, or 2-level procedures 90-d postoperative infection not defined Transforaminal or interlaminar ESI Matched comparison group No funding or conflicts of interest reported CPT, current ...…”

“…Nine studies met all criteria for selection, ascertainment of exposure, ascertainment of outcome, and reporting. 5 , 6 , 21 , 22 , 23 , 24 , 26 , 27 , 28 The most common sources of bias were related to selection, 29 , 30 ascertainment of exposure, 29 , 31 ascertainment of outcome, 31 , 32 and reporting. 25 …”

“… 5 , 6 , 21 , 22 , 23 , 24 , 26 , 27 , 28 The most common sources of bias were related to selection, 29 , 30 ascertainment of exposure, 29 , 31 ascertainment of outcome, 31 , 32 and reporting. 25 …”

“…Two studies used a similar temporal category (<3 months) to indicate when the preoperative ESIs were performed ( Table 2 ). 5 , 32 In the Cancienne et al 5 study, POIs were reported separately for anterior and posterior fusion surgeries. The summary point estimate of risk difference for a POI in patients receiving a cervical ESI <3 months before cervical spine surgery was 0.0014 (95% CI, -0.0013 to 0.0041; P =.3219; I 2 =59%).…”