Do Preoperative Epidural Steroid Injections Increase the Risk of Infection After Lumbar Spine Surgery?

Abstract

Study Design. Retrospective study. Objective. To elucidate an association between preoperative lumbar epidural corticosteroid injections (ESI) and infection after lumbar spine surgery. Summary of Background Data. ESI may provide diagnostic and therapeutic benefit; however, concern exists regarding whether preoperative ESI may increase risk of postoperative infection. Methods. Patients who underwent lumbar decompression alone or fusion procedures for radiculopathy or stenosis between 2000 and 2017 with 90 days follow-up were identified by ICD/CPT codes. Each cohort was categorized as no preoperative ESI, less than 30 days, 30 to 90 days, and greater than 90 days before surgery. The primary outcome measure was postoperative infection requiring reoperation within 90 days of index procedure. Demographic information including age, sex, body mass index (BMI), Charlson Comorbidity Index (CCI) was determined. Comparison and regression analysis was performed to determine an association between preoperative ESI exposure, demographics/comorbidities, and postoperative infection. Results. A total of 15,011 patients were included, 5108 underwent fusion and 9903 decompression only. The infection rate was 1.95% and 0.98%, among fusion and decompression patients, respectively. There was no association between infection and preoperative ESI exposure at any time point (1.0%, P = 0.853), ESI within 30 days (1.37%, P = 0.367), ESI within 30 to 90 days (0.63%, P = 0.257), or ESI > 90 days (1.3%, P = 0.277) before decompression surgery. There was increased risk of infection in those patients undergoing preoperative ESI before fusion compared to those without (2.68% vs. 1.69%, P = 0.025). There was also increased risk of infection with an ESI within 30 days of surgery (5.74%, P = 0.005) and when given > 90 days (2.9%, P = 0.022) before surgery. Regression analysis of all patients demonstrated that fusion (P < 0.001), BMI (P < 0.001), and CCI (P = 0.019) were independent predictors of postoperative infection, while age, sex, and preoperative ESI exposure were not. Conclusion. An increased risk of infection was found in patients with preoperative ESI undergoing fusion procedures, but no increased risk with decompression only. Fusion, BMI, and CCI were predictors of postoperative infection. Level of Evidence: 3

Lumbar Spinal Steroid Injections and Infection Risk after Spinal Surgery: A Systematic Review and Meta-Analysis

“…This association was noted to be stronger for fusion surgery (OR, 2.67; 95% CI, 2.12-3.35) and nonsignificant for decompression surgery (OR, 2.04; 95% CI, 0.96-4.34) on subgroup analysis. Similar results have been reported by Singla et al [9] (OR, 2.59; 95% CI, 2.01-3.34), Kreitz Kreitz et al [12] has presented separate data analysis for decompression and fusion surgery, which was used separately as Kreitz (D) and Kreitz (F), respectively in this study. LSSI can directly inoculate bacteria/organisms from skin flora, especially when the proper sterile precautions have not been taken [6,27].…”

“…Nine studies met the inclusion criteria after following the PRISMA protocol, as shown in Fig. 1 [8,9,[11][12][13][14][15]19,20]. Two studies have used the same database with overlapping years [8,11].…”

“…Thus, only one of those studies was used for meta-analysis to avoid overlapping the patient population [11]. Nine studies were used for systematic qualitative review [8,9,[11][12][13][14][15]19,20], and eight studies were used for quantitative meta-analysis [9,[11][12][13][14][15]19,20] (Tables 1, 2).…”

“…Table 3 reports a critical appraisal of the included studies using MINORS criteria. One study was a prospective cohort study [20], two studies were retrospective comparative cohort studies [12,14], while the remaining six studies were retrospective database studies [9,11,[13][14][15]19]. A clearly stated aim was overserved in all the studies.…”

“…Apart from these risks, the recent literature has expressed some concern that immunomodulatory and anti-inflammatory effects of the steroid can alter the local host environment, making it more susceptible to postoperative infection after subsequent lumbar spine surgeries. Several retrospective and database studies have reported an increased postoperative infection rate in patients who have received preoperative LSSI [8][9][10][11], while other studies have concluded no association [12][13][14][15]. Given the potentially devastating consequences associated with spinal surgical-site infections, it is of paramount importance to determine whether such a relationship truly exists or not.…”