Elsevier

The Spine Journal

Volume 17, Issue 9, September 2017, Pages 1209-1214
The Spine Journal

Clinical Study
The effect of preoperative lumbar epidural corticosteroid injection on postoperative infection rate in patients undergoing single-level lumbar decompression

https://doi.org/10.1016/j.spinee.2017.04.003Get rights and content

Abstract

Background Context

Lumbar epidural corticosteroid injections (LECIs) are frequently used in the treatment of lumbar intervertebral disc herniation with radiculopathy and lumbar spinal stenosis. Although widely used, their effect on the outcomes and complications of subsequent surgery is unclear. Postoperative infection can be a morbid complication following spine surgery, and recent literature has suggested that the risk may be increased in patients undergoing lumbar spinal surgery who had previously received LECIs.

Purpose

The purpose of this study is to define the overall postoperative infection rate in patients undergoing lumbar spine decompression surgery in the Military Health System (MHS) patient population and examine the effects of LECIs on postoperative infection rates.

Study Design/Setting

This is a retrospective case control database study (Level III study).

Patient Sample

The sample comprised all patients in the MHS who had a LECI before single-level lumbar decompression surgery from 2009 to 2014.

Outcome Measures

Postoperative infection within 90 days of surgery was used as the primary outcome measure for this study. Postoperative infection was identified using the International Classification of Diseases, 9th revision (ICD-9) diagnosis codes for postoperative infection.

Methods

The Military Health System Data Repository (MDR) database was searched for all patients who underwent single-level lumbar spine decompression surgery from 2009 to 2014 using Current Procedural Terminology (CPT) codes. Current Procedural Terminology codes were used to identify the subset of patients who received preoperative LECIs. For patients receiving an injection, cohorts were established based on the timing of the preoperative injection: <30 days, 30–90 days, 91–180 days, 181–365 days, and >365 days. An age-based cohort, composed of patients 65 years of age and older, was also analyzed. A subgroup analysis of patients receiving more than one preoperative injection was performed. Postoperative infection within 90 days of surgery was identified using ICD-9 codes, and infection rates for all groups were calculated and compared with the control group who did not receive preoperative LECIs. No external funding was received for this study.

Results

We identified 6,535 patients (847 preoperative LECI and 5,688 control) for analysis. The overall infection rate for patients undergoing single-level lumbar decompression surgery in the MHS was 0.81%. The rate ranged from 0% to 1.57% in the injection groups, with an overall infection rate in the injection group of 1.18% versus 0.76% in the control group. Despite an increased odds ratio of 1.57 following injection, no statistically significant differences were found between the control group and any injection group based on timing of injection, patient age, or number of preoperative injections.

Conclusions

The results of this study suggest that within the MHS, preoperative LECIs do not significantly increase the risk of postoperative infection after single-level lumbar decompression. If a difference does exist, it is likely small.

Introduction

Lumbar epidural corticosteroid injections (LECIs) are frequently used in the treatment of lumbar intervertebral disc herniation with radiculopathy and lumbar spinal stenosis [1], [2], [3], [4]. They are often used as a temporizing measure to relieve radicular pain before surgery, as a diagnostic and prognostic adjunct, and in some cases as a definitive treatment [5], [6], [7], [8]. Although widely used, their effect on the outcomes of subsequent surgery is unclear [1], [2], [3]. Postoperative infection can be a morbid complication following spine surgery, and recent literature has suggested that the risk may be increased in patients undergoing lumbar spinal surgery who had previously received LECIs [9], [10]. Another recent series, however, found no significant association between injections and postoperative infection after surgery for degenerative lumbar spine disease [11].

Despite several recent articles, overall there is a paucity of evidence in the spine literature examining this topic. Furthermore, with the available literature, there is a lack of consensus on the effects of LECIs on postoperative infection. We sought to characterize the overall postoperative infection rate in patients undergoing lumbar spine decompression surgery in the Military Health System (MHS) patient population and examine the effects of LECIs on postoperative infections. Based on reports from spine and total joint arthroplasty literature [9], [10], [12], [13], we hypothesized that the postoperative infection rate would be increased in patients who had received preoperative LECIs in the MHS and that this effect would be more pronounced the shorter the interval between the LECIs and surgery.

Section snippets

Methods

The Military Health System Data Repository contains comprehensive data on all health care provided or paid for by the MHS to active duty servicemembers, retirees, and their dependents. Following approval by our local Institutional Review Board, the Military Health System Management Analysis and Reporting Tool (M2) was used to search the Military Health System Data Repository for all patients who had undergone lumbar spine surgery from 2009 to 2014 and refined using Current Procedural

Results

The search identified 6,535 patients who had undergone single-level lumbar decompression surgery from 2009 to 2014 within the MHS. Of these, 847 patients had received at least one LECI before surgery: 167 patients received LECIs within 30 days of surgery, 318 patients between 31 and 90 days, 202 patients between 91 and 180 days, 89 patients between 181 and 365 days, and 71 patients greater than 365 days before surgery. Our control group consisted of the remaining 5,688 patients who had

Discussion

The overall postoperative infection rate for all patients in the MHS undergoing lumbar decompressive surgery was 0.81%, and the postoperative infection rate for patients in our control population was 0.76%. Postoperative infection rates in the various subgroups of patients receiving preoperative LECIs ranged from 0% to 1.57%, with an overall postoperative infection rate of 1.18% for all patients receiving injections. These rates are comparable with the postoperative infection rates of 0.8%–1.7%

References (34)

  • S.M. Leung et al.

    Clinical value of transforaminal epidural steroid injection in lumbar radiculopathy

    Hong Kong Med J

    (2015)
  • T.J. Kaufmann et al.

    Clinical effectiveness of single lumbar transforaminal epidural steroid injections

    Pain Med

    (2013)
  • A. Bhatia et al.

    Transforaminal epidural steroid injections for treating lumbosacral radicular pain from herniated intervertebral discs: a systematic review and meta-analysis

    Anesth Analg

    (2016)
  • N.A. Manson et al.

    Transforaminal epidural steroid injections prevent the need for surgery in patients with sciatica secondary to lumbar disc herniation: a retrospective case series

    Can J Surg

    (2013)
  • N. Zusman et al.

    Preoperative epidural spinal injections increase the risk of surgical wound complications but do not affect overall complication risk or patient-perceived outcomes

    J Neurosurg Spine

    (2015)
  • S. Hartveldt et al.

    Is there an association of epidural corticosteroid injection with postoperative surgical site infection after surgery for lumbar degenerative spine disease?

    Spine

    (2016)
  • Department of Defense

    2014 Demographics Profile of the Military Community

  • Cited by (0)

    FDA device/drug status: Not approved for this indication (epidural steroid injection).

    Author disclosures: JGS: Nothing to disclose. GCB: Nothing to disclose. TS: Nothing to disclose. MH: Nothing to disclose. DEG: Nothing to disclose. SCW: Nothing to disclose.

    The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com.

    No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. The views expressed in this article are those of the authors and do not reflect the official policy of the Department of Army/Navy/Airforce, Department of Defense, or U.S. Government.

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