CESI's and Post-Operative Infections

[drusso]

Cervical Spine

Do Preoperative Epidural Steroid Injections Increase the Risk of Postoperative Complications Following Cervical Disc Replacement?

Hameed, Zuhaad BSa; Vengsarkar, Ved A. BSa,b; Green, Clare K. MDa; Yalamuru, Bhavana MDc; Shimer, Adam L. MDa; Lockey, Stephen D. MD, MBAa
Author Information
Spine ():10.1097/BRS.0000000000005376, April 24, 2025. | DOI: 10.1097/BRS.0000000000005376
Buy
PAP

Metrics
Abstract
Study Design.
Retrospective database analysis.

Objective.
To determine whether any associations exist between the use of preoperative epidural steroid injections (ESIs) and postoperative complications following cervical disc replacement (CDR).

Summary of Background Data.
Preoperative ESIs are a commonly used modality for patients with cervical spine pathology. Previous studies have demonstrated cervical ESIs to be associated with higher complications after anterior cervical discectomy and fusion. To date, there is little known about the impact of cervical ESIs on the postoperative outcomes after CDR.

Methods.
The PearlDiver Database was queried for patients who underwent CDR between 2010 and 2022. Patients were stratified based on ESI use within 90 days prior to surgery. Propensity-score matching was used to account for baseline differences. Outcomes collected included 90-day complications, readmissions, and 2-year reoperation rates.

Results.
Patients receiving preoperative ESI had significantly higher rates of postoperative urinary tract infections (3.2% vs. 1.6%, OR=2.03, P<0.001). Recurrent radiculopathy was more prevalent in the ESI group (63.1% vs. 16.1%, OR=9.02, P<0.001), and ESI patients experienced a higher rate of revision surgery within 2 years compared to control patients (7.8% vs. 2.4%, OR=3.50, P<0.001). Additionally, ESI patients experienced higher rates of emergency department visits at 30 days (6.2% vs. 4.8%, OR=1.31, P=0.020), and readmission rates at both 30 days (2.8% vs. 1.1%, OR=2.52, P<0.001) and 90 days (9.7% vs. 2.0%, OR=5.29, P<0.001) postoperatively.

Conclusion.
Preoperative ESI within 90 days of surgery is associated with increased rates of postoperative complications, readmissions, and reoperation following CDR.

---

Members don't see this ad.

 

[clubdeac]

The data however does not show increased postoperative spinal infections. In the lumbar spine this is not the case. Epidurals within 3 months of lumbar surgery increase risk of postoperative spinal infections

 

[bedrock]

The data however does not show increased postoperative spinal infections. In the lumbar spine this is not the case. Epidurals within 3 months of lumbar surgery increase risk of postoperative spinal infections

Deac, can you please direct me to that study regarding lumbar esi and post surgical infections? I had a patient ask me about that awhile ago and I believe I gave them the wrong answer. I wonder if that study differentiated infections in fusion patients vs lami/disc, only?


To the attendings on this board, how do you approach this topic with patients and with surgeons? Many surgeons prefer for insurance and liability reasons for a patient to have had an ESI, which if they fail, would likely be within one month of surgery?

 

[SSdoc33]

Deac, can you please direct me to that study regarding lumbar esi and post surgical infections? I had a patient ask me about that awhile ago and I believe I gave them the wrong answer. I wonder if that study differentiated infections in fusion patients vs lami/disc, only?


To the attendings on this board, how do you approach this topic with patients and with surgeons? Many surgeons prefer for insurance and liability reasons for a patient to have had an ESI, which if they fail, would likely be within one month of surgery?

it is good practice to avoid any shots until at least 6 months after a surgery. let the surgeon deal with any fallout from the surgery. if you do a shot you can get blamed for anything, regardless of causality.

as far as pre-op:

The impact of preoperative epidural injections on postoperative infection in lumbar fusion surgery

OBJECTIVE Lumbar epidural steroid injections (LESIs) are performed for both diagnostic and therapeutic purposes for a variety of indications, including low-back pain, the leading cause of disability and expense due to work-related conditions in the US. The steroid agent used in epidural...

thejns.org

this is corroborated in the joint world, where it has been show that steroids increase infection risk after a hip or a knee

the problem with this is that a lot of times a patient comes in with a hot radic, and it doesnt help. then what? wait 3 months or have the surgery with the steroid on board? that is a conversation you should have with the patient and document before the ESI

 

[callmeanesthesia]

They don’t stratify by type of steroid but I’d be particulate carries risk and dexamethasone doesn’t. The whole reason we give particulate is for it to hang around in the area. Intraop dex is common for PONV, and isn’t associated with increased risk of infection (oddly enough in this study it was associated with lower risk. I didn’t look too closely but I wonder whether individual anesthesiologists were choosing not to give dex to diabetics, who would be higher risk for complication).

With that in mind, probably another reason to choose TFESI with dex for acute disc herniation.

 

[bedrock]

it is good practice to avoid any shots until at least 6 months after a surgery. let the surgeon deal with any fallout from the surgery. if you do a shot you can get blamed for anything, regardless of causality.

as far as pre-op:

The impact of preoperative epidural injections on postoperative infection in lumbar fusion surgery

OBJECTIVE Lumbar epidural steroid injections (LESIs) are performed for both diagnostic and therapeutic purposes for a variety of indications, including low-back pain, the leading cause of disability and expense due to work-related conditions in the US. The steroid agent used in epidural...

thejns.org

this is corroborated in the joint world, where it has been show that steroids increase infection risk after a hip or a knee

the problem with this is that a lot of times a patient comes in with a hot radic, and it doesnt help. then what? wait 3 months or have the surgery with the steroid on board? that is a conversation you should have with the patient and document before the ESI

Thank for your thoughts and the article.

There is an important distinction to be made both with peripheral joints and spine surgery and CSI, however. This higher rate of infection seems to only be demonstrated for cases involving surgical implants.

Most orthopedic surgeons will still do a knee scope even if patient had a steroid injection in the past month, but they will not offer a total knee, and will require the patient to wait 3 months before the TKA.

It appears that the same 3 month rule should apply to spinal fusions and ESI.
It also seems that it is reasonable that this rule should not apply to patients who would only need a discectomy or laminectomy.

Is anyone aware of good data demonstrating increased infections after ESI for spine surgeries, that did not include hardware?

Maybe we don’t need to worry about that yet with LESI if the patient wouldn’t be facing a fusion? Unfortunately, this concern would still apply to all CESI.

 

[bedrock]

They don’t stratify by type of steroid but I’d be particulate carries risk and dexamethasone doesn’t. The whole reason we give particulate is for it to hang around in the area. Intraop dex is common for PONV, and isn’t associated with increased risk of infection (oddly enough in this study it was associated with lower risk. I didn’t look too closely but I wonder whether individual anesthesiologists were choosing not to give dex to diabetics, who would be higher risk for complication).

With that in mind, probably another reason to choose TFESI with dex for acute disc herniation.

Agree with your general premise. However, Per my post above, I don’t this applies to orthopedic surgeries without hardware.

It may not increase risk of infection to have ESI with dex, but it might if ESI done with particulate. But even then, the risk would only apply to ESI done with particulate before fusion surgery but not before a lami and/or a discectomy.

This might be the only justifiable reason to use dex for a CESI, if it’s a large disc with a high chance of going to ACDF?

 

[Baron Samedi]

My own personal practice is in an anterior cervical surgery or a single level lumbar laminectomy to do the ESI and not really worry about the timing if the surgeon is OK with it. For a posterior cervical fusion I won't do within 30 days, same for any lumbar fusion I wait 30 days. This is more based on fear of malunion/wound healing and honestly I haven't thought too much about the infection risk. I should probably re-visit and read more about this as it sounds like maybe I am being too lax.

 

[clubdeac]

Deac, can you please direct me to that study regarding lumbar esi and post surgical infections? I had a patient ask me about that awhile ago and I believe I gave them the wrong answer. I wonder if that study differentiated infections in fusion patients vs lami/disc, only?


To the attendings on this board, how do you approach this topic with patients and with surgeons? Many surgeons prefer for insurance and liability reasons for a patient to have had an ESI, which if they fail, would likely be within one month of surgery?

I learned this 3 months ago at the Cleveland clinic conference. I’ll try and find the data from the slides if I can. But you’re right, it only pertains to fusions as far as I’m aware, not lami’s or discectomies

 

[MD87]

Thank for your thoughts and the article.

There is an important distinction to be made both with peripheral joints and spine surgery and CSI, however. This higher rate of infection seems to only be demonstrated for cases involving surgical implants.

Most orthopedic surgeons will still do a knee scope even if patient had a steroid injection in the past month, but they will not offer a total knee, and will require the patient to wait 3 months before the TKA.

It appears that the same 3 month rule should apply to spinal fusions and ESI.
It also seems that it is reasonable that this rule should not apply to patients who would only need a discectomy or laminectomy.

Is anyone aware of good data demonstrating increased infections after ESI for spine surgeries, that did not include hardware?

Maybe we don’t need to worry about that yet with LESI if the patient wouldn’t be facing a fusion? Unfortunately, this concern would still apply to all CESI.

Not aware of any for non-fusions... even the fusion data is meh.

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

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.

pubmed.ncbi.nlm.nih.gov

Letter to the Editor - "Do Preoperative Epidural Steroid Injections Increase the Risk of Infection After Lumbar Surgery?" - PubMed

Letter to the Editor - "Do Preoperative Epidural Steroid Injections Increase the Risk of Infection After Lumbar Surgery?"

pubmed.ncbi.nlm.nih.gov

Funny fact - first link is the article by the surgeons, second link is the article by the physiatrists, both from the same practice

 

[GoBeers]

ortho extremity surgeons always made a big deal about peri-operative steroid injections, whether or not it was at the same site of surgery, within 3 months. however i have never heard of any ortho or neuro spine surgeon care about ESI and spine surgery.

 

[bedrock]

ortho extremity surgeons always made a big deal about peri-operative steroid injections, whether or not it was at the same site of surgery, within 3 months. however i have never heard of any ortho or neuro spine surgeon care about ESI and spine surgery.

Ironically our hand surgeon could care less about steroid injections before a hand surgery.