Lumbar epidural steroid injections (LESIs) are administered to
patients with low-back pain and associated leg pain. The injection
delivers corticosteroid medications to the epidural space, an area just
outside the spinal sac containing the spinal cord and nerve roots.
there, the medicine's anti-inflammatory effects reduce nerve root
inflammation, local ischemia, and the pain resulting from both. LESI is a
standard nonsurgical option to treat persistent and severe low-back
pain and radicular leg pain (sciatica).
‘There is an increased risk of infection when lumbar epidural steroid injections (LESIs) are administered within three months prior to lumbar spinal fusion surgery.’
LESI treatment is generally
considered safe, although sometimes complications, such as infection,
nerve damage, or bleeding, can occur. In some cases lumbar spinal fusion
surgery must be performed if LESI fails to provide durable pain relief.
Lumbar spinal fusion surgery is performed to stabilize parts of the
spine that, through injury or age-related degeneration, may have
weakened, shifted location, or changed shape, causing inflammation,
pain, and/or reduced function. During surgery, a bone graft is used to
bind two adjacent vertebrae together, eliminating painful movement in
that portion of the spine.
Research conducted at the University of Virginia suggests that
patients may wish to take a one to three month break from lumbar epidural
steroid injections (LESIs) before undergoing lumbar spinal fusion
An increased risk of infection has been identified when
LESIs are administered within three months prior to surgery.
can be found in the article "The impact of preoperative epidural
injections on postoperative infection in lumbar fusion surgery" by Anuj
Singla and colleagues, published online today in the Journal of Neurosurgery: Spine
Using the nationwide, insurance-based PearlDiver patient record
database, the authors collected information on patients 65 years of age
or older who had undergone a one-level or two-level lumbar spinal
fusion. The search identified 88,540 patients. Of these, 1,699 patients
received LESI within one month before surgery, 5,491 patients received the
injection one to three months before surgery, and 10,493 patients received
the injection three to six months before surgery; the remaining 70,857
patients did not receive LESI prior to lumbar surgery.
The researchers reviewed data on patient outcomes during the first
90 days following surgery, paying specific attention to incidences of
postoperative infection. They found infection rates of 3.9% in patients
who underwent surgery within 1 month after LESI, 2.2% in patients who
underwent surgery one to three months after LESI, and 1.3% in patients who
underwent surgery 3 to 6 months after LESI. The infection rate in
patients who did not receive LESI prior to surgery (the control group)
was 1.5%. The differences in infection rates between both groups of
patients who underwent surgery within three months of receiving LESI and the
control group were statistically significant. There was no significance
in the difference in infection rates between patients who underwent
surgery three to six months after receiving LESI and the control group of
patients who did not receive LESI prior to surgery.
These findings show a significant added risk of infection when LESI
is administered less than three months before the patient undergoes lumbar
fusion surgery. The risk of infection is greatest when LESI is
administered within one month before surgery.
The importance of this study lies both in the large number of
patient records reviewed and the timing of injections that were
examined. Previous studies indicated that administration of LESI shortly
before lumbar spinal fusion surgery may result in an increased rate of
infection, but fewer patient records were reviewed and varying times of
injections were not compared. In the present study, the researchers
found that the incidence of infection was highest when LESI was
administered within one month before surgery and lowest when administered three
to six months before surgery. The researchers pose the possibility that
the immunosuppressive effect of LESI may wear off after a specific time
and no longer increase the risk of infection. They admit that a very
brief time between LESI and surgery could also indicate that patients
had more severe symptoms indicating a greater disability and longer
operative time, which could lead to a higher risk of infection. The
researchers encourage future in-depth studies.
The researchers recommend that their findings be included when
advising patients who have received LESI on the timing of future lumbar
fusion surgery. They conclude, "Although the overall infection rate
remains low despite the use of preoperative LESIs, increasing the time
interval to more than three months from injections to surgery may help to
reduce this increased risk."
When asked about the importance of this study, Dr. Singla responded,
"Patients tend to undergo LESI routinely before surgery, which was
always considered a risk for infection because of its steroidal content.
The results of this study provide a clear association between the
timing of the injections and the risk of infection after subsequent
spinal fusion surgery."