Timing Epidural Steroid Injections to Reduce Postoperative Infection Risk

At a Glance

  • Back pain is a common complaint among patients.
  • Epidural steroid injections are increasingly prescribed to treat back pain.
  • UVA researchers found that ESIs increase the risk of infection for patients who must undergo surgery if administered within three months of surgery.

As you know, back pain is one of the most common complaints that bring patients to their doctors’ offices. It affects people who sit behind desks all day as well as people who perform manual labor, becoming more prevalent with age. It is a major cause of disability and depression.

In addition to exercise, medications and lifestyle changes, physicians increasingly prescribe epidural steroid injections (ESIs) to treat back pain, particularly as an alternative to surgery. Since 2000, the number of ESIs administered has increased dramatically. More than 2.3 million are performed each year in the Medicare population alone. By suppressing the immune response, steroids decrease inflammation in the nerve roots. Typically, physicians recommend that patients have no more than three ESIs a year.

“For many people, these injections work very well,” says UVA orthopedic surgeon Anuj Singla, MD. “But because of their immunosuppressive qualities, we wanted to determine if these injections can increase the incidence of postoperative infection in patients who must undergo surgery.”

Singla is particularly concerned about postoperative infections because, while rare, they are difficult to treat. In cases of lumbar or cervical fusion, surgeons may have to remove the screws and the metal cage they inserted to strengthen the spine. Furthermore, an infection in the spine is a huge risk factor for infection after subsequent surgeries.

A Systematic and Comprehensive Analysis
Over the last two years, Singla and his colleagues at UVA have conducted a series of studies, using the massive PearlDiver Patients Records Database (including more than 4 billion patient records) to better understand the relationship between ESIs and the incidence of postoperative infection. Previous studies have used much smaller patient populations. The researchers looked at single-level lumbar decompression, at posterior cervical fusion and anterior cervical discectomy and fusion, and lumbar fusion. In every case, they determined that surgeons should wait for three months to elapse after the last ESI before performing surgery.

“Sooner than three months and the risk of infection goes up,” Singla says. “After three months, the incidence of infection is virtually indistinguishable from patients who have never had an ESI.”

These articles seem to have struck a chord with physicians and surgeons who treat back pain. According to Altmetric, a service that tracks citation, news coverage and social media references to research, the response to Singla’s paper on ESIs and lumbar fusion surgery was in the top 5 percent of the 7.4 million articles it has tracked.

Singla has been pleased that the results of these papers have been widely circulated. “Our goal is to try to improve the best possible outcomes for patients undergoing spine surgery, whether at UVA or elsewhere in the world,” he says. “Anything that reduces postoperative infections can have a huge impact.”

Learn more about the services provided at UVA Spine Center.