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

Tyler M. Kreitz, MD; John Mangan, MD; Gregory D. Schroeder, MD; Christopher K. Kepler, MD, MBA; Mark F. Kurd, MD; Kris E. Radcliff, MD; Barrett I. Woods, MD; Jeffery A. Rihn, MD; D. Greg Anderson, MD; Alexander R. Vaccaro, MD, PhD; Alan S. Hilibrand, MD


Spine. 2021;46(3):E197-E202. 

In This Article

Abstract and Introduction


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 radiculopathy occurs in up to 5% of the adult population and can result in significant disability.[1] Lumbar epidural corticosteroid injections (ESI) provide diagnostic and therapeutic benefit in the nonoperative management of radiculopathy.[2–6] Corticosteroids exert therapeutic effect through reduced nerve root edema, improved vascular circulation, and inhibition of pro inflammatory cytokines.[7–9] The number of lumbar epidural steroid injections performed has increased substantially in recent time, with more than 2 million performed annually among Medicare patients.[10,11] Some patients who receive lumbar ESIs may ultimately require surgical intervention. Due to modulation of immune and inflammatory pathways, there is concern regarding postoperative infection in those patients receiving preoperative ESI.

Recently, several studies have evaluated the association between preoperative ESI and postoperative infection in patients undergoing lumbar surgery. Two retrospective single-institution studies have demonstrated no association between preoperative ESI and postoperative infection in patients undergoing lumbar decompression only,[12,13] while another demonstrated increased rate of surgical site infection in patients undergoing lumbar fusion.[14] Two large retrospective database studies have demonstrated increased risk of surgical site infection in Medicare patients undergoing lumbar decompression[15] and those undergoing lumbar fusion[16] receiving ESI within 3 months of surgery. The purpose of this study was to evaluate the association and possible temporal relationship between preoperative ESI, patient demographics, and comorbidities on postoperative infection in a large population of patients undergoing lumbar fusion and those undergoing decompression procedures at a single institution.