Lumbar Spinal Steroid Injections and Infection Risk after Spinal Surgery: A Systematic Review and Meta-Analysis

Association of Untreated Pre-surgical Depression With Pain and Outcomes After Spinal Surgery

STUDY DESIGN

Prospective Cohort Study.

OBJECTIVE

Untreated pre-surgical depression may prolong post-surgical pain and hinder recovery. However, research on the impact of untreated pre-surgical depression on post-spinal surgery pain is lacking. Therefore, this study aimed to assess pre-surgical depression in patients and analyze its relationship with post-surgical pain and overall post-surgical outcomes.

METHODS

We recruited 100 patients scheduled for lumbar spine surgery due to spondylolisthesis, degenerative lumbar disc diseases, and herniated lumbar disc diseases. Psychiatrists evaluated them for the final selection. We assessed the Beck Depression Inventory (BDI), Japanese Orthopaedic Association (JOA), Oswestry Disability Index (ODI), and EuroQoL 5 Dimensions (EQ-5D) scores, numerical back and leg pain scales, and medication dosage data collected before and at 6 weeks, 3 months, and 6 months after surgery.

RESULTS

Ninety-one patients were included in this study; 40 and 51 were allocated to the control and depression groups, respectively. The pre- and post-surgical leg pain, back pain, and functional scores were not different. However, the depression group showed higher ODI and EQ-5D and lower JOA scores than the control group 3 months post-surgery. Partial correlation analysis revealed an inverse correlation between the JOA and BDI scores and a positive correlation between the EQ-5D and BDI scores at 3 months postoperatively.

CONCLUSION

Untreated depression can prolong postoperative pain and hinder recovery. Detecting and treating depression in patients before spine surgery may improve their overall quality of life and functional recovery.

Risk of SARS-CoV-2 following joint and epidural corticosteroid injections: A retrospective study

OBJECTIVE

The immunosuppressive effects of corticosteroid (CS) injections have come under more scrutiny during the coronavirus disease 2019 (COVID-19) pandemic. The aim of the study was to explore any relationship between joint/epidural CS injection and SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) polymerase chain reaction (PCR) positivity.

METHODS

A retrospective chart review was conducted on patients 18 years or over who received at least one joint or epidural CS injection by physiatrists in a tertiary care center between January 1, 2020, and December 31, 2021. This cohort of patients was then compared to a control group who did not receive any CS injection during this time period.

RESULTS

A total of 766 patients were identified in the CS injection group and 1546 patients in the control group. Overall, 12.27% of patients turned SARS-CoV-2 PCR positive in the CS injection group, which was similar to 11.90% in the control group (p = 0.797). But 3-month SARS-CoV-2 PCR positivity rate showed a statistically significant higher rate among the CS injection group (3.30% in the CS injection group vs. 2.10% in the control group; p = 0.027). In multivariate regression analysis, after adjusting both groups for Charlson Comorbidity Index (CCI), there was statistically significant higher SARS-CoV-2 PCR positivity rate in the CS injection group (p = 0.024). However, after adjusting both groups for age and total number of comorbidities, there was no difference between the groups in regard to SARS-CoV-2 PCR positivity rate (p = 0.081). In the subgroup analysis of only COVID-19 vaccinated patients, there was an increased 3-month SARS-CoV-2 PCR positivity rate among patients with severe comorbidities in the CS injection group (p = 0.036).

CONCLUSION

The study was not conclusive on the effect of joint or epidural CS injection on SARS-CoV-2 PCR positivity rate, although adjusted analysis suggests higher 3-month SARS-CoV-2 PCR positivity rate after CS injection in patients with severe comorbidities with significant disease burden when compared to controls.

The Impact of Preoperative Spinal Injection Timing on Postoperative Complications of Lumbar Decompression Surgery

BACKGROUND AND OBJECTIVES

Epidural steroid injections (ESIs) are commonly used for lower back pain management. The effect of these injections on lumbar decompression surgery outcomes is hitherto underexplored. The study objective was to determine the impact of ESIs on postoperative rates of medical and surgical complications and to define the appropriate interval before lumbar decompression surgery.

METHODS

This retrospective all-payer database analysis identified 587 651 adult patients undergoing one- to three-level laminectomies from January 2010 to October 2021. A 2:1 propensity score match accounting for comorbidities, levels of surgery, and demographics was performed to create two cohorts: (1) 43 674 patients who had received an ESI in the 90 days before laminectomy and (2) 87 348 patients who had not received an ESI. The primary outcome was the rates of medical and surgical complications between groups at 30 days postoperatively. Patients were divided into five cohorts based on injection time before surgery: 1 to 30 days, 31 to 45 days, 46 to 60 days, 61 to 75 days, and 76 to 90 days. Logistic regression was performed between groups to identify temporal associations of complication rates. Confidence intervals of 95% are provided when appropriate. P values < .01 were considered significant.

RESULTS

Rates of medical complications within 30 days of surgery were significantly higher in those with ESI compared with control (4.83% vs 3.9%, P < .001). Cerebrospinal fluid (CSF) leak rates were increased in the ESI group at 0.28% vs 0.1% (P < .001), but surgical site infection rates were not significantly different between groups (1.31% vs 1.42% P = .11). ESI performed within 30 days was associated with increased odds of CSF leak (OR: 5.32, 95% CI: 3.96-7.15).

CONCLUSION

Preoperative ESI increases the risk of CSF leak and medical complications after lumbar decompression. Because these complications were significantly associated with ESIs given 1 to 30 days before surgery, avoiding ESIs at least 30 days before surgery may be advisable.

Systematic review of intraoperative corticosteroid injections and the risk of infection in arthroscopic surgery

Background

Despite the fact that preoperative corticosteroid injections within three to six months of surgery increase the risk of postoperative infection, there is a growing trend of using corticosteroid injections intraoperatively as an effort to decrease postoperative pain and opiate use. Our aim with this review was to answer the question "Do intraoperative corticosteroid injections increase the risk of infections in arthroscopic surgery?"

Methods

A systematic search of MEDLINE, Cochrane, and PMC databases was conducted adhering to PRISMA 2020 guidelines after registration with PROSPERO (ID: CRD42023459138). We included studies comparing infection rates in patients who received intraoperative corticosteroid injections (IOCSI) to those who received no injection. The MINORS risk of bias tool was used to assess the quality of included studies.

Results

305 individual records were screened and a total of 8 studies met the criteria for inclusion in the study, containing data from over 700,000 patient records. All 7 retrospective studies showed an increase in infection rates and the single small randomized controlled trial had no infections in either the control or intervention group. The combined weighted odds ratio of infection rates in comparable studies was 2.23 95% CI (1.66-3.11).

Conclusions

Current data shows that IOCSIs more than double the risk of postoperative infection during arthroscopic surgery. Surgeons should consider and weigh the impact of infection to the minor clinical benefit corticosteroid injections add over other multimodal injections. We expect similar increases in infection rates in other surgeries where IOCSIs are used due to the inherent immunosuppressive mechanisms of corticosteroids.

Relationship Between Types of Warming Devices and Surgical Site Infection in Patients Who Underwent Posterior Fusion Surgery Based on National Data

OBJECTIVE

Perioperative hypothermia can lead to various complications. Although various warming techniques have been used to prevent perioperative hypothermia, the effect of these techniques on surgical site infection (SSI) during posterior fusion surgery is unclear. The effects of warming devices on SSI rates were therefore analyzed using data complied by the Health Insurance and Review Assessment (HIRA) Service in Korea.

METHODS

This study included 5,406 patients in the HIRA Service database who underwent posterior fusion surgery during the years 2014, 2015, and 2017. Factors related to SSI in these patients, including warming devices, antibiotics, and transfusion, were analyzed.

RESULTS

The incidence of SSI was higher in patients who underwent forced air warming than in those who did not undergo active warming (odds ratio [OR], 1.73; p = 0.039), especially above 70 years old (OR, 4.11; p = 0.014). By contrast, the incidence of SSI was not significantly higher in patients who underwent device using conduction. Infection rates were higher in patients who received prophylactic antibiotics within 20 minutes before incision, than within 21 to 60 minutes (OR, 2.07; p = 0.001) and who received more blood transfusions (1 pint < volume ≤ 2 pint; OR, 1.75; p = 0.008, > 2 pint; OR, 2.73; p = 0.004).

CONCLUSION

SSI rates were higher in patients who underwent warming with forced air devices than with devices using conduction, as well as being higher in patients who older age, received blood transfusions and administered antibiotics within 20 minutes before incision. Devices using conduction have more advantages in preventing SSI than forced air warming device. In addition, the reduction of other risk factors for SSI may improve postoperative results.

Preoperative Epidural Steroid Injections and Postoperative Infections After Lumbar or Cervical Spine Surgery: A Systematic Review and Meta-Analysis

Objective

To determine the risk difference and 95% prediction intervals (PIs) for postoperative infections (POIs) associated with preoperative epidural steroid injections (ESIs) in adults undergoing lumbar or cervical spine surgery.

Methods

Comprehensive database searches were conducted from inception dates through December 2023. Inclusion criteria included all study designs involving adults receiving a preoperative ESI before lumbar or cervical decompression or fusion spine surgery. Risk of bias was assessed using a modified tool developed for uncontrolled studies. The summary estimates of risk difference and the corresponding PIs were reported.

Results

A total of 12 studies were included in the systematic review, of which 9 were included in the meta-analysis. Preoperative ESIs within 1 month of lumbar spine decompression or fusion surgery were associated with a 0.6% and 2.31% greater risk of a POI, respectively. In adults ≥65 years of age, ESIs within 1 or 1-3 months of lumbar spine decompression or fusion surgery were associated with a 1.3% and 0.6% greater risk of a POI, respectively. Preoperative ESIs within 3 months of cervical spine fusion were not associated with an increased risk of a POI. The bounds of all corresponding 95% PIs were nonsignificant.

Conclusion

The observations of this study provide summary estimates of risk difference and 95% PIs, which could be used to support shared decision-making about the use of ESIs before cervical or lumbar spine surgery.

Association between in situ steroids and spine surgical site infections among instrumented procedures

OBJECTIVE

To estimate the association between in situ steroids and spine surgical-site infections (SSIs), assessing spinal instrumentation as an effect modifier and adjusting for confounders.

DESIGN

Case-control study.

SETTING

Rural academic medical center.

PARTICIPANTS

We identified 1,058 adults undergoing posterior fusion and laminectomy procedures as defined by the National Healthcare Safety Network without a pre-existing SSI between January 2020 and December 2021. We identified 26 SSI as cases and randomly selected 104 controls from the remaining patients without SSI.

METHODS

The primary exposure was the intraoperative administration of methylprednisolone in situ (ie, either in the wound bed or as an epidural injection). The primary outcome was a clinical diagnosis of SSI within 6 months of a patient's first spine surgery at our facility. We quantified the association between the exposure and outcome using logistic regression, using a product term to assess for effect modification by spinal instrumentation and the change-in-estimate approach to select significant confounders.

RESULTS

Adjusting for Charlson comorbidity index and malignancy, in situ steroids were significantly associated with spine SSI relative to no in situ steroids for instrumented procedures (adjusted odds ratio [aOR], 9.93; 95% confidence interval [CI], 1.54-64.0), but they were not associated with spine SSIs among noninstrumented procedures (aOR, 0.86; 95% CI, 0.15-4.93).

CONCLUSIONS

In situ steroids were significantly associated with spine SSI among instrumented procedures. The benefits of in situ steroids for pain management following spine surgery should be weighed against the risk of SSI, especially for instrumented procedures.

Incidence and treatment trends of infectious spondylodiscitis in South Korea: A nationwide population-based study

The incidence of infectious spondylodiscitis (IS) has increased in recent years due to an increase in the numbers of older patients with chronic diseases, as well as patients with immunocompromise, steroid use, drug abuse, invasive spinal procedures, and spinal surgeries. However, research focusing on IS in the general population is lacking. This study investigated the incidence and treatment trends of IS in South Korea using data obtained from the Health Insurance Review and Assessment Service. A total of 169,244 patients (mean age: 58.0 years) diagnosed from 2010 to 2019 were included in the study. A total of 10,991 cases were reported in 2010 and 18,533 cases in 2019. Hence, there was a 1.5-fold increase in incidence rate per 100,000 people from 22.90 in 2010 to 35.79 in 2019 (P < 0.05). The incidence rate of pyogenic spondylodiscitis per 100,000 people increased from 15.35 in 2010 to 33.75 in 2019, and that of tuberculous spondylodiscitis decreased from 7.55 in 2010 to 2.04 in 2019 (P < 0.05, respectively). Elderly individuals ≥ 60 years of age accounted for 47.6% (80,578 patients) of all cases of IS. The proportion of patients who received conservative treatment increased from 82.4% in 2010 to 85.8% in 2019, while that of patients receiving surgical treatment decreased from 17.6% to 14.2% (P < 0.05, respectively). Among surgical treatments, the proportions of corpectomy and anterior fusion declined, while proportion of incision and drainage increased (P < 0.05, respectively). The total healthcare costs increased 2.9-fold from $29,821,391.65 in 2010 to $86,815,775.81 in 2019 with a significant increase in the ratio to gross domestic product. Hence, this population-based cohort study demonstrated that the incidence rate of IS has increased in South Korea. The conservative treatment has increased, while the surgical treatment has decreased. The socioeconomic burden of IS has increased rapidly.

Preoperative epidural steroid injections do not increase the risk of postoperative infection in patients undergoing lumbar decompression or fusion: a systematic review and meta-analysis

PURPOSE

Epidural corticosteroid injections (ESI) are a mainstay of nonoperative treatment for patients with lumbar spine pathology. Recent literature evaluating infection risk following ESI after elective orthopedic surgery has produced conflicting evidence. Our primary objective was to review the literature and provide a larger meta-analysis analyzing the temporal effects of steroid injections on the risk of infection following lumbar spine surgery.

METHODS

We conducted a query of the PubMed, Embase, and Scopus databases from inception until April 1, 2022 for studies evaluating the risk of infection in the setting of prior spinal steroid injections in patients undergoing lumbar spine decompression or fusion. Three meta-analyses were conducted, (1) comparing ESI within 30-days of surgery to control, (2) comparing ESI within 30-days to ESI between 1 and 3 months preoperatively, and (3) comparing any history of ESI prior to surgery to control. Tests of proportions were utilized for all comparisons between groups. Study heterogeneity was assessed via forest plots, and publication bias was assessed quantiatively via funnel plots and qualitatively with the Newcastle-Ottawa Scale.

RESULTS

Nine total studies were included, five of which demonstrated an association between ESI and postoperative infection, while four found no association. Comparison of weighted means demonstrated no significant difference in infection rates between the 30-days ESI group and control group (2.67% vs. 1.69%, p = 0.144), 30-days ESI group and the > 30-days ESI group (2.34% vs. 1.66%, p = 0.1655), or total ESI group and the control group (1.99% vs. 1.70%, p = 0.544). Heterogeneity was low for all comparisons following sensitivity analyses.

CONCLUSION

Current evidence does not implicate preoperative ESI in postoperative infection rates following lumbar fusion or decompression. Operative treatment should not be delayed due to preoperative steroid injections based on current evidence. There remains a paucity of high-quality data in the literature evaluating the impact of preoperative ESI on postoperative infection rates.

LEVEL OF EVIDENCE

II.

Chronological Analysis of Primary Cervical Spine Infection: A Single-Center Analysis of 59 Patients over Three Decades (1992–2018)

Primary cervical spine infections progress quickly and cause neurological impairment at an early stage. Despite their clinical significance, few studies have investigated primary cervical spine infections, owing to the rarity of the condition. This study analyzed the characteristics of 59 patients treated for primary cervical spine infections between 1992 and 2018 at our hospital. Clinical and radiological analyses were conducted. Moreover, a comparative analysis was performed, incorporating each patient’s underlying disease, mortality and complications, and treatment results. Comparison between groups based on the chronological period (1992–2000, 2001–2009, and 2010–2018) revealed that the mean age of onset has increased significantly in recent years. The rate of neurological impairment, duration of antibiotic use, and frequency of underlying disease increased significantly with time. No significant differences among groups were observed in the hematological and microbiological analyses. The incidence rate of epidural abscess and multisegmental infection increased significantly in recent years. There was no statistically significant difference in the complication and mortality rates, according to the time period. We think that prompt diagnosis and appropriate treatment are necessary, considering the current trends in primary cervical spine infection.