Preoperative Lumbar Epidural Steroid Injection Increases the Risk of a Dural Tear During Minimally Invasive Lumbar Discectomy

Abstract

Background: Preoperative lumbar epidural steroid injections (LESI) are known to be a risk factor for intraoperative dural tears in traditional spine surgery. However, whether the same holds true after minimally invasive surgery is debatable. The authors decided to investigate the incidence of complications in patients undergoing minimally invasive lumbar discectomy after a preoperative LESI.Methods: A retrospective analysis was carried out on patients ages 21 to 65 years who underwent minimally invasive lumbar discectomy over 3 years between November 2017 and October 2020. These were classified into 2 groups based on the administration of an LESI within a year of surgery. Those receiving LESI were further subdivided on the basis of the proximity of the injection to the surgery. The complications encountered during and up to 6 months after the surgery were recorded. Various demographic variables were also noted.Results: A total of 315 patients were included in the study, of which 129 were in the LESI group and 186 were in the non-LESI group. The overall complication rate was 13.65%, with 17.83% in the LESI group and 10.75% in the non-LESI group (P = 0.07). Patients receiving an LESI were 2.49 times more likely to suffer from intraoperative dural tears compared to the other group (95% CI: 1.00-6.20, P = 0.049). This was more prevalent in those who were administered an LESI within 3 months of the surgery (OR: 3.24, 95% CI: 1.12-9.40, P = 0.03). However, the rates of other complications including infections were comparable.Conclusions: A history of LESI within 3 months of the surgery is a risk factor of intraoperative dural tears. However, other complications, including infections, are not affected by a preoperative LESI.Clinical Relevance: A history of an LESI within 3 months of a proposed minimally invasive discectomy should make the surgeon extra-cautious of the risk of a dural tear.Level of Evidence: 3.

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

“…No POIs were reported in the Ozturk et al 30 study. In the Shakya et al 31 study, 1 of 129 patients in the ESI group compared with 2 of 186 in the no ESI group developed POIs ( Table 2 ).…”

“… 29 Postoperative infections were reported in 2 retrospective studies after single-level minimally invasive microdiscectomies. 30 , 31 The mean time between the preoperative ESI and surgery in the Ozturk et al 30 study was 5.2 months, and the time period for the preoperative ESI in the Shakya et al 31 study was 0-12 months ( Table 2 ). No POIs were reported in the Ozturk et al 30 study.…”

“…For the lumbar spine group, a total of 12 studies met inclusion and exclusion criteria ( Table 1 ). 6 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 30 , 31 Study designs included 11 retrospective comparative studies 6 , 21 , 22 , 23 , 25 , 26 , 27 , 28 , 29 , 30 , 31 and 1 prospective comparative study. 24 In a single study, POIs associated with lumbar spine decompression and fusion surgeries were reported separately.…”

“…Two lumbar decompression studies and 1 lumbar fusion study used the same proprietary Medicare claims database (PearlDriver), 6 , 21 , 26 2 studies used the same military health system database, 23 , 25 1 study used a proprietary nationally representative database (MarketScan), 28 and 5 studies were conducted at single academic institutions. 22 , 24 , 27 , 29 , 30 , 31 For the cervical spine group, 2 retrospective studies met inclusion and exclusion criteria. 5 , 32 One study used a proprietary Medicare claims database (PearlDriver) 5 and POIs for anterior and posterior fusions were reported separately, and another study used a proprietary nationally representative database (MarketScan) 32 and POIs for anterior and posterior fusions were combined.…”

“… Number of fused levels ranged from 1-6. Infection requiring reoperation within 30 d Method for identifying and performing ESI not specified Comparison group not matched Consultancy, fees, grants, and stock ownership reported Cohort only included patients that completed a preoperative and month 3 postoperative self-report assessment of functionality Lumbar Spine Minimally Invasive Discectomy Ozturk et al, 30 2018 Retrospective review at a single academic institution Single-level lumbar microdiscectomy 2011-2015 30-d and 90-d postoperative infection identified by retrospective review Fluoroscopically guided TFESI 18 received single-level ESI, 13 received 2-level and 1 received 3-level ESI Comparison group randomly selected but not matched to ESI group No funding or conflicts of interest reported Study cohort of 64 selected from a group of 2461 patients, 32 excluded for medical or surgical reasons Shakya et al, 31 2022 Retrospective study at a single tertiary care spine center Single-level minimally invasive microtubular lumbar discectomy 2017-2020 6-mo postoperative infection identified by chart review Single TFESI performed within 1 y of surgery Comparison group not matched No funding or conflicts of interest reported Time period of postoperative infection in TFESI group not specified beyond 1-y before surgery Cervical Spine Anterior and Posterior Fusion Cancienne et al, 5 2016 Proprietary Medicare claims database (PearlDriver) searched using CPT and ICD-9 codes 2005-2012 Anterior cervical discectomy and fusion, posterior cervical fusion 90-d postoperative infection defined using ICD-9 and CPT codes Transforaminal or interlaminar ESI Matched comparison group No funding reported. Personal fees, royalties reported Infection rates for anterior and posterior fusion reported separately Wadhwa et al, 32 2021 Proprietary nationally representative database (MarketScan) searched using ICD-9 and CPT codes 2007-2016 Anterior cervical discectomy and fusion, posterior cervical fusion, 1-level, or 2-level procedures 90-d postoperative infection not defined Transforaminal or interlaminar ESI Matched comparison group No funding or conflicts of interest reported …”