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Special Note: Preliminary Findings—Epidural Steroid Paste in Posterior Lumbar SurgerySurgical Site Complications in a Case-Controlled Cohort

Asomugha, Eva Umoh MD*; McLain, Robert F. MD

doi: 10.1097/BRS.0000000000000379
Preliminary Report

Study Design. Retrospective cohort analysis of consecutive, case-matched patients.

Objective. To determine the risk of acute postoperative complications in patients receiving epidural steroid paste.

Summary of Background Data. Epidural steroid agents reduce postoperative pain and inflammation after lumbar surgery, reducing postoperative narcotic use and improving McGill pain scores. Small studies have suggested an increase in surgical site infections after use of steroid-containing pain-paste. However, no larger study exists to address this concern.

Methods. A total of 364 patients undergoing lumbar decompression by surgeons routinely or never using an analgesic steroid paste were reviewed. A total of 123 patients met specific inclusion criteria: 61 steroid-paste (StP) group, 62 in no-paste (NoP) group. Surgical procedures were laminectomy/laminotomy at 1 to 2 adjacent levels. Patients undergoing instrumentation or revision surgery were excluded. Surgical and postoperative protocols were uniform. Retrospective review of clinical data assessed the incidence of postoperative surgical site complications.

Results. Patient demographics, characteristics, and perioperative protocols were similar. Only in-patient admission differed—75% in the steroid-paste (StP) group versus 45% in the no-paste (NoP) group (P < 0.0001). There were 5 acute infections, 4 in the StP (6.7% [1.8%–15.9%]) and 1 in the NoP groups (1.67% [0.03%–8.7%]), P = 0.21. One additional StP patient had delayed wound healing. All StP group infections/complications occurred in patients with identifiable comorbid risk factors.

Conclusion. The observed 4-fold increase in wound complications in the StP group is concerning, although the difference in infection rates was not significant. Stratifying patients by identifiable risk factors could account for some of this difference. The benefits of an epidural agent may outweigh the small risk of surgical site complications in most patients, but we recommend caution when treating patients with identifiable risk factors. A larger study is in progress.

Level of Evidence: 3

In a cohort study of acute surgical site complications, patients treated with steroid paste were compared with patients treated without it. Patient groups were matched. There were 4 cases of infection in the paste group (6.7%) versus 1 in the no-paste group (1.67%) (P = 0.21). All cases of infections occurred in patients with risk factors. The trend of complication rates recommends caution when treating patients with additional risk factors.

*Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH; and

Center for Spine Health, Neurological Institute, and Department of Orthopaedic Surgery, the Spine Research Laboratory, Cleveland Clinic, Cleveland, OH.

Address correspondence and reprint requests to Robert F. McLain, MD, The Center for Spine Health, Lutheran Hospital, 1730 W 25th St, Cleveland, OH 44113; E-mail:

Acknowledgment date: May 8, 2013. First revision date: January 30, 2014. Second revision date: March 11, 2014. Acceptance date: April 7, 2014.

The device(s)/drug(s) is/are FDA-approved or approved by corresponding national agency for this indication.

No funds were received in support of this work.

No relevant financial activities outside the submitted work.

© 2014 by Lippincott Williams & Wilkins