Anesth Pain Med.  2024 Oct;19(4):294-301. 10.17085/apm.24140.

Diagnosis and management of infections related to spinal pain interventions

• Yoon SC
• Choi EJ

• KMID: 2563571
• DOI: http://doi.org/10.17085/apm.24140

Abstract

Although relatively rare, infections related to spinal pain interventions pose significant risks with an increase in the frequency of these procedures. This review investigates the incidence, risk factors, and management of infections following spinal pain interventions, such as epidural steroid injections, nucleoplasty, and facet joint injections. Most of the existing literature comprises case reports and retrospective studies with limited prospective research, owing to the nature of these infections. Our analysis revealed that while the overall infection rate is low, potential complications, such as epidural abscesses and spondylodiscitis, can be severe and life-threatening. The risk factors include advanced age, diabetes, immunosuppression, and multiple spinal procedures. Early diagnosis and timely intervention are critical to prevent long-term morbidity. These findings emphasize the importance of developing standardized diagnostic algorithms and treatment guidelines to support clinicians in managing these infections effectively. Future research should focus on large-scale studies to understand the impact of these infections better and refine clinical management strategies.

Keyword

Complication; Epidural; Infection; Injection; Pain; Pyogenic; Spinal; Spondylitis

Figure

• 

  Fig. 1. Algorithm for diagnosing infections related to spinal pain interventions. MRI: magnetic resonance imaging, WBC: white blood cell count, CRP: C-reactive protein, ESR: erythrocyte sedimentation rate.

Reference

1. Bicket MC, Chakravarthy K, Chang D, Cohen SP. Epidural steroid injections: an updated review on recent trends in safety and complications. Pain Manag. 2015; 5:129–46.

2. Hooten WM, Kinney MO, Huntoon MA. Epidural abscess and meningitis after epidural corticosteroid injection. Mayo Clin Proc. 2004; 79:682–6.

3. Windsor RE, Storm S, Sugar R. Prevention and management of complications resulting from common spinal injections. Pain Physician. 2003; 6:473–83.

4. Kim YI, Kim SE, Jang HC, Jung SI, Song SK, Park KH. Analysis of the clinical characteristics and prognostic factors of infectious spondylitis. Infect Chemother. 2011; 43:48–54.

5. Cho SI, Shin S, Jung H, Moon JY, Lee HJ. Analysis of judicial precedent cases regarding epidural injection in chronic pain management in Republic of Korea. Reg Anesth Pain Med. 2020; 45:337–43.

6. Lee CS, Park YJ, Moon JY, Kim YC. Deep spinal infection after outpatient epidural injections for pain: a retrospective sample cohort study using a claims database in South Korea. Anesthesiology. 2021; 134:925–36.

7. Mylona E, Samarkos M, Kakalou E, Fanourgiakis P, Skoutelis A. Pyogenic vertebral osteomyelitis: a systematic review of clinical characteristics. Semin Arthritis Rheum. 2009; 39:10–7.

8. Cottle L, Riordan T. Infectious spondylodiscitis. J Infect. 2008; 56:401–12.

9. Zimmerli W. Vertebral osteomyelitis. N Engl J Med. 2010; 362:1022–9.

10. Shofwan S, Liem L, Janitra G, Basuki N, Rhatomy S. Discitis following radiofrequency nucleoplasty: a case report. Anesth Pain Med. 2020; 10:e110322.

11. Lee JW, Lee E, Lee GY, Kang Y, Ahn JM, Kang HS. Epidural steroid injection-related events requiring hospitalisation or emergency room visits among 52,935 procedures performed at a single centre. Eur Radiol. 2018; 28:418–27.

12. Wu B, He X, Peng BG. Pyogenic discitis with an epidural abscess after cervical analgesic discography: a case report. World J Clin Cases. 2020; 8:2318–24.

13. Lee SJ, Choi EJ, Nahm FS. Spondylodiscitis after cervical nucleoplasty without any abnormal laboratory findings. Korean J Pain. 2013; 26:181–5.

14. Chen F, Lü G, Kang Y, Ma Z, Lu C, Wang B, et al. Mucormycosis spondylodiscitis after lumbar disc puncture. Eur Spine J. 2006; 15:370–6.

15. Asakura Y. Just think about pyogenic spondylodiscitis before performing the epidural steroid injection for low back pain. Korean J Anesthesiol. 2018; 71:161–2.

16. Shinta Y, Hori M, Okada H. Pyogenic spondylitis four years after an injection into the paraspinal muscles. Cureus. 2024; 16:e64810.

17. Park MS, Moon SH, Hahn SB, Lee HM. Paraspinal abscess communicated with epidural abscess after extra-articular facet joint injection. Yonsei Med J. 2007; 48:711–4.

18. Okazaki K, Sasaki K, Matsuda S, Yuge I, Omiya K, Kido H, et al. Pyogenic arthritis of a lumbar facet joint. Am J Orthop (Belle Mead NJ). 2000; 29:222–4.

19. Lim S, Yoo YM, Kim KH. No more tears from surgical site infections in interventional pain management. Korean J Pain. 2023; 36:11–50.

20. Yeom JA, Lee IS, Suh HB, Song YS, Song JW. Magnetic resonance imaging findings of early spondylodiscitis: interpretive challenges and atypical findings. Korean J Radiol. 2016; 17:565–80.

21. Dullerud R, Nakstad PH. Side effects and complications of automated percutaneous lumbar nucleotomy. Neuroradiology. 1997; 39:282–5.

22. Guyer RD, Ohnmeiss DD, Mason SL, Shelokov AP. Complications of cervical discography: findings in a large series. J Spinal Disord. 1997; 10:95–101.

23. Weingarten TN, Hooten WH, Huntoon MA. Septic facet joint arthritis after a corticosteroid facet injection. Pain Med. 2006; 7:52–6.

24. Verhagen AP, Downie A, Popal N, Maher C, Koes BW. Red flags presented in current low back pain guidelines: a review. Eur Spine J. 2016; 25:2788–802.

25. Bavinzski G, Schoeggl A, Trattnig S, Standhardt H, Dietrich W, Reddy M, et al. Microsurgical management of postoperative disc space infection. Neurosurg Rev. 2003; 6:102–7.

26. Ozuna RM, Delamarter RB. Pyogenic vertebral osteomyelitis and postsurgical disc space infections. Orthop Clin North Am. 1996; 27:87–94.

27. Raghavan M, Lazzeri E, Palestro CJ. Imaging of spondylodiscitis. Eur Rev Med Pharmacol Sci. 2012; 16:8–19.

28. DeSanto J, Ross JS. Spine infection/inflammation. Radiol Clin North Am. 2011; 49:105–27.

29. Oztekin O, Calli C, Kitis O, Adibelli ZH, Eren CS, Apaydin M, et al. Reliability of diffusion weighted MR imaging in differentiating degenerative and infectious end plate changes. Radiol Oncol. 2010; 44:97–102.

30. Millot F, Bonnaire B, Clavel G, Deramond H, Fardellone P, Grados F. Hematogenous Staphylococcus aureus discitis in adults can start outside the vertebral body. Joint Bone Spine. 2010; 77:76–7.

31. Narváez J, Nolla JM, Narváez JA, Martinez-Carnicero L, De Lama E, Gómez-Vaquero C, et al. Spontaneous pyogenic facet joint infection. Semin Arthritis Rheum. 2006; 35:272–83.

32. Kang BU, Lee SH, Ahn Y, Choi WC, Choi YG. Surgical site infection in spinal surgery: detection and management based on serial C-reactive protein measurements. J Neurosurg Spine. 2010; 13:158–64.

33. Meyer B, Schaller K, Rohde V, Hassler W. The C-reactive protein for detection of early infections after lumbar microdiscectomy. Acta Neurochir (Wien). 1995; 136:145–50.

34. Bohnen JM, Haseeb S, Kasina R. C-reactive protein levels predict postoperative septic complications. Arch Surg. 1987; 122:69–73.

35. Zheng S, Wang Z, Qin S, Chen JT. Usefulness of inflammatory markers and clinical manifestation for an earlier method to diagnosis surgical site infection after spinal surgery. Int Orthop. 2020; 44:2211–9.

36. Jönsson B, Söderholm R, Strömqvist B. Erythrocyte sedimentation rate after lumbar spine surgery. Spine (Phila Pa 1976). 1991; 16:1049–50.

37. Sobottke R, Seifert H, Fätkenheuer G, Schmidt M, Gossmann A, Eysel P. Current diagnosis and treatment of spondylodiscitis. Dtsch Arztebl Int. 2008; 105:181–7.

38. Cheung WY, Luk KD. Pyogenic spondylitis. Int Orthop. 2012; 36:397–404.

39. Duarte RM, Vaccaro AR. Spinal infection: state of the art and management algorithm. Eur Spine J. 2013; 22:2787–99.

40. Khan IA, Vaccaro AR, Zlotolow DA. Management of vertebral diskitis and osteomyelitis. Orthopedics. 1999; 22:758–65.

41. Wirtz DC, Genius I, Wildberger JE, Adam G, Zilkens KW, Niethard FU. Diagnostic and therapeutic management of lumbar and thoracic spondylodiscitis--an evaluation of 59 cases. Arch Orthop Trauma Surg. 2000; 120:245–51.

42. Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ. Hematogenous pyogenic spinal infections and their surgical management. Spine (Phila Pa 1976). 2000; 25:1668–79.

43. Roblot F, Besnier JM, Juhel L, Vidal C, Ragot S, Bastides F. Optimal duration of antibiotic therapy in vertebral osteomyelitis. Semin Arthritis Rheum. 2007; 36:269–77.

44. Livorsi DJ, Daver NG, Atmar RL, Shelburne SA, White AC Jr, Musher DM. Outcomes of treatment for hematogenous Staphylococcus aureus vertebral osteomyelitis in the MRSA ERA. J Infect. 2008; 57:128–31.

45. Perronne C, Saba J, Behloul Z, Salmon-Céron D, Leport C, Vildé JL, et al. Pyogenic and tuberculous spondylodiskitis (vertebral osteomyelitis) in 80 adult patients. Clin Infect Dis. 1994; 19:746–50.

46. Darouiche RO. Spinal epidural abscess. N Engl J Med. 2006; 355:2012–20.

47. Yoshimoto M, Takebayashi T, Kawaguchi S, Tsuda H, Ida K, Wada T, et al. Pyogenic spondylitis in the elderly: a report from Japan with the most aging society. Eur Spine J. 2011; 20:649–54.