硬膜外类固醇注射治疗紧挨腰椎融合术——术后感染风险增加

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感控热点丨硬膜外类固醇注射治疗紧挨腰椎融合术——术后感染风险增加

原创 2017-06-07 SIFIC热点团队 SIFIC感染官微

译者丨孔晓明

审核丨陈志锦

    在弗吉尼亚大学进行的研究推荐，患者可能需要在进行腰椎硬膜外类固醇注射（LESIs）后休息1-3个月，然后再进行腰椎融合手术。为什么呢？因为研究已经确定，在手术前3个月内进行LESIs会增加术后感染风险。Anuj Singla博士及其同事在3月14日《神经外科：脊柱》杂志上发表的《术前硬膜外注射对腰椎融合手术后感染的影响》一文中有具体的研究细节。

腰椎硬膜外类固醇注射（LESIs）用于下背痛和腿部相关疼痛患者的治疗。     该疗法将皮质类固醇药物注射至硬膜外腔，这是一个包含脊髓和神经根的脊髓囊外区域。类固醇一旦到达该处，药物的抗炎作用就可以减少神经根炎症和局部缺血以及由脊髓神经根引起的疼痛。LESI是治疗持续性和严重性下背痛和针状腿痛（坐骨神经痛）的标准非手术方案。即使有时会发生并发症，如感染、神经损伤或出血，但LESI治疗通常被认为是安全的。在某些情况下，如果LESI不能提供持久的疼痛缓解，就必须进行腰椎融合手术。

    腰椎融合手术是用来稳固因损伤或年龄相关性退化的脊椎部分，这些部位已经退变、移位或变形，从而引起炎症、疼痛或功能减退。手术过程中，采用植入物将两个相邻的椎骨固定在一起，达到消除部分脊柱运动性疼痛的目的。

    作者采用全美基于保险的PearlDiver患者记录数据库，收集了65岁以上接受一级或两级腰椎融合术的患者信息。共纳入了88540名患者，其中1699名患者在术前1个月内接受了LESI治疗，5491名患者在术前1-3个月接受了LESI治疗，10493名患者在术前3-6个月接受了LESI治疗；剩下的70857名患者在术前并未接受过LESI治疗。

    研究人员回顾性调查了术后头90天的结果，特别注意术后感染的发生率。他们发现，术前1个月内接受过LESI治疗的患者感染率为3.9％，术前1-3个月接受了LESI治疗的感染率为2.2％，术前3-6个月接受了LESI治疗的感染率为1.3％。术前没有接受LESI治疗的患者（对照组）感染率为1.5%。术前三个月内接受了LESI治疗的患者与对照组的感染率差异有统计学意义。术前3-6个月接受了LESI治疗的与术前没有接受LESI治疗（对照组）的患者感染率差异无统计学意义。

    这些研究结果表明，患者在进行腰椎融合手术前不到三个月的时间内接受LESI治疗，发生感染的风险会显著增加。其中在手术前一个月内进行LESI给药，感染风险最大。

    这项研究的价值在于回顾了大量的患者资料及LESI的注射时间。以前的研究仅仅表明在腰椎融合手术之前接受LESI治疗可能导致感染率增加，但是对患者的评估较少，且不同注射次也没有进行比较。而在本研究中，研究人员发现，在手术前一个月内进行LESI治疗，感染发生率最高；术前3-6个月进行LESI治疗时，感染率最低。因此，研究人员提出LESI的免疫抑制作用可能会在特定时间后消失而不再增加感染风险的假设。他们承认，LESI和手术间隔时间非常短还可以使患者出现更严重的症状，而这些严重的症状，引起更严重的残疾和更长的手术时间长，最终导致更高的感染风险。研究人员鼓励未来对这方面进行深入研究。

    研究人员建议，对以后接受LESI治疗的患者提供腰椎融合手术时间建议时，应考虑他们的发现。他们得出的结论：尽管在腰椎融合手术前接受LESIs治疗的整体感染率仍然很低，但从注射治疗到手术的时间间隔增加到三个月以上仍可能有助于减少这种增加感染的风险。

当被问及这项研究的意义时，Singla博士回答说：“患者在手术前往往会常规接受LESI治疗，而这种治疗的类固醇内容物一直被认为是感染的风险因素。本研究的结果表明了LESI的注射时间和后续脊柱融合手术后感染风险之间的明确关联性。”

文献：Singla A, YangS, Werner BC, Cancienne JM, Nourbakhsh A, Shimer AL, Hassanzadeh H, Shen FH:The impact of preoperative epidural injections on postoperative infection inlumbar fusion surgery, Journal of Neurosurgery: Spine, published today online,ahead of print, March 14, 2017; DOI: 10.3171/2016.9.SPINE16484.

Increased Riskof Post-op Infection When Surgery Closely Follows Epidural Steroid Injection

Researchconducted at the University of Virginia suggests that patients may wish to takea one- to three-month break from lumbar epidural steroid injections(LESIs) before undergoing lumbar spinal fusion surgery. Why? An increased riskof infection has been identified when LESIs are administered within threemonths prior to surgery. Full details can be found in the article "Theimpact of preoperative epidural injections on postoperative infection in lumbarfusion surgery" by Anuj Singla, MD, and colleagues, published online todayin the Journal of Neurosurgery: Spine.

Lumbar epiduralsteroid injections (LESIs) are administered to patients with low-back pain andassociated leg pain. The injection delivers corticosteroid medications to theepidural space, an area just outside the spinal sac containing the spinal cordand nerve roots. Once there, the medicine's anti-inflammatory effects reducenerve root inflammation, local ischemia, and the pain resulting from both. LESIis a standard nonsurgical option to treat persistent and severe low-back painand radicular leg pain (sciatica). LESI treatment is generally considered safe,although sometimes complications, such as infection, nerve damage, or bleeding,can occur. In some cases lumbar spinal fusion surgery must be performed if LESIfails to provide durable pain relief.

Lumbar spinalfusion surgery is performed to stabilize parts of the spine that, throughinjury or age-related degeneration, may have weakened, shifted location, orchanged shape, causing inflammation, pain, and/or reduced function. Duringsurgery, a bone graft is used to bind two adjacent vertebrae together,eliminating painful movement in that portion of the spine.

Using thenationwide, insurance-based PearlDiver patient record database, the authorscollected information on patients 65 years of age or older who had undergone aone-level or two-level lumbar spinal fusion. The search identified 88,540 patients.Of these, 1,699 patients received LESI within one month before surgery,5,491 patients received the injection one to three months before surgery,and 10,493 patients received the injection three to six months beforesurgery; the remaining 70,857 patients did not receive LESI prior to lumbarsurgery.

The researchersreviewed data on patient outcomes during the first 90 days following surgery,paying specific attention to incidences of postoperative infection. They foundinfection rates of 3.9% in patients who underwent surgery within one monthafter LESI, 2.2% in patients who underwent surgery one to threemonths after LESI, and 1.3% in patients who underwent surgery threeto six months after LESI. The infection rate in patients who did notreceive LESI prior to surgery (the control group) was 1.5%. The differences ininfection rates between both groups of patients who underwent surgerywithin three months of receiving LESI and the control group werestatistically significant. There was no significance in the difference ininfection rates between patients who underwent surgery three to 6sixmonths after receiving LESI and the control group of patients who did notreceive LESI prior to surgery.

These findingsshow a significant added risk of infection when LESI is administered lessthan three months before the patient undergoes lumbar fusion surgery. Therisk of infection is greatest when LESI is administeredwithin one month before surgery.

The importanceof this study lies both in the large number of patient records reviewed and thetiming of injections that were examined. Previous studies indicated thatadministration of LESI shortly before lumbar spinal fusion surgery may resultin an increased rate of infection, but fewer patient records were reviewed andvarying times of injections were not compared. In the present study, theresearchers found that the incidence of infection was highest when LESI wasadministered within one month before surgery and lowest whenadministered three to six months before surgery. The researchers posethe possibility that the immunosuppressive effect of LESI may wear off after aspecific time and no longer increase the risk of infection. They admit that avery brief time between LESI and surgery could also indicate that patients hadmore severe symptoms indicating a greater disability and longer operative time,which could lead to a higher risk of infection. The researchers encouragefuture in-depth studies.

The researchersrecommend that their findings be included when advising patients who havereceived LESI on the timing of future lumbar fusion surgery. They conclude,"Although the overall infection rate remains low despite the use ofpreoperative LESIs, increasing the time interval to more than three monthsfrom injections to surgery may help to reduce this increased risk."

When asked aboutthe importance of this study, Singla responded, "Patients tend to undergoLESI routinely before surgery, which was always considered a risk for infectionbecause of its steroidal content. The results of this study provide a clearassociation between the timing of the injections and the risk of infectionafter subsequent spinal fusion surgery."

Reference: Singla A, YangS, Werner BC, Cancienne JM, Nourbakhsh A, Shimer AL, Hassanzadeh H, Shen FH:The impact of preoperative epidural injections on postoperative infection inlumbar fusion surgery, Journal of Neurosurgery: Spine, published today online,ahead of print, March 14, 2017; DOI: 10.3171/2016.9.SPINE16484.

Source: Journal ofNeurosurgery Publishing Group

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