Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P52. Cervical epidural steroid injections: incidence and determinants of subsequent surgery

Abstract

BACKGROUND CONTEXT Cervical epidural steroid injections (CESIs) are increasingly used in the nonsurgical management of cervical disorders despite conflicting evidence for efficacy. The proportion of patients who delay or avoid surgery with lumbar or cervical ESIs varies widely in the literature, and contradictory determinants of subsequent surgery have been described. PURPOSE The goals of this study were to determine (1) the incidence of surgery following CESI, (2) the time between CESI and subsequent surgery, and (3) the factors associated with progression to surgery following CESI. STUDY DESIGN/SETTING Retrospective analysis of deidentified administrative claims data. PATIENT SAMPLE A national outpatient and inpatient database from 2007 to 2014 was reviewed, containing 149million unique patients from 2007 to 2014. Inclusion criteria were CESI for diagnoses of cervical disc herniation, myelopathy, radiculopathy, or stenosis, and active enrollment for 1 year prior to the CESI to screen for exclusion criteria. Exclusions include prior cervical surgery, associated neoplasm, pregnancy, inflammatory spondyloarthropathies, fracture (pathologic, nonunion, stress or acute), or infection (abscess, discitis or osteomyelitis). OUTCOME MEASURES The incidence of subsequent surgery and overall survival, measured as the time from CESI to surgery. METHODS Patients were followed longitudinally for up to 6years until they either underwent cervical surgery or had a lapse in health plan enrollment, at which time they were censored. Survival analyses were performed. The rate of surgery and overall survival following CESI were assessed with the Kaplan-Meier survival curve and 95% confidence interval (CI), and factors associated with subsequent surgery were assessed with multivariable Cox proportional hazard models (p RESULTS A total of 44,621 unique CESI patients met the inclusion and exclusion criteria (age 50.1±10.7years, 51.3% female). Forty-eight percent of patients underwent more than 1 CESI, 94.3% of which occurred within 1 year. Within 6 months of CESI, 12.2% (95% CI: 11.9%, 12.5%) of patients underwent surgery, increasing to 15.3% (95% CI: 15.0%, 15.7%) within 1 year and 22.2% (95% CI: 21.7%, 22.8%) within 5years. The factors associated with subsequent surgery were age, diagnosis, number of CESIs, depression, chronic obstructive pulmonary disease, alcohol use, U region, and rural versus urban location. Cardiac comorbidities other than congestive heart failure or infarction had lower risk for surgery. Patients with radiculopathy were less likely to progress to surgery following CESI than stenosis or herniation. Additional CESIs reduced the risk for subsequent surgery, with 75% (95% CI: 57%, 95%) higher risk with 1 versus 4 CESIs (p CONCLUSIONS Following CESI, 22.2% of patients underwent surgery within 5years. Multiple patient-specific risk factors for subsequent surgery were identified, and patients undergoing repeated injections were at lower risk of proceeding to surgery. Additional analyses comparing matched cohorts of surgical patients with and without prior CESI will further advance our understanding of the value and risks of CESI.