Research Summary

Incidence and Risk Factors for Complications After Cervical Epidural Steroid Injections

Miranda Manier, BA

Key Highlights:

  • Complications after cervical epidural steroid injections (CESIs) increased from 1.7% at 7 days to 8.0% at 90 days.
  • Neurologic complications occurred in 0.5% of cases at 7 days, making them the most common procedural complication.
  • The transforaminal approach was associated with higher odds of procedural and neurologic complications compared with the interlaminar approach.
  • Risk factors included anticoagulant and antiplatelet medication use, history of neurologic deficit, and history of venous thromboembolism.

Cervical epidural steroid injections (CESIs) are widely used to manage cervical spine pathology, but their safety profile has not been fully defined. This large-scale analysis found that overall complication rates after CESI were relatively low but increased over time, reaching 8.0% within 90 days. Neurologic complications were the most frequent procedural issue, occurring in 0.5% of cases within 7 days, and procedural risks were significantly higher with the transforaminal approach compared with the interlaminar technique.

Although CESIs are a common intervention, prior reports of severe adverse events have been limited to rare case series, leaving clinicians with incomplete data on incidence and risk factors. This study was designed to clarify complication rates in a real-world population and to identify patient- and procedure-related characteristics that may influence outcomes.

Using a retrospective cohort design, investigators examined a national administrative claims database to assess CESI safety. A total of 229,412 patients (mean age 52.2 years, 57.1% female) underwent 448,209 CESIs between 2008 and 2015. Eligible patients were required to have continuous health plan enrollment one year prior to and 90 days following CESI. Exclusion criteria included neoplasm, fracture, infection, inflammatory spondyloarthropathy, or prior cervical surgery. Complications were classified as procedural or medical, and multivariable repeated-measures logistic regression was applied to identify risk factors at 7, 30, and 90 days, with Bonferroni adjustments.

Within 7 days of CESI, 1.7% of patients experienced complications, increasing to 4.1% at 30 days and 8.0% at 90 days. Procedural complications were observed in 0.6% of cases within 7 days, with neurologic events comprising 0.5%. Medical complications occurred in 1.1%, 3.6%, and 7.2% of cases at 7, 30, and 90 days, respectively. The transforaminal approach carried greater odds of both overall procedural and neurologic complications compared with interlaminar injection (odds ratio [OR], 1.55; 95% CI, 1.35-1.77; OR for neurologic complications, 1.69; 95% CI, 1.45-1.95; both P < .001). Key risk factors for complications within 30 days included anticoagulant prescription (OR, 5.40; 95% CI, 4.55-6.41; P < .001) and a history of venous thromboembolism (OR, 3.01; 95% CI, 2.40-3.77; P < .001). At 7 days, neurologic deficit (OR, 3.04; 95% CI, 2.65-3.50; P < .001) and antiplatelet medication use (OR, 2.21; 95% CI, 1.49-3.27; P = .003) were most strongly associated with procedural complications.

 “Complications following CESIs are infrequent,” Wadhwa et al concluded. “Neurologic complications were most common among procedural complications at 0.5% at 7 days. The transforaminal approach was associated with higher procedural complication rate compared to the interlaminar approach. Procedural and neurological complications were also associated with multiple factors including obesity, existing neurologic deficit, anxiety, and antiplatelet medication prescription. Attention should be given to these factors to mitigate procedural complications.”

Reference:
Wadhwa H, Rohde M, Koltsov JCB, Cabell A, Smuck M, Hu SS, Kleimeyer JP. Incidence and risk factors for complications following cervical epidural steroid injections. Spine J. 2025;25(5):886-902. doi:10.1016/j.spinee.2024