Patients with cancer often require chemotherapeutic and/or radiation treatment. These patients, as well as those with chronic steroid use, immunomodulation therapy use for inflammatory disorders, and inborn or acquired immunodeficiencies are at higher risk of infection. Laboratory values suggestive of an immunosuppressed state include leukopenia and pancytopenia. Steroids can potentiate immunosuppression, even if relatively small amounts are injected into the epidural space. Systemic effects of corticosteroids may increase risk of infection or viral reactivation.
The risks of rare but serious infections must be weighed with the expected benefits of pain relief and functional improvement from epidural steroid injections. Case reports have emerged documenting infectious complications following epidural steroid injections. The root cause of a series of fungal infections following epidural steroid injection was traced to contaminated vial batches of methylprednisolone in the 2010’s . Specific reports have been described for herpes zoster. One report describes herpes esophagitis following a cervical epidural steroid injection . Another case describes cutaneous herpes zoster eruption following serial lumbar epidural steroid injections . Finally numerous case reports describe epidural abscess formation even in the absence of known immunodeficiency . As such, providers should seriously consider the higher risk of infection in the immunosuppressed patient population. Currently, antibiotic prophylaxis is not recommended for epidural steroid injections.