Management of Fever After Epidural Injection in Spine
When a patient presents with fever after an epidural injection for spine pain, immediate evaluation and management are necessary to rule out infectious complications which can lead to serious morbidity and mortality.
Initial Assessment
Signs and Symptoms to Evaluate
- Fever (temperature >38°C/100.4°F)
- Back pain or tenderness at injection site
- Erythema or swelling at injection site
- Headache (especially if non-positional)
- Neck stiffness or photophobia
- Neurological symptoms (weakness, sensory changes)
- Radiating pain
- Mental status changes 1
Immediate Diagnostic Workup
Blood tests:
- Complete blood count with differential (elevated WBC suggests infection)
- C-reactive protein and erythrocyte sedimentation rate (inflammatory markers)
- Blood cultures if systemic infection is suspected 1
Imaging studies if neurological symptoms or severe back pain present:
- MRI of the spine (preferred) to evaluate for abscess, discitis, or meningitis
- CT scan if MRI contraindicated 1
Cerebrospinal fluid analysis if meningitis suspected:
Management Algorithm
Step 1: Immediate Actions
- Remove the epidural catheter if still in place and culture the tip 1
- Obtain appropriate cultures (blood, CSF if indicated) 1
Step 2: Antibiotic Therapy
- Initiate empiric broad-spectrum antibiotics immediately if infectious etiology is suspected, without waiting for culture results 1
- Consider coverage for skin flora (particularly Staphylococcus species) which are common causative organisms 2
- Consult infectious disease specialist for antibiotic guidance 1
Step 3: Determine Type of Complication
Based on clinical presentation and diagnostic results:
A. Superficial Infection
- Local tenderness, erythema, swelling at injection site
- Management: Antibiotics, local wound care
B. Epidural Abscess
- Back pain, fever, neurological deficits
- Management: Urgent surgical consultation for possible drainage 1
C. Meningitis
- Fever, headache, neck stiffness, photophobia
- Management: IV antibiotics, supportive care 2
D. Chemical Meningitis (Non-infectious)
- Similar symptoms to infectious meningitis but sterile CSF cultures
- Management: Supportive care, symptoms typically resolve within 48-72 hours 2
E. Non-infectious Causes
- Transient post-procedural fever (common side effect)
- Management: Symptomatic treatment, close monitoring 3
Special Considerations
Distinguishing Between Infectious and Non-infectious Causes
- Facial flushing with subjective fever occurs in approximately 9.3% of patients after cervical epidural injections and typically resolves within 12 hours 3
- Persistent fever beyond 24 hours, severe headache, or neurological symptoms warrant urgent evaluation for infectious complications 2
High-Risk Patients
- Immunocompromised patients may not manifest typical signs of infection 1
- Patients with accidental dural puncture during epidural placement are at higher risk for meningitis 1
- Unwitnessed disconnection of epidural catheters increases infection risk 1
Prevention Strategies for Future Procedures
- Strict aseptic technique during epidural placement
- Use of chlorhexidine with alcohol for skin preparation
- Wearing masks covering both mouth and nose
- Minimizing catheter disconnections
- Removing catheters as soon as clinically appropriate 1
Follow-up
- Close monitoring of clinical response to treatment
- Repeat imaging if symptoms worsen or fail to improve
- Adjust antibiotics based on culture results and clinical response
Remember that infectious complications after epidural injections are rare but potentially devastating. Early recognition and aggressive management are essential to prevent serious morbidity and mortality.