Cite as: Lane O, Beck B, Alessandro NMMD. Management of inadvertent intradiscal access during fluoroscopic guided epidural spinal procedures and the role of antibiotic therapy. ASRA Pain Medicine News 2026;51. https://doi.org/10.52211/asra050126.015.

Introduction

Lumbar epidural steroid injections are among the most frequently performed procedures in pain clinics worldwide, utilized as a part of the non-surgical management of lumbosacral radicular pain.^1-3 Access to the epidural space can be achieved through different approaches. The caudal approach is through the sacral hiatus, while the interlaminar lumbar approach (ILESI) uses a needle inserted midline or just paramedian between two contiguous vertebrae.¹ Alternatively, the transforaminal approach (TFESI) involves inserting the needle through the intervertebral neuroforamen to deposit medication (corticosteroid) close to the nerve root, providing a more targeted anti-inflammatory effect.^1,4,5

The use of fluoroscopy during interventional procedures provides real-time visualization of the anatomy, needle trajectory, and contrast dye flow patterns, enhancing the precision, accuracy, and safety of needle placement. Despite careful technique, inadvertent disc access (defined as unintentional placement of the needle into the annulus) may occur.⁶ Unintentional disc puncture is clinically significant because while relatively rare, it can still lead to infectious discitis, which can be devastating. The avascular nature of the disc may limit effective antibiotic penetration, and treatment with parenteral antibiotics may be difficult. Immediate recognition, documentation, patient counseling, and timely consideration of empiric antibiotic therapy are therefore essential.⁷

Incidence of Inadvertent Intradiscal Injection

The reported incidence of inadvertent intradiscal access during lumbar epidural steroid injections differs based on the procedural approach. Case reports and retrospective studies regard the incidence of intradiscal injection during an ILESI to be 0.02%, but higher at 0.17%- 0.25% with a subpedicular or “safe triangle” approach when performing a TFESI.^8-11 In contrast, Hong et al., in a prospective study of 251 TFESI injections, reported a 2.3% incidence, with discrepancies attributed to underestimation of this complication rate or to interventionalists not recognizing an accidental intradiscal injection. A study of the TFESI retrodiscal (“Kambin’s triangle”) approach by Levi et al. reported a rate of 4.7% (12/257) for unintended intradiscal injections.¹² Thus, while the absolute numbers are low in some series (0.17%-0.25%), other approaches (especially retrodiscal) report rates as high as 2%-5%, suggesting that technique and anatomical variation significantly influence risk.

Risk Factors

Most cases of unplanned intradiscal entry are reportedly due to anatomical risk factors (such as those that may redirect the needle trajectory) and the specific technical approach used. Anatomical risk factors include ipsilateral neuroforaminal stenosis, spondylolisthesis, central or lateral canal stenosis, previous lumbar surgery, disc degeneration, disc extrusion/herniation, and foraminal herniation (Table 1).^8-11,13 The TFESI approach has a complication rate 12 times higher than the ILESI approach.⁹ While unintentional disc access typically occurs at the same spinal segment, Yeh et al. described a case of intradiscal injection at an adjacent L5/S1 segment during a properly performed S1 TFESI. These findings demonstrate anatomic variations in the setting of severe disc degeneration and a grade 5 annular fissure leading to a “vacuum disc” effect with negative intradiscal pressure and a low-pressure gradient that promotes contrast suction into the disc and an atypical dye distribution pattern (Table 1).¹¹

Recognizing Inadvertent Intradiscal Injection

Real-time, live fluoroscopic visualization of contrast should be considered the gold standard for identifying an intradiscal injection. The contrast dye pattern would differ from the linear or triangular epidurogram expected during a TFESI.^8,9,11 Little or no contrast tracks along the nerve root sleeve or into the epidural space, and contrast may instead be seen coursing centrally along the needle trajectory into the disc.^10,13 Other characteristic fluoroscopic findings include centralized pooling of contrast within the disc, delineation of the disc margins, concentric or “discogram-like” contrast spread, and a contained or “spoked” pattern. Case reports and prospective series describe these fluoroscopic features and emphasize the need for continuous, live imaging rather than relying solely on static images or aspiration to detect needle malposition. Intradiscal contrast spread should be quickly recognized, and appropriate management should be started promptly (Table 2).^8,10,13

Infection Risk and Lessons from Discography

Discography studies provide the best reference for understanding the risk of infection following an intradiscal injection. These studies consistently demonstrate a low incidence of discitis in both the lumbar and cervical spine when aseptic technique is employed. The data show that stringent sterility is the main factor in reducing infection risk, while the routine use of prophylactic antibiotics has not clearly demonstrated additional benefit.^14,15 A systematic review of cervical discography by Kapoor et al. found discitis in 0.15% of injected discs and in 0.44% of patients, again under carefully controlled sterile conditions.⁷ Sharma et al. reviewed preventive strategies and concluded that intravenous (IV) or intradiscal prophylactic antibiotics have not been clearly shown to further reduce discitis rates. In the same review, chlorhexidine-based skin preparation had statistically fewer bacterial colonies than povidone-iodine, supporting chlorhexidine as the preferred antiseptic agent.¹⁴ Furthermore, the double-needle technique (a large introducer needle placed through the skin with a smaller gauge needle sterilely passed through), especially when performed with a stylet, further minimizes contamination.^14,15

However, evidence suggests that the use of a styletted needle may be more important than needle configuration (eg, double-needle technique) in reducing infection risk, as outlined in the ASRA Pain Medicine consensus guidelines for infection control. These guidelines provide recommendations for the mitigation, diagnosis, and management of infectious complications in the context of regional anesthesia and chronic pain medicine. The ASRA Pain Medicine consensus guidelines support a risk-stratified approach to infection prevention by classifying pain procedures by infection risk. Although multifactorial, a breach in sterile technique has been implicated in most cases; thus, escalation of aseptic technique is based on procedural risk with full sterile precautions recommended for neuraxial and implantable device procedures. Within this context, discitis following discography is rare, though the risk increases with multilevel disc access.¹⁶

Collectively, these studies suggest that when strict sterile technique is used, the baseline absolute risk of discitis after intradiscal access is very low, and routine prophylactic antibiotics are not supported by strong evidence (the data estimates discitis rates of less than 0.25% per patient and less than 0.15% per disc), reinforcing that the absolute risk with proper technique is minimal, but not negligible.¹⁷

Data specific to TFESI further support this. Plastaras et al. reported an inadvertent intradiscal injection prevalence of 0.17% during lumbar TFESI, with all affected patients receiving prophylactic antibiotics and no subsequent discitis or serious sequelae.⁸ Hong et al. prospectively evaluated 251 TFESIs and found an incidence of intradiscal injection of 2.3%, again without documented infectious complications, although the authors emphasized the theoretical risk of discitis and the need for vigilance.¹⁰ Candido and colleagues, in a case series and subsequent commentary, also described inadvertent intradiscal injections during lumbar TFESI and ILESI injections, noting that these events are rare, but potentially serious and that existing discography data do not support routine prophylactic antibiotics in all patients.⁹

While no formal practice advisories or large randomized trials specifically address the use of prophylactic antibiotics when the disc is breached, the decision should be individualized based on patient or procedure-related risk factors and the clinician’s professional judgment.

Risk Stratification

Low-risk scenarios that may not warrant antibiotics include a healthy patient, clean, sterile, single-pass technique, brief disc entry, minimal contrast injected, and an unpressurized disc with no injectate deposited. High-risk scenarios that may warrant the use of systemic antibiotics include an immunocompromised patient, a diabetic patient, the use of long-acting corticosteroids, a large contrast bolus, high-pressure injection, and/or persistent dwell time. High-risk scenarios may warrant both systemic and intradiscal antibiotics (Table 3).^8,14

Antibiotic Considerations

Current evidence does not demonstrate a clear advantage of one prophylactic antibiotic route over another, whether intravenous or intradiscal (Table 4).¹⁴

Note: The use of prophylactic antibiotics after inadvertent intradiscal injection is not without risk. Intradiscal administration of antibiotics can cause a disc herniation or force antibiotic solution through annular defects with the risk of the antibiotic potentially entering the subdural or intrathecal space. Cefazolin is neurotoxic and known to cause seizures and even death if accidentally introduced into the intrathecal space.¹⁴

Discography literature supports selective prophylactic antibiotic use, and this rationale is often extrapolated to spinal interventional procedures when disc entry occurs.⁸ A potential distinction between discitis risk during discography versus lumbar TFESI lies in the “health” of the disc. During the discography, a control disc as well as the “abnormal” disc are injected. The morphologically “normal” or control disc has a higher risk of infection due to its avascular nature. On the other hand, a disc that is inadvertently penetrated during a TFESI is less likely to be more vascular, thus potentially carrying a lower risk of infection. In the series by Plastaras et al., all patients with inadvertent disc entry received prophylactic antibiotics, and no cases of discitis were reported.⁸

Local antimicrobial resistance patterns, captured in institutional or regional antibiograms, should guide empiric antibiotic selection. Antibiograms are the foundation of antimicrobial stewardship because they summarize susceptibility data for bacterial isolates within a specific hospital, health system, or geographic area, including regional public health and specialty-specific datasets. By reflecting resistance profiles in the local practice environment, they help clinicians target the most likely pathogens and avoid unnecessarily broad therapy.¹⁸

Patients at higher risk of resistant organisms, such as those with known methicillin-resistant Staphylococcus aureus (MRSA) colonization, immunosuppression, recent hospitalization, or residence in high-prevalence MRSA regions, should receive empiric antibiotic coverage with agents such as vancomycin. In contrast, in areas with low MRSA prevalence and high susceptibility to first-generation cephalosporins, narrower-spectrum agents are appropriate.¹⁹

Monitoring/Patient Presentation

Patients with known discitis will typically present with fever and an increase in spinal pain. Other symptoms can include an increase in extremity pain, new neurological deficits with a median time of symptom presentation of 7 days.^7,8 Evaluation and management include a thorough history, physical exam, laboratory studies (C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and complete blood count (CBC)) and magnetic resonance imaging (MRI) which is the gold standard imaging to detect discitis.⁷ Prompt recognition is crucial, as serious sequelae of discitis can include epidural abscess or vertebral osteomyelitis (Table 5).²⁰

Treatment of Confirmed Discitis

Management of confirmed discitis varies considerably due to a lack of consensus among experts on whether to initiate broad-spectrum antibiotics immediately or delay treatment until culture sensitivities are available to guide antibiotic selection.²¹ However, the initial use of broad-spectrum antibiotics is acceptable until cultures result because covering for Staphylococcus species is an important first step in management.²¹

Conclusion

The risk of discitis after inadvertent disc access is minimal when strict aseptic technique, appropriate skin preparation (preferably with chlorhexidine), and a double-needle, stylet approach are employed. While no formal practice advisories or large randomized trials specifically address the use of prophylactic antibiotics when the disc is breached, the decision should be individualized based on patient or procedure-related risk factors and the clinician’s professional judgment. The reported infection rates after lumbar and cervical discography are very low, suggesting that prophylactic antibiotics are not routinely required. This rationale is often extended to inadvertent disc access during spinal interventional procedures, though the supporting evidence originates from studies focused on discography rather than interventional procedures.^7,8 Thus, some clinicians may choose to utilize it on a case-by-case basis, as preventing a potential iatrogenic infection may be considerably easier than treating it. Nonetheless, infectious discitis can be a significant source of morbidity and even mortality. Complications such as new neurologic deficits, abscess formation, vertebral destruction, and spinal instability have been documented. Patients may require prolonged hospitalization and in many cases, surgical intervention. They may also be left with permanent neurologic sequelae and chronic pain. Delays in diagnosis, infections caused by resistant organisms such as MRSA, and certain anatomical factors such as involvement of higher spinal levels (e.g., the cervical or upper thoracic spine) are all associated with worse outcomes.^22-24 When there is a documented iatrogenic breach into the disc, patients must be counseled regarding the associated risk, followed closely with a high index of suspicion, and monitored for early signs of infection.^23,24

References

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