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Pappalardo G, Schneider S, Kotsias A, Jeyaraman M, Schäfer L, Migliorini F. Negative pressure wound therapy in the management of postoperative spinal wound infections: a systematic review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2303-2313. [PMID: 38753028 DOI: 10.1007/s00590-024-03983-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 04/29/2024] [Indexed: 08/02/2024]
Abstract
INTRODUCTION Postoperative wound infection after spinal surgery might be a challenge to manage. A wide range of procedures have been described for managing infected spinal wounds. An increasingly common procedure in the management of surgical site infections (SSI) is negative pressure wound therapy (NPWT), also known as vacuum-assisted closure. As there is a paucity of clear clinical advice the present investigation aims to update current evidence on the use of NPWT to manage postoperative SSI occurring after instrumented spine surgery. METHODS This systematic review was conducted according to the preferred reporting Items for systematic reviews and meta-analyses: the 2020 PRISMA statement. In January 2024, the following databases were accessed: PubMed, Web of Science, and Google Scholar. No time constraint was set for the search. All the clinical studies investigating the unique use of NPWT in treating postoperative spinal wound infections were accessed. RESULTS A total of 381 patients were included in the present study. Of them 52.5% (200 of 381 patients) were women. The mean age was 52.2 ± 15.2 years. The average length of the NPWT was 21.2 days (range 7-90 days). CONCLUSION NPWT could be a valuable adjuvant therapy for the management of SSI after spine surgery. Additional high-quality investigations are required to assess the efficacy and safety of NPWT in SSI after spine surgery, especially if combined with contraindications or risk factors, such as the presence of intraoperative CSF leak. LEVEL OF EVIDENCE Level IV, Systematic review.
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Affiliation(s)
| | - Sascha Schneider
- Department of Spine Surgery, Oberlinhaus, 14482, Potsdam, Germany
| | - Andreas Kotsias
- Department of Spine Surgery, Oberlinhaus, 14482, Potsdam, Germany
| | - Madhan Jeyaraman
- Department of Orthopaedics, ACS Medical College and Hospital, Dr MGR Educational and Research Institute, Chennai, Tamil Nadu, 600077, India
| | - Luise Schäfer
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, 39100, Bolzano, Italy
| | - Filippo Migliorini
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, 39100, Bolzano, Italy.
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Eun DC, Suk KS, Kim HS, Kwon JW, Moon SH, Lee YH, Lee BH. Is Vancomycin More Effective than Taurolidine? Comparative Analysis of Their Preventive Effect against Spinal Infection in 1000 Patients with Spinal Fusion. Antibiotics (Basel) 2022; 11:antibiotics11101388. [PMID: 36290047 PMCID: PMC9598915 DOI: 10.3390/antibiotics11101388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/07/2022] [Accepted: 10/10/2022] [Indexed: 11/25/2022] Open
Abstract
This study aimed to examine the effect of taurolidine irrigation on preventing surgical site infection by comparing the spinal infection rate after spinal fusion surgery using vancomycin powder application and taurolidine irrigation. Of 1081 participants, 369 underwent taurolidine irrigation, 221 underwent vancomycin powder application, and 491 were controls. Of the 20 surgical site infections (1.85%), 14 occurred in the control group (2.85%), 5 in the vancomycin group (2.26%), and 1 (0.27%) in the taurolidine group. Among the various variables, age at the time of surgery, smoking, surgical site, and hemovac removal time were significant in the univariate logistic regression. The final result was derived after variable selection using the stepwise method. In the univariate model, the odds ratios were 0.09 and 0.79 in each of the vancomycin and taurolidine groups compared to that of the control group. In the multivariate model, the odds ratios were 0.09 and 0.83 in each of the vancomycin and taurolidine groups compared to that of the control group. The preventive effect of vancomycin powder application was not statistically significant. However, the vancomycin group showed a less effective tendency than the taurolidine group. Taurolidine irrigation may be a good substitute for the vancomycin powder application.
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Laubach M, Kobbe P, Hutmacher DW. Biodegradable interbody cages for lumbar spine fusion: Current concepts and future directions. Biomaterials 2022; 288:121699. [PMID: 35995620 DOI: 10.1016/j.biomaterials.2022.121699] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/14/2022] [Accepted: 07/22/2022] [Indexed: 11/16/2022]
Abstract
Lumbar fusion often remains the last treatment option for various acute and chronic spinal conditions, including infectious and degenerative diseases. Placement of a cage in the intervertebral space has become a routine clinical treatment for spinal fusion surgery to provide sufficient biomechanical stability, which is required to achieve bony ingrowth of the implant. Routinely used cages for clinical application are made of titanium (Ti) or polyetheretherketone (PEEK). Ti has been used since the 1980s; however, its shortcomings, such as impaired radiographical opacity and higher elastic modulus compared to bone, have led to the development of PEEK cages, which are associated with reduced stress shielding as well as no radiographical artefacts. Since PEEK is bioinert, its osteointegration capacity is limited, which in turn enhances fibrotic tissue formation and peri-implant infections. To address shortcomings of both of these biomaterials, interdisciplinary teams have developed biodegradable cages. Rooted in promising preclinical large animal studies, a hollow cylindrical cage (Hydrosorb™) made of 70:30 poly-l-lactide-co-d, l-lactide acid (PLDLLA) was clinically studied. However, reduced bony integration and unfavourable long-term clinical outcomes prohibited its routine clinical application. More recently, scaffold-guided bone regeneration (SGBR) with application of highly porous biodegradable constructs is emerging. Advancements in additive manufacturing technology now allow the cage designs that match requirements, such as stiffness of surrounding tissues, while providing long-term biomechanical stability. A favourable clinical outcome has been observed in the treatment of various bone defects, particularly for 3D-printed composite scaffolds made of medical-grade polycaprolactone (mPCL) in combination with a ceramic filler material. Therefore, advanced cage design made of mPCL and ceramic may also carry initial high spinal forces up to the time of bony fusion and subsequently resorb without clinical side effects. Furthermore, surface modification of implants is an effective approach to simultaneously reduce microbial infection and improve tissue integration. We present a design concept for a scaffold surface which result in osteoconductive and antimicrobial properties that have the potential to achieve higher rates of fusion and less clinical complications. In this review, we explore the preclinical and clinical studies which used bioresorbable cages. Furthermore, we critically discuss the need for a cutting-edge research program that includes comprehensive preclinical in vitro and in vivo studies to enable successful translation from bench to bedside. We develop such a conceptual framework by examining the state-of-the-art literature and posing the questions that will guide this field in the coming years.
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Affiliation(s)
- Markus Laubach
- Australian Research Council (ARC) Training Centre for Cell and Tissue Engineering Technologies, Queensland University of Technology (QUT), Brisbane, QLD, 4000 Australia; Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD 4000, Australia; Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD 4059, Australia; Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany.
| | - Philipp Kobbe
- Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Dietmar W Hutmacher
- Australian Research Council (ARC) Training Centre for Cell and Tissue Engineering Technologies, Queensland University of Technology (QUT), Brisbane, QLD, 4000 Australia; Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD 4000, Australia; Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD 4059, Australia; Max Planck Queensland Center for the Materials Science of Extracellular Matrices, Queensland University of Technology, Brisbane, QLD 4000, Australia.
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Choi SW, Lee JC, Lee WS, Hwang JY, Baek MJ, Choi YS, Jang HD, Shin BJ. Clinical differences between delayed and acute onset postoperative spinal infection. Medicine (Baltimore) 2022; 101:e29366. [PMID: 35713438 PMCID: PMC9276148 DOI: 10.1097/md.0000000000029366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 04/11/2022] [Indexed: 11/25/2022] Open
Abstract
Spine surgeons often encounter cases of delayed postoperative spinal infection (PSI). Delayed-onset PSI is a common clinical problem. However, since many studies have investigated acute PSIs, reports of delayed PSI are rare. The purpose of this study was to compare the clinical features, treatment course, and prognosis of delayed PSI with acute PSI.Ninety-six patients diagnosed with postoperative spinal infection were enrolled in this study. Patients were classified into 2 groups: acute onset (AO) within 90 days (n = 73) and delayed onset (DO) after 90 days (n = 23). The baseline data, clinical manifestations, specific treatments, and treatment outcomes were compared between the 2 groups.The history of diabetes mellitus (DM) and metallic instrumentation at index surgery were more DO than the AO group. The causative organisms did not differ between the 2 groups. Redness or heat sensation around the surgical wound was more frequent in the AO group (47.9%) than in the DO group (21.7%) (P = .02). The mean C-reactive protein levels during infection diagnosis was 8.9 mg/dL in the AO and 4.0 mg/dL in the DO group (P = .02). All patients in the DO group had deep-layer infection. In the DO group, revision surgery and additional instrumentation were required, and the duration of parenteral antibiotic use and total antibiotic use was significantly longer than that in the AO group. Screw loosening, disc space collapse, and instability were higher in the DO group (65.2%) than in the AO group (41.1%) (P = .04). However, the length of hospital stay did not differ between the groups.Delayed-onset PSI requires more extensive and longer treatment than acute-onset surgical site infection. Clinicians should try to detect the surgical site infection as early as possible.
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Affiliation(s)
- Sung-Woo Choi
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jae Chul Lee
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Won Seok Lee
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jin Yeong Hwang
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Min Jung Baek
- Department of Obstetrics and Gynecology, Bundang CHA Hospital, Seongnam, Korea
| | - Yoon Seo Choi
- Early Childhood Education, Ewha Woman's University, Korea
| | - Hae-Dong Jang
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Byung-Joon Shin
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
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Urie R, McBride M, Ghosh D, Fattahi A, Nitiyanandan R, Popovich J, Heys JJ, Kilbourne J, Haydel SE, Rege K. Antimicrobial laser-activated sealants for combating surgical site infections. Biomater Sci 2021; 9:3791-3803. [PMID: 33876069 PMCID: PMC9617567 DOI: 10.1039/d0bm01438a] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Surgical-site infections (SSIs) occur in 2-5% of patients undergoing surgery in the US alone, impacting 300 000-500 000 lives each year, and presenting up to 11 times greater risk of death compared to patients without SSIs. The most common cause of SSI is Staphylococcus aureus, and methicillin-resistant S. aureus (MRSA) is the most common pathogen in community hospitals. Current clinical devices used for approximating incisions and traumatic lacerations include sutures, adhesives, tapes, or staples with or without antimicrobial incorporation. However, current closure technologies may not provide adequate protection against infection, are susceptible to wound dehiscence, and can result in delayed biomechanical recoveries. Laser-activated tissue repair is a sutureless technique in which chromophore-loaded sealants convert laser light energy to heat in order to induce rapid tissue sealing. Here, we describe the generation and evaluation of laser-activated sealant (LASE) biomaterials, in which, indocyanine green (ICG), an FDA-approved dye, was embedded in a silk fibroin matrix and cast into films as wound sealants. Silk-ICG films were subjected to different near-infrared (NIR) laser powers to identify temperatures optimal for laser sealing of soft tissues. A mathematical model was developed in order to determine the photothermal conversion efficiency of LASEs following laser irradiation. NIR laser activation of silk-ICG LASEs increased the recovery of skin biomechanical strength compared to sutured skin in full-thickness incisional wounds in immunocompetent mice, and live animal imaging indicated persistence of silk-ICG LASEs over several days. LASEs loaded with the antibiotic vancomycin demonstrated higher efficacies for combating MRSA infections in a mouse model of surgical site infection compared to antibacterial sutures. Our results demonstrate that LASEs can be loaded with antimicrobial drugs and may serve as new multifunctional biomaterials for rapid tissue sealing, repair and surgical site protection following surgery.
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Affiliation(s)
- Russell Urie
- Chemical Engineering Program, School for Engineering of Matter, Transport, and Energy, Arizona State University, Tempe, AZ 85287, USA.
| | - Michelle McBride
- Biodesign Institute Center for Bioelectronics and Biosensors, Arizona State University, Tempe, AZ 85287, USA.
| | - Deepanjan Ghosh
- Biological Design Graduate Program, Arizona State University, Tempe, AZ 85287, USA
| | - Ali Fattahi
- Chemical Engineering Program, School for Engineering of Matter, Transport, and Energy, Arizona State University, Tempe, AZ 85287, USA.
| | | | - John Popovich
- Biodesign Institute Center for Bioelectronics and Biosensors, Arizona State University, Tempe, AZ 85287, USA.
| | - Jeffrey J Heys
- Chemical and Biological Engineering Department, Montana State University, Bozeman, MT 59717, USA
| | - Jacquelyn Kilbourne
- Department of Animal Care and Technologies, Arizona State University, Tempe, AZ 85287, USA
| | - Shelley E Haydel
- Biodesign Institute Center for Bioelectronics and Biosensors, Arizona State University, Tempe, AZ 85287, USA. and School of Life Sciences, Arizona State University, Tempe, AZ 85287, USA
| | - Kaushal Rege
- Chemical Engineering Program, School for Engineering of Matter, Transport, and Energy, Arizona State University, Tempe, AZ 85287, USA. and Biological Design Graduate Program, Arizona State University, Tempe, AZ 85287, USA
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Ahsan K, Hasan S, Khan SI, Zaman N, Almasri SS, Ahmed N, Chaurasia B. Conservative versus operative management of postoperative lumbar discitis. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2020; 11:198-209. [PMID: 33100770 PMCID: PMC7546051 DOI: 10.4103/jcvjs.jcvjs_111_20] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 07/20/2020] [Indexed: 11/28/2022] Open
Abstract
Background: Treatment option of postoperative discitis (POD) is either conservative or operative, but till date, there are no established validated protocols of the treatment of postoperative lumbar discitis. Aim: The aim of this study was to assess the outcome of conservative versus operative management of POD following single-level lumbar discectomy. Methods: We prospectively studied a total of 38 cases of POD. The patients were diagnosed clinically, radiologically, and by laboratory investigations and followed up with serial erythrocyte sedimentation rate (ESR), C-reactive protein, X-ray, computed tomography (CT), and magnetic resonance imaging. Demographic data, clinical variables, length of hospital stay, duration of antibiotic treatment, and posttreatment complications were collected, and pre- and postoperative assessment was done using the Visual Analog Scale (VAS) and Japanese Orthopaedic Association (JOA) score. Functional outcome of the study was measured by the modified criteria of Kirkaldy–Willis. Results: VAS score for pain was significantly decreased in both groups after treatment. However, posttreatment differences were not statistically significant. In posttreatment mean JOA score, differences were not statistically significant in both groups except the mean difference (−0.47) of restriction of daily activities, which was statistically significant (95% confidence interval: −0.88–−0.07, P = 0.025, unpaired t-test). About 73.7% and 84.2% of the patients had a satisfactory functional outcome in conservative and operative management groups, respectively, at the end of 12-month follow-up. Conclusions: Operative management yielded better outcomes than traditional conservative treatment in terms of functional outcomes, length of hospital stays, and duration of antibiotic treatment as determined by both the pain and daily activity levels.
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Affiliation(s)
- Kamrul Ahsan
- Department of Orthopaedic Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Sariful Hasan
- Department of Orthopaedic Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Shahidul Islam Khan
- Department of Orthopaedic Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Naznin Zaman
- Department of Anesthesiology, Sarkari Karmachari Hospital, Dhaka, Bangladesh
| | | | - Nazmin Ahmed
- Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Bipin Chaurasia
- Department of Neurosurgery, Neurosurgery Clinic, Birgunj, Nepal
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Does preventive care bundle have an impact on surgical site infections following spine surgery? An analysis of 9607 patients. Spine Deform 2020; 8:677-684. [PMID: 32162198 DOI: 10.1007/s43390-020-00099-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 02/25/2020] [Indexed: 10/24/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES The purpose was to analyze the effect of care bundle protocol on SSI in our institution. Postoperative surgical site infections (SSI) pose significant health burden. In spite of the use of prophylactic antibiotics, surgical advances and postoperative care, wound infection continues to affect patient outcomes after spine surgery. METHODS Retrospective analysis of 9607 consecutive patients who underwent spine procedures from 2014 to 2018 was performed. Preventive care bundle was implemented from January 2017 consisting of (a) preoperative bundle-glycemic control, chlorhexidine gluconate (CHG) bath, (b) intra-operative bundle-time specified antibiotic prophylaxis, CHG+ alcohol-based skin preparation (c) postoperative bundle-five moments of hand hygiene, early mobilization and bundle auditing. Patients operated from January 2017 were included in the post-implementation cohort and prior to that the pre-implementation cohort was formed. Data were drawn from weekly and yearly spine audits from the hospital infection committee software. Infection data were collected based on CDC criteria, further sub classification was done based on procedure, spinal disorders and spine level. Variables were analyzed and level of significance was set as < 0.05. RESULTS A total of 7333 patients met the criteria. The overall SSI rate decreased from 3.42% (131/3829) in pre-implementation cohort to 1.22% (43/3504, p = 0.0001) in post-implementation cohort (RR = 2.73, OR = 2.79). Statistically significant reduction was seen in all the groups (a) superficial and deep, (b) early and late and (c) instrumented and uninstrumented groups but was more pronounced in early (p = 0.0001), superficial (p = 0.0001) and instrumented groups (p = 0.0001). On subgroup analysis based on spine level and spinal disorders, significant reduction was seen in lumbar (p = 0.0001) and degenerative group (p = 0.0001). CONCLUSIONS Our study revealed significant reduction of SSI secondary to strict bundle adherence and monitored compliance compared to patients who did not receive these interventions. LEVEL OF EVIDENCE III.
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Sawh-Martinez R, Lin A, Timberlake A, Wu RT, Shah A, Chen W, Steinbacher D, Diluna M, Au A. Immediate plastic surgery closure at index spinal surgery minimizes complications compared to delayed reconstruction: A retrospective cohort review. J Plast Reconstr Aesthet Surg 2020; 73:1499-1505. [PMID: 32546424 DOI: 10.1016/j.bjps.2019.11.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 10/05/2019] [Accepted: 11/22/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Complex spine surgery in patients with major comorbidities leads to increased need for midline back wound reconstruction by plastic surgeons. Literature suggests that back wound reconstruction concurrent with high-risk immediate/index spine surgery may lead to fewer complication. This study aimed to validate this claim in a large cohort treated at a tertiary center. We hypothesize that immediate reconstruction may lead to fewer adverse events in comparison to delayed reconstruction. METHODS This was a retrospective single-center review of 659 patients who underwent spinal surgery with/without reconstruction by plastic surgeons between November 2011 and December 2015. Three main cohorts were evaluated: patients who underwent spinal surgery with no reconstruction, patients with delayed reconstruction after spine surgery, and patients with immediate back wound reconstruction with index spine surgery. Demographic, clinical, and outcomes data were collected from electronic medical records. Primary endpoints were the incidence of any complications such as dehiscence, infection, seroma/hematoma, and exposed hardware. The secondary endpoint was return to the operating room and most recent follow-up. RESULTS Forty-three patients underwent index reconstruction (follow-up 25.3 ± 12.7 months), 33 were delayed (follow-up 23.7 ± 12.5 months), and 583 had no reconstruction (follow-up 22.1 ± 15.2 months). Patients who underwent index reconstruction had more spinal levels involved than delayed reconstruction (7.8 ± 0.75 vs 5.6 ± 0.68; p = 0.03). The overall complications rate was 7.7%, most commonly wound dehiscence (2.7%), infections (0.9%), exposed hardware (2.0%), cerebrospinal fluid leaks (0.6%), and return to OR (3.8%). Patients who underwent index spinal wound reconstruction had a significantly lower complication rate (4.65%) than secondary spinal surgery patients (27.3%; p = 0.048). CONCLUSIONS The data confirmed significantly decreased complication rates for index back wound reconstructions for high-risk patients compared to delayed spine wound reconstruction. Increased rates of wound dehiscence, exposed hardware, and revisions occurred with delayed reconstruction. Early employment of tension free, robust vascular flap closure may attribute to a decreased complication profile.
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Affiliation(s)
- Rajendra Sawh-Martinez
- Section of Plastic Surgery, Department of Surgery, Yale University School of Medicine, 333 Cedar Street, Boardman Building, 3rd Floor, New Haven, CT 06511, United States.
| | - Alex Lin
- Section of Plastic Surgery, Department of Surgery, Yale University School of Medicine, 333 Cedar Street, Boardman Building, 3rd Floor, New Haven, CT 06511, United States
| | - Andrew Timberlake
- Section of Plastic Surgery, Department of Surgery, Yale University School of Medicine, 333 Cedar Street, Boardman Building, 3rd Floor, New Haven, CT 06511, United States
| | - Robin T Wu
- Section of Plastic Surgery, Department of Surgery, Yale University School of Medicine, 333 Cedar Street, Boardman Building, 3rd Floor, New Haven, CT 06511, United States
| | - Ajul Shah
- Section of Plastic Surgery, Department of Surgery, Yale University School of Medicine, 333 Cedar Street, Boardman Building, 3rd Floor, New Haven, CT 06511, United States
| | - William Chen
- Section of Plastic Surgery, Department of Surgery, Yale University School of Medicine, 333 Cedar Street, Boardman Building, 3rd Floor, New Haven, CT 06511, United States
| | - Derek Steinbacher
- Section of Plastic Surgery, Department of Surgery, Yale University School of Medicine, 333 Cedar Street, Boardman Building, 3rd Floor, New Haven, CT 06511, United States
| | - Michael Diluna
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Alexander Au
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
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Abstract
In July of 2018, the Second International Consensus Meeting (ICM) on Musculoskeletal Infection convened in Philadelphia, PA was held to discuss issues regarding infection in orthopedic patients and to provide consensus recommendations on these issues to practicing orthopedic surgeons. During this meeting, attending delegates divided into subspecialty groups to discuss topics specifics to their respective fields, which included the spine. At the spine subspecialty group meeting, delegates discussed and voted upon the recommendations for 63 questions regarding the prevention, diagnosis, and treatment of infection in spinal surgery. Of the 63 questions, 9 focused on implants questions in spine surgery, for which this article provides the recommendations, voting results, and rationales.
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Do Prophylactic Antibiotics Reach the Operative Site Adequately?: A Quantitative Analysis of Serum and Wound Concentrations of Systemic and Local Prophylactic Antibiotics in Spine Surgery. Spine (Phila Pa 1976) 2020; 45:E196-E202. [PMID: 31490860 DOI: 10.1097/brs.0000000000003238] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVE To analyze the serum and drain concentrations of antibiotics administered by two different routes and compare the results. SUMMARY OF BACKGROUND DATA Systemic antibiotics are expected to reach the surgical site and maintain adequate concentrations of the drug to prevent infection. However, it is unknown whether systemically administered antibiotics reach and maintain such adequate concentrations at the surgical wound or not. METHODS Forty patients undergoing elective spine surgery received intra-wound Vancomycin (1 GM) before the wound closure and single dose of intravenous Gentamycin (80MG) immediately after surgery. Blood and drain samples were collected postoperatively to estimate serum and drain concentrations of Gentamycin and Vancomycin. Drug Estimation Protocol: Drug concentrations were estimated by ADVIA Centaur CP immunoassay (direct chemiluminescence). Gentamycin and vancomycin in the test samples competes with their respective acridinium ester-labeled gentamicin and vancomycin derivatives for monoclonal mouse anti-gentamycin and anti-vancomycin antibodies which are covalently coupled to paramagnetic particles in the solid phase. RESULTS Gentamycin attained peak serum levels at 6 hours following administration with an average value of 9.90 ± 3.1 μg/mL which was decreased to 6.76 ± 2.6 μg/mL at 12 hours and steadily declining thereafter. Even though, the drug concentrations in the drain collection from the wound also attained peak levels at 6 hours, the drug concentrations were lower (3.75 ± 1.4 μg/mL) than that of serum concentrations and inadequately attained the recommended target peak of Gentamycin (4-12 μg/mL).Wound levels of local vancomycin were significantly higher at 6 hours (413.4 ± 217.3 μg/mL) and well maintained even at 72 hours. Serum vancomycin levels were observed to be highest at 6 hours in negligible concentrations of 6.06 ± 2.2 μg/mL. CONCLUSION After prophylactic systemic administration of the antibiotics, the antibiotic drug concentrations in the wound are much lower than the serum concentrations at any given time. After local intra-wound application of antibiotics, the drug concentrations in the wound are well maintained even after 72 hours. LEVEL OF EVIDENCE 3.
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García-Casallas JC, Blanco-Mejía JA, Fuentes- Barreiro YV, Arciniegas-Mayorga LC, Arias-Cepeda CD, Morales-Pardo BD. Prevención y tratamiento de las infecciones del sitio operatorio en neurocirugía. Estado del arte. IATREIA 2019. [DOI: 10.17533/udea.iatreia.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
El manejo adecuado de las infecciones del sitio operatorio (ISO) en neurocirugía es fundamental para la disminución de la carga de morbilidad y mortalidad en estos pacientes. La sospecha y confirmación diagnóstica asociadas al aislamiento microbiológico son esenciales para asegurar el tratamiento oportuno y el adecuado gerenciamiento de antibióticos. En esta revisión se presenta de forma resumida los puntos fundamentales para la prevención y el tratamiento de infecciones del sitio operatorio en neurocirugía y se incluye un apartado sobre el uso de antibióticos intratecales/intraventriculares.
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Kalfas F, Severi P, Scudieri C. Infection with Spinal Instrumentation: A 20-Year, Single-Institution Experience with Review of Pathogenesis, Diagnosis, Prevention, and Management. Asian J Neurosurg 2019; 14:1181-1189. [PMID: 31903360 PMCID: PMC6896624 DOI: 10.4103/ajns.ajns_129_19] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objective and Importance Instrumentation has become an integral component in the management of various spinal pathologies. The rate of infection varies from 2% to 20% of all instrumented spinal procedures. Postoperative spinal implant infection places patients at risk for pseudo-arthrosis, correction loss, spondylodiscitis, and adverse neurological sequelae and increases health-care costs. Materials and Methods We performed a cohort study of 1065 patients who underwent instrumented spinal procedures in our institution between 1995 and 2014. Fifty-one patients (4.79%) contracted postoperative spinal infection. Isolated bacterial species, infection severity, diagnosis/treatment timing, surgical/medical strategy treatment, and patient's medical background were evaluated to assess their relationship with management outcome. Results Multiple risk factors for postoperative spinal infection were identified. Infections may be early or delayed. C-reactive protein and magnetic resonance imaging are important diagnostic tools. Prompt diagnosis and aggressive therapy (debridement and parenteral antibiotics) were responsible for implant preservation in 49 of 51 cases, whereas implant removal noted in two cases was attributed to delayed treatment and uncontrolled infection with implant loosening or late infection with spondylodesis. Infection in the setting of instrumentation is more difficult to diagnose and treat due to biofilm. Conclusion Retention of the mechanically sound implants in early-onset infection permits fusion to occur, whereas delayed treatment and multiple comorbidities will most likely result in a lack of effectiveness in eradicating the infecting pathogens. An improved understanding of the role of biofilm and the development of newer spinal implants has provided insight into the pathogenesis and management of infected spinal implants. It is important to accurately identify and treat postoperative spinal infections. The treatment is multimodal and prolonged.
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Affiliation(s)
- Fotios Kalfas
- Department of Neurological Surgery, Galliera Hospitals, Genova, Italy
| | - Paolo Severi
- Department of Neurological Surgery, Galliera Hospitals, Genova, Italy
| | - Claudia Scudieri
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
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13
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Rudy HL, Cho W, Oster BA, Morris MT, Schulz J. Treatment of Isolated Serosanguinous Incision Drainage after Thoracolumbar Surgery: Is Surgical Management Always Necessary? Surg Infect (Larchmt) 2019; 21:227-230. [PMID: 31589565 DOI: 10.1089/sur.2019.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: There is no consensus regarding how to care for a patient presenting with early isolated incision drainage after thoracolumbar spine surgery. Although drainage is the most common presenting symptom of surgical site infection (SSI), it has low specificity for SSI in the absence of other symptoms. Given that invasive treatment for SSI is costly and high risk, it would be beneficial to determine whether antibiotic treatment alone is sufficient for isolated drainage and what factors predispose to failure of this conservative strategy. Methods: The authors retrospectively reviewed a clinical database of patients who underwent thoracolumbar spine surgery at a single center between 2012-2017. Patients were included if serosanguinous drainage was present within six weeks of surgery without other signs and symptoms of infection such as fever, chills, purulent discharge, fluctuance, wound dehiscence, or erythema. Results: Fifty-eight patients met the study inclusion criteria. After initial conservative management with antibiotics, drainage resolved in 51 patients. The seven patients with drainage that did not resolve were treated with operative surgical washout. Although the groups were similar in most respects, there was a significant difference in the American Society of Anesthesiologists (ASA) score, which is a marker of overall health (surgical group score 2.89 ± 0.33 versus 2.06 ± 0.61; p < 0.0001). In addition, patients with greater estimated blood loss, length of hospital stay, operative time, and spinal levels treated were more likely to require surgical washout, although these differences were not statistically significant. Groups were similar with respect to age, Body Mass Index, smoking status, diabetes mellitus status, revision versus primary surgery, and drainage latency. Conclusion: Most patients who present with isolated serosanguinous incision drainage within six weeks of surgery may be managed successfully using antibiotics only. Patients who fail to respond to conservative therapy have significantly worse general health, as indicated by the ASA score.
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Affiliation(s)
- Hayeem L Rudy
- Department of Orthopaedic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Woojin Cho
- Department of Orthopaedic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Brittany A Oster
- Department of Orthopaedic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Matthew T Morris
- Department of Orthopaedic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Jacob Schulz
- Department of Orthopaedic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
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Fanous AA, Kolcun JPG, Brusko GD, Paci M, Ghobrial GM, Nakhla J, Eleswarapu A, Lebwohl NH, Green BA, Gjolaj JP. Surgical Site Infection as a Risk Factor for Long-Term Instrumentation Failure in Patients with Spinal Deformity: A Retrospective Cohort Study. World Neurosurg 2019; 132:e514-e519. [PMID: 31449998 DOI: 10.1016/j.wneu.2019.08.088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 08/13/2019] [Accepted: 08/14/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Surgical site infection (SSI) remains a complication of spine deformity surgery. Although fusion/instrumentation failure in the setting of SSI has been reported, few studies have investigated the relationship between these entities. We examine the relationship between early SSI and fusion/instrumentation failure after instrumented fusion in patients with thoracolumbar scoliosis. METHODS A retrospective review of a prospectively maintained case series for patients undergoing spine surgery between January 1, 2006, and October 3, 2017. Inclusion criteria included age ≥18 years and surgery performed for correction of thoracolumbar scoliosis. Data collected included various demographic, clinical, and operative variables. RESULTS 532 patients met inclusion criteria, with 20 (4%) experiencing SSI. Diabetes mellitus was the only demographic risk factor for increased SSI (P = 0.026). Number of fused levels, blood volume loss, and operative time were similar between groups. Fusion/instrumentation failure occurred in 68 (13%) patients, 10 of whom (15%) had SSI, whereas of the 464 patients with no fusion/instrumentation failure, only 10 (2%) had SSI (P < 0.001). Of the 20 patients with SSI, 10 (50%) had fusion/instrumentation failure, whereas in the 512 patients with no infection, only 58 (11%) had fusion/instrumentation failure (P < 0.001). Patients with infection also experienced significantly shorter time to fusion/instrumentation failure (P = 0.025), higher need for revision surgery (P < 0.001), and shorter time to revision surgery (P = 0.012). CONCLUSIONS Early SSI significantly increases the risk of fusion/instrumentation failure in patients with thoracolumbar scoliotic deformity, and it significantly shortens the time to failure. Patients with early SSI have a significantly higher likelihood of requiring revision surgery and after a significantly shorter time interval.
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Affiliation(s)
- Andrew A Fanous
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - John Paul G Kolcun
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - G Damian Brusko
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
| | - Michael Paci
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - George M Ghobrial
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jonathan Nakhla
- Department of Neurological Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Ananth Eleswarapu
- Department of Orthopedic Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Nathan H Lebwohl
- Department of Orthopedic Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Barth A Green
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Joseph P Gjolaj
- Department of Orthopedic Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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Recent Increase in the Rate of Spinal Infections May be Related to Growing Substance-use Disorder in the State of Washington: Wide Population-based Analysis of the Comprehensive Hospital Abstract Reporting System (CHARS) Database. Spine (Phila Pa 1976) 2019; 44:291-297. [PMID: 30059485 DOI: 10.1097/brs.0000000000002819] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Epidemiological study. OBJECTIVE The aim of this study was to evaluate trends in the incidence of spinal infections (SI) and the possible role of substance use disorder (SUD) as a key associated factor. SUMMARY OF BACKGROUND DATA SI pose major diagnostic and therapeutic challenge in developed countries, resulting in substantial morbidity and mortality. With an estimated incidence of up to 1:20,000, recent clinical experiences suggest that this rate may be rising. METHODS To evaluate a possible change in trend in the proportion of SI, we searched the Washington state Comprehensive Hospital Abstract Reporting System (CHARS) data during a period of 15 years. We retrieved ICD-9 and 10 codes, searching for all conditions that are regarded as SI (discitis, osteomyelitis, and intraspinal abscess), as well as major known SI-related risk factors. RESULTS We found that the proportion of SI among discharged patients had increased by around 40% during the past 6 years, starting at 2012 and increasing steadily thereafter. Analysis of SI-related risk factors within the group of SI revealed that proportion of SUD and malnutrition had undergone the most substantial change, with the former increasing >3-fold during the same period. CONCLUSION Growing rates of drug abuse, drug dependence, and malnutrition throughout the State of Washington may trigger a substantial increase in the incidence of spinal infections in discharged patients. These findings may provide important insights in planning prevention strategies on a broader level. LEVEL OF EVIDENCE 4.
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Immediate Reconstruction of Complex Spinal Wounds Is Associated with Increased Hardware Retention and Fewer Wound-related Complications: A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2076. [PMID: 30859036 PMCID: PMC6382244 DOI: 10.1097/gox.0000000000002076] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 10/22/2018] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Patients undergoing surgeries involving extensive posterior spine instrumentation and fusion often have multiple risk factors for wound healing complications. We performed a systematic review and meta-analysis of the available evidence on immediate (proactive/prophylactic) and delayed (reactive) spinal wound reconstruction. We hypothesized that immediate soft-tissue reconstruction of extensive spinal wounds would be associated with fewer postoperative surgicalsite complications than delayed reconstruction. Methods: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a PubMed database search was performed to identify English-language, human-subject literature published between 2003 and 2018. Data were summarized, and the pooled prevalence of various wound complications was calculated, weighted by study size, using the generic inverse variance method. A subgroup analysis of all studies with a comparison group (Oxford Centre for Evidence-based Medicine level 3 or better) was performed, and Forest plots were created. Results: The database search yielded 16 articles including 828 patients; 428 (51.7%) received an immediate spinal wound reconstruction and 400 (48.3%) had a delayed reconstruction. Spinal neoplasm was the most common index diagnosis. Paraspinous muscle flap reconstruction was performed in the majority of cases. Pooled analysis of all studies revealed immediate reconstruction to be associated with decreased rates of overall wound complications (28.5% versus 18.8%), hardware loss (10.7% versus 1.8%), and wound infections (10.7% versus 7.6%) compared with delayed reconstruction. Conclusions: Immediate soft-tissue reconstruction of high-risk spinal wounds is associated with fewer wound healing complications and increased hardware retention.
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Alcoholism as a predictor for pseudarthrosis in primary spine fusion: An analysis of risk factors and 30-day outcomes for 52,402 patients from 2005 to 2013. J Orthop 2018; 16:36-40. [PMID: 30662235 DOI: 10.1016/j.jor.2018.12.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 12/09/2018] [Indexed: 11/23/2022] Open
Abstract
Introduction This study assessed the incidence and risk factors for pseudarthrosis among primary spine fusion patients. Methods Retrospective review of ACS-NSQIP (2005-2013). Differences in comorbidities between spine fusion patients with and without pseudarthrosis (Pseud, N-Pseud) were assessed using chi-squared tests and Independent Samples t-tests. Binary logistic regression assessed patient-related and procedure-related predictors for pseudarthrosis. Results 52,402 patients (57yrs, 53%F, 0.4% w/pseudarthrosis). Alcohol consumption (OR:2.6[1.2-5.7]) and prior history of surgical revision (OR:1.6[1.4-1.8]) were risk factors for pseudarthrosis operation. Pseud patients at higher risk for deep incisional SSI (at 30-days:OR:6.6[2.0-21.8]). Pseud patients had more perioperative complications (avg:0.24 ± 0.43v0.18 ± 0.39,p=0.026). Conclusions Alcoholism and surgical revision are major risk factors for pseudarthrosis in patients undergoing spine fusion.
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18F-FDG-PET/CT localizes intervertebral disc space infection following posterior lumbar interbody fusion surgery leading to successful retention of percutaneously inserted pedicle screws: a case report. Spinal Cord Ser Cases 2018; 4:81. [PMID: 30210813 DOI: 10.1038/s41394-018-0119-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 08/16/2018] [Indexed: 11/09/2022] Open
Abstract
Introduction Postoperative infection is a potentially devastating complication of spine surgery and an appropriate strategy and timely decision-making are essential for successful treatment of deep surgical site infection (SSI) after spinal instrumentation surgeries. However, there is a lack of consensus on implant removal or retention. We report on a case of deep SSI after posterior lumbar interbody fusion (PLIF) surgery in which we achieved clinical cure by debridement and removal of the interbody fusion cage without removing the percutaneously inserted pedicle screws (PPS). Case presentation A case was a 53-year-old woman with deep SSI after PLIF surgery using the PPS system at the L4-5 level. Computed tomography (CT) showed no clear radiolucent line around the screws and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET)/CT demonstrated abnormal FDG uptake around the cages and no uptake around the pedicle screws. Intervertebral cages were removed and iliac bone grafts were inserted between the vertebral bodies, without removing the pedicle screws. The infection was cleared and bone fusion was achieved after the revision surgery. Discussion Targeting active infection using FDG-PET/CT is considered useful in narrowing the surgical margins and determining whether to preserve instrumentation in revision surgery after SSI. PLIF using the PPS system could be useful in preventing the easy spread of infection from the intervertebral space to the insertion point of PPS through the interstitial space.
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19
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Byvaltsev VA, Stepanov IA, Borisov VE, Abakirov MD. SURGICAL SITE INFECTIONS IN PATIENTS AFTER POSTERIOR LUMBAR SPINE FUSION. COLUNA/COLUMNA 2018. [DOI: 10.1590/s1808-185120181703193839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Objective: Infectious complications are the most common cause of unsatisfactory results of surgical treatment and prolongation of hospitalization in patients following spinal surgery. The purpose - to assess the microbiological characteristics of SSI in patients after posterior lumbar fusion for degenerative disease, and to determine the relationship between these characteristics and surgical features of SSIs. Methods: A single-center retrospective non-randomized cohort study was performed, 1563 patients aged 37 to 59 years were included in the study. Microbiological characteristics were analyzed, and their interrelations with the surgical features of all cases of SSIs were determined. Results: The incidence of SSIs was 2.67% (41). Monomicrobial SSIs were detected in 46.3% (19) patients, polymicrobial in 36.5% (15) cases, and negative results of inoculation in 17.07% (7) patients. The most frequent pathogens of SSIs in the study group were S. aureus and S. epidermidis - 37.9% (33) and 24.1% (21), respectively. The period of development of symptoms of SSIs in patients after posterior lumbar fusion averaged 25.9±65.3 days. Methicillin-resistant S. aureus and S. epidermidis (MRSA and MRSE) were verified in 24.1% (21) cases. Conclusions: Assessment of microbiological characteristics should be carried out in all diagnosed cases of SSIs in patients after spine surgical interventions, as these are closely linked to the surgical features of the infectious process. Also, the treatment tactics for this group of patients should be determined by a medical team working in conjunction. Level of evidence IV; Descriptive study.
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Laratta JL, Lombardi JM, Shillingford JN, Reddy HP, Gvozdyev BV, Kim YJ. Permanent implantation of antibiotic cement over exposed instrumentation eradicates deep spinal infection. JOURNAL OF SPINE SURGERY (HONG KONG) 2018; 4:471-477. [PMID: 30069547 PMCID: PMC6046320 DOI: 10.21037/jss.2018.04.03] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 04/04/2018] [Indexed: 12/26/2022]
Abstract
In this case series, we describe an infection treatment protocol involving permanent implantation of antibiotic cement that is effective in eradicating deep infection. Surgical site infection (SSI) is a devastating complication of spine surgery. Unlike the gold-standard two-stage revision in North American hip and knee arthroplasty, there exists no standardized, accepted protocol for the management of deep SSI with instrumentation. Because removal of hardware in an unstable, instrumented spine can result in serious neurologic sequelae, retention of instrumentation with elimination of bacterial colonization on implants is the goal. Using Current Procedural Terminology (CPT) codes, institutional medical records were queried to identify all posterior spinal procedures performed by the senior surgeon from 2008 through 2014. Thirty-four patients were identified as having an implant-associated SSI. Exclusion criteria included: (I) superficial SSI, and (II) those with less than 36 months of follow-up. The study population consisted of ten patients with deep implant-associated SSI who underwent our novel protocol of operative debridement and permanent coating of exposed implants with high-dose antibiotic cement. Postoperative infection presented after an average of 41.4±57.5 days (range, 6.0-207.0 days) from the index procedure. The mean follow-up was 64.4±18.1 months (range, 44.0-98.0 months). At final follow-up, none of the ten patients (0%) in our series had evidence of continued deep infection and none required removal of hardware. Ten of the ten patients (100%) were able to clear infection with a single stage debridement and coating with antibiotic cement. Only 1 of the 10 patients (10%) developed a pseudarthrosis. In conclusion, permanent implantation of antibiotic cement over exposed instrumentation is effective in preserving spinal instrumentation during infection eradication, preventing infection recurrence, and minimizing operative debridements.
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Affiliation(s)
| | - Joseph M. Lombardi
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Jamal N. Shillingford
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Hemant P. Reddy
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | | | - Yong J. Kim
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
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Kobayashi K, Ando K, Ito K, Tsushima M, Morozumi M, Tanaka S, Machino M, Ota K, Ishiguro N, Imagama S. Factors associated with extension of the scheduled time for spine surgery. Clin Neurol Neurosurg 2018; 169:128-132. [PMID: 29656173 DOI: 10.1016/j.clineuro.2018.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 03/29/2018] [Accepted: 04/01/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Adherence to scheduled times in surgery is important in hospital management. However, sudden surgical changes or unexpected intraoperative problems may lead to prolongation of operative times. The purpose of this study was to investigate operative times in spinal surgery and to identify causes of delays during surgery. PATIENTS AND METHODS A retrospective review of 488 cases of spinal surgery was performed to investigate operations prolonged for >2 h and to identify factors associated with prolongation. RESULTS There were 250 cases without a delay, and 144, 64, and 30 with delays of <1 h, 1-2 h, and >2 h, respectively. Delays >2 h were caused by interruptions due to loss of transcranial motor-evoked potential (Tc-MEP) signals in spinal cord monitoring (n = 15), reinsertion due to screw misplacement (n = 5), intraoperative pathology procedures (n = 5), extension of fusion range with instrumentation (n = 3), and complete resection of an intramedullary tumor (n = 2). Surgeries with delays >2 h (n = 30) had greater rates of scheduled surgery for >5 h (40% vs. 23%; P < 0.05), instrumentation use (70% vs. 47%; P < 0.05), reoperation (33% vs. 7%; P < 0.01%), and estimated blood loss (EBL) (1573 vs. 435 ml; P < 0.01), compared to all other surgeries (n = 458). In multivariate logistic regression, reoperation (HR 3.15, 95% CI 1.52-6.55; p < 0.01) and EBL ≥ 1000 ml (HR 3.35, 95% CI 1.56-7.18; p < 0.01) were significantly associated with prolongation of surgery by >2 h. CONCLUSION Information suggesting potential prolongation of surgery should be shared with all medical staff. Reliable surgical techniques and hemostasis may also reduce delays in surgery.
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Affiliation(s)
- Kazuyoshi Kobayashi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai Showa-ward, Aichi, Nagoya, 466-8550, Japan
| | - Kei Ando
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai Showa-ward, Aichi, Nagoya, 466-8550, Japan
| | - Kenyu Ito
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai Showa-ward, Aichi, Nagoya, 466-8550, Japan
| | - Mikito Tsushima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai Showa-ward, Aichi, Nagoya, 466-8550, Japan
| | - Masayoshi Morozumi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai Showa-ward, Aichi, Nagoya, 466-8550, Japan
| | - Satoshi Tanaka
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai Showa-ward, Aichi, Nagoya, 466-8550, Japan
| | - Masaaki Machino
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai Showa-ward, Aichi, Nagoya, 466-8550, Japan
| | - Kyotaro Ota
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai Showa-ward, Aichi, Nagoya, 466-8550, Japan
| | - Naoki Ishiguro
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai Showa-ward, Aichi, Nagoya, 466-8550, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai Showa-ward, Aichi, Nagoya, 466-8550, Japan.
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Management of spinal infection: a review of the literature. Acta Neurochir (Wien) 2018; 160:487-496. [PMID: 29356895 PMCID: PMC5807463 DOI: 10.1007/s00701-018-3467-2] [Citation(s) in RCA: 162] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 01/08/2018] [Indexed: 12/17/2022]
Abstract
Spinal infection (SI) is defined as an infectious disease affecting the vertebral body, the intervertebral disc, and/or adjacent paraspinal tissue and represents 2–7% of all musculoskeletal infections. There are numerous factors, which may facilitate the development of SI including not only advanced patient age and comorbidities but also spinal surgery. Due to the low specificity of signs, the delay in diagnosis of SI remains an important issue and poor outcome is frequently seen. Diagnosis should always be supported by clinical, laboratory, and imaging findings, magnetic resonance imaging (MRI) remaining the most reliable method. Management of SI depends on the location of the infection (i.e., intraspinal, intervertebral, paraspinal), on the disease progression, and of course on the patient’s general condition, considering age and comorbidities. Conservative treatment mostly is reasonable in early stages with no or minor neurologic deficits and in case of severe comorbidities, which limit surgical options. Nevertheless, solely medical treatment often fails. Therefore, in case of doubt, surgical treatment should be considered. The final result in conservative as well as in surgical treatment always is bony fusion. Furthermore, both options require a concomitant antimicrobial therapy, initially applied intravenously and administered orally thereafter. The optimal duration of antibiotic therapy remains controversial, but should never undercut 6 weeks. Due to a heterogeneous and often comorbid patient population and the wide variety of treatment options, no generally applicable guidelines for SI exist and management remains a challenge. Thus, future prospective randomized trials are necessary to substantiate treatment strategies.
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Reoperation within 2 years after lumbar interbody fusion: a multicenter study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:1972-1980. [DOI: 10.1007/s00586-018-5508-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 01/16/2018] [Accepted: 01/30/2018] [Indexed: 11/26/2022]
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Intrawound Tobramycin Powder Eradicates Surgical Wound Contamination: An In Vivo Rabbit Study. Spine (Phila Pa 1976) 2017; 42:E1393-E1397. [PMID: 28399544 DOI: 10.1097/brs.0000000000002187] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Therapeutic anti-infective trial in rabbits. OBJECTIVE The purpose of the present study was to assess the efficacy of intrawound tobramycin powder in terms of eradicating a known bacterial contamination in an Escherichia coli-infected rabbit spinal implantation model. SUMMARY OF BACKGROUND DATA Implant-associated surgical site infections (SSIs) remain a dreaded complication of spinal surgery. Currently, >30% of all spine SSIs are secondary to gram-negative bacteria. METHODS Twenty healthy New Zealand white female rabbits underwent simulated partial laminectomies and implantation of a 10-mm titanium wire at L5-L6. All surgical sites were inoculated with 100 μL of tobramycin-sensitive E coli (EC ATCC 25922, 1 × 10 colony-forming units [CFU]/mL). Before closure, tobramycin powder (120 mg) was placed into the wound of 10 rabbits. All rabbits were sacrificed on postoperative day 4. Tissue and wire samples were explanted for bacteriologic analysis. A Fisher exact test was used to assess differences in categorical variables and an independent samples t test was used to assess mean group differences. RESULTS The experimental and control rabbits were similar in weight (mean ± standard deviation, 3.22 ± 0.12 kg and 3.22 ± 0.14 kg, respectively, P = 1.0), sex distribution, and duration of surgery (13.1 ± 2.4 minutes and 11.6 ± 2.1 minutes, P = 0.39). Bacterial cultures of the tissue samples were negative for all 10 tobramycin-treated rabbits and positive for all 10 control rabbits (P < 0.0001). Bacterial growth occurred in 39 of 40 samples from control rabbits, but zero of the 40 samples from the tobramycin group (P < 0.0001). Blood culture samples from all rabbits were negative for bacterial growth. No rabbit had evidence of sepsis or tobramycin toxicity. CONCLUSION In a rabbit spine-infection model, intrawound tobramycin eliminated E coli surgical site contamination. All rabbits without intrawound tobramycin had persistent E coli contamination. LEVEL OF EVIDENCE N /A.
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Wang TY, Back AG, Hompe E, Wall K, Gottfried ON. Impact of surgical site infection and surgical debridement on lumbar arthrodesis: A single-institution analysis of incidence and risk factors. J Clin Neurosci 2017; 39:164-169. [PMID: 28202380 DOI: 10.1016/j.jocn.2017.01.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 01/22/2017] [Indexed: 12/26/2022]
Abstract
This study identifies the rate of pseudarthrosis following surgical debridement for deep lumbar spine surgical site infection and identify associated risk factors. Patients who underwent index lumbar fusion surgery from 2013 to 2014 were included if they met the following criteria: 1) age >18years, 2) had debridement of deep lumbar SSI, and had 3) lumbar spine AP, lateral and flexion/extension X-rays and computed tomography (CT) at 12months or greater postoperatively. Criteria for fusion included 1) solid posterolateral, facet, or disk space bridging bone, 2) no translational or angular motion on flexion/extension X-rays, and 3) intact posterior hardware without evidence of screw lucency or breakage. Twenty-five patients (age 63.2±12.6years, 10 male) involving 58 spinal levels met inclusion criteria. They underwent fusion at a mean of 2.32 [range 1-4] spinal levels. Sixteen (64.0%) patients received interbody grafts at a total of 34 (58.6%) spinal levels. All underwent surgical debridement with removal of all non-incorporated posterior bone graft and devascularized tissue. At one-year postoperatively, (56%) patients and 30 (52%) spinal levels demonstrated radiographic evidence of successful fusion. Interbody cage during initial fusion was significantly associated with successful arthrodesis at follow-up (p=0.017). There is a high rate of pseudoarthrosis in 44% of patients (48% of levels) undergoing lumbar fusion surgery complicated by SSI requiring debridement. Use of interbody cage during initial fusion was significantly associated with higher rate of arthrodesis.
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Affiliation(s)
- Timothy Y Wang
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC, USA
| | - Adam G Back
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC, USA
| | - Eliza Hompe
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC, USA
| | - Kevin Wall
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC, USA
| | - Oren N Gottfried
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC, USA.
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McCunniff PT, Young ES, Ahmadinia K, Ahn UM, Ahn NU. Smoking is Associated with Increased Blood Loss and Transfusion Use After Lumbar Spinal Surgery. Clin Orthop Relat Res 2016; 474:1019-25. [PMID: 26642788 PMCID: PMC4773328 DOI: 10.1007/s11999-015-4650-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 11/23/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Little is known about the association between smoking and intraoperative blood loss and perioperative transfusion use in patients undergoing spinal surgery. However, we found that although many of the common complications and deleterious effects of smoking on surgical patients had been well documented, the aspect of blood loss seemingly had been overlooked despite data reported in nonorthopaedic sources to suggest a possible connection. QUESTIONS/PURPOSES We asked: (1) Is smoking associated with increased estimated blood loss during surgery in patients undergoing lumbar spine surgery? (2) Is smoking associated with increased perioperative transfusion usage? METHODS Between 2005 and 2009, 581 lumbar decompression procedures (with or without fusion) were performed at one academic spine center. Of those, 559 (96%) had sufficient chart documentation to categorize patients by smoking status, necessary intra- and postoperative data to allow analysis with respect to bleeding and transfusion-related endpoints, and who did not meet exclusion criteria. Exclusion criteria included: patients whose smoking status did not fit in our two categories, patients with underlying coagulopathy, patients receiving anticoagulants (including aspirin and platelet inhibitors), history of hepatic disease, history of platelet disorder or other blood dyscrasias, and patient or family history of any other known bleeding disorder. Smoking history in packs per day was obtained for all subjects. We defined someone as a smoker if the patient reported smoking up until the day of their surgical procedure; nonsmokers were patients who quit smoking at least 6 weeks before surgery or had no history of smoking. We used a binomial grouping for whether patients did or did not receive a transfusion perioperatively. Age, sex, number of levels of discectomies, number of levels decompressed, number of levels fused, and use of instrumentation were recorded. The same approaches were used for transfusions in all patients regardless of smoking history; decisions were made in consultation between the surgeon and the anesthesia team. Absolute indications for transfusion postoperatively were: a hemoglobin less than 7 g/dL, continued symptoms of dizziness, tachycardia, decreased exertional tolerance, or hypotension that failed to respond to fluid resuscitation. Multiple linear regression analyses correcting for the above variables were performed to determine associations with intraoperative blood loss, while logistic regression was used to analyze perioperative transfusion use. RESULTS After controlling for potentially relevant confounding variables noted earlier, we found smokers had increased estimated blood loss compared with nonsmokers (mean, 328 mL more for each pack per day smoked; 95% CI, 249-407 mL; p < 0.001). We also found that again correcting for confounders, smokers had increased perioperative transfusion use compared with nonsmokers (odds ratio, 13.8; 95% CI, 4.59-42.52). CONCLUSIONS Smoking is associated with increased estimated surgical blood loss and transfusion use in patients undergoing lumbar spine surgery. Patients who smoke should be counseled regarding these risks and on smoking cessation before undergoing lumbar surgery. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Peter T. McCunniff
- Department of Orthopaedic Surgery, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106-5043 USA
| | - Ernest S. Young
- Department of Orthopaedic Surgery, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106-5043 USA
| | - Kasra Ahmadinia
- Department of Orthopaedic Surgery, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106-5043 USA
| | - Uri M. Ahn
- New Hampshire NeuroSpine Institute, Bedford, NH USA
| | - Nicholas U. Ahn
- Department of Orthopaedic Surgery, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106-5043 USA
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Abstract
Postoperative spinal wound infection increases the morbidity of the patient and the cost of healthcare. Despite the development of prophylactic antibiotics and advances in surgical technique and postoperative care, wound infection continues to compromise patient outcome after spinal surgery. Spinal instrumentation also has an important role in the development of postoperative infections. This review analyses the risk factors that influence the development of postoperative infection. Classification and diagnosis of postoperative spinal infection is also discussed to facilitate the choice of treatment on the basis of infection severity. Preventive measures to avoid surgical site (SS) infection in spine surgery and methods for reduction of all the changeable risk factors are discussed in brief. Management protocols to manage SS infections in spine surgery are also reviewed.
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Lewkonia P, DiPaola C, Street J. Incidence and risk of delayed surgical site infection following instrumented lumbar spine fusion. J Clin Neurosci 2016; 23:76-80. [DOI: 10.1016/j.jocn.2015.05.039] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 05/02/2015] [Indexed: 10/23/2022]
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Chieng LO, Hubbard Z, Salgado CJ, Levi AD, Chim H. Reconstruction of open wounds as a complication of spinal surgery with flaps: a systematic review. Neurosurg Focus 2015; 39:E17. [DOI: 10.3171/2015.7.focus15245] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
A systematic review of the available evidence on the prophylactic and therapeutic use of flaps for the coverage of complex spinal soft-tissue defects was performed to determine if the use of flaps reduces postoperative complications and improves patient outcomes.
METHODS
A PubMed database search was performed to identify English-language articles published between 1990 and 2014 that contained the following phrases to describe postoperative wounds (“wound,” “complex back wound,” “postoperative wound,” “spine surgery”) and intervention (“flap closure,” “flap coverage,” “soft tissue reconstruction,” “muscle flap”).
RESULTS
In total, 532 articles were reviewed with 17 articles meeting the inclusion criteria of this study. The risk factors from the pooled analysis of 262 patients for the development of postoperative complex back wounds that necessitated muscle flap coverage included the involvement of instrumentation (77.6%), a previous history of radiotherapy (33.2%), smoking (20.6%), and diabetes mellitus (17.2%). In patients with instrumentation, prophylactic coverage of the wound with a well-vascularized flap was shown to result in a lower incidence of wound complications. One study showed a statistically significant decrease in complications compared with patients where prophylactic coverage was not performed (20% vs 45%). The indications for flap coverage after onset of wound complications included hardware exposure, wound infection, dehiscence, seroma, and hematoma. Flap coverage was shown to decrease the number of surgical debridements needed and also salvage hardware, with the rate of hardware removal after flap coverage ranging from 0% to 41.9% in 4 studies.
CONCLUSIONS
Prophylactic coverage with flaps in high-risk patients undergoing spine surgery reduces complications, while therapeutic coverage following wound complications allows the salvage of hardware in the majority of patients.
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Affiliation(s)
| | | | | | - Allan D. Levi
- 3Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida
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Parchi PD, Evangelisti G, Andreani L, Girardi F, Darren L, Sama A, Lisanti M. Postoperative Spine Infections. Orthop Rev (Pavia) 2015; 7:5900. [PMID: 26605028 PMCID: PMC4592931 DOI: 10.4081/or.2015.5900] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 07/22/2015] [Accepted: 07/22/2015] [Indexed: 12/14/2022] Open
Abstract
Postoperative spinal wound infection is a potentially devastating complication after operative spinal procedures. Despite the utilization of perioperative prophylactic antibiotics in recent years and improvements in surgical technique and postoperative care, wound infection continues to compromise patients’ outcome after spinal surgery. In the modern era of pending health care reform with increasing financial constraints, the financial burden of post-operative spinal infections also deserves consideration. The aim of our work is to give to the reader an updated review of the latest achievements in prevention, risk factors, diagnosis, microbiology and treatment of postoperative spinal wound infections. A review of the scientific literature was carried out using electronic medical databases Pubmed, Google Scholar, Web of Science and Scopus for the years 1973-2012 to obtain access to all publications involving the incidence, risk factors, prevention, diagnosis, treatment of postoperative spinal wound infections. We initially identified 119 studies; of these 60 were selected. Despite all the measures intended to reduce the incidence of surgical site infections in spine surgery, these remain a common and potentially dangerous complication.
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Affiliation(s)
| | | | | | - Federico Girardi
- Spine Care Institute Hospital For Special Surgery , New York, NY, USA
| | - Lebl Darren
- Spine Care Institute Hospital For Special Surgery , New York, NY, USA
| | - Andrew Sama
- Spine Care Institute Hospital For Special Surgery , New York, NY, USA
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Scheverin N, Steverlynck A, Castelli R, Sobrero D, Kopp NV, Dinelli D, Sarotto A, Falavigna A. PROPHYLAXIS OF SURGICAL SITE INFECTION WITH VANCOMYCIN IN 513 PATIENTS THAT UNDERWENT TO LUMBAR FUSION. COLUNA/COLUMNA 2015. [DOI: 10.1590/s1808-185120151403149776] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective:To assess the prophylactic effects of local vancomycin on an infection of the surgical site in patients undergoing lumbar instrumented fusion.Methods:Retrospective study from January 2011 to June 2014 in patients with symptomatic and refractory lumbar spine stenosis and listhesis who underwent instrumented pedicle screw spinal fusion. Two groups of patient were analyzed, one using vancomycin on the surgical site, vancomycin group (VG) and the control group (CG) without topical vancomycin. The routine prophylactic procedures were performed in both groups: aseptic scrub technique, skin preparation, preoperative intravenous antibiotic therapy. The VG received a dose of 1g of vancomycin mixed with the bone graft every three spinal levels fused and the group consisted of 232 patients.Results:513 patients were analyzed, 232 in the VG and 281 in the CG. There was no statistical difference between the groups when the sex, mean surgery length, and mean bleeding volume were considered. The rate of infection for VG was reduced from 4.98% to 1.29% when compared with CG.Conclusion:The use of vancomycin added to the bone graft in posterior spinal fusion is associated with significantly lower rates of infection.
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Chen SH, Lee CH, Huang KC, Hsieh PH, Tsai SY. Postoperative wound infection after posterior spinal instrumentation: analysis of long-term treatment outcomes. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 24:561-70. [DOI: 10.1007/s00586-014-3636-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 10/20/2014] [Accepted: 10/22/2014] [Indexed: 12/22/2022]
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Scolaro JA, Schenker ML, Yannascoli S, Baldwin K, Mehta S, Ahn J. Cigarette smoking increases complications following fracture: a systematic review. J Bone Joint Surg Am 2014; 96:674-81. [PMID: 24740664 DOI: 10.2106/jbjs.m.00081] [Citation(s) in RCA: 190] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Smoking has been suggested to increase the rate of perioperative complications including soft-tissue complications, to decrease the rate of fracture union, and to prolong healing time. The purpose of our study was to systematically evaluate and analyze the literature regarding the relationship between smoking and healing following operative treatment of long-bone fractures. METHODS We searched the MEDLINE, Embase, and Cochrane databases by pairing the search terms "smoking," "tobacco," and "nicotine" with the terms "fracture," "nonunion," delayed union," and "healing." Articles and citations were evaluated for relevance. Inclusion and exclusion criteria were established to maintain data quality for analysis. Relevant information was independently extracted and compared to ensure agreement. The methodological quality of the studies was determined. A random-effects model was used. The adjusted odds ratios (ORs) and frequency-weighted means for the primary and secondary outcome measures were calculated. RESULTS Our initial search identified 7110 articles. Of the 237 articles that underwent further evaluation of the abstract, nineteen (seven prospective and twelve retrospective cohort studies) were included. The adjusted OR of nonunion in the smoking group compared with the nonsmoking group was 2.32 (95% confidence interval [CI], 1.76 to 3.06; p < 0.001). An increased nonunion rate was observed in smokers with a tibial fracture (OR, 2.16; 95% CI, 1.55 to 3.01; p < 0.001) and those with an open fracture (OR, 1.95; 95% CI, 1.3 to 2.9; p < 0.001). For all fractures, the mean healing time was longer for smokers (30.2 weeks; 95% CI, 22.7 to 37.7 weeks) than for nonsmokers (24.1 weeks; 95% CI, 17.3 to 30.9 weeks) (p = 0.18). Trends toward more superficial and deep infections of postoperative or traumatic wounds in smokers were noted; however, the differences in superficial and deep infection rates were not significant (p = 0.13 and p = 0.33, respectively). CONCLUSIONS Smoking significantly increased the risk of nonunion of fractures overall, tibial fractures, and open fractures. Nonsignificant trends toward increased time to union in all fractures and toward increased postoperative rates of superficial and deep infections were noted in smokers compared with nonsmokers.
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Affiliation(s)
- John A Scolaro
- Department of Orthopaedics and Sports Medicine, University of Washington, Harborview Medical Center, 325 9th Avenue, Seattle, WA 98104
| | - Mara L Schenker
- Department of Orthopaedic Surgery, University of Pennsylvania, 3400 Spruce Street, 2 Silverstein Pavilion, Philadelphia, PA 19104. E-mail address for J. Ahn:
| | - Sarah Yannascoli
- Department of Orthopaedic Surgery, University of Pennsylvania, 3400 Spruce Street, 2 Silverstein Pavilion, Philadelphia, PA 19104. E-mail address for J. Ahn:
| | - Keith Baldwin
- Department of Orthopaedic Surgery, University of Pennsylvania, 3400 Spruce Street, 2 Silverstein Pavilion, Philadelphia, PA 19104. E-mail address for J. Ahn:
| | - Samir Mehta
- Department of Orthopaedic Surgery, University of Pennsylvania, 3400 Spruce Street, 2 Silverstein Pavilion, Philadelphia, PA 19104. E-mail address for J. Ahn:
| | - Jaimo Ahn
- Department of Orthopaedic Surgery, University of Pennsylvania, 3400 Spruce Street, 2 Silverstein Pavilion, Philadelphia, PA 19104. E-mail address for J. Ahn:
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Zebala LP, Chuntarapas T, Kelly MP, Talcott M, Greco S, Riew KD. Intrawound vancomycin powder eradicates surgical wound contamination: an in vivo rabbit study. J Bone Joint Surg Am 2014; 96:46-51. [PMID: 24382724 DOI: 10.2106/jbjs.l.01257] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Surgical site infection remains a complication of spine surgery despite routine use of prophylactic antibiotics. Retrospective clinical studies of intrawound vancomycin use have documented a decreased prevalence of surgical site infection after spine surgery. The purpose of the present study was to assess the efficacy of intrawound vancomycin powder in terms of eradicating a known bacterial surgical site contamination in a rabbit spine surgery model. METHODS Twenty New Zealand White rabbits underwent lumbar partial laminectomy and wire implantation. The surgical sites were inoculated, prior to closure, by injecting 100 μL of cefazolin-sensitive and vancomycin-sensitive Staphylococcus aureus (S. aureus) (1 × 10⁸ colony-forming units [CFU]/mL) into the wound. Preoperative cefazolin was administered to all rabbits, and vancomycin powder (100 mg) was placed into the wound of ten rabbits prior to closure. The rabbits were killed on postoperative day four, and tissue and wire samples were obtained for bacteriologic assessment. An independent samples t test was used to assess mean group differences, and a Fisher exact test was used to assess differences in categorical variables. RESULTS The vancomycin-treated and the control rabbits were similar in weight (mean [and standard deviation], 4.1 ± 0.5 kg and 4.0 ± 0.4 kg, respectively; p = 0.60) and sex distribution and had similar durations of surgery (21.7 ± 7.7 minutes and 16.9 ± 6.7 minutes; p = 0.15). The bacterial cultures of the surgical site tissues were negative for all ten vancomycin-treated rabbits and positive for all ten control rabbits (p < 0.0001). Bacterial growth occurred in thirty-nine of forty samples from the control group but in zero of forty samples from the vancomycin group (p < 0.0001). All blood and liver samples were sterile. No rabbit had evidence of sepsis or vancomycin toxicity. Gross examination of the surgical sites showed no differences between the groups. CONCLUSIONS In a rabbit spine-infection model, intrawound vancomycin powder in combination with preoperative cefazolin eliminated S. aureus surgical site contamination. All rabbits that were managed with only prophylactic cefazolin had persistent S. aureus contamination. CLINICAL RELEVANCE This animal study supports the findings in prior clinical reports that intrawound vancomycin powder helps reduce the risk of surgical site infections.
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Affiliation(s)
- Lukas P Zebala
- Departments of Orthopaedic Surgery (L.P.Z., T.C., M.P.K., and K.D.R.) and Comparative Medicine (M.T. and S.G.), Washington University in St. Louis, One Barnes-Jewish Hospital Plaza, Suite 11300 WP, CB 8233, St. Louis, MO 63110. E-mail address for L.P. Zeb
| | - Tapanut Chuntarapas
- Departments of Orthopaedic Surgery (L.P.Z., T.C., M.P.K., and K.D.R.) and Comparative Medicine (M.T. and S.G.), Washington University in St. Louis, One Barnes-Jewish Hospital Plaza, Suite 11300 WP, CB 8233, St. Louis, MO 63110. E-mail address for L.P. Zeb
| | - Michael P Kelly
- Departments of Orthopaedic Surgery (L.P.Z., T.C., M.P.K., and K.D.R.) and Comparative Medicine (M.T. and S.G.), Washington University in St. Louis, One Barnes-Jewish Hospital Plaza, Suite 11300 WP, CB 8233, St. Louis, MO 63110. E-mail address for L.P. Zeb
| | - Michael Talcott
- Departments of Orthopaedic Surgery (L.P.Z., T.C., M.P.K., and K.D.R.) and Comparative Medicine (M.T. and S.G.), Washington University in St. Louis, One Barnes-Jewish Hospital Plaza, Suite 11300 WP, CB 8233, St. Louis, MO 63110. E-mail address for L.P. Zeb
| | - Suellen Greco
- Departments of Orthopaedic Surgery (L.P.Z., T.C., M.P.K., and K.D.R.) and Comparative Medicine (M.T. and S.G.), Washington University in St. Louis, One Barnes-Jewish Hospital Plaza, Suite 11300 WP, CB 8233, St. Louis, MO 63110. E-mail address for L.P. Zeb
| | - K Daniel Riew
- Departments of Orthopaedic Surgery (L.P.Z., T.C., M.P.K., and K.D.R.) and Comparative Medicine (M.T. and S.G.), Washington University in St. Louis, One Barnes-Jewish Hospital Plaza, Suite 11300 WP, CB 8233, St. Louis, MO 63110. E-mail address for L.P. Zeb
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Kasliwal MK, Tan LA, Traynelis VC. Infection with spinal instrumentation: Review of pathogenesis, diagnosis, prevention, and management. Surg Neurol Int 2013; 4:S392-403. [PMID: 24340238 PMCID: PMC3841941 DOI: 10.4103/2152-7806.120783] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 06/06/2013] [Indexed: 12/12/2022] Open
Abstract
Background: Instrumentation has become an integral component in the management of various spinal pathologies. The rate of infection varies from 2% to 20% of all instrumented spinal procedures. Every occurrence produces patient morbidity, which may adversely affect long-term outcome and increases health care costs. Methods: A comprehensive review of the literature from 1990 to 2012 was performed utilizing PubMed and several key words: Infection, spine, instrumentation, implant, management, and biofilms. Articles that provided a current review of the pathogenesis, diagnosis, prevention, and management of instrumented spinal infections over the years were reviewed. Results: There are multiple risk factors for postoperative spinal infections. Infections in the setting of instrumentation are more difficult to diagnose and treat due to biofilm. Infections may be early or delayed. C Reactive Protein (CRP) and Magnetic Resonance Imaging (MRI) are important diagnostic tools. Optimal results are obtained with surgical debridement followed by parenteral antibiotics. Removal or replacement of hardware should be considered in delayed infections. Conclusions: An improved understanding of the role of biofilm and the development of newer spinal implants has provided insight in the pathogenesis and management of infected spinal implants. This literature review highlights the mechanism, pathogenesis, prevention, and management of infection after spinal instrumentation. It is important to accurately identify and treat postoperative spinal infections. The treatment is often multimodal and prolonged.
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Affiliation(s)
- Manish K Kasliwal
- Department of Neurosurgery, RUSH University Medical Center Chicago, IL, USA
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Surgical site infections in spine surgery: identification of microbiologic and surgical characteristics in 239 cases. Spine (Phila Pa 1976) 2013; 38:E1425-31. [PMID: 23873240 DOI: 10.1097/brs.0b013e3182a42a68] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis. OBJECTIVE The objective of this study was to describe the microbiology of surgical site infection (SSI) in spine surgery and relationship with surgical management characteristics. SUMMARY OF BACKGROUND DATA SSI is an important complication of spine surgery that results in significant morbidity. A comprehensive and contemporary understanding of the microbiology of postoperative spine infections is valuable to direct empiric antimicrobial treatment and prophylaxis and other infection prevention strategies. METHODS All cases of spinal surgery associated with SSI between July 2005 and November 2010 were identified by the hospital infection control surveillance program using Centers for Disease Control National Health Safety Network criteria. Surgical characteristics and microbiologic data for each case were gathered by direct medical record review. RESULTS Of 7529 operative spine cases performed between July 2005 and November 2010, 239 cases of SSI were identified. The most commonly isolated pathogen was Staphylococcus aureus (45.2%), followed by Staphylococcus epidermidis (31.4%). Methicillin-resistant organisms accounted for 34.3% of all SSIs and were more common in revision than in primary surgical procedures (47.4% vs. 28.0%, P = 0.003). Gram-negative organisms were identified in 30.5% of the cases. Spine surgical procedures involving the sacrum were significantly associated with gram-negative organisms (P < 0.001) and polymicrobial infections (P = 0.020). Infections due to gram-negative organisms (P = 0.002) and Enterococcus spp. (P = 0.038) were less common in surgical procedures involving the cervical spine. Cefazolin-resistant gram-negative organisms accounted for 61.6% of all gram-negative infections and 18.8% of all SSIs. CONCLUSION Although gram-positive organisms predominated, gram-negative organisms accounted for a sizeable portion of SSI, particularly among lower lumbar and sacral spine surgical procedures. Nearly half of infections in revision surgery were due to a methicillin-resistant organism. These findings may help guide choice of empiric antibiotics while awaiting culture data and antimicrobial prophylaxis strategies in specific spine surgical procedures. LEVEL OF EVIDENCE 3.
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Savage JW, Anderson PA. An update on modifiable factors to reduce the risk of surgical site infections. Spine J 2013; 13:1017-29. [PMID: 23711958 DOI: 10.1016/j.spinee.2013.03.051] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2012] [Revised: 02/12/2013] [Accepted: 03/20/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Despite an increase in physician and public awareness and advances in infection control practices, surgical site infection (SSI) remains to be one of the most common complications after an operation. Surgical site infections have been shown to decrease health-related quality of life, double the risk of readmission, prolong the length of hospital stay, and increase hospital costs. PURPOSE To critically evaluate the literature and identify modifiable factors to reduce the risk of SSI. STUDY DESIGN/SETTING Systematic review of the literature. METHODS A critical review of the literature was performed using OVID, Pubmed, and the Cochrane database and focused on eight identifiable factors: preoperative screening and decolonization of methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus protocols, antiseptic showers, antiseptic cloths, perioperative skin preparation, surgeon hand hygiene, antibiotic irrigation and/or use of vancomycin powder, closed suction drains, and antibiotic suture. RESULTS Screening protocols have shown that 18% to 25% of patients undergoing elective orthopedic surgery are nasal carriers of S. aureus and that carriers are more likely to have a nosocomial infection and SSI. The evidence suggests that an institutionalized prescreening program, followed by an appropriate eradication using mupirocin ointment and chlorhexidine soap/shower, will lower the rate of nosocomial S. aureus infections. Based on the current literature, definitive conclusions cannot be made on whether preoperative antiseptic showers effectively reduce the incidence of postoperative infection. The use of a chlorhexidine bathing cloth before surgery may decrease the risk of SSI. There is no definitive clinical evidence that one skin preparation solution effectively lowers the rate of postoperative infection compared with another. The use of dilute betadine irrigation or vancomycin powder in the wound before closure likely decreases the incidence of SSI. CONCLUSIONS There is strong evidence in the literature that optimizing specific preoperative, intraoperative, and postoperative variables can significantly lower the risk of developing an SSI.
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Affiliation(s)
- Jason W Savage
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 676 N. St. Clair St, Suite 1350, Chicago, IL 60611, USA.
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Li H, Hamza T, Tidwell JE, Clovis N, Li B. Unique antimicrobial effects of platelet-rich plasma and its efficacy as a prophylaxis to prevent implant-associated spinal infection. Adv Healthc Mater 2013; 2:1277-84. [PMID: 23447088 DOI: 10.1002/adhm.201200465] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 01/16/2013] [Indexed: 11/10/2022]
Abstract
Platelet-rich-plasma (PRP) has attracted great attention and has been increasingly used for a variety of clinical applications including orthopedic surgeries, periodontal and oral surgeries, maxillofacial surgeries, plastic surgeries, and sports medicine. However, very little is known about the antimicrobial activities of PRP. PRP is found to have antimicrobial properties both in vitro and in vivo. In vitro, the antimicrobial properties of PRP are bacterial-strain-specific and time-specific: PRP significantly (80-100 fold reduction in colony-forming units) inhibits the growth of methicillin-sensitive and methicillin-resistant Staphylococcus aureus, Group A streptococcus, and Neisseria gonorrhoeae within the first few hours but it has no significant antimicrobial properties against E. coli and Pseudomonas. The antimicrobial properties of PRP also depend on the concentration of thrombin. In vivo, an implant-associated spinal infection rabbit model is established and used to evaluate the antimicrobial and wound-healing properties of PRP. Compared to the infection controls, PRP treatment results in significant reduction in bacterial colonies in bone samples at all time points studied (i.e. 1, 2, and 3 weeks) and significant increase in mineralized tissues (thereby better bone healing) at postoperative weeks 2 and 3. PRP therefore may be a useful adjunct strategy against postoperative implant-associated infections.
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Affiliation(s)
- Hongshuai Li
- Department of Orthopaedics, School of Medicine, West Virginia University, Morgantown, WV 26506, USA; Department of Orthopaedics, University of Pittsburgh, Pittsburgh, Pennsylvania 15219, USA
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Barrey C, Launay O, Freitas E, Michel F, Laurent F, Chidiac C, Perrin G, Ferry T. The follow-up of patients with postoperative infection of the spine. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2013; 23 Suppl 1:S29-34. [DOI: 10.1007/s00590-013-1243-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 05/15/2013] [Indexed: 11/25/2022]
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Hegde V, Meredith DS, Kepler CK, Huang RC. Management of postoperative spinal infections. World J Orthop 2012; 3:182-9. [PMID: 23330073 PMCID: PMC3547112 DOI: 10.5312/wjo.v3.i11.182] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 10/21/2012] [Accepted: 11/01/2012] [Indexed: 02/06/2023] Open
Abstract
Postoperative surgical site infection (SSI) is a common complication after posterior lumbar spine surgery. This review details an approach to the prevention, diagnosis and treatment of SSIs. Factors contributing to the development of a SSI can be split into three categories: (1) microbiological factors; (2) factors related to the patient and their spinal pathology; and (3) factors relating to the surgical procedure. SSI is most commonly caused by Staphylococcus aureus. The virulence of the organism causing the SSI can affect its presentation. SSI can be prevented by careful adherence to aseptic technique, prophylactic antibiotics, avoiding myonecrosis by frequently releasing retractors and preoperatively optimizing modifiable patient factors. Increasing pain is commonly the only symptom of a SSI and can lead to a delay in diagnosis. C-reactive protein and magnetic resonance imaging can help establish the diagnosis. Treatment requires acquiring intra-operative cultures to guide future antibiotic therapy and surgical debridement of all necrotic tissue. A SSI can usually be adequately treated without removing spinal instrumentation. A multidisciplinary approach to SSIs is important. It is useful to involve an infectious disease specialist and use minimum serial bactericidal titers to enhance the effectiveness of antibiotic therapy. A plastic surgeon should also be involved in those cases of severe infection that require repeat debridement and delayed closure.
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Savage JW, Weatherford BM, Sugrue PA, Nolden MT, Liu JC, Song JK, Haak MH. Efficacy of surgical preparation solutions in lumbar spine surgery. J Bone Joint Surg Am 2012; 94:490-4. [PMID: 22437997 DOI: 10.2106/jbjs.k.00471] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Postoperative spinal wound infections are relatively common and are often associated with increased morbidity and poor long-term patient outcomes. The purposes of this study were to identify the common bacterial flora on the skin overlying the lumbar spine and evaluate the efficacy of readily available skin-preparation solutions in the elimination of bacterial pathogens from the surgical site following skin preparation. METHODS A prospective randomized study was undertaken to evaluate 100 consecutive patients undergoing elective lumbar spine surgery. At the time of surgery, the patients were randomized to be treated with one of two widely used, and Food and Drug Administration (FDA)-approved, surgical skin-preparation solutions: ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol) or DuraPrep (0.7% available iodine and 74% isopropyl alcohol). Specimens for aerobic and anaerobic cultures were obtained prior to skin preparation (pre-preparation), after skin preparation (post-preparation), and after wound closure (post-closure). A validated neutralization solution was used for each culture to ensure that the antimicrobial activity was stopped immediately after the sample was taken. Positive cultures and specific bacterial pathogens were recorded. RESULTS Coagulase-negative Staphylococcus, Propionibacterium acnes, and Corynebacterium were the most commonly isolated organisms prior to skin preparation. The overall rate of positive cultures prior to skin preparation was 82%. The overall rate of positive cultures after skin preparation was 0% (zero of fifty) in the ChloraPrep group and 6% (three of fifty) in the DuraPrep group (p = 0.24, 95% confidence interval [CI] = 0.006 to 0.085). There was an increase in positive cultures after wound closure, but there was no difference between the ChloraPrep group (34%, seventeen of fifty) and the DuraPrep group (32%, sixteen of fifty) (p = 0.22, 95% CI = 0.284 to 0.483). Body mass index (BMI), duration of surgery, and estimated blood loss did not a show significant association with post-closure positive culture results. CONCLUSIONS ChloraPrep and DuraPrep are equally effective skin-preparation solutions for eradication of common bacterial pathogens on the skin overlying the lumbar spine.
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Affiliation(s)
- Jason W Savage
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 1350, Chicago, IL 60611, USA
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Dipaola CP, Saravanja DD, Boriani L, Zhang H, Boyd MC, Kwon BK, Paquette SJ, Dvorak MFS, Fisher CG, Street JT. Postoperative infection treatment score for the spine (PITSS): construction and validation of a predictive model to define need for single versus multiple irrigation and debridement for spinal surgical site infection. Spine J 2012; 12:218-30. [PMID: 22386957 DOI: 10.1016/j.spinee.2012.02.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 09/22/2011] [Accepted: 02/07/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND CONTEXT There is very little evidence to guide treatment of patients with spinal surgical site infection (SSI) who require irrigation and debridement (I&D) in deciding need for single or multiple I&Ds or more complex wound management such as vacuum-assisted closure dressing or soft-tissue flaps. PURPOSE The purpose of this study was to build a predictive model that stratifies patients with spinal SSI, allowing us to determine which patients will need single versus multiple I&D. The model will be validated and will serve as evidence to support a scoring system to guide treatment. STUDY DESIGN A consecutive series of 128 patients from a tertiary spine center (collected from 1999 to 2005) who required I&D for spinal SSI were studied based on data from a prospectively collected outcomes database. METHODS More than 30 variables were identified by extensive literature review as possible risk factors for SSI and tested as possible predictors of risk for multiple I&D. Logistic regression was conducted to assess each variable's predictability by a "bootstrap" statistical method. A prediction model was built in which single or multiple I&D was treated as the "response" and risk factors as "predictors." Next, a second series of 34 different patients meeting the same criteria as the first population were studied. External validation of the predictive model was performed by applying the model to the second data set, and predicted probabilities were generated for each patient. Receiver operating characteristic curves were constructed, and the area under the curve (AUC) was calculated. RESULTS Twenty-four of one hundred twenty-eight patients with spinal SSI required multiple I&D. Six predictors: anatomical location, medical comorbidities, specific microbiology of the SSI, the presence of distant site infection (ie, urinary tract infection or bacteremia), the presence of instrumentation, and the bone graft type proved to be the most reliable predictors of need for multiple I&D. Internal validation of the predictive model yielded an AUC of 0.84. External validation analysis yielded AUC of 0.70 and 95% confidence interval of 0.51 to 0.89. By setting a probability cutoff of .24, the negative predictive value (NPV) for multiple I&D was 0.77 and positive predictive value (PPV) was 0.57. A probability cutoff of .53 yielded a PPV of 0.85 and NPV of 0.46. CONCLUSIONS Patients with positive methicillin-resistant Staphylococcus aureus culture or those with distant site infection such as bacteremia were strong predictors of need for multiple I&D. Presence of instrumentation, location of surgery in the posterior lumbar spine, and use of nonautograft bone graft material predicted multiple I&D. Diabetes also proved to be the most significant medical comorbidity for multiple I&D. The validation of this predictive model revealed excellent PPV and good NPV with appropriately chosen probability cutoff points. This study forms the basis for an evidence-based classification system, the Postoperative Infection Treatment Score for the Spine that stratifies patients who require surgery for SSI, based on specific spine, patient, infection, and surgical factors to assess a low, indeterminate, and high risk for the need for multiple I&D.
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Affiliation(s)
- Christian P Dipaola
- Department of Orthopaedics, University of Massachusetts Medical Center, Worcester, MA 01605, USA.
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Meredith DS, Kepler CK, Huang RC, Brause BD, Boachie-Adjei O. Postoperative infections of the lumbar spine: presentation and management. INTERNATIONAL ORTHOPAEDICS 2012; 36:439-44. [PMID: 22159548 PMCID: PMC3282873 DOI: 10.1007/s00264-011-1427-z] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Accepted: 11/10/2011] [Indexed: 12/15/2022]
Abstract
PURPOSE Postoperative surgical site infections (SSI) are a frequent complication following posterior lumbar spinal surgery. In this manuscript we review strategies for prevention, diagnosis and treatment of SSI. METHODS The literature was reviewed using the Pubmed database. RESULTS We identified fifty-nine relevant manuscripts almost exclusively composed of Level III and IV studies. CONCLUSIONS Risk factors for SSI include: 1) factors related to the nature of the spinal pathology and the surgical procedure and 2) factors related to the systemic health of the patient. Staphylococcus aureus is the most common infectious organism in reported series. Proven methods to prevent SSI include prophylactic antibiotics, meticulous adherence to aseptic technique and frequent release of retractors to prevent myonecrosis. The presentation of SSI is varied depending on the virulence of the infectious organism. Frequently, increasing pain is the only presenting complaint and can lead to a delay in diagnosis. Magnetic resonance imaging and the use of C-reactive protein laboratory studies are useful to establish the diagnosis. Treatment of SSI is centered on surgical debridement of all necrotic tissue and obtaining intra-operative cultures to guide antibiotic therapy. We recommend the involvement of an infectious disease specialist and use of minimum serial bactericidal titers to monitor the efficacy of antibiotic treatment. In the most cases, SSI can be adequately treated while leaving spinal instrumentation in place. For severe SSI, repeat debridement, delayed closure and involvement of a plastic surgeon may be necessary.
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Affiliation(s)
- Dennis S Meredith
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery/Weill Cornell Medical Center, New York, NY, USA.
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Gerometta A, Rodriguez Olaverri JC, Bitan F. Infections in spinal instrumentation. INTERNATIONAL ORTHOPAEDICS 2012; 36:457-64. [PMID: 22218913 DOI: 10.1007/s00264-011-1426-0] [Citation(s) in RCA: 108] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 11/10/2011] [Indexed: 12/19/2022]
Abstract
Surgical-site infection (SSI) in the spine is a serious postoperative complication. Factors such as posterior surgical approach, arthrodesis, use of spinal instrumentation, age, obesity, diabetes, tobacco use, operating-room environment and estimated blood loss are well established in the literature to affect the risk of infection. Infection after spine surgery with instrumentation is becoming a common pathology. The reported infection rates range from 0.7% to 11.9%, depending on the diagnosis and complexity of the procedure. Besides operative factors, patient characteristics could also account for increased infection rates. These infections after instrumented spinal fusion are particularly difficult to manage due to the implanted, and possibly infected, instrumentation. Because the medical, economic and social costs of SSI after spinal instrumentation are enormous, any significant reduction in risks will pay dividends. The goal of this literature review was to analyse risk factors, causative organisms, diagnostic elements (both clinical and biological), different treatment options and their efficiency and consequences and the means of SSI prevention.
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Algorithmus zur Behandlung tiefer Wirbelsäuleninfektionen und der Spondylodiszitis bei einliegender Instrumentierung. DER ORTHOPADE 2011; 41:51-7. [DOI: 10.1007/s00132-011-1841-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Chikawa T, Sakai T, Bhatia NN, Sairyo K, Utunomiya R, Nakamura M, Nakano S, Shimakawa T, Minato A. Retrospective study of deep surgical site infections following spinal surgery and the effectiveness of continuous irrigation. Br J Neurosurg 2011; 25:621-4. [PMID: 21848439 DOI: 10.3109/02688697.2010.546902] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Surgical site infection (SSI) is an unfortunate and unpreventable complication of any surgical intervention including spinal surgery. Early deep SSI (EDSSI) after instrumented spinal fusion are particularly difficult to manage due to the implanted, and possibly infected, instrumentation. The purpose of this study is to retrospectively review patients who underwent spinal surgery, investigate the rate of EDSSI, identify patient-related and surgery-related risk factors and to assess the effectiveness of continuous indwelling irrigation on the eradication of these infections. A total of 814 patients (319 women and 495 men) who underwent spinal surgery were enrolled. Mean age at the initial surgery was 57.4 years old. Infections that penetrated the deep fascia within 1 month after the initial operation were considered as EDSSI. The rate of EDSSI, causal organisms, infection management and resolution were studied. Furthermore, we examined the patient-related and the operation-related risk factors. An overall incidence of EDSSI of 1.1% was found. In 177 patients with diabetes mellitus (DM), two patients (1.1%) developed EDSSI. In 28 patients receiving chronic haemodialysis (HD), two patients with infections (7.1%) were identified, which was statistically significantly greater than the other patient populations. Both operative time and intraoperative blood loss were significantly greater in patients with EDSSI than in non-infected patients. Furthermore, the rate of EDSSI in patients undergoing instrumented spinal fusion (3.8%) was significantly higher than that in the other patients. In the nine patients who developed EDSSI, the causal organisms were identified and treated by surgical debridement, antibiotic therapy and continuous indwelling surgical site irrigation. All infections resolved, and no recurrence has been observed at final follow-up. Removal of the instrumentation was required in only one patient. Based on our results, we believe that continuous surgical site irrigation is an effective adjunct in the surgical treatment for early SSI following spinal surgery.
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Affiliation(s)
- Takashi Chikawa
- Department of Orthopedic Surgery, Tokushima Municipal Hospital, Tokushima, Japan.
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Lazennec JY, Fourniols E, Lenoir T, Aubry A, Pissonnier ML, Issartel B, Rousseau MA. Infections in the operated spine: update on risk management and therapeutic strategies. Orthop Traumatol Surg Res 2011; 97:S107-16. [PMID: 21856262 DOI: 10.1016/j.otsr.2011.07.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 04/18/2011] [Indexed: 02/02/2023]
Abstract
UNLABELLED Among the possible risks of spine surgery, surgical site infection (SSI) is far from negligible. Incidence is higher than in other locomotor system procedures, with more severe local and general impact. Certain broad guidelines can be formulated. The risk of SSI should be taken into account in the choice of treatment options discussed with the patient. Antibiotic prophylaxis, surgical prevention of iatrogenic infection and an SSI surveillance protocol should be implemented. SSI should be suspected in case of any abnormality in postoperative course, and biological and imaging (MRI or CT) measures should be taken. Local sampling for bacteriological identification is mandatory. Treatment strategy should ideally be discussed in a multidisciplinary coordination meeting, and adapted in the light of local bacterial ecology and resistance data. The information provided to the patient should be transparent and adapted to the patient's individual context. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- J-Y Lazennec
- Service de chirurgie orthopédique et traumatologie, groupe hospitalier Pitié-Salpêtrière, Assistance publique des Hôpitaux de Paris, 47, boulevard de l'hôpital, 75013 Paris cedex, France.
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O'Neill KR, Smith JG, Abtahi AM, Archer KR, Spengler DM, McGirt MJ, Devin CJ. Reduced surgical site infections in patients undergoing posterior spinal stabilization of traumatic injuries using vancomycin powder. Spine J 2011; 11:641-6. [PMID: 21600853 DOI: 10.1016/j.spinee.2011.04.025] [Citation(s) in RCA: 246] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Revised: 03/26/2011] [Accepted: 04/28/2011] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Despite improvements through the use of prophylactic systemic antibiotics, surgical site infections remain a significant problem in the treatment of traumatic spine injuries. Infection rates as high as 10% have been reported in this population. The impact on patients and cost of treating such infections is profound. Local delivery of antibiotics has been found to be efficacious in animal and human studies as an adjunct to systemic antibiotics in surgical site infection prophylaxis. PURPOSE To evaluate the efficacy of using vancomycin powder in surgical sites to prevent infections. STUDY DESIGN Retrospective case review. PATIENT SAMPLE Patients who underwent posterior spine fusions for traumatic injuries over a 2-year period at a single academic center. OUTCOME MEASURES Clinical outcome determined was the incidence of either superficial or deep postoperative wound infections. METHODS A retrospective review of 110 patients with traumatic spine injuries treated with instrumented posterior spine fusions over a 2-year period at a single academic center was performed. One group (control group) received standard systemic prophylaxis only, whereas another (treatment group) received vancomycin powder in the surgical wound in addition to systemic prophylaxis. Patient demographics and perioperative information obtained included history of previous spine surgeries, substance use, diabetes, body mass index, level of injury, presence of neurologic deficit, operative time, and estimated blood loss. Incidence of infection was the primary outcome evaluated. RESULTS The control (N=54) and treatment groups (N=56) were statistically similar. A statistically significant difference in infection rate was found between the treatment group (0%) and control group (13%, p=.02) without any adverse events. No adverse effects were noted from use of the vancomycin powder. CONCLUSIONS The use of vancomycin powder in surgical wounds may significantly reduce the incidence of infection in patients with traumatic spine injuries treated with instrumented posterior spine fusion. Applying vancomycin powder to surgical wounds is a promising means of preventing costly and harmful postoperative wound infections in high-risk populations.
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Affiliation(s)
- Kevin R O'Neill
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
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Rayes M, Colen CB, Bahgat DA, Higashida T, Guthikonda M, Rengachary S, Eltahawy HA. Safety of instrumentation in patients with spinal infection. J Neurosurg Spine 2010; 12:647-59. [PMID: 20515351 DOI: 10.3171/2009.12.spine09428] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Treatment of spine infection remains a challenge for spine surgeons, with the most effective method still being a matter of debate. Most surgeons agree that in early stages of infection, antibiotic treatment should be pursued; under certain circumstances, however, surgery is recommended. The goals of surgery include radical debridement of the infective focus. In some cases, when surgery causes mechanical spinal instability, the question arises whether the risk of recurrent infection outweighs the benefits of spinal instrumentation and stabilization. The authors report their series of cases in which instrumentation was placed in actively infected sites and review the relevant literature. METHODS The authors performed a retrospective analysis of all cases of spinal infection that were surgically treated with debridement and placement of instrumentation at their institution between 2000 and 2006. Patient presentation, risk factor, infective organism, surgical indication, level of involvement, type of procedure, and ultimate outcome were reviewed. Improved outcome was based on improvement of initial American Spinal Injury Association Impairment Score. RESULTS Forty-seven patients (32 men, 15 women) were treated with instrumented surgery for spinal infection. Their average age at presentation was 54 years (range 37-78 years). Indications for placement of instrumentation included instability, pain after failure of conservative therapy, or both. Patients underwent surgery within an average of 12 days (range 1 day to 5 months) after their presentation to the authors' institution. The average length of hospital stay was 25 days (range 9-78 days). Follow-up averaged 22 months (range 1-80 months). Eight patients died; causes of death included sepsis (4 patients), cardiac arrest (2), and malignancy (2). Only 3 patients were lost to follow-up. Using American Spinal Injury Association scoring as the criterion, the patients' conditions improved in 34 cases and remained the same in 5. Complications included hematoma (2 cases), the need for hardware revision (1), and recurrent infection (2). Hardware replacement was required in 1 of the 2 patients with recurrent infection. CONCLUSIONS Instrumentation of the spine is safe and has an important role in stabilization of the infected spine. Despite the presence of active infection, we believe that instrumentation after radical debridement will not increase the risk of recurrent infection. In fact, greater benefit can be achieved through spinal stabilization, which can even promote accelerated healing.
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Affiliation(s)
- Mahmoud Rayes
- Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, Michigan 48201, USA
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