Intrawound application of vancomycin for prophylaxis in instrumented thoracolumbar fusions: efficacy, drug levels, and patient outcomes

Intrawound application of vancomycin reduces wound infection after open release of post-traumatic stiff elbows: a retrospective comparative study

BACKGROUND

With the improvements in wound healing through the use of intravenous prophylactic antibiotics and technical refinements, postoperative elbow infections have become less common but still occur in certain elective elbow surgeries. The objective of this study was to evaluate the safety and efficacy of prophylactic application of vancomycin into the operative site to reduce the incidence of infection after the open release of post-traumatic stiff elbows.

METHODS

A retrospective review of 272 such patients during a 4-year period was performed. In the control group (93 patients), simple prophylaxis with standard intravenous antibiotics was performed; in the vancomycin group (179 patients), vancomycin powder was applied directly into the wound before closure along with standard intravenous prophylaxis.

RESULTS

After a follow-up of at least 6 months, the control group was found to have 6 infections (6.45%; confidence interval: 2.40%-13.52%) compared with none (0%; confidence interval: 0-2%.04%) in the vancomycin group, which was a statistically significant difference (P = .0027). No adverse effects were documented from the direct use of the vancomycin powder.

CONCLUSIONS

The local application of vancomycin powder may be a promising means of preventing postoperative elbow infections after elbow release in patients with post-traumatic elbow stiffness.

[Application of vancomycin powder into the wound during spine surgery: systematic review and meta-analysis]

OBJECTIVE

To determine the effects of applying vancomycin powder within the surgical wound on the risk of surgical infections, pseudo-arthrosis and adverse events, in patients undergoing spinal surgery.

MATERIAL AND METHODS

A meta-analysis was carried out, including controlled studies that evaluated the risk of postoperative infections and/or pseudo-arthrosis in patients undergoing spinal surgery in which vancomycin powder was applied within the surgical wound.

RESULTS

were presented as pooled relative risks, with its 95% confidence intervals. Additionally, the frequency of complications attributable to vancomycin was also assessed.

RESULTS

A total of six controlled studies (3,379 subjects) were included. Pooled relative risks were: surgical site infection, 0.11 (95%CI: 0.05-0.25; P<.00001), and pseudo-arthrosis, 0.87 (95%CI; 0.34-2.21; P=.77). No statistically significant heterogeneity was found in both analyses. In 1,437 patients treated with vancomycin, there were no recorded vancomycin-related adverse events.

CONCLUSIONS

Application of vancomycin powder into the wound was associated with a significantly reduced risk of surgical site infections, without increasing pseudo-arthrosis or adverse events. However, randomized controlled trials are needed, in order to confirm the present results and make recommendations with more certainty.

Intraoperative vancomycin use in spinal surgery: single institution experience and microbial trends

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To demonstrate the microbial trends of spinal surgical site infections in patients who had previously received crystallized vancomycin in the operative bed.

SUMMARY OF BACKGROUND DATA

Prior large, case control series demonstrate the significant decrease in surgical site infection with the administration of vancomycin in the wound bed.

METHODS

A single institution, electronic database search was conducted for all patients who underwent spinal surgery who had received prophylactic crystalline vancomycin powder in the wound bed. Patients with a prior history of wound infection, intrathecal pumps, or spinal stimulators were excluded.

RESULTS

A total of 981 consecutive patients (494 males, 487 females; mean age, 59.4 yr; range, 16-95 yr) were identified from January 2011 to June 2013. The average dose of vancomycin powder was 1.13 g (range, 1-6 g). Sixty-six patients (6.71%) were diagnosed with a surgical site infection, of which 51 patients had positive wound cultures (5.2%). Of the 51 positive cultures, the most common organism was Staphylococcus aureus. The average dose of vancomycin was 1.3 g in the 38 cases where a gram-positive organism was cultured. A number of gram-negative infections were encountered such as Serratia marcescens, Enterobacter aerogenes, Bacteroides fragilis, Enterobacter cloacae, Citrobacter koseri, and Pseudomonas aeruginosa. The average dose of vancomycin was 1.2 g in 23 cases where a gram-negative infection was cultured. Fifteen of the 51 positive cultures (29.4%) were polymicrobial. Eight (53%) of these 15 polymicrobial cultures contained 3 or more distinct organisms.

CONCLUSION

Prophylactic intraoperative vancomycin use in the wound bed in spinal surgery may increase the incidence of gram-negative or polymicrobial spinal infections. The use of intraoperative vancomycin may correlate with postoperative seromas, due to the high incidence of nonpositive cultures. Large, randomized, prospective trials are needed to demonstrate causation and dose-response relationship.

The use of vancomycin powder reduces surgical reoperation in posterior instrumented and noninstrumented spinal surgery

BACKGROUND

Surgical site infections can complicate posterior spine surgery. Multiple hospital admissions may be required to adequately treat a surgical site infection, which is associated with increased costs and lower patient satisfaction. The objective of this study was to evaluate the efficacy of prophylactic intra-wound vancomycin powder in reducing the incidence of repeat surgery for infections after posterior instrumented and noninstrumented spine surgery.

METHODS

A series of consecutive patients who underwent instrumented or noninstrumented posterior spine surgery for any indication by two surgeons from July 2010 to July 2012 were reviewed. The preoperative antibiotic regimens of both surgeons were identical, except that one surgeon applied 1 g vancomycin powder directly to the surgical bed before wound closure, while the other did not. Patient demographics, operative details, and rates of reoperation for wound infection in the control and the treatment groups were compared.

RESULTS

Both the control group and treatment group consisted of 150 patients; mean ages were 58.33 and 54.14 years, respectively. Both groups had low rates of deep infection requiring surgical intervention. The treatment group had a significantly lower rate of infection requiring reoperation or surgical debridement (0 %; 95 % CI: 0 %-2.4 %) compared with the control group (4 %; 95 % CI: 1.5 %-8.5 %) (P = 0.0297). The six infections identified in the control group resulted in 12 repeat operative debridement procedures. Gram-positive organisms were identified in 66.7 % of infections. No complications were related to the application of vancomycin powder.

CONCLUSIONS

The results of this study demonstrate that adjunctive vancomycin powder applied directly to the surgical bed before closure seems effective in preventing deep infections that require operative debridement following posterior spine surgery.

Effectiveness of local vancomycin powder to decrease surgical site infections: a meta-analysis

BACKGROUND CONTEXT

Some surgeons use systemic vancomycin to prevent surgical site infections (SSIs), but patients who do not carry methicillin-resistant Staphylococcus aureus have an increased risk of SSIs when given vancomycin alone for intravenous prophylaxis. Applying vancomycin powder to the wound before closure could increase the local tissue vancomycin level without significant systemic levels. However, the effectiveness of local vancomycin powder application for preventing SSIs has not been established.

PURPOSE

Our objective was to systematically review and evaluate studies on the effectiveness of local vancomycin powder for decreasing SSIs.

STUDY DESIGN

Meta-analysis.

SAMPLE

We included observational studies, quasi-experimental studies, and randomized controlled trials of patients undergoing surgical procedures that involved vancomycin powder application to surgical wounds, reported SSI rates, and had a comparison group that did not use local vancomycin powder.

OUTCOME MEASURES

The primary outcome was postoperative SSIs. The secondary outcomes included deep incisional SSIs and S. aureus SSIs.

METHODS

We performed systematic literature searches in PubMed, the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Cochrane Central Register of Controlled Trials via Wiley, Scopus (including EMBASE abstracts), Web of Science, ClinicalTrials.gov, BMC Proceedings, ProQuest Dissertation, and Thesis in Health and Medicine, and conference abstracts from IDWeek, the Interscience Conference on Antimicrobial Agents and Chemotherapy, the Society for Healthcare Epidemiology of America, and the American Academy of Orthopedic Surgeons annual meetings, and also the Scoliosis Research Society Annual Meeting and Course. We ran the searches from inception on May 9, 2013 with no limits on date or language. After reviewing 373 titles or abstracts and 22 articles in detail, we included 10 independent studies and used a random-effects model when pooling risk estimates to assess the effectiveness of local vancomycin powder application for preventing SSIs, the outcome of interest. We used the I²-index, Q-statistic, and corresponding p value to assess the heterogeneity of the risk estimates, and funnel plots to assess publication bias.

RESULTS

We included seven quasi-experimental studies, two cohort studies, and one randomized controlled trial, encompassing 5,888 surgical patients. The pooled effects showed that applying local vancomycin powder was significantly protective against SSIs (pooled odds ratio [pOR] 0.19; 95% confidence interval [CI] 0.09-0.38), deep incisional SSIs (pOR 0.23; 95% CI 0.09-0.57), and SSIs caused by S. aureus (pOR 0.22; 95% CI 0.08-0.58). However, significant heterogeneity was present for studies evaluating all SSIs or deep incisional SSIs. When we pooled the risk estimates from the eight studies that assessed patients undergoing spinal operations, vancomycin powder remained significantly protective against SSIs (pOR 0.16; 95% CI 0.09-0.30), deep incisional SSIs (pOR 0.18; 95% CI 0.09-0.36), and SSIs caused by S. aureus (pOR 0.11; 95% CI 0.03-0.36). The pooled ORs from studies of spinal operations were lower than those for all studies and the estimates from spinal operation studies were homogeneous. However, there was evidence of publication bias.

CONCLUSIONS

Local administration of vancomycin powder appears to protect against SSIs, deep incisional SSIs, and S. aureus SSIs after spinal operations. Large, high-quality studies should be performed to evaluate this intervention before it is used routinely.

Experience with intrawound vancomycin powder for spinal deformity surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate the ability of local vancomycin powder to prevent deep wound infection after thoracolumbar and lumbar spinal fusion for open deformity cases.

SUMMARY OF BACKGROUND DATA

Recent studies report that local delivery of vancomycin powder is associated with a decrease in spinal surgical site infection (SSI). This study compares deformity fusion cases before and after the routine application of spinal vancomycin powder.

METHODS

Posterior spinal deformity surgical procedures by a single institution were reviewed from January 2011 to April 2013. Routine application of vancomycin powder started in April 2012. Inclusion criteria included adult patients who underwent posterior fusion for deformity pathologies, including spondylolisthesis, kyphosis, sagittal imbalance, and scoliosis. Each cohort's baseline characteristics including infection risk factors, operative data, and rates of wound infection were compared. Associations between infection and vancomycin powder, with and without propensity score adjustment for risk factors were determined using logistic regression.

RESULTS

A total of 306 patients were included in the study. All measured baseline and operative variables were statistically similar between untreated (n = 150) and those who received vancomycin powder (n = 156). No significant change in deep wound infection rate was seen between the control (5.3%) and intervention group (5.1%, P = 0.936). Logistic regression with and without propensity score adjusted for risk factors demonstrated that the use of vancomycin powder did not impact the development of SSI (odds ratio [95% confidence interval]: 1.01 [0.36-2.79], P = 0.9910) and (odds ratio [95% confidence interval]: 0.87 [0.31-2.42], P = 0.7876), respectively.

CONCLUSION

The local application of powdered vancomycin was not associated with a significant difference in the rate of deep SSI after spinal deformity surgery, and other treatment modalities are necessary to limit infection for this high-risk group. This study is in contrary to prior studies, which have reported a decrease in SSI with vancomycin powder.

LEVEL OF EVIDENCE

2.

Intrawound vancomycin powder eradicates surgical wound contamination: an in vivo rabbit study

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.

Effects of using intravenous antibiotic only versus local intrawound vancomycin antibiotic powder application in addition to intravenous antibiotics on postoperative infection in spine surgery in 907 patients

STUDY DESIGN

A prospective randomized controlled trial.

OBJECTIVE

To assess the ability of local vancomycin powder in controlling postoperative infection in spine surgery.

SUMMARY OF BACKGROUND DATA

Despite improvements through the use of prophylactic systemic antibiotics, surgical site infections remain a significant problem in spine surgical procedures. Various retrospective and prospective studies have reported the efficacy of local application of vancomycin powder in reducing the infection in animal and human studies. However, there were no randomized control trials that reported on its efficacy.

METHODS

Prospective randomized controls of 907 patients with various spinal pathologies were treated surgically during a period of 18 months. The control group received standard systemic prophylaxis only, whereas the treatment group received vancomycin powder in the surgical wound in addition to systemic prophylaxis. Patient demographics, comorbidities, level of spinal pathology, estimated blood loss, nutritional status, and hemoglobin were recorded. Incidence of infection was the primary outcome evaluated.

RESULTS

There were 8 infections (1.68%) in the control group (6 instrumented and 2 noninstrumented, 6 deep and 2 superficial) with bacteria cultured in 3 (1 Escherichia coli and 2 Staphylococcus aureus). In the treatment group, 7 infections (1.61%) were observed (6 instrumented and 1 noninstrumented surgical procedures, 6 deep and 1 superficial) with bacteria cultured in 3 (1 Staphylococcus aureus and 2 Klebsiella). No adverse effects were observed from the use of vancomycin powder. Statistically no significant difference was seen in infection rate between the treatment group and control group.

CONCLUSION

The local application of vancomycin powder in surgical wounds did not significantly reduce the incidence of infection in patients with surgically treated spinal pathologies. The use of vancomycin powder may not be effective when incidence of infection is low.

Infection with spinal instrumentation: Review of pathogenesis, diagnosis, prevention, and management

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.

An evidence-based clinical guideline for antibiotic prophylaxis in spine surgery

BACKGROUND CONTEXT

The North American Spine Society's (NASS) Evidence-Based Clinical Guideline on Antibiotic Prophylaxis in Spine Surgery provides evidence-based recommendations to address key clinical questions regarding the efficacy and the appropriate antibiotic prophylaxis protocol to prevent surgical site infections in patients undergoing spine surgery. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of June 2011.

PURPOSE

Provide an evidence-based educational tool to assist spine surgeons in preventing surgical site infections.

STUDY DESIGN

Systematic review and evidence-based clinical guideline.

METHODS

This guideline is a product of the Antibiotic Prophylaxis in Spine Surgery Work Group of NASS Evidence-Based Guideline Development Committee. The work group consisted of neurosurgeons and orthopedic surgeons who specialize in spine surgery and are trained in the principles of evidence-based analysis. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE (PubMed), ACP Journal Club, Cochrane Database of Systematic Reviews Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials, EMBASE (Drugs and Pharmacology), and Web of Science to identify articles published since the search performed for the original guideline. The relevant literature was then independently rated using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were developed via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Levels I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.

RESULTS

Sixteen clinical questions were formulated and addressed, and the answers are summarized in this article. The respective recommendations were graded by the strength of the supporting literature, which was stratified by levels of evidence.

CONCLUSIONS

The clinical guideline for antibiotic prophylaxis in spine surgery has been created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients undergoing spine surgery. The entire guideline document, including the evidentiary tables, suggestions for future research, and all the references, is available electronically on the NASS Web site at http://www.spine.org/Pages/PracticePolicy/ClinicalCare/ClinicalGuidlines/Default.aspx and will remain updated on a timely schedule.

Prophylactic intrawound application of vancomycin powder in instrumented spinal fusion surgery

Objective

We evaluated the effect of intrawound application of vancomycin powder for infection prophylaxis in wounds caused by instrumented spinal surgery.

Methods

From July 2012 to December 2012, 74 instrumented spinal fusion procedures were performed by 1 neurosurgeon at a single institute. We divided the patients into 2 groups, depending on the use of local application of vancomycin powder: Group A (intrawound application of vancomycin powder with perioperative intravenous cefazolin) and Group B (perioperative intravenous cefazolin alone). A retrospective cohort comparative study was conducted between the 2 groups. The age, sex, comorbidities, smoking, surgical procedure, and surgical site infection (SSI) of consecutive patients were analyzed.

Results

Among the 74 patients, 34 patients were assigned to group A and 40 patients to group B. No wound infections were found in group A. However, in group B, 5 cases of SSI (12.5%) were found. A statistically significant reduction in SSI incidence was observed in group A (p<0.033). The 5 cases of SSI in group B consisted of 3 cases of deep wound infection and 2 cases of superficial wound infection. All SSIs were found in cases of posterior approach surgery and tended to be more frequent in older patients.

Conclusion

Adjunctive intrawound local application of vancomycin powder is a simple uncomplicated procedure and can result in a significant reduction of SSI in instrumented spinal fusions. Furthermore, culture of the drainage tip is very important for confirmation of deep wound infection.

An update on modifiable factors to reduce the risk of surgical site infections

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.

Comparative effectiveness and cost-benefit analysis of local application of vancomycin powder in posterior spinal fusion for spine trauma

Object

Surgical site infection (SSI) is a morbid complication with high cost in spine surgery. In this era of health care reforms, adjuvant therapies that not only improve quality but also decrease cost are considered of highest value. The authors introduced local application of vancomycin powder into their practice of posterior spinal fusion for spine trauma and undertook this study to determine the value and cost benefit of using vancomycin powder in surgical sites to prevent postoperative 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 institution was performed. One group (control group) received standard systemic prophylaxis only, whereas another (treatment group) received 1 g of locally applied vancomycin powder (spread over the surgical wound) in addition to systemic prophylaxis. Data were collected on patient demographic characteristics, clinical variables, surgical variables, and 90-day morbidity. Incidence of infection was the primary outcome evaluated, and billing records were reviewed to determine total infection-related medical cost (cost of reoperation/wound debridement, medications, and diagnostic tests). The payer's cost was estimated to be 70% of the total billing cost.

Results

A total of 110 patients were included in the study. The control (n = 54) and treatment groups (n = 56) were similar at baseline. Use of vancomycin powder led to significant reduction in infection rate (13% infection rate in the control group vs 0% in the treatment group, p = 0.02). There were no adverse effects noted from the use of vancomycin powder. The total mean cost of treating postoperative infection per patient was $33,705. Use of vancomycin powder led to a cost savings of $438,165 per 100 posterior spinal fusions performed for traumatic injuries.

Conclusions

The use of adjuvant vancomycin powder was associated with a significant reduction in the incidence of postoperative infection as well as infection-related medical cost. These findings suggest that use of adjuvant vancomycin powder in high-risk patients undergoing spinal fusion is a cost-saving option for preventing postoperative infections, as it can lead to cost-savings of $438,165 per 100 spinal fusions performed.

Combined S-1 and S-2 sacral alar-iliac screws as a salvage technique for pelvic fixation after pseudarthrosis and lumbosacropelvic instability

Lumbosacropelvic pseudarthrosis after long spinal fusions for treatment of adult degenerative scoliosis remains a challenging condition. Moreover, although pelvic fixation with iliac screws is widely used in deformity surgery to provide a biomechanically strong distal anchor for long thoracolumbar constructs, there are very few options available after failed pelvic fixation with iliac screws. The authors conducted a retrospective review of the surgical charts and imaging findings of patients subjected to revision surgery for lumbosacropelvic pseudarthrosis from August 2011 to August 2012. This review identified 5 patients in whom a salvage technique combining both S-1 and S-2 sacral alar-iliac (SAI) screws had been performed. In this technical note, the authors present a detailed anatomical discussion and an appraisal of the sequential intraoperative steps of this new technique involving a combination of S-1 and S-2 SAI screws. The discussion is illustrated with a surgical case in which this technique was used to treat a patient with pseudarthrosis that had developed after fixation with classic iliac screws. In conclusion, although S-2 SAI screws have previously been reported as an interesting alternative to classic iliac wing screws, this report is the first on the use of combined S-1 and S-2 SAI screws for pelvic fixation as a salvage technique for lumbosacropelvic instability. According to the reported experience, this technique provides a biomechanically robust construct for definitive pelvic fixation during revision surgeries in the challenging scenarios of pseudarthrosis and instability of the lumbosacropelvic region.

Adjunctive vancomycin powder in pediatric spine surgery is safe

STUDY DESIGN

Therapeutic level II cohort study.

OBJECTIVE

To evaluate the safety of adjunctive local application of vancomycin powder (VP) for infection prophylaxis in posterior instrumented thoracic and lumbar spine wounds in pediatric patients weighing more than 25 kg.

SUMMARY OF BACKGROUND DATA

Spine surgeons have largely turned to vancomycin prophylaxis in an attempt to decrease the incidence of late surgical site infection and acute surgical site infection from methicillin-resistant Staphylococcus aureus. In adult patients, the adjunctive local application of VP with an intravenous cephalosporin has been shown to decrease postsurgical wound infection rates significantly; however, the safety of VP as an adjunct in pediatric spine surgery has not been reported.

METHODS

We reviewed data collected under a systematic protocol specifically designed to monitor the safety profile of VP. We measured changes in creatinine and systemic vancomycin levels after intrawound application of 500 mg of unreconstituted VP during spine deformity correction surgery in patients weighing more than 25 kg (patients also received routine intravenous cephalosporin prophylaxis). Laboratory values were measured preoperatively and on postoperative days 1 and 4. Any adverse reactions and infections through available follow-up (2-8 mo) were recorded.

RESULTS

Eighty-seven consecutive pediatric patients with spinal deformity weighing more than 25 kg who received intraoperative VP during a 9-month period were identified. Sixty-three percent of the patients in this series had adolescent idiopathic scoliosis, 15% congenital scoliosis, 15% neuromuscular scoliosis, and 5% spondylolisthesis. The average change in creatinine levels between the preoperative and postoperative day 1 draw was -0.03 and between the preoperative and postoperative day 4 draw was -0.075. The postoperative systemic vancomycin levels remained undetectable. None of the patients experienced nephrotoxicity or red man syndrome. Three of the 87 patients developed a surgical site infection.

CONCLUSION

In this cohort there were no clinically significant changes in creatinine level or systemic vancomycin level caused by use of intraoperative VP.

LEVEL OF EVIDENCE

2.

Circulatory collapse after topical application of vancomycin powder during spine surgery

A hypersensitivity reaction, either anaphylactic or anaphylactoid, is a well-known adverse effect following intravenous and oral administration of vancomycin. The authors report a case of circulatory collapse and its management after the topical application of vancomycin powder during spinal instrumentation surgery. A 52-year-old woman with breast cancer and metastasis to her spine underwent a vertebrectomy of the T-10 vertebra with instrumented reconstruction from T-8 to T-12. The patient was hemodynamically stable during most of the procedure despite a 2-L blood loss requiring administration of crystalloids, colloids, packed red blood cells, and fresh-frozen plasma. During closure of the subcutaneous layer, there was a sudden drop in blood pressure from 120/60 to 30/15 mm Hg and an increase in heart rate from 95 to 105 bpm. No skin erythema or rash was visible, and there was no bronchospasm or increase in airway pressure. The patient was treated with fluids, boluses of ephedrine, phenylephrine, and adrenaline. The operation was completed and the patient woke up neurologically intact but did require blood pressure support with a norepinephrine infusion for the next 4 hours. She was discharged from hospital in a good clinical state on the 4th postoperative day. It was speculated that the rapid absorption of vancomycin powder applied on the surgical wound caused an anaphylactoid reaction and the circulatory collapse. With an increase in the use of topical vancomycin in surgical wounds, communication and awareness among all intraoperative team members is important for rapid diagnosis of an adverse reaction and for appropriate management.

Intrawound vancomycin powder reduces surgical site infections in posterior cervical fusion

STUDY DESIGN

Retrospective comparative study using prospectively collected data.

OBJECTIVE

To compare the rate of infection with and without the use of vancomycin powder application during posterior cervical instrumentation.

SUMMARY OF BACKGROUND DATA

Surgical site infections (SSI) are a significant source of morbidity in multilevel posterior-instrumented fusions for cervical spondylotic myelopathy (CSM). Local delivery of antibiotics has been associated with decreased rates of SSI in posterior-instrumented fusions, but no study has addressed the effects of these measures on a population composed of exclusively multilevel posterior cervical instrumentation performed with decompression for CSM.

METHODS

All patients undergoing multilevel posterior decompression and instrumentation for CSM by a single surgeon from 2003-2011 were included. Post hoc analysis of prospectively collected data was analyzed comparing consecutive patients treated without the use of vancomycin powder with those treated after the initiation of vancomycin powder prophylaxis. Intervention cohort and controls were examined for differences in SSI rate, body mass index, neurological status, comorbidities, and complications.

RESULTS

A total of 112 patients were included in the study. Intervention (n = 40) and control (n = 72) groups were statistically similar with regard to age, body mass index, comorbidities, estimated blood loss, and operative time. Univariate analysis showed a significant decrease in infection rate in the intervention group (0%) compared with the control group (15%) in this high-risk population (P = 0.007; power = 81%). No adverse events were noted in the intervention group associated with the use of vancomycin powder.

CONCLUSION

The local application of vancomycin was associated with a significant reduction in the risk of SSI in multilevel posterior cervical-instrumented fusions for CSM. This study supports the growing body of evidence that vancomycin powder placed in the wound can reduce the incidence of postoperative wound infections, and is the first that addresses this specific population.

LEVEL OF EVIDENCE

2.

Decreased risk of wound infection after posterior cervical fusion with routine local application of vancomycin powder

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

To assess the ability of local vancomycin powder to prevent wound infection after posterior cervical fusion.

SUMMARY OF BACKGROUND DATA

Wound infections are a significant source of morbidity and cost associated with spine surgery. Intraoperative application of vancomycin powder to the wound edges has been shown to lower the infection risk after posterior instrumented thoracolumbar fusion. There is little data on the efficacy and safety of local vancomycin powder in cervical spine surgery.

METHODS

All cases of posterior cervical fusion by a single surgeon were reviewed from 2007 to 2011. Routine application of 1 gram of vancomycin powder was started in August 2009. Baseline characteristics, operative details, and rates of wound infection and pseudarthrosis were compared between untreated patients and those who received vancomycin powder.

RESULTS

A total 171 patients underwent posterior cervical fusion between 2007 and 2011. Baseline and operative variables were similar between untreated patients (n = 92) and those who received vancomycin powder (n = 79). Patients were followed for a minimum of 1 year (range, 1.1-5.7 yr). The infection rate fell from 10.9% to 2.5% (P = 0.0384) following the introduction of vancomycin powder. The untreated and treated groups had similar rates of pseudarthrosis (5.4% vs. 5.1%). No complications attributable to vancomycin powder were identified.

CONCLUSION

Routine local application of vancomycin powder is a low-cost effective strategy for preventing wound infection after posterior cervical fusion. Further studies are needed to optimize dosing, assess long-term safety, and evaluate use in other spinal operations.

LEVEL OF EVIDENCE

2.

Lumbar laminectomy and fusion with routine local application of vancomycin powder: decreased infection rate in instrumented and non-instrumented cases

OBJECTIVE

Wound infections are one of the most common and potentially devastating complications of spinal surgery. Intra-wound application of vancomycin powder has been shown to lower the infection risk following posterior instrumented fusion, but little evidence supports use in other spinal operations. The goal of this study is to assess the efficacy of vancomycin powder for lumbar laminectomy and fusion, both instrumented and non-instrumented.

METHODS

All cases of lumbar laminectomy and posterior fusion (with or without pedicle screw fixation) by a single surgeon were reviewed from 2007 to 2011. Routine application of 1g vancomycin powder was started in August 2009. Baseline characteristics and operative data were compared between untreated patients and those who received vancomycin powder. Rates of wound infection were compared for all fusions, and then separately for instrumented and non-instrumented cases.

RESULTS

253 patients underwent lumbar laminectomy and fusion between 2007 and 2011. Baseline and operative variables were similar between untreated patients (n=97) and those who received vancomycin powder (n=156). Patients were followed for at least one year. The infection rate fell significantly following introduction of vancomycin powder (from 11% to 0%, p=0.000018). Subgroup analysis revealed significant infection reduction for both instrumented cases (from 12% to 0%, p=0.000806) and non-instrumented cases (from 10% to 0%, p=0.0496). No complications attributable to vancomycin powder were identified.

CONCLUSION

Local vancomycin powder appears to lower the risk of wound infection following lumbar laminectomy and fusion, both instrumented and non-instrumented. Further studies are needed to optimize dosing of vancomycin powder, assess long-term safety and efficacy, and evaluate use in other spinal operations.

Coronal realignment and reduction techniques and complication avoidance

Scoliosis is a broad term encompassing multiple pathologies with different etiologies. Patients may range from the infant with congenital deformity, to the adolescent with idiopathic scoliosis, to the elderly patient with severe degenerative scoliosis. Treatment must be tailored to individual circumstances and the pathoanatomy of each deformity. Various coronal reduction techniques have been described and will be discussed within this article. While scoliosis is generally considered a deformity in the coronal plane, often deformity is present in the sagittal and axial planes also. Treatment of these deformities can require osteotomies or vertebral column resections, techniques further discussed in accompanying articles.

Perioperative antibiotic use for spinal surgery procedures in US children's hospitals

STUDY DESIGN

Retrospective cohort study using the Pediatric Health Information System database.

OBJECTIVE

To describe longitudinal patterns of prophylactic antibiotic use and determinants of antibiotic choice for spinal fusion surgical procedures performed at US children's hospitals.

SUMMARY OF BACKGROUND DATA

Surgical site infections (SSIs) account for a significant proportion of post-spinal surgery complications, particularly among children with complex conditions such as neuromuscular disease. Antimicrobial prophylaxis with intravenous cefazolin or cefuroxime has been a standard practice, but postoperative infections caused by organisms resistant to these antibiotics are increasing in prevalence. Studies describing the choice of antibiotic prophylaxis for pediatric spinal surgery are lacking.

METHODS

We included children 6 months to 18 years of age discharged from 37 US children's hospitals between January 1, 2006, and June 30, 2009, with (1) an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure code indicating a spinal fusion and (2) combinations of diagnosis codes indicating adolescent idiopathic scoliosis (AIS) (n = 5617) or neuromuscular scoliosis (NMS) (n = 3633). After identifying antibiotics ordered on the operative day, we described variation in broad-spectrum antibiotic use over time and measured associations between patient/surgery characteristics and antibiotic choice.

RESULTS

Prophylactic antibiotic choice varied across hospitals and over time. Broad-spectrum antibiotics were used in 37% of AIS and 52% of NMS operations. Seven (19%) hospitals used broad-spectrum coverage for more 80% of all cases. For NMS procedures, broad-spectrum antibiotic use was associated with patient characteristics known to be associated with high SSI risk. Use of vancomycin and broad gram-negative agents increased over time.

CONCLUSION

Broad-spectrum antimicrobial prophylaxis varied across hospitals and was often associated with known risk factors for SSI. These results highlight the need for future studies comparing the effectiveness of various prophylaxis strategies, particularly in high-risk subgroups. This research can inform the development of best practice for SSI prevention in spinal fusion procedures.

Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery

Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) has been recognized as a public health concern since the mid-1990s. Because of the increase in reports of this pathogen, it has become increasingly tempting for clinicians to provide prophylaxis against this entity using antibiotics known to be effective against MRSA. The goal of this study was to assess the use of MRSA prophylaxis to determine whether it is safe and effective. A systematic search of the literature was performed to identify articles that examined the use of vancomycin in clean orthopedic surgery. Infection rates and adverse events were extracted, and the data were aggregated and analyzed using a DerSimonian and Laird random effects model. Publication bias and study quality were also assessed. No benefit of parenteral administration of vancomycin was identified. Local, vancomycin-impregnated cement and powder are associated with lower infection rates. Few adverse events occurred, and most of those that occurred involved infusion rate.Cost, resistance, and side effects are concerns in using vancomycin therapy in addition to standard antibiotic prophylaxis. Given the lack of efficacy of intravenous vancomycin, the authors do not recommend its routine use in clean orthopedic surgery. However, local administration appears to be safe and effective. The data are most compelling in orthopedic spine surgery in which a patient without prophylaxis is more than 4 times as likely to have a deep postoperative wound infection compared with a patient who received local vancomycin. The authors recommend the use of local antibiotics when possible in clean orthopedic surgery.

Failure of irrigation and débridement for early postoperative periprosthetic infection

BACKGROUND

Irrigation and débridement (I&D) of periprosthetic infection (PPI) is associated with infection control ranging from 16% to 47%. Mitigating factors include organism type, host factors, and timing of intervention. While the influence of organism type and host factors has been clarified, the timing of intervention remains unclear.

QUESTIONS/PURPOSES

We addressed the following questions: What is the failure rate of I&Ds performed within 90 days of primary surgery? And what factors are associated with failure?

METHODS

We performed a multicenter retrospective analysis of I&D for PPI within 90 days of primary surgery. We included 86 patients (44 males, 42 females) with an average age of 61 years. Failure was defined as return to the operating room for an infection-related problem. We determined the failure rate of I&D within 90 days of primary surgery and whether the odds of rerevision for infection were associated with Charlson Comorbidity Index, age, sex, joint, organism type, and timing. The minimum followup was 24 months (average, 46 months; range, 24-106 months).

RESULTS

54 of 86 patients (63%) failed. Eight of 10 (80%) failed within the first 10 days, 32 of 57 (56%) within 4 weeks, and 22 of 29 (76%) within 31 to 90 days postoperatively. No covariates were associated with subsequent revision surgery for infection.

CONCLUSIONS

I&D for PPI is frequently used in the early postoperative period to control infection. While it is assumed early intervention will lead to control of infection in most cases, our data contradict this assumption.

Management of postoperative spinal infections

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.

Complications associated with posterior and transforaminal lumbar interbody fusion

Posterior lumbar interbody fusion and transforaminal lumbar interbody fusion are commonly performed to obtain a 360° arthrodesis through a posterior-only approach. These techniques are currently used in the management of spondylolisthesis, degenerative scoliosis, pseudarthrosis, recurrent disk herniation, and chronic low back pain with associated degenerative disk disease. Several adverse events have been described, including intraoperative neurologic injury, implant migration or subsidence, dural tears, infection, heterotopic ossification, BMP-related radiculitis, and osteolysis. Although the use of newer materials (eg, bone morphogenetic proteins) and procedures (eg, minimally invasive surgery) is on the rise, they are associated with unique concerns. Understanding the potential adverse events and steps that can be taken to prevent, detect, and manage complications is critical in patient counseling and perioperative decision making.

Surgical site infection after pediatric spinal deformity surgery

The incidence of surgical site infection (SSI) after spinal deformity surgery for adolescent idiopathic scoliosis ranges from 0.5-6.7%. The risk of infection following spinal fusion in patients with neuromuscular scoliosis is greater, with reported rates of 6.1-15.2% for cerebral palsy and 8-41.7% for myelodysplasia. SSIs result in increased patient morbidity, multiple operations, prolonged hospital stays, and significant financial costs. Recent literature has focused on elucidating the most common organisms involved in SSIs, as well as identifying modifiable risk factors and prevention strategies that may decrease the rates of infection. These include malnutrition, positive urine cultures, antibiotic prophylaxis, surgical site antisepsis, antibiotic-loaded allograft, local application of antibiotics, and irrigation solutions. Acute and delayed SSIs are managed differently. Removal of instrumentation is required for effective treatment of delayed SSIs. This review article examines the current literature on the prevention and management of SSIs after pediatric spinal deformity surgery.

Infections associated with spinal implants

Spinal infections represent a difficult challenge to treating clinicians. Infections in the presence of implants are even more so. In this review the literature appears to reflect a change of practice in which the aim is to retain implants if possible. The newer spinal procedures such as disc replacements pose different problems largely due to the more difficult access. The situation in the spine is more difficult than in general orthopaedics when dealing with infection due to the requirement for stability and to protect neurological function. The main thrust of management, therefore, is early diagnosis and a high index of suspicion followed by adequate if not radical management in a multidisciplinary setting. In the event prevention is better than cure and therefore consideration of the various mechanisms to avoid infection must be taken. There are some 'novel' considerations for the avoidance of infection alongside the tried and tested techniques. There are also new procedures for wound closure and the elimination of dead space.