Best Practice Guidelines for Surgical Site Infection in High-risk Pediatric Spine Surgery: Definition, Prevention, Diagnosis, and Treatment

Surgical site infection risk in neuromuscular scoliosis patients undergoing posterior spinal fusion

PURPOSE

Scoliosis in neuromuscular scoliosis (NMS) is a spinal deformity often treated with posterior spinal fusions (PSF). There is a relatively high risk to develop surgical site infection (SSI) after PSF in NMS compared to adolescent idiopathic scoliosis (AIS) patients. The purpose of this retrospective cohort study was to determine perioperative risk factors for NMS patients undergoing PSF.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric database was queried for patients who underwent PSF for NMS and/or cerebral palsy from 2015 to 2020. Statistical analysis of patient characteristics was completed utilizing likelihood ratio chi-squared test for categorical factors and median test or Wilcoxon rank sum test for quantitative factors. Logistic regression was used for odds ratios for quantitative factors.

RESULTS

4145 patients underwent PSF for NMS, and 102 developed an SSI (2.5%). Identified risk factors include American Society of Anesthesiologists (ASA) ≥ 3 (p = 0.030, odds ratio 2.4), preoperative corticosteroids (p = 0.049, odds ratio 2.4), preoperative ostomy (p = 0.026, odds ratio 1.6), prolonged anesthetic time (p = 0.045, odds ratio 1.09 per 60 min), prolonged operative time (p = 0.043, odds ratio 1.1 per 60 min), and postoperative development of urinary tract infection (UTI) (p < 0.001, odds ratio 4.5). Patients with SSI had higher body mass index (p = 0.047, odds ratio 1.3 per 5 kg/m2).

CONCLUSION

The prevalence of deep SSI was 2.5% in this cohort, and risk factors include ASA ≥ 3, preoperative ostomy, prolonged anesthetic or operative time, and postoperative UTI. Large multicenter database studies can help identify and stratify risk factors for SSI in this high-risk patient population.

LEVEL OF EVIDENCE: 3

An International Consensus on Evaluation and Management of Idiopathic Genu Valgum: A Modified Delphi Survey

BACKGROUND

Idiopathic genu valgum beyond physiological limits may require treatment, which is based on age, growth remaining, and the magnitude of the deformity. There is no consensus on clinical, or radiologic evaluation, indications, and management of idiopathic genu valgum, which can range from observation to surgical treatment using various modalities. If available, such guidelines will help surgeons offer optimal treatment to their patients. The aim of our study was to establish an expert consensus on the evaluation and treatment of idiopathic genu valgum.

METHODS

An international panel of 29 pediatric orthopaedic surgeons from 17 countries with clinical and research experience in the management of limb deformity participated in a modified Delphi survey. Surgeons were provided with patient and deformity characteristics and voted on 46 statements on history, clinical examination, radiographic evaluation, and treatment options for idiopathic genu valgum in round 1. Consensus was defined as when statements received ≥70% votes. Statements that were important but received <70% votes were reworded for clarity in round 2 (n=13).

RESULTS

Consensus was achieved for 28/46 statements and included obtaining a full-length standing radiograph of the lower extremities and measuring joint orientation angles. Participants did not agree to offer surgical treatment based only on the intermalleolar distance. They recommended surgical treatment if the mechanical axis falls in zone 2 or beyond on the lateral side and using guided growth by tension-band plating when the growth remaining is at least 2 years. The panel agreed on performing common peroneal nerve decompression for specific indications such as acute, opening wedge osteotomy of >20 degrees, but not for gradual correction. Consensus was not reached for indications and methods of bone age assessment, treatment when growth remaining is <1 year, indications for implant removal after guided growth in younger children, and the type of osteotomy for acute deformity correction.

CONCLUSIONS

We have generated consensus statements to guide the management of idiopathic genu valgum. Statements that lack consensus are areas for future multicenter research.

LEVEL OF EVIDENCE

Level V.

Analysis of adolescent idiopathic scoliosis population for Surgical Site Infection Risk Factors

Objective

The incidence of surgical site infection (SSI) in adolescent idiopathic scoliosis (AIS) patients undergoing surgical correction varies but is commonly reported between 0.5 and 6.7 %. The identification of modifiable risk factors is crucial to preventing these infections in the AIS population. Some potential modifiable risk factors include the use of stainless-steel implants, a larger volume of instrumentation and an increased volume of blood products transfused. However, evidence in support of these factors and others representing true risk for the development of SSI is limited and often varies. We aimed to determine the incidence of SSI in AIS undergoing primary scoliosis fusion at our hospital, and explore demographic and clinical variables in the development of SSI in AIS.

Methods

This was a case control retrospective study. Patients aged 10-19 year-old that underwent posterior spinal fusion for initial correction of AIS at our hospital between the years 2012-2020 were eligible. Patients with any previous spine surgery or spine fracture were excluded. A descriptive analysis was then performed on the data.

Results

Of the 334 patients on which data was collected, one SSI was identified resulting in an incidence of infection of 0.3 %. The largest ethnicity represented was Caucasian with 254 patients. The average age was 14.3 years with averaged follow-up of 6.6 years. The majority of patients (252) received implants composed of titanium and cobalt chrome. The average operation duration was 5 h and 7.7 min, and the average hospital stay was 4.2 days. The average amount of blood loss was 553 ml. Chlorhexidine wipes or some other antimicrobial preparation was used on 197 patients and betadine solution was used on 321.185 patients were recorded to have received either antibiotic-loaded allograft or antibiotic powder and 326 patients were recorded to have received intraoperative antibiotics.

Conclusions

The long term clinical follow up of our study and low incidence of infection provide additional evidence for the benefit of antimicrobial techniques and risk factor mitigation previously suggested in the literature for the prevention of SSI in AIS.

Level of evidence

Level III.

What is the role of plastic surgery for incisional closures in pediatric spine surgery? Results from a pediatric spine study group survey

Current best practice guidelines recommend a plastics-style multilayer wound closure for high-risk pediatric spine surgery. However, plastic surgery closure of spinal incisions remains controversial. This study investigates surgeon perceptions and practice patterns regarding plastic surgery multilayered closure (PMC) in pediatric spine surgery. All surgeons in an international pediatric spine study group received a 30-question survey assessing incisional closure practices, frequency of plastic surgery collaboration, and drain management. Relationship to practice size, setting, geographic region, and individual diagnoses were analyzed. 87/178 (49%) surgeons responded from 79% of participating sites. Plastics utilization rates differed by diagnosis: neuromuscular scoliosis 16.9%, early onset scoliosis 7.8%, adolescent idiopathic scoliosis 2.8% ( P  < 0.0001). Plastics were used more for early onset scoliosis [odds ratio (OR) 18.5, 95% confidence interval (CI): 8.5, 40.2; P  < 0.001] and neuromuscular scoliosis [OR 29.2 (12.2, 69.9); P  < 0.001] than adolescent idiopathic scoliosis. Plastics use was unrelated to practice size, setting, or geographic region ( P  ≥ 0.09). Respondents used plastics more often for spina bifida and underweight patients compared to all other indications ( P  < 0.001). Compared to orthopaedic management, drains were utilized more often by plastic surgery (85 vs. 21%, P  = 0.06) and for longer durations ( P  = 0.001). Eighty-nine percent of surgeons felt plastics increased operative time (58 ± 37 min), and 34% felt it increased length of hospitalization. Surgeons who routinely utilize plastics were more likely to believe PMC decreases wound complications ( P  = 0.007). The perceived benefit of plastic surgery varies, highlighting equipoise among pediatric spine surgeons. An evidence-based guideline is needed to optimize utilization of plastics in pediatric spine surgery.

Incisional negative pressure wound therapy for the prevention of surgical site complications in Paediatric patients with non-idiopathic scoliosis: A randomized clinical trial

Surgical wound complications are adverse events with important repercussions for the health of patients and health system. Surgical site infections and wound dehiscences are among the most important surgical wound complications, with a high incidence in paediatric patients undergoing surgery for non-idiopathic scoliosis. Incisional negative pressure wound therapy for surgical incisions is used as a preventive measure against surgical wound complications in adults; however, there has been scant evidence for using it in children. The purpose of this study is to evaluate the cost-effectiveness of incisional negative pressure wound therapy in preventing surgical wound complications in paediatric patients undergoing surgery to treat non-idiopathic scoliosis. Randomized clinical trial. Children younger than 18 years of age undergoing surgery for non-idiopathic scoliosis were randomly assigned into two groups to receive one of two different types of dressings for the first 7 days after surgery. One group were treated with a postoperative hydrofibre and hydrocolloid dressing with silver for wounds (control group), and the other group received a single-use incisional negative pressure wound therapy system (intervention group). The wounds were assessed after removal of the dressings at 7 days after surgery and again at 30, 90, and 180 days after surgery. Surgical wound complications, sociodemographic variables, variables related to the procedure and postoperative period, economic costs of treatment of surgical wound complications, and time to healing of the surgical wound were recorded. Per protocol and per intention to treat analysis was made. The per protocol incidence of surgical wound complications was 7.7% in the intervention group versus 38.5% in the control group (p = 0.009; Fisher exact test. RR = 0.20 IC95%: 0.05-0.83). Surgical wound dehiscence, surgical site infections, seroma, and fibrin were the most common surgical wound complications. The type of surgery, duration of surgery, and patients' age were associated with a higher risk for surgical wound complications. Postoperative hydrofibre and hydrocolloid dressing with silver for wounds were found to be associated with a longer time to healing. Initial costs for dressings in the group receiving incisional negative pressure wound therapy were higher, but the total postoperative costs were higher for those receiving postoperative hydrofibre and hydrocolloid dressing with silver for wounds. It was found that for each US$1.00 of extra costs for using incisional negative pressure wound therapy, there was a benefit of US$12.93 in relation to the cost of complications prevented. Incisional negative pressure wound therapy is cost-effective in the prevention of surgical wound complications in children undergoing surgery for non-idiopathic scoliosis.

Early mobilization can reduce the incidence of surgical site infections in patients undergoing spinal fusion surgery: A nested case-control study

BACKGROUND

To examine the influence of early mobilization on the risk of surgical site infections (SSI) in patients undergoing spinal fusion surgery.

METHODS

The retrospective cohort consisted of all consecutive patients who underwent spinal fusion surgery at our institution. For each case of SSI, 2 control patients without SSI at the corresponding index date were selected. Mobilization was predefined as "delayed" if it occurred more than 36 hours postoperatively. To account for potential confounding variables, we performed further adjustments using conditional logistic regression models. Subgroup analyses were conducted to evaluate the robustness of the statistical associations.

RESULTS

Following the predefined statistical protocol and matching criteria, we matched 236 control cases to the SSI cases. Upon adjustment for confounding factors, our findings revealed that the risk of SSI was 120% higher in the group beginning mobilization more than 36 hours after surgery compared to the group beginning mobilization within 36 hours postoperatively (odds ratio = 2.206, 95% confidence interval 1.169-4.166, P = .015). In subgroup analyses, this statistical trend remained consistent.

CONCLUSIONS

Early mobilization within 36 hours following spinal fusion surgery significantly reduces the risk of SSI. This pattern of reduced risk remains consistent among patients with degenerative diseases or spinal deformities.

Fifteen Years of Spinal Fusion Outcomes in Children With Cerebral Palsy: Are We Getting Better?

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVE

We reviewed 15-year trends in operative factors, radiographic and quality of life outcomes, and complication rates in children with cerebral palsy (CP)-related scoliosis who underwent spinal fusion.

SUMMARY OF BACKGROUND DATA

Over the past two decades, significant efforts have been made to decrease complications and improve outcomes of this population.

MATERIALS AND METHODS

We retrospectively reviewed a multicenter registry of pediatric CP patients who underwent spinal fusion from 2008 to 2020. We evaluated baseline and operative, hospitalization, and complication data as well as radiographic and quality of life outcomes at a minimum 2-year follow-up.

RESULTS

Mean estimated blood loss and transfusion volume declined from 2.7±2.0 L in 2008 to 0.71±0.34 L in 2020 and 1.0±0.5 L in 2008 to 0.5±0.2 L in 2020, respectively, with a concomitant increase in antifibrinolytic use from 58% to 97% (all, P <0.01). Unit rod and pelvic fusion use declined from 33% in 2008 to 0% in 2020 and 96% in 2008 to 79% in 2020, respectively (both, P <0.05). Mean postoperative intubation time declined from 2.5±2.6 to 0.42±0.63 days ( P< 0.01). No changes were observed in preoperative and postoperative coronal angle and pelvic obliquity, operative time, frequency of anterior/anterior-posterior approach, and durations of hospital and intensive care unit stays. Improvements in the Caregiver Priorities and Child Health Index of Life with Disabilities postoperatively did not change significantly over the study period. Complication rates, including reoperation, superficial and deep surgical site infection, and gastrointestinal and medical complications remained stable over the study period.

CONCLUSIONS

Over the past 15 years of CP scoliosis surgery, surgical blood loss, transfusion volumes, duration of postoperative intubation, and pelvic fusion rates have decreased. However, the degree of radiographic correction, the rates of surgical and medical complications (including infection), and health-related quality of life measures have broadly remained constant.

Consensus-Based Best Practice Guidelines for the Management of Spinal Deformity and Associated Tumors in Pediatric Neurofibromatosis Type 1: Screening and Surveillance, Surgical Intervention, and Medical Therapy

BACKGROUND

Spinal conditions, such as scoliosis and spinal tumors, are prevalent in neurofibromatosis type 1 (NF1). Despite the recognized importance of their early detection and treatment, there remain knowledge gaps in how to approach these manifestations. The purpose of this study was to utilize the experience of a multidisciplinary committee of experts to establish consensus-based best practice guidelines (BPGs) for spinal screening and surveillance, surgical intervention, and medical therapy in pediatric patients with NF1.

METHODS

Using the results of a prior systematic review, 10 key questions that required further assessment were first identified. A committee of 20 experts across medical specialties was then chosen based on their clinical experience with spinal deformity and tumors in NF1. These were 9 orthopaedic surgeons, 4 neuro-oncologists/oncologists, 3 neurosurgeons, 2 neurologists, 1 pulmonologist, and 1 clinical geneticist. An initial online survey on current practices and opinions was conducted, followed by 2 additional surveys via a formal consensus-based modified Delphi method. The final survey involved voting on agreement or disagreement with 35 recommendations. Items reaching consensus (≥70% agreement or disagreement) were included in the final BPGs.

RESULTS

Consensus was reached for 30 total recommendations on the management of spinal deformity and tumors in NF1. These were 11 recommendations on screening and surveillance, 16 on surgical intervention, and 3 on medical therapy. Five recommendations did not achieve consensus and were excluded from the BPGs.

CONCLUSION

We present a set of consensus-based BPGs comprised of 30 recommendations for spinal screening and surveillance, surgical intervention, and medical therapy in pediatric NF1.