Surgical Site Infection After Primary Spinal Fusion Surgery for Adolescent Idiopathic Scoliosis: An Analysis of Risk Factors From a Nationwide Insurance Database

Indications for and outcomes of muscle flap reconstruction after pediatric posterior spinal fusion: An ACS-NSQIP analysis of 32,466 surgeries

BACKGROUND

Muscle flap reconstruction immediately after pediatric spinal fusion surgeries has been associated with favorable post-operative outcomes. This study employed a database with large geographic coverage to further characterize indications for and outcomes of such reconstructions.

METHODS

Overall, 32,466 posterior spinal fusion cases from 2016 to 2022 were identified within the ACS-NSQIP Pediatric (NSQIP-P) database. Multivariable logistic regression was used to identify variables independently associated with the outcomes of flap reconstruction. Efficacy of muscle flap reconstruction was assessed using a training set, validation set without flap reconstruction, and test set with flap reconstruction, followed by difference-in-differences analysis between the validation and test sets (p<0.05).

RESULTS

Muscle flap reconstruction occurred in 3.0% of the cases with the rate increasing from 1.7% in 2016 to 4.4% in 2022. When compared to idiopathic spinal deformity, neuromuscular (OR: 1.56, 95% CI: 1.27-1.91) classification was associated with an increased likelihood of flap reconstruction. Moreover, 13+ instrumented levels (OR: 2.41, 95% CI: 1.84-3.14), prior spine surgery (OR: 2.48, 95% CI: 2.08-2.97), and American Society of Anesthesiologists class >2 (OR: 1.47, 95% CI: 1.24-1.75) also increased the likelihood of flap reconstruction. Flap reconstruction was associated with a lower rate of post-operative complications than the expected rate calculated in a cohort that did not use such reconstruction (p<0.001).

CONCLUSION

Muscle flap reconstruction in pediatric spinal fusion cases has increased more than twofold in prevalence and occurs in cases with higher surgical complexity and risk. Flap reconstruction is independently associated with a lower rate of post-operative complications than expected.

Effectiveness of negative pressure wound therapy in treating deep surgical site infections after spine surgery: a meta-analysis of single-arm studies

BACKGROUND

One of the common complications in spinal surgery patients is deep surgical site infections (SSIs). Deep SSIs refer to infections that involve the deeper soft tissues of the incision, such as the fascia and muscle layers. This complication can lead to prolonged hospitalization, repeated surgeries, and even life-threatening conditions. In recent years, Negative Pressure Wound Therapy (NPWT) has been widely used as an effective wound healing method in the management of post-surgical infections. However, there is a lack of systematic research and comprehensive reviews regarding the exact effectiveness of NPWT in the treatment of deep SSIs following spinal surgery. Therefore, we conducted this meta-analysis to explore the efficacy of NPWT in treating deep SSIs after spinal surgery, aiming to provide clearer evidence to support clinical practice.

METHODS

A comprehensive search of databases, including CNKI, Wanfang data, VIP data, CBM, PubMed, Embase, Cochrane Library, and Web of Science, was conducted for studies up to August 20, 2024, examining the use of NPWT in treating SSIs after spinal surgery. Using Stata 15.0 software, we employed either fixed or random models to calculate combined effect sizes, depending on the level of heterogeneity observed.

RESULTS

Of the 571 publications initially screened, 19 studies meeting the inclusion criteria were selected for analysis. The meta-analysis revealed that the mean duration of vacuum sealing drainage (VSD) treatment was 17.45 days [95% confidence interval (CI) (11.63 days, 23.28 days)], and the mean number of VSD uses was 2.57 times[95% CI (1.53times, 3.60times)]. Additionally, the recurrence rate of infection post-discharge was 2% (95% CI = 0-4%). The reoperation rate for internal fixation in NPWT-treated patients was 4% (95% CI = 0-14%).

CONCLUSION

Available evidence supports the effectiveness of NPWT in treating deep SSIs following spinal surgery, suggesting its clinical utility. However, further studies are needed to compare NPWT with other treatment options for SSIs management.

REGISTRATIONS

PROSPERO CRD42024612412.

Intrawound Vancomycin Powder Reduces Delayed Deep Surgical Site Infections Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

STUDY DESIGN

Retrospective.

OBJECTIVE

Evaluate whether the use of vancomycin powder (VP) placed in the surgical site before wound closure prevents delayed deep surgical site infections (DDI).

SUMMARY OF BACKGROUND DATA

DDI after posterior spinal fusion (PSF) in adolescent idiopathic scoliosis (AIS) patients remains a significant and major complication. The use of VP to prevent acute surgical site infection has been reported, but the impact on DDI is unknown.

MATERIALS AND METHODS

AIS patients treated over the past 20 years with PSF or instrumentation from a large multicenter registry were reviewed. Patients were divided into two groups: intraoperative vancomycin powder placed in the wound (VP) or no antibiotics placed in the wound (NVP). DDI was defined as an infection that occurred >90 days after surgery and required surgical intervention in the operating room. Patients who developed a DDI had secondary verification of VP use or not. χ 2 and Kaplan-Meier (K-M) survivorship analyses were used to compare demographics and the incident rate of DDI between groups.

RESULTS

Totally, 4145 cases met the inclusion criteria for this study. A total of 43 DDI cases were identified (1.0%). The incidence of DDI for the VP group was 0.2% (4/2111), and 1.9% (39/2034) in the NVP group ( P <0.001). Given the difference in follow-up for the two groups, a cumulative survival and Kaplan-Meier analysis revealed the VP group had significantly better "survival" (no DDI) than the NVP group ( P <0.001).

CONCLUSION

DDIs are significant adverse events that can greatly complicate patient recovery after PSF for AIS, including rehospitalization. This study found that patients who received VP intraoperatively were 10 times less likely to develop a DDI than those who did not receive VP. Although other advances and changes in surgical techniques may contribute to the significant decrease in infections found in the more recent VP cohort, VP should be considered as a prophylactic measure.

LEVEL OF EVIDENCE

4.

Analysis of 5,070 consecutive pedicle screws placed utilizing robotically assisted surgical navigation in 334 patients by experienced pediatric spine deformity surgeons: surgical safety and early perioperative complications in pediatric posterior spinal fusion

PURPOSE

This study evaluates the intraoperative and short-term complications associated with robotically assisted pedicle screw placement in pediatric posterior spinal fusion (PSF) from three surgeons at two different institutions.

METHODS

We retrospectively reviewed 334 pediatric patients who underwent PSF with robotic-assisted navigation at 2 institutions over 3 years (2020-2022). Five thousand seventy robotically placed screws were evaluated. Data collection focused on intraoperative and early postoperative complications with minimum 30-day follow-up. Patients undergoing revision procedures were excluded.

RESULTS

Intraoperative complications included 1 durotomy, 6 patients with neuromonitoring alerts not related to screw placement, and 62 screws (1.2%) with documented pedicle breaches, all of which were revised at time of surgery. By quartile, pedicle breaches statistically declined from first quartile to fourth quartile (1.8% vs. 0.56%, p < 0.05). No breach was associated with neuromonitoring changes or neurological sequelae. No spinal cord or vascular injuries occurred. Seventeen postoperative complications occurred in eleven (3.3%) of patients. There were five (1.5%) patients with unplanned return to the operating room.

CONCLUSION

Robotically assisted pedicle screw placement was safely and reliably performed on pediatric spinal deformity by three surgeons across two centers, demonstrating an acceptable safety profile and low incidence of unplanned return to the operating room.

Predictive modeling for identifying infection risk following spinal surgery: Optimizing patient management

Infection is known to occur in a substantial proportion of patients following spinal surgery and predictive modeling may provide a useful means for identifying those at higher risk of complications and poor prognosis, which could help optimize pre- and postoperative management strategies. The outcome measure of the present study was to investigate the occurrence of all-cause infection during hospitalization following scoliosis surgery. To meet this aim, the present study retrospectively analyzed 370 patients who underwent surgery at the Second Affiliated Hospital, Zhejiang University School of Medicine (Hangzhou, China) between January 2016 and October 2022, and patients who either experienced or did not experience all-cause infection while in hospital were compared in terms of their clinicodemographic characteristics, surgical variables and laboratory test results. Logistic regression was subsequently applied to data from a subset of patients in order to build a model to predict infection, which was validated using another subset of patients. All-cause, in-hospital postoperative infections were found to have occurred in 66/370 patients (17.8%). The following variables were included in a predictive model: Sex, American Society of Anesthesiologists (ASA) classification, body mass index (BMI), diabetes mellitus, hypertension, preoperative levels of white blood cells and preoperative C-reactive protein (CRP) and duration of surgery. The model exhibited an area under the curve of 0.776 against the internal validation set. In conclusion, dynamic nomograms based on sex, ASA classification, BMI, diabetes mellitus, hypertension, preoperative levels of white blood cells and CRP and duration of surgery may have the potential to be a clinically useful predictor of all-cause infection following scoliosis. The predictive model constructed in the present study may potentially facilitate the real-time visualization of risk factors associated with all-cause infection following surgical procedures.

A 10-year perspective on the question of whether surgeries for adolescent idiopathic scoliosis are "one and done"?

PURPOSE

Posterior scoliosis fusion (PSF) for adolescent idiopathic scoliosis (AIS) is considered a highly successful surgery with excellent outcomes. However, especially as many patients "graduate" from their pediatric surgeons, there is the need to quantify the long-term outcomes of such surgeries.

METHODS

The 2010-2022 Pearldiver M161 dataset was queried for those who were 10 to 18 years old with AIS undergoing PSF with at least 10 years follow-up. Patient characteristics were abstracted. Reoperations were identified based on coding for any subsequent thoracic/lumbar surgery/revision. The 10-year reoperation rate and reasons for reoperation were determined, and multivariate regression was performed to determine risk factors.

RESULTS

In total, 3,373 AIS PSF patients were identified. Of the study cohort, 324 (9.6%) underwent reoperation within 10-years with an interquartile range for timing of surgery of 81-658 days, of which 29.6% were done for infection. Reoperations were done within the first three months for 152 (46.9% of reoperations), three months to 2 years for 97 (29.9%), and 2 years to 10 years for 74 (22.8%). Based on multivariate regression, need for reoperation was associated with male sex (OR: 1.70), asthma (OR: 1.36) and greater than thirteen segments of instrumentation (OR: 1.48) (p < 0.05 for each) but not age, other comorbidities, or insurance.

CONCLUSIONS

The current study of a large national AIS PSF population found 9.6% to undergo reoperation in the 10 years following their index operation. Although specifics about the curve pattern could not be determined, the reoperation incidence and correlation with specific risk factors are notable and important for patient counselling.

Dosing Cefazolin for Surgical Site Infection Prophylaxis in Adolescent Idiopathic Scoliosis Surgery: Intermittent Bolus or Continuous Infusion?-A Pilot Study

Background: Cefazolin may minimize the risk of surgical site infection (SSI) following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Cefazolin dosing recommendations vary and there is limited evidence for achieved tissue concentrations. Methods: We performed a randomized, controlled, prospective pharmacokinetic pilot study of 12 patients given cefazolin by either intermittent bolus (30 mg/kg every 3 h) or continuous infusion (30 mg/kg bolus followed by 10/mg/kg per hour) during PSF for AIS. Results: Patients were well matched for demographic and perioperative variables. While total drug exposure, measured as area-under-the-curve (AUC), was similar in plasma for bolus and infusion dosing, infusion dosing achieved greater cefazolin exposure in subcutaneous and muscle tissue. Using the pharmacodynamic metric of time spent above minimal inhibitory concentration (MIC), both bolus and infusion dosing performed well. However, when targeting a bactericidal concentration of 32 µg/mL, patients in the bolus group spent a median of 1/5 and 1/3 of the typical 6 h operative time below target in subcutaneous and muscle tissue, respectively. Conclusions: We conclude that intraoperative determination of cefazolin tissue concentrations is feasible and both bolus and infusion dosing of cefazolin achieve concentrations in excess of typical MICs. Infusion dosing appears to more consistently achieve bactericidal concentrations in subcutaneous and muscle tissues.