Plastic Surgeon Closure of Index Spinal Cases: A Single-Institution Review of 928 Cases

Optimizing Wound Healing Following Cervical Spine Surgery

INTRODUCTION

The volume of cervical spine procedures continues to grow. Plastic and reconstructive surgeons (PRSs) commonly address complex wound-related issues in such cases. The present study investigates whether routine PRS closure of cervical spinal wounds improves outcomes compared with those performed without.

METHODS

Data of patients operated on for cervical spine procedures by the senior author (P.J.T.) between January 2016 and June 2023 were analyzed. Only posterior surgical approaches were included. Demographics, medical status, procedure indication, and surgical characteristics were reviewed. Wound-related and medical complications were examined within a 30-day postoperative period, along with incidences of unplanned reoperation or readmission. Outcomes were compared with 12,943 CPT-matched cases reported by the American College of Surgeons National Surgical Quality Improvement Program.

RESULTS

Five hundred eighty-eight cases were included: 511 (87%) were performed for degenerative spine conditions, 60 (10%) for traumatic injuries, 7 (1%) for neoplasms, 7 (1%) for congenital conditions, and 3 (0.5%) for infected cyst management. The PRS group demonstrated a greater prevalence of diabetes (27% vs 22%, P = 0.016) and chronic obstructive pulmonary disease (10% vs 6%, P < 0.001). Those who received PRS closure were less likely to return to the operating room (1% vs 3%, P = 0.005) or experience a wound-related readmission (2% vs 5%, P < 0.001).

CONCLUSION

PRS closure of cervical spine cases minimizes the risk of reoperation and readmission, even among a population with comorbidities known to be associated with wound-related complications. Improved outcomes were especially observed for more complex wounds requiring local flap closure. Thus, there is strong evidence to support PRS involvement in cervical spine surgery.

Optimizing wound healing following lumbar spine surgery

The prevalence of open lumbar spine procedures has increased due to surgical advancements and an aging population. This study examined prophylactic closure by the plastic and reconstructive surgery (PRS) service compared to similar procedures from the National Surgical Quality Improvement Program (NSQIP) database. Patients who underwent lumbar spine surgery closed primarily by the PRS service at a large academic surgical center between January 2016 and June 2023 were included, while grafts or flaps were excluded. Charts were reviewed for demographics, preoperative risk factors, operative course, superficial surgical site infection (SSI), deep SSI, organ/space SSI, wound dehiscence, seroma, hematoma, cerebrospinal fluid leak, and medical complications. Unplanned readmission and revision surgeries related to the procedure were noted. Outcomes were assessed 30 days postoperatively. Outcomes within 30 days postoperatively were recorded in 46,006 NSQIP cases after matching by Current Procedural Terminology (CPT) and International Classification of Diseases - 10 (ICD-10) codes. A total of 888 consecutive lumbar surgery patients closed by PRS were reviewed. Wound-related revisional surgeries (1.2% vs. 2.6%, p = 0.013) and wound-related readmissions (1.5% vs. 4.2%, p < 0.001) were significantly lower for the PRS group than the NSQIP group. Transfusion (2.7% vs. 4.4%, p = 0.013) and urinary tract infection rates (0.2% vs. 1.3%, p = 0.005) were also lower for the PRS group. PRS closure also showed significantly decreased odds of revisional surgery (ß = 0.587, p = 0.021) and any wound infection (ß = 0.503, p = 0.026) after logistic regression. Thus, PRS closure of lumbar spine procedures may decrease the risk of wound-related revisional surgeries, readmissions, and infections. Therefore, this study supports the use of prophylactic PRS closure in such cases.

Prevention and Management of Posterior Wound Complications Following Oncologic Spine Surgery: Narrative Review of Available Evidence and Proposed Clinical Decision-Making Algorithm

STUDY DESIGN

Narrative Review.

OBJECTIVE

Contextualized by a narrative review of recent literature, we propose a wound complication prevention and management algorithm for spinal oncology patients. We highlight available strategies and motivate future research to identify optimal and individualized wound management for this population.

METHODS

We conducted a search of recent studies (2010-2022) using relevant keywords to identify primary literature in support of current strategies for wound complication prevention and management following spine tumor surgery. When primary literature specific to spine tumor cases was not available, data were extrapolated from studies of other spine surgery populations. Results were compiled into a proposed clinical algorithm to guide practice considering available evidence.

RESULTS

Based on available literature, we recommend individualized stratification of patients according to identifiable risk factors for wound complication and propose several interventions which might be employed preventatively, including intrawound antibiotic administration, negative pressure wound therapy, and primary flap closure of the surgical wound. Of these, the available evidence, weighing possible risks vs benefits, most strongly favors primary flap closure of surgical wounds, particularly for patients with multiple risk factors. A secondary algorithm to guide management of wound complications is also proposed.

CONCLUSIONS

Wound complications such as SSI and dehiscence remain a significant source of morbidity following spine tumor surgery. Triaging patients on an individualized basis according to risk factors for complication may aid in selecting appropriate prophylactic strategies to prevent these complications. Future research in this area is still needed to strengthen recommendations.

Exploring the definition of surgical wound dehiscence in literature: a Scoping Review

BACKGROUND

Surgical wound dehiscence (SWD) is interpreted differently amongst healthcare professionals due to a lack of uniformity in definitions in literature. Inconsistent defining impedes accurate diagnosis, appropriate care, intercollegiate consultation, and benchmarking. Despite the introduction of a consensus-driven definition by the World Union of Wound Healing Societies (WUWHS) in 2018, its application in literature and clinical practice remains unclear.

A OBJECTIVES

This scoping review aims to systematically explore the literature to identify existing SWD definitions, provide an overview, identify knowledge gaps, and extract articles that reference the WUWHS definition.

METHODS

This review was performed in accordance with the PRISMA-ScR guidelines and Joanna Briggs Institute Methodology for Scoping Reviews. A systematic literature search was performed through MEDLINE, EMBASE, Cochrane Library and Google Scholar. Eligibility screening and data extraction were independently performed by two researchers.

RESULTS

This study included 34 articles: 28 systematic reviews, two randomized clinical trials, three retrospective studies, and one book chapter. SWD was defined in different ways, such as "breakdown/disruption of the surgical wound" (n = 17), "separation/splitting apart of the wound edges" (n = 13), "gaping/re-opened wound" (n = 7), mechanical failure (n = 2), or infection (n = 1). Other studies defined SWD in relation to its depth (skin layers involved) or length over the incision, both complete and partial (n = 9). One study referenced the WUWHS definition.

CONCLUSION

Existing literature demonstrates a substantial variety in defining SWD, and little adoption of the WUWHS definition following its introduction in 2018. Uniform use of the definition should be considered as this will improve the quality of care.

Inter-rater reliability among healthcare professionals in assessing postoperative wound photos for the presence or absence of surgical wound dehiscence: A Pretest - Posttest study

BACKGROUND

Surgical wound dehiscence (SWD) has various definitions, which complicates accurate and uniform diagnosis. To address this, the World Union Wound Healing Societies (WUWHS) presented a consensus based definition and classification for SWD (2018).

AIM

This quasi-experimental pretest-posttest study investigates the inter-rater reliability among healthcare professionals (HCP) and wound care professionals (WCP) when assessing wound photos on the presence or absence of SWD before and after training on the WUWHS-definition.

METHODS

Wound expert teams compiled a set of twenty photos (SWD+: nineteen, SWD-: one), and a video training. Subsequently, 262 healthcare professionals received the pretest link to assess wound photos. After completion, participants received the posttest link, including a (video) training on the WUWHS-definition, and reassessment of fourteen photos (SWD+: thirteen, SWD-: one).

PRIMARY OUTCOMES

1) pretest-posttest inter-rater-reliability among participants in assessing photos in congruence with the WUWHS-definition 2) the impact of training on assessment scores.

SECONDARY OUTCOME

familiarity with the WUWHS-definition.

RESULTS

One hundred thirty-one participants (65 HCPs, 66 WCPs) completed both tests. The posttest inter-rater reliability among participants for correctly identifying SWD was increased from 67.6 % to 76.2 %, reaching statistical significance (p-value: 0.001; 95 % Confidence Interval [1.8-2.2]). Sub-analyses per photo showed improved SWD posttest scores in thirteen photos, while statistical significance was reached in seven photos. Thirty-three percent of participants knew the WUWHS-definition.

CONCLUSION

The inter-rater reliability among participants increases after training on the WUWHS-definition. The definition provides diagnostic criteria for accurate SWD diagnosis. Widespread use of the definition may improve uniformity in care for patients with SWD.

Systematic Review of Prophylactic Plastic Surgery Closure to Prevent Postoperative Wound Complications Following Spine Surgery

Spinal surgeries are increasingly performed in the United States, but complication rates can be unacceptably high at up to 26%. Consequently, plastic surgeons (PS) are sometimes recruited by spine surgeons (SS) for intraoperative assistance with soft tissue closures. An electronic multidatabase literature search was systematically conducted to determine whether spinal wound closure performed by PS minimizes postoperative wound healing complications when compared to closure by SS (neurosurgical or orthopedic), with the hypothesis that closures by PS minimizes incidence of complications. All published studies involving patients who underwent posterior spinal surgery with closure by PS or SS at index spine surgery were identified. Filtering by exclusion criteria identified 10 studies, 4 of which were comparative in nature and included both closures by PS and SS. Of these 4, none reported significant differences in postoperative outcomes between the groups. Across all studies, PS were involved in cases with higher baseline risk for wound complications and greater comorbidity burden. Closures by PS were significantly more likely to have had prior chemotherapy in 2 of the 4 (50%) studies (P = 0.014, P < 0.001) and radiation in 3 of the 4 (75%) studies (P < 0.001, P < 0.01, P < 0.001). In conclusion, closures by PS are frequently performed in higher risk cases, and use of PS in these closures may normalize the risk of wound complications to that of the normal risk cohort, though the overall level of evidence of the published literature is low.

Plastic surgeon closure is comparable to orthopedic closure when a perioperative optimization protocol is instituted for pediatric patients with neuromuscular scoliosis

BACKGROUND CONTEXT

Since 2015, plastic multilayer closure (PMC) has been gaining attraction due to improved wound healing outcomes for medically complex patients. Plastic multilayer closure has been readily used for complex spine surgery closures in patients susceptible to wound healing issues (ie, dehiscence, surgical site infection [SSI]). However, PMC requires extensive soft tissue manipulation compared with standard orthopedic spine surgeon closure (SOC) and can result in extended operative times, increased transfusion rates, and more frequent returns to the operating room.

PURPOSE

From 2016 to 2019, our institution implemented a perioperative protocol designed to decrease postoperative complication rates in NMS patients. A retrospective cohort study was performed to determine if PMC imparted advantages over SOC above and beyond that from the perioperative protocol.

STUDY DESIGN/SETTING

Retrospective study at a single academic institution.

PATIENT SAMPLE

Eighty-one pediatric patients with neuromuscular scoliosis undergoing spinal fixation surgery.

OUTCOME MEASURES

Postoperative wound complications such as surgical site infection, hematoma, and superficial/deep dehiscence were the main outcome measures. Respiratory and neuromuscular complications along with duration of surgery were also recorded.

METHODS

A retrospective review was conducted of NMS patients undergoing spinal fixation at a single academic pediatric hospital over 4 years. Cases were labeled as SOC (n=41) or PMC (n=40) based on the closure technique applied. Reported 90-day complications were evaluated as the primary outcome.

RESULTS

Of the 81 reviewed patients, 45 reported complications, roughly equal between the study groups. While we found no statistically significant differences in rates of postoperative complications or SSIs, SOC cases were 30 minutes shorter on average with fewer returns to the operating room for additional surgery.

CONCLUSIONS

With the implementation of our perioperative protocol for NMS patients, PMC did not result in fewer complications than SOC but the surgeries did take longer.

Plastic multilayered closure versus orthopedic surgeon closure after spinal instrumentation in pediatric neuromuscular scoliosis

Objective

To compare wound complication rates between orthopedic closure (OC) and plastic multilayered closure (PMC) in patients undergoing primary posterior spinal fusion for neuromuscular scoliosis (NMS). We hypothesize that multilayered closure will be associated with better postoperative outcomes.

Methods

We collected data on pediatric patients diagnosed with NMS who underwent first time spinal instrumentation between 1 January 2018 and 31 May 2021. Patient demographics, length of surgery, spinal levels fused and operative variables, wound complication rate, treatments, and need for wound washout were reviewed in depth and recorded.

Results

In total, 86 patients were reviewed: 46 with OC and 40 with PMC. There was a significant increase in operating room (OR) time with PMC compared with OC (6.7±1.2 vs 7.3±1.3, p=0.016). There was no difference in complication rate, mean postoperative day of complication or unplanned return to the OR for OC and PMC, respectively. There was a slightly significant increase in the number of patients going home with a drain in the PMC cohort compared with the OC cohort (2.1% vs 15%, p=0.046).

Conclusions

PMC demonstrated longer OR times than OC and did not demonstrate a statistically significant reduction in wound complications or unplanned returns to the OR. However, other studies have demonstrated statistical and clinical significance with these variables. Surgical programs should review internal patient volumes and outcomes for spinal fusion in NMS patients and consider if PMC after spinal fusions in pediatric patients with NMS or other scoliosis subtypes is an appropriate option in their institution to minimize postoperative wound complications.

Increased Surgical Site Subcutaneous Fat Thickness Is Associated with Infection after Posterior Cervical Fusion

Background: Previous literature has associated increased body mass index (BMI) with risk of surgical site infection (SSI) after posterior cervical fusion (PCF) surgery. However, few studies have examined the association between local adiposity and risk of SSI, re-admission, and re-operation after PCF. Local adiposity is easily measured on pre-operative magnetic resonance imaging (MRI) and may act as a more accurate predictor compared with BMI. Patients and Methods: Subjects undergoing PCF from 2013-2018 at a single institution were identified retrospectively. Posterior cervical subcutaneous fat thickness, paraspinal muscle thickness, and lamina-to-skin distance measurements were obtained from computed tomography (CT) or MRI scans. Subjects with active infection, malignancy, or revision procedures were excluded. Results: Two hundred five patients were included with 20 developing SSIs. Subjects with SSIs had a longer fusion construct (4.90 vs. 3.71 levels; p = 0.001), higher Elixhauser comorbidity index (ECI; 2.05 vs. 1.34; p = 0.045), had a history of diabetes mellitus (30% vs. 10.8%; p = 0.026), higher subcutaneous fat thickness (30.5 vs. 23.6 mm; p = 0.013), and higher lamina-to-skin distance (66.4 vs. 57.9 mm; p = 0.027). Subcutaneous fat thickness (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.10]; p = 0.026) and lamina-to-skin distance (OR, 1.05; 95% CI, 1.01-1.09]; p = 0.014) were associated with SSI in multivariable analysis. A subcutaneous fat thickness cutoff value of 23.2 mm had 90% sensitivity and 54.1% specificity for prediction of SSI. There was no association need for re-admission or re-operation. Conclusions: Increased posterior cervical fat may increase the risk of SSI after PCF. Pre-operative advanced imaging may be a valuable tool for assisting with patient counseling, optimization, and risk stratification.

The Value of an Orthoplastic Approach to Management of Lower Extremity Trauma: Systematic Review and Meta-analysis

Background:

Management of traumatic lower extremity injuries requires a skill set of orthopedic surgery and plastic surgery to optimize the return of form and function. A systematic review and meta-analysis was performed comparing demographics, injuries, and surgical outcomes of patients sustaining lower extremity traumatic injuries receiving either orthoplastic management or nonorthoplastic management.

Methods:

Preferred Reporting Items for Systematic Reviews and Meta-Analysis, Cochrane, and GRADE certainty evidence guidelines were implemented for the structure and synthesis of the review. PubMed, Embase, Cochrane Library, Web of Science, Scopus, and CINAHL databases were systematically and independently searched. Nine studies published from 2013 through 2019 compared 1663 orthoplastic managed patients to 692 nonorthoplastic managed patients with traumatic lower extremity injuries.

Results:

Orthoplastic management, compared to nonorthoplastic management likely decreases time to bone fixation [standard mean differences: −0.35, 95% confidence interval (CI): −0.46 to −0.25, P < 0.0001; participants = 1777; studies = 3; I² = 0%; moderate certainty evidence], use of negative pressure wound therapy [risk ratios (RR): 0.03, 95% CI: 0.00–0.24, P = 0.0007; participants = 189; studies = 2; I² = 0%; moderate certainty evidence] with reliance on healing by secondary intention (RR: 0.02, 95% CI: 0.00–0.10, P < 0.0001; participants = 189; studies = 2; I² = 0%; moderate certainty evidence), and risk of wound/osteomyelitis infections (RR: 0.37, 95% CI: 0.23–0.61, P < 0.0001; participants = 224; studies = 3; I² = 0%; moderate certainty evidence). Orthoplastic management likely results in more free flaps compared to nonorthoplastic management (RR: 3.46, 95% CI: 1.28–9.33, P = 0.01; participants = 592; studies = 5; I² = 75%; moderate certainty evidence).

Conclusion:

Orthoplastic management of traumatic lower extremity injuries provides a synergistic model to optimize and expedite definitive skeletal fixation and free flap-based soft-tissue coverage for return of extremity form and function.