Risk factors for surgical site infection following spinal surgery: A meta-analysis

Challenging the Dogma of Dead Space Obliteration With Muscle Flaps in Deep Spinal Surgical Site Infections

Background

A deep surgical site infection (SSI) after spinal surgery is a serious complication. The defect formed is often a complex 3-dimensional dead space due to tissue loss, frequently containing spinal hardware. Traditionally, obliteration of that dead space is performed with the use of muscle flaps. We challenge this dogma in reconstructive surgery by using the medial dorsal intercostal artery perforator (MDICAP) flap as an alternative in the reconstruction. It adheres to the concept of replacing "like with like," as there are no muscles at the posterior midline.

Methods

A retrospective study was performed of a cohort of 18 patients with deep SSI and a posterior midline defect after spinal surgery who received reconstruction with the MDICAP flap. A review of postoperative imaging with focus on dead space was performed.

Results

All patients had satisfactory functional and aesthetic outcomes. No patients had a recurrent deep SSI during follow-up (average 64 mo, range 3-384 mo). In the 16 patients who had postoperative imaging performed, dead space was not present at the flaps' recipient site.

Conclusions

The MDICAP flap is a good alternative to muscle flaps in reconstructive surgery for complex posterior midline defects caused by a deep SSI after spinal surgery. Postoperative imaging showed no dead space with the use of MDICAP flaps. All patients had an uneventful postoperative course with no recurrent infections. This challenges the dogmata of (1) the need for muscle flaps in such reconstruction and (2) the obligate need for dead space obliteration at the time of operation.

Comparison of Surgical Site Infection After Instrumented Spine Surgery in Patients With High Risk of Infection According to Different Antibiotic Prophylaxis Protocols: A Cohort Study of 132 Patients With a Minimum Follow-Up of 1 year

Study DesignObservational Study.ObjectivesSurgical site infections (SSIs) are one of the major complications in spine surgery. Numerous factors that increase the risk of SSI have been widely described. However, clinical guidelines on antibiotic prophylaxis are usually common for all patients. There are no specific guidelines for patients with a high risk of infection. The aim of this paper is to create a specific protocol for patients at high risk of SSI.MethodsThis is a three-cohort study using a prospective database. Risk patients are those who meet at least two of the following criteria: obesity, diabetes, reoperation and immunosuppression. Between October 2021 and April 2023, 132 patients were recruited.They were divided into three cohorts: cohort A, 46 patients, standard prophylaxis with cefazolin 2 g/8 h for 24 h; cohort B, 46 patients, cefazolin 2 g/8h and amikacin 500 mg/12 h for 24 h; cohort C, 40 patients, cefazolin 2 g/8h and amikacin 500 mg/12 h for 72 h.ResultsThere was a significant decrease in the infection rate depending on the prophylaxis (23.9% in cohort A, 8.7% in cohort B, and 2.5% in cohort C). When logistic regression models were applied and cohorts B and C were compared with A, the following results were obtained: OR of 0.30 (CI: 0.08 - 0.97; P = 0.057) and 0.08 (IC: 0.00 - 0.45; P = 0.019), respectively.ConclusionsProphylaxis with prolonged double antibiotic therapy with cefazolin and amikacin is associated with a statistically significant decrease in the rate of SSI in patients with a high risk of infection.

Important issues on the prevention of surgical site infections and the management of prophylactic antibiotics

In this article, we have addressed the recent published article by Wang et al which examines risk factors associated with surgical site infections (SSIs) and evaluates the effectiveness of prophylactic antibiotics in their prevention. Wang et al identified several significant risk factors of SSIs, including age ≥ 60 years, diabetes mellitus, and surgical complications such as insufficient cystic duct stump closure, gallbladder perforation, empyema, and postoperative hematoma. Their findings suggest that prophylactic antibiotics can serve as a protective factor against SSIs. However, other reported risk factors and preventive strategies warrant consideration to further reduce the incidence of SSIs, lower healthcare costs, and enhance patient outcomes. Additionally, the judicious use of prophylactic antibiotics is crucial in light of the growing global challenge of antibiotic resistance caused by the misuse and overuse of antibiotics. Effective management strategies for prophylactic antibiotic use should be prioritized to balance infection control with the need to combat antimicrobial resistance.

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.

Infectious complications after traumatic spine injury requiring surgery in a French level-1 trauma center: An observational study

BACKGROUND

Traumatic spine injury (TSI) is a prevalent condition that often requires surgical intervention. Two serious infectious complications after surgery are surgical site infections (SSI) and lower respiratory tract infections (LRTI). Yet, studies on SSI and LRTI on trauma patients, particularly with a specific focus on microbiology are lacking. The primary aim of this study is to investigate the prevalence rate of early SSI, occurring within one month of surgery or three months when instrumented, and LRTI in level-1 trauma center patients requiring surgery after TSI.

METHODS

This monocenter retrospective observational study was conducted at an academic level-1 trauma center, including patients with TSI requiring surgery. Data on patients' baseline characteristics, trauma related information, initial and intra-operative management, infectious complications data and hospitalization outcomes were collected. The two primary outcomes were the prevalence of early SSI and LRTI. Secondary outcomes included the identification of factors associated with developing these infections, analysis of identified organisms, and assessment of clinical outcomes.

RESULTS

A total of 2606 patients were screened between May 2018 and October 2022, 194 were included. Most of them were polytrauma patients defined by Injury Severity Score ≥ 16 (71 %). Early SSI occurred in 20 patients (10 %) and LRTI occurred in 58 patients (30 %). The number of vertebral levels instrumented (odds ratio [OR] 1.24, 95 % confidence interval [95 % CI] 1.01-1.52) was associated with SSI. The causative organisms were predominantly Gram-positive cocci (19/36 identified organisms). Factors associated with LRTI were an injury severity score ≥ 25 (OR 7.41; 95 % CI, 3.28-17.99), spinal injury at levels C3-C7 (OR 2.24; 95 % CI 1.01-5.14) and antibiotics during initial management (OR 7.09; 95 % CI, 2.71-20.49). The causative organisms were predominantly Gram-negative bacilli (58/80 identified organisms). Patients with LRTI experienced longer hospital stays, extended durations of mechanical ventilation, and higher mortality rates at 30 days and one year than those without.

CONCLUSION

Early SSI and LRTI are underestimated complications in severe trauma patients with TSI requiring surgery. Identifying risk factors and causative organisms is an important step for advancing research on targeted prevention and treatment of SSI and LRTI after trauma.

The neutrophil-to-lymphocyte ratio (NLR) levels predicting the surgical site infection in spinal surgery: a systematic review

Background

Surgical site infection (SSI) is a prevalent complication in spinal surgery, associated with significant morbidity, prolonged hospital stays, and increased healthcare costs. The early detection of SSI can lead to timely intervention. Among available diagnostic methods, the neutrophil-to-lymphocyte ratio (NLR) has emerged as a simple, accessible marker with potential predictive value for SSIs. This systematic review aims to evaluate the diagnostic role of NLR, in the early detection of SSIs following spinal surgery.

Methods

Following PRISMA guidelines, we conducted a comprehensive literature search in MEDLINE, Web of Science, Embase, and Scopus databases for studies examining the utility of NLR in predicting SSIs in all types of spinal surgery patients. Ultimately, 7 studies met the inclusion criteria; all retrospective in design, with sample sizes ranging from 77 to 384. Studies focused on NLR values measured at different postoperative days, solely or along with some integrating additional markers, including C-reactive protein (CRP) and body mass index (BMI), into predictive models.

Results

Our study confirmed that NLR serves as a significant predictor of SSIs post-spinal surgery. Analyses of included studies revealed variable optimal NLR cutoff values, ranging from 3.21 to 4.91, dependent on postoperative day and surgery type. The highest predictive accuracy was observed when NLR was combined with CRP and lymphocyte percentage, enhancing early SSI detection. However, the variability in cutoff values and measurement timing across studies suggests limitations due to heterogeneity in study designs and patient populations, indicating the need for further research to establish standardized protocols.

Conclusions

NLR could be of value for early SSI detection in spinal surgery, with its diagnostic accuracy potentially improved by combining it with other markers. However, variability in cutoff values and timing across studies suggests the need for further research to standardize these parameters. Establishing consistent protocols could improve SSI detection, enabling faster interventions and potentially enhancing patient outcomes in spinal surgery.

A Study of Risk Factors for Surgical Site Infections and Direct Economic Losses in Clean Orthopedic Surgery

Background: Surgical site infection (SSI) is a serious complication after clean orthopedic surgery. Patients and Methods: We retrospectively gathered data on 18,140 patients who underwent clean incision orthopedic operations at two institutions between January 2023 and April 2024. The study included 87 patients with SSIs in the case group and 80 matched controls without SSIs. Age, diabetes mellitus, and intra-operative blood transfusions were all examined using uni-variable and conditional multi-variable logistic regression to detect risk and independent risk factors for SSI. Differences in hospital charges and length of stay were also investigated. Results: Among the 18,140 surveyed patients, 87 developed SSIs, yielding an infection rate of 0.48%. Significant risk factors for SSI included hypertension (31.3% vs. 15.0%, p = 0.015), more than two surgical procedures (28.8% vs. 8.8%, p = 0.001), and durations of indwelling urinary catheters (p ＜ 0.001) and drains (p = 0.003). Independent risk factors included age ≥60 years [odds ratio (OR): 36.011, p = 0.025], more than two surgical procedures (OR: 7.001, p = 0.034), and durations of indwelling urinary catheters (OR: 2.164, p = 0.033) and drains (OR: 1.426, p = 0.004). The median hospitalization cost was $5,289.3 for patients with SSIs compared with $3,653.9 for those without infections. The cost difference was statistically significant (Z = -3.409, p = 0.001), with an additional median expense of $1,366.5 attributed to SSIs. Patients in the infection group were hospitalized for a median of 30 days, compared with 15 days in the non-infected group, a statistically significant difference (Z = -7.32, p < 0.001), resulting in 17 additional days of hospitalization. The total direct economic loss attributed to 80 SSI cases across both hospitals amounted to $162,415.8. Conclusion: The study identifies multiple risk factors for SSIs following orthopedic clean surgical procedures. Hospital-related departments should aim to mitigate these risks to decrease the incidence of SSIs and reduce the financial burden on patients.

Construction and validation of a nomogram predictive model for assessing the risk of surgical site infections following posterior lumbar fusion surgery

Surgical site infections (SSIs) are a significant concern following posterior lumbar fusion surgery, leading to increased morbidity and healthcare costs. Accurate prediction of SSI risk is crucial for implementing preventive measures and improving patient outcomes. This study aimed to construct and validate a nomogram predictive model for assessing the risk of SSIs following posterior lumbar fusion surgery. A retrospective study was conducted on 1015 patients who underwent posterior lumbar fusion surgery at our hospital from January 2019 to December 2022. Clinical data, including patient demographics, comorbidities, surgical details, and postoperative outcomes, were collected. SSIs were defined based on the Centers for Disease Control and Prevention (CDC) criteria. Univariate analysis identified significant risk factors, which were then included in a binary logistic regression to develop the nomogram. The model's performance was evaluated using the concordance index (C-index), calibration curves, and receiver operating characteristic (ROC) curves. The incidence of SSIs was 5.02% (51/1015). The most common pathogens were Staphylococcus aureus and Escherichia coli. Significant risk factors for SSIs included smoking history, diabetes, surgery duration ≥ 3 h, intraoperative blood loss ≥ 300 ml, ASA classification ≥ 3, postoperative closed drainage duration ≥ 5 days, incision length ≥ 10 cm, BMI ≥ 30 kg/m2, and the presence of internal fixation. The nomogram demonstrated a C-index of 0.779 and an AUC of 0.845, indicating high predictive accuracy. The calibration curve closely matched the ideal curve, confirming the model's reliability. The constructed nomogram predictive model demonstrated high accuracy in predicting SSI risk following posterior lumbar fusion surgery. This model can aid clinicians in identifying high-risk patients and implementing targeted preventive measures to improve surgical outcomes.

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.

Risk factors for deep surgical site infection following open posterior lumbar fusion: A retrospective case-control study

This study aimed to identify risk factors for deep surgical site infection (SSI) following open posterior lumbar fusion (OPLF). We retrospectively analyzed the clinical data of patients who underwent OPLF between January 2014 and December 2022. Patients were divided into SSI and non-SSI groups according to whether deep SSI occurred following OPLF. Patient's sex, age, body mass index (BMI), history of diabetes mellitus and smoking, American Society of Anesthesiologists score, surgical segment, surgical time, preoperative albumin level, local use of vancomycin, and cerebrospinal fluid (CSF) leakage were compared between the 2 groups. Univariate and multivariate logistic regression analyses were used to identify risk factors for postoperative deep SSI. The deep SSI rate was 5.0% (63/1256). Among them, age (P < .001), BMI (P = .008), surgical segment (P < .001), surgical time (P < .001), prevalence of diabetes mellitus (P = .036), and CSF leakage (P < .001) were significantly higher in the SSI group, whereas the preoperative albumin level (P < .001) and proportion of local use of vancomycin (P = .046) were significantly lower in the SSI group than those in the non-SSI group. Multivariate analysis indicated that higher age (P = .046, odds ratio [OR]: 1.036, 95% confidence interval [CI]: 1.001-1.073), BMI (P = .038, OR: 1.113, 95% CI: 1.006-1.232), lower preoperative albumin level (P = .041, OR: 0.880, 95% CI: 0.778-0.995), higher surgical segment (P = .004, OR: 2.241, 95% CI: 1.297n3.871), and CSF leakage (P = .046, OR: 2.372, 95% CI: 1.015-5.545) were risk factors, and the local use of vancomycin (P < .001, OR: 0.093, 95% CI: 0.036-0.245) was the protective factor for deep SSI following OPLF. We identified 5 risk factors (older age and BMI, lower preoperative albumin level, higher surgical segment, and CSF leakage) and 1 protective factor (local use of vancomycin powder) for deep SSI following OPLF. To address these risk and protective factors, comprehensive evaluations and recommendations should be provided to patients to reduce SSI rates.

Predicting Surgical Site Infections in Spine Surgery: Association of Postoperative Lymphocyte Reduction

OBJECTIVE

Postoperative lymphopenia is reported as an excellent indicator to predict surgical-site infection (SSI) after spine surgery. However, there is still controversy concerning which serological markers can predict spinal SSI. This study aims to evaluate excellent and early indicators for detecting SSI, focusing on spine instrumented surgery.

MATERIALS AND METHODS

This study included 268 patients who underwent spinal instrumented surgery from January 2022 to December 2023 (159 female and 109 male, average 62.9 years). The SSI group included 20 patients, and the non-SSI group comprised 248 patients. Surgical time, intraoperative blood loss, and glycemic levels were measured in both groups. The complete blood cell counts, differential counts, albumin, and C-reactive protein (CRP) levels were measured pre-surgery and postoperative on Days 1, 3, and 7. In comparing the groups, the Mann-Whitney U test analysis was used for continuous variables, while the chi-squared test and Fisher's exact test were used for dichotomous variables.

RESULTS

The incidence of SSI after spinal instrumentation was 7.46% and was relatively higher in scoliosis surgery. The SSI group had significantly longer surgical times (248 min vs. 180 min, p = 0.0004) and a higher intraoperative blood loss (772 mL vs. 372 mL, p < 0.0001) than the non-SSI group. In the SSI group, the Day 3 (10.5 ± 6.2% vs. 13.8 ± 6.0%, p = 0.012) and Day 7 (14.4 ± 4.8% vs. 18.8 ± 7.1%, p = 0.012) lymphocyte ratios were lower than the non-SSI group. Albumin levels on Day 1 in the SSI group were lower than in the non-SSI group (2.94 ± 0.30 mg/dL vs. 3.09 ± 0.38 mg/dL, p = 0.045). There is no difference in CRP and lymphocyte count between the two groups.

CONCLUSIONS

SSI patients had lower lymphocyte percentages than non-SSI patients, which was a risk factor for SSI, with constant high inflammation. The Day 3 lymphocyte percentage may predict SSI after spinal instrumented surgery.

Prophylactic closed-incisional negative pressure wound therapy following posterior instrumented spinal fusion: a single surgeon's experience and cost-benefit analysis

PURPOSE

Surgical site infections (SSIs) following spine surgery are associated with morbidity and resource utilization. Applying prophylactic closed-incisional negative pressure wound therapy (ciNPWT) during posterior instrumented fusion has mixed results in reducing rates of wound complications and SSI. We evaluated the clinical efficacy and potential cost-savings associated with ciNPWT in high-risk patients receiving posterior instrumented spinal fusion.

METHODS

We retrospectively reviewed patients receiving posterior instrumented spinal fusion for any surgical indication between July 1, 2017 and December 31, 2019, and compared rates of wound dehiscence, SSI, and reoperation for wound complications between standard surgical dressings and ciNPWT. Surgical dressing selection was based on the senior author's assessment of infection risk factors.

RESULTS

A total of 229 patients (n = 85 standard surgical dressings, n = 144 ciNPWT) were included. The ciNPWT group had significantly more risk factors for wound-related complications, including older age (61.8 vs. 58.5 years, p = 0.042), diabetes mellitus (36.8% vs. 23.5%, p = 0.037), more instrumented levels (5.6 vs. 3.9, p < 0.0001), estimated blood loss (1298 vs. 998 mL, p = 0.036), and deformity was the predominant operative indication (29.9% vs. 17.7%, p = 0.040). Prophylactic ciNPWT was associated with significantly lower rates of wound dehiscence (21.5% vs. 34.1%, p = 0.036) and SSI (8.3% vs. 21.2%, p = 0.005). Number needed to treat with ciNPWT to prevent one SSI was 8 patients. The cost of preventing one SSI was $4,560. Cost-benefit analysis demonstrated a potential mean savings of $21,662 per operative SSI prevented and $270,775 per 100 patients undergoing posterior instrumented fusion with ciNPWT.

CONCLUSIONS

Prophylactic ciNPWT use is a cost-effective means of reducing rates of wound dehiscence and SSI following posterior instrumented fusion.

Evaluation of ERAS protocol implementation on complex spine surgery complications and length of stay: a single institution study

BACKGROUND CONTEXT

With the goal of improving patient outcomes, the Integrated Spine Center at UT Southwestern Medical Center implemented an enhanced recovery after surgery (ERAS) protocol which includes pre- and postsurgery guidelines. Numerous studies have shown benefit of implementation of ERAS protocols to standardize perioperative care in line with best practices; however, the literature on complication rates, LOS, and readmissions shows mixed results.

PURPOSE

The goal of this study was to investigate the impact of the ERAS protocol implementation on complication rates in the perioperative period, as well as hospital and ICU length of stay and hospital re-admission rates.

STUDY DESIGN/SETTING

A retrospective cohort study was performed on all patients who underwent spine surgery between September 2016 and September 2021 at a single institution. Patients who met inclusion criteria were divided into non-ERAS and ERAS groups, and comparative statistics were used to evaluate ERAS protocol effectiveness.

PATIENT SAMPLE

All patients who underwent spine surgery at UT Southwestern between September 2016 and September 2021 were evaluated for inclusion in the study. The patient sample was further refined to include only complex patient cases which were able to receive the full ERAS protocol (nonemergent admissions).

OUTCOME MEASURES

Presence of absence of postoperative complications including surgical site infection, AKI, DVT, MI, sepsis, pneumonia, PE, stroke, shock, and other complications were compared between groups, as were hospital and ICU length of stay, and 7, 30, and 90 day readmissions. Self-reported or functional measures were not used in outcome evaluation.

METHODS

A database of patient and surgery characteristics was built using an EMR query tool with spot checks performed by the authors. Control and treatment groups were matched for gender, age, BMI, ASA score, and surgery type. Total number of complication rates was compared between ERAS and non-ERAS groups, and comparative statistics were used to determine significance.

RESULTS

Significant differences between ERAS versus non-ERAS groups were found in rates of UTI (6.8% vs 3.1%, respectively; p=.031), constipation (20.6% vs 11.4%, respectively; p=.001), and any complications (31.4% vs 19.4%, respectively; p<.001). There was no significant difference in the rates of other complications, in length of hospital or ICU stay, or readmissions at 7, 30, and 90 days.

CONCLUSIONS

Implementation of the ERAS protocol did not decrease complication rates or length of stay, and ERAS patients had significantly higher rates of UTI, constipation, and any complications. There may have been confounding factors due to the impact of COVID-19 on delivery of care, as well as misalignment between ERAS goals and outcome measures.

A Randomized Controlled Trial of 2% Chlorhexidine Gluconate Skin Preparation Cloths for the Prevention of Surgical Site Infections in Adults Undergoing Spine Surgeries: Residual Reduction in Skin Bacterial Load for 4 Days

Background

Surgical site infections (SSI) result in increased morbidity and mortality, prolonged recovery, longer hospital length of stay for medication or possible additional surgeries, and escalated health care costs. The purpose of this randomized controlled trial was to compare SSI rates and overall skin flora burden between those using chlorhexidine (CHG) cloths versus soap and water preoperatively in the adult spine surgery population.

Methods

Subjects were randomized preoperatively to use 2% CHG cloths versus soap and water the night before and morning of surgery prior to the operation. A skin culture was obtained at enrollment prior to any cleansing, again at post-operation day 4 or hospital discharge (whichever came first), and finally at the surgeons' postoperative visits. A blinded advanced practice nurse served as the assessor for SSI.

Results

Those enrolled in the research arm had more growth on their screening skin culture than the control arm (P = .02). While there was no difference in rates of SSI between groups, the CHG group had lower skin flora burden at hospital discharge (P = .004), indicating residual protection.

Conclusion

Surgical incisions are most vulnerable to bacterial entry prior to 72 hours post-operation before completion of epithelialization, which establishes a barrier from microbes. The use of CHG, which has a residual impact for up to 4 days, could offer additional risk reduction for SSI development.

Effect of pre-operative HbA1c and blood glucose level on the surgical site infection after lumbar instrumentation surgery

BACKGROUND

This study aims to investigate the effect of pre-operative hemoglobin A1c (HbA1c) and pre-operative blood glucose control on the rate of surgical site infection (SSI) after posterior lumbar instrumentation surgery in diabetes mellitus (DM) patients.

METHODS

A total of 1046 patients who had undergone posterior lumbar instrumentation surgery were reviewed. Based on pre-operative HbA1c, patients were divided into three groups: non-DM group, low HbA1c group (HbA1c < 7.0 % in DM) and high HbA1c group (≥7.0). As well, based on the status of blood glucose control in DM patients immediately before surgery, patients were divided into two groups: good control group (post-prandial blood glucose [PBG] < 200 mg/dl) and poor control group (≥200). The rate of SSI was compared among these groups.

RESULTS

SSI occurred in 1.9 % in non-DM group, 2.4 % in low HbA1c group, and 9.3 % in high HbA1c group. Compared with non-DM group, high HbA1c group had significantly higher rate of SSI (p = 0.001). There was not statistically different between non-DM and low HbA1c groups (p = 0.550). SSI occurred in 2.2 % in good control group, and 10.2 % in poor control group. The rate of SSI was significantly lower in good control group (p = 0.013).

CONCLUSION

This study showed that the rate of SSI after posterior lumbar instrumentation surgery tend to be higher in DM patients with high HbA1c. However, the rate might be reduced to the same level as that of non-DM group by lowering PBG to <200 mg/dl immediately before surgery.

Perioperative complications and cost of posterior decompression with fusion in thoracic spine for ossification of the posterior longitudinal ligament and ossification of the ligamentum flavum -a comparative study using a national inpatient database

BACKGROUND

Although posterior decompression with fusion (PDF) are effective for treating thoracic myelopathy, surgical treatment has a high risk of various complications. There is currently no information available on the perioperative complications in thoracic ossification of the longitudinal ligament (T-OPLL) and thoracic ossification of the ligamentum flavum (T-OLF). We evaluate the perioperative complication rate and cost between T-OPLL and T-OLF for patients underwent PDF.

METHODS

Patients undergoing PDF for T-OPLL and T-OLF from 2012 to 2018 were detected in Japanese nationwide inpatient database. One-to-one propensity score matching between T-OPLL and T-OLF was performed based on patient characteristics and preoperative comorbidities. We examined systemic and local complication rate, reoperation rate, length of hospital stays, costs, discharge destination, and mortality after matching.

RESULTS

In a total of 2,660 patients, 828 pairs of T-OPLL and T-OLF patients were included after matching. The incidence of systemic complications did not differ significantly between the T-OPLL and OLF groups. However, local complications were more frequently occurred in T-OPLL than in T-OLF groups (11.4% vs. 7.7% P = 0.012). Transfusion rates was also significantly higher in the T-OPLL group (14.1% vs. 9.4%, P = 0.003). T-OPLL group had longer hospital stay (42.2 days vs. 36.2 days, P = 0.004) and higher medical costs (USD 32,805 vs. USD 25,134, P < 0.001). In both T-OPLL and T-OLF, the occurrence of perioperative complications led to longer hospital stay and higher medical costs. While fewer patients in T-OPLL were discharged home (51.6% vs. 65.1%, P < 0.001), patients were transferred to other hospitals more frequently (47.5% vs. 33.5%, P = 0.001).

CONCLUSION

This research identified the perioperative complications of T-OPLL and T-OLF in PDF using a large national database, which revealed that the incidence of local complications was higher in the T-OPLL patients. Perioperative complications resulted in longer hospital stays and higher medical costs.

A Sodium Oxychlorosene-Based Infection Prevention Protocol Safely Decreases Postoperative Wound Infections in Adult Spinal Deformity Surgery

INTRODUCTION

This study sought to determine the efficacy of a complex multi-institutional sodium oxychlorosene-based infection protocol for decreasing the rate of surgical site infection after instrumented spinal surgery for adult spinal deformity (ASD). Infection prevention protocols have not been previously studied in ASD patients.

METHODS

A retrospective analysis was performed of patients who underwent posterior instrumented spinal fusion of the thoracic or lumbar spine for deformity correction between January 1, 2011, and May 31, 2019. The efficacy of a multi-modal infection prevention protocol was examined. The infection prevention bundle consisted of methicillin-resistant Staphylococcus aureus testing, chlorhexidine gluconate bathing preoperatively, sodium oxychlorosene rinse, vancomycin powder placement, and surgical drain placement at the time of surgery.

RESULTS

About 254 patients fit the inclusion criteria. Among these patients, nine (3.5%) experienced post-surgical deep-wound infection. Demographics and surgical characteristics amongst infected and non-infected cohorts were similar, although diabetes trended towards being more prevalent in patients who developed a postoperative wound infection (p=0.07). Among 222 patients (87.4%) who achieved a minimum of two years of follow-ups, 184 patients (82.9%) experienced successful fusion, comparing favorably with pseudarthrosis rates in the ASD literature. Rates of pseudarthrosis and proximal junction kyphosis were similar amongst infected and non-infected patients.

CONCLUSION

An intraoperative comprehensive sodium oxychlorosene-based infection prevention protocol helped to provide a low rate of infection after major deformity correction without negatively impacting other postoperative procedure-related metrics.

Investigating the efficacy of vacuum sealing drainage versus traditional negative pressure drainage in treating deep incision infections following posterior cervical internal fixation-a retrospective cohort study

BACKGROUND

Assessing the efficacy and safety of Vacuum Sealing Drainage (VSD) in treating deep incision infections (DII) following posterior cervical internal fixation.

METHODS

We retrospectively studied the clinical effects of VSD and Traditional Negative Pressure Drainage (TND) on 12 patients with deep incision infection after posterior cervical fixation surgery who were treated in our department from 2012 to 2020. A comparison of patient-related factors (age, gender, BMI, comorbidities, initial internal fixation surgery segment, preoperative laboratory inflammation indicators) and surgical-related factors (postoperative duration of fever, positive rate of drainage fluid bacterial culture, Visual Analogue Scale (VAS) score at 3 days after surgery, laboratory indicators at 3 days after surgery, debridement frequency and drainage time, hospital stay, internal fixation retention rate, and infection recurrence rate) between the VSD group and the TND group was conducted using independent sample t tests to draw experimental conclusions.

RESULTS

This study included 12 patients, with six cases of VSD (5 males and 1 female) and six cases of TND (4 males and 2 females). The VSD group had significantly lower postoperative fever time (1.50 ± 0.46 days vs. 4.28 ± 0.97 days, P < 0.05), a higher positive rate of bacterial cultures in drainage fluid (5/6 vs. 2/6, P < 0.05), lower 3 day VAS scores (3.13 ± 0.83 vs. 3.44 ± 0.88, P < 0.05), lower 3 day CRP levels (66.89 ± 23.65 mg/L vs. 57.11 ± 18.18 mg/L, P < 0.05), a shorter total drainage time (14.50 ± 2.98 days vs. 22.56 ± 3.01 days, P < 0.05), and a higher total drainage flow rate (395.63 ± 60.97 ml vs. 155.56 ± 32.54 ml, P < 0.05) than the TND group (the total drainage volume throughout the entire treatment process). In addition, the frequency of debridement (2.67 ± 0.52 times vs. 3.17 ± 0.41 times, P < 0.05) and average hospital stay (23.13 ± 3.27 days vs. 34.33 ± 6.86 days, P < 0.05) were significantly lower in the VSD group, although both groups retained internal fixation.

CONCLUSIONS

VSD is a secure and effective treatment for deep incision infections that results from cervical posterior internal fixation surgery.

Risk Factors for Postoperative Surgical Site Infection in Patients Undergoing Spinal Tumor Surgery

STUDY DESIGN

A retrospective comparative case-control study.

OBJECTIVE

The aim of this study was to determine the risk factors for postoperative surgical site infection (SSI) in patients with spinal tumors requiring reoperation during the perioperative period.

SUMMARY OF BACKGROUND DATA

SSI is a common postoperative complication of spinal surgery. The occurrence of SSI not only increases the mortality rate but prolongs the patient's hospital stay and increases the medical cost.

METHODS

Included in this study were 202 patients with spinal tumors who received surgical treatment between January 2008 and December 2018, of whom 101 patients who developed SSI and underwent secondary surgery were used as the SSI group, and the other 101 patients with no SSI who were matched with the SSI group by age (±10), pathologic diagnosis (malignant/no-malignant), tumor site (C/T/L/S), surgical approach (anterior/posterior/combined), and surgical team were used as the control group. The clinical data of the 202 patients in both groups were analyzed by logistic regression modeling to identify SSI-associated risk factors.

RESULTS

Multivariate logistic regression analysis showed that the revision status ( B =1.430, P =0.028), the number of spinal levels fused ≥4 ( B =0.963, P =0.006), and the use of bone cement ( B =0.739, P =0.046) were significantly associated with the increased risk of developing postoperative SSI.

CONCLUSIONS

This study identified the revision status, the number of spinal levels fused ≥4, and the use of bone cement as independent risk factors for SSI in patients with spinal tumors who underwent reoperation during the perioperative period.

The correlation of psoriasis and its treatment medications with lumbar discectomy postoperative infections

BACKGROUND CONTEXT

Psoriasis is a chronic, autoimmune disease of the skin that affects approximately 3% of the US adult population. Patients with psoriasis may be predisposed to spine surgical site infections (SSI) related to the condition and/or related medications following surgeries such as lumbar laminotomy/discectomy.

PURPOSE

To assess the potential correlation of psoriasis and its related treatment medications on the risk of infection-related complications after lumbar laminotomy/discectomy.

STUDY DESIGN

Retrospective case control, national administrative database study.

PATIENT SAMPLE

Adult patients who underwent isolated single-level lumbar discectomy between 2010 and Q1 of 2021 were identified in the PearlDiver Mariner Ortho151 national administrative database (excluding those with concurrent diagnoses of fractures, neoplasms, or infections).

OUTCOME MEASURES

Ninety-day postoperative rates of surgical site infection and sepsis.

METHODS

Lumbar laminotomy/discectomy patients with versus without psoriasis were matched 1:4 based on age, sex, and Elixhauser Comorbidity Index. The risk of SSI and sepsis in the 90-day postoperative window between the cohorts were compared with multivariable analyses. Five-year reoperation rates were also compared with log rank test. The matched psoriasis cohort was further subdivided by psoriasis treatment regimens - no medication treatment (NT), topical therapies only (TT), topical therapies with oral systemic treatments (TT/OS), and topical therapies with biologics (TT/B). Multivariable logistic regression was used to assess the risk of SSI and sepsis within 90 days after lumbar laminotomy/discectomy for each treatment subgroup compared to patients without psoriasis.

RESULTS

In total, 2,262 patients with psoriasis who underwent single-level lumbar laminotomy/discectomy were identified and matched by age, sex, and Elixhauser Comorbidity Index to 9,044 patients without psoriasis. Multivariable logistic regression showed that, compared to the patients without psoriasis, patients with psoriasis had a 1.795 times higher chance of developing SSI (odds ratio [OR]) (p<.001) and sepsis (OR: 1.743, p=.027) within 90 days of surgery. Having psoriasis did not significantly correlate with 5-year reoperation rates. Of those with psoriasis, NT subcohort had 1,038 patients, TT subcohort 571 patients, TT/OS subcohort 226 patients, and TT/B subcohort 140 patients. Based on multivariable analysis and compared to nonpsoriasis patients, those in the NT, TT, TT/OS were not at greater odds of postoperative SSI or sepsis. Conversely, those in the TT/B subcohort were at significantly greater odds of SSI (OR: 3.102, p=.019) and sepsis (OR: 6.367, p=.027).

CONCLUSIONS

Of single-level lumbar laminotomy/discectomy patients with psoriasis, only those on topical therapies and biologics were at greater risk of postoperative SSI and sepsis. This subcohort warrants specific attention when undergoing lumbar laminotomy/discectomy and possibly holding such medications for a period prior to surgery may be warranted if possible.

Plastic Surgery Closure of Complex Spinal Wounds

Wound breakdown and infection are common complications after complex spine surgery and may occur in up to 40% of high-risk patients. These are challenging scenarios which can result in a prolonged hospital stay, revision surgery, and elevated costs. Reconstructive specialists can do prophylactic closures for high-risk groups to potentially reduce the risk of developing a wound complication. These plastic surgery techniques often involve multilayered closure, with the addition of local muscle and/or fasciocutaneous flaps. The goal of this study was to review the literature for risks associated with wound complications, identification of high-risk patients, and the advantages of using plastic surgery techniques. In addition, we elaborate on the multilayered and flap closure technique for complex spine surgery which is done at our institution.

Local contamination is a major cause of early deep wound infections following open posterior lumbosacral fusions

PURPOSE

Postoperative surgical site infection in patients treated with lumbosacral fusion has usually been thought to be caused by perioperative contamination. With the proximity of these incisions to the perineum, this study sought to determine if contamination by gastrointestinal and/or urogenital flora should be considered as a major cause of this complication.

METHODS

We conducted a retrospective review of adults treated with open posterior lumbosacral fusions between 2014 and 2021 to identify common factors in deep postoperative infection and the nature of the infecting organisms. Cases of tumor, primary infection and minimally invasive surgery were excluded.

RESULTS

489 eligible patients were identified, 20 of which required debridement deep to the fascia (4.1%). Mean age, operative time, estimated blood loss and levels fused were similar between both groups. The infected group had a significantly higher BMI. The mean time from primary procedure to debridement was 40.8 days. Four patients showed no growth, 3 showed Staphylococcus sp. infection (Perioperative Inside-Out) requiring debridement at 63.5 days. Thirteen showed infection with intestinal or urogenital pathogens (Postoperative Outside-In) requiring debridement at 20.0 days. Postoperative Outside-In infections led to debridement 80.3 days earlier than Perioperative Inside-Out infections (p = 0.007).

CONCLUSIONS

65% of deep infections in patients undergoing open lumbosacral fusion were due to early contamination by pathogens associated with the gastrointestinal and/or urogenital tracts. These required earlier debridement than Staphylococcus sp.

INFECTIONS

There should be renewed focus on keeping these pathogens away from the incision during the early stages of wound healing.

Progress in the study of biomarkers for early prediction of systemic inflammatory response syndrome after percutaneous nephrolithotomy

Urolithiasis is a common and frequent disease in urology. Percutaneous nephrolithotomy (PCNL) is preferred for the treatment of upper urinary tract stones and complicated renal stones &gt;2 cm in diameter, but it has a higher rate of postoperative complications, especially infection, compared with other minimally invasive treatments for urinary stones. Complications associated with infection after percutaneous nephrolithotomy include transient fever, systemic inflammatory response syndrome (SIRS), and sepsis, which is considered one of the most common causes of perioperative death after percutaneous nephrolithotomy. In contrast, SIRS serves as a sentinel for sepsis, so early intervention of SIRS by biomarker identification can reduce the incidence of postoperative sepsis, which in turn reduces the length of stay and hospital costs for patients. In this paper, we summarize traditional inflammatory indicators, novel inflammatory indicators, composite inflammatory indicators and other biomarkers for early identification of systemic inflammatory response syndrome after percutaneous nephrolithotomy.