Deep postoperative spine infection treated by negative pressure therapy in patients with progressive spinal deformities

Tension Pneumocephalus Associated with Negative Pressure Wound Therapy with Instillation and Dwell Time for Methicillin-resistant Staphylococcus aureus Infection After Spinal Deformity Surgery

PURPOSE

Surgical site infection (SSI) is a serious complication after spine surgery. Recently, it has become possible to perform negative pressure wound therapy with instillation and dwell time (NPWTi-d) for postoperative infected wounds. We report the first rare case of symptomatic pneumoencephalopathy following NPWTi-d for methicillin-resistant Staphylococcus aureus (MRSA) infection after spinal deformity surgery.

METHODS

Retrospective review of a patient's medical record and imaging.

RESULTS

A 77-year-old female patient underwent posterior corrective fixation with no intraoperative complications. On the 10th postoperative day, SSI was diagnosed, and debridement was performed. Since MRSA was detected in the wound culture, and a prolonged inflammatory reaction was observed, NPWTi-d was started to preserve the instrumentation. Gradually, good granulation was observed, and the extensive soft tissue defect decreased. On the 29th day after the start of NPWTi-d, the patient experienced sudden headache and neck pain while standing, and head computed tomography led to the diagnosis of symptomatic pneumoencephalopathy. NPWTi-d was discontinued, and when surgery was performed to close the wound, dural injury was found, which was not present at the time of the initial surgery, and dural repair was performed. After 2 weeks of bed rest, the patient's pneumoencephalopathy improved. Three years have passed since the surgery, and no recurrence of cerebrospinal fluid leakage or infection has been observed.

CONCLUSIONS

Although NPWTi-d is a useful treatment for SSI, it is always necessary to pay attention to the development of pneumoencephalopathy and promptly diagnose and treat it because of the risk of life-threatening complications.

Negative Pressure Wound Therapy in Spinal Surgery

Negative pressure wound therapy (NPWT) has demonstrated promise in the management of surgical site infections as well as assisting in surgical wound healing. In this manuscript, we describe the mechanisms and applications of NPWT for surgical wounds and existing evidence for NPWT in cardiac, plastic, and general surgery, followed by a discussion of the emerging evidence base for NPWT in spinal surgery. We also discuss the different applications of NPWT for open wounds and closed incisions, and the promise of newer closed-incision NPWT (ciNPWT) devices. There is nominal but promising prospective evidence on NPWT's efficacy in select at-risk populations for post-operative wound complications after spinal surgery. As there is currently a paucity of robust clinical evidence on its efficacy, rigorous randomized prospective clinical trials are needed.

Short-term outcome of double-shelled braces in neuromuscular scoliosis

INTRODUCTION

Scoliosis in patients with neuromuscular disease is a common issue and leads to secondary impairment. It is thus important to help such patients to regain and retain best possible stability to improve their quality of life. One option is the double-shelled brace (DSB). The aim of this study was to provide information on the degree of correction when using a DSB on patients with neuromuscular scoliosis.

METHODS

We included patients with neuromuscular scoliosis treated with double-shelled braces in this retrospective study. Radiographs of the full spine were taken with and without the DSB, the Cobb angles were measured and compared. The correction was expressed in percent of the lumbar and thoracic Cobb angles. In addition, compounding factors such as age, sex, type of the curves, and movement disorder were included.

RESULTS

We analyzed data from 84 patients with scoliosis with different neuromuscular disorders. The mean age was 12.3 years (± 5.9). In the lumbar spine we detected an improvement of 27.5% (SD ± 32.9), in the thoracic spine 25.3% (SD ± 38.0).

INTERPRETATION

Short-term corrections with a double-shelled brace in neuromuscular scoliosis present an average improvement of one fourth of the lumbar and thoracic Cobb angles and, independent of age, sex, movement disorder, shape or type of the curve. Only spasticity has an influence on the lumbar scoliosis outcome.

Continuous local antibiotic perfusion for patients with surgical site infection after instrumented spinal surgery; a novel technique to retain the implants

OBJECTIVES

To describe the novel technique of continuous local antibiotic perfusion (CLAP) for a surgical site infection (SSI) after instrumented spinal surgery.

METHODS

CLAP was applied to 4 continuous patients at our institution who developed SSI after instrumented spinal surgery.

RESULTS

All 4 patients were successfully treated and the infection was controlled. The implant was retained in all patients. The duration of CLAP ranged from 2 to 3 weeks. The blood level of the antibiotic used (gentamicin) at 1 week after the initiation of CLAP did not increase in any patient. No other adverse events occurred in any patient. Dramatic improvements in laboratory parameters, including the white blood cell (WBC) counts and C-reactive protein (CRP) levels were seen in every patient at 1 week after the initiation of CLAP.

CONCLUSIONS

CLAP controlled the infection without severe adverse events in all 4 patients, and the implants were retained. Despite its cost and the discomfort of patients, CLAP may become an option for the treatment of SSIs after instrumented spinal surgery. A large number of case series are needed to verify the efficacy of CLAP for patients with SSIs after instrumented spinal surgery.

The use of incisional vacuum-assisted closure system following one-stage incision suture combined with continuous irrigation to treat early deep surgical site infection after posterior lumbar fusion with instrumentation

Background

Previous reports concerning deep surgical site infection (SSI) after posterior spinal instrumentation treated with vacuum-assisted closure (VAC) system indicated that most patients must suffer from a delayed incision suture. To date, there are no published reports about the application of incisional VAC following a one-stage incision suture in the treatment of spinal infections. The purpose of this study was to evaluate the feasibility and efficacy of using an incisional VAC system following a one-stage incision suture combined with continuous irrigation to treat early deep SSI after posterior lumbar fusion with instrumentation.

Methods

Twenty-one patients who were identified as early deep SSI after posterior lumbar fusion with instrumentation were treated by incisional VAC following a one-stage incision suture combined with continuous irrigation at our spine surgery center between January 2014 and March 2020. Detailed data from medical records were collected and analyzed, including age, gender, primary diagnosis, original operation, number of VAC dressing changes, duration of continuous irrigation, hospital stay, risk factors for infection, bacteria type, and laboratory data. Clinical efficacy was assessed using the pre- and postoperative visual analog scale (VAS) for back pain and Kirkaldy-Willis functional criteria by regular follow-up.

Results

All the patients were cured and retained implants with an average of 1.9 times of VAC dressing replacement, and an average of 10.2 days of continuous irrigation. There were significant differences between pre-operation and post-operation in ESR, CRP, and VAS score of back pain, respectively (P < 0.05). The satisfactory rate was 90.5% according to Kirkaldy-Willis functional criteria. One patient developed a back skin rash with itching around the wound because of long-time contact with the VAC dressing. There was no recurrent infection or other complications during follow-up.

Conclusions

Our preliminary results support that the treatment protocol is feasible and effective to treat early deep SSI following posterior lumbar fusion with instrumentation.

Surgical Site Infection Prophylaxis and Wound Management in Spine Surgery

Surgical site infection (SSI) is a potentially devastating complication of spinal surgery that increases patient morbidity and healthcare costs. SSIs have complex and multifactorial etiologies; therefore, there are numerous opportunities for prevention and risk mitigation. The aim of this narrative review was to describe the incidence, risk factors, and outcomes of SSIs in spine surgery with an emphasis on postoperative wound care. We list and describe the preoperative, intraoperative, and postoperative evidence-based interventions that can be applied to potentially prevent SSI after spinal surgery.

Negative Pressure Wound Therapy in children: A 25 cases series

Negative Pressure Wound Therapy is a device applied to a wound that causes local depression. There are a few series showing the effectiveness of this treatment in Pediatric. The objective of this work is to try to clarify the indications in children. This is a retrospective series of 25 children between 2004 and 2019. The inclusion criteria were all children with a wound treated with Negative Pressure Wound Therapy. The characteristics retained were their age, the context of occurrence, the treatment time, the depression applied, the technique of skin covering wound and the average healing time. We included 25 patients. The average age was 8.8 years. The context of the wound occurrence was mainly a road (44%) or a domestic (36%) accident. Substance losses were mainly located in the lower limb (84%). The depression applied was -90mmHg. The healing time was 18.4 days. Thin skin grafting was the main method chosen (88%). No complications related to Negative Pressure Wound Therapy equipment have been identified. Despite the weakness of the literature and the lack of consensus regarding its use, Negative Pressure Wound Therapy is an essential therapy in pediatric. It is a simple and effective technique in children. It can reduce the need for flaps coverage, even in the event of exposure of noble elements. The flaps should not, however, be excluded from the decision-making algorithm, on pain of complications or sequelae.

Sublaminar polyester bands for the correction of idiopathic and neuromuscular scoliosis

Recent literature suggests that sublaminar bands (SB) can provide good coronal plane correction, comparable to pedicle screw constructs, as well as good correction in the sagittal plane, even in patients with preoperative hypokyphosis; comparable results have been reported in patients with adolescent idiopathic scoliosis (AIS) and in patients with neuromuscular scoliosis (NMS). Two types of SB constructs can be performed: the band-only construct, indicated for non-ambulatory patients with NMS, and the hybrid construct indicted for ambulatory patients with NMS and for patients with AIS. SB are made of polyester or acrylic material and do provide a safe alternative to sublaminar Luque-type wires (stainless steel) as well as an increased contact area between SB and bone allowing higher corrective forces and reduced laminar fracture risk; the use of SB is not associated with increased risk of neurological injury nor with an increased risk of deep postoperative infection. SB used in a hybrid or in a band-only construct in patients with AIS and NMS, appear to be safe in a trained surgeon hands and can achieve well-balanced spine in both coronal and sagittal planes. This article aimed to provide a review of how SB can restore normal frontal and sagittal spine alignment in patients with AIS and NMS.