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Stoehr JR, Le NK, Urban D, Koussayer B, Kuykendall L, Hayman E, Troy JS. Reducing drain use with paraspinal muscle flaps for spinal closures: A retrospective cohort study. J Plast Reconstr Aesthet Surg 2023; 87:83-90. [PMID: 37826967 DOI: 10.1016/j.bjps.2023.09.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 08/15/2023] [Accepted: 09/12/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Paraspinal muscle (PSM) flaps can be mobilized with superficial undermining and lateral release from the thoracolumbar fascia and/or deep undermining and medial release from the transverse processes and ribs. The objective of the study was to compare the effect of the PSM flap technique on drain use, retention, and complication rates. METHODS A retrospective chart review was performed for patients who underwent spinal coverage with PSM flaps at a single institution from April 2020 to June 2021. Patient demographics, preoperative comorbidities, surgical technique, drain usage, and postoperative complications were analyzed to compare the effects of different PSM flap surgical techniques on postoperative drain use and complications. RESULTS Sixty patients were included. Both superficial and deep releases were performed in half (47%) of the cases, while the remainder was split between superficial (25%) and deep (28%) releases. Drains were used less frequently for the deep release (35%) than the superficial (93%) or both releases (96%, p < 0.01). The deep release had shorter mean drain retention time (5.8 days) than the superficial (30.3 days) or both releases (24.8 days, p < 0.01). There were no significant differences between the techniques in terms of complications. For the deep release, the use of drains was not associated with a reduction in complications (odds ratio 0.91 [0.84 - 0.98], p = 0.97). CONCLUSIONS In a selected patient population, a "deep release only" PSM flap technique may allow for drainless spinal closure without an increased risk of seroma or other complications.
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Affiliation(s)
- Jenna R Stoehr
- Department of Plastic Surgery, University of South Florida, Tampa, FL, USA
| | - Nicole K Le
- Department of Plastic Surgery, University of South Florida, Tampa, FL, USA
| | - DaKota Urban
- Department of Plastic Surgery, University of South Florida, Tampa, FL, USA
| | - Bilal Koussayer
- Department of Plastic Surgery, University of South Florida, Tampa, FL, USA
| | - Lauren Kuykendall
- Department of Plastic Surgery, University of South Florida, Tampa, FL, USA
| | - Erik Hayman
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - Jared S Troy
- Department of Plastic Surgery, University of South Florida, Tampa, FL, USA.
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Shah NV, Coste M, Wolfert AJ, Gedailovich S, Ford B, Kim DJ, Kim NS, Ikwuazom CP, Patel N, Dave AM, Passias PG, Schwab FJ, Lafage V, Paulino CB, Diebo BG. The Impact of Prematurity at Birth on Short-Term Postoperative Outcomes Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis. J Clin Med 2023; 12:jcm12031210. [PMID: 36769858 PMCID: PMC9917850 DOI: 10.3390/jcm12031210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/20/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
Prematurity is associated with surgical complications. This study sought to determine the risk of prematurity on 30-day complications, reoperations, and readmissions following ≥7-level PSF for AIS which has not been established. Utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)-Pediatric dataset, all AIS patients undergoing ≥7-level PSF from 2012-2016 were identified. Cases were 1:1 propensity score-matched to controls by age, sex, and number of spinal levels fused. Prematurity sub-classifications were also evaluated: extremely (<28 weeks), very (28-31 weeks), and moderate-to-late (32-36 weeks) premature. Univariate analysis with post hoc Bonferroni compared demographics, hospital parameters, and 30-day outcomes. Multivariate logistic regression identified independent predictors of adverse 30-day outcomes. 5531 patients (term = 5099; moderate-to-late premature = 250; very premature = 101; extremely premature = 81) were included. Premature patients had higher baseline rates of multiple individual comorbidities, longer mean length of stay, and higher 30-day readmissions and infections than the term cohort. Thirty-day readmissions increased with increasing prematurity. Very premature birth predicted UTIs, superficial SSI/wound dehiscence, and any infection, and moderate-to-late premature birth predicted renal insufficiency, deep space infections, and any infection. Prematurity of AIS patients differentially impacted rates of 30-day adverse outcomes following ≥7-level PSF. These results can guide preoperative optimization and postoperative expectations.
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Affiliation(s)
- Neil V. Shah
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Marine Coste
- Department of General Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Adam J. Wolfert
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Samuel Gedailovich
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Brian Ford
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT 06030, USA
| | - David J. Kim
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Nathan S. Kim
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Chibuokem P. Ikwuazom
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Neil Patel
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Amanda M. Dave
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Peter G. Passias
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY 10010, USA
| | - Frank J. Schwab
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY 10075, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY 10075, USA
| | - Carl B. Paulino
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY 11203, USA
- Department of Orthopaedic Surgery, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY 11215, USA
- Correspondence:
| | - Bassel G. Diebo
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY 11203, USA
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, East Providence, RI 02903, USA
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Best Practice Guidelines for Surgical Site Infection in High-risk Pediatric Spine Surgery: Definition, Prevention, Diagnosis, and Treatment. J Pediatr Orthop 2022; 42:e1008-e1017. [PMID: 36037438 DOI: 10.1097/bpo.0000000000002255] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Prior "best practice guidelines" (BPG) have identified strategies to reduce the risk of acute deep surgical site infection (SSI), but there still exists large variability in practice. Further, there is still no consensus on which patients are "high risk" for SSI and how SSI should be diagnosed or treated in pediatric spine surgery. We sought to develop an updated, consensus-based BPG informed by available literature and expert opinion on defining high-SSI risk in pediatric spine surgery and on prevention, diagnosis, and treatment of SSI in this high-risk population. MATERIALS AND METHODS After a systematic review of the literature, an expert panel of 21 pediatric spine surgeons was selected from the Harms Study Group based on extensive experience in the field of pediatric spine surgery. Using the Delphi process and iterative survey rounds, the expert panel was surveyed for current practices, presented with the systematic review, given the opportunity to voice opinions through a live discussion session and asked to vote regarding preferences privately. Two survey rounds were conducted electronically, after which a live conference was held to present and discuss results. A final electronic survey was then conducted for final voting. Agreement ≥70% was considered consensus. Items near consensus were revised if feasible to achieve consensus in subsequent surveys. RESULTS Consensus was reached for 17 items for defining high-SSI risk, 17 items for preventing, 6 for diagnosing, and 9 for treating SSI in this high-risk population. After final voting, all 21 experts agreed to the publication and implementation of these items in their practice. CONCLUSIONS We present a set of updated consensus-based BPGs for defining high-risk and preventing, diagnosing, and treating SSI in high-risk pediatric spine surgery. We believe that this BPG can limit variability in practice and decrease the incidence of SSI in pediatric spine surgery. LEVEL OF EVIDENCE Not applicable.
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Reier L, Fowler JB, Arshad M, Siddiqi J. Drains in Spine Surgery for Degenerative Disc Diseases: A Literature Review to Determine Its Usage. Cureus 2022; 14:e23129. [PMID: 35464540 PMCID: PMC9001810 DOI: 10.7759/cureus.23129] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/13/2022] [Indexed: 11/21/2022] Open
Abstract
No guidelines currently exist for surgeons to follow regarding drain use after spine surgery for degenerative disc disease. Therefore, we conducted a literature review to determine what situations warrant drain placement versus those which do not. When placed, we further investigate optimal drain duration. The goal of this article is to provide spine surgeons insight into the current literature and guidance when deciding if a drain should be used or discontinued. We performed a PubMed search and analyzed 44peer-reviewed journal articles. Only studies that had the full article available were included. The highest-quality studies that were reviewed, demonstrated that in most situations using a drain is not associated with superior outcomes. It revealed that when drains are retained for a longer duration they run a greater risk of surgical site infection (SSI). Additionally, drains are associated with increased blood loss, a greater chance of requiring blood transfusions, and longer hospital stays. We conclude that drains are currently being overused in spine surgery for cases of degenerative disc disease, which exposes patients to unnecessary complications while providing minimal benefit.
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Hamilton J, Mohamed M, Witt B, Wimmer M, Shafikhani S. Therapeutic assessment of N-formyl-methionyl-leucyl-phenylalanine (fMLP) in reducing periprosthetic joint infection. Eur Cell Mater 2021; 42:122-138. [PMID: 34435345 PMCID: PMC8459619 DOI: 10.22203/ecm.v042a09] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Despite many preventive measures, including prophylactic antibiotics, periprosthetic joint infection (PJI) remains a devastating complication following arthroplasty, leading to pain, suffering, morbidity and substantial economic burden. Humans have a powerful innate immune system that can effectively control infections, if alerted quickly. Unfortunately, pathogens use many mechanisms to dampen innate immune responses. The study hypothesis was that immunomodulators that can jumpstart and direct innate immune responses (particularly neutrophils) at the surgical site of implant placement would boost immune responses and reduce PJI, even in the absence of antibiotics. To test this hypothesis, N-formyl-methionyl-leucyl-phenylalanine (fMLP) (a potent chemoattractant for phagocytic leukocytes including neutrophils) was used in a mouse model of PJI with Staphylococcus aureus (S. aureus). Mice receiving intramedullary femoral implants were divided into three groups: i) implant alone; ii) implant + S. aureus; iii) implant + fMLP + S. aureus. fMLP treatment reduced S. aureus infection levels by ~ 2-Log orders at day 3. Moreover, fMLP therapy reduced infection-induced peri-implant periosteal reaction, focal cortical loss and areas of inflammatory infiltrate in mice distal femora at day 10. Finally, fMLP treatment reduced pain behaviour and increased weight-bearing at the implant leg in infected mice at day 10. Data indicated that fMLP therapy is a promising novel approach for reducing PJI, if administered locally at surgical sites. Future work will be toward further enhancement and optimisation of an fMLP-based therapeutic approach through combination with antibiotics and/or implant coating with fMLP.
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Affiliation(s)
- J.L. Hamilton
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL 60612-3806, USA,Department of Internal Medicine, Rush University Medical Center, Chicago, IL 60612-3806, USA
| | - M.F. Mohamed
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL 60612-3806, USA
| | - B.R. Witt
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL 60612-3806, USA
| | - M.A. Wimmer
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL 60612-3806, USA,Department of Internal Medicine, Rush University Medical Center, Chicago, IL 60612-3806, USA
| | - S.H. Shafikhani
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL 60612-3806, USA,Microbial Pathogens and Immunity, Rush University Medical Center, Chicago, IL 60612-3806, USA,Cancer Center, Rush University Medical Center, Chicago, IL 60612-3806, USA,Address for correspondence: Sasha H. Shafikhani, Department of Medicine, Division of Hematology, Oncology and Cell Therapy, Department of Microbial Pathogens and Immunity, Cancer Center, Rush University Medical Center, 1735 W. Harrison Street, Chicago, IL 60612-3806, USA. Telephone number: +1 3129421368
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Li ZE, Lu SB, Kong C, Sun WZ, Wang P, Zhang ST. Comparative short-term outcomes of enhanced recovery after surgery (ERAS) program and non-ERAS traditional care in elderly patients undergoing lumbar arthrodesis: a retrospective study. BMC Musculoskelet Disord 2021; 22:283. [PMID: 33731057 PMCID: PMC7968191 DOI: 10.1186/s12891-021-04166-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 03/11/2021] [Indexed: 02/06/2023] Open
Abstract
Background Enhanced recovery after surgery (ERAS) program is an evidence-based improvement over non-ERAS traditional care. The aim of the present study was to analyze the safety, feasibility, and efficacy of an ERAS program in patients over 70 years undergoing lumbar arthrodesis by comparison with non-ERAS traditional care. Methods During January 2018 to December 2018, patients enrolled received non-ERAS traditional care, while the ERAS program was implemented from January to December 2019. Demographic characteristics, comorbidities, surgical data and postoperative recovery parameters were collected from all patients. Postoperative pain scores were evaluated by visual analog scales (VAS). The clinical outcomes were length of stay (LOS), postoperative complications and postoperative pain scores. Compliance results were also collected. Result A total of 127 patients were enrolled, including 67 patients in the non-ERAS traditional care group and 60 patients in the ERAS group. The demographic characteristics and comorbidities of the two groups showed no significant differences. The LOS of patients treated with ERAS program (13.6 ± 4.0 days) was significantly less than that of patients treated with non-ERAS traditional care (15.6 ± 3.9 days) (p = 0.034). Complication rate was 8.3% in the ERAS group versus 20.9% in the non-ERAS traditional care group (p = 0.048). VAS (back) in the ERAS group was significantly lower on postoperative day (POD) 1 and POD2. Postoperative recovery parameters were improved in the ERAS group. The overall compliance with the ERAS program was 94%. Conclusions Based on our results, ERAS program is safer and more effective for elderly patients over 70 undergoing lumbar arthrodesis than non-ERAS traditional care.
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Affiliation(s)
- Zhong-En Li
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Beijing, China.,Capital Medical University, Beijing, China
| | - Shi-Bao Lu
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China. .,National Clinical Research Center for Geriatric Diseases, Beijing, China.
| | - Chao Kong
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Beijing, China.,Capital Medical University, Beijing, China
| | - Wen-Zhi Sun
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Beijing, China.,Capital Medical University, Beijing, China
| | - Peng Wang
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Beijing, China.,Capital Medical University, Beijing, China
| | - Si-Tao Zhang
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Beijing, China
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Warren DK, Nickel KB, Han JH, Tolomeo P, Hostler CJ, Foy K, Banks IR, Fraser VJ, Olsen MA. Postdischarge antibiotic use for prophylaxis following spinal fusion. Infect Control Hosp Epidemiol 2020; 41:789-798. [PMID: 32366333 PMCID: PMC7641990 DOI: 10.1017/ice.2020.117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Despite recommendations to discontinue prophylactic antibiotics after incision closure or <24 hours after surgery, prophylactic antibiotics are continued after discharge by some clinicians. The objective of this study was to determine the prevalence and factors associated with postdischarge prophylactic antibiotic use after spinal fusion. DESIGN Multicenter retrospective cohort study. PATIENTS This study included patients aged ≥18 years undergoing spinal fusion or refusion between July 2011 and June 2015 at 3 sites. Patients with an infection during the surgical admission were excluded. METHODS Prophylactic antibiotics were identified at discharge. Factors associated with postdischarge prophylactic antibiotic use were identified using hierarchical generalized linear models. RESULTS In total, 8,652 spinal fusion admissions were included. Antibiotics were prescribed at discharge in 289 admissions (3.3%). The most commonly prescribed antibiotics were trimethoprim/sulfamethoxazole (22.1%), cephalexin (18.8%), and ciprofloxacin (17.1%). Adjusted for study site, significant factors associated with prophylactic discharge antibiotics included American Society of Anesthesiologists (ASA) class ≥3 (odds ratio [OR], 1.31; 95% CI, 1.00-1.70), lymphoma (OR, 2.57; 95% CI, 1.11-5.98), solid tumor (OR, 3.63; 95% CI, 1.62-8.14), morbid obesity (OR, 1.64; 95% CI, 1.09-2.47), paralysis (OR, 2.38; 95% CI, 1.30-4.37), hematoma/seroma (OR, 2.93; 95% CI, 1.17-7.33), thoracic surgery (OR, 1.39; 95% CI, 1.01-1.93), longer length of stay, and intraoperative antibiotics. CONCLUSIONS Postdischarge prophylactic antibiotics were uncommon after spinal fusion. Patient and perioperative factors were associated with continuation of prophylactic antibiotics after hospital discharge.
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Affiliation(s)
- David K. Warren
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Katelin B. Nickel
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Jennifer H. Han
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Pam Tolomeo
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher J. Hostler
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, NC, USA
- Infectious Diseases Section, Durham VA Health Care System, Durham, NC, USA
| | - Katherine Foy
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, NC, USA
| | - Ian R. Banks
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Victoria J. Fraser
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Margaret A. Olsen
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
- Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
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Prophylactic postoperative measures to minimize surgical site infections in spine surgery: systematic review and evidence summary. Spine J 2020; 20:435-447. [PMID: 31557586 DOI: 10.1016/j.spinee.2019.09.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/12/2019] [Accepted: 09/13/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND CONTEXT There are three phases in prophylaxis of surgical site infections (SSI): preoperative, intraoperative and postoperative. There is lack of consensus and paucity of evidence with SSI prophylaxis in the postoperative period. PURPOSE To systematically evaluate the literature, and provide evidence-based summaries on postoperative measures for SSI prophylaxis in spine surgery. STUDY DESIGN Systematic review, meta-analysis, evidence synthesis. METHODS A systematic review conforming to PRIMSA guidelines was performed utilizing PubMed (MEDLINE), EMBASE, and the Cochrane Database from inception to January 2019. The GRADE approach was used for quality appraisal and synthesis of evidence. Six postoperative care domains with associated key questions were identified. Included studies were extracted into evidence tables, data synthesized quantitatively and qualitatively, and evidence appraised per GRADE approach. RESULTS Forty-one studies (nine RCT, 32 cohort studies) were included. In the setting of preincisional antimicrobial prophylaxis (AMP) administration, use of postoperative AMP for SSI reduction has not been found to reduce rate of SSI in lumbosacral spine surgery. Prolonged administration of AMP for more than 48 hours postoperatively does not seem to reduce the rate of SSI in decompression-only or lumbar spine fusion surgery. Utilization of wound drainage systems in lumbosacral spine and adolescent idiopathic scoliosis corrective surgery does not seem to alter the overall rate of SSI in spine surgery. Concomitant administration of AMP in the presence of a wound drain does not seem to reduce the overall rate of SSI, deep SSI, or superficial SSI in thoracolumbar fusion performed for degenerative and deformity spine pathologies, and in adolescent idiopathic scoliosis corrective surgery. Enhanced-recovery after surgery clinical pathways and infection-specific protocols do not seem to reduce rate of SSI in spine surgery. Insufficient evidence exists for other types of spine surgery not mentioned above, and also for non-AMP pharmacological measures, dressing type and duration, suture and staple management, and postoperative nutrition for SSI prophylaxis in spine surgery. CONCLUSIONS Despite the postoperative period being key in SSI prophylaxis, the literature is sparse and without consensus on optimum postoperative care for SSI prevention in spine surgery. The current best evidence is presented with its limitations. High quality studies addressing high risk cohorts such as the elderly, obese, and diabetic populations, and for traumatic and oncological indications are urgently required.
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Measures to reduce end-of-case wound contamination: the impact of intra-wound vancomycin powder and betadine irrigation on surgical site infections in posterior spinal fusion. Spine Deform 2020; 8:45-50. [PMID: 31981142 DOI: 10.1007/s43390-020-00033-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 07/11/2019] [Indexed: 10/25/2022]
Abstract
STUDY DESIGN Retrospective descriptive, single-center study. OBJECTIVES To determine the effect of standardized intrawound vancomycin powder and betadine irrigation on surgical site infection (SSI) rates after posterior spinal fusion (PSF) in idiopathic scoliosis. Since 2005, our pediatric spine center has implemented a series of changes to lower the risk of SSI. The most recent interventions-intrawound vancomycin powder and betadine irrigation-are applied just before closure, aiming to reduce the culture-positive bacterial contamination known to occur in many cases. We sought to determine the impact of these end-of-case measures on our center's SSI rate. METHODS We retrospectively reviewed patients who underwent PSF for idiopathic scoliosis at our institution from January 1, 2010, to June 30, 2018, identifying all cases that returned to the operating room for surgical debridement within 90 days of PSF. Cases were surgeon-audited to ensure inclusion of all infections that met Centers for Disease Control and Prevention (CDC) criteria for acute SSI. Vertical expandable prosthetic titanium ribs, growing rods, staged procedures, and nonidiopathic cases were excluded. Annual rates of SSIs were correlated with the initiation of each SSI prevention measure. RESULTS Among 740 cases of PSF for idiopathic scoliosis from 2010 to 2018, the overall acute SSI rate by CDC criteria was 0.68%. The idiopathic SSI rate dropped significantly, from 1.70 to 0.20%, after the standardized introduction of intrawound vancomycin powder and betadine irrigation before closure (p < 0.04). The implementation of these end-of-case measures in 2012-2013 was soon followed by an institution best 3.5-year SSI-free period for idiopathic cases. CONCLUSIONS Since intrawound vancomycin powder and betadine irrigation were added to our SSI prevention bundle, we have seen a significantly lower SSI rate after PSFs for idiopathic scoliosis. These findings suggest that anti-SSI interventions to reduce wound contamination at the end of the case may have a particularly positive impact on SSI reduction. LEVEL OF EVIDENCE Level III, therapeutic.
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Abstract
STUDY DESIGN A systematic review and meta-analysis. OBJECTIVE The objective of this study was to investigate the incidence of surgical site infection (SSI) in patients following spine surgery and the rate of microorganisms in these cases. SUMMARY OF BACKGROUND DATA Many studies have investigated the incidence and risk factors of SSI following spinal surgery, whereas no meta-analysis studies have been conducted regarding the comprehensive epidemiological incidence of SSI after spine surgery. METHODS We searched the PubMed, Embase, and Cochrane Library databases for relevant studies that reported the incidence of SSI after spine surgery, and manually screened reference lists for additional studies. Relevant incidence estimates were calculated. Subgroup analysis, sensitivity analysis, and publication bias assessment were also performed. RESULTS Our meta-analysis included 27 studies, with 603 SSI cases in 22,475 patients. The pooled SSI incidence was 3.1%. Subgroup analysis revealed that the incidence of superficial SSI was 1.4% and the incidence of deep SSI was 1.7%. Highest incidence (13.0%) was found in patients with neuromuscular scoliosis among the different indications. The incidences of SSI in cervical, thoracic, and lumbar spine were 3.4%, 3.7%, and 2.7%, respectively. Compared with posterior approach surgery (5.0%), anterior approach showed a lower incidence (2.3%) of SSI. Instrumented surgery had a higher incidence of SSI than noninstrumented surgery (4.4% vs. 1.4%). Patients with minimally invasive surgery (1.5%) had a lower SSI incidence than open surgery (3.8%). Lower incidence of SSI was found when vancomycin powder was applied locally during the surgery (1.9%) compared with those not used (4.8%). In addition, the rates of Staphylococcus aureus, Staphylococcus epidermidis, and methicillin-resistant Staphylococci in microbiological culture results were 37.9%, 22.7%, and 23.1%, respectively. CONCLUSION The pooled incidence of SSI following spine surgery was 3.1%. These figures may be useful in the estimation of the probability of SSI following spine surgery. LEVEL OF EVIDENCE 3.
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Yaszay B, Bartley CE, Sponseller PD, Abel M, Cahill PJ, Shah SA, Miyanji F, Samdani AF, Daquino C, Newton PO. Major complications following surgical correction of spine deformity in 257 patients with cerebral palsy. Spine Deform 2020; 8:1305-1312. [PMID: 32720268 PMCID: PMC7384279 DOI: 10.1007/s43390-020-00165-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 06/25/2020] [Indexed: 12/02/2022]
Abstract
STUDY DESIGN Observational. OBJECTIVES To report on the rate of major complications following spinal fusion and instrumentation to treat spinal deformity in patients with cerebral palsy (CP). Understanding the risk of major complications following the surgical treatment of spine deformities in patients with CP is critical. METHODS A prospectively collected, multicenter database of patients with CP who had surgical correction of their spinal deformity (scoliosis or kyphosis) was reviewed for all major complications. Patients with ≥ 2 year follow-up or who died ≤ 2 years of surgery were included. A complication was defined as major if it resulted in reoperation, re-admission to the hospital, prolongation of the hospital stay, was considered life-threatening, or resulted in residual disability. Overall complication and revision rates were calculated for the perioperative (Peri-op; occurring ≤ 90 days postoperative) and delayed postoperative (Delayed; > 90 days) time periods. RESULTS Two hundred and fifty-seven patients met inclusion. Seventy-eight (30%) patients had a major complication, 18 (7%) had > 1. There were 92 (36%) major complications; 64 (24.9%) occurred Peri-op. The most common Peri-op complications were wound (n = 16, 6.2%) and pulmonary issues (n = 28, 10.9%), specifically deep infections (n = 12, 4.7%) and prolonged ventilator support (n = 21, 8.2%). Delayed complications (n = 28, 10.9%) were primarily deep infections (n = 8, 3.1%) and instrumentation-related (n = 6, 2.3%). There were 42 additional surgeries for an overall unplanned return to the operating room rate of 16% (Peri-op: 8.6%, Delayed: 7.8%). Thirty-six (14.0%) reoperations were spine related surgeries (wound or instrumentation-related). Eleven (4.3%) patients died between 3 months to 5.6 years postoperatively; 4 occurred ≤ 1 year of surgery. Two deaths were directly related to the spinal deformity surgery. CONCLUSION Spinal deformity surgery in CP patients with greater than 2 years of follow-up have a postoperative major complication rate of 36% with a spine-related reoperation rate of 14.0%. LEVEL OF EVIDENCE Therapeutic-IV.
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Affiliation(s)
- Burt Yaszay
- Division of Orthopedics and Scoliosis, Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA. .,Department of Orthopedics, University of California, San Diego, CA, USA.
| | - Carrie E. Bartley
- Division of Orthopedics and Scoliosis, Rady Children’s Hospital, 3020 Children’s Way, MC 5062, San Diego, CA 92123 USA
| | - Paul D. Sponseller
- Department of Orthopedics, Johns Hopkins Children’s Center, Baltimore, MD USA
| | - Mark Abel
- Department of Orthopedics, University of Virginia Medical Center, Charlottesville, VA USA
| | - Patrick J. Cahill
- Department of Orthopedics, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Suken A. Shah
- Nemours Alfred I. duPont Hospital for Children, Wilmington, DE USA
| | - Firoz Miyanji
- Department of Orthopedics, British Columbia Children’s Hospital, Vancouver, BC Canada
| | - Amer F. Samdani
- Department of Orthopedics, British Columbia Children’s Hospital, Vancouver, BC Canada
| | - Carlie Daquino
- Division of Orthopedics and Scoliosis, Rady Children’s Hospital, 3020 Children’s Way, MC 5062, San Diego, CA 92123 USA
| | - Peter O. Newton
- Division of Orthopedics and Scoliosis, Rady Children’s Hospital, 3020 Children’s Way, MC 5062, San Diego, CA 92123 USA ,Department of Orthopedics, University of California, San Diego, CA USA
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Prolonged Post-surgical Drain Retention Increases Risk for Deep Wound Infection After Spine Surgery. World Neurosurg 2019; 130:e846-e853. [DOI: 10.1016/j.wneu.2019.07.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 06/30/2019] [Accepted: 07/01/2019] [Indexed: 01/25/2023]
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Common Elements in Surgical Site Infection Care Bundles for Adolescent Idiopathic Scoliosis at North American Pediatric Institutions: A Survey of POSNA QSVI Challenge Participants. J Pediatr Orthop 2019; 39:e514-e519. [PMID: 31157753 DOI: 10.1097/bpo.0000000000001328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgical site infection (SSI) following posterior spinal fusion for idiopathic scoliosis is a difficult complication, with little information published regarding the best preventative comprehensive care plan. The Spine Subgroup of the Quality, Safety, Value Initiative (QSVI) committee of the Pediatric Orthopaedic Society of North America undertook a survey to generate an overview of bundle elements in comprehensive SSI care bundles across institutions in North America. The purpose of this study was to develop a toolkit of SSI care bundle elements that could be used in developing future SSI care bundles. METHODS A survey email was sent to pediatric orthopaedic surgeons requesting a copy of the SSI prevention care bundle used in their practice. Surgeons were included if they had participated in the 2016 POSNA QSVI challenge, indicated they performed pediatric spine surgery, and had a spine SSI bundle. These bundles were evaluated by the QSVI committee and divided into preoperative, intraoperative, and postoperative elements with the frequency of use of each element recorded. A follow-up qualitative questionnaire was sent assessing the implementation and development of these SSI bundles. RESULTS In total, 16 care bundles from 15 different institutions were included for review. The response rate for this survey was 44% of individuals (50/113 QSVI challenge participants) and 43% (15/35) of unique institutions. The most common elements included: use of preoperative antibiotics, use of preoperative chlorhexidine wipes, use of wound irrigation intraoperatively, and a standardized prescription for the length of postoperative antibiotic. Each of these elements was included in ≥75% of the SSI bundles evaluated. CONCLUSIONS SSI care bundles are increasingly being used by pediatric institutions to lower the risk of SSI following pediatric spinal surgery. This study provides an overview of various care elements used in established SSI care bundles across multiple institutions in North America. It is hoped this data will provide institutions interested in developing their own SSI care bundle with useful information for beginning this process. LEVEL OF EVIDENCE Level V-Decision Analysis.
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Worm PV, Finger G, Brasil AVB, Teles AR. Postoperative Supine Position Increases the Risk of Infection After Spinal Surgery by Posterior Approach. World Neurosurg 2019; 126:e580-e585. [PMID: 30831303 DOI: 10.1016/j.wneu.2019.02.098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 02/10/2019] [Accepted: 02/11/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Spine surgeries performed via the posterior approach have a higher infection rate. Several theories have been proposed, including poor hygienic condition of bed sheets and traumatized muscle associated with supine position promoting circulatory impairment. We investigated the influence of supine position on the rate of deep wound infection after spine surgery by the posterior approach. METHODS A total of 106 patients were randomly divided into 2 groups: lateral decubitus only versus dorsal and lateral decubitus. Patient follow-up after hospital discharge was performed at 30, 60, 180, and 360 days. Deep wound infection was diagnosed according to U.S. Centers for Disease Control and Prevention criteria. RESULTS Patient sample was mainly composed of patients with neoplastic disease and patients with trauma. Postoperative wound infection developed in 12 cases (11.3%), and Streptococcus aureus was the most common pathogen. Incidence of postsurgical deep wound infection was significantly greater in the control group (P = 0.004). CONCLUSIONS Supine position was significantly correlated with higher rates of wound infection among patients who underwent spine surgery by the posterior approach. Avoidance of supine position may represent a modifiable risk factor to diminish postoperative spine infection rates.
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Affiliation(s)
- Paulo Valdeci Worm
- Department of Neurological Surgery, Hospital São José, Complexo Hospitalar Santa Casa de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil; Neurosurgery Department of Cristo Redentor Hospital, Porto Alegre, Rio Grande do Sul, Brazil.
| | - Guilherme Finger
- Neurosurgery Department of Cristo Redentor Hospital, Porto Alegre, Rio Grande do Sul, Brazil
| | - Albert Vincent Berthier Brasil
- Department of Neurological Surgery, Hospital São José, Complexo Hospitalar Santa Casa de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
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Epstein NE. Preoperative measures to prevent/minimize risk of surgical site infection in spinal surgery. Surg Neurol Int 2018; 9:251. [PMID: 30637169 PMCID: PMC6302553 DOI: 10.4103/sni.sni_372_18] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 10/29/2018] [Indexed: 01/29/2023] Open
Abstract
Background: Multiple measures prior to spine surgery may reduce the risks of postoperative surgical site infections (SSIs). Methods: The incidence of SSI following spinal surgery (including reoperations and readmissions) may be markedly reduced by performing less extensive procedures and avoiding fusion where feasible. Preoperative testing up to 3 weeks postoperatively should include other studies to limit the perioperative SSI risk; cardiac stress tests (e.g., older patients/cardiac comorbidities), starting tamsulosin in males over 60 (e.g. avoid urinary retention due to benign prostatic hypertrophy), albumin/prealbumin levels (e.g., low levels increase SSI risk), and HBA1C levels to identify new/treat known diabetics (normalize/reduce preoperative levels). Results: Other measures include the timely administration of preoperative antibiotics (e.g., cefazolin 2 g nonpenicillin allergic), one dose of gentamicin (adjusted dose/weight), nasal cultures for methicillin-resistant Staphylococcus aureus (patients/health-care workers), and bathing 2 weeks preoperatively with chlorhexidine gluconate 4% (not just night before/morning of surgery). Additionally, prior to surgery, the following medications that increase the bleeding risk should be stopped (e.g. for varying periods); anticoagulants, antiplatelet therapies (e.g., aspirin for at least 7–10 days), nonsteroidal anti-inflammatories (NSAIDS: timing depends on the drug), vitamin E, and herbal supplements. Additionally, avoiding elective spinal surgery in morbidly obese patients and recognizing other major medical contraindications to spinal surgery should help reduce infection, morbidity, and mortality rates. Conclusions: Appropriate preoperative and intraoperative prophylactic maneuvers may reduce the risk of postoperative spinal SSI. Specific attention to these details may avoid infections and improve outcomes.
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Affiliation(s)
- Nancy E Epstein
- Clinical Professor of Neurological Surgery, School of Medicine, State University of N.Y. at Stony Brook, and Chief of Neurosurgical Spine/Education at NYU Winthrop Hospital, Mineola, NY 11501, USA
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Chung MMT, Cheung JPY. Psoas hematoma formation after violation of the intertransverse plane during posterior spinal surgery for adolescent idiopathic scoliosis. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2018; 52:480-484. [PMID: 30006237 PMCID: PMC6318502 DOI: 10.1016/j.aott.2018.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 01/23/2018] [Accepted: 06/19/2018] [Indexed: 11/29/2022]
Abstract
Psoas hematoma is a rare yet potentially serious complication following posterior spinal surgery as it is a possible nidus for infection. We present a case of psoas hematoma formation following scoliosis surgery due to intraoperative violation of the intertransverse plane. A 13-year-old female patient with adolescent idiopathic scoliosis underwent a posterior deformity correction and instrumented fusion which was complicated with intraoperative inadvertent violation of the intertransverse plane during dissection of the posterolateral gutter leading to a unilateral psoas hematoma. She experienced abdominal pain and a CT scan confirmed the presence of a psoas hematoma. Antibiotic coverage was provided in view of positive blood culture of Bacillus species to avoid infective seeding of the hematoma. Resolution of the hematoma was observed on the reassessment CT one month postoperatively. It is not uncommon for patients to develop atrophic transverse processes due to spinal deformity. This may cause difficulties in identification of the anatomy intraoperatively and thus, extra caution should be exercised during dissection to prevent violation of the intertransverse plane and subsequent psoas hematoma complication.
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Affiliation(s)
- Marvin Man Ting Chung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong, SAR, China
| | - Jason Pui Yin Cheung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong, SAR, China.
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Mallet C, Caseris M, Doit C, Simon AL, Michelet D, Madre C, Mazda K, Bonacorsi S, Ilharreborde B. Does Staphylococcus aureus nasal decontamination affect the rate of early surgical site infection in adolescent idiopathic scoliosis surgery? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:2543-2549. [PMID: 30145656 DOI: 10.1007/s00586-018-5744-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 07/30/2018] [Accepted: 08/17/2018] [Indexed: 01/28/2023]
Abstract
PURPOSE Surgical site infection (SSI) is a main complication after adolescent idiopathic scoliosis (AIS) surgery. Nasal colonization with S. aureus is a known risk factor for developing nosocomial infections in cardiac surgery. However, the risk in orthopedic surgery remains unclear, especially in spine surgery. This study aims to report the efficacy of a preoperative nasal decontamination program in S. aureus carriers on the incidence of early SSI after AIS posterior surgery. METHODS Between January 2014 and July 2017, all AIS patients were screened preoperatively with nasal swabs and decontaminated if positive 5 days before surgery. Early SSI was identified, and microorganisms findings were analyzed within nasal carriage and compared to a previous series published before the decontamination program (2007-2011). RESULTS Among the 331 AIS posterior fusion performed during the study period, incidence of positive nasal swab was 23% (n = 75). Those were preoperatively decontaminated. In comparison with the period before the nasal decontamination program, incidence of S. aureus early SSI significantly decreased from 5.1 to 1.3%, p < 0.05. None of those S. aureus decontaminated patients had an early S. aureus SSI. In all cases of S. aureus infections, S. aureus nasal screening was negative with a mean delay of 315 days (± 115) before surgery, which was significantly different from the global cohort (104 days ± 67, p < 0.05). CONCLUSIONS Preoperative S. aureus nasal decontamination was associated with a significant decrease in S. aureus SSI. Optimal delay of nasal screening needs to be optimized in order to diagnose intermittent S. aureus carriers. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Cindy Mallet
- Pediatric Orthopedic Department, Robert Debré University Hospital, Paris Diderot University, 48 Boulevard Sérurier, 75019, Paris, France.
| | - Marion Caseris
- Pediatric Infectious Disease Department, Robert Debré University Hospital, Paris Diderot University, Paris, France
| | - Catherine Doit
- Microbiology Department, Robert Debré University Hospital, Paris Diderot University, Paris, France
| | - Anne-Laure Simon
- Pediatric Orthopedic Department, Robert Debré University Hospital, Paris Diderot University, 48 Boulevard Sérurier, 75019, Paris, France
| | - Daphné Michelet
- Anesthesiology and Intensive Care Department, Robert Debré University Hospital, Paris Diderot University, Paris, France
| | - Chrystel Madre
- Pediatric Orthopedic Department, Robert Debré University Hospital, Paris Diderot University, 48 Boulevard Sérurier, 75019, Paris, France
| | - Keyvan Mazda
- Pediatric Orthopedic Department, Robert Debré University Hospital, Paris Diderot University, 48 Boulevard Sérurier, 75019, Paris, France
| | - Stéphane Bonacorsi
- Microbiology Department, Robert Debré University Hospital, Paris Diderot University, Paris, France
| | - Brice Ilharreborde
- Pediatric Orthopedic Department, Robert Debré University Hospital, Paris Diderot University, 48 Boulevard Sérurier, 75019, Paris, France
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