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Ferrer Pomares P, Duque Santana P, Moreno Mateo F, Mengis Palleck CL, Tomé Bermejo F, Álvarez Galovich L. 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. Global Spine J 2024:21925682241270097. [PMID: 39089872 DOI: 10.1177/21925682241270097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/04/2024] Open
Abstract
STUDY DESIGN Observational Study. OBJECTIVES Surgical 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. METHODS This 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. RESULTS There 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. CONCLUSIONS Prophylaxis 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.
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Affiliation(s)
| | - Pablo Duque Santana
- Spinal Conditions Unit, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | | | | | - Felix Tomé Bermejo
- Department of Orthopaedic and Trauma Surgery, General University Hospital of Villalba, Madrid, Spain
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Zhang H, Zhao Y, Du Y, Yang Y, Zhang J, Wang S. Early mobilization can reduce the incidence of surgical site infections in patients undergoing spinal fusion surgery: A nested case-control study. Am J Infect Control 2024; 52:644-649. [PMID: 38232902 DOI: 10.1016/j.ajic.2024.01.007] [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: 09/22/2023] [Revised: 01/09/2024] [Accepted: 01/11/2024] [Indexed: 01/19/2024]
Abstract
BACKGROUND To examine the influence of early mobilization on the risk of surgical site infections (SSI) in patients undergoing spinal fusion surgery. METHODS The retrospective cohort consisted of all consecutive patients who underwent spinal fusion surgery at our institution. For each case of SSI, 2 control patients without SSI at the corresponding index date were selected. Mobilization was predefined as "delayed" if it occurred more than 36 hours postoperatively. To account for potential confounding variables, we performed further adjustments using conditional logistic regression models. Subgroup analyses were conducted to evaluate the robustness of the statistical associations. RESULTS Following the predefined statistical protocol and matching criteria, we matched 236 control cases to the SSI cases. Upon adjustment for confounding factors, our findings revealed that the risk of SSI was 120% higher in the group beginning mobilization more than 36 hours after surgery compared to the group beginning mobilization within 36 hours postoperatively (odds ratio = 2.206, 95% confidence interval 1.169-4.166, P = .015). In subgroup analyses, this statistical trend remained consistent. CONCLUSIONS Early mobilization within 36 hours following spinal fusion surgery significantly reduces the risk of SSI. This pattern of reduced risk remains consistent among patients with degenerative diseases or spinal deformities.
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Affiliation(s)
- Haoran Zhang
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yiwei Zhao
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - You Du
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Yang
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jianguo Zhang
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
| | - Shengru Wang
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
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Zaidat B, Shrestha N, Rosenberg AM, Ahmed W, Rajjoub R, Hoang T, Mejia MR, Duey AH, Tang JE, Kim JS, Cho SK. Performance of a Large Language Model in the Generation of Clinical Guidelines for Antibiotic Prophylaxis in Spine Surgery. Neurospine 2024; 21:128-146. [PMID: 38569639 PMCID: PMC10992653 DOI: 10.14245/ns.2347310.655] [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: 12/10/2023] [Revised: 01/29/2024] [Accepted: 02/17/2024] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVE Large language models, such as chat generative pre-trained transformer (ChatGPT), have great potential for streamlining medical processes and assisting physicians in clinical decision-making. This study aimed to assess the potential of ChatGPT's 2 models (GPT-3.5 and GPT-4.0) to support clinical decision-making by comparing its responses for antibiotic prophylaxis in spine surgery to accepted clinical guidelines. METHODS ChatGPT models were prompted with questions from the North American Spine Society (NASS) Evidence-based Clinical Guidelines for Multidisciplinary Spine Care for Antibiotic Prophylaxis in Spine Surgery (2013). Its responses were then compared and assessed for accuracy. RESULTS Of the 16 NASS guideline questions concerning antibiotic prophylaxis, 10 responses (62.5%) were accurate in ChatGPT's GPT-3.5 model and 13 (81%) were accurate in GPT-4.0. Twenty-five percent of GPT-3.5 answers were deemed as overly confident while 62.5% of GPT-4.0 answers directly used the NASS guideline as evidence for its response. CONCLUSION ChatGPT demonstrated an impressive ability to accurately answer clinical questions. GPT-3.5 model's performance was limited by its tendency to give overly confident responses and its inability to identify the most significant elements in its responses. GPT-4.0 model's responses had higher accuracy and cited the NASS guideline as direct evidence many times. While GPT-4.0 is still far from perfect, it has shown an exceptional ability to extract the most relevant research available compared to GPT-3.5. Thus, while ChatGPT has shown far-reaching potential, scrutiny should still be exercised regarding its clinical use at this time.
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Affiliation(s)
- Bashar Zaidat
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nancy Shrestha
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ashley M. Rosenberg
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Wasil Ahmed
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rami Rajjoub
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Timothy Hoang
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mateo Restrepo Mejia
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Akiro H. Duey
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Justin E. Tang
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jun S. Kim
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel K. Cho
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Zhan B, Fang S, Lv X, Xie X, Wang X. Effect of drain placement in short-level spinal surgery on postoperative wound infection: A meta-analysis. Int Wound J 2024; 21:e14508. [PMID: 38037852 PMCID: PMC10898379 DOI: 10.1111/iwj.14508] [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: 10/25/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 12/02/2023] Open
Abstract
In the meta-analysis, we evaluated the efficacy of placing drainage channels following single- or double-level spine surgery in order to decrease the incidence of postoperative injury. We conducted the analysis with the help of four databases: PubMed, Embase, Cochrane Library and Web of Science. A review of related studies was carried out after evaluating the quality of the literature against the classification and exclusion criteria set for the trial. Calculation of 95% CI, OR and MD was performed with fixed-effect models. A meta-analysis of the data was carried out with RevMan 5.3. Meta-analyses of randomized controlled trial (RCT) did not indicate that there were a statistically significantly different incidence of postoperative wound infections among those who received drainage compared to those who did not receive drainage (OR, 2.29; 95% CI, 0.50, 10.41 p = 0.28). Moreover, there were no statistically significant differences in post-operation hematoma (OR, 1.20; 95% CI, 0.27, 5.28 p = 0.81) and visual analogue scale score (MD, -0.01; 95% CI, -1.34, 1.33 p = 0.99). Thus, placing drainage in short-levels of spine operation did not significantly influence the outcome of postoperative wound complications. Nevertheless, because of the limited sample size chosen for this meta-analysis, caution should be exercised when treating these data. More high-quality RCT trials with a large number of samples are required to confirm the findings.
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Affiliation(s)
- Baoming Zhan
- Department of Spinal SurgeryPeople's Hospital Affiliated to Shandong First Medical UniversityJinanChina
| | - Shiqiang Fang
- Department of Spinal SurgeryPeople's Hospital Affiliated to Shandong First Medical UniversityJinanChina
| | - Xiuhong Lv
- Department of Spinal SurgeryPeople's Hospital Affiliated to Shandong First Medical UniversityJinanChina
| | - Xuesheng Xie
- Department of Spinal SurgeryPeople's Hospital Affiliated to Shandong First Medical UniversityJinanChina
| | - Xing Wang
- Department of Trauma and OrthopedicsPeople's Hospital Affiliated to Shandong First Medical UniversityJinanChina
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Wang W, Sun J, Aarabi G, Peters U, Fischer F, Klatt J, Gosau M, Smeets R, Beikler T. Effect of tetracycline hydrochloride application on dental pulp stem cell metabolism-booster or obstacle for tissue engineering? Front Pharmacol 2023; 14:1277075. [PMID: 37841936 PMCID: PMC10568071 DOI: 10.3389/fphar.2023.1277075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 09/18/2023] [Indexed: 10/17/2023] Open
Abstract
Introduction: Stem cells and scaffolds are an important foundation and starting point for tissue engineering. Human dental pulp stem cells (DPSC) are mesenchymal stem cells with self-renewal and multi-directional differentiation potential, and are ideal candidates for tissue engineering due to their excellent biological properties and accessibility without causing major trauma at the donor site. Tetracycline hydrochloride (TCH), a broad-spectrum antibiotic, has been widely used in recent years for the synthesis of cellular scaffolds to reduce the incidence of postoperative infections. Methods: In order to evaluate the effects of TCH on DPSC, the metabolism of DPSC in different concentrations of TCH environment was tested. Moreover, cell morphology, survival rates, proliferation rates, cell migration rates and differentiation abilities of DPSC at TCH concentrations of 0-500 μg/ml were measured. Phalloidin staining, live-dead staining, MTS assay, cell scratch assay and real-time PCR techniques were used to detect the changes in DPSC under varies TCH concentrations. Results: At TCH concentrations higher than 250 μg/ml, DPSC cells were sequestered, the proportion of dead cells increased, and the cell proliferation capacity and cell migration capacity decreased. The osteogenic and adipogenic differentiation abilities of DPSC, however, were already inhibited at TCH con-centrations higher than 50 μg/ml. Here, the expression of the osteogenic genes, runt-related transcription factor 2 (RUNX2) and osteocalcin (OCN), the lipogenic genes lipase (LPL), as well as the peroxisome proliferator-activated receptor-γ (PPAR-γ) expression were found to be down-regulated. Discussion: The results of the study indicated that TCH in concentrations above 50 µg/ml negatively affects the differentiation capability of DPSC. In addition, TCH at concentrations above 250 µg/ml adversely affects the growth status, percentage of living cells, proliferation and migration ability of cells.
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Affiliation(s)
- Wang Wang
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jiangling Sun
- Department of Science and Education, Guiyang Stomatological Hospital, Guiyang, Guizhou, China
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ghazal Aarabi
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ulrike Peters
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Frank Fischer
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Klatt
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Gosau
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ralf Smeets
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Oral and Maxillofacial Surgery, Division of Regenerative Orofacial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Beikler
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Rocos B, Kato S, Lewis SJ, Shaffrey CI, Lenke LG. Antibiotic Use in Adult Spine Deformity Surgery: Results From the AO Spine Surveillance of the Management of Patients With Adult Spine Deformity. Global Spine J 2023:21925682231201240. [PMID: 37683295 DOI: 10.1177/21925682231201240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/10/2023] Open
Abstract
STUDY DESIGN Cross-sectional international survey with literature review. OBJECTIVES To evaluate the evidence for these strategies and to understand the current trends in prophylactic antibiotic use during ASD surgery through an international survey. METHODS An online survey was conducted among international AO Spine members regarding the peri-operative management of patients with ASD. The details of perioperative systemic and topical antibiotic use were solicited. Descriptive data were summarized for the responding surgeons who perform at least 10 long-segment fusions of >5 levels extending to the pelvis annually. RESULTS The literature supports the use of prophylactic antibiotic effective against gram positive organisms. The use of topical vancomycin remains debated, and there is limited evidence for topical tobramycin use. A total of 116 responses were received. 74 (64%) surgeons use topical vancomycin, most usually deep to the fascia only 45 (61%). The most usual dose used is 1-2 g. 4 (3%) surgeons use topical tobramycin deep to fascia. Following surgery, 90 (78%) surgeons use prophylactic cephalosporin with 3 (3%) using cloxacillin, 5 (4%) using ciprofloxacin and 9 (8%) using vancomycin and 6 (5%) using clindamycin either in addition or alone. CONCLUSIONS The present survey identifies a trend towards systemic and topical antibiotic prophylaxis primarily targeted at gram positive pathogens. The use of topical tobramycin, proposedly effective against gram negative infections, remains uncommon. There is a lack of consensus in the selection of perioperative antibiotic prophylaxis, thus a prospective study of the rates of infection with each strategy would be useful to inform guidelines.
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Affiliation(s)
- Brett Rocos
- Division of Spine Surgery, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- AO Knowledge Forum Deformity, Davos, Switzerland
| | - So Kato
- AO Knowledge Forum Deformity, Davos, Switzerland
- Department of Orthopaedic Surgery, The University of Tokyo, Tokyo, Japan
| | - Stephen J Lewis
- AO Knowledge Forum Deformity, Davos, Switzerland
- Department of Orthopaedic Surgery, Toronto Western Hospital, Schroeder Arthritis Institute, University of Toronto, Toronto, ON, Canada
| | - Christopher I Shaffrey
- Division of Spine Surgery, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- AO Knowledge Forum Deformity, Davos, Switzerland
| | - Lawrence G Lenke
- AO Knowledge Forum Deformity, Davos, Switzerland
- Department of Orthopedic Spine Surgery, The Spine Hospital, Columbia University Medical Center, New York, NY, USA
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Rocos B, Davidson B, Rabinovitch L, Rampersaud YR, Nielsen C, Jiang F, Vaisman A, Lewis SJ. Local contamination is a major cause of early deep wound infections following open posterior lumbosacral fusions. Spine Deform 2023; 11:1209-1221. [PMID: 37147477 DOI: 10.1007/s43390-023-00694-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 04/15/2023] [Indexed: 05/07/2023]
Abstract
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.
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Affiliation(s)
- Brett Rocos
- Schroeder Arthritis Institute, Department of Orthopaedic Surgery, Toronto Western Hospital, 399 Bathurst Street, 442, 1 East Wing, Toronto, ON, M5T 2S8, Canada
| | - Bela Davidson
- Schroeder Arthritis Institute, Department of Orthopaedic Surgery, Toronto Western Hospital, 399 Bathurst Street, 442, 1 East Wing, Toronto, ON, M5T 2S8, Canada
| | - Lily Rabinovitch
- Schroeder Arthritis Institute, Department of Orthopaedic Surgery, Toronto Western Hospital, 399 Bathurst Street, 442, 1 East Wing, Toronto, ON, M5T 2S8, Canada
| | - Y Raja Rampersaud
- Schroeder Arthritis Institute, Department of Orthopaedic Surgery, Toronto Western Hospital, 399 Bathurst Street, 442, 1 East Wing, Toronto, ON, M5T 2S8, Canada
| | - Christopher Nielsen
- Schroeder Arthritis Institute, Department of Orthopaedic Surgery, Toronto Western Hospital, 399 Bathurst Street, 442, 1 East Wing, Toronto, ON, M5T 2S8, Canada
| | - Fan Jiang
- Schroeder Arthritis Institute, Department of Orthopaedic Surgery, Toronto Western Hospital, 399 Bathurst Street, 442, 1 East Wing, Toronto, ON, M5T 2S8, Canada
| | - Alon Vaisman
- Infection Prevention and Control, University Health Network, Toronto Western Hospital, Toronto, ON, M5T 2S8, Canada
| | - Stephen J Lewis
- Schroeder Arthritis Institute, Department of Orthopaedic Surgery, Toronto Western Hospital, 399 Bathurst Street, 442, 1 East Wing, Toronto, ON, M5T 2S8, Canada.
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Wang X, Lin Y, Yao W, Zhang A, Gao L, Feng F. Surgical site infection in spinal surgery: a bibliometric analysis. J Orthop Surg Res 2023; 18:337. [PMID: 37158874 PMCID: PMC10165768 DOI: 10.1186/s13018-023-03813-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/24/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Surgical site infection (SSI) is a common complication in spinal surgery that can significantly affect the patient's prognosis. Despite advances in surgical techniques and infection control measures, SSI remains a considerable concern for healthcare providers and patients alike. In recent years, there has been a steady increase in studies related to SSI in spine surgery, leading to the publication of numerous informative articles. However, the current state and trends of research in the field of spinal SSI remain unclear. This study aims to conduct a bibliometric analysis of SSI-related articles in spine surgery to identify research status and trends. Meanwhile, we identify the top 100 most cited articles for further analysis. METHODS We searched for all articles related to spinal SSI in the Web of Science Core Collection, recording the publication year, country, journal, institution, keywords, and citation frequency for further analysis. In addition, we identified and analyzed the top 100 most cited articles. RESULTS A total of 307 articles related to spinal SSI were identified. All of these articles were published between 2008 and 2022, with the number of publications showing an increasing trend over the years. The related articles originated from 37 countries, with the USA contributing the most (n = 138). The institution with the highest number of publications and citations was Johns Hopkins University (14 articles; 835 citations). Among the journals, Spine had the highest number of articles (n = 47). The prevention of spinal SSI has been a research hotspot in recent years. Among the top 100 most cited articles, the most common research theme was the risk factors associated with spinal SSI. CONCLUSIONS In recent years, research related to spinal SSI has attracted the attention of numerous clinicians and scholars. As the first bibliometric analysis of spinal SSI, our study aims to provide pragmatic guidance for clinicians to learn the research status and trends in this field and improve their vigilance toward SSI.
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Affiliation(s)
- Xun Wang
- Zhejiang Chinese Medical University, Hangzhou, 310053, Zhejiang, China
| | - Yanze Lin
- Zhejiang Chinese Medical University, Hangzhou, 310053, Zhejiang, China
| | - Wenchao Yao
- Department of Orthopaedics, The First People's Hospital of Chun'an County, Hangzhou, 311700, Zhejiang, China
| | - Aiqi Zhang
- Zhejiang Chinese Medical University, Hangzhou, 310053, Zhejiang, China
| | - Liqing Gao
- Zhejiang Chinese Medical University, Hangzhou, 310053, Zhejiang, China
| | - Fabo Feng
- Center for Plastic and Reconstructive Surgery, Department of Orthopedics, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China.
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Saleem Z, Ahsan U, Haseeb A, Altaf U, Batool N, Rani H, Jaffer J, Shahid F, Hussain M, Amir A, Rehman IU, Saleh U, Shabbir S, Qamar MU, Altowayan WM, Raees F, Azmat A, Imam MT, Skosana PP, Godman B. Antibiotic Utilization Patterns for Different Wound Types among Surgical Patients: Findings and Implications. Antibiotics (Basel) 2023; 12:678. [PMID: 37107040 PMCID: PMC10135394 DOI: 10.3390/antibiotics12040678] [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: 02/28/2023] [Revised: 03/20/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
Antimicrobial prophylaxis is effective in reducing the rate of surgical site infections (SSIs) post-operatively. However, there are concerns with the extent of prophylaxis post-operatively, especially in low- and middle-income countries (LMICs). This increases antimicrobial resistance (AMR), which is a key issue in Pakistan. Consequently, we conducted an observational cross-sectional study on 583 patients undergoing surgery at a leading teaching hospital in Pakistan with respect to the choice, time and duration of antimicrobials to prevent SSIs. The identified variables included post-operative prophylactic antimicrobials given to all patients for all surgical procedures. In addition, cephalosporins were frequently used for all surgical procedures, and among these, the use of third-generation cephalosporins was common. The duration of post-operative prophylaxis was 3-4 days, appreciably longer than the suggestions of the guidelines, with most patients prescribed antimicrobials until discharge. The inappropriate choice of antimicrobials combined with prolonged post-operative antibiotic administration need to be addressed. This includes appropriate interventions, such as antimicrobial stewardship programs, which have been successful in other LMICs to improve antibiotic utilization associated with SSIs and to reduce AMR.
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Affiliation(s)
- Zikria Saleem
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahuddin Zakaria University, Multan 60800, Pakistan
| | - Umar Ahsan
- Department of Infection Prevention and Control, Alnoor Specialist Hospital, Ministry of Health, Makkah 24241, Saudi Arabia
| | - Abdul Haseeb
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah 24382, Saudi Arabia
| | - Ummara Altaf
- Department of Pharmacy, Ghurki Trust Teaching Hospital, Lahore 54000, Pakistan
| | - Narjis Batool
- Center of Health Systems and Safety Research, Faculty of Medicine, Health and Human Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney 2109, Australia
| | - Hira Rani
- Department of Pharmacy, Faculty of Pharmacy, University of Lahore, Lahore 54000, Pakistan
| | - Javeria Jaffer
- Department of Pharmacy, Faculty of Pharmacy, University of Lahore, Lahore 54000, Pakistan
| | - Fatima Shahid
- Department of Pharmacy, Faculty of Pharmacy, University of Lahore, Lahore 54000, Pakistan
| | - Mujahid Hussain
- Department of Pharmacy, Indus Hospital and Health Network, Karachi 75190, Pakistan
| | - Afreenish Amir
- Department of Microbiology, Armed Forces Institute of Pathology, National University of Medical Sciences, Rawalpindi 46000, Pakistan
| | - Inaam Ur Rehman
- Punjab University College of Pharmacy, Faculty of Pharmacy, University of the Punjab, Lahore 54000, Pakistan
| | - Umar Saleh
- Punjab University College of Pharmacy, Faculty of Pharmacy, University of the Punjab, Lahore 54000, Pakistan
| | - Sana Shabbir
- Punjab University College of Pharmacy, Faculty of Pharmacy, University of the Punjab, Lahore 54000, Pakistan
| | - Muhammad Usman Qamar
- Institute of Microbiology, Faculty of Life Sciences, Government College University Faisalabad, Faisalabad 38000, Pakistan
| | - Waleed Mohammad Altowayan
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Buraydah 52571, Saudi Arabia
| | - Fahad Raees
- Department of Medical Microbiology, Faculty of Medicine, Umm Al-Qura University, Makkah 24382, Saudi Arabia
| | - Aisha Azmat
- Department of Physiology, Faculty of Medicine, Umm Al-Qura University, Makkah 24382, Saudi Arabia
| | - Mohammad Tarique Imam
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdul Aziz University, Al Kharj 11942, Saudi Arabia
| | - Phumzile P. Skosana
- Department of Clinical Pharmacy, School of Pharmacy, Sefako Makgatho Health Sciences University, Molotlegi Street, Ga-Rankuwa, Pretoria 0208, South Africa
| | - Brian Godman
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Pretoria 0208, South Africa
- Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow G4 0RE, UK
- Centre of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman 346, United Arab Emirates
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Ham CH, Kwon WK, Moon HJ, Kim JH, Park YK, Hofstetter CP. Use of prophylactic perioperative antibiotics for lumbar spinal fusions: A nationwide population-based cohort study. J Infect Public Health 2023; 16:354-360. [PMID: 36682101 DOI: 10.1016/j.jiph.2023.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/28/2022] [Accepted: 01/08/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Perioperative prophylactic antibiotic (PPA) use in spine surgery is known to reduce the rate of surgical site infections. In the past decade, several evidence-based guidelines have been published and surveillance systems to monitor the proper use of antimicrobials had been adapted by many institutes. OBJECTIVE To report the trends of PPA prescription in lumbar fusion surgeries nationwide in the Republic of Korea. METHODS This is a nationwide registry study. Using the population-based data from the Republic of Korea provided by the Korean Health Insurance Review and Assessment Service, data of all lumbar spinal fusion surgeries performed between 2010 and 2018 in adult patients (age ≥19 years) were reviewed. RESULTS The most frequently used antibiotics were first-generation cephalosporins, which accounted for 38.2 % of total PPA prescriptions and were prescribed in 58.96 % of lumbar fusion surgeries. A gradual increase in prescription trends was observed. The second most frequently used PPAs were second-generation cephalosporins, which showed decrease in use from 2016. The frequency of vancomycin prescriptions gradually increased over the observation period and showed an almost four-fold increase in 2018 compared to 2010. First- and second-generation cephalosporins were prescribed less frequently to patients with renal disease. CONCLUSION The pattern of PPA use has changed remarkably over the observation period. Furthermore, specific differences in PPA prescriptions were observed among patients with certain co-morbidities.
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Affiliation(s)
- Chang Hwa Ham
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Woo-Keun Kwon
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea.
| | - Hong Joo Moon
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea; Department of Orthopaedic Surgery, Washington University in St.Louise, MO, USA
| | - Joo Han Kim
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Youn-Kwan Park
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
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Zhang N, Ma L, Ding W. The Diagnostic Value of Blood Next-Generation Sequencing in Early Surgical Site Infection After Spine Surgery. Int J Gen Med 2023; 16:37-45. [PMID: 36636713 PMCID: PMC9830415 DOI: 10.2147/ijgm.s394255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/28/2022] [Indexed: 01/06/2023] Open
Abstract
Objective To determine the diagnostic value of blood next-generation sequencing (NGS) in early surgical site infection after spine surgery. Because the blood is sterile in healthy individuals, it is expected that blood NGS is both sensitive and specific for the detection of infection. Methods A total of 28 patients with definitive spinal surgical site infections and controls (n=30) were retrospectively included. The postoperative results of NGS and culture on different samples, such as blood and drainage fluid, were obtained and compared to evaluate the diagnostic value of blood NGS. The diagnostic value parameters (sensitivity, specificity, etc.) were calculated. Results Among the four bacteriological exam methods, blood NGS was both sensitive and specific for the determination of infection after spine surgery. The sensitivities of blood and drainage fluid NGS were similar (0.82 vs 0.89, P=0.617). However, the specificities of the two assessments differed, which were 0.97 for blood NGS and 0.40 for drainage fluid NGS (P<0.001). The sensitivities of bacterial culture were lower than those of NGS (blood: 0.82 vs 0.25, P<0.001; drainage fluid: 0.89 vs 0.61, P<0.001), regardless of the sample type. However, the specificities of bacterial culture were equal to or higher than those of NGS (blood: 0.97 vs 0.97, P=1.000; drainage fluid: 0.40 vs 0.80, P=0.002). Conclusion This article emphasizes the superiority of blood NGS in infection detection and bacterial determination in patients undergoing spine surgery. Compared with traditional drainage fluid bacterial culture and NGS, blood NGS was more sensitive and specific, and its extensive application could be expected.
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Affiliation(s)
- Nan Zhang
- Department of Spine Surgery, 3rd Hospital of Hebei Medical University, Shijiazhuang, People’s Republic of China
| | - Lei Ma
- Department of Spine Surgery, 3rd Hospital of Hebei Medical University, Shijiazhuang, People’s Republic of China
| | - Wenyuan Ding
- Department of Spine Surgery, 3rd Hospital of Hebei Medical University, Shijiazhuang, People’s Republic of China,Correspondence: Wenyuan Ding, Department of Spine Surgery, 3rd Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, 050051, People’s Republic of China, Email
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The Utility of Closed Incision Negative Pressure Wound Therapy following Spinal Fusion: A Systematic Review and Meta-Analysis. World Neurosurg 2022; 168:258-267.e1. [PMID: 36116727 DOI: 10.1016/j.wneu.2022.09.048] [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: 09/04/2022] [Accepted: 09/11/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To determine if closed incision negative pressure wound therapy (ciNPWT) decreases surgical site infection (SSI) or wound dehiscence following spinal fusion. METHODS Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a systematic review and meta-analysis was conducted to identify studies utilizing ciNPWT following spinal fusion. Funnel plots and quality scores of the articles were performed to determine if the articles were at risk of bias. Forest plots were conducted to identify the treatment effect of ciNPWT following spinal fusion. RESULTS A total of 8 studies comprising 1,061 patients who received ciNPWT or a standard postoperative dressing following spinal fusion were included. The rate of SSI [ciNPWT: 4.49% (95% CI: 2.48, 8.00) vs. control: 11.32% (95% CI: 7.51, 16.70), p=0.0103] was significantly lower for patients treated with ciNPWT. A fixed-effects model showed no significant difference between patients who received ciNWPT or a standard postoperative dressing with respect to requiring reoperations for wound debridement (OR: 1.25, 95% CI: 0.64, 2.41). Additionally, wound dehiscence was not significantly different between the two groups although it was non-significantly lower in ciNWPT-treated patients [ciNPWT: 4.59% (95% CI: 2.49, 8.31) vs control: 7.48% (95% CI: 4.38, 12.47), p=0.23]. CONCLUSION Closed incision NPWT may reduce the rates of SSI following spinal fusion. The use of ciNWPT may also significantly reduce the burden associated with postoperative wound complications, but the meta-analysis was insufficiently powered to make this association. Additional, studies may identify a subset of patients who benefit from ciNPWT for other wound-related complications.
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Surgical Antimicrobial Prophylaxis in Neonates and Children Undergoing Neurosurgery: A RAND/UCLA Appropriateness Method Consensus Study. Antibiotics (Basel) 2022; 11:antibiotics11070856. [PMID: 35884111 PMCID: PMC9311924 DOI: 10.3390/antibiotics11070856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/17/2022] [Accepted: 06/22/2022] [Indexed: 11/25/2022] Open
Abstract
Pediatric neurosurgery is a highly specialized branch of surgery in which surgical site infections (SSIs) are potentially serious complications that can also adversely affect a good surgical outcome, compromising functional recovery and, in some cases, even putting the patient’s life at risk. The main aim of this consensus document is to provide clinicians with a series of recommendations on antimicrobial prophylaxis for neonates and children undergoing neurosurgery. The following scenarios were considered: (1) craniotomy or cranial/cranio-facial approach to craniosynostosis; (2) neurosurgery with a trans-nasal-trans-sphenoidal approach; (3) non-penetrating head injuries; (4) penetrating head fracture; (5) spinal surgery (extradural and intradural); (6) shunt surgery or neuroendoscopy; (7) neuroendovascular procedures. Patients undergoing neurosurgery often undergo peri-operative antibiotic prophylaxis, with different schedules, not always supported by scientific evidence. This consensus provides clear and shared indications, based on the most updated literature. This work has been made possible by the multidisciplinary contribution of experts belonging to the most important Italian scientific societies, and represents, in our opinion, the most complete and up-to-date collection of recommendations on the behavior to be held in the peri-operative setting in this type of intervention, in order to guide physicians in the management of the patient, standardize approaches and avoid abuse and misuse of antibiotics.
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14
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Surgical Applications of Materials Engineered with Antimicrobial Properties. Bioengineering (Basel) 2022; 9:bioengineering9040138. [PMID: 35447700 PMCID: PMC9030825 DOI: 10.3390/bioengineering9040138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/17/2022] [Accepted: 03/24/2022] [Indexed: 02/06/2023] Open
Abstract
The infection of surgically placed implants is a problem that is both large in magnitude and that broadly affects nearly all surgical specialties. Implant-associated infections deleteriously affect patient quality-of-life and can lead to greater morbidity, mortality, and cost to the health care system. The impact of this problem has prompted extensive pre-clinical and clinical investigation into decreasing implant infection rates. More recently, antimicrobial approaches that modify or treat the implant directly have been of great interest. These approaches include antibacterial implant coatings (antifouling materials, antibiotics, metal ions, and antimicrobial peptides), antibacterial nanostructured implant surfaces, and antibiotic-releasing implants. This review provides a compendium of these approaches and the clinical applications and outcomes. In general, implant-specific modalities for reducing infections have been effective; however, most applications remain in the preclinical or early clinical stages.
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Salimi S, Khayat Kashani HR, Azhari S, Sadeghi S, Sheikhghomy S, Paryan P, KhayatKashani M. Local vancomycin therapy to reduce surgical site infection in adult spine surgery: a randomized prospective study. 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 2022; 31:454-460. [PMID: 34750670 DOI: 10.1007/s00586-021-07050-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/07/2021] [Accepted: 10/28/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE This prospective randomized controlled trial hypothesizes that intra wound vancomycin reduces postoperative infection. METHODS In this RCT study, the patients were randomly divided into two groups of treatment and control. In the treatment group, 1-2 g of intra wound vancomycin was used, and no drug was used for the control group. SSI and the type of microorganism causing postoperative infection were assessed at a three-month follow-up. Factors affecting postoperative infection such as age, sex, site of operation, surgical levels, and risk factors affecting postoperative infection, such as diabetes, blood pressure, ischemic heart disease, smoking, blood transfusion, BMI, neurologic deficit, CSF leakage, UTI, COPD and surgery time were examined in two groups. RESULTS In this study, 375 patients, including 187patients in the treatment group and 188 patients in the control group, were studied. Among the patients, 228 had surgery without instrumentation, and 147 had surgery with instrumentation. There were 12 cases of SSI in the treatment group and 11 in the control group, and there was no statistically significant difference between the two groups. There was no difference between the two groups with and without instrumentation in the evaluation of postoperative infection. In the subgroups with and without instruments, there was no significant difference between treatment and control groups. Due to the microorganism causing the infection, gram-negative bacteria were more common in the treatment group. CONCLUSION Intra-wound vancomycin has no effect on SSI; in addition, it can increase the rate of gram-negative infections.
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Affiliation(s)
- Sohrab Salimi
- Clinical Research and Development Unit, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Reza Khayat Kashani
- Department of Neurosurgery, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Madani street, Tehran, Iran.
| | - Shirzad Azhari
- Department of Neurosurgery, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Madani street, Tehran, Iran
| | - Sohrab Sadeghi
- Department of Neurosurgery, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Madani street, Tehran, Iran
| | - Siavash Sheikhghomy
- Department of Neurosurgery, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Madani street, Tehran, Iran
| | - Poorya Paryan
- Department of Neurosurgery, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Madani street, Tehran, Iran
| | - Maryam KhayatKashani
- Clinical Research and Development Unit, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Macki M, Hamilton T, Lim S, Mansour TR, Telemi E, Bazydlo M, Schultz L, Nerenz DR, Park P, Chang V, Schwalb J, Abdulhak MM. The role of postoperative antibiotic duration on surgical site infection after lumbar surgery. J Neurosurg Spine 2022; 36:254-260. [PMID: 34534952 DOI: 10.3171/2021.4.spine201839] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 04/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite a general consensus regarding the administration of preoperative antibiotics, poorly defined comparison groups and underpowered studies prevent clear guidelines for postoperative antibiotics. Utilizing a data set tailored specifically to spine surgery outcomes, in this clinical study the authors aimed to determine whether there is a role for postoperative antibiotics in the prevention of surgical site infection (SSI). METHODS The Michigan Spine Surgery Improvement Collaborative registry was queried for all lumbar operations performed for degenerative spinal pathologies over a 5-year period from 2014 to 2019. Preoperative prophylactic antibiotics were administered for all surgical procedures. The study population was divided into three cohorts: no postoperative antibiotics, postoperative antibiotics ≤ 24 hours, and postoperative antibiotics > 24 hours. This categorization was intended to determine 1) whether postoperative antibiotics are helpful and 2) the appropriate duration of postoperative antibiotics. First, multivariable analysis with generalized estimating equations (GEEs) was used to determine the association between antibiotic duration and all-type SSI with adjusted odds ratios; second, a three-tiered outcome-no SSI, superficial SSI, and deep SSI-was calculated with multivariable multinomial logistical GEE analysis. RESULTS Among 37,161 patients, the postoperative antibiotics > 24 hours cohort had more men with older average age, greater body mass index, and greater comorbidity burden. The postoperative antibiotics > 24 hours cohort had a 3% rate of SSI, which was significantly higher than the 2% rate of SSI of the other two cohorts (p = 0.004). On multivariable GEE analysis, neither postoperative antibiotics > 24 hours nor postoperative antibiotics ≤ 24 hours, as compared with no postoperative antibiotics, was associated with a lower rate of all-type postoperative SSIs. On multivariable multinomial logistical GEE analysis, neither postoperative antibiotics ≤ 24 hours nor postoperative antibiotics > 24 hours was associated with rate of superficial SSI, as compared with no antibiotic use at all. The odds of deep SSI decreased by 45% with postoperative antibiotics ≤ 24 hours (p = 0.002) and by 40% with postoperative antibiotics > 24 hours (p = 0.008). CONCLUSIONS Although the incidence of all-type SSI was highest in the antibiotics > 24 hours cohort, which also had the highest proportions of risk factors, duration of antibiotics failed to predict all-type SSI. On multinomial subanalysis, administration of postoperative antibiotics for both ≤ 24 hours and > 24 hours was associated with decreased risk of only deep SSI but not superficial SSI. Spine surgeons can safely consider antibiotics for 24 hours, which is equally as effective as long-term administration for prophylaxis against deep SSI.
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Affiliation(s)
| | | | | | | | | | | | | | - David R Nerenz
- 3Center for Health Policy and Health Services Research, Henry Ford Hospital, Detroit, Michigan; and
| | - Paul Park
- 4University of Michigan, Ann Arbor, Michigan
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Kim EK, Donnelley CA, Tiee M, Roberts HJ, Von Kaeppler E, Shearer D, Morshed S. Prophylactic Topical Antibiotics in Fracture Repair and Spinal Fusion. Adv Orthop 2021; 2021:1949877. [PMID: 34691783 PMCID: PMC8531801 DOI: 10.1155/2021/1949877] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 09/09/2021] [Accepted: 09/11/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The objective of this systematic review with meta-analysis is to determine whether prophylactic local antibiotics prevent surgical site infections (SSIs) in instrumented spinal fusions and traumatic fracture repair. A secondary objective is to investigate the effect of vancomycin, a common local antibiotic of choice, on the microbiology of SSIs. METHODS An electronic search of PubMed, EMBASE, and Web of Science databases and major orthopedic surgery conferences was conducted to identify studies that (1) were instrumented spinal fusions or fracture repair and (2) had a treatment group that received prophylactic local antibiotics. Both randomized controlled trials (RCTs) and comparative observational studies were included. Meta-analysis was performed separately for randomized and nonrandomized studies with subgroup analysis by study design and antibiotic. RESULTS Our review includes 44 articles (30 instrumented spinal fusions and 14 fracture repairs). Intrawound antibiotics significantly decreased the risk of developing SSIs in RCTs of fracture repair (RR 0.61, 95% CI: 0.40-0.93, I 2 = 32.5%) but not RCTs of instrumented spinal fusion. Among observational studies, topical antibiotics significantly reduced the risk of SSIs in instrumented spinal fusions (OR 0.34, 95% CI: 0.27-0.43, I 2 = 52.4%) and in fracture repair (OR 0.49, 95% CI: 0.37-0.65, I 2 = 43.8%). Vancomycin powder decreased the risk of Gram-positive SSIs (OR 0.37, 95% CI: 0.27-0.51, I 2 = 0.0%) and had no effect on Gram-negative SSIs (OR 0.95, 95% CI: 0.62-1.44, I 2 = 0.0%). CONCLUSIONS Prophylactic intrawound antibiotic administration decreases the risk of SSIs in fracture surgical fixation in randomized studies. Therapeutic efficacy in instrumented spinal fusion was seen in only nonrandomized studies. Vancomycin appears to be an effective agent against Gram-positive pathogens. There is no evidence that local vancomycin powder is associated with an increased risk for Gram-negative infection.
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Affiliation(s)
- Eric K. Kim
- University of California San Francisco, School of Medicine, San Francisco, California, USA
| | - Claire A. Donnelley
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedics, University of California, San Francisco, California, USA
| | - Madeline Tiee
- University of California San Francisco, School of Medicine, San Francisco, California, USA
| | - Heather J. Roberts
- University of California San Francisco, Department of Orthopaedic Surgery, San Francisco, California, USA
| | - Ericka Von Kaeppler
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedics, University of California, San Francisco, California, USA
| | - David Shearer
- University of California San Francisco, Department of Orthopaedic Surgery, San Francisco, California, USA
| | - Saam Morshed
- University of California San Francisco, Department of Orthopaedic Surgery, San Francisco, California, USA
- University of California San Francisco, Department of Epidemiology and Biostatistics, San Francisco, California, USA
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Amelot A, Riche M, Latreille S, Degos V, Carpentier A, Mathon B, Korinek AM. Antimicrobial prophylaxis in noninstrumented spine surgery: a prospective study to determine efficacy and drawbacks. J Neurosurg Spine 2021; 35:366-375. [PMID: 34243156 DOI: 10.3171/2020.11.spine201891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 11/23/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors sought to evaluate the roles of perioperative antibiotic prophylaxis in noninstrumented spine surgery (NISS), both in postoperative infections and the impact on the selection of resistant bacteria. To the authors' knowledge, only one prospective study recommending preoperative intravenous (IV) antibiotics for prophylaxis has been published previously. METHODS Two successive prospective IV antibiotic prophylaxis protocols were used: from 2011 to 2013 (group A: no prophylactic antibiotic) and from 2014 to 2016 (group B: prophylactic cefazolin). Patient infection rates, infection risk factors, and bacteriological status were determined. RESULTS In total, 2250 patients (1031 in group A and 1219 in group B) were followed for at least 1 year. The authors identified 72 surgical site infections, 51 in group A (4.9%) and 21 in group B (1.7%) (p < 0.0001). A multiple logistic regression hazard model identified male sex (HR 2.028, 95% CI 1.173-3.509; p = 0.011), cervical laminectomy (HR 2.078, 95% CI 1.147-3.762; p = 0.016), and postoperative CSF leak (HR 43.782, 95% CI 10.9-189.9; p < 0.0001) as independent predictive risk factors of infection. In addition, preoperative antibiotic prophylaxis was the only independent favorable factor (HR 0.283, 95% CI 0.164-0.488; p < 0.0001) that significantly reduced infections for NISS. Of 97 bacterial infections, cefazolin-resistant bacteria were identified in 26 (26.8%), with significantly more in group B (40%) than in group A (20.9%) (p = 0.02). CONCLUSIONS A single dose of preoperative cefazolin is effective and mandatory in preventing surgical site infections in NISS. Single-dose antibiotic prophylaxis has an immediate impact on cutaneous flora by increasing cefazolin-resistant bacteria.
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Affiliation(s)
- Aymeric Amelot
- 1Department of Neurosurgery, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris
- 2Department of Neurosurgery, Bretonneau Hospital, Hopitaux de Tours
| | - Maximilien Riche
- 1Department of Neurosurgery, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris
| | - Samuel Latreille
- 3Department of Neuro-anesthesiology, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris; and
| | - Vincent Degos
- 3Department of Neuro-anesthesiology, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris; and
- 4Sorbonne University, Paris, France
| | - Alexandre Carpentier
- 1Department of Neurosurgery, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris
- 4Sorbonne University, Paris, France
| | - Bertrand Mathon
- 1Department of Neurosurgery, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris
- 4Sorbonne University, Paris, France
| | - Anne-Marie Korinek
- 3Department of Neuro-anesthesiology, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris; and
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Shawky Abdelgawaad A, El Sadik MHM, Hassan KM, El-Sharkawi M. Perioperative antibiotic prophylaxis in spinal surgery. SICOT J 2021; 7:31. [PMID: 33973847 PMCID: PMC8112232 DOI: 10.1051/sicotj/2021029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/17/2021] [Indexed: 12/12/2022] Open
Abstract
Study design: Complete audit cycle. Introduction: To highlight the unjustified overuse of perioperative antibiotics in clean non-instrumented lumbar spinal surgeries. To convince orthopedic surgeons in a methodological way of local field comparison between common practice on the use of perioperative antibiotics prophylaxis (PAP) in clean non-instrumented lumbar spinal surgeries and the ideal practice according to “The guidelines published by North American Spine Society (NASS)”. Methods: A complete audit cycle had been done. One hundred and eight patients underwent clean non-instrumented lumbar spinal surgeries in a tertiary spine center, during the period from the 1st of April to the 31st of June 2017 (primary audit period) and during the period from the 8th of May to the 21st of November 2018 (re-audit period). Group I: audit group (n = 54) was given the usual regimen (IV first-generation cephalosporin for 1–6 days, followed by oral antibiotics, till the removal of stitches) and Group II: re-audit group (n = 54) received only the IV antibiotics for one day). The study protocol was approved by our institution’s Ethical Committee (17100582). Results: This study showed a wide gap between international standards and local prescribing practices and calls for multiple interventions to improve our practice. Out of the 108 patients, only one case (1.85%) developed surgical site infection (SSI) in the audit group (Group I). The difference in infection rates between the two groups was statistically insignificant. Conclusion: A single-day postoperative dose of antibiotics effectively prevents postoperative wound infection following non-instrumented lumbar spinal surgery and is not associated with a higher infection rate.
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Affiliation(s)
- Ahmed Shawky Abdelgawaad
- Department of Orthopaedic and Trauma Surgery, Assiut University Hospitals, 71515 Assiut, Egypt - Spine Center, Helios Klinikum Erfurt, Nordhaeuser Street 7, 99089 Erfurt, Germany
| | | | - Khalid Mohammed Hassan
- Department of Orthopaedic and Trauma Surgery, Assiut University Hospitals, 71515 Assiut, Egypt
| | - Mohammad El-Sharkawi
- Department of Orthopaedic and Trauma Surgery, Assiut University Hospitals, 71515 Assiut, Egypt
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Mwita JC, Ogunleye OO, Olalekan A, Kalungia AC, Kurdi A, Saleem Z, Sneddon J, Godman B. Key Issues Surrounding Appropriate Antibiotic Use for Prevention of Surgical Site Infections in Low- and Middle-Income Countries: A Narrative Review and the Implications. Int J Gen Med 2021; 14:515-530. [PMID: 33633461 PMCID: PMC7901404 DOI: 10.2147/ijgm.s253216] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 01/07/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND There is a concern with the growing use of antimicrobials across countries increasing antimicrobial resistance (AMR) rates. A key area within hospitals is their use for the prevention of surgical site infections (SSI) with concerns with timing of the first dose, which can appreciably impact on effectiveness, as well as duration with extended prophylaxis common among low- and middle-income countries (LMICs). This is a concern as extended duration increases utilization rates and AMR as well as adverse events. Consequently, there is a need to document issues of timing and duration of surgical antibiotic prophylaxis (SAP) among LMICs together with potential ways forward to address current concerns. METHODS Narrative review of timings and duration of SAP among LMICs combined with publications documenting successful approaches to improve SAP to provide future direction to all key stakeholder groups. RESULTS There were documented concerns with the timing of the first dose of antibiotics, with appropriate timing as low as 6.7% in Egypt, although as high as 81.9% in Turkey. There was also an extensive duration of SAP, ranging from long duration times in all patients in a study in Nigeria with a mean of 8.7 days and 97% of patients in Egypt to 42.9% of patients in Pakistan and 35% in Turkey. Successful interventions to improve SAP typically involved multiple approaches including education of all key stakeholder groups, monitoring of usage against agreed guidelines,as well as quality targets. Multiple approaches typically improved timing and duration as well as reduced costs. For instance, in one study appropriateness increased from 30.1% to 91.4%, prolonged duration reduced to 5.7% of patients, and mean costs of antibiotics decreased 11-fold. CONCLUSION There are considerable concerns with the timing and duration of SAP among LMICs. Multiple interventions among LMICs can address this providing future directions.
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Affiliation(s)
- Julius C Mwita
- Department of Internal Medicine, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Olayinka O Ogunleye
- Department of Pharmacology, Therapeutics and Toxicology, Lagos State University College of Medicine, Lagos, Nigeria
- Department of Medicine, Lagos State University Teaching Hospital, Lagos, Nigeria
| | - Adesola Olalekan
- Department of Medical Laboratory Science, University of Lagos, Lagos, Nigeria
- Centre for Genomics of Non-Diseases and Personalized Healthcare (CGNPH), University of Lagos, Lagos, Nigeria
| | | | - Amanj Kurdi
- Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, UK
- Department of Pharmacology, College of Pharmacy, Hawler Medical University, Erbil, Iraq
| | - Zikria Saleem
- Department of Pharmacy Practice, Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | | | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, UK
- School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
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Kerezoudis P, Kelley PC, Watts CR, Heiderscheit CJ, Roskos MC. Using a Data-Driven Improvement Methodology to Decrease Surgical Site Infections in a Community Neurosurgery Practice: Optimizing Preoperative Screening and Perioperative Antibiotics. World Neurosurg 2021; 149:e989-e1000. [PMID: 33515799 DOI: 10.1016/j.wneu.2021.01.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 01/13/2021] [Accepted: 01/15/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We used a data-driven methodology to decrease the departmental surgical site infection rate to a goal of 1%. METHODS A prospective interventional study with historical controls comparing preimplementation/intervention (unknown methicillin-sensitive Staphylococcus aureus [MSSA]/methicillin-resistant Staphylococcus aureus [MRSA] status and standard weight and drug allergy-based preoperative antibiotics) with postimplementation/intervention (optimized preoperative chlorhexidine showers, MSSA/MRSA screening, MSSA/MRSA decolonization, and optimized preoperative antibiotic order set implementation). The American College of Surgeons National Surgical Quality Improvement Program was used for case surveillance. The primary outcome was the presence of a surgical site infection with a secondary outcome of cost(s) of implementation. RESULTS A total of 317 National Surgical Quality Improvement Program abstracted neurosurgical cases were analyzed, 163 cases before implementation and 154 cases after implementation. There were no significant differences between the preimplementation and postimplementation cohorts regarding patient demographics and baseline comorbidities, with the exceptions of inpatient and functional status (P < 0.001). The most common procedures were lumbar decompression (31%), lumbar discectomy (27%), and anterior cervical discectomy and fusion (10.4%). After implementation, 30 patients were MSSA positive (20%) and 4 MRSA positive (2.6%). Thirty patients received preoperative intranasal mupirocin decolonization (88%), and 4 patients received adjusted preoperative antibiotics (12%). After protocol implementation, the surgical site infection rate decreased from 6.7% (odds ratio, 2.82) to 0.96% (odds ratio, 0.91). The cost of implementation was $27,179, or $58 per patient. CONCLUSIONS The findings highlight the importance of systematically investigating areas of gap in existing clinical practice and quality improvement projects to increase patient safety and enhance the value of care delivered to neurosurgical patients.
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Affiliation(s)
| | - Parker C Kelley
- Department of Neurosurgery, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Charles R Watts
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurosurgery, Mayo Clinic Health System, La Crosse, Wisconsin, USA.
| | - Chris J Heiderscheit
- Department of Clinical Quality Management, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Michael C Roskos
- Department of Surgery, Mayo Clinic Health System, La Crosse, Wisconsin, USA
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22
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Kerbel YE, Kirchner GJ, Sunkerneni AR, Lieber AM, Moretti VM, Khalsa AS, Levine MJ. The Cost-Effectiveness of Vancomycin Powder in Lumbar Laminectomy. Global Spine J 2021; 11:28-33. [PMID: 32875834 PMCID: PMC7734260 DOI: 10.1177/2192568219888451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Break-even cost analysis. OBJECTIVE The goal of this study is to examine the cost-effectiveness of vancomycin powder for preventing infection following lumbar laminectomy. METHODS The product cost of vancomycin powder was obtained from our institution's purchasing records. Infection rates and revision costs for lumbar laminectomy and lumbar laminectomy with fusion were obtained from the literature. A break-even analysis was then performed to determine the absolute risk reduction (ARR) in infection rate to make prophylactic application of vancomycin powder cost-effective. Analysis of lumbar laminectomy with fusion was performed for comparison. RESULTS Costing $3.06 per gram at our institution, vancomycin powder was determined to be cost-effective in lumbar laminectomy if the infection rate of 4.2% decreased by an ARR of 0.015%. Laminectomy with fusion was also determined to be cost-effective at the same cost of vancomycin powder if the infection rate of 8.5% decreased by an ARR of 0.0034%. The current highest cost reported in the literature, $44.00 per gram of vancomycin powder, remained cost-effective with ARRs of 0.21% and 0.048% for laminectomy and laminectomy with fusion, respectively. Varying the baseline infection rate did not influence the ARR for either procedure when the analysis was performed using the product cost of vancomycin at our institution. CONCLUSIONS This break-even analysis demonstrates that prophylactic vancomycin powder can be highly cost-effective for lumbar laminectomy. At our institution, vancomycin powder is economically justified if it prevents at least one infection out of 6700 lumbar laminectomy surgeries.
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Affiliation(s)
| | - Gregory J. Kirchner
- Drexel University, Philadelphia, PA, USA,Gregory J. Kirchner, Department of Orthopedic Surgery, Drexel University College of Medicine, 245 N 15th Street, MS 420, Philadelphia, PA 19102, USA.
| | | | | | - Vincent M. Moretti
- Philadelphia Veteran’s Affairs Hospital, Philadelphia, PA, USA,The University of Pennsylvania, Philadelphia, PA, USA
| | | | - Marc J. Levine
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
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23
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Taleghani ER, Thompson SR, Yarboro SR, Schaller TM, Miller MD. Treatment Algorithm for Surgical Site Infections Following Extensor Mechanism Repair. JBJS Rev 2020; 8:e20.00078. [PMID: 33405493 DOI: 10.2106/jbjs.rvw.20.00078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Despite general agreement regarding techniques for extensor mechanism repair, there is very limited guidance in the literature for the management of surgical site infections (SSIs) that may occur after these procedures. » Early or mild superficial SSIs, such as cellulitis, can be managed on an outpatient basis while monitoring for improvement, with escalated intervention if the symptoms do not resolve within 1 week. » Deep SSIs should be managed more aggressively with surgical irrigation and debridement (I&D), including the knee joint, depending on the results of the aspiration, removal of all braided nonabsorbable suture (if necessary) with immediate or delayed exchange with monofilament suture, and the administration of parenteral antibiotics based on culture results and an infectious disease consult. » Arthrocentesis should be performed early to monitor for the spread of infection to the joint space, and diagnosis of a septic knee joint should be immediately followed by arthroscopic or open I&D. » For refractory cases (i.e., wound coverage issues or persistent infections despite multiple attempts at debridement), a consult with a plastic surgeon for consideration of a gastrocnemius flap is recommended, and surgeons should remain suspicious of the possibility of the contiguous spread of osteomyelitis.
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Affiliation(s)
- Eric R Taleghani
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Stephen R Thompson
- Northern Light Orthopaedics, Eastern Maine Medical Center, University of Maine, Bangor, Maine
| | - Seth R Yarboro
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Thomas M Schaller
- Department of Orthopaedics, University of South Carolina School of Medicine, Greenville, South Carolina
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
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24
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Muthu S, Ramakrishnan E, Natarajan KK, Chellamuthu G. Risk-benefit analysis of wound drain usage in spine surgery: a systematic review and meta-analysis with evidence summary. 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 2020; 29:2111-2128. [PMID: 32700123 DOI: 10.1007/s00586-020-06540-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 06/22/2020] [Accepted: 07/13/2020] [Indexed: 02/05/2023]
Abstract
STUDY DESIGN Systematic review, meta-analysis, evidence synthesis. OBJECTIVES To analyse the literature evidence available to support the usage of wound drain in various scenarios of spine surgery and provide an evidence summary on the surgical practice. MATERIALS AND METHODS We conducted independent and duplicate electronic database searches adhering to PRISMA guidelines in PubMed, Embase, and Cochrane Library till April 2020. Quality appraisal was done as per Cochrane ROB tool, and evidence synthesis was done as per GRADE approach. Five domains of spine surgery with associated key questions were identified. Evidence tables were generated for each question and critical appraisal done as per the GRADE approach. RESULTS Twenty-three studies (9-RCTs, 4-prospective studies, 10-retrospective studies) were included. Analysis of studies in cervical spine either by anterior or posterior approach and single/multilevel thoracolumbar spinal surgeries did not show any evidence of reduction in surgical site infection (SSI) or haematoma formation with the use of drain. Deformity correction surgeries and surgeries done for trauma or tumour involving spine also did not find any added benefit from the use of wound drains despite increasing the total blood loss. CONCLUSION Evidence from this review suggests that routine use of drain in various domains of spine surgery does not reduce the risk of SSI and their absence did not increase the risk of haematoma formation. The current best evidence is presented with its limitations. High-quality studies to address their use in spine surgeries in cervical, trauma, and tumour domains are required to further strengthen the evidence synthesised from available literature.
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Affiliation(s)
- Sathish Muthu
- Government Hospital, Velayuthampalayam, Karur, Tamil Nadu, India.
- Orthopaedic Research Group, Coimbatore, Tamil Nadu, India.
| | - Eswar Ramakrishnan
- Institute of Orthopaedics and Traumatology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, India
- Orthopaedic Research Group, Coimbatore, Tamil Nadu, India
| | - Karthick Kumar Natarajan
- Lokmanya Tilak Municipal General Hospital and Medical College, Sion, Mumbai, India
- Orthopaedic Research Group, Coimbatore, Tamil Nadu, India
| | - Girinivasan Chellamuthu
- Ganga Hospitals, Coimbatore, Tamil Nadu, India
- Orthopaedic Research Group, Coimbatore, Tamil Nadu, India
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25
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Complexities of spine surgery in obese patient populations: a narrative review. Spine J 2020; 20:501-511. [PMID: 31877389 PMCID: PMC7136130 DOI: 10.1016/j.spinee.2019.12.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 02/03/2023]
Abstract
The obese population is particularly challenging to the spine surgeon in all phases of care. A narrative literature review was performed to review difficulties in spine surgery on the obese patient population and techniques for mitigation. We specifically aimed to assess several topics with regard to this population: patient selection and preoperative care; intraoperative and surgical techniques; and postoperative care, outcomes, and complications. The literature review demonstrated that obese patients are at increased surgical risk with spine surgery due to a variety of factors at all stages of intervention. Preoperatively, obese patients have worse outcomes with physical therapy and present technical difficulties for injections. Transport to a hospital, imaging, resuscitation, and intubation are all challenged by increased body habitus. Intraoperatively, obese patients have increased operative times, blood loss, surgical site infections, and nerve palsies. Patient positioning and intraoperative imaging may be limited. Surgery itself may be technically challenging due to body habitus and minimally invasive techniques are becoming more prevalent in this population. Postoperatively, several studies demonstrate that obese patients have inferior outcomes compared with nonobese counterparts. Patient selection is a key for elective interventions, and appropriate infrastructure aids in the ultimate outcomes for both elective and nonelective surgical treatments. Overall, obese patients present several challenges to the spine surgeon, and certain precautions can be undertaken preoperatively, intraoperatively, and postoperatively to mitigate the associated risks to optimize outcomes.
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26
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Chen H, Yang J, Liu T, Tian Y, Ding K, Zhou Y, Huang D, Hao D. [Effect of hydrogen peroxide on anti-infection and reducing postoperative drainage in multi-segmental lumbar surgery]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:313-317. [PMID: 32174075 DOI: 10.7507/1002-1892.201905049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To investigate the effect of hydrogen peroxide on anti-infection and reducing postoperative drainage in multi-segmental lumbar surgery. Methods A clinical data of 510 patients with multi-segmental lumbar degenerative diseases who were treated with surgery between January 2017 and January 2018 was retrospectively analyzed. In study group, the incisions of 230 cases were washed with hydrogen peroxide before suture. In control group, the incisions of 280 cases were washed with normal saline before suture. There was no significant difference in gender, age, lesion type, disease duration, operative segment, and other clinical data between the two groups ( P>0.05). The operation time, intraoperative blood loss, postoperative drainage volume, and postoperative incidence of infection were recorded and compared between the two groups. The Centers for Disease Control and Prevention (CDC) standard was used to evaluate infection, which was divided into superficial infection and deep infection. Results All operations completed successfully. There was no significant difference in operation time and intraoperative blood loss between the two groups ( P>0.05). The postoperative drainage volume in the study group was significantly less than that in the control group ( t=-2.990, P=0.005). A total of 13 patients developed infection after operation, including 10 cases of superficial infection (2 cases in the study group and 8 cases in the control group) with the infection time of (7.3±1.5) days, and 3 cases of deep infection (all in the control group) with the infection time of (16.6±3.1) days. The incidences of superficial and deep infections in the study group were lower than those in the control group, but there was no significant difference between the two groups ( χ 2=2.595, P=0.123; P=0.256). All the superficial infections were Staphylococcus aureus infection and recovered after active dressing change. Among the patients with deep infections, 2 cases were infected by Staphylococcus aureus and 1 case was infected by Escherichia coli; and the incisions healed after being washed and sutured thoroughly, and active dressing change. Conclusion The incidence of postoperative infection and postoperative drainage volume can be reduced by washing the incision with hydrogen peroxide in multi-segmental lumbar surgery.
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Affiliation(s)
- Hao Chen
- Department of Spine Surgery, Honghui Hospital Affiliated to Medical School of Xi'an Jiaotong University, Xi'an Shaanxi, 710054, P.R.China;Xi'an Medical University, Xi'an Shaanxi, 710021, P.R.China
| | - Junsong Yang
- Department of Spine Surgery, Honghui Hospital Affiliated to Medical School of Xi'an Jiaotong University, Xi'an Shaanxi, 710054, P.R.China
| | - Tuanjiang Liu
- Department of Spine Surgery, Honghui Hospital Affiliated to Medical School of Xi'an Jiaotong University, Xi'an Shaanxi, 710054, P.R.China
| | - Ye Tian
- Department of Spine Surgery, Honghui Hospital Affiliated to Medical School of Xi'an Jiaotong University, Xi'an Shaanxi, 710054, P.R.China;Xi'an Medical University, Xi'an Shaanxi, 710021, P.R.China
| | - Keyuan Ding
- Department of Spine Surgery, Honghui Hospital Affiliated to Medical School of Xi'an Jiaotong University, Xi'an Shaanxi, 710054, P.R.China;Xi'an Medical University, Xi'an Shaanxi, 710021, P.R.China
| | - Yumin Zhou
- Department of Rehabilitation, Shanghai Fifth People's Hospital, Shanghai, 200240, P.R.China
| | - Dageng Huang
- Department of Spine Surgery, Honghui Hospital Affiliated to Medical School of Xi'an Jiaotong University, Xi'an Shaanxi, 710054, P.R.China
| | - Dingjun Hao
- Department of Spine Surgery, Honghui Hospital Affiliated to Medical School of Xi'an Jiaotong University, Xi'an Shaanxi, 710054, P.R.China
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27
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Perioperative Complications Associated with Severity of Anemia in Geriatric Patients Undergoing Spinal Procedures. World Neurosurg 2020; 135:e307-e320. [DOI: 10.1016/j.wneu.2019.11.159] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 11/25/2019] [Accepted: 11/26/2019] [Indexed: 01/28/2023]
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28
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Chen H, Yang JS, Zou P, Zhao YT, Liu TJ, Tian Y, Ding KY, Liu P, Zhang JN, Hao DJ. Safety and Efficacy of Hydrogen Peroxide in Controlling Blood Loss and Surgical Site Infection After Multisegmental Lumbar Spine Surgery: A Retrospective, Case-Controlled Study. World Neurosurg 2020; 133:e303-e307. [DOI: 10.1016/j.wneu.2019.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 09/02/2019] [Accepted: 09/03/2019] [Indexed: 12/13/2022]
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Abstract
Fracture-related infection (FRI) remains a challenging complication that imposes a heavy burden on orthopaedic trauma patients. The surgical management eradicates the local infectious focus and if necessary facilitates bone healing. Treatment success is associated with debridement of all dead and poorly vascularized tissue. However, debridement is often associated with the formation of a dead space, which provides an ideal environment for bacteria and is a potential site for recurrent infection. Dead space management is therefore of critical importance. For this reason, the use of locally delivered antimicrobials has gained attention not only for local antimicrobial activity but also for dead space management. Local antimicrobial therapy has been widely studied in periprosthetic joint infection, without addressing the specific problems of FRI. Furthermore, the literature presents a wide array of methods and guidelines with respect to the use of local antimicrobials. The present review describes the scientific evidence related to dead space management with a focus on the currently available local antimicrobial strategies in the management of FRI. LEVEL OF EVIDENCE:: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.
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30
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Urquhart JC, Collings D, Nutt L, Kuska L, Gurr KR, Siddiqi F, Rasoulinejad P, Fleming A, Collie J, Bailey CS. The Effect of Prolonged Postoperative Antibiotic Administration on the Rate of Infection in Patients Undergoing Posterior Spinal Surgery Requiring a Closed-Suction Drain: A Randomized Controlled Trial. J Bone Joint Surg Am 2019; 101:1732-1740. [PMID: 31577678 DOI: 10.2106/jbjs.19.00009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Closed-suction drains are frequently used following posterior spinal surgery. The optimal timing of antibiotic discontinuation in this population may influence infection risk, but there is a paucity of evidence. The aim of this study was to determine whether postoperative antibiotic administration for 72 hours (24 hours after drain removal as drains were removed on the second postoperative day) decreases the incidence of surgical site infection compared with postoperative antibiotic administration for 24 hours. METHODS Patients undergoing posterior thoracolumbar spinal surgery managed with a closed-suction drain were prospectively randomized into 1 of 2 groups of postoperative antibiotic durations: (1) 24 hours, or (2) 24 hours after drain removal (72 hours). Drains were discontinued on the second postoperative day. The duration of antibiotic administration was not blinded. All subjects received a single dose of preoperative antibiotics, as well as intraoperative antibiotics if the surgical procedure lasted >4 hours. The primary outcome was the rate of complicated surgical site infection (deep or organ or space) within 1 year of the surgical procedure. RESULTS The trial was terminated at an interim analysis, when 552 patients were enrolled, for futility with respect to the primary outcome. In this study, 282 patients were randomized to postoperative antibiotics for 24 hours and 270 patients were randomized to postoperative antibiotics for 72 hours. A complicated infection developed in 17 patients (6.0%) in the 24-hour group and in 14 patients (5.2%) in the 72-hour group (p = 0.714). The superficial infection rate did not differ between the groups (p = 0.654): 9.6% in the 24-hour group compared with 8.1% in the 72-hour group. Patients in the 72-hour group had a median hospital stay that was 1 day longer (p < 0.001). At 1 year, patient-rated outcomes including leg and back pain and physical and mental functioning were not different between the groups. CONCLUSIONS The extension of postoperative antibiotics for 72 hours, when a closed-suction drain is required, was not associated with a reduction in the rate of complicated surgical site infection after posterior thoracolumbar spinal surgery. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of Levels of Evidence.
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Affiliation(s)
- Jennifer C Urquhart
- Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada
| | - Darryl Collings
- Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Lori Nutt
- Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre, London, Ontario, Canada
| | - Linda Kuska
- Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre, London, Ontario, Canada
| | - Kevin R Gurr
- Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada.,Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Fawaz Siddiqi
- Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada.,Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Parham Rasoulinejad
- Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada.,Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Alyssa Fleming
- Lawson Health Research Institute, London, Ontario, Canada
| | - Joanne Collie
- Lawson Health Research Institute, London, Ontario, Canada
| | - Christopher S Bailey
- Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada.,Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
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31
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Ishida W, Perdomo-Pantoja A, Elder BD, Locke J, Holmes C, Witham TF, Lo SFL. Effects of Intraoperative Intrawound Antibiotic Administration on Spinal Fusion: A Comparison of Vancomycin and Tobramycin in a Rat Model. J Bone Joint Surg Am 2019; 101:1741-1749. [PMID: 31577679 DOI: 10.2106/jbjs.18.00988] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Local, intrawound use of antibiotic powder, such as vancomycin and tobramycin, in spinal fusion surgery has become an increasingly common prophylactic measure in an attempt to reduce rates of postsurgical infection. However, the effects of localized antibiotic delivery on fusion remain unclear. The objective of this study was to examine the in vivo effects of intraoperative local delivery of 2 antibiotics commonly used in bone-grafting surgery on spinal fusion outcomes in a rat model. METHODS Single-level (L4-L5), bilateral posterolateral intertransverse process lumbar fusion surgery was performed on 60 female Lewis rats (6 to 8 weeks of age) using syngeneic iliac crest allograft mixed with clinical bone-graft substitute and varying concentrations of antibiotics (n = 12 each): (1) control without any antibiotics, (2) low-dose vancomycin (14.3 mg/kg), (3) high-dose vancomycin (71.5 mg/kg), (4) low-dose tobramycin (28.6 mg/kg), and (5) high-dose tobramycin (143 mg/kg). Eight weeks postoperatively, fusion was evaluated via micro-computed tomography (µCT), manual palpation, and histological analysis, with blinding to treatment group. In the µCT analysis, fusion-mass volumes were measured for each rat. Each spine specimen (L4-L5) was rated (manual palpation score) on a scale of 2 to 0 (2 = fused, 1 = partially fused, and 0 = non-fused). RESULTS The mean fusion-mass volume on µCT (mm) was as follows: control, 29.3 ± 6.2; low-dose vancomycin, 26.3 ± 8.9; high-dose vancomycin, 18.8 ± 7.9; low-dose tobramycin, 32.7 ± 9.0; and high-dose tobramycin, 43.8 ± 11.9 (control versus high-dose vancomycin, p < 0.05; and control versus high-dose tobramycin, p < 0.05). The mean manual palpation score for each group was as follows: control, 1.46 ± 0.58; low-dose vancomycin, 0.86 ± 0.87; high-dose vancomycin, 0.68 ± 0.62; low-dose tobramycin, 1.25 ± 0.71; and high-dose tobramycin, 1.32 ± 0.72 (control versus high-dose vancomycin, p < 0.05). The histological analyses demonstrated a similar trend with regard to spinal fusion volume. CONCLUSIONS Intraoperative local application of vancomycin, particularly at a supraphysiological dosage, may have detrimental effects on fusion-mass formation. No inhibitory effect of tobramycin on fusion-mass formation was observed. CLINICAL RELEVANCE When spine surgeons decide to use intraoperative intrawound antibiotics in spinal fusion surgery, they should weigh the reduction in surgical site infection against a possible inhibitory effect on fusion.
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Affiliation(s)
- Wataru Ishida
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - John Locke
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christina Holmes
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy F Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sheng-Fu L Lo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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32
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Balakirski G, Felcht M, Bayer H, Schmitt L. Analyse des Status quo der perioperativen Antibiotikaprophylaxe in der Dermatochirurgie in Deutschland: Ergebnisse der DESSI-Studie. J Dtsch Dermatol Ges 2019; 17:703-715. [PMID: 31364303 DOI: 10.1111/ddg.13864_g] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 02/23/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Galina Balakirski
- Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum der Rheinischen Friedrich-Wilhelms-Universität Bonn
| | - Moritz Felcht
- Dermatologie, Venerologie und Allergologie, Universitätsmedizin Mannheim der Universität Heidelberg, Exzellenzzentrum Dermatologie des Landes Baden-Württemberg, und European Center for Angioscience (ECAS), Medizinische Fakultät Mannheim der Universität Heidelberg, Mannheim
| | - Hans Bayer
- Klinik für Dermatologie und Venerologie, Universitätsklinik Freiburg
| | - Laurenz Schmitt
- Klinik für Dermatologie und Allergologie, Universitätsklinikum der RWTH Aachen
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33
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Ghosh D, Urie R, Chang A, Nitiyanandan R, Lee JK, Kilbourne J, Rege K. Light-Activated Tissue-Integrating Sutures as Surgical Nanodevices. Adv Healthc Mater 2019; 8:e1900084. [PMID: 31066511 DOI: 10.1002/adhm.201900084] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/26/2019] [Indexed: 01/13/2023]
Abstract
Sutures are typically the primary means of soft tissue repair in surgery and trauma. Despite their widespread use, sutures do not result in immediate sealing of approximated tissues, which can result in bacterial infection and leakage. Nonabsorbable sutures and staples can be traumatic to tissue, and the trauma can be exacerbated by their subsequent removal. Use of cyanoacrylate glues is limited because of their brittleness and toxicity. In this work, laser-activated tissue-integrating sutures (LATIS) are described as novel nanodevices for soft tissue approximation and repair. Incorporation of gold nanorods within fibers generated from collagen result in LATIS fibers which demonstrate robust photothermal responses following irradiation with near infrared laser light. Compared to conventional sutures, LATIS fibers result in greater biomechanical recovery of incised skin in a mouse model of skin closure after spine surgeries. Histopathology analyses show improved repair of the epidermal gap in skin, which indicate faster tissue recovery using LATIS. The studies indicate that LATIS-facilitated approximation of skin in live mice synergizes the benefits of conventional suturing and laser-activated tissue integration, resulting in new approaches for faster sealing, tissue repair, and healing.
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Affiliation(s)
- Deepanjan Ghosh
- Biological Design Arizona State University Tempe AZ 85287 USA
| | - Russell Urie
- Chemical Engineering Arizona State University Tempe AZ 85287 USA
| | - Andy Chang
- Chemical Engineering Arizona State University Tempe AZ 85287 USA
| | | | - Jung Keun Lee
- Diagnostic Pathology Center College of Veterinary Medicine Midwestern University Glendale AZ 85308 USA
| | - Jacquelyn Kilbourne
- Department of Animal Care and Technologies (DACT) Arizona State University Tempe AZ 85287 USA
| | - Kaushal Rege
- Biological Design Arizona State University Tempe AZ 85287 USA
- Chemical Engineering Arizona State University Tempe AZ 85287 USA
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Balakirski G, Felcht M, Bayer H, Schmitt L. Analysis of the status quo of perioperative antibiotic prophylaxis in dermatosurgery in Germany: results of the DESSI-study. J Dtsch Dermatol Ges 2019; 17:703-713. [PMID: 31124600 DOI: 10.1111/ddg.13864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 02/23/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Perioperative antibiotic prophylaxis (PAP) is recommended for the prevention of postoperative infections by the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute. However, how PAP is currently used in the field of dermatosurgery in Germany is unclear. METHODS All members of the German Society for Dermatosurgery (DGDC) were asked to participate in a web-based survey in order to investigate the use of PAP by German dermatological surgeons. RESULTS 78 DGDC members completed the questionnaire. Of these, 89.7 % (70/78) were medical specialists with a median work experience of 15 years in the field of dermatosurgery, and 53.8 % (42/78) of the respondents regularly use PAP in dermatosurgery. Of these, 35.7 % (15/42) reported that they perform PAP for immunocompromised patients. Only a small proportion of skin surgeons stated that they administer PAP parenterally (5.9 %, 4/67). The most commonly used drug was cephalosporin cefuroxime. The duration of the PAP varied between single-dose and prolonged administration for more than five days. CONCLUSION Currently, the use of PAP in dermatosurgical procedures in Germany is not standardized. Prospective randomized dermatosurgical studies are needed in order to investigate whether the PAP recommendations of KRINKO are applicable to the field of dermatological surgery.
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Affiliation(s)
- Galina Balakirski
- Department of Dermatology and Allergology, University Hospital of Bonn, Bonn, Germany
| | - Moritz Felcht
- Department of Dermatology, Venereology and Allergology, University Medicine Mannheim, Ruprecht-Karls-University of Heidelberg, Mannheim, Germany
| | - Hans Bayer
- Department of Dermatology and Venereology, University Hospital of Freiburg, Freiburg, Germany
| | - Laurenz Schmitt
- Department of Dermatology and Allergology, University Hospital of RWTH Aachen, Aachen, Germany
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Smith JS, Shaffrey CI, Ames CP, Lenke LG. Treatment of adult thoracolumbar spinal deformity: past, present, and future. J Neurosurg Spine 2019; 30:551-567. [PMID: 31042666 DOI: 10.3171/2019.1.spine181494] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 01/22/2019] [Indexed: 01/27/2023]
Abstract
Care of the patient with adult spinal deformity (ASD) has evolved from being primarily supportive to now having the ability to directly treat and correct the spinal pathology. The focus of this narrative literature review is to briefly summarize the history of ASD treatment, discuss the current state of the art of ASD care with focus on surgical treatment and current challenges, and conclude with a discussion of potential developments related to ASD surgery.In the past, care for ASD was primarily based on supportive measures, including braces and assistive devices, with few options for surgical treatments that were often deemed high risk and reserved for rare situations. Advances in anesthetic and critical care, surgical techniques, and instrumentation now enable almost routine surgery for many patients with ASD. Despite the advances, there are many remaining challenges currently impacting the care of ASD patients, including increasing numbers of elderly patients with greater comorbidities, high complication and reoperation rates, and high procedure cost without clearly demonstrated cost-effectiveness based on standard criteria. In addition, there remains considerable variability across multiple aspects of ASD surgery. For example, there is currently very limited ability to provide preoperative individualized counseling regarding optimal treatment approaches (e.g., operative vs nonoperative), complication risks with surgery, durability of surgery, and likelihood of achieving individualized patient goals and satisfaction. Despite the challenges associated with the current state-of-the-art ASD treatment, surgery continues to be a primary option, as multiple reports have demonstrated the potential for surgery to significantly improve pain and disability. The future of ASD care will likely include techniques and technologies to markedly reduce complication rates, including greater use of navigation and robotics, and a shift toward individualized medicine that enables improved counseling, preoperative planning, procedure safety, and patient satisfaction.Advances in the care of ASD patients have been remarkable over the past few decades. The current state of the art enables almost routine surgical treatment for many types of ASD that have the potential to significantly improve pain and disability. However, significant challenges remain, including high complication rates, lack of demonstrated cost-effectiveness, and limited ability to meaningfully counsel patients preoperatively on an individual basis. The future of ASD surgery will require continued improvement of predictability, safety, and sustainability.
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Affiliation(s)
- Justin S Smith
- 1Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Christopher I Shaffrey
- 2Departments of Neurosurgery and Orthopaedic Surgery, Duke Medical Center, Durham, North Carolina
| | - Christopher P Ames
- 3Department of Neurosurgery, University of California, San Francisco, California; and
| | - Lawrence G Lenke
- 4Department of Orthopaedic Surgery, Columbia University, New York, New York
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