Anterior cervical spine surgical site infection and pharyngoesophageal perforation. Ten-year incidence in 1475 patients

Esophageal perforation after anterior cervical spine surgery

Objective

To report our updated experience in the management of esophageal perforation resulting from anterior cervical spine surgery, and to compare two wound management approaches.

Methods

This is a retrospective review of patients managed for esophageal perforations resulting from anterior cervical spine surgery (2007-2020). We examine outcomes based on 2 wound management approaches: closed (closed incision over a drain) versus open (left open to heal by secondary intention). We collected data on demographics, operative management, resolution (resumption of oral intake), time to resolution, number of procedures needed for resolution, microbiology, length of stay, and neck morbidity.

Results

A total of 13 patients were included (10 men). Median age was 52 years (range, 24-74 years). All patients underwent surgical drainage, repair, or attempted repair of perforation, hardware removal, and establishment of enteral access. Wounds were managed closed versus open (6 closed, 7 open). There were 2 early postoperative deaths due to acute respiratory distress syndrome and aspiration (open group), and 1 patient was lost to follow-up (closed group). Among the remaining 10 patients: resolution rate was 80% versus 100%, resolution in 30 days was 20% versus 100%, median number of procedures needed for resolution was 3 versus 1, and median hospital stay was 23 versus 14 days, for the closed and open groups, respectively.

Conclusions

Esophageal perforation following anterior cervical spine surgery should be managed in a multidisciplinary fashion with surgical neck drainage, primary repair when feasible, hardware removal, and establishment of enteral access. We advocate open neck wound management to decrease the time-to-resolution, number of procedures, and length of stay.

Incidence and local risk factors of infection after anterior sub-axial cervical spine surgery: retrospective database analysis of 4897 consecutive procedures

INTRODUCTION

The anterior cervical spine approach is safe and effective in many cervical spine pathologies. It is considered one of the most common approaches in spine surgery. Postoperative infections after anterior cervical surgery are rare but serious.

MATERIALS AND METHODS

This study is a retrospective database analysis. In this study, the incidence, and the local risk factors of postoperative infection after anterior-only sub-axial cervical spine surgery in a high-volume spine center were analyzed. The data of patients operated in a teaching hospital is electronically stored in a comprehensive medical database program. Postoperative infection after anterior cervical surgery from C2 to C7 was calculated and analyzed. In the study period, 4897 patients were operated. Twenty-four infections after a primary aseptic operation were detected. Independent local risk factors were estimated.

RESULTS

Postoperative infection occurred in 24/4897 patients (0.49%). The incidence of infection after cervical trauma was 3% (7/229), after spinal cord injury 4.3% (2/46), with myelopathy 1.98% (11/556), and after revision surgery 1.25% (7/560). The incidence showed a significant increase (p = 0.00, 0.01, 0.02). In 14 of the postoperatively infected patients (58.3%) an oesophageal injury was diagnosed. Odds ratios (OR) with a confidence interval (CI) of 95% was calculated. Independent risk factors for the postoperative infections were: Cervical trauma (OR 8.59, 95% CI 3.52-20.93), revision surgery (OR 3.22, 95% CI 1.33-7.82), The presence of cervical myelopathy (OR 6.71, 95% CI 2.99-15.06), and spinal cord injury (OR 9.33, 95% CI 2.13-40.83).

CONCLUSIONS

Postoperative infection after anterior cervical surgery is low (0.49%). In addition to the general risk factor for infection, the local risk factors are trauma, myelopathy, spinal cord injury, and revision surgeries. In the case of postoperative infection, an oesophageal injury should be excluded.

Comparison of the surgeries for the ossification of the posterior longitudinal ligament-related cervical spondylosis: A PRISMA-compliant network meta-analysis and literature review

OBJECTIVE

We designed and performed a network meta-analysis to compare the clinical outcomes among the 5 surgeries-anterior cervical corpectomy and fusion (ACCF), anterior controllable antedisplacement fusion (ACAF), laminoplasty (LP), laminectomy (LC), and posterior decompression with instrumented fusion (PDF)-for patients with cervical spondylosis related to the ossification of the posterior longitudinal ligament (OPLL).

METHODS

Databases, including PubMed, EMBASE, Cochrane Library, Google Scholar, and Web of Science (firstly available-2019) were selected for literature search. We performed a network meta-analysis with the included studies. A Newcastle-Ottawa scale was employed to assess the study quality of the included studies.

RESULTS

Total 23 studies with 1516 patients were included in our analysis. We found that ACCF achieved the most improvement in the Japanese Orthopaedic Association Scores and excellent and good recovery rate, ACAF achieved the best improvement of the improvement rate and lordosis. LP got the best operative time and blood loss.

CONCLUSIONS

Our results suggested that both anterior (ACCF and ACAF) and posterior (LP, LC, and PDF) procedures have their strengths and weaknesses. Clinicians need to select the most appropriate surgery with a comprehensive consideration of the clinical condition of each patient with OPLL-related cervical spondylosis.

Mechanisms of Immune Evasion and Bone Tissue Colonization That Make Staphylococcus aureus the Primary Pathogen in Osteomyelitis

PURPOSE OF REVIEW

Staphylococcus aureus is the primary pathogen responsible for osteomyelitis, which remains a major healthcare burden. To understand its dominance, here we review the unique pathogenic mechanisms utilized by S. aureus that enable it to cause incurable osteomyelitis.

RECENT FINDINGS

Using an arsenal of toxins and virulence proteins, S. aureus kills and usurps immune cells during infection, to produce non-neutralizing pathogenic antibodies that thwart adaptive immunity. S. aureus also has specific mechanisms for distinct biofilm formation on implants, necrotic bone tissue, bone marrow, and within the osteocyte lacuno-canicular networks (OLCN) of live bone. In vitro studies have also demonstrated potential for intracellular colonization of osteocytes, osteoblasts, and osteoclasts. S. aureus has evolved a multitude of virulence mechanisms to achieve life-long infection of the bone, most notably colonization of OLCN. Targeting S. aureus proteins involved in these pathways could provide new targets for antibiotics and immunotherapies.