Enterobacter Infection after Spine Surgery: An Institutional Experience

Broad-spectrum antibiotic prophylaxis in tumor and infected orthopedic surgery-the prospective-randomized, microbiologist-blinded, stratified, superiority trials: BAPTIST Trials

BACKGROUND

The perioperative antibiotic prophylaxis with 1st or 2nd generation cephalosporins is evidence-based in orthopedic surgery. There are, however, situations with a high risk of prophylaxis-resistant surgical site infections (SSI).

METHODS

We perform a superiority randomized controlled trial with a 10% margin and a power of 90% in favor of the broad-spectrum prophylaxis. We will randomize orthopedic interventions with a high risk for SSI due to selection of resistant pathogens (open fractures, surgery under therapeutic antibiotics, orthopedic tumor surgery, spine surgery with American Society of Anesthesiologists (ASA) score ≥ 3 points) in a prospective-alternating scheme (1:1, standard prophylaxis with cefuroxime versus a broad-spectrum prophylaxis of a combined single-shot of vancomycin 1 g and gentamicin 5 mg/kg parenterally). The primary outcome is "remission" at 6 weeks for most orthopedic surgeries or at 1 year for surgeries with implant. Secondary outcomes are the risk for prophylaxis-resistant SSI pathogens, revision surgery for any reason, change of antibiotic therapy during the treatment of infection, adverse events, and the postoperative healthcare-associated infections other than SSI within 6 weeks (e.g., urine infections or pneumonia). With event-free surgeries to 95% in the broad-spectrum versus 85% in the standard prophylaxis arm, we need 2 × 207 orthopedic surgeries.

DISCUSSION

In selected patients with a high risk for infections due to selection of prophylaxis-resistant SSI, a broad-spectrum combination with vancomycin and gentamycin might prevent SSIs (and other postoperative infections) better than the prophylaxis with cefuroxime.

TRIAL REGISTRATION

ClinicalTrial.gov NCT05502380. Registered on 12 August 2022. Protocol version: 2 (3 June 2022).

Perioperative Urinary Catheter Use and Association to (Gram-Negative) Surgical Site Infection after Spine Surgery

This study evaluates potential associations between the perioperative urinary catheter (UC) carriage and (Gram-negative) surgical site infections (SSIs) after spine surgery. It is a retrospective, single-center, case-control study stratifying group comparisons, case-mix adjustments using multivariate logistic regression analyses. Around half of the patients (2734/5485 surgeries) carried a UC for 1 day (median duration) (interquartile range, 1-1 days). Patients with perioperative UC carriage were compared to those without regarding SSI, in general, and Gram-negative, exclusively. The SSI rate was 1.2% (67/5485), yielding 67 revision surgeries. Gram-negative pathogens caused 16 SSIs. Seven Gram-negative episodes revealed the same pathogen concomitantly in the urine and the spine. In the multivariate analysis, the UC carriage duration was associated with SSI (OR 1.1, 95% confidence interval 1.1-1.1), albeit less than classical risk factors like diabetes (OR 2.2, 95%CI 1.1-4.2), smoking (OR 2.4, 95%CI 1.4-4.3), or higher ASA-Scores (OR 2.3, 95%CI 1.4-3.6). In the second multivariate analysis targeting Gram-negative SSIs, the female sex (OR 3.8, 95%CI 1.4-10.6) and a UC carriage > 1 day (OR 5.5, 95%CI 1.5-20.3) were associated with Gram-negative SSIs. Gram-negative SSIs after spine surgery seem associated with perioperative UC carriage, especially in women. Other SSI risk factors are diabetes, smoking, and higher ASA scores.

Spinal versus general anesthesia for minimally invasive transforaminal lumbar interbody fusion: implications on operating room time, pain, and ambulation

OBJECTIVE

There has been increasing interest in the use of spinal anesthesia (SA) for spine surgery, especially within Enhanced Recovery After Surgery (ERAS) protocols. Despite the wide adoption of SA by the orthopedic practices, it has not gained wide acceptance in lumbar spine surgery. Studies investigating SA versus general anesthesia (GA) in lumbar laminectomy and discectomy have found that SA reduces perioperative costs and leads to a reduction in analgesic use, as well as to shorter anesthesia and surgery time. The aim of this retrospective, case-control study was to compare the perioperative outcomes of patients who underwent minimally invasive surgery (MIS)-transforaminal lumbar interbody fusion (TLIF) after administration of SA with those who underwent MIS-TLIF under GA.

METHODS

Overall, 40 consecutive patients who underwent MIS-TLIF by a single surgeon were analyzed; 20 patients received SA and 20 patients received GA. Procedure time, intraoperative adverse events, postoperative adverse events, postoperative length of stay, 3-hour postanesthesia care unit (PACU) numeric rating scale (NRS) pain score, opioid medication, and time to first ambulation were collected for each patient.

RESULTS

The two groups were homogeneous for clinical characteristics. A decrease in total operating room (OR) time was found for patients who underwent MIS-TLIF after administration of SA, with a mean OR time of 156.5 ± 18.9 minutes versus 213.6 ± 47.4 minutes for patients who underwent MIS-TLIF under GA (p < 0.0001), a reduction of 27%. A decrease in total procedure time was also observed for SA versus GA (122 ± 16.7 minutes vs 175.2 ± 10 minutes; p < 0.0001). No significant differences were found in intraoperative and postoperative adverse events. There was a difference in the mean maximum NRS pain score during the first 3 hours in the PACU as patients who received SA reported a lower pain score compared with those who received GA (4.8 ± 3.5 vs 7.3 ± 2.7; p = 0.018). No significant difference was observed in morphine equivalents received by the two groups. A difference was also observed in the mean overall NRS pain score, with 2.4 ± 2.1 for the SA group versus 4.9 ± 2.3 for the GA group (p = 0.001). Patients who received SA had a shorter time to first ambulation compared with those who received GA (385.8 ± 353.8 minutes vs 855.9 ± 337.4 minutes; p < 0.0001).

CONCLUSIONS

The results of this study have pointed to some important observations in this patient population. SA offers unique advantages in comparison with GA for performing MIS-TLIF, including reduced OR time and postoperative pain, and faster postoperative mobilization.

Impact of COVID-19 on Neurosurgery in Brazil's Health System: The Reality of a Developing Country Affected by the Pandemic

BACKGROUND

The coronavirus disease identified in 2019 (COVID-19) pandemic changed neurosurgery protocols to provide ongoing care for patients while ensuring the safety of health care workers. In Brazil, the rapid spread of the disease led to new challenges in the health system. Neurooncology practice was one of the most affected by the pandemic due to restricted elective procedures and new triage protocols. We aim to characterize the impact of the pandemic on neurosurgery in Brazil.

METHODS

We analyzed 112 different types of neurosurgical procedures, with special detail in 11 neurooncology procedures, listed in the Brazilian Hospital Information System records in the DATASUS database between February and July 2019 and the same period in 2020. Linear regression and paired t-test analyses were performed and considered statistically significant at P < 0.05.

RESULTS

There was an overall decrease of 21.5% (28,858 cases) in all neurosurgical procedures, impacting patients needing elective procedures (-42.46%) more than emergency surgery (-5.93%). Neurooncology procedures decreased by 14.89%. Nonetheless, the mortality rate during hospitalization increased by 21.26%. Linear regression analysis in hospitalizations (Slope = 0.9912 ± 0.07431; CI [95%] = 0.8231-1.159) and total cost (Slope = 1.03 ± 0.03501; CI [95%] = 0.9511-1.109) in the 11 different types of neurooncology procedures showed a P < 0.0001. The mean cost per type of procedure showed an 11.59% increase (P = 0.0172) between 2019 and 2020.

CONCLUSIONS

The COVID-19 pandemic has increased mortality, decreased hospitalizations, and therefore decreased overall costs, despite increased costs per procedure for a variety of neurosurgical procedures. Our study serves as a stark example of the effect of the pandemic on neurosurgical care in settings of limited resources and access to care.

Perioperative Comparison of Robotic-Assisted Versus Fluoroscopically Guided Minimally Invasive Transforaminal Lumbar Interbody Fusion

OBJECTIVE

Robotic surgical systems have been developed to improve spine surgery accuracy. Studies have found significant reductions in screw revision rates and radiation exposure with robotic assistance compared with open surgery. The aim of the present study was to compare the perioperative outcomes between robot-assisted (RA) and fluoroscopically guided (FG) minimally invasive (MI) transforaminal lumbar interbody fusion (TLIF) performed by a single surgeon.

METHODS

The present retrospective cohort study analyzed all patients with lumbar degenerative disease who had undergone MI-TLIF by a single surgeon from July 2017 to March 2020. One group had undergone FG MI-TLIF and one group had undergone RA MI-TLIF.

RESULTS

Of the 101 patients included in the present study, 52 had undergone RA MI-TLIF and 49, FG MI-TLIF. We found no statistically significant differences in the operative time (RA, 241 ± 69.3 minutes; FG, 246.2 ± 56.3 minutes; P = 0.681). The mean radiation time for the RA group was 32.8 ± 28.8 seconds, and the mean fluoroscopy dose was 31.5 ± 30 mGy. The RA radiation exposure data were compared with similar data for the FG MI-TLIF group in a previous study (59.5 ± 60.4 mGy), with our patients' radiation exposure significantly lower (P = 0.035). The postoperative complications and rates of surgical revision were comparable.

CONCLUSIONS

Our results have demonstrated that RA MI-TLIF provides perioperative outcomes comparable to those with FG MI-TLIF. A reduced radiation dose to the patient was observed with RA compared with FG MI-TLIF. No differences were noted between the RA and FG cohorts in operative times, complication rates, revision rates, or length of stay.

Using a Data-Driven Improvement Methodology to Decrease Surgical Site Infections in a Community Neurosurgery Practice: Optimizing Preoperative Screening and Perioperative Antibiotics

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.

Telemedicine Utilization in Neurosurgery During the COVID-19 Pandemic: A Glimpse Into the Future?

OBJECTIVE

To describe telemedicine utilization in neurosurgery at a single tertiary institution to provide outpatient care during the coronavirus disease 2019 (COVID-19) pandemic, with 315 telemedicine visits performed by the neurosurgery department.

PATIENTS AND METHODS

In response to the COVID-19 pandemic national stay-at-home orders and postponed elective surgeries, we converted upcoming clinic visits into telemedicine visits and rescheduled other patients thought not to be markedly affected by surgical postponement. We reviewed the charts of all patients who had telehealth visits from April 1 through April 30, 2020, and collected demographic information, diagnosis, type of visit, and whether they received surgery; a satisfaction questionnaire was also administered.

RESULTS

In March 2020, 94% (644 of 685) of the neurosurgery clinic visits were face-to-face, whereas in April 2020, 55% (315 of 573) of the visits were telemedicine (P<.001). In April, of the 315 telemedicine visits, 172 (55%) were phone consults and 143 (45%) video consults; 101 (32%) were new consults, 195 (62%) return visits, and 18 (6%) postoperative follow-up. New consults were more likely to be video with audio than return visits and postoperative follow-up (P<.001). Only 39 patients (12%) required surgery. Ninety-one percent of the questionnaire respondents were very likely to recommend telemedicine.

CONCLUSION

Rapid implementation of telemedicine to evaluate neurosurgery patients became an effective tool for preoperative consultation, postoperative and follow-up visits during the COVID-19 pandemic, and decreased risks of exposure to severe acute respiratory syndrome coronavirus 2 to patients and health care staff. Future larger studies should investigate the cost-effectiveness of telemedicine used to triage surgical from nonsurgical patients, potential cost-savings from reducing travel burdens and lost work time, improved access, reduced wait times, and impact on patient satisfaction.

Awake minimally invasive transforaminal lumbar interbody fusion with a pedicle-based retraction system

OBJECTIVE

Recently there has been increasing interest in the use of regional anesthesia for minimally-invasive transforaminal lumbar interbody fusion (TLIF) and laminectomy, with the goal of reducing the side effects and risks associated with general anesthesia and also to improve patient satisfaction. The goal of this technical note is to describe important perioperative aspects to safely perform an awake spine surgery and to describe a novel technique to preform minimally-invasive TLIF using a pedicle-based retraction system.

METHODS

We report our patient selection criteria, perioperative anesthesia protocol and surgical technique for awake TLIF with the Maximum Access Surgery (MAS) TLIF Retraction System. We describe an illustrative case of a 66-year-old female that presented with leg pain, lumbar MRI revealed a grade one spondylolisthesis at L4-5 with severe canal stenosis. She underwent a L4-5 Awake MIS TLIF using the MAS TLIF Retraction System.

RESULTS

The first 10 awake TLIF we performed with the MAS TLIF Retraction System had a mean procedure time of 117.3 min with a standard deviation (SD) of 13, and a mean total OR time of 151 min, SD 14.5. No surgery was converted under general anesthesia. No intraoperative complications were reported. Average length of stay was 1.3 ± 0.46 days.

CONCLUSION

Awake MAS TLIF is a safe and effective technique, with the advantage of reducing the risk and side effect of general anesthesia and the approach-associated damage to soft tissues and morbidity. The pedicle-based distraction allows easier access to the intervertebral disc space for both disc preparation and cage placement.

Postoperative Restrictions After Anterior Cervical Discectomy and Fusion

No scientific evidence on restrictions for patients following an anterior cervical discectomy and fusion (ACDF) is available. The goal of this study is to assess the practice and patterns of restrictions after single-level and multilevel ACDF at an academic institution. We submitted two questionnaires, for restrictions after single-level and multilevel ACDF, to 18 spine surgeons at our institution. Questions included length of time in practice, use of cervical collar, postoperative restrictions and practices. We received 10 complete responses. Four (40%) of the respondents were in practice for less than 5 years; 3 (30%) 5 or more years, but less than 10; 1 (10%) 10 or more years, but less than 20; 2 (20%) 20 or more years. Only two (20%) surgeons recommend a cervical collar after a single-level ACDF, while seven (70%) do so after a multilevel ACDF, for an average of 9.1 weeks and standard deviation (SD) of 2.8. Nine surgeons (90%) reported providing lifting restrictions after a single-level and multilevel ACDF, with a mean of 10 kg and SD of 2.5 in both cases. 5 (50%) give driving restrictions after a single-level ACDF, eight (80%) do so after a multilevel. eight (80%) recommend physical therapy after both single-level and multilevel ACDF. three (30%) obtain a CT to confirm fusion at one year. Only two (20%) recommend a bone stimulator. Significant variability exists among surgeons in regards to restrictions following ACDF, but some areas of consensus emerged: 90% of respondents give lifting restrictions, with a mean of 10 kg, 80% recommend physical therapy for a range of motion and muscle strengthening.

Microbial predictors of healing and short-term effect of debridement on the microbiome of chronic wounds

Chronic wounds represent a large and growing disease burden. Infection and biofilm formation are two of the leading impediments of wound healing, suggesting an important role for the microbiome of these wounds. Debridement is a common and effective treatment for chronic wounds. We analyzed the bacterial content of the wound surface from 20 outpatients with chronic wounds before and immediately after debridement, as well as healthy skin. Given the large variation observed among different wounds, we introduce a Bayesian statistical method that models patient-to-patient variability and identify several genera that were significantly enriched in wounds vs. healthy skin. We found no difference between the microbiome of the original wound surface and that exposed by a single episode of sharp debridement, suggesting that this debridement did not directly alter the wound microbiome. However, we found that aerobes and especially facultative anaerobes were significantly associated with wounds that did not heal within 6 months. The facultative anaerobic genus Enterobacter was significantly associated with lack of healing. The results suggest that an abundance of facultative anaerobes is a negative prognostic factor in the chronic wound microbiome, possibly due to the increased robustness of such communities to different metabolic environments.