Safety and Efficacy of Hydrogen Peroxide in Controlling Blood Loss and Surgical Site Infection After Multisegmental Lumbar Spine Surgery: A Retrospective, Case-Controlled Study

Irrigation techniques used in spine surgery for surgical site infection prophylaxis: a systematic review and meta-analysis

Background

The greater likelihood of morbidity, mortality, length of hospital stays and poorer long-term outcomes as a result of surgical site infections secondary to spinal surgery makes prophylactic measures an imperative focus. Therefore, the aim of this review was to evaluate the available research related to the efficacy of different intraoperative irrigation techniques used in spinal surgery for surgical site infection (SSI) prophylaxis.

Methods

We performed a comprehensive search using Ovid Medline, EMBASE, Web of Science and the Cochrane library pertaining to this topic. Our meta-analysis was conducted according to PRISMA guidelines. The inclusion criteria consist of spine surgeries with intraoperative use of any wound irrigation technique, comparison groups with a different intraoperative irrigation technique or no irrigation, SSI identified with bacterial cultures or clinically in the postoperative period, reported SSI rates. Data extracted from eligible studies included, but was not limited to, SSI rates, irrigation technique and control technique. Exclusion criteria consist of articles with no human subjects, reviews, meta-analyses and case control studies and no details about SSI identification or rates. Pooled risk ratios were calculated. A meta-analysis was performed with a forest plot to determine risk estimates’ heterogeneity with I² index, Q-statistic, and p value under a random-effects model. Funnel plot was used to assess publication bias. All databases were last checked on January, 2022. PROBAST tool was used to assess both risk of bias and applicability concerns.

Results

After reviewing 1494 titles and abstracts, 18 articles met inclusion criteria. They included three prospective randomized-controlled trials, 13 retrospective cohort studies, two prospective cohort studies. There were 54 (1.8%) cases of SSIs in the povidone-iodine irrigation group (N = 2944) compared to 159 (4.6%) in the control group (N = 3408). Using intraoperative povidone-iodine wound irrigation produced an absolute risk reduction of 2.8%. Overall risk ratio was 0.32 (95% CI 0.20–0.53, p < 0.00001). In a global analysis, study heterogeneity and synthesizing mostly retrospective data were primary limitations.

Conclusion

The most evidence exists for povidone-iodine and has Level 2 evidence supporting SSI reduction during spinal surgery. Other antiseptic solutions such as dilute chlorhexidine lack published evidence in this patient population which limits the ability to draw conclusions related to its use in spinal surgery.

Level of Evidence

II – Systematic Review with Meta-Analysis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05763-2.

Myocardial Infarction After Lumbar Surgery: A Critical Meta-Analysis of Cohort versus Database Studies for a Rare Complication

BACKGROUND

One potentially fatal complication of spine surgery is myocardial infarction (MI). There is still uncertainty of the true incidence of MI within subsets of spine surgeries. The aim of this study was to survey the contemporary spine literature and ascertain the true incidence of MI after lumbar spine surgery, as well as to provide commentary on the inherent assumptions made when interpreting cohort versus database studies on this topic.

METHODS

A systematic search of 4 electronic databases from inception to November 2020 was conducted following PRISMA guidelines. Articles were screened against prespecified criteria. MI incidence was then estimated by random-effects meta-analyses of proportions based on cohort versus database studies.

RESULTS

A total of 34 cohort studies and 32 database studies describing 767,326 lumbar procedures satisfied all criteria for selection. There were 12,170 (2%) cases from cohort studies and 755,156 (98%) cases from database studies. Cohort studies reported a significantly older patient cohort (P < 0.01) and longer follow-up period than did database studies (P < 0.03). Using cohort studies only, the incidence of MI was 0.44% (P heterogeneity < 0.01), whereas using database studies only, the incidence of MI was 0.41% (P heterogeneity < 0.01). These 2 incidences were statistically different (P interaction = 0.01). Bias analysis indicated that cohort studies were more vulnerable to small-study biases than were database studies.

CONCLUSIONS

Although infrequent, the incidence of MI after lumbar spine surgery is unequivocally nonzero. Furthermore, the literature on this topic remains skewed based on study type, and translation of academic findings into practice should be wary of this.

Incidences and reasons of postoperative surgical site infection after lumbar spinal surgery: a large population study

PURPOSE

The purpose of this study was to determine the incidences of postoperative acute surgical site infection (SSI) after lumbar spinal surgery and its possible reasons in our hospital during the past 9 years.

METHODS

This is a retrospective study with a large sample size. The medical records of all included patients were reviewed, and patients with acute SSI were identified. The incidence and possible reasons of SSI were determined.

RESULTS

A total of 7240 patients who underwent posterior lumbar spinal surgery were included in this study, and the total incidence of postoperative SSI was 1.53% (111/7240). Gram-negative bacteria were found to be dominant in postoperative wound infections after lumbar spinal surgery. And Escherichia coli were the most common pathogen in patients with SSI. The rate of postoperative SSI following lumbar spinal surgery was increased at first and then decreased during the past 9 years. Additionally, from 2011 to 2014, it was mainly deep infection in these patients, and then was mainly superficial infection from 2015 to 2019. Patients with lumbar spinal stenosis had the highest incidence of postoperative SSI (2.39%, P < 0.001). There was also a significant difference for the number of SSI cases among different surgeons.

CONCLUSION

Based on a large population analysis, Gram-negative bacteria were the most common pathogen in postoperative SSI after lumbar spinal surgery. And patients with lumbar spinal stenosis had the highest incidence of SSI. Increasing the intervention of Gram-negative may be an important step to reduce the postoperative SSI after lumbar spinal surgery.

Origin and Use of Hydrogen Peroxide in Neurosurgery

Hydrogen peroxide (H2O2) is a chemical with a wide range of applications. This includes its use in the medical field, in which its use has been ubiquitous but is most useful as an antiseptic and in achieving hemostasis. Neurosurgeons have been using H2O2 for well over a century, primarily for its hemostatic and antiseptic effects. This is in spite of the fact that the actual effectiveness of H2O2 as an antiseptic is questionable, and its use, in general, may be more dangerous than it appears. We review the application of H2O2 in medicine generally and, more specifically, in neurosurgery. This review outlines the reasoning behind the use of H2O2 as an antiseptic and details why it may not be as effective as one might think. We also detail its use as a hemostatic agent in neurosurgery, reviewing a number of techniques in which it has been useful in this role. Finally, we review the documented cases of complications associated with the use of H2O2 in neurosurgery. Ultimately, we conclude that the use of H2O2 in neurosurgery be reconsidered because of its lack of effectiveness as an antiseptic and potentially fatal complications.

Gas Embolism After Hydrogen Peroxide Use During Spine Surgery: Case Report and Literature Review

BACKGROUND

As an irrigant, an antiseptic, and a hemostatic agent, hydrogen peroxide (H₂O₂) is widely used in surgical treatment, but it has been surrounded by persistent controversy. Fatal or near-fatal embolic events caused by H₂O₂ have been reported sporadically in spine surgery.

CASE DESCRIPTION

In this report, we present an 87-year-old man who underwent lumbar instrumentation removal and debridement consequent to surgical site infection in a prone position. H₂O₂ was used to irrigate the infected screw tracks and surrounding tissues during the procedures. Soon after irrigation, the patient suddenly developed tachycardia, hypotension, and rapid oxygen desaturation, followed by bradycardia. Transesophageal echocardiography indicated gas embolism. After prompt first aid treatment, the patient's condition improved and the gas embolus disappeared within a few minutes without any evidence of organ embolism.

CONCLUSIONS

Spine surgeons should reconsider the pending results of using H₂O₂ during surgery. Prolonged prone positioning and semiclosed cavities may increase the risk of gas embolism. An early diagnosis and timely intervention may be the key measures to prevent the occurrence of fatal consequences caused by gas embolism.

Oxygen Embolism and Pneumocephalus After Hydrogen Peroxide Application During Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery: A Case Report and Literature Review

BACKGROUND

Hydrogen peroxide (H₂O₂) solution is commonly used to irrigate wounds because of its hemostatic and antiseptic properties. Previous studies suggest that H₂O₂ can result in toxicity to keratinocytes and fibroblasts, but complications after H₂O₂ application, including oxygen embolism, which is one of the most severe, have rarely been reported.

CASE DESCRIPTION

A 40-year-old woman was diagnosed with L4-5 lumbar spinal stenosis and subsequently underwent minimally invasive transforaminal lumbar interbody fusion treatment at another hospital. Hypotension, hypoxia, and a decrease in end-tidal carbon dioxide pressure occurred immediately after H₂O₂ irrigation. After the operation, she was able to be extubated but remained comatose. Postoperative computed tomography scan revealed intracranial air trapping in the right frontal lobe and multiple cerebral infarction foci.

CONCLUSIONS

When using a knee-prone surgical position or in cases of dural laceration, the application of undiluted H₂O₂ solution should be avoided, especially in a surgical wound within a closed cavity. When hypotension, hypoxia, and a decrease in end-tidal carbon dioxide pressure occur immediately after H₂O₂ irrigation, oxygen embolism should be strongly suspected.