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Yang H, Bao L, Li J, Wang Y, Yang J. Effect of wound drainage on the wound infection and healing in patients undergoing spinal surgery: A meta-analysis. Int Wound J 2024; 21:e14778. [PMID: 38356179 PMCID: PMC10867381 DOI: 10.1111/iwj.14778] [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: 01/14/2024] [Accepted: 01/28/2024] [Indexed: 02/16/2024] Open
Abstract
A meta-analysis was conducted to comprehensively evaluate the impact of wound drainage on postoperative wound infection and healing in patients undergoing spinal surgery. Computer searches were performed, from database inception to October 2023, in EMBASE, Google Scholar, Cochrane Library, PubMed, Wanfang and China National Knowledge Infrastructure databases for studies related to the application of wound drainage in spinal surgery. Two researchers independently screened the literature, extracted data and conducted quality assessments. Stata 17.0 software was employed for data analysis. Overall, 11 articles involving 2102 spinal surgery patients were included. The analysis showed that, compared to other treatment methods, the use of wound drainage in spinal surgery patients significantly shortened the wound healing time (standardized mean difference [SMD]: -1.35, 95% confidence intervals [CI]: -1.91 to -0.79, p < 0.001). However, there was no statistical difference in the incidence of wound infection (odds ratio: 1.35, 95% CI: 0.83-2.19, p = 0.226). This study indicates that wound drainage in patients undergoing spinal surgery is effective, can accelerate wound healing and is worth promoting in clinical practice.
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Affiliation(s)
- Huiming Yang
- Department of Orthopedic SurgeryChinese Medicine Hospital of Tiantai CountyTaizhouChina
| | - Lizhen Bao
- Department of Orthopedic SurgeryChinese Medicine Hospital of Tiantai CountyTaizhouChina
| | - Jianchun Li
- Department of Orthopedic SurgeryChinese Medicine Hospital of Tiantai CountyTaizhouChina
| | - Yipeng Wang
- Department of Orthopedic SurgeryTaizhou Municipal HospitalTaizhouChina
| | - Jun Yang
- Department of Orthopedic SurgeryThe People's Hospital of Tiantai CountyTaizhouChina
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Issa TZ, Trenchfield D, Mazmudar AS, Lee Y, McCurdy MA, Haider AA, Lambrechts MJ, Canseco JA, Hilibrand AS, Vaccaro AR, Kepler CK, Schroeder GD. Subfascial Lumbar Spine Drain Output Does Not Affect Outcomes After Incidental Durotomies in Elective Spine Surgery. World Neurosurg 2024; 181:e615-e619. [PMID: 37890770 DOI: 10.1016/j.wneu.2023.10.100] [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: 10/19/2023] [Accepted: 10/22/2023] [Indexed: 10/29/2023]
Abstract
OBJECTIVE Postoperative drains have long been regarded as a preventive measure to mitigate the risks of complications such as neurological impairment by reducing fluid accumulation following spine surgery. Our study aims to contribute to the existing body of knowledge by examining the effects of postoperative drain output on the 90-day postoperative outcomes for patients who experienced an incidental durotomy after lumbar decompression procedures, with or without fusion. METHODS All patients aged ≥18 years with an incidental durotomy from spinal decompression with or without fusion surgery between 2017 and 2021 were retrospectively identified. The patient demographics, surgical characteristics, method of dural tear repair (DuraSeal, suture, and/or DuraGen), surgical outcomes, and drain data were collected via medical record review. Patients were grouped by readmission status and final 8-hour drain output. Those with a final 8-hour drain output of ≥40 mL were included in the high drain output (HDO) group and those with <40 mL were in the low drain output (LDO) group. RESULTS There were no statistically significant differences in preoperative patient demographics, surgical characteristics, method of dural tear repair, length of stay (HDO, 4.02 ± 1.90 days; vs. LDO, 4.26 ± 2.10 days; P = 0.269), hospital readmissions (HDO, 10.6%; vs. LDO, 7.96%; P = 0.744), or occurrence of reoperation during readmission (HDO, 6.06%; vs. LDO, 2.65%; P = 0.5944) between the 2 groups. CONCLUSIONS For patients undergoing primary lumbar decompression with or without fusion and experiencing an incidental durotomy, no significant association was found between the drain output and 90-day patient outcomes. Adequate fascial closure and the absence of symptoms may be satisfactory criteria for standard patient discharge regardless of drain output.
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Affiliation(s)
- Tariq Z Issa
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA; Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.
| | - Delano Trenchfield
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Aditya S Mazmudar
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Yunsoo Lee
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michael A McCurdy
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ameer A Haider
- Department of Orthopaedic Surgery, Washington University Hospital, St. Louis, Missouri, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Washington University Hospital, St. Louis, Missouri, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, 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 2023; 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] [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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Jang HD, Park SS, Kim K, Kim EH, Lee JC, Choi SW, Shin BJ. Is Routine Use of Drain Really Necessary for Posterior Lumbar Interbody Fusion Surgery? A Retrospective Case Series with a Historical Control Group. Global Spine J 2023; 13:621-629. [PMID: 33733887 DOI: 10.1177/21925682211001801] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN A retrospective case-control study. OBJECTIVES The usefulness of a drain in spinal surgery has always been controversial. The purposes of this study were to determine the incidence of hematoma-related complications after posterior lumbar interbody fusion (PLIF) without a drain and to evaluate its usefulness. METHODS We included 347 consecutive patients with degenerative lumbar disease who underwent single- or double-level PLIF. The participants were divided into 2 groups by the use of a drain or not; drain group and no-drain group. RESULTS In 165 cases of PLIF without drain, there was neither a newly developed neurological deficit due to hematoma nor reoperation for hematoma evacuation. In the no-drain group, there were 5 (3.0%) patients who suffered from surgical site infection (SSI), all superficial, and 17 (10.3%) patients who complained of postoperative transient recurred leg pain, all treated conservatively. Days from surgery to ambulation and length of hospital stay (LOS) of the no-drain group were faster than those of the drain group (P < 0.001). In a multiple regression analysis, a drain insertion was found to have a significant effect on the delayed ambulation and increased LOS. No significant differences existed between the 2 groups in additional surgery for hematoma evacuation, or SSI. CONCLUSIONS No hematoma-related neurological deficits or reoperations caused by epidural hematoma and SSI were observed in the no-drain group. The no-drain group did not show significantly more frequent postoperative complications than the drain use group, hence the routine insertion of a drain following PLIF should be reconsidered carefully.
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Affiliation(s)
- Hae-Dong Jang
- Department of Orthopaedic Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Seong San Park
- Department of Orthopaedic Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Kyungbum Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Eung-Ha Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Jae Chul Lee
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Sung-Woo Choi
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Byung-Joon Shin
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
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Molina M, Torres R, Castro M, Gonzáles L, Weissmann K, Martinez M, Ganga M, Postigo R. Wound drain in lumbar arthrodesis for degenerative disease: an experimental, multicenter, randomized controlled trial. Spine J 2023; 23:473-483. [PMID: 36509378 DOI: 10.1016/j.spinee.2022.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Drains for surgical wound management are frequently used in spine surgery. They are often used to decrease the incidence of postoperative hematoma and decrease wound tension. No conclusive evidence in the literature supports using drains to avoid complications in degenerative lumbar spine surgery. PURPOSE We aimed to evaluate wound drains in patients with lumbar arthrodesis for degenerative disorders based on clinical outcomes, complications, hematocrit, and length of stay. STUDY DESIGN A multicenter randomized prospective controlled clinical trial. PATIENT SAMPLE We enrolled surgical candidates for posterior lumbar decompression and fusion surgery for degenerative disorders from October 2019 to August 2021. Patients were randomized into the drain or nondrain group at nine hospitals. The inclusion criteria were as follows: patients aged 40 to 80 years with lumbar and radicular pain, lumbar degenerative disorder, and primary surgery up to three levels. The exclusion criteria were bleeding abnormalities, bleeding >2,500 mL and dural tears. OUTCOME MEASURES Preoperative data including Oswestry disability index (ODI), SF-36, lumbar and lower extremity visual analog scale (VAS), body mass index (BMI), hematocrit, and temperature were recorded. Surgical parameters, including surgical time, complications, estimated blood loss (EBL), postoperative temperature and hematocrit (days 1 and 4), dressing saturation, and length of hospital stay (LOS), were registered. METHODS The two groups were assessed preoperatively, perioperatively and at the 1-month follow-up. A REDCap database was used for registration. Data analysis was performed using classical statistics. RESULTS One hundred one patients were enrolled using the Redcap database, and 93 patients were evaluated at the final follow-up. Forty-five patients were randomized to the drain group, and 48 were randomized to the nondrain group. The preoperative characteristics were equivalent in both groups: demographic aspects, pain, ODI, SF-36, BMI, hematocrit, and spine pathology. Surgical time, EBL and complications were similar, with no difference between the groups. No difference was found between BMI and complications. No difference was observed in dressing saturation or postoperative temperature between the groups. The postoperative day 4 hematocrit was higher in the nondrain group [36.4% (32-39)] than in the drain group [34% (29.7-37.6)] without statistically differences (p=.054). The LOS was higher in the drain group [4 (3-5) days] than in the nondrain group [3 (2-4) days] (p=.007). The quality-of-life score, SF-36, was higher in the nondrain group [67.9 (53.6-79.2)] than in the drain group [56.7 (49.1-66)] (p=.043). CONCLUSIONS Nondrain patients presented shorter LOS and better outcomes, with similar complication rates. No difference was found between BMI and complications. Based on this study, in patients undergoing primary posterior spinal decompression and fusion up to three levels for degenerative lumbar disorders, we do not recommend the use of postoperative drains.
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Affiliation(s)
- Marcelo Molina
- Department of Orthopaedic Surgery, Spine Center, Clínica Las Condes, Santiago, Chile; Instituto Traumatológico de Santiago, Santiago, Chile; Research and Clinical Epidemiology Unit, Finis Terrae University, Santiago, Chile.
| | - Ramón Torres
- Instituto Traumatológico de Santiago, Santiago, Chile; Department of Orthopaedic Surgery, Clínica Santa Maria, Santiago, Chile
| | - Magdalena Castro
- Research and Clinical Epidemiology Unit, Finis Terrae University, Santiago, Chile
| | | | | | - Maripaz Martinez
- Research and Clinical Epidemiology Unit, Finis Terrae University, Santiago, Chile
| | - Marcos Ganga
- Department of Orthopaedic Surgery, Clínica Santa Maria, Santiago, Chile
| | - Roberto Postigo
- Department of Orthopaedic Surgery, Clínica Universidad de los Andes, Santiago, Chile
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Egenolf P, Lenz M, Schnake KJ, Harland A, Oikonomidis S, Eysel P, Scheyerer MJ. When to remove? Evaluation of postoperative drainage volume after single-level posterior lumbar interbody fusion. J Orthop 2023; 37:1-4. [PMID: 36718421 PMCID: PMC9883175 DOI: 10.1016/j.jor.2023.01.008] [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] [Received: 01/03/2023] [Revised: 01/15/2023] [Accepted: 01/22/2023] [Indexed: 01/24/2023] Open
Abstract
Study design prospective, observational. Background Wound drainage's indwelling duration and general use are the centre of ongoing discussion. The aim of our prospective observational study was to evaluate the total drainage volume postoperatively and its course after lumbar interbody fusion surgeries to define an ideal point in time for drainage removal. Methods We included all patients who underwent monosegmental lumbar interbody fusion via transforaminal or posterior lumbar interbody fusion (TLIF/PLIF). After application of the exclusion criteria, 27 patients were included in our study. Drainage volume was measured three times a day and at the time of drain removal. Results The PLIF group reached higher total drainage volume (337.14 ml) than the TLIF group (215.5 ml) (p = 0.047. Drainage volume's plateau was reached after 33.0 h (±1.8 h) in the TLIF group and 25.3 h (±1.7 h) in the PLIF group following surgery. Conclusions Our study shows, that drainage volume did not increase significantly after the evening of the first postoperative day at latest. This was on average 33.0 h after surgery. Therefore, extraction of the drainage tube hereafter can be assumed to be safe.
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Affiliation(s)
- Philipp Egenolf
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Orthopaedic and Trauma Surgery, Cologne, Germany
| | - Maximilian Lenz
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Orthopaedic and Trauma Surgery, Cologne, Germany
| | - Klaus John Schnake
- Center of Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany
- Department of Orthopaedics and Traumatology, Paracelsus Private Medical University Nuernberg, Nuremberg, Germany
| | - Arne Harland
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Orthopaedic and Trauma Surgery, Cologne, Germany
| | - Stavros Oikonomidis
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Orthopaedic and Trauma Surgery, Cologne, Germany
| | - Peer Eysel
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Orthopaedic and Trauma Surgery, Cologne, Germany
| | - Max Joseph Scheyerer
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Orthopaedic and Trauma Surgery, Cologne, Germany
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Elfiky T, Shehata R, Nafady M. Negative versus natural drainage after single-level posterior lumbar interbody fusion. A prospective randomized study. BRAIN & SPINE 2022; 3:101709. [PMID: 37383464 PMCID: PMC10293117 DOI: 10.1016/j.bas.2022.101709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/31/2022] [Accepted: 12/20/2022] [Indexed: 06/30/2023]
Abstract
Introduction Despite of their extensive use, drains remain controversial without clear guidelines, and there is unclear evidence on drain use in spine procedures. Negative pressure drainage is theoretically more effective in preventing postoperative hematomas. On the contrary, it may result in excessive drainage and blood loss.The aim of this study was to compare the outcome between the uses of negative versus natural drainage in single level posterior lumbar interbody fusion (PLIF). Research question The aim is to compare between negative versus natural drainage after single-level PLIF as regard to postoperative wound infection, wound healing, temperature, pain and neurological deficits. Materials and methods A prospective randomized study of consecutive PLIF patients at a single level for lumbar disc prolapse was performed between January 2019 and January 2020. The patients were randomly assigned to either the negative suction drainage group or natural drainage group. Negative suction was created by maximum compression of the reservoir to create negative pressure. In the other group, natural pressure drainage was kept without any negative pressure.Our study included a total of 62 patients who met the inclusion criteria. They were divided into two groups; 33 patients had negative suction drains and 29 patients had natural drainage. There were 32 female (51.6%) and 30 male (48.4%). Their ages ranged between of 23-69 years, with a mean age of 42.11 ± 8.89 years. Results Drainage volume was statistically higher in the negative group on the day of surgery (day 0) as well as the 1st and second days after. However, no significant differences were observed as regards to postoperative temperature, pain, wound infection, temperature, or neurological deficits. Discussion &conclusion In this prospective randomized study, our results revealed that natural drainage in short term can reduce the total amount of blood in the drain, and therefore the blood loss without significant differences in postoperative wound infection, wound healing, temperature, pain, or neurological deficits in single-level PLIF.
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Affiliation(s)
- Tarek Elfiky
- Spine Unit, Orthopedic Department, Elhadra University Hospital, Amprozo, Alexandria, Egypt
| | - Ramy Shehata
- Addenbrooke's- Cambridge University Hospital, King’s College NHS Trust, UK
| | - Mahmoud Nafady
- Spine Unit, Orthopedic Department, Elhadra University Hospital, Amprozo, Alexandria, Egypt
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Buser Z, Chang KE, Kall R, Formanek B, Arakelyan A, Pak S, Schafer B, Liu JC, Wang JC, Hsieh P, Chen TC. Lumbar surgical drains do not increase the risk of infections in patients undergoing spine surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:1775-1783. [PMID: 35147769 DOI: 10.1007/s00586-022-07130-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/07/2022] [Accepted: 01/23/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE The aim of this study was to characterize if the use of surgical drains or length of drain placement following spine surgery increases the risk of post-operative infection. METHODS Records of patients undergoing elective spinal surgery at a tertiary care center were collected between May 5, 2016 and August 16, 2018. Pre-operative baseline characteristics were recorded including patient's demographics and comorbidities. Intraoperative procedure information was documented related to procedure type, blood loss, and antibiotics used. Following surgery, patients were then further subdivided into two groups: patients who were discharged with a spinal surgical site drain and patients who did not receive a drain. Post-operative surgical variables included length of stay (LOS), drain length, number of antibiotics given, and type of post-operative infection. Univariate and multivariate statistical analysis was conducted. RESULTS A total of 671 patients were included in the current study, 386 (57.5%) with and 285 (42.5%) without the drain. The overall infection rate was 5.7% with 6.22% among patients with the drain compared to 4.91% in patients without drain. The univariate analysis identified the following variables to be significantly associated with the infection: total number of surgical levels, spinal region, blood loss, redosing of antibiotics, length of stay, length of drain placement, and number of antibiotics (P < 0.05). However, the multivariate analysis none of the predictors was significant. CONCLUSIONS The current study shows that the placement of drain does not increase rate of infection, irrespective of levels, length of surgery, or approach.
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Affiliation(s)
- Zorica Buser
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Ki-Eun Chang
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ronald Kall
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Blake Formanek
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Anush Arakelyan
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Sarah Pak
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Betsy Schafer
- Spine Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - John C Liu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jeffrey C Wang
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Patrick Hsieh
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Thomas C Chen
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Echt M, Poeran J, Zubizarreta N, Girdler SJ, Mazumdar M, Galatz LM, Memtsoudis SG, Hecht AC, Chaudhary S. Enhanced Recovery Components for Posterior Lumbar Spine Fusion: Harnessing National Data to Compare Protocols. Clin Spine Surg 2022; 35:E194-E201. [PMID: 34321395 DOI: 10.1097/bsd.0000000000001242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 06/23/2021] [Indexed: 10/20/2022]
Abstract
STUDY DESIGN This was a retrospective cohort study. OBJECTIVE The aim of this study was to assess the most commonly used components of enhanced recovery after surgery (ERAS) combinations and their relative effectiveness. SUMMARY OF BACKGROUND DATA Data is lacking on use and effectiveness of various ERAS combinations which are increasingly used in spine surgery. MATERIALS AND METHODS Posterior lumbar fusion cases were extracted from the Premier Healthcare claims database (2006-2016). Seven commonly included components in spine ERAS protocols were identified: (1) multimodal analgesia, (2) tranexamic acid, (3) antiemetics on the day of surgery, (4) early physical therapy, (5) no urinary catheter, (6) no patient-controlled analgesia, and (7) no wound drains. Outcomes were: length of stay, "any complication," blood transfusion, and hospitalization cost. Mixed-effects models measured associations between the most common ERAS combinations and outcomes, separately for 2006-2012 and 2013-2016. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported. RESULTS Among 97,419 (74%; 2006-2012) and 34,932 (26%; 2013-2016) cases ERAS component variations decreased over time. The most commonly used combinations included multimodal analgesia, antiemetics, early physical therapy, avoidance of a urinary catheter, patient-controlled analgesia and drains (10% n=9401 and 19% n=6635 in 2006-2012 and 2013-2016, respectively), and did not include tranexamic acid. Multivariable models revealed minor differences between ERAS combinations in terms of length of stay and costs. The most pronounced beneficial effects in 2006-2012 were seen for the second most commonly (compared with less often) used ERAS combination(s) in terms of blood transfusion (OR: 0.65; CI: 0.59-0.71) and "any complication" (OR: 0.73; CI: 0.66-0.80), both P<0.05. In 2013-2016 the third most commonly used ERAS combination showed the strongest effect: blood transfusion OR: 0.63; CI: 0.50-0.78, P<0.05. CONCLUSIONS ERAS component variations decreased over time; maximum benefits were particularly seen in terms of transfusion and complication risk reduction. These findings may inform future ERAS utilization and clinical trials comparing various ERAS protocols.
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Affiliation(s)
- Murray Echt
- Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx
- Department of Orthopedics
| | - Jashvant Poeran
- Department of Orthopedics
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai
| | - Nicole Zubizarreta
- Department of Orthopedics
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai
| | | | - Madhu Mazumdar
- Department of Orthopedics
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai
| | - Leesa M Galatz
- Department of Orthopedics
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care, and Pain Management, Hospital for Special Surgery, New York, NY
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10
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Abstract
Symptomatic postoperative epidural hematomas are rare, with an incidence of 0.10% to 0.69%. Risk factors have varied in the literature, but multiple studies have reported advanced age, preoperative or postoperative coagulopathy, and multilevel laminectomy as risk factors for hematoma. The role of pharmacologic anticoagulation after spine surgery remains unclear, but multiple studies suggest it can be done safely with a low risk of epidural hematoma. Prophylactic suction drains have not been found to lower hematoma incidence. Most symptomatic postoperative epidural hematomas present within the first 24 to 48 hours after surgery but can present later. Diagnosis of a symptomatic hematoma requires correlation of clinical signs and symptoms with a compressive hematoma on MRI. Patients will usually first complain of a marked increase in axial pain, followed by radicular symptoms in the extremities, followed by motor weakness and sphincter dysfunction. An MRI should be obtained emergently, and if it confirms a compressive hematoma, surgical evacuation should be carried out as quickly as possible. The prognosis for neurologic improvement after evacuation depends on the time delay and the degree of neurologic impairment before evacuation.
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Affiliation(s)
- Mladen Djurasovic
- Norton Leatherman Spine Center, 210 East Gray Street, #900, Louisville, KY 40202, USA.
| | - Chad Campion
- Norton Leatherman Spine Center, 210 East Gray Street, #900, Louisville, KY 40202, USA
| | - John R Dimar
- Norton Leatherman Spine Center, 210 East Gray Street, #900, Louisville, KY 40202, USA
| | - Steven D Glassman
- Norton Leatherman Spine Center, 210 East Gray Street, #900, Louisville, KY 40202, USA
| | - Jeffrey L Gum
- Norton Leatherman Spine Center, 210 East Gray Street, #900, Louisville, KY 40202, USA
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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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Mikhail C, Pennington Z, Arnold PM, Brodke DS, Chapman JR, Chutkan N, Daubs MD, DeVine JG, Fehlings MG, Gelb DE, Ghobrial GM, Harrop JS, Hoelscher C, Jiang F, Knightly JJ, Kwon BK, Mroz TE, Nassr A, Riew KD, Sekhon LH, Smith JS, Traynelis VC, Wang JC, Weber MH, Wilson JR, Witiw CD, Sciubba DM, Cho SK. Minimizing Blood Loss in Spine Surgery. Global Spine J 2020; 10:71S-83S. [PMID: 31934525 PMCID: PMC6947684 DOI: 10.1177/2192568219868475] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
STUDY DESIGN Broad narrative review. OBJECTIVE To review and summarize the current literature on guidelines, outcomes, techniques and indications surrounding multiple modalities of minimizing blood loss in spine surgery. METHODS A thorough review of peer-reviewed literature was performed on the guidelines, outcomes, techniques, and indications for multiple modalities of minimizing blood loss in spine surgery. RESULTS There is a large body of literature that provides a consensus on guidelines regarding the appropriate timing of discontinuation of anticoagulation, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements prior to surgery. Additionally, there is a more heterogenous discussion the utility of preoperative autologous blood donation facilitated by erythropoietin and iron supplementation for healthy patients slated for procedures with high anticipated blood loss and for whom allogeneic transfusion is likely. Intraoperative maneuvers available to minimize blood loss include positioning and maintaining normothermia. Tranexamic acid (TXA), bipolar sealer electrocautery, and topical hemostatic agents, and hypotensive anesthesia (mean arterial pressure (MAP) <65 mm Hg) should be strongly considered in cases with larger exposures and higher anticipated blood loss. There is strong level 1 evidence for the use of TXA in spine surgery as it reduces the overall blood loss and transfusion requirements. CONCLUSION As the volume and complexity of spinal procedures rise, intraoperative blood loss management has become a pivotal topic of research within the field. There are many tools for minimizing blood loss in patients undergoing spine surgery. The current literature supports combining techniques to use a cost- effective multimodal approach to minimize blood loss in the perioperative period.
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Affiliation(s)
| | | | - Paul M. Arnold
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Norman Chutkan
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - John G. DeVine
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Daniel E. Gelb
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Fan Jiang
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Brian K. Kwon
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas E. Mroz
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ahmad Nassr
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - K. Daniel Riew
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lali H. Sekhon
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | | | | | | | | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,Samuel K. Cho, Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York, NY 10029, USA.
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13
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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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Do postoperative drain volumes correlate with intraoperative blood loss and postoperative transfusion requirements in posterior spinal fusion for adolescent idiopathic scoliosis? J Pediatr Orthop B 2019; 28:368-373. [PMID: 30431538 DOI: 10.1097/bpb.0000000000000568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Most studies have excluded postoperative drain volumes in analyzing blood loss associated with scoliosis surgery. We sought to analyze patient and surgical factors that influenced postoperative drain outputs. A retrospective review was conducted on 50 consecutive patients who had undergone posterior spinal fusion with pedicle screw instrumentation and subfascial drain placement over a 6-year period at a single institution for adolescent idiopathic scoliosis. Postoperative drain volumes were correlated to patient factors, surgical variables, and change in postoperative hemoglobin values. The association between drain output volumes and the need for allogeneic blood transfusion was also analyzed using univariate and multivariate analysis. Total postoperative drain volume positively correlated with Cell Saver volume (r=0.28, P=0.049), units of packed red blood cells transfused intraoperatively (r=0.31, P=0.03), and a number of Ponte osteotomies (r=0.43, P=0.002). On the basis of multiple linear regression analysis, only the number of osteotomies performed was associated with increasing total drain volume (R=0.25, P=0.003). Total drain output did not correlate with postoperative change in hemoglobin (P=0.85), the need for postoperative blood transfusion (P=0.22), or the total volume of blood transfused perioperatively (P=0.06). Patients with large intraoperative blood loss or multiple osteotomies are more likely to have higher postoperative drain volumes. Drain volume alone, however, should not be used as a trigger for recommending a postoperative blood transfusion.
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15
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Impact of closed suction drainage after surgical fixation of acetabular fractures. Arch Orthop Trauma Surg 2019; 139:907-912. [PMID: 30687873 DOI: 10.1007/s00402-019-03110-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The purpose of the present study was to evaluate the prevalence of closed suction drainage after a Kocher-Langenbeck (K-L) approach for surgical fixation of acetabular fractures and to determine the impact of closed suction drainage on patient outcomes. METHODS This retrospective study reports on 171 consecutive patients that presented to a single level I trauma center for surgical fixation of an acetabular fracture. Medical records were reviewed to evaluate the use of closed suction drains. The primary outcomes measures were rate of packed red blood cell (PRBC) transfusion and length of hospital stay (LOS). Secondary outcome measures were 30-day post-operative wound complication and 1-year deep infection rates. RESULTS Of the 171 patients included in this study, 140 (82%) patients were treated with drains. There was a significant association between the use of closed suction drainage and post-operative blood transfusion rate (p = 0.002). Thirty-five patients (25%) treated with drains required a post-operative blood transfusion compared to 0% in the no drain cohort. Regarding the total number of drains used, for every additional closed suction drain that was placed beyond a single drain, the odds of receiving a blood transfusion doubled (p = 0.002). Use of closed suction drainage was associated with a significantly longer LOS (p = 0.015), and no difference in wound complication or deep infection rates. CONCLUSION The use of closed suction drains for treatment of acetabular fractures using a K-L approach is associated with increased rates of blood transfusion and increased length of hospital stay, with no impact on surgical site infection rates. The results of this study suggest against routine drain usage in acetabular surgery.
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Closed Wound Subfascial Suction Drainage in Posterior Fusion Surgery for Adolescent Idiopathic Scoliosis: A Prospective Randomized Control Study. Spine (Phila Pa 1976) 2019; 44:377-383. [PMID: 30299415 DOI: 10.1097/brs.0000000000002892] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective randomized control study. OBJECTIVE The aim of this study was to compare the complication rate in adolescent idiopathic scoliosis (AIS) posterior spinal fusion (PSF) surgery with and without drainage. SUMMARY OF BACKGROUND DATA PSF is the mainstay of surgical treatment for AIS. Drains are commonly used despite contradictory findings in the literature for their having any clear advantage. METHODS A total of 100 AIS patients undergoing instrumented PSF were blindly randomized into two groups of either a deep drain or no drain. The collected data included wound follow-up findings, hemoglobin, hematocrit, vital signs and fever levels, and mean 20 months follow-up. RESULTS Fifty-two patients were randomly allocated to the "no drain" group and 48 to the "drain" group. There were no differences in patient characteristics, surgical data, and hemoglobin and hematocrit levels between the two groups. Only 4 units of packed cells were given in total. Fever during the first postoperative 1 to 3 days was equal, but increased in the no drain group on day 6 (P = 0.017). Length of hospitalization was equal (6 days) for all the patients. The mean follow-up period was 20 months [8.5-30.7 (SD 6.4)]. Complications included one case (1.9%) of pneumonia in the "no-drain" group, wound dehiscence in two cases (3.8%) in the "no-drain" group and in one case (2.1%) in the "drain" group, and two cases (3.8%) of superficial wound infection in the "no-drain" group. There was no case of deep infection in either group. CONCLUSION The current results indicate that there is no advantage to deep drainage in AIS patients undergoing PSF. The number of wound healing complications was low and identical for both the drain and no-drain groups. LEVEL OF EVIDENCE 2.
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17
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Herrick DB, Tanenbaum JE, Mankarious M, Vallabh S, Fleischman E, Kurra S, Burke SM, Roguski M, Mroz TE, Lavelle WF, Florman JE, Riesenburger RI. The relationship between surgical site drains and reoperation for wound-related complications following posterior cervical spine surgery: a multicenter retrospective study. J Neurosurg Spine 2018; 29:628-634. [DOI: 10.3171/2018.5.spine171313] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 05/11/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEUse of surgical site drains following posterior cervical spine surgery is variable, and its impact on outcomes remains controversial. Studies of drain use in the lumbar spine have suggested that drains are not associated with reduction of reoperations for wound infection or hematoma. There is a paucity of studies examining this relationship in the cervical spine, where hematomas and infections can have severe consequences. This study aims to examine the relationship between surgical site drains and reoperation for wound-related complications following posterior cervical spine surgery.METHODSThis study is a multicenter retrospective review of 1799 consecutive patients who underwent posterior cervical decompression with instrumentation at 4 tertiary care centers between 2004 and 2016. Demographic and perioperative data were analyzed for associations with drain placement and return to the operating room.RESULTSOf 1799 patients, 1180 (65.6%) had a drain placed. Multivariate logistic regression analysis identified history of diabetes (OR 1.37, p = 0.03) and total number of levels operated (OR 1.32, p < 0.001) as independent predictors of drain placement. Rates of reoperation for any surgical site complication were not different between the drain and no-drain groups (4.07% vs 3.88%, p = 0.85). Similarly, rates of reoperation for surgical site infection (1.61% vs 2.58%, p = 0.16) and hematoma (0.68% vs 0.48%, p = 0.62) were not different between the drain and no-drain groups. However, after adjusting for history of diabetes and the number of operative levels, patients with drains had significantly lower odds of returning to the operating room for surgical site infection (OR 0.48, p = 0.04) but not for hematoma (OR 1.22, p = 0.77).CONCLUSIONSThis large study characterizes current practice patterns in the utilization of surgical site drains during posterior cervical decompression and instrumentation. Patients with drains placed did not have lower odds of returning to the operating room for postoperative hematoma. However, the authors’ data suggest that patients with drains may be less likely to return to the operating room for surgical site infection, although the absolute number of infections in the entire population was small, limiting the analysis.
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Affiliation(s)
- Daniel B. Herrick
- 1Department of Neurosurgery, Tufts Medical Center
- 2Department of Neurosurgery, Tufts University School of Medicine, Boston, Massachusetts
| | - Joseph E. Tanenbaum
- 3Case Western Reserve University School of Medicine, Cleveland
- 5Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, Ohio
| | - Marc Mankarious
- 1Department of Neurosurgery, Tufts Medical Center
- 2Department of Neurosurgery, Tufts University School of Medicine, Boston, Massachusetts
| | - Sagar Vallabh
- 3Case Western Reserve University School of Medicine, Cleveland
- 4Center for Spine Health, Cleveland Clinic, Cleveland
| | - Eitan Fleischman
- 4Center for Spine Health, Cleveland Clinic, Cleveland
- 6Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Swamy Kurra
- 7Department of Orthopedic Surgery, SUNY Upstate Medical University, Syracuse, New York
| | - Shane M. Burke
- 1Department of Neurosurgery, Tufts Medical Center
- 2Department of Neurosurgery, Tufts University School of Medicine, Boston, Massachusetts
| | - Marie Roguski
- 1Department of Neurosurgery, Tufts Medical Center
- 2Department of Neurosurgery, Tufts University School of Medicine, Boston, Massachusetts
| | - Thomas E. Mroz
- 4Center for Spine Health, Cleveland Clinic, Cleveland
- 8Department of Neurosurgery, Cleveland Clinic, Cleveland
- 9Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio; and
| | - William F. Lavelle
- 7Department of Orthopedic Surgery, SUNY Upstate Medical University, Syracuse, New York
| | | | - Ron I. Riesenburger
- 1Department of Neurosurgery, Tufts Medical Center
- 2Department of Neurosurgery, Tufts University School of Medicine, Boston, Massachusetts
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Role of closed drain after multi-level posterior spinal surgery in adults: a randomised open-label superiority trial. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 28:146-154. [DOI: 10.1007/s00586-018-5791-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 07/02/2018] [Accepted: 10/04/2018] [Indexed: 10/28/2022]
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Adogwa O, Khalid SI, Elsamadicy AA, Voung VD, Lilly DT, Desai SA, Sergesketter AR, Cheng J, Karikari IO. The use of subfascial drains after multi-level anterior cervical discectomy and fusion: does the data support its use? JOURNAL OF SPINE SURGERY 2018; 4:227-232. [PMID: 30069511 DOI: 10.21037/jss.2018.05.10] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Subfascial drains are routinely used after multi-level anterior cervical discectomy and fusion (ACDF) procedures despite little evidence to support their use. Proponents of drain use argue that drain placement reduces the incidence of post-operative hematomas and surgical site infections (SSI). The aim of this study is to determine whether the use of subfascial drains after multi-level ACDFs are associated with a decreased incidence of hematomas and SSIs. Methods This is a retrospective study of 321 consecutive adult patients (18 years and older) with degenerative cervical stenosis that undergoing an index multi-level ACDF procedure. Only patients undergoing multilevel ACDF were included in the study. Patients were separated into one of two groups depending whether a subfascial drain was placed during surgery. The decision to place a drain was based on surgeon preference. Baseline characteristics, operative details, as well as rates of hematoma formation and SSIs were gathered by direct medical record review. Results Of the 321 patients enrolled in the study, 58 (18%) patients had subfascial drains placed at the time of surgery. Baseline demographics and co-morbidities were similar between both cohorts; however, on average, patients in the "Drain Use" cohort were older when compared to those in the "No Drain" cohort (64 vs. 56 years old, P<0.0001). There was no observed difference between both groups in the incidence of post-operative hematoma formation (P=0.99) or SSI (P=0.99). Five percent of patients in the "Drain Use" cohort required a post-operative allogenic blood transfusion compared to less than 1% (0.4%) in the comparison cohort. The duration of hospital stay was almost 2-fold longer in the in the "Drain use" cohort compared to the comparison cohort ("Drain Use": 2.82 days vs. "No Drain": 1.58 days, P<0.0001). Conclusions The use of subfascial drains after multi-level ACDF procedures were not associated with a decreased incidence of hematoma formation or SSIs. In fact, patients in which a subfascial drain was used were 14 times more likely to require a post-operative blood transfusion and with an almost 2-fold increase in the duration of in-hospital stay.
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Affiliation(s)
- Owoicho Adogwa
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Syed I Khalid
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | | | - Victoria D Voung
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Daniel T Lilly
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Shyam A Desai
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | | | - Joseph Cheng
- Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | - Isaac O Karikari
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
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Adogwa O, Elsamadicy AA, Sergesketter AR, Shammas RL, Vatsia S, Vuong VD, Khalid S, Cheng J, Bagley CA, Karikari IO. Post-operative drain use in patients undergoing decompression and fusion: incidence of complications and symptomatic hematoma. JOURNAL OF SPINE SURGERY 2018; 4:220-226. [PMID: 30069510 DOI: 10.21037/jss.2018.05.09] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Surgical drains are commonly used after spine surgery to minimize infection and hematoma formation. The aim of this study was to determine the incidence of post-operative complications after spinal decompression and fusion with and without a subfascial drain. Methods The medical records of 139 adult (≥18 years old) spinal deformity patients undergoing elective spinal decompression and fusion at a major academic institution were reviewed. We identified 116 (83.5%) who had a post-operative drain and 23 (16.5%) who did not have a postoperative drain (No-Drain: n=23; Drain-Use: n=116). Patient demographics, comorbidities, intra- and post-operative complication rates were collected for each patient. The primary outcome investigated in this study was the rate of post-operative complications, specifically surgical site infections (SSI) and hematoma formation. Results Patient demographics and comorbidities were similar between both cohorts, with the body mass index (BMI) slightly higher in the Drain-Use cohort (No-Drain: 26.1 kg/m2vs. Drain-Use: 29.1 kg/m2, P=0.02). Operative time and the median number of levels fused were similar between the cohorts. The postoperative complications profile was similar between both cohorts, including deep and superficial SSIs (P=0.52 and P=0.66, respectively), and incidence of hematoma formation (P=0.66). Length of hospital stay (LOS) was significantly higher for the Drain-use cohort compared to the No-Drain cohort (5.0 vs. 2.8 days, P<0.0001). There were no significant differences in the 30-day hospital readmission rate or incidence of 30-day wound dehiscence, draining wound, incision & drainage (I & D), or bleeding between both patient groups. Conclusions Our study suggests that the use of postoperative subfascial drains in patients undergoing spinal decompression with fusion may not be associated with a reduction in SSIs or hematoma formation.
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Affiliation(s)
- Owoicho Adogwa
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Aladine A Elsamadicy
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | | | - Ronnie L Shammas
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Sohrab Vatsia
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Victoria D Vuong
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Syed Khalid
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Joseph Cheng
- Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | - Carlos A Bagley
- Department of Neurosurgery, University of Texas Southwestern, Dallas TX, USA
| | - Isaac O Karikari
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
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Davidoff CL, Rogers JM, Simons M, Davidson AS. A systematic review and meta-analysis of wound drains in non-instrumented lumbar decompression surgery. J Clin Neurosci 2018; 53:55-61. [PMID: 29680443 DOI: 10.1016/j.jocn.2018.04.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 04/09/2018] [Indexed: 02/03/2023]
Abstract
Wound drains are routinely used in lumbar decompressive surgery (LDS). However, it remains unclear whether this practice helps to prevent symptomatic epidural hematoma formation and associated complications, particularly following non-instrumented procedures. A systematic review and meta-analysis was therefore completed to critically appraise the literature. The search protocol was conducted using the Ovid MEDLINE, EMBASE, Scopus, Cochrane Library, and Google Scholar databases. Articles meeting the following criteria were included: (i) examined patients undergoing LDS; (ii) included cases receiving post-operative wound drains; (iii) detailed adverse outcomes including symptomatic epidural hematomas or wound infection; and (iv) were published in English in a peer-reviewed journal. Pooled risk differences (RD) for adverse outcomes were calculated using Comprehensive Meta-Analysis software. Three Level 1b prospective randomized studies and five Level 2b retrospective cohort studies were included, from which 5327 cases were identified as having received a surgical drain and 773 were identified as having received no drainage following non-instrumented LDS. There was no difference between groups in the risk of symptomatic epidural hematoma (RD = 0.02; 95% CI -0.02 - 0.06, p = 0.28) or post-operative infection (RD = 0.00; 95% CI -0.01 - 0.01, p = 0.91). In conclusion, symptomatic epidural hematomas and infection are rare following non-instrumented LDS, with incidence rates unaffected by the routine use of wound drainage.
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Affiliation(s)
- Christopher L Davidoff
- Macquarie Neurosurgery, Macquarie University Hospital, Sydney, New South Wales 2109, Australia; Department of Neurosurgery, Nepean Hospital, Penrith, New South Wales 2750, Australia.
| | - Jeffrey M Rogers
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, New South Wales 2109, Australia
| | - Mary Simons
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, New South Wales 2109, Australia
| | - Andrew S Davidson
- Macquarie Neurosurgery, Macquarie University Hospital, Sydney, New South Wales 2109, Australia; Department of Neurosurgery, Nepean Hospital, Penrith, New South Wales 2750, Australia; Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, New South Wales 2109, Australia
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Aspirin therapy discontinuation and intraoperative blood loss in spinal surgery: a systematic review. Neurosurg Rev 2018; 41:1029-1036. [PMID: 29362950 DOI: 10.1007/s10143-018-0945-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 01/10/2018] [Indexed: 10/18/2022]
Abstract
The purpose of this study was to determine the effect of aspirin therapy discontinuation on intraoperative blood loss in spinal surgery. We searched Medline and Google Scholar 1946 to January 2017 inclusive for case-control studies, cohort studies, and controlled trials reporting intraoperative blood loss during spinal surgery in patients on pre-operative aspirin. Other outcome measures reported in the eligible studies were collected as secondary outcomes. Two reviewers independently screened and extracted data from each study. Five retrospective cohort and two case-control studies were eligible for inclusion. Of the 1173 patients identified, 587 patients were never on aspirin (Ax), 416 patients had aspirin discontinued before surgery (Ad), ranging from 3 to 10 days, and 170 patients had aspirin continued until surgery (Ac). Six out of seven studies reported no statistically significant difference in intraoperative blood loss irrespective of aspirin discontinuation. Meta-analysis was not possible due to high risk of bias. Of the secondary outcome measures, operative time and postoperative complications were most commonly reported. One of six studies evaluating operative time reported a significantly longer operative time in the Ad group compared with the Ac group. The overall risk of postoperative haematoma in Ax, Ad, and Ac groups is 0.2% (n/N = 1/587), 0.2% (n/N = 1/416), and 1.2% (n/N = 2/170), respectively. No study reported a statistically significant difference in postoperative complications. There is no strong evidence demonstrating a difference in intraoperative blood loss, operation time, and postoperative complications, irrespective of aspirin discontinuation. This is, however, based on a limited number of studies and higher-quality research is required to answer this question with a higher degree of confidence.
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Brazolino MAN, Jacob Júnior C, Cardoso IM, Batista Júnior JL, Maia TC, Debom TG, Roncaglio B. POSTOPERATIVE COMPLICATIONS OF SUCTION DRAIN IN PATIENTS SUBMITTED TO 1-LEVEL LUMBAR ARTHRODESIS. COLUNA/COLUMNA 2017. [DOI: 10.1590/s1808-185120171604175959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: To evaluate the complications inherent in the use or not of continuous suction drain in postoperative period of patients undergoing 1-level lumbar arthrodesis. Methods: An analytical, comparative, randomized study was performed with a sample of 60 patients submitted to 1-level 360o lumbar arthrodesis with TLIF technique, 30 of whom used the suction drain for three days after surgery and another 30 did not use the suction drain in the postoperative period. The complications that occurred on the 3rd, 14th, and 28th postoperative days of patients of both groups and the Visual Analog Scale for pain were evaluated and compared. The complications assessed were seroma, superficial infection and suture dehiscence. Results: A total of 23.3% surgical wound complications were found, the most frequent being seroma (16%). In total, each group presented seven complications. There were no statistical differences observed in the evaluation of seroma, infection, wound dehiscence on the 3rd, 14th, and 28th postoperative days in both groups. Conclusion: The use or not of suction drain in 1-level lumbar surgeries does not interfere with complications such as seroma, infection, and suture dehiscence.
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Hung PI, Chang MC, Chou PH, Lin HH, Wang ST, Liu CL. Is a drain tube necessary for minimally invasive lumbar spine fusion surgery? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 26:733-737. [DOI: 10.1007/s00586-016-4672-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 05/26/2016] [Accepted: 06/18/2016] [Indexed: 12/28/2022]
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