Wound Closure in Nonidiopathic Scoliosis: Does Closure Matter?

Wound closure techniques for spinoplastic surgery: a review of the literature

PURPOSE

The approach to skin closure in spinal surgery is dependent on surgeon preference and experience. Wound complications, including dehiscence and surgical site infection (SSI), are common following spine surgery. The authors reviewed various wound closure techniques employed in spinal surgery.

METHODS

A systematic review was conducted to identify articles comparing wound closure techniques after posterior spinal surgery. Articles that employed experimental or observational cohort study designs and reported rates of SSI, dehiscence, or scarring following spinal surgery were included.

RESULTS

Eight studies examining closure techniques of the skin were identified: five retrospective cohort studies and three randomized-controlled trials. No differences in the incidence of SSI were reported based on suture technique, although staples were associated with higher SSI rates in single level spinal fusion, and barbed suture resulted in decreased wound complications. The use of intracutaneous sutures was associated with a higher incidence of wound dehiscence when compared to tension-relieving far-near near-far suture (FNS) and far-near near-far interrupted point (FNP) sutures. However, the latter two also resulted in the highest rates of delayed wound healing (i.e., time to fully heal). Modified Allgöwer-Donati suture (MADS) resulted in smaller scar area when compared to vertical mattress suture.

CONCLUSION

Significant differences exist in wound healing when comparing suture techniques in spinal surgery. Surgical staples allow for faster closing time, but are also associated with higher wound complications. Intracutaneous sutures appear to have higher rates of dehiscence compared to vertical mattress suture but display faster wound healing. Future studies are necessary to elucidate contributory factors, including local ischemia and changes in tensile forces.

LEVEL OF EVIDENCE

Level IV.

What is the role of plastic surgery for incisional closures in pediatric spine surgery? Results from a pediatric spine study group survey

Current best practice guidelines recommend a plastics-style multilayer wound closure for high-risk pediatric spine surgery. However, plastic surgery closure of spinal incisions remains controversial. This study investigates surgeon perceptions and practice patterns regarding plastic surgery multilayered closure (PMC) in pediatric spine surgery. All surgeons in an international pediatric spine study group received a 30-question survey assessing incisional closure practices, frequency of plastic surgery collaboration, and drain management. Relationship to practice size, setting, geographic region, and individual diagnoses were analyzed. 87/178 (49%) surgeons responded from 79% of participating sites. Plastics utilization rates differed by diagnosis: neuromuscular scoliosis 16.9%, early onset scoliosis 7.8%, adolescent idiopathic scoliosis 2.8% (P < 0.0001). Plastics were used more for early onset scoliosis [odds ratio (OR) 18.5, 95% confidence interval (CI): 8.5, 40.2; P < 0.001] and neuromuscular scoliosis [OR 29.2 (12.2, 69.9); P < 0.001] than adolescent idiopathic scoliosis. Plastics use was unrelated to practice size, setting, or geographic region (P ≥ 0.09). Respondents used plastics more often for spina bifida and underweight patients compared to all other indications (P < 0.001). Compared to orthopaedic management, drains were utilized more often by plastic surgery (85 vs. 21%, P = 0.06) and for longer durations (P = 0.001). Eighty-nine percent of surgeons felt plastics increased operative time (58 ± 37 min), and 34% felt it increased length of hospitalization. Surgeons who routinely utilize plastics were more likely to believe PMC decreases wound complications (P = 0.007). The perceived benefit of plastic surgery varies, highlighting equipoise among pediatric spine surgeons. An evidence-based guideline is needed to optimize utilization of plastics in pediatric spine surgery.

Systematic Review of Prophylactic Plastic Surgery Closure to Prevent Postoperative Wound Complications Following Spine Surgery

Spinal surgeries are increasingly performed in the United States, but complication rates can be unacceptably high at up to 26%. Consequently, plastic surgeons (PS) are sometimes recruited by spine surgeons (SS) for intraoperative assistance with soft tissue closures. An electronic multidatabase literature search was systematically conducted to determine whether spinal wound closure performed by PS minimizes postoperative wound healing complications when compared to closure by SS (neurosurgical or orthopedic), with the hypothesis that closures by PS minimizes incidence of complications. All published studies involving patients who underwent posterior spinal surgery with closure by PS or SS at index spine surgery were identified. Filtering by exclusion criteria identified 10 studies, 4 of which were comparative in nature and included both closures by PS and SS. Of these 4, none reported significant differences in postoperative outcomes between the groups. Across all studies, PS were involved in cases with higher baseline risk for wound complications and greater comorbidity burden. Closures by PS were significantly more likely to have had prior chemotherapy in 2 of the 4 (50%) studies (P = 0.014, P < 0.001) and radiation in 3 of the 4 (75%) studies (P < 0.001, P < 0.01, P < 0.001). In conclusion, closures by PS are frequently performed in higher risk cases, and use of PS in these closures may normalize the risk of wound complications to that of the normal risk cohort, though the overall level of evidence of the published literature is low.

Plastic surgeon closure is comparable to orthopedic closure when a perioperative optimization protocol is instituted for pediatric patients with neuromuscular scoliosis

BACKGROUND CONTEXT

Since 2015, plastic multilayer closure (PMC) has been gaining attraction due to improved wound healing outcomes for medically complex patients. Plastic multilayer closure has been readily used for complex spine surgery closures in patients susceptible to wound healing issues (ie, dehiscence, surgical site infection [SSI]). However, PMC requires extensive soft tissue manipulation compared with standard orthopedic spine surgeon closure (SOC) and can result in extended operative times, increased transfusion rates, and more frequent returns to the operating room.

PURPOSE

From 2016 to 2019, our institution implemented a perioperative protocol designed to decrease postoperative complication rates in NMS patients. A retrospective cohort study was performed to determine if PMC imparted advantages over SOC above and beyond that from the perioperative protocol.

STUDY DESIGN/SETTING

Retrospective study at a single academic institution.

PATIENT SAMPLE

Eighty-one pediatric patients with neuromuscular scoliosis undergoing spinal fixation surgery.

OUTCOME MEASURES

Postoperative wound complications such as surgical site infection, hematoma, and superficial/deep dehiscence were the main outcome measures. Respiratory and neuromuscular complications along with duration of surgery were also recorded.

METHODS

A retrospective review was conducted of NMS patients undergoing spinal fixation at a single academic pediatric hospital over 4 years. Cases were labeled as SOC (n=41) or PMC (n=40) based on the closure technique applied. Reported 90-day complications were evaluated as the primary outcome.

RESULTS

Of the 81 reviewed patients, 45 reported complications, roughly equal between the study groups. While we found no statistically significant differences in rates of postoperative complications or SSIs, SOC cases were 30 minutes shorter on average with fewer returns to the operating room for additional surgery.

CONCLUSIONS

With the implementation of our perioperative protocol for NMS patients, PMC did not result in fewer complications than SOC but the surgeries did take longer.

In Vitro and In Vivo Evaluation of Ultrasound-Triggered Release From Novel Spinal Device

OBJECTIVES

Bacterial infection following spinal fusion is a major clinical concern with up to 20% incidence. An ultrasound-triggered bulk-release system to combat postsurgical bacterial survival was designed and evaluated.

METHODS

Polylactic acid (PLA) clips were loaded with vancomycin (VAN) and microbubbles (Sonazoid, GE HealthCare) in vitro. Stability was determined over 14 days. VAN-loaded clips were submerged in water and insonated using a Logiq E10 scanner (GE HealthCare) with a curvilinear C6 probe. Doppler-induced VAN release was quantified using spectrophotometry. For in vivo testing, clips were loaded with methylene blue (MeB) solution and Sonazoid. These clips were implanted into a rabbit along the spine at L2 and L5, as well as a pig at L1 and L3, then insonated in Doppler mode using the C6 probe.

RESULTS

Sonazoid microbubbles were better preserved when incubated in VAN compared with distilled water at 4°C, 25°C, and 37°C incubation temperatures (P = .0131). Contrast enhancement was observed from both solutions when incubated at 4°C storage conditions. Insonated clips achieved average cumulative VAN release of 101.8 ± 2.8% (81.4 ± 2.8 mg) after 72 hours. Uninsonated clips had only 0.3 ± 0.1% (0.3 ± 0.1 mg) average cumulative VAN release (P < .0001). Clips retrieved from the rabbit did not rupture with insonation nor produce MeB staining of surrounding tissues. In the pig, the PLA film was visibly ruptured and MeB tissue was observed following insonation, whereas the uninsonated clip was intact.

CONCLUSION

These results demonstrate ultrasound-triggered release of an encapsulated prophylactic solution and provide an important proof-of-concept for continuing large animal evaluations for translational merit.

Update on the Diagnosis and Management of Early-onset Scoliosis

PURPOSE OF REVIEW

In this article, we review the most recent advancements in the approaches to EOS diagnosis and assessment, surgical indications and options, and basic science innovation in the space of early-onset scoliosis research.

RECENT FINDINGS

Early-onset scoliosis (EOS) covers a diverse, heterogeneous range of spinal and chest wall deformities that affect children under 10 years old. Recent efforts have sought to examine the validity and reliability of a recently developed classification system to better standardize the presentation of EOS. There has also been focused attention on developing safer, informative, and readily available imaging and clinical assessment tools, from reduced micro-dose radiographs, quantitative dynamic MRIs, and pulmonary function tests. Basic science innovation in EOS has centered on developing large animal models capable of replicating scoliotic deformity to better evaluate corrective technologies. And given the increased variety in approaches to managing EOS in recent years, there exist few clear guidelines around surgical indications across EOS etiologies. Despite this, over the past two decades, there has been a considerable shift in the spinal implant landscape toward growth-friendly instrumentation, particularly the utilization of MCGR implants. With the advent of new biological and basic science treatments and therapies extending survivorship for disease etiologies associated with EOS, the treatment for EOS has steadily evolved in recent years. With this has come a rising volume and variation in management options for EOS, as well as the need for multidisciplinary and creative approaches to treating patients with these complex and heterogeneous disorders.

Early Complications After Posterior Spinal Fusion in Patients With Rett Syndrome

BACKGROUND

Neuromuscular scoliosis in Rett syndrome (RS) is common, progressive, and often requires posterior spinal fusion (PSF). While PSF is associated with improved overall outcomes, there is a paucity of information describing complications. We aimed to report the postoperative complications, readmissions, and reoperations for patients with RS undergoing PSF.

METHODS

Female pediatric patients with RS treated by PSF with segmental instrumentation, with or without concurrent pelvis fixation, during January 2012 to August 2022 were included. Preoperative patient characteristics, intraoperative data (estimated blood loss, cell saver, packed red blood cells transfused), postoperative complications according to the Modified Clavien-Dindo-Sink classification within 90 days, unplanned readmissions within 30 days, and unplanned reoperations within 90 days were recorded.

RESULTS

A total of 25 females were included. The mean (SD) age at surgery was 12.9 (1.8) years and the mean follow-up of 38.6 (24.9) months. The mean preoperative major coronal curve was 79 degrees (23 degrees) which decreased to 32 degrees (15 degrees) by the last follow-up ( P <0.001). The median estimated blood loss was 600 mL and length of stay was 7 days. There were 81 total postoperative complications (3.2 complications/patient). Eight (32%) had grade IVa complications (disseminated intravascular coagulopathy, hypotensive shock, respiratory failure, chronic urosepsis). Five (20%) patients experienced seizures, 48% had pulmonary complications, and 56% had gastrointestinal complications. There were 3 readmissions (12%) within 30 days for pneumonia and 2 (8%) reoperations (an incision and drainage and C2-T2 fusion for significant kyphosis) within 90 days. One patient also had their fusion extended to the pelvis 1 year later. There were more nonambulatory patients in the group fused to the pelvis, but otherwise no differences between those fused and unfused to the pelvis.

CONCLUSIONS

This is the largest review of early postoperative complications for patients with RS who underwent PSF. PSF effectively reduced the major coronal curve, but surgeons and families should be aware of a high postoperative seizure and respiratory complication rate, as well as 8% having reoperations within 90 days and 12% being readmitted within 30 days.

LEVEL OF EVIDENCE

Level IV-therapeutic study.

Plastic multilayered closure versus orthopedic surgeon closure after spinal instrumentation in pediatric neuromuscular scoliosis

Objective

To compare wound complication rates between orthopedic closure (OC) and plastic multilayered closure (PMC) in patients undergoing primary posterior spinal fusion for neuromuscular scoliosis (NMS). We hypothesize that multilayered closure will be associated with better postoperative outcomes.

Methods

We collected data on pediatric patients diagnosed with NMS who underwent first time spinal instrumentation between 1 January 2018 and 31 May 2021. Patient demographics, length of surgery, spinal levels fused and operative variables, wound complication rate, treatments, and need for wound washout were reviewed in depth and recorded.

Results

In total, 86 patients were reviewed: 46 with OC and 40 with PMC. There was a significant increase in operating room (OR) time with PMC compared with OC (6.7±1.2 vs 7.3±1.3, p=0.016). There was no difference in complication rate, mean postoperative day of complication or unplanned return to the OR for OC and PMC, respectively. There was a slightly significant increase in the number of patients going home with a drain in the PMC cohort compared with the OC cohort (2.1% vs 15%, p=0.046).

Conclusions

PMC demonstrated longer OR times than OC and did not demonstrate a statistically significant reduction in wound complications or unplanned returns to the OR. However, other studies have demonstrated statistical and clinical significance with these variables. Surgical programs should review internal patient volumes and outcomes for spinal fusion in NMS patients and consider if PMC after spinal fusions in pediatric patients with NMS or other scoliosis subtypes is an appropriate option in their institution to minimize postoperative wound complications.

Biomechanical considerations of the posterior surgical approach to the lumbar spine

BACKGROUND CONTEXT

The effect of the posterior midline approach to the lumbar spine, relevance of inter- and supraspinous ligament (ISL&SSL) sparing, and potential of different wound closure techniques are largely unknown despite their common use.

PURPOSE

The aim of this study was to quantify the effect of the posterior approach, ISL&SSL resection, and different suture techniques.

STUDY DESIGN

Biomechanical cadaveric study.

METHODS

Five fresh frozen human torsi were stabilized at the pelvis in the erect position. The torsi were passively loaded into the forward bending position and the sagittal angulation of the sacrum, L4 and T12 were measured after a level-wise posterior surgical approach from L5/S1 to T12/L1 and after a level-wise ISL&SSL dissection of the same sequence. The measurements were repeated after the surgical closure of the thoracolumbar fascia with and without suturing the fascia to the spinous processes.

RESULTS

Passive spinal flexion was increased by 0.8±0.3° with every spinal level accessed by the posterior approach. With each additional ISL&SSL resection, a total increase of 1.6±0.4° was recorded. Suturing of the thoracolumbar fascia reduced this loss of resistance against lumbar flexion by 70%. If the ISL&SSL were resected, fascial closure reduced the lumbar flexion by 40% only. In both settings, suturing the fascia to the spinous processes did not result in a significantly different result (p=.523 and p=.730 respectively).

CONCLUSION

Each level accessed by a posterior midline approach is directly related to a loss of resistance against passive spinal flexion. Additional resection of ISL&SSL multiplies it by a factor of two.

CLINICAL SIGNIFICANCE

The surgical closure of the thoracolumbar fascia can reduce the above mentioned loss of resistance partially. Suturing the fascia to the spinal processes does not result in improved passive stability.

Team Approach: The Management of Adolescents and Adults with Scoliosis and Spina Bifida

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Globally, the prevalence of myelomeningocele, the most common subtype of spina bifida, is 0.2 to 6.5 per 1,000 live births. In the U.S., adults account for >67% of the overall population with spina bifida.

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With an estimated prevalence of up to 50%, scoliosis is one of the most common and severe orthopaedic conditions in patients with myelomeningocele.

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The variable effects that scoliosis can have on an individual, the comorbidities associated with progressive scoliosis, and the risks associated with spine surgery call for a strong partnership and care coordination between medical and surgical teams to deliver a patient-centered approach.

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A coordinated, structured, planned, and incremental team approach can help individuals achieve the overall goals of functionality and independence, as well as successful transition to adulthood.

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Teams should consider a patient's social determinants of health (e.g., poverty or language barriers) and the effect of scoliosis on quality of life before proceeding with spinal deformity correction.

The role of postoperative antibiotic duration on surgical site infection after lumbar surgery

OBJECTIVE

Despite a general consensus regarding the administration of preoperative antibiotics, poorly defined comparison groups and underpowered studies prevent clear guidelines for postoperative antibiotics. Utilizing a data set tailored specifically to spine surgery outcomes, in this clinical study the authors aimed to determine whether there is a role for postoperative antibiotics in the prevention of surgical site infection (SSI).

METHODS

The Michigan Spine Surgery Improvement Collaborative registry was queried for all lumbar operations performed for degenerative spinal pathologies over a 5-year period from 2014 to 2019. Preoperative prophylactic antibiotics were administered for all surgical procedures. The study population was divided into three cohorts: no postoperative antibiotics, postoperative antibiotics ≤ 24 hours, and postoperative antibiotics > 24 hours. This categorization was intended to determine 1) whether postoperative antibiotics are helpful and 2) the appropriate duration of postoperative antibiotics. First, multivariable analysis with generalized estimating equations (GEEs) was used to determine the association between antibiotic duration and all-type SSI with adjusted odds ratios; second, a three-tiered outcome-no SSI, superficial SSI, and deep SSI-was calculated with multivariable multinomial logistical GEE analysis.

RESULTS

Among 37,161 patients, the postoperative antibiotics > 24 hours cohort had more men with older average age, greater body mass index, and greater comorbidity burden. The postoperative antibiotics > 24 hours cohort had a 3% rate of SSI, which was significantly higher than the 2% rate of SSI of the other two cohorts (p = 0.004). On multivariable GEE analysis, neither postoperative antibiotics > 24 hours nor postoperative antibiotics ≤ 24 hours, as compared with no postoperative antibiotics, was associated with a lower rate of all-type postoperative SSIs. On multivariable multinomial logistical GEE analysis, neither postoperative antibiotics ≤ 24 hours nor postoperative antibiotics > 24 hours was associated with rate of superficial SSI, as compared with no antibiotic use at all. The odds of deep SSI decreased by 45% with postoperative antibiotics ≤ 24 hours (p = 0.002) and by 40% with postoperative antibiotics > 24 hours (p = 0.008).

CONCLUSIONS

Although the incidence of all-type SSI was highest in the antibiotics > 24 hours cohort, which also had the highest proportions of risk factors, duration of antibiotics failed to predict all-type SSI. On multinomial subanalysis, administration of postoperative antibiotics for both ≤ 24 hours and > 24 hours was associated with decreased risk of only deep SSI but not superficial SSI. Spine surgeons can safely consider antibiotics for 24 hours, which is equally as effective as long-term administration for prophylaxis against deep SSI.

Comparison of Plastic Surgeon and Spine Surgeon Closure in Revision Short Segment Thoracolumbar Spinal Fusions

STUDY DESIGN

Retrospective cohort analysis.

OBJECTIVE

To compare outcomes of plastic versus spine surgeon wound closure in revision 1 to 4 level thoracolumbar fusions.

SUMMARY OF BACKGROUND DATA

Plastic surgeons perform layered musculocutaneous flap closures in high-risk spine patients such as revision posterior spinal fusion and complex deformity correction surgeries. Few studies have assessed outcomes of revision fusion performed with plastic surgical closures, particularly in nondeformity thoracolumbar spinal surgery.

METHODS

A retrospective review of 1 to 4 level revision thoracolumbar fusion performed by Orthopedic or Neurosurgical spine surgeons. Patient charts were reviewed for demographics and perioperative outcomes. Patients were divided into two cohorts: wound closures performed by spine surgeons and those closed by plastic surgeons. Outcomes were analyzed before and after propensity score match for prior levels fused, iliac fixation, and levels fused at index surgery. Significance was set at P < 0.05.

RESULTS

Three hundred fifty-seven (87.3%) spine surgeon (SS) and 52 (12.7%) plastic surgeon (PS) closures were identified. PS group had significantly higher number of levels fused at index (PS 2.7 ± 1.0 vs. SS 1.8 ± 0.9, P < 0.001) and at prior surgeries (PS 1.8 ± 1.2 vs. SS 1.0 ± 0.9, P < 0.001), and rate of iliac instrumentation (PS 17.3% vs. SS 2.8%, P < 0.001). Plastics closure was an independent risk factor for length of stay  > 5 days (odds ratio 2.3) and postoperative seroma formation (odds ratio 7.8). After propensity score match, PS had higher rates of seromas (PS 36.5% vs. SS 3.8%, P < 0.001). There were no differences between PS and SS groups in surgical outcomes, perioperative complication, surgical site infection, seroma requiring aspiration, or return to operating room at all time points until follow-up (P > 0.05 for all).

CONCLUSION

Plastic spinal closure for 1 to 4 level revision posterior thoracolumbar fusions had no advantage in reducing wound complications over spine surgeon closure but increased postoperative seroma formation.Level of Evidence: 4.

Short-term surgical complications of spinal fusion in myelomeningocele

STUDY DESIGN

Retrospective review of a prospective database.

PURPOSE

To determine the rate of short-term surgical complications in the 3-month postoperative period in patients with myelomeningocele (MMC) who underwent surgical correction of spine deformities.

METHODS

This study reviewed the medical records of MMC patients, aged ≤ 18 years, who underwent spine deformity correction between 2012 and 2018. Clinical, radiological, and surgical variables were considered.

RESULTS

Forty-six patients with primary preoperative curve, pelvic obliquity, and kyphosis mean values of 84.9º, 21.5º, and 76.1º, respectively, were included. Thirty-four (74%) patients underwent scoliosis correction and 12 (26%), kyphectomy. A trend in reduction of %EBV (estimated blood volume) loss with antifibrinolytic use from 50.2 ± 32.3 to 33.8 ± 17.2% was observed (p = 0.103). Simultaneous detethering was performed in 13 (27.7%) patients and was not associated with higher short-term complication rates. There were 12 cases of short-term surgical complications (26.1%); among them, six had deep wound infection requiring surgical debridement, and one a superficial wound infection. Drainage time longer than 4 days was significantly associated with wound infection (OR = 15.8, p = 0.01).

CONCLUSIONS

The surgical treatment of neuromuscular scoliosis in MMC patients is challenging because of the high comorbidity rate. Still, we found an admissible rate of short-term surgical complications with a multidisciplinary approach in a setting with extensive spine deformity surgery experience.

Bilateral paraspinal muscle flap closure technique for reduction of wound complications from posterior thoracolumbar spinal fusion: results of a series of 716 patients

OBJECTIVE

Wound complications such as surgical site infection (SSI) and dehiscence are among the most common complications of thoracolumbar spinal fusion surgery and are particularly prevalent in patients with risk factors such as obesity, diabetes, smoking, malignancy, and multilevel and/or revision procedures. A specialized wound closure technique with muscle flap mobilization, which reduces tension at the wound edges and increases the bulk of vascularized tissue in the midline, can be employed as a salvage procedure to manage wound complications. The authors evaluated the effectiveness of prophylactic muscle flap closure for reducing SSI in patients with risk factors for wound complications who undergo thoracolumbar fusion surgery.

METHODS

A retrospective review of thoracolumbar fusion surgeries over a 15-year period was conducted in a group of patients at risk for wound complications to compare outcomes of patients who underwent prophylactic muscle flap closure with outcomes of patients who had conventional wound closure. Patients were selected for specialized closure based upon a protocol adopted during the study period. Patients were excluded if they had active infections or underwent tubular retractor-mediated decompression and did not have open surgery with a midline incision.

RESULTS

Of 716 patients, wound closure was performed in 455 patients using conventional closure and in 261 using muscle flap closure. There were no significant differences in the ratios of male to female patients, with 251 men and 204 women with conventional closure and 133 men and 128 women with muscle flap closure, but the muscle flap patients were older than the conventional closure patients, with mean ages of 65.2 versus 62.9 years (p < 0.005). Indications for surgery in the muscle flap group and the conventional group, respectively, were metastatic disease in 44 (17%) and 32 (7%) patients; trauma in 10 (4%) and 14 (3%) patients; and degenerative disease, including spondylolisthesis, spondylolysis, and stenosis, in 207 (79%) and 409 (90%) patients, with more muscle flap patients having metastasis (p < 0.00001). Patients having muscle flaps had significantly higher rates of diabetes, smoking, and revision surgery, and a higher mean BMI and number of operative levels. The serum albumin level was slightly lower in the muscle flap group (p < 0.047). The wound infection rate was significantly lower in the muscle flap group (0.4%) compared with the conventional closure group (2.4%) (p < 0.033).

CONCLUSIONS

Prophylactic muscle flap closure significantly lowers the rate of SSI in patients undergoing thoracolumbar spinal fusion who harbor risk factors for wound complications, with even fewer infections seen than in a group of patients without similar risk factors. Given the success of the technique, consideration of wider use for thoracolumbar fusion cases, even those without a high level of complexity, may be warranted.

Multilayered and Flap Closure Technique for Pediatric Spinal Deformity Surgery

Wound complications after pediatric spinal deformity surgery are a relatively common and challenging complication that results in emotional, physical, and monetary costs to the patients, families, and healthcare providers. The role of wound closure techniques for the prevention of wound complications is being increasingly explored. Interdisciplinary care by spinal surgeons and plastic surgeons has been recently found to decrease wound complication rates in patients with nonidiopathic scoliosis.

Plastic Multilayered Closure in Pediatric Nonidiopathic Scoliosis Is Associated With a Lower Than Expected Incidence of Wound Complications and Surgical Site Infections

OBJECTIVE

To compare the incidence of surgical site infection (SSI) and wound complications between standard and plastic multilayered closure (PMC) in patients with pediatric nonidiopathic scoliosis undergoing primary or revision instrumentation or fusion.

STUDY DESIGN

Retrospective cohort study.

SUMMARY OF BACKGROUND DATA

Although PMC has been used for adult spine patients as well as infected spinal wound closure, it has not been reported as routine closure in the pediatric nonidiopathic scoliosis population.

METHODS

Patients with nonidiopathic scoliosis undergoing primary or revision instrumentation or fusion between 2013 and 2016 were enrolled. Clinical charts and operative reports were reviewed. Following September 2015, all patients with nonidiopathic scoliosis received PMC closure by plastic or orthopedic surgery. The SSI and wound complication incidence in patients undergoing PMC was compared to standard closure. The mean Risk Severity Score (RSS) for SSI, which uses patient characteristics to calculate the excepted SSI probability, was compared to the observed (actual) incidence. The CDC definition of SSI (infection ≤90 days of surgery) was used.

RESULTS

115 patients were identified, including 56 standard closure and 59 PMC (mean age of 10.6 years; 54.8% female; mean preoperative major curve = 57.5°). There was no significant difference in age, sex, race, preoperative major curve, BMI, hemoglobin, blood loss, mean RSS score, or etiology between both groups (p > .05). Following PMC implementation, the observed incidence of wound complications decreased significantly from 19.6% in standard closures to 5.1% in the PMC group (p = .02), and the SSI incidence decreased from 8.9% to 1.7% (p = .11). The overall change in the observed (actual) incidence versus expected (RSS score) incidence of SSI indicated a 7.1% reduction following PMC.

CONCLUSION

Utilizing PMC in patients undergoing spinal surgery for nonidiopathic scoliosis significantly decreases the incidence of wound complications. Surgeons should consider using PMC in patients with nonidiopathic scoliosis.

LEVEL OF EVIDENCE

Level II.

Wound Closure After Posterior Multi-level Lumbar Spine Surgery: An Anatomical Cadaver Study and Technical Note

Meticulous attention to wound closure in posterior lumbar spine surgery is an important principle in reducing surgical site infections. We detail standardized wound closure used for posterior lumbar spine surgery at a tertiary care referral center and illustrate this as a step-by-step cadaveric dissection. The lumbar spine of a cadaveric specimen (male, 73 years at death) was used for dissection. Standardizing wound closure in posterior lumbar spine surgery may help limit wound complications and infection. Some key points of our technique, as demonstrated on a cadaveric specimen, include separating fascial compartments, avoiding suture abscesses, and creating a tension-free wound.

Is There an Optimal Wound Closure Technique for Major Posterior Spine Surgery? A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

In patients undergoing posterior spinal fusion: (1) What are the types and risks of wound complications in major (≥3 levels) surgery, and does the risk vary by number of levels fused? (2) What types of fascial closure result in the fewest wound complications? (3) What subcutaneous closure technique is more effective in preventing wound complications for obese patients (body mass index >30 kg/m²)? (4) What type of skin closure results in the fewest wound complications? (5) What type of dressing results in the fewest wound complications?

METHODS

Electronic databases and reference lists of key articles were searched from January 1, 2000 to December 4, 2017 to identify studies meeting inclusion criteria.

RESULTS

Six lower quality retrospective studies (evidence level III) met the inclusion criteria. The risk of wound complications in patients with ≥3 level posterior spine fusion ranges from 1.5% to 3.7% depending on the definition of wound complications. Skin closure with sutures resulted in fewer wound infections compared with staples (0.0% vs 8.0%, P = .023). We were unable to demonstrate an association between the number of levels fused and infection risk. Wound infections, primarily superficial, occurred less frequently with Silverlon dressing versus routine dressing.

CONCLUSIONS

We were unable to determine if infection risk changed with increasing number of levels fused. There is a lack of evidence for optimal wound closure technique in posterior spine surgery. Several questions still remain unanswered, such as the optimal fascial closure technique or the optimal subcutaneous closure technique in obese patients.