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Gomez DA, Mazarei M, Abdulwadood I, Casey WJ, Rebecca AM, Reece EM. Wound closure techniques for spinoplastic surgery: a review of the literature. Neurosurg Rev 2024; 47:460. [PMID: 39174840 DOI: 10.1007/s10143-024-02704-6] [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: 02/12/2024] [Revised: 07/02/2024] [Accepted: 08/11/2024] [Indexed: 08/24/2024]
Abstract
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.
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Affiliation(s)
- Diego A Gomez
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | | | | | - William J Casey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Alanna M Rebecca
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Edward M Reece
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA.
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Zusman NL, Valenzuela-Moss JN, Wren TAL, Tetreault TA, Illingworth KD, Brooks JT, Skaggs DL, Andras LM, Heffernan MJ. What is the role of plastic surgery for incisional closures in pediatric spine surgery? Results from a pediatric spine study group survey. J Pediatr Orthop B 2024:01202412-990000000-00206. [PMID: 38900150 DOI: 10.1097/bpb.0000000000001195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
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.
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Affiliation(s)
- Natalie L Zusman
- Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Keck School of Medicine of USC
| | | | - Tishya A L Wren
- Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Keck School of Medicine of USC
| | - Tyler A Tetreault
- Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Keck School of Medicine of USC
| | - Kenneth D Illingworth
- Cedars-Sinai Medical Center, Cedars Spine Center Orthopaedics, Los Angeles, California
| | - Jaysson T Brooks
- Orthopedic and Sports Medicine Center, Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
| | - David L Skaggs
- Cedars-Sinai Medical Center, Cedars Spine Center Orthopaedics, Los Angeles, California
| | - Lindsay M Andras
- Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Keck School of Medicine of USC
| | - Michael J Heffernan
- Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Keck School of Medicine of USC
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Guo CR, Rivera Perla KM, Leary OP, Sastry RA, Borrelli MR, Liu DD, Khunte M, Gokaslan ZL, Liu PY, Kwan D, Fridley JS, Woo AS. Systematic Review of Prophylactic Plastic Surgery Closure to Prevent Postoperative Wound Complications Following Spine Surgery. World Neurosurg 2024; 184:103-111. [PMID: 38185457 DOI: 10.1016/j.wneu.2024.01.007] [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: 08/07/2023] [Revised: 01/01/2024] [Accepted: 01/02/2024] [Indexed: 01/09/2024]
Abstract
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.
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Affiliation(s)
- Cynthia R Guo
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Plastic and Reconstructive Surgery, Rhode Island Hospital, Providence, Rhode Island, USA.
| | - Krissia M Rivera Perla
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Owen P Leary
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Rahul A Sastry
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Mimi R Borrelli
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Plastic and Reconstructive Surgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - David D Liu
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mihir Khunte
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Ziya L Gokaslan
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Paul Y Liu
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Plastic and Reconstructive Surgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Daniel Kwan
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Plastic and Reconstructive Surgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jared S Fridley
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Albert S Woo
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; Department of Plastic and Reconstructive Surgery, Rhode Island Hospital, Providence, Rhode Island, USA
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Grush AE, Mohan VE, Roy MG, Burns HR, Monson LA. Plastic surgeon closure is comparable to orthopedic closure when a perioperative optimization protocol is instituted for pediatric patients with neuromuscular scoliosis. Spine J 2024; 24:454-461. [PMID: 37979696 DOI: 10.1016/j.spinee.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 11/02/2023] [Accepted: 11/05/2023] [Indexed: 11/20/2023]
Abstract
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.
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Affiliation(s)
- Andrew E Grush
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, 6701 Fannin St, Suite 610, TX, USA; Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, 6701 Fannin St, Suite 610, TX, USA
| | - Vamsi E Mohan
- Texas Tech University Health Sciences Center El Paso, 5001 El Paso Drive, El Paso, TX 79905, USA
| | - Michelle G Roy
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, 6701 Fannin St, Suite 610, TX, USA; Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, 6701 Fannin St, Suite 610, TX, USA
| | - Heather R Burns
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, 6701 Fannin St, Suite 610, TX, USA; Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, 6701 Fannin St, Suite 610, TX, USA
| | - Laura A Monson
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, 6701 Fannin St, Suite 610, TX, USA; Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, 6701 Fannin St, Suite 610, TX, USA.
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Delaney LJ, Isguven S, Hilliard R, Lacerda Q, Oeffinger BE, Machado P, Schaer TP, Hickok NJ, Kurtz SM, Forsberg F. In Vitro and In Vivo Evaluation of Ultrasound-Triggered Release From Novel Spinal Device. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:2357-2368. [PMID: 37249416 PMCID: PMC10524871 DOI: 10.1002/jum.16263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 03/17/2023] [Accepted: 05/05/2023] [Indexed: 05/31/2023]
Abstract
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.
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Affiliation(s)
- Lauren J. Delaney
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, 19107
| | - Selin Isguven
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, 19107
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA, 19107
| | - Rachel Hilliard
- Department of Clinical Studies, New Bolton Center, University of Pennsylvania School of Veterinary Medicine, Kennett Square, PA, 19348
| | - Quezia Lacerda
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, 19107
- School of Biomedical Engineering, Science & Health Systems, Drexel University, Philadelphia, PA, 19104
| | - Brian E. Oeffinger
- School of Biomedical Engineering, Science & Health Systems, Drexel University, Philadelphia, PA, 19104
| | - Priscilla Machado
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, 19107
| | - Thomas P. Schaer
- Department of Clinical Studies, New Bolton Center, University of Pennsylvania School of Veterinary Medicine, Kennett Square, PA, 19348
| | - Noreen J. Hickok
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA, 19107
| | - Steven M. Kurtz
- School of Biomedical Engineering, Science & Health Systems, Drexel University, Philadelphia, PA, 19104
- Exponent, Inc., Philadelphia, PA, 19104
| | - Flemming Forsberg
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, 19107
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Ashebo L, Anari JB, Cahill PJ. Update on the Diagnosis and Management of Early-onset Scoliosis. Curr Rev Musculoskelet Med 2023; 16:447-456. [PMID: 37615932 PMCID: PMC10497459 DOI: 10.1007/s12178-023-09848-w] [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] [Accepted: 05/30/2023] [Indexed: 08/25/2023]
Abstract
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.
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Affiliation(s)
- Leta Ashebo
- Division of Orthopaedics, Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19142, USA
| | - Jason B Anari
- Division of Orthopaedics, Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19142, USA
| | - Patrick J Cahill
- Division of Orthopaedics, Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19142, USA.
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Taylor TN, Bridges CS, Nordstrom LA, Hanson DS, Gerow FT, Smith BG. Early Complications After Posterior Spinal Fusion in Patients With Rett Syndrome. J Pediatr Orthop 2023; 43:e326-e330. [PMID: 36882895 DOI: 10.1097/bpo.0000000000002384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
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.
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Ezeokoli EU, Tamma PL, Borici N, Inneh I, Buchanan EP, Smith BG. Plastic multilayered closure versus orthopedic surgeon closure after spinal instrumentation in pediatric neuromuscular scoliosis. WORLD JOURNAL OF PEDIATRIC SURGERY 2023; 6:e000485. [PMID: 36817713 PMCID: PMC9933758 DOI: 10.1136/wjps-2022-000485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 01/12/2023] [Indexed: 02/17/2023] Open
Abstract
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.
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Affiliation(s)
- Ekene U Ezeokoli
- Department of Orthopedic Surgery, Texas Children's Hospital, Houston, Texas, USA
| | | | - Neritan Borici
- Department of Orthopedic Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Ifeoma Inneh
- Department of Orthopedic Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Edward P Buchanan
- Department of Plastic Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Brian G Smith
- Department of Orthopedic Surgery, Texas Children's Hospital, Houston, Texas, USA,Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas, USA
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Biomechanical considerations of the posterior surgical approach to the lumbar spine. Spine J 2022; 22:2066-2071. [PMID: 35964832 DOI: 10.1016/j.spinee.2022.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 08/02/2022] [Accepted: 08/04/2022] [Indexed: 02/03/2023]
Abstract
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.
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The Plastic's Closure. Plast Reconstr Surg 2022; 149:1501-1502. [PMID: 35446799 DOI: 10.1097/prs.0000000000009056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bradko V, Castillo H, Conklin M, Fremion E, Rocque B, Hanson D, Sanz-Cortes M, Whitehead W, Castillo J. Team Approach: The Management of Adolescents and Adults with Scoliosis and Spina Bifida. JBJS Rev 2022; 10:01874474-202203000-00004. [PMID: 35230996 DOI: 10.2106/jbjs.rvw.21.00167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
» 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. » With an estimated prevalence of up to 50%, scoliosis is one of the most common and severe orthopaedic conditions in patients with myelomeningocele. » 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. » 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. » 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.
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Affiliation(s)
- Viachaslau Bradko
- Meyer Center for Developmental Pediatrics, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Heidi Castillo
- Meyer Center for Developmental Pediatrics, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Michael Conklin
- Department of Orthopedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ellen Fremion
- Departments of Internal Medicine and Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Brandon Rocque
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Darrell Hanson
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, Texas
| | | | - William Whitehead
- Department of Pediatric Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Jonathan Castillo
- Meyer Center for Developmental Pediatrics, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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Macki M, Hamilton T, Lim S, Mansour TR, Telemi E, Bazydlo M, Schultz L, Nerenz DR, Park P, Chang V, Schwalb J, Abdulhak MM. The role of postoperative antibiotic duration on surgical site infection after lumbar surgery. J Neurosurg Spine 2022; 36:254-260. [PMID: 34534952 DOI: 10.3171/2021.4.spine201839] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 04/01/2021] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | | | - David R Nerenz
- 3Center for Health Policy and Health Services Research, Henry Ford Hospital, Detroit, Michigan; and
| | - Paul Park
- 4University of Michigan, Ann Arbor, Michigan
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Comparison of Plastic Surgeon and Spine Surgeon Closure in Revision Short Segment Thoracolumbar Spinal Fusions. Spine (Phila Pa 1976) 2021; 46:1279-1286. [PMID: 34435992 DOI: 10.1097/brs.0000000000003984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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de Araújo AO, Gomes CR, Fava D, Borigato EVM, Duarte LMR, de Oliveira RG. Short-term surgical complications of spinal fusion in myelomeningocele. Spine Deform 2021; 9:1151-1159. [PMID: 33620695 DOI: 10.1007/s43390-021-00304-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 02/01/2021] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Alex Oliveira de Araújo
- Department of Orthopedic Surgery, Pediatrics and Rehabilitation, SARAH Network of Rehabilitation Hospitals, SMHS Qd 301 Bloco A, Brasília, DF, 70335-901, Brazil
| | - Cícero Ricardo Gomes
- Department of Orthopedic Surgery, Pediatrics and Rehabilitation, SARAH Network of Rehabilitation Hospitals, SMHS Qd 301 Bloco A, Brasília, DF, 70335-901, Brazil
| | - Daniela Fava
- Department of Orthopedic Surgery, Pediatrics and Rehabilitation, SARAH Network of Rehabilitation Hospitals, SMHS Qd 301 Bloco A, Brasília, DF, 70335-901, Brazil
| | - Eliana Valverde Magro Borigato
- Department of Orthopedic Surgery, Pediatrics and Rehabilitation, SARAH Network of Rehabilitation Hospitals, SMHS Qd 301 Bloco A, Brasília, DF, 70335-901, Brazil
| | - Lenamaris Mendes Rocha Duarte
- Department of Orthopedic Surgery, Pediatrics and Rehabilitation, SARAH Network of Rehabilitation Hospitals, SMHS Qd 301 Bloco A, Brasília, DF, 70335-901, Brazil
| | - Rafael Garcia de Oliveira
- Department of Orthopedic Surgery, Pediatrics and Rehabilitation, SARAH Network of Rehabilitation Hospitals, SMHS Qd 301 Bloco A, Brasília, DF, 70335-901, Brazil.
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15
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Houten JK, Weinstein GR, Collins MJ, Komlos D. Bilateral paraspinal muscle flap closure technique for reduction of wound complications from posterior thoracolumbar spinal fusion: results of a series of 716 patients. J Neurosurg Spine 2021; 34:211-217. [PMID: 33065537 DOI: 10.3171/2020.6.spine20755] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/09/2020] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- John K Houten
- 1Departments of Surgery and
- 2Orthopedic Surgery, Maimonides Medical Center, Brooklyn; and
- 3Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | | | | | - Daniel Komlos
- 2Orthopedic Surgery, Maimonides Medical Center, Brooklyn; and
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Garg S, Khechoyan D, Kim EB, French B. Multilayered and Flap Closure Technique for Pediatric Spinal Deformity Surgery. J Am Acad Orthop Surg 2020; 28:e92-e99. [PMID: 31977607 DOI: 10.5435/jaaos-d-18-00601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
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.
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Affiliation(s)
- Sumeet Garg
- From the Pediatric Orthopaedics and Spine Surgery (Dr. Garg), Children's Hospital Colorado, the Pediatric Plastic and Reconstructive Surgery (Dr. Khechoyan and Dr. French), Children's Hospital Colorado, and the Musculoskeletal Research Center (Kim), Children's Hospital Colorado, Aurora, CO
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Mackenzie WGS, McLeod L, Wang K, Crotty J, Hope JE, Imahiyerobo TA, Ko RR, Anderson RCE, Saiman L, Vitale MG. Team Approach: Preventing Surgical Site Infections in Pediatric Scoliosis Surgery. JBJS Rev 2019; 6:e2. [PMID: 29406434 DOI: 10.2106/jbjs.rvw.16.00121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- W G Stuart Mackenzie
- Departments of Orthopaedic Surgery (W.G.S.M., K.W., J.C., J.E.H., and M.G.V.), Anesthesiology (R.R.K.), and Neurological Surgery (R.C.E.A.), Columbia University Medical Center, New York, NY
| | - Lisa McLeod
- Children's Hospital Colorado, Aurora, Colorado
| | - Kevin Wang
- Departments of Orthopaedic Surgery (W.G.S.M., K.W., J.C., J.E.H., and M.G.V.), Anesthesiology (R.R.K.), and Neurological Surgery (R.C.E.A.), Columbia University Medical Center, New York, NY
| | - Jennifer Crotty
- Departments of Orthopaedic Surgery (W.G.S.M., K.W., J.C., J.E.H., and M.G.V.), Anesthesiology (R.R.K.), and Neurological Surgery (R.C.E.A.), Columbia University Medical Center, New York, NY
| | - Jennifer E Hope
- Departments of Orthopaedic Surgery (W.G.S.M., K.W., J.C., J.E.H., and M.G.V.), Anesthesiology (R.R.K.), and Neurological Surgery (R.C.E.A.), Columbia University Medical Center, New York, NY
| | - Thomas A Imahiyerobo
- Division of Plastic Surgery, Department of Surgery (T.A.I.), Division of Pediatric Infectious Diseases, Department of Pediatrics (L.S.), and Department of Infection Prevention and Control (L.S.), New York Presbyterian/Columbia University Medical Center, New York, NY
| | - Riva R Ko
- Departments of Orthopaedic Surgery (W.G.S.M., K.W., J.C., J.E.H., and M.G.V.), Anesthesiology (R.R.K.), and Neurological Surgery (R.C.E.A.), Columbia University Medical Center, New York, NY
| | - Richard C E Anderson
- Departments of Orthopaedic Surgery (W.G.S.M., K.W., J.C., J.E.H., and M.G.V.), Anesthesiology (R.R.K.), and Neurological Surgery (R.C.E.A.), Columbia University Medical Center, New York, NY
| | - Lisa Saiman
- Division of Plastic Surgery, Department of Surgery (T.A.I.), Division of Pediatric Infectious Diseases, Department of Pediatrics (L.S.), and Department of Infection Prevention and Control (L.S.), New York Presbyterian/Columbia University Medical Center, New York, NY
| | - Michael G Vitale
- Departments of Orthopaedic Surgery (W.G.S.M., K.W., J.C., J.E.H., and M.G.V.), Anesthesiology (R.R.K.), and Neurological Surgery (R.C.E.A.), Columbia University Medical Center, New York, NY
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Imahiyerobo T, Minkara AA, Matsumoto H, Vitale MG. Plastic Multilayered Closure in Pediatric Nonidiopathic Scoliosis Is Associated With a Lower Than Expected Incidence of Wound Complications and Surgical Site Infections. Spine Deform 2019; 6:454-459. [PMID: 29886919 DOI: 10.1016/j.jspd.2017.12.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 12/11/2017] [Accepted: 12/15/2017] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Thomas Imahiyerobo
- Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032, USA
| | - Anas A Minkara
- Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032, USA
| | - Hiroko Matsumoto
- Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032, USA.
| | - Michael G Vitale
- Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032, USA
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Yilmaz E, Tawfik T, O'Lynnger TM, Iwanaga J, Blecher R, Abdul-Jabbar A, Tubbs RS, Schmidt CK, Oskouian RJ, Chapman J. Wound Closure After Posterior Multi-level Lumbar Spine Surgery: An Anatomical Cadaver Study and Technical Note. Cureus 2018; 10:e3595. [PMID: 30675448 PMCID: PMC6336212 DOI: 10.7759/cureus.3595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Emre Yilmaz
- Surgery, Swedish Neuroscience Institute, Seattle, USA
| | - Tamir Tawfik
- Neurosurgery, Swedish Neuroscience Institute, Seattle, USA
| | | | - Joe Iwanaga
- Medical Education and Simulation, Seattle Science Foundation, Seattle, USA
| | - Ronen Blecher
- Neurosurgery, Swedish Neuroscience Institute, Seattle, USA
| | | | - R Shane Tubbs
- Neurosurgery, Seattle Science Foundation, Seattle, USA
| | | | - Rod J Oskouian
- Neurosurgery, Swedish Neuroscience Institute, Seattle, USA
| | - Jens Chapman
- Neurosurgery, Swedish Neuroscience Institute, Seattle, USA
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Yilmaz E, Blecher R, Moisi M, Ankush C, O’Lynnger TM, Abdul-Jabbar A, Dettori JR, Oskouian RJ. Is There an Optimal Wound Closure Technique for Major Posterior Spine Surgery? A Systematic Review. Global Spine J 2018; 8:535-544. [PMID: 30258761 PMCID: PMC6149048 DOI: 10.1177/2192568218774323] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Emre Yilmaz
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA,
USA
- Seattle Science Foundation, Seattle, WA, USA
- BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum,
Germany
- Emre Yilmaz, Swedish Neuroscience Institute, Swedish
Medical Center, 550 17th Avenue, Seattle, WA 98122, USA.
| | - Ronen Blecher
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA,
USA
| | - Marc Moisi
- Wayne State University, Detroit, MI, USA
| | | | | | - Amir Abdul-Jabbar
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA,
USA
| | | | - Rod J. Oskouian
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA,
USA
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