Surgical Site Infection Prevention Following Spine Surgery

Is Aggressive Surgery Always Necessary for Suspected Early-Onset Surgical Site Infection after Lumbar Surgery? A 10-Year Retrospective Analysis

OBJECTIVE

Surgical site infection (SSI) after spinal surgery is still a persistent worldwide health concern as it is a worrying and devastating complication. The number of samples in previous studies is limited and the role of conservative antibiotic therapy has not been established. This study aims to evaluate the clinical efficacy and feasibility of empirical antibiotic treatment for suspected early-onset deep spinal SSI.

METHODS

We conducted a retrospective study to identify all cases with suspected early-onset deep SSI after lumbar instrumented surgery between January 2009 and December 2018. We evaluated the potential risks for antibiotic treatment, examined the antibiotic treatment failure rate, and applied logistic regression analysis to assess the risk factors for empirical antibiotic treatment failure.

RESULTS

Over the past 10 years, 45 patients matched the inclusion criteria. The success rate of antibiotic treatment was 62.2% (28/45). Of the 17 patients who failed antibiotic treatment, 16 were cured after a debridement intervention and the remaining one required removal of the internal fixation before recovery. On univariate analysis, risk factors for antibiotic treatment failure included age, increasing or persisting back pain, wound dehiscence, localized swelling, and time to SSI (cut-off: 10 days). Multivariate analysis revealed that infection occurring 10 days after primary surgery and wound dehiscence were independent risk factors for antibiotic treatment failure.

CONCLUSION

Appropriate antibiotic treatment is an alternative strategy for suspected early-onset deep SSI after lumbar instrumented surgery. Antibiotic treatment for suspected SSI occurring within 10 days after primary surgery may improve the success rate of antibiotic intervention. Patients with wound dehiscence have a significantly higher likelihood of requiring surgical intervention.

Prognostic Nutritional Index and the Risk of Postoperative Complications After Spine Surgery: A Meta-Analysis

BACKGROUND

A low prognostic nutritional index (PNI) may reflect malnutrition, which has been associated with poor prognosis in patients with various clinical conditions. The aim of the systematic review and meta-analysis was to investigate the association between preoperative PNI and risk of postoperative complications in adult patients after spine surgery.

METHODS

An extensive search was conducted on PubMed, Embase, and Web of Science to identify relevant cohort studies. Random-effects models were employed to combine the findings, taking into account the potential influence of heterogeneity.

RESULTS

Ten cohort studies involving 3,249 patients receiving spine surgeries were included. Pooled results showed that a low preoperative prognostic nutritional index (PNI) was associated with an increased risk of overall postoperative complications in these patients (odds ratio [OR]: 1.82, 95% confidence interval [CI]: 1.42 to 2.34, P < 0.001; I2 = 49%). Specifically, a preoperative malnutrition as evidenced by a low PNI was associated with a higher incidence of postoperative delirium (OR: 2.36, 95% CI: 1.52 to 3.66, P < 0.001; I2 = 38%) and surgical site infection (OR: 1.41, 95% CI: 1.15 to 1.73, P = 0.001; I2 = 0%). Sensitivity analyses by excluding one study at a time did not significantly change the results (P all <0.05).

CONCLUSIONS

A preoperative low prognostic nutritional index (PNI) may be a risk factor of increased incidence of overall postoperative complications, postoperative delirium, and surgical site infection in adult patients after spine surgeries.

Effect of drain placement in short-level spinal surgery on postoperative wound infection: A meta-analysis

In the meta-analysis, we evaluated the efficacy of placing drainage channels following single- or double-level spine surgery in order to decrease the incidence of postoperative injury. We conducted the analysis with the help of four databases: PubMed, Embase, Cochrane Library and Web of Science. A review of related studies was carried out after evaluating the quality of the literature against the classification and exclusion criteria set for the trial. Calculation of 95% CI, OR and MD was performed with fixed-effect models. A meta-analysis of the data was carried out with RevMan 5.3. Meta-analyses of randomized controlled trial (RCT) did not indicate that there were a statistically significantly different incidence of postoperative wound infections among those who received drainage compared to those who did not receive drainage (OR, 2.29; 95% CI, 0.50, 10.41 p = 0.28). Moreover, there were no statistically significant differences in post-operation hematoma (OR, 1.20; 95% CI, 0.27, 5.28 p = 0.81) and visual analogue scale score (MD, -0.01; 95% CI, -1.34, 1.33 p = 0.99). Thus, placing drainage in short-levels of spine operation did not significantly influence the outcome of postoperative wound complications. Nevertheless, because of the limited sample size chosen for this meta-analysis, caution should be exercised when treating these data. More high-quality RCT trials with a large number of samples are required to confirm the findings.

Mycological Methods for Routine Air Sampling and Interpretation of Results in Operating Theaters

Many infectious diseases are transmitted via the air and are, therefore, particularly difficult to combat. These infections include various invasive mycoses caused by molds. The usual route of infection is the inhalation of conidia. In hospitals, infection can also occur through the deposition of conidia in otherwise sterile anatomical sites during surgical and other invasive procedures. Therefore, knowledge of airborne mold concentrations can lead to measures to protect patients from fungal infections. The literature on this topic contains insufficient and sometimes ambiguous information. This is evidenced by the fact that there are no international recommendations or guidelines defining the methodology of air sampling and the interpretation of the results obtained. Surgical departments, intensive care units and medical mycology laboratories are, therefore, left to their own devices, leading to significant differences in the implementation of mycological surveillance in hospitals. The aim of this mini-review is to provide an overview of the current methods of air sampling and interpretation of results used in medical mycology laboratories.

The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) levels following erector spinae plane block (ESPB) in posterior lumbar decompression: a randomized, controlled trial

PURPOSE

Neutrophile-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are the inflammatory biomarkers of the stress response. In this study, we aimed to evaluate the effects of erector spinae plane block (ESPB) on posterior lumbar decompression and stabilization by comparing NLR, PLR, postoperative pain, opioid consumption, and functional recovery between sham block and ESPB.

METHODS

This was a prospective, double-blinded, randomized controlled trial in a tertiary referral hospital. Sixty patients were randomized into two equal groups, each receiving either a sham block or ESPB. The primary outcome was the NLR and PLR 12 h and 24 h after lumbar posterior decompression and stabilization. The secondary outcomes were total opioid consumption and pain score 24 h postoperatively. Also, functional recovery determined by getting out of bed, verticalization, and walking by the balcony were reviewed as secondary outcomes.

RESULTS

Significant differences existed between the sham block and ESPB group in NLR (29.08 ± 12.29 vs. 16.97 ± 10.38; p < 0.0001) and PLR (556.77 ± 110.32 vs. 346.43 ± 117.34; p < 0.0001) 12 h after surgery. Also, there was a significant difference in NLR (p = 0.0466) and PLR (p < 0.0001) 24 h after surgery. In addition, there was a substantial difference in pain score, total opioid consumption, and functional recovery.

CONCLUSION

ESPB performance during spinal surgery lowers NRL and PLR ratios 12 h and 24 h after surgery. In addition, ESPB provides better analgesia and improves functional recovery compared to sham block following posterior lumbar decompression and stabilization.

[Plastic and reconstruction surgery for non-healing wound after posterior spinal surgery]

OBJECTIVE

To investigate the clinical significance of different plastic surgeries in the treatment of poor healing wound after posterior spinal internal fixation.

METHODS

In this study, 16 patients with poor incision healing after posterior spinal internal fixation were retrospectively included, and dif-ferent plastic surgery treatment plans were determined according to the wound characteristics and defect condition. The measures included debridement, vacuum sealing drainage (VSD), and different tissue flaps according to the location and extent of the defect.

RESULTS

A total of 16 patients meeting the criteria were included, of whom 3 were treated with debridement combined with VSD and wound suture directly, 6 were treated with debridement combined with Z-flap for wound repair, 1 was treated with bilateral sacrospinous muscle flap for dural defect repair combined with Z-flap for skin wound repair, 1 was treated with lectus dorsi flap for wound repair, 3 were treated with the fourth lumbar artery perforator flap for wound repair. The wound was repaired with local rotating flap in 1 case and gluteus maximus musculocutaneous flap in 1 case. Among the 16 patients, 7 cases were positive for wound culture, including 3 cases of Staphylococcus aureus, 1 case of Pseudomonas aeruginosa, 1 case of Staphylococcus epidermidis, 1 case of Escherichia coli, 1 case of Klebsiella pneumoniae, and the other 9 cases were negative. After surgery, there were 7 patients with different degrees of poor wound healing, including 3 patients undergoing dressing change, 2 patients undergoing secondary debridement and suture, 1 patient undergoing free scalp skin graft, and 1 patient undergoing local effusion suction treatment. All the above 7 patients were discharged from hospital after improvement, and the remaining 9 patients had good first-stage wound hea-ling after surgery. None of the 16 patients underwent internal fixation.

CONCLUSION

Multiple factors could lead to poor wound healing after posterior spinal internal fixation. Early intervention, thorough debridement, removal of necrotic/infected tissue, and selection of suitable skin flap for effective wound fil-ling and covering were important means to ensure wound healing after spinal surgery and reduce removal of internal fixation.

Incidence of surgical site infections after cervical spine surgery: results of a single-center cohort study adhering to multimodal preventive wound control protocol

PURPOSE

The incidence of surgical site infections is considered a relevant indicator of perioperative and postoperative care quality. The aim of this study is to analyze and evaluate SSIs after elective cervical spine surgery under the guidance of our preventive multimodal wound protocol.

METHODS

A monocentric observational cohort study analyzed 797 patients who underwent cervical spine surgery from 2005 to 2010 (mean age 51.58 ± 11.74 year, male 56.09%, mean BMI 26.87 ± 4.41, ASA score 1-2 in 81.68% of patients), fulfilling the entry criteria: (1) cervical spine surgery performed by neurosurgeons (degenerative disease 85.19%, trauma 11.04%, tumor 3.76%), (2) elective surgery, (3) postoperative care in our neurointensive care unit. Our preventive wound control protocol management focused mainly on antibiotic prophylaxis, wound hygiene regime, and drainage equipment. All wound complications and surgical site infections were monitored up for 1 year after surgery.

RESULTS

We had only 2 (0.25%) patients with SSI after cervical spine surgery-one organ/space infection (osteomyelitis, primary due to liquorrhea) after anterior surgical approach, and one deep surgical site infection (due to dehiscence) after posterior approach. We had 17 (2.13%) patients with some wound complications (secretion 7, dehiscence 4, hematoma 1, edema 3, and liquorrhea 2) that were not classified as SSI according to the CDC guidelines.

CONCLUSION

Concerning our study population of patients undergoing elective cervical surgery, with ASA scores 1-2 in 81.68% of our patients, the incidence of SSI was 0.14% after anterior surgical approach, 1.4% after posterior surgical approach, and 0.25% altogether in the referred cohort.

Vancomycin Flushing Syndrome After the Use of Vancomycin-Impregnated Bone Graft During Spine Surgery: A Case Report

CASE

Intrawound vancomycin in spine surgery is a common clinical practice. We report a case of a 14-year-old adolescent girl undergoing surgery for scoliosis correction who developed features of vancomycin flushing syndrome after the use of vancomycin-impregnated bone graft. After resuscitation, she was extubated and had an uneventful postoperative recovery. At 1-year follow-up, she is back to her routine without any sequelae of the intraoperative event.

CONCLUSION

The use of intrawound vancomycin can result in life-threatening reactions. With the increase in its use, the anesthetist and the surgeon must be aware of such complications.

Wound drain in lumbar arthrodesis for degenerative disease: an experimental, multicenter, randomized controlled trial

INTRODUCTION

Drains for surgical wound management are frequently used in spine surgery. They are often used to decrease the incidence of postoperative hematoma and decrease wound tension. No conclusive evidence in the literature supports using drains to avoid complications in degenerative lumbar spine surgery.

PURPOSE

We aimed to evaluate wound drains in patients with lumbar arthrodesis for degenerative disorders based on clinical outcomes, complications, hematocrit, and length of stay.

STUDY DESIGN

A multicenter randomized prospective controlled clinical trial.

PATIENT SAMPLE

We enrolled surgical candidates for posterior lumbar decompression and fusion surgery for degenerative disorders from October 2019 to August 2021. Patients were randomized into the drain or nondrain group at nine hospitals. The inclusion criteria were as follows: patients aged 40 to 80 years with lumbar and radicular pain, lumbar degenerative disorder, and primary surgery up to three levels. The exclusion criteria were bleeding abnormalities, bleeding >2,500 mL and dural tears.

OUTCOME MEASURES

Preoperative data including Oswestry disability index (ODI), SF-36, lumbar and lower extremity visual analog scale (VAS), body mass index (BMI), hematocrit, and temperature were recorded. Surgical parameters, including surgical time, complications, estimated blood loss (EBL), postoperative temperature and hematocrit (days 1 and 4), dressing saturation, and length of hospital stay (LOS), were registered.

METHODS

The two groups were assessed preoperatively, perioperatively and at the 1-month follow-up. A REDCap database was used for registration. Data analysis was performed using classical statistics.

RESULTS

One hundred one patients were enrolled using the Redcap database, and 93 patients were evaluated at the final follow-up. Forty-five patients were randomized to the drain group, and 48 were randomized to the nondrain group. The preoperative characteristics were equivalent in both groups: demographic aspects, pain, ODI, SF-36, BMI, hematocrit, and spine pathology. Surgical time, EBL and complications were similar, with no difference between the groups. No difference was found between BMI and complications. No difference was observed in dressing saturation or postoperative temperature between the groups. The postoperative day 4 hematocrit was higher in the nondrain group [36.4% (32-39)] than in the drain group [34% (29.7-37.6)] without statistically differences (p=.054). The LOS was higher in the drain group [4 (3-5) days] than in the nondrain group [3 (2-4) days] (p=.007). The quality-of-life score, SF-36, was higher in the nondrain group [67.9 (53.6-79.2)] than in the drain group [56.7 (49.1-66)] (p=.043).

CONCLUSIONS

Nondrain patients presented shorter LOS and better outcomes, with similar complication rates. No difference was found between BMI and complications. Based on this study, in patients undergoing primary posterior spinal decompression and fusion up to three levels for degenerative lumbar disorders, we do not recommend the use of postoperative drains.

Prophylactic Application of Vancomycin Powder in Preventing Surgical Site Infections After Spinal Surgery

OBJECTIVE

We sought to analyze the preventive effect of local vancomycin powder application on surgical site infection (SSI) in spinal surgeries and provide the basis for future clinical practice.

METHODS

Through PubMed, Medline, Elsevier, and the Cochrane Library, with MeSH words "vancomycin powder," "local/intraoperative/topical/intra-wound," "spine/spinal/lumbar/cervical/thoracolumbar," "surgery," "infection," and "SSI," we searched for case-control research papers on the impact of prophylactic application of vancomycin powder on the incidence of SSI and compared the rate of infection using RevMan 5.3 meta-analysis software.

RESULTS

A total of 1950 publications were found using the mesh words, and 50 of those studies were selected for final analysis. There were 34,301 cases in total, including 14,793 cases in vancomycin group and 19,508 cases in the control group. Results of meta-analysis showed that the incidence of SSI was significantly lower in the prophylactic vancomycin powder group than the control group (P < 0.001). Further subgroup analysis showed that the incidence of SSI was significantly lower in the prophylactic vancomycin powder group than the control group in spine surgeries with internal fixation, deformity correction, and deep tissue infections (P < 0.001). Meanwhile, there were no significant differences between the 2 groups concerning patients undergoing noninstrumented spine surgeries and the incidence of superficial tissue infection.

CONCLUSIONS

Overall, prophylactic application of vancomycin powder in spinal surgery can significantly reduce the incidence of SSI in deep tissues, and this effect is more prominent in patients undergoing internal fixation and deformity correction surgeries.

A microbiology study on the wounds of pediatric patients undergoing spinal fusion for scoliosis

PURPOSE

Surgical site infection is a significant complication in posterior spinal fusion for scoliosis in pediatric and adolescent patients. Current literature demonstrates a lack of consensus regarding best prophylactic systemic and topical antibiotic regimens for reducing infection rates. This study aims to identify which common microbes are present at particular locations in the spine, and whether these are covered by our current systemic and topical antibiotic prophylaxis regimens.

METHODS

A prospective observational study at a National Children's Hospital was conducted on 21 consecutive patients who underwent elective surgery for spinal deformity. Swabs were taken from four layers of the spine, including the superficial skin surface at the start of the case (after surgical site preparation with povidone-iodine), the deep dermis, and the deep surgical bed at the end of exposure and again after the corrective maneuver prior to closure. At each layer, swabs were taken from the proximal, middle, and distal portion of the wound. Swabs were sent to the laboratory for culture and susceptibility testing.

RESULTS

Thirteen (62%) of patients had positive microbial growth. Two microbes were identified, Staphylococcus epidermidis (9.5% of patients) and Cutibacterium acnes (Propionibacterium acnes) (52% of patients). 100% of these microbes were sensitive to cefazolin and vancomycin. 3% of patients had positive growth at the skin layer, 32% positive at the dermal layer, 17% positive after exposure, and 40% positive at the conclusion of the case (p = 0.006). No difference was observed in microbial presence in the upper thoracic, lower thoracic and lumbar spine.

CONCLUSION

Despite adequate surgical site preparation and sterile procedure, microbial contamination remains abundant in the dermal layer and deeper in the spinal wound throughout the case.

Predictors for surgical site infection after fasciotomy in patients with acute leg compartment syndrome

BACKGROUND

Surgical site infection (SSI) is one of the most common complications of orthopedic surgery, which can result in fever, pain, and even life-threatening sepsis. This study aimed to determine the predictors of SSI after fasciotomy in patients with acute leg compartment syndrome (ALCS).

METHODS

We collected information on 125 ALCS patients who underwent fasciotomy in two hospitals between November 2013 and January 2021. Patients with SSI were considered as the SSI group and those without SSI as the non-SSI group. Univariate analysis, logistic regression analysis, and receiver operating characteristic (ROC) curve analyses were used to evaluate patient demographics, comorbidities, and admission laboratory examinations.

RESULTS

In our research, the rate of SSI (26 of 125) was 20.8%. Several predictors of SSI were found using univariate analysis, including body mass index (BMI) (p = 0.001), patients with open fractures (p = 0.003), and patients with a history of smoking (p = 0.004). Besides, the levels of neutrophil (p = 0.022), glucose (p = 0.041), globulin (p = 0.010), and total carbon dioxide were higher in the SSI group than in the non-SSI group. According to the results of the logistic regression analysis, patients with open fractures (p = 0.023, OR 3.714), patients with a history of smoking (p = 0.010, OR 4.185), and patients with a higher BMI (p = 0.014, OR 1.209) were related predictors of SSI. Furthermore, ROC curve analysis indicated 24.69 kg/m² as the cut-off value of BMI to predict SSI.

CONCLUSIONS

Our results revealed open fractures, BMI, and smoking history as independent risk factors for SSI following fasciotomy in patients with ALCS and determined the cut-off value of BMI, enabling us to individualize the evaluation of the risk for SSI to implement early targeted treatments.

Investigating the Association of Patient Body Mass Index With Posterior Subcutaneous Fat Thickness in the Cervical Spine: A Retrospective Radiographic Study

INTRODUCTION

Although BMI is often used as a surrogate for posterior cervical subcutaneous fat thickness (SFT), the association of BMI with cervical SFT is unknown. We performed a retrospective radiographic study to analyze the relationship between BMI and cervical SFT.

METHODS

This was a retrospective cohort study of patients with cervical CT scans. SFT was assessed by measuring the distance (mm) from the spinous processes of C2-C7 to the skin edge. Pearson correlations and linear regression were used to analyze the relationship between BMI and SFT. One-way ANOVA was used to analyze differences in C2-C7 distances while stratifying by BMI.

RESULTS

A total of 96 patients were included. BMI had a moderate correlation with average C2-C7 (r=0.546, p < 0.05) SFT, and a weak to moderate correlation with each individual C2-C7 distance. The strongest correlation was at the C7 level (r= 0.583, p < 0.05). These analyses remained significant controlling for potential confounders of patient age, sex, and diabetes. No difference was found in the average C2-C7 distance in patients with BMIs of 25-30 compared to those with BMIs of 30-40 (p=0.996), whereas in patients with BMI <25 and BMI >40, differences were significant (p < 0.05).

CONCLUSIONS

BMI is not strongly correlated with SFT in the cervical spine. Although BMI less than 25 or greater than 40 is correlated with respectively decreased or increased cervical SFT, BMI of 25-40 is not correlated with cervical SFT. This is clinically important information for surgeons counseling patients on perioperative risk before undergoing cervical spine procedures, namely infection. Further research delineating the relationship between posterior SFT and surgical site infection in the cervical spine is warranted.

The implementation of enhanced recovery after surgery pathway in patients undergoing posterior thoracolumbar fusion for degenerative spinal deformity

PURPOSE

The prevalence of degenerative spinal deformity (DSD) and the increased cost of correction surgery impose substantial burdens on the health care and insurance system. The aim of our study was to investigate the effects of the implementation of Enhanced Recovery After Surgery (ERAS) protocol on postoperative outcomes after complex spinal surgery.

METHODS

A retrospective analysis of prospectively established database of DSD was performed. The consecutive patients who underwent open correction surgery for degenerative spinal deformity between August 2016 and February 2022 were reviewed. We extracted demographic data, preoperative radiographic parameters, and surgery-related variables. The ERAS patients were 1:1 propensity-score matched to a historical cohort by the same surgical team based on age, gender, BMI, and number of levels fused. We then compared the length of hospital stay (LOS), physiological functional recovery, and the rates of complications and readmissions within 90 days after surgery between the groups.

RESULTS

There were 108 patients included, 54 patients in the ERAS cohort, and 54 patients matched control patients in the historical cohort. The historical and ERAS cohorts were not significantly different regarding demographic characteristics, comorbidities, preoperative parameters, operative time, and reoperation rate (P > 0.05). Patients in the ERAS group had significantly shorter postoperative LOS (12.0 days vs. 15.1 days, P = 0.001), average days of drain and urinary catheters placement (3.5 days vs. 4.4 days and 1.9 days vs 4.8 days, respectively), and lower 90-day readmission rate (1.8% vs. 12.9%, P = 0.027). The first day of assisted-walking and bowel movement occurred on average 1.9 days (2.5 days vs. 4.4 days, P = 0.001) and 1.7 days (1.9 days vs. 3.6 days, P = 0.001) earlier respectively in the ERAS group. Moreover, the rate of postoperative urinary retention (3.7% vs. 16.7%, P = 0.026) and surgical site infection (0% vs. 7.4%, P = 0.046) were significantly lower with ERAS protocol applied.

CONCLUSIONS

Our study confirmed that the ERAS protocol was safe and essential for patients undergoing thoracolumbar deformity surgery for DSD. The ERAS protocol was associated with a shorter postoperative LOS, a lower rate of 90-day readmission, less rehabilitation discharge, and less postoperative complications.

The Diagnostic Value of Blood Next-Generation Sequencing in Early Surgical Site Infection After Spine Surgery

Objective

To determine the diagnostic value of blood next-generation sequencing (NGS) in early surgical site infection after spine surgery. Because the blood is sterile in healthy individuals, it is expected that blood NGS is both sensitive and specific for the detection of infection.

Methods

A total of 28 patients with definitive spinal surgical site infections and controls (n=30) were retrospectively included. The postoperative results of NGS and culture on different samples, such as blood and drainage fluid, were obtained and compared to evaluate the diagnostic value of blood NGS. The diagnostic value parameters (sensitivity, specificity, etc.) were calculated.

Results

Among the four bacteriological exam methods, blood NGS was both sensitive and specific for the determination of infection after spine surgery. The sensitivities of blood and drainage fluid NGS were similar (0.82 vs 0.89, P=0.617). However, the specificities of the two assessments differed, which were 0.97 for blood NGS and 0.40 for drainage fluid NGS (P<0.001). The sensitivities of bacterial culture were lower than those of NGS (blood: 0.82 vs 0.25, P<0.001; drainage fluid: 0.89 vs 0.61, P<0.001), regardless of the sample type. However, the specificities of bacterial culture were equal to or higher than those of NGS (blood: 0.97 vs 0.97, P=1.000; drainage fluid: 0.40 vs 0.80, P=0.002).

Conclusion

This article emphasizes the superiority of blood NGS in infection detection and bacterial determination in patients undergoing spine surgery. Compared with traditional drainage fluid bacterial culture and NGS, blood NGS was more sensitive and specific, and its extensive application could be expected.

Management of deep surgical site infections of the spine: a Canadian nationwide survey

Background

Deep surgical site infections after spinal instrumentation represent a significant source of patient morbidity and poorer outcomes. Given lack of evidence or guidelines on the variety of procedural options in the management of deep spine surgical site infections, the purpose of this survey was to document and investigate the use of these techniques across Canada.

Methods

A 34-question survey evaluating surgical techniques for irrigation and debridement in postoperative thoracolumbar infection was distributed to Canadian adult spine surgeons. Results were analyzed qualitatively, and comparisons by specialty, years of training, and number of cases were completed using Fischer's exact tests. We defined consensus as >70% agreement.

Results

We received 53 responses (62% response rate) from a comprehensive sample of Canadian adult spine surgeons. There was a consensus to retain hardware (80%) and interbody implants (93%) in acute infection, to retain interbody implants in chronic/recurrent infection (71%), and application of topical antibiotics in recurrent infection (85%). There was consensus on the use of absorbable suture to close fascia in acute (83%) and chronic (87%) infection. Eighty-five percent of surgeons used nonabsorbable materials such as Nylon or staples for skin closure in chronic infection, however, there was no consensus in acute infection. Surgeons varied significantly in type, volume and pressure of fluids, adjuvant solvents, graft management, use of topical antibiotics acutely, and the use of negative pressure wound therapy. Partial hardware exchange was controversial. Additionally, specialty or surgeon experience had no impact on management strategy.

Conclusions

This survey demonstrates significant heterogeneity amongst Canadian adult spine surgeons regarding key steps in the surgical management of deep instrumented spine infection, concordant with scarce literature addressing these steps.

Surgical site infection is a major risk factor of pseudarthrosis in adult spinal deformity surgery

BACKGROUND CONTEXT

Despite the evidence in appendicular skeletal surgery, the effect of infection on spinal fusion remains unclear, particularly after Adult Spinal Deformity (ASD) surgery.

PURPOSE

The purpose of this study was to determine the impact of surgical site infection (SSI) in ASD surgery fusion rates and its association with other risks factors of pseudarthrosis.

STUDY DESIGN

We conducted an international multicenter retrospective study on a prospective cohort of patients operated for spinal deformity.

PATIENT SAMPLE

A total of 956 patients were included (762 females and 194 males).

OUTCOME MEASURES

Patient's preoperative characteristics, pre and postoperative spinopelvic parameters, surgical variables, postoperative complications and were recorded. Surgical site infections were asserted in case of clinical signs associated with positive surgical samples. Each case was treated with surgical reintervention for debridement and irrigation. Presence of pseudarthrosis was defined by the association of clinical symptoms and radiological signs of nonfusion (either direct evidence on CT-scan or indirect radiographic clues such as screw loosening, rod breakage, screw pull out or loss of correction). Each iterative surgical intervention was collected.

METHODS

Univariate and multivariate analysis with logistic regression models were performed to evaluate the role of risk factors of pseudarthrosis.

RESULTS

Nine hundred fifty-six surgical ASD patients with more than two years of follow-up were included in the study. 65 of these patients were treated for SSI (6.8%), 138 for pseudarthrosis (14.4%), and 28 patients for both SSI and pseudarthrosis. On multivariate analysis, SSI was found to be a major risk factor of pseudarthrosis (OR=4.4; 95% CI=2.4,7.9) as well as other known risks factors: BMI (OR=1.1; 95% CI=1.0,1.1), smoking (OR=1.6; 95% CI=1.1,2.9), performance of Smith-Petersen osteotomy (OR = 1.6; 95% CI 1.0,2.6), number of vertebrae instrumented (OR=1.1; 95% CI=1.1,1.2) and the caudal level of fusion, with a distal exponential increment of the risk (OR max for S1=6, 95% CI=1.9,18.6).

CONCLUSION

SSI significantly increases the risk of pseudarthrosis with an OR of 4.4.

Use of antibiotic-impregnated beads in the treatment of lumbosacral surgical site infection: A retrospective case series

Background

Different adjuvant local-antibiotic techniques are described in management of surgical-site infections (SSIs). Antibiotic-laden polymethyl methacrylate (PMMA) spacers have been used in peri-prosthetic infections. However, their role in treatment of spinal SSIs is not well-recognised.

Methods

After approval from Institutional Review Board, we retrospectively evaluated the data of patients aged≥18 years, who were treated for SSIs of lumbo-sacral region (2010-2019). Among them, those who underwent treatment with the placement of cement beads (temporarily/permanently) were identified. This approach was utilised for post-surgical spondylodiscitis patients with significant, associated infection or abscess involving the paraspinal musculature. Only those with≥2 years' follow-up, were included.Patient demographic details, site of infection, details regarding laboratory/radiological investigations, management-protocol followed, pathogen grown, antibiotics used (their dosage and duration of use), complications encountered and outcome were recorded.

Results

13 patients [4 males, age:57.3 ± 12.4 years] were included. Seven had co-morbidities. One had upper-lumbar involvement, one sacral and others had lower-lumbar (L4/distally) disease. While 7 had recent-onset infection (≤2 months since primary surgery), 6 had chronic infection. In 2, 8, 2, and 1 patients, primary surgery was microdiscectomy, TLIF, PLF, and adult-deformity surgery, respectively.Nine underwent two-staged intervention and 4 underwent single procedure. Eleven had PMMA beads, while 2 underwent calcium sulphate bead insertion. Culture grew E coli in 3, Pseudomonas in 2; and E fecalis, K pneumoniae, MSSA and MRSA in one patient each. In 4 patients, beads were not removed. All patients underwent 2 weeks of parenteral antibiotics, followed by 8-12 weeks of oral medications. There was complete remission in all patients, except one who required additional VAC therapy.

Conclusion

Local antibiotic-laden bead application is an effective adjuvant strategy (along with debridement and systemic antibiotics) for the treatment of spinal SSI, where there is substantial infection involving the paraspinal musculature. It is cost-effective and often necessitates second procedure for bead removal.

Comparative Study of the Usage of Closed Suction and Nonsuction Drains in Cervical Laminoplasty

Introduction

Although previous studies reported the clinical significance of drains in lumbar surgery, their role in and effects on the clinical outcomes of cervical spine surgery remain unclear. The present study compared the clinical outcomes of cervical laminoplasty (CLP) using a closed suction drain (CSD) and closed nonsuction drain (CNSD).

Methods

Prospectively recorded surgical data on consecutive patients who underwent CLP at a single institution between 2014 and 2020 and were followed up for at least 1 year were examined. CSD was used prior to January 2018, and CNSD has since been employed. One hundred patients who underwent surgery before and after the change in drain type (the CSD and CNSD groups, respectively) were selected for analysis. Primary outcome measures were the drainage amount, blood count, and fluid collection at the surgical site defined by magnetic resonance images. The Japanese Orthopaedic Association (JOA) score for the cervical spine was also evaluated as a functional outcome.

Results

No significant differences were observed in demographic, baseline clinical, or surgical data between the CSD and CNSD groups. The drainage amount was significantly greater in the CSD group than in the CNSD group (224 vs. 143 mL, P<0.001). Hemoglobin and hematocrit levels were significantly decreased in the CSD group than in the CNSD group. Medium or large fluid collection was significantly more common in the CNSD group than in the CSD group. No significant differences were observed in the number of surgical site infections, the formation of symptomatic hematoma, or JOA scores between the two groups.

Conclusions

The use of CNSD in CLP decreased the drainage amount and maintained the hemoglobin level compared with that of CSD. Although no patients developed symptomatic hematoma, the amount of epidural fluid collected was larger in the CNSD group than in the CSD group.

Individualized perioperative management in transoral spine surgery: a single-center cohort study evaluating surgical wound complications and wound infections

Background

Transoral spine surgery is specific due to both its surgical approach and the spectrum of diseases it targets. Patients with high age and elevated clinical frailty scores are often involved, and there are reports of increased risks of surgical site infection (SSI) due to extended exposures requiring maxilotomy or mandibulotomy. Our case series describes surgical wound complications under the meticulous application of individualized perioperative multimodal management.

Methods

Our primary outcome was the occurrence of SSI and the secondary outcome was the occurrence of other noninfectious wound complications evaluated in 22 adult patients who consecutively underwent the transoral spine surgery from 2001 to 2018 (trauma – C2, cervical nonunion: 6 patients, 27%; tumor: 4 patients, 18%; osteomyelitis: 6 patients, 27%; other non-traumatic cases: 6 patients, 27%). Structuralized data comprising parameters related to nosocomial infections after spine surgery were continuously processed and put into specialized database of preventive multimodal nosocomial infection control protocol that was used as a main source of analyzed parameters. The mean age of studied cohort was 54.9 \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\pm$$\end{document}± 15.5 years, with 68% males, mean body mass index (BMI) 24.9 \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\pm$$\end{document}± 5.22, and the mean clinical frailty score was 2.59 \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\pm$$\end{document}± 1.07. There were 7 patients (32%) who only had the transoral approach and 15 patients (68%) having this approach followed by additional posterior approach. We observed SSI from all wound complications for up to one year after surgery.

Results

There were 4 (18%) superficial wound complications from transoral approach, but none of them were infected. We had 2 patients (13%) with deep wound infections after subsequent posterior approach, but only one (4.5%) was classified as SSI.

Conclusions

We describe the wound complications and the incidence of SSI in a series of 22 patients after the transoral surgery. Considering the average values of the clinical frailty score reaching 2.59, American Society of Anesthesiologists score of 2.73, and the BMI of 26.87, the transoral spine surgery did not seem to be a considerable risk for SSI in the analyzed cohort, provided preventive perioperative multimodal management is properly individualized and followed.

Enhanced recovery after surgery pathway: association with lower incidence of wound complications and severe hypoalbuminemia in patients undergoing posterior lumbar fusion surgery

Background

Wound complications are associated with worse satisfaction and additional costs in patients undergoing posterior lumbar fusion (PLF) surgery, and the relationship between enhanced recovery after surgery (ERAS) pathway and wound complications remains poorly characterized.

Methods

In this retrospective single-center study, we compared 530 patients receiving ERAS pathway care with previous 530 patients in non-ERAS group. The primary aim of our study was to identify the relationship between the ERAS program and the incidence of postoperative wound-related complications and other complications following PLF surgery; other outcomes included the length of stay (LOS), 90-day hospital and rehabilitation center readmission.

Results

The average patient age was 65 yr. More patients with old cerebral infarction were in ERAS group (p < 0.01), and other demographics and comorbidities were similar between groups. Patients in the ERAS group had a lower incidence of postoperative wound-related complications than the non-ERAS group (12.4 vs. 17.8%, p = 0.02). The non-ERAS group had a significantly higher rate of wound dehiscence or poor wound healing (6% vs. 3%, p = 0.02). ERAS group had a lower incidence of severe postoperative hypoalbuminemia (serum albumin less than 30 g/L) (15.8% vs. 9.0% p < 0.01). Additionally, ERAS patients had shorter postoperative LOS (8.0 ± 1.5 vs. 9.5 ± 1.7, p < 0.01), lower rate of readmission within 90 days (1.9% vs. 6.4%, p < 0.01) and discharge to rehabilitation center (4.2% vs. 1.0%, p < 0.01).

Conclusion

ERAS pathway might help decrease the rates of postoperative wound complications and severe hypoalbuminemia following PLF surgery; additionally, it demonstrated that ERAS pathway was also associated with shorter LOS and lower rate of readmissions within 90 days.

Thickness of the Subcutaneous Fat as a Risk Factor for Surgical Site Infection Following Fragility Hip Fracture Surgery

INTRODUCTION

Surgical site infection (SSI) following fragility hip fracture (FHF) surgery is associated with increased morbidity and mortality.

SIGNIFICANCE

Prediction of patients at risk for SSI is fundamental. We aimed to determine whether subcutaneous radiographic fat measurement (SRM) is associated with increased SSI risk.

METHODS

A retrospective case-control comparison of SRMs at 3 locations around the hip. Patients diagnosed with SSI in the first post-operative year were matched with age, gender, surgical year, Charlsons' co-morbidity index score, and surgical type controls, not diagnosed with SSI, at a 1:2 ratio. Measurements included the distance between (1) the sourcil to skin surface (SS), (2) the tip of the greater trochanter to skin surface (TGTS), and (3) the most prominent lateral aspect of the greater trochanter to skin surface.

RESULTS

1430 patients were operated during the study period, of whom 45 patients presented with a diagnosis of SSI and compared to 90 controls. Infections occurred 27.4 ( ± 24.8) days following surgery. SRM significantly differed between groups, and all were higher in the study group; SS, 86.8 ± 25.5 cm vs 74.2 ± 15.3 cm; TGTS, 59.8 ± 26.3 cm vs 47.0 ± 15.8 cm; and LGTS, 45.4 ± 25.1 cm vs 33.2 ± 15.1 cm (P = .003, .004, and .004, respectively). Intraclass correlation coefficients (intra-rater) were high for all measurements (.999 for all). Intraclass correlation coefficients (inter-rater) for SS, TGTS and LGTS were high, .749 (.663.815), .792 (.719.847) and .817 (.751.866), respectively.

CONCLUSIONS

SRMs were found to be a valid and reproducible tool for predicting high risk of SSI in geriatric patients sustaining FHFs.

LEVEL OF EVIDENCE

III.

Altered gut microbiota composition with antibiotic treatment impairs functional recovery after traumatic peripheral nerve crush injury in mice: effects of probiotics with butyrate producing bacteria

OBJECTIVE

Antibiotics (ABX) are widely used for life-threatening infections and also for routine surgical operations. Compelling evidence suggests that ABX-induced alterations of gut microbiota composition, termed dysbiosis, are linked with diverse disease states including neurological and neurodegenerative conditions. To combat the consequences of dysbiosis, probiotics (PBX) are widely used. ABX-induced dysbiosis is reported to impair neurological function after spinal cord injury. Traumatic peripheral nerve injury (TPNI) results in profound neurologic impairment and permanent disability. It is unknown whether ABX treatment-induced dysbiosis has any impact on TPNI-induced functional recovery, and if so, what role medical-grade PBX could have on TPNI recovery.

RESULTS

In this study, ABX-induced dysbiosis and PBX-induced microbiota enrichment models were used to explore the potential role of gut microbiome in TPNI. Stool analysis with 16S ribosomal RNA (rRNA) gene sequencing confirmed ABX-induced dysbiosis and revealed that ABX-induced changes could be partially restored by PBX administration with an abundance of butyrate producing bacteria. Pre-injury ABX significantly impaired, but pre-injury PBX significantly improved post-TPNI functional recovery. Importantly, post-injury PBX protected against pre-injury ABX-induced functional impairment. These findings demonstrate that reestablishment of gut microbiota composition with butyrate producing PBX during ABX-induced dysbiosis could be a useful adjuvant therapy for TPNI.

[Reasons analysis on unplanned reoperation of degenerative lumbar spine diseases]

Objective

To review the research on the reasons of unplanned reoperation (URP) for degenerative lumbar spine diseases, and to provide new ideas for improving the quality of surgery for degenerative lumbar spine diseases.

Methods

The literature about the URP of degenerative lumbar spine diseases at home and abroad in recent years was reviewed and analyzed.

Results

At present, the reasons for URP include surgical site infection (SSI), hematoma formation, cerebrospinal fluid leakage (CSFL), poor results of surgery, and implant complications. SSI and hematoma formation are the most common causes of URP, which happen in a short time after surgery; CSFL also occurs shortly after surgery but is relatively rare. Poor surgical results and implant complications occurred for a long time after surgery. Factors such as primary disease and surgical procedures have an important impact on the incidence of URP.

Conclusion

The main reasons for URP are different in various periods after lumbar spine surgery. Interventions should be given to patients with high-risk URP, which thus can reduce the incidence of URP and improve the surgery quality and patients' satisfaction.

The Utility of Prolonged Prophylactic Systemic Antibiotics (PPSA) for Subfascial Drains After Degenerative Spine Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of the current investigation was to evaluate the impact of prolonged prophylactic systemic antibiotics (PPSA) on the development of surgical site infection rate (SSIR) in degenerative spine surgery.

SUMMARY OF BACKGROUND DATA

Surgical drains are utilized postoperatively in posterior spine surgery to help minimize the risk of seroma formation. Prophylactic antibiotics while drains are in place are frequently used to reduce SSIR, though the practice remains controversial.

METHODS

We performed a single center, retrospective review of all patients that underwent posterior spinal surgery for cervical and lumbar degenerative pathology over a 3.5 year period (January 2016-July 2019). Patients underwent a traditional open posterior midline procedure with postoperative placement of a subfascial surgical drain. Antibiotics were administered for the duration of the drain (PPSA group) or for 24 hours postoperatively (non-PPSA group). The number of surgical site infections, organism, and Clostridium difficile infections was recorded.

RESULTS

Three hundred thirty six patients were identified, 168 patients in the PPSA group and 168 in the non-PPSA groups. The overall SSIR was 5.36% (18/336). The SSIR for the non-PPSA and PPSA groups were 7.14% (12/168) and 3.57% (6/168), respectively (P = 0.146). While difference of SSIR between the groups was two-fold, it was not statistically significant. For the non-PPSA and PPSA groups, the SSIR for cervical (5.95% [5/84] vs. 2.38% [2/84], P = 0.443) and lumbar (8.33% [7/84], vs. 4.76% [4/84], P = 0.535) regions were not significantly different. C. difficile cases in the PPSA and non-PPSA groups were 1/168 and 0/168 respectively (P = 1.00).

CONCLUSION

Our series demonstrate a two-fold reduction of SSI with implementation of PPSA regimen. This benefit was demonstrated separately for both cervical and lumbar regions. Randomized trials and increase in sample size are warranted to elucidate the significance of PPSA in posterior spinal surgery.Level of Evidence: 3.

Bacterial adhesion on spinal implants: An in vitro study of "hot spots"

Few studies evaluated bacterial colonization of spinal implants from a "topographic" point of view. This lack of knowledge could hinder the development of more effective strategies in the prevention and treatment of postoperative spinal infections. The aim of this in vitro study was the analysis of the adhesion pattern of sessile cells on conventional spinal implants, to identify "hot spots" on implants where bacterial adhesion could be favored. Clinically relevant Staphylococcus aureus, Staphylococcus epidermidis, and Pseudomonas aeruginosa isolates were grown on commercially available end product spinal implants. To identify sessile cells attached to implant surfaces, confocal laser scan microscopy was used. Different areas from the spinal instrumentations (both Ti and CoCr) were selected for biofilm quantification. Bacterial biofilm was markedly increased in the cut of the rods, both Ti and CoCr, as the uneven surface deriving from the cut might foster cell adhesion. Though not statistically significant, a difference was observed between the rod and the area of the notch, possibly as a consequence of the smoothening effect deriving from the bending of the rod. Finally, the amount of biofilm produced on cobalt-chromium surfaces was always more significant than that formed on titanium surfaces. This study highlights how bacterial adhesion through biofilm formation is favored on the surfaces of higher irregularity and that staphylococci are able to increase sessile biomass on CoCr surfaces. These preliminary results show how surface modifications on the implants may play a key role in bacterial adhesion, opening an exciting field for future research.

The Role of Vancomycin Powder During Spinal Cord Stimulator Implantation: A Case Series and Review of the Literature

OBJECTIVE

We examined the role of intrawound vancomycin powder as prophylaxis against postoperative surgical site infection (SSI) after spinal cord stimulator (SCS) implantation.

METHODS

We performed a retrospective analysis of 153 consecutive patients who had undergone permanent SCS implantation surgery via open laminectomy between 2014 and 2020. We queried the patients' medical records for patient age, sex, relevant medical history, and whether intrawound vancomycin had been administered. We compared the rates of SSI (primary outcome) and seroma (secondary outcome) within 3 months after surgery between the vancomycin and no-vancomycin groups. Finally, we conducted multivariable logistic regression analyses to identify independent predictors of postoperative SSI or seroma.

RESULTS

Of the 153 patients, 59% were women, and the average age was 65.4 years. Overall, 3 patients (2%) had developed an SSI: 2 (methicillin-resistant Staphylococcus aureus, Klebsiella) in the vancomycin group and 1 (methicillin-sensitive Staphylococcus aureus) in the no-vancomycin group. This difference in SSI rate between the 2 groups was insignificant (P = 0.73). Three seromas, all in the no-vancomycin group, accounted for a statistically significant difference in seroma formation between the 2 groups (P = 0.04). Multivariate logistic regression failed to identify any perioperative characteristics as independent predictors of postoperative SSI or seroma.

CONCLUSIONS

Our experience suggests open laminectomy for SCS implantation surgery can be performed with a low postoperative SSI rate, with or without the use of powdered vancomycin. We found no evidence suggesting that the use of powdered vancomycin is unsafe or related to postoperative seroma formation. We failed to draw any definitive conclusions regarding its efficacy, despite referencing the largest single case series of SCS implantation to date.

Removal of instrumentation for postoperative spine infection: systematic review

OBJECTIVE

Currently, no consensus exists as to whether patients who develop infection of the surgical site after undergoing instrumented fusion should have their implants removed at the time of wound debridement. Instrumentation removal may eliminate a potential infection nidus, but removal may also destabilize the patient's spine. The authors sought to summarize the existing evidence by systematically reviewing published studies that compare outcomes between patients undergoing wound washout and instrumentation removal with outcomes of patients undergoing wound washout alone. The primary objectives were to determine 1) whether instrumentation removal from an infected wound facilitates infection clearance and lowers morbidity, and 2) whether the chronicity of the underlying infection affects the decision to remove instrumentation.

METHODS

PRISMA guidelines were used to review the PubMed/MEDLINE, Embase, Cochrane Library, Scopus, Web of Science, and ClinicalTrials.gov databases to identify studies that compared patients with implants removed and patients with implants retained. Outcomes of interest included mortality, rate of repeat wound washout, and loss of correction.

RESULTS

Fifteen articles were included. Of 878 patients examined in these studies, 292 (33%) had instrumentation removed. Patient populations were highly heterogeneous, and outcome data were limited. Available data suggested that rates of reoperation, pseudarthrosis, and death were higher in patients who underwent instrumentation removal at the time of initial washout. Three studies recommended that instrumentation be uniformly removed at the time of wound washout. Five studies favored retaining the original instrumentation. Six studies favored retention in early infections but removal in late infections.

CONCLUSIONS

The data on this topic remain heterogeneous and low in quality. Retention may be preferred in the setting of early infection, when the risk of underlying spine instability is still high and the risk of mature biofilm formation on the implants is low. However, late infections likely favor instrumentation removal. Higher-quality evidence from large, multicenter, prospective studies is needed to reach generalizable conclusions capable of guiding clinical practice.

Preoperative Opioid Weaning Before Major Spinal Fusion: Simulated Data, Real-World Insights

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To identify gaps in opioid prescription immediately prior to spinal fusion and to study the effect of such simulated "opioid weaning/elimination" on risk of long-term postoperative opioid use.

SUMMARY OF BACKGROUND DATA

Numerous studies have described preoperative opioid duration and dose thresholds associated with sustained postoperative opioid use. However, the benefit and duration of preoperative opioid weaning before spinal fusion has not been elaborated.

METHODS

Humana commercial insurance data (2007-Q1 2017) was used to study primary cervical and lumbar/thoracolumbar fusions. More than 5000 total morphine equivalents in the year before spinal fusion were classified as chronic preoperative opioid use. Based on time between last opioid prescription (<14-days' supply) and spinal fusion, chronic opioid users were divided as; no gap, >2-months gap (2G) and >3-months gap (3G). Primary outcome measure was long-term postoperative opioid use (>5000 total morphine equivalents between 3 and 12-mo postoperatively). The effect of "opioid gap" on risk of long-term postoperative opioid use was studied using multiple-variable logistic regression analyses.

RESULTS

17,643 patients were included, of whom 3590 (20.3%) had chronic preoperative opioid use. Of these patients, 41 (1.1%) were in the 3G group and 106 (3.0%) were in the 2G group. In the 2G group, 53.8% patients ceased to have long-term postoperative use as compared with 27.8% in NG group. This association was significant on logistic regression analysis (OR 0.30, 95% CI: 0.20-0.46, P < 0.001).

CONCLUSIONS

Chronic opioid users whose last opioid prescription was >2-months prior to spinal fusion and less than 14-days' supply had significantly lower risk of long-term postoperative opioid use. We have simulated "opioid weaning" in chronic opioid users undergoing major spinal fusion and our analysis provides an initial reference point for current clinical practice and future clinical studies.Level of Evidence: 3.

Risk Factors Associated with Postoperative Infection in Cancer Patients Undergoing Spine Surgery

OBJECTIVES

To determine the rate of and main risk factors for postoperative infection in cancer patients who underwent spine surgery in the last 5 years in order to determine whether there is an association between postoperative infection and increased mortality during hospitalization.

METHODS

All cancer patients who underwent surgical procedures between January 2015 and December 2019 at a single hospital specializing in spine cancer surgery were analyzed. The primary outcome of interest was postoperative infection. Bivariate logistic regression was used to estimate the odds ratio and 95% confidence interval for each variable in relation to the occurrence of infection.

RESULTS

We evaluated 324 patients, including 176 men (54.3%) and 148 women (45.7%) with a mean age of 56 years. The incidence of postoperative infection was 20.37%. Of the 324 patients, 39 died during hospitalization (12%).

CONCLUSIONS

Surgical time greater than 4 hours, surgical instrumented levels greater than 6, and an Eastern Cooperative Oncology Group of 3 or 4 were associated with an increased risk of postoperative infection, but these factors did not lead to an increase in mortality during hospitalization.

Risk-benefit analysis of wound drain usage in spine surgery: a systematic review and meta-analysis with evidence summary

STUDY DESIGN

Systematic review, meta-analysis, evidence synthesis.

OBJECTIVES

To analyse the literature evidence available to support the usage of wound drain in various scenarios of spine surgery and provide an evidence summary on the surgical practice.

MATERIALS AND METHODS

We conducted independent and duplicate electronic database searches adhering to PRISMA guidelines in PubMed, Embase, and Cochrane Library till April 2020. Quality appraisal was done as per Cochrane ROB tool, and evidence synthesis was done as per GRADE approach. Five domains of spine surgery with associated key questions were identified. Evidence tables were generated for each question and critical appraisal done as per the GRADE approach.

RESULTS

Twenty-three studies (9-RCTs, 4-prospective studies, 10-retrospective studies) were included. Analysis of studies in cervical spine either by anterior or posterior approach and single/multilevel thoracolumbar spinal surgeries did not show any evidence of reduction in surgical site infection (SSI) or haematoma formation with the use of drain. Deformity correction surgeries and surgeries done for trauma or tumour involving spine also did not find any added benefit from the use of wound drains despite increasing the total blood loss.

CONCLUSION

Evidence from this review suggests that routine use of drain in various domains of spine surgery does not reduce the risk of SSI and their absence did not increase the risk of haematoma formation. The current best evidence is presented with its limitations. High-quality studies to address their use in spine surgeries in cervical, trauma, and tumour domains are required to further strengthen the evidence synthesised from available literature.