Incidence, Management and Outcome of Delayed Deep Surgical Site Infection Following Spinal Deformity Surgery: 20-Year Experience at a Single Institution

Intrawound Vancomycin Powder Reduces Delayed Deep Surgical Site Infections Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

STUDY DESIGN

Retrospective.

OBJECTIVE

Evaluate whether the use of vancomycin powder (VP) placed in the surgical site before wound closure prevents delayed deep surgical site infections (DDI).

SUMMARY OF BACKGROUND DATA

DDI after posterior spinal fusion (PSF) in adolescent idiopathic scoliosis (AIS) patients remains a significant and major complication. The use of VP to prevent acute surgical site infection has been reported, but the impact on DDI is unknown.

MATERIALS AND METHODS

AIS patients treated over the past 20 years with PSF or instrumentation from a large multicenter registry were reviewed. Patients were divided into two groups: intraoperative vancomycin powder placed in the wound (VP) or no antibiotics placed in the wound (NVP). DDI was defined as an infection that occurred >90 days after surgery and required surgical intervention in the operating room. Patients who developed a DDI had secondary verification of VP use or not. χ 2 and Kaplan-Meier (K-M) survivorship analyses were used to compare demographics and the incident rate of DDI between groups.

RESULTS

Totally, 4145 cases met the inclusion criteria for this study. A total of 43 DDI cases were identified (1.0%). The incidence of DDI for the VP group was 0.2% (4/2111), and 1.9% (39/2034) in the NVP group ( P <0.001). Given the difference in follow-up for the two groups, a cumulative survival and Kaplan-Meier analysis revealed the VP group had significantly better "survival" (no DDI) than the NVP group ( P <0.001).

CONCLUSION

DDIs are significant adverse events that can greatly complicate patient recovery after PSF for AIS, including rehospitalization. This study found that patients who received VP intraoperatively were 10 times less likely to develop a DDI than those who did not receive VP. Although other advances and changes in surgical techniques may contribute to the significant decrease in infections found in the more recent VP cohort, VP should be considered as a prophylactic measure.

LEVEL OF EVIDENCE

4.

Topical vancomycin powder for the prevention of surgical site infections in spinal deformity surgery: a systematic review and meta-analysis

PURPOSE

To assess the effectiveness and safety of topical vancomycin powder (VP) in preventing surgical site infections (SSIs) in spinal deformity surgeries.

METHODS

A literature search was conducted on Web of Science, PubMed, and Cochrane Library databases for comparative studies of VP in spinal deformity surgeries published before February 2024. Two reviewers independently screened eligible articles based on the inclusion and exclusion criteria, assessed study quality, and extracted data. Data analysis was performed using Review Manager 5.4 software.

RESULTS

Of all 143 papers screened, a meta-analysis was conducted on 10 articles, which included a total of 8,166 surgeries. The results of the meta-analysis indicated that the incidence of deep SSI in VP group was 0.28 times that in non-VP group (p < 0.001). In the subgroup analysis, VP treatment significantly reduced the risk of deep SSI in both adult spinal deformity (ASD) (RR 0.40, 95% CI 0.21-0.77, p = 0.006) and pediatric scoliosis (PS) (RR 0.25, 95% CI 0.16-0.38, p < 0.001) surgeries. However, this effect was not observed in neuromuscular scoliosis (NMS) patients (RR 0.66, 95% CI 0.26-1.66, p = 0.38). Bacterial culture results indicated that VP treatment significantly reduced polymicrobial infections (p = 0.007) and gram-positive infections (p = 0.001).

CONCLUSION

From the literature available at present, VP was associated with reduced deep SSIs rates in spinal deformity patients. However, particular attention should be paid to the lack of the effectiveness of VP in NMS patients. The current literature did not report local cytotoxicity or renal toxicity related to VP in spinal deformity patients.

Implant-associated Infection After Pediatric Spine Deformity Surgery: Is Removal of Hardware Indicated?

BACKGROUND

Postoperative spinal implant infection following pediatric spinal surgery often presents a management dilemma. We aimed to characterize our experience in this cohort of patients, hoping to provide further insight when approaching these challenging cases.

METHODS

A retrospective, observational study was performed of all children who underwent spinal surgery from January 2015 to June 2021 in a tertiary pediatric spinal surgery referral center in Queensland, Australia. Records were reviewed to identify cases of postoperative surgical site infection, with particular focus on children with infection directly involving implants. Preoperative prophylaxis, microbiology, clinical course and outcomes were analyzed.

RESULTS

A total of 580 children underwent 933 procedures during the study period. The most common pathology requiring surgery was idiopathic scoliosis in 257 children (44.3%) followed by neuromuscular scoliosis in 192 children (33.1%). There were 35 cases of surgical site infection (6.03%), and 9 were implant-associated (1.55%). Infection rate among children with neuromuscular spinal deformity was almost 3-fold higher (11.5%) than idiopathic (3.89%). Methicillin-sensitive Staphylococcus aureus was the most commonly isolated organism (n = 15). Four implant-associated infections were successfully managed with retention of implant; all were diagnosed within 32 days (median = 20 days) and cultured either Staphylococcus aureus or Pseudomonas aeruginosa . Conversely, infections that necessitated implant removal had a more indolent onset (median = 175 days), and more often cultured Cutibacterium acnes and coagulase-negative Staphylococci .

CONCLUSIONS

Postoperative spinal implant infection can be treated successfully with hardware retention in select cases. Earlier presentation and recognition appear to be associated with better rates of retention and are linked to certain organisms. Further exploration of specific preventative strategies may be key in preventing devastating late-onset infections.

Efficacy of single antibiotic therapy versus antibiotic combination in implant-free staphylococcal post-surgical spinal infections: a retrospective observational study

BACKGROUND

Post-surgical spinal infections (pSSIs) are a serious complication of spinal surgeries, with Staphylococcus spp. being one of the most prominent bacteria identified. Optimal antimicrobial therapy for staphylococcal spinal infections without spinal implants is not well documented.

METHODS

This single center retrospective 7-year observational study described and compared the outcome (treatment failure or mortality rate one year after diagnosis) of 20 patients with staphylococcal-implant-free pSSI treated with single or combination antibiotics.

RESULTS

Median duration of treatment was 40 days (IQR 38-42), with 6 days (IQR 5-7) on intravenous antibiotics and 34 days (IQR 30-36) on oral therapy. Four patients (20%) underwent new surgical debridement, all due to surgical failure, and 1 patient died within the first year without significant differences between both treatment group.

CONCLUSION

This study raises the possibility of single antibiotic therapy for patients with implant-free post-surgical spinal infections due to Staphylococcus spp.

Advances and Evolving Challenges in Spinal Deformity Surgery

BACKGROUND

Surgical intervention is a critical tool to address adult spinal deformity (ASD). Given the evolution of spinal surgical techniques, we sought to characterize developments in ASD correction and barriers impacting clinical outcomes.

METHODS

We conducted a literature review utilizing PubMed, Embase, Web of Science, and Google Scholar to examine advances in ASD surgical correction and ongoing challenges from patient and clinician perspectives. ASD procedures were examined across pre-, intra-, and post-operative phases.

RESULTS

Several factors influence the effectiveness of ASD correction. Standardized radiographic parameters and three-dimensional modeling have been used to guide operative planning. Complex minimally invasive procedures, targeted corrections, and staged procedures can tailor surgical approaches while minimizing operative time. Further, improvements in osteotomy technique, intraoperative navigation, and enhanced hardware have increased patient safety. However, challenges remain. Variability in patient selection and deformity undercorrection have resulted in heterogenous clinical responses. Surgical complications, including blood loss, infection, hardware failure, proximal junction kyphosis/failure, and pseudarthroses, pose barriers. Although minimally invasive approaches are being utilized more often, clinical validation is needed.

CONCLUSIONS

The growing prevalence of ASD requires surgical solutions that can lead to sustained symptom resolution. Leveraging computational and imaging advances will be necessary as we seek to provide comprehensive treatment plans for patients.

Reinstrumentation for progressive hyper-kyphotic deformity after implant removal despite obtaining physiological alignment by posterior corrective surgery for adolescent idiopathic scoliosis with flat back: a case report

This case report describes a 13-year-old female patient with adolescent idiopathic scoliosis (AIS) and flat back who experienced progressive kyphotic deformity after implant removal despite obtaining physiological alignment postoperatively. The patient underwent multiple surgeries, and a late-developing infection complicated her treatment course. Despite hard bracing to prevent kyphotic change, the kyphosis progressed to 74° within a year after implant removal, leading to a decrease in patient height and back pain. Revision surgery was eventually necessary. Possible factors for the kyphotic progression include injury to paraspinal back muscles due to multiple surgeries or insufficient bony fusion from late-developing infection. This case highlights the importance of thorough evaluation and follow-up for optimal patient outcomes after implant removal in AIS patients, particularly those with flat back.

REVISION RECONSTRUCTION OF THE CERVICAL SPINE IN A PATIENT WITH EARLY DEEP SSI COMPLICATED BY ANGULAR KYPHOSIS: clinical case and literature review

Background. Deep surgical site infection (DSSI) is one of the most severe complications in spinal surgery. The timing and nature of DSSI are the determining criteria in the choice of treatment tactics. Aim. To present a unique clinical case of early deep SSI after ACDF in a patient with multisegmental degenerative spinal canal stenosis, complicated by epidural abscess and angular kyphotic deformity. Angular kyphosis correction, corpectomy of C4-6 and three-column cervical reconstruction were performed in one surgical session. Case presentation. A 57-year-old patient was admitted to the clinic after staged surgical interventions on the cervical spine for multilevel degenerative stenosis of the spinal canal. The primary surgical interventions were complicated by DSSI in the early period after the second surgery with formation of angular kyphosis of the cervical spine. The patient underwent revision one-stage reconstructive intervention to correct the deformity, decompress the spinal canal, and three-column reconstruction of C3-7 segments. Long-term follow-up showed persistent reduction of pain syndrome, improved quality of life and absence of recurrence of DSSI. Conclusion. The presented case illustrates the possibilities of one-stage revision three-column cervical spine reconstruction for correction of sagittal profile, decompression of intracanal neural structures and ensuring stability of operated segments. Use of DSSI treatment algorithms based on Prinz V. and Vajkoczy P. classification contributes to the selection of the optimal tactics of patient management.

Clinical differences between delayed and acute onset postoperative spinal infection

Spine surgeons often encounter cases of delayed postoperative spinal infection (PSI). Delayed-onset PSI is a common clinical problem. However, since many studies have investigated acute PSIs, reports of delayed PSI are rare. The purpose of this study was to compare the clinical features, treatment course, and prognosis of delayed PSI with acute PSI.Ninety-six patients diagnosed with postoperative spinal infection were enrolled in this study. Patients were classified into 2 groups: acute onset (AO) within 90 days (n = 73) and delayed onset (DO) after 90 days (n = 23). The baseline data, clinical manifestations, specific treatments, and treatment outcomes were compared between the 2 groups.The history of diabetes mellitus (DM) and metallic instrumentation at index surgery were more DO than the AO group. The causative organisms did not differ between the 2 groups. Redness or heat sensation around the surgical wound was more frequent in the AO group (47.9%) than in the DO group (21.7%) (P = .02). The mean C-reactive protein levels during infection diagnosis was 8.9 mg/dL in the AO and 4.0 mg/dL in the DO group (P = .02). All patients in the DO group had deep-layer infection. In the DO group, revision surgery and additional instrumentation were required, and the duration of parenteral antibiotic use and total antibiotic use was significantly longer than that in the AO group. Screw loosening, disc space collapse, and instability were higher in the DO group (65.2%) than in the AO group (41.1%) (P = .04). However, the length of hospital stay did not differ between the groups.Delayed-onset PSI requires more extensive and longer treatment than acute-onset surgical site infection. Clinicians should try to detect the surgical site infection as early as possible.

Local vancomycin therapy to reduce surgical site infection in adult spine surgery: a randomized prospective study

PURPOSE

This prospective randomized controlled trial hypothesizes that intra wound vancomycin reduces postoperative infection.

METHODS

In this RCT study, the patients were randomly divided into two groups of treatment and control. In the treatment group, 1-2 g of intra wound vancomycin was used, and no drug was used for the control group. SSI and the type of microorganism causing postoperative infection were assessed at a three-month follow-up. Factors affecting postoperative infection such as age, sex, site of operation, surgical levels, and risk factors affecting postoperative infection, such as diabetes, blood pressure, ischemic heart disease, smoking, blood transfusion, BMI, neurologic deficit, CSF leakage, UTI, COPD and surgery time were examined in two groups.

RESULTS

In this study, 375 patients, including 187patients in the treatment group and 188 patients in the control group, were studied. Among the patients, 228 had surgery without instrumentation, and 147 had surgery with instrumentation. There were 12 cases of SSI in the treatment group and 11 in the control group, and there was no statistically significant difference between the two groups. There was no difference between the two groups with and without instrumentation in the evaluation of postoperative infection. In the subgroups with and without instruments, there was no significant difference between treatment and control groups. Due to the microorganism causing the infection, gram-negative bacteria were more common in the treatment group.

CONCLUSION

Intra-wound vancomycin has no effect on SSI; in addition, it can increase the rate of gram-negative infections.