Risk factors for deep surgical site infection following thoracolumbar spinal surgery

Surgical outcomes and predictive value for major complications of robot-assisted radical cystectomy of real-world data in a single institution in Japan

OBJECTIVE

The objective of the study was to describe the surgical outcome of robot-assisted radical cystectomy and predictive factors for major complications in real-world clinical practice at a single institution in Japan.

METHODS

We retrospectively analyzed 208 consecutive patients undergoing robot-assisted radical cystectomy at our institution between 2019 and 2023. Patient and disease characteristics, intraoperative details, and perioperative outcomes were reviewed. Postoperative complications were defined as minor complications (Clavien-Dindo grades 1-2) or major complications (grades 3-5). Predictors of complications were examined using multivariable logistic analysis.

RESULTS

Overall, 147 men and 61 women, median age 70 years (interquartile range, 62-77), were included in this study. Median operative time and estimated blood loss were 8.4 h and 185 mL, respectively; 11 patients (5%) received intraoperative blood transfusions. For urinary diversions, ileal conduit, neobladder, and cutaneous ureterostomy were performed in 153 (74%), 49 (24%), and 6 (3%) patients, respectively. Urinary diversions were primarily performed with extracorporeal urinary diversion. In total, 140 complications occurred in 111 patients (53%) within 30 days. Of these patients, 31 major complications occurred in 28 patients, and one perioperative death (0.5%) with a postoperative cardiovascular event. Multivariable analysis showed only prolonged operative time (odds ratio: 4.34, 95% confidence interval: 1.82-10.35, p < 0.01) was the independent risk factor for major complications.

CONCLUSIONS

This study reports surgical outcomes at our single institution. Prolonged operative time was a significant prognostic factor for major complications. As far as we know, this study reports the largest number of robot-assisted radical cystectomy cases at a single center in Japan.

Negative pressure wound therapy in the management of postoperative spinal wound infections: a systematic review

INTRODUCTION

Postoperative wound infection after spinal surgery might be a challenge to manage. A wide range of procedures have been described for managing infected spinal wounds. An increasingly common procedure in the management of surgical site infections (SSI) is negative pressure wound therapy (NPWT), also known as vacuum-assisted closure. As there is a paucity of clear clinical advice the present investigation aims to update current evidence on the use of NPWT to manage postoperative SSI occurring after instrumented spine surgery.

METHODS

This systematic review was conducted according to the preferred reporting Items for systematic reviews and meta-analyses: the 2020 PRISMA statement. In January 2024, the following databases were accessed: PubMed, Web of Science, and Google Scholar. No time constraint was set for the search. All the clinical studies investigating the unique use of NPWT in treating postoperative spinal wound infections were accessed.

RESULTS

A total of 381 patients were included in the present study. Of them 52.5% (200 of 381 patients) were women. The mean age was 52.2 ± 15.2 years. The average length of the NPWT was 21.2 days (range 7-90 days).

CONCLUSION

NPWT could be a valuable adjuvant therapy for the management of SSI after spine surgery. Additional high-quality investigations are required to assess the efficacy and safety of NPWT in SSI after spine surgery, especially if combined with contraindications or risk factors, such as the presence of intraoperative CSF leak.

LEVEL OF EVIDENCE

Level IV, Systematic review.

Is an Elevated Preoperative CRP Level a Predictive Factor for Wound Healing Disorders following Lumbar Spine Surgery?

Postoperative wound infections are a prevalent concern among the hospital-associated infections in Europe, leading to prolonged hospital stays, increased morbidity and mortality, and substantial patient burdens. Addressing the root causes of this complication is crucial, especially given the rising number of spine surgeries due to aging populations.

METHODS

A retrospective analysis was conducted on a cohort of 3019 patients who underwent lumbar spine surgery over a decade in our department. The study aimed to assess the predictors of wound healing disorders, focusing on laboratory values, particularly inflammatory parameters.

RESULTS

Of the 3019 patients, 2.5% (N = 74) experienced deep or superficial wound healing disorders, showing the significant correlation between C-reactive protein (CRP) levels and these disorders (p = 0.004). A multivariate analysis identified several factors, including age, sex, hypertension, diabetes, cardiac comorbidity, surgical duration, dural injury, and blood loss, as being correlated with wound healing disorders.

CONCLUSION

Demographic factors, pre-existing conditions, and perioperative variables play a role in the occurrence of adverse effects related to wound healing disorders. Elevated CRP levels serve as an indicator of increased infection risk, though they are not a definitive diagnostic tool for wound healing disorders.

Mechanical Vertebral Body Augmentation Versus Conventional Balloon Kyphoplasty for Osteoporotic Thoracolumbar Compression Fractures: A Systematic Review and Meta-Analysis of Outcomes

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

Surgical management of osteoporotic vertebral compression fractures (OVCFs) has traditionally consisted of vertebroplasty or kyphoplasty procedures. Mechanical percutaneous vertebral body augmentation (MPVA) systems have recently been introduced as alternatives to traditional methods. However, the effectiveness of MPVA systems vs conventional augmentation techniques for OVCFs remains unclear. This serves as the premise for this study.

METHODS

A systematic review and meta-analysis was conducted as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies of interest included randomized controlled trials (RCTs) which directly compared patient outcomes following kyphoplasty to patients treated with MPVA systems. Clinical and radiological findings were collated and compared for significance between cohorts.

RESULTS

6 RCTs were identified with 1024 patients total. The mean age of all patients was 73.5 years. 17% of the cohort were male, 83% were female. 515 patients underwent kyphoplasty and 509 underwent mechanical vertebral body augmentation using MPVA systems. MPVAs showed similar efficacy for restoration of vertebral body height (P = .18), total complications (P = .36), cement extravasation (P = .58) and device-related complications (P = .06). MPVAs also showed reduced rates of all new fractures (16.4% vs 22.2%; P = .17) and adjacent fractures (14.7% vs 18.9%; P = .23), with improved visual analogue scale (VAS) scores at 6-month (P = .13).

CONCLUSION

The results of this meta-analysis highlight no significant improvement in clinical or radiological outcomes for MPVA systems when compared to balloon kyphoplasty for vertebral body augmentation. Further research is needed to establish a true benefit over traditional operative methods.

Single Surgeon Comparison of Midline Versus Overlapping Locoregional Flap Closure Following Spinal Instrumentation

BACKGROUND

Two techniques for paraspinous muscle flap closure of spine surgeries have been described: one with tension-free mobilization of the muscle flaps approximated at the midline and one with perforators more aggressively dissected to allow for overlapping of the flaps. We seek to compare the surgical outcomes in patients who underwent either type of complex spinal closure as no investigation has yet evaluated a superior technique.

METHODS

An institutional review board (IRB)-approved retrospective analysis was conducted on all patients who underwent spine surgery followed by locoregional muscle flap complex closure performed by a single plastic surgeon between January 2016 and July 2021. Patients were divided into 2 groups based on which closure method was employed. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed by multivariable logistic regression with Firth's correction.

RESULTS

One hundred and 10 patients with similar baseline demographics were included. There were significantly more smokers (15% vs. 0%, P = 0.02) and a significantly greater rate of postoperative radiation (40% vs. 17%, P = 0.009) in the overlapping group. After controlling for smoking and postoperative radiation, the incidence of surgical site infection, skin necrosis, dehiscence, hematoma, and seroma did not differ between the groups. The procedure length per centimeter of closure was shorter in the midline approximation group, although this data fell just short of significance (3.2 vs. 3.8 minutes/cm, P = 0.08).

CONCLUSIONS

The present study demonstrates that both the overlapping and midline approximation of muscle flaps are equally safe and effective strategies for locoregional closure of spinal wounds.

Epidemiology and prognostic factors for new-onset deep venous thrombosis after unicompartmental knee arthroplasty: a retrospective study

BACKGROUND

Patients who underwent knee joint arthroplasty were at risk of venous thromboembolic events (VTEs), however, less studies were conducted to demonstrate the epidemiology and risk factors of deep venous thrombosis (DVT) following unicompartmental knee arthroplasty (UKA). Objective of this study was to explore the incidence and prognostic factors of DVT after UKA.

METHODS

Patients who underwent primary UKA from December 2018 to June 2022 were recruited in this study. Demographic characteristics, operation related variables and laboratory index were extracted and analyzed. Receiver operating characteristic analysis was performed to detect the optimum cut-off value for variables of interest. Univariate and multivariate logistic analysis were performed to identify risk factors of DVT.

RESULTS

351 UKAs with a mean age of 65.4 ± 7.1 years were reviewed. After 12.9 ± 11.2 months follow-up, 35 DVTs were confirmed which indicating an incidence of 9.9%. The results showed that occupation (agricultural laborer) (P = 0.008), disease duration > 8.5 years (P = 0.035), operation time > 169 min (P = 0.003), intraoperative blood loss > 102 ml (P < 0.001), BMI > 26.8 kg/m 2 (P = 0.001), preoperative D-dimer > 0.29 mg/L (P = 0.001), prothrombin time < 10.7 s (P = 0.033) and INR < 0.98 (P = 0.032) between DVT and Non-DVT group were significantly different. Multivariate logistic regression analysis showed intraoperative blood loss > 102 ml (OR, 3.707; P, 0.001), BMI > 26.8 kg/m 2 (OR, 4.664; P, 0.004) and D-dimer > 0.29 mg/L (OR, 2.882; P, 0.009) were independent risk factors of DVT after UKA.

CONCLUSION

The incidence of DVT in the present study was 9.9%, extensive intraoperative blood loss, advanced BMI and high level of D-dimer would increase the risk of lower extremity thrombosis by 2-4 times.

Investigating the efficacy of vacuum sealing drainage versus traditional negative pressure drainage in treating deep incision infections following posterior cervical internal fixation-a retrospective cohort study

BACKGROUND

Assessing the efficacy and safety of Vacuum Sealing Drainage (VSD) in treating deep incision infections (DII) following posterior cervical internal fixation.

METHODS

We retrospectively studied the clinical effects of VSD and Traditional Negative Pressure Drainage (TND) on 12 patients with deep incision infection after posterior cervical fixation surgery who were treated in our department from 2012 to 2020. A comparison of patient-related factors (age, gender, BMI, comorbidities, initial internal fixation surgery segment, preoperative laboratory inflammation indicators) and surgical-related factors (postoperative duration of fever, positive rate of drainage fluid bacterial culture, Visual Analogue Scale (VAS) score at 3 days after surgery, laboratory indicators at 3 days after surgery, debridement frequency and drainage time, hospital stay, internal fixation retention rate, and infection recurrence rate) between the VSD group and the TND group was conducted using independent sample t tests to draw experimental conclusions.

RESULTS

This study included 12 patients, with six cases of VSD (5 males and 1 female) and six cases of TND (4 males and 2 females). The VSD group had significantly lower postoperative fever time (1.50 ± 0.46 days vs. 4.28 ± 0.97 days, P < 0.05), a higher positive rate of bacterial cultures in drainage fluid (5/6 vs. 2/6, P < 0.05), lower 3 day VAS scores (3.13 ± 0.83 vs. 3.44 ± 0.88, P < 0.05), lower 3 day CRP levels (66.89 ± 23.65 mg/L vs. 57.11 ± 18.18 mg/L, P < 0.05), a shorter total drainage time (14.50 ± 2.98 days vs. 22.56 ± 3.01 days, P < 0.05), and a higher total drainage flow rate (395.63 ± 60.97 ml vs. 155.56 ± 32.54 ml, P < 0.05) than the TND group (the total drainage volume throughout the entire treatment process). In addition, the frequency of debridement (2.67 ± 0.52 times vs. 3.17 ± 0.41 times, P < 0.05) and average hospital stay (23.13 ± 3.27 days vs. 34.33 ± 6.86 days, P < 0.05) were significantly lower in the VSD group, although both groups retained internal fixation.

CONCLUSIONS

VSD is a secure and effective treatment for deep incision infections that results from cervical posterior internal fixation surgery.

Efficacy of Antibiotic Bone Cement in the Treatment of Burkholderia cepacia Infection After Spinal Internal Fixation Surgery: Case Report and Literature Review

BACKGROUND

In recent years, the number of spinal internal fixation operations has increased significantly, correlating with an elevated risk of postoperative surgical site infection and a rising incidence rate. While the conventional treatment approach involves surgical debridement combined with antibiotic administration, there is a notable gap in reported strategies for Burkholderia cepacia infection and patients exhibiting multidrug resistance.

METHODS

Surgical site infection occurred in a patient following internal fixation surgery for thoracic vertebral fractures. Despite the application of systemic antibiotics and regular dressing changes, no improvement was observed. Bacterial culture and drug sensitivity experiments revealed a multidrug-resistant Burkholderia cepacia infection. Two comprehensive debridement procedures were performed along with continuous post-operative irrigation combined with antibiotic administration; however, no significant improvement was observed. The patient's infection was significantly controlled following treatment with vancomycin loaded bone cement.

RESULTS

Following spinal internal fixation surgery, the management of a B. cepacian infection with multidrug resistance presented a significant challenge, despite the application of debridement procedures and systemic antibiotics. In this case, after 20 days of treatment with vancomycin-loaded bone cement, the patient's C-reactive protein level decreased to 54 mg/L, was normalized by February, and normal levels were maintained in the surgical area 1 month and 6 months after bone cement removal.

CONCLUSIONS

The use of vancomycin-loaded bone cement proves effective in treating postoperative B. cepacian infection in a multidrug-resistant case following spinal internal fixation surgery.

The Surgical Outcomes of Pedicle Subtraction Osteotomy per Different First Assistant: Retrospective Analysis of 312 Cases

INTRODUCTION

Pedicle subtraction osteotomies (PSOs) are complex spinal deformity surgeries that are associated with high complication rates. They are typically done by an experienced spine surgeon with another attending, resident, or physician assistant serving as the first assistant. The purpose of this study was to determine whether selecting a surgical team for single-level PSO based on case difficulty and fusion length could equalize intraoperative and perioperative outcomes among three groups: dual-attending (DA), attending and orthopaedic resident (RS), and attending and physician assistant (PA).

METHODS

This study was a retrospective cohort analysis of 312 patients undergoing single-level thoracic or lumbar PSO from January 2007 to December 2020 by a fellowship-trained orthopaedic spine surgeon. Demographic, intraoperative, and perioperative data within 30 days and 2 years of the index procedure were analyzed.

RESULTS

Patient demographics did not markedly differ between surgical groups. The mean cohort age was 64.5 years with BMI 31.9 kg/m 2 . Patients with the DA approach had a significantly longer surgical time (DA = 412 min vs. resident = 372 min vs. physician assistant = 323 min; P < 0.001). Patients within the DA group experienced a significantly lower rate of infection (DA = 2.1% [3/140] vs. RS = 7.9% [9/114] vs. PA = 1.7% [1/58], P = 0.043), surgical complication rate (DA = 26% [37/140] vs. RS = 41% [47/114] vs. PA = 33% [19/58], P < 0 .001), and readmission rate (DA = 6.4% [9/140] vs. RS = 12.3% [14/114] vs. PA = 19% [11/58] P = 0.030) within 30 days of surgery. No notable differences were observed among groups in 2-year complication, infection, readmission, or revision surgery rates.

CONCLUSIONS

These study results support the DA surgeon approach. Resident involvement, even in less complex cases, can still negatively affect perioperative outcomes. Additional selection criteria development is needed.

Preoperative Epidural Steroid Injection Does Not Increase Infection Risk Following Posterior Cervical Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The purpose of this study was to characterize the infection risk of preoperative epidural steroid injection (ESI) in patients undergoing posterior cervical surgery.

SUMMARY OF BACKGROUND DATA

ESI is a helpful tool for alleviating pain and is often used as a diagnostic tool before cervical surgery. However, a recent small-scale study found that ESI before cervical fusion was associated with an increased risk of postoperative infection.

MATERIALS AND METHODS

Patients from 2010 to 2020 with cervical myelopathy, spondylosis, and radiculopathy who underwent posterior cervical procedure including laminectomy, laminoforaminotomy, fusion, or laminoplasty were queried from the PearlDiver database. Patients who underwent revision or fusion above C2 or who had a diagnosis of neoplasm, trauma, or preexisting infection were excluded. Patients were divided on whether they received an ESI within 30 days before the procedure and subsequently matched by age, sex, and preoperative comorbidities. The χ 2 analysis was used to calculate the risk of postoperative infection within 90 days. Logistic regression controlling for age, sex, Elixhauser Comorbidity Index, and operated levels was conducted within the unmatched population to assess infection risk for injected patients across procedure subgroups.

RESULTS

Overall, 299,417 patients were identified with 3897 having received a preoperative ESI and 295,520 who did not. Matching resulted in 975 in the injected group and 1929 in the control group. There was no significant difference in postoperative infection rate in those who received an ESI within 30 days preoperatively and those who did not (3.28% vs. 3.78%, odds ratio=0.86, 95% CI: 0.57-1.32, P =0.494). Logistic regression accounting for age, sex, Elixhauser Comorbidity Index, and levels operated demonstrated that injection did not significantly increase infection risk in any of the procedure subgroups.

CONCLUSIONS

The present study found no association between preoperative ESI within 30 days before surgery and postoperative infection in patients undergoing posterior cervical surgery.

Assistive diagnostic indicators for infections related to lumbar posterior interbody fusion internal fixation: platelet count and mean platelet volume

BACKGROUND

The most severe complication after posterior single-segment lumbar interbody fusion and internal fixation (PIFIF) surgery for degenerative lumbar diseases is deep surgical site infection (DSSI). Preoperatively diagnosing such complications proves to be challenging. Platelets, as acute-phase reactants, undergo changes in response to infections and inflammation. This study aims to assess whether platelet indices can further aid in the diagnosis of DSSI.

METHODS

A single-center retrospective study was conducted from January 2016 to February 2021 at Xi'an Jiaotong University-Affiliated Honghui Hospital, involving 83 patients who underwent revision surgery after PIFIF due to lumbar degenerative diseases. Among them, 24 patients were diagnosed with DSSI based on combined bacterial culture and imaging data. Preoperative complete serological indicators including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and platelet count and mean platelet volume ratio (P/M ratio) were analyzed using receiver operating characteristic (ROC) curve analysis to determine cutoff values, sensitivity, and specificity. This was done to further assess the ability of these serological indicators to identify the occurrence of DSSI after PIFIF.

RESULTS

There were no significant differences in baseline demographic characteristics between the two patient groups (P > 0.05). The P/M ratio was 13.54 ± 5.05 in the aseptic revision group, while it was 19.21 ± 6.30 in the DSSI revision patients, showing a significant difference (P < 0.001). ROC curve analysis revealed that the optimal cutoff value for the P/M ratio was 17.50, with a sensitivity of 58.3% and a specificity of 78.6%. The areas under the curve (AUC) for ESR, CRP, and P/M ratio were 0.797, 0.845, and 0.756, respectively. The negative predictive value (NPV) was 87.04%, 89.47%, and 82.45%, respectively; the positive predictive value (PPV) was 58.62%, 69.23%, and 53.84%, respectively, for ESR, CRP, and P/M ratio, respectively. When P/M ratio is used in combination with ESR and CRP, the AUC is 0.887, with a sensitivity of 95.4%, specificity of 67.8%, NPV of 97.56%, PPV of 54.76%. The diagnostic performance of the model for evaluating DSSI is significantly improved compared to using ESR and CRP alone (P < 0.05).

CONCLUSION

Platelets and their related serum biomarkers are closely associated with DSSI. The P/M ratio can serve as a reliable test for screening DSSI and is worth considering for inclusion in the assessment of patients at risk of developing DSSI after potential PIFIF surgery.

The correlation of psoriasis and its treatment medications with lumbar discectomy postoperative infections

BACKGROUND CONTEXT

Psoriasis is a chronic, autoimmune disease of the skin that affects approximately 3% of the US adult population. Patients with psoriasis may be predisposed to spine surgical site infections (SSI) related to the condition and/or related medications following surgeries such as lumbar laminotomy/discectomy.

PURPOSE

To assess the potential correlation of psoriasis and its related treatment medications on the risk of infection-related complications after lumbar laminotomy/discectomy.

STUDY DESIGN

Retrospective case control, national administrative database study.

PATIENT SAMPLE

Adult patients who underwent isolated single-level lumbar discectomy between 2010 and Q1 of 2021 were identified in the PearlDiver Mariner Ortho151 national administrative database (excluding those with concurrent diagnoses of fractures, neoplasms, or infections).

OUTCOME MEASURES

Ninety-day postoperative rates of surgical site infection and sepsis.

METHODS

Lumbar laminotomy/discectomy patients with versus without psoriasis were matched 1:4 based on age, sex, and Elixhauser Comorbidity Index. The risk of SSI and sepsis in the 90-day postoperative window between the cohorts were compared with multivariable analyses. Five-year reoperation rates were also compared with log rank test. The matched psoriasis cohort was further subdivided by psoriasis treatment regimens - no medication treatment (NT), topical therapies only (TT), topical therapies with oral systemic treatments (TT/OS), and topical therapies with biologics (TT/B). Multivariable logistic regression was used to assess the risk of SSI and sepsis within 90 days after lumbar laminotomy/discectomy for each treatment subgroup compared to patients without psoriasis.

RESULTS

In total, 2,262 patients with psoriasis who underwent single-level lumbar laminotomy/discectomy were identified and matched by age, sex, and Elixhauser Comorbidity Index to 9,044 patients without psoriasis. Multivariable logistic regression showed that, compared to the patients without psoriasis, patients with psoriasis had a 1.795 times higher chance of developing SSI (odds ratio [OR]) (p<.001) and sepsis (OR: 1.743, p=.027) within 90 days of surgery. Having psoriasis did not significantly correlate with 5-year reoperation rates. Of those with psoriasis, NT subcohort had 1,038 patients, TT subcohort 571 patients, TT/OS subcohort 226 patients, and TT/B subcohort 140 patients. Based on multivariable analysis and compared to nonpsoriasis patients, those in the NT, TT, TT/OS were not at greater odds of postoperative SSI or sepsis. Conversely, those in the TT/B subcohort were at significantly greater odds of SSI (OR: 3.102, p=.019) and sepsis (OR: 6.367, p=.027).

CONCLUSIONS

Of single-level lumbar laminotomy/discectomy patients with psoriasis, only those on topical therapies and biologics were at greater risk of postoperative SSI and sepsis. This subcohort warrants specific attention when undergoing lumbar laminotomy/discectomy and possibly holding such medications for a period prior to surgery may be warranted if possible.

Ultrasound-guided percutaneous micro-drainage tube irrigation combined with high negative pressure tube drainage versus debridement with closed suction irrigation for treating deep surgical site infection after spinal surgery

It is difficult to avoid deep surgical site infection after spinal surgery. Debridement combined with closed suction irrigation (CSI) and other treatment methods lead to greater trauma and lower satisfaction. We developed a new method for the treatment of SSI, which has the advantages of less invasiveness and lower cost. The cohort of this retrospective study comprised 26 patients with SSI after undergoing spinal surgery in our hospital from August 2017 to March 2022. The patients were divided into CSI and microtube drainage group according to treatment methods. The durations of antibiotic use and hospital stay, hospitalization costs, and functional scores during follow-up were compared between the two groups. The only baseline characteristic that differed between the two groups was sex. Infection was controlled in both groups and there were no recurrences during follow-up. However, the length of hospital stay after the first operation and the total length of stay were significantly greater in the CSI group. Hospitalization costs and antibiotic costs were significantly higher in the CSI group. Additionally, the duration of intravenous antibiotic use was significantly longer in the CSI group. Both the CSI and microtube drainage groups had significantly improved of Short Form Health Survey (SF-36) scores 6 months postoperatively. However, 3 months postoperatively, SF-36 scores were significantly lower in the CSI group. Compared with debridement followed by CSI, percutaneous micro-drainage tube irrigation combined with high negative pressure tube drainage is a more efficient and economical means of treating SSI after spinal surgery.

The Human Microbiome and Its Role in Musculoskeletal Disorders

Musculoskeletal diseases (MSDs) are characterized as injuries and illnesses that affect the musculoskeletal system. MSDs affect every population worldwide and are associated with substantial global burden. Variations in the makeup of the gut microbiota may be related to chronic MSDs. There is growing interest in exploring potential connections between chronic MSDs and variations in the composition of gut microbiota. The human microbiota is a complex community consisting of viruses, archaea, bacteria, and eukaryotes, both inside and outside of the human body. These microorganisms play crucial roles in influencing human physiology, impacting metabolic and immunological systems in health and disease. Different body areas host specific types of microorganisms, with facultative anaerobes dominating the gastrointestinal tract (able to thrive with or without oxygen), while strict aerobes prevail in the nasal cavity, respiratory tract, and skin surfaces (requiring oxygen for development). Together with the immune system, these bacteria have coevolved throughout time, forming complex biological relationships. Changes in the microbial ecology of the gut may have a big impact on health and can help illnesses develop. These changes are frequently impacted by lifestyle choices and underlying medical disorders. The potential for safety, expenses, and efficacy of microbiota-based medicines, even with occasional delivery, has attracted interest. They are, therefore, a desirable candidate for treating MSDs that are chronic and that may have variable progression patterns. As such, the following is a narrative review to address the role of the human microbiome as it relates to MSDs.

Risk factors for incisional complications after lumbar internal fixation via posterior midline approach: A case-control study of 455 consecutive cases

To analyse the clinical data of patients who developed incisional complications and those who did not develop incisional complications after lumbar internal fixation, and investigate the risk factors for incisional complications in patients after lumbar internal fixation with posterior midline incision. A standardised data collection form was used to collect the clinical data of patients who were admitted and underwent lumbar internal fixation in our hospital from July 2018 to July 2021. Patients who experienced any one of the incisional complications, such as incision exudates, swelling, blisters, bruising, superficial/deep incisional infections, poor healing and scarring, after surgery were included in the incisional complication group, and patients who did not develop the above-mentioned incisional complications were included in the control group. Univariate logistic regression analysis was first performed to identify potential risk factors, significant factors from univariate analysis were then included in multivariable logistic regression analysis to identify independent risk factors for incisional complications after lumbar spine surgery. Among 455 patients included in the study, postoperative incision complications occurred in 82 patients, with an incidence rate of 18.02%. Multivariate regression analysis identified seven independent risk factors for incisional complications: age, body mass index, preoperative albumin level, hypertension, diabetes mellitus, operation time and local anaesthetic infiltration at the incision site after surgery. Our findings documented that age, body mass index, preoperative albumin level, hypertension, diabetes mellitus, operation time, and postoperative local anaesthetic infiltration at the incision site were risk factors for incisional complications after lumbar internal fixation with posterior median incision. Awareness of these risk factors can enable surgeons to develop a more appropriate perioperative management plan for patients undergoing lumbar internal fixation, thus helping them recover faster.

No Benefits in Using Magnetically Controlled Growing Rod as Temporary Internal Distraction Device in Staged Surgical Procedure for Management of Severe and Neglected Scoliosis in Adolescents

BACKGROUND

Severe spinal curvatures (SSCs) in children and adolescents have long been treated with preoperative Halo traction, in its various variations. There are also several radical techniques available for the management of neglected SSCs, such as osteotomies; however, these can be risky. Comparing the treatment outcomes when using preoperative Halo Gravity Traction (HGT) against the use of a Magnetically Controlled Growing Rod (MCGR) as a temporary internal distraction (TID) device, we evaluated the differences in surgical and radiological outcomes.

METHODS

We conducted a retrospective study of 30 patients with SSCs, treated with HGT followed by posterior spinal fusion (PSF; Group 1, n = 18) or treated using a temporary MCGR as a TID followed by PSF (Group 2, n = 12). All patients underwent surgical treatment between 2016 and 2022. The inclusion criteria were SSC > 90°, flexibility < 30%, and the use of preoperative HGT followed by PSF or the two-stage surgical procedure with initial TID rod placement (Stage 1) followed by PSF (Stage 2). The evaluated parameters were as follows: rib hump, trunk height, and radiographic outcomes. All parameters were collected preoperatively, after the initial surgery, after final correction and fusion, and during the final follow-up.

RESULTS

In Group 1, we evaluated 18 patients with a mean age of 15.5 years; in Group 2, we evaluated 12 patients with a mean age of 14.2 years. The interval between the staged procedures averaged 32.7 days. The mean preoperative main curves (MC) were 118° and 112° in Group 1 and Group 2, respectively. After definitive surgery, the MC was corrected to 42° and 44° in G1 and G2, respectively. The mean percentage correction of the MC was similar in both groups (65% vs. 61% in G1 and G2, respectively). The mean preoperative thoracic kyphosis was 92.5° in G1 and 98° in G2, corrected to 43.8° in G1 and 38.8° in G2. Trunk height increased by 9 cm on average.

CONCLUSIONS

There are no benefits in using a MCGR as a temporary internal distraction device in the management of neglected scoliosis in adolescents. Surgical treatment of severe scoliosis may be safe, with a reduced risk of potential complications, when using preoperative HGT. A specific intraoperative complication when using a MCGR as a temporary internal distraction device was a 50% risk of transient neuromonitoring changes, due to significant force applied to the spine and radical distraction of the spine. We achieved similar clinical, radiographic, and pulmonary function outcomes for both techniques. The use of HGT causes less blood loss with a shorter overall time under anesthesia. Partial correction significantly aids the subsequent operation by facilitating a gradual reduction in the curvature, thereby reducing the difficulty of surgical treatment and the risk of neurological deficits.

Predicting deep surgical site infection in patients receiving open posterior instrumented thoracolumbar surgery: A-DOUBLE-SSI risk score - a large retrospective multicenter cohort study in China

BACKGROUND

To develop a practical prediction model to predict the risk of deep surgical site infection (SSI) in patients receiving open posterior instrumented thoracolumbar surgery.

METHODS

Data of 3419 patients in four hospitals from 1 January 2012 to 30 December 2021 were evaluated. The authors used clinical knowledge-driven, data-driven, and decision tree model to identify predictive variables of deep SSI. Forty-three candidate variables were collected, including 5 demographics, 29 preoperative, 5 intraoperative, and 4 postoperative variables. According to model performance and clinical practicability, the best model was chosen to develop a risk score. Internal validation was performed by using bootstrapping methods.

RESULTS

After open posterior instrumented thoracolumbar surgery, 158 patients (4.6%) developed deep SSI. The clinical knowledge-driven model yielded 12 predictors of deep SSI, while the data-driven and decision tree model produced 11 and 6 predictors, respectively. A knowledge-driven model, which had the best C-statistics [0.81 (95% CI: 0.78-0.85)] and superior calibration, was chosen due to its favorable model performance and clinical practicality. Moreover, 12 variables were identified in the clinical knowledge-driven model, including age, BMI, diabetes, steroid use, albumin, duration of operation, blood loss, instrumented segments, powdered vancomycin administration, duration of drainage, postoperative cerebrospinal fluid leakage, and early postoperative activities. In bootstrap internal validation, the knowledge-driven model still showed optimal C-statistics (0.79, 95% CI: 0.75-0.83) and calibration. Based on these identified predictors, a risk score for deep SSI incidence was created: the A-DOUBLE-SSI (Age, D [Diabetes, Drainage], O [duration of Operation, vancOmycin], albUmin, B [BMI, Blood loss], cerebrospinal fluid Leakage, Early activities, Steroid use, and Segmental Instrumentation) risk score. Based on the A-DOUBLE-SSI score system, the incidence of deep SSI increased in a graded fashion from 1.06% (A-DOUBLE-SSIs score ≤8) to 40.6% (A-DOUBLE-SSIs score>15).

CONCLUSIONS

The authors developed a novel and practical model, the A-DOUBLE-SSIs risk score, that integrated easily accessible demographics, preoperative, intraoperative, and postoperative variables and could be used to predict individual risk of deep SSI in patients receiving open posterior instrumented thoracolumbar surgery.

Incidence of Surgical Site Infection Following Lateral Lumbar Interbody Fusion Compared With Posterior/Transforaminal Lumbar Interbody Fusion: A Propensity Score-Weighted Study

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The objective of this study was to compare the incidence of surgical site infection (SSI) after lateral lumbar interbody fusion (LLIF) and posterior/transforaminal lumbar interbody fusion ( P /TLIF).

SUMMARY OF BACKGROUND DATA

Previous studies have shown that LLIF can improve neurological symptoms to a comparable degree to P /TLIF. However, data on the risk of SSI after LLIF is lacking compared with P /TLIF.

MATERIALS AND METHODS

The study was conducted under a retrospective cohort design in patients undergoing LLIF or P /TLIF for lumbar degenerative diseases between 2013 and 2020 using a hospital administrative database. We used propensity score overlap weighting to adjust for confounding factors including age, sex, body mass index, comorbidities, number of fusion levels, hospital size, and surgery year. We estimated weighted odds ratios (ORs) and 95% CIs for SSI within 30 days postoperatively.

RESULTS

We compared the risk of SSI between 2874 patients who underwent LLIF and 24,245 patients who received P/TLIF Patients who had received LLIF were at significantly less risk of experiencing an SSI compared with those receiving P/TLIF (0.7% vs. 1.2%; weighted OR: 0.57; 95% CI: 0.36 -0.92; P=0.02). As a secondary outcome, patients who had received LLIF had less risk of transfusion (7.8% vs. 11.8%; weighted OR: 0.63; 95% CI:0.54 -0.73; P <0.001).

CONCLUSIONS

In this large retrospective cohort study of adults undergoing lumbar interbody fusion, LLIF was associated with a significantly lower risk of SSI than P /TLIF. The small, but significantly, decreased risk of SSI associated with LLIF may inform decisions regarding the technical approach for lumbar interbody fusion.

Complication, fusion, and revision rate in the lumbar cortical bone trajectory and pedicle screw fixation techniques: a systematic review and meta-analysis

BACKGROUND

To obtain the complication rate, fusion rate, and revision rate of the lumbar cortical bone trajectory technique and pedicle screw fixation technique in lumbar interbody fusion surgery by single-arm meta-analysis and lay a basis for orthopedic surgeons to select the fixation techniques and perioperative management.

METHODS

PubMed, Ovid Medline, Web of Science, CNKI, and Wanfang databases were searched comprehensively. Data extraction, content analysis, and quality assessment of the literature were performed by two independent reviewers according to the Cochrane Collaboration guidelines using R and STATA software for single-arm meta-analysis.

RESULTS

The total complication rate of the lumbar cortical bone trajectory technique was 6%, including a hardware complication rate of 2%, ASD (adjacent segment degeneration) rate of 1%, wound infection rate of 1%, dural damage rate of 1%, hematoma rate tending to 0%, fusion rate of 94%, and revision rate of 1%. Lumbar pedicle screw fixation techniques had a total complication rate of 9%, with a hardware complication rate of 2%, ASD rate of 3%, wound infection rate of 2%, dural damage rate of 1%, hematoma rate tending to 0%, fusion rate of 94%, and revision rate of 5%. This study was registered with PROSPERO, CRD42022354550.

CONCLUSION

Lumbar cortical bone trajectory was associated with a lower total complication rate, ASD rate, wound infection rate, and revision rate than pedicle screw fixation. The cortical bone trajectory technique reduces the incidence of intraoperative and postoperative complications and can be an alternative in lumbar interbody fusion surgery.

MRSA Prophylaxis in Spine Surgery Decreases Postoperative Infections

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To compare infection rates before and after the implementation of a quality improvement protocol focused on methicillin-resistant Staphylococcus aureus (MRSA) screening and decolonization in patients undergoing lumbar fusion and/or decompression.

SUMMARY OF BACKGROUND DATA

Prior studies have demonstrated MRSA infections comprise a sizable portion of SSIs. Additional studies are required to improve our understanding of the risks and benefits of MRSA decolonization with vancomycin prophylaxis.

METHODS

A retrospective cohort analysis was conducted on patients who underwent spinal fusion or laminectomy before (2008-2011) and after (2013-2016) the implementation of an MRSA screening and treatment protocol. Odds ratios for MRSA, methicillin-sensitive Staphylococcus aureus (MSSA), and Vancomycin-resistant Enterococcus (VRE) infection before and after screening was calculated. Multivariate analysis assessed demographic characteristics as potential independent predictors of infection.

RESULTS

A total of 8425 lumbar fusion and 2558 lumbar decompression cases met inclusion criteria resulting in a total cohort of 10,983 patients. There was a significant decrease in the overall rate of infections ( P <0.001), MRSA infections ( P <0.001), and MSSA infections ( P <0.001) after protocol implementation. Although VRE infections after protocol implementation were not significantly different ( P =0.066), VRE rates as a percentage of all postoperative infections were substantially increased (0 vs. 3.36%, P =0.007). On multivariate analysis, significant predictors of the infection included younger age (OR=0.94[0.92-0.95]), shorter length of procedure (OR=1.00[0.99-1.00]), spinal fusion (OR=18.56[8.22-53.28]), higher ASA class (OR=5.49[4.08-7.44]), male sex (OR=1.61[1.18-2.20]), and history of diabetes (OR=1.58[1.08-2.29]).

CONCLUSION

The implemented quality improvement protocol demonstrated that preoperative prophylactically treating MRSA colonized patients decreased the rate of overall infections, MSSA infections, and MRSA infections. In addition, younger age, male sex, diabetic status, greater ASA scores, and spinal fusions were risk factors for postoperative infection.

Full-Endoscopic Lumbar Discectomy Approach Selection: A Systematic Review and Proposed Algorithm

STUDY DESIGN

A systematic review of the literature to develop an algorithm formulated by key opinion leaders.

OBJECTIVE

This study aimed to analyze currently available data and propose a decision-making algorithm for full-endoscopic lumbar discectomy for treating lumbar disc herniation (LDH) to help surgeons choose the most appropriate approach [transforaminal endoscopic lumbar discectomy (TELD) or interlaminar endoscopic lumbar discectomy (IELD)] for patients.

SUMMARY OF BACKGROUND DATA

Full-endoscopic discectomy has gained popularity in recent decades. To our knowledge, an algorithm for choosing the proper surgical approach has never been proposed.

MATERIALS AND METHODS

A systematic review of the literature using PubMed and MeSH terms was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Patient samples included patients with LDH treated with full-endoscopic discectomy. The inclusion criteria were interventional research (randomized and nonrandomized trials) and observation research (cohort, case-control, case series). Exclusion criteria were case series and technical reports. The criteria used for selecting patients were grouped and analyzed. Then, an algorithm was generated based on these findings with support and reconfirmation from key expert opinions. Data on overall complications were collected. Outcome measures included zone of herniation, level of herniation, and approach (TELD or IELD).

RESULTS

In total, 474 articles met the initial screening criteria. The detailed analysis identified the 80 best-matching articles; after applying the inclusion and exclusion criteria, 53 articles remained for this review.

CONCLUSIONS

The proposed algorithm suggests a TELD for LDH located in the foraminal or extraforaminal zones at upper and lower levels and for central and subarticular discs at the upper levels considering the anatomic foraminal features and the craniocaudal pathology location. An IELD is preferred for LDH in the central or subarticular zones at L4/L5 and L5/S1, especially if a high iliac crest or high-grade migration is found.

Cutibacterium spp. Infections after Instrumented Spine Surgery Have a Good Prognosis Regardless of Rifampin Use: A Cross-Sectional Study

Infection after spinal instrumentation (IASI) by Cutibacterium spp. is being more frequently reported. The aim of this study was to analyse the incidence, risk factors, clinical characteristics, and outcome of a Cutibacterium spp. IASI (CG) compared with non-Cutibacterium IASI (NCG) infections, with an additional focus on the role of rifampin in the treatment. All patients from a multicentre, retrospective, observational study with a confirmed IASI between January 2010 and December 2016 were divided into two groups: (CG and NCG) IASI. Baseline, medical, surgical, infection treatment, and follow-up data were compared for both groups. In total, 411 patients were included: 27 CG and 384 NCG. The CG patients were significantly younger. They had a longer median time to diagnosis (23 vs. 13 days) (p = 0.025), although 55.6% debuted within the first month after surgery. Cutibacterium patients were more likely to have the implant removed (29.6% vs. 12.8%; p = 0.014) and received shorter antibiotic regimens (p = 0.014). In 33% of Cutibacterium cases, rifampin was added to the baseline therapy. None of the 27 infections resulted in treatment failure during follow-up regardless of rifampin use. Cutibacterium spp. is associated with a younger age and may cause both early and late IASIs. In our experience, the use of rifampin to improve the outcome in the treatment of a Cutibacterium spp. IASI is not relevant since, in our series, none of the cases had therapeutic failure regardless of the use of rifampin.

Does the use of epicutaneous vacuum-assisted closure after revision surgery on the spine reduce further wound revision surgery?

PURPOSE

This study aimed to investigate the effect of epicutaneous vacuum therapy on the rate of unplanned spinal wound revisions compared with conventional wound dressing.

METHODS

This retrospective study included patients who underwent unplanned revision spine surgery after primary aseptic spine surgery who were treated at a level I spine centre between December 2011 and December 2019. Patients with revision surgery who required a further unplanned revision surgery during the inpatient stay were considered a treatment failure. The epicutaneous vacuum-assisted closure (Epi-VAC) therapy was the standard treatment method beginning in 2017 (the epi-VAC group). Before, conventional wound dressing was used (the control group (CG)). In addition, a one-to-one matched-pair comparison analysis was performed between both groups.

RESULTS

Of 218 patients, 48 were in the epi-VAC group. The mean age was 65.1 years (epi-VAC 68.2 to CG 64.3 years (P = 0.085)), and the mean body mass index (BMI) was 28.2 kg/m² (epi-VAC 29.4 to CG 27.9 kg/m² (P = 0.16)). No significant differences in the treatment failure rate could be detected between the two groups (epi-VAC 25% to CG 22.4% (P = 0.7)). There was also no significant difference for the matched-pair analysis (epi-VAC 26.1% to CG 15.2% (P = 0.3)). An elevated CRP level (C-reactive protein) immediately before the first wound revision was a significant risk factor for further revision surgery (treatment failure: 135.2 ± 128.6; no treatment failure: 79.7 ± 86.1 mg/l (P < 0.05)).

CONCLUSION

Concerning repeat unplanned wound revision after spinal revision surgery, we cannot demonstrate an advantage of the epicutaneous vacuum therapy over conventional wound dressing.

Early Experience With an Endocrinology Preoperative Fast-Track Program for Optimizing Spine Surgery Candidates With Poorly Controlled Diabetes Mellitus

INTRODUCTION

Previous studies demonstrated an increase in adverse outcomes for patients undergoing elective surgeries with poorly controlled diabetes mellitus. At a large, tertiary-care spine center with a notable population of patients with poorly controlled diabetes, an Endocrinology Fast-Track (EFT) program was developed to improve patient optimization before elective spine surgery. The purpose of this study was to report our early experience.

METHODS

Seventy-five patients who were scheduled for elective spine surgery were noted to have Hgb A1c > 7 on preoperative evaluation. Thirty-two patients accepted referral to the EFT program and 43 declined (non-EFT). Mean preoperative Hgb A1c was similar between groups (EFT: 8.79 versus non-EFT: 9.26, P = 0.221). The Fast-Track program included counseling, education, and medical management.

RESULTS

Patients in the two groups were similar in number of females (EFT: 17 versus non-EFT: 17, P = 0.348), age (EFT: 57.7 versus non-EFT: 60.6, P = 0.280), and body mass index (EFT: 34.6 versus non-EFT: 33.0, P = 0.341). A smaller number of smokers were there in the EFT group (1) compared with the non-EFT group (15, P = 0.003). The proportion of patients on insulin (EFT: 19 versus non-EFT: 23, P = 0.814) and oral hypoglycemics (EFT: 29 versus non-EFT: 39, P = 0.983) was similar between the two groups. Surgical clearance for patients with a documented preoperative Hgb A1c of < 7 or equivalent fructosamine level was significantly better in the Fast-Track group compared with the non-Fast-Track group (91% versus 42%, P = 0.000). Although most patients who declined the Fast-Track program did not obtain clearance for surgery, mean Hgb A1c was improved at the latest follow-up in both groups for those who obtained surgical clearance (7.10 versus 6.78, P = 0.470).

DISCUSSION

A novel EFT program was successful in obtaining acceptable blood glucose control in patients recommended for spine surgery who had poorly controlled diabetes mellitus on preoperative evaluation. The improved blood glucose control was maintained at the latest follow-up.

Escalation of antimicrobial resistance among MRSA part 2: focus on infections and treatment

INTRODUCTION

MRSA is associated with causing a variety of infections including skin and skin structure infections, catheter and device-related (e.g. central venous catheter, prosthetic heart valve) infections, infectious endocarditis, blood stream infections, bone, and joint infections (e.g. osteomyelitis, prosthetic joint, surgical site), central nervous system infections (e.g. meningitis, brain/spinal cord abscess, ventriculitis, hydrocephalus), respiratory tract infections (e.g. hospital-acquired pneumonia, ventilator-associated pneumonia), urinary tract infections, and gastrointestinal infections. The emergence and spread of multidrug resistant (MDR) MRSA clones has limited therapeutic options. Older agents such as vancomycin, linezolid and daptomycin and a variety of newer MRSA antimicrobials and combination therapy are available to treat serious MRSA infections.

AREAS COVERED

The authors discuss infections caused by MRSA as well as common older and newer antimicrobials and combination therapy for MRSA infections. A literature search of MRSA was performed via PubMed (up to September 2022), using the keywords: antimicrobial resistance; β-lactams; multidrug resistance, Staphylococcus aureus, vancomycin; glycolipopeptides.

EXPERT OPINION

Innovation, discovery, and development of new and novel classes of antimicrobial agents are critical to expand effective therapeutic options. The authors encourage the judicious use of antimicrobials in accordance with antimicrobial stewardship programs along with infection-control measures to minimize the spread of MRSA.

Inflammatory biomarkers behavior profile among patients following elective degenerative spine surgery and their differences with those coursing with a postoperative spinal infection: Protocol for a Systematic Review

BACKGROUND

The incidence of postoperative spinal infection (PSI) ranges from 0% to 10%, devastatingly affecting the patient prognosis and increasing costs to the healthcare system because of higher morbidity. Postoperative spinal infections require a high level of suspicion as they are difficult to diagnose, especially in the early postoperative state, because of many confounding factors such as clinical symptoms, serum biomarkers rise or confusing imaging studies. Current research has focused on serum biomarkers at the early stages of disease, nevertheless, most rely on retrospective cohorts with serum biomarkers studied individually and at different time points.

OBJECTIVE

To determine the Inflammatory biomarkers behavior profile among patients following elective degenerative spine surgery and their differences with those coursing with postoperative spinal infection.

METHODS

The proposed systematic review will follow the PRISMA statement. This protocol was registered at PROSPERO on January 19th, 2022, obtaining the following register CRD42022304645 on February 19th, 2022. We will include studies related to biomarkers in adult patients operated on because of degenerative spinal diseases, and those developing a postoperative spinal infection. The following information will be extracted: (1)study title; (2)Study Author (3)year; (4)evidence-level; (5)Research-type; (6)diagnosis group (elective postoperative degenerative disease / PSI); (7a)region (Cervical, Thoracic, Lumbosacral, Coccigeal); (7b)Type of infection by anatomical or radiological site, (8)Surgery-Type (including instrumentation or not); (9)number of cases; (10)mean age or individual age; and (11) individual serum biomarker values from the preoperative state up to 90 days postop for both groups including: (10a)interleukine-6, (10b)Presepsine, (10c)Erythrocyte Sedimentation Rate, (10d)Leukocyte Count, (10e)Neutrophil Count, (10f)C-Reactive Protein, (10g)Serum Amyloid, (10h)White Cell Count, (10i)Albumin, (10j)Prealbumin, (10k)Procalcitonin, (10L)Retinol associated protein, (10M)Dickopf-1, (11)postoperative days at symptoms or diagnosis, (12)Type of organism, (13)day of starting antibiotics, (14)duration of treatment and (15)any biases (including comorbidities, especially those affecting immunological status). All biomarkers' data will be presented graphically over time. Figure 1 contains the flow diagram of the methodology.

RESULTS

No ethical approval will be required, as this review is based on published data and does not involve interaction with human participants. The search for this systematic review commenced in February 2021, and we expect to publish the findings in middle 2023.

CONCLUSIONS

The present study will provide the biomarkers' behavior profile for PSI and patients following elective surgery for degenerative spinal diseases from the preoperative period up to 90 days postoperative providing cut-off values at the day of diagnosis. It will provide clinicians with a better background to diagnose based on highly trustable information based on cut-off values from this systematic review. Finally we expect this review to provide a basis for future research on biomarkers to establish more accurate and timely diagnosis in the early stages of illness ultimately impacting the patient's physical and mental health, reducing the disease burden.

CLINICALTRIAL

PROSPERO register ID: CRD42022304645.

Full-endoscopic spine surgery diminishes surgical site infections - a propensity score-matched analysis

BACKGROUND CONTEXT

Surgical site infections (SSI) are one the most frequent and costly complications following spinal surgery. The SSI rates of different surgical approaches need to be analyzed to successfully minimize SSI occurrence.

PURPOSE

The purpose of this study was to define the rate of SSIs in patients undergoing full-endoscopic spine surgery (FESS) and then to compare this rate against a propensity score-matched cohort from the National Surgical Quality Improvement Program (NSQIP) database.

DESIGN

This is a retrospective multicenter cohort study using a propensity score-matched analysis of prospectively maintained databases.

PATIENT SAMPLE

One thousand two hundred seventy-seven non-instrumented FESS cases between 2015 and 2021 were selected for analysis. In the nonendoscopic NSQIP cohort we selected data of 55,882 patients.

OUTCOME MEASURES

The occurrence of any SSI was the primary outcome. We also collected any other perioperative complications, demographic data, comorbidities, operative details, history of smoking, and chronic steroid intake.

METHODS

All FESS cases from a multi-institutional group that underwent surgery from 2015 to 2021 were identified for analysis. A cohort of cases for comparison was identified from the NSQIP database using Current Procedural Terminology of nonendoscopic cervical, thoracic, and lumbar procedures from 2015 to 2019. Trauma cases as well as arthrodesis procedures, surgeries to treat pathologies affecting more than 4 levels or spine tumors that required surgical treatment were excluded. In addition, nonelective cases, and patients with wounds worse than class 1 were also not included. Patient demographics, comorbidities, and operative details were analyzed for propensity matching.

RESULTS

In the non-propensity-matched dataset, the endoscopic cohort had a significantly higher incidence of medical comorbidities. The SSI rates for nonendoscopic and endoscopic patients were 1.2% and 0.001%, respectively, in the nonpropensity match cohort (p-value <.011). Propensity score matching yielded 5936 nonendoscopic patients with excellent matching (standard mean difference of 0.007). The SSI rate in the matched population was 1.1%, compared to 0.001% in endoscopic patients with an odds ratio 0.063 (95% confidence interval (CI) 0.009-0.461, p=.006) favoring FESS.

CONCLUSIONS

FESS compares favorably for risk reduction in SSI following spinal decompression surgeries with similar operative characteristics. As a consequence, FESS may be considered the optimal strategy for minimizing SSI morbidity.

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.

Initial single surgeon evaluation comparing C-arm fluoroscopy with the Cirq robotic assistance device for instrumentation of the thoracolumbar spine

OBJECTIVE

To compare our experience with pedicle screw insertion of the thoracolumbar spine utilizing the Cirq robot assistance device compared with traditional paradigm using fluoroscopy.

METHODS

We prospectively collected data of patients undergoing pedicle screw instrumentation in the thoracolumbar spine performed by a single surgeon at three different centers. One center took delivery of the Cirq robotic assistance device. Remaining two centers used C-arm fluoroscopy. Demographic information, diagnosis, total OR time, intraoperative complications, unexpected return to the operating room, and hospital readmissions within 90 days was compared between the two cohorts.

RESULTS

A total of 166 screws were placed during the study period. Forty percent were placed using the Cirq. Two thirds the patients had traumatic diagnoses with remaining degenerative spine disease. There were no misplaced pedicle screws in either group. While total OR time was longer in the Cirq cohort by 123 min (p = 0.04), actual procedural time was not statistically different (p = 0.11). Nonetheless there were also more hospital readmissions in the Cirq cohort compared with the C arm group (p = 0.04).

CONCLUSIONS

Thoracolumbar screws inserted using C-arm fluoroscopy utilize less total operating room time with similar accuracy compared with the Cirq robotic assistance device. Further studies are warranted.

Safety and efficacy of negative pressure wound therapy in treating deep surgical site infection after lumbar surgery

PURPOSE

To evaluate the efficacy and safety of negative pressure wound therapy (NPWT) for post-operative deep surgical site infection (SSI) after posterior instrumented spinal surgery.

METHODS

We retrospectively compared the clinical outcomes of NPWT with standard debridement for deep SSI after posterior instrumented spinal surgery from 2012 to 2020 in our department. The primary outcomes were peri-operative characteristics including positive organism results, duration of fever, and visual analogue scale (VAS) pain scores three days after re-operation. The secondary outcomes were post-operative characteristics including implant infection recurrence, implant retention rate, duration of hospitalization, and VAS at discharge. Pearson's chi-squared analysis (categorical) and Student's t test (continuous) were used to determine the differences.

RESULTS

Thirty-four patients were included, of which 19 underwent NPWT, and 15 underwent standard debridement. Patients in the NPWT group all significantly improved primary outcomes including duration of fever after re-operation (0.95 ± 1.13 vs 4.07 ± 5.35, P = 0.001), positive organism results (14 of 19 vs 2 of 15, P < 0.01), and VAS at 3 days after re-operation (2.58 ± 0.69 vs 3.40 ± 1.06, P < 0.05). Patients in NPWT group exhibited significant decrease in implant infection recurrence (0 of 19 vs 5 of 15, P < 0.01), implant retention rate (19 of 19 vs 10 of 15, P < 0.01), duration of hospitalization (27.74 ± 10.95 vs 37.67 ± 13.67, P < 0.01).

CONCLUSIONS

NPWT is a feasible and safe treatment option for deep SSI after posterior instrumented spinal surgery.

Evaluation of Comorbidities as Risk Factors for Fracture-Related Infection and Periprosthetic Joint Infection in Germany

Introduction: Fracture-related infections (FRI) and periprosthetic joint infections (PJI) represent a major challenge in orthopedic surgery. Incidence of both entities is annually growing. Comorbidities play an important role as an influencing factor for infection and thus, for prevention and treatment strategies. The aims of this study were (1) to analyze the frequency of comorbidities in FRI and PJI patients and (2) to evaluate comorbidities as causative risk factor for PJI and FRI. Methods: This retrospective cohort study analysed all ICD-10 codes, which were coded as secondary diagnosis in all in hospital-treated FRI and PJI in the year 2019 in Germany provided by the Federal Statistical Office of Germany (Destatis). Prevalence of comorbidities was compared with the prevalence in the general population. Results: In the year 2019, 7158 FRIs and 16,174 PJIs were registered in Germany, with 68,304 comorbidities in FRI (mean: 9.5 per case) and 188,684 in PJI (mean: 11.7 per case). Major localization for FRI were infections in the lower leg (55.4%) and forearm (9.2%), while PJI were located mostly at hip (47.4%) and knee joints (45.5%). Mainly arterial hypertension (FRI: n = 3645; 50.9%—PJI: n = 11360; 70.2%), diabetes mellitus type II (FRI: n = 1483; 20.7%—PJI: n = 3999; 24.7%), obesity (FRI: n = 749; 10.5%—PJI: n = 3434; 21.2%) and chronic kidney failure (FRI: n = 877; 12.3%—PJI: n = 3341; 20.7%) were documented. Compared with the general population, an increased risk for PJI and FRI was reported in patients with diabetes mellitus (PJI: 2.988; FRI: 2.339), arterial hypertension (PJI: 5.059; FRI: 2.116) and heart failure (PJI: 6.513; FRI: 3.801). Conclusion: Patients with endocrinological and cardiovascular diseases, in particular associated with the metabolic syndrome, demonstrate an increased risk for orthopedic implant related infections. Based on the present results, further infection prevention and treatment strategies should be evaluated.

Clinical Outcomes at One-year Follow-up for Patients With Surgical Site Infection After Spinal Fusion

STUDY DESIGN

Retrospective case-control study.

OBJECTIVE

To compare health-related quality of life outcomes at one-year follow-up between patients who did and did not develop surgical site infection (SSI) after thoracolumbar spinal fusion.

SUMMARY OF BACKGROUND DATA

SSI is among the most common healthcare-associated complications. As healthcare systems increasingly emphasize the value of delivered care, there is an increased need to understand the clinical impact of SSIs.

MATERIALS AND METHODS

A retrospective 3:1 (control:SSI) propensity-matched case-control study was conducted for adult patients who underwent thoracolumbar fusion from March 2014 to January 2020 at a single academic institution. Exclusion criteria included less than 18 years of age, incomplete preoperative and one-year postoperative patient-reported outcome measures, and revision surgery. Continuous and categorical data were compared via independent t tests and χ 2 tests, respectively. Intragroup analysis was performed using paired t tests. Regression analysis for ∆ patient-reported outcome measures (postoperative minus preoperative scores) controlled for demographics. The α was set at 0.05.

RESULTS

A total of 140 patients (105 control, 35 SSI) were included in final analysis. The infections group had a higher rate of readmission (100% vs. 0.95%, P <0.001) and revision surgery (28.6% vs. 12.4%, P =0.048). Both groups improved significantly in Physical Component Score (control: P =0.013, SSI: P =0.039), Oswestry Disability Index (control: P <0.001, SSI: P =0.001), Visual Analog Scale (VAS) Back (both, P <0.001), and VAS Leg (control: P <0.001, SSI: P =0.030). Only the control group improved in Mental Component Score ( P <0.001 vs. SSI: P =0.228), but history of a SSI did not affect one-year improvement in ∆MCS-12 ( P =0.455) on regression analysis. VAS Leg improved significantly less in the infection group (-1.87 vs. -3.59, P =0.039), which was not significant after regression analysis (β=1.75, P =0.050).

CONCLUSION

Development of SSI after thoracolumbar fusion resulted in increased revision rates but did not influence patient improvement in one-year pain, functional disability, or physical and mental health status.

Clinical Outcome of Postoperative Surgical Site Infection in Patients with Posterior Thoracolumbar and Lumbar Instrumentation

OBJECTIVE

Postoperative surgical site infection (SSI) is associated with greater rates of disability, especially in instrumented spinal surgeries. The management of implant-associated surgical site infections (SSI) is challenging. We analyzed the data from our hospital databases to assess the incidence and characteristics related to postoperative surgical site infection (SSI) after posterior thoracolumbar and lumbar instrumentation.

METHODS

Patient demographics, infection characteristics, details of treatment, and perioperative factors were reviewed (Jan 2010 to Dec 2020). The Oswestry disability index (ODI), Patient Health Questionnaire-9 (PHQ-9), and Visual Analog Scale (VAS) scores for back and leg pain were analyzed preoperatively and postoperatively until last follow-up.

RESULTS

Of the 27,881 procedures collected from the databases, 521 were diagnosed with SSI (1.8%), and 191(36.7%) received at least one revision surgery for SSI. Infection rate was significantly higher in patients with lumbar spinal stenosis than those with scoliosis or kyphosis (P<0.01). Methicillin-sensitive Staphylococcus aureus (43.4%) was the most commonly isolated pathogen. The rate of complication secondary to antibiotics treatment was 7.8%, and long-term antibiotic suppression was reported in 15.2% of patients. Instrumentation was retained in 175 patients (91.6%) and all SSIs were controlled without recurrence during the follow-up.

CONCLUSION

Analysis of 27,881 patients showed an average SSI rate of 1.8%. Patients with deep wound SSI can be successfully treated in most cases with retention of instrumentation. Early diagnosis, positive revision surgery with strict irrigation, thorough debridement, and a long-term course of antibiotics are critical for eradicating infection, retaining implants, decreasing morbidity, and achieving wound healing.

Incidence and Risk Factors for Surgical Site Infection after Femoral Neck Fracture Surgery: An Observational Cohort Study of 2218 Patients

Background

Surgical site infection (SSI) was a formidable challenge for surgical management of femoral neck fractures; however, there was a lack of studies with comprehensive variables. We conducted this study to investigate the incidence and risk factors of SSI in elderly patients with femoral neck fractures.

Methods

This was a retrospective study of patients who presented with femoral neck fractures and underwent surgery in our institution between January 2016 and April 2020. All data were collected from a previously validated database. Patients were divided into SSI and non-SSI groups. Univariate and multivariate logistic regression analyses were conducted to identify the risk factors for SSI.

Results

A total of 2218 patients with femoral neck fractures were enrolled in the study, of whom 22 (1%) developed SSI, including 15 (0.7%) superficial and 7 (0.3%) deep SSIs. After multivariable adjustment for confounding factors, patients with and without SSI significantly differ in terms of gender, prolonged time to surgery, CHE < 5 U/L, and injury mechanism.

Conclusions

Our results were helpful for stratification of SSI risk and improved management of hip fracture. Clinicians should be alert to patients with these factors and improve modifiable factors such as preoperative waiting time.

Towards interpretable, medically grounded, EMR-based risk prediction models

Machine-learning based risk prediction models have the potential to improve patient outcomes by assessing risk more accurately than clinicians. Significant additional value lies in these models providing feedback about the factors that amplify an individual patient's risk. Identification of risk factors enables more informed decisions on interventions to mitigate or ameliorate modifiable factors. For these reasons, risk prediction models must be explainable and grounded on medical knowledge. Current machine learning-based risk prediction models are frequently 'black-box' models whose inner workings cannot be understood easily, making it difficult to define risk drivers. Since machine learning models follow patterns in the data rather than looking for medically relevant relationships, possible risk factors identified by these models do not necessarily translate into actionable insights for clinicians. Here, we use the example of risk assessment for postoperative complications to demonstrate how explainable and medically grounded risk prediction models can be developed. Pre- and postoperative risk prediction models are trained based on clinically relevant inputs extracted from electronic medical record data. We show that these models have similar predictive performance as models that incorporate a wider range of inputs and explain the models' decision-making process by visualizing how different model inputs and their values affect the models' predictions.

Average Lumbar Hounsfield Units Predicts Osteoporosis-Related Complications Following Lumbar Spine Fusion

STUDY DESIGN

Retrospective Study.

OBJECTIVE

To compare methods of assessing pre-operative bone density to predict risk for osteoporosis related complications (ORC), defined as proximal junctional kyphosis, pseudarthrosis, accelerated adjacent segment disease, reoperation, compression fracture, and instrument failure following spine fusions.

METHODS

Chart review of primary posterior thoracolumbar or lumbar fusion patients during a 7 year period. Inclusion criteria: preoperative dual-energy x-ray absorptiometry (DXA) test within 1 year and lumbar CT scan within 6 months prior to surgery with minimum of 1 year follow-up. Exclusion criteria: <18 years at time of index procedure, infection, trauma, malignancy, skeletal dysplasia, neuromuscular disorders, or anterior-posterior procedures.

RESULTS

140 patients were included. The average age was 67.9 years, 83 (59.3%) were female, and 45 (32%) had an ORC. There were no significant differences in patient characteristics between those with and without an ORC. Multilevel fusions were associated with ORCs (46.7% vs 26.3%, p = 0.02). Patients with ORCs had lower DXA t-scores (-1.62 vs -1.10, p = 0.003) and average Hounsfield units (HU) (112.1 vs 148.1, p ≤ 0.001). Multivariable binary logistic regression analysis showed lower average HU (Adj. OR 0.00 595% CI 0.0001-0.1713, p = 0.001) was an independent predictor of an ORC. The odds of an ORC increased by 1.7-fold for every 25 point decrease in average HU.

CONCLUSIONS

The gold standard for assessing bone mineral density has been DXA t-scores, but the best predictor of ORC remains unclear. While both lower t-scores and average HU were associated with ORC, only HU was an independent predictor of ORC.

30-day postoperative sepsis risk factors following laminectomy for intradural extramedullary tumors

BACKGROUND

Posterior laminectomy (LA) for resection of intradural extramedullary tumors (IDEMTs) is associated with postoperative complications, including sepsis. Sepsis is an uncommon but serious complication that can lead to increased morbidity and mortality, prolonged hospital stays, and greater costs. Given the susceptibility of a solid tumor patients to sepsis-related complications, it is important to recognize IDEMT patients as a unique population when assessing the risk factors for sepsis after laminectomy.

METHODS

The study design was a retrospective cohort study. Adult patients undergoing LA for IDEMTs from 2012 to 2018 were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Baseline patient characteristics/comorbidities, operative and hospital variables, and 30-day postoperative complications were collected.

RESULTS

Of 2,027 total patients undergoing LA for IDEMTs, 38 (2%) had postoperative sepsis. On bivariate analysis sepsis was associated with superficial surgical site infection [odds ratio (OR) 11.62, P<0.001], deep surgical site infection (OR 10.67, P<0.001), deep vein thrombosis (OR 10.75, P<0.001), pulmonary embolism (OR 15.27, P<0.001), transfusion (OR 6.18, P<0.001), length of stay greater than five days (OR 5.41, P<0.001), and return to the operating room within thirty days (OR 8.72, P<0.001). Subsequent multivariate analysis identified the following independent risk factors for sepsis and septic shock: operative time ≥50th percentile (OR 2.11, P=0.032), higher anesthesia class (OR 1.76, P=0.046), dependent functional status (OR 2.23, P=0.001), diabetes (OR 2.31, P=0.037), and chronic obstructive pulmonary disease (OR 3.56, P=0.037).

CONCLUSIONS

These findings can help spine surgeons identify high-risk patients and proactively deploy measures to avoid this potentially devastating complication in individuals who may be more vulnerable than the general elective spine population.

Incidence and risk factors associated with surgical site infection after surgically treated hip fractures in older adults: a retrospective cohort study

BACKGROUND

Surgical site infection (SSI) is one of the most common complications in the traumatic orthopedics field, but remains not adequately studied after hip fractures.

AIMS

This study aims to investigate the incidence and risk factors associated with SSI after surgically treated hip fractures in older adults.

METHODS

A retrospective cohort study including 2932 older adult patients (1416 with femoral neck fracture and 1516 with intertrochanteric fracture) surgically treated from Jan 2015 to Dec 2019 due to hip fractures was performed. Their data on demographics, injury-related data, surgery-related data, and preoperative laboratory test results were collected from hospitalization medical records. Univariate analyses were used to compare between the patients with and without SSI, and multivariate logistic regression analyses were used to identify the risk factors.

RESULTS

A total of 89 patients developed SSI, with an accumulated incidence rate of 3.04% (95%CI 2.41-3.66). Staphylococcus aureus was the most common source of infection. In univariate analysis, 11 items were found to be significant in femoral neck fractures and 5 items were found to be significant in intertrochanteric fracture. In the multivariable logistic regression model, cerebrovascular disease (OR 2.17, 95%CI 1.14-4.15) and hematocrit (HCT) (< Lower limit) (OR 3.46, 95%CI 1.13-10.56) were independent risk factors for SSI in femoral neck fracture. Heart disease (OR 2.13, 95%CI 1.18-3.85) was a risk factor for SSI, while LDH (> 250 U/L) (OR 0.44, 95%CI 0.20-0.95) was a protective factor for SSI in intertrochanteric fracture.

DISCUSSION

We observed 89 cases (3.04%) of SSI in 2932 older adult patients with hip fractures in this study. Cerebrovascular disease and lower HCT were two independent risk factors for SSI in femoral neck fracture, whereas heart disease was a risk factor and LDH was a protective factor for SSI in intertrochanteric fracture.

CONCLUSIONS

Targeted preoperative management, such as predicting the probability of SSI and taking appropriate measures accordingly is essential and highly regarded. Future multicentric studies with more patients evaluated are expected to better address the risk factors for SSI in older hip fracture patients.

The impact of diabetes mellitus on spinal fracture with diffuse idiopathic skeletal hyperostosis: A multicenter retrospective study

BACKGROUND

Patients with diffuse idiopathic skeletal hyperostosis (DISH) are susceptible to spinal column injuries with neurological deterioration. Previous studies indicated that the prevalence of diabetes mellitus (DM) in patients with DISH was higher than that in patients without DISH. This study investigates the impact of DM on surgical outcomes for spinal fractures in patients with DISH.

METHODS

We retrospectively evaluated 177 spinal fractures in patients with DISH (132 men and 45 women; mean age, 75 ± 10 years) who underwent surgery from a multicenter database. The subjects were classified into two groups according to the presence of DM. Perioperative complications, neurological status by Frankel grade, mortality rate, and status of surgical site infection (SSI) were compared between the two groups.

RESULTS

DM was present in 28.2% (50/177) of the patients. The proportion of men was significantly higher in the DM group (DM group: 86.0% vs. non-DM group: 70.1%) (p = 0.03). The overall complication rate was 22.0% in the DM group and 19.7% in the non-DM group (p = 0.60). Poisson regression model revealed that SSI was significantly associated with DM (DM group: 10.0% vs. non-DM group: 2.4%, Relative risk: 4.5) (p = 0.048). Change in neurological status, mortality rate, instrumentation failure, and nonunion were similar between both groups. HbA1c and fasting blood glucose level (SSI group: 7.2% ± 1.2%, 201 ± 67 mg/dL vs. non-SSI group: 6.6% ± 1.1%, 167 ± 47 mg/dL) tended to be higher in patients with SSI; however, there was no significant difference.

CONCLUSIONS

In spinal fracture in patients with DISH, although DM was an associated factor for SSI with a relative risk of 4.5, DM did not negatively impact neurological recovery. Perioperative glycemic control may be useful for preventing SSI because fasting blood glucose level was high in patients with SSI.

Vacuum-Assisted Wound Closure Management for Posterior Lumbar Spine Infections

A postoperative infection involving the tissues deep to the fascia is defined as a deep wound infection (DWI). Management of such infections after lumbar spinal surgery remains a challenge. One strategy is the use of vacuum-assisted wound closure (VAC) which applies negative pressure to the wound to improve microcirculation and to promote the formation of granulation tissue. When combined with antibiotics, VAC has been shown to successfully treat DWIs and is now a common strategy for treating deep postoperative wound infections after spinal surgery. In this article, we review the technique of VAC, its mechanism of action, indications and contraindications, and clinical outcomes in the treatment of DWIs after lumbar spinal surgery.

Complications in spinal tumor surgery (review of literature)

Combined anterior and posterior approaches are required in spinal tumor surgery and considered highly invasive. Anatomical and physiological features of the surgical intervention area should be taken into consideration as well. Thus, these criteria reflect the severity of intraoperative complications during the surgical treatment of spinal tumors. The authors reviewed the scientific literature on the frequency and nature of complications in surgical interventions for spinal tumors.The most significant risk factors for intraoperative complications have been considered, the main of which are: the proximity of the location of the main vessels and viscera, the development of postoperative liquorrhea, as well as surgical site infection. Based on the studied information, we presented the methods of prevention and surgical tactics options in complications.

Medicosurgical management of deep wound infections after thoracolumbar instrumentation: risk factors of poor outcomes

BACKGROUND

Surgical site infection (SSI) after thoracolumbar osteosynthesis is a common complication. Its management relies on surgical revision and antibiotic therapy, but treatment failure is not uncommon. The aim of our study was to assess the frequency of SSI management failure and its risk factors.

METHODS

A retrospective study of patients hospitalized from 2011 to 2019 at the University Hospital of Caen was carried out. The infection rate and the time to onset of failure were assessed over a minimum follow-up of 1 year. Treatment failure was defined as the occurrence of a new intervention in the spine in the year following the end of antibiotic therapy, the establishment of long-term suppressive antibiotic therapy, or death from any cause within 1 year of the end of antibiotic therapy. We compared the treatment failure group with the treatment success group to determine risk factors for treatment failure.

RESULTS

A total of 2881 patients underwent surgery during the study period, and 92 developed an SSI, corresponding to an SSI rate of 3.19%. Thirty-six percent of the patients with an SSI presented treatment failure. The median time to failure was 31 days. On multivariate analysis, diabetes mellitus was identified as a risk factor for treatment failure, whereas prolonged postoperative drainage for 4 to 5 days was a protective factor.

CONCLUSIONS

The number of failures was significant, and failure occurred mainly during the early phase. To decrease the risk of treatment failure, prolonged duration of postoperative drainage seems to be helpful. Additionally, as diabetes is a risk factor for treatment failure, good control of glycemia in these patients might impact their outcomes.

Infección temprana de la malla quirúrgica en herniorrafia incisional. Incidencia, factores de riesgo y desenlaces en más de 60.000 pacientes

Introducción. La infección de la malla en cirugía de reparación de hernias de pared abdominal es un desenlace pobre, asociado a un incremento en el riesgo de complicaciones. El objetivo del presente estudio fue analizar la incidencia, los factores asociados y desenlaces en pacientes llevados a herniorrafia incisional con malla con posterior diagnóstico de infección temprana. Métodos. Estudio de cohorte retrospectiva. Se utilizaron los datos de egresos hospitalarios de la National Inpatient Sample (NIS) de los Estados Unidos de América para identificar a todos los pacientes adultos llevados a herniorrafia incisional durante los años 2010 a 2015. Se utilizaron modelos de regresión logística bivariada y multivariada para evaluar los factores de riesgo en infección temprana de la malla, y finalmente, modelos de regresión logística y lineal, según el tipo de variable dependiente, de tipo stepwise forward para evaluar la asociación entre el diagnóstico de infección de malla y los desenlaces adversos. Resultados. En total se incluyeron 63.925 pacientes. La incidencia de infección temprana de la malla fue de 0,59 %, encontrando como factores asociados: comorbilidades (obesidad, desnutrición proteico calórica, anemia carencial y depresión), factores clínico-quirúrgicos (adherencias peritoneales, resección intestinal, cirugía laparoscópica y complicaciones no infecciosas de la herida) y administrativos o asistenciales. Conclusiones. La infección temprana, aunque infrecuente, se asocia con un aumento significativo en el riesgo de complicaciones. La optimización prequirúrgica con base en los factores de riesgo para este desenlace nefasto es un elemento clave para la reducción de la incidencia y mitigación del impacto de la infección en los pacientes con herniorrafía incisional con malla.

Development and Internal Validation of Supervised Machine Learning Algorithms for Predicting the Risk of Surgical Site Infection Following Minimally Invasive Transforaminal Lumbar Interbody Fusion

Purpose: Machine Learning (ML) is rapidly growing in capability and is increasingly applied to model outcomes and complications in medicine. Surgical site infections (SSI) are a common post-operative complication in spinal surgery. This study aimed to develop and validate supervised ML algorithms for predicting the risk of SSI following minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF).

Methods: This single-central retrospective study included a total of 705 cases between May 2012 and October 2019. Data of patients who underwent MIS-TLIF was extracted by the electronic medical record system. The patient's clinical characteristics, surgery-related parameters, and routine laboratory tests were collected. Stepwise logistic regression analyses were used to screen and identify potential predictors for SSI. Then, these factors were imported into six ML algorithms, including k-Nearest Neighbor (KNN), Decision Tree (DT), Support Vector Machine (SVM), Random Forest (RF), Multi-Layer Perceptron (MLP), and Naïve Bayes (NB), to develop a prediction model for predicting the risk of SSI following MIS-TLIF under Quadrant channel. During the training process, 10-fold cross-validation was used for validation. Indices like the area under the receiver operating characteristic (AUC), sensitivity, specificity, and accuracy (ACC) were reported to test the performance of ML models.

Results: Among the 705 patients, SSI occurred in 33 patients (4.68%). The stepwise logistic regression analyses showed that pre-operative glycated hemoglobin A1c (HbA1c), estimated blood loss (EBL), pre-operative albumin, body mass index (BMI), and age were potential predictors of SSI. In predicting SSI, six ML models posted an average AUC of 0.60–0.80 and an ACC of 0.80–0.95, with the NB model standing out, registering an average AUC and an ACC of 0.78 and 0.90. Then, the feature importance of the NB model was reported.

Conclusions: ML algorithms are impressive tools in clinical decision-making, which can achieve satisfactory prediction of SSI with the NB model performing the best. The NB model may help access the risk of SSI following MIS-TLIF and facilitate clinical decision-making. However, future external validation is needed.

Single-dose antibiotic prophylaxis compared with multiple-dose protocol in clean pediatric neurosurgical interventions: a nonrandomized, historically controlled equivalence trial

OBJECTIVE

Guidelines recommend antimicrobial prophylaxis (AMP) preoperatively for "clean" spinal and cranial surgeries, while dose and timing remain controversial. The use of multiple-dose AMP for such surgeries is under debate in the pediatric context. In this clinical study, the authors aimed to compare single-dose with multiple-dose prophylactic antibiotic usage in cranial and spinal neurosurgical interventions of pediatric patients.

METHODS

All neurosurgical patients aged 28 days to 18 years who underwent surgery at a single tertiary center were assessed. Three cohorts (noninstrumented clean spinal, noninstrumented cranial, and instrumented cranial interventions), each of which comprised two 50-patient arms (i.e., single-dose AMP and multiple-dose AMP), were included after propensity score-matched retrospective sampling and power analysis. Records were examined for surgical site infections. Using a previously published meta-analysis as the prior and 80% acceptance of equivalence (margin of OR 0.88-1.13), logistic regression was carried out for the total cohort and each subcohort and adjusted for etiology by consideration of multiple-dose AMP as reference.

RESULTS

The overall sample included 300 age- and sex-matched patients who were evenly distributed in 3 bi-arm cohorts. There was no statistical intercohort difference based on etiology or type of operation (p < 0.05). Equivalence analysis revealed nondiscriminating results for the total cohort (adjusted OR 0.65, 95% CI 0.27-1.57) and each of the subcohorts (noninstrumented clean spinal, adjusted OR 0.65, 95% CI 0.12-3.44; noninstrumented cranial, adjusted OR 0.52, 95% CI 0.14-2.73; and instrumented cranial, adjusted OR 0.68, 95% CI 0.13-3.31).

CONCLUSIONS

No significant benefit for multiple-dose compared with single-dose AMPs in any of the pediatric neurosurgery settings could be detected. Since unnecessary antibiotic use should be avoided as much as possible, it seems that usage of single-dose AMP is indicated.

Surgical Site Infection Prophylaxis and Wound Management in Spine Surgery

Surgical site infection (SSI) is a potentially devastating complication of spinal surgery that increases patient morbidity and healthcare costs. SSIs have complex and multifactorial etiologies; therefore, there are numerous opportunities for prevention and risk mitigation. The aim of this narrative review was to describe the incidence, risk factors, and outcomes of SSIs in spine surgery with an emphasis on postoperative wound care. We list and describe the preoperative, intraoperative, and postoperative evidence-based interventions that can be applied to potentially prevent SSI after spinal surgery.

Identifying risks factors in thoracolumbar anterior fusion surgery through predictive analytics in a nationally representative inpatient sample

PURPOSE

Anterior thoracolumbar (TL) surgical approaches provide more direct trajectories compared to posterior approaches. Proper patient selection is key in identifying populations that may benefit from anterior TL fusion. Here, we utilize predictive analytics to identify risk factors in anterior TL fusion in patients with trauma and deformity.

METHODS

In this retrospective cohort study of patients receiving anterior TL fusion (between and including T12/L1), population-based regression models were developed to identify risk factors using the National Readmission Database 2016-2017. Readmissions were analyzed at 30- and 90-day intervals. Risk factors included hypertension, obesity, malnutrition, smoking, alcohol use, long-term opioid use, and frailty. Multivariate regression models were developed to determine the influence of each risk factor on complication rates.

RESULTS

A total of 265 and 375 patients were identified for the scoliosis and burst fracture cohorts, respectively. In patients with scoliosis, alcohol use was found to increase the length of stay (LOS) (p = 0.00061) and all-payer inpatient cost following surgery (p = 0.014), and frailty was found to increase the inpatient LOS (p = 0.0045). In patients with burst fractures, malnutrition was found to increase the LOS (p < 0.0001) and all-payer cost (p < 0.0001), obesity was found to increase the all-payer cost (p = 0.012), and frailty was found to increase the all-payer cost (p = 0.031) and LOS (p < 0.0001).

DISCUSSION

Patient-specific risk factors in anterior TL fusion surgery significantly influence complication rates. An understanding of relevant risk factors before surgery may facilitate preoperative patient selection and postoperative patient triage and risk categorization.

Comparison of the effect of epidural versus intravenous patient controlled analgesia on inpatient and outpatient functional outcomes after adult degenerative scoliosis surgery: a comparative study

BACKGROUND

Perioperative pain can negatively impact patient recovery after spine surgery and be a contributing factor to increased hospital length of stay and cost. Most data currently available is extrapolated from adolescent idiopathic cases and may not apply to adult and geriatric populations with thoracolumbar spine degeneration.

PURPOSE

Study the impact of epidural analgesia on pain control and outcomes after adult degenerative scoliosis surgery in a large single-institution series of adult patients undergoing thoraco-lumbar-pelvic fusion.

STUDY DESIGN/SETTING

Retrospective single-center review of prospectively collected data.

PATIENT SAMPLE

Patients undergoing thoracolumbar fusion with pelvic fixation.

OUTCOME MEASURES

Self-reported measures: Visual analog scale for pain. Physiologic Measures: Oral pain control requirements converted into daily morphine equivalents. Functional Measures: Ambulation perimeter after surgery, urinary retention and constipation rates.

METHODS

We retrospectively reviewed patient data for the years 2016 and 2017 before the use of patient controlled epidural analgesia (PCEA), and then 2018 and 2019 after its implementation, for all thoracolumbar degenerative procedures, and compared their postoperative outcomes measures.

RESULTS

There were 46 patients in the PCEA group and 37 patients in the intravenous PCA (IVPCA) groups. All patients underwent long segment posterolateral thoracolumbar spinal fusion with pelvic fixation. Patients in the PCEA group had lower pain scores and ambulated greater distances compared with those in the IVPCA group. PCEA patients also had lower urinary retention and constipation rates, but no increased intraoperative or postoperative complications related to catheter placement.

CONCLUSIONS

PCEA can provide optimal pain control after adult degenerative scoliosis spine surgery, and may promote greater early ambulation, while decreasing postoperative constipation and urinary retention rates.

Web-Based Calculator Predicts Surgical-Site Infection After Thoracolumbar Spine Surgery

BACKGROUND

Surgical-site infection (SSI) after spine surgery leads to increased length of stay, reoperation, and worse patient quality of life. We sought to develop a web-based calculator that computes an individual's risk of a wound infection following thoracolumbar spine surgery.

METHODS

We performed a retrospective review of consecutive patients undergoing elective degenerative thoracolumbar spine surgery at a tertiary-care institution between January 2016 and December 2018. Patients who developed SSI requiring reoperation were identified. Regression analysis was performed and model performance was assessed using receiver operating curve analysis to derive an area under the curve. Bootstrapping was performed to check for overfitting, and a Hosmer-Lemeshow test was employed to evaluate goodness-of-fit and model calibration.

RESULTS

In total, 1259 patients were identified; 73% were index operations. The overall infection rate was 2.7%, and significant predictors of SSI included female sex (odds ratio [OR] 3.0), greater body mass index (OR 1.1), active smoking (OR 2.8), worse American Society of Anesthesiologists physical status (OR 2.1), and greater surgical invasiveness (OR 1.1). The prediction model had an optimism-corrected area under the curve of 0.81. A web-based calculator was created: https://jhuspine2.shinyapps.io/Wound_Infection_Calculator/.

CONCLUSIONS

In this pilot study, we developed a model and simple web-based calculator to predict a patient's individualized risk of SSI after thoracolumbar spine surgery. This tool has a predictive accuracy of 83%. Through further multi-institutional validation studies, this tool has the potential to alert both patients and providers of an individual's SSI risk to improve informed consent, mitigate risk factors, and ultimately drive down rates of SSIs.