Sequential Changes of Plasma C-Reactive Protein, Erythrocyte Sedimentation Rate and White Blood Cell Count in Spine Surgery : Comparison between Lumbar Open Discectomy and Posterior Lumbar Interbody Fusion

Interleukin-6 as a critical inflammatory marker for early diagnosis of surgical site infection after spine surgery

PURPOSE

Early diagnosis of surgical site infections (SSIs) could prevent surgical revision. Inflammatory markers (IMs), such as procalcitonin (PCT), interleukin-6 (IL-6), and tumor necrosis factor α (TNF-α), seem more accurate in diagnosing SSI than C-reactive protein (CRP) and white blood cell (WBC) count. The aim was to compare the predictive values of CRP, WBC count, PCT, IL-6, and TNF-α in SSI detection.

METHODS

A total of 130 patients undergoing dorsal spondylodesis from 2019 to 2024 were enrolled in a prospective diagnostic study at a maximum care spine center. IMs were measured preoperatively and on the postoperative days (PODs) 1, 2, 3, 5, and 7. Patients with high suspicion of SSI underwent revision surgery. SSI was diagnosed when the microbiological evidence was positive. Patients were divided a posteriori into the non-infection and infection groups.

RESULTS

IMs of 118 patients (66.9 ± 13.0 years, 61.0% females) were measured. Fifteen of the 118 patients (12.7%) developed an SSI. The groups differed with respect to existing hypertension, number of instrumented segments, region of surgery, CRPPOD1,7, PCTPOD7, and IL-6POD3,5,7. Binary logistic regression for SSI detection including these parameters showed an area under the curve (AUC) of 0.88 (95% CI 0.79-0.98; P < 0.001). The main effect for SSI detection was maintained by IL-6POD7 (odds ratio = 1.13; 95% CI 1.05-1.23; P = 0.001), which itself showed an AUC of 0.86 (95% CI 0.75-0.97).

CONCLUSION

Compared to CRP, WBC count, PCT, and TNF-α, IL-6 seems to be the critical IM for the early detection of an SSI.

TRIAL REGISTRATION

drks.de: DRKS00033773, date of registration: 29.02.2024, retrospectively registered; Postoperative Markers of Inflammation in Spine Surgery (POMIS) Trial.

Post-operative C-reactive protein and white blood cells changes pattern following spinal deformity surgery and its clinical correlation

OBJECTIVE

Following the changing pattern of post-operative CRP and WBC counts and compare them to the patient's clinical condition to find which one is better for early detection of early infection.

METHODS

A total of 50 patients who underwent spinal deformity correction surgery without clinical signs of infection such as fever, wound redness, or discharge were enrolled in this prospective study. The C-reactive protein (CRP) and white blood cell (WBC) counts were measured the 2nd and 7th post-operative days. We try to detect the type of correlation between both CRP and WBCs level and clinical condition of patient regarding wound local condition.

RESULTS

All cases showed high CRP by the 2nd day post-operative which decreased significantly but not reaching normal levels even by the 7th day. All cases showed elevated WBCs count by the 2nd day which decreased to normal levels by the 3rd day in 86% of patients, and by the 7th day, 94% of cases showed normal levels. In addition, WBCs in the 2nd day post-operative significantly positive correlated with fusion level and operative time. There was no significant correlation between WBCs and blood transfusion or age. No significant correlation between CRP and number of fusion levels, blood transfusion nor operative time.

CONCLUSION

WBCs count returned earlier to normal levels than CRP in our cases, so monitoring early changes in the 1st week in WBCs count pattern is more indicative of an ongoing infectious process.

No more tears from surgical site infections in interventional pain management

As the field of interventional pain management (IPM) grows, the risk of surgical site infections (SSIs) is increasing. SSI is defined as an infection of the incision or organ/space that occurs within one month after operation or three months after implantation. It is also common to find patients with suspected infection in an outpatient clinic. The most frequent IPM procedures are performed in the spine. Even though primary pyogenic spondylodiscitis via hematogenous spread is the most common type among spinal infections, secondary spinal infections from direct inoculation should be monitored after IPM procedures. Various preventive guidelines for SSI have been published. Cefazolin, followed by vancomycin, is the most commonly used surgical antibiotic prophylaxis in IPM. Diagnosis of SSI is confirmed by purulent discharge, isolation of causative organisms, pain/tenderness, swelling, redness, or heat, or diagnosis by a surgeon or attending physician. Inflammatory markers include traditional (C-reactive protein, erythrocyte sedimentation rate, and white blood cell count) and novel (procalcitonin, serum amyloid A, and presepsin) markers. Empirical antibiotic therapy is defined as the initial administration of antibiotics within at least 24 hours prior to the results of blood culture and antibiotic susceptibility testing. Definitive antibiotic therapy is initiated based on the above culture and testing. Combination antibiotic therapy for multidrug-resistant Gram-negative bacteria infections appears to be superior to monotherapy in mortality with the risk of increasing antibiotic resistance rates. The never-ending war between bacterial resistance and new antibiotics is continuing. This article reviews prevention, diagnosis, and treatment of infection in pain medicine.

Spinal Surgery and Subsequent ESR and WBC Changes Pattern: A Single Center Prospective Study

Objective

Postoperative inflammation and infections are common complications of spinal surgery and have similar symptoms. However, postoperative infection may lead to a poor outcome and must be differentiated from postoperative inflammation. The objective of this study is determine the changing pattern of postoperative ESR and WBC counts, and investigate the effects of different variables.

Methods

A total of 61 patients who underwent spinal surgery were enrolled in this prospective study. The erythrocyte sedimentation rate (ESR) and white blood cell (WBC) counts were measured the day before surgery and on 1st, 3rd, 5th, 7th, and 14th postoperative days.

Results

WBC counts increased on the 1st postoperative day in comparison with the preoperative day (p<0.001), and they gradually decreased until the preoperative value was reached on the 14th postoperative day (p=0.14). The ESR also increased postoperatively, reaching a peak on the 5th postoperative day in comparison with the preoperative day (p<0.001) and gradually decreased thereafter. However, on the 14th postoperative day, the ESR was significantly greater than the preoperative value (p<0.001). In addition, a significant positive correlation was observed between ESR and age, duration of surgery, intraoperative blood loss, and duration of anesthesia.

Conclusion

WBC count continued to rise and was the highest on the 1st postoperative day, after which it gradually decreased and attained normal values on the 14th postoperative day, while the ESR increased on the 1st postoperative day, reached the highest level in patients with and without simultaneous instrumentation on 7th and 5th postoperative days, respectively, and gradually decreased.

C-reactive protein in spinal surgery: more predictive than prehistoric

PURPOSE

In spinal surgery, surgical site infections (SSI) after dorsal spondylodesis lead to severe short- and long-term complications. Despite various clinical and serological evidence, the detection of a postoperative SSI remains crucial. In this retrospective cohort study, we determined the prognostic value of C-reactive protein (CRP) kinetics after open reduction and dorsal spondylodesis in the development of a SSI.

METHODS

We retrospectively analyzed 192 patients from 2016 to 2018 undergoing open reduction and dorsal spondylodesis with and without SSI for 20 days at a level-I trauma center and assessed their serological and clinical characteristics.

RESULTS

On day 7 and 8 after surgery, patients who developed a SSI displayed significantly higher CRP levels. A second peak after the initial maximum of CRP and a restricted failure to decline as well as a maximum CRP of more than 225 mg/l predict an infectious complication with a sensitivity of 92.9%, and a specificity of 78.2%. A binary logistic regression leads to 85.7% and 69.7%, respectively. A one-phase decay exponential regression can predict 75.6% of the variance after the initial peak of CRP.

CONCLUSION

Our study demonstrates a high value of postoperative CRP kinetics in SSI detection after dorsal spondylodesis. Moreover, we observed typical CRP levels with a specific course as indicative predictors that may facilitate an early SSI detection in clinical practice.

Changes of Biomarkers before and after Antibiotic Treatment in Spinal Infection

Objective

The laboratory biomarkers used to diagnose spinal infection include white blood cell (WBC) counts, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). Recently, procalcitonin (PCT) has been used as a biomarker to distinguish between bacterial infection and non-bacterial infection. We aimed to compare the changes of conventional biomarker and PCT in patients with spinal infection before and after antibiotic treatment.

Methods

ESR, CRP, WBC counts, and PCT were measured in 29 patients diagnosed with pyogenic spinal infection at our hospital between May 2016 and December 2018 prior to antibiotic administration. After antibiotic administration, the values were followed up for 4 weeks at 1-week intervals.

Results

A total of 29 patients were enrolled, with a mean age of 67.8 years, consisting of 16 men and 13 women. Twenty-five patients had lumbar infections, and 2 each had cervical and thoracic infections. The mean ESR, CRP, PCT, and WBCs decreased at week 4 of antibiotic treatment compared to their baseline values. CRP and WBCs were significantly decreased after 4 weeks of treatment compared to before treatment. The mean ESR and PCT was not statistically significant compared to pretreatment and after antibiotic treatment (p-value>0.05).

Conclusion

Among several biomarker, CRP and WBCs are biomarkers that can aid early evaluation of the effects of antibiotic treatment in pyogenic spondylitis. Although PCT did not have statistical significance, it can be used as a biomarker that reflects the effect of antibiotic and severity of infection.

Correlation Between Clinical Course and Biochemical Analysis in Odontogenic Space Infections

OBJECTIVE

To correlate the clinical course and biochemical analysis in odontogenic space infections.

METHODS

A randomized prospective study was undertaken in 50 patients presenting with infections of odontogenic origin. The data were subjected to statistical analysis to co-relate the values of CRP, WBC count and ESR with the clinical course of odontogenic infections. The statistical analysis was carried out using SPSS Version 17.0 clinical parameters included pain, swelling, mouth opening, dyspnea, dysphagia, hoarseness, body temperature, active discharge, length of hospital stay and number of fascial spaces involved.

RESULTS

There was a significant correlation between all the clinical parameters and biochemical markers preoperatively as well as on various postoperative days.

CONCLUSION

According to the percentage rate of fall, CRP was considered as the best indicator of clinical course/recovery of the patient, followed by WBC count and ESR, respectively.

Strategies for the Prevention and Treatment of Surgical Site Infection in the Lumbar Spine

Surgical site infection (SSI) following spine surgery can be devastating for both the patient and the surgeon. It leads to significant morbidity and associated health care costs, from readmissions, reoperations, and subsequent poor clinical outcomes. Complications associated with SSI following spine surgery include pseudarthrosis, neurological deterioration, sepsis, and death. Its management can be very challenging. The diagnosis of SSI involves the interpretation of combined clinical, laboratory, and occasionally radiologic findings. Most infections can be treated with an appropriate course of antibiotics and bracing if required. Surgical intervention is usually reserved for infections resistant to medical management, the need for open biopsy/culture, evolving spinal instability or deformity, and neurologic deficit or deterioration. A thorough knowledge of associated risk factors is required and patients should be stratified for risk preoperatively. The multifaceted approach of risk stratification, early diagnosis and effective treatment, is essential for successful prevention and effective treatment and crucial for a satisfactory outcome.

Comparison of Surgical Invasiveness Between Microdiscectomy and 3 Different Endoscopic Discectomy Techniques for Lumbar Disc Herniation

OBJECTIVE

Muscle injury is inevitable during surgical exposure of the spine. This study compared paraspinal muscle injury after 4 surgical techniques: microdiscectomy (MD), percutaneous endoscopic lumbar discectomy (PELD), percutaneous endoscopic interlaminar discectomy (PEID), unilateral biportal endoscopic discectomy (UBED).

METHODS

Eighty patients who underwent MD, PELD, PEID, and UBED were prospectively observed. Creatine phosphokinase (CPK) and C-reactive protein levels were measured on admission and postoperative days 1, 3, 5, and 7. CPK ratio was calculated as CPK on postoperative day 1/CPK on admission. Cross-sectional area of the high-intensity lesion in the paraspinal muscle was measured on magnetic resonance imaging after surgery. Operative time and hospital stay duration were also examined. Clinical outcome was evaluated using the visual analog scale for back and leg pain.

RESULTS

MD group had the highest CPK levels on postoperative days 1 and 3 and CPK ratio (P < 0.01, P = 0.02, P = 0.04). Serial C-reactive protein levels were highest in MD group (P < 0.01). PELD and PEID groups had lower C-reactive protein level on postoperative day 1 than UBED group. MD group had largest cross-sectional area (P < 0.01). Cross-sectional area was larger in UBED group than in PELD and PEID groups (P < 0.01). Operative time and hospital stay duration were shortest in PELD group (P < 0.01, P < 0.01). MD group had significantly higher visual analog scale scores for back pain on postoperative days 1 and 3 than the other groups (P < 0.01, P = 0.02).

CONCLUSIONS

PELD is the least invasive spinal surgical technique.