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

BACKGROUND CONTEXT

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

PURPOSE

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

STUDY DESIGN

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

PATIENT SAMPLE

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

OUTCOME MEASURES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Sagittal Balance Using Position and Orientation of Each Vertebra in an Asymptomatic Population

STUDY DESIGN

A monocentric, retrospective radiographic study with 99 asymptomatic volunteers.

OBJECTIVE

The authors performed the postural analysis commonly scheduled when evaluating sagittal balance in a vertebra-by-vertebra manner by enrolling an asymptomatic population. They measured the position and angulation of each vertebra to reveal those for which the spatial positioning could be relevant during spinal surgeries.

SUMMARY OF BACKGROUND DATA

Several recent publications detailed the sagittal alignment parameters and focus on global analysis parameters. Some patients with identical commonly evaluated spinal parameters have exhibited very different profiles, with notable differences in vertebral positions and orientations. Therefore, a fine segmental analysis of position of each vertebra could be interest to gain understanding of spine alignment.

MATERIALS AND METHODS

The authors obtained full-spine EOS x-rays of 99 volunteers in the standard free-standing position. We used a validated three-dimensional reconstruction technique to extract current spinal parameters and the positions and angulations of all vertebrae and lumbar discs. Particular attention was paid to the positions and angulations of the apical and transitional vertebrae in the general population and in subgroups according to pelvic incidence (PI).

RESULTS

T1 was the most common transitional cervicothoracic vertebra (in 89.9% of subjects) and was oriented downwards by an average of 22.0° (SD=7.3°, minimum=2.3°, maximum=40.1°). The thoracic apex trio of T5 (22.2%), T6 (28.3%), and T7 (36.4%) were equally found. The transitional thoracolumbar vertebrae were L1 (39.4%) and T12 (33.3%). The lumbar apex was usually the L3-L4 disc (36.4%). T1 seemed to be the transitional vertebra (90%) irrespective of the PI. For the other relevant vertebrae, the greater the PI, the more cranial the vertebra.

CONCLUSIONS

We performed a detailed three-dimensional assessment of overall spinal balance using positional and rotational parameters. The positions and orientations of all vertebrae were specified, particularly the apical and transitional vertebrae.

LEVEL OF EVIDENCE

Level 3.