Postoperative Spinal Infections Research Articles

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

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. 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. 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 ± 15.2years. The average length of the NPWT was 21.2days (range 7-90days). 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 IV, Systematic review.

Crucial Insights: Post-Op Spinal Infections in Lumbar Fusion

Postoperative spinal infections following lumbar fusion with posterior lumbar interbody fusion (PLIF) are a concerning complication, particularly in cases of degenerative spinal disease. However, factors contributing to infection risk remain unclear. This retrospective study analyzed data from 124 adults who underwent instrumented fusion for degenerative spinal conditions between 2015 and 2020. Multivariate proportional hazards regression identified risk factors associated with surgical site infections (SSI). Results revealed a 16.9% incidence of SSI, with 92.4% of cases showing positive microbiological cultures. Prolonged hospital stay, prior surgeries, advanced age, diabetes, and obesity were correlated with infection risk. Notably, 95% of infected patients were successfully treated with surgical intervention or antibiotics without hardware removal. This underscores the importance of early identification and intervention in managing postoperative spinal infections, mitigating the need for hardware removal and improving patient outcomes.

Effectiveness of vancomycin powder for preventing postoperative spinal infection

ObjectiveThis study aimed to assess the effectiveness of Vancomycin Power (VP) and the occurrence of resistant organisms after four-year of routine VP use. MethodsThe study included 1063 patients who underwent posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) between January 2010 and February 2020. Intrawound VP was applied to all instrumented fusions starting in January 2016. The patients were divided into two groups: those who did not apply VP (non-VP) (n = 605) between 2010 and 2015, and those who did apply VP (VP) (n = 458) between 2016 and 2020. The baseline characteristics, clinical symptoms, infection rate, and causative organisms were compared between the two groups. ResultsThe rate of PSI was not significantly different between the non-VP group (1.32 %, n = 8) and the VP group (1.09 %, n = 5). Although adjusted by diabetes mellitus, VP still did not show statistical significance (OR = 0.757 (0.245–2.345), p = 0.630). There were no critical complications that were supposed to relation with vancomycin powder. In the 13 cases of PSI, seven pathogens were isolated, with a gram-negative organism identified in the non-VP group. However, the type of organism was not significantly different between the two groups. ConclusionsThe use of intrawound VP may not affect the PSI and occurrence of resistant organism and may not cause critical complications. Therefore, clinicians may decide whether to use VP for preventing PSI not worrying about its safety.

Spinal infection after vertebral augmentation: a covert complication with serious havoc.

Vertebral augmentation, including percutaneous vertebroplasty (PVP) or kyphoplasty (PKP), is the current least invasive surgical option and has been widely used to treat the painful osteoporotic vertebral compression fractures (OVCF). However, the postoperative infections could be life-threatening, even though they rarely occur. Our studies aim to clarify the causation and outcomes of spinal infections following augmentation and meanwhile to identify the risk factors. A retrospective study was conducted on patients with OVCF who underwent PVP or PKP, and were subsequently admitted to our institution with postoperative spinal infection between January 2010 and December 2022. A total of 33 patients were finally included. The rate of spinal infection after augmentation in our single institute was 0.05% (2/3893). In addition to these 2 patients, the remaining 31 were referred from other hospitals. All 33 patients exhibited elevated inflammatory parameters, 14 patients presented with fever, and 9 patients experienced neurological deficits. Additionally, 29 patients had comorbidity and risk factors. Pathogens were identified in 26 patients, while only 7 patients were examined as culture negative. 27 patients underwent revision surgery and 6 patients only received conservative therapy. Anterior surgery was performed in 2 patients, while posterior surgery was performed in 20 patients. A combined anterior-posterior surgery was performed in 5 patients. At the final follow-up, 18 patients had unrestricted mobility, 10 patients required assistance from crutches or a walker for ambulation, 4 patients needed a wheelchair, and 1 patients died after revision surgery. Spinal infection after vertebral augmentation is rare, but it cannot be ignored. Surgeons should make every effort to detect the potential preoperative spondylitis or discitis. Once postoperative spinal infection is confirmed, a prompt intravenous antibiotic therapy is warranted. If medication therapy fails, revision surgery involving debridement and spinal reconstruction should be considered.

A practical approach to interpretation of 18F-fluorodeoxyglucose positron emission tomography/computed tomography for postoperative spine infection.

18F-fluorodeoxyglucose-PET/CT is the imaging modality of choice for the diagnosis of postoperative spine infection. Published interpretation criteria are variable and often incompletely described. The objective was to develop a practical and standardized approach. Two-hundred-twenty-seven FDG-PET/CTs performed on 140 postoperative patients over a 7-year period were reviewed retrospectively. The presence or absence of infection was determined from clinical history, microbiology, other investigations, and clinical outcome during a minimum 6-month follow-up. No activity attributable to normal healing was seen in the post-discectomy space or at the bone-hardware interface in the absence of a complication at any stage. Within the incision, activity from normal healing persisted for months. Wound infections were diagnosed clinically, and most had already been treated before FDG-PET/CT was done to assess deep structures. With proven infection, 95% of cases had activity in bone or soft tissue outside the surgical field. The remaining 5% had activity confined to the post-discectomy space. Sterile hardware loosening may cause elevated activity which remains confined to the bone/hardware interface. Pathogens are introduced directly at the time of surgery and may be avirulent resulting in indolent infection with low-grade activity. At the same time, activity from non-infectious causes can be intense. A semi-quantitative method using SUVmax performed poorly compared with assessment of the distribution of activity. These observations have been incorporated into a checklist which is now being used at the time of interpretation. The potential sensitivity and specificity in the diagnosis of infection are close to 100%.

Methylene Blue Adjunct Debridement for Postoperative Spinal Infection

Methylene Blue Adjunct Debridement for Postoperative Spinal Infection

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.

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. To determine the Inflammatory biomarkers behavior profile among patients following elective degenerative spine surgery and their differences with those coursing with postoperative spinal infection. 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. 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. 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. PROSPERO register ID: CRD42022304645.

Epidemiology of postoperative spinal wound infection in the Middle East and North Africa (MENA) region

BackgroundDespite the extensive literature on postoperative spinal wound infection, yet to our knowledge, there is no previous study containing combined data from several sites in the Middle East and North Africa (MENA) region. This study aimed to estimate the incidence of surgical site infection (SSI) following spine surgeries, its associated factors, and management. MethodsIn a retrospective cohort study, medical records of all patients ≥18 years of age who underwent spine surgery at 6 tertiary referral centers in the MENA region between January 2014 to December 2019 (n=5,872) were examined to collect data on the following: (1) Patient's characteristics, (2) Disease characteristics, (3) Spine surgery approach, and (4) Characteristics of Postoperative SSI. The determinants of postoperative SSI were identified using logistic regression analysis. Receiver operating characteristic (ROC) curve was applied to identify the cut-off of the length of stay in the hospital postoperatively till the infection is likely to occur. Significance was set at p<.05. ResultsThe overall incidence of SSI was 4.2% (95% CI: 3.72–4.77), in the form of deep (46.4%), superficial (43.1%), dehiscence (9.3%), and organ space (1.2%) infections. After adjusting for all possible confounders, significant predictors of postoperative SSI were; diabetes (OR=2.12, p<.001), smoking (OR=1.66, p=.002), revision surgery (OR=2.20, p<.001), open surgery (OR=2.73, p<.001), perioperative blood transfusion (OR=1.45, p=.033), ASA class III(OR=2.08, p=.002), and ≥4 days length of stay "LOS" (OR= 1.71, p=.001). A cut-off of 4 days was the optimum LOS above which postoperative SSI is more likely to occur, with 0.70 sensitivity, 0.47 specificity, and 0.61 area under the curve. ConclusionsThis is the first study that highlighted the incidence of postoperative SSI in spine surgery in the MENA region. Incidence figures are comparable to figures in different areas of the world. Identifying predictors of SSI might help high‑risk patients benefit from more intensive wound management.

Risk factors for tuberculous or nontuberculous spondylitis after percutaneous vertebroplasty or kyphoplasty in patients with osteoporotic vertebral compression fracture: A case-control study.

ObjectivesThe contributing factors for spondylitis after percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP) remain unclear. Here, we sought to investigate the factors affecting spondylitis occurrence after PVP/PKP. We also compared the clinical characteristics between patients with tuberculous spondylitis (TS) and nontuberculous spondylitis (NTS) following vertebral augmentation.MethodsLiterature searches (from January 1, 1982 to October 16, 2020) using MEDLINE, EMBASE, Google Scholar and Web of science databases were conducted to identify eligible studies according to predefined criteria. The local database was also retrospectively reviewed to include additional TS and NTS patients at our center.ResultsThirty studies from the literature and 11 patients from our local institute were identified, yielding a total of 23 TS patients and 50 NTS patients for analysis. Compared with NTS group, patients in the TS group were more likely to have a history of trauma before PVP/PKP treatment. Univariate analyses of risk factors revealed pulmonary tuberculosis and diabetes were significant factors for TS after PVP/PKP. Analyzing NTS, we found obesity, a history of preoperative trauma, urinary tract infection, diabetes and multiple surgical segments (≥2) were significantly associated with its occurrence following PVP/PKP treatment. Multivariate logistic analyses showed a history of pulmonary tuberculosis and diabetes were independent risk factors for TS after PVP/PKP, while diabetes and the number of surgically treated segments independently influenced NTS development.ConclusionsA history of pulmonary tuberculosis and diabetes were independent risk factors for TS. For NTS, diabetes and the number of surgically treated segments significantly influenced the occurrence of postoperative spinal infection. These data may be helpful for guiding risk stratification and preoperative prevention for patients, thereby reducing the incidence of vertebral osteomyelitis after PVP/PKP.

Does Postoperative Spine Infection Bacterial Gram Type Affect Surgical Debridement or Antibiotic Duration?

This is a retrospective cohort study. The aim was to evaluate differences in readmission rates, number of debridements, and length of antibiotic therapy when comparing bacterial gram type following lumbar spinal fusion infections. Surgical site infections (SSIs) after spinal fusion serve as a significant source of patient morbidity. It remains to be elucidated how bacterial classification of the infecting organism affects the management of postoperative spinal SSI. Patients who underwent spinal fusion with a subsequent diagnosis of SSI between 2013 and 2019 were retrospectively identified. Patients were grouped based on bacterial infection type (gram-positive, gram-negative, or mixed infections). Poisson regressions analyzed the relationship between the type of bacterial infection and the number of irrigation and debridement (I&D) reoperations, and the duration of intravenous (IV) antibiotic therapy. Significance was set at P <0.05. Of 190 patients, 92 had gram-positive (G+) infections, 57 had gram-negative (G-) infections, and 33 had mixed (M) infections. There was no difference in 30 or 90-day readmissions for infection between groups (both P =0.051). Patients in the M group had longer durations of IV antibiotic treatment (G+: 46.4 vs. G-: 41.0 vs. M: 55.9d, P =0.002). Regression analysis demonstrated mixed infections were 46% more likely to require a greater number of debridements ( P =0.001) and 18% more likely to require an increased duration of IV antibiotic therapy ( P <0.001), while gram-negative infections were 10% less likely to require an increased duration of IV antibiotic therapy ( P <0.001) when compared with G- infections. Spinal SSI due to a mixed bacterial gram type results in an increased number of debridements and a longer duration of IV antibiotics required to resolve the infection compared with gram-negative or gram-positive infections. Level III.

Clinical differences between delayed and acute onset postoperative spinal infection.

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

Cefazolin prophylaxis in spine surgery: patients are frequently underdosed and at increased risk for infection

BACKGROUND CONTEXTPerioperative antibiotics are critical in reducing the risk of postoperative spine infections. However, the efficacy and optimal weight-based prophylactic cefazolin dosing is unclear. PURPOSETo determine (1) if inadequate weight-based prophylactic dosing of cefazolin affects infection rates after spinal fusions, and (2) identify the optimal dosing of cefazolin. STUDY DESIGN/SETTINGSingle center retrospective cohort PATIENT SAMPLEPatients undergoing posterior cervical or lumbar spinal fusion between January 2000 and October 2020 OUTCOME MEASURESPostoperative surgical site infection status METHODSPatients were grouped based on our institutionally derived dosing adequacy standards, 1 g for <60 kg, 2 g for 60 to 120 kg, and 3 g for >120 kg. Univariate comparisons and multivariate regressions identified the effect of inadequate dosing on infection rate. Patients were subsequently regrouped into cefazolin dose (grams) administered and logistic regression and receiver operating characteristic curves were compiled to determine the probability of infection based on cefazolin dose and patient weight. Alpha was set at 0.05. RESULTSA total of 2,643 patients met inclusion criteria and 95 infections (3.6%) were identified. The infection rate was higher in the inadequate dosing group (5.86% vs. 2.58%, p<.001). Adequate dosing was a predictor of decreased infections after lumbar fusion (OR: 0.43, p<.001), but not posterior cervical fusions (OR: 0.47, p=.065). Patients were subsequently regrouped into 1 g or 2 g of cefazolin administered resulting in a 5.01% and 2.77% infection rate, respectively (p=.005). The area under the curve (AUC) and 95% confidence interval for one (0.850 [0.777–0.924]) and two (0.575 [0.493–0.657]) g of cefazolin demonstrated lower infection rates for patients given 2 g cefazolin. CONCLUSIONSPatients receiving an inadequate weight-based dose of preoperative cefazolin had an increased risk of infection following spinal fusion surgery. Two grams prophylactic cefazolin significantly reduces the likelihood of infection.

Usage of procalcitonin and sCD14-ST as diagnostic markers for postoperative spinal infection

ObjectiveIdentifying biomarkers for early diagnosis of postoperative spinal infection is essential to avoid complications after spine surgery. The presented study evaluated serum levels of procalcitonin (PCT), C-reactive protein (CRP), and soluble CD14 subtype (sCD14-ST) in patients who underwent spinal surgery to assess the diagnosis values of PCT and sCD14-ST.MethodsSerum levels of PCT, CRP, and sCD14-ST were measured in 490 (289 male/201 female) patients who underwent spinal surgery (SS) before and 1 day after surgery. PCT and sCD14-ST levels of patients diagnosed with postoperative infection (PI) and patients diagnosed with postoperative non-infection (PN) were compared.ResultsSerum levels of PCT, CRP, and sCD14-ST were significantly increased after surgery (F = 58.393, P = 0.000). In patients diagnosed as having a PI, serum levels of PCT and sCD14-ST were positively correlated with each other (r = 0.90, P < 0.01) and with operation duration (r = 0.92, 0.88, P < 0.01). Receiver operating characteristic (ROC) models showed that both PCT (AUC = 0.817, optimal cutoff: 0.69 ng/ml, P = 0.000) and sCD14-ST (AUC = 0.824, optimal cutoff: 258.27 pg/ml, P = 0.000) can distinguish PI versus PN patients well.ConclusionOur results demonstrated that serum levels of PCT and sCD14-ST have the potential to be used as a diagnostic markers for postoperative spinal infection.

Animal Models for Postoperative Implant-Related Spinal Infection.

Postoperative infections following implant‐related spinal surgery are severe and disastrous complications for both orthopaedic surgeons and patients worldwide. They can cause neurological damage, disability, and death. To better understand the mechanism of these destructive complications and intervene in the process, further research is needed. Therefore, there is an urgent need for efficient, accurate, and easily available animal models to study the pathogenesis of spinal infections and develop new and effective anti‐bacterial methods. In this paper, we provide a general review of the commonly used animal models of postoperative implant‐related spinal infections, describe their advantages and disadvantages, and highlight the significance of correctly choosing the model according to the infection aspect under investigation. These models are valuable tools contributing to the better understanding of postoperative spinal infections and will continue to facilitate the invention of novel preventative and treatment strategies for patients with postoperative spinal infections. However, although they are valid and reproducible in some respects, the current animal models present certain limitations. Future ideal spinal infection animal models may assess the bacterial load of the same animal in real‐time in vivo, and better mimic the human anatomy as well as surgical techniques. Strains other than Staphylococcus aureus account for a large proportion of postoperative spinal infections, and thus, the establishment of models to evaluate other types of microbial infections is expected in the future. Furthermore, novel transgenic models established on advancements in genome editing are also likely to be developed in the future.

Case Series of the Management of Surgical Site Infection following Thoracic Spinal Surgeries during COVID Pandemic

Introduction: Post-operative spinal wound infection increases the morbidity of the patient and the cost of healthcare. Despite the development of prophylactic antibiotics and advances in surgical technique and post-operative care, wound infection continues to compromise patient outcome after spinal surgery. This kind of infection places the patient at risk for pseudoarthrosis, adverse neurologic sequelae, chronic pain, deformity, and even death. In spite of all preventive measures, the SSI following spinal surgeries are 1% among operated spinal instrumentation. Case Series: Here, we present a series of three patients who presented to us with post-operative surgical site infection (SSI) in spine surgery in the form of wound, discharge, and other complaints. Out of all, two of them were operated with debridement and skin closure followed by broad spectrum IV antibiotics and one of them managed with vacuum-assisted closure dressing and high antibiotics sensitive to organisms found in wound culture. Optimization by building up hemoglobin, supplementing micronutrients including Vitamin C, D, and B12 and high protein diet was started as adjuvant therapy and all of them was discharged with healthy wound. Conclusion: SSI in spine surgery is a common but challenging complication, particularly after instrumental spinal arthrodesis. Using meticulous aseptic technique, intra-operative irrigation, prophylactic antibiotics, and optimizing patient factors preoperatively are key to preventing a SSI. In patients who still develop an infection despite efforts at prevention, timely diagnosis and treatment are critical. Instrumentation can be retained while still successfully clearing an early infection, although following fusion, instrumentation can be removed if lifetime oral antibiotic suppression is either not indicated or undesirable. Keywords: Spine surgery, Postoperative infections, Surgical site infection, Spinal instrumentation.

Çift Salımlı Gentamisin İçeren Kollajen Malzemenin Postoperatif Omurga Enfeksiyonunu Önlemedeki Etkinliğinin Değerlendirilmesi: Deneysel Çalışma (Hayvan Deneyi)

Objective: We studied that collagen material containing double-release gentamicin sponge for preventing of experimental postoperative spinal infection animal model. Material and Methods: A total of 28 adult female rats were used, in 4 groups each having 7 rats. Group 1: Only cutaneous-subcutaneous, fascia opened, muscles stripped; Group 2: Laminectomy of 2 levels+sterile normal saline; Group 3: Laminectomy of 2 levels+Staphylococcus aureus [106 colony forming unit (CFU)/10 ult]; Group 4: Laminectomy of 2 levels+S. aureus (106 CFU/10 ult)+collagen material containing double-release gentamicin sponge. With a light microscope, epidural fibrosis, inflammatory cell infiltration and fibroblast density of sections were evaluated and graded. Results: Group 2 had higher epidural fibrosis, fibroblast cell density and inflammatory cell density than those of Group 1. Group 3 had higher epidural fibrosis, fibroblast cell density and inflammatory cell density than those of Group 1. Group 1 had lower epidural fibrosis, fibroblast cell density and inflammatory cell density than those of Group 4. The inflammatory cell density was higher in Group 3 than that of Group 2. The epidural fibrosis and inflammatory cell density were lower in Group 4 than those of Group 2. The Group 4 had lower epidural fibrosis, fibroblast cell density and inflammatory cell density than those of Group 3. Conclusion: We therefore consider that the material used for this study could be used for prophylaxis to prevent epidural fibrosis and infection in spinal surgery.

Removal of instrumentation for postoperative spine infection: systematic review.

Currently, no consensus exists as to whether patients who develop infection of the surgical site after undergoing instrumented fusion should have their implants removed at the time of wound debridement. Instrumentation removal may eliminate a potential infection nidus, but removal may also destabilize the patient's spine. The authors sought to summarize the existing evidence by systematically reviewing published studies that compare outcomes between patients undergoing wound washout and instrumentation removal with outcomes of patients undergoing wound washout alone. The primary objectives were to determine 1) whether instrumentation removal from an infected wound facilitates infection clearance and lowers morbidity, and 2) whether the chronicity of the underlying infection affects the decision to remove instrumentation. PRISMA guidelines were used to review the PubMed/MEDLINE, Embase, Cochrane Library, Scopus, Web of Science, and ClinicalTrials.gov databases to identify studies that compared patients with implants removed and patients with implants retained. Outcomes of interest included mortality, rate of repeat wound washout, and loss of correction. Fifteen articles were included. Of 878 patients examined in these studies, 292 (33%) had instrumentation removed. Patient populations were highly heterogeneous, and outcome data were limited. Available data suggested that rates of reoperation, pseudarthrosis, and death were higher in patients who underwent instrumentation removal at the time of initial washout. Three studies recommended that instrumentation be uniformly removed at the time of wound washout. Five studies favored retaining the original instrumentation. Six studies favored retention in early infections but removal in late infections. The data on this topic remain heterogeneous and low in quality. Retention may be preferred in the setting of early infection, when the risk of underlying spine instability is still high and the risk of mature biofilm formation on the implants is low. However, late infections likely favor instrumentation removal. Higher-quality evidence from large, multicenter, prospective studies is needed to reach generalizable conclusions capable of guiding clinical practice.

12. Late spinal infections are more common among pediatric vs adult spinal deformity patients

<h3>BACKGROUND CONTEXT</h3> Late-onset postoperative infections after surgical correction of spinal deformity represent an uncommon, but significant complication of spine surgery. The incidence of late infection following posterior spinal fusion (PSF) in pediatric patients with AIS has been reported to be up to 7.5%. However, there is limited literature on late infections following ASD surgery suggesting that this phenomenon may be less frequent in adults. <h3>PURPOSE</h3> The objective of this study is to characterize the incidence, timing, and pathogenic etiology of late spinal infections after instrumentation for spinal arthrodesis in both age groups who present with spinal deformity. <h3>STUDY DESIGN/SETTING</h3> Retrospective review, single institution <h3>PATIENT SAMPLE</h3> Institutional data was retrospectively queried from 2000 to 2015 to identify patients who underwent instrumented PSF. Patients with more than 12 months follow-up, spinal arthrodesis spanning greater than 5 levels, and idiopathic or degenerative spinal pathology were selected for inclusion. A total of 1113 patients met inclusion criteria<b>:</b> 607 pediatric AIS patients and 506 adult spinal deformity patients. Within the pediatric AIS cohort, 76.1% (462/607) were female compared to 70.9% (359/506) within the ASD cohort. Mean follow-up was 3.9 ± 2.86 years for the AIS patients vs 4.6 ± 3.16 years for the ASD patients. <h3>OUTCOME MEASURES</h3> The following outcomes were assessed and were compared by age cohort of less than 21 vs greater than or equal to 21 years: rate of late-onset spinal infection, timing of late-onset spinal infection, and causative microorganism(s) associated with late-onset spinal infections. Demographic and surgical data were also compared between the two cohorts. <h3>METHODS</h3> The individual charts of all patients were personally reviewed by study team members to identify those who went on to develop late spinal infections. We classified late-onset as spinal infections occurring beyond 6 months (180 days) from the index operation. Diagnosis was established on the basis of return to the operating room for intraoperative bacterial cultures and sensitivities, and irrigation and debridement. <h3>RESULTS</h3> A total of 26 (4.29%) AIS patients and 2 (0.4%) ASD patients developed a late postoperative spinal infection (p = 0.01). Average onset of infection was 4.2 years (1.0-11.6) in the AIS group and 4.0 years (0.6-7.3) in the ASD group. There were significant differences in number of levels fused and reported blood loss between the two groups (p <0.001). After controlling for these intraoperative factors, age remained a significantly correlated with onset of late spinal infection (p < 0.001). Cutibacerium acnes and coagulase-negative Staphylococci were the most commonly detected microorganisms for both groups. <h3>CONCLUSIONS</h3> Pediatric patients are at significantly increased risk for late-onset postoperative spinal infections compared to adults. Skin and indolent organisms are the primary identifiable causative agents in both cohorts. Further research on these differences in infection patterns among adolescents and adults may help tailor personalized management protocols. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

13. The diagnostic utility of biomarkers: spinal instability or underlying infection

<h3>BACKGROUND CONTEXT</h3> Surgical site infection is a devastating complication of surgery that increases morbidity for patients undergoing spinal surgery. However, diagnosis in some cases remains challenging often requiring a trip to the operating room to obtain cultures. Current literature has provided evidence that preoperative blood markers are diagnostic of infection in patients undergoing hip arthroplasty and total knee replacement, but there has been limited investigation on biomarker diagnostic utility in patients undergoing spinal surgery. <h3>PURPOSE</h3> To identify the diagnostic utility of laboratory markers to diagnose postoperative spinal infection. <h3>STUDY DESIGN/SETTING</h3> Retrospective case-control analysis <h3>PATIENT SAMPLE</h3> Patients having undergone prior spine surgery with a confirmed positive intraoperative culture during revision for presumed infection. An additional aseptic cohort was established with patients undergoing revision surgery for reasons other than infection. <h3>OUTCOME MEASURES</h3> White blood cell (WBC), erythrocyte sedimentation rate (ESR), c-reactive protein (CRP), mean platelet volume (MPV), platelet number, MPV/platelet ratio, diagnostic sensitivity, specificity and threshold values for the diagnosis of spinal infection. <h3>METHODS</h3> A retrospective review was conducted at a single center academic hospital. Patients undergoing spinal fusion with a diagnosis of surgical site infection (SSI) from the dates of 2013 to 2019 were identified. In the aseptic cohort, any individual that had overt signs of infection or had infection within one year of revision procedure was excluded. Patients with a history of cancer, trauma, autoimmune disease on suppressive therapy, or noncompliance with medical therapy were excluded. WBC, ESR, CRP, MPV, MPV/Platelet ratio and demographic data was compared between groups and an AUC analysis was performed to determine threshold values. <h3>RESULTS</h3> A total of 418 patients were included, 224 in the aseptic cohort and 194 in the infection cohort. In terms of baseline demographics, there were significant differences between the cohorts in BMI, CCI, and ASA (p<0.05). BMI in the infection cohort was found to be greater than the aseptic cohort with a mean value of 33.7 vs 30.9 respectively. CCI and ASA was also elevated in the infections cohort as compared to the aseptic cohort with mean values of 3.84 for CCI and 2.90 for ASA as compared to 1.08 and 2.45 in the aseptic cohort. Significant differences were found between the cohorts with respect to MPV/platelet ratios, platelet number, MPV, CRP, ESR and WBC (p<0.01). Platelet ratio, platelet number, CRP, ESR and WBC were all greater in the infection group as compared to the aseptic group (platelet ratio 36.1 vs 24.7, platelet number 347 vs 249, CRP 9.99 vs 4.81, ESR 76.6 vs 46.5, WBC 9.87 vs 7.82 p<0.01) These differences were used to determine predictive cutoffs. The most sensitive markers for predicting postoperative infection were platelet number (cutoff 284 AUC 0.751; sensitivity 0.662) and ESR (cutoff 40.00 AUC 0.715; sensitivity 0.838). The most specific markers for predicting postoperative infection were platelet ratio (cutoff 31.02 AUC 0.758; specificity 0.842) and platelet count (cutoff 284.00 AUC 0.715; specificity 0.804). <h3>CONCLUSIONS</h3> This study concluded that preoperative platelet number and ESR are best used as screening measures, while MPV/platelet ratio and count are useful confirmatory markers. Further analysis will allow for a more depth investigation into optimal combination of biomarkers to result in the greatest diagnostic utility, but this initial report serves as evidence that preoperative biomarker collection may be a valuable tool to confirm the diagnosis in suspected postoperative surgical site infections. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Invasive dental procedures as risk factors for postoperative spinal infection and the effect of antibiotic prophylaxis.

AimTo identify invasive dental procedures as a risk factor for postoperative spinal infection (PSI) and evaluate the effectiveness of antibiotic prophylaxis.Materials and MethodsWe analysed 229,335 patients who underwent spinal surgery with instrumentation from 2010 to 2017, using the nationwide database. The incidence of spinal infection 2 years after surgery was determined. Invasive dental procedures as a risk factor for PSI and the effects of antibiotic prophylaxis during this period were also analysed.ResultsA total of 15,346 patients (6.69%) were diagnosed with PSI. It was found that advanced age, male sex, and a high Charlson Comorbidity Index were risk factors for PSI. The risk of PSI did not increase following dental procedures (adjusted hazard ratio [HR] 0.850; 95% confidence interval [CI], 0.793–0.912) and was not affected by antibiotics (adjusted HR 1.097; 95% CI, 0.987–1.218). Patients who received dental treatment as early as 3 months after spinal surgery had the lowest risk of postoperative infection (adjusted HR 0.869; 95% CI, 0.795–0.950).ConclusionsInvasive dental procedure does not increase the risk of PSI, and antibiotic prophylaxis before dental procedure was not effective in preventing spinal infection.