European Spine Journal

, Volume 19, Issue 10, pp 1711–1719 | Cite as

Risk factors for deep surgical site infections after spinal fusion

  • J. J. P. SchimmelEmail author
  • P. P. Horsting
  • M. de Kleuver
  • G. Wonders
  • J. van Limbeek
Original Article


Surgical site infections (SSI) are undesired and troublesome complications after spinal surgery. The reported infection rates range from 0.7 to 11.9%, depending on the diagnosis and the complexity of the procedure. Besides operative factors, patient characteristics could also account for increased infection rates. Because the medical, economic and social costs of SSI are enormous, any significant reduction in risks will pay dividends. The purpose of this study is to compare patients who developed deep SSI following lumbar or thoracolumbar spinal fusion with a randomly selected group of patients who did not develop this complication in order to identify changeable risk factors. With a case–control analysis nested in a historical cohort of patients who had had a spinal fusion between January 1999 and December 2008, we identified 36 cases with deep SSI (CDC criteria). Information regarding patient-level and surgical-level risk factors was derived from standardized but routinely recorded data and compared with those acquired in a random selection of 135 uninfected patients. Univariate analyses and a multivariate logistic regression were performed. The overall rate of infection in 1,615 procedures (1,568 patients) was 2.2%. A positive history of spinal surgery was associated with an almost four times higher infection rate (OR = 3.7, 95% BI = 1.6–8.6). The risk of SSI increased with the number of levels fused, patients with diabetes had an almost six times higher risk and smokers had more than a two times higher risk for deep SSI. The most common organism cultured was Staphylococcus aureus. All infected patients underwent at least one reoperation, including an open débridement and received appropriate antibiotics to treat the organism. Patients who had had a previous spinal surgery are a high-risk group for infection compared with those that never had surgery. Total costs associated with preventive measures are substantial and should be compensated by health care insurance companies by means of separate clinical pathways. High-risk patients should be informed about the increased risk of complications.


Surgical site infection Risk factors Preventive measures Spinal fusion 


  1. 1.
    Ahn N, Klug R, Nho S et al (2002) Smoking, smoking cessation, and wound complications after lumbar spine surgery. The Spine Journal 2(5), 113–114 (Abstract)Google Scholar
  2. 2.
    Ammerlaan HS, Kluytmans JA, Wertheim HF et al (2009) Eradication of methicillin-resistant Staphylococcus aureus carriage: a systematic review. Clin Infect Dis 48:922–930CrossRefPubMedGoogle Scholar
  3. 3.
    Brown EM, Pople IK, de Louvois J et al (2004) Spine update: prevention of postoperative infection in patients undergoing spinal surgery. Spine (Phila Pa 1976.) 29:938–945Google Scholar
  4. 4.
    Chen S, Anderson MV, Cheng WK et al (2009) Diabetes associated with increased surgical site infections in spinal arthrodesis. Clin Orthop Relat Res 467:1670–1673CrossRefPubMedGoogle Scholar
  5. 5.
    Fang A, Hu SS, Endres N et al (2005) Risk factors for infection after spinal surgery. Spine 30:1460–1465CrossRefPubMedGoogle Scholar
  6. 6.
    Hellbusch LC, Helzer-Julin M, Doran SE et al (2008) Single-dose vs multiple-dose antibiotic prophylaxis in instrumented lumbar fusion–a prospective study. Surg Neurol 70:622–627CrossRefPubMedGoogle Scholar
  7. 7.
    Ho C, Sucato DJ, Richards BS (2007) Risk factors for the development of delayed infections following posterior spinal fusion and instrumentation in adolescent idiopathic scoliosis patients. Spine 32:2272–2277CrossRefPubMedGoogle Scholar
  8. 8.
    Kao LS, Meeks D, Moyer VA et al (2009) Peri-operative glycaemic control regimens for preventing surgical site infections in adults. Cochrane Database Syst Rev 8(3):CD006806Google Scholar
  9. 9.
    Massie JB, Heller JG, Abitbol JJ et al (1992) Postoperative posterior spinal wound infections. Clin Orthop Relat Res 284:99–108Google Scholar
  10. 10.
    Mok JM, Guillaume TJ, Talu U et al (2009) Clinical outcome of deep wound infection after instrumented posterior spinal fusion: a matched cohort analysis. Spine (Phila Pa 1976.) 34:578–583Google Scholar
  11. 11.
    Muilwijk J, van den Hof S, Wille JC (2007) Associations between surgical site infection risk and hospital operation volume and surgeon operation volume among hospitals in the Dutch nosocomial infection surveillance network. Infect Control Hosp Epidemiol 28:557–563Google Scholar
  12. 12.
    Muilwijk J, Walenkamp GH, Voss A et al (2006) Random effect modelling of patient-related risk factors in orthopaedic procedures: results from the Dutch nosocomial infection surveillance network ‘PREZIES’. J Hosp Infect 62:319–326CrossRefPubMedGoogle Scholar
  13. 13.
    Olsen MA, Mayfield J, Lauryssen C et al (2003) Risk factors for surgical site infection in spinal surgery. J Neurosurg 98:149–155PubMedGoogle Scholar
  14. 14.
    Olsen MA, Nepple JJ, Riew KD et al (2008) Risk factors for surgical site infection following orthopaedic spinal operations. J Bone Joint Surg Am 90:62–69CrossRefPubMedGoogle Scholar
  15. 15.
    Prokuski L (2008) Prophylactic antibiotics in orthopaedic surgery. J Am Acad Orthop Surg 16:283–293PubMedGoogle Scholar
  16. 16.
    Sasso RC, Garrido BJ (2008) Postoperative spinal wound infections. J Am Acad Orthop Surg 16:330–337PubMedGoogle Scholar
  17. 17.
    Thomsen T, Tonnesen H, Moller AM (2009) Effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation. Br J Surg 96:451–461CrossRefPubMedGoogle Scholar
  18. 18.
    Urban JA (2006) Cost analysis of surgical site infections. Surg Infect (Larchmt.) 7(Suppl 1):S19–S22CrossRefGoogle Scholar
  19. 19.
    van Rijen M, Bonten M, Wenzel R et al (2008) Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers. Cochrane Database Syst Rev 8(4):CD006216Google Scholar
  20. 20.
    Watters WC III, Baisden J, Bono CM et al (2009) Antibiotic prophylaxis in spine surgery: an evidence-based clinical guideline for the use of prophylactic antibiotics in spine surgery. Spine J 9:142–146CrossRefPubMedGoogle Scholar
  21. 21.
    Weinstein MA, McCabe JP, Cammisa FP Jr (2000) Postoperative spinal wound infection: a review of 2,391 consecutive index procedures. J Spinal Disord 13:422–426CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • J. J. P. Schimmel
    • 1
    Email author
  • P. P. Horsting
    • 2
  • M. de Kleuver
    • 2
  • G. Wonders
    • 1
  • J. van Limbeek
    • 1
  1. 1.Department of Research Development and EducationSint MaartenskliniekNijmegenThe Netherlands
  2. 2.Department of OrthopaedicsSint MaartenskliniekNijmegenThe Netherlands

Personalised recommendations