Skip to main content

Management and outcome of spinal implant-associated surgical site infections in patients with posterior instrumentation: analysis of 176 cases



The management of implant-associated surgical site infections (SSI) in patients with posterior instrumentation is challenging. Evidence regarding the most appropriate treatment and the need for removal of implants is equivocal. We sought to evaluate the management and outcome of such patients at our institution.


We searched our prospectively documented databases for eligible patients with posterior spinal instrumentation, excluding the cervical spine (January 2008–June 2018). Patient files were reviewed, demographic data and treatment details were recorded. Patient-reported outcome (PRO) was assessed with the Core Outcome Measures Index (COMI) preoperatively and postoperatively at 3 and 12 months.


A total of 170 patients underwent 210 revisions for 176 SSIs. Two-thirds presented within four weeks (105/176, 59.7%, median 22.5d, 7d–11.1y). The most common pathogens were Staphylococcus aureus (n = 79/210, 37.6%) and Staphylococcus epidermidis (n = 56/210, 26.7%). Debridement and implant retention was performed in 135/210 (64.3%) revisions and partial replacement in 62/210 (29.5%). In 28/176 SSI (15.9%), persistent infection required multiple revisions (≤ 4). Surgery was followed by intravenous and oral antimicrobial treatment (10–12w). In 139/176 SSIs (79%) with ≥ 1y follow-up, infection was cured in 115/139 (82.7%); relapse occurred in 9 (relapse rate: 5.1%). Two patients (1.4%) died. COMI decreased significantly (8.2 ± 1.5 vs. 4.8 ± 2.9, p < 0.0001) over 12 months. 72.7% of patients were (very) satisfied with their care.


Patients with SSI after posterior (thoraco-)lumbo(-sacral) instrumentation can be successfully treated in most cases with surgical and specific antibiotic treatment. An interdisciplinary approach is recommended. Loose implants should be replaced. In some cases, multiple revisions may be necessary. Patient outcomes were satisfactory.

This is a preview of subscription content, access via your institution.

Fig. 1

Availability of data and material

Data can be made available in an anonymized fashion upon request to the corresponding author.

Code availability

Not applicable.


  1. Chaichana KL, Bydon M, Santiago-Dieppa DR, Hwang L, McLoughlin G, Sciubba DM, Wolinsky JP, Bydon A, Gokaslan ZL, Witham T (2014) Risk of infection following posterior instrumented lumbar fusion for degenerative spine disease in 817 consecutive cases. J Neurosurg Spine 20:45–52.

    Article  PubMed  Google Scholar 

  2. Yeramaneni S, Gum JL, Carreon LY, Klineberg EO, Smith JS, Jain A, Hostin RA (2018) Impact of readmissions in episodic care of adult spinal deformity: event-based cost analysis of 695 consecutive cases. J Bone Joint Surg Am 100:487–495.

    Article  PubMed  Google Scholar 

  3. Yeramaneni S, Robinson C, Hostin R (2016) Impact of spine surgery complications on costs associated with management of adult spinal deformity. Curr Rev Musculoskelet Med 9:327–332.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Ahmed R, Greenlee JD, Traynelis VC (2012) Preservation of spinal instrumentation after development of postoperative bacterial infections in patients undergoing spinal arthrodesis. J Spinal Disord Tech 25:299–302.

    Article  PubMed  Google Scholar 

  5. Sierra-Hoffman M, Jinadatha C, Carpenter JL, Rahm M (2010) Postoperative instrumented spine infections: a retrospective review. South Med J 103:25–30.

    Article  PubMed  Google Scholar 

  6. Chen SH, Lee CH, Huang KC, Hsieh PH, Tsai SY (2015) Postoperative wound infection after posterior spinal instrumentation: analysis of long-term treatment outcomes. Eur Spine J 24:561–570.

    Article  PubMed  Google Scholar 

  7. Viola RW, King HA, Adler SM, Wilson CB (1997) Delayed infection after elective spinal instrumentation and fusion. A retrospective analysis of eight cases. Spine (Phila Pa 1976) 22:2444–2450; discussion 2450–2441.

  8. Picada R, Winter RB, Lonstein JE, Denis F, Pinto MR, Smith MD, Perra JH (2000) Postoperative deep wound infection in adults after posterior lumbosacral spine fusion with instrumentation: incidence and management. J Spinal Disord 13:42–45.

    CAS  Article  PubMed  Google Scholar 

  9. Maruo K, Berven SH (2014) Outcome and treatment of postoperative spine surgical site infections: predictors of treatment success and failure. J Orthop Sci 19:398–404.

    CAS  Article  PubMed  Google Scholar 

  10. Richards BR, Emara KM (2001) Delayed infections after posterior TSRH spinal instrumentation for idiopathic scoliosis: revisited. Spine (Phila Pa 1976) 26:1990–1996.

    CAS  Article  Google Scholar 

  11. Randall G, Lagunoff M, Roizman B (1997) The product of ORF O located within the domain of herpes simplex virus 1 genome transcribed during latent infection binds to and inhibits in vitro binding of infected cell protein 4 to its cognate DNA site. Proc Natl Acad Sci U S A 94:10379–10384.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  12. Kim JI, Suh KT, Kim SJ, Lee JS (2010) Implant removal for the management of infection after instrumented spinal fusion. J Spinal Disord Tech 23:258–265.

    Article  PubMed  Google Scholar 

  13. Bodmann K-F GB, Kresken M, Derendorf H, Stahlmann R, Ott SR, Olzowy B, Eckmann C, Wagenlehner F, Sunderkötter C, Vossen MG, Dohmen PM, Shah PM, Mutters R, Walger P, Wilke M für die Expertenkommission* (2019) S2k Leitlinie: Kalkulierte parenterale Initialtherapie bakterieller Erkrankungen bei Erwachsenen – Update 2018. In. pp. 233–234

  14. Mannion AF, Porchet F, Kleinstuck FS, Lattig F, Jeszenszky D, Bartanusz V, Dvorak J, Grob D (2009) The quality of spine surgery from the patient’s perspective: part 2. Minimal clinically important difference for improvement and deterioration as measured with the Core Outcome Measures Index. Eur Spine J 18(Suppl 3):374–379.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Mannion AF, Porchet F, Kleinstuck FS, Lattig F, Jeszenszky D, Bartanusz V, Dvorak J, Grob D (2009) The quality of spine surgery from the patient’s perspective. Part 1: the Core Outcome Measures Index in clinical practice. Eur Spine J 18(Suppl 3):367–373.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Carlsson AM (1983) Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain 16:87–101.

    Article  PubMed  Google Scholar 

  17. Parker SL, Adogwa O, Paul AR, Anderson WN, Aaronson O, Cheng JS, McGirt MJ (2011) Utility of minimum clinically important difference in assessing pain, disability, and health state after transforaminal lumbar interbody fusion for degenerative lumbar spondylolisthesis. J Neurosurg Spine 14:598–604.

    Article  PubMed  Google Scholar 

  18. Kasliwal MK, Tan LA, Traynelis VC (2013) Infection with spinal instrumentation: review of pathogenesis, diagnosis, prevention, and management. Surg Neurol Int 4:S392-403.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Schairer WW, Carrer A, Deviren V, Hu SS, Takemoto S, Mummaneni P, Chou D, Ames C, Burch S, Tay B, Sawyer A, Berven SH (2013) Hospital readmission after spine fusion for adult spinal deformity. Spine (Phila Pa 1976) 38:1681–1689.

    Article  Google Scholar 

  20. Blumberg TJ, Woelber E, Bellabarba C, Bransford R, Spina N (2018) Predictors of increased cost and length of stay in the treatment of postoperative spine surgical site infection. Spine J 18:300–306.

    Article  PubMed  Google Scholar 

  21. Dapunt U, Burkle C, Gunther F, Pepke W, Hemmer S, Akbar M (2017) Surgical site infections following instrumented stabilization of the spine. Ther Clin Risk Manag 13:1239–1245.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  22. Falavigna A, Righesso O, Traynelis VC, Teles AR, da Silva PG (2011) Effect of deep wound infection following lumbar arthrodesis for degenerative disc disease on long-term outcome: a prospective study: clinical article. J Neurosurg Spine 15:399–403.

    Article  PubMed  Google Scholar 

  23. Petilon JM, Glassman SD, Dimar JR, Carreon LY (2012) Clinical outcomes after lumbar fusion complicated by deep wound infection: a case-control study. Spine (Phila Pa 1976) 37:1370–1374.

    Article  Google Scholar 

  24. Atesok K, Vaccaro A, Stippler M, Striano BM, Carr M, Heffernan M, Theiss S, Papavassiliou E (2019) Fate of hardware in spinal infections. Surg Infect (Larchmt).

    Article  Google Scholar 

  25. Wang TY, Back AG, Hompe E, Wall K, Gottfried ON (2017) Impact of surgical site infection and surgical debridement on lumbar arthrodesis: a single-institution analysis of incidence and risk factors. J Clin Neurosci 39:164–169.

    Article  PubMed  Google Scholar 

  26. Forsth P, Olafsson G, Carlsson T, Frost A, Borgstrom F, Fritzell P, Ohagen P, Michaelsson K, Sanden B (2016) A randomized, controlled trial of fusion surgery for lumbar spinal stenosis. N Engl J Med 374:1413–1423.

    CAS  Article  PubMed  Google Scholar 

  27. Ghogawala Z, Dziura J, Butler WE, Dai F, Terrin N, Magge SN, Coumans JV, Harrington JF, Amin-Hanjani S, Schwartz JS, Sonntag VK, Barker FG 2nd, Benzel EC (2016) Laminectomy plus fusion versus laminectomy alone for lumbar spondylolisthesis. N Engl J Med 374:1424–1434.

    CAS  Article  PubMed  Google Scholar 

  28. Haddad S, Nunez-Pereira S, Pigrau C, Rodriguez-Pardo D, Vila-Casademunt A, Alanay A, Acaroglu ER, Kleinstueck FS, Obeid I, Perez-Grueso FJS, Pellise F, European Spine Study G (2018) The impact of deep surgical site infection on surgical outcomes after posterior adult spinal deformity surgery: a matched control study. Eur Spine J 27:2518-2528.

  29. Parker SL, Mendenhall SK, Shau D, Adogwa O, Cheng JS, Anderson WN, Devin CJ, McGirt MJ (2012) Determination of minimum clinically important difference in pain, disability, and quality of life after extension of fusion for adjacent-segment disease. J Neurosurg Spine 16:61–67.

    Article  PubMed  Google Scholar 

Download references


No funding has been received for this study.

Author information

Authors and Affiliations



A-KH, DB, TP, ML, NE, MV, YA, AFM, DOR have collected the data. A-KH performed the statistical analyses with the aid of AFM. A-KH, YA, TF, DJ, and DH have outlined the study plan. A-KH has written the manuscript draft. All authors have repeatedly reviewed the manuscript and consent to its publication.

Corresponding author

Correspondence to Anne-Katrin Hickmann.

Ethics declarations

Conflict of interest

A.-K. Hickmann is a consultant to BrainLab. D. Jeszensky is a consultant to DePuy Synthes Spine and Medacta Spine. D. Bratelj, T. Pirvu, M. Loibl, A. F. Mannion, D. O’Riordan, T. Fekete, N. Eberhard, Markus Vogt, Y. Achermann, D. Haschtmann have no conflicts of interest to declare.

Ethical approval

The local ethics committee approved the study (Kantonale Ethikkommission Zürich, Basec-Nr. 2018-00635). It was conducted in accordance with the Declaration of Helsinki, as well as with local and national standards. All patients provided general consent for using their routinely collected data for research before prospective data collection.

Consent to participate

All patients have consented to collection and scientific analysis of their data.

Consent for publication

All patients have consented to anonymous publication of their data.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Hickmann, AK., Bratelj, D., Pirvu, T. et al. Management and outcome of spinal implant-associated surgical site infections in patients with posterior instrumentation: analysis of 176 cases. Eur Spine J 31, 489–499 (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Surgical site infection
  • Spine
  • Fusion surgery
  • Outcome
  • Quality of life