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

Abstract

Purpose

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.

Methods

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.

Results

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.

Conclusion

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.

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Availability of data and material

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

Code availability

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Funding

No funding has been received for this study.

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Authors and Affiliations

Authors

Contributions

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.

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

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All patients have consented to anonymous publication of their data.

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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). https://doi.org/10.1007/s00586-021-06978-y

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  • DOI: https://doi.org/10.1007/s00586-021-06978-y

Keywords

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