Abstract
Purpose
Postoperative surgical site infection in patients treated with lumbosacral fusion has usually been thought to be caused by perioperative contamination. With the proximity of these incisions to the perineum, this study sought to determine if contamination by gastrointestinal and/or urogenital flora should be considered as a major cause of this complication.
Methods
We conducted a retrospective review of adults treated with open posterior lumbosacral fusions between 2014 and 2021 to identify common factors in deep postoperative infection and the nature of the infecting organisms. Cases of tumor, primary infection and minimally invasive surgery were excluded.
Results
489 eligible patients were identified, 20 of which required debridement deep to the fascia (4.1%). Mean age, operative time, estimated blood loss and levels fused were similar between both groups. The infected group had a significantly higher BMI. The mean time from primary procedure to debridement was 40.8 days. Four patients showed no growth, 3 showed Staphylococcus sp. infection (Perioperative Inside–Out) requiring debridement at 63.5 days. Thirteen showed infection with intestinal or urogenital pathogens (Postoperative Outside–In) requiring debridement at 20.0 days. Postoperative Outside–In infections led to debridement 80.3 days earlier than Perioperative Inside–Out infections (p = 0.007).
Conclusions
65% of deep infections in patients undergoing open lumbosacral fusion were due to early contamination by pathogens associated with the gastrointestinal and/or urogenital tracts. These required earlier debridement than Staphylococcus sp. infections. There should be renewed focus on keeping these pathogens away from the incision during the early stages of wound healing.
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Data availability
Data is made available through direct communication with the corresponding author.
Code availability
Not applicable.
References
Atesok K, Papavassiliou E, Heffernan MJ et al (2020) Current strategies in prevention of postoperative infections in spine surgery. Global Spine J. https://doi.org/10.1177/2192568218819817
Petilon JM, Glassman SD, Dimar JR et al (2012) Clinical outcomes after lumbar fusion complicated by deep wound infection: a case-control study. Spine. https://doi.org/10.1097/BRS.0b013e31824a4d93
Calderone RR, Garland DE, Capen DA et al (1996) Cost of medical care for postoperative spinal infections. Orthop Clin North Am 27(1):71–182
Casper DS, Zmistowski B, Hollern DA et al (2018) The effect of postoperative spinal infections on patient mortality. Spine. https://doi.org/10.1097/BRS.0000000000002277
Barnes S, Spencer M, Graham D et al (2014) Surgical wound irrigation: a call for evidence-based standardization of practice. Am J Infect Control. https://doi.org/10.1016/j.ajic.2014.01.012
Savage JW, Weatherford BM, Sugrue PA et al (2012) Efficacy of surgical preparation solutions in lumbar spine surgery. J Bone Joint Surg Am. https://doi.org/10.2106/JBJS.K.00471
Ahn DK, Park HS, Kim TW et al (2013) The degree of bacterial contamination while performing spine surgery. Asian Spine J. https://doi.org/10.4184/asj.2013.7.1.8
Pesenti S, Pannu T, Andres-Bergos J et al (2018) What are the risk factors for surgical site infection after spinal fusion? A meta-analysis. Eur Spine J. https://doi.org/10.1007/s00586-018-5733-7
Xing D, Ma JX, Ma XL et al (2013) A methodological, systematic review of evidence-based independent risk factors for surgical site infections after spinal surgery. Eur Spine J. https://doi.org/10.1007/s00586-012-2514-6
Manian FA (2014) The role of postoperative factors in surgical site infections: time to take notice. Clin Infect Dis. https://doi.org/10.1093/cid/ciu552
Tan T, Lee H, Huang MS et al (2020) Prophylactic postoperative measures to minimize surgical site infections in spine surgery: systematic review and evidence summary. Spine J. https://doi.org/10.1016/j.spinee.2019.09.013
Shillingford JN, Laratta JL, Reddy H et al (2018) Postoperative surgical site infection after spine surgery: an update from the scoliosis research society (SRS) morbidity and mortality database. Spine Deform. https://doi.org/10.1016/j.jspd.2018.04.004
Weinstein MA, McCabe JP, Cammisa FP Jr (2000) Postoperative spinal wound infection: a review of 2,391 consecutive index procedures. J Spinal Disord. https://doi.org/10.1097/00002517-200010000-00009
Horwitz NH, Curtin JA (1975) Prophylactic antibiotics and wound infections following laminectomy for lumber disc herniation. J Neurosurg. https://doi.org/10.3171/jns.1975.43.6.0727
Bains RS, Kardile M, Mitsunaga LK et al (2017) Postoperative spine dressing changes are unnecessary. Spine Deform. https://doi.org/10.1016/j.jspd.2017.04.005
Christodoulou AG, Givissis P, Symeonidis PD et al (2006) Reduction of postoperative spinal infections based on an etiologic protocol. Clin Orthop Relat Res. https://doi.org/10.1097/01.blo.0000201174.10506.cc
CDC and Healthcare Infection Control Practices Advisory. Surgical Site Infection (SSI) Event. Available: https://apic.org/Resource_/TinyMceFileManager/Academy/ASC_101_resources/Surveillance_NHSN/NHSN_9pscSSIcurrent_jan2015.pdf; cited: 26th August.2022;
Weihe R, Taghlabi K, Lowrance M et al (2022) Culture yield in the diagnosis of native vertebral osteomyelitis: a single tertiary center retrospective case series with literature review. Open Forum Infect Dis. https://doi.org/10.1093/ofid/ofac026
Kremers HM, Nwojo ME, Ransom JE et al (2015) Trends in the epidemiology of osteomyelitis: a population-based study, 1969 to 2009. JBJS. https://doi.org/10.2106/jbjs.N.01350
Soroceanu A, Burton DC, Diebo BG et al (2015) Impact of obesity on complications, infection, and patient-reported outcomes in adult spinal deformity surgery. J Neurosurg Spine. https://doi.org/10.3171/2015.3.Spine14743
Long DR, Bryson-Cahn C, Pergamit R et al (2021) Young investigator award winner: anatomic gradients in the microbiology of spinal fusion surgical site infection and resistance to surgical antimicrobial prophylaxis. Spine. https://doi.org/10.1097/BRS.0000000000003603
Mackenzie WG, Matsumoto H, Williams BA et al (2013) Surgical site infection following spinal instrumentation for scoliosis: a multicenter analysis of rates, risk factors, and pathogens. J Bone Joint Surg Am. https://doi.org/10.2106/JBJS.L.00010
Croft LD, Pottinger JM, Chiang HY et al (2015) Risk factors for surgical site infections after pediatric spine operations. Spine. https://doi.org/10.1097/BRS.0000000000000693
Jaber A, Hemmer S, Klotz R et al (2021) Bowel dysfunction after elective spinal surgery: etiology, diagnostics and management based on the medical literature and experience in a university hospital. Orthopade. https://doi.org/10.1007/s00132-020-04034-z
Worm PV, Finger G, Brasil AVB et al (2019) Postoperative supine position increases the risk of infection after spinal surgery by posterior approach. World Neurosurg. https://doi.org/10.1016/j.wneu.2019.02.098
Togawa D, Hasegawa T, Yamato Y et al (2018) Postoperative disability after long corrective fusion to the pelvis in elderly patients with spinal deformity. Spine. https://doi.org/10.1097/BRS.0000000000002540
Kirsner RS, Eaglstein WH (1993) The wound healing process. Dermatol Clin 11:629–640
Rocos B, Blom AW, Bowker K (2010) Cyanoacrylate dressings: are they microbiologically impermeable? J Hosp Infect. https://doi.org/10.1016/j.jhin.2010.01.008
Tan T, Rutges J, Marion T et al (2020) Cyanoacrylate dermal closure in spine surgery: systematic review and pooled analysis. Global Spine J. https://doi.org/10.1177/2192568219861619
Yao R, Tan T, Tee JW et al (2018) Prophylaxis of surgical site infection in adult spine surgery: a systematic review. J Clin Neurosci. https://doi.org/10.1016/j.jocn.2018.03.023
Solla F, Lefebvre R, Clement JL et al (2021) Prevention of surgical site infections in pediatric spines: a single-center experience. Childs Nerv Syst. https://doi.org/10.1007/s00381-021-05095-x
Andrew Glennie R, Dea N, Street JT (2015) Dressings and drains in posterior spine surgery and their effect on wound complications. J Clin Neurosci. https://doi.org/10.1016/j.jocn.2015.01.009
Schar RT, Jesse CM, Montalbetti M et al (2021) Negligible systemic uptake of suprafascial vancomycin powder following instrumented posterior spinal fusion-preliminary results from a randomized clinical trial (VANCO Trial). Neurosurgery. https://doi.org/10.1093/neuros/nyab362
Macki M, Hamilton T, Lim S et al (2021) The role of postoperative antibiotic duration on surgical site infection after lumbar surgery. J Neurosurg Spine. https://doi.org/10.3171/2021.4.SPINE201839
Street JT, Lenehan BJ, DiPaola CP et al (2012) Morbidity and mortality of major adult spinal surgery a prospective cohort analysis of 942 consecutive patients. Spine J. https://doi.org/10.1016/j.spinee.2011.12.003
Zhang X, Liu P, You J (2022) Risk factors for surgical site infection following spinal surgery: a meta-analysis. Medicine. https://doi.org/10.1097/md.0000000000028836
Kalevski SK, Peev NA, Haritonov DG (2010) Incidental dural tears in lumbar decompressive surgery: incidence, causes, treatment, results. Asian J Neurosurg 5:54–59
Puvanesarajah V, Hassanzadeh H (2017) The true cost of a dural tear: medical and economic ramifications of incidental durotomy during lumbar discectomy in elderly medicare beneficiaries. Spine. https://doi.org/10.1097/brs.0000000000001895
Takenaka S, Makino T, Sakai Y et al (2019) Dural tear is associated with an increased rate of other perioperative complications in primary lumbar spine surgery for degenerative diseases. Medicine. https://doi.org/10.1097/md.0000000000013970
Yoshihara H, Yoneoka D (2013) Incidental dural tear in lumbar spinal decompression and discectomy: analysis of a nationwide database. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-013-1843-1
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BR MD FRCS (Tr & Orth) Data collection, analysis and manuscript preparation. Approved final manuscript. BD Data collection and analysis. Approved final manuscript. LR Data collection and analysis. Approved final manuscript. YRR MD, FRCS(C) Data collection and analysis. Approved final manuscript. CN MD FRCS(C) Data collection and analysis. Approved final manuscript. FJ MD FRCS(C) Data collection and analysis. Approved final manuscript. AV MD MAS FRCPC Data collection and analysis. Approved final manuscript. SJL MD MSc FRCS(C) Study conception, manuscript preparation, Approved final manuscript.
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SL receives grant funding from AO Spine, Scoliosis Research Society and the British Scoliosis Research Foundation; Instrument design royalties from Medtronic and has leadership roles in AO Knowledge Forum Deformity and the Scoliosis Research Society. BR, BD, LR, YRR, CN, FJ, AV have no declarations.
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Rocos, B., Davidson, B., Rabinovitch, L. et al. Local contamination is a major cause of early deep wound infections following open posterior lumbosacral fusions. Spine Deform 11, 1209–1221 (2023). https://doi.org/10.1007/s43390-023-00694-x
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DOI: https://doi.org/10.1007/s43390-023-00694-x