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CHAPTER

151 Sumeet Garg


Jacob M. Buchowski

Postoperative Early and Late


Wound/Implant Infections

INTRODUCTION for degenerative scoliosis and spinal deformity. The latest


National Nosocomial Infections Surveillance report from the
Postoperative infection is one of the most frequent complica- federal CDC over a 12-year period reported an infection rate of
tions following spinal surgery for both degenerative diseases 2.1% following spinal fusion and 1.25% after laminectomy.
and deformity. Infections can range from superficial infections Postoperative spinal infection results in an increased pseudart-
to deep abscesses with systemic sepsis. Often multiple trips to hrosis rate, lengthier hospital stays, increased cost, and greater
the operating room are required for adequate clearance of the physical and mental burden for the patient.
infection. The burden of disease is large for both the surgeon Several large series have identified risk factors for postoper-
and the patient. Despite vast advances in the technology of spi- ative spinal infection. Many of these risk factors are intertwined
nal surgery and emergence of minimally invasive surgical tech- with each other. For example, longer surgeries intuitively will
niques, surgical site infection rates continue to be reported have a higher infection rate. Longer surgery includes those for
from 1% to 10%. tumor, involve higher blood loss, more fusion levels, and
Postoperative spinal infections can develop both early and require more assistants. These are all risk factors identified for
after several years with involvement of deep implants. Deep postoperative spinal infection in univariate analysis. Table 151.2
infection may at times necessitate removal of implants and has a summary of patient and surgeon risk factors for postop-
often requires revision fixation due to pseudarthrosis. Implants erative infection.
are usually retained in early infections to preserve spinal stabil- In an attempt to identify independent risk factors for infec-
ity and allow for fusion. Infections are almost always bacterial tion, Olsen et al reviewed the cases of 2316 consecutive ortho-
and are increasingly becoming polymicrobial and/or drug pedic spinal surgeries done at a single institution from 1998 to
resistant. The mainstay of treatment of all but some superficial 2002. The overall infection rate was 2% (46 of 2316) using the
infections is meticulous irrigation and debridement in the CDC definitions for surgical site infection. Eighteen infections
operating room with systemic treatment with intravenous anti- were superficial and the rest were either deep (20) or organ
biotics. In severe cases, infection results in a soft tissue void and space (8). These cases were compared with 227 uninfected con-
inability to close the wound. Flap coverage may be required in trol patients to identify independent risk factors for infections
these cases. using multivariate logistic regression. Typically implicated risk
Reduction of infection rates is a goal of all surgeons. Patient, factors were described including obesity, diabetes, improper
surgeon, and systemic factors may be modified in the effort to timing of prophylactic antibiotics, and a decreased risk in cervi-
reduce infection rates. A coordinated and disciplined approach cal surgery. Most notably, elevated serum glucose levels, both
to the patients medical and surgical needs after postoperative preoperatively (125 mg/dL) and postoperatively (200 mg/
spinal infection can still result in a successful outcome. dL) were also implicated with an odds ratio of 3.3. This was
independent of a diagnosis of diabetes. The authors postulate
that aggressive blood glucose control in all patients may pre-
BACKGROUND vent postoperative infection. In contrast to previous research,
there was no evidence for higher infection rates in revision sur-
There have been several large retrospective series reviewing the gery, use of instrumentation, or use of bone graft.12 Olsens
incidence and identifying risk factors for postoperative spinal group also reviewed postoperative spinal infection in a large
infection over the last decade. The Centers for Disease Control neurosurgery population. An overall infection rate of 2.8%
(CDC) defines surgical site infection as either superficial, deep, (41/1918) was described. They included 7 superficial infec-
or organ space (Fig. 151.1). Surgical site infection occurs within tions, 25 deep infections, and 9 organ space infections. Risk
30 days of surgery or 1 year of surgery if implants are placed. factors identified by multivariate analysis included postopera-
Table 151.1 lists the criteria for each of these categories.7 tive incontinence, posterior approach, tumor surgery, and mor-
Infection rates for smaller spinal procedures such as micro- bid obesity. Use of instrumentation was again not found to
scopic discectomy, simple decompressions, and single-level result in an increased infection rate. Nearly half of all culture
laminectomy are lower than that for larger procedures done positive infections were gram-negative organisms. The rate of
1608

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Chapter 151 Postoperative Early and Late Wound/Implant Infections 1609

Skin
Superficial
incisional
SSI
Subcutaneous
tissue

Deep soft tissue Deep incisional


(fascia and muscle) SSI
Figure 151.1. Definition of superficial, deep, and
organ/space surgical site infections (SSIs). (Redrawn
from Horan TC, Gaynes RP, Martone WJ, Jarvis WR,
Emori TG. CDC definitions of nosocomial surgical site Organ/Space
Organs/Space
infections, 1992: a modification of CDC definitions of SSI
surgical wound infections. Infect Control Hosp Epide-
miol 1992;13(10):606608.)

gram-negative infection was higher in those having lumbar or There are two proposed mechanisms for inoculation of spi-
lumbosacral procedures suggesting direct contamination of nal wounds leading to infection. Microorganisms can enter the
the posterior wound.11 wound either directly from the skin or operating environment
Patients with neuromuscular scoliosis have the highest rates or via hematogenous spread. A recent study evaluated intraop-
of infection and other complications after spinal procedures. A erative cultures from skin and from implants during spinal sur-
10-year multicenter review of 210 patients having spinal defor- gery and found a high rate of skin contamination. High rates of
mity surgery for neuromuscular curves identified an infection polymicrobial and gram-negative infections also suggest that
rate of 12%. The cohort included all children with either myel- direct contamination of wounds is a frequent source of infec-
odysplasia or cerebral palsy undergoing spinal fusion. Risk fac- tion. This can occur both intraoperatively as well as postopera-
tors identified for infection in this neuromuscular cohort were tively as evidenced by the association of incontinence with
increasing levels of cognitive impairment and use of allograft. infection. Common pathologic organisms are listed in Table
More than 50% of the culture positive infections were polymi- 151.3. Infections presenting months to years after surgery,
crobial, suggesting an enteric source for many of the postoper- however, are likely due to hematogenous spread. Although
ative infections. Gram-negative organisms were prevalent in infections occurring greater than 1 year after surgery do not
this series of neuromuscular patients.17 qualify as surgical site infections by the CDC guidelines, they
Trauma surgery has also been studied as a risk factor for can be just as devastating to the patient.
postoperative infection. Two recent studies by Rechtine and In a comprehensive review of spinal deformity cases done at
Blam evaluated a cohort of patients treated for spinal trauma. a single institution Buchowski et al2 found a bimodal distribu-
Rechtine reviewed the cases of 235 patients with spinal frac- tion of time to infection. Out of 58 patients with postoperative
tures treated from 1986 to 1997 at a single institution.14 Of spinal infection, 33 presented within 6 months of surgery and
these, 117 patients required surgery and 12 developed postop- 25 presented more than 6 months after surgery (10 more than
erative infection (10%). More than two thirds of all infections 3 years after surgery). Implants allow microorganisms to create
were polymicrobial. The most significant finding was that a biofilm, which offers protection from the activity of antibiot-
patients with a complete neurologic injury had a much higher ics as well as the immune system. Therefore, late infections are
rate of infection compared to those with no neurologic injury often easier to treat than acute infections since implants can
(41% vs. 5%). Blam et al1 compared a cohort of 256 patients usually be removed and the infectious burden reduced more
requiring surgery for spinal trauma with 2990 patients with rapidly. Pseudarthrosis rates, however, are similar for both
elective spinal surgery.1 The infection rate for trauma was 9.9% treated acute and chronic infections. Buchowski reported a
versus 3.7% for elective procedures. Independent risk factors pseudarthrosis rate of approximately 25% in both acute and
for infection included increased length of ICU stay, delay to chronic infections after appropriate treatment.
surgery, and a single versus combined surgical team. Half of all
infections were polymicrobial. Univariate risk factors included
those previously listed in Table 151.2. The authors postulate DIAGNOSIS
that higher infection rate was due to more severe soft tissue
injury and energy imparted to patients with neurologic injury. Superficial infections are usually diagnosed easily in the imme-
Expeditious surgery following spinal trauma and close atten- diate postoperative period by history and clinical examination.
tion to nutritional status to combat the catabolic state occur- They generally occur within the first few weeks of surgery and
ring following trauma are recommended. present with draining or nonhealing wound. In this case, the

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1610 Section XIV Complications

TABLE 151.1 Criteria for Defining a Surgical Site Infection (SSI)

Superficial Incisional SSI


Infection occurs within 30 days after the operation and infection involves only skin or subcutaneous tissue of the incision and at least one of
the following:
1. Purulent drainage, with or without laboratory confirmation, from the superficial incision.
2. Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision.
3. At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat and superficial incision
is deliberately opened by surgeon, unless incision is culture-negative.
4. Diagnosis of superficial incisional SSI by the surgeon or attending physician.
Do not report the following conditions as SSI:
1. Stitch abscess (minimal inflammation and discharge confined to the points of suture penetration).
2. Infection of an episiotomy or newborn circumcision site.
3. Infected burn wound.
4. Incisional SSI that extends into the fascial and muscle layers (see deep incisional SSI).
Note: Specific criteria are used for identifying infected episiotomy and circumcision sites and burn wounds
Deep Incisional SSI
Infection occurs within 30 days after the operation if no implant* is left in place or within 1 year if implant is in place and the infection
appears to be related to the operation and infection involves deep soft tissues (e.g., fascial and muscle layers) of the incision and at least one
of the following:
1. Purulent drainage from the deep incision but not from the organ/space component of the surgical site.
2. A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or
symptoms: fever (38C), localized pain, or tenderness, unless site is culture-negative.
3. An abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by
histopathologic or radiologic examination.
4. Diagnosis of a deep incisional SSI by a surgeon or attending physician.
Notes:
1. Report infection that involves both superficial and deep incision sites as deep incisional SSI.
2. Report an organ/space SSI that drains through the incision as a deep incisional SSI.
Organ/Space SSI
Infection occurs within 30 days after the operation if no implant* is left in place or within 1 year if implant is in place and the infection
appears to be related to the operation and infection involves any part of the anatomy (e.g., organs or spaces), other than the incision, which
was opened or manipulated during an operation and at least one of the following:
1. Purulent drainage from a drain that is placed through a stab wound into the organ/space.
2. Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space.
3. An abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by
histopathologic or radiologic examination.
4. Diagnosis of an organ/space SSI by a surgeon or attending physician.

*National Nosocomial Infection Surveillance definition: a nonhuman-derived implantable foreign body (e.g., prosthetic heart valve,
nonhuman vascular graft, mechanical heart, or hip prosthesis) that is permanently placed in a patient during surgery.

If the area around a stab wound becomes infected, it is not an SSI. It is considered a skin or soft tissue infection, depending on its depth.
Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC
definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992;13(10):606608.

Risk Factors for Postoperative Common Pathogenic


TABLE 151.2
Spinal Infection TABLE 151.3 Organisms in Postoperative
Spinal Infection
Patient Factors Surgeon Factors
Staphylococcus aureus
Advanced age Length of surgery Coagulase negative Staphylococcus
Increased body mass index Blood loss Pseudomonas aeruginosa
Tobacco use Complexity of surgery Escherichia coli
Diabetes Increased number of residents/ Corynebacterium
students Propionibacterium
Hyperglycemia (125 mg/ Posterior approach Serratia marcescens
dL preoperatively, 200 Enterobacter
mg/dL postoperatively) Tumor surgery
Malnutrition (albumin Trauma surgery
3.5 g/dL)
Postoperative incontinence Inadequate antibiotic prophylaxis
Alcohol abuse Use of steroids
Previous spinal infection
American Society of
Anesthesiologists (ASA)
Score

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Chapter 151 Postoperative Early and Late Wound/Implant Infections 1611

diagnosis is straightforward and treatment can proceed. Occa- MRI is an indispensable tool in the evaluation of acute and
sionally a superficial infection will present with erythema, delayed spinal infections. Despite metallic artifact, abscesses
warmth, and tenderness over a healed surgical incision. This can often be easily identified and their extent determined with
should prompt close clinical evaluation and most often repre- MRI. If there is compression of the spinal cord or nerve roots,
sents a postoperative infection. Palpation of the wound will this can be seen on MRI as well. Abscesses appear hyperintense
often reveal areas of fluctuance. Despite the clinical appear- on T2 imaging and will often enhance with gadolinium. In the
ance of a healed incision, fluid or pus can often be expressed case of delayed infection, MRI can demonstrate fluid collec-
in this case. Any nonhealing or draining wound should be tions around the spinal column and osteomyelitis. MRI should
probed to determine its depth. Small wounds often belie a be ordered in all cases of suspected delayed infection. Patients
deep infection. Care should be taken while probing wounds; with a clear clinical diagnosis of an acute infection do not man-
however, especially in the case of previous laminectomy since date MRI evaluation. It should be ordered if there is any neuro-
the spinal cord or nerve roots may be unprotected. A thorough logic deficit or if one is contemplating nonoperative treatment
neurologic examination should be performed. Large abscesses to rule out deep abscess. For patients going to surgery, a good
may lead to compression of the spinal cord or nerve roots. exploration obviates the need for preoperative MRI.
In the case of acute infection, fever and malaise are often Bone scans and tagged white blood cell scans are often help-
present. In severe cases, patients may even present in septic ful in the diagnosis of osteomyelitis. Bone scan identifies areas
shock requiring airway and cardiovascular support. Organ of increased bone turnover whereas tagged white blood cell
space infection in the spinal patient may present as meningi- scans identify areas of white blood cell pooling. This often cor-
tis. Laboratory evaluation will usually reveal an elevated white relates to areas of infection. Tagged ciprofloxacin scanning has
blood cell count with left shift. Erythrocyte sedimentation also been described to diagnose late infection. The tagged anti-
rate (ESR) and C-reactive protein (CRP) levels are often ele- biotic concentrates on living bacteria and can be detected using
vated and should be obtained when evaluating for infection. nuclear imaging. It has a reported sensitivity of 100%, however,
Even if the diagnosis is clear, declining ESR and CRP levels plagued by false positives when used in the acute setting.
can be used to follow resolution of infection. ESR may take Specificity is increased when evaluating for delayed infection.6
several weeks to return to normal after successful clearance Tagged positron emission tomography (PET) has also been
of infection, but CRP will drop within a matter of several found to be useful for the diagnosis of delayed infection. In a
days. prospective study of 57 patients with suspected postoperative
A recent study used white blood cell differential to assist spinal infection, the authors found the tagged PET scan to be
in the diagnosis of early infection. White blood cell counts 100% sensitive with a 100% negative predictive value. Specificity
are elevated in all patients after surgery; however, in patients was only 81%, although this was due to several false positives in
with infection they will continue to rise after postoperative patients studied within 6 months of surgery. The numbers of
day 4 instead of decreasing back to normal. Moreover, in false positives drop when evaluating only for delayed infection.4
uninfected patients the lymphocyte count returned to nor- Notably, both tagged ciprofloxacin and tagged PET scans are
mal (after dropping postoperatively as expected) by postop- not hindered by metallic implants. These technologies are
erative day 4, whereas in patients who developed infection emerging and are not yet widely available (Fig. 151.3).
the lymphocyte percentage was less than 10% until day 11.19
Blood cultures should be obtained since they may sometimes
identify a pathologic organism. Areas of fluctuance can be TREATMENT AND OUTCOMES
aspirated and sent for Gram stain and culture. If the patient
is not septic, cultures should be drawn prior to the initiation Basic principles of surgical treatment of infection apply to the
of antibiotics. spine. In most cases of early infection, irrigation and debride-
The diagnosis of a delayed infection is not usually as simple ment in the operating room is recommended to thoroughly
as an acute infection. While sometimes patients present with remove all infectious and necrotic tissue from the wound.
wound breakdown or a draining wound, often the surgical inci- Loose and infected appearing bone graft should be removed;
sion appears intact. In the latter case, infection should be sus- however, most surgeons recommend retention of well adherent
pected if the patient complains of fevers, weight loss, or deteri- bone graft that appears healthy. Surgical exploration is also rec-
oration in clinical condition after having previously been ommended to assess whether the infection is truly superficial
improved. A full laboratory evaluation should be done with or whether it penetrates deep into the superficial fascia. This
blood counts, ESR, and CRP. Blood cultures are usually less use- assessment is more easily accomplished with a wide exposure
ful in the case of chronic infection; however, they still can pro- and an anesthetized patient as compared to assessment in the
vide information if positive. clinic. Occasionally with a small superficial infection that can-
Radiologic evaluation should begin with plain radiographs. not be probed deeply one can consider treatment with local
In acute infections, these are usually normal. In the case of wound care and antibiotics. The surgeon must watch the wound
delayed infection, radiographs can be more useful. Broken closely and proceed to the operating room should the patients
implants can be a sign of pseudarthrosis, which often occurs condition worsen or not improve (Fig. 151.4).
with infection. Vertebral body or posterior element destruction After thorough irrigation and debridement, the surgeon
or lucency occurs with osteomyelitis in chronic infection. must decide whether the wound is suitable for closure in layers
Computed tomography can be used in cases of osteomyelitis to over drains or whether it should be left open. In general, clo-
assess the extent of bone destruction; however, magnetic sure in layers is recommended to prevent wound retraction. If
resonance imaging (MRI) is usually done instead since it gives repeat washout is planned, the wound should be closed loosely.
better resolution of neural and other soft tissue structure If the surgeon can achieve thorough debridement and does
(Fig. 151.2). not plan routine return to the operating room the wound

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1612 Section XIV Complications

A B

C D

Figure 151.2. A 42-year-old woman was treated for a symptomatic L5-S1 disc herniation with a microdiscectomy. The procedure was unevent-
ful and the patient had received preoperative cefazolin within 30 minutes prior to incision. She presented to the emergency department 2 weeks
later with brown fluid draining from her wound. Plain radiographs taken at the time are unremarkable (A and B). Magnetic resonance images,
however, reveal a distinct and well-defined fluid collection at the site of the laminotomy (C and D). Laboratory values included erythrocyte sedi-
mentation rate (ESR) 57, C-reactive protein (CRP) 28.3, white blood cell count 8.6. The wound was aspirated in the emergency department;
Gram stain showed gram positive cocci. Culture grew group B Streptococcus. The patient was taken for operative debridement. Intraoperative deep
cultures confirmed the pathologic organism as group B Streptococcus. The patient was treated with a 4-week course of culture-specific antibiotics.
After the antibiotic course, her wound was healed, symptoms resolved, and laboratory values included ESR 100 and CRP 1.07. As is usually the
case, the CRP returned to normal more quickly than the ESR.

should be closed tightly in layers over drains. There is little minimal output. Sewing the drains in helps prevent inadvertent
harm in a second-look return in 48 to 72 hours to the operat- dislodgement during dressing changes. Several surgeons have
ing room in the case of suspected infection and the surgeon shown good success using a combined system of indwelling irri-
should err to the side of caution if there is any concern regard- gation and suction catheters. In a series of 452 patients with
ing adequacy of the debridement. Patients should continue to spinal fusion with instrumentation Vender reported an infec-
have repeat irrigation and debridement until there is no infec- tion rate of 3.8%. All 17 patients with postoperative infection
tious or necrotic tissue encountered upon entrance of the were treated with standard surgical treatment and implantation
wound. Throughout the clinical course, the nutritional status of closed suction/irrigation systems. The irrigation fluid used
of the patient should be optimized. Often total parenteral was a solution of saline and antibiotics. The system was contin-
nutrition or dietary supplementation is required to maintain or ued until cultures from the fluid were negative. All patients suc-
restore normal nutritional parameters. cessfully resolved their infections without removal of implants,
Use of closed suction drains is recommended by most sur- although one did have recurrent infection treated successfully
geons to allow for egress of postoperative fluid and blood. This with repeat treatment with the irrigation/suction system.
decreases the functional dead space for bacteria to accumulate Systemic antibiotics were also utilized in the treatment of these
and proliferate. Drains should be left in place until there is patients.20

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Chapter 151 Postoperative Early and Late Wound/Implant Infections 1613

A B

Figure 151.3. A 67-year-old woman with cervical myelopathy was treated with a C3-C6 laminoplasty and C2-T2 instrumented posterior fusion
as shown (A). She did well initially with improvement in her neurologic symptoms, however, developed bacterial meningitis with methicillin-resis-
tant Staphylococcus aureus 4 months following her cervical procedure. To determine whether the meningitis had developed from a periprosthetic
infection a positron emission tomography (PET) scan was done since both a computed tomography (CT) scan and magnetic resonance imaging
are difficult to interpret alone due to metallic artifact. PET scan images localized an area of osteomyelitis anteriorly at C1-C2. The increased sig-
nal intensity on the PET scan (yellow in this example) is correlated to the linked CT scan for anatomic localization at the C1-C2 level (B).

Metallic implants provide a fertile home for bacteria. They ies, however, show mixed results when comparing bacterial
adhere easily to metal and form protective biofilm. Clinical colonization on stainless steel and titanium implants. In the
studies have suggested a decreased rate of implant-associated absence of overwhelming evidence, both remain appropriate
infections with titanium compared with stainless steel. The pro- choices for spinal implants and other factors such as MRI com-
posed mechanism for this argues that the increased biocompat- patibility and structural properties should be used by the sur-
ibility of titanium leads to more host growth onto the implant, geon in deciding which material to use in a given case. For
and inversely, less biofilm formation by bacteria. In vitro stud- delayed infection in a patient with a solid arthrodesis removal

Patient with suspected infection

Operative debridement
Obtain fluid/tissue cultures

Surgical treatment Medical treatment

Repeat debridement in 48hrs Empiric antibiotics


Optimize nutrition

Wound clean?
Organism identified?
No

No Yes

Yes Continue empiric antibiotics Narrow antibiotics


Based on sensitivities
Figure 151.4. Medical and surgical treatment Complete antibiotic course
algorithm for suspected wound or implant infection. No further surgery unless clinically indicated
CRP, C-reactive protein; ESR, erythrocyte sedimenta- Follow ESR/CRP
tion rate.

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1614 Section XIV Complications

of implants has been suggested to decrease the infectious bur-


den. With a solid fusion the implants are not thought to pro-
vide major structural support. Buchowski et al2 reported that C3
two thirds of patients with delayed infection had their implants Turnover paraspinal
removed during the treatment of the infection. Soultanis et al16 muscle flap
also theorized that the bulk of the implants (especially cross- Trapezius muscle flap
Latissimus muscle flap
links) contributed to the development of infection. All patients
with infection in a series of 60 patients they reported presented
with a sinus tract to a cross-link. They reported successful reso- T7 Turnover paraspinal
lution of infection after delayed infection with implant removal muscle flap
Latissimus muscle flap
along with a closed irrigation/suction system. Reverse latissimus
Removal of implants, however, is not mandatory even in the muscle flap
case of delayed infection. Interbody fusion implants can be dif- L1 Turnover paraspinal
ficult to remove, and the morbidity of removal may outweigh muscle flap
the benefits of removal. Mirovsky et al9 reported resolution of Latissimus muscle flap
eight cases of infected posterior lumbar interbody fusions with- Bipedicle latissimus
muscle and gluteus
out removal of implants. Nearly half of the 58 patients with maximus muscle flap
postoperative infection reported by Buchowski did not require S5
implant removal to clear their infection.2 Retention of implants
when feasible, however, may also be prudent. There have been
recent reports showing progression of spinal deformity, espe-
cially in the sagittal plane, after removal of implants in patients Figure 151.5. Posterior spine soft tissue coverage options based
with intraoperatively verified solid fusions.13 on location. (Redrawn from Singh K, Smartzis D, Heller JG, An HS,
With the emergence of drug-resistant bacteria and increas- Vaccaro AR. The management of complex soft-tissue defects after spi-
ing incidence of polymicrobial infection it is prudent to involve nal instrumentation. J Bone Joint Surg Br 2006;88(1):815.)
infectious disease specialists in the antibiotic management of
patients with postoperative spinal infection. A broad regimen is
recommended until culture and sensitivities have come back three times daily with standard wet-to-dry packing, which
from the laboratory. In general, a minimum of 6 weeks of intra- improves patient comfort. The system has been utilized with
venous antibiotics is used. Often this is supplemented with oral success in postoperative spinal infection and may reduce prob-
antibiotics to offer synergistic action against microorganisms. lems with soft tissue coverage. New sponges have recently been
After final surgical closure of the wound antibiotic treatment developed, which include antimicrobial substances within the
can usually be done at home or a skilled nursing facility after substance of the sponge.
placement of an indwelling central catheter. The catheter In rare instances primary soft tissue closure is not possible
should not be placed until the surgical wound is clean to pre- after treatment of postoperative spinal infection. This almost
vent secondary line sepsis. always is for large posterior wounds following spinal arthrode-
Occasionally with massive infection closure of the surgical sis. Assistance from plastic and reconstructive surgeons is sug-
wound cannot be done either due to severe tissue loss or due to gested for obtaining soft tissue coverage. Several flaps have
excessive contamination. In the latter case, the surgeon may been described to achieve coverage of posterior spinal wounds
elect to pack the wound open due to fear of recurrent abscess after infection. The most popular are latissimus myofascial or
formation by surgical wound closure. Often the wound may still myofasciocutaneous flaps or for most distal wounds gluteus
be closed once a clean tissue bed is created after multiple surgi- maximus flaps. Figure 151.5 lists flap options for various poste-
cal washouts. Rarely the wound cannot be closed and soft tissue rior spinal regions.
flaps are needed to cover the spine and spinal implants. Overall, the literature describes good results using a variety
Recently use of the vacuum-assisted closure device (VAC, of algorithms in the treatment of postoperative spinal infec-
Kinetic Concepts Inc., San Antonio, TX) has been proposed to tion. Even with a significant pseudarthrosis rate Buchowski
improve wound healing, prevent tissue retraction, and mini- et al2 demonstrated that Oswestry and SRS-22 scores rose from
mize the need or size of soft tissue flaps. This system involves their preoperative values after resolution of infection.
placement of an open cell polyurethane foam sponge over the Numerous other authors have shown that by following basic
wound. The sponge is connected to a negative pressure suction principles of surgical treatment of infection most patients can
system to provide either constant or intermittent suction. clear their infection and go onto have good outcomes. Close
Constant suction is usually preferred due to increased patient monitoring, thorough surgical debridement, and a multidisci-
discomfort with intermittent suction. The VAC system has been plinary approach to the care of patients with postoperative spi-
used for a wide variety of wound and surgical indications with nal infection are recommended to optimize the patients out-
excellent results. The system is felt to improve wound healing, come (Table 151.4).
prevent wound retraction, and decrease infectious burden
through a variety of mechanisms. Animal studies have demon-
strated a fourfold increase in microcirculation at the site of PREVENTION
VAC application resulting in increased oxygen tension at the
wound.10 The VAC also removes waste products, decreases bac- Prevention of spinal infections can entail modification of both
terial counts, reduces tissue edema, and decreases wound size. patient and surgeon risk factors as listed in Table 151.2. From
Dressing changes occur every 48 to 72 hours instead of two to the patients perspective, weight reduction, smoking cessation,

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Chapter 151 Postoperative Early and Late Wound/Implant Infections 1615

Methods to Improve Methods of Surgical Site


TABLE 151.5
TABLE 151.4 Outcome Following Wound Infection Prophylaxis
Infection Appropriate choice and dosage of preoperative antibiotics
Administration of antibiotics within 60 min of incision
Medical Surgical
Readministration of antibiotics based on case length
Appropriate antibiotic Thorough wound debridement Readministration of antibiotics based on blood loss
coverage Limit operating room traffic
Nutritional support (enteral Serial surgical assessment Minimizing intraoperative fluoroscopy/radiographs
or parenteral) (q4872 hr) until wound clean Medical optimization of patient preoperatively
Patient mobilization Staging surgical procedures
Aggressive blood glucose Early coverage of exposed bone/ Bowel hygiene
control implants Periodic wound irrigation
Bowel hygiene Removal of implants if possible Periodic glove changes
Minimize dead space

and control of alcohol consumption all are modifiable risk fac- contamination. A first-generation cephalosporin is appropri-
tors. Patients should be counseled preoperatively of their ate and has extensive support in the literature. Anterior
higher risk of infection. Appropriate direction to assistance thoracolumbar procedures should also be covered well with a
with weight loss, smoking cessation, and alcohol treatment first-generation cephalosporin as long as there is no inadver-
should be available. If possible, these risk factors should be tent injury to the enteric system. Repeat doses should be
optimized prior to elective spinal surgery. Evaluation of nutri- given throughout surgery to maintain a therapeutic concen-
tional status should be through both biometric data and labora- tration in the circulatory system. It is advised to repeat the
tory assessment of blood counts, albumin, and prealbumin in antibiotic dose with every passing of a single half-life. Adding
any patient suspected to suffer from malnutrition. This can also a statement verifying preoperative antibiotic administration
be optimized preoperatively through use of nutritional supple- to the surgical time-out has been shown to improve compli-
ments, shakes, and diet modification. ance at achieving appropriate timing of medication delivery
Diabetic patients should have thorough endocrine evalua- within 1 hour of incision.15
tion to improve blood glucose control preoperatively. As Olsen Prophylaxis should not extend beyond 24 hours after surgery.
et al12 demonstrated, hyperglycemia is an independent risk fac- Several authors have described no benefit to extended dosing of
tor for postoperative spinal infection with an odd ratio of 3.3. antibiotics. Kanayama et al compared 1113 patients with multi-
Postoperative glycemic control should be done vigilantly by the ple doses of antibiotics for 5 to 7 days to 464 with less than
surgical team. Even in patients without diabetes, blood glucose 24 hours of antibiotics after lumbar spine surgery. All received a
should be monitored and kept within a normal range in an prophylactic dose within an hour of incision. No difference was
attempt to modify this risk factor for postoperative infection. found in the infection rate between the groups.8 Dobzyniak et al5
Research is needed to determine whether this may reduce the described similar findings in a retrospective review of more than
rates of postoperative spinal infection. 600 patients undergoing microdiscectomy. Extended duration of
Incontinence has been demonstrated to be an independent antibiotics does not seem to decrease infection rates and may
risk factor for spinal infection as well. Use of an occlusive dress- instead lead to development of resistant bacterial strains. It also
ing may prevent contamination of the wound in patients at risk places the patient at risk for side effects from the medication
for incontinence. These include patients suffering from spinal such as Clostridium difficile colitis and other drug-specific side
trauma, cerebral palsy, or other neuromuscular or syndromic effects. Antibiotics should be appropriately dosed before and
problems. A rectal tube may also decrease rates of wound con- during the surgical procedure. When using cefazolin, patients
tamination in patients with incontinence. Routine inspection weighing 80 kg should receive 2 g cefazolin preoperatively as
of the wound should be done by nursing staff throughout the opposed to 1 g. Cefazolin should also be redosed every 4 hours
postoperative period and sterile dressing changes performed if or with every 2000 mL blood loss to maintain an appropriate
there is any soilage of the dressing. serum level for antimicrobial activity.
Surgeon factors can also be modified in an attempt to Another emerging technology in spinal fusion surgery may
reduce infection rates (Table 151.5). All members of the sur- also play a role in the prevention of infection. The use of bone
gical team must adhere to strict antiseptic technique. Routine morphogenic protein (BMP) has been increasing worldwide
wound irrigation, regular glove changes, and limiting traffic to assist with spinal fusion. Use in spinal surgery, with the
in the operating room are recommended. Many of the risk exception of anterior lumbar interbody fusion with threaded
factors listed in Table 151.2 are related to length of surgery, cages, remains off-label. In an animal model, the use of BMP
which is dictated by the complexity of the procedure and not in addition to antibiotics was able to achieve healing in a femur
easily modifiable. The most well studied surgeon risk factor is fracture after inoculation of the fracture with Staphylococcus
use of prophylactic antibiotics. Use of prophylactic antibiot- aureus.3 Human studies have also demonstrated a nearly 50%
ics to prevent surgical site infection has been well studied reduced risk of infection in grade III open tibia fractures
among many surgical disciplines. It has been demonstrated treated with reamed intramedullary nail fixation and BMP
that in order to be effective antibiotics must be given within insertion at the fracture site.18 It remains to be seen whether
1 hour of surgical incision. Prophylactic antibiotics for these findings will translate to reduced infection rates after
posterior spinal procedures should protect against skin spinal surgery.

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1616 Section XIV Complications

5. Dobzyniak MA, Fischgrund JS, Hankins S, Herkowitz HN. Single versus multiple dose anti-
CONCLUSION biotic prophylaxis in lumbar disc surgery. Spine 2003;28(21):E453E455.
6. Gemmel F, De Winter F, Van Laere K, Vogelaers D, Uyttendaele D, Dierckx RA. 99mTc
Postoperative spinal infection can be a devastating complica- ciprofloxacin imaging for the diagnosis of infection in the postoperative spine. Nucl Med
Commun 2004;25(3):277283.
tion for a patient resulting in increased morbidity and mortal- 7. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial
ity. The resultant increased length of stay and costs are a surgical site infections, 1992: a modification of CDC definitions of surgical wound infec-
tions. Infect Control Hosp Epidemiol 1992;13(10):606608.
significant burden for individual patients, hospitals, and soci- 8. Kanayama M, Hashimoto T, Shigenobu K, Oha F, Togawa D. Effective prevention of
ety. Adherence to well-established surgical principles offers the surgical site infection using a Centers for Disease Control and Prevention guideline-
best chance at resolution of infection. Medical and even critical based antimicrobial prophylaxis in lumbar spine surgery. J Neurosurg Spine 2007;6(4):
327329.
care support may be required for acute infection and sepsis. 9. Mirovsky Y, Floman Y, Smorgick Y, et al. Management of deep wound infection after poste-
Appropriate choice and delivery of antibiotics is also necessary rior lumbar interbody fusion with cages. J Spinal Disord Tech 2007;20(2):127131.
to eradicate infection. A multidisciplinary approach is often 10. Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W. Vacuum-assisted closure: a new
method for wound control and treatment: animal studies and basic foundation. Ann Plast
necessary to provide the best outcome for the patient. Infection Surg 1997;38(6):553562.
complicates up to 10% of all spinal operations and affects all 11. Olsen MA, Mayfield J, Lauryssen C, et al. Risk factors for surgical site infection in spinal
surgery. J Neurosurg 2003;98(2 Suppl):149155.
patient populations undergoing treatment. Although there 12. Olsen MA, Nepple JJ, Riew KD, et al. Risk factors for surgical site infection following ortho-
have been several identified patient and surgeon risk factors, paedic spinal operations. J Bone Joint Surg Am 2008;90(1):6269.
there has been little improvement in infection rates over the 13. Rathjen K, Wood M, McClung A, Vest Z. Clinical and radiographic results after implant
removal in idiopathic scoliosis. Spine 2007;32(20):21842188.
past decade. Prevention of postoperative infection remains a 14. Rechtine GR, Bono PL, Cahill D, Bolesta MJ, Chrin AM. Postoperative wound infection
challenge and research continues to find solutions to reduce after instrumentation of thoracic and lumbar fractures. J Orthop Trauma 2001;15(8):
the rate of this often crippling complication. 566569.
15. Rosenberg AD, Wambold D, Kraemer L, et al. Ensuring appropriate timing of antimicro-
bial prophylaxis. J Bone Joint Surg Am 2008;90(2):226232.
16. Soultanis K, Mantelos G, Pagiatakis A, Soucacos PN. Late infection in patients with scoliosis
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4. De Winter F, Gemmel F, Van De Wiele C, Poffijn B, Uyttendaele D, Dierckx R. 18-Fluorine 20. Vender JR, Hester S, Houle PJ, Choudhri HF, Rekito A, McDonnell DE. The use of closed-
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