Skip to main content

Advertisement

SpringerLink
Log in

Postoperative infections of the lumbar spine: presentation and management

  • Review Article
  • Published:
International Orthopaedics Aims and scope Submit manuscript

Abstract

Purpose

Postoperative surgical site infections (SSI) are a frequent complication following posterior lumbar spinal surgery. In this manuscript we review strategies for prevention, diagnosis and treatment of SSI.

Methods

The literature was reviewed using the Pubmed database.

Results

We identified fifty-nine relevant manuscripts almost exclusively composed of Level III and IV studies.

Conclusions

Risk factors for SSI include: 1) factors related to the nature of the spinal pathology and the surgical procedure and 2) factors related to the systemic health of the patient. Staphylococcus aureus is the most common infectious organism in reported series. Proven methods to prevent SSI include prophylactic antibiotics, meticulous adherence to aseptic technique and frequent release of retractors to prevent myonecrosis. The presentation of SSI is varied depending on the virulence of the infectious organism. Frequently, increasing pain is the only presenting complaint and can lead to a delay in diagnosis. Magnetic resonance imaging and the use of C-reactive protein laboratory studies are useful to establish the diagnosis. Treatment of SSI is centered on surgical debridement of all necrotic tissue and obtaining intra-operative cultures to guide antibiotic therapy. We recommend the involvement of an infectious disease specialist and use of minimum serial bactericidal titers to monitor the efficacy of antibiotic treatment. In the most cases, SSI can be adequately treated while leaving spinal instrumentation in place. For severe SSI, repeat debridement, delayed closure and involvement of a plastic surgeon may be necessary.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Bassewitz HL, Fischgrund JS, Herkowitz HN (2000) Postoperative spine infections. Semin Spine Surg 12:203–211

    Google Scholar 

  2. Wilson DH, Harbaugh R (1981) Microsurgical and standard removal of the protruded lumbar disc: A comparative study. Neurosurg 8:422–425

    Article  CAS  Google Scholar 

  3. Stolke D, Sollmann WP, Seifert V (1989) Intra- and postoperative complications in lumbar disc surgery. Spine 14:56–59

    Article  PubMed  CAS  Google Scholar 

  4. Weinstein MA, McCabe JP, Cammisa FP Jr (2000) Postoperative spinal wound infection: a review of 2,391 consecutive index procedures. J Spinal Disord 13:422–426

    Article  PubMed  CAS  Google Scholar 

  5. Weiner BK, Kilgore WB (2007) Bacterial shedding in common spine surgical procedures. Spine 32:918–920

    Article  PubMed  Google Scholar 

  6. Bible JE, O’Neill KR, Crosby CG, Schoenecker JG, McGirt MJ, Devin CJ (2011) Microscope sterility during spine surgery. Spine (Phila Pa 1976). Jun 11 [Epub ahead of print]

  7. National Nosocomial Infections Surveillance System (2004) National nosocomial infections surveillance (NNIS) system report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control 32:470–485

    Article  Google Scholar 

  8. Fang A, Hu SS, Endres N, Bradford DS (2005) Risk factors for infection after spinal surgery. Spine 30:1460–1465

    Article  PubMed  Google Scholar 

  9. Olsen MA, Mayfield J, Lauryssen C, Polish LB, Jones M, Vest J, Fraser VJ (2003) Risk factors for surgical site infection in spinal surgery. J Neurosurg 98(2 Suppl):149–155

    PubMed  Google Scholar 

  10. Olsen MA, Nepple JJ, Riew KD, Lenke LG, Bridwell KH, Mayfield J, Fraser VJ (2008) Risk factors for surgical site infection following orthopaedic spinal operations. J Bone Joint Surg Am 90:62–69

    Article  PubMed  Google Scholar 

  11. Glassman SD, Dimar JR, Puno RM, Johnson JR (1996) Salvage of instrumental lumbar fusions complicated by surgical wound infection. Spine 21:2163–2169

    Article  PubMed  CAS  Google Scholar 

  12. Pull ter Gunne AF, Cohen DB (2009) Incidence, prevalence, and analysis of risk factors for surgical site infection following adult spinal surgery. Spine 34:1422–1428

    Article  PubMed  Google Scholar 

  13. Parker SL, Adogwa O, Witham TF, Aaronson OS, Cheng J, McGirt MJ (2011) Post-operative infection after minimally invasive versus open transforaminal lumbar interbody fusion (TLIF): literature review and cost analysis. Minim Invasive Neurosurg 54:33–37

    Article  PubMed  CAS  Google Scholar 

  14. Blam OG, Vaccaro A, Vanichkachorn JS et al (2003) Risk factors for surgical site infection in the patient with spinal injury. Spine 28:1475–1480

    PubMed  Google Scholar 

  15. Koutsoumbelis S, Hughes AP, Girardi FP, Cammisa FP, Finerty EA, Nguyen JT, Gausden E, Sama AA (2011) Risk factors for postoperative infection following posterior lumbar instrumented arthrodesis. J Bone Joint Surg Am 93:1627–1633

    Article  PubMed  Google Scholar 

  16. Wimmer C, Gluch H, Franzreb M, Ogon M (1998) Predisposing factors for infection in spine surgery: a survey of 850 spinal procedures. J Spinal Disord 11:124–128

    PubMed  CAS  Google Scholar 

  17. Massie JB, Heller JG, Abitbol JJ, McPherson D, Garfin SR (1992) Postoperative posterior spinal wound infections. Clin Orthop Relat Res 284:99–108

    PubMed  Google Scholar 

  18. Levi AD, Dickman CA, Sonntag VK (1997) Management of postoperative infections after spinal instrumentation. J Neurosurg 86:975–980

    Article  PubMed  CAS  Google Scholar 

  19. Maragakis LL, Cosgrove SE, Martinez EA, Tucker MG, Cohen DB, Perl TM (2009) Intraoperative fraction of inspired oxygen is a modifiable risk factor for surgical site infection after spinal surgery. Anesthesiology 110:556–562

    Article  PubMed  Google Scholar 

  20. Cammisa FP Jr, Girardi FP, Sangani PK, Parvataneni HK, Cadag S, Sandhu HS (2000) Incidental durotomy in spine surgery. Spine 25:2663–2667

    Article  PubMed  Google Scholar 

  21. Klein JD, Hey LA, Yu CS, Klein BB, Coufal FJ, Young EP, Marshall LF, Garfin SR (1996) Perioperative nutrition and postoperative complications in patients undergoing spinal surgery. Spine 21:2676–2682

    Article  PubMed  CAS  Google Scholar 

  22. Carreon LY, Puno RM, Dimar JR 2nd, Glassman SD, Johnson JR (2003) Perioperative complications of posterior lumbar decompression and arthrodesis in older adults. J Bone Joint Surg Am 85:2089–2092

    PubMed  Google Scholar 

  23. Cassinelli EH, Eubanks J, Vogt M, Furey C, Yoo J, Bohlman HH (2007) Risk factors for the development of perioperative complications in elderly patients undergoing lumbar decompression and arthrodesis for spinal stenosis: an analysis of 166 patients. Spine 32:230–235

    Article  PubMed  Google Scholar 

  24. Patel N, Bagan B, Vadera S, Maltenfort MG, Deutsch H, Vaccaro AR, Harrop J, Sharan A, Ratliff JK (2007) Obesity and spine surgery: relation to perioperative complications. J Neurosurg Spine 6:291–297

    Article  PubMed  Google Scholar 

  25. Peng CW, Bendo JA, Goldstein JA, Nalbandian MM (2009) Perioperative outcomes of anterior lumbar surgery in obese versus non-obese patients. Spine J 9:715–720

    Article  PubMed  Google Scholar 

  26. Simpson JM, Silveri CP, Balderston RA, Simeone FA, An HS (1993) The results of operations on the lumbar spine in patients who have diabetes mellitus. J Bone Joint Surg Am 75:1823–1829

    PubMed  CAS  Google Scholar 

  27. Friedman ND, Sexton DJ, Connelly SM, Kaye KS (2007) Risk factors for surgical site infection complicating laminectomy. Infect Control Hosp Epidemiol 28:1060–1065

    Article  PubMed  Google Scholar 

  28. Capen DA, Calderone RR, Green A (1996) Perioperative risk factors for wound infections after lower back fusions. Orthop Clin North Am 27:83–86

    PubMed  CAS  Google Scholar 

  29. Thalgott JS, Cotler HB, Sasso RC, LaRocca H, Gardner V (1991) Postoperative infections in spinal implants. Classification and analysis. A multicenter study. Spine 16:981–984

    Article  PubMed  CAS  Google Scholar 

  30. Goodson WH 3rd, Hung TK (1977) Studies of wound healing in experimental diabetes mellitus. J Surg Res 22:221–227

    Article  PubMed  Google Scholar 

  31. Rechtine GR, Bono PL, Cahill D, Bolesta MJ, Chrin AM (2001) Postoperative wound infection after instrumentation of thoracic and lumbar fractures. J Orthop Trauma 15:566–569

    Article  PubMed  CAS  Google Scholar 

  32. Barker FG II (2002) Efficacy of prophylactic antibiotic therapy in spinal surgery: A meta-analysis. Neurosurgery 51:391–400

    PubMed  Google Scholar 

  33. Transfeldt EE, Lonstein JE (1985) Wound infections in elective reconstructive spinal surgery. Orthopaedic Transactions 9:128–129

    Google Scholar 

  34. Pahys J, Riew KD (2010) Methods to decrease post-operative infections following posterior cervical spine surgery. Proceed Cervical Spine Res Society [abstract] Charlotte NC

  35. Kanayama M, Oha F, Togawa D, Shingenobu K, Hashimoto T (2010) Is closed-suction drainage necessary for single-level lumbar decompression?: A review of 560 cases. Clin Orthop Relat Res 468:2690–2694

    Article  PubMed  Google Scholar 

  36. Payne DH, Fischgrund JS, Herkowitz HN, Barry RL, Kurz LT, Montgomery DM (1996) Efficacy of closed wound suction drainage after single-level lumbar laminectomy. J Spinal Disord 9:401–403

    Article  PubMed  CAS  Google Scholar 

  37. Brown MD, Brookfield KF (2004) A randomized study of closed wound suction drainage for extensive lumbar spine surgery. Spine 29:1066–1068

    Article  PubMed  Google Scholar 

  38. Gruenberg MF, Campaner GL, Sola CA, Ortolan EF (2004) Ultraclean air for prevention of postoperative infection after posterior spinal fusion with instrumentation. A comparison between surgeries performed with and without a vertical exponential filtered air-flow system. Spine 29:2330–2334

    Article  PubMed  Google Scholar 

  39. Silber JS, Anderson DG, Vaccaro AR, Anderson PA, McCormick P (2002) Management of post procedural discitis. Spine J 2:279–287

    Article  PubMed  Google Scholar 

  40. Sponseller PD, LaPorte DM, Hungerford MW, Eck K, Bridwell KH, Lenke LG (2000) Deep wound infections after neuromuscular scoliosis surgery: A multicenter study of risk factors and treatment outcomes. Spine 25:2461–2466

    Article  PubMed  CAS  Google Scholar 

  41. Lindholm TS, Pylkkanen P (1982) Discitis following removal of intervertebral disc. Spine 7:618–622

    Article  PubMed  CAS  Google Scholar 

  42. Ozuna RM, Delamarter RB (1996) Pyogenic vertebral osteomyelitis and postsurgical disc space infections. Orthop Clin North Am 27:87–94

    PubMed  CAS  Google Scholar 

  43. Carragee EJ (1997) Pyogenic vertebral osteomyelitis. J Bone Joint Surg Am 79:874–880

    Article  PubMed  CAS  Google Scholar 

  44. Visuri T, Pihlajmaki H, Eskelin M (2005) Long-term vertebral changes attributable to postoperative lumbar discitis: a retrospective study of six cases. Clin Orthop Relat Res 433:97–105

    Article  PubMed  Google Scholar 

  45. Chew FS, Kline MJ (2001) Diagnostic yield of CT-guided percutaneous aspiration procedures in suspected spontaneous infectious diskitis. Radiology 218:211–214

    PubMed  CAS  Google Scholar 

  46. Przybylski GJ, Sharan AD (2001) Single-stage autogenous bone grafting and internal fixation in the surgical management of pyogenic disciits and vertebral osteomyelitis. J Neurosurg 94:1–7

    Article  PubMed  CAS  Google Scholar 

  47. Pee YH, Park JD, Choi YG, Lee SH (2008) Anterior debridement and fusion followed by posterior pedicle screw fixation in pyogenic spondylodiscitis: autologous iliac bone strut versus cage. J Neurosurg Spine 8:405–412

    Article  PubMed  Google Scholar 

  48. Kuklo TR, Potter BK, Bell RS, Moquin RR, Rosner MK (2006) Single-stage treatment of pyogenic spinal infection with titanium mesh cages. J Spinal Disord Tech 19:376–382

    Article  PubMed  Google Scholar 

  49. 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 

  50. Pappou IP, Papadopoulos EC, Sama AA, Girardi FP, Cammisa FP (2006) Postoperative infections in interbody fusion for degenerative spinal disease. Clin Orthop Relat Res 444:120–128

    Article  PubMed  Google Scholar 

  51. Weiss LE, Vaccaro AR, Scuderi G, McGuire M, Garfin SR (1997) Pseudarthrosis after postoperative wound infection in the lumbar spine. J Spinal Disord 10:482–487

    Article  PubMed  CAS  Google Scholar 

  52. Viola RW, King HA, Adler SA, Wilson CB (1997) Delayed infection after elective spinal instrumentation and fusion. A retrospective analysis of eight cases. Spine 22:2444–2450

    Article  PubMed  CAS  Google Scholar 

  53. Toulson C, Walcott-Sapp S, Hur J, Salvati E, Bostrom M, Brause B, Westrich GH (2009) Treatment of infected total hip arthroplasty with a 2-stage reimplantation protocol. J Arthroplasty 24:1051–1060

    Article  PubMed  Google Scholar 

  54. Westrich GH, Walcott-Sapp S, Bornstein LJ, Bostrom MP, Windsor RE, Brause BD (2010) Modern treatment of infected total knee arthroplasty with a 2-stage reimplantation protocol. J Arthroplasty 25:1015–1021

    Article  PubMed  Google Scholar 

  55. Volin SJ, Hinrichs Sh, Garvin KL (2004) Two-stage reimplantation of total joint infections: a comparison of resistant and non-resistant organisms. Clin Orthop Relat Res 427:94–100

    Article  PubMed  Google Scholar 

  56. Weinstein MP, Stratton CW, Hawley HB, Ackley A, Reller LB (1987) Multicenter collaborative evaluation of a standardized serum bactericidal test as a predictor of therapeutic efficacy in acute and chronic osteomyelitis. Am J Med 83:218–222

    Article  PubMed  CAS  Google Scholar 

  57. Liu C, Bayer A, Cosgrove SE et al (2011) Clinical practice guidelines by the infectious diseases society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 52:285–292

    Article  PubMed  Google Scholar 

  58. Mitra A, Mitra A, Harlin S (2004) Treatment of massive thoracolumbar wounds and vertebral osteomyelitis following scoliosis surgery. Plast Reconstr Surg 113:206–213

    Article  PubMed  Google Scholar 

  59. Dumanian GA, Ondra SL, Liu J, Schafer MF, Chao JD (2003) Muscle flap salvage of spine wounds with soft tissue defects or infection. Spine 28:1203–1211

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery/Weill Cornell Medical Center, New York, NY, USA

    Dennis S. Meredith, Russel C. Huang & Oheneba Boachie-Adjei

  2. Department of Orthopedic Surgery, Rothman Institute/Thomas Jefferson University, Philadelphia, PA, USA

    Christopher K. Kepler

  3. Department of Infectious Diseases, Hospital for Special Surgery/Weill Cornell Medical Center, New York, NY, USA

    Barry D. Brause

  4. Hospital for Special Surgery, 535 E 70th St, New York, NY, 10021, USA

    Dennis S. Meredith

Authors
  1. Dennis S. Meredith
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Christopher K. Kepler
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Russel C. Huang
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Barry D. Brause
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Oheneba Boachie-Adjei
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Dennis S. Meredith.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Meredith, D.S., Kepler, C.K., Huang, R.C. et al. Postoperative infections of the lumbar spine: presentation and management. International Orthopaedics (SICOT) 36, 439–444 (2012). https://doi.org/10.1007/s00264-011-1427-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00264-011-1427-z

Keywords

Search

Navigation