Abstract
Purpose
Inconsistent results have been reported in the literature on the association between obesity, expressed as increased body mass index (BMI), and risk for surgical site infection (SSI) following spine surgery. The objective of this study was to review and quantify the association between increased BMI and risk of spinal SSI in adults.
Methods
We performed a comprehensive search for relevant studies using PubMed, Embase, and references of published manuscripts. Study-specific risk measures were transformed into slope estimates and combined using the random effects meta-analysis model to establish the risk of SSI associated with every 5-unit increase in BMI.
Results
Thirty-four articles underwent full-text review. Variations were noted among these studies in relation to SSI diagnosis criteria and BMI cut-off levels used to define obesity. Data from 12 retrospective studies were included in the analyses. Results showed that BMI was significantly positively associated with the risk of spinal SSI. Unadjusted risk estimates demonstrated that a 5-unit increase in BMI was associated with 13 % increased risk of SSI [Crude odds ratio (OR): 1.13; 95 % CI: 1.07–1.19, p < 0.0001]. Pooling of risk estimates adjusted for diabetes and other confounders resulted in a 21 % increase in risk of spinal SSI for every 5-unit increase in BMI (adjusted OR: 1.21; 95 % CI 1.13–1.29, p < 0.0001).
Conclusion
Higher BMI is associated with the increased risk of SSI following spine surgery. Prospective studies are needed to confirm this association and to determine whether other measures of fat distribution are better predictors of risk of SSI.
Similar content being viewed by others
References
Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR (1999) Guideline for prevention of surgical site infection, 1999. Hospital infection control practices advisory committee. Infect Control Hosp Epidemiol 20(4):250–278
European Centre for Disease Prevention and Control (2012) Surveillance of surgical site infections in European hospitals—HAISSI protocol. ECDC, Stockholm (version 1.02)
Edwards JR, Peterson KD, Mu Y, Banerjee S, Allen-Bridson K, Morrell G, Dudeck MA, Pollock DA, Horan TC (2009) National healthcare safety network (NHSN) report: data summary for 2006 through 2008, issued. Am J Infect Control 37(10):783–805
Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ (2002) The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol 23(4):183–189
de Lissovoy G, Fraeman K, Hutchins V, Murphy D, Song D, Vaughn BB (2009) Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control 37(5):387–397
Watters WC 3rd, Baisden J, Bono CM, Heggeness MH, Resnick DK, Shaffer WO, Toton JF, North American Spine Society (2009) Antibiotic prophylaxis in spine surgery: an evidence-based clinical guideline for the use of prophylactic antibiotics in spine surgery. Spine J 9(2):142–146
Schuster JM, Rechtine G, Norvell DC, Dettori JR (2010) The influence of perioperative risk factors and therapeutic interventions on infection rates after spine surgery: a systematic review. Spine (Phila Pa 1976) 35(9 suppl):S125–S137
Pull ter Gunne AF, Hosman AJ, Cohen DB, Schuetz M, Habil D, van Laarhoven CJ, van Middendorp JJ (2012) A methodological systematic review on surgical site infections following spinal surgery: part 1: risk factors. Spine (Phila Pa 1976) 37(24):2017–2033
Xing D, Ma JX, Ma XL, Song DH, Wang J, Chen Y, Yang Y, Zhu SW, Ma BY, Feng R (2013) A methodological, systematic review of evidence-based independent risk factors for surgical site infections after spinal surgery. Eur Spine J 22(3):605–615
Borenstein M, Hedges LV, Higgins JPT, Rothstein HR (2009) Vote counting—a new name for an old problem. In: Introduction to meta-analysis, 1st edn. Wiley, West Sussex, pp 251–255
Rihn JA, Kurd M, Hilibrand AS, Lurie J, Zhao W, Albert T, Weinstein J (2013) The influence of obesity on the outcome of treatment of lumbar disc herniation: analysis of the Spine Patient Outcomes Research Trial (SPORT). J Bone Jt Surg Am 95(1):1–8
Waisbren E, Rosen H, Bader AM, Lipsitz SR, Rogers SO Jr, Eriksson E (2010) Percent body fat and prediction of surgical site infection. J Am Coll Surg 210(4):381–389
World Health Organisation (2000) Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser 894(i–xii):1–253
World Health Organisation (1995) Physical status: the use and interpretation of anthropometry. Report of a WHO expert committee. World Health Organ Tech Rep Ser 854(i–x):1–452
Ho-Pham LT, Campbell LV, Nguyen TV (2011) More on body fat cutoff points. Mayo Clin Proc 86(6):584
Wright JG, Swiontkowski MF, Heckman JD (2003) Introducing levels of evidence to the journal. J Bone Jt Surg Am 85(1):1–3
Berlin JA, Longnecker MP, Greenland S (1993) Meta-analysis of epidemiologic dose-response data. Epidemiology 4(3):218–228
Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ 327(7414):557–560
Egger M, Davey Smith G, Schneider M, Minder C (1997) Bias in meta-analysis detected by a simple, graphical test. BMJ 315(7109):629–634
Duval S, Tweedie R (2000) Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 56(2):455–463
Guido Schwarzer (2012) Meta: meta-analysis with R. R package version 2.1-4
Apisarnthanarak A, Jones M, Waterman BM, Carroll CM, Bernardi R, Fraser VJ (2003) Risk factors for spinal surgical-site infections in a community hospital: a case-control study. Infect Control Hosp Epidemiol 24(1):31–36
Boston KM, Baraniuk S, O’Heron S, Murray KO (2009) Risk factors for spinal surgical site infection, Houston, Texas. Infect Control Hosp Epidemiol 30(9):884–889
Chen S, Anderson MV, Cheng WK, Wongworawat MD (2009) Diabetes associated with increased surgical site infections in spinal arthrodesis. Clin Orthop Relat Res 467(7):1670–1673
Friedman ND, Sexton DJ, Connelly SM, Kaye KS (2007) Risk factors for surgical site infection complicating laminectomy. Infect Control Hosp Epidemiol 28(9):1060–1065
Koutsoumbelis S, Hughes AP, Girardi FP, Cammisa FP Jr, Finerty EA, Nguyen JT, Gausden E, Sama AA (2011) Risk factors for postoperative infection following posterior lumbar instrumented arthrodesis. J Bone Jt Surg Am 93(17):1627–1633
Mehta AI, Babu R, Karikari IO, Grunch B, Agarwal VJ, Owens TR, Friedman AH, Bagley CA, Gottfried ON (2012) 2012 Young investigator award winner: the distribution of body mass as a significant risk factor for lumbar spinal fusion postoperative infections. Spine (Phila Pa 1976) 37(19):1652–1656
Mehta AI, Babu R, Sharma R, Karikari IO, Grunch BH, Owens TR, Agarwal VJ, Sampson JH, Lad SP, Friedman AH, Kuchibhatla M, Bagley CA, Gottfried ON (2013) Thickness of subcutaneous fat as a risk factor for infection in cervical spine fusion surgery. J Bone Jt Surg Am 95(4):323–328
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
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 Jt Surg Am 90(1):62–69
Sciubba DM, Nelson C, Gok B, McGirt MJ, McLoughlin GS, Noggle JC, Wolinsky JP, Witham TF, Bydon A, Gokaslan ZL (2008) Evaluation of factors associated with postoperative infection following sacral tumor resection. J Neurosurg Spine 9(6):593–599
Schwarzkopf R, Chung C, Park JJ, Walsh M, Spivak JM, Steiger D (2010) Effects of perioperative blood product use on surgical site infection following thoracic and lumbar spinal surgery. Spine (Phila Pa 1976) 35(3):340–346
Watanabe M, Sakai D, Matsuyama D, Yamamoto Y, Sato M, Mochida J (2010) Risk factors for surgical site infection following spine surgery: efficacy of intraoperative saline irrigation. J Neurosurg Spine 12(5):540–546
Andreshak TG, An HS, Hall J, Stein B (1997) Lumbar spine surgery in the obese patient. J Spinal Disord 10(5):376–379
Angsuwat M, Kavar B, Lowe AJ (2010) Early detection of spinal sepsis. J Clin Neurosci 17(1):59–63
Campbell PG, Yadla S, Malone J, Zussman B, Maltenfort MG, Sharan AD, Harrop JS, Ratliff JK (2010) Early complications related to approach in cervical spine surgery: single-center prospective study. World Neurosurg 74(2–3):363–368
Cizik AM, Lee MJ, Martin BI, Bransford RJ, Bellabarba C, Chapman JR, Mirza SK (2012) Using the spine surgical invasiveness index to identify risk of surgical site infection: a multivariate analysis. J Bone Jt Surg Am 94(4):335–342
Desai A, Bekelis K, Ball PA, Lurie J, Mirza SK, Tosteson TD, Zhao W, Weinstein JN (2012) Outcome variation across centers after surgery for lumbar stenosis and degenerative spondylolisthesis: the SPORT experience. Spine (Phila Pa 1976) (Epub ahead of print)
Fang A, Hu SS, Endres N, Bradford DS (2005) Risk factors for infection after spinal surgery. Spine (Phila Pa 1976) 30(12):1460–1465
Liao JC, Chen WJ, Chen LH, Niu CC (2006) Postoperative wound infection rates after posterior instrumented spinal surgery in diabetic patients. Chang Gung Med J 29(5):480–485
Pull ter Gunne AF, Cohen DB (2009) Incidence, prevalence, and analysis of risk factors for surgical site infection following adult spinal surgery. Spine (Phila Pa 1976) 34(13):1422–1428
Pull ter Gunne AF, van Laarhoven CJ, Cohen DB (2010) Incidence of surgical site infection following adult spinal deformity surgery: an analysis of patient risk. Eur Spine J 19(6):982–988
Savage JW, Weatherford BM, Sugrue PA, Nolden MT, Liu JC, Song JK, Haak MH (2012) Efficacy of surgical preparation solutions in lumbar spine surgery. J Bone Jt Surg Am 94(6):490–494
Schoenfeld AJ, Ochoa LM, Bader JO, Belmont PJ Jr (2011) Risk factors for immediate postoperative complications and mortality following spine surgery: a study of 3475 patients from the National surgical quality improvement program. J Bone Jt Surg Am 93(17):1577–1582
Senker W, Meznik C, Avian A, Berghold A (2011) Perioperative morbidity and complications in minimal access surgery techniques in obese patients with degenerative lumbar disease. Eur Spine J 20(7):1182–1187
Willems KF, Slot GH, Anderson PG, Pavlov PW, de Kleuver M (2005) Spinal osteotomy in patients with ankylosing spondylitis: complications during first postoperative year. Spine (Phila Pa 1976) 30(1):101–107
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(2):124–128
Abdul-Jabbar A, Takemoto S, Weber MH, Hu SS, Mummaneni PV, Deviren V, Ames CP, Chou D, Weinstein PR, Burch S, Berven SH (2012) Surgical site infection in spinal surgery: description of surgical and patient-based risk factors for postoperative infection using administrative claims data. Spine (Phila Pa 1976) 37(15):1340–1345
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(3):556–562
Kraft CN, Krüger T, Westhoff J, Lüring C, Weber O, Wirtz DC, Pennekamp PH (2011) CRP and leukocyte-count after lumbar spine surgery: fusion vs. nucleotomy. Acta Orthop 82(4):489–493
O’Neill KR, Smith JG, Abtahi AM, Archer KR, Spengler DM, McGirt MJ, Devin CJ (2011) Reduced surgical site infections in patients undergoing posterior spinal stabilization of traumatic injuries using vancomycin powder. Spine J 11(7):641–646
Wachter D, Brückel A, Stein M, Oertel MF, Christophis P, Böker DK (2010) 2-Octyl-cyanoacrylate for wound closure in cervical and lumbar spinal surgery. Neurosurg Rev 33(4):483–489
Walid MS, Robinson JS 3rd, Robinson ER, Brannick BB, Ajjan M, Robinson JS Jr (2010) Comparison of outpatient and inpatient spine surgery patients with regards to obesity, comorbidities and readmission for infection. J Clin Neurosci 17(12):1497–1498
Rao SB, Vasquez G, Harrop J, Maltenfort M, Stein N, Kaliyadan G, Klibert F, Epstein R, Sharan A, Vaccaro A, Flomenberg P (2011) Risk factors for surgical site infections following spinal fusion procedures: a case-control study. Clin Infect Dis 53(7):686–692
Schimmel JJ, Horsting PP, de Kleuver M, Wonders G, van Limbeek J (2010) Risk factors for deep surgical site infections after spinal fusion. Eur Spine J 19(10):1711–1719
Symons MJ, Moore DT (2002) Hazard rate ratio and prospective epidemiological studies. J Clin Epidemiol 55(9):893–899
Sterne JA, Gavaghan D, Egger M (2000) Publication and related bias in meta-analysis: power of statistical tests and prevalence in the literature. J Clin Epidemiol 53(11):1119–1129
Filardo G, Hamilton C, Hamman B, Ng HK, Grayburn P (2007) Categorizing BMI may lead to biased results in studies investigating in-hospital mortality after isolated CABG. J Clin Epidemiol 60(11):1132–1139
Wisse BE (2004) The inflammatory syndrome: the role of adipose tissue cytokines in metabolic disorders linked to obesity. J Am Soc Nephrol 15(11):2792–2800
Romero-Corral A, Somers VK, Sierra-Johnson J, Thomas RJ, Collazo-Clavell ML, Korinek J, Allison TG, Batsis JA, Sert-Kuniyoshi FH, Lopez-Jimenez F (2008) Accuracy of body mass index in diagnosing obesity in the adult general population. Int J Obes (London) 32(6):959–966
Okorodudu DO, Jumean MF, Montori VM, Romero-Corral A, Somers VK, Erwin PJ, Lopez-Jimenez F (2010) Diagnostic performance of body mass index to identify obesity as defined by body adiposity: a systematic review and meta-analysis. Int J Obes (London) 34(5):791–799
Allison DB, Faith MS, Heo M, Kotler DP (1997) Hypothesis concerning the U-shaped relation between body mass index and mortality. Am J Epidemiol 146(4):339–349
May S, Bigelow C (2006) Modeling nonlinear dose–response relationships in epidemiologic studies: statistical approaches and practical challenges. Dose Response 3(4):474–490
Egger M, Schneider M, Davey Smith G (1998) Spurious precision? Meta-analysis of observational studies. BMJ 316(7125):140–144
Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, Moher D, Becker BJ, Sipe TA, Thacker SB (2000) Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of observational studies in epidemiology (MOOSE) group. JAMA 283(15):2008–2012
Egger M, Zellweger-Zähner T, Schneider M, Junker C, Lengeler C, Antes G (1997) Language bias in randomised controlled trials published in English and German. Lancet 350(9074):326–329
Vaidya R, Carp J, Bartol S, Ouellette N, Lee S, Sethi A (2009) Lumbar spine fusion in obese and morbidly obese patients. Spine (Phila Pa 1976) 34(5):495–500
Edmiston CE, Krepel C, Kelly H, Larson J, Andris D, Hennen C, Nakeeb A, Wallace JR (2004) Perioperative antibiotic prophylaxis in the gastric bypass patient: do we achieve therapeutic levels? Surgery 136(4):738–747
Culver DH, Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG, Banerjee SN, Edwards JR, Tolson JS, Henderson TS et al (1991) Surgical wound infection rates by wound class, operative procedure, and patient risk index. National nosocomial infections surveillance system. Am J Med 91(3B):152S–157S
Ercole FF, Chianca TC, Duarte D, Starling CE, Carneiro M (2011) Surgical site infection in patients submitted to orthopedic surgery: the NNIS risk index and risk prediction. Rev Lat Am Enfermagem 19(2):269–276
Conflict of interest
None.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Abdallah, D.Y., Jadaan, M.M. & McCabe, J.P. Body mass index and risk of surgical site infection following spine surgery: a meta-analysis. Eur Spine J 22, 2800–2809 (2013). https://doi.org/10.1007/s00586-013-2890-6
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00586-013-2890-6