Case studyImpact of surgical site infection and surgical debridement on lumbar arthrodesis: A single-institution analysis of incidence and risk factors
Introduction
Advances in surgical techniques and patient selection have resulted in improved outcomes following spine fusion. However, these procedures still require the introduction of foreign hardware and significant tissue dissection and manipulation of native anatomy. As a result, spine fusion patients can experience significant postoperative pain and other less common complications including cerebrospinal fluid (CSF) leak, hardware failure, hematoma, and nerve damage [9]. Surgical site infection is another uncommon but morbid complication for lumbar spine fusion, and has an incidence of 0.3%-9%, depending on a multitude of factors including preoperative diagnosis, type of operation, and patient demographics [1], [11], [17], [21], [22], [23]. Following diagnosis of postoperative wound infection, patients typically undergo wound irrigation and debridement with removal of graft bone. Postoperatively, patients are then placed on oral or intravenous (IV) antibiotics and then monitored for resolution of infection [14].
Infection and debridement surgery has significant short-term and long-term sequelae including increased hospital stay, 30-day readmission, decreased quality of life and decreased satisfaction with the index procedure [7], [19], [26]. However, there is no consensus on the impact of irrigation and debridement or wound infection on long-term fusion rates. There has been previous laboratory data suggesting inflammatory markers associated with infection are beneficial in achieving bone growth [13], [25], [28]. However, other groups have not shown this association, and in fact, have suggested that the inflammatory response is detrimental for achieving successful arthrodesis [8]. Therefore, the authors designed a retrospective review to assess the rate of arthrodesis following irrigation and debridement following lumbar spine fusion. By doing so, the authors hope to better characterize the rate of arthrodesis following surgical debridement for wound infection, and identify any pre-, peri-, and post-operative factors predictive of either arthrodesis or pseudoarthrosis.
Section snippets
Materials and methods
Patients who were: 1) age ⩾18 years at time of surgery, 2) had lumbar spine fusion between 2008 and 2014, 3) debridement of deep lumbar SSI, and 4) lumbar spine anterior and posterior (AP), lateral flexion/extension X-rays and computed tomography (CT) at 12 months or greater postoperatively were retrospectively included for statistical analysis. Institutional Review Board (IRB) approval was obtained prior to data collection and chart review.
Demographic data including age, sex, race, and body
Patient characteristics
In total, 25 patients (15 female, 10 male) involving 58 spinal levels met inclusion criteria and were reviewed in this study. From 2008 to 2014, an additional 8 patients underwent lumbar spine fusion complicated by infection and wound debridement, but did not meet inclusion criteria due to lack of imaging follow-up. The mean age and BMI were 63.2 ± 12.6 years and 31.6 ± 7.5 kg/m2, respectively. Fifteen (60%) patients were obese (BMI >30.0 kg/m2), 2 (8.0%) were active smokers, 4 (16.0%) had CAD, 19
Discussion
The goals of spinal surgery ultimately remain in achieving adequate decompression of neural elements and achievement of successful arthrodesis through the incorporation of spinal instrumentation. Despite appropriate pre-incisional antibiotics and skin preparation, infection remains a well-known complication of spinal surgery. Current literature estimates the rate of spine surgery wound infection between 0.3% and 9%, depending on risk factors including diabetes, smoking, obesity, malnutrition,
Conclusion
Post-operative infection results in a high rate of pseudoarthrosis in patients undergoing lumbar fusion surgery complicated by SSI requiring debridement. The use of interbody cage during initial fusion was significantly associated with higher rate of arthrodesis likely from the retained and protected bone graft not removed at debridement as well as increased stability. Despite post-operative infection, when interbody grafts are placed there is a high rate of fusion.
Disclosures
No funding of any kind was received for this manuscript.
Sources of support
None.
Conflicts of interest
None.
References (28)
- et al.
Posterior lumbar interbody fusion with the keystone graft: technique and results
Surg Neurol
(1987) - et al.
Nonsteroidal anti-inflammatory drugs and bone metabolism in spinal fusion surgery: a pharmacological quandary
J Pharmacol Toxicol Methods
(2000) The effect of cyclooxygenase-2 inhibitors on bone healing
Region Anesth Pain M
(2003)- et al.
The effect of nonsteroidal anti-inflammatory drugs on osteogenesis and spinal fusion
Region Anesth Pain M
(2001) - et al.
Treatment of postoperative wound infections following spinal fusion with instrumentation
J Spinal Disord
(1995) - et al.
Anterior lumbar interbody fusion using rhBMP-2 with tapered interbody cages
J Spinal Disord Tech
(2002) Posterior lumbar interbody fusion updated
Clin Orthop Relat Res
(1985)Total disc replacement: a modified posterior lumbar interbody fusion. Report of 750 cases
Clin Orthop Relat Res
(1985)- et al.
Effect of deep wound infection following lumbar arthrodesis for degenerative disc disease on long-term outcome: a prospective study: clinical article
J Neurosurg Spine
(2011) - et al.
Risk factors for infection after spinal surgery
Spine
(2005)
Swedish lumbar spine study G: complications in lumbar fusion surgery for chronic low back pain: comparison of three surgical techniques used in a prospective randomized study. A report from the Swedish Lumbar Spine Study Group
Euro Spine J
Salvage of instrumental lumbar fusion complicated by surgical wound infection
Spine
Spinal stenosis and posterior lumbar interbody fusion
Clin Orthop Relat Res
Infection with spinal instrumentation: review of pathogenesis, diagnosis, prevention, and management
Surg Neurol Int
Cited by (17)
Clinical outcome of postoperative surgical site infections in patients with posterior thoracolumbar and lumbar instrumentation
2022, Journal of Hospital InfectionCitation Excerpt :Some researchers have suggested implant retention in early (4–6 weeks) SSI and exchange/removal in late SSI [36,37]. Following partial removal of the dorsal instrumentation during revision surgery, Wang et al. reported pseudarthrosis of up to 44% after SSI, particularly in cases without a cage implanted during the index surgery, potentially covered by a biofilm [38]. In this study, all 191 patients received thorough debridement, and loose implants were removed or exchanged.
Surgical Site Infection as a Risk Factor for Long-Term Instrumentation Failure in Patients with Spinal Deformity: A Retrospective Cohort Study
2019, World NeurosurgeryCitation Excerpt :Even fewer have studied the relationship between SSI and failure of spinal fusion in these patients.2 In fact, several studies have reported cases of instrumentation failure in the setting of infection.2-6 However, all these studies were case reports with a small number of patients, suggesting a possible link between infection and the failure of instrumentation.
Deep surgical site infection following thoracolumbar instrumented spinal surgery. Ten years of experience
2019, Revista Espanola de Cirugia Ortopedica y TraumatologiaAlcoholism as a predictor for pseudarthrosis in primary spine fusion: An analysis of risk factors and 30-day outcomes for 52,402 patients from 2005 to 2013
2019, Journal of OrthopaedicsCitation Excerpt :Some studies suggest infection actually mediates bony growth through biological inflammatory markers, supported by observations that anti-inflammatory medications like NSAIDs taken in the post-operative period inhibit osteogenesis and rates of bony fusion.26–28 Conversely, other studies such as Wang et al. found that post-operative infection, including deep incisional SSI, was correlated with higher rates of pseudarthrosis in patients who underwent lumbar fusion.29 This study is limited by its reliance on a large national database (NSQIP) for data collection, where patient data is inherently limited to the database design.
The role of lymphocyte count in the early diagnosis of surgical site infection following posterior lumbar fusion
2023, European Review for Medical and Pharmacological Sciences