Deep surgical site infection after posterior instrumented fusion for rheumatoid upper cervical subluxation treated with antibiotic-loaded bone cement

Abstract

Introduction: Patients with rheumatoid arthritis (RA) tend to be immunosuppressed due to RA itself and the therapeutic drugs administered. The management of surgical site infection (SSI) following upper cervical spinal instrumented fusion in RA patients is challenging; however, literature on the treatment for such conditions is scarce. We report 3 consecutive patients with RA, who developed deep SSI following upper cervical posterior fusion and were treated using antibiotic-loaded bone cement (ALBC). Patient Concerns: All 3 patients reported in the current study experienced compression myelopathy with upper cervical spinal deformity and received prednisolone and methotrexate for controlling RA preoperatively. The patient in Case 1 underwent C1–2 posterior fusion and developed deep SSI due to methicillin-sensitive Staphylococcus aureus at 3 months postoperatively; the patient in Case 2 underwent occipito-C2 posterior fusion and developed deep SSI due to methicillin-sensitive Staphylococcus aureus at 2 weeks postoperatively; and the patient in Case 3 underwent occipito-C2 posterior instrumented fusion and laminoplasty at C3–7, and developed deep SSI due to methicillin-resistant coagulase negative staphylococci at 3 weeks postoperatively. Diagnosis: All patients developed deep staphylococcal SSI in the postoperative period. Interventions: All 3 patients were treated using ALBC placed on and around the instrumentation to cover them and occupy the dead space after radical open debridement. Outcomes: The deep infection was resolved uneventfully after the single surgical intervention retaining spinal instrumentation. Good clinical outcomes of the initial surgery were maintained until the final follow-up without recurrence of SSI in all 3 cases. Conclusion: ALBC embedding spinal instrumentation procedure can be a viable treatment for curing SSI in complex cases, such as patients with RA who undergo high cervical fusion surgeries without implant removal.

Use of antibiotic-impregnated beads in the treatment of lumbosacral surgical site infection: A retrospective case series

“…The principles of management of SSIs include thorough, extensive debridement of the necrotic tissues, copious irrigation to dilute the infective foci, ensure stability of the concerned spinal segment, minimize the dead space around the infected tissues and ensure appropriate delivery of antibiotics through systemic or alternate routes. 1,11,20,21 Among these aforementioned strategies, the importance of performing a thorough debridement of the sequestrated tissues cannot be understated. The presence of a biofilm confers the organisms a high degree of resistance to antibiotics (even 1000 times higher than their therapeutic concentrations).…”

Utilization of Antibiotic Bone Cement in Spine Surgery: Pearls, Techniques, and Case Review

“…It can be delivered manu-ally to the spine to fill large defects in the vertebral body or disc space. 60,61 Some surgeons have also described coating the instrumentation constructs with cement to minimize the risk of local infection and biofilm formation. 62,63 Multiple delivery methods exist to allow for direct delivery to the vertebral body.…”

Antibiotic Cement Utilization for the Prophylaxis and Treatment of Infections in Spine Surgery: Basic Science Principles and Rationale for Clinical Use

“…Masuda et al successfully treated 11 patients with spinal SSI refractory to other treatments using ABC [ 71 ]. Ogihara et al successfully treated three cases of deep SSI after cervical spine deformity surgery using ABC placed over and around the instrumentation [ 72 ]. Laratta et al published a case series showing complete resolution of deep surgical site infections in ten spine surgery patients treated with permanent implantation of ABC over exposed instrumentation [ 73 ].…”