Management of postoperative spinal infections

Abstract

Postoperative surgical site infection (SSI) is a common complication after posterior lumbar spine surgery. This review details an approach to the prevention, diagnosis and treatment of SSIs. Factors contributing to the development of a SSI can be split into three categories: (1) microbiological factors; (2) factors related to the patient and their spinal pathology; and (3) factors relating to the surgical procedure. SSI is most commonly caused by Staphylococcus aureus. The virulence of the organism causing the SSI can affect its presentation. SSI can be prevented by careful adherence to aseptic technique, prophylactic antibiotics, avoiding myonecrosis by frequently releasing retractors and preoperatively optimizing modifiable patient factors. Increasing pain is commonly the only symptom of a SSI and can lead to a delay in diagnosis. C-reactive protein and magnetic resonance imaging can help establish the diagnosis. Treatment requires acquiring intra-operative cultures to guide future antibiotic therapy and surgical debridement of all necrotic tissue. A SSI can usually be adequately treated without removing spinal instrumentation. A multidisciplinary approach to SSIs is important. It is useful to involve an infectious disease specialist and use minimum serial bactericidal titers to enhance the effectiveness of antibiotic therapy. A plastic surgeon should also be involved in those cases of severe infection that require repeat debridement and delayed closure.

Variables associated with remission in spinal surgical site infections

“…We think that none knows the ideal duration of intravenous or total antibiotic therapy, which moreover might be patient or pathogen-dependent. Most author groups report a minimum length of parenteral antibiotic courses of 4-6 weeks and a total duration up to three months (3,(6)(7)(8)(9)15,17,21), although some authors only recommend 2 weeks of parental therapy (9,29) or even only 2-3 days (16), without further compromising the success when compared to the literature. To cite examples, Clark and Shufflebarger treated delayed infections with surgery and 48-72 hours of parenteral antibiotics followed by ten days of targeted oral antibiotics.…”

“…Most publications or experts recommend a minimum length of intravenous antibiotic courses of 4-6 weeks, often followed by prolonged oral antimicrobial regimens (3,(6)(7)(8)(9), or they do not pronounce on detailed antibiotic modalities at all (10)(11)(12). Most of these recommendations are reviews and lack own data (6)(7)(8)(9). Any benefits of long-term antibiotic use remain to be determined (3).…”

Entero-paraspinous fistula from recurrent spinal metastatic renal cell carcinoma

“…Eradication of infection with debridement and antibiotics in the presence of hardware has been demonstrated in several reports. 4,7,10 acknowledgment We thank Faith Vaughn for her invaluable assistance in the preparation and editing of this manuscript.…”

Multiple recurrent postoperative spinal infections due to an unrecognized presacral abscess following placement of bicortical sacral screws: case report

“…3,4,7,8,10,12,14,15,19 Additionally, the presence of instrumentation can make infections more difficult to treat. 14,15,19 Longer operating times and prolonged retraction associated with the placement of instrumentation probably contribute.…”