Management of deep surgical site infections of the spine: a Canadian nationwide survey

Abstract

Background Deep surgical site infections after spinal instrumentation represent a significant source of patient morbidity and poorer outcomes. Given lack of evidence or guidelines on the variety of procedural options in the management of deep spine surgical site infections, the purpose of this survey was to document and investigate the use of these techniques across Canada. Methods A 34-question survey evaluating surgical techniques for irrigation and debridement in postoperative thoracolumbar infection was distributed to Canadian adult spine surgeons. Results were analyzed qualitatively, and comparisons by specialty, years of training, and number of cases were completed using Fischer’s exact tests. We defined consensus as >70% agreement. Results We received 53 responses (62% response rate) from a comprehensive sample of Canadian adult spine surgeons. There was a consensus to retain hardware (80%) and interbody implants (93%) in acute infection, to retain interbody implants in chronic/recurrent infection (71%), and application of topical antibiotics in recurrent infection (85%). There was consensus on the use of absorbable suture to close fascia in acute (83%) and chronic (87%) infection. Eighty-five percent of surgeons used nonabsorbable materials such as Nylon or staples for skin closure in chronic infection, however, there was no consensus in acute infection. Surgeons varied significantly in type, volume and pressure of fluids, adjuvant solvents, graft management, use of topical antibiotics acutely, and the use of negative pressure wound therapy. Partial hardware exchange was controversial. Additionally, specialty or surgeon experience had no impact on management strategy. Conclusions This survey demonstrates significant heterogeneity amongst Canadian adult spine surgeons regarding key steps in the surgical management of deep instrumented spine infection, concordant with scarce literature addressing these steps.

Incidence and Recurrence of Deep Spine Surgical Site Infections

“…Beyond the interventions discussed above, there is little evidence for other deep SSI management strategies. Sarraj et al 15 present a survey of Canadian spinal surgeons’ infection management strategies for acute and delayed infections. The authors found significant variation in type, volume and pressure of fluids used in irrigation, management of bone graft and instrumentation, the use of intrawound antibiotics, and closure techniques.…”

“…Factors during surgery include but are not limited to type and volume of irrigation used, implant exchange or removal, 12,13 bone graft removal, postoperative antimicrobials, 14 and vacuum-assisted closure (VAC) techniques. However, among high-volume adult spinal surgeons, there is relatively little consensus on surgical technique and management in the setting of instrumented thoracolumbar spine SSI 15 …”

“…However, among high-volume adult spinal surgeons, there is relatively little consensus on surgical technique and management in the setting of instrumented thoracolumbar spine SSI. 15 The current state of evidence for the management of instrumented spinal SSI is in stark contrast to other surgical fields, such as hip and knee arthroplasty, where rigorous guidelines for diagnosis and management are widely accepted and used. 16,17 The objective of this investigation was to systematically determine the global incidence of deep SSI after instrumented thoracolumbar surgery, determine the incidence of recurrence, and identify the evidence for various surgical treatment modalities.…”