Journal List > J Korean Soc Spine Surg > v.16(4) > 1035866

Ahn, Choi, Park, Kim, Chun, and Yang: Precautions Against Infection Following Posterior Spinal Fusion Based on Types of Infection and Risk Factors

Abstract

Study Design

This is a retrospective preparative study and prospective study

Objective

We instituted and verified the precautions against postoperative spinal infection.

Summary of the Literature Review

Postoperative infection comes from contamination during the operation and various strategies have been recommended to prevent it.

Materials and Methods

583 cases that underwent instrumented posterior spinal fusion during two years (group I), were reviewed to discover the risk factors, and intraoperative cultures were done to detect the contamination routes and the causative microorganisms for the next 4 months. Six precautions, based on the results, were instituted. We analyzed 354 cases that underwent operation in the following year (group II) using the precautions.

Results

Twenty cases (3.4%) were infected in group I and the types of infection were superficial wound infection (4 cases), deep wound infection (4 cases), osteomyelitis around the interbody space (7 cases), osteomyelitis around the pedicle screws (4 cases) and a combination of wound infection and osteomyelitis around the pedicle screws (1 case). Infections happened more frequently in the cases of interbody fusion (p=0.034), revision (p=0.087) and those done in the summer season (p=0.025). S. epidermidis, as the causative bacteria, was cultured from both the operation environments and wounds. Six precautions based on the preliminary results were instituted as follows; irrigation method reformation, delayed opening of instruments, turning-off local air conditioners, changing of gowns before instrumentation, local bone irrigation and limited indications for interbody fusion. After implementation, two cases (0.6%) of infection developed in group II (p=0.002, odds ratio=0.160; 95% confidence interval = 0.037 to 0.688).

Conclusion

Wounds, grafted bones or instruments can be contaminated under longer-time exposure to operating room air and so produce interbody or pedicle osteomyelitis without wound infection. The precautions were effective to decrease the postoperative infection rates following posterior spinal fusion.

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Fig. 1.
Osteomyleitis around interbody graft. (A, B) Blurring of endplate signal and rod breakage were noticed on postoperative 4 month follow-up radiographs. (C, D) 1mm-fine cutting CT showed punched-out lesion on endplate which was strongly suggestive finding of intervertebral osteomyelitis.
jkss-16-274f1.tif
Fig. 2.
Osteomyelitis around pedicle screws. (A,B) A pedicle screw cut out upper endplate at 3 month follow-up. (C,D) T1 view showed low signal on vertebral body with suggesting osteomyelitis but there was no signal change on soft tissue suggesting superficial or deep wound infection.
jkss-16-274f2.tif
Table 1.
Risk factors for postoperative infection in group I
  No infection Infection p-value
Total cases 563 20  
Age (years) 61.3±9.6 61.5±9.3 0.779
Sex     0.378
Female 390 12  
Male 173 8  
Numbers of fusion segments 1.4±0.7 1.4±0.6 0.547
Length of fusion segments     0.609
Less than 3 level 517 19  
3 or more level 46 1  
Amount of blood loss (ml) 975±305 1050±332 0.465
Operation time (min) 198±53 201±57 0.908
Major types of operation     0.034∗
Posterior or posterolateral fusion 61 0  
Posterior interbody fusion 502 20  
Dominant types of bone graft     0.357
Local chips 550 20  
Allograft 13 0  
Virgin or Revision operation     0.087∗
Virgin 494 15  
Revision 68 5  
Seasons of operation     0.025∗
Winter season(Oct. to Mar.) 224 3  
Summer season(Apr. to Sep.) 339 17  
Diabetes Mellitus      
DM negative 479 18 0.753
DM positive 84 2  

∗ Statistically significant (confidence interval 10% to reduce beta error intentionally)

Table 2.
Types of infection and causative microorganism
Types of infection   Microorganism  
Wound infection (8 cases)      
Superficial wound infection 4 S. epidermidis 7
Deep wound infection 4 No-growth 1
Osteomyelitis (12 cases)      
Around interbody grafts 7 S. epidermidis 1
Around pedicle screws 4 S. aureus 1
Around pedicle screws with wound infection 1 No-growth 2
    Unavailable 8
Table 3.
Comparable variables between the groups
  Group I Group II p-value
Total cases 583 354  
Age (years) 61.3±9.5 62.9±10.0 0.005∗
Sex     0.017∗
Female 402 217  
Male 181 137  
Numbers of fusion segments 1.4±0.7 1.5±0.9 0.074
Length of fusion segments     0.916
Less than 3 level 538 326  
3 or more level 45 28  
Amount of blood loss (ml) 978±305 1218±527 0.000∗
Operation time (min) 198±53 209±65 0.049∗
Major types of operation     0.000∗
Posterior or posterolateral fusion 63 83  
Posterior interbody fusion 500 271  
Dominant types of bone graft     0.002∗
Local chips 570 332  
Allograft 13 22  
Virgin or Revision operation     0.081
Virgin 509 295  
Revision 73 59  
Seasons of operation     0.943
Winter season (Oct. to Mar.) 227 137  
Summer season(Apr. to Sep.) 356 217  
Diabetes Mellitus     0.084
DM negative 497 286  
DM positive 86 68  

∗ Statistically significant (confidence interval 5%)

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