Management of Deep Spinal Wound Infections Following Instrumentation Surgery with Subfascial Negative Pressure Wound Therapy

Abstract

Background and Study Aims The treatment of infections following a spine surgery continues to be a challenge. Negative pressure wound therapy (NPWT) has been an effective method in the context of infection therapy, and its use has gained popularity in recent decades. This study aims to analyze the impact of known risk factors for postoperative wound infection on the efficiency and length of NPWT therapy until healing.

Patients and Methods We analyzed 50 cases of NPWT treatment for deep wound infection after posterior and posteroanterior spinal fusion from March 2010 to July 2014 retrospectively. We included 32 women and 18 men with a mean age of 69 years (range, 36–87 years). Individual risk factors for postoperative infection, such as age, gender, obesity, diabetes, immunosuppression, duration of surgery, intraoperative blood loss, and previous surgeries, as well as type and onset (early vs. late) of the infection were analyzed. We assessed the associations between these risk factors and the number of revisions until wound healing.

Results In 42 patients (84%), bacterial pathogens were successfully detected by means of intraoperative swabs and tissue samples during first revision. A total of 19 different pathogens could be identified with a preponderance of Staphylococcus epidermidis (21.4%) and S. aureus (19.0%). Methicillin-resistant S. aureus (MRSA) was recorded in two patients (2.6%). An average of four NPWT revisions was required until the infection was cured. Patients with infections caused by mixed pathogens required a significantly higher number of revisions (5.3 vs. 3.3; p < 0.01) until definitive wound healing. For the risk factors, no significant differences in the number of revisions could be demonstrated when compared with the patients without the respective risk factor.

Conclusion NPWT was an effective therapy for the treatment of wound infections after spinal fusion. All patients in the study had their infections successfully cured, and all spinal implants could be retained. The number of revisions was similar to those reported in the published literature. The present study provides insights regarding the effectiveness of NPWT for the treatment of deep wound infection after spinal fusion. Further investigations on the impact of potential risk factors for postoperative wound healing disorders are required. Better knowledge on the impact of specific risk factors will contribute to a higher effectiveness of prophylaxis for postoperative wound infections considering the patient-specific situation.

Keywords

spinal surgery - infection risk factors - postoperative wound infection - negative pressure wound therapy

Publication History

Received: 01 March 2020

Accepted: 22 June 2020

Article published online:
27 January 2021

• References

• 1 Rickert M, Fleege C, Rauschmann M. Algorithm for treatment of spinal infections and first results of a retrospective analysis of postoperative wound infection and application of a vacuum system for infection treatment. Wirbelsäule 2017; 1: 265-272
• 2 Palmer C, Jones C, Park D. Postoperative infections of the spine. Semin Spine Sur 2015; 28 (03) 134-145
• 3 Gastmeier P, Geffers C. Nosocomial infections in Germany. What are the numbers, based on the estimates for 2006?. Dtsch Med Wochenschr 2008; 133 (21) 1111-1115
• 4 Hauer T, Lacour M, Gastmeier P. et al. Nosocomial infections in Germany. Microbiological diagnosis, preventive antibiotics and antibiotic therapy. Med Klin (Munich) 1996; 91 (11) 681-686
• 5 Rickert M, Schleicher P, Fleege C. et al. Management of postoperative wound infections following spine surgery: first results of a multicenter study. Orthopade 2016; 45 (09) 780-788
• 6 Cahill PJ, Warnick DE, Lee MJ. et al. Infection after spinal fusion for pediatric spinal deformity: thirty years of experience at a single institution. Spine 2010; 35 (12) 1211-1217
• 7 Schuster JM, Rechtine G, Norvell DC, Dettori JR. The influence of perioperative risk factors and therapeutic interventions on infection rates after spine surgery: a systematic review. Spine 2010; 35 (09) S125-S137
• 8 Kampf G, Gastmeier P, Wischnewski N. et al. Analysis of risk factors for nosocomial infections: results from the first national prevalence survey in Germany (NIDEP study, part 1). J Hosp Infect 1997; 37 (02) 103-112
• 9 Mehbod AA, Ogilvie JW, Pinto MR. et al. Postoperative deep wound infections in adults after spinal fusion: management with vacuum-assisted wound closure. J Spinal Disord Tech 2005; 18 (01) 14-17
• 10 Fang A, Hu SS, Endres N, Bradford DS. Risk factors for infection after spinal surgery. Spine 2005; 30 (12) 1460-1465
• 11 Knapik JJ, Bedno SA. Epidemiological evidence and possible mechanisms for the association between cigarette smoking and injuries (part 1). J Spec Oper Med 2018; 18 (01) 108-112
• 12 Correia MI, Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr 2003; 22 (03) 235-239
• 13 Penel N, Lefebvre D, Fournier C, Sarini J, Kara A, Lefebvre JL. Risk factors for wound infection in head and neck cancer surgery: a prospective study. Head Neck 2001; 23 (06) 447-455
• 14 Olsen MA, Nepple JJ, Riew KD. et al. Risk factors for surgical site infection following orthopaedic spinal operations. J Bone Joint Surg Am 2008; 90 (01) 62-69
• 15 Brandt C, Hansen S, Sohr D, Daschner F, Rüden H, Gastmeier P. Finding a method for optimizing risk adjustment when comparing surgical-site infection rates. Infect Control Hosp Epidemiol 2004; 25 (04) 313-318
• 16 Bible JE, Biswas D, Devin CJ. Postoperative infections of the spine. Am J Orthop 2011; 40 (12) E264-E271
• 17 Ploumis A, Mehbod AA, Dressel TD, Dykes DC, Transfeldt EE, Lonstein JE. Therapy of spinal wound infections using vacuum-assisted wound closure: risk factors leading to resistance to treatment. J Spinal Disord Tech 2008; 21 (05) 320-323
• 18 Schimmel JJ, Horsting PP, de Kleuver M, Wonders G, van Limbeek J. Risk factors for deep surgical site infections after spinal fusion. Eur Spine J 2010; 19 (10) 1711-1719
• 19 Petilon JM, Glassman SD, Dimar JR, Carreon LY. Clinical outcomes after lumbar fusion complicated by deep wound infection: a case-control study. Spine 2012; 37 (16) 1370-1374
• 20 Pull ter Gunne AF, Cohen DB. Incidence, prevalence, and analysis of risk factors for surgical site infection following adult spinal surgery. Spine 2009; 34 (13) 1422-1428
• 21 Fleischmann W, Lang E, Russ M. Treatment of infection by vacuum sealing. Unfallchirurg 1997; 100 (04) 301-304
• 22 Dunford CE. Treatment of a wound infection in a patient with mantle cell lymphoma. Br J Nurs 2001; 10 (16) 1058-1065 , 1060, 1062, 1064–1065
• 23 Lee R, Beder D, Street J. et al. The use of vacuum-assisted closure in spinal wound infections with or without exposed dura. Eur Spine J 2018; 27 (10) 2536-2542
• 24 Ridwan S, Grote A, Simon M. Safety and efficacy of negative pressure wound therapy for deep spinal wound infections after dural exposure, durotomy, or intradural surgery. World Neurosurg 2020; 134: e624-e630
• 25 Ousey KJ, Atkinson RA, Williamson JB, Lui S. Negative pressure wound therapy (NPWT) for spinal wounds: a systematic review. Spine J 2013; 13 (10) 1393-1405
• 26 World Union of Wound Healing Societies (WUWHS), Vakuum-assistierter Verschluss: Anwendungsempfehlungen, Ein Konsensusdokument. London: World Union of Wound Healing Societies; 2008
• 27 Chaichana KL, Bydon M, Santiago-Dieppa DR. et al. Risk of infection following posterior instrumented lumbar fusion for degenerative spine disease in 817 consecutive cases. J Neurosurg Spine 2014; 20 (01) 45-52
• 28 Peel AL, Taylor EW. Surgical Infection Study Group. Proposed definitions for the audit of postoperative infection: a discussion paper. Ann R Coll Surg Engl 1991; 73 (06) 385-388
• 29 Tsubouchi N, Fujibayashi S, Otsuki B. et al. Risk factors for implant removal after spinal surgical site infection. Eur Spine J 2018; 27 (10) 2481-2490
• 30 Nam D, Sershon RA, Levine BR, Della Valle CJ. The use of closed incision negative-pressure wound therapy in orthopaedic surgery. J Am Acad Orthop Surg 2018; 26 (09) 295-302
• 31 Willy C. Die Vakuumtherapie: Grundlagen, Indikationen, Fallbeispiele, praktische Tipps. 1st ed. Berlin: Anna Lindqvist Book Publishing; 2005
• 32 Jones GA, Butler J, Lieberman I, Schlenk R. Negative-pressure wound therapy in the treatment of complex postoperative spinal wound infections: complications and lessons learned using vacuum-assisted closure. J Neurosurg Spine 2007; 6 (05) 407-411
• 33 van Rhee MA, de Klerk LW, Verhaar JA. Vacuum-assisted wound closure of deep infections after instrumented spinal fusion in six children with neuromuscular scoliosis. Spine J 2007; 7 (05) 596-600
• 34 Labler L, Keel M, Trentz O, Heinzelmann M. Wound conditioning by vacuum assisted closure (V.A.C.) in postoperative infections after dorsal spine surgery. Eur Spine J 2006; 15 (09) 1388-1396
• 35 Glassman SD, Dimar JR, Puno RM, Johnson JR. Salvage of instrumental lumbar fusions complicated by surgical wound infection. Spine (Phila Pa 1976) 1996; 21 (18) 2163-2169
• 36 Picada R, Winter RB, Lonstein JE. et al. Postoperative deep wound infection in adults after posterior lumbosacral spine fusion with instrumentation: incidence and management. J Spinal Disord 2000; 13 (01) 42-45
• 37 Yao R, Zhou H, Choma TJ, Kwon BK, Street J. Surgical site infection in spine surgery: who is at risk?. Global Spine J 2018; 8 (04) 5S-30S
• 38 Reihsaus E, Waldbaur H, Seeling W. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 2000; 23 (04) 175-204 , discussion 205
• 39 Pull ter Gunne AF, Hosman AJ, Cohen DB. et al. A methodological systematic review on surgical site infections following spinal surgery: part 1: risk factors. Spine 2012; 37 (24) 2017-2033
• 40 Pull ter Gunne AF, Mohamed AS, Skolasky RL, van Laarhoven CJ, Cohen DB. The presentation, incidence, etiology, and treatment of surgical site infections after spinal surgery. Spine 2010; 35 (13) 1323-1328
• 41 Collins I, Wilson-MacDonald J, Chami G. et al. The diagnosis and management of infection following instrumented spinal fusion. Eur Spine J 2008; 17 (03) 445-450
• 42 Rihn JA, Lee JY, Ward WT. Infection after the surgical treatment of adolescent idiopathic scoliosis: evaluation of the diagnosis, treatment, and impact on clinical outcomes. Spine 2008; 33 (03) 289-294
• 43 Mok JM, Guillaume TJ, Talu U. et al. Clinical outcome of deep wound infection after instrumented posterior spinal fusion: a matched cohort analysis. Spine 2009; 34 (06) 578-583