Infections In Spine Surgery Syllabus
2015-04-01
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3/30/2015 Ira M. Goldstein, MD FAANS Associate Professor Department of Neurological Surgery Rutgers – New Jersey Medical School Newark, New Jersey Discussion #2: Indications for medical intervention of primary osteodiskitis and epidural abscess - Diagnosis - Treatment considerations - When to consider surgical consultation Disclosures: Alphatec spine consulting Biomet spine consulting DepuySynthes spine – travel expenses, speaking honorarium Globus spine – travel expenses Zimmer spine consulting This presentation will not include product names, promote use of any company’s products, or promote the off-label use of any drugs or devices 1. Diagnosis of osteomyelitis and epidural abscess - Clinical presentation - Laboratory markers - Imaging studies 1 3/30/2015 1. Diagnosis of osteomyelitis and epidural abscess -Clinical presentation Onset or exacerbation of neck or back pain No relief with rest or analgesics Pain often worse at night Fever New neurologic deficit Cachexia Tsiodras S, Falagas ME. Clinical assessment and medical treatment of spine infections. Clin Orthop Relat Res 2006;444:38e50. Fantoni M, Trecarichi EM, Rossi B, Mazzotta V, Di Giacomo G, Nasto LA, Di Meco E, Pola E. Epidemiological and clinical features of pyogenic spondylodiskitis. Eur Rev Med Pharmacol Sci. 2012 Apr;16 Suppl 2:2-7. Ziu M, Dengler B, Cordell D, Bartanusz V. Diagnosis and management of primary pyogenic spinal infections in intravenous recreational drug users. Neurosurg Focus. 2014 Aug;37(2):E3. 1. Diagnosis of osteomyelitis and epidural abscess -Clinical presentation Epidemiologic features: Immunosuppression: HIV infection, chemotherapy, organ transplantation, chronic steroid use Intravenous drug use Advanced age Diabetes mellitus Chronic renal disease Chronic liver disease Malignancy Prior trauma or surgery Carragee EJ. Pyogenic vertebral osteomyelitis. J Bone Joint Surg Am 1997;79:874e80. Fantoni M, Trecarichi EM, Rossi B, Mazzotta V, Di Giacomo G, Nasto LA, Di Meco E, Pola E. Epidemiological and clinical features of pyogenic spondylodiskitis. Eur Rev Med Pharmacol Sci. 2012 Apr;16 Suppl 2:2-7. Ziu M, Dengler B, Cordell D, Bartanusz V. Diagnosis and management of primary pyogenic spinal infections in intravenous recreational drug users. Neurosurg Focus. 2014 Aug;37(2):E3. Illustrative case – ‘Tony’ 60 yo M, h/o DM and HTN. s/p MVA 4 months ago. Presented to outside hospital with 3 months of thoracic back pain, chest pain and SOB CT chest PE study obtained demonstrating bony destruction and surrounding mediastinal enhancement Patient was transferred to University Hospital 2 3/30/2015 1. Diagnosis of osteomyelitis and epidural abscess -Laboratory Markers Peripheral WBC Sedimentation Poor sensitivity orRate specificity for epidural abscess or osteomyelitis Elevated neutrophil count from peripheral smear more useful C- high ESR Reactive sensitivity Protein for 50% pyogenic infection Leukocytosis sensitivity or less Level tends to remain high for prolonged period Acute phase reactant – faster response to clinical picture Poor specificity – generalized marker of infection/inflammation Procalcitonin Poor specificity AcuteLiver upregulation in presence of infection production – dampened response with hepatic insufficiency Not affected by noninfectious inflammatory processes (eg trauma, MI, recent surgery, DVT) Highly sensitive and specific for infection Black S, Kushner I, Samols D. C-reactive Protein. J Biol Chem 2004; 279: 48487–48490. Takahashi J, Ebara S, Kamimura M, Kinoshita T, Itoh H, Yuzawa Y et al. Early-phase enhanced inflammatory reaction after spinal instrumentation surgery. Spine 2001; 26: 1698–1704. Mok JM, Pekmezci M, Piper SL, Boyd E, Berven SH, Burch S, Deviren V, Tay B, Hu SS. Use of C-reactive protein after spinal surgery: comparison with erythrocyte sedimentation rate as predictor of early postoperative infectious complications. Spine (Phila Pa 1976). 2008 Feb 15;33(4):415-21. Huang K, Du G, Wei C, Gu S, Tang J. Elevated serum lactoferrin and neopterin are associated with postoperative infectious complications in patients with acute traumatic spinal cord injury. Arch Med Sci. 2013 Oct 31;9(5):865-71. Nie H, Jiang D, Ou Y, Quan Z, Hao J, Bai C, Huang X, An H. Procalcitonin as an early predictor of postoperative infectious complications in patients with acute traumatic spinal cord injury. Spinal Cord. 2011 Jun;49(6):715-20. Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ. Hematogenous pyogenic spinal infections and their surgical management. Spine (Phila Pa 1976). 2000 Jul 1;25(13):1668-79. Higher serum procalcitonin (PCT) levels (p<0.001) and C-reactive protein (p<0.01) seen in postop infection From Nie et al Normal postoperative CRP values and deterioration in patients without complication. Values represent decrease from postop peak CRP value (peak is variable and typically seen postop day 2-3). From Mok et al 1. Diagnosis of osteomyelitis and epidural abscess -Laboratory Markers Greater elevation of WBC, ESR, CRP, and PRL seen in pyogenic compared to tuberculous osteomyelitis Greater yield of blood cultures (40-50%) in pyogenic compared to tuberculous osteomyelitis (0-10%) Spine (Phila Pa 1976). 2010 Oct 1;35(21):E1096-100. doi: 10.1097/BRS.0b013e3181e04dd3. A comparative study of pyogenic and tuberculous spondylodiscitis. Kim CJ1, Song KH, Jeon JH, Park WB, Park SW, Kim HB, Oh MD, Choe KW, Kim NJ. 3 3/30/2015 1. Diagnosis of osteomyelitis and epidural abscess -Radiology MRI CT CT +/- gadolinium is gold standard for spinal canal imaging MRI PET-CT MRI DWI to distinguish abscess from other collection Helpful at sequence demonstrating bony involvement/erosion Radionuclide studies Contrast enhancement of paraspinal PET imaging not susceptible to metalcollection artifact can suggest abscess Not specific or sensitive to infection – increased uptake with inflammation Tagged WBC studies poorlythan specific to WBCs inofvertebral Less sensitive and specific MRI due for evaluation infection marrow Tc99m uptake in osteoporosis, degenerative disease, and metastases in addition to infection Riccio SA, Chu AK, Rabin HR, Kloiber R. Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Interpretation Criteria for Assessment of Antibiotic Treatment Response in Pyogenic Spine Infection. Can Assoc Radiol J. 2015 Jan 13. Diehn FE. Imaging of spine infection. Radiol Clin North Am. 2012 Jul;50(4):777-98. Radcliff KE, Morrison WB, Kepler C, Moore J, Sidhu G, Gendelberg D, Miller L, Sonagli M, Vaccaro AR. Distinguishing Pseudomeningocele, Epidural Hematoma, and Postoperative Infection on Postoperative MRI. J Spinal Disord Tech. 2013 Nov 5. Moritani T, Kim J, Capizzano AA, Kirby P, Kademian J, Sato Y. Pyogenic and non-pyogenic spinal infections: emphasis on diffusion-weighted imaging for the detection of abscesses and pus collections. Br J Radiol. 2014 Sep;87(1041):20140011. Lee IS, Lee JS, Kim SJ, Jun S, Suh KT. Fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography imaging in pyogenic and tuberculous spondylitis: preliminary study. J Comput Assist Tomogr. 2009 Jul-Aug;33(4):587-92. Palestro CJ. Radionuclide imaging of osteomyelitis. Semin Nucl Med. 2015 Jan;45(1):32-46. Thivolle P, Mathieu L, Mathieu P, Raynal M, Bouyoucef SE, Damideaux J, Vignon E, Berger M. Significance of solitary spine abnormalities on technetium-99m bone imaging. Clin Nucl Med. 1988 Jul;13(7):527-8. Illustrative case – ‘Tony’ Illustrative case – ‘Tony’ CT looked suspicious for osteomyelitis, however only axial views present PEx: AAOx3, Neurologically nonfocal exam Mild SOB Tender to palpation/percussion over thoracic spine Afebrile Blood cultures ordered (subsequently demonstrated no growth) WBC 7.1 ESR 97 CRP 34 HIV negative Quantiferon gold negative Neurosurgery consulted – MRI Tspine +/- contrast recommended as well as TLSO brace 4 3/30/2015 Illustrative case – ‘Tony’ MRI Tspine: T2 T1 T1 + gad 2. Antibiotic treatment factors -Empiric abx – pro/con -Isolation of organism -Treatment duration 2. Antibiotic treatment factors -Empiric abx – pro/con Broad-spectrum coverage generally advocated until organism isolated Immobilization of infected spinal column via bracing Short term course of abx (<4 days) reported to not impact yield of biopsy In some cases an organism is never isolated Marschall J, Bhavan KP, Olsen MA, Fraser VJ, Wright NM, Warren DK. The impact of prebiopsy antibiotics on pathogen recovery in hematogenous vertebral osteomyelitis. Clin Infect Dis. 2011 Apr 1;52(7):867-72. Pola E, Logroscino CA, Gentiempo M, Colangelo D, Mazzotta V, Di Meco E, Fantoni M. Medical and surgical treatment of pyogenic spondylodiscitis. Eur Rev Med Pharmacol Sci. 2012 Apr;16 Suppl 2:35-49. Rankine JJ, Barron DA, Robinson P, Millner PA, Dickson RA. Therapeutic impact of percutaneous spinal biopsy in spinal infection. Postgrad Med J. 2004 Oct;80(948):607-9. 5 3/30/2015 2. Antibiotic treatment factors -Isolation of organism: Yield of blood culture (20-50%) Yield of percutaneous CT guided biopsy (53% Marschall; 32% Heyer; 72% Luzzatti; 48% Pupaibool ) Yield of surgical biopsy (91% Marschall; 92% Luzzatti) 60% concordance between blood culture result and biopsy result (Nanda) Lower yield if TB is organism Lower yield in diabetic patient Greater yield if presence of paraspinal abscess Greater yield if higher CRP value Heyer CM, Brus LJ, Peters SA, Lemburg SP. Efficacy of CT-guided biopsies of the spine in patients with spondylitis--an analysis of 164 procedures. Eur J Radiol. 2012 Mar;81(3):e244-9. Pupaibool J, Vasoo S, Erwin PJ, Murad MH, Berbari EF. The utility of image-guided percutaneous needle aspiration biopsy for the diagnosis of spontaneous vertebral osteomyelitis: a systematic review and meta-analysis. Spine J. 2015 Jan 1;15(1):122-31. Gras G, Buzele R, Parienti JJ, Debiais F, Dinh A, Dupon M, Roblot F, Mulleman D, Marcelli C, Michon J, Bernard L. Microbiological diagnosis of vertebral osteomyelitis: relevance of second percutaneous biopsy following initial negative biopsy and limited yield of post-biopsy blood cultures. Eur J Clin Microbiol Infect Dis. 2014 Mar;33(3):371-5. Marschall J, Bhavan KP, Olsen MA, Fraser VJ, Wright NM, Warren DK. The impact of prebiopsy antibiotics on pathogen recovery in hematogenous vertebral osteomyelitis. Clin Infect Dis. 2011 Apr 1;52(7):867-72. Rankine JJ, Barron DA, Robinson P, Millner PA, Dickson RA. Therapeutic impact of percutaneous spinal biopsy in spinal infection. Postgrad Med J. 2004 Oct;80(948):607-9. Kim CJ, Song KH, Park WB, Kim ES, Park SW, Kim HB, Oh MD, Kim NJ. Microbiologically and clinically diagnosed vertebral osteomyelitis: impact of prior antibiotic exposure. Antimicrob Agents Chemother. 2012 Apr;56(4):2122-4. Connor DE Jr, Chittiboina P, Caldito G, Nanda A. Comparison of operative and nonoperative management of spinal epidural abscess: a retrospective review of clinical and laboratory predictors of neurological outcome. J Neurosurg Spine. 2013 Jul;19(1):119-27. Luzzati R, Giacomazzi D, Danzi MC, Tacconi L, Concia E, Vento S. Diagnosis, management and outcome of clinically- suspected spinal infection. J Infect. 2009 Apr;58(4):259-65. Pupaibool J, Vasoo S, Erwin PJ, Murad MH, Berbari EF. The utility of image-guided percutaneous needle aspiration biopsy for the diagnosis of spontaneous vertebral osteomyelitis: a systematic review and meta-analysis. Spine J. 2015 Jan 1;15(1):122-31. Illustrative case – ‘Tony’ MRI Tspine interpreted as consistent with osteomyelitis at T8-9 Minimal kyphosis Minimal canal stenosis Infectious Disease consulted TLSO brace ordered Interventional Radiology consulted for CT guided biopsy of T8-9 disk Illustrative case – ‘Tony’ 6 3/30/2015 Illustrative case – ‘Tony’ Following failure of CT guided biopsy to identify an organism, in the rib head or otherwise, neurosurgery is consulted to perform an intraoperative, fluoroscopically guided biopsy: 2. Antibiotic treatment factors -Treatment duration: Standardized duration (6 weeks) vs Serial monitoring of serologies (Yoon et al and Bettini et al, below): followup ESR, CRP for appropriate response at 4 weeks (ESR >55 and CRP > 2.75 corresponded with treatment failure); treatment duration based on lab value responses to treatment Yoon SH, Chung SK, Kim KJ, Kim HJ, Jin YJ, Kim HB. Pyogenic vertebral osteomyelitis: identification of microorganism and laboratory markers used to predict clinical outcome. Eur Spine J. 2010 Apr;19(4):575-82. doi: 10.1007/s00586-009-1216-1. Bettini N, Girardo M, Dema E, Cervellati S. Evaluation of conservative treatment of non specific spondylodiscitis. Eur Spine J. 2009 Jun;18 Suppl 1:143-50. Connor DE Jr, Chittiboina P, Caldito G, Nanda A. Comparison of operative and nonoperative management of spinal epidural abscess: a retrospective review of clinical and laboratory predictors of neurological outcome. J Neurosurg Spine. 2013 Jul;19(1):119-27. Riccio SA, Chu AK, Rabin HR, Kloiber R. Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Interpretation Criteria for Assessment of Antibiotic Treatment Response in Pyogenic Spine Infection. Can Assoc Radiol J. 2015 Jan 13. Bernard L, Dinh A, Ghout I, Simo D, Zeller V, Issartel B, Le Moing V, Belmatoug N, Lesprit P, Bru JP, Therby A, Bouhour D, Dénes E, Debard A, Chirouze C, Fèvre K, Dupon M, Aegerter P, Mulleman D; on behalf of the Duration of Treatment for Spondylodiscitis (DTS) study group. Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomised, controlled trial. Lancet. 2014 Nov 5. 2. Antibiotic treatment factors Treatment failure/recurrence: Most treatment failure seen within 2 years; average under 5 months Most failure seen with S. aureus as organism and greater duration of infection prior to treatment Treatment failure more likely with shorter duration of antibiotic therapy Failure LESS likely in osteomyelitis cases with no isolated organism 75% rate of failure of medical treatment of cervical epidural abscess due to neurologic deterioration (Alton) Greater likelihood of treatment failure with tuberculous osteomyelitis due to deformity and/or neurologic deficit (Colmenero) Gupta A, Kowalski TJ, Osmon DR, Enzler M, Steckelberg JM, Huddleston PM, Nassr A, Mandrekar JM, Berbari EF. Long-term outcome of pyogenic vertebral osteomyelitis: a cohort study of 260 . patients. Open Forum Infect Dis. 2014 Dec 5;1(3):ofu107 Kim J, Kim YS, Peck KR, Kim ES, Cho SY, Ha YE, Kang CI, Chung DR, Song JH. Outcome of culture-negative pyogenic vertebral osteomyelitis: comparison with microbiologically confirmed pyogenic vertebral osteomyelitis. Semin Arthritis Rheum. 2014 Oct;44(2):246-52. Alton TB, Patel AR, Bransford RJ, Bellabarba C, Lee MJ, Chapman JR. Is there a difference in neurologic outcome in medical versus early operative management of cervical epidural abscesses? Spine J. 2015 Jan 1;15(1):10-7 Colmenero JD, Jiménez-Mejías ME, Sánchez-Lora FJ, Reguera JM, Palomino-Nicás J, Martos F, García de las Heras J, Pachón J. Pyogenic, tuberculous, and brucellar vertebral osteomyelitis: a descriptive and comparative study of 219 cases. Ann Rheum Dis. 1997 Dec;56(12):709-15. 7 3/30/2015 Illustrative case – ‘Tony’ Intraoperative biopsy is positive for Streptococcus group G Patient is started on IV vancomycin and Zosyn once biopsy obtained and PICC line is placed; subsequently abx changed to IV ertepenem Do note the TLSO brace the patient is wearing wbc esr crp 2 weeks of treatment 5.4 81 14 4 weeks of treatment 6.1 54 5 IV abx stopped at 5 weeks, changed to PO keflex 6 weeks of treatment 5.6 57 6 Resume IV ertepenem 8 weeks of treatment 4.9 52 4 10 weeks of treatment 5.3 21 3 IV abx stopped 14 weeks of treatment 5.6 13 3 Illustrative case – ‘Tony’ No vertebral edema, ventral phlegmon resolved; sclerotic endplates with mild kyphosis on CT scan 9 months post-biopsy 3. When to consider surgical referral Developmentofofspinal Development spinaldeformity deformity Onset of Onset ofneurologic neurologicdeficit deficit Failure to Failure toidentify identifyorganism organism viavia CT-guided CT-guided biopsy biopsy Infection recalcitrant to medical therapy Patel AR, Alton TB, Bransford RJ, Lee MJ, Bellabarba CB, Chapman JR. Spinal epidural abscesses: risk factors, medical versus surgical management, a retrospective review of 128 cases. Spine J. 2014 Feb 1;14(2):326-30 Srinivasan D, Terman SW, Himedan M, Dugo D, La Marca F, Park P Risk factors for the development of deformity in patients with spinal infection. Neurosurg Focus. 2014 Aug;37(2):E2 Alton TB, Patel AR, Bransford RJ, Bellabarba C, Lee MJ, Chapman JR. Is there a difference in neurologic outcome in medical versus early operative management of cervical epidural abscesses? Spine J. 2015 Jan 1;15(1):10-7. Arnold R, Rock C, Croft L, Gilliam BL, Morgan DJ. Factors associated with treatment failure in vertebral osteomyelitis requiring spinal instrumentation. Antimicrob Agents Chemother. 2014;58(2):880-4. Srinivasan D, Terman SW, Himedan M, Dugo D, La Marca F, Park P Risk factors for the development of deformity in patients with spinal infection. Neurosurg Focus. 2014 Aug;37(2):E2 Ghobrial GM, Beygi S, Viereck MJ, Maulucci CM, Sharan A, Heller J, Jallo J, Prasad S, Harrop JS. Timing in the surgical evacuation of spinal epidural abscesses. Neurosurg Focus. 2014 Aug;37(2):E1. Bydon M, De la Garza-Ramos R, Macki M, Naumann M, Sciubba DM, Wolinsky JP, Bydon A, Gokaslan ZL, Witham TF. Spinal instrumentation in patients with primary spinal infections does not lead to greater recurrent infection rates: an analysis of 118 cases. World Neurosurg. 2014 Dec;82(6):e807-14. Connor DE Jr, Chittiboina P, Caldito G, Nanda A. Comparison of operative and nonoperative management of spinal epidural abscess: a retrospective review of clinical and laboratory predictors of neurological outcome. J Neurosurg Spine. 2013 Jul;19(1):119-27. Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ. Hematogenous pyogenic spinal infections and their surgical management. Spine (Phila Pa 1976). 2000 Jul 1;25(13):1668-79. Gasbarrini AL, Bertoldi E, Mazzetti M, Fini L, Terzi S, Gonella F, Mirabile L, Barbanti Bròdano G, Furno A, Gasbarrini A, Boriani S. Clinical features, diagnostic and therapeutic approaches to haematogenous vertebral osteomyelitis. Eur Rev Med Pharmacol Sci. 2005 Jan-Feb;9(1):53-66. 8 3/30/2015 • Thank you! 9 3/31/2015 Indications and Techniques for Surgical Intervention for Primary Vertebral Osteomyelitis/Discitis (PVO) Patrick C. Hsieh, M.D. Associate Professor USC Spine Center Department of Neurological Surgery USC Keck School of Medicine Disclosures • Depuy Spine – Consultant and research support • Medtronic – Consultant Pathophysiology • PVO can lead to: – Epidural abscess – Spinal instability – Sepsis • Spinal Cord/Nerve Compression • Vascular compromise – Arteritis – Thrombophlebitis 1 3/31/2015 Diagnostic Work-Up • Clinical suspicion • Laboratory – – – – CBC with differential ESR CRP Blood Cultures (~50-60%) • Imaging – MRI – CT with contrast • Biopsy • Lumbar puncture? Treatment • Timely treatment impacts outcome – Sepsis – Paralysis – Death • The mortality of SEA dropped from 34% in the period of 1954-1960 to 15% in 19911997 (Reihsaus et al; Spinal epidural abscess: a meta-analysis of 915 patients) Treatment • Medical treatment – – – – – – Culture based antibiotics Rx Empiric antibiotics Rx ID consult Neurosurgery/neurology consult Serial neuro monitoring Favorable factors • • • • • Neurological intact patient Lumbar or sacral disease Minimal spinal canal compromise Age Trending CBC/ESR/CRP/fever – Optimize volume status and BP 2 3/31/2015 Surgical Treatment • Surgical treatment indications – – – – Neurological deficits Failed medical treatment Spinal instability Post-infectious deformity • Timing – – – – Emergent/urgent versus Delayed Neurological status Location of abscess Degree of spinal canal compromise Goals of Surgical Treatment of PVO • Neural decompression • Confirm tissue diagnosis • Debridement of devitalized bone and tissues • Spinal stabilization when indicated • Surgical options – Decompression only • Laminectomy – Decompression and stabilization • Anterior • Posterior 3 3/31/2015 Page: 1 of 1 Surgery Options • Posterior approach – Laminectomy – Laminectomy and fusion • Anterior approach – Corpectomy and fusion cm • Anterior and posterior approaches Compressed 32:1 IM: 1001 – Posterolateral corpectomy and PSF Surgical Consideration • Minimize foreign bodies/non-vascularized – PEEK implant? • Implant selection – Titanium Vs. Stainless Steel • Graft selection – Autograft – Vascularized graft – rhBMP-2 • Tissue management – Obliterate dead space – Vascularized tissues Summary • Vertebral osteomyelitis/discitis with spinal epidural disease is associated with high morbidity/mortality rate • Early diagnosis and treatment is paramount • Antibiotics therapy is mainstay therapy • Surgery indicated in progressive neurological deficits, failure of medical treatment, postinfectious instability or deformity. 4 3/25/2015 Treatment of postoperative infection Nader Dahdaleh, MD Assistant professor Northwestern Neurosurgery Conflict of Interest • None Postoperative infection Early: weeks Delayed: months Superficial Deep Non instrumented Instrumented 1 3/25/2015 Postoperative infection Early: weeks Delayed: months Superficial Wound care and antibiotics Deep Non instrumented Instrumented Postoperative infection Early: weeks Delayed: months Superficial Deep Surgical debridement and antibiotics Non instrumented Instrumented Postoperative infection Early: weeks Delayed: months Superficial Deep Non instrumented Instrumented 2 3/25/2015 Risk factors Patient factors: • Advanced age • Malnutrition • Immunocompromised Intra-operative factors: • Length of surgery • Number of levels • Posterior surgical approach • Open surgery • Use of intra-operative equipment: microscopes, O-arm or C-arm Timing • Early: Staphylococcus aureus and betahemolytic Streptococcus • Delayed: less virulent pathogens, most commonly Propionibacterium acnes Management of deep wound postoperative infections in the presence of hardware • Retaining versus removing the hardware • Duration of antibiotics 3 3/25/2015 Lall RR, J clin neurosc, 2015 Lall RR, J clin neurosc, 2015 Case 1 • 70 year old man • Metastatic lung Ca: diagnosed 2005 • L5 metastases: s/p chemo and Rx Therapy X2 4 3/25/2015 Presented 4 weeks post op: Confusion, draining wound Fever, SBP: 90 WBC: 22,000 CRP 25 ESR >120 Blood cultures: E coli and Proteus Vulgaris Wound washout: emergent + broad spectrum antibiotics Wound cultures: same as blood cultures Post op: CRP dropped then increased over the next few days 2nd wound washout: broad spectrum antibiotics, discharged Presented with draining wound, increasing crp 10 days later 3rd wound washout and replacing hardware 5 3/25/2015 18 month follow up: Wound healed Suppressive antibiotic treatment: Ciprofloxacin Case 2 • 73 year old female • Metastatic melanoma • Mid thoracic pain, Neurologically normal T5 metastases 6 3/25/2015 Presented 4 weeks later with draining wound No fevers Nl WBC count Nl CRP Wound washout hardware retained 4 weeks oxacillin 4 weeks cephalexin Case 3 • 25 yo female with history of adolescent idiopathic scoliosis s/p selective thoracic fusion • She presented to the ED with right sided paraspinal pain and bump, s/p aspiration at an outside hospital 7 3/25/2015 Taken for wound exploration and washout Intraoperative purulent material involving the hardware on both sides Stainless steel hardware removal Cultures: P. Acnes Anbiotics: vancomycin then Meropenem X 12 weeks 8 3/25/2015 Deep wound infection in the presence of hardware Recent: weeks Gram positive Wound washout/keep hadware Antibiotics, Follow clinically CRP Delayed: months/years Gram negative Multiple Wound washouts, consider replacing hardware Antibiotics, Follow clinically CRP Wound washout removal of hardware Antibiotics, Follow clinically CRP 9 3/30/2015 Prevention and Cost of Post-Operative Infection VuMedi LSRS Presents: Infections in Spine Surgery Webinar Daniel S. Yanni, MD Director, Comprehensive Spine Neurosurgery Service March 31st, 2015 Rates of Post-Operative Infection • Rates of spinal SSI range from 1-12% • Surgery type, duration, and risk factors influence (Beiner, 2003) • Bone grafts and instrumentation increase risk of SSI • Implantation of foreign bodies • Revisions have a higher rate of SSI (up to 12%) (Radcliff, 2015) • MIS may have lower rate of SSI • Medical comorbidities WILL increase rates of SSI considerably • Time of day procedure performed can also influence • Surgery performed later in the day have been found to carry higher risk of SSI (Gruskay, 2012) Beiner, J. M., Grauer, J., Kwon, B. K. & Vaccaro, A. R. Postoperative wound infections of the spine. Neurosurg Focus 15, E14 (2003). Gruskay, J., Kepler, C., Smith, J., Radcliff, K. & Vaccaro, A. Is surgical case order associated with increased infection rate after spine surgery? Spine 37, 1170-1174, doi:10.1097/BRS.0b013e3182407859 (2012). Radcliff, K. E. et al. What is new in the diagnosis and prevention of spine surgical site infections. The spine journal : official journal of the North American SpineSurgery Society 15,31,336-347, doi:10.1016/j.spinee.2014.09.022 (2015). 2 Neurological | March 2015 Surgical Infections MIS Groups carry Decreased risk of surgical infections • O’Toole et al. retrospective review of 1338 MIS procedures – Simple decompression SSI 0.10% – Fusion SSI 0.74% – Composite for all MIS procedures 0.22% • Historically, open procedures SSI 2-6% – Decompression < 1% – Fusion > 10% SSI = surgical site infection O'Toole JE, Eichholz KM, Fessler RG. Surgical site infection rates after minimally invasive spinal surgery. J Neurosurg Spine. 2009 Oct;11(4):471-6. 3 1 3/30/2015 Prevention: Patient Selection and Modifiable Risk Factors • Consider conservative/non-operative management • multiple medical comorbidities, osteoporosis, and advanced age should be managed medically or OPTIMIZE prior to surgical intervention • Obese patients should be encouraged to reduce BMI <30 prior to surgery (De la Garza-Ramos, 2015) • Significantly higher risk of post-op complications with elevated BMI • Smoking cessation interventions for 1-2 months minimum before surgery can reduce risk of SSI (Thomsen, 2009) • Strict pre- and post-operative control of serum glucose levels • <125 mg/dL pre-op and <200mg/dL postop can reduce post-op SSI (Olsen, 2008) De la Garza-Ramos, R. et al. The impact of obesity on short- and long-term outcomes after lumbar fusion. Spine 40, 56-61, doi:10.1097/brs.0000000000000655 (2015). Olsen, M. A. et al. Risk factors for surgical site infection following orthopaedic spinal operations. The Journal of bone and joint surgery. American volume 90, 62-69, doi:10.2106/jbjs.f.01515 (2008). Thomsen, T., Tonnesen, H. & Moller, A. M. Effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation. The British journal of surgery 96, 451-461, doi:10.1002/bjs.6591 (2009). 4 Neurological Surgery | March 31, 2015 Prevention: Preoperative Reduction of Bacterial Colonization • Bathe preoperatively with Chlorhexidine gluconate (4%) • reduce postoperative spinal infections (Epstein, 2011) • Screening and decolonization of known nasal carriers of S. aureus • Also can reduce risk of SSI (Bode, 2010) Bode, L. G. et al. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. The New England journal of medicine 362, 9-17, doi:10.1056/NEJMoa0808939 (2010). Epstein, N. E. Preoperative, intraoperative, and postoperative measures to further reduce spinal infections. Surgical neurology international 2, 17, doi:10.4103/2152-7806.76938 (2011). 5 Neurological Surgery | March 31, 2015 Prevention: OR Prep of the Surgical Site • Significant variability in surgeon practices of preoperative skin preparation in spine surgery • Chlorhexidine appears to be more effective than povidoneiodine alone at reducing SSI (Al Maqbali, 2013) • Preoperative antiseptic skin preparation using chlorhexidine followed by povidone-iodine has been shown to reduce SSI in neurosurgical procedures (Guzel, 2009) • Thorough, sterile antiseptic skin preparation by a trained provider is critical in reducing SSI Al Maqbali, M. A. Preoperative antiseptic skin preparations and reducing SSI. British journal of nursing (Mark Allen Publishing) 22, 1227-1233, doi:10.12968/bjon.2013.22.21.1227 (2013). Guzel, A. et al. Evaluation of the skin flora after chlorhexidine and povidone-iodine preparation in neurosurgical practice. Surgical neurology 71, 207-210; discussion 210, doi:10.1016/j.surneu.2007.10.026 (2009). 6 Neurological Surgery | March 31, 2015 2 3/30/2015 Prevention: Intraoperative Contamination • Time in-room prior to procedure (>1hr) has been shown to increase SSI in spine surgery (Radcliff, 2013) • Insufficient intraoperative irrigation of the wound has been shown to be a risk factor for spinal SSI (Watanabe, 2010) • Many surgeons opt to use antibiotic-impregnated (Bacitracin) saline irrigation to reduce intraoperative bacterial growth, • reduction of SSIs is not clear (Savitz, 1998; Barnes, 2014) Barnes, S., Spencer, M., Graham, D. & Johnson, H. B. Surgical wound irrigation: a call for evidence-based standardization of practice. American journal of infection control 42, 525-529, doi:10.1016/j.ajic.2014.01.012 (2014). Radcliff, K. E. et al. Preoperative delay of more than 1 hour increases the risk of surgical site infection. Spine 38, 1318-1323, doi:10.1097/BRS.0b013e31828f1f0b (2013). Savitz, S. I., Savitz, M. H., Goldstein, H. B., Mouracade, C. T. & Malangone, S. Topical irrigation with polymyxin and bacitracin for spinal surgery. Surgical neurology 50, 208-212 (1998). Watanabe, M. et al. Risk factors for surgical site infection following spine surgery: efficacy of intraoperative saline irrigation. Journal of neurosurgery. Spine 12, 540-546, doi:10.3171/2009.11.spine09308 (2010). 7 Neurological Surgery | March 31, 2015 Paraspinal Muscle Injury and Infection MIS vs Open Paraspinal Muscle Ischemia and Infection • Stevens et al. compared intramuscular pressure generated by open vs MIS retractors – Cadaveric model showed 3 x higher pressure in open retractors vs MIS • Tissue perfusion pressure = retractor pressure – MAP • Open retractors can give a zero tissue perfusion pressure – Recommend taking down retractors and irrigating periodically during lengthy procedures – Correlated on post-op MRI with significant increase in T2 and ADC measurements • Attributed to edema associated with denervation and ischemia *ADC = apparent diffusion coefficient •Stevens KJ, Spenciner DB, Griffiths KL, Kim KD, Zwienenberg-Lee M, Alamin T, Bammer R. Comparison of minimally invasive and conventional open posterolateral lumbar fusion using magnetic resonance imaging and retraction pressure studies. J Spinal Disord Tech. 2006 Apr;19(2):77-86. 8 Prevention: Intraoperative Local Application of Antibiotics • Vancomycin powder is an easy, safe and inexpensive option for reduction of SSIs in spine surgery • Multiple studies and meta-analyses have demonstrated reduction in spinal SSI with use of vancomycin powder • Greater benefit in instrumented spine cases (Khan, 2014) • Some reports of sterile seromas with use of vancomycin powder Bakhsheshian, J., Dahdaleh, N. S., Lam, S. K., Savage, J. W. & Smith, Z. A. The Use of Vancomycin Powder In Modern Spine Surgery: Systematic Review and Meta-Analysis of the Clinical Evidence. World neurosurgery, doi:10.1016/j.wneu.2014.12.033 (2014). Khan, N. R. et al. A meta-analysis of spinal surgical site infection and vancomycin powder. Journal of neurosurgery. Spine 21, 974-983, doi:10.3171/2014.8.spine1445 (2014). 9 Neurological Surgery | March 31, 2015 3 3/30/2015 Prevention: Postoperative Antibiotic Prophylaxis • Antibiotic prophylaxis has been demonstrated to reduce spinal SSI by 63% (Barker 2002) • NASS recommends prophylactic antibiotics for instrumented and non-instrumented spine surgery • JCAHO recommends Administration of IV antibiotics within 1 hour of incision • Increase the antibiotic dosage to adjust for obesity Barker, F. G., 2nd. Efficacy of prophylactic antibiotic therapy in spinal surgery: a meta-analysis. Neurosurgery 51, 391-400; discussion 400-391 (2002). Olsen, M. A. et al. Risk factors for surgical site infection following orthopaedic spinal operations. The Journal of bone and joint surgery. American volume 90, 62-69, doi:10.2106/jbjs.f.01515 (2008). Savage, J. W. & Anderson, P. A. An update on modifiable factors to reduce the risk of surgical site infections. The spine journal : official journal of the North American Spine Society 13, 1017-1029, doi:10.1016/j.spinee.2013.03.051 (2013). 10 Neurological Surgery | March 31, 2015 Prevention: Closed-Suction Drains and Suture • Closed-suction drains have not been shown to have a significant affect on spinal fusion SSIs (Scuderi, 2005; Diab, 2012) • Some studies suggest antibacterial-coated sutures reduce the adherence of bacteria to the suture and may decrease the rate of SSI (Edmiston, 2006) • Antibiotic coated suture may reduce SSI when compared to non-treated suture (Ueno, 2013) Diab, M. et al. Use and outcomes of wound drain in spinal fusion for adolescent idiopathic scoliosis. Spine 37, 966-973, doi:10.1097/BRS.0b013e31823bbf0b (2012). Edmiston, C. E. et al. Bacterial adherence to surgical sutures: can antibacterial-coated sutures reduce the risk of microbial contamination? Journal of the American College of Surgeons 203, 481-489, doi:10.1016/j.jamcollsurg.2006.06.026 (2006). Scuderi, G. J., Brusovanik, G. V., Fitzhenry, L. N. & Vaccaro, A. R. Is wound drainage necessary after lumbar spinal fusion surgery? Medical science monitor : international medical journal of experimental and clinical research 11, Cr64-66 (2005). Ueno, M. et al. Triclosan-coated sutures reduce wound infections after spinal surgery: a retrospective, nonrandomized, clinical study. The spine journal : official journal of the North American Spine Society, doi:10.1016/j.spinee.2013.06.046 (2013). 11 Neurological Surgery | March 31, 2015 Prevention: Dressing • A Cochrane review found no particular wound dressing is more effective than others in reducing the rates of SSI • Silver-impregnated dressings may decrease rates of SSI in lumbar fusions (Epstein, 2007) • may be preferable for patients with moderate to high risk of infection (Leaper, 2010) Dumville, J. C., Gray, T. A., Walter, C. J., Sharp, C. A. & Page, T. Dressings for the prevention of surgical site infection. The Cochrane database of systematic reviews 9, Cd003091, doi:10.1002/14651858.CD003091.pub3 (2014). Epstein, N. E. Do silver-impregnated dressings limit infections after lumbar laminectomy with instrumented fusion? Surgical neurology 68, 483-485; discussion 485, doi:10.1016/j.surneu.2007.05.045 (2007). Leaper, D., Nazir, J., Roberts, C. & Searle, R. Economic and clinical contributions of an antimicrobial barrier dressing: a strategy for the reduction of surgical site infections. Journal of medical economics 13, 447-452, doi:10.3111/13696998.2010.502077 (2010). 12 Neurological Surgery | March 31, 2015 4 3/30/2015 Cost: Healthcare System Costs • Nearly 1 million SSIs happen in the US every year, with an estimated total cost of $1.6 billion (Zhan, 2003) • Direct health care cost of spinal SSI cervical and lumbar fusions ranges from $4,067 - $17,552 per infection • Can increase significantly when hardware affected • More study is needed in this area to assess the costs of SSI in spinal surgery Kuhns, B. D. et al. Cost and quality of life outcome analysis of postoperative infections after subaxial dorsal cervical fusions. Journal of neurosurgery. Spine, 1-6, doi:10.3171/2014.10.spine14228 (2015) McGirt, M. J. et al. Comparative analysis of perioperative surgical site infection after minimally invasive versus open posterior/transforaminal lumbar interbody fusion: analysis of hospital billing and discharge data from 5170 patients. Journal of neurosurgery. Spine 14, 771-778, doi:10.3171/2011.1.spine10571 (2011). Whitmore, R. G. et al. Patient comorbidities and complications after spinal surgery: a societal-based cost analysis. Spine 37, 1065-1071, doi:10.1097/BRS.0b013e31823da22d (2012). Zhan, C. & Miller, M. R. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. Jama 290, 1868-1874, doi:10.1001/jama.290.14.1868 (2003). 13 Neurological Surgery | March 31, 2015 Cost: Patient Costs • Average 23 additional missed workdays for patients with dorsal cervical SSIs • approximately $3739 more in lost income (Kuhns, 2015) • Medicaid patients have higher risk of SSI • higher associated cost • with a concurrent reduction in reimbursement following passage of the ACA (Manoso, 2014) Kuhns, B. D. et al. Cost and quality of life outcome analysis of postoperative infections after subaxial dorsal cervical fusions. Journal of neurosurgery. Spine, 1-6, doi:10.3171/2014.10.spine14228 (2015) Manoso, M. W. et al. Medicaid status is associated with higher surgical site infection rates after spine surgery. Spine 39, 1707-1713, doi:10.1097/brs.0000000000000496 (2014). 14 Neurological Surgery | March 31, 2015 Key Points • Appropriate patient selection and counseling reduces risk of SSI • Reduction in bacterial colonization of skin and nares is a prevention strategy • Copious irrigation and use of local and systemic perioperative antibiotic prophylaxis reduces SSI rate in spinal surgery • Cost of spinal SSI is high for the health care system and patients and negatively affects outcomes 15 Neurological Surgery | March 31, 2015 5 3/30/2015 Thank you! 6
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