Infections In Spine Surgery Syllabus
2015-04-01
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3/30/2015
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Discussion #2:
Indications for medical intervention of
primary osteodiskitis and epidural
abscess
Ira M. Goldstein, MD FAANS
Associate Professor
Department of Neurological Surgery
Rutgers –New Jersey Medical School
Newark, New Jersey
- Treatment considerations
- Diagnosis
- 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
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1. Diagnosis of osteomyelitis and
epidural abscess
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.
-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
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
1. Diagnosis of osteomyelitis and
epidural abscess
-Clinical presentation
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
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1. Diagnosis of osteomyelitis and
epidural abscess
-Laboratory Markers
Peripheral WBC
C- Reactive Protein
Poor sensitivity or specificity for epidural abscess or osteomyelitis
Elevated neutrophil count from peripheral smear more useful
Leukocytosis sensitivity 50% or less
Acute phase reactant –faster response to clinical picture
Poor specificity
Liver production –dampened response with hepatic insufficiency
Sedimentation Rate
ESR high sensitivity for pyogenic infection
Level tends to remain high for prolonged period
Poor specificity –generalized marker of infection/inflammation
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.
Procalcitonin
Acute upregulation in presence of infection
Not affected by noninfectious inflammatory processes (eg trauma,
MI, recent surgery, DVT)
Highly sensitive and specific for infection
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
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.
-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%)
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1. Diagnosis of osteomyelitis and
epidural abscess
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.
-Radiology
MRI
MRI
CT
MRI
CT
PET-CT
MRI
CT
PET-CT
Radionuclide studies
MRI +/- gadolinium is gold standard for spinal canal imaging
MRI DWI sequence to distinguish abscess from other collection
Helpful at demonstrating bony involvement/erosion
Contrast enhancement of paraspinal collection can suggest abscess
Not specific or sensitive
PET imaging not susceptible to metal artifact
Not specific to infection –increased uptake with inflammation
Less sensitive and specific than MRI for evaluation of infection
Tagged WBC studies poorly specific due to WBCs in vertebral marrow
Tc99m uptake in osteoporosis, degenerative disease, and metastases
in addition to infection
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
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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
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.
-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
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2. Antibiotic treatment factors
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.
-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
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’
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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
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.
-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
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.
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)
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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
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.
3. When to consider surgical referral
Development of spinal deformityDevelopment of spinal deformity
Onset of neurologic deficit
Development of spinal deformity
Onset of neurologic deficit
Failure to identify organism via CT-guided biopsy
Development of spinal deformity
Onset of neurologic deficit
Failure to identify organism via CT-guided biopsy
Infection recalcitrant to medical therapy
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•Thank you!
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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
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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 1991-
1997 (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
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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
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Surgery Options
•Posterior approach
–Laminectomy
–Laminectomy and
fusion
•Anterior approach
–Corpectomy and
fusion
•Anterior and posterior
approaches
–Posterolateral
corpectomy and PSF
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Compressed 32:1Compressed 32:1
cm
cm
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, post-
infectious instability or deformity.
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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
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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
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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 beta-
hemolytic 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
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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
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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
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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
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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
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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
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Deep wound infection in the presence of hardware
Recent: weeks Delayed: months/years
Gram positive Gram negative
Wound
washout/keep
hadware
Antibiotics, Follow
clinically CRP
Multiple Wound
washouts,
consider replacing
hardware
Antibiotics, Follow
clinically CRP
Wound washout
removal of
hardware
Antibiotics, Follow
clinically CRP
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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
2
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)
Neurological Surgery | March 31, 2015
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 Spine Society 15, 336-347, doi:10.1016/j.spinee.2014.09.022 (2015).
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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.
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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)
Neurological Surgery | March 31, 2015
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).
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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)
Neurological Surgery | March 31, 2015
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).
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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 povidone-
iodine 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
Neurological Surgery | March 31, 2015
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).
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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)
Neurological Surgery | March 31, 2015
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).
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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.
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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
Neurological Surgery | March 31, 2015
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).
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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
Neurological Surgery | March 31, 2015
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).
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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)
Neurological Surgery | March 31, 2015
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).
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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)
Neurological Surgery | March 31, 2015
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).
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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
Neurological Surgery | March 31, 2015
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).
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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)
Neurological Surgery | March 31, 2015
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).
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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
Neurological Surgery | March 31, 2015
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Thank you!
