Is there algorithm for management of post operative SSI of the spine with instruments?
Until now, there is no clear algorithm for management of post operative SSI of the spine with instruments. SSIs following spinal surgery remain an important complication that requires urgent detection. Even with the use of sterile technique and antibiotic prophylaxis a significant proportion of patients develop infection, which may require reoperation and aggressive antibiotic therapy. Classically, the SSI is divided into incisional (superficial or deep) or organ/space infections, depending on the tissue compartment concerned. Clinical symptoms vary greatly, with the most frequent being fever, spinal pain, local signs of inflammation, wound discharge, and (rarely) new neurologic deficits. CT scans and MRI offer an interesting basis for the diagnosis of spinal and intraspinal infections. Inflammatory biomarkers are highly variable in their expression; the most useful are procalcitonin and amyloid serum A levels. When possible, CSF should be assessed in cases with suspected intradural infections. Causative pathogens are most often gram-positive skin flora, particularly Staphylococcus aureus. Most patients with superficial wound infections and limited deeper infections are treated with local wound care and antibiotics only, but these cases require careful monitoring and should be considered for surgery if complications arise. Operative management may be indicated for drainage or dehiscence of the incision, clinical sepsis, neurologic deficits secondary to fluid collection or mass effect, a spinal or epidural abscess, or instability from bone destruction or failure of an implant or fixation. If treated quickly and vigorously, SSI may resolve without sequelae, but complications may occur, especially in patients with deep infections. Sequels consist of spinal instability and deformity, pseudarthrosis, residual neurologic deficits, and chronic spinal pain.
Thank you for this valuable information . Regarding antibiotics duration . How you decided duration for antibiotics . Or you give all patients for 6 weeks
four weeks i.v. antibiotic therapy based on SSI specimen isolation and negative pressure local medication: if after four weeks there is no resolution, I prefer surgical revision and washing
Management depends on whether the infection is considered deep or superficial. Most are superficial. If there is erythema, none to minimal drainage and no dehiscence, i treat with 7 days of broad spectrum oral antibiotics. If no improvement or if there is wound dehiscence or significant drainage, i would take the patient to OR for irrigation, debridement and exploration. During exploration i inspect the fascial closure to determine if the infection extends deep or not. If superficial, i treat the patient with 6 weeks of antibiotics based on intraoperative cultures or ID consult recommendation. If the infection is deep, i wash it out more thoroughly (possibly twice) and then treat with 6 months of antibiotics. At 6 months i get a CT scan to confirm solid fusion, then stop antibiotics and observe the patient for possible recurrence clinically for at least a month. If there is any sign of recurrent infection, i wash them out again and remove hardware (if fusion is solid they no longer need it).
In my opinion even in recurrent infection hardware removal should be avoided as long as possible, as in spine deformity corrective surgery instrumentation removal, even with a solid fusion assessed bi CT scan, can easily cause loss of deformity correction
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