SPINAL INFECTIONS
20
WOUND INFECTIONS IN
RECONSTRUCTIVE SPINE SURGERY
Steven M. Theiss, MD, John E. Lonstein, MD,
Since the advent of reconstructive spine
surgery, wound infections have been a feared
and respected complication. When infection
does occur, it can result both in significant mor-
bidity for the patient but also in a loss of signifi-
cant health care resources. Wound infections can
double both the cost and duration of hospitaliza-
tion postoperatively.' Though modem surgical
techniques have diminished the incidence of
wound infections, they still occur at a significant
rate. This article examines the risk factors, diag-
nosis, treatment, and methods of prevention of
postoperative wound infections in reconstruc-
tive spine surgery.
RISK FACTORS
The development of postoperative wound
infections, following deformity surgery, de-
pends on a multitude of factors. These factors
can be related to the nature of the procedure it-
self or related to the patient as a host for poten-
tial infection. The development of spinal in-
strumentation certainly had an effect on the
postoperative infection rate. Before the use of
instrumentation, infection rates following pos-
terior fusion were reported to range from 0.9%
to 4.6% in several series, with an average of ap-
proximately 2%.9,11.20 With the advent of Har-
rington instrumentation, the infection rate ex-
From the Department of Orthopaedic Surgery, The University of Alabama at Birmingham, Birmingham, Alabama (SMT);
and Department of Orthopaedic Surgery, University of Minnesota, Minnesota Spine Center (JEL, RBW), Fairview River-
side Medical Center, Minneapolis, Minnesota GEL)
ORTHOPEDIC CLINICS OF NORTH AMERICA
VOLUME 27. NUMBER 1 • JANUARY 1996
0030-5898/96 $0.00 + .
and Robert B. Winter, MD
pectedly rose, with rates increasing from 1% to
12%, or an average of about 6%. Therefore, the
use of instrumentation definitely is a risk factor
for the development of a postoperative wound
infection. 6,9,20 All of these series were before the
routine use of prophylactic antibiotics, but
even since the institution of prophylaxis, in-
strumented cases have a higher rate of infec-
tion than noninstrumented cases. 10,22 Whether
all of this difference can be attributed to the in-
strumentation is difficult to ascertain, because
certainly other technical aspects of the proce-
dure can increase the risk of infection. Blood
loss, operating time, and operating room traffic
are just a few examples of factors that can in-
fluence the infection rate and should be con-
trolled as carefully as possible.P'?
Although numerous patient factors influence
the infection rate, perhaps the most important
is the cause of the spine deformity. It has been
well established that the lowest incidence of in-
fection is in patients with adolescent idiopathic
scoliosis.P-? Using modem surgical techniques,
the infection rate has been lowered to 0.1% in
routine adolescent idiopathic scoliosis
surgery.21.22 This is undoubtedly related par-
tially to the age of the patients but also to the
generally excellent health of this population.
Patients with congenital spine deformities have
comparable infectious risks to those with idio-
pathic scoliosis. Winter et al reported on peste-
105
106 THEISS et al
rior spine fusion with and without instrumen-
tation in 290 patients, ages 5 to 19, and found
only four cases of infection, all before routine
antibiotic prophylaxis.P Some neuromuscular
patients, however, can be at higher infectious
risk. A higher incidence of postoperative infec-
tions have been reported in patients with cere-
bral palsy, with Lonstein and Akbarnia report-
ing a 5% infection rate" and Gersoff and
Renshaw reporting 15% wound infections in 33
cases.' Other series, however, have not verified
these findings.F Perhaps with recent improve-
ment in the nutritional and general medical sta-
tus of these patients, their infectious risk is de-
creasing. The population, however, that
definitely poses an increased risk of infection
are those patients with myelodysplastic defor-
mities. This has been shown by numerous au-
thorS. 1,9,13,17,22 Because of the particular suscepti-
bility of patients with myelodysplasia, it is
important to have a clean operative site, with
good skin coverage before any procedure. Pre-
operative plastic surgery consultation is of
great help in this regard. Also, because of their
high incidence of urinary tract infections, pre-
operative urinary culture with prophylactic an-
tibiotics, based on urine cultures and sensitivi-
ties, are necessary to bring the infection rate to
an acceptable level.P Other neuromuscular de-
formities, such as spinal muscular atrophy and
the muscular dystrophies, have not been associ-
ated with an increased risk of infection. 1S,18,22
A multitude of other host factors also influ-
ence the infectious risk. Lonstein et al found
age to be an important factor, with those pa-
tients greater than 20 having a greater inci-
dence of infection.v? The same can be inferred
from the increased infection rate in those pa-
tients treated for adult scoliosis.l? Optimizing
the nutritional status of the patient also helps
to decrease the change of infection. Jensen et al
suggested that a history of weight loss greater
than 10 lb, a serum albumin level of less than
3.4 g/ dL, or a total lymphocyte count of less
than 1500 cells/mL necessitated a complete nu-
tritional assessment before elective surgery.
Any deficiencies are then corrected with either
enteral or parenteral nutritional supplements.f
Interestingly, controlling for all other factors, a
diabetic with well-regulated glucose levels
poses no increased risk. Therefore, every effort
should be made to control glucose level ade-
quately before elective surgery." Remote infec-
tions should be identified and eradicated be-
fore surgery. If this is not possible, prophylactic
antibiotics should cover the responsible organ-
isms identified on preoperative culture and
sensitivity.P Obesity, chronic steroid therapy,
and prolonged preoperative hospitalization or
traction are difficult factors to remedy, but they
too are recognized as increasing the infectious
risk of a surgical candidate.t-? In reality, be-
cause many of these factors are interrelated, it
is difficult to establish the exact contribution of
each. Each patient, however, should be as-
sessed in the preoperative period to determine
the relative risk for a postoperative infection.
DIAGNOSIS OF INFECTION
The diagnosis of a wound infection can often
be difficult. Infections occur both early and late
in the postoperative period, but in both in-
stances, diagnosis may be delayed. Some series
have shown the diagnosis to be delayed by as
many as 48 days." Diagnosis begins by always
maintaining a high index of suspicion. The real
difficulty in the diagnosis is the lack of specific
findings. The patient often presents with
vague, nonspecific complaints. Fever mayor
may not be present. Examination of the wound
can show the pathognomnic erythema, fluctu-
ance, and tenderness, but it also may appear
deceivingly benign.v" Drainage, if present, of-
ten appears late in the clinical presentation.
Laboratory values also can be nondiagnostic.
The white blood cell count (WBC) is often nor-
mal, and although the erythrocyte sedimenta-
tion rate (ESR) may be elevated, surgery itself
raises the sedimentation rate for several weeks,
so this is unreliable.v'? Given the usual lack of
definitive evidence, how, then, can the diagno-
sis best be made? First, any temperature eleva-
tion or increased pain in the postoperative pe-
riod demands prompt investigation. The
wound should be inspected for any erythema
or tenderness, and any drainage should be sent
for Gram stain and culture, after careful skin
preparation. In wounds with no drainage, as-
piration is the best method of obtaining a sam-
ple for analysis.v '? The deep wound is aspi-
rated using a large bore needle after thorough
skin preparation. Treatment, however, of a
draining wound should not be delayed until
culture results are available. Attributing
wound drainage to implant allergies is incor-
rect and costly. A recent review from Texas
Scottish Rite Hospital showed the presence of
indolent bacteria in late draining wounds that
occasionally required up to 2 weeks of incuba-
tion before identification.l" Laboratory values
are most helpful when serial studies show an
increasing WBC or ESR.8 Blood cultures should
also be obtained, because, rarely, sepsis is the
first sign of a wound infection, followed later
 WOUND INFECTIONS IN RECONSTRUCTIVE SPINE SURGERY
by wound signs and drainage. Yet, even with
appropriate suspicion and diagnostic tech-
niques, some infections are still incidentally
found late on explorations for pseudarthrosis
or increased pain.
Staphylococcus aureus and epidermis are the
most common pathogens. 9,lO,22 Lonstein and
coworkers identified 70% of the organisms to
be Staphylococcus,9 whereas Massie et al identi-
fied 50% of the organisms cultured to be
Staphylococcus.1° Transfeldt found 79% of the
patients to be infected with S. aureus specifi-
cally.22 Some, however, have suggested that
gram-negative infections and polymicrobial in-
fections are on the rise.v'? Low-virulence skin
flora also may be responsible for infection and
should not be dismissed as a contaminant.l"
The most likely time of wound contamination
is during the surgical procedure.v? Yet innocu-
lums can also take place from other sources of
infection. The urinary tract is a common source
of bacteria, with Transfeldt finding 18% of pa-
tients having one organism cultured from both
the wound and the urine. 22 It also is possible to
have a hematoma that drains, allowing the
wound to become secondarily infected.
TREATMENT
Once an infection is identified, prompt, ag-
gressive, surgical treatment is mandated.v'-"
The indications for operative intervention are
any wound that is draining, has a recurrent
hematoma, has a positive culture on aspira-
tion, or is clinically suspicious for infection."
Suspected infections should not be treated
with local wound care and antibiotics, be-
cause this is doomed to failure." The wound
should be opened in its entirety, from top to
bottom, and to the depths of the wound. Cul-
tures, both aerobic and anaerobic, are taken. It
is important to obtain good cultures before
the institution of antibiotic treatment, to allow
identification of the infecting organisms. All
necrotic tissue is then sharply debrided until
viable tissue is identified. The wound is then
copiously irrigated with pulsatile lavage.
Bone graft should be removed, cleaned, and
replaced. In the event of a forming fusion,
those pieces of bone graft that are obviously
necrotic should be removed. Instrumentation
should also be left in place. 2,4,6,8,2o Some, early
in the development of Harrington instrumen-
tation, attempted to remove the rods, but this
consistently led to poor results with loss of
correction and pseudarthrosis.v" In addition,
the presence of the implants has not been
107
shown to significantly inhibit the ability to
treat the infection.
Management of the wound can then take
one of several courses. Which course is chosen
depends on the time of presentation of the in-
fection as well as the amount of necrotic tissue
present and status of the wound after debride-
ment. Infections can be divided into infections
that present early, or generally less than 3
months postoperatively, and those that present
late. First, in dealing with infections that are di-
agnosed early, if the wound is very clean fol-
lowing irrigation and debridement with little
necrosis present, it may be primarily closed
over suction drains. When more marked infec-
tions are present but the wound is still devoid
of residual necrotic tissue following debride-
ment, the wound may be closed primarily over
irrigation-suction systems. High-flow rates are
used for the first 12 hours, following which
rates are decreased to about 125 mL/hr. Saline
is used as the irrigant; antibiotics are given sys-
temically. The irrigation is generally continued
for 3 to 4 days or until the fever, WBC, and ESR
decrease, indicating resolving infection. Then,
the irrigation is stopped and all tubes are put
to suction for 24 hours before they are discon-
tinued. The fluid is only cultured if the infec-
tion is not responding to treatment, and new
organisms are suspected. The cosmetic result is
usually excellent (Fig. 1). In wounds with
residual necrosis, multiple organisms, or
where the surgeon is unsure of the cleanliness
of the wound following debridement, the
wound should be packed open and repeat irri-
gation and debridement performed in 48
hours. Debridement is the repeated until the
wound is clean and granulating. The wound
may then be secondarily closed, with or with-
out irrigation and suction. In cases with uncon-
trollable or persistent infection, the wound
should be allowed to granulate with no at-
tempt at closure. This is possible even over ex-
posed instrumentation but may take several
months (Fig. 2).
Wound infections that present late mandate
slightly different treatment because of the ma-
turity of the fusion. Following diagnosis, the
wound again is opened in its entirety and de-
brided of all necrotic bone graft and tissue. The
wound is cultured and lavaged. In this in-
stance, however, the instrumentation is re-
moved to allow exploration of the fusion. If the
fusion is solid, the wound is serially debrided
until it is clean and granulating and then sec-
ondarily closed. If a pseudarthrosis is present,
the infection is repeatedly debrided until the
wound is clean, and then the spine is reinstru-
108 THEISS et al
Figure 1. A 16-year-old girl with idiopathic scoliosis who
developed a wound infection 2 weeks following a poste-
rior spine fusion with instrumentation. She was treated
by a single irrigation and debridement, with insertion of
suction-irrigation tubes. Her wound was closed during
the same procedure. She healed uneventfully, with no
recurrence of the infection, and obtained a solid fusion.
Figure 2. This 38-year-old woman developed an infection after a posterior fusion with instrumentation for congenital
scoliosis. She was debrided, and suction-irrigation tubes were inserted. The infection recurred shortly after removal of
the tubes. Her wound was thus allowed to granUlate over her instrumentation. (A, B) The wound during the granulation
process; (C) the final cosmetic result.
mented. The wound is still debrided one to
two more times, to ensure healthy granulation
tissue. It may then be bone grafted and secon-
darily closed, or closed and bone grafted in 3
months (Fig. 3).
Appropriate broad-spectrum antibiotics are
begun, in any instance, after adequate cultures
have been taken. This usually consists of a first
generation cephalosporin and possibly an
aminoglycoside in suspected gram-negative in-
fections. Antibiotics then can be adjusted based
on the initial culture and sensitivity data. An
infectious disease specialist should always be
consulted to help determine the appropriate
agents and duration of treatment. Intravenous
antibiotics are usually continued from 10 to 14
days or longer if multiple debridements are
necessary. Provided that the patient is afebrile,
the wound is no longer showing signs of infec-
tion, and the WBC and ESR are decreasing,
oral antibiotics may be begun and continued
for 6 to 12 weeks. Repeat cultures during
subsequent debridements are not necessary in
routine cases where the infection is being con-
trolled. In the event of persistent fevers or un-
controllable infections, however, they should
be repeated to ensure antibiotic coverage of all
organisms present. The sedimentation rate and
WBC should also be monitored to help assess
the response to treatment.
 WOUND INFECTIONS IN RECONSTRUCTIVE SPINE SURGERY 109

Figure 3. This case shows a 37-year-old woman who underwent a staged anterior and posterior spine fusion with in-
strumentation for adult scoliosis. She developed a delayed wound infection and pseudarthrosis. She was treated with
instrumentation removal and multiple debridements, until healthy granulation tissue was present throughout the wound
(A). Instrumentation was then reinserted, but the wound was still packed open (B). Following the next debridement, the
pseudarthrosis was bone grafted and the wound was secondarily closed. She obtained the result shown, as well as a
solid fusion (C).

PREVENTION rin in healthy patients, but the spectrum may

Even with successful treatment of a wound
infection, one can expect inferior surgical re-
sults. Numerous authors have found an in-
creased pseudarthrosis rate,6,9.20.22 once again
emphasizing the importance of leaving the in-
strumentation in place. Interestingly, wounds
treated by suction-irrigation had a higher
pseudarthrosis rate than those treated with re-
peated debridements.F In addition, subse-
quent procedures on patients with previous in-
fections result in a significant reinfection rate. 22
Therefore, prevention is of the utmost impor-
tance. First, those patients that are at high risk
must be identified and their medical and nutri-
tional status optimized before surgery. Next,
appropriate prophylactic antibiotics are given.
The benefit of prophylactic antibiotics is clear.
Reviewing our experience at the Minnesota
Spine Center, prophylactic antibiotics dropped
the infection rate from 4.4% to 1.2%. This dif-
ference was most marked in idiopathic scolio-
sis where the infection rate dropped to 0.1 % af-
ter routine prophylaxis.v-? The antibiotic of
choice is usually a first-generation cephalospo-
be expanded in those patients with chronic dis-
ease or particularly susceptible hostS. 10,13,21
Also, in patients with a positive urine culture,
antibiotics should be chosen to cover organ-
isms identified on urine culture and sensitivity.
The critical period to have adequate blood lev-
els of antibiotics is during the actual proce-
dure, when the majority of wound contamina-
tion takes place." The antibiotics are continued
for 48 hours postoperatively or until the drains
are removed. Meticulous surgical technique
also helps prevent infection. Careful SUbpe-
riosteal dissection, minimizing soft-tissue in-
jury and necrosis, with frequent wound irriga-
tion, all help decrease the risk. 9,10 Self-retaining
retractors should also be periodically released
to avoid excessive muscle necrosis.F Finally, a
meticulous closure, with subcutaneous drains,
reduces the likelihood of a wound hematoma
that can either drain in the postoperative pe-
riod or act as a medium for any present bacte-
ria.'?
Postoperative infection in deformity surgery
is, in reality, a relatively infrequent occurrence.
There are, however, a number of factors that
110 THEISS et al
are directly controlled by the surgeon, and oth-
ers that are not. It is important to recognize the
cases that are associated with increased risk
and to take appropriate preventative measures.
Then, when an infection is suspected, prompt
diagnosis is necessary. This should result in ag-
gressive, definitive treatment, to obtain the
best possible surgical result with the least pos-
sible morbidity.
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Address reprintrequests to
John E. Lonstein, MD
Minnesota Spine Center
606 24th Ave. South, Suite 602
Minneapolis, MN 55454-1419