Abstract
Objective
The purpose of this study is to investigate the efficacy of the GAID-Protocol, a bundle of intra- and postoperative infection prevention measures, to reduce implant-associated infections in patients undergoing posterior spinal fusion with instrumentation. These preventive measures are organized into a protocol that includes recommendations for four critical areas of implant protection (acronym GAID): Gloves, Antiseptics: sodium hypochlorite/hypochlorous acid (NaOCl/HOCl), Implants and Drainage-use in large wounds.
Methods
We performed a single-site retrospective review of cases undergoing posterior spinal fusion with instrumentation for primarily degenerative spinal diseases before and after implementation of the GAID-Protocol that was specifically designed to protect against implant-associated infections. The primary outcome was postoperative wound complications requiring surgical intervention, with a particular focus on infectious spondylitis/discitis.
Results
230 cases were included: 92 (Group A) before and 138 (Group B) after protocol implementation. Overall, wound complications requiring surgical intervention occurred in 7.6% patients in Group A and in 3.6% patients in Group B (p = 0.2297). Of these, infectious spondylitis/discitis was present in 5.4% in Group A and in none of Group B (p = 0.0096). The ratio of infectious spondylitis/discitis to other wound problems was 71% to 29% in Group A, while it was 0% to 100% in Group B (p = 0.0278). The mean time interval between the first revision surgery for wound complications and hospital discharge was significantly different, 38 days SD 20.3 in Group A and 14.4 days SD 8.6 in Group B (p = 0.0442).
Conclusions
In our study, adherence to the GAID-Protocol resulted in a shift from severe to significantly less severe and easier to treat wound complications. Adoption of the GAID-Protocol might contribute to the reduction of implant-associated infections.
Keywords: surgical site infection, spinal infections, implant-associated infection, sodium hypochlorite/hypochlorous acid, spinal fusion, spondylodiscitis, vertebral osteomyelitis
1. Introduction
Refining measures to prevent surgical site infections is a constant challenge for surgeons. However, evidence-based recommendations for individual preventive measures are difficult to obtain. We generally rely on recommendations from large reviews and meta-analyses, but often, only evidence from methodologically weak studies is available. Moreover, the impact of individual recommendations is often small. To address this problem, so-called “evidence-based care bundles,” i.e., an overall package of meaningful recommendations to reduce surgical site infections, have been proposed and examined with some success in several spinal studies (1–7).
Incidences of surgical site infections are highly dependent on patient risk factors and the type and course of surgical procedures (8, 9). Implant-associated infections of the spine that also affect the vertebral bodies (spondylitis) and/or intervertebral discs (discitis) are associated with complicated treatment courses, high morbidity and with in-hospital mortality rates of up to 15% (10, 11).
We have compiled a bundle of intra- and postoperative infection prevention measures specifically designed to protect against implant-associated infections in often complex and lengthy spine surgeries. These preventive measures are organized into a protocol that includes recommendations for four critical areas of implant protection: Gloves, Antiseptics, Implants and Drainage-use in large wounds—the acronym GAID-Protocol is suggested.
The purpose of this study is to investigate the efficacy of the GAID-Protocol to reduce implant-associated infections in patients undergoing posterior spinal fusion with instrumentation.
2. Materials and methods
2.1. Study design
We performed a single-site retrospective review of cases undergoing posterior spinal fusion with instrumentation for primarily degenerative spinal diseases from January 2019 to June 2020 (Group A) and after implementation of the new infection prevention measures from July 2020 to October 2022 (Group B). Surgical approaches included conventional open approaches and minimally invasive mini-open approaches. The local ethics committee (Ethikkommissionen bei der Ärztekammer Schleswig-Holstein) was consulted.
A digital search was performed in the hospital information system for all cases that had undergone posterior spinal fusion with instrumentation during the specified periods. Data from the local quality management report was included. The primary outcome was postoperative wound complications requiring surgical intervention, with a particular focus on infectious spondylitis/discitis.
Epifascial wound problems were distinguished from subfascial wound problems, and cases of infectious spondylitis/discitis were considered separately for subfascial findings. The distinction was based on radiologic findings, intraoperative findings, and especially on locally assignable microbiologic findings.
2.2. Infection prevention measures
In general, we adhere to the recommendations of the German Commission for Hospital Hygiene and Infection Prevention (12). Prior to July 2020 (Group A), however, the finer points of infection prevention were left to the discretion of the surgeon. From July 2020 onward (Group B), mandatory practices in some areas of intra/postoperative infection prevention have been agreed upon (Table 1). The creation and implementation of the GAID protocol was the result of a quality improvement project in our department. The working group for this project consisted of our hospital hygienist, two experienced operating room nurses and a spine surgeon with an academic background (senior author).
Table 1.
GAID-Protocol.
| Gloves | • Double-gloving. |
| • Change outer gloves after sterile draping. | |
| • Change outer gloves at intervals of 1.5–3 h, before implant manipulation and before wound closure. | |
| • Avoid touching draped C-arm. | |
| • Change light handles at intervals of 1.5–3 h or manipulate the light handle with a sterile cloth which is then discarded. | |
| Antiseptics | • Sodium hypochlorite/hypochlorous acid (NaOCl/HOCl): |
| |
| • Iodine-impregnated incision drape. | |
| Implants | • Keep sterile implants and instruments at distance or covered during patient positioning. |
| • Implants remain covered until they are inserted. | |
| • Do not directly touch implants & materials that will remain in the patient. If necessary, use sterile cloth for manipulation. | |
| • Pre-moisten implants and wires with (NaOCl/HOCl) before insertion. | |
| • Keep tissues to be re-implanted, such as bone fragments, moist and covered. | |
| Drainage-use in large wounds | • Drainage-use in large wounds from multilevel instrumentations separately in the subfascial and epifascial compartments. |
| • Cover drainage outlet points with Iodine-impregnated incision drape. | |
| • The sub-fascial drainage system should be removed on day 4 at the latest. With minimal drainage volumes and early mobilization of the patient, even earlier. | |
| • The epi-fascial drainage system is removed when the drainage volume is <30–40 ml/24 h. Regardless of the drainage volume, it is never left in place for more than 10 days. | |
| • Consider Epidermal VAC (Vacuum Assisted Closure) Dressings in High Risk Patients. |
Table 1 shows the new infection prevention measures for instrumented spinal surgeries agreed from July 2020. The acronym GAID is suggested.
2.3. Statistical analysis
Statistical analyses were performed using Prism 7.0e for Mac OS X, GraphPad Software, La Jolla California USA. Descriptive statistics including mean, median, minimum, maximum, standard deviation and interquartile range were calculated. For statistical testing between groups for categorical variables Fisher’s exact tests or chi-square tests were performed, for continuous variables Mann–Whitney tests or t-tests for unpaired samples were performed. All statistical tests were two-sided, and a p-value < 0.05 was considered statistically significant. Figures were created with the same software version.
3. Results
230 patients with posterior spinal fusion with instrumentation for primarily degenerative spinal diseases were included in this retrospective study. 92 surgeries were performed before (Group A) and 138 were performed after (Group B) implementation of the new infection prevention measures. The mean documented follow-up time at our institution was 22 months SD 17 (Group A) and 12 months SD 8 (Group B).
No significant differences were found between the groups with regard to demographic data (age, sex) and risk factors (body mass index, diabetes, rheumatologic diseases, smoking, previous spine surgery) (Table 2). Both groups presented with severe disability according to ODI. There were no differences in the main indications for spine surgery, with the exception of recurrent disc herniation (p = 0.0215).
Table 2.
Patient data.
| Group A | Group B | P value | |
|---|---|---|---|
| Number of patients | 92 | 138 | |
| Demographics | |||
| Age at surgery (years; mean SD; range) | 60 (15; 26–82) | 62 (13; 27–82) | 0.2638a |
| Sex | >0.9999b | ||
| Male | 46% | 46% | |
| Female | 54% | 54% | |
| Risk factors | |||
| BMI (mean SD; range) | 28 (4; 19–40) | 30 (5; 18–43) | 0.0814a |
| Obesity (BMI ≥ 30) | 33% | 45% | 0.1171b |
| Diabetes | 14% | 12% | 0.6857b |
| Rheumatological disease | 10% | 9% | 0.8177b |
| Smoking | 29% | 23% | 0.3553b |
| Previous spine surgeries | 40% | 36% | 0.4893b |
| Preoperative oswestry disability index (mean SD; range) | 45 (19; 8–98) | 47 (16; 8–89) | 0.2993a |
| Main indications for instrumented spinal surgery | |||
| Foraminal stenosis (often associated with spondylolisthesis or segmental scoliotic deformity) | 28% | 30% | 0.8826b |
| Degenerative deformity | 13% | 16% | 0.5758b |
| Degenerative pathological hypermobility | 11% | 12% | >0.9999b |
| Spondylolisthesis | 10% | 6% | 0.3069b |
| Central canal stenosis (often associated with myelopathy) | 9% | 7% | 0.6102b |
| Recurrent disc herniations | 11% | 3% | 0.0215b |
| Modic endplate changes | 5% | 7% | 0.7870b |
| Adjacent segment pathology | 3% | 9% | 0.1103b |
| Implant failure | 5% | 7% | 0.7870b |
| Spinal fracture | 1% | 4% | 0.4060b |
| Primary spondylodiscitis | 1% | 0% | 0.4000b |
| Postoperative spondylodiscitis | 0% | 1% | >0.9999b |
| Reinstrumentation after implant-associated infection | 2% | 1% | 0.5655b |
Table 2 illustrates patient data, major preoperative risk factors and pathological findings triggering our decision for instrumented spinal surgery. BMI, body mass index; SD, standard deviation.
P values in bold are considered statistically significant test results (p < 0.05).
t test.
Fisher’s exact test.
3.1. Surgical data
In general, we found comparable results in surgical data (Table 3). However, modest differences were found in the number of dorsally instrumented levels, ranging from 1 to 15 levels, with a mean of 2.1 SD 1.9 in Group A and 2.4 SD 2.0 in Group B (p = 0.0241), as well as in surgical time (p = 0.0139) and duration of wound drainage (p < 0.0001).
Table 3.
Surgical data.
| Group A | Group B | P value | |
|---|---|---|---|
| Number of patients | 92 | 138 | |
| Dorsally instrumented levels (mean SD; range) | 2.1 (1.9; 1–9) | 2.4 (2.0; 1–15) | 0.0241b |
| 1–2 levels | 78% | 67% | 0.1587c |
| 3–4 levels | 14% | 25% | |
| 5–8 levels | 4% | 7% | |
| >8 levels | 3% | 2% | |
| Intervertebral cages (mean SD; range) | 0.8 (0.7; 0–3) | 0.9 (0.7; 0–4) | 0.1270b |
| Dorsal mini-open approaches | 24% | 35% | 0.0820a |
| Lumbar levels | 91% | 91% | >0.9999a |
| Thoracic levels | 10% | 11% | 0.8299a |
| Cervical levels | 3% | 6% | 0.5325a |
| Surgical time (minutes; mean SD; range) | 286 (94; 137–556) | 312 (95; 99–797) | 0.0139b |
| Estimated blood lossd | |||
| <100 ml | 32% | 38% | 0.6302c |
| 100–500 ml | 39% | 33% | |
| 500–1,000 ml | 20% | 24% | |
| >1,000 ml | 9% | 5% | |
| Wound drainage | 47% | 56% | 0.1817a |
| Wound drainage (days; mean SD; range)e | 2.8 (1.3; 1–6) | 4.2 (1.3; 2–7) | <0.0001b |
Table 3 reports surgical data.
SD, standard deviation.
P values in bold are considered statistically significant test results (p < 0.05).
Fisher’s exact test.
Mann–Whitney test.
Chi-square test.
Incomplete data 53% (44% Group A, 59% Group B).
Incomplete data: 52% (47% Group A, 56% Group B).
3.2. Surgical site infections
Overall, wound complications requiring surgical intervention occurred in 7 (7.6%) patients in Group A and in 5 (3.6%) patients in Group B (p = 0.2297) (Figure 1).
Figure 1.
Wound complications requiring surgical intervention before (Group A) and after (Group B) implementation of the GAID protocol (p = 0.2297).
Of these, infectious spondylitis/discitis was present in 5 (5.4%) in Group A and in none of Group B (p = 0.0096) (Figure 2A).
Figure 2.
Postoperative infectious spondylitis/discitis before (Group A) and after (Group B) implementation of the GAID protocol (p = 0.0096) (A), and ratios of infectious spondylitis/discitis to other wound problems (p = 0.0278) (B).
The ratio of infectious spondylitis/discitis to other wound problems was 5 (71%) to 2 (29%) in Group A, while it was 0% to 5% (100%) in Group B (p = 0.0278) (Figure 2B).
With regard to demographic data, risk factors and surgical data, patients with wound complications showed comparable results in Groups A and B (Table 4). The median time interval between index surgery to revision surgery for wound complications was 20 days IQR 8–140 for Group A and 21 days IQR 13–42 for Group B (p = 0.9596).
Table 4.
Patients with surgical site infections.
| Group A | Group B | P value | |
|---|---|---|---|
| Number of wound complications | 7 | 5 | |
| Patient data | |||
| Age at surgery (years; mean SD; range) | 61 (11; 47–79) | 68 (7; 59–75) | 0.2590a |
| Sex | 0.5758b | ||
| Male | 43% | 20% | |
| Female | 57% | 80% | |
| BMI (mean SD; range) | 30 (5; 26–39) | 31 (5; 26–38) | 0.7944a |
| Obesity (BMI ≥ 30) | 43% | 60% | >0.9999b |
| Diabetes | 14% | 40% | 0.5227b |
| Rheumatological disease | 29% | 40% | >0.9999b |
| Smoking | 14% | 0% | >0.9999b |
| Previous spine surgeries | 29% | 40% | >0.9999b |
| Surgical data | |||
| Dorsally instrumented levels (mean SD; range) | 2 (1.2; 1–4) | 2.4 (2.0; 1–5) | 0.9621c |
| Surgical time (minutes; mean SD; range) | 303 (71; 216–420) | 319 (71; 223–380) | 0.5303c |
| Wound drainage | 43% | 40% | >0.9999b |
| Time intervals | |||
| Time index surgery to revision surgery (days; median IQR; range) | 20 (8–140; 8–219) | 21 (13–42; 9–48) | 0.9596c |
| Time Revision Surgery To Hospital Discharge (Days; Mean SD; Range) | 38.0 (20.3; 8–66) | 14.4 (8.6; 1–24) | 0.0442c |
Table 4 illustrates characteristics of patients with surgical site infections. SD, standard deviation; BMI, body mass index; IQR, interquartile range.
P values in bold are considered statistically significant test results (p < 0.05).
t Test.
Fisher's Exact test.
Mann–Whitney test.
Chi-square Test.
The mean time interval between the first revision surgery for wound complications and hospital discharge was significantly different, 38 days SD 20.3 in Group A and 14.4 days SD 8.6 in Group B (P = 0.0442) (Figure 3, Table 4). In-hospital mortality rate was 0% in both groups.
Figure 3.
Time interval between the first revision surgery for wound complications and hospital discharge (p = 0.0442).
Descriptive microbiological data is provided in (Table 5).
Table 5.
Microbiological data.
| Group A | Group B | |
|---|---|---|
| Number of wound complications | 7 | 5 |
| Patients | ||
| 1 | Scattered Staph. epidermidis (multiresistent) in all samples, subfascial. | Scattered Streptococcus dysgalaktiae in 2 of 9 samples, epifascial. |
| 2 | After enrichment Cutibacterium acnes in all samples, subfascial & on screws. | Scattered Staph. epidermidis in 1 of 4 samples, subfascial. |
| 3 | No bacteria detected, epifascial. | Scattered Klebsiella oxytoca in all samples, epifascial. |
| 4 | Scattered Peptostreptococcus harei & Staph. epidermidis (multiresistent) in all samples, subfascial & on screws. | After enrichment Staph. aureus in all samples, subfascial. |
| 5 | Moderate Cutibacterium acnes, Staph. epidermidis, Staph. simulans, Staph. capitis & Staph. hominis in all samples, subfascial, on cage & on screws. | Abundant Staph. aureus in 1 of 3 samples, epifascial. |
| 6 | Abundant E. coli in all samples, subfascial, disc & in screwholes. | |
| 7 | After Enrichment Cutibacterium Acnes & Staph. Capitis In 7 Of 11 Samples, Subfascial, On Cage & On Screws. | |
Table 5 shows descriptive microbiological data.
No adverse effects of the antiseptic sodium hypochlorite/hypochlorous acid or of the iodine-impregnated incision drape were observed.
4. Discussion
We investigated intra- and postoperative infection prevention measures (GAID-Protocol) specifically designed to protect against implant-associated infections. The study population consisted of elderly patients with severe disabilities according to the Oswestry Disability Index (46 SD 17) with a high rate of previously performed spine surgeries (37%) who underwent posterior spinal fusion with instrumentation for mainly degenerative spinal disorders. 92 of the surgeries (Group A) were performed before and 138 of the surgeries (Group B) were performed after the new infection prevention measures were implemented. Groups A and B had comparable characteristics in terms of patient data and surgical data (Tables 2, 3) and showed high risk factors for surgical site infections in terms of prevalence of known risk factors such as obesity (33%/45%), diabetes (14%/12%), rheumatological disease (10%/9%), and smoking (29%/23%), respectively (8, 13, 14).
In our study, a significant decrease in severe surgical site infections related to infectious spondylitis/discitis from 5.4% (Group A) to zero (Group B) was observed (p = 0.0096), (Figure 2A).
Wound complications requiring surgical intervention were observed in 7.6% (Group A) and 3.6% (Group B), with no statistically significant difference (p = 0.2297). However, the ratio of infectious spondylitis/discitis to other wound problems, most of which were much less severe, was 71% to 29% in Group A, whereas it was 0% to 100% in Group B (p = 0.0278), (Figure 2B). Thus, adherence to the GAID-Protocol resulted in a shift from severe to significantly less severe and easier to treat wound complications. This is also indicated by the lower mean time interval between first revision surgery and hospital discharge of 14.4 days SD 8.6 in Group B compared with 38 days SD 20.3 in Group A (p = 0.0442), (Figure 3, Table 4). Because of the small sample size, meaningful comparison of descriptive microbiologic data is difficult, but the trends toward more epifascial wound complications and fewer bacteria-positive samples in Group B may underscore our observations (Table 5).
4.1. Care bundles to prevent surgical site infections
The introduction of car bundles, i.e., an overall package of meaningful recommendations for action, has led to significant reductions in surgical site infection rates in several studies (Table 6) (1–7).
Table 6.
Studies reporting implementation of care bundles.
| Studies (references) | Care bundles | SSI rate without/with care bundle | Surgical procedures |
|---|---|---|---|
| (1) | Preoperative nasal mupirocin and chlorohexidine body decontaminations, storage optimization of operating room supplies, preoperative antibiotic administration algorithm, staff training on povidone-iodine scrub and paint, intrawound vancomycin in instrumented cases, postoperative early patient mobilization, wound checks at 2 and 6 weeks postoperatively. | 4.1%/2% p = 0.01 | Discectomy, decompression, spinal fusion, vertebral augmentation. |
| (2) | Only in high risk patients (19%): preoperative nasal mupirocin and chlorohexidine body decontaminations, additional intravenous vancomycin prophylaxis, diluted povidone-iodine wound irrigation. | 3.8%/0.7% p < 0.01 | Spinal instrumentation surgeries. |
| (3) | Sterile technique for surgical dressing changes, dressings to be changed daily for 7 days, physician awareness program/surveillance feedback. | 3.8%/2.1% p = 0.03 | Spinal fusion. |
| (4) | 5–7 days hydrocellular foam dressing, early mobilization, staff training, use of surveillance feedback. | 19.4%/2.6% p = 0.001 | Lumbar surgery: disc herniation, spinal stenosis, spondylolisthesis, scoliosis, kyphosis, trauma. |
| (5) | Preoperative: chlorhexidine scrubs, screening with nasal swabbing, and decolonization of S. aureus. Perioperative antibiotic administration. Diluted povidone-iodine wound irrigation, application of intrawound vancomycin powder. | 6%/<2% p not reported | Laminectomies, spinal fusions. |
| (6) | Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high-risk pediatric spine surgery (15). | 8%/1% p = 0.005 | Spinal fusion for neuromuscular scoliosis. |
| (7) | Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high-risk pediatric spine surgery (15). | 16.1%/4.4% p = 0.005 | Spinal fusion for neuromuscular scoliosis. |
Table 6 lists studies reporting the implementation of care bundles to prevent surgical site infections (SSI) in spinal surgery.
A number of these studies do not classify surgical site infections into subgroups (1, 3, 5). A common classification is based on the Centers for Disease Control and Prevention (United States of America) definitions of superficial, deep and organ/space infections, which can be roughly translated into epifascial, subfascial and vertebral bone/disc infections in the spine (16).
Two of these studies reported similar findings to ours in terms of a shift from severe to less severe wound complications (2, 6). Glotzbecker et al. reported the implementation of a best practice guideline (15) for the prevention of surgical site infections in spinal fusion for neuromuscular scoliosis. The overall infection rate did not change significantly from 9% to 6%, but there was a significant shift from deep to superficial infections before and after implementation of the best practice guideline. The ratio of deep to superficial infections changed from 92% to 8% before implementation to 14%–86% after implementation (6). Similarly, Yamada et al. reported on the implementation of a preventive care bundle in spinal instrumentation surgery. The ratio of deep site and/or organ infections to superficial infections changed from 75% to 25% before implementation to 50%–50% after implementation (2). Similar to our study, both investigators used an antiseptic, in their cases diluted povidone-iodine, for wound irrigation as part of their care bundle.
There are a number of problems in interpreting and comparing the results of studies in this area, as there is a great deal of heterogeneity in terms of patient characteristics, surgical procedures, and agreement in the field on what basic infection prevention measures are, and which are being studied in terms of new adaptation. This leads to confounding factors that are difficult to control in these mostly retrospective observational studies. Table 6 also shows the wide variety of infection prevention measures that have been developed for the preoperative, intraoperative and postoperative settings. Each individual prevention measure can play a critical role in orchestrating an effective strategy to reduce surgical site infections. Investigating each prevention intervention separately in large randomized controlled trials, however, is difficult to realize in practice and could be ethically questionable in some cases. In this light, pragmatic testing of carefully selected care bundles for their ability to reduce surgical site infections makes sense and could be an important future strategy.
4.2. GAID-protocol
Previous care bundles for the prevention of wound infections contain general recommendations such as preoperative nasal and body decontamination and structured postoperative wound care (Table 6). These are part of our basic prevention measures, for which we generally follow the recommendations of the German Commission for Hospital Hygiene and Infection Prevention (12). Another recommended source is the Global Guidelines for Surgical Site Infections of the World Health Organization (17). More specific recommendations include the use of antiseptics or intrawound vancomycin powder (1, 2, 5–7). Interestingly, staff training and surveillance feedback appear to play an important role in reducing surgical site infections (3, 4).
As an important complement to our basic prevention measures, a bundle of intra- and postoperative infection prevention measures has been defined specifically to protect against implant-associated infections in spine surgery. These preventive measures are organized in a protocol that includes recommendations for four critical areas of implant protection: gloves, antiseptics, implants and drainage-use in large wounds (Table 1).
4.2.1. Gloves
Surgical gloves can be perforated unnoticed or noticed in up to 40% of surgical procedures (18). Therefore, we advocate the wearing of two gloves (double-gloving) for surgeons and surgical nurses. After surgical access alone, bacterial contamination was found in more than 12% of gloves in some studies of orthopedic prosthesis implantation (19, 20). In an observational study of 389 lumbar fusions, changing outer gloves during double gloving prior to implant placement demonstrated a significant reduction in wound infections (21). Two reviews focusing on spine surgery recommend double gloving with 2 h glove changes and changes before contact with implants (22, 23). Other sources of glove contamination include light handles and C-arm covers. Contamination in 15%–50% of sterile light handles has been noted in orthopedic procedures (24, 25). Contamination of the sterile C-arm drape is to be expected already during draping and as the duration of the procedure increases (26). Contact of the sterile C-arm drapes with gloves, instruments, or the surgical field should be avoided. The wound area should always be covered during radiographs and 3D rotations.
4.2.2. Antiseptics
Decontamination of the surgical wound is attempted with either antiseptic irrigation or intrawound antibiotics.
The results of a systematic review indicated that topical vancomycin application may be a potential strategy to reduce the incidence of surgical site infections in spine surgery. However, its use is mainly based on retrospective studies with some methodological weaknesses that do not allow for firm conclusions (27). Experimental studies suggest cytotoxic effects of topical application of vancomycin (28). However, the major concern of widespread use is the emergence of vancomycin-resistant organisms and pressure for more gram-negative and polymicrobial infections at the surgical site. A meta-analysis found that topical vancomycin powder may reduce the overall rate of wound infections from 3.8% to 2.3% (OR 0.60; 95% CI 0.51–0.71; p < 0.05): but with the accompanying reduction in the rate of Gram-positive wound infections, the risk for developing more difficult-to-treat Gram-negative or polymicrobial wound infections was nearly twice as high in the topical vancomycin group (29). Therefore, the authors recommend limiting its use to patients who need it most because of high risk factors.
A significant reduction in wound infection rates can be achieved with different antiseptic irrigations prior to wound closure (12). Three other reviews conclude that the available literature shows that the use of intraoperative topical antiseptics is of clinical relevance to prevent infection of orthopedic implants (30–32). A meta-analysis of 20 studies of instrumented spine surgery showed that topical antibiotics can reduce the risk by threefold, while antiseptic irrigation with povidone-iodine can reduce the risk of wound infection by sevenfold (33). For example, an observational study of 323 spine surgeries showed a significant reduction in deep wound infections after establishing 90 s wound irrigation every 1.5 h using 1% povidone-iodine (34). In addition, povidone-iodine showed comparable to better results than vancomycin in preventing postoperative infections in a network meta-analysis (32). In conclusion, antiseptics are, in our view, the better choice for topical infection prophylaxis.
4.2.2.1. Sodium hypochlorite/hypochlorous acid (NaOCl/HOCl)
In our clinical work, we chose 0.08% NaOCl/HOCl, a newer antiseptic, in which we saw potential advantages compared with commonly used antiseptics. Kramer et al. provide an excellent review and consensus recommendation with characterization and comparison of antiseptics suitable for intraoperative use (35). There, NaOCl/HOCl is reported as highly effective against vegetative bacteria, bacterial spores, aspergilli, oocysts of cryptosporidium, and enveloped viruses. In efficacy against biofilms, NaOCl/HOCl is described to be more effective than a polyhexanide/betaine combination. Onset of action occurs more rapidly than with povidone-iodine, octenidine, and polyhexanide (35) in between 30 s and 5 min (36). Unlike commonly used surface-active antiseptics, NaOCl/HOCl acts by a physiological bactericidal mechanism, leaving only NaCl and water as end products (37). Better biocompatibility and less cytotoxicity as well as improved wound healing compared to povidone-iodine have been reported in experimental and clinical studies (35), but literature for spine surgery applications is lacking. Unlike established antiseptics such as povidone iodine or polyhexanide, which are contraindicated for use on nervous tissue, NaOCl/HOCl is considered compatible for this application (35). In summary, NaOCl/HOCl appears to us to be a modern antiseptic with the best properties for use in spinal surgery.
4.2.2.2. Intervertebral disc as a possible source of infection
An analysis of 169 discs from 87 patients operated on for non-inflammatory spinal problems showed bacteria-positive cultures in 45% (20% P. acnes, 18% coagulase-negative staphylococci, 7% other). Patients who underwent surgery for disc herniation and degenerative disc disease showed a significant association with positive bacterial cultures compared to control patients (trauma, deformities) (x2 = 15.37; p = 0.000088) (38). In addition, a similar study of 368 patients undergoing disc herniation surgery demonstrated the formation of a biofilm in the disc by P. acnes (39). Because intravenous antibiotic prophylaxis does not reliably achieve sufficient bactericidal doses in the disc space (40, 41), topical application of effective antiseptics (42) to the disc space prior to implant placement appears reasonable, although not yet proven. Therefore, we flush the disc space with NaOCl/HOCl during nucleotomy and disc preparation and before cage implantation.
4.2.2.3. Iodine-impregnated incision drape
The use of non-antiseptically impregnated incision drape significantly increases the risk of wound infection, which is why this application is not recommended (12). However, iodine-impregnated incision drapes are antimicrobial, with iodine penetrating into deeper skin layers (43). Recent randomized trials confirmed a significant reduction in wound contamination (44, 45).
4.2.3. Implants
Pedicle screws placed on the instrument table showed initial contamination with staphylococci and micrococci after only 20 min (46). Similarly, other studies showed contamination rates of up to 55% in exposed implants, which could be significantly reduced by simply covering them (23, 47–49). To protect implants and sterile instruments, it should be considered that patient positioning can result in more than 4-fold higher bacterial concentrations in the air in the operating room and in some cases exceed the standards for ultra-clean air (50).
4.2.4. Drainage-use in large wounds
In our clinical practice, we usually use drainages only in large wounds with conventional open spinal instrumentations. We adapted a drainage management protocol of Ward et al. who reported a reduction in wound complication rates from 19% to 0% in a study of 76 cases of neuromuscular scoliosis surgery (51), (Table 1). It should be noted here, that some studies have indeed shown a correlation of the incidence of wound infection with the duration of drainage placement (52, 53). High-quality reviews, however, show that there is no consistent, let alone high-quality, evidence on the impact of longer position times of wound drainages on wound infection rates after spine surgery (54). The varying results in this question may result from the dressing technique at the drainage exit site. Commonly used, simple bandage dressings are quickly perfused or peel off in bed. This quickly creates an entry point for germs. Therefore, we additionally cover the drainage dressing with an iodine-impregnated incision drape, which can remain in place for up to 5 days. Dressing changes should be performed using aseptic technique. There is no evidence-based literature for this approach yet. We have not observed any adverse effects with this procedure and it seems to be well tolerated by our patients.
Epidermal VAC (Vacuum Assisted Closure) dressings for spinal fusion reduced wound dehiscence and infection in first observational studies (55, 56), especially in cases at high risk for infection (57). We agree that primarily, epidermal VAC therapy is appropriate for patients who are at high risk for infection and/or wound dehiscence (58).
4.3. Limitations and strength of this study
Our study compares two well-characterized cohorts of patients who are well matched for patient and surgical data. Our organizational structure provided high compliance with the GAID-Protocol. Limitations include those inherent to a retrospective report using historical controls. These include a general increased awareness of the medical team after implementation of the GAID-Protocol as a confounding factor. The small overall sample size provides only limited statistical power. We acknowledge that our data set is not able to clearly distinguish the additive effect of each measure, but we believe that the cumulative effect is compelling. Moreover, each of these measures is low-risk and low-cost, so we do not believe there are any relevant drawbacks to adopting the GAID protocol. Further higher-powered studies would be useful to further evaluate the GAID-Protocol or components of it, such as the use of NaOCl/HOCl for wound and disc space irrigation.
5. Conclusions
In our study, adherence to the GAID-Protocol, a bundle of infection prevention measures specifically designed to protect against implant-associated infections in spine surgery, resulted in a shift from severe to significantly less severe and easier to treat wound complications. A significant decrease in severe surgical site infections related to infectious spondylitis/discitis from 5.4% to zero was observed. Adoption of the GAID-Protocol might contribute to the reduction of implant-associated infections.
Acknowledgments
We would like to thank Yvonne Post, Maya Derber and Stephan Behrens for their contributions as part of the working group that developed and implemented the new infection prevention measures, and Christoph Lepinat for his support in extracting the relevant data from the hospital information system.
Funding Statement
The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.
Data availability statement
The ananomized raw data supporting the conclusions of this article will be made available by the authors, with undue reservation.
Ethics statement
Ethical approval was not required for the study involving humans in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was not required from the participants or the participants’ legal guardians/next of kin in accordance with the national legislation and the institutional requirements.
Author contributions
JP: Data curation, Formal analysis, Investigation, Writing – review & editing. AH: Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
References
- 1.Featherall J, Miller JA, Bennett EE, Lubelski D, Wang H, Khalaf T, et al. Implementation of an infection prevention bundle to reduce surgical site infections and cost following spine surgery. JAMA Surg. (2016) 151:988–90. 10.1001/jamasurg.2016.1794 [DOI] [PubMed] [Google Scholar]
- 2.Yamada K, Abe H, Higashikawa A, Tonosu J, Kuniya T, Nakajima K, et al. Evidence-based care bundles for preventing surgical site infections in spinal instrumentation surgery. Spine (Phila Pa 1976). (2018) 43:1765–73. 10.1097/BRS.0000000000002709 [DOI] [PubMed] [Google Scholar]
- 3.Agarwal N, Agarwal P, Querry A, Mazurkiewicz A, Tempel ZJ, Friedlander RM, et al. Implementation of an infection prevention bundle and increased physician awareness improves surgical outcomes and reduces costs associated with spine surgery. J Neurosurg Spine. (2018) 29:108–14. 10.3171/2017.11.SPINE17436 [DOI] [PubMed] [Google Scholar]
- 4.Castellà L, Sopena N, Rodriguez-Montserrat D, Alonso-Fernández S, Cavanilles JM, Iborra M, et al. Intervention to reduce the incidence of surgical site infection in spine surgery. Am J Infect Control. (2019) 48(5):550–4. 10.1016/j.ajic.2019.09.007 [DOI] [PubMed] [Google Scholar]
- 5.Tomov M, Wanderman N, Berbari E, Currier B, Yaszemski M, Nassr A, et al. An empiric analysis of 5 counter measures against surgical site infections following spine surgery-a pragmatic approach and review of the literature. Spine J. (2019) 19:267–75. 10.1016/j.spinee.2018.05.043 [DOI] [PubMed] [Google Scholar]
- 6.Glotzbecker M, Troy M, Miller P, Berry J, Cohen L, Gryzwna A, et al. Implementing a multidisciplinary clinical pathway can reduce the deep surgical site infection rate after posterior spinal fusion in high-risk patients. Spine Deform. (2019) 7:33–9. 10.1016/j.jspd.2018.06.010 [DOI] [PubMed] [Google Scholar]
- 7.Stephan SR, Illingworth KD, Gupta K, Andras LM, Skaggs DL. Surgical site infection following neuromuscular posterior spinal fusion fell 72% after adopting the 2013 best practice guidelines. Spine (Phila Pa 1976). (2021) 46:1147–53. 10.1097/BRS.0000000000004050 [DOI] [PubMed] [Google Scholar]
- 8.Yao R, Zhou H, Choma TJ, Kwon BK, Street J. Surgical site infection in spine surgery: who is at risk. Global Spine J. (2018) 8:5S–30S. 10.1177/2192568218799056 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Zhou J, Wang R, Huo X, Xiong W, Kang L, Xue Y. Incidence of surgical site infection after spine surgery: a systematic review and meta-analysis. Spine (Phila Pa 1976). (2020) 45:208–16. 10.1097/BRS.0000000000003218 [DOI] [PubMed] [Google Scholar]
- 10.Lang S, Frömming A, Walter N, Freigang V, Neumann C, Loibl M, et al. Is there a difference in clinical features, microbiological epidemiology and effective empiric antimicrobial therapy comparing healthcare-associated and community-acquired vertebral osteomyelitis. Antibiotics (Basel). (2021) 10:1410. 10.3390/antibiotics10111410 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Lang S, Walter N, Schindler M, Baertl S, Szymski D, Loibl M, et al. The epidemiology of spondylodiscitis in Germany: a descriptive report of incidence rates, pathogens, in-hospital mortality, and hospital stays between 2010 and 2020. J Clin Med. (2023) 12:3373. 10.3390/jcm12103373 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut. Prävention postoperativer wundinfektionen. Bundesgesundheitsblatt—Gesundheitsforschung—Gesundheitsschutz. (2018) 61:448–73. 10.1007/s00103-018-2706-2 [DOI] [PubMed] [Google Scholar]
- 13.Koyama K, Ohba T, Ebata S, Haro H. Postoperative surgical infection after spinal surgery in rheumatoid arthritis. Orthopedics. (2016) 39:e430–3. 10.3928/01477447-20160404-05 [DOI] [PubMed] [Google Scholar]
- 14.Echt M, De la Garza Ramos R, Nakhla J, Gelfand Y, Cezayirli P, Holland R, et al. The effect of cigarette smoking on wound complications after single-level posterolateral and interbody fusion for spondylolisthesis. World Neurosurg. (2018) 116:e824–9. 10.1016/j.wneu.2018.05.103 [DOI] [PubMed] [Google Scholar]
- 15.Vitale MG, Riedel MD, Glotzbecker MP, Matsumoto H, Roye DP, Akbarnia BA, et al. Building consensus: development of a best practice guideline (BPG) for surgical site infection (SSI) prevention in high-risk pediatric spine surgery. J Pediatr Orthop. (2013) 33:471–8. 10.1097/BPO.0b013e3182840de2 [DOI] [PubMed] [Google Scholar]
- 16.National Healthcare Safety Network. Surgical Site Infection Event (SSI). (2023). Available at: http://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf
- 17.World Health Organization. Global guidelines for the prevention of surgical site infection. 2nd ed. World Health Organization; (2018). Available at: https://www.who.int/publications/i/item/9789241550475 [PubMed] [Google Scholar]
- 18.Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut. Händehygiene in einrichtungen des gesundheitswesens. Bundesgesundheitsblatt—Gesundheitsforschung—Gesundheitsschutz. (2016) 59:1189–220. 10.1007/s00103-016-2416-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Dawson-Bowling S, Smith J, Butt D, Cottam H, Umasankar S, Armitage A. Should outer surgical gloves be changed intraoperatively before orthopaedic prosthesis implantation. J Hosp Infect. (2011) 78:156–7. 10.1016/j.jhin.2011.02.014 [DOI] [PubMed] [Google Scholar]
- 20.Beldame J, Lagrave B, Lievain L, Lefebvre B, Frebourg N, Dujardin F. Surgical glove bacterial contamination and perforation during total hip arthroplasty implantation: when gloves should be changed. Orthop Traumatol Surg Res. (2012) 98:432–40. 10.1016/j.otsr.2011.10.015 [DOI] [PubMed] [Google Scholar]
- 21.Rehman A, Rehman AU, Rehman TU, Freeman C. Removing outer gloves as a method to reduce spinal surgery infection. J Spinal Disord Tech. (2015) 28:E343–6. 10.1097/BSD.0b013e31829046ca [DOI] [PubMed] [Google Scholar]
- 22.Anderson PA, Savage JW, Vaccaro AR, Radcliff K, Arnold PM, Lawrence BD, et al. Prevention of surgical site infection in spine surgery. Neurosurgery. (2017) 80:S114–23. 10.1093/neuros/nyw066 [DOI] [PubMed] [Google Scholar]
- 23.Agarwal A, Schultz C, Goel VK, Agarwal A, Anand N, Garfin SR, et al. Implant prophylaxis: the next best practice toward asepsis in spine surgery. Global Spine J. (2018) 8:761–5. 10.1177/2192568218762380 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Davis N, Curry A, Gambhir AK, Panigrahi H, Walker CR, Wilkins EG, et al. Intraoperative bacterial contamination in operations for joint replacement. J Bone Joint Surg Br. (1999) 81:886–9. 10.1302/0301-620x.81b5.9545 [DOI] [PubMed] [Google Scholar]
- 25.Schweitzer D, Klaber I, Fischman D, Wozniak A, Botello E, Amenábar PP. Surgical light handles: a source of contamination in the surgical field. Acta Orthop Traumatol Turc. (2015) 49:421–5. 10.3944/AOTT.2015.14.0401 [DOI] [PubMed] [Google Scholar]
- 26.Biswas D, Bible JE, Whang PG, Simpson AK, Grauer JN. Sterility of C-arm fluoroscopy during spinal surgery. Spine (Phila Pa 1976). (2008) 33:1913–7. 10.1097/BRS.0b013e31817bb130 [DOI] [PubMed] [Google Scholar]
- 27.Maria S, Deyanira C, Francesca S, Lucia M, Alessandro R, Silvia T, et al. Spinal fusion surgery and local antibiotic administration: a systematic review on key points from preclinical and clinical data. Spine (Phila Pa 1976). (2020) 45:339–48. 10.1097/BRS.0000000000003255 [DOI] [PubMed] [Google Scholar]
- 28.Eder C, Schenk S, Trifinopoulos J, Külekci B, Kienzl M, Schildböck S, et al. Does intrawound application of vancomycin influence bone healing in spinal surgery. Eur Spine J. (2016) 25:1021–8. 10.1007/s00586-015-3943-9 [DOI] [PubMed] [Google Scholar]
- 29.Gande A, Rosinski A, Cunningham T, Bhatia N, Lee YP. Selection pressures of vancomycin powder use in spine surgery: a meta-analysis. Spine J. (2019) 19:1076–84. 10.1016/j.spinee.2019.01.002 [DOI] [PubMed] [Google Scholar]
- 30.Lüdemann M, Munoz P, Wagner M, Malzahn U, Horas K, Heuschmann P, et al. The effect of antiseptics in the prophylaxis of infection in orthopaedic surgery. Z Orthop Unfall. (2018) 156:567–73. 10.1055/a-0608-5292 [DOI] [PubMed] [Google Scholar]
- 31.Edmiston CE, Spencer M, Leaper D. Antiseptic irrigation as an effective interventional strategy for reducing the risk of surgical site infections. Surg Infect (Larchmt). (2018) 19:774–80. 10.1089/sur.2018.156 [DOI] [PubMed] [Google Scholar]
- 32.Lin L, Cheng S, Wang Y, Chen X, Zhao G, Wang Z, et al. Efficacy of intrawound treatments to prevent surgical site infection after spine surgery: a systematic review and network meta-analysis. Pain Physician. (2021) 24:E709–20. 10.36076/ppj.2021.24.E709 [DOI] [PubMed] [Google Scholar]
- 33.Lemans JVC, Wijdicks SPJ, Boot W, Govaert GAM, Houwert RM, Öner FC, et al. Intrawound treatment for prevention of surgical site infections in instrumented spinal surgery: a systematic comparative effectiveness review and meta-analysis. Global Spine J. (2019) 9:219–30. 10.1177/2192568218786252 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Onishi Y, Masuda K, Tozawa K, Karita T. Outcomes of an intraoperative povidone-iodine irrigation protocol in spinal surgery for surgical site infection prevention. Clin Spine Surg. (2019) 32:E449–52. 10.1097/BSD.0000000000000908 [DOI] [PubMed] [Google Scholar]
- 35.Kramer A, Dissemond J, Kim S, Willy C, Mayer D, Papke R, et al. Consensus on wound antisepsis: update 2018. Skin Pharmacol Physiol. (2018) 31:28–58. 10.1159/000481545 [DOI] [PubMed] [Google Scholar]
- 36.Kramer A. Wundantiseptik: Evidenz, Indikationen, Wirkstoffauswahl und Perspektiven. Ars Med. (2016) 9:419–28. [Google Scholar]
- 37.Wang L, Bassiri M, Najafi R, Najafi K, Yang J, Khosrovi B, et al. Hypochlorous acid as a potential wound care agent: part I. Stabilized hypochlorous acid: a component of the inorganic armamentarium of innate immunity. J Burns Wounds. (2007) 6:e5. [PMC free article] [PubMed] [Google Scholar]
- 38.Coscia MF, Denys GA, Wack MF. Propionibacterium acnes, coagulase-negative Staphylococcus, and the “biofilm-like” intervertebral disc. Spine (Phila Pa 1976). (2016) 41:1860–5. 10.1097/BRS.0000000000001909 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Capoor MN, Ruzicka F, Schmitz JE, James GA, Machackova T, Jancalek R, et al. Propionibacterium acnes biofilm is present in intervertebral discs of patients undergoing microdiscectomy. PLoS One. (2017) 12:e0174518. 10.1371/journal.pone.0174518 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Walters R, Moore R, Fraser R. Penetration of cephazolin in human lumbar intervertebral disc. Spine. (2006) 31:567–70. 10.1097/01.brs.0000201244.24003.2d [DOI] [PubMed] [Google Scholar]
- 41.Capoor MN, Lochman J, McDowell A, Schmitz JE, Solansky M, Zapletalova M, et al. Intervertebral disc penetration by antibiotics used prophylactically in spinal surgery: implications for the current standards and treatment of disc infections. Eur Spine J. (2019) 28:783–91. 10.1007/s00586-018-5838-z [DOI] [PubMed] [Google Scholar]
- 42.Nakase K, Fukushima H, Yukawa T, Nakaminami H, Fujii T, Noguchi N. Propionibacterium acnes has low susceptibility to chlorhexidine digluconate. Surg Infect (Larchmt). (2018) 19:298–302. 10.1089/sur.2017.220 [DOI] [PubMed] [Google Scholar]
- 43.Casey AL, Karpanen TJ, Nightingale P, Conway BR, Elliott TS. Antimicrobial activity and skin permeation of iodine present in an iodine-impregnated surgical incise drape. J Antimicrob Chemother. (2015) 70:2255–60. 10.1093/jac/dkv100 [DOI] [PubMed] [Google Scholar]
- 44.Hesselvig AB, Arpi M, Madsen F, Bjarnsholt T, Odgaard A, ICON SG. Does an antimicrobial incision drape prevent intraoperative contamination? A randomized controlled trial of 1187 patients. Clin Orthop Relat Res. (2020) 478(5):1007–15. 10.1097/CORR.0000000000001142 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45.Rezapoor M, Tan TL, Maltenfort MG, Parvizi J. Incise draping reduces the rate of contamination of the surgical site during hip surgery: a prospective, randomized trial. J Arthroplasty. (2018) 33:1891–5. 10.1016/j.arth.2018.01.013 [DOI] [PubMed] [Google Scholar]
- 46.Agarwal A, Lin B, Wang JC, Schultz C, Garfin SR, Goel VK, et al. Efficacy of intraoperative implant prophylaxis in reducing intraoperative microbial contamination. Global Spine J. (2019) 9:62–6. 10.1177/2192568218780676 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 47.Dalstrom DJ, Venkatarayappa I, Manternach AL, Palcic MS, Heyse BA, Prayson MJ. Time-dependent contamination of opened sterile operating-room trays. J Bone Joint Surg Am. (2008) 90:1022–5. 10.2106/JBJS.G.00689 [DOI] [PubMed] [Google Scholar]
- 48.Bible JE, O’Neill KR, Crosby CG, Schoenecker JG, McGirt MJ, Devin CJ. Implant contamination during spine surgery. Spine J. (2013) 13:637–40. 10.1016/j.spinee.2012.11.053 [DOI] [PubMed] [Google Scholar]
- 49.Menekse G, Kuscu F, Suntur BM, Gezercan Y, Ates T, Ozsoy KM, et al. Evaluation of the time-dependent contamination of spinal implants: prospective randomized trial. Spine (Phila Pa 1976). (2015) 40:1247–51. 10.1097/BRS.0000000000000944 [DOI] [PubMed] [Google Scholar]
- 50.Brown AR, Taylor GJ, Gregg PJ. Air contamination during skin preparation and draping in joint replacement surgery. J Bone Joint Surg Br. (1996) 78:92–4. 10.1302/0301-620X.78B1.0780092 [DOI] [PubMed] [Google Scholar]
- 51.Ward JP, Feldman DS, Paul J, Sala DA, Errico TJ, Otsuka NY, et al. Wound closure in nonidiopathic scoliosis: does closure matter? J Pediatr Orthop. (2015) 37(3):166–70. 10.1097/BPO.0000000000000610 [DOI] [PubMed] [Google Scholar]
- 52.Rao SB, Vasquez G, Harrop J, Maltenfort M, Stein N, Kaliyadan G, et al. Risk factors for surgical site infections following spinal fusion procedures: a case-control study. Clin Infect Dis. (2011) 53:686–92. 10.1093/cid/cir506 [DOI] [PubMed] [Google Scholar]
- 53.Liu JM, Deng HL, Chen XY, Zhou Y, Yang D, Duan MS, et al. Risk factors for surgical site infection after posterior lumbar spinal surgery. Spine (Phila Pa 1976). (2018) 43:732–7. 10.1097/BRS.0000000000002419 [DOI] [PubMed] [Google Scholar]
- 54.Tan T, Lee H, Huang MS, Rutges J, Marion TE, Mathew J, et al. Prophylactic postoperative measures to minimize surgical site infections in spine surgery: systematic review and evidence summary. Spine J. (2019). 20(3):435–47. 10.1016/j.spinee.2019.09.013 [DOI] [PubMed] [Google Scholar]
- 55.Adogwa O, Fatemi P, Perez E, Moreno J, Gazcon GC, Gokaslan ZL, et al. Negative pressure wound therapy reduces incidence of postoperative wound infection and dehiscence after long-segment thoracolumbar spinal fusion: a single institutional experience. Spine J. (2014) 14:2911–7. 10.1016/j.spinee.2014.04.011 [DOI] [PubMed] [Google Scholar]
- 56.Naylor RM, Gilder HE, Gupta N, Hydrick TC, Labott JR, Mauler DJ, et al. Effects of negative pressure wound therapy on wound dehiscence and surgical site infection following instrumented spinal fusion surgery—a single surgeon’s experience. World Neurosurg. (2020) 137:e257–62. 10.1016/j.wneu.2020.01.152 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 57.Dyck BA, Bailey CS, Steyn C, Petrakis J, Urquhart JC, Raj R, et al. Use of incisional vacuum-assisted closure in the prevention of postoperative infection in high-risk patients who underwent spine surgery: a proof-of-concept study. J Neurosurg Spine. (2019) 31:430–9. 10.3171/2019.2.SPINE18947 [DOI] [PubMed] [Google Scholar]
- 58.Stannard JP, Gabriel A, Lehner B. Use of negative pressure wound therapy over clean, closed surgical incisions. Int Wound J. (2012) 9(Suppl 1):32–9. 10.1111/j.1742-481X.2012.01017.x [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The ananomized raw data supporting the conclusions of this article will be made available by the authors, with undue reservation.