Abstract
Background: Reduction of surgical site infections (SSIs) is important in improving cervical spine surgery outcomes. Plastic surgery involvement and an enhanced modified prophylaxis protocol may reduce infection rates. Methods: A total of 962 cervical spine operations were conducted by a single surgeon (TFC). An enhanced modified prophylaxis protocol and plastic surgery were used in some operations. Differences in infection rates, surgical approach, previous operations, prophylaxis use, and plastic surgery involvement were compared using Fisher’s exact tests and multivariate linear regression. Results: Four patients (0.42%) experienced SSIs. All 4 infections involved the standard protocol, posterior approach, and did not involve plastic surgery. The infection rate was lower in the enhanced protocol group when compared to the standard protocol (β −0.78, 95% CI −1.23 to −0.33, P = .0008). The enhanced protocol group had an increased percentage of operations with plastic surgery (β 0.19, 95% CI 0.10 to 0.28, P < .0001). The infection rate among the plastics group was 0.00% compared to 0.60% for the non-plastics group (P = .32). The plastics group had a lower rate of anterior approach when compared to the non-plastics group (β −0.20, 95% CI −0.24 to −0.15, P = .049). Among the posterior approach group, procedures with plastic surgery had an infection rate of 0.00% compared to 2.53% without plastic surgery (P = .13). Conclusion: The enhanced protocol was associated with a lower SSI rate and increased plastic surgery involvement. Posterior approaches were associated with increased infection rates and the likelihood of utilizing plastic surgery. Both the enhanced protocol and plastic surgery may decrease infection.
Keywords: cervical spine, infection, plastic surgery, prophylaxis
Résumé
Contexte: La réduction des infections du site opératoire est importante pour améliorer les résultats de la chirurgie de la colonne cervicale. L’implication de la chirurgie plastique et d’un protocole amélioré de prophylaxie modifiée peuvent réduire les taux d’infection. Méthodes: Un total de 962 opérations sur la colonne cervicale a été effectué par un seul chirurgien (TFC). Un protocole amélioré de prophylaxie modifiée et la chirurgie plastique ont été utilisés au cours de certaines interventions. Les différences dans les taux d’infection, l’abord chirurgical, les opérations précédentes, l’utilisation de la prophylaxie et l’implication de la chirurgie plastique ont été évalués au moyen de tests exacts de Fisher et d’une régression linéaire multifactorielle. Résultats: Quatre patients (0.42%) ont présenté une infection de la cicatrice opératoire (ICO). Les quatre infections impliquaient le protocole standard, l’abord postérieur et l’absence de chirurgie plastique. Le taux d’infection a été moindre dans le groupe de protocole amélioré, comparativement au protocole standard (β −0.78, IC à 95%: −1.23 à −0.33, P = .0008). Le pourcentage d’opérations avec chirurgie plastique était augmenté dans le groupe au protocole amélioré (β 0.19, IC à 95%: 0.10 à 0.28, P < .0001). La fréquence des infections dans le groupe de chirurgie plastique était de 0.00%, comparée à 0.60% dans le groupe sans chirurgie plastique (P = .32). Le groupe avec chirurgie plastique avait un taux d’abord antérieur inférieur comparativement au groupe sans chirurgie plastique (β −0.20, IC à 95%: −0.24 à −0.15, P = .049). Dans le groupe avec abord postérieur, le taux d’infections était de 0.00% avec chirurgie plastique contre 2.53% sans chirurgie plastique (P = .13). Conclusion: Le protocole amélioré a été associé à un taux d’OCI inférieur et à une plus grande implication de la chirurgie plastique. Un abord postérieur a été associé à des taux augmentés d’infection et à une plus grande probabilité d’utilisation de la chirurgie plastique. Le protocole amélioré et la chirurgie plastique peuvent tous deux réduire les infections.
Introduction
Postoperative surgical site infection (SSI) is a common complication after spine surgery with reported incidence rates between 0.1% and 10.3%.1–10 SSI can lead to increased morbidity and mortality due to increased length of stay, readmission, postoperative pain, and postoperative complications. It can also require additional surgical procedures and significantly increase the cost of care.11–20 Thus, reduction of SSI is an important goal in neurosurgery.
Within cervical spine surgery, the reported incidence of SSI is generally higher for posterior procedures (2.9%-10.3%) compared to anterior procedures (0.1%-1.6%).3,21 Potential reasons for this include longer procedures, larger surgical fields, and more tissue dissection.3,21 Some identified risk factors for cervical SSI include obesity and obesity-related comorbidities such as heart disease and diabetes, and chronic steroid use. 3 Strategies for prevention of cervical SSI include careful wound closure and drain placement. 3 Use of vancomycin powder has also been reported, but its efficacy is unclear with conflicting prior studies.3,22–24
Other reported strategies for decreasing the incidence of SSI are improving preoperative skin antisepsis and involvement of plastic surgery. Plastic surgery involvement has been shown to decrease infection rates in spine surgery in 1 study. 25 A prior study by the same group of an enhanced modified prophylaxis protocol at a single institution by a single neurosurgeon showed no infections for anterior and posterior cervical operations. 26 Here the authors provide an update to the prior study of enhanced prophylaxis protocol and examine the efficacy of plastic surgery involvement.
Methods
The institutional review board granted approval for this study on March 27, 2018 with a waiver of patient consent in accordance with the principles in the Helsinki Declaration (ID: IF2444112). The present retrospective study analyzed the incidence of postoperative SSI following a consecutive series of 962 cervical spine operations performed at a single institution by the first author between October 2001 and December 2019. Plastic surgery assisted in closing surgical incision sites in some cases due to (a) concerns about patient healing potential, (b) concerns about the difficulty of closure, (c) patient request, or (d) difficulties with closure intraoperatively. All cases with plastic surgery were simple wound closures and did not involve flaps. Patients with operations in December 2005 or later received an enhanced prophylaxis protocol as previously described (Table 1). 26
Table 1.
Standard and Enhanced Prophylaxis Protocol Measures.
| Indication | Standard protocol | Enhanced protocol |
|---|---|---|
| Patient skin preparation | Standard betadine/iodine scrub/paint. Select use of alcohol pads |
|
| Alcohol pad preparation | Select use | Regular use |
| Patient prep performance | Select attending performance | Regular attending performance |
| Pulse irrigator (saline with bacitracin) | Select use | Regular use for posterior instrumentation |
| Surgical drains | Select use | Regular use |
| Prophylactic Antibiotic Coverage (unless allergic) | IV Cefuroxime for 24 h select use of IV Vancomycin (in case of cephalosporin allergy only) | Regular use for the posterior instrumentation: 1. IV Cefuroxime for 24 h, IV Vancomycin until drain removal Non-instrumentation cases 1. IV Cefuroxime for 24 h |
Notes: Comparison of the standard protocol versus enhanced protocol. Dosage and administration of antibiotics were calculated based on the patient’s weight and renal clearance. Standard doses were not used.
(1). Two isopropyl alcohol wipes were swabbed over the incision site and immediate surrounding regions 6 times. (2). Betadine ointment is applied to the incision site and immediately surrounding region after the use of alcohol wipes. Only used in skin preparation, not after closure. (3). Drains were removed when output reached <30 cc/8 h shift. (4). Drains are used regularly for instrumented cases and selectively for non-instrumented cases.
SSIs were recorded and defined as per the standard of the Centers for Disease Control and Prevention (CDC) definitions. 27 Inclusion criteria were adult patients undergoing elective cervical spine operations (either primary or revision) by the first author within the stated date restrictions. Exclusion criteria consisted of only those patients with preexisting infections. Patients were not excluded on the basis of medical comorbidities (diabetes, congestive heart failure (CHF), low serum protein, etc.) or procedure length.
Data collection consisted of a retrospective review of a patient database of all spinal procedures performed by the first author drawn from medical records, anesthesia reports, and operative reports. Demographic data included age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) Physical Status Classification System status and procedure length. The cervical distinction was defined by the operative location on the patient’s spine. The primary outcome variable evaluated was the incidence of SSI, which was defined per CDC standards and confirmed with wound cultures. 27 All data were collected and analyzed by independent reviewers uninvolved in the surgical treatment of the patient’s study.
Statistical analysis was performed by GraphPad Prism 7.0 (GraphPad Software) and RStudio (RStudio Software). Two-tailed Fisher’s exact tests and multivariate logistic regression were used. For all analyses, α = 0.05.
Results
A total of 964 patients met the inclusion criteria for the present study, of which 20.0% underwent cervical spine surgery with the standard protocol (n = 193). The remaining 80.0% underwent surgery with the enhanced protocol (n = 771). Plastic surgery was involved in wound closure of 30.4% of the operations (n = 292). The remaining 69.6% did not involve plastic surgery (n = 672). There were 4 cases of SSI as defined by the CDC, for an overall infection rate of 0.42%. Patients with the enhanced protocol had increased age, more female patients, increased BMI, and longer procedures compared to patients with the standard protocol. Patients with plastic surgery involvement had longer procedures but did not differ by age, sex, BMI, or ASA status compared to patients without plastic surgery involvement. Patients with posterior cervical procedures had increased age, less female patients, higher ASA status, and longer procedures compared to anterior cervical procedures (Table 2).
Table 2.
Patient Demographics.
| Standard protocol (n = 193) | Enhanced protocol (n = 771) | P value | No plastics (n = 672) | Plastics (n = 292) | P value | Anterior (n = 667) | Posterior (n = 287) | P value | |
|---|---|---|---|---|---|---|---|---|---|
| Age (SD) | 53.2 (15.1) | 57.0 (13.5) | P = .002 | 55.9 (13.3) | 57.6 (13.9) | P = .08 | 54.7 (13.2) | 58.4 (14.19) | P < .0001 |
| Female Sex | 36.5% | 52.6% | P < .0001 | 49.4% | 48.8% | P = .89 | 54.1% | 42.0% | P = .0003 |
| BMI (SD) | 27.5 (5.1) | 28.5 (6.6) | P = .046 | 28.2 (6.7) | 28.6 (6.1) | P = .41 | 28.3 (5.9) | 28.1 (6.3) | P = .60 |
| ASA (SD) | 2.5 (0.7) | 2.5 (0.6) | P = .83 | 2.5 (0.7) | 2.6 (0.6) | P = .25 | 2.4 (0.6) | 2.7 (0.7) | P < .0001 |
| Procedure length hours (SD) | 4.0 (1.3) | 4.3 (1.5) | P = .015 | 4.1 (1.4) | 4.5 (1.5) | P = .0005 | 4.0 (1.4) | 4.6 (1.5) | P < .0001 |
Abbreviation: BMI, body mass index.
Standard Versus Enhanced Protocol
Among the standard protocol surgeries, 68% of procedures had an anterior approach, and the remaining 32% had a posterior approach (Table 3). For the enhanced protocol surgeries, 71% had an anterior approach, and 29% had a posterior approach. Rates of anterior and posterior approaches did not differ significantly between the 2 protocol groups. For those undergoing surgery with the standard protocol, 42% of patients had a history of prior cervical spine surgery. For the enhanced protocol, 37% had a history of prior cervical spine surgery. Standard protocol surgeries were associated with 4 infections compared to no infections with the enhanced protocol (2% vs 0%, P = .002). Enhanced protocol procedures were more likely to involve plastic surgery compared to standard protocol procedures (36% vs 6%, P < .0001). In a multivariate analysis controlling for surgical approach and demographic differences, lower infection rates remained associated with the enhanced protocol (β −0.78, 95% CI −1.23 to −0.33, P = .0008). Plastic surgery involvement also remained significantly associated with enhanced protocol use (β 0.19, 95% CI 0.10 to 0.28, P < .0001, Table 3).
Table 3.
Univariate and Multivariate Analysis of Standard Versus Enhanced Protocol.
| Standard (n = 193) | Enhanced (n = 771) | P value | |
|---|---|---|---|
| Anterior approach | 68.4% (132/193) | 70.7% (545/771) | P = .54 |
| Posterior approach | 31.6% (61/193) | 29.3% (226/771) | P = .54 |
| Multiple surgeries | 42.0% (81/193) | 37.4% (287/767) | P = .25 |
| Infections | 2.07% (4/193) | 0.00% (0/771) | P = .0016* |
| Plastics | 6.22% (12/193) | 36.3% (280/771) | P < .0001* |
| Multivariate analysis of enhanced protocol | |||
| β | 95%CI | P value | |
| Anterior approach | 0.072 | 0.012 to 0.133 | P = .02 |
| Infections | −0.78 | −1.23 to −0.33 | P = .0008 |
| Plastics | 0.19 | 0.10 to 0.28 | P < .0001 |
| Age | 0.0018 | −0.0003 to 0.0038 | P = .09 |
| Female sex | 0.17 | 0.10 to 0.24 | P < .0001 |
| BMI | 0.0058 | 0.0008 to 0.0109 | P = .02 |
| Procedure length hours | 0.016 | 0.001 to 0.031 | P = .04 |
Abbreviation: BMI, body mass index.
Plastic Surgery
Next, the authors sought to better characterize the population needing plastic surgery. Procedures with plastic surgery involvement included a significantly lower portion of anterior approach procedures compared to those without plastics (163 of 292 (56%) vs 514 of 672 (77%), P < .0001, Table 4). Plastic surgery involvement was significantly more likely to be associated with posterior approaches compared to surgeries without plastics (129 of 292 (44%) vs 158 of 672 (24%), P < .0001). Among the patients with surgeries requiring plastic involvement, 39% had a history of at least 1 other cervical spine procedure. Among those without plastic surgery involvement, 38% of patients had a history of multiple surgeries (P = .89). Finally, though all surgeries that resulted in infections did not involve plastic surgery, there was no significant difference in infection rates among cases without plastic surgery versus cases with plastics involvement in univariate analysis (4 of 672 (0.60%) vs 0 of 292 (0.00%), P = .32), and plastic surgery was not associated with decreased infection in multivariate analysis (β −0.14, 95% CI −0.50 to 0.21, P = .43). Multivariate analysis controlling for demographic differences confirmed that plastic surgery involvement was associated with a less frequent anterior approach (β −0.20, 95% CI −0.24 to −0.15, P = .049) and greater use of the enhanced protocol (β 0.14, 95% CI 0.08 to 0.20, P < .0001) (Table 4).
Table 4.
Univariate and Multivariate Analysis of Plastic Surgery Involvement.
| Plastics (n = 292) | No plastics (n = 672) | P value | |
|---|---|---|---|
| Anterior approach | 55.8% (163/292) | 76.5% (514/672) | P < .0001* |
| Posterior approach | 44.2% (129/292) | 23.5% (158/672) | P < .0001* |
| Multiple surgeries | 38.8% (113/291) | 38.1% (255/669) | P = .89 |
| Infections | 0.00% (0/292) | 0.60% (4/672) | P = .32 |
| Enhanced protocol | 95.89% (280/292) | 1.79% (12/672) | P < .0001* |
| Multivariate analysis of plastic surgery involvement | |||
| Β | 95%CI | P value | |
| Anterior approach | −0.20 | −0.24 to −0.15 | P = .049 |
| Infections | −0.14 | −0.50 to 0.21 | P = .43 |
| Enhanced protocol | 0.14 | 0.08 to 0.20 | P < .0001 |
| Procedure time hours | 0.014 | 0.002 to 0.027 | P = .03 |
Posterior Approach Subgroup Analyses
Subgroup analyses were performed including only surgeries with the posterior approach. Within posterior approach operations, plastic surgery involvement was not associated with a significant difference in SSI rate in univariate (0.00% vs 2.53%, P = .13) or multivariate analysis (β −0.036, 95% CI −0.511 to 0.439, P = .88) (Table 5).
Table 5.
Posterior Cervical Approach: Univariate and Multivariate Analysis of Plastic Surgery Involvement.
| Plastics (n = 129) | No plastics (n = 158) | P value | |
|---|---|---|---|
| Enhanced protocol | 97.8% (126/129) | 63.3% (100/158) | P < .0001* |
| Multiple surgeries | 46.9% (60/128) | 50.6% (80/158) | P = .55 |
| Infections | 0.00% (0/129) | 2.53% (4/158) | P = .13 |
| Multivariate analysis of plastic surgery involvement | |||
| β | 95%CI | P value | |
| Enhanced protocol | 0.26 | 0.12 to 0.41 | P = .0004 |
| Infections | −0.036 | −0.511 to 0.439 | P = .88 |
| Female sex | −0.27 | −0.45 to −0.09 | P = .004 |
| Age | −0.0017 | −0.0055 to 0.0021 | P = .38 |
| ASA | −0.030 | −0.119 to 0.058 | P = .50 |
| Procedure time hours | 0.016 | −0.024 to 0.057 | P = .43 |
Infections
Of the 4 patients with a postoperative SSI, all were male, with an age range between 51 and 80 years old, and BMI ranging from 24 to 35 (Table 6). Organisms cultured from the surgical wounds included methicillin-sensitive Staphylococcus aureus (MSSA), methicillin-resistant S aureus (MRSA), Escherichia coli, and Pseudomonas. None of these procedures involved plastic surgery, and all but 1 patient had a previous cervical spine procedure. All 4 patients had hypertension, 1 had diabetes mellitus, and none had coronary artery disease. One procedure involved the upper cervical spine, 2 involved the subaxial cervical spine, and 1 involved the cervicothoracic junction (Table 6). Three (75%) cases required instrumentation.
Table 6.
Infection Characteristics.
| Infection | 1 | 2 | 3 | 4 |
|---|---|---|---|---|
| Organism(s) | MRSA | MSSA | Coagulase-negative Staphylococcus, Escherichia coli | Coagulase-negative Staphylococcus, Staphylococcus epidermidis, and Pseudomonas |
| Age | 60 | 51 | 64 | 80 |
| Sex | Male | Male | Male | Male |
| BMI | 35 | 32 | 27 | 24 |
| Plastic surgery | No | No | No | No |
| Previous cervical spine surgery | Yes | Yes | Yes | No |
| Operation | Bilateral C6-T1 posterior cervical foraminotomies | Posterior cervical C3-C6 laminectomies, foraminotomies, partial facetectomies, arthrodesis, local autograft, and instrumentation | Posterior cervical C3-C7 laminectomies, foraminotomies, partial facetectomies, arthrodesis, local autograft, and instrumentation | Posterior cervical C1-C2 hemilaminotomies and partial facetectomies, arthrodesis, local autograft, instrumentation, and sublaminar wiring |
| Hypertension | Yes | Yes | Yes | Yes |
| Diabetes mellitus | Yes | No | No | No |
| CAD | No | No | No | No |
Abbreviations: BMI: body mass index; CAD: coronary artery disease; MRSA: methicillin-resistant Staphylococcus aureus; MSSA: methicillin-sensitive Staphlococcus aureus.
Discussion
The present study demonstrates that enhanced prophylaxis protocol was associated with decreased infection rate and increased use of plastic surgery in both univariate and multivariate analyses. Plastic surgery alone was not associated with decreased infection in univariate and multivariate analyses, but it was associated with increased use in posterior cervical cases and decreased use in anterior cervical cases. These findings suggest that both enhanced prophylaxis protocol and plastic surgery may contribute to decreased rates of postoperative SSI.25,26 Due to the low overall infection rate and multifactorial enhancements in the enhanced prophylaxis protocol, it is difficult to know which component of care had a larger effect on SSI. Many of these components have been previously reported to affect SSI.13,14,23,28
Similar reductions in SSI have been reported after the implementation of various prophylaxis protocol modifications.3,21,23,28,29 However, other studies have suggested that rates of SSI have not significantly changed despite the introduction of new evidence-based guidelines.30,31 The low infection rates reported in this study and prior studies make it difficult to elucidate differences by implementing a given protocol, and further study on these protocols with larger patient samples is warranted.
Regarding plastic surgery, 1 prior study has been performed reporting decreased infection incidence in spine surgeries at all levels with plastic surgery involvement. Cervical spine procedures were associated with decreased wound complications, but the association between cervical procedures and infection rate was not studied. 25 Here, the authors report that plastic surgery involvement may be contributing to reduced infection after cervical spine procedures, 4 infections of 672 cases without plastic surgery (0.60%) versus 0 infections of 292 cases with plastic surgery (0.00%), however, the data analysis only suggests a trend, rather than an association.
The specific related benefits of plastic surgery involvement may be the increased efficiency of closure with decreased operative times. 25 Having a plastic surgeon available for closure without significant delay should shorten operative times. Since operative time is a known risk factor for complications, plastic surgery involvement may improve patient outcomes through decreased complications. 32
One drawback to plastic surgery involvement is the added cost to the procedure. However, this may be offset by the increased cost of a postoperative SSI, which usually requires readmission for additional treatment. 25 The specific cost-effective analysis of the use of plastic surgery in reducing SSI has yet to be determined. Another drawback is additional traffic in the operating room, which has been shown to increase infections. 33
The present study aligns with prior studies showing an increased SSI incidence in posterior cervical operations compared to anterior cervical operations. Reported SSI for anterior cervical discectomy and fusion is between 0.1% and 1.6% while reported SSI for posterior decompression and fusion is between 2.9% and 10.3%.3,21 In this study, 0% of anterior cervical procedures had SSI, 1.4% of posterior cervical procedures had SSI, and 0% of posterior cervical procedures with enhanced prophylaxis or plastic surgery had SSI. Increased plastic surgery involvement was also associated with posterior cervical operations, partly due to the associated increased risk of infection. Subgroup analyses including only posterior approach surgeries demonstrated no differences in rates of SSI between surgeries with and without plastic involvement. However, given that plastic surgery was more likely to assist with complex cases that otherwise would have conferred a higher infection risk, a similar SSI rate may suggest its usefulness in reducing infection incidence. Future studies adjusting for the relative infection risk of each operation are warranted to clarify this conclusion.
Limitations
The primary limitation of the study was low statistical power because of the low SSI rate, with only 4 infections for 964 patients. Moreover, due to the retrospective nature of this study, results depend on accurate past reporting of complications. All procedures were performed by a single neurosurgeon which may introduce bias. No protocol was used to determine which patients were involved in plastic surgery, which may introduce selection bias. Patients who experienced a postoperative infection but were lost to follow up may not be captured in the analysis. While knowing the specific indication for plastic surgery involvement would be useful, we were not able to obtain this data, and this variable is an important avenue for future study. Finally, the differences between plastic surgeons in skill and experience were not captured in this study or controlled for in the analysis.
Conclusions
In the present series of patients undergoing cervical spine procedures, all 4 instances of SSI involved the standard protocol, a posterior approach, and no plastic surgery involvement. Enhanced prophylaxis protocol is associated with a lower infection rate following cervical spine surgeries, but these procedures were also more likely to involve plastic surgery. Both the enhanced protocol and plastic surgery involvement may contribute to a lower rate of SSIs. Posterior surgical approaches are associated with an increased likelihood of plastic surgery involvement during wound closure. Plastic surgery involvement may reduce infection rates in high infection-risk cases.
Footnotes
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
Ethical Approval: The institutional review board at Mount Sinai Hospital granted approval for this study on March 27, 2018 with a waiver of patient consent in accordance with the principles in the Helsinki Declaration (ID: IF2444112). All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.
ORCID iDs: Adam Y. Li https://orcid.org/0000-0001-7654-1469
Nickolas Dreher https://orcid.org/0000-0002-0229-8897
Theodore Hannah https://orcid.org/0000-0001-6527-9725
Previous Presentations: A previous version of this study was presented at the 2021 AANS Scientific Meeting.
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