Abstract
Study Design:
Retrospective literature review of spine surgical site infection (SSI).
Objective:
To perform a review of SSI risk factors and more specifically, categorize them into patient and surgical factors.
Methods:
A review of published literature on SSI risk factors in adult spine surgery was performed. We included studies that reported risk factors for SSI in adult spinal surgery. Excluded are pediatric patient populations, systematic reviews, and meta-analyses. Overall, we identified 72 cohort studies, 1 controlled-cohort study, 1 matched-cohort study, 1 matched-paired cohort study, 12 case-controlled studies (CCS), 6 case series, and 1 cross-sectional study.
Results:
Patient-associated risk factors—diabetes mellitus, obesity (body mass index >35 kg/m2), subcutaneous fat thickness, multiple medical comorbidities, current smoker, and malnutrition were associated with SSI. Surgical associated factors—preoperative radiation/postoperative blood transfusion, combined anterior/posterior approach, surgical invasiveness, or levels of instrumentation were associated with increased SSI. There is mixed evidence of age, duration of surgery, surgical team, intraoperative blood loss, dural tear, and urinary tract infection/urinary catheter in association with SSI.
Conclusion:
SSIs are associated with many risk factors that can be patient or surgically related. Our review was able to identify important modifiable and nonmodifiable risk factors that can be essential in surgical planning and discussion with patients.
Keywords: infection, cervical, lumbar, thoracic
Introduction
Surgical site infection (SSI), with its associated morbidity, mortality, hospital length of stay (LOS), and cost, remains a common problem among spine surgery patients. The rate of SSI (superficial and deep) can range from 0.2% to 16.7%, depending on a number of patient-, pathology-, and procedure-related factors.1,2 The treatment for SSI can be challenging requiring prolonged antibiotics, multiple revision surgeries, prolonged hospital stay, and in some patients, advanced soft tissue reconstructions. Numerous studies have attempted to identify the unique risk factors associated with SSI but are all too often limited to one specific diagnosis or procedure. Among previously identified factors associated with increased risk of SSI are excessive intraoperative blood loss, longer operative time, preoperative smoking, obesity, and higher degree of case complexity (as estimated by the Spine Surgery Invasiveness Index).3 The purpose of this study is to perform a review of risk factors for spine SSI and to categorize them into patient- and surgical-related factors.
Methods
Study Design and Search Strategy
We conducted a review of all published literature discussing risk factors for SSI in adult spine surgery. The search was performed using PubMed from its inception to July 20, 2017. Search terms used were (risk factor) AND (surgical site infection) AND (spine).
Study Selection
We included studies that reported risk factors for SSI in adult spinal surgery. Exclusion criteria included those which reported on pediatric patient populations, systematic reviews, meta-analyses, those articles published in languages other than English or articles without an abstract.
Results
Search Results
The initial PubMed search returned 389 unique titles, of which 138 were included. Of those initially included, 1 was in a language other than English, 4 were meta-analyses, 18 were systematic reviews, 19 reported on pediatric populations, and 2 were excluded as full text could not be obtained. This left 94 unique studies for final and complete review.
Overview of Included Studies
A total of 72 cohort studies, 1 controlled-cohort study, 1 matched-cohort study, 1 matched-paired cohort study, 12 case-controlled studies (CCS), 6 case series, and 1 cross-sectional study were identified. A summary of these studies can be found in Table 1. Twenty-one studies evaluated only a single potential risk factor, while 73 studies evaluated multiple potential variables as risk factors. Variables identified as associated or not associated with SSI are summarized in Tables 2, 3, and 4, arranged by study.
Table 1.
Author | Study Design | Analysis | Level of Evidence | Group Demographics (Overall) | Group Demographics (Infected) | Group Demographics (Control)—If Applicable | Significant Variables | Non-significant Variables | Spinal levels | Approach | Instrumentation? | Indication for Surgery | Surgical Procedure | ||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Number of Patients | Mean Age (y) | Special Characteristics | Number of Patients | Mean Age (y) | Number of Patients | Mean Age (y) | |||||||||||
Abdul-Jabbar et al4 2012 | Retro, Cohort | Uni-/multivariate logistic regression | III | 6628 | 56.5 | Administrative claims database | 193 | 6435 | Sacral involvement, number of levels fused (>7), bone or connective tissue cancer, approach (A/P combined) | CAD, DM, surgical region, smoking, obesity, IA, diagnosis, transfusion, procedure type | C/T/L | A/P/Comb | Some | Degenerative, deformity, tumor | Decompression, fusion, deformity | ||
Aoude et al5 2016 | Retro, Cohort | Multivariate logistic regression | III | 13 695 | NS | NSQIP database, focused on blood transfusion | Transfusion (lumbar fusion only, not thoracic) | — | T/L | A/P/comb | Y | NS (excluded trauma) | Fusion | ||||
Asomugha et al6 2016 | Retro, Controlled-Cohort | Multivariate logistic regression | III | 238 | Epidural steroid paste, renal disease, immunosuppression | Procedure type, preoperative admission to hospital, surgical duration, EBL, durotomy, CHF, age, BMI, HTN, CAD, smoking, asthma, COPD | L | P | N | Degenerative | Decompression | ||||||
Atkinson et al7 2016 | Retro, Cohort | Uni-/bivariate logistic regression | III | 152 | 60.6 | Spinal metastases | Number of levels operated, surgical region (thoracic) | Age, gender, emergency surgery, Waterlow score, BMI, EtOH, smoking, ASA, preoperative albumin, preoperative protein, preoperative WBC, preoperative CRP, incision length, interval between admission and surgery, number of staff in operating room | C/T/L | A/P | NS | Metastases | NS | ||||
Babu et al8 2012 | Retro, Cohort | Uni-/multivariate logistic regression | IV | 20 | 47 | Tracheostomy/ACDF for SCI | — | Early tracheostomy | C | A | Y | Trauma, degenerative | Decompression, fusion | ||||
Barnes et al9 2012 | Retro, Cohort | Multivariate logistic regression | III | 90 | 44.8 | 15 | 75 | Philadelphia collar, trauma | — | C | P | Y | Trauma, degenerative | Decompression, fusion | |||
Berney et al10 2008 | Retro, Cohort | ANOVA | III | 71 | 40.28 ± 19.22 | Tracheostomy in SCI (quadriplegia) | — | Early tracheostomy | C | A/P/comb | Y | Trauma | Fusion | ||||
Blam et al11 2003 | Retro, Cohort | Uni-/multivariate logistic regression | III | 256 | 43 | Trauma | 24 | 55 | 232 | 37 | Delay to surgery (>160 hours), postoperative ICU stay (>1 day), number of surgical teams (orthopedic only vs combined orthopedic/neurosurgery) | Gender, race, BMI, drug use, smoking, open injury/abrasion at surgical site, GCS, ASA, albumin, steroid use, EBL, surgical duration, bone graft use, instrumentation, approach | C/T/L | A/P/comb | Y | Trauma | Decompression, fusion |
Bohl et al12 2016 | Retro, CCS | Multivariate Poisson regression | III | 10 825 | NS | NSQIP database, focused on malnutrition | Albumin (<3.5 g/dL) | — | L | P | NS | Degenerative, deformity | Fusion | ||||
Boston et al13 2009 | Retro, CCS | Multivariate logistic regression | III | 55 | 44 | 179 | 45 | Surgical duration, presence of comorbidities | Workers’ compensation, method of hair removal, smoking, incontinence | NS | NS | NS | NS | Fusion, laminectomy, other | |||
Browne et al14 2007 | Retro, Cohort | Multivariate logistic regression | III | 197 461 | 48.95 ± 18.16 | Focused on DM | DM | — | L | ? | ? | Degenerative, deformity | Fusion | ||||
Chaichana et al15 2014 | Retro, Cohort | Multivariate logistic regression | III | 817 | 56 ± 14 | 37 | 780 | Age (>70 y), DM, obesity, prior spine surgery, LOS (>7 days) | Smoker, number of levels operated, number of levels fused, number of levels decompressed, CSF leak, perioperative DVT/PE | L | P | Y | Degenerative | Decompression, fusion | |||
Chen et al16 2009 | Retro, Cohort | Multivariate logistic regression | II | 244 | NS | DM, EBL | Age, gender, BMI, surgical duration, ASA, antibiotic redosing, bone allograft use, drain placement, smoking | L | P | Y | Degenerative, deformity | Fusion | |||||
Chen et al17 2011 | Retro, Cohort | Uni-/multivariate logistic regression | III | 45 | 49.6 | Sacral chordoma | 16 | Albumin, prior surgery, surgical duration (>6 hours) | Gender, obesity, smoking, alcohol, DM, tumor size, radiation, instrumentation | S | P | Some | Tumor (sacral chordoma) | Tumor resection | |||
Cizik et al3 2012 | Retro, Cohort | Multivariate logistic regression | III | 1532 | 49.5 | 63 | 53.5 | 1469 | 49.4 | BMI (>35 kg/m2), HTN, surgical region (thoracic, lumbosacral), SII (>21), renal disease | Revision, primary diagnosis, bleeding disorder, RA, liver disease, cancer, PVD, asthma, COPD, CVA, CHF, MI, smoking | C/T/L | A/P/comb | Some | Degenerative, tumor, trauma | Decompression, fusion, deformity correction | |
De La Garza Ramos et al18 2015 | Retro, Cohort | Student’s t test, chi-square, univariate analysis, log-binomial model | IV | 732 | NS | Focused on obesity | Obesity | — | L | P | Y | Degenerative | Fusion | ||||
De La Garza Ramos et al19 2016 | Retro, Cohort | Multivariate logistic regression | III | 36 440 | NS | 264 | 61.2 ± 11.6 | 36 176 | 60.5 ± 11.9 | Chronic steroid use, surgical duration, renal disease (lumbar only), hemato-oncological disease (lumbar only), DM (lumbar only), obesity (lumbar only), LOS (lumbar only) | CAD, respiratory disease, hepatobiliary disease, neurologic disease, smoking | C/L | A/P/comb | Some | Degenerative | Decompression or fusion | |
De La Garza Ramos et al20 2017 | Retro, CCS | Multivariate logistic regression | III | 293 | NS | Three-column osteotomy complex spine deformity | 15 | 57 ± 14 | 278 | 61 ± 13 | Obesity (class II), multilevel 3-column osteotomy | Bleeding disorder, type of deformity, ASA, anemia | T/L | NS | Y | Deformity | Deformity correction and fusion |
Demura et al21 2009 | Retro, Cohort | Uni-/multivariate logistic regression | III | 113 | 56 | Spinal metastases | 8 | 113 | DM, preoperative radiation | Age, gender, nutrition, ASA, chemotherapy, steroid use, neurologic deficit, emergency surgery, procedure type (en bloc vs debulking versus palliative) | C/T/L | NS | NS | Spinal metastases | Decompression, fusion, tumour resection (en bloc, debulking) | ||
Dubory et al22 2015 | Pro, Cohort | Uni-/multivariate logistic regression | II | 518 | 47.8 ± 19.1 | Acute spinal trauma injury | 25 | 493 | Age, DM, surgical duration | BMI, number of levels operated, EBL, approach, neurologic decomp, intraoperative transfusion, bladder catheter, NNIS | C/T/L | A/P | Y | Trauma only | Decompression/fusion | ||
Ee et al23 2014 | Retro, CCS | Multivariate logistic regression | III | 27 | 61.6 ± 13.7 | 162 | 56.8 ± 14.9 | Open surgery (compared with MIS), DM, number of levels operated, BMI | Age, surgical duration, preoperative glucose level, gender, race, number of surgical assistants, allograft use, instrumentation, L5-S1 involvement, EtOH, steroid use, smoking, ASA | L | P | Some | NS | Decompression or fusion | |||
Fang et al24 2005 | Retro, CCS | Uni-/multivariate logistic regression | III | Both adult and pediatric patients; only including adult results | 21 | 29 | Age (>60 y), prior infection, EtOH | Prior surgery, steroid use, smoking, BMI, gender, instrumentation, allograft use, EBL, staged procedures, surgical duration, number of levels operated | C/T/L/S | A/P/comb | Some | Deformity, degenerative, disc disease | Decompression, fusion, discectomy, deformity correction, ACDF, other | ||||
Fehlings et al25 2012 | Pro, Cohort | Pearson chi-square, multivariate regression | II | 302 | 57 | Cervical spondylotic myelopathy | Approach (posterior) | Procedure type (laminoplasty vs posterior decompression and fusion) | C | A/P/comb | Some | Cervical spondylotic myelopathy | ACDF, corpectomy, decompression and fusion, laminoplasty | ||||
Fisahn et al26 2017 | Retro, Cohort | Chi-square | III | 56 | NS | Major deformity surgery (>8 level fusion), focused on allogeneic transfusion | Allogenic transfusion | — | C/T/L | P | Y | Degenerative, deformity | Fusion | ||||
Glassman et al27 2016 | Retro, Cohort | Binary logistic regression | III | 2653 | NS | Based on 3 databases (Denmark, Japan, United States) | Gender, LOS, BMI, number of levels fused | Diagnosis, age, smoking, ASA, surgical duration | L | A/P/lateral/? comb | NS | Degenerative | Fusion | ||||
Golinvaux et al28 2014 | Retro, Cohort | Multivariate logistic regression | III | 15 480 | NS | NSQIP database, focused on DM (insulin vs non–insulin dependent) | Insulin-dependent DM (vs non–insulin dependent) | L | A/P/lateral/? comb | NS | NS | Fusion | |||||
Gruskay et al29 2012 | Retro, Cohort | Step-down binary logistic regression | III | 6666 | NS | Case order (in lumbar decompression only), approach (posterior, in cervical or lumbar fusion only), revision (cervical only), surgical duration (lumbar decompression or fusion), ASA (lumbar fusion only), age (lumbar fusion only) | Surgical duration (cervical only), age (lumbar decompression or cervical only), ASA (lumbar decompression or cervical only), gender, revision (lumbar decompression or fusion only) | C/L | A/P | Some | Degenerative, deformity | Decompression, fusion | |||||
Haddad et al30 2016 | Retro, Cohort | Multivariate logistic regression | III | 1 872 327 | NS | NIS database | Age, gender (male), race (African American), hospital size (medium or large), hospital type (rural), approach (posterior or combined), trauma, neurologic injury (SCI or myelopathy) | Payer (self-pay vs Medicare), hospital region, calendar year | C | A/P/comb | Yes | Degenerative, trauma, cervical myelopathy | Decompression, fusion, stabilization | ||||
Hayashi et al31 2015 | Retro, Cohort | Multivariate logistic regression | III | 125 | 53.8 | Total en bloc spondylectomy for vertebral tumor (primary or metastases) | 8 | 117 | Instrumentation, approach (A/P combined) | Age, tumor histology, prior surgery, surgical duration | NS | A/P/comb | Y | En bloc spondylectomy | Fusion, en bloc tumor resection | ||
Hijas-Gomez et al32 2017 | Retro, Cohort | Uni-/multivariate logistic regression | III | 892 | 55 | 35 | 61 | 857 | 54 | DM, COPD, dirty surgery, surgical duration (>75th percentile) | Gender, obesity, renal disease, cancer, malnutrition, cirrhosis, immunodeficiency, neutropenia, transfusion, emergency surgery, razor shaving, inappropriate antibiotic prophylaxis, drains | C/T/L | A/P/comb | Some | Degenerative, disc disease, cervical myelopathy, deformity, other NS | Decompression, fusion | |
Hikata et al33 2014 | Retro, Cohort | Chi-square, Mann-Whitney, Fisher’s exact tests | III | 347 | NS | DM, preoperative HbA1c | Age, gender, BMI, obesity, preoperative LOS, insulin use, steroid use, prior surgery, preoperative muscle weakness, preoperative incontinence, number of levels fused, surgical duration, EBL, transfusion | T/L | P | Y | Degenerative, deformity | Fusion | |||||
Jalai et al34 2016 | Retro, Cohort | Multivariate logistic regression | III | 3057 | 60.71 | NSQIP database | 35 | 56.54 | 3022 | 60.75 | Approach (posterior), surgical duration (>208 min), ASA (>3) | Smoking, steroid use, comorbid conditions, obesity, DM | C | A/P/comb | Y | Cervical spondylotic myelopathy | Decompression, fusion |
Kanafani et al35 2009 | Retro, Cohort | Chi square, T-test | III | 997 | 27 | 59 | 54 | 47 | DM, instrumentation, age | Gender, prior surgery, diagnosis, surgical duration, antibiotic duration | NS | NS | Y | Disc disease and tumor | Decompression, fusion | ||
Keam et al36 2014 | Retro, Cohort | Student’s t test, Wilcoxon rank-sum test, chi-square, Fisher’s exact test | III | 165 | NS | Spinal metastases with preoperative radiation | — | Type of preoperative radiation (conventional XRT versus hypofractionated) | C/T/L/S | A/P/comb | Some | Tumor/metastases | Decompression, fusion, stabilization, tumor resection | ||||
Kerwin et al37 2008 | Retro, Matched cohort | Student’s t test | III | 16 812 | NS | Spinal fracture | — | Time to surgery | C/T/L | C/T/L | NS | Trauma | Stabilization | ||||
Kim et al38 2014 | Retro, Cohort | Multivariate logistic regression | III | 4588 | NS | NSQIP database, focused on surgical duration | Surgical duration | — | L | A/P/lateral/comb | Y | NS (excluded trauma) | Fusion (single-level) | ||||
Kim et al39 2017 | Retro, Cohort | Multivariate logistic regression, single variate t test | III | 1831 | NS | 30 | 63.7 | 1801 | 63.6 | Surgical duration | Gender, local bone irrigation, intradiscal irrigation | L | P | Y | NS | Fusion (PLIF) | |
Klekamp et al40 1999 | Retro, CCS | Chi-square, Fisher’s exact test | III | 2614 | NS | Lymphopenia, chronic infection, EtOH, recent hospitalization, steroid use | DM, weight, gender, trauma, inpatient status, smoking, UTI, age, cholesterol, albumin, total protein, ESR, triglycerides | C/T/L | NS | Some | NS | NS | |||||
Klemencsics et al41 2016 | Pro, Cohort | Multivariate logistic regression | II | 1030 | 50 | 37 | 993 | Age, BMI, DM, CAD, arrhythmia, chronic liver disease, autoimmune disease | SII, instrumentation | L | P | Y | Degenerative | Decompression, fusion | |||
Koutsoumbelis et al42 2011 | Retro, Cohort | Multivariate logistic regression | II | 3218 | 56.9 | 86 | 60 | Gender (female), DM, osteoporosis, CAD, number of comorbidities, obesity, number of personnel in operating room, dural tear, EBL (>500 cm3) | Age, smoking, HTN, cholesterol, OSA, CHF, RA, number of comorbidities, number of surgeons, number of residents or fellows, surgical duration, number of drains, LOS, revision | L | P | Y | NS (excluded infection) | Fusion (PLIF) | |||
Kudo et al43 2016 | Retro, Cohort | Chi-square and Mann-Whitney U | III | 105 | 64.4 | Infection based on CRP | 35 | 65.9 ± 16.9 | 70 | 63.6 ± 14.2 | Surgical duration | Age, gender, BMI, smoking, EtOH, DM, EBL, instrumentation, preoperative total lymphocyte, preoperative transferrin, preoperative prealbumin, preoperative retinol binding protein | C/T/L | NS | NS | NS | NS |
Kukreja et al44 2015 | Retro, Cohort | Multivariate logistic regression | III | 266 439 | 55.6 | Emergency surgery, timing of surgery (after day of incident in emergency cases) | — | L | A/P/comb | Some | Degenerative, deformity, metastases, trauma | Fusion | |||||
Kumar et al45 2015 | Retro, Cohort | Multivariate logistic regression | III | 98 | 60.1 | Spinal metastases | 17 | 81 | Number of levels operated (≥7), albumin (low), neurologic disability (trend) | Absorbable skin closure material, age, lymphocyte count, perioperative steroids, MUST | NS | P/comb | NS | Spinal metastases | NS | ||
Kurtz et al46 2012 | Retro, Cohort | Kaplan-Meier survival analysis, Cox regression | III | 15 069 | NS | Medicare database | Age, obesity, Charleston comorbidity index, socioeconomic status, revision, number of levels fused, approach | Gender, race, smoking, DM, allograft use, transfusion | L | A/P/comb | Y | NS | Fusion | ||||
Lee et al47 2014 | Retro, Cohort | Pearson chi-square, Fisher’s exact test, multivariate logistic regression | III | 1532 | 49.5 | Spine End Result Registry (SEER) | 66 | SII, DM, CHF | Age, gender, RA, trauma, BMI | C/T/L | NS | NS | NS | NS | |||
Lee et al48 2016 | Retro, Cohort | Multivariate logistic regression | III | 149 | 53.5 ± 15.8 | Maximum fat thickness (T12-L5, operated levels or L4), prior surgery | Age, DM, smoking (within 1 y), preoperative albumin, BMI, obesity, number of levels operated, surgical duration | L | P | Some | NS | Decompression, fusion | |||||
Li et al49 2013 | Retro, Cohort | Multivariate logistic regression | III | 387 | 46.4 | Sacral tumors | Prior radiation, rectum rupture, surgical duration, CSF leak | Age, gender, DM, preoperative albumin, prior sacral tumor resection, tumor size, histopathological diagnosis, blood control method, incision type (Y vs 2-way), proximal sacral segment resected, instrumentation, EBL | S | A/P/comb | Some | Primary tumor | Tumor resection | ||||
Lieber et al50 2016 | Retro, Cohort | Multivariate logistic regression | III | 60 179 | 57.1 | NSQIP database | 1110 | 59 069 | Gender (female), inpatient, BMI, preoperative steroid use, anemia, ASA (>2), surgical duration | Instrumentation, bone graft use, transfusion, DM, functional status, COPD, disseminated cancer, weight loss, preoperative transfusion, dialysis, deformity, hematocrit | C/T/L | A/P/lateral/comb | Some | NS (excluded trauma) | NS | ||
Lim et al51 2014 | Retro, Cohort | Chi-square | III | 3353 | NSQIP database | 86 | Obesity, ASA (>2), surgical duration (>6 hours) | Smoking, DM | L | A/P/lateral/comb | Y | NS (excluded trauma) | Fusion (single-level) | ||||
Lonjon et al52 2012 | Pro, Cohort | Univariate, Fisher’s exact test/Wilcoxon test | IV | 169 | 50.0 ± 20.1 | Spinal trauma | Age, ASA, DM, surgical duration (>3 hours), time from injury to surgery (>3 days), number of levels fused, EBL (>600 cm3), urinary catheter (>5 days) | Gender, BMI, smoking, EtOH, antiplatelet agent/anticoagulant use, spinal region of trauma, neurologic impairment, surgical time of day (day vs night), approach, MIS, intraoperative transfusion, bedrest duration, drain | C/T/L | A/P/comb | Y | Trauma | Decompression, stabilization | ||||
Manoso et al53 2014 | Retro, Cohort | Multivariate logistic regression | III | 1532 | SII, CHF, payer (Medicaid), DM | Age, gender, smoking, EtOH, drug use, BMI, medical comorbidity, prior surgery, primary diagnosis, spinal region, approach | C/T/L | A/P/comb | Some | Degenerative, trauma, tumor/metastases, infection, deformity, other | Decompression, fusion, stabilization, deformity correction, tumor resection | ||||||
Maragakis et al54 2009 | Retro, CCS | Multivariate logistic regression | III | 104 | 55.3 | 104 | 55.3 | Surgical duration, ASA (≥3), surgical region (lumbo-sacral), approach (posterior), instrumentation, obesity, razor shaving before surgery, intraoperative administration of inspired O2 <50% | Age, gender, race, smoking, DM, CAD, Karnofsky score, prior surgery, emergent/urgent surgery, appropriate timing of antibiotic prophylaxis, intraoperative nitrous oxide administration, perioperative glucose, intraoperative temperature, intraoperative infusion rate, dural tear, CSF leak, transfusion | NS (included L/S) | A/P/? comb | Some | NS | Decompression, fusion | |||
Marquez-Lara et al55 2014 | Retro, Cohort | Chi-square, Student’s t test | IV | 24 196 | NS | Focused on BMI | BMI (>24.99 kg/m2) | — | L | A/P/comb | Some | NS | Decompression, fusion | ||||
Martin et al56 2016 | Retro, Cohort | Multivariate logistic regression | III | 35 777 | Focused on smoking | Smoking | — | L | A/P | Some | NS | Decompression, fusion, deformity correction | |||||
Mehta et al57 2012 | Retro, Cohort | Student’s t test, Wilcoxon signed-rank test, chi-square, logistic regression | III | 298 | 24 | 56 | 274 | 60 | Number of levels operated, obesity, skin to lamina distance, thickness of subcutaneous fat | BMI, DM | L | P | Y | NS | Decompression, fusion | ||
Murphy et al58 2017 | Retro, Cohort | Multivariate logistic regression | III | 8744 | 65 | Focused on age | — | Age | L | P | N | Degenerative | Decompression | ||||
Northrup et al59 1995 | Retro, Case series | None | IV | 11 | 30 | Tracheostomy in SCI (quadriplegia) | — | Tracheostomy pre-anterior cervical fusion | C | A | Some | Trauma | Decompression, fusion | ||||
Ogihara et al60 2015 | Pro, Cohort | Fisher’s exact test, Wilcoxon signed-rank test, multivariate logistic regression | III | 2736 | 24 | Steroid use, surgical duration (>3 hours), gender (female) | BMI, ASA, DM, smoking, prior surgery, instrumentation, emergency surgery, intraoperative fluoroscopy, dural tear, iliac crest bone graft, surgical region | T/L | P | Some | Trauma, disc disease, degenerative, tumor/metastases, deformity | NS | |||||
Ohya et al61 2017 | Retro, Cohort | Multivariate logistic regression | III | 47 252 | 65.4 | Japanese Diagnosis Procedure Combination Database, focused on effect of month of surgery | 438 | 46 814 | Month of surgery (timing when medical staff rotate, only in academic hospitals) | C/T/L | A/P/comb | Y | NS | Decompression, fusion | |||
Oichi et al62 2017 | Retro, Matched-pair cohort | Multivariate logistic regression | III | 6921 | Focused on Parkinson’s disease | Parkinson’s disease | — | C/T/L | A/P/comb | Some | NS | NS (included fusion) | |||||
Ojo et al63 2016 | Retro, Cross-section | Fisher’s exact test | IV | 62 | 44.2 | 10 | DM, surgical region (cervical), procedure type (laminectomy and fixation), surgical duration | Obesity, TB, anemia, diagnosis, instrumentation | C/L | P | Some | Trauma, degenerative, tumor | Decompression, instrumentation, tumor resection | ||||
Olsen et al64 2003 | Retro, CCS | Uni-/multivariate logistic regression | III | 219 | 41 | 54.3 | 178 | 52.9 | Postoperative fecal incontinence, approach (posterior), tumor resection, obesity (morbid) | Fusion, timing of prophylactic antibiotics, trauma surgery, intraoperative hypothermia, dural tear, instrumentation | C/T/L | A/P/comb | Y | Degenerative, tumor, trauma | Decompression, fusion, tumor resection | ||
Olsen et al65 2008 | Retro, CCS | Multivariate logistic regression | III | 273 | 52.4 | 46 | 227 | DM, timing of prophylactic antibiotics (>1 hour before surgery), preoperative glucose (>125), postoperative glucose (>200), obesity, number of residents (≥2) | Fusion, instrumentation, bone graft use, irrigation with antibiotic solution, number of levels operated, surgical duration, hemovac, intraoperative steroid, number of levels, BMI, diagnosis, transfusion, approach | NS (included C) | A/P/comb | Y | NS | Decompression, fusion | |||
Omeis et al66 2011 | Retro, Cohort | t test, chi-square | III | 678 | Nonsacral tumor (primary or metastases) | 65 | 52.1 | 613 | 47.4 | Prior surgery, preoperative radiation, any comorbidity, number of surgical teams involved (>1), complex plastics closure, LOS, hospital acquired infection | Gender, race, age, albumin, steroid use, intra versus extradural, metastatic versus primary, allograft use, instrumentation | C/T/L/S (LS junction, not primary S) | A/P/comb | Some | Tumor/metastases | Tumor resection | |
Pull ter Gunne et al1 2009 | Retro, Cohort | Cochran/Mantel-Haenszels chi-square, multivariate | III | 3174 | 55.6 ± 15.5 | Obesity, approach (not anterior), DM, prior SSI, EBL (>1 L), surgical duration (>2 hours) | Gender, HTN, prior surgery, diagnosis, number of levels fused, procedure type | C/T/L/S | A/P/comb | Some | Hardware irritation, trauma, disc herniation, degenerative, deformity, stenosis, tumor/metastases, arthritis, pseudoarthrosis | Discectomy, decompression, fusion, deformity correction, ROH, debridement, soft tissue | |||||
Pull ter Gunne et al67 2010 (deformity) | Retro, Cohort | Chi-square, multivariate | III | 830 | 55.4 ± 16.1 | Adult spinal deformity | Obesity, history of SSI | Gender, DM, NSAID use, HTN, other cardiovascular pathology, smoking, preoperative protein, preoperative albumin, prior surgery, number of levels fused, approach, procedure type, surgical region, surgical duration, EBL, number of attending surgeons | C/T/L/S | A/P/comb | Y | Deformity | Deformity correction and fusion | ||||
Pull ter Gunne et al68 2010 (osteotomy) | Retro, Cohort | Multivariate logistic regression | III | 363 | 55.8 | Types of osteotomies | 20 | 343 | VCR, obesity | — | C/T/L | A/P/comb | Y | NS (excluded infection) | Fusion/osteotomy | ||
Radcliff et al69 2013 | Retro, Cohort | Student’s t test | III | 7991 | 53.7 | Focused on anesthesia ready time | 276 | 58.4 | Anesthesia ready time (>1 hour) | — | C/T/L | A/P/comb | Some | NS (excluded infection) | Decompression, fusion, tumor resection | ||
Ramos et al70 2016 | Retro, Cohort | Unadjusted and adjusted logistic regression analysis | IV | 668 | 63.9 | Also included arthroplasty patients; review only looking at spine cohort; Focused on S aureus colonization | 10 | — | S aureus colonization | C/T/L | NS | NS | NS | NS | |||
Rao et al71 2011 | Retro, CCS | Uni-/multivariate logistic regression | III | 57 | 55 ± 15 | 181 | 57±15 | BMI, gender (male), drain duration | Age, DM, CAD, HTN, COPD, active malignancy, smoking, revision, diagnosis, emergency surgery, timing of antibiotic prophylaxis, number of surgical teams (orthopedic-neurosurgery combined vs either alone), approach, graft type, EBL, intraoperative transfusion, intraoperative temperature, surgical duration | NS | P | NS | Degenerative, deformity, trauma, tumor | Fusion | |||
Rechtine et al72 2001 | Retro, Case series | Not listed | IV | 117 | NS | Thoracolumbar fracture | 12 | Complete neurologic injury | Incomplete neurologic injury | T/L | A/P | Y | Trauma | Decompression, stabilization | |||
Rodgers et al73 2010 | Retro, Cohort | Multivariate logistic regression, Student’s t test, chi-square | III | 600 | 61.4 | Focused on XLIF procedure | Open surgery (vs XLIF) | — | L | XLIF | Y | Degenerative | Fusion | ||||
Ruggieri et al74 2012 | Retro, Case series | Kaplan-Meier survival analysis, log-rank test | IV | 82 | 47 | Primary sacral tumors | Procedure type (intralesional vs marginal vs wide resection), surgical duration | Age, level of resection (proximal vs distal), location of prior treatment (same institution vs other institution), tumor volume, neurological status (bowel-bladder continence) | S | A/P/comb | Some | Primary tumor | Tumor debulking or resection | ||||
Saeedinia et al75 2015 | Retro, Cohort | Chi-square, ANOVA, multivariate regression | III | 978 | 46 | 27 | 951 | Muscle weakness, sphincter dysfunction, DM, HTN, smoking, bedridden, preoperative glucose, surgical region, instrumentation, allograft use, dural tear, incision length, number of levels operated, surgical time of day, surgical duration, LOS | Age, gender, BMI, myelopathy, IVDU, approach, revision | C/T/L | A/P | Some | Trauma, tumor, degenerative, disc disease, intradural (tumor, tethered cord) | NS | |||
Salvetti et al76 2017 | Retro, Case-control cohort | Chi-square, multivariate logistic regression | III | 32 | 74 | Prealbumin (low), DM | Age, gender, BMI, surgical duration, comorbidities | C/T/L | P | NS | NS (excluded trauma, infection, tumor) | NS (included fusion) | |||||
Satake et al77 2013 | Retro, Cohort | Chi-square, Mann-Whitney U | III | 110 | 11 | DM, proteinurea | Age, BMI, ASA, smoking, creatinine, BUN, EBL, surgical duration | NS | NS | Y | NS | Instrumentation, not otherwise specified | |||||
Schimmel et al2 2010 | Retro, Cohort | Uni-/multivariate logistic regression | III | 1568 | 36 | 135 | Prior surgery, number of levels operated, DM, smoking | Gender, age, height, weight, BMI, presence of any comorbidity, CAD, respiratory disease, RA, spinal region, surgical duration, bone graft type, approach, instrumentation | C/T/L | A/P/AP | Y | Degenerative, deformity | Fusion, deformity correction | ||||
Schoenfeld et al78 2013 | Retro, Cohort | Uni-/multivariate logistic regression | III | 5887 | 55.9 | NSQIP database | BMI, resident involvement, ASA (>2), surgical duration | Age, DM, respiratory disease, CAD, HTN, PVD, renal disease, neurologic disease, infection, steroid use, preoperative albumin, spinal region, procedure type, diagnosis | C/T/L | A/P | Y | NS | Fusion | ||||
Schwarzkopf et al79 2010 | Retro, CCS | Multiple logistic regression | III | Focus on blood transfusion | 61 | 56 | 71 | 53 | BMI, transfusion | Gender, smoking, EtOH, DM, HTN, steroid use | T/L | ? | Some | NS | Discectomy, decompression, fusion | ||
Sciubba et al80 2008 | Retro, Cohort | Univariate, Fisher’s exact test | IV | 46 | 46 | Sacral tumors | Prior lumbosacral surgery, number of surgeons | Preoperative albumin, EBL, CSF leak, DM, instrumentation, laminectomies, obesity, plastic surgery closure, prior radiation, gender, smoking, age, bowel-bladder dysfunction, complex tissue reconstruction | S | A/P/comb | Some | Primary tumor | Tumor resection | ||||
Sebastian et al81 2016 | Retro, Cohort | Student’s t test, chi-square/Fisher’s exact test, multivariate | III | 5441 | 59 ± 13.6 | NSQIP database | 160 | 56.9 ± 12.2 | BMI (>35 kg/m2), chronic opioid use, surgical duration (>197 min) | Type of posterior surgery, DM, smoking, resident involvement, paralysis | C | P | Some | NS | Decompression, fusion, laminoplasty | ||
Shousha et al82 2014 | Retro, Cohort | NS | IV | 139 | 53.6 | Transoral approach for upper cervical spine | Indication (rheumatologic or tumor cases higher risk) | Age, gender, presence of metal implant | C | Transoral | Some | Infection, trauma, congenital anomaly, rheumatologic, tumor | Odontoidectomy, fusion, stabilization, tumor resection | ||||
Singla et al83 2017 | Retro, Cohort | Chi-square | III | 88 540 | Lumbar epidural steroid injection prior to surgery | 1411 | 87 129 | Lumbar epidural steroid injection (within 3 mo) prior to surgery | — | L | P | Y | Degenerative | Fusion | |||
Skovrlj et al84 2015 | Retro, Cohort | Chi-square | III | 5117 | 51.8 | Adult scoliosis, focused on surgeon experience | Less surgeon experience | — | T/L | NS | Y | Deformity | Deformity correction and fusion | ||||
Stambough et al85 1992 | Retro, Case series | NS | IV | 19 | 44 | Malnutrition, trauma, UTI (all based on % of patients with these risk factors, no formal analysis) | No formal analysis | C/T/L | NS | Some | Trauma, degenerative, deformity, tumor, disc disease | Decompression, fusion, deformity correction | |||||
Sugita et al86 2016 | Retro, Cohort | Mann-Whitney U, chi-square | III | 279 | 63 | Spinal metastases with intraoperative radiation | 41 | 62 | 238 | 64 | Katagiri/Tokuhashi’s prognostic score, postoperative Frankel score, preoperative radiation, and postoperative performance | Surgical duration, EBL | NS | P | Y | Spinal metastases | Decompression/fusion, radiation |
Tempel et al87 2015 | Retro, Case series | None | IV | 83 | 56 | Serum prealbumin below normal range (no formal analysis) | No formal analysis | C/T/L/S | NS | Some | Degenerative, trauma, tumor, deformity, hematoma, syringomyelia | Fusion, decompression, shunt | |||||
Tominaga et al88 2016 | Retro, Cohort | Mann-Whitney U and Fisher’s, multiple logistic regression | III | 825 | 59 | 14 | 57.5 | 811 | 59 | Surgical duration, ASA (class 3), instrumentation, surgical region (thoracic in non-instrumented cases) | Two stage, revision, DM, smoking, BMI, anemia, preoperative UTI, number of levels, incision length, number of personnel or surgeons | A/P/comb | Y | Degenerative, infection, tumor, scoliosis | Decompression, fusion, deformity | ||
Veeravagu et al89 2009 | Retro, Cohort | Uni-/multivariate logistic regression | III | 24 774 | NS | Veterans Affairs’ NSQIP database | 752 | DM, ASA (>2), weight loss, dependent functional status, intraoperative transfusion, cancer, fusion/instrumentation, surgical duration (>3 hours) | Age, gender, race, emergency surgery, bleeding disorder, smoking, EtOH, WBC, creatinine | C/T/L | NS | Some | NS (excluded trauma) | Decompression, fusion, instrumentation | |||
Watanabe et al90 2010 | Retro, Cohort | Uni-/multivariate logistic regression | III | 223 | 53 | Focused on effect of intraoperative irrigation | 14 | 49 | 209 | 53 | DM, trauma | Surgical duration, EBL, instrumentation, gender, age, smoking, obesity | C/T/L | A/P/comb | Y | Trauma, tumor, degenerative, deformity | Decompression, fusion, deformity |
Weinstein et al91 2000 | Retro, Case series | None | IV | 46 | 57.2 | Type of surgery (based on overall rate of infection, not statistically challenged) | No formal analysis | C/L | A/P | Some | Degenerative, cervical myelopathy, nonunion, metastases, trauma, disc disease | Decompression, discectomy, fusion, instrumentation | |||||
Wimmer et al92 1998 | Retro, Cohort | F test, paired Wilcoxon | III | 850 | Included some pediatric patients | 22 | Preoperative hospitalization (extended), surgical duration, EBL (>1 L), prior surgery, DM, smoking, EtOH, obesity, steroid use | NS | NS | A/P | Some | Deformity, trauma, degenerative | Fusion, instrumentation, not otherwise specified | ||||
Woods et al93 2013 | Retro, CCS | Conditional logistic regression | III | Focused on perioperative transfusions | 56 | 61 ± 12 | 91 | 60 ± 14.8 | Perioperative transfusion | — | L | A/P | Some | NS | Decompression, fusion | ||
Yang et al94 2016 | Retro, Cohort | Pearson chi-square | III | 18 931 | Patients >65, lumbar epidural steroid injection prior to surgery | 196 | Lumbar epidural steroid injection (within 3 months) prior to OR | — | L | P | N | Degenerative | Decompression |
Abbreviations: ACDF, anterior cervical discectomy and fusion; ASA, American Society of Anesthesiologists class; BMI, body mass index; CAD, coronary artery disease; CCS, case-controlled study; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; CSF, cerebrospinal fluid; CVA, cerebrovascular accident; DM, diabetes mellitus; DVT, deep vein thrombosis; EBL, estimated blood loss; EtOH, alcohol use; GCS, Glasgow Coma Scale; HTN, hypertension; IA, inflammatory arthropathy; IVDU, intravenous drug use; LOS, length of stay; MI, myocardial infarction; MIS, minimally invasive surgery; MUST, Malnutrition Universal Screening Tool score; NNIS, National Nosocomial Infection Surveillance index; NS, not specified; NSAID, nonsteroidal anti-inflammatory drug; NSQIP, National Surgical Quality Improvement Program; OSA, obstructive sleep apnea; PE, pulmonary embolus; Pro, prospective; PVD, peripheral vascular disease; RA, rheumatoid arthritis; Retro, retrospective; SCI, spinal cord injury; SII, surgical invasiveness index; UTI, urinary tract infection; XLIF, extreme lateral interbody fusion. C, cervical; T, thoracic; L, lumbar; A, anterior; P, posterior; Comb, A/P combined.
Table 2.
Author | Age | Albumin/Protein/Nutrition | Alcohol Use | ASA Class | Asthma/COPD | Bleeding Disorder/Anticoagulation | BMI | Congestive Heart Failure | Coronary Artery Disease | Diabetes | Fat Thickness | Gender | Glucose/HbA1c | History of Infection | Hypertension | Immunodeficiency | Incontinence/Bowel-Bladder Dysfunction | Inflammatory Arthropathy | Insulin Use | Liver Disease | Neurologic Deficit/Injury | Neurologic Disorder | Obesity | Prior Surgery | Renal Disease | Smoking | Steroid Use | White Blood Cell Count |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Abdul-Jabbar et al4 2012 | N | N | N | N | N | |||||||||||||||||||||||
Aoude et al5 2016 | ||||||||||||||||||||||||||||
Asomugha et al6 2016 | N | N | N | N | N | Y | Y | N | ||||||||||||||||||||
Atkinson et al7 2016 | N | NN | N | N | ||||||||||||||||||||||||
Babu et al8 2012 | N | |||||||||||||||||||||||||||
Barnes et al9 2012 | ||||||||||||||||||||||||||||
Berney et al10 2008 | ||||||||||||||||||||||||||||
Blam et al11 2003 | N | N | N | N | N | N | ||||||||||||||||||||||
Bohl et al12 2016 | Y | |||||||||||||||||||||||||||
Boston et al13 2009 | N | N | ||||||||||||||||||||||||||
Browne et al14 2007 | Y | |||||||||||||||||||||||||||
Chaichana et al15 2014 | Y | Y | Y | Y | N | |||||||||||||||||||||||
Chen et al16 2009 | N | N | Y | N | N | |||||||||||||||||||||||
Chen et al17 2011 | Y | N | N | N | N | N | ||||||||||||||||||||||
Cizik et al3 2012 | N | N | Y | N | N | Y | N | N | Y | N | ||||||||||||||||||
De La Garza Ramos et al18 2015 | Y | |||||||||||||||||||||||||||
De La Garza Ramos et al19 2016 | N | N | Y | N | N | Y | Y | N | Y | |||||||||||||||||||
De La Garza Ramos et al20 2017 | N | N | Y | |||||||||||||||||||||||||
Demura et al21 2009 | N | N | N | Y | N | N | N | |||||||||||||||||||||
Dubory et al22 2015 | Y | N | Y | |||||||||||||||||||||||||
Ee et al23 2014 | N | N | N | Y | Y | N | N | N | ||||||||||||||||||||
Fang et al24 2005 | Y | Y | N | N | Y | N | N | N | ||||||||||||||||||||
Fehlings et al25 2012 | ||||||||||||||||||||||||||||
Fisahn et al26 2017 | ||||||||||||||||||||||||||||
Glassman et al27 2016 | N | N | Y | Y | N | |||||||||||||||||||||||
Golinvaux et al28 2014 | C | Y | ||||||||||||||||||||||||||
Gruskay et al29 2012 | C | C | N | |||||||||||||||||||||||||
Haddad et al30 2016 | Y | Y | Y | |||||||||||||||||||||||||
Hayashi et al31 2015 | N | N | ||||||||||||||||||||||||||
Hijas-Gomez et al32 2017 | N | Y | Y | N | N | N | N | N | N | |||||||||||||||||||
Hikata et al33 2014 | N | Y | N | Y | N | N | N | N | ||||||||||||||||||||
Jalai et al34 2016 | N | N | N | N | ||||||||||||||||||||||||
Kanafani et al35 2009 | Y | Y | N | N | ||||||||||||||||||||||||
Keam et al36 2014 | ||||||||||||||||||||||||||||
Kerwin et al37 2008 | ||||||||||||||||||||||||||||
Kim et al38 2014 | ||||||||||||||||||||||||||||
Kim et al39 2015 | N | |||||||||||||||||||||||||||
Klekamp et al40 1999 | N | N | Y | N | N | Y | N | N | Y | Y | ||||||||||||||||||
Klemencsics et al41 2016 | Y | Y | Y | Y | Y | |||||||||||||||||||||||
Koutsoumbelis et al42 2011 | N | N | Y | Y | Y | N | N | Y | N | |||||||||||||||||||
Kudo et al43 2016 | N | N | N | N | N | N | N | |||||||||||||||||||||
Kukreja et al44 2015 | N | |||||||||||||||||||||||||||
Kumar et al45 2015 | N | Y | Y | N | ||||||||||||||||||||||||
Kurtz et al46 2012 | Y | N | N | Y | N | |||||||||||||||||||||||
Lee et al 472 014 | N | N | Y | Y | N | N | ||||||||||||||||||||||
Lee et al48 2016 | N | N | N | N | Y | N | Y | N | ||||||||||||||||||||
Li et al49 2013 | N | N | N | N | ||||||||||||||||||||||||
Lieber et al50 2016 | Y | N | Y | N | Y | |||||||||||||||||||||||
Lim et al51 2014 | Y | N | Y | N | ||||||||||||||||||||||||
Lonjon et al52 2012 | Y | N | Y | N | N | Y | N | N | N | |||||||||||||||||||
Manoso et al53 2014 | N | N | N | Y | Y | N | N | N | ||||||||||||||||||||
Maragakis et al54 2009 | N | Y | N | N | N | N | Y | N | N | |||||||||||||||||||
Marquez-Lara et al55 2014 | Y | |||||||||||||||||||||||||||
Martin et al56 2016 | Y | |||||||||||||||||||||||||||
Mehta et al57 2012 | N | N | Y | Y | ||||||||||||||||||||||||
Murphy et al58 2017 | N | |||||||||||||||||||||||||||
Northrup et al59 1995 | ||||||||||||||||||||||||||||
Ogihara et al60 2015 | N | N | N | Y | N | N | Y | |||||||||||||||||||||
Ohya et al61 2017 | ||||||||||||||||||||||||||||
Oichi et al62 2017 | Y | |||||||||||||||||||||||||||
Ojo et al63 2016 | Y | N | ||||||||||||||||||||||||||
Olsen et al64 2003 | Y | Y | ||||||||||||||||||||||||||
Olsen et al65 2008 | N | Y | Y | Y | ||||||||||||||||||||||||
Omeis et al66 2011 | N | N | N | Y | N | |||||||||||||||||||||||
Pull ter Gunne et al1 2009 | Y | N | Y | N | Y | N | ||||||||||||||||||||||
Pull ter Gunne et al67 2010 (deformity) | N | N | N | Y | N | Y | N | N | ||||||||||||||||||||
Pull ter Gunne et al68 2010 (osteotomy) | Y | |||||||||||||||||||||||||||
Radcliff et al69 2013 | ||||||||||||||||||||||||||||
Ramos et al69 2016 | ||||||||||||||||||||||||||||
Rao et al71 2011 | N | N | Y | N | N | Y | N | N | ||||||||||||||||||||
Rechtine et al72 2001 | C | |||||||||||||||||||||||||||
Rodgers et al73 2010 | ||||||||||||||||||||||||||||
Ruggieri et al74 2012 | N | N | ||||||||||||||||||||||||||
Saeedinia et al75 2015 | N | N | Y | N | Y | Y | N | Y | ||||||||||||||||||||
Salvetti et al76 2017 | N | Y | N | Y | N | |||||||||||||||||||||||
Satake et al77 2013 | N | N | Y | N | ||||||||||||||||||||||||
Schimmel et al2 2010 | N | N | N | Y | N | N | Y | Y | ||||||||||||||||||||
Schoenfeld et al78 2013 | N | N | Y | Y | N | N | N | N | N | N | N | |||||||||||||||||
Schwarzkopf et al79 2010 | N | Y | N | N | N | N | N | |||||||||||||||||||||
Sciubba et al80 2008 | N | N | N | N | N | N | ||||||||||||||||||||||
Sebastian et al81 2016 | N | N | N | |||||||||||||||||||||||||
Shousha et al82 2014 | N | N | ||||||||||||||||||||||||||
Singla et al83 2017 | ||||||||||||||||||||||||||||
Skovrlj et al84 2015 | ||||||||||||||||||||||||||||
Stambough et al85 1992 | Y | |||||||||||||||||||||||||||
Sugita et al86 2016 | ||||||||||||||||||||||||||||
Tempel et al87 2015 | Y | |||||||||||||||||||||||||||
Tominaga et al88 2016 | Y | N | N | N | ||||||||||||||||||||||||
Veeravagu et al89 2009 | N | N | Y | N | Y | N | N | N | ||||||||||||||||||||
Watanabe et al90 2010 | N | Y | N | N | N | |||||||||||||||||||||||
Weinstein et al91 2000 | ||||||||||||||||||||||||||||
Wimmer et al92 1998 | Y | Y | Y | Y | Y | Y | ||||||||||||||||||||||
Woods et al93 2013 | ||||||||||||||||||||||||||||
Yang et al94 2016 |
Abbreviations: Y, yes–association found; C, conditional–association under certain conditions; N, no association found; BMI, body mass index; COPD, chronic obstructive pulmonary disease.
Table 3.
Author | Deformity | Intra- vs Extradural | Tumor Size | Tumor Histopathological Diagnosis | Primary vs Metastatic Tumor |
---|---|---|---|---|---|
Abdul-Jabbar et al4 2012 | Y | ||||
Aoude et al5 2016 | |||||
Asomugha et al6 2016 | |||||
Atkinson et al7 2016 | |||||
Babu et al8 2012 | |||||
Barnes et al9 2012 | |||||
Berney et al10 2008 | |||||
Blam et al11 2003 | |||||
Bohl et al12 2016 | |||||
Boston et al13 2009 | |||||
Browne et al14 2007 | |||||
Chaichana et al15 2014 | |||||
Chen et al16 2009 | |||||
Chen et al17 2011 | |||||
Cizik et al3 2012 | |||||
De La Garza Ramos et al18 2015 | |||||
De La Garza Ramos et al19 2016 | |||||
De La Garza Ramos et al20 2017 | C | ||||
Demura et al21 2009 | |||||
Dubory et al22 2015 | |||||
Ee et al23 2014 | |||||
Fang et al24 2005 | |||||
Fehlings et al25 2012 | |||||
Fisahn et al26 2017 | |||||
Glassman et al27 2016 | |||||
Golinvaux et al28 2014 | |||||
Gruskay et al29 2012 | |||||
Haddad et al30 2016 | |||||
Hayashi et al31 2015 | N | ||||
Hijas-Gomez et al32 2017 | |||||
Hikata et al33 2014 | |||||
Jalai et al34 2016 | |||||
Kanafani et al35 2009 | |||||
Keam et al36 2014 | |||||
Kerwin et al37 2008 | |||||
Kim et al38 2014 | |||||
Kim et al39 2015 | |||||
Klekamp et al40 1999 | |||||
Klemencsics et al41 2016 | |||||
Koutsoumbelis et al42 2011 | |||||
Kudo et al43 2016 | |||||
Kukreja et al44 2015 | |||||
Kumar et al45 2015 | |||||
Kurtz et al46 2012 | |||||
Lee et al47 2014 | |||||
Lee et al48 2016 | |||||
Li et al49 2013 | N | N | |||
Lieber et al50 2016 | Y | ||||
Lim et al51 2014 | |||||
Lonjon et al52 2012 | |||||
Manoso et al53 2014 | |||||
Maragakis et al54 2009 | |||||
Marquez-Lara et al55 2014 | |||||
Martin et al56 2016 | |||||
Mehta et al57 2012 | |||||
Murphy et al58 2017 | |||||
Northrup et al59 1995 | |||||
Ogihara et al60 2015 | |||||
Ohya et al61 2017 | |||||
Oichi et al62 2017 | |||||
Ojo et al63 2016 | |||||
Olsen et al64 2003 | |||||
Olsen et al65 2008 | |||||
Omeis et al66 2011 | N | N | |||
Pull ter Gunne et al1 2009 | |||||
Pull ter Gunne et al67 2010 (deformity) | |||||
Pull ter Gunne et al68 2010 (osteotomy) | |||||
Radcliff et al69 2013 | |||||
Ramos et al70 2016 | |||||
Rao et al71 2011 | |||||
Rechtine et al72 2001 | |||||
Rodgers et al73 2010 | |||||
Ruggieri et al74 2012 | N | ||||
Saeedinia et al75 2015 | |||||
Salvetti et al76 2017 | |||||
Satake et al77 2013 | |||||
Schimmel et al2 2010 | |||||
Schoenfeld et al78 2013 | |||||
Schwarzkopf et al79 2010 | |||||
Sciubba et al80 2008 | |||||
Sebastian et al81 2016 | |||||
Shousha et al82 2014 | |||||
Singla et al83 2017 | |||||
Skovrlj et al84 2015 | |||||
Stambough et al85 1992 | |||||
Sugita et al86 2016 | |||||
Tempel et al87 2015 | |||||
Tominaga et al88 2016 | |||||
Veeravagu et al89 2009 | |||||
Watanabe et al90 2010 | |||||
Weinstein et al91 2000 | |||||
Wimmer et al92 1998 | |||||
Woods et al93 2013 | |||||
Yang et al94 2016 |
Abbreviations: Y, yes–association found; C, conditional–association under certain conditions; N, no association found.
Table 4.
Author | Antibiotic Timing/Redosing | Approach | Bone Graft | Case Order | Cervical Collar | Complex Closure | Delay to Surgery | Drain Presence/Duration | Dural Tear/CSF Leak | Early Tracheostomy | EBL | Emergency Surgery | Epidural Steroid | Incision Length | Instrumentation | Intraoperative Temperature | Length of Stay | Number of Levels Operated/Fused | Number of Staff | Number of Surgical Teams | Open vs MIS | Preoperative Admission | Procedure Type | Resident-Fellow | Revision | Surgical Duration | Surgical Invasiveness | Surgical Region | Transfusion | UTI |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Abdul-Jabbar et al4 2012 | Y | Y | N | N | N | |||||||||||||||||||||||||
Aoude et al5 2016 | C | |||||||||||||||||||||||||||||
Asomugha et al6 2016 | N | Y | N | N | N | |||||||||||||||||||||||||
Atkinson et al7 2016 | N | N | N | Y | N | Y | ||||||||||||||||||||||||
Babu et al8 2012 | N | |||||||||||||||||||||||||||||
Barnes et al9 2012 | Y | |||||||||||||||||||||||||||||
Berney et al10 2008 | N | |||||||||||||||||||||||||||||
Blam et al11 2003 | N | N | Y | N | N | Y | N | |||||||||||||||||||||||
Bohl et al12 2016 | ||||||||||||||||||||||||||||||
Boston et al13 2009 | Y | |||||||||||||||||||||||||||||
Browne et al14 2007 | ||||||||||||||||||||||||||||||
Chaichana et al15 2014 | N | Y | N | |||||||||||||||||||||||||||
Chen et al16 2009 | N | N | N | Y | N | |||||||||||||||||||||||||
Chen et al17 2011 | N | Y | ||||||||||||||||||||||||||||
Cizik et al3 2012 | N | Y | Y | |||||||||||||||||||||||||||
De La Garza Ramos et al18 2015 | ||||||||||||||||||||||||||||||
De La Garza Ramos et al19 2016 | Y | |||||||||||||||||||||||||||||
De La Garza Ramos et al20 2017 | C | |||||||||||||||||||||||||||||
Demura et al21 2009 | N | N | ||||||||||||||||||||||||||||
Dubory et al22 2015 | N | N | N | Y | N | |||||||||||||||||||||||||
Ee et al23 2014 | N | N | Y | N | Y | N | ||||||||||||||||||||||||
Fang et al24 2005 | N | N | N | N | C | |||||||||||||||||||||||||
Fehlings et al25 2012 | Y | N | ||||||||||||||||||||||||||||
Fisahn et al26 2017 | Y | |||||||||||||||||||||||||||||
Glassman et al27 2016 | Y | N | ||||||||||||||||||||||||||||
Golinvaux et al28 2014 | ||||||||||||||||||||||||||||||
Gruskay et al29 2012 | C | C | C | C | ||||||||||||||||||||||||||
Haddad et al30 2016 | Y | |||||||||||||||||||||||||||||
Hayashi et al31 2015 | Y | Y | N | |||||||||||||||||||||||||||
Hijas-Gomez et al32 2017 | N | N | N | Y | N | |||||||||||||||||||||||||
Hikata et al33 2014 | N | N | N | N | N | N | ||||||||||||||||||||||||
Jalai et al34 2016 | Y | Y | ||||||||||||||||||||||||||||
Kanafani et al35 2009 | Y | N | ||||||||||||||||||||||||||||
Keam et al36 2014 | ||||||||||||||||||||||||||||||
Kerwin et al37 2008 | N | |||||||||||||||||||||||||||||
Kim et al38 2014 | Y | |||||||||||||||||||||||||||||
Kim et al39 2015 | Y | |||||||||||||||||||||||||||||
Klekamp et al40 1999 | ||||||||||||||||||||||||||||||
Klemencsics41 et al 2016 | N | N | ||||||||||||||||||||||||||||
Koutsoumbelis et al42 2011 | N | Y | Y | N | Y | N | N | N | ||||||||||||||||||||||
Kudo et al43 2016 | N | N | Y | |||||||||||||||||||||||||||
Kukreja et al44 2015 | Y | Y | ||||||||||||||||||||||||||||
Kumar et al45 2015 | Y | |||||||||||||||||||||||||||||
Kurtz et al46 2012 | Y | N | Y | Y | N | |||||||||||||||||||||||||
Lee et al47 2014 | Y | |||||||||||||||||||||||||||||
Lee et al48 2016 | N | N | ||||||||||||||||||||||||||||
Li et al49 2013 | Y | N | N | |||||||||||||||||||||||||||
Lieber et al50 2016 | N | N | Y | N | ||||||||||||||||||||||||||
Lim et al51 2014 | Y | |||||||||||||||||||||||||||||
Lonjon et al52 2012 | N | Y | N | Y | Y | N | Y | N | N | |||||||||||||||||||||
Manoso et al53 2014 | N | Y | N | |||||||||||||||||||||||||||
Maragakis et al54 2009 | N | Y | N | N | Y | N | Y | Y | N | |||||||||||||||||||||
Marquez-Lara et al55 2014 | ||||||||||||||||||||||||||||||
Martin et al56 2016 | ||||||||||||||||||||||||||||||
Mehta et al57 2012 | Y | |||||||||||||||||||||||||||||
Murphy et al58 2017 | ||||||||||||||||||||||||||||||
Northrup et al59 1995 | N | |||||||||||||||||||||||||||||
Ogihara et al60 2015 | N | N | N | N | Y | N | ||||||||||||||||||||||||
Ohya et al61 2017 | ||||||||||||||||||||||||||||||
Oichi et al62 2017 | ||||||||||||||||||||||||||||||
Ojo et al63 2016 | N | Y | Y | Y | ||||||||||||||||||||||||||
Olsen et al64 2003 | N | Y | N | N | N | N | ||||||||||||||||||||||||
Olsen et al65 2008 | Y | N | N | N | N | N | N | Y | N | N | ||||||||||||||||||||
Omeis et al66 2011 | N | Y | N | Y | Y | |||||||||||||||||||||||||
Pull ter Gunne et al1 2009 | Y | Y | N | N | Y | |||||||||||||||||||||||||
Pull ter Gunne et al67 2010 (deformity) | N | N | N | N | N | N | N | |||||||||||||||||||||||
Pull ter Gunne et al68 2010 (osteotomy) | Y | |||||||||||||||||||||||||||||
Radcliff et al69 2013 | ||||||||||||||||||||||||||||||
Ramos et al70 2016 | ||||||||||||||||||||||||||||||
Rao et al71 2011 | N | N | N | Y | N | NN | N | N | N | N | N | |||||||||||||||||||
Rechtine et al72 2001 | ||||||||||||||||||||||||||||||
Rodgers et al73 2010 | Y | |||||||||||||||||||||||||||||
Ruggieri et al74 2012 | Y | Y | N | |||||||||||||||||||||||||||
Saeedinia et al75 2015 | N | Y | Y | Y | Y | Y | Y | N | Y | Y | ||||||||||||||||||||
Salvetti et al76 2017 | N | |||||||||||||||||||||||||||||
Satake et al77 2013 | N | N | ||||||||||||||||||||||||||||
Schimmel et al2 2010 | N | N | N | Y | N | N | ||||||||||||||||||||||||
Schoenfeld et al78 2013 | N | Y | Y | N | ||||||||||||||||||||||||||
Schwarzkopf79 et al 2010 | Y | |||||||||||||||||||||||||||||
Sciubba et al80 2008 | N | N | N | N | Y | |||||||||||||||||||||||||
Sebastian et al81 2016 | N | N | Y | |||||||||||||||||||||||||||
Shousha et al82 2014 | C | |||||||||||||||||||||||||||||
Singla et al83 2017 | Y | |||||||||||||||||||||||||||||
Skovrlj et al84 2015 | ||||||||||||||||||||||||||||||
Stambough et al85 1992 | Y | |||||||||||||||||||||||||||||
Sugita et al86 2016 | N | N | ||||||||||||||||||||||||||||
Tempel et al87 2015 | ||||||||||||||||||||||||||||||
Tominaga et al88 2016 | N | Y | N | N | N | Y | C | N | ||||||||||||||||||||||
Veeravagu et al89 2009 | N | Y | Y | Y | ||||||||||||||||||||||||||
Watanabe et al90 2010 | N | N | N | |||||||||||||||||||||||||||
Weinstein et al91 2000 | Y | |||||||||||||||||||||||||||||
Wimmer et al92 1998 | Y | Y | Y | |||||||||||||||||||||||||||
Woods et al93 2013 | Y | |||||||||||||||||||||||||||||
Yang et al94 2016 | Y |
Abbreviations: Y, yes–association found; C, conditional–association under certain conditions; N, no association found; CSF, cerebrospinal fluid; EBL, estimated blood loss; MIS, minimally invasive surgery; UTI, urinary tract infection.
Patient-Associated Risk Factors
There were a number of modifiable and nonmodifiable patient-associated risk factors for SSI that were identified, including age, diabetes, nutritional status, smoking, and obesity.
Age
The relationship between patient age and the risk of SSI is not consistently reported in the literature, with numerous studies that implicating advanced age as a risk factor for SSI, and numerous studies finding no such association. Chaichana et al15 reviewed 817 consecutive lumbar degenerative cases and found age of >70 years to be an independent risk factor for increased SSI. Manoso et al53 found that Medicaid patients were at an increased risk for SSI but age alone was not an independent factor. In most studies, it was not possible to parse out the effect of age from other age-related comorbidities. Given the heterogeneity of results, it is not possible to definitively determine the role that age plays in the risk of SSI. The intuitive association between age and SSI is most likely related to other age-related comorbidities or the accumulation of co-morbidities that are globally manifest as patient frailty.
General Comorbidities
Koutsoumbelis et al42 reviewed 3128 patients undergoing lumbar fusion at a single institution. The authors found several comorbidities that are associated with increased SSI, including diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), and osteoporosis. The hypothesis of osteoporosis and the association with SSI is thought to be related to loss of collagen in skin as well as bone, leading to aberrant wound healing.42 Klemencsics et al41 concluded that patients with DM, CAD, arrhythmia, chronic liver disease, and autoimmune disease were at a higher risk of SSI. Furthermore, patients with multiple comorbidities are at an increased risk for SSI. Kurtz et al46 found that patients with Charleston comorbidity index (CCI) of 5 versus 0 had an adjusted hazard ratio of 2.48 in developing a postoperative SSI.
Diabetes Mellitus
It has been clearly established in the literature DM is an independent risk factor for SSI. There are several presumed pathophysiologies for this. Microvascular disease associated with DM can impair nutrition and oxygen delivery to the peripheral tissues and reduce the systemic ability to resist infection. Hyperglycemia can impair leukocyte functions such as adherence, chemotaxis, and phagocytosis. Furthermore, DM can lead to impaired collagen synthesis and fibroblast proliferation that delays wound healing. Browne et al14 reviewed the Nationwide Inpatient Sample (NIS) database of 11 000 patients who underwent lumbar fusion. The reported that DM was associated with increased SSI, blood transfusion, increased LOS and nonroutine discharge. Chen et al17 found that patients with DM had an adjusted relative risk of 4.1 of developing an SSI. Golinvaux et al27 further delineated the risk factors by reporting that insulin dependent DM portends a higher SSI risk than non–insulin-dependent diabetes. In patients with the diagnosis of DM, preoperative glycemic control is essential in minimizing the risk of SSI. Since HbA1c reflects the average blood glucose over a period of 6 to 12 weeks, it is an important indicator of how well diabetes is being managed. Hikata et al33 found that patients with DM had a higher rate of SSI than nondiabetics (16.7% vs 3.2%). Furthermore, while immediate perioperative glycemic control did not differ between those DM patients that did or did not develop an SSI, the immediate preoperative HbA1C was significantly higher in those who developed SSI (7.6%) than in those who did not (6.9%). In the same study, SSI developed in none of the patients with HbA1C <7.0% and in 35.5% of patients with HbA1C >7.0%. Thus, pre- and perioperative glycemic control are significant modifiable risk factors for SSI and should be part of a systematic infection prevention strategy.
Nutrition
There are several serum markers such as transferrin, prealbumin, albumin, total lymphocyte count that can be measured for early detection of nutritional deficits. Bohl et al12 performed a retrospective review of the ACS-NSQIP database and found the overall prevalence of hypoalbuminemia (defined as <3.5 g/dL) as 4.8% in patients who underwent posterior lumbar fusion of 1 to 3 levels. The authors found patients with preoperative hypoalbuminemia had a higher risk of wound dehiscence, SSI and urinary traction infection. Furthermore, those patients also had longer inpatient stay and a higher risk of unplanned hospital readmission within 30 days of surgery. Chen et al17 found that hypoalbuminemia was an independent risk factor for SSI in a cohort of patients who underwent sacral chordoma resection.
While albumin has been routinely used as a surrogate marker for nutritional status, recent studies have shown that prealbumin (half-life of 2 days) may also be used to assess a patient’s nutritional status in the perioperative period. Salvetti et al76 found that preoperative prealbumin level of <20 mg/dL had higher risk of developing SSI with adjusted hazard ratio of 2.12. This collection of literature would suggest that for the reduction of SSI, it is advisable to assess nutritional status pre-operatively by checking prealbumin, albumin and total lymphocyte count. Nutritional supplementation may be considered if the patient is malnourished and undergoing complex surgical reconstruction.
Smoking
Nicotine leads to peripheral vasoconstriction and tissue hypoxia and results in impaired local angiogenesis and epithelialization. Smoking leads to decreased wound collagen production in in vitro and in animal studies. Martin et al56 in 2016 found that active smokers are at a significantly higher risk of SSI compared with former smokers. That study from the ACS-NSQIP database, of patients who underwent elective lumbar surgery, categorized patients into: never smoked, former smoker (quit 12 months ago) and active smoker. Active smokers had a significantly higher risk of SSI compared with nonsmokers. Former smoker had an increased risk, but it was not significantly different from nonsmokers. Pack years of 1 to 20 and 20 to 40 were both found to have increased risk for SSI.
Obesity/Body Mass Index
Much has been studied about the relationship between obesity/body mass index (BMI) and SSI. Cizik et al3 performed a retrospective review of all patients who had spine surgery at a single institution and found that BMI >35 kg/m2 was an independent risk factor for increased risk of SSI. In a retrospective cohort review, De la Garza-Ramos et al18 found that obesity (BMI >30 kg/m2) resulted in an increased risk of SSI (risk ratio 3.11) in patients who underwent one to three level lumbar fusion surgery. Marquez-Lara et al55 also found that BMI >30 kg/m2 (class I obesity) had increased risk of superficial wound infection. Furthermore, Mehta et al57 found that body mass distribution, in particular increased skin to lamina distance and subcutaneous fat thickness, are independent risk factors for SSI. This study may indicate that although higher BMI is an independent risk factor associated with increased SSI, in patients with higher muscle mass, BMI may not be the most accurate variable to predict postoperative SSI. Lee et al48 found that for every 1-mm of thickness in subcutaneous fat there was 6% increase in risk of SSI. Patients with at least 50 mm of posterior lumbar fat thickness had 4-fold increase in risk of SSI compared to those with less than 50 mm.
Surgery-Associated Risk Factors
Timing and Duration of Surgery
Most studies have found no significant association between “emergency surgery” and SSI.7,21,31,52,54,60,71,89 Three studies have shown that increased duration from time of injury or admission to time of surgery was associated with increased risk of SSI.11,44,52 Lonjon et al52 found no association between the risk of SSI and surgery being done at night or after-hours.
A large number of studies have found that increased operative time increases the risk of SSI,* with a smaller number of contradicting studies.6,11,16,23,27,35,48,67,71,86 Several studies used a cutoff of surgical duration in determining an association with SSI, although this varies between papers, ranging anywhere from 100 minutes to 5 hours,13,24 and no conclusions can be made with regards to a specific duration as an inflection point in the risk for SSI.
Surgical Approach, Procedure, and Invasiveness
Surgical Approach: Anterior, Posterior, or Combined
If one considers studies that evaluate only cervical25,30,34 or only lumbar procedures2,46 separately, or separately analyzed approach in each spinal level subgroup,28,64 most find an association between approach and SSI. In all studies with either cervical only groups or cervical subanalysis,25,28,30,34,64 a posterior approach is consistently reported as a risk factor for SSI as compared with an anterior approach. Of those examining lumbar procedures,2,28,46,64 for the most part, a combined anterior-posterior or posterior only approach was a risk factor for SSI as compared with anterior approach. Only 1 study had a thoracic subgroup analysis for approach, with Olsen et al64 finding a posteriorly only approach to be associated with SSI as compared anterior alone. For the most part, those studies that have not found an association11,22,52,65,68,71,75,77 have included a combination of cervical, thoracic, and lumbar procedures, which may confound the significance of approach given that the relative risk of an anterior versus posterior approach is different at various spinal levels. In those studies showing approach to be a risk factor for SSI,1,4,25,28,30,31,34,46,54,64 the general trend is for a combined anterior-posterior approach to have the highest risk for SSI, followed by a posterior approach, with the anterior approach often reducing the risk for SSI.
Minimally Invasive Versus Open Surgery
Both Ee et al23 and Rodgers et al73 found that open surgery was associated with a higher risk of SSI as compared to MIS techniques (procedures performed through a tubular retractor system or extreme lateral interbody fusion (XLIF)) in elective lumbar spine surgery. Dubory et al22 and Lonjon et al52 found no such difference in SSI rates in spinal trauma. It should be noted the latter studies come from the same group, one of two that utilized only univariate analysis, and the type of MIS technique used was not defined, making it difficult to compare these results with those of either Ee et al23 or Rodgers et al73
Surgical “Invasiveness”
Surgical invasiveness can be considered a composite of a number of variables as previously described, including number of levels operated on, the type of procedure performed at each level, and approach used. To allow comparison of the invasiveness of disparate spinal procedures, a surgical invasiveness index (SII) was developed by Mirza et al.95 This index is a composite score based on the number of vertebral levels operated on, the type of intervention on each vertebra—decompression, fusion, instrumentation—as well as the approach used at each level, and has been validated against both blood loss and surgical duration. Of the 4 studies that evaluated SII as a variable with regards to SSI, 3 found that an increase in SII was associated with SSI.3,48,53 However, Klemencsics et al1 found no such association. This may be related to the populations and procedure types studied, as Klemencsics et al1 looked at elective routine degenerative lumbar procedures, with a maximal SII of 15, while the other 3 studies looked across a broad range of surgery types using large databases and presumed higher maximal SII scores.3,48,53 If this is the case, the association between SII and SSI may only exist in the upper range of the SII.
Perioperative Interventions
Tracheostomy
Despite theoretical concerns, all 3 studies evaluating the potential of cross-contamination, have found no increased SSI risk for early tracheostomy (either pre- or postoperatively) in anterior cervical spine surgery. Babu et al8 and Berney et al10 found a low rate of SSI with early tracheostomy after anterior cervical stabilization for acute cervical trauma with spinal cord injury. Northrup et al,59 in a review of 11 spinal cord injury patients, concluded that an existing tracheostomy was not a risk factor for SSI for subsequent anterior cervical spine stabilization.
Cervical Orthosis
Barnes et al9 reported that the use of a Philadelphia collar for a minimum of 48 hours postoperatively increased the rate of SSI in posterior cervical spine surgery. This is in keeping with the known effects of pressure on skin and soft tissue from cervical orthoses.96
Blood Transfusion
Transfusion is an independent risk factor for SSI in other surgical specialties,97,39,98 and it has been strongly suggested to similarly be a risk factor in adult spine surgery. There exists some conflict in the literature to date, with a majority of studies finding a significant increase in SSI associated with transfusion,4,5,28,61,79,89,93 but others finding it not to be of significance.22,31,33,46,52,54,71 However, of those studies that have focused on the implications of blood transfusion in adult spine surgery,5,28,79,93 all 4 have shown transfusion to be an independent risk factor for SSI. The association of transfusion with SSI has been thought to be a result of transfusion-related immunomodulation (TRIM), a phenomenon whereby antigens in blood products may result in T-cell unresponsiveness and subsequent immunosuppression.99 Bacterial contamination of blood products are another potential explanation for the effects of transfusion on SSI.100
Urinary tract infection (UTI) has been investigated as a possible source and hence risk factor for SSI,88,101 and presence of a catheter is a well-established risk for UTI.102 However, there has been limited study into urinary catheters as an independent risk factor for SSI in spine surgery, with both articles on this topic coming from the same group.22,52 While Dubory et al22 found that presence of a bladder catheter was not a significant risk for SSI after multivariate analysis, Lonjon et al52 did find that a prolonged duration of catheterization greater than five days was associated with SSI after univariate analysis, although no multivariate analysis was performed. Based on these results, limited if any conclusion about urinary catheterization and SSI can be made.
Radiation is known to have deleterious effects on tissue, both in short-term effects on wound healing such as skin breakdown, lower tensile strength, and delayed healing rates from damage to epithelial cells and fibroblasts,103 and in long-term effects on soft tissue resulting in fibrosis, poor vascularity, and a higher propensity to go onto atrophy or necrosis.104 As such, preoperative radiation, whether recent or remote, has been regarded as a substantial risk factor for SSI. In nonsacral tumors, 3 studies focused on risk factors for SSI in spinal metastases or primary spinal tumors found preoperative radiation to be a significant risk for SSI.21,66,86 In primary sacral tumors, the results have been more mixed, with 2 studies suggesting no significant association between previous radiation and SSI17,80 against 1 study finding previous radiation to be a risk factor.49 This is unsurprising, given the complexities of sacral tumor resection, higher infection rates, and smaller case numbers within each study by which to find association.
Evidence from a single controlled-cohort study suggests that use of epidural steroid paste in lumbar decompression is a risk factor for SSI, with the rate of SSI in the steroid paste group being 5.83% as compared to 1.11% in the control group.5. Two studies from the same institution have shown preoperative lumbar epidural injections, if within 3 months of surgery, can also be a risk factor for SSI in both lumbar decompression94 and lumbar fusion83 surgery.
Surgical Team
Only 1 study has looked at surgeon experience in relation to SSI, with Skovrlj et al84 finding that in adult scoliosis surgery, candidate members as compared with active members for the Scoliosis Research Society had a 2-fold increase in the rate of superficial, though not deep, SSI which was statistically significant. In regards to the effect of resident involvement and experience, 3 studies looking at different aspects of this have found an association with SSI.61,65,78 Looking at seasonal variation in the risk of reoperation for SSI, Ohya et al.61 found that April, during which medical staff turnover in Japan, was associated with the highest rate of SSI and reoperation for the same in academic centers while no such seasonal variation occurred in nonacademic hospitals, suggesting that the influx in new and henceforth inexperienced staff may be a contributor to this result. More directly, Schoenfeld et al.78 found that resident involvement was an independent risk factor for SSI even after multivariate analysis encompassing procedure time and patient comorbidity, while Olsen et al.65 found that the participation of 2 or more residents increased the risk of SSI although the latter assumed this to be a proxy for surgical complexity rather than a result of resident involvement. Koutsoumbelis et al,42 however, found no significant association between number of residents and fellows and SSI and Sebastian et al81 found no association between resident involvement and SSI. As such, it remains unclear as to the effect of residents on SSI.
The number of surgeons involved in spine surgery does not appear to be a significant risk factor, with 3 studies,23,67,88 finding no significant association between number of scrubbed or senior surgeons and SSI. However, Sciubba et al.80 found a larger number of surgeons to be associated with SSI in sacral tumor resection, where a multidisciplinary surgical team is often required. Koutsoumbelis et al42 found that the overall number of personnel may be a risk if 10 or more personnel are present in the operating room. Operating room traffic and the number of personnel both have been linked to an increase in airborne contaminants103 and could thereby increase the risk of contamination of the surgical wound.
The effects of involvement of more than one surgical team on SSI is not well studied and is confounded by the fact the presence of additional surgical teams may imply greater surgical complexity and therefore potential risk for infection. Blam et al11 found that the combined involvement of both orthopedic and neurosurgical teams had a reduced rate of SSI as compared with orthopedics alone, with a trend toward the same as compared with neurosurgery alone, despite the greater operating room traffic involved although no clear explanation could be had for this effect. On the other hand, Rao et al71found no significant association between involvement of both services as compared with either orthopedics or neurosurgery alone. Involvement of more than 1 surgical team was found by Omeis et al66 to be a risk for SSI in spinal tumors. However, in most cases this was due to involvement of plastic surgery and the requirement of a complex soft tissue reconstruction with its attendant risks with regard to infection, confounding the effect on SSI. In the case of sacral tumors, Sciubba et al80 found no statistically significant association between having a plastic surgeon for closure and SSI.
Intraoperative Concerns and Complications
Increased intraoperative blood loss has not been clearly shown to be a risk factor for SSI, with a number of studies on either side of whether an association exists or not.† It is difficult to separate blood loss from other confounding variables such as surgical duration, invasiveness, as well as the need for transfusion. Only 3 studies reporting on intraoperative blood loss also reported on transfusion, with one showing an independent association between each and SSI,93 one showing no association between either and SSI,22 and one showing an association between blood loss but not transfusion and SSI.52 Enough contradiction exists to preclude any conclusions with regard to blood loss as a possible risk factor.
Intraoperative hypothermia has been viewed as a potential risk factor for of SSI due to its induction of vasoconstriction and its negative effects on oxygenation, neutrophil function, and wound healing.105 However, intraoperative temperature has not been found to be a risk factor so far for SSI in spine surgery, with all three studies including this variable demonstrating no significant association between intraoperative temperature and SSI.54,64,71 In the lone study examining the effect of intraoperative inspired oxygen, Maragakis et al54 found that intraoperative administration of fractionated inspired oxygen less than 50% was an independent risk factor for SSI, even after adjusting for other variables. The authors suggested that its effects may be related to the role of oxygen in the bactericidal process of leukocytes.
The argument behind a potential association between intraoperative dural tear and SSI is based on the longer surgical time required to repair a dural tear, as well as the risk of persistent cerebrospinal fluid leakage compromising wound healing. However, no clear relationship between intraoperative dural tear and SSI has been found. Three studies demonstrated no association between dural tear and spinal SSI,54,60,64 in contrast to a single study finding dural tear to be associated with an increased risk of SSI.42 In sacral tumors, no definitive association can be made between CSF leak and SSI, as the 2 studies found opposing results.49,80
Discussion
SSIs are associated with many risk factors that can be patient or surgically related. Our review was able to identify important modifiable and nonmodifiable risk factors that can be essential in surgical planning and discussion with patients.
Factor | Conclusion |
---|---|
Patient-associated factors | |
Age | In general, the literature suggests a mixed finding of association between age and SSI. |
Diabetes mellitus (DM) | In general, the literature suggests a strong association between DM/A1c and SSI. |
General comorbidities | In general, the literature has mixed finding of specific comorbid conditions in association of SSI. There is evidence to suggest higher number of comorbidities is associated with SSI. |
Nutrition | In general, the literature suggests malnutrition is associated with SSI. |
Smoking | In general, the literature has mixed results of association between smoking and SSI. More recent evidence would suggest there is correlation between the two. |
Obesity/Body mass index | In general, the literature suggests a strong association between obesity and SSI. |
Surgery-associated factors | |
Time and duration of surgery | In general, the literature is mixed, with conflicting results, making it difficult to firmly establish an association. |
Surgical approach/Invasiveness | In general, the literature is mixed with general trend indicating combined approach have highest incidence of SSI, followed by posterior approach. There is strong evidence increased invasiveness is associated with SSI. |
Perioperative interventions | Preoperative radiation and postoperative blood transfusion have strong association with SSI. There is mixed evidence of UTI/urinary catheter in association of SSI. |
Surgical team | In general, there is mixed evidence of resident/fellow involvement, number of surgeons and SSI, unable to establish an association. |
Intraoperative concerns and complications | There is mixed evidence of intraoperative blood loss, dural tear, hypothermia and SSI, no established association can be made. |
Footnotes
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This Supplement was supported by funding from AOSpine North America.
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