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Global Spine Journal logoLink to Global Spine Journal
. 2018 Dec 13;8(4 Suppl):5S–30S. doi: 10.1177/2192568218799056

Surgical Site Infection in Spine Surgery: Who Is at Risk?

Reina Yao 1, Hanbing Zhou 1,, Theodore J Choma 2, Brian K Kwon 1, John Street 1
PMCID: PMC6295819  PMID: 30574441

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.

Characteristics of Studies Included in Review.

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.

Patient-Associated Variables and Association With Surgical Site Infection by Study.

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.

Diagnosis-Associated Variables and Association With Surgical Site Infection by Study.

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.

Surgery-Associated Variables and Association With Surgical Site Infection by Study.

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.
*

References 1, 4, 13, 19, 22, 28, 31, 34, 38, 39, 43, 51, 52, 54, 60, 63, 78, 81, 92.

References 1, 6, 11, 16, 22, 33, 42, 43, 49, 52, 67, 80, 86, 92, 93.

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.

References

  • 1. Pull ter Gunne AF, Cohen DB. Incidence, prevalence, and analysis of risk factors for surgical site infection following adult spinal surgery. Spine (Phila Pa 1976). 2009;34:1422–1428. [DOI] [PubMed] [Google Scholar]
  • 2. Schimmel JJP, Horsting PP, de Kleuver M, Wonders G, van Limbeek J. Risk factors for deep surgical site infections after spinal fusion. Eur Spine J. 2010;19:1711–1719. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3. Cizik AM, Lee MJ, Martin BI, et al. Using the Spine Surgical Invasiveness Index to identify risk of surgical site infection. J Bone Joint Surg Am. 2012;94:335–342. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4. Abdul-Jabbar A, Takemoto S, Weber MH, et al. Surgical site infection in spinal surgery: description of surgical and patient-based risk factors for postoperative infection using administrative claims data. Spine (Phila Pa 1976). 2012;37:1340–1345. [DOI] [PubMed] [Google Scholar]
  • 5. Aoude A, Nooh A, Fortin M, et al. Incidence, predictors, and postoperative complications of blood transfusion in thoracic and lumbar fusion surgery: an analysis of 13 695 patients from the American College of Surgeons National Surgical Quality Improvement Program database. Global Spine J. 2016;6:756–764. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6. Asomugha EU, Miller BS, McLain RF. Surgical site infections in posterior lumbar surgery: a controlled-cohort study of epidural steroid paste. Spine (Phila Pa 1976). 2017;42:63–69. [DOI] [PubMed] [Google Scholar]
  • 7. Atkinson RA, Stephenson J, Jones A, Ousey KJ. An assessment of key risk factors for surgical site infection in patients undergoing surgery for spinal metastases. J Wound Care. 2016;25(suppl 9):S30–S34. [DOI] [PubMed] [Google Scholar]
  • 8. Babu R, Owens TR, Thomas S, et al. Timing of tracheostomy after anterior cervical spinal fixation. J Trauma Acute Care Surg. 2013;74:961–966. [DOI] [PubMed] [Google Scholar]
  • 9. Barnes M, Liew S. The incidence of infection after posterior cervical spine surgery: a 10 year review. Global Spine J. 2012;2:3–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10. Berney S, Opdam H, Bellomo R, et al. An assessment of early tracheostomy after anterior cervical stabilization in patients with acute cervical spine trauma. J Trauma. 2008;64:749–753. [DOI] [PubMed] [Google Scholar]
  • 11. Blam OG, Vaccaro AR, Vanichkachorn JS, et al. Risk factors for surgical site infection in the patient with spinal injury. Spine (Phila Pa 1976). 2003;28:1475–1480. [DOI] [PubMed] [Google Scholar]
  • 12. Bohl DD, Shen MR, Mayo BC, et al. Malnutrition predicts infectious and wound complications following posterior lumbar spinal fusion. Spine (Phila Pa 1976). 2016;41:1693–1699. [DOI] [PubMed] [Google Scholar]
  • 13. Boston KM, Baraniuk S, O’Heron S, Murray KO. Risk factors for spinal surgical site infection, Houston, Texas. Infect Control Hosp Epidemiol. 2009;30:884–889. [DOI] [PubMed] [Google Scholar]
  • 14. Browne JA, Cook C, Pietrobon R, Bethel MA, Richardson WJ. Diabetes and early postoperative outcomes following lumbar fusion. Spine (Phila Pa 1976). 2007;32:2214–2219. [DOI] [PubMed] [Google Scholar]
  • 15. Chaichana KL, Bydon M, Santiago-Dieppa DR, et al. Risk of infection following posterior instrumented lumbar fusion for degenerative spine disease in 817 consecutive cases. J Neurosurg Spine. 2014;20:45–52. [DOI] [PubMed] [Google Scholar]
  • 16. Chen S, Anderson MV, Cheng MK, Wongworawat MD. Diabetes associated with increased surgical site infections in spinal arthrodesis. Clin Orthop Relat Res. 2009;467:1670–1673. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17. Chen KW, Yang HL, Lu J, et al. Risk factors for postoperative wound infections of sacral chordoma after surgical excision. J Spinal Disord Tech. 2011;24:230–234. [DOI] [PubMed] [Google Scholar]
  • 18. De la Garza-Ramos R, Bydon M, Abt NB, et al. The impact of obesity on short- and long-term outcomes after lumbar fusion. Spine (Phila Pa 1976). 2014;40:56–61. [DOI] [PubMed] [Google Scholar]
  • 19. De la Garza-Ramos R, Abt NB, Kerezoudis P, et al. Deep-wound and organ-space infection after surgery for degenerative spine disease: an analysis from 2006-2012. Neurol Res. 2016;38:117–123. [DOI] [PubMed] [Google Scholar]
  • 20. De la Garza-Ramos R, Nakhla J, Nasser R, Bhashyam N, Kinon MD, Yassari R. Case-control study of risk factors for surgical site infection after three-column osteotomy for spine deformity [published online June 2, 2017]. Turk Neurosurg. doi:10.5137/1019-5149.JTN.20372-17.0 [DOI] [PubMed] [Google Scholar]
  • 21. Demura S, Kawahara N, Murakami H, et al. Surgical site infection in spinal metastasis: risk factors and countermeasures. Spine (Phila Pa 1976). 2009;34:635–639. [DOI] [PubMed] [Google Scholar]
  • 22. Dubory A, Giorgi H, Walter A, et al. Surgical-site infection in spinal injury: incidence and risk factors in a prospective cohort of 518 patients. Eur Spine J. 2015;24:543–554. [DOI] [PubMed] [Google Scholar]
  • 23. Ee WW, Lau WL, Yeo W, Von Bing Y, Yue WM. Does minimally invasive surgery have a lower risk of surgical site infections compared with open spinal surgery? Clin Orthop Relat Res. 2014;472:1718–1724. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24. Fang A, Hu SS, Endres N, Bradford DS. Risk factors for infection after spinal surgery. Spine (Phila Pa 1976). 2005;30:1460–1465. [DOI] [PubMed] [Google Scholar]
  • 25. Fehlings MG, Smith JS, Kopjar B, et al. Perioperative and delayed complications associated with the surgical treatment of cervical spondylotic myelopathy based on 302 patients from the AOSpine North America Cervical Spondylotic Myelopathy Study. J Neurosurg Spine. 2012;16:425–432. [DOI] [PubMed] [Google Scholar]
  • 26. Fisahn C, Jeyamohan S, Norell DC, et al. Association between allogeneic blood transfusion and postoperative infection in major spine surgery. Clin Spine Surg. 2017;30:E988–E992. [DOI] [PubMed] [Google Scholar]
  • 27. Glassman S, Carreon LY, Andersen M, et al. Predictors of hospital readmission and surgical site infection in the United States, Denmark, and Japan: is risk stratification a universal language? Spine (Phila Pa 1976). 2017;42:1311–1315. [DOI] [PubMed] [Google Scholar]
  • 28. Golinvaux NS, Varthi AG, Bohl DD, Basques BA, Grauer JN. Complication rates following elective lumbar fusion in patients with diabetes: insulin dependence makes the difference. Spine (Phila Pa 1976). 2014;39:1809–1816. [DOI] [PubMed] [Google Scholar]
  • 29. Gruskay J, Kepler C, Smith J, Radcliff K, Vaccaro A. Is surgical case order associated with increased infection rate after spine surgery? Spine (Phila Pa 1976). 2012;37:1170–1174. [DOI] [PubMed] [Google Scholar]
  • 30. Haddad S, Milhouse PW, Maltenfort M, Restrepo C, Kepler CK, Vaccaro AR. Diagnosis and neurologic status as predictors of surgical site infection in primary cervical spine surgery. Spine J. 2016;16:632–642. [DOI] [PubMed] [Google Scholar]
  • 31. Hayashi H, Murakami H, Demura S, et al. Surgical site infection after total en bloc spondylectomy: risk factors and the preventive new technology. Spine J. 2015;15:132–137. [DOI] [PubMed] [Google Scholar]
  • 32. Hijas-Gomez AL, Egea-Gamez RM, Martinez-Martin J, Gonzalez-Diaz R, Losada-Vinas JI, Rodriguez-Caravaca G. Surgical wound infection rates and risk factors in spinal fusion in a university teaching hospital in Madrid, Spain: Spine (Phila Pa 1976). 2017;42:748–754. [DOI] [PubMed] [Google Scholar]
  • 33. Hikata T, Iwanami A, Hosogane N, et al. High preoperative hemoglobin A1c is a risk factor for surgical site infection after posterior thoracic and lumbar spinal instrumentation surgery. J Orthop Sci. 2014;19:223–228. [DOI] [PubMed] [Google Scholar]
  • 34. Jalai CM, Worley N, Poorman GW, Cruz DL, Vira S, Passias PG. Surgical site infections following operative management of cervical spondylotic myelopathy: prevalence, predictors of occurrence, and influence on peri-operative outcomes. Eur Spine J. 2016. 25:1891–1896. [DOI] [PubMed] [Google Scholar]
  • 35. Kanafani ZA, Dakdouki GK, El-Dbouni O, Bawwab T, Kanj SS. Surgical site infections following spinal surgery at a tertiary care center in Lebanon: incidence, microbiology, and risk factors. Scand J Infect Dis. 2006;38:589–592. [DOI] [PubMed] [Google Scholar]
  • 36. Keam J, Bilsky MH, Laufer I, et al. No association between excessive wound complications and preoperative high-dose, hypofractionated, image-guided radiation therapy for spine metastasis. J Neurosurg Spine. 2014;20:411–420. [DOI] [PubMed] [Google Scholar]
  • 37. Kerwin AJ, Griffen MM, Tepas JJ, 3rd, Schinco MA, Devin T, Frykberg ER. Best practice determination of timing of spinal fracture fixation as defined by analysis of the National Trauma Data Bank. J Trauma. 2008;65:824–831. [DOI] [PubMed] [Google Scholar]
  • 38. Kim BD, Hsu WK, De Oliviera GS, Jr, Saha S, Kim JY. Operative duration as an independent risk factor for postoperative complications in single-level lumbar fusion: an analysis of 4588 surgical cases. Spine (Phila Pa 1976). 2014;39:510–520. [DOI] [PubMed] [Google Scholar]
  • 39. Kim JL, Park JH, Han SB, Cho IY, Jang KM. Allogeneic blood transfusion is a significant risk factors for surgical-site infection following total hip and knee arthroplasty: a meta-analysis. J Arthroplasty. 2017;32:320–325. doi:10.1016/j.arth.2016.08.026 [DOI] [PubMed] [Google Scholar]
  • 40. Klekamp J, Spengler DM, McNamara MJ, Haas DW. Risk factors associated with methicillin-resistant staphylococcal wound infection after spinal surgery. J Spinal Disord. 1999;12:187–191. [PubMed] [Google Scholar]
  • 41. Klemencsics I, Lazary A, Szoverfi Z, Bozsodi A, Eltes P, Varga PP. Risk factors for surgical site infection in elective routine degenerative lumbar surgeries. Spine J. 2016;16:1377–1383. [DOI] [PubMed] [Google Scholar]
  • 42. Koutsoumbelis S, Hughes AP, Girardi FP, et al. Risk factors for postoperative infection following posterior lumbar instrumented arthrodesis. J Bone Joint Surg Am. 2011;93:1627–1633. [DOI] [PubMed] [Google Scholar]
  • 43. Kudo D, Miyakoshi N, Hongo M, et al. Relationship between preoperative serum rapid turnover proteins and early-stage surgical wound infection after spine surgery. Eur Spine J. 2017;26:3156–3161. [DOI] [PubMed] [Google Scholar]
  • 44. Kukreja S, Ambekar S, Ahmed OI, Menger RP, Sin AH, Nanda A. Impact of elective versus emergent admission on perioperative complications and resource utilization in lumbar fusion. Clin Neurol Neurosurg. 2015;136:52–60. [DOI] [PubMed] [Google Scholar]
  • 45. Kumar S, van Popta D, Rodrigues-Pinto R, et al. Risk factors for wound infection in surgery for spinal metastasis. Eur Spine J. 2015;24:528–532. [DOI] [PubMed] [Google Scholar]
  • 46. Kurtz SM, Lau E, Ong KL, et al. Infection risk for primary and revision instrumented lumbar spine fusion in the Medicare population. J Neurosurg Spine. 2012;17:342–347. [DOI] [PubMed] [Google Scholar]
  • 47. Lee MJ, Cizik AM, Hamilton D, Chapman JR. Predicting surgical site infection after spine surgery: a validated model using a prospective surgical registry. Spine J. 2014;14:2112–2117. [DOI] [PubMed] [Google Scholar]
  • 48. Lee JJ, Odeh KI, Holcombe SA, et al. Fat thickness as a risk factor for infection in lumbar spine surgery. Orthopedics. 2016;39:e1124–e1128. [DOI] [PubMed] [Google Scholar]
  • 49. Li D, Guo W, Qu H, et al. Experience with wound complications after surgery for sacral tumors. Eur Spine J. 2013;22:2069–2076. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50. Lieber B, Han BJ, Strom RG, et al. Preoperative predictors of spinal infection within the National Surgical Quality Inpatient Database. World Neurosurg. 2016;89:517–524. [DOI] [PubMed] [Google Scholar]
  • 51. Lim S, Edelstein AI, Patel AA, Kim BD, Kim JY. Risk factors for postoperative infections following single level lumbar fusion surgery. Spine (Phila Pa 1976). 2018;43:215–222. [DOI] [PubMed] [Google Scholar]
  • 52. Lonjon G, Dauzac C, Fourniols E, Guigui P, Bonnomet F, Bonnevialle P; French Orthopaedic Surgery Traumatology Society. Early surgical site infections in adult spinal trauma: a prospective, multicentre study of infection rates and risk factors. Orthop Traumatol Surg Res. 2012;98:788–794. [DOI] [PubMed] [Google Scholar]
  • 53. Manoso MW, Cizik AM, Bransford RJ, Bellabarba C, Chapman J, Lee MJ. Medicaid status is associated with higher surgical site infection rates after spine surgery. Spine (Phila Pa 1976). 2014;39:1707–1713. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 54. Maragakis LL, Cosgrove SE, Martinez EA, Tucker MG, Cohen DB, Perl TM. Intraoperative fraction of inspired oxygen is a modifiable risk factor for surgical site infection after spinal surgery. Anesthesiology. 2009;110:556–562. [DOI] [PubMed] [Google Scholar]
  • 55. Marquez-Lara A, Nandyala SV, Sankaranarayanan S, Noureldin M, Singh K. Body mass index as a predictor of complications and mortality after lumbar spine surgery. Spine (Phila Pa 1976). 2014;39:798–804. [DOI] [PubMed] [Google Scholar]
  • 56. Martin CT, Gao Y, Duchman KR, Pugely AJ. The impact of current smoking and smoking cessation on short-term morbidity risk after lumbar spine surgery. Spine (Phila Pa 1976). 2016;41:577–584. [DOI] [PubMed] [Google Scholar]
  • 57. Mehta AO, Babu R, Karikari IO, et al. The distribution of body mass as a significant risk factor for lumbar spinal fusion postoperative infections. Spine (Phila Pa 1976). 2012;37:1652–1656. [DOI] [PubMed] [Google Scholar]
  • 58. Murphy ME, Gilder H, Maloney PR, et al. Lumbar decompression in the elderly: increased age as a risk factor for complications and nonhome discharge. J Neurosurg Spine. 2017;26:353–362. [DOI] [PubMed] [Google Scholar]
  • 59. Northrup BE, Vaccaro AR, Rosen JE, Balderson RA, Cotler JM. Occurrence of infection in anterior cervical fusion for spinal cord injury after tracheostomy. Spine (Phila Pa 1976). 1995;20:2449–2453. [DOI] [PubMed] [Google Scholar]
  • 60. Ogihara S, Yamazki T, Maruyama T, et al. Prospective multicenter surveillance and risk factor analysis of deep surgical site infection after posterior thoracic and/or lumbar spinal surgery in adults. J Orthop Sci. 2015;20:71–77. [DOI] [PubMed] [Google Scholar]
  • 61. Ohya J, Chikuda H, Oichi T, et al. Seasonal variations in the risk of reoperation for surgical site infection following elective spinal fusion surgery: a retrospective study using the Japanese Diagnosis Procedure Combination database. Spine (Phila Pa 1976). 2017;42:1068–1079. [DOI] [PubMed] [Google Scholar]
  • 62. Oichi T, Chikuda H, Ohya J, et al. Mortality and morbidity after spinal surgery in patients with Parkinson’s disease: a retrospective matched-pair cohort study. Spine J. 2017;17:531–537. [DOI] [PubMed] [Google Scholar]
  • 63. Ojo OA, Owolabi BS, Oseni AW, Kanu OO, Bankole OB. Surgical site infection in posterior spine surgery. Niger J Clin Pract. 2016;19:821–826. [DOI] [PubMed] [Google Scholar]
  • 64. Olsen MA, Mayfield J, Lauryssen C, et al. Risk factors for surgical site infection in spinal surgery. J Neurosurg Spine. 2003;98:149–155. [PubMed] [Google Scholar]
  • 65. Olsen MA, Nepple JJ, Riew KD, et al. Risk factors for surgical site infection following orthopaedic spinal operations. J Bone Joint Surg Am. 2008. 90:62–69. [DOI] [PubMed] [Google Scholar]
  • 66. Omeis IA, Dhir M, Sciubba DM, et al. Postoperative surgical site infections in patients undergoing spinal tumor surgery. Spine (Phila Pa 1976). 2011;36:1410–1419. [DOI] [PubMed] [Google Scholar]
  • 67. Pull ter Gunne AF, van Laarhoven CJHM, Cohen DB. Surgical site infection after osteotomy of the adult spine: does type of osteotomy matter? Spine J. 2010;10:410–416. [DOI] [PubMed] [Google Scholar]
  • 68. Pull ter Gunne AF, van Laarhoven CJHM, Cohen DB. Incidence of surgical site infection following adult spinal deformity surgery: an analysis of patient risk. Eur Spine J. 2010;19:982–988. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 69. Radcliff KE, Rasouli MR, Neusner A, et al. Preoperative delay of more than 1 hour increases the risk of surgical site infection. Spine (Phila Pa 1976). 2013;38:1318–1323. [DOI] [PubMed] [Google Scholar]
  • 70. Ramos N, Stachel A, Phillips M, Vigdorchik J, Slover J, Bosco JA. Prior Staphylococcus aureus nasal colonization: a risk factor for surgical site infections following decolonization. J Am Acad Orthop Surg. 2016;24:880–885. [DOI] [PubMed] [Google Scholar]
  • 71. Rao SB, Vasquez G, Harrop J, et al. Risk factors for surgical site infections following spinal fusion procedures: a case-control study. Clin Infect Dis. 2011;53:686–692. [DOI] [PubMed] [Google Scholar]
  • 72. Rechtine GR, Bono PL, Cahill D, Bolesta MJ, Chrin AM. Postoperative wound infection after instrumentation of thoracic and lumbar fractures. J Orthop Trauma. 2001;15:566–569. [DOI] [PubMed] [Google Scholar]
  • 73. Rodgers WB, Gerber EJ, Patterson J. Intraoperative and early postoperative complications in extreme lateral interbody fusion. Spine (Phila Pa 1976). 2010;36:26–33. [DOI] [PubMed] [Google Scholar]
  • 74. Ruggieri P, Angelini A, Pala E, Mercuri M. Infections in surgery of primary tumors of the sacrum. Spine (Phila Pa 1976). 2012;37:420–428. [DOI] [PubMed] [Google Scholar]
  • 75. Saeedinia S, Nouri M, Azarhomayoun A, et al. The incidence and risk factors for surgical site infection after clean spinal operations: a prospective cohort study and review of the literature. Surg Neurol Int. 2015;6:154 doi:10.4103/2152-7806.166194 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 76. Salvetti DJ, Tempel ZJ, Gandhoke GS, et al. Preoperative prealbumin level as a risk factor for surgical site infection following elective spine surgery. Surg Neurol Int. 2015;6(suppl 19):S500–S503. doi:10.4103/2152-7806.166893 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 77. Satake K, Kanemura T, Matsumoto A, Yamaguchi H, Ishikawa Y. Predisposing factors for surgical site infection of spinal instrumentation surgery for diabetes patients. Eur Spine J. 2013;22:1854–1858. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 78. Schoenfeld AJ, Carey PA, Cleveland AW, Bader JO, Bono CM. Patient factors, comorbidities, and surgical characteristics that increase mortality and complication risk after spinal arthrodesis: a prognostic study based on 5887 patients. Spine J. 2013;13:1171–1179. [DOI] [PubMed] [Google Scholar]
  • 79. Schwarzkopf R, Chung C, Park JJ, Walsh M, Spivak JM, Steiger D. Effects of perioperative blood product use on surgical site infection following thoracic and lumbar spinal surgery. Spine (Phila Pa 1976). 2010;35:340–346. [DOI] [PubMed] [Google Scholar]
  • 80. Sciubba DM, Nelson C, Gok B, et al. Evaluation of factors associated with postoperative infection following sacral tumor resection. J Neurosurg Spine. 2008;9:593–599. [DOI] [PubMed] [Google Scholar]
  • 81. Sebastian A, Huddleston P, 3rd, Kakar S, Habermann E, Wagie Z, Nassr A. Risk factors for surgical site infection after posterior cervical spine surgery: an analysis of 5441 patients from the ACS NSQIP 2005-2012. Spine J. 2016;16:504–509. [DOI] [PubMed] [Google Scholar]
  • 82. Shousha M, Mosafer A, Boehm H. Infection rate after transoral approach for the upper cervical spine. Spine (Phila Pa 1976). 2014;39:1578–1583. [DOI] [PubMed] [Google Scholar]
  • 83. Singla A, Yang S, Werner BC, et al. The impact of preoperative epidural injections on postoperative infection in lumbar fusion surgery. J Neurosurg Spine. 2017;26:645–649. [DOI] [PubMed] [Google Scholar]
  • 84. Skovrlj B, Cho SK, Caridi JM, Bridwell KH, Lenke LG, Kim YJ. Association between surgeon experience and complication rates in adult scoliosis surgery: a review of 5117 cases from the Scoliosis Research Society database 2004-2007. Spine (Phila Pa 1976). 2015;40:1200–1205. [DOI] [PubMed] [Google Scholar]
  • 85. Stambough JL, Beringer D. Postoperative wound infections complicating adult spine surgery. J Spinal Disord. 1992;5:277–285. [DOI] [PubMed] [Google Scholar]
  • 86. Sugita S, Hozumi T, Yamakawa K, Goto T, Kondo T. Risk factors for surgical site infection after posterior fixation surgery and intraoperative radiotherapy for spinal metastases. Eur Spine J. 2016;25:1034–1038. [DOI] [PubMed] [Google Scholar]
  • 87. Tempel Z, Grandhi R, Maserati M, et al. Prealbumin as a serum biomarker of impaired perioperative nutritional status and risk for surgical site infection after spine surgery. J Neurol Surg A Cent Eur Neurosurg. 2015;76:138–143. [DOI] [PubMed] [Google Scholar]
  • 88. Tominaga H, Setoguchi T, Ishidou Y, Nagano S, Yamamoto T, Komiya S. Risk factors for surgical site infection and urinary tract infection after spine surgery. Eur Spine J. 2016;25:3908–3915. [DOI] [PubMed] [Google Scholar]
  • 89. Veeravagu A, Patil CG, Shivanand PL, Boakye M. Risk factors for postoperative spinal wound infections after spinal decompression and fusion surgeries. Spine (Phila Pa 1976). 2009;34:1869–1872. [DOI] [PubMed] [Google Scholar]
  • 90. Watanabe M, Sakai D, Matsuyama D, Yamamoto Y, Sato M, Mochida J. Risk factors for surgical site infection following spine surgery: efficacy of intraoperative saline irrigation. J Neurosurg Spine. 2010;12:540–546. [DOI] [PubMed] [Google Scholar]
  • 91. Weinstein MA, McCabe JP, Cammisa FP., Jr Postoperative spinal wound infection: a review of 2391 consecutive index procedures. J Spinal Disord. 2000;13:422–426. [DOI] [PubMed] [Google Scholar]
  • 92. Wimmer C, Gluch H, Franzreb M, Ogon M. Predisposing factors for infection in spine surgery a survey of 850 spinal procedures. J Spinal Disord. 1998;11:124–128. [PubMed] [Google Scholar]
  • 93. Woods BI, Rosario BL, Chen A, et al. The association between perioperative allogeneic transfusion volume and postoperative infection in patients following lumbar spine surgery. J Bone Joint Surg Am. 2013;95:2105–2110. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 94. Yang S, Werner BC, Cancienne JM, et al. Preoperative epidural injections are associated with increased risk of infection after single-level lumbar decompression. Spine J. 2016;16:191–196. [DOI] [PubMed] [Google Scholar]
  • 95. Mirza SK, Deyo RA, Heagerty PJ, et al. Development of an index to characterize the “invasiveness” of spine surgery: validation by comparison to blood loss and operative time. Spine (Phila Pa 1976). 2008;33:2651–2661. [DOI] [PubMed] [Google Scholar]
  • 96. Ham WHW, Schoonhoven L, Schuurmans MJ, Leenen LPH. Pressure ulcers, indentation marks and pain from cervical spine immobilization with extrication collars and headblocks: an observational study. Injury. 2016;47:1924–1931. [DOI] [PubMed] [Google Scholar]
  • 97. Horvath KA, Acker MA, Chang H, et al. Blood transfusion and infection after cardiac surgery. Ann Thorac Surg. 2013;95:2194–2201. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 98. Oliveira RA, Turrini RNT, Poveda VB. Risk factors for development of surgical site infections among liver transplantation recipients: an integrative literature review. Am J Infect Control. 2018;46:88–93. doi:10.1016/j.ajic.2017.05.021 [DOI] [PubMed] [Google Scholar]
  • 99. Raghavan M, Marik PE. Anemia, allogenic blood transfusion, and immunomodulation in the critically ill. Chest. 2005;127:295–307. [DOI] [PubMed] [Google Scholar]
  • 100. Vamvakas EC, Blajchman MA. Transfusion-related mortality: the ongoing risks of allogeneic blood transfusion and the available strategies for their prevention. Blood. 2009;113:3406–3417. [DOI] [PubMed] [Google Scholar]
  • 101. Nunez-Pereira S, Pellise F, Rodriguez-Pardo D, et al. Individualized antibiotic prophylaxis reduces surgical site infections by gram-negative bacteria in instrumented spinal surgery. Eur Spine J. 2011;20(suppl 3):397–402. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 102. Chenoweth CE, Saint S. Urinary tract infections. Infect Dis Clin North Am. 2016;30:869–885. [DOI] [PubMed] [Google Scholar]
  • 103. Andersson AE, Bergh I, Karlsson J, Eriksson BI, Nilsson K. Traffic flow in the operating room: an explorative and descriptive study on air quality during orthopedic trauma implant surgery. Am J Infect Control. 2012. 40:750–755. [DOI] [PubMed] [Google Scholar]
  • 104. Straub JM, New J, Hamilton CD, Lominska C, Shnayder Y, Thomas SM. Radiation-induced fibrosis: mechanisms and implications for therapy. J Cancer Res Clin Oncol. 2015;141:1984–1994. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 105. Reynolds L, Beckmann J, Kurz A. Perioperative complications of hypothermia. Best Pract Res Clin Anaesthesiol. 2008;22:645–657. [DOI] [PubMed] [Google Scholar]

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