Review Question - QID 717

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Degenerative Spondylolisthesis Complications Surgical site infection (0.1-2%) QID: 717 (OBQ07.56)

QID 717 (Type "717" in App Search)

A 47-year-old male underwent L4-5 posterior lumbar decompression and fusion with instrumentation. During the six-week clinical visit, he complains of pain in the region of his wound. On physical exam, there is wound erythema but no exudate. Laboratory studies show an erythrocyte sedimentation rate of 78 mm/h (normal up to 20 mm/h) and WBC count of 11,200/mm3 (normal 3,500 to 10,500/mm3). An MRI is performed and shows a fluid collection dorsal to the thecal sac. What is the most appropriate next step in management?

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CT guided aspiration of the fluid collection and cultures

27%

976/3651

Surgical debridement followed by delayed closure and retention of instrumentation

64%

2325/3651

Surgical debridement followed by delayed closure and removal of instrumentation

142/3651

Parenteral Cephalexin for 10 days followed by repeat laboratory studies

74/3651

Broad spectrum intravenous antibiotics for 6 weeks followed by repeat laboratory studies

108/3651

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The clinical presentation is consistent with a postoperative spinal wound infection. Treatment should include surgical debridement with retention of hardware. Unless there is gross motion, hardware should be retained as stability promotes fusion and aids in the eradication of infection by promoting angiogenesis.

Weinstein et al. found the infection rate was 1.9% and the most common organism was Staphylococcus aureus. Infection was more common in patients undergoing fusion with instrumentation and in patients with cancer metastatic to the spine. Their final recommendations for postoperative wound infections in patients with lumbar instrumentation included an aggressive surgical approach with repeated debridement followed by delayed closure. They report instrumentation may be safely left in situ to provide stability for fusion.

Rayes et al. found that despite the presence of active infection, instrumentation after radical debridement will not increase the risk of recurrent infection. In fact, they suggest greater benefit can be achieved through spinal stabilization, which can even promote accelerated healing.

Mok et al. found in patients with postoperative lumbar wound infection, if patients are treated with early irrigation, debridement, and retention of hardware they can expect a medium-term clinical outcome similar to patients in whom infection did not occur.