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Impact of Irrigation and Debridement on Interbody Fusion Rate following Index Lumbar Spine Surgery
NASS 31st Annual Meeting Proceedings / The Spine Journal 16 (2016) S251–S337 3.35 mm dorsal to the anterior margin of the spine, respectively. From the least to most stiff plate, the strain in the posterior elements as a result of extension was 93.2 microstrain, 105.7 microstrain and 115.3 microstrain. CONCLUSIONS: Results indicate that plates of different bending stiffness change the distribution and magnitude of spinal loading and modulate the location of the IAR. Increasing plate stiffness caused decreasing interbody loading but increased posterior element loading. This occurs likely as a result of an IAR located more anteriorly (and thus a longer fulcrum) with increasing plate stiffness. Plate stiffness can alter spine kinematics and therefore the distribution of loads. This suggests that spinal load distribution and kinematics after spinal arthrodesis can be controlled through plate design. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. http://dx.doi.org/10.1016/j.spinee.2016.07.349
P25. Impact of Irrigation and Debridement on Interbody Fusion Rate following Index Lumbar Spine Surgery Timothy Y. Wang1, Oren N. Gottfried, MD2; 1Duke University Medical Center, Durham, NC, USA; 2Duke University, Durham, NC, USA BACKGROUND CONTEXT: Surgical site infection (SSI) is not an uncommon complication after lumbar fusion and is associated with morbidity and need for increased care including antibiotics and surgical debridement. The impact on spinal arthrodesis from graft removal during debridement and inflammatory response from the infection are not well described. PURPOSE: We sought to identify the rate of pseudarthrosis following surgical debridement for deep lumbar spine SSI and identify associated risk factors. STUDY DESIGN/SETTING: Retrospective review. PATIENT SAMPLE: Patients who underwent index lumbar fusion surgery at Duke University from 2013–2014 were included if they met the following criteria: 1) age >18 years, 2) had debridement of deep lumbar SSI, and had 3) lumbar spine AP and flexion/extension x-rays and computed tomography (CT) at 12 months or greater postoperatively. OUTCOME MEASURES: Incidence of arthrodesis at greater than one year from index surgery. METHODS: Demographic data, comorbidities, pre-, peri- and postoperative data, details of debridement, and culture results were recorded. The imaging above were used to determine which patients had achieved complete fusion. Criteria for fusion included: 1) solid posterolateral, facet, or disc space bridging bone, 2) no translational or angular motion on flexion/ extension x-rays, and 3) intact posterior hardware without evidence of screw lucency or breakage. All collected data were compared between patients who achieved fusion and those who did not. RESULTS: A total of 25 patients (age 63.2±12.6 years, 10 male) involving 58 spinal levels met inclusion criteria. They underwent fusion at a mean of 2.32 (range: 1–4) spine levels. Sixteen (64%) patients received interbody grafts at a total of 34 (58.6%) spinal levels. Fifteen patients were obese (BMI>30), 7 had type II diabetes mellitus, 2 were active smokers and 5 had osteoporosis, with no significant differences in any comorbidities between fusion and pseudoarthrosis groups. All underwent surgical debridement with removal of all nonincorporated posterior bone graft and devascularized tissue, pulse lavage with antibiotic and drain placement. Intraoperative and postoperative antibiotic regimen did not significantly differ between groups. Five patients required a second washout, no patients required hardware removal, and no patients showed persistent or chronic infections at final radiological and clinic follow-up. At follow-up imaging, 14 (56%) patients and 30 (52%) spinal levels demonstrated radiographic evidence of successful fusion. While use of interbody cage during initial fusion was significantly associated with successful arthrodesis at follow-up (76.7% vs 39.3%, p=.017), no other surgical factors including extent of decompression impacted arthrodesis.
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Culture results confirmed staphylococcus aureus (48%) as the most common agents of infection, and there was no significant difference between type of bacteria and arthrodesis. CONCLUSIONS: There is a high rate of pseudarthrosis in 44% of patients (48% of levels) undergoing lumbar fusion surgery complicated by SSI requiring debridement. Use of interbody cage during initial fusion was significantly associated with higher rate of arthrodesis likely from the retained and protected bone graft not removed at debridement as well as increased stability. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. http://dx.doi.org/10.1016/j.spinee.2016.07.350
P26. Reduction in Wound Complications and Revision Surgery with Plastic Surgery Closure in the Treatment of Neuromuscular Scoliosis Brandon W. Cook, MD1, David C. Briski, MD2, Joseph M. Zavatsky, MD3; 1 Ochsner Foundation Clinic, Jefferson, LA, USA; 2Ochsner Medical Center, Jefferson, LA, USA; 3Spine & Scoliosis Specialists, Tampa, FL, USA BACKGROUND CONTEXT: Postoperative infections after posterior spinal fusion (PSF) surgery can be potentially devastating. Infection rates after PSF has been reported as high as 23% in neuromuscular scoliosis (NMS) patients. A multilayered plastic surgery closure can decrease potential dead space and better protect spinal instrumentation. We compared surgically treated neuromuscular scoliosis patients with and without plastic surgery wound closure. PURPOSE: We sought to compare a plastic surgery multilayer wound closure with advancement flaps compared to standard closure to evaluate a decrease in wound complications, deep space infections, and revision surgery. We hypothesize that plastics closure will decrease dead space and protect the spinal instrumentation reducing rates of wound complications. STUDY DESIGN/SETTING: Multicenter retrospective review. PATIENT SAMPLE: Fifty patients met inclusion criteria for the database, of which 39 had complete data and met inclusion criteria. OUTCOME MEASURES: Radiographic Cobb, deep space infections and revision surgery. METHODS: All NMS patients treated with PSF from 2008 to 2014 with 2-year follow-up and completed charts were reviewed. Patients were categorized into 2 Groups: Group 1 [Plastic Closure (PC)]; included patients with a multilayered closure and advancement flaps when necessary; Group 2–Standard Closure (SC). Differences in demographic, radiographic and clinical parameters were analyzed. RESULTS: Fifty patients met inclusion criteria for the database, of which 39 had complete 2-year data. Group 1 had 11 patients, each having a multilayered plastic surgery wound closure. Group 2 included 28 patients who had a standard wound closure. There was no difference in age, male gender, number of levels fused or postoperative max coronal Cobb angles between the Groups (Table 1). There was a significant difference in deep space infections (0 vs 7, p=.0057), revision surgeries (0 vs 7, p=.0057), EBL (2425 vs 644 cc, p=1.46E-06), OR time (467 vs 245 min, p=1.97E08), iliac screw fixation (58% v. 21%, p=.022) and preoperative max coronal Cobb angle (58.29 vs 71.99°, p=.043) in the PC vs SC Groups, respectively. CONCLUSIONS: Even with associated risk factors for infection including increased EBL, OR time and iliac screw fixation, the PC Group had significantly less deep space infections and revision surgeries. Utilizing a plastic surgery closure can reduce dead space and provide better softtissue coverage of the spinal instrumentation reducing deep space infections and revision surgery. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. http://dx.doi.org/10.1016/j.spinee.2016.07.351
Refer to onsite annual meeting presentations and postmeeting proceedings for possible referenced figures and tables. Authors are responsible for accurately reporting disclosure and FDA device/drug status at time of abstract submission.
P25. Impact of Irrigation and Debridement on Interbody Fusion Rate following Index Lumbar Spine Surgery Timothy Y. Wang1, Oren N. Gottfried, MD2; 1Duke University Medical Center, Durham, NC, USA; 2Duke University, Durham, NC, USA BACKGROUND CONTEXT: Surgical site infection (SSI) is not an uncommon complication after lumbar fusion and is associated with morbidity and need for increased care including antibiotics and surgical debridement. The impact on spinal arthrodesis from graft removal during debridement and inflammatory response from the infection are not well described. PURPOSE: We sought to identify the rate of pseudarthrosis following surgical debridement for deep lumbar spine SSI and identify associated risk factors. STUDY DESIGN/SETTING: Retrospective review. PATIENT SAMPLE: Patients who underwent index lumbar fusion surgery at Duke University from 2013–2014 were included if they met the following criteria: 1) age >18 years, 2) had debridement of deep lumbar SSI, and had 3) lumbar spine AP and flexion/extension x-rays and computed tomography (CT) at 12 months or greater postoperatively. OUTCOME MEASURES: Incidence of arthrodesis at greater than one year from index surgery. METHODS: Demographic data, comorbidities, pre-, peri- and postoperative data, details of debridement, and culture results were recorded. The imaging above were used to determine which patients had achieved complete fusion. Criteria for fusion included: 1) solid posterolateral, facet, or disc space bridging bone, 2) no translational or angular motion on flexion/ extension x-rays, and 3) intact posterior hardware without evidence of screw lucency or breakage. All collected data were compared between patients who achieved fusion and those who did not. RESULTS: A total of 25 patients (age 63.2±12.6 years, 10 male) involving 58 spinal levels met inclusion criteria. They underwent fusion at a mean of 2.32 (range: 1–4) spine levels. Sixteen (64%) patients received interbody grafts at a total of 34 (58.6%) spinal levels. Fifteen patients were obese (BMI>30), 7 had type II diabetes mellitus, 2 were active smokers and 5 had osteoporosis, with no significant differences in any comorbidities between fusion and pseudoarthrosis groups. All underwent surgical debridement with removal of all nonincorporated posterior bone graft and devascularized tissue, pulse lavage with antibiotic and drain placement. Intraoperative and postoperative antibiotic regimen did not significantly differ between groups. Five patients required a second washout, no patients required hardware removal, and no patients showed persistent or chronic infections at final radiological and clinic follow-up. At follow-up imaging, 14 (56%) patients and 30 (52%) spinal levels demonstrated radiographic evidence of successful fusion. While use of interbody cage during initial fusion was significantly associated with successful arthrodesis at follow-up (76.7% vs 39.3%, p=.017), no other surgical factors including extent of decompression impacted arthrodesis.
S261
Culture results confirmed staphylococcus aureus (48%) as the most common agents of infection, and there was no significant difference between type of bacteria and arthrodesis. CONCLUSIONS: There is a high rate of pseudarthrosis in 44% of patients (48% of levels) undergoing lumbar fusion surgery complicated by SSI requiring debridement. Use of interbody cage during initial fusion was significantly associated with higher rate of arthrodesis likely from the retained and protected bone graft not removed at debridement as well as increased stability. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. http://dx.doi.org/10.1016/j.spinee.2016.07.350
P26. Reduction in Wound Complications and Revision Surgery with Plastic Surgery Closure in the Treatment of Neuromuscular Scoliosis Brandon W. Cook, MD1, David C. Briski, MD2, Joseph M. Zavatsky, MD3; 1 Ochsner Foundation Clinic, Jefferson, LA, USA; 2Ochsner Medical Center, Jefferson, LA, USA; 3Spine & Scoliosis Specialists, Tampa, FL, USA BACKGROUND CONTEXT: Postoperative infections after posterior spinal fusion (PSF) surgery can be potentially devastating. Infection rates after PSF has been reported as high as 23% in neuromuscular scoliosis (NMS) patients. A multilayered plastic surgery closure can decrease potential dead space and better protect spinal instrumentation. We compared surgically treated neuromuscular scoliosis patients with and without plastic surgery wound closure. PURPOSE: We sought to compare a plastic surgery multilayer wound closure with advancement flaps compared to standard closure to evaluate a decrease in wound complications, deep space infections, and revision surgery. We hypothesize that plastics closure will decrease dead space and protect the spinal instrumentation reducing rates of wound complications. STUDY DESIGN/SETTING: Multicenter retrospective review. PATIENT SAMPLE: Fifty patients met inclusion criteria for the database, of which 39 had complete data and met inclusion criteria. OUTCOME MEASURES: Radiographic Cobb, deep space infections and revision surgery. METHODS: All NMS patients treated with PSF from 2008 to 2014 with 2-year follow-up and completed charts were reviewed. Patients were categorized into 2 Groups: Group 1 [Plastic Closure (PC)]; included patients with a multilayered closure and advancement flaps when necessary; Group 2–Standard Closure (SC). Differences in demographic, radiographic and clinical parameters were analyzed. RESULTS: Fifty patients met inclusion criteria for the database, of which 39 had complete 2-year data. Group 1 had 11 patients, each having a multilayered plastic surgery wound closure. Group 2 included 28 patients who had a standard wound closure. There was no difference in age, male gender, number of levels fused or postoperative max coronal Cobb angles between the Groups (Table 1). There was a significant difference in deep space infections (0 vs 7, p=.0057), revision surgeries (0 vs 7, p=.0057), EBL (2425 vs 644 cc, p=1.46E-06), OR time (467 vs 245 min, p=1.97E08), iliac screw fixation (58% v. 21%, p=.022) and preoperative max coronal Cobb angle (58.29 vs 71.99°, p=.043) in the PC vs SC Groups, respectively. CONCLUSIONS: Even with associated risk factors for infection including increased EBL, OR time and iliac screw fixation, the PC Group had significantly less deep space infections and revision surgeries. Utilizing a plastic surgery closure can reduce dead space and provide better softtissue coverage of the spinal instrumentation reducing deep space infections and revision surgery. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. http://dx.doi.org/10.1016/j.spinee.2016.07.351
Refer to onsite annual meeting presentations and postmeeting proceedings for possible referenced figures and tables. Authors are responsible for accurately reporting disclosure and FDA device/drug status at time of abstract submission.