Abstract

BackgroundIn this short review/perspective, we asked what the frequencies would be for both postoperative spinal epidural hematomas (SpEH) and postoperative surgical site infections (SSI) in predominantly posterior lumbar procedures performed with or without the placement of wound drains?

MethodsMany spine surgeons are trained to use wound drains to decrease the risk of postoperative SpEH, despite the potential increased risk of SSI. Alternatively, avoiding drains may increase the risk of SpEH but likely decrease the potential for SSI.

ResultsPerforming predominantly posterior lumbar procedures with or without wound drains resulted in largely comparable frequencies of postoperative spinal epidural hematomas (SpEH; range of 0.10%-0.69%) and postoperative surgical site infections (SSI: range of 0.75%-7.3%). Notably, however, two studies documented that drains increased transfusion requirements, with one study showing a prolongation of the in-hospital length of stay. Critically, these series emphasized the importance of early/emergent diagnosis (i.e., with MR) and surgical treatment of SpEH to minimize residual neurological deficits.

ConclusionHere, we showed that patients undergoing predominantly lumbar spine surgery performed with or without wound drains demonstrated comparable frequencies of postoperative SpEH and SSI. Nevertheless, spine surgeons must assess on a case-by-case basis whether, based on their education, training, and experience, placing a wound drain is appropriate for their particular patient.

Keywords: Drain Placement, Frequency of Infection, Impact of Drains, Incidence Postoperative Spinal Epidural Hematomas (SpEH), Lumbar Spine Surgery, Morbidity, No Drains, Predominant, SSI: Surgical Site Infection, Wound Drain

INTRODUCTION

A question typically raised in spine surgery is whether or not to place a wound drain. Many spine surgeons are taught that drains likely reduce the incidence of postoperative spinal epidural hematomas (SpEH), but potentially increase the risk for surgical site infections (SSI). Alternatively, without a drain, although SSI’s should typically decrease, the incidence of SpEH’s could increase. In this short review/perspective, we asked whether placing or avoiding wound drains would result in different frequencies of SpEH and SSI for patients undergoing predominantly lumbar spine surgery [ Table 1 ].[ 1 - 10 ]

Table 1:

Incidence of Postoperative Spinal Epidural Hematomas (SpEH) and Surgical Site Infections (SSI) in Predominantly Lumbar Spine Surgery.

Similar Rates of Postoperative Spinal Epidural Hematomas (SpEH) and Surgical Site Infections (SSI) With or Without Drains For Predominantly Posterior Lumbar Surgery

Irrespective of whether wound drains were used, multiple series of predominantly posterior lumbar spine operations showed similar frequencies of postoperative spinal epidural hematomas (SpEH: range 0.10%-0.69%) and surgical site infections (SSI: range 0.75% - 7.3%) [ Table 1 ].[ 1 - 4 , 6 , 9 , 10 ] In an analysis of 10 lumbar spine series, Waly et al. (2015) concluded that closed-system (CS) wound drains (WD) vs. no drains did not differentially impact the frequencies of postoperative SpEH (1.1-16.7%) or superficial (1.0-7.3%)/deep (1.0-7.1%) SSI.[ 9 ] Glennie et al. found that the presence or absence of wound drains did not alter the frequency of postoperative SpEH, wound hematomas, or SSI.[ 3 ] Following 15,562 lumbar procedures, Kao et al. documented 25 (0.16%) SpEH requiring reoperations.[ 4 ] For 1333 patients undergoing 1-2 level lumbar laminectomy, Zijlmans et al. (2016) concluded that “routine” subfascial or subcutaneous wound drains did not significantly alter the frequencies of SpEH or SSI; with drains, 2 (0.47%) of 423 patients developed SpEH vs. 0% of 910 patients without drains, while with drains 2 (0.47%) patients developed SSI vs. 8 (0.88%) instances of SSI without wound drains.[ 10 ] Liu et al. (2016) found; “No evidence to support placing closed system drains for posterior spine surgery.”[ 6 ] Djurasovic et al. (2022) and Butler et al. (2022) similarly observed comparable frequencies of SpEH following spinal procedures performed with or without drains.[ 1 , 2 ]

Symptom Onset and Factors Causing/Contributing to Postoperative SpEH

Two studies identified early symptomatic complaints and risk factors causing/contributing to postoperative SpEH [ Table 1 ].[ 2 , 4 ] In Kao et al. (2015) series of 25 (0.16%) SpEH out of 15,562 lumbar operations, typical symptoms of SpEH included; 20 (80%) loss of motor function, 14 (56%) onset of intractable pain, and 19 (76%) instances of saddle anesthesia.[ 4 ] Risk factors likely causing/contributing to SpEH included; preoperative elevated diastolic blood pressures, intraoperative application of Gelfoam (Pfizer, Kalamazoo, Michigan), and increased postoperative drainage. Djurasovic et al. (2022) similarly found patients with SpEH exhibited increased pain, radicular/motor deficits, and sphincter dysfunction; additionally, older age, coagulation deficiencies, and multilevel lumbar laminectomies contributed to SpEH.[ 2 ] Butler et al. (2022) also documented that patients experiencing the onset of SpEH developed increased motor deficits, and more back pain.[ 1 ]

Wound Drains in 2 Spine Series Increase Estimated Blood Loss (EBL)/Transfusion Requirements, and In One Study, Prolonged the Length-of-Stay

Two studies highlighted that placing wound drains for spinal procedures increased estimated blood loss, and transfusion requirements [ Table 1 ].[ 7 , 9 ] For Waly et al. (2015) 10 lumbar series, drains did not change the frequency of SpEH or SSI but did increase transfusion requirements by 3.5-fold.[ 9 ] Reier et al. also found drains did not improve outcomes, but did result in greater blood loss/transfusion requirements while also prolonging the hospital lengths-of-stay.[ 7 ]

With SpEH, Early Diagnosis (i.e., with MR) and Emergent Treatment Critical to Minimize Residual Neurological Deficits

Multiple studies documented that early diagnosis of SpEH with MR scans and emergent treatment were critical to minimize residual neurological deficits/maximize recoveries [ Table 1 ].[ 1 , 3 - 5 ] For Kao et al. 25 patients (0.16%) with SpEH, greater blood loss, multiple levels of laminectomy/fusions, and the timely diagnosis/treatment determined the extent of residual postoperative motor dysfunction.[ 4 ] In France, Leroy et al. (2021) performed a medicolegal analysis of 14 SpEH; in one case, the surgeon failed to operate in a timely fashion, in 2 cases, the nurses failed to alert spine surgeons about the onset of paraparesis, while 11 were considered to be “no fault” of the surgeon.[ 5 ] The authors also highlighted the import of early diagnosis and surgery. Djurasovic et al. (2022) also emphasized the import of emergent appropriate MR studies to diagnose/document SpEH that should be decompressed acutely to improve outcomes.[ 2 ] Butler et al. (2022) similarly concluded that emergent MR scans and surgery enhanced postoperative neurological recovery.[ 1 ]

Postoperative Use of Drains for Spinal Surgery for Did Not Decrease Incidence of SSI

Two series highlighted that placing wound drains for lumbar spine procedures did not impact or alter the risk of SSI [ Table 1 ].[ 7 , 8 ] In their meta-analysis, Tan et al. (2020) observed; “...prophylactic utilization of wound drains for Lumbar Spine Surgery (LSS), Thoracolumbar Fusions (TLF), or Adolescent Idiopathic Scoliosis Surgery (AIS) surgery did not decrease the incidence of postoperative SSI”.[ 8 ] Further, the postoperative continuation of antibiotics for over 48 h or until drains were removed also did not reduce the frequency of SSI. Of interest, Reier et al. (2022) concluded that drains were “overused” in spine surgery and warned they posed a heighted risk for SSI.[ 7 ]

CONCLUSION

In this short review/perspective, we showed that, with or without wound drains, patients undergoing predominantly lumbar spine surgery demonstrated similar frequencies of postoperative SpEH and SSI [ Table 1 ]. Nevertheless, spine surgeons must assess their patients on a case-by-case basis, based on their education, training, and experience, to determine whether or not wound drainage is indicated in their particular patient.

Ethical approval

Institutional Review Board approval is not required.

Declaration of patient consent

Patient’s consent not required as there are no patients in this study.

Financial support and sponsorship

Nil.

Conflict of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

References

1. Butler AJ, Donnally CJ, Goz V, Basques BA, Vaccaro AR, Schroeder GD. Symptomatic postoperative epidural hematoma in the lumbar spine. Clin Spine Surg. 2022. 35: 354-62

2. Djurasovic M, Campion C, Dimar 2nd JR, Glassman SD, Gum JL. Postoperative epidural hematoma. Orthop Clin North Am. 2022. 53: 113-21

3. Glennie RA, Dea N, Street JT. Dressings and drains in posterior spine surgery and their effect on wound complications. J Clin Neurosci. 2015. 22: 1081-7

4. Kao FC, Tsai TT, Chen LH, Lai PL, Fu TS, Niu CC. Symptomatic epidural hematoma after lumbar decompression surgery. Eur Spine J. 2015. 24: 348-57

5. Leroy HA, Portella T, Amouyel T, Bougeard R, Assaker R, Mourier KL. Management of symptomatic postoperative epidural hematoma in spine surgery: Medicolegal implications. Orthop Traumatol Surg Res. 2021. 107: 103024

6. Liu Y, Li Y, Miao J. Wound drains in posterior spinal surgery: A meta-analysis. J Orthop Surg Res. 2016. 11: 16

7. Reier L, Fowler JB, Arshad M, Siddiqi J. Drains in spine surgery for degenerative disc diseases: A literature review to determine its usage. Cureus. 2022. 14: e23129

8. Tan T, Lee H, Huang MS, Rutges J, Marion TE, Mathew J. Prophylactic postoperative measures to minimize surgical site infections in spine surgery: Systematic review and evidence summary. Spine J. 2020. 20: 435-47

9. Waly F, Alzahrani MM, Abduljabbar FH, Landry T, Oellet J, Moran K. The outcome of using closed suction wound drains in patients undergoing lumbar spine surgery: A systematic review. Global Spine J. 2015. 5: 479-85

10. Zijlmans JL, Buis DR, Verbaan D, Vandertop WP. Wound drains in non-complex lumbar surgery: A systematic review. Bone Joint J. 2016. 98: 984-9