- Department of Neurosurgery, RUSH University Medical Center Chicago, IL, USA
Correspondence Address:
Vincent C. Traynelis
Department of Neurosurgery, RUSH University Medical Center Chicago, IL, USA
DOI:10.4103/2152-7806.120783
Copyright: © 2013 Kasliwal MK. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.How to cite this article: Kasliwal MK, Tan LA, Traynelis VC. Infection with spinal instrumentation: Review of pathogenesis, diagnosis, prevention, and management. Surg Neurol Int 29-Oct-2013;4:
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Abstract
Background:Instrumentation has become an integral component in the management of various spinal pathologies. The rate of infection varies from 2% to 20% of all instrumented spinal procedures. Every occurrence produces patient morbidity, which may adversely affect long-term outcome and increases health care costs.
Methods:A comprehensive review of the literature from 1990 to 2012 was performed utilizing PubMed and several key words: Infection, spine, instrumentation, implant, management, and biofilms. Articles that provided a current review of the pathogenesis, diagnosis, prevention, and management of instrumented spinal infections over the years were reviewed.
Results:There are multiple risk factors for postoperative spinal infections. Infections in the setting of instrumentation are more difficult to diagnose and treat due to biofilm. Infections may be early or delayed. C Reactive Protein (CRP) and Magnetic Resonance Imaging (MRI) are important diagnostic tools. Optimal results are obtained with surgical debridement followed by parenteral antibiotics. Removal or replacement of hardware should be considered in delayed infections.
Conclusions:An improved understanding of the role of biofilm and the development of newer spinal implants has provided insight in the pathogenesis and management of infected spinal implants. This literature review highlights the mechanism, pathogenesis, prevention, and management of infection after spinal instrumentation. It is important to accurately identify and treat postoperative spinal infections. The treatment is often multimodal and prolonged.
Keywords: Biofilm, infection, instrumentation, spinal surgery
INTRODUCTION
Instrumentation, now an integral component in the treatment of numerous spinal pathologies, is correlated with a 2-20% infection rate. The ability to manage postoperative wound infections has become, therefore, more critical and challenging, as they are positively associated with extended hospitalizations, increased morbidity and healthcare costs, poorer long-term outcomes, and greater dissatisfaction with the initial operative procedure.
Nevertheless, there are no universally accepted protocols for treating deep wound infections utilizing spinal instrumentation. Traditionally, it was thought that spinal instrumentation can act as a locus minoris resistentiae for bacteria and therefore explanation of the hardware was critical. However, more current practices vary in terms of the need for implant removal. This manuscript reviews the mechanism, pathogenesis, prevention, and management of infection following the application of spinal instrumentation, and reports on how biofilms impact these infections.
COMPREHENSIVE LITERATURE REVIEW OF INSTRUMENTED SPINAL INFECTIONS
A comprehensive review of the literature from 1990 to 2012 was performed utilizing PubMed and several key words: Infection, spine, instrumentation, implant, management and biofilms. Current articles that reviewed the pathogenesis, diagnosis, prevention and management of instrumented spinal infections were identified.
Epidemiology and risk factors for spinal infections
The incidence of surgical site infections (SSIs) after adult spine surgery varies from 0.7% to 20% [
The risk of intraoperative/postoperative infection is increased by utilizing a posterior surgical approach, applying instrumentation, using allograft, requiring a blood transfusion, and longer operations. The utilization of intraoperative equipment (e.g., surgical microscopes, fluoroscopy, intraoperative computed tomography [CT]) also increases the risk of infection through breaches in sterile technique. Additional strict adherence to proper postoperative wound care is also critical in minimizing the risk of postoperative wound infections.[
Surgical factors contributing to spinal infections
Multiple factors increase the rates of infection following spinal surgery.[
Attributes of closed suction drainage to limit spinal infections
The use of closed suction drainage is thought to lower the risk of SSI as even small postoperative hematomas can provide a medium for bacterial overgrowth. Although routine postoperative drainage of spinal wounds does not uniformly decrease the incidence of early postoperative spinal infections, Ho et al. established that the failure to drain wounds correlates with a significantly higher risk of delayed spinal infections.[
Increased infection risk with posterior spinal instrumentation
A well-recognized risk factor for the development of postoperative spinal wound infections is the utilization of posterior instrumentation. However, this finding is largely based on suboptimal retrospective analyses; only two studies actually document a clear, statistically significant increase in infection rates associated with the use of spinal instrumentation.[
Lesser risk of infection with anterior spinal instrumentation
In contrast, anterior spinal exposures are correlated with a reduced risk of infection as exposures typically traverse relatively avascular tissue planes, and avoid significant muscle dissection.[
Risk of infection may vary with type of implant and susceptibility to biofilm
The risk of infection may also vary with the type of implant due to an increased susceptibility to the development of biofilm.[
Nonsurgical factors increase the rate of postoperative spinal infections
There are multiple nonsurgical issues that appear to increase the rate of postoperative spinal infections. Olsen et al. performed a multivariate analysis involving 2316 spinal procedures and found that the following variables significantly increased the likelihood of postoperative infections; diabetes, suboptimal timing of prophylactic antibiotic therapy, elevated pre-or postoperative serum glucose levels, obesity, and two or more residents on a case.[
Timing of administration of preoperative antibiotics increases postoperative infection risk
The timing of administration of preoperative antibiotics is strongly correlated with an increased risk of postoperative infection. Ideally, preoperative prophylactic antibiotics should be administered within an hour of surgery (e.g., cephalosporin except in penicillin allergic patients); administration up to 15 minutes prior to the incision may be even more effective.[
Postoperative incontinence increases postoperative infection rate
Postoperative incontinence following laminectomy and/or fusion has also been reported to be independently associated with increased risk of postoperative infection.[
Spinal surgery for tumor resection increases spinal infection risk
Spinal surgery for tumor resection is also independently associated with an increased risk of postoperative infection.[
Early postoperative spinal infections
Definition of early spinal infections
Early infections, defined as those occurring within a month of surgery, are attributed to the intraoperative inoculation of the surgical wound with the microorganism. They typically become evident within 2-3 weeks of surgery.
Symptoms and signs of early postoperative spinal wound infections
The signs and symptoms of early postoperative spinal wound infections may include pain, fever, erythema, swelling, warmth, tenderness, and wound drainage. Pain may herald the development of infection particularly when it is escalating in nature. Fever is an unreliable parameter, and often absent. Wound drainage is common for both superficial or deep SSI, and may be present in up to 90% of patients.[
Virulent pathogens responsible for early postoperative spinal infections
Early postoperative spinal infections are most frequently due to relatively virulent pathogens such as Staphylococcus aureus, beta-hemolytic streptococci, and aerobic Gram-negative bacilli. Staphylococcus aureus is the most common bacteria responsible for early postoperative infection after spinal surgery.[
There has been an increase in the frequency of infections caused by Gram-negative bacteria, and other organisms such as Pseudomonas aeruginosa, Escherichia coli, Enterobacter, and Acinetobacter.[
Delayed infections
Although there is no standardized definition for delayed or chronic postoperative spinal infections, many studies have defined these as occurring between 10 days to more than a year after the index procedure/surgery.[
Majority of delayed instrumented spinal infections (0.2-6.9%) Occur in scoliosis patients
The majority of delayed infections following instrumented spinal fusions (range 0.2-6.9%) occur following scoliosis surgery.[
Delayed infections are often culture negative vs. Early infections
Delayed infections are more often culture negative vs. early infections because as they are frequently caused by less virulent pathogens (e.g., Propionibacterium acnes, coagulase negative Staphylococcus epidermidis, bacillus, and micrococcus species).[
Biofilm
Certain bacteria can adhere to the surface of implants to form a biofilm, defined as a microbial derived sessile community characterized by cells that are embedded in a matrix of extracellular polymeric substances, which they produce.[
Common organisms have predilection for forming biofilm
Unfortunately the common organisms implicated in postoperative infections after spinal instrumentation like S. aureus, coagulase negative Staphylococcus and Propionibacterium, have a predilection for biofilm formation.[
Implant materials exhibit variable susceptibility to biofilm
Implants vary in their susceptibility to the development of biofilm. Bacterial adherence to the implant, a prerequisite for biofilm formation, was studied in vitro by Schildhauer et al.[
Biofilm makes identification of causative infectious organism difficult
Biofilm can increase the difficulty of identifying the causative infectious organism. Analysis of nonspinal prosthetic infections with suspected biofilm show that multiple cultures of peri-implant tissue may not be accurate, and can result in missed diagnoses.[
Age of biofilm influences susceptibility to antibiotics
The age of the biofilm influences the susceptibility of instrumented fusions to antimicrobial therapy.[
Potential future role of antimicrobial coated implants against formation of biofilms
As the role of biofilms has been increasingly recognized in implant-related infections, strategies to prevent bacterial adherence and subsequent biofilm formation are being developed and hold promise. Antimicrobial coated implants represent a potential advance, but many factors need to be addressed before this strategy is applicable to the clinic.[
Prevention of spinal implant infection
Perioperative antimicrobial agents utilized to limit infection of spinal implants
Identification of multiple risk factors that contribute to infections following instrumented spinal fusions helps decrease the infection risk. Barker et al.'s meta-analysis (utilizing pooled data from six randomized control trials [RCTs]) documented a lower incidence of infection following spinal surgery utilizing antibiotic prophylaxis (Odds ratio, 0.37, 95% CI 0.17-0.78, P < 0.01).[
Other intraoperative adjunctive measures to prevent infection of spinal implants
Little has been published on other adjunctive measures utilized to prevent postoperative SSIs in spinal surgery. The “no shaving” data for spinal and other procedures and the use of sophisticated air filtering systems have been positive.[
There were no sound data, other than provided by Ho et al., to support the benefit of closed suction drainage to prevent acute postoperative surgical-site infection after spine surgery.[
Diagnosis of superficial vs. Deep spinal infection
Infections following instrumented spinal fusions can be superficial or deep. By definition, superficial infections are confined to the dermis and subcutaneous tissue, while deep infections are those occurring below the fascia.[
Laboratory evaluation of infected spinal instrumentation
Laboratory studies are an important part of the evaluation of infected spinal implants. Erythrocyte sedimentation rate (ESR), C reactive protein (CRP), and total leukocyte count (TLC) are routinely ordered when there is a suspicion of a postoperative infection.[
Diagnostic imaging of infected spinal implants
Plain radiography, CT, and magnetic resonance imaging (MRI) are routinely ordered when an infection is suspected. Early implant loosening, rapid loss of adjacent level disc height, and abnormal soft tissue swelling are indirect markers of infection on plain X-rays, but are often not seen until a few weeks after the onset of infection. CT delineates hardware position and bony changes more accurately than plain radiographs, and CT also shows fluid collections, it is not as sensitive to infection as MRI.
MRI scans with/without contrast: Great value in diagnosing infection
MRI scans without and with contrast are of great value in diagnosing discitis, osteomyelitis, and epidural abscesses after spinal surgery. However, it is not often possible to distinguish a sterile seroma from a purulent collection (e.g., differentiation between postoperative changes and infection) utilizing early contrast enhanced CT or MRI studies following the implantation of spinal instrumentation.[
Radionuclide imaging not primary choice for diagnosing postoperative spinal infections
The use of radionuclide imaging is not a primary imaging modality for diagnosing postoperative spinal infections as recent surgery can result in positive studies even when no infection is present. However, an early negative radionuclide scan may indicate that an infection is not likely present. Alternatively, these scans may prove an effective diagnostic technique for diagnosing delayed infections.
Radionuclide tracer imaging of infected spinal implants
Bone scintigraphy utilizing multiple radionuclide tracers
There are several means by which the skeleton may be imaged using radionuclide tracers. Bone scintigraphy is most commonly performed using technetium-99m (Tc-99m) methylene diphosphate (MDP). Three-phase imaging is the radionuclide procedure of choice for evaluating osteomyelitis in bone not affected by any underlying condition. This tracer binds to the hydroxyapetite crystal; uptake is a function of blood flow, and the rate of new bone formation. There is a dynamic sequence (e.g., the flow or perfusion phase), followed immediately by the acquisition of static images of the region of interest (e.g., the blood pool or soft tissue phase). The final phase consists of static images of the region of interest obtained 2-4 hours after the initial injection of the tracer. Focal hyperperfusion and hyperemia with increased delayed bony uptake is diagnostic for osteomyelitis. Recent surgery or the presence of hardware may result in a false positive three phase scan.[
Gallium-67 citrate used to localize spinal infections
Gallium-67 citrate (Ga-67) has been used to localize spinal infections for many decades. Within 24 hours, 25% of the radionuclide is excreted by the kidneys; further excretion occurs via the large intestine. Two to three days after the injection, 75% of the tracer is still in the body where it is equally distributed in the liver, soft tissues, and bone.
Utilizing gallium-67 and bone scintigraphy to diagnose osteomyelitis
Gallium accumulates at sites of infection or inflammation via a variety of mechanisms, and osteomyelitis is usually diagnosed by combining Ga-67 with bone scintigraphy.[
Labeled leukocyte imaging of spinal infections
Labeled leukocyte imaging represents a significant advance in the ability to detect spinal infections. The uptake of labeled cells depends on several variables; intact chemotaxis, the number and type of cell labeled, and the cellular response to the infection. A total white blood cell count of 2000/mL is required to obtain satisfactory images. Usually the majority of the labeled cells are neutrophils. However, this technique is less sensitive for processes in which the predominant cellular response is not neutrophilic (e.g., tuberculosis).[
Fluorine-18 fluorodeoxyglucose-positron emission tomography utilized to diagnose spinal infections
Fluorine-18 (F-18) fluorodeoxyglucose-positron emission tomography (FDG-PET) may also be used to identify spinal infections. However, this technology is expensive and requires sophisticated equipment thus making it not widely available. Similar to radionuclide studies, the utility of FDG-PET is limited in the acute postoperative setting, but is useful for establishing the diagnosis of delayed infections surrounding instrumentation.[
Ultrasound detects postoperative fluid collections and helps guide fluid aspiration
Although ultrasonography can detect postoperative fluid collections, it cannot determine whether these represent noninfectious vs. infectious processes (e.g., sonomorphological criteria such as internal echo structures, septation, demarcation from the environment, and reaction of the surrounding tissue). Ultrasound is, however, useful in guiding aspiration of fluid collections resulting in a high diagnostic accuracy.[
Management of infections following spinal surgery with instrumentation
The management of infection after spinal instrumentation is controversial, and requires careful consideration of the two most critical variables: The duration of antimicrobial therapy and whether or not the implants should to be removed. Treatment paradigms have evolved greatly over the past 10-15 years, and the present recommendation is to preserve rather than remove the spinal instrumentation in the majority of cases. However, the timing of infection after surgery (e.g., early vs. delayed) can be an important guiding factor determining the management choice.[
Surgical treatment of early deep postoperative infection following instrumented spinal fusion
The surgical treatment of early deep postoperative infection following spinal instrumentation is variable. There is a lack of consensus as to whether to utilize; irrigation/debridement alone, wound vacuums, continuous irrigation systems, antimicrobial beads, whether to revise instrumentation (e.g., instrumentation failure), whether to prophylactically remove instrumentation, and which antibiotic protocol to utilize.[
Presence of biofilm leads to recommendation to remove infected spinal instrumentation
Given the pathogenic role of prostheses-based biofilm, most infectious disease physicians now recommend removal of the underlying spinal instrumentation.[
A key factor in deciding whether or not to remove spinal instrumentation relates to biofilm. In vitro laboratory investigations document that biofilms may develop within 5-6 hours after bacterial inoculation, and the age of the biofilm has major clinical implications related to its tenaciousness and antimicrobial susceptibility.[
Delayed wound infections often require instrumentation removal/replacement
Although acute infections may be adequately treated by surgical debridement and antimicrobial therapy, the development of a delayed wound infection often requires removal or replacement of the instrumentation.[
More morbidity with retention of spinal instrumentation after delayed infection
Retention of spinal instrumentation after delayed infection is fraught with more morbidity and less success. Ho et al. reported the strong propensity for recurrence of infection (up to 50%) in the absence of implant removal. They found that treating infected retained spinal implants with irrigation and debridement was associated with multiple procedures irrespective of the type of organism and graft.[
Advocacy of prophylactic removal of infected spinal instrumentation
Prophylactic removal of spinal instrumentation is advocated by some authors to minimize the risk of developing infection relapses or if fastidious organisms like Propionibacter are identified.[
General operative treatment
Surgical debridement and irrigation of infected spinal instrumentation
Surgical debridement and irrigation (frequently with a wound drain) have been an important means of treating early postoperative infections following the implantation of spinal instrumentation.[
Antibiotic impregnated beads and suction/irrigation devices utilized to treat infected spinal instrumentation
Glassman et al. described the successful treatment of infection following the implantation of spinal instrumentation by placing antibiotic impregnated beads and utilizing close suction irrigation techniques.[
Vacuum-assisted closure facilitates wound healing and eradicates spinal infections
VAC is a useful adjunct that facilitates wound healing and eradication of complex postoperative bacterial spinal infections.[
Antimicrobial therapy
Duration of antimicrobial therapy
Another unresolved aspect of postoperative infections after spinal instrumentation relates to the duration of pharmacological treatment. It is optimal to base antimicrobial choice on the culture results, and antibiotic sensitivity of the organisms. Although there is general agreement on the need for 6-8 weeks of parental therapy, data addressing the need for and duration of long-term oral suppressive antibiotic therapy are lacking.[
CONCLUSION
It is important to recognize the clinical symptoms and signs of postoperative spinal infections, and confirm the diagnosis with appropriate laboratory and imaging studies. Prompt, aggressive debridement coupled with utilizing the correct antibiotic therapy (typically 6-8 weeks of intravenous antibiotics) and, in some cases, chronic suppressive antibiotic treatment (e.g., for up to 1 year), have yielded the most successful results. Instrumentation can usually be preserved in patients with early infections (e.g., <6 weeks), but instrumentation removal should be considered for infections presenting in a delayed fashion (e.g., >6 weeks to even years). Patients should be adequately followed for one postoperative year, to ensure that the infection has been fully eradicated. Emerging techniques are increasingly preventing the formation of biofilm on instrumentation, facilitate the removal of biofilm, and increase the culture yield of biofilms on implant surfaces. For example, implant sonication provides cultures for direct identification of active and/or persistent biofilm, while the introduction of enzymes that dissolve the biofilm matrix (e.g., DNase and alginate lyase) and quorum-sensing inhibitors that increase biofilm susceptibility to antibiotics may further help manage postoperative infection. These and other techniques may further enhance the potential for successfully salvaging instrumentation, while eradicating spinal infections. Additionally, changes in antibiotic prophylaxis to prevent postoperative infections following spinal instrumentation remain active areas for further investigation.
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