Antibiotic prophylaxis in high-risk pediatric spine surgery: Is cefazolin enough?

STUDY DESIGN: Retrospective study. OBJECTIVE: To describe pathogens found in SSI during pediatric-instrumented spine surgery, and to assess the relationship between pathogens and the etiology of the spinal deformity. Surgical site infection (SSI) after pediatric spine fusion is a well-known complication with incidence rates between 0.5 and 42%, associated with the patient underlying disorder. Pathogens involved in SSI seem to be related to patient characteristics, such as the etiology of the spinal deformity. GNB (gram-negative bacilli) are more frequent in neuropathic, muscular, and syndromic conditions. High-risk pediatric patients with a spine deformity undergoing instrumented surgery might benefit from receiving perioperative intravenous prophylaxis for GNB. METHODS: We conducted a retrospective study at our tertiary-care pediatric hospital from January 2010 to January 2017. We reviewed records of all episodes of SSI that occurred in the first 12 months postoperatively. All patients who underwent instrumented spine surgery were included in this study. RESULTS: We assessed 1410 pediatric-instrumented spine surgeries; we identified 68 patients with deep SSIs, overall rate of 4.8%. Mean age at instrumented spine surgery was 12 years and 9 months. Time elapsed between instrumented surgery and debridement surgery was 28.8 days. Cultures were positive in 48 and negative in 20. Of the 48 positive culture results, 41 (72%) were GNB, 12 (21%) gram-positive cocci (GPC), three (5%) gram-positive anaerobic cocci (GPAC), and one (2%) coagulase-negative staphylococci (CoNS). Of the 68 patients with primary SSIs, 46 were considered to have a high risk of infection, which reported GNB in 81%, GPC in 15%, GPAC in 2%, and CoNS in 2%. CONCLUSION: Cefazolin prophylaxis covers GPC and CoNS, but GNB with unreliable effectiveness. Gram-negative pathogens are increasingly reported in SSIs in high-risk patients. Adding prophylaxis for GNB in high-risk patients should be taken into account when considering spine surgery. LEVEL OF EVIDENCE: IV.

Proximal junction kyphosis after posterior spinal fusion for early-onset scoliosis.

STUDY DESIGN: Retrospective study. OBJECTIVE: The aim of this study was to assess the presence of proximal junctional kyphosis (PJK) in our population of children with early-onset scoliosis (EOS) and to identify the predisposing factors for the development of PJK in the postoperative period after posterior spinal fusion (PSF). Few studies have been conducted to evaluate the incidence of proximal junction kyphosis (PJK) in children after early-onset scoliosis (EOS) after posterior spinal fusion (PSF). MATERIALS AND METHODS: Overall, 114 pediatric patients aged < 10 years who underwent surgery for scoliosis or kyphoscoliosis at a single center between 2013 and 2015 were evaluated. Forty-five patients submitted to PSF of five or more levels met the inclusion criteria. The sample included 12 female and 10 male patients. Mean age at surgery was 7 years and 8 months. RESULTS: PJK was observed in 22 patients (48.9%). Overall, the mean proximal junctional angle at 12 and 36 months was 17.1° and 22°, respectively. The uppermost instrumented vertebra (UIV) with the highest PJK rate was T6-T7. The lowest instrumented vertebra (LIV) with the highest PJK rate was L2. Etiology was idiopathic in 4, neuromuscular in 11, congenital in 14, and syndromic in 16. According to underlying disorder, prevalence of PJK was 78% in those with a congenital, 50% in those with a syndromic, 12% in those with idiopathic, and 9% in those with a neuromuscular EOS. Surgical revision rate was 4% (one patient). Mean postoperative follow-up was of 3 years and 4 months (range 3-4 years and 1 month). CONCLUSION: Congenital and syndromic etiology, but not age at PJK onset or sex of the patient, significantly affected the incidence rate of PJK. The UIV with the highest PJK rate was T6-T7 and the LIV with the highest PJK rate was L2. The patients had a low surgical revision rate. LEVEL OF EVIDENCE: Level IV.