Prevalence and Predictors of Pressure Injuries From Spine Surgery in the Prone Position: Do Body Morphological Changes During Deformity Correction Increase the Risks?

MINI: Pressure injuries are prevalent in patients undergoing spine surgery while prone. Multiple risk factors exist and should be addressed. We found that patients undergoing spinal deformity correction surgery are at unique risk (odds ratio 3.31, P = 0.010) due to body morphological changes occurring secondary to intraoperative changes in spinal alignment. STUDY DESIGN: Review of data and prospective study. OBJECTIVE: To investigate the prevalence and predictive factors of pressure injuries in spine surgery performed in the prone position, and to determine whether morphological changes and truncal shifts occurring during deformity correction predispose to this complication. SUMMARY OF BACKGROUND DATA: Spine surgery performed in the prone position presents the risk of developing pressure injuries. This risk is potentially increased in deformity correction, because it tends to involve more extensive procedures, with associated longer operating times. METHODS: Cases of pressure injuries after spine surgery in the prone position were reviewed to ascertain prevalence and determine risk factors. Data including patient factors (age, sex, height, weight, body mass index, American Society of Anesthesiologists grade, comorbidities, Braden scale, neurological status, spinal pathology) and surgical factors (approach, procedure type, number of screws, operated levels, operative time) were collected. Independent risk factors were identified via multivariate analysis. A subsequent prospective analysis of all patients undergoing spinal deformity correction was conducted by performing intraoperative measurements of body morphological changes and shifts in truncal positions. Statistical correlation was performed to determine whether positional shifts cause pressure injuries. RESULTS: The prevalence of pressure injuries was 23.0%. Previous skin problems (P = 0.034), myelopathy (P = 0.013), operative time >300 minutes (P = 0.005), and more than four operated levels (P = 0.006) were independent predictors of pressure injuries. Being a spinal deformity patient was also an independent risk factor for developing pressure injuries (odds ratio 3.31, P = 0.010). Significant changes in body measurements during deformity correction were predictive of pressure injuries. CONCLUSION: Pressure injuries are prevalent in patients undergoing spine surgery while prone. Future studies should investigate strategies to prevent this complication based on the multiple risk factors identified in the present study. Patients undergoing spinal deformity correction surgery are particularly at risk due to intraoperative body morphological changes. Improved padding methods should be trialed in future studies. LEVEL OF EVIDENCE: 3.

Is Intraoperative Local Vancomycin Powder the Answer to Surgical Site Infections in Spine Surgery?

STUDY DESIGN: This is a retrospective cohort comparative study of all patients who underwent instrumented spine surgery at a single institution. OBJECTIVE: To compare the rate of surgical site infection (SSI) between the treatment (vancomycin) and the control group (no vancomycin) in patients undergoing instrumented spine surgery. SUMMARY OF BACKGROUND DATA: SSI after spine surgery is a dreaded complication associated with increased morbidity and mortality. Prophylactic intraoperative local vancomycin powder to the wound has been recently adopted as a strategy to reduce SSI but results have been variable. METHODS: In the present study, there were 117 (30%) patients in the treatment group and 272 (70%) patients in the comparison cohort. All patients received identical standard operative and postoperative care procedures based on protocolized department guidelines. The present study compared the rate of SSI with and without the use of prophylactic intraoperative local vancomycin powder in patients undergoing various instrumented spine surgery, adjusted for confounders. RESULTS: The overall rate of SSI was 4.7% with a decrease in infection rate found in the treatment group (0.9% vs. 6.3%). This was statistically significant (P = 0.049) with an odds ratio of 0.13 (95% confidence interval 0.02-0.99). The treatment group had a significantly shorter onset of infection (5 vs. 16.7 days; P < 0.001) and shorter duration of infection (8.5 vs. 26.8 days; P < 0.001). The most common causative organism was Pseudomonas aeruginosa (35.2%). Patient diagnosis, surgical approach, and intraoperative blood loss were significant risk factors for SSI after multivariable analysis. CONCLUSION: Prophylactic Intraoperative local vancomycin powder reduces the risk and morbidity of SSI in patients undergoing instrumented spine surgery. P. aeruginosa infection is common in the treatment arm. Future prospective randomized controlled trials in larger populations involving other spine surgeries with a long-term follow-up duration are recommended. LEVEL OF EVIDENCE: 3.

Reproducibility of sagittal radiographic parameters in adolescent idiopathic scoliosis-a guide to reference values using serial imaging.

BACKGROUND CONTEXT: Knowledge of sagittal radiographic parameters in adolescent idiopathic scoliosis (AIS) patients has not yet caught up with our understanding of their roles in patients with adult spinal deformity. It is likely that more emphasis will be placed in restoring sagittal parameters for AIS patients in the future. Therefore, we need to understand how these parameters may vary in AIS to facilitate management plans. PURPOSE: This study aimed to determine the reproducibility of sagittal spinal parameters on lateral film radiographs in patients with AIS. STUDY DESIGN/SETTING: This was a retrospective, comparative study conducted in a tertiary health-care institution from January 2013 to February 2016 (3-year period). PATIENT SAMPLE: All AIS patients who underwent deformity correction surgery from January 2013 to February 2016 and had two preoperative serial lateral radiographs taken within the time period of a month were included in the study. OUTCOME MEASURES: Radiographic sagittal spinal parameters including sagittal vertical axis (SVA), cervical lordosis (CL), thoracic kyphosis (TK), thoracolumbar alignment (TL), lumbar lordosis (LL); standard spinopelvic measurements such as pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS); as well as end and apical vertebrae of cervical, thoracic, and lumbar curves were the outcome measures. METHODS: All patient data were pooled from electronic medical records, and X-ray images were retrieved from Centricity Enterprise Web. Averaged X-ray measurements by two independent assessors were analyzed by comparing two radiographs of the same patients performed within a 1-month time period. Chi-squared and Wilcoxon signed-rank tests were used for categorical and continuous variables. RESULTS: The study cohort comprised 138 patients, 28 men and 110 women, with a mean age of 15 years (range 11-20). Between the two lateral X-rays, there was a mean difference of 0.79 cm in SVA (p<.001), 0.70° in LL (p=.033), and 0.73° in PT (p=.010). In the combined Lenke 1 and 2 subgroup, there was a similar 0.77 cm (p=.002), 0.79° (p=.009), and 1.49° (p=.001) mean difference in SVA, LL, and PT, respectively. Additionally, there was also a 1.85° (p=.009) and 1.76° (p=.006) mean difference seen in TL and SS, respectively. The overall profile of the sagittal curves remained largely similar, with only the lumbar apex shifting from L3 to L4 during the first and the second X-rays, respectively (p<.001). This occurred for the combined Lenke 1 and 2 subgroup as well (p<.001). CONCLUSION: Most radiographic sagittal spinal parameters in AIS patients are generally reproducible with some variations up to a maximum of 4°. This natural variation should be taken into account when interpreting these radiographic sagittal parameters so as to achieve the most accurate results in surgical planning.

Spinal Implants Can Be Inserted in Patients With Deep Spine Infection: Results From a Large Cohort Study.

STUDY DESIGN: A retrospective, cohort study of 84 patients with deep spine infection managed at a major tertiary hospital over 14 years with a minimum follow up of 2 years. OBJECTIVE: To determine the role of instrumentation in spines with deep infection. SUMMARY OF BACKGROUND DATA: It is often believed that implants should not be inserted in patients with deep spine infection because of the risk of persistent or recurrent infection. However, there are often concerns about spinal stability and a paucity of evidence to guide clinical practice in this field. METHODS: We compared the mortality, reoperation, and reinfection rates in patients with spine infection treated with antibiotics alone, antibiotics with debridement, and antibiotics with debridement and instrumentation. Significant outcome predictors were determined using multivariable logistic regression model. RESULTS: Forty-nine males and 35 females with a mean age was 62.0 years had spine infection affecting the lumbar spine predominantly. The most common form of infection was osteomyelitis and spondylodiscitis (69.4%). Staphylococcus aureus was the most common causative organism (61.2%).There was no difference in terms of reoperation or relapse for patients treated with antibiotics alone, antibiotics with debridement, or antibiotics with debridement and instrumentation. However, compared with antibiotics alone, the crude inhospital mortality was lower for patients treated with instrumentation (odds ratio, OR, 0.82; P = 0.01), and antibiotics with debridement (OR 0.80; P = 0.02). CONCLUSION: Spinal instrumentation in an infected spine is safe and not associated with higher reoperation or relapse rates. Mortality is lower for patients treated with instrumentation. LEVEL OF EVIDENCE: 3.