Efficacy of surgical preparation solutions in lumbar spine surgery.

BACKGROUND: Postoperative spinal wound infections are relatively common and are often associated with increased morbidity and poor long-term patient outcomes. The purposes of this study were to identify the common bacterial flora on the skin overlying the lumbar spine and evaluate the efficacy of readily available skin-preparation solutions in the elimination of bacterial pathogens from the surgical site following skin preparation. METHODS: A prospective randomized study was undertaken to evaluate 100 consecutive patients undergoing elective lumbar spine surgery. At the time of surgery, the patients were randomized to be treated with one of two widely used, and Food and Drug Administration (FDA)-approved, surgical skin-preparation solutions: ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol) or DuraPrep (0.7% available iodine and 74% isopropyl alcohol). Specimens for aerobic and anaerobic cultures were obtained prior to skin preparation (pre-preparation), after skin preparation (post-preparation), and after wound closure (post-closure). A validated neutralization solution was used for each culture to ensure that the antimicrobial activity was stopped immediately after the sample was taken. Positive cultures and specific bacterial pathogens were recorded. RESULTS: Coagulase-negative Staphylococcus, Propionibacterium acnes, and Corynebacterium were the most commonly isolated organisms prior to skin preparation. The overall rate of positive cultures prior to skin preparation was 82%. The overall rate of positive cultures after skin preparation was 0% (zero of fifty) in the ChloraPrep group and 6% (three of fifty) in the DuraPrep group (p = 0.24, 95% confidence interval [CI] = 0.006 to 0.085). There was an increase in positive cultures after wound closure, but there was no difference between the ChloraPrep group (34%, seventeen of fifty) and the DuraPrep group (32%, sixteen of fifty) (p = 0.22, 95% CI = 0.284 to 0.483). Body mass index (BMI), duration of surgery, and estimated blood loss did not a show significant association with post-closure positive culture results. CONCLUSIONS: ChloraPrep and DuraPrep are equally effective skin-preparation solutions for eradication of common bacterial pathogens on the skin overlying the lumbar spine.

A kyphectomy technique with reduced perioperative morbidity for myelomeningocele kyphosis.

STUDY DESIGN: The lumbar sacropelvis in 11 patients with myelomeningocele and kyphosis was treated with a subtraction kyphectomy technique and posterior instrumentation. The results of this procedure in the 11 patients were evaluated and compared with previous results. OBJECTIVE: To examine critically their experience using the subtraction (decancellation) vertebrectomy technique combined with posterior instrumentation for myelomeningocele kyphosis, the authors reviewed the charts of 18 myelomeningocele patients who underwent surgery for lumbar kyphosis between 1994 and 1998. SUMMARY OF BACKGROUND: The benefits of restoring sagittal spinal alignment in myelomeningocele patients with severe lumbar kyphosis deformity to achieve postural stability and improved sitting balance generally are accepted. The optimal method of deformity correction, the extent of instrumentation, and the role of limited arthrodesis remain undefined. METHODS: Of the 18 patients considered, 11 met the inclusion criteria of having undergone reconstruction using a subtraction (decancellation) vertebrectomy technique, preservation of the thecal sac, limited arthrodesis with posterior transpedicular lumbosacral instrumentation, and a minimum follow-up evaluation of 2 years. The study considered the age of the patient, number of levels fused, estimated blood loss, preoperative deformity, immediate postoperative correction, magnitude of correction, and maintenance of correction at latest follow-up assessment. RESULTS: The average age at the time of the index procedure was 6 years (range, 3-12 years). The average preoperative kyphosis was 88 degrees (range, 50-149 degrees ). Immediately after surgery, the average curve measurement was 3 degrees lordosis (range, 50 degrees to 50 degrees ). The average magnitude of postoperative sagittal plane deformity correction was 91 degrees (range, 43-126 degrees ). Finally, the magnitude of correction maintained at the final follow-up assessment averaged 66 degrees (range, 22-114 degrees ). This represented an average loss of correction at 2 years of 24 degrees (range, 0-84 degrees ). There were no deaths, episodes of acute-onset hydrocephalus, vascular complications, or chronic deep wound infections. CONCLUSIONS: The subtraction (decancellation) vertebrectomy technique with preservation of the dural sac is a safe and efficacious technique for correction and stabilization of myelomeningocele kyphosis in young patients. Morbidity is reduced, as compared with that of excision techniques. Restoration of sagittal alignment at the time of initial correction and stabilization to achieve a balanced spine led to acceptable results.