Surgical site infections following spinal instrumentation: A review of risk factors and treatment options

Postoperative infection of the instrumented spine carries serious morbidity, great cost, and even failure of the original objective. In the present review, we discuss the predisposing risk factors, analyze the effectiveness of preventive measures, and evaluate evidence-based treatment options for surgical site infections (SSIs) in spinal instrumentation procedures. Several risk factors are identified. Preoperative factors include concomitant infections, immunocompromised host conditions, advanced age, obesity, malnutrition, uncontrolled diabetes mellitus, tobacco use, and previous spinal surgery with instrumentation. Intraoperative factors include perioperative hypothermia, prolonged duration of surgery, posterior spinal approach, and violation of sterile conditions. Postoperative factors include paralytic patient and prolonged hospital bed rest. Distinct treatment options have been devised for the management of postoperative infection without the need of removing the instrumentation. Debridement is the initial approach and antibiotic therapy is an adjunctive step. Closure of the wound after infection may be accomplished by delayed primary, secondary intention closure or by other surgical methods such as continuing suction irrigation,VAC, and hyperbaric oxygen treatment. Infections with extensive soft tissue destruction and myonecrosis are best dealt with using muscle flaps after extensive debridement. Specific measures should be taken to minimize or eliminate the risk factors and optimize the patient's condition before spinal surgery with implants. However, if infection occurs despite prophylaxis, treatment should be instituted quickly and aggressively to prevent or reduce its consequences.