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Risk factors for deep surgical site infection following posterior instrumented fusion for degenerative diseases in the thoracic and/or lumbar spine: a multicenter, observational cohort study of 2913 consecutive cases

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Abstract

Purpose

Surgical site infection (SSI) is one of the most devastating complications following spinal instrumented fusion surgeries because it may lead to a significant increase in morbidity, mortality, and poor clinical outcomes. Identifying the risk factors for SSI can help in developing strategies to reduce its occurrence. However, data on the risk factors for SSI in degenerative diseases are limited. This study aimed to identify risk factors for deep SSI following posterior instrumented fusion for degenerative diseases in the thoracic and/or lumbar spine in adult patients.

Methods

This was a multicenter, observational cohort study conducted at 10 study hospitals between July 2010 and June 2015. The subjects were consecutive adult patients who underwent posterior instrumented fusion surgery for degenerative diseases in the thoracic and/or lumbar spine and developed SSI. Detailed patient-specific and procedure-specific potential risk variables were prospectively recorded using a standardized data collection chart and retrospectively reviewed.

Results

Of the 2913 enrolled patients, 35 developed postoperative deep SSI (1.2%). Multivariable regression analysis identified three independent risk factors: male sex (P = 0.002) and American Society of Anesthesiologists (ASA) score of ≥ 3 (P = 0.003) as patient-specific risk factors, and operation including the thoracic spine (P = 0.018) as a procedure-specific risk factor.

Conclusion

Thoracic spinal surgery, an ASA score of ≥ 3, and male sex were risk factors for deep SSI after routine thoracolumbar instrumented fusion surgeries for degenerative diseases. Awareness of these risk factors can enable surgeons to develop a more appropriate management plan and provide better patient counseling.

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Code availability

All data analyses in the current study were conducted using SPSS Statistics ver. 24 (IBM Corp., Armonk, NY).

Abbreviations

ASA:

American Society of Anesthesiologists

BMI:

Body mass index

CEZ:

Cefazolin

CI:

Confidence interval

CNS:

Coagulase-negative staphylococci

OR:

Odds ratio

SD:

Standard deviation

SSI:

Surgical site infection

References

  1. Pesenti S, Pannu T, Andres-Bergos J, Lafage R, Smith JS, Glassman S, de Kleuver M, Pellise F, Schwab F, Lafage V, Scoliosis Research Society (SRS) (2018) What are the risk factors for surgical site infection after spinal fusion? A meta-analysis. Eur Spine J 27:2469–2480. https://doi.org/10.1007/s00586-018-5733-7

    Article  PubMed  Google Scholar 

  2. Janssen DMC, van Kuijk SMJ, d'Aumerie B, Willems P (2019) A prediction model of surgical site infection after instrumented thoracolumbar spine surgery in adults. Eur Spine J 28:775–782. https://doi.org/10.1007/s00586-018-05877-z

    Article  PubMed  Google Scholar 

  3. Chaichana KL, Bydon M, Santiago-Dieppa DR, Hwang L, McLoughlin G, Sciubba DM, Wolinsky JP, Bydon A, Gokaslan ZL, Witham T (2014) Risk of infection following posterior instrumented lumbar fusion for degenerative spine disease in 817 consecutive cases. J Neurosurg Spine 20:45–52. https://doi.org/10.3171/2013.10.SPINE1364

    Article  PubMed  Google Scholar 

  4. Rao SB, Vasquez G, Harrop J, Maltenfort M, Stein N, Kaliyadan G, Klibert F, Epstein R, Sharan A, Vaccaro A, Flomenberg P (2011) Risk factors for surgical site infections following spinal fusion procedures: a case-control study. Clin Infect Dis 53:686–692. https://doi.org/10.1093/cid/cir506

    Article  PubMed  Google Scholar 

  5. Lieber B, Han B, Strom RG, Mullin J, Frempong-Boadu AK, Agarwal N, Kazemi N, Tabbosha M (2016) Preoperative predictors of spinal infection within the National surgical quality inpatient database. World Neurosurg 89:517–524. https://doi.org/10.1016/j.wneu.2015.12.085

    Article  PubMed  Google Scholar 

  6. Kurtz SM, Lau E, Ong KL, Carreon L, Watson H, Albert T, Glassman S (2012) Infection risk for primary and revision instrumented lumbar spine fusion in the Medicare population. J Neurosurg Spine 17:342–347. https://doi.org/10.3171/2012.7.SPINE12203

    Article  PubMed  Google Scholar 

  7. Abdul-Jabbar A, Takemoto S, Weber MH, Hu SS, Mummaneni PV, Deviren V, Ames CP, Chou D, Weinstein PR, Burch S, Berven SH (2012) Surgical site infection in spinal surgery: description of surgical and patient-based risk factors for postoperative infection using administrative claims data. Spine 37:1340–1345. https://doi.org/10.1097/BRS.0b013e318246a53a

    Article  PubMed  Google Scholar 

  8. Koutsoumbelis S, Hughes AP, Girardi FP, Cammisa FP Jr, Finerty EA, Nguyen JT, Gausden E, Sama AA (2011) Risk factors for postoperative infection following posterior lumbar instrumented arthrodesis. J Bone Jt Surg Am 93:1627–1633. https://doi.org/10.2106/JBJS.J.00039

    Article  Google Scholar 

  9. Schimmel JJ, Horsting PP, de Kleuver M, Wonders G, van Limbeek J (2010) Risk factors for deep surgical site infections after spinal fusion. Eur Spine J 19:1711–1719. https://doi.org/10.1007/s00586-010-1421-y

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Li Z, Liu P, Zhang C, Xu G, Zhang Y, Chang Y, Liu M, Hou S (2019) Incidence, prevalence, and analysis of risk factors for surgical site infection after lumbar fusion surgery:  ≥ 2-year follow-up retrospective study. World Neurosurg 131:e460–e467. https://doi.org/10.1016/j.wneu.2019.07.207

    Article  PubMed  Google Scholar 

  11. Rechtine GR, Bono PL, Cahill D, Bolesta MJ, Chrin AM (2001) Postoperative wound infection after instrumentation of thoracic and lumbar fractures. J Orthop Trauma 15:566–569

    Article  CAS  Google Scholar 

  12. Cooper K, Glenn CA, Martin M, Stoner J, Li J, Puckett T (2016) Risk factors for surgical site infection after instrumented fixation in spine trauma. J Clin Neurosci 23:123–127. https://doi.org/10.1016/j.jocn.2015.08.023

    Article  PubMed  Google Scholar 

  13. Gu W, Tu L, Liang Z, Wang Z, Aikenmu K, Chu G, Zhang E, Zhao J (2018) Incidence and risk factors for infection in spine surgery: a prospective multicenter study of 1764 instrumented spinal procedures. Am J Infect Control 46:8–13. https://doi.org/10.1016/j.ajic.2017.09.025

    Article  PubMed  Google Scholar 

  14. Ramo BA, Roberts DW, Tuason D, McClung A, Paraison LE, Moore HG 4th, Sucato DJ (2014) Surgical site infections after posterior spinal fusion for neuromuscular scoliosis: a thirty-year experience at a single institution. J Bone Jt Surg Am 96:2038–2048. https://doi.org/10.2106/JBJS.N.00277

    Article  Google Scholar 

  15. Malamo-Lada H, Zarkotou O, Nikolaides N, Kanellopoulou M, Demetriades D (1999) Wound infections following posterior spinal instrumentation for paralytic scoliosis. Clin Microbiol Infect 5:135–139

    Article  Google Scholar 

  16. Sugita S, Hozumi T, Yamakawa K, Goto T, Kondo T (2016) Risk factors for surgical site infection after posterior fixation surgery and intraoperative radiotherapy for spinal metastases. Eur Spine J 25:1034–1038. https://doi.org/10.1007/s00586-015-4116-6

    Article  PubMed  Google Scholar 

  17. Pennington Z, Lubelski D, Molina C, Westbroek EM, Ahmed AK, Sciubba DM (2019) Prolonged post-surgical drain retention increases risk for deep wound infection after spine surgery. World Neurosurg 130:e846–e853. https://doi.org/10.1016/j.wneu.2019.07.013

    Article  PubMed  Google Scholar 

  18. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR (1999) Guideline for prevention of surgical site infection, 1999. Hospital Infection control practices advisory committee. Am J Infect Control 27:97–132 quiz 133-4; discussion 96

    Article  CAS  Google Scholar 

  19. Owens WD, Felts JA, Spitznagel EL Jr (1978) ASA physical status classifications: a study of consistency of ratings. Anesthesiology 49:239–243

    Article  CAS  Google Scholar 

  20. Kao LS, Ghaferi AA, Ko CY, Dimick JB (2011) Reliability of superficial surgical site infections as a hospital quality measure. J Am Coll Surg 213:231–235. https://doi.org/10.1016/j.jamcollsurg.2011.04.004

    Article  PubMed  PubMed Central  Google Scholar 

  21. Imajo Y, Taguchi T, Yone K, Okawa A, Otani K, Ogata T, Ozawa H, Shimada Y, Neo M, Iguchi T (2015) Japanese 2011 nationwide survey on complications from spine surgery. J Orthop Sci 20:38–54. https://doi.org/10.1007/s00776-014-0656-6

    Article  PubMed  Google Scholar 

  22. Sebaaly A, Sylvestre C, El Quehtani Y, Riouallon G, Larrieu D, Boissiere L, Steib JP, Roussouly P, Wolff S, Obeid I (2018) Incidence and risk factors for proximal junctional kyphosis: results of a multicentric study of adult scoliosis. Clin Spine Surg 31:E178–E183. https://doi.org/10.1097/BSD.0000000000000630

    Article  PubMed  Google Scholar 

  23. Yan C, Li Y, Yu Z (2016) Prevalence and consequences of the proximal junctional kyphosis after spinal deformity surgery: a meta-analysis. Medicine (Baltimore) 95(20):e3471. https://doi.org/10.1097/MD.0000000000003471

    Article  Google Scholar 

  24. Lee WD, Lee JU, Kim MY, Lee LK, Park BS, Yang SM, Noh JW, Shin YS, Kim JH, Kwak TY, Lee TH, Park J, Kim J (2016) Differences in the body pressure-related sensory changes between the floor and mattress in a static supine position for physiotherapy research: a randomized controlled pilot trial. J Phys Ther Sci 28:1086–1091. https://doi.org/10.1589/jpts.28.1086

    Article  PubMed  PubMed Central  Google Scholar 

  25. Nakashima S, Yamanashi H, Komiya S, Tanaka K, Maeda T (2018) Prevalence of pressure injuries in Japanese older people: a population-based cross-sectional study. PLoS ONE 13(6):e0198073. https://doi.org/10.1371/journal.pone.0198073

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Worm PV, Finger G, Brasil AVB, Teles AR (2019) Postoperative supine position increases the risk of infection after spinal surgery by posterior approach. World Neurosurg 126:e580–e585. https://doi.org/10.1016/j.wneu.2019.02.098

    Article  PubMed  Google Scholar 

  27. Sankar A, Johnson SR, Beattie WS, Tait G, Wijeysundera DN (2014) Reliability of the American society of anesthesiologists physical status scale in clinical practice. Br J Anaesth 113:424–432. https://doi.org/10.1093/bja/aeu100

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Deng H, Chan AK, Ammanuel S, Chan AY, Oh T, Skrehot HC, Edwards S, Kondapavulur S, Nichols AD, Liu C, Yue JK, Dhall SS, Clark AJ, Chou D, Ames CP, Mummaneni PV (2019) Risk factors for deep surgical site infection following thoracolumbar spinal surgery. J Neurosurg Spine 32:292–301. https://doi.org/10.3171/2019.8.SPINE19479

    Article  PubMed  Google Scholar 

  29. Resende VAC, Neto AC, Nunes C, Andrade R, Espregueira-Mendes J, Lopes S (2018) Higher age, female gender, osteoarthritis and blood transfusion protect against periprosthetic joint infection in total hip or knee arthroplasties: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-018-5231-9

    Article  PubMed  Google Scholar 

  30. Aghdassi SJS, Schröder C, Gastmeier P (2019) Gender-related risk factors for surgical site infections. Results from 10 years of surveillance in Germany. Antimicrob Resist Infect Control. https://doi.org/10.1186/s13756-019-0547-x

    Article  PubMed  PubMed Central  Google Scholar 

  31. Morikane K, Honda H, Suzuki S (2016) Factors associated with surgical site infection following gastric surgery in Japan. Infect Control Hosp Epidemiol 37:1167–1172. https://doi.org/10.1017/ice.2016.155

    Article  PubMed  Google Scholar 

  32. Kong L, Cao J, Zhang Y, Ding W, Shen Y (2017) Risk factors for periprosthetic joint infection following primary total hip or knee arthroplasty: a meta-analysis. Int Wound J 14:529–536. https://doi.org/10.1111/iwj.12640

    Article  PubMed  Google Scholar 

  33. Neidhart S, Zaatreh S, Klinder A, Redanz S, Spitzmüller R, Holtfreter S, Warnke P, Alozie A, Henck V, Göhler A, Ellenrieder M, AbouKoura M, Divchev D, Gümbel D, Napp M, Steinhoff G, Nienaber C, Ekkernkamp A, Mittelmeier W, Güthoff C, Podbielski A, Stengel D, Bader R (2018) Predictors of colonization with Staphylococcus species among patients scheduled for cardiac and orthopedic interventions at tertiary care hospitals in north-eastern Germany—a prevalence screening study. Eur J Clin Microbiol Infect Dis 37:633–641. https://doi.org/10.1007/s10096-017-3154-x

    Article  CAS  PubMed  Google Scholar 

  34. Yoshiike N, Matsumura Y, Zaman MM, Yamaguchi M (1998) Descriptive epidemiology of body mass index in Japanese adults in a representative sample from the National Nutrition Survey 1990–1994. Int J Obes Relat Metab Disord 22:684–687. https://doi.org/10.1038/sj.ijo.0800651

    Article  CAS  PubMed  Google Scholar 

  35. Blüher M (2019) Obesity: global epidemiology and pathogenesis. Nat Rev Endocrinol 15:288–298. https://doi.org/10.1038/s41574-019-0176-8

    Article  PubMed  Google Scholar 

  36. Tominaga H, Setoguchi T, Ishidou Y, Nagano S, Yamamoto T, Komiya S (2016) Risk factors for surgical site infection and urinary tract infection after spine surgery. Eur Spine J 25:3908–3915. https://doi.org/10.1007/s00586-016-4674-2

    Article  PubMed  Google Scholar 

  37. Xing D, Ma JX, Ma XL, Song DH, Wang J, Chen Y, Yang Y, Zhu SW, Ma BY, Feng R (2013) A methodological, systematic review of evidence-based independent risk factors for surgical site infections after spinal surgery. Eur Spine J 22(3):605–615. https://doi.org/10.1007/s00586-012-2514-6

    Article  PubMed  Google Scholar 

  38. Zhang F, Liu X, Tan Z, Li J, Fu D, Zhu L (2020) Effect of postoperative hypoalbuminemia and supplement of human serum albumin on the development of surgical site infection following spinal fusion surgery: a retrospective study. Eur Spine J 29:1483–1489. https://doi.org/10.1007/s00586-020-06306-w

    Article  PubMed  Google Scholar 

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Acknowledgements

We would like to express our gratitude to all the spine surgeons at the participating hospitals who performed the surgeries and collected the data. We did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors for this research. The manuscript submitted does not contain information about medical device(s)/drug(s).

Funding

No funds were received in support of this work. No benefits in any form have been or will be received from any commercial party related directly or indirectly to the subject of this manuscript.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan

    Satoshi Ogihara & Kazuo Saita

  2. Department of Orthopaedic Surgery, Musashino Red Cross Hospital, 1-26-1 Kyonancho, Musashino, Tokyo, 180-8610, Japan

    Takashi Yamazaki & Nobuhiro Hara

  3. Information Technology Center, Saitama Medical University, 38 Morohongo Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan

    Michio Shiibashi

  4. Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa, Maebashi, Gunma, 371-8511, Japan

    Hirotaka Chikuda

  5. Department of Orthopaedic Surgery, Saitama Rehabilitation Center, 148-1 Nishikaizuka, Ageo, Saitama, 362-0057, Japan

    Toru Maruyama

  6. Department of Orthopaedic Surgery, Yokohama Rosai Hospital, 3211 Kozukuecho, Kouhoku-ku, Yokohama, Kanagawa, 222-0036, Japan

    Kota Miyoshi & Yujiro Takeshita

  7. Department of Orthopaedic Surgery, Iwai Orthopaedic Medical Hospital, 8-17-2 Minamikoiwa, Edogawa-ku, Tokyo, 133-0056, Japan

    Hirohiko Inanami

  8. Department of Orthopaedic Surgery, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan

    Yasushi Oshima & Sakae Tanaka

  9. Department of Orthopaedic Surgery, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan

    Seiichi Azuma & Rentaro Okazaki

  10. Department of Spine and Orthopaedic Surgery, Japanese Red Cross Medical Center, 4-1-22 Hiroo, Shibuya-ku, Tokyo, 150-8935, Japan

    Naohiro Kawamura

  11. Department of Orthopaedic Surgery and Musculoskeletal Oncology, Tokyo Metropolitan Komagome Hospital, 3-18 Honkomagome, Bunkyo-ku, Tokyo, 113-0021, Japan

    Kiyofumi Yamakawa

  12. Department of Orthopaedic Surgery, Sanraku Hospital, 2-5 Surugadai, Kanda, Chiyoda-ku, Tokyo, 101-8326, Japan

    Jiro Morii

Authors
  1. Satoshi Ogihara
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  2. Takashi Yamazaki
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  3. Michio Shiibashi
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  4. Hirotaka Chikuda
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  5. Toru Maruyama
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  6. Kota Miyoshi
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  8. Yasushi Oshima
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  9. Seiichi Azuma
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  11. Kiyofumi Yamakawa
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  13. Jiro Morii
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  14. Rentaro Okazaki
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  15. Yujiro Takeshita
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  16. Sakae Tanaka
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  17. Kazuo Saita
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Contributions

SO and TY were involved in conceptualization; SO, TY, HC, TM, KM, HI, YO, SA, NK, KY, NH, JM, RO, and YT helped in data curation; SO helped in investigation; MS and SO contributed to statistical analysis; TY, ST, and KS were involved in supervision; SO wrote original draft; SO and TY were involved in writing—review and editing. All authors read and approved the final manuscript.

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Correspondence to Satoshi Ogihara.

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Ogihara, S., Yamazaki, T., Shiibashi, M. et al. Risk factors for deep surgical site infection following posterior instrumented fusion for degenerative diseases in the thoracic and/or lumbar spine: a multicenter, observational cohort study of 2913 consecutive cases. Eur Spine J 30, 1756–1764 (2021). https://doi.org/10.1007/s00586-020-06609-y

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