Case ReportDelayed infection after instrumented spine surgery: case reports and review of the literature☆
Introduction
The reported incidence rate of delayed infection after instrumented spine surgery is 0.2% to 4.7% [1], [2], [3], [4], [5]. A delayed infection can be difficult to diagnosis. Clinical symptoms vary and may or may not include back pain, feeling of malaise, swelling or drainage at the incision, or elevated erythrocyte sedimentation rates (ESR) and white blood count (WBC). Diagnostic imaging, such as computer tomography (CT), magnetic resonance imaging (MRI) and gallium scans, may be helpful for determining the presence of infection, but the physician must have a clinical suspicion for infection to order the appropriate tests.
This report describes four cases of delayed infection that occurred of over 500 instrumented- spine procedures performed by this author between 1990 and 2001. Furthermore, we review the cases of delayed infection reported in the literature with regard to the clinical symptoms and risk factors, possible causes of infection and treatment.
Section snippets
Case 1
The patient was a 59-year-old man who was diagnosed with stage II Hodgkin's disease in 1976. He underwent a full evaluation, including staging laparotomy splinectomy and radiation therapy, and he obtained good results. He had no evidence of recurrence since that time. He originally hurt his back at work when he fell off a ladder. He had a lumbar discectomy at L4–L5 and L5–S1 and spine fusion without instrumentation in March 1990. After this, the patient continued to have symptoms and developed
Discussion
A summary of 97 cases of delayed infections reported in the literature since 1993 is shown in Table 1 [1], [2], [3], [4], [5], [6], [7], [8], [9], [10]. The reported theories as to the possible causes of delayed infections include intraoperative inoculation of low-virulence bacteria, metal fretting causing sterile inflammation and hematogenous seeding. Intraoperative seeding often appears clinically as a wound infection that occurs early in the postoperative period [5], [11], [12]. However,
Sterile inflammation
Some reports of the late presentation of local drainage indicate that metal fretting or micromotion between the parts of the implant caused a sterile inflammatory response [6], [7]. In the case reported by Hatch et al. [7], the patient had inflammatory adherence of paraspinous musculature to the fusion mass and small pockets of purulent-looking fluid adjacent to the hardware, but the cultures were found to be negative for bacteria organisms. Dubousset et al. [6] reported sterile inflammatory
Summary
A delayed infection after instrumented spine surgery can be difficult to diagnose. It appears that there may be three possible causes for the complications: intraoperative seeding, metal fretting causing a sterile inflammatory response or stimulating low-virulent organisms to fester and hematogenous seeding. Effective treatment usually includes removal of the implants, irrigation and debridement, followed by the administration of antibiotics. However, if the infection is not deep, the
References (19)
- et al.
Spinal epidural abscess: contemporary trends in etiology, evaluation, and management
Surg Neurol
(1999) - et al.
Infectious and inflammatory processes of the spine
Radiol Clin North Am
(1991) - et al.
Cotrel-Dubousset instrumentation in idiopathic scoliosis a 5-year follow-up
Acta Orthopaedica Belg
(1997) - et al.
Late-developing infection in instrumented idiopathic scoliosis
Spine
(1999) - et al.
Delayed infections after posterior TSRH spinal instrumentation for idiopathic scoliosis
Spine
(2001) - et al.
Delayed infection after elective spinal instrumentation and fusion. A retrospective analysis of eight cases
Spine
(1997) - et al.
Postoperative spinal wound infection: a review of 2,391 consecutive index procedures
J Spinal Disord
(2000) - et al.
Late “infection” with CD instrumentation
Orthop Trans
(1994) - et al.
Late complication after single-rod instrumentation
Spine
(1998)
Cited by (74)
Implant-Associated Spinal Infections in Children: How Can We Improve Diagnosis and Management?
2022, Infectious Disease Clinics of North AmericaSpinal implant-associated infections: a prospective multicentre cohort study
2020, International Journal of Antimicrobial AgentsCitation Excerpt :However, several issues remain controversial, including the choice of diagnostic procedures, criteria for implant retention or partial removal, and the type and duration of antibiotic therapy. Clinical symptoms and laboratory results are unspecific, and the radiological findings are difficult to interpret [7,8]. Whilst most authors recommend debridement and retention of the spinal implant in early-onset infections [9], complete removal of hardware is suggested in late-onset infections.
Postoperative spine infections
2019, Seminars in Spine SurgeryAntibiotic prophylaxis in spine surgery: a comparison of single-dose and 72-hour protocols
2019, Journal of Hospital InfectionCitation Excerpt :Increasing sophistication of spinal instrumentation and developments in anaesthesia have allowed surgical intervention in increasingly complex spinal pathologies. This, in turn, has increased the SSI risk [12,14,16–23]. The vast majority of recommendations for AMP are based on one-day or single-dose protocols.
Bacterial Interactions With PEEK
2019, PEEK Biomaterials Handbook, Second EditionThe innate response to biomaterials
2017, Comprehensive Biomaterials II
- ☆
FDA device/drug status: approved for this indication (pedicle screw fixation, Isola).
Nothing of value received from a commercial entity related to this research.