Elsevier

The Spine Journal

Volume 3, Issue 5, September–October 2003, Pages 394-399
The Spine Journal

Case Report
Delayed infection after instrumented spine surgery: case reports and review of the literature

https://doi.org/10.1016/S1529-9430(03)00023-8Get rights and content

Abstract

BACKGROUND CONTEXT: A delayed infection after instrumented spine surgery can be difficult to diagnose because of its low incidence and variety of clinical symptoms.

PURPOSE: To describe four cases of delayed infection after instrumented spine surgery and to review the literature of such cases with regard to the clinical symptoms and risk factors, possible causes of infection and treatment.

STUDY DESIGN/SETTING: Personal review of cases and literature review.

PATIENT SAMPLE: Four cases in this report and 93 other cases reported in the literature.

OUTCOME MEASURES: Not measured.

METHODS: Summary of the clinical symptoms, risk factors, causes of infection and treatment regimens.

RESULTS: Three possible causes of a delayed infection have been cited: intraoperative seeding, metal fretting causing a sterile inflammatory response or stimulating low-virulent organisms to fester and hematogenous seeding. A variety of clinical symptoms were found, but spontaneous drainage appears to be most common. Many patients had either a fluctuant mass, localized drainage or an abscess. Abscesses or drainage material is typically contiguous with the instrumentation and the fusion mass. Fever was present in only six patients. Effective treatment usually includes removal of the implants, irrigation and debridement, followed by the administration of antibiotics.

CONCLUSIONS: A high level of suspicion is needed to diagnose a delayed infection after instrumented spine surgery.

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

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FDA device/drug status: approved for this indication (pedicle screw fixation, Isola).

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