Jason W. Savage

An update on modifiable factors to reduce the risk of surgical site infections

BACKGROUND CONTEXT Despite an increase in physician and public awareness and advances in infection control practices, surgical site infection (SSI) remains to be one of the most common complications after an operation. Surgical site infections have been shown to decrease health-related quality of life, double the risk of readmission, prolong the length of hospital stay, and increase hospital costs. PURPOSE To critically evaluate the literature and identify modifiable factors to reduce the risk of SSI. STUDY DESIGN/SETTING Systematic review of the literature. METHODS A critical review of the literature was performed using OVID, Pubmed, and the Cochrane database and focused on eight identifiable factors: preoperative screening and decolonization of methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus protocols, antiseptic showers, antiseptic cloths, perioperative skin preparation, surgeon hand hygiene, antibiotic irrigation and/or use of vancomycin powder, closed suction drains, and antibiotic suture. RESULTS Screening protocols have shown that 18% to 25% of patients undergoing elective orthopedic surgery are nasal carriers of S. aureus and that carriers are more likely to have a nosocomial infection and SSI. The evidence suggests that an institutionalized prescreening program, followed by an appropriate eradication using mupirocin ointment and chlorhexidine soap/shower, will lower the rate of nosocomial S. aureus infections. Based on the current literature, definitive conclusions cannot be made on whether preoperative antiseptic showers effectively reduce the incidence of postoperative infection. The use of a chlorhexidine bathing cloth before surgery may decrease the risk of SSI. There is no definitive clinical evidence that one skin preparation solution effectively lowers the rate of postoperative infection compared with another. The use of dilute betadine irrigation or vancomycin powder in the wound before closure likely decreases the incidence of SSI. CONCLUSIONS There is strong evidence in the literature that optimizing specific preoperative, intraoperative, and postoperative variables can significantly lower the risk of developing an SSI.

The Professional Athlete Spine Initiative: outcomes after lumbar disc herniation in 342 elite professional athletes.

BACKGROUND CONTEXT Although clinical outcomes after lumbar disc herniations (LDHs) in the general population have been well studied, those in elite professional athletes have not. Because these athletes have different measures of success, studies on long-term outcomes in this patient population are necessary. PURPOSE This study seeks to define the outcomes after an LDH in a large cohort of professional athletes of American football, baseball, hockey, and basketball. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE A total of 342 professional athletes from four major North American sports from 1972 to 2008 diagnosed with an LDH were identified via a previously published protocol. Two hundred twenty-six players underwent lumbar discectomy, and 116 athletes were treated nonoperatively. Only those players who had at least 2 years of follow-up were included. OUTCOME MEASURES Functional outcome measures as defined by successful return-to-play (RTP), career games, and years played for each player cohort were recorded both before and after treatment. Conversion factors based on games/regular season and expected career length (based on individual sport) were used to standardize the outcomes across each sport. METHODS Using Statistical Analysis Software v. 9.1, outcome measures were compared in each cohort both before and after treatment using linear and mixed regression analyses and Cox proportional hazards models. A Kaplan-Meier survivorship curve was calculated for career length after injury. Statistical significance was defined as p<.05. RESULTS After the diagnosis of an LDH, professional athletes successfully returned to sport 82% of the time, with an average career length of 3.4 years. Of the 226 patients who underwent surgical treatment, 184 successfully returned to play (81%), on average, for 3.3 years after surgery. Survivorship analysis demonstrated that 62.3% of players were expected to remain active 2 years after diagnosis. There were no statistically significant differences in outcome in the surgical and nonoperative cohorts. Age at diagnosis was a negative predictor of career length after injury, whereas games played before injury had a positive effect on outcome after injury. Major League Baseball (MLB) players demonstrated a significantly higher RTP rate than those of other sports, and conversely, National Football League (NFL) athletes had a lower RTP rate than players of other sports (p<.05). However, the greatest positive treatment effect from surgery for LDH was seen in NFL players, whereas for MLB athletes, a lumbar discectomy led to a shorter career compared with the nonoperative cohort (p<.05). CONCLUSIONS Professional athletes diagnosed with an LDH successfully returned to play at a high rate with productive careers after injury. Whereas older athletes have a shorter career length after diagnosis of LDH, experienced players (high number of games played) demonstrate more games played after treatment than inexperienced athletes. Notably, surgical treatment in baseball players led to significantly shorter careers, whereas for NFL athletes, posttreatment careers were longer than those of the corresponding nonoperative cohort. The explanation for this is likely multifactorial, including the age at diagnosis, respective contractual obligations, and different physical demands imposed by each individual professional sport.

Cancer Risk from Bone Morphogenetic Protein Exposure in Spinal Arthrodesis

BACKGROUND The U.S. Food and Drug Administration reported a higher incidence of cancer in patients who had spinal arthrodesis and were exposed to a high dose of recombinant human bone morphogenetic protein-2 (rhBMP-2) compared with the control group in a randomized controlled trial. The purpose of this study was to determine the risk of cancer after spinal arthrodesis with BMP. METHODS We retrospectively analyzed the incidence of cancer in 467,916 Medicare patients undergoing spinal arthrodesis from 2005 to 2010. Patients with a preexisting diagnosis of cancer were excluded. The average follow-up duration was 2.85 years for the BMP group and 2.94 years for the control group. The main outcome measure was the relative risk of developing new malignant lesions after spinal arthrodesis with or without exposure to BMP. RESULTS The relative risk of developing cancer after BMP exposure was 0.938 (95% confidence interval [95% CI]: 0.913 to 0.964), which was significant. In the BMP group, 5.9% of the patients developed an invasive cancer compared with 6.5% of the patients in the control group. The relative risk of developing cancer after BMP exposure was 0.98 in males (95% CI: 0.94 to 1.02) and 0.93 (95% CI: 0.90 to 0.97) in females. The control group showed a higher incidence of each type of cancer except pancreatic cancer. CONCLUSIONS Recent clinical use of BMP was not associated with a detectable increase in the risk of cancer within a mean 2.9-year time window. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Dysphagia after anterior cervical spine surgery: a systematic review of potential preventative measures

BACKGROUND CONTEXT Anterior cervical spine surgery is one of the most common spinal procedures performed around the world, but dysphagia is a frequent postoperative complication. Many factors have been associated with an increased risk of swallowing difficulties, including multilevel surgery, revision surgery, and female gender. PURPOSE The objective of this study was to review and define potential preventative measures that can decrease the incidence of dysphagia after anterior cervical spine surgery. STUDY DESIGN This was a systematic literature review. METHODS A systematic review in the Medline database was performed. Articles related to dysphagia after anterior cervical spine surgery and potential preventative measures were included. RESULTS Twenty articles met all inclusion and exclusion criteria. These articles reported several potential preventative measures to avoid postoperative dysphagia. Preoperative measures include performing tracheal exercises before the surgical procedure. Intraoperative measures can be summarized as avoiding a prolonged operative time and the use of recombinant human bone morphogenetic protein in routine anterior cervical spine surgery, using small and smoother cervical plates, using anchored spacers instead of plates, application of steroid before wound closure, performing arthroplasty instead of anterior cervical fusion for one-level disease, decreasing tracheal cuff pressure during medial retraction, using specific retractors, and changing the dissection plan. CONCLUSIONS Current literature supports several preventative measures that may decrease the incidence of postoperative dysphagia. Although the evidence is limited and weak, most of these measures did not appear to increase other complications and can be easily incorporated into a surgical practice, especially in patients who are at high risk for postoperative dysphagia.

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.

Male-female differences in scoliosis research society-30 scores in adolescent idiopathic scoliosis

Study Design. Longitudinal cohort study. Objective. To compare functional outcomes between male and female patients before and after surgery for adolescent idiopathic scoliosis (AIS). Summary of Background Data. There is no clear consensus in the existing literature with respect to sex differences in functional outcomes in the surgical treatment of AIS. Methods. A prospective, consecutive, multicenter database of patients who underwent surgical correction for adolescent idiopathic scoliosis was analyzed retrospectively. All patients completed Scoliosis Research Society-30 (SRS-30) questionnaires before and 2 years after surgery. Patients with previous spine surgery were excluded. Data were collected for sex, age, Risser grade, previous bracing history, maximum preoperative Cobb angle, curve correction at 2 years, and SRS-30 domain scores. Paired sample t tests were used to compare preoperative and postoperative scores within each sex. Independent sample t tests were used to compare scores between sexes. A P value of <0.05 was considered statistically significant. Results. Seven hundred forty-four patients (621 females and 123 males) were included. On average, males were 1 year older than females. There were no differences between sexes in Risser grade, bracing history, maximum curve magnitude, or correction after surgery. Both males and females had similar improvement in all SRS-30 domains after surgery. Self-image/appearance had the greatest relative improvement. Males had better self-image/appearance scores preoperatively, better pain scores at 2 years, and better mental health and total scores both preoperatively and at 2 years. Both males and females were similarly satisfied with surgery. Conclusions. Males treated with surgery for AIS report better preoperative self-image, less postoperative pain, and better mental health than females. These differences may be clinically significant. For both males and females, the most beneficial effect of surgery is improved self-image/appearance. Overall, the benefits of surgery for AIS are similar for both sexes. Level of Evidence: Level II

Vertebroplasty and kyphoplasty for the treatment of osteoporotic vertebral compression fractures.

Vertebroplasty and kyphoplasty have been used to treat osteoporotic compression fractures for many years. In 2009, two randomized controlled trials demonstrated limited effectiveness of vertebroplasty over sham treatment; thus, the American Academy of Orthopaedic Surgeons published evidence-based guidelines recommending “against vertebroplasty for patients who present with an osteoporotic spinal compression fracture.” However, several other trials have since been published that contradict these conclusions. A recent meta-analysis cited strong evidence in favor of cement augmentation in the treatment of symptomatic vertebral compression fractures.

Statistical performance in National Football League athletes after lumbar discectomy.

Objective: It is currently unknown how a lumbar disk herniation (LDH) impacts a professional athletes performance and/or career. No studies have evaluated the effects of LDH on National Football League (NFL) skill position players. Our objective was to determine if NFL athletes who sustain an LDH and subsequently undergo discectomy can return to competitive play with no significant effects on performance. Design: Retrospective cohort study. Setting: National Football League. Patients: During a 22-year period (1986-2008), offensive skill position players in the NFL (quarterbacks, running backs, wide receivers, and tight ends) who sustained an LDH and subsequently underwent a lumbar discectomy were included in this study. Intervention: Lumbar discectomy. Main Outcome Measures: Performance-based outcomes were analyzed, and data were recorded for games played, yards gained, and touchdowns scored. Results: Data were analyzed for 23 NFL offensive skill position players who had an LDH and underwent discectomy. Seventy-four percent of players returned to competitive play in the NFL. The average length of career after treatment was 36 games over a 4.1-year period. There was no significant difference in performance when comparing pre-injury and post-injury statistics. Conclusions: Although an LDH has career-threatening implications for NFL athletes, 74% of players who underwent lumbar discectomy returned to competitive play in the NFL. There was no significant change in performance when comparing pre-injury and post-injury statistics.

Fixed Sagittal Plane Imbalance

Study Design Literature review. Objective To discuss the evaluation and management of fixed sagittal plane imbalance. Methods A comprehensive literature review was performed on the preoperative evaluation of patients with sagittal plane malalignment, as well as the surgical strategies to address sagittal plane deformity. Results Sagittal plane imbalance is often caused by de novo scoliosis or iatrogenic flat back deformity. Understanding the etiology and magnitude of sagittal malalignment is crucial in realignment planning. Objective parameters have been developed to guide surgeons in determining how much correction is needed to achieve favorable outcomes. Currently, the goals of surgery are to restore a sagittal vertical axis < 5 cm, pelvic tilt < 20 degrees, and lumbar lordosis equal to pelvic incidence ± 9 degrees. Conclusion Sagittal plane malalignment is an increasingly recognized cause of pain and disability. Treatment of sagittal plane imbalance varies according to the etiology, location, and severity of the deformity. Fixed sagittal malalignment often requires complex reconstructive procedures that include osteotomy correction. Reestablishing harmonious spinopelvic alignment is associated with significant improvement in health-related quality-of-life outcome measures and patient satisfaction.

Rationale for the Surgical Treatment of Lumbar Degenerative Spondylolisthesis.

Study Design. A questionnaire survey. Objective. The aim of this study was to determine the effect of patient age, dynamic instability, and/or low back pain on the treatment of patients with a degenerative spondylolisthesis, and if the operative approach is affected by surgeon specialty, location, or practice model. Summary of Background Data. The classic treatment for patients with symptomatic degenerative spondylolisthesis is decompression and fusion; however in a select group of patients, an isolated decompression may be reasonable. Methods. A survey was sent to surgeon members of the Lumbar Spine Research Society and AOSpine requesting information regarding their preferred treatment of degenerative spondylolisthesis for a number of different clinical scenarios. Determinants included patient age, the presence of instability, symptoms of low back pain, surgeons location, surgeons specialty, and practice model. Results. A total of 223 spine surgeons completed the survey. Age of the patient, the presence of instability, and low back pain all significantly (P < 0.0001) affected the recommended treatment, which were independent of surgeon factors. Older patients were significantly less likely to be offered an interbody fusion and more likely to be recommended for an isolated decompression (P < 0.0001), and the presence of dynamic instability made an interbody fusion more likely than an isolated decompression (P < 0.0001). Of those who responded, 53.2% of surgeons reported they would recommend an isolated decompression for a properly selected patient with a degenerative spondylolisthesis. Conclusion. The most common operative treatment for a degenerative spondylolisthesis is a decompression and fusion; however, the results of this survey demonstrate that surgeons consider degenerative spondylolisthesis a heterogeneous condition that requires an individualized surgical plan. Future studies are needed to evaluate the effect of variables such as age, the presence of low back pain, and the presence of dynamic instability on patient reported outcomes from various surgical options. Level of Evidence: N/A.