Michael P. Glotzbecker

Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high-risk pediatric spine surgery.

Background: Perioperative surgical site infection (SSI) after pediatric spine fusion is a recognized complication with rates between 0.5% and 1.6% in adolescent idiopathic scoliosis and up to 22% in “high risk” patients. Significant variation in the approach to infection prophylaxis has been well documented. The purpose of this initiative is to develop a consensus-based “Best Practice” Guideline (BPG), informed by both the available evidence in the literature and expert opinion, for high-risk pediatric patients undergoing spine fusion. For the purpose of this effort, high risk was defined as anything other than a primary fusion in a patient with idiopathic scoliosis without significant comorbidities. The ultimate goal of this initiative is to decrease the wide variability in SSI prevention strategies in this area, ultimately leading to improved patient outcomes and reduced health care costs. Methods: An expert panel composed of 20 pediatric spine surgeons and 3 infectious disease specialists from North America, selected for their extensive experience in the field of pediatric spine surgery, was developed. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were as follows: (1) surveyed for current practices; (2) presented with a detailed systematic review of the relevant literature; (3) given the opportunity to voice opinion collectively; and (4) asked to vote regarding preferences privately. Round 1 was conducted using an electronic survey. Initial results were compiled and discussed face-to-face. Round 2 was conducted using the Audience Response System, allowing participants to vote for (strongly support or support) or against inclusion of each intervention. Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible. Repeat voting for consensus was performed. Results: Consensus was reached to support 14 SSI prevention strategies and all participants agreed to implement the BPG in their practices. All agreed to participate in further studies assessing implementation and effectiveness of the BPG. The final consensus driven BPG for high-risk pediatric spine surgery patients includes: (1) patients should have a chlorhexidine skin wash the night before surgery; (2) patients should have preoperative urine cultures obtained; (3) patients should receive a preoperative Patient Education Sheet; (4) patients should have a preoperative nutritional assessment; (5) if removing hair, clipping is preferred to shaving; (6) patients should receive perioperative intravenous cefazolin; (7) patients should receive perioperative intravenous prophylaxis for gram-negative bacilli; (8) adherence to perioperative antimicrobial regimens should be monitored; (9) operating room access should be limited during scoliosis surgery (whenever practical); (10) UV lights need NOT be used in the operating room; (11) patients should have intraoperative wound irrigation; (12) vancomycin powder should be used in the bone graft and/or the surgical site; (13) impervious dressings are preferred postoperatively; (14) postoperative dressing changes should be minimized before discharge to the extent possible. Conclusions: In conclusion, we present a consensus-based BPG consisting of 14 recommendations for the prevention of SSIs after spine surgery in high-risk pediatric patients. This can serve as a tool to reduce the variability in practice in this area and help guide research priorities in the future. Pending such data, it is the unsubstantiated opinion of the authors of the current paper that adherence to recommendations in the BPG will not only decrease variability in practice but also result in fewer SSI in high-risk children undergoing spinal fusion. Level of Evidence: Not applicable.

Thromboembolic disease in spinal surgery: a systematic review.

Study Design. Systematic review of the literature and analysis of pooled data. Objectives. To better understand the incidence of thromboembolic disease in postoperative spinal patients, and to establish a starting point for defining appropriate postoperative prophylaxis protocols. Summary of Background Data. The risk of thromboembolic disease is well studied for some orthopedic procedures. However, the incidence of postoperative thromboembolic disease is less well-defined in patients who have had spinal surgery. Methods. The MEDLINE database was queried using the search terms deep venous thrombosis or DVT, pulmonary embolus, thromboembolic disease, and spinal or spine surgery. Abstracts of all identified articles were reviewed. Detailed information from eligible articles was extracted. Data were compiled and analyzed by simple summation methods when possible to stratify rates of DVT and/or pulmonary embolus for a given prophylaxis protocol, screening method, and type of spinal surgery. Results. Twenty-five articles were eligible for full review. DVT risk ranged from 0.3% to 31%, varying between patient populations and methods of surveillance. Pooling data from the 25 studies, the overall rate of DVT was 2.1%. DVT rate was influenced by prophylaxis method: no prophylaxis, 2.7%; compression stockings (CS), 2.7%; pneumatic sequential compression device (PSCD), 4.6%; PSCD and CS, 1.3%; chemical anticoagulants, 0.6%; and inferior vena cava filters with/without another method of prophylaxis, 22%. DVT rate was also influenced by the method of diagnosis, ranging from 1% to 12.3%. Conclusion. As risk of DVT after routine elective spinal surgery is fairly low, it seems reasonable to use CS with PSCD as a primary method of prophylaxis. There is insufficient evidence to support or refute the use of chemical anticoagulants in routine elective spinal surgery. In addition, there is insufficient evidence to suggest that screening patients undergoing elective spinal surgery with ultrasound or venogram is routinely warranted.

Postoperative spinal epidural hematoma: a systematic review.

Study Design. Surgeon survey. Objective. To characterize the incidence of epidural hematoma in postoperative spinal patients; to assess the effect of chemical thromboprophylaxis on the risk of epidural hematoma. Summary of Background Data. The precise indications and/or timing of anticoagulation for thromboembolic prophylaxis following spinal surgery are not clear. Patients who endure periods of extended recumbency and limited mobility after major operative spinal interventions may be at increased risk of thromboembolic disease. Among other factors, spine surgeons must weigh the risk of a symptomatic postoperative epidural hematoma against the benefit of DVT/PE prevention when deciding to initiate chemoprophylaxis. However, the incidence of postoperative epidural hematoma is not well-known, leading to uncertainty regarding the real versus perceived risk of this complication. Methods. The MEDLINE database was queried using the search terms epidural hematoma and spinal or spine surgery. Abstracts of all identified articles were reviewed. Studies were deemed eligible if they specifically documented the incidence of clinically significant epidural hematoma in a series of patients who underwent spinal surgery. Detailed information from eligible articles was extracted. Data were compiled and analyzed to examine incidences of clinically relevant postoperative epidural hematoma (i.e., resulted in new, associated neurologic deficit). Results. Of 493 abstracts that were identified in the search, a total of sixteen articles were eligible for full review. From this review, the range of reported incidences of epidural hematoma in the literature ranges from 0% to 0.7% in studies where patients received chemical anticoagulation and 0% and 1% in all of the included studies. In no study was the incidence of clinically relevant epidural hematoma greater than 1%. Conclusion. The catastrophic morbidity of a symptomatic postoperative epidural hematoma remains a substantial disincentive to start chemopropylaxis after spinal surgery. The rarity of this complication makes study of its risk factors difficult. Although many surgeons perceive the risk to be higher, the reported incidences of clinically relevant postoperative epidural hematoma are lower, ranging from 0% to 1%. Despite this finding, there is insufficient published data available to precisely define the safety of postoperative chemoprophylaxis. Though not pertaining to prophylaxis, the available evidence does suggest that use of therapeutic doses of heparin in postoperative spinal patients who sustain a PE may have a higher incidence of bleeding complications.

What's the evidence? Systematic literature review of risk factors and preventive strategies for surgical site infection following pediatric spine surgery.

Background: Despite relatively high rates of surgical site infections (SSIs) after pediatric spine surgery, practice guidelines are absent. We performed a systematic review of the literature, determining the level of evidence for risk factors for SSIs and prevention practices to reduce SSIs following pediatric spine surgery. Methods: The search utilized the root search words “spine,” “scoliosis,” and “infection” resulting in 9594 abstracts. Following removal of duplicate abstracts, those that assessed only SSI rates, SSI treatment, nonoperative spine infections, or adult populations, 57 relevant studies were rated for level of evidence and graded using previously validated scales. Results: Very few studies lead to grade A (good evidence) or grade B (fair evidence) recommendations. Ceramic bone substitute did not increase the risk of SSIs when compared with autograft (grade A). Comorbid medical conditions, particularly cerebral palsy or myelodysplasia; urinary or bowel incontinence; nonadherence to antibiotic prophylaxis protocols; and increased implant prominence increase the risk of SSIs (grade B). SSIs caused by gram-negative bacilli were more frequent in neuromuscular populations and first-generation stainless steel implants increased the risk of delayed infection compared to newer generation titanium implants (grade B). Evaluations of other risk factors for SSIs yielded conflicting or poor-quality evidence (grade C); these included malnutrition or obesity; number of levels fused or fusion extended to the sacrum/pelvis; blood loss; and use of allograft. Insufficient evidence (0 to 1 published studies) was available to recommend numerous practices shown to reduce SSI risk in other populations such as chlorhexidine skin wash the night before surgery, preoperative nasal swabs for Staphylococcus aureus, chlorhexidine skin disinfection, perioperative prophylaxis with intravenous vancomycin, vancomycin, or gentamicin powder in the surgical site or graft. Conclusions: Few studies have evaluated risk factors and preventive strategies for SSIs following pediatric spine surgery. This systematic review documents the relative lack of evidence supporting SSI prevention practices and highlights priorities for research. Level of Evidence: Level III therapeutic study.

Langerhans cell histiocytosis: a primary viral infection of bone? Human herpes virus 6 latent protein detected in lymphocytes from tissue of children.

To better understand the etiology of Langerhans cell histiocytosis (LCH), the authors analyzed tissue from 35 children diagnosed with LCH for the presence of viral proteins and DNA by immunohistochemistry (IHC) and in situ hybridization (ISH). Eighteen control biopsies were obtained from patients without LCH. Confirmatory ISH was randomly performed on four positive and two negative cases determined by IHC. Twenty-five (71.4%) tissue samples with LCH involvement stained by IHC with the 101-kDa antibody against human herpesvirus-6 (HHV-6). None were positive with antibodies against the p41/38 or gp110 viral proteins. Five (27.7%) positive control tissues demonstrated presence of the 101-kDa viral protein in a similar fashion. The difference in the prevalence of HHV-6 in LCH-positive tissues (25/35) when compared with control tissues from patients without LCH involvement (5/18) was statistically significant. ISH confirmed the IHC in all six tissues tested. These findings demonstrate an association between HHV-6 and LCH, suggesting a role for the HHV-6B in the etiology of this disease.

Primary non-hodgkin's lymphoma of bone in children

BACKGROUND Primary non-Hodgkins lymphoma of bone, often more simply referred to as primary lymphoma of bone, is a rare subset of non-Hodgkins lymphoma in children. There are only a few small series of primary lymphoma of bone in children with long-term follow-up, and none have appeared in the orthopaedic literature. METHODS A review of our institutions Pediatric Tumor Registry identified fifteen cases of primary lymphoma of bone among 306 cases of diagnosed non-Hodgkins lymphoma between 1970 and 2003. Retrospective evaluation included collection of demographic, clinical, radiographic, treatment, and follow-up data. A univariate analysis was used to assess the prognostic significance of risk factors with respect to survival of patients from this series and in a summary analysis of data collected from similar series in the literature. RESULTS The patients included ten male and five female patients with a mean age of 11.6 years. Most patients had a presenting complaint of pain and had swelling and/or tenderness on physical examination. Eight children had a solitary bone lesion, and seven had multiple bone lesions. Overall, the mean number of bones involved was 3.1 per patient. The femur and the pelvis were the most frequently involved bones. The ten surviving patients were followed for a mean of 13.6 years. Five patients died: three of disease progression, one of treatment-related complications, and one of an unrelated cause. The mean time from diagnosis to death was 2.1 years. Nine patients received chemotherapy only, whereas six patients received a combination of chemotherapy and radiation therapy. In the present study, an age of nine years or less was predictive of poor survival (p < 0.05). In the summary analysis of cases collected from the literature, advanced stage, young age, non-large-cell histology, and multiple-bone involvement were predictive of poor survival (p < 0.05). CONCLUSIONS On the basis of the present series and a comprehensive review of similar series in the literature involving patients with primary lymphoma of bone, it appears that younger age, advanced-stage disease, multiple-bone involvement, and non-large-cell histology are associated with decreased survival as compared with older age, localized disease, single-bone involvement, and large-cell histology, respectively.

Surgical site infection after pediatric spinal deformity surgery

The incidence of surgical site infection (SSI) after spinal deformity surgery for adolescent idiopathic scoliosis ranges from 0.5–6.7%. The risk of infection following spinal fusion in patients with neuromuscular scoliosis is greater, with reported rates of 6.1–15.2% for cerebral palsy and 8–41.7% for myelodysplasia. SSIs result in increased patient morbidity, multiple operations, prolonged hospital stays, and significant financial costs. Recent literature has focused on elucidating the most common organisms involved in SSIs, as well as identifying modifiable risk factors and prevention strategies that may decrease the rates of infection. These include malnutrition, positive urine cultures, antibiotic prophylaxis, surgical site antisepsis, antibiotic-loaded allograft, local application of antibiotics, and irrigation solutions. Acute and delayed SSIs are managed differently. Removal of instrumentation is required for effective treatment of delayed SSIs. This review article examines the current literature on the prevention and management of SSIs after pediatric spinal deformity surgery.

Pediatric primary bone lymphoma-diffuse large B-cell lymphoma: morphologic and immunohistochemical characteristics of 10 cases.

Most primary bone lymphomas (PBLs) are diffuse large B-cell lymphomas (DLBCLs). Pediatric PBL-DLBCL has a favorable prognosis but remains poorly characterized. Herein, 10 such cases are detailed. They involved 11- to 20-year-old males with bone lesions that were often painful. They were diagnosed often after months to years of symptoms, suggesting an indolent disease. All were successfully treated with chemotherapy with or without radiotherapy (0.5- to 24-year followup). Biopsy revealed that the lymphomas were paratrabecular or diffuse and were medium- to large-sized with round to irregular nuclei, dispersed chromatin, indistinct to small nucleoli, and abundant cytoplasm. Other features included varying levels of necrosis, cytoplasmic retraction, and myeloid hyperplasia. All cases marked as mature B cells, and most were CD10+ (7/10). Typical centroblastic morphologic features with nucleoli were rare, multilobated nuclei were uncommon, and CD10 negativity did not predict poor prognosis, unlike in the adult PBL-DLBCL. These findings suggest that pediatric and adult PBL-DLBCLs are distinct entities.

Acute compartment syndrome in children and teenagers with tibial shaft fractures: incidence and multivariable risk factors.

Objectives: To identify the incidence of acute compartment syndrome (ACS) in children and teenagers with tibial shaft fractures and report associated risk factors. Design: Retrospective Case Control. Setting: Level 1 pediatric trauma hospital. Patients/Participants: Two hundred sixteen tibial shaft fractures in 212 patients (160 males and 52 females; median age, 13 years) over a 5-year period were reviewed. Intervention: One hundred thirty-two (61%) fractures were treated with closed reduction and casting, 36 with external fixation, 27 with locked intramedullary nails, and 21 with flexible intramedullary nails. Main Outcome Measures: ACS was diagnosed clinically or by intracompartment pressure. Multivariable logistic regression analysis tested age, gender, weight, physeal status, mechanism of injury, time to surgery, fracture type, and treatment intervention as possible risk factors for development of ACS. Results: There were 25 (11.6%) cases of ACS. Multivariable predictors of ACS included age of 14 years and older (22/96 = 23% vs. 3/120 = 3%, P < 0.001) and motor vehicle accident (MVA) (13/57 = 23% vs. 12/159 = 8%, P < 0.001). Incidence of ACS was 48% among patients aged 14 years and older, who sustained MVA (12/25). Gender, physeal status, time to surgery, and surgical fixation were not predictive of ACS. Conclusions: This is the largest study in children and teenagers reporting the incidence of ACS from tibial shaft fractures. The incidence of 11.6% is higher than previously reported and much higher in patients older than14 years of age and involved in an MVA. Surgeons should be especially aware and suspicious of this diagnosis in teenagers with tibial shaft fractures. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Best Practices in Intraoperative Neuromonitoring in Spine Deformity Surgery: Development of an Intraoperative Checklist to Optimize Response

STUDY DESIGN Consensus-based creation of a checklist and guideline. OBJECTIVE To develop a consensus-based checklist to guide surgeon responses to intraoperative neuromonitoring (IONM) changes in patients with a stable spine and to develop a consensus-based best practice guideline for IONM practice in the United States. SUMMARY OF BACKGROUND DATA Studies show that checklists enhance surgical team responses to crisis situations and improve patient outcomes. Currently, no widely accepted guidelines exist for the response to IONM changes in spine deformity surgery. METHODS After a literature review of risk factors and recommendations for responding to IONM changes, 4 surveys were administered to 21 experienced spine surgeons and 1 neurologist experienced in IONM. Areas of equipoise were identified and the nominal group process was used to determine items to be included in the checklist. The authors reevaluated and modified the checklist at 3 face-to-face meetings over 12 months, including a period of clinical validation using a modified Delphi process. The group was also surveyed on current IONM practices at their institutions. This information and existing IONM position statements were used to create the IONM best practice guideline. RESULTS Consensus was reached for the creation of 5 checklist headings containing 26 items to consider in the response to IONM changes. Consensus was reached on 5 statements for inclusion in the best practice guideline; the final guideline promotes a team approach and makes recommendations aimed at decreasing variability in neuromonitoring practices. CONCLUSIONS The final products represent the consensus of a group of expert spine surgeons. The checklist includes the most important and high-yield items to consider when responding to IONM changes in patients with a stable spine, whereas the IONM guideline represents the group consensus on items that should be considered best practice among IONM teams with the appropriate resources.