Late Infection of Spinal Instrumentation

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Ralph O’Connor’
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1 Abstract Late Infection of Spinal Instrumentation Jae-Ik Shim, M.D., Taik-Seon Kim, M.D., Sung-Jong Lee, M.D., Suk-Ha Lee, M.D., Dong-Ki Lee, M.D., Yoen-Sik Yu, M.D., Yun-Yeup Kim, M.D. Department of Orthopaedic Surgery, Korea Veterans Hospital, Seoul, Korea Study Design : A retrospective analysis of five cases of late spinal infection after spinal instrumentation and fusion. Objectives : These cases are reviewed to verify risk factors for late spinal infection after elective instrumentation and to manifest the treatment of this complication. Summary of Literature Review : Late spinal infection after elective spinal instrumentation and fusion are uncommon. The diagnosis is usually hard and requires much clinical suspicion. Materials and Methods : 5 cases were in total 374 patients of the author s cases. These cases are reviewed retrospectively. R e s u l t s : All patients reported aggravated back pain. 4 patients had elevated erythrocyte sedimentation rates, averaging 44.8 /hour and elevated C-reactive protein, averaging 26.2/L. No distance foci of infection was identified. All patients got the radiolucent zone around screw fixation site, averaging 4.6width. The organisms were S. epidermidis in 1 case and coagulase(-) staphylococcus in 1 case. All cases were treated by operative method with debridement, instrument removal with or without revision and postoperative intravenous antibiotics. The average follow-up period was 18.2 months, one patient recurred back pain at 7 months after operation. Conclusion : The diagnosis of late infection after elective spinal instrumentation and fusion requires high suspicion of clinical symptoms and signs. All except one were successfully treated by operative treatment. Key Words : Spine, Late infection, Instrumentation and fusion. Address reprint requests to Suk-Ha Lee, M.D. Department of Orthopaedic Surgery, Korea Veterans Hospital #6-2 Dunchon-dong, Kangdong-ku, Seoul, Korea Tel : , Fax :

2 Table 1. Data of preoprative patient characteristics Age (yrs.) Diagnosis Dx. of infection Spine Op. prior to No. of spine Op. Case 1 65 stenosis PSIF 2 spondylolisthesis Case 2 64 stenosis PSIF 1 Case 3 58 stenosis PSIF 3 spondylolisthesis Case 4 73 stenosis PSIF 1 Case 5 69 stenosis PSIF 1 Result/ Avr. stenosis(5) all PSIF 1 procedure(3) Summary 65.8 yrs spondylolisthesis(2) 2 procedure(1) 3 procedure(1) PSIF : posterior spinal instrumentation and fusion Table 2. Data on the initial operation No. of Evidence of Duration EBL Cell saver Bone fused level Postop. Inf. of Op.(min.) () graft Case 1 2 None None ICBG Case 2 2 None None ICBG Case 3 2 None None ICBG Case 4 3 None None ICBG Case 5 5 None None ICBG Result/ Avr. all Avr. Avr. None all Summary 2.8 None ICBG EBL : estimated blood loss ICBG : iliac crest bone graft

3 Table 3. Data at infection diagnosis Time to P/Ex. of Sx. prior Fever prior ESR CRP WBC Radiologic Dx.(Mos.) infection to Dx. to Dx. (/hr) (/L) (cells/ L) Findings Case 1 22 Fluctuation Back pain none wks Case Back pain none wks Case Back pain none wks Case Back pain none wks Case 5 16 Fluctuation Back pain none wks Result/ Avr. Fluctuation(2) All have none Avr. Avr. Avr. Avr. Summary 18.5 back pain Avr. 26wks Halo sign Table 4. Data on Treatment Management Intraop. Pseudoarthrosis Condition of Intraop. of infection Findings instrument culture Case 1 Instrument Removal Purulence - loose - 1 closure covering fixation Case 2 Instrument Removal Purulence + loose Coagulase(-) Revision covering fixation Staphylococcus 1 closure Case 3 Instrument Removal Purulence + loose - Revision covering fixation 1 closure Case 4 Instrument Removal Purulence + loose - Revision covering fixation 1 closure Case 5 Instrument Removal Purulence - loose S. epidermidis 1 closure covering fixation Result/ Removal (2) Purulence Pseudoarthrosis(3) loose Summary Removal & covering(5) fixation(5) revision (3)

4 Table 5. Data on postop. & follow-up Postop. WBC ESR CRP Subsequent Outcome Follow-up antibiotics normalization spine op. (Mo.) Case 1 ceftizoxime 6wks 10 days 12wks 10wks none Inf. resolved 46 Floxin 6wks balance stable Case 2 ceftizoxime 4wks all not elevated PSIF Inf. resolved 13 Floxin 6wks preop. balance stable Case 3 ceftizoxime 4wks - 6wks 4wks PSIF Inf. resolved 12 Floxin 6wks balance stable Case 4 YAMA 6wks - 8wks 6wks PSIF Inf. resolved 14 Floxin 2wks balance stable Case 5 YAMA 6wks - 6wks 4wks none Inf. resolved 12 Floxin 2wks balance stable Result/ PSIF(3) Avr. Summary 18.2 YAMA : cefotetam sodium

This lateral lumbar spine radiographs showed primary postoperative state. Fig. 1-B.

5 A B C Fig. 1-A. 65-year-old man underwent 2 times operation in lumbar spine with instrumentation. This lateral lumbar spine radiographs showed primary postoperative state. Fig. 1-B. This radiographs showed secondary postoperative state. Fig. 1-C. 22 months later, radiograph showed radiolucent zone 7width(arrow head). D Fig. 1-D. He underwent device removal and debridement

6 A B C Fig. 2-A. 58-year-old man underwent 3 times operation in lumbar spine with instrumentation. This radiograph showed last operative state. Fig. 2-B. 13 months later, radiograph showed 3 mm halo sign with bony destruction lesion(arrow head). Fig. 2-C. He underwent device removal, debridement and revision

7 REFERENCES 11) Bauer TW and Saltarelli MG : Infection versus aseptic loosening in revision arthroplasty : Predictive value of frozen section and other laboratory tests, Orthop Trans, 17:1054, ) Dubousset J, Shufflebarger H and Wenger D : Late infec - tion with Cotrel-Dubousset instrumentation, Orthop Trans,

8 18:121, ) Hegeness MH, Esses SI, Errico T and Yuan HA : Late infection of spinal instrumentation by hematogenous seed - ing, Spine, 18: , ) Kostuik JP, Israel J and Hall JE : Scoliosis surgery in adult, Clin Orthop, 93: , ) Louis R : Fusion of the lumbar and sacral spine by internal fixation with screw plates, Clin Orthop, 203:18-33, ) Merritt K and Dowd JD : Role of internal fixation in infection of open fractures: Studies with Staphylococcus aureus and Proteus mirabilis, J Orthop Res, 5:23-28, ) Richards BS : Delayed infections following posterior spinal instrumentation for the treatment of idiopathic scolo - sis, J Bone Joint Surg, 77-A: , ) Roy-Camille R, Saillant G and Mazel C : Internal fixation of the lumbar spine with pedicle screw plating, Clin Orthop, 203:7-17, ) Schofferman L, Zucherman J, Schofferman J and et al. : Diptheroids and associated infections as a cause of failed instrument stabilization procedures in the lumbar spine, Arch Pathol, 16: , ) Shufflebarger HL, Thompson J and Clark CE : C o m p l i - cations of Cotrel-Dubousser instrumentation in idiopathic scoliosis, Ortho Trans, 16: , ) Transfeldt EE and Lonstein JE : Wound infections in elective reconstructive spinal surgery, Orthop Trans, 9:128, ) Viola RW, King HA, Adler SM and Wilson CB : D e l a y e d infection after elective spinal instrumentation and fusion, Orthop Trans, 9:128,

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