Better guidelines needed to manage postoperative spine infection
NEW YORK — Compared to the literature available about how to manage acute and chronic infection in the total joint arthroplasty, few guidelines are available to help orthopedic surgeons manage postoperative infection in spine surgery patients, an orthopedic spine surgeon said at the Musculoskeletal Infection Society Annual Open Scientific Meeting, here.
“The large national associations, like the North American Spine Society and [American Academy of Orthopaedic Surgeons] AAOS, we really don’t have guidelines from them and that’s partly because of the data or the lack thereof. Clinical practice is highly variable,” Joseph H. Schwab, MD, MS, said.
He took a straw poll among the group of surgeons with which he practices.
“In terms of approaching the management and diagnosis of these patients, it is really all over the place, even in my hospital. It is a blind spot that we have. We lag behind arthroplasty quite a bit,” Schwab said.
What is known, however, is irrigation and debridement with retention of hardware for acute infection has been around from as far back as the 1950s when the Harrington rod was developed for scoliosis correction, according to Schwab.
“You really don’t want to take out that rod if you have an infection,” he said.
The diagnosis of a suspected acute infection in patients after spine surgery should typically involve an investigation of the clinical presentation of signs of possible infection, such as wound drainage, unexplained pain or fever, according to Schwab.
“Serologic factors are also important,” he said.
C-reactive protein and erythrocyte sedimentation rate tests are reasonable studies to undertake in such cases, but “it is not always going to be diagnostic, especially in the acute setting,” Schwab, who is chief of spine surgery at Massachusetts General Hospital in Boston, said.
Clinicians should consider ordering an MRI in patients who develop unexplained pain after spine surgery. This practice is done, he said, not necessarily because a patient is suspected of having an acute infection, but because it may reveal a hematoma or other noninfectious cause of pain.
“Your index of suspicion, why you are ordering the test, I think can help you in terms of interpreting the results of that test,” Schwab said.
Chronic spine infection, which Schwab said is a less common problem, is defined as infection that occurs more than 1 year postoperatively.
Once the diagnosis is made, “they need surgical debridement,” he said.
Whether the instrumentation is retained or explanted at this time, “depends on whether or not fusion has occurred, how stable do you think the spine is if you were to remove the instrumentation.” Schwab said. – by Susan M. Rapp
Schwab JH. Postoperative spine infections with collections (paraspinal, epidural and subdural). Presented at: Musculoskeletal Infection Society Annual Open Scientific Meeting; Aug. 2-3, 2019; New York.
Disclosure: Schwab reports he is a paid presenter or speaker for Stryker.