Behrooz A. Akbarnia, Muharrem Yazici and George H. Thompson (eds.)The Growing Spine10.1007/978-3-662-48284-1_37

37. Post-operative Infection in Early-Onset Scoliosis

Francisco J. Sanchez Pérez-Grueso¹

(1)

Department of Spine Surgery Orthopedics, Hospital Universitario La Paz., P° De La Castellana 261, Madrid, 28046, Spain

Francisco J. Sanchez Pérez-Grueso

Email: perezgrueso@gmail.com

37.1 Introduction

37.2 Pathophysiology

37.3 Clinical Diagnosis

37.4 Treatment

References

Keywords

Early-onset scoliosisPostoperative infectionDistraction-based techniquesGrowth-friendly techniques

Key Points

The prevalence of deep postoperative surgical site infection associated with growth-friendly techniques is higher than that associated with standard spine fusion in adolescents.
The reported post-operative infection rate is 5.3–30 % in patients treated with distraction-based systems.
Significant risk factors for deep postoperative infection are repeated surgeries, neuromuscular diagnoses and stainless-steel implants.
A deep infection will require aggressive irrigation, debridement and specific intravenous antibiotics.
Even though traditional concept suggests the removal of the implants to clear the infection, new available data confirm that many patients with deep infection and implants left in place had completed the growing-rod treatment or continued the lengthening programme.

37.1 Introduction

Spinal surgery in children under 10 years of age is mainly used to treat deformities such as congenital scoliosis that requires early short fusion treatment with or without hemivertebra resection [11] or more commonly to treat deformities that affect a large part of the spine and that cannot be fused early due to a risk of serious repercussions on the length of the spinal column and the shape of the rib cage. Distraction-based growing systems (VEPTR, growing rods) [5, 21, 22] reduce the magnitude of the deformity and at the same time allow the spine and chest to grow using repeated lengthening surgeries.

There is hardly any information on the incidence of post-operative infections in children subjected to short arthrodesis [12], but it appears to be minimal and depends on the use of implants, the size of which may compromise the child’s skin and the healing process of the surgical wound.

Information on post-operative infections in distraction-based systems is more abundant but mostly in relation to its incidence and not to its management and medium- and long-term results [1, 3]. A recent study has provided valuable information about how deep postoperative infection ultimately affects treatment outcomes in growth-friendly techniques [13].

37.2 Pathophysiology

The post-operative infection rate is 5.3–30 % in patients treated with distraction-based systems [15, 17] with the most significant risk factors being repeated surgeries and neuromuscular diagnoses such as myelodysplasia (poor quality of soft tissue) and cerebral palsy and non-ambulatory status. Other potential risk factors include low body weight in relation to age, a congenital absence of musculature in the rib cage and prominent implants [1, 7, 14, 20]. Stainless-steel implant material is also a significant risk factor for deep surgical site infection [13].

Subcutaneous or submuscular (sub-fascia) position of implants can also have a noticeable influence on the incidence of infection with 26 % on subcutaneous rods and 10 % for those submuscular rods [3].

Microorganisms most commonly identified as causal agents of infection have been coagulase-negative Staphylococcus, Pseudomonas and Proteus mirabilis. Some authors have emphasized the frequency of gram-negative organisms as causing infection in neuromuscular patients [4, 8].

37.3 Clinical Diagnosis

Deep postoperative surgical site infection has been defined by the Centers for Disease Control and Prevention (CDC) and modified by Horan et al. [10] as an infection occurring within 30 days after the operation if no implant is left in place or within 1 year if implant is in place and the infection appears to be related to the operation and involves deep soft tissues of the incision.

Clinical symptoms of infection are pain, redness and swelling around the wound and eventually exudate of the surgical wound accompanied by fever and an increase in white blood cells and CRP in blood tests. In general, imaging has little diagnostic value in severe post-operative infections.

The eradication of deep infection has been defined [13] as the return of ESR and CRP level to normal, a clean and intact wound with no drainage and no fever.

37.4 Treatment

Treatment for post-operative infection in children subject to definitive fusion should follow the same guidelines prescribed for adolescents [9]. A deep infection will require surgical intervention to carry out aggressive debridement and cleansing of the wound as well as instrumentation and bone grafting, all these accompanied by specific intravenous antibiotic treatment. The ultimate objective will be to try to maintain the instrumentation until obtaining a solid arthrodesis. The early removal of the surgical implant will cause instability and loss of the correction. Late removal once an apparently solid fusion is obtained will not guarantee that it will maintain the correction especially in cases with residual kyphosis [16].

Only gold members can continue reading. Log In or Register to continue