Cervical spine surgery is commonly performed in patients with rheumatoid arthritis (6,13,31). These patients may be at increased risk for infection secondary to prolonged chemotherapeutic treatment as well as general systemic illness. Many are on long-term steroid regimens, which in itself is a known risk factor (5,32). Clark et al. (31) reviewed the results of dorsal cervical arthrodesis in 41 patients with rheumatoid arthritis. Three (7.3%) developed a superficial wound infection, with no reports of deep infection or osteomyelitis. Of note, the authors successfully managed these complications with antibiotics alone without surgical debridement. Boakye et al. (23) found that patients with cervical spondylotic myelopathy were at greater risk of infection following surgery than those with cervical spondylosis (0.43% vs. 0.15%, respectively).

Genetic and congenital disorders are believed to increase the infection risk as well (4,19). Postoperative infections in this population can significantly impact outcome. Segal et al. (19) studied a series of 10 patients with Down syndrome who underwent dorsal arthrodesis for atlantoaxial instability. The overall complication rate was high, with infection at either the wound or halo pin sites in three patients (30%). Multiple wound debridements were necessary for eradication of the infected wounds. In a series of 15 Down’s syndrome patients, Doyle et al. (4) observed one case each of wound infection and dehiscence. The wound infection resolved after surgical debridement.

Several recent investigations have more substantially quantified systemic factors that increase the risk
of postoperative infection following spinal surgery (5,23,24,32). In a large series of patients, Pull ter Gunne and Cohen (32) identified diabetes, hypertension, obesity, and a history of prior wound infection as significant risk factors for the development of postoperative infection. Interestingly, in this investigation, multivariate analysis revealed that obesity was the sole systemic factor that significantly increased the risk of infection postoperatively.

In a similar study, Olsen et al. (5) identified diabetes, obesity, and multiple medical comorbidities (American Society of Anesthesiology score of 3 or 4) as factors increasing the risk of surgical site infection. Diabetes was reported to carry the greatest risk of postoperative infection, with preoperative serum glucose levels greater than 125 mg/dL associated with a fivefold increased risk of infection (5).

The advancement of solid organ transplant technology has led to an increase in the number of these life-saving procedures being performed. Patients are living longer and with a greater quality of life, so their demands for elective surgery, such as joint replacement and spine surgery, are expected to increase. A major concern in this population is an increased risk for infection (33,34). Chronic immunosuppression is no longer a contraindication to elective surgery (33), although comparatively few reports of spine surgery in transplant recipients exist. Dunn and Aiona (33) documented successful operative treatment of scoliosis in a renal allograft recipient. The patient healed her wounds with no signs of infection. When operating on a posttransplantation individual, the surgeon must keep in mind that skin, integument, and soft tissues may be thin and attenuated from chronic immunosuppressive therapy. Modifications of prophylactic antibiotic regimens, including more broad-spectrum coverage should also be considered, especially for those on renal dialysis. These individuals can be especially prone to infection with Pseudomonas aeruginosa.

The population of patients infected with human immunodeficiency virus (HIV) continues to increase. As a result of effective antiretroviral therapy, an increasing number of these patients are living longer and will require both elective and emergent spine surgical interventions (35, 36 and 37). As the population of HIV-positive individuals remains healthier for longer periods of time as a result of improvements in treatment and prophylaxis, these issues become more relevant to spinal surgeons who perform elective cervical operations.

Surgery in this population may result in higher infection rates than the general population (35,36). It behooves surgeons to be familiar with the pertinent values used to gauge the degree of immunocompromise. One such value is the helper T-cell count, more popularly referred to as the CD4 count. It is currently believed that patients with values greater than 600 to 700 are at no greater risk for infectious complications than HIV-negative subjects, while those with 200 or less have a significantly higher risk (35,36). Although some operations in those with a CD4 count of less than 200 are emergent, elective cases in such patients might benefit from delay until the immune system is more fortified (36).

Young et al. (37) recently reviewed their experience with elective spine surgery in asymptomatic seropositive HIV patients. The average CD4 count in this cohort was 279. Of 11 patients receiving elective spine surgery in this series, only 1 developed a superficial wound infection, and this was successfully treated with antibiotic therapy only.

The relative rates of infection following ventral and dorsal surgery may approximate each other, although some authors report differences. Each approach has unique features that must be recognized in order to avoid infection.

The ventral cervical approach is used for a variety of diagnoses, including traumatic, degenerative, and congenital disorders. Perhaps the most common indication is degenerative disk disease with or without associated neurologic deficit. In these cases, the infection rate is typically low. In a series of 253 patients who underwent ventral disk surgery, Lunsford et al. (16) reported an overall rate of 1%. Bohlman et al. (12) reported no postoperative infections in 122 patients after anterior cervical discectomy and fusion, while Chin et al. (17) documented a 0% incidence in 581 consecutive patients. Bertalanffy and Eggert (1) documented 8 infections (1.6%) in 450 cases of discectomy without arthrodesis, and Fountas et al. (22) maintained a rate of 0.1% in 1,015 patients receiving anterior cervical discectomy and fusion.

Cervical surgery is often necessary in a patient with a tracheotomy. Because of the proximity of the surgical wound to the tracheotomy site, it is thought that there is an increased risk for wound infection. Northrup et al. (38) examined this question in a retrospective series of 11 patients undergoing a ventral cervical approach following a tracheostomy that had been made an average of 27 days before the ventral cervical surgery. With follow-up ranging from 6 to 51 months, no instance of wound infection was documented. Of note, the authors had studied a select group of patients with cervical cord damage resulting from blunt injury.