Imaging

• Contrast-enhanced magnetic resonance imaging (MRI) to evaluate for fluid collections/abscesses, soft tissue masses, and spinal cord involvement
  
  
  
  
  • Artifact from hardware may limit evaluation of the spinal canal
  
  
• Computed tomography (CT) without contrast to evaluate osseous erosions and hardware integrity; thin-slice acquisition with sagittal and coronal reconstructions (spine protocol)
  
• Computed tomography with contrast to evaluate extent of soft tissue involvement and characterize fluid collections; either spine-protocol or routine body CT with contrast; may be less important if a contrast-enhanced MRI is performed
  
• Plain film may show endplate erosive changes, change in hardware position
  
• Gallium scan is nuclear medicine modality of choice and can assist in cases where diagnosis is unclear. Indium-labeled leukocyte scan is less sensitive, as false positive and false negative results are not uncommon. Technetium-labeled leukocyte scan is unreliable.
  
• Bone scan can sometimes give added information in addition to gallium scan; needs to be performed prior to gallium scan because of overlapping emission spectrum
  
• Postoperative inflammation and granulation tissue formation may decrease sensitivity to detecting a mild infection
  
• Positron emission tomography-CT and technetium-labeled ciprofloxacin may have a role in the future

Laboratory Investigations

• C-reactive protein and erythrocyte sedimentation rate at baseline and periodically to monitor treatment progress
  
• Interventional/open biopsies are often low-yield and infrequently needed
  
• Wound cultures are effective in identifying organism(s)

• Cephalexin 500 mg by mouth every 6 hours for 2 weeks for virtually any postoperative wound concern
  
• Wound cultures, aspirates better than swabs
  
• Keep superficial wound infections from spreading to involve hardware
  
• Consider infectious diseases consultation

Preoperative Care

• Antibiotic shampoo/shower
  
• Prophylactic antibiotics should be used to prevent secondary infection from skin organisms (do not omit prophylactic antibiotics to “improve culture yields”)
  
• Patient and family must understand that there are multiple competing problems, including infection, pain, neurologic deficits, instability/malalignment, etc. Multiple procedures and a lengthy course of treatment may be required to address these problems. Ideally, the possibility of wound infection was dicsussed before initial procedure.
  
• Important philosophical point: it is better to have an infected wound where the neural elements are decompressed and the spine is fused in good alignment than have a sterile wound which is unstable or has persisting compression.

Equipment

• Standard spine retractors
  
• Pulsed lavage with appropriate antibiotics
  
• Be prepared to remove/replace implants

Operating Room Set-up

• Prepare for complete decompression and decompression of infected tissues

Positioning

• Dictated by region of spine to be addressed

Exposure

• Be prepared to extend exposure to allow for complete débridement and to permit stabilization with possibility of extending levels to be treated if ligamentous laxity noted in adjacent segments
  
• If the fascia is intact and there is no compelling reason to open it, do not (it may now be possible to use a vacuum assisted closure device)

Decompression

Reconstruction

• Remove, clean, and replace bone graft material; consider supplementing with allograft/synthetics especially if they can serve as carriers for appropriate antibiotics.
  
• Anticipate ligamentous laxity because of infection.
  
• Carefully evaluate adjacent segments.

• Drain wound to prevent collection formation which may become infected
  
• Consider closed irrigation system
  
• Bracing to support instrumentation