Incidence and Recurrence of Deep Spine Surgical Site Infections: A Systematic Review and Meta-analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: To determine a pooled incidence rate for deep surgical site infection (SSI) and compare available evidence for deep SSI management among instrumented spinal fusions. SUMMARY OF BACKGROUND DATA: Deep SSI is a common complication of instrumented spinal surgery associated with patient morbidity, poorer long-term outcomes, and higher health care costs. MATERIALS AND METHODS: We systematically searched Medline and Embase and included studies with an adult patient population undergoing posterior instrumented spinal fusion of the thoracic, lumbar, or sacral spine, with a reported outcome of deep SSI. The primary outcome was the incidence of deep SSI. Secondary outcomes included persistent deep SSI after initial debridement, mean number of debridements, and microbiology. The subsequent meta-analysis combined outcomes for surgical site infection using a random-effects model and quantified heterogeneity using the χ 2 test and the I2 statistic. In addition, a qualitative analysis of management strategies was reported. RESULTS: Of 9087 potentially eligible studies, we included 54 studies (37 comparative and 17 noncomparative). The pooled SSI incidence rate was 1.5% (95% CI, 1.1%-1.9%) based on 209,347 index procedures. Up to 25% of patients (95% CI, 16.8%-35.3%), had a persistent infection. These patients require an average of 1.4 (range: 0.8-1.9) additional debridements. Infecting organisms were commonly gram-positive, and among them, staphylococcus aureus was the most frequent (46%). Qualitative analysis suggests implant retention, especially for early deep SSI management. Evidence was limited for other management strategies. CONCLUSIONS: The pooled incidence rate of deep SSI post-thoracolumbar spinal surgery is 1.5%. The rate of recurrence and repeat debridement is at least 12%, up to 25%. Persistent infection is a significant risk, highlighting the need for standardized treatment protocols. Our review further demonstrates heterogeneity in management strategies. Large-scale prospective studies are needed to develop better evidence around deep SSI incidence and management in the instrumented thoracolumbar adult spinal fusion population.

The Effect of Ponte Osteotomies on the Sagittal Shape of Rods and Spine Derotation in Adolescent Idiopathic Scoliosis: A Single-Center, Retrospective Cohort Study.

Background: Adding a Ponte osteotomy (PO) to other surgical techniques for correcting adolescent idiopathic scoliosis (AIS) profoundly affects the entire sagittal shape of the rod. POs are an effective procedure for correcting thoracic hypokyphosis in patients with AIS. Methods: A retrospective review of 40 patients with AIS was conducted. The sample was divided into 2 groups: PO and non-PO. On a lateral radiograph, the rod end angle (A) was calculated using the intersections of the tangents with the rod end points. The maximal deflection (D) was obtained for each rod. In addition, the rod apex angle (B) was calculated using the intersection of the tangents at 2 points, each 1 cm to 1 side of the rod apex; the distance between the rods at the apex was then measured. Results: Concave rods tended to be straight or even lordotic at the apex in the non-PO group (-0.9° vs. +5.9° in the PO group; P = 0.000). The rod end angle and deflection were significantly lower in the non-PO group (15.2° and 7.1 mm vs. 26.3° and 17.8 mm in the PO group; P = 0.000 and P = 0.000). The convex rods were less kyphotic in the non-PO group; for the non-PO group, the end angle and deflection were 27.6° and 16 mm versus 33.4° and 23.8 mm in the PO group (P = 0.03 and P = 0.000). No significant difference between the groups was observed for the convex rod apex angle (P = 0.8). The rod apices were more superimposed in the PO group (2.9 mm vs. 9.3 mm in the non-PO group; P = 0.000). Conclusions: POs increase the overall sagittal kyphosis and improve the three-dimensional derotation of the apex in patients with AIS.

Ponte osteotomies increase risk of intraoperative neuromonitoring alerts in adolescent idiopathic scoliosis surgery.

Background: Ponte osteotomies (PO) are commonly used in adolescent idiopathic scoliosis (AIS) surgeries to improve the coronal and sagittal deformity correction. Here, we compared the incidence of perioperative neurologic complications for patients undergoing AIS with versus without PO. Methods: In a retrospective cohort study of 80 consecutive AIS patients undergoing scoliosis correction, 40 underwent PO, while 40 did not. All operations were performed by one surgeon at one tertiary care center. Patients' demographics, Lenke classifications, surgical data, and deformity characteristics were comparable in both groups. Perioperative neurologic complications, defined as spinal cord or nerve root injuries identified by the surgeon, were tracked for those undergoing AIS surgery with or without PO being performed. Results: The risk of IOM alerts was significantly higher in the PO patients (12.5%: 5 patients) versus those in the No-PO group (0%, P = 0.021). Despite these changes, no patient incurred an increased postoperative deficit. Nevertheless, PO group patients demonstrated a higher coronal deformity correction rate (PO: 71% ± 10.9 vs. NoPO: 64.2% ± 11.5, P = 0.008) and a greater kyphosis Cobb angle (PO: 25.2 ± 6 vs. No-PO: 17.5 ± 9.4, P = 0.0001) on postoperative follow-up. Conclusion: While PO improved 3D correction of AIS, it increased the risk of IOM alerts in 12.5% of cases.