单中心8818例脊柱畸形矫形术后深部感染的处理策略

目的探讨脊柱畸形矫形术后深部感染的发生率及其相应的处理策略。方法回顾性分析1998年1月至2017年12月接受脊柱畸形矫形术治疗8818例患者的病历资料,根据患者术后的临床症状、影像学检查及实验室检查判断是否发生深部感染。将初次手术后3个月之内发生的感染定义为早发性感染,初次手术3个月后发生的感染定义为迟发性感染。所有感染患者行清创灌洗、术后引流冲洗,并静脉应用敏感抗生素。若感染无法根除,如手术后时间不足2年,暂予伤口换药保留内固定;如手术后时间达到2年,评估融合情况满意后可在伤口清创的同时取出内固定。摄站立位全脊柱正、侧位X线片测量冠状面和矢状面参数,评估取出内固定者矫正丢失情况。结果共有60例(0.68%,60/8818)术后发生深部感染,早发性感染11例(发生率为0.12%,11/8818),迟发性感染49例(发生率为0.56%,49/8818)。两组患者在年龄、性别、手术入路及融合节段数方面的差异均无统计学意义。术后2~5年是深部感染发生的高峰期。特发性脊柱侧凸及强直性脊柱炎患者术后感染的发生率最低,综合征性及神经肌源性脊柱侧凸术后感染的发生率较高。初次培养阴性率较高,早发性感染中金黄色葡萄球菌和大肠埃希菌居多;迟发性感染中痤疮丙酸杆菌和凝固酶阴性葡萄球菌占比明显增高。经治疗后早发性感染组中9例保留内固定,2例换药至术后2年取出内固定。迟发性感染组中5例保留内固定,10例换药至术后2年取出内固定,34例手术时间超过2年直接取出内固定;其中1例患者取出内固定后1个月重新植入内固定;另有1例患者因矫正丢失在取出内固定3年后重新植入内固定。末次随访时取出内固定的患者出现了明显的冠状面矫正丢失。结论脊柱畸形矫形术后深部感染的发生率为0.68%,早发性感染发生率较低,迟发性感染较高;神经肌源性脊柱侧凸与综合征性脊柱侧凸患者有着较高的感染风险。如果感染在反复清创后无法根除,推荐在术后2年骨融合后取出内固定,但仍存在矫正丢失的风险。

Incidence and management of deep surgical site infection following spinal deformity surgery:8818 cases at a single institution

Objective To investigate the incidence and management of deep surgical site infection(SSI)after the spinal deformity surgery.Methods This study retrospectively reviewed a consecutive cohort of 8818 patients with spinal deformity who received spinal deformity surgery between January1998 and December 2017 at our center.The diagnosis of deep SSI was based on the clinical symptoms,imaging data and laboratory findings.Early infection and late infection were defined as deep infections occurring<3 months and>3 months after the initial procedure,respectively.All deep SSIs were first treated with irrigation and debridement,closed suction irrigation system and antibiotics.If the infection cannot be eradicated,dressing change is recommended within 2 years after the initial surgery.The instrumentation can be removed 2 years after the initial surgery with careful evaluation of the fusion mass.The posterior-anterior and lateral radiographs were used to measure the coronal parameters and sagittal alignment.Results Sixty patients were diagnosed as deep SSI after spinal deformity surgery,including 11 patients with early infection and 49 patients with late infection.No significant difference was observed in terms of age,gender ratio,surgical approach and fusion levels between the two groups.Deep SSI seemed to be more likely to occur between 2 and 5 years after surgery.Incidence of SSI was lowest in the patients with idiopathic scoliosis and ankylosing spondylitis,and highest in the patients with neuromuscular and syndromic scoliosis.There was a high rate of negative culture in the primary culture.Staphylococcus aureus and Escherichia coli were the most common organisms in the early infection,while patients with late infection had a high rate of low-virulent skin flora.In the early infection group,nine patients retained instrumentation while the implants were removed 2 years after the primary surgery in 2 patients.In patients with late infection,instrumentation was retained in 5 cases and removed in 10 cases until 2 years after the primary surgery.34 cases were infected 2 years after the primary surgery and the implants were removed directly.One patient underwent reoperation with instrumentation 1 month after implant removal,another patient underwent reoperation 3 years after implant removal due to progression of deformity.Significant loss of coronal correction was noted at the latest follow-up.Conclusion The rate of deep SSI after spinal deformity surgery was 0.68%,of which the incidence of early infection and delayed infection was 0.12%and 0.56%,respectively.An increased risk of SSI in patients with neuromuscular and syndromic scoliosis was noted.If the infection cannot be eradicated after repeated debridement,we recommend instrumentation removal 2 years after the initial surgery,but there is still a high risk of loss of correction in these patients.