1、脊柱手术部位感染,俞武良 2016-10-12,手术部位感染(Surgical site infection SSI)是一种相对常见的脊柱手术并发症，发生率为1%-14%，具有潜在的灾难性的后果。,美国托马斯杰斐逊大学的Radcliff等筛选并总结了近5年成人脊柱手术后手术部位感染的发生率、危险因素、诊断、预防及治疗的相关研究，发表在2015年The Spine Journal杂志。,1、Incidence,a prospectively collected database of 108,419 cases, the overall infection rate for lumbar sur
2、gery was 2.1% (superficial=0.8%, deep=1.3%),The incidence of SSI appears to be lower after minimally invasive spinal (MIS) surgeries A review of 1,338 MIS surgeries from multiple institutions revealed an infection rate of 0.74% in fusion/fixations and 0.22% overall a review by Parker et al compared
3、postoperative infection after open and minimally invasive transforaminal lumbar interbody fusions. 362 MIS and 1,333 open surgeries，infection rate of 4% in open spinal fusions versus 0.6% after MIS (p=0.005),2、Risk factors for infection,Medical comorbidities：anemia, diabetesmellitus, coronary artery
4、 disease, diagnosis of coagulopathy, neoplasmobesityhigher American Society of Anesthesiologist scoremalnutrition,diabetes, obesity has been found to be a risk factor for SSI skin fold thickness and L4 spinous process-skinthickness are spine-specific SSI risk factors independent of body mass index t
5、he distribution of adipose tissue and the depth of adipose tissue overlying the operative field increased the risk of SSI,the particular diagnosis is an infection risk factor patients undergoing surgery for degenerative disease have a lower infection rate compared to deformity (1.4% vs. 4.2%) Patien
6、ts undergoing surgery for trauma have a higher risk for infection compared to spinal fusion (9.4% vs. 3.7%) the risk of infection is correlated with the severityof the trauma,case order may contribute to the rate of SSI after spine surgery lumbar decompression performed later in the day (third case)
7、 led to three times higher incidence of SSI compared with those performed as the days first case contamination of the operating room, cross-contamination between health care providers during the course of the day, use of flash sterilization, and mid-day shift changes.,seasonal effect on the rate of
8、postoperativeeffect SSI incidence peaks in the summer and fall with statistically significant drops in infection rate in the spring and winter,complex procedures may present a higher risk of perioperative complications more extensive tissue dissection increased blood losslonger operative time,3、Diag
9、nosis,Increased wound drainage approximately 10 to 14 days the most common early sign of wound infection present in 67% of patients with SSI increased pain feverwound erythema,There are no universally accepted clinical diagnostic criteria for SSI.,laboratory markers,C-reactive protein (CRP) the most
10、 sensitive and is elevated in more than 98% of cases CRP rises and falls reliably in noninfected patients during the postoperative period with a peak occurring at approximately postoperative Day 3（ operative duration, region, surgery type, preoperative CRP level, number of levels ）a second peak or f
11、ailure of CRP level to normalize was a relatively accurate predictor of postoperative infection,laboratory markers,Erythrocyte sedimentation rate (ESR) a later peak than CRP, typically occurring aroundpostoperative Day 4 Absolute neutrophil count (ANC) no significant difference between the normal an
12、d infected groups up to 4 days postoperativelya significant rise in the periods 4 to 7 and 8 to 11 days postoperatively in the infected patients,laboratory markers,Serum amyloid-A (SAA) SAA is a superior marker for infection compared with CRP because of the more dramatic change in value and earlier
13、return to base line with similar kinetics Procalcitonin (PCT) PCT and CRP showed statistically significantcorrelations with the development of SSIPCT is superior to CRP in early prediction of SSI,laboratory markers,Interleukin-6(IL-6)well studied in joint replacement surgery Leukocyte esterase a rec
14、ently reported marker in periprosthetic knee joint infection 80.6% sensitivity and 100% specificity in diagnosing joint infection,In particular, few laboratory markers have been validated as a gold standard in association with culture-positive SSI.,4、Intraoperative measures,intraoperative measures t
15、o reduce infections skin preparation intraoperative behaviors wound irrigation topical antibiotic application wound closure postoperative drain use,a significant level of wound contamination occurs intraoperatively 23% of patients had positive intraoperative cultures. Of those that cultured positive
16、,11.5% developed an early SSI Implants exposed to the operating room environment significantly reduced when the implants were covered during the case the level of contamination increases directly with the amount of time it is open in the operating field.,skin preparation a significant decrease in SS
17、I rate with the use of chlorhexidine versus iodine skin prep ？Intraoperative techniques and behaviors the operative gown sterile instrument draping use of intraoperative fluoroscopy operative scrub cleanliness,wound irrigation The only irrigation agent to have been demonstrated to reduce SSI rate is
18、 povidone-iodine(PVP-I) Soaked with dilute PVP-I for 3 minutes（5% 0.35%） Copiously irrigated with normal saline before bone decortication,significant decrease in SSI after local administration of vancomycin powder,Postoperative protocols an increased mean number of days of closed suction wound drain
19、age in patients with infection versus patients without infectionuse of 2-octyl-cyanoacrylate for skin closure may decrease the rate of infection,5、Treatment,Treatment of SSI relies on early identification early diagnosis early evacuation of gross purulent material,Treatment options irrigation and de
20、bridement intravenous antibioticsprimary closure closed vacuum systemhardware retentionplastic surgery reconstruction(rotational flaps),Postoperative Infection Treatment Score for the Spine,7 14 low risk2133 high risk,6、Conclusions,Postoperative spinal SSIs can be devastating complications for both
21、the patient and the surgeon Diagnosis of a SSI after surgery on the spine is still very much a clinical diagnosis,a multifaceted approach to prevention is the key to managing infection risk the importance of strict sterile conduct during the operation is reemphasizedefforts should be made to minimize time spent in the operating suite(preoperative and intraoperative) applying local vancomycin to the surgicalregular use of antibiosis in high risk patients,
