The X-Ray Shows Instrumentation Failure-What I Do Christopher - - PowerPoint PPT Presentation

The X-Ray Shows Instrumentation Failure-What I Do

Christopher Brown M.D. Duke University

Disclosure

• NuVasive:

– Royalties – Consulting – Fellowship Support

Classification of Complications

• Biologic Failure related to:

– Infection – Pseudarthrosis

• Biomechanical Failure
• Error in thought process
• Error in application

Early Hardware Failure

• HPI: 70 y/o male with bilateral LE leg pain for

greater than 2 years, failed conservative

• treatment. Initially had a good response to

ESI.

• L4/L5 Lateral interbody fusion, L5/S1 ALIF,

L4-S1 Posterior spinal fusion

• Post operatively had complete resolution of

his lower extremity complaints

• Discharged to home POD # 2

• 4 weeks post op was admitted with acute
• nset back pain and bilateral lower extremity

complaints.

– Afebrile, WBC 10.5, CRP 1.82, SED Rate: 78

• MRI:
• CT: L4-L5 cage subsidence, loosening of

right L4 screw

Spinal Infection

• Up to 2.8-6% of instrumented cases (1,2,3).
• Risk factors:

– DM, Smoking, previous spine surgery, obesity, malnutrition, immunocompromised, corticosteroids (4, 5, 6).

• Three potential sources for infection:

– Direct inoculation – Contaminated during early postoperative period – Hematogenous seeding (7, 8, 9).

• Gram positive organism account for more than 50% of infections:

– Staph aureus (most common), staph epidermidis (2, 10, 11). – Infections that present greater than 1 year are generally caused by low-verulence organisms such as coagulase-negative staph and propionibacterium (9, 12).

Clinical Presentation

• Most common presenting symptom is pain.
• Generally have an interval pain free period

immediately following surgery and then develop increasing pain(13).

• Fever is the most common constitutional

symptoms however, many patients with deep infection will have no systemic symptoms (13).

Laboratory Testing

• WBC with differential, ESR, CRP
• ESR should normalize following surgery in 3-

6 wks (14, 15).

• CRP levels generally peak on post operative

day three and return to baseline by 10-14 days (15, 16).

• Blood cultures should be obtained.
• The most accurate cultures are those
• btained during surgical debridement (13).

Imaging

• Plain radiographs typically require 4 weeks to

pass until evidence of infection is evident (17).

• CT allows for earlier detection. Evaluate for

endplate changes, bony lysis and or soft tissue fluid collection (13).

• MRI with and without gadolinium is the most

effective imaging technique available.

– The most reliable finding consentient with early infection is increased signal intensity of the adjacent vertebral body on T1 weighted images (58).

Management

• The ultimate goal is eradication of the

infection

• Surgical debridement should consist of

excision of all infected dermal margins and subcutaneous layer with exploration of the deep fascia (13).

Management

• After specimens for culture have been
• btained broad spectrum antibiotics are

started.

• Bone graft that is infected or loosened should

be removed (19,20,21,22).

Management

• Instrumentation should be routinely
• inspected. Implants with obvious signs of

loosening should be removed (13).

• Well fixed instrumentations can remain (28,29, 30,

31, 32, 33).

• Ideally instrumentation is maintained until

fusion occurs (13).

• Pt underwent I and D with revision of L4-L5

lateral interbody cage with extension of posterior fusion to L3.

• Cultures + pan-sensitive Proprionibacterium
• Treated with 6 weeks IV antibiotics

Late Failure

• 70 y/o males s/p

previous L4-L5 posterior lateral fusion. Initially did well then had worsening back and leg pain.

• MRI showed bilateral

foraminal stenosis at L4-L5 and L5-S1

• CT lumbar spine

showed Lucency around the L4 and L5 screws

Pseudarthrosis

• Rate of pseudarthrosis after lumbar fusion is

between 5% and 35% (33, 34, 35, 36).

• Pseudarthrosis is defined by a complete

absence of continuous trabeculation between adjacent vertebrae, implant radiolucency, and or motion on dynamic films (37,38,39).

• US FDA’s define successful fusion as less than

3 mm of translation and less than 5 degrees of angular motion on flexion and extension.

Imaging

• Plain radiographs have a high false negative

rate (a11) and have a limited ability to show pseudarthrosis in the first 2-3.5 years (40, 42).

• CT has become the modality of choice for

diagnosing pseudarthrosis (42).

– At 12 months a radiolucent zone of greater than 1 mm has shown to be an early predictor of pseudarthrosis (43).

Treatment

• 360 fusion has been shown to have the

highest fusion rates (44).

• ALIF has the added advantage of avoiding

midline scar formation (45)

• Pt underwent revision

lumbar fusion

• Removal of hardware,

L3-L5 Lateral interbody fusion, L5-S1 anterior interbody fusion, with posterior instrumented fusion L3-S1

Biomechanical failure Sagittal Balance

• 68 yo 12 months post op
• Intractable back and leg pain
• Normal exam
• Normal infectious labs

Asymptomatic Hardware Failure

• 75 yo eight years after lumbar fusion
• No complaints of back or leg pain

References

1. Rechtine GR, Bono PL, Cahill D, et al: Postoperative wound infection after instrumentation of thoracic and lumbar fractures. J Orthop Trauma 2001; 15: pp. 566-569 2. Massie JB, Heller JG, Abitbol JJ, et al: Postoperative posterior spinal wound infections. Clin Orthop Relat Res 1992; 284: pp. 99-108 3. Hodges SD, Humphreys SC, Eck JC, et al: Low postoperative infection rates with instrumented lumbar fusion. South Med J 1998; 91: pp. 1132- 1136 4. aa 5. Cruse PJ, and Foord R: The epidemiology of wound infection. A v10-year prospective study of 62,939 wounds. Surg Clin North Am 1980; 60:

• pp. 27-40

6. Mishriki SF, Law DJ, and Jeffery PJ: Factors affecting the incidence of postoperative wound infection. J Hosp Infect 1990; 16: pp. 223-230 7. Sponseller PD, LaPorte DM, Hungerford MW, et al: Deep wound infections after neuromuscular scoliosis surgery: a multicenter study of risk factors and treatment outcomes. Spine 2000; 25: pp. 2461-2466 8. de Jonge T, Slullitel H, Dubousset J, Miladi L, Wicart P, and Illes T: Late-onset spinal deformities in children treated by laminectomy and radiation therapy for malignant tumours. Eur Spine J 2005; 14: pp. 765-771 9. Heggeness MH, Esses SI, Errico T, and Yuan HA: Late infection of spinal instrumentation by hematogenous seeding. Spine 1993; 18: pp. 492- 496 10. Zeidman SM, Ducker TB, and Raycroft J: Trends and complications in cervical spine surgery:1989-1993. J Spinal Disord 1997; 10: pp. 523-526 11. Wimmer C, Gluch H, Franzreb M, and Ogon M: Predisposing factors for infection in spine surgery: a survey of 850 spinal procedures. J Spinal Disord 1998; 11: pp. 124-128 12. Weinstein MA, McCabe JP, and Cammisa FP: Postoperative spinal wound infection: a review of 2,391 consecutive index procedures. J Spinal Disord 2000; 13: pp. 422-426 13. Book 14. Kapp JP, and Sybers WA: Erythrocyte sedimentation rate following uncomplicated lumbar disc operations. Surg Neurol 1979; 12: pp. 329-330 15. Thelander U, and Larsson S: Quantitation of C-reactive protein levels and erythrocyte sedimentation rate after spinal surgery. Spine 1992; 17:

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16. Fouquet B, Goupille P, Jattiot F, et al: Discitis after lumbar disc surgery. Features of “aseptic” and “septic” forms. Spine 1992; 17: pp. 356-358 17. Silber JS, Anderson DG, Vaccaro AR, et al: Management of postprocedural discitis. Spine J 2002; 2: pp. 279-287 18. Boden SD, Davis DO, Dina TS, et al: Postoperative diskitis: distinguishing early MR imaging findings from normal postoperative disk space

• changes. Radiology 1992; 184: pp. 765-771

19. Richards BR, and Emara KM: Delayed infections after posterior TSRH spinal instrumentation for idiopathic scoliosis: revisited. Spine 2001; 26:

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20. Li YZ: [Wound infection after spinal surgery: analysis of 15 cases]. Zhonghua Wai Ke Za Zhi 1991; 29: pp. 484-486

References

21. Thalgott JS, Cotler HB, Sasso RC, et al: Postoperative infections in spinal implants. Classification and analysis—a multicenter study. Spine 1991; 16: pp. 981- 984 22. Smilanich RP, Bonnet I, and Kirkpatrick JR: Contaminated wounds: the effect of initial management on outcome. Am Surg 1995; 61: pp. 427-430 23. Richards BR, and Emara KM: Delayed infections after posterior TSRH spinal instrumentation for idiopathic scoliosis: revisited. Spine 2001; 26:

• pp. 1990-1996

24. Clark CE, and Shufflebarger HL: Late-developing infection in instrumented idiopathic scoliosis. Spine 1999; 24: pp. 1909-1912 25. Hahn F, Zbinden R, and Min K: Late implant infections caused by Propionibacterium acnes in scoliosis surgery. Eur Spine J 2005; 14: pp. 783-788 26. Page CP, Bohnen JM, Fletcher JR, et al: Antimicrobial prophylaxis for surgical wounds. Guidelines for clinical care. Arch Surg 1993; 128: pp. 79-88 27. Bhandari M, Adili A, and Schemitsch EH: The efficacy of low-pressure lavage with different irrigating solutions to remove adherent bacteria from bone. J Bone Joint Surg Am 2001; 83-A: pp. 412-419 28. Glassman SD, Dimar JR, Puno RM, and Johnson JR: Salvage of instrumental lumbar fusions complicated by surgical wound infection. Spine 1996; 21: pp. 2163-2169 29. Li S, Zhang J, Li J, et al: Wound infection after scoliosis surgery: an analysis of 15 cases. Chin Med Sci J 2002; 17: pp. 193-198 30. Perry JW, Montgomerie JZ, Swank S, et al: Wound infections following spinal fusion with posterior segmental spinal instrumentation. Clin Infect Dis 1997; 24: pp. 558-561 31. Moe JH: Complications of scoliosis treatment. Clin Orthop Relat Res 1967; 53: pp. 21-30 32. Bose B: Delayed infection after instrumented spine surgery: case reports and review of the literature. Spine J 2003; 3: pp. 394-399 33. Lonstein J, Winter R, Moe J, and Gaines D: Wound infection with Harrington instrumentation and spine fusion for scoliosis. Clin Orthop Relat Res 1973; 96: pp. 222-233 34. Argenta LC, and Morykwas MJ: Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997; 38: pp. 563-576 35. Albert TJ, Pinto M, Smith MD, Balderston RA, Cotler JM, Park CH: Accuracy of SPECT scanning in diagnosing pseu-doarthrosis: a prospective study. J Spinal Disord 11:197– 199, 1998 36. DePalma AF, Rothman RH: The nature of pseudarthrosis. Clin Orthop Relat Res 59:113–118, 1968 37. Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG: Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older

• adults. JAMA 303:1259–1265, 2010

38. Herkowitz HN, Sidhu KS: Lumbar spine fusion in the treatment of degenerative conditions: current indications and recommendations. J Am Acad Orthop Surg 3:123–135, 1995 39. Kanemura T, Matsumoto A, Ishikawa Y, Yamaguchi H, Satake K, Ito Z, et al.: Radiographic changes in patients with pseudarthrosis after posterior lumbar interbody arthrodesis using carbon interbody cages: a prospective five-year study. J Bone Joint Surg Am 96:e82, 2014 40. Kannan A, Dodwad SN, Hsu WK: Biologics in spine arthrodesis. J Spinal Disord Tech 28:163–170, 2015

References

41. Cruse PJ, and Foord R: The epidemiology of wound Infection. A v10-year prospective study of 62,939 wounds. Surg Clin North Am 1980; 60: pp. 27-40 42. Richards BS: Delayed infections following posterior spinal instrumentation for the treatment of idiopathic scoliosis. J Bone Joint Surg Am 1995; 77: pp. 524-529 43. Mishriki SF, Law DJ, and Jeffery PJ: Factors affecting the incidence of postoperative wound

• infection. J Hosp Infect 1990; 16: pp. 223-230

44. Djukic S, Lang P, Morris J, et al: The postoperative spine. Magnetic resonance imaging. Orthop Clin North Am 1990; 21: pp. 603-624 45. Blam OG, Vaccaro AR, Vanichkachorn JS, et al: Risk factors for surgical site infection in the patient with spinal injury. Spine 2003; 28: pp. 1475-1480 46. Kapp JP, and Sybers WA: Erythrocyte sedimentation rate following uncomplicated lumbar disc

• perations. Surg Neurol 1979; 12: pp. 329-330

47. Potter BK, Freedman BA, Verwiebe EG, et al: Transforaminal lumbar interbody fusion: clinical and radiographic results and complications in 100 consecutive patients. J Spinal Disord Tech 2005; 18: pp. 337-346 48. Lowe TG, Tahernia AD, O’Brien MF, et al: Unilateral transforaminal posterior lumbar interbody fusion (TLIF): indications, technique, and 2 year results. J Spinal Disord Tech 2002; 15: pp. 31- 38