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  • Lumbar Laminectomy And Fusion With Routine Local Application Of Vancomycin Powder: Decreased Infection Rate In Instrumented And Non-instrumented Cases

    Final Number:

    Russell G. Strom MD; Donato Pacione; Stephen Kalhorn MD; Anthony K. Frempong-Boadu

    Study Design:
    Clinical Trial

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2013 Annual Meeting

    Introduction: Wound infections are one of the most common and potentially devastating complications of spinal surgery. Intra-wound application of vancomycin powder has been shown to lower the infection risk following posterior instrumented thoracolumbar fusion, but little evidence supports use in other spinal operations. The goal of this study is to assess the efficacy of vancomycin powder for lumbar laminectomy and fusion, both instrumented and non-instrumented.

    Methods: All cases of lumbar laminectomy and posterior fusion (with or without pedicle screw fixation) by the senior author were reviewed from 2007 to 2011. Routine local application of 1 gram vancomycin powder was started in August 2009. Baseline and operative characteristics were compared between untreated patients and those who received vancomycin powder. Rates of wound infection were compared for all fusions, and then separately for instrumented and non-instrumented cases.

    Results: 253 patients underwent lumbar laminectomy and fusion between 2007 and 2011. Baseline and operative variables were similar between untreated (n=97) and treated patients (n=156) (Table 1). Follow-up ranged from 1.1 to 5.8 years. The infection rate fell significantly following introduction of vancomycin powder (from 11% to 0%, p=0.000018). Subgroup analysis revealed significant infection reduction for both instrumented and non-instrumented cases (Table 2). Vancomycin powder was not associated with pseudarthrosis (0/97 untreated patients versus 1/156 treated patients). There were no cases of renal failure, hearing loss, or other systemic complications attributable to vancomycin powder.

    Conclusions: Local vancomycin powder appears to lower the risk of wound infection following lumbar laminectomy and fusion, both instrumented and non-instrumented. Pseudarthrosis and selection for resistant organisms are important potential complications, and while not found in this series, some cases may have been missed owing to limited follow-up. Further studies are needed to optimize dosing and assess long-term safety and efficacy.

    Patient Care: Wound infections are one of the most common and potentially devastating complications of spine surgery. Vancomycin powder is a low-cost prophylactic measure but it is unclear which populations benefit from this intervention. This study suggests that vancomycin powder is effective at preventing infection in patients undergoing either instrumented or non-instrumented lumbar spine surgery.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) Discuss the efficacy of vancomycin powder in instrumented and non-instrumented lumbar spine surgery 2) Discuss the potential complications of vancomycin powder 3) Appreciate the need for further studies on proper dosing and long-term safety and efficacy.

    References: 1. Calderone RR, Garland DE, Capen DA, Oster H. Cost of medical care for postoperative spinal infections. Orthop Clin North Am 1996;27:171-182. 2. Collins I, Wilson-MacDonald J, Chami G, Burgoyne W, Vineyakam P, Berendt T, Fairbank J. The diagnosis and management of infection following instrumented spinal fusion. Eur Spine J 2008;17:445-450. 3. Rechtine GR, Bono PL, Cahill D, Bolesta MJ, Chrin AM. Postoperative wound infection after instrumentation of thoracic and lumbar fractures. J Orthop Trauma 2001;15:566-569. 4. Schimmel JJ, Horsting PP, de Kleuver M, Wonders G, van Limbeek J. Risk factors for deep surgical site infections after spinal fusion. Eur Spine J 2010;19:1711-1719. 5. O'Neill KR, Smith JG, Abtahi AM, Archer KR, Spengler DM, McGirt MJ, Devin CJ. Reduced surgical site infections in patients undergoing posterior spinal stabilization of traumatic injuries using vancomycin powder. Spine J 2011;11:641-646. 6. Wimmer C, Gluch H, Franzreb M, Ogon M. Predisposing factors for infection in spine surgery: a survey of 850 spinal procedures. J Spinal Disord 1998;11:124-128. 7. Milstone AM, Maragakis LL, Townsend T, Speck K, Sponseller P, Song X, Perl TM. Timing of preoperative antibiotic prophylaxis: a modifiable risk factor for deep surgical site infections after pediatric spinal fusion. Pediatr Infect Dis J 2008;27:704-708. 8. Prokuski L. Prophylactic antibiotics in orthopaedic surgery. J Am Acad Orthop Surg 2008;16:283-293. 9. Sweet FA, Roh M, Sliva C. Intrawound application of vancomycin for prophylaxis in instrumented thoracolumbar fusions: efficacy, drug levels, and patient outcomes. Spine (Phila Pa 1976) 2011;36:2084-2088. 10. Molinari RW, Khera OA, Molinari WJ, 3rd. Prophylactic intraoperative powdered vancomycin and postoperative deep spinal wound infection: 1,512 consecutive surgical cases over a 6-year period. Eur Spine J 2012;21 Suppl 4:S476-482. 11. Edin ML, Miclau T, Lester GE, Lindsey RW, Dahners LE. Effect of cefazolin and vancomycin on osteoblasts in vitro. Clin Orthop Relat Res 1996:245-251.

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