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  • SSI Risk Reduction Techniques in Spine Surgery

    Final Number:

    Adam MacMillan; Melissa Brodsky; Aakash Agarwal PhD; Bruce M. Frankel MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2017 Annual Meeting

    Introduction: According to a prospective randomized control trial conducted by McClelland et al, the incident rate for thoracolumbar SSI can occur in the range of 2-13%, with recent findings indicating that the incident rate is around 12.7%.[1] Furthermore, a SSI is estimated to extend a patient’s hospital stay from 7-19.5 days, with orthopedic SSI’s requiring an average of 14 additional days of hospitalization, incurring a cost of $4500 per day.[2]

    Methods: We performed a systematic review of literature to find the upcoming practices associated with SSI risk reduction in spine surgery.

    Results: The new practices involved the following: 1. Better implant handling: In a randomized prospective trial analyzing 105 consecutive instrumented surgical cases, implant coverage was found to significantly reduce the contamination rate (p=0.016).[3] A contamination rate of 2.0% (n=51) versus the 16.7% (n=59) with uncovered implants. 2. Terminally sterilized devices: In a prospective study of 49 patients, the infection rate with a terminally sterilized device was 2%. Though they lacked a control group, this rate is at the lowest end of SSI rates after spinal surgery, reported in the literature (2-12.7%).[4] Furthermore more, it was shown that within a time period of 72 hours, re-sterilized devices in hospitals had a positive bacterial growth as opposed to no bacterial growth on a terminally sterilized device.[5]

    Conclusions: SSI have been deemed by CMS as not the payers’ responsibility, as such the management of these complications should be borne by hospitals and health care providers.[6] The average hospitalization cost for an SSI resulting from orthopedic surgery is $63,000 per case at an average frequency of 5.5% of cases (built in cost of $3465 for every surgery).[1, 2] This has resulted in the advent of newer practices of better implant handling and the use of terminally sterilized devices.

    Patient Care: Reduction in the rate of surgical site infection by adapting the latest and proven practices

    Learning Objectives: . The implant coverage significantly reduces contamination rate. 2. Terminally sterilized devices results in the lowest SSI rate. 3. The cleaning and sterilization at hospitals are not as effective as the rigorously validated procedure incorporated by the implant manufactures.

    References: 1. McClelland, S., 3rd, et al., Analysis of Postoperative Thoracolumbar Spine Infections in a Prospective Randomized Controlled Trial Using the Centers for Disease Control Surgical Site Infection Criteria. Int J Spine Surg, 2016. 10: p. 14. 2. Whitehouse, J.D., et al., The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol, 2002. 23(4): p. 183-9. 3. Bible, J.E., et al., Implant contamination during spine surgery. The Spine Journal, 2013. 13(6): p. 637-640. 4. Litrico, S., et al., Single-use instrumentation in posterior lumbar fusion could decrease incidence of surgical site infection: a prospective bi-centric study. European Journal of Orthopaedic Surgery & Traumatology, 2016. 26(1): p. 21-26. 5. Hogg, N.J. and A.D. Morrison, Resterilization of instruments used in a hospital-based oral and maxillofacial surgery clinic. J Can Dent Assoc, 2005. 71(3): p. 179-82. 6. Daniels, A.H., et al., Hospital charges associated with “never events”: comparison of anterior cervical discectomy and fusion, posterior lumbar interbody fusion, and lumbar laminectomy to total joint arthroplasty. Journal of Neurosurgery: Spine, 2016. 25(2): p. 165-169.

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