Spine

Prevention

General Principles

• Question 1: What can one do if an inadvertent contamination during instrumented spine surgery occurs?
• Question 2: How should patients with postoperative diarrhea following spine surgery be managed?

Antimicrobials

• Question 1: Is there a role for oral antibiotics in the prevention of infection in patients with draining wounds following spinal surgery?
• Question 2: Is there a role for the addition of gentamicin to perioperative prophylactic antibiotics in spine surgery?
• Question 3: Should prophylactic antibiotic prophylaxis be repeated during spine surgery? If so, when?
• Question 4: Should vancomycin powder be applied to the wound in patients undergoing spinal surgeries? Are there any potential harms associated with this practice?
• Question 5: What is the optimal perioperative antibiotic prophylaxis for patients undergoing spine surgery? What considerations should be made in cases of drug allergies?
• Question 6: What is the optimal prophylactic antibiotics for patients with neurogenic bladder in patients undergoing spine surgery?

Bone Graft

• Question 1: Does the use of allograft increase the risk of spinal infection?
• Question 2: Can allograft, synthetic bone substitute, or autograft be used during revision spinal surgery in patients with prior spine infection?

Risk Factors

• Question 1: Does prior or active tuberculosis preclude patients from undergoing spine surgery?
• Question 2: Should routine MRSA screening be in place prior to spine surgery?
• Question 3: Is there a role for routine decolonization of patients undergoing spine surgery? If so, what is the optimal agent(s)?
• Question 4: How should patients currently using DMARDs be managed in the perioperative period?
• Question 5: Is postoperative hyperglycemia a risk factor for the development of infection following spinal surgery?
• Question 6: Is there an association between UTI and SSI following spinal surgery?
• Question 7: What are the risk factors predisposing a patient to SSI after spine surgery?
• Question 8: What is the diagnostic algorithm of patients with suspected hematogenous vertebral osteomyelitis? Is the algorithm different for patients with tuberculosis?
• Question 9: Should all patients with psoas abscesses be screened for both spine and hip infections?

Wound Care

• Question 1: Is negative pressure wound therapy safe on spinal wounds in patients with a CSF leak?
• Question 2: What are the risks and benefits for the use of Vac assisted devices/PICO dressings following spine surgery?
• Question 3: What type of surgical dressing is most effective for lowering rates of surgical site infection (SSI) in patients undergoing spine surgery?

Diagnosis

General Principles

• Question 1: What is the definition of surgical site infection in spinal surgery?
• Question 2: What defines delay in the diagnosis of a spine infection?
• Question 3: Is there an optimal window for diagnosis of an early spine infection?
• Question 4: How do early and late infectious complications differ following spine surgery?
• Question 5: Are there patients with degenerative pathology, such as disc herniations, who are actually infected with a low-grade infection (e.g. Propionibacterium acnes)?
• Question 6: What is the diagnostic algorithm of patients with suspected hematogenous vertebral osteomyelitis? Is the algorithm different for patients with tuberculosis?
• Question 7: Should antibiotics be held prior to image guided biopsy/aspiration for a suspected spine infection?
• Question 8: What is the incidence of infectious meningitis following spinal surgery? Does the use of instrumentation affect this?
• Question 9: What are the early infectious complications after operations on the spine following the use of instrumentation?

Biomarkers

• Question 1: Are there any diagnostic tools that are useful for early SSI detection following spinal surgery? Does this differ if there was instrumentation or not?
• Question 2: When do common blood biomarkers (e.g. CRP, ESR, Procalcitonin) normalize after spine surgery?
• Question 3: Is there a role for the use of serum biomarker for diagnosis of spinal surgical site infection?
• Question 4: Is there a role for molecular techniques such as polymerase chain reaction (PCR) or next-generation sequencing (NGS) for diagnosis of spinal surgery infection? If so, in which group of patients should this be done?
• Question 5: What investigations should samples obtained by image-guided biopsy be sent for?
• Question 6: How many intraoperative tissue samples should be sent for culture in suspected spinal surgery infection?

Imaging

• Question 1: What is the optimal imaging in diagnosis of spine infections? If MRI is contraindicated, what imaging modality should be used?
• Question 2: Is there a role for CT scan with contrast in the diagnosis of spinal infections in patients who cannot undergo MRI?
• Question 3: Is there a role for nuclear imaging (e.g. PET scan) in the diagnosis of spinal infections?
• Question 4: How can postoperative infections be distinguished from normal postoperative changes on MRI?

Treatment

General Principles

• Question 1: Can non-surgical approach be used to treat postoperative spine infections? If so, what factors predict successful outcome?
• Question 2: When should patients with suspected infections of the spine be referred to Infectious Disease?
• Question 3: Which patients with vertebral osteomyelitis are suitable for outpatient management? Does any criteria exist to aid in decision making?
• Question 4: What is the optimal treatment of spinal infections caused by Propionebacterium acnes?

Antibiotics

• Question 1: Is there a role for oral antibiotics in the treatment of early postoperative spine infections?
• Question 2: Is there a role for the use of oral antibiotic in treatment of acute and chronic spinal infections?
• Question 3: Is there a role for chronic antibiotic suppression after treating patients with retained infected spinal hardware?
• Question 4: Is there a role for combination antibiotics (ie dual or triple) in treating patients with SSI following spinal surgery?
• Question 5: How long should antibiotic be administered after surgical debridement for an acute postsurgical spinal infection?
• Question 6: How long should antibiotics be continued where spinal wounds are left to heal by secondary intention?
• Question 7: What is the optimal duration of antibiotic treatment following spine infection in patients in whom hardware is retained? Is the antibiotic treatment different for those with spine infection without hardware?
• Question 8: What tests should be used to monitor response to antibiotic treatment in patients with spine infection?
• Question 9: Which is the best alternative antimicrobial therapy for fluoroquinolone-resistant gram negative acute post-surgical infection of spinal surgery?
• Question 10: Is there a difference in the efficacy of Vancomycin beads versus vancomycin powder for spinal implant infections?

Implants

• Question 1: Should a cage be removed in patients with postoperative spine infection?
• Question 2: Is there a length of time of infection beyond which instrumentation should be removed?
• Question 3: Should bone graft be removed in patients with postoperative spine infection? If yes, should a distinction be made between allograft and autograft?
• Question 4: What are the indications for implant retention or removal of hardware in spinal infections?
• Question 5: Is there a role for one-stage exchange of hardware in the presence of spinal infections?

Wound Care

• Question 1: Should infected wounds undergo primary closure or a two-stage closure?
• Question 2: What is the indication for muscle advancement flaps in patients with spinal infections?
• Question 3: What is the optimal irrigation solution (volume, type, and frequency) during clean or infected spinal surgery cases?
• Question 4: Is negative pressure wound therapy effective in the treatment of wounds that are left to heal by secondary intention?