Factors associated with deep surgical site infection in spinal surgery

Introduction: Surgical site infection (SSI) rate in spinal surgery ranges from 1% to 9%, depending on the type of procedure and institution. SSI gives rise to increased morbidity, poorer outcomes and increased healthcare costs. Various risk factors have been reported in the literature but there is no such related report from Malaysia. This pilot study aimed to determine the incidence and risk factors of deep surgical site infections which require surgical debridement in patients who had undergone spinal surgeries. Materials and Methods: Patients who had undergone spinal surgery at Hospital Tengku Ampuan Afzan, Kuantan from the 1st January 2016 to the 31st December 2017 were included in this study. Associations between SSI and risk factors were analysed with IBM SPSS version 21. Age, body mass index, number of vertebral level involvement, hemoglobin reduction and white blood cell count were analysed by the student t-test while gender, smoking status, spinal cord involvement, fracture dislocation at thoraco-lumbar junction and history of pre-operative blood product transfusion were analysed by Fisher’s exact test. Results: Four (17%) out of 24 patients developed deep SSI which required surgical debridement. Fracture dislocation at the thoraco-lumbar junction (p=0.008) and history of pre-operative blood product transfusion (p=0.003) were associated with deep SSI. Conclusions: This study highlighted different risk factors associated with deep SSI in spinal surgeries. A larger study is needed to further confirm these findings

Factors associated with deep surgical site Infection following Spinal surgery: a pilot study

Introduction: Surgical site infection (SSI) is the most common healthcare-related infection in surgical patients. Patients who have undergone spinal surgeries and have contracted postoperative SSI face increased morbidity and mortality, which invariably leads to additional burden on the healthcare system and higher costs. The risk factors for the increase in SSI in patients who have undergone spinal surgery have been investigated in numerous studies but no studies have been performed in Malaysia. The aim of this pilot study is to determine the incidence and factors associated with deep SSIs in patients that have undergone spinal surgeries. Methods : This retrospective study includes all patients who underwent spinal surgeries at Tengku Ampuan Afzan Hospital, Kuantan, from 1 January 2016 to 31 December 2017. Patients with an active spinal infection, polytrauma, and open fractures were excluded from this study. Patient characteristics and laboratory investigations were extracted to determine the risk factors for deep SSI events. Associations between SSI and risk factors were analyzed with SPSS V21.0 (IBM, Armonk, NY). Results: The univariate analysis indicated that fracture dislocation at the thoraco-lumbar junction (p=0.008) and a history of preoperative blood product transfusion (p=0.003) were associated with deep SSI. Other factors such as age (p=0.162), gender (p=0.262), body mass index (p=0.215), smoking status (0.272), number of vertebrae involved in the surgery (p=0.837), spinal cord involvement (p=0.259), postoperative hemoglobin reduction (p=0.816), and preoperative white blood cell count (p=0.278) were not associated with deep SSI. Conclusions: This pilot study highlights the factors associated with deep SSI in spinal surgeries. A larger study is needed to further confirm these findings

Spine tuberculosis:The greatest mimicker

INTRODUCTION: Spinal tuberculosis is a destructive form of tuberculosis. Common clinical manifestations are often vague and may mimic other medical conditions. We are presenting a case report of a lady who initially presented with clinical presentation suggestive of spine metastasis, however intraoperative and post operative findings turned out to be spine tuberculosis. This patient benefitted from early surgical decompression and drainage with rapid recovery of her neurology. CASE REPORT: 68 years old lady presented with back pain with bilateral lower limb weakness and numbness for the past 2 weeks with bowel and bladder incontinence. She denied any TB contact and has no family history of malignancy. On examination, patient has a thyroid swelling. She was paraplegic with reduced sensation T6 downwards. Back pain was aggravated with movement. MRI film and report showed presence of intraspinal extramedullary lesion at T6-T7 with impression of cord compression with suspicious of metastasis. From the clinical presentation and investigation result, the condition was highly suspicious of spine metastasis. Tuberculosis workout done was negative. Intraoperatively noted caseous material seen from vertebral body compressing anterior aspect of the cord with pus formation. PSIF (T4-T9), laminectomy (T5-T6), transpedicular corpectomy (T6) with trapdoor osteotomy approach and mesh cage with bone grafting was done. Patient was started on anti TB medications. Post operatively, the instability pain resolved completely and improvement in neurology of the patient was noted as early as one week post-op. DISCUSSION: Spinal tuberculosis is a destructive form of tuberculosis. Common clinical manifestations are often vague and may mimic other medical conditions. For the diagnosis of spinal tuberculosis MRI is more sensitive and specific than x-ray and CT scan. However, these findings may sometimes be mistaken for spine metastasis or severe degenerative spine. Neuroimaging-guided needle biopsy is the gold standard technique for early histopathological diagnosis. Antituberculous treatment remains the cornerstone of treatment. Surgery may be required in selected cases, e.g. large abscess formation, severe kyphosis, an evolving neurological deficit, or lack of response to medical treatment. In our patient,early decompression with drainage of the collection surrounding the cord provided good results after surgery with improvement in patient’s neurology. CONCLUSION: Diagnosis of TB spine has often been a challenge to orthopedic surgeons. Its clinical presentations is often non specific and may mimic other diseases, thus the name “The Greatest Mimicker”. With early diagnosis and early treatment, prognosis is generally good

Traumatic pediatric atlantoaxial rotatory dislocation successfully reduced with 1 month total of halter traction: a case report

The occurrence of atlantoaxial rotatory subluxation is fairly uncommon; however, it is more common to be encountered in the paediatric population, typically seen after a retropharyngeal inflammation or after a minor trauma. Ligamentous laxity, shallower and more horizontally oriented facet joints especially at the C1-2 joint making them prone to have atlantoaxial subluxation or dislocation. If recognized early it can be successfully managed non-surgically before chronic inflammatory changes affect the ligaments and joint structure of the C1-2 complex. However, there is no standard treatment protocol as some authors like Nael et al and Haliasos and Norris recommended more invasive Halo skull traction. Thus, we report this case managed with less invasive Halter traction with no risk of pin site infections. We present the case of a 12-year-old Malay boy with traumatic atlantoaxial dislocation who came to us after he slipped and fell, presented with neck pain and torticollis to the left side but without other neurological deficits. A computed-tomography (CT) scan revealed an atlantoaxial rotation of 47 to the left without any signs of osseous lesions. MRI was also done and all ligaments were intact. The neck was then reduced by cautious rotation with Halter traction with the cervical spine in the neutral position with slight flexion thus avoiding harm by potential posttraumatic disc lesions. The patient was put on Halter traction for a total of one month. Post-traction revealed full range of motion of the neck without any tenderness, head and neck alignment restored to neutral position. In the children population, atlantoaxial subluxation is a rare condition but is severe if left untreated. Early treatment implies a non-surgical approach and a good outcome is observed in our case as well as reported by other authors

“Postural Kyphoscoliosis”: an atypical presentation of herniated lumbar nucleus pulposus

INTRODUCTION: Herniated Nucleus Pulposus is displacement of disc material beyond the intervertebral disc normal margins resulting in pain, weakness or numbness following the myptomal or dermatomal distribution. We present a patient with severe L4/L5 herniated nucleus pulposis who presented with “postural kyphoscoliosis” CASE REPORT: Mr YMC, a 22-year-old healthy gentleman presented with abnormal posture and back pain for 3 months. There was no history of trauma. Clinically the “kyphoscoliosis” was postural due to severe back pain on straightening the back. On examination, straight leg raising test was positive with L4 mytomal symptoms. Plain radiograph of the thoracolumbar region did not reveal any deformity. The magnetic resonance imaging of lumbosacral revealed a herniated lumbar nucleus pulposus over the L4/L5 region, impinging on the L4 exiting nerve root. The patient underwent laminectomy L4 and discectomy L4/5 without any complication. Post-operatively, the patient recovered well with normal posture. DISCUSSIONS: It is still controversial in terms of outcomes of medical and or physical therapy compared to surgical intervention in herniated nucleus pulposus. In those patient that warrant surgical intervention, patient with age<40 and sugery within 6 months would predict a good surgical outcomes. In our patient, the surgery improves the motor function, correct the posture and improve his quality of life. CONCLUSION: This case highlights the surgical role in terms of managing patients with prolapsed nucleus pulposus that failed conservative management. Early surgical intervention yields a good functional outcome in those patient with severe disease

A rare case Of thyroid follicular cancer presented with isolated spine metastasis with spinal cord compression

INTRODUCTION: Metastatic tumors are the most common tumors of the spine; however spinal cord compression as the first presentation of metastatic thyroid follicular cancer without thyroid enlargement is unusual and rare. Thyroid cancer accounts for about 1% of all new malignant disease and affects female more than male with the ratio of 3:1 and spine is the commonest bony metastatic site in thyroid carcinoma. CASE REPORT: Miss Z, a 67 years old lady with underlying hypertension presented with two months history of gradual lower limb weakness and numbness; two days history of bowel incontinence. She had no thyroid enlargement, no thyroid symptoms and normal thyroid biochemical profile and tumor markers. Her magnetic resonance imaging (MRI) of spine shows a lobulated solid mass compressing the spinal cord at T4 vertebra involving both the spinal and paraspinal areas. CT-guided biopsy of the spine shows follicular thyroid metastasis. She then underwent laminectomy of T3, T4 and T5 vertebra with cord decompression surgery. Post-surgery there is a recovery of lower limb neurology and bowel continence. DISCUSSIONS: Thyroid carcinoma generally responds well to treatment, and spinal metastasis is uncommon. The presence of distant metastasis from thyroid carcinoma decreases patient 10-year survival rate to 50%. The follicular type typically affects middle-aged females and 90% presents as a simple thyroid nodule. Only 5% presents firstly as distant metastasis, commonly to the bone, lungs and lymph nodes. Spinal metastasis more frequently occur in the thoracic spine (60-80%), followed by lumbar spine (15-30%) and cervical spine (<10%), usually either through Batson plexus, direct spread or local invasion. Thyroid carcinoma has predilection for vertebral body and often presents as back pain as a result of vertebral collapsed due to pathological fracture; rarely with spinal cord compression as result of direct invasion. Prognosis of spine metastasis due to thyroid cancer is better compared to other metastatic spine cancers. CONCLUSION: Bone metastasis is frequent complication especially if it causes compression fracture with spinal cord compression and pain. With high index of clinical suspicion correlating with imaging, early diagnosis and treatment show good prognosis for patient with metastatic spinal cord compression

Quality of life and functional outcomes following supracondylar humeral fractures in a paediatric population

The course of recovery in children post injury remains unclear despite recent focus on quality of life (QOL) and func<onal outcomes following trauma. There is a need for accurate assessment of the impact and course of such injuries on a child’s func<onal status and perceived well-being. Determining when and whether or not func<onal outcome and QOL plateaus, will allow health care providers and researchers to focus more intensely on rehabilita<on during period of gain. This will lead to a more adap<ve rehabilita<on aEer plateaus are achieved

Cervical vertebral fracture: A report of two cases of “Near-Miss” C6 fractures

Cervical spine injury is commonly associated with road-traffic accidents. The true incidence of cervical spine injuries is unknown due to under-reporting of such injuries. Cervical spine injury is associated with high morbidity and mortality if it is missed. With the advancement of imaging modalities, the number of missed cervical injuries has reduced. Nevertheless, some clinicians are dependent solely on imaging tools to rule out cervical spine injury in a trauma victim. We report two cases of a “near miss” C6 fracture to highlight the importance of a detailed clinical history and clinical examination with imaging as an adjunct to rule out cervical injury