Implementation of an evidence-based infection prevention protocol for spinal fusion surgery: a single-institution, two-surgeon experience

Introduction: Surgical site infections (SSIs) following instrumented spinal fusion are relatively common, with an incidence of nearly 3%. In 2018, an evidence-based clinical protocol for infection prevention after spinal fusion surgery was implemented in our center, including preoperative, intraoperative, and postoperative measures. In situ vancomycin was used in all posterior fusion procedures.

Methods: All spinal fusion procedures performed by two surgeons in a single institution between January 2018 and December 2022 were identified from a prospectively maintained procedural database. Patients with a pre-existent spinal infection (i.e. osteomyelitis) were excluded. Medical records were retrospectively reviewed.

Results: One-hundred-eighty-seven spinal fusion surgeries in 150 patients were performed by two surgeons. There were 108 men (72%) and 42 (28%) women with a median age 60 years (range 19-90). Indications for fusion were: degenerative disc disease in 71 (47.3%), traumatic fracture in 61 (40.7%), spinal tumor in 18 (12%). A posterior approach was used in 114 (occipitocervical: 5, cervical: 46, cervicothoracic: 20, thoracic: 13, thoracolumbar: 14, lumbar: 11, lumbosacral: 3, thoracolumbosacral: 2), with median number of levels fused of 4 (range 1-10). An anterior approach was used in 73 (cervical: 69, cervicothoracic: 4), with median number of levels fused of 2 (range 1-4). Median surgical time (skin incision-closure) was 200 minutes (mean 221, range 76-932). A closed suction drain was placed in 149 cases (79.7%), with a median length of stay of 2 days (range 1-7). Twelve patients were lost to followup (8%) after discharge. After a median follow-up of 5.2 months (range 0.2-57.1), not a single SSI occurred in this series. However, in one patient (0.67%), an esophageal injury occurred during anterior cervical fusion, resulting in a neck abscess, necessitating surgical drainage.

Conclusion : Using a pragmatic, evidence-based infection prevention protocol, the rate of SSI after spinal fusion surgery can be effectively reduced to zero.