Management Of Dehiscence After Spinal Surgery: An Evidence-based Approach To Soft Tissue Reconstruction
Meher A. Saleem, BA1, Mark D. Mishu, BA1, Elizabeth G. Zolper, BS2, Sarah R. Sher, MD2, Christopher E. Attinger, MD2, Kenneth L. Fan, MD2, Karen K. Evans, MD2.
1Georgetown University School of Medicine, Washington, DC, USA, 2MedStar Georgetown University Hospital, Washington, DC, USA.
Purpose: Postoperative dehiscence and surgical site infection after spinal surgery can carry significant morbidity. Effective multidisciplinary management with involvement of plastic surgery is essential to minimize morbidity and achieve definitive closure. However, a standardized approach to management of this population is lacking. The aim of this study was to identify effective interventions to create an evidence-based management protocol.
Methods: A retrospective review was performed at a single tertiary institution and identified 45 patients who required plastic surgery management for wounds secondary to spinal surgery from 2010- 2019. An algorithm to treatment is presented (Figure 1). Statistical analysis was performed to for demographics, comorbidities, and treatment methods.
Results: The mean age at time of closure was 61.9 years (±13.8) with a mean BMI of 32.6 ± 9.9 kg/m2. The average Charlson Comorbidity Index was 3.4 ± 2.1. The most common comorbidities were diabetes (28.3%) and active tobacco use (17.4%). The majority of patients had spinal hardware placement during spinal surgery (95.7%). Sixty-seven percent of patients had undergone at least two prior spine procedures at the site of subsequent dehiscence. Patients received an average of 1.7 debridements (range 0-5) prior to closure. Paraspinal advancement flaps (71.7%) were the most common operative intervention for closure. Antibiotic beads were placed at time of closure in 12.5%. Incisional negative pressure wound therapy (iNPWT) was utilized in 60.4%. The overall complication rate was 37.0% with healing complications occurring in 13% and seroma in 10.9%. Forty patients were completely healed at median follow up was 8.9 months (IQR 2.7-16.8) while five patients were lost to follow up. Use of antibiotic beads did not rate of infection occurrence after wound closure (p= 1.000). Use of iNPWT was significant for reduced time to healing (p=0.038). Patients treated without iNPWT healed at median of 2.1 months (IQR 1.5-5.1 mo) while the patients who received iNPWT healed in 1.3 months (IQR 0.9-1.5 mo). Demographics and comorbidities between these two groups were similar.
Conclusions: Timely involvement of plastic surgery results in improved healing for patients with spinal wound dehiscence. In our cohort, antibiotic beads had no effect on the rate of infectious complications after wound closure, while iNPWT significantly reduced both healing time. Patients with history of multiple spinal procedures with hardware placement, diabetes, or smoking are at significant risk for dehiscence. Future study is required to examine if this high-risk patients benefit from prophylactic plastic surgery intervention prior to dehiscence.
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