The spine clinics - Postoperative spinal infections - Clinical scenarios

Upendra, B., et al. (2018). Indian Spine Journal 1(1): 32-45.
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This symposium illustrates four different clinical scenarios and the different lines of treatment chosen in the management of patients presented with postoperative surgical site infections after spinal surgery. One clinical scenario (case 3) reported a patient who underwent routine fenestration microdiscectomy for a L4–L5 disc prolapse. Following prolonged complications, examination of the patient revealed a yellowish thick purulent discharge from the operative site. Emergency thorough debridement and drainage of the abscess was performed. The wound underwent saline lavage and the placement of local vancomycin prior to closure. Operative cultures grew s. aureus sensitive to vancomycin. IV teicoplanin and linezolid were given twice a day for 2 weeks. The patient was discharged with further antibiotic treatment for 1 month. The patient recovered well with no signs of local infection. However, at 6 weeks post debridement the patient presented with difficulty in walking and significant back and leg pain. Subsequent CT scans showed L4-L5 partial endplate destruction and MRI showed enhanced soft tissue on contrast study in the interbody region. Surgical management involved pedicle screws at L3, L4 and S1 bilaterally. L5 instrumentation was not possible due to L5 upper half destruction. Thorough debridement of the interbody region was performed, and calcium sulphate pellets mixed with vancomycin (1g) were packed in the interbody region to give anterior column support and act as an antibiotic carrier. Again, operative cultures grew S. aureus sensitive to vancomycin.  IV antibiotic were administered twice daily for 2 weeks. On recovery, the patient developed fever spikes at 2 weeks and examination found a large gluteal abscess with minimal discharge. This was drained with repeat lavage of the surgical wound. The implants were secure and not removed. The cultures again grew S.aureus  sensitive to amikacin, linezolid, rifampicin, and clindamycin. IV linezolid and clindamycin were administered twice daily for 2 weeks. Her wound healed with no signs of infection locally or in blood parameters with no further bony destruction or implant loosening on radiographs. She was discharged with oral antibiotic administration. Three-year follow-up showed good consolidation and fusion of the L4-L5 interbody region with no implant loosening. She had regained ankle dorsiflexion and was able to walk without support. The abstract and full paper can be read here.

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