Elsevier

The Spine Journal

Volume 7, Issue 5, September–October 2007, Pages 596-600
The Spine Journal

Clinical Study
Vacuum-assisted wound closure of deep infections after instrumented spinal fusion in six children with neuromuscular scoliosis

https://doi.org/10.1016/j.spinee.2006.09.002Get rights and content

Abstract

Background context

The rate of infection after spinal fusion in neuromuscular scoliosis is reported to range from 4% to 20%. Infection persists in about 50% after traditional treatment including debridement and closure. Instrumentation removal is necessary in up to 28%.

Purpose

To analyze the outcome of vacuum-assisted wound closure (VAC) in combination with antibiotics for the treatment of deep wound infection after instrumented spinal fusion in pediatric neuromuscular scoliosis.

Study design

Six prospective consecutive neuromuscular patients with scoliosis.

Patient sample

Between 2001 and 2005, six consecutive pediatric patients (average age, 12.6 years) with neuromuscular scoliosis with a postoperative deep wound infection after instrumented spinal fusion were included in the study.

Outcome measures

Measurement of the duration of wound closure and infection parameters during treatment.

Methods

The patients were treated with a VAC system in combination with antibiotics.

Results

Wound closure averaged 3 months. Infection parameters were normalized within 6 weeks. Removal of the instrumentation was not necessary in any patient, and there were no signs of infection at follow-up ranging from 9 to 42 months.

Conclusion

The VAC system, in combination with antibiotic therapy, seems to be a useful method for treatment of deep wound infections after spinal fusion in pediatric neuromuscular scoliosis. It may prevent removal of the instrumentation and multiple surgery for irrigation and closure of the wound.

Introduction

Scoliosis surgery in pediatric patients can be considered as major surgery for them. The risks include neurological damage or deterioration, (deep) infection, pseudarthrosis and failure of instrumentation. Patients with neuromuscular scoliosis are even more prone to these complications. Surgery in neuromuscular scoliosis is associated with increased bleeding, less satisfactory bone stock, the need for longer fusion, and a higher risk of infection because of metabolic compromise and the length of the spinal fusion procedure. Diminished pulmonary function, seizures, and mental retardation often contribute to the increased risk. Patients with meningomyelocele and cerebral palsy have the highest risk of infection [1]. The infection rate in neuromuscular scoliosis surgery ranges from 4% to 20% [2], [3], [4], [5], [6]. Treatment of these infections is a challenging problem, especially in the early postoperative period. Because fusion has not yet been established, removal of the instrumentation will probably result in a severe progressive deformity. Therefore, removal of instrumentation should be avoided whenever possible. At present, treatment of infection consists of surgical debridement and irrigation, whether open or closed. Results vary, but Skaggs et al. [7] reported that in up to 28% of 53 patients control of infection could only be achieved by removal of the instrumentation.

The use of the vacuum-assisted wound closure (VAC; KCI Medical B.V., Houten, The Netherlands) system in children with postoperative infection after spinal fusion for scoliosis is new and we have found only one case report. Here we describe six consecutive pediatric patients in which the VAC system was used to treat deep wound infections after scoliosis surgery.

Section snippets

Patients and methods

From 2001 until 2005, 169 patients with a scoliosis were operated in Sophia Children's Hospital (Erasmus University Medical Centre, Rotterdam, The Netherlands). A total of 139 patients had a neuromuscular scoliosis. Posterior fusion was performed from the upper thoracic region (T1–T3) to the lumbosacral region (L5 or S1). All instrumention used was made of titanium. In the upper thoracic region, hooks were used to fix the rod, whereas in the lower thoracic region and lumbar region pedicle

Results

All infections occurred within 6 weeks (range, 2–5 weeks) postoperatively and were all caused by Staphylococcus aureus, one of which was methicillin resistant. In one case, an Enterobacter cloacae were also cultured (Table 2).

At diagnosis of infection, the CRP averaged 289 mg/L (normal reference <11 mg/L), and the ESR averaged 74 mm/h (normal reference, 1–10 mm/h). Six weeks after the start of treatment, the CRP had dropped down to an average of 22 mg/L and the ESR to 35 mm/h (Table 2). The

Discussion

It is known that infections after spinal surgery for scoliosis occur more often in patients with a neuromuscular disorder. These patients frequently have problems with incontinence, a general decline in immune status, and scarred, divergent tissue/muscles resulting in more tension on the wound [6]. The incidence of infection after spinal fusion in neuromuscuar patients ranges from 4% to 20% [2], [3], [4], [5], [6]. In our total population of six patients with a spinal fusion, the incidence of

Conclusion

Neuromuscular patients undergoing scoliosis surgery have an increased risk of deep infection, which is difficult to treat. The use of a VAC system combined with antiobiotic treatment is a good solution for deep infections after instrumented spine fusions. It is safe and probably helps to prevent removal of the spinal instrumentation and extensive and multiple surgical debridement. Particularly in patients, such as those with neuromuscular diseases, this is of importance.

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