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SICOT e-Newsletter

Issue No. 45 - June 2012

Editorial by Keith Baldwin & John P. Dormans

Update for Patient Safety in Paediatric Spine Surgery

In the present day, more powerful tools are at our disposal for the treatment of paediatric spinal deformities. Growth sparing constructs have allowed for earlier intervention in patients with more difficult diagnoses in early life. With all of these technical advances, the surgical options, and hence the indications for operative intervention have become more broad. With these new advances, attention has rightly turned to improving the safety of paediatric spinal surgery.

Infection is an important and devastating complication of spinal deformity surgery. Though an uncommon complication in adolescent idiopathic scoliosis, infection is an important cause of significant morbidity in congenital and neuromuscular populations. Many methods have been employed to decrease infection rate, from wound closure techniques to limited OR traffic, to the usage of pre operative chlorhexadine baths. Recently, a series of five studies have examined the usage of vancomycin intrawound powder to decrease infection rate in a variety of adult and some adolescent spinal procedures. These studies together found a ten time decrease in infection rate by using vancomycin powder. Intrawound antibiotics are not a new concept, but through improved evidence, this technique has gained popularity and is being used with good results. Perhaps more importantly, very few adverse effects have been noted. Some authors have even examined the systemic exposure to vancomycin with this technique and found very low blood levels of vancomycin in the blood stream, which suggests that the method of action is similar to a topical medication.

In addition to vancomycin powder, several institutions have instituted policies and procedures with the goal being zero post operative infections. These initiatives include multidisciplinary teams which devise anti infection protocols. The protocols include preop interventions (such as hibiclens wash, MRSA screen, history of recent antibiotic use), intraoperative interventions (such as gowns and gloves for line placement, pre-incision antibiotics, antibiotic repeat dosing, and decreased OR traffic) and post operative initiatives (such as discontinuing antibiotics 24 hours post operatively, removing the drain by day 2, and aggressive post operative pulmonary toilet). We have additionally found that in the compromised neuromuscular population an impervious water-proof post op dressing which is not removed for 5 days (such as Ioban) is helpful to prevent fecal soiling of the wound. Other strategies such as silver impregnated dressings are also now available for routine use. Additionally vacuum assisted closure has made the management of protracted post operative drainage and wound complications possible without use of multiple trips to the operating room, or several times daily dressing changes.

Prevention of neurologic complications is another important safety consideration in spinal surgery. Even in the hands of skilled surgeons, new neurologic deficit rates are about 1.3%. As such spinal cord neuromonitoring remains an important safety measure. Additionally, usage of intraoperative CT navigation or intraoperative CT scans to assess screw placement has been shown to decrease the rate of non-optimal screws. Though this is an expensive technology, it appears to provide superior screw placement when compared to free-hand technique. An important consideration in this growing population is, however, that CT scans require a large dose of radiation in a young patient. As this technology develops, methods must be also developed to minimize the radiation exposure by either decreasing the field or decreasing the radiation per CT scan. Recently we examined the utility of post operative films in the setting of CT navigation of screws placed. The post operative X-rays were found to add little in terms of predictive value for need for repeat intervention. Perhaps by decreasing the necessity of post operative films we can recoup some of the radiation expended during surgery.

As paediatric spine surgery advances, and our ability to correct even complex deformities using more advanced instrumentation and techniques, we must at the same time strive to improve the safety of the procedure and limit the patient’s exposure to risk of complications in both the intraoperative and post operative period.

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