Spinal surgery is generally considered an invasive procedure; however, even minimally invasive (MIS) spine procedures carry the same risk of postoperative infection. Why? Regardless of the level of invasiveness, bacteria and fungi consistently remain the primary causes of surgical site infection(SSI).
Spinal fusion surgeries have a higher risk of SSI because they involve spinal hardware such as screws, rods, and cages, which pose a greater risk of infection than surgeries without instrumentation. Cases with instrumentation have resulted in a 28% higher infectionrates than cases without implants. In this article, I discuss the nature and causes of postoperative infections, their possible consequences, and the alternative to traditional spinal fusion – Deuk Laser Disc Repair. It’s the better way.
The Culprits: Bacteria, Fungi, and Their Origins
Postoperative infections are caused by microorganisms that breach the body's natural defenses during or after surgery. The sources of these pathogens can be diverse.
Bacteria: The overwhelming majority of spinal SSIs are caused by bacteria. The most frequent culprits are Staphylococcus aureus, which is commonly found on the skin and in the nasal passages of many healthy individuals, and Staphylococcus epidermidis, another common skin resident. Gram-negative bacteria like Escherichia coli (E. coli) and Pseudomonas aeruginosa are also implicated, though less commonly.
Fungi: Fungal infections, while rare, can also occur. Species like Candida albicans may cause infections, particularly in patients who are immunocompromised or have been on long-term antibiotic therapy.
These microorganisms can come from several sources at the surgical site.
Operating Room Environment: The operating room is a major source, as microorganisms can be present in the air, on surgical instruments, or on surfaces within the room.
Patients Own Flora: The most common source is the patient's own skin, nasal passages, or gastrointestinal tract.
Surgical Team: Members of the surgical team can unintentionally transfer microbes, although this is rare due to strict adherence to sterile protocols.
Postoperative Contamination: The wound can become contaminated after surgery, either during dressing changes or through other means before the incision is fully healed.
The Critical Role of Sterilization
Given the potential for contamination, preventing infection is a top priority in spinal surgery. Sterilization is the cornerstone of this effort. It involves a multi-faceted approach to eliminate or kill all microorganisms in the surgical environment.
Instrument Sterilization: All surgical instruments undergo a rigorous cleaning and sterilization process using methods like steam autoclaving, chemical sterilization, or dry heat to ensure they are free of any pathogens.
Operating Room Environment: Operating rooms are designed with specialized ventilation systems that filter the air to reduce airborne particles. Surfaces are regularly disinfected.
Surgeon and Staff Protocols: The surgical team performs extensive hand and arm scrubbing with antiseptic soap before donning sterile gowns and gloves.
Patient Preparation: The patient's skin at the surgical site is meticulously cleaned with an antiseptic solution just before the incision is made. Preoperative antibiotics are also administered, typically within an hour before surgery, to help the body fight off any bacteria that might enter the wound.
These layers of precaution work together to create a sterile field, dramatically reducing the risk of a surgical site infection.
Two Main Types of Surgical Site Infections
Postoperative infections following spinal surgery are generally categorized based on their location and depth relative to the surgical incision. This classification helps guide diagnosis and treatment.
- Superficial Wound Infections
Superficial SSIs are the more common and less severe type of infection. They are limited to the skin and subcutaneous tissue, the layers directly beneath the skin that were cut during the procedure. These infections usually appear within 30 days after surgery. A typical example of a superficial infection is cellulitis, a bacterial skin infection marked by redness, swelling, and warmth at the surgical site.
Cellulitis occurs when bacteria enter through a break in the skin and begin to spread in the tissue just below the surface. The most immediate and common complication is the spread of the infection. The bacteria can quickly move from the initial site into deeper tissues, which may lead to an abscess that might require drainage, osteomyelitis causing chronic bone infection, or even necrotizing fasciitis (flesh-eating disease) resulting in tissue death (gangrene). The bacteria can also enter the bloodstream and spread throughout the body, causing systemic infections like bacteremia, sepsis, or endocarditis.
Even after the initial infection is gone, cellulitis can have long-term effects, especially with repeated episodes of lymphedema and ongoing pain and discomfort. In severe cases where the infection is not managed and causes significant tissue death, amputation of the affected limb may be necessary to stop the infection from spreading further.
2. Deep Wound Infections
Deep SSIs are a more serious concern. These infections penetrate beyond the skin and subcutaneous layers, affecting the deeper tissues such as the muscles, fascia (the connective tissue surrounding muscles), and the spinal structures themselves. The impact of deep wound infections can be severe and long-lasting.
Spinal instrumentation (hardware like plates, screws ,and plates) are reported to increase the rate of SSI by up to 28% by some authors. This increase in SSI rate in implant surgery is due to increased exposure of the wound to air, extensive soft tissue dissection, and muscle/skin retraction. Compared with non-fusion spinal surgeries, spinal fusion surgeries have a 33% greater rate of SSI].
Deep infections can occur within 30 days of the initial surgery. Still, they may also develop up to a year later, especially if surgical implants like rods, screws, or cages were used. Because these infections involve the area directly around the spine and spinal cord, they pose a much greater risk and require aggressive treatment. When an infection penetrates the deep tissues surrounding the spine, it can manifest in several specific and severe forms:
Discitis: Discitis is an infection of the intervertebral disc, the cushion-like structure between the vertebrae. Because discs have a minimal blood supply, it is difficult for the body's immune system and antibiotics to reach the infection site. Patients with discitis often experience severe, localized back pain that worsens with movement. The occurrence of discitis is generally between 2% to 5%, with rates potentially reaching 2.4% to 8.5% when instrumentation is added to the fusion
Vertebral Osteomyelitis: Vertebral osteomyelitis is an infection of the vertebral bone itself. It can occur alongside discitis or independently. The infection causes inflammation and can lead to the destruction of bone tissue, potentially compromising spinal stability. Symptoms include severe back pain, fever, and sometimes neurological deficits if the infection affects nearby nerves. After spinal surgery, the incidence rate of vertebral osteomyelitis is estimated to range from 3% to 5%.
Epidural Abscess: An epidural abscess is a buildup of pus in the epidural space—the space between the dura mater (the protective cover of the spinal cord) and the vertebrae. This condition is a neurosurgical emergency. As the abscess enlarges, it can compress the spinal cord and nerve roots, causing quickly worsening neurological symptoms. These symptoms may include severe pain, weakness or paralysis in the limbs, loss of sensation, and incontinence. An epidural abscess needs urgent surgery to drain the pus and reduce pressure on the spinal cord. The incidence rate of epidural abscesses with spinal instrumentation accounts for 5.5% of epidural abscesses.
The Ripple Effect: Complications of Spinal Infections
The consequences of a deep spinal infection can be profound and far-reaching, affecting a patient's long-term health and quality of life.
Need for Additional Surgery: Deep infections almost always require one or more additional surgical procedures. This involves debridement, where the surgeon reopens the wound to clean it out, remove infected tissue, and wash the area thoroughly. If implants are present and believed to be the source of the infection, they may need to be removed.
Failure of Fusion (pseudoarthrosis): Active infection can disrupt healing. It can prevent the bone graft from fusing with the vertebrae, resulting in a failed fusion, also called pseudoarthrosis. This means the bones do not join properly, and the initial pain and instability may return.
Hardware Loosening or Removal: Infection around screws and rods can weaken the bone they are anchored into, causing the hardware to loosen. If the infection cannot be controlled, the surgeon may need to remove all the hardware. This can compromise spinal stability and may necessitate a new fusion once the infection clears.
Recurrent Infections: Even after successful treatment, there is a risk that the infection can return. This is particularly true if biofilm—a slimy matrix produced by bacteria—has formed on spinal implants, making the bacteria resistant to antibiotics.
Immobility and Related Issues: The pain from the infection and the recovery from additional surgeries can lead to extended periods of immobility. This immobility can cause its own set of complications, such as bedsores (pressure ulcers)from prolonged pressure on the skin, muscle atrophy, and an increased risk of blood clots.
Long-Term Antibiotic Use: Treatment for deep spinal infections necessitates a prolonged course of high-dose intravenous (IV) antibiotics, often lasting six weeks or more. This requires the insertion of a semi-permanent IV line (like a PICC line) and can have significant side effects.
Narcotics Addiction: Surgical site infections don’t cause narcotics addiction directly, but by prolonging pain and recovery, they increase the duration and dosage of opioid prescriptions, which can trigger dependence and addiction.
Systemic Complications of Antibiotics
The powerful antibiotics used to treat these infections can be highly toxic to other organs, causing further complications:
Inflammation of the Colon (pseudomembranous colitis): Pseudomembranous colitis is an advanced inflammation of the colon caused by the tissue-damaging bacterium Clostridium difficile. It is typically caused by the use of antibiotics, which disrupts the normal balance of bacteria in the gut.
Kidney damage (nephrotoxicity): Nephrotoxicity is kidney damage caused by drugs, chemicals, or other toxins. Its implications range from acute, reversible injury like acute kidney injury (AKI ) and to irreversible, long-term kidney failure like chronic kidney disease (CKD).
Liver disruption (hepatotoxicity): Hepatotoxicity caused by antibodies is primarily an immune-mediated process rather than direct cellular poisoning. This type of drug-induced liver injury (DILI) is typically idiosyncratic and unpredictable. The most well-understood mechanism involves the immune system attacking the liver in response to new antigens created by a drug, which may or may not be the antibody itself. are serious risks that require regular blood monitoring.
Bone Marrow Suppression: The use of antibiotics, particularly prolonged courses, can cause bone marrow suppressionby depleting the gut microbiota, which is crucial for maintaining normal hematopoiesis. This suppression can lead to anemia, neutropenia, and thrombocytopenia leading to a decrease in the production of red blood cells, white blood cells, and platelets.
The Better Way: Deuk Laser Disc Repair (DLDR)
Navigating a postoperative spinal infection is a difficult journey for any patient and clearly reduces your chances of a successful recovery. I want to share that my revolutionary procedure - Deuk Laser Disc Repair (DLDR) — offers a better way to cure your neck or back pain without the worry of infection. DLDR is less invasive than even minimally invasive surgeries, and I never use hardware implants, which are the most common source of infection.
A Game-changing Procedure
DLDR is a minimally invasive form of endoscopic spine surgery performed in a modern surgery center under sedation, allowing patients to relax during the procedure. The procedure is done endoscopically using a high-definition camera inserted through a tiny 4mm incision to view the injured area. DLDR uses a precision laser to vaporize the herniated tissue. Fascia, muscles, ligaments, or bone are not damaged or removed. Fusions and artificial discs are not necessary. After surgery, patients wake up to immediate relief and a surgical scar so small that the surgeon can cover it with a Band-Aid.
Watch Deuk Laser Disc Repair in Action
Our goal is to be completely transparent about our process and procedures for treating back issues. We livestream surgeries with our patients’ written consent, allowing you to observe our technique.
Make the First Move to Move Pain-Free
Upload your latest MRI for a complimentary review and consultation with me, Dr. Ara Deukmedjian, M.D., founder of Deuk Spine Institute and creator of the procedure. Our team will reach out to you to help you regain your life.
