Intrathecal Drug Delivery Device Infection

Intrathecal Drug Delivery Device Infection

A major complication of Intrathecal Drug Delivery Device (IDDD) implantationis infection.

Morgalla et al., assessed IDD-related complications in 51 patients who had IDD systems implanted for the treatment of chronic pain or spasticity.

Twelve patients (23.5%) presented a total of 22 complications. The main type of complication was catheter-related (50%), followed by pump failure, infection, and inappropriate refilling 1).


Device-related and surgical wound infection occurred in 12 patients (3%), and nine were regarded as severe in the series of Taira et al., 2).

Risk Factors

Patients with extremely low muscle bulk, visceral pumps may be impractical or impossible, with increased risks of dehiscence and infection 3).


Periodic refills of intrathecal implanted pumps do not seem to be a risk factor for infection if standard sterile refill procedures are performed. In a study, it was clear that comorbid infections from other parts of the body do not present as a risk for device contamination 4).

Prevention

Follett et al., concluded from the available data that the most effective antiinfection measures consist of adherence to published guidelines and recommendations that apply to surgical site infections (SSIs) in general 5).


The use of vancomycin powder in patients with implants in the series of is series of Ghobrial et al., did not reduce infection rates compared to published historical controls, and was elevated compared to institutional controls 6).


The combination of local neomycin/polymyxin with systemic antibiotic therapy can lead to a significantly lower rate of postoperative infection than when systemic antibiotics are used alone 7).


The subfascial implantation technique was associated with a reduced rate of local wound and pump infections and provided optimal cosmetic results as compared with that observed in retrospective cases 8).

Treatment

The current standard of care in the treatment of IDDD infection necessitates that the pump be explanted and the infection treated prior to implantation of a new IDDD. This process leads to long hospital stays, interruptions in optimal medical management, and a high risk for dangerous drug withdrawals.


Infections can be treated with repetitive local application of gentamicin-impregnated collagen fleece 9).


Leibold et al., describe a technique that allows for the explantation of the infected pump and implantation of a new pump concurrently, which they have named the “Turner Switch” technique in honor of its inventor.

The authors conducted a retrospective analysis of cases of infected IDDDs in which patients underwent simultaneous explantation of the infected pump and implantation of a new pump. Demographics and clinical data were collected.

Data from a total of 17 patients (11 male, 6 female) who underwent simultaneous IDDD explantation and implantation to treat infections were analyzed from a 3-year period. No patients experienced infection of the newly implanted pump or catheter. Of the 17 patients, 14 (82.4%) had baclofen pumps to treat spasticity and 3 (17.6%) had fentanyl pumps to treat chronic pain. The median hospital stay was 7 days, with 16 of 17 (94.1%) patients able to be discharged home or to a facility with a level of care similar to their preoperative care. All patients ultimately experienced complete resolution of their initial infections. Five patients (29.4%) required a return to the operating room within the next 5 months (for repair of a CSF leak in 2 cases, for treatment of infection at the old pump site in 2 cases, and for treatment of a CSF leak compounded with infection in 1 case). No patient experienced infection of the newly implanted pump or catheter.

IDDD infections represent a large portion of morbidity associated with these devices. The current standard of care for deep pump infections requires pump explantation and a course of antibiotics prior to reimplantation of the IDDD. The authors demonstrate the effectiveness of a procedure involving simultaneous explantation of an infected pump and implantation of a new pump on the contralateral side in the treatment of IDDD infections 10).


Ingale et al., suggested that consideration should be given to selective dorsal rhizotomy (SDR) as an alternative in patients previously implanted with Intrathecal Drug Delivery systems complicated by infection or nearing end of battery life 11).

Case reports

A patient with pump-site infection and Escherichia coli meningitis secondary to transcolonic perforation of an intrathecal baclofen pump catheter. While this is rare, we review the intraoperative precautions and best practices that should be taken to prevent and manage this unusual complication 12).


Intrathecal drug delivery device infection with Mycobacterium fortuitum was not been reported previously. Aliabadi et al., reported a case of an implanted baclofen pump infection and associated mycobacterium meningitis due to Mycobacterium fortuitum. The entire pump system was removed and the patient was treated successfully with a prolonged regimen of antibiotics 13).


In a case neurological complaints were pain and dysaesthesiae in the lower back and thigh, as well as paresis of the ileopsoas muscle. MRI of the lumbar spine showed an intradural-extramedullary mass at the level of L1 homogeneously enhancing with gadolinium. This mass was situated at the tip of an intrathecal catheter implanted 11 years before for a morphine trial infusion as therapy for phantom pain after amputation of the right arm. Now, removal of the catheter was performed. Cultures of lumbar CSF and the catheter tip demonstrated coagulase negative staphylococcus. Antibiotic medication with cephalosporines was given for 6 weeks. After removal of the catheter, the patient was free of pain and he progressively regained full neurological function. Although most catheter-associated granulomas reported so far were sterile in nature, bacterial infection should still be considered even years after catheter placement 14).


A patient who experienced a prolonged course of intrathecal baclofen withdrawal syndrome after removal of an implantable baclofen pump for treatment of pump infection and meningitis. The current literature outlines management options for the acute management of this syndrome. In this report the authors discuss the long-term presentation of this syndrome and suggest a treatment strategy for management of the syndrome. A 37-year-old man who presented with a baclofen pump infection and meningitis experienced acute onset of intrathecal baclofen withdrawal syndrome 12 hours after the pump had been surgically removed. The patient’s symptoms evolved into a severe, treatment-refractory withdrawal syndrome lasting longer than 1 month. Oral baclofen replacement with adjunctive administration of parenteral gamma-aminobutyric acid agonists only served to stabilize the patient’s critical condition throughout his hospital course. Replacement of the baclofen pump and restoration of intrathecal delivery of the medication was necessary to trigger the patient’s dramatic recovery and complete reversal of the withdrawal syndrome within approximately 48 hours. These findings indicate that a more direct method of treating infected baclofen pumps than immediate surgical removal is necessary to prevent the onset of intrathecal baclofen withdrawal syndrome. Various options for preventing the onset of the syndrome while simultaneously treating the infection are discussed 15).

References

1)

Morgalla M, Fortunato M, Azam A, Tatagiba M, Lepski G. High-Resolution Three-Dimensional Computed Tomography for Assessing Complications Related to Intrathecal Drug Delivery. Pain Physician. 2016 Jul;19(5):E775-80. PubMed PMID: 27389121.
2)

Taira T, Ueta T, Katayama Y, Kimizuka M, Nemoto A, Mizusawa H, Liu M, Koito M, Hiro Y, Tanabe H. Rate of complications among the recipients of intrathecal baclofen pump in Japan: a multicenter study. Neuromodulation. 2013 May-Jun;16(3):266-72; discussion 272. doi: 10.1111/ner.12010. Epub 2012 Dec 14. PubMed PMID: 23240625.
3)

Waqar M, Ellenbogen JR, Kumar R, Sneade C, Zebian B, Williams D, Pettorini BL. Indwelling intrathecal catheter with subcutaneous abdominal reservoir: a viable baclofen delivery system in severely cachectic patients. J Neurosurg Pediatr. 2014 Oct;14(4):409-13. doi: 10.3171/2014.6.PEDS13686. Epub 2014 Aug 1. PubMed PMID: 25084089.
4)

Dario A, Scamoni C, Picano M, Fortini G, Cuffari S, Tomei G. The infection risk of intrathecal drug infusion pumps after multiple refill procedures. Neuromodulation. 2005 Jan;8(1):36-9. doi: 10.1111/j.1094-7159.2005.05218.x. PubMed PMID: 22151381.
5)

Follett KA, Boortz-Marx RL, Drake JM, DuPen S, Schneider SJ, Turner MS, Coffey RJ. Prevention and management of intrathecal drug delivery and spinal cord stimulation system infections. Anesthesiology. 2004 Jun;100(6):1582-94. Review. PubMed PMID: 15166581.
6)

Ghobrial GM, Thakkar V, Singhal S, Oppenlander ME, Maulucci CM, Harrop JS, Jallo J, Prasad S, Saulino M, Sharan AD. Efficacy of intraoperative vancomycin powder use in intrathecal baclofen pump implantation procedures: single institutional series in a high risk population. J Clin Neurosci. 2014 Oct;21(10):1786-9. doi: 10.1016/j.jocn.2014.04.007. Epub 2014 Jun 14. PubMed PMID: 24938386.
7)

Miller JP, Acar F, Burchiel KJ. Significant reduction in stereotactic and functional neurosurgical hardware infection after local neomycin/polymyxin application. J Neurosurg. 2009 Feb;110(2):247-50. PubMed PMID: 19263587.
8)

Kopell BH, Sala D, Doyle WK, Feldman DS, Wisoff JH, Weiner HL. Subfascial implantation of intrathecal baclofen pumps in children: technical note. Neurosurgery. 2001 Sep;49(3):753-6; discussion 756-7. PubMed PMID: 11523691.
9)

Peerdeman SM, de Groot V, Feller RE. In situ treatment of an infected intrathecal baclofen pump implant with gentamicin-impregnated collagen fleece. J Neurosurg. 2010 Jun;112(6):1308-10. doi: 10.3171/2009.8.JNS081692. PubMed PMID: 19731988.
10)

Leibold AT, Weyhenmeyer J, Lee A. Simultaneous explantation and implantation of intrathecal pumps: a case series. J Neurosurg. 2019 Apr 12:1-7. doi: 10.3171/2019.1.JNS18919. [Epub ahead of print] PubMed PMID: 30978693.
11)

Ingale H, Ughratdar I, Muquit S, Moussa AA, Vloeberghs MH. Selective dorsal rhizotomy as an alternative to intrathecal baclofen pump replacement in GMFCS grades 4 and 5 children. Childs Nerv Syst. 2016 Feb;32(2):321-5. doi: 10.1007/s00381-015-2950-9. Epub 2015 Nov 9. PubMed PMID: 26552383.
12)

Devine OP, Harborne AC, Lo WB, Price R. Colonic perforation by an intrathecal baclofen pump catheter causing delayed Escherichia coli meningitis. BMJ Case Rep. 2017 Dec 20;2017. pii: bcr-2017-222539. doi: 10.1136/bcr-2017-222539. PubMed PMID: 29269368.
13)

Aliabadi H, Osenbach RK. Intrathecal Drug Delivery Device Infection and Meningitis due to Mycobacterium Fortuitum: A Case Report. Neuromodulation. 2008 Oct;11(4):311-4. do 10: i: 10.1111/j.1525-1403.2008.00181.x. PubMed PMID: 22151146.
14)

Lehmberg J, Scheiwe C, Spreer J, van Velthoven V. Late bacterial granuloma at an intrathecal drug delivery catheter. Acta Neurochir (Wien). 2006 Aug;148(8):899-901; discussion 901. Epub 2006 Jun 23. PubMed PMID: 16791432.
15)

Douglas AF, Weiner HL, Schwartz DR. Prolonged intrathecal baclofen withdrawal syndrome. Case report and discussion of current therapeutic management. J Neurosurg. 2005 Jun;102(6):1133-6. Review. PubMed PMID: 16028775.

AOSpine Advanced Seminar—Tumor, Infection, Metabolic and Inflammatory Disorders of the Thoracolumbar Spine

AOSpine Advanced Seminar—Tumor, Infection, Metabolic and Inflammatory Disorders of the Thoracolumbar Spine

November 2 — November 3

Vilnius, Lithuania

More Information

Update: Spinal instrumentation infection

Spinal instrumentation infection

Instrumentation has become an integral component in the management of various spinal disorders. The rate of infection varies from 2% to 20% of all instrumented spinal procedures.
Surgical site infection (SSI) in the spine is a serious postoperative complication. Factors such as posterior surgical approach, arthrodesis, use of spinal instrumentation, age, obesity, diabetes, tobacco use, operating-room environment and estimated blood loss are well established in the literature to affect the risk of infection 1).

Diagnosis

There are multiple risk factors for postoperative spinal infections. Infections in the setting of instrumentation are more difficult to diagnose and treat due to biofilm. Infections may be early or delayed. C Reactive Protein (CRP) and Magnetic Resonance Imaging (MRI) are important diagnostic tools. 2).


Blood specimens were obtained from patients who underwent posterior decompression, instrumentation with pedicular screws, and posterolateral fusion from June 2009 to January 2011. CRP and ESR levels were measured on the day before surgery and on postoperative days 1, 3, 7, 11, 14, 28, and 42.
Mean CRP levels peaked on the third day postoperatively in all groups. By day 7 postoperatively, it had dropped rapidly. At the 14th and 28th postoperative days, decreases to normal CRP levels were found in 16% and 80% of all patients, respectively. The pattern of decline in CRP was similar among groups. Values of ESR increased and peaked between the third and seventh postoperative days. ESR values gradually decreased. At the 42 day postoperatively, ESR level still remain above normal values in all groups 3).


MRI is a useful tool for the early diagnosis of a deep SSI. However, the diagnosis is frequently difficult with feverish patients with clear wounds after posterior spinal instrumentation (PSI) because of artifacts from the metallic implants. There are no reports on MRI findings that are specific to a deep SSI after PSI.
Kimura et al. found that fluid collection outside the head of the PS on an axial MRI scan (PS fluid sign) strongly suggested the possibility of an abscess.
The SSI group comprised 17 patients with a deep SSI after posterior lumbar spinal instrumentation who had undergone an MRI examination at the onset of the SSI. The non-SSI group comprised 64 patients who had undergone posterior lumbar spinal instrumentation who did not develop an SSI and had an MRI examination within 4 weeks after surgery. The frequency of a positive PS fluid sign was compared between both groups.
The PS fluid sign had a sensitivity of 88.2%, specificity of 89.1%, positive predictive value of 68.1%, and negative predictive value of 96.6%. The 2 patients with a false-negative PS fluid sign in the SSI group had an infection at the disk into which the interbody cage had been inserted. Three of the 7 patients with a false-positive PS fluid sign in the non-SSI group had a dural tear during surgery.
The PS fluid sign is a valuable tool for the early diagnosis of a deep SSI. The PS fluid sign is especially useful for diagnosing a deep SSI in difficult cases, such as feverish patients without wound discharge 4).

Treatment

Optimal results are obtained with surgical debridement followed by parenteral antibiotics.
Until today the role of spinal instrumentation in the presence of a wound infection has been widely discussed and recently many authors leave the hardware in place with appropriate antibiotic therapy 5).
Removal or replacement of hardware should be considered in delayed infections.
An improved understanding of the role of biofilm and the development of newer spinal implants has provided insight in the pathogenesis and management of infected spinal implants. It is important to accurately identify and treat postoperative spinal infections. The treatment is often multimodal and prolonged 6).

Evidence based medicine

In a study, from the Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, USA evidence based medicine was used to assess optimal surgical and medical management of patients with post-operative deep wound infection following spinal instrumentation. A computerized literature search of the PubMed database was performed. Twenty pertinent studies were identified. Studies were separated into publications addressing instrumentation retention versus removal and publications addressing antibiotic therapy regimen. The findings were classified based on level of evidence (I-III) and findings were summarized into evidentiary tables.
No level of evidence 1 or level of evidence 2 was identified. With regards to surgical management, five studies support instrumentation retention in the setting of early deep infection. In contrast, for delayed infection, the evidence favors removal of instrumentation at the time of initial debridement. Surgeons should be aware that for deformity patients, even if solid fusion is observed, removal of instrumentation may be associated with significant loss of correction. A course of intravenous antibiotics followed by long-term oral suppressive therapy should be pursued if instrumentation is retained. A shorter treatment course may be appropriate if hardware is removed 7).


The objective of a study was to investigate the morbidity and mortality associated with instrumented fusion in the setting of primary spinal infection.
A search was performed in the PubMed and Medline databases for clinical case series describing instrumented fusion in the setting of primary spinal infection between 2003 and 2013. The search was limited to the English language and case series including at least 20 patients. The primary outcome measure was postoperative infection (recurrent local infection) + surgical site infection (SSI); secondary outcome measures included reoperation rates, development of other complications, and perioperative mortality.
There were 26 publications that met the inclusion criteria, representing 931 patients with spondylodiscitis who underwent decompression, debridement, and instrumented fusion. Spinal infections occurred most commonly in the lumbosacral spine (39.1%) followed by the thoracic spine (27.1%). The most common microorganisms were Staphylococcus spp. After decompression, debridement, and instrumented fusion, the overall rate of postoperative infection was 6.3% (1.6% recurrent infection rate + 4.7% SSI rate). The perioperative complication rate was 15.4%, and the mortality rate was estimated at 2.3%. Reoperation for wound debridement, instrumentation removal, pseudoarthrosis, and/or progressive neurological deficit was performed in 4.5% of patients.
The findings in this literature review suggest that the addition of instrumentation in the setting of a primary spinal infection has a low local recurrent infection rate (1.6%). However, the combined risk of postoperative infection is 6.3% (recurrent infection + SSI), more than three-fold the current infection rate following instrumentation procedures for degenerative spine disease. Moreover, the addition of hardware does usher in complications such as instrumentation failure and pseudoarthrosis requiring reoperation 8).

Case series

2017

A retrospective, cohort study of 84 patients with deep spine infection managed at a major tertiary hospital over 14 years with a minimum follow up of 2 years.
It is often believed that implants should not be inserted in patients with deep spine infection because of the risk of persistent or recurrent infection. However, there are often concerns about spinal stability and a paucity of evidence to guide clinical practice in this field.
Dennis et al. compared the mortality, reoperation, and reinfection rates in patients with spine infection treated with antibiotics alone, antibiotics with debridement, and antibiotics with debridement and instrumentation. Significant outcome predictors were determined using multivariable logistic regression model.
Forty-nine males and 35 females with a mean age was 62.0 years had spine infection affecting the lumbar spine predominantly. The most common form of infection was osteomyelitis and spondylodiscitis (69.4%). Staphylococcus aureus was the most common causative organism (61.2%).There was no difference in terms of reoperation or relapse for patients treated with antibiotics alone, antibiotics with debridement, or antibiotics with debridement and instrumentation. However, compared with antibiotics alone, the crude inhospital mortality was lower for patients treated with instrumentation (odds ratio, OR, 0.82; P = 0.01), and antibiotics with debridement (OR 0.80; P = 0.02).
Spinal instrumentation in an infected spine is safe and not associated with higher reoperation or relapse rates. Mortality is lower for patients treated with instrumentation 9).


A retrospective review of patients with MRSE-related SSIs from 665 consecutive cases of SI surgery performed between 2007 and 2014
During the study period, SSIs occurred in 21 patients. MRSE was isolated from cultures obtained from surgical wounds in nine of the 21 patients (43%). There were four males and five females with a mean age of 63.9 ± 15.1 years. Six patients presented with inflammatory signs, such as wound drainage, pyrexia, erythema, and elevated C-reactive protein. Three patients did not have signs of infection, but had early implant failure, and were diagnosed by positive cultures collected at the time of revision surgery. The mean time from index surgery to the diagnosis of infection was 23.6 days (range, 7-88 days). In one patient, the implant was removed before antibiotic treatment was administered because of implant failure. Eight patients were managed with antibiotics and implant retention. During the follow-up period, MRSE-related SSIs in seven of the eight patients were resolved with implant retention and antibiotics without the need for further surgical intervention. One patient did not complete the antibiotic course because of side effects, and implant removal was required to control the infection.
Early detection, surgical debridement, and administration of appropriate antibiotics for a suitable duration enabled infection control without the need for implant removal in the treatment of MRSE-related SSI after SI surgery 10).


Eleven patients with SSI after undergoing spinal surgery involving instrumentation were studied. All had been refractory to conventional treatments, including intravenous antibiotic administration and conventional debridement and irrigation. Antibiotic-loaded bone cement was placed on and around the instrumentation to cover them and to occupy the surrounding dead space. Two general types of antibiotics were loaded into the polymethylmethacrylate bone cement. The recipes for the mixture were changed depending on the bacterial cultures. Sensitive antibiotics were administered generally for 2-6 weeks until the C-reactive protein level was normalized.
All patients were treated successfully using antibiotic-loaded bone cement. Only 1 patient needed a repeat of this procedure to treat an infection. Antibiotic-loaded bone cement was placed in situ in all patients during the follow-up period and there were no significant adverse events.
Antibiotic-loaded bone cement treatment reduces the dead space and achieves the targeted drug delivery simultaneously. Treatment using antibiotic-loaded bone cement is an effective treatment option for complex spinal SSI 11).


Between 2010 and 2015, 12 out of 514 patients who developed a deep infection after spinal surgery, were selected and reviewed retrospectively at multiple centers (MGM Hospital, Kamothe and Center for Orthopaedic & Spine Surgery, New Panvel, Navi Mumbai, India). Out of 12 patients, one of the patients needed a partial implant exchange although none of the cases needed complete implant removal. All patients had achieved clean closed wounds along with a retention of the instrumentation. There was no need for flap surgery to cover wound defect in any case. However, antibiotic treatment was necessary in all cases. None of the patients showed a new infection after the treatment.
The study demonstrates the usefulness of VAC therapy as an alternative management for wound conditioning of a back wound with the high complexity in nature after instrumented spine surgeries as it eliminates complex secondary surgeries, prolong use of antibiotics and removal of the implants 12).

2015

A retrospective database review of consecutive patients with traditional open lumbar spinal surgery was performed. SSIs patients were identified and reviewed for clinically relevant details, and postoperative SSIs’ incidence was calculated for the entire cohort as well as for subgroups with or without spinal implants. In 15 years, 1,176 patients underwent open lumbar spinal surgery with spinal implants and 699 without. Thirty-eight developed postoperative SSIs. Total SSI rate for the entire group was 2.03%. The incidence of postoperative SSIs in the nonimplant group was relatively low. Patients received antibiotics, hyperbaric oxygen therapy, and wet dressing.
Liu et al. provided the precise rates of postoperative SSIs in traditional open spinal surgery obtained from a single-centre data. Patients with spinal implants had higher SSIs’ incidence than those without 13).

2014

Thirty-six patients underwent only decompression, and 82 underwent decompression and instrumented fusion. In the decompression-only group, 8.33% of patients had continued osteomyelitis/discitis compared with 9.76% of patients in the instrumented group (P = 0.807). Importantly, the reoperation rate was also similar between the decompression-only group (19.44%) and the instrumented group (17.07%; P = 0.756). Similarly, subanalyses based on infection location revealed no significant increase in rates of recurrent infection or reoperation in patients who underwent instrumentation 14).


Patients who received just decompression for spinal infection had similar reoperation and continued infection rates as patients who additionally underwent instrumentation, irrespective of infection location within the spine. These findings suggest that instrumentation of the infected spine may be a safe treatment modality and should be considered when the spinal integrity is compromised 15).

2008

A 10-year retrospective audit. (1) The incidence of infection; (2) causative organisms; (3) whether eradication of infection is achievable with spinal implant retention; (4) patient outcome. The reported incidence of infection following posterior spinal instrumentation is between 2.6 and 3.8%. Management of infection is controversial, with some advocating serial wound debridement while others report that infection cannot be eradicated with retention of implants. There are no published data demonstrating that propionibacteria are associated with early postoperative infection. The management of infected cases at our institution includes eventual removal of their implants. Our population was identified by studying the case notes of all patients who had undergone removal of spinal implants and cross-referencing this population with positive microbiology or histology reports. The incidence of infection was 3.7%. Propionibacteria were isolated in 45% of cases. The diagnosis of infection was unexpected in 25% of patients, following removal of implants for prominence of implants or back pain. Sixty per cent of patients with acute postoperative deep wound infection had continuing active infection on subsequent removal of implants, despite long-term antibiotics and wound debridement. Fourty-six per cent of patients had a stable, pain-free spine at the end of their treatment. This is the largest reported series of infections following posterior spinal instrumented fusions of which we are aware. Propionibacteria are a common cause of infection and successful eradication of infection cannot be reliably achieved with antibiotics and wound debridement alone 16).

1997

Twenty-three of 238 patients (9.7%) developed wound infections following segmental spinal instrumentation. When the infected group and a matched control group were compared, the infected group had a significantly higher number of patients with cerebral palsy and myelodysplasia (nonambulatory), patients with wound hematomas, patients with fusions that extended into the sacral region, and patients who were incontinent of urine. A high incidence of infections with gram-negative aerobic bacilli correlated with the extension of the surgery into the sacral region and bowel and/or bladder incontinence. Prophylactic antibiotics with broader coverage for gram-negative bacilli may be warranted for these procedures. Postoperative wound infections were managed by surgical drainage and debridement as well as antibiotics. Removal of the hardware was not necessary to control the infection in these patients who underwent segmental spinal instrumentation 17).
1)

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Kunakornsawat S, Tungsiripat R, Putthiwara D, Piyakulkaew C, Pluemvitayaporn T, Pruttikul P, Kittithamvongs P. Postoperative Kinetics of C-Reactive Protein and Erythrocyte Sediment Rate in One-, Two-, and Multilevel Posterior Spinal Decompressions and Instrumentations. Global Spine J. 2017 Aug;7(5):448-451. doi: 10.1177/2192568217699389. Epub 2017 Apr 11. PubMed PMID: 28811989; PubMed Central PMCID: PMC5544159.
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Kimura H, Shikata J, Odate S, Soeda T. Pedicle Screw Fluid Sign: An Indication on Magnetic Resonance Imaging of a Deep Infection After Posterior Spinal Instrumentation. Clin Spine Surg. 2017 May;30(4):169-175. doi: 10.1097/BSD.0000000000000040. PubMed PMID: 28437330.
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Dobran M, Mancini F, Nasi D, Scerrati M. A case of deep infection after instrumentation in dorsal spinal surgery: the management with antibiotics and negative wound pressure without removal of fixation. BMJ Case Rep. 2017 Jul 28;2017. pii: bcr-2017-220792. doi: 10.1136/bcr-2017-220792. PubMed PMID: 28756380.
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Lall RR, Wong AP, Lall RR, Lawton CD, Smith ZA, Dahdaleh NS. Evidence-based management of deep wound infection after spinal instrumentation. J Clin Neurosci. 2015 Feb;22(2):238-42. doi: 10.1016/j.jocn.2014.07.010. Epub 2014 Oct 11. Review. PubMed PMID: 25308619.
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DE LA Garza-Ramos R, Bydon M, Macki M, Abt NB, Rhee J, Gokaslan ZL, Bydon A. Instrumented fusion in the setting of primary spinal infection. J Neurosurg Sci. 2017 Feb;61(1):64-76. Epub 2015 Apr 15. Review. PubMed PMID: 25875732.
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Dennis Hey HW, Nathaniel Ng LW, Tan CS, Fisher D, Vasudevan A, Liu KG, Thambiah JS, Kumar N, Lau LL, Wong HK, Tambyah PA. Spinal Implants Can Be Inserted in Patients With Deep Spine Infection: Results From a Large Cohort Study. Spine (Phila Pa 1976). 2017 Apr 15;42(8):E490-E495. doi: 10.1097/BRS.0000000000001747. PubMed PMID: 27333342.
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Takizawa T, Tsutsumimoto T, Yui M, Misawa H. Surgical Site Infections Caused by Methicillin-resistant Staphylococcus epidermidis After Spinal Instrumentation Surgery. Spine (Phila Pa 1976). 2017 Apr 1;42(7):525-530. doi: 10.1097/BRS.0000000000001792. PubMed PMID: 27428392.
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Masuda S, Fujibayashi S, Otsuki B, Kimura H, Matsuda S. Efficacy of Target Drug Delivery and Dead Space Reduction Using Antibiotic-loaded Bone Cement for the Treatment of Complex Spinal Infection. Clin Spine Surg. 2017 Jul 7. doi: 10.1097/BSD.0000000000000567. [Epub ahead of print] PubMed PMID: 28692571.
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Kale M, Padalkar P, Mehta V. Vacuum-Assisted Closure in Patients with Post-operative Infections after Instrumented Spine Surgery: A Series of 12 Cases. J Orthop Case Rep. 2017 Jan-Feb;7(1):95-100. doi: 10.13107/jocr.2250-0685.706. PubMed PMID: 28630851; PubMed Central PMCID: PMC5458710.
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Liu JT, Liao WJ, Chang CS, Chen YH. Management of Deep Infection after Instrumentation on Lumbar Spinal Surgery in a Single Institution. Biomed Res Int. 2015;2015:842010. doi: 10.1155/2015/842010. Epub 2015 Jul 26. PubMed PMID: 26273650; PubMed Central PMCID: PMC4529929.
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Bydon M, De la Garza-Ramos R, Macki M, Naumann M, Sciubba DM, Wolinsky JP, Bydon A, Gokaslan ZL, Witham TF. Spinal Instrumentation in Patients with Primary Spinal Infections Does Not Lead to Greater Recurrent Infection Rates: An Analysis of 118 Cases. World Neurosurg. 2014 Jun 14. pii: S1878-8750(14)00560-9. doi: 10.1016/j.wneu.2014.06.014. [Epub ahead of print] Review. PubMed PMID: 24937598.
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Perry JW, Montgomerie JZ, Swank S, Gilmore DS, Maeder K. Wound infections following spinal fusion with posterior segmental spinal instrumentation. Clin Infect Dis. 1997 Apr;24(4):558-61. PubMed PMID: 9145726.
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