Evidence-Based Recommendations for Spine Surgery
This is a systematic review by Fisher et al; they reviewed 6 studies published in 2010 addressing various issues related to spine surgery.
The studies were:
- Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus
Bode L, Kluytmans J, Wertheim H, et al. NEJM 2010;362(1):9-17
- Chlorhexidine-Alcohol Versus Povidone-Iodine for Surgical-Site Antisepsis
Darouiche R, Wall M, Itani K, et al. NEJM 2010;362(1):18-26.
- Vertebroplasty Versus Conservative Treatment in Acute Osteoporotic Vertebral Compression Fractures (VertosII): An Open-Label Randomized Trial
Klazen C, Lohle P, deVries J, et al. Lancet , August 2010.
- Trends, Major Medical Complications, and Charges Associated with Surgery for Lumbar Spinal Stenosis in Older Adults
Deyo R, Mirza S, Martin B, et al. JAMA 2010;303(13):1259-65.
- Factors Associated with Recurrent Back Pain and Cyst Recurrence after Surgical Resection of One Hundred Ninety-Five Spinal Synovial Cysts
Xu R, McGirt MJ, Parker SL, et al. Spine 2010;35:1044-53.
- Does an Interspinous Device (CoflexTM ) Improve the Outcome of Decompressive Surgery in Lumbar Spinal Stenosis? One-Year Follow-up of a Prospective Case Control Study of 60 Patients
Richter A, Schutz C, Hauck M, et al. Eur Spine J 2010;19:283-9.
For every study, the authors give a summary and then provide a methodological review. Most importantly, the authors of this systematic review extrapolate recommendations for how this can affect clinical practice.
This summary of the review will focus on the 2 studies about preventing surgical-site infection: Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus and Chlorhexidine-Alcohol Versus Povidine-Iodine for Surgical Site Antisepsis.
Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus
Recommendations for Clinical Practice: All patients at high risk for S. aureus should be screened by the treating physician. Those at high risk are: patients undergoing revision procedures, those with prior or recent spinal infections, those with recent nonspinal infections, and smokers.
It should be noted that the cost-effectiveness of this screening protocol should be further investigated before suggesting universal screening. Similarly, a standardized treatment protocol cannot be strongly recommended until further research has been done. For now, positive carriers should be treated.
Chlorhexidine-Alcohol Versus Povidine-Iodine for Surgical Site Antisepsis
Clinical Practice Recommendations: This study suggests a possible treatment protocol for reducing the number of postsurgical infections: chlorhexidine-alcohol was significantly more protective than povidine-iodine in preventing superficial incisional infections and deep incisional infections.
However, the authors of the systematic review can give only a weak recommendation. All the study authors received financial support from the maker of chlrohexidine-alcohol, so this could cause a bias.
Further study of antiseptic agents in spine surgery should be done (carefully controlling for potential conflicts of interest).
Fisher et al present a number of evidence-based recommendations for spine surgeons. First, active screening for S. aureus and treatment with mupirocin ointment reduces the risk of infection. Chlorhexidine-alcohol is superior to cleansing when compared to povidine-iodine in a major study, although financial bias may play a role, as the former treatment costs 20 times the latter.
While the review authors have limited practice recommendations, some additional findings are worth noting from the other papers.
Vertebroplasty is effective in reducing pain even one year out and is cost effective.
As expected, elderly patients with major surgeries have greater complication rates.
Fusion has been shown to reduce back pain and synovial cyst recurrence compared to simple decompression for patients with synovial cysts.
For lumbar stenosis, laminectomy is as effective as decompression with interspinous process device placement.