New wound closure technique may decrease infection after scoliosis surgery

Technique reduced complications in patients who underwent scoliosis surgery.

Surgeons at NYU Langone Medical Center developed a new wound closure technique for scoliosis surgery they say has the potential to reduce infections postoperatively.

Perspective from Steven D Glassman, MD

Inter-departmental cooperation has long been a staple of NYU Langone Medical Center, according to Thomas J. Errico, MD, Chief of the Division of Spine Surgery at NYU Langone. He said the orthopedic surgery department enlisted the help of the plastic surgery department to develop an improved soft tissue coverage and closure technique used with scoliosis surgery.

“As spinal instrumentation techniques evolved in a similar fashion, we started to use increasingly sophisticated hardware in adolescent neuromuscular patients and other complex revision spine cases. Similar wound problems arose and it was a natural for us to turn to our experienced plastic surgery department to help us solve them. When a complex spine case is finished, we will turn the case over to plastics for mobilization of soft tissues and a complex closure to provide a ‘tension free’ fascial closure over the hardware. Management of both deep and superficial hematoma through drains is a critical component to keep the pressure off of the primary fascial closure,” Errico told Spine Surgery Today.

Multilayered flap closure

Both departments have worked together since the 1970s to improve techniques and procedures. The neurological services at NYU Langone were tackling difficult intradural spinal cord tumors and the primary, as well as the revision cases were irradiated which further complicated issues. Wound closure and infection became problematic in these procedures, Errico said.

The new technique features a multilayered flap closure that facilitates the closure of several layers of muscle and fascia while maintaining blood supply. Conventional closing techniques, on the other hand, involve a bulk skin closure without mobilization of flaps.

According to Errico, patients who underwent spine fusion for non-idiopathic scoliosis were 25% to 76% more likely to experience a complication than patients with idiopathic scoliosis. Researchers showed these patients were also 4% to 23% more likely to develop an infection than patients with idiopathic scoliosis.

Eliminates dead space

The elimination of dead space or pockets around the spinal hardware with this new procedure can reduce complications and rates of infection after scoliosis surgery, Errico and colleagues noted.

In their study of the new technique, they analyzed 76 charts of patients aged 8 years to 25 years with non-idiopathic scoliosis who underwent posterior spine fusion. Forty-two patients had their incisions closed with the conventional technique, and 34 patients had their incisions closed with the multilayered flap technique. Among the patients treated with the new technique, the complication rate was 0%. There was a 19% wound complication rate with the traditional technique.

“The study reports on the end result of a learning curve that commenced 40 years ago,” Errico said.

There has been little published in terms of the best technique for wound closure after scoliosis surgery, he noted. – by Robert Linnehan

Reference:
New method of closing the incision during scoliosis surgery nearly eliminates infections. http://nyulangone.org/press-releases/new-method-of-closing-the-incision-during-scoliosis-surgery-nearly-eliminates-infections. Accessed Sept. 15, 2015.

For more information:
Thomas J. Errico, MD, can be reached at NYU Langone Medical Center, 333 E. 38th St., New York, NY 10016; email: thomas.errico@nyumc.org.

Disclosure: Errico reports no relevant financial disclosures.

Perspective

Steven D Glassman, MD

Wound complications, including infection, represent a significant risk in the management of complex spinal deformities in general and neuromuscular scoliosis in particular. This study in the Journal of Pediatric Orthopaedics is another example in the growing body of literature that demonstrates the benefit of a team approach to the management of these complex cases.

In this study, the authors demonstrate a decreased infection rate in high risk neuromuscular scoliosis cases managed using a multilayered wound closure incorporating flap coverage, undertaken by a dedicated plastic surgeon.

Neuromuscular and syndromic scoliosis cases carry an extremely high risk for wound complications and it seems possible, if not likely, that this approach might be cost-effective as well as efficacious. The authors report the plastic surgery closure added an average of about 50 minutes to the cases, and while this was not found to be statistically significant, longer duration will probably be the tradeoff. Whether increased OR time is associated with a higher incidence of non-wound-related complications remains an important question.

Finally, the authors imply that this approach might be appropriate for a wider array of spinal deformity cases outside of the pediatric neuromuscular deformity population. While this raises significant questions in terms of feasibility and cost-effectiveness, it seems like a concept worthy of further study.

Steven D Glassman, MD

Norton Leatherman Spine Center

Disclosures: Disclosure: Glassman reports no relevant financial disclosures.