脊柱畸形后路内固定矫形术后深部感染的治疗

Treatment of deep surgical site infection after posterior spinal fusion and instrumentation in spinal deformity

中文关键词:  脊柱畸形  手术部位感染  内置物  持续冲洗引流

英文关键词:Spinal deformity  Surgical site infection  Implants  Irrigation and drainage

中文摘要:

  【摘要】 目的：探讨脊柱畸形后路内固定矫形术后深部感染的治疗效果。方法：2012年6月～2014年12月167例脊柱畸形患者行后路内固定矫形术，11例术后并发切口深部感染，男3例，女8例，年龄14.6±4.7岁（11～27岁）；其中早发性感染（术后90d内）9例，迟发性（术后90d后）感染2例。9例早发性感染患者中，伤口渗出液或在B超引导下深层穿刺取脓液细菌培养阳性6例，其中2例为耐甲氧西林金黄色葡萄球菌（MRSA）、3例为甲氧西林敏感金黄色葡萄球菌（MSSA），1例为大肠杆菌；另3例培养阴性者，依据伤口脓性渗液、持续胀痛及术中大量脓性积液而诊断为早发性切口深部感染。2例迟发性感染患者分别于矫形术后7个月和10个月时因腰背部持续性疼痛不适，经MRI检查提示切口深部积液形成，以及血沉、C反应蛋白等炎性指标显著高于正常值而确诊，清创术时取内固定旁组织细菌培养均为表皮葡萄球菌感染。均行彻底清创、置管持续冲洗引流，同时联合敏感抗生素治疗。结果：9例早发性感染经一期切口清创、置管持续冲洗引流及联合敏感抗生素治疗后，伤口均愈合，感染获得控制，内置物得以保留；随访13.5±5.8个月（6～36个月），无内置物松动及感染复发迹象。2例迟发性感染经多次清创、置管持续冲洗引流及联合敏感抗生素治疗仍无法控制感染，于矫形术后1年时取出内置物后治愈，取出内置物后分别随访6个月和14个月，无感染复发迹象，但分别有25°和17°的矫形丢失。结论：对脊柱畸形后路内固定矫形术后早发性深部感染，积极采取彻底清创、置管持续冲洗引流联合敏感抗生素治疗，可有效控制感染，避免取出内置物；而迟发性感染则可能需取出内置物才能控制感染，但有矫形丢失风险。

英文摘要:

  【Abstract】 Objectives: To evaluate the efficacy of management for deep surgical site infection after posterior spinal fusion and instrumentation in spinal deformity. Methods: A total of 167 patients underwent posterior spinal fusion and instrumentation due to spinal deformity from June 2012 to December 2014. Eleven patients(8 females and 3 males) were diagnosed with deep surgical site infections with an average age at admission of 14.6±4.7 years(range, 11-27 years). Among the 11 cases, 9 cases had early postoperative infections(within 90 days after surgery), the other 2 cases had late infections(more than 90 days after surgery). Among the 9 early infections, 6 patients were culture positive, including 2 cases for resistant methicillin-resistant Staphylococcus aureus (MRSA), 3 cases for methicillin sensitive Staphylococcus aureus(MSSA), and 1 case for Escherichia coli. The other 3 cases were culture negative and were diagnosed based on wound purulent exudation, continuous pain and a large amount of purulent fluid in the wound during debridement. The 2 cases with late infections presented with low back pain at 7 months and 10 months after the index surgery, the MRI examination showed that the formation of deep effusion, and the inflammatory indexes(ESR, CRP) were significantly higher than the baseline values, and the culturing of tissue was Staphylococcus epidermis. All the 11 cases were surgically treated with thorough debridement, continuous irrigation and drainage, and adjutant antibiotics therapy. Results: All the 9 early infections had wound healed after continuous irrigation. The removal of instrumentation was not necessary in any patient, and there were no signs of infection and implant loosening at follow-up for a duration of 13.5±5.8 months(range, 6-36 months). While the 2 late infections required multiple debridement, and required implant removal eventually at 12 months after index surgery. At 6 months and 14 months follow-up respectively, there was no recurrence of infection, but 25° and 17° loss of correction was noted respectively. Conclusions: Along with sensitive antibiotic treatment, early postoperative deep wound infection can be effectively cured with thorough debridement, continuous irrigation and drainage. For the late infections, however, the removal of implant is indicated to control the infection, but risk of loss of correction should be paid attention.