Reducing Surgical Site Infections in Spine Tumor Surgery

A Comparison of Three Methods

Addisu Mesfin, MD; Avionna Baldwin, BS; David N. Bernstein, MBA, MA; Eric Emanski, MD; Robert Molinari, MD; Emmanuel Menga, MD; Paul T. Rubery, MD


Spine. 2019;44(24):E1428-E1435. 

In This Article

Abstract and Introduction


Study Design: Case control series.

Objective: The aim of this study was to evaluate and compare the effectiveness of methods to decrease surgical site infections (SSIs) following spine tumor surgery.

Summary of Background Data: With the aging population of the United States, the prevalence of cancer and associated metastatic spine disease is increasing. The most common complication of spine tumor surgery is SSI.

Methods: This a single-institution case-control series of patients undergoing spine tumor surgery from June 2003 to October 2018. Patients were grouped into the following groups: Betadine irrigation and intrawound vancomycin powder (BIVP), intrawound vancomycin powder only (IVP), and patients receiving neither (NONE). The primary outcome was SSIs/wound complications.

Results: One hundred fifty-one spine tumor patients undergoing 174 procedures meeting our inclusion criteria were identified. The BIVP group had 60 patients (73 procedures); the IVP group had 46 patients (47 procedures); and the NONE group had 45 patients (54 procedures). The overall infection rate was 8.6% of all procedures (15/174) and 9.9% (15/151) of all patients. Bivariate analysis comparing patients with and without infections noted the patients with SSIs had significantly higher rates of preoperative radiation treatment (53.3% in infection group vs. 25.5% in noninfection group), P = 0.02. Patients undergoing procedures in the BIVP group had a significantly lower rate of infections (2.7%) than the patients in the IVP (12.8%) and NONE (13%) groups, P = 0.04. Stepwise regression analysis was used to evaluate further factors associated with SSIs. Elevated BMI was significantly associated with SSIs in the model [P = 0.02, odds ratio (OR) 1.14]. BIVP was also protective against infections as compared to the IVP and NONE groups, P = 0.02, OR 0.02.

Conclusion: BIVP led to a significant decrease in SSI rates following spine tumor surgery. Administration of BIVP is not time consuming and decreased SSI rates.

Level of Evidence: 3


The spine is the most common site of metastases within the skeletal system. The frequency of spine metastases has been attributed to the valveless Batson plexus, which may facilitate the spread of metastases; however, the arterial system may also be involved.[1,2] Direct spread from lesions in the rectum or lung may also occur.[3] If the rare primary malignant or benign aggressive tumors are encountered, often a potentially curative en-bloc resection and reconstruction is recommended[4–6] Conversely, the management metastatic spine tumors is often palliative and many metastatic patients have been treated with radiation treatment before surgery.[7,8]

The incidence of surgical site infections (SSIs) following spine tumor surgery ranges from 4.9% to 30%.[9–19] Risk factors include preoperative radiation treatment, revision surgery, and malnutrition. Common causative organisms include the Staphylococcus species. Some emerging strategies to decrease wound infections in spine tumor surgery include the administration of intrawound vancomycin powder, collaboration with plastic surgery for soft tissue reconstruction, and use of minimally invasive instrumentation.[20–24] Betadine irrigation in combination with vancomycin powder has been shown to decrease SSI rates in spine surgery but has not been specifically evaluated for spine tumor surgery.[25,26]

The primary objective of this study is to evaluate SSI rates in spine tumor patients treated with one of the following techniques: (1) Betadine irrigation and intrawound vancomycin powder (BIVP), (2) Intrawound vancomycin powder only (IVP), and (3) No Betadine irrigation or intrawound vancomycin powder (NONE). The secondary objective is to evaluate risk factors for SSI.