Incidence of Surgical Site Infection After Pine Surgery

A Systematic Review and Meta-Analysis

Jiaming Zhou, MD; Rui Wang, MD; Xiaoyang Huo, MD; Wuyi Xiong, MD; Liang Kang, MD; Yuan Xue, MD, PhD


Spine. 2020;45(3):208-216. 

In This Article

Abstract and Introduction


Study Design: A systematic review and meta-analysis.

Objective: The objective of this study was to investigate the incidence of surgical site infection (SSI) in patients following spine surgery and the rate of microorganisms in these cases.

Summary of Background Data: Many studies have investigated the incidence and risk factors of SSI following spinal surgery, whereas no meta-analysis studies have been conducted regarding the comprehensive epidemiological incidence of SSI after spine surgery.

Methods: We searched the PubMed, Embase, and Cochrane Library databases for relevant studies that reported the incidence of SSI after spine surgery, and manually screened reference lists for additional studies. Relevant incidence estimates were calculated. Subgroup analysis, sensitivity analysis, and publication bias assessment were also performed.

Results: Our meta-analysis included 27 studies, with 603 SSI cases in 22,475 patients. The pooled SSI incidence was 3.1%. Subgroup analysis revealed that the incidence of superficial SSI was 1.4% and the incidence of deep SSI was 1.7%. Highest incidence (13.0%) was found in patients with neuromuscular scoliosis among the different indications. The incidences of SSI in cervical, thoracic, and lumbar spine were 3.4%, 3.7%, and 2.7%, respectively. Compared with posterior approach surgery (5.0%), anterior approach showed a lower incidence (2.3%) of SSI. Instrumented surgery had a higher incidence of SSI than noninstrumented surgery (4.4% vs. 1.4%). Patients with minimally invasive surgery (1.5%) had a lower SSI incidence than open surgery (3.8%). Lower incidence of SSI was found when vancomycin powder was applied locally during the surgery (1.9%) compared with those not used (4.8%). In addition, the rates of Staphylococcus aureus, Staphylococcus epidermidis, and methicillin-resistant Staphylococci in microbiological culture results were 37.9%, 22.7%, and 23.1%, respectively.

Conclusion: The pooled incidence of SSI following spine surgery was 3.1%. These figures may be useful in the estimation of the probability of SSI following spine surgery.

Level of Evidence: 3


Surgical site infection (SSI) is the third most common complication after spinal surgery.[1–3] Within the literature, the incidence of SSI ranges between 0.2% and 16.1%.[4–8] It leads to readmission to the hospital, poor outcomes and additional costs.[9] In the United States, this has resulted in direct and indirect medical expenditure amounting from 1 billion to 10 billion, with 8000 deaths per year.[10] Treatment of SSI often requires multiple readmissions, wound debridement or implant removal, and prolonged antibiotic therapy.[11]

According to United States Center for Disease Control, SSI was classified as superficial, deep, or organ space.[12] A superficial infection occurs within 30 days of surgery involving skin and subcutaneous tissues and is associated with one of the following: purulent drainage, positive culture obtained aseptically, symptoms of infection and wound opened by surgeon, or diagnosis as such by surgeon or attending physician. A deep infection occurs within 30 days (or 1 year if implantation) involving deep soft tissues (e.g., fascial and muscle layers) along with one of the following: purulent drainage from deep tissues, a dehiscence or opening by surgeon with positive identification of microorganisms, abscess or other evidence of infection, or diagnosis of a deep SSI by a surgeon or attending physician. An organ space infection occurs deep to the muscles and fascia and has the same criteria as deep infection.

A few studies have identified risk factors for SSI in spine surgery, including diabetes, obesity, hypertension, transfusion, urinary tract infection, CSF leak, and longer duration of surgery.[9,13–17] Meanwhile, bacterial culture indicated that the most common causative microorganisms of SSI in spinal surgery are Staphylococcus aureus and other members of Staphylococcus species.[18,19]

Although many studies have investigated the incidence and risk factors of SSI following spinal surgery, no meta-analysis studies have been conducted regarding the comprehensive epidemiological incidence of SSI after spine surgery. In addition, the rate of related bacteria of culture still needs to investigate. Therefore, the purpose of the present study was to review the related literature referring to SSI following spine surgery and to investigate microorganisms of SSI.