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Commentary and Perspective

Reflection on Infection

Commentary on an article by Brandon A. Ramo, MD, et al.: “Surgical Site Infections After Posterior Spinal Fusion for Neuromuscular Scoliosis. A Thirty-Year Experience at a Single Institution”

Caird, Michelle S. MD1,*

Author Information
The Journal of Bone and Joint Surgery: December 17, 2014 - Volume 96 - Issue 24 - p e201
doi: 10.2106/JBJS.N.00863
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  • Disclosures


Patients with neuromuscular scoliosis are a diverse group who are challenging to treat, with higher rates of surgical site infection following posterior spinal fusion than patients with idiopathic scoliosis1. Surgical site infection after posterior spinal fusion is costly, is difficult to manage, and may require multiple procedures including implant removal. Ramo et al. performed a retrospective review of patients at one institution who underwent posterior spinal fusion for neuromuscular scoliosis over a thirty-year period. They examined surgical site infection in this population and reviewed patient and treatment factors associated with surgical site infection.

The study, which spans three decades, is the largest reported in the literature, with 428 patients and an overall surgical site infection rate of 10.3%. Important highlights from the analyses that are consistent with other published reports include a 22% infection rate for the sixty-five patients with myelomeningocele2, a high rate of gram-negative infections (41%), and a high rate of polymicrobial infections (45%). On multivariate logistic regression analysis, factors that were significantly related to surgical site infection included incontinence, inadequate cefazolin dosing for weight (≤20 mg/kg), occurrence of other major complications, and length of hospital stay.

Although retrospective, the study provides excellent information based on the very large number of patients included. In addition, the length of time over which the study was conducted allows a look at changes in practice with posterior spinal fusion in neuromuscular scoliosis over three decades. The infection rate was examined by decade, and although univariate analysis showed it to be higher earlier in the study period, this was not significant on multivariate analysis.

Ramo et al. bring the story right up to 2009, a time when we began refocusing on surgical site infection nationally in scoliosis surgery. Many factors were being examined for their impact on surgical site infection in this group, including dosing and timing of antibiotics, instrumentation construct and type of metal, blood loss and its management, close monitoring of the nutritional status of patients, and use of drains. Simultaneously, Best Practice Guidelines3 for preventing surgical site infection in neuromuscular scoliosis were being constructed. This study will allow excellent comparisons in the current decade for implementations of new Best Practice Guidelines.

Overall, the findings in the large number of patients in this study add to a good foundation for construction of Best Practice Guidelines aimed at decreasing the rate of surgical site infection after spinal surgery for neuromuscular scoliosis. Coordinated efforts and prospective studies on the subject will ultimately help us decrease the rate of this complication and increase the safety of posterior spinal fusion in neuromuscular scoliosis.

*The author received no payments or services, either directly or indirectly (i.e., via her institution), from a third party in support of any aspect of this work. Neither the author nor her institution has had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, the author has not had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.


1. Master DL, Poe-Kochert C, Son-Hing J, Armstrong DG, Thompson GH. Wound infections after surgery for neuromuscular scoliosis: risk factors and treatment outcomes. Spine (Phila Pa 1976). 2011 Feb 1;36(3):E179-85.
2. Hatlen T, Song K, Shurtleff D, Duguay S. Contributory factors to postoperative spinal fusion complications for children with myelomeningocele. Spine (Phila Pa 1976). 2010 Jun 1;35(13):1294-9.
3. Vitale MG, Riedel MD, Glotzbecker MP, Matsumoto H, Roye DP, Akbarnia BA, Anderson RC, Brockmeyer DL, Emans JB, Erickson M, Flynn JM, Lenke LG, Lewis SJ, Luhmann SJ, McLeod LM, Newton PO, Nyquist AC, Richards BS 3rd, Shah SA, Skaggs DL, Smith JT, Sponseller PD, Sucato DJ, Zeller RD, Saiman L. Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (surgical site infection) prevention in high-risk pediatric spine surgery. J Pediatr Orthop. 2013 Jul-Aug;33(5):471-8.
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