Scientific Articles   |    
Methods to Decrease Postoperative Infections Following Posterior Cervical Spine Surgery
Joshua M. Pahys, MD1; Jenny R. Pahys, MPH1; Samuel K. Cho, MD2; Matthew M. Kang, MD3; Lukas P. Zebala, MD4; Ammar H. Hawasli, MD, PhD4; Fred A. Sweet, MD5; Dong-Ho Lee, MD4; K. Daniel Riew, MD4
1 Department of Orthopaedic Surgery, Albert Einstein Medical Center, 5501 Old York Road/WCB 4, Philadelphia, PA 19141
2 Department of Orthopaedic Surgery, Mt. Sinai School of Medicine, 5 East 98th Street, Box 1188, New York, NY 10029
3 Department of Neurosurgery, Regions Hospital, 640 Jackson Street, St. Paul, MN 55101
4 Department of Orthopaedic Surgery, Washington University School of Medicine, One Barnes Jewish Plaza, Suite 11300, West Pavilion, St. Louis, MO 63110. E-mail address for K.D. Riew: riewd@wudosis.wustl.edu
5 Rockford Spine Center, 2902 McFarland Road, Suite 300, Rockford, IL 61107
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Investigation performed at the Cervical Spine Service of Washington University Orthopaedics, St. Louis, Missouri

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has 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.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Mar 20;95(6):549-554. doi: 10.2106/JBJS.K.00756
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To decrease surgical site infections, we initiated a protocol of preliminary preparation of the skin and surrounding plastic drapes with alcohol foam, and the placement of a suprafascial drain in addition to a subfascial drain in obese patients in 2004. In 2008, we additionally placed 500 mg of vancomycin powder into the wound prior to closure. The purpose of this study was to analyze the infection rates for three groups: Group C (control that received standard perioperative intravenous antibiotics alone), Group AD (alcohol foam and drain), and Group VAD (vancomycin with alcohol foam and drain).


A consecutive series of 1001 all-posterior cervical spine surgical procedures performed at one institution by the senior author from 1995 to 2010 was retrospectively reviewed. These surgical procedures included foraminotomy, laminectomy, laminoplasty, arthrodesis, instrumentation, and/or osteotomies. There were 483 patients in Group C, 323 in Group AD, and 195 in Group VAD.


In Group C, nine (1.86%) of the 483 patients had an acute postoperative deep infection, in which methicillin-resistant Staphylococcus aureus was the most common pathogen. A significantly higher rate of infection was found in patients with an active smoking history (p = 0.008; odds ratio = 2.6 [95% confidence interval, 1.0 to 7.1]), rheumatoid arthritis (p = 0.005; odds ratio = 4.0 [95% confidence interval, 1.4 to 7.9]), and a body mass index of ≥30 kg/m2 (p = 0.005; odds ratio = 4.1 [95% confidence interval, 1.5 to 7.7]). Group AD (n = 323) had one infection, a significant decrease compared with Group C (p = 0.047). In Group VAD, none of the 195 patients had infections, which was also a significant decrease compared with Group C (p = 0.048).


In this study, preliminary preparation with alcohol foam and the placement of suprafascial drains for deep wounds resulted in one postoperative deep infection in 323 surgical procedures. The addition of intrawound vancomycin powder in 195 consecutive posterior cervical spine surgical procedures resulted in no infections and no adverse effects. To our knowledge, this is the first description of a technique for significantly decreasing postoperative cervical spine infections.

Level of Evidence: 

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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