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Using the Spine Surgical Invasiveness Index to Identify Risk of Surgical Site InfectionA Multivariate Analysis
Amy M. Cizik, MPH1; Michael J. Lee, MD1; Brook I. Martin, PhD, MPH2; Richard J. Bransford, MD3; Carlo Bellabarba, MD3; Jens R. Chapman, MD1; Sohail K. Mirza, MD, MPH2
1 Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, 1959 N.E. Pacific Street, Box 356500, Seattle, WA 98195-6500. E-mail address for A.M. Cizik: amorgan2@uw.edu
2 Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Spine Center, One Medical Center Drive, Lebanon, NH 03756
3 Department of Orthopaedic Surgery, Harborview Medical Center, 325 9th Avenue, Box 359798, Seattle, WA 98104
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Investigation performed at the University of Washington Medical Center and Harborview Medical Center, Seattle, Washington



Disclosure: One or more 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 an aspect of this work. In addition, 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 © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Feb 15;94(4):335-342. doi: 10.2106/JBJS.J.01084
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Abstract

Background: 

Surgical site infection after spine surgery is a well-known complication that can result in poor outcomes, arthrodesis-site nonunion, and neurological injury. We hypothesized that a higher surgical invasiveness score will increase the risk for surgical site infection following spine surgery.

Methods: 

Data were examined from patients undergoing any type of spinal surgery from January 1, 2003, to December 31, 2004, at two academic hospitals. The surgical invasiveness index is a previously validated instrument that accounts for the number of vertebral levels decompressed, arthrodesed, or instrumented as well as the surgical approach. Relative risks and 95% confidence intervals were calculated for each of the categorical variables. Multivariate binomial stepwise logistic regression was used to examine the association between surgical invasiveness and surgical site infection requiring a return to the operating room for treatment, adjusting for confounding risk factors.

Results: 

The regression analysis of 1532 patients who were evaluated for surgical site infection identified the following significant risk factors for surgical site infection: a body mass index of >35 (relative risk, 2.24 [95% confidence interval, 1.21 to 3.86]; p = 0.01), hypertension (relative risk, 1.73 [95% confidence interval, 1.05 to 2.85]; p = 0.03), thoracic surgery versus cervical surgery (relative risk, 2.57 [95% confidence interval, 1.20 to 5.60]; p = 0.01), lumbosacral surgery versus cervical surgery (relative risk, 2.03 [95% confidence interval, 1.10 to 4.05]; p = 0.02), and a surgical invasiveness index of >21 (relative risk, 3.15 [95% confidence interval, 1.37 to 6.99]; p = 0.01).

Conclusions: 

Patients undergoing more invasive spine surgery as measured with the surgical invasiveness index had greater risk for having a surgical site infection that required a return to the operating room for treatment. Surgical invasiveness was the strongest risk factor for surgical site infection, even after adjusting for medical comorbidities, age, and other known risk factors. The magnitude of this association should be considered during surgical decision-making and intraoperative and postoperative care of the patient. These findings further validate the importance of the invasiveness index when performing safety and clinical outcome comparisons for spine surgery.

Level of Evidence: 

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

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    Accreditation Statement
    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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