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Yuma Okamura, Keisuke Maruyama, Shin Fukuda, Hiroshi Horikawa, Nobuyoshi Sasaki, Akio Noguchi, Motoo Nagane, and Yoshiaki Shiokawa

OBJECTIVE

While cerebrospinal fluid (CSF) shunt surgery plays an essential role in the treatment of hydrocephalus, postoperative infection due to the implantation of foreign materials is still one of the most common and potentially serious complications of this procedure. Because no previously reported protocol has been proven to prevent postoperative infection after CSF shunt surgeries in adults, the authors investigated the effectiveness of a protocol introduced in their institution.

METHODS

A detailed standardized surgical protocol to prevent infection in patients undergoing CSF shunt surgeries was introduced in the authors’ institution in December 2011. The protocol included a series of detailed rules regarding the surgical procedure, the surgical environment to minimize contamination from air, double gloving, local injection of antibiotics, and postoperative management. The rate of CSF shunt infection during the 3 years after surgery before and after implementation of the protocol was compared in patients undergoing their first CSF shunt surgeries. The inclusion periods were from January 2006 to November 2011 for the preprotocol group and from December 2011 to December 2014 for the postprotocol group.

RESULTS

The study included 124 preprotocol patients and 52 postprotocol patients. The mean patient age was 59 years in both groups, ranging from 40 days to 88 years. Comparison of patient background factors, including known risk factors for surgical site infections, showed no significant difference between the patient groups before and after implementation of the protocol. While 9 patients (7.3%) developed shunt infections before protocol implementation, no shunt infections (0%) were observed in patients who underwent surgery after protocol implementation. The difference was statistically significant (p = 0.047).

CONCLUSIONS

The authors’ detailed protocol for CSF shunt surgeries was effective in preventing postoperative infection regardless of patient age.

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Tomoaki Shimizu, Masao Koda, Tetsuya Abe, Tomoyuki Asada, Kosuke Sato, Yosuke Shibao, Mamoru Kono, Fumihiko Eto, Kousei Miura, Kentaro Mataki, Hiroshi Noguchi, Hiroshi Takahashi, Toru Funayama, and Masashi Yamazaki

OBJECTIVE

The goal of this study was to clarify the clinical utility of paravertebral foramen screws (PVFSs) and to determine intraoperative indicators for appropriate screw placement during posterior cervical fusion surgery to improve its safety.

METHODS

The authors included data from 46 patients (29 men and 17 women, mean age 61.7 years) who underwent posterior cervical spine surgery with 94 PVFSs. Of the 94 PVFSs, 77 were used in C6, 9 in C3, 5 in C4, and 3 in C5. According to the cervical lateral radiographic view, the authors divided the 94 PVFSs into 3 groups as follows: a longer group, in which the tip of PVFS was located anteriorly from the line of the posterior wall of the vertebral body (> +0 mm); an intermediate group, in which the screw tip was located up to 2 mm posteriorly to the posterior wall of the vertebral body (–2 to 0 mm); and a shorter group, in which the screw tip was located more than 2 mm posteriorly (< –2 mm). The accuracy of screw placement was assessed using CT imaging in the axial plane, and the proportion of screws penetrating a vertebral foramen or a transverse foramen was compared between the 3 groups. Screw loosening was defined as a lucent zone around the screw evaluated on cervical radiography at 1 year after surgery. Complications related to PVFS insertion and revision surgery related to PVFS were evaluated.

RESULTS

The authors classified 25 PVFSs into the longer group, 43 into the intermediate group, and 26 into the shorter group. The proportion of screws penetrating a vertebral foramen was largest in the shorter group, and the proportion penetrating a transverse foramen was largest in the longer group. Screw loosening was confirmed for 3 of 94 PVFSs. One PVFS inserted in C6 unilaterally within a long construct from C2 to C7 showed loosening, but it did not cause clinical symptoms. Revision surgery was required for 2 PVFSs inserted in C3 bilaterally as the lower instrumented vertebra in occiput–cervical fusion because they pulled out. There was no neurovascular complication related to PVFS insertion.

CONCLUSIONS

PVFSs are useful for posterior cervical fusion surgery as alternative anchor screws, and the line of the posterior wall of the cervical body on lateral fluoroscopic images is a potential intraoperative reference to indicate an appropriate trajectory for PVFSs.