Surgical site infection in spinal surgery: detection and management based on serial C-reactive protein measurements

Clinical article

Restricted access


C-reactive protein (CRP) is a well-known sensitive laboratory parameter that shows an increase within 6 hours after the onset of bacterial infection. In relation to surgery, a normal CRP response is a rapid increase followed by a gradual reduction, eventually returning to the normal range. The goal of this study was to determine the diagnostic significance of CRP as a detector for early onset surgical site infection in spinal surgery and to discuss effective medical treatment through clinical interpretation and application of the measured CRP values.


A prospective study was performed in 348 consecutive cases involving patients who underwent spinal surgery under general anesthesia between February and September 2008. Blood samples were obtained preoperatively and on postoperative Days 1, 3, and 5 in patients undergoing single-level decompression surgery. An additional blood specimen was obtained at postoperative Day 7 in patients requiring more extensive surgeries. Recorded laboratory results were compared with the patients' clinical course to determine the diagnostic significance of CRP. All of the patients received intravenous prophylactic antibiotic therapy. Once an abnormal response of CRP, indicated by a tendency toward continuous elevation, was noted on Day 5 or Day 7, the prophylactic antibiotics were replaced with another regimen and administration was resumed along with careful observation for signs of surgical site infection.


Monitoring of CRP revealed a characteristic increase and decrease pattern in 332 of 348 patients (95.4%) showing a normal clinical course with regard to early infectious complications. The mean measured CRP (reference range < 4 mg/L) averaged 14.9 ± 20.3 mg/L on Day 1, 15.4 ± 25.1 mg/L on Day 3, and 7.9 ± 13.3 mg/L on Day 5. In contrast, there were 16 cases (4.6%) of abnormal CRP responses resulting in the resumption of intravenous antibiotic treatment, which included a second rise (in 12 cases) and a steady rise (in 4) in the CRP value. Five (1.4%) of 16 patients experienced infectious complications related to spinal surgery. Three patients (0.9%) received long-term antibiotic therapy for 4–6 weeks; however, all patients recovered with medical treatment alone and did not experience gross wound disruption or subsequent discitis. As a predictor for early wound infection, the sensitivity, specificity, positive predictive value, and negative predictive value for abnormal CRP responses were calculated as 100%, 96.8%, 31.3%, and 100%, respectively.


The above results demonstrate that CRP screening is a simple and reliable test for the detection of early infectious complications after spinal surgery. Close observation and appropriate medical management should be performed in a timely fashion when abnormal CRP responses are observed at 5 or 7 days after surgery.

Abbreviations used in this paper: CRP = C-reactive protein; ESR = erythrocyte sedimentation rate; NPV = negative predictive value; PPV = positive predictive value; SSI = surgical site infection.

Article Information

Address correspondence to: Byung-Uk Kang, M.D., 50-3, Dongin-Dong, Jung-Gu, Wooridul Spine Hospital, Daegu, Korea 700-732. email:

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Mean CRP values for 332 patients without infectious complications. The labels C1, C3, C5, and C7 refer to CRP measurements on Day 1, Day 3, Day 5, and Day 7, respectively.

  • View in gallery

    Mean ESR for 332 patients without infectious complications. The labels E1, E3, E5, and E7 refer to ESR measurements on Day 1, Day 3, Day 5, and Day 7, respectively.


  • 1

    An HSSeldomridge JA: Spinal infections: diagnostic tests and imaging studies. Clin Orthop Relat Res 444:27332006

  • 2

    Bassewitz HLFischgrund JSHerkowitz HN: Postoperative spine infections. Semin Spine Surg 12:2032112000

  • 3

    Boden SDBohlman HH: The Failed Spine PhiladelphiaLippincott Williams & Wilkins2003. 257271

  • 4

    Carr WP: The role of the laboratory in rheumatology. Acute-phase proteins. Clin Rheum Dis 9:2272391983

  • 5

    Clark CEShufflebarger HL: Late-developing infection in instrumented idiopathic scoliosis. Spine 24:190919121999

  • 6

    Esses SISachs BLDreyzin V: Complications associated with the technique of pedicle screw fixation. A selected survey of ABS members. Spine 18:223122391993

    • Search Google Scholar
    • Export Citation
  • 7

    Foglar CLindsey RW: C-reactive protein in orthopedics. Orthopedics 21:6876911998

  • 8

    Hatch RSSturm PFWellborn CC: Late complication after single-rod instrumentation. Spine 23:150315051998

  • 9

    Heggeness MHEsses SIErrico TYuan HA: Late infection of spinal instrumentation by hematogenous seeding. Spine 18:4924961993

  • 10

    Hodges SDHumphreys SCEck JCCovington LAKurzynske NG: Low postoperative infection rates with instrumented lumbar fusion. South Med J 91:113211361998

    • Search Google Scholar
    • Export Citation
  • 11

    Jiménez-Mejías MEde Dios Colmenero JSánchez-Lora FJPalomino-Nicás JReguera JMGarcía de la Heras J: Postoperative spondylodiskitis: etiology, clinical findings, prognosis, and comparison with nonoperative pyogenic spondylodiskitis. Clin Infect Dis 29:3393451999

    • Search Google Scholar
    • Export Citation
  • 12

    Kindmark CO: The concentration of C-reactive protein in sera from healthy individuals. Scand J Clin Lab Invest 29:4074111972

  • 13

    Kock-Jensen CBrandslund ISøgaard I: Lumbar disc surgery and variations in C-reactive protein, erythrocyte sedimentation rate and the complement split product C 3 d. Acta Neurochir (Wien) 90:42441988

    • Search Google Scholar
    • Export Citation
  • 14

    Kornblum MBWesolowski DPFischgrund JSHerkowitz HN: Computed tomography-guided biopsy of the spine. A review of 103 patients. Spine 23:81851998

    • Search Google Scholar
    • Export Citation
  • 15

    Larsson SThelander UFriberg S: C-reactive protein (CRP) levels after elective orthopedic surgery. Clin Orthop Relat Res 275:2372421992

    • Search Google Scholar
    • Export Citation
  • 16

    Mangram AJHoran TCPearson MLSilver LCJarvis WR: Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) hospital infection control practices advisory committee. Am J Infect Control 27:971321999

    • Search Google Scholar
    • Export Citation
  • 17

    Massie JBHeller JGAbitbol JJMcPherson DGarfin SR: Postoperative posterior spinal wound infections. Clin Orthop Relat Res 284:991081992

    • Search Google Scholar
    • Export Citation
  • 18

    Meyer BSchaller KRohde VHassler W: The C-reactive protein for detection of early infections after lumbar microdiscectomy. Acta Neurochir (Wien) 136:1451501995

    • Search Google Scholar
    • Export Citation
  • 19

    Mok JMPekmezci MPiper SLBoyd EBerven SHBurch S: Use of C-reactive protein after spinal surgery: comparison with erythrocyte sedimentation rate as predictor of early postoperative infectious complications. Spine 33:4154212008

    • Search Google Scholar
    • Export Citation
  • 20

    Palosuo THusman TKoistinen JAho K: C-reactive protein in population samples. Acta Med Scand 220:1751791986

  • 21

    Pepys MB: C-reactive protein fifty years on. Lancet 1:6536571981

  • 22

    Rechtine GRBono PLCahill DBolesta MJChrin AM: Postoperative wound infection after instrumentation of thoracic and lumbar fractures. J Orthop Trauma 15:5665692001

    • Search Google Scholar
    • Export Citation
  • 23

    Richards BS: Delayed infections following posterior spinal instrumentation for the treatment of idiopathic scoliosis. J Bone Joint Surg Am 77:5245291995

    • Search Google Scholar
    • Export Citation
  • 24

    Rodiek SO: [Diagnostic methods in spinal infections.]. Radiologe 41:9769862001. (Ger)

  • 25

    Rothman SL: The diagnosis of infections ot the spine by modern imaging techniques. Orthop Clin North Am 27:15311996

  • 26

    Sasso RCGarrido BJ: Postoperative spinal wound infections. J Am Acad Orthop Surg 16:3303372008

  • 27

    Sponseller PDLaPorte DMHungerford MWEck KBridwell KHLenke LG: Deep wound infections after neuromuscular scoliosis surgery: a multicenter study of risk factors and treatment outcomes. Spine 25:246124662000

    • Search Google Scholar
    • Export Citation
  • 28

    Takahashi JEbara SKamimura MKinoshita TItoh HYuzawa Y: Early-phase enhanced inflammatory reaction after spinal instrumentation surgery. Spine 26:169817042001

    • Search Google Scholar
    • Export Citation
  • 29

    Thelander ULarsson S: Quantitation of C-reactive protein levels and erythrocyte sedimentation rate after spinal surgery. Spine 17:4004041992

    • Search Google Scholar
    • Export Citation
  • 30

    Varma RLander PAssaf A: Imaging of pyogenic infectious spondylodiskitis. Radiol Clin North Am 39:2032132001

  • 31

    Viola RWKing HAAdler SMWilson CB: Delayed infection after elective spinal instrumentation and fusion. A retrospective analysis of eight cases. Spine 22:244424511997

    • Search Google Scholar
    • Export Citation
  • 32

    Watters WC IIIBaisden JBono CMHeggeness MHResnick DKShaffer WO: Antibiotic prophylaxis in spine surgery: an evidence-based clinical guideline for the use of prophylactic antibiotics in spine surgery. Spine J 9:1421462009

    • Search Google Scholar
    • Export Citation


Cited By



All Time Past Year Past 30 Days
Abstract Views 363 363 78
Full Text Views 184 180 4
PDF Downloads 90 73 0
EPUB Downloads 0 0 0


Google Scholar