Use of incisional vacuum-assisted closure in the prevention of postoperative infection in high-risk patients who underwent spine surgery: a proof-of-concept study

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OBJECTIVE

This proof-of-concept study was conducted to determine whether negative-pressure wound therapy, through the use of incisional vacuum-assisted closure (VAC), is associated with a reduction in surgical site infections (SSIs) when compared to standard wound dressings in patients undergoing open posterior spinal fusion who have a high risk of infection.

METHODS

A total of 64 patients were examined; 21 patients received incisional VAC application (VAC group) versus 43 diagnosis-matched patients who received standard wound dressings (control group). Patients in the VAC group were prospectively enrolled in a consecutive series between March 2013 and March 2014 if they met the following diagnostic criteria for high risk of infection: posterior open surgery across the cervicothoracic junction; thoracic kyphosis due to metastatic disease; high-energy trauma; or multilevel revision reconstructive surgery. Patients in the VAC group also met one or more comorbidity criteria, including body mass index ≥ 35 or < 18.5, diabetes, previous radiation at surgical site, chemotherapy, steroid use, bedridden state, large traumatic soft-tissue disruption, or immunocompromised state. Consecutive patients in the control group were retrospectively selected from the previous year by the same high-risk infection diagnostic criteria as the VAC group. All surgeries were conducted by the same surgeon at a single site. The primary outcome was SSI. All patients had 1 year of follow-up after their surgery. Baseline demographics, intraoperative parameters, and postoperative wound infection rates were compared between groups.

RESULTS

Patient demographics including underlying comorbidities were similar, with the exception that VAC-treated patients were malnourished (p = 0.020). VAC-treated patients underwent longer surgeries (p < 0.001) and required more postoperative ICU admissions (p = 0.039). The median length of hospital stay was not different between groups. In total, 9 control patients (21%) developed an SSI, versus 2 VAC-treated patients (10%).

CONCLUSIONS

Patients in this cohort were selected to have an increased risk of infection; accordingly, the rate of SSI was high. However, negative-pressure wound therapy through VAC application to the postoperative incision resulted in a 50% reduction in SSI. No adverse effects were noted secondary to VAC application. The preliminary data confirm the authors’ proof of concept and strongly support the need for a prospective randomized trial.

ABBREVIATIONS ASA = American Society of Anesthesiologists; BMI = body mass index; LOS = length of hospital stay; NPWT = negative-pressure wound therapy; RCT = randomized controlled trial; SSI = surgical site infection; VAC = vacuum-assisted closure.

Article Information

Correspondence Christopher S. Bailey: University of Western Ontario, London Health Sciences Centre, London, ON, Canada. chris.bailey@lhsc.on.ca.

INCLUDE WHEN CITING Published online May 10, 2019; DOI: 10.3171/2019.2.SPINE18947.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Flow diagram of the wound closure paradigm.

  • View in gallery

    Incisional VAC application (VAC devices and materials obtained from KCI/Acelity). A: Primary closure. B: Exposed skin edges of the clean, closed incision are covered with a VAC Drape. C: A 1-inch × 1-inch piece of VAC Granufoam is cut to fit the size of the incision. D: A VAC Drape and SensaT.R.A.C. Pad cover the incision and surrounding wound area to make an airtight seal. Negative pressure is applied using a KCI Prevena V.A.C. device at 75 mm Hg. Asterisks mark a secondary (10-Fr) deep drain that is placed outside of the VAC dressing. Figure is available in color online only.

  • View in gallery

    Bar graphs showing significant differences between control and VAC-treated patients. A: Significantly more VAC-treated patients were malnourished at baseline. Values are percents ± SE. B: Average length of surgery was significantly longer for VAC-treated patients. Values are mean ± 95% CI. C: Significantly more VAC-treated patients required postoperative ICU admission. Values are percents ± SE. *p < 0.05; **p < 0.001.

  • View in gallery

    Bar graph showing the incidence of SSIs in control (21%) and VAC-treated (9.5%) patients. The relative risk of developing an SSI with VAC treatment was 0.5 (95% CI 0.1–1.9, p = 0.491). Values are percent ± SE.

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