Commentary on: “Sterile Seroma Resulting from Multilevel XLIF Procedure as Possible Adverse Effect of Prophylactic Vancomycin Powder: A Case Report”

نویسندگان

  • Scott L. Parker
  • Clinton J. Devin
چکیده

Postoperative surgical site infection (SSI) is the second most common health care–associated infection in the United States, second only to urinary tract infections, and resulting in an estimated 8,205 deaths in 2002 alone.1 Furthermore, SSIs have been shown to result in a prolongation of hospital stay by 9.7 days and increase treatment cost by $20,842 per admission.2As such, significant attention has been focused on means of reducing SSIs and their associated morbidity and excess health care costs. Gram-positive microorganisms are the most common cause of SSI following spine surgery.3 The use of prophylactic intrawound vancomycin powder has recently become a more common practice due to its ease of application, low cost, and ability to achieve high local concentrations with low systemic levels.4,5 A recent meta-analysis found that vancomycin powder was associated with a significant reduction in SSI (odds ratio: 0.19, 95% confidence interval: 0.09–0.38).6 Furthermore, cost analyses on patients undergoing lumbar fusion procedures have demonstrated that the use of vancomycin powder was associated with a cost savings of $438,165 per 100 spinal fusions performed.7 As with any new technology, medication, or technique, adverse events and/or sequelaewill inevitably surface following generalized practice implementation. Well-described adverse drug reactions to systemic intravenous vancomycin use include red man syndrome, vasculitis, anaphylaxis, ototoxicity, nephrotoxicity, neutropenia, thrombocytopenia, fever, phlebitis, and Stevens–Johnson syndrome.8 The authors of the current study report a case of persistent/recurrent sterile seroma formation following multilevel lumbar decompression and fusion. The authors postulate that this persistent fluid collection may have been secondary to the application of intrawound vancomycin powder in a mechanism mediated through a hypersensitivity reaction. Because topical vancomycin powder does not result in persistently elevated serum or local vancomycin levels,4,5 we feel it would unlikely be the principal underlying factor leading to a persistent/recurrent seroma collection. In the current case report, the authors describe that the seroma needed to be drained a total of nine times from 1 to approximately 4 months postoperatively. By this time, the local and serum levels of vancomycinwould be essentially nonexistent; as such, we feel this reaction and fluid formationwould more likely be the result of a permanent implant (pedicle screw, rod, interbody graft, etc.) that resulted in a persistent allergic response. This is supported by the fact that hypersensitivity reactions have been reported for implanted metals, including titanium and stainless steel, which are common elements of spinal hardware systems.9,10However, given the current data of this case, it is impossible to definitively state the underlying culprit for the persistent, recurrent seroma collection. Nevertheless, it should be emphasized that all medications carry risks of adverse reactions. Open and transparent reporting of these adverse events, with analysis to determine causality, is critical as any new treatment is implemented by the masses. Application of intrawound vancomycin should occur in a thoughtful and evidence-based manner, reserving for those at risk of SSI. At our institution, we currently employ vancomycin powder (up to 2 g) in patients undergoing open posterior spinal fusion procedures or thosewithmultiple risk factors for infection. We do not routinely use vancomycin powder in patients undergoing minimally invasive procedures (decompression alone or fusion), discectomy, or single-

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Sterile Seroma Resulting from Multilevel XLIF Procedure as Possible Adverse Effect of Prophylactic Vancomycin Powder: A Case Report

Study Design Case report. Objective The objective of this study was to present the unusual case of a 59-year-old woman with a reoccurring sterile postoperative seroma. Methods A patient was observed postoperatively for any complications or adverse side effects resulting from an initial multilevel anterior/posterior lumbar fusion surgery where 2 g (1 g combined with the bone graft used for poste...

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Reply to the Letter to the Editor on: “Sterile Seroma Resulting from Multilevel XLIF Procedure as Possible Adverse Effect of Prophylactic Vancomycin Powder: A Case Report” (Evid Based Spine Care J 2014;5(2):127–133)

I appreciate the insight provided by this letter to the authors regarding the issue of sagittal malalignment in this case report. Although the case report was directed at the postoperative seroma and potential relationship with the use of vancomycin, andwas not related to the sagittal alignment per se, the input provided in this case ismuch appreciated. In fact, I went back and remeasured the p...

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Letter to the Editor on: “Sterile Seroma Resulting from Multilevel XLIF Procedure as Possible Adverse Effect of Prophylactic Vancomycin Powder: A Case Report” (Evid Based Spine Care J 2014;5(2):127–133)

The case published by Youssef et al is highly interesting in my opinion, but not for what the presentation focuses on but rather for what it omits.1 The preoperative lumbar sagittal alignment (Fig. 2) is rather nice with 50 degrees from T12 to S1, despite the severe degenerative changes that led to the indication for surgery. The postoperative film (Fig. 5) shows a severe loss of lumbar lordosi...

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عنوان ژورنال:

دوره 5  شماره 

صفحات  -

تاریخ انتشار 2014