Ogihara Satoshi, Murase Shuhei, Oguchi Fumihiko, Saita Kazuo
Department of Orthopaedic Surgery, Spine Center, Sagamihara National Hospital, Minami-ku, Sagamihara City, Kanagawa, Japan.
Department of Orthopaedic Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan.
Medicine (Baltimore). 2020 Jun 26;99(26):e20892. doi: 10.1097/MD.0000000000020892.
Patients with rheumatoid arthritis (RA) tend to be immunosuppressed due to RA itself and the therapeutic drugs administered. The management of surgical site infection (SSI) following upper cervical spinal instrumented fusion in RA patients is challenging; however, literature on the treatment for such conditions is scarce. We report 3 consecutive patients with RA, who developed deep SSI following upper cervical posterior fusion and were treated using antibiotic-loaded bone cement (ALBC).
All 3 patients reported in the current study experienced compression myelopathy with upper cervical spinal deformity and received prednisolone and methotrexate for controlling RA preoperatively. The patient in Case 1 underwent C1-2 posterior fusion and developed deep SSI due to methicillin-sensitive Staphylococcus aureus at 3 months postoperatively; the patient in Case 2 underwent occipito-C2 posterior fusion and developed deep SSI due to methicillin-sensitive Staphylococcus aureus at 2 weeks postoperatively; and the patient in Case 3 underwent occipito-C2 posterior instrumented fusion and laminoplasty at C3-7, and developed deep SSI due to methicillin-resistant coagulase negative staphylococci at 3 weeks postoperatively.
All patients developed deep staphylococcal SSI in the postoperative period.
All 3 patients were treated using ALBC placed on and around the instrumentation to cover them and occupy the dead space after radical open debridement.
The deep infection was resolved uneventfully after the single surgical intervention retaining spinal instrumentation. Good clinical outcomes of the initial surgery were maintained until the final follow-up without recurrence of SSI in all 3 cases.
ALBC embedding spinal instrumentation procedure can be a viable treatment for curing SSI in complex cases, such as patients with RA who undergo high cervical fusion surgeries without implant removal.
类风湿关节炎（RA）患者由于RA本身及所使用的治疗药物往往处于免疫抑制状态。类风湿关节炎患者上颈椎器械融合术后手术部位感染（SSI）的管理具有挑战性；然而，关于此类情况治疗的文献却很匮乏。我们报告3例连续的类风湿关节炎患者，他们在上颈椎后路融合术后发生了深部SSI，并采用含抗生素骨水泥（ALBC）进行治疗。
本研究报告的所有3例患者均经历了伴有上颈椎畸形的压迫性脊髓病，并在术前接受泼尼松龙和甲氨蝶呤以控制类风湿关节炎。病例1的患者接受了C1-2后路融合术，术后3个月因对甲氧西林敏感的金黄色葡萄球菌发生深部SSI；病例2的患者接受了枕骨-C2后路融合术，术后2周因对甲氧西林敏感的金黄色葡萄球菌发生深部SSI；病例3的患者接受了枕骨-C2后路器械融合术及C3-7椎板成形术，术后3周因耐甲氧西林凝固酶阴性葡萄球菌发生深部SSI。
所有患者在术后均发生了深部葡萄球菌SSI。
所有3例患者均采用在器械周围及上方放置ALBC的方法进行治疗，以覆盖器械并在彻底开放清创后填充死腔。
在保留脊柱器械的单次手术干预后，深部感染顺利得到解决。所有3例患者直至最后随访均维持了初次手术的良好临床效果，且SSI未复发。
对于复杂病例，如接受高颈椎融合手术且未取出植入物的类风湿关节炎患者，ALBC包埋脊柱器械手术可作为治疗SSI的一种可行方法。
