Irrigation techniques used in spine surgery for surgical site infection prophylaxis: a systematic review and meta-analysis

Abstract

Background: The greater likelihood of morbidity, mortality, length of hospital stays and poorer long-term outcomes as a result of surgical site infections secondary to spinal surgery makes prophylactic measures an imperative focus. Therefore, the aim of this review was to evaluate the available research related to the efficacy of different intraoperative irrigation techniques used in spinal surgery for surgical site infection (SSI) prophylaxis.

Methods: We performed a comprehensive search using Ovid Medline, EMBASE, Web of Science and the Cochrane library pertaining to this topic. Our meta-analysis was conducted according to PRISMA guidelines. The inclusion criteria consist of spine surgeries with intraoperative use of any wound irrigation technique, comparison groups with a different intraoperative irrigation technique or no irrigation, SSI identified with bacterial cultures or clinically in the postoperative period, reported SSI rates. Data extracted from eligible studies included, but was not limited to, SSI rates, irrigation technique and control technique. Exclusion criteria consist of articles with no human subjects, reviews, meta-analyses and case control studies and no details about SSI identification or rates. Pooled risk ratios were calculated. A meta-analysis was performed with a forest plot to determine risk estimates' heterogeneity with I² index, Q-statistic, and p value under a random-effects model. Funnel plot was used to assess publication bias. All databases were last checked on January, 2022. PROBAST tool was used to assess both risk of bias and applicability concerns.

Results: After reviewing 1494 titles and abstracts, 18 articles met inclusion criteria. They included three prospective randomized-controlled trials, 13 retrospective cohort studies, two prospective cohort studies. There were 54 (1.8%) cases of SSIs in the povidone-iodine irrigation group (N = 2944) compared to 159 (4.6%) in the control group (N = 3408). Using intraoperative povidone-iodine wound irrigation produced an absolute risk reduction of 2.8%. Overall risk ratio was 0.32 (95% CI 0.20-0.53, p < 0.00001). In a global analysis, study heterogeneity and synthesizing mostly retrospective data were primary limitations.

Conclusion: The most evidence exists for povidone-iodine and has Level 2 evidence supporting SSI reduction during spinal surgery. Other antiseptic solutions such as dilute chlorhexidine lack published evidence in this patient population which limits the ability to draw conclusions related to its use in spinal surgery.

Level of evidence: II - Systematic Review with Meta-Analysis.

Keywords: Complications; Infection prophylaxis; Irrigation techniques; Spinal surgery; Surgical irrigation; Surgical site infection.

Fig. 1

Flow diagram demonstrating article selection

Fig. 2

Comparison between intraoperative wound irrigation with povidone-iodine versus controls in their association with SSIs. Legends: CI, confidence interval; M-H, Mantel–Haenszel; PVPI, povidone-iodine

Fig. 3

Funnel plot of the association between estimated effect size of each povidone-iodine study and standard error. Legends: RR, risk ratio; SE, standard error

Fig. 4

Comparison between povidone-iodine (only RCT and prospective cohort studies) versus controls in their association with SSIs. Legends: PVPI, povidone-iodine; RCT, randomized clinical trials; CI, confidence interval; M-H, Mantel–Haenszel