17-Year-Delayed Fistula Formation After Elective Spinal Instrumentation: A Case Report
Introduction: A late-developing infection after an uneventful initial spinal instrumentation procedure is rare. Delayed infection and new fistula formation have been reported from a few months to 13 years. Here we report an unusual 17-year-delayed fistula formation after primary spinal instrumentation. The patient underwent hardware removal surgery with antibiotic therapy as a definitive treatment.
Case Presentation: Here we report an unusual 17-year delayed fistula formation after primary spinal instrumentation due to spinal trauma. He was admitted to Ghaem General Hospital, a chief referral center, Mashhad, North-East of Iran in August 2014. The patient underwent hardware removal surgery with antibiotic therapy as a definitive treatment.
Conclusions: Late inflammation may occur around spinal instruments and results in cutaneous fistula formation. After oral or intravenous antibiotic treatment, total device extraction is the cornerstone of treatment.
Keywords: Delayed; Fistula; Instrumentation
Postoperative wound infection following spinal surgery poses high morbidity and mortality, and in this regard, posterior instrumentation has been reported the most frequent procedure (1). Total instrument removal and subsequent primary wound closure with systemic antibiotics is the treatment of choice (2, 3). However, the situation becomes problematic where insufficient bony fusion or pseudarthrosis requires spinal stabilization. Primary implant removal with subsequent reinstrumentation is susceptible to complications of the potentially infectious wound.
2. Case Presentation
A 53-year-old man complaining of exudative fluid discharge of his right flank since one month ago, was admitted to Ghaem General Hospital, a chief referral center, in Mashhad City, North-East of Iran in August 2014. On the physical examination, he was not pyretic; a draining fistula was located in his right flank, associated with pain, erythema, and local edema. His past history was positive for a falling accident 17 years ago with burst fracture of the third lumbar vertebra, and subsequent posterolateral fusion and instrumentation. The surgical and postsurgical periods were both uneventful with a 10-year follow up. Fistula tract was demonstrated on the fistulography and CT-fistulography, opening to the first lumbar pedicle screw (Figure 1A, 1B). There was no abnormality in his laboratory tests except for elevated erythrocyte sedimentation rate. Blood and smear samples were collected, which they were both negative for any microorganism.
Our patient underwent hardware removal surgery with perioperative empirical antibiotics (cephalexin and ciprofloxacin). During the procedure exudative fluid was discovered at the site of the right first lumbar pedicle screw. Adequate smear and culture were obtained with a specimen withdrawn for pathological studies. All the samples were negative for bacteria. The pathological study was consistent with fibro-muscular tissue and non-specific chronic inflammation. Fistula site healed spontaneously and our patient was discharged 10 days after the operation without any complication (Figure 2A, 2B).
A, Fistula Drainage preoperatively; B, Resolved Fistula Drainage 6 Months Follow-up
Spinal fusion and instrumentation infection rate varies from 0.7% to 8.5% in the early postoperative course (4). However, the late onset (longer than one month postoperatively) infection is uncommon, as we demonstrated a 17 years gap between the incident and the fistula formation. Delayed infection rate was reported after instrumented spine surgery from 0.2% to 6.9% (5, 6).
Table 1 summarizes the cases with late infection reported in the literature since 1993. The period between the initial surgical procedure and the inflammatory symptoms varies from a few months to many years, as Mhaidli et al. reported a case with spontaneous drainage 13 years after the first spinal instrumentation (7). Here we report the longest interval, about 17 years.
Staphylococcus species was the most common organism found in the surgical site (8-11), with the next most detected bacteria being Propionibacterium acnes (2, 5, 12). The inflammatory reaction against the metallic device may have a role in these cases, so the removal of the instrument is necessary whether the organism is detected or not. Very late inflammation reaction may occur around spinal instruments and results in cutaneous fistula formation. After oral or intravenous antibiotic treatment, total device extraction is the cornerstone of treatment.
Summary of Late Infections Reported After Instrumented Spine Surgery a
- 1. Muschik M, Luck W, Schlenzka D. Implant removal for late-developing infection after instrumented posterior spinal fusion for scoliosis: reinstrumentation reduces loss of correction. A retrospective analysis of 45 cases. Eur Spine J. 2004;13(7):645-51. [DOI] [PubMed]
- 2. Clark CE, Shufflebarger HL. Late-developing infection in instrumented idiopathic scoliosis. Spine (Phila Pa 1976). 1999;24(18):1909-12. [PubMed]
- 3. Wimmer C, Gluch H. Aseptic loosening after CD instrumentation in the treatment of scoliosis: a report about eight cases. J Spinal Disord. 1998;11(5):440-3. [PubMed]
- 4. Robertson PA, Taylor TK. Late presentation of infection as a complication of Dwyer anterior spinal instrumentation. J Spinal Disord. 1993;6(3):256-9. [PubMed]
- 5. Viola RW, King HA, Adler SM, Wilson CB. Delayed infection after elective spinal instrumentation and fusion. A retrospective analysis of eight cases. Spine (Phila Pa 1976). 1997;22(20):2444-50. [PubMed]
- 6. Hahn F, Zbinden R, Min K. Late implant infections caused by Propionibacterium acnes in scoliosis surgery. Eur Spine J. 2005;14(8):783-8. [DOI] [PubMed]
- 7. Mhaidli HH, Der-Boghossian AH, Haidar RK. Propionibacterium acnes delayed infection following spinal surgery with instrumentation. Musculoskelet Surg. 2013;97(1):85-7. [DOI] [PubMed]
- 8. Bose B. Delayed infection after instrumented spine surgery: case reports and review of the literature. Spine J. 2003;3(5):394-9. [PubMed]
- 9. Kowalski TJ, Berbari EF, Huddleston PM, Steckelberg JM, Mandrekar JN, Osmon DR. The management and outcome of spinal implant infections: contemporary retrospective cohort study. Clin Infect Dis. 2007;44(7):913-20. [DOI] [PubMed]
- 10. Mok JM, Guillaume TJ, Talu U, Berven SH, Deviren V, Kroeber M, et al. Clinical outcome of deep wound infection after instrumented posterior spinal fusion: a matched cohort analysis. Spine (Phila Pa 1976). 2009;34(6):578-83. [DOI] [PubMed]
- 11. Sierra-Hoffman M, Jinadatha C, Carpenter JL, Rahm M. Postoperative instrumented spine infections: a retrospective review. South Med J. 2010;103(1):25-30. [DOI] [PubMed]
- 12. Heggeness MH, Esses SI, Errico T, Yuan HA. Late infection of spinal instrumentation by hematogenous seeding. Spine (Phila Pa 1976). 1993;18(4):492-6. [PubMed]
- 13. Dubousset J, Shufflebarger H, Wenger D. Late “infection” with CD instrumentation. Orthop Trans. 1994;18(3):121-6.
- 14. Antuna SA, Mendez JG, Lopez-Fanjul JC, Paz Jimenez J. Cotrel-Dubousset instrumentation in idiopathic scoliosis a 5-year follow-up. Acta Orthop Belg. 1997;63(2):74-81. [PubMed]
- 15. Hatch RS, Sturm PF, Wellborn CC. Late complication after single-rod instrumentation. Spine (Phila Pa 1976). 1998;23(13):1503-5. [PubMed]
- 16. Weinstein MA, McCabe JP, Cammisa FJ. Postoperative spinal wound infection: a review of 2,391 consecutive index procedures. J Spinal Disord. 2000;13(5):422-6. [PubMed]
- 17. Richards BR, Emara KM. Delayed infections after posterior TSRH spinal instrumentation for idiopathic scoliosis: revisited. Spine (Phila Pa 1976). 2001;26(18):1990-6. [PubMed]
- 18. Soultanis K, Mantelos G, Pagiatakis A, Soucacos PN. Late infection in patients with scoliosis treated with spinal instrumentation. Clin Orthop Relat Res. 2003;(411):116-23. [DOI] [PubMed]
- 19. Emel E, Karagoz Guzey F, Guzey D, Seyithanoglu H, Sel B, Alatas I. Delayed infection 6 years after spinal instrumentation: a case report. Turk Neurosurg. 2007;17(2):116-20. [PubMed]
- 20. Farshad M, Sdzuy C, Min K. Late Implant Removal After Posterior Correction of AIS With Pedicle Screw Instrumentation—A Matched Case Control Study With 10-Year Follow-up. Spin Deformity. 2013;1(1):68-71. [DOI]
- 21. Messina AF, Berman DM, Ghazarian SR, Patel R, Neustadt J, Hahn G, et al. The management and outcome of spinal implant-related infections in pediatric patients: a retrospective review. Pediatr Infect Dis J. 2014;33(7):720-3. [DOI] [PubMed]