17-Year-Delayed Fistula Formation After Elective Spinal Instrumentation: A Case Report

AUTHORS

Hamid Etemadrezaei 1 , Samira Zabihyan 1 , Aidin Shakeri 1 , Babak Ganjeifar 1 , *

1 Department of Neurological Surgery, Ghaem Hospital, Mashhad University of Medical Sciences (MUMS), Mashhad, IR Iran

How to Cite: Etemadrezaei H, Zabihyan S, Shakeri A, Ganjeifar B. 17-Year-Delayed Fistula Formation After Elective Spinal Instrumentation: A Case Report, Iran Red Crescent Med J. 2015 ; 17(5):e28090. doi: 10.5812/ircmj.17(5)2015.28090.

ARTICLE INFORMATION

Iranian Red Crescent Medical Journal: 17 (5); e28090
Published Online: May 25, 2015
Article Type: Case Report
Received: February 20, 2015
Revised: March 19, 2015
Accepted: April 18, 2015
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Abstract

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

Copyright © 2015, Iranian Red Crescent Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Introduction

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).

Figure 1. Fistulography
Fistulography

A, CT Fistulography; B, Coronal view.

A, Fistula Drainage preoperatively; B, Resolved Fistula Drainage 6 Months Follow-up
Figure 2. A, Fistula Drainage preoperatively; B, Resolved Fistula Drainage 6 Months Follow-up

3. Discussion

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.

Table 1. Summary of Late Infections Reported After Instrumented Spine Surgery a
Reference Number of PatientsClinical SymptomsRisk FactorsRisk FactorsFindings From CultureTreatmentSuspected CauseYear of Publication
Heggeness et al. (12)6Back pain (3), fever (3), spontaneous drainage of painful swelling (4), retroperitoneal abscess (1), fluctuation mass (1)Paraplegia with neurogenic bladder (2), Pyelonephritis/ renal calculi (1), intravenous drug abuse (2)Paraplegia with neurogenic bladder (2), Pyelonephritis/ renal calculi (1), intravenous drug abuse (2)Propionibacterium acnes (1), S.aureus (3), Streptococcus morvillorium (1), S.epidermides (1)Instrument removed (3), abscess drainage under CT guidance (1), needle aspiration (1)Hematogenous seeding1993
Robertson and Taylor (4)3Elevated ESR (2), feeling of malaise (3), abscess in groin (2)Not statedNot statedProteus mirabilis (1), none found (1) not stated (1)Instrumentation removedIntraoperative inoculation1993
Dubousset et al. (13)18Incisional swelling and pain, spontaneous drainageNot statedNot statedS.epidermis (2), negative (16)Instrumentation removedMicromotion; metal fretting causing s sterile inflammation1994
Viola et al. (5)8Wound drainage (2), abscess (4) back pain (8), Elevated ESR (7)Smoker (3), Malnutrition (1), Neurogenic bladder (2)Smoker (3), Malnutrition (1), Neurogenic bladder (2)S.epidermidis (6), Proprionibacterium acnes (1), negative (13)Instrumentation removedIntraoperative inoculation1997
Antuna et al. (14)1Pain, spontaneous drainageNoneNoneNot reportedInstrumentation removedNot stated1997
Hatch et al. (15)1Back pain, tenderness over instrumentation, Westergren sedimentation rate 38%NoneNoneNegativeInstrumentation removedMetal fretting, Chronic inflammation or low virulent bacteria1998
Wimmer and Gluch (3)8Aseptic loosening of hardware, radiolucency around pedicle screws, pain and swelling in 6 patients who had discharging sinusNoneNoneNegative (6), no culture taken (2)Instrumentation removed (6), none (2)Metal fretting, micromotion1998
Clark and Shufflebarger (2)22Fluctuant mass or drainage, pain rarely a factor, no fevernonenoneS.epidermides (6), Enterococcus (2), S.aureus (1), Propionibacterium acnes (3)Instrumentation removedIntraoperative inoculation1999
Weinstein et al. (16)3 (of a series of 46 infections)Not specifically stated for 3 patientsNot specifically statedNot specifically statedNot specifically stated; S. aureus found in 34 of 46Instrumentation removedNot stated2000
Richards and Emara (17)23Spontaneous drainage (15) fluctuance (6), pain (9), fever (3)Reoperation for dislodgement of hook (1), intravenous drug abuse (1)Reoperation for dislodgement of hook (1), intravenous drug abuse (1)Propionibacterium acnes (12), S epidermides (4), Micrococcus varians (13), S. aureus (1), negative (5)Instrumentation removedIntraoperative inoculation2001
Soultanis et al. (18)5local subcutaneous abscess, whereas the remaining patients had a local drainageinstrumentation failure and looseninginstrumentation failure and looseningcoagulase-negative Staphylococci (3), Acinetobacter baumani (1), Peptostreptococcus (1)Instrumentation removedNot stated2003
Bose (8)4Back pain (1), incisional swelling (2), spontaneous drainage (1), abscess (1), hip pain (1), mental confusion (1)Dental infection (1), neurogenic bladder (1), kidney infection (1), Knee replacement surgery (1)Dental infection (1), neurogenic bladder (1), kidney infection (1), Knee replacement surgery (1)S. aureus (2), not tested (1) S. aureus suspected but no organisms found probably due to long-term course of antibioticsIrrigation/debridement (2), instrumentation removed (2), antibiotic therapy alone (1)Hematogenous seeding (4)2003
Muschik et al. (1)45Wound sinus and spontaneous drainage of fluid (40), local pain (38), swelling (34), redness (28), Fever > 38.0°C (7)History of allergic predisposition, protracted postoperative fever, and nonunion of the fusionHistory of allergic predisposition, protracted postoperative fever, and nonunion of the fusionStaphylococcus aureus (6) Staphylococcus epidermidis (2)Instrumentation removedImplant bulk, metallurgic reactions, contamination with low-virulence microorganisms2004
Hahn et al. (6)7Sudden Onset Local pain and swelling (7), Sinus Drainage (2)NoneNonePropionibacterium acnes (6), Not found (1)Instrumentation removedIntraoperativeinoculation2005
Kowalski et al. (9)51Back Pain (33), Wound drainage (16), Sinus tract present (13), Neurologic deficits (8)Diabetes mellitus (1), Systemic malignancy (6), Hepatic failure (1), Immunosuppressive medication use (8), End-stage renal disease (1)Diabetes mellitus (1), Systemic malignancy (6), Hepatic failure (1), Immunosuppressive medication use (8), End-stage renal disease (1)coagulase-negative staphylococci (9), Propionibacterium acnes (6), Staphylococcus aureus (11), Gram-negative bacilli (1), Streptococci (4), Polymicrobial infection (12), negative (8)Antibiotic therapy (6), Instrumentation removed (45)Intraoperative inoculation of low-virulence organisms2007
Emel et al. (19)1Purulent flow developed in the posterior skin scarL3-Giant cell tumorL3-Giant cell tumorStaphylococcus aureusInstrumentation removedIntraoperative inoculation2007
Mok et al. (10)4Drainage (2), Operative site pain (2)NoneNoneS. epidermidis (4 of 4), Propionibacterium acnes (3 of 4)2009
Sierra-Hoffman et al. (11)7Drainage (4), Fever (3), Erythema (1)Not specified, For late onset infectionNot specified, For late onset infectionMethicillin-sensitive Staphylococcus aureus (3), Pseudomonas aeruginosa (2), Enterococcus faecalis (2)Antibiotic therapy (1), Instrumentation removed (6)Intraoperativeinoculation2010
Mhaidli et al. (7)1Spontaneous drainageNon StatedNon StatedPropionibacterium acnesInstrumentation removedIntraoperative inoculation2012
Farshad et al. (20)7Sudden Pain, Swelling and FlactuationNot StatedNot StatedPropionibacterium acnes (6)Instrumentation removedIntraoperative inoculation, metal fretting2012
Messina et al. (21)7 (of a series of 23 infections)Not specifically, stated, wound drainage (19), pain (8), fever (7)Not StatedNot StatedNot specified, for late onset infectionInstrumentation removedIntraoperative inoculations2014
Our Case1Elevated ESR, Fistula formationnonenonenegativeInstrumentation removedNot stated

a Abbreviation: ESR: erythrocyte sedimentation rate.

Footnote

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