Revision spine surgery in patients without clinical signs of infection: How often are there occult infections in removed hardware?

Purpose: To examine the incidence of occult infection in revision spine surgeries and its correlation with preoperative inflammatory markers. Methods: We retrospectively reviewed all patients who underwent revision spine surgery and hardware removal between 2010 and 2016. Patients who had preoperative clinical signs of infection were excluded. The hardware and surrounding tissue culture results were obtained. The patients’ diagnosis and preoperative inflammatory marker (ESR, CRP, and procalcitonin) levels were recorded. Results: A total of 162 consecutive patients were included in this study. The patients’ mean age was 61 years (range 14–88). One hundred and three patients (63.6%) were female. Seventy-two patients (44.4%) had loose hardware and 88 patients (54.3%) had pseudarthrosis. Postoperatively, the hardware and/or surrounding tissue culture was positive in 15 patients (9.3%). The most commonly identified organisms were Propionibacterium acnes (7/15, 46.7%) and Staphylococcus (6/15, 40.0%). The other identified organisms were Pseudomonas aeruginosa (1/15, 6.7%) and Serratia marcescens (1/15, 6.7%). Only four patients with positive cultures had elevated preoperative ESR and CRP levels. Only two patients with positive cultures had elevated preoperative procalcitonin levels. There is no correlation between the patients’ preoperative ESR, CRP, procalcitonin levels, and positive culture results (p > 0.05). Conclusions: Our study shows that occult infections are present in 9.3% of patients who underwent revision spine surgery and hardware removal although they did not have clinical signs of infection. Those commonly used preoperative inflammatory markers such as ESR, CRP, and procalcitonin may not be sensitive enough to detect occult infections in these patients. Graphical abstract: These slides can be retrieved under Electronic Supplementary Material.[Figure not available: see fulltext.].