Surgical site infections (SSIs) following spinal surgery and its treatment are highly debated topics over decades, constituting one of the major causes of morbidity in patients undergoing spine surgery. The importance of this topic lies in the fact that, if ignored, it can lead to high morbidity and mortality, which may require prolonged hospitalization. This review deals with rates of SSI in various spine surgeries, then dwells on few studies exploring causes and prevention of SSI, provides a summary of SSI preventive protocols by various organizations, recommendations for antibiotic prophylaxis, and finally on medical management of established postoperative infections.

The spectrum of postoperative spinal infections includes superficial and deep infections, wound infections, spondylodiscitis, intraspinal epidural abscess, infective arachnoiditis, the extraspinal pre- and paravertebral extension of intraspinal abscesses, and necrotic collections. Imaging modalities for detection of these pathologies include plain radiographs, multidetector computed tomography, magnetic resonance imaging (MRI), and radionucleotide scintigraphy. MRI allows adequate visualization of both the bony structures and soft tissues. Contrast enhanced MRI with gadolinium is the imaging modality of choice to delineate postprocedural and postoperative spine infections and complications. MRI has high sensitivity and specificity in the diagnosis of postoperative spondylodiscitis, epidural abscesses, and infective arachnoiditis. Metallic orthopedic hardware may produce artifacts that degrade image quality which is resolved by a metal artifacts reduction sequence to optimize the image quality in bone and soft tissues. F-18 fluorodeoxyglucose positron-emitted tomography is superior to MRI not only in patients with surgical history and high grade infection but also in the patient with low grade spondylodiscitis.

The primary goals for treating infectious spinal conditions are to make an accurate diagnosis, isolate the causative organism, and prescribe effective antibiotic therapy based on the culture reports. A positive culture is extremely important for successful treatment and prevention of further morbidity. Surgically collected samples have shown to have a greater chance of demonstrating growth of organism on culture as compared to computed tomography-guided fine-needle samples. Surgical drainage and/or reconstruction with/or without fixation is usually indicated when there is no or poor response to antibiotic therapy, systemic toxicity with evidence of large collections, progressive spinal deformity, or instability or neurological impairment. However, the incidence of perioperative morbidity is particularly increased in elderly patients or in those with a poor general condition. With improved instrumentation and techniques in minimally invasive spine surgery, spinal infections can be successfully treated by minimally invasive debridement followed by pharmacological treatment, without causing any destabilization to spine. Where major reconstruction and fixation procedures are deemed mandatory, various MIS techniques can be utilized to decrease the surgery related morbidity and allow for faster rehabilitation. These procedures are associated with steep learning curve. With the advent of intraoperative navigation, the exposure to radiations can be significantly reduced.

Spinal infections in immunocompromised patients are a potential threat due to atypical presentations and delay in diagnosis. These patients often present with back pain, fever, and neurological deficits. It is crucial to have knowledge of atypical etiology of vertebral osteomyelitis. Immunocompromised status of the patients presumably prevents them from mounting an inflammatory or vascular response necessary to counter the disease process. The diagnostic delay of such disastrous conditions remains unsatisfactorily long. Identification of the causative microorganisms and timely initiation of treatment are of prime importance in the management of such infections. Magnetic resonance imaging with/without gadolinium contrast is the choice of noninvasive investigation in spinal infections, and an appropriate tissue biopsy for isolation of causative organism is required for confirmation of the diagnosis. Patients are best managed by a multidisciplinary approach. Surgical intervention may be necessary for effective management and prevention of complications due to atypical spinal infections.

This section of the symposium brings four different clinical scenarios in patients presenting with postoperative surgical site infections (SSI) after spine surgery. The patients were managed in various medical centres having different infrastructures and different spine care professionals. The spine clinics aims at providing the reader with an overview of the difficult scenarios faced in the setting of postoperative spinal infection and the different lines of treatment chosen by the attending spine surgeons at their centres. The section ends with few literature supported guidelines in the management of surgical site infection (SSI) after spine surgery.

Background: The socioeconomic impact after cervical spine surgery in patients with cervical spine injury have not been reviewed. The aim of this study was to analyze the clinico-radiological results and socioeconomic impact even after radiologically successful surgery. Materials and Methods: One hundred and thirteen surviving individuals (out of 166) were included in this retrospective study from hospital record who belonged to lower socioeconomic group as per Kuppuswamy scale. All patients had undergone cervical spine surgery (anterior or posterior) for cervical spinal injury from 2007 to 2014. The injury sustained was either purely traumatic or trivial trauma in an existing cervical myelopathy. Average income per family was Rs. 2215.13 ± 870.46 ($39.55) per month with cervical spine injury who underwent surgery. Pre- and postoperative Oswestry Disability Index, Kuppuswamy score, and Nurick Scale were used to assess the degree of loss of function in individuals and roentograms for fixation assessment. The individuals were contacted on phone or during hospital visit to evaluate their expectations and daily living. Results: The average age of study group was 46.65 ± 16.89 years with 65 (57%) comprising males. Fifty-one (46.7%) patients were laborers or farmers, 24/47% lost their jobs after injury. About 19% (Rs. 414.9 ± 162.89) of the monthly expenditure was spent on their rehabilitation and medicines and 63 (56%) had expectations to get government support in the form of financial help or rehabilitation. The Nurick scale did not show any significant change in pre- and postoperative periods (3.06 vs. 2.83; P = 0.180). The postoperative Oswestry Disability Index score was not significantly decreased as compared to the preoperative stage (82.4 ± 1.8 vs. 78.2 ± 2.9 P > 0.05). However, there was a significant reduction in the Kuppuswamy score in the postoperative period (12.5 ± 2.5 vs. 8.2 ± 1.5, P < 0.05). Despite good radiological results and improvement in the clinical symptoms, the socioeconomic condition of the individuals deteriorated in the study group. Conclusions: These findings suggest a socioeconomic impact after cervical spine injury. Cervical spine surgery alone does not make sure of a good functional outcome for the patients of spinal cord injury. It also required a good rehabilitation program which is always a challenge in the lower socioeconomic group, hence socieconomic status of an individual, possibility/ availability of rehabilitation program should be kept in mind to predict/ prognosticate the outcome.

Background: The success and popularity of the transforaminal approach in the lumbar spine has been made possible by the routine use of pedicle screws in the lumbar spine. Transforaminal approach in the cervical spine can give access to the disc and the vertebral body anteriorly and avoid an additional anterior approach in certain clinical situations. We report technical aspects of transforaminal approach in the lower cervical spine with the authors learning experience. Materials and Methods: Fifteen patients underwent transforaminal approach with cervical pedicle screw (CPS) instrumentation at our institute from July 2011 to October 2014. Five patients underwent foraminal decompression alone (Group-1); 9 patients underwent transforaminal cervical interbody fusion (TCIF) with foraminal decompression, discectomy, and interbody bone grafting (Group-2); and 1 patient underwent partial corpectomy (Group-3). All patients were evaluated for the placement of pedicle screws, for clinical improvement using modified Japanese Orthopaedic Association (mJOA) scoring and interbody graft positioning. The average follow-up was 34.6 months (22–64 months). Results: The average age was 45 years (25–80 years). The average blood loss was 198 ml (100–450 ml) and the average operative time was 142 min (90–200 min). Interbody graft pieces extruded anteriorly in 4 patients (Group-II). The preoperative average mJOA score of 11.4 (0–15) improved to 15.73 (0–18) at final followup. Conclusion: Transforaminal approach in lower cervical spine, though has a learning curve, seems to be a feasible technique along with the use of cervical pedicle screws. Safety and reproducibility of the approach needs to be substantiated with a larger study. Further, TCIF can avoid an additional anterior surgery in certain situations in the cervical spine.

Migration of disc fragment into the dorsal epidural space is a rare phenomenon. It happens when a sequestrated disc fragment transgresses the anatomical barriers to reach dorsal to the dural sheath. We describe a rare situation where a dorsally migrated, sequestrated disc fragment also had a partial intradural extension. The case is highlighted for the extreme rarity of such presentation, role of magnetic resonance imaging scan on the preoperative diagnosis and crucial surgical principles.

Cervical ribs are well-described anomalous additional ribs arising from the seventh cervical vertebrae, but they can be a potential cause for wrong-level surgery. We report a case of a 71-year-old female with bilateral lower limb weakness and numbness due to spinal stenosis from T8 to T11 correlated on magnetic resonance imaging (MRI). However, computed tomography (CT) of thoracic spine showed ossification of the yellow ligament (OYL) one level distal at T9-T12. The whole spine CT revealed the presence of cervical ribs, and the initial discrepancy was caused by counting thoracic spinal levels according to the rib heads. Intraoperative decompression confirmed the dura had merged with OYL at T8–T11. The patient made a partial neurological recovery and could walk independently at 6-month follow-up. This case serves as a reminder for spine surgeons surgical implications of cervical ribs when operating on the thoracic spine, and the authors suggest additional radiological examinations to include the cervical spine to minimize the chances of wrong-level surgery.