From Medscape Medical News

Direct Vancomycin Deposits Safe in Spine Surgery

Laird Harrison

February 13, 2012 (San Francisco, California) Depositing vancomycin directly into deep spinal surgery wounds is associated with a low deep-infection rate, researchers reported here at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting. "This may be a cost-effective method of lowering infection rates," said William J. Molinari III, MD, a resident at the University of Rochester in New York. Previous research has shown that perioperative intravenous antibiotics can reduce the incidence of deep infection from spinal surgery, but do not completely eliminate this potentially fatal complication. The Rochester researchers wanted to see what benefit they could find by sprinkling a gram of vancomycin into the spinal surgical wound just prior to closure. In theory, this approach should achieve the highest concentration of antibiotic where it is needed most. The approach was used in 1512 consecutive adult spinal surgery cases from 2005 to 2010. Of these, 849 were uninstrumented procedures and 443 were instrumented posterior thoracic or lumbar, 27 were instrumented anterior or lumbar, 146 were instrumented anterior cervical, and 47 were instrumented posterior cervical procedures. The investigators retrospectively reviewed the medical records of these patients to evaluate postoperative wound infection rates. They found that 13 (0.86%) patients had evidence of postoperative deep-wound infection. All patients underwent wound irrigation, debridement, and reclosure. The most commonly identified organisms in these infections were Staphylococcus aureus strains, including methicillin-resistant strains. In the instrumented surgeries, the rate of deep-wound infection was 0.9%; in uninstrumented surgeries, the rate was 0.8%. Among multilevel instrumented posterior spinal fusions, the rate was only 0.9%. In open posterior lumbar interbody fusion procedures, it was 0.73%, and in single-level instrumented posterior fusions, it was 0.81%. None of the patients who had uninstrumented spinal fusion showed signs of deep infection. The rate of infection ranged from 0.33% in 2010 to 1.50% in 2006. In comparison, a study of the Scoliosis Research Society morbidity and mortality database for all reported spine surgery cases from 2004 to 2007 demonstrated an overall infection rate of 2.1%, with 0.8% superficial and 1.3% deep infections.

Dr. Molinari noted that vancomycin cost only $4.27 for each procedure. "There was really no science behind the decision to [use 1 g of powdered vancomycin] instead of 2 g," he said. "We essentially put just enough to cover the wounds." The patients experienced no adverse reactions that could be directly attributed to vancomycin in the wound. One patient experienced vancomycin toxicity, but this patient was on prolonged intravenous vancomycin. Two patients suffered transient and unexplained hearing loss. One patient suffered unexplained acute renal failure. The researchers did not notice any intrawound or local effects. Dr. Molinari reported that some other centers have done studies along these lines, also with nothing to report. The real test of such an approach would be a case-controlled trial, George Furey, MD, chief of orthopedic spine surgery at Case Western Reserve in Cleveland, Ohio, told Medscape Medical News. However, he pointed out, institutional review boards might object to such a trial. Although directly depositing vancomycin in this way is not the standard of care, many clinicians have already adopted this approach, and enough evidence exists that the review boards might say it cannot be withheld from a group of patients. "I think it's useful, and it's relatively inexpensive," he said. "It's a good idea and it's safe." Dr. Molinari and Dr. Furey have disclosed no relevant financial relationships. American Academy of Orthopaedic Surgeons (AAOS) 2012 Annual Meeting: Abstract 20. Presented February 8, 2012. Medscape Medical News 2012 WebMD, LLC

Early Imaging of Low Back Pain Unnecessary, Harmful

James Brice

June 5, 2012 As part of its "Promoting Good Stewardship in Clinical Practice," the National Physicians Alliance recommended against imaging for low back pain within the first 6 weeks of onset unless red flags are present. Now, a new literature and financial analysis supports and explains that recommendation. In one sense, the analysis by Shubha V. Srinivas, MD, MPH, from the Department of Medicine, University of Connecticut Health Center, Farmington, and colleagues covers well-traveled ground from the 30-year history of clinical guidelines indicating that most cases of lumbar back pain resolve themselves with minimal clinical intervention. However, the findings of the analysis, published online June 4 in the Archives of Internal Medicine, as part of the "Less is More" series, also help maintain momentum for Choosing Wisely, a multimedical society initiative designed to encourage physicians and their patients to make smart choices about the use of expensive medical technologies that do not deliver improved clinical outcomes in every situation.

The recommendation to avoid early imaging for low back pain was included in the National Physicians Alliances list of " 'Top 5' Health Care Activities for Which Less Is More" which was published in the August 8, 2011, issue of the Archives of Internal Medicine. In the current literature review, Dr. Srinivas and colleagues report that imaging for lower back pain is extremely common. A 2011 study ( Spine J. 2011;11:622-632) indicated that 42% of patients with back pain undergo imaging (mainly plain radiography) within a year of the onset of pain. Of that total, 6 of 10 patients had imaging on the same day as their diagnosis. Eight of 10 underwent imaging within a month. Dr. Srinivas and colleagues also note that another review concluded that lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes ( Lancet. 2009;373:463-472). Furthermore, Dr. Srinivas and colleagues estimated that nearly $300 million could be saved annually by restricting imaging during the first 6 weeks of lumbar back pain to specific severe indications, including severe or progressive neurological deficits or when serious underlying conditions, such as osteomyelitis, are suspected. They surmised that the only benefit of authorizing early low back imaging would be to cater to the patient's demands and emotional need for clinical action. With that issue at hand, they cited an article titled, "Getting to 'No': Strategies Primary Care Physicians Use to Deny Patient Requests" as an example of how to deny imaging to patients with lower back pain without inciting rebellion ( Arch Intern Med. 2010;170:381-388). Daniel Wolfson, MHSA, executive vice president of the American Board of Internal Medicine Foundation, Philadelphia, Pennsylvania, picked up on this theme in an invited commentary. "Srinivas et al recognize the problem of translating guidelines and comparative effectiveness research into practice, but they do not offer solutions," he wrote. So, Wolfson has offered for consideration the efforts of the American Board of Internal Medicine Foundation, along with 9 medical specialist societies and Consumer Reports, to bring their lists of scientifically questionable medical practices to the attention of the general public. Choosing Wisely features "Five Things Physicians and Patient Should Question," lists, which are geared to educating each society's physician members and their patients about the clinical appropriateness and costs of popular medical tests and therapies. The lists were announced simultaneously April 4. "Choosing Wisely will test whether this type of campaign will spur translation of clinical recommendations into practice," Wolfson said. Consistent with Dr. Srinivas's article, lists supported by the American Academy of Family Physicians and the American College of Physicians both advise against imaging of low back pain within the first 6 weeks unless red-flag conditions are suspected. Arch Intern Med. Published online June 4, 2012. Medscape Medical News 2012 WebMD, LLC