Clinical relevance of occult infections in spinal pseudarthrosis revision()

BACKGROUND: Occult infections in spinal pseudarthrosis revisions have been reported in the literature, but the relevance of such an infection on patient outcomes is unknown. We aimed to elucidate clinical outcomes and re-revision risks between patients with and without occult infections in spinal revision surgery for pseudarthrosis. METHODS: In this matched case-control study, we identified 128 patients who underwent thoracolumbar revision surgery from 2014–2019 for pseudarthrosis of the spine. Among them, 13 (10.2%) revealed an occult infection (defined by at least two positive intraoperative tissue samples with the same pathogen), and nine of these 13 were available for follow-up. We selected 18 of the 115 controls using a 2:1 fuzzy matching based on fusion length and length of follow-up. The patients were followed up to assess subsequent re-revision surgeries and the following postoperative patient-reported outcome measures (PROMs): overall satisfaction, Oswestry Disability Index, 5-level EQ-5D, and Short Form 36. RESULTS: Patient characteristics, surgical data, and length of follow-up were equal between both study groups. The rate of re-revision free survival after the initial pseudarthrosis revision surgery was higher in the occult infection group (77.8%) than the non-infectious controls (44.4%), although not significantly (0.22). The total number of re-revision surgeries, including re-re-revisions, was thirteen (in ten patients) in the control and two (in two patients) in the occult infection group (p = 0.08) after a median follow-up of 24 months (range 13-75). Four cases in the control group underwent re-revision for pseudarthrosis compared to none in the infected group. Satisfactory scores were recorded in all PROMs, with similar scores between the two groups. CONCLUSIONS: The presence of an occult infection accompanying spinal pseudarthrosis revision was not inferior to non-infected pseudarthrosis revisions in a matched, small sample size cohort study. This may be explained due to the possibility of targeted treatment of the identified cause of pseudarthrosis.