Postoperative Considerations

Introduction

Revision lumbar spine surgery comes with unique challenges and special considerations in the postoperative setting. In this chapter, we will cover some topics pertinent to postoperative care. Specifically, we will cover drains, antibiotic prophylaxis, venous thromboembolic prophylaxis, bracing, and physical therapy.

Postoperative Drains

Current literature does not strongly recommend for or against the use of postoperative drains following lumbar surgery. In particular, limited literature exists about drains in the realm of revision spinal surgery. Proponents of drains argue that judicious use can decrease rates of hematoma formation, lower the burden of exudate within deadspace, and decrease the risk of infection. The location of drains can vary from subfascial to suprafascial. Subfascial placement can serve to protect exposed neural structures from deep exudate and hematoma formation. In patients with deep wounds and a pronounced fat layer between the fascia and skin, a suprafascial drain may address exudate and blood in this potential deadspace.

Unfortunately, no consensus exists on the exact indications for drain use, location of placement, duration, and thresholds for drain output before removal. A multicenter retrospective study assessing the use of closed suction wound drains in posterior spinal fusions for scoliosis found that 72% of surgeons used drains. Of those who used drains, close to half stated that drains were used based on habit and without specific reasoning. Other less frequent reasons included concern for excessive bleeding, open vertebral canal, or an elevated international normalized ratio (INR). Only 6 of the 50 surgeons involved in the multicenter study specifically cited revision cases as an indication for drain placement. Roughly half of the surgeons removed drains based on a drain output threshold of less than 30 mL per 24 hours, whereas others removed them after a set time (1–3 days) regardless of the exact drain output.

Several studies argue that drains may actually have a detrimental effect. Adult reconstruction literature suggests that drains may be associated with higher rates of blood transfusion. Transfusion rates were similarly found to be higher in patients with drains than those without drains when undergoing posterior spinal fusion and instrumentation for scoliosis. Furthermore, the potential benefits of drains have not been clearly supported in the literature. Rates of wound infection, general infection, and neurological injury (from space-occupying lesions such as hematoma) were equivalent among patients, with and without drains, after undergoing thoracic and lumber spinal surgery. Some studies suggest that patients with postoperative drains may actually have higher rates of infection. Even the use of perioperative antibiotics for the duration of the drain does not decrease the risk of infection from the drain itself.

The decision to use or avoid a negative pressure drain in the postoperative setting of spinal surgery can be complex and only becomes more difficult in revision spinal surgery. In revision cases, dissection planes can be substantially altered, which affects the integrity of the fascia and muscle. Concerns arise about hematoma formation, development of neurological deficits, the presence of deadspace, and postoperative infection. Given the paucity of evidence to clearly support drains after spinal surgery, distinct, thoughtful, and goal-oriented reasoning should be applied before drain placement, on an individual patient basis. Placement of a drain does not eliminate the risk of complications. Continued prudent care is imperative with clear criteria in mind for timely drain removal.