|Year : 2019 | Volume
| Issue : 1 | Page : 1-5
Analysis of efficacy in postoperative use of closed suction drain in cases of traumatic dorsolumbar spine injury
Vineet Kumar, Ajai Singh, Shah Waliullah, Deepak Kumar
Department of Orthopedic Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Web Publication||19-Aug-2019|
Dr. Vineet Kumar
Department of Orthopedic Surgery, Dr. RML Institute of Medical Sciences, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: The use of closed suction drain has been controversial considering its utility in reducing infection and hematoma formation in the postoperative period. This study aims at analyzing the use of closed suction drain in patients of traumatic dorsolumbar spine injury managed by open posterior instrumentation. Materials and Methods: A total of 110 cases of traumatic spine injury with neurological deficit in the age group 18–65 years of either sex were included in this study. All the patients were managed by short-segment fixation without open decompression of the cord and without primary fusion. The use of closed suction drain in the postoperative period was randomized by randomized controlled trial table. Results: On comparing the difference between pre- and post-operative hemoglobin, C-reactive protein, visual analog scale, and duration of hospital stay, there was no statistically significant difference between the two groups. Conclusion: The use of closed suction drain in posterior instrumentation done for the cases of traumatic dorsolumbar spine injury within described parameters did not reduce postoperative wound infection, clinically significant hematoma formation or risk of further neurological injury.
Keywords: Closed suction drain, epidural hematoma, infection, traumatic spine injury
|How to cite this article:|
Kumar V, Singh A, Waliullah S, Kumar D. Analysis of efficacy in postoperative use of closed suction drain in cases of traumatic dorsolumbar spine injury. J Orthop Traumatol Rehabil 2019;11:1-5
|How to cite this URL:|
Kumar V, Singh A, Waliullah S, Kumar D. Analysis of efficacy in postoperative use of closed suction drain in cases of traumatic dorsolumbar spine injury. J Orthop Traumatol Rehabil [serial online] 2019 [cited 2019 Nov 13];11:1-5. Available from: http://www.jotr.in/text.asp?2019/11/1/1/264734
| Introduction|| |
Traumatic dorsolumbar spine injury with neurological deficit is a frequent occurrence seen at our emergencies. Among the patients who are operated, there has always been a controversy, as to whether we should use a closed suction drain or not. The use of closed suction drains in postoperative period is a common practice in orthopedic surgeries, with an aim to reduce or prevent the formation of hematoma.
In the spine literature, the two most common complications talked of are surgical wound infection and postsurgical epidural hematoma, the incidence of which are 0.7%–16%, and 0.2%–2.9%,,, respectively.
There is a common notion among orthopedic fraternity that postoperative hematomas in the surgical field leads to increase tension on incisions, which in turn may lead to delayed wound healing as well as infection. In case of operated spine injury patients, this hematoma is due to local tissue or epidural venous plexus bleeding, which by many is believed to be a cause for spinal cord compression and even paralysis after such surgeries.,, In contrast to above, there is another school of thought, discouraging the use of closed suction drain in such surgeries, as it may act as a potential cause leading to retrograde infection and increased postoperative blood loss, warranting even transfusion in many cases.,
As such, there has always been a controversy on the use of closed suction drain in posterior spinal surgeries.,,,,, Therefore, we conducted a prospective, open-ended, case–control study on cases of posttraumatic dorsolumbar spine injuries with neurological deficit undergoing surgical intervention with or without the use of closed suction drain to provide evidence on existing data at our center.
| Materials and Methods|| |
This study was carried out in the Department of Othopaedic Surgery, King George's Medical University, Lucknow, India. Cases of traumatic dorsolumbar spine injury with neurological deficit in the age group of 18–65 years, of either sex with normal hematological profile who presented to our emergency and outdoor between January 2016 and December 2016 within 7 days of injury and undergoing surgical intervention (thoracolumbar injury classification and severity score ≥3) by short-segment fixation without decompression and primary fusion, with or without use of closed suction drain postoperatively and giving informed consent were included in the study [Figure 1]. All cases with open fractures of spine, polytrauma cases, head injury, multiple comorbidities, bleeding/coagulation disorder, surgical site infection, mental illness, and on any drugs (for cardiac disorders or long-term steroids which may have an effect on coagulation profile) were excluded from the study. All the individuals were managed surgically following the standard surgical protocol by stabilization of fractured vertebrae and alignment of spine by pedicle screw and rod system through open posterior approach. As a protocol, a single preoperative dose (6 h before surgery) of antibiotic is given in all the cases. All the cases were operated under general anesthesia, and perioperatively antifibrinolytic agent (tranexamic acid) was given (10 mg/kg loading followed by 1 mg/kg/h). All the patients were managed by short-segment fixation, without open decompression of the cord and without primary fusion. Intraoperative loss of blood was estimated for all the cases. 0.25% bupivacaine was instilled locally at the surgical site before closure and injected at the suture site after closure. The use of closed suction drain in the postoperative period was randomized by randomized controlled trial table. Group-A cases were with closed suction drain. Postoperatively, intravenous infusion of paracetamol was given for 24 h to ensure pain relief. A single shot of antibiotic was also given postoperatively. The closed suction drain in Group-A individuals was removed on the 3rd day of surgery (i.e., after 48 h) and drain tip was sent for culture. There was no steroid used in the perioperative period in any of the individuals. Sutures were removed on postoperative day 10 (unless any situation of infection arises).
| Results|| |
A total of 110 individuals giving informed consent were included in the study as per the defined inclusion and exclusion criteria. In the study population, 80% (88/110) were males with male and female ratio being 4:1 and the mean age being 37.85 ± 4.24 (range: 22–63) years.
Closed suction drain was used in 52 cases (Group-A) and 58 cases were managed postoperatively without a suction drain (Group-B). The demographic details of the two groups are shown in [Table 1]. There was no statistically significant difference between the two groups in terms of age and sex distribution (P = 1). The duration to surgery after injury was also comparable in both the groups of patients.
The individuals in both the groups were evaluated clinically in the postoperative period for the presence of pain (visual analog scale [VAS]), clinically significant surgical site hematoma, and fever [Table 2]. Only three cases had fever in the postoperative period (two in Group-A and one in Group-B). In all the three cases, the fever subsided on postoperative day 2 on symptomatic treatment by paracetamol. There were no cases with clinically significant surgical site hematoma in either group of patients till their hospital stay. The pain was analyzed by VAS on the postoperative day 1, 3, and 8. There was no statistically significant difference found between the groups on respective postoperative days, but there was a significant improvement in pain score in both the groups from postoperative day 1–8 (P < 0.0001). The mean duration of hospital stay was also similar in both the groups of patients showing no statistically significant difference.
Hematologically, individuals were analyzed for hemoglobin and C-reactive protein (CRP) pre- and post-operatively [Table 3]. The intraoperative blood loss was evaluated for each case and mean values of the above parameters in both the groups were evaluated. The difference in the mean volume of intraoperative blood loss was not statistically significant. The difference in the values of pre- and post-operative hemoglobin in both the groups as well as in between the groups on postoperative day 1, 2, and 8 was found to be statistically insignificant. The P value when comparing the difference between pre- and post-operative (day 8) hemoglobin between the groups was not significant (P > 0.999). There was no need of blood transfusion in any of the cases postoperatively as the criteria for blood transfusion was limited to patients with hemoglobin level of <10 g/dl. The CRP was evaluated in postoperative period on day 1, day 3, and day 8 in both the groups and there was no statistically significant difference found in between the groups on all day.
Both the groups were evaluated in postoperative period complications of superficial and deep wound infection and neurological deterioration [Table 4].
None of the cases had any serious complication in postoperative period till the date of discharge in both groups, except superficial infection which was there in two patients of Group-A and one patient of Group-B. These were efficiently treated by an extended course of oral antibiotics.
| Discussion|| |
Using closed suction drains in any invasive procedure of orthopedics has long been a matter of debate. In this study, we are putting forth our observation on the usage of closed suction drains postoperatively in cases of traumatic dorsolmbar spine injury being managed and stabilized surgically with a defined set of inclusion and exclusion criteria.
Surgical site infections have been a nightmare for any surgeon and are still the most difficult and challenging part to deal with. Postoperative infection has been reported after 2%–6% of spinal surgeries. The incidence of postoperative infection varies depending on the type of procedure ranging from <1% after decompressive surgeries to the extent of more than 10% after fusions. There has been a subset of surgeon population advocating the use of closed section drains to reduce the incidence of infection and postoperative surgical site hematoma,, and thus reducing the morbidity and cost of treatment whereas the other surgeon group is of the thought that there is no difference in the incidence of complications whether you use or do not use a closed suction drain.,,, We in our study have found that there is no statistical difference in the incidence of infection between the two groups. Our findings are consistent with the results of Choi et al. in which he retrospectively analyzed 70 patients; out of which, 42 and 28 patients were included in the drainage and the nondrainage groups, respectively. The frequency of the postoperative infection cases was higher in the nondrainage group than in the drainage group; however, there was no significant statistical difference between the two groups (P = 0.157). In our study, the incidence of infection in Group-A cases was two and in Group-B cases was one. One major advantage that suction drain may have is in prior detection of infection by sending the suction tip for culture as is shown by Sankar et al. He concluded that positive tip culture predicts wound infection in 50% and a negative culture virtually excludes the possibility of a deep infection. None of the cases in Group-B individuals had a drain tip positive culture.
CRP was done for all the cases on day 1, 3, and 8 of surgery and was found to be within normal limits [Table 2]. Infection encountered in all the three cases of the study population was a superficial infection which was managed efficiently by local dressing and extended duration of broad-spectrum antibiotic cover (third-generation cephalosporin).
One of the major issues in post operative period of open spine surery is the post operative hematoma, which when symptomatic may present as increased surgical site pain and rarely neurological deficit. We in our study have not confronted any symptomatic hematoma in either group of patients neither did we came across any incidence of further neurological deterioration in any of the cases in postoperative period.
Further, in our study, there was no statistically significant difference in the difference between pre- and post-operative hemoglobin levels at final evaluation between both the groups (P > 0.999). We had very minimal blood loss intraoperatively due to perioperative use of tranexamic acid. Our findings were consistent with those of Blank et al. who reported similar transfusion requirements for both the groups of patients, although his study included cases operated on for idiopathic scoliosis.
Our study outcomes are strongly supported by the results of meta-analysis conducted by Liu et al. on wound drains in posterior spinal surgery in which they concluded that the use of drainage in posterior spinal surgery did not reduce postoperative wound infection, hematoma, neurological injury, or estimated blood loss.
The duration of hospital stay was also similar in both the groups of patients, there being no statistically significant difference between the two groups (P = 0.3144).
This study has some limitations. The sample size was small, and the cases were observed for the above variables only till their hospital stay. Delayed infections were not observed and analyzed.
| Conclusion|| |
The use of drainage in posterior instrumentation done for cases of traumatic spine injury within described parameters did not reduce postoperative wound infection rates, clinically significant hematoma, or risk of further neurological injury. Although it is the surgeon's decision to use or not a surgical drain it should be considered in patients with deranged bleeding or coagulation profile. More studies need to be conducted about this subject of a surgical drain.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Holt BT, Parks NL, Engh GA, Lawrence JM. Comparison of closed-suction drainage and no drainage after primary total knee arthroplasty. Orthopedics 1997;20:1121-4.
O'Toole JE, Eichholz KM, Fessler RG. Surgical site infection rates after minimally invasive spinal surgery. J Neurosurg Spine 2009;11:471-6.
Schimmel JJ, Horsting PP, de Kleuver M, Wonders G, van Limbeek J. Risk factors for deep surgical site infections after spinal fusion. Eur Spine J 2010;19:1711-9.
Awad JN, Kebaish KM, Donigan J, Cohen DB, Kostuik JP. Analysis of the risk factors for the development of post-operative spinal epidural haematoma. J Bone Joint Surg Br 2005;87:1248-52.
Kou J, Fischgrund J, Biddinger A, Herkowitz H. Risk factors for spinal epidural hematoma after spinal surgery. Spine (Phila Pa 1976) 2002;27:1670-3.
Scuderi GJ, Brusovanik GV, Fitzhenry LN, Vaccaro AR. Is wound drainage necessary after lumbar spinal fusion surgery? Med Sci Monit 2005;11:CR64-6.
Kim YH, Cho SH, Kim RS. Drainage versus nondrainage in simultaneous bilateral total knee arthroplasties. Clin Orthop Relat Res 1998;(347):188-93.
Li ZJ, Fu X, Xing D, Zhang HF, Zang JC, Ma XL. Is tranexamic acid effective and safe in spinal surgery? A meta-analysis of randomized controlled trials. Eur Spine J 2013;22:1950-7.
Parker MJ, Roberts CP, Hay D. Closed suction drainage for hip and knee arthroplasty. A meta-analysis. J Bone Joint Surg Am 2004;86-A: 1146-52.
Chen ZY, Gao Y, Chen W, Li X, Zhang YZ. Is wound drainage necessary in hip arthroplasty? A meta-analysis of randomized controlled trials. Eur J Orthop Surg Traumatol 2014;24:939-46.
Zhang QD, Guo WS, Zhang Q, Liu ZH, Cheng LM, Li ZR. Comparison between closed suction drainage and nondrainage in total knee arthroplasty: A meta-analysis. J Arthroplasty 2011;26:1265-72.
Blank J, Flynn JM, Bronson W, Ellman P, Pill SG, Lou JE, et al.
The use of postoperative subcutaneous closed suction drainage after posterior spinal fusion in adolescents with idiopathic scoliosis. J Spinal Disord Tech 2003;16:508-12.
Brown MD, Brookfield KF. A randomized study of closed wound suction drainage for extensive lumbar spine surgery. Spine (Phila Pa 1976) 2004;29:1066-8.
Diab M, Smucny M, Dormans JP, Erickson MA, Ibrahim K, Lenke LG, et al.
Use and outcomes of wound drain in spinal fusion for adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 2012;37:966-73.
Kanayama M, Oha F, Togawa D, Shigenobu K, Hashimoto T. Is closed-suction drainage necessary for single-level lumbar decompression?: Review of 560 cases. Clin Orthop Relat Res 2010;468:2690-4.
Payne DH, Fischgrund JS, Herkowitz HN, Barry RL, Kurz LT, Montgomery DM. Efficacy of closed wound suction drainage after single-level lumbar laminectomy. J Spinal Disord 1996;9:401-3.
Sen O, Kizilkilic O, Aydin MV, Yalcin O, Erdogan B, Cekinmez M, et al.
The role of closed-suction drainage in preventing epidural fibrosis and its correlation with a new grading system of epidural fibrosis on the basis of MRI. Eur Spine J 2005;14:409-14.
Chimenti P, Molinari R. Post-operative spinal epidural hematoma causing American spinal injury association B spinal cord injury in patients with suction wound drains. J Spinal Cord Med 2013;36:213-9.
Sokolowski MJ, Garvey TA, Perl J 2nd
, Sokolowski MS, Cho W, Mehbod AA, et al.
Prospective study of postoperative lumbar epidural hematoma: Incidence and risk factors. Spine (Phila Pa 1976) 2008;33:108-13.
Amiri AR, Fouyas IP, Cro S, Casey AT. Postoperative spinal epidural hematoma (SEH): Incidence, risk factors, onset, and management. Spine J 2013;13:134-40.
Chen S, Anderson MV, Cheng WK, Wongworawat MD. Diabetes associated with increased surgical site infections in spinal arthrodesis. Clin Orthop Relat Res 2009;467:1670-3.
Choi HS, Lee SG, Kim WK, Son S, Jeong TS. Is surgical drain useful for lumbar disc surgery? Korean J Spine 2016;13:20-3.
Sankar B, Ray P, Rai J. Suction drain tip culture in orthopaedic surgery: A prospective study of 214 clean operations. Int Orthop 2004;28:311-4.
Liu Y, Li Y, Miao J. Wound drains in posterior spinal surgery: A meta-analysis. J Orthop Surg Res 2016;11:16.
[Table 1], [Table 2], [Table 3], [Table 4]