Case Study: Incision and Lumbar of wound lumbar spine
This patient underwent an L4 to S1 lumbar fusion in the past. They then presented to the emergency room requesting a need for revision of the right S1 sacral screw which we agreed to do.
We performed revision of the fusion with replacement of the sacral screw after which their radiculopathy and foot weakness significantly improved. At that time, we did find yellowish fluid in the wound and partial dehiscence of the left-sided incision. The culture swabs at the time were negative.
They developed cellulitis around the wound, presented to ER this past Saturday, given Keflex and discharged home. However, the tenderness and erythema worsened with some discharge from the wound. We advised them to go back to the emergency room and they were admitted to the medicine service and underwent an MRI showing a rim-enhancing collection and was started on IV vancomycin and cefepime.
We brought them back to the OR for wound incision and drainage with wound exploration and revision. The risks, benefits, alternatives, and potential complications of the surgery were explained to them. All questions were answered until no further issues were raised and they provided written informed consent which was placed in the chart.
The patient was brought to the operating room. their identity was verified. Surgical timeout was performed. General anesthesia was induced. They were intubated by the
Anesthesia Service. Respiratory and cardiac monitoring leads were placed. They were positioned prone on a Wilson frame. All pressure points were carefully padded.
Their indwelling skin surgical staples were removed. The skin was cleaned with chlorhexidine and sterilized with iodine prep. Sterile drapes were placed in the usual manner. The incision was opened with scissors and #10 blade scalpel. The Vicryl sutures both subdermal and fascial were removed with scissors and forceps.
There was a dark red kind of seroma versus hematoma found in the wound which was evacuated out with suction and irrigation. No purulence or obvious signs of infection were identified. Hemostasis was obtained with Bovie and Aquamantys bipolar electrocautery. 3 L of antibiotic-infused irrigation was applied with pulse lavage.
I explored down to the right-sided pedicle screw and rod hardware, did not identify any deep infection or purulence. After washing everything out and confirming hemostasis, I obtained both deep and superficial culture swabs for aerobic and anaerobic bacteria and these were sent to microbiology for culturing.
I left a deep subfascial medium size Hemovac drain which was tunneled through the skin and secured with 3-0 nylon suture. The fascia was then closed in watertight fashion with 0 Vicryl suture. Exparel long-acting local anesthetic was infused in the soft tissues.
A 7 mm Jackson-Pratt drain was tunneled through a #15-blade stab skin incision, secured with 3-0 nylon suture and left in the space between the fascia and the skin. The subdermal layer was closed with 2-0 Vicryl suture. The skin was reapproximated with running 3-0 nylon suture, cleaned, dried sterilely and dressed with Mepilex bacteriostatic dressing.
The bulb suction and Hemovac canister were applied to suction. The patient was then turned supine on the cart, extubated uneventfully and transported to the recovery room in stable condition. At the end of the case, all sponge counts, needle counts, and instrument counts were correct. The patient tolerated the procedure well.
The patient followed up in two weeks and showed no signs of infection. They also stated significant improvements with their radiculopathy and right foot weakness.
Disclaimer – Patient’s name, age, sex, dates, events have been changed or modified to protect patient privacy.