What is the procedure for spinal wound debridement?

Spinal Wound Debridement Procedure

Spinal wound debridement should involve aggressive surgical removal of all necrotic tissue, foreign bodies, and infected material while maintaining spinal neurologic and structural integrity, with the specific approach determined by the location and extent of infection.1

Pre-Debridement Assessment

• Evaluate the wound using appropriate imaging:

  • MRI with IV contrast is the preferred imaging modality (sensitivity 96%, specificity 94%) 1
  • CT with IV contrast if MRI is contraindicated (sensitivity 79%, specificity 100%) 1

• Assess for:

  • Neurological deficits or cauda equina syndrome requiring immediate intervention
  • Vertebral destruction with instability
  • Epidural abscess formation
  • Extent of infection (superficial vs. deep)
  • Signs of infection (redness, swelling, drainage, fever) 1

Debridement Approaches

1. Surgical Debridement

• Sharp/surgical debridement is the preferred method for spinal wounds 2
• The approach depends on the specific segment of the spine and structures involved:

Anterior Surgical Approach

• Appropriate for infections confined to disc space or vertebral body
• Entire disc and surrounding bones should be removed (complete corpectomy may be required)
• Less morbidity in terms of muscle manipulation and wound healing
• Well-tolerated for anterior cervical and retroperitoneal lumbar spine surgery 1

Lateral Surgical Approach

• Access to vertebral column from T3 to L3
• Traditional thoracotomy or VATS can expose T3-L2 from either side
• Lateral retroperitoneal approach for L1-L4 access
• Complete corpectomy if vertebral destruction is present 1

Posterior Surgical Approach

• Can be used for any segment of the spine
• Typically employed to decompress an epidural abscess
• More painful due to muscle dissection
• Caution needed when decompressing ventral epidural abscess in cervical/thoracic spine 1

2. Minimally Invasive Options

• Image-guided needle aspiration for liquid abscesses
• Can be therapeutic if adequate aspiration is achieved 1
• Vacuum-assisted wound closure (VAC) may be used after surgical debridement
  • Typically requires an average of 1.4 procedures until wound closure
  • Wound closure occurs approximately 7 days after initial VAC placement 3

Debridement Procedure

1. Cleanse the wound of debris and digested material by gently rubbing with gauze saturated with normal saline 4

2. For thick eschar, crosshatch with a #10 blade to allow better surface contact with necrotic debris 4

3. Remove as much loosened detritus as possible with forceps and scissors 4

4. Ensure intraoperative findings correlate with preoperative imaging to avoid retained infected bone or soft tissue 1

5. Use an operative microscope to inspect the surgical bed following debridement 1

6. For deep surgical site infections (dSSIs) after instrumented spinal surgery, consider autologous platelet-rich fibrin (PRF) augmentation to promote wound healing 5

Post-Debridement Care

1. Apply appropriate topical antibiotics if infection is present 4

2. Consider appropriate dressing based on wound characteristics:

   • Moistened saline gauze for dry wounds
   • Hydrogels for dry/necrotic wounds
   • Alginates or foams for exudative wounds 2

3. Immobilization may be necessary:

   • Cervical collar for neck
   • Thoracolumbosacral orthosis brace for thoracolumbar spine 1

4. Monitor for signs of persistent infection:

   • Persistent pain
   • Residual neurologic deficits
   • Elevated markers of systemic inflammation (ESR >50 mm/hour and CRP >2.75 mg/dL after 4 weeks may indicate higher risk of treatment failure) 1

Special Considerations

• Avoid routine spinal immobilization with rigid cervical collars and long spine boards 1

• For patients with bleeding disorders or on anticoagulants, exercise caution during debridement 2

• Assess peripheral circulation before debridement in patients with diabetes or vascular compromise 2

• Continue debridement until necrotic tissue is completely removed and granulation tissue is well established 4

• Monitor wound healing with regular follow-up visits and repeat debridement as needed 2

• Consider VAC therapy for complex spinal wounds, particularly with MRSA or multibacterial infections that may require repeat debridements 3

Aggressive surgical debridement is essential for spinal wound infections as antifungal and antibiotic therapy options may be less effective without thorough removal of infected tissue 1. The goal is to optimize medical therapy through extensive debridement while maintaining spinal neurologic and structural integrity.