Analysis of Risk Factors for Incisional Infection after Spinal Tumor Resection ()
1. Introduction
With advances in tumor diagnosis and treatment, surgical resection has become the primary therapeutic approach for spinal tumors. By excising lesions and reconstructing spinal stability, this procedure can effectively alleviate pain and other symptoms, enhance neurological function, and extend patient survival. However, spinal tumor surgery is associated with complex anatomy, significant surgical trauma, prolonged operative time, and substantial intraoperative blood loss. These challenges are further compounded by the frequent presence of advanced age, malnutrition, underlying comorbidities, or a history of preoperative radiotherapy and chemotherapy among patients, resulting in a markedly higher risk of postoperative incision infection compared to standard spinal surgery [1]. According to domestic and international reports, the infection rate following conventional spinal surgery is approximately 1% - 3%, whereas the postoperative incision infection rate after spinal tumor resection may reach 5% - 18% [2] [3]. Should an incision infection occur, it not only prolongs postoperative recovery and significantly increases healthcare costs, but may also lead to severe complications such as spondylitis, epidural abscess, and nerve injury. This can further result in internal fixation loosening, surgical failure, and a marked decline in patient quality of life. In some instances, persistent infection may necessitate repeated surgical interventions, and in severe cases, can be life-threatening [4]. Currently, most research on risk factors for postoperative incision infection in spinal surgery focuses on general spinal procedures, with studies specific to the unique population of spinal tumor patients remaining limited. Therefore, this study aims to retrospectively analyze the clinical data of patients who have undergone spinal tumor resection, systematically identify factors that may influence postoperative incision infection, and determine their independent risk factors. These findings will provide data support for early clinical identification of high-risk patients and optimization of perioperative management, thereby reducing the incidence of postoperative incision infection.
2. Materials and Methods
2.1. General Information
From January 2024 to January 2025, 195 patients who underwent posterior open spinal tumor resection at Sun Yat-sen University Cancer Center were included as study subjects. Based on the occurrence of incision infection, patients were categorized into an observation group (incision infection, n = 20) and a control group (no incision infection, n = 175). Inclusion criteria were as follows: ① All patients underwent posterior open spinal tumor resection surgery; ② Met the early postoperative incision infection diagnostic criteria established by the United States Centers for Disease Control and Prevention (centers for disease control and prevention, CDC) [5]; ③ Complete medical records; ④ Patient age greater than 18 years, with informed consent obtained from both patients and their families. Early incision infection was diagnosed if any one of the following criteria was met: ① The incision displayed redness, swelling, heat, pain, with fluctuation, abscess, or purulent discharge; ② Bacterial culture of incision exudate or wound drainage fluid was positive; ③ Intraoperative irrigation or tissue bacterial culture during debridement surgery was positive; ④ Laboratory indicators—including routine blood tests, C reactive protein (C-reactive protein, CRP), procalcitonin—as well as imaging or histopathological examination, confirmed the presence of SSI; ⑤ Infection occurring within 30 days postoperatively. Exclusion criteria were: ① Preoperative traumatic brain injury or dysfunction of other organs; ② Coagulation dysfunction; ③ Age younger than 18 years; ④ Incomplete data; ⑤ Indeterminate wound infection.
2.2. Methods
Surgical procedure for spinal tumor resection: prophylactic antibiotic therapy is administered prior to surgery. If the operative duration exceeds 3 h, supplemental antibiotics are given. During surgery, patients are positioned laterally or supine, and a midline longitudinal incision is utilized. At the conclusion of surgery, prior to wound closure, the surgical cavity is irrigated with 100 ml of hydrogen peroxide. Following irrigation, one or two silicone drainage tubes are placed, and the incision is closed in layers with absorbable sutures, Simultaneously record the wound size. Postoperatively, routine antibiotics are administered to prevent wound infection. When the drainage volume is less than 30 ml/day, the drainage tube may be removed while simultaneously assessing the wound and characteristics of the drainage fluid. If the drainage fluid appears turbid or the patient exhibits signs of fever, wound secretions, drainage fluid, or blood samples should be sent for bacterial and fungal cultures.
2.3. Observational Indicators
This study analyzes the incidence and influencing factors of early surgical site infection following spinal tumor resection. A total of 18 variables were considered, including patient gender, age, BMI, history of diabetes, history of hypertension, smoking history, history of radiotherapy at the surgical site, presence of preoperative hypoalbuminemia (ALB < 35 g/l), disease duration, operation time, intraoperative blood loss, use of internal fixation, whether the procedure was a repeat surgery at the same segment, surgical site, wound size, number of tumor resection segments, duration of wound drainage tube placement, and postoperative cerebrospinal fluid leakage.
2.4. Statistical Analysis
All data were analyzed using SPSS version 27. Univariate analyses were conducted using t-tests or χ2 tests, with statistical significance defined as P < 0.05. For multivariate analysis, logistic regression was performed, with a significance threshold of α = 0.05; differences with P < 0.05 were considered statistically significant.
3. Results
3.1. Incidence of Incision Infection after Spinal Tumor Resection
Among 195 patients who underwent spinal tumor resection, a total of 20 cases of incision infection were observed, corresponding to an infection rate of 10.25%. The detailed distribution of infections was as follows: 6 cases of Staphylococcus epidermidis, 4 cases of Escherichia coli, 4 cases of Staphylococcus aureus, 2 cases of Pseudomonas aeruginosa, 2 cases of hemolytic staphylococcus, 1 case of Candida tropicalis, and 1 case of coagulase-negative staphylococcus infection.
3.2. Analysis of Clinically Related Indicators
Statistical analysis of all patient data revealed that a history of radiotherapy at the surgical site, preoperative hypoalbuminemia, operative time exceeding 3 hours, larger wound size, and drainage tube duration over 3 days are risk factors for surgical incision infection. The differences in were statistically significant (P < 0.05). Details are presented in Table 1.
3.3. Multivariate Analysis
Multivariate logistic regression analysis revealed that a history of radiotherapy at the surgical site, preoperative hypoalbuminemia, and a drainage tube duration of more than three days are independent risk factors for influencing early infection of the surgical incision following spinal tumor resection (P<0.05). Detailed results are provided in Table 2.
Table 1. Analysis of clinical relevant indicators in the two groups of patients.
Influencing factors |
Observation group (20) |
Control group (175) |
t/χ2 value |
P value |
Gender |
Male |
14 |
95 |
1.798 |
0.180 |
female |
6 |
80 |
Gender |
<60 |
12 |
118 |
0.446 |
0.504 |
≥60 |
8 |
57 |
BMI |
<18.4 |
2 |
13 |
0.177 |
0.915 |
18.5 - 23.9 |
11 |
101 |
≥24 |
7 |
61 |
Preoperative hypoalbuminemia |
Yes |
10 |
46 |
4.931 |
0.026 |
No |
10 |
129 |
History of diabetes |
Yes |
0 |
12 |
0.515 |
0.473 |
No |
20 |
163 |
History of hypertension |
Yes |
6 |
34 |
1.230 |
0.267 |
No |
14 |
141 |
Smoking history |
Yes |
1 |
34 |
1.652 |
0.197 |
No |
19 |
141 |
History of radiotherapy |
Yes |
11 |
23 |
21.844 |
<0.001 |
No |
9 |
159 |
Course of disease |
<1 year |
9 |
105 |
1.663 |
0.197 |
≥1 year |
11 |
70 |
Placement of internal fixation |
Have |
20 |
10 |
0.415 |
0.373 |
None |
0 |
165 |
Surgery time |
<3 h |
7 |
103 |
4.155 |
0.042 |
≥3 h |
13 |
72 |
Reoperation at the same spinal segment |
Yes |
18 |
161 |
0.095 |
0.758 |
No |
2 |
14 |
Surgical site |
Cervical vertebrae |
1 |
10 |
14.349 |
0.002 |
Thoracic vertebrae |
3 |
99 |
Lumbar vertebrae |
11 |
69 |
Sacrum |
5 |
18 |
Decompression segment |
Single segment |
11 |
106 |
0.232 |
0.630 |
Multi-segment |
9 |
69 |
Duration of drainage tube placement |
≤3 days |
5 |
151 |
42.134 |
<0.001 |
>3 days |
15 |
24 |
Is there cerebrospinal fluid leakage |
Yes |
3 |
16 |
0.193 |
0.661 |
No |
17 |
159 |
Wound size |
23.00 ± 5.477 |
17.98 ± 7.716 |
−2.825 |
0.005 |
Intraoperative blood loss |
1060.00 ± 557.62 |
825.89 ± 713.94 |
−1.417 |
0.158 |
Table 2. Multivariate retrospective analysis of postoperative incision infection in the two groups.
Indicator |
β value |
OR value |
95% CI |
P value |
Is it hypoalbuminemia |
1.801 |
6.057 |
1.541 - 23.817 |
0.010 |
History of radiotherapy |
2.023 |
7.562 |
1.975 - 28.955 |
0.003 |
Surgery duration |
0.031 |
1.031 |
0.230 - 4.621 |
0.968 |
Surgical site |
1.988 |
7.301 |
0.252 - 211.147 |
0.247 |
Wound size |
0.026 |
1.026 |
0.948 - 1.111 |
0.521 |
Duration of drainage tube retention |
2.737 |
15.433 |
2.997 - 79.471 |
0.001 |
4. Discussion
In the present study, the incidence of postoperative incision infection was found to be 10.25%. The identified risk factors included preoperative hypoalbuminemia, a history of radiotherapy, and a drainage tube retention time exceeding 3 days. These findings are consistent with those reported in multiple studies both in China and abroad [6] [7].
The significant association between preoperative hypoalbuminemia and the risk of early postoperative incisional infection may be attributed to several pathophysiological mechanisms [8]: ① Impaired immune response and dysregulated inflammation. Albumin plays a crucial role in maintaining immune homeostasis, and spinal tumor surgery represents a profound physiological stressor that elicits a robust inflammatory reaction. In malnourished patients, the immune system is unable to effectively respond to surgical trauma and potential bacterial invasion, facilitating the breach of the body’s defense barriers and consequently elevating the risk of infection. ② Compromised tissue repair and wound healing. Wound healing is a complex, energy-intensive biological process that requires substantial amounts of proteins and amino acids as substrates. In the context of spinal tumor surgery, the extensive and deep incisions, along with the presence of internal implants, demand robust healing capacity. Poor wound healing creates an ideal environment for bacterial colonization and proliferation, thereby establishing a vicious cycle from delayed healing to infection. Therefore, comprehensive preoperative screening and risk assessment should be implemented, and serum albumin measurement should be incorporated as a standard preoperative test for patients with spinal tumors. If hypoalbuminemia is detected, preoperative nutritional intervention should be initiated. Active nutritional support therapies, including oral nutritional supplements (ONS), enteral nutrition (EN), or even parenteral nutrition (PN), should be employed to correct albumin levels to a safe range.
Radiotherapy coordinates through multiple mechanisms to establish a local microenvironment that is highly susceptible to infection: ① immunosuppression results in reduced patient immunity; ② impaired cellular function leads to delayed wound healing; ③ local tissue fibrosis, diminished elasticity of soft tissues, complicating intraoperative suturing and increasing the risk of postoperative dead space formation, thereby providing a favorable environment for bacterial proliferation. Surgical procedures for spinal tumors inflict considerable trauma and significant intraoperative blood loss, substantially increasing the risk of infection. Consequently, regarding the application of adjuvant radiotherapy, Itshayek et al. [9] recommend that the optimal interval between preoperative or postoperative adjuvant radiotherapy and surgery should be at least one week to minimize the incidence of wound complications.
During closure and fascial suturing in open spinal surgery, substantial fluid exudation from deep tissues may persist. If not promptly evacuated, this accumulation can cause compression of the spinal cord and nerves within the spinal canal, potentially leading to severe functional deficits. Consequently, spinal surgeons typically place drainage tubes at wound closure to evacuate postoperative exudate, minimize hematoma formation, and manage dead space. Olsen et al. [10] conducted a study involving 2136 postoperative spinal surgery cases and found that a postoperative drainage duration of >3 days is an independent risk factor for surgical site infection. Each additional day of drainage is associated with an increased risk of wound infection. This may be attributable to the drainage tube, as a foreign body, provoking a local inflammatory response, and to resident skin flora migrating retrogradely through the tube into deeper wound sites, thereby elevating infection risk. Therefore, for patients whose indications for tube removal are not met within an extended period, clinicians should closely monitor the wound, drainage fluid, and body temperature, ensure proper management of both incision and drainage tube, and adjust antibiotic use as appropriate [11].
This study did not identify cerebrospinal fluid leakage as a risk factor for incision infection, which differs from previous research findings. The discrepancy may be attributed to the fact that patients in our hospital promptly adopted routine and standardized preventive measures against incision infection when cerebrospinal fluid leakage occurred. These measures include strict aseptic techniques and isolation, mandatory adherence to sterile procedures during dressing changes for leaking incisions, the use of waterproof dressings to isolate the incision from external contamination, and, when appropriate, extending the duration of prophylactic antibiotic administration. The discrepancy in results may also be attributed to an insufficient sample size.
5. Limitations and Prospects
This study has certain limitations. Despite efforts to maximize data integrity and objectivity, the collection of case information inevitably involved various uncertain factors. Furthermore, while some relevant risk factors for incisional infection were identified, the analysis did not yield precise indicators, such as hypoalbuminemia levels. Due to the limited sample size, further research on the risk factors for early postoperative incisional infection following spinal tumor surgery requires large-sample, multi-center, and prospective clinical trials for comprehensive elucidation.