Abscess s/p SCS Explant

[jwheezy]

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Wanted to get some opinions from the group -

Got called at 2 AM last night by a local ER. Patient I explanted 3 weeks ago had gone in with concerns of dehiscence and possible infection. Wound seemed to be healing fine at her post op visit. Not systemically ill per ER (non febrile, normal CBC, ESR/CRP). ER doc asking me what they should do, though she apologizes for not actually having laid eyes on it so that was helpful. CT showing rim enhancing fluid at both surgical sites 3 x 5 cm each roughly, but no communication into the epidural space (per ER doc terminates above the spinous process). I asked that she culture if there's drainage and start ABX, or if it looks ok just leave it for now. Either way coming to clinic this morning so I can eval.

Assuming there's an abscess under, what's the course of action? To OR for I&D, washout then primary closure and course of oral antibiotics? I&D and pack? There's no hardware retained and again at this time doesn't seem that she's systemically ill.

Thanks for the feedback!

 

[paindoc007]

Wanted to get some opinions from the group -

Got called at 2 AM last night by a local ER. Patient I explanted 3 weeks ago had gone in with concerns of dehiscence and possible infection. Wound seemed to be healing fine at her post op visit. Not systemically ill per ER (non febrile, normal CBC, ESR/CRP). ER doc asking me what they should do, though she apologizes for not actually having laid eyes on it so that was helpful. CT showing rim enhancing fluid at both surgical sites 3 x 5 cm each roughly, but no communication into the epidural space (per ER doc terminates above the spinous process). I asked that she culture if there's drainage and start ABX, or if it looks ok just leave it for now. Either way coming to clinic this morning so I can eval.

Assuming there's an abscess under, what's the course of action? To OR for I&D, washout then primary closure and course of oral antibiotics? I&D and pack? There's no hardware retained and again at this time doesn't seem that she's systemically ill.

Thanks for the feedback!

Look at it. Trust your eyes. If if needs to go back to the OR, do NOT close with primary closure. Irrigate, pack, home health does wet to dry.

 

[lobelsteve]

Needle aspirate, culture, ID consult. Post pics of wounds.

 

[jwheezy]

Needle aspirate, culture, ID consult. Post pics of wounds.

If she's not systemically ill ID outpatient consult while cultures grow?

 

[lobelsteve]

If she's not systemically ill ID outpatient consult while cultures grow?

Yes. Had neck pain and shoulder 48 y/o this AM. Just back from Caribbean cruise with girlfriends. All have a rash. Painful rash. Looks shiglish (started a day ago, not large pustules yet). As 3 have this per patient report, it ain't shingles. ID in house here so I get her down the hall. Dx shingles, starting meds today, can get injections with me next week. Did not see the other folks rashes, but I assume they are not the same.

 

[jwheezy]

Needle aspirate, culture, ID consult. Post pics of wounds.

Photo as requested...

I did needle aspiration, pulled out about 5 cc seroma from the prior IPG pocket and sent for cultures. Couldn't get anything out of midline incisions. Started on Bactrim DS and follow up in a week for wound check, in the mean time change out gauze a few times a day to keep it dry. I suspect cellulitis and likely seroma seen on CT scan, and likely just didn't heal well though patient claims everything looked fine then suddenly opened up a week ago.

 

[SSdoc33]

Photo as requested...

I did needle aspiration, pulled out about 5 cc seroma from the prior IPG pocket and sent for cultures. Couldn't get anything out of midline incisions. Started on Bactrim DS and follow up in a week for wound check, in the mean time change out gauze a few times a day to keep it dry. I suspect cellulitis and likely seroma seen on CT scan, and likely just didn't heal well though patient claims everything looked fine then suddenly opened up a week ago.

spitting image

 

[SSdoc33]

wait for the cultures, but i think that needs to come out.

 

[jwheezy]

wait for the cultures, but i think that needs to come out.

It's already out, this is s/p explant. No hardware retained. Explant was not due to infection, was for psychological reasons.

 

[Orin]

Rim enhancing fluid in the setting of an explant can be seroma with the 'rim' being the foreign body reaction/capsule around the hardware. The incisions though look to be at least superficially infected with dehiscence of the closure.

I generally recommend closing primarily and trying to avoid the wound care things unless there is clear abscess tracking. Your closure can be looser and with staples or mattress sutures for the skin to allow for more drainage, but I just hate having to rely on patient's or wound care nurses to pack/etc.

For wounds like this that are draining, I'm a fan of the silver foam dressings to help absorb and also 'antimicrobialize' the surface.

 

[Czech777]

I had similar story. Washout and primary closure resulted in seroma re-accumulation. Cultures negative but WBC and fevers lead to broad spectrum abx and drain placement after speaking with surgical colleagues. I think they got better with time and abx and not certain the drain did anything but increase infection risk.

 

[clubdeac]

So glad I quit doing these. No more headaches. All stims fail by 10 yrs anyway. And y’all know it…hehe

 

[lobelsteve]

So glad I quit doing these. No more headaches. All stims fail by 10 yrs anyway. And y’all know it…hehe

Got a call last month from patient that I had not seen in years. St Jude IPG died and her pain returned. Just wanted to meet me at OR to get new one put in. Umm, how about you are a new patient again and they might want paperwork to allow insurance approval.

 

[bedrock]

So glad I quit doing these. No more headaches. All stims fail by 10 yrs anyway. And y’all know it…hehe

particularly for weaker indications. If the clear majority of their pain is in a limb and neuropathic, they definitely seem to last longer and respond to a newer IPG if one fails

But unfortunately, it seems that most SCS is put in for patients with >50% axial spine pain. For those I agree, they all fail, usually less than 5 years frequently less than 2 years and those are not worth another SCS attempt. .

 

[clubdeac]

particularly for weaker indications. If the clear majority of their pain is in a limb and neuropathic, they definitely seem to last longer and respond to a newer IPG if one fails

But unfortunately, it seems that most SCS is put in for patients with >50% axial spine pain. For those I agree, they all fail, usually less than 5 years frequently less than 2 years and those are not worth another SCS attempt. .

I do miss that very distinct pop when going through the LF with a 14g

 

[Centurion38]

Photo as requested...

I did needle aspiration, pulled out about 5 cc seroma from the prior IPG pocket and sent for cultures. Couldn't get anything out of midline incisions. Started on Bactrim DS and follow up in a week for wound check, in the mean time change out gauze a few times a day to keep it dry. I suspect cellulitis and likely seroma seen on CT scan, and likely just didn't heal well though patient claims everything looked fine then suddenly opened up a week ago.

Just a poorly healing wound, probably because of seroma. Not a lot you can do. Bactrim won't help. There's no infection here.

I've found BID dressing changes with bacitracin ointment allow for moist wound healing environment and re-epithelization, which is what needs to occur in this case.

Give it a few weeks, and if no improvement take back to OR, ellipse out the bad tissue and re-close primarily with nylons.

Make sure your deep sutures are tight and close the capsule. Go gentle on the superficial sutures; just bring the wound edges together and let the body do the rest. Pics posted above I see often with over-tensioned skin sutures.

 

[Ducttape]

So glad I quit doing these. No more headaches. All stims fail by 10 yrs anyway. And y’all know it…hehe

i have 5 patients who have had stims in for >10 years, 2 from before i started. one has had a stim since 2002. has had 3 battery replacements. has 1 4 contact lead.

you can modulate the failure rate by being very selective ie rarely going to trial.

 

[clubdeac]

i have 5 patients who have had stims in for >10 years, 2 from before i started. one has had a stim since 2002. has had 3 battery replacements. has 1 4 contact lead.

you can modulate the failure rate by being very selective ie rarely going to trial.

5 out of how many implants over your career? That’s not a good percentage. And are those 5 managing well without opioids

 

[Ducttape]

5 of them have had stims for >10 years.

of those 5, only one is on opioids in the form of butrans patch (not including lyrica - i think 3 or 4 are on that).

the one i mentioned is the only 1 that is younger than 60, and she is still working full time in an elementary school.

over the past 15 years, ive referred maybe 100 patients for implants. about 10 for explant. of course, some of them may have sought explant on their own.

 

[clubdeac]

So even with those numbers you’re at 5% that’s still have them in and find them useful at 10 yrs. 🤔

 

[Ducttape]

um, no. not sure why you are making these assumptions out of thin air.

the 5 are patients who have had a stim in for >15 years. these 5 i know for sure as i am still seeing them for continued med management.

best case scenario, i have 90 patients out of 100 who have kept stims placed in the past 15 years. but i agree, with leakage, it is probably closer to 60-70.