Stimulator infections

[NJPAIN]

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I know that this was discussed to some degree several year ago but I would like some current opinions.

When removing an infected spinal cord stimulator how are you deciding on whether you will do a primary closure at the time of explanation vs. packing wound and allowing to close by secondary intention vs packing and doing a delayed primary closure? Placing any drains for primary closure?

With regard to packing what are you using and how often are you changing the packing? Are many of you using VacPack?

thanks

 

[Jcm800]

I know that this was discussed to some degree several year ago but I would like some current opinions.

When removing an infected spinal cord stimulator how are you deciding on whether you will do a primary closure at the time of explanation vs. packing wound and allowing to close by secondary intention vs packing and doing a delayed primary closure? Placing any drains for primary closure?

With regard to packing what are you using and how often are you changing the packing? Are many of you using VacPack?

thanks

depends how gross...

if pretty gnarly, then i will clean the edges up, until the bleed, pule irrigate the thing, strip the capsule. Leave a penrose and staple wide...

very rare occurrence.

if not bad, i will just take it out, clean wound out, and staple.

knock on wood, it has been a few years...

but i did aspirate a big hematoma a few months ago...like 20 ccs out of pocket.

 

[Tenesma]

since most pain docs have limited experience with dealing with infected pockets or even worse infections down into the spine - I would strongly encourage having a spine surgeon or a at least a general surgeon scrub in with you...

 

[NJPAIN]

Anyone else routinely have a surgeon scrub on an infected stim that you implanted?
Anyone else willing to share their way of handling these unfortunate cases?

 

[bedrock]

Anyone else routinely have a surgeon scrub on an infected stim that you implanted?
Anyone else willing to share their way of handling these unfortunate cases?

Not exactly routine. This is a rare issue, with years between such cases.
I echo the recommendation to have a spine surgeon or at least a general surgeon scrub in with you.

A pain doc should always maintain a close relationship with several, (or at least one) spine surgeon that will back you up promptly in case of implant infection, epidural hematoma, etc.

 

[Jcm800]

since most pain docs have limited experience with dealing with infected pockets or even worse infections down into the spine - I would strongly encourage having a spine surgeon or a at least a general surgeon scrub in with you...

i have had the surgeon scrub in on the first 1 right out of fellowship, and we cleaned edges, pulse irrigated, stripped the capsule, and put a penrose in.

my partner then scrubbed in with me on the next one, 1 year later, he did 3 years of general surgery. Guess what? we cleaned up the edges, pulse irrigated, stripped the capsule and put a penrose in...

now guess what i do? its actually been a long time, over 3 years...

 

[ParaVert]

Thankfully a rare occurence for me, but I've never left a wound open after explant. I think the above approach is MORE than adequate for anything short of necrosis. A penrose for 24-48 hrs, then pull it out. Decent abx for 14 days.

The most important thing about the management of an implant infection is not to sit on it for weeks. If it looks bad, doesn't get tremendously better after 24-48 hrs on ABX, cut it out. Don't wait until the skin over the stim turns black! 99% of complicated surgical site infections are caused or exacerbated by delayed treatment. Be aggressive and have a low threshold for explant.

 

[NJPAIN]

Thanks for the replies. This is an SCS placed in late October on a 50yo diabetic. Ten days postop when staples removed looked like superficial cellulitis at IPG site. No systemic signs of infection. Was on prohylactic Duricef. Switched to Doxycycline to cover MRSA and sent to ID. ID felt no active infection but cultured small open area of wound and left on Doxycycline until cultures back. Cultured out pseudomonas so ID switched to Levaquin. Remained on Levaquin until 12/21/2011. Seen by ID and discharged. Two days ago developed "blister" at lead achoring site. Following day began to drain purulent fluid. Returned to ID that day. ID called me to let me know what was going on but said looks superficial. Put back on Levaquin. Cultures sent again. Yesterday evening I saw patient. Pus draining from open lower pole of wound and obvious collection of pus palpated. Given what ID said, not what I expected to see. Scheduled for removal tomorrow. My luck this is at the lead anchoring site and not the pocket. I spoke with a GS today who unequivocally states that I should not close but rather pack and allow to close by secondary intention. I will see what I am up against tomorrow. .

 

[hyperalgesia]

I would take everything out, irrigate and close primarily. If you have an effective abx and you don't have hardware or other nidus, bacteria loses the battle. A drain tube is just another place for bacteria to hide from the toxic blood.

I wouldn't dream of trying to salvage the IPG at this point. No matter what it looks like inside, the thing is dirty. Get your crap out and let the body heal...

 

[lobelsteve]

I would take everything out, irrigate and close primarily. If you have an effective abx and you don't have hardware or other nidus, bacteria loses the battle. A drain tube is just another place for bacteria to hide from the toxic blood.

I wouldn't dream of trying to salvage the IPG at this point. No matter what it looks like inside, the thing is dirty. Get your crap out and let the body heal...

Agreed. Once it goes past cellutlitis to deeper tissue infection- all hardware out (including anchors/suture material). ID consulted to help with ABX selection/duration. Primary closure unless tissue is buggered, then loosely approximated.

 

[Jcm800]

Thanks for the replies. This is an SCS placed in late October on a 50yo diabetic. Ten days postop when staples removed looked like superficial cellulitis at IPG site. No systemic signs of infection. Was on prohylactic Duricef. Switched to Doxycycline to cover MRSA and sent to ID. ID felt no active infection but cultured small open area of wound and left on Doxycycline until cultures back. Cultured out pseudomonas so ID switched to Levaquin. Remained on Levaquin until 12/21/2011. Seen by ID and discharged. Two days ago developed "blister" at lead achoring site. Following day began to drain purulent fluid. Returned to ID that day. ID called me to let me know what was going on but said looks superficial. Put back on Levaquin. Cultures sent again. Yesterday evening I saw patient. Pus draining from open lower pole of wound and obvious collection of pus palpated. Given what ID said, not what I expected to see. Scheduled for removal tomorrow. My luck this is at the lead anchoring site and not the pocket. I spoke with a GS today who unequivocally states that I should not close but rather pack and allow to close by secondary intention. I will see what I am up against tomorrow. .

take it out. clean the edges. pulse irrigate, scrape the capsule, put a penrose in...