Post-Operative Infection Following Multi-Level Posterior Lumbar Spinal Instrumentation in the Vancomycin Powder Era

Abstract

Background:

Since the early 2010s, prophylactic vancomycin powder has been widely adopted in spine surgery, with many surgeons crediting it for low surgical site infection (SSI) rates (1%–2%). However, its efficacy remains debated.

Purpose:

To compare post-operative SSI and related complications in multi-level posterior lumbar spinal surgery before and after the widespread use of vancomycin powder.

Design:

Retrospective study using the TriNetX Research Network.

Patient Sample:

Adult patients undergoing posterior spinal instrumentation (≥3 levels) for lumbar stenosis or spondylolisthesis.

Outcome Measures:

Primary: Composite rate of post-operative infections (superficial/deep incisional SSI, organ/space SSI, sepsis). Secondary: Incidence of incision and drainage (I&D) for SSIs.

Methods:

Patients were divided into two cohorts: 2003–2013 (pre-vancomycin era) and 2014–2023 (vancomycin era). Propensity matching was controlled for age, gender, race, and comorbidities. Post-operative infections requiring I&D within 90 days were identified using procedural and diagnostic codes.

Results:

Of 33,320 patients (mean age: 63.6 y; 43.3% male), 28,649 (86.0%) underwent surgery in 2014–2023 and 4,671 (14.0%) in 2003–2013. After propensity matching (4,668 patients per cohort), the 2014–2023 group had significantly lower odds of requiring I&D (odds ratio [OR] = 0.337) and developing post-operative infections (OR = 0.606).

Conclusion:

This large-scale, propensity-matched analysis suggests that the likelihood of post-operative infections or requiring I&D following multi-level posterior lumbar spinal instrumentation is approximately 40%–60% lower in the vancomycin era compared with the pre-vancomycin period.