Wound Closure and Wound Dressings in Adult Spinal Deformity Surgery From the AO Spine Surveillance of Post-Operative Management

Abstract

Study Design

An e-mail-based online survey for adult spinal deformity (ASD) surgeons.

Objective

Wound closure and dressing techniques may vary according to the discretion of the surgeon as well as geographical location. However, there are no reports on most common methods. The purpose of this study is to clarify the consensus.

Methods

An online survey was distributed via email to AO Spine members. Responses from 164 ASD surgeons were surveyed. The regions were divided into 5 regions: Europe and South Africa (ESA), North America (NA), Asia Pacific (AP), Latin America (LA), and Middle East and North Africa (MENA). Wound closure methods were evaluated by glue(G), staples(S), external non-absorbable sutures (ENS), tapes(T), and only subcuticular absorbable suture (SAS). Wound Dressings consisted of dry dressing (D), plastic occlusive dressing (PO), G, Dermabond Prineo (DP).

Results

The number of respondents were 57 in ESA, 33 in NA, 36 in AP, 22 in LA, and 16 in MENA. S (36.4%) was the most used wound closure method. This was followed by ENS (26.2%), SAS (14.4%), G (11.8%), and T (11.3%). S use was highest in ESA (44.3%), NA (28.6%), AP (31.7%), and MENA (58.8%). D was used by 50% of surgeons postoperatively. AP were most likely to use PO (36%). 21% of NA used DP, while between 0%-9% of surgeons used it in the rest of the world.

Conclusion

Wound closure and dressings methods differ in the region. There are no current guidelines with these choices. Future studies should seek to standardize these choices.

Keywords

scoliosis deformity orthopaedic geriatric

Introduction

Surgical site infections are a common and morbid complication in adult spinal deformity surgery. Infection rates remain over 3%–10% and are doubly higher in obese patients.^1-3 Non-infectious wound complications are uncommon, including wound dehiscence, with rate of .5%.⁴ On the other hand, it is high incidence in ASD patients with complex wound closures (23%).⁵

There are many methods of wound closure and wound dressing, but there is a lack of evidence for them in the field of spine surgery.⁶ Typical methods of wound closure include 2-octyl-cyanoacrylate (Glue), staples, sutures (subcuticular and external nylon skin sutures), tapes, etc. Closure methods can be compared in terms of surgical time and effect on surgical site infections (SSI). Staples can reduce surgical time as compared to sutures.⁷ On the other hand, compared to staples, total wound closure using sutures demonstrates a reduced incidence of SSI and superior cosmetic outcomes in terms of scarring.^8,9 Shani et al.¹⁰ reported a higher infection rate of for staples (11.8%) in a study of posterior spinal surgery as compared to external nylon sutures (4.2%). However, one report indicates no difference in infection rates between staples and nylon sutures.¹¹ Glue also has the advantage of not requiring removal of stitches, wound dressing and to resist contact with water.⁷ Moreover, glue has also been shown to have a much lower infection rate (0%–.43%) in reports comparing it to staples.^12,13

Another possible intervention to prevent wound complications is type of dressing. In a Cochrane review for all types of clean surgery, the authors concluded that there is no particular wound dressing that may decrease SSI, although there is very low certainty evidence supporting hydrocolloid and silver-containing dressings .¹⁴ In a network review in total joint arthroplasty, silver-containing, alginate and hydrofiber dressings were found to significantly decrease wound infections as compared to gauze.¹⁵

There are no reports with a high level of evidence regarding the choice of wound closure or wound dressing in the spine surgery, and these are often left to the discretion of the surgeon. Few reports have investigated which methods are commonly chosen in the world, and perhaps this may vary by region and social context. The purpose of this study was to confirm expert consensus by emailing AO spine members around the world and asking questions about wound closure and wound dressing.

Material and Methods

A peri-operative spine survey was formulated by a study group within AO Spine. The study group included experts in the knowledge forum (KF) degenerative and KF deformity spine. The questionnaire included demographic information on participants and was designed to cover various aspects of peri-operative care such as wound management, antibiotics, bracing and activity instructions. An online survey was distributed via email to AO Spine users and members between March 3 and March 22, 2022. The survey was targeted at surgeons performing at least 10 cases per year using one or more of the following procedures:

a) Long fusion (>5 levels) for adult spine deformity patients extending to pelvis

b) Long fusion (>5 levels) for adult spine deformity patients NOT extending to pelvis

c) Open 1 or 2 level fusion for adult lumbar degenerative pathologies

d) MIS 1 or 2 level fusion for adult lumbar degenerative pathologies

e) Open 3 to 5 level fusion for adult lumbar degenerative pathologies

It was estimated that over 6000 surgeons that were AO Spine users and members received the email. Among all those who received the email, 354 responded and 280 completed the survey. Of the surgeons who completed the survey, 164 performed adult spine deformity surgeries (procedures a and/or b) and 261 performed adult spinal degenerative surgeries (procedures c, d and/or e).

This study included 164 adult spinal deformity surgeons from 51 countries. The country of residence was divided into regions as follows: Europe and South Africa (ESA), North America (NA), Asia Pacific (AP), Latin America (LA), and Middle East and North Africa (MENA). Options for wound closure were glue, staples, external non-absorbable suture (ENS), tapes, or only subcuticular absorbable suture (SAS). In addition, the question items regarding fascial suture are the type of suture (absorbable braided suture, non-absorbable braided suture, absorbable, monofilament suture, or non-absorbable monofilament suture), whether to perform muscular layer approximation, suture method (continuous suture, interrupted suture, or both). For wound dressing, selection of postoperative dressing (dry dressing [D], plastic occlusive dressing [PO], G, incisional wound vacuum [IWV], or Aquacel Ag [AA]), timing of initial removal of dressing, and dressing after removal.

Literature Review

We conducted literature review to identify relevant articles on wound closure and wound dressings in spine surgery. We consulted PubMed. The search strategy was as follows; “skin closure” [All Fields] OR “wound closure” [All Fields] OR “wound suture” [All Fields] AND “spine surgery” [All Fields] in wound closure. On the other hand, the search strategy in wound dressings was constructed after discussion and consensus of all authors and included these terms: “wound care” [All Fields] AND “spine surgery” [All Fields] AND “dressing” [All Fields]. Two authors (GS, MG) independently inspected the bibliographic quotes and identified relevant abstracts. The full-text article was analyzed for included studies. References from the selected articles were also reviewed and added through cross reference if appropriate.

Then, eligible articles were selected and reviewed.

Results

Wound Closure

A total of 164 AO spine members responded: 57 from ESA, 33 from NA, 36 from AP, 22 from LA, and 16 from MENA (Table 1). In terms of gender, most were male. Worldwide, surgeons were distributed across ages, the group aged 35-44 was the most (39.7%), followed by the group aged 45-54 (31.1%). These trends held across most regions, but the 45-54 year old group in LA and MENA was smaller than in other regions (ESA: NA: AP: LA: MENA = 33.3%: 36.4%: 41.7%: 13.7%: 12.5%). Also, compared to other regions, LA had more young people aged 25-34 (13.6%), and there were relatively many people aged 65 or more in MENA (12.5%).

Table 1.

Wound Closure.

Number of spine doctors		ESA	NA	AP	LA	MENA	Total
Number of spine doctors		57	33	36	22	16	164
Sex (male)		57 (100%)	31 (93.9%)	35 (97.2%)	21 (95.5%)	16 (100%)	160 (97.6%)
Age	25-34	4 (7.0%)	1 (3.0%)	1 (2.8%)	3 (13.6%)	1 (6.3%)	10 (6.3%)
	35-44	20 (35.1%)	11 (33.3%)	15 (41.7%)	12 (54.5%)	7 (43.8%)	65 (39.7%)
	45-54	19 (33.3%)	12 (36.4%)	15 (41.7%)	3 (13.7%)	2 (12.5%)	51 (31.1%)
	55-64	13 (22.8%)	8 (24.2%)	4 (11.1%)	3 (13.7%)	4 (25%)	32 (19.5%)
	>65	1 (1.8%)	1 (3.0%)	1 (2.8%)	1 (4.5%)	2 (12.5%)	6 (3.7%)
No. Of answers for each wound closure		70	42	41	26	17	196
Glue (%, per answers)		8 (11.4%)	10 (23.8%)	3 (7.3%)	2 (7.7%)	0 (0%)	23 (11.7%)
Staples (%, per answers)		31 (44.3%)	12 (28.6%)	13 (31.7%)	5 (19.2%)	10 (58.8%)	71 (36.2%)
ENS (%, per answers)		19 (27.1%)	9 (21.4%)	6 (14.6%)	14 (53.8%)	3 (17.6%)	51 (26.0%)
Tapes (%, per answers)		7 (10.0%)	5 (11.9%)	9 (22.0%)	1 (3.8%)	0 (0%)	22 (11.2%)
Only SAS (%, per answers)		5 (7.1%)	6 (14.3%)	10 (24.4%)	4 (15.4%)	4 (23.5%)	28 (14.3%)
No SAS (%, per no. Of doctors)		31 (54.4%,31/57)	11 (33.3%,11/33)	12 (33.3%,12/36)	10 (45.5%,10/22)	8 (50%,8/16)	72 (43.9%,72/164)

ESA; Europe and South Africa, NA; North America, AP; Asia Pacific, LA; Latin America, MENA; Middle East and North Africa, SAS; subcuticular absorbable suture, ENS; external non-absorbable sutures.

Multiple responses are possible, so the number of responses by region for wound closure was 70 in ESA, 42 in NA, 41 in AP, 26 in LA, and 17 in MENA. Staples were the most common wound closure globally (36.2%), followed by ENS (26%), Only SAS (14.3%), glue (11.7%), and finally tapes (11.2%). By region, the usage rate of staples was the highest in ESA (44.3%), NA (28.6%), AP (31.7%), and MENA (58.8%), but ENS was the most common wound closure in LA (53.8%). Glue use was low in most regions, but NA had the second highest use (23.8%). Furthermore, less than half (43.9%) of all surgeons responded that they would not perform SAS for wound closure. It was especially low at 33.3% for NA and AP.

Results for fascia closure were shown in Table 2. Most commonly, absorbable braided suture (71.8%) was used, followed by absorbable monofilament suture (16.5%). This trend was similar for each region. 75.6% of respondents answered that they would not perform muscular layer approximation, and this was consistent across all regions.

Table 2.

Fascia Closure.

Number of spine doctors		ESA	NA	AP	LA	MENA	Total
Number of spine doctors		57	33	36	22	16	164
Sutures	Absorbable braided suture	38 (66.7%)	28 (77.8%)	29 (76.3%)	15 (68.2%)	12 (70.6%)	122 (71.8%)
	Non-absorbable braided suture	5 (8.8%)	2 (5.6%)	1 (2.6%)	2 (9.1%)	2 (11.8%)	12 (7.1%)
	Absorbable monofilament suture	11 (19.3%)	4 (11.1%)	7 (18.4%)	4 (18.2%)	2 (11.8%)	28 (16.5%)
	Non-absorbable monofilament suture	3 (5.3%)	2 (5.6%)	1 (2.6%)	1 (4.5%)	1 (5.9%)	8 (4.7%)
	Total answers	57	36	38	22	17	170
	No answer (no. Of doctors)	0	1	1	0	0	2
Muscular layer approximation	Yes	13 (22.8%)	9 (27.3%)	5 (13.9%)	8 (36.4%)	5 (31.3%)	40 (24.4%)
	No	44 (77.2%)	24 (72.7%)	31 (86.1%)	14 (63.6)	11 (68.8%)	124 (75.6%)
	Total answers	57	33	36	22	16	164
Types of sutures	Continuous	21 (50%)	3 (17.6%)	10 (45.5%)	9 (60%)	6 (46.2%)	49 (45.0%)
	Interrupted	12 (28.6%)	14 (82.4%)	8 (36.4%)	5 (33.3%)	4 (30.8%)	43 (39.4%)
	Both	9 (21.4%)	0	4 (18.2%)	1 (6.7%)	3 (23.1%)	17 (15.6%)
	No answer (no. Of doctors)	15	16	14	7	3	55
	Total answers	42	17	22	15	13	109

ESA; Europe and South Africa, NA; North America, AP; Asia Pacific, LA; Latin America, MENA; Middle East and North Africa.

Continuous suturing technique was slightly more popular than interrupted suture (45.0% vs 39.4%). ESA, AP, LA, and MENA tended to have more continuous sutures, while NA had the overwhelming majority of interrupted sutures (82.4% vs 17.6%).

Literature for Wound Closure

The search for wound closure identified 136 articles, of which 132 were full text. Out of 132 papers, only 6 articles discussed the specific methods of total wound closure using glue, staples, sutures, and tape (Table 3).^{10,12,13,16-18} All literatures were low evidence level or small sample size. Two of the 3 publications comparing Glue and conventional skin closure (skin suture or staples) suggested efficacy of Glue for SSI.^12,13,16 Shani et al compared staples and skin sutures and reported that skin sutures are effective in preventing SSI (staples 11.8% vs skin suture 4.2%, P = .017).¹⁰ Grottkau et al¹⁷ conducted a randomized control trial of wound closure in patients with spinal deformity under 18 years of age, dividing them into two groups: tapes (n = 13) and subcuticular suture (n = 12) . The results showed no difference in wound complications, but tapes reported a faster time to wound closure than subcuticular sutures. Tang et al compared interrupted suture and barbed suture for the fascial layer in patients who underwent posterior cervical surgery and reported that there was no difference in wound complications between the two groups (interrupted suture 10.1% vs barbed suture 10.7%).¹⁸

Table 3.

Literature Review.

Author	Level of Evidence	Study Design	Intervention	Outcomes	Conclusion
Ando et al¹⁰	Level Ⅲ	Retrospective cohort	A: Glue (N = 315) vs B: Staple (N = 294)	SSIA: B = 0/315. (0%): 8/294 (2.7%)P < .01	Glue was effective
Wachter et al¹²	Level Ⅳ	Cohort study compared to literature data	A: Glue (N = 235) vs B: Skin suture (N = 503)	SSIA:B = 1/235 (.43%) vs 11/503 (2.2%)No statistical analysis	Glue was effective
Howard et al¹³	Level Ⅲ	Retrospective cohort	A: Glue (N = 353) vs B: Nylon or staple (N = 27)	Wound complicationsA:B = 11/353 (3.3%) vs 4/27 (14.8%)No significant difference	No difference
Shani et al¹⁶	Level Ⅲ	Retrospective cohort	A: Staples (N = 127) vs skin suture (N = 143)	SSIA:B = 15/127 (11.8%) vs 6/143 (4.2%)P = .017	Skin suture was effective than staples for SSI
Grottkau et al¹⁷	Level Ⅱ	Randomized control trial	A: Tapes (N = 13) vsSubcuticular suture (N = 12)	・Time for skin closureA:B = 290 sec. Vs 674 sec. (Mean incision length A:B = 31 cm vs 34 cm)・Wound complicationsNo difference (no data in this paper)	Tapes is a useful for time-saving
Tang et al¹⁸	Level Ⅲ	Retrospective cohort	Suture for the fascial layerA: Interrupted suture (N = 89) vs B: Barbed suture (N = 28)	Wound complicationsA:B = 9/89 (10.1%) vs 3/28 (10.7%)”No significant difference	No difference

Glue; 2-octyl-Cyanoacrylate, SSI; surgical site infection

Dressings Survey Results

As shown in Table 4, dry dressings remained the most common initial dressing, with highest use in ESA (56%), MENA (69%) and NA (61%). Plastic occlusive dressings were the most common dressing in AP (36%) and were used by 27% of LA and 21% of NA surgeons.

Table 4.

Initial Wound Dressing After Surgery.

	ESA (N = 57)	NA (N = 33)	AP (N = 36)	LA (N = 22)	MENA (N = 16)	Overall (N = 164)
Dry dressing
+	32 (56.1%)	20 (60.6%)	13 (36.1%)	7 (31.8%)	11 (68.8%)	83 (50.6%)
-	25 (43.9%)	13 (39.4%)	23 (63.9%)	15 (68.2%)	5 (31.3%)	81 (49.4%)
Plastic occlusive dressing
+	11 (19.3%)	7 (21.2%)	13 (36.1%)	6 (27.3%)	0 (0%)	37 (22.6%)
-	46 (80.7%)	26 (78.8%)	23 (63.9%)	16 (72.7%)	16 (100%)	127 (77.4%)
Glue
+	2 (3.5%)	3 (9.1%)	1 (2.8%)	0 (0%)	0 (0%)	6 (3.7%)
-	55 (96.5%)	30 (90.9%)	35 (97.2%)	22 (100%)	16 (100%)	158 (96.3%)
Dermabone prineo dressing
+	2 (3.5%)	7 (21.2%)	3 (8.3%)	2 (9.1%)	0 (0%)	14 (8.5%)
-	55 (96.5%)	26 (78.8%)	33 (91.7%)	20 (90.9%)	16 (100%)	150 (91.5%)
Incisional wound vacuum
+	2 (3.5%)	3 (9.1%)	2 (5.6%)	1 (4.5%)	0 (0%)	8 (4.9%)
-	55 (96.5%)	30 (90.9%)	34 (94.4%)	21 (95.5%)	16 (100%)	156 (95.1%)
Aquacel Ag
+	0 (0%)	1 (3.0%)	0 (0%)	0 (0%)	0 (0%)	1 (.6%)
-	57 (100%)	32 (97.0%)	36 (100%)	22 (100%)	16 (100%)	163 (99.4%)

Other closure techniques were sparingly used. Glue was used by only 4% of surgeons. Dermabond Prineo dressings were used in NA, LA, and AP (21%, 9% and 8% respectively), but sparingly used in ESA and MENA. Similarly, incisional wound vacuum saw 9% NA use, 6% AP use and 5% LA use, but very little use in ESA and MENA. Only one NA surgeon used AA dressings.

There was heterogeneity with respect to the timing of the first dressing change (Table 5). Unfortunately, 30% of respondents did not respond to this line of questions, and 12% changed dressings depending on removal of the drain. Most surgeons removed the first dressing on POD2 (20%) or POD3 (17%), with 9% of surgeons waiting until POD7 or later.

Table 5.

The Timing of the First Dressing Change.

	ESA (N = 57)	NA (N = 33)	AP (N = 36)	LA (N = 22)	MENA (N = 16)	Overall (N = 164)
DressRem
POD1	4 (7.0%)	2 (6.1%)	0 (0%)	3 (13.6%)	1 (6.3%)	10 (6.1%)
POD2	16 (28.1%)	3 (9.1%)	6 (16.7%)	4 (18.2%)	4 (25.0%)	33 (20.1%)
POD3	7 (12.3%)	13 (39.4%)	5 (13.9%)	1 (4.5%)	1 (6.3%)	27 (16.5%)
POD4	1 (1.8%)	0 (0%)	1 (2.8%)	0 (0%)	1 (6.3%)	3 (1.8%)
POD5	4 (7.0%)	2 (6.1%)	1 (2.8%)	1 (4.5%)	0 (0%)	8 (4.9%)
POD6	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)
POD7 or later	4 (7.0%)	2 (6.1%)	7 (19.4%)	2 (9.1%)	0 (0%)	15 (9.1%)
depending On removal of drain	3 (5.3%)	7 (21.2%)	5 (13.9%)	0 (0%)	4 (25.0%)	19 (11.6%)
Missing	18 (31.6%)	4 (12.1%)	11 (30.6%)	11 (50.0%)	5 (31.3%)	49 (29.9%)

All 164 surgeons answered the survey questions about second dressings (Table 6). While 8% of surgeons used no subsequent dressing, most surgeons switched to dry dressings (52%) or plastic occlusive dressing (15%). There was some regional variation, with 24% of NA surgeons choosing no dressings, 58% choosing dry dressings and only 6% using plastic occlusive dressings. In contrast, very few or no surgeons in other jurisdictions selected no dressing and 33% and 27% chose plastic occlusive dressings in AP and LA.

Table 6.

Second Wound Dressing After Removal of Initial Dressing.

	ESA (N = 57)	NA (N = 33)	AP(N = 36)	LA (N = 22)	MENA (N = 16)	Overall (N = 164)
Dry dressing
+	35 (61.4%)	19 (57.6%)	13 (36.1%)	7 (31.8%)	11 (68.8%)	85 (51.8%)
-	22 (38.6%)	14 (42.4%)	23 (63.9%)	15 (68.2%)	5 (31.3%)	79 (48.2%)
Plastic occlusive dressing
+	4 (7.0%)	2 (6.1%)	12 (33.3%)	6 (27.3%)	0 (0%)	24 (14.6%)
-	53 (93.0%)	31 (93.9%)	24 (66.7%)	16 (72.7%)	16 (100%)	140 (85.4%)
Glue
+	1 (1.8%)	0 (0%)	2 (5.6%)	0 (0%)	0 (0%)	3 (1.8%)
-	56 (98.2%)	33 (100%)	34 (94.4%)	22 (100%)	16 (100%)	161 (98.2%)
No dressing
+	3 (5.3%)	8 (24.2%)	1 (2.8%)	1 (4.5%)	0 (0%)	13 (7.9%)
-	54 (94.7%)	25 (75.8%)	35 (97.2%)	21 (95.5%)	16 (100%)	151 (92.1%)

Wound Care and Dressings Literature Review

Our search strategy identified 18 studies regarding wound dressings in spine surgery. Out of these 18 literature sources, we selected 7 that discussed wound dressings and postoperative wound complications such as SSI (Table 7). Five included studies were retrospective, observational, and comparative investigations, and two were systematic reviews. Except for one (Adogwa et al. ¹⁹), they were not specific for spine deformity correction but for spine surgery in general.

Table 7.

Literature Review for Wound Dressing.

Author	Level of evidence	Study design	Intervention	Outcomes	Conclusion
Adogwa et al¹⁹	Level Ⅲ	Retrospective cohort	Negative pressure wound therapy (n = 46)	SSI 10.63% vs 14.91%, (P = .04), favours negative pressure wound therapy. Dehiscence 6.38% vs 12.28% (P = .02) favours negative pressure wound therapy	Incisional wound vacuum was effective
Akhter et al²⁰	Level Ⅳ	Retrospective cohort	Negative pressure wound therapy (PREVENA) (n = 42)	SSI 0 % vs 7.1 %, (P = .034), favours negative pressure wound therapy. Dehiscence 2.4 % vs 7.1% (P = .276) favours negative pressure wound therapy	Incisional wound vacuum was effective
Glennie et al²⁴		Systematic review		Occlusive dressing superior to non-occlusive. Overall complication rate 6.7 % vs 16.3 % (OR 2.09; 95% CI 1.44-3.02). No difference antimicrobial coated vs standard dressing (1 % vs 1.2 %)	Occlusive dressing was effective
Bains et al²³	Level Ⅲ	Retrospective cohort	No dressing change until POD 5 (n = 6158)	SSI decreased from 3.9% (97/2473) to .93% (57/6158) (P < 0001)	No-dressing change was effective
Epstein et al²¹	Level IV	Retrospective cohort	Silver-impregnated dressing (n = 106)	SSI 3 cases in standard dressing group vs none in silver-impregnated dressing	Silver-impregnated dressing was effective
Felbaum et al²²	Level IV	Retrospective cohort	Surgical adhesive drape (IO-ban) (n = 157)	SSI .64 % vs 3.5 % (P = .1) favours surgical adhesive drape over standard drape	No difference
Tan et al²⁵		Systematic review		There is insufficient evidence on the efficacy of any dressing type or duration for which wound dressing should remain intact to reduce rate of SSI in any type of spine surgery

SSI; surgical site infection

All papers were Level 3 or 4 evidence. There is some support for IWC being effective in ASD surgery for SSI^19,20 and for dehiscence.¹⁹ There is also some low-level evidence supporting silver-impregnated antimicrobial dressings,²¹ antimicrobial film.²² and in a no-dressing-change protocol.²³ in spine surgery, but these are not specific to ASD.

A systematic review on wound dressings in spine surgery (not specific to ASD) suggested that occlusive dressings are superior to non-occlusive.²⁴ In contrast, another systematic review suggested no conclusive evidence on the efficacy of any suture or dressing type.²⁵

Discussion

Surgeons have many choices in wound closure and dressings in ASD, but the choices have not yet been clarified. In other surgical domains, there is much interest and uncertain literature regarding choice of wound closure and impact wound infection and drainage rates.^14,26,27 While the rate of ASD surgery wound complications are high, there is little literature to guide our choices. In this investigation, we document geographical variations in wound closure and dressing techniques.

Although the literature review did not find studies with a high level of evidence for wound closure, the results in Table 3 suggest that Glue may be more effective in preventing SSI than other wound closures. However, staples were the most frequently used wound closure in all regions except for LA (Table 1). This may be due to cost performance and perceived ease of use. Considered further, the cost and time required to close a 10 cm incision are US$25 for 20 s with glue, and US$38.5 for 48 s with staples, and thus glue may be superior in terms of cost performance.¹³ Nonetheless, as shown in Table 1, Glue usage is low globally, except perhaps in NA. This may reflect the higher density of medical suppliers in NA, and thus newer medical supplies are more readily. The most prevalent wound closure in LA was ENS. In a survey similar to this study of neurosurgeons and orthopedic surgeons mainly in South America (mostly Mexico), 82% reported skin suture with nylon as their wound closure method, and the remaining 18% reported staples.²⁸

Table 2 describes the method used to suture the fascia, and absorbable sutures were overwhelmingly the most common type of suture throughout all regions. Of these, absorbable braided suture was selected by the majority of surgeons compared to absorbable monofilament suture. This may be due to the fact that many surgeons consider the difficulty of thread loosening to be more important for fascia sutures. Muscular layer approximation was also not performed by an average of 75.6% of surgeons across all regions, indicating that muscular layer approximation is not common across all regions.

In this study, in over 74% of surgeons, initial post-operative dressing choices were mostly dry dressings or plastic occlusive dressings (Table 4). In contrast, the use of glue or hydrofibre dressing (AA) were very limited. The Dermabond Prineo dressing, and the Incisional Vacuum dressing were used by 8.5% and 5% of world surgeons respectively, but with some important geographical variations, namely high use rates in NA (21% DP and 9% Incisional Vacuum). The most likely explanation for high NA use is cost, as surgical expenses in the US are generally higher than other jurisdictions.²⁹

New dressing technologies could improve wound healing performance. The Dermabond Prineo dressing consists of a self-adhesive mesh and traditional skin glue (2-octyl cyanoacrylate) (Ethicon, US). The purported advantages are to avoid intradermal sutures and decrease wound stress, avoid need for dressing changes, and that it forms an anti-microbial layer.^30,31 There are few reports of DP use in spine surgery, and none in ASD. Stricker et al. ³¹ described successful use in 50 pediatric non-instrumented cases, including 45 intra-dural surgeries. They reported a very high satisfaction rate with respect to ease of use. However, while rare, allergic reactions to skin glue can occur in approximately .5% to 2% of cases.³² and can lead to reoperations. While the effect of DP dressing on wound complications may be decreased drainage and less operating time,^33,34 it is expensive as compared to DD or PO dressings.

Incisional vacuum dressings in spine have been used in the management of known surgical site infections,³⁵ but there is little evidence when used at the index surgical closure to prevent infection (Table 7). Adogwa et al. ¹⁹ analyzed the effect of incisional wound vacuum on wound infection and dehiscence rates in ASD surgery. A significant decrease in the incidence of wound dehiscence (6.4% vs 12.3%, P = .02) and postoperative surgical site infection (10.6% vs 14.9%, P = .04) was observed in the IWV patient cohort. The authors concluded that this therapy was related to reduced wound complications in patients undergoing deformity surgery. Dyck et al.³⁶ in a small series, have also reported that prophylactic use of IWV in high-risk spine wounds can decrease SSI.

The timing and type of second dressings after ASD surgery was also quite heterogeneous. Despite some evidence supporting minimizing dressing changes in spine surgery,²³ most surgeons changed the dressings by POD3.

Conclusions

A survey of surgeons performing ASD surgery revealed that although stales are common for wound closures and dry dressing is common for wound dressings, there is some regional variation in the choice. However, there are no current guidelines to help surgeons with these choices, and these data are not informative. Given high rates of wound complications in ASD surgery, there is an opportunity for high-quality trials to determine if wound closure and dressing choices can decrease complications.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Shin Oe

Martin Gagliardi

Stephen J. Lewis

Appendix

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