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J Neurosurg Pediatr. 2018 Dec 1;22(6):701-709. doi: 10.3171/2018.6.PEDS18243.

Development of best practices to minimize wound complications after complex tethered spinal cord surgery: a modified Delphi study.

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1Department of Neurological Surgery, Columbia University Medical Center, New York, New York.
2Department of Neurological Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
3Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Alabama, Birmingham, Alabama.
4Department of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah.
5Department of Neurosurgery, University of Washington Seattle Children's Hospital, Seattle, Washington.
6Department of Neurosurgery, Stanford University, Stanford, California.
7Department of Neurosurgery, Children's Hospital of Philadelphia, Pennsylvania.
8Department of Pediatric Neurosurgery, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado.
9Department of Neurosurgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin.
10Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana.
11Department of Neurological Surgery, USC Keck School of Medicine/Children's Hospital of Los Angeles, California.
12Department of Neurosurgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio.
13Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri.
14Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
15Department of Neurosurgery, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts.
16Department of Neurosurgery, McGovern Medical School/University of Texas Health Science Center, Houston, Texas.
17Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; and.
18Rutgers New Jersey Medical School, Newark, New Jersey.


OBJECTIVEComplications after complex tethered spinal cord (cTSC) surgery include infections and cerebrospinal fluid (CSF) leaks. With little empirical evidence to guide management, there is variability in the interventions undertaken to limit complications. Expert-based best practices may improve the care of patients undergoing cTSC surgery. Here, authors conducted a study to identify consensus-driven best practices.METHODSThe Delphi method was employed to identify consensual best practices. A literature review regarding cTSC surgery together with a survey of current practices was distributed to 17 board-certified pediatric neurosurgeons. Thirty statements were then formulated and distributed to the group. Results of the second survey were discussed during an in-person meeting leading to further consensus, which was defined as ≥ 80% agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree).RESULTSSeventeen consensus-driven best practices were identified, with all participants willing to incorporate them into their practice. There were four preoperative interventions: (1, 2) asymptomatic AND symptomatic patients should be referred to urology preoperatively, (3, 4) routine preoperative urine cultures are not necessary for asymptomatic AND symptomatic patients. There were nine intraoperative interventions: (5) patients should receive perioperative cefazolin or an equivalent alternative in the event of allergy, (6) chlorhexidine-based skin preparation is the preferred regimen, (7) saline irrigation should be used intermittently throughout the case, (8) antibiotic-containing irrigation should be used following dural closure, (9) a nonlocking running suture technique should be used for dural closure, (10) dural graft overlay should be used when unable to obtain primary dural closure, (11) an expansile dural graft should be incorporated in cases of lipomyelomeningocele in which primary dural closure does not permit free flow of CSF, (12) paraxial muscles should be closed as a layer separate from the fascia, (13) routine placement of postoperative drains is not necessary. There were three postoperative interventions: (14) postoperative antibiotics are an option and, if given, should be discontinued within 24 hours; (15) patients should remain flat for at least 24 hours postoperatively; (16) routine use of abdominal binders or other compressive devices postoperatively is not necessary. One intervention was prioritized for additional study: (17) further study of additional gram-negative perioperative coverage is needed.CONCLUSIONSA modified Delphi technique was used to develop consensus-driven best practices for decreasing wound complications after cTSC surgery. Further study is required to determine if implementation of these practices will lead to reduced complications. Discussion through the course of this study resulted in the initiation of a multicenter study of gram-negative surgical site infections in cTSC surgery.


CSF = cerebrospinal fluid; Delphi method; SSI = surgical site infection; TCS = tethered cord syndrome; cTSC = complex tethered spinal cord; cerebrospinal fluid leak; spine; surgical site infection; tethered spinal cord


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