Surgical site infection in thoracic and lumbar fractures: incidence and risk factors in 11,401 patients from a nationwide administrative database

Published:October 21, 2022DOI:


      • Few studies have focused on complications resulting from non-elective spine surgery.
      • There is a 7.5% risk of SSI after fusion surgery for thoracic/lumbar fractures.
      • Obesity and the Elixhauser Comorbidity Index are independent predictors of SSI in this cohort.



      The rate of surgical site infection (SSI) following elective spine surgery ranges from 0.5%‒10%. Published reports suggest a higher SSI rate in non-elective spine surgery such as spine trauma; however, there is a paucity of large database studies examining this issue.


      The objective of this study was to investigate the incidence and risk factors of SSI in patients undergoing spine surgery for thoracic and lumbar fractures in a large population database.


      This is a retrospective study utilizing the PearlDiver Patient Claims Database.


      Patients undergoing spine surgery for thoracic and lumbar fractures between 2015-2020 were identified in the PearlDiver Patient Claims Database using ICD-10 codes. Patients were excluded who had another surgery either 14 days before or 21 days after the index spine surgery, or pathologic fracture.


      Rate of surgical site infection.


      Clinical data collected from the PearlDiver database based on ICD-10 codes included gender, age, diabetes, smoking status, obesity, Elixhauser Comorbidity Index (ECI), Charlson Comorbidity Index (CCI), and SSI. Univariate analysis was used to assess the association of potential risk factors and SSI. Multivariable analysis was used to identify independent risk factors of SSI. The authors have no conflicts of interest or funding sources to declare.


      A total of 11,401 patients undergoing spine surgery for thoracic and lumbar fractures met inclusion criteria, and 1,065 patients were excluded. 860 patients developed SSI (7.5%). Risk factors significantly associated with SSI in univariate analysis included diabetes (OR 1.50; 95% CI, 1.30‒1.73; p<.001), obesity (OR 1.66; 95% CI, 1.44‒1.92; p<.001), increased age (p<.001), ECI (p<.001), and CCI (p<.001). On multivariable analysis, obesity and ECI were independently associated with SSI (p<.001 and p<.001, respectively).


      Non-elective surgery for thoracic and lumbar fractures is associated with a 7.5% risk of SSI. Obesity and ECI are independent predictors of SSI in this population. Limitations include the reliance on accurate insurance coding which may not fully capture all SSI, and in particular superficial SSI. These findings provide a broad overview of the risk of SSI in this population at a national level and may also help counsel patients regarding risk.


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        • Spatenkova V
        • Bradac O
        • Jindrisek Z
        • Hradil J
        • Fackova D
        • Halacova M.
        Risk factors associated with surgical site infections after thoracic or lumbar surgery: a 6-year single centre prospective cohort study.
        J Orthop Surg Res. 2021; 16
        • Olsen MA
        • Mayfield J
        • Lauryssen C
        • Polish LB
        • Jones M
        • Vest J
        • et al.
        Risk factors for surgical site infection in spinal surgery.
        J Neurosurg: Spine. 2003; 98: 149-155
        • Levi ADO
        • Dickman CA
        • Sonntag VKH.
        Management of post-operative infections after spinal instrumentation.
        J Neurosurg. 1997; 86: 975-980
        • Kurtz SM
        • Lau E
        • Ong KL
        • Carreon L
        • Watson H
        • Albert T
        • et al.
        Infection risk for primary and revision instrumented lumbar spine fusion in the Medicare population: Clinical article.
        J Neurosurg: Spine. 2012; 17: 342-347
        • Fang A
        • Hu SS
        • Endres N
        • Bradford DS.
        Risk factors for infection after spinal surgery.
        Spine (Phila Pa 1976). 2005; 30: 1460-1465
        • Chaichana KL
        • Bydon M
        • Santiago-Dieppa DR
        • Hwang L
        • McLoughlin G
        • Sciubba DM
        • et al.
        Risk of infection following posterior instrumented lumbar fusion for degenerative spine disease in 817 consecutive cases: Clinical article.
        J Neurosurg: Spine. 2014; 20: 45-52
        • Pull Ter Gunne AF
        • Mohamed AS
        • Skolasky RL
        • van Laarhoven CJHM
        • Cohen DB.
        The presentation, incidence, etiology, and treatment of surgical site infections after spinal surgery.
        Spine (Phila Pa 1976). 2010; 35: 1323-1328
        • Edwards JR
        • Peterson KD
        • Andrus ML
        • Dudeck MA
        • Pollock DA
        • Horan TC.
        National Healthcare Safety Network (NHSN) Report, data summary for 2006 through 2007, issued November 2008.
        AmJ InfectControl. 2008; 36: 609-626
        • Hickmann AK
        • Bratelj D
        • Pirvu T
        • Loibl M
        • Mannion AF
        • O’Riordan D
        • et al.
        Management and outcome of spinal implant-associated surgical site infections in patients with posterior instrumentation: analysis of 176 cases.
        Eur Spine J. 2022; 31: 489-499
        • Petilon JM
        • Glassman SD
        • Dimar JR
        • Carreon LY.
        Clinical outcomes after lumbar fusion complicated by deep wound infection: acase-control study.
        Spine (Phila Pa 1976). 2012; 37: 1370-1374
        • Urquhart JC
        • Gurr KR
        • Siddiqi F
        • Rasoulinejad P
        • Bailey CS.
        The impact of surgical site infection on patient outcomes after open posterior instrumented thoracolumbar surgery for degenerative disorders.
        J Bone Joint Surg Am. 2021; 103: 2105-2114
        • Blumberg TJ
        • Woelber E
        • Bellabarba C
        • Bransford R
        • Spina N.
        Predictors of increased cost and length of stay in the treatment of postoperative spine surgical site infection.
        Spine J. 2018; 18: 300-306
        • Bernatz JT
        • Anderson PA.
        Thirty-day readmission rates in spine surgery: systematic review and meta-analysis.
        Neurosurg Focus. 2015; 39
        • Kuhns BD
        • Lubelski D
        • Alvin MD
        • Taub JS
        • McGirt MJ
        • Benzel EC
        • et al.
        Cost and quality of life outcome analysis of postoperative infections after subaxial dorsal cervical fusions.
        J Neurosurg Spine. 2015; 22: 381-386
        • Yeramaneni S
        • Robinson C
        • Hostin R.
        Impact of spine surgery complications on costs associated with management of adult spinal deformity.
        Curr Rev Musculoskelet Med. 2016; 9: 327-332
        • Pennington Z
        • Sundar SJ
        • Lubelski D
        • Alvin MD
        • Benzel EC
        • Mroz TE.
        Cost and quality of life outcome analysis of postoperative infections after posterior lumbar decompression and fusion.
        J Clin Neurosci. 2019; 68: 105-110
        • Fei Q
        • Li J
        • Lin JS
        • Li D
        • Wang BQ
        • Meng H
        • et al.
        Risk factors for surgical site infection after spinal surgery: a meta-analysis.
        World Neurosurg. 2016; 95: 507-515
        • Anderson PA
        • Savage JW
        • Vaccaro AR
        • Radcliff K
        • Arnold PM
        • Lawrence BD
        • et al.
        Prevention of surgical site infection in spine surgery.
        Neurosurgery. 2017; 80: S114-S123
        • Rechtine GR
        • Bono PL
        • Cahill D
        • Bolesta MJ
        • Chrin AM.
        Post-operative wound infection after instrumentation of thoracic and lumbar fractures.
        J Orthop Trauma. 2001; 15: 566-569
        • Blam OG
        • Vaccaro AR
        • Vanichkachorn JS
        • Albert TJ
        • Hilibrand AS
        • Minnich JM
        • et al.
        Risk factors for surgical site infection in the patient with spinal injury.
        Spine (Phila Pa 1976). 2003; 28: 1475-1480
        • Cooper K
        • Glenn CA
        • Martin M
        • Stoner J
        • Li J
        • Puckett T.
        Risk factors for surgical site infection after instrumented fixation in spine trauma.
        J Clin Neurosci. 2016; 23: 123-127
        • Verlaan JJ
        • Diekerhof CH
        • Buskens E
        • van der Tweel I
        • Verbout AJ
        • Dhert WJA
        • et al.
        Surgical treatment of traumatic fractures of the thoracic and lumbar spine: a systematic review of the literature on techniques, complications, and outcome.
        Spine (Phila Pa 1976). 2004; 29: 803-814
        • Koutsoumbelis S
        • Hughes AP
        • Girardi FP
        • Cammisa Jr., FP
        • Finerty EA
        • Nguyen JT
        • et al.
        Risk factors for post-operative infection following posterior lumbar instrumented arthrodesis.
        J Bone Joint Surg Am. 2011; 93: 1627-1633
        • Maragakis LL
        • Cosgrove SE
        • Martinez EA
        • Tucker MG
        • Cohen DB
        • Perl TM.
        Intraoperative fraction of inspired oxygen is a modifiable risk factor for surgical site infection after spinal surgery.
        Anesthesiology. 2009; 110: 556-562
        • Schuster JM
        • Rechtine G
        • Norvell DC
        • Dettori JR.
        The influence of perioperative risk factors and therapeutic interventions on infection rates after spine surgery: a systematic review.
        Spine (Phila Pa 1976). 2010; 35
        • Apisarnthanarak A
        • Jones M
        • Waterman BM
        • Carroll CM
        • Bernardi R
        • Fraser VJ.
        Risk factors for spinal surgical-site infections in a community hospital: a case-control study.
        Infect Control Hosp Epidemiol. 2003; 24: 31-36
        • Pull Ter Gunne AF
        • Hosman AJF
        • Cohen DB
        • Schuetz M
        • Habil D
        • van Laarhoven CJHM
        • et al.
        A methodological systematic review on surgical site infections following spinal surgery: part 1: risk factors.
        Spine (Phila Pa 1976). 2012; 37: 2017-2033
        • Moore BJ
        • White S
        • Washington R
        • Coenen N
        • Elixhauser A.
        Identifying increased risk of readmission and in-hospital mortality using hospital administrative data: the AHRQ Elixhauser Comorbidity Index.
        Med Care. 2017; 55: 698-705
        • Elixhauser A
        • Steiner C
        • Harris DR
        • Coffey RM.
        Comorbidity measures for use with administrative data.
        Med Care. 1998; 36: 8-27
        • Quan H
        • Li B
        • Couris CM
        • Fushimi K
        • Graham P
        • Hider P
        • et al.
        Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries.
        Am J Epidemiol. 2011; 173: 676-682
        • Charlson ME
        • Pompei P
        • Ales KL
        • MacKenzie CR.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Menendez ME
        • Ring D
        • Harris MB
        • Cha TD.
        Predicting in-hospital mortality in Eederly patients with cervical spine fractures: acomparison of the Charlson and Elixhauser Comorbidity Measures.
        Spine (Phila Pa 1976). 2015; 40: 809-815
        • Baron RB
        • Neifert SN
        • Ranson WA
        • Schupper AJ
        • Gal JS
        • Cho SK
        • et al.
        A comparison of the Elixhauser and Charlson Comorbidity Indices: predicting in-hospital complications following anterior lumbar interbody fusions.
        World Neurosurg. 2020; 144: e353-e360
        • Maron SZ
        • Neifert SN
        • Ranson WA
        • et al.
        Elixhauser Comorbidity Measure is superior to Charlson Comorbidity Index in-predicting hospital complications following elective posterior cervical decompression and fusion.
        World Neurosurgery. 2020; 138: e26-e34
        • Mueller K
        • Zhao D
        • Johnson O
        • Sandhu FA
        • Voyadzis JM.
        The difference in surgical site infection rates between open and minimally invasive spine surgery for degenerative lumbar pathology: a retrospective single center experience of 1,442 cases.
        Oper Neurosurg (Hagerstown). 2019; 16: 750-755
        • Uchida K.
        Post-surgical immune suppression: another target to improve postoperative outcomes.
        J Anesth. 2019; 33: 625-627
        • Marshall JC
        • Charbonney E
        • Gonzalez PD.
        The immune system in critical illness.
        Clin Chest Med. 2008; 29: 605-616