The surgical literature indicates that length of operation or operation requiring instrumentation of multiple vertebral levels is associated with an increased risk of postoperative infection [2]. Higher implant density is required with associated muscular dissection and longer retractor deployment with greater degree of tissue necrosis. However, even with less invasive surgical procedures, recolonization of the epidermis and wound occurs. Host flora begins to expand and multiply with locally occurring bacteria from a patient’s dermal adnexa, e.g., oil glands, hair follicles, and sweat glands. These bacteria recolonize over time even in relatively simple operations. The skin preparation is able to eradicate bacteria for only a limited period of time. Some surgeons advocate for re-prepping the skin at different time points during the case. However, it is clear that recolonization should be assumed for any case that lasts greater than 4 h [3].

To minimize the risk for surgical site infection, we have instituted several treatment strategies at our institution. In our patient population, we determine if patients are carriers of methicillin-resistant Staphylococcus aureus (MRSA) by preoperative nasal culture surveillance. For patients who have MRSA-positive nasal cultures, we prescribe Bactroban (mupirocin) as literature has found a reduction in postoperative SSI in patients who are treated with appropriate topical nasal antimicrobial therapy [4].

In an effort to reduce bacterial skin colonization, we begin topical skin prep with chlorhexidine gluconate skin towelettes beginning 3 days prior to operation. Preoperative skin preparation is first alcohol, followed by either a chlorhexidine or Betadine skin prep. We then administer a broad-spectrum anti-staphylococcal intravenous antibiotic dose within 1 h of skin incision (cefazolin or clindamycin) and may combine this with vancomycin for high-risk patients or procedures. Our guidelines have been accomplished with the assistance of infectious diseases physicians based upon the high prevalence of MRSA present in our community. At the conclusion of the operation and prior to placement of bone graft, we irrigate our posterior spine wounds with 4 L of dilute Betadine containing solution (3 % weight/volume) and then irrigate until clear with normal saline. This diminishes the bacterial counts in wounds which have been open for longer periods of time. We subsequently add 1–2 g of vancomycin powder (depending on wound size) prior to closure. Using the aforementioned procedures, we have been able to reduce our SSI over 50 % [5].

Adequate pain control is paramount not only to patient experience and satisfaction but also to early post-op ambulation and rehabilitation. These factors are closely linked to reduction of perioperative complications such as ileus, embolic events, and length of stay.

Efficacious pain protocols are variable among institutions; however, the need of standard protocols is paramount to delivering quality perioperative care to this patient population. Pain management is often complicated by long history of chronic pain and opiate dependence and necessitates individualized pain management regimes. The involvement of a proficient pain management team in the care of the most complicated patients is advised.

For chronic pain patients, an account of all analgesics being taken should be recorded and converted to IV morphine equivalents and noted in the preoperative assessment to facilitate intraoperative and postoperative pain requirements. Careful consideration should be given to patients with pain pumps. The type and dosage of the medication and the brand of the pump should be carefully noted. A pre-op CT scan should be considered to delineate the route of the catheter. Patients receiving opiates through their pumps need to be provided with equivalent preoperative medication dosing.

Surgeons must be particularly aware of the patients with intrathecal baclofen (ITB) pumps. Acute withdrawal of ITB may lead to a life-threatening syndrome of high fever, altered mental status, and profound muscular rigidity that may progress to fatal rhabdomyolysis. The definitive treatment for ITB withdrawal is the restoration of drug administration by the same route [6]. Surgeons must plan their surgical dissection by carefully studying the route of the catheter on pre-op CT scan to avoid severing the catheter and also plan of having catheter repair kits available in case it is damaged during the surgery. It is prudent to notify the device representative to be available if such issues arise.

Effective pain management protocols can be divided to the preoperative, intraoperative, and postoperative periods.

There is scant evidence and clinical trials regarding postoperative brace use. Although many deformity surgeons brace their patients postoperatively, there is variability regarding the most appropriate type, duration, and indications for immobilization. With adult deformity reconstruction, the high rates of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are significant concerns, and many surgeons attempt to protect their patients with postoperative orthosis. However, no evidence exists to support bracing influencing the incidence of PJK or PJF. Further prospective, clinical studies may play role in evaluating the efficacy of postoperative bracing protocols.