Drains in Spine Surgery

As spine surgeons strive to improve patient outcomes, decrease complications, and control costs, they must determine which pharmacologic and surgical measures are worth implementing. Surgical drains are used by some in an effort to reduce the risk of complications, such as surgical site infection (SSI), compressive hematoma, and delayed wound healing. However, drain use could also increase infection risk and postoperative blood loss. Given the lack of consensus on drain utilization, we review the literature on wound drains in spine surgery to help delineate their potential efficacy and limitations.

Cervical Spine

Drain use in the cervical spine after treating degenerative cervical pathology is tailored to different risks associated with the anterior and posterior cervical approaches. Some spine surgeons place a drain following anterior cervical discectomy and fusion (ACDF) to prevent wound hematoma, which can lead to airway compromise. Upper airway compromise occurring in the immediate postoperative period most commonly stems from an expanding hematoma and has a reported prevalence of 0.2% to 1.9%.[1] Clinically significant retropha- ryngeal hematomas typically appear within 6 to 12 hours postoperatively but can appear as late as 6 days after surgery.[2] A retrospective cohort study found that patients with increased body mass index (BMI) and those undergoing ACDF at two or more levels had increased drain output and thus may benefit from surgical drain placement. 3 However, another retrospective review assessing 2,375 anterior cervical spine procedures found that only 0.7% of patients experienced a clinically significant postoperative hematoma, and 88% of patients with hematomas had a drain placed at the conclusion of the index surgery.[4] Moreover, 27% of these patients still had their drains in place at the time of hematoma diagnosis.[4] Drain placement may not be trivial even in multilevel cervical cases, as it is possible that drain removal can aggravate a vessel or muscle bed and lead to hematoma formation. A retrospective study assessing 321 multi-level ACDF procedures comparing a drain cohort to a no-drain cohort found no difference in postoperative hematoma formation with a 14 times increased odds of postoperative allogenic blood transfusion in the drain cohort.[5] A systematic review and meta-analysis using this evidence along with that of other studies concluded that utilization of a drain in anterior cervical spine surgery does not prevent hematoma formation and does not provide any additional benefits, although a definitive conclusion would require more randomized controlled trials (RCTs).[6] It is therefore imperative that surgeons who use drains in the setting of ACDF do not allow this to provide them with a false sense of security—meticulous hemostasis should be obtained at the conclusion of every case regardless of whether or not a drain will be used.

Drains in posterior cervical spine surgery are often used in an effort to prevent epidural hematomas, wound breakdown, and SSIs. The incidence of a clinically significant postoperative epidural hematoma is about 0.1%.[7] A retrospective study assessing risk factors for postoperative spinal epidural hematoma after 14,932 surgeries from 1984 to 2002 found patients to be at increased risk if they had one of the following associated variables: age greater than 60, pre-operative non-steroidal anti-inflammatory use, more than 5 operative levels, or blood loss greater than 1 liter.[8] Drains were used in 72% of patients who experienced an epidural hematoma, and the lack of a subfascial drain was not associated with the development of a postoperative epidural hematoma.[8] A more recent retrospective review assessing posterior cervical spine surgery also found that the rates of reoperation for hematoma did not differ between drain and no-drain cohorts (0.68% in drain, 0.48% no-drain, p = 0.62) even after adjusting for significant risk factors such as diabetes and number of operative levels (OR = 1.22, p = 0.77).[9] However, patients with drains did have significantly lower odds of returning to the operating room for SSI (OR 0.48, p = 0.04) after adjusting for significant risk factors.[9] SSI tends to be more common after posterior than anterior cervical spine surgery with reported rates as high as 18%.[10] In a retrospective review, Sebastian et al found that among 5,441 patients, the incidence of SSI after posterior cervical surgery was 2.94%, and only a third of these patients required readmission.11 While Sebastian et al found obese patients (BMI >35) and those on chronic steroids to be at a significantly elevated risk of SSI, they did not assess for drain use.[11] Nonetheless, suprafascial drain use in obese patients has been shown to significantly reduce postoperative deep infections in posterior cervical procedures.[12]

Lumbar Spine

The rationale for drain use following the treatment of degenerative lumbar pathology is similar. The incidence of an asymptomatic early postoperative lumbar spine hematoma after lumbar discectomy on MRI has been found to be as high as 89% in patients without a subfascial drain and 36% in those with one.[13] However, the incidence of a symptomatic epidural hematoma occurring in the majority of lumbar spine epidemiology studies is around 0.1% to 0.9%.[14] A systematic review investigating wound drains in noncomplex lumbar spine surgery involving 1- or 2-level laminectomies and/or discectomies demonstrated that routine drain use does not prevent symptomatic postoperative epidural hematomas, nor does the absence of a drain lead to a significant change in the incidence of wound infection.[15] Another meta-analysis assessing non-instrumented lumbar decompressions found no difference in risk of symptomatic epidural hematoma or postoperative infection between the 5,327 cases identified as having a drain and the 773 cases without a drain.[16] A study of 1- to 3-level posterolateral fusions with or without interbody fusion found that drain use increased length of stay but did not reduce complication rates.[17] Moreover, a retrospective study by Walid et al found that patients with drains for 1- to 3-level lumbar fusions reported a statistically significantly higher incidence of post-hemorrhagic anemia compared to those without drains (23.5% vs 7.7%, p < 0.001) as well as an increased risk for allogenic blood transfusion (23.9% vs 6.8%, p < 0.001).[18]

Thoracolumbar Deformity

Deformity operations are prone to wound breakdown and SSI due to their prolonged operative times, increased muscle dissection and retraction, and longer periods of relative immobility after surgery. A prospective RCT assessing drain use in adult deformity patients observed SSI in 12.7% of patients with a drain compared to 7% with no drain ( p = 0.07).[19] Of note, use of perioperative antibiotics for the entire drain duration versus the standard first 24 hours after surgery did not decrease the rate of SSI in the drain cohort.[19] Drain utilization in pediatric spinal deformity correction has also not provided any additional benefit in reducing the risk of SSI or reoperation.[6] A prospective RCT comparing a cohort with subfascial drains to a cohort with no drain in adolescent idiopathic scoliosis (AIS) cases found no advantage to subfascial drains—there was an identical number of wound healing complications.[20] A multicenter retrospective analysis evaluating closed-suction wound drainage after posterior spinal fusion in AIS patients similarly reported no differences in the cohorts with regard to wound infection but did demonstrate more postoperative transfusions in the drain cohort (43% vs 22%, p < 0.001).[21]

Trauma and Tumor

Although there have been several studies assessing the efficacy of closed-suction drainage after surgery for degenerative spine diseases, there is limited high level evidence on drain use in nonelective spinal pathologies such as trauma and tumor. In the setting of traumatic instability, utilization of a drain may not reduce the risk of SSI or provide additional benefits.[6] In a randomized study of 110 patients assessing the impact of drain use in the setting of dorsolumbar spine surgery for trauma and neurologic deficits, Kumar et al found no statistically significant difference between groups in terms of postoperative wound infection rates, clinically significant hematomas, or risk of further neurological injury.[22] Intradural involvement via trauma or tumor creates an additional problem: cerebrospinal fluid (CSF) leakage. Utilization of closed-suction drainage may promote continuous leakage of CSF even despite attempted dural repair. A retrospective study assessed the benefit of closed-suction drainage and prevention of CSF leak-related complications after surgery for primary intradural spinal cord tumors.[23] Among the 134 patients, postoperative MRI found CSF fluid collections in 9.7% of patients in the drain group and 10.8% of patients in the no-drain group (p = 0.87). These collections resolved uneventfully regardless of drain use, except in 2 patients in the no-drain group who required revision for wound-related problems (p = 0.20).[23]

Conclusion

Drain utilization continues to be utilized by some surgeons after spine surgery for degenerative conditions, deformity, trauma, and tumors. Nonetheless, the vast majority of literature demonstrates that the use of a drain does not lower the rate of symptomatic

hematoma formation but instead may increase postoperative anemia, transfusion rates, SSI, and length of stay. While certain subgroups may benefit from drain placement for the prevention of wound complications (i.e., after posterior cervical surgery), this appears to be the exception rather than the rule.

References

1. Palumbo MA, Aidlen JP, Daniels AH, Thakur NA, Caiati J. Airway compromise due to wound hematoma following anterior cervical spine surgery. Open Orthop J. 2012;6:108-113.

2. Debkowska MP, Butterworth JF, Moore JE, Kang S, Appelbaum EN, Zuelzer WA. Acute post-operative airway complications following anterior cervical spine surgery and the role for cricothyrotomy. J Spine Surg. 2019;5(1):142-154.

3. Patil SR, Kishan A, Gabbita A, Varadharaju DN, Jagannath PM. Anterior cervical surgery: drain needed or not? J Spine Surg. 2015;2(2):37-41.

4. O’Neill KR, Neuman B, Peters C, Riew KD. Risk factors for postoperative retropharyngeal hematoma after anterior cervical spine surgery. Spine (Phila Pa 1976). 2014;39(4):E246-52.

5. Adogwa O, Khalid SI, Elsamadicy AA, Voung VD, Lilly DT, Desai SA, Sergesketter AR, Cheng J, Karikari IO. The use of subfascial drains after multi-level anterior cervical discectomy and fusion: does the data support its use? J Spine Surg. 2018;4(2):227-232.

6. Muthu S, Ramakrishnan E, Natarajan KK, Chellamuthu G. Risk-benefit analysis of wound drain usage in spine surgery: a systematic review and meta-analysis with evidence summary. Eur Spine J. 2020;29(9):2111-2128.

7. Schroeder GD, Hilibrand AS, Arnold PM, et al. Epidural hematoma following cervical spine surgery. Global Spine J. 2017;7(1 Suppl):120S-126S.

8. Awad JN, Kebaish KM, Donigan J, Cohen DB, Kostuik JP. Analysis of the risk factors for the development of post-operative spinal epidural haematoma. J Bone Joint Surg Br. 2005;87-B(9):1248-1252

9. Herrick DB, Tanenbaum JE, Mankarious M, et al. The relationship between surgical site drains and reoperation for wound-related complications following posterior cervical spine surgery: a multicenter retrospective study. J Neurosurg Spine . 2018;29(6):628-634.

10. Reier L, Fowler JB, Arshad M, Siddiqi J. Drains in spine surgery for degenerative disc diseases: a literature review to determine its usage. Cureus. 2022;14(3):e23129.

11. Sebastian A, Huddleston P 3rd, Kakar S, Habermann E, Wagie A, Nassr A. Risk factors for surgical site infection after posterior cervical spine surgery: an analysis of 5,441 patients from the ACS NSQIP 20052012. Spine J. 2016;16(4):504-509.

12. Pahys JM, Pahys JR, Cho SK, et al. Methods to decrease postoperative infections following posterior cervical spine surgery. J Bone Joint Surg Am. 2013;95(6):549-554.

13. Mirzai H, Eminoglu M, Orguc S. Are drains useful for lumbar disc surgery? A prospective, randomized clinical study. J Spinal Disord Tech. 2006;19:171-177.

14. Butler AJ, Donnally CJ 3rd, Goz V, Basques BA, Vaccaro AR, Schroeder GD. Symptomatic postoperative epidural hematoma in the lumbar spine. Clin Spine Surg. 2022;35(9):354-362.

15. Zijlmans JL, Buis DR, Verbaan D, Vandertop WP. Wound drains in non-complex lumbar surgery: a systematic review. Bone Joint J. 2016;98-B(7):984-989.

16. Davidoff CL, Rogers JM, Simons M, Davidson AS. A systematic review and meta-analysis of wound drains in non-instrumented lumbar decompression surgery. J Clin Neurosci. 2018;53:55-61.

17. Molina M, Torres R, Castro M, et al. Wound drain in lumbar arthrodesis for degenerative disease: an experimental, multicenter, randomized controlled trial. Spine J. 2023;23(4):473-483.

18. Walid MS, Abbara M, Tolaymat A, et al. The role of drains in lumbar spine fusion. World Neurosurg. 2012; 77(3-4):564-568.

19. Takemoto RC, Lonner B, Andres T, et al. Appropriateness of twenty-fourhour antibiotic prophylaxis after spinal surgery in which a drain is utilized: a prospective randomized study. J Bone Joint Surg Am. 2015;97(12):979-86.

20. Ovadia D, Drexler M, Kramer M, Herman A, Lebel DE. Closed wound subfascial suction drainage in posterior fusion surgery for adolescent idiopathic scoliosis: a prospective randomized control study. Spine (Phila Pa 1976). 2019;44(6):377-383.

21. Diab M, Smucny M, Dormans JP, et al. Use and outcomes of wound drain in spinal fusion for adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2012;37(11):966-973.

22. Kumar, V, Singh A, Waliullah S, Kumar D. Analysis of efficacy in postoperative use of closed suction drain in cases of traumatic dorsolumbar spine injury. J Orthoped Trauma Rehabil. 2019;1(1):1-5.

23. Sohn S, Chung CK, Kim CH. Is closed-suction drainage necessary after intradural primary spinal cord tumor surgery? Eur Spine J. 2013;22(3):577–583.

Dean Perfetti, MD, MPH

Alexander M. Satin, MD

Peter B. Derman, MD, MBA