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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 265-270

Psoriasis complicating wound healing after minimally invasive lumbar spinal fusion


Division of Spine, Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Jalan Tan Tock Seng, Singapore

Date of Submission10-Jul-2019
Date of Decision23-Oct-2019
Date of Acceptance29-Oct-2019
Date of Web Publication13-Jul-2020

Correspondence Address:
Dr. Jacob Yoong-Leong Oh
Division of Spine, Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Jalan Tan Tock Seng.
Singapore
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/isj.isj_51_19

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  Abstract 

Postoperative infections after spine surgery can be frustrating for the patient and the surgeon. Particularly, in a patient with psoriasis, the altered genetic and cellular defense mechanisms result in a higher risk of infection that can be difficult to manage. We encountered a 55-year-old woman with multiple plaque psoriasis and psoriatic arthropathy for 15 years, who underwent L4-S1 navigation-assisted minimally invasive fusion procedure for symptomatic lumbar spondylosis while under perioperative systemic antipsoriatic medications. During the early postoperative period, blistering and operative site infection complicated the wound-healing process. The patient developed what appeared to be a pustular flare of psoriasis with widespread erythema and desquamating plaques over multiple areas. The wounds remained nonhealing with marginal necrosis that demanded repeated debridement procedures. Ultimately, negative-pressure dressing was the only modality that prevented the spread of infection, induced healthy granulation, and enhanced wound contraction. Such an extensive dermatological condition with superadded infection complicating wound healing after spine surgery is rarely reported. These conditions can be difficult to manage and require a multidisciplinary approach involving the surgeon, dermatologist, and infectious disease physician.

Keywords: Negative-pressure wound dressing, postoperative period, psoriasis, spine, spondylosis


How to cite this article:
Yeo QY, Kaliya-Perumal AK, Oh JY. Psoriasis complicating wound healing after minimally invasive lumbar spinal fusion. Indian Spine J 2020;3:265-70

How to cite this URL:
Yeo QY, Kaliya-Perumal AK, Oh JY. Psoriasis complicating wound healing after minimally invasive lumbar spinal fusion. Indian Spine J [serial online] 2020 [cited 2020 Aug 15];3:265-70. Available from: http://www.isjonline.com/text.asp?2020/3/2/265/289655




  Introduction Top


Psoriasis is a relatively common chronic inflammatory condition affecting 1%–2% of the general population.[1] 15%–20% of them have extensive cutaneous involvement or severe disease manifestation requiring systemic therapy. The altered genetic and cellular defense mechanism in patients with psoriasis results in higher risk of infection.[2] Many authors have also described the higher incidence of postoperative infection in patients with psoriasis.[3],[4] We encountered such a patient with multiple plaque psoriasis and psoriatic arthropathy for 15 years, who underwent an L4-S1 fusion procedure for symptomatic lumbar spondylosis. The pre- and postoperative problems faced during management of this case are briefly discussed in this report.


  Case Report Top


A 55-year-old woman with a history of multiple plaque psoriasis and psoriatic arthropathy for 15 years, who was under long-term oral leflunomide, methotrexate, and prednisolone, presented to our spine clinic with worsening right sciatica associated with low back pain for 1 month. On neurological examination, bilateral lower limb L4 and L5 motor power was 4/5, and there was reduced sensation over the L5 dermatome bilaterally. Lumbar spine X-rays showed L4-L5 grade 1 spondylolisthesis and L5-S1 spondylosis with a marked reduction in disc space [Figure 1]. Magnetic resonance imaging (MRI) showed L4-L5 spinal canal and bilateral lateral recess stenosis along with facet joint hypertrophy; in addition, L5-S1 disc level showed left lateral recess stenosis and modic changes of adjacent vertebras [Figure 2].
Figure 1: X-ray images showing L4-L5 grade 1 spondylolisthesis and L5-S1 spondylosis marked by a reduction in disc space: (A) anteroposterior and (B) lateral view

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Figure 2: Lumbar MRI images. (A) Sagittal cut image demonstrating L4-L5 spinal canal stenosis and L5-S1 modic changes. (B) L4-L5 axial cut image showing bilateral lateral recess stenosis along with facet joint hypertrophy. (C) L5-S1 level showing left lateral recess stenosis

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A minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) of L4-S1 was considered; however, the patient developed a psoriatic flare and surgery was deferred. She was conservatively managed along with systemic and topical management of psoriasis. Within 2 months, she became wheelchair-bound because of the progressive pain. At this point in time, her skin condition was better [Figure 3]; hence, considering the deteriorating functional status, surgery in the form of navigation-assisted L4-S1 MIS-TLIF was carried out [Figure 4]. She was kept on oral methotrexate and leflunomide perioperatively; however, prednisolone was held off and no intravenous (IV) hydrocortisone stress dose was given. Considering her multidrug allergy, postoperative IV vancomycin was the best available option for which she was not reportedly allergic to, and hence was given for antibacterial prophylaxis.
Figure 3: Skin condition before surgery

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Figure 4: Postoperative X-ray images showing the implants in situ

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On the third postoperative day, blisters were noticed around the lower two operative wounds; however, the upper tracker site wound was spared [Figure 5]. Daily dressing change was performed; however, on the sixth postoperative day, she developed what appeared to be a pustular flare of psoriasis with widespread erythema over the face, trunk, and limbs [Figure 6]A. On the ninth postoperative day, there were multiple extensive desquamating patches and plaques [Figure 6]B. Skin biopsy showed psoriasiform dermatitis with subcorneal pustules and dermal eosinophilia, consistent with acute generalized exanthematous pustulosis (AGEP). Her methotrexate dose was increased to 17.5mg/week and topical mometasone was started. Considering the possibility of AGEP, antibiotic was changed to clindamycin.
Figure 5: Blisters around the operative site on the third postoperative day

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Figure 6: (A) Suspected pustular flare of psoriasis with widespread erythema. (B) Desquamating plaques and patches. (C) Marginal necrosis of the operative wounds. (D) Intact deep fascia stitches visualized during debridement

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By the 11th postoperative day, the operative wounds remained nonhealing and showed signs of necrosis [Figure 6]C. Wound culture grew Acinetobacter baumannii sensitive to co-trimoxazole. Surgical debridement was carried out on the 14th day. During the procedure, the superficial slough was debrided and sent for culture; however, deep fascia stitches were intact and clean [Figure 6]D. Primary closure of the wounds was carried out. Cultures revealed extended-spectrum beta-lactamase (ESBL) Escherichia coli, which was sensitive to meropenem. With no progress in wound healing, stitches were once again removed after a week and a second debridement was carried out to freshen the edges [Figure 7]A. On the basis of the plastic surgeon’s advice, the wounds were not closed and long-term negative-pressure dressing was considered [Figure 7]B.
Figure 7: (A) Appearance of the wounds during the second debridement procedure. (B) Negative-pressure dressing

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The negative-pressure dressing induced a healthy granulation, which was noticed 5 weeks after initial surgery [Figure 8]A and enhanced wound contraction eventually [Figure 8]B. Subsequent wound swab results of cultures were negative, and the patient was under IV meropenem cover for 11 weeks. The negative-pressure dressing was continued throughout inpatient stay and also after discharge, at home, with a change in dressing every 3 days by a home nurse. Overall, the patient had the negative-pressure dressing for 5 months. Complete healing of the wound took 6 months [Figure 8]C and there was no recurrence of radicular or back pain throughout the follow-up period. The patient continues to be under our follow-up for the last 1 year and has consented for her case to be reported.
Figure 8: (A) Healthy granulation that was noticed 5 weeks after initial surgery. (B) Decrease in size of the wounds with negative-pressure dressing. (C) Completely healed wound

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  Discussion Top


Patients with psoriasis have an increased risk of infection because of their intrinsic immunologic disturbances and staphylococcus carriage in their plaques.[5] Wakkee et al.[6] reported an increased risk of infectious diseases leading to hospitalizations among patients with psoriasis as compared to control subjects, with respiratory tract, abdominal, and skin infections being the most frequent causes. Various authors have also reported a higher rate of infection after orthopedic surgeries in patients with psoriasis. This is often linked to delayed wound healing, which interferes with functional outcomes following surgery.

Saini and Shupack[7], from their survey among dermatologists, and orthopedic and plastic surgeons, reported that “with proper preoperative measures and dermatologic treatment, surgery can be performed on active psoriatic skin in most cases with minimal reservations.” Therefore, preoperatively, we ensured that the surgical skin site was optimal and free from psoriatic plaques. As per dermatologist opinion, methotrexate and leflunomide were continued over the perioperative period. Although in vitro and experimental animal studies suggest that methotrexate can adversely affect wound healing, many clinical studies suggest the opposite and advise low-dose perioperative methotrexate if indicated.[8] We followed this strategy in view of the higher risk of psoriatic flare that may occur with any interruption to systemic medications.[9]

Even so, our management was complicated by postoperative wound infection, and the wound was nonhealing even after repeated debridement procedures and an attempt to primary closure. However, prolonged negative-pressure dressing along with antibiotics effectively controlled and prevented the infection from spreading deeper. As described by various authors, it also induced a healthy granulation bed and enhanced wound contraction, leading to secondary healing of the wounds.[10]


  Conclusion Top


Operative site infections after spine surgery can be debilitating. Especially, postoperative infection in a patient with psoriasis can be difficult to manage and requires a multidisciplinary approach involving the surgeon, dermatologist, and the infectious disease physician. Perioperative continuation of systemic antipsoriatic medications, broad-spectrum postoperative antibiotic cover, and appropriate wound care is advised. For nonhealing wounds, early debridement, and if secondary suturing is not feasible, negative-pressure dressing can be considered, which can accelerate the healing process.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Huerta C, Rivero E, Rodríguez LA. Incidence and risk factors for psoriasis in the general population. Arch Dermatol 2007;143:1559-65.  Back to cited text no. 1
    
2.
Zeeuwen PL, de Jongh GJ, Rodijk-Olthuis D, Kamsteeg M, Verhoosel RM, van Rossum MM, et al. Genetically programmed differences in epidermal host defense between psoriasis and atopic dermatitis patients. PLoS One 2008;3:e2301.  Back to cited text no. 2
    
3.
Beyer CA, Hanssen AD, Lewallen DG, Pittelkow MR. Primary total knee arthroplasty in patients with psoriasis. J Bone Joint Surg Br 1991;73:258-9.  Back to cited text no. 3
    
4.
Stern SH, Insall JN, Windsor RE, Inglis AE, Dines DM. Total knee arthroplasty in patients with psoriasis. Clin Orthop Relat Res 1989;108-10; discussion 11.  Back to cited text no. 4
    
5.
Marples RR, Heaton CL, Kligman AM. Staphylococcus aureus in psoriasis. Arch Dermatol 1973;107:568-70.  Back to cited text no. 5
    
6.
Wakkee M, de Vries E, van den Haak P, Nijsten T. Increased risk of infectious disease requiring hospitalization among patients with psoriasis: A population-based cohort. J Am Acad Dermatol 2011;65:1135-44.  Back to cited text no. 6
    
7.
Saini R, Shupack JL. Psoriasis: To cut or not to cut, what say you? Dermatol Surg 2003;29:735-40.  Back to cited text no. 7
    
8.
Pountos I, Giannoudis PV. Effect of methotrexate on bone and wound healing. Expert Opin Drug Saf 2017;16:535-45.  Back to cited text no. 8
    
9.
Bakkour W, Purssell H, Chinoy H, Griffiths CE, Warren RB. The risk of post-operative complications in psoriasis and psoriatic arthritis patients on biologic therapy undergoing surgical procedures. J Eur Acad Dermatol Venereol 2016;30:86-91.  Back to cited text no. 9
    
10.
Jha RK, Xia C, Li Z, Wang W, Deng K. Combined negative pressure wound therapy with open bone graft for infected wounds with bone defects: An experimental study. Indian J Orthop 2017;51:318-23.  Back to cited text no. 10
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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