Shaving the surgical site before spinal surgery

AORN Journal,  Nov, 2007  by George Allen

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Spine July 2007

Neurosurgeons generally perform preoperative shaving of patients undergoing cranial or spinal surgery to clarify the surgeon's orientation, facilitate preoperative marking of the surgical site, and prevent infections. Shaving, however, has been shown to cause a change in or the loss of protective skin flora at the incision site as well as microtrauma of the affected area that can increase bacterial colonization, both of which are associated with increased risk of infection. A review of the literature indicated that the incidence of postoperative infection did not increase when the patient was not shaved and that the incidence of preoperative shaving and infection rates may be inversely correlated. Additionally, numerous studies have shown that a hairy incision line did not increase the postoperative infection rate in patients who underwent cranial surgery. No study, however, has evaluated the effects of preoperative shaving in patients undergoing spinal surgery. The purpose of this double-blind, prospective study was to determine the effect of shaving the incision site before spinal surgery on the incidence of postoperative infections.

Between January 2000 and September 2004, 789 patients having spinal surgery performed by the same surgeon at a hospital in Istanbul, Turkey, were randomly assigned to one of two groups: those whose surgical sites were shaved preoperatively (ie, the shaved group) and those whose surgical sites were not shaved (ie, the non-shaved group). Surgical procedures included lumbar disc surgery, surgery for lateral recess syndrome, and complex spinal procedures such as those for spinal stenosis, excision of a tumor, or placement of instrumentation. Patients were excluded if they had

* a suboptimal skin condition such as acne, a local sebaceous cyst, a furuncle, or a hairy nevus;

* a malignancy;

* a nutritional or immune deficiency;

* an allergy or hypersensitivity to antibiotics;

* surgery in the month before the study period; or

* treatment with antibiotics within seven days before the surgery.

After patients had been positioned and had received a general anesthetic, their skin was prepped, they were draped, and the incision was made. Patients in the shaved group were shaved with a razor after they were positioned and before the prepping and draping. All of the patients received antibiotic prophylaxis of 1 g IV cefazolin sodium and 80 mg gentamicin two hours before the incision and for 48 hours after the procedure. Infection was diagnosed when any of the following signs and symptoms developed:

* purulent discharge from the surgical site;

* increasing pain, tenderness, or redness around the incision site along with hematological test results showing a high polymorphonuclear lymphocyte count or an increasing erythrocyte sedimentation rate;

* clinical features of meningitis; or

* an abscess identified by imaging studies and the results of hematological tests.

Common statistical procedures, including means, standard error of the mean, and the Student t test, were used to analyze differences between the two groups.

FINDINGS. There were a total of 371 patients in the shaved group and 418 patients in the nonshaved group. The groups were not of equal size because of incomplete follow-up on 47 patients in the shaved group. There were significant differences in the incidence of complex spinal procedures such as those for spinal stenosis, excision of a tumor, or placement of instrumentation between the non-shaved group and the shaved group (30 versus 22, respectively; P = < .05) and in the mean duration of anesthesia (50.1 minutes [+ or -] 17.3 minutes versus 51.7 minutes [+ or -] 18.2 minutes, respectively; P > .05). The postoperative infection rate was significantly higher in the shaved group versus the non-shaved group (P = .01); postoperative infections developed in four patients in the shaved group (1.07%) and one patient in the non-shaved group (0.23%).

CLINICAL IMPLICATIONS, The results of this study revealed that not shaving the surgical site did not impede the performance of the surgical procedure and that shaving the incision site immediately before spinal surgery may increase the rate of postoperative infections. Perioperative nurses should understand that the results of this study strongly suggest that preoperative shaving before spinal surgery is unnecessary; however, more detailed prospective studies are needed to confirm these results. Consequently, perioperative nurses should be prepared to assist in such studies. Additionally, they should use clippers instead of razors when preoperative hair removal is deemed necessary, and they should ensure that antibiotic prophylaxis is administered between 30 and 60 minutes before the incision is made, depending on the antibiotic.

Celik SE, Kara A. Does shaving the incision site increase the infection rate after spinal surgery? Spine. 2007;32(15):1575-1577.

GEORGE ALLEN

PHD, RN, CNOR, CIC

DIRECTOR OF INFECTION CONTROL