• Satoshi Ogihara, Shuhei Murase, Fumihiko Oguchi, and Kazuo Saita.
• Department of Orthopaedic Surgery, Spine Center, Sagamihara National Hospital, Minami-ku, Sagamihara City, Kanagawa, Japan.
• Medicine (Baltimore). 2020 Jun 26; 99 (26): e20892e20892.

IntroductionPatients with rheumatoid arthritis (RA) tend to be immunosuppressed due to RA itself and the therapeutic drugs administered. The management of surgical site infection (SSI) following upper cervical spinal instrumented fusion in RA patients is challenging; however, literature on the treatment for such conditions is scarce. We report 3 consecutive patients with RA, who developed deep SSI following upper cervical posterior fusion and were treated using antibiotic-loaded bone cement (ALBC).Patient ConcernsAll 3 patients reported in the current study experienced compression myelopathy with upper cervical spinal deformity and received prednisolone and methotrexate for controlling RA preoperatively. The patient in Case 1 underwent C1-2 posterior fusion and developed deep SSI due to methicillin-sensitive Staphylococcus aureus at 3 months postoperatively; the patient in Case 2 underwent occipito-C2 posterior fusion and developed deep SSI due to methicillin-sensitive Staphylococcus aureus at 2 weeks postoperatively; and the patient in Case 3 underwent occipito-C2 posterior instrumented fusion and laminoplasty at C3-7, and developed deep SSI due to methicillin-resistant coagulase negative staphylococci at 3 weeks postoperatively.DiagnosisAll patients developed deep staphylococcal SSI in the postoperative period.InterventionsAll 3 patients were treated using ALBC placed on and around the instrumentation to cover them and occupy the dead space after radical open debridement.OutcomesThe deep infection was resolved uneventfully after the single surgical intervention retaining spinal instrumentation. Good clinical outcomes of the initial surgery were maintained until the final follow-up without recurrence of SSI in all 3 cases.ConclusionALBC embedding spinal instrumentation procedure can be a viable treatment for curing SSI in complex cases, such as patients with RA who undergo high cervical fusion surgeries without implant removal.

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