Strategies to prevent post-operative surgical site infection in spinal surgery: a narrative review

Post-operative surgical site infections (SSIs) remain a major source of morbidity following spinal surgery, contributing to prolonged hospitalisations, re-operation, implant failure and increased healthcare costs. Despite advances in surgical technique and peri-operative care, SSI prevention in spine surgery remains challenging. To provide a narrative synthesis of contemporary evidence relating to the prevention of SSIs in spinal surgery across the pre-operative, intra-operative, and post-operative phases, with additional emphasis on emerging and translational technologies. A structured literature review of MEDLINE/PubMed (1990–2024) was performed. Systematic reviews, randomized controlled trials, high-quality cohort studies, and major international guideline statements were selectively included to synthesise current preventive strategies in spinal surgery. SSI prevention in spinal surgery requires a multimodal peri-operative strategy. Pre-operative optimisation includes smoking cessation, glycaemic control, nutritional assessment, anaemia correction, and targeted Staphylococcus aureus screening and decolonisation. Intra-operative measures supported by moderate-to-high-quality evidence include chlorhexidine–alcohol skin preparation, weight-adjusted antibiotic prophylaxis with appropriate re-dosing, dilute povidone–iodine irrigation, meticulous tissue handling, and intrawound vancomycin powder in selected high-risk posterior instrumented cases. Post-operative interventions such as extended occlusive dressings, silver-impregnated dressings, and prophylactic negative-pressure wound therapy may reduce SSI risk in high-risk populations. Prolonged post-operative antibiotic administration beyond 24 h has not demonstrated additional benefit and may increase antimicrobial resistance. Emerging technologies targeting biofilm formation and antimicrobial resistance represent promising future directions. Preventing SSIs in spinal surgery requires an integrated peri‑operative approach informed by evolving evidence. While several strategies are supported by consistent data, significant gaps remain, particularly regarding emerging technologies. Ongoing high‑quality clinical studies are needed to refine SSI prevention frameworks in spine surgery.