BACKGROUND CONTEXT:Increasing number of patients are undergoing surgical treatment for adult spinal deformity (ASD). The main indications are pain, disability and loss of function. Multiple patient- reported health related quality of life (HRQOL) measures are utilized to assess functional status and disability before and after the surgery. Some components of these questionnaires may be more pertinent in the elderly population. PURPOSE:Primary aim was to assess key functional outcomes were most relevant to elderly patients undergoing multilevel fusion surgery for ASD. Secondary aim was to assess if these functional improvements were maintained over the follow up period. STUDY DESIGN/SETTING:Post hoc analysis of prospectively collected data from multicenter observational study, where primary outcome was the absolute changes in the SRS-22r total and subtotal scores between baseline and 2-years FU. PATIENT SAMPLE:A total of 219 patients. OUTCOME MEASURES:Self-reported and functional measures were included. Function was assessed using the Scoliosis Research Society 22r (SRS-22r) function domain, and the personal care, walking, sitting and standing sections from the Oswestry disability index (ODI) and EuroQol- 5 Dimension (EQ-5D-3L scores). METHODS:Patients ≥60 years of age from 12 international centres undergoing spinal fusion of at least 5 levels were included. Follow up visits were performed at 10 weeks, 12 months, 24 months and 60 months. RESULTS:A total of 219 patients (80.4% females) were included with a mean age of 67.5 years. The mean SRS-22r function scores preoperative were 2.70 (CI: 2.60-2.80), which improved to 3.46 (CI: 3.36-3.56) by 2 years postsurgery and were maintained at 5 years (3.39, CI: 3.27-3.51). 44.9% patients were either bedbound or had primarily no activity before the surgery which reduced to 18.3 % at 2 years and 17.4% at 5 years follow up. Similarly, the percentage of patients that could stand >30 minutes improved from 24.5% to 68.6% at 2 years and 59.4% at 5 years. 26% of the patients could walk for a mile or more before surgery which improved to 63.1 % at 2 years and maintained in 58.7% patients at 5 years. 43.1 % had unlimited sitting preoperatively, that improved to 65.3% at 2 years and 64.7% at 5 years. Normal social life was seen in 19.2% of patients at baseline compared to 57.5% at 2 years and 52.7% at 5 years. CONCLUSIONS:Elderly patients undergoing multilevel spinal fusions for ASD experienced significant functional improvements, which were maintained at 5 years postoperatively. This practical information can be utilized during patient counselling preoperatively when considering functional outcomes after major ASD surgery in patients over 60 years of age.

Study DesignLiterature review with clinical recommendation.ObjectivesTo provide the readers with a concise curation of the relevant spine literature regarding patient-specific alignment planning in patients with adult spinal deformity (ASD) and set out recommendations for how the practicing clinician should interpret and make use of this evidence.MethodsKey articles on patient-specific alignment planning for ASD were reviewed to develop clinical recommendations by consensus. Recommendations are graded as strong or conditional, based on methodological quality and expert opinion.ResultsFour articles were selected by the AO Spine Knowledge Forum Deformity and each evaluated for the strength of methodology and scientific evidence.ConclusionsThe 4 reviewed publications illustrate the progression from descriptive to proportional and finally continuous alignment concepts in adult spinal deformity surgery. The Roussouly morphotypes help clinicians understand native sagittal shape and compensatory patterns, the SRS-Schwab classification remains useful for standardized description and communication, the GAP Score introduces pelvic-incidence-based proportionality, the T4-L1-Hip axis offers continuous, directly modifiable angular targets. Used together, these models offer complementary perspectives that enhance preoperative planning and postoperative evaluation. Integrating their strengths, while considering patient-specific factors such as bone quality, physiologic reserve, and surgical goals, supports more individualized and durable alignment strategies.

Background There are limited studies describing the feasible removal of broken pedicle screws. A surgical technique demonstrating the removal of broken sacral pedicle screws using commonly available instruments in a patient treated for high grade spondylolisthesis is illustrated in this report. Methods A 15-year-old female patient underwent uncomplicated revision spondylolisthesis correction at L5/S1 with revision decompression, implant removal including bilateral S1 broken screws and L4-pelvis instrumented fusion for pseudarthrosis and persistent L5 radiculopathy. The broken S1 screws were not removable with the standard broken screw removal kit. A groove was cut into the top of the retained shaft of the screw using a metal cutting wheel burr. An osteotome was then used to unscrew the remaining fragments of the retained S1 screws. Results The broken pedicle screws were successfully removed. Conclusions This technical note provides a useful tip for spine surgeons illustrating a method to remove broken pedicle screws with a wheel burr and osteotome. With the large volumes of spinal fusion revisions required and the great variability of different instrumentation systems utilized, innovative techniques with commonly available instruments may be required in removing implants.

Study Design: Systematic review and meta-analysis. Objective: To systematically evaluate early postoperative morbidity and mortality after elective spine surgery in patients aged 80 years or older, and to critically appraise the adequacy and limitations of the current evidence to inform surgical risk stratification and patient counseling in this high-risk population. Summary of Background Data: The population aged 80 years or older is rapidly increasing, accompanied by rising demand for surgical management of degenerative spinal disease. Reported morbidity and mortality outcomes after elective spine surgery in this group vary widely, limiting accurate risk estimation. Improved evidence synthesis is needed to inform counseling and guide surgical decision-making. Methods: A comprehensive search of MEDLINE, Embase, and CINAHL identified studies published between 1996 and 2024 reporting patients aged 80 years or older undergoing elective spine surgery. Data on survival, complications, and comorbidities were extracted. Methodological quality was assessed with the Newcastle-Ottawa Scale and the Joanna Briggs Institute checklist. Random-effects meta-analyses were performed where feasible. Results: Twelve studies encompassing 89,529 patients met the inclusion criteria. Pooled 30-day survival was high (98%, 95% CI: 94–99), though estimates varied across studies. Complications were frequent: the pooled overall rate was 16.0%, increasing to 21.8% unweighted. Major complications occurred in 5% to 10% of patients and minor complications in 8% to 10%. Studies enrolled relatively healthy older adults (ASA II–III), yet even in this select group, morbidity remained substantial. Reporting was inconsistent, with half of the studies providing major complication data and one-third reporting minor complications, underscoring gaps in the literature. Conclusion: Elective spine surgery in selected octogenarians shows excellent short-term survival but carries clinically meaningful complication rates. Current evidence largely reflects outcomes in the healthiest older adults, suggesting these results represent a best-case scenario. Despite increasing demand, high-quality, standardized data are lacking, limiting our ability to provide evidence-based counseling and prepare health systems for the growing burden of spine disease in an aging population.

Study DesignNarrative Literature Review.ObjectiveTo provide a comprehensive literature review of neurologic complications in Adult Spinal Deformity (ASD) surgery in the pre-operative, peri-operative and post-operative periods.MethodsA broad review of the literature was conducted using the multiple databases including Pubmed, Embase, Scopus and the Cochrane library. Individual studies of relevance were appraised and included at the discretion of the authors on the basis of pertinence, impact on practice and scientific merit.ResultsThe evidence regarding epidemiology, classification of complications, pre-operative evaluation of patients, peri-operative strategies to mitigate risk, intra-operative management of neuromonitoring changes and post-operative management of neurologic injury was critically appraised. Patients with the highest risk of neurologic complication include those with pre-surgery neuroaxis abnormality, high Deformity Angular Ratio, 3 column osteotomies and increased blood loss. Accurate and timely identification of intraoperative neuromonitoring changes is critical to ensuring appropriate response depending on whether changes are perfusion based (maintain adequate MAP and Hb, reverse corrective maneuvers) or traumatic (decompression of neural elements, assessment of instrumentation, reversal of corrective maneuvers, steroids). Surgical checklists can help surgeons navigate these stressful events to ensure appropriate steps and interventions are taken.ConclusionNeurological injuries occurring during the course of ASD surgery are potentially devastating complication, with regards to both patient morbidity and economic impact. Pre-operative identification of high risk patients, perioperative strategies to improve safety, timely recognition and management of intra-operative neuromonitoring changes and post-operative supportive measures can potentially reduce the incidence and significance of neurological injuries.

Study DesignNarrative literature review.ObjectivesTo summarize the evidence for perioperative blood conservation for patients undergoing surgery for adult spine deformity.MethodsA systematic literature review with narrative analysis was conducted to describe the evidence for blood conservation strategies before, during and after surgery for adult spine deformity. The evidence is critically analyzed and recommendation drawn.ResultsThe evidence for iron supplementation, autologous blood donation, screening for diatheses, the constitution of the surgical team, hypotensive anaesthesia, osteotomy, patient positioning, antifibrinolytics, transfusion thresholds, cell salvage, surgical technique, topical hemostasis, postoperative drainage, postoperative tranexamic acid and the management of thromboprophylaxis and anticoagulants is critically evaluated. The management of haemorrhage in surgery for adult spine deformity is complex and multifaceted, requiring the surgeon to consider tactics in conservation at every stage of the process. There is a paucity of evidence for many techniques, whilst hypotensive anaesthesia, tranexamic acid, surgical team members and surgical duration have the most significant effects on blood loss and transfusion requirements.ConclusionsThe astute surgeon must consider strategies to prevent excessive haemorrhage in the pre- intra- and postoperative phases of care. Although some commonly used techniques have robust evidence, others may be at best poorly evidenced, and at worst ineffective. Surgeons should consider the members of the operative team, minimizing surgical time, preoperative correction of anemia, hypotensive anesthesia and the use of intravenous and topical tranexamic acid at a minimum.

BACKGROUND CONTEXT: Cervical spine surgery is rapidly increasing, and our knowledge of the natural history of degenerative cervical myelopathy (DCM) is limited.PURPOSE: To synthesize accurate time-based estimates of meaningful neurologic decline in patients with DCM managed conservatively and to provide formulae to help communicate survi-vorship estimates to patients.STUDY DESIGN: Systematic review and meta-analysis.METHODS: A systematic review and meta-analysis was conducted using Cochrane and PRISMA guidelines. A librarian-assisted search strategy using multiple databases with broad search terms and validated filter functions was used. All articles were reviewed in duplicate.RESULTS: A total of 9570 studies were captured in the initial search, which after deletion of duplicates and manual review of abstracts and full texts revealed 6 studies for analyses. All studies were prospective cohorts or randomized controlled trials. The pooled survival estimates for neurologic stability (95% CrI) for mild DCM patients are: 91% (83%-97%) at one year; 85% (72%-94%) at 2 years; 84% (70%-94%) at 3 years; 75% (54%-90%) at 5 years; 66% (40%-86%) at 15 years; and 65% (39%-86%) at 20 years. The pooled survival estimates for neurologic stability (95% CrI) for moderate/severe DCM patients are: 83% (76%-89%) at 1 year; 72% (62%-81%) at 2 years; 71% (60%-80%) at 3 years; 55% (41%-68%) at 5 years; 44% (27%-59%) at 15 years; and 43% (25%-58%) at 20 years.CONCLUSIONS: This is the first quantitative synthesis of the totality of published data on DCM natural history. Our review confirms a slow decline in neurologic function. We developed formulae which can be easily used by surgeons to communicate to patients their risk of neurologic deterioration. These formulae can be used to facilitate the shared decision-making process. (c) 2023 Elsevier Inc. All rights reserved.

Study Design Multicenter, international prospective study. Objective This study investigated the clinical outcome up to 2 years after multi-level spinal deformity surgery in the elderly by reporting the minimal clinically important difference (MCID) of EuroQol 5-dimensions (EQ-5D), EQ-VAS, and residential status. Methods As an ancillary study of 219 patients ≥60 years with spinal deformity undergoing primary instrumented fusion surgery of ≥5 levels, this study focuses on EQ-5D (3-L) as the primary outcome and EQ-VAS and residential status as secondary outcomes. Data on EQ-5D were compared between pre-operatively and postoperatively at 10 weeks, 12 months, and 24 months. An anchor-based approach was used to calculate the MCID. Results The EQ-5D index and EQ-VAS, respectively, improved significantly at each time point compared to pre-operatively (from .53 (SD .21) and 55.6 (SD 23.0) pre-operatively to .64 (SD .18) and 65.8 (SD 18.7) at 10 weeks, .74 (SD .18) and 72.7 (SD 18.1) at 12 months, and .73 (SD .20) and 70.4 (SD 20.4) at 24 months). 217 (99.1%) patients lived at home pre-operatively, while 186 (88.6%), 184 (98.4%), and 172 (100%) did so at 10 weeks, 12 months, and 24 months, respectively. Our calculated MCID for the EQ-5D index at 1 year was .22 (95% CI .15-.29). Conclusions The EQ-5D index significantly increased at each time point over 24 months after ≥5 level spinal deformity surgery in elderly patients. The MCID of the EQ-5D-3 L was .22. Patients living at home pre-operatively can expect to be able to live at home 2 years postoperatively.

Study Design. Systematic review and meta-analysis. Objective. To determine a pooled incidence rate for deep surgical site infection (SSI) and compare available evidence for deep SSI management among instrumented spinal fusions. Summary of Background Data. Deep SSI is a common complication of instrumented spinal surgery associated with patient morbidity, poorer long-term outcomes, and higher health care costs. Materials and Methods. We systematically searched Medline and Embase and included studies with an adult patient population undergoing posterior instrumented spinal fusion of the thoracic, lumbar, or sacral spine, with a reported outcome of deep SSI. The primary outcome was the incidence of deep SSI. Secondary outcomes included persistent deep SSI after initial debridement, mean number of debridements, and microbiology. The subsequent meta-analysis combined outcomes for surgical site infection using a random-effects model and quantified heterogeneity using the χ2 test and the I 2 statistic. In addition, a qualitative analysis of management strategies was reported. Results. Of 9087 potentially eligible studies, we included 54 studies (37 comparative and 17 noncomparative). The pooled SSI incidence rate was 1.5% (95% CI, 1.1%–1.9%) based on 209,347 index procedures. Up to 25% of patients (95% CI, 16.8%–35.3%), had a persistent infection. These patients require an average of 1.4 (range: 0.8–1.9) additional debridements. Infecting organisms were commonly gram-positive, and among them, staphylococcus aureus was the most frequent (46%). Qualitative analysis suggests implant retention, especially for early deep SSI management. Evidence was limited for other management strategies. Conclusions. The pooled incidence rate of deep SSI post-thoracolumbar spinal surgery is 1.5%. The rate of recurrence and repeat debridement is at least 12%, up to 25%. Persistent infection is a significant risk, highlighting the need for standardized treatment protocols. Our review further demonstrates heterogeneity in management strategies. Large-scale prospective studies are needed to develop better evidence around deep SSI incidence and management in the instrumented thoracolumbar adult spinal fusion population.

Objectives: To determine the impact of dedicated orthopaedic trauma room (DOTR) implementation on operating room efficiency and finances. Design: Retrospective cost-analysis. Setting: Single midsized academic-affiliated community hospital in Toronto, Canada. Participants: All patients that underwent the most frequently performed orthopaedic trauma procedures (hip hemiarthroplasty, open reduction internal fixation of the ankle, femur, elbow and distal radius), over a 4-year period from 2016 to 2019 were included. Intervention: Patient data acquired for 2 years before the implementation of a DOTR was compared with data acquired for a 2-year period after its implementation, adjusting for the number of cases performed. Main Outcome Measurements: The primary outcome was surgical duration. The secondary outcome was financial impact, including after-hours costs incurred and opportunity cost of displaced elective surgeries. Results: One thousand nine hundred sixty orthopaedic cases were examined pre- and post-DOTR. All procedures had reduced total operative time post-DOTR (mean improvement of 33.4%). The number of daytime operating hours increased 21%, whereas after-hours decreased by 37.8%. Overtime staffing costs were reduced by $24,976 alongside increase in opportunity costs of $22,500. This resulted in a net profit of $2476. Conclusions: Our results support the premise that DOTRs improve operating room efficiency and can be cost efficient. Our study also specifically addresses the hesitation regarding potential loss of profit from elective surgeries. Widespread implementation can improve patient care while still remaining financially favorable. Level of Evidence: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

1) McMaster University, Division of Orthopedic Surgery, Department of Surgery, Hamilton General Hospital, Ontario, Canada 2) McMaster University, Department of Internal Medicine, Hamilton General Hospital, Ontario, Canada 3) Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland 4) Division of Orthopaedic Surgery, St. Michael’s Hospital, Ontario, Canada 5) Division of Orthopedic Surgery, Western University, Ontario, Canada 6) McMaster University, Department of Health Research Methods, Evidence and Impact, Ontario, Canada

Study Design.Systematic review and meta-analysis. Objective.To determine a pooled incidence rate for deep surgical site infection (SSI) and compare available evidence for deep SSI management among instrumented spinal fusions. Summary of Background Data.Deep SSI is a common complication of instrumented spinal surgery associated with patient morbidity, poorer long-term outcomes, and higher health care costs. Materials and Methods.We systematically searched Medline and Embase and included studies with an adult patient population undergoing posterior instrumented spinal fusion of the thoracic, lumbar, or sacral spine, with a reported outcome of deep SSI. The primary outcome was the incidence of deep SSI. Secondary outcomes included persistent deep SSI after initial debridement, mean number of debridements, and microbiology. The subsequent meta-analysis combined outcomes for surgical site infection using a random-effects model and quantified heterogeneity using the & chi;(2) test and the I-2 statistic. In addition, a qualitative analysis of management strategies was reported. Results.Of 9087 potentially eligible studies, we included 54 studies (37 comparative and 17 noncomparative). The pooled SSI incidence rate was 1.5% (95% CI, 1.1%-1.9%) based on 209,347 index procedures. Up to 25% of patients (95% CI, 16.8%-35.3%), had a persistent infection. These patients require an average of 1.4 (range: 0.8-1.9) additional debridements. Infecting organisms were commonly gram-positive, and among them, staphylococcus aureus was the most frequent (46%). Qualitative analysis suggests implant retention, especially for early deep SSI management. Evidence was limited for other management strategies. Conclusions.The pooled incidence rate of deep SSI post-thoracolumbar spinal surgery is 1.5%. The rate of recurrence and repeat debridement is at least 12%, up to 25%. Persistent infection is a significant risk, highlighting the need for standardized treatment protocols. Our review further demonstrates heterogeneity in management strategies. Large-scale prospective studies are needed to develop better evidence around deep SSI incidence and management in the instrumented thoracolumbar adult spinal fusion population.

Background: The benefit of surgical intervention over conservative treatment for degenerative lumbar spondylolisthesis (DLS) patients with neurologic symptoms is well-established. However, it is currently unclear what breadth of available evidence exists on regional and global sagittal alignment in DLS surgery. As such, the purpose of the current study is to conduct a scoping review to map and synthesize the DLS literature regarding the current radiographic assessment of sagittal spinal alignment in DLS surgery. Methods: A comprehensive search of the MEDLINE, EMBASE and Cochrane databases from January 1971 to January 2023 was performed for all DLS studies examining sagittal spinal alignment parameters with DLS surgery according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review (PRISMA-ScR) protocol. Results: From 2,222 studies, a total of 109 studies were included, representing 10,730 patients with an average age of 63.0 years old and average follow-up of 35.1 months postoperatively. Among included studies, 93 (85%), were largely published in the last decade and predominantly represented retrospective cohorts 70 (64%) or case series 22 (20%). A common theme among the reporting of radiographic parameters in the included investigations was the assessment of the magnitude and/or maintenance of a radiographic change postoperatively, with 92 (84%) studies reporting these findings. The majority of studies focused on index DLS level [33 (30%) studies] or lumbar spine radiographic imaging [33 (30%) studies] only. Thirty-seven (34%) studies reported spinopelvic parameters, with only 13 (12%) of included studies assessing 36-inch standing lateral radiographs and overall alignment. Conclusions: There is increasing prevalence of investigations assessing sagittal spinal alignment parameters in DLS surgery. Although, there is an increasing prevalence of studies investigating sagittal spinal alignment parameters in DLS surgery the quality of the currently available literature on this topic is of overall low evidence and largely retrospective in nature. Additionally, there is limited analysis of global sagittal spinal alignment in DLS suggesting that future investigational emphasis should prioritize longitudinally followed large prospective cohorts or multi-centre randomized controlled trials. Attempts at standardizing the radiographic and functional outcome reporting techniques across multi-centre investigations and prospective cohorts will allow for more robust, reproducible analyses of significance to be conducted on DLS patients.

# CPSS-1. Abstract ID 108. Radiographic reporting in adolescent idiopathic scoliosis: Is there a discrepancy between radiologists’ reports and surgeons’ assessments? {#article-title-2} Cobb angle measurement is a standard method for quantification of scoliosis in patients with adolescent

STUDY DESIGN:Systematic review. OBJECTIVES:Review the surgical techniques and construct options aimed at improving the biomechanical strength of cervical constructs. METHODS:A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search of the MEDLINE, Embase, and Cochrane Library databases was performed to identify all studies examining biomechanical strategies utilized in the osteoporotic cervical spine. Screening was performed in duplicate for all stages of the review process. RESULTS:An initial search returned 3887 articles. After deletion of duplications and review of abstracts and full text, 39 articles met inclusion criteria. Overall, the surgical techniques reviewed aimed at obtaining rigid fixation in the setting of poor bone quality, or dispersing the forces at the bone-implant interface. We identified 6 key techniques to improve biomechanical fixation. These include bicortical fixation, appropriate screw selection (size and trajectory), PMMA augmentation, load sharing techniques, consideration of ancillary fixation around the occipitocervical junction, and supplementing the construct with post-operative collar or halo. CONCLUSION:The summation of the literature highlights a framework of modalities available to surgeons to improve biomechanical fixation in the cervical spine. While these may improve construct strength in the setting of osteoporosis, there is a paucity of evidence available to make recommendations in this patient population.

Case: The global reach of coronavirus disease 2019 has led to the rollout of new generation messenger ribonucleic acid (mRNA) vaccines. As populations are vaccinated, some side effects will become more apparent. We present a case of unilateral lymphadenopathy resulting in a transient plexopathy presenting as neuralgic pain, paresthesia, and numbness in the hand. Conclusion: Multiple image modalities and electrodiagnostic studies were used to infer the diagnosis. This condition was expectantly managed, and the patient’s symptoms resolved within weeks.

Study Design Systematic Review Objectives To conduct a meta-analysis on the survivorship of commonly performed cervical spine procedures to develop survival function curves for (i) second surgery at any cervical level, and (ii) adjacent level surgery. Methods A systematic review of was conducted following PRISMA guidelines. Articles with cohorts of greater than 20 patients followed for a minimum of 36 months and with available survival data were included. Procedures included were anterior cervical discectomy and fusion (ACDF), cervical disc arthroplasty (ADR), laminoplasty (LAMP), and posterior laminectomy and fusion (PDIF). Reconstructed individual patient data were pooled across studies using parametric Bayesian survival meta-regression. Results Of 1829 initial titles, 16 citations were included for analysis. 73 811 patients were included in the second surgery analysis and 2858 patients in the adjacent level surgery analysis. We fit a Log normal accelerated failure time model to the second surgery data and a Gompertz proportional hazards model to the adjacent level surgery data. Relative to ACDF, the risk of second surgery was higher with ADR and PDIF with acceleration factors 1.73 (95% CrI: 1.04, 2.80) and 1.35 (95% CrI: 1.25, 1.46) respectively. Relative to ACDF, the risk of second surgery was lower with LAMP with deceleration factor .06 (95% CrI: .05, .07). ADR decreased the risk of adjacent level surgery with hazard ratio .43 (95% CrI: .33, .55). Conclusions In cases of clinical equipoise between fusion procedures, our analysis suggests superior survivorship with anterior procedures. For all procedures, laminoplasty demonstrated superior survivorship.

Primary sacral tumors are rare, representing fewer than 7

Background Deep surgical site infections after spinal instrumentation represent a significant source of patient morbidity and poorer outcomes. Given lack of evidence or guidelines on the variety of procedural options in the management of deep spine surgical site infections, the purpose of this survey was to document and investigate the use of these techniques across Canada. Methods A 34-question survey evaluating surgical techniques for irrigation and debridement in postoperative thoracolumbar infection was distributed to Canadian adult spine surgeons. Results were analyzed qualitatively, and comparisons by specialty, years of training, and number of cases were completed using Fischer’s exact tests. We defined consensus as >70% agreement. Results We received 53 responses (62% response rate) from a comprehensive sample of Canadian adult spine surgeons. There was a consensus to retain hardware (80%) and interbody implants (93%) in acute infection, to retain interbody implants in chronic/recurrent infection (71%), and application of topical antibiotics in recurrent infection (85%). There was consensus on the use of absorbable suture to close fascia in acute (83%) and chronic (87%) infection. Eighty-five percent of surgeons used nonabsorbable materials such as Nylon or staples for skin closure in chronic infection, however, there was no consensus in acute infection. Surgeons varied significantly in type, volume and pressure of fluids, adjuvant solvents, graft management, use of topical antibiotics acutely, and the use of negative pressure wound therapy. Partial hardware exchange was controversial. Additionally, specialty or surgeon experience had no impact on management strategy. Conclusions This survey demonstrates significant heterogeneity amongst Canadian adult spine surgeons regarding key steps in the surgical management of deep instrumented spine infection, concordant with scarce literature addressing these steps.