Skip to main content

Advertisement

SpringerLink
Log in

Spine Reconstruction: From Basics to Cutting Edge

  • PLASTIC SURGERY (M HANASONO & E CHANG, SECTION EDITORS)
  • Published:
Current Surgery Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Plastic surgery reconstruction involving the spinal region may be necessary to fill dead space, buttress a durotomy repair to help prevent or treat a cerebrospinal fluid (CSF) leak, resurface the skin, and/or transfer vascularized bone to augment stabilization after vertebrectomy or sacrectomy. Reconstruction can be employed in the prophylactic setting—in patients at high-risk for wound healing complications – or in the therapeutic setting, to treat wound healing complications after they have occurred. In general, the goals of soft tissue reconstruction include coverage of vitals structures and spinal hardware, obliteration of dead space, and a layered water-tight closure; goals of bony reconstruction include providing a stable vertebral construct by increasing the rapidity and durability of the osseous union.

Recent Findings

Paraspinous muscle advancement flaps remain the workhorse for midline posterior trunks wounds. Multiple studies including a systematic review and meta-analysis have established that immediate spinal reconstruction decreases wound complications and increases hardware retention. This approach has been shown to be cost-effective and safe in those considered to be at high-risk for wound healing complications. Regarding osseous reconstruction, transferring vascularized bone is associated with a higher union rate and a shortened time to union in patients requiring vertebrectomy or sacrectomy for primary bony tumors.

Summary

Plastic surgery reconstruction remains an important adjunctive maneuver to optimize healing in high-risk spinal surgery patients. A multidisciplinary approach between the spinal surgery team and plastic surgery team is key for surgical planning and patient optimization. It is important to consider the utility of prophylactic spinal reconstruction in patients who are deemed high-risk for wound healing complications (previous spine surgery, previous radiation, obese, diabetes, malnutrition) in order to prevent complications before they occur. Once a postoperative wound healing complication has occurred following spinal surgery, spinal reconstruction can also be pursued with the goal of protecting spinal hardware and preventing impending exposure.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Chang DW, Friel MT, Youssef AA. Reconstructive strategies in soft tissue reconstruction after resection of spinal neoplasms. Spine. 2007;32(10):1101–6.

    Article  Google Scholar 

  2. Devulapalli C, et al. Soft-tissue reconstruction of large spinal defects: a 12-year institutional experience. Plast Reconstr Surg. 2017;140(4):806–14.

    Article  CAS  Google Scholar 

  3. Dumanian GA, et al. Muscle flap salvage of spine wounds with soft tissue defects or infection. Spine. 2003;28(11):1203–11.

    Article  Google Scholar 

  4. • Garvey PB, et al. Immediate soft-tissue reconstruction for complex defects of the spine following surgery for spinal neoplasms. Plast Reconstr Surg. 2010;125(5):1460–6. This article was one of the first to demonstrate an advantage to prophylactic muscle flap reconstruction of complex spinal wounds.

  5. Mericli AF, et al. Immediate reconstruction of complex spinal wounds is associated with increased hardware retention and fewer wound-related complications: a systematic review and meta-analysis. Plastic and Reconstructive Surgery-Global Open. 2019. https://doi.org/10.1097/GOX.0000000000002076.

    Article  Google Scholar 

  6. •• Mericli AF, et al. Immediate reconstruction of oncologic spinal wounds is cost-effective compared with conventional primary wound closure. Plast Reconstr Surg. 2019;144(5):1182–95. This article was the first to identify a cost savings associated with reconstructing high risk spinal wounds. This article established that not only was a preventative approach clinical effective, but it was also cost effective from a third-party payor perspective.

  7. Sawh-Martinez R, et al. Immediate plastic surgery closure at index spinal surgery minimizes complications compared to delayed reconstruction: A retrospective cohort review. J Plast Reconstr Aesthet Surg. 2020;73(8):1499–505.

    Article  Google Scholar 

  8. •• Saraph VJ, et al. Evaluation of spinal fusion using autologous anterior strut grafts and posterior instrumentation for thoracic/thoracolumbar kyphosis. Spine. 2005;30(14):1594–601. This article identified that there is a significantly higher complication rate associated with nonvascularized bone grafts placed in the spine longer than 4 cm in length.

  9. Clemens MW, et al. Composite extremity and trunk reconstruction with vascularized fibula flap in postoncologic bone defects: a 10-year experience. Plast Reconstr Surg. 2012;129(1):170–8.

    Article  CAS  Google Scholar 

  10. Houdek MT, et al. Outcomes and complications of reconstruction with use of free vascularized fibular graft for spinal and pelvic defects following resection of a malignant tumor. Journal of Bone and Joint Surgery-American. 2017. https://doi.org/10.2106/JBJS.16.01458.

    Article  Google Scholar 

  11. Moran SL, et al. The use of vascularized fibular grafts for the reconstruction of spinal and sacral defects. Microsurgery. 2009;29(5):393–400.

    Article  Google Scholar 

  12. Bradford DS, Daher YH. Vascularized Rib grafts for stabilization of kyphosis. Journal of Bone and Joint Surgery-British. 1986;68(3):357–61.

    CAS  Google Scholar 

  13. Bradford DS, et al. Anterior strut-grafting for the treatment of kyphosis - review of experience with 48 patients. Journal of Bone and Joint Surgery-American. 1982;64(5):680–90.

    Article  CAS  Google Scholar 

  14. Lonstein JE, Winter RB. Long multiple struts for severe kyphosis. Clin Orthop Relat Res. 2002;394:130–8.

    Article  Google Scholar 

  15. Mericli AF, et al. Paraspinous muscle flap reconstruction of complex midline back wounds risk factors and postreconstruction complications. Ann Plast Surg. 2010;65(2):219–24.

    Article  CAS  Google Scholar 

  16. Mericli AF, et al. Technical changes in paraspinous muscle flap surgery have increased salvage rates of infected spinal wounds. Eplasty. 2008;8: e50.

    Google Scholar 

  17. •• Mericli AF, et al. Reconstruction of complex posterior cervical spine wounds using the paraspinous muscle flap. Plast Reconstr Surg. 2011;128(1):148–53. This article established that paraspinous muscle flaps could be effectively utilized for posterior cervical spine wound reconstruction. Prior to this article, the trapezius flap was considered standard of care; the trapezius flap is notorious for a higher seroma rate.

  18. Disa JJ, Smith AW, Bilsky MH. Management of radiated reoperative wounds of the cervicothoracic spine: The role of the trapezius turnover flap. Ann Plast Surg. 2001;47(4):394–7.

    Article  CAS  Google Scholar 

  19. Sadigh PL, et al. The trapezius perforator flap: an underused but versatile option in the reconstruction of local and distant soft-tissue defects. Plast Reconstr Surg. 2014;134(3):449e–56e.

    Article  CAS  Google Scholar 

  20. Mcgeorge DD, Stilwell JH. The use of the reverse latissimus dorsi flap in the closure of lower spinal defects. Zeitschrift Fur Kinderchirurgie-Surgery in Infancy and Childhood. 1988;43:30–2.

    Google Scholar 

  21. O’Shaughnessy BA, et al. Pedicled omental flaps as an adjunct in the closure of complex spinal wounds. Spine. 2007;32(26):3074–80.

    Article  Google Scholar 

  22. Coon D, et al. Use of biological tissue matrix in postneurosurgical posterior trunk reconstruction is associated with higher wound complication rates. Plast Reconstr Surg. 2016;138(1):104e–10e.

    Article  CAS  Google Scholar 

  23. Moon SH, et al. Feasibility of a deepithelialized superior gluteal artery perforator propeller flap for various lumbosacral defects. Ann Plast Surg. 2015;74(5):589–93.

    Article  CAS  Google Scholar 

  24. Atkin G, Mathur P, Harrison R. Mesh repair of sacral hernia following sacrectomy. J R Soc Med. 2003;96(1):28–30.

    Article  CAS  Google Scholar 

  25. Hernekamp JF, et al. Perforator-based flaps for defect reconstruction of the posterior trunk. Ann Plast Surg. 2021;86(1):72–7.

    Article  CAS  Google Scholar 

  26. Pietro, GDIS., et al., Reconstruction of Spinal Soft Tissue Defects With Perforator Flaps From the Paraspinal Region. In Vivo, 2019. 33(3): p. 827–832.

  27. Falinower, H., et al., Use of the Propeller Lumbar Perforator Flap: A Series of 32 Cases. Plastic and Reconstructive Surgery-Global Open, 2020. 8(1).

  28. Asaad M, et al. Flap reconstruction for sacrectomy defects: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg. 2020;73(2):255–68.

    Article  Google Scholar 

  29. •• Akdeniz-Dogan Z, et al. Free flap reconstruction of posterior trunk soft-tissue defects: single-institution experience and systematic literature review. Plast Reconstr Surg. 2021;147(3):728–40. This is the largest series to date detailing free flap reconstruction of large posterior trunk wounds. The article includes a systematic literature review and meta-analysis as well as a single institution experience. It offers technical suggestions for the use vein grafts and also provides important information for postoperative care.

  30. • Mericli AF, et al. Free fibula flap for restoration of spinal stability after oncologic vertebrectomy is predictive of bony union. Plast Reconstr Surg. 2020;145(1):219–29. This article establishes that the free fibula flap is superior to bone allograft for vertebrectomy defect reconstruction.

  31. •• Mericli AF, et al. Restoration of spinopelvic continuity with the free fibula flap after limb-sparing oncologic resection is associated with a high union rate and superior functional outcomes. Plast Reconstr Surg. 2020;146(3):650–62. This article establishes that the free fibula flap is safe and effective for function reconstruction of hemipelvectomy and sacrectomy wounds.

  32. Randall RL, et al. Sacral resection and reconstruction for tumors and tumor-like conditions. Orthopedics. 2005;28(3):307–13.

    Article  Google Scholar 

  33. Tang XD, et al. Factors Associated With Spinopelvic Fixation Mechanical Failure After Total Sacrectomy. Spine. 2018;43(18):1268–74.

    Article  Google Scholar 

  34. Wellings EP, et al. Comparison of free vascularized fibular flaps and allograft fibular strut grafts to supplement spinopelvic reconstruction for sacral malianancies. Bone & Joint Journal. 2021;103-B(8):1414–20.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Plastic Surgery, M.D. Anderson Cancer Center, The University of Texas, 1400 Pressler Street, Unit 1488, Houston, TX, 77030, USA

    Ashleigh M. Francis & Alexander F. Mericli

Authors
  1. Ashleigh M. Francis
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Alexander F. Mericli
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Alexander F. Mericli.

Ethics declarations

Conflict of interest

Neither Dr. Mericli nor Dr. Francis have any relevant conflicts of interest in regard to the content of this review article.

Human and animal rights informed consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Plastic Surgery.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Francis, A.M., Mericli, A.F. Spine Reconstruction: From Basics to Cutting Edge. Curr Surg Rep 10, 255–264 (2022). https://doi.org/10.1007/s40137-022-00331-y

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40137-022-00331-y

Keywords

Search

Navigation