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Yang S, Morton Z, Colcord M, Jackson RS, Moore EJ, Thuener J, Bewley AF, Coughlin A, Khariwala SS, Richmon JD, Pipkorn P, Winters R, Militsakh ON, Zender CA, Wright J, Wax MK. Fibula Free Flap Reconstruction of Cervical Spine Defects: A Multi-Institutional Study. Laryngoscope 2024. [PMID: 38984420 DOI: 10.1002/lary.31625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/03/2024] [Accepted: 06/25/2024] [Indexed: 07/11/2024]
Abstract
INTRODUCTION Cervical spine defects result in spinal instability, putting the spinal cord and vertebral arteries at risk of damage and possibly devastating neurological injuries. The fibula free flap can span the spinal defects for stability. There is a paucity of literature on this technique. METHOD Multi-institutional retrospective case series reviewing patients who underwent cervical spine reconstruction with a fibula free flap. Patient demographic information, comorbidities, characteristics of cervical spine defects, and free flap complications were collected. RESULTS A total of 1187 fibula free flaps across 10 different institutions were reviewed. Thirteen patients (1.09%) underwent cervical spine reconstruction with a fibula free flap. Average age was 52.3 years old with an age range of 12-79 years. There were six males (46.1%) and seven females (53.8%). The most common defect etiology was infection (n = 6, 46.1%). Most commonly involved cervical spine level of the defect was C5 (n = 10) followed by C6 (n = 9) and C4 (n = 8). The majority of reconstructed defects spanned three or more cervical levels, (n = 9, 69.2%). Facial artery was the most common arterial anastomosis (n = 8). Eight patients (61.5%) required a tracheostomy during their postoperative course. None of the patients had symptomatic or radiographic nonunion. CONCLUSION This case series demonstrates that a vascularized fibula flap is a potential reconstructive option for cervical spine defects, especially in defects greater than three cervical levels, in the setting of infection, and previously radiated patients. LEVEL OF EVIDENCE Level 4 Laryngoscope, 2024.
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Affiliation(s)
- Sara Yang
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Zoey Morton
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Maddie Colcord
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Ryan S Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St. Louis, St Louis, Missouri, U.S.A
| | - Eric J Moore
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Jason Thuener
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals, Cleveland, Ohio, U.S.A
| | - Arnaud F Bewley
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, California, U.S.A
| | - Andrew Coughlin
- Department of Surgery, Creighton University School of Medicine, Nebraska Methodist Hospital, Omaha, Nebraska, U.S.A
| | - Samir S Khariwala
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, U.S.A
| | - Jeremy D Richmon
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, U.S.A
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St. Louis, St Louis, Missouri, U.S.A
| | - Ryan Winters
- Department of Otolaryngology-Head and Neck Surgery, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Oleg N Militsakh
- Department of Surgery, Creighton University School of Medicine, Nebraska Methodist Hospital, Omaha, Nebraska, U.S.A
| | - Chad A Zender
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, U.S.A
| | - James Wright
- Department of Neurosurgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Mark K Wax
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
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Sacco R, Fuxing X, Yiqiang L, Xu H, Canavese F. Uninstrumented fusion in cervical kyphosis due to neurofibromatosis type I: report of two paediatric cases. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:2846-2853. [PMID: 37993743 DOI: 10.1007/s00586-023-08039-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 09/09/2023] [Accepted: 11/01/2023] [Indexed: 11/24/2023]
Abstract
PURPOSE Severe cervical kyphosis (CK) in neurofibromatosis type 1 (NF-1) is associated with a high risk for progression and neurologic impairment in children. We present our surgical technique and mid-term outcomes of uninstrumented anterior tibial strut grafting for severe CK secondary to NF-1. METHODS Case report. The Consensus-based Clinical Case Reporting Guideline Development (CARE) guidelines were followed. RESULTS Two paediatric patients (8- and 3-year-old) presented with severe CK secondary to NF-1. A halo body jacket (HV) allowed the progressive distraction of the cervical spine, avoiding neurological compromise and deformity progression. Circumferential fusion was obtained with anterior tibial strut autograft and posterior onlay bone graft. Cervical spine fusion was successfully maintained at a minimum 4-year follow-up in both patients. CONCLUSION In children with severe CK secondary to NF-1, cervical distraction and immobilisation with a HV followed by uninstrumented anterior tibial strut grafting and posterior bone grafting, provided spinal fusion and stability without increasing the risk of neurological injury and donor site morbidity. The reported surgical technique appears to be a valuable tool in the armamentarium of the spinal surgeon.
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Affiliation(s)
- Riccardo Sacco
- Department of Orthopedic Surgery, CHU de Rouen, 76000, Rouen, France
| | - Xun Fuxing
- Department of Pediatric Orthopaedics, Guangzhou Women and Children's Medical Center, GuangZhou Medical University, Guangzhou, China
| | - Li Yiqiang
- Department of Pediatric Orthopaedics, Guangzhou Women and Children's Medical Center, GuangZhou Medical University, Guangzhou, China
| | - HongWen Xu
- Department of Pediatric Orthopaedics, Guangzhou Women and Children's Medical Center, GuangZhou Medical University, Guangzhou, China
| | - Federico Canavese
- Department of Pediatric Orthopaedic Surgery, Jeanne de Flandre Hospital, CHU de Lille, Rue Eugène Avinée, 59037, Lille Cedex, France.
- Department of Pediatric Orthopedic Surgery, University Hospital Estaing, 1 Place Lucie Et Raymond Aubrac, 63003, Clermont Ferrand, France.
- Faculty of Medicine, Nord-de-France Lille University, 59000, Lille, France.
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Pedicled Vascularized Clavicular Graft for Anterior Cervical Arthrodesis: Cadaveric Feasibility Study, Technique Description, and Case Report. Spine (Phila Pa 1976) 2017; 42:E1266-E1271. [PMID: 28296812 DOI: 10.1097/brs.0000000000002150] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cadaveric feasibility study. OBJECTIVE To assess the anatomic and technical feasibility of rotating a clavicular segment on a sternocleidomastoid muscle (SCM) pedicle into the ventral cervical spine using a cadaveric model and to provide the first clinical case description of performing this procedure. SUMMARY OF BACKGROUND DATA Reconstruction of the anterior cervical spine in patients with a high risk of pseudoarthrosis may require the use of a vascularized bone graft (VBG). A vascularized clavicular graft rotated on an SCM pedicle would afford all the benefits of a VBG without the added morbidity of free-tissue transfer; however, this technique has not been described. METHODS A multidisciplinary team hypothesized that it would be anatomically and technically feasible to rotate a pedicled clavicular bone graft from the bottom of C2 to the top of T2 via an anterior approach. Five cadavers underwent bilateral anterior neck dissections for a total of 10 clavicular graft assessments. A case report describes the use of a clavicular VBG in a patient with a 3-level corpectomy defect and a history of failed fusion. RESULTS Ten clavicles were rotated on an SCM pedicle. The grafts were either harvested as an entire segment or as the superior two-thirds of clavicle, leaving the inferior one-third in situ with pectoralis attachments intact. All grafts reached from the bottom of C2 to the top of T2. When the entire length of exposed clavicle was mobilized, it could cover five to six levels. The case report highlights technical challenges of this procedure in a living patient and provides the clinical context for its potential utility in the reconstruction of the ventral cervical spine. CONCLUSION This surgical technique is best suited for patients with long-segment cervical defects and an increased risk of pseudarthrosis. Further clinical experience with this technique is required before definitive conclusions can be made. LEVEL OF EVIDENCE 5.
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Powell DK, Jacobson AS, Kuflik PL, Persky MS, Silberzweig JE, Khorsandi AS. Fibular flap reconstruction of the cervical spine for repair of osteoradionecrosis. Spine J 2013; 13:e17-21. [PMID: 23932779 DOI: 10.1016/j.spinee.2013.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 04/06/2013] [Accepted: 06/01/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Although cervical spine reconstruction with osteocutaneous fibular flap microvascular grafting has been described, simultaneous reconstruction of the cervical vertebral column and laryngectomy have not been described. PURPOSE To present a unique case of combined cervical spine and laryngectomy reconstruction. STUDY DESIGN Case report. METHODS We modified a previously reported procedure reconstituting the cervical spine and pharynx with a single fibular flap in a case of posterior pharyngeal ulceration and osteomyelitis/osteoradionecrosis without spinal deformity. RESULTS We present a case of simultaneous cervical stabilization and pharynx reconstruction with a fibular graft in a life-saving treatment of osteoradionecrosis complicated by acute cervical kyphosis and spinal cord compression in a 55-year-old patient with extensive head and neck cancer history and recent recurrence of hypopharyngeal cancer. CONCLUSIONS Rigid anterior plate fixation and subsequent posterior fixation were required after corpectomy and total laryngectomy in our patient with extensive surgical scarring and radiation history because of severe spinal deformity secondary to osteoradionecrosis. We achieved successful preservation of neurologic function and resolution of pain.
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Affiliation(s)
- Daniel K Powell
- Radiology, Beth Israel Medical Center, First Ave. at 16th St., 2 Karpas, New York, NY 10003, USA.
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Use of the Vascularized Free Fibula Graft with an Arteriovenous Loop for Fusion of Cervical and Thoracic Spinal Defects in Previously Irradiated Pediatric Patients. Plast Reconstr Surg 2011; 127:1932-1938. [DOI: 10.1097/prs.0b013e31820cf4a6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Moche JA, Chopra K, Gastman B. Vascularized free fibula for cervical spine reconstruction following complicated retropharyngeal abscess. Otolaryngol Head Neck Surg 2011; 145:178-9. [PMID: 21493342 DOI: 10.1177/0194599811398193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jason A Moche
- University of Maryland School of Medicine, Baltimore, Maryland, USA
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Thankappan K, Duarah S, Trivedi NP, Panikar D, Kuriakose MA, Iyer S. Vascularised fibula osteocutaneous flap for cervical spinal and posterior pharyngeal wall reconstruction. Indian J Plast Surg 2010; 42:252-4. [PMID: 20368870 PMCID: PMC2845377 DOI: 10.4103/0970-0358.59294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a case of vascularised fibula osteocutaneous flap used for composite cervical spinal and posterior pharyngeal wall reconstruction, in a patient with recurrent skull base chordoma, resected by an anterior approach via median labio-mandibular glossotomy approach. Bone stability and pharyngeal wall integrity were simultaneously restored.
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Affiliation(s)
- Krishnakumar Thankappan
- Department of Head and Neck Surgery, Amrita Institute of Medical Sciences, Elamakkara, Kochi, India
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Papadimas D, Paraskeuopoulos T, Anagnostopoulou S. Cutaneous perforators of the peroneal artery: Cadaveric study with implications in the design of the osteocutaneous free fibular flap. Clin Anat 2009; 22:826-33. [DOI: 10.1002/ca.20847] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Moran SL, Bakri K, Mardini S, Shin AY, Bishop AT. The use of vascularized fibular grafts for the reconstruction of spinal and sacral defects. Microsurgery 2009; 29:393-400. [DOI: 10.1002/micr.20655] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Bourdais L, Hamel A, Hamel O, Pannier M, Duteille F. Intérêt d’un péroné vascularisé pour la reconstruction du rachis dans le cadre d’une neurofibromatose de type 1. ANN CHIR PLAST ESTH 2008; 53:293-7. [DOI: 10.1016/j.anplas.2007.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2007] [Accepted: 05/11/2007] [Indexed: 11/24/2022]
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Chapman TWL, Harris NM, Rachapalli V, Mahajan AL, Fitton AR. A novel use of vascularised free fibula graft as a bracket to stabilize severe cervico-thoracic kyphosis associated with neurofibromatosis type 1. EUROPEAN JOURNAL OF PLASTIC SURGERY 2007. [DOI: 10.1007/s00238-006-0075-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
The use of vascularized bone grafts in complex spine reconstruction is particularly attractive in situations that involve large segmental bone defects, failed previous attempts at arthrodesis, poor soft tissue beds secondary to infection or radiation exposure necrosis or failed arthrodesis in neuromuscular disease processes. This article details the indications and rationale for vascularized bone grafting as well as the results of vascularized bone grafting of the spine.
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Affiliation(s)
- Alexander Y Shin
- Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic, Clinic 200 1st Street SW, Rochester, MN 55905, USA.
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Erdmann D, Meade RA, Lins RE, McCann RL, Richardson WJ, Levin LS. Use of the Microvascular Free Fibula Transfer as a Salvage Reconstruction for Failed Anterior Spine Surgery due to Chronic Osteomyelitis. Plast Reconstr Surg 2006; 117:2438-45; discussion 2446-7. [PMID: 16772953 DOI: 10.1097/01.prs.0000219077.73229.af] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Several factors influence the osseous union of spinal fusions, including the substrate used for arthrodesis, the biology of the fusion bed, as well as local host factors. While cancellous bone grafting is useful in simple cases with no major bony defects, corticocancellous strut grafts are indicated in reconstructions requiring mechanical support. The size and location of the spinal defect to be reconstructed determine what type of vascularized bone graft is indicated. According to the literature, locations suitable for reconstruction using a microvascular free fibula graft include the cervical spine and, less frequently, the cervicothoracic, thoracic, thoracolumbar, and lumbar spine. Using the microvascular free vascularized fibula graft as a salvage procedure for failed anterior spine surgery due to bacterial spinal osteomyelitis has not been reported. METHODS AND RESULTS Four cases of spinal osteomyelitis after attempted spinal fusion are presented. In all cases, a microvascular free fibula graft was successfully used for secondary spinal fusion and clearance of documented bacterial osteomyelitis. The operative approach is described. CONCLUSIONS Use of the vascularized free fibula graft for correction of primary and secondary spinal deformities, as well as for reconstruction after excision of malignant spine tumors, has been well documented. On the basis of their experience, the authors also recommend microvascular fibula transplantation as a salvage procedure for failed anterior spine surgery due to chronic osteomyelitis.
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Affiliation(s)
- Detlev Erdmann
- Division of Plastic, Reconstructive, Maxillofacial, and Oral Surgery, Duke University Medical Center, Durham, NC 27710, USA.
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Ng RLH, Beahm E, Clayman GL, Hassenbusch SJ, Miller MJ. Simultaneous reconstruction of the posterior pharyngeal wall and cervical spine with a free vascularized fibula osteocutaneous flap. Plast Reconstr Surg 2002; 109:1361-5. [PMID: 11964992 DOI: 10.1097/00006534-200204010-00024] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Roy L H Ng
- Department of Plastic and Reconstructive Surgery, M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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Abstract
The treatment of severe structural kyphosis poses a difficult problem. The use of an anterior fusion has proven to be an integral part of the surgical treatment of any kyphosis. In addition, the use of multiple struts has helped solve the treatment problem in severe kyphosis. The use of multiple struts and the role of vascularized grafts, technical details, complications, and errors and how to prevent them are discussed in the current study.
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