Internal thoracic vessels used as pedicle graft for anastomosis with vascularized bone graft to reconstruct C7-T3 spinal defects: a new technique

Multipoint fixation with vascularised fibular bone graft and myotomy for atlanto-axial instability in cervical dystonia: a case report

Spinal instability is a challenging condition to manage in patients with cervical dystonia. Standard surgical stabilisation approaches may fail to cope with additional stress forces created by spasmodic muscles leading to construct failure either in the immediate or late post-operative period. Long-term stabilisation relies on the management of dystonic symptoms and adjunctive strategies to increase fusion success rate. We discuss the management of a challenging patient with translational C1/2 instability who had three metalwork failures with standard occipito-cervical fixation techniques within a 12 month period. A combined surgical approach using multipoint fixation, sternocleidomastoid myotomy and a vascularised fibular occiput-C2 bone graft successfully prevented further metalwork failure at over 2 years follow up.

Novel Surgical Treatment Strategies for Unstable Lumbar Osteodiscitis: A 3-Patient Case Series

BACKGROUND

Lumbar osteomyelitis frequently affects patients with medical comorbidities and poor preoperative health. Surgery is indicated when medical management fails or patients present with spinal instability or neural compromise. Successful arthrodesis can be difficult and sometimes requires alternative surgical techniques.

OBJECTIVE

To report 3 novel methods, each illustrated by a case, for achieving arthrodesis for lumbar osteomyelitis.

METHODS

A retrospective review was performed of 3 cases of surgical treatment of lumbar osteomyelitis. Novel aspects of the surgical techniques are reported, as are perioperative clinical details and imaging results.

RESULTS

In the first patient, a vascularized iliac crest graft on a quadratus lumborum pedicle was rotated into the posterolateral fusion bed of the affected level. In the second, an anterior approach with debridement of affected lumbar levels was followed by rotation of a vascularized iliac crest graft on an iliacus muscle pedicle into the anterior lumbar defect. In the third, a structural, nonvascularized iliac crest graft was harvested via a lateral approach to provide better surgical access, and an autologous tricortical bone graft was obtained for placement in the debridement defect. Follow-up imaging suggested successful early incorporation of all the grafts in the fusion beds.

CONCLUSION

Patients with multiple risk factors for pseudarthrosis and recurrent infection often require alternative surgical strategies to augment fusion. These 3 novel methods for lumbar debridement, fixation, and fusion using vascularized or nonvascularized autograft accommodate posterior, anterior, and lateral surgical approaches. Further experience with these techniques is required to compare outcomes with those of traditional techniques.

Osteocutaneous free transfer of vascularized fibula in cervico-thoracic spinal reconstruction with filling of an esophageal fistula: A case report

The case under review is a 60-year-old patient with a vertebral plasmocytoma treated by cervico-thoracic fusion 2 years previously. He presented a thoracic spinal septic non-union complicated by esophagospinal fistula. We performed vascularized fibula transplant with cutaneous pad to fill the esophageal fistula. Control CT at day 5 confirmed vascular anastomosis permeability and bone transplant position. Osseointegration was achieved at 18 months postoperatively. The patient was alive 3 years after the last procedure (5 years after tumorectomy). A systematic review of the literature on spinal reconstruction by vascularized fibula transplant showed the diversity of surgical techniques available. In view of the multiplicity of possible organ and soft tissue defects involving the spine, reminders are provided of the different approaches and recipient vessels in this type of reconstruction depending on location.

Selection of surgical treatment approaches for cervicothoracic spinal tuberculosis: A 10-year case review

Background

Cervicothoracic spinal tuberculosis is a rare disease. Due to its difficult and challenging surgical exposure, its surgical treatment approach remains inconclusive. Long-term follow-up studies to address this puzzling issue are rarely seen in the literature. The purpose of this study was to explore the selection of surgical treatment approaches for cervicothoracic spinal tuberculosis through a 10-year case review.

Methods

From January 2003 to January 2013, 45 patients suffering from cervicothoracic spinal tuberculosis were treated surgically. According to the relation between the tuberculosis lesion segments and the suprasternal notch on sagittal MRI, 19 patients were treated with a single-stage anterior debridement, fusion and instrumentation approach, and the other 26 patients were treated with a single-stage anterior debridement and fusion, posterior fusion and instrumentation approach. The clinical efficacy was evaluated using statistical analysis based on the Cobb angle of kyphosis, the Neck Disability Index (NDI) and the Japanese Orthopedic Association (JOA) scoring system. The neurofunctional recovery was assessed by the American Spinal Injury Association (ASIA) system.

Results

All patients were followed up for 6.6 years on average (range 3–13 years). No instrumentation loosening, migration or breakage was observed during the follow-up. The kyphosis angle and NDI and JOA scores were significantly changed from preoperative values of 34.7±6.8°, 39.6±4.6 and 10.7±2.8 to postoperative values of 10.2±2.4°, 11.4±3.6 and 17.6±2.4, respectively (p<0.05). Aside from one recurrent patient, bone fusion was achieved in the other 44 patients within 6 to 9 months (mean 7.2 months). No severe postoperative complications occurred, and patients’ neurologic function was improved in various degrees.

Conclusions

In the surgical treatment of cervicothoracic spinal tuberculosis, single-stage cervical anterior approach with or without partial manubriotomy is capable of complete debridement for tuberculosis lesions. The manner of fixation should be selected based on the anatomical relation of the suprasternal notch and the diseased segments as revealed on sagittal MRI images.

Subscapularis Transthoracic Versus Posterolateral Approaches in the Surgical Management of Upper Thoracic Tuberculosis: A Prospective, Randomized Controlled Study

The objective of the present study was to evaluate the clinical, radiological, and functional outcomes of a subscapularis transthoracic surgical approach and a posterolateral surgical approach with debridement, bone graft fusion, and internal fixation for the treatment of upper thoracic tuberculosis.There is currently debate over the best surgical approach for the treatment of upper thoracic tuberculosis. Traditionally, the subscapularis transthoracic approach has been preferred; however, the posterolateral approach has gained popularity in the past few years.A prospective, consecutive cohort of 43 upper thoracic tuberculosis patients with a mean age of 39 years (range: 20-52 years) was followed up for a minimum of 12 months (range: 12-60 months). Patients were randomly divided into 2 groups. Group A (n = 21) was treated by the subscapularis transthoracic approach and group B (n = 22) was treated by the posterolateral approach. All cases were evaluated for clinical, radiological, and functional outcomes. Intraoperative blood loss, operative duration, intraoperative and postoperative complications, hospital stay, the cure rate, fusion time, and the Frankel scale were used for clinical and functional evaluation, whereas the kyphosis angle was used for radiological evaluation.Grafted bones were fused by 10 months in all cases. There was no statistically significant difference between groups before surgery in terms of gender, age, segmental tuberculosis, erythrocyte sedimentation rate (ESR), Frankel scale, or Cobb's angle (P > 0.05). The average operative duration for Group B was lower than that of Group A. There were no significant differences in intraoperative blood loss, intraoperative and postoperative complications, hospital stay, grafted bone fusion time, or cure rate between groups (P > 0.05). The Cobb's angle correction rate for group B (68.5%) was significantly better than that of group A (30.9%). The neurological score showed significant postoperative improvement in both groups, with no significant difference between the groups.The subscapularis transthoracic approach and the posterolateral approach with debridement, bone graft fusion, and internal fixation are both sufficient and satisfactory for the surgical treatment of upper thoracic tuberculosis. However, the posterolateral approach is superior to the subscapularis transthoracic approach in terms of surgical trauma, operative time, and kyphosis correction.

Free Vascularized Fibular Strut Autografts to the Lumbar Spine in Complex Revision Surgery: A Report of Two Cases

This case report presents two patients who underwent fibular strut grafting for complex revisions of previous lumbar spine arthrodeses. A case review of the Electronic Medical Record at the index institution was performed to evaluate the timeline of events of the two patients who underwent fibular strut grafting for complex revisions of previous lumbar spine arthrodesis, including imaging studies, progress notes, and laboratory results. One patient had developed chronic L3 vertebral body osteomyelitis from a prior fibular allograft and instrumentation placed for a traumatic burst fracture. The second patient had a severe scoliosis recalcitrant to prior arthrodeses in the context of Marfan syndrome and a persistent L4-5 pseudarthrosis. Both patients underwent free vascularized fibular autograft revision arthrodeses. At most recent long-term follow-up, both patients had improved clinically and neither had required further revision. The use of free vascularized fibular grafting is an excellent option for a variety of spinal indications, and these two reports indicate that the technology may have an indication for use after multiple failed surgeries for osteomyelitis or correction of a multi-level large spinal deformity secondary to Marfan syndrome.

Spinal reconstruction with free vascularised bone grafts; approaches and selection of acceptor vessels

The use of free vascularised bone grafts is an infrequently performed surgical technique for the reconstruction of spinal defects. This field of surgery brings many challenges concerning the choice of free vascularised bone graft, planning of the operative procedure and selection of recipient vessels. This study aims to report our experience with free vascularised bone grafts, with special emphasis on the surgical approach and the selection of recipient vessels. Over a period of 17 years (1994-2011), we used these grafts for anterior spinal reconstruction in 30 patients. In 28 patients, a free vascularised fibular graft was used, and in two cases a free vascularised iliac crest graft was used. The spinal segments reconstructed involved the cervical or cervicothoracic spine (6 cases), the thoracic spine (11 cases) and the thoracolumbar and lumbosacral spine (13 cases). Revascularisation of the free vascularised bone graft proved to be technically feasible in 30 patients, but failed in one fibular graft due to difficulties with recipient vessels in the lumbar region. Technical challenges were met with respect to the choice of the recipient vessel at various anatomical sites. Availability of acceptor vessels was highly de-pendant of the type of surgery (resection or stabilisation) and the selected surgical approach. Based on these findings, a preferred approach is given for each region. The use of free vascularised bone grafts is a valuable technique for the reconstruction of complex spinal disorders. Successful execution requires microvascular expertise with respect to graft harvesting and appropriate choice of recipient vessels. Adequate preoperative planning in a multidisciplinary setting and adherence to the basic principles for spinal reconstruction are required.

Debridement and bone grafting with internal fixation via anterior approach for treatment of cervicothoracic tuberculosis

The objective of this study was to investigate the outcome of the patients with cervicothoracic tuberculosis who underwent radical debridement, reconstruction with bone autograft or allograft, and plate internal fixation via anterior approach. From June 2000 to December 2010, 20 patients with tuberculosis in cervicothoracic junction underwent a standard cervical approach, which was combined with a partial median osteotomy and transverse osteotomy through the synostosis between the manubrium and body of the sternum to expose the lesion adequately. Radical debridement was performed, then tricortical iliac crest bone autograft or allograft was placed and internal fixation was done to reconstruct the spinal column. The pathologic change regions were as follows: 10 in the C7-T1 segment, 6 in the T1 segment, 3 in the T1-T3 segment, and 1 in the T2-T3 segment. The classifications of Frankel were as follows: 2 at grade A, 4 at grade B, 7 at grade C, 2 at grade D, and 5 at grade E. There was no injury of blood vessel, spinal cord, or recurrent nerve during the surgery. The follow-up period ranged approximately 16 to 39 months. Bony fusion was obtained in all patients, and there was no internal fixation failure and tuberculosis recurrence in any of these patients. The nerve function of the spinal cord recovered at different degrees: 2 at grade A, 1 at grade B, 1 at grade C, 3 at grade D, and 13 at grade E. The anterior approach can provide direct and safe access to the lesion. The structural iliac crest autograft or allograft and anterior instrumentation could work effectively to stabilize the cervicothoracic junction.

Using segmental renal artery as recipient artery for spinal reconstructive surgery

STUDY DESIGN

Report of the use of one segmental artery from the left renal artery as inflow source for reconstructing a spine with recalcitrant osteomyelitis.

OBJECTIVE

To describe one difficult case of spinal osteomyelitis and our reconstruction procedure.

SUMMARY OF BACKGROUND DATA

The use of a vascularized fibular flap for spinal osteomyelitis has been reported previously, with vascular graft having a higher successful rate of bone union and overcoming poor perfusion beds. Because repeated spinal surgery may lead to severe scarring, the choice of recipient vessels may become a difficult issue.

METHODS

A 49-year-old man with T12-L1 vertebral osteomyelitis experienced progressive spinal cord involvement. Because previous multiple sessions of antibiotic treatment and surgery proved unsuccessful, a 2-stage surgery was planned. Posterior lateral fusion from T9 to L3 with MOSS Miami spine system (DePuy, Spine Inc, Raynham, MA) and allogenous bone graft were performed, followed by anterior debridement and reconstruction with free vascularized fibular graft 1 week later. End-to-side vascular anastomosis was performed between the peroneal artery and the upper anterior segment artery of the left renal artery.

RESULTS

After more than 50 months follow-up, the patient was able to walk smoothly without the aid of a brace, walker, or crutches. There were no complications, and the radiograph showed good bony union. Furthermore, renal function was normal.

CONCLUSION

The segmental renal artery can be selected as one of the recipient vessels in spinal reconstruction surgery without detrimental effect on renal function in our case. The use of vascularized fibular flap is preferable in cases of recalcitrant spinal osteomyelitis. Staged surgery in the presence of spinal infection can offer good spinal stability and good bony union with lower infection risk.