Pedicled omental flaps as an adjunct in the closure of complex spinal wounds

Locoregional Flap Closure for High-risk Multilevel Spine Surgery

Background:

Postoperative wound complications pose a challenge to patients undergoing complex spine surgery. Long-term sequelae can be devastating including decreased quality of life, meningitis, prolonged hospital stay, and need for reoperation. Among high-risk patients, postoperative wound complications have been shown to approach 40% in the literature. The aim of this study was to identify predictive factors for postoperative complications following soft-tissue reconstruction after high-risk spine surgery with the hypothesis that it would result in significantly fewer postoperative wound complications.

Methods:

A retrospective review of 67 consecutive spine operations at an academic, tertiary care center was performed, evaluating outcomes with a single plastic surgeon in conjunction with the spine surgery team. Data regarding patient demographics, perioperative risk variables, flap type, location of defect, and postoperative outcomes were obtained through retrospective chart review. Complications included soft-tissue complications and a number of reoperations. A bivariate analysis was used to identify predictors of postoperative complication. These data were compared to literature-reported averages.

Results:

A total of 67 consecutive spinal reconstructive operations were included with a mean follow-up of 11.8 months. Thirty-seven patients (55.2%) underwent immediate reconstruction at the time of the index operation, and 30 (44.8%) underwent delayed reconstruction for secondary wound healing problems following the index operation (in which plastic surgery was not involved). The majority of both immediate (95%, n = 35) and delayed (100%, n = 30) patients was defined as high risk based on literature standards. Patients in this series demonstrated a 7.5% complication rate, compared to 18.7% complication rate in the literature. We did not find a difference between major wound complications in the immediate (8.1%) or delayed (6.7%) reconstructive setting (P > 0.99). There were no specific variables identified that predicted postoperative complications.

Conclusion:

This study illustrates a postoperative complication rate of 7.5% among patients undergoing paraspinous or locoregional muscle flap closure by plastic surgery, which is significantly lower than that reported in contemporary literature for these high-risk patients.

Omental flap for treatment of spondylodiscitis with lumbosacral dehiscence: A case report

We report a case of pedicled omental flap use together with osteosynthesis treatment of a chronic L4-L5 spondylodiscitis due to a large sacral eschar. The 43-years-old patient was paraplegic and had depleted regional flaps solutions due to multiple previous surgeries. The procedure was carried out in supine position then in prone position whereby the dissected flap was recovered through the spine. The surgery was performed by a multidisciplinary team. First, we used an anterior approach for spine osteosynthesis with a metal implant and flap harvest. Then, in a prone position, we completed the vertebral reconstruction by an L3 athrodesis to the pelvis. The flap was recovered through the spine defect, on the side of the implant. It was a right sided pedicled. Complete wound healing was 120 days. The omental flap proved to be a reliable solution in the absence of recipient vessels for free flap transfer and depleted regional flap solutions. It also spared the latissimus dorsi muscle required for a wheelchair user as in our case. The omental flap is still performed in spine surgery especially in oncologic context to prevent wound dehiscence and for spondylodiscitis coverage. The anterior approach allows for both spine osteosynthesis and flap dissection.

Immediate Reconstruction of Complex Spinal Wounds Is Associated with Increased Hardware Retention and Fewer Wound-related Complications: A Systematic Review and Meta-analysis

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Background:

Patients undergoing surgeries involving extensive posterior spine instrumentation and fusion often have multiple risk factors for wound healing complications. We performed a systematic review and meta-analysis of the available evidence on immediate (proactive/prophylactic) and delayed (reactive) spinal wound reconstruction. We hypothesized that immediate soft-tissue reconstruction of extensive spinal wounds would be associated with fewer postoperative surgicalsite complications than delayed reconstruction.

Methods:

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a PubMed database search was performed to identify English-language, human-subject literature published between 2003 and 2018. Data were summarized, and the pooled prevalence of various wound complications was calculated, weighted by study size, using the generic inverse variance method. A subgroup analysis of all studies with a comparison group (Oxford Centre for Evidence-based Medicine level 3 or better) was performed, and Forest plots were created.

Results:

The database search yielded 16 articles including 828 patients; 428 (51.7%) received an immediate spinal wound reconstruction and 400 (48.3%) had a delayed reconstruction. Spinal neoplasm was the most common index diagnosis. Paraspinous muscle flap reconstruction was performed in the majority of cases. Pooled analysis of all studies revealed immediate reconstruction to be associated with decreased rates of overall wound complications (28.5% versus 18.8%), hardware loss (10.7% versus 1.8%), and wound infections (10.7% versus 7.6%) compared with delayed reconstruction.

Conclusions:

Immediate soft-tissue reconstruction of high-risk spinal wounds is associated with fewer wound healing complications and increased hardware retention.

Pedicled omental flaps in the treatment of complex spinal wounds after en bloc resection of spine tumors

STUDY DESIGN

The present paper presents a retrospective study of 5 patients who underwent pedicled omental flap procedure following spine tumor removal.

SUMMARY OF BACKGROUND DATA

Postoperative wound dehiscence represents a major complication in spinal surgery, particularly after en bloc tumor resection, because of the extended sacrifice of soft tissues and adjuvant radiation therapy and chemotherapy.

METHODS

Five patients, with a mean age of 52 years (range, 24-71 years), who underwent omental flaps for the treatment of postoperative complication in spine tumor resections were retrospectively evaluated.

RESULTS

Four of 5 patients underwent omental transposition after a mean of 15 months (range, 4-27) from the previous surgery because of dehiscence of the wound (all of them had cerebrospinal fluid leak: 1 transpleural and in 3 cases, associated with deep infection), whereas one patient underwent the omental flap procedure at the time of elective spinal surgery because of several contemporary risk factors for wound healing. At the time of discharge after a mean of 36 days (range, 23-53), all patients had well-healed surgical wounds with an acceptable structural and aesthetic result. One of the patients had ileus, requiring surgical lysis of abdominal adhesions 3 months after omentum flap procedure. No other complications were observed.

CONCLUSION

Our data suggest that pedicled omental flap is a viable option for the treatment of complicated spinal wounds, helping in the resolution of the infection and CSF leak.

Reconstruction of open wounds as a complication of spinal surgery with flaps: a systematic review

OBJECT

A systematic review of the available evidence on the prophylactic and therapeutic use of flaps for the coverage of complex spinal soft-tissue defects was performed to determine if the use of flaps reduces postoperative complications and improves patient outcomes.

METHODS

A PubMed database search was performed to identify English-language articles published between 1990 and 2014 that contained the following phrases to describe postoperative wounds (“wound,” “complex back wound,” “postoperative wound,” “spine surgery”) and intervention (“flap closure,” “flap coverage,” “soft tissue reconstruction,” “muscle flap”).

RESULTS

In total, 532 articles were reviewed with 17 articles meeting the inclusion criteria of this study. The risk factors from the pooled analysis of 262 patients for the development of postoperative complex back wounds that necessitated muscle flap coverage included the involvement of instrumentation (77.6%), a previous history of radiotherapy (33.2%), smoking (20.6%), and diabetes mellitus (17.2%). In patients with instrumentation, prophylactic coverage of the wound with a well-vascularized flap was shown to result in a lower incidence of wound complications. One study showed a statistically significant decrease in complications compared with patients where prophylactic coverage was not performed (20% vs 45%). The indications for flap coverage after onset of wound complications included hardware exposure, wound infection, dehiscence, seroma, and hematoma. Flap coverage was shown to decrease the number of surgical debridements needed and also salvage hardware, with the rate of hardware removal after flap coverage ranging from 0% to 41.9% in 4 studies.

CONCLUSIONS

Prophylactic coverage with flaps in high-risk patients undergoing spine surgery reduces complications, while therapeutic coverage following wound complications allows the salvage of hardware in the majority of patients.

Soft-tissue reconstruction after total en bloc sacrectomy

OBJECT

Total en bloc sacrectomy is a dramatic procedure that results in extensive sacral defects. The authors present a series of patients who underwent flap reconstruction after total sacrectomy, report clinical outcomes, and provide a treatment algorithm to guide surgical care of this unique patient population.

METHODS

After institutional review board approval, data were collected for all patients who underwent total sacrectomy between 2002 and 2012 at The Johns Hopkins Hospital. Variables included demographic data, medical history, tumor characteristics, surgical details, postoperative complications, and clinical outcomes. All subtotal sacrectomies were excluded.

RESULTS

Between 2002 and 2012, 9 patients underwent total sacrectomy with flap reconstruction. Diagnoses included chordoma (n = 5), osteoblastoma (n = 1), sarcoma (n = 2), and metastatic colon cancer (n = 1). Six patients received gluteus maximus (GM) flaps with a prosthetic rectal sling following a single-stage, posterior sacrectomy. Four required additional paraspinous muscle (PSM) or pedicled latissimus dorsi (LD) fasciocutaneous flaps. Three patients underwent multistage sacrectomy with an anterior-posterior approach, 2 of whom received pedicled vertical rectus abdominis myocutaneous (VRAM) flaps, and 1 of whom received local GM, LD, and PSM flaps. Flap complications included dehiscence (n = 4) and infection (n = 1). During the 1st year of follow-up, 2 of 9 patients (22%) were able to ambulate with an assistive device by the 1st postoperative month, and 6 of 9 (67%) were ambulatory with a walker by the 3rd postoperative month. By postoperative Month 12, 5 of 9 patients (56%)—or 5 of 5 patients not lost to follow-up (100%)—were able to able to ambulate independently.

CONCLUSIONS

The authors' experience suggests that the GM and pedicled VRAM flaps are reliable options for softtissue reconstruction of total sacrectomy defects. For posterior-only operations, GM flaps with or without a prosthetic rectal sling are generally used. For multistage operations including a laparotomy, the authors consider the pedicled VRAM flap to be the gold standard for simultaneous reconstruction of the pelvic diaphragm and obliteration of dead space.

Utility of the omentum in sacral reconstruction following total sacrectomy due to recurrent and irradiated giant cell tumour of the spine

Reconstruction of the lumbosacral region after surgical excision of irradiated and recurrent spinal giant cell tumours remains a challenging problem. In this case report, we describe the use of the pedicled omentum flap in reconstruction of an irradiated and infected wide sacral defect of a 19-year-old male patient. The patient had radiotherapy and subsequent wide surgical resection after recurrence of the tumour. A myocutaneous flap from the gluteal area had failed previously. Local flap options could not be used because of the recent radiotherapy to the gluteal area. Since the patient had a laparotomy for tumour resection and a colostomy, abdominal muscles were not considered reliable for reconstructive procedures. A pedicled omentum flap was chosen as a reconstructive option because of its rich blood supply, large surface area, and angiogenic capacity. This report aims to describe the use of the pedicled omentum flap for reconstruction of the lumbosacral area following surgical resection of a spinal tumour, when gluteal and abdominal flap options for reconstruction are jeopardised.

Treatment of a thoracic dural-pleural fistula with a vascularized omental flap: a case report

STUDY DESIGN

Case report.

OBJECTIVE

To report an unusual case of pseudomeningocele with dural-pleural fistula formation and spinal cord herniation after anterior thoracic decompression, as well as a unique surgical method for treating this complication.

SUMMARY OF BACKGROUND DATA

Thoracic pseudomeningocele with fistula formation is a rare but serious complication of spinal surgery. The negative pressure environment created in the pleural space can complicate management and result in dural-plural fistula formation. We report on the use of a vascularized omental flap to treat this complication after failure of more traditional techniques.

METHODS

A 76-year-old man presented with complaints of myeloradiculopathy, including weakness of lower extremities, with gait and bowel and bladder dysfunction after 2 previous decompressions at the T6-T7 level. Revision surgery was complicated by a dural-plural fistula and spinal cord herniation with neurological deterioration requiring reoperation.

RESULTS

Treatment with vascularized omental flap successfully treated the fistula, and the patient had resolution of all symptoms with the exception of some lower extremity neuropathic pain. Postoperative imaging showed excellent decompression of the spinal canal and a small, stable pseudomeningocele without evidence of cerebrospinal fluid hypotension or active dural-pleural fistula.

CONCLUSION

Treatment of thoracic psuedomeningoceles and fistulas can be difficult due to the unique negative intrathoracic pressure environment that complicates closure using traditional methods. Alternative treatment options may be necessary when more traditional techniques fail. Our report highlights one such option, a vascularized omental flap, which was used to successfully treat the patient.