Muscle Flap Closure following Complex Spine Surgery: A Decade of Experience

Racial and ethnic disparities in reception of muscle flap closure during oncologic spinal surgery

BACKGROUND

Racial disparities persist in surgical outcomes after spine surgery for primary and metastatic cancers. Muscle flap closure of spinal defects after oncologic resection has been shown to reduce wound complication rate with favorable cost-effectiveness. It is currently unknown whether racial disparities may affect the reception of this treatment.

METHODS

Spinal surgery procedures for tumor resection and subsequent reconstruction were identified in the 2011-2022 National Surgical Quality Improvement Program databases. Cases were propensity score matched for covariates like age, comorbidities, number of vertebral levels reconstructed, and length of stay to isolate the predictive impact of race on reception of muscle flap closure (p < 0.05).

RESULTS

A total of 9467 patients who underwent oncologic spine surgery and had known race and ethnicity were identified in the final cohort. Two hundred thirty-two (2.5%) cases included muscle flap closure during the index surgery. After matching (n = 4196), minority race/ethnicity was associated with lower rates of muscle flap closure (2.2%) than non-Hispanic White race/ethnicity (3.8%) (p = 0.0037). Upon weighted univariate logistic regression, minority racial and ethnic identification also predicted lower likelihood of muscle flap closure (OR: 0.57, 95% CI: 0.52-0.63, p < 0.001). Among patients who received muscle flap closure, the overall rate of all major or minor thirty-day postoperative complications was not different depending on race and ethnicity (p > 0.05).

CONCLUSION

There are evident racial disparities in the reception of muscle flap closure after oncologic spine surgery. Further work may investigate the role of intersecting socioeconomic factors like insurance status and hospital characteristics.

LAY SUMMARY

Muscle flap closure is a surgical technique within plastic surgery that has been associated with lower rates of complications after spine surgery to remove tumors. Our study shows that minority racial and ethnic groups are less likely on average to receive muscle flap closure.

Cranial stair-step incision for minimizing postoperative complications in neuro-oncologic surgery: A propensity score-matched analysis

PURPOSE

Craniotomies for tumor resection can at times result in wound complications which can be devastating in the treatment of neuro-oncological patients. A cranial stair-step technique was recently introduced as an approach to mitigate these complications, especially in this patient population who often exhibit additional risk factors including steroids, chemoradiation, and VEGF inhibitor treatments. This study evaluates our cranial stair-step approach by comparing its postoperative complications using propensity score matching with those of a standard craniotomy wound closure.

METHODS

A retrospective chart review was conducted on patients with intracranial neoplasms undergoing primary craniotomy at a single institution. Patients with prior craniotomies and less than three months of follow-up were excluded. Analyses were performed using R Studio.

RESULTS

383 patients were included in the study, 139 of whom underwent the stair-step technique while the rest underwent traditional craniotomy closures. The stair-step cohort was older, had higher ASA classes, and had a higher prevalence of coronary artery disease. The stair-step patients were administered fewer steroids before (40.29% vs. 56.56%, p < 0.01) and after surgery (87.05% vs. 94.26%, p = 0.02), fewer immunotherapy (12.95% vs. 20.90%, p = 0.05), but they received more radiation preoperatively (15.11% vs. 8.61%, p = 0.05). They also underwent fewer operations for recurrences and residuals (0.72% vs. 10.66%, p = 0.01). On propensity score matching, we found 111 matched pairs with no differences except follow-up duration (p < 0.01). The stair-step group had fewer soft tissue infections (0% vs. 3.60%, p = 0.04), fewer total wound complications (0% vs. 4.50%, p = 0.02), was operated on less for these complications (0% vs. 3.60%, p = 0.04), and had a shorter length of stay (6 vs. 9 days, p < 0.01). Notably, the average time to wound complication in our cohort was 44 days, well within our exclusion criteria and follow-up duration.

CONCLUSION

The cranial stair-step technique is safe and effective in reducing rates of wound complications and reoperation for neuro-oncologic patients requiring craniotomy.

Paraspinous Muscle Flaps in Complex Pediatric Spine Surgeries: A 12-Year Single Institution Experience

PURPOSE

The benefits of paraspinous flaps in adult complex spine surgery patients are established in the literature; however, their use in pediatric patients has not been well described. This study compares clinical outcomes with and without paraspinous muscle flap closure in pediatric patients who have undergone spine surgery.

METHODS

We conducted a retrospective review of all pediatric spine surgeries at the University of California, San Francisco from 2011 to 2022. Patients were divided into 2 cohorts based on whether the plastic surgery service closed or did not close the wound with paraspinous muscle flaps. We matched patients by age, American Society of Anesthesiology classification, prior spinal surgical history, and diagnosis. Surgical outcomes were compared between the 2 cohorts.

RESULTS

We identified 226 pediatric patients who underwent at least one spinal surgery, 14 of whom received paraspinous flap closure by plastic surgery. They were matched in a 1:4 ratio with controls (n = 56) that did not have plastic surgery closure. The most common indication for plastic surgery involvement was perceived complexity of disease by the spine surgeon with concern for inadequate healthy tissue coverage (78.6%), followed by infection (21.4%). Postoperative complications were similar between the two groups. The plastic surgery cohort had a higher rate of patients who were underweight (57.1% vs 14.3%, P < 0.01) and had positive preoperative wound cultures (28.6% vs 8.9%, P = 0.05), as well as a higher rate of postoperative antibiotic usage (78.6 vs 17.9%, P < 0.01). There was no difference in recorded postoperative outcomes.

CONCLUSIONS

Spine surgeons requested paraspinous flap closure for patients with more complex disease, preoperative infections, history of chemotherapy, or if they were underweight. Patients with paraspinous flap coverage did not have increased postoperative complications despite their elevated risk profile. Our findings suggest that paraspinous muscle flaps should be considered in high-risk pediatric patients who undergo spine surgery.

Plastic surgeon closure is comparable to orthopedic closure when a perioperative optimization protocol is instituted for pediatric patients with neuromuscular scoliosis

BACKGROUND CONTEXT

Since 2015, plastic multilayer closure (PMC) has been gaining attraction due to improved wound healing outcomes for medically complex patients. Plastic multilayer closure has been readily used for complex spine surgery closures in patients susceptible to wound healing issues (ie, dehiscence, surgical site infection [SSI]). However, PMC requires extensive soft tissue manipulation compared with standard orthopedic spine surgeon closure (SOC) and can result in extended operative times, increased transfusion rates, and more frequent returns to the operating room.

PURPOSE

From 2016 to 2019, our institution implemented a perioperative protocol designed to decrease postoperative complication rates in NMS patients. A retrospective cohort study was performed to determine if PMC imparted advantages over SOC above and beyond that from the perioperative protocol.

STUDY DESIGN/SETTING

Retrospective study at a single academic institution.

PATIENT SAMPLE

Eighty-one pediatric patients with neuromuscular scoliosis undergoing spinal fixation surgery.

OUTCOME MEASURES

Postoperative wound complications such as surgical site infection, hematoma, and superficial/deep dehiscence were the main outcome measures. Respiratory and neuromuscular complications along with duration of surgery were also recorded.

METHODS

A retrospective review was conducted of NMS patients undergoing spinal fixation at a single academic pediatric hospital over 4 years. Cases were labeled as SOC (n=41) or PMC (n=40) based on the closure technique applied. Reported 90-day complications were evaluated as the primary outcome.

RESULTS

Of the 81 reviewed patients, 45 reported complications, roughly equal between the study groups. While we found no statistically significant differences in rates of postoperative complications or SSIs, SOC cases were 30 minutes shorter on average with fewer returns to the operating room for additional surgery.

CONCLUSIONS

With the implementation of our perioperative protocol for NMS patients, PMC did not result in fewer complications than SOC but the surgeries did take longer.

Plastic multilayered closure versus orthopedic surgeon closure after spinal instrumentation in pediatric neuromuscular scoliosis

Objective

To compare wound complication rates between orthopedic closure (OC) and plastic multilayered closure (PMC) in patients undergoing primary posterior spinal fusion for neuromuscular scoliosis (NMS). We hypothesize that multilayered closure will be associated with better postoperative outcomes.

Methods

We collected data on pediatric patients diagnosed with NMS who underwent first time spinal instrumentation between 1 January 2018 and 31 May 2021. Patient demographics, length of surgery, spinal levels fused and operative variables, wound complication rate, treatments, and need for wound washout were reviewed in depth and recorded.

Results

In total, 86 patients were reviewed: 46 with OC and 40 with PMC. There was a significant increase in operating room (OR) time with PMC compared with OC (6.7±1.2 vs 7.3±1.3, p=0.016). There was no difference in complication rate, mean postoperative day of complication or unplanned return to the OR for OC and PMC, respectively. There was a slightly significant increase in the number of patients going home with a drain in the PMC cohort compared with the OC cohort (2.1% vs 15%, p=0.046).

Conclusions

PMC demonstrated longer OR times than OC and did not demonstrate a statistically significant reduction in wound complications or unplanned returns to the OR. However, other studies have demonstrated statistical and clinical significance with these variables. Surgical programs should review internal patient volumes and outcomes for spinal fusion in NMS patients and consider if PMC after spinal fusions in pediatric patients with NMS or other scoliosis subtypes is an appropriate option in their institution to minimize postoperative wound complications.

Comparison of Plastic Surgeon and Spine Surgeon Closure in Revision Short Segment Thoracolumbar Spinal Fusions

STUDY DESIGN

Retrospective cohort analysis.

OBJECTIVE

To compare outcomes of plastic versus spine surgeon wound closure in revision 1 to 4 level thoracolumbar fusions.

SUMMARY OF BACKGROUND DATA

Plastic surgeons perform layered musculocutaneous flap closures in high-risk spine patients such as revision posterior spinal fusion and complex deformity correction surgeries. Few studies have assessed outcomes of revision fusion performed with plastic surgical closures, particularly in nondeformity thoracolumbar spinal surgery.

METHODS

A retrospective review of 1 to 4 level revision thoracolumbar fusion performed by Orthopedic or Neurosurgical spine surgeons. Patient charts were reviewed for demographics and perioperative outcomes. Patients were divided into two cohorts: wound closures performed by spine surgeons and those closed by plastic surgeons. Outcomes were analyzed before and after propensity score match for prior levels fused, iliac fixation, and levels fused at index surgery. Significance was set at P < 0.05.

RESULTS

Three hundred fifty-seven (87.3%) spine surgeon (SS) and 52 (12.7%) plastic surgeon (PS) closures were identified. PS group had significantly higher number of levels fused at index (PS 2.7 ± 1.0 vs. SS 1.8 ± 0.9, P < 0.001) and at prior surgeries (PS 1.8 ± 1.2 vs. SS 1.0 ± 0.9, P < 0.001), and rate of iliac instrumentation (PS 17.3% vs. SS 2.8%, P < 0.001). Plastics closure was an independent risk factor for length of stay  > 5 days (odds ratio 2.3) and postoperative seroma formation (odds ratio 7.8). After propensity score match, PS had higher rates of seromas (PS 36.5% vs. SS 3.8%, P < 0.001). There were no differences between PS and SS groups in surgical outcomes, perioperative complication, surgical site infection, seroma requiring aspiration, or return to operating room at all time points until follow-up (P > 0.05 for all).

CONCLUSION

Plastic spinal closure for 1 to 4 level revision posterior thoracolumbar fusions had no advantage in reducing wound complications over spine surgeon closure but increased postoperative seroma formation.Level of Evidence: 4.