Use of the Vascularized Free Fibula Graft with an Arteriovenous Loop for Fusion of Cervical and Thoracic Spinal Defects in Previously Irradiated Pediatric Patients
ABSTRACT Extensive spinal neoplasms are difficult to manage. Following resection, arthrodesis of the spine can be performed with instrumentation, but this often fails in the setting of radiation therapy. Use of the free fibula flap for anterior spinal fusion to correct deformities has been described in multiple studies, but its use for posterior spinal fusion has been limited. In addition, its use in the pediatric population for this purpose has not been reported.
A retrospective review was performed of three pediatric cases of cervical and thoracic spine tumor resection with posterior fusion of the spine with a microvascular fibula flap over a 2-year period. Data recorded included patient demographics, medical/surgical history, indications for surgery, length of free fibula flap, recipient vessels, ischemic time, number of osteotomies performed on the fibula, complications, and time to computed tomography-documented fusion of the fibula to the remaining spinal column.
All three microvascular anastomoses were successfully performed using an arteriovenous loop of saphenous vein graft to the anterior neck or subscapular vessels. The average length of fibula harvested was 23.7 cm, the average length of ischemic time was 220 minutes, the number of osteotomies in all cases was two, and there was bony fusion at an average of 15.7 weeks postoperatively.
The free fibula flap is ideally suited for accelerated posterior spinal fusion after extensive resection of cervical or thoracic spinal neoplasms. An arteriovenous saphenous vein loop facilitates the microvascular anastomosis in this anatomical region that lacks suitable recipient vessels.
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ABSTRACT: When reconstructing combined defects of the cervical spine and the posterior pharyngeal wall the goals are bone stability along with continuity of the aerodigestive tract. We present a case of a patient with a cervical spine defect, including C1 to C3, associated with a posterior pharyngeal wall defect after excision of a chordoma and postoperative radiotherapy. The situation was successfully solved with a free fibula osteo-adipofascial flap. The reconstruction with a fibula osteo-adipofascial flap provided several benefits in comparison with a fibula osteo-cutaneous flap in our case, including an easier insetting of the soft tissue component at the pharyngeal level and less bulkiness of the flap allowing our patient to resume normal deglutition. © 2013 Wiley Periodicals, Inc. Microsurgery, 2013.Microsurgery 05/2014; 34(4). DOI:10.1002/micr.22217 · 2.42 Impact Factor
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ABSTRACT: Transfer of a vascularised free fibular bone for reconstruction of the cervical spine has been described previously.(1-4) However, this is the first report of a reconstruction with both an osteocutaneous fibular flap for anterior stabilisation and a double-islanded osteocutaneous fibular flap for posterior stability. We present a case of an osteoclastoma in C2 initially treated with radiotherapy 1.8 Gy × 30. Two months after radiotherapy, the patient developed severe osteoradionecrosis and luxation of C2 causing neurological impairment. The patient was treated with cervical traction for 10 days. Resection of C2 was performed through a posterior approach and a secondary transoral approach. The spine was stabilised from a posterior approach using allografts and a titanium plate and rod construct (Vertex) from the occipital squama to C5 and from an anterior approach with allograft filled cage from C1 to C3. Two months later, rupture of the pharyngeal wall was noted with exposure of the anterior cage. A few days later, the posterior scar ruptured. The anterior cage was removed and the pharyngeal wall was sutured. Revision of the posterior wound was performed, leaving the implants in place. To secure stability of the spine, the patient was treated with a HALO. Once again, the pharyngeal wall ruptured. Reconstruction of the posterior pharyngeal wall and the anterior column of the spine was performed with an osteocutaneous fibular flap from the skull base to C3. Five months later, a computed tomography (CT) scan showed insufficient bony fusion of both anterior and posterior bone grafts, and the posterior wound had not healed. A second osteocutaneous fibular flap was placed bilaterally from the occipital squama to the posterior elements of Th1, closing the wound defect. Apart from the occipital squama, fusion was seen at all sites after 14 months, and the HALO was removed.Journal of Plastic Reconstructive & Aesthetic Surgery 03/2012; 65(9):1262-4. DOI:10.1016/j.bjps.2012.02.014 · 1.47 Impact Factor
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ABSTRACT: Background: According to World Health Organization (WHO) classification of tumors, malignant peripheral nerve sheath tumors (MPNST) encompass the tumors, which were previously termed as malignant schwannoma, neurogenic sarcoma, and neurofibrosarcoma. These are rare tumors constituting only 5% of all malignant soft tissue tumors. As per their name, they arise from the malignant proliferation of cells forming sheath of a nerve root. They cause spinal cord compression, secondary changes in the surrounding bone with variable amount of tumor tissue going into the paraspinal space. However, purely intraosseous origin of the MPNST with no visible connection with a nerve root or dura is rare and few cases have been described in the literature. Case Description: We present a primary intraosseous MPNST arising from the body of a thoracic spine with a minimal intraspinal component. However, there was a huge tumor part occupying the paraspinal and retrospinal region. The latter component was so large that it extended to lie just beneath the skin. The intraspinal component was confined to only one level. The giant extraspinal part was spanning multiple corresponding spinal level. We could not find such presentation in the literature. Conclusion: Gross total removal (GTR) followed by adjuvant chemo-radiotherapy is the optimal treatment for MPNST of spine. In case of multiple laminectomy or gross spinal instability, spinal instrumentation makes the treatment protocol complete.Surgical Neurology International 12/2012; 3(1):157. DOI:10.4103/2152-7806.105096 · 1.18 Impact Factor