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C
omplex defects of the spine resulting from imum life expectancy of 3 to 6 months who do not
resection of spinal neoplasms present a chal- respond to nonoperative therapy for symptomatic
lenge. The spine is the most common site of vertebral metastases experience a significant im-
bony metastasis and the third most common site provement in quality of life with operative
of distant metastasis from solid tumors.1,2 Patients resection.3 Advances in radiologic diagnosis, sur-
with metastases to the vertebral column often ex- gical approaches to the entire vertebral column,
perience pain that is unrelenting and progressive, spinal instrumentation, adjuvant chemoradiation,
motor weakness, paralysis, or incontinence. Re- and anesthesia and perioperative critical care have
cent studies have shown that patients with a min- allowed extirpation of advanced primary and met-
astatic neoplasms of the spine, even in patients
who are elderly, have multiple comorbidities, are
From the Departments of Plastic Surgery, Neurosurgery, and immunosuppressed from disease or treatment, or
Biostatistics, The University of Texas M. D. Anderson Can-
are nutritionally deficient.
cer Center.
Received for publication July 29, 2009; accepted November As a result, an increased population of patients
12, 2009. with a diminished capacity for wound healing re-
Presented at the 2009 Annual Meeting of the Texas Society
of Plastic Surgeons, in Grapevine, Texas, September 25
through 27, 2009. Disclosure: None of the authors has a financial
Copyright 2010 by the American Society of Plastic Surgeons interest associated with this publication.
DOI: 10.1097/PRS.0b013e3181d5125e
1460 www.PRSJournal.com
Volume 125, Number 5 Immediate Reconstruction of the Spine
quires repair of extensive defects following aggres- last follow-up appointment. We defined major
sive extirpation of tumors.4,5 Studies have reported complications as those that required a return to
complication rates following resection of spinal me- the operating room for management.
tastases that range between 19 and 25 percent.2,3 In Statistical analysis of the collected data in-
particular, patients receiving radiation therapy have cluded the use of descriptive statistics such as
been shown to experience increased morbidity fol- mean (range) for continuous variables and fre-
lowing resection of spinal metastases. Breakdown of quency (percentage) for categorical variables.
wounds or infections at the surgical site that expose The Wilcoxon rank sum test was used to test the
instrumentation and/or vital neural structures can differences in age distribution and in body mass
have devastating effects on these patients.2 Such index distribution between the complication
wounds are difficult to treat, because the stabiliza- group and the noncomplication group. Fishers
tion devices typically cannot be removed without exact test was used to assess associations between
risking spinal injury and instability.6,7 Secondary re- pairs of categorical variables and between cate-
construction of complex spinal wounds that develop gorical variables and complications. All tests were
after primary closure typically requires complex two-sided, and values of p ! 0.05 were considered
strategies that use multiple flaps from local or distant statistically significant. We used SAS version 9.1.3
donor sites.5,714 (SAS Institute, Inc., Cary, N.C.) for the analyses.
We have shown in a previous study that de-
layed reconstruction for complex wounds of the
spine was associated with a higher complication
RESULTS
rate compared with immediate or prophylactic We found 52 consecutive spine tumor patients
reconstruction. Our previous findings led to a who underwent immediate reconstruction for
change in our practice to minimize the develop- complex wounds of the spine from May of 2004 to
ment of spinal wound complications.15 Since 2004, December of 2008. The mean age of the patients
we have developed an approach where patients was 55.4 years (range, 17 to 81 years). The mean
identified to be at high risk for wound complica- follow-up after surgery was 9.7 months (range, 0.7
tions are provided with immediate soft-tissue cov- to 55.3 months).
erage using well-vascularized muscle flaps at the Table 1 lists flap types used by defect location.
time of tumor extirpation and spinal stabilization. Paraspinous muscle-advancement flaps were the
The purpose of this study was to determine the most commonly used flaps at all spinal levels. Of
outcomes of immediate prophylactic muscle-flap 52 cases, 25 (48 percent) were reconstructed with
reconstruction for complex wounds of the spine. two or more muscle flaps.
Table 2 lists preoperative risk factors for post-
PATIENTS AND METHODS operative complications and the defect location.
We retrospectively reviewed the medical Thirty-four patients (65 percent) had wounds that
records of all patients who underwent immediate had previously been irradiated, and 27 patients
soft-tissue reconstruction for complex wounds of (52 percent) had received prior chemotherapy.
the spine at The University of Texas M. D. Ander- Overall, 17 patients (33 percent) had prior surgery
son Cancer Center between May of 2004 and De-
cember of 2008. The M. D. Anderson Cancer Cen- Table 1. Reconstructive Methods
ter Institutional Review Board approved our study
Flap Type No. of Patients (%)
protocol.
We collected information on patient demo- Cervical (n " 6)
Paraspinous 4 (67)
graphics (age and sex), the indication for recon- Paraspinous, trapezius 2 (33)
struction, location of the defect, reconstructive Thoracic (n " 37)
method, factors potentially associated with recon- Paraspinous 13 (35)
Trapezius 1 (3)
structive outcome (body mass index, cardiovascu- LD 1 (3)
lar disease, diabetes mellitus, active smoking, prior Paraspinous, trapezius 12 (32)
spine surgery, prior chemotherapy, radiation ther- Paraspinous, LD 3 (8)
Paraspinous, trapezius, LD 6 (16)
apy, presence of spinal instrumentation), postop- Trapezius, LD 1 (3)
erative complications (infection, dehiscence, total Lumbosacral (n " 9)
or partial flap loss, hematoma, seroma, cerebro- Paraspinous 6 (67)
Paraspinous, LD, gluteus maximus 1 (11)
spinal fluid leak, exposed instrumentation, Lumbar perforator 1 (11)
paraspinal hernia), need for revision surgery, post- Free rectus abdominis 1 (11)
operative follow-up time, and success of closure at LD, latissimus dorsi.
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Plastic and Reconstructive Surgery May 2010
to the spine. Prior surgery of the spine was more tation. The difference in age between the group
common among patients with cervical spine of patients who developed a wound dehiscence
wounds than among patients with thoracic or lum- and the group who did not was significant (p "
bar spine wounds (cervical, 83 percent; thoracic, 0.039), although only two of the 52 patients (4
22 percent; lumbar, 44 percent; p " 0.008). In- percent) had wound dehiscence. These two pa-
strumentation for spinal stabilization was placed tients were aged 69 and 81 years, compared with
in 85 percent of the wounds. The use of instru- a mean age of 55.4 years among all 52 patients.
mentation was more common in patients with cer- Except for age, we did not find statistically sig-
vical (83 percent) and thoracic (95 percent) spine nificant associations between preoperative co-
wounds than in patients with lumbar spine wounds morbid conditions and any of the five major
(44 percent; p " 0.002). postoperative complications (infection, dehis-
Postoperative complications (Table 3) in- cence, hematoma, seroma, and cerebrospinal
cluded seroma (25 percent), infection (15 per- fluid leak) or the need for a return to the op-
cent), cerebrospinal fluid leak (10 percent), erating room (Table 3). With the exception of
wound dehiscence (4 percent), and hematoma one patient who died postoperatively in the in-
(4 percent). Six patients (12 percent) required tensive care unit from exacerbation of conges-
a return visit to the operating room. None of the tive heart failure, all patients (98 percent) had
patients required removal of spinal instrumen- a closed wound at their last follow-up.
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Volume 125, Number 5 Immediate Reconstruction of the Spine
CODING PERSPECTIVE
This information prepared by Dr. Raymond
Janevicius is intended to provide coding guid-
ance.
15734 Muscle, myocutaneous, or
fasciocutaneous flap; trunk
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