Paravertebral turnover flaps for closure of large spinal defects following tethered cord repair

Terminal myelocystocele: Surgical management

Background:

The authors describe clinical and imaging findings, surgical technique, and outcomes in myelocystocele.

Methods:

We describe a surgical procedure performed in six patients, four males and two females, with myelocystocele treated at our hospital. We review the images obtained at the time of diagnosis and after surgery. The patients’ age range was 12–56 months and had undergone surgery for terminal myelocystocele between 2015 and 2020. All patients had a large lumbar mass covered with healthy skin and presented spontaneous movements at birth. Two patients presented VACTERL syndrome.

Results:

A watertight closure of the soft tissues was performed in all cases. None of the patients presented postsurgical complications, such as cerebrospinal fluid leak or infection. All the patients had undergone excision of the meningocele sacs, the tethering bands were lysed, and the filum was detethered. The mean follow-up period was 34 (12–56) months. A motor deficit was seen in 2 patients (33.3%).

Conclusion:

Prenatal diagnosis and early corrective surgical intervention are recommended to prevent deterioration in neurological function. VACTERL association is a common condition and should be investigated.

Closure of a large lumbosacral myelomeningocele defect with a human pericardial graft: a case report

INTRODUCTION

Myelomeningocele (MMC) is a complex congenital defect resulting from incomplete closure of the neural tube. The aim of this study is to present an unusual technique for the closure of a large defect.

CASE REPORT

Here we report a patient that was prenatally diagnosed with MMC. At birth, a skin defect of approximately 5 x 7 cm was observed. To repair the defect, a Z-plasty was performed; however, necrosis of the flap developed 3 days after the surgery. The devitalized tissue was removed, and a human pericardial graft was used to cover the defect.

DISCUSSION

Different techniques have been described for the repair of MMC with a large skin defect, such as rotation skin flaps as well as synthetic and biological grafts. In our patient, a new technique without prior experience consisting of the application of human cadaveric pericardial graft was used with good results and no complications.

CONCLUSION

Closure of MMC is often a surgical challenge. Here we describe a surgical technique for the closure of large skin defects.

High Prevalence of Gram-Negative Rod and Multi-Organism Surgical Site Infections after Pediatric Complex Tethered Spinal Cord Surgery: Preliminary Report from a Single-Center Study

BACKGROUND

Surgical site infections (SSIs) are one of the most common complications following pediatric complex tethered spinal cord release. This patient population is similar in some ways to the neuromuscular scoliosis population, in which higher-than-expected rates of gram-negative SSIs have been identified.

METHODS

We conducted a single-center retrospective chart review of all patients who underwent complex tethered spinal cord release over a 10-year period between 2007 and 2017.

RESULTS

A total of 69 patients were identified, with 10 documented SSIs (14%). 50% of the SSIs were polymicrobial or included at least 1 gram-negative organism. Among the organisms isolated, 3 were fully or -partially resistant to cefazolin, the most common antibiotic prophylaxis in this population.

CONCLUSION

Among children undergoing complex tethered spinal cord release, gram-negative and polymicrobial infections are a significant cause of SSIs. Although further multicenter data are needed, these findings suggest that standard antibiotic prophylaxis with cefazolin may not be sufficient.

Development of best practices to minimize wound complications after complex tethered spinal cord surgery: a modified Delphi study

OBJECTIVEComplications after complex tethered spinal cord (cTSC) surgery include infections and cerebrospinal fluid (CSF) leaks. With little empirical evidence to guide management, there is variability in the interventions undertaken to limit complications. Expert-based best practices may improve the care of patients undergoing cTSC surgery. Here, authors conducted a study to identify consensus-driven best practices.METHODSThe Delphi method was employed to identify consensual best practices. A literature review regarding cTSC surgery together with a survey of current practices was distributed to 17 board-certified pediatric neurosurgeons. Thirty statements were then formulated and distributed to the group. Results of the second survey were discussed during an in-person meeting leading to further consensus, which was defined as ≥ 80% agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree).RESULTSSeventeen consensus-driven best practices were identified, with all participants willing to incorporate them into their practice. There were four preoperative interventions: (1, 2) asymptomatic AND symptomatic patients should be referred to urology preoperatively, (3, 4) routine preoperative urine cultures are not necessary for asymptomatic AND symptomatic patients. There were nine intraoperative interventions: (5) patients should receive perioperative cefazolin or an equivalent alternative in the event of allergy, (6) chlorhexidine-based skin preparation is the preferred regimen, (7) saline irrigation should be used intermittently throughout the case, (8) antibiotic-containing irrigation should be used following dural closure, (9) a nonlocking running suture technique should be used for dural closure, (10) dural graft overlay should be used when unable to obtain primary dural closure, (11) an expansile dural graft should be incorporated in cases of lipomyelomeningocele in which primary dural closure does not permit free flow of CSF, (12) paraxial muscles should be closed as a layer separate from the fascia, (13) routine placement of postoperative drains is not necessary. There were three postoperative interventions: (14) postoperative antibiotics are an option and, if given, should be discontinued within 24 hours; (15) patients should remain flat for at least 24 hours postoperatively; (16) routine use of abdominal binders or other compressive devices postoperatively is not necessary. One intervention was prioritized for additional study: (17) further study of additional gram-negative perioperative coverage is needed.CONCLUSIONSA modified Delphi technique was used to develop consensus-driven best practices for decreasing wound complications after cTSC surgery. Further study is required to determine if implementation of these practices will lead to reduced complications. Discussion through the course of this study resulted in the initiation of a multicenter study of gram-negative surgical site infections in cTSC surgery.

Offset layered closure reduces deep wound infection in early-onset scoliosis surgery

Deep wound infection is a common complication in early-onset scoliosis (EOS) surgery. Soft tissue technique has received less attention as a means to reduce infection. A retrospective review of 1170 EOS surgeries (single surgeon, institution) investigated the impact of offset layered closure (OLC) and soft tissue awareness. The introduction of OLC reduced deep infection from 3.0% in 99 surgeries to 0.37% in 1071. Logistic regression confirmed that OLC led to significantly lower odds of infection (P=0.007). This deep infection rate (0.37%) is more typical of elective surgery, providing a more optimistic view of infection in EOS surgery than generally reported.

Use of the bovine pericardial patch and fibrin sealant in meningomyelocele closure

BACKGROUND

Meningomyelocele is the most common and complex birth defect of the central nervous system. The operative principle of meningomyelocele repair consists of consecutive separate closures of the neural placode, dura mater, lumbar fascia, subcutaneous layer, and skin. While the neurosurgical techniques for the closure of the neural placode and dura mater have been well accepted, the most appropriate soft tissue closure technique has not yet been applied.

METHODS

This study reviews a case series of eight meningomyelocele patients treated with the bovine pericardial patch and fibrin sealant. Following the reconstruction of the neural placode and the closure of the dura mater, soft tissue coverage was achieved using the bovine pericardial patch and fibrin sealant.

RESULTS

In this series of eight patients, stable coverage was achieved with the application of a bovine pericardial patch and fibrin sealant technique. After the operations, none of the possible complications such as cerebrospinal fluid leak, seroma, hematoma, skin necrosis, deep or superficial infection, and wound breakdown was observed.

CONCLUSIONS

The usage of the bovine pericardial patch and fibrin sealant technique at the fascial level-between the dural sac and the skin-provides adequate soft tissue coverage in meningomyelocele repair surgery.

Outcomes of tethered cord repair with a layered soft tissue closure

BACKGROUND

Previous studies have demonstrated the benefit of releasing symptomatic tethered cords; however, complications such as seroma, cerebrospinal fluid leak, and infection continue to plague these patients. We propose that composite tissue closure of tethered cord repairs yields superior outcomes and that a collaborative effort between neurosurgery and plastic surgery may result in enhanced structural and functional results.

METHODS

This is a retrospective study comprised of consecutive patients with tethered cord syndrome by 2 neurosurgeons and 2 plastic surgeons between 1994 and 2008 at a single institution. All consecutive patients who underwent tethered cord release by neurosurgery and subsequent composite tissue closure with fascial and musculofascial flaps by plastic surgery were included. Data were collected by retrospective chart review and analyzed using parametric methods.

RESULTS

A total of 86 consecutive patients were included in this study, with follow-up ranged from 12 to 144 months (average follow-up, 29 months). There were no statistical differences in follow-up time, comorbidities, or surgeon when comparing hospital readmission or reoperation. There was no statistical difference in complications when comparing the different flap closures. We had a 1.2% infection rate, a 4.7% readmission rate, and a 3.5% reoperation rate.

CONCLUSION

We believe that local soft tissue rearrangement improves the closure by providing an additional layer of vascularized tissue between the skin and the spinal cord. We believe our series represents a significant sample size compared with those previously reported for an experience that achieves multilayered soft tissue closure after tethered cord repair. Our results support the idea that neurosurgeons should consider consultation of plastic surgeons when treating patients with tethered cord syndrome surgically.

Extradural myelomeningocele reconstruction using local turnover fascial flaps and midline linear skin closure

Myelomeningocele is the most common neural tube defect. Repair typically involves deep closure with regional muscle flaps (e.g. latissimus dorsi, gluteus maximus) and skin closure with rotation, bipedicle, or rhomboid flaps. We describe the reconstruction of large myelomeningocele defects using (1) local fascial turnover flaps with or without paraspinous muscle flaps for deep coverage of the dural repair followed by (2) linear, midline skin closure.

Local and regional flap closure in myelomeningocele repair: a 15-year review

PURPOSE

A trend in large myelomeningocele defect repair involves soft tissue closure with muscle and fascial flap techniques to provide a durable, protective, and tension-free soft tissue covering. We propose that composite tissue closure yields superior outcomes regardless of defect size.

METHODS

We present a retrospective review of our 15-year, single-institution experience using this approach. Our study includes 45 consecutive patients treated using combinations of muscle and fascia flaps for primary closure of a myelomeningocele defect.

RESULTS

Lumbosacral fascia closures were used in 18 cases (40%) with paraspinous muscle closure and 12 cases (27%) without paraspinous closure. Fascial closure with bony pedicle periosteum and gluteal muscle and fascial closure were used in four cases (9%) each. Other techniques included latissimus dorsi flaps and combinations of these techniques. Postoperatively, none of our patients experienced a cerebrospinal fluid leak, and only one patient required reoperation for skin flap necrosis.

CONCLUSIONS

Objective measures show that universal application of flap techniques may lead to better outcomes for soft tissue closure during myelomeningocele repair.