Complex cervical spine neoplastic disease: reconstruction after surgery by using a vascularized fibular strut graft. Case report

The Advent of Spinoplastics: Easing the Growing Global Disease Burden of Spinal Injury

Epidemiologic studies have demonstrated a growing global disease burden of pathologies affecting the vertebral column. Allograft or implant-based reconstruction and fusion surgeries have been the mainstay of treatment. The efficacy of various surgical methods and the reliability of instrumentation or implants to execute these surgeries continue to be debated in the literature. Advances such as the free-tissue transfer have improved postoperative measures; however, they add high operative risk. The advent of spinoplastics introduces a practical surgical model to augment these spinal surgeries using vascularized bone grafts. As this technique becomes more widespread, it can be utilized to ease the growing disease burden that spinal injury places on both patients and the health care system. Ultimately, it will ameliorate strains on health care resources, reduce health care costs, and improve patient outcomes and quality of life.

Application of vascularized fibular graft for reconstruction and stabilization of multilevel cervical tuberculosis: A case report

Multilevel cervical reconstruction and fusion after cervical tuberculosis has always been a challenge. The current implantation materials for cervical fusion, including titanium mesh, cage, and plate are limited by its inferior biological mechanical characteristics and the properties of the metallic material. This has led to the increased risk of recurrent infection after surgery. In addition, the unique nature of tuberculosis infection results in the low rate of cervical fusion and high risk of recurrence. This case report presents 1 patient who suffered from long segmental cervical tuberculosis and had reconstruction surgery using a vascularized fibula graft. The patient had successful graft incorporation 3 months postsurgery and was followed-up for 30 months. In this review, we detail the advantages of using vascularized fibular grafts and compare it with other types of grafts.

Vascularised fibula osteocutaneous flap for cervical spinal and posterior pharyngeal wall reconstruction

We report a case of vascularised fibula osteocutaneous flap used for composite cervical spinal and posterior pharyngeal wall reconstruction, in a patient with recurrent skull base chordoma, resected by an anterior approach via median labio-mandibular glossotomy approach. Bone stability and pharyngeal wall integrity were simultaneously restored.

Chordoma of the mobile spine: fifty years of experience

STUDY DESIGN

A consecutive series of 52 chordomas of the mobile spine observed over a 50-year period includes a retrospective review of 15 cases treated prior to 1991 and a prospective group of 37 cases treated from 1991 to 2002.

OBJECTIVES

This series reviews epidemiologic issues as well as clinical patterns of spinal chordomas. We attempt to correlate tumor extent, treatment, and outcomes over time.

SUMMARY OF BACKGROUND DATA

Chordoma is the most frequent primary tumor of the mobile spine. Due to slow growth, both initial symptoms and recurrences after treatment arise later, making it difficult to evaluate the effectiveness of treatment protocols.

METHODS

A prospective series of 37 cases is compared with a retrospective group of 15 patients observed between 1954 and 1991. In the prospective study, all patients had imaging studies, and oncologic and surgical staging. When en bloc resection was not feasible, intralesional extracapsular excision was combined with radiation therapy. The prospective patients were clinically evaluated and imaged. Patients in the retrospective group were evaluated by chart and available images; of these, only one en bloc resection (intralesional margin) was performed. Survivors were all evaluated clinically and had radiographic studies.

RESULTS

Forty-eight patients were available for long-term follow-up. Four died due to post-operative complications, and six due to disease less than 2 years after treatment. Forty-two patients were followed over 2 years; 26 patients had over 5 years follow-up. All patients having radiation alone, intralesional excision, or a combination had recurrences in less than 2 years, and died in some cases after a long survival with symptomatic disease. Intralesional extracapsular excision with radiation had a high rate of recurrence (12 of 16 at average 30 months), but 3 patients are continuously disease-free (CDF) at mean 52 months and 5 are alive with disease at average 69 months (ranging 24 to 146). Twelve of 18 patients having en bloc resection are CDF at average 8 years (48 to 155 months). The remaining 6 recurred and of these 1 died. All of these (6) had been previously treated and/or had en bloc resections with contaminated margins.

CONCLUSIONS

The only treatment protocol associated with CDF at follow-up longer than 5 years is margin-free en bloc resection.

Osteoradionecrosis of the cervical spine resulting from radiotherapy for primary head and neck malignancies: operative and nonoperative management

✓ Osteoradionecrosis is a process of dysvascular bone necrosis and fibrous replacement following exposure to high doses of radiation. The poorly vascularized necrotic tissue may cause pain and/or instability, and it cannot resist infection well, which may result in secondary osteomyelitis. When these processes affect the cervical spine, the resulting instability and neurological deficits can be devastating, and immediate reestablishment of spinal stability is paramount. Reconstruction of the cervical spine can be particularly challenging in this subgroup of patients in whom the spine is poorly vascularized after radical surgery, high-dose irradiation, and infection. The authors report three cases of cervical spine osteoradionecrosis following radiotherapy for primary head and neck malignancies. Two patients suffered secondary osteomyelitis, severe spinal deformity, and spinal cord compression. These patients underwent surgery in which a vascularized fibular graft and instrumentation were used to reconstruct the cervical spine; subsequently hyperbaric oxygen (HBO) therapy was instituted. Fusion occurred, spinal stability was restored, and neurological dysfunction resolved at the 2- and 4-year follow-up examinations, respectively. The third patient experienced pain and dysphagia but did not have osteomyelitis, spinal instability, or neurological deficits. He underwent HBO therapy alone, with improved symptoms and imaging findings. Hyperbaric oxygen is an essential part of treatment for osteoradionecrosis and may be sufficient by itself for uncomplicated cases, but surgery is required for patients with spinal instability, spinal cord compression, and/or infection. A vascularized fibular bone graft is a very helpful adjunct in these patients because it adds little morbidity and may increase the rate of spinal fusion.

Titanium Cage-assisted Polymethylmethacrylate Reconstruction for Cervical Spinal Metastasis: Technical Note

OBJECTIVE:

Reconstruction and stabilization of the cervical spine after vertebrectomy is an important goal in the surgical management of spinal metastasis. The authors describe their reconstruction technique using a titanium cage-Silastic tube construct injected with polymethylmethacrylate (PMMA) augmented by an anterior cervical plate. The surgical results using this technique are reviewed.

METHODS:

Six patients ranging from 43 to 70 years of age underwent resection of metastatic tumor in the cervical spine followed by cage-assisted PMMA reconstruction of the anterior spinal column. The following reconstruction technique was performed. A Silastic tube is incised longitudinally and placed circumferentially around a titanium cage with the opening facing anteriorly. The cage-Silastic tube construct is carefully tapped into the corpectomy defect and filled with PMMA. The final construct is then augmented with anterior cervical plate fixation.

RESULTS:

Two patients required additional posterior stabilization with lateral mass screws and rods. All patients achieved immediate stabilization, restoration of vertebral body height and normal lordosis, and preservation of the ability to walk independently. Five patients experienced significant palliation of biomechanical neck pain. There were no complications of neurological worsening, postoperative hematoma, wound infection, subsidence, graft dislodgement, or construct failure during a follow-up period of 1 to 19 months (mean, 6.8 mo).

CONCLUSION:

Titanium cage-assisted PMMA reconstruction augmented with an anterior cervical plate is an effective means of reconstruction after tumor resection in patients with cervical spinal metastasis. The Silastic tube holds the PMMA within the cage and protects the spinal cord from potential thermal injury.

Surgical management of cervical spinal metastasis: anterior reconstruction and stabilization techniques

Anterior cervical corpectomy followed by reconstruction and stabilization is an effective strategy in the management of spinal metastasis in some patients. Various techniques are available in the armamentarium of the spine tumor surgeon. In patients with a limited life expectancy,reconstruction with PMMA achieves immediate stability and thus obviates the need for an external orthosis and allows for early mobilization. The addition of anterior cervical plate fixation provides extra support to prevent distraction failure. In some cases, posterior stabilization may be necessary to achieve adequate stability.

Use of structural allografts in spinal osteomyelitis: a review of 47 cases

OBJECT

The use of structural allografts in spinal osteomyelitis remains controversial because of the perceived risk of persistent infection related to a devitalized graft and spinal hardware. The authors have identified 47 patients over the last 3.5 years who underwent a surgical decompression and stabilization procedure in which fresh-frozen allografts were used after aggressive removal of infected and devitalized tissue. The patients subsequently underwent 6 weeks of postoperative antibiotic therapy (12 months for those with tuberculosis [TB]).

METHODS

Follow-up data included results of serial clinical examinations, radiography, laboratory analysis (erythrocyte sedimentation rate and white blood cell count), and clinical outcome questionnaires. Of the original 47 patients (14 women and 33 men, aged 14-83 years), 39 were available for follow up. The average follow-up period at the time this article was submitted was 17 +/- 9 months (median 14 months, range 6-45 months). In the majority of cases (57%), a Staphylococcus species was the infectious organism. Predisposing risk factors included intravenous drug abuse (IVDA), previous surgery, diabetes, TB, and concurrent infections. During the follow-up period only two patients suffered recurrent infection at a contiguous level; both had a history of IVDA and one also had a chronic excoriating skin condition. No other recurrent infections have been identified, and no patient has required reoperation for persistent infection or allograft/hardware failure.

CONCLUSIONS

It is the authors' opinion that the use of structural allografts in combination with aggressive tissue debridement and adjuvant antibiotic therapy provide a safe and effective therapy in cases of spinal osteomyelitis requiring surgery.