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20 Radiation Therapy for Spinal Metastases
253
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Reconstructive Flap Coverage
Dmitry Zavlin and Michael J. Klebuc
21
Background
Flap reconstruction plays an important role in the
management of metastatic spine disease. Flaps
can be employed prophylactically to signicantly
decrease the rates of wound healing complications and instrumentation exposure associated
with metastatic tumor extirpation [1]. Their ability to obliterate dead space, enhance local perfusion, and facilitate collagen deposition apportions
ap reconstruction with a pivotal role along with
thorough debridement and antimicrobial therapy
in the management of complex postoperative
wounds. A regional approach based on location,
size, blood supply, and donor site morbidity can
be utilized to facilitate ap selection and enhance
the potential for successful wound healing [2, 3].
The spinal column is the most frequent site of
bony metastasis for solid tumors, and individuals
who fail to respond to nonoperative therapy often
experience progressive recalcitrant pain, weakness, pathologic fractures, and incontinence.
D. Zavlin, MD
Institute for Reconstructive Surgery, Houston
Methodist Hospital, Houston, TX, USA
e-mail: dzavlin@houstonmethodist.org
M. J. Klebuc, MD (*)
Institute for Reconstructive Surgery, Houston
Methodist Hospital, Weill Cornell Medical College,
Houston, TX, USA
e-mail: mklebuc@houstonmethodist.org
Surgical intervention has the potential to signicantly enhance quality of life in this patient population; however, major complications can be
encountered in up to 52% of individuals undergoing resection of spinal metastasis [4]. Tumor
extirpation is often extensive, producing complex
soft tissue defects and bony instability requiring
the use of internal xation. Patients are frequently
elderly with multiple comorbidities and have
often undergone previous radiation and chemotherapy causing various degrees of immunosuppression and malnutrition [5]. In many ways, this
creates a perfect storm for the development of
wound healing complications that can yield signicant consequences. Wound breakdown with
associated hardware exposure and infection creates a risk for meningitis and sepsis [6]. Treatment
frequently requires serial debridement, lengthy
intravenous antibiotic therapy, and prolonged
hospitalization and is associated with an increased
risk of readmission. If removal of instrumentation is necessary, then spinal instability with progressive loss of neurologic function is a
considerable risk [3, 7]. If the full health-related
quality of life benets stemming from the surgical treatment of spinal metastasis are to be realized, then uncomplicated wound healing is
paramount. In the presence of postoperative
wound healing complications, the plastic surgeon’s role in the multidisciplinary team becomes
even more pivotal if favorable outcomes are to be
realized [8].
© Springer International Publishing AG, part of Springer Nature 2018
R. A. W. Marco (ed.), Metastatic Spine Disease, https://doi.org/10.1007/978-3-319-76252-4_21
255
256
D. Zavlin and M. J. Klebuc
The provision of stable, well-vascularized soft
tissue coverage and prevention of wound healing
complications are the principal roles of plastic
and reconstructive surgery in the multidisciplinary management of the patient with metastatic spine disease. Flap coverage, timing of
surgical intervention, physiologic optimization,
and wound healing strategies are all employed to
this end.
Principles of Flap Coverage
Supercial wounds with limited contamination
can be successfully managed with local skin and
muscle-sparing fasciocutaneous aps. However,
these types of defects are rare in this patient population with most individuals demonstrating
deep, spatially complex wounds with associated
hardware often in the presence of bacterial colonization and/or infection.
In this type of hostile wound environment,
muscle and/or myocutaneous ap coverage have
proved superior outcomes to local skin and/or
fasciocutaneous aps for obtaining stable soft tissue coverage. Muscle aps are pliable, can effectively obliterating dead space, and can aid in
preventing seroma formation. They demonstrate
superior blood ow and improved wound oxygenation as compared to skin and fasciocutaneous ap. This enhanced perfusion accelerates
leukocyte activity and antibiotic delivery producing more rapid bacterial elimination while
enhancing collagen deposition [9]. The posterior
thorax possesses a series of muscles that can be
utilized for ap coverage (i.e., trapezius, latissimus dorsi, paraspinous, and gluteus). A regional
approach is employed in ap selection giving
careful consideration to the muscles arch of rotation, bulk, and the functional decit produced by
its utilization. In patients with previous radiation,
it is important that the muscle segment employed
in the reconstruction has not been subjected to
radiation and that the wound is covered with
well-vascularized, non-radiated tissue. The ap
pedicle should be outside the zone of injury, and
one must give careful consideration to old incisions and a history of previous spinal exposures
that may produce vascular pedicle injury. Deep
wounds will often require a two-ap reconstruction with one ap dedicated to obliteration of
dead space, while the other provides skin coverage. Fasciocutaneous aps often sufce for the
more supercial portion of the reconstruction.
However, it is critically important to provide
complete coverage of any spinal instrumentation
with well-vascularized soft tissue. If this goal has
been achieved, then the development of limited
regions of supercial wound separation can usually be managed with local wound care avoiding
return trips to the operating room as hardware
exposure becomes unlikely.
Surgical Timing and Risk Factors for Wound Complications
There are a series of preoperative risk factors that
are predictive for the development of complex,
postoperative spine wounds and infections. A
series of studies have identied the presence of
spinal instrumentation, previous spinal surgery,
spinal malignancy, preoperative radiation, and
chemotherapy along with advanced age as primary concerns. A multitude of comorbid factors
has also been acknowledged to have a detrimental
effect on wound healing including diabetes,
hypertension/coronary artery disease, chronic
obstructive pulmonary disease, morbid obesity,
paralysis, tobacco, and chronic steroid use [6, 10].
In this “high-risk” patient population, several
studies have demonstrated a signicant reduction
in postoperative wound healing complications
with the use of prophylactic muscle aps [1].
Garvey etal. reported on the use of “preemptive”
muscle ap coverage in 52 high- risk patients
undergoing immediate soft tissue reconstruction
following spinal neoplasm resection [11]. They
identied a 12% major complication rate that
compared favorably to the 38% complication rate
they had witnessed in an earlier study prior to
adopting prophylactic soft tissue reconstruction.
None of the patients required hardware removal,
and all went on to achieve a healed wound.
Similarly, Spector etal. describe their experience
with the use of prophylactic muscle aps in 96
21 Reconstructive Flap Coverage
patients [12]. There was a 0 and 6.8% rate of
wound healing complications in the increased risk
and high-risk group, respectively. This compared
favorably to historical controls where wound
healing complications are encountered in nearly
30% of patients. The value of prophylactic ap
coverage in high-risk patients is also demonstrated by Dumanian and associates who encountered no wound healing complications in patients
treated with immediate ap coverage verses a rate
of 26% in the delayed coverage group [13]. It is
apparent that immediate soft tissue reconstruction
at the time of tumor excision has the potential to
facilitate uncomplicated wound healing and has
become an integral part of our surgical approach
to the patient with metastatic spine disease.
Strategies for Delayed Management of Complex Spine Wounds
In addition to prophylactic soft tissue coverage,
muscle aps in particular can play a central role
in management of complex postoperative
wounds. Infection and hardware exposure frequently necessitate a return to the operating
room. The wound is explored, soft tissue is sent
for culture, and broad-spectrum empiric intravenous antibiotics are initiated. Meticulous debridement is then performed removing all devitalized
tissue. This is usually best performed as a collaborative effort between the plastic surgeon and
spine surgeon. Hydrosurgery systems, for example, Versajet (Smith & Nephew Plc, London,
UK), can be utilized to perform a precise, layered
removal of tissue, and pulse lavage with a
povidone- iodine is used to treat exposed hardware taking advantage of its detergent effect [14].
In the absence of a cerebrospinal uid leak, temporary wound coverage is achieved with either an
antibiotic bead pouch [15, 16] or negative pressure wound therapy. Antibiotic beads fashioned
from polymethylmethacrylate containing vancomycin, tobramycin, and/or voriconazole have the
potential to produce high local antimicrobial concentrations, up to 100 times MIC with limited
systemic absorption (Fig. 21.1). This can prove
valuable in reducing bacterial colonization and
257
Fig. 21.1 Antibiotic bead placement prior to denite
reconstruction
preparing the wound for closure [17]. Alternately,
negative pressure wound therapy (NPWT) can
provide an effective means of covering the wound
between debridements. NPWT removes excess
uid from the wound, reduces edema, and
enhances local blood ow stimulating formation
of granulation tissue [18].
Regional Approach to Flap Selection
Posterior spine wounds can be stratied into
zones in an effort to facilitate the ap selection
process, with the upper third ranging from C1 to
T7, the middle third spanning T7–L1, and the
lower third extending from L1 to S5. Flap choices
can also be categorized as primary, secondary,
and tertiary options based on the frequency of
their utilization. Table21.1 and Figs.21.2, 21.3,
and 21.4 provide a broad overview of reconstructive management options for spinal defects based
on their location.
Upper third defects (C1–T7) are most frequently managed with the trapezius ap [19].
The inferior portion of the muscle is perfused by
the descending branch of the transverse cervical
artery and can be used as a rotation, advancement, or turnover ap. During the standard, vertical ap elevation, the dissection is terminated at
the level of the scapular spine to maintain
muscular attachments that prevent shoulder
258
Table 21.1 Overview of ap techniques for various spinal defects
Spinal
region Primary options Secondary options Tertiary options
C1–T7 • Trapezius
• Latissimus dorsi
• Combined muscle ap with
fasciocutaneous advancement ap for
deep wounds
T7–L1 • Latissimus dorsi rotation-advancement
or v-y
• Reverse latissimus dorsi
• Paraspinous muscle ap
• Combined paraspinous and latissimus
dorsi muscle aps ± fasciocutaneous
advancement for deep wounds
L1–S5 • Reverse latissimus dorsi
• Paraspinous muscle ap (turnover or
bipedicle)
• Superior gluteal artery perforator
(SGAP) ap
• Parascapular fasciocutaneous ap
• Freestyle perforator aps, keystone
aps
• Intercostal neurovascular ap
• Freestyle perforator aps, keystone
aps
• Posterior thigh ap
• Lumbar artery perforator ap
• Composite latissimus dorsi and
segmental gluteus maximus
myocutaneous ap
• Segmental gluteus maximus
myocutaneous ap
• Freestyle perforator aps, keystone
aps
D. Zavlin and M. J. Klebuc
• Free aps
• Pedicled omental
ap
• Free aps ± A-V
loop
• Pedicled omental
ap
• Free aps ± A-V
loop
• Transabdominal
VRAM
Fig. 21.2 Delineation of muscular and musculocutane-
ous aps. Anterior trunk view
Fig. 21.3 Delineation of muscular and musculocutane-
ous aps. Posterior trunk view
21 Reconstructive Flap Coverage
Fig. 21.4 Delineation of fasciocutaneous aps. Posterior
trunk view
droop. The mobilized muscle segment will reliably reach the cervical spine and skull base; however, the muscle ap dissection can be extended
proximally to further enhance its reach. A skin
island can be incorporated into the ap design;
however, it should be situated directly over the
muscle with limited extension past its borders to
maximize reliability. The defects produced by
extirpation of metastatic spine defects are typically deep and spatially complex. The trapezius is
often utilized to obliterate dead space, while skin
coverage is achieved with a second ap (fasciocutaneous advancement aps, latissimus dorsi
myocutaneous ap, parascapular ap, freestyle
perforator ap) [3]. The latissimus dorsi rotationadvancement ap is another primary option in
259
proximal third defects with the humeral insertion
of the muscle frequently released to extend its
reach (Fig.21.5) [20].
Less spatially complex wounds can be managed with parascapular fasciocutaneous aps
designed around the circumex scapular artery
[21]. Additionally, there are clusters of cutaneous
perforators in the thoracic and lumbar region that
can be utilized inlocal ap design [22, 23]. In the
thoracic region, a high density of perforators is
present in a zone 10 cm from the midline and
0–15cm from C7. In the lumbar region, two clusters of perforators are situated within 10–20cm
of the coccyx and 10 cm from the midline. A
“freestyle” skin or fasciocutaneous ap can be
designed around one or more cutaneous perforators with the ap usually being oriented perpendicular to the midline to maximize perforasome
vascular connections. Similarly, these cutaneous
perforators can be incorporated into a modied
V-Y advancement or “keystone” ap to cover
more supercial defects in all three zones [24].
Free ap reconstruction can also be employed
in proximal third defects; however, they are considered tertiary options with the exception of free
bula bone aps [25, 26] that can be effectively
utilized to achieve bony union in a previously
radiated eld.
In middle third defects, the (reverse) latissimus
dorsi and paraspinous muscle aps are the most
frequently utilized (Figs. 21.6 and 21.7) [20, 27,
28]. The latissimus dorsi muscle/myocutaneous
ap provides a versatile treatment option in this
zone and can be employed as a muscular rotationadvancement ap or reversed turnover ap to manage dead space. Blood supply to the reverse
latissimus dorsi ap emanates from three large vascular pedicles branching off of the 9th, 10th, and
11th intercostal arteries that are situated approximately 5cm lateral to the midline. During ap elevation the thoracodorsal vessels are temporarily
occluded with bulldog clamps to verify adequate
retrograde perfusion prior to ligation. Incorporation
of a cutaneous island or mobilizing the ap as a
musculocutaneous V-Y advancement allows provision of well-vascularized cutaneous coverage. A
two-ap strategy is effective and frequently
employed in this zone. Paraspinous muscle aps
are utilized to obliterate dead space, and cutaneous
260
D. Zavlin and M. J. Klebuc
Fig. 21.5 Latissimus
dorsi ap. (a)
Radiograph of spinal
instrumentation
following excision of
cervical spine metastasis
and postoperative
radiation. (b) Complex
posterior, cervical
wound following
hardware revision. (c)
Surgical plan for
latissimus dorsi
myocutaneous ap. (d)
Initial ap inset. (e)
Three-month
postoperative follow-up
a
b
c
d e
de
21 Reconstructive Flap Coverage
261
a
b
c
Fig. 21.6 Reverse latissimus dorsi ap with paraspinous
ap. (a) Draining sinus tract after resection of metastatic
renal cell carcinoma to the spine and hardware stabilization. (b) Debridement and antibiotic bead placement for
treatment of methicillin-sensitive staphylococcus aureus
(MSSA) colonization. (c) Planning for muscle ap coverage. (d) Elevation of reverse latissimus dorsi muscle ap.
(e) Obliteration of dead space and complete hardware
coverage with left reverse latissimus dorsi muscle ap and
right paraspinous muscle ap
262
ab
c d
D. Zavlin and M. J. Klebuc
Fig. 21.7 Bilateral paraspinous ap (a) complex back
wound (middle third) following serial debridement. (b)
Mobilization of bilateral paraspinous muscle aps. (c)
coverage is provided with a latissimus dorsi myocutaneous ap. If adequate skin laxity is present in
this region, then either the latissimus dorsi muscle
ap or the paraspinous muscle ap can be utilized
to manage dead space and bilateral fasciocutaneous advancement aps can provide skin coverage.
Additional fasciocutaneous ap mobility can be
achieved by carrying the dissection past the musculocutaneous perforators. The fascia lateral to the
perforators is then incised vertically allowing
greater movement toward the midline.
Secondary ap options in this zone include
freestyle perforator [29] and keystone aps.
Intermittently, one will encounter a situation
where the primary ap options have been previously utilized “burned bridges” and the posterior
thoracic region demonstrates extensive scarring.
In this event, the intercostal neurovascular ap
has the ability to import well-vascularized, sensate tissue from an adjacent region and can pro-
Obliteration of dead space and full muscle coverage of
vertebrae. (d) Bilateral fasciocutaneous advancement
aps for skin coverage
vide an elegant solution to a complex problem
[30, 31]. The ap is designed around the 9th,
10th, or 11th posterior intercostal arteries, and
incorporation of the lateral cutaneous branch at
the midaxillary line permits inclusion of a sizeable skin island. Segmental resection of the
cephalic rib enhances the arch of rotation allowing the ap to reach the mid-thoracic region.
Although seldom employed the omental ap
remains an important salvage option and can
function well in individuals with large, complex
wounds where reconstructive options have been
limited by prior surgery [32, 33]. The omentum
has a large surface area (~25 × 30 cm) and a
dense lymphatic network providing immunologic
privilege and good functionality in previously
contaminated wounds. The ap can be designed
on either the right or left gastroepiploic arteries,
and its reach can be further enhanced by the
release of its internal vascular arcade. It can be