Circumferential Reconstruction Research Articles

Single-stage posterolateral transpedicular approach for resection of epidural metastatic spine tumors involving the vertebral body with circumferential reconstruction: results in 140 patients. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004.

Patients with metastatic spine tumors often have multicolumn involvement and high-grade epidural compression, requiring circumferential decompression and instrumentation. Secondary medical and oncological issues add morbidity to combined approaches. The authors present their experience in using the single-stage posterolateral transpedicular approach (PTA) to decompress the spine circumferentially and to place instrumentation. From September 1997 to February 2004, 140 patients with spine metastases underwent the PTA. Magnetic resonance imaging revealed high-grade spinal cord compression in 120 patients (86%) and lytic vertebral body destruction in all patients. Preoperatively 84 patients (60%) received radiotherapy directed to the involved level and 42 (30%) underwent tumor embolization. Following circumferential decompression, all patients underwent anterior reconstruction with polymethylmethacrylate and Steinmann pins, and posterior segmental fixation. The median operative time was 5.1 hours, the median blood loss was 1500 ml, and the median hospital stay was 9 days. Ninety-six percent of the patients experienced postoperative pain improvement and improvement in or stabilization of neurological status. In 51 nonambulatory patients with poor Eastern Cooperative Oncology Group grades, 75% regained the ability to walk. One month postoperatively 90% of patients achieved good-to-excellent performance scores. The overall median patient survival time was 7.7 months. Patients with colon and lung carcinomas had significantly shorter survival times. Major operative complications occurred in 20 patients (14.3%). Wound complications occurred in 16 patients (11.4%), but this was not correlated with preoperative radiation treatment. The PTA allows circumferential epidural tumor decompression and the placement of anterior and posterior spinal column instrumention. Immediate spinal stability is achieved without the use of brace therapy. This technique achieved a high success rate for pain palliation, neurological preservation, and functional improvement, while avoiding the morbidity associated with combined approaches.

4:04 Circumferential reconstruction of the cervical spine

Purpose of study: A significant number of adults have pain, cosmetic deformity or neurologic injury related to cervical malalignment. The majority of such cases involve sagittal plane malalignment with loss of lordosis, kyphosis or double curve (swan-neck) deformity of the subaxial spine. A smaller number of patients have coronal plane malalignment or scoliosis in the subaxial spine or various anomalies of the occipitoatlantoaxial complex. In the following, we describe 50 cases within the past 5 years in which circumferential approaches have been applied for the correction of cervical deformities.Methods used: At our institution, more than 50 cases of multisegmental cervical or occipitocervical deformity corrections have been performed since 1995. Thirty cases have at least 24 months of follow-up. Causative pathologies include rheumatoid arthritis, congenital dysplasias, late posttraumatic deformity, iatrogenic postsurgical deformity, severe degenerative disease, tumors, vascular malformations and infections. All subaxial cases involved sagittal plane restoration. One in four also required coronal or axial realignment. Two thirds of occipitoatlantoaxial cases involved sagittal corrections; half with axial or coronal restoration as well. Two thirds of all cases, including 540 degree reconstructions, could be completed in a single day with a single anesthetic.of findings: An aggressive approach to anterior and posterior osteotomy followed by anterior distraction and posterior compression allowed correction of kyphotic deformity in all subaxial cases. Partial loss of correction occurred in one third of cases secondary to cage or strut settling or telescoping, despite rigid fixation. Intraoperative correction of coronal or axial deformities was maintained with little, if any, subsequent loss. Rigid screw fixation to the suboccipital keel and to the C1–C2 region with long C2 pars screws or C1–C2 transarticular screws allowed maintenance of intraoperative correction with no apparent late loss. There were no deaths and no spinal cord or nerve root injuries in this series. Two vertebral artery injuries related to C1–C2 transarticular screw placement occurred; one resulted in a delayed Wallenburg's syndrome. Two next-segment failures occurred, requiring reoperation for extension of fusion. There was a measurable loss of anterior distractive height restoration in one third of cases over time. In no case was this clinically significant. Anterior cage or strut settling occurred with both rigid and dynamic anterior buttresses and in the face of rigid anterior and posterior hardware.Relationship between findings and existing knowledge: The literature on spinal deformity is largely concerned with thoracic and thoracolumbar pathology. Traditional surgical approaches to cervical deformity using nonrigid internal fixation with wire or cable and/or semirigid external fixation in halo vests or Minerva casts were of limited use in the correction of deformity in any plane either above or below C2.Overall significance of findings: Modern reconstructive techniques allow for clinically significant correction of cervical and occipitocervical deformities associated with chronic pain, cosmetic deformity and neurologic deficit. An aggressive circumferential approach to decompression and osteotomy allows near-anatomic correction of geometric deformity in any plane.Disclosures: No disclosures.Conflict of interest: No conflicts.

1:48 Comparing anterolateral, extracavitary and transpedicular approaches to thoracolumbar spine reconstruction

Purpose of study: Multiple approaches are used to access the anterior thoracolumbar spine. Although variations of posterior approaches were developed, improvements in anesthesia and internal fixation fostered anterolateral (AL) approaches to the thoracolumbar spine. Advocates suggest improved visualization reduces the risk of neurological injury. However, some have raised concerns about increased perioperative morbidity after thoracotomy. Although the lateral extracavitary (LEC) approach offers better anterior visualization than the transpedicular (TP) approach, both offer more limited visualization than the AL approach. This study examines operative parameters and complications of these approaches in anterior spinal reconstruction to identify a preferred approach.Methods used: A prospective analysis of a consecutive series of 87 patients requiring thoracolumbar spinal reconstructions by one surgeon over 68 months was performed. Patients were grouped by approach including AL (n=21), TP (n=37) and LEC (n=29). The office, hospital and anesthesia records and radiographs were examined. Demographic parameters examined included age, gender and pathological indication. Operative parameters recorded included number of levels fused, estimated blood loss and operative time. Perioperative and postoperative complications were identified. Parameters were compared with analysis of variance and t tests using a p=.05 level of significance.of findings: The common reasons for reconstruction were trauma (AL=13, TP=12, LEC=12), neoplasm (AL=6, TP=10, LEC=8), and infection (AL=0, TP=14, LEC=9). Two thirds fewer segments were fused in AL patients when compared with LEC or TP patients. The estimated blood loss was significantly higher in patients treated with LEC compared with TP (p<.022). Moreover, the operative duration was significantly longer in LEC in comparison to TP and AL (p<.00024). Twenty-two complications were observed. No postoperative wound infections occurred after AL, whereas seven occurred in TP and three in LEC. Seven instrumentation or graft complications occurred (AL=1, TP=3, LEC=3). Three patients had transient neurological worsening (AL=1, LEC=2). Finally, both perioperative deaths were observed in elderly patients undergoing TP for pyogenic osteomyelitis. One died of respiratory failure, and the other died from a myocardial infarction. Median follow-up exceeds 2 years.Relationship between findings and existing knowledge: Less frequent infectious complications and shorter segment fixation are achieved with AL. However, TP allows safe circumferential reconstruction with less time and blood loss, providing a viable alternative. The LEC requires more time and has more frequent blood loss without improving neurological outcome over TP.Overall significance of findings: Several approaches allow access to the anterior thoracolumbar spine. Conclusions drawn from this study are limited by the retrospective analysis. However, AL approaches, even in older patients, do not appear to be associated with increased perioperative morbidity and allow successful reconstruction with shorter segment fixation. In contrast, TP approaches allow more rapid reconstruction with less blood loss than AL. The LEC approach does not seem to offer an advantage over the other approaches. Consequently, AL approaches may be preferred in most patients requiring thoracolumbar spine reconstructions. However, TP approaches may reduce operative duration and blood loss but are accompanied by more frequent infectious complications.Disclosures: No disclosures.Conflict of interest: No conflicts.

SUBSTITUTION URETHROPLASTY WITH BUCCAL MUCOSAL-FREE GRAFTS

Buccal mucosal grafts and the Barbagli technique are recent developments in the treatment of urethral strictures. We reviewed the results of and experience with urethroplasty using buccal mucosal graft in 128 patients. The re-stricture rate was 11% for patch grafts and 45% for tube grafts. There were no other complications. Buccal mucosal graft is at least as good as any other material for substitution urethroplasty with fewer complications. The 2-stage is more reliable than the stage 1 approach for circumferential reconstruction of the urethra.

The Lateral Island Trapezius Myocutaneous Flap for Circumferential Reconstruction of Hypopharynx and Cervical Esophagus

The lateral island trapezius was utilized for reconstruction of hypopharyngeal and cervical esophagus defects in high-risk patients, avoiding entry into the celomic cavities as an approach to decrease morbidity and mortality. Seven male patients were treated at the State University of New York between 1988 and 1991 and underwent reconstruction with the lateral island trapezius flap. There was no mortality, 2 patients developed pharyngocutaneous fistulas; 1 patient operated after radiation treatment failure remained with positive margins at resection but his fistula never healed, and another patient underwent a minor revision with successful closure of the fistula. All patients regained swallowing and none required dilatations. The preferred methods of reconstruction for the reasonable risk patient are gastric pull-up and free jejunal transfer; both of which require entry into cavities. The lateral island is a reliable alternate method of reconstruction for high-risk patients in whom intracavitary surgery may lead to unacceptably high morbidity and mortality. When the vascular anatomy is not favorable, rerouting of the vessels may be required utilizing microvascular reconstruction. The donor site defect is closed primarily or skin grafted, and subsequent functional limitations are minimal and well tolerated.

Changing practice in anterior urethroplasty.

To describe our experience of penile urethral repair and reconstruction, cataloguing the change in practice from one-stage flap to two-stage free graft procedures for anterior urethroplasty. Between January 1992 and December 1996, 79 patients underwent anterior urethroplasty. Of the 45 one-stage bulbar patch urethroplasties, 37 (76%) used buccal mucosal free grafts rather than flaps. Of the 34 penile urethroplasties, 26 (82%) (including all of the circumferential reconstructions) were two-stage procedures. Buccal mucosal free grafts were at least as good as local skin flaps for patch urethroplasty and two-stage repairs gave much better results than one-stage repairs for total circumferential reconstruction of the penile urethra. For a patch urethroplasty of an uncomplicated stricture in the bulbar urethra, buccal mucosal free grafts are now the material of choice. For a patch urethroplasty of an uncomplicated stricture in the penile urethra the Orandi procedure remains the 'gold standard'. For a circumferential repair of the urethra, particularly the penile urethra, a two-stage repair using a free graft gives better results than a one-stage repair using a flap.

Reconstruction of the External Auditory Canal with a Laterocervical Twisted Flap (Snail Flap)

A case of circumferential reconstruction of the external auditory canal following basal cell carcinoma is described using a laterocervical tubed flap. One-stage reconstruction with a single flap, absence of donor-site deformity, and easy dissection are the main advantages of the procedure, which also can be conveniently used to reconstruct part of the concha and the tragal region.

Long-term functional results after pharyngoesophageal reconstruction with the radial forearm free flap

For recovery to be deemed adequate, the laryngectomized patient requires restoration of both the ability to swallow and to speak. Immediate results and long-term functional recovery after pharyngoesophageal (PE) reconstruction with the radial forearm free flap were studied in 22 consecutive patients who had undergone primary (n = 3) or secondary (n = 19) reconstructions after total laryngectomy. Circumferential reconstructions were done in 13 patients (mean length 10 cm, range 6 to 16) and patch reconstructions in 9 patients (defect size range 4 x 4 cm to 8 x 7 cm). Flap leakage was evaluated for all patients, and postoperative diet and ability to swallow were evaluated for 16 patients with an intact tongue base. Voice was evaluated for 6 patients with circumferential reconstructions who had later undergone tracheoesophageal puncture with placement of a Blom-Singer voice prosthesis, and the results compared with those of a control group of 5 voice-restored patients who had undergone laryngectomy with primary closure of the pharyngoesophagus. All 22 flaps survived and none of the patients died. Although 7 (32%) reconstructions leaked, all but 1 closed spontaneously. Fourteen (88%) of the patients with an intact tongue base have no dysphagia and are on a regular diet, and 2 remain on an oral liquid diet. Compared with controls, patients with a radial free-flap reconstruction had similar loudness with soft speech (43 dB for controls versus 52 dB for radial patients) and loud speech (61 dB versus 63 dB), comparable fundamental frequencies (136 Hz versus 125 Hz), and increased jitter (2% versus 5%). Speech intelligibility was judged by untrained listeners as excellent for 4 of the patients with radial flaps and good for the other 2. The radial free flap offers the advantages of rapid harvest, high flap reliability, and minimal donor-site and patient morbidity. Leakage rate and deglutition restoration were similar to those of other reconstructions, including the free jejunal flap. Speech rehabilitation in patients secondarily reconstructed with the radial free flap was nearly equivalent to that of total laryngectomy patients who have primary closure of the pharynx and was superior to that reported with other popular PE reconstructions, including the gastric pull-up and the free jejunal flap.

Dorsal and circumferential sheath reconstructions for flexor sheath defect with concomitant bony injury

Dorsal and circumferential flexor sheaths were reconstructed by autogenous sheath graft in flexor tendon repair in 28 white leghorn chickens. The effect of the sheath reconstructions was evaluated by use of an experimental model of tendon transection associated with bony injury, superficial tendon excision, and 3 weeks of immobilization. Six weeks after reconstruction, the gliding excursion was assessed and adhesion formation, tendon healing, and survival of the grafted sheath were evaluated both macroscopically and histologically. Dorsal and circumferential sheath grafts resulted in tendon gliding that was significantly better than the group with sheath defect not reconstructed. The adhesion formation was apparently less severe, and tendon healing was better in the groups with sheath reconstruction than in the group without reconstruction. The group with dorsal sheath reconstruction did not differ significantly from that with circumferential reconstruction in gliding excursion and adhesion formation. This study demonstrates that separation of the injured tendons from the bony surface by autoeenous sheath grafts may be beneficial to tendon gliding and for reducing adhesion formation.

Pharyngocutaneous Fistulas

After total laryngectomy, postoperative pharyngocutaneous fistula still constitutes a most troublesome and challenging problem. We present 9 cases of postoperative fistulas managed by one-stage flap reconstruction. Possible contributing factors related to earlier management or medical status are identified. When the posterior pharyngeal wall was intact in a large pharyngocutaneous fistula, 4 pectoralis major and 2 latissimus dorsi double island musculocutaneous flaps were used. Autogenous jejunal free grafts were used in 3 patients when circumferential reconstruction was required. The cervical esophagus was successfully reconstructed, facilitating swallowing function, in a one-stage procedure in each patient.

Total reconstruction of the hypopharynx and cervical esophagus.

Patients with extensive circumferential tumors of the hypopharynx and those with carcinomas of the cervical esophagus usually require resection of a cylindrical segment of the upper digestive tube. These patients present similar difficulties of reconstruction and also share a very poor prognosis. At times, the same complicated technical effort is required for palliation and definitive cure alike. From 1970 through 1982 at the University of Texas-M.D. Anderson Hospital at Houston, 78 patients underwent complete resection of the hypopharynx (54 patients) or the cervical esophagus (24 patients) for advanced malignant tumors. Seventy-three tumors were squamous cell carcinomas, and the remaining 5 were cancers that originated in the salivary gland. These large tumors were not staged according to the TNM system, since they frequently involved two different anatomic structures and a precise clinical assessment was not always possible. The only criterion for inclusion of patients in this series was the need to replace the entire pharynx or cervical esophagus after removal of the cancer. Of the 78 patients, 64 received their entire treatment at our institution, and of this group, 44 patients had only one surgical procedure. All patients in the series had circumferential resection as the final surgical step at our institution. The types of repair used in this group of patients were a cutaneous flap or graft in 44 patients, a colon bypass in 16 patients, a lateral trapezius musculocutaneous flap in 9 patients, and a pectoralis major musculocutaneous flap in 6 patients. In three additional patients, the reconstruction was initially delayed for various reasons and was ultimately abandoned. Technical considerations and a detailed analysis of the complications and palliative value of each procedure are presented. The merit of these procedures is judged according to the quality and the length of the patient's survival. Although the degree of palliation varies considerably according to the technique used, the survival rates were similar in all cases, the average being 43 percent at 5 years after the first treatment attempt and 27 percent at 5 years after the surgical resection that required a complete circumferential reconstruction.

Management of Cervical and Mediastinal Lesions of the Trachea

Although many tracheal tumors are benign or of low-grade malignancy, without local invasion or metastases, cure has been rare because dependable methods of wide circumferential excision and reconstruction have not been available. In the thorax, it was believed that only four tracheal rings (2 cm) could be removed and an end-to-end anastomosis done. Prosthetic replacements often fail, because of (1) leakage, with fatal mediastinitis; (2) stenosis, due to scarring and fatigue of prostheses; (3) recurrent tumor, due to inadequate resection; and (4) hemorrhage, due to erosion by prostheses. In the neck, reconstructive methods have often been complex, slow to heal, and many-staged. Excision of the trachea without replacement—with permanent end-tracheostomy—is not satisfactory when a functional larynx remains. Review of past experience with 32 primary tumors of the trachea treated at the Massachusetts General Hospital and the Massachusetts Eye and Ear Infirmary, Boston, during a period of 25 years reveals that