Paraspinous Muscle Flap Reconstruction of Complex Midline Back Wounds: Risk Factors and Incidence of Post-flap Complications at a Busy Regional Spine Center
Alexander F. Mericli, B.S., Nicholas Tarola, M.D., John H. Moore, Jr., M.D., Steven E. Copit, M.D., James Fox, M.D., Gary A. Tuma, M.D..
Jefferson Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
PURPOSE: The purpose of this study is to examine the effect of various preoperative risk factors on postoperative complications after paraspinous muscle flap reconstruction of non-healing back wounds. As one of thirteen spinal cord injury centers in the United States, exposure to complicated spinal problems is common. With increasingly complex spine surgeries now performed on a more comorbid patient population, the reconstruction of midline back wounds from these procedures is becoming a frequent dilemma encountered by plastic surgery.
METHODS: An 11-year retrospective office and hospital chart review was conducted between July 1996 and August 2007. All patients who underwent reconstruction using paraspinous muscle flaps during this time period were included. There were 92 patients in the study, representing the largest reported series to-date for this procedure.
RESULTS: The average age was 56; 49 of the patients were male and 43 were female. Of this patient population 41% had hypertension, 35% were obese, 33% had a history of smoking, 32% had diabetes, 17% suffered from paraplegia or quadriplegia, 16% were on chronic steroids, 14% had history of more than two spine surgeries, and 9% had a history of radiation to the wound area. Spinal wound complications necessitating reconstruction included infection (82%), dehiscence (17%), seroma (11%), and hematoma (7%). 23 patients (25%) developed a post-reconstruction wound complication and 15 patients (16%) developed a post-reconstruction wound complication requiring hospital admission. Post-reconstruction complications included infection (13%), seroma (12%), hematoma (1%), and dehiscence (1%). Factors associated with a statistically significant (p<.05) increased rate of post-reconstruction wound complication include emergent initial spine surgery, a history of more than two spine surgeries, hypertension, radiation to the wound area, and smoking (Table 1). 86/92 (93%) patients undergoing wound reconstruction had initial spine surgery requiring hardware. Patients who retained their hardware (50/86) had significantly fewer post-reconstruction complications compared to patients who had their hardware removed pre-reconstruction (26/86) (14% vs. 31%; p<.001).
CONCLUSION: Risk factors resulting in macroscopic injury to the wound bed, such as a history of multiple spine surgeries or radiation therapy, are associated with a greater statistically significant wound healing complication rate as compared to risk factors resulting in biochemical injury, such as malnutrition or steroids. Hardware should not be removed before wound reconstruction, as hardware removal is associated with a greater number of post-reconstruction wound complications.
Table 1: Associated Complication Rates
|Complication Rate (%)||Baseline Complication Rate (%)||% of Pt in Group with Complication||p|
|Demographics and PMHx|
|Hx. Of > 2 spine surgeries||78.6||30.8||57.1||0.0007|
|Emergent Spinal Surgery||56.2||34.2||43.8||0.04|