Use of the Vascularized Free Fibula Graft with an Arteriovenous Loop for Fusion of Cervical and Thoracic Spinal Defects in a Pediatric Population
Shareef Jandali, David W. Low, M.D..
University of Pennsylvania Health System, Philadelphia, PA, USA.
BACKGROUND:Extensive spinal neoplasms are difficult to manage, since many have undergone preoperative radiation therapy and require a radical resection and then stabilization of the spine. Arthrodesis of the spine can be performed with instrumentation, but this often fails in cases of multiple level corpectomies and vertebrectomies, and in the setting of poor tissue beds secondary to radiation therapy. Conventional nonvascularized bone grafts can be used for short segments of bone loss, but these are inadequate for more extensive defects. Vascularized bone grafting results in accelerated healing, earlier fusion, and increased strength. Use of the free fibula flap for anterior spinal fusion to correct deformities has been described in multiple studies, but its use for posterior spinal fusion has been limited. In addition, its use in the pediatric population for this purpose has not been reported.
METHODS:A retrospective review was performed of three pediatric cases of cervical and thoracic spine tumor resection with posterior fusion of the spine with a microvascular fibula flap. Data recorded included: patient demographics, past medical/surgical history, indications for surgery, length of free fibula flap, recipient vessels, ischemic time, number of osteotomies performed on the fibula, complications, and time to computed tomography-documented fusion of the fibula to the remaining spinal column.
RESULTS:In all cases, the microvascular anastomoses were successfully performed using an arteriovenous loop of saphenous vein graft to the anterior neck or subscapular vessels. The average length of fibula harvested was 23.7 cm (range 23-24 cm), the average length of ischemic time was 220 min (range 30-330 min), the number of osteotomies in all cases was 2, and there was CT-documented bony fusion at an average of 15.7 weeks (range 11-23 weeks) postoperatively.
CONCLUSIONS:The free fibula flap is ideally suited for accelerated posterior spinal fusion after extensive resection of cervical or thoracic spinal neoplasms. An arteriovenous saphenous vein loop facilitates the microvascular anastomosis in this anatomic region which lacks suitable recipient vessels.
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