Reconstruction of vertebral column defects with vascularized bone flaps increase rates of bony union, decreases the time to union, and decrease rates of complications as compared to alloplastic reconstruction using interbody cages and titanium rods.1,2 However, reconstruction of the thoracic spine is challenging given a paucity of recipient vessels.3 Branches of the aorta and vena cava have been described as an option but they may not be available in reoperative cases.4 End to side anastomosis to the aorta and inferior vena cava requires cross clamping and may be risky in patients with previous radiation, infections or multiple operations. Additional secondary options include long vein grafts from regional pedicles which, though reliable, are subject to kinking or compression during their tortuous extrathoracic to intrathoracic course. Faced with a challenging salvage thoracic spine reconstruction, we present the use of the gastroepiploic vessels with the omentum as an additional vascular pedicle option (figure 1).
Figure 1:
Schematic diagram of the operation (© 2021 Memorial Sloan Kettering Cancer Center. All rights reserved).
A 37-year-old female presented to our center with severe debilitation after multiple treatments for giant cell tumor of the T8 thoracic spine, including two resections, an embolization, reconstruction of T7 to T9 vertebral defect with pedicle screws and titanium mesh cage and reoperation for cerebrospinal fluid leak. Unfortunately, the reconstruction failed and her titanium cage and pedicle screws became malpositioned, resulting in lower limb weakness with limited ambulation, gait instability and severe chronic pain. Imaging revealed nonunion, hyperkyphotic spinal alignment, and cage subsidence (See Figure, Supplemental digital content 1, which demonstrates preoperative anteroposterior and lateral computed tomographic images showing malpositioned hardware and thoracic kyphosis, INSERT HYPERLINK HERE).
Surgical correction was performed in 2 stages. The first operation consisted of a posterior approach to remove the old hardware, place new screws and rods, and provide durable soft tissue coverage with paraspinous and trapezius muscle advancement flaps. The second operation consisted of an anterior approach via redo right lateral thoracotomy to remove the malpositioned titanium cage. The 3 segment (T7 to T9) vertebral body defect was reconstructed with a double barrel free fibula flap; one segment spanned the interbody defect and the other was placed adjacent to it as vascularized bone support (See Figure, Supplemental digital content 2, which demonstrates the fibula free flap osteotomized into 2 segments, INSERT HYPERLINK HERE) (See Figure, Supplemental digital content 3 which demonstrates the fibula free flap inset as 2 barrels into the 3-level vertebral body defect, INSERT HYPERLINK HERE). Bony fixation was performed with screws. As there were no local recipient vessel options, a midline epigastric laparotomy was performed and an omental flap was raised in standard form based on the right gastroepiploic artery and vein (See Figure, Supplemental digital content 4, which demonstrates the omental flap based on the right gastroepiploic vessels, INSERT HYPERLINK HERE). An opening was made in the posterior right hemidiaphragm, through which the omentum was passed to the right thoracic cavity (figure 2). Microvascular anastomosis was performed between the right gastroepiploic and peroneal vessels. A polyglactin 910 (VICRYL®) mesh was placed around the diaphragmatic opening on the thoracic side, to minimize the risk of herniation. The post-operative course was uncomplicated. Imaging showed improvement of kyphosis from 45 to 25 degrees (See Figure, Supplemental digital content 5, which demonstrates the anteroposterior (AP) and lateral X rays show improvement in thoracic kyphosis, INSERT HYPERLINK HERE). She was able to ambulate independently and weaned off narcotic medications.
Figure 2:
Omentum passed through the posterior aspect of the right hemidiaphragm and right gastroepiploic vessels anastomosed to the peroneal vessels. Fibula is inset into the defect and fixated with screws.
The omentum has a long history in microsurgery.5 While commonly utilized as a pedicled or free flap, the reliability of its long vascular pedicle should be kept in mind for intrathoracic free flaps when faced with a lack of local options.
Supplementary Material
Figure, Supplemental digital content 1: Preoperative anteroposterior and lateral computed tomographic images showing malpositioned hardware and thoracic kyphosis.
Figure, Supplemental digital content 2: Fibula free flap osteotomized into 2 segments.
Figure, Supplemental digital content 3: Fibula free flap inset as 2 barrels into the 3-level vertebral body defect.
Figure, Supplemental digital content 4: Omental flap based on the right gastroepiploic vessels.
Figure, Supplemental digital content 5: Anteroposterior (AP) and lateral X rays show improvement in thoracic kyphosis.
Funding:
This research was funded in part through National Institutes of Health/National Cancer Institute Cancer Center Support Grant P30 CA008748.
Footnotes
Disclosures: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.
Presented at the American Society for Reconstructive Microsurgery annual conference (finalist best save competition), Fort Lauderdale, Jan 2020
References
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Supplementary Materials
Figure, Supplemental digital content 1: Preoperative anteroposterior and lateral computed tomographic images showing malpositioned hardware and thoracic kyphosis.
Figure, Supplemental digital content 2: Fibula free flap osteotomized into 2 segments.
Figure, Supplemental digital content 3: Fibula free flap inset as 2 barrels into the 3-level vertebral body defect.
Figure, Supplemental digital content 4: Omental flap based on the right gastroepiploic vessels.
Figure, Supplemental digital content 5: Anteroposterior (AP) and lateral X rays show improvement in thoracic kyphosis.