Jeger, Jonathan L.

Summary: Pseudoarthrosis is a severe complication of spinal fusion surgery with occurrence rates as high as 35%–40%. Current options of revision surgery to correct pseudoarthrosis frequently carry high failure rates and risk of developing junctional kyphosis. Pedicled vascularized bone grafts (VBGs) are an innovative approach to boost spinal fusion rates via improving structural integrity and increasing the delivery of blood to the donor site. This versatile technique can be performed at different spinal levels without additional skin incisions and with minimal added operative time. Here we present the first bilateral rib and iliac crest VBG spinoplastic surgery performed to augment spinal fusion in a 68-year-old woman with distal junctional kyphosis and severe positive sagittal balance with low back and neck pain and significant difficulty standing upright. The patient had history of multiple spinal operations with preoperative CT imaging demonstrating loosening and pull out of L3 and fracture of L2 screws. She underwent two-stage surgical treatment involving anterior lumbar interbody fusion L3-S1 followed by removal of hardware, T4 to pelvis fusion with L2-3 prone lateral interbody fusion, and T11-S1 posterior column osteotomies. The surgery was augmented by bilateral rib and iliac crest VBGs performed by plastic surgery. At three-month follow-up the patient demonstrated functional improvement, being able to maintain upright posture and walk; was satisfied with the result of the surgery; and demonstrated no graft-related complications. In conclusion, utilization of pedicled VBGs is a novel, promising approach to augment spinal surgery in high risk patients.

ABSTRACT The role of plastic surgeons in the world of spine surgery is quickly evolving. The plastic surgeon now serves both a therapeutic and prophylactic role in addressing complications of complex and revision spine surgery. The field of Spino-plastic Surgery is characterized by the use of vascularized bone grafts (VBGs). VBGs are bone segments transferred on their corresponding muscular attachments without the inclusion of a named vessel. The bone graft is adequately vascularized through the connection of the tendon by Sharpey's fibers and their associated microvasculature. VBGs provide an autologous, pedicled tissue rearrangement option with osteoinductive properties and adequate structural support for complex spine reconstruction. VBGs are associated with a lower risk of adverse events and shorter times to fusion than allografts, and bypass the need for lengthy microsurgical anastomosis. Five types of VBGs for spine reconstruction are described in this article, including iliac crest, rib, occiput, scapula, and spinous process VBG. Virtually any vertebral level can be reached for arthrodesis using one or more of these VBGs. Highlights Vascularized bone grafts are bone segments transferred on muscular attachments without the inclusion of a named vessel.Vascularized bone grafts provide an autologous, pedicled tissue rearrangement option for complex spine reconstruction with a lower risk of adverse events and shorter times to fusion than allografts.Five types of vascularized bone grafts for spine reconstruction have been described: iliac crest, rib, occiput, scapula, and spinous process.Virtually any vertebral level can be reached for arthrodesis using one or more vascularized bone grafts.