Shvedova, Maria

Background: Vertebral body defects pose a significant challenge in spinal reconstructive surgery. Compression fractures of the vertebral corpus are typically treated with vertebral augmentation procedures. There are significant risks associated with the introduction of foreign material in the spine, including infection and pseudarthrosis. Vascularized bone grafts (VBGs) have become a popular alternative for spinal reconstruction in the last decade thanks to their robust blood supply and autologous nature. VBGs have been described predominantly for the reconstruction of posterior vertebral defects. The objective of this study is to describe a novel procedure for the reconstruction of vertebral corpus defects in the lumbar and distal thoracic spine. Methods: This is a cadaveric anatomy study. The authors performed the novel surgical technique on an anonymized cadaveric donor in the prone position and recorded the procedure through clinical photography. Consent for the procedure and photography was obtained from the Center for Procedural Innovation. Results: A 5-cm-long posterior iliac crest VBG (IC-VBG) was successfully harvested on a pedicle of the quadratus lumborum muscle. The VBG was rotated and mobilized anteromedially to the vertebral corpus. In this donor, the IC-VBG could be inset with minimal tension anywhere along the vertebral bodies of the spine from the L5 to the T9 level. Conclusions: A rotated, anteromedially mobilized IC-VBG represents a novel technique for reconstruction of the anterior vertebral corpus of the lumbar and distal thoracic spine with a lower risk of infection and pseudarthrosis than reconstruction with foreign materials.

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.