RECONSTRUCTIVE

Immediate Soft-Tissue Reconstruction for

Complex Defects of the Spine following
Surgery for Spinal Neoplasms
Patrick B. Garvey, M.D.
Laurence D. Rhines, M.D.
Wenli Dong, M.S.
David W. Chang, M.D.
Houston, Texas
Background: Innovations in surgical approaches and instrumentation for spinal
stabilization have allowed radical resections of advanced spinal neoplasms.
Wounds that expose instrumentation and vital neural structures can have dev-
astating consequences. In this study, the authors present a paradigm shift in the
way complex wounds of the spine are managed, where immediate, prophylactic
muscle-flap reconstruction is provided, particularly for those patients identified
to be at high risk for wound-healing complications. The purpose of this study
was to determine the outcomes of this new prophylactic approach to managing
complex spine wounds.
Methods: The authors retrospectively reviewed spine tumor patients who un-
derwent immediate reconstruction for complex wounds of the spine from 2004
to 2008. From the prospectively maintained database and medical records, the
authors collected information regarding reconstructive methods, defect loca-
tion, patient conditions, complications, and revision operations.
Results: Of the 52 patients, 34 (65 percent) had undergone prior irradiation,
17 (33 percent) had undergone prior surgery to the spine, and 44 (85 percent)
had undergone spine instrumentation. Overall, six patients (12 percent) had
major complications that required surgical intervention. The instrumentation
did not need to be removed in any of the patients. All patients had a closed
wound at their last clinic visit.
Conclusions: Complex wounds of the spine benefit from immediate prophy-
lactic reconstruction with muscle flaps. This approach has a high rate of success
in achieving a stable, closed wound while minimizing major wound complications,
even in the presence of adverse conditions such as prior irradiation, prior opera-
tions, and the presence of hardware. (Plast. Reconstr. Surg. 125: 1460, 2010.)

C
omplex defects of the spine resulting from
resection of spinal neoplasms present a chal-
lenge. The spine is the most common site of
bony metastasis and the third most common site
of distant metastasis from solid tumors.1,2 Patients
with metastases to the vertebral column often ex-
perience pain that is unrelenting and progressive,
motor weakness, paralysis, or incontinence. Re-
cent studies have shown that patients with a min-
From the Departments of Plastic Surgery, Neurosurgery, and
Biostatistics, The University of Texas M. D. Anderson Can-
cer Center.
Received for publication July 29, 2009; accepted November
12, 2009.
Presented at the 2009 Annual Meeting of the Texas Society
of Plastic Surgeons, in Grapevine, Texas, September 25
through 27, 2009.
Copyright 2010 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3181d5125e
imum life expectancy of 3 to 6 months who do not
respond to nonoperative therapy for symptomatic
vertebral metastases experience a significant im-
provement in quality of life with operative
resection.3 Advances in radiologic diagnosis, sur-
gical approaches to the entire vertebral column,
spinal instrumentation, adjuvant chemoradiation,
and anesthesia and perioperative critical care have
allowed extirpation of advanced primary and met-
astatic neoplasms of the spine, even in patients
who are elderly, have multiple comorbidities, are
immunosuppressed from disease or treatment, or
are nutritionally deficient.
As a result, an increased population of patients
with a diminished capacity for wound healing re-
Disclosure: None of the authors has a financial
interest associated with this publication.

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Volume 125, Number 5 Immediate Reconstruction of the Spine

quires repair of extensive defects following aggres-
sive extirpation of tumors.4,5 Studies have reported
complication rates following resection of spinal me-
tastases that range between 19 and 25 percent.2,3 In
particular, patients receiving radiation therapy have
been shown to experience increased morbidity fol-
lowing resection of spinal metastases. Breakdown of
wounds or infections at the surgical site that expose
instrumentation and/or vital neural structures can
have devastating effects on these patients.2 Such
wounds are difficult to treat, because the stabiliza-
tion devices typically cannot be removed without
risking spinal injury and instability.6,7 Secondary re-
construction of complex spinal wounds that develop
after primary closure typically requires complex
strategies that use multiple flaps from local or distant
donor sites.5,714
We have shown in a previous study that de-
layed reconstruction for complex wounds of the
spine was associated with a higher complication
rate compared with immediate or prophylactic
reconstruction. Our previous findings led to a
change in our practice to minimize the develop-
ment of spinal wound complications.15 Since 2004,
we have developed an approach where patients
identified to be at high risk for wound complica-
tions are provided with immediate soft-tissue cov-
erage using well-vascularized muscle flaps at the
time of tumor extirpation and spinal stabilization.
The purpose of this study was to determine the
outcomes of immediate prophylactic muscle-flap
reconstruction for complex wounds of the spine.
PATIENTS AND METHODS
We retrospectively reviewed the medical
records of all patients who underwent immediate
soft-tissue reconstruction for complex wounds of
the spine at The University of Texas M. D. Ander-
son Cancer Center between May of 2004 and De-
cember of 2008. The M. D. Anderson Cancer Cen-
ter Institutional Review Board approved our study
protocol.
We collected information on patient demo-
graphics (age and sex), the indication for recon-
struction, location of the defect, reconstructive
method, factors potentially associated with recon-
structive outcome (body mass index, cardiovascu-
lar disease, diabetes mellitus, active smoking, prior
spine surgery, prior chemotherapy, radiation ther-
apy, presence of spinal instrumentation), postop-
erative complications (infection, dehiscence, total
or partial flap loss, hematoma, seroma, cerebro-
spinal fluid leak, exposed instrumentation,
paraspinal hernia), need for revision surgery, post-
operative follow-up time, and success of closure at
last follow-up appointment. We defined major
complications as those that required a return to
the operating room for management.
Statistical analysis of the collected data in-
cluded the use of descriptive statistics such as
mean (range) for continuous variables and fre-
quency (percentage) for categorical variables.
The Wilcoxon rank sum test was used to test the
differences in age distribution and in body mass
index distribution between the complication
group and the noncomplication group. Fishers
exact test was used to assess associations between
pairs of categorical variables and between cate-
gorical variables and complications. All tests were
two-sided, and values of p ! 0.05 were considered
statistically significant. We used SAS version 9.1.3
(SAS Institute, Inc., Cary, N.C.) for the analyses.
RESULTS
We found 52 consecutive spine tumor patients
who underwent immediate reconstruction for
complex wounds of the spine from May of 2004 to
December of 2008. The mean age of the patients
was 55.4 years (range, 17 to 81 years). The mean
follow-up after surgery was 9.7 months (range, 0.7
to 55.3 months).
Table 1 lists flap types used by defect location.
Paraspinous muscle-advancement flaps were the
most commonly used flaps at all spinal levels. Of
52 cases, 25 (48 percent) were reconstructed with
two or more muscle flaps.
Table 2 lists preoperative risk factors for post-
operative complications and the defect location.
Thirty-four patients (65 percent) had wounds that
had previously been irradiated, and 27 patients
(52 percent) had received prior chemotherapy.
Overall, 17 patients (33 percent) had prior surgery
Table 1. Reconstructive Methods
Flap Type No. of Patients (%)
Cervical (n " 6)
Paraspinous 4 (67)
Paraspinous, trapezius 2 (33)
Thoracic (n " 37)
Paraspinous 13 (35)
Trapezius 1 (3)
LD 1 (3)
Paraspinous, trapezius 12 (32)
Paraspinous, LD 3 (8)
Paraspinous, trapezius, LD 6 (16)
Trapezius, LD 1 (3)
Lumbosacral (n " 9)
Paraspinous 6 (67)
Paraspinous, LD, gluteus maximus 1 (11)
Lumbar perforator 1 (11)
Free rectus abdominis 1 (11)
LD, latissimus dorsi.

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 Plastic and Reconstructive Surgery May 2010

Table 2. Preoperative Risk Factors by Defect Location

No. of Patients by Defect Location (%)

Risk Factor Total (n ! 52) Cervical (n ! 6) Thoracic (n ! 37) Lumbar (n ! 9) p

DM 9 (17) 0 (0) 9 (24) 0 (0) 0.15
CVD 23 (44) 2 (33) 19 (51) 2 (22) 0.25
Prior chemotherapy 27 (52) 3 (50) 21 (57) 3 (33) 0.46
Prior XRT 34 (65) 4 (67) 25 (68) 5 (56) 0.89
Smoking 15 (29) 1 (17) 13 (35) 1 (11) 0.34
Prior spine surgery 17 (33) 5 (83) 8 (22) 4 (44) 0.008
Instrumentation 44 (85) 5 (83) 35 (95) 4 (44) 0.002
DM, diabetes mellitus; CVD, cardiovascular disease; XRT, radiation therapy.

to the spine. Prior surgery of the spine was more
common among patients with cervical spine
wounds than among patients with thoracic or lum-
bar spine wounds (cervical, 83 percent; thoracic,
22 percent; lumbar, 44 percent; p " 0.008). In-
strumentation for spinal stabilization was placed
in 85 percent of the wounds. The use of instru-
mentation was more common in patients with cer-
vical (83 percent) and thoracic (95 percent) spine
wounds than in patients with lumbar spine wounds
(44 percent; p " 0.002).
Postoperative complications (Table 3) in-
cluded seroma (25 percent), infection (15 per-
cent), cerebrospinal fluid leak (10 percent),
wound dehiscence (4 percent), and hematoma
(4 percent). Six patients (12 percent) required
a return visit to the operating room. None of the
patients required removal of spinal instrumen-
tation. The difference in age between the group
of patients who developed a wound dehiscence
and the group who did not was significant (p "
0.039), although only two of the 52 patients (4
percent) had wound dehiscence. These two pa-
tients were aged 69 and 81 years, compared with
a mean age of 55.4 years among all 52 patients.
Except for age, we did not find statistically sig-
nificant associations between preoperative co-
morbid conditions and any of the five major
postoperative complications (infection, dehis-
cence, hematoma, seroma, and cerebrospinal
fluid leak) or the need for a return to the op-
erating room (Table 3). With the exception of
one patient who died postoperatively in the in-
tensive care unit from exacerbation of conges-
tive heart failure, all patients (98 percent) had
a closed wound at their last follow-up.

Table 3. Postoperative Wound Complications with Preoperative and Intraoperative Variables

No. of Patients (%) with Complications

Exposed Wound Wound CSF Major

Risk Factor Instrumentation Infection Dehiscence Hematoma Seroma Leak Complications
Total 1 (2) 8 (15) 2 (4) 2 (4) 13 (25) 5 (10) 6 (12)
Location of defect
Cervical 0 (0) 2 (33) 0 (0) 1 (17) 0 (0) 1 (17) 2 (33)
Thoracic 0 (0) 5 (14) 1 (3) 1 (3) 12 (32) 3 (8) 3 (8)
Lumbar 1 (11) 1 (11) 1 (11) 0 (0) 1 (11) 1 (11) 1 (11)
p 0.29 0.39 0.50 0.25 0.18 0.60 0.19
Instrumentation
Yes 1 (2) 5 (11) 2 (5) 1 (2) 12 (27) 5 (11) 5 (11)
No 0 (0) 3 (38) 0 (0) 1 (13) 1 (13) 0 (0) 1 (13)
p 1.00 0.09 1.00 0.29 0.66 1.00 1.00
Prior irradiation
Yes 1 (3) 7 (21) 1 (3) 1 (3) 9 (27) 4 (12) 4 (12)
No 0 (0) 1 (6) 1 (6) 1 (6) 4 (22) 1 (6) 2 (11)
p 1.00 0.24 1.00 1.00 1.00 0.65 1.00
Prior chemotherapy
Yes 0 (0) 4 (15) 1 (4) 0 (0) 7 (26) 1 (4) 1 (4)
No 1 (4) 4 (16) 1 (4) 2 (8) 6 (24) 4 (16) 5 (20)
p 0.48 1.00 1.00 0.23 0.87 0.18 0.09
Prior surgery
Yes 0 (0) 4 (24) 1 (6) 2 (12) 3 (18) 2 (12) 4 (24)
No 1 (3) 4 (11) 1 (3) 0 (0) 10 (29) 3 (9) 2 (6)
p 1.00 0.41 1.00 0.10 0.51 1.00 0.08
CSF, cerebrospinal fluid.

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Volume 125, Number 5 Immediate Reconstruction of the Spine
DISCUSSION
In our previous study, we evaluated the com-
plication rates of immediate versus delayed soft-
tissue reconstruction for complex defects of the
spine; our results prompted a change in the man-
agement of complex spinal wounds at our insti-
tution. The ultimate conclusions of that study
were to recognize high-risk situations for poten-
tial wound-healing problems and then provide
preemptive soft tissue coverage at the time of the
initial spinal surgery.15 Since 2004, we have fol-
lowed our own recommendations and have been
more aggressive in providing immediate, prophy-
lactic soft-tissue reconstruction for complex
wounds of the spine. In the present study, we
examined the results of this paradigm shift, and
the findings are compelling.
In this series of 52 patients undergoing im-
mediate reconstruction after resection of spinal
neoplasm, the rate of major complications was 12
percent, with only six of the 52 patients requiring
a return to the operating room following imme-
diate soft-tissue reconstruction. Among the pa-
tients in the current study with spinal instrumen-
tation, the rate of major complications was 12
percent. In our previous study, the rate of major
complications overall was 38 percent. We consider
a reduction in major complications at our insti-
tution from 38 percent to 12 percent a consider-
able achievement and to be largely attributable to
using the principles of prophylactic soft-tissue re-
construction for complex spinal wounds.
In particular, patients receiving radiation ther-
apy have been shown to experience increased
morbidity following resection of spinal tumors. In
his study of complication rates following surgery
for metastatic disease of the spine, Wise et al.
reported that two of their nine patients (25 per-
cent) experienced a postoperative complication,
and one patient (11 percent) developed a surgical-
site infection.2 All nine of the patients had under-
gone preoperative irradiation of the surgical site.
Wise et al. concluded that preoperative radiation
therapy correlated with the development of post-
operative complications.2 A study by Bridwell et al.
showed that in patients who received preoperative
radiation therapy, 12 percent experienced wound
dehiscence.16 Surgical-site infections were also
more common in irradiated patients in this study
(21 percent) than in patients who had not under-
gone preoperative irradiation (6 percent).
Sixty-five percent of the patients in our study
underwent preoperative irradiation. However, we
did not see significantly higher wound complica-
tions in patients after prior irradiation. Bringing
nonirradiated muscle flaps with robust perfusion
into the wound to obliterate dead space appears to
facilitate wound healing. Furthermore, except for
age, we did not find statistically significant associ-
ations between other preoperative comorbid con-
ditions and the postoperative complications. It has
been well established that advancing age inter-
feres with wound healing, and our experience
does agree with this principle, although only two
of the 52 patients (4 percent) had wound dehis-
cence. Our experience indicates that the preemp-
tive and prophylactic application of soft-tissue re-
construction for complex defects of the spine at
the time of ablative surgery decreases the fre-
quency and severity of postoperative complica-
tions, even in patients with comorbid conditions.
The relatively high incidence of seromas in
our study highlights the importance of the liberal
use of closed-suction drains in immediate spinal
reconstruction. Spinal instrumentation for stabi-
lization creates a rigid scaffold that suspends the
muscle flaps and prevents the complete oblitera-
tion of dead space. A plastic surgeon working with
a neurosurgeon unfamiliar with soft-tissue recon-
struction for spinal defects may encounter some
resistance from the neurosurgeon in determining
the appropriate length of time before removal of
closed-suction drains. Neurosurgeons typically re-
move epidural drains within a few days of spinal
instrumentation placement, as soon as the drain
output is no longer high. Subcutaneous and in-
termuscular drains typically have a protracted pe-
riod of high output after these procedures, even
when the dura remains intact. Drains may remain
in place for as long as 4 weeks after the initial
operation. None of the patients in our series de-
veloped hardware infections caused by the pro-
tracted presence of closed-suction drains.
The muscles of the back can be classified into
superficial, intermediate, and deep groups. The
superficial group includes the muscles that are
connected to and concerned with the movements
of the upper limbs: the trapezius, latissimus dorsi,
levator scapulae, and rhomboid muscles. As was
demonstrated in our experience, these superficial
muscles are often a valuable source for a secondary
flap to augment paraspinous muscle flap recon-
struction for deep, extensive defects or defects
requiring a skin island. The intermediate group of
back muscles, such as the serratus posterior and
levator costarum, also serve as the superficial re-
spiratory muscles and are not typically useful in
coverage of the posterior spine. The deep muscles
of the back, or erector spinae muscles, are the
1463
 Plastic and Reconstructive Surgery May 2010

group of intrinsic back muscles dedicated to the

maintenance of posture. These erector spinae
muscles are what are more commonly referred to
as the paraspinous muscles. The erector spinae
muscles are further subclassified into a superficial
layer, an intermediate layer, and a deep layer. The
superficial layer is made up of the splenius capitis
and the splenius cervicis muscles, which are both
found in the cervical spine. The three muscle col-
umns of the intermediate layer, the iliocostalis, lon-
gissimus, and spinalis muscles, extend along the en-
tire length of the vertebral column. Finally, the deep
layer of erector spinae muscles includes the trans-
versospinal muscles that extend from the trans-
verse to the spinous processes: the semispinalis,
Fig. 2. The paraspinous muscle flaps are raised as a group from
multifidus, and rotatores muscles.17
the underlying involved vertebrae and advanced as bipedicled
The paraspinous muscles were our most com-
muscle flaps perfused by the lateral row of segmental intercostal
mon source of muscle flaps for repair of these
perforators.
complex defects of the spine. Historically, paraspi-
nous muscle turnover flaps or unipedicled flaps
have most commonly been described to recon-
struct the deepest portion of wounds in the mid-
line posterior trunk, as these flaps obliterate dead
space and provide a rich vascular supply that pro-
motes wound healing.18 22
The paraspinous muscle flaps are raised as a
group from the underlying involved vertebrae,
with care taken to maintain meticulous hemostasis
during dissection by identifying and ligating the
medial row of segmental intercostal perforating
vessels. Our practice has been to advance the mus-
cles as bipedicled muscle flaps perfused by the
lateral row of segmental intercostal perforators
(Figs. 1 through 3). If the paraspinous muscle
group is compromised by the tumor resection or
previous irradiation, the closure may be aug-
mented by pedicled superficial muscle flaps such

Fig. 3. Schematic diagram of the blood supply to the paraspi-

nous muscle.

as a trapezius muscle flap for cervical or upper

Fig. 1. A thoracic spine wound with spinal instrumentation.
thoracic defects; a pedicled latissimus dorsi mus-
cle flap, detached from its humeral insertion, for
thoracic defects; or a turnover latissimus or glu-
teus maximus muscle flap for lumbosacral recon-
struction (Fig. 4). In this study, 25 of 52 cases (48
percent) underwent reconstruction with two or
more muscle flaps.
The goal is to completely cover the spinal re-
construction, particularly the hardware, so that
there are layers of well-vascularized tissue covering
the underlying vital structures. If this goal is
achieved, the occurrences of a minor wound

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Volume 125, Number 5 Immediate Reconstruction of the Spine

spinal wounds resulting from tumor extirpation

ideally should include preoperative recognition of
high-risk patients by the spine surgeon and pre-
operative assessment by a plastic surgeon.

CODING PERSPECTIVE
This information prepared by Dr. Raymond
Janevicius is intended to provide coding guid-
ance.
15734 Muscle, myocutaneous, or
fasciocutaneous flap; trunk

Each group of muscles in the turnover flap

is reported separately with code 15734.
Fig. 4. If the paraspinous muscle group is compromised by the
Each individual muscle of the group is not
tumor resection or previous irradiation, the closure may be aug-
separately reported, as they are elevated
mented by superficial muscle flaps such as a pedicled latissimus
and transposed as a group. The transfer of
dorsi muscle flap.
two muscle groups depicted in Figure 2 is
reported as:
15734 Right paraspinous muscle flap
breakdown will not expose the hardware and
15734-51 Left paraspinous muscle flap
other vital structures.
Postoperative care typically involves patients Even though the procedure is performed
ambulating on postoperative day 1 if the dura was bilaterally, the bilateral modifier, 50, is not
not violated during tumor extirpation. Patients used in this case, as payers do not recognize
requiring dural repair are kept on bed rest for 3 15734 as a bilateral procedure.
days before mobilization, and a lumbar drain is If a superficial muscle flap is also used, it is
frequently used to keep cerebrospinal fluid pres- separately reported as:
sures low. It is preferable to avoid prolonged pres-
sure on the midline incision. To avoid this, an 15734 Right paraspinous muscle flap
acceptable protocol entails rotating the patient by 15734-51 Left paraspinous muscle flap
placing pillows under the patients hip and shoul- 15734-51 Latissimus dorsi muscle flap
der and alternating sides every 2 hours.
Some payers may require the separate pro-
cedure modifier, 59, to indicate that three
CONCLUSIONS separate muscle flaps are performed:
In this study, we evaluated our paradigm shift 15734 Right paraspinous muscle flap
in the way we manage complex wounds of the 15734-59 Left paraspinous muscle flap
spine. Spine tumor patients identified to be at 15734-59 Latissimus dorsi muscle flap
high risk for wound-healing complications (e.g.,
previous spinal surgery, preoperative irradiation, A layered closure is generally performed.
spinal instrumentation, postoperative irradiation, This is considered part of the global muscle
smokers, comorbid medical conditions) should be flap code, 15734, and should not be re-
considered for immediate soft-tissue reconstruc- ported separately.
tion with muscle flaps. Immediate soft-tissue re-
construction should also be considered when dif-
ficulty with wound closure is anticipated in
patients with extensive defects. In our experience, David W. Chang, M.D.
patients who have undergone immediate soft-tis- Department of Plastic Surgery, Unit 443
The University of Texas M. D. Anderson Cancer Center
sue reconstruction for complex defects of the 1515 Holcombe Boulevard
spine have a low incidence of major complica- Houston, Texas 77030
tions. A team approach to the management of dchang@mdanderson.org

1465

ACKNOWLEDGMENT
The authors thank Hiroo Suami, M.D., Ph.D., for
the graphic illustration in Figure 3.
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