Vieira Samuel, Nabil Ahmed, Maza Guillermo, Shahein Mostafa, Vankoevering Kyle, Patel Krupal B, Prevedello Daniel, Carrau Ricardo, Ozer Enver, Silveira-Bertazzo Giuliano, Albonette-Felicio Thiago
Department of Neurological Surgery, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA.
Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA.
World Neurosurg. 2020 Jun;138:485-490. doi: 10.1016/j.wneu.2020.03.108. Epub 2020 Mar 27.
Craniocervical junction chordoma treated with surgery and Proton Beam Therapy evolved with Osteonecrosis and CSF leak. As the vascularization of the head was compromised, we harvested an Anterolateral thigh musculofascial flap to seal the leak.
A 56-year-old man presented with a history of chronic headaches and dysarthria with tongue deviation to the right. Magnetic resonance imaging showed a lesion at the craniocervical junction with imaging characteristics compatible with chordoma. Endoscopic endonasal resection was followed by proton beam therapy. Recurrence of the chordoma was subsequently resected via far lateral approach again followed by proton beam therapy accumulating a total dose of 75 Gy. Unfortunately, this led to osteoradionecrosis of the skull base resulting in a cerebrospinal fluid (CSF) leak more than 1 year after treatment. After multiple failed attempts to seal the defect using local vascularized tissue and free fat grafts, the defect was reconstructed with a vastus lateralis free tissue transfer. Six weeks later, the flap had mucosalized, the patient was pain free, and there was no evidence of a CSF leak.
In select cases, vascularized free flaps offer a superior reconstruction for osteoradionecrosis because radiotherapy often compromises the blood supply of local tissues.
