Bongers Michiel E R, Ogink Paul T, Chu Katrina F, Patel Anuj, Rosenthal Brett, Shin John H, Lee Sang-Gil, Hornicek Francis J, Schwab Joseph H
Departments of1Orthopedic Surgery, Orthopedic Oncology Service.
2Radiology.
J Neurosurg Spine. 2020 Nov 6;34(2):283-292. doi: 10.3171/2020.6.SPINE20521. Print 2021 Feb 1.
Reconstruction of the mobile spine following total en bloc spondylectomy (TES) of one or multiple vertebral bodies in patients with malignant spinal tumors is a challenging procedure with high failure rates. A common reason for reconstructive failure is nonunion, which becomes more problematic when using local radiation therapy. Radiotherapy is an integral part of the management of primary malignant osseous tumors in the spine. Vascularized grafts may help prevent nonunion in the radiotherapy setting. The authors have utilized free vascularized fibular grafts (FVFGs) for reconstruction of the spine following TES. The purpose of this article is to describe the surgical technique for vascularized reconstruction of defects after TES. Additionally, the outcomes of consecutive cases treated with this technique are reported.
Thirty-nine patients were treated at the authors' tertiary care institution for malignant tumors in the mobile spine using FVFG following TES between 2010 and 2018. Postoperative union, reoperations, complications, neurological outcome, and survival were reported. The median follow-up duration was 50 months (range 14-109 months).
The cohort consisted of 26 males (67%), and the median age was 58 years. Chordoma was the most prevalent tumor (67%), and the lumbar spine was most affected (46%). Complete union was seen in 26 patients (76%), the overall complication rate was 54%, and implant failure was the most common complication, with 13 patients (33%) affected. In 18 patients (46%), one or more reoperations were needed, and the fixation was surgically revised 15 times (42% of reoperations) in 10 patients (26%). A reconstruction below the L1 vertebra had a higher proportion of implant failure (67%; 8 of 12 patients) compared with higher resections (21%; 5 of 24 patients) (p = 0.011). Graft length, number of resected vertebrae, and docking the FVFG on the endplate or cancellous bone was not associated with union or implant failure on univariate analysis.
The FVFG is an effective reconstruction technique, particularly in the cervicothoracic spine. However, high implant failure rates in the lumbar spine have been seen, which occurred even in cases in which the graft completely healed. Methods to increase the weight-bearing capacity of the graft in the lumbar spine should be considered in these reconstructions. Overall, the rates of failure and revision surgery for FVFG compare with previous reports on reconstruction after TES.
对于患有恶性脊柱肿瘤的患者，在对一个或多个椎体进行整块全脊椎切除术（TES）后重建可活动脊柱是一项具有挑战性的手术，失败率很高。重建失败的一个常见原因是骨不连，在使用局部放射治疗时这一问题会变得更加棘手。放射治疗是脊柱原发性恶性骨肿瘤治疗不可或缺的一部分。带血管蒂移植物可能有助于预防放射治疗情况下的骨不连。作者已使用游离带血管蒂腓骨移植物（FVFG）在TES后重建脊柱。本文的目的是描述TES后缺损的带血管蒂重建的手术技术。此外，还报告了采用该技术治疗的连续病例的结果。
2010年至2018年期间，39例患者在作者所在的三级医疗机构接受了TES后使用FVFG治疗可活动脊柱恶性肿瘤。报告了术后骨愈合情况、再次手术情况、并发症、神经功能结果和生存率。中位随访时间为50个月（范围14 - 109个月）。
该队列包括26名男性（67%），中位年龄为58岁。脊索瘤是最常见的肿瘤（67%），腰椎受累最严重（46%）。26例患者（76%）实现了完全骨愈合，总体并发症发生率为54%，植入物失败是最常见的并发症，13例患者（33%）受影响。18例患者（46%）需要进行一次或多次再次手术，10例患者（26%）的内固定进行了15次手术翻修（占再次手术的42%）。与高位切除（21%；24例中的5例）相比，L1椎体以下的重建植入物失败比例更高（67%；12例中的8例）（p = 0.011）。在单因素分析中，移植物长度、切除椎体数量以及将FVFG对接在终板或松质骨上与骨愈合或植入物失败无关。
FVFG是一种有效的重建技术，特别是在颈胸椎。然而，已观察到腰椎的植入物失败率很高，即使在移植物完全愈合的病例中也会发生。在这些重建中应考虑增加腰椎移植物承重能力的方法。总体而言，FVFG的失败率和翻修手术率与先前关于TES后重建的报告相当。
