From the Craniofacial Center, Division of Plastic and Craniofacial Surgery, and Department of Neurosurgery, Seattle Children's Hospital.
Plast Reconstr Surg. 2022 Aug 1;150(2):435e-438e. doi: 10.1097/PRS.0000000000009331. Epub 2022 Jun 9.
Following neurosurgical repair of spinal dysraphism defects, soft-tissue reconstruction is often required to obtain robust coverage of the dura. Layered closure utilizing local muscle and muscle fascia has proven reliable for this purpose, but it often results in significant dead space necessitating closed suction drainage. Progressive-tension sutures have been reported as an alternative to drains for prevention of fluid collection in several other procedures. In this study, the use of progressive-tension sutures for eliminating subcutaneous dead space and obtaining tension-free skin closure was prospectively evaluated in pediatric patients undergoing soft-tissue reconstruction for congenital spinal anomalies. Primary outcomes of interest included wound breakdown, seroma, hematoma, and cerebrospinal fluid leak. Patients were excluded if a lumbar, submuscular, or subcutaneous drain was placed during the index procedure. Over a 3-year period, 45 patients underwent muscle flap reconstruction for coverage of dural defects. The primary diagnoses were myelomeningocele (10 patients), lipomyelomeningocele (eight patients), myelocystocele (three patients), tethered cord release (15 patients), meningocele (three patients), spinal tumor (two patients), and hardware exposure following spinal instrumentation (three patients). During the follow-up period, three patients (6.7 percent) had postoperative wound complications. One patient had superficial dehiscence, one had cerebrospinal fluid leak requiring operative revision, and one had a surgical site infection necessitating operative drainage. No patients developed hematomas, seromas, cerebrospinal fluid fistulae, or wound breakdown requiring operative revision. The use of progressive-tension sutures is an effective method for eliminating subcutaneous dead space in pediatric soft-tissue reconstruction and eliminates the need for drain placement.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
脊髓脊膜膨出缺陷经神经外科修复后，通常需要进行软组织重建以获得坚韧的硬脑膜覆盖。利用局部肌肉和肌肉筋膜进行分层闭合已被证明对此非常可靠，但通常会导致大量死腔，需要闭式负压引流。在其他几种手术中，已报道使用渐进式张力缝线替代引流管以预防积液。在这项研究中，前瞻性评估了在接受先天性脊柱畸形软组织重建的儿科患者中使用渐进式张力缝线消除皮下死腔并获得无张力皮肤闭合的效果。主要观察指标包括伤口裂开、血清肿、血肿和脑脊液漏。如果在指数手术中放置了腰椎、肌下或皮下引流管，则将患者排除在外。在 3 年期间，有 45 名患者接受了肌肉瓣重建以覆盖硬脑膜缺陷。主要诊断为脊髓脊膜膨出（10 例）、脂肪脊膜膨出（8 例）、脊髓脊膜膨出（3 例）、脊髓栓系松解术（15 例）、脑膜膨出（3 例）、脊髓肿瘤（2 例）和脊柱器械固定后硬件暴露（3 例）。在随访期间，有 3 名患者（6.7％）发生术后伤口并发症。1 例出现浅表裂开，1 例出现需要手术修复的脑脊液漏，1 例出现手术部位感染需要手术引流。没有患者出现血肿、血清肿、脑脊液瘘或需要手术修复的伤口裂开。渐进式张力缝线的使用是小儿软组织重建中消除皮下死腔的有效方法，并且消除了放置引流管的需要。
临床问题/证据水平：治疗，IV。
