Eight (14.5%) of the patients required revision surgery for major complications. Specifically, three patients (5%) required debridement of failed pedicled vertical rectus abdominis myocutaneous (VRAM) flaps covering sacral defects. All three underwent delayed reconstruction. At exploration, all three flaps were found to be hypoperfused as a result of tension on the relatively short pedicle as it spanned the pelvis to provide myocutaneous cover of sacral hardware and dead space. Following debridement of devitalized tissue, these defects were then reconstructed with free latissimus dorsi flaps, without complication, as a second procedure. One patient (2%) required debridement of bilateral grade-IV ischial pressure ulcers secondary to pressure necrosis partly related to instrumentation. These defects required reconstruction with bilateral anterolateral thigh fasciocutaneous flaps as a second procedure. Four patients (7%) developed deep cavity abscesses with associated sinus formation in the overlying skin, which required irrigation and debridement of devitalized tissue, with removal of instrumentation in two of the four patients. Exposure of instrumentation of the cervical spine occurred in one patient (2%), requiring bilateral trapezius myocutaneous advancement flaps to cover the exposed hardware and achieve tension-free wound closure. At the time of the latest follow-up, all patients had closed wounds.
The heterogeneity of the cohort with regard to patient, disease, and treatment-related factors (Tables I and II) prevents a sound statistical analysis; however, trends regarding the association of certain factors with higher complication rates were identified (Table III). Twenty-two (40%) of the patients reported a history of smoking, and the complication rate was 68% for the smokers compared with 21% for the nonsmokers. Thirty-three (60%) of the patients underwent reconstruction of surgical defects that had previously been irradiated, and the complication rate was 57% in these patients compared with 10% in those who had required no radiation therapy. The mean body-mass index (BMI) of the cohort was 26.7 kg/m2, with thirty-eight (69%) of the patients reported as clinically obese (BMI, ≥25 kg/m2), and the complication rate was 53% in those patients compared with 12% in those of normal BMI.
Over one-quarter of the cohort (fifteen, 27%) had had prior spinal surgery and forty (73%) had instrumentation for osseous stabilization, and the latter patients had a complication rate of 50% compared with 13% for those who did not have spinal instrumentation. Twenty-five (45.5%) of the patients had spinal surgery involving at least two levels, and the complication rates in those patients was 60% compared with 23% in those who did not have multiple-level spinal surgery.
Twenty-five (45.5%) of the patients had received prior chemotherapy. Seventeen (31%) of the patients had diabetes mellitus, and twelve (22%) had a history of either peripheral vascular or ischemic heart disease. With respect to preoperative nutritional status, few patients in this cohort were identified with hypoalbuminemia (eight, 14.5%) or anemia (nine, 16%).
The response rate among the fifty-two living patients invited to complete the SF-36 and EORTC QLQ-C30 questionnaires was 19% (ten) for the first postoperative time point. Given this low response rate and the resulting risk of respondent bias, we did not further analyze these results.
The response rate for the second time point was 62% (thirty-two), with a mean postoperative follow-up time of 40.1 months (range, thirteen to 111 months). The mean scores for each SF-36 domain were obtained, and patients were dichotomized into immediate and delayed reconstruction groups. Of the thirty-two respondents, nineteen (59%) had undergone immediate, prophylactic reconstruction of defects and thirteen (41%) had undergone delayed reconstruction. The patients who had undergone delayed reconstruction had lower mean raw SF-36 scores (indicating poorer functioning) in the physical functioning (p = 0.02), role limitations (p = 0.01), and general health (p = 0.03) domains and the PCS (p = 0.04) compared with the patients who had undergone immediate reconstruction of defects (Table IV).
Similarly, on the EORTC QLQ-C30 functional domains, the patients who had undergone delayed reconstruction had lower mean raw scores (indicating poorer functioning) in the physical functioning (p = 0.04) and role functioning (p = 0.01) domains compared with the patients who had undergone immediate reconstruction (Table V). For the symptom and single-item QLQ-C30 scales, the patients who had undergone delayed reconstruction had higher mean raw scores (indicating poorer functioning) in the fatigue (p = 0.04), insomnia (p = 0.02), and appetite loss (p = 0.01) scales compared with the patients who had undergone immediate reconstruction (Table V).
Tumor-related spinal surgery has been revolutionized by recent advances in spinal instrumentation, novel allograft constructs, neuroimaging, and perioperative intensive medicine1,7. Despite advancements in modern spinal surgery, complex defects of the spine and sacrum remain a substantial reconstructive challenge1-7. In this series of tumors of the spine and sacrum, we evaluated surgical and HRQoL outcomes of patients following radical resection and soft-tissue reconstruction, with or without osseous reconstruction, in the immediate and delayed settings, and we identified factors predictive of wound complications.
Analysis of surgical outcomes revealed an overall wound complication rate of 36%. Despite a paucity of similar spinal reconstruction series, our findings are comparable with those reported previously8. It is postulated that higher complication rates following reconstruction of spinal defects are attributed to the diminished wound-healing capacity of patients with spinal tumors (advanced age, multiple comorbidities, chemotherapy and/or radiation therapy, and use of spinal instrumentation and allograft material). We propose that the high comorbidity risk profile in our cohort (73% with spinal instrumentation, 64% with previous radiation therapy, 47% clinically obese, 40% with a smoking history, 36% who underwent delayed reconstruction, and 31% with diabetes mellitus) combined with the complexity of cases presenting for tertiary and quaternary-level management may be substantial predisposing factors for higher wound complication rates.
The timing of reconstruction has been identified as a key prognostic indicator of surgical outcomes following spinal defect reconstruction7,8, and this was confirmed in the present study by the higher rates of wound-related complications associated with delayed reconstruction. High rates of major wound complications associated with delayed reconstruction may have potentially devastating consequences because such complications may expose vital neural structures, spinal instrumentation, and allograft material8. Challenges are multifactorial in the delayed setting and include the creation of a large defect or dead space following wound debridement requiring multiple flaps from local or distant sites, with limited tissue mobilization and unreliable perfusion secondary to radiation-induced fibrosis. Furthermore, there is a higher risk of iatrogenic spinal injury and instability associated with removal of stabilization devices due to infection5,9,22-27.
Thus, there has been a shift in the management of complex tumors of the spine to provide definitive, prophylactic (immediate) soft-tissue reconstruction at the time of tumor resection, in an attempt to optimize surgical outcomes for at-risk patients. This streamlined orthoplastics management strategy has been implemented at our institution, with the present study revealing a fivefold increase in prophylactic soft-tissue coverage over the study period. In concordance with the threefold reduction in the major complication rate previously cited following implementation of prophylactic reconstruction8, we report a twofold higher wound complication rate for the delayed (60%) compared with the immediate (29%) spinal reconstruction group (p = 0.03). Specifically, higher rates of free flap failure and revision surgery were observed in the delayed reconstruction group. These data add further credence to the role of prophylactic soft-tissue reconstruction in achieving stable, definitive wound closure with minimal patient morbidity. However, it is impractical to have a plastic surgeon’s input for every spinal tumor case in which the patient has a potential wound-healing problem and to have ready availability of the plastic surgeon if primary closure proves impossible intraoperatively1.
There is a broad consensus that assessing surgical outcomes in terms of patients’ subjective reports and psychological functioning provides an additional component to achieving a meaningful understanding of the effects of treatment11-17,28-31. To our knowledge, this is the first study to report HRQoL outcomes following soft-tissue reconstruction of oncologic spinal defects. In the present study, the patients who underwent delayed reconstruction reported significantly lower mean SF-36 PCS scores and EORTC QLQ-C30 physical functioning scores (poorer functioning) and higher EORTC QLQ-C30 symptom scale scores (more symptomatic) compared with the patients who underwent immediate, prophylactic reconstruction. These findings may reflect a negative impact of the higher wound complication rates, prolonged treatment period, and additional treatment interventions associated with delayed reconstructions on patients’ perception of their physical functioning. The HRQoL data, while subjective, may add further support to the benefits of immediate, prophylactic reconstructions for this subgroup of patients.
This study has several limitations. First, there are the inherent limitations associated with a retrospective study design and a heterogeneous patient sample. A further limitation is the difficulty associated with assessing HRQoL and functional outcomes in the postoperative setting without an appropriate preoperative comparison. The present study does, however, provide strong preliminary data for a subsequent comprehensive longitudinal study evaluating the association of specific biomedical factors with HRQoL scores and functional outcome following soft-tissue reconstruction of oncologic defects of the spine and sacrum.
Investigation performed at the Departments of Plastic & Reconstructive Surgery and Trauma & Orthopaedic Surgery, Nuffield Orthopaedic Hospital, Oxford University Hospitals, Oxford, United Kingdom
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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