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Minh H. Nguyen, Krishna Patel, Julie West, Thomas Scharschmidt, Matthew Chetta, Steven Schulz, Ehud Mendel, and Ian L. Valerio

OBJECTIVE

The consequences of failed spinal hardware secondary to wound complications can increase the burden on the patient while also significantly escalating the cost of care. The objective of this study was to demonstrate the effectiveness of a protocol-based multidisciplinary approach in optimizing wound outcome in complex oncological spine care patients.

METHODS

A retrospective consecutive case series was performed from 2015 to 2019 of all patients who underwent oncological spine surgery. A protocol was established to identify oncological patients at high risk for potential wound complications. Preoperative and postoperative treatment plans were developed by the multidisciplinary tumor board team members. Wound healing risk factors such as diabetes, obesity, prior spine surgery, pre- or postoperative chemotherapy or radiation exposure, perioperative steroid use, and poor nutritional status were recorded. Operative details, including the regions of spinal involvement, presence of instrumentation, and number of vertebral levels operated on, were reviewed. Primary outcomes were the length of hospitalization and major (requiring reoperation) and minor wound complications in the setting of the aforementioned identified risk factors.

RESULTS

A total of 102 oncological cases were recorded during the 5-year study period. Of these patients, 99 had local muscle flap reconstruction with layered closure over their surgical hardware. The prevalence of smoking, diabetes, and previous spine surgery for the cohort was 21.6%, 20.6%, and 27.5%, respectively. Radiation exposure was seen in 72.5% of patients (37.3% preoperative vs 48% postoperative exposure). Chemotherapy was given to 66.7% of the patients (49% preoperatively and 30.4% postoperatively). The rate of perioperative steroid exposure was 60.8%. Prealbumin and albumin levels were 15.00 ± 7.47 mg/dL and 3.23 ± 0.43 mg/dL, respectively. Overall, an albumin level of < 3.5 mg/dL and BMI < 18.5 were seen in 64.7% and 13.7% of the patients, respectively. The mean number of vertebral levels involved was 6.76 ± 2.37 levels. Instrumentation of 7 levels or more was seen in 52.9% of patients. The average spinal wound defect size was 22.06 ± 7.79 cm. The rate of minor wound complications, including superficial skin breakdown (epidermolysis) and nonoperative seromas, was 6.9%, whereas that for major complications requiring reoperation within 90 days of surgery was 2.9%.

CONCLUSIONS

A multidisciplinary team approach utilized in complex multilevel oncological spine reconstruction surgery optimizes surgical outcomes, reduces morbidities, and improves care and satisfaction in patients with known risk factors.

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Ehud Mendel, Narendra Nathoo, Thomas Scharschmidt, Carl Schmidt, James Boehmler, and Joel L. Mayerson

En bloc resection with negative tumor margins remains the principal treatment option for control or cure of primary pelvic chondrosarcomas, as current adjuvant therapies remain ineffective. Iliosacral chondrosarcomas with involvement of the sciatic notch are sufficiently challenging tumors. However, when there is concomitant lumbar extension requiring resection of the pedicles to maintain negative surgical margins, transpedicular screw fixation is not possible, making reconstruction of the lumbopelvic junction extremely challenging. A patient with an iliosacral chondrosarcoma with lumbar spine extension is presented in this report to illustrate a novel lumbopelvic spinal construct. Following combined external pelvectomy and hemisacrectomy with contralateral L3–5 hemilaminectomy and ipsilateral pediculotomy, bicortical transvertebral body screws were substituted for the missing pedicles, resulting in the creation of “false pedicles,” which were further supplemented with an autologous vascularized fibular strut graft from the amputated lower limb and applied to the lateral aspect of the vertebral bodies. The creation of false pedicles allowed for a robust reconstruction of the lumbopelvic junction, including maintaining pelvic ring integrity with a “neo-pelvis”, creating a functional load-bearing construct adequate for early mobilization and ambulation. The biomechanical dynamics of this unique construct are also discussed.