Myofascial Flap Closure in Treatment of Patients with Craniocervical Instability
Connie Lu, MD, Gal Wald, BA, Jeffrey Greenfield, MD, David Otterburn, MD.
Weill Cornell Medicine, New York, NY, USA.
BACKGROUND: Craniocervical instability (CCI) is a congenital condition that may lead to pathological deformation of the brainstem, upper spinal cord and cerebellum. There is an association between CCI and Ehlers-Danlos Syndrome (EDS), a hereditary connective tissue disorder that affects joints, skin and wound healing. Primary treatment of CCI is decompression and craniocervical fusion surgery however numerous postoperative complications such as cerebrospinal fluid leak, pseudomeningocele, seroma, hemorrhage, aseptic meningitis and infection have been reported. Recent studies have shown the advantages of myofascial flap closure in various spinal procedures. As EDS is theoretically associated with poor healing with greater levels of dissection, this study was designed to analyze the effectiveness of flap surgery in this cohort.
METHODS: A retrospective review of patients presenting to Weill Cornell Medical Center from 2010 to 2017 for craniocervical surgery was performed. All patients who underwent craniocervical surgery, regardless of plastic surgical involvement, were included in the study. Data including demographics, history of diagnosed EDS, comorbidities, surgical history, complications and follow-up were collected and analyzed. Patients were divided into 2 groups, CCI surgery with flap closure and CCI without flap closure. A sub-group analysis was performed on patients diagnosed with EDS.
RESULTS: A total of 39 patients underwent flap closure and 18 patients without flap closure. Patients with CCI undergoing surgery have a significantly lower reoperative rate with muscle flap closure (Fisher’s exact t-test, p=0.0096). There were no statistical differences in complication rates of cerebrospinal fluid leak, infection, wound breakdown, seroma, or hematoma between the two groups. Similarly, complication rates in patients with EDS undergoing flap closure were similar to those without flaps. Patients with EDS trended towards decreased reoperative rate, but without statistical significance (Fisher’s exact t-test, p=0.1265).
CONCLUSIONS: Patients with CCI undergoing decompression and/or fusion surgery have a lower reoperative rate with muscle flap closure. Bringing in well-vascularized tissue can decrease rates of reoperation. There may be an additional benefit for EDS patients, although further analysis and greater power is warranted.
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