INTRODUCTION The treatment of high-risk patients in spine stabilization can be fraught with complications. Patients who have had prior surgery for spine reconstruction, a history of perioperative spine infection, radiation therapy and multi-organ disease are at high risk for failure using conventional spine stabilization with bone grafts. More involved methods have been described to improve reliability, including microvascular bone transfer, but these pose the potential for additional complications and morbidity. A combined construct, using a pedicled myo-osseus costal flap integrated in a titanium cage, provides the benefits of each: immediate robust stabilization even in hostile circumstances, while minimizing peri-operative morbidity.

METHODS A prospective study of fourteen high-risk patients (aged 43 to 63) is presented, including patient outcomes, CT studies and bone scans. All patient outcomes are compared to results of conventional reconstructive methods. A latissimus-sparing left thoracotomy is performed with harvest of an anterior rib segment and surrounding intercostal musculature pedicled on its neurovascular bundle. Anterior spinal decompression and stabilization is facilitated by the approach and rib harvest, allowing for wide exposure and tension-free inset of the pedicled costal flap, integrated within its titanium construct.

RESULTS 100% viability of the vascular construct was found in all cases. Fourteen patients with 31 comorbidities demonstrate clinical and radiologic stability in a variety of challenging circumstances over a mean 19 month follow-up period. Three mortalities are reported from primary disease processes with intact spinal stabilization. The average harvest, thoracotomy, and inset time was 100 minutes. No technical complications occurred.

CONCLUSION The vascular rib construct is safe, reliable, and time efficient. It effectively stabilizes the spine and obliterates the dead space associated with traditional techniques. This construct offers major advantages over traditional non-vascularized bone grafting in hostile reconstructive circumstances. We propose an algorithm for its application routinely after failure of conventional reconstruction, and describe a rationale for its use as primary reconstruction for a defined population of high-risk patients.
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