Spinal Reconstruction With Free Vascularized Fibular Grafts: A Modification in Technique

Our objective is to report a series of three cases of progressive thoracolumbar osteomyelitis treated with anterior corpectomy and spinal fusion using an expandable titanium cage, supplemented with an indwelling free vascularized fibular strut graft and we aim to document a new technique using intra-abdominal vessels as the recipient vessels for the microanastomosis of free vascularized fibula grafts.

Reconstruction of bony defects in the surgical management of vertebral osteomyelitis can be a challenging endeavor.  Goals of surgical management include adequate debridement, reconstitution of structural integrity, and delivery of antibiotics to the area of interest.  To achieve these objectives many strategies have been conceived, including the use of vascularized bone graft.^1,2,3At the current time, we are unaware of a report of using intra-abdominal vessels at the recipient vessels for the microanastomosis of vascularized bone graft.

Three patients failed conservative treatment for vertebral osteomyelitis and suffered a pathologic fracture; they were indicated for surgical management.  Their treatment consisted of staged posterior irrigation & debridement (I&D) with segmental fixation, followed by a thoracoabdominal approach multiple-level thoracolumbar corpectomy.  Reconstruction was performed with a custom, expandable titanium cage and free vascularized fibular graft placed within the cage.  The vascularized fibular graft was anastamosed to an intra-abdominal recipient vessel in all three cases.

The corpectomy and reconstruction procedures, including the dissection and anastomosis between the left gastroepiploic vessels and the peroneal vessels, were successfully performed. The patients showed clinical improvement postoperatively, with no neurologic deficits noted, and all three were ambulating with assistive devices prior to discharge.  At latest follow-up their neurologic status was unchanged, and they showed evidence of successful fusion.

Free vascularized bone grafts continue to be excellent option for multilevel spinal defects related to osteomyelitis. Intra-abdominal recipient vessels such as the left gastroepiploic are appropriate recipient vessels, their diameter, length, and accessibility allow vascularized bone graft reconstruction of vertebral column defects of the thoracolumbar region.