The Use of Bilateral Paraspinous Muscle Flaps and Bilateral Composite Latissimus Dorsi and Gluteus Maximus Flaps for Closure of Lumbosacral Myelomeningcele Defects in Infants

Purpose

            Myelomeningocele is the most common congenital malformation of the central nervous system, with a prevalence of 4.4 to 4.6 per 10,000 live births in the United States. They are most commonly observed in the lumbosacral region, as this is the last region of the neural tube to fuse¹. Robust, reliable and reproducible closure of lumbosacral myelomeningocele defects remains a challenge. Closure of spinal defects following neurosurgical procedures with well-vascularized flaps in high-risk patients has been shown to reduce complications in the adult population².   In infants with lumbosacral myelomeningocele, in addition to the relatively standard neurosurgical repair that consists of placode tubularization and dural repair, multiple methods of soft tissue coverage have been described. These include various cutaneous, fascial and muscle flaps and grafts. We present here our unique closure technique with well-vascularized flaps following lumbosacral myelomeningocele repair.

Methods

            After the neurosurgical repair of lumbosacral myelomeningocele is completed, bilateral composite latissimus dorsi musculocutanous and gluteus maximus fasciocutanous flaps are elevated. The gluteus maximus fasciocutaneous flaps are completely elevated from their insertion on the ileum and sacrum. The paraspinous muscle flaps are then elevated and medialized based on the lateral row arterial perforators to provide complete muscular coverage of the dural repair. The bilateral composite latissimus dorsi muscleocutanous and gluteus maximus fasciocutanous flaps are medialized, reapproximated with the sacrum, and closed over the paraspinous muscle flap repair.

            Demographic and outcomes data of 9 patients from June 2014 to present were retrospectively reviewed.

Results

            Of the 9 patients that underwent the above technique for closure of myelomeningocele defects, all repairs were performed between days of life 0-3. Seven of 9 (77.8%) had Chiari 2 malformation and 3 of 9 (33.3%) required ventriculoperitoneal shunt. There have been no episodes of dehiscence with a median follow-up of 52 weeks (6-161 weeks). One patient experienced a small area of superficial skin necrosis requiring surgical excision and reclosure.

Conclusion

Use of bilateral paraspinous muscle flaps covered with bilateral composite latissimus dorsi and gluteus maximus flaps provides robust and durable coverage of lumbosacral defects following neurosurgical myelomeningocele repair in infants.

 

Citations

1. Kural, Solmax, Tehli, Emiz, Kutlay, Daneyemez, Izci. Evaluation and management of lumbosacral myelomeningoceles in children. Eurasian J Med. 2015; 47(3): 174-178.
2. Kesan, Kothari, Gupta, Gupta, Karkera, Ranjan, Mutkhedkar, Sandlas. Closure of large meningomyelocele wound defects with subcutaneous based pedicle flap with bilateral V-Y advancement: our experience and review of literature. Eur J Pediatr Surg. 2015; 25(2): 189-194.