The essential multidisciplinary spine reference on optimizing complex bony and soft tissue reconstruction


Lessons learned from soft tissue reconstruction, wound healing, and infection prevention in plastic surgery and bony arthrodesis strategies and spinal alignment in orthopaedic surgery and neurosurgery have merged to create a new field of surgery. Spinoplastic Reconstruction, edited by Alexander E. Ropper, Sebastian J. Winocour, Michael A. Bohl, and Edward M. Reece provides in-depth discussion of multidisciplinary techniques and complication management in complex bony and soft tissue reconstruction, with the goal of improved outcomes for spine surgery patients.


This textbook encompasses the nomenclature, indications, evidence-based techniques, outcomes, and alternatives that laid the groundwork for spinoplastic surgery. Organized into nine sections and 42 chapters, the book begins by delineating the historical and future relevance of multidisciplinary surgery and advent of spinoplastic surgery to ease the growing global disease burden of spine disease. The second section discusses applied anatomy, biomechanics, and bony spinal stability. Sections three to nine provide detailed discussion and pearls on bone healing, bone adjuncts, perioperative management, surgical spine exposures, vascularized autologous bone grafts and flaps, soft tissue spinal reconstruction, and complication management.

Contributions from an impressive group of multidisciplinary spinoplastic surgery founders and innovators exemplifies the ethos of this emerging field
Traditional and novel approaches for managing common challenges in spine surgery, including pseudoarthrosis and wound infection
High-quality operative photos, illustrations, and 12 videos provide visual understanding of spinal anatomy and techniques
This unique resource provides spine surgeons with a better understanding of the tenets of soft tissue reconstruction and plastic surgeons with a clearer understanding of the challenges faced in complex spine surgery, thereby improving collaborative patient management.


This print book includes complimentary access to a digital copy on https: //medone.thieme.com.


Preface
Section I Introduction
1 History of Multidisciplinary Spine Surgery: Spinoplastics
1.1 Evolution of Spinal Surgery as a Multidisciplinary Endeavor
1.2 Introduction to the Modern Era of Spinal Surgery
1.3 Traditional Role of Plastic Surgeons in Spine Surgery
1.3.1 Complications
1.3.2 Patient Presentation and Care
1.4 Prophylactic Involvement of Plastic Surgeons in Spine Surgery
1.4.1 Risk Factors
1.5 Prophylactic Involvement of Plastic Surgery
1.6 Introduction to Spinoplastics
1.7 History of Vascularized Bone Grafting in Spine Surgery
1.7.1 Advantages over Traditional Grafts
1.8 Advent of Spinoplastics
1.9 References
2 The Future of Multidisciplinary Surgery
2.1 Introduction
2.2 Multidisciplinary Team Meetings Tumor Boards and Case Conferences
2.3 Surgical Co-Management Enhanced Recovery after Surgery (ERAS) Protocols
2.4 Cleft Care
2.5 Breast Cancer Care
2.6 Orthoplastic Surgery
2.7 Spinoplastic Surgery
2.8 Future Directions
2.9 Conclusion
2.10 References
3 The Advent of Spinoplastic Surgery: Easing the Growing Global Burden of Spine Disease
3.1 Who is the Modern Spine Surgeon?
3.2 Spine Surgical Principles
3.3 Status of Global Spine Surgery
3.4 Oncological Spine Disease
3.5 Pediatric Spine Surgery
3.6 Traumatic Spine Condition
3.7 Infectious Condition of the Spine
3.8 Health Economic Aspects of Spinoplastic Surgery
3.9 Risk Factors
3.10 The Global Perspective
3.11 Summary
3.12 Conclusion
3.13 References
Section II Anatomy and Biomechanics for the Spinoplastic Surgeon
4 Applied Anatomy of the Cervical Spine
4.1 Introduction
4.2 Spinal Column
4.2.1 Occipitocervical Junction
4.2.2 Subaxial Cervical Spine
4.3 Neural Elements
4.3.1 Spinal Cord
4.3.2 Spinal Nerves
4.4 Vascular Anatomy
4.4.1 Carotid Artery
4.4.2 Vertebral Artery
4.5 Adjacent Structures
4.6 Conclusion
4.7 References
5 Applied Anatomy of the Thoracic and Lumbar Spine
5.1 Introduction
5.2 Spinal Column
5.2.1 Spinal Alignment
5.2.2 Osseous Structures
5.2.3 Discoligamentous Structures
5.3 Neural Elements
5.3.1 Spinal Cord
5.3.2 Spinal Nerves
5.4 Vascular Anatomy
5.4.1 Arterial Supply of the Spine
5.4.2 Arterial Supply of the Spinal Cord
5.4.3 Venous Drainage
5.5 Conclusion
5.6 References
6 Applied Anatomy of the Sacral Spine
6.1 Introduction
6.2 Bony Anatomy
6.2.1 Sacral Joints and Ligaments
6.3 Neural Anatomy
6.3.1 Major Nerves Exiting the Pelvis
6.3.2 Major Pelvic Nerves
6.4 Vascular Anatomy
6.5 Visceral Anatomy
6.6 Conclusion
6.7 References
7 Biomechanics and Bony Spinal Stability
7.1 Principles of Spine Biomechanics
7.2 Research Tools for Spine Biomechanics
7.3 Biomechanics of Spinal Components
7.3.1 Vertebrae
7.3.2 Intervertebral Disks
7.3.3 Ligaments
7.3.4 Muscles and Tendons
7.3.5 Facet Joints
7.4 Regional Biomechanics of the Bony Spine
7.4.1 Cervical Spine
7.4.2 Thoracic and Lumbar Spine
7.4.3 Physiological Curves
7.5 Spinal Instability
7.5.1 Traumatic Instability
7.5.2 Degenerative Instability
7.5.3 Neoplastic Instability
7.6 Spine Operations and Stability
7.7 Conclusion
7.8 References
Section III Bone Healing
8 Bone Modeling and Remodeling
8.1 Bone and Fusion Healing
8.2 Bone Modeling and Remodeling
8.3 Applications in Spinal Fusion
8.4 Conclusion
8.5 References
9 Biology and Anatomy of Spinal Fusion
9.1 Biology of Bone Fusion
9.1.1 Clinical Use and Considerations
9.2 Anatomical Areas of Spinal Fusion
9.2.1 Introduction
9.2.2 Intervertebral/Anterior Spinal Arthrodesis
9.2.3 Intertransverse/Posterior Spinal Arthrodesis
9.2.4 Conclusion
9.3 References
10 Patient Considerations in Bone Healing
10.1 Introduction
10.2 Bone Healing in Spinal Fusion
10.3 Overview of Bone Grafting
10.3.1 Autografts
10.3.2 Allografts
10.4 Osteoporosis in Spine Surgery
10.4.1 Complications Associated with Spine Surgery in Osteoporosis
10.5 Osteoporosis Treatment in Spine Surgery
10.5.1 Medical Optimization
10.5.2 Operative Techniques in Osteoporosis Mitigation
10.6 Other Factors in Spine Surgery Bone Healing
10.7 Conclusion
10.8 References
11 Bone Grafts versus Flaps: How to Evaluate the Spinal Fusion Bed to Determine Which Is Best for Your Patient
11.1 Introduction
11.2 Background
11.3 Case Examples
11.3.1 Case 1
11.3.2 Case 2
11.4 Conclusion
11.5 References
Section IV Bone Adjuncts
12 Bone Void Fillers: Allograft
12.1 Introduction
12.2 Bone Graft Characteristics
12.3 Bone Graft Selection
12.4 Allograft
12.5 Corticocancellous Allograft
12.6 Demineralized Bone Matrix
12.6.1 Cellular Bone Matrices
12.7 Synthetic Bone Graft Substitutes
12.8 Ceramics
12.8.1 Bioactive Glass
12.8.2 Polymer-Based Compounds
12.8.3 Allograft Delivery
12.9 Conclusion
12.10 References
13 Bone Void Fillers: Autograft and Harvest Techniques
13.1 Introduction
13.2 Anterior Iliac Crest
13.3 Posterior Iliac Crest
13.4 Rib
13.5 Fibula
13.6 Conclusion
13.7 References
14 Biologics in Spine Fusion
14.1 Introduction
14.2 Autografts
14.2.1 Overview
14.2.2 Bone Marrow Aspirates
14.2.3 Platelet-Rich Plasma
14.3 Allografts
14.4 Current Commercial Biologics: Bone Morphogenetic Proteins (BMP) and P-15 Peptide
14.4.1 Bone Morphogenetic Proteins (BMP)
14.4.2 BMP-7
14.4.3 rhBMP-2
14.4.4 rhBMP-2 Side Effect Profile
14.4.5 Improving rhBMP-2 Delivery
14.4.6 i-FACTOR (P-15)
14.5 Frontiers in Biologics
14.5.1 Systemic Therapies Teriparatide, Denosumab, Zoledronic Acid
14.5.2 New Biologic Molecules
14.5.3 Mesenchymal Stem Cells (MSCs)
14.6 Conclusion
14.7 References
Section V Perioperative Management of the Spinoplastic Patient
15 Preoperative Optimization of the Spinoplastic Patient
15.1 Introduction
15.2 Preoperative Optimization of Medical Comorbidities
15.2.1 Diabetes Mellitus
15.2.2 Obesity
15.2.3 Osteoporosis
15.2.4 Smoking
15.2.5 Rheumatoid Arthritis
15.3 Medications
15.3.1 Corticosteroids
15.3.2 Steroid-Sparing Immunosuppressive Medications
15.4 Nutritional Status
15.5 Chronic Pain and Opioid Use Disorder
15.6 Cognitive and Psychological Considerations for the Elderly Patient
15.7 Physical Dependence, Frailty, and Prehabilitation
15.8 Active Patient Engagement and Social Considerations
15.9 Conclusion
15.10 References
16 Postoperative Management of the Spinoplastic Patient
16.1 Introduction
16.2 New Postoperative Neurologic Deficits
16.3 Pulmonary
16.4 Hemodynamics
16.5 Venous Thromboembolic Events
16.6 Pain Management
16.7 Gastrointestinal/Nutrition
16.8 Renal and Urologic
16.9 Surgical Site Infection and Antibiotics
16.10 Drains
16.11 Postoperative Wound Dressing Management
16.12 Conclusion
16.13 References
17 Perioperative Management of the Pediatric Spine Patient
17.1 Introduction
17.2 Preoperative Management
17.3 Intraoperative Considerations
17.3.1 Intraoperative SSI-Reducing Interventions
17.3.2 Incision Management and Other Considerations
17.4 Postoperative Management
17.5 Conclusion
17.6 References
Section VI Surgical Spine Exposures
18 Exposures to the Cervical Spine: Anterior and Posterior
18.1 Introduction
18.1.1 History of Cervical Spine Surgery
18.2 Posterior Cervical Approach
18.2.1 History
18.2.2 Anesthesia
18.2.3 Positioning
18.2.4 Anatomy
18.2.5 Surgical Steps
18.3 Anterior Cervical Approach
18.3.1 History
18.3.2 Anesthesia
18.3.3 Positioning
18.3.4 Anatomy
18.3.5 Surgical Steps
18.3.6 Practical Consideration
18.3.7 Approaches to the Upper Cervical Spine
18.4 Conclusion
18.5 References
19 Exposures to the Thoracic Spine: Lateral and Posterior
19.1 Introduction
19.1.1 Transfacet Pedicle-Sparing
19.1.2 Transpedicular
19.1.3 Costotransversectomy
19.1.4 Lateral Extracavitary
19.1.5 Extradural Diskectomy
19.1.6 Transdural Diskectomy
19.1.7 Complications and Outcomes
19.2 Lateral and Anterolateral Approaches to the Thoracic Spine
19.2.1 Transpleural (Transthoracic)
19.2.2 Retroperitoneal Approach Undermining the Diaphragm for T12 L2
19.2.3 Retrodiaphragmatic Approach
19.2.4 Retropleural Approach
19.3 Conclusion
19.4 References
20 Exposure to the Lumbar and Sacral Spine
20.1 Introduction
20.1.1 Traditional Posterior Approach
20.1.2 Paramedial Approaches to the Spine
20.1.3 Anterior Approaches to the Spine
20.2 Soft Tissue Coverage of Spine Defects
20.2.1 Paraspinal Muscles
20.2.2 Trapezius Muscle
20.2.3 The Latissimus Dorsi Muscle
20.2.4 Perforator Flaps
20.2.5 Common Muscle Flaps
20.2.6 Bone Flaps
20.3 Conclusion
20.4 References
21 Exposures of the Previously Operated Spine
21.1 Introduction
21.2 General Considerations
21.3 Approaches for Reoperations in the Cervical Spine
21.4 Approaches for Reoperations in the Thoracolumbar Spine
21.5 Conclusion
21.6 References
Section VII Vascularized Autologous Bone Grafts and Flaps
22 The History of Pedicled Myo-Osseous Flaps in Spinal Reconstruction
22.1 Introduction to Pedicle Myo-Osseous Flaps in Spinal Reconstruction
22.2 Basic Terminology
22.3 Advantages of VBGs and VBFs in Spinal Reconstruction
22.4 Vascularized vs. Nonvascularized Bone Transfer
22.5 Early Origins of Vascularized Bone Transfer
22.6 Early Considerations of Vascularized Bone Transfer in Spinal Reconstruction
22.7 Current Options for Myo-Osseous Bone Flaps (VBGs) in Spinal Reconstruction
22.7.1 Occiput
22.7.2 Clavicle
22.7.3 Scapula
22.7.4 Rib
22.7.5 Iliac Crest
22.7.6 Spinous Process and Other Posterior Elements
22.8 Conclusion
22.9 References
23 Vascularized Rib Bone Flap: Indications, Techniques, and Outcomes
23.1 Introduction
23.2 Indications
23.3 Technique
23.4 Case Example
23.5 Outcomes and Alternatives
23.6 Conclusion
23.7 References
24 The Free Fibula Flap for Reconstruction of the Spine and Pelvis
24.1 Introduction
24.2 Free Bone Flaps
24.2.1 Free Vascularized Fibula Flap
24.2.2 Fibula Inset
24.2.3 Recipient Vessel Selection
24.2.4 Postoperative Evaluation and Follow-Up
24.2.5 Outcomes
24.3 Conclusion
24.4 References
25 Nomenclature of Vascularized Bone Grafts
25.1 Introduction
25.2 Clarification of Existing VBGs
25.2.1 Occiput
25.2.2 Clavicle
25.2.3 Scapula
25.2.4 Rib
25.2.5 Iliac Crest
25.2.6 Posterior Elements
25.3 Discussion
25.4 Conclusion
25.5 References
26 Vascularized Occipital Bone Grafting: Indications, Techniques, Clinical Outcomes, and Alternatives
26.1 Introduction
26.2 Indications
26.3 Technique
26.4 Case Example
26.5 Outcomes and Alternatives
26.6 Conclusion
26.7 References
27 Vascularized Clavicle Graft for Anterior Cervical Arthrodesis
27.1 Introduction A Brief History of Vascularized Bone Transfers
27.2 Anterior Cervical Arthrodesis Present Methods and the Future
27.3 Clavicular Flaps An Alternative to Traditional Vascularized Bone Transfers
27.3.1 Surgical Technique
27.3.2 Case Description
27.4 Conclusion
27.5 References
28 Vascularized Scapular Bone Grafting: Indications, Techniques, Clinical Outcomes, and Alternatives
28.1 Introduction to Vascularized Bone Grafts
28.2 Origins of the Use of the Scapula in Plastic Surgery
28.3 Anatomy of the Scapula
28.3.1 Bony Anatomy
28.3.2 Musculature
28.3.3 Vasculature
28.3.4 Flaps Involving the Scapula
28.3.5 Surgical Considerations for the Scapula
28.4 Vascularized Scapular Bone Flaps and Grafts
28.4.1 Vascularized Scapular Bone Flaps
28.4.2 Vascularized Scapular Bone Grafts
28.5 Vascularized Scapular Bone Grafts in Spinoplastics
28.5.1 Indications
28.5.2 Technique
28.5.3 Clinical Outcomes
28.5.4 Alternatives
28.6 Conclusion
28.7 References
29 Vascularized Posterior Iliac Crest Bone Grafting: Indications, Techniques, Clinical Outcomes, and Alternatives
29.1 Introduction
29.2 Pseudarthrosis
29.3 Vascularized Bone Flaps
29.4 Anatomy and Surgical Technique
29.5 Clinical Outcomes
29.6 Alternatives
29.7 Conclusion
29.8 Acknowledgments
29.9 References
Section VIII Soft Tissue Spinal Reconstruction
30 Principles and Techniques to Wound Closure
30.1 Basic Principles and Theory of Wound Healing
30.1.1 Phases of Wound Healing
30.1.2 Types of Wound Healing
30.1.3 Factors Affecting Wound Healing
30.2 Assessment and Classification of Spinal Wounds
30.2.1 Location
30.2.2 Size and Depth
30.2.3 Factors That Impair Wound Healing
30.3 Optimization of Systemic Factors Affecting Wound Healing
30.4 Principles of Wound Closure
30.4.1 Spinal Reconstructive Ladder
30.4.2 When to Avoid Wound Closure
30.5 Conclusion
30.6 References
31 Biologics and Adjuncts to Wound Healing
31.1 Wound Healing Optimization
31.1.1 Stages of Wound Healing
31.1.2 Nutrition
31.1.3 Glycemic Control
31.1.4 Smoking
31.1.5 Pressure Offloading
31.1.6 Radiation
31.1.7 Other Factors That Affect Wound Healing: Medications and Infection
31.2 Biologics in Wound Healing
31.2.1 Bioactive Materials
31.2.2 Skin Substitutes
31.3 Adjuncts to Wound Healing
31.3.1 Role of Antibiotics
31.3.2 Negative Pressure Wound Therapy
31.3.3 Closed Suction Drains
31.3.4 Hyperbaric Oxygen Supplementation
31.3.5 Electrical Stimulation
31.4 Conclusion
31.5 References
32 Soft Tissue Flap Coverage in the Cervical Spine
32.1 Introduction
32.2 Soft Tissue Coverage of the Posterior Cervical Spine
32.2.1 Trapezius Muscle Flap and Lower Trapezius Island Myocutaneous Flap
32.2.2 Paraspinous Muscle Flap
32.2.3 Reverse Latissimus Dorsi Muscle Flap
32.2.4 Dorsal Intercostal Artery Perforator Flap
32.2.5 Intercostal Muscle Perforator Flap
32.2.6 Free Flaps
32.2.7 Postoperative Management for Posterior Spine Surgery
32.2.8 Complications
32.3 Soft Tissue Coverage of the Anterior Cervical Spine
32.3.1 Supraclavicular Artery Island Flap
32.3.2 Submental Island Flap
32.3.3 Island Sternocleidomastoid Myocutaneous Flap
32.3.4 Postoperative Management for Anterior Spine Surgery
32.3.5 Complications
32.4 Conclusion
32.5 References
33 Soft Tissue Flap Coverage in the Thoracic Spine
33.1 Local Anatomy
33.2 Patient Selection and Preoperative Management
33.3 Muscle Flap Coverage, Classification, and Surgical Technique
33.4 Postoperative Management
33.5 Conclusion
33.6 References
34 Soft Tissue Flap Coverage in the Lumbosacral Spine
34.1 Introduction
34.2 Methods of Closure of the Lumbosacral Spine
34.2.1 Primary and Secondary Intention
34.2.2 Adjacent Tissue Transfer
34.2.3 Local and Regional Flaps
34.2.4 Free Flaps
34.3 Conclusion
34.4 References
35 Free Flap Soft Tissue Coverage of the Spine and Pelvis
35.1 Introduction
35.2 Pertinent Anatomy and Defect Etiologies Pelvis
35.3 Pertinent Anatomy and Defect Etiologies Spine and Posterior Trunk
35.4 Defect Location and Recipient Vessel Options
35.4.1 Posterior Neck/Cervical Spine
35.4.2 Posterior Chest Wall
35.4.3 Lumbar Back and Sacral Area
35.5 Vein Grafts and Arteriovenous Loops
35.6 Flap Options
35.6.1 Considerations in Free Flap Selection
35.7 Postoperative Management
35.7.1 Anticoagulation
35.7.2 Mobilization Protocols
35.7.3 Nutrition
35.7.4 Physical Therapy/Occupational Therapy
35.8 Complications
35.9 Case Examples
35.9.1 Case 1
35.9.2 Case 2
35.10 Conclusion
35.11 References
36 Soft Tissue Reconstruction in the Pediatric Patient
36.1 Introduction
36.2 Myelomeningocele
36.2.1 Introduction to Myelomeningocele
36.2.2 Preoperative Considerations in Myelomeningocele
36.2.3 Intraoperative Considerations in Myelomeningocele
36.2.4 Postoperative Considerations in Myelomeningocele
36.3 Scoliosis
36.3.1 Introduction to Scoliosis
36.3.2 Preoperative Considerations in Scoliosis
36.3.3 Intraoperative Considerations in Scoliosis
36.3.4 Postoperative Management
36.4 References
Section IX Complications in Spine Surgery and Their Management
37 Management of Soft Tissue Complications
37.1 Introduction
37.2 Preoperative Evaluation
37.3 Hematoma or Seroma
37.4 Surgical Site Infections
37.5 Wound Dehiscence
37.6 Injury to Adjacent Structures
37.7 Conclusion
37.8 References
38 Failure in Cervical Spinal Fusion and Management
38.1 Introduction
38.2 Case Examples
38.2.1 Case 1
38.2.2 Case 2
38.3 Case Summaries
38.4 Conclusion
38.5 References
39 Failure in Thoracic Spinal Fusions and Management
39.1 Biomechanical/Anatomic Aspects of Thoracic Spine
39.2 Complications
39.3 Optimization of Modifiable Risk Factors
39.4 Case Examples
39.4.1 Case 1
39.4.2 Case 2
39.5 Conclusion
39.6 References
40 Failure in Lumbar Spine Fusion and Management
40.1 Psychosocial Considerations
40.2 An Incorrect Diagnosis
40.2.1 Timing of Pain Recurrence Postoperatively
40.3 Mechanical Failures
40.3.1 Recurrent Herniated Nucleus Pulposus (HNP)
40.3.2 Hardware Complications
40.3.3 Pseudarthrosis
40.3.4 Instability
40.3.5 Imbalance
40.3.6 Ectopic Bone Formation
40.4 Nonmechanical Failures
40.4.1 Adhesive Arachnoiditis
40.4.2 Radiculitis
40.4.3 Perineural Scarring
40.4.4 Neuropathic Pain
40.5 Wound Complications
40.5.1 Dehiscence
40.5.2 Chronic Infection
40.5.3 Pseudomeningocele
40.6 Compensation and Reciprocal Change
40.6.1 Global Alignment and Proportion Score (GAP Score)
40.7 Conclusion
40.8 References
41 Management of Infection in the Instrumented Spine
41.1 Epidemiology/Risk Factors
41.2 Pathogenesis and Microbiology
41.3 Clinical Presentation
41.4 Diagnosis
41.4.1 Laboratory Tests
41.4.2 Summary
41.5 Management
41.5.1 Medical Management/Antimicrobial Therapy
41.5.2 Surgical Treatment
41.6 Conclusion
41.7 References
42 Management of Pharyngoesophageal Complications in Spine Surgery
42.1 Introduction
42.2 Anatomy of Pharynx and Esophagus
42.2.1 Oropharynx
42.2.2 Hypopharynx
42.2.3 Esophagus
42.3 Pharyngoesophageal Complications Associated with the Anterior Approach to the Cervical Spine
42.3.1 C1 C2 Approach
42.3.2 C3 C7 Anterior Approach
42.4 Conclusion
42.5 References
Contributors
Index