Innovations in Spinoplastic Surgery: Shaping the Future of Complex Spinal Reconstruction

The role of plastic surgeons in spine reconstruction has historically been limited to management of postoperative spinal wound complications. Over the last decade, however, plastic surgeons have played an increasingly important role in the world of spine surgery. Particularly in complex and revision spine surgery cases, plastic surgeons frequently collaborate with their neurosurgery and orthopedic surgery colleagues to treat and prevent complications. Recent developments in the field, expanding indications for spine surgery, the increased global burden of spinal osteomyelitis, and the relatively high likelihood of wound and other complications secondary to complex spine surgery have led to greater degrees of plastic surgery involvement, including plastic surgeons functioning in both therapeutic and prophylactic capacities [1-5]. Specifically, a variety of techniques and approaches used in the emerging field of Spinoplastic Surgery, characterized by the use of autologous Vascularized Bone Grafts (VBGs), offer superior outcomes in spine reconstructive surgery compared to the use of nonvascularized and allogenic grafts [6,7].

Spinal reconstructive procedures have traditionally been performed with a combination of cadaveric allografts consisting of cancellous and cortical bone, and nonvascularized autologous bone grafts, including iliac crest grafts. These grafts are implanted without a blood supply and consequently depend on the recipient site vascular network for incorporation [8]. Allografts are associated with greater risk of infection and immunologic rejection [9]. In an effort to circumvent these risks, synthetic and biologic options have been developed, though these frequently fail to provide the structural support necessary for larger-scale reconstructions [10]. By contrast, VBGs are comprised of bone segments transferred on their respective muscular attachments and are vascularized by tendinous Sharpey’s fibers with their associated microvasculature [8]. Because the vessels of Sharpey’s fibers supply blood directly into the periosteum and Haversian canal system, the biological and mechanical properties of the bone graft are retained, allowing for primary union healing at the interface between the graft and the bone at the recipient site, resulting in higher rates of fusion, osteoinduction, increased mechanical resistance, shorter time to complete arthrodesis, and lower risk of postoperative infection when compared to nonvascularized alternatives [6,8]. Furthermore, because VBGs are a form of pedicled tissue transfer involving maintenance of the native blood supply, there is no need for microsurgical anastomosis to recipientsite vasculature, and this method similarly obviates the need for recipient-site surgical exploration to determine the presence of appropriate vascular anastomotic sites [6,8]. In fact, both the harvesting and inset of the VBG can often be performed through the same incision used by the spine surgeon, thus minimizing postoperative morbidity [5]. The remaining benefits of VBG include decreased total operative time compared to free flap procedures, elimination of the need for a surgical microscope, and decreased risk of transmissible disease, graft rejection, and reactive bone formation. Because of these numerous advantages, VBGs represent a superior option for select patients (i.e., those with history of radiation, obesity, diabetes, previous surgeries, etc.), [11] and may be especially beneficial in patients with history of osteomyelitis or those who undergo spine surgery for spinal metastasis and have impaired recipient-site vascular beds due to infection and radiation, respectively [6,8,12].

In the last few years, there has been an increased interest in VBGs in complex spine surgery from both a clinical and a research perspective. Last year, our group published a literature review on the field of Spinoplastic Surgery [5]. This paper aims to provide an overview of the use of VBGs in spine reconstruction, as well as summarize our group’s work to date and highlight the novel findings and future directions of our research.

Vascularized bone grafts

There are several types of VBGs, each of which is suitable for a range of surgical contexts and are associated with a unique assortment of advantages. First, the iliac crest Vascularized Bone Graft (IC-VBG) makes use of a section of the posterior iliac crest pedicled from the quadratus lumborum muscle, and for patients with increased risk of pseudarthrosis, this VBG can help to augment spinal fusion and reconstruction of the distal thoracic and lumbar spine [13]. This graft has an extensive range of mobility and allows for harvesting robust tricortical bone while eliminating the need for additional skin incisions [5]. The IC-VBG has demonstrated efficacy in a L2-L4 arthrodesis [14], though it may be a suboptimal choice in patients with a history of bone disorders such as osteoporosis.

Next, the rib vascularized bone graft (R-VBG) has similarly shown promising results with respect to outcomes in patients having experienced pseudarthrosis [15], and is best-suited for enhancement of fusion of the upper lumbar and thoracic spine, though it may be employed at levels as inferior as the L4-L5 level. The graft is typically obtained from the eighth rib, though utilization of ribs 2-12 may be possible, as was demonstrated in a cadaveric feasibility study [16]. This VBG is pedicled on a cuff of intercostal or subcostal muscle [5]. This R-VBG is typically harvested via a separate posterolateral incision, fashioned by releasing intercostal muscle attachments, and then bluntly dissected from the underlying pleura. The graft can be cut down to match the size of the recipientsite defect, and the excised portion of bone may be used as a nonvascularized bone graft. The R-VBG is placed in the posterolateral gutter and can be fastened with hardware such as top-loading rods, and paraspinous muscle flaps may be used for adequate soft tissue coverage at the time of closure. The rib’s natural curvature may be used to mimic the native kyphosis or lordosis of the particular spine segment where the graft is to be implanted [15], and this technique has proven successful in the treatment of L2-L3 neuropathic arthropathy as well as in an 18-patient case series showing an average time to union of 6.8 months [15,17].

Further cephalad in the spine, the occiput vascularized bone graft (O-VBG) is an option for enhancement of cervical fusions, and this method is particularly useful in light of this region’s increased risk of infection, hardware failure, pseudarthrosis, and need for repeat surgery [18]. This VBG may be pedicled on the splenius capitis or semispinalis capitis muscles [5]. This graft has successfully been employed in a revision atlantoaxial arthrodesis [19], though the graft’s range of motion may allow for use as caudally as the T1 level [16].

Scapular vascularized bone graft (S-VBG) may be used in patients with an increased risk of failure in the setting of cervicothoracic arthrodesis and can help to reach areas of defect that R-VBG cannot [20]. This VBG may be pedicled on the rhomboid minor or trapezius muscles [5]. This technique has been used in the treatment of neck pain and cervical spine alignment for cervical spondylitic myelopathy accompanied by kyphotic cervical spine deformity [20].

Lastly, the spinous process vascularized bone graft (SP-VBG) is suited for enhancing arthrodesis in the context of posterolateral fusion procedures. Pedicled to the paraspinal muscles, this arrangement helps to connect two adjacent transverse processes and has demonstrated success in the treatment of three patients suffering from spinal stenosis and associated low-grade spondylolisthesis [5,7].

Novel findings and future directions

There has been an increased interest in the field of Spinoplastic Surgery in recent years. This field was the topic of a panel presentation at the American Society of Plastic Surgeons’ 92nd annual Plastic Surgery the Meeting© (PSTM23) in Austin, Texas in October, 2023. At this panel, some of the goals of future research were outlined: exploring novel uses for VBGs and expanding the indications for the previously described VBGs. As part of this aim, our group has started various research projects in the last 12 months.

One example of a novel use for VBGs is a cadaveric feasibility study of an IC-VBG for the reconstruction of anterior vertebral corpus defects. Initial findings of this research were presented at the 9th annual Mountain West Society of Plastic Surgery© meeting in Whistler, Canada in March, 2024 [21]. As the above literature review suggests, VBGs in spine reconstruction have predominantly been described for reconstruction of posterior vertebral defects. The aim of the cadaveric feasibility study was to describe a new procedure for reconstruction of vertebral corpus defects in the lumbar and distal thoracic spine using an IC-VBG pedicled on a strip of quadratus lumborum muscle. In this study, a 5-cm section of posterior iliac crest on a pedicle of quadratus lumborum muscle was harvested from an anonymized cadaveric donor. The VBG was subsequently rotated and mobilized in an anteromedial direction towards the vertebral corpi. In that donor, the VBG had an adequate range of mobility so that the graft could be inset with minimal tension anywhere along the vertebral bodies from theT9 to L5 level [21]. This research project is ongoing, and further work is required to ensure the safety of this procedure prior to attempting it in a living patient.

A novel indication for previously described VBGs was published as a case report in April 2024 [22]. In this article, the authors describe the use of bilateral simultaneous rib and iliac crest VBGs in a 68-year-old female patient suffering from distal junctional kyphosis and severe positive sagittal balance with symptoms of lower back pain, neck pain, and difficulty standing upright. This patient had a complex history including multiple spinal surgeries and was found to have loose hardware in situ in her lumbar spine. She was treated with a two-stage surgical approach, in which the Neurosurgery team performed anterior lumbar interbody fusion (L3-S1), removal of hardware, T4-pelvis fusion with prone lateral interbody fusion (L2-3), and posterior column osteotomies (T11-S1). Her surgical treatment was augmented with bilateral R-VBGs and IC-VBGs performed by the Plastic Surgery team. The patient did well in the immediate post-operative setting and demonstrated functional improvement at her 3-month follow-up visit [22].

The field of Spinoplastic Surgery aims to provide interdisciplinary care to complex spine surgery patients with collaboration between plastic surgeons, neurosurgeons, orthopedic surgeons, general surgeons, and all other specialties involved in the care of this challenging patient population. Future research in this field should be aimed at optimizing the surgical approaches to VBGs, as well as clearly describing the indications and contraindications for these procedures. An area for possible future research is the incorporation of virtual surgical planning (VSP) in spine reconstruction with VBGs. VSP has become widely used in the field of Orthognathic Surgery over the last 2 decades, and has become a viable alternative to traditional surgical planning for a variety of orthognathic surgeries [23]. Furthermore, the use of artificial intelligence (AI) has been hypothesized to be a viable tool to augment virtual surgical planning [24,25]. As the uses and indications of VBGs for spine reconstruction evolve, we hypothesize that VSP and AI may become powerful tools to assist the multidisciplinary surgical team in treating even the most complex revision spine surgery patients.

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