Vascularized Bone Grafts for Spinal Fusion—Part 2: The Rib

Abstract

BACKGROUND Pseudoarthrosis, or failure to achieve bony union, is a well-known complication of spinal fusion operations. Rates range from 5% to 40% and are influenced by both patient and technical factors. Patients who do not achieve complete fusion may experience a return or worsening of their preoperative pain. For patients with complicated pathologies, vascularized bone grafts (VBGs) have been shown to provide better outcomes than nonvascularized bone grafts (N-VBGs). OBJECTIVE To enhance an instrumented spinal fusion by the innovative technique presented herein that utilizes a rotated, pedicled VBG from the left eighth rib under the paraspinous musculature into the midlumbar posterolateral gutter. METHODS For posterior approaches, the rib can be easily accessed and rotated into the appropriate strut position. The rib is dissected out, identifying and preserving the neurovascular bundle medially. The rib is then tunneled medially and appropriately positioned as the spinal graft, with the curve providing anatomic kyphosis or lordosis, depending on the surgical location. It is then successfully fixated with plates and spinal screws. RESULTS In our limited experience to date, vascularized rib grafting procedures augment fusion and reduce operating room time and bleeding compared to free flap procedures. No patients have experienced complications related to these grafts. CONCLUSION Pedicled vascularized rib grafts can be utilized to provide the advantages of a vascularized bone flap in complicated pathologies requiring spinal fusion as far as the L2-L3 level, without the morbidity associated with free tissue transfer.

Novel Approach to Difficult Spinal Reconstruction: Bilateral Simultaneous Rib and Iliac Crest Vascularized Bone Graft Spinoplastic Surgery

“…Pedicled R-VBG provides the advantages of a vascularized bone flap in complicated spinal fusion cases, without the morbidity associated with free tissue transfer. 2 In the lumbar spine, the current gold standard in the management of pseudoarthrosis is the autologous nonvascularized iliac crest bone graft. Improvement can be achieved using pedicled VBGs.…”

“…Pedicled R-VBG provides the advantages of a vascularized bone flap in complicated spinal fusion cases, without the morbidity associated with free tissue transfer. 2 …”

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Pseudoarthrosis is a severe complication of spinal fusion and the leading cause of pain with occurrence rates as high as 35%-40%. [1][2] Risk factors for pseudarthrosis after spinal arthrodesis include obesity, diabetes, osteoporosis, malnutrition, chronic steroid use, chronic illnesses, age, smoking, previous surgery, and irradiated field. 1 Autografts are considered the gold standard in spinal fusion grafting.

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