Extensive wounds of the spine: a comprehensive approach to debridement and reconstruction.

Extensive wounds involving the spine (greater than three vertebral segments exposed) may threaten its indispensable roles of biomechanical support and vital neurologic function. Although there have been select reports of specific flap applications in this body region in the reconstructive surgical literature, there has been a paucity of comprehensive descriptions of pertinent anatomy, pathophysiology, and the perioperative care of such patients--including the degree to which the spine is suited to aggressive debridement. Four patients with complex spine wounds involving greater than three vertebral segments were treated by the authors from 1986 through 1988. These patients ranged from 28 to 80 years of age. They were all found to have multiple risk factors, including neoplasm (4), severe nutritional depletion (3), advanced age (2), wound sepsis (2), and multiple other general medical problems (4). All patients underwent wide bony and soft-tissue debridement. A new clinically essential four-pillar concept of spinal support predicted spinal instability in two of the four patients. These patients could thus be protected from neurologic compromise with internal stabilization (1) or external orthotic support (1). Wound closure was achieved with skin graft (1) or traditional or extended musculocutaneous flap coverage (3). With 7 to 20 months of follow-up, wound healing has been complete in all patients despite a 100 percent complication rate and one late postoperative death. Multisegment spine wounds tend to arise in the setting of multiple medical problems or risk factors. Despite these risk factors and a high postoperative complication rate, gratifying results may be achieved in these patients with a comprehensive understanding of regional surgical anatomy and a multidisciplinary approach to their care.

Esophageal perforation following anterior cervical spine surgery.

The authors surveyed the Cervical Spine Research Society to compile a series of esophageal perforations following anterior cervical spine surgery. Twenty-two cases were assembled. Six occurred at the time of surgery, 6 in the postoperative period, and 10 weeks to months later. Eight surgeries were because of fracture. Hardware was implicated in 25% of cases occurring after surgery. Diagnosis was confirmed most often by direct vision at reexploration or esophography. Treatment usually consisted of drainage, repair, and parenteral antibiotics; 2 cases were successfully treated by enteral feeding and antibiotics alone. There was one fatality, and all patients required prolonged hospitalization. Cervical fracture and the use of hardware may be associated with this complication. Clinical suspicion and esophography are important diagnostic tools. Drainage and parenteral antibiotics are recommended treatment.

The influence of halothane and nitroprusside on canine spinal cord hemodynamics.

Regional spinal cord blood flow was measured in 12 halothane-anesthetized mongrel dogs by means of 15 +/- 3 u radiolabeled microspheres under (1) control conditions, (2) 60-torr mean arterial blood pressure (MAP) using sodium nitroprusside (NPS), (3) 50-torr MAP using NPS, and (4) after reestablishment of normotension. With the onset of either level of hypotension, there were nonsignificant decreases from control conditions in cardiac output and pulmonary capillary wedge pressure (PCWP). A rise in heart rate was seen at 50 torr MAP. There were no significant changes in spinal cord blood flow (SCBF) under either hypotensive condition in any region of the cord, indicating an intact autoregulatory response. Sensitivity of SCBF to changes in the PaCO2 was shown to be 1.02 ml/min/100 g tissue per torr PaCO2. These data showed that (1) deliberate hypotension with NPS did not change SCBF in the dog; (2) sensitivity to PaCO2 was high under halothane anesthesia; and (3) SCBF was relatively homogeneous throughout the length of the cord.