A 56-year-old woman, hypertensive, with a history of poliomyelitis at one year of life and left lower limb sequelae, required multiple interventions to enable adequate walking, as well as lumbar spine surgery at 42 years of age.
She was diagnosed with spinal pathology of D11-D12 and L3-L4, underwent posterolateral arthrodesis L1-L5 plus a laminate graft and bone hybridization, presenting a bad evolution of viable necrosis, with dementia
After the third intervention, a vacuum therapy system was introduced and the patient was referred to our Department, a referral center for Reconstructive Surgery.
The time elapsed between the first spinal surgery and the time of referral to our service was approximately 18 days.
The patient's spine was fixed in a stretcher, as she presented important ambulation and material in both lower limbs, as well as a defect in the dorsolumbar area of approximately 20 x 5 cm in diameter, with vertebral exposure.
There were no signs of infection.
1.
We performed a study of the extension of the defect using Computed Axial Tomography (CAT) which reported instrumented arthrodesis from L1-S1 with resection of posterior elements and increase of surgical soft tissue abscesses.
We also performed thoracolumbar CT angiography to determine the feasibility of muscle-cutaneous punctures.
1.
We maintained the vacuum therapy system in the surgical wound for 20 days, while imaging studies and preanesthetics were completed to help clean the lesion.
The planning of the surgical procedure included debridement of urethral tissue, coverage of deep bone structures with well vascularized tissue and closure of the skin defect without tension.
Under general anesthesia, with the patient in the left lateral decubitus position, we performed debridement of the excision margins and of the fibrous connective tissue in the lumbar region.
We designed and raised a reverse wide dorsal muscle flap based on secondary defects, transposition of the flap to the lumbar defect by tunneling and fixed in healthy perilesional muscle tissue.
We placed 4 infected drainages, 2 in the donor area and 2 in the receiving area, one in the submuscular plane and the other in the subcutaneous plane.
The closing of the donor area was direct, by planes, without tension.
Skin closure of the receiving area was performed prior Friedrich edges without tension and without compressing the muscle flap.
1.
Five days after surgery, there was an increase in the right volume due to sudden mobilization of the patient in bed.
We performed an ultrasound examination that reported the presence of an intramuscular hematoma due to a right atrium measuring 15 x 2 cm in size.
Under general anesthesia, we evacuated a clotted hematoma and checked the viability of the muscle flap, closing the wound again.
Eighteen days later the patient began to suffer from mental illness with the help of a walker, recovering the functionality of the lower limbs and was discharged on postoperative day 22.
During the 2-year follow-up after surgery, the patient presented normal ambulation and excellent local evolution of the flap.
