Cervical vertebral osteoradionecrosis: surgical management, complications and flap coverage--a case report and brief review of the literature

Abstract

A case description and a review of the literature. To report a case of deformity secondary to cervical vertebral osteoradionecrosis (ORN) associated with severe wound complications and review the pertinent medical literature. The incidence of deformity after ORN is rare and its association with extensive damage of soft tissues makes surgical treatment difficult. The spine surgeon should be aware of this to adapt the evaluation and surgery and be prepared to manage the numerous potential complications. A case of post-irradiation symptomatic kyphosis involving ORN of C5-C6 is reported. Failure of the anterior approach surgery was observed, and the secondary course was marked by the development of substantial cutaneous necrosis associated with severe and extensive post-irradiation cutaneous and muscular atrophy. Failure of the anterior approach surgery justified the use of posterior stabilization. Secondary destabilization of the posterior fixation at the cervico-thoracic junction required extension of the osteosynthesis to the middle thoracic region. Extensive posterior stabilization permitted obtaining reliable mechanical control of the radio-induced kyphosis with a 3-year follow-up. Wound freshening and covering with well-vascularized tissue was used to fill dead spaces and helped prevent soft-tissue complications after revision surgery. Radio-induced kyphotic deformity is an important entity. Surgeons should be aware of the complications that can lead to further deformity. Corrective procedures are also at high risk for mechanical, atrophic and infectious complications. Surgical repair strategies should be based on thorough comprehension and work-up of the disorder.

Fig. 1

X-rays made in 1994 and 1998 showing the exacerbation of degenerative disc and bone lesions leading to kyphosis and substantial offset of the facet joints in flexion

Fig. 2

Photograph showing important extension of severe post-irradiation cutaneous and muscular atrophy already present during the first surgery

Fig. 3

Radiographic verification at the end of the antibiotic treatment showing the absence of fusion in C6–C7 and C4–C5, and the persistence of kyphosis

Fig. 4

a CT scan showing pseudarthrosis and subsequent kyphosis; b T2-weighted MRI showing severe posterior soft-tissue atrophy without damage of the epidural canal or spinal cord

Fig. 5

Subsequent destabilization at the caudal extremity of the frame

Fig. 6

Extension of the posterior osteosynthesis to T7

Fig. 7

Most recent clinical follow-up (2006), posterior and right lateral views