Restoration of Neck Extension after Severe Oncological Surgery of the Posterior Cervical Trunk

Abstract

Reconstruction of posterior cervical trunk defects secondary to tumor resection carries significant morbidity when vertebral hardware or the spinal cord is exposed, and neck extension is interrupted. Complete reconstruction includes the coverage and obliteration of dead spaces, but functional outcomes are necessary to prevent the head dropping. This report documents the first known technique, using a free latissimus dorsi neurovascular flap to provide neck extension after ablative oncological surgery affecting trapezium and paraspinal muscles of the neck. The author explains the method by using a branch of the accessory nerve as the donor nerve. While keeping the head in a neutral position, the tendinous part of the neurovascular flap was firmly attached to the occipital periosteum and to the cephalad remnants of the trapezius, splenius capitis, and semispinalis muscles. At the caudal portion of the defect, cardinal notches were used to set the muscle at rest, avoiding excessive fiber tension. The maximal length of the muscle at rest was measured before flap elevation, calculated via the anatomical 3D print model. The thoracodorsal nerve was stimulated until the muscle shortened its length to 50%. Head extension was tested several times via neurostimulation and electromyographic control. The described procedure may provide neck extension and circumvent the problem with donor nerve providing synergy to the desired function.

Fig. 1.

Posterior neck defect after ablative surgery. LD flap is seen on top, before insetting. White arrows show muscles involved in neck extension and hardware.

Fig. 2.

Sterilized 3D model and LDNVF prior to reconstruction. The model was useful to orientate the flap adequately.

Fig. 3.

Schematic representation of a posterior cervical defect: Red lines represent the setting of LDNVFF. The tendinous part of the muscle is anchored to the periosteum and muscle remnants of the occipital area. The distal part is attached to the rest of the trapezium muscle. End-to-side nerve anastomosis is represented in the augmented view.