title: Soft-tissue defects after spinal instrumentation in 5 children: risk factors, management strategies, and outcomes.
abstract: OBJECTIVE
  Wound-related complications following complex posterior spine procedures in children may result in the need for serial debridements and may place spinal instrumentation at risk. In this study, the authors review their experience with the management of soft-tissue defects from spinal instrumentation in 5 high-risk pediatric patients. The use of various rotational and transpositional flaps in the management of these complicated cases is discussed, as well as their outcomes.
  
  
  METHODS
  The authors retrospectively reviewed the medical records of 5 patients who returned to the Neuro-Spine service at Texas Children's Hospital for erosion of spinal instrumentation through the skin between September 1, 2007, and October 31, 2012. Patient demographics and clinical and operative data were recorded.
  
  
  RESULTS
  Risk factors such as young age (1 case), poor nutritional status (1 case), multiple previous surgeries (3 cases), severe neurological deficits (2 cases), and history of radiation therapy for malignancy (2 cases) were noted in the 5 patients. The paraspinous flap (4 cases) was the mainstay of the treatment. Follow-up ranged from 7.5 to 17.5 months (mean 11 ± 4.2 months). One of the patients required more than 1 procedure for revision of the wound. Cultures were positive in 2 of the 5 cases. Spinal instrumentation was removed in 3 of the 5 cases; however, in all 3 of the cases there was evidence of delayed instability that developed after the removal of spinal instrumentation.
  
  
  CONCLUSIONS
  The use of local tissue flaps is safe and efficacious for treatment of posterior wound complications due to spinal instrumentation in children. Removal of spinal instrumentation should be avoided due to the development of delayed instability. Highly vascularized tissue is used to speed healing, clear bacteria, and eliminate dead space, obviating the need to remove contaminated spinal instrumentation.
authors.affiliation: Neuro-Spine Program, Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine;
authors.forename: Christina
authors.initials: C
authors.lastname: Sayama
authors.forename: Sudhakar
authors.initials: S
authors.lastname: Vadivelu
authors.forename: Andrew
authors.initials: A
authors.lastname: Livingston
authors.forename: Allen
authors.initials: A
authors.lastname: Ho
authors.forename: Shayan A
authors.initials: SA
authors.lastname: Izaddoost
authors.forename: Valentina
authors.initials: V
authors.lastname: Briceño
authors.forename: Thomas G
authors.initials: TG
authors.lastname: Luerssen
authors.forename: Andrew
authors.initials: A
authors.lastname: Jea
mesh_terms: D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007262:Infusions, Intravenous; D008297:Male; D019635:Neurosurgical Procedures / Q000009:adverse effects*; D012189:Retrospective Studies; D012307:Risk Factors; D018401:Sample Size; D017695:Soft Tissue Injuries / Q000209:etiology* / Q000601:surgery; D013131:Spine / Q000601:surgery*; D013524:Surgical Flaps; D013529:Surgical Wound Dehiscence / Q000209:etiology* / Q000601:surgery; D013530:Surgical Wound Infection / Q000188:drug therapy / Q000209:etiology* / Q000601:surgery; D013781:Texas
chemical_list: D000900:Anti-Bacterial Agents
keywords: BMP = bone morphogenetic protein; CRP = C-reactive protein; EBL = estimated blood loss; ESR = erythrocyte sedimentation rate; WBC = white blood cell; erosion; pediatric spine; spinal instrumentation; wound infection