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Surgical Factors Associated with Prolonged Hospitalization After Reconstructive Spinal Surgery
Hannah Carl, BS, Devin Coon, MD MSE, Nicholas Calotta, BA, Rachel Pedriera, BA, Justin Sacks, MD MBA.
Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Purpose: Posterior trunk reconstruction following oncological resection is increasingly possible as a result of advances in spinal instrumentation, reconstructive approaches, and perioperative critical care. Extensive cases often require a muscle flap or complex closure to obliterate dead space. Postsurgical wound complications and subsequent reoperations can lead to neural injury, higher hospital costs, and longer hospitalizations. We aim to identify risk factors that are associated with increased length of stay (LOS) for patients receiving flaps to close a spinal defect.
Methods: A single institution, retrospective cohort study was performed on all patients from 2002-2014 who received a muscle flap to close a spinal defect. Medical and perioperative variables that were significantly associated with LOS (p<0.05) in univariate analysis were included in a stepwise regression model.
Results: A total of 288 cases were included in this study. In terms of tumor etiology, 34.3% of the cohort had primary spinal tumors, 22.6% had metastatic spinal tumors, 28.5% underwent hardware revision or spinal fusion, and the rest had benign lesions or other rare tumors. All factors that were significantly associated with increased LOS in univariate analysis are presented in Table 1. Presence of instrumentation, pre-operative chemotherapy, wound dehiscence, CSF leak, partial/total flap loss, and medical morbidity occurrence were all independently associated with increased LOS in a combined multivariate model (p<0.02 for each of the six variables). Importantly, Kaplan-Meier analysis demonstrated that post-operative wound dehiscence increased length of stay by twelve days (median LOS 11 [95% CI 9-14] versus 23 [95% CI 14-28]).
Conclusions: Spine tumor resections often create large cavitary defects that necessitate the use of muscle flaps for closure. Patients who have received adjuvant chemotherapy, require
instrumentation, or those who develop specific wound-related or medical complications are at an increased risk for prolonged hospitalization following spinal reconstruction. Thus, with knowledge of the effects of these complications, simple interventions can be employed to enhance the safety of the post-operative period and reduce the financial burden associated with unnecessarily long post-operative admissions.
Table 1: Univariate analysis of factors significantly associated with LOS
VariableNo. of CasesLOS (days)p Value
History of Chemotherapy within 5 Years0.002
No22016.17
Yes6824.96
Instrumentation Present0.004
No7513.68
Yes21319.85
Post-operative Complication<0.001
No15813.2
Yes13024.4
Major Post-operative Complication Requiring Re-operation<0.001
No21114.06
Yes7729.71
Medical Morbidity<0.001
No21714.1
Yes7130.92
Post-operative Wound Dehiscence0.002
No23816.59
Yes5026.14
Post-operative CSF leak0.003
No26917.09
Yes1934.63
Flap Loss (Partial + Total)0.025
No26417.13
Yes2430.58
Infection<0.001
No21815.65
Yes7026.33
DVT0.005
No24417.23
Yes4423.89
Tumor Volume0.008


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