Endoscopic Debridement with Fascia Lata Free Flap Coverage: A New Paradigm in Treatment of Refractory Cervical Spine Osteomyelitis

Background Cervical spine osteomyelitis (CSO) is an uncommon and potentially debilitating disease. Patients with CSO may present with pain, fever, and neurological deficits. Traditional management of CSO relies on long-term antimicrobial therapy and surgical debridement of necrotic tissue. We describe complete resolution of a case of CSO refractory to long-term antimicrobial therapy with combined endoscopic transnasal and transoral debridement and minimally invasive placement of a fascia lata free flap.

Method Case Presentation A 69-year-old man with a history of nasopharyngeal adenosquamous carcinoma underwent primary chemoradiation therapy. Four months posttreatment, he presented with acute neck pain and significant nasopharyngeal necrosis. Due to concern for persistence of disease, he was taken to the operating room. Intraoperatively, devitalized nasopharyngeal tissue was surgically debrided and biopsies were negative for carcinoma. Cultures grew Escherichia coli, Aspergillus niger, Candida krusei, and Candida glabrata and patient was started on ertapenem, micafungin, and voriconazole. Despite 6 months of intravenous antimicrobial therapy, he experienced progressive neck pain, dysphagia, and trismus. Repeat imaging was concerning for progressive CSO. He was therefore taken to the operating room for aggressive but nondestabilizing debridement and coverage with vascularized tissue. Intraoperatively, there was diffuse bony necrosis from the sphenoid floor to the second cervical vertebra. The necrotic tissue was debrided endoscopically and a fascia lata free flap was delivered transorally via lateral palatal split to reconstruct the defect. In a minimally invasive fashion, the flap pedicle was tunneled and anastomosed to the facial vessels. The inferior portion of the flap was sutured to the oropharynx and the superior portion was positioned in the nasopharynx endoscopically. Two nasal trumpets were placed to stabilize the flap. Postoperatively, the patient was continued on intravenous antimicrobial therapy. His neck pain, dysphagia, and trismus resolved and imaging showed resolution of CSO. The flap was well healed on endoscopic examination and the patient was symptom free with normal swallow and nasal respiration at 5 months follow-up.

Discussion Radiation-related CSO is a rare disorder. Factors associated with development of CSO include accelerated hyperfractionated irradiation and reirradiation. Cases of CSO secondary to osteoradionecrosis are notoriously difficult to treat due to poor vascularization, poor penetration of antimicrobials, and exposure of the field to saliva and secretions. Management of CSO involves intravenous antimicrobial therapy, debridement of necrotic tissue, and cervical fusion after resolution of infection in cases of cervical spine instability. Vascularized tissue for treatment of chronic osteomyelitis in other parts of the body has been described. The fascia lata free flap provides pliable, vascularized tissue to cover the defect without compromising speech, swallow, or nasal respiration. Additionally, when harvested in perforator fashion, the long vascular pedicle of this flap allows for facile reach to angular or facial vessels. Resolution of CSO in this patient was achieved and cervical fusion avoided by placing vascularized fascia lata free flap over the necrotic region.

Conclusion A fascia lata free flap was successfully used to treat medically refractory CSO secondary to osteoradionecrosis. This technique may prove to be a useful solution for challenging reconstructive and infectious cases.

No conflict of interest has been declared by the author(s).