Anterior occipital cervical reconstruction with a free vascularized osteocutaneous graft: a case report

Free vascularized osteocutaneous bone grafts are an unusual but effective method to reconstruct complex and extensive defects of skin and bone of the extremities due to trauma, tumor, or infections. Many recent publications support their utility in these situations. In distinction, little literature exists to document the use of free vascularized osteocutaneous flaps in the spine. This is likely due to the infrequent occurrence of concomitant skin and osseous defects that are not manageable by routine spinal and plastic surgical approaches. We recently managed a particularly challenging patient in whom six prior operations--three anterior and three posterior--to decompress and stabilize the occipital-cervical junction had failed. We used a free vascularized distal radius osteocutaneous flap for three purposes: to provide the patient with an optimal chance to obtain an extensive and critically important anterior occipital-cervical arthrodesis, to supply a stable soft tissue envelope for protection of a tenuous dural repair, and to reconstruct an atrophic and scarred posterior pharyngeal wall. We are unaware of any report to date that documents the use of a graft of this type in the spine. We wrote this brief article to document the indications for this operation, to illustrate the problems we encountered in this difficult reconstructive situation, and to report on the progress of our patient to date.