Spinal reconstruction with free vascularised bone grafts; approaches and selection of acceptor vessels

The use of free vascularised bone grafts is an infrequently performed surgical technique for the reconstruction of spinal defects. This field of surgery brings many challenges concerning the choice of free vascularised bone graft, planning of the operative procedure and selection of recipient vessels. This study aims to report our experience with free vascularised bone grafts, with special emphasis on the surgical approach and the selection of recipient vessels. Over a period of 17 years (1994-2011), we used these grafts for anterior spinal reconstruction in 30 patients. In 28 patients, a free vascularised fibular graft was used, and in two cases a free vascularised iliac crest graft was used. The spinal segments reconstructed involved the cervical or cervicothoracic spine (6 cases), the thoracic spine (11 cases) and the thoracolumbar and lumbosacral spine (13 cases). Revascularisation of the free vascularised bone graft proved to be technically feasible in 30 patients, but failed in one fibular graft due to difficulties with recipient vessels in the lumbar region. Technical challenges were met with respect to the choice of the recipient vessel at various anatomical sites. Availability of acceptor vessels was highly dependant of the type of surgery (resection or stabilisation) and the selected surgical approach. Based on these findings, a preferred approach is given for each region. The use of free vascularised bone grafts is a valuable technique for the reconstruction of complex spinal disorders. Successful execution requires microvascular expertise with respect to graft harvesting and appropriate choice of recipient vessels. Adequate preoperative planning in a multidisciplinary setting and adherence to the basic principles for spinal reconstruction are required.