When does a spinal surgeon need a plastic surgeon

Discussions with colleagues at meetings indicate that some spine surgeons often ask plastic surgery to close both primary and secondary adult instrumented spinal fusions (ISFs). This raises a major concern; if plastic surgeons rotate complex muscle flaps, the prolonged use of multiple drains will increase infection rates. Thus, I would assume that most spine surgeons still routinely close their own primary and secondary ISF, with the rare exceptions of; infection, multiple revisions, prior radiation therapy, or other factors that have contributed to compromised skin. To test this hypothesis, I polled the spine surgeons on the Editorial Board of Surgical Neurology International (SNI) Spine Supplement, and asked two questions: Do you utilize plastic surgery to close primary ISF? Do you utilize plastic surgery to close secondary ISF? I also invited them to comment on the role of plastic surgery in primarily or secondarily closing ISF. Additionally, I reviewed pertinent literature. Nineteen spine surgeons from the Editorial Board answered the questionnaire. The 12 neurosurgeons and 7 orthopedic surgeons were from 9 different US states, and 2 were from Japan. Sixteen of the 19 who responded practice spine surgery in university settings, and 7 were chairman of departments. This is what I learned. The cumulative data revealed that no one routinely used a plastic surgeon to close adult primary or secondary ISF wounds. Only 2 of 19 surgeons advocated utilizing plastic surgeons to perform primary ISF wound closures (e.g., for infected or irradiated wounds). For secondary ISF closures, 12 of 19 surgeons rarely asked plastic surgeons to close their wounds, while 7 never asked plastic surgeons to be involved. The rare secondary indications for plastic surgeons to rotate complex muscle flaps included: infections, a history of radiation, multiple wound revisions (particularly posterior cervical), persistent cerebrospinal fluid leaks, pediatric spina bifida, and wide tissue defects. The 19 surgeons had various comments. One surgeon commented, “I do not use plastics to close any of my incisions/wounds. We do all our own closures. The only time we might use them is in pediatrics for closing a spina bifida.” Another commented, “On very rare occasions, maybe once every 3-4 years I may ask for help in a multioperated, radiated tumor patient because of poor tissue. In these cases we need a flap rotated. Very very rare situation.” Another stated “Kind of odd. I just never thought about needing to have this done by them (plastic surgeons). I have had some wound infections where they raise some local flaps, and have needed them on some occipital cervical infections in rheumatoids, but do not use them routinely.” Yet another surgeon responded, “We never ask anyone to close our wounds, with or without instrumentation, primary or secondary incisions. My orthopedic colleagues close their own wounds as well. They’re our wounds, and our responsibility to close them. Our wound infection rate is below the University Health System Consortium (UHC) standard, which we use as our benchmark. Also, if I were an insurer, I would not routinely pay extra for this, so it will probably come out of our reimbursement for the procedure.” I found four studies in the literature in which plastic surgeons closed secondary ISF wounds to address infection, irradiated skin, multiple revisions, and other factors requiring the rotation of complex muscle flaps to obtain closure.[1,2,3,4] Only one of these studies involved plastic surgeons to “prophylactically” close primary infected or irradiated ISF wounds.[1] In summary, there appears to be little precedent for spine surgeons to routinely request the assistance of plastic surgeons to close adult primary or secondary wounds for ISF. However, in rare secondary ISF cases, plastic surgeons may rotate complex muscle flaps in the presence of infection, prior radiation therapy, persistent cerebrospinal fluid leak, multiple revisions (including posterior cervical wounds), and other factors compromising skin closure.