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Bilateral Paraspinous Muscle Flaps “Double vest over pants technique” and literature review of medial and lateral mobilization methods in Management of Lumbar Pseudomeningocele and CSF fistulas
Mirsad Mujadzic, MD1, John Vender, MD1, Brandy Cross, MD1, Mirza Mujadzic, JMS2, Edmond F. Ritter, MD1.
1MCG, Augusta, GA, USA, 2GHSU, Augusta, GA, USA.

PURPOSE: Since work of Cormack and Lamberty, Dr Balogh et all and Wilhelmi et al paraspinous muscle flap has become versatile option in management of lumbar spinal problems. We present our patient series and literature review of two methods of paraspinous flap with aim to determine does medial perforator ligation in medial mobilization with direct advancement has higher complication rate comparing to lateral mobilization (turnover method) which has no perforator sacrifice
METHODS:
Between January 2004 and December 2010, 17 patients (9 male, 8 female) underwent repair with bilateral paraspinous muscle flap done for 13 patients with pseudomeningocele and 4 patients with CSF fistulas. The mean length of hospital stay was six days. All patients had follow-up of at least 6 months.
The technique we describe is a modification of medial mobilization method and includes repair of the dural defect with acellular dermal patch, resection of pseudomeningocoele leaving adequate residual tissue to make a two layers vest over pants closure. Follows wide mobilization of paraspinous muscles with medial perforatorÕs ligation and mobilization of muscle into wound in overlapping fashion, thereby obliterating dead space and tamponading the dural repair and doing second, this time muscle vest over pants repair.
We did literature review comparing lateral mobilization( turnover technique) with no perforator ligation versus medial mobilization with direct advancement and medial perforator ligations in regard to complication rate of wound dehiscence, infection rate, CSF leak and seroma development
RESULTS: In our series one patient developed a partial wound separation. One patient developed cellulitis which resolved rapidly with oral antibiotic. Two patients developed seromas which were aspirated in the office.
Literature review showed no statistical difference in wound infection between the two methods. However wound dehiscence CSF leak and seroma rate were significantly higher in medial mobilization method.
CONCLUSION: Paraspinous muscle flap with double vest over pants modification has showed low complication rate in our series of patients. However literature review showed that overall complication rate in medial mobilization with direct advancement method was higher comparing to lateral mobilization ( turnover technique). Lower complication rate in lateral mobilization comparing to medial mobilization method might be attributed to preservation of medial row of perforators, hence better vascular supply.


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