Staged Preoperative Tissue Expansion and Flap Closure for Posterior Spinal Fusion in an Adolescent with Repaired Myelomeningocele and Severe Neuromuscular Scoliosis: A Case Report

Abstract

Background/Objective(s)/Introduction: Severe neuromuscular scoliosis in patients with spina bifida and prior myelomeningocele repair presents substantial operative challenges, particularly regarding soft tissue closure over spinal instrumentation. Scarred, thin posterior tissues and exposed dural elements increase the risk of wound breakdown, cerebrospinal fluid leak, and infection. Preoperative tissue expansion may improve the available soft tissue envelope for definitive reconstruction. Case Presentation: We report the case of a 16-year-old male with L3-level myelomeningocele repaired in infancy, hydrocephalus with a nonfunctional ventriculoperitoneal shunt, tethered cord, Chiari II malformation, and progressive rigid neuromuscular scoliosis. Radiographs demonstrated worsening deformity with thoracic Cobb angles exceeding 90° and lumbar curvature over 120°, associated with pelvic obliquity and impaired sitting tolerance. Due to extensive posterior scarring and limited soft tissue coverage, a staged multidisciplinary approach was undertaken. Bilateral lumbar tissue expanders were placed preoperatively, followed by gradual outpatient expansion. Subsequent posterior spinal fusion from T3 to the pelvis was performed with plastic surgical involvement for closure. Results: Tissue expander placement was complicated by superficial wound dehiscence and port migration requiring operative revision. Progressive expansion was ultimately achieved. Definitive correction included posterior spinal fusion with multilevel osteotomies and removal of expanders. Closure was completed using bilateral paraspinal muscle advancement flaps and a dermal rotation flap. Postoperative imaging confirmed improved spinal alignment without hardware complication. Conclusion: A staged multidisciplinary approach combining preoperative tissue expansion, posterior spinal fusion, and vascularized flap-based closure was feasible in this high-risk adolescent. At six-month follow-up, wound healing remained satisfactory without infection, hardware complication, or reconstructive reoperation. Early collaboration between spine and plastic surgery teams may be valuable when compromised posterior soft tissues are anticipated.