Pericranial and scalp rotation flaps for occipitocervical hardware exposure with CSF leak in rheumatoid arthritis patient: A case report and review of the literature

Background: There are several etiologies of craniocervical junction instability (CCJI); trauma, rheumatoid arthritis (RA), infections, tumors, congenital deformity, and degenerative processes. These conditions often require surgery and craniocervical fixation. In rare cases, breakdown of such CCJI fusions (i.e., due to cerebrospinal fluid [CSF] leaks, infection, and wound necrosis) may warrant the utilization of occipital periosteal rescue flaps and scalp rotation flaps to achieve adequate closure. Case Description: A 33-year-old female with RA, cranial settling, and high cervical cord compression underwent an occipitocervical instrumented C0-C3/C4 fusion. Two months later, revision surgery was required due to articular screws pull out, CSF leakage, and infection. At the second surgery, the patient required screws removal, the application of laminar clamps, and sealing the leak with fibrin glue. However, the CSF leak persisted, and the skin edges necrosed leaving the hardware exposed. The third surgery was performed in conjunction with a plastic surgeon. It included operative debridement and covering the instrumentation with a pericranial flap. The resulting cutaneous defect was then additionally reconstructed with a scalp rotation flap. Postoperatively, the patient adequately recovered without sequelae. Conclusion: A 33-year-old female undergoing an occipitocervical fusion developed a postoperative persistent CSF leak, infection, and wound necrosis. This complication warranted the assistance of plastic surgery to attain closure. This required an occipital periosteal rescue flap with an added scalp rotation flap.