Successful treatment of a non-healing lumbar incision post-radiotherapy using vacuum sealing drainage: A case report

Abstract

BACKGROUND

The current method of cleaning and changing dressings for non-healing lumbar incisions post-radiotherapy is time-consuming and laborious, with very poor results. We here report a patient with radiation dermatitis who developed a non-healing wound after lumbar spinal surgery. The wound was successfully treated with vacuum sealing drainage therapy, confirming its feasibility in complex wound healing.

CASE SUMMARY

The patient was a 76-year-old female with lung cancer, positron emission tomography/computed tomography showed bone metastasis in L2 and L3 vertebrae. After 2 months of local radiotherapy to the lumbar spine, symptoms did not improve and pain worsened. She had lumbar lesion clearance and internal fixation surgery, but developed a nonhealing wound of approximately 15 cm postoperatively. After 12 rounds of clearing necrotic and unhealthy tissue, 78 days of negative pressure therapy promoted granulation tissue growth and wound healing, resulting in wound healing.

CONCLUSION

Vacuum sealing drainage therapy has shown efficacy in treating nonhealing wounds after radiotherapy, promoting wound healing and reducing infection risk.

Key Words: Radiotherapy; Radiation dermatitis; Nonhealing wound; Vacuum sealing drainage; Case report

Core Tip: Treating non-healing lumbar incision post-radiotherapy is challenging, especially for midline incisions after lumbar spine surgery, which are difficult to heal. The current approach involves repeated wound cleaning and dressing changes, with unsatisfactory results. We used vacuum sealing drainage in a patient with radiation dermatitis who developed a non-healing wound after lumbar spinal surgery. The method is not only simple to perform but also shows clinical effectiveness. This is the first case of non-healing lumbar incision post-radiotherapy successfully treated using closed negative pressure drainage.

INTRODUCTION

The incidence of poor wound healing after lumbar spinal surgery is high, which is a challenge for doctors. The incidence rate of poor wound healing after posterior lumbar surgery is reported to be 3.4%-24.4%. In a study of 1269 patients, the postoperative wound infection rate was 3.4%[1]. Another study showed that the rate of delayed wound healing after surgery was 24.4% in 954 patients[2]. Factors such as age, obesity, diabetes, hypertension, malnutrition, smoking, and alcohol consumption are also risk factors, and the midline incision during surgery is a major contributing factor due to poor blood supply and lack of muscle coverage in the subcutaneous tissue, leading to the formation of dead spaces.

In the aforementioned circumstances, wound nonhealing is more common after radiotherapy, making treatment more challenging. This results from tissue ischemia and fibrosis induced by radiotherapy. Radiation may also reduce regenerative capacity. The incidence rate of radiation dermatitis is high, with statistics showing that 87%-95% of patients receiving radiotherapy experience varying degrees of radiation dermatitis[3]. Clinical manifestations of radiation dermatitis range from mild erythema and dry desquamation to severe moist desquamation and ulcer formation. Severe radiation dermatitis affects the treatment and may lead to treatment interruption, affecting treatment outcomes[4]. Chronic radiation dermatitis is characterized by epidermal atrophy, thinning, loss of epidermal papillae, superficial dermal fibrosis, cellular necrosis, and is prone to causing nonhealing of postoperative wounds.

Surgery on the skin of patients with radiation dermatitis presents a formidable challenge, as tissue hypoxia, vascular damage, and reduced healing capacity resulting from radiation damage can lead to a significantly increased incidence of nonhealing surgical incisions[5]. The rate of poor wound healing following skin surgery post-radiotherapy can be as high as 30%-60%, surpassing that of regular surgeries[6]. Below, we present a case of a patient with a non-healing wound of approximately 15 cm at the lumbar spine incision site after radiotherapy. The wound successfully healed following treatment with vacuum sealing drainage (VSD).

CASE PRESENTATION

Chief complaints

A 76-year-old female presented to the spine clinic with unexplained lower back pain and bilateral leg pain while urinating for the past 2 months.

History of present illness

Without any clear precipitating factors, the patient began to experience back pain and bilateral leg pain two months ago, which had been worsening over time. Local radiotherapy was administered at a different hospital, considering the possibility of a metastatic tumor.

History of past illness

The patient was diagnosed with lung cancer 6 years ago and underwent lung radiotherapy for 5 years. However, two months ago, she started experiencing back pain and a positron emission tomography/computed tomography scan revealed a high suspicion of metastasis to the L2/L3 vertebral bodies.

Personal and family history

The patient denied any family history of malignant tumors.

Physical examination

Upon examination, severe lumbar spinal movement restriction was noted, along with tenderness and radiating pain at L2/L3, particularly on the left side. Muscle strength in both legs was decreased, and a positive straight leg raise test was observed on the left side.

Laboratory examinations

Laboratory tests revealed an erythrocyte sedimentation rate of 54 mm/hour and a C-reactive protein of 32 mg/dL, with the rest of the examination results being essentially normal.

Imaging examinations

Lumbar spine lateral X-ray revealed visible destruction of L2 and L3 vertebral bodies with narrowing of the L2/L3 space (Figure 1A and B). Positron emission tomography/computed tomography suggested bone metastasis from lung cancer to L2 and L3 vertebrae (Figure 1C and D). Magnetic resonance imaging showed increased signals in L2 and L3 vertebral bodies and intervertebral space (Figure 1E and F).

Figure 1 Imaging examinations before surgery. A and B: Visible destruction of the L2 and L3 vertebral bodies, with narrowing of the L2/L3 space; C and D: Positron emission tomography/computed tomography suggest bone metastasis of lung cancer to the L2 and L3 vertebrae; E and F: Magnetic resonance imaging indicates increased signals in the L2 and L3 vertebral bodies and intervertebral space.

Further diagnostic work-up

After completing preoperative examinations, the patient underwent lumbar decompression and internal fixation surgery. During the procedure, a window was opened on the left side of the L2/L3 vertebral body, revealing necrotic tissue in the dural sac and nerve root canal (Figure 2A). The intervertebral disc tissue was removed, the upper and lower cartilaginous endplates were scraped, and autologous bone grafts were implanted. Rapid pathology results showed bone, fibrous, and unstructured tissue. Postoperative pathology revealed significant proliferation of dermal sclerotic fibrous scar tissue with necrosis (Figure 2B and C). Multiple cultures of wound secretions and intraoperative tissues were negative for bacteria.

Figure 2 Intraoperative details and postoperative pathology. A: Internal fixation during surgery; B: Postoperative case with intervertebral bone tissue, fibrous tissue, and necrotic tissue. The orange arrow points to the site of the lesion; C: Postoperative case with obvious proliferation of dermal sclerosis fibrous scar tissue accompanied by necrosis, suggesting chronic radiation dermatitis. The blue arrow points to the site of the pathology; D: Lower end of the incision was not healing, accompanied by inflammatory exudate.

FINAL DIAGNOSIS

Based on the patient’s pathology findings and clinical presentation, the postoperative diagnosis was: Infection of the lumbar spine (L2/L3), and radiation dermatitis.

TREATMENT

Two weeks after the operation, the incision showed signs of redness, swelling, and discharge, with exacerbation of local tissue necrosis. The lower end of the incision was not healing, accompanied by inflammatory exudate (Figure 2D). Immediate debridement was carried out, with the incision measuring 15 cm. The tissue inside the wound was necrotic and there was no active bleeding, accompanied by secretions. It is considered that hindrance of the healing process was due to the patient’s previous exposure to radiotherapy (total dose of 50 Gray in 25 fractions), resulting in inadequate local blood flow, coupled with postoperative infection. A sealed negative pressure drainage system (VSD) was placed at the incision site, and regular debridement and VSD replacement were performed every 5-7 days. VSD was connected to the hospital’s central negative pressure, maintaining a pressure of -125 mmHg and allowing for fluctuations. The outside was covered with a transparent occlusive membrane, without any additional dressings. The negative pressure compression status of the sponge was monitored in real time. The patient had no obvious pain, and the negative pressure drainage tube was 4-5 m long, which ensured that the patient could move around the bed. Following VSD treatment, the patient’s incision healed 78 days after surgery (Figure 3).

Figure 3 The treatment process for vacuum sealing drainage of the lumbar incision post-radiotherapy. A: Initial vacuum sealing drainage (VSD); B: Fresh wound after initial VSD surgery with residual necrotic tissue; C: Sixth application of VSD; D: Fresh wound (5 weeks post-surgery); E: Healing on the left side after the eighth application of VSD, but the right side remained unhealed (7 weeks post-surgery); F: Removal of the right internal fixation (8 weeks post-surgery); G: 11^th application of VSD (9 weeks post-surgery); H: Wound healing after 12^th application of VSD.

OUTCOME AND FOLLOW-UP

During the six months of follow-up, the patient’s wound continued to heal. After two years, there has been no breakdown or recurrence of the wound.

DISCUSSION

Non-healing of the lumbar incision after radiotherapy is a clinical challenge, especially in patients undergoing lumbar surgery, where tissue damage and poor blood supply caused by radiotherapy are important factors leading to poor incision healing. In addition, poor blood flow in the midline incision can lead to dead spaces[7]. Our patient had post-radiotherapy lumbar infection clearance, with increased wound secretion and local redness leading to non-healing of the wound. After initial assessment, the patient had a midline incision in the lumbar spine, and intraoperative pathology suggested chronic radiation dermatitis. It was decided to use VSD therapy. After 12 debridements and VSD therapy with a suction pressure set at -125 mmHg, the wound eventually healed after 78 days. The healing time was longer and the process was more difficult, highlighting the challenges of wound healing in radiation dermatitis.

Tissue damage following radiotherapy can affect wound healing[8]. Radiotherapy can lead to enhanced local tissue inflammation, impaired angiogenesis, and dysfunction of fibroblasts[9]. Prevention and treatment of radiation dermatitis have been a focus of clinical research. Various prevention and treatment strategies have been developed, including topical preparations, biological dressings, and various physical therapy methods[10]. However, once wound healing is compromised, treatment often becomes complex and challenging. Early intervention and personalized treatment plans have been shown to be crucial for improving outcomes[11]. There is currently no standardized approach for the treatment of non-healing wounds post-radiotherapy. Traditional treatment methods include local dressings and hyperbaric oxygen therapy, but the results are often unsatisfactory[12]. Compared to traditional methods, VSD demonstrates significant advantages. Clinically, negative pressure wound therapy promotes faster healing and superior granulation tissue formation through active fluid removal and improved microcirculation. Economically, while the initial setup cost is higher, it reduces the need for frequent dressing changes and can shorten hospital stays, leading to potential overall cost savings. Regarding patient comfort, negative pressure wound therapy provides a sealed, moist environment, resulting in less pain during dressing changes and greater mobility compared to conventional treatments.

VSD is an innovative wound treatment method that has developed in recent years. It uses continuous negative pressure to remove wound exudate, reduce local edema, eliminate infection factors and necrotic tissue, promote granulation tissue growth, improve local blood supply, and accelerate wound healing[13,14]. Multiple studies have confirmed that VSD has unique advantages in treating complex and difficult-to-heal wounds[15]. Recent research suggests that VSD may provide a new treatment option for these types of challenging wounds. VSD not only effectively controls infection and promotes wound healing, but also reduces patient discomfort and shortens hospital stay[8]. It is reported that continuous negative pressure can remove exudate, maintain wound cleanliness, promote local blood circulation, and improve tissue ischemia, mechanical stress stimulation can promote granulation tissue growth, and the closed environment can reduce the risk of infection[13]. VSD can promote the healing of surgical incisions after radiotherapy. This technology, through continuous negative pressure suction, can reduce wound exudate, promote vascular reconstruction, and accelerate granulation tissue growth[5].

CONCLUSION

This case suggests that surgery should be avoided on skin with radiation dermatitis, and if surgery is necessary, a midline incision should be avoided postoperatively. Based on the successful healing of the wound in this case, VSD treatment for nonhealing incisions after radiotherapy has been shown to be a simple and effective solution.