Journal of Neurosurgery: Spine. 2026;45(4):660-667
Soft-tissue closure deserves consideration as part of the reconstructive strategy in posterior cervical surgery, particularly when instrumentation leaves a substantial wound cavity. Adida and colleagues examine whether advancing the paraspinal musculature is associated with fewer wound complications than conventional closure after posterior cervical decompression and fusion. Their comparison of 508 patients provides a clinically relevant signal of fewer infections and wound-related reoperations in adjusted analyses, while illustrating the difficulty of separating a closure technique from changes in perioperative care. The practical contribution is a rationale for vascularized coverage and dead-space reduction, rather than definitive evidence that one closure method should replace all others.
Objective
To compare wound complications and wound-related reoperations after conventional closure or bilateral paraspinal muscle flap advancement following posterior cervical decompression and fusion.
Methods
The investigators compared 380 patients treated with conventional closure between 2011 and 2022 with a prospectively maintained series of 128 consecutive patients receiving muscle flap advancement between 2023 and 2025 at a single academic quaternary center. Active local or systemic infection and follow-up shorter than three months were exclusion criteria. Indications included degenerative disease, deformity, trauma and malignancy; approximately one fifth of each cohort underwent revision surgery.
Wound events included infection, dehiscence, hematoma and seroma. Wound-related reoperation was recorded per patient. Analyses included time-to-event comparisons and Firth-penalized logistic regression. Importantly, the methods and Table 2 describe adjustment with individual covariates rather than a single model simultaneously controlling for every potential confounder.
Main results
Infection was recorded in 31 of 380 conventional-closure patients and 4 of 128 muscle-flap patients, approximately 8% and 3%. Wound-related reoperation occurred in 47 and 9 patients, approximately 12% and 7%, respectively. The reported regression estimates associated muscle flap closure with lower odds of infection (OR 0.275, 95% CI 0.085-0.702) and wound-related reoperation (OR 0.445, 95% CI 0.198-0.912).
Dehiscence remained similar, at approximately 12% versus 11%. Seroma was numerically more frequent with muscle advancement, approximately 9% versus 5%, without a statistically significant difference. Hardware removal occurred in five conventional-closure patients and no muscle-flap patients. These small event counts do not establish a reliable hardware-retention advantage.
The time-to-event analyses were less conclusive than the logistic models. Log-rank comparisons for infection-free and reoperation-free survival did not reach statistical significance, and the reported Cox estimates had confidence intervals crossing unity. Thus, the evidence does not support describing the benefit as uniformly demonstrated across analytical approaches.
Interpretation
The operative decision is whether to incorporate paraspinal muscle advancement at the index operation to improve coverage of the instrumented cervical wound. The authors describe mobilizing the muscle complex and bringing vascularized tissue into the midline cavity. Their initial Lembert closure imbricated muscle into the defect; the subsequently adopted vest-over-pants configuration overlapped the advanced muscle margins. Both used absorbable sutures, and superficial drainage was described above the reconstructed muscle layer.
These details support a reconstructive concept: address the deep wound cavity and soft-tissue coverage rather than relying solely on superficial approximation. However, the study did not compare the two flap configurations, quantify tension reduction or perfusion, or establish which patients derive the greatest benefit. Its results also cannot define an optimal drain regimen or justify a specific antimicrobial adjunct independently of the overall closure strategy.
Limitations
The cohorts were noncontemporaneous, with retrospective ascertainment in the earlier group and prospective maintenance of the later series. Changes in practice, case selection and complication detection may therefore contribute to the observed associations. The muscle-flap cohort was older, and baseline characteristics were not identical. Limited events and adjustment one covariate at a time leave substantial potential for residual confounding.
Co-interventions are particularly important. Topical vancomycin was used in every muscle-flap case but only most conventional cases, while incisional negative-pressure therapy was introduced during the study and used in 63 muscle-flap patients. The contributions of these measures cannot be isolated. Drain number, duration and removal criteria were not analyzed. The two flap techniques were pooled, and a three-month minimum follow-up does not ensure equivalent long-term observation across cohorts.
The contrast between logistic and time-to-event findings further limits certainty. The study supports an association and a plausible operative rationale, not a causal estimate of how many infections or reoperations muscle advancement itself prevents.
Clinical takeaway
Paraspinal muscle advancement is a promising option for reconstructing the posterior cervical wound after decompression and fusion. The strongest practical message is to plan deep soft-tissue coverage and dead-space management deliberately. This series does not establish universal superiority over conventional closure, favor Lembert over vest-over-pants repair, or determine the independent benefit of drains, topical antibiotics or negative-pressure therapy.