Anterior approach to the cervicothoracic junction: case series and literature review

Abstract

Objectives: the authors report their experience with the anterior approach to the cervicothoracic junction at C7 to T4 vertebral bodies, how the radiological investigation was performed in order to define the need for manubriotomy, how was the surgical pitfalls and the clinical evaluation. Methods: prospective cohort study with 14 patients who underwent an anterior approach to the cervicothoracic surgery during the period of January 1996 to January 2009. The patients underwent radiographic evaluation with computed tomography and magnetic resonance before surgery in order to identify when the manubriotomy was necessary. The surgery was usually performed from the left side through an anterior Smith-Robinson approach and manubriotomy when necessary. Mesh and cervical plate system were used for stabilization when corpectomy was performed. Nevertheless, in RESUMOObjetivo: relatar a experiência dos autores no acesso anterior da junção cervicotorácica C7 a T4, em relação à definição de quando é necessária a realização da manubriotomia, quais as particularidades desta cirurgia e a avaliação dos resultados. the cases with discal herniation C7-T1, the reconstruction was done with PEEK and cervical plate system. Results: the mean age was 63 years old (range, 30-77 years) and seven of the patients were men. The majority of cases had metastatic disease (n=8) or disc herniation (n=4). There were two complications related to the surgical procedures: one patient with dysphonia caused by a local hematoma and other one with lung infection. The mean surgical time, bleeding volume, pain intensity, medication intake and length of hospital stay were lower in the cases in which manubriotomy was not necessary. Conclusions: the anterior approach to the cervicothoracic junction is effective and presents low morbidity rate. In cases of injuries involving the C7 vertebral body and C7-T1 intervertebral disc herniation, a transcervical approach without the manubriotomy was indicated; when a T1 and/or T2 corpectomy was necessary, the transmanubrial approach usually was necessary in order to provide a good working space to perform a corpectomy and reconstruction. Performing manubriotomy increases surgical time, bleeding, pain intensity, analgesic drugs intake and the length of hospital stay. KEYWORDS:

Anterior approach to the cervicothoracic junction: proposed indication for manubriotomy based on preoperative computed tomography findings

“…10,24,36,55 In some selected cases we may even need to perform the manubriotomy to approach the CTJ. 9,13,14,17,18,22,42,44,50,52,56 In these cases a standard anterior supramanubrial cervicotomy can be used to reach the proximal thoracic vertebrae. 9,13,14,17,18,22,42,44,50,52,56 The features to be assessed to predict manubriotomy were the superior healthy vertebral inclination and the patient's anatomical characteristics, such as marked junctional kyphosis, congenital high sternum, short neck, or anatomical vascular features.…”

“…9,13,14,17,18,22,42,44,50,52,56 In these cases a standard anterior supramanubrial cervicotomy can be used to reach the proximal thoracic vertebrae. 9,13,14,17,18,22,42,44,50,52,56 The features to be assessed to predict manubriotomy were the superior healthy vertebral inclination and the patient's anatomical characteristics, such as marked junctional kyphosis, congenital high sternum, short neck, or anatomical vascular features. 5,11,13,14,23,[36][37][38]49,56,58 Performing manubriotomy increases morbidity, and it is important that the surgical team and the family be made aware, during the preoperative period, of the real need for manubriotomy.…”

“…3,24,36,38,56,58 Once it has been found not to have vascular restrictions, the surgeons should decide whether the manubrium is an obstacle to the surgical approach. 13,14,17,22,26,36,49,50,56,58 Several authors have previously described their radiological methods to identify in which cases the anterior approach could be performed and when manubriotomy was needed; nevertheless, the reproducibility of the technique was not straightforward, several different measurements were described and analyzed without considering the vascular anatomy, and the relationship of the inclination of the vertebrae above the lesion to the manubrium was not taken into account. 14,17,22,26,36,49,50,56,58 Performing manubriotomy increases surgical time, bleeding, postoperative pain intensity, and LOS.…”

“…13,14,17,22,26,36,49,50,56,58 Several authors have previously described their radiological methods to identify in which cases the anterior approach could be performed and when manubriotomy was needed; nevertheless, the reproducibility of the technique was not straightforward, several different measurements were described and analyzed without considering the vascular anatomy, and the relationship of the inclination of the vertebrae above the lesion to the manubrium was not taken into account. 14,17,22,26,36,49,50,56,58 Performing manubriotomy increases surgical time, bleeding, postoperative pain intensity, and LOS. 7,13,14,20,24,37 Due to these approach-related morbidities, during the preoperative period the surgical team must be aware that the need for manubriotomy must be established so that they can plan the surgery and discuss the expected surgical risks and morbidities with the family.…”

“…14,17,22,26,36,49,50,56,58 Performing manubriotomy increases surgical time, bleeding, postoperative pain intensity, and LOS. 7,13,14,20,24,37 Due to these approach-related morbidities, during the preoperative period the surgical team must be aware that the need for manubriotomy must be established so that they can plan the surgery and discuss the expected surgical risks and morbidities with the family.…”