Anterior surgical approaches to the cervicothoracic junction: when to use the manubriotomy?

Lee

et al. 2015

J Korean Neurosurg Soc

ObjectiveThe cervicothoracic junction (CTJ) is a biomechanically and anatomically complex region that has traditionally posed problems for surgical access. In this retrospective study, we describe our clinical experiences of the treatment of metastatic spinal tumors at the CTJ and the results.MethodsFrom June 2006 to December 2011, 23 patients who underwent surgery for spinal tumors involving the CTJ were enrolled in our study. All of the patients were operated on through the posterior approach, and extent of resection was classified as radical, debulking, and simple neural decompression. Adjuvant radiation therapy (RT) was also considered. Visual analog scale score for pain assessment and Medical Research Council (MRC) grade for motor weakness were used, while pre- and post-operative performance status was evaluated using the Eastern Cooperative Oncology Group (ECOG).ResultsAlmost all of the patients were operated using palliative surgical methods (91.3%, 21/23). Ten complications following surgery occurred and revision was performed in four patients. Of the 23 patients of this study, 22 showed significant pain relief according to their visual analogue scale scores. Concerning the aspect of neurological and functional recovery, mean MRC grade and ECOG score was significantly improved after surgery (p<0.05). In terms of survival, radiation therapy had a significant role. Median overall survival was 124 days after surgery, and the adjuvant-RT group (median 214 days) had longer survival times than prior-RT (63 days) group.ConclusionAlthough surgical procedure in CTJ may be difficult, we expect good clinical results by adopting a palliative posterior surgical method with appropriate preoperative preparation and postoperative treatment.

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Surgical Management with Radiation Therapy for Metastatic Spinal Tumors Located on Cervicothoracic Junction : A Single Center Study

Lee

et al. 2015

J Korean Neurosurg Soc

“…This approach to the CTJ includes clavicle resection or separation of the sternoclavicular joint and has a risk of nonunion. The anterior midline approach is the best option from the perspective of effective decompression and direct stabilization and the low morbidity rate 15) . The midline full sternotomy approach, which is commonly applied in cardiac surgery, provides a wide bony window but the lower extent of the surgical field at the CTJ would not be extended because the main barrier to the anterior vertebral aspect is the great vessels not the osseous window.…”

Section: Discussionmentioning

confidence: 99%

The Transmanubrial Approach for Cervicothoracic Junction Lesions : Feasibility, Limitations, and Advantages

Jeong

et al. 2015

J Korean Neurosurg Soc

ObjectiveWe report on the technical feasibility and limitations of the transmanubrial approach for cervicothoracic junction (CTJ) lesions and emphasize the advantage of bisecting the upper part of the manubrium in an inverted Y-shape.MethodsThirteen patients who underwent the fourteen transmanubrial approach for various CTJ lesions were enrolled during 2005-2014. For the evaluation of the accessibility for the CTJ lesion, we analyzed the two parallel line defined as a straight line parallel to the inferior and superior plateau of the upper and lower healthy vertebrae, the angle of the two parallel lines and the distance from the sternal notch to lines at the sternum on preoperative magnetic resonance images. Surgical limitations and perspectives, as well as postoperative clinical outcomes were evaluated retrospectively.ResultsThe CTJ lesions were six metastases, three primary bone tumors, two herniated discs, and one each of a traumatic dislocation with syrinx formation and tuberculous spondylitis and ossification of the posterior longitudinal ligament. If two parallel lines pass below the sternal notch, the manubriotomy should be inevitably performed. The mean preoperative Visual analogue scale score was 8 (range, 5-10), which improved to 4 (range, 0-6) postoperatively. Seven cases showed an increase in Frankel score postoperatively.ConclusionThe spatial relationship between the sternal notch and the two parallel lines to the lesion was rational to determine the feasibility of manubriotomy. The transmanubrial approach for CTJ lesions can achieve favorable clinical outcomes by providing direct decompression of lesion and effective reconstruction.

“…The anterior approach with manubriotomy was not considered because the lesion was below the cervicothoracic angle. 13 Transthoracic thoracotomy is safe and rarely associated with neurologic deterioration. 14 …”

Section: Discussionmentioning

confidence: 99%

Thoracic Spondylodiscitis Caused by Methicillin-resistant Staphylococcus aureus as a Superinfection of Pulmonary Tuberculous Granuloma in an Immunocompetent Patient: A Case Report

Donnarumma

Tarantino

Palmarini

et al. 2014

Global Spine Journal

Self Cite

Study Design Case report. Objective To describe a very rare case of an immunocompetent man who underwent surgery for thoracic spondylodiscitis caused by methicillin-resistant Staphylococcus aureus (MRSA) that developed as a superinfection of a pulmonary tuberculous granuloma. Methods Posterior decompression and pedicle screw vertebral fixation were followed by T5–T6 anterior somatotomy with implant of an expandable mesh and lateral plating as symptoms worsened. During the anterior approach, an atypical resection of the left lower lobe was also performed. Results A tuberculous granuloma was detected on histology. Ziehl-Neelsen stain confirmed the diagnosis. Culture also detected MRSA. Conclusions Early medical management is the first choice for spondylodiscitis to eradicate the infection and alleviate pain. Immobilization of the affected spine segments can protect the patient from vertebral collapse and from the appearance of neurologic deficits. Surgery is suggested if there are compressive effects on the spinal cord, spinal epidural abscess, vertebral collapse, and deformity. We decided to remove the abscess and to restore the anterior column using an anterior approach. Moreover, in this case, an anterior approach allowed us to identify the etiology of the lesion and to determine the best chemotherapy regimen.