Surgical management for upper thoracic spine tumors by a transmanubrium approach and a new space

Abstract

The anterior aspect of the upper thoracic spine is a difficult region to approach in spinal surgery. Many vital structures including osseus, articular, vascular and nervous ones hinder the exposure. With increasing frequency, spine surgeons are being asked to provide decompression and stabilization in patients with spinal tumors .The traditional exposure is between the esophagus and trachea medially and the left common carotid or the brachiocephalic artery (BCA) laterally, and the disadvantages were that the ligation and section of the left innominate vein is proposed to reach T4 and the injury of the thoracic duct could occur. The right space of the BCA or the ascending aorta (AA) (the exposure between the right brachiocephalic vein and the BCA or between the AA and superior caval vein) is recommended in exposing the upper thoracic vertebrae; this new space is technically feasible; the exposure is sufficient for vertebral body resection and reconstruction and fixation. Twentyeight patients with upper thoracic spine tumors underwent surgery by the use of this new space between June 2000 and October 2005. A strut graft was fixed anteriorly after decompression of the spinal cord. Levels C7-T5 can be well exposed through this new space, allowing complete vertebral body removal at level T1-T4. After body removal, the posterior longitudinal ligament is well exposed, allowing complete release of the spinal cord. Curettage was performed in one case of aneurysmal bone cyst and three cases of bone giant cell tumors. For other tumors, vertebrectomies or sagittal resections were performed. Four patients underwent surgery by a combination of anterior and posterior approach.

Mini-open anterior approach to the cervicothoracic junction: a cadaveric study

“…Because of the deep location of vertebral bodies due to the kyphosis of the upper thoracic spine and the presence of neurovascular and osseous obstacles over the operative field in this region, surgical access is often limited [15,17,22,25]. As for neurovascular obstacles, such as the brachiocephalic veins, thoracic duct, and recurrent laryngeal nerves, they can be easily injured which might lead to significant complications [10,12,19,25]. The best way is to bypass them and to reach the spine through neurovascular space.…”

“…But the manubrium sterni and clavicles often hinder access to T3, T4 and below. To gain access, surgical techniques such as the trans-sternal, the transclavicular trans-manubrial and trans-manubrial approaches have been recommended [1,3,4,18,19,22,25]. Each approach has its advocates, but all of them have limitations.…”

“…Thereafter, a modified trans-manubrial approach (unilateral manubriotomy) was used by Darling et al [6] in 4 cases, by Xiao et al [25] in 28 cases. This technique could access T4, occasionally T5.…”

“…Anterior surgical approaches such as the trans-sternal [3], the transclavicular trans-manubrial [1,4,18] and transmanubrial [19,22,25] approaches have been recommended. From the spinal and cardiothoracic literature, however, it is clear that splitting the sternum or resecting part of clavicle might lead to some complications, such as chronic pain, pneumothorax, infection, sternal dehiscence, nonunion of the clavicle, pseudarthrosis, and instability of the sternoclavicular joint [1,5,7,13,20,22].…”

An anterior approach to spinal pathology of the upper thoracic spine through a partial manubriotomy

“…5, Approach 4); 8 creation of an interaortocaval subinnominate window to allow access to the upper thoracic spine; 4 and a transmanubrium approach with a corridor between the brachiocephalic trunk and the ascending aorta. 25 The sternum-splitting technique allows direct visualization of T-1 to T-4 and is considered the most invasive (Fig. 5, Approach 3).…”