Transcript view poster
Optimal Anterior Approach for the
Cervicothoracic Junction Lesions
Dept. of Neurosurgery
Soonchunhyang University Bucheon, Korea
Prof. Soo-Bin Im
Dong-Seung Shin, Bum-Tae Kim, Won-Han Shin
Anatomical & Clinical peculiarity
Reversal of lordosis to Kyphosis
visualization deeper.
Limited by sternum, clavicle, vital structures
Trachea, esophagus, great vessels, thoracic duct, lung apex, recurrent
laryngeal n. brachial plexus
Pathologic process usually occurs in anterior segment.
Lung
apex
Anterior Approach for CTJ lesion
enables direct decompression &
stabilization.
Great vessels
Case summary of surgery on CTJ
Transmanubrial approach
1. 67/F Plasmacytoma
2. 61/M Metastatic tumor
3. 51/M Metastatic tumor
4. 20/F Giant cell tumor
5. 22/F Giant cell tumor (recurred)
5. 46/M TB spondylitis
6. 47/M TB spondylitis
7. 56/F Spondylotic myelopathy
8. 62/F Ruptured disc
9. 69/M Ruptured disc
10. 45/M Bursting fracture with syrynx
Supramanubrial approach
11. 44/F Metastatic tumor
T2
T1
T3
C7T12
C7T12
T2
T23
C7T1
T12
T12
T2
T1
Operating Scene for approach
Extended incision from cervical to manubriosternal junction
Finger dissection of posterior surface of the manubrium.
Inverted T-shape manubriotomy with oscillating saw
Strong short
retractor for
splitted
manubrium
Long retractor for
visceral structure
Spatial relationship between supramanubrial border
and Upper and lower parallel line is critical for
exposure and decision of manubriotomy length
If upper parallel line is below
supramanubrial border
manubriotomy is inevitable.
If only Inferior parallel line is below
supramanubrial border
relative indication for
manubriotomy
*
Decision for manubriotomy length should be made
- By two parallel line to the lesion.
- Not by number of vertebrae.
T1
C7
*
Not need
manubriotomy
*
Relative Ix for
manubriotomy
*
T2
Manubriotomy
is mandatory
Length of manubriotomy
Regardless of the full sternotomy, the caudal extent is limited to
T3 by the innominate vein, aortic arch.
Inverted T-shape Manubriotomy at the 2nd intercostal space is
optimal and usual.
Variation of vertebral level and kyphotic angulation deformity
Common Pitfall
61/F plasmacytoma with kyphotic angulation
Preop.
Postop.
Postop. 2 yrs
Reconstruction
Iliac bone graft with anterior plating ------------------------- 1
Flanged titanium mesh only ------------------------------------ 5
Titanium mesh + anterior plating ------------------------------ 2
Mesh + Plate + posterior augmentation --------------------- 2
T1
Result & Complications
Neurologic recovery -----------------------------------Recurrent laryngeal nerve injury -------------------Trachea, Esophageal injury ------------------------Local hematoma, infection --------------------------Nonunion or pain on manubriotomy site-----------Thoracic duct injury, Chylothorax ------------------Recurrence of tumor( giant cell tumor, 3 yrs )----
9
0
0
0
0
1
1
Thoracic duct injury
Unfamiliar complication to spine surgeon.
Might be avoided by limiting the dissection.
medial to the carotid artery,
Find and ligation rather than dissection.
Chylothorax occurs chest tube drainage, lipid free
diet.
T1
Conclusions
Anterior approach for CTJ lesion is challenging but
provides direct decompression and effective
reconstruction method.
Inverted T-partial manubriotomy is optimal for the T1-T3.
Manubriotomy can be decided by upper and lower
parallel line to the lesion.
The spatial relationship between upper parallel line and
supramanubrial border is critical for exposure.
*