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.

Wearing titanium particle‐induced osteoclastogenesis, accompanied by peri‐implant osteolysis, is the main cause of long‐term failure of hip prosthesis. Currently, medications used for the prevention and treatment of peri‐implant osteolysis show serious side effects. Therefore, development for more effective new drugs with less side effects is extremely urgent. Vaccarin is a natural flavonoid extracted from Vaccaria segetalis, with various biological functions, including antioxidantory, anti‐inflammatory, and promotion of angiogenesis. However, the putative role of vaccarin in the inhibition of titanium particle‐induced osteolysis has not been reported. In this study, it was indicated that vaccarin could effectively inhibit RANKL‐induced osteoclastogenesis, fusion of F‐actin rings, bone resorption, and expression of osteoclast marker genes in a dose‐dependent manner in vitro. Moreover, vaccarin could also inhibit RANKL‐induced osteoclastogenesis via the inhibition of NF‐κB and MAPK (p38, ERK, and JNK) signaling pathways, and inhibit the transcription of downstream transcription factors, such as c‐Fos and NFATc1. Consistent with in vitro results, this in vivo study showed that vaccarin exhibited an inhibitory effect on titanium particle‐induced osteolysis by antiosteoclastogenesis. In conclusion, vaccarin could be a promising agent for preventing and treating peri‐implant osteolysis.

C2 pedicle screw and plate combined with C1 titanium cable could be used to treat atlantoaxial instability in the cases not suitable for placement of C1 screw.