Anterior surgical management of the cervicothoracic junction lesions at T1 and T2 vertebral bodies

Abstract

-Lesions of the cervicothoracic junction have a high propensity for causing instability and present unique challenges in the surgical treatment. Several surgical approaches to this region have been described in the literature. We report our experience in the surgical treatment of six patients with unstable lesions involving the cervicothoracic junction at T1 and T2 vertebral bodies. The patients underwent an anterior left Smith-Robinson approach and manubriotomy. Mesh and cervical plate system were used for stabilization and reconstruction of the region. No complication related to the surgical procedure was observed. In our experience, in injuries involving the T1 and T2 vertebral bodies, the transmanubrial approach offers good working room to remove the lesions and anterior reconstruction.KEY WORDS: spine, cervicothoracic junction, instability, surgical treatment. Manejo cirúrgico via anterior das lesões da junção cérvico-torácica nos corpos vertebrais de T1 e T2Resumo -Lesões da junção cérvico-torácica têm alta tendência em causar instabilidade e apresentam grandes desafios ao tratamento cirúrgico. Diversas abordagens cirúrgicas a esta região foram descritas na literatura. Relatamos nossa experiência no tratamento cirúrgico de seis pacientes com lesões instáveis envolvendo a junção cérvico-torácica em corpos vertebrais de T1 e T2. Os pacientes foram submetidos a uma abordagem anterior de Smith-Robinson pela esquerda e manubriotomia. Mesh e placa cervical foram utilizados para estabilização e reconstrução da região. Nenhuma complicação relacionada ao procedimento cirúrgico foi observada. Em nossa experiência, em lesões que envolvem os corpos vertebrais de T1 e T2, a abordagem transmanubrial oferece bom campo de trabalho para remoção das lesões e estabilização anterior.

An RCT study on the feasibility of anterior transpedicular screw fixation in the cervicothoracic junction

“…Gaining anterior access to this region is difficult and potentially dangerous not only because of the nearby vital, complex anatomical structures, but also because of the bony obstructions [5,12,[18][19][20]. This region is a transition area from a mobile cervical spine to a rigid thoracic spine.…”

“…However, ventral exposure of the CTJ is difficult because of the deep location of the vertebral bodies caused by the thoracic kyphosis and the crossing of vital structures over the operative field in the upper mediastinum [6,[11][12][13]. Furthermore, the CTJ is one of the most challenging regions in spinal surgery, anterior stabilization alone reveals a high incidence of construct failure, and supplementary fixation should be considered to augment the construct [14,15].…”

Vascularized Fibula Strut Graft Used in Neurofibromatosis Type 1-Related Kyphosis: A Case of Almost Complete Reversal of Deformity-Induced Tetraparesis

“…No comments were drawn regarding a laminectomy or osteotomy or on the type of instrumentation used. The anterior approach to the cervicothoracic junction is fraught with pitfalls, from planning to execution 1. Depending on the patient's anatomy, wide dissection on the thoracic cage and dissection of the major vessels is necessary.…”

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

“…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.…”

“…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.…”