Mini Transsternal Approach to the Anterior High Thoracic Spine (T1–T4 Vertebrae)

Abstract

Purpose. The anterior high thoracic spine is one of the most complex segments to be accessed surgically due to anatomical constraints and transitional characteristics. We describe in detail the mini transsternal approach to metastatic, infective, traumatic, and degenerative pathologies of T1 to T4 vertebral bodies. We analyse our surgical series, indications, and outcomes. Methods. Over a 5-year period 18 consecutive patients with thoracic myelopathy due to metastatic, infective, traumatic, and degenerative pathologies with T1 to T4 vertebral bodies involvement received a mini transsternal approach with intraoperative monitoring. Frankel scoring system was used to grade the neurological status. Results. Mean follow-up was 40 months. 78% patients improved in Frankel grade after surgery and 22% patients remained unchanged. Average operation time was 210 minutes. There were no intraoperative complications. One patient developed postoperative pneumonia successfully treated with antibiotics. Conclusion. The mini transsternal is a safe approach for infective, metastatic, traumatic, and degenerative lesions affecting the anterior high thoracic spine and the only one allowing an early and direct visualisation of the anterior theca. This approach overcomes the anatomical constraints of this region and provides adequate room for optimal reconstruction and preservation of spinal alignment in the cervicothoracic transition zone with good functional patient outcomes.

The Shame–Blame Game: Is It Still Necessary? A National Survey of Shame-based Teaching Practice in Canadian Plastic Surgery Programs

“… 3 , 8 It is understandable, then, how SBL can contribute to the development of physician burnout, substance abuse, and suicide. 1 – 4 , 11 Given that shamers are often in positions of authority, SBL can be classified as a form of bullying and harassment. 6 Recently, awareness has been drawn to the “endemic” culture of harassment in the Australian medical system localized predominantly in surgical specialties.…”

Right infraaxillary thoracotomy approach for upper thoracic vertebral decompression and fusion at T2–T6 levels: a technical note

“…In the anterior trans-sternal approach (C4-T4) widely used to treat challenging upper thoracic spine disorders, adequate exposure is always hindered by many vital structures, including the great vascular and thoracic duct [12][13][14]. However, the extensive dissection and exposure associated with the approach increases patients' risk of injury to adjacent blood vessels and thoracic duct, if the spine surgeon is not be familiar with it [9,[15][16][17].…”

“…However, it is still difficult to decompression severe direct anterior spinal cord compression [5,6]. And other direct upper thoracic vertebral approaches can be mainly divided into the high transthoracic approach (C6-T4), and the modified anterior approach (C3-T4) [7,8]; however, using these approaches, it is not easy to decompress the spinal cord at the upper thoracic (T1-T4) level of the anterior column and difficult to create an adequate operative space because of the scapula block [3,9,10].…”

Transaxillary Transthoracic Approach to Upper Dorsal Spine Lesions: An Anatomical Corridor with Muscle Preservation

“…In 2016, Christian brogan et al did a study on mini trans sternal approach for upper dorsal spine lesion, where average operative time wa150 -280 minutes, 75% neurological improvement, 22% remained same, 0% mortality no CSF leak or dural tear was encountered in their study 2 patient had got severe postoperative pain, one patient got pneumonia and one patient got postoperative hematoma. 21 Another study conducted on manubriotomy for upper thoracic spine by Asdrubal Falavigna et al, in which they mentioned the average operative time was 3.7 hrs, the average blood loss of 280 ± 122 minutes along with manubriotomy they performed staged posterior instrumentation also. Patients also experienced severe postoperative pain, spinal instability and hematoma formation.…”

“…6 It creates surgical challenges for surgeon approaching upper thoracic spine lesions because narrow thoracic outlet, vital contents of mediastinum the heart, lung and neurovascular structures along with limitation by the shoulder and scapular muscles. 7 A variety of surgical approaches are tailored depending upon feasibly on the surgeon and location of lesion, and most common are supraclavicular, transmanubrium transthoracic and lateral para scapular extra pleural approaches. 8 We describe our experience with the trans-axillary transthoracic an anatomical approach in a variety of lesions involving the upper dorsal spine.…”