Minimally invasive endoscopic approach to the cervicothoracic junction for vertebral metastases: report of two cases

Abstract

The anterior cervicothoracic junction is difficult to expose and many techniques have previously been described. Most of them require an extensile exposure, which can lead to significant morbidity. The aim of this study is to present a less invasive approach, allowing the same exposure on the spine as a larger one. The approach begins with the same incision as the Smith-Robinson technique: a blunt dissection of the posterior face of the manubrium is performed with the finger. An endoscope is inserted through 10-mm trocars, one above the manubrium and the second through the second rib space. The upper mediastinal space is exposed; the dissection is performed on the left side, between the esophagus and trachea medially, between the innominate vein and brachio-cephalic artery distally, and between the left common carotid and internal jugular vein laterally. The recurrent nerve must be protected. Two patients with spine metastases underwent this new approach. A strut graft was fixed anteriorly after decompression of the spinal cord. Levels T1-T3 can be well exposed through this approach, allowing complete vertebral body removal at level T1 or T2. After body removal, the posterior longitudinal ligament is well exposed, allowing complete release of the spinal cord. The use of the endoscope is the key to providing a good view of the spine without an extensile exposure. This new approach is technically feasible. The exposure is sufficient for vertebral body resection and reconstruction by strut graft. The procedure is less aggressive and painful than sternotomy.

Surgical Management of Spinal Metastases

“…One area that has received much attention recently is the use of endoscopes in the resection of metastatic tumors in the thoracic spine [60][61][62][63][64]. Although an endoscope can be used with open approaches, it is most often used in conjunction with a minimally invasive anterior transthoracic approach.…”

Trans-upper-sternal Approach to the Cervicothoracic Junction

“…Various approaches have been suggested to provide safe and effective access to this region [3,8,10,12,13,15,18]. Our small series suggests the trans-upper-sternal approach is a technically feasible, less invasive, and effective exposure to gain access to the CTJ.…”

“…Therefore, left exposure by the trans-upper-sternal approach is preferable to decrease the risk of iatrogenic recurrent laryngeal nerve injury. The most frequent complication related to the anterior approach to the CTJ is vocal cord paresis secondary to injury of the recurrent laryngeal nerve [13] with the reported incidence ranging from 4.76% to 16.67% [16,17]. Morbidity of the recurrent laryngeal nerve has been attributed to numerous factors, including direct insult during sharp dissection, overstretching of the nerves [5] especially at the recurrent point of the recurrent laryngeal nerve, ligation of the inferior thyroid vessels without identification of the nerve, anatomic variations of the nerve, compression of the recurrent laryngeal nerve by the endotracheal tube [1], or soft tissue swelling and hematoma [5].…”

Minimal invasive approaches in metastatic spinal tumors

“…Le-Huec and colleagues described a "mini-open" retrosternal approach to the upper thoracic spine (C7-Th3) (20). Percutaneous lumbar pedicle screw instrumentation has been widely reported in several studies (23, 24).…”

“…Thoracoscopic anterior stabilization may be achieved with bone graft or PMMA, and an anterolateral plate is specifically designed for endoscopic application. Thoracoscopy can be used to access the entire spine from T1 to T12, allowing for tumor resection (20,25). Less incisional pain, earlier ambulation, shorter hospital stays, decreased intercostal neuralgia, and less pulmonary complications are the main advantages of this procedure (29,30) Patients with severe pulmonary dysfunction, extensive pleural adhesions and patients that had previous surgery cannot tolerate the procedure due to single-lung ventilation.…”