Surgical challenges in posterior cervicothoracic junction instrumentation

Abstract

Objectives: The cervicothoracic junction (CTJ) is a region of the spine submitted to signi cant mechanical stress. The peculiar anatomical and biomechanical characteristics make posterior surgical stabilization of this area particularly challenging. We present and discuss our surgical series highlighting the speci c surgical challenges provided by this region of the spine. Methods: We have analyzed and reported retrospective data from patients who underwent a posterior cervicothoracic instrumentation between 2011 and 2019 at the Neurosurgical Department of the Geneva University Hospitals. We have discussed C7 and Th1 instrumentation techniques, rods design, extension of constructs and spinal navigation. Results: 36 patients were enrolled. We have preferentially used lateral mass (LM) screws in the subaxial spine, pedicle screws (PS) in C7, Th1 and upper thoracic spine. We have found no superiority of 3D navigation techniques over 2D uoroscopy guidance in PS placement accuracy, probably due to the relatively small case series. Surgical site infection was the most frequent complication, signi cantly associated with tumor as diagnosis. Conclusions: When technically feasible, PS represent the technique of choice for C7 and Th1 instrumentation although other safe techniques are available. Different rods constructs are described although signi cant differences in biomechanical stability still need to be clari ed. Spinal navigation should be used whenever available even though 2D uoroscopy is still a safe option. Posterior instrumentation of the CTJ is a challenging procedure but with correct surgical planning and technique it is safe and effective.

Strategy and Efficacy of Surgery for Congenital Cervicothoracic Scoliosis with or without Hemivertebra Osteotomy

“…Failure of internal fixation is a frequently reported complication. The difficulty of screw placement in the cervicothoracic spine is greatly increased by factors such as narrow pedicles and abnormal vertebral structures 18 . Preoperative spinal CT can show the structure of spinal deformities and the size of the pedicle, and individualized surgical plans can be made according to different patient conditions, such as the position and depth of screw placement.…”

“…The difficulty of screw placement in the cervicothoracic spine is greatly increased by factors such as narrow pedicles and abnormal vertebral structures. 18 Preoperative spinal CT can show the structure of spinal deformities and the size of the pedicle, and individualized surgical plans can be made according to different patient conditions, such as the position and depth of screw placement. 3D printing can be used to display the shape of the spine more intuitively, which is helpful for surgical planning and as an intuitive reference during surgery.…”

Crossing the Cervicothoracic Junction

“…Their findings indicate that pedicle screws are the most common means of screw fixation at C7 and provide the highest biomechanical strength. [45][46][47] Risks for placement of C7 pedicle screws include perforation of the pedicle wall, nerve root injury with lateral deviation or spinal cord injury with medial deviation, and esophageal injury with anterior breech, with reported rates varying from 6.9%-65%. Despite these risks, pedicle screws offer the highest axial-load-to-failure strength and improved stability (Video 1, Supplemental Digital Content 2, http://links.lww.com/CLINSPINE/A258).…”

“…They provide an in-depth description and literature review on lateral mass screws, pedicle screws, transfect screws, and intralaminar screws. Their findings indicate that pedicle screws are the most common means of screw fixation at C7 and provide the highest biomechanical strength 45–47. Risks for placement of C7 pedicle screws include perforation of the pedicle wall, nerve root injury with lateral deviation or spinal cord injury with medial deviation, and esophageal injury with anterior breech, with reported rates varying from 6.9%–65%.…”

Accuracy and Outcomes of Freehand Thoracic Pedicle Screw Placement using Qi’s Technique

“…10 Several authors have proposed a variety of techniques of freehand thoracic PS placement by focusing on the location of entry points and trajectories in the transverse and sagittal planes. 4,11,12 However, novice surgeons insufficiently familiar with the finer details of the thoracic spine anatomy may be uncertain in the selection of an appropriate entry points and trajectories. In practice, novice surgeons planning to specialize in spinal surgery should be encouraged to focus on one technique and practice it under the supervision of an experienced surgeon until the technique becomes consistent and accurate.…”