Optimal Anterior Approach for the
Cervicothoracic Junction Lesions
Dept. of Neurosurgery
Soonchunhyang University Bucheon, Korea
Prof. Soo-Bin Im
Dong-Seung Shin, Bum-Tae Kim, Won-Han Shin
Anatomical & Clinical peculiarity
 Reversal of lordosis to Kyphosis
 visualization deeper.
 Limited by sternum, clavicle, vital structures
Trachea, esophagus, great vessels, thoracic duct, lung apex, recurrent
laryngeal n. brachial plexus
 Pathologic process usually occurs in anterior segment.
Lung
apex
Anterior Approach for CTJ lesion
enables direct decompression &
stabilization.
Great vessels
Case summary of surgery on CTJ
Transmanubrial approach
1. 67/F Plasmacytoma
2. 61/M Metastatic tumor
3. 51/M Metastatic tumor
4. 20/F Giant cell tumor
5. 22/F Giant cell tumor (recurred)
5. 46/M TB spondylitis
6. 47/M TB spondylitis
7. 56/F Spondylotic myelopathy
8. 62/F Ruptured disc
9. 69/M Ruptured disc
10. 45/M Bursting fracture with syrynx
Supramanubrial approach
11. 44/F Metastatic tumor
T2
T1
T3
C7T12
C7T12
T2
T23
C7T1
T12
T12
T2
T1
Operating Scene for approach
 Extended incision from cervical to manubriosternal junction
 Finger dissection of posterior surface of the manubrium.
 Inverted T-shape manubriotomy with oscillating saw
 Strong short
retractor for
splitted
manubrium
 Long retractor for
visceral structure
Spatial relationship between supramanubrial border
and Upper and lower parallel line is critical for
exposure and decision of manubriotomy length

If upper parallel line is below
supramanubrial border
 manubriotomy is inevitable.

If only Inferior parallel line is below
supramanubrial border
 relative indication for
manubriotomy
*
Decision for manubriotomy length should be made
- By two parallel line to the lesion.
- Not by number of vertebrae.
T1
C7
*
Not need
manubriotomy
*
Relative Ix for
manubriotomy
*
T2
Manubriotomy
is mandatory
Length of manubriotomy



Regardless of the full sternotomy, the caudal extent is limited to
T3 by the innominate vein, aortic arch.
Inverted T-shape Manubriotomy at the 2nd intercostal space is
optimal and usual.
Variation of vertebral level and kyphotic angulation deformity
Common Pitfall
61/F plasmacytoma with kyphotic angulation
Preop.
Postop.
Postop. 2 yrs
Reconstruction




Iliac bone graft with anterior plating ------------------------- 1
Flanged titanium mesh only ------------------------------------ 5
Titanium mesh + anterior plating ------------------------------ 2
Mesh + Plate + posterior augmentation --------------------- 2
T1
Result & Complications







Neurologic recovery -----------------------------------Recurrent laryngeal nerve injury -------------------Trachea, Esophageal injury ------------------------Local hematoma, infection --------------------------Nonunion or pain on manubriotomy site-----------Thoracic duct injury, Chylothorax ------------------Recurrence of tumor( giant cell tumor, 3 yrs )----
9
0
0
0
0
1
1
Thoracic duct injury




Unfamiliar complication to spine surgeon.
Might be avoided by limiting the dissection.
medial to the carotid artery,
Find and ligation rather than dissection.
Chylothorax occurs chest tube drainage, lipid free
diet.
T1
Conclusions




Anterior approach for CTJ lesion is challenging but
provides direct decompression and effective
reconstruction method.
Inverted T-partial manubriotomy is optimal for the T1-T3.
Manubriotomy can be decided by upper and lower
parallel line to the lesion.
The spatial relationship between upper parallel line and
supramanubrial border is critical for exposure.
*