Presentation on theme: "Optimal Anterior Approach for the Cervicothoracic Junction Lesions Dept. of Neurosurgery Soonchunhyang University Bucheon, Korea Prof. Soo-Bin Im Dong-Seung."— Presentation transcript:
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 Great vessels Anterior Approach for CTJ lesion enables direct decompression & stabilization.
Case summary of surgery on CTJ Transmanubrial approach 1. 67/F Plasmacytoma T /M Metastatic tumor T /M Metastatic tumor T /F Giant cell tumor C7T /F Giant cell tumor (recurred) C7T /M TB spondylitis T /M TB spondylitis T /F Spondylotic myelopathy C7T /F Ruptured disc T /M Ruptured disc T /M Bursting fracture with syrynxT2 Supramanubrial approach /F Metastatic tumor T1
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 Operating Scene for approach
If upper parallel line is below supramanubrial border manubriotomy is inevitable. If only Inferior parallel line is below supramanubrial border relative indication for manubriotomy * Spatial relationship between supramanubrial border and Upper and lower parallel line is critical for exposure and decision of manubriotomy length
* * * Manubriotomy is mandatory Relative Ix for manubriotomy Not need manubriotomy T1T1 C7 Decision for manubriotomy length should be made - By two parallel line to the lesion. - Not by number of vertebrae. T2
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 2 nd intercostal space is optimal and usual. Variation of vertebral level and kyphotic angulation deformity Innominate vein Trachea Carotid artery
Common Pitfall 61/F plasmacytoma with kyphotic angulation Preop. Postop. 2 yrsPostop.
Reconstruction Iliac bone graft with anterior plating Flanged titanium mesh only Titanium mesh + anterior plating Mesh + Plate + posterior augmentation 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 )---- 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. T1T1
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. *