Summary
Background
With increasing frequency, spine surgeons are being asked to provide decompression and stabilization in patients with spinal metastases. While no region of the spine is easily treated, the upper thoracic spine is perhaps the least accessible. Traditional approaches to this region involve either thoracotomy or at least limited sternotomy. The authors present an approach to anterior pathology of the upper thoracic spine that obviates the need for sternotomy.
Methods
Within the past two years, two patients with cervicothoracic metastases underwent anterior decompression and fusion without sternotomy. In both patients, the bodies of C7, T1, and T2 were removed. While both patients were prepared and draped for sternotomy, each required a neck dissection only. In both patients, left-sided incisions were made along the leading edge of the sternocleidomastoid. The platysma was divided with the overlying skin. With further dissection, the strap muscles were tagged and divided approximately one centimeter above their sternal attachments. The loose areolar tissue of the superior mediastinum was then bluntly dissected. Along the entire length of the incision, the vascular plane medial to the carotid sheath was developed to facilitate exposure of the anterior spine. A Farley-Thompson retractor system was then employed to retract and protect the superior mediastinal structures. With this exposure, corpectomies were carried out using a high speed drill. Fusion was accomplished through insertion of Steinmann pins into the adjacent intact bodies above and below. This was followed by application of methyl methacrylate. Both patients had immediate postoperative stability with preservation of spinal cord function. Both patients subsequently underwent removal of dorsally located tumor with posterior fusion.
Conclusions
The goal of cancer surgery is to provide for increased functional survival without undue morbidity. The authors feel that when possible, the pain of sternal and clavicular osteotomies should be avoided. The described approach works well in conjunction with a methyl methacrylate/Steinmann pin construct. Because of the intact sternum, the surgeon has a downward angle to access the superior endplate of T3. With adequate soft tissue dissection and retraction as described, however, T3 and perhaps even T4 are easily accessible. While this downward angle would likely not permit an anterior plating procedure, it lends itself nicely to Steinmann pin/methyl methacrylate fusion and spares the patient the pain and potential morbidity of sternotomy.
Similar content being viewed by others
References
Black P (1979) Spinal metastases: current status and guidelines for management. Neurosurgery 5: 726–746
Calliauw L, Dallenga A, Caemaert J (1994) Transsternal approach to intraspinal tumours in the upper thoracic region. Acta Neurochir (Wien) 127: 227–231
Cauchoix J, Binet J (1957) Anterior surgical approaches to the spine. Ann R Coll Surg Engl 27: 237–243
Dalton ML, Connally SR (1993) Median sternotomy. Surg Gynecol Obstet 176: 615–624
Eastridge CE, Mahfood SS, Walker WA, Cole FH Jr (1991) Delayed chest wall pain due to sternal wire sutures. Ann Thorac Surg 51: 56–59
Fielding JW, Stillwell WT (1976) Anterior cervical approach to the upper thoracic spine: a case report. Spine 1: 158–161
Gumbs RV, Peniston RL, Nabhani HA, Henry LJ (1991) Rib fractures complicating median sternotomy. Ann Thorac Surg 51: 952–955
Hernigou P, Duparc F (1994) Lateral exposure of the cervicothoracic spine for anterior decompression and osteosynthesis. Neurosurgery 35: 1121–1125
Hodgson AR, Stock FE, Fang HSY, Ong GB (1960) Anterior spinal fusion: the operative approach and pathologic findings in 412 patients with Pott's disease of the spine. Br J Surg 48: 172–178
Hugo NE, Sultan MR, Ascherman JA, Patsis MC, Smith CR, Rose EA (1994) Single-stage management of 74 consecutive sternal wound complications with pectoralis major myocutaneous advancement flaps. Plast Reconstr Surg 93: 1433–1441
Locke TJ, Griffiths TL, Mould H, Gibson GJ (1990) Rib cage mechanics after median sternotomy. Thorax 45: 465–468
McDonald P, Letts M, Sutherland G, Unruh H (1992) Aneurysmal bone cyst of the upper thoracic spine. An operative approach through a manubrial sternotomy. Clin Orthop 279: 127–132
Sanders G, Uyeda RY, Karlan MS (1983) Nonrecurrent inferior laryngeal nerves and their association with a recurrent branch. Am J Surg 146: 501–503
Stillwell WT, Fielding JW (1984) Aneurysmal bone cyst of the cervicodorsal spine. Clin Orthop 187: 144–146
Stoelting RK (1994) Brachial plexus injury after median sternotomy: an unexpected liability for anesthesiologists. J Cardiothorac Anesth 8: 2–4
Sundaresan N, Bains M, McCormack P (1985) Surgical treatment of spinal cord compression in patients with lung cancer. Neurosurgery 16: 350–356
Sundaresan N, Hilaris B, Martini N (1987) The combined neurosurgical thoracic management of superior sulcus tumors. J Clin Oncol 5: 1739–1745
Sundaresan N, Shah J, Feghali JG (1984) A transsternal approach to the upper thoracic vertebrae. Am J Surg 148: 473–477
Sundaresan N, Shah J, Foley KM, Rosen G (1984) An anterior surgical approach to the upper thoracic vertebrae. J Neurosurg 61: 686–690
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Comey, C.H., McLaughlin, M.R. & Moossy, J. Anterior thoracic corpectomy without sternotomy: A strategy for malignant disease of the upper thoracic spine. Acta neurochir 139, 712–718 (1997). https://doi.org/10.1007/BF01420043
Issue Date:
DOI: https://doi.org/10.1007/BF01420043