Revealed By The Suprasternal Approach To The Cervicothoracic Anatomical Study And Clinical Application

The cervicothoracic junction can be defined as an area extending from vertebral segments C6 to T4. This area is unique in that it is a transition area from a lordotic cervical spine to a kyphotic thoracic spine. The anterior approach is used for the direct exposure of the compressed site to decompress in the anterior compression to the spinal cord in cervicothoracic region. There is no a well recognized anterior approach to this region for the complicated anatomical structures and difficult surgical exposure. Between March 1997 and January 2005, the authors performed surgery in 16 patients with cervicothoracic spinal cord compression through the trans-upper-sternal approach resulting enough exposure and satisfactory effect. Materials and methodSixteen patients were enrolled in the study. There were 11 male and 5 female patients aging from 33-67 years with medical history of 10 days to 2 years. Compression level: C6-7(1),C6-T1(1),T1-2(1),T2(1) and T3(1), C7(3), C7-T1(3), T1(5). Lesion type: fracture(4), fracture and dislocation(6), plasmocytoma(1), tuberculosis(1), fibrolipoangioma(1), lung cancer metastasis(1), esophageal carcinoma metastasis (1) ,and unknown primary lesion(1). Preoperative evaluation of the spinal cord function by Frankel classification: Frankel A(2) with fracture, Frankel B (4)including fracture(2), unknown primary lesion(1) and plasmocytoma(1), Frankel C (6) including lung cancer metastasis(1), esophageal carcinoma metastasis(1), tuberculosis(1), 3 fracture and dislocation(3), Frankel D (4)including fibrolipoangioma(1) and fracture and dislocation(3). There were 14 patients with sphincter dysfunction.All the patients had the complaint of back pain in cervicothoracic region, tenderness, percussion pain and limited motion in the cervicothoracic spine. The main signs, symptoms and associated conditions include: pain and numbness in left shoulder and forearm (1), bilateral shoulder pain radiating down to two arms (1), numbness in two arms(1), numbness in middle finger, ring finger, and little finger(1), numbness and hypoesthesia below the level of nipples, muscle weakness (grade Ⅰ-Ⅳ), and accentuated bilateral patella tendon reflex(4), complete motor and sensation loss below the level of nipples(1), bradycardia(heart rate 50-58bpm)(3), hypotesion(l), Horner's syndrome in right side(1), stress gastric ulcer, pulmonary infection, and compartmental syndrome in left leg(1), esophageal carcinoma with metastasis to left lung, left pleural effusion and atelectasis(1), pleural calcification and latent coronary artery disease(1), lung cancer with metastasis to mediastinal lymph nodes(1).A left anterior longitudinal incision was made in operation, starting 4.0cm below the mamillary process, along the medial border of the stemomastoid muscle down to the point 3cm above the jugular notch and going down vertically to the lower border of sternal angle, ending at the level between the second and third ribs. The dissection was taken in the space medial to the carotid sheath. After exposure of the sternum, the tissue behind the sternum was bluntly dissected. The splitting along the midline or left one third of the sternum was performed distally just 1cm below the sternal angulus according to the different vertebral level to be exposed. The two parts of the split sternum were then partially or completely cut transversely. A rib spreader was used for exposure. The thyroid, trachea, and esophagus were retracted medially, and the carotid sheath was retracted laterally for complete exposure of the cervicothoracic region with the upper border in C3 . The lower border in T5 could be reached through additional exposure of the ascending branch of aorta and distal retraction (or ligation) of left innominate vein.A C-Arm was used for the localization of the affected vertebral body. The surgical methods include complete tumor resection or subtotal corpectomy of the affected vertebral body with long window decompression(1 merely tumor resection, 1 partial corpectomy of C7 and T1, 1 subtotal corpectomy of T3, 2 partial corpectomy of C7 and T1 respectively, 4 subtotal corpectomy of C7, 5 subtotal cprpecyomy of T1), completeanterior decompression and interbody fusion with an oblong auto graft of tricortical iliac bone or titanium mesh with auto bone graft or allograft inside(10 auto iliac bone,5 titanium mesh with allograft, 15 anterior internal fixation with locking plate). A tube was placed behind the sternum for closed drainage and the split sternum was put together with sternal sutures. Of the 16 patients, the bleeding volume ranged from 200ml to 1000ml with an average of 600ml. And the operation time was 2 to 5 hours. ResultsNo intraoperative complication was met in these 16 patients and the paraoperative period passed uneventfully. After the sutures were removed, the patients were discharged 1 to 2 weeks after operation. One patient developed chyle leakage of 50 ml one day after surgery and the leakage stopped 2 days after continuous drainage. An esophageal fistula was found in one patient one week after surgery and was treated successfully. Two patients had transient hoarse voice which resolved in 3 months. All the patients were followed up (range 6-50months). One patient had pachynsis pleurae. One patient with T1 plasmocytoma died of pulmonary infection 4 years postsurgery. The bony fusion was achieved in 3-4months postoperatively. No un-union and pain in sternum was found. 15 patients (another one patient had no vertebral lesion and only received a tumor resection) had their cervicothoracic physiologic curve and stability restored with good positioning of the interbody bone graft. There was no failure of internal fixation. The 14 patients with sphincter dysfunction had gained bowel and bladder control 1 month after surgery and had their neurological function restored to some extent. ConclusionThe trans-upper-sternal approach is a convenient for anterior decompression to the spinal cord compression in the cervicothoracic region. It allows satisfactory anterior decompression in cervicothoracic canal, fusion with bone graft and internal fixation with enough exposure of cervicothoracic vertebral body, less invasion, safe surgical procedure and less complications.