Atlas-of-Neurosurgical-Techniques-Spine-and-Peripheral-Nerves

37
Surgical Management of Intramedullary Spinal Cord Tumors
283
Figure37-4
Thedura is opened longitudinally over the solid tumor
mass.
useit, place the "platted tips" between the tumor and the
adjacent tissues
and
gently
release
the
instrument
(Fig.37-7). The tension is evenly distributed
over a relatively
widesurface area, causing no danger of tissue perforation.
Place5-0 hung pial-arachnoid sutures for gentle traction by
simplyhanging small clamps on the sutures (Fig. 37-8).
Workingwith Q Tumor
Itisdangerous to define a plane of cleavage around the tu-
mor.Theseneoplasms must be removed from "inside out,"
workinguntil a glia-tumor
interface is recognized by
thechangein color and consistency of the adjacent tissues
(Fig.37-9). There is rarely a true plane of dissection. Futile
effortsto define its presence may result in unnecessary
retractionand manipulation of thin functional neural tissue.
Inthe presence of a cystic holocord neoplasm, initiate tu-
morremovalat the most bulky part and proceed carefully
tothe sides. Once you have reached the rostral or caudal
poleof the neoplasm, approach the tumor-cyst junction
Figure 37-5
Thecord should usuallybe entered through the midline
raphe, which will enable spreading of the dorsal columns to the side.
from within the tumor while minimizing further splitting of
the cord. When there is no bordering cyst, tumor shape is
often conical. In this case as well, to minimize damage to
the surrounding normal tissue, remove the tumor from
within the existing cavity.
Take special care at the most anterior aspect of the tumor
to prevent damage to the pyramidal tracts and the anterior
spinal artery. Use intraoperative
ultrasound to carefully
monitor the progress and avoid this damage. First use the
UAto remove the bulk of the neoplasm. Continue with suc-
tion with bipolar coagulation to resect the visible remaining
fragments.
Ependymomas often have a "true" cleavage plane be-
tween the tumor and adjacent neural tissue.3Although this
contributes to the "total" excision of these neoplasms, it
may also be a potential hazard. Seeing a cleavageplane en-
courages the surgeon to attempt an en bloc resection, hop-
ing to remove the entire mass in one or two large pieces.
Anyattempt at an en bloc resection will cause excessiveand
unnecessary manipulation of normal neural tissue. Under

284
MidcervicalSpine:PosteriorApproach
.
Figure37-6
Bipolarcautery isused to coagulate the veins priorto
arachnoiddissection.
no circumstancesshould this be permitted. Rather, you must
debulk an ependymoma as you would an astrocytoma, from
the inside out. Onlyafter the center of the tumor has been
removed maythe surgeon develop the plane of cleavage be-
tween the tumor and adjacent tissues. Toaccomplish this,
retract the remaining tumor tissue into the residual cavity.
Donot retract the spinal cord from the tumor.
FocusonSpecialLocations:FilumTermina/e,
Conus,CaudaEquina
In the most common case, an ependymoma in this area ex-
pands the filum terminale. The filum terminale will then
appear much like a sausage-shaped mass that displaces the
normal nerve elements of the cauda equina circumferen-
tially around it. In these cases, it is relatively simple to
remove the tumor en bloc. First divide the distal filum
Figure 37-7
Pial-arachnoid sutures are used for simple retractionof
the dura.
terminale caudal to the tumor. Then displace the entire
mass out of the cauda equina. Finally,incise the remainder
of the tumor just below the conus. In many cases, the entire
mass is contained within the filum and it is not necessaryto
pursue
tumor
fragments
rostrally
into
the
conus.
Occasionally, pursuing tumor fragments may be necessary
in aneffortto obtaina surgicalcure.However,it isessential
that no neural tissue in the conus be manipulated in any
way.The tumor fragments must be extracted from below.
A few ependymomas of the cauda equina seem to have
grown from the region of the conus and to have erupted out
of the filum, with tumor tissue filling the entire thecal sac
below the conus. In these cases, the normal neural elements
of the cauda equina are not displaced circumferentially
around the mass. Rather, the nerve elements run right
through the tumor tissue, often making total tumor excision
impossible. In these cases, it is necessary to remove the

I
37
SurgicalManagement of Intramedullary SpinalCordTumors
285
Figure37-8
Abipolarshould be seen coagulating veinson the sur-
faceofthe cord before myelotomy.
tumor bit by bit, working between and around the neural
elements until as much as possible of the neoplastic tissue
is removed. It is also often necessary in these cases to ex-
tract residual tumor fragments from the conus. It is again
important, however, that the neural tissue in the conus be
left undisturbed. Removetumor fragments by slowly work-
ing through that area throughout which the tumor has
grown into the thecal sac.
Closure
Patientswith extensivetumors,and especiallythose who have
been previously irradiated, are at high risk for wound dehis-
cence and spinal fluid fistula.There are two principles of clo-
sure followingtumor removal.First,at least one layermust be
CSFtight. Second,use permanent colored sutures for the CSF
tight layers.These stitches providea midline direction in case
a reoperation isrequired, particularlyin scolioticpatients.
Use running 5-0 Prolene sutures to close the dura (Fig.
37-10). Replacethe bone and secure it with 2-0 long-termab-
sorbabtle monofilament sutures that go through holes in the
bone edges. The fascia and muscle are completely released,
both superficially from the subcutaneous tissues and deeply
from the bony elements. Ifthis is not enough to achieve clo-
sure with no tension, relaxing incisions with monopolar
cautery are performed. Close the musculofascial layer with
two layersoffigure-of-eight Novafilor Prolenesutures, tightly
knotted. Ifthere isany doubt regarding the water tightness of
the closure,test it with an injectionoffluidunder pressure.
The skin is usually closed in three layers: a deep subcuta-
neous layer,a superficial layer,and the skin itself.
Always use drainage for the subcutaneous space. Leave
the drainage in place for a few days until the volume of dis-
charge is less than 20 mLper day.

..
286
MidcervicalSpine:PosteriorApproach
Figure 37-9
The tumor is removed from the inside out until a tumor interface is recognized by the change in tissue color and consistency.
Figure 37-10
The wound is dosed in layers starting at the dura. The layers should be sutured tightly and one layer should consist of a permanent
colored suture providing a midline in case reoperation is required.

37
SurgicalManagement of IntramedullarySpinalCordTumors
287
EvokedPotentials Monitoring
.
Complications
Theinformationthat
is provided
by somatosensory
evoked
potentials (SEPs) is sufficient
to assess the functional
in-
tegrity of the motor system in procedures
where
insults usu-
ally affect
both
the
sensory
and
the
motor
pathways
simultaneously. However, during
operations
for IMSCfs, the
motor tract may be damaged
independently
of the sensory
system.In addition,
the SEPsare often lost following
midline
myelotomy. We therefore
routinely
monitor
motor
evoked
potentials (MEPs).14.15Following
the laminectomy,
place both
rostral and caudal epidural
electrodes.
The electrode
proxi-
mal to the stimulus
serves as a control. The distal electrode
isusedfor monitoring
the operation.
(Note that for anesthe-
siawe use a combination
of propofol
and narcotics.)
Several basic principles
apply for both
SEPs and MEPs.
First, information
must
be immediately
available
and uti-
lized by the surgeon
to modify
the operative
dissection.
Second,data should be continuously
updated
and commu-
nicatedto the surgeon. Third, criteria for significant changes
shouldbe set and tailored for each patient according to the
pathologyand the baseline potentials.
Improvedelectrical conductivity following tumor removal
isinvariablyassociated with a benign postoperative course.
Impairedactivity as compared with the preoperative base-
lineis not uncommon, and it is not necessarily a~sociated
with neurological morbidity. Nevertheless, the majority of
patientswith deteriorated activity may have transiently
greaterneurological dysfunction. In most circumstances the
functionwas ultimately
recovered. Note that in patients
withimpaired proprioception preoperatively, it is rarely pos-
sibleto obtain baseline SEPsfor monitoring.
Usetranscortical electrical stimulation
for MEPs,16with
bothepidural and distal recordings. This is a very reliable
intraoperative
technique
that monitors
the upper
motor
neurons without
synapses
on the way. It has the disadvan-
tageof not differentiating between left and right.
TheMEPsare most helpful during tumor removal while
workingat the most anterior and lateral aspects of the tumor
cavity.Although the threshold for motor recovery has never
beenscientifically determined in such a setup, it is our rou-
tinenot to push dissection beyond a 50%fall in MEPs.If and
whensuch a decline occurs we would stop manipulating the
cordinthis area and wait for the recovery of potentials.
References
1. Constantini S. Miller DC. Allen JC. Rorke LB. Freed D. Epstein FJ. Radi-
cal excision of intramedullary
spinal cord tumors:
surgical
morbidity
and long-term
follow-up
evaluation
in 164 children
and young adults.
J Neurosurg Spine 2000;93:183-193
2. Epstein F. Epstein N.Surgicaltreatment of spinal cord astrocytomas of
childhood:
a series of 19 patients.
J Neurosurg
1982;57:685-689
3. Epstein F. FarmerJP.Freed D.Adult intramedullary astrocytoma of the
spinal cord.J Neurosurg
1992;77:355-359
4. GohKYC.Velasquez L. Epstein F.Pediatric intramedullary spinal cord
tumors:
is surgery
alone enough?
Pediatr
Neurosurg
1997;27:34-39
5. Constantini
S. Epstein F. Surgical management
of intramedullary
spinal
cord tumors.
In: Schmiedek
HH. Sweet
WHo eds. Operative
In our series of 164 children
with
IMSCTs we had no surgi-
cal mortality.1
The morbidity
can be categorized
as increased
neurologi-
cal dysfunction
and orthopedic
problems.
Increased Neurological Dysfunction
Patients with severe preoperative disability and extensive
noncystic tumors are very likelyto deteriorate from surgery.
The incidence of a significant
motor morbidity in intact
patients was below 5%.It is therefore essential to treat
patients with a known IMSCfassoon as possible,operating
before a significant neurological dysfunction develops.
Impaired position sense,even in the presence of normal
motor function, is a serious functional disability andrequires
extensive physical therapy to learn compensation tech-
niques. On the basis of our experience, we emphasize this
potential
complication
in our preoperative
discussion with
patients and parents. The risk of injury to deep sensation is
significantly smaller when operating
on a childhood astrocy-
toma as compared with adult ependymoma.
If there is no preoperative bowel and bladder dysfunction.
it will occur postoperatively
only if the conus is disrupted. It
is, therefore,
essential
that the myelotomy
not be extended
over the conus because this will invariably result in postop-
erative sphincter dysfunction that may be permanent.
Orthopedic Problems
Scoliosisand kyphosis frequently
evolve after surgery. In our
pediatric series, for 37% ofthe
children
the deformity was se-
vere enough
to require
surgery.
In a recent
retrospective
study
of 45 patients who have had surgery for an IMSCf, we looked
at the effect of performing an osteoplastic laminotomy versus
a simple laminectomy on the incidence of progressive postop-
erative kyphoscoliosis (PPOKS)in children. The incidence of
PPOKS,with a mean follow-up time of3.4years, was 3{20 in
the osteoplastic laminotomy group, and a significantly higher
9{25 in the laminectomy
group. We therefore concluded that
replacement of the bone is preferable to a simple laminec-
tomy, although it does not prevent the postsurgical evolution
of spinal deformity ifthe tumor recurs.
Neurosurgical
Techniques.
Vol 2. Philadelphia:
WB Saunders;
1995:
2095-2106
6.
Li MH. Hotlas S. MR imaging
of spinal
intramedullary
tumors.
Acta
Radiol1991
;32:505-513
7.
Patel U. Pinto RS. Miller DC, et al. MR of spinal cord ganglioglioma.
AJNRAm J NeuroradioI1998;19:879-887
8.
Parizel PM, Baleriaux D. Rodesh G, et al. Gd-DTPA.Am J Radiol
1989;8:339-346
9.
Shoshan
Y. Constantini
S, Ashkenazi
E. et al. Intramedullary
spinal
cord renal carcinoma
metastasis
diagnosed
by gadolinium-enhanced
MRI. Neuro-orthopedics
1991;11 :117-123

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MidcervicalSpine: Posterior Approach
...
10.
(onstantini
S. Epstein F. Ultrasonic
dissection.
In: Wilkins
RH. Ren-
gachary
55. eds. Neurosurgery.
2nd
ed. New York: McGraw-Hili;
1995:607-608
11.
Abbott R. Feldstein N. Wisoff J. Epstein F. Osteoplastic
laminotomy
in
children. Pediatr Neurosurg
1992; 18: 153- 156
12.
Epstein F.Farmer JP. Schneider
SJ. Intraoperative
ultrasonography:
an
important
adjunct
for
intramedullary
tumors.
J
Neurosurg
1991;74:729-733
13.
Epstein FJ.Ozek M. The plated bayonet:
a new instrument
to facilitate
surgery for intra-axial
neoplasms
of the spinal
cord and brain stem
[technical note].J Neurosurg
1993;78:505-507
14.
Deletis V.Intraoperative
monitoring
of the functional
integrity of the
motor
pathways.
In: Devinsky
O. Beric A. Dogali M. eds. Advances in
Neurology. Vol 63. New York: Raven Press; 1994:201 -214
15.
Morota N, Deletis V, (onstantini
5, et at. The role of motor evoked po-
tentials
during surgery
for intramedullary
spinal cord tumors. Neuro-
surgery
1997;41 :1327- 1336
16.
Merton
PA. Morton
HB. Stimulation
of the cerebral
cortex in the in-
tact human
subject. Nature 1980;285:227

38
PosteriorApproach for Resectionof Intradural
ExtramedullaryTumors
RichardW. Byrneand Mina Foroohar
. Indications
. Contraindications
. Advantages
. Disadvantages
. Objective
. SurgicalTechnique
Anesthesia and Positioning
Resecting
intradural,extramedullary tumors in the cervical
spinecanbebothtechnicallychallenging and rewarding be-
causemostofthe tumors found in this space are pathologi-
callybenign and patient outcomes
are usually very good.
Theposterioror posterolateral
approaches
to these tumors
arefamiliarto most neurosurgeons
and are adequate
in
mostcases. The advent of spinal instrumentation
for stabi-
lizationallows for more
aggressive
bony
removal
for expo-
sureofventrally placed
tumors.
.
Indications
. Schwannoma
. Meningioma
. Neurofibroma
. Other
. Contraindications
. Medicalillness precluding major surgery
. Small,ventral, centrally located tumors
.
Advantages
. Approachis familiar to most surgeons.
. Ableto entirely resect lesion in many instances
Extradural Exposure
Intradural Exposure
Meningioma
Cervical Intradural
Schwannoma
Dumbbell Neurofibromas
Malignant
Nerve Sheath Tumors
Closure of the Mid- to Lower Cervical Posterior
Incision
.
Disadvantages
. Riskof spinal cord injury
. Mayneed to resect nerve roots or dura
.
Cerebrospinal fluid (CSF)leakage
. Riskof spinal instability postoperatively
. Deepmusculardissection
. Significantbleedingcanoccurduringapproach.
.
Objective
The surgical objectiveis to obtain intradural accessade-
quate toview the cranialand caudalpole ofthe tumorand
the interfaceofthe tumor,spinalcordand nerveroots.
. Surgical
Technique
Anesthesia and Positioning
General anesthesia with the option of awake fiberoptic in-
tubation
is used in these cases. The prone position is
generally preferred over the sitting position because it
allows for better hand control during microsurgical dissec-
tion. Preoperative awake cervical flexion testing is done
to determine tolerance of intraoperative positioning. The
Stryker frame, Jackson table, or prone positioning in May-
field fixation can be used. Careshould be taken to avoid ab-
dominal pressure or elevated airway pressures because this
289

290
MidcervicalSpine:PosteriorApproach
...
will lead to annoyingepidural bleeding during the resec-
tion. Somatosensory evoked potential (SSEP)monitoring
may be helpfulinmonitoring cord compromise from posi-
tioning andgiveswarning for traction related to spinal cord
injury.
ExtraduralExposure
Inallcasesa midline skin incision is made over the appro-
priatelevels with exposure to at least the spinal levels cra-
nialand caudal to the level of the tumor. The avascular mid-
line plane is followed down to the spinous processes and
the muscle is elevated and retracted. In nearly all cases a bi-
lateral exposure is necessary; the rare exception would be a
dumbbell foraminal tumor with only a small extension into
the canal. A laminectomy is performed by drilling the
laminae at the facet junction
with a high-speed
drill
(Fig. 38-1A). The laminae are elevated. In most cases the
tumor can be located by visual inspection or gentle palpa-
tion. Forcases of ventrally placed meningiomas, the tumor
location can be identified with ultrasound. Prior to opening
the dura, the extent of bony exposure necessary for s.afetu-
mor removal should be determined by examination of the
preoperative studies and the operative field. Ventrally
placed tumors generally require a more lateral bony expo-
sure to the appropriate side. This may require a partial face-
tectomy or drilling of the pedicle at the level of the tumor.
Intradural Exposure
Onceadequate extradural exposure is achieved, the dura is
opened in the midline with the aid of the microscope. The
dura is best opened cranial to the tumor first. This allows
for earlyvisualization of normal spinal cord. Starting cranial
to the tumor also avoids potential caudal migration of the
spinal cord over the tumor if the dura and arachnoid are
first opened below the tumor and CSFescapes. The dura can
be sharply dividedor can be torn along its fibers in a cranial
to caudal direction. Traction sutures are placed to keep the
dura open. In cases of ventral or ventrolateral tumor loca-
tion, nerve roots and dentate ligaments will overlie the tu-
mor. Dentate ligaments are sectioned and small tacking su-
tures can be placed in the ligaments to gently rotate the
spinal cord if necessary.In the cervical spine, all efforts are
made to spare ventral nerve roots from C4 to T1.Adorsal
nerve root can usually be taken if necessary, resulting in
minimal sensory deficit.
Meningioma
Cervical intradural meningiomas are most usefully divided
into dorsal, lateral, and ventral. Easeofcervical meningioma
removal is largely related to their position. Ventral place-
ment is the most challenging and the most common. Other
factors such as size, firmness, and vascularity are also im-
portant. In spinal meningiomas, a broad dural attachment is
commonly found. This can make opening the dura at the
level of the tumor difficult in cases of dorsally located
meningiomas. In these dorsally located tumors, dural resec-
tion may make opening and tumor removal easier. Early
exposure of both poles of the tumor is followed by gentle
coagulation and separation of the tumor from its dural at-
tachment. In some cases there may be a significantepidural
component to the tumor (Fig. 38-18). In these cases the
epidural portion of the tumor is removed first. Oncethe
dura is opened cotton pledgets are placed around the tumor
to keep the subarachnoid space free of blood. In casesof
large meningiomas with severe spinal cord compression,in-
ternal debulking of the tumor should precede further tumor
manipulation. This is done under the microscope bycoagu-
lating the capsule with bipolar coagulation and openingthe
capsule sharply. The meningioma is then internally de-
bulked with suction, an ultrasonic aspirator, or laser,de-
pending on the consistency of the meningioma. Oncethe
tumor is largely debulked and the spinal cord compression
relieved, the dural attachments of the meningioma areco-
agulated and divided circumferentially. With the tumor
separated from the dura, it is usually easy to removebe-
cause an arachnoid plane is present between the tumor
capsule and the spinal cord. This arachnoid plane cannotbe
relied upon in cases of malignant meningioma or heavily
calcified meningioma or in reoperative cases. In any case,
direct visualization of the tumor-spinal cord interfaceisde-
sirable as the capsule is removed. An important principleto
follow in laterally and ventrally placed tumors is to deliver
tumor into the space created by prior debulking rather than
exposinghidden tumor bymanipulationofthe spinalcord
(Fig. 38-1C). Ventral visualization is aided by rotating the
table away from the surgeon and by gentle traction on
Prolene sutures placed in the sectioned dentate ligaments.
Resection of the dural interface from which the menin-
gioma arose is usually not necessary. In most series with
long-term follow-up, a gross total resection of tumor with
coagulation of attachments leads to recurrence rates ofless
than 5%.Anexception would be in the case of an atypicalor
malignant meningioma. In these cases an attempt shouldbe
made to remove the dural attachments. Awatertight dural
patching procedure would follow.
CervicalIntradural Schwannoma
The details of anesthesia, positioning, intradural, and ex-
tradural exposure for cervical schwannomas
are almost
identical to those outlined for cervical meningiomas. The
only exceptions are for cervical schwannomas, more exten-
siveexposureofthe foramen,and extraforaminalnerveroot
are necessary. To accomplish this, flexion positioning,
traction, and a wide foraminal opening are necessary.
For schwannomas with tumor extending outside of the
canal and foramen, a complete unilateral facetectomy is
necessary.
Schwannomas usually arise from dorsal nerve roots.
They may have intraspinal, intraforaminal, and paraspinal
portions. The intradural portion in the canal for the most
part will be intra-arachnoidal. This portion of the tumor is
well encapsulated
and thus is easily separated from the
spinal cord with microsurgical techniques (Fig. 38-2A-C).
If this cannot be done without manipulating
the spinal
cord, the tumor is internally debulked. Once the caudal
and cranial poles of the tumor are identified and the tu-
mor is debulked, the origin of the tumor is identified on

38
Posterior Approach for Resection of Intradural Extramedullary Tumors
291
A
(
B
Figure 38-1
(A) Dorsal view of spine where laminec-
tomies are performed.
(B) Extradural extension of
tumor. (C) Identification of a laterally based intradural
tumor.
theaffectednerve.Dorsalroot fibers can usually be seen
mergingwiththe tumor.Thenerve proximaland distalto
thetumor is identified. Occasionally a small tumor can be
dissectedfrom the remaining normal nerve, thus preserv-
ingthe nerve. Usually this is not possible and the dorsal
nerve root of origin must be sacrificed. The resulting sen-
sory deficit is minimal and well tolerated. If the tumor
arises from or involves a ventral nerve root in the midcer-
vical spine, all efforts are made to preserve the nerve. If
this root must be sacrificed, the resulting motor deficit is

292
MidcervicalSpine:Posterior Approach
A
I J
I
I
I J
r
I' J
B
Figure 38-2
(A) Microsurgical exposure of a large intradural schwan-
noma. (8) Microsurgicaldissectionof anintradural schwannoma.(C) Dorsal
nerve root fibers sacrificedfor removalof tumor.
usually not functionally significant. This possibility should
be discussed
with the patient before surgery. In cases
with an extensive component outside of the spinal canal,
initial removal of the portion
in the canal is recom-
mended. This ensures protection of the spinal cord during
c
resection of the rest of the tumor. If the paraspinal por-
tion has anterior extension, care is taken to avoid the ver-
tebral
artery. This is especially
true in the upper cervical
spine at (1 and (2 where the vertebral artery is not pro-
tected.
If concern
for vertebral
artery
involvement
exists,

38
PosteriorApproachfor Resectionof IntraduralExtramedullaryTumors
293
Facetectomy
Figure38-3
Dural closure utilizing a running nonabsorbable suture.
proximal control with early caudal exposure or proximal
balloon catheter control can be obtained.
Laterally ex-
tending paraspinal schwannomas
should be internally
debulked to allow mobilization of the capsule. Direct vi-
sualization of the lateral capsule minimizes the risk of in-
jury to the long thoracic and dorsal scapular nerves. If the
extent of paraspinal tumor extends anterior to the verte-
bral artery or extends laterally into the brachial plexus,
the posterior exposure can be combined with an anterior
or lateral approach.
Once the tumor is removed, meticulous hemostasis is
obtained and the dura is closed in a watertight fashion
(Fig.38-3). Ifa unilateral facetectomy was done, considera-
tion is given for instrumentation
support, especially if the
patient has a kyphotic cervical spine. Artifact from this in-
strumentation may. however. limit follow-up magneticres-
onanceimaging(MRI).
Dumbbell Neurofibromas
Neurofibromas most frequently occur in the cervical and
lumbar spine. Neurofibromas generally arise from sensory
nerve roots, extend into the paravertebral soft tissue, and
can have both intradural and extradural components. They
often present as a fusiform enlargement of the spinal nerve
(Fig. 38-4A,B). It is usually impossible to surgically detach
these tumors from their nerve root without sacrificing the
nerve root.
A
I ~
II
I J
IfJ
B
Figure38-4
(A) Neurofibroma
arising from spinal nerve. (8) Removal of tumor
after sectioning
spinal nerve.

294
MidcervicalSpine:Posterior Approach
..
Cervicalneurofibromas are removed via a midline poste-
rior approach. The details of approach and exposure are
similar to cervical meningiomas and schwannomas. Cervi-
cal flexionand traction, if tolerated, help to open the facet
joints. Intraoperative x-ray is helpful for localizing the
proper spine level. For details of the opening, refer to the
earliersection on resection of schwannomas.
The laminectomy should extend above and below the le-
sion. Care should be taken to avoid disrupting the facet
joints unless necessary for complete resection. For dumb-
bell neurofibromas it is necessary to perform a facetectomy
to have adequate exposure for complete tumor removal.
Specialattention should also be paid to adequate hemosta-
sis from the epidural space prior to the dural opening. Intra-
operative ultrasound can help verify location and extension
ofthe lesion prior to the dural opening.
The dura is opened in the midline with magnification.
The durotomy is extended rostrally and caudally above the
lesion. The dura is retracted on both sides. Sometimes, it is
necessary to extend the dural opening at a right angle along
the nerve root to have adequate tumor exposure. If the
arachnoid has not been opened, it is then opened and dis-
sected along the tumor. The plane between the tumor and
spinal cord is identified and dissected. Because neurofibro-
mas involve the sensory (posterior) nerve root, it is usually
necessary to sacrifice the dorsal rootlets involving the tu-
mor. Patients usually suffer minimal neurological deficit
from sacrificing the posterior root. For anteriorly located
neurofibromas, it might be necessary to sacrifice an ante-
rior nerve root for complete resection. This most likely will
causean acceptable neurological deficit.
Depending on the size of the tumor, slight rotation of the
spinal cord might be necessary for access to the entire tu-
mor.Thedentate ligament can be cut and used for rotation.
Theincisedposterior nerve root can also be used to help ro-
tate the spinal cord. If the tumor is very large it might be
necessary to debulk the tumor prior to dissection. Debulk-
ingcan be done piecemeal with the ultrasonic aspirator and
laser.The intradural portion of the tumor and its attached
nerve root are completely removed.
Fortumors having an extradural component, it might be
necessary to debulk the extradural component prior to re-
secting the intradural component. The decision to resect the
extradural component depends on the location, size, and
symptoms caused by the tumor. Once the intradural tumor
has been adequately removed, attention is turned to the
foraminal and paraspinal portion of the tumor. Acircumfer-
ential dissection of the lesion is then performed to define
the interface of the tumor with the anterior nerve root and
the vertebral artery. Internal debulking of the tumor may be
done to aid this dissection. Occasionallya small portion of a
benign neurofibroma cannot be safely separated from the
vertebral artery and may be left as residual. The wound is
irrigated and hemostasis is achieved. The dura isclosedwa-
tertight with nonabsorbable suture in a running fashion.
The muscle, fascia, subcutaneous tissue, and skin arewell
approximated in multiple layers.
Malignant Nerve Sheath Tumors
These rare tumors are most commonly associated with neu-
rofibromatosis. Malignant nerve sheath tumors are rarely
cured with surgery.
Chemotherapy
and radiation
therapy
are also ineffective. Because of this, in patients without
metastatic
disease, radical surgery may be the only possibil-
ity of cure.
Surgical
resection
of all involved
elements
should be considered
unless the spinal cord is involved. Be-
cause this is not commonly
possible, palliative decompres-
sion along with adjuvant
therapy is usually the goal.
Closure of the Mid. to Lower Cervical
Posterior
Incision
A posterior midline cervical incision should be closedin
multiple layers. Each layer, including the muscle layer.fas-
cia layer, subcutaneous tissue, and skin should be approxi-
mated well during closure. In all posterior cervical proce-
dures, the principles and technique of closure remainthe
same. During the opening, it is important to recognizethe
proper layers and strictly adhere to the midline. Amidline
incision through the skin and subcutaneous tissue should
be followed by meticulous dissection through the deepcer-
vical fascia while manually palpating the spinous processes
to avoid straying from the midline. Strict adherence tothe
midline not only avoids unnecessary muscle bleedingbut
also helps for a nicer closure and better wound healing.
Oncethe wound is properly irrigated with antibioticsolu-
tion and hemostasis is obtained, the muscle layer isapproxi-
mated prior to closing the fascial layer.The muscle layerin-
cludes the superficial muscle layer, the splenius capitisand
cervicis; the intermediate muscle layer, semispinalis capitis,
longissimus,and iliocostalis;and the deep muscle layer.rota-
tores cervicis,interspinalis cervicis, and multifidus muscles.
The muscle layer closure not only provides protection tothe
spinal cord but also fillsthe dead space. The fasciais thenap-
proximated with heavier suture in a simple interrupted or
running stitch. It is usually not difficult to identify the fascia
layer from the muscle layer below and subcutaneous layer
above.The fasciais closed in a watertight fashion (Fig.38-3~
This closure provides an additional seal to prevent CSFleak-
age. Oncethe fascia isapproximated, the subcutaneous layer
is approximated to avoid dead space. In individuals witha
thin subcutaneous layer, one-layer closure is adequate. The
skin is brought together with skin staples or monofilament
suture. Anepidural drain isoptional.

Section III
Cervicothoracic Junction
A.Pathology of the Cervicothoracic Junction
. 39. Tumorsofthe Cervicothoracic
junction
B.Anterior Approach
. 40. Supraclavicular Approach to the
Cervicothoracic junction
. 41. The Transsternal Approach to the
Cervicothoracic junction
. 42. Transmanubrial Transclavicular
Approach to the Cervicothoracic
junction
.
43. Vertebrectomy following Anterior
Approaches
.
44. Anterior Reconstruction following
Decompression via Anterior
Approaches
C. Anterolateral Approach
.
45. Transthoracic Approach to the
Thoracic Spine
D. Posterolateral Approach
.
46. LateralParascapular Extrapleural
Exposureofthe UpperThoracicSpine

39
Tumorsof the Cervicothoracic Junction
ArthurL.Jenkins III and Noell. Perin
.
Anatomy
SpinalAnatomy
Extraspinal Anatomy
.
Radiological Evaluation
.
Other Tests
.
Metastatic lesions
lung Cancer
BreastCancer
Prostate Cancer
Thischapter will assist the clinician in designing treatment
protocols for lesions found within
the cervicothoracic
re-
gion.The decision to intervene
surgically
must be based on
theclinicalcondition, the natural history of the lesion, and
thepotentialsurgical risks of such an intervention. The sur-
gicalplan requires a knowledge of regional anatomy and
thetypesof tumors that can occur here.
Ultimately, it is necessary to weigh the surgical risks
againstthe known natural history and progression of the
diseaseto determine the best approach to the individual
patient.Determining the nature of the condition depends
onthe location as well as certain helpful radiographic cor-
relates,including osteoblastic or osteolytic changes, degree
and heterogeneity of enhancement,
and local structural
changes.Tumor biology includes any known concomitant
metabolicor neoplastic disease, any pathological informa-
tion (prior resection or biopsy results), and inferences
drawnfrom the first two categories. With this information,
thesurgeoncan ascertain the likely evolution of the lesion
bothwith and without intervention. This chapter reviews
theanatomyof the region, the types of preoperative tests to
assistin the diagnosis and determination of stability in this
region,and the types of lesion that can occur here.
. Anatomy
Thecervicothoracic junction
has several features that make
this a particularly
difficult region for surgical intervention.
The reversal of lordosis to kyphosis causes more strain on a
postfusion segment. The great vessels and bony obstructions
like the clavicle, scapula,
and manubrium
make
surgical
lymphoma
Others
. local
Spread
from
Nonspinal
lesions
.
Primary lesions
Extraaxial and Epidural lesions
Plasma Cell Dyscrasias
Nonneoplastic lesions That Present as Mass lesions
.
Conclusion
approaches difficult.Becausethis region isthe source ofneu-
rons that innervate the arm and hand, it is relatively intoler-
ant of manipulation. Knowledge of this area's anatomy will
maximize the efficiencyofany intervention in this region.
Spinal Anatomy
SpecificIssuesin theCervicothoracicRegion
The cervicothoracic region is a complex junction of two dis-
tinct anatomical regions, being the transition between the
lordosis of the cervical spine and the kyphosis of the tho-
racic spine. It is the change between the flexible cervical
spine and the rigid thoracic spine with its rib cage as exter-
nal brace. It also contains the spinal nerve roots that inner-
vate the upper extremity.
The region is bounded by (5 superiorly and 13 inferiorly.
These margins are somewhat arbitrary but are below the
thyroid cartilage in the cervical region and at the start of
the brachial plexus. We have chosen 13 as inferior margin
because it is the inflection point of the cervicallordosisand
the thoracic kyphosis as well as being at the bottom of a
surgical construct that might have to bridge a lesion found
atC7-T1.
This region includes numerous anatomical idiosyncrasies,
including the fact that the canal is at its narrowest in this
region. yet the cord has its widest diameter here.This is due
to the large number of secondary motor neurons of the up-
per extremities located in the spinal gray matter. Thus,
when there is impingement of neural elements by an ex-
panding mass lesion in this region, there is little room for
compression prior to becoming symptomatic.
297

298
CervicothoracicJunction: Pathology of the Cervicothoracic Junction
Another unique feature of the cervicothoracic junction is
that this is a vascular watershed area, with cervical radicu-
lar branches from the vertebral and cervicalarteries feeding
the anterior spinal artery from around C5-C6 and thoracic
radicular arteries coming off the descending aorta around
T4.Posterior spinal arteries receive radicular artery supply
at about C6and T2bilaterally.
ExtraspinalAnatomy
Tounderstand and approach lesions of the cervicothoracic
region, it is first important to understand the anatomy of
this region. The anatomy can, for the purposes of this chap-
ter, be broken down into three segments: cervical soft tis-
sue, thoracic soft tissue, and spine. This is relevant for the
anatomical discussion of the surgical approaches, as well as
understanding what local tumors can spread to the spine in
this region.
Lowercervical anatomy can be broken down into its vari-
ous compartments, anterolateral, and posterior. The antero-
lateral muscles and fascia contain the muscles of the hy-
popharynx and the muscles related to swallowing and neck
position. The carotid sheath and its contents (carotid artery,
jugular vein, vagus nerve); the esophagus (on the left); and
the trachea are located deep to the sternocleidomastoid
muscle.The thyroid and parathyroid glands are located ven-
tral to the trachea. The posterior compartment
contains
paraspinal and limb muscles such as the trapezius, scalenes,
longuscolli,and spinus capitis.
Upperthoracic anatomy can be subdivided into mediasti-
nal anatomy, pulmonary and rib cage anatomy, and spinal
anatomy.The upper mediastinum contains such structures
as the thymus and the great vessels. It is protected anteri-
orlyby structures such as the clavicle, the sternum, and the
manubrium. It also contains the inferior extensions of
structures in the lower cervical anterior compartment, such
as the trachea and esophagus. The pulmonary and upper rib
cageincludesthe axial muscles that attach to structures like
the ribs, the scapula, and the arms. It includes the
paraspinal muscles as well as the sympathetic chain. It also
includes the lung,with its parietal and visceral pleura.
.
RadiologicalEvaluation
The radiographic appearance of spinal lesions can give clues
to the biologicaldiagnosis.Thisinformation is gleaned from
several features that can be seen on the different radi-
ographic studies. Differenttypes of x-rays can be obtained.
Plain films can point to osteoblastic or osteolytic changes in
the bones and loss of bony landmarks such as erosion of the
pedicle (winking owl sign) (Table39-1). Compression frac-
tures can point to lesions that have undermined the osseous
stability. Flexion and extension films, although helpful for
determining stability, usually do not add significantly to the
pathological diagnosis. However, oblique films are helpful
to view the neural foramen to see if there is any expansion
or erosion of the bony margins.
Magnetic resonance imaging (MRI)has become the most
important diagnostic test available. Agood sagittal survey
Rare:melanoma, seminoma, teratocarcinoma, carcinoid.
will demonstrate any spinal cord compression. MRIisvery
sensitive
in determining
the presence
of lesions in and
around
the spine. The difference
in water content and fat
content
demonstrated
by MRI can demonstrate
tiny le-
sions. Because of the replacement
of marrow by tumor and
the loss of fatty signal, the difference
between
tumor and
the normal marrow is well demonstrated on T1 sequences.
but the differentiation is less dramatic, and evenabsentif
given contrast. For tumors that do enhance, the degreeof
enhancement
as well as the pattern
of enhancement
(ho-
mogeneous
vs heterogeneous)
can gives clues to the un-
derlying
tumor. Signal intensity
can demonstrate
the rela-
tive water
content
of the lesion as well as the degree (or
absence) of calcium. Nearby reaction of tissues maygive
clues to the identity of the tumor. Degree of vascularitycan
also be used to define a differential
diagnosis
because cer-
tain tumors are more or less vascular. Presence of a capsule
as well as shape of the lesion can also help.
Computed
tomographic
(CT) scanning,
especially incon-
junction with multiplanar reconstructions, can helpto de-
fine the bony anatomy
in addition
to x-rays. Bone density
and presence
of calcium
are better
viewed
with a than
MRI, but differentiating
types of soft tissue
may be easier
with MRI.
Myelography and postmyelogram CThelp to definethe
subarachnoid
spaces
but T2-weighted
MRI can do this
almost as well, as long as there is no significant magnetic
artifact
and the quality
of the scan is good. Myelography
can also help to determine if a dye block exists, which
may assist the surgeon
in determining
the urgency ofan
intervention.
A bone scan can give data to the clinician related tothe
rate of deposition
or resorption
of bone. The sensitivityof
the bone scan in the setting of bony involvement
by anos-
teoblastic lesion is very high, although it is not veryhelpful
for lytic lesions that do not have a reactive sclerosis.
Table39-1
Osteoblastic
Osteolytic
-
Prostate
Yes
Maybe
Breast
Maybe
Yes
Lung
No
Yes
Thyroid
No
Yes
Renal(hypernephroma)
No
Yes
Testicular
No
Yes
Leukemia/lymphoma
No
Yes
Liver
No
Yes
Rarely
Stomach
Maybe
Usually
Colon
No
Yes
Bladder
Maybe
Usually
Pancreas
Maybe
Usually

. OtherTests
39
Tumorsof the CervicothoracicJunction
299
Inaddition to the radiographic
and anatomical
data, certain
other studies are useful,
including
serological
and urine
studies such as electrophoresis,
tumor
markers,
and the
presenceof other lesions
in the body. Tumor
biology
and
natural history of the lesion are important
in determining
the scope and appropriateness
of an intervention
because
the life expectancy
for diffentent
metastatic
tumors
can
range from 4 months
to several
years. This difference
in
outcomes leads to different
surgical
urgencies
in the con-
text of unstable spines or spinal
epidural
metastases.
The
underlyingpathological diagnosis may be obtained by
biopsyofthe lesionaswell as a systematic search for a pri-
marylesion with imaging studies of the chest, abdomen,
pelvis,extremities, and other organs that are likely sources
formetastatic tumors.
. Metastatic Lesions
Metastaticlesions to the spine are vastly more common
thanprimary lesions (anywhere
from 25 to 85% of some se-
riesof spinal tumors
in adults;
see Table 39-2).
These le-
sions are most common
in this region
because
they
are
mostcommon elsewhere
in the spine, although
many can-
cers metastasizeto regions near their primary origin due to
localextensionor localvenous drainage.
Radiographicevaluation of metastatic disease includes
plainfilmsto evaluate for presence of pathological fracture
andangulation. MRI is performed
to evaluate
the presence
ofepidural compression,
either
from disease
or from frac-
turefragments. The bone scan is the most sensitive
for de-
tectionof lesions.
LungCancer
Lungcancer metastases make up from 12 to 20% of all
metastasesto the spine with spinal cord compression.! The
primaryradiographic presentation is that of lytic exophytic
Table39-2
Incidence of Spinal Metastases inVarious Cancers
(WhenCancer Is Metastatic)
lesions, and as a result of the lung being immediately
up-
stream of the heart, metastases can be hematogenously
spread to the entire body.
The median
life expectancy
for a patient
who presents
with
radiographic
appearance
of lung metastases
to the
spine is about 7 months.2 Patients who present
with spinal
cord compression
as the primary presentation
have a me-
dian survival of less than 3 months, whereas those who
have the spinal cord compression in cases of known pul-
monary primary cancer do worse, with only a 2-month sur-
vival.3Longer survivals have been reported in the subgroup
of patients
who have undergone
aggressive resections
in-
cluding removal of local adjacent
structures,
including
the
chest walJ.2 These lesions have a variable response to radio-
therapy and may require resection for treatment of neuro-
logical deficits.
The issue of local spread of superior sulcuslung cancers is
addressed in a later section.
Breast Cancer
Spinal metastases of breast cancer have an incidence of up
to 85%of cases at autopsy, and clinically up to half of sur-
vivors
will be symptomatic.
This is a frequent
primary
source of metastatic disease, ranging from 10 to 25%of all
spinal metastases.! The average life expectancy of a patient
with spinal metastases is -45
months from initial radi-
ographic appearance
of tumor in the spine.2 Treatment
with
surgical decompression
has been shown
to lead to signifi-
cant life expectancy
afterward.
Symptomatic
spinal metas-
tasis is rarely the first symptom.3 These lesions respond
to
radiation
and may show response
to hormonal
therapy
or
tamoxifen.
The radiographic appearance of breast metastases to the
spine is predominantly
one of lytic lesions that erode and
expand, but with treatment
blastic changes can be seen
after therapy. Epidural extension
with spinal cord compres-
sion is common
and pathological
fractures
are also com-
mon. These lesions lead to instability due to loss of bony
elements and erosion of ligaments.
ProstateCancer
Prostate cancer, when metastatic, has a high incidence of
bony and specifically spinal metastases. This cancer makes
up between 4 and 15%of all symptomatic spinal metastases.
The average life expectancy is the longest outside of lym-
phoma, at 4.5 years from initial radiographic evidence of
spinal metastases.2The median survival drops off dramati-
cally once spinal cord compression
occurs, with -IS-month
survival in those with no prior diagnosis of prostate cancer,
and 7 months in those with known prostatic disease.3These
lesions respond to radiation and can show dramatic re-
sponses to hormonal therapy, such aswith surgical or phar-
macological orchiectomy.
The radiographic appearance of prostate metastases to
the spine is either
lytic or blastic. Epidural extension
with
spinal cord compression
is relatively common,
but survival
is dramatically worse for those who do eventually present
with spinal epidural lesions.
CancerType
Incidence (%)
Breast
85
Prostate
85
Lung
32
Kidney
24
Pancreas
13
Rectum
13
Stomach
11
Colon
9
Ovary
9
All ca ncers
27

..
300
Cervicothoracic Junction: Pathology of the Cervicothoracic Junction
Prostate cancer can metastasize directly to the dural or
epidural space, presumably via Batson's plexus. This is far
more common in the lower spine than in the cervicotho-
racicjunction.
lymphoma
Lymphoma,or more specifically,non-Hodgkin's lymphoma,
presents with a radiographic appearance of either lytic,
blastic, or mixed appearance. Lymphomas make up from 1
to 11%ofall spinal compressive metastases.
The lesions enhance with contrast. The median survival
for the lesion depends on whether the lesion is the primary
presentation of the lesion or whether the patient has a prior
diagnosis of lymphoma. Forthose presenting with epidural
compression as the primary manifestation,
the life ex-
pectancy is on the order of almost 7 years. However, pa-
tients with a known diagnosis of lymphoma have a life ex-
pectancy on the order of 8 months. This lesion is usually
radiosensitive (focused-beam radiation, 3000 to 4000 rads
depending on fractionation) and responds well to steroids.
Others
RenalCell
Renal cell tumors make up from 3 to 12%of spinal metas-
tases.1Renal cell carcinoma is a highly invasive and highly
vascular lytic lesion when it spreads to the spine. Radi-
ographically,it has the typical appearance of lytic expansile
lesions that enhance strongly with contrast on CTand MRI.
Themedian life expectancy for a patient with spinal metas-
tases is 2 years from radiographic appearance of disease in
the spine of patients with known disease. Sosurgical inter-
vention is indicated when neurological function or stability
is impaired. Embolization is recommended as a preopera-
tive adjunct due to the extreme vascularity. This tumor does
not respondwell to radiation or chemotherapy.
ThyroidCancer
This makes up from 2 to 4%of symptomatic spinal metas-
tases. Thistumor has similar characteristics to that of renal
cell carcinoma. It is a lytic lesion that enhances strongly
with MRIand CT.Prognosis is good, with a 64%5-year sur-
vival. Nonsurgical treatment is primarily with radioiodine-
131.It is also a very vascular tumor that requires preopera-
tive embolization to control blood loss intraoperatively.
GastrointestinalAdenocarcinoma
These tumors are infrequent to the cervicothoracic spine.
They have lytic appearances,
although some can have
blastic features. Gastric carcinoma, which is a highly ma-
lignant and lethal cancer without
the issue of spinal
metastases,
has a median
survival with symptomatic
spinal metastases
of on the order of 4 months. For these
patients, palliative treatment
is recommended except in
extreme circumstances.
Patients with metastatic lesions
in the cervicothoracic junction of colonic origin havea
survival of less than 6 months.
. LocalSpread from NonspinalLesions
By some reports, the most common spinal lesion in the cer-
vicothoracic
region
is the local spread
of a primary pul-
monary
mass lesion. In the earlier literature,
this was fre-
quently a tuberculoma
of the pulmonary
apex, althoughin
the current literature,
it is more commonly that of a primary
lung cancer, known as Pancoast's tumor or a superior sulcus
tumor. Because of differences
in the ratio of circulationto
aeration
(physiology
textbook),
tuberculomas
were ableto
grow, and for the same reason, airborne carcinogens suchas
tobacco by-products
were able to induce mitogenic changes
and become established.
These mass lesions erode through
the pleura
and into the spinal or epidural
spaces, causing
bony erosion and spinal cord compression.
These tumors
spread
into the epidural
space and invade
bone locally, causing more epidural compression than insta-
bility, although
surgical
decompression
will often leadto
instability
if not addressed
with an appropriate
fusionand
instrumentation.
Treatment
usually consists of biopsy followed by defini-
tive treatment,
depending
on the results of the biopsy.Sur-
gical morbidity is related to the structures in the area,such
as the great vessels, the brachial plexus, the superior cervi-
cal ganglion
(leading
to a Horner's
syndrome),
and the(8
and 11 nerve roots that frequently need to be sacrificed.
Due to the wide variety of tissues located in the lower
cervical region. there are several pathological processesthat
can expand into the spinal area. These include but arenot
limited
to adenocarcinomas
arising from the trachea and
esophagus,
tumors
arising from lymph nodes and cervical
ganglia, and primary sarcomas arising in this region.
Neuroblastoma,
usually arising from the paravertebral gan-
glia and encroaching
on the spinal canal and vertebral bod-
ies, is almost unheard
of outside
the pediatric
population.
Neuroblastomas
behave in a malignant
fashion, and incom-
plete resection is not uncommon.
Survival can be correlated
with histological grading (90-100% 5-year survivalforstage
I-lIla, 25%for stage IV) and absence of intraspinal extension.
Ganglioneuromas, also arising from the autonomicgan-
glia in the paravertebral regions, are much more frequentin
the adult population
but still make up only half of the total
number of ganglioneuromas.
These are histologically mixed
tumors and run a more benign clinical course.
.
Primary Lesions
Extra-axial and Epidural lesions
Cartilage Tumors
.
Osteochondroma
Osteochondromas have a pedunculated stalk with a bony
base and cartilagenous cap. Tumor growth has been linked

~
39
Tumorsof the CervicothoracicJunction
301
tothe growth spurt of puberty.4 Although most cases are
isolated,casesof multiple lesions occur and are often trans-
mittedwithautosomaldominant inheritance.1 Theage of
onsetvaries with number of lesions, with single lesions
havinga peakincidence in the third decade and multiple le-
sionsin the second decade.6.7Osteochondromas can be in-
ducedby radiation therapy, especially after receiving more
than25Gy.Pediatricage of radiation therapy, especially be-
ingunder2 years of age at time of therapy, also correlates
with incidence.8
Mostcases are asymptomatic
and can be managed
con-
servatively.Plain radiography
usually reveals the exostosis,
but computed
tomography
better
demonstrates
the
anatomyof the entire lesion in continuity
with normal bone
and its cartilaginous
cap.6 Malignant
transformation
to a
chondrosarcoma should be suspected
if the cartilage
cap is
greater than 1.0 cm.6.7Surgical intervention
should be un-
dertakento ascertain diagnosis, for treatment
of intractable
pain,andforneurologicaldeficit.9
. Chondrosarcoma
Chondrosarcomasarise either primarily (most common) or
secondarilyfrom malignant deterioration of preexisting en-
chondromasor osteochondromas. Pain is usually the first
symptom,with recumbent pain, nocturnal pain, and pain
thatisprogressiveall more likelyto be froma chondrosar-
coma.Patientsfrequently have neurological findings at the
timeofdiagnosis.6.7.10
Because the mass frequently involves
theposteriorelements, many patients will present with a
palpable soft tissue
mass.7
Chondrosarcomas typically demonstrate
osteolytic le-
sionswitha spotty or stippled calcification of the soft tissue
mass,although some lesions may not have significant calci-
fication.1IThe amount
of calcification
appears
to correlate
withdegree of differentiation
12(thus, inversely so with de-
greeof malignancy).
Angiography
and preoperative
em-
bolization can assist in the appreciation
and reduction
of
vascularity of the lesion.13
Thehistologicalgrade correlates with survival and likeli-
hoodofrecurrence; however, even low-grade tumors may
recurlocally.Cure rates range from 26 to 33%,with higher
ratesin small series of highly aggressive gross total resec-
tions.lO,14
Assuch, gross total resection, including spondylec-
tomyif necessary, should be the goal of surgical interven-
tion.lONeither radiation therapy nor chemotherapy
has
demonstrateda positive effect on disease-free interval or
survival,and as such should be reserved for palliation.12.14-16
Becausethis is a slow-growing tumor, 5-year survival rates
havebeenaround 50 to 60%,but the recurrencerates are
around
65 to 75%.10.14
BoneTumors
. Osteoid Osteoma
Mostcases of osteoid osteoma occur in the posterior
columns:50 to 75%are in the lamina or pedicle.6.17Rarely
does the tumor
involve the vertebral
body, epidural
space,or paravertebral soft tissues. Most cases occur in pa-
tients5to 30 years of age,with a strong male prevalence.6.18.19
Osteoid osteomas usually present in the cervicothoracic
junction with pain, limited range of motion, and torticollis
or scoliosis(painful scoliosisis a classic presentation).20
This pain is aggravated by weight-bearing activity, is fre-
quently worse at night, and is frequently relieved by oral
salicylates, although patients gradually require increasing
amounts of salicylates for control of pain.
Atechnetium bone scan will locate lesions with a mini-
mal amount of bone production and is the most sensitive
test for finding an osteoid osteoma. Even small lesions can
be localized to a specific level, thereby focusing the site for
further studies. CTexamination affordsprecise definition of
the site of the osteoid osteoma at the designated level and
allows for preoperative planning.
Osteoid osteomas, because of their small size,are usually
self-limited tumors that have little potential for growth.
Treatment of a symptomatic osteoid osteoma that has failed
conservative management is primarily surgical. Complete
excision of the nidus is curative in almost 100%of cases,but
subtotal resection may lead to a recurrence. Resectionofthe
reactive bone surrounding the nidus is not necessary be-
cause this resolves spontaneously.17Surgicalexcision results
in a partial or complete correction of the associated scolio-
sis or torticollis in most cases.17.18Successful percutaneous
resection under CTguidance has been reported.21.22Radia-
tion therapy is not indicated. Some cases have been de-
scribed to spontaneously regress.12
.
Osteoblastoma
Osteoblastomas have many clinical features in common
with osteoid osteomas. Both present with pain, tend to oc-
cur in the posterior elements, are more common in males,
and have an associated painful scoliosis or torticollis.23.24
Unlike osteoid osteoma, the pain caused by osteoblastoma
rarely responds to salicylates and is often progressive, con-
tinuous, and dull, associated with paravertebral spasm.25
The larger size of osteoblastomas is associated with more
frequent involvement of multiple functional units of the
spine, such as lamina and pedicle or body, or adjacent lev-
els.17.23The size of the lesions also makes osteoblastomas
more likely to cause myelopathy by compression of the
spinal cord. Because the cortex surrounding an osteoblas-
toma is thinner than in osteoid osteoma, epidural soft tissue
extension of tumor is frequently found.20
Osteoblastomas are larger than 1 to 2 cm. Plain radiogra-
phy may show an expansile bone tumor with a scleroticrim.
Expansion along the rim may produce a poorly defined mar-
gin. These ill-defined margins are frequently associatedwith
soft tissue extension.23Technetium bone scan has the best
sensitivity for this lesion,and CTdetails the specificanatomy.
Myelography with postmyelography CTor MRIassists in the
evaluation of spinal cord or nerve root compression.
Complete surgical excision of the lesion is curative in
most cases,26with a recurrence rate of _10%,27although
subtotal resection leads to a higher probability of recur-
rence. Because these tumors are radioresistant, aggressive
surgical management with stabilization and instrumenta-
tion is often required.28 Malignant transformation
into
osteosarcoma is possible,12which makes early surgical in-
tervention more important.

302
Cervicothoracic Junction: Pathology of the Cervicothoracic Junction
.
Osteosarcoma
Osteosarcoma of the spine has a bimodal age of onset.12
with a peak incidence in the second and third decade29for
primary lesions, and a second peak occurring in older pa-
tients (those over60) for secondary lesions due to such con-
ditions as Paget's disease of bone. fibrous dysplasia, benign
brain tumors. and retinoblastoma.6.3o.31Radiation induced
tumors typically present after at least 30 Gy of radiation
and from3 to 20 years after exposure.29
Most patients have as their initial symptom local pain,
but by the time a diagnosis is made. two thirds have devel-
oped a neurological deficit. ranging from a radiculopathy to
paraplegia.32-34Plain radiographs ofthe spine typically re-
veal a mixture of osteoblastic and osteolytic activity. associ-
ated with an ossified soft tissue mass.35Tumor frequently
arises in the vertebral body and extends into the posterior
elements, as opposed to osteoblastomas. which arise typi-
cally in the posterior elements and extend into the verte-
brae.29MRIis useful for evaluating soft tissue involvement.
epidural compression. and bone marrow infiltration.36
The survival for a spinal osteosarcoma is poor due to the
large size at presentation as well as the difficulty with com-
plete excisions. with a mean survival of less than 1 year.6
Aggressivesurgical resection combined with chemotherapy
has been shown to improve long-term
survival over
laminectomy and radiation therapy.37With more aggressive
resections as surgical techniques have improved. survival is
increasing as well. These tumors are radioresistant
and
should be managed with systemic chemotherapy. surgery,
and palliative radiotherapy. When metastatic, the survival
drops dramatically, with an 11%survival at 20 months.29
Giant CellTumors
These are relatively benign neoplasms of the spine that can
exhibit a high degree of invasiveness. and there is a 10%in-
cidenceof malignancy,often associated with prior radiation
(the higher the dose, the higher the incidence).6.12.38Most
patients are older than 20 years of age.
The radiographic appearance is that of a lytic expansile
lesion with no mineralized matrix within the lesion. On cr
scan. the tumor is soft tissue density with a sclerotic mar-
gin. although hemorrhage within the lesion can make for a
more heterogeneous appearance. Sometimes cr scanning
demonstrates a classic"soap bubble" vertebral expansion.38
MRIappearance is that of low to intermediate signal inten-
sity on both T1- and T2-weighted sequences. Although this
lesion is primarily located in the vertebral body, it can ex-
pand into the posterior elements. the epidural space. or
even into and across the disk space (unlike most other tu-
mors). If the entire vertebral body is involved. a compres-
sion fracture is possible. Bonescanning is of little use due to
the destruction without any bone production.
Subtotal resections. such as intralesional curettage. have a
recurrence rate of up to 60%.6.38Aggressive surgical resec-
tion consisting of vertebrectomy and instrumentation has
been performed with good results.28.39.40
This therapy leads
to the longest disease-free survival time without the risks of
radiation.41 In cases in which complete resection is not
possible. radiation therapy may be of benefit.42Preoperative
arterial embolization
has been shown to be ofbenefit.43 Ra-
diation therapy typically consists of 3500 to 4500 rads frac-
tionated
focused beam.
Plasma Cell Dyscrasias
Multiple myeloma (MM) and solitary plasmacytoma of
bone (SPB)represent a spectrum within the plasmacelltu-
mors.whichare clonalBcelltumors involvingbone.MM,
by far the more common presentation. consists ofa dissem-
inated disease involving the marrow diffusely. whereas
plasmacytoma consists of one or two foci without diffuse
marrow involvement.
SPBis only 3%of all plasma cell tumors and consistsof
one (or sometimes two) lesions. There is a 2-3:1 maletofe-
malepredominanceand anaverageageofover50years.1l44
Clinicalpresentation is related to either local painor theef-
fect of root or cord compression.
In MM. the male:female
prevalence is equal. with a
higherageat presentation(> 60years)than SPB.45
Thean-
nual incidence in the general population is -0.002%.The
spine is almost always involved but not always sympto-
matic (45%of all symptomatic lesions are in the spineI2.44).
Back pain is a frequent first symptom. with neurological
compromise often what causes patients to seek attention.
Plain radiographs will demonstrate lytic lesions. compres-
sion fractures. and osteopenia. MRIis very sensitive inde-
tecting presence or recurrence. Care must be taken toob-
tain a noncontrast
scan prior to contrast
injection to
prevent underappreciating the degree of diffuse marrowin-
volvement.46 Soft tissue extension. either into the spinal
canal or into the paraspinal regions. is common. Bonescan-
ning, MRI,and skeletal survey radiography are performedto
rule out additionallesions.47
Radiotherapy is the first-line treatment for SPBandMM
lesions not presenting with rapid neurological deteriora-
tion.45.48Local recurrence is rare when more than 45 Gy
dose is given.49.50Localcontrol with radiation therapy isex-
cellent, with rates of up to 96%quoted in the literature and
survival of up to 11years.50Chemotherapy is a vital partof
the treatment of the myeloma patient. especially the alky-
lating agents: cyclophosphamide. melphalan. carmustine,
and lomustine.44Steroids are given concomitantly.
Prognosis is poor for MM.with all published seriesde-
scribinglessthan 2.5yearsmediansurvivaland 18%5-year
survival.11.12When epidural compression is the presenting
symptom. the median survival drops to less than 8 months,
and when the patient with a known history of MMpresents
with new epidural compression. median survival dropsto2
months.3 Poorer survival is associated with the presenceof
anemia. hypercalcemia, renal failure. multiple lesions,and
hyperproteinuria.
Surgical resection is important for patients with SPBwho
present with symptoms of neural compression, significant
neurologial deterioration. or bony instability. Completere-
section and reconstruction with bone graft and instrumen-
tation are the goal in plasmacytoma because cure canbe
achieved.28.48.51Subtotal tumor resection should be fol-
lowed by radiation therapy and possibly chemotherapy.44
Paraprotein
levels should be followed for evidence of

recurrenceor dissemination, and presence of an im-
munoglobulinM (lgM) component
has been shown to pre-
dictprogressionto myeloma.52SPBhas a 50%incidence of
progressionto MM at 5 years, with most occurring
within
the first 2 years.
Vascular
Tumors
Hemangiomas
ofthe spine are a frequent lesion (estimates
rangeupto 10-12%of the population) that infrequently re-
sultsin surgery or instability. They are commonly
(> 50%)
anasymptomaticlesion seen on radiographic
workup. They
aremorecommon in the thoracolumbar
junction
and lum-
barspine than in the cervicothoracic
junction.
The radi-
ographicappearance is that of a honeycombed
region of the
vertebralbody,which is best seen on cr or x-rays (although
tobevisibleon an x-ray, one third of the body needs to be
involved).They may have extension
outside
the vertebral
body,andepiduralextension is rare. Paravertebral soft tis-
suedenisty may represent
either
tumor
or hematoma.
Symptomscorrelatewith degree of vascularity, but the pro-
gressionof asymptomatic
lesions to symptomatic
ones is
rare.Aspirinis highly effective in treating
the associated
pain,andthiscanbe considered almost diagnostic if the pa-
tient'spain responds aspirin therapy.
Large draining
veins
canbepresent and an angiogram should be performed
shouldthisbe suspected and surgical intervention is con-
sidered.
Surgicalintervention should be reserved for those with
significantspinalcord compression. These lesions respond
welltototalresectionas well as to subtotal resection with
radiation.
. Chordoma
Chordomasare slow-growing, malignant tumors derived
fromnotochordalrests within the vertebral body.53Half of
thelesionsthatpresent in the mobile spine do so in the cer-
vicalspine.54 Chordomasoccur in adults, with a peak inci-
dencein the fifth or sixth decade.I1.12In the cervical spine,
thecomplaintsare related to local pain or to the effects of
nerverootor cordcompression.12
a mayrevealosteolytic, osteosclerotic,
or mixed oste-
olytic-osteoscleroticfindings,56often centered on the mid-
line.6lntratumoralcalcification; a large, soft, nonenhancing
tissuemass;andinvolvement of adjacent vertebral bodies
areoftenfound.6.55In the nonsacral spine, the chordoma
mayinvolveseveraladjacent vertebral bodies but spare the
intervertebraldisks.55 MRI with contrast demonstrates en-
hancementextension of tumor and soft tissue mass. 56 A
highsignalintensity on T2-weighted magnetic resonance
imagingischaracteristic.6.55Chordomas are not significantly
vascular.12
Becauseof the aggressive invasion and location near
criticalstructures,chordomas have a high local recurrence
rateandmetastatic rates from 5 to 43%.6.12In addition,
theyare highly resistant to standard radiotherapy
and
chemotherapy.For this reason, aggressive surgical resec-
tionoffersthe bestchance for a prolonged survival. Resec-
tionof the involved vertebrae and all gross tumor is
advocated.55
Proton and photon irradiation therapy has
39
Tumorsof the CervicothoracicJunction
303
been reported to achieve a significant success rate in local
diseasecontro1.57.58
Nonneoplastic lesions That Present as Mass lesions
Aneurysmal Bone Cyst
This is a benign, proliferative,nonneoplastic disease of bone
due either to trauma or to another lesion nearby,6.59such as
giant cell tumors or osteoblastomas.59Theonset is primarily
in the firstand seconddecadeofIife.6.59.6oTheprimarypre-
sentation is with pain, although neurological compromise
from epidural extension can occur as well.
The radiographic appearance is that ofa lesion in the pos-
terior elements, with an outer periosteal rim and septations
within.6 Often, fluid levels can be seen that represent hem-
orrhage and sedimentation. This lesion is usually bright on
Tl- and T2-weightedMRIimagesdue to the methemoglo-
bin content. Contrast enhancement is usually visualized in
the periphery as well in the septations.61These lesions can
cross or involvejoint spaces (facets and disks) as well as ex-
tend into paravertebral structures.6 Bonescans demonstrate
increased uptake in the periphery only.6Angiography can
demonstrate hypervascularity in the periphery of the lesion
as well as locating any nearby draining
and feeding
vessels.12
Surgical resection is often difficult, requiring preoperative
embolization to minimize blood loss. Surgery with resec-
tion or aggressive curettage can be curative, although recur-
rence rates are related to degree of resection. Blood recy-
cling techniques should be utilized in this type of surgery.
Some of these lesions can be treated nonsurgically either
with embolization alone62or with radiation, although radi-
ation-induced sarcomas are a possible side effect.
Extramedullary
Hematopoesis
This is primarily a reaction of the marrow to inadequate
production of red blood cells by the rest of the body's mar-
row. This is an exophytic expansion of the marrow of the
vertebral body in to the paravertebral space and sometimes
into the epidural space. On plain films, a paravertebral mass
may be seen, although MRIand cr scans demonstrate this
more effectively. On cr scans, this has the appearance ofa
bilateral, lobulated, smooth mass with low density due to
the high amount of fatty marrow in the lesion. On MRI,the
lesion has the appearance of increased signal on T1-and de-
creased signal on T2-weighted images, as befits the fatty
content of the marrow.
EpiduralHematoma
Epidural hematomas may appear acutely as an epidural
mass that is dense on cr scan and high in signal intensity
on Tl- and T2-weighted images. They are more difficult to
discern in the region of the cervicothoracicjunction due the
fact that the absence of significant amounts of epidural fat
in this region gives less contrast between the hematoma
and the surrounding tissue. There is frequently no signifi-
cant finding on plain radiographs.

304
Cervicothoracic Junction: Pathology of the Cervicothoracic Junction
DegenerativeDiskHerniation
Degenerative changescan result in a herniated disk of the
lower cervical spine. This would have the appearance of an
epidural mass; however, the location (arising from the disk
space)would likely lower the clinician's index of suspicion
that this is a tumor. The disk can have low signal on T1 and
high signal on T2, although the actual signal characteristics
depend on the amount of degeneration and how dessicated
the disk hasbecome. On CT,the disk may have calcified as
well. Plain radiographs may show a concomitant narrowed
disk spacewith or without osteophytes, reflecting the ongo-
ing degeneration.
Another phenomenon of disk herniation is the Schmorl's
nodule, which is the result of a notochordal remnant that
results in a lack of chondrification
of the disk, which then
leads to a defect in the bone and allows disk material to
herniate upward into this defect. This has the appearance of
a well-demarcated,
sclerotic, round defect in the bone,
which may be either central or eccentric. This has upwards
of 20% incidence as an incidental
finding
and is rarely
symptomatic. The key factor that differentiates
this lesion
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.
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Tumors of the cervicothoracic junction
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Skeletal Radio11992:21
:523-527

40
SupraclavicularApproach to the
CervicothoracicJunction
SooHo Choi and Srinath Samudrala
.
Indications
.
Contraindications
.
Advantages
.
Disadvantages
. Anatomy
.
SurgicalTechnique
Anesthesiaand Positioning
Incision
Approach
The vast majority of pathological lesions occurring in
the cervicothoracic junction affect the anterior portion of
the vertebral bodies.! However, any anterior approach to
the cervicothoracic junction can be difficult due to several
factors.The great vessels, sternum, and clavicle all hinder
the surgicalaccess.Additionally,the degree of kyphosis and
the limitations of the thoracic inlet further complicate the
surgical exposure.2-4Several approaches exist for treating
lesionsin this area. These include the supraclavicular, trans-
manubrial transclavicular, and median sternotomy. Because
the other techniques are addressed in subsequent chapters,
the followingdiscussion focuses on the modified supraclav-
icular approach.
Clowardand Smith and Robinsonoriginally described the
anterior cervicalapproach.5.6Since then, others have modi-
fied and popularized this technique. The supraclavicular
approach provide excellent exposure to the cervical spine
and also allows for simultaneous decompression, grafting,
and internal fixation. However, the standard anterior ap-
proach offers only a limited exposure of the cervicothoracic
junction. Therefore, several modifications must be made to
optimize the surgicalaccessto this anatomical area.
.
Indications
. Primary or metastatic tumor
.
Structural deformity
. Infection
306
.
Contraindications
.
Pathology below T1
.
Anomalies of great vessels that may obstruct exposures
.
Advantages
. Provides adequate
access to several vertebral levels
through a relatively bloodless plane
.
Allows simultaneous decompression, grafting, and in-
ternal fixation
.
Disadvantages
.
Limitedaccessbelowfirstthoracicvertebra
.
Noaccessto posteriorspinalcolumn
. Anatomy
Fivefasciallayersinvestthe structuresof the cervical
spine,7.8These include the superficial fascia, the three layers
of the deep cervical fascia, and the prevertebral fascia.Just
beneath the skin, the superficial fascia covers the platysma.
Next, the superficial layer of the deep cervical fascia

40
SupraclavicularApproach
307
surrounds the sternocleidomastoid
(SCM) muscle and can
be identified at the anterior
border
of this structure.
The
middle layer of the deep cervical fascia invests the strap
muscles and forms the visceral fascia surrounding
the tra-
chea,esophagus.
thyroid, and larynx. The next layer is the
deeplayerof the cervical fascia, which fuses in the midline
tothe visceral fascia and also forms the two carotid sheaths.
Finally,the prevertebral
fascia covers the spine and longus
collimuscles and is the final layer of fascia encountered
be-
forethe diskectomyor vertebrectomy can proceed.
Identifyingthe sternocleidomastoid muscle is critical in
locatingthe proper, bloodless plane.9 This muscle extends
fromthe mastoid process and attaches to the sternum and
clavicle.Medial to the SCMand carotid sheath lie the mid-
linestructures.includingthe strap muscles.trachea,esoph-
agus,and thyroid gland. Specifically. the omohyoid, ster-
nohyoid.sternothyroid. and thyrohyoid constitute the strap
musclesofthe neck that depress the larynx and hyoid bone.
Theleft recurrent laryngeal nerve arises from the vagus
nerveand loops around the aortic arch to run superiorly be-
tweenthetracheaand esophagus.Similarly,the rightrecur-
rentlaryngeal nerve branches from the vagus and courses
aroundthe subclavianartery. Becausethe left nervejoins
Superior vena cava
Figure40-1
Vascularanatomyat the baseofthe neck.
the tracheoesophageal groove more caudally than the con-
tralateral nerve and usually is not aberrant, the left recur-
rent laryngeal nerve is less vulnerable to injury.
Locatedwithin the longus colli muscles, the sympathetic
chain can be injured during dissection of this muscle from
C2 to the cervicothoracic junction.9 The superior cervical
ganglion can be found at the second or third cervical
level whereas the middle ganglion lies near the sixth cervi-
cal vertebra. The inferior ganglion forms the stellate
ganglion near the first thoracic vertebra.s Injury to this
sympathetic plexus can cause a Horner's syndrome. consist-
ing of ptosis, miosis, and anhydrosis.
Important
vascular structures
of the superior medi-
astinum include the internal jugular vein,subclavianartery
and vein, brachiocephalic artery and vein, and common
carotid arteries (Fig. 40-1). Additionally, the thoracic duct
lies in close proximity to the thoracic inlet but lateral to the
carotid artery at the junction of the left internal jugular and
subclavian veins.!
The thoracic inlet is bounded by the first thoracic verte-
bra and manubrium and laterally by the first ribs. It is
important to remember that the cupula of the lung liesjust
inferior to the thoracic inlet.
Common carotid artery
Vagus nerve
Internal jugular
vein
Thoracic duct

308
Cervicothoracic Junction: Anterior Approach
. SurgicalTechnique
Approach
Anesthesia
and Positioning
General endotracheal anesthesia is induced. Ifthere is evi-
dence ofspinal cordcompression, myelopathy,or instability,
an awake,fiberoptic intubation must be performed. In addi-
tion, the patient should be examined neurologically and the
spinal cord monitored both before and after intubation. A
nasogastric tube should be inserted to help localize the
esophagus.Subsequently,the patient is placed supine on the
bed with the neck slightly hyperextended and rotated away
from the side of the operation. Wrist straps are placed and
the shoulders are pulled down toward the foot of the bed in
preparation for the localizing radiograph. Ifnecessary, the
straps can be pulled manually during the operation for addi-
tional exposure of the cervicothoracicjunction.
Incision
The anterior
neck and upper chest are prepped
and
draped. Make a transverse skin incision 2 cm above the
clavicle extending from the midline past the lateral border
of the SCMmuscle (Fig. 40-2). Most surgeons advocate a
left-sided approach due to the more consistent course of
the left recurrent laryngeal nerve.2.6The surgeon should
use the most comfortable approach but be cognizant of
the possibility of an aberrant course of the right recurrent
laryngeal nerve.
-
C6-T1
Figure
40-2
Transverse skin incision of the
supraclavicular
approach.
After cutting through the skin and subcutaneous tissues,
the platysma is encountered. This thin muscle can easilybe
recognized by its vertical fibers. Once identified, the
platysma is separated from the underlying structures with
blunt dissection, thereby preventing damage to the muscles
below. The platysma and the superficial fascia are divided
and undermined. Ligateand divide the anterior and exter-
nal jugular veins if necessary. Located immediately beneath
the platysma, the SCMmuscle is the first important land-
mark that must be identified. Beginning at the anterior bor-
der of this muscle, the superficial layer of the deep cervical
fascia should be dissected in a cephalad and caudad direc-
tion for maximal exposure. Circumferentially isolate the
SCMmuscle with finger dissection and transect the sternal
and clavicular heads from their distal attachments ina sub-
periosteal manner. The bulk of the SCMmuscle can thenbe
reflected superiorly (Fig.40-3). Foradditional exposure,the
medial third of the clavicle can be resected with the Gigli
saw.
After
the
clavicle
is
disarticulated
from the
manubrium, the free-floating portion of the claviclecanbe
removed. However,care must be taken not to injure theun-
derlying subclavian vein. After division of the omohyoid10
and sternohyoid muscles, the anterior scalene musclewill
be visualized along with the phrenic nerve. The secondim-
portant landmark, the carotid sheath, can now be identified
by finger palpation of the carotid artery. Located beneath
the SCM,the carotid artery and sheath should be retracted
laterally. Dissection should proceed along this anatomical
plane between the trachea and esophagus medially andthe
carotid sheath laterally.8.10-12Because the recurrent laryn-
geal nerve runs in the groove between the trachea and
esophagus, it must be protected from injury. Additionally,
the phrenic nerve, which is located on the anterior aspectof
the scalene muscle. should be retracted away from the sur-
gical field. Finally,because the thoracic duct is located later-
ally at the junction of the internal jugular and subclavian
veins,dissectionmedial to the carotid sheath shouldpre-
vent potential damage to this structure. Other structures
that are vulnerable to injury include the subclavian artery
and the thyrocervical trunk. The left SCMand the carotid
sheath are retracted laterally toward the patient's leftwith
handheld retractors. Similarly, the trachea, esophagus, and
recurrent laryngeal nerve are retracted medially towardthe
patient's right to expose the prevertebral fascia coveringthe
vertebral bodies (Fig. 40-4). The prevertebral fascia must
now be incised in the midline to complete the exposure
down to the first thoracic vertebra. Depending on the
degree of kyphosis and the size of the thoracic inlet, the
second thoracic vertebra may also be visualized.
Alternatively, the dissection can proceed posterior tothe
carotid sheath.13Byretracting this structure anteriorly and
ligating the inferior thyroid artery, the underlying longus
colliand the vertebral bodies can be visualized.
Upon identification
of the vertebral column, a spinal
needle can be placed into the most superior disk spacefor
the localizing radiograph. This ensures that the spinal nee-
dle will be well visualized and not obscured by the shoul-
ders on the lateral cervical radiograph. Asthe film is being
developed, the longus colli muscles can be stripped later-

...
40
Supraclavicular Approach
309
/
Common carotid artery
~
Esophagus
Recurrent
laryngeal nerve
Trachea
Sternohyoid and
sternothyroid
muscle
Omohyoid (cut)
--
/
/
\
'
\.
Common carotid artery
Jugular vein
Esophagus
Trachea
Figure 40-3
Detach the sternocleidomastoid
muscle (SCM)fromthe sternum and clavicleand
reflectsuperiorly.
Figure 40-4
Dissectionshould proceed along an
anatomical plane between the carotid artery and
sheath laterallyand trachea/esophagus medially.

310
Cervicothoracic Junction: Anterior Approach
..
Occipital
bone
'\
Atlas
Vertebral artery
Thyrocervical
trunk
Common
carotid artery
Superior
cervical
ganglion
Longus
capitis
muscle
Middle cervical
ganglion
Stellate
ganglion
Figure 40-5
Aggressive lateral dissectionofthe
longus colli muscles can damage the sympathetic
plexusorthe vertebralartery.
Longus colli muscle
allyfromthe vertebralbodiesto createa cuffofmusclefor
placement of the handheld retractors. This maneuver is
important in preventing
retractor injury to the carotid
artery and the esophagus.s Proper identification
of the
avascular midline will not only minimize bleeding but also
avoid injury to the sympathetic
chain or the vertebral
artery that can be caused by aggressive lateral dissection
(Fig. 40-5). Todo this, the bipolar or monopolar cautery
can be used to coagulate the medial portion of the muscle.
If using the monopolar cautery, a red rubber catheter can
be used to insulate the proximal portion of the cautery tip
so that the risk of inadvertent injury to adjacent structures
is minimized. Subsequently, the longus colli stripper can
be used to complete the dissection. Handheld retractors
are then positioned for the duration of the operation such
that the carotid artery lies laterally and the trachea and
esophagus
medially (Fig. 40-6). Patency of the carotid
artery
can then
be confirmed
by palpating
for a distal
pulse. Once adequate
exposure
is obtained,
the remainder
of the operation
can be completed
under
the operating
microscope.
The retractors are removed and the wound is copiously
irrigated with antibiotic
solution. A surgical drain is placed.
The strap muscles are reattached and the SCMis suturedto
the clavicular periosteum. The platysma and skinare reap-
proximated in two separate layers with an absorbablesu-
ture. Finally,a sterile dressing and a rigid, cervicalcollarare
applied.
Because of the narrow opening of the thoracic inlet,wide
surgical access is not possible without removal ofeitheror
both the clavicle and manubrium. Therefore, the additionof
a transclavicular{transmanubrial or sternum splittingtech-
nique will further increase the exposure of the cervicotho-
racicjunction and the upper thoracic vertebrae.

....
40
SupraclavicularApproach
311
/
Sternohyoidand
sternothyroidmuscle
(cut)
Recurrentlarygngeal nerve
Esophagus
\..
.
d
Common
carotid
artery
Ragus nerve
Jugular
vein
Omohyoid
muscle
(cut)
Sternocleidomastoid
muscle
Longus colli muscle
Figure40-6
Ultimate surgical exposure of the cervicothoracic junction revealing the vertebral bodies.
References
1. Kurz LT. Herkowitz
HN. Anterior
exposures
of the cervicothoracic
junction
and
upper
thoracic
spine.
In: Albert
Tj. Balderston
RA.
Northrup BEeds. Surgical Approaches
to the Spine.
Philadelphia:
WB
Saunders: 1997:61-79
2. Sundaresan
N. DiGiacinto
GV.Surgical approaches
to the cervicotho-
racic junction.
In: Sundaresan
N. Schmidek
HH. Schiller AL.Rosenthal
01. eds.
Tumors
of
the
Spine.
Philadelphia:
WB
Saunders:
1990:358-368
3. Kurz LT.Pursel SE. Herkowitz
HN. Modified
anterior
approach
to the
cervicothoracicjunction.
Spine 1991 ;16(10 Suppl):S542-S547
4. Corney CH. Mclaughlin
MR. Moossy j. Anterior
thoracic
corpectomy
without
sternotomy:
a strategy
for malignant
disease
of the upper
thoracic spine. Acta Neurochir
(Wien) 1997:139:712-718
S. Cloward RB. The anterior
approach
for removal
of ruptured
cervical
disks.j Neurosurg
1958:15:602-617
6. Smith GW. Robinson
RA.The treatment
of certain
cervical-spine
dis-
orders by anterior
removal
of the intervertebral
disc and interbody
fusion.j Bone joint Surg Am 1958:40-A:607-624
7.
Kelley LA.Whitecloud
TS. Surgical approaches
to the anterior
cervical
spine.
In: Whitecloud
TS. Dunsker
SB. eds. Anterior
Cervical Spine
Surgery.
New York: Raven Press; 1993:1-14
8.
Albert Tj. Relevant
cervical
anatomy
and anterior
middle
and lower
cervical exposures.
In: Albert Tj. Balderston
RA.Northrup
BE.eds. Sur-
gical Approaches
to the Spine. Philadelphia:
WB Saunders;
1997:2-24
9.
Riley LHJr. Surgical approaches
to the anterior
structures
of the cervi-
cal spine. Clin Orthop
1973:91 :16-20
10.
McAfee Pc. Anterior
surgical
approaches
to the lower and upper cer-
vical spine. In: Sherk HH. ed. The Cervical Spine: An Atlas of Surgical
Procedures.
Philadelphia:
Lippincott;
1994:37-69
11.
Fielding jW. Stillwell
WT. Anterior
cervical
approach
to the upper
thoracic
spine. a case report. Spine 1976; 1:158-161 (pI)
12.
Sundaresan
N. Shah j. Foley KM. Rosen G. An anterior
surgical
ap-
proach to the upper
thoracic
vertebrae.
j Neurosurg
1984;61 :686-690
13.
Micheli Lj. Hood RW. Anterior
exposure
of the cervicothoracic
spine
using a combined
cervical
and thoracic
approach.
j Bone joint
Surg
Am 1983:65:992-997

41
.
The Transsternal Approach
to the Cervicothoracic
Junction
Sanjay Ghosh and Srinath Samudrala
.
Indications
.
Contraindications
.
Advantages
.
Disadvantages
.
SurgicalTechnique
Anesthesia and Positioning
Dissection
Thoracotomy
Closure
Thecervicqthoracicjunction poses a challenge to the neuro-
surgeon for several reasons. First, the cervicothoracic junc-
tion is bound by the thoracic inlet and its contents. These
include the esophagus, trachea, vagus and recurrent laryn-
geal nerves, and great vessels (Fig. 41-1). Second, the
manubrium shields the anterior elements of the upper
thoracic spine, making exposure of this region of the spine
more difficult.
The transcervical, supraclavicular
approach provides
access to this region of the spine without disrupting the
sternum or clavicle.This approach, however, has two disad-
vantages. Theoperative field can become quite deep due to
the angle ofapproach to the second and third thoracic ver-
tebrae over the manubrium (Fig. 41-2). In addition, this
acute angle ofapproach limits the surgeon's ability to place
anterior instrumentation along the bodies of the second and
third thoracic vertebrae.
The transmanubrial, trans clavicular approach alleviates
this problem by providing a direct corridor to the cervi-
cothoracic junction. With this procedure, a corridor that is
perpendicular
to the upper thoracic vertebral bodies is
made, facilitating surgical dissection and instrumentation
312
(Fig. 41-2). This approach also provides autologousbone
graft and obviates
the need to harvest
bone from a second
site. The width of the surgical field is limited by the extent
of manubrial
resection.
Consequently,
this can result ina
large manubrial
defect.
This chapter
describes
a modified
transsternal
approach
to the cervicothoracic
junction.
This involves splitting the
sternum
to just past the junction
of the manubrium and
sternum. Complete sternotomy is often not necessarybe-
cause the heart and great vessels limit the caudal extentof
the exposure. Consequently, little is gained from a complete
sternotomy
compared
with one just past the manubrium.
This modified transsternal approach provides an excellent
view of the cervicothoracic junction to as low as the third
thoracic vertebra in some patients. Likethe transmanubrial
approach,
this provides
a corridor
that is perpendicular to
the vertebral bodies, thus decreasing the distance to thesur-
gical target and enabling anterior plating if needed. Thispro-
cedure
carries with it the attendant
risks of a sternotomy
such as sternal nonunion
and mediastinitis;
however, itpro-
vides the neurosurgeon
with an effective means to approach
the anterior elements of the cervicothoracic
spine.

I
41
TranssternalApproach
313
Figure41-1
This is an axial view of the anatomy at the second thoracic vertebrae. The dotted line represents the path taken from the manubrium
to the vertebral
body. The esophagus
and trachea
are dissected
medially,
whereas
the contents
of the carotid
sheath
are swept
laterally.
Figure 41-2
The manubrium
often shields the Tl- T2 intervertebral
disk space. Conse-
quently, the supraclavicular approach takes an acute angle over the sternal notch, making
the placement
of anterior plating difficult. The trajectory
of the transsternal
approach is
perpendicular to the vertebral bodies. This reduces the depth of the operative field and facil-
itates anterior plating.

314
CervicothoracicJunction: Anterior Approach
. Indications
.
Vertebralbody fracture
.
Vertebralbody neoplasm or metastasis
.
Osteomyelitisor Pott's disease
.
Herniated nucleus pulposus
. Diskitis
. Anteriorintramedullaryor extramedullarytumors
. Aneurysmalbonecystofthe vertebralbody
.
Mediastinaltumor with extension into the vertebral
body
.
Postlaminectomyinstability
.
Contraindications
.
Severeor other medical diseases that preclude major
surgery
. Lifeexpectancy less than 6 months
. Advantages
.
Provides excellent anterior
midline exposure of the
lower cervical and upper thoracic vertebrae down to T3
.
Allows adequate ventral exposure for instrumentation
and plating of the second or third thoracic vertebral
bodies if necessary
. Spares the sternoclavicular joint
.
Preserves the sternal insertion of the sternocleidomas-
toid muscle
.
Allowsfor reunion of the sternum and does not leave a
large manubrial defect
.
Disadvantages
.
Carries the risk of sternal nonunion, mediastinitis, and
brachial plexusinjury
. Does not allow access to the posterior elements of the
spine
.
Autologous bone graft must be harvested from a second
site
.
The corridor of exposure is limited to the uncovertebral
joints.
.
Surgical Technique
Anesthesia and Positioning
Somatosensory evoked potentials are obtained prior to in-
duction with general anesthesia to obtain baseline record-
ings. The patient is intubated using an awake, fiberoptic
technique if the spine is unstable, or conventional means if
the spine is stable. The patient is placed in the supine posi-
tion with the neck in the neutral position. If the spine issta-
ble, approximately
10 to 15 degrees of extension of the neck
will facilitate
exposure.
A nasogastric
tube can facilitate
identification
of the esophagus.
The iliac crest is prepared
for autologous bone graft if necessary.
Dissection
Askin incision is made along the anterior borderof theleft
sternocleidomastoid
muscle to the sternal notch (Fig.41-3).
The platysma is identified and divided. Next,the external
layer of the deep cervical fascia is divided. Deepto this
fascial plane, the sternocleidomastoid, sternothyroid,ster-
nothyroid,
and omohyoid muscles are found. The dissection
is continued
anterior
to the medial border of the sternoclei-
domastoid.
The omohyoid
muscle
is tagged and divided
(Fig. 41-4). An avascular plane is identified medialtothe
carotid
sheath
and lateral
to the esophagus
and trachea
(Fig. 41- 1). Care must be taken to avoid injury to the recur-
rent laryngeal
nerve, which
lies in the tracheoesophageal
groove medially. The internal
layer of the deep cervicalfas-
cia, also termed the prevertebral
fascia, is identified invest-
ing the longus colli muscles and spine.
Figure 41-3
Thisdemonstrates the external landmarksrelevantto
the dissection. The cervical incision extends along the anteriorborder
of the sternocleidomastoid
to the sternal notch. The thoracic incision
extends to just past the junction of the manubrium and sternum.

41
TranssternalApproach
315
Thoracotomy
Theinferiorborder of the neck incision is extended from the
sternalnotch to the junction of the manubrium and sternum.
Amidlinedissection is performed between the left and right
pectoralismajor muscles through the periosteum. The left
pectoralismajor muscle isthen reflectedfrom the manubrium
toallowvisualizationofthe second intercostalspace.
Bluntfinger dissection is then performed over the sternal
notchto free the mediastinal contents from the inner table
ofthe sternum. The sternum is then divided in a cephalad
tocaudaddirection using a pneumatic sternal saw.The nose
plateof the saw is placed under the sternum at the sternal
notch.Gentle upward traction of the nose plate against the
innertable of the sternum is performed to protect the bra-
chiocephalicvein and mediastinal structures from the saw.
The sternotomy is performed to the second intercostal
space.The sternotomy is then extended to the left between
thearticulation of the second and third ribs. Care must be
takento avoid injury to the internal mammary artery dur-
ingthis part of the sternotomy. Bone bleeding may be con-
trolledwith judicious use of electrocautery and bone wax.
Excessiveuse of either hemostatic technique may poten-
tiallylead to pseudarthrosis or nonunion of the sternum.
Figure 41-4
This figure demonstrates the cervical dissec-
tion. The skin incision extends along the anterior border of the
sternocleidomastoid
to the sternal notch. The platysma is di-
vided. The omohyoid
muscle is divided. The sternohyoid
and
sternothyroid
muscles are identified at their sternal insertions.
A plane is developed
between
the contents
of the carotid
sheath and the esophagus and trachea.
A complete sternotomy through the xiphoid process
maybe performed;
however, this does not provide any
additional exposure. The heart and great vessels limit the
caudal extent of the exposure. Consequently, a partial
sternotomy
to the second intercostal
space maximizes
the exposure while minimizing the extent of the ster-
notomy.
The sternohyoid and sternothyroid muscles are divided
near their sternal origin. The sternocleidomastoid muscle
is preserved. The cervical and thoracic portions of the dis-
section are now in continuity (Fig. 41-5). Sternal retrac-
tors may be placed to reveal the left innominate vein
crossing the surgical field. The inferior thyroid artery
coming from the thyrocervical trunk is identified and di-
vided. as are the middle and inferior thyroid veins. Gentle
inferior retraction, just medial to the left common carotid
artery, wiIl then provide access to the prevertebral fascia
of the upper thoracic vertebrae (Fig.41-6). The left recur-
rent laryngeal nerve will lie below the caudal and the re-
tractor blade as the nerve travels from the aortic arch to
the tracheoesophageal
groove. Care must be taken to
avoid overly vigorous caudal or medial retraction during
the procedure to prevent injury to the recurrent laryngeal
nerve.

316
Cervicothoracic Junction: Anterior Approach
-
Closure
A soft Silastic drain is placed in the prevertebral space of
the neck. The sternohyoid and sternothyroid muscles are
reattached to their sternal origins.The platysma muscle and
skin are then approximated.
The sternal edge is lifted and the internal mammary
artery is inspected for evidence of bleeding. The sternum is
then approximated using no. 5 steel wire sutures. If the
sternum is osteoporotic or unusually fragile. a different
technique may be necessary. A figure-of-eight
closure
maybe employed. In this technique. the wire is placed
through the first and second intercostal space in a figure-of-
eight
manner.
The wire
is then
brought
together and
twisted for closure.
In addition, the manubrium can be reinforced byplacing
continuous
parasternal
wires between
the costal cartilage.
Manubrial
sutures
are then passed around the parasternal
wires and twisted
together
to bring the sternum together.
This effectively distributes
the tension of the wire overthe
support
wire
rather
than
solely
on
the
bone of the
manubrium.
Care must be taken to avoid injury to the inter-
nal mammary
arteries
and intercostal
neurovascular bun-
dles during closure of the manubrium.
The pectoralis mus-
cle fascia is then reapproximated.
as are the subcutaneous
fat and skin.
Figure 41-5
Asternotomy ismade just past the junctionofthe
manubrium and sternum. The sternotomy
is then extended tothe
left second intercostal
space. Care must be taken to controlthe
left internal
mammary
artery during
this portion of the ster.
notomy. The sternohyoid
and sternothyroid
muscles are divided
near their sternal insertions. The left innominate vein isidentified.
The left middle thyroid vein maybe identified and ligated ifthe
middle cervical spine is to be exposed. The prevertebral fasciaand
the longus colli muscles are identified.

...
41
TranssternalApproach
317
SuggestedReadings
1. Calliauw L. Dallenga
A. Caemaert J.Transsternal
approach to in-
traspinal tumors in the upper
thoracic
region.
Acta Neurochir
(Wien)
1994:127:227-231
2. AnHS,Vaccaro A. Cotler JM. Un S. Spinal
disorders
at the cervicotho-
racicjunction. Spine 1994:19:2557-2564
3. WalshGL.Gokaslan ZL. McCutcheon
IE. et al. Anterior
approaches
to
the thoracic spine
in patients
with
cancer:
indications
and
results.
Ann Thorac
Surg
1997:64:
1611-1618
4. Naunheim KS. Barnett
MG. Crandall
DG. et al. Anterior
exposure
of
thethoracic spine. Ann Thorac
Surg 1994:57: 1436-1439
S. CharlesR.Govender S. Anterior
approach
to the upper
thoracic
verte-
brae.) BoneJoint Surg Br 1989:71 :81-84
6. Birch R. Bonney G. Marshall
RW. A surgical
approach
to the
cervi-
cothoracic spine.J Bone Joint Surg Br 1990;72:904-907
7. KurzLT.Pursel SE.Herkowitz
HN. Modified
anterior
approach
to the
cervicothoracicjunction.
Spine 1991 :16(10 Suppl):S542-S547
8. Darling GE. McBroom
R. Perrin
R. Modified
anterior
approach
to the
cervicothoracic junction.
Spine 1995:20: 1519-1521
9. Sundaresan N. Shah J. Foley
KM.
Rosen
G. An anterior
surgical
ap-
proachto the upper thoracic
vertebrae.
J Neurosurg 1984:61 :686-690
10. SundaresanN. Shah J. Feghall JG. A transsternal
approach
to the upper
thoracicvertebrae. AmJ Surg 1984: 148:473-477
11. Nazzaro)M. Arbit
E. Burt
M. Trap
door
exposure
of the cervicotho-
racicjunction.J Neurosurg
1994:80:338-341
12. GiegerM. Roth PA. Wu JK. The anterior
cervical
approach
to the cervi-
cothoracicjunction.
Neurosurgery
1995:37:704-710
Figure 41-6
Gentle inferior retraction on the innominate vein
revealsthe third thoracic vertebra. Care must be taken to avoid
overly vigorous caudal retraction on the innominate vein because
the left recurrent laryngeal nerve travels from the aortic arch to
the tracheoesophagealgroove in this region.
13.
Anderson TM. Mansour KA. Miller JI.Thoracic approaches to anterior
spinal operations:
anterior
thoracic
approaches. Ann Thorac Surg
1993:55:1447-1452
14.
Corney CH. Mclaughlin
MR. Moossy J.Anterior
thoracic
corpectomy
without
sternotomy:
a strategy for malignant
disease of the upper
thoracic spine. Acta Neurochir (Wien) 1997:139:712-718
15. McDonaldP.Letts M. Sutherland G. Unruh H. Aneurysmal bone cyst of
the upper thoracic spine. Clin Orthop 1992:279:127-132
16. Kraus DH.HuoJ. Burt M.Surgical access to tumors of the cervicotho-
racicjunction.
Head Neck 1995:17:131-136
17. Dimarco RF.Lee MW.BekoeS. Grant KJ.Woelfel GF.Pellegrini RV.In-
terlocking figure-of-8 closure
of the
sternum.
Ann Thorac Surg
1989:47:927-929
18.
Robicsek F. Daugherty
HK. CookJW. The prevention
and treatment
of
sternum separation following open-heart surgery. J ThoracCardiovasc
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19.
Heitmiller
RF.Thoracic incisions. In: BaueAE. GehaAS.Hammond GL.
Naunheim
KS. eds. Glenn's Thoracic
and Cardiovascular Surgery.
1996:73-89
20.
Stangl R.Altendorf-Hofman
A. von der EmdeJ.Brachial plexus lesions
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sternotomy
in cardiac
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21.
Gokaslan ZL.York JE.Walsh GL.et al.Transthoracic vertebrectomy for
metastatic spinal tumors.J Neurosurg 1998:89:599-609

42
Transmanubrial Transclavicular Approach to
the Cervicothoracic Junction
Larry T. Khoo and Srinath Samudrala
.
Indications
.
Contraindications
.
Advantages
.
Disadvantages
.
Objective
.
Surgical Technique
Preoperative Planning
Anesthesia and Positioning
Approach and Dissection
Closure
.
Postoperative Care
The treatment of pathology at the cervicothoracic junction
presents a daunting challenge to spinal surgeons. The need
for adequate operative exposure must be weighed against
potential injury to the numerous muscular, visceral, and
neurovascularstructures confined within the small space of
the thoracicinlet.Techniques such as costotransversectomy,
lateral rhacotomy, and the lateral extra cavitary approach
typically utilized in the thoracic spine are often limited in
their exposure of (1 to 13 by the scapula and its associated
muscular complex.I-3Spondylosis, disk degeneration, pri-
mary and metastatic tumors of the bone and neural ele-
ments, and infectious lesions of the cervicothoracic region
often originate within the vertebral bodies themselves and
thus mandate a more anteriorly directed surgical corridor.4
Additionally,these processes can often lead to a progressive
gibbus or kyphosis of the spine. Ascompared with posterior
fusion, anterior reconstruction is more likely to resist com-
pressive forces and thus provide better surgical restoration
of lordosis.s
The supraclavicular, transsternal, and transmanubrial
transclavicular approaches are the best established of the
various anterior surgical techniques. Ofthese, the supra-
clavicular is perhaps the most familiar because it is essen-
tially an oblique extension of the typical anteromedial ap-
proach to the low cervical spine.6,7Extensileexposure of the
upper thoracic vertebrae is, however, limited by the size
318
and position of the anterior
bony thorax. Furthermore, use
of the
supraclavicular
approach
is often
precluded in
patients
with obesity, prominent
muscular
development,a
short neck, or marked kyphosis. The transsternal
technique
provides a more direct corridor to the upper thoracicbodies
by mobilizing
the thorax
and mediastinal
viscera. Techni-
cally challenging,
the approach
generally requires the assis-
tance of a skilled thoracic surgeon
and has been associated
with a markedly
higher rate of morbidity
and mortality.s-Io
A subsequent
modification
of
these
techniques by
Sundaresan
and associates
in 1984 led to the development
of the
transmanubrial
transclavicular
approach,u,12The
medial
third
of the clavicle and a limited
portion ofthe
manubrium are typically removed. Despite this limitedmo-
bilization of the bony thorax, an excellent extensile expo-
sure of the superior thoracic vertebrae (T1-13) is afforded
by the approach.
Furthermore,
the degree of osseomuscular
exposure can also be customized to each individualcase.B,w
Whereas the clavicle and manubrium are ideal bonyauto-
grafts in cases of corpectomy,
they can also be preservedas
flap in less extensive cases. The ability to expose boththe
cervical and the thoracic
segments
of the cervicothoracic
junction is also a particularly attractive feature ofthistech-
nique. In experienced hands, the transmanubrial transclav-
icular approach is a safe and effective means for treating
anterior pathology of the cervicothoracic
junction.15,16

42
TransmanubrialTransclavicularApproach
319
.
Indications
.
SurgicalTechnique
.
Spondylosis
.
Vertebral neoplasm
.
Spinal cord neoplasm
.
Disk degeneration
.
Osteomyelitis
.
Bacterial infection
.
Traumatic fracture
.
Kyphotic deformity
.
Metastatic tumor
.
Skeletal disorders
. Diskitis
.
Tuberculosis
.
Vascular malformation
.
Pathological or insufficiency
fracture
. Contraindications
. Terminalillness with life expectancy less than 3 months
.
Unacceptably high surgical
risk
. Severeinstability
of posterior
elements (relative, con-
sider combined
approach)
. Largeanterolateral
soft tissue mass (relative)
. Lackof experience with procedure or regional anatomy
.
Advantages
. Simultaneous extensile exposure of whole cervicotho-
racicjunction ((5-(6
to 12- T3)
. Surgicalcorridor providing direct anterior exposure of
vertebralpathology
. Decreasedmorbidity and mortality
over sternotomy ap-
proaches
.
Disadvantages
. Prerequisitedetailed understanding of complex regional
anatomyof thoracic inlet
. Prolongedsurgical dissection and exposure
. Increasedrisk of significant
hemorrhage from major
proximal vascular structures
. Increasedrisk of injury to organsof pleural and medi-
astinum
. Objective
Toobtaina direct anterior extensile exposure of the cervi-
cothoracicspine while minimizing
risk to the visceral and
neurovascularstructures of the thoracic inlet
Preoperative Planning
Prior to undertaking any anterior cervical operation, ade-
quate anatomical evaluation of the target pathology is pre-
requisite. The bony vertebral anatomy, neural elements, ad-
jacent vascular anatomy, degree of kyphosis/lordosis,
and
extent of disease spread are but some of the major consid-
erations that should be assessed.Of equal importance is the
relationship
of the thoracic inlet to the vertebral column.
The kidney-shaped inlet typically measures 5 cm (antero-
posterior) by 10 cm (transverse), but there is great variabil-
ity in its obliquity, size,and shape.
Anomalies of the great vesselsincluding the innominate,
common carotid, and left subclavian vesselsshouldbeascer-
tained preoperatively becausethey may affect the sidechosen
for the approach.A high aortic arch with a distal origin of the
innominate artery may necessitate a left-sided approachto
prevent excessiveretraction during the exposure.Theseobjec-
tives cantypically be achieved through acombination of plain
radiographic, computed tomographic, myelographic, radionu-
cIeotide,angiographic,and magnetic resonanceimaging.
The surgeon should choosean appropriate orthotic device
depending on the nature of the instability,
strength of the
surgical construct, degree of bony removal, habitus of the
neck, and compliance of the patient. Premeasuring the pa-
tient before surgery allows for timely placement of the or-
thotic afterward. In casesof severespinal instability, immo-
bilization
should be initiated
prior
to the induction
of
general anesthesia.
Anesthesia and Positioning
The patient is placed on the operating table in a supine posi-
tion. Prior to the induction of general anesthesia, the degree
of spinal instability should be known. In cases of a highly
mobile vertebral column, it is preferable to have the patient
already secured in either a halo vest, halo traction, or a May-
field pinholder headrest before intubation. The neck ideally
should be slightly extended;
however, extremes
of extension
or flexion should generally be avoided. All potential pressure
areas should be well padded. Wrist restraints
are often help-
ful so that the arms may be pulled down for intraoperative
lateral fluoroscopy or radiographs. Regardless of the final
position, the patient should be neurologically assessed
through the entire planned
operative
range of motion while
awake. The use of somatosensory evoked potentials (SSEPs)
is indicated
in patients with severe spinal instability, signifi-
cant neurological deficits, myelopathy, spinal cord compres-
sion, or intradural pathology. Early placement of the SSEP
leads is helpful in providing additional surveillance during
the positioning and intubation phase. Anappropriate level
of anesthesia should be maintained to prevent interference
with SSEPmonitoringduringthe case.Intravenousantibi-
otics and glucocorticoids should be givenprior to incision.
Generalanesthesia with endotracheal intubation ofthe pa-
tient can then be completed
by one of several techniques.
For
cases with significant neural compromise
or spinal instabil-
ity, conscious fiberoptic intubation should be utilized to min-
imize excessive movement of the neck and to allow for con-

320
CervicothoracicJunction: Anterior Approach
-
stant neurologicalreevaluation of the patient. Asopposed to
a transthoracicapproach,lengthy double-lumen intubation is
typically not needed. In cases where the cupula of the lung
ipsilateralto the approach is particularly high riding, unilat-
eral deflationmayhelp prevent unintentional intraoperative
injury to that lung. Single-lumen intubation with the use of
high frequencyventilation also allows for minimal inflation
of the retracted cupula while maintaining adequate ventila-
tion ofthe remainder of the ipsilateral lung. Standard single-
lumen intubation and ventilation are generally suitable for
the majorityof transmanubrial transclavicular cases.
Approach and Dissection
After induction of general anesthesia and final positioning,
the anterior neck and upper chest area should be widely
prepared and draped. Typically, a T-shaped incision is
utilized. The curvilinear horizontal limb usually lies 1 to
2 cm above the clavicle and extends to the lateral border of
the sternocleidomastoid muscle on both sides (Fig. 42-1).
The vertical portion
of the incision extends past the
manubriosternal junction halfway down the sternum. In
cases where only a small exposure is needed, the horizontal
limb is opened only on the side of the approach. The skin in-
cision is continued
and deepened
to the level of the
platysma muscle, which is then sharply opened in the same
direction as the incision. Subplatysmal flaps are created via
blunt and sharp dissection to insure an adequate degree of
rostrocaudal exposure. Superficial anterior veins can be cau-
terized and sectioned. Awide mobilization will prevent un-
necessary traction on these skin flaps during the procedure.
Theexternal jugular veins, jugular venous arch, and medial
supraclavicularnerves should be identified and mobilized at
this point. They can often be safely retracted but may need
to be sacrificedfor better exposure (Fig.42-2). Although left
up to the individualsurgeon'schoice,a left-sidedexposure
is typically performed because the recurrent laryngealnerve
is less variable on this side and further from the midline.2
The left sternocleidomastoid muscle with its twosepa-
rate heads is then identified. The sternal head arisesfrom
the anterosuperior
manubrium
and is typically more
rounded and tendinous. The clavicular head is morefleshy
in character and attaches on the anterosuperior surfaceof
the medial clavicle.The muscle heads are sharplydissected
with cautery from their osseous attachments and reflected
superiorly and laterally. In a similar fashion, the ipsilateral
sternohyoid and sternothyroid strap muscles are alsoiden-
tified and sectioned just above their sternoclavicularinser-
tion and elevated (Fig.42-3). With careful dissectionofthe
superficial and middle layers of the deep cervicalfascia.
these muscles can be mobilized from their underlying
structures while still preserving their neurovascularsupply.
The fatty and areolar tissues are then cleared fromthe
suprasternal space of Burns, which is formed by a splitin
the superficial layer of the deep cervical fascia.Byentering
this
midline space, a subperiosteal
dissection of the
manubrium is begun. Stripping along this plane iscontin-
ued under the left two thirds of the manubrium andthe
medial third of the clavicle. Blunt dissection should becom-
pleted behind the manubrium
with either an instrument or
a finger. The origin of the pectoralis
major is freed laterally
off the body of the inferior
manubrium
and sternum. The
omohyoid muscle is then divided to reveal the anteriorpor-
tions of the internal jugular vein and common carotid
artery.
The
periosteum
and
anterior
extension
of the
transthoracic
fascia are usually left intact to protect the un-
derlying brachiocephalic
vessels and mediastinal structures.
Using either a Gigli saw or a high-speed
drill, the medial
third of the clavicle is then resected. The first costalcarti-
lage is also usually divided. The sternoclavicular joint is
D-.
----
------
Figure 42-1
The patient is placed in a supine
position
with the
neck in slight extension. A
T-shaped incision is marked over the chest such
that the curvilinear horizontal limb lies 1 to 2 em
above the clavicleand extends to the lateralbor-
ders of the sternocleidomastoid muscles.The
vertical limb extends in the midline past the
manubriosternal
junction.

---
42
TransmanubrialTransclavicularApproach
321
"
Figure42-2
After being widely mobilized, the skin and subplatysmal flaps are reflected with either handheld or table-fixed retractors. The superfi-
cialcervicalfascia has been omitted for clarity. 1, stern hyoid muscle; 2 internal jugular vein; 3, omohyoid muscle; 4, phrenic nerve; 5, anterior jugular
vein;6, clavicle;7, pectoralis major; 8, manubriosternal
junction; 9, manubrium; 10, sternothyroid
muscle; 11, sternocleidomastoid
muscle (sternal
head);12, sternocleidomastoid
muscle (clavicular head); 13, supraclavicular
nerves; 14, external jugular vein; 15. thyroid gland; 16, cricothyroid
muscle;17. trachea.

\
322
Cervicothoracic
Junction: Anterior Approach
.,.
Figure 42-3
The sternocleidomastoid,
sternohyoid.
sternothyroid,
and omohyoid muscles have been cut at their osseous attachments andre-
flected. The pectoralis major muscle has been freed from its sternal and clavicular attachments.
The underlying neurovascular
structures areseen
(carotid sheath omitted). The left recurrent laryngeal and its relationship to the viscerocarotid space is demonstrated.
1, carotid artery; 2.sternohy-
oid muscle; 3, sternothyroid muscle; 4, thoracic duct; 5, internal jugular vein; 6, vagus nerve; 7, pectoralis major (reflected); 8, viscerocarotidspace
(opened); 9,Ieft recurrent laryngeal nerve; 10, sternocleidomastoid
muscle (reflected).
sharply disarticulated and the fragment of clavicle re-
moved. Caution should be exercised to avoid injuring the
subclavian vein.which lies immediately posterior and infe-
rior to the clavicle.The bone fragments can either be saved
for future use as a bone graft or for eventual reconstruction
of the opening. With the high-speed drill, a rectangular
piece of the manubrium is then removed. Typically. the
drill is used to thin the edges of the bone down to the level
of the posterior periosteum. Apair of heavy scissors is then
used to complete the final cuts. Briskbleeding is commonly
encountered at this point and complete hemostasis should
be obtained with cautery and bone wax before proceeding.
Meticulous care is needed to prevent compromise of the
innominate
vein. which traverses the superior
medi-
astinum.
If an
adequate
subperiosteal
dissection
is
achieved behind the manubrium and clavicle,these struc-
tures may be resected en bloc with a craniotomy osteotome
blade and preserved. In this manner. the entire piece can
later be reattached via small plates to provide a cosmetic
bony closure of the operative
site. Variations of these steps
should be tailored
to the anatomy
and particular
needsof
each individual patient.
The remaining periosteum is now removed to exposethe
underlying vascular structures. The inferior thyroidveinas
well as other smaller venous tributaries of the innominate
vein should be doubly ligated and sectioned at thispoint.
The innominate
itself can usually
be mobilized
inferiorly
with a medium-width retractor and rarely requiresdirect
ligation. The thymus and any additional fat present inthe
superior mediastinum should be either mobilizedor re-
sected (Fig. 42-4). The infrahyoid muscles. brachiocephalic
artery and branches, subclavian and common carotidarter-
ies, trachea, thyroid gland. scalenus anterior muscle,phrenic
nerve. first rib. brachial plexus. and thoracic duct areoften
now visible.Earlyidentification of these structures mayhelp
prevent unintentional injury to them later on.

42
TransmanubrialTransclavicularApproach
323
Figure42-4
The medial third of the clavicle has been resected with the use of a Gigli saw. A high-speed
drill is used to resect the left two thirds of
themanubrium.
Caution is exercised to avoid injury to the underlying
innominate
and subclavian veins. The inferior thyroid
veins have been doubly
ligatedand divided.
Handheld,
smooth-edged,
Richardson-type
retractors
have been used to further
open the viscerocarotid
space after blunt dis-
section.The vertebral
column
and longus colli muscles are seen (prevertebral
fascia omitted).
1, anterior
longitudinal
ligament;
2 longus colli mus-
cles;3, clavicle (cut edge); 4, innominate
vein; 5, inferior thyroid veins (ligated); 6 vertebral column.
Attention is then directed toward the proximal aspect of
thesurgical exposure. The middle and deep cervical fascial
layerscircumferentially fuse around the carotid arteries,
internaljugular vein, and vagus nerve to form the carotid
sheath.At the thoracic inlet, it merges with the subclavian
arteryto form the axillary sheath. The trachea and esopha-
gusare wrapped within the visceral fascia, which contin-
ues down into the superior mediastinum.
The viscero-
carotidspace is thus located between the neurovascular
compartment laterally and the visceral compartment me-
dially. Initially, this avascular potential
space can be
opened sharply just medial to the carotid sheath. Direct
palpationof the carotid pulsations and identification of the
artery itself is crucial. Blunt dissection
with the use
ofsmooth, handheld Richardson retractors is then used to
developthis plane.
Early on, it is important to identify the course of the left
recurrent
laryngeal nerve. Its location in the tracheoe-
sophageal groove on the left side is almost invariable. It is
often of a good size and can be safely mobilized under the
medial retractor. On the right side, the nerve typically tra-
verses the operative field anywhere from (6 to T2making it
more prone to injury. Thus particular attention should be
paid to properly identifying and mobilizing it out of the sur-
gical field. Laterally, the thoracic duct is also prone to po-
tential injury. The duct runs dorsal and to the left of the
esophagus between the visceral and alar fasciaas it ascends
to the inferior cervical spine. There it courses caudal, lateral,
and ventral to the thyrocervical trunk and phrenic nerve. It
usually terminates at the posterior junction of the internal
jugular and subclavian veins. On the right side, a similar
lymphatic trunk is often found. Anatomical variations of

324
Cervicothoracic Junction: Anterior Approach
these relationships are common. Overall, it is important
that an adequate degree of superior and inferior exposure
be obtained to achieve a relaxed extensile exposure. Inade-
quate mobilization can lead to unwarranted
traction on
neurovascular and visceral structures thereby leading to ia-
trogenic injury. The aortic arch and its branches ultimately
limit the caudal aspect of the exposure. Exposure below the
superior aspect of the T3 body is thereby restricted.
The exposure is continued posteriorly until the alar and
mediastinal fasciae are encountered. Sharp incision and ad-
ditional blunt dissection will then bring the prevertebral
fascia and the longus colli muscles into view. The vertebral
bodies, anterior osteophytes, and disk spaces are often pal-
pable if not visible as well. Secondary changes of the sur-
rounding tissue in cases of infection and tumor can also be
seen. At this point, intraoperative fluoroscopy or a lateral
radiograph
is obtained to confirm the exact levels oftheex-
posure. Counting
from a higher spinal level may be neces-
sary in cases where the shoulders
prevent adequate lateral
imaging.
After confirmation
of the appropriate
vertebral
level, a midline
incision
is made
with
unipolar cautery
through
the prevertebral
fascia. Using a combination ofa
bipolar cautery and a longus colli periosteal elevator,flaps
are developed
under
each of the longus colli musclesas
they are elevated
off the vertebral
bodies. The ligaments
and periosteum
are also stripped
laterally off the bodies
with elevators
as far as possible. Either handheld-type re-
tractors
or self-retaining
retractors
are then placed under-
neath each longus colli muscle. Most self-retaining retractor
systems utilize a pair of toothed blades laterally underneath
the muscles. An additional pair of smooth bladesisthen
placed superiorly and inferiorly (Fig. 42-5). Caution must
Figure 42-5
Sharp dissection is used to develop flaps under each longus colli muscle and self-retaining, toothed retractor blades are placedtohold
these
flaps laterally.
A smooth
medium-width
retractor
is used to gently
pull the great
vessels
out of the operative
exposure.
The cervicothoracieYel'
tebral bodies and the anterior longitudinal ligament are well visualized. 1, longus colli (retracted); 2, innominate vein (inferiorly retracted); 3,Ieft~
current
laryngeal
nerve; 4, cervicothoracicjunction
(Tl body).
l

42
TransmanubrialTransclavicularApproach
325
beexercisedduring the placement of these retractor blades
topreventinjury to the esophagus, trachea, recurrent laryn-
gealnerve,and carotid artery. After obtaining the desired
degreeofexposure, vertebrectomy, diskectomy, decompres-
sion,and stabilization can be completed as indicated. Dur-
ingthe remainder of the operative procedure, the retractor
systemshould be intermittently loosened to prevent trac-
tioninjuryto the underlyingstructures. Theirpositioning
shouldalso be reconfirmed each time because they can of-
teninadvertently migrate during the course of the surgery.
Closure
Afterappropriate removal and stabilization of the patho-
logicalprocess, copious antibiotic-impregnated
irrigation
shouldbe used to wash out the operative site. Complete
hemostasisshould be obtained and rechecked prior to cIo-
sure.lntraoperative imaging to confirm the placement of
bonygrafts and instrumentation
is left to the discretion of
thesurgeon.The wound is then typically closed in layers
overvacuumdrainage. We routinely employ either a no. 7
orno.10Jackson-Pratt drain for several days postopera-
tively.Ifthere is any evidence of thoracic or pleural viola-
tion,a chest tube can also be inserted through a separate
stabwound and placed to suction or water seal. If the
manubriumand clavicle were removed en bloc, they can
be reattached via small fixation plates or wires at this
time.Thestrap muscles are loosely reapproximated with
absorbablesuture. The sternocleidomastoid
is then reat-
tachedto whatever clavicular periosteum remains. Closure
ofthesubcutaneous tissue and skin is then completed in a
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1. Menard V.Etude Pratique sur Ie Mal de Pott. Paris: Masson;
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2. Capener N. The evolution
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3. Larson SJ. Holst RA, Hemmy DC. et al. Lateral extracavitary
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4. Johnson RM, Southwick
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In:
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FA.eds. The Spine. 2nd ed. Philadelphia:
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Saunders; 1982:67-187
5. Winter RB.MoeJH, WangJF.
Congenital
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and thirty
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tients.J Bone Joint Surg Am 1973;55:223-256
6. Nanson EM. The anterior
approach
to upper
dorsal
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SurgGynecol Obstet 1957;104:118-120
7. Fielding JW, Stillwell
WT. Anterior
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8. CauchoixJ. BinetJP. Anterior
surgical
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ColiSurg Eng11957;21 :234-243
9. Hodgson AR. Stock FE. Fang HSY,Ong GB. Anterior
spinal fusion:
the
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routine fashion. Prior to waking the patient, appropriate
external
immobilization
(e.g., halo, hard-collar,
brace)
should be secured in place to prevent movement at the
operative site.
.
Postoperative Care
Patients who undergo prolonged surgical manipulation or
retraction may experience significant airway and oropha-
ryngeal edema. This is especially true for cases of multiple-
level decompressions and combined anteroposterior stabi-
lizations. Excessive use of intravenous fluids during the
operation may also exacerbate fluid shifts and secondary
pulmonary edema. A thorough postoperative evaluation
should be made by both the surgeon and the anesthesiolo-
gist before prematurely extubating the patient. Many pa-
tients will also experience transient hoarseness from trac-
tion of the recurrent
laryngeal nerve. Damage to the
superior laryngeal nerve can cause the patient difficulty
with clearing secretions thereby increasing the risk of aspi-
ration. Reintubation in such circumstances can be exceed-
ingly difficult and often requires specialized techniques. For
these reasons, we recommend that these patients be closely
monitored in an intensive care setting postoperatively. A
comprehensive rehabilitation regimen combining occupa-
tional, physical,and speech therapy should be implemented
early on. Rapid mobilization of the patient, aggressive pul-
monary toilet, adequate
prophylaxis against deep vein
thromboses, and a cautious advancement of oral intake are
essential in avoiding secondary postoperative complications.
10.
Standefer
M, Hardy RW Jr, Marks K, et al. Chondromyxoid
fibroma of
the cervical
spine: a case report
with a review
of the literature
and a
description
of an operative
approach
to the lower
anterior
cervical
spine. Neurosurgery
1982;11 :288-292
11.
Sundaresan
N, Shah J. Foley KM, et al. An anterior
surgical
approach
to the upper thoracic
vertebrae.
J Neurosurg
1984;61 :686-690
12.
Sundaresan
N, Shah J. Feghali JG. The transsternal
approach
to the up-
per thoracic
vertebrae.
Am J Surg 1984; 148:473-477
13.
Kurz LT,Pursel SE, Herkowitz
HN. Modified
anterior
approach
to the
cervicothoracic
junction.
Spine 1991; 16(10 Suppl):S542-S547
14.
Birch R. Bonney
G. Marshall
RW. A surgical
approach
to the cervi-
cothoracic
spine. J Bone Joint Surg Br 1990;72:904-907
15.
Charles R. Govender
S. Anterior approach
to the upper thoracic verte-
brae. J Bone Joint Surg Br 1989;71 :81-84
16.
Fessler
RG, Dietze
DO. Surgical
approaches
to the cervicothoracic
junction.
In: Schmidek
HH, Sweet WH, eds. Operative
Neurosurgical
Techniques:
Indications,
Methods,
and Results. 3rd ed. Philadelphia:
WB Saunders;
1995: 1875-1886

43
.
Vertebrectomy following Anterior
Approaches
Mark A. Liker,
Larry T. Khoo,
LaceyBresnahan, and
Srinath Samudrala
.
Approach
.
Decompression
.
Surgical Technique
Diskectomy
Corpectomy
End Plate Preparation
Techniques for anterior exposure to the cervicothoracic
spine have been presented in the three previous chapters.
One main indication for these approaches, and in fact, the
advantage they offer,is that they allow decompression to be
performed via the anterior
approach. Because a large
amount of pathology of the cervicothoracic junction origi-
nates in the anterior structures of the spine, decompression
through these exposures is a valuable tool in the armamen-
tarium ofthe spine surgeon. This chapter focuses on diskec-
tomy,vertebrectomy, and decompression after anterior ex-
posure to the cervicothoracicjunction.
. Approach
Ingeneral, neural compression caused by anteriorly located
pathology is best treated by an anterior approach for de-
compression. Thisphilosophy is as valid in the cervicotho-
racic spine as it is in the other portions of the spine. The
anatomical difficulties imposed by the bony thorax, and
vascular structures of the upper chest had previously im-
posed restrictions on access to the anterior cervicothoracic
spine. Posterior, posterolateral, or anterolateral exposures
had been favored and made direct decompression of the
ventral aspect of the spine difficult.These approaches only
allowed for indirect decompression and thus increased the
risk of neurological injury.With modern techniques and an-
terior exposures, decompression can be performed with a
direct view of the compressive elements. This insures that
neural elements are not compromised during decompres-
sion. Wide decompression for multiple levels can be readily
addressed with options for grafting and fixation.
326
.
Decompression
The indications for selecting an anterior approachhave
been discussed in previous chapters. Once the decisionhas
been made that the anterior approach is most appropriate,
the extent of decompression should be considered. Neural
compression must be confirmed by magnetic resonance
imaging (MRI)or myelography and must coincide with the
patient's signs and symptoms.
Decompression may consist of diskectomy, vertebrec-
tomy, or multilevel vertebrectomy, depending on the nature
of the pathology and the extent of disease. Trauma willusu-
ally lead to single-level vertebral fracture with possible disk
disruption. Infectious pathology will generally cause disk
space destruction with variable involvement of adjoining
end plates. Anotable exception is mycobacterial infections
that may predominantly lead to vertebral body destruction.
Neoplastic involvement is frequently centered near the
pedicles and spreads throughout the vertebrae, leading to
pathological fracture and epidural compression from either
tumor cells or retropulsed bony fragments.
.
SurgicalTechnique
Afterthe initial exposure has been performed, localizationof
affected levelsand identificationoflandmarks isessential.Be-
cause of the difficulty of obtaining intraoperative
radiographs
at this level, it may be necessary
to mark a disk space at the
upper portion of the exposure, (the lower cervical spine) and
count down. The longus colli muscles are identified
and the
center of the spine may be estimated by where the right and

43
Vertebrectomy following Anterior Approaches
327
leftmuscles approximate in the midline. In some patients
hematoma,tumor, or granulation tissue from infection may
haveobscured the natural landmarks. It is worthwhile to get
anestimateof midline and lateral boundaries by first identi-
fyingthese landmarks in normal segments adjacent to the
areaofpathology.Thisinitial step makes inadvertent lateral
deviationlesslikelyonce decompression has begun.
Diskectomy
Thelongus colli muscles are dissected away from the un-
derlyingbone and reflected laterally using both sharp dis-
sectionand bipolar cautery. Monopolar cautery may be
usedby confident and experienced hands but may carry a
higherrisk of damage to critical structures due to a mis-
guidedelectrical arc. Care must be taken when using the
cauterydevices to avoid damage to the esophagus medially
andcarotid vessels laterally. Current passage along other
metallicobjects to critical tissues must also be avoided.
Sharp-toothed, self-retaining retractors can be placed af-
ter adequate lateral mobilization of the longus colli mus-
cles. Fingersof remaining muscle fibers attached to the un-
derlying anterior longitudinal ligament will prevent secure
anchoring of the retractors. Therefore,the muscle should be
well mobilized. Dislodgment or rotation of the retractor
blades during surgery may risk damage to the esophagus,
carotid vessels, and venous structures or nerve tissue.
The operating microscope maybe introduced in the oper-
ative field at any time after the retractors are in place. We
generally use it for all portions of the decompression. It is
useful in facilitating disk and vertebral body removal, al-
lowing excellent visualization of the spatial relationship be-
tween the instruments and the dura. Identification of the
superior and inferior disks and their respective marginscan
be performed with a large-bore spinal needle. The disk is
incised with a no. 11 scalpel (Fig. 43-1). This incision
should be carried laterally to identify the Luschkajoints,
which will demarcate the lateral borders of the decompres-
Figure 43-1
The inferior disk is incised with a scalpel and carried laterally to identify the location of the Luschka joints. A Kerrison rongeur is used
to remove the disk material.

328
Cervicothoracic Junction: Anterior Approach
.
Corpectomy
sion. These can be identified by the upward course of the
end plates. Acombination of rongeurs, curettes, and pitu-
itary rongeurs allows expeditious removal of disk material
(Fig.43-1). Removalofthe disk is performed to the level of
the posterior longitudinal ligament. In situations where
vertebrectomy is to be performed, diskectomy above and
beloweachvertebra should be performed prior to initiating
the corpectomy. Earlyidentification of the dura at the disk
space levelwill allow more aggressive vertebrectomy.
Soft tissue remaining on the ventral aspect of the verte-
bralbodyofinterest and those aboveand belowis cleared
from end plate to end plate using monopolar cautery,
curettes, and rongeurs. This will expose the position of the
rostral and caudal vertebral bodies, for future placement of
the anterior plating system. Performing this preparation at
this time is easier because bone bleeding from the corpec-
tomy site has not begun. Furthermore, any increases in ex-
posure that are necessary can be done at this time and the
retractors may be left in place while the remainder of the
operation is being completed. Havingto obtain further expo-
sure, prepare instrumentation sites, or replace retractors af-
ter decompression tends to cause delay and inefficiency.
After the diskectomies are completed and rostral, caudal,
and lateral borders of the decompression have been iden-
tified, bony removal is performed using a high-speed drill
with a 3 or 4 mm cutting bit (Fig. 43-2). It may be appro-
priate to use a Leksell rongeur to initiate the corpectomy.
Care must be taken during the corpectomy to maintaina
rectangular configuration to the region of decompression.
Creating this shape will both insure adequate decompres-
sion has been done as well as create an excellent graftre-
cipient
site.
After
the
anterior
cortical
bone and
medullary
bone are removed,
some surgeons prefer
changing to a diamond bur to facilitate removal of the
posterior
cortex of bone. The posterior
cortical bone
should be drilled completely off or down to a very thin
plate that can easily be removed using a curette or a 1to2
mm Kerrison rongeur (Fig. 43-3). The posterior longitudi-
nalligament (PLL)is then lifted with a nerve hook whilea
small Kerrison rongeur is used to bite off PLLand bone
fragments. Incases of infection or tumors that havebeen
radiated, the distinction between the PLLand the duracan
Figure43-2
After both disks are removed and the borders ofthe decompression identified the bone isremoved using a high-speed drill.Care
must be taken during the corepectomy
to create and maintain a rectangular
configuration
in the region of decompression
to ensure an excellent
graft recipient site.

43
Vertebrectomyfollowing AnteriorApproaches
329
Figure43-3
Using a 1 to 2 mm Kerrison rongeur, the remaining
thin plate of the posterior
cortical
bone is easily removed.
A nerve hook is used to
liftthe posterior longitudinal
ligament
(PLL) while a small Kerrison rongeur
removes the PLLand remaining
bone.
bevery difficult.
If adequate decompression has been as-
sured,the potential
benefits
of further
tumor
removal
must be weighed
against the risk of problematic
cere-
brospinal fluid leakage. The adequacy of the decompres-
sionis judged by carefully
sliding the blunt nerve hook
under the superior
and inferior
vertebral
bodies. Ade-
quatedecompression of the neural foramina is performed
using a similar
technique
in the appropriate
locations.
Bleedingmay also be encountered from large veins in the
lateral gutters of the spinal canal and may be managed
with standard hemostatic agents.
Suggested Readings
End Plate Preparation
After decompression of the thecal sac has been performed,
one should insure the decompression site is an adequate
graft recipient
site. This may involve preparing the end
plates by removing cartilagenous end plate, or by slightly
drilling the end plates to insure they are parallel. Subchon-
dral cortical bone should be preserved to adequately hold
the bone graft in place for fusion to occur. Drilling or enter-
ing into the medullary bone of the adjacent segment will in-
creasethe risk of subsidence of the load-bearing strut graft.
Rothman
RH, Simeone
FA. The Spine.
3rd ed. Philadelphia:
WB Saunders:
1995
Schmidek
HH. Sweet
WHo eds.
Operative
Neurosurgical
Techniques:
Indications,
Methods.
and
Results.
3rd
ed. Philadelphia:
WB Saunders:
1995
Sundaresan N.Shah J. Foley KM.et al. An anterior approach to the upper thoracic vertebrae. JNeurosurg 1984:61:686-690

44
Anterior Reconstructionfollowing
Decompressionvia Anterior Approaches
Srinath Samudrala and LarryT.Khoo
.
Advantages
.
Disadvantages
.
Objectives
.
Typesof Strut Grafts
Methyl Methacrylate
Autograft versus Allograft
.
Surgical Technique
Preparation of Corpectomv Site for Grafting
EndPlate Removal
KyphosisCorrection
Anterior Instrumentation
Reconstructionof the cervicothoracic junction is mandatory
after most anterior decompressive procedures in this area.
Thejunction of the relatively immobile thoracic spine and
the highly mobile cervical spine causes significant forces to
occur in this region. In patients with trauma, tumor, or in-
fection who have had significant destruction of their nor-
mal stabilizingstructures, further destabilization by decom-
pression cancreate a highly unstable spine if reconstruction
is not performed.
.
Advantages
.
Instrumentationcan be placedduring the decompres-
sive procedure.
.
Disadvantages
.
Lack of adequate fluoroscopic imaging makes screw
placement more difficult.
.
Kyphotic curvature of this region requires bending of
some plates.
330
. Objectives
The primary goal of reconstruction
is to achieve a stable
spine that preserves neurological integrity, is not painful,
and maintains alignment without deformity (Table44-1).
Re-creation of the anterior column load-bearing systemis
the single most important factor of this reconstruction.Loss
of anterior column support that occurs with traumatic frac-
ture, pathological fracture from neoplastic involvement,or
iatrogenic decompression will lead to the developmentof
kyphosis by virtue of the center of gravity of the bodybeing
anterior to the vertebrae. Instrumentation
will allowgraft
incorporation by providing immediate stability and anopti-
mal environment for fusion. Anterior instrumentation isad-
vantageous because it can be placed during the same opera-
tion and because of the inherent difficulties with posterior
instrumentation
in this area. Ifanterior instrumentation is
not possible or is inadequate, posterior instrumentation op-
tions can be considered to impart the necessary stability
until fusion has occurred (Table 44-2). Some type ofinstru-
mentation is necessary because of the high forces imparted
to this portion of the spine and the relative difficultyinim-
mobilizing this segment with external orthoses.

44
Anterior Reconstruction following Decompression
331
Table44-1
Goalsof ReconstructiveProceduresinthe
Cervicothoracic Spine
Correction of kyphosis, lordosis
Correction of translation
Provide anterior
column
support
Provide immediate
stability
with instrumentation
Table44-2
PosteriorConstructsto SupplementAnterior
Strut Grafts
Sublaminarwires under cervical, thoracic lamina, with Luque rod
Lateralmassscrews,plates, incervicallateralmasses, thoracic pedicles
Pediatriclaminar hooks in cervical spine, thoracic spine with rods
. Typesof Strut Grafts
Thetype of pathology that is encountered will dictate the
optimalgraft material to be selected. Options for grafts are
numerous (Table 44-3).
The main dichotomy
in grafting
materialis between
bone or methyl methacrylate.
MethylMethacrylate
Ingeneral,methyl methacrylate may be used in patients
withneoplasmwho have a limited life expectancy(1 <
year).Itcaneither be inserted as a preshaped blockor be
heldin placewith Steinmannpins or Silastictubing (Fig.
44-1A,B).The advantage of methyl methacrylate is that it
resistsdestruction by tumor. Because it is not a biological
material,tumor regrowth may occur around the strut but
will not undermine its load-resisting capacity. Methyl
Table44-3
ChoicesofGraftMaterial
Graft
Advantages
Disadvantages
Autograftiliaccrest
Readilyavailable
High fusion rate
Probablybest in infection
Allograftfibula
Readilyavailable
No donor site morbidity
Clavicle
Mesh
Readilyavailable
Usefulfor long segments
Variablesizesandshapes
Readilyavailable
Resiststumor invasion
Methylmethacrylate
methacrylate is thought to lose its ability to provide com-
pressive support after approximately 1 year. However. it has
been used occasionally for longer periods in slow-growing
tumors. The solidification of methyl methacrylate
is an
exothermic reaction and generates significant heat. Care
must be taken to prevent its contact with the dura during
the hardening period to prevent thermal damage to the
spinal cord. This may be difficult with the spinal cord in a
gravity-dependent
position during anterior approaches to
the cervicothoracic spine.
Autograft versus Allograft
Autograft iliac crest. clavicle. or rib is perhaps the optimal
graft material in patients who have adequate bone stock.
These materials have the greatest likelihood of fusion and
may resist infection better than allograft or metal implants:
The size. axial load-resisting properties. relative percentage
of cortical versus cancellous bone, and donor site morbidity
must all be considered in determining the most suitable
type of autograft. Claviclethat is harvested during the expo-
sure is often adequate for a single-level corpectomy defect.
Iliac crest is suitable for one- or two-level corpectomy de-
fects (Fig. 44-2). Forlonger defects or in large patients rib
graft should be considered. Rib grafts in patients of slight
build may be very thin and may not provide anterior col-
umn support. They may be combined so that two or three
grafts can be placed into the same corpectomy site. The cur-
vature of a rib may also be very suitable for the gentle
kyphosis of the upper thoracic spine.
Donor site morbidity consisting of blood loss. infection
risk, extended operative time. and chronic pain should be
considered in the decision to obtain autograft. When these
risks appear to exceed the relative benefits of autograft.
fibular allograft is appropriate.
Cannot be used for long
segments (>than two levels)
May bedestroyed bytumor
Donor site morbidity
Decreasedfusion versusautograft
Maytelescope in osteoporotic bone
May bedestroyed bytumor
May bedestroyed bytumor
Maytelescope in osteoporotic bone
Requiresautograft
Willnot fuse
Not suitable with infection

..
332
CervicothoracicJunction: Anterior Approach
Figure 44-1
Amethyl methacrylate
graft can (A) be inserted into the vertebral body as a preshaped
block or (8) be held in place with Steinmann
pins or Silastic tubing.
Figure 44-2
Iliaccrest graft materialcanbe
used for a one- or two-level
corpectomy.