An anterior approach to spinal pathology of the upper thoracic spine through a partial manubriotomy

Surgical pathology in the region of the upper thoracic spine (T1-4) is uncommon compared with other regions of the spine. Often times posterior and posterolateral approaches can be used, but formal anterior decompression often requires a low anterior cervical approach combined with a sternotomy, which yields significant perioperative morbidity. The authors describe a modified low anterior cervical dissection combined with a partial manubriotomy that they have used to successfully access and decompress anterior pathology of the upper thoracic spine. Their modified approach spares the sternoclavicular joints and leaves the sternum intact, decreasing the morbidity associated with these added procedures.     

颈胸段脊柱肿瘤的外科治疗

目的 观察比较不同手术入路方法治疗颈胸段脊柱肿瘤的疗效。方法 本组９例,共１０例次。对其中４例肿瘤同时累及椎体及椎体后部结构的患者,选择前后路同期手术,经前路切除肿瘤、椎管减压及钢筋骨水泥或前路钢板固定,并同期行后路肿瘤切除术,其中１例行Ｌａｕｑｕｅ棒固定;对４例肿瘤仅累及椎体者,选择经前路切除肿瘤、椎管减压、钢筋骨水泥固定;另２例肿瘤单纯累及椎体后部结构者,经后路行肿瘤切除和椎管减压术。术后４例     

Anterior transsternal approach to the upper thoracic spine.

Cervicothoracic junction and upper thoracic spine down to T4 can be reached through anterior approach via sternotomy. Transsternal approach is the best route to gain access to lesions localized within vertebral bodies of the upper thoracic spine allowing for their resection, interbody fusion and replacement with bone cement. Consecutive modifications of transsternal approach evolved towards less extensive osteotomy from full median sternotomy, through manubriotomy with clavicle resection to partial lateral manubriotomy. Less extensive modifications provide limited lateral exposure of the spine and are more demanding technically. We present two cases of the upper thoracic spine tumours operated on through full medial sternotomy. We believe that median sternotomy has several advantages over less extensive modifications: it is technically simple to perform approach for trained thoracic surgeon, safer as it provides better exposure of the mediastinum and thus sufficient control of great vessels including subclavian ones, gives better exposure of T3, T4 and even T5 vertebral bodies, allows perpendicular sight and attack to anterior surface of the upper thoracic spine and therefore good visualizing of the posterior longitudinal ligament and dura, do not destabilize shoulder girdle nor affect function of the upper limb. Additional caudal exposure of the thoracic spine as down as T5 can be obtained by dissecting a plane between the brachiocephalic vein, vena cava superior and ascending aorta.     

Approaching the upper thoracic vertebrae without sternotomy or thoracotomy: a radiographic analysis with clinical application

STUDY DESIGN: The distribution of the lowest vertebra tangential to the suprasternal notch and the lowest intervertebral disc visualized above the sternum was determined on magnetic resonance imaging (MRI) studies. The method is illustrated in seven patients undergoing upper thoracic spinal reconstruction to define a surgical approach without sternotomy or thoracotomy. OBJECTIVES: The relation of the sternal notch to thoracic vertebrae was examined by MRI to estimate the thoracic level approachable anteriorly without sternotomy. SUMMARY OF BACKGROUND DATA: Upper thoracic spine (T1-T4) visualization is considered difficult. The thoracic vertebrae that can be visualized anteriorly without sternotomy is unknown. METHODS: The vertebral level tangential to the suprasternal notch and the lowest intervertebral disc visualized in its entirety above the sternum was determined from 106 consecutive midsagittal cervicothoracic MRI studies. The method was evaluated in seven patients to illustrate application of a low suprasternal, lateral extracavitary, or transpedicular approach to performing upper thoracic reconstruction. RESULTS: The midportion of the T3 vertebra is often above the sternal notch, whereas the trajectory of the T1-T2 intervertebral disc is usually rostral to the sternum. All four patients with disease above the sternal notch on MRI underwent a low left suprasternal approach, whereas three others were treated with a lateral extracavitary or transpedicular approach. No patient worsened neurologically and all ambulated independently after surgery. CONCLUSIONS: Upper thoracic vertebrae can be exposed without sternotomy or thoracotomy by a low left suprasternal approach. Midsagittal cervicothoracic MRI can identify the thoracic vertebrae above the sternum, thereby determining whether a low suprasternal approach is feasible. Otherwise, a lateral extracavitary or transpedicular approach can be used to avoid sternotomy or thoracotomy.     

A bioresorbable osteosynthesis device can induce an earlier sternal fusion after median sternotomy

OBJECTIVES We examined the impact of the bioresorbable osteosynthesis sternal pin (Super Fixsorb 30) on sternal healing after median sternotomy. METHODS Sixty-three patients who underwent aortic surgery through median sternotomy between January 2006 and March 2009 were analysed. Sternal pins were utilized in 36 patients in addition to the standard closure of the sternum with Ethibond sutures (Group A), and 27 patients received no pins with the standard Ethibond sternal closure (Group B). The occurrence of transverse sternal dehiscence, anterior-posterior displacement and complete fusion of the sternum were evaluated by a computed tomography scan. The cross-sectional cortical bone density area (CBDA) of the sternum was examined to evaluate the osteoconductivity of the sternal pin over a 12-month period. RESULTS There was no sternal displacement (0%) observed in Group A at discharge. Meanwhile, five displacements (18.5%) were observed in Group B (P?=?0.007). The complete sternal fusion rates at 12 months postoperatively were 100% in Group A, and 21.6% in Group B (P?相似文献   

胸椎后纵韧带骨化症术后临床疗效及其相关因素分析

目的探讨胸椎后纵韧带骨化症减压融合术后的临床疗效,及其相关因素。方法 2000年1月～2011年1月,本院收治胸椎后纵韧带骨化症患者64例,其中男39例,女25例,年龄为42～67岁,平均54.1岁。采用后路椎板广泛切除、减压、植骨融合治疗36例,采用前路减压、植骨融合治疗12例,后外侧经关节突减压植骨融合9例,前后路联合减压植骨融合7例。评估患者的年龄,病程,影像学表现,病变类型,手术方式,术前合并疾患,及术后并发症和手术疗效的关系。手术疗效采用日本骨科学会（Japanese Orthopaedic Association,JOA）评分及其改善率进行判定。结果所有患者均获随访,随访时间为1～12年,平均4.6年。术前JOA评分为4.5±1.9分,末次随访时7.8±2.1分,改善率为（48.4±38.1）%。后路椎板广泛切除、减压、植骨融合组为（37.6±36.8）%,前路减压、植骨融合组为（62.9±32.6）%,后外侧经关节突减压植骨组为（30.8±29.2）%,前后路联合减压植骨融合组为（59.5±39.1）%。患者的术前病程、年龄、手术方式、MRI T2加权像信号改变及是否合并糖尿病对术后疗效有显著影响（P〈0.05）。30例（46.9%）患者术后合并1种或多种并发症：17例患者术后神经功能恶化,12例患者合并脑脊液漏,3例患者硬膜外血肿形成,5例合并肺部感染。结论对于胸椎后纵韧带骨化症外科治疗可以获得较好的疗效,患者术前病程、年龄、手术方式、MRI T2加权像信号改变及是否合并糖尿病是影响手术疗效的主要因素。     

Single-stage posterolateral transpedicle approach for spondylectomy, epidural decompression, and circumferential fusion of spinal metastases

STUDY DESIGN: Retrospective review of prospectively maintained institutional spine database. OBJECTIVES: To assess the pain, neurologic, and functional outcome of patients with metastatic spinal cord compression using a posterolateral transpedicular approach with circumferential fusion. SUMMARY OF BACKGROUND DATA: Patients with spinal metastases often have patterns of disease requiring both an anterior and posterior surgical decompression and spinal fusion. For patients whose concurrent illness or previous surgery makes an anterior approach difficult, a posterior transpedicular approach was used to resect the involved vertebral bodies, posterior elements, and epidural tumor. This approach provides exposure sufficient to decompress and instrument the anterior and posterior columns. METHODS: During the past 15 months, 25 patients were operated on using a posterolateral transpedicular approach. The primary indications for surgery were back pain (15 patients) and neurologic progression (10 patients). All patients had vertebral body disease, and 21 patients had high-grade spinal cord compression from epidural disease as assessed by magnetic resonance imaging. Seven patients underwent preoperative embolization for vascular tumors. In each patient, the anterior column was reconstructed with polymethyl methacrylate and Steinmann pins and the posterior column with long segmental fixation. RESULTS: All patients achieved immediate stability. Pain relief was significant in all 23 patients who had had moderate or severe pain. Neurologic symptoms were stable or improved in 23 patients. One patient with an acutely evolving myelopathy was immediately worse after surgery, and one patient had a delayed neurologic worsening, progressing to paraplegia. CONCLUSIONS: The posterolateral transpedicular approach provides a wide surgical exposure to decompress and instrument the anterior and posterior spine. This technique avoids the morbidity associated with anterior approaches and provides immediate stability. Vascular tumors may be removed safely after embolization. Patients can be mobilized early after surgery.     

Treatment of tumors of the cervical spine

In 34 patients with primary or metastatic tumors of the cervical spine over a ten-year period, the presenting symptom was neck pain. Eleven patients demonstrated evidence of radiculopathy, one a myelopathy, and three a combined myeloradiculopathy. Surgical stabilization, combined in eight cases with cord decompression, successfully relieved pain and prevented further neurologic deterioration in 17 of 18 patients with radioresistant tumors. Complications included two patients who were treated with short posterior fusions displacing as a result of tumors progressing above and below the fusion, and one patient in whom an anterior methacrylate mass became dislodged and appeared to jeopardize the esophagus. Methacrylate was used to augment the grafts posteriorly to facilitate early mobilization without the need for a halo splint. Mean patient survival was not significantly increased by surgical intervention (26 weeks vs. 20 weeks). While most lesions of the cervical spine can best be managed by nonoperative methods, in selected patients long posterior fusion with wires and methacrylate appears successful in relieving pain, halting progress of neurologic deficits, and facilitating early mobilization.     

EUROSPINE 2016 FULL PAPER AWARD: Wire cerclage can restore the stability of the thoracic spine after median sternotomy: an in vitro study with entire rib cage specimens

Purpose

The influence of the anterior rib cage on the stability of the human thoracic spine is not completely known. One of the most common surgical interventions on the anterior rib cage is the longitudinal median sternotomy and its fixation by wire cerclage. Therefore, the purpose of this in vitro study was to examine, if wire cerclage can restore the stability of the human thoracic spine after longitudinal median sternotomy.

Methods

Six fresh frozen human thoracic spine specimens (C7–L1, 56 years in average, range 50–65), including the intact rib cage without intercostal muscles, were tested in a spinal loading simulator and monitored with an optical motion tracking system. While applying 2 Nm pure moment in flexion/extension (FE), lateral bending (LB), and axial rotation (AR), the range of motion (ROM) and neutral zone (NZ) of the functional spinal units of the thoracic spine (T1–T12) were studied (1) in intact condition, (2) after longitudinal median sternotomy, and (3) after sternal closure using wire cerclage.

Results

The longitudinal median sternotomy caused a significant increase of the thoracic spine ROM relative to the intact condition (FE: 12° ± 5°, LB: 18° ± 5°, AR: 25° ± 10°) in FE (+12 %) and AR (+22 %). As a result, the sagittal cut faces of the sternum slipped apart visibly. Wire cerclage fixation resulted in a significant decrease of the ROM in AR (?12 %) relative to condition after sternotomy. ROM increased relative to the intact condition, in AR even significantly (+8 %). The NZ showed a proportional behavior compared to the ROM in all loading planes, but it was distinctly higher in FE (72 %) and in LB (82 %) compared to the ROM than in AR (12 %).

Conclusions

In this in vitro study, the longitudinal median sternotomy resulted in a destabilization of the thoracic spine and relative motion of the sternal cut faces, which could be rectified by fixation with wire cerclage. However, the stability of the intact condition could not be reached. Nevertheless, a fixation of the sternum should be considered clinically to avoid instability of the spine and sternal pseudarthrosis.

     

Surgical management for upper thoracic spine tumors by a transmanubrium approach and a new space

The anterior aspect of the upper thoracic spine is a difficult region to approach in spinal surgery. Many vital structures including osseus, articular, vascular and nervous ones hinder the exposure. With increasing frequency, spine surgeons are being asked to provide decompression and stabilization in patients with spinal tumors .The traditional exposure is between the esophagus and trachea medially and the left common carotid or the brachiocephalic artery (BCA) laterally, and the disadvantages were that the ligation and section of the left innominate vein is proposed to reach T4 and the injury of the thoracic duct could occur. The right space of the BCA or the ascending aorta (AA) (the exposure between the right brachiocephalic vein and the BCA or between the AA and superior caval vein) is recommended in exposing the upper thoracic vertebrae; this new space is technically feasible; the exposure is sufficient for vertebral body resection and reconstruction and fixation. Twenty-eight patients with upper thoracic spine tumors underwent surgery by the use of this new space between June 2000 and October 2005. A strut graft was fixed anteriorly after decompression of the spinal cord. Levels C7–T5 can be well exposed through this new space, allowing complete vertebral body removal at level T1–T4. After body removal, the posterior longitudinal ligament is well exposed, allowing complete release of the spinal cord. Curettage was performed in one case of aneurysmal bone cyst and three cases of bone giant cell tumors. For other tumors, vertebrectomies or sagittal resections were performed. Four patients underwent surgery by a combination of anterior and posterior approach.     

The application of poly (L-lactide) sternal coaptation pins for median sternotomy

Poly (L-lactide) sternal coaptation pin has been developed as an assistant material for the fixation of sternum. We used the novel material to a patient who underwent median sternotomy. A 21-year-old male was suspected to have invasive thymoma in the anterior mediastinum. The median sternotomy was indicated as an approach for the resection of tumor. Tumor was completely resected and there was no invasion to sternum. For the fixation of sternum, three poly (L-lactide) sternal coaptation pins were inserted in the bone marrow of sternum and five stainless steel wires were used as conventional procedure. Sternum was adapted without slippage and no complication from the material was observed in the post-surgical period. The application of poly (L-lactide) sternal coaptation pin is a good option for ensuring the fixation of sternum.     

The unstable thoracic cage injury: The concomitant sternal fracture indicates a severe thoracic spine fracture

IntroductionThe thoracic cage is an anatomical entity composed of the upper thoracic spine, the ribs and the sternum. The aims of this study were primarily to analyse the combined injury pattern of thoracic cage injuries and secondarily to evaluate associated injuries, trauma mechanism, and clinical outcome. We hypothesized that the sternal fracture is frequently associated with an unstable fracture of the thoracic spine and that it may be an indicator for unstable thoracic cage injuries.Patients and methodsInclusion criteria for the study were (a) sternal fracture and concomitant thoracic spine fracture, (b) ISS ≥ 16, (c) age under 50 years, (d) presence of a whole body computed-tomography performed at admission of the patient to the hospital. Inclusion criteria for the control group were as follows: (a) thoracic spine fracture without concomitant sternal fracture, (b)–(d) same as study cohort.ResultsIn a 10-year-period, 64 patients treated with a thoracic cage injury met inclusion criteria. 122 patients were included into the control cohort. In patients with a concomitant sternal fracture, a highly unstable fracture (AO/OTA type B or C) of the thoracic spine was detected in 62.5% and therefore, it was significantly more frequent compared to the control group (36.1%). If in patients with a thoracic cage injury sternal fracture and T1–T12 fracture were located in the same segment, a rotationally unstable type C fracture was observed more frequently. The displacement of the sternal fracture did not influence the severity of the concomitant T1–T12 fracture.ConclusionsThe concomitant sternal fracture is an indicator for an unstable burst fracture, type B or C fracture of the thoracic spine, which requires surgical stabilization. If sternal and thoracic spine fractures are located in the same segment, a highly rotationally unstable type C fracture has to be expected.     

前路减压植骨内固定治疗胸腰椎爆裂性骨折

目的探讨前路减压植骨融合内固定手术在治疗胸腰椎爆裂性骨折的疗效。方法回顾性分析2000年5月～2005年3月前路减压植骨融合內固定治疗胸腰椎爆裂性骨折58例。骨折节段—单椎体骨折:T101例,T114例,T1213例,L118例,L211例,L32例;双椎体骨折:T12与L16例,L1与L23例。结果平均随访13.5个月,按Frankel分级评定神经功能恢复1级以上。影像学检查比较,未发现明显的矫正度丢失。植骨块位于中央、己融合,无假关节形成及內固定失败。结论前路减压植骨内固定治疗胸腰椎爆裂性骨折,减压更彻底、更安全,能较好地重建前中柱稳定性。     

经胸骨柄“U”形切除入路治疗上胸椎爆裂骨折并截瘫

目的探讨经胸骨柄“U”形切除入路治疗上胸椎爆裂骨折的可行性及临床疗效。方法12例上胸椎爆裂骨折并截瘫患者，全部采用经胸骨柄“U”形切除入路行伤椎次全切除减压、植骨、颈椎前路钢板内固定术。结果随访1～7年，椎间植骨均愈合好，内固定无松动、断裂，无切口感染、颈前血肿、窒息、气胸、乳糜漏、肺部感染等并发症。9例术后感觉、运动神经功能均有不同程度改善。Frankel分级：术前A级6例术后恢复至B级1例、C级2例、3例无明显改善；B级1例恢复至C级；C级3例恢复至D级2例、E级1例；D级2例恢复至E级。结论经胸骨柄“U”形切除入路解决了低位下颈椎前方入路因胸骨柄遮挡带来的操作不便，又可避免切断胸骨、锁骨的相关并发症。通常能显露至T4，并能在直视下完成T3及以上椎体的前方减压、植骨和钢板内固定，是治疗上胸椎爆裂骨折理想的手术入路。     

Cervicomanubrial route for the ventral upper thoracic spine: technical note about six cases

Ventrolateral cervicotomy provides a narrowed working space for surgical management of upper thoracic spine. We report our experience about ventral upper thoracic spinal cord decompression with reconstruction and plating via the cervicomanubrial route. Six patients (24 to 75 years old) were operated on by the same operator (LN) by cervicomanubriotomy from 2002 to 2007 for upper thoracic spinal cord compression (one case of Pott's disease, three cases of metastases, one fracture, one invasive hemangio-epithelioma), with a good outcome in five patients. Lesions were located from the cervicothoracic junction down to the fourth thoracic vertebra (T4). In all cases, anterior spinal cord decompression, strut graft reconstruction (iliac bone in two cases, cement in four cases) and osteosynthesis were performed. In two cases, a second stage posterior decompression with fixation was performed. The approach begins by a left sided anterior cervicotomy, medial to the sternocleidomastoid muscle and lateral to the trachea and esophagus, associated with division of the infrahyoid muscles close to their insertion at the upper thoracic outlet followed by osteotomy of the manubrium sterni. Then, division of the thyropericardic fascia and thymus, control of the brachiocephalic vein, control of the thoracic lymphatic duct and the horizontal thoracic aorta are performed. The ventral part of fifth cervical vertebra body down to T4 is then exposed between the left primitive carotid artery laterally, the esophagus medially and the thoracic aorta caudally. Compared to total sternotomy without or with clavicle resection, cervicomanubriotomy seems to be a less aggressive, safe and reliable procedure.     

胸腔镜辅助下胸椎、上腰椎前路手术的体会

目的 探讨胸腔镜技术在胸、腰椎前路手术的适应证、操作要点以及单肺或双肺通气麻醉的选择。方法 对5例结核病人行胸腔镜下结核病灶清除术，其中2例同时行自体髂骨植骨术，1例以自固化磷酸钙人工骨(CPC)植入；对3例爆裂性骨折截瘫及1例L1陈旧性爆裂骨折并马尾综合征病人进行脊髓减压、自体髂骨植骨、钢板螺丝钉内固定术。结果 全部病例都得到随访，术后切口一期愈合，X光、CT检查也都显示病灶清除彻底，脊髓减压充分，复位满意，内固定可靠，位置良好。结论 胸椎、上腰椎结核或骨折，不论是否并发脊髓、马尾神经压迫的病例，均适宜在胸腔镜辅助下进行病灶清除、脊髓减压、脊柱前路内固定术。     

Sternal re-entry using the retractor for harvesting internal thoracic artery

The number of redo cardiac operations, especially coronary artery bypass grafting (CABG), has recently been increasing mainly due to the failure of saphenous vein grafts. Re-opening a median sternotomy is troublesome, because of possible adhesion of the heart to the sternum. Preoperative computed tomography is quite useful and helpful in determining the degree of the adhesion of the heart and ascending aorta to the back of the sternum. We report here a safe and useful technique for sternal re-entry using a retractor for harvesting the internal thoracic artery (ITA). When re-opening a median sternotomy the incision is made to the sternal wires; the wires are then cut and removed. Small rake retractors, which are connected to the ITA retractor, are hooked to both ends of the left side of the sternum. The ITA retractor is gently wound up to lift up the sternum. An oscillating saw is then applied to divide the anterior table of the sternum. When the posterior table of the sternum is carefully divided, the left side of the sternum is automatically elevated slightly. Complete division of the sternum can be confirmed by this slight elevation. If the left side of the sternum is elevated a little bit more by the ITA retractor, the dissection of the adhesion between the sternum and the heart can be performed without assistance. This technique is most beneficial for a case of redo CABG with the use of the left ITA, but it can be applied in any patients who previously underwent median sternotomy.     

Role of video-assisted thoracic surgery for the treatment of myasthenia gravis: extended thymectomy by median sternotomy versus the thoracoscopic approach with sternal lifting

The role of video-assisted thoracic surgery (VATS) thymectomy is still being studied, and many surgeons remain skeptical of the value of this recent option. We made a retrospective evaluation to ascertain whether VATS-extended thymectomy is as reliable as standard median sternotomy in the treatment of myasthenia gravis (MG) and whether the endoscopic procedure presents any advantages for patients. Eighteen consecutive patients requiring extended thymectomy for MG were treated between April 1997 and September 2003 at our hospital. Nine patients received VATS-extended thymectomy, and the remaining nine patients received standard extended thymectomy by sternotomy. In the VATS group, the anterior mediastinal space was well visualized by sternal lifting. The mean operative time was 268.3 +/- 51.1 minutes in the VATS group and 177.3 +/- 92.5 minutes in the sternotomy group. Operative time was significant longer in the VATS group than in the sternotomy group (P < 0.05). The mean operative bleeding was 68.6 +/- 47.8 ml in the VATS group and 154.1 +/- 109.0 ml in the sternotomy group. Operative bleeding was significantly less in the VATS group than in the sternotomy group (P < 0.05). There was no significant difference between the two groups with regard to postoperative duration of chest tube or the level of serum C-reactive protein on the first operative day. There was a downward trend in nicotinic acetylcholine receptors antibody levels after thymectomy compared with before thymectomy in both groups. VATS thymectomy should be considered a valid alternative to the established approaches aimed at achieving a "curative thymectomy" in patients with MG.     

胸椎骨折39例治疗分析

目的探讨胸椎骨折的损伤特点及治疗。方法对39例胸椎骨折患者的临床资料作回顾性分析。稳定压缩骨折10例单纯保守治疗,不稳定压缩骨折15例行后路减压植骨融合加椎弓根螺钉内固定,爆裂骨折10例行前路减压植骨融合Z-plate前路钢板内固定;骨折脱位3例及爆裂脱位1例采用前后联合入路。结果全部病例均获随访,时间6~24个月,平均12个月。神经功能明显改善,术后6个月植骨融合率达100%,未见内植物松动及断裂现象。结论胸椎骨折的治疗应根据骨折的类型及稳定性,对于不稳定骨折应行融合及内固定手术,合并有不完全性脊髓损伤者还应同时行减压手术。     

Circumspinal decompression for thoracic myelopathy due to combined ossification of the posterior longitudinal ligament and ligamentum flavum

Ossification of the posterior longitudinal ligament (OPLL) combined with ossification of the ligamentum flavum (OLF) in the thoracic spine can result in serious myelopathy, leading to circumferential compression of the spinal cord in advanced stages of the disease. The authors performed circumspinal decompression (circumferential decompression of the spinal cord) on these patients. This operation consists of two steps: posterior and lateral decompression of the spinal cord by removal of the OLF (first step) and anterior removal of the OPLL for anterior decompression (second step), followed by interbody fusion. In the first step, two deep parallel gutters, covering the extent of the OPLL to be removed anteriorly, are drilled down from the rear into the vertebral body along both sides of the dura to easily and safely remove the OPLL anteriorly at the second step. In the second step, the surgical approach varies according to the affected level; costotransversectomy in the upper thoracic spine and standard thoracotomy in the middle or lower thoracic spine. According to the authors, circumspinal decompression is not an easy procedure, but from their results in 10 patients, they identify it as a radical and promising surgical procedure.