Anterior approach to the second thoracic vertebral body for surgical treatment (vertebrectomy, bone grafting, and titanium alloy plate fixation)

Anterior transsternal approach for a lesion in the upper thoracic vertebral body

OBJECT

Access to the upper thoracic vertebrae has been hampered by numerous anatomical structures and is further impaired by the transition from cervical lordosis to thoracic kyphosis. Therefore, the authors endeavored to study an anterior transsternal approach for upper thoracic disease (T1–4).

METHODS

Fifty-four patients with upper thoracic disease underwent anterior decompression and fusion with sternotomy. Ages in the 33 men and 21 women ranged from 37 to 69 years (average 49 years). Before surgery, there were 7 patients with Frankel Grade B function, 17 with Grade C, 21 with Grade D, and 9 with Grade E. For a T-1 and T-2 lesion, the authors used “inside window of the brachiocephalic artery”: the brachiocephalic artery and right arteria carotis communis were retracted to the right, and the tracheoesophageal sheath was retracted to left. For a T-3 and T-4 lesion, the authors used the “outside window of the brachiocephalic artery”: the trachea, esophagus, and brachiocephalic artery were retracted to the left, the proximal portion of the right innominate vein was retracted to the right, and the left innominate vein was retracted inferolaterally. The patients were followed up for 24–48 months.

RESULTS

The surgery was successful. The operation time was 120–150 minutes, and bleeding during the operation was 300–800 ml. After surgery, pain resolved in all patients, and improvement in motor deficits was noted in those who had presented with radiculopathy or myelopathy. Postoperative histological examinations showed that 33 patients had tuberculosis, 14 had metastatic neoplasm, 5 had eosinophilic granuloma, and 2 had traumatic fracture. Four patients died of systemic metastatic cancer between 10 and 21 months after surgery. There was no serious approach-related postoperative complication and no breakage of screws or failure of the internal fixation during follow-up.

CONCLUSIONS

Upper thoracic vertebrae can be exposed with sternotomy. This approach can provide excellent access to a lesion.

Posterior 360-degree stabilisation of the upper thoracic spine: a technical note

PURPOSE

To describe a technique involving posterior 360-degree stabilisation of the upper thoracic spine: spinal cord decompression, posterior vertebral body replacement, and then posterior instrumentation and intercostal posterolateral vertebral stabilisation.

METHODS

Three men and 4 women aged 41 to 77 (mean, 58) years underwent posterior 360-degree stabilisation of the upper thoracic spine. Their indications for surgery were bone metastasis (n=5), burst fracture (n=1), and osteoporotic collapse with cord compression (n=1). Their clinical and radiological findings and treatment outcomes were retrospectively reviewed.

RESULTS

Pain status of all patients improved after surgery: 4 had severe and 3 had mild pain preoperatively; in 3 pain became minimal and 4 had none postoperatively. All patients except one had Frankel/American Spinal Injury Association scores of E after surgery indicating complete recovery of sensory and motor function. There were no complications related to surgery or instrumentation construct. At the time of review, one patient had died of old age 8.6 years after surgery and another from local recurrence and lung metastasis 5.7 years after surgery. All other patients were living.

CONCLUSION

One-stage posterior 360-degree stabilisation and vertebral body replacement is a useful technique for upper thoracic spine surgery.

Solitary bone and extramedullary plasmacytoma

Less than 5% of patients with a plasma cell dyscrasia present with a single bone (SBP) or extramedullary plasmacytoma (EMP) without evidence of systemic disease (normocalcemia, absence of anemia, preservation of uninvolved immunoglobulins, or renal disease attributable to myeloma). Diagnosis requires biopsy confirmation of a monoclonal plasma cell infiltrate from a single site. The treatment of choice for both entities is radiotherapy given with curative intent (> 4000 cGy) resulting in long term disease-free survival in approximately 30% of patients with SBP and 65% of patients with EMP.

Anterior Stabilization of the Upper Thoracic Spine via an “Interaortocaval Subinnominate Window”

Because of the limitations imposed by the thoracic cage and the paravertebral structures, anterior access to T3 remains a challenge, particularly for the application of anterior fixation devices. Specifically, the appropriate trajectory for the correct placement of T3 screws requires significant caudal access; this may necessitate the addition of a high-level thoracotomy to the traditional combined neck exposure/sternotomy approach to the cervicothoracic junction (ie, the "trap door" exposure). The authors describe a technique for the placement of the T3 screws of a T1-T3 spinal titanium alloy plate via an "interaortocaval subinnominate window" in a patient who underwent a T2 vertebrectomy and polymethylmethacrylate reconstruction. The case history, imaging studies, illustrations, and intraoperative photographs are presented. This novel technique allows for the optimal placement of anterior fixation devices in the upper thoracic spine without the need to extend the caudal exposure with an anterolateral thoracotomy.