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

Cervicodorsal spine tuberculosis-- surgical approach

Background

Tuberculosis (TB) of CT junction is uncommon (5 % of all spinal TB), and difficult to approach surgically in view of its deep location with sternum in front and scapula in the back. We present 7 consecutively treated cases of cervico-thoraccic TB for outcome of treatment and discuss rationale of choosing surgical approach.

Methods

Present study includes 7 freshly diagnosed cases of CT junction TB. Plain radiographs, sagittal reconstruction of CT spine that included sternum on CT/MRI was performed in all cases. Disc space below the distal healthy vertebrae was identified and a line parallel to disc space was drawn. If this line passes above suprasternal notch, it was inferred that this VB can be accessed by anterior cervical approach. If disease focus was at or below suprasternal notch level, manubriotomy/sternotomy was added for better visualization of the lesion.

Results

All seven cases were female, with mean age of 20 years (9-45 years). The vertebral lesion involved 2VB (n = 3), 3VB (n = 2) and >3 VB (n = 2). The average Cervico-thoracic kyphosis was 15° (range 10-25°). All 7 cases were operated for anterior decompression, kyphotic deformity correction and instrumented stabilization. Anterior cervical approach and manubriotomy/sternotomy approach was performed in three cases each. In two pan-vertebral cases we performed 360° procedure. Six cases have shown first sign of neural recovery within 3 weeks of surgery and almost complete neural recovery at 3 months follow-up while one case showed partial recovery. ATT was stopped after 12 months once healed stage was demonstrated on contrast MRI in all.

Conclusions

CT junction TB usually presents with severe kyphotic deformity/neural deficit. These cases require anterior decompression/corpectomy, deformity correction, gap grafting and instrumented stabilization with anterior cervical plate. Lesion with pan-vertebral disease is stabilized 360°. These lesions can be decompressed by lower anterior cervical approach with/without manubriotomy. The Karikari method was useful in deciding the need for manubriotomy to decompress the lesion.

The Transaxillary Approach as a Direct Route in the Management of Upper Thoracic Spine Pathology: A Technical Note with Case Series

This retrospective case series of prospective data aims to describe the transaxillary approach for the treatment of upper thoracic spine pathology. Various surgical techniques and approaches have been reported across the literature to address upper thoracic spine pathology, including the cervicothoracic approach, anterior transsternal approach, posterolateral approach, supraclavicular approach, and lateral parascapular approaches. These techniques are invasive. A minimally invasive, less morbid, and direct access approach to the pathology of the upper thoracic spine has not been reported in the literature. Patients with pathology affecting the first thoracic vertebra up to the sixth thoracic vertebra were classified into the upper thoracic spine group. Patients with pathology below the sixth thoracic vertebra were excluded. Patients not having a minimum follow-up of 12 months were also excluded. The study analyzed 18 patients. The mean preoperative modified Japanese Orthopedic Association score was 7.2±1.44, which improved to 10.16±1.2 (p<0.05). The majority (14/18) of the patients had an excellent outcome. Three patients had good outcomes, and one patient had a fair outcome. Five cases of intraoperative dural leak were recorded, and one patient had postoperative neurological deficit. The transaxillary approach is a safe, viable, muscle-sparing, and minimally invasive approach for ventral pathologies of the upper thoracic spine.

Anterior Access to the Cervicothoracic Junction via Partial Sternotomy: A Clinical Series Reporting on Technical Feasibility, Postoperative Morbidity, and Early Surgical Outcome

Surgical access to the cervicothoracic junction (CTJ) is challenging. The aim of this study was to assess technical feasibility, early morbidity, and outcome in patients undergoing anterior access to the CTJ via partial sternotomy. Consecutive cases with CTJ pathology treated via anterior access and partial sternotomy at a single academic center from 2017 to 2022 were retrospectively reviewed. Clinical data, perioperative imaging, and outcome were assessed with regards to the aims of the study. A total of eight cases were analyzed: four (50%) bone metastases, one (12.5%) traumatic instable fracture (B3-AO-Fracture), one (12.5%) thoracic disc herniation with spinal cord compression, and two (25%) infectious pathologic fractures from tuberculosis and spondylodiscitis. The median age was 49.9 years (range: 22-74 y), with a 75% male preponderance. The median Spinal Instability Neoplastic Score (SINS) was 14.5 (IQR: 5; range: 9-16), indicating a high degree of instability in treated cases. Four cases (50%) underwent additional posterior instrumentation. All surgical procedures were performed uneventfully, with no intraoperative complications. The median length of hospital stay was 11.5 days (IQR: 9; range: 6-20), including a median of 1 day in an intensive care unit (ICU). Two cases developed postoperative dysphagia related to stretching and temporary dysfunction of the recurrent laryngeal nerve. Both cases completely recovered at 3 months follow-up. No in-hospital mortality was observed. The radiological outcome was unremarkable in all cases, with no case of implant failure. One case died due to the underlying disease during follow-up. The median follow-up was 2.6 months (IQR: 23.8; range: 1-45.7 months). Our series indicates that the anterior approach to the cervicothoracic junction and upper thoracic spine via partial sternotomy can be considered an effective option for treatment of anterior spinal pathologies, exhibiting a reasonable safety profile. Careful case selection is essential to adequately balance clinical benefits and surgical invasiveness for these procedures.

"Cave-in" decompression under unilateral biportal endoscopy in a patient with upper thoracic ossification of posterior longitudinal ligament: Case report

Background

Thoracic ossification of the posterior longitudinal ligament (TOPLL) requires surgery for spinal cord decompression. Traditional open surgery is extremely invasive and has various complications. Unilateral biportal endoscopy (UBE) is a newly developed technique for spine surgery, especially in the lumbar region, but rare in the thoracic spine. In this study, we first used a different percutaneous UBE "cave-in" decompression technique for the treatment of beak-type TOPLL.

Methods

A 31-year-old female with distinct zonesthesia and numbness below the T3 dermatome caused by beak-type TOPLL (T2-T3) underwent a two-step UBE decompression procedure. In the first step, the ipsilateral lamina, left facet joint, partial transverse process, and pedicles of T2 and T3 were removed. In the second step, a cave was created by removing the posterior third of the vertebral body (T2-T3). The eggshell-like TOPLL was excised by forceps, and the dural sac was decompressed. All procedures are performed under endoscopic guidance. A drainage tube was inserted, and the incisions were closed after compliance with the decompression scope via a C-arm. The patient's preoperative and postoperative radiological and clinical results were evaluated.

Results

Postoperative CT and MR films conformed complete decompression of the spinal cord. The patient's lower extremity muscle strength was greatly improved, and no complications occurred. The mJOA score improved from 5 to 7, with a recovery rate of 33.3%.

Conclusion

UBE spinal decompression for TOPLL showed favorable clinical and radiological results and offers the advantages of minimal soft tissue dissection, shorter hospital stays, and a faster return to daily life activities.

Investigation of Radiologic Landmarks Used to Decide the Appropriate Surgical Approach for Upper Thoracic Ventral Degenerative Disorders

BACKGROUND

Ventral lesions of upper thoracic spinal cord due to degenerative diseases are rare and often have poor operative outcomes. Anterior decompression of the lesion is difficult because of the local anatomy. This retrospective study aimed to evaluate reproducible anatomic measurements for selecting the best surgical approach for anterior decompression of ventral lesions of upper thoracic spinal cord.

METHODS

Cases of anterior decompression of ventral lesions of upper thoracic spinal cord due to degenerative diseases at our institution from 2004 to 2015 were assessed. Several lines were drawn on magnetic resonance imaging and computed tomography scans of midsagittal sections of the upper thoracic spine to evaluate the most optimal approach for treating upper thoracic lesions. A line from the suprasternal notch to the vertebral body (suprasternal notch to vertebral body [SV] line) was accepted as baseline.

RESULTS

The caudal edge of the lesion was above the SV line in 10 cases, each of which was treated via an anterior approach without sternotomy. The caudal edge was below the SV line in 7 cases, 5 of which underwent surgery with the sternum-splitting or transthoracic approach. The other 2 lesions were approached via an obliquely deviated route without sternotomy. The SV line sometimes changed with patients' posture alterations.

CONCLUSIONS

The SV line, a useful landmark for upper thoracic lesions, is not sufficiently reliable because it changes according to the patient's posture. By leaning in the direction of the surgical microscope, more caudal upper thoracic lesions can be reached than when using the SV line as a surgical landmark.

Surgical management for middle or lower thoracic spinal tuberculosis (T5-T12) in elderly patients: Posterior versus anterior approach

BACKGROUND

Spinal tuberculosis accounts for more than 50% of bone tuberculosis cases. This study compared clinical, radiological and functional outcomes between anterior and posterior approaches for treatment of middle or lower thoracic spinal tuberculosis in elderly patients.

METHODS

We retrospectively examined middle or lower thoracic spinal tuberculosis (T5-T12) in patients over 65 years. All procedures included debridement, decompression, autologous bone graft and fixation. Surgical procedure, surgical duration, estimated blood loss during surgery and laboratory results were recorded. Pleural effusion volume, thoracic cavity volume, Oswestry Disability Index score, neurological status, radiological parameters and complication rate were evaluated.

RESULTS

No significant difference was found in surgical duration, blood loss, kyphosis angle correction, loss of correction, thoracic cavity volume, or complication rate between the two groups (P > 0.05). Average postoperative pleural effusion volumes were 605.9 ± 209.5 mL (377-1074 mL) and 262.9 ± 228.1 mL (0-702.4 mL) in the anterior and posterior groups, respectively (P = 0.004). Average hospitalization durations were 26.4 ± 10.5 days (17-53 days) and 19.2 ± 5.0 days (14-30 days) (P = 0.04). Average postoperative serum albumin levels were 24.19 ± 3.84 g/L (19-29.5 g/L) and 28.24 ± 2.52 g/L (24.4-31.6 g/L) (P = 0.01). No relapse or reinfection was observed in either group at the final follow-up. Surgical revision was not required in either group.

CONCLUSIONS

Both anterior and posterior surgeries can be used to treat middle or lower thoracic spinal (T5-T12) tuberculosis in elderly patients. In general, the posterior approach might be superior, especially for patients with poor general health.

Surgical approach and management outcomes for junction tuberculous spondylitis: a retrospective study of 77 patients

Background

Junction tuberculous spondylitis involves the stress transition zone of the spine and has a high risk of progression to kyphosis or paraplegia. Problems still exist with treatment for spinal junction tuberculosis. This study investigated the surgical approach and clinical outcomes of junction spinal tuberculosis.

Methods

From June 1998 to July 2014, 77 patients with tuberculous spondylitis were enrolled. All patients received 2–3 weeks of anti-tuberculous treatment preoperatively; treatment was prolonged for 2–3 months when active pulmonary tuberculosis was present. The patients underwent anterior debridement and were followed up for an average of 29.4 months clinically and radiologically.

Results

The cervicothoracic junction spine (C7-T3) was involved in 15 patients. The thoracolumbar junction spine (T11-L2) was involved in 39 patients. The lumbosacral junction spine (L4-S1) was involved in 23 patients. Two patients with recurrence underwent reoperation; the drugs were adjusted, and all patients achieved bone fusion. The preoperative cervicothoracic and thoracolumbar kyphosis angle and lumbosacral angle were 31.4 ± 10.9°, 32.9 ± 9.2°, and 19.3 ± 3.7°, respectively, and the corresponding postoperative angles were ameliorated significantly to 9.1 ± 3.2°, 8.5 ± 2.9°, and 30.3 ± 2.8°. The preoperative ESR and C-reactive protein level of all patients were 48.1 ± 11.3 mm/h and 65.5 ± 16.2 mg/L which decreased to 12.3 ± 4.3 mm/h and 8.6 ± 3.7 mg/L at the final follow-up, respectively. All patients that had neurological symptoms achieved function status improvement at different degrees.

Conclusion

For spinal tuberculosis of spinal junctions, anterior debridement, internal fixation, and fusion can be preferred and achieved. If multiple segment lesions are too long or difficult for operation of anterior internal fixation, combining posterior pedicle screw fixation is appropriate.

Local Spinal Cord Decompression Through a Full Endoscopic Percutaneous Transcorporeal Approach for Cervicothoracic Ossification of the Posterior Longitudinal Ligament at the T1-T2 Level

OBJECTIVE

To describe a percutaneous full endoscopic transcorporeal procedure to excise local ossification of the posterior longitudinal ligament (OPLL) lesions and decompress the spinal cord at the cervicothoracic transitional segment is safe and effective with respect to surgical complications.

METHODS

A 67-year-old woman presented with nuchal pain and numbness below the T2 dermatome for 3 months and a 2-week history of paraplegia. T1-T2 myelopathy and paraplegia caused by OPLL was diagnosed based on clinical presentation, computed tomography, and magnetic resonance imaging. An anterior percutaneous full endoscopic transcorporeal procedure addressed local OPLL and achieved local spinal cord decompression at T1-T2. After surgery, magnetic resonance imaging was repeated to evaluate degree of spinal cord decompression. Visual analog scale, Neck Disability Index, and Japanese Orthopaedic Association scores were evaluated at each follow-up.

RESULTS

The patient tolerated the full endoscopic operation successfully. Operative time was 225 minutes. On postoperative day 6, muscle strength of the bilateral lower extremities had progressed from grade 0/5 preoperatively to grade 2-/5 on the right and grade 2+/5 on the left. No surgery-related complications were discovered.

CONCLUSIONS

The percutaneous full endoscopic transcorporeal procedure is an alternative to previously described surgical methods of local spinal cord decompression for T1-T2 OPLL with fewer complications, effective spinal cord decompression, and a satisfactory cosmetic result. Successful cases confirm that treatment of spinal cord-limited compression by endoscopic technology is feasible.

Accessibility of the Cervicothoracic Junction Through an Anterior Approach: An MRI-based Algorithm

STUDY DESIGN

Cross-sectional observational study.

OBJECTIVE

To formulate a reliable method and modality for preoperative planning and to determine the effects of height, body mass index (BMI), and age on accessibility to the upper thoracic vertebrae through an anterior cervical approach.

SUMMARY OF BACKGROUND DATA

Various modalities have been proposed to determine the lowest spinal-level accessible through a traditional anterolateral cervical approach and the consequent need for manubriotomy. Past methods have routinely involved a variety of imaging studies such as plain radiographs and computed tomography but the reliability of these methods has not been assessed.

METHODS

The Magnetic Resonance Imaging (MRI) images of 180 patients classified by age and gender were evaluated and the most caudal accessible intervertebral disc space was determined from an approach angle beginning at the suprasternal notch. Plain cervical radiographs were also reviewed when available. In patients with multiple imaging studies, the reliability of the measurements was compared. Rate of accessibility was compared across different heights, BMIs, and ages.

RESULTS

A novel algorithm that utilized both the scout and mid-sagittal T2 MRIs was able to determine the most caudal cervicothoracic level accessible for anterior access in 93.3% of patients with a reliability of 96.8%. Conversely, plain radiograph evaluation led to low reliability (66.7%) and low agreement with MRI (60%) with an average error of one spinal level. In this patient sample, the T1 to T2 disc space was accessible in 82.7% of patients. Age and BMI were independent variables associated with accessibility (p < 0.01) while height was determined not to be significant (p = 0.09).

CONCLUSION

Data in this study suggest an MRI-based algorithm with a combination of scout and sagittal T2 images offers a reliable and consistent assessment of accessibility to upper thoracic levels through an anterior approach. Age and body mass index are major determinants of accessibility.