Expansile manubriotomy for ventral cervicothoracic junction disease
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.222851
Source of Support: None, Conflict of Interest: None
Keywords: Cervicothoracic junction, expansile manubriotomy, transmanubrial, transthoracic
The cervicothoracic junction, extending from the C7–T4 vertebral level, has several unique anatomic features. This forms the junction between the lordotic cervical spine and the kyphotic thoracic spine. It forms the boundary of the thoracic inlet along with the ribs and sternum. This inlet is the smallest part of the thoracic cavity and has multiple mediastinal structures traversing it along with the apical segment of the lung. The narrow inlet with mediastinal structures within it limits exposure both anteriorly and laterally. Laterally and posteriorly, the brachial plexus is located along with strong shoulder and scapular musculature, which limit the surgical exposure from this direction. There are four fundamental approaches to provide access to anterior vertebral elements of the upper thoracic vertebrae. These approaches are transmanubrial,,,,, supraclavicular,,, transthoracic,,, and lateral parascapular. These approaches reflect the direction in which the vertebral body is approached. Rest of the approaches [Table 1] are modifications of these approaches. The two posterior approaches, laminectomy, and costotransversectomy, may be preferred for attempting a biopsy or for gaining access to a lesion located on the lateral aspect of the vertebral body. However, they cannot adequately address the diseased anterior vertebral segment completely and are associated with significant failures in performing complete excision of the lesions.,
The pathological processes involving this area are not common., They include traumatic vertebral fractures, metastasis, bacterial and tuberculous infections, primary bony tumors, and congenital connective tissue/skeletal disorders (mucopolysaccharidoses). Neurological sequel to these lesions are common due to the narrow size of the spinal canal at this level and the tenuous blood supply of this region. This area of the spinal cord represents a watershed zone that is often prone to ischemic deficits, commonly presenting with features of myelopathy. Only occasionally, patients have radiculopathy in the form of costobrachalgia.
The present report describes an operative approach that enables thoracic inlet (the narrowest region of the thorax) to be expanded, thus enabling more side-to-side retraction of anatomical structures. It also gives enough exposure to access the superior mediastinal structures to facilitate looping of the brachiocephalic vein instead of dividing it, and also enables the widest superior-inferior and side-to-side exposure. The inferior aspect is limited to the region above the superior mediastinum, and the pericardium need not be exposed in this approach. In addition, it does not involve major muscle or bony resection.
Anesthesia and positioning
The operation is carried out under general anesthesia with the patient intubated using a normal endotracheal tube. The patient is positioned supine with the neck in neutral position. Traction is applied in cases where there is collapse of a vertebra or there is a multiple vertebral body disease. Painting and draping is done to expose the lower part of neck and upper chest until the nipples.
The medial border of the sternocleidomastoid, the sternal notch, and the sternal angle are felt and marked for the skin incision. A vertical skin incision along the medial border of the sternocleidomastoid traversing from the right side towards the midline to the sternal notch and then continuing in the midline until the sternal angle, is made [Figure 1]a. The incision is made deeper, the deep fascia is incised, and the suprasternal space of Burns is exposed. The subcutaneous tissue over the manubrium is incised at the midline and dissected to the right side towards the right second intercostal space.
The suprasternal space of Burns is exposed by a blunt dissection. This facilitates the subperiosteal dissection of the manubrium. Whileprotecting the superior mediastinal structures, the manubrium is incised with a high-speed saw in the midline from the superior to the inferior direction. Once the sternal angle is reached, the cut is carried out until the second intercostal space [Figure 1]b. Extra care is taken so as not to damage the long thoracic artery. This allows the right side of manubrium, clavicle, and the first rib to be retracted as a single unit.
Reaching the vertebra
A self-retaining rib retractor is placed which opens the thoracic inlet [Figure 1]c. This opening also results in the circumferential expansion of the thoracic inlet. Care should be taken not to avulse the lateral thoracic artery located on the lateral aspect. This artery may be subsequently utilized as a pedicled donor graft in coronary artery bypass surgery. Dissection is carried out in the superior mediastinum and the a loop is placed around the brachiocephalic vein and artery. Small tributaries of the brachiocephalic vein may be ligated and sectioned. The thymus can be mobilized and resected. The brachiocephalic vein can be retracted downwards. If the inferior exposure is suboptimal, the brachiocephalic artery can be taken in a circumferential loop and retracted gently downwards [Figure 1]d. The retraction should not obliterate the lumen of the artery completely and it must be ensured that blood is going to the right common carotid artery. The loop around the vessel should also be released intermittently. This is required when the anterior aspect of the D4 vertebra needs to be exposed to place the screws. A plane is created between the carotid arteries that lie laterally, and the trachea and esophagus that lie medially, carrying out the exposure of the space from the superior to the inferior direction. The prevertebral fascia is reached. With blunt dissection, the visceral structures can be separated from the prevertebral fascia inferiorly to maximize the extent of exposure. In most cases, the third thoracic vertebra can be reached with a straight trajectory and the fourth vertebra is exposed with a slightly oblique trajectory. This exposure allows screws to be placed in the T4 vertebral body in an oblique direction. This technique facilitates the vertebral and disc space decompression and fusion utilizing the same approach.
The longus colli muscles on either side are dissected to facilitate placement of hand-held or self-retaining retractors. The vertebrectomy is performed using the same technique utilized during interventions performed in the subaxial cervical spine. In the upper thoracic spine, the vertebral artery is not encountered. Laterally, the vertebral artery may occasionally enter the foramen transversarium at the T1, C7 or C6 level and care should be taken to detect this abnormality. The pathology guides the extent of the vertebrectomy and the fusion procedure. Fusion can be performed with a cage or an autologous iliac bone filled cage supplemented by vertebral plates and screws. This provides stability; in very rare cases, posterior fusion may be required to augment the anterior procedure.
On removing the self-retaining rib retractor from the manubrium, the manubrium snaps back into position. Hemostasis is achieved and the manubrium is fixed with a stainless steel wire.
Twelve patients with cervicothoracic vertebral body disease underwent expansile manubriotomy with decompression and fusion. The indications for surgery were mycobacterial osteitis in 9 patients, and pyogenic epidural infection, metastatic as well as traumatic vertebral body involvement in one patient each respectively. All of the included patients were suffering from significant myelopathy at the time of presentation. The patient suffering from pyogenic epidural infection also had end-stage renal disease and was undergoing regular dialysis while awaiting transplantation. Nine patients had a two-level involvement, while one patient had a three-level involvement of the vertebral bodies. The disease did not extend below the T3 level in any of the patients. The clinical details of the patients are summarized in [Table 1].
All patients, except one, underwent vertebral body decompression followed by fusion with iliac crest bone graft/cage and anterior cervical plates. The screws could be placed on the anterior aspect of the T4 vertebral body by utilizing an inferiorly directed trajectory in 2 cases. While dissecting towards the thoracic inlet, the maximum anterior exposure that could be achieved was to the middle of T4 vertebral body level. During the retraction of the brachiocephalic vessels, 2000 IU of heparin was given intravenously to prevent iatrogenic thrombosis of the retracted vessels. It did not lead to excessive bleeding in any of our recruited patients. The patient who was suffering from the anteriorly placed C7–T2 spinal epidural abscess underwent an oblique corpectomy at the T1 and T2 levels, a task made easier due to the absence of vertebral artery at those levels. She did not require spinal stabilization. The average blood loss was 200 ml. The patients were electively ventilated and extubated the next day. One patient required reintubation due to his developing respiratory compromise in the postoperative period and was extubated after 2 days. All patients showed improvement in their Nurick's grade at follow-up visit. The patient with metastasis had a primary tumor (adenocarcinoma) within the lung tissue and was subsequently referred for radiotherapy. The patient with traumatic vertebral fracture had severe pain with myelopathy at admission, which improved on his follow-up visit after surgery. The patient with an epidural abscess had severe comorbidities in the form of uncontrolled diabetes, hypertension, and end-stage renal disease. She was referred 24 hours after developing grade 0/5 paraplegia. She improved to grade 2/5 power in the quadriceps muscles but succumbed to septicemia after 3 weeks. The clinical details of the recruited patients are summarized in [Table 1].
There was no paravertebral soft tissue, clavicular or brachial plexus injury noted following surgery. Adequate decompression and fusion could be performed with this approach. No anterior resurgery or a reinforcing posterior fusion procedure was required.
A 48-year old male patient presented with myelopathy and severe neck pain. He underwent a cervical radiograph [Figure 2]a and a magnetic resonance scan [Figure 2]b and [Figure 2]c. The radiology showed T3 vertebral collapse with epidural and paravertebral soft tissue and marrow edema. He underwent an expansile manubriotmy, T3 corpectomy and fusion with a tricorticate iliac crest bone graft. His T4 body was firm enough to facilitate the screw placement, and so he underwent a T2-T4 fusion with anterior cervical plates and screws. [Figure 3] shows the intraoperative photograph at the end of the procedure. Postoperative radiographs [Figure 4]a and [Figure 4]b and computed tomographic scan [Figure 4]c showed a satisfactory result. [Figure 5] shows the well- healed scar. The patient showed significant resolution in his myelopathy at follow-up visits.
The advantages and shortcomings of the present approach and the alternative approaches utilized
Several ventral approaches have been described for operation conducted at the cervicothoracic junctional level [Table 2]. The lower ventromedial cervical approach is similar to the one used for lower cervical spine. It is limited in inferior exposure to the T1–2 vertebral level, even in patients with a long neck. There was 36% graft/plate failure when this approach was used alone. However, the extent of exposure during surgery was found to be adequate in all the patients in whom this approach was chosen. The transsternal approaches provide a better exposure from C3 to T4.,, However, there is a high operative mortality to the tune of 40%., Nazzaro described the “trap door” exposure of the cervicothoracic region in 1994. Although all his patients did well, it is considered a morbid procedure, and has not gained acceptance owing to the extent of dissection involved. Sundaresan proposed the manubrial osteotomy as a variation of the transsternal approach. It is performed using osteotomy of the manubrium, with or without medial claviculotomy., Sundaresan further recommends resection of the medial third of the clavicle along with creation of a window in the manubrium. The claviculotomy has been associated with clavicular nonunion and recurrent laryngeal nerve palsy. These approaches involve separation of the sternocleidomastoid muscle from its attachment to the sternum and clavicle, which may cause respiratory compromise and impairment. LeSoin further modified the approach by leaving the sternocleidomastoid attachment to the clavicle and sternum in place and resecting the medial third of the clavicle along with the manubrium as a block to approach the T1-4 vertebrae.
The transverse supracalvicular approach was initially described for performing an upper thoracic sympathectomy., A transverse skin incision parallel to the clavicle and extending beyond the lateral border of the sternocleidomastoid is used for this approach. The sternocleidomastoid, omohyoid, and strap muscles are divided. The neurovascular structures are protected. Medial retraction of these structures limits the access to the anterior aspect of the C7 vertebra. The transclavicular approach provides adequate access to the cervicothoracic junction; however, it is most suitable for the paravertebral plexus involvement. Dividing the clavicle in this approach assists in separating mediastinal structures from the lung. A zigzag incision over the clavicle is used. The transaxillary extrapleural approach is a high thoracic variant of the transthoracic approach. It preserves the pectoral and shoulder girdle muscles but places brachial plexus at risk of developing retraction and stretch injury. The approach involves an incision dividing the pectoralis as well as the latissimus dorsi muscle over the third rib space, and the third rib is partially resected. With blunt dissection, the extrapleural retraction of the apex of the lung is performed., The limitation of the approach is the lateral access to the vertebral body that it provides and its inability to reach the C7 –T1 vertebral level. The transpleural transthoracic approach is performed following resection of the fourth rib. The limitation of the approach is that the operative trajectory is oblique in such cases and exposure of the C7–T1 vertebral level is not achieved.
The lateral parascapular extrapleural approach involves reflection of the parascapular shoulder muscles that extend from the vertebral spinous processes to the scapula, with preservation of neurovascular structures. The upper dorsal ribs are removed, the rami communicants of C8 and T1 are transected, and the sympathetic chain is displaced ventrolaterally. The approach provides an easy access to the T2–4 vertebrae. However, the ability to deal with an anteriorly situated pathology is limited.
The expansile manubriotomy described in this report gives an adequate exposure from the C4 to T4 levels. A proper superior mediastinal exposure ensures that the brachocephalic vessels are exposed and a loop is placed around them to facilitate their downward retraction. This enhances the inferior-most extent of exposure that may extend to the mid-T4 vertebral segment. Even in patients with a short neck, by retracting the looped brachiocephalic vein, further inferior exposure may be provided. The vessel does not require ligation and division to provide exposure to the anterior aspect of the upper cervical vertebrae. Retraction of the brachiocephalic vessels for a short period of time, utilizing loops placed around them, helps in the placement of the inferior-most screws on the upper thoracic vertebrae. This ensures stability of the graft construct and prevents failure of their fusion with the vertebrae located above and below.
Similar to other transternal and trapdoor exposures, the expansile manubriotomy opens up the thoracic inlet, allowing for a greater side-to-side maneuverability of instruments by increasing the exposed area. However, the procedure-related morbidity or mortality is minimal, unlike some of the previously described approaches. In contrast to approaches that require the resection of the medial half of the clavicle to gain access to the thoracic inlet, the currently described approach does not involve detachment of any muscles, and therefore, does not lead to any increase in the respiratory morbidity. The sternum, clavicle, and muscles are preserved. The manubrium is known to fuse in a period of three months.
Expansile manubriotmy is a modified ventral approach which limits the exposure to superior mediastinum without significantly disturbing the postion of the anterior mediastinal structures. It expands the thoracic inlet to increase the operative area. It also enables inferior retraction of the brachiocephalic vessels. It allows the addressal of the disease process of the vertebral body above the T4 level. It is the least morbid of all approaches to the ventral cervicothoracic junction.
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The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]