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Table of Contents    
COMMENTARY
Year : 2018  |  Volume : 66  |  Issue : 1  |  Page : 174-175

Expansile manubriotomy versus standard approach for accessing ventral cervicothoracic junction disease: Methods to improve the decision-making process


Department of Neurosurgery, James Cook University Hospital, Middlesbrough, United Kingdom

Date of Web Publication11-Jan-2018

Correspondence Address:
Dr. Manjunath Prasad
Department of Neurosurgery, James Cook University Hospital, Middlesbrough
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.222832

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How to cite this article:
Prasad M, Mukerji N. Expansile manubriotomy versus standard approach for accessing ventral cervicothoracic junction disease: Methods to improve the decision-making process. Neurol India 2018;66:174-5

How to cite this URL:
Prasad M, Mukerji N. Expansile manubriotomy versus standard approach for accessing ventral cervicothoracic junction disease: Methods to improve the decision-making process. Neurol India [serial online] 2018 [cited 2019 Apr 22];66:174-5. Available from: http://www.neurologyindia.com/text.asp?2018/66/1/174/222832




Surgery for pathology in the bony spine is indicated if there is rapid progress of neurological deficits due to cord compression, spinal instability, unacceptable deformity and pain due to instability affecting the quality of life. The procedures, therefore, could be decompression only, decompression with stabilisation, or stabilisation alone. This depends on the indication. The decision-making process is influenced by other factors like the need for or suitability of adjuvant treatment, co-morbidities, performance status and life expectancy. Decompression is mandatory if neurological deficits are acute and rapidly progressive. Stabilisation alone might suffice in patients with longstanding problems, especially where adjuvant therapy is relevant. There is no blanket rule and decisions are made on an individual case basis after discussion in local multidisciplinary team meetings. Surgery is not indicated in all cases.

This leads to the next issue of selecting the approach. The general rule is to approach the compressive pathology without cord retraction and the approach depends on this.

The cervicothoracic junction (CTJ) is a particularly challenging area. This generally refers to the region between C7 and T4. If the compression is not acute and is being treated by adjuvant therapy, posterior stabilisation alone becomes a reasonable option in many cases. Sometimes this can be combined with transpedicular decompression or biopsy.

Anterior approaches to the CTJ are challenging. Anterior access to spinal pathology in the region between C7 and T4 is at times not feasible with the standard anterior cervical approach or thoracotomy. Approaches for accessing pathology anterior to the cord at the CTJ include the standard low anterior cervical, transmanubrial, transsternal, transpedicular approaches, and thoracotomy.[1]

The criteria described by Karikari et al.,[2] or Teng et al.,[3] could be used to decide if a special approach is needed.

In the first method [2] the lowest accessible disc space that can be approached with the standard anterior cervical approach is determined by constructing a straight line passing through and parallel to the disc space that also passes above the manubrium on sagittal computed tomographic (CT) scan reconstruction [Figure 1]. Access to lesions below this line might need the addition of a manubriotomy.
Figure 1: Method described by Karikari et al

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In the second method, the midsagittal plane on the cervicothoracic magnetic resonance (MR) imaging study is used. A line is drawn from the suprasternal notch (SSN) and extended horizontally to the corresponding anterior vertebral border; another line is drawn from the same point in the SSN to the midpoint of the anterior border of the C7/T1 intervertebral disc. The angle formed at the SSN is the cervicothoracic angle (CTA). Lesions are classified as Type A (above the upper line of the CTA), Type B (located within the CTA) or Type C (located below the CTA) [Figure 2].
Figure 2: Method described by Teng et al

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Type A lesions can be approached by the standard anterior cervical approach. Type B lesions can be approached by standard anterior cervical approach with or without manubriotomy. Type C lesions can be accessed by manubriotomy, lateral parascapular thoracotomy, or transpedicular posterior approach.

Dubey and Agrawal have described their experience with “expansile manubriotomy for ventral cervicothoracic junction disease” and the results are good.[4] The selection criteria for the chosen approach are not explicit (the authors do not mention the Karikari/Teng criteria) in all cases and one has to assume that the decisions were made on an individual case basis taking all information into consideration. This is a major surgical undertaking and must not be taken lightly. The authors also do not mention the frequency with which this procedure was undertaken; over what period were these 12 operations performed? The procedure should be embarked upon with due diligence and careful consideration of indications, patient factors, pathology and support from anaesthesia/intensive care and perhaps colleagues from cardiothoracic/vascular surgery. Alternative methods of treating the pathology, including conservative measures, adjuvant medical management, brace stabilization and posterior fixation must all be adequately discussed in the consenting process.



 
  References Top

1.
Sattarov KV, Fard SA, Patel AS, Alkadhim M, Avila MJ, Walter CM, et al. Peribrachiocephalic approaches to the anterior cervicothoracic spine. J Clin Neurosc 2015;22:1822-6.  Back to cited text no. 1
    
2.
Karikari IO, Powers CJ, Isaacs RE. Simple method for determining the need for sternotomy/manubriotomy with the anterior approach to the cervicothoracic junction. Neurosurgery. 2009;65(6 Suppl):E165-6.  Back to cited text no. 2
    
3.
Teng H, Hsiang J, Wu C, Wang M, Wei H, Yang X, et al. Surgery in the cervicothoracic junction with an anterior low suprasternal approach alone or combined with manubriotomy and sternotomy: An approach selection method based on the cervicothoracic angle. J Neurosurgery. Spine 2009;10:531-42.  Back to cited text no. 3
    
4.
Dubey S, Agarwal A. Expansile manubriotomy for ventral cervicothoracic junction disease. Neurol India 2018:66:168-73.  Back to cited text no. 4
    


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