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Table of Contents    
CORRESPONDENCES
Year : 2018  |  Volume : 66  |  Issue : 2  |  Page : 585-586

Vintage trans-sternal approaches: Consigned to the graveyard!


Department of Neurosurgery, Kovai Medical Centre and Hospital, Coimbatore, Tamil Nadu, India

Date of Web Publication15-Mar-2018

Correspondence Address:
Dr. J K B C Parthiban
Flat 7, Block 4, Orchid Pars Sesh Nestle Campus, Nanjundapuram Road, Coimbatore - 641 036, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.227283

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How to cite this article:
C Parthiban J K. Vintage trans-sternal approaches: Consigned to the graveyard!. Neurol India 2018;66:585-6

How to cite this URL:
C Parthiban J K. Vintage trans-sternal approaches: Consigned to the graveyard!. Neurol India [serial online] 2018 [cited 2019 Oct 19];66:585-6. Available from: http://www.neurologyindia.com/text.asp?2018/66/2/585/227283




A ventral approach to the cervico-thoracic junction is always technically challenging and needs special expertise to perform. Over the years, many modifications have been carried out in the vintage trans-sternal approaches [Figure 1] with the prime aim of reducing morbidity. However, all these modifications are fraught with problems due to a narrow and tunnel-like approach necessitating the need for a good illumination, long instruments and expertise in inserting the grafts and implants. The technical diffculty in placing screws in the T4 vertebral bodies to secure the anterior plate instrumentation is especially very high.
Figure 1: Trans-sternal approach. Exposure of the anterior mediastinum, the heart, and the space between the right brachiocephalic and the left common carotid arteries (arrow)

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The article 'Expansile manubriotomy for ventral cervicothoracic junction lesions' written by Dubey and colleagues [1] is excellent, and we as one of the groups who routinely do this procedure for indicated ventral cervicothoracic lesions, appreciate the authors' interest in this approach. As a policy, we always get the exposures done by our thoracic surgeons not only to avoid medicolegal problems but also to get a better care for our patients in the postoperative period since most of procedures are conducted in the posterior mediastinal space. Moreover, we are of the view that the surgeons who perform the exposure should also be versatile in tackling the complications that may arise in that region, which in this case, are predominantly related to the thoracic cavity and the mediastinum.

Recollecting our first experience related to the trans-sternal approach published in 1995 in Neurology India,[2] the T3 lesion was excised and a tricortical iliac crest graft was placed between the T2 and T4 vertebral bodies. Though observing the beating heart was a new experience for us, the lesionectomy was easier due to the fact that the operative field was wide and closer to the surgeon, and hence, the surgery was easier to perform. The luxury of being closer to the lesion in the conventional open approaches to the lesions in this area has been taken away by all of the modifications of the approach that have been introduced for the benefit of attempting to decreasing morbidity; the primary goal of progress in surgery, however, is to try to optimize exposure while reducing complications and one must accept the role of minimally invasive approaches in attempting to achieve this goal.

The significant angulation of the trajectory while placing the T4 screws that has been experienced by many of the surgeons while utilizing this approach is due to two factors: the anteroinferiorly facing anterior cortex of vertebral body at that level, and the arching aorta. The arch of aorta can be pushed down gently to minimize the screw angulation [Figure 2]. It is also advisable to use a long screw driver with a protective sheath over it to insert the screw in the vertebral body. Securing a screw in the T4 vertebral body is challenging and a meticulous dissection, a good knowledge of the anatomy in the region as well as reaching out to other subspecialties for assistance in accessing lesions are mandatory to achieving a good result. With developments in technology related to the conduct of minimal access surgeries with ease, the vintage transsternal approach have been virtually consigned to the graveyard for the treatment of cervicothoracic junction lesions.
Figure 2: Expansion manubriotomy with retractor over the arch of aorta (arrow)

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  References Top

1.
Dubey S, Agarwal A. Expansile manubriotomy for ventral cervicothoracic junction disease. Neurol India 2018;66:168-73.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Parthiban J, Subba RA, Joseph t, Vinodan K, Rao A. Transsternal approach. Neurol India 1995;43:219-20.  Back to cited text no. 2
    


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