The anterior approach to the cervicothoracic junction is generally considered to be difficult because the operative field is narrow. It is limited by the sternum, the clavicles, and the vascular and neural structures of the superior mediastinum. The posterior approach may appear to be simpler, but it is less logical because most lesions are situated in the vertebral bodies. Moreover, if the posterior approach is used, postoperative care is more demanding, with a higher level of pain and a greater risk of sepsis. Consequently, many specialized centers prefer the anterior approach. In most cases, this approach is a standard anterolateral cervical approach extended caudally by full sternotomy or partial sternotomy. We analyzed the technical results of a series of 20 patients operated on at the cervicothoracic junction through an anterior approach. The technique used was a standard cervical approach anterior to the carotid sheath. Distal extension of this exposure was as straightforward and minimally invasive as possible.

Methods

We treated 20 patients with cervicothoracic tuberculosis; the follow-up period ranged approximately 16 to 39 months. There were 17 male and 3 female patients who ranged in age from 25 to 46 years. The pathologic change regions were as follows: 10 in the C7-T1 segment, 6 in the T1 segment, 3 in the T1–T3 segment, and 1 in the T2–T3 segment. The classifications of Frankel were as follows: 2 at grade A, 4 at grade B, 7 at grade C, 2 at grade D, and 5 at grade E. All of the patients who had tuberculosis were operated on under chemotherapeutic coverage according to category I Directly Observed Therapy. All of the patients with tuberculosis in the cervicothoracic junction underwent a standard anterolateral cervical approach, which was combined with a partial median osteotomy and transverse osteotomy through the synostosis between the manubrium and body of the sternum to expose the lesion adequately. Radical debridement was performed, then tricortical iliac crest bone autograft or allograft was placed and internal fixation was done to reconstruct the spinal column (Fig. 1).

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Results

All of the patients were satisfied with the results and regained ambulatory status. There was no injury of blood vessel, spinal cord, or recurrent nerve during the surgery. The follow-up period was a range of approximately 16 to 39 months. Bony fusion was obtained in all patients, and there was no internal fixation failure or tuberculosis recurrence in any of these patients. The nerve function of the spinal cord recovered at different degrees: 2 at grade A, 1 at grade B, 1 at grade C, 3 at grade D, and 13 at grade E.

Discussion

Access to the cervicothoracic junction through an anterior approach is generally considered to be difficult. The bony rampart constituted by the thoracic wall and the vascular rampart formed by the supra-aortic vessels are the principal obstacles. The superior approach, caudal extension of a standard anterolateral cervical approach, is limited by thoracic kyphosis and the sternum, whereas the scapula, plexus brachial, and major vessels limit the access by thoracotomy.1 The difficulty of this surgery is reflected in the variety of reported techniques. The cervical approach with full sternotomy provides extensive access to the cervicothoracic junction, but there is substantial accompanying morbidity. Moreover, despite the sternotomy, exposure remains limited distally by the left brachiocephalic trunk and by the aortic arch. Pointillart et al2 used an approach between the aorta and the vena cava for corpectomy of T2 with osteosynthesis from T1–T3. This technique calls for dissection of the large vessels and appears to be relatively invasive. Numerous alternatives to the approach have been reported, including partial sternotomies with or without clavicular osteotomies. Xie et al3 practiced a partial upper sternotomy associated with resection of the medial third of the left clavicle, for which approach the severity of the cosmetic and functional sequelae was not evaluated. The partial sternotomy reported by Zhang et al4 includes two segments. The first is vertical, from the manubrium sternum to the fourth intercostal space; the second is horizontal in the same intercostal space to open the chest using a superior “trapdoor.” For most spinal lesions, such a wide exposure is superfluous. Spinal cord decompression and osteosynthesis generally require a strictly median access. Consequently, the osteotomy of the medial third of the clavicle or a sternocostal flap to widen the approach appears somewhat excessive, except in certain cases for which the anterolateral aspect of the vertebrae must be exposed.5 For more distal access, bone resection limited to the manubrium sternum may be necessary. Because the resection of bone remained sagittal, no destabilization of the sternoclavicular joint and no fracture or opening of the sternum occurred.6 Therefore, we consider that this bony resection is not a sternotomy. It is sufficient to expose the upper thoracic spine caudally to T5. It causes no functional changes and eliminates the risk of pseudarthrosis involving sternal and clavicular osteotomies. Distal osteosynthesis screws were often slightly oblique in an inferior and posterior direction, but this had no adverse effect on the stability of the construct.

This approach is less invasive than full or partial sternotomies. It allows central spinal cord decompression and vertebral osteosynthesis caudally to T5 with few complications. Even though the anatomy of this region is complex, the procedure is relatively straightforward. Extensive dissection of vascular and neural structures of the superior mediastinum is unnecessary. The avascular space anterior to the vertebrae constitutes a safe pathway to follow from the cervical region to the upper thoracic vertebrae.7 If wider access to anterolateral aspects of the vertebrae is necessary, the trapdoor sternotomy proposed by Crocker et al8 is a useful alternative because it allows anatomic reconstruction. The anterior approach to the cervicothoracic junction as often described may appear demanding and invasive. Most spinal lesions down to T4 can be operated using a standard anterior cervical approach extended caudally and associated with limited manubrial resection, if necessary. The systematic dissection of surrounding vascular and neural structures needlessly increases the duration of surgery and the risk of complications. This approach is particularly adapted to the management of patients with severe systemic disorders, including individuals with metastases, because it facilitates postoperative care.