Transmanubrial Approach to the Cervicothoracic Junction Pathology
- Manubriotomy technique -
Sang H. Lee MD, PhD
Professor, Department of Orthopedic Surgery
Kyung Hee University, School of Medicine, Seoul, Korea
CERVICOTHORACIC JUNCTION (CTJ)
Definition of CTJ
C7~T4 (variable)
Pathologies
Degenerative, tumor, infection, trauma, deformity
Anterior surgical exposure; challenging because of
Kyphotic alignment of the upper thoracic spine → deep location of vertebral bodies
Anatomical obstacles
- Vascular: brachiocephalic trunks, aortic arch, lymphatics
- Neural: recurrent laryngeal N., phrenic N., brachial plexus
- Osseous: sternum, clavicles, 1st ribs
ANTERIOR APPROACHES TO THE CTJ
Low anterior cervical (LAC)
Trans-sternal
Trans-clavicular-trans-manubrial
Trans-manubrial
- Manubrium resection technique
- Manubriotomy technique
Low anterior cervical approach
= supra-sternal, supra-manubrial approach
Same as a conventional Smith-Robinson approach
Anterior approach up to T1~2
Accessibility depends on the patient’s thoracic inlet anatomy
- Musculature, neck length, soft tissue etc.
Trans-sternal approach
By Cauchoix & Binet (1957), for T1-3 chondrosarcoma
High incidence of morbidity (≈ 25%)
- Pain, pneumothorax, infection, sternal nonunion etc.
Operative mortality 40% - Hodgson et al. (1960)
Approach below T4 is impossible because of the limited retraction of aortic arch
Trans-clavicular-trans-manubrial approach
By Sundaresan et al. (1984)
Removal of rectangular block of the sternum & medial 1/3 of the clavicles
Mainly for extensive resection of CTJ tumors
Cx.- clavicle nonunion, shoulder dysfunction etc.
Tranmanubrial approach
Manubrium resection technique
- By Darling et al. (1995), Luk et al. (2002) etc.
- Transverse resection of the manubrim (unilaterally or bilaterally)
Manubriotomy technique
- Pointillart et al. (2007)
- Accessibility: down to T5
- Partial resection (upper part) of the manubrium
- Preserving the sternoclavicular (SC) joint
- Doable by spine surgeons
SURGICAL TECHNIQUES OF MANUBRIOTOMY
Skin incision
Anterior border of the SCM ~ extend several cm down along the midline of the sternum
Release the muscles
Sternal head of SCM
Manubrial part of pectoralis major
2~3 cm from the sternal insertion of infrahyoid muscles
Dissection of the retromanubrial space
Blunt finger dissection of the retrosternal fat
Manubriotomy Rectangular shape resection by osteotome & high-speed burr
Between the margin of both SC joints ~ down to manubrium-sternal body junction
Resect the interclavicular ligaments
Exposure of the spine
Split the thymus (variable sized)
Ligate the inferior thymic veins and/or inferior thyroid veins
Retract the Lt. innominate vein downward
Retract the esophagus & trachea to the Rt. side (of the patient) & Lt. common carotid artery to the Lt. side (of the patient)
DECISION OF SURGICAL APPROACH TO THE C-T JUNCTION
The lowest accessible disc space (by Karikari et al. 2009)
By CT sagittal image
Determined by a straight line passing through and parallel to the disc space that also passes above the manubrium
Cervicothoracic angle (CTA) (by Teng et al. 2009)
By midsagittal MR image
3 points by the horizontal line on the suprasternal notch & anterior point of C7-T1 disc
Routine utilization of a standard Smith-Robinson approach (by Cho et al. 2012)
By a plain lateral radiograph
If the lowest instrumented vertebra can be seen and a line passing from the intended skin incision site to this level lies on top of the manubrium
→ a routine Smith-Robinson approach can be used
REFERENCES
Cauchoix J, Binet JP. Anterior surgical approaches to the spine. Ann R Coll Surg Engl 1957;21:234–43.
Cho W, Buchowski JM, Park Y et al. Surgical approach to the cervicothoracic junction. Can a standard Smith-Robinson approach be utilized? J Spinal Dis Tech 2012;25:264-7.
Darling GE, McBroom R, Perrin R. Modified anterior approach to the cervicothoracic junction. Spine 1995;20:1519–21.
Hodgson AR, Stock FE, Fang HS, et al. Anterior spinal fusion: the operative approach and pathological findings in 412 patients with Pott’s disease of the spine. Br J Surg 1960;48:172
Karikari IO, Powers CJ, Issacs RE et al. Simple method for determining the need for sternotomy/manubriotomy with the anterior approach to the cervicothoracic junction. Neurosurg 2009;65[ONS supple1]:onsE165-6.
Luk KD, Cheung KM, Leong JC. Anterior approach to the cervicothoracic junction by unilateral or bilateral manubriotomy. A report of five cases. J Bone Joint Surg Am 2002;84- A:1013–7
Pointillart V, Aurouer N, Gangnet N, et al. Anterior approach to the cervicothoracic junction without sternotomy. Spine 2007;32:2875-9.
Teng H, Hsiang J, Wu C 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 Neurosurg Spine 2009;10:531-42.
Sundaresan N, Shah J, Feghali JG. A transsternal approach to the upper thoracic vertebrae. Am J Surg 1984;148:473–7.