Protocol to Anticipate the Possibility and the Risk of the Anterior Approach to the Cervicothoracic Junction

Abstract

Introduction Several authors have previously described their radiological methods to identify in which cases the anterior approach could be performed and when the manubriotomy was needed; nevertheless, the reproducibility of the technique was not straightforward, several different measurements were described and analyzed, without considering the vascular anatomy and the relationship of the inclination of the vertebrae above the lesion to the manubrium was not taken into account. The purpose of this study was to present a straightforward preoperative protocol to define the possibility and the risk of the anterior approach to the cervicothoracic junction (CTJ). Patients and Methods A prospective cohort study of 19 consecutive patients who underwent an anterior approach in cervicothoracic surgery. Radiographic evaluation of the patients was performed with magnetic resonance imaging to study the disease features and to address the feasibility of the anterior approach through knowledge of the vascular anatomy. Computed tomography with sagittal reconstructions images including the manubrium was done to apply the “surgeons' view line.” This line is parallel to the inferior plateau of the superior healthy vertebrae or the vertebrae above the herniated intervertebral disc and the decision concerning the feasibility and need for manubriotomy depends on the correlation between this line and the great vessels and the manubrium, respectively. Results A preoperative planning of the need for manubriotomy was correct in all cases. Manubriotomy was never performed in C7 corpectomy or C7–T1 discectomy cases, nevertheless manubriotomy was needed in half the cases when the T1 corpectomy was the lowest level to be resected ( n = 8), and in four cases, the lowest level to be approached was T2 ( n = 5). The mean surgical time, bleeding volume, postoperative pain intensity, and length of hospital stay were less in the cervicotomy group when compared with the manubriotomy group. Conclusion Using the “surgeons' view line” and its correlation with the manubrium, the need for manubriotomy can be predicted without compromising decompression and reconstruction. The statistical differences observed in the surgical variables between the manubriotomy and cervicotomy cases justified the usefulness of the preoperative evaluation of the need for manubriotomy to perform surgical planning and give the patient and family realistic expectations about the surgery.