Cervicothoracic Junction Research Articles

Surgical Treatment of Cervicothoracic Junction Lesions in Children: A Series of 18 Cases

Purpose The cervicothoracic junction (CTJ) lesions in children is rare. Surgical treatment for lesions at the cervicothoracic junction is challenging due to the presence of the great vessels and other thoracic structures. There are no criteria that help select a surgical approach to manage cervicothoracic lesions in children so far. This study focuses on the cervicothoracic junction lesions in children(C7-T4) and provides experience for the appropriate surgical approach for them. Methods: This retrospective study enrolled 18 children with cervicothoracic junction lesions who underwent surgical treatment in our Hospital from January 2015 to September 2019. They were evaluated with preoperative CT or MR imaging and diagnosed postoperatively by pathological examination. Results: This study included 2 patients with congenital lesions, 4 patients with benign lesions, and 12 patients with malignant lesions. Lesions with a margin below C7-T3, including benign and malignant tumors could be resected using a simple low anterior cervical approach (LACA). Congenital lesions and benign lesions with a margin below T4 could also be treated with this approach. Two-thirds of the malignant lesions below T4 were resected through the LACA combined with video-assisted thoracoscopic surgery (VATS). 1 patient with malignant lesion extending to T4 was removed by the LACA combined with posterolateral thoracotomy. Conclusions: The lesions at the cervicothoracic junction (C7–T4) in children may be managed with the simple LACA used in most patients. For malignancies extending to the T4 level, LACA and VATS could be performed in combination to resect lesions completely and invasively.

Modified Transclavicular-Transmanubrial Approach to Cervicothoracic Spine: Revisiting and Renovating the Path - Lessons Learned.

Introduction:A thorough knowledge of the vital structures adds to the safety in approaching the cervicothoracic spine junction. The best described method to reach the spine is via viscero-neurovascular space. We present our experience of 10 cases operated at our institute using the modified transclavicular transmanubrial approach to the cervicothoracic spine pathology.As we gained experience we have used various corridors to the operating field and used a new space to approach the lower cervicothoracic junction spine.Methods:Between February 2011 to August 2015, 10 patients with disease in upper thoracic vertebral body were admitted and evaluated clinically and radiologically. Neurological status in all cases was graded according to Frankel grading system.Patients were followed up with Histopathological reports and treated accordingly.Results:All patients(except metastasis) improved by 1 or 2 grade in post op period. Metastasis patients remained in same grade.Conclusion:Anterior approach with its modifications are the better suited biomechanically for exploring the pathology of cervicothoracic spine,its decompression and stabilization. Also it preserves the stability of shoulder girdle with good neurological and cosmetic outcome.

A Case of Pancoast Syndrome Caused By an Extramedullary Plasmacytoma in Relapsed Multiple Myeloma

Extramedullary plasmacytomas are present in 7-18% of multiple myeloma at diagnosis, and up to 13-20% at the time of disease relapse. (Blade J et al., 2011; Varettoni M et al., 2010) A case series in 2010 with 1003 patients found involvement of soft tissues surrounding the axial skeleton in 85% of cases at diagnosis, and 72% of cases at time of relapse. Other sites of involvement included lymph nodes, liver, kidney, airways, skin, breast, and the gastrointestinal tract. (Varettoni M et al., 2010) An extramedullary plasmacytoma leading to Pancoast syndrome has been reported only 3 times in previous literature, in 1979, 1983, and 1984. (Brenner B et al., 1984; Chen KT et al., 1983; Wilson KS et al., 1979) A case of this uncommon presentation is reported here. The patient is a 70-year-old male with a diagnosis of ISS-3 IgG Kappa multiple myeloma (serum monoclonal protein 10 g/L, Kappa light chain 2356.29 mg/L, free light chain ratio 386.28, bone marrow biopsy 61.8% plasma cells) the year prior to the current presentation. He was not a candidate for autologous stem cell transplant due to poor pulmonary function, and hence had a treatment plan for 9 cycles of cyclophosphamide/bortezomib/dexamethasone (CyBorD), of which 6 were completed. Treatment was then stopped due to a macrocytic hypoproliferative anemia thought to be related to early hypoplasia from prior CyBorD. At this time, he was in complete remission with bone marrow biopsy showing 2.8% plasma cells. His medical history was otherwise significant for coronary artery disease with prior myocardial infarction, previous transient ischemic attack with carotid stenosis and carotid endarterectomy, hypertension, dyslipidemia, spinal stenosis with multilevel degenerative changes most pronounced at L3-4, and osteoarthritis. He had a 30 pack-year smoking history, and continued to smoke cigars. The patient presented to hospital 5 months after completion of the above therapy with 2 weeks of right shoulder pain radiating down the arm, and right hand weakness, numbness, and tingling. He had also noted right lower extremity weakness and numbness with some incontinence. The physical exam was significant for right ptosis and myosis (Figure 1), decreased strength and sensation in the right C8-T1 distribution, inability to lift the right lower extremity off the bed, reduced anal sphincter tone, and a post-void residual volume of 700 mL. CT brain and cervical spine showed new abnormal mass-like tissue within the right hemithorax apical region with apparent extension into the cervicothoracic junction. Given his history of multiple myeloma as well as his smoking history, the mass was thought to either be a primary lung malignancy, or an extramedullary plasmacytoma. The patient was therefore admitted for ongoing management and diagnostic work-up. He was seen by the inpatient Hematology service, and noted to have progression of his multiple myeloma with Kappa light chain 885.99 mg/L (free light chain ratio 48.67). He was started on pulse steroids with a plan for daratumumab/lenalidomide/dexamethasone (DRd) with dose reduction of the lenalidomide given his prior history of myelosuppression. Further imaging with MR entire spine showed the right lung apical soft tissue mass extending into the epidural space from C7-T2 with severe spinal cord compression and spinal cord edema (Figure 2), as well as epidural extension of disease at L5 resulting in moderate spinal canal stenosis. The patient was then seen by Radiation Oncology and received 8 Gy as a single fraction to the apical lung mass. Subsequent biopsy of the mass showed a plasma cell neoplasm, Kappa restricted by in-situ hybridization, and compatible with a plasmacytoma. The patient then received two cycles of DRd and thought to be in very good partial response with Kappa light chain 32 mg/L, free light chain ratio 3.8, and resolution of previous apical lung mass and L5 epidural extension on subsequent MR spine. We document here a rare case of plasmacytoma leading to Pancoast syndrome. Given the difference in therapeutic options and prognosis between an extramedullary plasmacytoma and a primary lung malignancy, it is important to recognize this presentation as a diagnostic possibility, and to pursue relevant investigation and targeted management for the same. Disclosures Sharma: Enstasis therapeutics: Current equity holder in private company; Pfizer: Current equity holder in private company; Gilead: Other: shareholder; Contrafect corporation: Current equity holder in private company; Moderna: Other: shareholder.

Modified Technique for the Visualization of C6/C7 in Lateral Cervical Spine Radiography

Introduction: In the Swimmer’s view, the C6 and C7 can be visualized as superimposed on the shoulders. This study aimed to explore the technique to demonstrate C1 to C7 in the lateral spine and improve the diagnostic value in that region. Material and Methods: An experimental study was carried out using a RANDO phantom to obtain images of the lateral cervical spine. Twelve radiographs were taken using different kVps at different centering points. The image quality of the radiographs was evaluated by two radiographers using the modified image quality criteria score sheet adapted from the Commission of European Communities on image quality. A dose area product meter was utilized to estimate the entrance surface dose (ESD); however, CALDose_X5 Monte Carlo software was used to estimate the effective dose. Results: The findings indicated that a higher centering point at 2 inches above the pinna of the ear can clearly visualize the lower cervical spine (C6/C7) and cervicothoracic junction (C7/T1). The results of the Kruskal-Wallis test revealed significant differences (p 0.05) in the ESD between different utilized centering points. The effective dose of the modified technique was reported to be lower, compared to that for the Swimmer’s view. Conclusion: The modified lateral technique can be used to replace the Swimmer’s view to adequately demonstrate the lower cervical spine and cervicothoracic junction with a lower radiation dose while not harming the patient due to movement during positioning.

Crossing the Cervicothoracic Junction During Posterior Cervical Fusion for Myelopathy Is Associated With Superior Radiographic Parameters But Similar Clinical Outcomes.

For laminectomy and posterior spinal fusion (LPSF) surgery for cervical spondylotic myelopathy (CSM), the evidence is unclear as to whether fusions should cross the cervicothoracic junction (CTJ). To compare LPSF outcomes between those with and without lower instrumented vertebrae (LIV) crossing the CTJ. A consecutive series of adults undergoing LPSF for CSM from 2012 to 2018 with a minimum of 12-mo follow-up were identified. LPSF with subaxial upper instrumented vertebrae and LIV between C6 and T2 were included. Clinical and radiographic outcomes were compared. A total of 79 patients were included: 46 crossed the CTJ (crossed-CTJ) and 33 did not. The mean follow-up was 22.2 mo (minimum: 12 mo). Crossed-CTJ had higher preoperative C2-7 sagittal vertical axis (cSVA) (33.3±16.0vs 23.8±12.4mm, P=.01) but similar preoperative cervical lordosis (CL) and CL minus T1-slope (CL minus T1-slope) (P > .05, both comparisons). The overall reoperation rate was 3.8% (crossed-CTJ: 2.2%vs not-crossed: 6.1%, P=.37). In adjusted analyses, crossed-CTJ was associated with superior cSVA (β = -9.7; P=.002), CL (β = 6.2; P=.04), and CL minus T1-slope (β = -6.6; P=.04), but longer operative times (β = 46.3; P=.001). Crossed- and not-crossed CTJ achieved similar postoperative patient-reported outcomes [Visual Analog Scale (VAS) neck pain, VAS arm pain, Nurick Grade, Modified Japanese Orthopedic Association Scale, Neck Disability Index, and EuroQol-5D] in adjusted multivariable analyses (adjusted P>.05). For the entire cohort, higher postoperative CL was associated with lower postoperative arm pain (adjusted Pearson's r -0.1, P=.02). No postoperative cervical radiographic parameters were associated with neck pain (P>.05). Subaxial LPSF for CSM that crossed the CTJ were associated with superior radiographic outcomes for cSVA, CL, and CL minus T1-slope, but longer operative times. There were no differences in neck pain or reoperation rate.

Thoracolumbar transitional vertebrae in a feline: Case report

The transitional vertebra is a congenital anomaly characterized by a vertebra that assumes anatomical characteristics of another vertebra in the adjacent region and occurs at the cervicothoracic, thoracolumbar, lumbosacral, and sacrococcygeal junctions. It is the most common congenital anomaly in dogs and cats and is diagnosed by radiography. The present work aims to report a case of thoracolumbar transitional vertebrae in a feline, 11 years old, addressing the radiographic findings. The patient was received in the Laboratório de Diagnóstico por Imagem e Cardiologia (LADIC) of the Universidade Federal de Pelotas Veterinary Teaching Hospital for thoracic radiography to investigate the presence of lung metastasis. Radiographs in orthogonal views of the thorax were obtained and demonstrated the presence of ribs bilaterally inserted in the first lumbar vertebrae (L1), in addition to spondylosis along the thoracic spine. The patient did not have clinical signs compatible with these vertebral changes. The thoracolumbar transitional vertebrae have a large importance in the decision making of clinicians and surgeons when facing thoracic procedures. The radiologist must pay attention to this change and communicate it so that the clinician, surgeon, and the owner can acquire knowledge, thus avoiding possible medical errors that may harm the patient.

Clinical characteristics and long-term surgical outcomes of spinal pilocytic astrocytoma: a report of twenty cases.

Primary spinal pilocytic astrocytoma (PA) is an extremely rare low-grade astrocytoma with unclear natural history. The demographic characteristics, imaging features, and long-term surgical outcomes have not been clarified due to low prevalence and limited reports. A retrospective review within a single institution between 2004 and 2018 of all patients with pathologically proven PA was conducted. Patient data including demographics, radiographic features, treatment modalities, and long-term outcomes were evaluated. Twenty consecutive patients were identified, and 16 (80%) were male patients, with a mean age at presentation of 29 ± 13years. The lesion was primarily located in cervical (n = 10, 50%), thoracic (n = 7, 35%), cervico-thoracic junction (n = 2), and lumbar level (n = 1, 5%). The tumor had a mean extension of 4 ± 2 (1-7) vertebral segments. Most PAs were located eccentrically (n = 16, 80%), with most being heterogeneous in appearance (cystic and solid) or purely cystic (n = 14, 70%), and had unclear margins (n = 16, 80%). Eleven patients (55%) had associated syringomyelia. Gross total resection (GTR) was achieved in 11 (55%) patients, and subtotal resection (STR) in 9 (45%). During a mean follow-up of 104 ± 56months, 2 patients died and recurrence was found in 4 patients (20%), translating to a mean progression-free survival of 21 ± 11months. Primary spinal PA is a rare entity with acceptable progression-free survival if treated appropriately. Surgical resection may provide reasonable prolongation of survival, and GTR should be achieved if possible. A close follow-up is recommended especially for residual lesions, and a further in-depth investigation of molecular biomarkers is needed to stratify risk and prognostic factors.

Radiographic findings and anatomical variations of the caudal cervical area in horses with neck pain and ataxia: case–control study on 116 horses

BackgroundAbnormalities of the ventral lamina of the sixth cervical vertebra (AVL-C6) are thought to exert abnormal stress on the articular process joints (APJs) of the cervicothoracic junction. The aim of...

Dynamic changes in longitudinal stretching of the spinal cord in thoracic spine: Focus on the spinal cord occupation rate of dural sac

ObjectivesThis study aimed to evaluate the anteroposterior diameters and cross-sectional areas of the dural sac and spinal cord in the thoracic spine, to elucidate the spinal cord occupation rate of the dural sac in these dynamic changes for each level using multidetector-row computed tomography (MDCT). Patients and MethodsFifty patients with cervical or lumbar spinal disease were prospectively enrolled. After preoperative myelography, MDCT was performed at maximum passive flexion and extension. The anteroposterior diameter and cross-sectional area of the dural sac and spinal cord in the axial plane and the thoracic spinal cord length in the sagittal plane were measured. The spinal cord occupation rate in the dural sac was calculated. ResultsThe spinal cord occupation rate of the dural sac in anteroposterior diameter was lower on flexion than on extension, with significant differences from the T1/T2 to T11/T12 levels (p < 0.0001). The spinal cord occupation rate of the dural sac in cross-sectional area was lower on flexion than on extension, with significant differences except from T3/T4 to T6/T7 levels (p < 0.01). There was a bimodal increase in the occupation rate with elevations at the cervicothoracic junction and thoracolumbar junction. The thoracic spinal cord length on flexion was significantly longer than that on extension (p < 0.0001). ConclusionsThe spinal cord occupation rate of the dural sac was lower on flexion than on extension, despite thoracic spine being considered a rigid region. The dynamic changes in longitudinal stretching and shrinkage of the spinal cord affected the occupation rate.

Cervicothoracic fixation using a tapered rod with posterior en bloc multilevel laminectomy for treatment of cervicothoracic pathology: a prospective case series

Background: Cervicothoracic junction pathologies are difficult to treat because of the biomechanical and anatomical considerations of this area. Anterior approaches in this area are highly demanding and often result in long-term morbidities. Posterior fixation of the cervicothoracic junction is difficult because of the change in anatomy of the vertebrae between the cervical and thoracic vertebrae. Traditional laminectomy may be hazardous to the spinal cord. The purpose of this study was to evaluate the results of cervicothoracic fixation using tapered rods and en bloc multilevel laminectomy for treatment of different pathologies in terms of effectiveness, neurological improvement, and complications. Methods: A prospective study was done between 2013 to 2016 on 17 patients with cervicothoracic pathologies. The mean age was 50.05±16.48 yr. There were seven patients with tumors, five patients with traumatic fractures (including one patient with ankylosing spondylitis), and five patients with cervicothoracic myelopathy due to degenerative disorders. The patients underwent a detailed history and clinical examination, and they were investigated with radiographs, CT scans, and MRI. The patients’ neurological functions were classified according to Frankel grades of paraplegia. All patients had preoperative neurological impairment. Results: All patients were operated through posterior approach. En bloc laminectomy and posterior fixation of at least the lower 3 cervical and upper 3 thoracic vertebrae were done using a tapered rod. The mean operative time was 164.40 min. The mean operative blood loss was 960.6 mL. One case had superficial infection that was treated with antibiotics and daily dressings until wound healing. Patients with spinal metastases received postoperative radiation 1 mo after surgery. No neurological deterioration occurred. The improvement in patients was gradual throughout the follow-up but started in some patients from 2 days postoperatively. Gait improved in all patients. No case of metal failure was observed during follow-up. Conclusions: Multilevel en bloc laminectomy is a safe technique that provides adequate decompression of the spinal cord and neurological improvement for patients suffering from cervicothoracic myelopathy due to various pathologies. The use of a tapered rod is a good alternative for connection of screws across the cervicothoracic region, with easy handling and minimal complications. Level of Evidence: Level IV.

P2. To cross or not to cross: a biomechanical investigation of crossing cervicothoracic junction in posterior cervical laminectomy and fusion

BACKGROUND CONTEXT Lower stopping point for the construct in posterior cervical laminectomy and fusion (PCLF) that involves the cervico-thoracic junction is highly debated. Constructs with C7 as lowest instrumented vertebra (LIV) have been implicated in higher incidence of adjacent level disease and junctional kyphosis, but the literature is not conclusive about these findings and many studies claim in difference in adjacent level disease or PJK. PURPOSE To investigate the biomechanical implications of having C7 as the lowest instrumented vertebra versus crossing the cervico-thoracic junction. STUDY DESIGN/SETTING Biomechanical cadaveric study PATIENT SAMPLE N/A OUTCOME MEASURES N/A METHODS Human cadaveric specimens of full subaxial cervical spine and torso with intact ribcage were used for the study. Six degrees of freedom pure-moment simulator were used to test the specimens in Flexion-Extension (FE), Lateral Bending (LB) and Axial Rotation (AR). Torque-controlled protocol (2.5 Nm, 1.5o/s) was utilized for testing of the intact specimens, while displacement control (based on the angle values obtained from the intact testing) was used for testing the constructs. After the intact testing, C3–7 laminectomy was performed in a standard fashion, and three different fusion constructs were tested in the same specimen: C3–C7, C3–T1, C3–T2. Optic tracking system was used to record range of motion (ROM) and intradiscal pressure (IDP) monitors with custom LabView based software was used to study the intradiscal pressures at the levels adjacent to the fusion constructs. Univariate analysis along with multivariate model was used to analyze the differences between the three constructs. RESULTS A total of nine cadaveric specimens were included in the study. There was partial IDP data missing on one of the specimens and the data was unreliable (statistical outlier on the other specimen) those specimens were excluded from the IDP analysis. ROM data were available for all nine specimens. There was a statistically significant difference in an absolute increase in the adjacent segment range of motion in both torque-controlled and displacement-controlled protocol on FE between constructs stopping at C7 and the ones stopping at T1 or T2. There was also a statically significant difference in absolute increase in the IDP using displacement-control protocol at the adjacent level in FE between constructs stopping at C7 and the ones stopping at T1 or T2. There was no statistically significant difference between changes in the ROM or IDP at the adjacent level in LB or AR. There was also no statistically significant difference in absolute change in ROM or IDP at the adjacent level between constructs stopping at T1 and T2, although a trend was towards lower increase in ROM and IDP with C3–T2 construct. CONCLUSIONS This is the first definitive biomechanical study demonstrating a significant difference in the increase in both ROM and IDP at the adjacent level for constructs terminating at C7 versus the ones crossing the cervico-thoracic junction. These findings suggest higher stress on the adjacent levels with likely implications for the adjacent level disease and PJK for multilevel constructs that involve C7 and do not cross the cervico-thoracic junction. FDA DEVICE/DRUG STATUS QUARTEX (Globus Medical) (Approved for this indication)

Cervicothoracic Fixation by Domino Connector in Cervicothoracic Junction Tuberculosis–A Case Report

AbstractCervicothoracic junction tuberculosis involves the C7 to D3 levels of the spine which constitutes 5% of all spinal tuberculosis. As the cervicothoracic junction is transitional zone and a weight-bearing area, the anatomical considerations for treatment of cervicothoracic junction is very difficult. We did a lateral mass screw for C5, 6, and 7 and pedicle screw of D3 and 4 levels, and connected cervical 3.5 mm rod with thoracic 5.5 mm rod using a domino connector. We gave antituberculosis therapy for 18 months. We followed-up the patient routinely and she significantly improved.

Myeloperoxidase-Antineutrophil Cytoplasmic Antibody Positive Hypertrophic Spinal Pachymeningitis at the Cervicothoracic Junction: A Case Report.

Myeloperoxidase-Antineutrophil Cytoplasmic Antibody Positive Hypertrophic Spinal Pachymeningitis at the Cervicothoracic Junction: A Case Report.

CO-relation between cervicothoracic angle and neck pain in adults

Introduction: Neck pain is the fourth most common cause of disability after lower back pain, depression, and joint pain. Cervical sagittal balance is as crucial as pelvic sagittal alignment and is related to the concept of T1 alignment. Materials and Methods: An observational cross sectional study was conducted on 235 Patients diagnosed as neck pain and treated at our institute between August 2017 to July 2019 with age between 20-80 years with neck pain complaints and on medication were included in this study. Pain and functional improvements were assessed using visual analogue scale (VAS) and neck disability index (NDI). Standing lateral view and standing swimmers lateral view of cervical spine radiographs were taken and studied for evaluating cervicothoracic parameters T1 slope and SVA (Saggital Vertical Axis) C2-7, following neck pain and compared with normal ranges. Variations of these criteria have been reported along with the scores of the questionnaire. Statistical analysis was carried out using the edition 21.0 of the Statistical Package for Social Sciences (SPSS). Results: After analysis, it was found that the average T1 slope was 27.82 + 14.33, the average male T1 slope was 26.74 + 14.21 and the average female T1 slope was 28.56 + 14.42. According to Sang et al average T1 slope is 25.7.5 + 6.4 which was taken as a reference for comparison with the asymptomatic population, our study had an increased value but was not significant. Conclusions: The pain in the neck increases with age. It is more prevalent in females. Study shows an increase in neck pain with increasing age due to degenerative changes in the T1 slope, SVA C2-C7. There is no significant correlation with cervical and neck pain or disability but a good relationship between the two. There was no substantial difference in cervical curve between symptomatic and asymptomatic patients. Keywords: Neck pain, Cervical pain, Cervicothoracic junction, T1 Slope.

Immediate effects of cervicothoracic junction mobilization versus thoracic manipulation on the range of motion and pain in mechanical neck pain with cervicothoracic junction dysfunction: a pilot randomized controlled trial

BackgroundCervicothoracic (CT) junction hypomobility has been proposed as a contributing factor for neck pain. However, there are limited studies that compared the effect of CT junction mobilization against an effective intervention in neck pain. Thoracic spine manipulation is a nonspecific intervention for neck pain where remote spinal segments are treated based on the concept of regional interdependence. The effectiveness of segment-specific spinal mobilization in the cervical spine has been researched in the last few years, and no definite conclusions could be made from the previous studies. The above reasons warrant the investigation of the effects of a specific CT junction mobilization against a nonspecific thoracic manipulation intervention in neck pain. The present study aims to compare the immediate effects of C7-T1 Maitland mobilization with thoracic manipulation in individuals with mechanical neck pain presenting with CT junction dysfunction specifically.MethodsA randomized clinical trial is conducted where participants with complaints of mechanical neck pain and CT junction dysfunction randomly assigned to either C7-T1 level Maitland mobilization group or mid-thoracic (T3-T6) manipulation group (active control group). In both the groups, the post graduate student (SJ) pursuing Master’s in orthopedic physiotherapy delivered the intervention. The outcomes of cervical flexion, extension, side flexion & rotation range of motion (ROM) were measured before & after the intervention with a cervical range of motion (CROM) device. Self-reported pain intensity was measured with the numerical pain rating scale (NPRS). The post-intervention between-group comparison was performed using a one-way ANCOVA test.ResultsForty-two participants with mean age CT junction group: 35.14 ± 10.13 and Thoracic manipulation group: 38.47 ± 11.47 were recruited for the study. No significant differences in the post-intervention baseline adjusted outcomes of cervical ROM & self-reported pain intensity were identified between the groups after the treatment (p = 0.08, 0.95, 0.01, 0.39, 0.29, 0.27for flexion, extension, bilateral lateral flexion & rotations respectively) & neck pain intensity (p = 0.68). However, within-group, pre, and post comparison showed significant improvements in cervical ROM and pain in both groups.ConclusionThis preliminary study identified that CT junction mobilization is not superior to thoracic manipulation on the outcomes of cervical ROM and neck pain when level-specific CT junction mobilization was compared with remote mid-thoracic manipulation in individuals with mechanical neck pain and CT junction dysfunction.Trial registrationCTRI: 2018/04/013088, Registered 6 April 2018, http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=24418

Reverse "L" surgical approach for the management of giant tumors of the cervicothoracic junction.

BackgroundAn isolated cervical or thoracic surgical approach provides insufficient exposure for achieving complete resection of tumors of the cervicothoracic junction. This study examines reverse “L” thoracotomy as a surgical approach to these tumors. Additionally, the feasibility, safety, and effectiveness of reverse “L” surgical incision for tumor resection was also analyzed.MethodsPatients with cervicothoracic tumors were identified from an internal database. Subjects were selected on the basis of undergoing reverse “L” thoracotomy from August 2014 to August 2018. The tumor characteristics, surgical technique, completeness of resection, morbidity, and patient outcome were reviewed.ResultsAll patients successfully underwent resection through reverse “L” surgical approach. No patients needed to undergo full sternotomy. There were 6 neurogenic tumors, 4 thyroid adenocarcinomas, 4 bronchogenic tumors, and 7 other cases in the study. The median operative time was 191.0 min (range, 113.0–348.0 min) and postoperative in-hospital stay ranged from 3 to 7 days. Horner syndrome was observed in 1 case. Hoarseness and lymphatic leakage were evident in 3 and 1 case(s), respectively. Hemidiaphragm paralysis was observed in 1 case. Three cases were unsuccessful in achieving R0 resection. The duration of follow-up ranged from 6 to 42 months. Eleven of 13 patients who underwent resection had no evidence of tumor recurrence. Two patients with metastatic disease died of distant progression within 15 months.ConclusionsApplying reverse “L” surgical approach is safe, feasible, and effective for the resection of giant tumors of the cervicothoracic junction.

Visualization of the Cervicothoracic Junction With EOS Imaging Is Superior to Conventional Lateral Cervical Radiographs.

Study Design:Single-center retrospective review.Objectives:The cervicothoracic junction (CTJ) is typically difficult to visualize using traditional radiographs. Whole-body stereoradiography (EOS) allows for imaging of the entire axial skeleton in a weightbearing position without parallax error and with lower radiation doses. In this study we sought to compare the visibility of the vertebra of the CTJ on lateral EOS images to that of conventional cervical lateral radiographs.Methods:Two fellowship-trained spine surgeons evaluated the images of 50 patients who had both lateral cervical radiographs and EOS images acquired within a 12-month period. The number of visible cortices of the vertebral bodies of C6-T2 were scored 0-4. Patient body mass index and the presence of spondylolisthesis >2 mm at each level was recorded. The incidence of insufficient visibility to detect spondylolisthesis at each level was also calculated for both modalities.Results:On average, there were more visible cortices with EOS versus XR at T1 and T2, whereas visible cortices were equal at C6 and C7. Patient body mass index was inversely correlated with cortical visibility on XR at T2 and on EOS at T1 and T2. There was a significant difference in the incidence of insufficient visibility to detect spondylolisthesis on EOS versus XR at C7-T1 and T1-2, but not at C6-7.Conclusions:EOS imaging is superior at imaging the vertebra of the CTJ. EOS imaging deserves further consideration as a diagnostic tool in the evaluation of patients with cervical deformity given its ability to produce high-quality images of the CTJ with less radiation exposure.

Traumatic Fracture: Dislocation of Cervicothoracic Junction—Grand Round Presentation of C7-T1 Instabilities and Different Instrumentation Techniques

Introduction Acute traumatic cervicothoracic junction spinal lesions are rare disorders and poorly documented. We report a case of a traumatic cervicothoracic fracture-dislocation. We present our experience in the operative treatment of an unstable fracture-dislocation at the cervicothoracic junction. Materials and Method. A seventy-year-old man was transferred to our hospital. We found paresthesia in the corresponding dermatome of C7 and C8 bilaterally. Initial CT scan shows vertebral body fracture of T1 with retropulsion into the spinal canal and anteroposterior dislocation of cervicothoracic junction type C according to AOSpine subaxial injury. Traumatic disc material at C7-T1 was removed by anterior cervical discectomy and fusion of C6-T2. Fixation was done from C6 to T2 in the prone position. Results At one-year postoperative follow-up, radiographs revealed bony fusion at the level of C7-T1, and the patient had no major functional disability. Conclusion We opted for the ventral-dorsal approach in our case for maximum stabilization and to prevent mechanical complications.

Fatigue Testing of a Titanium Tapered Rod versus Two Rods Connected by a Parallel Connector across the Cervicothoracic Junction: A Biomechanical Study

This study compares the fatigue failure of a tapered titanium-rod construct against two connected titanium rods (domino construct) across the cervicothoracic junction. All testing was carried out in a simulated flexion-extension plane. The 3.5-mm/6.0-mm tapered titanium rod and the 3.5-mm titanium rod, connected to a 6.0-mm titanium rod with a connector, were compared for their fatigue failures. Six specimens of each construct were tested in a cantilever displacement control method using 6 different amplitudes. Each specimen was cycled to failure or to 2.5 million cycles (run out) at 10 Hz. Failure was defined as rod fracture. The domino construct reached the test limit of 2.5 million cycles at± 0.45 mm (72 N) but failed in all the other tested amplitudes. The tapered rod construct reached the test run out limit of 2.5 million cycles at higher amplitudes than the domino construct at ± 0.9 mm and failed in all the other tested amplitudes. The study showed that the tapered-rod construct across the cervicothoracic junction is more fatigue resistant than the domino construct.

Crossing the Cervicothoracic Junction During Posterior Cervical Decompression and Fusion: Is It Necessary?

Posterior cervical fusion (PCF) is performed to treat cervical myelopathy, radiculopathy, and/or deformity. Constructs ending at the cervicothoracic junction (CTJ) may lead to higher rates of adjacent segment disease, and much debate exists regarding crossing the CTJ due to paucity of data in the literature. To determine whether extension of PCF constructs across the CTJ decreases incidence of adjacent segment disease and need for revision surgery. A single-center retrospective case series of patients undergoing multilevel PCFs since 2011 with at least 6-mo follow-up was conducted. Outcomes were analyzed and compared based on caudal extent of instrumentation via multivariate regression. A total of 149 patients underwent PCF, with a mean follow-up of 18.9 mo. A total of 15 (10.1%) revisions were performed, 7 (4.7%) of which were related to the construct. Five (8.3%) revisions were performed for constructs ending at C6, 1 (5.3%) at C7, 1 (2.6%) at T1, and none (0%) at T2 (P=.035). Mean procedure duration was 215min at C6, 214min at C7, 239min at T1, and 343min at T2 (P=.001). Mean estimated blood loss was 224mL at C6, 178mL at C7, 308mL at T1, and 575mL at T2 (P=.001). There was no difference in length of stay, disposition, surgical site infection, or radiographic parameters. Extension of PCFs across the CTJ leads to lower early revision rates, but also to increased procedure duration and estimated blood loss. As such, decisions regarding caudal extent of instrumentation must weigh the risk of pseudarthrosis against that of longer procedures with higher blood loss.