Authors of section

Authors

Carlo Bellabarba, Marcelo Gruenberg, Cumhur Oner

Executive Editor

Luiz Vialle

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Anterior approach to the cervico thoracic junction

1. Introduction

This approach is used for access to the anterior C7-T1 through T1–T2 levels for decompression or reconstruction of the injured anterior spinal column. Depending on the patient's anatomy, access to lower levels may also be possible.

anterior approach to the cervico thoracic junction

Access to the lower levels may require partial resection of the manubrium and clavicle (manubrial window).

anterior approach to the cervico thoracic junction

Although a formal sternotomy can be used for improved access to the upper thoracic spine below T2, this exposure can be achieved with greater ease and less morbidity using alternative posterolateral approaches.

anterior approach to the cervico thoracic junction

Injuries of the esophagus can be associated with fractures or occur as a complication of the approach.

In addition to the tracheo tube a nasogastric tube should be inserted to better identify and thus help prevent accidental injury to the esophagus.

These are serious and potentially lethal complications. Consultation with thoracic or ENT surgeons should be obtained.

anterior approach to the cervical spine

2. Incision

The incision is starts along the medial border of the sternomastoid muscle down to the sternal notch.

anterior approach to the cervical spine

One may estimate how caudally the cervicothoracic junction can be accessed by viewing the position of the sternum relative the cervicothoracic junction on lateral radiograph or sagittal CT image.

If looking through the manubrium notch (in red) you can see the upper thoracic, then a common lower cervical would be enough, as in the T3 example.

If you only can see the lower cervical an extended approach would be recommended.

A left sided approach places the thoracic duct at risk while a right sided approach may be more likely to injure the recurrent laryngeal nerve.

anterior approach to the cervico thoracic junction

3. Dissection

Platysma muscle is transected in line with the skin incision.

anterior approach to the cervical spine

The deep cervical fascia is identified and divided along the anteromedial border of the sternocleidomastoid muscle.

It is beneficial to sufficiently release the superficial fascia as this greatly facilitates exposure of the deeper anatomic layers.

anterior approach to the cervical spine

The omohyoid muscle crosses the surgical field at the level of C6 and can be transected to improve exposure.

Division of sternohyoid and sternothyroid muscles will facilitate the extensile exposure.

anterior approach to the cervico thoracic junction

The carotid pulse is palpated and the dissection is directed medial to the carotid sheath.

anterior approach to the cervical spine

A finger is then used to dissect bluntly between the carotid sheath laterally and trachea and esophagus medially down to the prevertebral fascia.

Injuries to the esophagus and carotid artery can be associated with fractures or occur as a complication of the approach. Approach related complications can be avoided by using blunt dissection.

Esophageal injuries are serious and potentially lethal complications. The best results are achieved with immediate recognition and repair. Consultation with thoracic or ENT surgeons should be obtained.

Note: In case of carotid artery injury direct pressure should be applied and vascular surgery consultation requested urgently.

anterior approach to the cervical spine

The incision is continued along the proximal third of the sternum.

anterior approach to the cervico thoracic junction

Depending on the exposure needed, a manubriotomy may be sufficient to provide sufficient access.

anterior approach to the cervico thoracic junction

If a more extensive approach is needed, a sternoclavicular approach may be used (as described below).

anterior approach to the cervico thoracic junction

The sternoclavicular joint is opened. At this point, the medial end of approximately 3 cm of the clavicle may be resected to facilitate access.

The resected clavicle can be used as a strut graft.

anterior approach to the cervico thoracic junction

Blunt dissection is made down to the brachiocephalic trunk which is mobilized as needed.

The lung is protected using a sponge if needed.

anterior approach to the cervico thoracic junction

The prevertebral fascia is cut longitudinally allowing direct visualization of the vertebra and the longus coli muscle.

The level is verified with fluoroscopy.

The sternothyroid, sternohyoid, and omohyoid muscles may be retracted or transected when necessary for a better exposure.

anterior approach to the cervico thoracic junction

4. Closure

The split muscles are approximated and the transected sutured.

anterior approach to the cervico thoracic junction

The platysma muscle is sutured followed by a subcutaneous and skin closure. Skin closure can be performed with a subcuticular suture to enhance cosmesis.

anterior approach to the cervical spine

A wound drain is inserted through a separate stab incision.

anterior approach to the cervical spine