Anterior Approaches to the Cervicothoracic Junction

Published on 02/04/2015 by admin

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Last modified 02/04/2015

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Chapter 20 Anterior Approaches to the Cervicothoracic Junction

TRANSCLAVICULAR–TRANSMANUBRIAL APPROACH

Radiological studies of the upper thoracic spine have indicated that at least the T3 vertebra can be visualized in the majority of patients in whom a suprasternal approach is undertaken after the splitting and mobilization of the manubrium.1

The external landmarks for level identification are T2–3 at the suprasternal notch and T4–5 at the sternal angle (Fig. 20-1). Before adopting this approach, it is important preoperatively to confirm the extent of the lesion and the position of the upper margin of the sternum on lateral radiographs. It also is essential to assess the affected spinal cord level and its relation to the level of the upper margin of the sternal manubrium because this relationship varies among individuals.

BONE REMOVAL

The medial third of the clavicle and manubrium is dissected periosteally. The clavicle is divided at the junction of the medial and middle thirds (Fig. 20-2). All procedures are safe when the periosteum is separated from the bone by using a raspatory. While excising the sternum, the sternum lining is carefully separated using the raspatory to avoid possible damage to the internal mammary artery (Fig. 20-3).2

The separation procedure is extended caudally to expose the level of the lesion, such as the upper thoracic spine. It is important to approach the vertebral body of the lower cervical spine and then extend the operative field to the caudal side. In such a case, no direct surgical procedure for the aortic arch and the great vessels is necessary. At some levels of the operative field, these great vessels may have to be retracted to the right or left, but directly separating them is unnecessary.

The left side of the manubrium can be removed piecemeal along its posterior periosteum.

Alternatively, the manubrium and sternoclavicular joint can be left intact and reflected with the sternal head of the sternocleidomastoid muscle (Fig. 20-4).

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