ANTERIOR THORACIC CORPECTOMY WITHOUT STERNOTOMY - A STRATEGY FOR MALIGNANT DISEASE OF THE UPPER THORACIC SPINE

Background: With increasing frequency, spine surgeons are being asked to provide decompression and stabilization in patients with spinal met astases. While no region of the spine is easily treated, the upper tho racic spine is perhaps the least accessible. Traditional approaches to this region involve either thoracotomy or at least limited sternotomy . The authors present an approach to anterior pathology of the upper t horacic spine that obviates the need for sternotomy. Methods: Within t he past two years, two patients with cervicothoracic metastases underw ent anterior decompression and fusion without sternotomy. In both pati ents, the bodies of C7, T1, and T2 were removed. While both patients w ere prepared and draped for sternotomy, each required a neck dissectio n only. In both patients, left-sided incisions were made along the lea ding edge of the sternocleidomastoid. The platysma was divided with th e overlying skin. With further dissection, the strap muscles were tagg ed and divided approximately one centimeter above their sternal attach ments. The loose areolar tissue of the superior mediastinum was then b luntly dissected. Along the entire length of the incision, the vascula r plane medial to the carotid sheath was developed to facilitate expos ure of the anterior spine. A Farley-Thompson retractor system was then employed to retract and protect the superior mediastinal structures. With this exposure, corpectomies were carried out using a high speed d rill. Fusion was accomplished through insertion of Steinmann pins into the adjacent intact bodies above and below. This was followed by appl ication of methyl methacrylate. Both patients had immediate postoperat ive stability with preservation of spinal cord function. Both patients subsequently underwent removal of dorsally located tumor with posteri or fusion. Conclusions: The goal of cancer surgery is to provide for i ncreased functional survival without undue morbidity. The authors feel that when possible, the pain of sternal and clavicular osteotomies sh ould be avoided. The described approach works well in conjunction with a methyl methacrylate/Steinmann pin construct. Because of the intact sternum, the surgeon has a downward angle to access the superior endpl ate of T3. With adequate soft tissue dissection and retraction as desc ribed, however, T3 and perhaps even T4 are easily accessible. While th is downward angle would likely not permit an anterior plating procedur e, it lends itself nicely to Steinmann pin/methyl methacrylate fusion and spares the patient the pain and potential morbidity of sternotomy.