THORACIC. VERTEBRAE ... of decompression and stabilisation are ... nerve is more constant in its location. TECHNIQUE. OF OPERATION. The patient .... thoracic vertebrae presents technical difficulties. In a patient with a long slender neck.
ANTERIOR
APPROACH
TO THE
RONALD
Front
King
tile
Edward
The anterior exposure We report our experience of one clavicle
UPPER
CHARLES,
VIII
THORACIC
SHUNMUGAM
Hospital
and
the
VERTEBRAE
GOVENDER
Universit;’
of Natal,
Durhan,
South
Africa
of the upper thoracic spine using standard methods is often difficult and limited. using a technique described by Sundaresan et al. (1984) in which the medial portion
and part of the manubrium
sterni
are excised.
In 10 cases
we found
this to be a useful
and safe
procedure.
Anterior
approaches
purposes
of
to
established,
but
transthoracic
methods especially
third
to this
route
sternotomy
al.
but
1960;
describe
et al.
resection
the
right
Brink
the in
when
patient
left
trachea area
help
left
identify
side
of
on the it is safer
recurrent
OF under
and
part
and
by
individual to use
left is
the
the
case. the
above
released
and
and
at
they are is made
parallel
from
the
to the
clavicle
vein.
is resected
using
so that the cortex
it can
Part
and
medial with
innominate
operation.
preserving anterior
the
and the subperiosteally
clavicle
retained
from
the
end
of
working. with the
transverse
clavicles,
extending
the
half care
The medial third a Gigli saw and
be replaced
of
manubrium.
the
The
of one clavicle are being taken not to
as a graft
manubrium
opposite sternoclavicular of the manubrium is cut
or half of the bone
at the
end
is
excised,
of
joint. The using a high
If side
more
and The
A
the
anaesthesia
and
head
vocal
sandbag
turned cords
Surgeon New York
is
away are
10805,
should
be
sent
to Dr
R. W.
JANUARY
1989
and
a
is used
to
placed
from
inspected
the by
USA.
FRCS, Senior Surgeon and Senior Lecturer of Orthopaedics, Faculty of Medicine, University Box 17039, Congella 4013, Republic of South Africa.
I,
on
manubrium exposed
carotid
either
start
from the lateral border of one sternocleidomastoid muscle to the other. The vertical limb is in the midline extending to the middle ofthe sternum. On the side of the approach, the sternocleidomastoid and the strap muscles
are
of the
the
stethoscope
oesophagus.
operation.
No.
1 cm
by
between
nerve
general
© 1989 British Editorial Society of Bone 0301 -620X/89/ 1019 $2.00 J Bone Joint Surg [Br] I 989:7 1-B :81-4.
71-B.
T2
the
OPERATION
or an oesophageal the
Correspondence
VOL.
and
revealed
laryngeal
R. W. Charles, MD, Orthopaedic 220 Pelham Road, New Rochelle, S. Govender, Department Natal, P.O.
of Tl
be approached
depending
the scapulae the
report
at
location.
tube
between
We
Memorial
and
sterni are
medially
may
is indicated
its
front
vertebrae
is intubated
nasogastric
at the
York,
manubrium
The
TECHNIQUE The
a median
described
working
the
limb
A
1980).
approach
approached
high
(Hodgson
Edmonson
the
in New
and
side
because
exposure
Hospital
The
or the
constant
is through
anaesthetist
procedure to confirm that A “T” shaped incision
present
is to be done.
spine
the
well
and and
limited
and
with
side.
laterally.
no specific
the
gives
of the
one
oesophagus
sheath
cervical exposure
grafting
for
are
damage
Sundaresan
the
of
also
(1984)
Sloane Kettering our results.
on
limited
experience
Sundaresan
partial
anterior
give part
this
spine
stabilisation
low
if bone
Vanden
our
clavicle
cervico-dorsal and
the
a problem,
et
the
decompression
of Fig.
I
Charles. Joint
Surgery
The operative field after been excised. The strap oesophagus are retracted The innominate vein is
part ofthe clavicle and ofthe manubrium have muscles are turned upwards, the trachea and to one side and the carotid sheath to the other. retracted downwards.
81
R. W. CHARLES,
82
speed steally
burr; with The
the posterior a strong pair plane
cortex is resected of scissors or bone
between
the
trachea
and
medially, and the carotid sheath laterally, the recurrent laryngeal nerve is identified the
innominate
prevertebral the
front
a
of the
radiograph
involvement. and The
vein
muscles
is
vertebrae is
(Fig.
taken down
decompression and excised clavicle
attached closed
and
to the periosteum. over
suction
downwards. metal
confirm
the
to T3
the
The
Postoperatively
is easily
collar
platysma
muscles
and
lateral
tomograms
patient
level
of
Ten
patients
months.
achieved
and
the
summarised used
to grade
1969).
Before
re-
al.
skin
are
and five involved
destructive
changes
patient
incomplete area were
T3
done
in
all
were
sufficiently
average
function failure
remaining No is destruction displacement tuberculosis.
of of
the the
5.9
respiratory
the Tl. There and lamina with Histology showed
from
of
respiratory patients 3
varied time
side
seven patient
from
no
which
three
THE
weeks
2).
Myelo-
the tomograms
to
1 1 months patient
with
poor
paralysis
died
from
after
neurological
operation.
at the time any shoulder
of
OF
with
recovery
the
performed
JOURNAL
swelling.
One
complete
part
(Fig.
of the and
LTS
were ambulant experienced
removed and replaced. Bone grafting was
tissue
when
et
complete
3).
months. three
showed
patients
(Fig.
and
soft
useful
clear
(Frankel had
radiographs to interpret,
prevertebral
18
classification
patients
Plain difficult
of
diagnoses
Frankel
five
with
CT scans
a period
involvement
paralysis. often
and
were
and
Follow-up
of
up.
histological
I. The
neurological operation,
T2
over
and
RESU
CT myelogram vertebral body, pedicle spinal cord to the left.
is allowed
operation data
in Table
in Tl,
not
this
clinical
was
are
showing
had
Their
are
were
10.
sandbags
PATIENTS
graphy
Case
with
markers,
tomograms
Fig.
is nursed
The
drains.
Case 9. Anteroposterior and Histology showed tuberculosis.
is applied
from
may be performed. as a bone graft, strap
the
on either side of the head. Provided that radiographs then show the graft to be in good position, a firm cervical
oesophagus
and stripped
stabilisation is replaced
is secured
subperionibblers.
is developed; and protected;
1). Using
to
Exposure
haemostasis
retracted
are now exposed
S. GOVENDER
BONE
AND
Two
but
the
of discharge. problem on
clavicle in eight
an
had
been
patients
and
JOINT
SURGERY
ANTERIOR
Fig. Case shown
APPROACH
graft months.
is
at final follow-up One patient had
all grafts only a
were partial
incorporated vertebrectomy
therefore
was
used,
and
another
atory and
failure was in a patient with old pulmonary tuberculosis.
gave
no problem
and
death
was
cases the graft in bed for three
(Fig.
had
bone which would not accept a graft. Problems and complications. The one death
one of the early patient was kept
VERTEBRAE
83
very
from
seemed resolved
soft
secondary deposit of thyroid carcinoma, the graft not be inserted because of profound osteoporosis.
respir-
chronic brochiectasis The operation itself not
attributed
displaced months
details
of
to be due to retraction within two weeks.
patient
was
Luque
rod
subsequently and
bone
stabilised
The the
Site
1
69
M
T2
An
anterior
presents
approach
technical
slender approach
to the difficulties.
neck and drooping can sometimes
upper In
2
63
F
11
3
56
F
4
45
5
VOL.
71-B,
Duration (months)
Pathology
Pre-op
Follow-up
Died
A
-
4
A
A
3
A
A
Thyroid
T2
2
Breast
F
Tl
3
? Tuberculosis
6
C
D
52
F
T2 and
8
Myeloma
5
A
D
6
35
F
Tl
10
Tuberculosis
11
A
E
7
50
M
Tl
2
Tuberculosis
9
B
E
8
53
M
T3
6
Tuberculosis
5
C
E
9
31
F
Tl,
1
Tuberculosis
4
C
E
Tuberculosis
6
B
E
53 Frankel
No.
grades
1, JANUARY
M : A, complete
1989
3
C7 and paraplegia
Tl
3
12 to E, free
of neurological
tumour
1* grade
Follow-up (months)
1
2
2 and
a
vertebrae with
shoulders an anterior give adequate exposure,
? Secondary
and
could This using
thoracic
a patient
1
10 *
posteriorly
it a
DISCUSSION
Franke Sex
and with
cement.
10 patients
Age (years)
Case
on the larynx one patient,
In
to it. In
slightly. and finally
was well incorporated. Hoarseness of voice occurred in one patient after surgery, though the vocal cords were recorded as functioning at the end of the procedure. The hoarseness
I. Clinical
THORACIC
4). and
graft
Table
UPPER
4
9. The at three
no graft
TO THE
secondary secondary
symptoms
a long cervical but in
R. W. CHARLES,
84
patients especially median
with normal physique access tends to be limited for bone grafting. The high transthoracic and sternotomy approaches to this area also give
S. GOVENDER
position and does the nerve
exposure. We found that partial excision of the clavicle and manubrium was technically simple, and enabled decompression and grafting to be performed with ease. We were able to visualise the body ofT3 in all cases. Because
to injury. We
ofthe
difference
The
nerve
on each
spine
from
limited
in the location
side, the
left
ofthe
it is less hazardous side.
Here
the
recurrent
laryngeal
to approach nerve
reaches
the its
method known
between
the trachea
and oesophagus
not cross the operative does cross the operative found
this
approach
field. field to
be
for a difficult area in the to all who perform anterior
authors are No benefits from a commercial this article.
grateful in any party
in the chest
On the right side and is thus prone a safe
spine; spinal
and
useful
it should surgery.
be
to Mrs B. Katia who typed the manuscript. form have been received or will be received related directly or indirectly to the subject of
REFERENCES Frankel
HL, Hancock reduction in the with paraplegia
DO, Hyslop initial management and tetraplegia.
G,
et al. The value of postural of closed injuries of the spine Parap/egia 1969;7:179-92.
Hodgson AR, Stock FE, Fang HSY, Ong GB. Anterior spinal fusion: the operative approach and pathological findings in 412 patients with Pott’s disease of the spine. Br J Surg 1960-1961 ;48:l72-8.
Sundaresan N, Shah J, approach to the l984;6l :686-90. Vanden
Foley upper
KM, Rosen thoracic
Brink KD, Edmonson AS. Crenshaw AH, eds. Campbe//’s ed. St. Louis, etc: CV Mosby,
THE
JOURNAL
G. An vertebrae.
anterior J
surgical Neurosurg
The spine. In : Edmonson operatit-e orthopaedics. Vol.2. 1980.
OF BONE
AND
JOINT
AS, 6th
SURGERY
