How to surgically approach the thoracic spine anteriorly

1. Dr. RABAIL AKBAR QAZI
NEUROSURGERY RESIDENT
ANTERIOR APPROACHES
TO THE THORACIC SPINE
ANTERIOR APPROACHES TO
THE THORACIC SPINE
Dr. RABAIL AKBAR QAZI
NEUROSURGERY RESIDENT

2. THREE APPROACHES
SUPRACLAVICULAR TRANSCLAVICULAR TRANSSTERNAL

3. ANATOMY OF THE NECK

4. ANATOMY OF THE NECK

6. ANATOMY OF THE NECK

7. ANATOMY OF THE NECK

8. ANATOMY OF THE UPPER THORAX

9. IMPORTANT LANDMARKS
• ANGLE OF MANDIBLE – C2
• HYOID BONE – C3
• THYROID CARTILAGE – C4-C5
• CRICOID CARTILAGE – C6

10. INDICATIONS:
 TUMOR
 FRACTURES
 INFECTIONS
 STRUCTURAL DEFORMITY
 SYMPTOMATIC PID (C7-T3)
THE SUPRACLAVICULAR APPROACH

11. CONTRAINDICATIONS:
 Pathology below T2
 Obstruction by anomalies of great vessels or lesions
involving great vessels of the neck.
 Limited exposure due to
Short Neck
Prominent Musculature
Kyphosis
THE SUPRACLAVICULAR APPROACH

12. MRI to assess spinal cord compression
Plain X-Rays to assess alignment
Dynamic flexion/extension radiographs
CT scan with sagittal reconstruction
PREOPERATIVE IMAGING

13. THE SURGICAL PATHWAY

14. THE SUPRACLAVICULAR APPROACH
• Place the patient in a supine
position
• Slightly hyperextend the neck
• Rotated away from the side of the
approach
POSITION

15. INCISION
 Identify the important
landmarks
 Make a transverse skin
incision 2 cm above the
clavicle
 Extending from the midline to
the posterior border of the
Sternocleidomastoid muscle.
THE SUPRACLAVICULAR APPROACH

16. THE SUPRACLAVICULAR APPROACH

17. THE SUPRACLAVICULAR APPROACH

18. THE SUPRACLAVICULAR APPROACH

19. Aggressive lateral
dissection of the
longus coli can
damage the
sympathetic plexus
or the vertebral
artery.
THE SUPRACLAVICULAR APPROACH

20. After grafting/instrumentation, area is copiously
washed with antibiotic impregnated normal
saline
No. 7 Jackson Pratt drain can be placed to
prevent hematoma formation and kept for 2-3
days
Place the patient in a Philadelphia cervical collar
ICU monitoring for a minimum of 24 hours
Monitor for respiratory difficulties
CXR
CLOSING AND POSTOPERATIVE CARE

21. INTRAOPERATIVE COMPLICATIONS

22. Respiratory complications
Soft tissue edema
Hematoma formation
Hoarseness
Horner’s syndrome
Infection
POSTOPERATIVE COMPLICATIONS

23. INDICATIONS
 Trauma
 Tumors
 Infection
 Degeneration
 Kyphosis Correction
 Vascular Malformations
 Compression Fractures of the vertebral bodies
TRANSMANUBRIAL-TRANSCLAVICULAR/
TRANSTERNAL APPROACH

24. Obstruction by anomalies of great vessels
Learning curve
High surgical risk
Medical contraindications
CONTRAINDICATIONS

25. ADVANTAGES DISADVANTAGES
• Provides access down to T3 • Thorough knowledge of anatomy in
the region
• Enables simultaneous decompression
and fixation
• Risk of Injury to vessels, pleura and
neural structures
• Less morbidity than the transsternal
approach
• Instrumentation at T4 is limited by
aortic arch
• Posterior stabilization cannot be
performed without repositioning the
patient

26.  Introduced by
Sundaresan et al in
1984
 Half of the manubrium
and the medial 1/3rd
of the clavicle is
excised
 A ventral approach to
vertebral levels C3 to
T4 is achieved
TRANSCLAVICULAR-TRANSMANUBRIAL
APPROACH

27. TRANSCLAVICULAR - TRANSMANUBRIAL
APPROACH
INCISION

28. TRANSCLAVICULAR – TRANSMANUBRIAL
APPROACH

29. THE PATHWAY

30. THE PATHWAY
The final corridor
to the vertebrae is
between the left
common carotid
artery and the
right Innominate
(Brachiocephalic)
artery

31. TRANSCLAVICULAR – TRANSMANUBRIAL
APPROACH
After the retraction of
the great vessels,
trachea and
esophagus, and cutting
the omohyoid muscle
crossing the incision,
the manubrial window
has been created.

32. TRANSCLAVICULAR – TRANSMANUBRIAL
APPROACH

33. THE TRANSTERNAL APPROACH

34. IMPORTANT STRUCTURES

35. TRANSTERNAL APPROACH

36. Copious antibiotic irrigation should be done
Complete hemostasis should be secured
The wound is closed in layers over a redivac
drain
If the clavicle and manubrium is removed in
one piece, it’s possible to reattach them with
miniplates
Strap muscles are loosely approximated and
sternocleidomastoid is reattached
THE CLOSURE

37.  The patient needs to be closely observed in ICU for
24-48 hours for signs of laryngeal or esophageal
edema.
 Hoarseness due to traction on recurrent laryngeal
nerve doesn’t need any special treatment.
 Damage to superior laryngeal nerve may cause
difficulty in clearing secretions. Re-intubation will be
necessary
 Keep the drain for 2-3 days to prevent hematoma
formation
POSTOPERATIVE CARE

38. INTRAOPERATIVE COMPLICATIONS

39. INTRAOPERATIVE COMPLICATIONS