1. Optimal Anterior Approach for the Cervicothoracic Junction Lesions Dept. of Neurosurgery Soonchunhyang University Bucheon, Korea Prof. Soo-Bin Im Dong-Seung Shin, Bum-Tae Kim, Won-Han Shin

2. Anatomical & Clinical peculiarity  Reversal of lordosis to Kyphosis  visualization deeper.  Limited by sternum, clavicle, vital structures Trachea, esophagus, great vessels, thoracic duct, lung apex, recurrent laryngeal n. brachial plexus  Pathologic process usually occurs in anterior segment. Lung apex Great vessels Anterior Approach for CTJ lesion enables direct decompression & stabilization.

3. Case summary of surgery on CTJ Transmanubrial approach 1. 67/F Plasmacytoma T2 2. 61/M Metastatic tumor T1 3. 51/M Metastatic tumor T3 4. 20/F Giant cell tumor C7T12 5. 22/F Giant cell tumor (recurred) C7T12 5. 46/M TB spondylitis T2 6. 47/M TB spondylitis T23 7. 56/F Spondylotic myelopathy C7T1 8. 62/F Ruptured disc T12 9. 69/M Ruptured disc T12 10. 45/M Bursting fracture with syrynxT2 Supramanubrial approach 11. 44/F Metastatic tumor T1

4.  Extended incision from cervical to manubriosternal junction  Finger dissection of posterior surface of the manubrium.  Inverted T-shape manubriotomy with oscillating saw  Strong short retractor for splitted manubrium  Long retractor for visceral structure Operating Scene for approach

5.  If upper parallel line is below supramanubrial border  manubriotomy is inevitable.  If only Inferior parallel line is below supramanubrial border  relative indication for manubriotomy * Spatial relationship between supramanubrial border and Upper and lower parallel line is critical for exposure and decision of manubriotomy length

6. * * * Manubriotomy is mandatory Relative Ix for manubriotomy Not need manubriotomy T1T1 C7 Decision for manubriotomy length should be made - By two parallel line to the lesion. - Not by number of vertebrae. T2

7. Length of manubriotomy  Regardless of the full sternotomy, the caudal extent is limited to T3 by the innominate vein, aortic arch.  Inverted T-shape Manubriotomy at the 2 nd intercostal space is optimal and usual.  Variation of vertebral level and kyphotic angulation deformity Innominate vein Trachea Carotid artery

8. Common Pitfall 61/F plasmacytoma with kyphotic angulation Preop. Postop. 2 yrsPostop.

9. Reconstruction  Iliac bone graft with anterior plating ------------------------- 1  Flanged titanium mesh only ------------------------------------ 5  Titanium mesh + anterior plating ------------------------------ 2  Mesh + Plate + posterior augmentation --------------------- 2 T1

10. Result & Complications  Neurologic recovery ------------------------------------ 9  Recurrent laryngeal nerve injury --------------------0  Trachea, Esophageal injury -------------------------0  Local hematoma, infection ---------------------------0  Nonunion or pain on manubriotomy site------------0  Thoracic duct injury, Chylothorax ------------------- 1  Recurrence of tumor( giant cell tumor, 3 yrs )---- 1

11. Thoracic duct injury  Unfamiliar complication to spine surgeon.  Might be avoided by limiting the dissection. medial to the carotid artery,  Find and ligation rather than dissection.  Chylothorax occurs  chest tube drainage, lipid free diet. T1T1

12. Conclusions  Anterior approach for CTJ lesion is challenging but provides direct decompression and effective reconstruction method.  Inverted T-partial manubriotomy is optimal for the T1-T3.  Manubriotomy can be decided by upper and lower parallel line to the lesion.  The spatial relationship between upper parallel line and supramanubrial border is critical for exposure. *