Anterior Cervicothoracic Junction Approach

Surgical approaches to the cervicothoracic junction frequently involve complicated dissection because of the restricted accessibility during the procedure and the close proximity of the great vessels. Common indications for surgical intervention include infections, neoplasms, and fractures. Approaches described here are useful for pathologies of the difficult-to-access upper thoracic spine (T1–T4). The modified anterior approach has become the method of choice at the authors’ institution. Care must be taken when using this approach so as not to injure the recurrent laryngeal nerve or the brachiocephalic vessels. When using the sternal splitting approach, it is important to keep in mind that it adds marked morbidity risk with the potential for a sternal wound infection. The transthoracic approach uses a proximal thoracotomy with removal of the third or fourth rib. Exposure to the first four thoracic ribs is adequate with this technique, but access to the lower cervical vertebrae can be difficult. Other complications associated with this approach are the added morbidity related to lung manipulation and the potential for Horner’s syndrome resulting from damage to the sympathetic chain. In general, neurologic results depend largely on the patient’s preoperative status and their underlying disease process. Postoperative complications, such as shoulder dysfunction, hardly ever occur, and swallowing dysfunction is usually short lived. A positive outcome is that some patients can achieve as much as a 20° correction of kyphosis. In conclusion, the authors have found that most patients recover quite well from this procedure, with the vast majority experiencing notable pain relief and a timely return to independent ambulation.