Ministerntomy to attack Upper Thoracic Lesions | ||||||||||||||||||||||||||||||||||||
Minia Journal of Medical Research | ||||||||||||||||||||||||||||||||||||
Article 20, Volume 34, Issue 2, April 2023, Page 167-175 PDF (723.76 K) | ||||||||||||||||||||||||||||||||||||
Document Type: Original Article | ||||||||||||||||||||||||||||||||||||
DOI: 10.21608/mjmr.2023.185809.1285 | ||||||||||||||||||||||||||||||||||||
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Authors | ||||||||||||||||||||||||||||||||||||
Walid zidan Nanous 1; Mohamed Abdlehameed El-Heeny2; Mohab mohamed nageeb Darwish 3 | ||||||||||||||||||||||||||||||||||||
1department of neurosurgery, faculty of medicine , mini university | ||||||||||||||||||||||||||||||||||||
2Department of neurosurgery, Faculty of medicine, Minia university | ||||||||||||||||||||||||||||||||||||
3Department of Neurosurgery, faculty of medicine , mini university | ||||||||||||||||||||||||||||||||||||
Abstract | ||||||||||||||||||||||||||||||||||||
background Surigcal intervention and access to the upper dorsal vertebrae through the anterior approach is difficult due to the anatomy of the region and the structures surrounding the upper dorsal spine, we go into precise detail about the mini-sternotomy approach in treating traumatic, infectious, and metastatic upper Dorsal vertebral body pathologies. Aim of the work our experience in using the ministernal approach in treatment of anterior upper dorsal pathologies. Patients and methodss This is a retrospective study on 10 patients with dorsal myelopathies due to traumatic, infection and metastases with D1 to D4 vertebral body involvement from 2018 treated with a mini-sternal approach in Minia university hospital. Results Follow up was for 12 months in mean. Frankel grade was used to assess patients after operation and showed improvement in 70% of cases while 30% showed no improvement. Mean operative time was 110 minutes and no intraoperative complications were encountered. Conclusion Infectious, metastatic, and traumatic lesions involving the anterior high dorsal spine can be treated safely with the mini transsternal approach, which is also the only one that allows for early and precise exposure of the anterior dura. With great functional patient outcomes, this approach bypasses the anatomical limitations of the region and provides enough space for the best restoration and maintenance of spinal alignment in the cervico-dorsal region transition zone. | ||||||||||||||||||||||||||||||||||||
Highlights | ||||||||||||||||||||||||||||||||||||
Conclusions The mini transternal technique is an effective and safe technique for addressing infective, metastatic, traumatic, and degenerative lesions that impact the anterior high dorsal spine. It is the only route that enables an early and direct visualisation of the anterior theca. This method effectively addresses the physical limitations of this area and allows for sufficient space to provide appropriate restoration and maintenance of spinal alignment in the cervicothoracic transition zone, resulting in favorable functional and clinical outcomes for the patient.
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Keywords | ||||||||||||||||||||||||||||||||||||
ministernotomy; upper thoracic lesions; dorsal discitis; transsternal approach | ||||||||||||||||||||||||||||||||||||
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Introduction
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Patient No |
Pre-operative |
Postoperative |
Percent of change |
1 |
B |
E |
70% |
2 |
D |
E |
|
3 |
D |
E |
|
4 |
C |
D |
|
5 |
B |
D |
|
6 |
D |
D |
|
7 |
D |
D |
|
8 |
D |
E |
|
9 |
C |
C |
|
10 |
C |
D |
It's noteworthy that none of the patients' neurological status deteriorated postoperatively. No patients experienced any wound complications. With a mean follow-up time of 12 months, follow-up was obtained for every patient (range 6-18 months). At the one year follow up, 3 (60%) of the 5 patients with grade D improved from grade D to E on the Frankel grading system , 1 of the 3 patients with grade C improved to grade E ,while another one improved from grade C to grade D and the 2 patients with grade B improved to grade D at the end of the 1st year follow up, with a total improvement percentage of 70% as shown in table (1).
Despite the fact that 3 patients (30%) 2 with grade D and one with grade C did not improve in Frankel grading postoperatively, they showed satisfaction due to relief of their back pain and no worsening of their neurological status happened. Each case received repeated radiographs and CT scans to verify the instrumentation's stability. There was no discernible difference in spinal alignment between the early postoperative condition and follow-up. None of the patients displayed any evidence of instrument failure or migration.
Case Illustration: Spine Metastases
[fig 1-8]
There is significant evidence to support the usefulness of the anterior approach in providing improved visualization and results for vertebral body lesions. However, due to anatomical constraints, access to T1-T4 through the anterior approach is anticipated to be the most difficult [7, 9, 11-15, 19].
Pott's disease was historically the focus of many early surgical efforts,[6,7,20] but similar concepts were later used to manage primary and metastatic tumors, pathological fracture-dislocation causing direct posterior displacement of bone fragments, disc herniations, and severe kyphotic deformities with anterior cord compression. [1-9, 21]
Mirnard performed a costotransversectomy in 1894 in order to gain limited access to the vertebral bodies[20].
Capener modified this procedure in 1954 by resecting a longer rib segment in order to allow an anterolateral spinal cord decompression. [22].
A median sternotomy direct approach to the cervicothoracic region was described by Cauchoix and Binet in 1957 [23]. Unfortunately, The transsternal approach was discontinued for more than 20 years after Hodgson et al. in 1960 [4] reported 40% intraoperative mortality in their study using the direct anterior access, advocating abandoning direct anterior exposure. Then, in 1984 [7], Sundaresan et al. showed that a direct surgical approach to the upper dorsal spine was technically feasible by performing a partial resection of the manubrium and clavicle. They also demonstrated low morbidity rate in their study. All patients postoperative outcomes were generally benign and comparable to those of patients having disc excision surgery using the Cloward or Robinson and Smith techniques.
The ventricle aspect of the spinal cord is decompressed indirectly with posterior, posterolateral, and anterolateral exposures, which raises the possibility of neurological damage. marked muscle dissection and rib resection are particularly necessary for dorsal lateral approaches from D1 to D4, which results in high morbidity. [24]
Because of the obliquity of the access, a cervical approach is not sufficient for effective decompression of the spinal cord below D1 nor does it allow good bone grafting. [21]
Anterior approaches, on the other hand, gives good exposure to the compressing elements and thus allowing adequate decompression to be done without harming neural structures. Furthermore, wide decompression can be easily done with grafting and fixation.
Because the heart and great vessels restrict the extending the exposure caudally, a full sternotomy is not required. A direct path to the T3 vertebra is provided by the transmanubrial transclavicular approach, which also offers autologous bone with no need for distant site bone grafting. A modified transmanubrial approach without clavicle resection was recently described by Xiao et al., in which sternotomy is done up to 2 cm below the sternal angle.
As a partial sternotomy is required, it cannot be regarded as a pure transmanubrial approach. To reach D3 to D5 using this technique you have to pass through the right space of the brachiocephalic trunk with an appropriate working angle. [16]
Our series demonstrates the technique's low morbidity rate as well as the feasibility of reaching the upper dorsal spine using the direct approach through a ministernotomy. In the Frankel scale, 70% of our patients showed a significant neurological improvement. Notably, none of the patients had any postoperative neurological decline. This is primarily because the dural sac can be seen clearly and early during surgery thanks to the direct surgical view of the anterior part of the theca. Moreover As shown in our series, it was simple to reconstruct the cervicothoracic junction due to better accessibility to the anterior column of the vertebral column, preserving neurological integrity, stability by instrumentation, relieving pain, maintaining alignment without deformity, and allowing for early mobilization.
We believe that the mini sternotomy approach to the upper dorsal spine can be used in treating various pathologies involving the anterior column of the spine and causing compression on the spinal cord for example; primary and metastatic tumors, pathologic fractures causing ventral compression, central or posterolateral disc herniations, infectious diseases like T.B involving the anterior column of the spine and marked kyphotic deformities causing anterior spinal cord compression.