Skip to main content

Advertisement

SpringerLink
Log in

Surgical challenges in posterior cervicothoracic junction instrumentation

  • Original Article
  • Published:
Neurosurgical Review Aims and scope Submit manuscript

Abstract

The cervicothoracic junction (CTJ) is a region of the spine submitted to significant mechanical stress. The peculiar anatomical and biomechanical characteristics make posterior surgical stabilization of this area particularly challenging. We present and discuss our surgical series highlighting the specific surgical challenges provided by this region of the spine. We have analyzed and reported retrospective data from patients who underwent a posterior cervicothoracic instrumentation between 2011 and 2019 at the Neurosurgical Department of the Geneva University Hospitals. We have discussed C7 and Th1 instrumentation techniques, rods design, extension of constructs, and spinal navigation. Thirty-six patients were enrolled. We have preferentially used lateral mass (LM) screws in the subaxial spine and pedicle screws (PS) in C7, Th1, and upper thoracic spine. We have found no superiority of 3D navigation techniques over 2D fluoroscopy guidance in PS placement accuracy, probably due to the relatively small case series. Surgical site infection was the most frequent complication, significantly associated with tumor as diagnosis. When technically feasible, PS represent the technique of choice for C7 and Th1 instrumentation although other safe techniques are available. Different rod constructs are described although significant differences in biomechanical stability still need to be clarified. Spinal navigation should be used whenever available even though 2D fluoroscopy is still a safe option. Posterior instrumentation of the CTJ is a challenging procedure, but with correct surgical planning and technique, it is safe and effective.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

Availability of data and material

All data are available upon specific request addressed to the corresponding author.

Code availability

Not applicable.

References

  1. Aydogan M, Enercan M, Hamzaoglu A, Alanay A (2012) Reconstruction of the subaxial cervical spine using lateral mass and facet screw instrumentation. Spine (Phila Pa 1976) 37:E335–E341. https://doi.org/10.1097/BRS.0b013e31824442eb

    Article  Google Scholar 

  2. Bayoumi AB, Efe IE, Berk S, Kasper EM, Toktas ZO, Konya D (2018) Posterior Rigid Instrumentation of C7: Surgical Considerations and Biomechanics at the Cervicothoracic Junction. A Review of the Literature. World Neurosurg 111:216–226. https://doi.org/10.1016/j.wneu.2017.12.026

    Article  PubMed  Google Scholar 

  3. Bledsoe JM, Fenton D, Fogelson JL, Nottmeier EW (2009) Accuracy of upper thoracic pedicle screw placement using three-dimensional image guidance. Spine J 9:817–821. https://doi.org/10.1016/j.spinee.2009.06.014

    Article  PubMed  Google Scholar 

  4. Braga BP, de Morais JV, Vilela MD (2010) Free-hand placement of high thoracic pedicle screws with the aid of fluoroscopy: evaluation of positioning by CT scans in a four-year consecutive series. Arq Neuropsiquiatr 68:390–395. https://doi.org/10.1590/s0004-282x2010000300012

    Article  PubMed  Google Scholar 

  5. Bueff HU, Lotz JC, Colliou OK, Khapchik V, Ashford F, Hu SS, Bozic K, Bradford DS (1995) Instrumentation of the cervicothoracic junction after destabilization. Spine (Phila Pa 1976) 20:1789–1792. https://doi.org/10.1097/00007632-199508150-00007

    Article  CAS  Google Scholar 

  6. Cecchinato R, Berjano P, Zerbi A, Damilano M, Redaelli A, Lamartina C (2019) Pedicle screw insertion with patient-specific 3D-printed guides based on low-dose CT scan is more accurate than free-hand technique in spine deformity patients: a prospective, randomized clinical trial. Eur Spine J 28:1712–1723. https://doi.org/10.1007/s00586-019-05978-3

    Article  PubMed  Google Scholar 

  7. Cheng I, Sundberg EB, Iezza A, Lindsey DP, Riew KD (2015) Biomechanical Determination of Distal Level for Fusions across the Cervicothoracic Junction. Glob Spine J 5:282–286. https://doi.org/10.1055/s-0035-1546418

  8. Clifton W, Louie C, Williams DB, Damon A, Dove C, Pichelmann M (2019) Safety and accuracy of the freehand placement of C7 pedicle screws in cervical and cervicothoracic constructs. Cureus 11(8):e5304. https://doi.org/10.7759/cureus.5304

  9. DalCanto RA, Lieberman I, Inceoglu S, Kayanja M, Ferrara L (2005) Biomechanical comparison of transarticular facet screws to lateral mass plates in two-level instrumentations of the cervical spine. Spine (Phila Pa 1976) 30:897–892. https://doi.org/10.1097/01.brs.0000158937.64577.25

  10. Daniels AH, Reid DBC, Durand WM, Hamilton DK, Passias PG, Kim HJ, Protopsaltis TS, Lafage V, Smith JS, Shaffrey CI, Gupta M, Klineberg E, Schwab F, Burton D, Bess S, Ames CP, Hart RA (2020) Upper-thoracic versus lower-thoracic upper instrumented vertebra in adult spinal deformity patients undergoing fusion to the pelvis: Surgical decision-making and patient outcomes. J Neurosurg Spine 32:600–606. https://doi.org/10.3171/2019.9.SPINE19557

    Article  Google Scholar 

  11. Desai S, Sethi A, Ninh CC, Bartol S, Vaidya R (2010) Pedicle screw fixation of the C7 vertebra using an anteroposterior fluoroscopic imaging technique. Eur Spine J 19:1953–1959. https://doi.org/10.1007/s00586-010-1513-8

    Article  PubMed  PubMed Central  Google Scholar 

  12. Du JP, Wang DH, Zhang J, Fan Y, Wu QN, Hao DJ (2018) Accuracy of pedicle screw insertion among 3 image-guided navigation systems: systematic review and meta-analysis. World Neurosurg 109:24–30

    Article  Google Scholar 

  13. Dunlap BJ, Karaikovic EE, Park H-S, Sokolowski MJ, Zhang L-Q (2010) Load sharing properties of cervical pedicle screw-rod constructs versus lateral mass screw-rod constructs. Eur Spine J 19:803–808. https://doi.org/10.1007/s00586-010-1278-0

    Article  PubMed  PubMed Central  Google Scholar 

  14. Eleraky M, Setzer M, Baaj AA, Papanastassiou I, Conrad BP, Vrionis FD (2010) Biomechanical comparison of posterior cervicothoracic instrumentation techniques after one-level laminectomy and facetectomy. J Neurosurg Spine 13:622–629. https://doi.org/10.3171/2010.5.SPINE09848

    Article  PubMed  Google Scholar 

  15. Fayed I, Toscano DT, Triano MJ, Makariou E, Lee C, Spitz SM, Anaizi AN, Nair MN, Sandhu FA, Voyadzis J-M (2020) Crossing the cervicothoracic junction during posterior cervical decompression and fusion: is it necessary? Neurosurgery 86:544–550. https://doi.org/10.1093/neuros/nyaa078

    Article  Google Scholar 

  16. Fernandes Joaquim A, Mudo ML, Tan LA, Riew KD (2020) Posterior subaxial cervical spine screw fixation: a review of techniques. J Spine Surg 6(1):252–261. https://doi.org/10.1177/2192568218759940

  17. Gertzbein S, Robbins S (1990) Accuracy of pedicular screw placement in vivo. Spine (Phila Pa 1976) 15:11–14. https://doi.org/10.1097/00007632-199001000-00004

    Article  CAS  Google Scholar 

  18. Godzik J, Dalton JF, Martinez-del-Campo E, Newcomb AGUS, Dominguez F, Reyes PM, Theodore N, Kelly BP, Crawford NR (2019) Biomechanical evaluation of cervicothoracic junction fusion constructs. World Neurosurg 124:e139–e146. https://doi.org/10.1016/j.wneu.2018.12.040

    Article  Google Scholar 

  19. Heller JG, Carlson GD, Abitbol JJ, Garfin SR (1991) Anatomic comparison of the Roy-Camille and Magerl techniques for screw placement in the lower cervical spine. Spine (Phila Pa 1976) 16:S552–S557. https://doi.org/10.1097/00007632-199110001-00020

    Article  CAS  Google Scholar 

  20. Hilibrand AS, Robbins M (2004) Adjacent segment degeneration and adjacent segment disease: The consequences of spinal fusion? Spine J 4:S190–S194. https://doi.org/10.1016/j.spinee.2004.07.007

    Article  Google Scholar 

  21. Hong JT, Tomoyuki T, Jain A, Orías AAE, Inoue N, An HS (2017) Which salvage fixation technique is best for the failed initial screw fixation at the cervicothoracic junction? A biomechanical comparison study. Eur Spine J 26:2417–2424. https://doi.org/10.1007/s00586-017-5239-8

    Article  PubMed  Google Scholar 

  22. Huang KT, Harary M, Abd-El-Barr MM, Chi JH (2019) Crossing the Cervicothoracic Junction in Posterior Cervical Decompression and Fusion: A Cohort Analysis. World Neurosurg 131:e514–e520. https://doi.org/10.1016/j.wneu.2019.07.219

    Article  PubMed  Google Scholar 

  23. Hyun S-J, Lee BH, Park J-H, Kim K-J, Jahng T-A, Kim H-J (2017) Proximal junctional kyphosis and proximal junctional failure following adult spinal deformity surgery. Korean J Spine 14:126–132. https://doi.org/10.14245/kjs.2017.14.4.126

    Article  PubMed  PubMed Central  Google Scholar 

  24. Ibaseta A, Rahman R, Andrade NS, Uzosike AC, Byrapogu VK, Ramji AF, Skolasky RL, Reidler JS, Kebaish KM, Riley LH, Sciubba DM, Cohen DB, Neuman BJ (2019) Crossing the cervicothoracic junction in cervical arthrodesis results in lower rates of adjacent segment disease without affecting operative risks or patient-reported outcomes. Clin Spine Surg 32:377–381. https://doi.org/10.1097/BSD.0000000000000897

    Article  PubMed  Google Scholar 

  25. Jeanneret B, Magerl F, Ward EH, Ward JC (1991) Posterior stabilization of the cervical spine with hook plates. Spine (Phila Pa 1976) 16:S56–S63. https://doi.org/10.1097/00007632-199103001-00010

    Article  CAS  Google Scholar 

  26. Jenkins AL, Singh H, Meyer SA, Hecht AC (2009) Novel fluoroscopic technique for localization at cervicothoracic levels. J Spinal Disord Tech 22:615–618. https://doi.org/10.1097/BSD.0b013e31818da7ce

    Article  PubMed  Google Scholar 

  27. Kaya RA, Türkmenoǧlu ON, Koç ÖN, Genç HA, Çavuçoǧlu H, Ziyal IM, Aydin Y (2006) A perspective for the selection of surgical approaches in patients with upper thoracic and cervicothoracic junction instabilities. Surg Neurol 65:454–463. https://doi.org/10.1016/j.surneu.2005.08.017

    Article  PubMed  Google Scholar 

  28. Kim HJ, Lenke LG, Shaffrey CI, Van Alstyne EM, Skelly AC (2012) Proximal junctional kyphosis as a distinct form of adjacent segment pathology after spinal deformity surgery: a systematic review. Spine (Phila. Pa. 1976) 15;37(22 Suppl):S144–64. https://doi.org/10.1097/BRS.0b013e31826d611b

  29. Kreshak JL, Kim DH, Lindsey DP, Kam AC, Panjabi MM, Yerby SA (2002) Posterior stabilization at the cervicothoracic junction: A biomechanical study. Spine (Phila Pa 1976) 27:2763–2770. https://doi.org/10.1097/00007632-200212150-00005

    Article  Google Scholar 

  30. Kulkarni AG, Dhruv AN, Bassi AJ (2015) Posterior cervicothoracic instrumentation, testing the clinical efficacy of tapered rods (Dual-Diameter Rods). J Spinal Disord Tech 28:382–388. https://doi.org/10.1097/bsd.0000000000000133

    Article  PubMed  Google Scholar 

  31. Kumar S, van Popta D, Rodrigues-Pinto R, Stephenson J, Mohammad S, Siddique I, Verma RR (2015) Risk factors for wound infection in surgery for spinal metastasis. Eur Spine J 24:528–532. https://doi.org/10.1007/s00586-013-3127-4

    Article  PubMed  CAS  Google Scholar 

  32. Lee DH, Cho JH, Jung JI, Baik JM, Jun DS, Hwang CJ, Lee CS (2019) Does stopping at C7 in long posterior cervical fusion accelerate the symptomatic breakdown of cervicothoracic junction? PLoS One 14:1–10. https://doi.org/10.1371/journal.pone.0217792

    Article  CAS  Google Scholar 

  33. Lee DH, Lee SW, Kang SJ, Hwang CJ, Kim NH, Bae JY, Kim YT, Lee CS, Daniel Riew K (2011) Optimal entry points and trajectories for cervical pedicle screw placement into subaxial cervical vertebrae. Eur Spine J 20:905–911. https://doi.org/10.1007/s00586-010-1655-8

    Article  PubMed  PubMed Central  Google Scholar 

  34. Lehman RA, Polly DW, Kuklo TR, Cunningham B, Kirk KL, Belmont PJ (2003) Straight-forward Versus anatomic trajectory technique of thoracic pedicle screw fixation: A biomechanical analysis. In: Spine. pp 2058–2065

  35. Little AS, Brasiliense LBC, Lazaro BCR, Reyes PM, Dickman CA, Crawford NR (2010) Biomechanical comparison of costotransverse process screw fixation and pedicle screw fixation of the upper thoracic spine. Oper Neurosurg 66:ons178–ons182. https://doi.org/10.1227/01.neu.0000350869.35779.05

    Article  Google Scholar 

  36. Roy-Camille R, Mazel C, Saillant G (1987) Treatment of cervical spine injuries by a posterior osteosynthesis with plates and screws. In: Kehr P, Weidner A (eds) Cervical spine I: Strasbourg 1985. Springer Vienna, Vienna, pp 163–174. https://doi.org/10.1007/978-3-7091-8882-8_29

  37. McGirt MJ, Sutter EG, Xu R, Sciubba DM, Wolinsky J-P, Witham TF, Gokaslan ZL, Bydon A (2009) Biomechanical comparison of translaminar versus pedicle screws at T1 and T2 in long subaxial cervical constructs. Neurosurgery 65:167–172; discussion 172. https://doi.org/10.1227/01.NEU.0000345642.50726.A3

    Article  PubMed  Google Scholar 

  38. Rienmüller A, Buchmann N, Kirschke JS, Meyer EL, Gempt J, Lehmberg J, Meyer B, Ryang YM (2017) Accuracy of CT-navigated pedicle screw positioning in the cervical and upper thoracic region with and without prior anterior surgery and ventral plating. Bone Jt J 99B:1373–1380. https://doi.org/10.1302/0301-620X.99B10.BJJ-2016-1283.R1

    Article  Google Scholar 

  39. Schatlo B, Molliqaj G, Cuvinciuc V, Kotowski M, Schaller K, Tessitore E (2014) Safety and accuracy of robot-assisted versus fluoroscopy-guided pedicle screw insertion for degenerative diseases of the lumbar spine: a matched cohort comparison - Clinical article. J Neurosurg Spine 20:636–643. https://doi.org/10.3171/2014.3.SPINE13714

    Article  PubMed  Google Scholar 

  40. Scheufler KM, Franke J, Eckardt A, Dohmen H (2011) Accuracy of image-guided pedicle screw placement using intraoperative computed tomography-based navigation with automated referencing, part I: Cervicothoracic spine. Neurosurgery 69:782–795. https://doi.org/10.1227/NEU.0b013e318222ae16

    Article  PubMed  Google Scholar 

  41. Schroeder GD, Kepler CK, Kurd MF, Mead L, Millhouse PW, Kumar P, Nicholson K, Stawicki C, Helber A, Fasciano D, Patel AA, Woods BI, Radcliff KE, Rihn JA, Greg Anderson D, Hilibrand AS, Vaccaro AR (2016) Is it necessary to extend a multilevel posterior cervical decompression and fusion to the upper thoracic Spine? Spine (Phila Pa 1976) 41:1845–1849. https://doi.org/10.1097/BRS.0000000000001864

    Article  Google Scholar 

  42. Stemper BD, Marawar SV, Yoganandan N, Shender BS, Rao RD (2008) Quantitative anatomy of subaxial cervical lateral mass: An analysis of safe screw lengths for Roy-Camille and Magerl techniques. Spine (Phila Pa 1976) 33:893–897. https://doi.org/10.1097/BRS.0b013e31816b4666

    Article  Google Scholar 

  43. Takayasu M, Hara M, Yamauchi K, Yoshida M, Yoshida J (2003) Transarticular screw fixation in the middle and lower cervical spine. Technical note. J Neurosurg 99:132–136. https://doi.org/10.3171/spi.2003.99.1.0132

    Article  PubMed  Google Scholar 

  44. Tessitore E, El-Hassani Y, Schaller K (2011) How i do it: Cervical lateral mass screw fixation. Acta Neurochir 153:1695–1699. https://doi.org/10.1007/s00701-011-1068-4

    Article  PubMed  Google Scholar 

  45. Tian NF, Huang QS, Zhou P, Zhou Y, Wu RK, Lou Y, Xu HZ (2011) Pedicle screw insertion accuracy with different assisted methods: A systematic review and meta-analysis of comparative studies. Eur Spine J 20:846–859

    Article  Google Scholar 

  46. Walker CT, Kakarla UK, Chang SW, Sonntag VKH (2019) History and advances in spinal neurosurgery. J Neurosurg Spine 31:775–785. https://doi.org/10.3171/2019.9.SPINE181362

    Article  PubMed  Google Scholar 

  47. Wang VY, Chou D (2007) The cervicothoracic junction. Neurosurg Clin N Am 18:365–371. https://doi.org/10.1016/j.nec.2007.02.012

    Article  PubMed  Google Scholar 

  48. Welke B, Schwarze M, Hurschler C, Nebel D, Bergmann N, Daentzer D (2018) In vitro investigation of two connector types for continuous rod construct to extend lumbar spinal instrumentation. Eur Spine J 27:1895–1904. https://doi.org/10.1007/s00586-018-5664-3

    Article  PubMed  Google Scholar 

  49. Xu R, Ebraheim NA, Ou Y, Skie M, Yeasting RA (2000) Anatomic considerations of costotransverse screw placement in the thoracic spine. Surg Neurol 53(4):349–354; discussion 354–5. https://doi.org/10.1016/s0090-3019(00)00203-2

  50. Yang JS, Buchowski JM, Verma V (2015) Construct type and risk factors for pseudarthrosis at the cervicothoracic junction. Spine (Phila Pa 1976) 40:E613–E617. https://doi.org/10.1097/BRS.0000000000000868

    Article  Google Scholar 

Download references

Acknowledgments

The authors would like to express their grateful thank to Alberto Bongiorno for the photographs used to describe the different instrumentation techniques.

Funding

The authors declare that they received no financial support for this work.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy

    Alberto Balestrino & Gianluigi Zona

  2. Division of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS San Martino Polyclinic Hospital, Largo Rosanna Benzi 10, 16132, Genoa, Italy

    Alberto Balestrino

  3. Neurosurgical Unit, Geneva University Hospitals, Geneva, Switzerland

    Renato Gondar, Gianpaolo Jannelli & Enrico Tessitore

  4. Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal And Children (DINOGMI), University of Genoa, Genoa, Italy

    Gianluigi Zona

  5. Faculty of Medicine, University of Geneva, Geneva, Switzerland

    Enrico Tessitore

Authors
  1. Alberto Balestrino
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Renato Gondar
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Gianpaolo Jannelli
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Gianluigi Zona
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Enrico Tessitore
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Enrico Tessitore and Alberto Balestrino conceived the study. Alberto Balestrino and Renato Gondar drafted the manuscript; Alberto Balestrino, Gianpaolo Jannelli, Renato Gondar, and Enrico Tessitore reviewed the literature. Alberto Balestrino and Gianpaolo Jannelli have given substantial contributions to acquisition, analysis, and interpretation of the data. All authors have participated to drafting the manuscript, and Enrico Tessitore, Alberto Balestrino, Renato Gondar, and Gianluigi Zona revised it critically. All authors read and approved the final version of the manuscript.

Corresponding author

Correspondence to Alberto Balestrino.

Ethics declarations

Ethics approval

This study has been approved by the local ethics committee, Geneva CCER (IRB approval N° 2020-01185).

Consent to participate

Not applicable.

Consent for publication

Formal patient consent is not required for our paper. No data from which individual can be identified are present.

Conflict of interest

The authors declare that they have no conflicts of interest and no competing interests to disclosure.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Balestrino, A., Gondar, R., Jannelli, G. et al. Surgical challenges in posterior cervicothoracic junction instrumentation. Neurosurg Rev 44, 3447–3458 (2021). https://doi.org/10.1007/s10143-021-01520-6

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10143-021-01520-6

Keywords

Search

Navigation