Right infraaxillary thoracotomy approach for upper thoracic vertebral decompression and fusion at T2–T6 levels: a technical note
Disorders of the upper thoracic spine can lead to serious disability and morbidity. However, operating on the upper thoracic vertebrae T2–T5 remains challenging because of the anatomical features of the thoracic spine. We describe a novel anterolateral upper thoracic approach, which is safe and reproducible and allows direct access to the upper thoracic spine from T2 to T6 inclusive, obviating the risk of damaging complex anatomical structures inherent in the anterior trans-sternal approach.
Three patients with upper thoracic spinal-related spinal cord compression disease, presented with progressive thoracic myelopathy and upper back pain. Magnetic resonance imaging showed direct spinal cord compression due to upper thoracic vertebral destruction. In addition preoperative computed tomography also revealed vertebral erosion and collapse. The surgical management of the three patients involved decompression and reconstruction via the right infraaxillary thoracotomy approach, and fixation with a titanium mesh cage and an anterior plate in each.
Clinical outcome measures including pre- and postoperative radiographic parameters were assessed. There were no complications associated with this technique. The back pain and neural function gradually improved, and plate placement was achieved in all patients. None of the patients experienced clinical symptoms or screw loosening or breakage in this study.
The technique described is a safe and novel right infraaxillary thoracotomy approach to provide direct access from vertebral bodies T2–T6 and to provide adequate room for upper thoracic vertebral decompression and fusion surgery. However, a suitable fixation implant should be designed.
KeywordsAnterolateral approach Upper thoracic vertebral decompression Fusion surgery
Conventionally, the anterior trans-sternal approach (C4–T4) is useful for the treatment of a variety of upper thoracic (T1–T4) anterior column-related spinal pathologies, including infection, oncologic and traumatic lesions, which can lead to serious disability and morbidity [1, 2, 3, 4]. However, with the increasing application of surgery, this technique is still challenging to perform on upper thoracic vertebrae down to T5 because of anatomical features including the aortic arch and great vessel block. To our knowledge, the posterior approach through costotransversectomy provides an indirect approach for accessing the rib head, neural foramen, pedicle, and anterolateral spinal canal. However, it is still difficult to decompression severe direct anterior spinal cord compression [5, 6]. And other direct upper thoracic vertebral approaches can be mainly divided into the high transthoracic approach (C6–T4), and the modified anterior approach (C3–T4) [7, 8]; however, using these approaches, it is not easy to decompress the spinal cord at the upper thoracic (T1–T4) level of the anterior column and difficult to create an adequate operative space because of the scapula block [3, 9, 10].
Consequently, the objectives of this study were firstly to report right infraaxillary thoracotomy, which usually use in minimally invasive cardiac surgery approach, which is also safe and reproducible and provides excellent direct access to the upper thoracic vertebral bodies (T2–T6); secondly, to highlight the technical challenges of this approach and approach-related complications; and third, to evaluate clinical outcomes using this surgical technique in three cases. We believe that the advantage of this anterolateral upper thoracic approach is not only the avoidance of unnecessary interference with the complex anatomical features associated with the anterior trans-sternal approach (C4–T4), but also the ability to avoid the scapula block of the high transthoracic approach (C6–T4).
Materials and methods
Between September 2016 and February 2017, three patients (all male) with upper thoracic (T1–T4) anterior column-related spinal cord compression disorders (one metastatic, one eosinophilic granuloma and one spinal tuberculosis) presented with thoracic myelopathy and upper back pain. The patients’ ages ranged from 9, 33 and 54 years (mean 32 years). All patients were treated by decompression and reconstruction via the upper right infraaxillary thoracotomy approach and then fixed with a titanium mesh cage and an anterior plate or thoracic anterior fixation system (which depend on vertebra body size in our hospital.
The value of the anterior approach to the spine in providing greater access and better outcomes of lesions affecting the vertebral body has been amply demonstrated. A variety of approaches have been used for upper thoracic vertebrae. In the anterior trans-sternal approach (C4–T4) widely used to treat challenging upper thoracic spine disorders, adequate exposure is always hindered by many vital structures, including the great vascular and thoracic duct [12, 13, 14]. However, the extensive dissection and exposure associated with the approach increases patients’ risk of injury to adjacent blood vessels and thoracic duct, if the spine surgeon is not be familiar with it [9, 15, 16, 17].
Upper thoracic vertebral body-related disease may cause complications such as spinal cord compression-related neurological deficit, spine instability or kyphotic deformity, and conservative treatment has a poor effect in patients, so surgical treatment is always necessary [18, 19, 20, 21]. Indications for surgery include severe back pain and/or neurological deficit in response to conservative treatment, neurological deficits associated with bone destruction, cold abscess, metastatic tumor and progressive deformity [22, 23, 24, 25]. The aim of surgical treatment is radical debridement, decompression of the spinal cord and restoration of spinal stability.
In this study, three patients with upper thoracic vertebral body bone destruction underwent decompression and fusion through a right infraaxillary thoracotomy approach, and all of them achieved a good outcome. This indicates that the anterolateral upper thoracic approach provides safe and effective access for surgical treatment of upper thoracic vertebral body disease. This approach makes it easy to expose lesions at T2–T6 levels and to perform vertebrectomy and complete neurological decompression. At the same time, this approach can treat the lung adhesions caused by tuberculosis infection as well and avoid infection diffusing to healthy spinal posterior column. Moreover, this approach avoids the mediastinum, minimizing the risk of injury to the esophagus, pleura, recurrent laryngeal nerve, vagus nerve, and major vessels. We recommend the right-sided anterolateral upper thoracic approach, because this approach avoids injury to many vital structures, including the heart, hilum, and most importantly the thoracic duct during exposure. In the present study, no other complications occurred. However, some points should be emphasized and observed during surgery: We recommend removal of the 4th rib, exposure of the lung, and, as in the transthoracic approach, exposure of the spine and division of the vertebral segmental vessels. Care should be taken during subperiosteal separation of the vertebral body to avoid injury to the left-sided thoracic duct.
Thoracoscope may provide a relatively ideal minimally invasive approach; however, thoracoscope learning may require a certain steep learning curve, and it is very difficult to handle pleural adhesions, adhesions as well as complete spinal cord decompression due to lesion adherent to the dura. Thoracoscopic technique was described by Dickman who also suggests that it is difficult to handle the upper thoracic vertebral lesions .
There are a number of limitations to this study, which must be considered before implementing any changes to existing practices. This was a single-surgeon, single-center, consecutive series. There was no control group or comparative group to assess the overall performance of our right infraaxillary thoracotomy approach compared to the existing anterior trans-sternal approach. Furthermore, so far, there is no suitable fixation implant for this approach. However, this is the first retrospective clinical study of its kind to assess the safety and efficacy of this approach. Up to the final follow-up visit, none of the patients suffered from any neurological postoperative deterioration and there were no incidences of screw loosening or plate breakage. Consequently, we feel our approach would be reproducible in other spinal practices. We also feel that this surgical technique has a role to play in allowing more direct access to pathology affecting the upper thoracic vertebrae, providing immediate stability with instrumentation and, as a consequence, preserving neurological integrity and pain relief, maintaining alignment without deformity, and providing early mobilization.
In conclusion, our novel right infraaxillary thoracotomy approach to directly access pathology affecting upper thoracic vertebrae can safely expose the upper thoracic vertebrae and allows good visualization and adequate operating space for T2–T6; however, a suitable fixation implant should be designed.
This work was supported by the scientific research project of Huizhou Municipal Science and Technology Bureau (Grant Number: 2015030205) and the National Natural Science Foundation of China (Grant Number: 81560213).
JL, SL, KH, XL, YS, KX and YT designed the study. JL, SL, KH, XL, YS, KX and YT were involved in acquisition of data. JL, SL, KH, XL, YS, KX and YT interpreted the data. JL, SL, KH, XL, YS, KX and YT were involved in manuscript preparation.
Compliance with ethical statement
Conflict of interest
All the authors declare that they have no conflict of interest.
Ethical approval was given by the Medical Ethics Committee of Youjiang Medical University for Nationalities.
- 3.Maciejczak A, Radek A, Kowalewski J, Palewicz A (1999) Anterior transsternal approach to the upper thoracic spine. Acta Chir Hung 38:83–86Google Scholar
- 4.Nakamura H, Yamano Y, Seki M, Konishi S (2001) Use of folded vascularized rib graft in anterior fusion after treatment of thoracic and upper lumbar lesions. Technical note. J Neurosurg 94:323–327Google Scholar
- 5.Kao FC, Tsai TT, Niu CC, Lai PL, Chen LH, Chen WJ (2017) One-stage posterior approaches for treatment of thoracic spinal infection: transforaminal and costotransversectomy, compared with anterior approach with posterior instrumentation. Medicine 96:e8352. https://doi.org/10.1097/md.0000000000008352 CrossRefGoogle Scholar
- 7.Kaya RA, Turkmenoglu ON, Koc ON, Genc HA, Cavusoglu 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 (discussion 463) CrossRefGoogle Scholar
- 17.Liu Z, Wang X, Xu Z, Zeng H, Zhang P, Peng W, Zhang Y (2016) Two approaches for treating upper thoracic spinal tuberculosis with neurological deficits in the elderly: a retrospective case-control study. Clin Neurol Neurosurg 141:111–116. https://doi.org/10.1016/j.clineuro.2016.01.002 CrossRefGoogle Scholar
- 22.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, Anderson DG, Hilibrand AS, Vaccaro AR (2016) is it necessary to extend a multilevel posterior cervical decompression and fusion to the upper thoracic spine? Spine 41:1845–1849. https://doi.org/10.1097/brs.0000000000001864 CrossRefGoogle Scholar
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.