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Anterior Approaches and Surgical Considerations for Pathology of the Cervicothoracic Junction


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  • Chapter Synopsis

  • Surgical exposure of the anterior cervicothoracic junction poses a unique challenge for spine surgeons. Several distinct features of this region contribute to the difficulty of approach. However, given the complexities and challenges of this region, subsequent modifications have been described. This chapter primarily focuses on two anterior cervicothoracic junction exposure techniques: the supraclavicular approach and the transmanubrial transclavicular approach.

  • Important Points

  • The supraclavicular approach is most familiar because it is essentially an oblique extension of the typical anteromedial approach.

  • If necessary, the surgical exposure in the supraclavicular approach can be extended by disarticulating the clavicle.

  • The recurrent laryngeal nerve is at risk, particularly during the caudal dissection of this approach.

  • The thoracic duct lies laterally in the field at the junction of the internal jugular and subclavian veins, and aberrant dissection lateral to the carotid sheath places the thoracic duct at risk for injury.

  • The transmanubrial transclavicular approach provides access to the anterior cervicothoracic junction by resecting the medial third of the clavicle and a portion of the manubrium.

  • The subclavian vein is at risk for injury during resection of the clavicle.

  • Care should be taken to assess for the presence of pleural violation and pneumothorax, which may necessitate placement of a chest tube.

Surgical exposure of the anterior cervicothoracic junction poses a unique challenge for spine surgeons. Several distinct features of this region contribute to the difficulty of approach. First, major anatomic structures can impede surgical access. These structures include the contents of the carotid sheath, the thyroid gland, and osseous structures such as the sternum and clavicle. Furthermore, many of the contents of the thoracic inlet, including the esophagus, trachea, thoracic duct, and essential nerves (i.e., vagus, recurrent laryngeal, phrenic, and sympathetic), must also be safely negotiated during the approach. Finally, in cases of significant disease, anatomic boundaries can be poorly defined, thus contributing to increased difficulty with anterior approaches to the cervicothoracic junction.

The anterior cervical approach was originally described in the 1950s. However, given the complexities and aforementioned challenges of this region, subsequent modifications of this technique were later described. In particular, approaches to the cervicothoracic junction require specific attention. This chapter primarily focuses on two anterior cervicothoracic junction exposure techniques: the supraclavicular approach and the transmanubrial transclavicular approach.

Cervicothoracic Junction: Anatomic Considerations

The cervicothoracic junction can pose multiple challenges given the presence of numerous visceral and vascular structures and the location of this region as a transition zone between two regions of the spine. The cervical spine has a developmentally normal anatomic lordosis and is generally flexible. In contrast, the thoracic spine is kyphotic and generally rigid.

This region has many unique characteristics, such as the ratio of the spinal canal to spinal cord diameter. The spinal canal diameter is the narrowest at the cervicothoracic junction, but the spinal cord in this region is near its widest diameter. Thus, pathologic processes in this region can cause early compressive symptoms. Furthermore, the cervicothoracic junction is a vascular watershed zone. Cervical radicular branches provide blood supply to the lower subaxial cord, whereas thoracic radicular arteries from the aorta provide much of the blood to the spinal cord parenchyma at the level of the cervicothoracic junction (C6 to T2).

Another surgical challenge to the lower neck includes the soft tissue, which traverses vasculature and essential peripheral nerves. The anterolateral region of the neck contains the muscles of the hypopharynx and the carotid sheath (including the carotid artery, jugular vein, and vagus nerve). Deep and medial to the sternocleidomastoid (SCM) muscle are the esophagus and trachea. Ventral to the trachea are the thyroid and parathyroid glands. Injury to any of these vital structures can produce undesired morbidity and contribute to the challenges of the cervicothoracic junction.

Developing a bloodless plane is critical to the surgical approach. Thus, identification of the SCM muscle is critical. This muscle originates from the mastoid process and inserts at the sternum and the clavicle. Just medial and deep to this muscle are the midline structures: strap muscles, trachea, and esophagus. The strap muscles include the sternohyoid, sternothyroid, omohyoid, and thyrohyoid. Between the SCM and strap muscles are multiple neurovascular structures. The right recurrent laryngeal nerve branches from the vagus nerve and curves around the subclavian artery. The left recurrent laryngeal nerve curves underneath the aortic arch and runs superiorly between the trachea and the esophagus in the tracheoesophageal groove more caudally (and is often less aberrant). Other important structures in this region include the carotid artery, the vagus nerve, and the jugular vein. Within the superior mediastinum, the subclavian artery and vein, the brachiocephalic artery and vein, and the thoracic duct can all be encountered. The thoracic duct is medially bounded by the first thoracic vertebrae and the manubrium and laterally by the first ribs. The cupula of the lung lies just inferior to the thoracic duct.

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