Kaya Ramazan Alper, Türkmenoğlu Osman Nuri, Koç Omer Nadir, Genç Haci Ali, Cavuşoğlu Halit, Ziyal Ibrahim Mustafa, Aydin Yunus
Sişili Etfal State Hospital, Clinic of Neurosurgery, Istanbul, Turkey.
Surg Neurol. 2006 May;65(5):454-63; discussion 463. doi: 10.1016/j.surneu.2005.08.017.
To reach the upper thoracic vertebrae, a number of extensive approaches have been proposed. The purpose of this study is to provide a clear perspective for the selection of surgical approaches in patients who undergo vertebral body resection, reconstruction, and stabilization for upper thoracic and cervicothoracic junction instabilities.
Seventeen patients with upper thoracic or cervicothoracic junction (C7-T6) instability underwent surgery between January 1999 and May 2004. All patients presented with pain and/or neurological deficits. The causes of instabilities were 10 traumas and 7 pathological fractures. The approach chosen was primarily dictated by 3 factors including (1) type of injury, (2) level of lesion, and (3) time of admission. Ventral surgical approach was performed to all pathological and traumatic fractures causing anterior spinal cord compression. Level of lesion determined the selection of the type of ventral surgical approach, namely, supramanubrial, transmanubrial, or lateral transthoracic. On the other hand, combined (anterior and posterior) approach was performed to all late admitted trauma patients.
Twelve anterior, 2 combined (anterior and posterior), and 3 posterior approaches were performed in this study. Anterior approaches included 3 transmanubrial, 5 upper lateral transthoracic, and 4 supramanubrial cervical dissection procedures for decompression, fusion, and plate-screw fixation depending on the levels of the lesion. The mean follow-up period was 18 months, ranging from 10 to 58 months. Nonunion or instrument-related complications were not observed. The postoperative neurological conditions were statistically significantly better than the preoperative ones (P = .003).
Consideration of the type of injury, level of lesion, and time of admission can provide a perspective for the selection of side of surgical approach for this transitional part of the spinal column. This study also suggests that supramanubrial cervical approach achieves sufficient exposure up to T2, transmanubrial approach for T3, and lateral transthoracic approach below T3.
为了到达上胸椎，已经提出了多种广泛的手术入路。本研究的目的是为接受椎体切除、重建和稳定手术以治疗上胸椎和颈胸交界区不稳的患者选择手术入路提供清晰的视角。
1999年1月至2004年5月期间，17例上胸椎或颈胸交界区（C7-T6）不稳的患者接受了手术。所有患者均有疼痛和/或神经功能缺损。不稳的原因包括10例创伤和7例病理性骨折。选择的手术入路主要由三个因素决定，包括（1）损伤类型，（2）病变节段，（3）入院时间。对所有导致脊髓前方受压的病理性和创伤性骨折均采用前路手术入路。病变节段决定了前路手术入路类型的选择，即胸骨上入路、经胸骨入路或经胸外侧入路。另一方面，对所有晚期入院的创伤患者均采用联合（前后路）入路。
本研究中进行了12例前路、2例联合（前后路）和3例后路手术。前路手术包括3例经胸骨入路、5例胸上段外侧经胸入路和4例胸骨上颈椎解剖手术，根据病变节段进行减压、融合和钢板螺钉固定。平均随访期为18个月，范围为10至58个月。未观察到骨不连或与器械相关的并发症。术后神经功能状况在统计学上明显优于术前（P = 0.003）。
考虑损伤类型、病变节段和入院时间可为脊柱这一过渡部位手术入路的选择提供视角。本研究还表明，胸骨上颈椎入路可充分暴露至T2，经胸骨入路用于T3，胸外侧经胸入路用于T3以下节段。
