Comey C H, McLaughlin M R, Moossy J
Department of Neurosurgery, University of Pittsburgh, PA, USA.
Acta Neurochir (Wien). 1997;139(8):712-8. doi: 10.1007/BF01420043.
With increasing frequency, spine surgeons are being asked to provide decompression and stabilization in patients with spinal metastases. While no region of the spine is easily treated, the upper thoracic spine is perhaps the least accessible. Traditional approaches to this region involve either thoracotomy or at least limited sternotomy. The authors present an approach to anterior pathology of the upper thoracic spine that obviates the need for sternotomy.
Within the past two years, two patients with cervicothoracic metastases underwent anterior decompression and fusion without sternotomy. In both patients, the bodies of C7, T1, and T2 were removed. While both patients were prepared and draped for sternotomy, each required a neck dissection only. In both patients, left-sided incisions were made along the leading edge of the sternocleidomastoid. The platysma was divided with the overlying skin. With further dissection, the strap muscles were tagged and divided approximately one centimeter above their sternal attachments. The loose areolar tissue of the superior mediastinum was then bluntly dissected. Along the entire length of the incision, the vascular plane medial to the carotid sheath was developed to facilitate exposure of the anterior spine. A Farley-Thompson retractor system was then employed to retract and protect the superior mediastinal structures. With this exposure, corpectomies were carried out using a high speed drill. Fusion was accomplished through insertion of Steinmann pins into the adjacent intact bodies above and below. This was followed by application of methyl methacrylate. Both patients had immediate postoperative stability with preservation of spinal cord function. Both patients subsequently underwent removal of dorsally located tumor with posterior fusion.
The goal of cancer surgery is to provide for increased functional survival without undue morbidity. The authors feel that when possible, the pain of sternal and clavicular osteotomies should be avoided. The described approach works well in conjunction with a methyl methacrylate/Steinmann pin construct. Because of the intact sternum, the surgeon has a downward angle to access the superior endplate of T3. With adequate soft tissue dissection and retraction as described, however, T3 and perhaps even T4 are easily accessible. While this downward angle would likely not permit an anterior plating procedure, it lends itself nicely to Steinmann pin/methyl methacrylate fusion and spares the patient the pain and potential morbidity of sternotomy.
脊柱外科医生越来越频繁地被要求为脊柱转移瘤患者提供减压和稳定手术。虽然脊柱的任何部位都不容易治疗，但上胸椎可能是最难接近的部位。传统的该区域手术方法包括开胸手术或至少有限的胸骨切开术。作者介绍了一种治疗上胸椎前部病变的方法，该方法无需进行胸骨切开术。
在过去两年中，两名颈胸段转移瘤患者在未进行胸骨切开术的情况下接受了前路减压和融合手术。两名患者均切除了C7、T1和T2椎体。虽然两名患者均已准备好并铺上了用于胸骨切开术的手术巾，但每人仅需要进行颈部解剖。两名患者均沿胸锁乳突肌前缘做左侧切口。将颈阔肌与覆盖的皮肤一起切开。进一步解剖后，标记并切断带状肌，在其胸骨附着点上方约1厘米处切断。然后钝性解剖上纵隔的疏松结缔组织。沿切口全长，在颈动脉鞘内侧的血管平面进行分离，以利于暴露脊柱前部。然后使用Farley-Thompson牵开器系统牵开并保护上纵隔结构。在此暴露下，使用高速钻进行椎体次全切除术。通过将斯氏针插入上下相邻的完整椎体来完成融合。随后应用甲基丙烯酸甲酯。两名患者术后即刻获得稳定，脊髓功能得以保留。两名患者随后均接受了后路融合手术以切除位于背部的肿瘤。
癌症手术的目标是在不造成过度并发症的情况下提高功能生存率。作者认为，在可能的情况下，应避免胸骨和锁骨截骨带来的疼痛。所描述的方法与甲基丙烯酸甲酯/斯氏针结构配合良好。由于胸骨完整，外科医生有一个向下的角度来进入T3的上终板。然而，通过如所述的充分的软组织分离和牵开，T3甚至可能T4都很容易暴露。虽然这个向下的角度可能不允许进行前路钢板固定手术，但它非常适合斯氏针/甲基丙烯酸甲酯融合，并且使患者免于胸骨切开术的疼痛和潜在并发症。
