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Chapter 18 Cervical Spine: Surgical Approaches 333
nger dissection. is helps reect the parietal pleura from
the posterior surface of the sternum and costal cartilage. e
sternum is cut longitudinally with an oscillating saw. e
inferior thyroid vein located just proximal to the suprasternal
notch must be avoided. A self-retainer is inserted to split the
sternum.
Blunt dissection is performed from the cranial toward the
caudal portion until the le brachiocephalic vein is exposed.
As in the modied anterior approach to the cervicothoracic
junction, the esophagus, trachea, le carotid sheath, le sub-
clavian artery, and brachiocephalic vein are retracted to the
patient’s le, whereas the esophagus, trachea, and right brachiocephalic artery and vein are mobilized to the right. e
prevertebral fascia can now be divided in the midline to
provide access to the C4–T4 vertebral bodies.
Transthoracic Approach
With the patient in the le lateral decubitus position, the right
chest is prepared and draped. e bony prominences are
padded accordingly, and a le roll is placed in the axilla to
prevent neurovascular compromise to the le upper extremity.
A right-sided approach is preferred because of the location of
the great vessels and heart in the le-sided approach. A standard thoracotomy centered on the third rib provides access to
the upper thoracic vertebra, but exposure to the low cervical
region is restricted. A rst or second rib level entry does not
improve access because these ribs are much shorter, and the
scapula interferes posteriorly.
e incision is made beginning at the anterior axillary line
and extending posteriorly to the lateral border of the paraspinal muscles. e scapula is retracted laterally by dividing the
trapezius and latissimus dorsi muscles. e subscapular space
is developed with blunt dissection, and the third rib is identi-
ed by counting down from the thoracic inlet.
While protecting the intercostal neurovascular bundle, the
appropriate rib is subperiosteally dissected out and resected
anteriorly and posteriorly as far as possible. A rib spreader is
inserted, and the lung is retracted anteriorly. e parietal
pleura is incised overlying the vertebral artery, making sure to
identify the segmental vessels.
Complications
Postoperative weakness secondary to weakness of the shoulder girdle musculature from the joint resection can occur.
e thoracic duct should be identied if approached from the
le. If damaged, the thoracic duct should be doubly ligated
proximally and distally to prevent chylothorax. Great caution
should be taken to avoid injuries to the sympathetic nerves,
the cupola of the pleura at the level of T1, the great vessels,
and the thoracic duct, which passes into the le venous angle
between the subclavian artery and the common carotid artery.
Potential complications of this approach include restriction
of scapular movement and paralysis of intercostal muscles
owing to the muscle-splitting aspects of this dissection. We
recommend use of this approach in older patients and perhaps
in patients with malignant conditions.
Posterior Approaches
Posterior exposures to the cervical spine are among the safest
and most used exposures for management of cervical spine
disorders, allowing direct access to the posterior elements
from the occiput to the thoracic spine.
anatomy of the upper cervical spine and the transitional
anatomy of the cervicothoracic junction should also be understood when approaching these regions posteriorly.
6,62
e particular
Posterior Approach to Upper Cervical Spine
e posterior approach to the upper cervical spine grants
exquisite access to the posterior elements of the occiput, atlas,
and axis, allowing for easy atlantoaxial and occipitocervical
decompression and fusion. e exposure begins with a midline
incision extending from the inion to the C4 spinous process,
an incision length that can be tailored depending on the
treated pathology. e incision should fall along an internervous plane in the midline that separates the muscles from the
segmental innervation supplied by the right and le posterior
rami of the cervical nerves. Staying in the midline, within the
avascular plane of the ligamentum nuchae minimizes bleeding
and the risk of injury to surrounding muscle tissue and neurovascular structures, while providing a stout tissue layer for
tissue closure at the end of the case. is principle is especially
important in the cervical spine as the posterior cervical musculature is particularly vascular.
If the location of pathology is at the occipitocervical junction, that is, in the case of basilar impression, fracture of the
odontoid with C1 fracture, or tumor, bone landmarks can be
used to determine the appropriate level. e external occipital
protuberance and the spinous process of C2 can typically be
easily palpated, with the incision made from the inion caudad
approximately 8 cm. As discussed earlier, the dissection is
continued through the ligamentum nuchae, and the paraspinal
muscles are stripped from C3 to the occiput. e surgeon
should be cautious when dissecting at the inferior edge of the
foramen magnum because uncontrollable bleeding from a
group of veins present in this location may be encountered.
Sharp subperiosteal dissection of the external occipital protuberance and lamina is performed, and care is taken to protect
the vertebral arteries at the lateral border of the atlas. With a
ne curet or an elevator, the posterior atlanto-occipital ligament can be separated from the posterior lip of the foramen
magnum if necessary.
e greater occipital nerve (C2) and the third occipital nerve
cross the eld and course laterally in the paracervical muscles.
Subperiosteal dissection and avoidance of vigorous lateral dissection should prevent injury to these nerves. If occipital xation is required, the inion is thickest at its prominence near the
ridge, and the passage of wires is possible without violating
both tables of the occiput. If screw xation is being used,
bicortical purchase is recommended for the occiput, and screw
lengths of typically 10 to 12 mm can be accepted in this region.
If access to the posterior elements of C1–C2 is necessary,
the incision can be extended inferiorly. Palpation of the large
63
SECTION
III
334 SURGICAL ANATOMY AND APPROACHES
C2 spinous process and the posterior C1 ring conrms the
correct level. e posterior arch of the atlas is deeper anteriorly
than the occiput and C2 spinous process, and the facet joint
of C1–C2 lies about 2.5 cm anterior to the C2–C3 joint. A
large broad elevator is used to dissect the posterior paracervical muscles from the arches of C1 and C2, and caution should
be taken to avoid plunging instruments into the spinal canal.
A small curet can be helpful to remove the muscular attachments on the bid spinous process of C2 while stabilizing the
arch of C2. Capsular ligaments of the facets should be preserved to maintain stability.
e passage of sublaminar wires at the C1–C2 level is
common because the spinal canal at this level is capacious, but
passage at lower cervical levels is associated with increased
risk of neurologic injury. e removal of the atlantoaxial ligament or atlanto-occipital membrane is not required except for
laminectomy cases. Careful separation of the membrane or
ligament from the bone is all that is usually needed to pass
sublaminar wires. is separation can be performed with a
small-angled curet or a small Freer elevator. Slight head exion
can also help by opening the space between the ring of C1 and
the occiput. e mean thickness of the posterior ring is 8 mm,
and the cortical bone is thin.64 Great care must be taken not
to fracture the posterior ring of C1 while dissecting the ligamentum avum.
An additional technique to expose the lateral aspect of C1
or C2 is to elevate the periosteum with a small Freer elevator.
is allows the vertebral artery to be protected at the lateral
aspect of the C1 arch. Lateral dissection should not exceed
greater than 1.5 cm from the midline in an adult and 1 cm in
a child due to risk of injury to the vertebral artery.
65,66
e
vertebral artery courses over the arch of the atlas and pierces
the lateral angle of the posterior atlanto-occipital membrane,
although preoperative imaging should be obtained to evaluate
the course of the vertebral artery and rule out anomalous
vascular anatomy.
Brief consideration is given here to the regional anatomy
for the C1–C2 transarticular screw xation (Magerl) tech-
67–69
nique,
technique,
C1 lateral mass and C2 pedicle screw (Harms)
69,70
and C2 translaminar screw.
69,71
A thin-cut CT
scan with sagittal reconstructions and/or MRI imaging are
necessary to fully track vertebral artery course and structure.
is imaging is especially important to obtain in rheumatoid
patients in whom an anomalous or enlarged foramen transversarium is common, which may place the vertebral arteries
at increased risk with this technique. Attention should be paid
to the presence of a ponticulus posticus, an anomalous ossi-
cation overlying the vertebral artery as it runs in the superior
sulcus of C1, which can occur in 15% of the population.
Regardless of the technique used, the intraoperative use of
anteroposterior and lateral uoroscopy can inform screw
inclination in the coronal and parasagittal plane.
Because of the amount of cephalad angulation required to
place the C1–C2 transarticular screw, subperiosteal exposure
should extend down to C4.65 e main landmark is the medial
part of the isthmus of the axis, which can be visualized directly
by subperiosteal dissection of the C2 lamina proceeding along
the bony contour around the spinal canal until the maximum
width in the coronal plane is reached. A Kirschner wire
(K-wire) can be used to retract the so tissues containing the
greater occipital nerve and accompanying the venous plexus.
e point of entry can be approximated as 3 mm cranial to
the C2–C3 facet joint and 3 mm medial to the lateral border
of the C2 inferior facet. e drilling for the screw is strictly
sagittal and extends through the pars interarticularis, before
perforating the atlantoaxial joint approximately in the posteromedial part entering the lateral mass of the atlas.72 Lateral
drill excursion should be avoided to prevent additional risk of
injury to the vertebral arteries.
In the case of placement of a C1 lateral mass screw, the
C1–C2 joint is the key anatomic landmark to be identied.70
is identication can be facilitated by caudal retraction of the
C2 nerve, which exposes the posterior aspect of the lateral
mass of C1.69 Subperiosteal dissection must be carried out on
the inferior edge of the posterior arch of C1. e starting point
of the C1 lateral mass screw lies directly in the midportion in
the lateral mass. Oen, a small emissary vein is located at this
point. e C2 pedicle screw is identied by delineating the
medial border of the isthmus and pars of the axis, as in the
C1–C2 transarticular screw. However, the trajectory of the C2
pedicle screw is more medial and follows the path of the
pedicle, as would be expected.
69,70
Technical challenges associated with the C1–C2 transarticular screw and C2 pedicle screw placement led to the
development of the C2 translaminar screw. Use of this screw
is possible because of the predictably large size of the C2
lamina combined with the fact that the use of this screw
eliminates the possibility for vertebral artery injury.
69,71
e
starting point is identied as the junction of the C2 spinous
process and the lamina, and the trajectory of the screw parallels the down slope of the dorsal aspect of the contralateral
lamina. Care should be taken not to breach the ventral aspect
of the lamina, resulting in placement of the screw within the
spinal canal and to ensure that the C2–C3 facet joint is not
violated by placement of a screw that is too long.
71
Posterior Approach to Lower Cervical Spine
A reverse Trendelenburg position minimizes venous bleeding
and reduces CSF pressure (Fig. 18.13). e posterior approach
uses a longitudinal midline incision that extends above and
below the segments required for the procedure. is extension
of the skin and subcutaneous tissues is necessary because the
skin of the posterior neck is less mobile and thicker for retraction. e skin is incised sharply, and electrocautery is used to
incise the ligamentum nuchae in the midline. With a wide, at
periosteal elevator such as a Cobb, the dissection is carried
subperiosteally down the spinous processes. Inadvertent penetration of instruments into the spinal canal can be minimized
by examining preoperative lms for evidence of spina bida and
other bony defects and by realizing that, in the cervical spine,
the laminae do not override each other as much as in the thoracic
spine, resulting in wider interlaminar spaces. Care should be
taken to stay subperiosteal because the bid nature of the spinous
processes may result in a bulbous expanse, and the dissection
may err into the paraspinal musculature. A supercial plexus of
Chapter 18 Cervical Spine: Surgical Approaches 335
SECTION
III
FIG. 18.13 Standard prone positioning for posterior cervical procedures.
The reverse Trendelenburg position minimizes venous bleeding and reduces
cerebrospinal uid pressure.
veins may be encountered, which should be cauterized as
needed. In general, subperiosteal dissection should be performed
in a caudal-to-cephalad direction to minimize bleeding.
Subperiosteal dissection of muscles is performed to expose
the spinous processes, lamina, lateral mass, and facet joints.
Dissection should extend laterally to the medial third of the
facet joint, with preservation of the capsule unless a fusion
is planned. Extreme caution is needed during the exposure
of the lamina and the interlaminar space to prevent dural
tear and CSF leakage. Care should be taken at the lateral
edge of the joint because the nerve root and vertebral artery
lie anterior to the spinolamellar membrane of the adjoining
transverse processes. Vigorous decortication or stripping may
damage the thin bone and subsequently the nerve root and
vertebral artery. e segmental artery at the lateral edge of
the facet joints may be cauterized as it exits between the transverse processes. Various retractors may be used to facilitate
exposure. For fusion cases, one should expose only the levels
to be fused because creeping fusion extension is common.
Supplementation of the fusion with posterior lateral mass
plating may obviate the need for a halo vest postoperatively.
First popularized by Roy-Camille and colleagues,73 placement of posterior cervical screws requires a thorough understanding of the lateral mass anatomy to minimize injury to
associated neurovascular structures. Dierent entry points
and screw orientations have been recommended. In the original description by Roy-Camille and colleagues,73 the entry
point was the center of the lateral mass, with the screw angled
10 degrees laterally (Fig. 18.14), whereas Magerl recommended
the drilling angle to be 25 degrees laterally and 45 degrees
superiorly. An and colleagues5 found that, by orienting the
screw 15 degrees cephalad and 30 degrees laterally with an
entry point 1 mm medial to the anatomic center of the lateral
mass, the facet joint and nerve root are avoided.
Posterior Approach to Cervicothoracic Junction
Lesions of the cervicothoracic junction are generally anterior,
for which extensive anterior approaches with or without
10°
FIG. 18.14 The Roy-Camille technique for lateral mass screws. The entry
point is at or near the anatomic center of the lateral mass and directed 10
degrees laterally.
posterior xation are usually required. Lesions that may
require posterior stabilization include lesions resulting from
tumors, trauma, postlaminectomy instability, or infection. If
the posterior elements are intact, the simple triple-wiring
procedure can be done for a short fusion, or rods may be used
for a longer fusion, using a standard posterior approach.
Pedicle screw xation is an alternative technique if the
posterior elements are decient. e transpedicular technique
at the cervicothoracic junction is an exacting procedure with
very little margin for error. rough cadaveric studies, the
pedicle landmarks and anatomic characteristics of the cervicothoracic region were found. A standard posterior approach
is used with the dissection performed to expose the lateral
mass and to the tips of the transverse processes of the upper
thoracic vertebrae. e facet joint to be fused is cleaned of its
capsule, and the articular margins are identied. e entry
point of the pedicle lies at the intersection of a horizontal line
at the midportion of the transverse processes and a vertical
line at the lamina–transverse process junction. is pedicle
entrance point is 1 mm inferior to the facet joint and the
middle point from the medial to the lateral margins of the
facet joint. e outer cortex is decorticated at this point with
a small bur, and a small Peneld elevator or straight curet is
used to probe bluntly and enter the pedicle. A 2.5-mm drill
may be used to enter the pedicle when it is identied. Medial
angulation is required for entry of the pedicle into the vertebral
body. Medial angulation has been observed to vary between
individuals, thus it must be measured preoperatively in preparation for surgery. An et al. most recently reported that medial
angulation averages 35.85 degrees at C7, 31.65 degrees at T1,
and 23.35 degrees at T2.74 Compared with the pedicles of the
lumbar spine, the superoinferior diameter of the thoracic
pedicles at the cervicothoracic junction is greater than its
336 SURGICAL ANATOMY AND APPROACHES
mediolateral diameter, which leaves little margin for error in
the mediolateral plane.
74
Complications
Complications associated with posterior approaches to the
upper and lower cervical spine are uncommon but can be
catastrophic. Bleeding can be minimized by staying subperiosteal and within the midline to prevent entering into the
paraspinous musculature. e arch of the atlas should be
dissected laterally only approximately 1.5 cm because the
vertebral artery is at risk. One should minimize dissecting at
the inferior edge of the foramen magnum to prevent uncontrollable venous bleeding.
Neurologic injury is a devastating complication of spine
surgery. Care is required during passage of sublaminar wires
or application of the screws to prevent injury to the brain
or spinal cord. Dissection on the ring of the atlas must be
done in a gentle manner because the direct pressure may
result in fracture or slippage of an instrument into the spinal
canal. A thorough understanding of the size, orientation,
and relationship of the pedicles and lateral masses to surrounding neurovascular structures is imperative before the
use of spinal instrumentation is undertaken. Posterior fusion
without decompressive laminectomy tends to compress the
spinal canal.
PEARLS
The anterior tubercle of the transverse process of C6 is an
1.
important palpable surface landmark for anterior cervical
approaches.
2.
The key to understanding the anterior approach to the cervical
spine lies in recognizing the various investing fascial layers of
the neck.
3.
Placement of the deep retractors anteriorly should be deep to
the longus colli to reduce the risk of injury to the sympathetic
chain.
4.
Posteriorly, the rst bony prominence palpated inferior to the
occiput is the spinous process of C2.
5.
Reformatted ne-cut CT scans of the cervical spine help to
improve understanding of the bony anatomy.
PITFALLS
The variable course of the vertebral artery as it ascends through
1.
the cervical spine places it at risk for injury during the anterior
and posterior cervical approach.
2.
The incorrect approach may be chosen without careful
preoperative imaging review.
3.
Increased rates of injury to surrounding structures may be observed
if a modied anterior approach to the cervical spine is not used.
4.
Increased bleeding is likely with dissection away from the
midline that is not subperiosteal.
5.
Airway obstruction after extubation may occur in the
postoperative period after anterior and posterior cervical
procedures.
KEY POINTS
1. Understanding the surgical anatomy of the cervical spine
requires knowledge of the bony, ligamentous, muscular, and
neurovascular anatomy of the neck and the complex
relationship these structures have to one another.
2. The surgical approach selected should take into account the site
of the pathologic process, the health of the patient, and the skill
and comfort level of the surgeon with each particular exposure.
3.
Understanding the advantages and limitation of each surgical
exposure improves patient outcome and reduces complications.
4.
Anatomic and surgical considerations at the occipitocervical
and cervicothoracic junction are particularly challenging and
should be thoroughly understood before approaching
pathologic processes in these regions.
5.
Complications of the cervical spine are infrequent but
potentially devastating; careful preoperative planning, precise
surgical technique, and a high index of suspicion should be
maintained to minimize and identify complications.
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2.
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4.
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47. Whitesides TE, Kelly RP. Lateral approach to the upper cervical
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48. Henry AK. Extensile Exposure. Baltimore: Williams & Wilkins;
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49. Hogson AR. An approach to the cervical spine (C3-C7). Clin
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52. Whitehill R. Late esophageal perforation from an autogenous
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Anatomy of the Anterior
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19
CHAPTER
e cervicothoracic spine corresponds to the region just
superior to the mediastinum and extends into the sternum
and T4–T5 intervertebral disc space. In this region, knowledge
of the vascular and neural anatomy is of utmost importance.
e le brachiocephalic vein is found posterior to the upper
sternum and lies directly posterior to the thymus gland. e
right and le brachiocephalic veins merge behind the right
rst intercostal space to form the superior vena cava. e
superior vena cava drains into the right atrium behind the
third costal cartilage.
e recurrent laryngeal nerve is a branch of the vagus
nerve that supplies the intrinsic muscles of the larynx with the
exception of the cricothyroid muscles. Injury to this nerve can
result in dysphonia and dysphagia. e le recurrent laryngeal
nerve can be found emerging from the vagus nerve anterior
to the arch of the aorta between T1 and T3. e phrenic nerve
can also be found in this region, anterior to the arch of the
aorta (Fig. 19.1). From there, its course is noted to predictably
travel in the tracheoesophageal groove. e right recurrent
laryngeal nerve, on the other hand, branches o the vagus
nerve in the upper cervical region and loops around the right
subclavian artery. It can also course anteriorly behind the
thyroid before entering the tracheoesophageal groove.
Given the important function of the recurrent laryngeal
nerve, there has been much debate as to whether a le- or
right-sided approach is safer, minimizing risk to the nerve. In
their classic work, Tew and Mayeld report the asymmetric
course between the right and le recurrent laryngeal nerves.1
According to their work, the le recurrent laryngeal nerve
takes a longer, more predictable, protected course around the
arch of the aorta. Because of this, they believed that a le-sided
approach minimized the risk of injury to the recurrent laryngeal nerve. Other work has reported no statistical dierence
between nerve injury rates and side of approach.2 Overall, for
anterior surgery, the reported incidence of dysphonia ranges
from 2% to 30%, and the incidence of dysphagia ranges from
28% to 57%.
Another important neural structure in the anterior cervicothoracic spine is the phrenic nerve. e phrenic nerve
innervates the diaphragm. It courses anterior to the pulmonary
hilum before reaching the diaphragm.
Last, mention should be made of the thoracic duct, which
is the largest lymphatic vessel in the body. It typically starts at
3
Cervicothoracic Spine
Kenneth A. Hood
Shyam Shridharani
the level of the twelh thoracic vertebra and enters the thorax
through the aortic opening of the diaphragm between the
aorta and azygos vein. In the mediastinum, it is located on
the le side behind the arch of the aorta and ascends between
the le subclavian artery and the esophagus, and drains at the
angle of junction of the le subclavian vein and le internal
jugular vein.
Surgical Approaches to the Anterior Thoracic Spine
Low Anterior Cervical and High Transsternal Approach
e cervicothoracic junction is a biomechanical transition
zone between the lordotic cervical spine and the kyphotic
thoracic spine. is approach allows for exposure of the
lower cervical spine and upper thoracic spine, from C7 to
T4. A successful approach to this region requires navigation
through numerous important neurovascular structures. Indications for this approach include infectious, traumatic, and
neoplastic processes that require decompression and fusion
or corpectomy.
e patient is positioned supine on a radiolucent table. A
towel roll or bump is placed between the scapulae, allowing
for gentle neck and shoulder extension. e arms are padded
and tucked at the sides. e shoulders are gently taped downward and the neck is turned slightly away from the approach
side, allowing for improved access and uoroscopic visualization. e shoulders should not be overaggressively taped, as
this can cause a traction injury to the brachial plexus. e table
can be positioned in slight Trendelenberg to minimize venous
engorgement and pooling.
As previously mentioned, there is controversy as to which
side the approach should be performed. Classically, a lesided approach is performed as the recurrent laryngeal nerve
is thought to follow a more predictable course in the tracheoesophageal groove, minimizing risk of injury.
Aer standard sterile preparation and drape, a skin incision
is made from the anterior border of the sternocleidomastoid
to the sternal notch (Fig. 19.2A). For cases requiring full
exposure, from C7 to T4, the vertical limb of the incision can
III
339
340 SURGICAL ANATOMY AND APPROACHES
B
Trachea
First rib
Esophagus
Left vagus
Vagus nerve on
Brachiocephalic
A
Right phrenic
nerve
Right jugular
vein
Vagus nerve
Trachea
artery
Superior
vena cava
FIG. 19.1 (A) Anteroposterior view of cervicothoracic junction. (B) Lateral view of cervicothoracic junction.
External
jugular vein
Phrenic nerve
behind left
jugular vein
Left recurrent
laryngeal nerve
Left subclavian
artery and vein
aortic arch
Phrenic
nerve
nerve
Aortic
arch
Sternal
angle
C7
T1
T2
T3
T4
T5
Left
subclavian
artery
Thoracic
duct
A
Strap muscle
C
FIG. 19.2 (A) Inverted L-shaped incision for cervicothoracic junction. Midsternal extension of incision can be
extended further vertically for more exposure distally. (B) Insertion of sternocleidomastoid muscle into clavicular
head. (C) Sternocleidomastoid muscle retracted laterally revealing underlying strap muscle. Carotid sheath and
jugular vein should be mobilized laterally as well.
be carried inferiorly over the middle of the manubrium to the
level of the third costal cartilage. Subcutaneous dissection is
performed down to the platysma. Once the platysma is well
dened, it is carefully split in a longitudinal fashion. One
should avoid injuring the underlying jugular veins, but they
can be sacriced if they hinder the approach.
Head of
clavicle
B
Carotid a.
Jugular v.
Next, the sternocleidomastoid and strap muscles are identied at their insertion onto the clavicle (Figs. 19.2B–C). e
clavicular and manubrial heads of the sternocleidomastoid are
elevated proximal and lateral in a subperiosteal manner. e
strap muscles are similarly elevated medially. Subperiosteal
exposure should be undertaken until the ipsilateral half of the
Chapter 19 Anatomy of the Anterior Cervicothoracic Spine 341
manubrium and junction of the medial and middle third of
the clavicle are exposed.
e clavicle is cut at the junction of the medial and middle
third with an osteotome or oscillating saw. Care should be
taken to ensure that the underlying neurovascular structures are protected during this process. Once free laterally,
the clavicle is gently lied up and disarticulated from the
manubrium.
For greater distal exposure, a sternal splitting approach can
be performed. is involves splitting the manubrium down
the midline to the level of exposure required. Retrosternal
adipose tissue and the thymus are retracted and protected.
e sternum is then exposed subperiosteally. e manubrium
is subsequently split with an oscillating or Gigli saw. e
inferior thyroid vessels can be ligated if necessary and the
le innominate vein is retracted caudally or ligated (if necessary). Care should be taken not to injure the thoracic duct,
which is located le of the esophagus starting at T4 as it
ascends to its junction with the le internal jugular vein and
subclavian vein.
e remainder of the dissection is similar to the SmithRobinson approach. e interval between the trachea and
esophagus medially and the carotid sheath laterally is identied and developed. When placing retractors it should be
ensured that they are safely placed to avoid injury to the
recurrent laryngeal nerve, which lies in the tracheoesophageal
groove. e right brachiocephalic artery can be taken to the
right along with the trachea and esophagus. e le brachiocephalic and subclavian veins are retracted inferiorly and to
the le. e longus colli muscles on either side of the spine
are identied and the prevertebral fascia is spread with a
Kittner, exposing the anterior thoracic spine.
Transpleural Transthoracic Third Rib Resection
An alternative approach to the low anterior cervical high
transsternal approach is the transpleural transthoracic third
rib resection. is approach allows excellent exposure of the
anterolateral thoracic spine from T1 to T4. e indications for
this approach are similar. e drawbacks to this approach
include the need for mobilization of the scapula and violating
of the chest wall musculature and pleural space.
For this approach, a double-lumen endotracheal tube
should be placed by anesthesia to allow for isolated lung deation on the approach side. e patient is positioned in the
lateral decubitus position with the approach side up. e knees
and elbows are gently exed and the arms are abducted. An
axillary roll is placed and all bony prominences are padded.
e patient can be secured to the table via bolsters or a
beanbag. e approach-side arm can be supported by stacked
pillows/towels or an arm holder. e area of prep and drape
is demarcated from the shoulder to above the iliac crest
(cephalad-caudad) and from the midline of the spine posteriorly to the umbilicus anteriorly (posterior-anterior).
e incision is carried from the paraspinous area at
approximately T1 distally along the medial border of the
scapula to the seventh rib (Fig. 19.3). It is then carried laterally and anteriorly toward the costal cartilage of the third
FIG. 19.3 Patient is positioned in lateral position on a Jackson spinal table
with incision marked for a high transthoracic approach. (From Le HN, Kim
DH. Anterolateral transthoracic approaches to the cervicothoracic junction
[transaxillary approach, transpleural transthoracic third rib resection
approach]. In: Kim DH, ed. Surgical Anatomy and Techniques to the Spine.
Philadelphia: Elsevier; 2006.)
rib. e trapezius and latissimus dorsi are divided, and the
scapula is retracted cephalad and medially (Fig. 19.4). e
third rib is identied. It should be kept in mind that the second
rib is typically the easiest rib to palpate, as it is elevated relative to the surrounding ribs. e rst rib sits medial to the
second rib.
4
e approach-side lung is now selectively deated. e
third rib is skeletonized in a subperiosteal manner (Fig. 19.5).
Anteriorly, this can be performed with Bovie electrocautery
and curettes. A Doyen is a great tool for performing posterior
subperiosteal dissection around the rib while protecting the
underlying neurovascular bundle (Fig. 19.6). e third rib is
cut as far anteriorly and posteriorly as possible and can be
used for bone gra (Fig. 19.7). e third rib bed—consisting
of the periosteum, endothoracic fascia, and parietal pleura—is
transected, allowing entrance into the thoracic cavity (Fig.
19.8). A chest spreader can be placed along with a second
retractor at a right angle to allow for maximum visualization.
e lung is retracted and protected with a malleable retractor
and moist lap sponge (Fig. 19.9).
e aorta, spine, parietal pleura, veins, and sympathetic
plexus are identied. Next, the parietal pleura is gently incised
in a longitudinal fashion over the indicated disc space. is
area is relatively avascular as compared to directly over the
vertebral body. e vertebral body is then exposed and the
intercostal arteries and veins are ligated and cut. Exposure can
be extended as necessary (Fig. 19.10).
Closure for this approach is as follows. e parietal pleura
is repaired, if feasible. Lung reexpansion is then performed.
e ribs are reapproximated with heavy nonabsorbable suture
or wire in gure-of-eight fashion utilizing a rib reapproximator. Care should be taken not to injure the neurovascular
bundle of the caudad rib being reapproximated when using
the rib reapproximator. e lung should also be protected
during this process. Last, a chest tube is placed through a
separate incision at the level of the ninth intercostal space and
set to water seal.
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III
AB
FIG. 19.4 Muscular exposure. (A) Note the relationship of the periscapular muscular anatomy. (B) Retracting or
detaching the latissimus muscle will reveal the underlying upper thoracic ribs and the attachments of the
serratus anterior muscles. (From Le HN, Kim DH. Anterolateral transthoracic approaches to the cervicothoracic
junction [transaxillary approach, transpleural transthoracic third rib resection approach]. In: Kim DH, ed. Surgical
Anatomy and Techniques to the Spine. Philadelphia: Elsevier; 2006.)
FIG. 19.5 Rib dissection can be exposed with use of cautery and
subperiosteal dissection. (From Le HN, Kim DH. Anterolateral transthoracic
approaches to the cervicothoracic junction [transaxillary approach,
transpleural transthoracic third rib resection approach]. In: Kim DH, ed.
Surgical Anatomy and Techniques to the Spine. Philadelphia: Elsevier; 2006.)
FIG. 19.6 A posterior subperiosteal dissection of the third rib is performed
using a doyen. (From Le HN, Kim DH. Anterolateral transthoracic approaches
to the cervicothoracic junction [transaxillary approach, transpleural
transthoracic third rib resection approach]. In: Kim DH, ed. Surgical Anatomy
and Techniques to the Spine. Philadelphia: Elsevier; 2006.)
FIG. 19.7 Third rib is resected using a rib cutter as far anteriorly and
posteriorly as possible. (From Le HN, Kim DH. Anterolateral transthoracic
approaches to the cervicothoracic junction [transaxillary approach,
transpleural transthoracic third rib resection approach]. In: Kim DH, ed.
Surgical Anatomy and Techniques to the Spine. Philadelphia: Elsevier; 2006.)
FIG. 19.8 Third rib bed consisting of periosteum, endothoracic fascia, and
parietal pleura is identied and transected to enter the thoracic cavity.
(From Le HN, Kim DH. Anterolateral transthoracic approaches to the
cervicothoracic junction [transaxillary approach, transpleural transthoracic
third rib resection approach]. In: Kim DH, ed. Surgical Anatomy and
Techniques to the Spine. Philadelphia: Elsevier; 2006.)