You are on page 1of 6

SPINE Volume 30, Number 11, pp E305–E310

©2005, Lippincott Williams & Wilkins, Inc.

Sternal Split Approach to the Cervicothoracic Junction

in Children

Kishore Mulpuri, MBBS, MS(Ortho),* Jacques G. LeBlanc, MD, FRCSC,‡

Christopher W. Reilly, MD, FRCSC,§ Kenneth J. Poskitt, MD, FRCPC,† Rachel L. Choit, BSc,*
Vic Sahajpal, MD, FRCSC,§ and Stephen J. Tredwell, MD, FRCSC§

Addressing complex spinal deformities around the cervi-

Study Design. We present a descriptive case series cothoracic junction is technically challenging because the
outlining the surgical technique and outcome in six pa- cervicothoracic vertebral bodies are relatively inaccessi-
tients managed with a combined anterior neck and ster-
nal splitting approach. ble due to the anatomic structures that impede the ante-
Objectives. To describe a surgical approach used in rior approach.1–3 Posterior approaches alone are insuf-
the management of severe cervicothoracic kyphosis ficient in severe cervicothoracic kyphosis. There have
and/or scoliosis in pediatric patients. been several different approaches described in the litera-
Summary of Background Data. There are few reports
in the literature that address the problem of accessing ture to resolve this difficulty.4 –9 Most reports that ad-
multileveled spinal deformities around the cervicotho- dress the anterior approach to the cervicothoracic junc-
racic junction requiring stabilization in the pediatric pop- tion describe gaining access to short segments of the
ulation. spine. This may be adequate to manage primary or met-
Methods. A detailed chart and radiographic review
was completed of six consecutive patients managed at astatic tumors affecting the upper thoracic vertebrae, the
our center with a combined anterior neck and sternal sequelae of Pott’s disease, or thoracic ossification of the
splitting approach. The indications, surgical technique, posterior longitudinal ligamentin in adults.1–3, 10 –13 But
and outcome are reviewed for each case. This technique these reports do not address the problem of accessing
was employed in 6 pediatric patients, aged 3–15 years, at
the authors’ institution. Diagnoses included Klippel-Feil multileveled spinal deformities requiring stabilization in
Syndrome (2 patients), Proteus Syndrome, Larsen Syn- the pediatric population. There are few reports in the
drome, and neurofibromatosis type I (2 patients). All pa- literature concerning the anterior approach to the cervi-
tients had severe cervicothoracic kyphosis requiring sur- cothoracic junction for instrumentation and fusion of
gical instrumentation. This technique allowed surgical
access from C5-T6. pediatric scoliosis.5
Results. This approach was invaluable in gaining ac- Cauchoix and Binet4 were the first in the literature to
cess to the cervicothoracic junction to address complex describe a trans-sternal approach to the upper thoracic
spinal deformities in pediatric patients. In one patient, a spine. They advocated that access to the cervical spine
separate thoracotomy was performed to access the lower
thoracic spine. The only significant complication related was best gained via an incision along the anterior margin
to the approach was recurrent laryngeal nerve palsy ex- of the sternomastoid muscle, and thoracic access is
perienced by one patient. This approach allowed stabili- gained by an incision in the midline of the sternum that is
zation of severe scoliotic and/or kyphotic deformities to carried down to the xiphoid process. The two-part inci-
impede curve progression.
Conclusions. This approach was invaluable in gaining sion is then merged into one operation area by dividing
multileveled access to the cervicothoracic junction to ad- the subhyoid muscles. Cauchoix used this anterior cervi-
dress complex spinal deformities in pediatric patients. cothoracic approach on 2 patients: a 4-year-old child
Key words: cervicothoracic junction, anterior ap- with quadriplegia secondary to Pott’s disease involving
proach, sternal split, pediatric, scoliosis; kyphosis. Spine
the first and second dorsal vertebrae with a sharp kypho-
sis and bilateral abscess requiring cord decompression,
and a 19-year-old man with complete spastic paraplegia
From the *Department of Orthopaedics, British Columbia’s Children’s whose plain films demonstrated an osteolytic tumor de-
Hospital; and the Departments of †Radiology, ‡Surgery, Division of stroying the first and second dorsal vertebrae and the
Cardiovascular Surgery, and §Orthopaedics, Division of Paediatric upper part of the third vertebra.4 The authors achieved
Orthopaedics, University of British Columbia, British Columbia’s
Children’s Hospital, Vancouver, British Columbia, Canada. satisfactory results with their two patients, but others
Acknowledgment date: April 15, 2004. First revision date: September who later used this approach demonstrated a high op-
10, 2004. Second revision date: September 20, 2004. Acceptance date:
September 23, 2004.
erative mortality and morbidity, and it was subse-
The manuscript submitted does not contain information about medical quently advocated that direct anterior exposures should
device(s)/drug(s). be abandoned.1
No funds were received in support of this work. No benefits in any
form have been or will be received from a commercial party related Hall5 outlined the specific indications for different an-
directly or indirectly to the subject of this manuscript. terior approaches to spinal deformities. In this review, he
Address correspondence and requests for reprints to Kishore Mulpuri, suggests that if access to the upper four thoracic verte-
Department of Orthopaedics, British Columbia’s Children’s Hospital,
A200-4480 Oak Street, Vancouver, British Columbia, V6H 3V4. E- brae is needed for correction of a rigid congenital scoli-
mail: osis then a staged approach be used whereby the apical

E306 Spine • Volume 30 • Number 11 • 2005

rior access is needed in children with severe kyphosis

because posterior fusion alone will not resist all the
forces on it nor will it resist curve progression as the child
grows. However, he does note that a posterior fusion
done on those with slight deformities may be sufficient to
arrest progression, and should further stabilization be
needed, the posterior fusion mass affords some stability
to simplify later attempts at anterior stabilization.5
Maciejczak et al8 recommended an anterior transtho-
racic, transpleural approach as the best route to gain
access to the vertebral bodies of the thoracic spine as it
allows wide exposure of the anterior spinal column and
makes surgical intervention possible. However, the au-
thors acknowledged that this approach does not allow
adequate exposure of the upper three thoracic vertebrae,
which can be best exposed by a direct anterior approach.
Knoller and Brethner 6 reviewed sternotomy ap-
proaches for surgical treatment of the spine at the cervi-
cothoracic junction. They recommended the approach
Figure 1. The patient is placed on the operating table in a supine first described by Cauchoix and Binet,4 noting that it
position and the neck is hyperextended and turned to the left, allowed adequate cervical spine exposure and had fewer
allowing a right sided approach. complications than the other anterior exposure tech-
niques such as the high anterior transthoracic approach
vertebral bodies are resected by splitting the sternum, used by Hodgson14 or the modified anterior approach
and posterior correction is then done with Harrington described by Kurtz et al.7 We present six pediatric cases
instrumentation and spinal fusion. Hall noted that ante- with severe cervicothoracic kyphosis and/or scoliosis re-

Figure 2. The sternum is

opened, the thymus gland re-
sected and the brachiocephalic
trunk is mobilized to allow con-
tiguous access to the anterior
cervical spine and upper tho-
racic spine.
Approach to the Cervicothoracic Junction in Children • Mulpuri et al E307

Figure 4. Medial displacement of the brachiocephalic trunk

allows more distal access to the thoracic spine.

Figure 3. Retraction of the trachea, esophagus and innominate mobilized and controlled with a vessel loop. At this point in the
artery provides access to the lower cervical and upper thoracic procedure the anterior cervical spine and upper thoracic spine
spine. are able to be accessed contiguously (Figure 2). The pericar-
dium was opened in two patients in this series to increase mo-
bility of the brachiocephalic trunk. However, the dissection of
quiring extensive access. In all cases, the lower cervical the brachiocephalic trunk can be done down to the pericardial
and upper thoracic spine was accessed using a neck dis- reflection without having to open the pericardium.
section and sternal splitting technique with the aid of a The trachea and esophagus are retracted slightly away from
cardiothoracic surgeon. the middle line with a right angle retractor, and a deep right
angle retractor is placed under the innominate artery and
pulled forward and downward as necessary to provide access
Materials and Methods to the lower cervical and upper thoracic spine (Figure 3). The
A detailed chart and radiographic review was completed of six distal extent of the exposure at this point will depend on the
consecutive patients managed at our center with a combined patient’s anatomy and deformity; in most cases, the surgeon
anterior neck and sternal splitting approach. The indications, will be able to access T4. Disc removal and instrumentation can
surgical technique, and outcome are reviewed for each case. now be safely completed. Aggressive distal exposure will place
Follow-up radiographs and clinical status were reviewed in the recurrent laryngeal nerve under traction and must be done
each case to determine the degree of correction and complica- carefully. Typically, left sided anterior cervical approaches are
tions, if any. preferred because of the distal course of the recurrent laryngeal
nerve on that side. We have elected to perform a right-sided
Anterior Neck and Sternal Splitting Surgical Technique approach with mobilization of the brachiocephalic trunk. Me-
The surgical approach is completed with the assistance of a dial displacement of the trunk facilitates exposure of more dis-
cardiothoracic surgeon. A standard extensile anterior cervical tal segments of the thoracic spine on the right side, down to T6
spine approach is used, incorporating an anterior sternal ex- in one patient in this series (Figure 4).
tension (Figure 1). The neck dissection is completed first in a After completion of the orthopaedic procedure, hemostasis
standard fashion. An incision is made along the medial border is established. The sternum is reapproximated with wires or
of the sternomastoid muscle, extending down to the sternal suture according to the age. The sterno-thyroid and omohyoid
notch. The sternomastoid muscle is retracted laterally with the muscles are reattached. The neck incision is closed in usual
neurovascular sheath, including the carotid artery, the jugular fashion. A small silastic drain may be required under the
vein, and the vagus nerve. Division of the omohyoid, sternohy- sterno-thyroid muscle if hemostasis is a problem in the cervical
oid and sternothyroid muscles facilitates extensile exposure. portion of the approach. A mediastinal tube is placed as in
The incision is extended as a midline sternotomy approach. cardiac surgical procedures.
Blunt digital dissection is used to mobilize the retrosternal soft Results
tissues. The stenum is then split using a sternal saw in a stan-
dard fashion. After opening the sternum, the thymus gland is The clinical features of these patients are summarized in
resected to provide exposure and the brachiocephalic trunk is Tables 1 and 2.

Table 1. Clinical Summary of Six Cases

Patient Diagnosis Sex Age (yrs) Prior Treatment Access Gained Follow-up

1 Klippel-Feil M 11 None C5-T5 9 years

2 Proteus Syndrome M 15 None C5-T4 3 years, 10 months
3 Neurofibromatosis I F 15 2 posterior fusions C6-T5 2 years, 8 months
4 Neurofibromatosis I M 4 None C5-T4 (thoracotomy performed for T5–T9 access) 2 years, 4 months
5 Larsen’s Syndrome F 3 3 posterior fusions C6-T6 22 months
6 Klippel-Feil F 13 2 C6-T5 6 months
E308 Spine • Volume 30 • Number 11 • 2005

Table 2. Pre- and Postoperative Scoliosis and Kyphosis and Summary of Complications
Patient Pre-op Scoliosis Post-op Scoliosis Pre-op Kyphosis Post-op Kyphosis Complications

1 40 30 45 55 Transient cervical ischemia *

2 80 72 70 61 None
3 65 30 20 20 Recurrent laryngeal nerve palsy
4 69 32 38 38 None
5 0 0 118 85 None
6 15 15 130 90 None
* Unrelated to approach

Representative Cases procedure with a neck dissection and sternal split ap-
proach with fusion from C6 to T6 and then went into
Case 4. A four-year-old boy with severe neurofibroma-
hanging traction. One month later, she underwent a pos-
tosis type I presented with a rapidly evolving scoliosis of
terior instrumentation and fusion from C6 to T7 with a
the cervical thoracic spine that progressed from 40° to
combination of pedicle and lateral mass screws. She was
80° over the course of 1 year. There were no neurological converted from hanging traction to a halo thoracic vest
sequelae from his curve. Preoperative computed tomog- for 8 weeks, and her postoperative course was unevent-
raphy (CT) showed extensive involvement of the spine ful. At 1 year after surgery imaging revealed a stable
with dystrophic changes at the apex of the curve. Mag- fusion mass (Figure 7).
netic resonance imaging revealed large plexiform neu-
roma in both sides of the chest with a huge neurofibroma Discussion
in the upper left chest. It was elected to attempt to stabi- This small case series demonstrates the usefulness of the
lize the curve both anteriorly and posteriorly because of direct anterior approach in gaining access to the cervico-
the rapid collapse and dystrophic nature of the defor- thoracic junction to address complex spinal deformities
mity. Surgical correction was done in a two step proce- in the pediatric population. With curves of this magni-
dure; the first stage was anterior cervical thoracic fusion tude, the goal of surgical intervention is to stabilize seg-
from C5 to T4 via a neck dissection and sternal split ments and impede curve progression. This extensile neck
approach. A right lateral thoracotomy was required for dissection and sternal split approach gave good exposure
anterior fusion from T5–T9. Five days later, the patient
was brought back to the operating room for the second
stage of correction, posterior instrumentation, and fu-
sion from C5 to T10. At 18 months after surgery, the
patient had returned to full activities and no complica-
tions were observed with regard to his spinal fusion (Fig-
ure 5).
Case 5. A 3-year-old girl with Larsen’s Syndrome pre-
sented with a collapsing high thoracic kyphosis that
threatened the viability of her spinal cord. Two previous
posterior spinal fusions had been attempted. The initial
surgery resulted in pseudarthrosis and ongoing angula-
tion. Halo traction was instituted and posterior fusion
was repeated in the corrected position. Following revi-
sion and prolonged immobilization, the patient could
not be removed from her halo because of curve progres-
sion and clinically obvious spinal instability. No neuro-
logical signs or symptoms were present. Magnetic reso-
nance imaging demonstrated that the apex of the curve
was at T3–T4 and that the subarachnoid space was ex-
tremely compromised though that region. A focus of in-
creased signal intensity was seen within the spinal cord
just distal to the apex of the kyphosis. A CT demon-
strated pseudoarthroses at two levels above the apex of
kyphosis. Incidentally it was found that she did not have
Figure 5. A and B, Postoperative radiographs of a 4-year-old boy
vertebral arteries in her vertebral foramens. Instead, the with neurofibromatosis type I (case 4) demonstrating extent of
vertebral arteries lay on the posterior aspect of the lam- anterior exposure. Additional thoracotomy was done to achieve
inae of the cervical spine (Figure 6). She had a staged access to distal 3 levels.
Approach to the Cervicothoracic Junction in Children • Mulpuri et al E309

Figure 6. A-C, Preoperative CT

(case 5). Note that the vertebral
arteries are not in the vertebral
foramens, they lie on posterior
aspect of the laminae of the cer-
vical spine.

from C5 to T6 to allow instrumentation and fusion. In The potential complications related to this approach
one patient an adjunctive thoracotomy was performed to are iatrogenic damage to the recurrent laryngeal nerve,
access the bodies of T5 through T9, an alternative to the the pericardium, and the esophagus. It is recommended
trap door approach to the lower thoracic spine. Few that the aid of a cardiothoracic surgeon be used because
reports in the literature address the extensive access re- we feel it is not an approach to be attempted by a spinal
quired for instrumentation and stabilization of severe surgeon alone due to the complexity of the exposure. In
scoliotic and kyphotic deformities. Although it appears this series the most significant complication related to
that little scoliotic and/or kyphotic correction was this approach was recurrent laryngeal nerve palsy in one
achieved (Table 2), the goal of stabilizing the spine and patient, a complication that had also been reported by
preventing curve progression was realized. others using an anterior approach.2 The central neuro-
logical impairment experienced by one patient fully re-
solved and was not related to the sternal splitting tech-
nique. This patient’s preoperative CT scan had
demonstrated an almost spondyloptosis of C7 on T1
with the body of T1 impinging into the spinal cord canal
with clinical evidence of cord compression and progres-
sive myelopathy. Postoperative imaging showed that the
cord lay in the channel, and there was no focal anomaly
that would suggest a total cord lesion. It was felt that the
patient had suffered a vascular injury to his cord that was
unrelated to the sternal spitting approach.
This surgical approach is complex and invasive. It is
recommended in rare cases where the treating surgeon
must achieve contiguous anterior cervicothoracic fusion
to stabilize the spine and protect the patients’ neurology.
The cases presented in this paper include severe dystro-
phic deformities, complex congenital kyphotic defor-
mities, and cases in which previous isolated posterior
Figure 7. Pre- (A) and postoperative (B) radiographs of a 3-year-
fusion attempts had failed. In our hands, with the as-
old girl with Larsen’s Syndrome and collapsing high thoracic sistance of a cardiothoracic surgeon, we have found
kyphosis (case 5). the anterior sternal split approach to be a safe and
E310 Spine • Volume 30 • Number 11 • 2005

effective approach to gain access to the cervicothoracic 5. Hall JE. The anterior approach to spinal deformities. Orthop Clin North Am
junction in children. 6. Knoller SM, Brethner L. Surgical treatment of the spine at the cervicothoracic
junction: an illustrated review of a modified sternotomy approach with the
description of tricks and pitfalls. Arch Orthop Trauma Surg 2002;122:
Key Points 365– 8.
7. Kurtz LT, Pursel SE, Herkowitz HN. Modified anterior approach to the
● The sternal splitting approach was useful in gain- cervicothoracic junction. Spine 1991;16:S542–7.
ing multileveled access in pediatric patients with 8. Maciejczak A, Radek A, Kowalewski, J et al. Anterior transsternal approach
to the upper thoracic spine. Acta Chir Hung 1999;38:83– 6.
severe cervicothoracic kyphosis and/or scoliosis.
9. Micheli LJ, Hood RW. Anterior exposure of the cervicothoracic spine using
● The sternal split and neck dissection technique a combined cervical and thoracic approach. JBJS 1983;65A:992–7.
are described 10. Kojima T, Waga S, Kubo Y, et al. Surgical treatment of ossification of the
● The aid of a cardiothoracic surgeon to provide posterior longitudinal ligament in the thoracic spine. Neurosurg 1994;34:
854 – 8.
anterior exposure is recommended
11. Fujimura Y, Nishi Y, Toyama Y, et al. Anterior decompression and fusion
for ossification of the posterior longitudinal ligament of the upper thoracic
References spine causing myelopathy using the manubrium splitting approach. Spinal
Cord 1996;34:387–93.
1. Calliauw J, Dallenga A, Caemaert J. Trans-sternal approach to intraspinal
12. McElvein RB, Nasca RJ, Dunham WK, et al. Transthoracic exposure for
tumours in the upper thoracic region. Acta Neurochir 1994;127:227–31.
2. Hanakita J, Suwa H. Sternal splitting approach to upper thoracic lesions anterior spinal surgery. Ann Thorac Surg 1988;45:278 – 83.
located anterior to the spinal cord. Neurol Med Chir 1999;39:428 –33. 13. Smith TK, Stallone RJ, Yee JM. The thoracic surgeon and anterior spinal
3. Sundaresan N, Shah J, Foley KM, et al. An anterior surgical approach to the surgery. J Thorac Cardiovasc Surg 1979;77:925– 8.
upper thoracic vertebrae. J Neurosurg 1984;61:686 –90. 14. Hodgson AR, Stock FE, Fang HSY et al. Anterior spinal fusion. The opera-
4. Cauchoix J, Binet JP. Anterior surgical approaches to the spine. Ann R Coll tive approach and pathologic findings in 412 patients with Pott’s disease of
Surg Engl 1957;21:237– 43. the spine. Br J Surg 1960;48:172– 8.