Advantages, disadvantages and stabilization techniques

1. TThhee mmiiddlliinnee aanndd llaatteerraall ppaarraassccaappuullaarr
eexxttrraapplleeuurraall eexxppoossuurreess..
AAddvvaannttaaggeess,, ddiissaaddvvaannttaaggeess aanndd ssttaabbiilliizzaattiioonn tteecchhnniiqquueess
GEORGE SAPKAS
ASC. PROFESSOR
1st Orthopaedic Department
Medical School-Athens University
Attikon Hospital
Metropolitan Hospital
Athens Greece

2. The cervicothoracic
junction (CTJ) is a
unique region in the spine.
Biomechanically, it has
unique mechanical
properties because of the
transition between the
cervical and the thoracic
spine.

3. The CTJ represents a
region that transitions
from the fairly mobile
cervical spine to the
fairly rigid thoracic
spine
An HS, et al. Spine 1994

4. The thoracic spine
is immobile because of
the rib cage, which limits
the mobility significantly.
In addition, it represents a
transition from the
lordotic cervical spine to
the kyphotic thoracic
spine
An HS, et al. Spine 1994

5. Radiographically,
it is a region that is
difficult to image,
particularly in
traumatic injury.

6. Surgically,
it may be difficult to
access this region
because of the
manubrium, sternum,
and neurovascular
structures in the
region.

7. Anatomically,
the CTJ posterior
has characteristics
that pose special
considerations to
spinal
instrumentation.

8. Strictly speaking, the
CTJ should involve the
C7 vertebra, the T1
vertebra, the disc
between these two
vertebrae, and their
associated ligaments.
C7
T1

9. Other investigators
include the T2 and
sometimes the T3-T4
vertebrae when
discussing the CTJ.
C6
T1
C7
T2
T3
Le Hoang et al, Neursurg 2003
Frank L Acosta et al, Spine, 2007
T4

10. Lesions involving the
T2 and T3 vertebrae
often face similar
difficulties for getting
access to them
through an anterior
approach.
C6
C7
T1
T2
T3

11. In addition, many of
the spinal fusion
constructs of the CTJ
often involve the T2
or T3 vertebra, and for
these reasons, the CTJ
can be defined as the
region involving the
C7 to T3 vertebrae.

12. As a result, this puts
significant stress
on the CTJ in the
static and dynamic
states.
Disruptions to the
structures in this
region can thus lead
to instability.
An HS, et al. Spine

13. Common causes
of
instability include:
An HS, et al. Spine 1994
Yasuoka S, et al. J Neurosurg 1982
Steinmetz MP, et al. J Neurosurg Spine 2006.
Schlenk RP, et al Neurosurg Focus 2003.

14. TTrraauummaa

15. TTuummoorr
PPnneeuummoonn’’ss mmeettaassttaassiiss

16. Post-laminectomy instability
swan-nec k deformity
IIaattrrooggeenniicc ccaauusseess

17. TTrraauummaa
ttoo tthhee
cceerrvviiccootthhoorraacciicc jjuunnccttiioonn

18. Trauma to the CTJ
ranges from 2% to 9%
of all cervical spine
trauma
Nichols CG, et al Ann Emerg Med 1987.
Evans DK. J Bone Joint Surg Br 1983.
Amin A, et al J Spinal Disord Tech 2005
C7
T1

19. Especially important is that a
significant number of CTJ injuries
are missed during the initial
evaluation
Injuries to the CTJ usually involve
fractures or dislocations
Ligamentous injuries, burst
fractures, and facet fractures are
common causes of fractures and
dislocations.
An HS, et al. Spine 1994
Amin A, et al J Spinal Disord Tech 2005.
Chapman JR, et al J Neurosurg 1996
Sapkas G, et al Eur Spine J 1999

20. Posterior fixation is
performed in almost all
cases, and this may be
supplemented with
anterior fixation
An HS, et al. Spine 1994
Chapman JR, et al J Neurosurg 1996
Sapkas G, et al Eur Spine J 1999

21. TTuummoorrss
ooff tthhee
cceerrvviiccootthhoorraacciicc jjuunnccttiioonn

22. Tumors of the CTJ are
a common cause of
instability in the region.
Metastatic lesions are
much more common
than primary tumors in
this region.
M. Riz.
F 41
15-6-1997
Chondrosarcoma

23. Primary tumors of the CTJ
may include:
angiosarcoma
chordoma
Lymphoma
plasmacytoma
Schwannoma
Osteosarcoma
giant cell tumor
An HS, et al. Spine 1994
Le Hoang, et al Neurosurg Focus 2003
CCaavveerrnnoouuss hheemmaaggiioossaarrccoommaa

24. Metastatic lesions include:
distant metastases (eg,
prostate, breast)
and
local extension of tumor
Le Hoang, et al Neurosurg Focus 2003
Mazel C, et al. Spine 2004
Pneumon’s metastasis

25. A pancoast
tumor often extends into
the junction between the
rib and the vertebral body,
but the vertebra is not
always involved.
PPaannccooaasstt

26. Other local tumors
include:
thyroid
and
esophageal tumors
that erode into the
vertebrae of the CTJ
Mazel C, et al. Spine 2004
Ulmar B, et al Acta Orthop Belg 2005

27. PPnneeuummoonn’’ss mmeettaassttaassiiss
Surgical treatment
depends on :
the tumor type
life expectancy of the
patient,
elements that are involved.

28. FFaaccttoorrss ffoorr eevvaalluuaattiioonn::
TThhee bbiioollooggyy ooff tthhee ttuummoorr
TThhee llooccaattiioonn
TThhee ppaaiinn
TThhee nneeuurroollooggiicc ddeeffiicciitt
TThhee ssppiinnaall iinnssttaabbiilliittyy
LLiiffee eexxppeeccttaannccyy
OOvveerraallll ccoonnddiittiioonn ooff tthhee ppaattiieenntt
Aboulafia A. Levine A., OKU Spine 2, 2004

29. WWeeiinnsstteeiinn BBoorriiaannii BBiiaaggnniinnii
SSuurrggiiccaall ccllaassssiiffiiccaattiioonn ssyysstteemm
Weinstein et al, 21st ISSSL annual meeting 1994

30. The two strategies are :
palliative
cord decompression and
spine stabilization
versus
curative with en bloc
radical resection of the
tumor and stabilization
Mazel C, et al. Spine 2004

31. A decompression
strategy usually
involves :
laminectomy
supplemented by
posterior fusion
An HS, et al. Spine 1994
Mazel C, et al. Spine 2004

32. A posterior procedure
may also be used for:
resection of tumors
involving the anterior
elements,
such as through a
transpedicular approach
or
costotransversectomy,
thus avoiding the more
morbid anterior approaches
Le Hoang, et al Neurosurg Focus 2003

33. En bloc resection
of local extension
from tumors like a
pancoast tumor often
involves
vertebrectomy,
and may include
an anterior approach
Mazel C, et al. Spine 2004
Mazel C, et al. Spine 2004

34. OOtthheerr ccoonnddiittiioonnss
tthhaatt aaffffeecctt tthhee
cceerrvviiccootthhoorraacciicc jjuunnccttiioonn

35. Osteomyelitis
TBC
TBC has a predilection to the
upper lobe of the lung; therefore,
spread to the CTJ is not
uncommon.
Instability occurs when there is
destruction of the anterior column.
Progressive kyphosis occurs as the
mobile cervical spine topples over
the thoracic spine
Mihir B, et al Spine 2006
TTBBCC

36. Ankylosing spondylitis
It predisposes the spine to
traumatic fractures and
dislocation as well as to
several deformities
Fox MW, et al. J Neurosurg 1993

37. Iatrogenic instability
multilevel laminectomy in the
cervical spine in children
predisposes the CTJ to instability
laminectomy across the CTJ
without instrumentation tends to
introduce instability to the CTJ
Yasuoka S, et al J Neurosurg
An HS, et al Spine

38. PPoosstteerriioorr aapppprrooaacchh
ttoo tthhee
cceerrvviiccootthhoorraacciicc jjuunnccttiioonn

39. MMiiddlliinnee pprroocceedduurree

41. Standard midline
posterior approach
is useful for :
A laminectomy for
decompression
or for
Tumors located in the
posterior column.
Decompressive
laminectomy

42. PPOOSSTTEERRIIOORR CCEERRVVIICCOO--
TTHHOORRAACCIICC FFIIXXAATTIIOONN
SSccrreeww ppoossiittiioonniinngg
CC44--55--66 ssccrreewwss
aarree
iinnttoo tthhee llaatteerraall mmaassss
CC77
LLaatteerraall mmaassss iimmppllaannttaattiioonn
oorr
PPeeddiiccllee iimmppllaannttaattiioonn
TT11--TT22--TT33--TT44--TT55
aarree
iinnttoo tthhee ppeeddiiccllee

43. LLAATTEERRAALL MMAASSSS SSCCRREEWW
FFIIXXAATTIIOONN TTEECCHHNNIIQQUUEESS
 RRooyy
CCaammiillllee
 MMaaggëërrll
 AAnnddeerrssoonn
 AAnn
 AAbbuummii
Rongming Xu Spine vol 24 numb 19 pp 2057-201

44. TTWWOO PPOOSSSSIIBBLLEE SSCCRREEWW
IIMMPPLLAANNTTAATTIIOONN IINN CC--77
LLaatteerraall mmaassss
iimmppllaannttaattiioonn
PPeeddiiccllee iimmppllaannttaattiioonn
C6
C7
T1
T2

45. TTHHOORRAACCIICC PPEEDDIICCLLEE SSCCRREEWW
IIMMPPLLAANNTTAATTIIOONN TTEECCHHNNIIQQUUEE
TTaakkeess aaddvvaannttaaggee ooff tthhee oobblliiqquuee mmeeddiiaall
ppeeddiiccllee oorriieennttaattiioonn ggiivviinngg ttoo tthhee ssccrreeww aa
bbeetttteerr ppuullll oouutt rreessiissttaannccee
Original Roy Camille
Screw position
Mazel C, et al. Spine 2004

46. PPOOSSTTEERRIIOORR IINNSSTTRRUUMMEENNTTAATTIIOONN
CCHHAARRAACCTTEERRIISSTTIICCSS
MMoosstt iinnssttrruummeennttaattiioonnss aarree
ddeevvootteedd ttoo cceerrvviiccaall oorr
tthhoorraacciicc ffiixxaattiioonnss
RRooddss ssiizzee aarree uussuuaallllyy
ddiiffffeerreenntt 33..55//66mmmm
SSoommee ssyysstteemmss hhaavvee ddoouubbllee
ddiiaammeetteerr rrooddss eennaabblliinngg
ccoonnnneeccttiioonn bbeettwweeeenn bbootthh

47. Transpedicular approach
may also be used for
limited access
to the
anterior column.

50. CCeerrvviiccootthhoorraacciicc JJuunnccttiioonn
If more lateral access is
needed:
a costotransversectomy
or
lateral extracavitary
approach can be used
An HS, et al Spine 1994
Kaya RA, et al. Surg Neurol 2006

51. CCeerrvviiccootthhoorraacciicc JJuunnccttiioonn
ppoosstteerroollaatteerraall aapppprrooaacchh
CCoossttoottrraannssvveerrsseeccttoommyy
MMeennaarrdd VV.. 11889944
LLaatteerraall rraacchhoottoommyy
CCaappeenneerr NN.. 11995544
LLaatteerraall eexxttrraaccaavviittaarryy aapppprrooaacchh
LLaarrssoonn SSJJ eett aall 11997766
LLaatteerraall ppaarraassccaappuullaarr eexxttrraapplleeuurraall aapppprrooaacchh
FFeesssslleerr RRGG eett aall 11999911

52. In a costotransversectomy,
a midline or paramedian
incision is used and the rib
head and costotransverse
joint are resected
Sometimes, the superior or
inferior pedicles may be
removed
Vaccaro et al Principles and practice of spine
surgery. 2003

53. The lateral extracavitary
approach is used for
limited access to the anterior
column and if the patient
cannot tolerate a
thoracotomy or anterior
approaches
Vaccaro et al Principles and practice of spine
surgery. 2003

54. In this case,
a short incision
is made over the rib at
the desired level, and the
rib head is removed,
along with the pedicle
and the posterior-lateral
vertebral body
Vaccaro et al Principles and practice of spine
surgery. 2003

55. PPoosstteerriioorr -- aanntteerriioorr pprroocceedduurreess

56. TThhyyrrooiidd mmeettaassttaassiiss

58. C6
T1

59. MRI Axial MRI Coronal

60. 1st operation
AAnntteerriioorr pprroocceedduurree
CCoorrppeeccttoommyy
VVeerrtteebbrraall bbooddyy
rreeppllaacceemmeenntt bbyy
eexxppaannddaabbllee ccaaggee --
PPeeeekk EE..CC..SS.. ((ZZiimmmmeerr))
SSttaabbiilliizzaattiioonn wwiitthh ppllaattee
aanndd ssccrreewwss
ZZeepphhyyrr ((MMeeddttrroonniicc))

61. 2nd operation
PPoosstteerriioorr pprroocceedduurree
CCeerrvviiccoo tthhoorraacciicc lleevveell
SSttaabbiilliizzaattiioonn bbyy
VVeerrtteexx ssyysstteemm
((MMeeddttrroonniicc))

62. 1st post-op. 1st post-op CT

63. 1st post-op CT

64. Biomechanical aannaallyyssiiss ooff iinnssttrruummeennttaattiioonn ooff
CCeerrvviiccootthhoorraacciicc JJuunnccttiioonn

65. The experience with
lateral mass and
pedicle screw fixation
across the CTJ has
been fairly positive.
Heller G et al JBJS (am), 1996
Kotani Y, et al, Spine, 1994

66. New constructs using a
screw-rod system have
been developed in the
past 10 years.
Kreshak JL, et al. Spine 2002
Mazel C, et al. Spine 2004
Rhee JM, et al Spine 2005
Jeanneret B. Eur Spine J 1996

67. Biomechanically, these
constructs provide
significant stabilization to
the CTJ in cadaver studies
Ulrich C et al, Eur. Spine, 2001
Kreshak JL, et al. Spine 2002

68. The pedicle screw fixation is
superior compared with
lateral mass fixation at C7 in
all biomechanical tests
Biomechanical studies have
yielded important information
about the number of levels
that should be included and
also the relative strength of
anterior and posterior
fixation.
This can be partially corrected
by adding another level of
fixation with lateral mass
screws at C6
Ulrich C, eta, Spine (sup), 1991
Mazel C, et al. Spine 2004
Le Hoang, et al Neurosurg Focus 2003
Chapman JR, et al. J Neurosurg 1996

69. Compared with the
intact spine, posterior
instrumentation with a
screw-rod system can
restore almost 100%
of the strength in a
two column but not a
three-column injury
Kreshak JL, et al. Spine 2002

70. Although some authors have used
only posterior fixation in trauma
that included the anterior column,
such as burst fracture,
biomechanical studies have
shown that in a three-column
injury, posterior fixation is not
sufficient to restore the stiffness to
the level of intact spine
It is therefore believed that a three-column
injury is probably better
treated with anterior and
posterior fixation.
Chapman JR, et al J Neurosurg 1996
Sapkas G, et al Eur Spine J 1999
Kreshak JL, et al. Spine 2002

71. In tumor cases, is
recommend that the
fusion be extended
three levels above and
three levels below if a
vertebrectomy is
performed.
Mazel C, et al. Spine 2004

72. The use of pedicle screws and lateral mass
fixation at the CTJ is safe.
In one study, breaching of
the pedicle was found on
postoperative CT scans in
9% of the screws when
inserted without any
guidance, but the incidence
was reduced to 3% when a
navigation system was used
Richter M. Orthop Traumatol 2005

73. The incidence of vascular
injury is extremely rare, and
radiculopathy is estimated
to be in the range of
1% to 2%
Deen HG, et al Spine J 2003
Mazel C, et al. Spine 2004

74. CCOONNCCLLUUSSIIOONNSS
CCeerrvviiccootthhoorraacciicc lleevveell iiss
ddiiffffiiccuulltt ttoo ddeeaall wwiitthh
CCoorrdd ccoommpprreessssiioonn ccaann
ooccccuurr aatt tthhee eeaarrllyy ssttaaggee ooff
tthhee ddiisseeaassee
DDiiffffiiccuulltt ssuurrggeerryy ccaann bbee
hhiigghhllyy rreewwaarrddiinngg

75. University Hospital “ATTIKON”