c. Divide the mediastinal pleura posterior to the hilum from the inferior pulmonary vein to just above the mainstem bronchus (T5–T8)
d. Displace the lung anteriorly and move it out of the way using wet lap pads
e. Open the mediastinal pleura anterior to the vertebral bodies vertically from the thoracic inlet to the level of the carina. Dissect and mobilize the mediastinal structures. Mobilize the azygos vein with tributaries and the esophagus using blunt and sharp dissection (right thoracotomy), or mobilize the descending thoracic aorta (left thoracotomy) (T1–T8)
f. Mobilize the thoracic duct anteriorly (T5–T8)
g. Retract diaphragm using sponge stick. Mobilize posterior attachments of diaphragm. Mobilize posterior mediastinal structures for anterior retraction (T9–T12)
13. Perform the decompression procedure over the desired segments based on preoperative imaging of levels that are compressed due to trauma:
a. Using Leksell rongeurs and hand-held high-speed air drill, resect the adjacent disk material immediately ventral to the posterior cortical bone of the vertebral bodies
b. Leave a thin shelf of bone immediately adjacent to posterior longitudinal ligament and dura intact:
i. This step avoids the cord falling ventrally, which can result in cord injury during the resection process
c. Remove adequate portion of subcortical bone, using high-speed air drill, across midline for decompression of ventral cord surface
d. Remove thin shelf of bone adjacent to posterior longitudinal ligament with rongeur
e. Control bone bleeding with bone wax
14. Perform posterior thoracic fusion with instrumentation (if necessary, as most often anterior approach is all that is needed):
a. Place and secure bone graft with cancellous screws to bridge the vertebra above and below the midpoint of the fracture, avoiding injury to vital structures
15. Achieve hemostasis
16. Drain the chest and inspect posterior mediastinum for lymph leak
17. If previously mobilized, reattach the diaphragm to the fascia of the posterior chest wall with sutures
18. Close muscle and skin incisions in appropriate fashion, often with placement of postoperative chest tube that can be removed after 2 to 3 days
Surgical Procedure Anterior Transsternal Decompression/Fusion
1. Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/NSAIDs/Advil/Celebrex/Ibuprofen/Motrin/Naprosyn/Aleve/other anticoagulants and anti-inflammatory drugs for at least 2 weeks
2. Appropriate intubation and sedation and lines (if necessary) as per the anesthetist
3. Patient placed in supine position with all pressure points padded
4. Neuromonitoring may be required to monitor nerves (if necessary and indicated)
5. Time out is performed with agreement from everyone in the room for correct patient and correct surgery with consent signed
6. Make an incision on medial border of right sternocleidomastoid, extending down over manubrium
7. Perform median sternotomy with sternal saw (see ▶Fig. 2.10)
8. Mobilize sternocleidomastoid laterally and trachea/esophagus medially, exposing anterior cervicothoracic spine
9. Perform the decompression procedure over the desired segments based on preoperative imaging of levels that are compressed due to trauma:
a. Using Leksell rongeurs and hand-held high-speed drill, remove disk material at the affected level
b. Remove the thick ligamentum and any bone spurs with Kerrison rongeurs with careful dissection beneath the ligament to ensure no adhesions exist to dura mater below and thus avoiding CSF leak
Fig. 2.10 Intraoperative images demonstrating anterior cervicothoracic view. (a, b) Represent the incision position for a transsternal approach to a T1 corpectomy. (c, d) The exposure of the ventral cervicothoracic junction using retractors, following a sternotomy. (Source: Cervicothoracic corpectomy. In: Fessler R, Sekhar L, eds. Atlas of Neurosurgical Techniques: Spine and Peripheral Nerves. 2nd ed. Thieme; 2016).
c. Perform complete decompression of anterior cord with Kerrison rongeurs as needed for appropriate decompression of nerve roots
d. Irrigate surgical site
10. Perform spinal fusion with instrumentation (if necessary, most often not needed):
a. Perform reconstruction with expandable cage and autograft
b. Perform screw-plate fixation
11. After appropriate hemostasis is obtained, muscle and skin incisions can then be closed in appropriate fashion, often with placement of postoperative Jackson-Pratt drains:
a. Achieve closure of sternum with sternal wires
Pitfalls
• Reduction in range of motion and mobility of fused spinal segments
• Intraoperative CSF leak
• Blood clot (deep vein thrombosis, or more severe pulmonary embolism)
• Damage to spinal nerves and/or cord
• Postoperative weakness or numbness or continued pain
• Postoperative wound infection
• Continued symptoms postsurgically/unresolved symptoms with no improvement to quality of life
• Prolonged hospitalization due to invasiveness of surgery and other comorbidities/iatrogenic infection
• Loss of sensation
• Progressive kyphosis
• Residual spinal compression
• Problems with bowel/bladder control
• Injury to artery of Adamkiewicz (generally originating from the left T8–L1) resulting in cord ischemia, radicular arteries (typically during dissection around intervertebral foramina), thoracic duct, chylothorax, and/or esophagus (from transthoracic approach)
• Vascular complications
• Atelectasis and pneumonia
• Hemothorax and empyema (managed with drainage and antibiotics)
• Injury to carotid sheath, trachea, esophagus, recurrent laryngeal nerves, great vessels, vertebral arteries, and/or sympathetic trunk (from transsternal approach)
Prognosis
• Hospitalization rates depend on the type of procedure performed, preoperative examination status, and patient’s age/comorbidities
• Pain medications for postsurgical pain
• Catheter placed in bladder and removed 1 to 2 days after surgery
• Physical therapy and occupational therapy will be needed postoperatively as outpatient to regain strength
• Brace (i.e., Jewett or Taylor type) placed after discharge (patient can be mobilized after 2 to 3 weeks of transthoracic decompression/fusion operation)