Surgical management for upper thoracic spine tumors by a transmanubrium approach and a new space

The anterior aspect of the upper thoracic spine is a difficult region to approach in spinal surgery. Many vital structures including osseus, articular, vascular and nervous ones hinder the exposure. With increasing frequency, spine surgeons are being asked to provide decompression and stabilization in patients with spinal tumors. The traditional exposure is between the esophagus and trachea medially and the left common carotid or the brachiocephalic artery (BCA) laterally, and the disadvantages were that the ligation and section of the left innominate vein is proposed to reach T4 and the injury of the thoracic duct could occur. The right space of the BCA or the ascending aorta (AA) (the exposure between the right brachiocephalic vein and the BCA or between the AA and superior caval vein) is recommended in exposing the upper thoracic vertebrae; this new space is technically feasible; the exposure is sufficient for vertebral body resection and reconstruction and fixation. Twenty-eight patients with upper thoracic spine tumors underwent surgery by the use of this new space between June 2000 and October 2005. A strut graft was fixed anteriorly after decompression of the spinal cord. Levels C7-T5 can be well exposed through this new space, allowing complete vertebral body removal at level T1-T4. After body removal, the posterior longitudinal ligament is well exposed, allowing complete release of the spinal cord. Curettage was performed in one case of aneurysmal bone cyst and three cases of bone giant cell tumors. For other tumors, vertebrectomies or sagittal resections were performed. Four patients underwent surgery by a combination of anterior and posterior approach.