Spondylectomy of T-2 according to the Tomita technique via an extended Fessler approach: a cadaveric study

Laboratory investigation

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Object

The authors' aim was to conduct a surgical anatomy and feasibility study on the use of an extended posterolateral approach to the cervicothoracic junction (Fessler approach) in cadavers to facilitate en bloc removal of the second thoracic vertebra using the Tomita technique. To apply this technique, it is mandatory to approach both sides of the vertebra. But such a maneuver is very difficult in the region of the cervicothoracic junction because the scapula and its muscles represent an anatomical barrier to the paravertebral compartment and lateral aspects of the vertebrae.

Methods

To study the extended posterolateral Fessler approach to the cervicothoracic junction and the possible application of the Tomita technique on the second thoracic vertebra, 3 fresh-frozen cadavers were used in the Laboratory of Human Anatomy at the University of Nantes.

Results

The proposed approach allows exposure of both the posterior arch and the body of the second thoracic vertebra without any significant resection or traction of the superficial and deep posterior thoracic muscles, enabling application of the Tomita technique and facilitating intraoperative spinal fixation.

Conclusions

The proposed surgical technique is technically feasible. Nevertheless, it should be an option reserved for selected patients for whom the surgical complexity can be justified by the characteristics of their malignancy and expected curative outcome.

Article Information

Address correspondence to: Massimo Miscusi, M.D., Ph.D., Department of Medico-Surgical Sciences and Biotechnologies, University of Rome “La Sapienza,” Polo Pontino, Latina 04100, Italy. email: m.miscusi@libero.it.

Please include this information when citing this paper: published online October 7, 2011; DOI: 10.3171/2011.9.SPINE10834.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Drawings depicting the initial steps in a total en bloc T-2 spondylectomy. A: The anatomical plane of dissection passes medially between the parascapular and paravertebral muscles and continues laterally along the posteromedial scapular border (dashed line). B: The costoscapular space is opened: the medial border of the scapula falls laterally and the upper dorsal rib cage is exposed (arrow). C: According to the Fessler approach, left paravertebral muscles (star) are dissected off the posterior vertebral elements and upper dorsal rib cage. Moreover, contralateral extension of the Fessler approach—that is, posterior exposure of the laminae and costovertebral joints of the second thoracic vertebra—is performed. D: Contralateral extension of the Fessler approach allows circumferential control of the second thoracic vertebra. Star indicates the paravertebral muscles; dotted line indicates the posteromedial scapular border. Th2 = T-2.

  • View in gallery

    Photographs obtained during cadaveric studies. A: Posterior view of cadaver. A midline incision is gently curved to the left scapular line. B: Posterior view of cadaver. The flap including the scapula and its muscles is mobilized laterally, allowing a posterolateral exposure of the left upper dorsal rib cage and dorsal vertebral elements of the cervicothoracic junction. C: Posterior view of cadaver. Before mobilizing the left paravertebral muscles (star), a posterior exposure of the laminae and costovertebral joints of the second thoracic vertebra is performed. D: Superior view of cadaver. After mobilization of the left paravertebral muscles (star), the right contralateral extension of the Fessler approach is complete. Dotted line indicates the medial scapular border. Th1 = T-1.

  • View in gallery

    Photograph showing left lateral view of cadaver. The paravertebral muscles (star) are dissected off the posterior arches of the junctional vertebrae and the proximal parts of the related ribs; they can be moved medially or laterally (arrows), maintaining their longitudinal continuity. The first thoracic nerve (N1) is identified entering the brachial plexus, deep within the left costoscapular space. RII = second rib; RIII = third rib.

  • View in gallery

    Photograph showing lateral view of cadaver. According to the Fessler approach, the proximal part of the second (RII) and third (RIII) rib is removed, and the left transverse processes of the first (Th1), second (Th2), and third (Th3) thoracic vertebrae are exposed. The second thoracic nerve (N2) has been resected and separated from the sympathetic chain (S). The blunt finger dissection of the anterior aspect of the spine from the mediastinal organs exposes the anterior longitudinal ligament (#). The first thoracic nerve (N1) is partially covered by the first intercostal muscle (ICM1) tilted on it; the third thoracic nerve (N3) runs below the third rib. The erector spinae and splenii muscles (star) are lifted up on the vertebral laminae. The pleural sac (Pleura) is under the ribs.

  • View in gallery

    A: Drawing showing resection of the T-2 pedicles according to the Tomita technique. The posterior vertebral arch can be removed in 1 piece. B: Photograph showing superior view of cadaver. Removing the T-2 posterior arch, the dural sac and the first 2 thoracic nerves from both sides are exposed. Solid white and white-outlined arrows indicate the first and second thoracic nerves, respectively. C and D: Drawing (C) and photograph (D) showing superior view of cadaver. According to the Tomita technique, after removal of the superior and inferior T-2 discs, the vertebral body, dissected from the mediastinal organs and pleural sac, is manually rotated right to left and removed from the spine in 1 piece. Star indicates erector spinae and splenius muscles.

  • View in gallery

    A: The second thoracic vertebra has been removed en bloc. B and C: Posterior and lateral views of a possible spinal fixation following T-2 vertebrectomy, performed according to our technique. The laminar hooks, positioned from C-6 to T-4, are connected to a carbon fiber cage through a unilateral pedicle.

References

  • 1

    Fessler RGDietze DD JrMillan MMPeace D: Lateral parascapular extrapleural approach to the upper thoracic spine. J Neurosurg 75:3493551991

    • Search Google Scholar
    • Export Citation
  • 2

    Kawahara NTomita KBaba HToribatake YFujita TMizuno K: Cadaveric vascular anatomy for total en bloc spondylectomy in malignant vertebral tumors. Spine (Phila Pa 1976) 21:140114071996

    • Search Google Scholar
    • Export Citation
  • 3

    Larson SJHolst RAHemmy DCSances A Jr: Lateral extracavitary approach to traumatic lesions of the thoracic and lumbar spine. J Neurosurg 45:6286371976

    • Search Google Scholar
    • Export Citation
  • 4

    Li WWLee TWYim AP: Shoulder function after thoracic surgery. Thorac Surg Clin 14:3313432004

  • 5

    Roy-Camille RSaillant GBisserié MJudet THautefort EMamoudy P: [Total excision of thoracic vertebrae (author's transl).]. Rev Chir Orthop Reparatrice Appar Mot 67:4214301981. (Fr)

    • Search Google Scholar
    • Export Citation
  • 6

    Tomita KKawahara NBaba HTsuchiya HFujita TToribatake Y: Total en bloc spondylectomy. A new surgical technique for primary malignant vertebral tumors. Spine (Phila Pa 1976) 22:3243331997

    • Search Google Scholar
    • Export Citation

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