Surgical Treatment of Tumors
Surgical Treatment of Tumors
Object: Tumors involving the cervicothoracic junction can have a high propensity for causing instability, with kyphosis and spinal cord compression resulting. Treatment with decompression only can lead to further instability and worsening neurological status. In this article, the authors review their surgical experience in the treatment of 19 patients with tumors involving the cervicothoracic junction. The various approaches and instrumentation techniques involved in decompression and stabilization of the cervicothoracic junction are also reviewed.
Methods: Aggressive instrumentation-augmented fusion after decompression of the cervicothoracic region can provide for immediate stabilization and early rehabilitation. Recent development of new hardware such as dual-diameter transition rods, polyaxial screws, and interlocking devices have enhanced the ability to fashion a strong construct for stabilization of the cervicothoracic junction.
Conclusions: Familiarity with complex instrumentation techniques and various surgical approaches to the cervicothoracic junction will be required for effective treatment of tumors causing instability of this region.
Surgical treatment of cervicothoracic junction diseases can be a challenging issue, as evidenced by diverse reports in the literature from practitioners of many different surgical specialties, including neurological; orthopedic; ear, nose, and throat; and cervicothoracic surgeons. Access to this region is complicated by the presence of major vascular elements as well as important visceral and soft-tissue structures. The cervicothoracic junction can be defined as an area extending from vertebral segments C-7 to T-4, and includes the lower brachial plexus, thoracic outlet, and superior mediastinum. This area is unique in that it is a transition area from a mobile, lordotic cervical spine to a rigid, kyphotic thoracic spine. Furthermore, the cervicothoracic junction, much like the thoracolumbar junction, represents an area under stress as the transfer of weight occurs between levels of the spinal column. In addition, the vertebral index decreases from the C-6 to the T-1 vertebrae, causing added stress to be applied to the more narrow and slender upper thoracic vertebrae.
Pathological processes such as trauma, degenerative processes, infection, and neoplastic involvement, combined with the abrupt change in the biomechanical function of this area, can predispose the cervicothoracic segment to instability. Previous surgeries at the cervicothoracic junction have been well known to destabilize the region. Several authors have reported increasing spinal deformity caused by a previous cervicothoracic junction laminectomy. Furthermore, spinal fusions ending at the cervicothoracic junction can also be a factor contributing to iatrogenic cervical instability. Progressive instability of this area ultimately leads to kyphosis and spinal cord compression.
Neoplastic involvement of the upper thoracic vertebrae accounts for 15% of patients with tumors of the spine. Furthermore, 10% of spinal metastases arise from the T14 region. Neurological involvement is a common sequela to cervicothoracic lesions causing instability, and can be as high as 80%. This predisposition to neurological injury may be related to the combination of a smaller spinal canal size at the cervicothoracic junction and a tenuous blood supply. Thus, treatment for lesions involving the cervicothoracic junction is often surgical, with goals encompassing neural decompression, immediate stabilization, restoration of anatomical spinal alignment, and early rehabilitation.
In this article we review our surgically treated cases of tumors involving the cervicothoracic region and review various options for surgical approaches and instrumentation- augmented fusion.
Object: Tumors involving the cervicothoracic junction can have a high propensity for causing instability, with kyphosis and spinal cord compression resulting. Treatment with decompression only can lead to further instability and worsening neurological status. In this article, the authors review their surgical experience in the treatment of 19 patients with tumors involving the cervicothoracic junction. The various approaches and instrumentation techniques involved in decompression and stabilization of the cervicothoracic junction are also reviewed.
Methods: Aggressive instrumentation-augmented fusion after decompression of the cervicothoracic region can provide for immediate stabilization and early rehabilitation. Recent development of new hardware such as dual-diameter transition rods, polyaxial screws, and interlocking devices have enhanced the ability to fashion a strong construct for stabilization of the cervicothoracic junction.
Conclusions: Familiarity with complex instrumentation techniques and various surgical approaches to the cervicothoracic junction will be required for effective treatment of tumors causing instability of this region.
Surgical treatment of cervicothoracic junction diseases can be a challenging issue, as evidenced by diverse reports in the literature from practitioners of many different surgical specialties, including neurological; orthopedic; ear, nose, and throat; and cervicothoracic surgeons. Access to this region is complicated by the presence of major vascular elements as well as important visceral and soft-tissue structures. The cervicothoracic junction can be defined as an area extending from vertebral segments C-7 to T-4, and includes the lower brachial plexus, thoracic outlet, and superior mediastinum. This area is unique in that it is a transition area from a mobile, lordotic cervical spine to a rigid, kyphotic thoracic spine. Furthermore, the cervicothoracic junction, much like the thoracolumbar junction, represents an area under stress as the transfer of weight occurs between levels of the spinal column. In addition, the vertebral index decreases from the C-6 to the T-1 vertebrae, causing added stress to be applied to the more narrow and slender upper thoracic vertebrae.
Pathological processes such as trauma, degenerative processes, infection, and neoplastic involvement, combined with the abrupt change in the biomechanical function of this area, can predispose the cervicothoracic segment to instability. Previous surgeries at the cervicothoracic junction have been well known to destabilize the region. Several authors have reported increasing spinal deformity caused by a previous cervicothoracic junction laminectomy. Furthermore, spinal fusions ending at the cervicothoracic junction can also be a factor contributing to iatrogenic cervical instability. Progressive instability of this area ultimately leads to kyphosis and spinal cord compression.
Neoplastic involvement of the upper thoracic vertebrae accounts for 15% of patients with tumors of the spine. Furthermore, 10% of spinal metastases arise from the T14 region. Neurological involvement is a common sequela to cervicothoracic lesions causing instability, and can be as high as 80%. This predisposition to neurological injury may be related to the combination of a smaller spinal canal size at the cervicothoracic junction and a tenuous blood supply. Thus, treatment for lesions involving the cervicothoracic junction is often surgical, with goals encompassing neural decompression, immediate stabilization, restoration of anatomical spinal alignment, and early rehabilitation.
In this article we review our surgically treated cases of tumors involving the cervicothoracic region and review various options for surgical approaches and instrumentation- augmented fusion.
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