[Surgical treatment for disorders of the cervicothoracic junction region].

PURPOSE OF THE STUDY: The complex anatomy of the cervicothoracic junction region makes a reliable assessment of plain radiographs in lateral projection difficult or even impossible, which may result in failure to detect fracture or other pathology in this region of the spine. The aim of this study was to evaluate the patients with spinal disorders in the region of the seventh cervical to the third thoracic vertebrae treated at our department.

MATERIAL: During the period from November 2001 to June 2004, 34 patients with disorders of the C7-T3 region were treated surgically at the Department of Spinal Surgery, Motol Teaching Hospital, which accounted for 2.1% of the 1537 patients treated for spinal diseases in this period. Instability of the cervicothoracic junction was caused by tumors in 15 and by injury in 14 patients. Other diagnoses included deformity associated with rheumatoid arthritis (RA) in two patients, spondylodiscitis in one, and hemivertebral deformity at C7 and T1, each in one patient. The group included 16 women and 18 men between 8 and 75 years, with the mean of 52.3 years (after excluding the two children with hemivertebral deformity aged 8 and 9 years, respectively). The trauma subgroup had a significantly lower mean age (43.6 years) than the tumor subgroup (59.9 years).

METHODS: We placed the patients in three groups according to the etiology of cervicothoracic junction disorder, namely, 1. tumors and spondylodiscitis; 2. injuries; 3. others. Group 1 included 16 patients, 15 with tumors and one with spondylodiscitis. Two patients were treated by dorsal stabilization, one by ventral stabilization and the rest underwent combined surgery. Of 14 patients in group 2, three were treated from the posterior approach, six from the anterior approach and five by the combined approach. All group 3 patients underwent surgery from the posterior approach, with two patients being treated without instrumentation.

RESULTS: Of the 34 patients, only 33 were included; one was lost to follow-up soon after the operation. In group 1, no excellent, five very good, five satisfactory and two unsatisfactory outcomes were recorded. No intraoperative complications such as injury to the major vessels or nerve structures occurred; in one patient, profuse bleeding from arteries supplying a metastatic tumor had to be arrested. Late complications included loosening of the dorsal instrumentation in two patients, who required repeat operations. In group 2, there were six excellent, four good, two satisfactory and one poor outcomes. Late complications in one patient included loosening of the ventral instrumentation, followed by repeat surgery. Group 3 showed two excellent and two satisfactory outcomes; the latter were in the RA patients. Late complications involved one loosening of the dorsal instrumentation requiring repeat surgery. No injury to the major vessels or nerve structures was recorded in either group 2 or group 3. No deep infection was recorded in any of the three groups.

DISCUSSION: The results of our evaluation are in agreement with those of other authors and, similarly to them, we had to deal with the difficult issues of diagnosis. Currently, we prefer, in addition to conventional X-ray examination, CT scans including sagittal and frontal reconstruction, recently completed with magnetic resonance imaging, in all patients with cervicothoracic junction disorders. This policy allows us to avoid delays in making correct diagnosis and to provide conditions for effective treatment. In stabilization from the posterior approach we use rod-screw fixation that, in the majority of cases, is not combined with thoracic fixation. Previously, we have inserted screws in the articular processes at the C7 level, but now we prefer transpedicular fixation. Complicated anterior surgical procedures, such as complete or partial sternotomy, are always performed with the assistance of a thoracic surgeon. A noticeably high number of patients with neurological deficit was seen also in our group. Postoperative care is always provided in cooperation with the spinal unit of our hospital. Intensive inter-disciplinary cooperation has an important role in that our patients have a minimum of complications in comparison with the literature data.

CONCLUSIONS: Injuries and diseases of the spine at the cervicothoracic junction present a complex issue with a high potential for mistakes and complications. The principle of success lies in a high-quality X-ray examination, CT scans with sagittal and frontal reconstruction, and magnetic resonance imaging of the region affected. The complex anatomy of that region requires demanding surgical procedures, which can be performed only by a highly qualified and specialized team with appropriate facilities.