Approaching the Upper Thoracic Vertebrae Without Sternotomy or Thoracotomy: A Radiographic Analysis With Clinical Application

Study Design. The distribution of the lowest vertebra tangential to the suprasternal notch and the lowest intervertebral disc visualized above the sternum was determined on magnetic resonance imaging (MRI) studies. The method is illustrated in seven patients undergoing upper thoracic spinal reconstruction to define a surgical approach without sternotomy or thoracotomy. Objectives. The relation of the sternal notch to thoracic vertebrae was examined by MRI to estimate the thoracic level approachable anteriorly without sternotomy. Summary of Background Data. Upper thoracic spine (T1–T4) visualization is considered difficult. The thoracic vertebrae that can be visualized anteriorly without sternotomy is unknown. Methods. The vertebral level tangential to the suprasternal notch and the lowest intervertebral disc visualized in its entirety above the sternum was determined from 106 consecutive midsagittal cervicothoracic MRI studies. The method was evaluated in seven patients to illustrate application of a low suprasternal, lateral extracavitary, or transpedicular approach to performing upper thoracic reconstruction. Results. The midportion of the T3 vertebra is often above the sternal notch, whereas the trajectory of the T1–T2 intervertebral disc is usually rostral to the sternum. All four patients with disease above the sternal notch on MRI underwent a low left suprasternal approach, whereas three others were treated with a lateral extracavitary or transpedicular approach. No patient worsened neurologically and all ambulated independently after surgery. Conclusions. Upper thoracic vertebrae can be exposed without sternotomy or thoracotomy by a low left suprasternal approach. Midsagittal cervicothoracic MRI can identify the thoracic vertebrae above the sternum, thereby determining whether a low suprasternal approach is feasible. Otherwise, a lateral extracavitary or transpedicular approach can be used to avoid sternotomy or thoracotomy.