Surgical Technique: Cervicothoracic Junction Arthroplasty
The procedure was performed via an extensile approach to expose C4-T1. The old plate was removed. The arthrodesis at C5/6 and C6/7 appeared solid. An anterior decompression was effected at the C7-T1 level. A thorough foraminotomy at this level was effected bilaterally. A 16-mm Bryan® disc prosthesis was then placed into this defect. Visualization was achieved radiographically by taping her shoulders to the foot of the operating table.
Attention then turned to the C4/5 space. A similar decompression was performed and a 16-mm prosthesis was again placed. An intraoperative view is shown below:
Postoperatively the patient awoke well with full power in her limbs and resolution of the pain in the neck and both arms. She was discharged well on the third posteroperative day and at six weeks is doing well. Postoperative imaging is shown below:
Flexion/Extension x-rays confirmed movement at both levels:
This is the first reported case of arthroplasty at the cervicothoracic junction. Of interest is that the prosthesis actually sits more anatomically at the C7/T1 level than the C4/5 level, reflecting the kyphosis present before surgery above the fusion. Intuitively, cervical degeneration occurs most commonly at the C5/6 and C6/7 levels, and as a result, most movement in the subaxial spine occurs here. The C7/T1 interspace in fact does not show as much movement, as witnessed by the dynamic films above. The key to this procedure was adequate intraoperative radiographic visualization.
The long-term prognosis of this intervention is not known. This case covers several controversial areas in the field of arthroplasty surgery, including the role of multilevel arthroplasties, the use of arthroplasty for adjacent segment disease and the use of arthroplasty at the cervicothroacic junction. It does however exemplify the exciting era that spinal surgery has entered in terms of the management of degenerative disease.