Surgical Technique: Cervicothoracic Junction Arthroplasty

Peer Reviewed
Surgical Technique
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:

intraoperative view

Figure 3

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:

postoperative MR

Figure 4

postoperative flexion x-ray

Figure 5a

postoperative extension x-ray

Figure 5b

Flexion/Extension x-rays confirmed movement at both levels:

postoperative lateral flexion x-ray

Figure 6a

postoperative lateral extension x-ray

Figure 6b

Discussion
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.

Updated on: 09/26/12
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Cervicothoracic Junction Arthroplasty
Todd Albert, MD
This case represents an interesting utilization of cervical total disc arthroplasty for junctional breakdown next to cervical fusion. The use of a cervical disc prosthesis at C-4/5 and C7-T1 adjacent to the solid fusion at C5-7 probably represents what will ultimately be the ideal indication for cervical disc arthroplasty. However, as yet the long-term results are completely unknown of this procedure and hence the reason for current FDA endorsed IDE trials. Caution should be utilized in assessing this case, as the author does not provide long-term follow up and it is reported in isolation of the longer term series currently available in the literature. Theoretically, it remains an exciting technology for this indication and time will tell whether it is the appropriate utilization and whether this particular device is the appropriate device.
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