title: Approaching the upper thoracic vertebrae without sternotomy or thoracotomy: a radiographic analysis with clinical application.
abstract: METHODS
  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.
  
  
  OBJECTIVE
  The relation of the sternal notch to thoracic vertebrae was examined by MRI to estimate the thoracic level approachable anteriorly without sternotomy.
  
  
  BACKGROUND
  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.
authors.affiliation: Departments of Neurosurgery, and Radiology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
authors.forename: A D
authors.initials: AD
authors.lastname: Sharan
authors.forename: G J
authors.initials: GJ
authors.lastname: Przybylski
authors.forename: L
authors.initials: L
authors.lastname: Tartaglino
mesh_terms: D000328:Adult; D000368:Aged; D000075202:Contraindications; D003937:Diagnosis, Differential; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D007403:Intervertebral Disc / Q000473:pathology / Q000601:surgery*; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D013122:Spinal Diseases / Q000175:diagnosis / Q000601:surgery*; D013123:Spinal Fusion / Q000379:methods*; D013249:Sternum / Q000601:surgery; D013904:Thoracic Vertebrae / Q000473:pathology / Q000601:surgery*; D013908:Thoracotomy