SPINE Volume 30, Number 11, pp E305–E310
©2005, Lippincott Williams & Wilkins, Inc.
Sternal Split Approach to the Cervicothoracic Junction
in Children
Kishore Mulpuri, MBBS, MS(Ortho),* Jacques G. LeBlanc, MD, FRCSC,‡
Christopher W. Reilly, MD, FRCSC,§ Kenneth J. Poskitt, MD, FRCPC,† Rachel L. Choit, BSc,*
Vic Sahajpal, MD, FRCSC,§ and Stephen J. Tredwell, MD, FRCSC§
Study Design. We present a descriptive case series
outlining the surgical technique and outcome in six pa-
tients managed with a combined anterior neck and ster-
nal splitting approach.
Objectives. To describe a surgical approach used in
the management of severe cervicothoracic kyphosis
and/or scoliosis in pediatric patients.
Summary of Background Data. There are few reports
in the literature that address the problem of accessing
multileveled spinal deformities around the cervicotho-
racic junction requiring stabilization in the pediatric pop-
ulation.
Methods. A detailed chart and radiographic review
was completed of six consecutive patients managed at
our center with a combined anterior neck and sternal
splitting approach. The indications, surgical technique,
and outcome are reviewed for each case. This technique
was employed in 6 pediatric patients, aged 3–15 years, at
the authors’ institution. Diagnoses included Klippel-Feil
Syndrome (2 patients), Proteus Syndrome, Larsen Syn-
drome, and neurofibromatosis type I (2 patients). All pa-
tients had severe cervicothoracic kyphosis requiring sur-
gical instrumentation. This technique allowed surgical
access from C5-T6.
Results. This approach was invaluable in gaining ac-
cess to the cervicothoracic junction to address complex
spinal deformities in pediatric patients. In one patient, a
separate thoracotomy was performed to access the lower
thoracic spine. The only significant complication related
to the approach was recurrent laryngeal nerve palsy ex-
perienced by one patient. This approach allowed stabili-
zation of severe scoliotic and/or kyphotic deformities to
impede curve progression.
Conclusions. This approach was invaluable in gaining
multileveled access to the cervicothoracic junction to ad-
dress complex spinal deformities in pediatric patients.
Key words: cervicothoracic junction, anterior ap-
proach, sternal split, pediatric, scoliosis; kyphosis. Spine
2005;30:E305–E310
From the *Department of Orthopaedics, British Columbia’s Children’s
Hospital; and the Departments of †Radiology, ‡Surgery, Division of
Cardiovascular Surgery, and §Orthopaedics, Division of Paediatric
Orthopaedics, University of British Columbia, British Columbia’s
Children’s Hospital, Vancouver, British Columbia, Canada.
Acknowledgment date: April 15, 2004. First revision date: September
10, 2004. Second revision date: September 20, 2004. Acceptance date:
September 23, 2004.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
No funds were received in support of this work. No benefits in any
form have been or will be received from a commercial party related
directly or indirectly to the subject of this manuscript.
Address correspondence and requests for reprints to Kishore Mulpuri,
Department of Orthopaedics, British Columbia’s Children’s Hospital,
A200-4480 Oak Street, Vancouver, British Columbia, V6H 3V4. E-
mail: kmulpuri@cw.bc.ca
Addressing complex spinal deformities around the cervi-
cothoracic junction is technically challenging because the
cervicothoracic vertebral bodies are relatively inaccessi-
ble due to the anatomic structures that impede the ante-
rior approach.1–3 Posterior approaches alone are insuf-
ficient in severe cervicothoracic kyphosis. There have
been several different approaches described in the litera-
ture to resolve this difficulty.4 –9 Most reports that ad-
dress the anterior approach to the cervicothoracic junc-
tion describe gaining access to short segments of the
spine. This may be adequate to manage primary or met-
astatic tumors affecting the upper thoracic vertebrae, the
sequelae of Pott’s disease, or thoracic ossification of the
posterior longitudinal ligamentin in adults.1–3, 10 –13 But
these reports do not address the problem of accessing
multileveled spinal deformities requiring stabilization in
the pediatric population. There are few reports in the
literature concerning the anterior approach to the cervi-
cothoracic junction for instrumentation and fusion of
pediatric scoliosis.5
Cauchoix and Binet4 were the first in the literature to
describe a trans-sternal approach to the upper thoracic
spine. They advocated that access to the cervical spine
was best gained via an incision along the anterior margin
of the sternomastoid muscle, and thoracic access is
gained by an incision in the midline of the sternum that is
carried down to the xiphoid process. The two-part inci-
sion is then merged into one operation area by dividing
the subhyoid muscles. Cauchoix used this anterior cervi-
cothoracic approach on 2 patients: a 4-year-old child
with quadriplegia secondary to Pott’s disease involving
the first and second dorsal vertebrae with a sharp kypho-
sis and bilateral abscess requiring cord decompression,
and a 19-year-old man with complete spastic paraplegia
whose plain films demonstrated an osteolytic tumor de-
stroying the first and second dorsal vertebrae and the
upper part of the third vertebra.4 The authors achieved
satisfactory results with their two patients, but others
who later used this approach demonstrated a high op-
erative mortality and morbidity, and it was subse-
quently advocated that direct anterior exposures should
be abandoned.1
Hall5 outlined the specific indications for different an-
terior approaches to spinal deformities. In this review, he
suggests that if access to the upper four thoracic verte-
brae is needed for correction of a rigid congenital scoli-
osis then a staged approach be used whereby the apical
E305
E306 Spine • Volume 30 • Number 11 • 2005

rior access is needed in children with severe kyphosis

Figure 1. The patient is placed on the operating table in a supine
position and the neck is hyperextended and turned to the left,
allowing a right sided approach.
vertebral bodies are resected by splitting the sternum,
and posterior correction is then done with Harrington
instrumentation and spinal fusion. Hall noted that ante-
because posterior fusion alone will not resist all the
forces on it nor will it resist curve progression as the child
grows. However, he does note that a posterior fusion
done on those with slight deformities may be sufficient to
arrest progression, and should further stabilization be
needed, the posterior fusion mass affords some stability
to simplify later attempts at anterior stabilization.5
Maciejczak et al8 recommended an anterior transtho-
racic, transpleural approach as the best route to gain
access to the vertebral bodies of the thoracic spine as it
allows wide exposure of the anterior spinal column and
makes surgical intervention possible. However, the au-
thors acknowledged that this approach does not allow
adequate exposure of the upper three thoracic vertebrae,
which can be best exposed by a direct anterior approach.
Knoller and Brethner 6 reviewed sternotomy ap-
proaches for surgical treatment of the spine at the cervi-
cothoracic junction. They recommended the approach
first described by Cauchoix and Binet,4 noting that it
allowed adequate cervical spine exposure and had fewer
complications than the other anterior exposure tech-
niques such as the high anterior transthoracic approach
used by Hodgson14 or the modified anterior approach
described by Kurtz et al.7 We present six pediatric cases
with severe cervicothoracic kyphosis and/or scoliosis re-

Figure 2. The sternum is

opened, the thymus gland re-
sected and the brachiocephalic
trunk is mobilized to allow con-
tiguous access to the anterior
cervical spine and upper tho-
racic spine.
 Approach to the Cervicothoracic Junction in Children • Mulpuri et al E307
Figure 3. Retraction of the trachea, esophagus and innominate
artery provides access to the lower cervical and upper thoracic
spine.
quiring extensive access. In all cases, the lower cervical
and upper thoracic spine was accessed using a neck dis-
section and sternal splitting technique with the aid of a
cardiothoracic surgeon.
Materials and Methods
A detailed chart and radiographic review was completed of six
consecutive patients managed at our center with a combined
anterior neck and sternal splitting approach. The indications,
surgical technique, and outcome are reviewed for each case.
Follow-up radiographs and clinical status were reviewed in
each case to determine the degree of correction and complica-
tions, if any.
Anterior Neck and Sternal Splitting Surgical Technique
The surgical approach is completed with the assistance of a
cardiothoracic surgeon. A standard extensile anterior cervical
spine approach is used, incorporating an anterior sternal ex-
tension (Figure 1). The neck dissection is completed first in a
standard fashion. An incision is made along the medial border
of the sternomastoid muscle, extending down to the sternal
notch. The sternomastoid muscle is retracted laterally with the
neurovascular sheath, including the carotid artery, the jugular
vein, and the vagus nerve. Division of the omohyoid, sternohy-
oid and sternothyroid muscles facilitates extensile exposure.
The incision is extended as a midline sternotomy approach.
Blunt digital dissection is used to mobilize the retrosternal soft
tissues. The stenum is then split using a sternal saw in a stan-
dard fashion. After opening the sternum, the thymus gland is
resected to provide exposure and the brachiocephalic trunk is
Table 1. Clinical Summary of Six Cases
Patient Diagnosis Sex Age (yrs) Prior Treatment
1 Klippel-Feil M 11 None
2 Proteus Syndrome M 15 None
3 Neurofibromatosis I F 15 2 posterior fusions
4 Neurofibromatosis I M 4 None
5 Larsen’s Syndrome F 3 3 posterior fusions
6 Klippel-Feil F 13 2 C6-T5
Figure 4. Medial displacement of the brachiocephalic trunk
allows more distal access to the thoracic spine.
mobilized and controlled with a vessel loop. At this point in the
procedure the anterior cervical spine and upper thoracic spine
are able to be accessed contiguously (Figure 2). The pericar-
dium was opened in two patients in this series to increase mo-
bility of the brachiocephalic trunk. However, the dissection of
the brachiocephalic trunk can be done down to the pericardial
reflection without having to open the pericardium.
The trachea and esophagus are retracted slightly away from
the middle line with a right angle retractor, and a deep right
angle retractor is placed under the innominate artery and
pulled forward and downward as necessary to provide access
to the lower cervical and upper thoracic spine (Figure 3). The
distal extent of the exposure at this point will depend on the
patient’s anatomy and deformity; in most cases, the surgeon
will be able to access T4. Disc removal and instrumentation can
now be safely completed. Aggressive distal exposure will place
the recurrent laryngeal nerve under traction and must be done
carefully. Typically, left sided anterior cervical approaches are
preferred because of the distal course of the recurrent laryngeal
nerve on that side. We have elected to perform a right-sided
approach with mobilization of the brachiocephalic trunk. Me-
dial displacement of the trunk facilitates exposure of more dis-
tal segments of the thoracic spine on the right side, down to T6
in one patient in this series (Figure 4).
After completion of the orthopaedic procedure, hemostasis
is established. The sternum is reapproximated with wires or
suture according to the age. The sterno-thyroid and omohyoid
muscles are reattached. The neck incision is closed in usual
fashion. A small silastic drain may be required under the
sterno-thyroid muscle if hemostasis is a problem in the cervical
portion of the approach. A mediastinal tube is placed as in
cardiac surgical procedures.
Results
The clinical features of these patients are summarized in
Tables 1 and 2.
Access Gained Follow-up
C5-T5 9 years
C5-T4 3 years, 10 months
C6-T5 2 years, 8 months
C5-T4 (thoracotomy performed for T5–T9 access) 2 years, 4 months
C6-T6 22 months
6 months
E308 Spine • Volume 30 • Number 11 • 2005

Table 2. Pre- and Postoperative Scoliosis and Kyphosis and Summary of Complications
Patient Pre-op Scoliosis Post-op Scoliosis Pre-op Kyphosis Post-op Kyphosis Complications

1 40 30 45 55 Transient cervical ischemia *

2 80 72 70 61 None
3 65 30 20 20 Recurrent laryngeal nerve palsy
4 69 32 38 38 None
5 0 0 118 85 None
6 15 15 130 90 None
* Unrelated to approach

Representative Cases procedure with a neck dissection and sternal split ap-
proach with fusion from C6 to T6 and then went into
Case 4. A four-year-old boy with severe neurofibroma-
hanging traction. One month later, she underwent a pos-
tosis type I presented with a rapidly evolving scoliosis of
terior instrumentation and fusion from C6 to T7 with a
the cervical thoracic spine that progressed from 40° to
combination of pedicle and lateral mass screws. She was
80° over the course of 1 year. There were no neurological converted from hanging traction to a halo thoracic vest
sequelae from his curve. Preoperative computed tomog- for 8 weeks, and her postoperative course was unevent-
raphy (CT) showed extensive involvement of the spine ful. At 1 year after surgery imaging revealed a stable
with dystrophic changes at the apex of the curve. Mag- fusion mass (Figure 7).
netic resonance imaging revealed large plexiform neu-
roma in both sides of the chest with a huge neurofibroma Discussion
in the upper left chest. It was elected to attempt to stabi- This small case series demonstrates the usefulness of the
lize the curve both anteriorly and posteriorly because of direct anterior approach in gaining access to the cervico-
the rapid collapse and dystrophic nature of the defor- thoracic junction to address complex spinal deformities
mity. Surgical correction was done in a two step proce- in the pediatric population. With curves of this magni-
dure; the first stage was anterior cervical thoracic fusion tude, the goal of surgical intervention is to stabilize seg-
from C5 to T4 via a neck dissection and sternal split ments and impede curve progression. This extensile neck
approach. A right lateral thoracotomy was required for dissection and sternal split approach gave good exposure
anterior fusion from T5–T9. Five days later, the patient
was brought back to the operating room for the second
stage of correction, posterior instrumentation, and fu-
sion from C5 to T10. At 18 months after surgery, the
patient had returned to full activities and no complica-
tions were observed with regard to his spinal fusion (Fig-
ure 5).
Case 5. A 3-year-old girl with Larsen’s Syndrome pre-
sented with a collapsing high thoracic kyphosis that
threatened the viability of her spinal cord. Two previous
posterior spinal fusions had been attempted. The initial
surgery resulted in pseudarthrosis and ongoing angula-
tion. Halo traction was instituted and posterior fusion
was repeated in the corrected position. Following revi-
sion and prolonged immobilization, the patient could
not be removed from her halo because of curve progres-
sion and clinically obvious spinal instability. No neuro-
logical signs or symptoms were present. Magnetic reso-
nance imaging demonstrated that the apex of the curve
was at T3–T4 and that the subarachnoid space was ex-
tremely compromised though that region. A focus of in-
creased signal intensity was seen within the spinal cord
just distal to the apex of the kyphosis. A CT demon-
strated pseudoarthroses at two levels above the apex of
kyphosis. Incidentally it was found that she did not have
Figure 5. A and B, Postoperative radiographs of a 4-year-old boy
vertebral arteries in her vertebral foramens. Instead, the with neurofibromatosis type I (case 4) demonstrating extent of
vertebral arteries lay on the posterior aspect of the lam- anterior exposure. Additional thoracotomy was done to achieve
inae of the cervical spine (Figure 6). She had a staged access to distal 3 levels.
 Approach to the Cervicothoracic Junction in Children • Mulpuri et al E309
Figure 6. A-C, Preoperative CT
(case 5). Note that the vertebral
arteries are not in the vertebral
foramens, they lie on posterior
aspect of the laminae of the cer-
vical spine.
from C5 to T6 to allow instrumentation and fusion. In
one patient an adjunctive thoracotomy was performed to
access the bodies of T5 through T9, an alternative to the
trap door approach to the lower thoracic spine. Few
reports in the literature address the extensive access re-
quired for instrumentation and stabilization of severe
scoliotic and kyphotic deformities. Although it appears
that little scoliotic and/or kyphotic correction was
achieved (Table 2), the goal of stabilizing the spine and
preventing curve progression was realized.
Figure 7. Pre- (A) and postoperative (B) radiographs of a 3-year-
old girl with Larsen’s Syndrome and collapsing high thoracic
kyphosis (case 5).
The potential complications related to this approach
are iatrogenic damage to the recurrent laryngeal nerve,
the pericardium, and the esophagus. It is recommended
that the aid of a cardiothoracic surgeon be used because
we feel it is not an approach to be attempted by a spinal
surgeon alone due to the complexity of the exposure. In
this series the most significant complication related to
this approach was recurrent laryngeal nerve palsy in one
patient, a complication that had also been reported by
others using an anterior approach.2 The central neuro-
logical impairment experienced by one patient fully re-
solved and was not related to the sternal splitting tech-
nique. This patient’s preoperative CT scan had
demonstrated an almost spondyloptosis of C7 on T1
with the body of T1 impinging into the spinal cord canal
with clinical evidence of cord compression and progres-
sive myelopathy. Postoperative imaging showed that the
cord lay in the channel, and there was no focal anomaly
that would suggest a total cord lesion. It was felt that the
patient had suffered a vascular injury to his cord that was
unrelated to the sternal spitting approach.
This surgical approach is complex and invasive. It is
recommended in rare cases where the treating surgeon
must achieve contiguous anterior cervicothoracic fusion
to stabilize the spine and protect the patients’ neurology.
The cases presented in this paper include severe dystro-
phic deformities, complex congenital kyphotic defor-
mities, and cases in which previous isolated posterior
fusion attempts had failed. In our hands, with the as-
sistance of a cardiothoracic surgeon, we have found
the anterior sternal split approach to be a safe and
E310 Spine • Volume 30 • Number 11 • 2005
effective approach to gain access to the cervicothoracic
junction in children.
Key Points
● The sternal splitting approach was useful in gain-
ing multileveled access in pediatric patients with
severe cervicothoracic kyphosis and/or scoliosis.
● The sternal split and neck dissection technique
are described
● The aid of a cardiothoracic surgeon to provide
anterior exposure is recommended
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