No Man’s Land Revisited: Managing Unstable High Thoracic Fractures

Fractures of the upper thoracic spine, T1-T5, provide a challenging surgical environment, even for the most skilled spinal surgeons secondary to limited ability to access compared with other regions of the spine. Unstable vertebral body fractures of the upper thoracic spine are difficult to access because of the surrounding structures unique to this location including the heart, the great vessels, and the lungs. Currently, these high fractures can be approached in a variety of ways - anterior approach, lateral thoracotomy, lateral extra-cavitary, posterolateral, or a combination of each of these. Each approach has advantages and disadvantages. Which approach is taken is usually based on the surgeon’s experience and comfort level with the technique, in addition to the availability of a thoracic access surgeon. Herein, the authors will discuss these various surgical approaches along with the necessary intra-operative techniques and instrumentation that help facilitate management of these unstable high thoracic vertebral body fractures from their recent cohort. From analysis of our surgical cohort, the authors will demonstrate improvement in overall functional ability, successful fusion rates for all approaches, no major complications. Recommendations that T1-T2 pathology is best managed with the lateral extra-cavitary approach or an anterior approach, whereas T3-T5 pathology is best managed with an anterior thoracotomy are presented when an access surgeon is available, otherwise a lateral extra-cavitary approach may suffice. In the setting of either solely posterior or posterolateral pathology with relatively intact spinal column, a simple posterior decompression with instrumentation was sufficient for stabilization and fusion. Through this study, the authors intend to present an algorithm for the challenging surgical management of T1-T5 pathology resulting in instability or spinal cord injury.