Stage 1

Stage 1 can be performed with patient in the lateral position and combined with stage 2, eliminating the need to reposition.

– Patient is taken from the supine position and placed prone on chest rolls and the head secured in a Mayfield head holder (Schaerer Mayfield, Randolph, MA). The cervical-thoracic region is cleaned and prepped in the usual sterile fashion. Prophylactic antibiotics are administered.

– The cervical-thoracic spine is exposed using the standard subperiosteal technique.

– Cervical lateral mass and thoracic pedicle screw instrumentation is inserted.

– Laminectomies are performed at the levels of interest. Nerve roots to be sacrificed are identified, ligated, and sectioned proximal to the dorsal root ganglion.

– Preoperatively, it is determined if the C8 and T1 nerve roots can be preserved, or if they will need to be sacrificed for oncologic reasons. If they are to be preserved, they are identified and traced laterally. The pedicle and the transverse process of T1 are resected. If the chest wall is involved in tumor, but there is no involvement of the vertebral column, then the rib heads are disarticulated from the vertebral body. If the vertebral column is involved in tumor, but the proximal portion of the rib is not, then the proximal portion of the T1 rib is resected. The C8 and T1 nerve roots are traced further laterally, identifying where they come together to form the lower trunk of the brachial plexus. The lower trunk of the brachial plexus is identified and protected during tumor resection. Injury to the C8 or T1 roots or the lower trunk of the brachial plexus can result in significant pain and loss of hand function.

– The lateral aspect of the vertebral column to be resected, contralateral to the tumor, is dissected, and the segmental vessels are ligated and cut.

– The most rostral and caudal disc spaces of the section of the vertebral column to be resected are identified. A Tomita-saw (MANI, Inc., Utsunomiya, Japan) is placed ventral to the thecal sac and posterior to the annulus at both of these disc spaces. The end of the saw, contralateral to the tumor, is tucked lateral to the vertebral column (to be retrieved later, during stage 2). If the most rostral disc space is C7-T1 or higher, this disc will be cut by means of a separate approach, using a standard anterior cervical discectomy technique.

Stage 2

– The patient is repositioned in the lateral decubitus position (tumor side up) on a bean bag. After the patient is properly positioned and secured to the table, the head is secured via a Mayfield head frame.

– The chest and posterior wound are cleaned, prepped, and draped.

– The posterior wound is reopened.

– The bronchus ipsilateral to the tumor is occluded and the lung deflated.

– A posterior-lateral thoracotomy is performed at the interspace below the section of chest wall involved with tumor. The skin incision is extended medially to intersect with the midline spinal incision. The paraspinous musculature is mobilized off of the transverse processes and ribs. The rostral aspect of the thoracotomy incision is elevated as a myocutaneous flap.

– The chest wall is then cut, starting at the level of the thoracotomy and extending rostrally, lateral to the extent of tumor involvement, until the rostral aspect of the tumor margin is passed. The intercostal nerves, arteries, veins, and musculature are sectioned with the chest wall.

– A formal lung lobectomy is performed proximal to the tumor, isolating the tumor from the lung.

– The contralateral Tomita-saws are retrieved ventral to the vertebral bodies, and using the saws, the discs are cut.

– The specimen is now completely mobilized and can be delivered en bloc. Pancoast tumors can be violated, and unlike the case for primary spinal tumors (i.e., chordoma and chondrosarcoma), if total resection with negative margins is achieved, the oncologic goals can still be met.

– The vertebral column defect is reconstructed, and arthrodesis is then performed.

– Two thoracostomy tubes are placed and tunneled out through separate incisions.

– A thoracoplasty is constructed, and the thoracotomy and posterior incisions are closed in the standard fashion.

IV. Complications

– Thoracic duct injury and chyle leak/chylothorax: Primary ligation of the thoracic duct to control the leak should be attempted. High-volume thoracostomy output suggests the possibility of a thoracic duct injury.

– Esophageal injury: Primary closure at the time of injury should be undertaken. Treat an injury in the postoperative period with a high degree of suspicion as such injuries carry significant morbidity and mortality.

– Pseudarthrosis

– Instrumentation failure

– C8, T1, lower trunk injury

– Bronchopleural fistula

– Vascular injury

V. Postoperative Care

– Intensive care unit (ICU)

– Thoracostomies to 20 cm H₂O suction until there is no evidence of pneumothorax, H₂O seal for 24 hours, then discontinue one thoracostomy every 24 hours.

– Incentive spirometry

VI. Outcomes