En bloc resection of multilevel cervicothoracic junction tumors via a combined posterior and osteomuscular-sparing transmanubrial anterior approach: a technical note and case series

BACKGROUND: Multilevel localized tumors of the cervicothoracic junction (CTJ) pose significant surgical challenges due to the complex regional anatomy and proximity to vital neurovascular structures. Building upon the pioneering work established the combined transmanubrial and posterior approach for CTJ tumor resection in the 1990s, this study reports our institutional experience with this combined approach for the en bloc resection of multilevel localized primary CTJ tumors. CASE PRESENTATION: Three patients with multilevel localized CTJ tumors underwent the combined posterior and transmanubrial osteomuscular-sparing anterior approach (TMA). The patients included a male with a C7-T2 giant cell tumor, a male with a large osteosarcoma involving the left chest wall at the C6-T2 level, and a female with recurrent C7-T3 epithelioid hemangioendothelioma. Postoperatively, all three cases preserved osteomuscular integrity and one patient exhibited postoperative intrinsic hand muscle weakness secondary to obligatory C8/T1 nerve root sacrifice; the other two patients maintained normal neurological function and spinal stability, with no evidence of spinal dysfunction during follow-up. CONCLUSION: The combined posterior and transmanubrial osteomuscular-sparing anterior approach is a viable surgical option for patients with multilevel CTJ tumors, especially those with a narrow cervicothoracic angle and anterolateral tumor extension requiring en bloc excision.