Background:
Ventral reconstruction at the cervicothoracic junction (CTJ) is technically demanding due to the depth of the operative field and the frequent need for manubrial or sternal extension to achieve adequate exposure. Although anterior plating is commonly recommended, instrumentation at C7–T1 is often difficult, and the role of uninstrumented structural grafting in this region remains poorly defined. This study evaluates the feasibility, radiological, and clinical outcomes of anterior corpectomy with uninstrumented autologous structural grafting at the CTJ.

Materials and Methods:
This retrospective observational series included patients with traumatic CTJ injuries who underwent anterior corpectomy with uninstrumented structural autograft reconstruction with/without posterior stabilization at a tertiary neurosurgical center by a single surgeon between 2012 and 2023. Demographic, radiological, surgical, and functional data were collected. Patients were followed clinically and radiologically at 6 months postoperatively and annually thereafter. Fusion was assessed using computed tomography and dynamic radiographs.

Results:
Seven patients (mean age 45.6 years; range 10–73), all with traumatic CTJ injuries, were included. Pathologies comprised C7–T1 spondyloptosis (n = 2), high-grade C6–7/C7–T1 listhesis or fracture-dislocation (n = 5). Corpectomy levels comprised four two-level corpectomies, two single-level corpectomies, and one three-level corpectomy. No patient required manubriotomy or sternotomy. Posterior stabilization was performed in six patients. Clinical follow-up was available in four patients (mean 34.8 months; range 15–129), with two demonstrating improvement in Nurick grade and two remaining neurologically stable. Radiological follow-up confirmed solid fusion in all evaluated cases. Two patients developed transient postoperative hoarseness; no other complications were observed.

Conclusion:
Uninstrumented structural grafting following anterior corpectomy at the CTJ is a feasible and safe ventral reconstruction strategy when combined with appropriate posterior stabilization. This technique achieves reliable fusion and avoids the need for manubriotomy or sternotomy in selected traumatic CTJ injuries.

INTRODUCTION
The cervicothoracic junction (CTJ) represents one of the most anatomically and biomechanically complex regions of the spine. The abrupt transition from the lordotic and highly mobile subaxial cervical spine to the rigid kyphotic thoracic spine creates a zone of high mechanical stress, particularly vulnerable to translation injury and junctional failure. The depth of the thoracic inlet, presence of the clavicles, manubrium, lung apices, and major mediastinal vessels narrows the operative corridor, making surgical access to C7–T1 challenging. These anatomical constraints have been recognized as major impediments to safe anterior decompression and instrumentation at the CTJ.[1-3]

Traumatic injuries at the CTJ – especially high-grade listhesis and spondyloptosis – are associated with mechanical instability and neurological impairment.[4-8] In many of these injuries, the inferior vertebral body migrates dorsally into the spinal canal and becomes the dominant ventral compressive element on the spinal cord. Consequently, closed traction or posterior-only strategies may fail to achieve adequate decompression. Effective reduction and restoration of canal dimensions often require direct anterior removal of the displaced vertebral body, necessitating surgical work at increasingly inferior levels and magnifying the technical challenges of anterior instrumentation.

Assessment and management of these injuries are further complicated by limited visualisation of the CTJ on standard lateral radiographs, where shoulder superimposition frequently obscures C7–T1. This limitation restricts reliable assessment of reduction during traction and underscores the need for controlled anterior decompression in selected cases.

Although traditional teaching has advocated manubriotomy or sternotomy to facilitate anterior exposure, particularly when plating is planned, recent series have demonstrated that C7–T1 (occasionally T2) can often be accessed through an extended low cervical approach. Nevertheless, the depth of the surgical field and restricted screw trajectories continue to limit safe anterior instrumentation at this level, contributing to graft- and plate-related complications.[9-14]

Uninstrumented structural autografting combined with robust posterior fixation offers a potential alternative strategy. In this construct, the anterior graft functions as a biological load-sharing strut, whereas posterior instrumentation provides primary mechanical stability. The present study reports a series of traumatic CTJ injuries treated with anterior corpectomy and uninstrumented autologous grafting, supplemented by posterior fixation, and evaluates the clinical and radiological outcomes of this approach.

MATERIALS AND METHODS
Study design and patient selection
This study is a retrospective observational series of patients who sustained cervicothoracic trauma and underwent anterior corpectomy with uninstrumented structural bone grafting at a tertiary care neurosurgical centre by a single surgeon (BVJ) between 2012 and 2023. This study was conducted in accordance with institutional ethical standards and the Declaration of Helsinki. Institutional ethics committee approval was not required for de-identified retrospective data, and informed consent for study participation was waived; all patients had provided routine surgical consent. Eligible cases included corpectomies centred at C6–T1 that were reconstructed using autologous structural grafts, with or without supplemental posterior fixation. Patients were identified from operative logs and electronic medical records with no exclusions based on age, chronicity, or neurological status.

Preoperative assessment
Demographic data, mechanism of injury, duration from trauma to surgery, and preoperative neurological functional status (Nurick grade) were recorded. All patients underwent standard radiographic evaluation, including cervical radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) to assess injury morphology, canal compromise, and soft-tissue involvement. Preoperative skeletal traction was applied for 2-3 days unless contraindicated.

Surgical technique
All operations were performed under general anesthesia using a right-sided anterior approach to the CTJ. Patients were positioned supine on skull traction with neck extended and placed on a cerebellar head rest. Exposure was achieved through a transverse or oblique cervical incision without the need for manubriotomy or sternotomy. Central corpectomy was performed using standard microsurgical technique to decompress the thecal sac. Mortices made in the upper and lower endplates into which a structural bone autograft (iliac crest, fibular strut, or tibia) was shaped and seated [Figure 1]. No anterior plates or screws were used.

Open multimedia modal
Figure 1Open multimedia modalTechnique of uninstrumented structural graft placement following anterior cervicothoracic corpectomy (a) Schematic illustration demonstrating the sequential technique of graft insertion. Under continuous axial traction, the structural autologous graft is seated into the prepared endplate mortices using controlled tapping, achieving a stable construct with restoration of anterior column height. (b) Illustration showing final view after graft placement in sagittal and axial planes demonstrating appropriate positioning of the structural graft (g) within the corpectomy defect and maintenance of segmental alignment. (c) Preoperative imaging from an illustrative case of a patient presenting with neck pain and progressive paraparesis 1 year following a fall, demonstrating a traumatic cervicothoracic listhesis with deformity at C7–T1. (d) Postoperative computed tomography from the same patient confirming satisfactory placement of the iliac crest autologous graft within the corpectomy defect and restoration of alignment
Posterior stabilization was performed using a combination of cervical lateral mass screws, upper thoracic pedicle screws, laminar or transverse process hooks, and interspinous wiring or cable systems, extending from the subaxial cervical spine into the upper thoracic spine as deemed necessary.

Postoperative care and follow-up
Patients were mobilized in a rigid cervical orthosis for 3 months. Clinical and radiological follow-up was conducted at 6 months postoperatively and annually thereafter. Neurological status was assessed using the Nurick grading system, and imaging was reviewed for alignment, construct integrity, and fusion.

Radiological fusion assessment
Fusion was assessed on CT or dynamic radiographs at last follow-up and defined by continuous trabecular bridging across graft–endplate interfaces, absence of lucency or graft migration, maintenance of alignment, and <2° angular or <2 mm translational motion where applicable.

Data analysis
Descriptive statistics were used to summarise demographic, clinical, surgical, and radiological variables. Continuous variables are reported as means, medians, and ranges, and categorical variables as frequencies and percentages. No inferential statistical analysis was performed due to the small cohort size. Data were analyzed using Microsoft Excel (Microsoft Corp., Redmond, WA, USA).

RESULTS
Seven patients underwent anterior corpectomy with uninstrumented structural bone grafting during the study period. The cohort comprised six males and one female, with a mean age of 45.6 ± 19.9 years (range, 10–73 years). Injuries most commonly resulted from falls (n = 5), with two following road-traffic accidents. Two patients had C7-T1 spondyloptosis, whereas the remaining cases demonstrated high-grade C6–7 or C7–T1 listhesis, fracture-dislocation, or burst fracture patterns. Two patients had chronic or neglected injuries (120 and 365 days post-trauma), whereas the remainder underwent surgery in the acute or early subacute setting (0–15 days). Preoperative Nurick grade ranged from 1 to 4, with a mean of 2.6 ± 1.1.

All patients underwent anterior central corpectomy centered on C6–T1, followed by reconstruction with an uninstrumented structural graft, and none required manubriotomy or sternotomy. Corpectomy levels included four two-level corpectomies (two at C6–7 and two at C7–T1), two single-level C7 corpectomies, and one three-level C5–7 corpectomy [Figure 2]. Iliac crest autograft was utilised in five patients, whereas fibular and tibial autografts were employed in one patient each. Additional posterior stabilization was performed in six patients. One patient with C7–T1 listhesis underwent anterior-only fusion [Table 1].

Open multimedia modal
Figure 2Open multimedia modal(a and b) Preoperative computed tomography (CT) and magnetic resonance imaging (MRI) demonstrating high-grade C7–T1 spondyloptosis with severe translational deformity and anterior spinal cord compression in a patient with prior cervical decompression surgery who sustained a fall. (c) Postoperative CT showing a three-level (C5–7) corpectomy reconstructed with an uninstrumented fibular structural autograft, with restoration of anterior column height and alignment. (d) Postoperative MRI confirming adequate decompression of the spinal cord across the reconstructed segment