Clinical application of Grunenwald incision in cervicothoracic junction surgery

Abstract

Background

To evaluate the clinical efficacy of Grunenwald incision in cervicothoracic junction surgery. Methods: A retrospective analysis was performed on 29 patients treated at the Fourth Hospital of Hebei Medical University, including 28 patients with cervicothoracic junction tumors (11cases of upper mediastinal tumors, 7 cases of superior sulcus tumors, 4 cases of thyroid tumors with upper mediastinal invasion, 4 cases of chest wall tumors, 2 cases of esophageal cancers with supraclavicular lymph node metastasis) and 1 patient with cervicothoracic junction penetrating trauma.

Grunenwald incision or additional posterolateral thoracic incision, median sternal incision or neck collar incision were used in all patients.

Results

There was no perioperative death in the whole group. Complete tumor resection was achieved in 25 cases; palliative resection was performed in three cases, and one case underwent complete foreign body removal. The operation time ranged from 120 to 430 minutes, with an average of (231.90 ± 85.30) minutes. The intraoperative blood loss was between 100 and 1000 milliliters, with an average of (286.56 ± 192.90) milliliters. The postoperative hospital stay lasted 6 to 28 days, with an average of (13.14 ± 5.12) days. Follow-up periods spanned 6 to 142 months, with an average of (66.66 ± 46.96) months. During the follow-up period, six patients died.

Conclusions

Grunenwald incision can provide good exposure of the structures near the cervicothoracic junction, preserve the integrity of the sternoclavicular joint, reduce shoulder deformity, and has advantages for patients with cervicothoracic junction tumor, high rib resection, and cervicothoracic junction trauma.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-025-03987-9.

Background

The cervicothoracic junction, a narrow space surrounded by bony structures with vital penetrating vessels and nerves, poses significant surgical challenges for tumor resection. The high risk of injuring critical structures in this area may lead to severe complications [1]. Although the classic Shaw-Paulson incision can adequately expose the posterior chest wall, the middle and posterior part of the thoracic outlet, as well as the pulmonary hilum, it offers poor exposure of the thoracic apex and anterior walls of the chest. Moreover, this approach often fails to provide sufficient exposure of the subclavian vessels, which may compromise the achievement of R0 resection [2]. In contrast, Dartevelle’s incision offers optimal visualization of thoracic inlet structures, including the subclavian vessels and brachial plexus. However, this approach requires partial clavicular resection and detachment of the pectoralis major and sternocleidomastoid muscles, resulting in chest wall asymmetry and shoulder instability [3].

The Grunenwald incision demonstrates distinct advantages in managing invaded subclavian vessels and neurovascular structures, effectively minimizing injury risks while preserving the sternoclavicular joint and maintaining upper thoracic aesthetic integrity [4]. Since 2011, our team has applied the Grunenwald approach in treating patients with cervicothoracic junction pathologies. This surgical technique has exhibited remarkable clinical efficacy, yielding outcomes that substantially exceed initial prognostic expectations. Here we summarize the data and report.

Methods

Patients and ethics

The clinical data of 28 patients with cervicothoracic junction tumor and one patient with cervicothoracic junction trauma in the single treatment group of the Department of Thoracic Surgery, the Fourth Hospital of Hebei Medical University, were retrospectively analyzed, including 21 males and eight females, aged 9–75 years, with an average of (50.00 ± 18.53) years. Among the 29 patients, there were 11 cases of upper mediastinal tumor, 7 cases of superior sulcus tumor, 4 cases of thyroid tumor invading the upper mediastinal, 4 cases of chest wall tumor, 2 cases of esophageal cancer combined with supraclavicular lymph node metastasis, and 1 case of foreign body penetrating injury at the cervicothoracic junction. All experimental procedures were approved by the Clinical Research Ethics Committee of the Fourth Hospital of Hebei Medical University (No: 2024KS044 approved on 17th May, 2024). All patients enrolled in this study signed a written informed consent and accepted the approved protocol by the Institutional Review Board of the Fourth Hospital of Hebei Medical University. Furthermore, the written permission has been obtained from patients whose photos would be taken during the surgery procedure and would be exhibited in the research papers. Patient inclusion criteria were: ⅰ) primary or recurrent benign and malignant tumor at the cervicothoracic junction; ⅱ) trauma to the cervicothoracic junction; ⅲ) Grunenwald incision or additional other incisions; ⅳ) complete follow-up data.

Operation method

All patients received general anesthesia. The incision was selected based on the primary lesion, with a simple Grunenwald incision or additional incisions (full-length median sternal incision or neck collar incision) performed in a supine position with shoulder elevation and head rotation toward the healthy side. For cases requiring an additional posterolateral thoracic incision, the procedure was conducted in the standard lateral position.

The skin incision originated from the anterior border of the sternocleidomastoid muscle, extended downward along the median manubrium to the first intercostal space, then diagonally outward toward the deltopectoral groove to the lateral midclavicular line (Fig. 1a). The anterior sternal muscles and periosteum were dissected to expose the sternoclavicular joint and first/second ribs. The posterior sternal space was separated, and the intercostal muscles were separated along the 1 st intercostal space adjacent to the sternum, and the intrathoracic artery was ligated (Fig. 1b). The sternum was longitudinally divided with a sternal saw, starting from the midline of the sternum and extending downward to the level of the first intercostal space (Fig. 1c). Subsequently, from the first intercostal space level on the affected side, an additional transverse sternotomy was performed toward the midline of the sternum to complete the sternal division (Fig. 1d). Then, the first costal cartilage was cut with a wire saw (Fig. 1e), and the sternoclavicular joint was preserved throughout the procedure. A traction belt was used to create traction on the broken end of the sternum, which allows for excellent visualization of the surgical field. Consequently, critical anatomical structures such as the subclavian artery, subclavian vein, vagus nerve, and phrenic nerve can be clearly exposed (Fig. 1f-g). Finally, the sternum was fixed with a wire needle after the operation, and suture the skin incision (Fig. 1h). For full median sternotomy, the sternum was first split longitudinally, followed by transverse transection at the first intercostal space.

Fig. 1.

Representative detailed surgical procedure diagram for the Grunenwald incision. a: Skin incision approach. b: Surgical field exposure. c-d: Sternum division. e: Division of the first rib cartilage. f-g: Clear exposure of anatomical structures. h: Sternal fixation and skin closure. Detailed annotations for each figure are provided in the main text

Statistical analysis

SPSS software version 21.0 (IBM Corp.) was used to analyze the data, and P ≤ 0.05 was considered to indicate a statistically significant difference.

Results

There was no perioperative death and no major postoperative complications in the whole group, and all patients were successfully discharged. Among the 29 patients, surgical approaches included: 16 cases via simple Grunenwald incision, 7 cases with an additional posterolateral chest incision, 4 cases with an additional neck collar incision, and 2 cases with an additional median sternal incision. Tumor resection outcomes were as follows: 25 cases achieved complete resection, 3 cases underwent palliative tumor resection, and 1 case involved complete foreign body removal. Operative duration ranged from 120 to 430 min, with an average of (231.90 ± 85.30) minutes. Intraoperative blood loss amounted to 100–1000 ml, with an average of (286.56 ± 192.90) ml. Postoperative hospital stay was 6–28 days, with an average of (13.14 ± 5.12) days (Table 1).

Table 1.

The surgical conditions of 29 cases with Grunenwald incision

Number of cases undergoing R0 resection	Operative time (min)	Intraoperative blood loss (ml)	Postoperative hospital stay (day)
26	231.90 ± 85.30	286.56 ± 192.90	13.14 ± 5.12

Three patients underwent palliative subtotal tumor resection. The first case involved a superior sulcus tumor of the right upper lobe. Exploration via a Grunenwald incision revealed tumor invasion of the first rib, right subclavian vein, right internal jugular vein, and right brachiocephalic vein. This necessitated first rib resection and palliative tumor debulking. Subsequent exploration through right posterolateral thoracotomy demonstrated right upper hilar lymph nodes in a peg-like frozen state, precluding dissection. An extended wedge resection of the right upper lung lobe was performed. The second case concerned a posterior superior mediastinal tumor (approximately 8 cm × 7 cm × 6 cm), extending superiorly to the supraclavicular region and inferiorly to the subaortic arch, with invasion of the thoracic vertebral body precluding complete resection. The tumor was cut in front of the vertebral body and palliative majority resection was performed. The third case involved another posterior superior mediastinal tumor (approximately 9 cm × 8 cm × 7 cm). The tumor invaded the pericardium and encased the right brachiocephalic vein, superior vena cava, brachiocephalic trunk, left common carotid artery, left subclavian artery, and a portion of the pericardium. Subtotal tumor resection was undertaken, followed by pericardial patch repair.

Postoperative pathological examination revealed eight cases of lung-origin malignant tumors, comprising four cases of lung adenocarcinoma, two cases of lung squamous cell carcinoma, one case of lung large cell neuroendocrine carcinoma, and one case of simple 1 st rib metastasis from lung squamous cell carcinoma. Additionally, six neurogenic tumors were identified, including five nerve sheath tumors and one ganglionic cell neurotumor. Other pathological types included three cases each of thyroid carcinoma and myofibroblastic tumor; two cases of esophageal cancer metastatic to supraclavicular lymph nodes; and one case each of nodular goiter, hemangioma, well-differentiated liposarcoma, vascular endothelial tumor, cavernous choroidal tumor, mucinous tumor, and foreign body.

Postoperative complications were as follows: There were no perioperative deaths. Pleural effusion occurred in 11 of the 29 patients; all effusions were exudative, attributed to incision trauma and sternal exudation, and resolved with thoracic closed drainage. Four patients required postoperative transfer to the intensive care unit due to extensive surgical trauma and prolonged operative time. These included two cases of superior sulcus tumor, one case of esophageal cancer, and one case of mediastinal tumor. One patient with thyroid cancer developed a postoperative neck incision infection, which improved with symptomatic management including local debridement and dressing changes. Additionally, on postoperative day 8, one patient with a right upper mediastinal tumor experienced sternal fixation wire breakage. This complication arose because only a single wire had been used to fixate the longitudinal and transverse sternal fracture ends during initial closure, resulting in unstable fixation, sternal displacement, and shoulder deformity. The patient subsequently underwent sternal refixation.

Twenty-nine patients were followed up for 6-142 months, with an average of (66.66 ± 46.96) months. Six patients died during the follow-up period. One patient with right upper lobe superior sulcus tumor (palliatively resected) died 12 months postoperatively due to respiratory failure and massive pleural effusion recurrence. One patient with left upper lobe superior sulcus tumor (completely resected) died of brain metastasis 6 months after surgery. One patient was reoperated for a recurrence of thyroid carcinoma after surgery and died of multiple metastasis at the 93rd postoperative month due to multi-organ failure. An advanced thyroid carcinoma patient developed recurrence at 12 months postoperatively, with tumor invasion into the trachea; death occurred after tracheal stenting due to hemoptysis complications. One patient with posterior superior mediastinal tumor (palliatively resected) died 8 months postoperatively from recurrence, pleural effusion, and cardiac failure. One case of esophageal carcinoma with purely postoperative metastasis to the right supraclavicular lymph node died 14 months after surgery due to systemic multiple metastases. Typical cases are shown in Figs. 1, 2 and 3 and Additional file 1–3.

Fig. 2.

Representative clinical applications of the Grunenwald incision. Male, 54 years old, after neoadjuvant treatment for superior sulcus tumor of right upper lobe (pathologic type squamous cell carcinoma), a major portion of the right 1 st and 2nd ribs were resected + bronchial sleeve resection of the right upper lobe was performed through Grunenwald incision with additional right posterolateral thoracic incision. a: Preoperative CT image suggested tumor invasion of the 1 st and 2nd ribs, and the tumor was located in the opening of the right upper lobe of the lung. b: Grunenwald incision for resection of the 1st and 2nd ribs, intraoperative anatomical free protection and labeling of important nerves and blood vessels. c: Right posterolateral thoracic incision for bronchial sleeve resection of the upper lobe. d: Grunenwald incision after suture closure is shown

Fig. 3.

Representative clinical applications of the Grunenwald incision. Male, nine years old patient with high differentiated liposarcoma of the left upper mediastinum recurred more than eight years after surgery, and the tumor was completely resected through Grunenwald incision with additional median sternal incision. a: Preoperative CT image suggested that the tumor is extensive and invades into the neck, left upper mediastinum, and left axilla, which is closely related to the important surrounding structures. b: Preoperative condition of the child. c: Postoperative condition of the child at the time of discharge from the hospital. d: Intraoperatively, the tumor was seen to have a close relationship with the left brachial plexus nerve, subclavian blood vessels, and the veins of the head and arm, and the important nerves and blood vessels were anatomically protected and labeled. e: Postoperative specimen presentation.

Discussion

The cervicothoracic junction is anatomically bounded by the sternum and clavicle anteriorly, cervical and thoracic vertebrae posteriorly, and central structures including blood vessels, trachea, and esophagus. This region harbors a dense network of vital structures, including the brachial plexus, cervical sympathetic trunk, subclavian artery/vein, common carotid artery, internal jugular vein, cervicothoracic vertebrae with corresponding segmental spinal cords, superior mediastinum with its major vessels, esophagus, trachea, vagus nerve, recurrent laryngeal nerve, and phrenic nerve, among others [1]. Resecting tumors in this region is challenging due to high surgical risk and technical difficulty, with the treatment principle emphasizing complete tumor removal while preserving vital neurovascular structures and organ function [5–8]. Complete intraoperative exposure of the tumor and invaded neurovascular structures is therefore a prerequisite for surgical success [9]. However, standard cervical or thoracic incisions often fail to provide adequate exposure for cervicothoracic junction tumors, potentially compromising complete resection [10, 11].

For most thoracic parietal tumors, the Shaw-Paulson procedure remains the classic surgical approach [2, 12]. The patient is positioned laterally with the affected side upward. The ipsilateral upper limb is extended anteriorly toward the head and immobilized. The incision extends cranially between the spinous process and the inner border of the scapula up to the level of the seventh cervical vertebra. The trapezius muscle is incised along the full length of the incision at the stop points of the 1 st and 2nd ribs, followed by a transverse extension downward curving around the inferior angle of the scapula to the anterior axillary line. This technique offers distinct advantages: it enables optimal exposure of the posterior chest wall, middle and posterior thoracic outlets, and pulmonary hilum, with particular visualization of the spine and thoracic nerve roots. This anatomical access facilitates resection of affected vertebral segments and thoracic nerve roots. However, this incision type has inherent limitations: it provides suboptimal exposure of the parietal and anterior thoracic wall, complicates adequate visualization of subclavian vessels, and hinders precise assessment of tumor invasion into subclavian vascular structures, nerves, and adjacent tissues. These factors may compromise achievement of R0 resection [13].

In 1993, Dartevelle et al. [3] proposed an anterior cervicothoracic approach for tumor exposure at the cervicothoracic junction. The incision follows the anterior border of the sternocleidomastoid muscle and extends along the second intercostal space, with partial claviculectomy performed to optimize exposure of the thoracic inlet structures. This approach provides complete visualization of critical thoracic inlet tissues, including the subclavian vessels and brachial plexus. It enables safe, thorough mobilization and resection of involved subclavian vessels and brachial plexus components, facilitating vascular reconstruction. The incision also permits hemivertebrectomy in cases of anterior vertebral body invasion. However, surgical resection of the medial clavicle segment and attachment points of the pectoralis major and sternocleidomastoid muscles may lead to notable chest wall asymmetry, compromising cosmetic outcomes. Clavicle resection can also lead to functional problems including shoulder instability.

In 1997, Grunenwald et al. [4] reported the resection of a tumor on the top of the chest by splitting the manubrium around the sternoclavicular joint. Grunenwald’s incision was made from the anterior edge of the sternocleidomastoid muscle downward, and then vertically outward along the sternal styloid median longitudinally to the 1 st intercostal space, and then dissecting the 1 st costal cartilage, preserving the sternoclavicular joint, which allowed for the complete visualization of the subclavian blood vessels, the innominate arteries and veins, common jugular artery, and the vagus nerve, brachial plexus and the upper thoracic vertebrae, as illustrated in Additional file 4. The key advantages include precise manipulation of affected subclavian vessels and major nerves with minimized injury risk, preservation of the sternoclavicular joint and clavicle to maintain upper limb functionality and upper chest aesthetic integrity. In addition, complex thoracic surgery can be accomplished by attaching other incisions.

The cervicothoracic junction is a small space with abundant peripheral blood vessels and nerves, so different surgical methods should be used according to the specific conditions of patients. In this group, 29 patients with cervicothoracic junction tumor or trauma were operated on using Grunenwald incision or additional incision, and the efficacy of the surgery was confirmed. Specifically, 11 upper mediastinal tumors were managed: 5 anterior upper mediastinal tumors were completely resected; among 6 posterior upper mediastinal tumors, 4 underwent complete resection and 2 palliative resection (the tumors were all large, with a large extent of invasion of the posterior mediastinum and poor exposure). Most mediastinal tumors were benign [14]. For some anterior superior mediastinal benign tumors, some scholars have performed surgical resection through supraclavicular approach combined with thoracoscopic surgery [15]. However, for large anterior superior mediastinal benign tumors or malignant tumors, supraclavicular approach is poor in exposing subclavicular vessels and nerves, making resection difficult. Grunenwald incision can not only well expose the subclavian blood vessels and nerves, but also easily free the tumor in the thoracic cavity through this incision, and the tumor can be completely resected from this incision without the need for a combined chest incision. We believe that the Grunenwald incision can be applied to anterior superior mediastinal tumors with excellent exposure and definitive outcomes. For posterior superior mediastinal tumors, the utility of the Grunenwald incision remains controversial: smaller lesions are readily resected via transthoracic or thoracoscopic approaches, and many can be radically resected using thoracoscopic or robot-assisted techniques [16]. However, some larger posterior superior mediastinal tumors are mostly closely related to surrounding structures and are difficult to resect completely. Grunenwald incision can be an option for posterior superior mediastinal tumor, at least for exposing the vertebral artery and other important structures.

In our group, all seven superior sulcus tumor cases were either of the anterior or lateral type, among which the 1 st case was palliatively resected (operation date 21 st December, 2011), and the remaining six cases were completely resected. As for surgical methods for superior sulci tumors, most literatures refer to case reports. It is generally believed that radical resection can be achieved with Shaw-Paulson incision for posterior superior sulci tumors [17], whereas this approach is suboptimal for anterior/lateral subtypes due to inadequate exposure of upper ribs and subclavian structures. We believe that the Grunenwald incision combined with a thoracic incision represents the optimal surgical strategy for anterior and lateral superior sulcus tumors. Yokoyama and colleagues [18] reported two cases of radical resection of superior sulcus tumor by Grunenwald incision, and Truin and colleagues [19] reported one case of radical resection of superior sulcus tumor by Grunenwald incision combined with thoracoscopic surgery, with satisfactory results. Notably, management of superior sulcus tumors requires a multimodal approach, with individualized optimization of preoperative neoadjuvant therapy, intraoperative technical considerations, and postoperative adjuvant therapy to maximize clinical outcomes [20].

In this series, four cases of thyroid tumors with retrosternal or subclavian invasion, and four cases of chest wall tumors (all combined with resection of the first rib or concomitant resection of the second rib) were completely resected. For these patients, the Grunenwald incision or its modified extension demonstrated distinct advantages in achieving radical resection. Additionally, two cases of esophageal cancer with supraclavicular lymph node metastasis involving subclavian bone invasion were managed with complete metastatic lymph node resection via the Grunenwald incision, indicating its feasibility for comprehensive lymph node dissection in such scenarios. However, for esophageal cancer patients with upper mediastinal lymph node metastasis, the long-term oncological outcomes require comprehensive evaluation. Furthermore, our group also performed an emergency surgery for a cervicothoracic junction injury caused by a penetrating metal nail foreign body, which had lacerated the subclavian vein. The Grunenwald incision enabled successful repair of the subclavian vein, and the patient recovered well postoperatively. This case highlights the Grunenwald incision as an effective life-saving surgical approach for cervicothoracic junction trauma, particularly in critically ill patients.

Collectively, Grunenwald incision provides optimal exposure of critical anatomical structures at the cervicothoracic junction, including the subclavian vessels, brachial plexus, vagus nerve, and phrenic nerve. This anatomical accessibility significantly enhances the feasibility of en bloc resection for tumors in this region, while preserving the sternoclavicular joint integrity and minimizing shoulder girdle deformity. Therefore, we propose that the Grunenwald incision is an effective surgical option for patients with tumors at the cervicothoracic junction, those requiring high rib resection, and those with trauma involving the cervicothoracic junction. Nevertheless, this study has certain limitations. Firstly, the sample size is relatively small, which may introduce selection bias. Secondly, the diverse disease types among the included patients result in insufficient homogeneity, potentially leading to confounding biases.In subsequent studies, we plan to expand the sample size and conduct long-term follow-up assessments for specific tumor types to further validate the long-term efficacy of the Grunenwald incision.

Conclusion

Grunenwald incision can provide good exposure of the structures near the cervicothoracic junction, preserve the integrity of the sternoclavicular joint, reduce shoulder deformity, and has advantages for patients with cervicothoracic junction tumor, high rib resection, and cervicothoracic junction trauma.

Authors’ contributions

Y.X. and Z.T. contributed to the conception and design of the work. J.Q., Y.Z., S.W., Z.L. and M.W. collected the patient data. P.S., C.H. and F.Z. analyzed the data. Y.X. and J.Q. wrote the paper. Z.T. reviewed and edited the manuscript. All authors contributed to the performance of the surgical procedure. All authors read and approved the final manuscript.

Funding

This work was supported by the Support Plan for Research and Innovation Team (Class A) of the Fourth Hospital of Hebei Medical University (No: 2023A02).

Data availability

The dataset supporting the conclusions of this article is included within the article.

Declarations

Ethics approval and consent to participate

This study was approved by the Clinical Research Ethics Committee of the Fourth Hospital of Hebei Medical University (No: 2024KS044). All patients enrolled in this study signed a written informed consent and accepted the approved protocol by Clinical Research Ethics Committee of the Fourth Hospital of Hebei Medical University.

Consent for publication

Written informed consent for publication was obtained from all participants prior to their enrollment in the study.

Competing interests

The authors declare no competing interests.