Pterion Prep CraniPro VUMC Case Prep
2026-06-27

Operative Approach: Transthoracic (Anterior Thoracic) Approach to the Spine

Case / Approach Snapshot

Figures, Imaging & Video

πŸŽ₯ Operative video β€” search operative video on YouTube β–Έ Β· The Neurosurgical Atlas β–Έ

AO Spine / Surgery Reference β€” anterior thoracic Β· Neurosurgical Atlas β€” Spine Β· Radiopaedia β€” thoracic disc/tumour Β· PubMed Central β€” transthoracic corpectomy

High-Yield Literature

Curated Image Set

Open-access figures are embedded from PubMed Central articles and kept unique to this guide.

Transthoracic Approach Spine β€” Fig. 1 Fig. 1. The fine tip of the ultrasonic bone scalpel allows the lateral vertebral body to be carefully tailored to the desired width rather than resected en toto as demonstrated on this molded… Source: A rib-sparing unilateral transpedicular thoracic corpectomy using the ultrasonic bone scalpel: a novel technique and pictorial guide β€” BMC Surgery 2024; CC BY-NC-ND.

Transthoracic Approach Spine β€” Fig. 3 Fig. 3. An axial post-gadolinium T1-weighted image of the thoracic spine in an elderly female demonstrating a homogeneously enhancing mass at T8 with pathology consistent with a plasma cell neoplasm Source: A rib-sparing unilateral transpedicular thoracic corpectomy using the ultrasonic bone scalpel: a novel technique and pictorial guide β€” BMC Surgery 2024; CC BY-NC-ND.

Transthoracic Approach Spine β€” Fig. 5 Fig. 5. A sagittal post-gadolinium T1-weighted image of the thoracic spine in an elderly male demonstrating disc-osteomyelitis of the T3 and T4 vertebral bodies with acute kyphotic deformity,… Source: A rib-sparing unilateral transpedicular thoracic corpectomy using the ultrasonic bone scalpel: a novel technique and pictorial guide β€” BMC Surgery 2024; CC BY-NC-ND.

Transthoracic Approach Spine β€” Fig. 1 Fig. 1. MRI of the thoracic spine: (A) T2-weighted sagittal sequence showing the intraspinal tumor T3-5 with hyperintense signal (arrow); (B) post-contrast T1-weighted sagittal sequences showed… Source: SPINAL DUMBBELL EPIDURAL HEMANGIOMA: TWO STAGE/SAME SITTING/SAME POSITION POSTERIOR MICROSURGICAL AND TRANSTHORACIC ENDOSCOPIC RESECTION – CASE REPORT AND REVIEW OF THE LITERATURE β€” Acta Clinica Croatica 2018; CC BY-NC-ND.

Transthoracic Approach Spine β€” Fig. 2 Fig. 2. Tumor composition of variably-sized vessels and capillaries that permeate adipose tissue: (A) low power; (B) high power. Immunostaining showed that vessels were positive for CD31… Source: SPINAL DUMBBELL EPIDURAL HEMANGIOMA: TWO STAGE/SAME SITTING/SAME POSITION POSTERIOR MICROSURGICAL AND TRANSTHORACIC ENDOSCOPIC RESECTION – CASE REPORT AND REVIEW OF THE LITERATURE β€” Acta Clinica Croatica 2018; CC BY-NC-ND.

Transthoracic Approach Spine β€” Fig. 3 Fig. 3. Postoperative MRI of the thoracic spine: (A) T2-weighted sagittal sequence showing complete resection of the tumor; (B, C) T2-weighted axial sequences; (D) post-contrast T1-weighted… Source: SPINAL DUMBBELL EPIDURAL HEMANGIOMA: TWO STAGE/SAME SITTING/SAME POSITION POSTERIOR MICROSURGICAL AND TRANSTHORACIC ENDOSCOPIC RESECTION – CASE REPORT AND REVIEW OF THE LITERATURE β€” Acta Clinica Croatica 2018; CC BY-NC-ND.

Transthoracic Approach Spine β€” Fig. 5 Fig. 5. The lines represent the 16 patients who attended the final follow-up and the small triangles represent the local kyphotic angles of the fusion levels before surgery (Pre-OP), at 3 months… Source: Circumspinal decompression and fusion through a posterior midline incision to treat central calcified thoracolumbar disc herniation: a minimal 2-year follow-up study with reconstruction CT β€” European Spine Journal 2013; CC BY.

Transthoracic Approach Spine β€” Figure 1 Figure 1. Lateral decubitus position of the patient for a left lateral transthoracic transpleural approach (patient Number 6). Source: Surgical Treatment of Calcified Thoracic Herniated Disc Disease via the Transthoracic Approach with the Use of Intraoperative Computed Tomography (iCT) and Microscope-Based Augmented Reality (AR) β€” Medicina 2024; CC BY.

Transthoracic Approach Spine β€” Figure 2 Figure 2. Use of standard C-arm X-ray for level definition prior to skin incision (same as Figure 1). Source: Surgical Treatment of Calcified Thoracic Herniated Disc Disease via the Transthoracic Approach with the Use of Intraoperative Computed Tomography (iCT) and Microscope-Based Augmented Reality (AR) β€” Medicina 2024; CC BY.

Transthoracic Approach Spine β€” Figure 3 Figure 3. Rigid fusion of levels of interest, with the segmented vertebras in yellow and the herniated disc in blue in the axial, coronal, and sagittal views (patient number 3). Source: Surgical Treatment of Calcified Thoracic Herniated Disc Disease via the Transthoracic Approach with the Use of Intraoperative Computed Tomography (iCT) and Microscope-Based Augmented Reality (AR) β€” Medicina 2024; CC BY.

The transthoracic approach reaches the front of the thoracic vertebral bodies β€” for corpectomy and anterior reconstruction, ventral cord decompression (calcified central disc, retropulsed burst fragment, tumor, infection), and deformity. It is performed as an open thoracotomy, thoracoscopic (VATS), or mini-open lateral retropleural exposure, with single-lung ventilation to deflate the lung and open the corridor. Its power is direct ventral access to the cord without any cord retraction; its demands are pulmonary, vascular (segmental arteries / artery of Adamkiewicz), and thoracic-access expertise.

General Considerations

Indications

Access Selection

Pathology / patient factor Open thoracotomy VATS / thoracoscopic Mini-open retropleural
Large tumor, multilevel corpectomy, major reconstruction Best exposure/control Limited Sometimes inadequate
Calcified central disc Strong direct access Possible in expert hands Useful for selected lateral/ventral targets
Poor pulmonary reserve More morbidity Less incision morbidity but still lung isolation May avoid pleural cavity
Need vascular control Best Limited Limited-moderate
Thoracolumbar junction Thoracoabdominal extension may be needed Less common Retropleural/retroperitoneal blend useful
Revision pleural disease Adhesions make difficult Often difficult Retropleural may help

Choose the exposure that gives safe ventral decompression and reconstruction, not just the smallest incision. A minimally invasive thoracic corridor that cannot control a bleeding segmental vessel or calcified transdural disc is the wrong minimally invasive corridor.

Relevant Surgical Anatomy

Preoperative Evaluation

Side and Vascular Planning

Logistics, OR Setup & Orders

Anesthesia & Neuromonitoring

Positioning

Exposure

  1. Thoracotomy over the appropriate rib (often the rib 1–2 levels above the target; the rib is harvested for graft) β€” or thoracoscopic portals; deflate the lung.
  2. Reflect the parietal pleura over the spine; identify and ligate the segmental vessels at the mid-vertebral-body level of the involved segment(s) β€” preserve the artery of Adamkiewicz per CTA.
  3. Confirm the level (fluoroscopy) before bone work.

Decompression & Reconstruction

Decompression Sequence

  1. Confirm level with fluoroscopy/navigation before rib resection and before vertebral body drilling.
  2. Control segmental vessels at the mid-body only after confirming the vascular plan; preserve critical radiculomedullary supply.
  3. Create a working cavity in disc/body first, then thin ventral compressive pathology into that cavity.
  4. For calcified discs, detach lateral/ventral margins before teasing the fragment away from dura; never lever a hard fragment into the cord.
  5. For tumor/infection, obtain pathology/cultures early and plan margins/debridement with reconstruction and adjuvant therapy in mind.
  6. Size cage/graft under compression and image confirmation; avoid over-distraction of the thoracic cord and segmental vessels.

Intraoperative Rescue

Closure

Bony anatomy (vertebra / pedicle detail)

Operative sequence (mini-thoracotomy example)

Preoperative MRI β€” paracentral T9/T10 disc compressing the cord (ventral target)

Cureus 2025;17:e94142 β€” CC BY 4.0.

Mini-thoracotomy β€” skin incision parallel to the rib (lateral decubitus)

Cureus 2025;17:e94142 β€” CC BY 4.0.

Box-shaped vertebral cavity created for ventral decompression

Cureus 2025;17:e94142 β€” CC BY 4.0.

Nuances & Pitfalls (surgeon-level)

Complications

Cord injury / infarction (Adamkiewicz / segmental sacrifice); pulmonary (pneumothorax, effusion, atelectasis, prolonged air leak); chylothorax; great-vessel/hemorrhage; hardware subsidence/failure; CSF leak (calcified transdural disc); intercostal neuralgia/post-thoracotomy pain; approach-related morbidity.

Figure Use & Attribution

About the figures. Copyrighted operative figures/videos are linked (Neurosurgical Atlas, AO Spine / Surgery Reference); embedded images are public-domain (Gray’s Anatomy), credited beneath each image. See media-sources.md and figures/CREDITS.md.

Technique references: AO Spine / Surgery Reference β€” Anterior thoracic Β· Neurosurgical Atlas β€” Spine Β· Radiopaedia β€” thoracic spine

Chief-Level Corridor Review

Use these as the senior-level mental model for Transthoracic (Anterior Thoracic) Approach to the Spine:

Common Pimp Questions

Use these to pressure-test preparation for Transthoracic (Anterior Thoracic) Approach to the Spine:

  1. What patient position and head rotation make gravity work for this corridor?
  2. What named nerve, vessel, sinus, or muscle/fascial plane is most commonly injured?
  3. What bone work or soft-tissue step creates the exposure rather than simply using more retraction?
  4. What is the bailout if exposure is inadequate, bleeding occurs, or the brain is tight?
  5. What closure maneuver prevents the signature complication of this approach?

Attending Preference Variables

Items that commonly vary by surgeon or institution:

Case Guides Using This Approach

References

  1. AO Foundation. Anterior approach to the thoracic and thoracolumbar spine. AO Spine / Surgery Reference. link
  2. McCormick PC. Retropleural/lateral extracavitary and transthoracic approaches to thoracic disc and tumor.
  3. Kaneda K, et al. Anterior decompression and stabilization for thoracolumbar burst fractures. J Bone Joint Surg Am. 1997.
  4. Mulier S, Debois V. Thoracoscopic anterior approaches to the thoracic spine (VATS technique and outcomes).