Anterior Approaches to Thoracic
and Thoraco-Lumbar Spine
Department of Thoracic Surgery, Cumhuriyet University,
School of Medicine Sivas-
Anterior surgical approaches have been used for lower cervical, thoracic, and upper lumbar
vertebrae since the beginning of the second half of the 20th century. Hodgson et al. were the
first surgeons to perform spinal fusion with anterior approach for the treatment of a
paraplegic patient with Pott’s disease in 1956. Cauchoix and Binet reported access to
vertebral corpuses from C7 to T4 using a median sternotomy in 1957. Moreover, in 1969,
Perot and Munro described trans-thoracic removal of a thoracic disc causing compression
on the spinal cord. Similarly Dwyer et al. described the use of anterior approach for the
surgical treatment of scoliosis (1969) and Harrington anteriorly stabilized vertebral fractures
due to tumors with methyl methacrylate. First investigators to describe anterior approach
with VATS were Mack et al. (1993) (1-4).
Surgical interventions for vertebral fractures include anterior, posterior and combined
approaches, with the anterior approach providing a very good exposure. Posterior approach
poses some technical inadequacy, with recurrence rates higher than the anterior approach.
In fractures causing angle deformity, anterior approach has been proposed as the
appropriate method. In fragmented fractures of the thoracolumbar spine, corpectomy with
anterior approach and grafting is an effective treatment modality (2,5-8). Anterior approach
not only provides a very good exposure to allow for decompression of the spinal canal, but
also it may help to improve the neurological status in patients with neurological deficits.
However, morbidity, which is mostly respiratory (atelectasis, respiratory failure, etc.), is
more frequent with anterior approach (2).
Anterior approach was first reported by Dwyer and Zielke for scoliosis surgery, with a
correction angle between 28,3º-66,6º. The average percentage of patients in whom correction
can be achieved is 57.5%. Bilateral approach can be used or posterior approach can be
combined with unilateral approach (1,3,9,10). In patients undergoing posterior surgery
alone, the likelihood of requiring a second operation is high (11). In cases with scoliosis, the
procedure should be performed at the side with widened intercostal spaces and convex
deformity. When the thoracotomy is performed at the point of maximum deformity, better
exposure is provided.
The primary indications for anterior approach in vertebral surgery include the conditions
associated with the destruction of one or more vertebral corpuses and intervertebral discs,
vertebral fractures, and deformities (Table 1). Whilst patients with deformities constitute the
main patient population in childhood and adolescence, degenerative diseases, malignancies,
and infections are the prevailing indications among adults. Recently, traumatic fractures
with or without neurologic deficits also represent another very important indication for the
anterior approach in spinal surgery. Pain relief, stabilization of the deformity, cosmetic
improvement, drainage of spinal infections, and reduction/prevention of neurological
deficits are primary objectives of such procedures (1,2,12,13).
Involvement by adjacent tumors
Primary tumor of vertebral body
Degeneratif disc disease (herniation)
Table 1. Indications for anterior approach in spine surgery.
A multidisciplinary team effort involving thoracic surgeons, neurosurgeons, and orthopedic
surgeons increases the likelihood of successful outcome with regard to operative results and
improves the quality of life postoperatively. Inclusion of a thoracic surgeon in the team
facilitates preoperative physiological assessments, determination of the best access route,
and postoperative wound care (1,2).
1.2 Preoperative assessments
The preoperative assessment algorithm is the same as that is used for thoracic surgery.
Pulmonary function tests and blood gas analyses are useful both for preoperative and
postoperative care and evaluation of the cardiac status may help prevent postoperative
Endotracheal general anesthesia with a single-lumen endotracheal tube is adequate for
cervical (C7-T2) interventions, while endotracheal tubes with double-lumen should be
preferred for thoracic and thoracolumbar procedures. Standard endotracheal tubes with a
Anterior Approaches to Thoracic and Thoraco-Lumbar Spine
single-lumen may also be used. In our unit, tubes with a single-lumen are preferred.
Retraction of the lung on the same surgical side without collapsing throughout the
procedure will provide adequate exposure. This approach allows efficient use of time, and
avoids some untoward occurrences such as malpositioning due to a double-lumen tube,
inadequate aspiration, and intolerance to single-lung ventilation.
Appropriate positioning of the patient simplifies the surgery, shortens duration of surgery,
and reduces the likelihood of morbidity. In cervical procedures the patient is brought to
supine position, arms are adducted, and the head is slightly rotated toward the opposite
side of the surgery. In case of open surgery between T2-12 or VATS, a standard lateral
decubitus position is preferred. In our unit, we also prefer to use lateral decubitus position
for anterior surgery in lower thoracic and upper lumber vertebrae during thoracoabdominal
procedures. In this case, a backward angulation between 10º-15º toward the operation table
provides better exposure.
Depending on the position of the lesion, four different anatomical levels may be defined as
follows: C7-T2, T2-T6, T6-T12, T12-L3 or L4. For lesions between C7 and T2, the best
approach consists of manubrium resection or partial sternotomy in addition to cervical
resection, while right thoracotomy is appropriate for T2-T6 lesions. We prefer left
thoracotomy starting from T3 level for traumatic vertebral fractures. Due to the close
adjacency of the descending aorta, aortic mobilization may be required in anterior
approaches at T3 and T4. In the upper thoracic levels between T2 and T6, thoracotomy
should be performed at the same level with the lesion. Between T6-T12, procedures are
performed via a left thoracotomy. At this level, thoracotomy at one or two level above the
lesion may provide better exposure due to downward inclination of the ribs. For lesions
between T12-L3, 4 a left thoracoabdominal approach should be undertaken. Removal of the
11th or 12th rib provides wider exposure. Particularly, removal of the 11th or 12th rib provides
easy extrapleural access to L1-L4 (2,14,15).
Over a 7-year period (2004-2011), 67 patients (17 females, 50 males) were operated on using
an anterior approach at our institution (2). The most indication for surgery was trauma
fracture in 50 (75%) patients. Distribution of ethiologies of the patients according to access
level was detailed in Table 2. Mean operation time was about 2 to 3,5 hrs, and estimated
blood loss was approximately 1000 mL. Among the 67 patients operated via the anterior
approach, we observed four postoperative complications. One patient had empyema
postoperatively which was treated with tube thoracotostomy and irrigation. Another patient
with vertebral tumor developed hemorrhagic drainage (1100 cc/24 h) during the early
postoperative period which resolved with conservative treatment. In two patients, wound
infection developed which were treated with debridement and suturation.
Remainder of this chapter, the procedures will be described detailed with operative pictures
and drawings especially the “thoraco-lumbar” procedure.
1.3 Anterior approach to the cervicothoracic spine
Anterior approach at cervicothoracic vertebrae poses some difficulties associated with the
local anatomy and requires a good deal of anatomical knowledge of the bony, ligamentous,
muscular, and neurovascular structures of the upper thoracic access routes. Cervical
resection, partial resection of the manubrium and clavicle and advances in the surgical
instrumentation provide adequate exposure.
Table 2. Distribution of ethiologies of the patients according to access levels.
A neck incision parallel to the sternocleidomastoid and extending up to the suprasternal
notch is made in addition to partial sternotomy reaching T4 level (Figure 1a-b).
Fig. 1. Oblique neck and upper sternotomi incision is showing in figure 1a, and surgical
exposure of C2 to T2 after the retraction of the vascular structures (Figure 1b). If clavicle is
disarticulated form the manubrium, exposure can now be carried out to the T3.
A subplatysmal flap is prepared and strep muscles are pulled upwards to expose the
sternoclavicular joint. Sternomastoid muscle is pulled laterally together with the jugular
vein, and strap muscles are pulled toward medial side. Thus, the carotid sheath is
positioned laterally, while the trachea and esophagus are positioned medially. Recurrent
laryngeal nerve injury is avoided at the tracheoesophageal canal. Trachea and esophagus are
pulled medially and the prevertebral fascia is exposed. Walsh et al recommend left sided
neck incision due to decreased likelihood of injury to the contralateral laryngeal nerve,
provided that there are no contraindications. Moreover, this approach provides better
exposure from C4 to T3 (1,14,15).
Sternotomy may not be necessary to access T1 vertebra. In that case, partial excision of the
manubrium and/or clavicle may provide adequate exposure. The sternocleidomastoid
Anterior Approaches to Thoracic and Thoraco-Lumbar Spine
muscle is cut with cautery, strap muscles are divided and pulled upward, the sternal part of
the pectoralis major is stripped toward lateral side, clavicle is stripped subperiosteally, and
disarticulated from sternum. In this way, vascular structures are pulled more laterally. If
required, inferior thyroid vein is ligated and manubrium is partially removed. A Hemovac
drainage tube is placed into the operation area and the layers are closed in accordance with
normal anatomic alignment.
1.4 Anterior Approach to the Thoracic Spine
The access route is determined by the spinal level and length of the procedure. In
deformities such as scoliosis, a thoracotomy is performed at the side with the wider
intercostal space where the deformity reaches its apex, which is defined as the most
prominent site of deformity. When required, the rib at the level of the incision can be
removed. Removal of the third rib provides a good exposure in T1-T4 lesions (1,2,6).
Presence of the liver on the right side may result in technical problems; for this reason, we
prefer left thoracotomy both for thoracic and lumbar procedures unless a contraindication
exists. In situations such as the presence of a tumor or hydatid cyst, a left or right
thoracotomy may be preferred depending on the location of the lesion (13,16-18).
After intubation in supine position, a lateral decubitus position with the left side on top is
used. A skin incision from the appropriate intercostal space and extending up to paraspinal
muscles is made and thoracotomy is commenced. Care should be experienced to provide
congruity between the incision and the costal margin. The anterior edge of the latissimus
dorsi is determined and cut by cauterization in the posterior direction. Serratus anterior is
cut toward anterior direction starting from its posterior side along the ribs. The first rib is
palpated under the scapula, ribs are counted, and intercostals muscles are cut at the
preferred level and thoracic cavity is accessed. We do not perform rib resection in middle
and lower thoracic procedures, since adequate exposure is achieved. If pleural adhesions are
present, they are released by blunt or sharp dissection. In case of intubation with a single-
lumen tube, a compression is placed upon the lung to provide mild compression. The
parietal pleura is opened in cephalad and caudad directions. The perforating arteries from
the aorta, if required, intercostal artery and vein are ligated and the vertebrae are accessed
(Figure 2). Following the procedure, bleeding control is achieved and a 32F or 36F chest tube
is placed in the pleural cavity before the layers are closed according to normal anatomical
alignment. After a daily drainage volume of 50 to 100 ml and expansion of the lungs, the
chest tube is usually withdrawn within 48-72 hours.
1.5 Anterior Approach to the Thoracolumbar Spine
Anatomy of the diaphragm is important for thoracolumbar approaches. The apex of the
dome of diaphragm may reach T7 level. It is attached to the xiphoid bone anteriorly; to the
ribs and costal cartilages laterally (ribs 6 to 12); and to the corpuses and transverse processes
of L1, L2, and L3 vertebrae with the lumbosacral arch via the crura posteriorly. The right
and left diaphragmatic crura reach the upper lumbar vertebrae by forming the aortic hiatus.
Since the diaphragm is innervated centrally, the incisions on the diaphragm should be
peripheral and circular.
The Adamkiewicz artery is the principal arterial supply to the spinal cord in the lumbar area
and its injury leads to paraplegia. It arises from the intercostal artery from the left and right