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
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