Surgical Approaches to the Cervical and Thoracolumbar Spine

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Indications

• Ventral cervical disc herniation or osteophyte causing radiculopathy or myelopathy.
• Cervical corpectomy for retrovertebral compression.
• Anterior column reconstruction after trauma, infection, tumour or deformity.
• Focal kyphotic pathology where posterior decompression alone will not move the cord away from ventral compression.

Technique

1. Position supine with the head supported and the neck neutral or gently extended.
2. Mark the skin crease incision level using imaging, then confirm level with fluoroscopy.
3. Incise skin and platysma; develop subplatysmal flaps as required.
4. Identify the plane between the medial visceral structures and lateral carotid sheath.
5. Retract trachea and oesophagus medially and carotid sheath laterally with gentle, time-aware retraction.
6. Identify longus colli; elevate it subperiosteally from the vertebral bodies to seat retractors.
7. Confirm the disc or vertebral level before discectomy, corpectomy or implant work.
8. Keep decompression midline until the uncinate/foraminal target is deliberately approached.
9. Protect endplates during preparation and avoid excessive lateral work near the vertebral artery.
10. Close in layers after haemostasis, implant confirmation and assessment for oesophageal or airway concern.

Decision points

• Side choice depends on previous surgery, pathology side, surgeon familiarity and nerve risk. The recurrent laryngeal nerve course must be understood, especially in revision surgery.
• Multilevel anterior work increases dysphagia, pseudarthrosis and implant risks; posterior or combined strategies may be better for some patients.
• Revision anterior cervical surgery has higher scar and recurrent laryngeal nerve risk; preoperative laryngoscopy is useful when prior anterior neck surgery or voice symptoms exist.

Indications

• Multilevel cervical stenosis with preserved lordosis.
• Posterior compression, posterior element pathology or posterior instability.
• Laminoplasty, laminectomy and fusion, deformity correction, trauma and tumour fixation.
• Upper cervical fixation when C1-C2 or occipitocervical instability requires posterior stabilisation.

Technique

1. Position prone with Mayfield fixation when needed; protect eyes and pressure points.
2. Confirm alignment and ensure neuromonitoring baseline when indicated.
3. Make a midline incision and elevate subperiosteally to the required lateral target.
4. Preserve posterior tension band and adjacent facet capsules unless fusion includes that level.
5. For decompression, remove lamina or create laminoplasty according to the plan while protecting dura and cord.
6. For fixation, choose lateral mass, pedicle, pars, C1 lateral mass, C2 pedicle/pars or occipitocervical fixation based on CT anatomy.
7. Confirm trajectory with imaging or navigation when anatomy is high-risk.
8. Prepare fusion bed, decorticate planned surfaces and place graft.
9. Close over meticulous haemostasis and consider drain use where appropriate.

Decision points

• Lateral mass screws are familiar and have a broad safety record, but may offer less purchase than pedicle screws.
• Cervical pedicle screws can be powerful but demand CT-based planning, trajectory control and awareness of vertebral artery and nerve root risk.
• C5 palsy, axial neck pain, wound complications and junctional failure must be part of counselling.

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Indications

• Thoracolumbar trauma requiring stabilisation, decompression or reduction.
• Degenerative stenosis, spondylolisthesis and posterior fusion.
• Posterior deformity correction.
• Posterior tumour decompression and stabilisation.

Technique

1. Position prone on a radiolucent table with the abdomen free.
2. Confirm the level before incision using imaging and anatomical landmarks.
3. Make a midline incision and expose spinous processes, laminae, facets and transverse processes only as far as required.
4. Preserve facet capsules above and below the planned fusion when possible.
5. Identify pedicle starting points and insert screws with fluoroscopy, navigation or freehand technique according to setting and anatomy.
6. Decompress by laminectomy, laminotomy, facetectomy or transpedicular route as indicated.
7. Reduce deformity or fracture using rods, ligamentotaxis, direct decompression or osteotomy when required.
8. Decorticate and graft planned fusion surfaces.
9. Close with attention to dead space, muscle coverage and wound risk.

Decision points

• Posterior-only surgery is common for many trauma patterns, but marked vertebral body loss, progressive kyphosis or anterior column deficiency may need anterior/lateral support.
• A transpedicular route can access selected ventral canal fragments, but it should not be used as a substitute for appropriate anterior column reconstruction when the body is structurally deficient.
• Short-segment fixation preserves motion but is more demanding when anterior support is weak.

Indications

• Thoracic or thoracolumbar vertebral body tumour.
• Infection requiring anterior debridement and reconstruction.
• Burst fracture with major anterior column failure.
• Disc herniation or deformity where anterior access is required.

Technique

1. Define the vertebral level, lesion length and relation to pleura, diaphragm, segmental vessels and great vessels.
2. Position lateral decubitus or thoracoabdominal according to the level.
3. Plan rib level, thoracotomy, retropleural, retroperitoneal or thoracoabdominal access.
4. Mobilise pleura, lung and diaphragm according to the exposure.
5. Control segmental vessels deliberately; avoid blind division.
6. Expose vertebral body and discs above and below the target.
7. Perform corpectomy, debridement or reconstruction with cord and dural protection.
8. Reconstruct anterior column and add posterior fixation when stability demands it.
9. Close pleura/diaphragm and manage chest drainage when required.

Decision points

• The approach is level-specific: upper thoracic, mid-thoracic, thoracolumbar junction and lumbar body access are not the same operation.
• Pulmonary reserve, infection, tumour vascularity, prior thoracotomy and need for circumferential stability influence the plan.
• An access surgeon may be appropriate when thoracic, vascular or complex retroperitoneal exposure risk is substantial.

Indications

• L5-S1 disc collapse requiring lordosis and disc height restoration.
• Isthmic spondylolisthesis where anterior column support is useful.
• Revision posterior surgery where anterior access avoids scarred neural tissues.
• Degenerative disc disease or deformity in carefully selected patients.

Technique

1. Position supine and review vascular imaging or cross-sectional anatomy.
2. Use a paramedian or transverse abdominal incision according to level and access plan.
3. Enter the retroperitoneal plane and mobilise peritoneal contents away from the spine.
4. Identify and protect ureter and sympathetic plexus.
5. Mobilise iliac vessels or great vessels according to the level, with vascular control available.
6. Expose the disc space, confirm level and perform annulotomy.
7. Prepare disc space while preserving endplates.
8. Insert cage with graft, restore height and lordosis, and apply fixation or supplemental posterior instrumentation as planned.
9. Close after haemostasis, vascular reassessment and abdominal closure.

Decision points

• L5-S1 is often favourable because the iliac vessels diverge, but anatomy varies.
• L4-L5 and higher ALIF levels require more vascular mobilisation and have a different risk profile.
• Retrograde ejaculation risk relates to sympathetic plexus injury and is important in counselling.

Indications

• Degenerative scoliosis and coronal plane correction.
• Disc height restoration with indirect decompression.
• Multilevel anterior column reconstruction with less posterior muscle dissection.
• Selected adjacent segment disease or revision scenarios.

Technique: LLIF

1. Position lateral decubitus with true AP and lateral imaging.
2. Mark the disc space and safe lateral corridor.
3. Use a lateral incision and split abdominal wall muscles.
4. Enter retroperitoneal space and sweep peritoneum anteriorly.
5. Traverse psoas with neuromonitoring and sequential dilation.
6. Dock on the disc space, confirm level and prepare the disc.
7. Insert a wide cage spanning apophyseal ring support.
8. Add posterior fixation or direct decompression when indicated.

Technique: OLIF

1. Position lateral decubitus and review the oblique corridor between great vessels and psoas.
2. Enter retroperitoneal space and mobilise peritoneal contents.
3. Work anterior to psoas rather than through the psoas.
4. Protect ureter, sympathetic chain and vascular structures.
5. Prepare disc space and insert cage through the oblique corridor.
6. Confirm indirect decompression goals and add posterior work if needed.

Decision points

• LLIF avoids great-vessel mobilisation but carries psoas and lumbar plexus risk.
• OLIF avoids the transpsoas corridor but requires careful vascular and ureteric planning.
• L5-S1 is not a standard LLIF level because the iliac crest and vascular anatomy limit access; OLIF51/ALIF-style strategies may be considered by experienced teams.