Thoracoscopic (VATS) Approach to the Thoracic Spine

What it exposes. The thoracoscopic (VATS) approach gives direct anterior access to the vertebral bodies and discs of the thoracic spine (T2-L1) - the side from which retropulsed bone, tumour, and disc compress the cord. Through three or four small intercostal ports, with the lung collapsed by single-lung ventilation, it reaches the body, the disc, and the segmental vessels for an anterior release, discectomy, corpectomy, sympathectomy, or biopsy. Why thoracoscopic (and not open thoracotomy). The endoscopic technique delivers the same anterior exposure as an open transthoracic approach while avoiding the morbidity of a large thoracotomy - smaller incisions, less chest-wall muscle and rib disruption, reduced postoperative pain and pulmonary compromise, and an earlier return of function. That matters most in the deformity population, where preserving respiratory mechanics is part of the goal. Primary indications: - Anterior release for spinal deformity - multiple discectomies and division of the anterior longitudinal ligament to gain flexibility in rigid scoliosis or kyphosis, usually followed by posterior instrumented fusion (or endoscopic anterior instrumentation)

• Anterior discectomy and interbody fusion - for discitis or selected degenerative thoracic disc disease with cord compression
• Corpectomy - for vertebral body tumour, burst fracture with retropulsed middle-column bone compressing the cord, or osteomyelitis requiring debridement and anterior column reconstruction
• Biopsy - of a vertebral body or paravertebral lesion where an anterior tissue sample is required
• Endoscopic thoracic sympathectomy - ablation of the T2 (and T3) sympathetic ganglia for palmar hyperhidrosis, facial blushing, or refractory regional pain syndromes
• Anterior spinal instrumentation - endoscopic single-rod or dual-rod constructs for adolescent idiopathic scoliosis
• Drainage of a paravertebral or epidural collection - in selected infective cases Contraindications: - Inability to tolerate single-lung ventilation - severe chronic obstructive or restrictive lung disease, very poor pulmonary reserve, or dependency on bilateral ventilation
• Previous thoracotomy or pleural disease with dense adhesions - precludes lung collapse and safe visualization (relative; may convert to open)
• Active pleural infection or empyema on the approach side
• Severe coagulopathy that cannot be corrected
• Haemodynamic instability or inability to tolerate the lateral decubitus position
• Extreme obesity - limited port access and ventilatory difficulty (relative)
• Pathology exceeding the capability of the technique - very vascular tumours, extensive multi-level corpectomy with complex anterior reconstruction, or anterior pathology at levels poorly reached endoscopically Alternative approaches: - Open transthoracic (thoracotomy) approach - the direct comparison; greater exposure and tactile feedback but more chest-wall morbidity
• Anterior thoracoabdominal approach - for the thoracolumbar junction (T10-L2) requiring diaphragm takedown
• Posterior or posterolateral (costotransversectomy / transpedicular) approach - for posterior or lateral disc and localised body access without entering the chest
• Lateral transpsoas (XLIF / OLIF-type) approaches - for the thoracolumbar and lumbar spine via the retroperitoneum

The exposure is the heart of this case: work from the lateral decubitus position through small intercostal ports, collapse the lung, count the ribs to the target level, then drop subpleurally onto the vertebral body - ligating the segmental vessels at the mid-body to open a window onto the disc and body. Position: lateral decubitus on a radiolucent table. The patient lies lateral decubitus with the approach side uppermost. An axillary roll protects the dependent brachial plexus; the dependent arm lies on an armboard and the upper arm is supported on a padded rest; a bean bag or hip bolsters and a kidney rest stabilise the trunk, and the table may be flexed at the waist to open the intercostal spaces and drop the upper hip clear of the C-arm. Pad the dependent fibular head (common peroneal nerve), ankles, and elbows. Side of approach is dictated by pathology and vascular anatomy, not a fixed rule. For idiopathic scoliosis the approach is made from the convexity of the curve - the right side for a typical right thoracic curve. For mid- and lower-thoracic pathology a right-sided approach is often preferred because the aorta lies to the left and the thin-walled inferior vena cava and liver on the right are easier to manage than a left-sided aortic and venous combination; for upper thoracic (T1-T4) lesions a left-sided approach may be chosen to avoid the venous anatomy of the right superior thorax. The dominant-side lung is generally kept dependent (ventilated) where possible, and the side is individualised at the planning stage. Surface landmarks. The spine of the scapula projects to roughly T3, and the inferior angle of the scapula to roughly T7-T8; the iliac crest marks L4 and the lower limit of the thoracolumbar exposure; the posterior, mid, and anterior axillary lines define the corridors along which portals are sited. Intrathoracic (endoscopic) landmarks. The second rib is the most prominent (broadest) intrathoracic rib and the starting point for counting (the first rib is generally not visible thoracoscopically). The rib heads are the single most important landmark on the spine itself - each articulates with the demifacets of its own vertebra and the vertebra immediately above, so the disc between, for example, T7 and T8 is reached at the level of the head of the eighth rib (the eleventh and twelfth ribs articulate only with their own vertebrae). The segmental (intercostal) vessels cross the waist of the vertebral body in a predictable horizontal course, and the sympathetic chain runs longitudinally over the rib heads just lateral to the vertebral bodies. Portal planning. Typically three to four ports are used - one camera (telescope) port and two or three working ports - triangulated toward the spine. Ports are sited in the axillary lines, straddling the target level so the instruments converge without crowding, and each is made over the superior border of the rib to avoid the intercostal neurovascular bundle that runs in the costal groove along the inferior rib border.

Structures at risk, by layer. The exposure crosses the chest wall, the pleural cavity, and the surface of the vertebral body before reaching the disc and canal. Each layer carries a distinct danger, and protection is a layer-by-layer discipline.

Extensile modifications. The upper thoracic spine (T1-T4) is the most demanding thoracoscopic territory because the scapula overlies the ribs and the subclavian vessels and brachial plexus are close; access may require partial detachment of the scapular musculature to drop the scapula forward, and many surgeons prefer an open approach for this region. Below the diaphragm the spine is retroperitoneal: reaching the thoracolumbar junction (T12-L1 and below) requires partial detachment of the diaphragm from its chest-wall attachment, leaving a peripheral cuff for repair, and development of the retroperitoneal plane - the transition toward an open thoracoabdominal approach, usually preferred for L1-L2 and below. Conversion to open thoracotomy is a planned contingency, not a failure. Convert for major vascular injury with haemorrhage that cannot be controlled endoscopically, loss of visualization from bleeding or inadequate lung deflation, dense pleural adhesions that cannot be safely separated, or pathology requiring reconstruction that exceeds endoscopic capability. A thoracotomy tray and vascular instruments must be immediately available, and the team should convert promptly rather than persist with a struggling endoscopic field. Combined approaches. For complex deformity or circumferential cord compression, an anterior thoracoscopic release or corpectomy is frequently combined with a posterior instrumented fusion - either in the same anaesthetic (turning prone after the anterior work) or as a staged procedure.

Post-operative care. A chest radiograph confirms lung re-expansion, drain position, and absence of pneumothorax; monitor chest-tube output and underwater-seal swinging; provide adequate analgesia (thoracic epidural or multimodal regimen) to prevent splinting and atelectasis; and monitor cord function neurologically. The drain stays on underwater seal until the lung is fully expanded and the output settles (no ongoing air leak, output below the unit threshold, lung expanded on a clamp trial or radiograph). Mobilise early with chest physiotherapy and incentive spirometry, and discharge once the drain is out, pain is controlled, and the patient is mobilising, with outpatient imaging to confirm fusion and alignment.

• Anterior release - multi-level discectomy and division of the anterior longitudinal ligament to render a rigid deformity flexible, usually followed by posterior fusion.
• Discectomy and interbody fusion - for thoracic disc disease with myelopathy or discitis.
• Corpectomy - for tumour, burst fracture, or osteomyelitis, with anterior column reconstruction (strut graft, cage, or bone graft plus a lateral plate or rod).
• Vertebral biopsy - of a body or paravertebral lesion.
• Thoracic sympathectomy - identification of the T2 (and T3) ganglion over the rib heads and ablation or resection for palmar hyperhidrosis.
• Anterior endoscopic instrumentation - single-rod or dual-rod scoliosis constructs.

The thoracoscopic approach to the thoracic spine is a well-established minimally invasive anterior technique recognised across worldwide curricula (advanced orthopaedic practice, and SICOT all teach the principles of single-lung ventilation, rib-head level localisation, segmental-vessel control, and protection of the artery of Adamkiewicz). Practice converges on patient selection that respects the ability to tolerate single-lung ventilation and on the readiness to convert to open thoracotomy for vascular injury or loss of visualization.

Global practice variation. In well-resourced centres, dedicated thoracoscopic spinal instrumentation, intraoperative neuromonitoring, and anaesthetic single-lung ventilation teams are routine. In resource-limited settings, the same anterior decompression is more often achieved through an open thoracotomy, reserving the endoscopic technique for units with the equipment and the anaesthetic expertise to deliver and maintain one-lung ventilation safely.