Transthoracic (Thoracotomy) Approach to the Thoracic Spine

What it exposes. The transthoracic (thoracotomy) approach gives direct anterior exposure of the thoracic vertebral bodies and discs from approximately T4 to T12 through a left (preferred) or right thoracotomy, after rib resection and transpleural entry. No other approach offers the same degree of anterior column access without traversing the spinal canal. Why this approach is chosen. It allows a complete corpectomy, decompression of the spinal canal from the front, and reconstruction with strut grafts, cages or vascularised fibula. It is therefore the workhorse exposure for anterior pathology where posterior approaches are inadequate or high-risk. Indications - Anterior corpectomy and reconstruction for tumour (primary or metastatic)

• Vertebral osteomyelitis with abscess or instability requiring debridement
• Thoracic disc herniation with myelopathy when anterior decompression is needed
• Post-traumatic kyphosis or burst fracture with anterior column deficiency
• Deformity correction requiring anterior release or osteotomy
• Failed posterior surgery with persistent anterior pathology Contraindications - Severe pulmonary disease precluding single-lung ventilation
• Previous thoracotomy with dense adhesions (relative)
• Active pleural infection or empyema
• Inability to tolerate the lateral decubitus position
• High thoracic levels (T1-T3) better accessed via manubrium or sternotomy Alternative approaches - Posterior transpedicular or costotransversectomy for selected tumours
• Lateral extracavitary approach for the thoracolumbar junction
• Endoscopic (VATS) transthoracic approach for selected disc herniations
• Combined anterior-posterior staged procedures for complex tumours

Position & landmarks. The patient is placed in the left lateral decubitus position on a radiolucent table. Confirm the double-lumen endotracheal tube with fibreoptic bronchoscopy, establish an arterial line and central venous access, and place a Foley catheter. Support position with a beanbag, place an axillary roll under the dependent axilla to protect the brachial plexus, pad every pressure point, and abduct the upper arm less than 90 degrees. Flexing the table at the thoracolumbar junction (with a kidney rest if needed) opens the intercostal spaces. C-arm or O-arm access is verified from both anterior and lateral; neuromonitoring leads (MEP/SSEP) are placed if used. Surface anatomy and incision planning - Spinous processes - counted from C7 (vertebra prominens) downward

• Scapula - the inferior angle lies approximately at T7
• Iliac crest - approximately the L4-L5 level, for reference
• Latissimus dorsi forms the posterior border of the incision, serratus anterior the anterior border, and the paravertebral muscles the medial limit The incision is centred over the rib to be resected - typically two levels cephalad to the target vertebra (for the T7 body, the eighth or ninth rib is commonly resected). It runs from the paravertebral line anteriorly in a gentle curve or hockey-stick shape, 15-20 cm long. Fluoroscopic confirmation of the rib level is mandatory before the skin incision. At thoracotomy the surgeon counts ribs directly: the first rib is identified by its articulation with the manubrium and its lack of a costal groove, while the second rib is the first to carry a costal groove.

Work down through the chest wall, protecting the intercostal neurovascular bundle during rib resection, enter the pleura and deflate the lung, then ligate segmental vessels at the mid-body to mobilise the aorta and expose the vertebral column.

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Chest-wall anatomy on the way in

Structures at risk, layer by layer

Adamkiewicz injury management - If suspected intraoperatively: maintain blood pressure, consider steroids per protocol, and obtain an urgent MRI.

• Postoperative paraplegia: immediate MRI, maintain mean arterial pressure greater than 85 mmHg, and consider a CSF drain.
• Prevention is paramount - preoperative angiography in elective tumour cases, careful ligation technique, and avoidance of hypotension. Extensile modifications - Proximal (cervicothoracic junction, T1-T3): the standard thoracotomy is limited by the scapula and first rib. Options are an extended incision with scapular mobilisation (Paulsen approach), a manubrial split or sternotomy with clavicle osteotomy, or a combined cervical and thoracic exposure.
• Distal (thoracolumbar junction, T11-L2): the diaphragm must be managed - a radial incision with peripheral detachment, circumferential detachment from the chest wall, or conversion to a formal thoracoabdominal approach, mobilising the psoas anteriorly to reach the lumbar bodies.
• Combined anterior-posterior: staged or same-day anterior decompression then posterior stabilisation is common for tumours and fractures; some centres do both in the lateral position through a separate posterior incision.
• Minimally invasive: VATS or mini-thoracotomy with tubular retractors for selected discs and biopsies reduces pulmonary morbidity but limits the extent of reconstruction. Complications

Closure and post-operative care - Chest tube: keep on underwater seal, monitor output and air leak, and obtain daily chest radiographs. Remove when output is less than 100 mL per day and the lung is fully expanded.

• Pain control: multimodal - PCA, intercostal blocks, NSAIDs and paracetamol; avoid excessive opioids that suppress respiration.
• Pulmonary toilet: incentive spirometry every hour while awake, early mobilisation to chair, chest physiotherapy.
• Neurological monitoring: hourly neurovascular checks for the first 24 hours (lower limb power, sensation, reflexes).
• DVT prophylaxis: mechanical (intermittent pneumatic compression) plus pharmacological (LMWH) once haemostasis is secure.
• Mobilisation: to chair on day 1 if stable; ambulate once the chest tube is out and pain is controlled; brace with a TLSO if the posterior elements are deficient or instrumentation is marginal; no heavy lifting or bending for 6-12 weeks.
• Follow-up: 2 weeks (wound, CXR, neurology), 6 weeks (radiographs, activity), 3 months (reconstruction stability), 6 months (function), 1 year (final review).

• Spine tumour decompression and stabilisation - the principal indication for this exposure.
• Anterior corpectomy with cage or strut-graft reconstruction for tumour, infection or fracture.
• Anterior decompression of a thoracic disc herniation with myelopathy.
• Debridement and reconstruction for vertebral osteomyelitis.
• En bloc or piecemeal resection of primary or metastatic vertebral tumours.
• Anterior release and fusion for scoliosis or kyphosis.
• Anterior instrumentation with plate or rod constructs. Reconstruction options: titanium or PEEK cage with autograft or allograft; vascularised fibular strut graft for large defects; anterior plate fixation (less common in the thoracic spine); or combined anterior and posterior instrumentation for instability.

The transthoracic approach is used worldwide for anterior thoracic spine pathology. Principles are consistent across advanced orthopaedic practice and other examination systems: careful patient selection, preoperative imaging to identify the artery of Adamkiewicz when possible, meticulous segmental vessel ligation at the mid-body, and mandatory chest tube drainage.

Registry evidence - The AO Spine Tumour Registry and similar databases show that anterior reconstruction improves local control and neurological outcomes in selected thoracic metastases.

• Pulmonary complication rates of 10-20 percent are consistently reported; aggressive perioperative pulmonary care is the key modifiable factor. Global practice variation In high-resource settings, navigation, intraoperative angiography and advanced reconstruction implants are routine. In resource-limited settings the same principles apply using standard rib resection, silk ties for vessels, and autograft from the resected rib. Chest tube management remains mandatory everywhere. Consent (globally applicable) Discuss paraplegia risk from Adamkiewicz injury (1-3 percent in experienced hands), chylothorax (1-3 percent), pulmonary complications (10-20 percent), wound infection (2-5 percent), post-thoracotomy pain, and the need for chest tube drainage for several days postoperatively.