Transthoracic approach to Thoracic Spine -

Decompression of neural elements when anterior neural compression has been documented.

traumatic
- decompression for documented neurocompression 2º to bone or disc fragments anterior to dura
infectious
- open biopsy for diagnosis, debridement & anterior strut grafting
degenerative
- removal of disc herniation with interbody fusions
neoplastic
- extradural metastatic disease
- 1º vertebral body tumour
deformity
- kyphosis/scoliosis
- (congen/acquired/idiopathic)

provides direct access to vertebral bodies T2 to T12
Midthoracic vertebral bodies are best exposed by this approach
Campbells
- L-sided thoracotomy preferred, heart may be retracted anteriorly
- R-sided thoracotomy used by some for approaching upper Tx spine to avoid subclavian & carotid arteries in L superior mediastinum, liver may present significant obstacle to exposure inferiorly
Hoppenfeld
- right side easier

Make incision 2 levels above
Eg. For L5 cut at L3
divide lateral dorsi & serratus arterior
Expose rib subperiosteally
(if multiple levels are involved, rib at upper level of proposed dissection should be removed) – inferior angle scapula is landmark

Use electrocautery to maintain hemostasis during exposure
Resect posterior 3/4 of rib
Take care to identify & preserve intercostal nerve lying along inferior aspect of rib as it localizes neural foramen leading into spinal canal
Insert rib spreader
Ask gas man to deflate lung
Divide pleura exposing lung
Retract lung anteriorly using lap pads
Identify oesophagus if on R side by palpating NG tube
Incise pleural over lateral side of oesopahagus so can retract oesophagus & reflect pleura exposing anterior spine, usually one vertebra above & one below involved segment, to allow adequate exposure for debridement & grafting
Identify & ligate segmental vessels & azygous vein crossing surgical field
Exposure from L is more difficult as need to retract aorta & ligate both R & L segmental arteries for full exposure
Carefully reflect periosteum overlying spine with elevators to expose involved vertebrae
Use small elevator to clearly delineate pedicle of vertebrae & Kerrison rongeur to remove pedicle, thus exposing dural sac. Identify disc spaces above & below vertebrae & incise anulus. Remove disc material using rongeurs & curettes. entire cross section of vertebral body is thus developed, & anterior margin of neural canal is identified with posterior longitudinal ligament lying in slight concavity on back of vertebral body. Expose sufficient segmental vessels & disc spaces to accomplish intended procedure—usually corpectomy & strut grafting