The direct anterior approach to the thoracolumbar junction: an anatomical feasibility study

The thoracolumbar junction (TJ) is traditionally exposed by lateral or posterior approaches. This usually requires splitting of the diaphragm, or extensile removal of the posterior elements. A circumferential exposure (i.e. simultaneous anterior and bilateral exposure) of the vertebral body is not possible. Direct anterior access would allow circumferential exposure of the vertebral body, with adjacent disc levels, and would avoid splitting the diaphragm or extensive removal of the posterior bony structures.

Twelve Thiel cadavers (8 f/4 m) were dissected to access T12 or L1 via a midline laparotomy. Supra- and infragastric laparatomy techniques were investigated. Six cadavers were used to reach T12 through the lesser omentum, six to reach L1 through the greater omentum.

T12 after bluntly dissecting the lesser omentum, the lesser gastric curvature and the caudate lobe of the liver were utilised as landmarks. A small retroperitoneal incision was performed to mobilise the aorta allowing exposure of the T12 vertebra and its adjacent discs. Discectomy, corpectomy and insertion of an anterior column support were possible. The L1 level can be reached through the greater omentum by mobilising the pancreas as a single retroperitoneal structure, leaving the aorta and celiac trunk as landmarks. Retraction of the great vessels is necessary to expose L1 with its adjacent discs. Implantation of an anterior column support was possible utilising this approach.

Direct anterior access to the TJ is feasible in a reproducible manner. This approach would avoid splitting the diaphragm, or dissection of the erector spinae muscles, and is likely to be less invasive than standard lateral or posterior approaches. This technique may offer a significant time reduction to surgery, especially in exposing the spine. Anterior column support can easily be performed, offering a better avoidance of kyphotic deformities.