Thoracic approaches to anterior spinal operations: anterior thoracic approaches

We performed a retrospective review of 36 patients aged 23 to 71 years (mean age, 52 years) who underwent 46 operations through a thoracic or thoracolumbar approach for orthopedic or neurosurgical procedures at Emory University Affiliated Hospitals. Pathologic indications for operation were metastatic disc disease in 10, herniated nucleus pulposus in 11, osteomyelitis in 6, vertebral fracture in 2, spinal deformities in 4, spinal abscess in 1, Pott's disease in 1, and liposarcoma in 1. Major indications for operation were infection and progressive paraparesis or paresthesias. Surgical approach consisted of a posterior lateral thoracotomy in 23, thoracotomy with retroperitoneal exposure in 6, thoracoabdominal exposure in 4, and cervical/upper sternotomy in 3. Diaphragmatic mobilization was required in 12. Surgical approach is dictated by the level of the lesion and its length. Lesions of T1 to T6 are approached through an upper sternotomy or right thoracotomy; lesions of T6 to L3, through a left thoracotomy with or without diaphragmatic mobilization. Specific techniques of segmental vessel division, diaphragmatic mobilization, and evaluation of artery of Adamkiewicz are emphasized. Rib grafts are harvested as needed. The thoracic surgeon can greatly enhance preoperative assessment, operative exposure and closure, and postoperative care for patients undergoing thoracotomy for spinal conditions.