Transthoracic Approach to Thoracic Spine

Thoracotomy incision (blue) in the fifth intercostal space for a transthoracic approach to the spine, placed 35 mm from the lateral border o
Thoracotomy incision (blue) in the fifth intercostal space for a transthoracic approach to the spine, placed 35 mm from the lateral border of the scapula to protect the long thoracic nerve (yellow). Image from Khadanovich A, Benes M, Kaiser R, Reynolds J, Mawhinney G, Stulik J, Kachlik D. Anatomy of the Long Thoracic Nerve in Relation to Thoracotomy for Spinal Approaches, How to Avoid Nerve Injury?. Oper Neurosurg. 2026, 31(2), 328-333. CC BY 4.0.

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

Transthoracic Approach to Thoracic Spine, vertebral column with the thoracic region highlighted, from gray’s anatomy
Vertebral column with the thoracic region highlighted, from Gray’s Anatomy. Image by Sebastianpin, Wikimedia Commons, CC BY-SA 3.0.

Indications

  • traumatic
    • decompression for documented neurocompression 2º to bone or disc fragments anterior to dura
  • infectious
    • open biopsy for diagnosis, debridement & anterior strut grafting
  • degenerative
  • neoplastic
  • deformity
    • kyphosis/scoliosis
    • (congen/acquired/idiopathic)

Use

  • 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

Prerequisites

  • Expertise at approach
  • Thoracic surgeon able to deal with hazards in area

Positioning

  • lateral decubitus position with right side down
  • inflatable beanbag with table flexed to ↑ exposure
  • Arm on operating side lateral to head
  • Ax roll
  • Attend to pressure points
  • NG tube

Incision

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

Procedure

  • Use electrocautery to maintain haemostasis 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 pleura over lateral side of oesophagus 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 annulus. 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

Complications

  • Atelectasis, Lung injury, pneumothorax, haemothorax
  • Vessel injury, Intercostals vessel damage
  • Visceral damage: Oesophagus
  • Nerve injury
  • Cord injury
  • Clicking of scapula over operative site

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.