Introduction Allows excellent visualization and access to the anterior thoracic spine Indications fusion of vertebral bodies spinal cord decompression corpectomies or reconstruction of vertebral bodies for cancer scoliotic deformity correction infection in the thoracic spine osteotomies biopsy Planes No true internervous or intermuscular plane Dissection is intramuscular through latissimus dorsi serratus anterior Position & Preparation Anesthesia general anesthesia with endotracheal tube Preparation radiolucent table with ability to flex for added exposure +/- imaging for instrumentation neuromonitoring at discretion of operating surgeon Position lateral decubitus move hard/arm above patient's head pad all pressure points operating surgeon positioned behind patient Side right side upper thoracic spine (T2-9) best approached from right side to avoid heart and aortic arch left side thoracolumbar spine (T10-L2) best approached from left side to avoid liver retraction Approach Incision make an incision starting halfway up the medial border of the scapula halfway between the scapula and thoracic spine curve incision down to a point two fingerbreadths below the tip of scapula finish the incision by curving upwards towards the inframammary crease Superficial dissection divide latissimus dorsi in the direction of the incision divide the serratus anterior along the same line to the ribs enter the chest via intercostal space or rib resection ribs resection approach offers greater exposure and bone for autograft intercostal approach considerations use 5th intercostal space for pathology from upper thoracic spine to T10 from T10 and lower, use 6th intercostal space technique cut the periosteum on upper border of rib entering on upper border of rib protects intercostal nerve and vessels enter the pleura resect posterior three fourths of the rib for added exposure insert rib spreader Deep dissection deflate lung retract lung anteriorly with moist lap sponge incise pleura over lateral esophagus to allow for retraction of esophagus retract esophagus anteriorly tie off as few intercostal vessels as possible reflect periosteum over spine with elevators to expose involved vertebrae Dangers Intercostal vessels vulnerable during rib resection when running along undersurface of rib, and exposure of vertebrae within chest avoid injury by entering pleura from above the ribs Lungs avoid injury by using sharp instruments wisely when within chest expand lungs every 30 minutes to prevent microatelectasis Esophagus avoid injury through adequate retraction of esophagus while working on spine Artery of Adamkiewicz travels on left side between T9-L2 in 60% of patients must preserve to prevent spinal cord ischemia