Anterior approach to thoracic and lumbar spine lesions: results in 145 consecutive cases

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The authors report on a series of 145 consecutive patients with different types of spine lesions surgically treated via an anterior approach (AA) at the thoracic and lumbar levels during the past 10 years. Indications, techniques, and surgical results are described.


This series included 92 patients with fractures, 30 with neoplasms, 13 with thoracic disc hernias, and 10 with spinal infections. Based on the lesion to be addressed, the AA was used for lesion excision, corpectomy, vertebral body reconstruction with cages, realignment, and/or plating or screwing. The approach was extracavitary in 55 patients and intracavitary in 90. In 126 patients (86.8%), neural decompression and spine stabilization were achieved via a stand-alone AA (SA-AA), whereas 19 patients (13.1%) were treated using a 2-stage anteroposterior approach. This circumferential approach was reserved for select cases of severe traumatic dislocation, particular types of tumors, or specific anatomical locations. The authors developed a simple neuronavigation-based method of identifying the severely injured patients who were eligible for the SA-AA by evaluating the angle of lateral dislocation.


There were no deaths and no instances of major surgery-related morbidity. Minor morbidity was almost always transitory and was reported in 13 patients (8.9%). Neurological improvement was reported in 20% of injured patients with a preoperative incomplete lesion. Postoperatively, all patients were able to stand or at least sit without load pain. During the follow-up (mean ± standard deviation 3.8 ± 2.4 years), there were no cases of failure, fracture, dislocation, or bending of the anterior instrumentation, and the rate of pseudarthrosis was 0%.


The anterior route provides direct access to most spine diseases and allows optimal neural decompression and the possibility of adequate realignment and strong reconstruction/fixation. Stability of the vertebral column is achieved, resolution of clinical pain is rapid and almost complete, and the rate of surgical complications is very low. The authors assert that the SA-AA offers so many advantages and has such good results that the 2-stage anteroposterior approach can be reserved for a minority of select cases and that the time for using the posterior approach alone is over.

Abbreviations used in this paper:AA = anterior approach; AO = Arbeitsgemeinschaft für Osteosynthesefragen; ASA = American Society of Anesthesiology; ASIA = American Spinal Cord Injury Association; CSF = cerebrospinal fluid; PA = posterior approach; SA-AA = stand-alone AA; TS-APA = 2-stage anteroposterior approach.

Article Information

Address correspondence to: Giuseppe Talamonti, M.D., Department of Neurosurgery, Ospedale Niguarda Cà Granda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy. email:

© AANS, except where prohibited by US copyright law.



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    Images obtained in an 18-year-old woman with a Type C fracture. Axial (A) and sagittal (B) CT scans showing a thoracic Type C fracture with severe laterolateral translation. Images (C and D) showing the selection of 2 points (entry and target points) on the precise center of the pedicles of 2 normal vertebrae below and above the fracture level. Then 2 trajectories are traced between the 2 points below and above the fracture level. High-resolution neuronavigator CT scan, coronal view (E), demonstrating the 2 trajectories that have been extended as straight lines along the same axis as far as the point at which they join each other. The intersection of these lines forms an angle of 18° (lateral dislocation angle). This angle identifies this Type C fracture as a candidate for TS-APA. Lateral radiograph (F) obtained 18 months after treatment, showing the cage, anterior plating, posterior instrumentation, good realignment, and maintenance of the correction of the posttraumatic deformity.

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    Posterior and delayed SA-AA fixation performed in a 17-year-old boy with incomplete neurological deficits and severe posturing pain. Preoperative lateral radiograph (A) and CT scan (sagittal reconstructed view, B) showing a transpedicular short-segment fixation with a decrease in the vertebral body height, tendency to mild kyphosis, and persistence of an osseous fragment inside the spinal canal. Postoperative CT scan (sagittal reconstructed view, C) obtained after removal of the posterior instrumentation and anterior corpectomy with body reconstruction with a cage and fixation, demonstrating complete decompression of the spinal canal, reconstruction of the body height, and

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    Type B fracture with severe anterior translation of the vertebral body. Preoperative sagittal MR image (A) showing a thoracic Type B fracture with severe anteroposterior vertebral dislocation. Postoperative CT scan (sagittal reconstructed view, B) obtained after an SA-AA, showing the cage that reconstructs continuity of the vertebral posterior wall being placed as much posterior as possible. Note the good spine realignment and reconstruction of body height.

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    Images obtained in a 19-year-old man who was in a traffic accident and sustained a Type C fracture with moderate lateral dislocation. Preoperative CT scan (coronal reconstructed view, A) showing a thoracic Type C fracture with laterolateral vertebral dislocation. Preoperative neuronavigator CT scans (coronal and 3D views, B) showing the angle of lateral dislocation is < 10°. Postoperative CT scans (coronal and sagittal reconstructed views, C and D) obtained following an SA-AA, showing good realignment in both the coronal and sagittal planes, adequate cord decompression, and reconstruction of the body height.

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    Images showing 4 examples of the angles of lateral dislocation in Type C fractures. The 2 images on the left demonstrate angles < 10°, and these cases could be successfully treated via an SA-AA. The 2 images on the right depict angles > 10°, and these cases required a TS-APA

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    Multiple noncontiguous thoracic Type B fractures in a 32-year-old man. Preoperative sagittal CT scan (A) showing 2 Type B fractures at 2 different spine levels (T-9 and T-12). Postoperative lateral radiograph (B) obtained following a single SAAA to manage both fractures, demonstrating that the T-12 lesion was handled using the Harms cage and the T-9 body was reconstructed using an expandable cage. Note the good realignment and reconstruction at both levels.

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    Complete excision of a dumbbell thoracic schwannomas via the Larson et al. approach. Preoperative sagittal T2-weighted MR image (A) showing a thoracic dumbbell schwannoma. Intraoperative photograph (B) depicting initial exposure of the dumbbell schwannoma through the extrapleural lateral rachiotomy. Intraoperative photograph (C) obtained following the removal of the dumbbell schwannoma, showing preservation of the parietal pleura and intercostal nerve.

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    Images obtained in a 52-year-old woman with a thoracic disc hernia responsible for severe radiculopathy and progressive paraparesis. Preoperative CT scan (sagittal reconstruction, A) showing a giant calcified thoracic disc hernia extended to 2 vertebral bodies. Preoperative axial T2-weighted MR image (B) demonstrating severe anterior compression and backward dislocation of the thoracic spinal cord. Postoperative CT scan (sagittal reconstruction, C) showing complete decompression of the spinal canal, reconstruction of the vertebral bodies by an expandable cage, and fixation by anterior screwing.

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    Images obtained in a 25-year-old woman with intrathoracic abscess and tubercular spondylitis causing rapid neurological deterioration. Preoperative sagittal T1-weighted MR image (A) showing an intrathoracic abscess and tubercular spondylitis of the T-8, T-9, and T-10 bodies. Note the spine deformity and cord compression. Postoperative CT scan (sagittal reconstruction, B) showing complete correction of the deformity and decompression of the spinal canal achieved with 3 corpectomies, vertebral reconstruction by an expandable cage, and anterior screwing.



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