Thoracic lateral extracavitary decompression and fusion

Abstract

The thoracic lateral extracavitary approach (LECA) provides surgical access to all three columns of the thoracic spine from T5 to T12. This can be accomplished through a single incision, without the need for substantial patient repositioning. The technique is commonly employed when ventral decompression and circumferential reconstruction are required. Frequent indications include trauma, intervertebral disc herniation, tumor, and infection. However, the technique is only one of the many options to address pathology of this nature, and the spinal surgeon is often left with challenging considerations when selecting the optimal approach. With this chapter, we describe the appropriate indications for the LECA and review the other surgical options such as anterior intracavitary and anterolateral approaches along with factors that should be included in the surgical decision-making process. This is followed by a discussion of the essential presurgical considerations and then a detailed review of the surgical steps for the classic open LECA and the more recent minimally invasive approach. This is supplemented by a discussion of the essential details of the costotransversectomy and transpedicular approaches to the vertebral body, which allow for less ventral visualization but also less invasive access. Additionally, this chapter outlines the modifications needed for a posterolateral approach to the upper thoracic vertebrae (T1-T4) through the lateral parascapular extrapleural approach. The chapter concludes with a case illustration and a discussion of potential complications and strategies for avoidance such as pulmonary-related morbidity, excessive blood loss, wound infections, and postoperative cutaneous cerebrospinal fluid leaks. Overall, the chapter should provide the surgeon with an experienced perspective on the decision-making process and surgical techniques to address ventral compressive pathology in the thoracic spine along with strategies to reduce the likelihood of adverse events.