Thoracoscopy: A Minimally Invasive Approach to the Anterior Thoracic Spine

M efforts are being made across all surgical specialties to adopt and improve minimally invasive surgical (MIS) techniques. The main goal of minimally invasive surgery is a surgical outcome that is equivalent or superior to traditional open surgical techniques, but with smaller incisions and less soft tissue disruption than traditional open surgery. The theoretical benefits of using MIS techniques are improved wound healing and wound aesthetics, decreased postoperative pain, and improved cost containment through reduced hospital stays. However, MIS techniques often require surgeons to use endoscopic instruments and to rely on limited anatomical landmarks. In addition, these procedures require advanced operative skills that many seasoned surgeons did not learn during residency. Although these skills can be learned, there is usually an initial learning curve awaiting the surgeons as they begin adopting these skills. Nevertheless, the requests from patients to be treated with MIS techniques, as well as the promise for improved patient outcomes and cost containment, have been the persistent impetus driving surgeons to develop and incorporate MIS techniques into their daily practices. Spine surgeons have long been proponents at least of the concepts, if not the adoption, of MIS techniques. The challenge with all MIS techniques in the spine is that the surgeon must maintain a high level of manual dexterity around areas that are very sensitive to manipulation and deformation (i.e., the spinal cord) while decreasing the size of the corridor through which the surAnterior approaches to the thoracic spine are among the most challenging treatment strategies for spine surgeons. An anterior approach is necessary for many types of thoracic spine pathology, in order to safely remove the lesion without causing injury to the spinal cord. Traditionally, the anterior thoracic spine is approached via an open thoracotomy; however, this type of approach is associated with an inherently high rate of morbidity. In an attempt to provide patients with a less morbid surgical treatment for these challenging lesions, the senior author, Dr. Curtis Dickman, spent the early part of his career developing less invasive surgical approaches to the anterior thoracic spine using endoscopic techniques (i.e., thoracoscopy). The benefits of thoracoscopy are many, including a lower rate of morbidity due to less intraoperative blood loss, improved cosmetic results due to smaller incisions, and potentially decreased medical costs as a result of shorter hospital stays and less postoperative pain. This article reviews the types of spinal pathology that are well suited to being treated by thoracoscopy.