DEFINITION

The costotransversectomy uses a posterolateral approach to the thoracic spine. This approach provides access to the posterior spine, the lateral spinal canal, and also to the anterolateral portion of the vertebral body.

In comparison to the formal anterior thoracotomy, the costotransversectomy approach allows extrapleural access to the thoracic spine. Because the pleural cavity is not violated, this reduces the risk of pulmonary complications.4,13 Additionally, although anterior thoracotomy provides limited access in the regions of

the thoracic inlet and the levels near the diaphragm, the costotransversectomy approach can expose any

level of the entire thoracic spine.

Limitations of the costotransversectomy approach center on its poor visualization of the anterior canal. This makes addressing midline pathology such as broad-based calcified discs or central herniation more difficult via the costotransversectomy approach. Furthermore, a transthoracic approach may be advantageous in situations of multilevel involvement in order to avoid operative blood loss and thoracic cage instability from rib resection.

 

 

ANATOMY

 

The thoracic vertebrae are chiefly distinguished from the adjacent cervical and lumbar spinal regions by the presence of complex osteoligamentous articulations with the ribs.7,8,10

 

Two major articulations account for the costovertebral joint.

 

 

Ventrally, each thoracic rib articulates with the adjacent vertebral body and rostral intervertebral disc by the anterior costovertebral ligament, also known as the radiate ligament. Dorsolaterally, the costotransverse ligaments support the costal articulation with the transverse process.

 

 

The superior costotransverse ligament extends from the inferior edge of the transverse process to the superior margin of the caudally adjacent vertebrae.

 

The medial costotransverse ligament, also known as the capsular ligament, attaches the posterior neck of the rib with the anterior margin of the transverse process.

 

Finally, the lateral costotransverse ligament attaches the transverse process to the posterior costal tubercle.

 

 

The osseous variability along the length of the spine adds to the complex three-dimensional anatomy of the region, making thoracic spine surgery a technical process requiring a thorough understanding and proper

preoperative planning.

 

There are 12 thoracic vertebrae, each with slight variations in measurable dimensions. Specifically, variations exist between vertebral body diameter, facet positioning, pedicle dimensions, and transverse process and spinous process dimensions.7,8,10

 

Pedicle widths gradually decrease from T1 to T4 and increase from T4 to T12. Pedicle width is approximately

4.5 mm at T4, whereas pedicle width at T12 is approximately 7.8 mm. Pedicle height and length tend to increase from T1 to T12. Medial orientation and transverse pedicle angle tend to decrease from T1 to T12.7,8,10

PATIENT HISTORY AND PHYSICAL FINDINGS

 

A thorough history and physical examination is the basis of complete preoperative planning. The history should include medical and surgical history, social history addressing functional disability and socioeconomic issues, and history of pain or neurologic symptoms.

 

The physical examination should consist of observation of deformity and gait, palpation for tenderness or masses, range of motion of the spine and joints, assessment of intact neurologic function with a sensory/motor examination, and rectal examination.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

As previously mentioned, safe preoperative planning relies on understanding the complex three-dimensional anatomy of the costovertebral articulations, vertebrae dimensions, and locations of the neurovascular bundles.

 

Proper imaging, including radiographs (FIG 1) and/or advanced imaging modalities, is essential to preoperative planning.

 

Magnetic resonance imaging (MRI) is the imaging modality of choice for most pathologies to characterize the soft tissue of the involved region, especially cases involving spinal cord compression.

 

Computed tomography (CT) myelography may offer comparable visualization of the neural elements and is especially beneficial in cases where spinal instrumentation has been used previously.

 

For bony anatomy, CT is the preferred modality. Sagittal reconstruction and three-dimensional CT imaging may be useful supplements to axial sequences.

 

Frequently, both MRI and CT imaging are obtained for preoperative planning to characterize both the regional soft tissue and bony anatomy, respectively.

 

 

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FIG 1 • A. AP view of T12 fracture-dislocation. B. Lateral view of T12 fracture-dislocation. The decision was made to perform a costotransversectomy to avoid taking down the diaphragm.

 

NONOPERATIVE MANAGEMENT

 

 

The decision to treat a patient operatively or nonoperatively depends on the underlying disease. With some tumors, radiation may be the first line of treatment.

 

With most thoracic disc herniations and other degenerative diseases, nonoperative treatment is often tried prior to consideration for surgery unless there is neurologic deterioration.

 

SURGICAL MANAGEMENT

 

 

The costotransversectomy was originally employed as a means to drain tuberculosis abscesses.1,6 Newer indications include the following2,5,6,9,12:

 

 

 

Anterolateral spinal decompression of infection/abscess Vertebral body biopsy or partial resection (neoplastic, traumatic) Anterior intraspinal tumor

 

 

 

Removal of paracentral herniated disc Congenital kyphosis or kyphoscoliosis Sympathectomy

 

 

Various fusions, including limited anterior spinal fusion Rib pain

Preoperative Planning

 

A thorough history and physical examination is essential. In cases in which a tumor or infection is suspected, the history may provide clues as to the origin of the tumor or infection.

 

Appropriate laboratory values should be obtained. These include a basic metabolic panel, complete blood count, prothrombin time, and partial thromboplastin time. In cases in which tumors or infections are suspected, an erythrocyte sedimentation rate and C-reactive protein are also recommended. In cases in which infections are suspected, blood cultures may be helpful in identifying an organism.

 

Arranging for appropriate blood products is recommended. In the case of tumors and infections, there can be considerable blood loss, and hemostasis may be difficult to achieve. In addition to packed red blood cells, fresh frozen plasma and platelets may also need to be called for ahead of time.

 

Appropriate imaging—including radiographs, MRI, and CT—is essential.

 

If time permits, a biopsy is recommended in the cases where tumors are suspected and a primary is not known. Embolization of tumors that have a propensity to bleed (renal cell carcinoma, hemangioma, hemangiosarcoma) is recommended.

 

Discussion with the anesthesiologist regarding maintaining mean arterial pressure above 70 mm Hg to ensure adequate perfusion to the spinal cord

 

Positioning

 

Various positioning techniques are available depending on the surgeon's preference. It is the authors' preference to use a prone position on the operating table. Longitudinal chest rolls with the arms tucked in on a radiolucent table is our preferred method to maintain stability during the corpectomy and allow access for fluoroscopy (FIG 2).

 

After desired positioning is achieved, the patient should be draped wide enough to allow adequate exposure of the ribs laterally. Additionally, the posterior iliac crests are commonly prepped and draped in the field on both sides in the event bone graft is necessary.

 

 

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FIG 2 • Patient positioning. We prefer a radiolucent table to facilitate the use of fluoroscopy.

 

Approach

 

In thoracic disc resection, the costotransversectomy approach should be performed on the affected side. This is usually the side with greater deficit on neurologic examination, which should correlate with imaging studies obtained preoperatively.

 

In cases of central herniations without lateralizing deficits or root pain, the right-sided approach has been favored to avoid injury to the artery of Adamkiewicz, which usually originates from the left intercostal arteries from T8 to L2.

 

The side of approach for other pathologies depends on the location of the lesion.

 

TECHNIQUES

• Incision and Exposure

 

The spinous process of the level desired should be palpated and confirmed using a lateral radiograph. Be aware that the thoracic spinous processes are relatively long and thin and tend to overlap adjacent levels. The incision should span over two to three levels above and below the level where the costotransversectomy is going to be performed.

 

Depending on the level of the lesion and extent of exposure required, various incisions may be used. Incisions vary from a straight midline incision, a midline incision with a T over the rib to be resected, a paramedian incision made midway between the spinous process, and medial scapular border for proximal lesions above T7 or a curvilinear incision. It is the authors' preference to use a midline incision that can be extended as needed to allow adequate exposure to resect the ribs. The importance of draping widely is emphasized here again.

 

After the skin incision is made through the subcutaneous fat, the trapezius is cut in a longitudinal direction in line with the incision to expose underlying muscles (TECH FIG 1A). Depending on the region of thoracic spine, the rhomboid muscles, latissimus dorsi, and thoracodorsal fascia are divided next to access the paraspinal muscles.

 

 

 

TECH FIG 1 • A. We prefer a standard midline approach. Following skin incision through the subcutaneous fat, the trapezius is cut in a longitudinal direction in line with the incision to expose underlying muscles. B. The muscles are then elevated off of the transverse processes and ribs to expose the costotransverse articulation (arrows). C. The anterior surface of the rib can then be elevated subperiosteally with caution taken not to disrupt the neurovascular bundle nestled under the inferior aspect of the rib. D. The rib is cut 6 to 10 cm from the costovertebral articulation. The transected rib can be elevated and the pleura swept away from the undersurface of the rib. E. To gain access to the discs above and below the vertebra and to avoid retraction on the spinal cord, the nerve roots above and below the pedicle need to be tied off and transected. Figure of the nerve root passing underneath the pedicle.

 

 

The paraspinal muscles are elevated off of the spinous processes and laminae to gain access to the spine. A subperiosteal dissection will minimize blood loss. The muscles are then elevated off of the transverse processes and ribs to expose the costotransverse articulation (TECH FIG 1B).

 

Pedicle screw fixation can be performed at this point if a fusion is planned, and a rod can be placed on the side opposite from the costotransversectomy. This will provide stability during the corpectomy.

 

The anterior surface of the rib can then be elevated subperiosteally with caution not to disrupt the neurovascular bundle nestled under the inferior aspect of the rib (TECH FIG 1C). Take care not to enter the pleural cavity.

 

In cases in which the pleural cavity is violated, the pleura may be repaired with 6-0 or 4-0 Prolene in running locked fashion. To ensure adequate closure of the pleural cavity,

 

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immerse the wound in saline and perform a Valsalva maneuver. If bubbles persist, a chest tube can be placed at the end of the procedure.

 

The rib is cut 6 to 10 cm from the costovertebral articulation (TECH FIG 1D). The transected rib can be

elevated and the pleura swept away from the undersurface of the rib. Any remaining muscle attachments to the rib should be cleared to visualize the costotransverse ligament, which can be removed. With careful reflection of the pleura from the anterolateral surface of the vertebral body, the costovertebral joint can be disarticulated by dissecting the anterior costovertebral ligament to free the rib.

 

Once disarticulation of the rib is complete, the transverse process can be removed to visualize the disc space.

 

The intercostal artery and nerve should be ligated or retracted to avoid significant bleeding during rib resection.

 

If a corpectomy is planned, a laminectomy can be useful to improve visualization and resection of the vertebral body. A laminectomy can be performed to visualize the spinal cord in standard fashion.

 

To gain access to the discs above and below the vertebra and to avoid retraction on the spinal cord, the nerve roots above and below the pedicle may need to be tied off and transected. We generally use 2-0 silk ties (TECH FIG 1E). This is generally well tolerated without significant side effects.

Corpectomy

 

Using a high-speed burr, the center of the pedicle can be burred down into the vertebral body.

 

Then, the lateral portion of the pedicle may be removed with a rongeur and the medial portion may be removed by pushing the pedicle wall laterally to avoid injury to the spinal cord.

 

In cases of infection, purulent drainage should be encountered at this point, and the cavity should be irrigated and débrided. In tumors cases, lytic or solid tumor masses may be encountered. With lytic lesions, the tumor may be débrided from the cavity and hemostasis obtained. With solid tumors, it might be possible to resect the tumor en bloc. These specimens may be sent to pathology for the appropriate tests.

 

Use of thrombin and Gelfoam and other hemostatic agents may be necessary, and preparation of these materials is recommended prior to entering the cavity.

 

Use of a cell saver can be considered, but in cases of tumor or infection, the use of an autogenous blood recovery system is not recommended.

 

Next, a Penfield no. 1 can be used to elevate the periosteum off of the vertebral body and separate the pleura away from the vertebra if more exposure is needed (TECH FIG 2A). To avoid injury to the segmental vessels, try to get the Penfield no. 1 under the periosteum and elevate the soft tissues subperiosteally from the lateral and anterior portions of the vertebral body.

 

If the segmental vessels are injured, clamp the vessels to obtain hemostasis. Then tie them with 2-0 silk ties or vessel clips.

 

Then, the vertebra may be removed posterolaterally with curettes and pituitary rongeurs (TECH FIG 2B). Be careful not to retract the spinal cord as this could lead to neurologic injury. With tumors or infections, there is often a cavity. Clean this cavity out using curettes and pituitaries.

 

Once the tumor or pus has been excavated from this cavity, the lateral wall of the vertebral body may be removed with a rongeur. If you need more exposure, knock the posterior wall of the vertebral body into the cavity that you have created with a downward facing curette and remove the pieces with a pituitary. This reduces the risk of spinal cord injury.

 

Always be cognizant of the integrity of the anterior wall of the vertebral body because the aorta and vena cava are just anterior to the anterior wall of the vertebral body. If the anterior wall has been destroyed by tumor or infection, elevate the periosteum off of the anterior wall of the vertebral body or define the anterior border of the vertebra prior to performing the corpectomy to reduce the risk of

vessel injury.

 

If further exposure is necessary, removal of another rib may provide better visualization and access.

 

Once the tumor, pus, and granulation tissue have been adequately resected, remove enough of the vertebral body to allow space for a strut or cage.

 

 

 

TECH FIG 2 • A. The periosteum is elevated off of the vertebral body with a Penfield no. 1 or periosteal elevator, and the pleura is separated away from the vertebra if more exposure is needed. The thin arrow is pointing at the dura. The thick arrow is pointing at the pedicle. B. Cavity created from resection of bone from the costotransversectomy approach.

 

 

 

Discectomy

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Remove the disc at each end of the cavity to expose the endplates of the vertebrae above and below.

 

Tying and ligating the exiting nerve roots will improve visualization of the discs and facilitate the discectomy. Make a box annulotomy with a no. 15 scalpel blade and remove the disc above and below

the corpectomy site. Start with a pituitary and remove as much of the disc as you can.

 

Use curettes to thoroughly remove the cartilaginous endplates. Remove the endplate in a posterolateral direction to avoid sending any material into the ventral portion of the spinal cord. Angled curettes and scrapers can be useful here to avoid injury to the spinal cord. Scrape the endplates in a mediolateral direction versus anteroposterior (AP) direction to avoid injury to the vessels anteriorly or the spinal cord posteriorly.

Cage Placement

 

Place an allograft strut or cage posterolaterally to sit securely on the endplates.

 

Our preference is to use an expandable cage. An expandable cage can be helpful in these cases to avoid retraction on the spinal cord and potential neurologic injury because it is smaller than standard cages or allograft struts when it is initially inserted.

 

 

 

TECH FIG 3 • A. Postoperative AP view of T12 corpectomy and posterior T10-L2 spinal fusion. B.

Lateral view of T12 corpectomy and reconstruction with lateral expandable cage.

 

 

The resected ribs provide an excellent source of graft material. If necessary, iliac crest may be obtained for additional graft. Demineralized bone matrix or other extenders may be necessary to obtain a fusion.

 

Calipers and trials are used to get the exact size of the cage. Evaluation of radiographs of the disc and vertebral body above and below the corpectomy site should give a rough estimation of the size of the cage.

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Fill the expandable cage with the harvested graft. Insert the cage in a posterolateral direction to avoid injury to the spinal cord (TECH FIG 3).

Expand the cage to secure the cage in place and get AP and lateral fluoroscopic views to check for good positioning of the cage. Leave the handle on the cage when taking the radiographs in case the cage must be repositioned. Expand the cage to obtain a good interference fit. You should be able to pull on the cage with a Kocher clamp without it moving.

Decorticate and pack the remaining graft in the posterolateral gutters and place the ipsilateral rod.

Closure

After the appropriate procedure is completed, closure is performed in routine fashion.

Use of a drain is recommended, especially in the case of tumors or infections to continue evacuation of infected material or tumor cells. Closure with unbraided, nonabsorbable suture is recommended to decrease the risk of infection or wound dehiscence.

 

 

PEARLS AND PITFALLS
	Imaging ▪ For any lesion requiring costotransversectomy, proper intraoperative imaging is helpful. Use of a radiolucent table will facilitate images. Tucking the arms in will also facilitate fluoroscopy.     Exposure ▪ Inadequate rib resection may create a more posterior-directed approach than anticipated, which restrains the view of more anterior structures. This could lead to improper exposure of the lesion necessitating spinal cord manipulation, which should always be avoided. This can be avoided by an adequately lateral rib resection to establish a proper posterolateral approach. Tying off the nerve roots will also allow easier access to the vertebral body and endplates.     Pleural ▪ In the case of pleural disruption, repair should proceed immediately. Flooding the injury operative field with irrigation while searching for air leakage during ventilation can check for undiscovered pleural leaks. A chest tube can be placed at the end of the case if need be.     Corpectomy ▪ The key to doing an adequate corpectomy is visualization and access. To gain adequate access, tie off the nerve roots and resect the rib as far lateral as necessary to view as much of the vertebra as you need.     Discectomy ▪ Obtaining adequate exposure will facilitate the discectomy. Angled instruments will also help. During the discectomy, move the curettes and rasps in a mediolateral direction to avoid injury to the ventral spinal cord.     Hemostasis ▪ Hemostasis should be maintained throughout surgery. Take time to obtain good vascular access and to ensure adequate blood products are available. When dealing with tumors, embolization of vascular tumors may decrease blood

 

	loss.

 

 

 

POSTOPERATIVE CARE

 

Management of the patient after spinal surgery of any region depends greatly on the pathology, level of surgery, and general health of the patient. It is the authors' normal practice to drain cavities created by costotransversectomy using bulb suction drainage.

 

Proper pain management is necessary to alleviate pain during respiratory movements, decreasing incidence of atelectasis or other respiratory problems.

 

Prophylaxis: Pulsatile compression stockings may be continued postoperatively.

 

During the first 12 postoperative hours, the patient is allowed to lie supine as pressure on the wound discourages hematoma development. The patient is rolled every 2 hours to prevent wound maceration and pressure ulcers. Dressings are changed at 48 hours and daily thereafter as needed. Sutures are removed after 14 to 17 days and the wound is not soaked during this time. In patients who have had radiation to the area, the sutures are left longer to allow the wound to heal completely.

 

Patients are encouraged to ambulate on postoperative day 1. Those with residual neurologic deficits can be mobilized to chair with assistance when possible; otherwise, repositioning with log rolling every 2 hours to prevent skin breakdown is necessary. Patients with neurologic deficits begin physical rehabilitation 48 hours after surgery, with both passive and active exercises performed in bed.

 

Bracing is not usually required. However, if fixation is a concern, thoracolumbar orthosis with or without thigh extension may be instituted until radiographs suggest adequate osseous support.

 

 

OUTCOMES

The outcomes for surgical procedures involving costotransversectomy vary depending on the type of pathology, preoperative extent of the lesion, and anatomic location.

Bohlman and Zdeblick2 described the results for 19 patients who underwent excision of herniated discs. Eleven of the patients had the costotransversectomy approach, whereas the

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remaining eight patients underwent an anterior transthoracic disc resection. After 5 years, five were freed from pain with normal neurologic examination, three suffered mild residual weakness or mild pain requiring occasional analgesics, one had continued debilitating back pain requiring workers compensation, and two suffered poor results with remaining paraplegia. Fusion was not performed in every patient. The authors' methods left the anterior disc space and anterior longitudinal ligament intact after remaining disc resection.

In another study, Smith et al12 used a single posterior midline incision and a costotransversectomy in the management of 16 patients with congenital kyphosis and acquired kyphoscoliosis. Thirteen patients had a satisfactory outcome, with no clinically important postoperative complications; two suffered substantial postoperative complications not requiring secondary surgery (including lower extremity dysesthesia and residual pelvic obliquity caudad to fusion); and one patient had poor results requiring revision surgery for failed instrumentation. Overall, the authors claimed costotransversectomy to be a useful approach for anterior spinal fusion when used in conjunction with a posterior approach in the management of

 

kyphoscoliosis.

Similar results were noted in a study by Sciubba et al,11 who reviewed seven cases in which a costotransversectomy was used in conjunction with an expandable cage to correct thoracolumbar kyphosis resulting from spinal tumors, osteomyelitis, or fractures. A costotransversectomy was chosen in these cases because a transthoracic approach was deemed too risky due to medical comorbidities. The authors noted a 53% kyphosis correction. None of the patients had a decline in neurologic function, and pain management consisted of minimal use of oral narcotics.

The costotransversectomy approach for tumor resection has also been studied. Cybulski et al3 conducted a retrospective review of 15 patients who had a modified costotransversectomy to treat metastatic tumors causing impinging on the thoracic spine. Ten of these patients also had a concurrent posterior spinal fusion. The authors noted adequate decompression of the spinal canal in all cases. Also, all patients who were ambulating preoperatively maintained the ability to ambulate postoperatively.

Improvements in pain and/or further neurologic improvement were noted in 75% of the patients.

The costotransversectomy approach can be a useful method to treat pathology of the thoracic spine. As noted in the studies cited, there are many risks associated with this procedure, and a thorough discussion with the patient regarding the risks and benefits of the surgery is recommended prior to surgery. However, it can have very good results when used for the right indications. It seems to have maximum benefit when a transthoracic approach is deemed too risky or morbid for the patient to tolerate.

 

 

COMPLICATIONS

Possible complications following costotransversectomy are those typical of spine surgery. The immediate proximity of osseous structures with neurovascular and visceral anatomy establishes a technical challenge with several possible complications to be aware of. But overall, complications tend to be uncommonly observed.

Intraoperatively, care should be taken to avoid pleural compromise. This complication is more common when the pleura are thickened in cases involving neoplasm, infection, or previous surgery. If necessary, a chest tube can be placed at the end of surgery.

Historically, blood loss has been recognized as a concern for posterolateral approaches but with recent attention to hemostasis, blood loss can be well controlled. Special attention to penetrating arteries is required during dissection and removal of portions of the pedicle and anterior aspect of the vertebral body.

The intercostal artery and nerve should be ligated or retracted to avoid significant bleeding during rib resection. Similarly, injury to the intercostal nerve should be avoided to prevent intercostal neuralgia.

Other nervous injuries, including nerve root injuries or dural tears are possible. Dural tears should be closed intraoperatively to prevent cerebrospinal fluid leakage.

Postoperatively, infectious complications such as pneumonia and urinary tract infection have been noted. Patients who undergo costotransversectomy usually suffer multiple comorbidities, which further complicates postoperative course. Postoperative atelectasis may result secondary to pain and immobility. Wound infections are not common but can be treated with appropriate irrigation and débridement and intravenous antibiotics.

REFERENCES

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2. Bohlman HH, Zdeblick TA. Anterior excision of herniated thoracic discs. J Bone Joint Surg Am 1988;70(7):1038-1047.

    

    

3. Cybulski GR, Stone JL, Opesanmi O. Spinal cord decompression via a modified costotransversectomy approach combined with posterior instrumentation for management of metastatic neoplasms of the thoracic spine. Surg Neurol 1991;35(4):280-285.

    

    

4. Fessler RG, Sturgill M. Review: complications of surgery for thoracic disc disease. Surg Neurol 1998;49(6):609-618.

    

    

5. Garrido E. Modified costotransversectomy: a surgical approach to ventrally placed lesions in the thoracic spinal canal. Surg Neurol 1980;13(2):109-113.

    

    

6. Herkowitz HN, Garfin SR, Balderston RA, et al. Thoracic spine: anterior. In: The Spine, ed 5. Philadelphia: Elsevier, 2006:308-319.

    

    

7. Lee DD, Lemma MA, Kostuik JP. Surgical approaches to the thoracic and thoracolumbar spine. In: Frymoyer JW, Wiesel SW, eds. The Adult & Pediatric Spine. Philadelphia: Lippincott Williams & Wilkins, 2004:1011-1041.

    

    

8. Lifshutz J, Lidar Z, Maiman D. Lateral extracavitary decompression. In: Benzel EC, ed. Spine Surgery: Techniques, Complications Avoidance, and Management, ed 2. Philadelphia: Elsevier, 2005:429-434.

    

    

9. Overby MC, Rothman AS. Anterolateral decompression for metastatic epidural spinal cord tumors. Results of a modified costotransversectomy approach. J Neurosurg 1985;62(3):344-348.

    

    

10. Papadopoulos SM, Fessler RG. Thoracic spine; Anatomy and surgical approaches and exposures of the vertebral column. In: Benzel EC, ed. Spine Surgery: Techniques, Complications Avoidance, and Management, ed 2. Philadelphia: Elsevier, 2005:281-293.

     

     

11. Sciubba DM, Gallia GL, McGirt MJ, et al. Thoracic kyphotic deformity reduction with a distractible titanium cage via an entirely posterior approach. Neurosurgery 2007;60(4 suppl 2):223-230.

     

     

12. Smith JT, Gollogly S, Dunn HK. Simultaneous anterior-posterior approach through a costotransversectomy for the treatment of congenital kyphosis and acquired kyphoscoliotic deformities. J Bone Joint Surg Am 2005;87(10):2281-2289.

     

     

13. Wiggins GC, Mirza S, Bellabarba C, et al. Perioperative complications with costotransversectomy and anterior approaches to thoracic and thoracolumbar tumors. Neurosurg Focus 2001;11(6):e4.