Thoracic Approach to Spine Procedures

The anterior approach to spine surgery is considered safe and has the potential for improving value in patient care. The unique advantages of the procedure (compared with posterior surgical instrumentation and fusion), particularly when used for correction of scoliosis, include avoiding disruption of spinal musculature for surgical exposure and reducing the number of fused vertebrae (thereby preserving postoperative spinal flexibility). In addition, there is evidence to suggest that there is a reduction in the risk of infection or need for blood transfusion in the perioperative period. Conducting a safe and appropriate anesthetic for this type of surgical approach requires careful preoperative planning with both the surgical and neurophysiology teams. Each anesthetic plan should involve appropriate patient selection in the preoperative period, an arterial line placement (for hemodynamic monitoring and blood gases), as well as appropriate venous access, intraoperative one-lung ventilation (OLV) to optimize the surgical field, and postoperative multimodal analgesia to help maximize early physical therapy with the goal of maintaining spine mobility. Intraoperatively, communication amongst teams and an intimate knowledge of physiology and complications of intrathoracic surgery and OLV remains essential to ensuring patient safety and a satisfactory surgical result. Although relatively few surgeons in the United States perform an anterior approach to thoracic spine surgery, it is gaining widespread favor as maintaining patient safety and outcome data continue to demonstrate that the approach offers unique advantages to the posterior approach.