Surgical Approaches to the Spine

The desire to expose the spine for surgery by anterior approaches at any level between the head and the sacrum is not new. Spinal pathology is often located anterior to the spinal cord and nerve roots in the cervical and thoracic spine, and anterior to the peripheral nerves that emerge from the lumbosacral spine below the first lumbar ver­ tebra. To treat such pathology one prefers to expose the front of the spine directly and widely enough to eradicate the pathology and to have full control of bleeding throughout the procedure. The posterior elements of the spine are important for mechanical stability of the spine, and therefore for the protection of the neural and vascular structures in the spine that would be threatened by instability. Extensive eradication of pathology posterior to the spinal canal and the intervertebral foraminae, including the transverse processes, may leave no adequate bony bed for the surgical creation of a stabilizing osseous fusion. In such a situation, an anterior fusion procedure is the only viable alternative to a posterior or posterolateral fusion. In situations where it is critically important to obtain a stable fusion, as in tuberculosis of the spine, both an anterior and a posterior fusion operation at the same motion segments is, in almost every instance, a guarantee of a stable osseous fusion. One should know both approaches.