Costotransversectomy

Some thoracic problems — a disc herniation lying towards the side of the canal, an area of cord compression, an infection or abscess, or a lesion needing biopsy — require access to the front or side of the spinal cord. Reaching these safely is challenging, because the cord cannot be retracted. Costotransversectomy provides an angled corridor from behind that allows the surgeon to work in front of the cord to a degree, offering an alternative to opening the chest for selected problems.

In a costotransversectomy, an incision is made at the back of the chest, and a short segment of the relevant rib, together with the transverse process of the vertebra, is removed. This opens a window that allows the surgeon to approach the side and front of the spinal canal without entering the chest cavity or retracting the cord. Through this corridor, a herniated disc can be removed, the cord decompressed, or tissue sampled or drained, depending on the problem. Modern practice increasingly incorporates minimally invasive adjuncts and, where the segment is destabilised, fixation may be added.

This approach can be considered for lateral thoracic disc herniations, for certain areas of thoracic decompression, and for procedures such as biopsy or drainage of an abscess where access to the front or side of the canal is needed but a full transthoracic approach is best avoided. It is less suitable for large, central, calcified discs that require the broad anterior access of a transthoracic route. The choice of approach — costotransversectomy versus transthoracic, lateral extracavitary or posterior routes — depends on the location and nature of the problem and the individual.

The evidence describes costotransversectomy as a versatile, established approach within the range of options for thoracic surgery. Reviews comparing the lateral extracavitary, costotransversectomy and transthoracic approaches examine their access, advantages and complication profiles, and series of thoracic disc surgery through costotransversectomy report good results for suitable, more lateral herniations. The literature positions it as one tool among several, chosen to match the problem. The balanced view is that costotransversectomy is a useful approach for selected thoracic problems, allowing access to the front of the cord while avoiding the chest, with the choice individualised.

The operation is performed under general anaesthetic, with the hospital stay and recovery depending on the underlying problem and whether fixation is added. Because the chest cavity is not opened, some of the recovery demands of a transthoracic approach are avoided. Where the cord has been decompressed, neurological improvement typically occurs gradually. Rehabilitation supports recovery. As with any operation there are risks, which are discussed fully beforehand. Whether a costotransversectomy is the best approach for a given person is decided together.

• —Lubelski D, et al. Lateral extracavitary, costotransversectomy, and transthoracic thoracotomy approaches to the thoracic spine: review of techniques and complications. J Spinal Disord Tech 2013. (PMID 22143047)
• —Spallone A, et al. Costotransversectomy in the surgical treatment of mediolateral thoracic disc herniations: long-term results and minimally invasive adjuncts. Acta Neurochir Suppl 2023. (PMID 38153496)
• —Nacar OA, et al. Thoracic discectomy through a unilateral transpedicular or costotransversectomy approach with intraoperative ultrasound guidance. Clin Spine Surg 2018. (PMID 30476309)
• —Simpson JM, et al. Thoracic disc herniation: re-evaluation of the posterior approach using a modified costotransversectomy. Spine 1993. (PMID 8235875)