• Filippo Gagliardi, Silvia Snider, Francesca Roncelli, Martina Piloni, Edoardo Pompeo, Anthony J Caputy, and Pietro Mortini.
• Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy. Electronic address: gagliardi.filippo@hsr.it.
• World Neurosurg. 2021 Jun 1; 150: e117-e126.

BackgroundPathologies of the ventral thoracic spine represent a challenge, igniting arguments about which should be the ideal surgical approach to access this area. Anterior transthoracic thoracotomy and a number of posterolateral routes have been developed. Among the latter, costotransversectomy has demonstrated to provide good ventral exposure with a lower, but not negligible, morbidity. The optimal approach should be the one minimizing surgical morbidity on both neural and extraneural structures while optimizing exposure.MethodsThe authors described the combined, rib-sparing, bilateral approach (CRBA) to the ventral mid/low-thoracic spine. The technique combines a transfacet pedicle partially sparing approach on one side and a transpedicular with transverse process resection on the contralateral one. A laboratory investigation was conducted. The technique was applied in a surgical setting, and a case was reported.ResultsCRBA is rib-sparing, completely extracavitary, and does not require pleural exposure and paraspinal muscle splitting, thus minimizing potential morbidity. The combination of 2 corridors ensures the greatest exposure compared with standard posterolateral approaches. The only blind corner is limited to a small area just in front of the dural sac. A bimanual approach optimizes control during surgical manipulation, even if the area of maneuverability and cross-section areas of surgical corridors are slightly limited compared to traditional costotransversectomy due to the minimally invasive nature of the procedure.ConclusionsCRBA represents a safe and effective option to access the ventral mid/low thoracic spine. It provides great exposure and bimanual manipulation of the surgical target, minimizes potential morbidity, and avoids entrance into the thoracic cavity and paraspinal muscle splitting.Copyright © 2021 Elsevier Inc. All rights reserved.

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