In recent trauma, MRI can give information on the spinal canal encroachment and spinal cord and, most important, on the posterior longitudinal ligament complex (PLC) integrity [15]. Other basic information required are anterior gap longitudinal extension (to be measured on CT scan 2D reconstruction images both along the posterior and anterior wall lines), local kyphosis and scoliosis if present, and superior and inferior adjacent end plates size. From the abovementioned data depends the implant size although these data are not enough to move in the operatory room. Surgical strategy also relies on multiple further aspects that strongly influence type of surgery, approach, and implant choice. The most important factors are presence of fixed or flexible deformity and previous surgery, with or without posterior instrumentation, and the previously mentioned PLC integrity. Anterior column reconstruction (ACR) alone is feasible in case of no deformity or corrigible deformity; therefore preoperative planning, in ancient trauma, must include flexion-extension and lateral bending X-rays. If incorrigible kyphosis depends on anterior ligament shortening or anterior bone bridging (new callus formation), then ACR only can be still considered, but surgical strategy will include anterior ligament release or bone bridging excision. In these cases, the anterior aspect of the vertebral column needs to be exposed at the chosen level. This can be done by moving in front the major vessels by blunt dissection after ligating and cutting the segmental arteries and veins. Posterior fusion (spontaneous or surgical, with or without instrumentation) and fixed deformity together are a contraindication to ACR alone, and posterior osteotomy (and/or hardware revision) should be considered instead. ACR will follow in case an anterior gap is left after posterior correction (Fig. 13.3). As the cage body is generally smaller compared to its end plates, then a complete corpectomy is generally unnecessary, and the surgeon can leave a bone shell in the front and in the contralateral side to protect the major vascular structures from unwanted injuries. On the other hand, disk removal and vertebral end plate preparation should be impeccable. The surgeono must take care not to break the bone surface during this step to ensure the largest contact between bone and cage end plates and favoring fusion. Expandable cages are very helpful in correcting local kyphosis via anterior approach nevertheless, the risk of cage subsidence through the vertebral end plates during this maneuver is high, especially if the patient bone stoke is not satisfactory. Accordingly, preoperative dual X-ray absorptiometry scan is strongly suggested in adult patients before a kyphosis correction by ACR, and this procedure should be considered in any case hazardous in female older than 50 and male older than 60. In such cases, vertebral body augmentation by cement ingjection can be achieved during the anterior approach, before cage expansion, reducing the risk for vertebral endplates failure. Relevance of PLC in surgical planning will be discussed later (Sect. 13.6.5).