Following induction of anesthesia with the placement of a double lumen intubation tube, the patient is turned to the left lateral position, with the right side of the chest upward. This position is maintained by flexion of the downside hip and knee and secured by using surgical tapes. An axillary roll is positioned to prevent pressure on the dependent shoulder [33–35].

Following the deflation of the lung and the introduction of the thoracoscopy instruments, the involved vertebra is identified under fluoroscopy and the segmental artery identified.

Regarding placement of thoracoscopic instruments, several strategies are possible.

Anterolateral approach also provides a surgical plane dissection between the azygos vein and the vertebrae. The spine could be fenced by temporary gauze placement in this plane thus maintaining a clear visual to the spine and adding extra protection to the anterior spinal structures during spinal release [23].

In a combined anterolateral and posterolateral approach, the portals are first placed along the anterior axillary line for spinal release and fusion [16, 20, 22] and then replaced posterolaterally for spinal instrumentation [23]. A disadvantage is the potential danger of working with instrument from an anterior to posterior direction into the spinal canal.

In an all posterolateral approach, all access portals are placed between the mid- and posterior axillary lines [24, 25]. The surgeon stands to face the back of the patient; both discectomy with fusion and instrumentation could be performed via these posterolateral portals without the need of additional anterolateral portals.

Comparing with conventional posterior instrumentation and fusion, an all posterolateral approach carries increased technical difficulties in performing a thorough discectomy and a lack of protection to the anterior vascular structure during the anterior longitudinal ligament release.

A successful intervertebral fusion and deformity correction requires a thorough discectomy [13] and end plate clearance. The parietal pleura on the spinal column is incised longitudinally along the peak of the disk where it is most avascular.

Intervertebral segmental vessels should be cauterized slowly, layer by layer; clear surgical field with minimal bleeding facilitates the thoracoscopic procedure.

Once the intervertebral disk is exposed beneath the pleura, the annulus is incised by a long handled no. 15 scalpel blade. A pituitary rongeur is used to remove the annulus disk complex. The cartilaginous end plates are separated from the subchondral vertebral bone by using a sharp cut Cobb elevator; and the final clearance of the disk space is carried out by a combination of straight and angled pituitary rongeurs and cup curettes.

Partial released of the anterior longitudinal ligament (ALL) is often adequate [25], and the residual ALL may assist in retaining the bone graft in the disk space. The posterior longitudinal ligament (PLL) is not incised during anterior spinal release and may act as a protective barrier to the spinal cord.

The resection of the proximal 2 cm of rib head (except when the level was below T11) is required to achieve thorough clearance at the posterolateral corner of the disk [6]. The foraminal ligaments are then cut to expose the superior edge of the pedicle. The superior part of the pedicle is resected to expose the spinal canal.

Rosenthal and Dickman reported the results of 55 consecutive patients undergoing VATS discectomy [7]. Seventy-nine percent of the radiculopathic patients recovered completely. When compared the VATS results to their patient treated by costotransversectomy or thoracotomy, they found VATS was associated with 50% less blood loss and an hour less operative time. Anand and Regan [6] reported their results of 100 consecutive cases of thoracic disease treated by VATS. They classified the disease according to the symptoms: Grade 1 (pure axial), Grade 2 (pure radicular), Grade 3A (axial and thoracic radicular), Grade 3B (axial with lower leg pain), Grade 4 (myelopathic), and Grade 5 (paralytic). An overall subjective patient satisfactory rate was 84%, and objective long-term clinical success was obtained in 70% of patients at 2 years.

Dickman et al. reported a comparable outcome in fracture management between VAT-vertebrectomy and open thoracotomy group [26].

Many authors had described the use of VATS in management of primary and metastatic spinal tumors [9, 28, 30–32]. Konno et al. reported the use of a combined hemi-laminectomy with medial facetectomy via a standard posterior approach and thoracoscopic resection for the management of five dumbbell-type thoracic cord tumors. No instrumentation was used. All patients regained their ability to walk. There was no recurrence of tumor and spinal instability at 3 years after the operation. In a series of 41 patients with metastatic tumor decompressed by VATS, there were two (5%) perioperative deaths, and both were related to respiratory complications [29].

Moreover thoracoscopy was increasingly used for vertebrectomy in the mid-1990s [26]. As the knowledge and the comfort of using such techniques expanded, the indications extended to vertebrectomy for tumor resections [26, 27]. The improved exposure, reduction in operative time, and blood loss, as well as improved recovery times, were notable. As a matter of fact, a thoracoscopic-assisted anterior approach could reduce the duration and the morbidity of a vertebrectomy without affecting oncological management.