The evolution of spinal surgical practice has been driven by three primary goals: decompression, stabilization, and correction of deformity.(1) Larson and his team at the Medical College of Wisconsin in 1976 defined a method in which the surgeon could safely approach lateral and anterior spine disease and perform posterior stabilization during the same procedure through the same incision. This procedure, called the “lateral extracavitary approach” (LECA) was initially devised for the treatment of Pott disease and vertebral osteomyelitis.(2) This novel approach provides access to the thoracolumbar spine both to dorsal and ventrolateral without the morbidity associated with traditional trans pleural and trans peritoneal approaches.(3). Most importantly it allows for posterior instrumentation through the same surgical incision. Since 1976, the popularity of the approach has grown, and the indications have expanded to include disc herniation, infection, tumor, and deformity. Ménard in 1894 described a novel approach for the treatment of the thoracolumbar spine, which in the modern literature is commonly referred to as the costotransversectomy.(1) Norman Capener of England, tackled this clinical problem, arguing that clinical outcomes could be improved and complications avoided by resecting the abscess in its entirety.(1) Because the bone involvement was typically found ventrally, available approaches had to be altered. Capener modified the costotransversectomy of Ménard, changing the plane of dissection. Whereas the dissection proposed by Ménard was medial to the dorsal paraspinal musculature, Capener split this muscle and retracted the ends both rostrally and caudally. (4) This procedure, which he termed the “lateral rhachotomy, ”gave the surgeon a more ventral exposure from a more lateral trajectory. The procedure was first used by Capener in 1933; it was reported by Seldon in 1935 and by Capener himself in 1954.(1) Sanford Larson altered and popularized Capener’s lateral approach to the spine in the 1970s and 1980s. Larson and his team at the Medical College of Wisconsin developed the LECA to the thoracic and lumbar spine.(5) Larson’s approach to the surgical exposure differed from Capener’s approach, predominately in the mobilization of the paraspinal musculature. Following a subperiosteal dissection, the thoracolumbar fascia, subcutaneous tissue, and skin are elevated as a flap, as they are incised together along the angled portion of the incision. At the lateral aspect of the erector spinae group, a plane of dissection is defined and developed. This group of muscles, rather than being divided as Capener described, are then elevated and retracted medially along the length of the incision. Subsequently, self-retaining retractors can be inserted into the operative field.(6) Once completed, the ventral and lateral aspects of the vertebral body come into view. In the thoracic spine, it is necessary to remove the rib head and the most proximal portions of the rib to access this exposure. In the treatment of lesions below L-3, the iliac crest may need to be resected to provide a similar exposure operative field. (6)The advantages of the procedure, as stated earlier, are the simultaneous exposure of both the ventrolateral and dorsal aspects of the spine, which would obviate the need for a separate incision and, potentially, a second operative procedure. In addition, it allows the surgeon to provide maximal protection of the neural structures by mobilizing abnormal tissue away from neural elements, rather than toward them. It permits the surgeon to work and progress in a logical sequence, by allowing initial anterior decompression, which is followed by posterior reduction of the deformity; instrumentation can be put in place before implantation of an anterior graft to ensure a proper fit. Afterward, posterior fusion can be accomplished if necessary.

The thoracolumbar spine (T10-L2) is one of the most common sites for vertebral injury. More than half of all spinal fractures occur in the thoracic or lumbar spine, and a majority of all traumatic spinal injuries are found at the thoracolumbar junction. There is a bimodal distribution of injuries of people between ages of 15 and 24 and of people older than 50 years.(7) The transition from the kyphotic thoracic spine to the lordotic lumbar spine, which makes the thoracolumbar junction particularly susceptible to damage from axial forces. In addition, the thoracic and thoracolumbar spine may not be as well vascularized, and the thoracic spine and conus is less tolerant of injury in contradistinction to the mid to low lumbar spine where spinal roots predominate(8) Current surgical management to address thoracolumbar lesions remains challenging as traditional surgical procedures anterior, posterior, and either combined or staged anterior-posterior approaches—are frequently associated with complications and morbidity. The extracavitary procedure uses one incision to address all three columns of the spine and, therefore, allow the surgeon to perform a circumferential decompression and fusion through a single incision. By remaining extra pleural and/or extra peritoneal, the extracavitary approach avoids many of these potential complications by using a single incision to provide direct access to anterior, middle, and posterior column, while offering direct visualization of the common dural sac and neural elements.(8) The flexibility granted by this procedure allows it to be used for the treatment of several spinal disorders including abnormalities of thoracic discs, tumors (primary and metastatic), infection, trauma, and deformity.(1,9,10) Table 1: Showing patient age, diagnosis, level of neurological involvement, preop ASIA score, level of pathology and outcome Sl. no Age Pathology Lower limb power Level of sensations American Spinal Injury Association(ASIA) Impairment Scale(AIS) Level of Injury Outcome 1 28yrs RTA Bilateral 0/5 Absent below the level of pubic symphysis A D12 # Paraplegic 2 31yrs Potts spine Bilateral 3/5 Paresthesia below the level of pubic symphysis C L2# Neurological deficits improved 3 24yrs RTA Bilateral 0/5 Absent below the level of pubic symphysis A D12# Paraplegic 4 39yrs Fall from height Bilateral 0/5 Absent below the level of pubic symphysis A L2# Neurological deficits improved 5 42yrs Potts spine Bilateral 3/5 Paresthesia below the level of pubic symphysis C D11-12# Neurological deficits improved 6 63yrs High grade lymphoma Bilateral 3/5 Paresthesia below the level of pubic symphysis C D11-12# Neurological deficits improved 7 38yrs Potts spine Bilateral 3/5 Paresthesia below the level of pubic symphysis C D12-L1 Neurological deficits improved 8 42yrs Potts spine Bilateral 4/5 Paresthesia below the level of pubic symphysis C D11-12 abscess Neurological deficits improved 9 34yrs Potts spine Bilateral 3/5 Paresthesia below the level of pubic symphysis C L1# Neurological deficits improved 10 59yrs Pathological #(Multiple Myeloma) Bilateral 3/5 Paresthesia below the level of pubic symphysis C D12-L1# Neurological deficits improved Despite these advantages, there are several drawbacks to this procedure. (6)The degree of difficulty posed by the operation requires experience, expertise, and a working knowledge of thoracic and retroperitoneal anatomical structures. The most common complications are similar to those of most major spinal operations. Blood loss, at times, may be excessive, and may lead to coagulopathy and anemia. Postoperative ileus may occur for 1 or 2 days. Pulmonary structures may be compromised or injured, requiring the need of chest tube drainage for 1 or 2 days and aggressive respiratory treatments. Infection rates have been reported to range between 2 and 3%.(6). Nevertheless, the LECA still has an important role in the treatment of patients with ventral disease of the thoracic and lumbar spine.

Nine out of the ten patients were males and one female. Most common pathology encountered in our study was tuberculosis of spine. Seven out of the ten patients presented with paraparesis and one patient with paraplegia showed neurological improvement during the postoperative follow up while two patients who presented with paraplegia, did not show much improvement in their neurological status. Nine out of the ten patients had uneventful post op recovery while one patient of Potts spine had surgical site infection, incidentally he was a case MDR TB, with vertebral abscess and multiple brain tubercles. the wound healed after changing the antibiotics as per culture sensitivity. The female patient was a case of primary spinal lymphoma, and one patient had pathological # due to multiple myeloma who were later referred after spinal canal decompression & stabilization for chemo radiation and were lost to follow up.

In our study of the 10 patients, nine were patients were operated on from the left side and one from the right side. Tuberculosis of spine was most common pathology in our study. A “T” shaped incision was taken with the horizontal limb being at the level of pathology. Skin and subcutaneous fascia were incised and skin flap raised. Trapezius and latissimus dorsi were incised along the skin flap and flaps tagged and raised. Left para spinal muscle was dissected subperiosteally from the spinous process and above the transverse process, and the lateral margin of the multifidus along with the erector spinae, raised as a single muscle flap (Fig 5) and two gauge tags used to mobilize and hold it medially (Fig 2). The eleventh/twelfth rib identified and intercostal muscles separated and the rib was resected out (Fig 3). The transverse process is also resected out. Spinal canal is decompressed (Fig 4). Posterior stabilization is achieved by inserting appropriate pedicle screws, after distraction fixation is achieved, the anterior pathology is addressed. In our series we decompressed the spinal canal and rein-enforced the anterior column with bone graft (bone chips/ tricorticate graft/ rib grafts). Closure done in layers over sub muscular drain.

The development of the LECA can trace its origins to the pioneering work of physicians who practiced more than a century ago. Through the innovative efforts of Ménard, Capener, and Larson, our community has been granted a safe means to decompress and fuse multiple areas within the thoracic and lumbar spinal canal. The LECA has been applied to most disorders that affect the spine, avoiding a staged procedure or a procedure that occurs on a different day and thus reducing patient morbidity, as numerous studies have indicated that these staged procedures result in more complications and longer patient hospitalizations(11) LECA is a useful operative technique and with the application of new technological innovations, it will remain a vital component of the neurosurgical armamentarium of the 21st century.

1. Benzel E, Steinmetz M. Benzel’s spine surgery: techniques, complication avoidance, and management. 2017. 2. Lifshutz J, Lidar Z, Maiman D. Evolution of the lateral extracavitary approach to the spine. Neurosurg Focus. 2004 Jan 15;16(1):E12. 3. Foreman PM, Naftel RP, Moore TA, Hadley MN. The lateral extracavitary approach to the thoracolumbar spine: a case series and systematic review. J Neurosurg Spine. 2016 Apr;24(4):570–9. 4. Capener N. The Evolution of Lateral Rhachotomy. J Bone Joint Surg Br. 1954 May 1;36-B(2):173–9. 5. Larson SJ, Holst RA, Hemmy DC, Sances A. Lateral extracavitary approach to traumatic lesions of the thoracic and lumbar spine. J Neurosurg. 1976 Dec;45(6):628–37. 6. Larson SJ, Maiman DJ. Surgery of the Lumbar Spine. Thieme; 1999. 360 p. 7. Shen FH, Haller J. Extracavitary Approach to the Thoracolumbar Spine. Semin Spine Surg. 2010 June 1;22(2):84–91. 8. Shen FH, Haller J. Extracavitary Approach to the Thoracolumbar Spine. Semin Spine Surg. 2010 June 1;22(2):84–91. 9. Arnold PM, Baek PN, Stillerman CB, Rice SG, Mueller WM. Surgical management of lumbar neuropathic spinal arthropathy (Charcot joint) after traumatic thoracic paraplegia: report of two cases. J Spinal Disord. 1995 Oct;8(5):357–62. 10. Arnold PM, Baek PN, Bernardi RJ, Luck EA, Larson SJ. Surgical management of nontuberculous thoracic and lumbar vertebral osteomyelitis: Report of 33 cases. Surg Neurol. 1997 June 1;47(6):551–61. 11. Shufflebarger HL, Grimm JO, Bui V, Thomson JD. Anterior and posterior spinal fusion. Staged versus same-day surgery. Spine. 1991 Aug;16(8):930–3.