Despite the disadvantages, thoracoscopy has been shown to reduce the incidence of pulmonary morbidity, intercostal neuralgia, and shoulder girdle dysfunction nearly versus open thoracotomy [8, 23, 28]. Patients suffer significantly less pain and incisional morbidity in thoracoscopic cases, with a lower rate of postthoracotomy pain syndrome [21]. Overall complication rates have been quoted to be significantly lower than those reported for thoracotomy, which ranges from 9 to 11.5% incidence of major complication [5, 7]. Nevertheless, the rate of complications including atelectasis, pneumothorax, hemothorax, and pleural effusion are still considerable, ranging from 14.1 to 29.4% [11, 29, 30]. Additionally, the burden of chest tube placement can still cause significant pain and limitation of postoperative patient mobilization.

3. Retropleural McCormick and Moskovitch described the retropleural approach to the anterolateral thoracic spine in the early 1990s as a method to avoid the morbidity associated with thoracotomy [31, 32]. Employing a retropleural approach allows for a ventral decompression without requiring entrance into the pleural cavity. McCormick’s report described 15 patients undergoing treatment ranging from discectomy to two-level corpectomy. In his surgical technique, a 12cm incision is performed from the posterior axillary line to 4cm lateral of midline, with exposure and removal of 8�C10cm of the rib. The endothoracic fascia is incised and dissected off of the parietal pleura, leaving a plane with only slight areolar tissue, which is dissected until the endothoracic fascia is opened over the rib head.

The costovertebral ligaments and proximal rib head are taken down to expose the vertebral body, facilitating corpectomy and reconstruction. Pleural tears are repaired primarily, and a chest tube is not required unless a significant tear is encountered. In the series of fifteen patients, adequate decompression and reconstruction were performed in all cases, although four patients did require chest tube placement. The significant exposure-related morbidity of this approach has limited its appeal and usage. Recent descriptions of a minimally invasive retropleural approach, however, have reopened the anterolateral corridor for corpectomy. Scheufler described a minimally invasive variant of the retropleural approach in 38 patients [33].

He made a 5-6cm incision laterally, removed an 8�C10cm segment of the rib, and dissected between the endothoracic fascia and pleura towards the rib head. He then placed retracting blades in a 360-degree fashion and performed anterolateral corpectomy. Four out of thirty-eight patients ultimately required Batimastat chest tube drainage, and all patients had adequate decompression and insertion of instrumentation. Uribe et al. furthered this approach by describing a tubular retractor based retropleural approach in a cadaveric series and a small patient series [12].