Excision of the affected vertebral body, often combined with decompression of the spinal cord, is now widely used for the surgical management of infection, especially tuberculosis (Hodgson and Stock 1960), spinal tumours

with decompression of the spinal cord, is now widely used for the surgical management of infection, especially tuberculosis (Hodgson and Stock 1960), spinal tumours (Harrington 1981) and congenital spinal deformity (LeathermanandDickson1979). Therehasthusbeenan increasing interest in a direct surgical approach to vertebral bodies. Surgical approaches which allow exposure of the anterior aspect of virtually the full length of the spine have been described. The upper thoracic spine (Tl—T3), however, remains a problem. These vertebral bodies can be visualised through a standard thoracotomy which enters the chest through the bed ofthe third rib. Access is greatly restricted, however, by the scapula and the remaining ribs, making a vertebrectomy and spinal cord decompression very difficult. Reconstruction of the vertebral defect and instrumentation to give spinal stability are equally difficult. The anterolateral approach by a costotransversectomy (Capener 1954) is feasible at this level but, again, access is very limited and decompression of the spinal cord with spinal instrumentation over more than one level is difficult. This paper describes a surgical approach which allows direct exposure of the first, second and third thoracic vertebral bodies, thus making operation on this portion of the spine easier and less hazardous. Operation. The patient lies in the lateral position with the uppermost arm supported on an arm-rest in front of the chest and at shoulder level. The right-sided approach is preferred,asthe straightcourseof the brachiocephalic