Ventrolateral transthoracic minimally invasive techniques, including the mini-open and endo­scopic approaches, have become more popular given the morbidity documented with conven­tional open transthoracic and thoracoabdomi­nal approaches to the thoracic spine [ 29 , 30 ]. Scheuffl er et al. retrospectively studied 38 patients with thoracic and thoracolumbar spon­dylosis, trauma, or metastasis who underwent minimally invasive vertebral body replacement with cages using an anterolateral retropleural (ALRA) or a combined lateral extrapleural/extra­peritoneal thoracolumbar approach (CLETA). They noted successful completion of each sur­gery without conversion to conventional open approach, 19.3° of average kyphotic correction, and results that are similar to those of standard open and endoscopic techniques [ 2 , 31 , 32 ]. The authors noted the reduction of sagittal deformity exclusively by anterior distraction using expand­able cages with no subsidence or loss of correc­tion over an 18-month follow-up period [ 2 ]. In three severely osteopenic patients in this series, cement augmentation was done at the adjacent vertebrae [ 2 ]. In a select group of patients with preexistent pulmonary disease, the ALRA and CLETA minimally invasive approaches have been shown in small studies to reduce the peri­operative risks commonly encountered with the conventional endoscopic and anterolateral trans­thoracic approaches [ 2 ]. Additionally, dimin- ished operative time, decreased intraoperative blood loss, absence of post-thoracotomy pain, and successful sagittal/coronal deformity correc­tion are all favorable factors with these minimally invasive approaches [ 33 ].