Spinal cord decompression via a modified costotransversectomy approach combined with posterior instrumentation for management of metastatic neoplasms of the thoracic spine. Fifteen patients with thoracic spinal cord compression from metastatic neoplastic processes were managed by spinal canal decompression via a modified costotransversectomy approach. Ten of the patients also underwent sequential posterior stabilization with Luque or Harrington instrumentation based upon proximity of the lesion to the thoracolumbar junction, prognosis for regaining or maintaining ambulatory ability, and additional spinal stability considerations. A modified lateral decubitus position with the scapula falling away from the side of exposure was used for T1-5 segment lesions, and a prone position was used for the (T-6)-(T-12) segment. Adequate decompression of the spinal canal was achieved in all cases. All patients who were ambulating preoperatively maintained ambulatory ability, and pain and/or further neurological improvement as well occurred in 75%. 