Standard anterior approach to the thoracic spine is by a posterolateral thoracotomy. Because of the morbidity associated with this incision, video-assisted thoracic surgery (VATS) has been used as a less invasive approach for many intrathoracic disease processes. We have applied VATS for anterior access to the thoracic spine. From April 1991 to September 1994, 95 patients underwent thoracic spine procedures using thoracoscopy as the sole method of anterior approach. Procedures performed include discectomy for herniation (n = 57), multilevel discectomy for correction of spinal deformity (27), corpectomy (9), and drainage of intervertebral disc space abscess (2). All levels of the thoracic spine from the T2-T3 level to the T12-L1 interspace were approached. Forty-four procedures were performed through the left side of the chest and 41 through the right. The planned procedure was accomplished by VATS in all but 1 patient who required conversion to an open procedure because of scarring from a previous spine procedure. Mean operative time was 2 hours 24 minutes (range, 45 minutes to 5 hours 10 minutes). Average chest tube duration was 1.4 days, and mean length of stay was 4.82 days (range, 2 to 21 days). Complications included intercostal neuralgia (6), atelectasis (5), excessive epidural blood loss (2,500 mL; 2) and temporary paraparesis in a scoliosis patient related to operative positioning. We conclude that VATS offers a new, less morbid anterior approach to the thoracic spine. Although there is a significant learning period, most procedures requiring an anterior access can be performed safely by this technique. The VATS approach mandates an expanded role for the thoracic surgeon in operative spine disease.