BACKGROUND CONTEXT Anterior approaches to the thoracocolmbar junction (TLJ) are often required to restore anterior column deficiency after spinal trauma. Conventional open approaches are often associated with significant morbidity, and hence there is a need for a minimally invasive approach to TLJ fractures. PURPOSE To report the feasibility and effectiveness of the thoracoscopic transdiaphragmatic approach (TTA) in the management of TLJ fractures. STUDY DESIGN A retrospective analysis of 212 patients undergoing surgery at two institutions by the TTA with neurological outcomes, fusion rates and complications. PATIENT SAMPLE This is a two-institution study of 212 patients managed by TTA, from Berufsgenossenschaftliche Unfallklinik Marnau, a regional trauma facility located in Murnau, Bavaria, Germany, and from Stanford University, Stanford, California from May 1996 to June 2002. Patient ages ranged from 16 to 75 years (mean, 36 years) and included 158 males and 62 females. OUTCOME MEASURES The neurological status was assessed by the Frankel Neurological Performance scale pre- and postoperatively. Plain radiographs obtained 1 year postoperatively assessed fusion radiologically. METHODS All patients underwent spinal decompression, reconstruction and instrumentation by the TTA. Seventy-five patients had anterior instrumentation alone, whereas the remaining 137 had combined anterior and posterior instrumentation. A Z-Plate was used for spinal instrumentation from May 1996 to October 1999 and the MACS-TL system from November 1999 to June 2002. RESULTS Monosegmental, bisegmental and multisegmental fixations were used in 46%, 48% and 6% of cases, respectively. Follow-up ranged from 12 months to 6 years (mean, 3.9 years). Surgical durations ranged between 70 minutes and 7 hours (mean, 3.5 hours). Successful bony fusion with maintenance of satisfactory spinal alignment was observed in approximately 90% of our patients. Anterior screw loosening was seen in five cases (2.4%), four involving the Z-Plate system and the other involving the MACS-TL system. Three patients (1.4%) required conversion to an open procedure. Access-related complications, such as pleural effusion, pneumothorax and intercostal neuralgia, were seen in 12 patients (5.7%). Three patients (1.4%) had superficial portal infections. We encountered no diaphragmatic herniations. CONCLUSIONS TTA provides excellent access to the entire TLJ, permitting satisfactory spinal decompression, reconstruction and instrumentation. Diaphragmatic opening and repair can be accomplished safely and effectively without special endoscopic instrumentation. It also precludes the need for retroperitoneoscopic or open thoracoabdominal approaches and thus avoids the associated significant morbidity.