Pathology affecting the spinal cord structures and/or vertebral segments at the TLJ is not uncommon. Trauma is the most frequent cause of dysfunction-compression at these levels and may result in permanent neurological disability and vertebral column instability. Patients with TLJ pathology must be evaluated carefully and thoroughly with serial neurological examinations and diagnostic radiographic studies as outlined. The treatment of patients who are documented to harbor TLJ pathology must be individualized and is determined by the type, extent, and level of the lesion, the presence of dislocation and/or instability, and the degree of neurological compromise. Surgical decompression is the treatment of choice for patients with tumor or herniated disk. Many of the TLJ trauma patients may be managed nonoperatively, but surgical decompression and stabilization will be required in selected patients to maximize their long-term functional recovery. There are several viable surgical options and approaches available for the treatment of TLJ lesions, depending on individual patient pathology and the experience and expertise of the surgical team. In general, ventral compressive lesions, depending on individual patient pathology and the experience and expertise of the surgical team. In general, ventral compressive lesions must be approached via a ventral or ventrolateral exposure allowing decompression without injury to neural structures. In our experience, the "modified" costotransversectomy approach is an efficacious approach for treatment of TLJ pathology and incorporates both a decompression procedure and a stabilization-fusion procedure (when required) into the same operative setting.