Introduction: Isolated dorsal instrumentation in thoraco-lumbar spine fractures may lead to loss of reduction after implant removal and subsequent re-kyphosing. Thus, reconstruction of the anterior body defect using expandable cages or allografts in addition to dorsal stabilization may enhance stability. Patients and Methods: In the following study we report on 89 patients (30 female, 59 male) with a mean age of 46.5 ± 20.6 years (MW ± SEM) who sustained unstable fractures or tumor destruction of the thoraco-lumbar spine. Fracture care included primary dorsal stabilization by internal fixator. All patients received in a second step ventral corporectomy and vertebral body replacement by expandable titanium cages (n = 75; Ulrich, Germany) or iliac crest bone grafts (n = 14). From T3 to L1 a thoracoscopic anterior approach was performed; L3 to L5 region was assessed by lumbotomy. In addition, the anterior column was stabilized by a fixed-angle plate (MACS, Aesculap, Germany) since 2002. Results: The operating time for the anterior approach averaged 160 ± 42 min. Patients tolerated the thoracoscopic approach well. We experienced no cage dislocation in the group of patients with fixed-angle plate fixation (before 2002 n = 4). There were n = 11 (9.8%) complications (aortic injury n = 1, iliac vein injury n = 1, cerebrospinal fluid leak n = 4, wound infection n = 5). Conclusion: Combined posterior–anterior stabilization of the thoraco-lumbar spine allows for a meticulous reconstruction and stabilization of graduated height of the anterior column. Primary dorsal instrumentation leads to tension stability and simplifies reduction. An additional anterior fixed-angle plate system may help to prevent cage dislocation.