Mini-open thoracoscopically assisted thoracotomy versus video-assisted thoracoscopic surgery for anterior release in thoracic scoliosis and kyphosis: a comparison of operative and radiographic results

The Thoracoscopic Approach in Spinal Cord Disease

Video-assisted thoracic surgery (VATS) has been growing in popularity over the past 2 decades as an alternative to open thoracotomy for the treatment of several spinal conditions, and in the field of minimally invasive surgery, it now acts as a keyhole to the thoracic spine.

MATERIALS AND METHODS

Most VATS approaches are from the right side for pathologies involving the middle and upper thoracic spine because there is a greater working spinal surface area lateral to the azygos vein than that lateral to the aorta. Below T-9, a left-sided approach is made possible because the aorta moves away from the left posterolateral aspect of the spine to an anterior position as it passes through the diaphragm.

RESULTS

VATS has been used extensively in spinal deformities such as scoliosis. The use of VATS in spine surgery includes the treatment of thoracic prolapsed disk diseases, vertebral osteomyelitis, fracture management, vertebral interbody fusion, tissue biopsy, anterior spinal release, and fusion without or with instrumentation (VAT-I) for spinal deformity correction. As the knowledge and the comfort of using such techniques have expanded, the indications have extended to corpectomy for tumor resections.

DISCUSSION AND CONCLUSIONS

In the field of minimally invasive surgery, VATS now acts as a keyhole to the thoracic spine and an alternative to open thoracotomy for the treatment of several spinal conditions.Although VATS can be performed in such spine conditions, it is most beneficial in the treatment of scoliotic deformity, which requires taking a multilevel approach, from the upper to the lower thoracic spine.

An unusual presentation of thoracic diffuse idiopathic skeletal hyperostosis (DISH) and video-assisted thoracoscopic surgery (VATS)

Introduction and importance

Diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier's disease and Forestier and Rotes-Querol disease, is a systemic condition characterized by calcification and ossification of ligaments and entheses which often mainly affects the thoracic spine. Anterior osteophyte compression of the esophagus resulting in dysphagia and dyspepsia is extremely rare in symptomatic thoracic DISH.

Case presentation

A 72-year-old male presented with dyspepsia and dysphagia for 10 months. A large beak-like anterior osteophyte, detected by a radiographic study and by a Barium esophagogram test at the T9-T10 level of the thoracic spine, was established by gastrointestinal medicine specialists to be the cause of the symptoms. The large anterior osteophyte was removed using video-assisted thoracoscopic surgery (VATS). At the one-year follow-up, the patient's symptoms had significantly improved and there was no recurrence of the osteophyte or the dyspepsia and dysphagia.

Clinical discussion

Thoracic DISH rarely presents with dysphagia and dyspepsia due to the greater mobility of the esophagus in the area of the thoracic spine than in the area of the cervical spine. This is the first reported case of symptomatic thoracic DISH treated by anterior thoracic osteophytectomy with VATS. The treatment was effective with no post-operative complications.

Conclusion

Anterior thoracic osteophytectomy with VATS is an effective surgical treatment option for this condition.

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Diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier's disease and Forestier and Rotes-Querol disease, is an extremely rare form of symptomatic thoracic DISH.

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Secondary dysphagia and dyspepsia can be caused by a giant beak-like anterior osteophyte at the T9-T10 levels of the thoracic spine.

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Surgical management with video-assisted thoracoscopic surgery (VATS) provides results superior to non-surgical treatments.

Early operative morbidity in 184 cases of anterior vertebral body tethering

Fusion is the current standard of care for AIS. Anterior vertebral body tethering (AVBT) is a motion-sparing alternative gaining interest. As a novel procedure, there is a paucity of literature on safety. Here, we report 90-day complication rates in 184 patients who underwent AVBT by a single surgeon. Patients were retrospectively reviewed. Approaches included 71 thoracic, 45 thoracolumbar, 68 double. Major complications were those requiring readmittance or reoperation, prolonged use of invasive materials such as chest tubes, or resulted in spinal cord or nerve root injury. Minor complications resolved without invasive intervention. Mean operative time and blood loss were 186.5 ± 60.3 min and 167.2 ± 105.0 ml, respectively. No patient required allogenic blood transfusion. 6 patients experienced major (3.3%), and 6 had minor complications (3.3%). Major complications included 3 chylothoracies, 2 hemothoracies, and 1 lumbar radiculopathy secondary to screw placement requiring re-operation. Minor complications included 1 patient with respiratory distress requiring supplementary oxygen, 1 superficial wound infection, 2 cases of prolonged nausea, and 1 Raynaud phenomenon. In 184 patients who underwent AVBT for AIS, major and minor complication rates were both 3.3%.

Essential lordosis revisited

AIMS

Significant correction of an adolescent idiopathic scoliosis in the coronal plane through a posterior approach is associated with hypokyphosis. Factors such as the magnitude of the preoperative coronal curve, the use of hooks, number of levels fused, preoperative kyphosis, screw density, and rod type have all been implicated. Maintaining the normal thoracic kyphosis is important as hypokyphosis is associated with proximal junctional failure (PJF) and early onset degeneration of the spine. The aim of this study was to determine if coronal correction per se was the most relevant factor in generating hypokyphosis.

METHODS

A total of 95 patients (87% female) with a median age of 14 years were included in our study. Pre- and postoperative radiographs were measured and the operative data including upper instrumented vertebra (UIV), lower instrumented vertebra (LIV), metal density, and thoracic flexibility noted. Further analysis of the post-surgical coronal outcome (group 1 < 60% correction and group 2 ≥ 60%) were studied for their association with the postoperative kyphosis in the sagittal plane using univariate and multivariate logistic regression.

RESULTS

Of the 95 patients, 71.6% (68) had a thoracic correction of > 60%. Most (97.8%) had metal density < 80%, while thoracic flexibility > 50% was found in 30.5% (29). Preoperative hypokyphosis (< 20°) was present in 25.3%. A postoperative thoracic hypokyphosis was four times more likely to occur in patients with thoracic correction ≥ 60% (odds ratio (OR) 4.08; p = 0.005), after adjusting for confounding variables. This association was not affected by metal density, thoracic flexibility, LIV, UIV, age, or sex.

CONCLUSION

Our study supports the 'essential lordosis' hypothesis of Roaf and Dickson, i.e. with a greater ability to translate the apical vertebra towards the midline, there is a commensurate lengthening of the anterior column due to the vertebral wedging. Cite this article: Bone Joint J 2020;102-B(4):513-518.

A unilateral less invasive posterolateral approach for disc debridement and titanium cage insertion supplemented by contralateral transfascial screw fixation for high-morbidity patients suffering from septic thoracolumbosacral spondylodiscitis

PURPOSE

This case series reports on the efficacy and safety of a less invasive posterolateral approach for septic thoracolumbosacral spondylodiscitis in high-morbidity patients.

METHODS

Twenty consecutive severe sick (ASA > III) patients (14 men and 6 women), with an average age of 64 ± 14 years, suffering from septic subacute and chronic thoracolumbosacral spondylodiscitis were selected to undergo a one-stage less invasive unilateral posterolateral disc space debridement, supplemented by an ipsilateral titanium cage implantation and pedicle screw fixation plus a contralateral transfascial pedicle screw fixation.

RESULTS

Two high-risk patients with severe comorbidities (ASA stage IV and V, respectively) died on days 1 and 8 postoperatively because of non-surgical complications such as massive lung embolism and acute myocardial infract, respectively. Three patients with incomplete paraplegia (ASIA C) preoperatively were improved after the surgery to ASIA D (two patients) and E (one patient), respectively, while there was no neurological deterioration in any patient postoperatively. From the 18 patients that survived, ten patients were available for the final follow-up 8.8 ± 2.7 years postoperatively. In two patients with spondylodiscitis caused by gram(-) bacteria, the posterior instrumentation was finally removed because of asymptomatic fistula emerging from posterior instrumentation solely, 15 and 19 months after surgery. The survivals at 2.5 and 10 years with revision as end point was 87.4% (95% CI 58.1-96.7); while in the "worst case scenario" the survivals at 2.5 and 10 years were: 66.7% (95% CI 40.4-83.4%); 47.7% (95% CI 23.2-68.8%) and 47.7% (95% CI 23.2-68.8%), respectively.

CONCLUSIONS

The less invasive posterolateral approach for disc debridement and titanium cage insertion seems to be an alternative surgery for severe sick adult immunosuppressed patients with septic thoracolumbosacral spondylodiscitis that cannot tolerate traditional open transthoracic, thoracolumbar, retroperitoneal or combined approaches. The study has been registered in the Public Registry ClinicalTrials.gov PRS with the ID: NCT03472131.

Transthoracic approach for lesions involving the anterior dorsal spine: A multidisciplinary approach with good outcomes

Introduction:

Anterior approach provides excellent visualization and access to the anterior thoracic spine. It may be used alone, in combination with a posterior midline approach or in a staged or sequential fashion.

Aims:

To analyse our institutional experience in transthoracic approaches and to determine the safety and benefit of this approach in our patient series.

Materials and Methods:

A total of 16 patients were operated for varying lesions of body of dorsal vertebra by the transthoracic approach. The study was for a period of 5 years from January 2011 to December 2015. Patients age ranged from 25 to 61 years with an average of 36.4 yrs. There were 7 males and 9 females. In our series 9 patients had Kochs spine, 4 patients were traumatic fracture spine and 3 had neoplastic lesion. Majority of patients had multiple symptoms with backache being present in all patients.

Results:

There was one post operative mortality which was unrelated to surgery. One patient had post operative delayed kyphosis. Remaining patients improved in their symptoms following surgery.

Conclusion:

With careful coordination by thoracic surgeons, neurospinal surgeons and anaesthetists, the anterior spine approach for dorsal spine is safe and effective. Adequate preoperative evaluation should stratify the risk and institute measures to reduce it. Accurate surgical planning and careful surgical technique are the key to yield a good outcome and to reduce the risk of complications.

[Simultaneous thoracoscopically assisted anterior release in prone position and posterior scoliosis correction : What are the limits?]

BACKGROUND

In spite of modern pedicle-based systems, the correction of a rigid rib hump or hypokyphosis remains a problem in posterior-only scoliosis surgery. As there has so far been no reliable method of predicting the intraoperative extent of kyphosis restoration or rib hump correction by posterior-only surgery, it has been difficult to determine the indication for an additional anterior release.

METHODS

The method described here circumvents this dilemma. Like an optional module, horacoscopically assisted release in prone position (TARP) can be added when it is obvious during posterior surgery that the correction is insufficient.

RESULTS

Between 1996 and 2005, a total of 161 patients (115 male, 46 female) under the age of 30, including 113 cases of idiopathic scoliosis, were released by simultaneous TARP and posterior surgery. Using the two-portal technique, 131 were mobilized from the right and 30 from the left hand side. Average surgical time spanned 69 min, in which on average 3.2 apical segments were addressed. In 3 individuals, an additional retroperitoneoscopic release was used to liberate a rigid lumbar curve. After 10 years, in a prospectively evaluated subgroup of 32 patients with adolescent idiopathic scoliosis, the index curve had maintained a coronal correction of 70 % (immediately post-surgery 75 %), kyphosis was permanently normalized at 30° (Th5-Th12), and indirect rib hump was reduced to 2.2 cm. In 23 out of 32 patients the lumbar curve corrected spontaneously, obviating the need for fusion. In 13 patients, the lower instrumented vertebra lay at Th12 or higher, thus leaving the thoraco-lumbar junction fairly free. Minor complications (Huang 1or 2) occurred in 4 patients; 1 patient with hematothorax required revision. A distance <25 mm from the spine to the chest wall precludes TARP. Other limitations (e.g., pleural adhesions) were not encountered.

CONCLUSION

Long-term evaluation after 10-18 years shows that an additional thoracoscopically assisted anterior release at the same time as a posterior standard scoliosis procedure is a justified and effective tool, yielding better results and maintaining them.

Surgical management for thoracic spinal tuberculosis posterior only versus anterior video-assisted thoracoscopic surgery

STUDY DESIGN

A comparable retrospective study.

OBJECT

To compare the clinical outcomes of surgical treatment by posterior only and anterior video-assisted thoracoscopic surgery for thoracic spinal tuberculosis (TSTB).

METHOD

145 patients with TSTB treated by two different surgical procedures in our institution from June 2001 to June 2014 were studied. All cases were retrospectively analyzed and divided into two groups according to the given treatments: 75 cases (32F/43M) in group A performed single-stage posterior debridement, transforaminal thoracic interbody fusion and instrumentation, and 70 cases (30F/40M) in group B underwent anterior video-assisted thoracoscopic surgery (VATS). Clinical and radiographic results in the two groups were analyzed and compared.

RESULTS

Patients in group A and B were followed up for an average of 4.6±1.8, 4.4±1.2 years, respectively. There was no statistically significant difference between groups in terms of the operation time, blood loss, bony fusion, neurological recovery and the correction angle of kyphotic deformity (P>0.05). Fewer pulmonary complications were observed in group A. Good clinical outcomes were achieved in both groups.

CONCLUSIONS

Both the anterior VATS and posterior approaches can effectively treat thoracic tuberculosis. Nevertheless, the posterior approach procedure obtained less morbidity and complications than the other.

Pulmonary function after less invasive anterior instrumentation and fusion for idiopathic thoracic scoliosis

Purpose

Standard thoracotomy for anterior instrumentation and fusion of the thoracic spine in idiopathic scoliosis may have detrimental effects on pulmonary function. In this study we describe a less invasive anterior surgical technique and show the pre- and postoperative pulmonary function with a minimum follow-up of 2 years.

Methods

Twenty patients with Lenke type 1 adolescent thoracic idiopathic scoliosis were treated with anterior spinal fusion and instrumentation. The mean preoperative Cobb angle of the thoracic curve was 53° ± 5.8. Pulmonary function tests (PFT) and radiographic evaluation was performed.

Results

The mean postoperative correction in Cobb angle of the thoracic curve was 27° ± 8.2 (49%).

The mean preoperative FEV1 was 2.81 ± 0.43 L, which increased to 3.14 ± 0.50 L at 2 years postoperatively (P = 0.000). The mean FEV1% did not change (89.60 ± 7.49% preoperatively, versus 90.53 ± 5.95% at 2 years follow-up, P = 0.467). The TLC increased from 4.62 ± 0.62 L preoperatively to 5.17 ± 0.63 L at 2 years follow-up (P = 0.000). The FEV1% at two years of follow-up improved to 104% of the FEV1% predicted value. The FEV1 improved to 97% of the FEV1 predicted value.

Conclusion

Anterior spinal fusion for idiopathic scoliosis by means of a minimal open thoracotomy proved to be a safe surgical technique that resulted in an improvement of pulmonary function. Our results are similar to those of thoracoscopic procedures reported in literature.

The impact of a distal expansion mechanism added to a standard pedicle screw on pullout resistance. A biomechanical study

BACKGROUND CONTEXT

Spinal deformity surgery in elderly patients is associated with an increased risk of implant loosening due to failure at the screw-bone interface. Several techniques can be used to increase the screw anchorage characteristics. Cement-augmented screw fixation was shown to be the most efficient method; however, this technique is associated with a risk of complications related to vertebral cement deposition and leakage. Hence, there is a need to further elaborate the alternative screw augmenting techniques to reduce the indications for bone cement.

PURPOSE

To analyze surgical alternatives to cement augmentation, the present study sought to quantify the impact of a distal expansion mechanism added to a standard pedicle screw on an axial pullout resistance.

STUDY DESIGN

A biomechanical laboratory study on the uniaxial pullout resistance of a standard pedicle screw versus a customized pedicle screw with a distal expansion mechanism.

METHODS

A total of 40 vertebrae from seven fresh-frozen human specimens were harvested and subjected to a computed tomography scanning and an analysis of the bone mineral density (BMD). The vertebrae were instrumented with a standard 6.0-mm pedicle screw and a modified 6.0-mm pedicle screw with a distal expansion mechanism added. The actual working length of both screws inside the vertebrae was identical. The distal expansion mechanism made up one-fifth of the shaft length. The accuracy of the screw insertion was assessed using biplanar radiographs and by inspection. Analysis of resistance to pullout was performed by a coaxial alignment of the pedicle screws and attachment to an electromechanical testing machine. The pullout rate was 5 mm/min, and the load-displacement curve was recorded until the force of the pullout resistance peaked. The peak load-to-failure was measured in Newtons and reported as the ultimate failure load. With each test, the mode of failure was noted and analyzed descriptively.

RESULTS

A total of 17 vertebrae with matched pairs of standard and expansion pedicle screws were eligible for the final statistical analysis. The BMD of the vertebrae tested was 0.67±0.19 g/cm³. The screw length was 50 mm, and the actual working length of both screws was 40.3±4.2 mm. The ultimate failure load of the standard screw was 773.8±529.4 N and that of the expansion screw was 910.3±488.3 N. Statistical analysis revealed a strong trend toward an increased failure load with the expansion screw (p=.06). The mean increase of the ultimate failure load was 136.5±350.4 N. Abrupt vertebral fracture at the vertebral body-pedicle junction and the pedicle occurred seven times with the expansion screw and only five times with the standard screw (p=.16).

CONCLUSIONS

Our study indicates that adding a distal expansion mechanism to a standard pedicle screw increases the failure load by one-fifth. Modern expansion screws might offer an intermediate solution for the augmentation of screw-rod constructs in osteoporotic bone while reducing the need for cement-augmented screws and avoiding the related risks.

Multivariate analysis of factors associated with kyphosis maintenance in adolescent idiopathic scoliosis

STUDY DESIGN

Multicenter retrospective cohort study of 269 patients.

OBJECTIVE

The purpose of this study is to evaluate the surgical and radiographical factors in adolescent idiopathic scoliosis (AIS) surgery that significantly affect kyphosis maintenance.

SUMMARY OF BACKGROUND DATA

Decreased kyphosis in the thoracic spine is a component of the 3-dimensional deformity in AIS. Suboptimal sagittal alignment after spinal fusion has been identified as a possible cause of lumbar and cervical spinal degeneration and junctional malalignment. Segmental spinal instrumentation continues to evolve, and although excellent coronal plane correction is readily achieved, sagittal plane thoracic hypokyphosis may be seen postoperatively.

METHODS

A retrospective analysis of prospectively collected data from a multicenter AIS database was performed to evaluate factors associated with kyphosis maintenance. A total of 526 patients were enrolled in the database and had a mean thoracic kyphosis (T5-T12) of 22°. In total, 269 patients were identified who had kyphosis of less than 22° and thus comprised the group to be included in this analysis. A complete radiographical series was obtained for each patient preoperatively, immediately postoperatively, and at 2 years postoperatively. All operative data, including the number of levels fused and implant type and density, were also recorded. Multivariate and regression analysis were performed.

RESULTS

Eight variables were found to be significantly correlated with kyphosis maintenance at 2 years postoperatively. Anterior approach (r = 0.37, P < 0.001), increased thoracic coronal curve (r = 0.20, P = 0.001), and a greater percentage of hooks in the construct (r = 0.18, P = 0.034) were associated with increased kyphosis at follow-up. A greater number of levels fused (r = -0.33, P < 0.001), preoperative kyphosis (r = -0.39, P < 0.001), percentage of screws in the construct (r = -0.18, P = 0.03), using standard stainless steel rods (r = -0.47, P = 0.011), and percent decrease in thoracic curve (r = -0.23, P < 0.001) all were correlated with hypokyphosis at follow-up.

CONCLUSION

Our multivariate analysis demonstrates that in patients with AIS who have thoracic hypokyphosis as part of their deformity, certain factors must be taken into account in the preoperative planning to prevent hypokyphosis after surgical correction.

Natural orifice translumenal endoscopic surgery for anterior spinal procedures

Background. NOTES techniques allow transesophageal access to the mediastinum. The aim of this study was to assess the feasibility of transesophageal biopsy of thoracic vertebrae. Methods. Nonsurvival experiments on four 50-kg porcine animals were performed. Transesophageal access to the mediastinum was attained using submucosal tunneling technique. Results. The posterior mediastinum was successfully accessed and navigated in all animals. Vertebral bodies and intervertebral spaces were easily approached while avoiding damage to adjacent vessels. Bone biopsy was successfully performed without complications, but the hardness of bone tissue resulted in small and fragmented samples. Conclusions. Peroral transesophageal access into the posterior mediastinum and thoracic vertebral bone biopsy was feasible and safe. The proximity of the esophagus to the vertebral column provides close and direct access to the thoracic spine and opens up new ground for the performance of multilevel anterior spine procedures using NOTES techniques.

Anterior debridement and reconstruction via thoracoscopy-assisted mini-open approach for the treatment of thoracic spinal tuberculosis: minimum 5-year follow-up

INTRODUCTION

Video-assisted thoracoscopic surgery (VATS) has been developed for surgical treatment of thoracic spinal tuberculosis to overcome the problems associated with a formal thoracotomy. VATS, however, is technically demanding with a difficult learning curve.

MATERIALS AND METHODS

We conducted a retrospective long-term follow-up study of anterior debridement and reconstruction via a thoracoscopy-assisted mini-open approach for the surgical treatment of thoracic spinal tuberculosis. There were 50 patients collected with mean age 38.3 years with thoracic spinal tuberculosis.

RESULTS

The average operative time was 210 min (range 170-300 min), the average blood loss during operation was 550 ml (range 300-1,000 ml), and the mean chest drainage duration was 3.5 days (3-5 days). Complications occurred in 17 patients (34%). The mean follow-up was 6.5 years. There was statistically difference in VAS 3 months after surgery compared to preoperatively (P<0.001), as well as final follow-up compared to 3 months post-op (P<0.001). In patients with minor pulmonary impairment as measured by pulmonary function testing, 15 improved to normal and 5 had no change. In patients with moderate pulmonary impairment, 6 improved to normal and 2 improved to minor impairment at final follow-up. Neurological improvement of one to three grades had occurred in 26 patients by final follow-up. There was statistically difference in kyphotic angle 3 months after surgery compared to preoperatively (P<0.05), as well as final follow-up compared to 3 months post-op (P<0.001). The average correction rate of kyphotic angle was 38.7% and the loss of correction rate was 1.3% at final follow-up. No recurrent tuberculosis was found.

CONCLUSION

Thoracoscopy-assisted mini-open approach can provide a simple, safe, and practical treatment option with minimal invasiveness in cases of thoracic spinal tuberculosis. Successful clinical and radiographic outcomes can be achieved via anterior debridement and reconstruction at long-term follow-up.

The morbidity of open transthoracic approach for anterior scoliosis correction

STUDY DESIGN

Retrospective study.

OBJECTIVE

To analyze the patient satisfaction and the patients' perceived approach-related morbidity (ArM) after open thoracotomy (OTC) for instrumented anterior scoliosis surgery.

SUMMARY OF BACKGROUND DATA

There is no mid- to long-term data on the patients' perceived ArM concerning chest wall dissection for open anterior scoliosis correction.

METHODS

A specific questionnaire was used to retrospectively evaluate mid- to long-term follow-up data concerning ArM after OTC of patients younger than 30 years (range, 11-28 years) who underwent anterior open transthoracic scoliosis surgery. The questionnaire was comprised of detailed scar-related questions. Applying strict inclusion criteria, we could analyze outcomes in terms of percentage morbidity (morbidity [%]) of 40 patients who underwent OTC for instrumented scoliosis correction.

RESULTS

Mean age of the patients was 16 ± 3.8 years, follow-up was 61.5 ± 72.6 months on average, and mean incision length was 25.7 ± 3.1 cm. Mean number of levels fused was 5.9 ± 1.5. Single thoracotomy was performed in 25 patients and a thoracoabdominal approach in 15 patients. Mean morbidity (0%, not delineating no ArM; 100%, delineating highest ArM) was 5.4% ± 11.3%; 47.5% of patients had no morbidity; 12.5% had morbidity >10% (mean: 28.5%). Signs of intercostal neuralgia (ICN) were present in 10%. Patients judged their clinical outcome as "good" in 20% and "excellent" in 80%. Statistical analysis did not reveal differences in outcomes and percentage morbidity concerning age of patients, extent of approach (thoracotomy vs. thoracoabdominal approach) and incision length, gender, or follow-up length. However, the presence of ICN had a significant effect on the outcome, showing high correlation with increased morbidity (P < 0.0001). In the clinical judgment of outcomes, the severity of the ArM after OTC was mild, except for 2 patients who had moderate approach and scar-related morbidity.

CONCLUSION

ArM after open thoracic spinal surgery or thoracoscopic procedures can be assessed using the questionnaire. The current study showed that ArM in young patients who underwent OTC for anterior instrumented scoliosis correction was low. Patients with increased signs of ICN did worse in terms of the questionnaire survey. The study showed that neither cosmesis nor scar-related problems were a concern for patients undergoing OTC.

Approach-related morbidity in transthoracic anterior spine surgery: a clinical study and review of literature

BACKGROUND: Anterior access to the thoracic spine is done by open thoracotomy (OTC) or video-assisted thoracoscopic surgery (VATS). VATS is known as the method which results in lower morbidity rates, but there is little evidence of its less invasiveness. Objective: The current study yielded for outcome data concerning patients' perception of approach-related morbidity (ArM) following OTC for spinal surgery and that of a control group having a chest tube thoracotomy (CTT). METHODS: We performed a questionnaire assessment of ArM after OTC and CTT. Applying strict inclusion criteria, we compared outcomes in terms of percentage morbidity (Morbidity %) of 43 patients that underwent OTC for instrumented scoliosis correction to 30 patients that had CTT for minor thoracic pathologies (e.g., pneumothorax). RESULTS: Mean age in CTT and OTC Group was 50.2 and 16.5 years old, follow-up was of 32.2 and 58.4 months, and mean incision length was 2.5 and 25.5 cm, respectively. Mean number of levels fused in the OTC Group was 5.8. Mean morbidity (0% delineating no cases, 100% delineating highest morbidity) for the CTT Group was 10.8±15.4% (0-59.5%), 42% of patients had no morbidity. Signs of intercostal neuralgia (ICN) were present in 16.7%. A total of 35.5% had a morbidity >10% (mean: 27.5%), and 10% of morbidity cases were defined as having a chronic post-thoracotomy pain (CPP). In the OTC Group, mean morbidity was 7.0±12.7% (0-52.1%), 44% had no morbidity. Out of the sample, 18.6% had morbidity >10% (mean: 28.6%). Signs of ICN were present in 14%. In both groups, the presence of ICN had a significant impact on and showed correlation with morbidity (p<0.0001). In terms of clinical judgement, the severity of the ArM after a CTT or OTC was generally mild except for one patient in each group. Age and follow-up were significantly different between groups (p<0.0001, p=0.02), but the intergroup difference in morbidity was not significant (p=0.08). CONCLUSIONS: ArM after open thoracic spinal surgery or VATS procedures can be assessed using the questionnaire. To put ArM of OTC into perspective, a Control Group with simple CTT was selected, demonstrating that morbidity was not different between the OTC and CTT groups. Patients with increased signs of ICN do worse which was reflected by increased morbidity in both groups. The study demonstrates that not only the cosmesis is not a concern for patients undergoing OTC, but neither is the ArM a concern, equalling that of a simple CTT.

Thoracoscopy-assisted mini-open surgery for anterior column reconstruction in thoracic spinal tuberculosis

OBJECTIVE

To evaluate the clinical effects of thoracoscopy-assisted mini-open surgery for anterior column reconstruction in thoracic spinal tuberculosis.

METHODS

Fifty-eight patients, 35 men and 23 women, aged 39.2 (range, 19-60) years with thoracic spinal tuberculosis with an average kyphotic angle of 29.2° (range, 18°-42°) underwent thoracoscopy-assisted mini-open surgeries, including thorough debridement and anterior spinal reconstruction. According to the Frankel Grading system, preoperative neurological function was judged as Grade B in 3 cases, Grade C in 7, Grade D in 28, and Grade E in 20. All patients were followed up for an average of 4.6 years. Outcomes were evaluated retrospectively.

RESULTS

Surgery was accomplished successfully in all cases. The average operation time was 230 min (range, 180-320 min), the average intraoperative blood loss 570 ml (range, 350-1200 ml), and the mean drainage duration 3.6 days (3-5 days). Complications occurred in 19 patients (32.8%). Neurological improvement of one to three grades had occurred in 29 patients by final follow-up. The average correction rate of the kyphotic angle was 36.4%, and no obvious correction loss was detected during follow-up. No recurrent tuberculosis was found in the group.

CONCLUSIONS

Thoracoscopy-assisted mini-open surgery provides a simple, safe, effective, and practical technology with minimal invasiveness for the treatment of thoracic spinal tuberculosis.

Thoracic pedicle screw instrumentation: the learning curve and evolution in technique in the treatment of adolescent idiopathic scoliosis

STUDY DESIGN

Retrospective review.

OBJECTIVE

The purpose of this study is to evaluate the learning curve and associated evolution in surgical technique with thoracic pedicle screw instrumentation in adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Common treatment for AIS now includes posterior spinal fusion, using thoracic pedicle screws (TPS). It is critical to assess the efficacy, safety profile, and learning curve associated with this technique as its use becomes more widespread among inexperienced surgeons.

METHODS

Retrospective review of the senior author's first 96 TPS cases for Lenke Type I AIS curves. Multiple regression techniques were used to discern whether increasing case number (CN) was associated with improved perioperative and 2-year minimum radiographic and clinical outcomes. The 96 cases were divided into 4 equal quartiles of 24 cases/group (i.e., Q1-Q4) and compared using analysis of variance measures.

RESULTS

A total of 1169 thoracic pedicle screws were placed in 96 patients. We found a significant correlation between CN and major curve correction at 2 years (P < 0.0001), inverse correlation between CN and length of stay (P = 0.02), and estimated blood loss (P = 0.03), but no differences in cell saver or complications. Univariate analysis revealed significant inverse correlations between increasing CN and transfusion rate (P = 0.02) and operative times (P = 0.0001). Total number of screws placed (Q1:9.4 vs. Q4:16.2, P < 0.0001) and number of screws/level (Q1:0.98 vs. Q4:1.64, P < 0.0001) increased linearly with increasing CN, whereas the average time for screw placement (Q1:24.2 vs. Q4:11.4 minutes, P < 0.0001) and ability to maintain T2-T12 kyphosis decreased (Q1:0.21 vs. Q4:-5.5 P = 0.02) with increasing CN.

CONCLUSION

There is a significant learning curve associated with thoracic pedicle screw placement in AIS. We describe several technical steps that can be taken to increase the safety of screw placement at the beginning of the learning curve. Inexperienced surgeons should expect a gradual improvement over time in radiographic and clinical outcomes.

The effect of anterior spinal fusion on spinal canal development in an immature porcine model

STUDY DESIGN

Experimental study.

OBJECTIVE

To investigate whether anterior spine fusion in the immature porcine spine has an adverse effect on the development of spinal canal.

SUMMARY OF BACKGROUND DATA

Neurocentral cartilage (NCC) is located in the posterior vertebral body and responsible for the development of posterior aspect of the spinal canal. Injury to the NCC interferes with the development of the spinal canal.

METHODS

Twelve 8-week-old domestic pigs were used to develop an anterior fusion model. A standard procedure as L3-L4, L4-L5 discectomy, and L3-L5 anterior instrumented spine fusion was performed. To evaluate the development of the spinal canal, all subjects had computed tomography scans before the procedure and at the final follow-up. The spinal canal area was measured at the control level (CL) (L2), arthrodesis level (AL) (L4), superior (L3), and inferior (L5) instrumented level (SIL and IIL). Percent change in spinal canal area from before surgery to final follow-up was also calculated. RESULTS.: Eleven subjects were available for the study. All subjects developed local kyphosis over the fused segments. The average area of L2 (CL) was 0.56 +/- 0.06 cm before surgery. The average areas of the L3 (SIL), L4 (AL), and L5 (IIL) were 0.62, 0.70, and 0.77 cm, respectively. At the final follow-up the average area of L2 was 1.20 cm. The average areas of the SIL, AL, and IIL were 1.16, 1.19, and 1.33 cm, respectively. The percent increase in spinal canal area at the CL was 116.6% whereas it was 85.8%, 71.0%, and 71.2% at SIL, AL, and IIL, respectively.

CONCLUSION

Anterior spinal arthrodesis in the immature porcine spine results in iatrogenic retardation on spinal canal growth. This effect is most likely related to the tethering effect of the interbody fusion over the NCC. Although, it is difficult to directly extrapolate these findings to clinical practice, the spine surgeons operating on pediatric patients should be aware of this possibility.

Video-assisted thoracoscopic spinal fusion compared with posterior spinal fusion with thoracic pedicle screws for thoracic adolescent idiopathic scoliosis

BACKGROUND

Although the gold standard for the surgical treatment of thoracic adolescent idiopathic scoliosis has been posterior spinal fusion, video-assisted thoracoscopic surgery recently has become a viable alternative. In the treatment of structural thoracic curves, video-assisted thoracoscopic surgery has demonstrated outcomes equivalent to those of posterior spinal fusion with use of an all-hook or hybrid pedicle screw-hook construct. No study to date, however, has compared this technique with posterior spinal fusion with thoracic pedicle screws, which has become the current standard of care.

METHODS

A matched-pair analysis of thirty-four consecutive patients (seventeen pairs) undergoing either video-assisted thoracoscopic surgery or posterior spinal fusion with thoracic pedicle screws for the treatment of structural scoliosis was performed; the study included eight male and twenty-six female patients with an average age of 15.0 years. Pairs were matched according to curve type and magnitude, patient age, and sex. Clinical data, the results of the Scoliosis Research Society questionnaire, and radiographic data were collected preoperatively and at a minimum of two years postoperatively and were compared between the groups.

RESULTS

Video-assisted thoracoscopic surgery was associated with significantly increased operative times (mean, 326 compared with 246 minutes; p = 0.033) and reduced blood loss (mean, 371 compared with 1018 mL; p = 0.001), but there were no differences between the groups in terms of the transfusion rate (18% compared with 29%; p = 0.69) or the length of stay. The percentage correction of the major curve was 57.3% for the video-assisted thoracoscopic surgery group and 63.8% for the posterior spinal fusion group (p = 0.08). With the numbers available, no differences were detected in terms of the cephalad thoracic curve, caudad compensatory lumbar curve, coronal balance, thoracic kyphosis, lumbar lordosis, sagittal balance, end vertebra tilt angle, or angle of trunk rotation measurements preoperatively or at the time of the latest follow-up. The average number of fused levels was 5.9 in the video-assisted thoracoscopic surgery group and 8.9 in the posterior spinal fusion group (p < 0.001). Relative to the Cobb end vertebra, the most caudad instrumented vertebra was 0.81 level more cephalad in the video-assisted thoracoscopic surgery group as compared with the posterior spinal fusion group (p = 0.004). No significant differences were detected in any of the questionnaire outcomes at any time point. Although both groups experienced similar improvement from baseline in terms of pulmonary function at two years, the posterior spinal fusion group had significantly improved peak flow measurements (p = 0.04) in comparison with the video-assisted thoracoscopic surgery group.

CONCLUSIONS

For single thoracic curves of <70 degrees in patients with a normal or hypokyphotic thoracic spine, video-assisted thoracoscopic surgery can produce equivalent radiographic results, patient-based clinical outcomes, and complication rates in comparison with posterior spinal fusion with thoracic pedicle screws, with the exception that posterior spinal fusion with thoracic pedicle screws may result in better major curve correction. The potential advantages of video-assisted thoracoscopic surgery over posterior spinal fusion with thoracic pedicle screws include reduced blood loss, fewer total levels fused, and the preservation of nearly one caudad fusion level, whereas the disadvantages include increased operative times and slightly less improvement in pulmonary function.

Approach-related complications of open versus thoracoscopic anterior exposures of the thoracic spine

This article reviews the approach-related complications of open versus thoracoscopic anterior exposures of the thoracic spine and suggests possible ways to avoid them.

Perioperative outcomes and complications related to teaching residents and fellows in scoliosis surgery

STUDY DESIGN

Single-surgeon retrospective case series of 303 consecutive operative patients with idiopathic scoliosis (IS).

OBJECTIVE

The purpose of this study is to evaluate the perioperative outcomes in patients undergoing surgery for IS as a function of the experience level of the surgical assistant.

SUMMARY OF BACKGROUND DATA

The experience level of the surgical assistant, who is often a resident or fellow, has never before been evaluated as an independent factor in predicting perioperative outcomes and morbidity in scoliosis surgery. We hypothesize that there is no difference in perioperative outcomes with varying experience level of the surgical assistant.

METHODS

We evaluated the clinical, radiographic, and operative records from 303 consecutive operative patients from consecutive patients with IS. Group I was comprised of residents or spine fellows as assistants (teaching service, n = 175), and Group II consisted of junior or senior attendings as assistants (private practice service, n = 128). Multivariable linear regression was used to evaluate the relationship between experience level of the assistant and curve correction, operative time, estimated blood loss (EBL), complications, transfusions, and length of stay.

RESULTS

In the posterior spinal fusion group (PSF, n = 164), there were no statistically significant differences in operative times between Groups I and II. Group I operative time was significantly increased, however, in patients undergoing anterior spinal surgery (ASF, P = 0.01), video-assisted thoracoscopic surgery (P = 0.0004), and combined anterior/posterior surgeries (ASF/PSF, P = 0.0063). There were no differences in EBL in ASF, video-assisted thoracoscopic surgery, or PSF surgeries, however, Group I had significantly higher EBL in the ASF/PSF group (P = 0.0016). No group differences were detected with respect to curve correction, transfusion rates, length of stay, or early complication rates.

CONCLUSION

The experience level of surgical assistant had little bearing on perioperative morbidity or radiographic outcomes in scoliosis surgery. Marginally increased operative times and EBL, without an increase in transfusions or complications, is an acceptably safe tradeoff for educating orthopedic residents and fellows.

Clinical Analysis of Video-assisted Thoracoscopic Spinal Surgery in the Thoracic or Thoracolumbar Spinal Pathologies

OBJECTIVE

Thoracoscopic spinal surgery provides minimally invasive approaches for effective vertebral decompression and reconstruction of the thoracic and thoracolumbar spine, while surgery related morbidity can be significantly lowered. This study analyzes clinical results of thoracoscopic spinal surgery performed at our institute.

METHODS

Twenty consecutive patients underwent video-assisted thoracosopic surgery (VATS) to treat various thoracic and thoracolumbar pathologies from April 2000 to July 2006. The lesions consisted of spinal trauma (13 cases), thoracic disc herniation (4 cases), tuberculous spondylitis (1 case), post-operative thoracolumbar kyphosis (1 case) and thoracic tumor (1 case). The level of operation included upper thoracic lesions (3 cases), midthoracic lesions (6 cases) and thoracolumbar lesions (11 cases). We classified the procedure into three groups: stand-alone thoracoscopic discectomy (3 cases), thoracoscopic fusion (11 cases) and video assisted mini-thoracotomy (6 cases).

RESULTS

Analysis on the Frankel performance scale in spinal trauma patients (13 cases), showed a total of 7 patients who had neurological impairment preoperatively : Grade D (2 cases), Grade C (2 cases), Grade B (1 case), and Grade A (2 cases). Four patients were neurologically improved postoperatively, two patients were improved from C to E, one improved from grade D to E and one improved from grade B to grade D. The preoperative Cobb's and kyphotic angle were measured in spinal trauma patients and were 18.9+/-4.4 degrees and 18.8+/-4.6 degrees , respectively. Postoperatively, the angles showed statistically significant improvement, 15.1+/-3.7 degrees and 11.3+/-2.4 degrees , respectively (P<0.001).

CONCLUSION

Although VATS requires a steep learning curve, it is an effective and minimally invasive procedure which provides biomechanical stability in terms of anterior column decompression and reconstruction for anterior load bearing, and preservation of intercostal muscles and diaphragm.

Emerging minimally invasive technologies for the management of scoliosis

Surgery for scoliosis has evolved dramatically over the past century -- from posterior surgery and casting that resulted in poor deformity correction and high pseudarthrosis rates and that required prolonged bed rest to anterior thoracoscopic and miniopen approaches that result in reproducible curve correction ranging from 55% to 70% with high fusion rates. The future of scoliosis surgery lies in the application of growth-modulation approaches by way of minimally invasive techniques, which will result in curve correction while maintaining spinal motion and disc and motion segment integrity. The optimal approach will use genetic testing to predict curve progression, thereby providing the clinical data required for determining the appropriate candidate for the use of this strategy.

Video-assisted thoracoscopic surgery in idiopathic scoliosis: evaluation of the learning curve

STUDY DESIGN

Retrospective review of patients with idiopathic scoliosis who underwent same-day or staged anterior and posterior spinal fusion and segmental spinal instrumentation.

OBJECTIVE

Evaluation of our learning curve with video-assisted thoracoscopic surgery (VATS) with respect to operative time, blood loss, and complications in patients with idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

VATS is a minimally invasive alternative to thoracotomy in the management of idiopathic scoliosis. An increased or steep learning curve has been described in the initial application of this technique.

METHODS

We began performing VATS in 1998. We compared our first 25 consecutive VATS patients (Group 2) and subsequent 28 consecutive VATS patients (Group 3) to our previous 16 consecutive patients (Group 1) with a thoracotomy (1991-1998) for idiopathic scoliosis. Training at a sponsored regional course was obtained before performing our first VATS procedure.

RESULTS

VATS allowed more disc to be excised in Group 2 (4.5 +/- 1, 5.7 +/- 1, and 4.4 +/- 1 discs in Group 1, Group 2, and Group 3, respectively) and significantly decreased the anterior operative time (215 +/- 33, 260 +/- 56, and 177 +/- 47 minutes) and time per individual disc excision (50 +/- 13, 47 +/- 12, and 41 +/- 12 minutes), while providing comparable correction of the thoracic deformity (67% +/- 12%, 66% +/- 10%, and 70% +/- 13% correction). There was no increase in estimated intraoperative anterior blood loss (228 +/- 213, 183 +/- 136, and 211 +/- 158 mL), estimated blood loss per disc excised (51 +/- 42, 34 +/- 29 and 48 +/- 37 mL), or complications in the VATS groups. Complications were primarily pulmonary and resolved with medical therapy. Postoperative chest tube drainage (855 +/- 397, 462 +/- 249, and 561 +/- 261 mL) and total perioperative anterior blood loss (1083 +/- 507, 647 +/- 309, and 773 +/- 308 mL) were significantly decreased in the VATS groups, but this was attributed to the use of Amicar.

CONCLUSIONS

VATS is an effective procedure for anterior spinal fusion in idiopathic scoliosis. The learning curve is short, provided appropriate training is obtained.