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

Thoracoscopic Surgery in the Management of Idiopathic Scoliosis: Systematic Literature Review according to the Prisma Protocol

Idiopathic scoliosis is characterized by a three-dimensional deformity of the spine with axial rotation and lateral inclination with an angle greater than 10° according to the Cobb method. Its approach can be conservative or surgical, depending on the degree of angulation, musculoskeletal development and age of the affected child or adolescent, or even depending on the functional impairment resulting from the condition. The aim of this study was to analyze the impact of videoassisted thoracoscopic surgery in the management of idiopathic scoliosis. This is a systematic literature review, built according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol and registered with PROSPERO under number CRD42022351466. The search for studies was performed between August 2022 and September of the same year, in bibliographic databases including MEDLINE, The Cochrane Library and Web of Science. The technique is a minimally invasive alternative to thoracotomy that has shown great evolution in recent years. The main advantages include less blood loss during the procedure, shorter hospital stay and improved post-surgical esthetics. One of the disadvantages mentioned by the authors is the greater complexity and technological requirement, longer surgical time and the need for careful selection of patients, according to degrees of vertebral deviation. The use of analgesics and anti-inflammatory drugs had no significant difference between traditional procedures (thoracotomy) or thoracoscopic surgery.

Selective Thoracic Fusion for Idiopathic Scoliosis: A Comparison of Three Surgical Techniques with Minimum 5-year Follow-up

STUDY DESIGN

Single-center retrospective review of outcomes among three surgical techniques in the treatment of thoracic idiopathic scoliosis (T-AIS) with a follow-up of at least 5 years.

OBJECTIVE

To investigate how outcomes compare in video-assisted anterior thoracic instrumentation (VATS), all hooks/hook-pedicle screw hybrid instrumentation (HHF), and all pedicle screw instrumentation (PSF) techniques for T-AIS.

SUMMARY OF BACKGROUND DATA

Studies comparing outcomes for anterior versus posterior fusion for T-AIS are few and with short follow-up.

METHODS

Three groups of patients with T-AIS who underwent thoracic fusion were included in this study: 98 patients with mean curve of 49.0° ± 9.5° underwent VATS (Group 1); 44 patients with mean curve of 51.1° ± 7.4° underwent HHF (Group 2); and 47 patients with mean curve of 47.6° ± 9.9° underwent PSF (Group 3). Radiological outcomes were compared at preoperative, and up to 5 years. Surgical outcomes were noted until latest follow-up.

RESULTS

Group 1 had less blood loss, less fusion levels, longer surgical time, and longer hospital stay compared with the other groups (P < 0.01). Groups 1 and 3 were comparable in all time periods with 78.8% and 78.2% immediate curve correction, and 72.9% and 72.1% at 5 years, respectively. Group 2 had lower correction in all time periods (P < 0.0001). Thoracic kyphosis and lumbar lordosis decreased in Group 3, but improved in both Groups 1 and 2 (P < 0.0001). Group 1 had more respiratory complications. The posterior groups had more deep wound infections. Two patients in Group 1 and one patient in Group 2 required revision surgery for implant-related complications. Reoperations for deep wound infections were noted only in the posterior groups.

CONCLUSION

This is the first report comparing 5 year outcomes between anterior and posterior surgery for T-AIS. All three surgical methods resulted in significant and durable scoliosis correction; however, curve correction using HHF was inferior to both VATS and PSF with the latter two groups achieving similar coronal correction. However, VATS involved fewer segments, kyphosis improvement, and no deep wound infection, whereas PSF has less surgical time, shorter hospital stays, and no revision surgery from implant-related complications.Level of Evidence: 3.

Neurofibromatosis Type 1 with Severe Dystrophic Kyphosis: Surgical Treatment and Prognostic Analysis of 27 Patients

OBJECTIVE

The aim of the present study was to explore the surgical treatment and prognosis of 27 cases of neurofibromatosis type 1 with severe dystrophic kyphosis.

METHODS

We performed surgical treatment for scoliosis and kyphosis caused by dystrophic curves at Peking Union Medical College Hospital, Beijing, China from December 2015 to December 2017. The study included 21 patients with moderate to severe kyphosis, 12 males and 9 females, with an average age of 14.95 ± 6.05 years. All patients had kyphosis angles greater than 70° and had more than four skeletal developmental defects. A total of 6 patients with severe kyphosis, 2 males and 4 females, with an average age of 12.5 years, had more than five skeletal developmental defects with a kyphosis angle greater than 90° or a lumbar kyphosis angle greater than 40°. According to the patient's own situation, we adopted a low-grade surgery scheme (grades 1 or 2) or a high-grade surgery scheme (grades 3-6). The low-grade surgery was mainly lower articular surface resection or pontodestomy, and the high-grade surgery was mainly apical vertebral body or upper discectomy. All patients were followed up to determine their prognosis.

RESULTS

Statistical analysis showed that there was a significant difference in preoperative and postoperative scores between the two groups (P < 0.05), and scoliosis correction showed that surgical treatment had a significant effect on scoliosis kyphosis. The mean follow-up time was 66.7 months. Follow-up results showed that 50% of complications after internal fixation were related to high-level surgery. Complications included displacement of the titanium cage, removal of the lamina hook, formation of pseudoarthrosis, and internal fixation failure (with a rate of 7.7%-14.3%). In contrast, there were no associated symptoms for low-grade surgery. In addition, the results showed that gender, age, extent of resection, height, and body mass index had no significant effect on preoperative, postoperative, and prognostic indicators of patients (P > 0.05).

CONCLUSION

Early identification of dysplastic scoliosis-related deformities plays an important role in surgical planning and prognosis, and low-level surgical procedures are more favorable for patients' prognosis.

Thoracoscopic Vertebrectomy for Thoracolumbar Junction Fractures and Tumors: Surgical Technique and Evaluation of the Learning Curve

STUDY DESIGN

Retrospective study.

OBJECTIVE

The authors evaluated the surgical technique and learning curve for video-assisted thoracoscopic surgery (VATS) for treating thoracolumbar junction burst fractures and bony tumors by examining surgical data and outcome for the first 30 VATS procedures performed by a single surgeon at a training institution.

SUMMARY OF BACKGROUND DATA

VATS is commonly used in the treatment of early-stage lung cancer. Widespread use of this technique among neurosurgeons is limited by the lack of cases and the steep learning curve.

METHODS

This study was a retrospective case series of the first 30 T12 and L1 thoracoscopic vertebrectomies from 2003 to 2008. The sample was limited to 1 surgeon and 1 region of the spine to minimize the potential variation so that a learning curve could be assessed. Surgical data and outcomes were analyzed. Estimated blood loss and operation time were analyzed using a linear generalized estimating equation model with a first-order autoregression correlation structure.

RESULTS

The average operative time for thoracoscopic corpectomy was 270±65 minutes (range, 160-416 min). Operating room time decreased significantly after the first 3 operations. The authors observed a stable linear decrease in operating time over the course of the study. The average blood loss during the thoracoscopic procedure was 433±330 mL (range, 100-1500 mL) and did not change as the series progressed. Complications and conversions to open procedures occurred in 2 patients and were evenly distributed throughout the series.

CONCLUSIONS

Thoracoscopic vertebrectomy at the thoracolumbar junction has a relatively long learning curve. In this series, operating room time improved dramatically after the first 3 cases but continued to improve subsequently. The learning curve can be accomplished without an increase in blood loss, complications, rate of conversion to open procedures, or frequency of misplaced instrumentation.

Invasiveness Reduction of Recent Total En Bloc Spondylectomy: Assessment of the Learning Curve

STUDY DESIGN

Case-control study.

PURPOSE

To evaluate the surgical magnitude and learning curve of "second-generation" total en bloc spondylectomy (TES).

OVERVIEW OF LITERATURE

In June 2010, we developed second-generation TES combined with tumor-induced cryoimmunology, which does not require autograft harvesting.

METHODS

TES was performed in 63 patients between June 2010 and September 2013. Three groups of patients were evaluated: 20 undergoing surgery in the first year of development of second-generation TES (group I), 20 in the second year (group II), and 23 in the third year (group III). Patient backgrounds showed no remarkable differences. Operating time, intraoperative blood loss, blood transfusion, and postoperative C-reactive protein and creatine phosphokinase were compared among the groups.

RESULTS

Mean±standard deviation operating time was 486±130 minutes in group I, 441±85 minutes in group II, and 396±75 minutes in group III. The time was significantly shorter in group III than in group I (p<0.05). Intraoperative blood loss was 901±646 mL in group I, 433±177 mL in group II, and 411±167 mL in group III. Blood loss was significantly lower in groups II and III than in group I (p<0.01). Transfusion was not required in 20 of 23 patients in group III, and mean C-reactive protein levels on postoperative day 3 were significantly lower in this group than in group I (6.12 mg/L vs. 10.07 mg/L; p<0.05). Postoperative creatine phosphokinase levels did not differ among the groups.

CONCLUSIONS

TES is associated with a significant learning curve. Thus, second-generation TES can no longer be considered highly invasive.

Quantitative analysis of a spinal surgeon’s learning curve for scoliosis surgery

Aims

The aim of this study was a quantitative analysis of a surgeon’s learning curve for scoliosis surgery and the relationship between the surgeon’s experience and post-operative outcomes, which has not been previously well described.

Patients and Methods

We have investigated the operating time as a function of the number of patients to determine a specific pattern; we analysed factors affecting the operating time and compared intra- and post-operative outcomes. We analysed 47 consecutive patients undergoing scoliosis surgery performed by a single, non-trained scoliosis surgeon. Operating time was recorded for each of the four parts of the procedures: dissection, placement of pedicle screws, reduction of the deformity and wound closure.

Results

The median operating time was 310 minutes (interquartile range 277.5 to 432.5). The pattern showed a continuous decreasing trend in operating time until the patient number reached 23 to 25, after which it stabilised with fewer patient-dependent changes. The operating time was more affected by the patient number (r =- 0.75) than the number of levels fused (r = 0.59). Blood loss (p = 0.016) and length of stay in hospital (p = 0.012) were significantly less after the operating time stabilised. Post-operative functional outcome scores and the rate of complications showed no significant differences. Take home message: We describe a detailed learning curve for scoliosis surgery based on a single surgeon’s practise, providing useful information for novice scoliosis surgeons and for those responsible for training in spinal surgery. Cite this article: Bone Joint J 2016;98-B:679–85.

[Training curves for endosurgical interventions in neonates and infants]

AIM

To demonstrate training curves for endosurgical interventions in neonates and infants.

MATERIAL AND METHODS

It was analyzed duration of thoracoscopic reconstruction of esophageal atresia (31 patients) and laparoscopic Nissen fundoplication (61 patients) performed for the period from January 2005 to December 2012. Graphs and tables reflecting correlation between duration and number of operations were framed.

RESULTS

Figures demonstrate reducing duration of surgery with increase of endosurgical interventions number.

CONCLUSION

Our data revealed that time necessary for minimally invasive procedures in infants and neonates decreases in process of experience accumulation.

Association Between Surgeon Experience and Complication Rates in Adult Scoliosis Surgery: A Review of 5117 Cases From the Scoliosis Research Society Database 2004-2007

STUDY DESIGN

Retrospective review of a multicenter database.

OBJECTIVE

To evaluate whether surgeon experience is associated with complication rates in adult spinal deformity (ASD) surgery.

SUMMARY OF BACKGROUND DATA

Multiple patient- and surgery-related factors have been shown to increase the risk of complications in ASD. No study exists evaluating surgeon experience as an associated factor with complications in ASD.

METHODS

The Scoliosis Research Society Morbidity and Mortality database was queried for patients older than 18 years who underwent ASD from 2004 to 2007. Patient demographics, surgical characteristics, complications, and surgeon membership status were analyzed. Two-tailed t test and χ tests were performed, with P value of less than 0.05 considered significant.

RESULTS

A total of 5117 patients underwent ASD surgery. The average patient age was 51.8 years. Patients operated by candidate members were older than those operated by active members (53.1 vs. 51.4, P = 0.003). Active members performed 3836 (75%) cases whereas candidate members performed 1281 cases. There were 1110 (21.7%) revisions. A total of 681 (13.3%) complications were recorded, 498 (13.0%) for active and 183 (14.3%) for candidate members, respectively (P = 0.24). Mortality rate was 0.29%. Spinal cord complications accounted for 0.68% of all cases. Active members had 21 (0.55%) spinal cord complications, whereas candidates had 14 (1.1%) (P = 0.049). There were a total of 174 (3.4%) surgical site infections (SSI). Active members had 82 (2.1%) deep SSI, whereas candidate members had 36 (2.8%) deep SSI (P = 0.164). Active members had 33 (0.9%) superficial SSI whereas candidate members had 23 (1.8%) superficial SSI (P = 0.008).

CONCLUSION

There was a statistically significant, 2-fold increase in the rate of spinal cord complications and superficial SSI among candidate compared with active members. Overall complication rates were similar between candidate and active members.

LEVEL OF EVIDENCE

4.

The effect of surgeon experience on outcomes of surgery for adolescent idiopathic scoliosis

BACKGROUND

Single-surgeon series investigating the learning curve involved in surgery for spinal deformity may be confounded by changes in technology and techniques. Our objective with this multicenter, prospective study was to present a cross-sectional analysis of the impact of surgeon experience on surgery for adolescent idiopathic scoliosis.

METHODS

All posterior-only surgical procedures for adolescent idiopathic scoliosis performed in the 2007 to 2008 academic year, with a minimum of two years of patient follow-up, were included. Two groups were created on the basis of surgeon experience: a young surgeons' group, which included patients of surgeons with less than five years of experience, and an experienced surgeons' group, which included patients of surgeons with five or more years of experience.

RESULTS

Nine surgeons (four young and five experienced) operated on a total of one hundred and sixty-five patients with adolescent idiopathic scoliosis. The surgeons' experience ranged from less than one year to thirty-six years in practice. The two groups had similar preoperative curve-magnitude measurements, SRS-22 (Scoliosis Research Society-22) scores, and distribution by Lenke curve type. There were significant operative and postoperative differences. The young surgeons fused an average of 1.2 levels more than the experienced surgeons (p = 0.045). The mean intraoperative estimated blood loss (EBL) of the young surgeons' group was more than twice that of the experienced surgeons' group (2042 mL compared with 1013 mL; p < 0.001). The duration of surgery was 458 minutes for the young surgeons compared with 265 minutes for the experienced surgeons (p < 0.001). The overall SRS-22 scores were significantly worse in the young surgeons' group (a mean of 4.1 compared with 4.5; p = 0.001). The difference between groups was also significant for the domains of pain (p = 0.016), self-image (p = 0.008), and function (p < 0.001). Complication rates did not differ significantly between the groups.

CONCLUSIONS

Operative results and health-related quality of life following surgery for adolescent idiopathic scoliosis were significantly and positively correlated with surgeon experience.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

En bloc resection of upper thoracic chordoma via a combined simultaneous anterolateral thoracoscopic and posterior approach

BACKGROUND

En bloc resection of chordomas is associated with increased patient survival. Achievement of en bloc resection, however, may present a great surgical challenge, particularly in the mobile spine. Novel multidisciplinary techniques may enable en bloc resection of lesions presenting in anatomically challenging locations. A combined simultaneous thoracoscopic and posterior approach in a patient with an upper thoracic chordoma is presented; en bloc resection was achieved.

OBJECTIVE

To show the feasibility, safety, and utility of performing a thoracoscopy-assisted en bloc resection of a chordoma involving the upper thoracic spine.

METHODS

A case study is presented of a patient with biopsy-proven chordoma of T2-3 with predominantly paravertebral involvement who underwent multilevel en bloc resection via a simultaneous combined anterolateral thoracoscopic and posterior approach. Thoracoscopic assistance achieved separation of the tumor and ventral spine from the adjacent mediastinal structures. En bloc resection proceeded without complication. The spine was stabilized with posterior instrumentation.

RESULTS

A multilevel en bloc resection was achieved with negative margins, preserving more than half of the remaining vertebral bodies and allowing short segment posterior fixation without extension into the cervical spine. The patient remained neurologically intact.

CONCLUSION

A combined simultaneous thoracoscopic and posterior approach is safe and effective for en bloc resection of multilevel chordoma involving the upper thoracic spine. This technique allows for a plane to be established ventrally between the tumor and the mediastinum, thus assisting with safe osteotomies via the posterior approach.

Surgical treatment of Lenke 1 main thoracic idiopathic scoliosis: results of a prospective, multicenter study

STUDY DESIGN

Prospective, consecutive, nonrandomized, multicenter study.

OBJECTIVE

The purpose of this study was to compare the outcomes of idiopathic scoliosis treatment for Lenke 1 curves with 3 treatment approaches.

SUMMARY OF BACKGROUND DATA

Surgical treatment options for Lenke 1 or primary main thoracic curve pattern in adolescent idiopathic scoliosis include thoracoscopic anterior spinal fusion, open anterior spinal fusion, and posterior spinal fusion (PSF) and instrumentation procedures.

METHODS

This was a prospective, consecutive, nonrandomized, multicenter study of surgical correction in adolescent idiopathic scoliosis. Patients with Lenke type 1 curve patterns from 7 sites were enrolled in this minimum 2-year follow-up study. Changes in pre- to postoperative radiographs, pulmonary function tests, Scoliosis Research Society questionnaire scores, and trunk rotation measures were compared.

RESULTS

A total of 149 patients (age: 14.5 ± 2 yr) were included (91% follow-up at 2 yr). The 3 groups were similar preoperatively in thoracic and lumbar curve size. There were 55 patients with thoracoscopic anterior spinal fusion, 17 patients with open anterior spinal fusion, and 64 patients with PSF. The fusion included on average 3 to 4 more levels in PSF than the 2 anterior approaches (P ≤ 0.001). Surgical time tended to be greater in the anterior groups by approximately 2 to 3 hours; however, blood loss was greatest with PSF. At 2 years, all 3 approaches showed similar improvements in the thoracic Cobb angle, coronal balance, the lumbar Cobb angle, Scoliosis Research Society questionnaire scores, and trunk rotation measures. The PSF approach resulted in overall reduction in kyphosis compared with the anterior approaches. Postoperative hyperkyphosis was an issue only in the 2 anterior groups. Major complication rates were similar.

CONCLUSION

All 3 approaches resulted in similarly satisfactory outcomes for the majority of patients with specific advantages to each technique. The patients with PSF had more levels fused, yet with the shortest operative time. The thoracoscopic anterior spinal fusion group had the smallest incisions and the lowest requirement for transfusion. The open anterior spinal fusion group had a modest loss of pulmonary function without any clear advantages compared with the other 2 groups.

LEVEL OF EVIDENCE

2.

Learning curve and clinical outcomes of minimally invasive transforaminal lumbar interbody fusion: our experience in 86 consecutive cases

STUDY DESIGN

Consecutive case series with prospective data collection.

OBJECTIVE

To define and analyze the learning curve for minimally invasive transforaminal lumbar interbody fusion (TLIF).

SUMMARY OF BACKGROUND DATA

Minimally invasive TLIF using a unilateral approach has recently been gaining popularity because of its potential for minimizing soft-tissue damage and reducing recovery time. However, a steep learning curve has been described for surgeons first performing this technique.

METHODS

Eighty-six consecutive patients with degenerative lumbar diseases who were treated by TLIF were included in the study. Surgeries were performed using a tubular retractor, and a cage was inserted using a unilateral transforaminal approach by a single surgeon. The corresponding segments were fixed with percutaneous pedicle screws. Eighty-three patients were followed up for more than 1 year, and the average follow-up period was 25 months. Single-level TLIF was performed in 60 cases, single-level TLIF plus adjacent-level decompression was performed in 13 cases, and double-level TLIF was performed in 13 cases. Corrected operative time per level, operative blood loss, postoperative blood drainage, total blood loss, and ambulation recovery time were measured. Transfusion rates and complication incidence were also identified. Clinical results were assessed using the Oswestry Disability Index (ODI) and a visual analogue scale (VAS). The learning curve was assessed using a logarithmic curve-fit regression analysis. In the single-level TLIF group (n = 60), 22 patients were defined as the "early" group (among the first 30 cases of the series), and the subsequent 38 cases were defined as the "late" group for comparison.

RESULTS

Corrected operative time gradually decreased as the series progressed, and an asymptote was reached after about 30 cases. ODI significantly decreased from an average of 24 at the preoperative stage to 10 at the final follow-up. Average VAS scores for lower back pain and radiating pain also significantly decreased from an average of 5.2 to 1.9 and 6.8 to 0.9, respectively. In the single-level TLIF series, operative time was significantly shorter in the late group (183 ± 23 min) than the early group (254 ± 44 min), and blood loss during the operation was significantly reduced in the late group (292 ± 280 mL) compared with the early group (508 ± 278 mL). Ambulation recovery time significantly decreased from 2.4 ± 0.6 days in the early group to 2.0 ± 0.5 in the late group. ODI and VAS scores for lower back pain and radiating pain did not differ between the 2 groups.

CONCLUSION

Although it is not easy to master the minimally invasive TLIF technique, the surgeon's experience with this operation correlated with reduced operation time and blood loss during surgery. After the initial learning curve, this technique could be an effective and reliable option for the surgical treatment of lumbar degenerative disease.

Is there a learning curve in foot and ankle surgery?

BACKGROUND

Previous studies of orthopaedic learning curves have largely described the introduction of new techniques to experienced consultants. End points have usually involved technical considerations. A paucity of evidence surrounds foot and ankle surgery. This study investigates the learning curve during a foot and ankle surgeon's first year, defined by functional outcome.

METHODS

150 patients underwent elective foot or ankle surgery during the whole period. Preoperative and 6 month postoperative functional scores were compared between the first and second 6 month groups.

RESULTS

Functional improvement was greater, approaching significance, in the second group (p=0.0605). There was no difference for forefoot cases (p=0.345). Functional improvement was significantly greater in the second group with forefoot cases removed (p=0.0333).

CONCLUSIONS

A learning curve exists in the first year of practice of foot and ankle surgery, demonstrated by functional outcome. This is confined to ankle, hindfoot and midfoot, but not forefoot surgery.

An evaluation of the learning curve for a complex surgical technique: the full endoscopic interlaminar approach for lumbar disc herniations

BACKGROUND CONTEXT

Compared with conventional microsurgical technique, the full endoscopic (FE) interlaminar approach is a more minimally invasive technique for the surgical treatment of lumbar disc herniations. Its efficacy and safety have been confirmed by numerous studies. However, a steep learning curve with the use of such a complex technique is a major concern for the initial adoption of this technique.

PURPOSE

To evaluate the learning curve of using an FE interlaminar technique for the surgical treatment of lumbar disc herniation.

STUDY DESIGN

A prospective study of patients with lumbar disc herniation who underwent discectomy via interlaminar approach assisted by FE instruments.

PATIENT SAMPLE

Thirty patients with lumbar disc herniation underwent discectomy using an interlaminar endoscopic-only approach between 2008 and 2009.

METHODS

The patients were divided into three groups of 10 sequential cases each. Group A consisted of the first 10 cases, Group B the subsequent 10 cases, and Group C the last 10 cases. The clinical evaluation data included operative time, length of hospital stay, visual analog scale (VAS) leg and back pain scores, complications, and rate of conversion to an open.

RESULTS

All patients were observed prospectively for 1.61 ± 0.22 years (range, 1.2-2.0 years). There was no measurable intraoperative bleeding and postoperative infections in the three groups. Compared with Group A, the operative time in Group B was significantly decreased (p < .001). The patients in Group C had much less operative time than in Group B (p = .002). There was no significant difference with length of hospital stay in the three groups (p = .897). The improvement of VAS leg and back pain scores in each group was similar: there was a significant improvement (p < .01) at 3 months after surgery when compared with preoperative scores, but there was no statistical difference (p > .05) in the VAS leg and back pain scores between 3 months after surgery and final follow-up. The complication rate was 12.5% for Group A, 10% for Group B, and 0% for Group C. The need for conversion to an open procedure for Group A was 20% compared with zero cases in both Groups B and C. There were no symptomatic recurrences in our study.

CONCLUSIONS

Excellent clinical and minimally invasive outcomes can be obtained in the surgical treatment of lumbar disc herniation via the interlaminar approach assisted by FE technique. However, attention must be paid to the steep learning curve by using this complex technique. Imprecise anatomic orientation and manipulation inside the spinal canal are key factors in the steep learning curve. Obtaining microsurgical experience, attending workshops, and suitable patient selection can help shorten the learning curve and decrease the complications.

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.

Video-assisted thoracoscopic surgery for correction of adolescent idiopatic scoliosis: comparison of 4.5 mm versus 5.5 mm rod constructs

PURPOSE

The purpose of this study is to report the comparative results of thoracoscopic correction achieved via cantilever technique using a 4.5 mm thin rod and the poly-axial reduction screw technique using a 5.5 mm thick rod in Lenke type 1 adolescent idiopathic scoliosis (AIS).

MATERIALS AND METHODS

Radiographic data, Scoliosis Research Society (SRS) patient-based outcome questionnaires, and operative records were reviewed for forty-nine patients undergoing surgical treatment of scoliosis. The study group was divided into a 4.5 mm thin rod group (n = 24) and a 5.5 mm thick rod group (n = 25). The radiographic parameters that were analyzed included coronal curve correction, the most caudal instrumented vertebra tilt angle correction, coronal balance, and thoracic kyphosis.

RESULTS

The major curve was corrected from 49.8 degrees and 47.2 degrees pre-operatively to 24.5 degrees and 18.8 degrees at the final follow-up for the thin and thick rod groups, respectively (50.8% vs. 60.2% correction). There were no significant differences between the two groups in terms of kyphosis, coronal balance, or tilt angle at the time of the final follow-up. The mean number of levels fused was 6.2 in the thin rod group, compared with 5.9 levels in the thick rod group. There were no major intraoperative complications in either group.

CONCLUSION

Significant correction loss was observed in the thin rod system at the final follow-up though both groups had comparable correction immediately post-operative. Therefore, the thick rod with poly axial screw system helps to maintain post-operative correction.

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.

The role of Amicar in same-day anterior and posterior spinal fusion for idiopathic scoliosis

STUDY DESIGN

A retrospective study of the effectiveness of Amicar (epsilon aminocaproic acid).

OBJECTIVE

Evaluate the effectiveness of Amicar in decreasing perioperative blood loss and transfusion requirements in same-day anterior (ASF) and posterior spinal fusion (PSF) with segmental spinal instrumentation (SSI) for idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

Preliminary prospective, prospective randomized double-blind, and fibrinogen studies have demonstrated Amicar to be effective in decreasing perioperative blood loss in patients with idiopathic scoliosis undergoing PSF with SSI. Increased fibrinogen secretion is a possible explanation.

METHODS

There were 73 consecutive patients divided into 3 study groups based on the administration of Amicar: Group 1 (n = 16), no Amicar; Group 2 (n = 18), Amicar for the PSF with SSI only; and Group 3 (n = 39), Amicar for both ASF and PSF with SSI. All patients were managed using the same general anesthesia technique, intraoperative procedure, postoperative care path, and indications for transfusion (hemoglobin <7 g/dL). Total perioperative blood loss (estimated intraoperative blood loss for both procedures and measured postoperative chest tube and PSF wound suction drainage) and total transfusion requirements between groups were compared using one-way ANOVA.

RESULTS

There were statistically significant decreases in mean estimated intraoperative PSF with SSI, total perioperative blood loss, and transfusion requirements in the 2 Amicar groups. However, Amicar had no significant effect on estimated intraoperative ASF blood loss, chest tube drainage, or PSF wound suction drainage. Total perioperative blood loss and transfusion requirements (cell saver, autologous, directed, and allogeneic blood) were: 3442.8 +/- 1344.0 mL and 1537.1 +/- 905.1 mL in Group 1; 2089.8 +/- 684.0 mL and 485.2 +/- 349.8 mL in Group 2; and 2184.1 +/- 1163.7 mL and 531.5 +/- 510.5 mL in Group 3. There were no Amicar related complications.

CONCLUSION

Amicar was highly effective in decreasing total perioperative blood loss and transfusion requirements in same-day ASF and PSF with SSI for idiopathic scoliosis. It results in less preoperative autologous blood donation, perioperative blood transfusion, costs, and potential transfusion-related complications. It was most effective in decreasing intraoperative estimated PSF with SSI blood loss. It had no significant effect during the ASF, postoperative chest tube, or PSF wound suction drainage. We now recommend that it be used for the PSF with SSI procedure only.

DECISION MAKING IN PEDIATRIC SPINAL DEFORMITY

OBJECTIVE

To review the concepts involved in the decision-making process for management of pediatric patients with spinal deformity.

METHODS

The literature was reviewed in reference to pediatric deformity evaluation and management.

RESULTS

Pediatric spinal deformity includes a broad range of disorders with differing causes, natural histories, and treatments. Appropriate categorization of pediatric deformities is an important first step in the clinical decision-making process. An understanding of both nonoperative and operative treatment modalities and their indications is requisite to providing treatment for pediatric patients with spinal deformity. The primary nonoperative treatment modalities include bracing and casting, and the primary operative treatments include nonfusion instrumentation and fusion with or without instrumentation. In this article, we provide a review of pediatric spinal deformity classification and an overview of general treatment principles.

CONCLUSION

The decision-making process in pediatric deformity begins with appropriate diagnosis and classification of the deformity. Treatment decisions, both nonoperative and operative, are often predicated on the basis of the age of the patient and the natural history of the disorder.

Anterior thoracoscopic instrumentation in adolescent idiopathic scoliosis: a systematic review

STUDY DESIGN

A Systematic Review of published series of patients with adolescent idiopathic scoliosis treated with anterior thoracoscopic instrumentation.

OBJECTIVE

To conduct a systematic review of the results of thoracoscopic surgery and to compare them with those of open anterior and posterior spine instrumentation to enable surgeons judge the applicability of the method.

SUMMARY OF BACKGROUND DATA

Instrumentation through video-assisted thoracoscopic surgery is an attractive alternative for the treatment of thoracic adolescent idiopathic scoliosis. The advantages claimed by its proponent over conventional instrumentations are better cosmesis and reduced morbidity due its minimal invasive nature. However, superiority of thoracoscopic instrumentation over conventional methods has not been proven so far.

METHODS

Via Medline, Pubmed, and other literature searches, 8 articles met the inclusion criteria for our systematic review. The evaluations were made according to the parameters employed for evaluating spinal deformities. Instrumentation through video-assisted thoracoscopic surgery results were compared to those of open anterior or posterior surgeries.

RESULTS

Mean number of instrumented levels was 7. The extent of disc excision was not indicated in any of the studies. The mean operative time was found to be approximately 5.2 hours. Average blood loss was 391.7 mL (100-1300 mL). The average Cobb curve correction was 64.6%. The mean preoperative kyphosis angle was 21.3 degrees ; the postoperative kyphosis angle was 25.2 degrees . These angular corrections were found to be comparable to posterior procedures using hooks, but less than with pedicle screws. Two studies reported on patient satisfaction favoring thoracoscopic instrumentation. Instrumentation-related complications were the most predominant.

CONCLUSION

Anterior thoracoscopic instrumentation is comparable in terms of curve correction to anterior or posterior procedures. Theoretical advantages of better cosmesis and less aggressiveness seem to be offset by the increased operative and intensive care unit time, and complication rate. More prospective studies need to be conducted to determine the benefit and general applicability of this procedure.

Fusion rates after thoracoscopic release and bone graft substitutes in idiopathic scoliosis

STUDY DESIGN

A retrospective assessment of fusion rates using either morselized allograft bone or demineralized bone matrix (DBM) following video-assisted thoracoscopic surgery (VATS) in idiopathic scoliosis.

OBJECTIVE

To compare fusion rates between allograft bone and demineralized bone matrix (Grafton DBM Flex) following VATS using on standard standing lateral spine radiographs.

SUMMARY OF BACKGROUND DATA

Both VATS and bone graft substitutes are accepted surgical techniques. However, their concomitant use in spinal deformity surgery has not been previously reported. Bone graft substitute has the advantage of decreasing operative time, blood loss, and donor site morbidity associated with autografts.

METHODS

Anterior thoracic discectomies were performed using VATS. Forty patients with 1 year or more follow-up were evaluated-12 with morselized allograft bone (Allograft group) and 28 with folded Grafton DBM Flex (DBM group). Factors analyzed included age, number of anterior levels fused, operative time, anterior perioperative blood loss, curve correction, and fusion rates. Clinical and radiographic evaluations were performed before surgery and at month, 1 year, and at most recent follow-up. Interbody fusion was assessed on standing lateral radiographs using the Newton et al 4-level grading scale.

RESULTS

There were no significant differences in age at surgery, number of anterior vertebral levels fused, anterior operative time per level, anterior intraoperative blood loss, chest tube drainage and duration, or total perioperative anterior blood loss between the 2 groups. Percent curve correction from before surgery to the most recent follow-up were very similar in both Allograft (68%) and DBM groups (67%). At most recent assessment, 60 of 73 disc spaces (82%) in the Allograft group and 100 of 109 disc spaces (92%) in the DBM group were rated as radiographically fused (Newton et al Grade I and II). There was no significant difference between the 2 groups (P = 0.088). No patients were observed to have crankshaft, pseudoarthrosis or hardware failure. There were no complications related to the bone graft material used.

CONCLUSION

Demineralized bone matrix (Grafton DBM Flex) seem to be an effective bone graft substitute in thoracoscopic surgery for idiopathic scoliosis.

Systematic review of general thoracic surgery articles to identify predictors of operating room case durations

BACKGROUND

Previous studies of operating room (OR) information systems data over the past two decades have shown how to predict case durations using the combination of scheduled procedure(s), individual surgeon and assistant(s), and type of anesthetic(s). We hypothesized that the accuracy of case duration prediction could be improved by the use of other electronic medical record data (e.g., patient weight or surgeon notes using standardized vocabularies).

METHODS

General thoracic surgery was used as a model specialty because much of its workload is elective (scheduled) and many of its cases are long. PubMed was searched for thoracic surgery papers reporting operative time, surgical time, etc. The systematic literature review identified 48 papers reporting statistically significant differences in perioperative times.

RESULTS

There were multiple reports of differences in OR times based on the procedure(s), perioperative team including primary surgeon, and type of anesthetic, in that sequence of importance. All such detail may not be known when the case is originally scheduled and thus may require an updated duration the day before surgery. Although the use of these categorical data from OR systems can result in few historical data for estimating each case's duration, bias and imprecision of case duration estimates are unlikely to be affected. There was a report of a difference in case duration based on additional information. However, the incidence of the procedure for the diagnosis was so uncommon as to be unlikely to affect OR management.

CONCLUSIONS

Matching findings of prior studies using OR information system data, multiple case series show that it is important to rely on the precise procedure(s), surgical team, and type of anesthetic when estimating case durations. OR information systems need to incorporate the statistical methods designed for small numbers of prior surgical cases. Future research should focus on the most effective methods to update the prediction of each case's duration as these data become available. The case series did not reveal additional data which could be cost-effectively integrated with OR information systems data to improve the accuracy of predicted durations for general thoracic surgery cases.

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.