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Surgical Outcomes Research

Use of Video-Assisted Thoracoscopic Surgery to Reduce Perioperative Morbidity in Scoliosis Surgery

Newton, Peter O. MD*†; Marks, Michelle , MS*; Faro, Frances , MD†; Betz, Randy , MD‡; Clements, David , MD‡; Haher, Tom , MD§; Lenke, Larry , MD∥; Lowe, Tom , MD¶; Merola, Andrew , MD§; Wenger, Dennis , MD*†

Study Design. A case series of idiopathic scoliosis patients treated with thoracoscopic anterior instrumentation was compared to a similar group of patients treated by open anterior instrumentation.

Objectives. To evaluate the morbidity associated with thoracoscopic instrumentation compared to the open approach for thoracic scoliosis.

Methods. A consecutive group of thoracoscopically treated patients with Lenke 1 adolescent idiopathic scoliosis was compared to similar patients gathered from the DePuy-AcroMed Harms Study Group database. Perioperative outcome measures as well as early postoperative functional outcomes (pulmonary function, shoulder strength) were compared.

Results. There were 38 thoracoscopic instrumentation cases with greater than 6 months’ follow-up that were compared to 68 anterior open instrumentation cases. The radiographic outcomes were similar (60% ± 11%vs. 59% ± 17% thoracic curve correction for the thoracoscopic and open groups, respectively). The reduction in forced vital capacity was significantly (P = 0.01) greater in the open group (0.6 ± 0.3 L) compared to the endoscopic group (0.4 ± 0.3 L). There was a trend towards greater return of shoulder girdle strength and range of motion 6 weeks after surgery in the thoracoscopic patients.

Conclusion. The thoracoscopic approach for instrumentation of scoliosis has advantages of reduced chest wall morbidity compared with the open thoracotomy method but allows comparable curve correction.

Video-assisted thoracoscopic spinal surgery began in the 1990s and has gained popularity, particularly in the treatment of scoliosis. 1–8 Thoracoscopy can be utilized for anterior thoracic spine release (disc excision) and grafting procedures as part of a combined anterior–posterior procedure, or the approach can be utilized to implant rod-screw constructs to achieve deformity correction. 9 For each of these procedures, the minimally invasive approach is thought to have less morbidity compared to the open approaches. Unfortunately, there are few data in the literature to document any differences in the outcome of these approaches. Landreneau et al have suggested that in the treatment of pulmonary pathology, thoracoscopy is associated with less pain compared to an open thoracotomy approach. 10 In the treatment of spinal pathology, however, very few corroborative data exists.

The rationale for the presumed reduction in chest wall and pulmonary function morbidity with thoracoscopy is straightforward. The thoracoscopic approach involves surgical access to the spine via several small incisions, 1.0 to 2.5 cm in length. Through these small incisions, a muscle splitting technique allows placement of soft or rigid cannulas (ports) to maintain the patency of the established path. Visualization of the chest cavity and spine is achieved with endoscopic video systems that are now standard in all operating rooms. Both straight and angled optics are available, which allow for a sharp, clear, magnified view not possible with the naked eye (Figure 1). Surgical instruments to perform spinal surgery are based on the tools utilized in open procedures and surgical steps of thoracoscopic surgery also mirror those of the open technique.

 

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Spine: 15 October 2003 – Volume 28 – Issue 20S – pp S249-S254