Surgical Outcomes Research

Study Design. Consecutive case prospective chart and radiographic review.

Objectives. The purpose of this study was to define the learning curve of spinal thoracoscopy.

Summary of Background Data. Thoracoscopy is an alternative to open thoracotomy in the treatment of pediatric spinal deformity. The learning curve for spinal thoracoscopy has not been described.

Methods. In this prospective study 65 consecutive cases of thoracoscopic anterior release with discectomy and fusion performed by one surgeon for the treatment of pediatric spinal deformity were reviewed. The patients were, on average, 14 ± 3 years old and had the following diagnoses: idiopathic scoliosis (n = 13), Scheuermann’s kyphosis (n = 9), neuromuscular spinal deformity (n = 35), congenital scoliosis (n = 4), and tumor/syrinx (n = 4).

Results. The average operative time for the thoracoscopic procedure was 161 ± 41 minutes (range, 50–240 minutes). There was a slight decrease in the average operative time as the series progressed. The average number of discs excised was 6.5 ± 1.5 (range, 3–10), and the number increased as the series progressed. The average operative time per disc was 29.3 ± 7.7 minutes in the first 30 patients compared with 22.3 ± 4.7 minutes in the next 35 patients (P < 0.01). The average blood loss during the thoracoscopic procedure was 301 ± 322 mL (range, 25–2000 mL) and did not decrease as the series progressed. Initial postoperative scoliosis and kyphosis corrections were 59% ± 17% and 92% ± 12%, respectively. Complications occurred in six patients (cases 4, 8, 17, 31, 39, and 46) and were evenly distributed throughout the series.

Conclusions. The learning curve for thoracoscopy is substantial, but not prohibitive. This technique provides a safe and effective alternative to thoracotomy in the treatment of pediatric spinal deformity.

Although thoracoscopy was first used in the 1920s, 6 this technique was not used regularly until the past 20 years. Video-assisted thoracoscopic surgery (VATS) has been widely accepted for the treatment of many nonspinal, intrathoracic conditions since the early 1980s. 3,8 VATS allows thoracic surgery to be performed by minimally invasive methods, with the potential to decrease morbidity compared with open thoracotomy. 5,9 The chest wall musculature is not divided, improving postoperative pain, cosmesis, and shoulder girdle and chest wall muscle function. The application of VATS in the treatment of pediatric spinal deformity is a relatively new technique. The indications, contraindications, and complications associated with VATS in the treatment of pediatric spinal deformity are still being defined.

The indications for the use of VATS for the treatment of pediatric spinal deformity are similar to the indications for thoracotomy-based spinal surgery. Anterior spinal surgery is indicated in cases with severe and/or rigid spinal deformity, both scoliosis and kyphosis, that would be resistant to acceptable correction with posterior surgery alone. 10,11,14–16 Release of the anulus fibrosis and the anterior longitudinal ligament increases the flexibility of the spine, allowing for more complete correction of severe and rigid deformities. Anterior release and fusion may also be indicated in skeletally immature patients who have the potential for postoperative crankshaft deformity. 4 The goal of anterior surgery in these patients, whether through thoracotomy or with VATS, is to arrest the anterior vertebral body growth centers that may contribute to curve progression. The surgeon using the VATS method should attempt to duplicate the thoracotomy-based method; in doing so, the degree of curve correction and anterior fusion rates should be comparable between both methods.

Several studies have demonstrated that anterior release and discectomy performed by either the VATS method or the standard thoracotomy method produce similar results on the mobility of the spine. 12,18 Although the fundamental techniques of anterior spinal surgery are the same whether performed by thoracotomy or VATS, the types of instruments used through the VATS portals have been modified. These modifications require adaptation and acquisition of new surgical skills. 7 A learning curve is associated with the development of any new surgical technique. Aspects of the learning curve include the definition of the indications, contraindications, and complications and the refinement and improvement of the technique.

The purpose of this prospective study was to define the learning curve for the application of VATS to pediatric spinal deformity. The authors analyzed the preliminary results of the first 65 consecutive cases of VATS performed by one surgeon (PON) at their institution. To define the learning curve, the authors analyzed the time required to perform the procedure, the complications related to the VATS surgery, and other parameters used in the assessment of pediatric spinal deformity.