青少年特发性胸椎侧凸胸腔镜辅助前路矫形的疗效

目的 介绍特发性胸椎侧凸胸腔镜辅助小切口前路矫形手术的技术要点和手术适应证选择,并对其临床结果进行分析.方法 2001年7月至2006年1月共进行胸椎侧凸小切口前路矫形手术37例,男4例,女33例,平均年龄14.1岁,冠状面Cobb角平均56°,Lenke分型Ⅰ A 14例,Ⅰ B14例,Ⅰ C 9例,均为胸椎右侧凸,Risser征++～++++,对手术时间、术中出血量、固定节段、矫正效果以及矫正丢失等进行分析.结果 平均手术时间220 min,术中出血量平均320 ml,平均固定节段7.8个,术后Cobb角平均16.8°,平均侧凸矫正率70%,随访18～36个月,平均矫正丢失4.6%,无内固定并发症发生.结论 胸椎侧凸前路胸腔镜辅助小切口矫形手术在减少手术创伤、降低麻醉要求、相对胸腔镜手术更为宽松的适应证选择基础上,可以达到传统开胸前路矫形或后路矫形手术的临床效果、且没有增加手术并发症.     

胸腔镜下前路矫形术治疗特发性胸椎侧凸的初步临床结果

目的总结胸腔镜下前路矫形术治疗特发性胸椎侧凸的临床应用初步结果,并分析其适应证的选择与疗效。方法2002年6月～2003年5月共施行胸腔镜下前路胸椎侧凸矫形术8例,均为女性特发性右侧胸椎侧凸患者,年龄13～16岁,平均14.8岁。术前冠状面Cobb角40°～72°,平均54°。例为KingⅢ型,2例为KingⅡ型,1例为KingⅤ型。Risser征( )～( )。胸弯在Bending相X线片上的自动矫正率为60%～75%。胸椎矢状面形态正常,无明显后凸和前凸畸形。对8例患者的手术时间、术中出血量、术后引流量、固定节段、矫正效果以及近期的矫正丢失等进行分析。结果平均手术时间为6.0h,平均术中出血量为629ml,平均术后引流量为500ml,平均固定节段7.4个,术后Cobb角平均15°,Cobb角矫正率平均74%。全部病例随访3～12个月,平均6.5个月。平均矫正丢失率为8.3%,但尚无内固定并发症发生。结论与传统开放前路或后路胸椎侧凸矫形手术相比,胸腔镜下前路矫形术同样能使特发性胸椎侧凸获得满意的早期矫形效果;但该术式存在手术时间长、难度大、适应证相对较窄、术者过量接受X线等缺点,其远期效果和并发症的评估尚待长期随访。     

胸腔镜下特发性胸椎侧凸的前方松解手术

目的:介绍胸腔镜下胸椎侧凸前方松解手术的技术要点,并对其初步临床结果进行分析。方法:16例青少年特发性脊柱侧凸,男1例,女15例,平均年龄15.8岁,Cobb角平均89°±11.3°,KingⅡ型11例,KingⅢ型5例,Risser征3~4级。行胸腔镜下胸椎侧凸前方松解手术,术后2周行后路TSRH矫形内固定加植骨融合术。对胸腔镜下松解手术的手术时间、松解节段数、术中出血量、术后引流量及后路矫形术后的侧凸矫正率等进行统计分析。结果:侧凸前方松解术的平均手术时间为192±25min,平均松解节段5.9±0.8个,术中出血量130±21ml,术后引流量550±80ml,引流时间70±15.5h。后路TSRH矫形内固定加植骨融合术后平均Cobb角38.8°±11.0°,侧凸矫正率为55.8±10.7%。随访半年无矫正丢失和内固定并发症发生。结论:胸腔镜下胸椎侧凸前方松解手术的初步临床结果令人满意,远期疗效尚需长期随访。     

胸腔镜下前路矫形治疗青少年特发性胸椎侧凸

目的探讨胸腔镜下前路矫形治疗青少年特发性胸椎侧凸的疗效。方法青少年特发性胸椎侧凸33例,男7例,女26例;年龄10～18岁,平均13.6岁。Lenke分型均为Ⅰ型,其中24例为ⅠA型,9例为ⅠB型。术前Cobb角:冠状面原发性胸弯平均57.4°(43°～68°),代偿性腰弯平均32.0°(20°～47°);27例存在胸椎后凸不足畸形,胸椎后凸平均6.3°(0°～18°)。手术方法为前路胸腔镜下切除椎间盘进行松解,应用CDHorizonEclipse矫形内固定,同时在椎间隙植骨。随访期间测量冠状面Cobb角及矢状面胸椎后凸成角,了解冠状面和矢状面畸形矫正情况。结果固定节段包括T4～T12,平均7.4个。平均手术时间为3h48min,平均术中出血量为308ml,平均住院时间4.4d。全部病例随访6～36个月,平均20.6个月。末次随访时原发性胸弯平均矫正60.2%,代偿性腰弯自然矫正平均50.3%,胸椎后凸平均矫正20.4°。1例出现假关节形成及内固定折断,2例出现胸壁麻木。结论胸腔镜下前路矫形治疗胸椎侧凸具有创伤小、术后恢复快等优点,能达到与开胸前路矫形术同样的矫形效果。     

胸腔镜与开胸前方松解在脊柱侧凸后路矫形中的作用

目的比较胸腔镜与开胸前方松解对脊柱侧凸后路矫形的作用,评估胸腔镜脊柱侧凸前方松解手术的临床效果。方法2001年11月～2002年9月共施行14例胸腔镜脊柱侧凸前方松解手术和22例开胸前方松解手术,所有病例均为特发性脊柱侧凸。胸腔镜组男1例,女13例;平均年龄15.9岁;其中KingⅡ型9例,KingⅢ型5例;Cobb角88°±10.4°,柔软度(Bending片侧凸矫正率)25.5%±6.1%;松解节段5.8±0.9个。开胸组男5例,女17例;平均年龄15.5岁;其中KingⅡ型13例,KingⅢ型9例;Cobb角90°±15.2°,柔软度24.8%±7.8%;松解节段6.0±1.1个。两组患者均于前方松解后2周行后路TSRH矫形手术。对两组的术后侧凸矫正率以及半年后的矫正丢失率进行比较。结果胸腔镜组术后Cobb角39.6°±10.8°,侧凸矫正率54.7%±10.3%,半年后矫正丢失率2.9%±1.1%;开胸组术后Cobb角41.9°±13.2°,侧凸矫正率53.2%±12.5%,半年后矫正丢失率3.2%±1.3%。两组比较差异均无显著性(P >0.05)。结论胸腔镜脊柱侧凸前方松解手术能达到开胸前方松解手术的临床效果。     

前路胸腔镜下青少年特发性胸椎侧凸矫形的初步临床结果

目的回顾胸腔镜下青少年特发性脊柱侧凸（adolecent idiopathic scoliosis,AIS）前路矫形的初步临床疗效。方法 2007年8月~2008年11月行胸腔镜下前路矫形患者8例,均为女性Lenkel A-型AIS患者,平均年龄为13.8岁。对手术前后及末次随访时的胸椎侧凸Cobb角、腰椎侧凸Cobb角、顶椎中点与C7中点垂线或骶骨平分线垂直距离（apical vertebral translation,AVT）、顶椎旋转角、胸椎后凸Cobb角及双肩高度差进行分析。结果所有患者术后随访3~12个月,胸椎侧凸Cobb角平均改善率为71%、矫形丢失率为6%;腰椎侧凸Cobb角平均改善率为60%、矫形丢失率为6%;AVT改善率为73%,丢失率为6%。所有患者顶椎旋转角度均无改善;胸椎后凸Cobb角无改变。双肩高度差除1例患者随访时丢失50%,其余改善率均为100%。结论柔韧度好的Lenkel A-型AIS行胸腔镜下前路矫形可获得良好的冠状面矫形,但矢状面矫形及椎体去旋转效果不佳,长期疗效有待继续观察。     

前路Moss Miami器械矫形治疗特发性胸腰段或腰段脊柱侧凸

目的:评价MossMiami前路矫形系统对特发性胸腰段或腰段脊柱侧凸的手术效果。方法:对21例胸腰段或腰段特发性脊柱侧凸患者经前路胸腹联合入路行MossMiami矫形内固定,自体肋骨椎间植骨融合术。测量手术前后Cobb角以及躯干侧方位移。结果:Cobb角术前平均53°,术后平均5°,矫正率为90%。上方代偿性胸椎侧凸术前平均17°,术后矫正至平均5°。下方代偿性腰骶椎侧凸术前平均43°,术后自发矫正至19°。随访12~24个月,Cobb角平均丢失19.7°,胸腰段(T11~L1)术前平均前凸0.3°(0~4°),术后平均后凸3°(0~5°)。躯干侧方位移从术前平均26mm矫正至术后5mm。1例术后出现一侧下肢交感神经切断症状,2例术后并发气胸。无感染、截瘫及内固定失败等并发症发生。结论:MossMiami前路器械具有操作简单和低切迹的优点。棒的预弯、去旋转矫形、正确选择螺钉置入部位和椎间植骨可防止固定节段后凸畸形的形成。对Risser征小于4度的患者应密切观察上方代偿性胸椎侧凸进展情况。     

胸腔镜下前路松解联合后路矫形治疗脊柱畸形

目的:评价胸腔镜下前路松解联合后路矫形对脊柱畸形的治疗效果。方法:回顾性分析我院收治的19例脊柱畸形行胸腔镜辅助前路松解及后路脊柱畸形矫形植骨融合术患者的临床资料及治疗结果。结果:胸腔镜手术时间平均120min,前路松解、阻滞椎间盘平均4.2个。术后14例特发性脊柱侧凸Cobb角平均被纠正到29.4°,4例神经纤维瘤病性脊柱侧凸Cobb角平均被纠正到28°,1例胸椎后凸Cobb角被纠正到58.5°。术后平均随访17.5个月,无矫正度的丢失和其它神经系统及血管损伤并发症。结论:胸腔镜辅助前路脊柱松解是安全、有效的微创手术,联合后路矫形治疗脊柱畸形可获得满意治疗效果。     

胸腔镜辅助下治疗特发性脊柱侧凸

[目的]评价胸腔镜下前路松解,前路或后路矫形治疗特发性脊柱侧凸的治疗效果。[方法]回顾本院自2003年7月~2005年12月施行的11例胸腔镜辅助下前路松解,前路或后路矫形治疗特发性脊柱侧凸病例。年龄12~16岁,平均14.6岁。LenkeⅠ型9例,术前冠状面Cobb s角54°~68°,平均59.7°;LenkeⅢ型2例,术前冠状面Cobb s角分别为58°和71°,平均64.5°。Bending X线片侧凸矫正率为21.8%~32.4%,平均26.4%。对11例患者在胸腔镜辅助下,采用等离子冷消融切除椎间盘松解,前或后路矫正。对手术后及随访时,冠状面和矢状面的Cobb s角进行测量,并对手术时间,术中出血量,围手术期并发症及矫正丢失等进行分析。[结果]平均手术时间290 min,平均术中出血171 ml。松解节段5~7个,平均4.4个。9例LenkeⅠ型术后Cobb s角平均20.4°,Cobb s角矫正率平均65.8%;2例LenkeⅢ型术后Cobb s角分别为20°和25°,Cobb s角矫正率平均65.1%;1例术后包裹性胸腔积液,术后平均随访18.6个月;1例出现矫正度丢失14°,无神经系统及血管损伤并发症。[结论]与传统开胸前路胸椎侧凸矫形手术相比,胸腔镜辅助下胸椎松解前后路矫形治疗脊柱侧凸是安全有效的微创手术,可达到与开胸手术同样效果。     

胸椎侧凸胸腔镜下和开放小切口前路矫形术椎间融合面积研究

目的 比较特发性胸椎侧凸胸腔镜下前路矫形术与胸腔镜辅助下开放小切口前路矫形术的椎间植骨和融合效果。方法 将34例特发性胸椎右侧凸患者分为两组，A组10例患者接受胸腔镜下胸椎侧凸前路矫形术，平均年龄14．4岁，平均Cobb角52．9°。B组24例患者接受开放小切口前路矫形手术，平均年龄14．5岁，平均Cobb角45．4°。两组患者均采用自体肋骨作为移植骨。所有患者术后均行固定节段的CT扫描并获得完整的随访资料。通过测量术后CT片以及不同随访时间的X线片，对两组病例的椎间植骨面积百分比、矫形效果以及矫正丢失进行分析。结果两组患者在年龄、侧凸柔软性和固定节段等方面差异均无统计学意义，A组术前胸弯大于B组。两组患者术后平均椎间植骨面积百分比均超过40％，且组间差异无统计学意义（P〉0．05）。A组术后早期矫正丢失明显高于B组，差异有统计学意义（P〈0．05）。但两组在术后6个月后均无明显矫正丢失。结论 胸腔镜下胸椎侧凸前路矫形手术能够获得与开放小切口前路矫形手术同样满意的椎间植骨和融合效果，前者早期矫正丢失明显可能与固定的棒较细有关。     

Selective ventral derotation spondylodesis in idiopathic thoracic scoliosis: a prospective study

AIM: Radiometric curve analysis of instrumented primary and spontaneous secondary curve correction after anterior correction and fusion of idiopathic thoracic scoliosis. METHOD: Sixty-four patients with idiopathic thoracic scoliosis were prospectively evaluated. All patients were operated either with the Zielke-VDS or with a primary stable double rod instrumentation with selective fusion of the thoracic curve from end-to end-vertebra. Follow-up averaged 29 months (24 - 52 months). RESULTS: The Cobb angle of the primary curve averaged 63.2 degrees preoperatively and was corrected to 21.4 degrees postoperatively with an average loss of correction of 5.3 degrees (58 % final curve correction). Apical thoracic vertebral rotation was corrected by 48 %. The secondary lumbar curve measured 38.2 degrees preoperatively (72 % correction on the bending films) and was spontaneously corrected by 57 % to 16.4 degrees without significant loss of correction in the final follow-up. Apical vertebral rotation averaged 11.3 degrees in the lumbar curve and was corrected spontaneously by 24 % to 8.6 degrees without significant loss of correction. Lumbar apex vertebra deviation showed no significant reduction. There was no case of lumbar curve decompensation in either frontal or sagittal plane. Implant related complications were observed in 7 patients (rod breakage), but no pseudarthrosis occurred. There were no neurological complications noted. CONCLUSION: Selective anterior correction and fusion in idiopathic thoracic scoliosis enables a satisfactory correction of both primary and lumbar secondary curves. The advantage of selective anterior correction and fusion of thoracic scoliosis is the short fusion length, better derotation and satisfactory correction of the secondary lumbar curve. The disadvantages of single threaded rod techniques in terms of lack of primary stability and a kyphogenic effect have been eliminated by the development of a primary stable, small size double rod instrumentation.     

Anterior surgery with short fusion using the Zielke procedure for thoracic scoliosis: focus on the correction of compensatory curves

Anterior instrumentation is recommended to correct idiopathic thoracolumbar or lumbar scoliosis through short fusion within the major curve. Only a few reports exist of anterior surgical correction for thoracic scoliosis. This study assessed the results of Zielke instrumentation for thoracic curve and analyzed the three-dimensional correction of deformity, especially correction of the uninstrumented compensatory curve. Seventeen patients, who had undergone selective thoracic correction and fusion using the Zielke procedure to treat thoracic scoliosis, had been followed for at least 3 years. Three-dimensional correction was evaluated radiographically. Furthermore, three-dimensional back deformities were evaluated using a topographic body scanner. Twelve patients with a single thoracic curve and five with a double curve were all female, with a mean age of 14.6 years. The preoperative main thoracic curve was 54.8 degrees +/- 10.5 degrees (range, 40-78 degrees), and it was 23.8 degrees +/- 10.5 degrees (range, 7-40 degrees) at the final follow-up examination (p < 0.0001). The average correction rate of the main curves was 56.6%. By correcting the thoracic curve, the upper and lower compensatory curves were corrected spontaneously without surgical instrumentation, with average correction rates of 45.1% and 50.2%, respectively. The average correction loss of the main curve was 2.3 degrees. The hump angle measured using a topographic body scanner decreased from 12.8 degrees +/- 4.5 degrees to 8.4 degrees +/- 4.3 degrees after surgery (p = 0.0001). Of the three patients in whom the rod broke up, only one showed a correction loss of 10 degrees; however, bony fusion was obtained. Anterior short fusion for thoracic scoliosis appears to offer significant correction, stabilization, and spontaneous correction of the compensatory lumbar curve without limiting lumbar motion.     

Spontaneous proximal thoracic curve correction after isolated fusion of the main thoracic curve in adolescent idiopathic scoliosis

STUDY DESIGN: Retrospective clinical, radiographic, and patient outcome review of surgically treated adolescent idiopathic scoliosis. OBJECTIVES: To evaluate the spontaneous correction of the noninstrumented proximal thoracic (PT) curve after isolated correction of the main thoracic (MT) curve by either an anterior (ASF) or posterior (PSF) instrumentation and fusion. SUMMARY OF BACKGROUND DATA: There are no studies comparing the structural PT curve response after anterior versus posterior instrumented fusion of the MT curve in adolescent idiopathic scoliosis. METHODS: Eighty-five patients (single surgeon) with adolescent idiopathic scoliosis underwent operative instrumentation and fusion of their MT curve. All patients had a PT curve > or =20 degrees (average 29 degrees, range 20-49 degrees; average residual side-bending 18 degrees, range 3-42 degrees ) and were evaluated for preoperative PT curve flexibility and postoperative curve correction after PSF with the PT curve not instrumented (n = 44) and ASF with the PT curve not instrumented (n = 41). Minimum follow-up was 2 years (average, 3.6 years). Preoperative, 1 week postoperative, and latest follow-up (minimum 2-year) full-length radiographs were evaluated for the PT, MT, and thoracolumbar-lumbar coronal, side-bending, and sagittal Cobb measurements, as well as T1 tilt, clavicle angle, radiographic shoulder height, and the PT, MT, and thoracolumbar-lumbar apical vertical translation. A patient outcome questionnaire was also completed to correlate patient satisfaction with respect to their shoulder balance and overall appearance. RESULTS: The two groups were found to be statistically equivalent (P = 0.66) in terms of preoperative PT curve, MT curve, and MT side-bending curves, with the PT side benders slightly more flexible for the ASF (43%) versus the PSF group (31%) (P = 0.02). RADIOGRAPHIC: The spontaneous improvement in the PT curve was significant (P < 0.0001) in both groups. Additionally, this correction was maintained over time. However, the spontaneous PT curve correction was significantly greater after an ASF versus PSF correction of the MT curve on both the immediate postoperative (P =0.017) and minimum 2-year (P = 0.0024) evaluations, whereas the MT curve correction was the same in both groups (P = 0.45). There was no difference in the postoperative sagittal change in the PT curve (P = 0.12) between the two groups, and there was no difference in radiographic shoulder height (P = 0.5883). PATIENT OUTCOME: Both groups reported improvement in shoulder balance and clinical appearance, but there was no statistical difference between the two groups (P = 0.24). Additionally, no patients reported deterioration in either parameter. CONCLUSIONS: Spontaneous proximal thoracic curve correction consistently occurs after instrumented correction of the main thoracic curve. Furthermore, this spontaneous correction is as good as or slightly better after an ASF versus PSF of the MT curve. The preoperative side bender radiographs (PT curve flexibility) positively correlate with the postoperative spontaneous PT curve correction.     

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

BACKGROUND CONTEXT: Combining anterior release and interbody fusion with posterior instrumented fusion is an accepted treatment for severe rigid spinal deformity. Video-assisted thoracoscopic surgery (VATS) and mini-open thoracoscopically assisted thoracotomy (MOTA) are two minimally invasive approaches to the thoracic spine. Both reduce surgical trauma, improve cosmesis and provide effective exposure for release and fusion. Published data and the authors' surgical experience have demonstrated that both techniques are equivalent in degree of release to traditional open thoracotomy, but no comparison between these two minimally invasive alternatives has been published to our knowledge. PURPOSE: This study compared MOTA and VATS under the hypothesis that both result in similar corrections and comparable operative parameters when used in conjunction with posterior instrumented fusion. STUDY DESIGN/SETTING: Retrospective chart review of consecutive case series by two surgeons. PATIENT SAMPLE: Twenty-one (13 female, 8 male) patients underwent MOTA and 24 patients (17 female, 7 male) underwent VATS for anterior release, discectomy and fusion prior to posterior instrumented fusion. OUTCOME MEASURES: Outcomes were measured at a minimum of 1-year follow-up and included radiographic Cobb measurements and operative parameters. METHODS: The indications for surgery included rigid and severe scoliosis or thoracic kyphosis. Data collection included preoperative demographics, number of levels released, primary curve correction, operative time and blood loss. Data were normalized per number of levels released anteriorly. Statistical analysis of results was done using a two-sample t test assuming equal variances with two-tail p values less than .05. RESULTS: More anterior levels were operated on average in the VATS group (6.33 vs. 4.38 levels). Curve correction per anterior level released was similar in both groups (8.7 and 8.8 degrees/level for MOTA and VATS, respectively). There was a significant difference in operative time with MOTA averaging 131.7 minutes and VATS averaging 162.8 minutes. However, a comparison of the operative time per anterior level operated, approached statistical significance in favor of VATS (33.0 vs. 28.4 minutes, p=.08). There was no significant difference in estimated blood loss during the anterior portion of the surgeries. There was a trend toward decreased blood loss per operated level favoring VATS (68.4 vs. 38.9 cc, p=.09). CONCLUSIONS: Both approaches resulted in corrections that compare favorably with open thoracotomy. We suggest that a factor in choosing between these two minimally invasive techniques is the number of thoracic levels requiring release. For four levels or less, MOTA provides an excellent alternative to standard thoracotomy. For five or more levels, VATS provides for excellent exposure of additional levels with the advantages of less operative time and blood loss per operated level.     

Thoracoscopic spinal fusion compared with posterior spinal fusion for the treatment of thoracic adolescent idiopathic scoliosis

BACKGROUND: Posterior spinal fusion with segmental instrumentation is the gold standard for the surgical treatment of thoracic adolescent idiopathic scoliosis. More recently, anterior surgery and video-assisted thoracoscopic surgery with spinal instrumentation have become available. The purpose of the present study was to compare the radiographic and clinical outcomes as well as pulmonary function in patients managed with either anterior thoracoscopic or posterior surgery. METHODS: Radiographic data, Scoliosis Research Society patient-based outcome questionnaires, pulmonary function, and operative records were reviewed for fifty-one patients undergoing surgical treatment of scoliosis. Data were collected preoperatively, immediately postoperatively, and at the time of the final follow-up. The radiographic parameters that were analyzed included coronal curve correction, the most caudad instrumented vertebra tilt angle correction, coronal balance, and thoracic kyphosis. The operative parameters that were evaluated included the operative time, the estimated blood loss, the blood transfusion rate, the number of levels fused, the type of bone graft used, and the number of intraoperative and postoperative complications. The pulmonary function parameters that were analyzed included vital capacity and peak flow. RESULTS: The thoracoscopic group included twenty-eight patients with a mean age of 14.6 years, and the posterior fusion group included twenty-three patients with a mean age of 14.3 years. The percent correction was 54.5% for the thoracoscopic group and 55.3% for the posterior group. With the numbers available, there were no significant differences between the two groups in terms of kyphosis (p = 0.84), coronal balance (p = 0.70), or tilt angle (p = 0.91) at the time of the final follow-up. The mean number of levels fused was 5.8 in the thoracoscopic group, compared with 9.3 levels in the posterior group (p < 0.0001). The estimated blood loss in the thoracoscopic group was significantly less than that in the posterior fusion group (361 mL compared with 545 mL; p = 0.03), and the transfusion rate in the thoracoscopic group was significantly lower than that in the posterior fusion group (14% compared with 43%; p = 0.01). Operative time in the thoracoscopic group was significantly greater than that in the posterior group (6.0 compared with 3.3 hours, p < 0.0001). There were no intraoperative complications in either group. Vital capacity and peak flow had returned to baseline levels in both groups at the time of the final follow-up. Patients in the thoracoscopic group scored higher than those in the posterior group in terms of the total score (p < 0.0001) and all of the domains (p < 0.01) of the Scoliosis Research Society questionnaire at the time of the final follow-up. CONCLUSIONS: Thoracoscopic spinal instrumentation compares favorably with posterior fusion in terms of coronal plane curve correction and balance, sagittal contour, the rate of complications, pulmonary function, and patient-based outcomes. The advantages of the procedure include the need for fewer levels of spinal fusion, less operative blood loss, lower transfusion requirements, and improved cosmesis as a result of small, well-hidden incisions. However, the operative time for the thoracoscopic procedure was nearly twice that for the posterior approach. Additional study is needed to determine the precise role of thoracoscopic spinal instrumentation in the treatment of thoracic adolescent idiopathic scoliosis.     

Radiographic evaluation of selective anterior thoracolumbar or lumbar fusion for adolescent idiopathic scoliosis

According to Lenke classification of adolescent idiopathic scoliosis (AIS), patients with type 5 curve in which the structural major curve is thoracolumbar or lumbar curve with nonstructural proximal thoracic and main thoracic curves, could be surgically treated with selective anterior thoracolumbar or lumbar (TL/L) fusion. This study retrospectively analyzed the radiographies of selective anterior TL/L fusion in 35 cases of AIS with Lenke type 5 curve. Segmental fixation with a single rigid rod through anterior thoracoabdominal approach was applied in all patients. Measurements of scoliosis curve in preoperative, immediate postoperative and follow-up radiographies were analyzed. The average follow up time was 36 months (24-42 months). The average preoperative Cobb angle of the TL/L curve was 45.6 degrees and improved into 9.7 degrees immediate postoperatively, with 79.7% curve correction. In addition, the minor thoracic curve decreased from 29.7 degrees preoperatively to 17.6 degrees postoperatively, with a spontaneous correction of 41.5%. During the follow-up, a loss of 4.6 degrees correction was found and the average Cobb angle of TL/L increased to 14.4 degrees . Also, the minor thoracic curve increased to average 20.1 degrees with a loss of 2.4 degrees correction. Trunk shift deteriorated slightly immediate postoperatively and improved at the follow-up. The lowest instrumented vertebra (LIV) tilt was improved significantly and maintained its results at the follow-up. During the follow-up, the coronal disc angle immediately above the upper instrumented vertebra (UIVDA) and below the LIV (LIVDA) aggravated, while the sagittal contours of T5-T12 and T10-L2 were well maintained. The lumbar lordosis of L1-S1 and the sagittal Cobb angle of the instrumented segments were reduced slightly postoperatively and at the follow-up. There were no major complications or pseudarthrosis. The outcomes of this study show that selective anterior thoracolumbar or lumbar fusion with solid rod instrumentation is effective for surgical correction of AIS with Lenke type 5 curve. The TL/L curve, minor thoracic curve, and LIV title can be improved significantly, with good maintenance of sagittal contour. However, the UIVDA and LIVDA aggravate postoperatively when the trunk rebalances itself during follow-up. The degeneration of LIV disc warrants longer-term follow-up.     

Anterior surgery for adolescent idiopathic scoliosis

Anterior open scoliosis surgery using the dual rod system is a safe and rather effective procedure for the correction of scoliosis (50–60 %). Thoracic hypokyphosis and rib hump correction with open anterior rather than posterior instrumentation appear to be the better approaches, although the latter is somewhat controversial with current posterior vertebral column derotation devices. In patients with Risser grade 0, hyperkyphosis and adding-on may occur with anterior thoracic spine instrumentation. Anterior thoracoscopic instrumentation provides a similar correction (65 %) with good cosmetic outcomes, but it is associated with a rather high risk of instrumentation (pull-out, pseudoarthrosis) and pulmonary complications. Approximately 80 % of patients with adolescent idiopathic scoliosis (AIS) curves of >70° have restrictive lung disease or smaller than normal lung volumes. AIS patients undergoing anterior thoracotomy or anteroposterior surgery will demonstrate a significant decrease in percentage of predicted lung volumes during follow-up. The thoracoabdominal approach and thoracoscopic approach without thoracoplasty do not produce similar changes in detrimental lung volume. In patients with severe AIS (>90°), posterior-only surgery with TPS provides similar radiographic correction of the deformity (44 %) with better pulmonary function outcomes than anteroposterior surgery. Vascular spinal cord malfunction after segmental vessel ligation during anterior scoliosis surgery has been reported. Based on the current literature, the main indication for open anterior scoliosis instrumentation is Lenke 5C thoracolumbar or lumbar AIS curve with anterior instrumentation typically between T11 and L3.     

Thoracoscopic approach for spine deformities

BACKGROUND: We reviewed our experience using anterior thoracoscopic procedures in the correction of severe idiopathic scoliosis and kyphotic deformities to evaluate the feasibility and effectiveness of such procedures. STUDY DESIGN: Twenty-four patients who underwent thoracoscopic surgical correction of the spine between March 1995 and December 2001 were retrospectively reviewed. A team consisting of one orthopaedic surgeon and one thoracic surgeon performed anterior thoracoscopic soft tissue release, disc excision, and bone grafting followed on the same day with posterior instrumentation and correction of deformity. RESULTS: There were 16 female and 8 male patients, with a median age of 16 years (range 11 to 47 years) with idiopathic scoliosis (20 patients) or kyphotic deformity (4 patients). The average time for the thoracoscopy was 125 minutes (range 60 to 175 minutes). Blood loss averaged 135 mL (range 20 to 350 mL), and a median number of five discs (range two to eight) were excised. The median ICU time was 2 days (range 1 to 8 days), and the median length of hospital stay was 6 days (range 4 to 11 days). One patient required conversion to an open procedure because of arterial bleeding from the cancellous bone (T5). Postoperative complications occurred in four patients (atelectasis, pneumothorax, pneumonia, and wound infection in one patient each). All patients had an uneventful hospital course after treatment. CONCLUSIONS: Thoracoscopic anterior procedures can be used safely and effectively in the treatment of idiopathic scoliosis and kyphotic deformity. This minimally invasive approach might decrease procedure-related trauma, operative time, blood loss, and length of hospitalization and may also alleviate postthoracotomy pain.     

Anterior fusion for idiopathic scoliosis

STUDY DESIGN: A review of the charts and radiographs of 22 patients with idiopathic lumbar, thoracolumbar, and thoracic scoliosis who underwent single-stage anterior fusion with rigid third-generation instrumentation and titanium surgical mesh implants. OBJECTIVES: To validate a new technique for scoliosis correction by assessing the initial correction of deformity, trunk shift, and rotation. Perioperative statistics as well as complications were reviewed. The maintenance of sagittal balance and rate of fusion were also determined after a minimum of 2 years' follow-up. SUMMARY OF BACKGROUND DATA: Posterior correction of scoliosis has been the preferred method of treatment since the introduction of Harrington rods. Recent advances in instrumentation and surgical techniques have allowed surgeons to approach scoliosis correction through the chest and abdomen. These new techniques must be validated before they become accepted alternatives to the standard of care. METHODS: One male and 21 female patients, aged 11-18 years, were observed for an average of 44 months. Matched-pairs t tests were used to compare pre- and postoperative curve measurements. RESULTS: Statistically significant curve improvements were seen when postoperative radiographs were compared with preoperative ones. The instrumented coronal plane curve was corrected 82%. A 65% spontaneous correction of the uninstrumented coronal plane curve was observed. Sagittal kyphosis improved 7 degrees, and apical rotation and tilt angles improved 71% and 80%, respectively. A mean loss of 4 degrees of correction was seen on final follow-up radiographs. Lumbar lordosis did not change significantly, and postoperative hyperlordosis was not detected. Ninety-six percent of all instrumented levels fused within 6 months. Although the perioperative complication rate was low, five patients (23%) had asymptomatic idiopathic retrolisthesis develop at the caudal end of the fused vertebrae. CONCLUSIONS: Accepted correction of idiopathic scoliosis can be achieved with anterior instrumented fusion alone.