25 Anterior Correction and Instrumentation for Thoracic Scoliosis

Thoracic scoliosis is defined as an appreciable lateral deviation of the spine in the frontal plane (rotation about the X-axis). The apex of the curve must lie within the T2 to T11-T12 disc. The diagnosis is made by physical examination (rib, shoulder, and/or waist asymmetry) an as well as measurements of a standing anteroposterior (AP) and lateral x-ray of the spine taken on a 36-inch cassette (Fig. 25–1).

Indications for Surgery

1. Thoracic curves in children with growth potential remaining

2. Significant thoracic cosmetic deformities

3. Severe thoracic curves in the mature patient

Contraindications

1. Thoracic hyperkyphosis

2. Structural proximal thoracic and lumbar curves

Advantages of Anterior Approach for Thoracic Curves

1. Shorter fusion

2. Improved correction and cosmesis

3. Reduction in blood loss

Disadvantages

1. Hyperkyphosis

2. Shoulder asymmetry with a proximal thoracic curve

3. Waist asymmetry with a structural lumbar curve

4. The associated morbidity of a thoracotomy

Procedure

Fusion Levels

With anterior surgery the vertebra most tilted into the curve on the standing film should be included in the instrumentation, encompassing the entire vertebra included in the Cobb angle (Fig. 25–2), usually from neutral to neutral vertebra rather than stable to stable vertebra as in a posterior fusion.

Incision Options

Option 1: The incision is made from the posterior angle of the rib two levels above the apex of the curve. The incision is carried along the body of the rib to the costal cartilage and carried down through the muscular layers of the thoracic wall. The periosteum of the rib is incised along the direction of the incision to allow a subperiosteal stripping and removal of the rib. The rib is divided at the posterior angle and at the junction of its costal cartilage (Fig. 25–3).

Option 2: The incision is made as explained above. The incision is carried between the ribs through the muscle wall. The rib is not harvested for graft. Some surgeons believe that this technique permits a more cosmetic chest closure.

Option 3: An incision may be made at the level of the ultimate vertebra in the curve. It allows excellent exposure of the proximal portion of the curve. To achieve exposure of the remaining vertebrae in the curve, osteotomies are performed of all ribs below the incision.

Option 4: The incision is made from the posterior angle of the rib two levels above the apex of the curve. The chest is entered through two subcutaneous thoracotomies, separated by four ribs. This option allows excellent exposure for large, rigid curves (Fig. 25–4).

Exposure Secrets

1. If exposure is limited secondary to a “tight chest wall,” small osteotomies of the adjacent ribs may be done.

Related posts:

Posterior Cervical Laminectomy and Fusion Odontoid Fixation Posterior Scoliosis Correction: King Type V/ Double Thoracic Curves Anterior Correction of Thoracic Scoliosis Using the Kaneda Anterior Scoliosis System (KASS) Posterior Scoliosis Correction: Pedicle Screws Total Lumbar Disc Replacement Using the SB III Charite Prosthesis

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