Harry L. Shufflebarger

Goals of Surgical Treatment

1. Anterior thoracoplasty is partial multiple posterior rib resections from within a thoracotomy. It is indicated in the surgical treatment of scoliosis when either an anterior procedure or a combination anterior/posterior procedure is performed.

2. The procedure includes excision of several rib heads, facilitating access to the disc space.

3. Chest wall mobility is increased, facilitating intrathoracic exposure.

4. If a posterior instrumented fusion is to be performed following the anterior, the ribs provide an excellent bone graft source.

5. Thoracoplasty improves the cosmetic result of the deformity surgery.

The surgical treatment of spinal deformity frequently includes an anterior procedure. The anterior procedure may be thoracic or thoracoabdominal. In either instance, the goals are similar: correction of the spinal deformity and accomplishment of spinal arthrodesis. The cosmetic result of the deformity surgery is considerably improved by the anterior thoracoplasty.

The purpose of the anterior surgery may include several items. The anterior procedure may be a stand-alone procedure, with anterior instrumentation and fusion. The anterior procedure may be for release and fusion, preceding a posterior instrumented fusion.

The thoracotomy may be accomplished by removing one entire rib, or it may be accomplished in the space between ribs. The anterior or internal thoracoplasty follows. Several, usually three to five, posterior portions of ribs are removed, including the heads of the ribs. This provides excellent access to the disc space. In addition, partial removal of several ribs softens the chest wall considerably, permitting greater exposure within the chest. The rib portions removed may be morselized and used for graft in each interspace. In addition the ribs may be transferred to the posterior setup and employed as graft for the posterior procedure.

Indications for Surgery

1. Anterior thoracoplasty is indicated whenever thoracotomy is indicated in the surgical treatment of spinal deformity.

2. Several diagnostic categories require anterior surgery. Idiopathic scoliosis (infantile, juvenile, adolescent, and adult) is the most common indication.

3. Anterior procedures may be required in idiopathic scoliosis in patients with large curves to increase mobility, improve correction, and improve arthrodesis rate.

4. Prevention of the crankshaft phenomenon is another indication for anterior surgery in idiopathic conditions.

5. Anterior surgery for nonidiopathic conditions is also frequently indicated. This includes congenital and neuromuscular deformities, as well as kyphotic deformities (e.g., Scheuermann’s kyphosis). In these conditions, anterior thoracoplasty is useful for the several reasons listed above.

6. Anterior thoracoplasty is a simple and valuable adjunct to anterior spinal surgery. It should be considered in any patient undergoing a thoracotomy for spinal deformity surgery.

Contraindications

There are no contraindications. If the patient is suitable for thoracotomy, the procedure should add no additional morbidity and little additional time.

Advantages

1. Rib head excision provides wide access to each disc space, permitting complete discectomy and division of the posterior longitudinal ligament if necessary.

2. If anterior instrumentation is to be done, screw placement is facilitated.

3. Excision of the posterior portions of several ribs permits much wider exposure of the spine as rib spreading is much easier.

4. The softened chest wall is closed much more easily, never requiring rib approximator instruments.

5. A large amount of autogenous bone graft is available from the resected ribs. This may be used on the posterior procedure if planned.

6. Cosmetic improvement is enhanced by anterior thoracoplasty, as it is by thoracoplasty accomplished from the posterior approach.