Mark Weidenbaum and Mladen Djurasovic

Goals of Surgical Treatment

To increase curve correction and augment fusion in thoracic deformities by anterior discectomy and anterior longitudinal ligament release prior to instrumentation.

Diagnosis

Thoracic scoliosis is a three-dimensional deformity involving hypokyphosis in the sagittal plane, lateral deviation in the coronal plane, and vertebral rotation in the axial plane. The curve apex lies between T2 and the T11–12 disc. Kyphosis involves deformity primarily in the sagittal plane. The diagnosis of either scoliosis or kyphosis is made by physical examination (shoulder or pelvic asymmetry, rib prominence, gross coronal or sagittal plane deformity, etc.) as well as with standing 36-inch posteroanterior (PA) and lateral scoliosis radiographs.

Indications (Similar to Open Anterior Releases)

1. Rigid scoliosis > 75 degrees (residual curve on bending > 50 degrees)

2. Scheuermann’s kyphosis > 70 to 75 degrees

3. Scoliosis > 50 degrees in skeletally immature patients at risk for crankshafting with posterior fusion alone

4. Neuromuscular, congenital, and metabolic deformities requiring anterior arthrodesis

5. Neurofibromatosis

6. Painful/progressive adult curves

Contraindications

1. Inability to tolerate single lung ventilation (severe respiratory insufficiency, pulmonary hypertension)

2. Extensive pleural adhesions (e.g., empyema, previous cardiac/thoracic procedure)

3. High airway pressures with positive pressure ventilation

4. Age/size limitations in the pediatric age group depending on tracheal/ main stem bronchus size and available endoscopic equipment

Advantages

1. Less postoperative pain than with open thoracotomy

2. Less blood loss

3. Better visualization of thoracic anatomy (magnification, illumination)

4. Fewer respiratory problems (less postoperative pain and chest wall splinting)

5. Minimal shoulder girdle dysfunction (less muscle transection)

6. Better cosmesis

7. Shorter hospitalization, possibly leading to lower costs

Disadvantages

1. Steep learning curve

2. Need for skilled endoscopic thoracic surgeon for early cases

3. Longer initial operative times until surgical team is sufficiently experienced (ultimately operative times will be reduced)

4. Extensive equipment needs (monitors, multichip camera, scopes, instrumentation)

Procedure

Preoperative Planning and Setup

1. All rigid levels should be released. Optimal release addresses enough levels to restore harmonious three-dimensional spine contour.

2. Working with a thoracic surgeon experienced with thoracoscopic techniques is strongly recommended.

3. Monitors on both sides of the table allow best visualization.

4. Single lung ventilation is mandatory.