27 Convex Thoracoplasty 1. To improve cosmesis 2. To decrease psychological effects 3. To improve the ability to sit in a chair 1. To increase flexibility during surgical correction (a concave rib osteotomy would probably also be required) 2. With rigid curves, the trunk does not always derotate despite current advanced spinal instrumentation systems, and a thoracoplasty is an excellent adjunctive procedure to posterior spinal fusion (PSF) or anterior instrumented procedure. 1. Adolescents with thoracic and double major curves. 2. Patients with a thoracolumbar curve undergoing a posterior approach may need to have the distal ribs resected. 3. Adult patients (> 21 years old) with rigid curves that will not derotate following posterior instrumentation. 4. Patients with residual rib prominence following successful PSF who complain of discomfort when they sit in a chair or lean against a wall. 5. Patients with psychological problems as a result of the deformity. A psychological consult is recommended. 1. A strong indication is a preoperative rib angle on radiograph or clinical examination of 15 degrees or more. 2. Consideration is given when the rib angle on radiograph is greater than 10 degrees. 3. Curve severity greater than 60 degrees. 4. Curve flexibility less than 20 % on bending films. 5. Postoperative correction of the Cobb angle of less than 50 % based on an intraoperative radiograph. 1. Patients in whom pulmonary function may be compromised. A decrease in pulmonary function is seen in the early postoperative period, which mandates proper patient selection. In one study (Lenke et al, 1995), pulmonary function test (PFT) values declined an average of 16 % at 3 months postsurgery in adolescents but returned to near normal at 2-year follow-up. The adults (> 30 years of age) experienced a PFT decline averaging 27 % at 3 months postsurgery, with a residual decline averaging 23 % at 2-year follow-up. 2. Thoracoplasty is not appropriate in patients with a severely rotated spine when the ribs do not protrude beyond the posterior margin of the spine. This can be assessed by a preoperative radiograph and computed tomography (CT) scan. Be aware that some patients with existing fusions complaining about the cosmesis are upset with trunk asymmetry, which won’t be corrected by thoracoplasty. Careful assessment may indicate that an osteotomy of the previous fusion to bring the apex of the curve closer to the midline should be combined with thoracoplasty. We use a midline incision instead of a two-incision technique because with better translation of the apex of the curve to the midline, less rib needs to be resected laterally than was necessary with a Harrington rod fusion. With Harrington rod distraction for severe curves needing a rib resection, the apex was minimally translated, and therefore most of the rib resection occurred laterally. Most of the rib resection now takes place at the medial-most attachment in adolescents. In adults, more rib laterally may need to be excised. 1. The patient is positioned as is standard for a PSF for idiopathic scoliosis. 2. The patient is draped from C7 to the midgluteal crease with wide margins posteriorly for adequate visualization of the rib prominence (Fig. 27–1). The lateral drapes should lay at the posterolateral axillary line, and wider if possible. 3. For a selected right thoracic fusion with thoracoplasty, it is necessary to extend the skin incision distally to approximately L2 or L3 to retract the thoracolumbar fascia adequately from the midline (Fig. 27–2). Stopping the skin incision at T12 does not provide adequate lateral exposure for this single-incision technique. Likewise, proximally the skin incision needs to be carried approximately 1/2 to one inch farther. Despite the slight increase in length of the incision, it is still much more cosmetically appealing than two incisions. 4. After skin incision, the spinous processes are outlined and the thoracolumbar fascia incised off the spinous process. In the L2-L3 region, the surgeon must be careful to pick up the very thin layer of thoracolumbar fascia with forceps. 5. Using sharp and blunt dissection, this fascia is elevated off the paravertebral muscle fascia, developing a plane by working laterally and proximally at the same time. The thoracolumbar fascia needs to be incised sequentially off the spinous processes as one proceeds proximally. This is a very easy and identifiable plane in a patient who has not previously had a spinal fusion. It can be tedious and more complex in revision spine surgery, but it can be done. 6. Once the fascia is retracted laterally, two Weitlaner self-retaining spring retractors are used at top and bottom to hold it. The patient should be told before surgery that some of the sensory nerves to the skin do transfer across this area and will need to be incised during the retraction.
Goals of Surgical Treatment
Primary
Secondary
Diagnosis
Indications for Surgery
Contraindications
Advantages and Disadvantages
Procedure
Convex Thoracoplasty with Posterior Instrumented Correction of Thoracic Adolescent Idiopathic Scoliosis
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