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Radiographic sagittal plane analysis of VATS (video-assisted thoracoscopic surgery) anterior instrumentation for adolescent idiopathic scoliosis. This is retrospective study. To report, in details about effects of VATS anterior instrumentation on the sagittal plane. Evaluations of the surgical outcome of scoliosis have primarily studied in coronal...
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Study design:
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Purpose:
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Methods
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Citations
... Fourteen studies were identified describing outcomes with ATS scoliosis surgery. Out of these fourteen studies, seven were case series [2,[12][13][14][15][16][17], four studies compared ATS and thoracotomy approaches [18][19][20][21], two compared ATS with PSIF [22,23], and one compared all three approaches (ATS, thoracotomy, and PSIF) [24]. All but one study described the outcomes of treatment in patients with AIS. ...
... Newton et al. [24] in his three-pronged comparative study reported significantly higher loss of kyphosis with posterior surgery as compared to the anterior corrective procedures. As with previous reports, these studies reiterated the kyphogenic effect of anterior surgery due to shortening the anterior vertebral column [14,18]. ...
Background: Minimally invasive surgical (MIS) techniques have gained popularity as a safe and effective alternative to open surgery for degenerative, traumatic, and metastatic spinal pathologies. In adolescent idiopathic scoliosis, MIS techniques comprise anterior thoracoscopic surgery (ATS), posterior minimally invasive surgery (PMIS), and vertebral body tethering (VBT). In the current systematic review, the authors collected and analyzed data from the available literature on MIS techniques in AIS. Methods: The articles were shortlisted after a thorough electronic and manual database search through PubMed, EMBASE, and Google Scholar. Results: The authors included 43 studies for the review; 14 described the outcomes with ATS, 13 with PMIS, and 16 with VBT. Conclusions: While the efficacy of the ATS approach is well-established in terms of comparable coronal and sagittal correction to posterior spinal fusion, the current use of ATS for instrumented fusion has become less popular due to a steep learning curve, high pulmonary and vascular complication rates, implant failures, and increased non-union rates. PMIS is an effective alternative to the standard open posterior spinal fusion, with a steep learning curve and longer surgical time being potential disadvantages. The current evidence, albeit limited, suggests that VBT is an attractive procedure that merits consideration in terms of radiological correction and clinical outcomes, but it has a high complication and re-operation rate, while the most appropriate indications and long-term outcomes of this technique remain unclear.
... [7][8][9][10][11][12] Video-assisted thoracoscopic scoliosis surgery (VATS) was introduced in the 1990s but subsequently declined in popularity with the advent of posterior instrumentation and fusion with pedicle screws. VATS current applications include its use as a definitive procedure for anterior instrumented fusion of selected Lenke 1 and Lenke 5 curve types, [13][14][15][16][17][18][19][20][21][22][23][24][25] and as an anterior release procedure for severe thoracic scoliosis before posterior instrumentation and fusion, [26][27][28] in non-fusion convex growth modulation procedures such as anterior vertebral body stapling (VBS) [29][30][31][32][33][34][35][36] or tethering. [34][35][36][37][38][39][40][41] This article aimed to provide an overview of the current state of knowledge of MIS for AIS surgery. ...
Posterior spinal instrumentation and fusion is the gold standard of surgical treatment for adolescent idiopathic scoliosis (AIS). This procedure is conventionally performed open, through a posterior midline approach. Minimally invasive spinal surgery (MIS) has been found to be associated with decreased blood loss, shorter duration of hospital stays, earlier mobilization, and decreased analgesic requirements in other areas of spinal surgery. In the treatment of patients with AIS, these principles can be applied via a posterior MIS approach and an anterior thoracoscopic approach. This article aimed to provide an overview of the current state of knowledge of MIS for AIS surgery. We will describe the rationale for the use of posterior MIS for AIS, a description of the surgical technique and a discussion of the current evidence for its use. We will also describe the indications, surgical technique, and evidence for MIS anterior spinal fusion as a definitive procedure for AIS and for non-fusion convex growth modulation procedures.
... Studies were categorized into levels of evidence according to guidelines by the Center for Evidence Based Medicine. A total of 13 articles were judged to meet inclusion criteria [6][7][8][9][10][11][12][13][14][15][16][17][18]. Of the 13 studies selected, there was 1 randomized trial (Level I) [15], 1 prospective comparative study (Level II) [8], 5 retrospective comparative studies (Level III) [6,10,11,16,18], and 6 clinical case series (Level IV) [7,9,[12][13][14]17]. Two studies directly compared thoracoscopic anterior instrumentation and fusion to posterior spinal fusion [16,18]. ...
... A total of 13 articles were judged to meet inclusion criteria [6][7][8][9][10][11][12][13][14][15][16][17][18]. Of the 13 studies selected, there was 1 randomized trial (Level I) [15], 1 prospective comparative study (Level II) [8], 5 retrospective comparative studies (Level III) [6,10,11,16,18], and 6 clinical case series (Level IV) [7,9,[12][13][14]17]. Two studies directly compared thoracoscopic anterior instrumentation and fusion to posterior spinal fusion [16,18]. ...
... Eleven studies included only adolescent idiopathic scoliosis patients [6,[8][9][10][11][12][13][14][15][16]18] (Table 2). Two studies also included a small proportion of neuromuscular scoliosis (8/100 patients in the Gatehouse study [7], and 2/11 in the Yu study) [17]. ...
Study design:
A systematic review and meta-analysis on thoracoscopic anterior instrumentation and fusion as a treatment for adolescent idiopathic scoliosis (AIS).
Objective:
The goal of this study is to determine the current status of thoracoscopic instrumentation and fusion as a treatment for AIS.
Summary of background data:
Traditional surgical techniques for AIS have been open anterior thoracotomy with instrumentation and posterior spinal fusion and instrumentation. With the growing clinical interest in growth modulation surgeries, such as vertebral body tethering, there is a resurgence of interest in a thoracoscopic technique.
Methods:
The most commonly used medical databases (PubMed, Medline, EMBASE, CINAHL, and the Cochrane library) were searched up to November 2016 using the search terms VATS, thoracoscopic scoliosis, and thoracoscopic scoliosis instrumentation.
Results:
Thirteen studies met the strict inclusion criteria. Five hundred thirty patients were reported: 81.7% females, with the majority diagnosed as AIS. The mean operative time was 371.5 minutes, mean blood loss of 502.85 mL, and mean hospital stay of 5.9 days. Mean preoperative curve magnitude was 52.9°; postoperative curve magnitude was 17.9°, with a correction of 62.7%. Number of levels instrumented was 6.3, pulmonary function tests returned to preoperative values by 2 years postoperation, and the complication rate was 21.3%. Compared to thoracotomy, VATS had similar complication rates, blood loss, operation theater time, curve correction, and number of fused levels. Compared to posterior fusion, VATS has higher complication rates and operation theater time. Blood loss and percentage correction were similar. VATS had a smaller number of fused segments.
Conclusions:
Advantages include less invasive, excellent curve correction, few levels fused, good satisfaction, and no long-term effect on pulmonary function. Drawbacks are increased operative time and incidence of pulmonary complications. With appropriate surgeon training and careful patient selection, this technique offers an acceptable alternative to the more traditional procedures.
Level of evidence:
Level II.
... Comparing the S1-PS group and S1-PALA group, the outcome endpoints for the cyclic loading test included completion of 2000 cycles as well as number of cycles and related loads at final cycle. For the coaxial pullout test, outcome endpoints were maximum failure load(N), applied work(Nm), displacement at maximum failure load(mm), and yield load(N). Maximum failure load was defined as the main outcome parameter, as postoperative stability is determined by fixation strength between the instrumentation and the biologic material 11 . The inclusion of continuous variables and binary parameters (factor levels: yes/no) yielded for correlation analysis. ...
Study design:
Biomechanical Laboratory Study.
Objective:
Analysis of the biomechanical characteristics of a novel sacral constrained dual-screw fixation device (S1-PALA), combining a S1-pedicle screw and a S1-ala screw, compared to a standard bicortical S1-pedicle screw (S1-PS) fixation.
Summary of background data:
Instrumented fusions to the sacrum are biomechanically challenging and plagued by a high risk of non-union when S1-PS is used as the sole means of fixation. Thus, lumbopelvic fixation is increasingly selected instead, although associated with a reasonable number of instrumentation-related complications.
Methods:
30 fresh-frozen human sacral bones were harvested and embedded after CT scans. Instrumentation was conducted in alternating order with bicortical 7.0mm S1-PS and with the S1-PALA including a S1-PS screw and a S1-ala screw, of 7.0mm and 6.0mm diameter, respectively. Specimens were subjected to cyclic loading with increasing loads (25-250N) until a maximum of 2000 cycles or displacement >2mm occurred. All implant sacral units (ISUs) were subject to coaxial pullout tests. Failure load, number of ISUs surpassing 2000 cycles, number of cycles and loads at failure were recorded and compared.
Results:
Donors' age averaged 77 ± 14.2years, and BMD was 115 ± 64.8mgCA-HA/ml. Total working length of screws implanted was 90 ± 8.6mm in the S1-PALA group and 46 ± 5mm in the S1-PS group(p = .0002). In the S1-PALA group, displacement >2mm occurred after 845 ± 325 cycles at 149 ± 41N compared to 512 ± 281 cycles at 106 ± 36N in the S1-PS group(p = .004; p = .002). In coaxial pull-out testing, failure load was 2118.1 ± 1166N at a displacement of 2.5 ± 1mm in the S1-PALA group compared to 1375.6 ± 750.1N at a displacement of 1.6 ± 0.5mm in the S1-PS group(p = .0007; p = .0003).
Conclusions:
The novel sacral constrained dual-screw anchorage (S1-PALA) significantly improved holding strength after cyclic loading compared to S1-PS. The S1-PALA demonstrated mechanical potential as a useful adjunct in the armamentarium of lumbosacral fixations indicated in cases that need advanced construct stability, but where instrumentation to the ilium or distal dissection to S2 should be avoided.
Level of evidence:
4.
... Anterior access to the thoracic and thoracolumbar spine has traditionally been gained by open posterolateral thoracotomy (OTC) or a thoraco-abdominal transdiaphragmatic approach. The indications for anterior-only surgeries remain [1][2][3][4][5] , although the frequency of anterior releases in scoliosis surgeries decreased due to more effective posterior-only techniques and transpedicular correction systems 2-7 . With the anterior approach, some surgeons support the usage of video-assisted thoracoscopic surgery (VATS), e.g., for anterior correction in adolescent idiopathic scoliosis (AIS) 4,7-10 or for the anterior decompression, fusion and instrumentation of thoracolumbar fractures 11 . ...
... Single OTC was performed in 25 patients (58.1%) and a thoraco-abdominal transdiaphragmatic approach in 18 patients (41.9%). Mean number of levels fused was 5.8±1.5 (range, [3][4][5][6][7][8]. Out of all patients, 10 (23.3%) had an academic educational level or were still at university, and 33 patients (76.7%) had a nonacademic educational level or were still attending school. ...
... Cranial and caudal exposures through a single thoracotomy were judged limited with single OTC, 10,22 the dissection of the latissimus dorsi was judged obligate 18 and a double thoracotomy suggested to be often required for longer anterior fusions 18,21 . VATS is minimally invasive and said to result in faster recovery, shorter hospital stay and finally less time to functional recovery while conferring improved cosmesis 3,4,9,11,[13][14][15][16][17][18][19][20][21][22]25,27,33 . However, proponents of VATS find it difficult to cite scientific articles that report homogenous comparative series shedding light on the assumption of less invasiveness of VATS in anterior spinal surgery compared to OTC 6 . ...
BACKGROUND: Anterior access to the thoracic spine is done by open thoracotomy (OTC) or video-assisted thoracoscopic surgery (VATS). VATS is known as the method which results in lower morbidity rates, but there is little evidence of its less invasiveness. Objective: The current study yielded for outcome data concerning patients' perception of approach-related morbidity (ArM) following OTC for spinal surgery and that of a control group having a chest tube thoracotomy (CTT). METHODS: We performed a questionnaire assessment of ArM after OTC and CTT. Applying strict inclusion criteria, we compared outcomes in terms of percentage morbidity (Morbidity %) of 43 patients that underwent OTC for instrumented scoliosis correction to 30 patients that had CTT for minor thoracic pathologies (e.g., pneumothorax). RESULTS: Mean age in CTT and OTC Group was 50.2 and 16.5 years old, follow-up was of 32.2 and 58.4 months, and mean incision length was 2.5 and 25.5 cm, respectively. Mean number of levels fused in the OTC Group was 5.8. Mean morbidity (0% delineating no cases, 100% delineating highest morbidity) for the CTT Group was 10.8±15.4% (0-59.5%), 42% of patients had no morbidity. Signs of intercostal neuralgia (ICN) were present in 16.7%. A total of 35.5% had a morbidity >10% (mean: 27.5%), and 10% of morbidity cases were defined as having a chronic post-thoracotomy pain (CPP). In the OTC Group, mean morbidity was 7.0±12.7% (0-52.1%), 44% had no morbidity. Out of the sample, 18.6% had morbidity >10% (mean: 28.6%). Signs of ICN were present in 14%. In both groups, the presence of ICN had a significant impact on and showed correlation with morbidity (p
... It was demonstrated in a previous report that, compared to posterior fusion, anterior thoracic fusion results in better restoration of thoracic kyphosis 12 . Similar results have also been found in anterior thoracic fusion assisted by thoracoscopy 20 . Accordingly, will anterior thoracolumbar fusion, in the same way, lead to loss of lordosis, or even increments in kyphosis of the fusion segments? ...
To investigate the effect of interbody cage support on reconstruction of the sagittal profile after anterior selective correction in Lenke type 5 adolescent idiopathic scoliosis (AIS) patients.
In this retrospective study, a total of 40 AIS patients with a Lenke type 5 curve who underwent anterior selective fusion (ASF) using a single rod were studied. They were divided into two groups: Group A, bone grafting with an interbody titanium mesh cage (TMC); and Group B, bone grafting without a TMC. There were 19 female and 1 male patient aged 12-18 years in Group A, and 17 female and 3 male patients aged 13-20 years in Group B. All patients were followed up for more than 18 months. The coronal correction of the scoliosis and reconstruction of the sagittal profile were evaluated retrospectively.
By final follow-up, more than 70% correction had been achieved for the primary curve and a spontaneous correction for the secondary curve in both groups. Satisfactory reconstructions on the sagittal plane were also observed. Similar changes were found in Group A and Group B, including increases in thoracic kyphosis, slight changes in thoracolumbar junctional kyphosis, no significant losses of lumbar lordosis, mild increases in proximal junctional measurement, and remarkable lordosis losses in the instrumented segments. With lessening of the sagittal balance and L(1) offset, a significant anterior shift of the C(7) plumb line was noted during follow-up in Group A, indicating a more balanced spine in this group.
Anterior selective single rod instrumentation and fusion is a recommended method for Lenke type 5C AIS. A structural interbody cage does not appear to improve the regional profile, nor the profiles in the instrumented area and the adjacent proximal and distal segments; yet could result in a better total balance in the long-term.
Study design:
Single-center retrospective review of outcomes among three surgical techniques in the treatment of thoracic idiopathic scoliosis (T-AIS) with a follow-up of at least 5 years.
Objective:
To investigate how outcomes compare in video-assisted anterior thoracic instrumentation (VATS), all hooks/hook-pedicle screw hybrid instrumentation (HHF), and all pedicle screw instrumentation (PSF) techniques for T-AIS.
Summary of background data:
Studies comparing outcomes for anterior vs posterior fusion for T-AIS are few and with short follow-up.
Methods:
Three groups of patients with T-AIS who underwent thoracic fusion were included in this study: 98 patients with mean curve of 49.0° ± 9.5° underwent VATS (Group 1); 44 patients with mean curve of 51.1° ± 7.4° underwent HHF (Group 2); and 47 patients with mean curve of 47.6° ± 9.9° underwent PSF (Group 3). Radiological outcomes were compared at pre-operative, and up to 5 years. Surgical outcomes were noted until latest follow-up.
Results:
Group 1 had less blood loss, less fusion levels, longer surgical time, and longer hospital stay compared to the other groups (p < .01). Groups 1 and 3 were comparable in all time periods with 78.8% and 78.2% immediate curve correction, and 72.9% and 72.1% at 5 years, respectively. Group 2 had lower correction in all time periods (p < .0001). Thoracic kyphosis and lumbar lordosis decreased in Group 3, but improved in both Groups 1 and 2 (p < .0001). Group 1 had more respiratory complications. The posterior groups had more deep wound infections. Two patients in Group 1 and one patient in Group 2 required revision surgery for implant-related complications. Re-operations for deep wound infections were noted only in the posterior groups.
Conclusion:
This is the first report comparing 5 year outcomes between anterior and posterior surgery for T-AIS. All three surgical methods resulted in significant and durable scoliosis correction, however curve correction using HHF was inferior to both VATS and PSF with the latter two groups achieving similar coronal correction. However, VATS involved fewer segments, kyphosis improvement, and no deep wound infection whereas PSF has less surgical time, shorter hospital stays, and no revision surgery from implant-related complications.Level of Evidence: 3.
Conventional open surgical procedures for the treatment of thoracic spine deformity can be associated with significant approach-related morbidity. Recent advances in minimal access technologies have led to the development of posterior minimally invasive approaches for thoracic deformity correction. Minimally invasive surgery (MIS) for thoracic spine deformity is very challenging area and MIS use is very limited in the thoracic spine deformity.
Study design:
Retrospective case series.
Objective:
To report the effect of repeated growing rod (GR) lengthenings on the sagittal and pelvic profile in patients with early-onset scoliosis.
Summary of background data:
Posterior distraction-based GRs have gained popularity as a technique for the surgical management of early-onset scoliosis. However, there are no published studies on the effect of serial GR lengthenings on sagittal balance, thoracic kyphosis (TK), lumbar lordosis (LL), and pelvic parameters.
Methods:
We retrospectively reviewed data from a multicenter early-onset scoliosis database. Forty-three patients who were able to walk with minimum 2-year follow-up who underwent single- or dual-GR surgery were included for review. Mean number of lengthenings was 6.4 (range, 3-16). Mean preoperative age was 5.6 years (standard deviation, 2.4 yr), and mean follow-up was 3.5 years. Maximum TK, LL, and sagittal balance were assessed preoperatively, after index surgery, and at the latest follow-up.
Results:
There was a significant decrease both in TK and LL after index surgery, which then increased during the lengthening period. There was a significant increase in both proximal junctional kyphosis and distal junctional angle. Pelvic parameters (pelvic tilt, pelvic incidence, sacral slope) were unchanged during the treatment period. Significant improvement was observed in sagittal balance. There was a correlation between the change in TK and change in LL.
Conclusion:
TK decreased after index surgery and increased between the index surgery and the latest follow-up, which was accompanied by an increase in LL. All-screw proximal constructs had mean 9° more proximal junctional kyphosis than all-hook proximal constructs. An increase in proximal junctional kyphosis and distal junctional angle was found during the treatment period. Although there was an independent effect of number of lengthenings on TK, there was no significant detrimental effect on other sagittal spinopelvic parameters. GRs had a positive effect on sagittal vertical axis, which returned patients to a more neutral alignment through the course of treatment.
Level of evidence:
4.
