Prone position endoscopic transthoracic release with simultaneous posterior instrumentation for spinal deformity: a description of the technique

Minimally invasive thoracoscopic approach to thoracolumbar junction fractures

AIMS

A retrospective analysis of patients with thoracolumbar junction fractures who underwent video-assisted thoracoscopic surgery via a minimally invasive approach (minithoracotomy) for reconstruction of the anterior spinal column.

METHODS

Between 2002 and 2014, a total of 176 patients were treated by this technique. The patients received either posterior stabilization and, at the second stage, the minimally invasive technique via an anterior approach, or the minimally invasive anterior procedure alone.

RESULTS

In the anterior procedure, the average operative time was 90 min. (50 to 130 min). Bony fusion without complications was achieved in all patients within a year of surgery. The loss of correction after the anterior procedure with an allograft or titanium cage was up to 2 degrees at two years follow-up.

CONCLUSION

The minimally invasive approach (minithoracotomy up to 6-7 cm) combined with thoracoscopy is an alternative to an exclusively endoscopic technique enabling us to provide safe surgical treatment of the anterior spinal column.

[Simultaneous thoracoscopically assisted anterior release in prone position and posterior scoliosis correction : What are the limits?]

BACKGROUND

In spite of modern pedicle-based systems, the correction of a rigid rib hump or hypokyphosis remains a problem in posterior-only scoliosis surgery. As there has so far been no reliable method of predicting the intraoperative extent of kyphosis restoration or rib hump correction by posterior-only surgery, it has been difficult to determine the indication for an additional anterior release.

METHODS

The method described here circumvents this dilemma. Like an optional module, horacoscopically assisted release in prone position (TARP) can be added when it is obvious during posterior surgery that the correction is insufficient.

RESULTS

Between 1996 and 2005, a total of 161 patients (115 male, 46 female) under the age of 30, including 113 cases of idiopathic scoliosis, were released by simultaneous TARP and posterior surgery. Using the two-portal technique, 131 were mobilized from the right and 30 from the left hand side. Average surgical time spanned 69 min, in which on average 3.2 apical segments were addressed. In 3 individuals, an additional retroperitoneoscopic release was used to liberate a rigid lumbar curve. After 10 years, in a prospectively evaluated subgroup of 32 patients with adolescent idiopathic scoliosis, the index curve had maintained a coronal correction of 70 % (immediately post-surgery 75 %), kyphosis was permanently normalized at 30° (Th5-Th12), and indirect rib hump was reduced to 2.2 cm. In 23 out of 32 patients the lumbar curve corrected spontaneously, obviating the need for fusion. In 13 patients, the lower instrumented vertebra lay at Th12 or higher, thus leaving the thoraco-lumbar junction fairly free. Minor complications (Huang 1or 2) occurred in 4 patients; 1 patient with hematothorax required revision. A distance <25 mm from the spine to the chest wall precludes TARP. Other limitations (e.g., pleural adhesions) were not encountered.

CONCLUSION

Long-term evaluation after 10-18 years shows that an additional thoracoscopically assisted anterior release at the same time as a posterior standard scoliosis procedure is a justified and effective tool, yielding better results and maintaining them.

Thoracoscopically assisted corpectomy and percutaneous transpedicular instrumentation in management of burst thoracic and thoracolumbar fractures

STUDY DESIGN

This is a prospective observational study.

PURPOSE

The aim of this study was to determine whether the combination of thoracoscopically assisted corpectomy with posterior percutaneous transpedicular instrumentation in prone position achieves treatment goals in burst thoracic or thoracolumbar fractures and minimizes the associated morbidities.

METHODS

Between December 2007 and December 2008, 26 patients with acute burst spinal fractures were operated upon in our hospital. Those patients underwent posterior percutaneous stabilization plus anterior thoracoscopically assisted corpectomy and fusion in prone position. Clinical and radiological outcomes of these patients were evaluated after a minimum follow-up period of 2 years. The Oswestry Disability Index (ODI) combined with clinical examination was used for clinical evaluation. Plain X-ray in two views was used for the radiological evaluation.

RESULTS

The mean operative time was 248 min. The average blood loss was 765 ml. Ten patients had preoperative neurological deficits ranging from Frankel A to D. One patient did not show any neurological improvement at the final follow-up. The mean ODI at final follow-up was about 7. The mean preoperative kyphosis angle was 25.58°, improved to 9.2° postoperatively and to 13.8° at the final follow-up. No cases of implant failure were reported at the final follow-up.

CONCLUSIONS

Minimal invasive spinal techniques including thoracoscopic decompression and fusion and short segment posterior percutaneous instrumentation showed good clinical outcomes and can be considered as alternative to open procedures with decreased rates of morbidities in managing burst thoracic and thoracolumbar fractures.

Quantitative evaluation of an automatic segmentation method for 3D reconstruction of intervertebral scoliotic disks from MR images

Background

For some scoliotic patients the spinal instrumentation is inevitable. Among these patients, those with stiff curvature will need thoracoscopic disk resection. The removal of the intervertebral disk with only thoracoscopic images is a tedious and challenging task for the surgeon. With computer aided surgery and 3D visualisation of the interverterbral disk during surgery, surgeons will have access to additional information such as the remaining disk tissue or the distance of surgical tools from critical anatomical structures like the aorta or spinal canal. We hypothesized that automatically extracting 3D information of the intervertebral disk from MR images would aid the surgeons to evaluate the remaining disk and would add a security factor to the patient during thoracoscopic disk resection.

Methods

This paper presents a quantitative evaluation of an automatic segmentation method for 3D reconstruction of intervertebral scoliotic disks from MR images. The automatic segmentation method is based on the watershed technique and morphological operators. The 3D Dice Similarity Coefficient (DSC) is the main statistical metric used to validate the automatically detected preoperative disk volumes. The automatic detections of intervertebral disks of real clinical MR images are compared to manual segmentation done by clinicians.

Results

Results show that depending on the type of MR acquisition sequence, the 3D DSC can be as high as 0.79 (±0.04). These 3D results are also supported by a 2D quantitative evaluation as well as by robustness and variability evaluations. The mean discrepancy (in 2D) between the manual and automatic segmentations for regions around the spinal canal is of 1.8 (±0.8) mm. The robustness study shows that among the five factors evaluated, only the type of MRI acquisition sequence can affect the segmentation results. Finally, the variability of the automatic segmentation method is lower than the variability associated with manual segmentation performed by different physicians.

Conclusions

This comprehensive evaluation of the automatic segmentation and 3D reconstruction of intervertebral disks shows that the proposed technique used with specific MRI acquisition protocol can detect intervertebral disk of scoliotic patient. The newly developed technique is promising for clinical context and can eventually help surgeons during thoracoscopic intervertebral disk resection.

Thoracoscopy for minimally invasive thoracic spine surgery

Thoracoscopy has been used worldwide for many years by thoracic surgeons. Despite a long learning curve and technical demands of the procedure, thoracoscopy has several advantages, including better cosmesis, adequate exposure to all levels of the thoracic spine from T2 to L 1, better illumination and magnification at the site of surgery, less damage to the tissue adjacent to the surgical field, less morbidity when compared with standard thoracotomy in terms of respiratory problems, pain, blood loss, muscle and chest wall damages, consequent shorter recovery time, less postoperative pulmonary function impairment, and shorter hospitalization. Good results at short- and medium-term follow-up need to be confirmed at long-term follow-up.

Prone thoracoscopic release does not adversely affect pulmonary function when added to a posterior spinal fusion for severe spine deformity

STUDY DESIGN

Prospective clinical study.

OBJECTIVE

To analyze the effect of adding a thoracoscopic release and fusion performed in the prone position with double lung ventilation to a posterior spinal fusion and instrumentation (PSFI) for severe idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

A prone thoracoscopic anterior release (TAR) offers the advantages of a minimally invasive approach, without requiring repositioning for the PSFI, and has significantly less acute pulmonary complications since single lung ventilation is avoided. It is unclear whether prone thoracoscopy adversely affects pulmonary function tests (PFT) when added to a PSFI for severe deformity.

METHODS

A prospective consecutive series of patients from a single institution undergoing spinal deformity surgery were reviewed. Those patients who underwent prone TAR followed by PSFI were compared to patients who had PSFI alone. In addition, those patients who had a thoracoplasty and PSF (PSFI-T) were compared to those who had a TAR and PSFI with T. (PFTs were measured before surgery and 1, 3, 6 weeks, 3 and 6 months, and 1 year after surgery. Forced vital capacity (FVC) and FE-1 parameters were compared to baseline levels for each patient. RESULTS.: There were 13 patients in the TAR + PSFI groups and 83 in the PSFI groups. The patients in the TAR + PSFI group had larger thoracic curves (83.2 degrees vs. 59.7 degrees ), greater correction (59.4% vs. 50.1%) (P = 0.07), and greater increase in thoracic height (16.4% vs. 6.8%) following surgery. (P < 0.05) PFTs declined more rapidly for the TAR + PSFI patients in the first 3 weeks, however, improved rapidly until 1 year when they were significantly better than the PSFI group for predicted FVC % (29.7% vs. 7.5% above baseline) and forced expiratory volume (FEV) 1% (28.5% and 8.9% above baseline). (P < 0.05) When a thoracoplasty was added to the procedure, the differences in PFTs between those who had a TAR and those who did not was not significant. The TAR + PSFI-T group had FVC % predicted of 5.3% above baseline compared to 4.3% above baseline for the PSFI-T group. The percent predicted FEV 1% was 10.4% above baseline for the TAR + PSFI-T group compared to 4.5% for the PSF-T group (P > 0.05).

CONCLUSION

When performing a prone thoracoscopic release for severe thoracic deformity, excellent coronal plane correction is achieved. There does not appear to be any detrimental effect on pulmonary function when a prone thoracoscopic release using double lung ventilation is added to a PSFI. This technique can be efficacious in achieving excellent deformity correction without adversely affecting pulmonary function and is recommended when treating severe spinal deformity. Adding a thoracoplasty provided a negative effect on pulmonary function and limited the benefits of performing a thoracoscopic release to the PSFI patients.

Minimally invasive posterior thoracic fusion

Thoracic spine fusion may be indicated in the surgical treatment of a wide range of pathologies, including trauma, deformity, tumor, and infection. Conventional open procedures for surgical treatment of thoracic spine disease can be associated with significant approach-related morbidity, which has motivated the development of minimally invasive approaches. Thoracoscopy and, later, video-assisted thoracoscopic surgery were developed to address diseases of the thoracic cavity and subsequently adapted for thoracic spine surgery. Although video-assisted thoracoscopic surgery has been used to treat a variety of thoracic spine diseases, its relatively steep learning curve and high rate of pulmonary complications have limited its widespread use. These limitations have motivated the development of minimally invasive posterior approaches to address thoracic spine pathology without the added risk of morbidity involved in surgically entering the chest. Many of these advances are ongoing and represent the forefront of minimally invasive spine surgery. As these techniques are developed and applied, it will be important to assess their equivalence or superiority in comparison with standard open techniques using prospective trials. In this paper the authors focus on minimally invasive posterior thoracic procedures that include fusion, and provide a review of the current literature, a discussion of future pathways for development, and case examples. The topic is divided by pathology into sections including trauma, deformity, spinal column tumors, and osteomyelitis.

Minimal access thoracic surgery in the pediatric population

Thoracoscopy was initially described for use in children to obtain pulmonary biopsy samples in the immunocompromised patient. With refinements in technique, development of better instrumentation, and advances in pediatric anesthesia, there are now many diagnostic and therapeutic indications for the use of thoracoscopy in children. One of the most common indications includes pleural debridement for empyema. Many centers consider this the optimal approach for biopsy of mediastinal lesions and excision of bronchogenic or duplication cysts. The technique is useful for pleural disorders, such as spontaneous pneumothorax and chylothorax. Thoracoscopy has been used to achieve exposure for spinal diskectomy in children with thoracic scoliosis, and newer techniques are being developed in performing anatomic lobectomies, repair of esophageal atesias, and closure of diaphragmatic hernias. The role of the robot in pediatric thoracoscopy is still in the early stages of definition.

Histomorphometric assessment of thoracoscopically assisted anterior release in a porcine model: safety and completeness of disc discectomy with surgeon learning curve

STUDY DESIGN

A retrospective study using histomorphometric analysis to quantify the percentage of discectomy following thoracoscopic anterior release and fusion in a porcine model.

OBJECTIVE

To investigate the safety and completeness of disc and endplate removal with respect to the learning curve of the surgeon in a porcine thoracoscopic anterior fusion model.

SUMMARY OF BACKGROUND DATA

The thoracoscopic approach has been used to perform an anterior release and fusion before an open posterior instrumentation, however, there is concern that the technique may not provide sufficient visualization or exposure to perform safely and completely.

METHODS

A total of 32 pigs (160 discs) were assigned to 2 groups (early experience, n = 16; late experience, n = 16), and underwent 5 level thoracoscopic anterior release followed by anterior instrumentation and fusion from T5 to T10. At 4 months after surgery, the spines were harvested, and each discectomy disc was histomorphometrically analyzed to determine the percentage of disc excision and amount of endplate removal.

RESULTS

There were no significant differences in the percent disc excision between the early (67% +/- 11%) and late groups (69% +/- 10%). Greater than 50% of the disc was excised in 151 of 160 discectomies (94%). Both superior and inferior endplates were resected in 92 of 160 disc levels (57%). The amount of endplate removal had improved over time in both early and late groups (P < 0.0001). The histologic examination revealed no evidence for posterior longitudinal ligament disruption or spinal canal encroachment in any disc.

CONCLUSIONS

Video-assisted thoracoscopic discectomy is safe and allows for a significant amount of disc material excision. This study did not demonstrate a learning curve with respect to the amount of disc material excised, but a learning curve was seen for endplate excision.

Experience with combined video-assisted thoracoscopic surgery (VATS) anterior spinal release and posterior spinal fusion in Scheuermann's kyphosis

STUDY DESIGN

Retrospective.

OBJECTIVES

To determine whether anterior endoscopic release and posterior spinal fusion could achieve stable correction in Scheuermann's kyphosis.

SUMMARY OF BACKGROUND DATA

The initial treatment of choice of Scheuermann's kyphosis is thoracic hyperextension and postural exercises and/or Milwaukee brace. Milwaukee bracing is most efficacious in the early stages when the curvature is flexible and in the skeletally immature. However, it is known that larger curves, vertebral wedging greater than 10 degrees, and skeletally mature patients will not usually respond to this treatment. Surgery is indicated in the skeletally immature with severe deformity where brace treatment has failed to prevent progression. Posterior spinal instrumentation can achieve adequate correction in the less rigid curves. However, the more rigid curves have been shown to be resistant to posterior spinal fusion alone, therefore needing anterior spinal release.

METHODS

Between 1995 and 2001, 19 patients underwent video-assisted thoracoscopic surgery and posterior spinal fusion for the treatment of Scheuermann's kyphosis. The average age was 17.4 years with closed triradiate cartilage in all. Average follow-up was 2.7 years. An average of 8.3 discs were released anteriorly; an average of 13 levels were fused posteriorly.

RESULTS

Average preoperative kyphosis was 84.8 degrees. Average postoperative kyphosis was 43.7 degrees. Average kyphosis at follow-up was 45.3 degrees. Only 1.6 degrees of correction loss was noted. No junctional kyphosis was present. Two patients developed pleural effusion; one required thoracocentesis. Two patients developed pneumothorax. One patient underwent revision surgery for inferior hook pullout. One required mechanical ventilation.

CONCLUSIONS

Combined video-assisted thoracoscopic surgery release and posterior spinal fusion for the treatment of Scheuermann's kyphosis is a viable option for the treatment of the more severe and rigid curves.

The treatment of large (>70 degrees) thoracic idiopathic scoliosis curves with posterior instrumentation and arthrodesis: when is anterior release indicated?

STUDY DESIGN

Retrospective clinical study from 2 centers.

OBJECTIVE

To analyze the efficacy of posterior instrumentation and arthrodesis for thoracic idiopathic scoliosis curves more than 70 degrees.

SUMMARY OF BACKGROUND INFORMATION

The increasing use of thoracoscopic techniques in deformity surgery has led several investigators to advocate anterior release followed by posterior instrumentation when treating "stiff" thoracic curves 60 degrees-70 degrees. To our knowledge, no study has been published to define indications for anterior surgery in thoracic idiopathic scoliosis.

METHODS

This is a retrospective review of patients 20 years and younger, with idiopathic scoliosis and thoracic curves more than 70 degrees treated with isolated posterior instrumentation and arthrodesis at 2 institutions from 1989 to 1999. A total of 50 patients were identified, and 46 were available for minimum 2-year radiographic follow-up. Of the 50 patients, 44 had bend films taken before surgery. All patients were treated with third-generation segmental spinal instrumentation using a varied combination of hooks, wires, and screws.

RESULTS

Average patient age at surgery was 14.4 years (range 10-20), and average radiographic follow-up was 4.4 years (range 2-11.5). Average preoperative thoracic curve was 75 degrees (range 70 degrees-88 degrees), and average bend was 47 degrees (range 28 degrees-60 degrees), a flexibility of 37%. Average postoperative curve was 25 degrees (range 10 degrees-46 degrees), and it was 27 degrees (range 11 degrees-46 degrees) at latest follow-up, a correction of 64%. The average length of surgery was 6.15 hours, mean hospital stay was 8 days, and average blood loss was 1100 cc. The Scoliosis Research Society 22 or 24 was available at a minimum of 2 years in 46 of 50 patients. Mean domain scores were: pain 4.4, self-image 4.3, function 4.3, mental health 4.3, satisfaction 4.7, and total 4.4. Complications included 1 pseudarthrosis, 1 implant removal for prominence, and 1 implant removal for late operative site pain.

CONCLUSION

Using posterior surgery only, we have been able to at least equal the results reported in the literature by investigators using combined approaches. Isolated posterior instrumentation and arthrodesis achieve satisfactory cosmetic, radiographic, and patient-based outcomes in adolescents with idiopathic scoliosis with thoracic curves 70 degrees-90 degrees, without the added expense and morbidity of anterior release.

Video-assisted thoracoscopic surgery: the Cincinnati experience

Video-assisted thoracoscopic surgery is an alternative to open thoracotomy. We analyzed our experience during a consecutive series of 100 patients who had this procedure and who were available for study at 3-year followup. Video-assisted thoracoscopic surgery was done on patients with the following diagnoses: idiopathic scoliosis (n = 49), neuromuscular spinal deformity (n = 15), Scheuermann kyphosis (n = 15), congenital and infantile scoliosis (n = 5), neurofibromatosis (n = 5), Marfan (n = 1), postradiation scoliosis (n = 1), and repair of pseudoarthrosis (n = 1). Four patients had excision of the first rib to treat thoracic outlet syndrome. One patient had excision of an intrathoracic neurofibroma and one a benign rib tumor. One had anterior arthrodesis after fracture-dislocation of the thoracic spine and another had anterior fusion for vertebral osteomyelitis. The average operative time for the thoracoscopic anterior release with discectomy and arthrodesis was 253 minutes. The average number of discs excised was 8. Final postoperative scoliosis and kyphosis corrections were 68% and 90%, respectively. Complications related to thoracoscopy occurred in eight patients. Video-assisted thoracoscopic surgery provides a safe and effective alternative to open thoracotomy in the treatment of thoracic pediatric spinal deformities.

Early experiences with video-assisted thoracoscopic surgery: our first 70 cases

STUDY DESIGN

Prospective consecutive series.

OBJECTIVE

Analysis of the results and outcomes of patients treated with video-assisted thoracoscopic surgery for spinal pathology.

SUMMARY OF BACKGROUND DATA

Video-assisted thoracoscopic surgery is an alternative to open thoracotomy. It has been suggested that the learning curve is substantial. The authors present their early experience in treating a variety of spinal pathologies with this technique.

METHODS

Seventy cases were available at the 2-year follow-up. Video-assisted thoracoscopic surgery with the goal of anterior spinal release and fusion was carried out on patients with the following diagnoses: idiopathic scoliosis, neuromuscular spinal deformity, Scheuermann kyphosis, congenital and infantile scoliosis, neurofibromatosis, Marfan syndrome, postradiation scoliosis, and repair of pseudarthrosis. Three patients had excision of the first rib to treat thoracic outlet syndrome. Two patients had excision of intrathoracic neurofibroma and a benign rib tumor. One had anterior fusion following thoracic spine fracture-dislocation.

RESULTS

The average operative time for the thoracoscopic anterior release with discectomy and fusion procedure was 256 minutes (range 150-405 minutes). The average number of discs excised was 8 (range 4-11 discs). The average operative time per disc was 32.5 minutes (range 20-45 minutes). The average blood loss during the thoracoscopic anterior release with diskectomy and fusion was 285 mL (range 150-405 mL). Final postoperative scoliosis and kyphosis corrections were 68% (range 41-91%) and 90% (range 47-100%), respectively. Complications related to thoracoscopy occurred in 3 patients. All deformity patients had evidence of anterior fusion radiographically.

CONCLUSION

Video-assisted thoracoscopic surgery provides a safe and effective alternative to open thoracotomy in the treatment of thoracic pediatric spinal deformities. The procedure remains time consuming.

A comparison between the prone and lateral position for performing a thoracoscopic anterior release and fusion for pediatric spinal deformity

STUDY DESIGN

Retrospective review of all patients who had a single stage thoracoscopic anterior release and spine fusion followed by a posterior spinal fusion with posterior instrumentation.

OBJECTIVE

To analyze the results and complications of patients undergoing a thoracoscopic anterior release and fusion comparing those performed prone with those in the lateral position.

SUMMARY OF BACKGROUND DATA

The lateral position has traditionally been used when performing a thoracoscopic anterior spinal release and fusion during a single-stage anterior spinal release and fusion/posterior spinal fusion with instrumentation. Although some have reported the thoracoscopic technique in the prone position, there are no direct comparison studies between the prone and lateral position.

METHODS

A retrospective review was performed of all patients who had a single stage thoracoscopic anterior spinal release and fusion and posterior spinal fusion with instrumentation from a single institution. The medical record was reviewed to determine demographic data, positioning of the patient, levels fused, anesthesia time, operative time, chest tube drainage, and complications. Radiographs were reviewed to determine preoperative curve magnitude and postoperative curve correction. The Student t test was used to compare groups and statistical significance was defined as P < 0.05.

RESULTS

There were 16 patients in the prone group and 27 in the lateral group. Adolescent idiopathic scoliosis was the most common diagnosis in both groups. All patients had a single-stage thoracoscopic anterior spinal release and fusion/posterior spinal fusion with instrumentation. In the prone group, the patient was positioned prone on a Hall-Relton frame or roll (small patients) for both the anterior spinal release and fusion and posterior spinal fusion with instrumentation. There were no significant differences between the prone and lateral groups with respect to age, gender, height, weight, and curve magnitude (73.8 degrees vs. 71.5 degrees ). There were fewer fused anterior levels in the prone group (5.3 vs. 6.2) (P = 0.05). When analyzing parameters that reflect potential difficulties imposed by the prone position, there were no statistically significant differences noted between groups, although there was a trend toward less anterior operative time per disc (24.3 vs. 25.9 minutes/disc), greater blood loss/anterior disc level (33.5 vs. 26.8 cc/disc), greater total chest tube drainage (445 vs. 419 cc), and less days with the chest tube in place (2.2 vs. 2.3 days) for the prone group when compared to the lateral group. There were statistically significant differences between the prone and lateral groups with respect to anesthesia preparation time (42.8 vs. 64.8 minutes), delay between the completion of the anterior procedure and the start of the posterior procedure (11.8 vs. 69.5 minutes), and the incidence of complications related to the use of single-lung ventilation (0 vs. 14.8%)(P < 0.05). Patients in the prone group required less time on oxygen after surgery (34.8 vs. 51.6 hours) and were discharged home earlier (4.6 vs. 5.5 days) (P < 0.05).

CONCLUSIONS

A thoracoscopic anterior spinal release and fusion in the prone position appears to achieve the same results as when performed in the lateral position for pediatric spinal deformity. The prone position saves time in the operating room due to decreasing the time needed by the anesthesiologists and the transition time between the anterior and posterior procedures. Potentially serious complications related to single-lung ventilation are avoided with bilateral-lung ventilation in the prone position.

Anterior endoscopic discectomy and fusion for adolescent idiopathic scoliosis

STUDY DESIGN

A review of adolescent patients with idiopathic scoliosis undergoing endoscopic release and spinal fusion.

OBJECTIVE

To describe the indications, techniques, results, and complications of thoracic anterior endoscopic scoliosis surgery.

SUMMARY OF BACKGROUND DATA

Anterior endoscopic treatment of thoracic adolescent idiopathic scoliosis has become an alternative method of surgical treatment.

METHODS

Twenty-one patients with adolescent idiopathic scoliosis have undergone a thoracic anterior endoscopic release and fusion followed by posterior instrumentation and fusion. Indications for the endoscopic fusion were large curve magnitude, skeletal immaturity, and/or thoracic hyperkyphosis. Eleven patients have undergone anterior endoscopic instrumentation and fusion for thoracic scoliosis curves between 45 degrees and 70 degrees, using a single screw/single rod construct and autogenous rib bone graft.

RESULTS

Results from the anterior endoscopic release and fusion procedures followed by a posterior instrumentation and fusion had an average preoperative curve of 82 degrees (range, 41 degrees -125 degrees ), with postoperative correction to 28 degrees (range, 5 degrees -60 degrees ) showing 70% correction. For patients undergoing an anterior endoscopic instrumentation and fusion, the average preoperative Cobb measurement of 53 degrees (range, 44 degrees -62 degrees ) was corrected to an average 26 degrees (range, 18 degrees -38 degrees ) for an average correction rate of 51%. One patient undergoing an anterior endoscopic release was converted to an open procedure for end plate bony bleeding without sequelae. One patient with an anterior endoscopic instrumentation and fusion had revision anterior surgery for a distal set screw dislodgment and subsequent posterior instrumentation and fusion for pseudarthrosis.

CONCLUSIONS

The use of both anterior endoscopic release and fusion combined with either anterior instrumentation or separate posterior instrumentation and fusion continues to evolve. Surgeons treating patients with these techniques must understand that there are specific indications for them and many technique options available to optimize surgical results.

Review: Complications of Minimally Invasive Spinal Surgery

COMPLICATIONS OF MINIMALLY invasive spinal surgery can be related to anesthesia, patient positioning, and surgical technique. The performance of successful minimally invasive spinal surgery is beset with several technical challenges, including the limited tactile feedback, two-dimensional video image quality of three-dimensional anatomy, and the manual dexterity needed to manipulate instruments through small working channels, which all account for a very steep learning curve. Knowledge of possible complications associated with particular minimally invasive spinal procedures can aid in their avoidance. This article reviews complications associated with minimally invasive spinal surgery in the cervical, thoracic, and lumbar spine by reviewing reported data of sufficient detail or with sufficient numbers of patients. In addition, possible complications associated with anesthesia use, patient positioning, and surgical techniques during thoracoscopic and laparoscopic spinal procedures are reviewed.