Comparison of Thoracoscopic Anterior Release Combined With Posterior Spinal Fusion Versus Posterior-only Approach With an All-pedicle Screw Construct in the Treatment of Rigid Thoracic Adolescent Idiopathic Scoliosis

The Use of Thoracoscopic Release in the Surgical Correction of Thoracic Scoliosis in Children

INTRODUCTION

Recently, the use of thoracoscopic methods in spinal deformity surgery has increased, however, the issue of the effectiveness of combining anterior release with posterior spinal fusion compared to single-stage posterior instrumentation remains controversial, which raises the issue of the effectiveness and feasibility of their use.

PURPOSE

To evaluate the effectiveness of endoscopic anterior release for thoracic scoliosis in children.

MATERIAL AND METHOD

A retrospective analysis of the results of surgical treatment of 48 patients with idiopathic scoliosis of the thoracic spine aged 12-17 years, with a thoracic curve of more than 60°, was carried out. To determine the stability of deformity, the stability index according to A.I. Kazmin was used. (SI) defined as the ratio of the angle of deformity in the supine position to the angle of deformity in the standing position. Indications for anterior release were incomplete skeletal growth and relatively stable deformities (SI 0.75-0.85). Group 1 included 27 patients operated on in one stage without anterior release, and group 2 included 21 patients in two stages, with preliminary anterior release using video-assisted thoracoscopy.

RESULTS

In group 1, the average Cobb angle of deformity was 71.8° with an average stability index of 0.8. In the second group, the average cobb angle of deformity was 69.7°, the average stability index was 0.82. In group 1 after surgery, the average Cobb angle was 27.8°, with an average correction of 63.39%. In the second group, the postoperative deformity angle was 17.4°, the average correction was 76.26%. Thus, we found a statistically significant increase in postoperative correction when using a combined anterior/posterior approach (p < 0.05).

CONCLUSION

In the study, in patients with relatively stable deformities, a statistically significant increase in the degree of postoperative correction was revealed (p < 0.05) when using a combined anterior/posterior approach. Performing an anterior thoracoscopic release for thoracic deformities can improve long-term results due to the formation of 360° spinal fusion at the apex of the deformity, as well as turning off the pathogenetic links in the progression of the deformity.

LEVEL OF EVIDENCE

III.

Impact of pleural effusion at an early period after posterior spinal fusion for adolescent idiopathic scoliosis on future pulmonary function and lung volume

Background

Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) has a potential risk for postoperative pleural effusion. Although pleural effusion at an early period after PSF for AIS occurs with a relatively high frequency and occasionally requires some treatments, the impact of postoperative pleural effusion on future pulmonary function or lung volume (LV) has not been clarified to date. The aim of this study was to evaluate the effect of pleural effusion after PSF for AIS on the postoperative pulmonary function and LV.

Methods

A total of 114 consecutive patients who underwent PSF for AIS followed up greater than 2 years at our institute were retrospectively reviewed. We evaluated postoperative pleural effusion by computed tomography (CT) at the 1-week follow-up and divided patients into the pleural effusion (PF) and non-pleural effusion (NP) groups. We investigated spirometry parameters recorded for testing included vital capacity (VC), forced expiratory volume in the first second (FEV1), %VC, and FEV1% and measured the LV using CT images and a workstation at baseline and 2 years after surgery.

Results

A total of 87 (76.3%) patients with postoperative pleural effusion were identified, but all patients were asymptomatic and did not require additional treatment for postoperative pleural effusion. All pulmonary function parameters at the 2-year follow-up exhibited no significant differences between the two groups. Although preoperative left LV (1.21±0.30 L vs. 1.36±0.34 L; p=.022) and total LV (2.68±0.62 L vs. 2.99±0.73 L; p=.031) were significantly lower in the PF group than in the NP group, all postoperative LV parameters were similar between the two groups.

Conclusions

Pleural effusion at an early period after PSF for AIS was a postoperative occurrence without an impact on future pulmonary function and LV.

Systematic Review and Meta-analysis: Does Anterior-Posterior Spinal Fusion Still have a Role in Severe Thoracic Adolescent Idiopathic Scoliosis?

Background

Debate exists as to whether anterior-posterior spinal fusion (APSF), rather than posterior-only spinal fusion (PSF), provides benefit for treating severe thoracic adolescent idiopathic scoliosis (AIS). This systematic review and meta-analysis compare (1) Cobb angle correction, (2) complication and reoperation rate, (3) pulmonary function, (4) number of fused segments, and 5) patient-reported outcome measures (PROMs) in both groups.

Methods

Electronic databases were searched to identify studies that met the following inclusion criteria: comparative studies (level 3 or above), severe thoracic curves (≥ 70°), age ≤ 16, AIS aetiology, Lenke 1-4 curves and follow-up ≥ 1 year for ≥ 95% of patient population. Literature was graded for quality and bias using GRADE and MINORS criteria.

Results

Eight studies were included, defined by GRADE as low or moderate level evidence. Three studies showed superior curve correction in the APSF group; however, the meta-analysis showed no significant difference in curve correction between groups (95% CI - 3.45-12.96, P = 0.26). There were more complications in the APSF group, without statistical significance (95% CI 0.53-3.39, P = 0.54; I 2 = 0%, P = 0.78). There were no re-operations in either group. Two studies reported pulmonary function; one showed better function in the APSF group, the other better function in the PSF group. One study showed fewer fused segments in the APSF group, however, no significance was observed in the meta-analysis (95%CI - 1.65-0.31, P = 0.18). Three studies reported PROMs with no differences reported between groups.

Conclusions

APSF and PSF have been found to have comparable results. The present evidence cannot support recommendations for guidelines on future practice with regards to effect on curve correction, complications, re-operations, pulmonary function or PROMs.

Level of evidence

Level III, Systematic review of Level-III studies.

Surgical treatment of severe adolescent idiopathic scoliosis through one-stage posterior-only approach: A systematic review and meta-analysis

The aim of this meta-analysis was to analyze the results of one-stage all-posterior spinal fusion for severe adolescent idiopathic scoliosis (AIS). A systematic search of articles about one-stage posterior spinal fusion for severe AIS was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data about population, pre-and postoperative radiographical data, surgical procedure details, and complications were extracted. Meta-analyses were performed when possible. Fourteen studies (640 patients) were included. The mean Cobb angle of the major curve varied from 80.0 ± 7.3 to 110.8 ± 12.1. The meta analysis showed a comprehensive coronal correction rate of the major curve of 58.6%, a comprehensive operative time of 274.5 min, and a comprehensive estimated intraoperative blood loss of 866.5 mL (95% confidence interval: 659.3-1073.6, I 2 ≈ 0%). A total of 48 complications (5.4%) were reported. Overall, the meta-analysis showed a major complication rate of 4%. In seven cases, revision surgery was needed. Posterior-only approach is effective enough to correct severe curves and can spare the patient possible adverse events due to anterior approach. However, when choosing this approach for severe AIS, screw density needs to be high and posterior column osteotomies may need to be planned to mobilize the spine and maximize correction.

Scoliosis: Causes and Treatments

Scoliosis is an abnormal curvature of the spine, which generally develops during childhood or adolescence. It affects 2–4 percent of the global population and is more prevalent among girls. Scoliosis is classified by its etiology: idiopathic, congenital, or neuromuscular. Among these, the former is the most common. Treatment options for scoliosis vary depending on the severity of the curve. Most scoliosis diagnoses tend to be mild and only require monitoring. However, curves between 20 and 40 degrees require bracing, while 40 degrees and above require surgery. There are various bracings available, such as Boston, Charleston, and Milwaukee. In severe cases of scoliosis, either fusion or fusionless surgery may be required. This review aims to discuss etiologies and different treatment interventions for scoliosis.

Severe Lenke 1 and 2 adolescent idiopathic scoliosis had poorer perioperative outcome, higher complication rate, longer fusion and higher operative cost compared to non-severe scoliosis

PURPOSE

To compare the perioperative outcome and operative cost of posterior spinal fusion (PSF) surgery between severe and non-severe Lenke 1 and 2 adolescent idiopathic scoliosis (AIS) patients.

METHODS

A total of 509 AIS patients who underwent single-staged PSF between 2013 and 2020 were reviewed. Fifty-four severe scoliosis patients (Cobb angle ≥ 90°) were categorized into Gp1, and 455 non-severe scoliosis (Cobb angle < 90°) patients into Gp2. Propensity score matching (PSM) analysis using one-to-one nearest neighbor matching and match tolerance of 0.001 were performed. Outcome measures were operative time, intraoperative blood loss (IBL), allogeneic transfusion rate, perioperative complication, length of stay, fusion level, number of screws used, postoperative Cobb angle, correction rate (CR), side bending correction index (SBCI) and operative cost.

RESULTS

From the PSM analysis, 35 patients from each group were matched. The operative time was 155.9 ± 41.4 and 130.0 ± 30.3 min for Gp1 and Gp2, respectively (p = 0.004). The IBL was 1349.2 ± 1019.0 and 781.9 ± 325.1 mLs for Gp1 and Gp2, respectively (p = 0.003). Fusion level (12.5 ± 0.8 vs. 11.2 ± 1.3, p < 0.001) and number of screws used (16.4 ± 1.6 vs. 14.6 ± 1.4, p < 0.001) were higher in Gp1. Four perioperative complications were observed in Gp1 compared to none in Gp2 (p < 0.039). Gp1 had larger postoperative Cobb angle (p < 0.001), lower CR (p = 0.005) and higher SBCI (p < 0.001). The operative cost was higher in Gp1 (p < 0.001).

CONCLUSIONS

Severe Lenke 1 and 2 AIS patients had poorer perioperative outcome, higher complication rate, longer fusion and higher operative cost than non-severe AIS.

Combination of Side-Bending and Traction Radiographs Do Not Influence Selection of Fusion Levels Compared to Either One Alone in Adolescent Idiopathic Scoliosis

STUDY DESIGN

A retrospective study.

OBJECTIVES

Curve flexibility in patients with adolescent idiopathic scoliosis (AIS) can be evaluated using different techniques. This study aimed to determine whether the combination of side-bending (SB) and traction (TX) radiographs influences preoperative planning for AIS than either radiograph alone.

METHODS

Thirty-two spine surgeons were asked to review 30 AIS Lenke type 1 cases and select an upper instrumented vertebra (UIV) and lower instrumented vertebra (LIV) for the posterior spinal instrumentation of each case. Each rater reviewed the cases 3 times in each round. The raters were provided with the full-length posteroanterior (PA) and lateral standing and SB radiographs for round 1; PA, lateral, and TX radiographs for round 2; and PA, lateral, SB, and TX radiographs for round 3. Intra- and inter-rater reliabilities were evaluated using Kappa statistics.

RESULTS

The intra-rater reliability for UIV and LIV was 0.657 and 0.612 between rounds 1 and 2, 0.634 and 0.692 between rounds 1 and 3, and 0.659 and 0.638 between rounds 2 and 3, respectively, which indicated substantial agreement between rounds. The inter-rater kappa reliabilities for UIV and LIV selection were 0.103 and 0.412 for round 1, 0.121 and 0.380 for round 2, and 0.125 and 0.368 for round 3, indicating slight to moderate agreement between raters.

CONCLUSIONS

Whether raters used either SB or TX radiography, or both in addition to PA and lateral standing radiographs, did not influence the decision making for UIV or LIV of AIS Lenke type 1 surgery.

Long-term experience with simultaneous prone video-assisted thoracoscopic anterior spinal release and posterior spinal fusion in severe rigid pediatric spinal deformities

PURPOSE

While posterior-alone techniques have been successful for most pediatric spinal deformities, anterior spinal release may be useful for severe rigid deformities. Traditional lateral-positioned video-assisted thoracoscopic surgical release (VATSR) followed by prone posterior spinal fusion (PSF) has been criticized for adding extensive operative morbidity. We aimed to reduce its disadvantages by performing prone VATSR and PSF simultaneously and evaluate its long-term outcomes.

METHODS

All consecutive patients from 1991 to 2012 undergoing VATSR and PSF at one institution were retrospectively reviewed. The inclusion criteria comprised severe rigid thoracic scoliosis (> 70°, bending correction > 45°) or kyphosis (> 75°, bolster correction > 45°), and a minimum 2 year follow-up. Demographics, operative data, hospital stay, and radiographic correction data were compared between patients who had undergone sequential VATSR followed by PSF and those who had undergone these procedures simultaneously.

RESULTS

Of 153 patients who had undergone VATSR and PSF, 53 met the inclusion criteria (31 sequential, 22 simultaneous; average follow-up, 50 [range, 24-86] months). Age, preoperative measurements and flexibility, and perioperative complications did not differ significantly. The simultaneous group showed significantly lower operative time (449 vs. 618 min), blood loss (1039 vs. 1906 cc), and hospital stay (6.3 vs. 8.5 days) (all, p < 0.05). Postoperative radiographic correction and maintenance at the final follow-up showed a non-significant trend favoring the simultaneous group.

CONCLUSION

Our simultaneous prone VATSR and PSF technique showed significantly lower operative time, blood loss, and hospital stay compared with the traditional sequential VATSR and PSF method, suggesting its value in treating rigid deformities.

Current concepts in the diagnosis and management of adolescent idiopathic scoliosis

BACKGROUND

Adolescent Idiopathic Scoliosis (AIS) is a complex 3D structural disorder of the spine that has a significant impact on a person's physical and emotionalstatus. Thus, efforts have been made to identify the cause of the curvature and improve management outcomes.

AIM

This comprehensive review looks at the relevant literature surrounding the possible aetio-pathogenesis of AIS, its clinical features, investigations, surgicalmanagement options, and reported surgical outcomes in anterior spinal fusion, posterior spinal fusion or combined approach in the treatment of AIS.

Posterior Correction Techniques for Adolescent Idiopathic Scoliosis

Adolescent idiopathic scoliosis represents a complex, three-dimensional deformity of the spine. Posterior spinal fusion is commonly performed in severe cases to avoid the long-term adverse sequelae associated with progressive spinal deformity. The goals of spinal fusion include halting the progression of deformity, optimizing spinal balance, and minimizing complications. Recent advances in short-segment spinal fixation have allowed for improved three-dimensional deformity correction. Preoperative planning and assessment of spinal flexibility is essential for successful deformity correction and optimization of long-term outcomes. Judicious use of releases and/or spinal osteotomies may allow for increased mobility of the spine but are associated with increased surgical time, blood loss, and risk of complications. Appreciation of implant design and material properties is critical for safe application of correction techniques. Although multiple reduction techniques have been described, no single technique is optimal for every patient.

Outcome of Posterior-Only Approach for Severe Rigid Scoliosis: A Retrospective Report

BACKGROUND

The management of severe scoliosis may lead to significant complications, and adequate mobilization is a key step to achieve maximal correction, usually requiring extensive approaches. There is still no consensus on the management of these severe and rigid curves. In this study we evaluated the clinical and radiologic outcome of a posterior-only approach with multilevel asymmetric Ponte osteotomy with a minimum of 2 years' follow-up.

METHODS

In this retrospective study, 23 patients with severe and rigid adolescent idiopathic scoliosis who underwent surgery with a single-staged posterior-only approach were included. The surgical procedures in these patients were excision of posterior ligaments and spinous process, partial laminectomy in caudal part of lamina, excision of the ligamentum flavum, facetectomies, and multilevel asymmetric posterior column osteotomies (Ponte) followed by instrumented fusion. Clinical records-including demographic data; operating time; hospitalization time; blood loss; number of segments instrumented, fused, and osteotomized; functional improvement; follow-up duration; and complications-were recorded.

RESULTS

The mean preoperative Cobb angle of major curve in coronal plan was 97.5° (range, 82°-131°) with the mean flexibility of 21.4° (range, 10°-25°) on bending radiography. The mean immediate postoperative Cobb angle of major curve was 34.8° (range, 17°-61°), showing a 64.2% correction. The mean preoperative coronal and sagittal imbalances of 3.8 and 4.2 cm were improved to 1.0 and 1.3 cm at postoperative measurements, respectively. A mean of 6.1 (range, 5-9) vertebral segments were osteotomized. We experienced no major complications.

CONCLUSIONS

We found that a posterior-only procedure in patients with severe and rigid adolescent idiopathic scoliosis could provide correction rate, coronal and sagittal balance, and clinical outcomes comparable with other procedures. Using this technique can eliminate the need for the anterior release, with the associated complications related to anterior surgery, in the treatment of severe rigid scoliosis.

Anterior and Posterior Fusion for Large, Rigid Idiopathic Scoliosis: Does Implant Density Matter?

BACKGROUND

Despite advancements in surgical techniques, controversy remains regarding the optimal implant density for the correction of idiopathic scoliosis. Recent evidence has suggested that equivalent radiographic and clinical outcomes can be achieved with lower implant densities for those with moderate curves and good flexibility. Among the experts, the consensus has continued that higher implant densities should be used for larger, stiffer curves. The purpose of the present study was to compare the radiographic results between high-implant density (HID) and low-implant density (LID) constructs in patients with large (>65°), rigid (<50% flexibility) curves who had undergone anterior release and posterior spinal fusion.

METHODS

We reviewed the idiopathic scoliosis cases performed at a single institution from 2006 to 2014. Only those meeting the inclusion criteria were selected. The patients were divided into HID and LID groups. The postoperative radiographs were compared for coronal correction, thoracic kyphosis, pelvic tilt, lumbar lordosis, and sagittal vertical axis.

RESULTS

A statistically significant improvement in coronal correction was detected in the HID group at all follow-up points (final follow-up: HID, 81.1% vs. LID, 70.4%; P = 0.01). When preoperative thoracic kyphosis was considered, no differences were found between the 2 groups. No differences were found in the other sagittal parameters.

CONCLUSION

In patients with large, rigid idiopathic scoliosis undergoing anterior release and posterior spinal fusion, a small, but statistically, significant improvement in the coronal Cobb angle was seen. It remains to be determined whether this small difference in radiographic correction will have any influence on the clinical outcome.

Factors associated with surgical approach and outcomes in cerebral palsy scoliosis

BACKGROUND

Neuromuscular scoliosis is often treated with posterior spinal fusion, with or without anterior release, and either a same-day or staged, 2-day procedure.

METHODS

We retrospectively reviewed 222 patients from a prospectively collected, multi-center database of patients with cerebral palsy scoliosis with 2-year follow-up. Baseline characteristics, perioperative, radiographic, and HRQoL measures were compared in six sub-analyses: (1) staged versus same-day surgeries, (2) posterior-only fusion (PSF) versus anterior-posterior spinal fusion (APSF), (3) same-day versus staged PSF, (4) staged versus same-day APSF, (5) same-day PSF versus same-day APSF, (6) staged PSF versus staged APSF.

RESULTS

Staged patients had larger curves and more pelvic obliquity, longer anesthesia and surgical times, longer hospital and ICU stays (p < 0.001), and more days intubated (p = 0.021). The staged PSF group had larger curves (p = 0.006), longer anesthesia (p = 0.020) and surgeries (p = 0.007), hospital (p = 0.009) and ICU stays (p = 0.028) compared to same-day PSF. The staged APSF group had longer hospital (p < 0.001) and ICU stays (p = 0.004) and anesthesia and surgeries (p < 0.001). Same-day APSF was associated with larger curves (p < 0.002), longer anesthesia (p = 0.012) and surgeries (p = 0.042), greater residual curves (p = 0.035), and greater absolute correction (p = 0.007) compared to same-day PSF. The staged APSF group had longer anesthesia times (p < 0.001) compared to the staged PSF group. No sub-analysis revealed significant differences in baseline characteristics, complications, or HRQoL.

CONCLUSION

Staged and circumferential approaches tend to be used for greater deformity, but were not associated with superior deformity correction, and were associated with longer operative time, hospital stays, ICU stays, and days intubated. However, for the most severe deformity, other patient factors may play more important roles in treatment decisions given that patients treated with a staged PSF or an APSF, whether staged or not, were similar at baseline.

LEVEL OF EVIDENCE

III. These slides can be retrieved under Electronic Supplementary Material.

Intraoperative Traction May Be a Viable Alternative to Anterior Surgery in Cerebral Palsy Scoliosis ≥100 Degrees

BACKGROUND

For large scoliosis, 2 strategies to maximize correction include intraoperative traction and/or anterior release. It is unclear which patients will benefit the most form either approach. The purpose of our study is to compare the radiographic, perioperative clinical outcomes, and health-related quality of life (HRQoL) outcomes of 2 approaches when used in severe neuromuscular scoliosis in the setting of cerebral palsy (CP).

METHODS

In total, 23 patients with minimum 2-year follow-up, major curves ≥100 degrees, and in whom treatment included posterior spinal fusion were evaluated. Eighteen were treated with posterior spinal fusion with intraoperative traction and 5 with anterior/posterior spinal fusion (APSF). The baseline characteristics, perioperative outcomes, and preoperative and 2-year follow-up data for HRQoL and radiographic measures were compared.

RESULTS

The groups had similar age, sex, nutritional and seizure status, GMFCS level, and change in CPCHILD scores. The groups had similar curve magnitude (120 vs. 105 degrees, P=0.330) and flexibility (28% vs. 40%, P=0.090), but the APSF group had less pelvic obliquity (POB) (24 vs. 42 degrees, P=0.009). There were similar postoperative major curves (37 vs. 40 degrees, P=0.350), but greater correction in POB (33.5 vs. 14 degrees of correction, P=0.007) in the traction group. The APSF group had longer anesthesia times (669 vs. 415 min, P=0.005), but similar hospital stays, intensive care unit and days intubated, estimated blood loss, cell saver, and red blood cells used. Although the APSF group had twice the rate of complications (22% vs. 40%) during the first 90 days postoperatively, this did not reach statistical significance.

CONCLUSIONS

Both intraoperative traction and anterior surgery were used to aid correction in severe CP scoliosis. Anterior surgery did not offer superior correction or better HRQoL, and was associated with increased operative times, whereas intraoperative traction was associated with greater correction of POB. Intraoperative traction may be a viable alternative to an anterior release in severe CP scoliosis.

LEVEL OF EVIDENCE

Level II.

Anterior release may not be necessary for idiopathic scoliosis with a large curve of more than 75° and a flexibility of less than 25

BACKGROUND CONTEXT

To improve correction and fusion rates, an anterior release is often needed for the treatment of idiopathic scoliosis with a curve of more than 75° before posterior correction, instrumentation, and fusion. However, there are disadvantages to anterior release, and we are concerned about whether it is necessary for anterior-posterior spinal fusion in these patients.

PURPOSE

The objective of this study was to compare the surgical results for idiopathic scoliosis with a curve of more than 75° and a flexibility of less than 25% between using posterior-only approach and combined anterior release followed by posterior correction with a hybrid construct (hooks and pedicle screws) and spinal fusion.

STUDY DESIGN/SETTING

This was a retrospective cohort study.

PATIENT SAMPLE

From 2000 to 2014, 388 consecutive patients with idiopathic scoliosis were treated surgically at our hospital. Of these patients, 53 whose primary curves were more than 75° with a flexibility of less than 25%, at an incidence of 13.6%, were included and divided into two groups. Thirty-one patients (mean age: 16.3 years old) who underwent anterior release followed by posterior correction, instrumentation, and fusion were included in the A+P group, and the remaining 22 patients (mean age: 17.3 years old) were designated as the P group for posterior procedure alone.

OUTCOME MEASURES

The clinical outcomes were analyzed in terms of correction and loss of correction and by the Scoliosis Patient Questionnaire: Version 30 functional questionnaire.

MATERIALS AND METHODS

In the A+P group, halo-femoral traction was applied for 1 week between the anterior release and the posterior procedure. Posterior instrumentation with a hybrid construct with hooks and pedicle screws was used for both groups. The radiological and functional outcomes were compared between the two groups.

RESULTS

The average preoperative Cobb angle was 85.3° for the A+P group, with an average 17.4% flexibility, and 80° for the P group, with 15.3% flexibility. The postoperative Cobb angle was 53.1° for the A+P group and 45.6° for the P group. The Cobb angle at the final follow-up for the A+P group was 55.2° and that for the P group was 48°. The average correction rates of the A+P and P groups were 37% and 43.4%, respectively. There were no statistically significant differences between the groups in gender, age, number of levels fused, and flexibility of coronal curve. With a minimum 2-year follow-up, similar results were found between these two groups in terms of correction rate, loss of correction, and functional outcome.

CONCLUSIONS

In this study, we found that a posterior-only approach with hybrid construct (hooks and pedicle screws) could provide a correction similar to that of an anterior-posterior approach. Also, the disadvantages of anterior release could be avoided by the posterior-only approach.

[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.