[Thoracoscopic interventions in deformities of the thoracic spine]

Is anterior release effective to increase flexibility in idiopathic thoracic scoliosis? Assessment by traction films

With the advent of thoracoscopy, anterior release procedures in adolescent idiopathic scoliosis (AIS) have come into more frequent use, however, the indication criteria for an anterior release in thoracic AIS are still controversial in the literature. To date, few studies have assessed the influence on spinal flexibility and no study has so far been able to show a beneficial effect on the correction rate as compared to a single posterior procedure. The objective of this study was to evaluate the influence of thoracic disc excision on coronal spinal flexibility. Six patients (5 females, 1 male) with AIS and a mean age of 15.6 years (range 13-20 years) underwent an open anterior thoracic release prior to posterior instrumentation. Cotrel dynamic traction along with radiographs of the whole spine including traction films were conducted pre- and postoperatively and were evaluated retrospectively. The mean preoperative thoracic curve was 89.7 degrees +/- 15.4 degrees (range 65 degrees-110 degrees). The flexibility rate in Cotrel traction was 22.8 +/- 8.1%. After performance of the anterior release the thoracic curve showed a mean increase of coronal correction by 5.5 degrees +/- 5.0 degrees as assessed by traction radiographs. The flexibility index changed by 6.2 +/- 5.6%. After posterior instrumentation the thoracic curve was corrected to a mean of 36.5 degrees +/- 10.1 degrees (correction rate 59.6%). Disc excision in idiopathic thoracic scoliosis only slightly increased spinal flexibility as assessed by traction films. In our view a posterior release with osteotomy of the concave ribs (concave thoracoplasty, CTP) is more effective in increasing spinal flexibility. According to our clinical experience, an anterior release prior to posterior instrumentation in AIS should only be considered in hyperkyphosis, coronal imbalance or massive curves.

Scheuermann’s kyphosis: surgical management

Indications for surgery in Scheuermann disease are not well codified and remain rare, as the natural history of the disease is in most cases benign. In the immature adolescent, conservative treatment, such as bracing or casting, can be tried for moderate curves. For larger curves, or in the adult, conservative treatment is usually not effective, and surgery can be considered. Such indications are mostly cosmetic for large curves above 75 degrees. Pain over the deformity or in the low back may represent another surgical indication, especially in the adult group. The question of anterior release or straight posterior fusion has become more of an actuality with the advent of powerful, third-generation stiff segmental instrumentation. However, the long-term results of a modern, posterior-only instrumentation fusion are not known. Concern about loss of correction, late pseudarthrosis or the need to remove instrumentation for infected hardware or due to late pain at the operative site must make us careful about choosing this method. Very rigid and large curves still require an anterior release, either done in a conventional or mini-open fashion, or through video-assisted thoracoscopic surgery. The extent of the posterior instrumentation has now been better defined. One must fuse the whole Cobb angle without hypercorrection and stop distally, above the first lordotic disc, to avoid sagittal decompensation. New approaches such as short anterior fusion with bone-on-bone techniques and pedicle substraction osteotomies have not yet been reported in the literature as having been used for treating Scheuermann's kyphosis. These should be considered experimental.

Upper sympathetic trunk lesion after video-assisted fracture stabilization of the thoracic spine: a case report

This case report draws attention to the upper sympathetic trunk lesion as a complication of video-assisted thoracic spine surgery. A 39-year-old man developed an upper sympathetic trunk lesion after right-sided thoracoscopic fracture stabilization of T5 and T6. Dizziness and reduced perspiration persisted at the most recent follow-up 8 months after surgery. This rare complication can be overlooked and remain undiagnosed. Diagnosis is based on clinical symptoms and neurologic examination. There are no treatment options. Symptoms can be bothersome for the patient and may persist. In the upper thoracic spine, the course of the sympathetic trunk lies in close proximity of the vertebral bodies; thus, care must be taken to avoid it when resecting the posterior parts of the vertebral body.

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.