DOI 10.3349/ymj.2011.52.1.130 Original Article pISSN: 0513-5796, eISSN: 1976-2437 Yonsei Med J 52(1):130-136, 2011 Video-Assisted Thoracoscopic Surgery Plus Lumbar Mini-Open Surgery for Adolescent Idiopathic Scoliosis Hyon Su Chong,1 Hak Sun Kim,1 Nanda Ankur,2 Phillip Anthony Kho,1 Sung Jun Kim,3 Do Yeon Kim,1 Jin Oh Park,1 Seong Hwan Moon,1 Hwan Mo Lee,1 and Eun Su Moon1 Departments of 1Orthopaedic Surgery and 3Radiology, Yonsei University College of Medicine, Seoul, Korea; 2Indian Spinal injuries Centre, New Delhi, India. Received: October 21, 2009 Purpose: The objectives of this study are to describe the outcome of adolescent Revised: January 4, 2010 idiopathic scoliosis (AIS) patients treated with Video Assisted Thoracoscopic Sur- Accepted: February 12, 2010 gery (VATS) plus supplementary minimal incision in the lumbar region for thorac- Corresponding author: Dr. Eun Su Moon, ic and lumbar deformity correction and fusion. Materials and Methods: This is a Department of Orthopaedic Surgery, Yonsei University College of Medicine, case series of 13 patients treated with VATS plus lumbar mini-open surgery for Gangnam Severance Hospital, AIS. A total of 13 patients requiring fusions of both the thoracic and lumbar re- 712 Eonju-ro, Gangnam-gu, gions were included in this study: 5 of these patients were classified as Lenke type Seoul 135-720, Korea. 1A and 8 as Lenke type 5C. Fusion was performed using VATS up to T12 or L1 Tel: 82-2-2019-3418 , Fax: 82-2-573-5393 vertebral level. Lower levels were accessed via a small mini-incision in the lumbar E-mail: [email protected] area to gain access to the lumbar spine via the retroperitoneal space. All patients ∙ The authors have no financial conflicts of had a minimum follow-up of 1 year. Results: The average number of fused verte- interest. brae was 7.1 levels. A significant correction in the Cobb angle was obtained at the final follow-up (p = 0.001). The instrumented segmental angle in the sagittal plane was relatively well-maintained following surgery, albeit with a slight increase. Scoliosis Research Society-22 (SRS-22) scores were noted have significantly im- proved at the final follow-up (p < 0.05). Conclusion: Indications for the use of VATS may be extended from patients with localized thoracic scoliosis to those with thoracolumbar scoliosis. By utilizing a supplementary minimal incision in the lumbar region, a satisfactory deformity correction may be accomplished with min- imal post-operative scarring. Key Words: Scoliosis, VATS, mini-open retroperitoneal approach INTRODUCTION © Copyright: The prevalence of idiopathic scoliosis with a Cobb angle of more than 10° in ado- Yonsei University College of Medicine 2011 lescents under 16 years of age is 2-3%. Surgical treatment is usually indicated for a This is an Open Access article distributed under the patient with a Cobb angle more than 40°, with a predilection for females rather terms of the Creative Commons Attribution Non- 1 Commercial License (http://creativecommons.org/ than males (10 : 1). In the surgical management of adolescent idiopathic scoliosis licenses/by-nc/3.0) which permits unrestricted non- (AIS), psychological impact is an important factor to be considered since the pa- commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. tients are usually girls who are concerned about cosmetic and physical appearance, 130 Yonsei Med J http://www.eymj.org Volume 52 Number 1 January 2011 VATS Plus Lumbar Mini-Open Surgery for AIS and for them the long postoperative scars may not be ac- scoliosis corrective surgeries done by a combined mini- ceptable.2 This fact may be a cause of delayed consultation, open retroperitoneal incision and VATS, especially for AIS which may lead to a missed opportunity for appropriate Lenke classification types 1A and 5C, which necessitate timing of surgical intervention. This may consequently re- lumbar segment fusion. sult in progression in the Cobb angle, which further neces- sitates the need to substantiate the number of fusion levels. It is for this reason that many spine surgeons have tried to MATERIALS AND METHODS concentrate their efforts in exploring minimally invasive access methods to reduce, if not completely eliminate, long We performed spinal fusion with anterior instrumentation and extensive incisions and approaches that would other- in the thoracic spine using VATS combined with a mini- wise resort in permanent lifetime disfigurement. Thoraco- open retroperitoneal approach to the lumbar spine for AIS scope-assisted surgeries have been recently utilized to patients. The results were analyzed retrospectively. There avoid not only this physical complication, but minimize as were 5 patients with Lenke type 1A, and 8 patients with well the potential risks in a formal thoracotomy approach. Lenke type 5C. Fusion level limits extended from the prox- This technique has been presently adapted in the form of imal end vertebra to the distal end vertebra of the main Video-Assisted Thoracoscopic Surgery (VATS) for the cor- structural curve. The minimum follow-up period was 1 rection of scoliosis. year. We evaluated preoperative as well as post-operative In the treatment of thoracic AIS, the posterior spinal fu- coronal balance, sagittal balance, coronal curve correction, sion technique, which involves segmental instrumentation and thoracic kyphosis using preoperative, post-operative, with either hooks or pedicle screws, is thought to be the and final follow-up radiographs taken in a standing posi- gold standard. Several clinical studies have attempted to tion. All patients were evaluated using the Scoliosis Re- evaluate the results of the anterior spinal approach com- search Society-22 (SRS-22) questionnaire which was ad- pared with posterior spinal instrumentation and fusion. Ad- ministered preoperatively and post-operatively. Total scores vantages of an open anterior approach include the ability to as well as individual domain scores for pain, self-image, fuse a smaller number of vertebral segments, achieve great- function, mental health, and satisfaction parameters were er correction in coronal plane, and better restoration of ky- calculated and analyzed for each patient. phosis in thoracic spine, with generally lesser blood loss.3,4 General anesthesia was administered via a double-lumen However, anterior surgery via an open thoracotomy ap- intubation technique for all patients. The patients were then proach has some disadvantages, such as pulmonary func- placed in a lateral position with the arms in the 90/90 posi- tion impairment, long post-operative scar, and marked post- tion and secured to the table with the help of body tape and operative pain. The development of VATS has been an im- restraints to eliminate potential movement of the patient portant step for the correction of scoliosis because a compa- during the surgery. Skin landmark markings for all involved rable coronal and sagittal plane correction can be achieved vertebral levels were done with C-arm guidance. Portal sites while minimizing the impact on pulmonary function. De- in line with the anterior and mid-axillary lines were also creased post-operative pain and improved cosmetic appear- marked as well as the planned incision markings for the ret- ance may be expected as a result of the use of small inci- roperitoneal approach. Two monitors were utilized: The sions.5-7 However a major limitation of the VATS technique first was positioned in front of and behind the patient to is that it cannot be used when the distal end of the major provide better visualization for the surgeons in both sides of curve extends into the lumbar area, as it is not possible to the surgical field. Specialized spinal implants (Moss Miami access the retroperitoneal space with a thoracoscope. A pos- screws, DePuy spine, Rayham, MA, USA) and basic endo- sible solution for such cases is to tackle the distal lumbar scopic instruments were used in the procedure. The instru- levels with a mini-open retroperitoneal approach in con- ments included a 0°, 30° scope, harmonic scalpel, long cu- junction with VATS being used for the proximal thoracic rettes, pituitaries, fan retractor, Kerrison rongeur, silicon part of the curve. Despite these merits, there are no reports ball headed tips, and some standard endoscopic instruments about the clinical and radiological outcomes with this oper- (kitners, endo-bovie, and hemostatic agents). Once the lung ative method in thoracolumbar idiopathic scoliosis. The was deflated, the proximal portal was first inserted in the purpose of our study, therefore, is to show the results of mid-axillary line. Upon insertion, digital inspection through Yonsei Med J http://www.eymj.org Volume 52 Number 1 January 2011 131 Hyon Su Chong, et al. the portal was performed to assure the lung was deflated bilizing the incision as far anteriorly and posteriorly as pos- and no adhesions were present. This was followed by the sible with careful subperiosteal dissection and subsequent placement of other portals along the mid-axillary as well as resection using a rib cutter. Deep dissection was then car- anterior axillary line under direct thoracoscopic visualiza- ried through the abdominal muscle layer down to the retro- tion. Incisions for the portals were placed at 2 interspaces peritoneal space. The peritoneum was then reflected off of apart, allowing for portal placement above and below the the psoas muscle, spine, and diaphragm. Spinal retractors rib at each level, thus enabling the surgeon to reach 2 levels were then inserted. The psoas was retracted posteriorly, and through a single skin incision. At the thoracolumbar junc- the discs and endplates were exposed and removed in the tion, an additional portal was needed for the retraction of standard fashion. Once all the discs were removed, iliac the diaphragm. After inserting the thoracoscope at the apex, bone graft was harvested from the posterior superior iliac the ribs were counted to confirm the level.