BACKGROUND:
Posterior spinal fusion with segmental instrumentation is the gold standard
for the surgical treatment of thoracic adolescent idiopathic scoliosis. More
recently, anterior surgery and video-assisted thoracoscopic surgery with
spinal instrumentation have become an option. The purpose of the present study
was to compare the radiographic and clinical outcomes as well as pulmonary
function in patients managed with either anterior thoracoscopic or posterior
surgery.
METHODS:
Radiographic data, Scoliosis Research Society patient-based outcome
questionnaires, pulmonary function, and operative records were reviewed for
fifty-one patients undergoing surgical treatment of scoliosis. Data were
collected preoperatively, immediately postoperatively, and at the time of the
final follow-up. The radiographic parameters that were analyzed included
coronal curve correction, the most caudad instrumented vertebra tilt angle
correction, coronal balance, and thoracic kyphosis. The operative parameters
that were evaluated included the operative time, the estimated blood loss, the
blood transfusion rate, the number of levels fused, the type of bone graft
used, and the number of intraoperative and postoperative complications. The
pulmonary function parameters that were analyzed included vital capacity and
peak flow.
RESULTS:
The thoracoscopic group included twenty-eight patients with a mean age of
14.6 years, and the posterior fusion group included twenty-three patients with
a mean age of 14.3 years. The percent correction was 54.5% for the
thoracoscopic group and 55.3% for the posterior group. With the numbers
available, there were no significant differences between the two groups in
terms of kyphosis (p = 0.84), coronal balance (p = 0.70), or tilt angle (p =
0.91) at the time of the final follow-up. The mean number of levels fused was
5.8 in the thoracoscopic group, compared with 9.3 levels in the posterior
group (p < 0.0001). The estimated blood loss in the thoracoscopic group was
significantly less than that in the posterior fusion group (361 mL compared
with 545 mL; p = 0.03), and the transfusion rate in the thoracoscopic group
was significantly lower than that in the posterior fusion group (14% compared
with 43%; p = 0.01). Operative time in the thoracoscopic group was
significantly greater than that in the posterior group (6.0 compared with 3.3
hours, p < 0.0001). There were no intraoperative complications in either
group. Vital capacity and peak flow had returned to baseline levels in both
groups at the time of the final follow-up. Patients in the thoracoscopic group
scored higher than those in the posterior group in terms of the total score (p
< 0.0001) and all of the domains (p < 0.01) of the Scoliosis Research
Society questionnaire at the time of the final follow-up.
CONCLUSIONS:
Thoracoscopic spinal instrumentation compares favorably with posterior
fusion in terms of coronal plane curve correction and balance, sagittal
contour, the rate of complications, pulmonary function, and patient-based
outcomes. The advantages of the procedure include the need for fewer levels of
spinal fusion, less operative blood loss, lower transfusion requirements, and
improved cosmesis as a result of small, well-hidden incisions. However, the
operative time for the thoracoscopic procedure was nearly twice that for the
posterior approach. Additional study is needed to determine the precise role
of thoracoscopic spinal instrumentation in the treatment of thoracic
adolescent idiopathic scoliosis.