Anterior thoracoscopic spine release in deformity surgery: a meta-analysis and review

Videoassisted thoracoscopic surgery (VATS) allows the surgeon to perform an anterior thoracoscopic spine release for spinal deformities. It is an alternative to open thoracotomy. Several years after its introduction the present author gives an update on the indications, surgical techniques, results, and complications of this new technology. A meta-analysis of previously published papers is organized in tables in an attempt to answer all the questions and controversies that this technique has aroused. A series of ten selected articles were available for review, comprising a total of 151 procedures. No study had any long-term follow-up. Most series were pediatric and involved a variety of etiologies (mostly neuromuscular, adolescent idiopathic scoliosis, and Scheuermann's kyphosis). The surgical technique was for most authors a convex side approach in the lateral decubitus through four or more ports in the anterior or midaxillary line. Single lung ventilation was used in most cases. Posterior surgery was carried out the same day in most cases. The total number of discs excised varied between 4 and 7, but the quality of disc excision was rarely reported. Most authors carried out a spine fusion at the time of the disc release. The total VATS procedure lasted between 2 h 30 min and 4 h, depending on the series and the surgeon's previous experience. In most series curves were in the range of 55 degrees-80 degrees, with an average of 65 . The percentage of Cobb angle correction was 55%-63% after VATS and posterior spine fusion. For kyphotic deformities only one series had significant numbers to allow conclusions to be drawn. The mean preoperative Cobb angle was 78 degrees and postoperatively the kyphosis was corrected to 44 degrees. Length of hospital stay was quite similar in most series and was around 9 days. The cost of the VATS procedure was studied in one series and was found to be 28% more expensive than thoracotomy. The total complications reported were 18%; most were pulmonary complications with prolonged ventilatory support in patients with neuromuscular pathologies. The VATS procedure has been used with success in most series for pediatric curves (average Cobb angle of 65 degrees or kyphosis of 75 degrees). No report of the surgical outcome (balance, rate of fusion, rib hump correction, cosmetic correction, pain, and patient satisfaction) was available for any series. Further prospective study including these parameters will be required to determine the real benefit of such procedures to the patient, bearing in mind that the correction of spinal deformities is the result of the surgeon's experience, skill, and the available technology.