Endoscopic thoracoplasty and anterior spinal release in scoliotic deformity

Severe rigid and complex deformities of the spine often require a first stage procedure to adequately mobilize the spine to provide adequate flexibility during the actual application of instrumentation for surgical correction. This first stage involves soft tissue releases and removal of intervertebral disks from the anterior spine. Exposure to the anterior spine has traditionally been accomplished through thoracotomy or a thoracolumbar incision. The open thoracotomy, however, has several disadvantages, such as post-thoracotomy pain, a large scar, and breathing difficulties. Since the first thoracoscopy at the beginning of this century, the procedure, at first limited by the available technology, has gradually gained more uses and favor among physicians. The last 10 years have seen significant improvement in optical technology and instrumentation. These advances have allowed the spine surgeon to begin performing anterior spinal releases using endoscopic techniques. These endoscopic techniques can carry the same efficacy as the open thoracotomy but less morbidity. Thoracoplasty, the resection of rib segments, is an excellent way to not only correct the convex rib deformities seen in scoliosis but it is also an excellent source of bone which can be used as a graft for fusion. Although traditionally, thoracoplasty has also been done through an open procedure, it can be performed endoscopically. This prospective study presents nine patients who underwent combined endoscopic anterior spinal release and thoracoplasty followed by same day posterior instrumentation and fusion for correction of their spinal deformities. All nine procedures were completed successfully endoscopically. It is our conclusion that in the hands of an experienced surgeon, the endoscopic technique is an excellent procedure providing the same efficacy as the open thoracotomy. There is however a learning curve associated with the procedure. In addition, a team approach in which the surgeon and an experienced anesthesiologist with experience with double lumen intubation and selective single lung ventilation and thoracoscopic surgery is crucial. Although there were no surgical complications related to the thoracoscopic technique one patient did require prolonged intubation postoperatively, which leads us to believe that single lung ventilation in and of itself is very demanding and each patient must be considered carefully prior to its undertaking.