CHAPTER 31 Thoracoscopic Approach to Spinal Deformities

Randall Kevin Wolf, A. Atiq Durrani

Introduction

The conventional approaches to the spine have been posterolateral, costotransverse, and anterior. To reach the anterior spine, anterior thoracotomy has traditionally been used. Problems associated with thoracotomy include a long incision, rib resection, significant rib spreading, tissue desiccation, alteration of pulmonary and shoulder girdle function, significant pain, associated morbidity, and poor cosmesis. The field of video-assisted thoracic surgery (VATS) presents the spinal surgeon with an endoscopic option for approaching the anterior vertebral column.

The use of video-assisted thoracoscopy can decrease the surgical morbidity associated with open procedures. The goals and objectives of this newer technique are the same as those for thoracotomy. The VATS approach to the spine has led to many exciting new techniques for treatment of the disk space. Surgical instruments, guided by an endoscope, are able to gain access to the chest through 15- to 20-mm ports rather than through the 8- to 10-inch-long incision required for thoracotomy.

In December 1993, at Children’s Hospital Medical Center in Cincinnati, we began performing VATS for the anterior release of severe spinal deformities in children and adolescents. The benefits of this procedure include minimal invasiveness, better visualization and magnification, diminished postoperative pain and ventilatory compromise, reduced blood loss, decreased hospitalization, reduced health-care costs, improved wound care, and earlier return to prehospital activities with minimal shoulder dysfunction.¹

Indications for Children and Adolescents

♦ Rigid idiopathic scoliosis deformities at or above 75 degrees in magnitude with correction to less than 50 degrees seen on side-bending radiographs

♦ Prevention of crankshaft phenomenon in the skeletally immature child who has more than a 50-degree curvature

♦ Kyphotic deformities greater than 70 degrees

♦ Neuromuscular deformities accompanied by at-risk pulmonary status

♦ Progressive spinal deformity and metabolic disease

♦ Severe rib hump deformity not corrected by spinal instrumentation

♦ Neurofibromatosis with intrathoracic tumors in addition to a significant spinal deformity

♦ Pseudarthrosis after anterior intervertebral fusion

♦ Anterior hemiepiphysiodesis for congenital scoliosis

♦ Incision and excision biopsy

We have extended our indications to include all the procedures addressing the thoracic spine that were previously approached by thoracotomy.²

Approach to Minimally Invasive Exposure of the Thoracic Spine

Order of Operative Steps

The order of steps of the operation is as follows: confirm somatosensory evoked potential (SSEP) monitoring, place the patient in the prone position, mark the topical anatomy under fluoroscopic control, establish ports, expose the appropriate disk levels, and provide exposure for disk removal or for stapling.

Key Points

♦ Working ports should be placed in order to align the instruments fairly straight into the disk spaces.

♦ At least three ports are recommended. One port is needed for a pediatric Wolf or Yankauer suction (Scanlon International, St. Paul, Minn). One port is used for the thoracoscope. This leaves one working port. An additional lower port or incision is used for the Endokittner (Ethicon Endosurgery, Cincinnati, Ohio) to depress the diaphragm. By shifting the instruments from port to port, T2 to L1 can be instrumented (Figure 31-1).

♦ The Harmonic scalpel is used to open the parietal pleura and, when indicated, to divide the intercostal vessels.

♦ The endoscopic hardware includes various angled thoracoscopes capable of magnifying up to 15 times, as well as specialized thoracospinal instruments (e.g., rongeurs, curettes, periosteal elevators, electrocautery, Harmonic scalpel, and suction irrigation devices).³

Figure 31-1 A, Typical ports for thoracic spine exposure. B, The thoracoscope usually is in the middle port, and instruments are placed in the superior and inferior ports.

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