|SYMPOSIUM: ADOLESCENT IDIOPATHIC SCOLIOSIS
|Year : 2020 | Volume
| Issue : 2 | Page : 207-215
Minimally invasive options in adolescent idiopathic scoliosis
Jiong Hao Tan, Hee-Kit Wong
University Spine Centre, Department of Orthopaedic Surgery, National University Hospital, National University Health System, Kent Ridge Road, Singapore
|Date of Submission||14-Sep-2019|
|Date of Decision||23-Oct-2019|
|Date of Acceptance||10-Feb-2020|
|Date of Web Publication||13-Jul-2020|
Dr. Jiong Hao Tan
1E Kent Ridge Road, NUHS Tower Block Level 11.
Source of Support: None, Conflict of Interest: None
Posterior spinal instrumentation and fusion is the gold standard of surgical treatment for adolescent idiopathic scoliosis (AIS). This procedure is conventionally performed open, through a posterior midline approach. Minimally invasive spinal surgery (MIS) has been found to be associated with decreased blood loss, shorter duration of hospital stays, earlier mobilization, and decreased analgesic requirements in other areas of spinal surgery. In the treatment of patients with AIS, these principles can be applied via a posterior MIS approach and an anterior thoracoscopic approach. This article aimed to provide an overview of the current state of knowledge of MIS for AIS surgery. We will describe the rationale for the use of posterior MIS for AIS, a description of the surgical technique and a discussion of the current evidence for its use. We will also describe the indications, surgical technique, and evidence for MIS anterior spinal fusion as a definitive procedure for AIS and for non-fusion convex growth modulation procedures.
Keywords: Adolescent idiopathic scoliosis, minimally invasive surgery, video-assisted thoracoscopic surgery
|How to cite this article:|
Tan JH, Wong HK. Minimally invasive options in adolescent idiopathic scoliosis. Indian Spine J 2020;3:207-15
Posterior spinal instrumentation and fusion (PSIF) is the gold standard of surgical treatment for adolescent idiopathic scoliosis (AIS). The benefits of PSIF include stable fixation and fusion with excellent deformity correction. Owing to these benefits and its familiarity to most spine surgeons, it is the most commonly performed form of surgery for AIS.
PSIF is not without disadvantages. These include the need for a posterior midline incision and detachment of paravertebral muscle insertions, which may lead to paravertebral muscle injury and denervation.,, Minimally invasive spinal surgery (MIS) has been found to be associated with decreased blood loss, shorter duration of hospital stay, earlier mobilization, and decreased analgesic requirements. Its principles include the avoidance of surgically induced muscle damage, disruption of tendon attachments, and the use of anatomic planes where possible.
In the treatment of patients with AIS, these principles can be applied via a posterior MIS approach and an anterior thoracoscopic approach. There is currently limited evidence to support the use of a posterior MIS approach in the treatment of AIS.,,,,, Video-assisted thoracoscopic scoliosis surgery (VATS) was introduced in the 1990s but subsequently declined in popularity with the advent of posterior instrumentation and fusion with pedicle screws. VATS current applications include its use as a definitive procedure for anterior instrumented fusion of selected Lenke 1 and Lenke 5 curve types,,,,,,,,,,,,, and as an anterior release procedure for severe thoracic scoliosis before posterior instrumentation and fusion,,, in non-fusion convex growth modulation procedures such as anterior vertebral body stapling (VBS),,,,,,, or tethering.,,,,,,,
This article aimed to provide an overview of the current state of knowledge of MIS for AIS surgery. We will describe the rationale for the use of posterior MIS for AIS, a description of the surgical technique and a discussion of the current evidence for its use. We will also describe the indications, surgical technique, and evidence for VATS.
| Posterior Minimally Invasive Surgery for AIS|| |
Posterior MIS is presently used for adult spinal trauma, spinal tumor, and adult scoliosis surgery. However, its use in AIS surgery is not fully established. The challenges inherent in this procedure include the safe and optimal placement of screws, performance of facet fusion, passing of the contoured rod, and performance of reduction maneuvers.,,
| Surgical Technique for Posterior MIS for AIS|| |
This procedure is performed with the patient prone on a radiolucent table and incision placement is planned with preoperative fluoroscopy. A single skin incision can be used in Lenke 5 deformity, whereas a dual incision approach has also been described. For other Lenke types, most authors make three separate skin incisions.,,,, The skin is then undermined laterally to allow paramedian fascial incisions on both sides of the spine and a blunt, muscle-sparing approach similar to that described by Wiltse, is used.
In Lenke type 5 curves, the entire structural curve is usually instrumented.,, In other Lenke types, de Bodman et al. and Sarwahi et al., have described instrumenting three vertebrae at each incision and leaving the intervening vertebrae that had not been surgically exposed between each incision uninstrumented. This would leave a total of 2 vertebrae un-instrumented in the final construct.
Placement of pedicle screws can be challenging in MIS AIS surgery due to a limited view of anatomical landmarks and rotation of the vertebrae. This is especially so at the apex of the curve where the vertebrae are most rotated. Most authors perform freehand placement of screws making use of the facet osteotomy and exposure of anatomical landmarks to guide the placement of screws.,,, These landmarks include the facet joints and transverse processes in both the lumbar and thoracic spine. Adequate exposure of these landmarks are crucial to the accurate placement of screws. However, the view of other landmarks, which guide the trajectory of screw placement, such as the spinous processes and the lamina, may be difficult to achieve. Zhu et al. and Urbanski et al. have also made use of O-arm navigation to guide pedicle screw placement.
The facet joints are decorticated using a high-speed burr, and bone graft, consisting of a mixture of autograft–allograft bone, is applied before definitive instrumentation. Facetectomies and bone grafting are performed on the intervening facet joints between incisions by mobilizing skin and soft-tissue flaps. Visualization of the facet joint and adequate exposure can be challenging, especially in the intervening vertebrae, and there is also limited space for placement of the bone graft.
The presence of a rigid curve, vertebral rotation, limited visualization, and soft tissue may make the passage of a contoured rod challenging. The multiple reduction maneuvers in AIS surgery (rod translation, rod derotation, in situ bending, direct vertebral rotation, and spine translation) would be limited by both the incision size and MIS instrumentation systems. Sarwahi et al., described the use of alternate reduction screws with extended tabs and MIS screws with open connectors (reduction tubes) between levels, whereas de Bodman et al. described the use of MIS screws with reduction tubes at every instrumented level, to facilitate insertion of the rod and apical derotation during deformity reduction. The convex rod is introduced first and derotation of the rod and gradual spine-to-rod reduction are used to correct the deformity, the rod is then secured and additional apical derotation may be performed. The second concave rod is over contoured in the sagittal plane to allow for further deformity correction in the transverse plane and inserted in a similar fashion. A final intraoperative radiograph is taken to confirm the position of the implants, and a layered closure without a drain is performed. Surgical approach and operative outcome for Posterior MIS for AIS is illustrated in [Figure 1].
|Figure 1: (A) Surgical approach for posterior minimally invasive spinal surgery. (B) Posterior minimally invasive scoliosis surgery pre- and postoperative radiographs|
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| Current Evidence in the Literature for Posterior MIS AIS Surgery|| |
de Bodman et al. published a retrospective analysis of 70 patients treated with posterior MIS; there were 8 male patients and 62 female patients. In these patients, forty curves were Lenke type 1, fifteen were type 2, three were type 3, two were type 4, eight were type 5, and two were type 6. The mean primary Cobb angle was corrected from 58.9° (±12.6°) preoperatively to 17.7° (±10.2°) postoperatively with a mean correction of 69% (±20%, P < 0.001). This was comparable to the mean reported correction in the literature, which ranged between 64% and 84%.,,, The mean operating time was 337.1 min (±121.3); the mean estimated blood loss (EBL) was 345.7 mL (±175.1) and the mean length of stay (LOS) was 4.6 days (±0.8). Mean operating time was comparable to that reported for PSIF, 187–458 min., The average LOS was 4.6 days, which was lower than the reported average in the literature of 5–6 days., There was also lower EBL and need for transfusion (0%) in these patients compared to that reported by Yoshihara and Yoneoka, where 30.4% patients required blood transfusion post posterior scoliosis surgery. The total rate of postoperative complications (11.4%) was comparable to that reported by Yoshihara and Yoneoka, who reported an in-hospital overall complication rate of 14.4% in patients who underwent surgery for AIS. However, the rate of delayed surgical infection was unusually high with three (4.4%) of the patients requiring surgical treatment for delayed infection. The rates of infection postoperatively for AIS are reported to range from 0.9% to 3%.,, This was attributed to the learning curve involved in this procedure.All cases of infection occurred during the first 25 cases where mean operating time was longer.
At present, there are three studies directly comparing MIS posterior AIS surgery to posterior instrumentation and fusion. Miyanji et al. reported their results comparing 16 patients treated with MIS who were matched for age, sex, curve type, and size to 16 patients treated with conventional open surgery. No significant difference was observed between MIS and open surgery in terms of Cobb angle correction (63% ± 13% versus 68% ± 8%, respectively) or postoperative thoracic kyphosis (21° ± 9° vs. 17° ± 5°, respectively). In the MIS group, EBL was significantly lower (277 ± 105 mL vs. 388 ± 158 mL), operating time (ORT) was significantly longer (444 ± 89 min vs. 350 ± 76 min), and hospital stay (LOS) was significantly shorter (4.63 ± 0.96 days vs. 6.19 ± 1.68 days) when compared to open surgery.
Zhu et al. compared 45 patients with Lenke type 5C AIS, 15 who underwent MIS under O-arm navigation and 30 who underwent posterior spinal fusion and instrumentation. No significant difference was observed in curve correction or complication rate between these two groups of patients. Patients undergoing MIS had a significantly longer estimated operating time; however, they also had significantly less blood loss, and better Scoliosis Research Society (SRS)-22 scores for self-image and pain. Overall, the accuracy of screw placement in scoliosis surgery using navigation has been estimated to range from 89% to 97%, whereas the accuracy of freehand pedicle screw placement in AIS has been reported to range from 75% to 99%. In a study by Su et al., the mean radiation dose in pediatric patients treated with low-dose pediatric O-arm was approximately four times that of the patients treated with C-arm. The effective dose of one low-dose pediatric O-arm scan was found to approximate 85s of the C-arm fluoroscopy time. This increased radiation, and the inherent risks of increased radiation exposure may negate the benefits of using navigation in this patient group.
In a retrospective controlled study comparing seven MIS patients with 15 PSIF patients using minimum 2-year follow-up data by Sarwahi et al., MIS patients did not have a significant decrease in EBL and had a mean ORT of 538 and 53 min per level fused, which was significantly longer. Also no significant difference was observed in postoperative recovery in terms of number of intensive care unit (ICU) days (P = 0.362), length of hospital stay (P = 0.472), time to mobilization (P = 1.00), visual analog scale pain scores (P = 0.698), or patient-controlled analgesia (P = 1.00). Both groups of patients had similar deformity correction, screw placement accuracy, and fusion status.
Posterior MIS for AIS may be associated with lower blood loss and decreased length of hospital stay while offering similar deformity correction when compared with standard open posterior technique. There may be increased operative time during the surgeon’s learning curve, which may be associated with an increased risk of infection. There is a need for prospective, long-term, adequately powered studies to establish its role in AIS surgery. Advantages and disadvantages of posterior minimally invasive spinal surgery for adolescent idiopathic scoliosis versus posterior spinal instrumentation and fusion is illustrated in [Table 1].
|Table 1: Advantages and disadvantages of posterior minimally invasive spinal surgery for adolescent idiopathic scoliosis versus posterior spinal instrumentation and fusion|
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| VATS for AIS|| |
Before the advent of pedicle screw instrumentation, anterior fusion and instrumentation was more widely performed as it was associated with better correction of scoliosis and hypokyphosis as well as preservation of more mobile segments., Thoracoscopic spinal surgery for scoliosis was introduced, and it gained popularity in the 1990s and early 2000s as it avoided the morbidity associated with an open thoracotomy. However, with the advent of modern pedicle screw based posterior instrumentation, its use has declined in recent years.
Patient selection and surgical technique
An ideal surgical candidate for VATS in scoliosis correction would be a patient with a right side thoracic, adolescent idiopathic scoliotic (AIS) Lenke type 1 curve. In patients with Lenke type 5 curves, a hybrid approach of VATS and a retroperitoneal mini-Anterior Lumbar Interbody Fusion (Mini-ALIF) can be performed. The magnitude of the structural curve should be less than 90°. Thoracic kyphosis should be less than 40° and the curve should be flexible and should bend to less than 45° on the bending film. Single lung ventilation is crucial for this procedure and preoperative pulmonary function testing is recommended. Poor pulmonary function, previous ipsilateral thoracic surgery, recurrent pneumonia, and pulmonary tuberculosis are contraindications to this approach. Selection criteria for Video-assisted thorascopic scoliosis surgery is illustrated in [Table 2].
|Table 2: Patient selectionin video-assisted thoracoscopic scoliosis surgery for adolescent idiopathic scoliosis|
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VATS is performed with the patient positioned in a lateral decubitus position with the convexity (right side) facing upward. Single lung ventilation is achieved using selective double lumen endotracheal intubation. It is not possible to perform VATS adequately without complete deflation of the lung. There is a learning curve for the anesthetic team in performing single lung ventilation, which may contribute to increased operating time and pulmonary complications. The placement of surgical portals, performance of discectomy and fusion, screw placement, and curve correction are the crucial aspects of this procedure.
The entry portals into the chest are estimated on preoperative chest or side-bending radiographs. Typically, four entry portals, located at the third, fifth, seventh, and ninth ribs allow transthoracic access from T4 to L1 vertebral bodies. An additional mini-retroperitoneal incision is made when anterior spinal fusion is required to L2 or L3. The location of the entry portal along each rib in the anteroposterior plane is determined using intraoperative image intensifier radiographs taking into account apical vertebral rotation.
The parietal pleura on the spinal column is incised longitudinally along the peak of the disc where it is most avascular, and the intervertebral segmental vessels are cauterized. In our institution, this is performed using a harmonic scalpel (Ultracision LCS, Ethicon Endosurgery, Piscataway, New Jersey). A clear surgical field is essential for performing this procedure.
Once the intervertebral disc is exposed beneath the pleura, the disc borders are outlined by cautery; the annulus is then incised and a pituitary rongeur is used to remove the annulus disc complex. The cartilaginous end plates are separated from the subchondral vertebral bone by using a sharp Cobb elevator; and the final clearance of the disc space is carried out by a combination of straight and angled pituitary rongeurs and cup curettes. The intervertebral space may be packed with rib autograft, iliac crest autograft, and augmented with demineralized bone matrix in a putty form. A fibular strut or femoral ring allograft can also be added at one or two distal levels of fusion to prevent excessive kyphosis in lower segments.
Each screw should be placed parallel to the end plates and in the center of the vertebral body, and this is performed under C-arm guidance. Placement of screws without accounting for the rotational deformity of each vertebra may result in iatrogenic spinal canal perforation. To avoid this, an image of a neutral vertebra of Moe should be obtained on the anteroposterior view on the fluoroscope, and any instrument directed into the spine should be placed perpendicular to the imaginary plane between the X-ray tube and the image intensifier on either ends of the C-arm.
To ensure bicortical purchase, we use an electronic conductivity device (ECD) (PediGuard; SpineGuard, France) to prepare the entry point of each screw, to ensure that both cortices are perforated and a bicortical screw can be placed. In patients requiring instrumentation to L1, L2, or L3, a small retroperitoneal incision is made to allow discectomies and fusion of T12/L1, L1/L2, and L2/L3 and placement of screws into the respective vertebral bodies. The rod may be passed under the diaphragm after detaching its attachment to the vertebra to reach the upper two lumbar screws.
The rod is inserted in a cephalocaudal manner using the cantilever method with pre-contouring to accommodate the adjacent minor curves. Placing the rod in a cephalad to caudal manner reduces stress on the cephalad screws, which are more likely to pull out. Intervertebral compression is performed in a cephalocaudal direction, and the final tightening of the rod screw construct is performed. A chest tube is inserted, and a layered closure is then performed. A supportive front–back shell thoracic lumbar sacral orthosis is used for 3 months. Surgical approach and operative outcome for Video-assisted thorascopic scoliosis surgery is illustrated in [Figure 2].
|Figure 2: (A) Video-assisted thorascopic scoliosis surgery (VATS) portals. (B) 16-year-old female with Lenke 1A curve, Cobb angle of 52°. (C) Post VATS surgery, T6 to L1 accessed via a transthoracic approach and L1 to L2 via a retroperitoneal approach. (D) Radiographs 9 years post VATS for adolescent idiopathic scoliosis|
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Current evidence in the literature for VATS AIS surgery
In a recent systematic review of patients of AIS treated with VATS, 530 patients in 13 single center studies were reviewed. The mean operative time was 371.5 min, mean blood loss was 503 mL, and mean hospital stay was 5.9 days. Mean preoperative curve magnitude was 52.9°; postoperative curve magnitude was 17.9°, with a correction of 62.7%. Mean number of levels instrumented was 6.3. Pulmonary function tests returned to preoperative values by two years post operation, and the complication rate was 21.3%. The most common complications were pulmonary (9%) and implant related (7%). Other complications made up 4.7%, including nonunion, transient periportal numbness, superficial wound infection, scapular winging, narcosis, and transient ulnar paresthesia.
There have been several studies comparing VATS to posterior spinal fusion. Newton et al. performed a prospective, multicenter study comparing thoracoscopic anterior spinal fusion, open anterior spinal fusion, and posterior spinal fusion and instrumentation in patients of AIS with Lenke type 1 curves. There were 55 patients with thoracoscopic anterior spinal fusion, 17 patients with open anterior spinal fusion, and 64 patients with PSIF. A significant decrease was observed in levels fused (6 ± 1 vs. 10 ± 2) and blood loss (470 ± 455 mL vs. 807 ± 608 mL) in patients undergoing VATS compared to patients undergoing PSIF. There was also a significantly lower transfusion rate and cumulative length of incision. However, surgical time was greater by 2–3 h in both the anterior surgical groups. At 2 years, all three approaches showed similar improvements in the thoracic Cobb angle, coronal balance, lumbar Cobb angle, Scoliosis Research Society questionnaire scores, and trunk rotation measures with no difference in major complications.
Lee et al. compared 42 patients undergoing thoracoscopic surgery and 23 patients undergoing posterior surgery for AIS. Patients undergoing thoracoscopic surgery required shorter levels of fusion and had less intraoperative blood loss, with a lower transfusion rate. However, they reported that patients undergoing thoracoscopic surgery had higher rates of loss of correction, implant failure, and significant pulmonary complications. Wong et al. also showed similar findings with shorter levels of fusion and blood loss, but higher length of operative time and duration of ICU stay in patients undergoing VATS compared to that in posterior instrumentation and fusion patients.
Longer surgical time and complications could be attributed to the significant learning curve associated with spinal thoracoscopy. In a series of 65 consecutive cases by Newton et al. of thoracoscopic anterior release with discectomy and fusion, a significant improvement was observed in operating time as the series progressed. Gatehouse et al. and Lonner et al. have also shown that operative time, fluoroscopy time, curve correction, and rate of implant-related complications in VATS AIS surgery improved with time.
Although there is a higher rate of pulmonary complications in patients undergoing thoracoscopic surgery, a meta-analysis by Lee et al. showed that at 2 years, no significant decrease was observed in pulmonary function in patients who had undergone VATS AIS surgery. Patients also reported significant improvement in self-image (P < 0.02), mental health (P < 0.03), and total score (P < 0.05) on the SRS questionnaire when compared to patients who had undergone posterior spinal fusion.
In summary, the advantages of VATS are decreased levels of fusion, less blood loss and transfusion requirement, improved cosmesis, patient satisfaction, and a lower infection rate. However, due to the steep learning curve, it is associated with longer operating times and hospital stay and an increased complication rate during the learning curve. Advantages and disadvantages of video-assisted thoracoscopic scoliosis surgery for adolescent idiopathic scoliosis versus posterior spinal instrumentation and fusion is shown in [Table 3].
|Table 3: Advantages and disadvantages of video-assisted thoracoscopic scoliosis surgery for adolescent idiopathic scoliosis versus posterior spinal instrumentation and fusion|
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The advent of anterior non-fusion growth modulations may lead to a revival in VATS use. Vertebral body stapling (VBS) uses C-shaped nitinol staples to compress the vertebral physes to prevent or reverse curve progression. These implants are placed via a thoracoscopic approach. At present, the largest series of patients by Cahill et al. showed that in patients with a thoracic curve, VBS prevents progression or fusion in 74% of patients treated. Another growth modulation technique, which uses a thoracoscopic approach is vertebral body tethering; VATS-placed screws are mechanically tensioned to correct scoliosis. Images of a patient post vertebral body tethering is illustrated in [Figure 3]. Samdani et al. reported their 1-year results in 32 patients. The mean preoperative thoracic curve magnitude was 42.8° ± 8.0°, which was corrected to 21.0° ± 8.5° on first postoperative radiograph, and 17.9° ± 11.4° at most recent radiograph. The preoperative lumbar curve of 25.2° ± 7.3° showed progressive correction (first erect = 18.0° ± 7.1°, 1 year = 12.6° ± 9.4°, P < 0.00001). At 2 years, two of their patients required repeat surgery to prevent overcorrection with a mean curve correction of 70%. Wong et al. have also published their results, which showed that anterior vertebral body tethering resulted in scoliosis deformity correction in the coronal and axial planes with preservation of curve flexibility. More experience with these non-fusion procedures is required to define their role and utility in the management of AIS.
|Figure 3: Images of a patient post vertebral body tethering. A tethering effect with progressive coronal correction was achieved at 2 years after tether application, with reversal of disc wedging in the tethered segments, followed by slight overcorrection until 4 years, without decompensation. (Reproduced with permission from Wong et al.)|
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| Conclusion|| |
Posterior MIS is a feasible option in selected cases with potential benefits of decreased blood loss and LOS. There may be an initial learning curve associated with longer operative time, increased use of imaging, and higher rates of infection. Further study is needed to establish its use in AIS surgery. VATS is a niche procedure in AIS. Its advantages include decreased blood loss, decreased levels of fusion, lower infection rates, and high patient satisfaction; however, it is technically demanding, and its use is limited to suitably trained surgeons in carefully selected patients. Newer anterior non-fusion anterior growth modulation surgeries may lead to a resurgence in its use. Open posterior instrumentation and fusion remains the gold standard in AIS surgery.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]