ENDOSCOPIC INSTRUMENTATION, CORRECTION AND FUSION OF THORACIC CURVES IN IDIOPATHIC ADOLESCENT SCOLIOSIS

George D. Picetti III,
MD; H. Uli Bueff, MD
* · (b–Sofamor Danek)

PURPOSE:
To present our endoscopic technique in the treatment of thoracic curves in patients with idiopathic adolescent scoliosis. In addition evaluate the efficacy of this technique.

METHODS:
Between December 1996 and April 1998, 50 patients with primary thoracic curves were endoscopically instrumented, corrected and fused. The average curve size was 57 degrees with a range of 42 to 98 degrees. The levels treated were between T4 and L1, with a range of six to eight levels instrumented. The age of patients ranged from 9 to 25 years old. The patients are approached from the direct lateral decubitus position after double lumen tube intubation. Between 3 and 5, eleven mm portals are utilized. Multilevel discectomy is performed in standard fashion. Cannulated 7.5mm screws are inserted into the vertebral bodies under endoscopic and fluoroscopic control. Fusion is performed using rib graft sections harvested adjacent to the portals. However the first 15 cases were fused using Grafton and allograft. A 4.5mm solid rod is measured accordingly and inserted into the most distal screw. Sequential reduction and fixation into the remaining screws is performed from distal to proximal. Similarly, compression is achieved sequentially from distal to proximal with specialized endoscopic instrumentation. A single chest tube is inserted through the inferior most portal prior to closure. A custom orthosis is worn for three months. Ambulation is initiated postoperative day one. Patients are discharged post–operative day 3 or 4.

RESULTS:
All patients were evaluated at a minimum of 24 months, with a range of 24 to 41 months. The average curve correction was 62 percent. Of the Grafton group 9 have developed pseudoarthrosis, two with rod fractures. Of the rib graft fusion patients one has developed a pseudoarthrosis. Five patients have developed mucus plugs delaying discharge.

CONCLUSION:
Endoscopic instrumentation, correction and fusion of thoracic scoliosis has resulted in curve correction comparable to the standard open technique. Initial operative times were long, but are now under four hours. The rehabilitation is significantly expedited and post–operative recovery and hospitalization are reduced. Fusion rates are unacceptable with Grafton. Although this procedure appears to be a safe and effective alternative method to the open approaches, a steep learning curve exist.

*· If noted, the author indicates something of value received. The codes are identified as: a–research or institutional support, b–miscellaneous funding, c–royalties, d–stock options, e–consultant or employee.