Results of Anterior Thoracoscopy Spine Surgery in Children Under Thirty Kilograms

Children's Hospital, San Diego, California, USA

PURPOSE:
Thoracoscopic surgery is effective for anterior release and fusion of pediatric spinal deformity. No series has reported the results of this technique in small children.

METHODS:
A retrospective chart review of patients who underwent thoracoscopic anterior spinal release and fusion was performed. "Small children", defined as those under 30 kg who had thoracoscopic surgery, are the main focus of this study. "Small children" were compared to a group of "large children" weighing over 30 kg who had thoracoscopic surgery and a "small open group" of children under 30 kg who had open anterior thoracic surgery.

RESULTS:
106 patients met inclusion criteria. There were 33 "small children" (31%, 13 male, 20 female, mean age 10.7 years, mean weight 22.8 kg) of whom 76% had neuromuscular scoliosis, 18% congenital scoliosis, and 6% juvenile idiopathic scoliosis. There were 48 "large children" (45%, 23 male, 25 female, mean age 14.7 years, mean weight 51.5 kg) of whom 42% had neuromuscular scoliosis, 27% idiopathic scoliosis, 19% idiopathic kyphosis, 4% congenital scoliosis, and 8% tumor or syrinx. Twenty-five patients comprised the "open group" (24%, 10 male, 15 female, mean age 7.8 years, mean weight 19.4 kg) of whom 42% had neuromuscular scoliosis, 40% congenital scoliosis, 4% post-laminectomy kyphosis, and 4% arthrogryposis. "Small children" had greater anterior blood loss per kilogram body weight (13.6 ml/kg vs. 6.2 ml/kg, p=0.003), greater chest tube output (27.5 ml/kg vs. 17.1 ml/kg, p=0.003), and a longer ICU stay (4.2 days vs. 1.5 days, p=0.001) than did "large children". There was no significant difference in quality of lung collapse or anesthesia time (time for monitoring line placement and selective lung intubation). "Small children" required more anesthesia time (80.2 min. vs. 64.2 min., p=0.002) than the "small open group". There was no significant difference in anterior blood loss, chest tube output, or ICU stay between these two groups. No significant difference was found between groups with regard to the number of discs excised, anterior operative time, duration of mechanical ventilation, chest tube duration, and total hospital stay. One "small child" (14 kg) was rescheduled due to inability to selectively intubate. One child from each thoracoscopic group required conversion to open thoracotomy.

CONCLUSIONS:
Despite the decreased working space within the chest and challenges of selective intubation, anterior thoracoscopic surgery for spinal release and fusion can be performed safely in small children. Increased blood loss (ml/kg), increased chest tube output (ml/kg), longer ICU stay, and the need for specialized intubation methods should be anticipated.