A Patients' Guide to Video-assisted Thoracoscopic Spinal Surgery (VATS)
Editor's Note: This is an excellent review for patients and health care providers. Please note this technique is an option that is utilized in advanced centers. Not all patients are candidates for this technique. Please check with your surgeon regarding his/her experience, outcomes and preferences.
General Indications for Spine Surgery
One of the most difficult jobs of a spine surgeon is deciding when surgical intervention is appropriate. There are five basic reasons to offer surgical treatment to patients with spinal disorders.
- Neurological dysfunction (compression)
- Structural instability (abnormal displacement)
- Pathologic lesions (such as a tumor or infection)
- Deformity (abnormal alignment)
- Pain (spinal column/discogenic/facetogenic)
Placing the patient in one or more of these categories allows the spinal surgeon to organize his/her thoughts. In general, nonoperative treatment should be considered first prior to surgical intervention. All of the groups can be managed nonoperatively or operatively. Once all conservative measures have been exhausted over a reasonable period of time, then surgical intervention may be appropriate. In general, minimally invasive endoscopic techniques may be considered prior to more extensive reconstructive procedures. The use of endoscopes allows surgical procedures to be performed through small incisions which may minimize postoperative pain, decrease length of hospital stay, facilitate recovery times, hasten return to work, and decrease costs of medical care.
Indications for Thoracoscopic Spinal Surgery (VATS)
Indications for performing a thoracoscopy can be extrapolated from the five basic indications for surgery of the spine patient.
Deformity: These include an anterior release for scoliosis or Scheuermann's kyphosis.
Instability: In cases of spinal fractures for instance, in addition to decompression, anterior column reconstruction using bone grafts and/or internal fixation devices can also be applied through a thoracoscopic approach.
Neural compression: This is probably the most common indication for a thoracoscopic spinal surgery. Nerve roots and the spinal cord can be decompressed through the resection of thoracic herniated nucleus pulposus.
Fig.1: Herniated Nucleus Pulpous
Pathologic lesions: A thoracoscopic approach may be used for the treatment of infection or tumor through biopsy, debridement, drainage of an abscess, resection of a tumor, or corpectomy.
Pain: Thoracoscopy may be used for the treatment of symptomatic spondylosis and/or degenerative disc disease by fusion of the painful motion segment (bone dowels or cages).
Thoracoscopy is a technique used in managing herniated thoracic discs. The advantages of thoracoscopy over the conventional transthoracic open procedures are
- enhanced visualization while using standard instruments through minimal incisions
- more extensive visualization of thoracic anatomy
- decreased incisional pain
- decreased need for chest tube drainage
- decreased respiratory complications
- decreased blood loss
- decreased potential for infection
- decreased postoperative pain which results in shorter hospital duration, shorter rehabilitation, and decreased medical costs.
The obstacles associated with thoracoscopy are that it requires
- technical skill
- deflation of the ipsilateral lung.
This procedure is therefore contraindicated for patients who:
- cannot tolerate one lung ventilation;
- have medical reasons that would prohibit surgery (uncontrollable coagulopathy, irrecoverable terminal illness, or severe cardiac or pulmonary disease );
- have had prior thoracotomy or another procedure in which they may have developed adhesions that might prohibit adequate access.
(Figure used with Permission: John J. Regan, M.D.)
Fig.2: O.R. Set-up for VATS
Fig.3: High Tech O.R. Equipped for Video Assisted Thoracoscopic Spine Surgery