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Introduction
Today new
technological advancements in thoracoscopy have made it possible
for thoracic scoliotic curves to be corrected utilizing minimally
invasive techniques. Thoracoscopy combines the science of endoscopy
(video-assisted surgery) with thoracotomy (access to chest, or
thoracic spine).
Utilizing
thoracoscopy, highly skilled spinal surgeons have determined lateral
(from the side) entry through the chest wall provides sufficient
access to the thoracic spine to enable thoracic scoliotic curve
correction.
Traditionally,
surgical treatment for thoracic scoliosis meant an open procedure
leaving the patient with a large unsightly scar. Instead of an
open procedure (large incision), the spine surgeon makes small
incisions - precisely located - to allow access to the thoracic
spine. Tiny, specially designed endoscopic instruments pass through
these incisional gateways and are maneuvered during surgery.
This is exciting
news for patients with progressive scoliotic curvature because
minimally invasive procedures offer so many benefits to the patient.
During an open procedure, the incisions slice through skin, layers
of fat, and muscle, which are then held back by clamps or pulled
aside with retracting instruments. Blood vessels are sealed to
prevent serious loss of blood. Conversely, patients who undergo
a thoracoscopic procedure find
1) scars
are dramatically reduced because the small incisions are simply
covered with small dressings
2) blood loss during surgery is reduced
3) there is less damage to muscles and other soft tissue
4) hospital stays are often shorter
5) patients recover faster.
Curve
Reduction
The spine
surgeon selects the procedure(s) that will provide the most benefit
to the patient. Scoliotic curve reduction usually involves the
removal of several intervertebral discs (discectomy), spinal instrumentation,
and fusion.
Spinal Instrumentation
and Fusion are surgical procedures utilized to correct spinal
deformity and to provide permanent stability to the spinal column.
These procedures join and solidify the level where a spinal element
has been damaged or removed (e.g. intervertebral disc). Instrumentation
utilizes medically designed implants such as rods, wires, and
screws. These devices hold the spine in place during fusion. Fusion
is the adhesive process joining bony spinal elements.
Pre-Thoracoscopy
Planning
The patient's
history is reviewed and a physical examination is performed. The
patient's pelvis and shoulders are observed for differences in
height, and spinal rotational flexibility. Posterior/anterior
(P/A) and lateral x-rays are obtained along with side bending
films. The degree of curvature is measured and marked utilizing
a full-length A/P x-ray.
Surgical
Preparation
General
anesthesia is administered to all patients. The anesthesiologist
decides the type of anesthesia based on many variables including
the patient's age and weight. The patient is positioned on the
operating table with the curvature side up (concave side down).
The hips and shoulders are taped into place securing the patient
in the proper position for surgery. The patient's position is
checked throughout the procedure. A C-Arm is a movable fluoroscopic
unit that projects a selected view of the spine onto a monitor
located at the foot of the operating table. As the C-Arm is moved
around the patient, the surgeon gains information important to
determining spinal landmarks (guides), as well as spinal rotation.
The landmarks represent specific areas where incisions will create
a portal. A portal is an opening through which tiny specialized
surgical instruments are inserted. These entry points (landmarks)
are marked directly onto the patient's skin.
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| C-Arm
Use |
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| Landmarking
Patient's Skin |
Landmarks
or Portals |
Landmarking
Patient's Skin
Landmarks or portals are created for precise entry into the chest. An endoscopic camera sends images to two monitors utilized
during the surgery. Each monitor is placed near the patient's
head, one anterior and the other posterior. This allows the surgeon
and his or her assistant to view the procedure.
Typical
Monitor Set Up in Operating Room
Surgical
Procedure
The portal
incisions are made, an endoscopic camera is inserted into the
chest, and surgery begins as tiny specialized instruments are
maneuvered through small hollow tubes. According to the surgical
plan, several intervertebral discs and adjoining endplates are
removed using a procedure termed discectomy.
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| Typical
Monitor Set Up in Operating Room |
Discectomy
Intervertebral Disc
Removal
Endplate Removal
After the
removal of necessary discs and endplates, the empty space is examined
using a scope and later packed with bone graft harvested from
the ribs. Bone graft is necessary for fusion. Discectomy is followed
by spinal instrumentation. The C-Arm is the surgeon's anatomical
guide assisting with many measurements associated with screw and
rod placement.
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Discectomy
Intervertebral Disc Removal |
Endplate
Removal |
C-Arm
Fluoroscopic View of Vertebral Screw Insertion
After the
rod has been cut to the correct length and affixed to the screws,
the spine is compressed. A rack and pinion device fits over two
screw heads on the rod and is turned distributing compressive
force evenly to correct spinal alignment. When the vertebral alignment
is corrected, the screws are plugged to hold the rod in proper
position. The endoscopic instruments and camera are removed and
the small incisions are closed and covered with small dressings.
Before the patient is transferred to the recovery room, A/P and
lateral x-rays are taken to record instrumentation and curve correction.
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| C-Arm
Fluoroscopic View of Vertebral Screw Insertion |
Recovery
Thoracoscopic
correction of thoracic scoliosis is a remarkable advancement in
corrective spinal surgery. Most patients are out of bed walking
the day following surgery and released from the hospital within
a few days. Although patients may be braced for 3 months, recovery
is rapid enabling most patients to return to many regular activities.
Children often return to school within 2 to 4 weeks. Patient progress
is monitored during one, three, six, and 12-month intervals, which
include an x-ray evaluation of the spine.
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