Scoliosis Surgery: Approaches and Procedures

SurgeonThe scoliosis spine surgeon will choose the procedure that best treats the patient's problem. Sometimes more than one surgery produces the most favorable results. The surgeon will present the pros and cons of the different procedures so the patient and their family can make an informed decision with his guidance.

This article will cover the various surgical approaches used to address scoliotic curves.  You can jump to the section you're most interested in.

Choices for scoliosis surgery include:

  • Posterior approach (back)
  • Anterior-posterior approach (front and back)
  • Anterior approach (front)
  • Thoracoscopic surgery (VATS, Video-Assisted Thoracoscopic Surgery)
  • Thoracoplasty (rib resection, rib removal)
  • Osteotomies (bone removal)
  • Hemivertebrae excision (partial or complete removal of a vertebra)
  • Kyphosis/flatback surgery (read our detailed article on flatback surgery)
  • Vertebral column resection

Posterior Approach (Back)

The posterior approach has been the gold standard for years and continues to be a surgical procedure applicable to most patients with scoliosis.

The procedure usually involves implanting two metal rods (stainless steel or titanium) to correct the abnormal curvature. Sometimes more than two rods are needed.  A combination of screws, hooks, and wire may be used to anchor the rods to the spine.

A spinal fusion procedure helps to weld the bone grafts and vertebral of the spinal column into a solid mass.

Thoracoplasty involves rib resection (partial or total removal) to decrease the size of the rib hump caused by scoliosis. The rib bone can be used as a source of bone graft used in the fusion procedure. Today, with pedicle screw fixation, thoracoplasty is less commonly performed than previously.

Important Posterior Approach Details

  • The posterior approach is usually required in patients with double or triple curves or curves associated with significant kyphosis.
  • In younger patients and adults with satisfactory bone density (strength), bracing is not used after surgery.
  • Posterior instrumentation (eg, rods, screws) without fusion or "growing rods" can be performed in patients with juvenile or infantile scoliosis under age 10. Growing rods allow for straightening of the spine and subsequent lengthening procedures until the patient reaches adolescence when a final fusion procedure is performed.
  • The average hospital stay for most operations ranges from four to seven days.

Images Showing Posterior Approach for Scoliosis

scoliosis, preoperative, posterior approach
scoliosis, postoperative, posterior approach
scoliosis, preoperative, posterior approach
scoliosis, postoperative, posterior approach

Spinal Fusion for Scoliosis: A Spine Surgery Option for Spinal Deformity

Scoliosis surgery and surgery for other types of spinal deformities requires the spine eventually to be fused solid as the current standard. Fusion is the process where motion segments (vertebrae) are welded together using bone grafts. Biologically speaking, the process of spinal fusion to completion takes three months to one year. During that time, the progress of the fusion is evaluated on x-rays.

Bone graft comes from different sources such as the pelvis (iliac crest of the hip), ribs, or the spine (local bone from the surgery site). Using local bone lessens the patient's pain caused by harvesting bone from other areas of the body. Allograft or cadaver bone is also often used and eliminates donor site morbidity.

In addition, protein bone graft substitutes (BMPs) may be used in select cases such as when an established failure of fusion (pseudoarthrosis) has occurred.

Since smoking interferes with fusion, patients should make every effort to stop months before their surgery. Smoking cessation should continue after surgery.

Anterior-Posterior Approach (Front-Back)

The anterior-posterior approach is performed in patients with severe stiff curves and in young, skeletally immature patients to prevent crankshaft phenomenon. This procedure may be performed in one day or separated into 2 procedures on different days.

Generally, one curve is approached from the front and back. If there is a second curve, it is approached only from the back. Sometimes, if there are two severe curves, a double anterior-posterior procedure is performed.

The anterior approach is the standard procedure performed to treat lumbar (low back) curves. Despite its name, it is actually performed through the patient's side to access the front of the spine. Anterior surgery can be performed using a scope inserted into the thoracic spine; also called thoracoscopic surgery.

The anterior-posterior approach is more involved than a single anterior or posterior procedure. Surgery may last six to 10 hours, the average hospital stay ranges between five days to two weeks, and recovery takes longer than a single approach procedure.

Images Showing Anterior-Posterior Approach in a Pediatric Patient
Anterior-posterior (front-back) surgery was performed in one day. The anterior part of the surgery was performed using thoracoscopy with 3 one-inch incisions.

Please note that the lumbar spine (low back) is mostly spared from fusion in this case.

scoliosis, pediatric, preoperative, anterior-posterior approach
scoliosis, pediatric, postoperative, anterior-posterior approach

Images Showing Anterior-Posterior Approach in an Adult Patient
Adult fusion was taken down to the sacrum (pelvic area) in this 57-year-old adult with back pain and disc degeneration.

scoliosis, adult, preoperative, anterior-posterior approach
scoliosis, adult, preoperative, anterior-posterior approach
scoliosis, adult, postoperative, anterior-posterior approach

Anterior Approach (Front)

Certain abnormal curves are ideally suited to this approach. Many thoracolumbar (thoracic-lumbar) and thoracic curves are approached this way. The instrumentation (rods) is implanted along the side of the spine.

The advantages of this surgical approach over posterior approaches include:

  • better correction
  • less blood loss
  • fewer spinal levels fused in many cases.

The anterior approach is often done using scopes and is termed video-assisted thoracoscopic surgery, or abbreviated VATS. Patients are hospitalized for three to six days.

Images of a Standard Anterior Approach

scoliosis, preoperative, standard anterior approach
Before (45°)
scoliosis, postoperative, standard anterior approach
After (0°)
scoliosis, preoperative, standard anterior approach
scoliosis, postoperative, standard anterior approach

Video-assisted Thoracoscopic Surgery (VATS)

This is a technique that applies to thoracic spine surgery. Not every patient with a thoracic curve is a VATS candidate. The procedure requires that one lung be temporarily deflated; some patients, due to anatomical reasons cannot have a lung deflated. Also, some curves do not allow for easy access to the spine using VATS. Of course, there are other reasons why VATS is not an option for some patients.

Small incisions called portals are made in the side of the chest. Scopes, cameras, and video monitoring devices are used by the surgeon to see the spine. These devices help make spine surgery less invasive to the patient while providing equal or better results. There is minimal effect on lung (pulmonary) function with VATS as our own studies and multiple other studies have shown.

After surgery, the small incisions are well hidden by the patient's arm. Scars are much smaller and more cosmetically appealing than standard open procedures.

Images of Video-assisted Thoracoscopic Surgery (VATS)

scoliosis, preoperative, video-assisted thoracoscopic surgery (VATS)
scoliosis, postoperative, video-assisted thoracoscopic surgery (VATS)

Clinical Photos after VATS
This 16-year-old patient is depicted in the preceding x-rays. Please note her body symmetry (left and right-sided balance) and minimal scarring.

scoliosis, postoperative, video-assisted thoracoscopic surgery (VATS), standing
scoliosis, postoperative, video-assisted thoracoscopic surgery (VATS), bending forward

scoliosis, postoperative, video-assisted thoracoscopic surgery (VATS), incisions

Thoracoplasty (Rib Resection)

Patients with scoliosis often have a prominent rib hump. One of the goals of corrective scoliosis surgery is to correct the rib hump.

Thoracoplasty is a surgical procedure that helps to reduce rib hump size. The procedure involves partially removing as many as five ribs. This procedure is usually performed as part of the scoliosis surgery, but it may be performed at a later time. Sometimes a chest tube drain is needed for a day or two after thoracoplasty is performed. Thoracoplasty is less commonly performed today than before because current advances in spinal instrumentation results in improved rotational correction of the deformity.

Osteotomies (Cutting and Removing Bone)

The term osteotomy means cutting into and removing bone. Osteotomies are performed in the front or back of the spine.

In treating scoliosis curves, an osteotomy is used to improve correction of the spinal deformity. Osteotomies are used to treat adults with rigid scoliotic curves, children with large curves causing deformity, flatback correction, and in spinal reconstructions where realignment is needed after a prior spinal fusion.

Images Showing Osteotomies
Osteotomies were performed using thoracoscopy in the anterior (front) spine and then from the back (posterior) in this 35-year-old female patient. The patient had severe and painful kyphosis.

Before surgery 85°
kyphosis treated using osteotomies
After surgery 43°

Hemivertebrae Excision (Removal)

A hemivertebra is a wedge-shaped vertebral body. A normal vertebra is shaped like a rectangle. This abnormality forms before birth and may result in scoliosis or kyphosis as the individual grows.

If scoliosis or kyphosis is progressive, and the patient is off balance, the abnormally shaped vertebra can be surgically removed. The surgical procedure is performed using an anterior-posterior approach or, more commonly today, solely from a posterior approach. The instrumentation (eg, rods, screws) is implanted posteriorly and patients are often braced for several months after surgery.

Images of Hemivertebrae Excision (Removal)
An 11-year-old female with a 49° curve due to a hemivertebra was removed by an anterior-posterior approach straightening the curve to 10°.

hemivertebrae removal (excision), preoperative
hemivertebrae removal (excision), preoperative
hemivertebrae removal (excision), postoperative
hemivertebrae removal (excision), postoperative

Vertebral Column Resection (VCR)

This procedure involves removing one or more complete vertebrae either using an anterior-posterior (front-back) or all posterior (back) approach. In the thoracic (ribbed spine) portions of the ribs, both sides that correspond to the resected areas, are removed.

Essentially, the spinal column is detached, realigned, and connected back together using spinal implants. This type of surgery is reserved for more severe curvatures and carrier greater neurological risk than other procedures. Results are most often extremely gratifying to the patient.

scoliosis, preoperative, vertebral column resection
scoliosis, postoperative, vertebral column resection

patient, postoperative, vertebral column resection, incisions
Surgical incisions

Updated on: 02/23/17
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