Severe deformity treated by endoscopic release and posterior fusion

History:The patient presented as a 14 year old girl that had been diagnosed with severe scoliosis at age 12. Brace treatment was not an effective option and the spinal curvature increased from over 60 degrees to 105 degrees. The patient also suffered from sickle cell disease and asthma.

Physical Examination:The patient was a cheerful adolescent walking with a normal gait. A severe deformity of the trunk was evident. On forward bend (Adam's test) the trunk asymmetry became even more striking. Lower extremity examination revealed no neurologic deficits.

Radiographic Evaluation:Standing X-rays revealed a thoracic primary right sided scoliotic curvature measuring 105 degrees. A left sided lumbar curvature measured 65 degrees. Bending films revealed some correction of the lumbar curvature but a very rigid thoracic curve that corrected to no more than 85 degrees.

Treatment Options:There are a number of treatment approaches to severe scoliosis. In this particular case, the fact that progression was noted and that curvature exceeded 100 degrees makes non-operative treatment ineffective in controlling further progression. Brace treatment can in some cases be effective in mild and moderate curves but not in severe progressive curves.

If surgical treatment is planned the goals are two-fold. First of all, stopping progression of the scoliotic deformity of the spinal column. Secondly, safe and controlled correction to ensure a balanced and fused spine. In general terms, the surgical options for severe scoliosis include posterior correction alone, anterior correction alone, anterior open spinal release (by thoracotomy) followed by posterior instrumented correction, or anterior endoscopic release and posterior instrumentation. The optimal approach for any particular patient is dependant upon a number of factors and each case must be treated in a very individualized manner.

Discussion:In this particular case it was felt that a posterior approach alone would be Limited in the ability to correct this very rigid deformity. The stiffness in the front of the spine would permit good correction if some form of anterior release is not pursued. An anterior approach alone (without posterior instrumentation) may offer some correction of the thoracic curve but not permit a balanced correction of both the thoracic and lumber curves. Another option is the anterior thoracotomy followed by posterior instrumentation. This approach can offer exposure at the apical levels of the scoliosis yet carries significant morbidity (large incision, post-thoracotomy syndrome). An endoscopic anterior release potentially offers significant advantages: multi-level anterior release is possible as is an endoscopic thoracoplasty (release of ribs and improvement of rib hump deformity), incisions are minimal (less than an inch scar per portal incision). The pain and recovery from anterior endoscopic surgery can be much less significant than with open procedures. This minimally invasive technique requires significant training and experience by the surgical team.

Treatment and Results: After careful review of the options and in depth discussion with the family a decision was made to proceed with an endoscopic anterior release and thoracoplasty/rib resection followed by posterior instrumentation all in one surgery (one anesthesia).

The patient thus had an endoscopic procedure which lasted under 3 hours and involved minimal blood loss. Posterior instrumentation and correction was then performed. A post-operative thoracic scoliosis correction to 40 degrees was obtained (pre-operative curve over 100 degrees).

The patient has obtained a balanced spinal fusion, she has gained some significant height due to her scoliosis correction and an improved appearance of her back.