Videotape-Assisted Thoracoscopy (VAT) for Anterior Release in Neuromuscular Scoliosis

Videotape-Assisted Thoracoscopy (VAT) for Anterior Release in

Neuromuscular Scoliosis

Thanet Wattanawong

Summary. This study reports the case of a 14-year-old Thai girl with neuro- muscular scoliosis. She received a diagnosis of neuromuscular scoliosis with asymptomatic syringomyelia that can be conservatively treated and closely followed up by the neurosurgeon. The cob angle from T

to T

was 95° and the kyphotic angle was 90°. The first stage was performed by videotape- assisted thoracoscopy (VAT) for anterior release, followed by second-stage posterior derotation and fusion with the pedicle screw technique from T

to T

. The final cob angle was 30°, and the kyphosis angle was 18° with normal sagittal balance without complications, and the hospital stay was 20 days post- operation. VAT for anterior release and second-stage posterior pedicle screw fusion can achieve a good result with a less invasive operation, less blood loss, and less soft tissue destruction. VAT for anterior release in neuromuscular scoliosis is a safe and less invasive technique that achieves a good result.

Key words. Videotape assisted, Thoracoscopic, Anterior release, Anterior decompression, Neuromuscular scoliosis

Introduction

The conventional approach for the severe curve of kyphoscoliosis deformity is open transthoracic anterior release and posterior fusion with instrumen- tation. After 1992, there were many reports of the use of video-tape-assisted thoracoscopy (VAT) for the anterior approach, such as in patients with tho- racic disc [1–6], idiopathic scoliosis [7–9], and fractures [10]. In Thailand in the year 2000 [11], we began to treat severe cases of neuromuscular scoliosis,

Department of Orthopaedics, Ramathibodi Hospital, Mahidol University, Rama 6 Road, Bangkok 10400, Thailand

25

for which anterior instrumentation is too dangerous, with VAT for anterior release and posterior pedicle screw fusion.

Materials and Method

This study reports the case of a 14-year-old Thai girl. She received a diagno- sis of neuromuscular scoliosis with asymptomatic syringomyelia that can be conservatively treated but the problem was thoracic kyphoscoliosis with severe pulmonary restriction. The physical examination (Figs. 1 and 2) found 26 T. Wattanawong

Fig. 1. Posterior view of the patient

Fig. 2. Forward-bending view of the patient

a height of 125 cm, a body weight of 40 kg, pelvic obliquity, a thoracic rib hump on the right of 6 cm, normal neurovascular status, and negative long tract sign.

The cob angle from T

to T

was 95°, and the kyphotic angle was 90° (Figs.

3 and 4). The force bending film X-ray was 95° on the right side bending and 85° on the left side bending. The pulmonary function test showed severe lung restriction. First-stage anterior decompression and discectomy was per- formed at the apex T

and T

with partial vertebrectomy at the T

vertebral body under three portals VAT technique. We recorded the operative time, blood loss, degree of correction of the deformity, trunk balance, neurological status, ambulation time, hospital stay, and complications up to 3 months postoperation.

28 T. Wattanawong

Fig. 3. Preoperative X-ray: thoracic spine AP view

Results

In the first-stage VAT for anterior decompression, the operative time was

240 min with only three portals and three incisions. The length of each inci-

sion was 1.5 cm. The operations were discectomy at T

and T

and partial

excision of the T

vertebral body without rib excision. The amount of bleed-

ing was about 200 ml. Six days later, second-stage posterior fusion was per-

formed with an RSS pedicle screw from T

to T

(Figs. 5 and 6). The operative

time was 100 min; the operative blood loss was 300 ml; the cob angle post-

operation was 30° and the postoperative kyphotic angle was 18°.The patient could

walk without external support 6 days after the second operation. The trunk

Fig. 4. Preoperative X-ray: thoracic spine lateral view

balance postoperation was normal (Figs. 7 and 8). The rib humb was 2.5 cm.

The height increased from 125 to 130 cm. At the third month postoperation, the patient could walk well without support and with no complications.

Discussion

VAT has many advantages when compared with open thoracotomy, such as decreased length of incision [12], blood loss, soft tissue damage, and infec- tion, without limited range of motion of the rib and shoulder joint. The patient has better cosmesis, faster ambulation, a shorter recovery period, and a shorter hospital stay. This patient recovered well after the first-stage thora- 30 T. Wattanawong

Fig. 5. Postoperative X-ray: thoracic spine AP view

coscopic anterior release, without intercostal nerve neuralgia and without

complications. Six days later she underwent the second-stage posterior cor-

rection with a pedicle screw from T

to T

. Finally she could walk without

postoperative external support. The hospital stay was 20 days without any

complications such as hemorrhage, injury to the aorta and large vessels [10],

transient peripheral nerve irritation, plural effusion, and infection. The major

advantage of posterior pedicle screw fusion is the strength of the device,

Fig. 6. Postoperative X-ray: thoracic spine lateral view

32 T. Wattanawong

Fig. 7. Posterior view of the patient postoperation

which allows her to ambulate without postoperative external support. The deformity was well corrected: the cob angle decreased from 95° to 30°

(68.4% correction), and the kyphotic angle decreased from 90° to 18° (80%

correction), with improved trunk balance and cosmesis posture. Long-term

monitoring should be performed for the percentage loss of correction,

pseudarthrosis, implant failure, and other complications.

Conclusions

VAT for anterior decompression and posterior fusion with a pedicle screw is one of the best operations, with less invasive technique, less soft tissue destruction without thoracotomy and rib excision, less postoperative pain, faster ambulation, a shorter hospital stay, fewer complications, and less bleed- ing, even in the surgeon on a learning curve.

Fig. 8. Side view of the patient postoperation

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