Minimally invasive scoliosis surgery: an innovative technique in patients with adolescent idiopathic scoliosis

Minimally invasive spine surgery is becoming more common in the treatment of adult lumbar degenerative disorders. Minimally invasive techniques have been utilized for multilevel pathology, including adult lumbar degenerative scoliosis. The next logical step is to apply minimally invasive surgical techniques to the treatment of adolescent idiopathic scoliosis (AIS). However, there are significant technical challenges of performing minimally invasive surgery on this patient population. For more than two years, we have been utilizing minimally invasive spine surgery techniques in patients with adolescent idiopathic scoliosis. We have developed the present technique to allow for utilization of all standard reduction maneuvers through three small midline skin incisions. Our technique allows easy passage of contoured rods, placement of pedicle screws without image guidance, and allows adequate facet osteotomy to enable fusion. There are multiple potential advantages of this technique, including: less blood loss, shorter hospital stay, earlier mobilization, and relatively less pain and need for pain medication. The operative time needed to complete this surgery is longer. We feel that a minimally invasive approach, although technically challenging, is a feasible option in patients with adolescent idiopathic scoliosis. Although there are multiple perceived benefits, long term data is needed before it can be recommended for routine use

Minimally Invasive Scoliosis Surgery: A Novel Technique in Patients with Neuromuscular Scoliosis

Minimally invasive surgery (MIS) has been described in the treatment of adolescent idiopathic scoliosis (AIS) and adult scoliosis. The advantages of this approach include less blood loss, shorter hospital stay, earlier mobilization, less tissue disruption, and relatively less pain. However, despite these significant benefits, MIS approach has not been reported in neuromuscular scoliosis patients. This is possibly due to concerns with longer surgery time, which is further increased due to more levels fused and instrumented, challenges of pelvic fixation, size and number of incisions, and prolonged anesthesia. We modified the MIS approach utilized in our AIS patients to be implemented in our neuromuscular patients. Our technique allows easy passage of contoured rods, placement of pedicle screws without image guidance, partial/complete facet resection, and all standard reduction maneuvers. Operative time needed to complete this surgery is comparable to the standard procedure and the majority of our patients have been extubated at the end of procedure, spending 1 day in the PICU and 5-6 days in the hospital. We feel that MIS is not only a feasible but also a superior option in patients with neuromuscular scoliosis. Long-term results are unavailable; however, short-term results have shown multiple benefits of this approach and fewer limitations

Paraspinal muscle approach for neuromuscular scoliosis: A comparative study evaluating deformity correction and perioperative morbidity in 91 patients with minimum 2-year follow-up

Purpose: We present the paraspinal approach use for neuromuscular scoliosis with focus on deformity correction, perioperative (≤30 days) morbidity and outcome at a minimal follow-up length of 2 years. Methods: We prospectively collected data of 61 neuromuscular scoliosis patients operated using a paraspinal (Wiltse) approach between 2013 and 2019. We additionally collected data of 104 control cases, operated using a midline approach between 2005 and 2016. Fifteen Wiltse, respectively 37 control patients were excluded due to a short follow-up (&lt;2 years), and 22 controls were excluded secondary to lacking follow-up data. Hence, 46 Wiltse and 45 control patients were compared. Results: Wiltse and control patients had comparable follow-up lengths, demographics, deformity corrections, complication rates, number of levels fused, and intensive care unit and hospital lengths of stay. Wiltse cases had a lower estimated blood loss (535 vs 1187 mL; p-value &lt; 0.001), allogenic transfusion rate (48% vs 96%; p-value &lt; 0.001), and operating time (ORT) (337 vs 428 min; p-value &lt; 0.001) than controls. This was also the case when selecting for patients without pelvic fixation (p-values &lt; 0.001). When selecting the cases with pelvic fixation (20 among 91 cases), only the number of levels fused and the ORT differed significantly according to the approach (p-value &lt;0.015 and &lt;0.041). Conclusion: The paraspinal approach for neuromuscular scoliosis is safe, associated with significant deformity correction, reduced estimated blood loss, and allogenic transfusion rate. These potential benefits still need to be evaluated, especially for cases with pelvic fixation, with further follow-up of larger cohorts. Level of evidence: level III.</p

Minimally Invasive Surgery for Adolescent Idiopathic Scoliosis: Anterior and Posterior Techniques

Purpose: Surgical gold standard for adolescent idiopathic scoliosis (AIS) is open posterior spinal instrumentation and fusion. This approach causes significant soft tissue disruption and paravertebral muscle detachment. This review attempts to provide an overview of the current state of knowledge of minimally invasive (MIS) surgery for AIS. Methods: The results of MIS for adult scoliosis are briefly reviewed as the rationale for its application to AIS. A review of the two currently available MIS techniques for AIS is then given, including indications, surgical technique, and results in the literature. Results: Thoracoscopic anterior spinal fusion and instrumentation (TASF) offers similar results and complication rates with decreased blood loss but is technically demanding and has limited indications. The posterior MIS technique seems to offer similar results and complication rates, decreased blood loss and shorter length of hospital stay, at the expense of a longer operative time. Conclusion: Both TASF and posterior MIS are valid alternatives to the gold standard. They have proven similar results and short-term safety to open posterior fusion, with the added theoretical advantage of a less traumatizing exposure and improved cosmesis. While TASF has fallen out of favor due to its technical challenges, specific instrumentation and limited indications, posterior MIS does not suffer from these drawbacks. The limited amount of literature on this technique warrants studies with further follow-up, demonstrating its long-term safety before recommending its routine use.

Navigated versus conventional pediatric spinal deformity surgery: Navigation independently predicts reoperation and infectious complications

Context: Literature on treating pediatric spinal deformity with navigation is limited, particularly using large nationally represented cohorts. Further, the comparison of single-institution data to national-level database outcomes is also lacking. Aim: (1) To compare navigated versus conventional posterior pediatric deformity surgery based on 30-day outcomes and perioperative factors using the National Surgical Quality Improvement Program (NSQIP) database and (2) to compare the outcomes of the NSQIP navigated group to those of fluoroscopy-only and navigated cases from a single-institution. Settings and Design: Retrospective cohort study. Subjects and Methods: Pediatric patients who underwent posterior deformity surgery with and without navigation were included. Primary outcomes were 30-day readmission, reoperation, morbidity, and complications. The second part of this study included AIS patients < 18 years old at a single institution between 2015 and 2019. Operative time, length of stay, transfusion rate, and complication rate were compared between single-institution and NSQIP groups. Statistical Analysis Used: Univariate analyses with independent t-test and Chi-square or Fisher's exact test was used. Multivariate analyses through the application of binary logistic regression models. Results: Part I of the study included 16,950 patients, with navigation utilized in 356 patients (2.1%). In multivariate analysis, navigation predicted reoperation, deep wound infection, and sepsis. After controlling for operative year, navigation no longer predicted reoperation. In Part II of the study, 288 single institution AIS patients were matched to 326 navigation patients from the NSQIP database. Operative time and transfusion rate were significantly higher for the NSQIP group. Conclusions: On a national scale, navigation predicted increased odds of reoperation and infectious-related events and yielded greater median relative value units (RVUs) per case but had longer operating room (OR) time and fewer RVUs-per-minute. After controlling for operative year, RVUs-per-minute and reoperation rates were similar between groups. The NSQIP navigated surgery group was associated with significantly higher operative time and transfusion rates compared to the single-institution groups

Minimally Invasive Versus Standard Surgery in Idiopathic Scoliosis Patients: A Comparative Study

Study design: Retrospective review of prospective case-control study. Objective: To compare minimally invasive scoliosis surgery (MIS) and posterior spinal fusion (PSF) in a large group of patients. Summary of background data: MIS, has been shown to have benefits over standard PSF in adolescent idiopathic scoliosis (AIS). Methods: Radiographic, clinical, and operative review of a multi-institutional prospective database from 2013 to 2018. MIS patients with minimum 2-year XR follow up were compared with open PSF technique patients. Results: Four hundred eighty five patients were included; 192 MIS and 293 PSF. Preoperative Cobb (P = 0.231) and kyphosis were similar (P = 0.501). Cobb correction was comparable (P = 0.46), however percent improvement in thoracic kyphosis was significantly higher in MIS (P &lt; 0.001). MIS had significantly lower blood loss (P &lt; 0.001), transfusions (P &lt; 0.001), fixation points (P &lt; 0.001), opioid consumption (P = 0.001), and hospital stay (P &lt; 0.001). Operative time was shorter (P = 0.001) and 30-day complications rate was similar (P = 0.81). Conclusion: This is the largest study comparing the surgical outcomes of MIS and PSF. MIS patients benefit from increased kyphosis, fewer transfusion, lower opioid consumption, and shorter hospital stay with similar Cobb correction. Increased postoperative kyphosis is likely from muscle sparing dissection in MIS.Level of Evidence: 3.</p