Nonoperative treatment of symptomatic spondylolysis.

SUMMARY OF BACKGROUND DATA: Symptomatic spondylolysis resulting from a stress fracture of the pars interarticularis is a cause of low back pain in the juvenile and adolescent patient. Treatment is conservative in the majority of cases. OBJECTIVE: To analyze the outcome of patients with symptomatic isthmic spondylolysis treated nonoperatively with a custom fit thoracolumbar orthosis and activity cessation for 3 months followed by an organized physical therapy program. STUDY DESIGN: Retrospective case series. PATIENT SAMPLE: Four hundred thirty-six juvenile and adolescent patients with spondylolysis. OUTCOME MEASURES: Pain improvement, hamstring flexibility, range of motion, resolution of back spasms, and return to previous activities. METHODS: Retrospective review of 436 juvenile and adolescent patients with symptomatic spondylolysis confirmed by single-photon emission computed tomography or computed tomography. Clinical outcomes were assessed through patient history and physical examination. RESULTS: Ninety-five percent of patients achieved excellent results according to a modified Odom's Criteria. The remaining 5% of patients achieved good results as they required occasional nonsteroidal anti-inflammatory drugs to relieve pain. Back spasms were resolved and hamstring tightness and range of motion returned to normal in all patients. All patients returned to their preinjury activity level. No patients went on to surgery. CONCLUSIONS: Symptomatic juvenile and adolescent patients with an isthmus spondylolysis may be effectively managed with a custom fit thoracolumbar orthosis brace and activity cessation for approximately 3 months followed by an organized physical therapy program.

The use of thoracoscopy in the management of adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective case cohort series. OBJECTIVE: To analyze the outcomes of thoracoscopy in the surgical treatment of adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Traditionally, progressive idiopathic scoliosis has been treated surgically with either an open posterior, anterior, or combined surgical approach. Surgical methods are being explored to minimize the extent of soft tissue disruption such as thoracoscopy followed spinal release, bone grafting, and instrumentation. Several authors have reported good results using thoracoscopy in the treatment of spinal deformity following a requisite learning curve. METHODS: A consecutive case cohort series of 45 adolescent patients with idiopathic scoliosis evaluated and treated at a single institution. Patients with a progressive deformity underwent a thoracoscopically assisted curve correction, fusion, and instrumentation procedure. After surgery, patients were assessed at 1, 3, 6, and 12 months and then annually. RESULTS: All patients underwent successful thoracoscopic instrumentation and fusion without the need for an open conversion. The average preoperative thoracolumbar Cobb measurement of the major curve was 51.6 degrees . The thoracolumbar levels instrumented anteriorly ranged from T7 to L3 and had an average postoperative Cobb angle of 6.58 degrees , with an overall improvement of 87.3%. To date, at a mean follow up of 4.6 years, all curves have maintained correction. Sagittal balance was recreated or maintained through the application of interbody femoral ring allografts. Operative times averaged 5 hours and 46 minutes, with a range of 3 hours, 48 minutes to 6 hours, 55 minutes. Hospital stays averaged 2.9 days, with a range of 2 to 7 days. All patients were completely off pain medication before their first postoperative visit at 4 weeks. Children were back to school between 2 and 4 weeks on average. There were a total of 3 complications. One patient experienced transient chest wall numbness, which resolved by 3 months. Two patients developed postoperative mucus plugging in the ventilated lung. CONCLUSION: Endoscopic thoracoscopic spinal deformity correction, fusion, and instrumentation is a safe and feasible method of surgical management of an adolescent patient with progressive scoliosis. The key to successful fusion is a total discectomy and complete endplate removal. This method appears to be comparable to open procedures in terms of curve correction with significantly shorter hospitalization and rehabilitation due to less surgical discomfort. The thoracoscopic correction of adolescent scoliosis warrants continued development and evaluation as a surgical method of scoliosis correction.

Thoracoscopy for correction of adult thoracic scoliosis.

The endoscopic technique of instrumentation, correction, and fusion for scoliosis has undergone radical modifications since the first surgery. Some key factors conducive to successful fusion, such as thorough discectomy and end plate removal, are common to endoscopic and non-endoscopic procedures. There are indeed special technical features in our endoscopic approach that clearly affect outcome, however, and their enumeration rightly chronicles the evolution of our experimental undertaking.

Thoracoscopic techniques for the treatment of scoliosis.

STUDY DESIGN: To determine the effectiveness of an endoscopic option in an anterior approach to the thoracolumbar spine for scoliosis treatment, 50 patients with follow-ups of 24-45 months were studied retrospectively. OBJECTIVE: The objective was to develop a safe, reproducible, and effective endoscopic technique for the treatment of scoliosis that will provide equal or better outcomes compared with formal open surgical techniques. Techniques for endoscopic treatment of spinal disorders have been under development since 1993. The benefits of thoracoscopic surgery in treating spinal deformities have been documented as improved visualization of the spine, enhanced access to the extremes of the curve, decreased operative times and blood loss, shorter hospital stays and recuperative periods, and decreased overall costs. Following more than 150 endoscopic procedures for the treatment of these spinal deformities, the next progression was to develop a thoracoscopic technique of instrumentation, correction, and fusion for primary thoracic scoliosis. The goals are to gain comparable results, fusion rates, and degrees of correction that meet or exceed the current gold standards of an open procedure. METHODS: From October 1996 to October 1998, 50 patients with a diagnosis of primary thoracic scoliosis were selected to undergo a thoracoscopic technique of instrumentation, correction, and fusion. Postoperatively, patients were assessed for restoration of spinal alignment, axial derotation, pain management, and incidence of complications. RESULTS. Successful endoscopic instrumentation occurred in all patients. Curve correction averaged 50.2%, improving to 68.6% in the last ten cases. Patients with hypokyphosis averaged 20.7 degrees of correction. The preoperative axial rotation, based on the scoliometer, averaged 16 degrees , which was corrected to 5 degrees postoperatively. Postoperative pain was less; patients were off all pain medication by 1-3 weeks compared with patients with a formal open procedure requiring pain medication for 6-12 weeks. The hospital stay averaged 2.9 days. Our initial complication rate was high, which can be attributed to the development of a new technique. The keys to successful fusions included total discectomy, complete endplate removal, and autogenous bone graft. CONCLUSIONS: Although still in early development, the initial results of thoracoscopic techniques are promising. With experience, surgical times are decreasing and fusion and curve correction rates are improving. With further evolution, patients should realize shortened hospitalization, decreased rehabilitation times, and decreased levels of postoperative pain. This is a technically demanding procedure and requires demonstrated skills in endoscopic discectomy and fusion.

Anterior endoscopic correction of scoliosis.

Our technique of anterior endoscopic scoliosis correction demonstrates the ability to perform an anterior approach through a minimally invasive technique with minimal disruption of the local biology. The initial results appear to equal curve correction and fusion rates to those of a formal open anterior approach. Additional benefits are: 1) shortened operative time, 2) lower blood loss, 3) shortened rehabilitation time, 4) less pain, and 5) shortened hospital stays. Endoscopic technique shows great promise in the management of scoliosis curves; however, this is a technically demanding procedure that requires cross-training in endoscopic discectomy and scoliosis management as well as familiarity with the anterior approach anatomy.

Thoracoscopic techniques for the treatment of scoliosis: early results in procedure development.

OBJECTIVE: The goal of this study was to determine the effectiveness of an endoscopic option for anterior approaches to the thoracolumbar spine for scoliosis treatment. Fifty patients with 24 to 45 months of follow-up data were retrospectively studied. Techniques for endoscopic treatment of spinal disorders have been under development since 1993. The benefits of thoracoscopic surgery for the treatment of spinal deformities have been documented as improved observation of the spine, enhanced access to the extremes of the curve, decreased operative times and blood losses, shorter hospital stays and recuperative periods, and decreased overall costs. After more than 150 endoscopic procedures for the treatment of these spinal deformities had been performed, the next step was to develop a thoracoscopic technique for instrumentation, correction, and fusion for the treatment of primary thoracic scoliosis. Our goal has been to develop a safe, reproducible, and effective endoscopic technique for the treatment of scoliosis that can provide equal or better outcomes, compared with formal open surgical techniques. METHODS: Between October 1996 and October 1998, 50 patients with a diagnosis of primary thoracic scoliosis were selected to undergo thoracoscopic instrumentation, correction, and fusion. Postoperatively, patients were assessed with respect to restoration of spinal alignment, axial derotation, pain management, and incidence of complications. RESULTS: Endoscopic instrumentation was successfully performed for all patients. Curve correction averaged 50.2%, improving to 68.6% in the last 10 cases. Patients with hypokyphosis averaged 20.7 degrees of correction. The preoperative axial rotation (as measured with a scoliometer) averaged 16 degrees, which was corrected to 5 degrees. Postoperative pain was less, and patients could discontinue the use of all pain medications by 1 to 3 weeks, compared with patients who underwent formal open procedures, who required pain medication for 6 to 12 weeks. The hospital stays averaged 2.9 days. Our initial complication rate was high, which could be attributed to the development of a new technique. Keys to successful fusions include total discectomy, complete endplate removal, and the use of autogenous bone graft. CONCLUSION: Although these techniques are still in early development, the initial results for our thoracoscopic techniques are promising. With experience, surgical times are decreasing and fusion and curve correction rates are improving. With further evolution, patients should realize shortened hospitalizations, decreased rehabilitation times, and decreased levels of postoperative pain. This is a technically demanding procedure that requires demonstrated skills in endoscopic discectomy and fusion.