Scoliosis requires three dimensional correction at a global level (curve correction) and at a local one (apical axial derotation) as well as sagittal balance management. Except for in situ contouring, previously reported surgical techniques for scoliosis correction hardly deal with all these issues. The aim of the current study was to evaluate long term clinical and radiological outcomes after in situ contouring in 85 patients with severe scoliosis (Cobb= 40 to 110°). Age influence (adults versus adolescents) and surgical approaches (anterior release and posterior correction and fusion versus posterior correction and fusion only) were also assessed. The results of the study show that the in situ contouring is comparable to other surgical techniques in terms of surgery duration and blood loss. Anterior release proved useful in severe scoliosis correction. No difference in peroperative complications was found between age groups nor between approach groups. However, adolescents recover faster than adults. No difference of revision rates in double approach versus posterior approach populations was found. No statistically significant differences were found between the adolescent and adult populations. The mean overall frontal correction reached 68%. The mean loss of correction amounted 5%. No significant evolution was found in sagittal curvatures, emphasizing the difficulties in restoring physiological curvatures in patients with severe scoliosis. Our results suggest the in situ contouring technique is fully appropriate for severe scoliosis correction, regardless of the patient’s age and approach. Besides it will not result in higher morbidity for one specific population and warrants similar outcome when properly applied.

Introduction and Aims: Traditional treatment for adolescent hyperkyphosis, including Scheuermann’s disease, has included apical anterior spine release/fusion (ASF) prior to posterior instrumented fusion. We wished to reassess the need for ASF when using a posterior column shortening technique with a threaded rod compression instrumentation system. Method: PSF-only group: 17 patients, mean age 15.7 years (range 12.8–18.5), underwent posterior column shortening by chevron-shaped lamina resection and fusion using hybrid hook/screw, dual 4.8mm threaded compression rod instrumentation (TRI). A/PSF group: seven patients, mean age 15.4 years (14–16.8), underwent open or endoscopic ASF followed by posterior TRI. Fourteen of 24 patients had strict Sorensen criteria of Scheuermann’s. At mean follow-up of 30 months (range 24–56), patients were assessed for amount and maintenance of correction, sagittal balance, and evidence of pseudoarthrosis. Results: Mean pre-operative measured kyphosis in PSF-only was 79.6 degrees (range 67–90), and was corrected to 38.2 degrees (22–55) post-operative, and 37.1 degrees (22–50, 53%) at final follow-up. In the A/PSF group, pre-operative kyphosis was 79.0 degrees (62–93), corrected to 41.6 degrees (34–48) post-operative, and was 42.6 degrees (25–48, 46%) at final follow-up. There was no difference in the amount of correction (p=.28) or its maintenance between the two groups. Similarly, there were no differences between groups in assessing pre-operative and final T2-12 kyphosis (p=.13), T12-S1 lordosis (p=.98), or C7 sagittal balance (p=.10). The mean T10-L2 sagittal alignment was improved in the PSF-only patients (final kyphosis 7.8°) vs. 18.9° in the A/PSF patients (p=.04). There was a greater correction of Voutsinas’ index (PSF-only=.08, A/PSF=.15, p=.01) for the posterior-only group. No patient lost > eight degrees correction (range 12–8) between immediate post-operative and final follow-up, and no instrumentation complications occurred. Conclusion: Using posterior column shortening and larger diameter (4.8mm) threaded rods with hooks cephalad to the apex and screws caudal, we have found no advantage in correction from preliminary anterior apical release, nor a difference in maintenance of correction. ASF is unnecessary when adolescent hyperkyphosis/Scheuermann’s is treated by this technique

Combined anterior/posterior scoliosis surgery is the mainstay of scoliosis surgery in large curves with Cobb angle more than 65°, in stiff curves that correct to above 40° only on the pre-operative bending films and in Steersman’s kyphosis greater than 90°. The combined anterior/posterior scoliosis surgery allows better correction of the curve, saving motion segments in the spine and eliminating the occurrence of the crankshaft phenomenon. Video-assisted spinal surgery (VATS) and Mini open thoracotomy, thoracoscopically assisted (MOT-TA) allow for the performing of multi level discectomies and soft tissue release, as an anterior adjunct to posterior spine fusion, through minimal approach to the thoracic spine in scoliosis surgery. During the last year we have begun using the MOT-TA for anterior thoracic spine release and fusion, as the first step in releasing, reducing, and fusing large and stiff scoliotic curves, utilizing standard surgical instrumentation and techniques. Materials and Methods: Mini-Thoracotomy Thoracoscopic Assisted was performed on 15 patients, age 4 to 48 (mean 20 years old) between January 2000 to present. There was a female predominance (12:3). In the group, 13 patients were scoliosis patients and 2 were kyphosis patients. All patients underwent anterior release and discectomy before performing posterior fusion. A mean of 4 discs (range 3 to 5 discs) was excised at surgery. The mean Cobb angle was 62°. No anterior instrumentation was placed in the first 14 cases. In case No. 15 an anterior crew-rod construct was placed through the mini thoracotomy incision. Technique: MOT-TA is performed with the patient positioned in a lateral decubitus with the convex side of the scoliotic curve up through a 5–7 cm skin incision above the apical vertebra obliquely from the posterior to the middle axillary line. Results: There was a short learning curve associated with the technique, which proved to be an easy and straight forward surgical technique. Pre-operative thoracic Cobb angle measured 50°–80° (average 62°) that bends to 30°–66° on the pre-operative thoracic bend films (average 45°). The pot-operative thoracic Cobb angle measured 15°–38° (average 28°). The overall curve correction was 59% on average. The anterior soft tissue releases and discectomies were a quick and relatively “dry” part of the surgery. Estimated blood loss ranged 50–800cc, less than a quarter of the total intra-operative blood loss averaging 220cc out of 1227cc of the total EBL. Anterior surgery time ranged 100 to 170 min averaging 147min for mean of 6.1 discs (range 4 to 9 discs). When compared to the total operative time, the anterior part of the surgery took about a 1/3 of the total surgery time. Discussion: The results of the study show that the mini open thoracotomy, thoracoscopically assisted, for anterior thoracic spine release and discectomies is a fast, easy to learn technique with a short learning curve leading to complete anterior release, short operative time, allowing same day front and back surgery with no difficulty in performing internal thoracoplasty that results in structural and cosmetically superior outcome. In the hands of an experienced surgeon, the usage of VATS could be an effective and beneficial in scoliosis surgery; however, in the case of less experienced surgeon, who has no experience in thoracoscopic surgery, the MOT-TA could be an elegant and useful way to perform the technically demanding anterior discectomies and releases in severely deformed and rigid scoliotic spine. In our last case we have demonstrated the ability to instrument the anterior spine utilizing the same mini thoracotomy incision, this advance will be carried further to more extensive instrumentation in the future. In conclusion: Mini open thoracotomy, thoracoscopically assisted, for anterior thoracic spine release and fusion is a faster, easier, cosmetically superior and surgically justified procedure

Objective: Surgical correction of late-onset idiopathic scoliosis (AIS) has been shown to be effective in obtaining correction in the frontal and sagittal planes, but is of questionable benefit in reducing the rib hump in the transverse plane The purpose of this study was to assess the effects of double rod and pedicle screw (AO USS) instrumentation on transverse plane asymmetry (on the convex and concave side of the scoliosis) in a single thoracic curve type (King III). Design: A consecutive, prospectively studied cohort treated by a single surgeon with either a single-stage or two-stage procedure. Subjects: Sixty-five patients with a King III adolescent idiopathic scoliosis were studied. There were 53 females and 12 males whose mean age at surgery was 14.5 years (range 11.1 to 17.9). A single-stage posterior fusion with instrumentation was performed in 46 patients whose mean Cobb angle at surgery was 56° (range 35 to 84). A two-stage procedure with thoracotomy and anterior spine release by multiple disc excisions (mean 6 levels) combined with internal costoplasty (mean 6 ribs), followed one week later by posterior spinal fusion with instrumentation, was performed in 15 patients whose mean Cobb angle was 78° (range 40 to 92). Outcome measures: All patients were assessed both radiographically and by Integrated Shape Imaging System (ISIS) surface topography pre-operatively, postoperatively (mean of 14 weeks) and at follow-up visits for a mean 2.7 years (range 1.5–6.1). Results: There were no non-unions or instrument failures in either group. Single-stage group: Post-operative improvement in the Cobb angle was a mean 54% with a mean 2° loss in correction at final follow-up. ISIS showed the angle of rib hump elevation (convexity side) was improved by a mean of 2.1° and the angle of rib depression (concavity side) was unchanged. At final follow-up the angle of rib hump elevation had recurred by a mean of 3.6° beyond the original pre-operative value. The angle of rib depression remained unchanged. Two-stage group: Post-operative improvement in the Cobb angle was a mean 64% with a mean 1° loss in correction at final follow-up. ISIS showed the angle of rib hump elevation (convexity side) was improved by a mean of 6.2° and the angle of rib depression (concavity side) was improved by a mean of 3.5°, producing a more balanced transverse plane. At final follow-up the angle of rib hump elevation only recurred by a mean 2.2°. This was compensated by a further improvement in the angle of rib depression by a mean of 2.5°, producing a further correction to balance the transverse plane. Conclusions: Single-stage surgery is not effective in improving the transverse plane deformity. Two-stage surgery improves the transverse plane deformity on both the convexity and concavity producing a more balanced spine with further improvement due to an improvement of the rib depression (concave side) during follow-up (growth)