Posterior Minimally Invasive Surgery for the Treatment of Adolescent Idiopathic Scoliosis
Creators: name: Dayer, Romain Olivier Pierre
Publisher: name: Université de Genève
Year: 2017
Subjects: info:eu-repo/classification/ddc/618
Adolescent idiopathic scoliosis
Surgery
Posterior spinal instrumentation and fusion
Minimally invasive surgery

description: Adolescent idiopathic scoliosis (AIS) represents the most frequent indication for scoliosis surgery at the pediatric age. The current gold standard for the surgical treatment of AIS is spinal instrumentation and fusion through an open approach. Despite reproducible good outcomes, this standard approach necessitates significant soft-tissue disruption and extensive paravertebral muscle detachment. It is consequently associated with long-lasting paravertebral muscle injury and denervation, leading to persistent atrophy and decreased trunk extension muscle strength. Minimally invasive surgery (MIS) techniques have been increasingly used over the last two decades for the treatment of lumbar degenerative disorders and thoracolumbar fractures in the adult patient population. Over the last decade, MIS techniques have also been increasingly reported for the treatment of adult spinal deformity. These less invasive techniques have been shown to be useful tools for the treatment of adult spine deformity, with reduced complication rates when compared with conventional open techniques. But they also appear to be less effective for correction of severe and/or fixed sagittal and/or coronal plane deformities. Adolescent spine deformity is generally considered less rigid than adult, thus theoretically more amenable to standalone MIS techniques. The pediatric spine, because of its inherent flexibility and ability to fuse, is theoretically ideal for MIS. Given the positive results obtained with MIS to treat adult spine pathologies, including deformities, the next logical step is the application of less invasive surgical techniques to the treatment of spine deformity at the pediatric age, and in particular AIS. During the nineties, a first attempt to propose an MIS treatment for AIS has been made with the development of thoracoscopic anterior spinal fusion and instrumentation (TASF) for AIS. This technically demanding procedure, with an acceptable complication rate, including during the learning curve, is however restricted for thoracic curves, and offers similar good or excellent results for these patients when compared to the gold standard (open posterior spine fusion). Due to an expanded degree of correction and reduced risk of instrumentation failure associated with modern posterior technique, most spine surgeons, including the proponents of this technique, have currently converted almost entirely to the open posterior approach for the treatment of thoracic AIS. In order to try to decrease the approach-related morbidity associated with the conventional posterior approach, a MIS technique for posterior spinal fusion, using 3 skin incisions and muscle splitting approach, has been recently proposed for AIS. The limited available data suggest that the use of posterior MIS technique for AIS is associated with deformity correction and complication rates equivalent to open posterior spinal fusion, with potential benefits related to a less traumatizing exposure, with low blood loss and a diminished length of hospital stay. However these encouraging results are obtained at the expense of a prolonged surgical time, which could be related, at least partially, to a learning curve effect. The longer-term safety of this procedure needs to be documented in larger studies with long-term follow-up, before recommending its routine use. The impact of some surgical strategies, like dual attending surgeon to try to lessen operative time, and intraoperative traction to address stiff curves, also needs to be better precised.