Original Thoracic

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Effect of Anterior Thoracoscopic Release Combined with the Posterior Correction Operation on the Pulmonary Function of Patients with Idiopathic Scoliosis Ming Li2

Jia-Yu Chen2,5

1 Department of Orthopedics, The Affiliated Hospital of Xuzhou

Medical College, Xuzhou, Jiangsu Province, China 2 Department of Orthopedics, Changhai Hospital Affiliated to Second Military Medical University, Shanghai, China 3 Department of Orthopedics, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Chongming Branch, Shanghai, China 4 Department of Orthopedics, The Second People’s Hospital of LianYun-Gang, Lian-yun-gang, Jiangsu Province, China 5 Department of Orthopedics, Kunming General Hospital of Chengdu Military Command, Kunming, China 6 Department of Otorhinolaryngology, The Affiliated Hospital of Xuzhou Medical College, Xuzhou, Jiangsu Province, China 7 Department of Orthopedics, Taizhou Municipal Hospital, Taizhou, Zhejiang Province, China

Li-Xin Wang3,4

Yue-Hua Qiao6

Address for correspondence Zhi-wei Wang, MD, Department of Orthopedics, Changhai Hospital Affiliated to Second Military Medical University, Shanghai 200433, China (e-mail: [email protected]).

Thorac Cardiovasc Surg 2015;63:437–442.

Abstract

Keywords

► idiopathic scoliosis ► pulmonary function ► thoracoscopic release operation ► posterior correction operation

received July 15, 2013 accepted after revision October 1, 2013 published online June 27, 2014

Background Anterior thoracoscopic release combined with posterior correction is a common surgery to treat idiopathic scoliosis (IS). However, whether it has detrimental effects on pulmonary function is still unknown. Aim The aim of the study is to evaluate the effect of anterior thoracoscopic release combined with posterior correction on the pulmonary function. Materials and Methods A retrospective study of 28 (12 male, 16 female) patients with IS undergoing anterior thoracoscopic release combined with posterior correction from 2009 to 2011 was performed. The radiographic and pulmonary function evaluations were performed preoperatively and at 24 months postoperatively. Results The average coronal Cobb angle was corrected from 88.36  25.6 degrees to 49.8  11.8 degrees, and average sagittal Cobb angle was corrected from 57.5  17.2 degrees to 26.3  4.7 degrees. The measured forced vital capacity (FVC) and total lung capacity (TLC) were significantly increased at 2 years postoperatively (3.21  1.18 versus 2.47  0.33; 4.32  1.41 versus 3.68  0.36; p < 0.01). However, no significant difference in the FVC% and TLC% was observed. The functional residual capacity percentage was 109.87  14.87 preoperatively and increased to 118.56  34.34 at

© 2015 Georg Thieme Verlag KG Stuttgart · New York

DOI http://dx.doi.org/ 10.1055/s-0033-1361086. ISSN 0171-6425.

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Bo Ran1,2 Quan Li2 Cheng Li1,3,4 Jun-Hui Guan7 Zhi-Wei Wang2

Effect of Anterior Thoracoscopic Release on the Pulmonary Function

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2 years postoperatively (p < 0.05). Both the measured residual volume (RV) and RV% were reduced postoperatively (p < 0.05). The maximum ventilatory volume percentage improved significantly (107.38  39.22 versus 77.46  12.37, p < 0.05). In addition, total airway resistance, inhaled airway resistance, and exhaled airway resistance were all decreased significantly. Conclusion Anterior thoracoscopic release combined with posterior correction has proved to be a safe surgical technique that results in minor pulmonary function impairment.

Introduction Idiopathic scoliosis (IS) is a structural, lateral, rotated curvature of the spine in otherwise healthy children at or around puberty.1 Although benign in the majority of patients, the natural course of the disease may lead to a significant disturbance of body morphology, reduced thoracic volume, impaired respiration, increased rates of back pain, and serious esthetic concerns, which all may seriously affect patients’ quality of life.2,3 Thus, several nonoperative and operative strategies (anterior, posterior, or combined anterior/posterior) are advocated to prevent curve progression, improve the deformity using instrumentation, and ultimately achieve spinal arthrodesis. Commonly, anterior release in combination with posterior spinal fusion is recommended for large (>70-degree Cobb) and stiff curves (less than 50% flexibility).4 The traditional approach for anterior spinal release has been performed by posterolateral open thoracotomy with or without concomitant rib resection.5 Recently, with the advancement of operation technology and endoscopic instruments, anterior thoracoscopic release has become increasingly popular in the treatment of idiopathic scoliosis,6–8 and has been shown to be associated with smaller incisions, less pain, less chest wall disruption and division of the musculature, and potentially less side effects on pulmonary function when compared with thoracotomies.9,10 Sucato et al11 further demonstrate that thoracoscopic release does not adversely affect pulmonary function when added to a posterior spinal fusion for severe spine deformity. However, the follow-up time is short and the pulmonary function index measures only forced expiratory volume in 1 second (FEV1) percentage, forced vital capacity (FVC) percentage, and absolute FEV1, FVC. Thus, it is still important to evaluate the patients’ pulmonary function after anterior thoracoscopic release combined with the posterior correction operation. In this study, we collected 28 patients who had the anterior thoracoscopic release combined with the posterior correction operation to assess the patients’ pulmonary function by measuring the indicators of pulmonary capacity, ventilation function, and thoracic compliance at a minimum 2-year follow-up.

Patients We retrospectively reviewed the medical records from 28 patients with IS undergoing the anterior thoracoscopic Vol. 63

Surgery Strategy All the patients gave their informed consent before inclusion in the study, and all human studies have been approved by China Ethics Committee and performed in accordance with the ethical standards. All the surgeries were performed by the senior author. All patients underwent general anesthesia and were intubated with a double-lumen cuffed endotracheal tube to allow single-lung ventilation. After the lung on the operated side was deflated, portals (usually three or four) were positioned in the midaxillary line or posterior axillary line at the sixth to seventh rib followed by insertion of the thoracoscope lens and correction of fixation segments. Intraoperatively, the intervertebral discs and the upper and lower end plates were excised to release the spine (four to six intervertebral spaces for each side). After the operation, all patients had closed thoracic drainage and the drainage volume was approximately 80 to 561 mL. Posterior correction operations were performed in either one stage (7 patients) or two stages (21 patients, postoperative 1 to 2 weeks) using pedicle screw instrumentation (M8 Multi Axial Screw, Medtronic Sofamor Danek, Memphis, Tennessee, United States). Fusion was performed with autologous bone graft.

Pulmonary Function

Materials and Methods

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release combined with the posterior correction operation according to the indications: moderate to severe scoliosis with the coronal Cobb angles > 70 degrees and flexibility < 30% between 2009 and 2011. Their average age was 16.3 years (range, 12 to 27 years old); there were 12 male and 16 female patients; 2 patients had left scoliosis, and 26 patients had right scoliosis (Lenke I ¼ 13 patients, Lenke II ¼ 15 patients). The scoliosis was diagnosed for an average of 2.4 years (1 to 7 years). The average Cobb angle in the coronal plane was 88.36  25.6 degrees and average sagittal Cobb angle was 57.5  17.2 degrees. The average distance between the two shoulders was 1.6 cm (1.0 to 2.2 cm), and the average razor back height was 2.7 cm (1.2 to 4.9 cm). All these patients showed no special nervous symptoms or special stain on the body surface.

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All patients underwent the pulmonary function examination preoperatively and 2 years after the operation using a portable lung function tester (Metalyzer 3B system, Cortex, Germany). Pulmonary function index included pulmonary

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resistance). Pulmonary function tests were performed with the patients standing; each measurement was repeated three times, and the highest reading was selected. The pulmonary injury extent was expressed by the percentage of the measured value to the predicted value of the

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capacity (FVC, functional residual capacity [FRC], residual volume [RV], and total lung capacity [TLC]), ventilation function (FEV1, FEV1/FEV, and maximum ventilatory volume [MVV]), and thoracic compliance (total airway resistance, inhaled airway resistance, and exhaled airway

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Fig. 1 An 18-year-old woman (Lenke type, 4AN) underwent the thoracoscopy-assisted anterior release operation combined with posterior spinal instrumentation. (A) The gross inspection photo; (B) preoperative anteroposterior standing X-ray; (C) preoperative lateral standing X-ray; (D) preoperative right bending X-ray; (E) preoperative left bending X-ray; (F) preoperative fulcrum bending X-ray; (G) postoperative anteroposterior standing X-ray; (H) postoperative lateral standing X-ray. The average Cobb angle in the coronal plane was significantly corrected from 82 degrees preoperatively to 36 degrees postoperatively, with the correction rate of 56%.

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2.32

0.03

2.55

0.04

4.77

0.01

t

p

1.13  0.38 2.68  0.90 3.21  1.18 2 y after the operation

1.22  0.39 2.86  0.47 2.47  0.33 Before the operation

RV FRC

Scoliosis is a common clinical problem usually manifested as an axial rotation of the vertebrae into the convexity of the

FVC

Discussion

Time

►Tables 1–2 to 3 show the preoperative to postoperative comparison of pulmonary function tests after anterior thoracoscopic release combined with the posterior correction operation. The measured FVC and TLC was significantly increased at 2 years after the operation (3.21  1.18 versus 2.47  0.33, p < 0.01; 4.32  1.41 versus 3.68  0.36, p < 0.01). However, there was no significant difference in the FVC% and TLC% between preoperation and postoperation values (p > 0.05). The FRC was 2.86  0.47 preoperatively and 2.68  0.90 2 years after operation (p < 0.05), but the FRC% increased significantly (118.56  34.34 versus 109.87  14.87, p < 0.05). Both the measured RV and RV% were reduced compared with the preoperative level (p < 0.05; ►Table 1). The FEV1% and FEV1/FEV% did not improve 2 years after the operation (p > 0.05), but the percentage of the measured value to the predicted value of the MVV improved significantly (107.38  39.22 versus 77.46  12.37, p < 0.05; ►Table 2). In addition, the total airway resistance, inhaled airway resistance, and exhaled airway resistance were all decreased significantly at 2 years after the operation (►Table 3).

Measured value

Evaluation of the Pulmonary Function

Abbreviations: FRC, functional residual capacity; FVC, forced vital capacity; RV, residual volume; TLC, total lung capacity.

0.42

93.45  27.11

0.72 0.01

7.78 2.78

0.01 0.63

0.39 5.86

0.00

141.78  34.22

115.45  42.65 118.56  34.34 76.73  23.45 4.32  1.41

TLC

FVC

The average anterior thoracoscopic release operation time was 112 minutes (range, 87 to 143 minutes). The average bleeding volume in the operation was 130 mL (range, 80 to 310 mL). All wounds healed well (stage I union) and no thoracic cavity infection occurred in all these patients. The surgery was successfully completed in all these patients, and the scoliosis deformity was significantly corrected after the operation with the average Cobb angle in the coronal plane corrected from 88.36  25.6 degrees preoperatively to 49.8  11.8 degrees at 2 years postoperatively, and average sagittal Cobb angle corrected from 57.5  17.2 degrees preoperatively to 26.3  4.7 degrees at 2 years postoperatively ( ►Fig. 1). All these patients were followed for an average of 28.3 months (range, 24 to 45 months).

109.87  14.87

General Conditions

76.90  5.31

Results

TLC

All data were analyzed with SPSS13.0 statistical software (SPSS, Inc., Chicago, Illinois, United States) package, and the data were expressed as mean  standard deviation. The postoperative and the preoperative pulmonary function parameters were compared by t test; p < 0.05 was considered statistically significant.

RV

Statistical Analysis

FRC

Percentage of the measured value to the predicted value

pulmonary capacity index and the ventilation function (using the arm span as representative in correction for age and height gain, %). 12

92.80  12.74

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3.68  0.36

Effect of Anterior Thoracoscopic Release on the Pulmonary Function

Table 1 Pulmonary capacity indexes before and after the operation

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Table 2 Ventilation function indexes before and after the operation Time

Measured value

Percentage of the measured value to the predicted value

FEV1 (L)

FEV1/FEV (%)

MVV

FEV1

MVV

Before the operation

2.12  0.67

83.82  7.72

84.39  8.45

76.34  12.58

77.46  12.37

2 y after the operation

2.71  1.29

85.94  6.17

113.30  46.31

78.46  23.69

107.38  39.22

t

1.88

1.32

9.94

1.12

8.78

p

0.08

0.27

0.01

0.35

0.01

Abbreviations: FEV, forced expiratory volume; FEV1, forced expiratory volume in one second; MVV, maximum ventilatory volume.

Time

Total airway resistance

Inhaled airway resistance

Exhaled airway resistance

Before the operation

4.33  0.87

3.45  0.92

4.27  1.31

2 y after the operation

3.35  1.69

2.56  1.20

2.37  1.39

t

2.74

2.91

7.38

p

0.01

0.01

0.00

curve and the spinous processes toward the concavity, which results in an altered alignment of the ribs in the thoracic region and limited rib movements necessary for normal breathing, thus decreasing action of the thorax and affecting the pulmonary function.13,14 In addition, as the rib cage becomes more deformed with scoliosis, the lungs, the heart, and the mediastinal structures are markedly displaced, altering the cardiac output and the pulmonary reserve.13,14 Although most of the patients with IS do not present pulmonary dysfunction in their daily life because of compensation mechanism, the pulmonary function index shows a decrease during the respiration function examination.15,16 Thus, it is important to correct the scoliosis and improve the pulmonary function. Although several studies have investigated the effect of anterior thoracoscopic release combined with the posterior correction approach on scoliosis Cobb angle correction and pulmonary function, the conclusions are controversial. For example, Gitelman et al17 found that the average thoracic Cobb correction was 27 degrees (61%) in the anterior release followed by posterior spinal fusion, but 36 degrees (52%) in the open thoracotomy followed by posterior spinal fusion group. The pulmonary function test parameters, FVC and FEV1, were statistically improved at 2 years postoperative versus preoperative in two groups, although no significant difference was observed between them. However, Faro et al18 found that the thoracoscopic group had a significantly smaller decline in FVC than the thoracotomy group at 3 months after surgery; the thoracoscopic group had recovered at 1 year after surgery, and FVC remained reduced in the open group. The decline in FEV1 from before surgery to 3 months after surgery was similar between the two groups; however, by 1 year after surgery, the thoracoscopic group showed greater recovery of pulmonary flow than the thoracotomy group.18 Maximal recovery of FVC,

FEV1%, and FVC% for the anterior and video-assisted thoracoscopic release group was equivalent to the posterior spinal fusion group but lower than anterior thoracoscopic release combined with posterior spinal fusion.19 As expected, in our research, we also found that the measured FVC was significantly improved after 2 years. Although there were no statistical differences in the FEV1 and FEV1/FEV preoperatively and postoperatively, the improved FVC and TLC and decreased FRC may promote breathing movement and respiratory rate followed by marked improvement in MVV and pulmonary function, which was first demonstrated in our study. In conclusion, our results show that although the thoracoscopic operation may open the thorax and damage the paraspinal tissue, the damage is minimal, resulting in small pulmonary function impairment. The pulmonary function index reaches and even exceeds the preoperative index 2 years after the operation, which was in accordance with a previous study.19 Thus, the anterior thoracoscopic release combined with the posterior correction operation may be suitable for patients with poor physical status, serious pulmonary function injury, stiff spinal deformity, and a demand for anterior release operation. However, there are still some limitations in this study. As our study evaluated only the effect of anterior thoracoscopic release combined with the posterior correction operation on pulmonary function at preoperatively and 2 years postsurgery, it is unknown how the patient’s pulmonary functions were at intermediary points following the surgery10; it is reported that there is a high percentage of combined pectus excavatum in IS.20 Patients have a much higher likelihood of decreased pulmonary function when the pectus excavatum is surgically repaired.21 However, no patients with pectus excavatum were included in our study. The sample size is small; therefore, further study is still needed. Thoracic and Cardiovascular Surgeon

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Table 3 Thoracic compliance before and after the operation

Effect of Anterior Thoracoscopic Release on the Pulmonary Function References 1 Weinstein SL, Dolan LA, Cheng JC, Danielsson A, Morcuende JA.

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Adolescent idiopathic scoliosis. Lancet 2008;371(9623): 1527–1537 Kotwicki T, Chowanska J, Kinel E, Czaprowski D, Tomaszewski M, Janusz P. Optimal management of idiopathic scoliosis in adolescence. Adolesc Health Med Ther 2013;4:59–73 Pellegrino LA, Avanzi O. Prospective evaluation of quality of life in adolescent idiopathic scoliosis before and after surgery. J Spinal Disord Tech 2012. http://www.ncbi.nlm.nih.gov/pubmed/23096129 [Epub ahead of print] Lenke LG, Betz RR, Harms J, et al. Adolescent idiopathic scoliosis: a new classification to determine extent of spinal arthrodesis. J Bone Joint Surg Am 2001;83-A(8):1169–1181 Graham EJ, Lenke LG, Lowe TG, et al. Prospective pulmonary function evaluation following open thoracotomy for anterior spinal fusion in adolescent idiopathic scoliosis. Spine 2000; 25(18):2319–2325 Karami M, Ilharreborde B, Morel E, Fitoussi F, Penneçot G-F, Mazda K. Video-assisted thoracoscopic surgery (VATS) for the treatment of scoliotic rib hump deformity. Eur Spine J 2007;16(9):1373–1377 Niemeyer T, Freeman BJ, Grevitt MP, Webb JK. Anterior thoracoscopic surgery followed by posterior instrumentation and fusion in spinal deformity. Eur Spine J 2000;9(6):499–504 Huang EY, Acosta JM, Gardocki RJ, et al. Thoracoscopic anterior spinal release and fusion: evolution of a faster, improved approach. J Pediatr Surg 2002;37(12):1732–1735 Kishan S, Bastrom T, Betz RR, et al. Thoracoscopic scoliosis surgery affects pulmonary function less than thoracotomy at 2 years postsurgery. Spine 2007;32(4):453–458 Lenke LG, Newton PO, Marks MC, et al. Prospective pulmonary function comparison of open versus endoscopic anterior fusion combined with posterior fusion in adolescent idiopathic scoliosis. Spine 2004;29(18):2055–2060 Sucato DJ, Erken YH, Davis S, Gist T, McClung A, Rathjen KE. Prone thoracoscopic release does not adversely affect pulmonary func-

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tion when added to a posterior spinal fusion for severe spine deformity. Spine 2009;34(8):771–778 Forster RE, DuBois A, Briscoe W, Fisher A. The Lung: Physiologic Basis of Pulmonary Function Tests. 3rd ed. Chicago, IL: Year Book Medical Publishers; 1986 Thulbourne T, Gillespie R. The rib hump in idiopathic scoliosis. Measurement, analysis and response to treatment. J Bone Joint Surg Br 1976;58(1):64–71 Lenke LG, Dobbs MB. Management of juvenile idiopathic scoliosis. J Bone Joint Surg Am 2007;89(Suppl 1):55–63 Gitelman Y, Lenke LG, Bridwell KH, Auerbach JD, Sides BA. Pulmonary function in adolescent idiopathic scoliosis relative to the surgical procedure: a 10-year follow-up analysis. Spine 2011; 36(20):1665–1672 Johnston CE, Richards BS, Sucato DJ, Bridwell KH, Lenke LG, Erickson M; Spinal Deformity Study Group. Correlation of preoperative deformity magnitude and pulmonary function tests in adolescent idiopathic scoliosis. Spine 2011;36(14):1096–1102 Gitelman Y, Lenke LG, Bridwell KH, Auerbach JD, Sides BA. Pulmonary function in adolescent idiopathic scoliosis relative to the surgical procedure: a 10-year follow-up analysis. (Phila Pa 1976). Spine 2011;36(20):1665–1672 Faro FD, Marks MC, Newton PO, Blanke K, Lenke LG. Perioperative changes in pulmonary function after anterior scoliosis instrumentation: thoracoscopic versus open approaches. Spine 2005;30(9): 1058–1063 Verma K, Lonner BS, Kean KE, Dean LE, Valdevit A. Maximal pulmonary recovery after spinal fusion for adolescent idiopathic scoliosis: how do anterior approaches compare? Spine 2011; 36(14):1086–1095 Berdan E, Saltzman D. The thoracic relationship: does pectus excavatum occur at a higher rate in patients with adolescent idiopathic scoliosis? J Surg Res 2013;179(2):343–343 Lawson ML, Mellins RB, Paulson JF, et al. Increasing severity of pectus excavatum is associated with reduced pulmonary function. J Pediatr 2011;159(2):256–261, e2

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442

Effect of Anterior Thoracoscopic Release Combined with the Posterior Correction Operation on the Pulmonary Function of Patients with Idiopathic Scoliosis.

Anterior thoracoscopic release combined with posterior correction is a common surgery to treat idiopathic scoliosis (IS). However, whether it has detr...
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