Thoracoscopic scoliosis surgery – a cheaper option? A cost analysis of 189 consecutive cases

INTRODUCTION: Increasing health care costs, limited resources and increased demand makes cost effective and cost-efficient delivery of Adolescent Idiopathic Scoliosis (AIS) management paramount. Rising implant costs in deformity correction surgery have prompted analysis of whether high implant densities are justified. The objective of this study was to analyse the costs of thoracoscopic scoliosis surgery, comparing initial learning curve costs with those of the established technique and to the costs involved in posterior instrumented fusion from the literature. METHODS: 189 consecutive cases from April 2000 to July 2011 were assessed with a minimum of 2 years follow-up. Information was gathered from a prospective database covering perioperative factors, clinical and radiological outcomes, complications and patient reported outcomes. The patients were divided into three groups to allow comparison; 1. A learning curve cohort, 2. An intermediate cohort and 3. A third cohort of patients, using our established technique. Hospital finance records and implant manufacturer figures were corrected to 2013 costs. A literature review of AIS management costs and implant density in similar curve types was performed. RESULTS: The mean pre-op Cobb angle was 53°(95%CI 0.4) and was corrected postop to mean 22.9°(CI 0.4). The overall complication rate was 20.6%, primarily in the first cohort, with a rate of 5.6% in the third cohort. The average total costs were $46,732, operating room costs of $10,301 (22.0%) and ICU costs of $4620 (9.8%). The mean number of screws placed was 7.1 (CI 0.04) with a single rod used for each case giving average implant costs of $14,004 (29.9%). Comparison of the three groups revealed higher implant costs as the technique evolved to that in use today, from $13,049 in Group 1 to $14577 in Group 3 (P<0.001). Conversely operating room costs reduced from $10,621 in Group 1 to $7573 (P<0.001) in Group 3. ICU stay was reduced from an average of 1.2 to 0 days. In-patient stay was significantly (P=0.006) lower in Groups 2 and 3 (5.4 days) than Group 1 (5.9 days) (i.e. a reduction in cost of approximately $6,140). CONCLUSIONS: The evolution of our thoracoscopic anterior scoliosis correction has resulted in an increase in the number of levels fused and reduction in complication rate. Implant costs have risen as a result, however, there has been a concurrent decrease in those costs generated by operating room use, ICU and in-patient stay with increasing experience. Literature review of equivalent curve types treated posteriorly shows similar perioperative factors but higher implant density, 69-83% compared to the 50% in this study. Thoracoscopic Scoliosis surgery presents a low density, reliable, efficient and effective option for selected curves. A cost analysis of Thoracoscopic Scoliosis Surgery using financial records and a prospectively collected database of all patients since 2000, demonstrating a clear cost advantage compared to equivalent posterior instrumentation and fusion.

Partial intervertebral fusion secures successful outcomes after thoracoscopic anterior scoliosis correction: A low-dose computed tomography study

Study Design Retrospective review of prospectively collected data. Objectives To analyze intervertebral (IV) fusion after thoracoscopic anterior spinal fusion (TASF) and explore the relationship between fusion scores and key clinical variables. Summary of Background Information TASF provides comparable correction with some advantages over posterior approaches but reported mechanical complications, and their relationship to non-union and graft material is unclear. Similarly, the optimal combination of graft type and implant stiffness for effecting successful radiologic union remains undetermined. Methods A subset of patients from a large single-center series who had TASF for progressive scoliosis underwent low-dose computed tomographic scans 2 years after surgery. The IV fusion mass in the disc space was assessed using the 4-point Sucato scale, where 1 indicates <50% and 4 indicates 100% bony fusion of the disc space. The effects of rod diameter, rod material, graft type, fusion level, and mechanical complications on fusion scores were assessed. Results Forty-three patients with right thoracic major curves (mean age 14.9 years) participated in the study. Mean fusion scores for patient subgroups ranged from 1.0 (IV levels with rod fractures) to 2.2 (4.5-mm rod with allograft), with scores tending to decrease with increasing rod size and stiffness. Graft type (autograft vs. allograft) did not affect fusion scores. Fusion scores were highest in the middle levels of the rod construct (mean 2.52), dropping off by 20% to 30% toward the upper and lower extremities of the rod. IV levels where a rod fractured had lower overall mean fusion scores compared to levels without a fracture. Mean total Scoliosis Research Society (SRS) questionnaire scores were 98.9 from a possible total of 120, indicating a good level of patient satisfaction. Conclusions Results suggest that 100% radiologic fusion of the entire disc space is not necessary for successful clinical outcomes following thoracoscopic anterior selective thoracic fusion.

Radiographic outcomes over time after endoscopic anterior scoliosis correction

A prospective, consecutive series of 106 patients receiving endoscopic anterior scoliosis correction. The aim was to analyse changes in radiographic parameters and rib hump in the two years following surgery. Endoscopic anterior scoliosis correction is a level sparing approach, therefore it is important to assess the amount of decompensation which occurs after surgery. All patients received a single anterior rod and vertebral body screws using a standard compression technique. Cleared disc spaces were packed with either mulched femoral head allograft or rib head/iliac crest autograft. Radiographic parameters (major, instrumented, minor Cobb, T5-T12 kyphosis) and rib hump were measured at 2,6,12 and 24 months after surgery. Paired t-tests and Wilcoxon signed ranks tests were used to assess the statistical significant of changes between adjacent time intervals.----- Results: Mean loss of major curve correction from 2 to 24 months after surgery was 4 degrees. Mean loss of rib hump correction was 1.4 degrees. Mean sagittal kyphosis increased from 27 degrees at 2 months to 30.6 degrees at 24 months. Rod fractures and screw-related complications resulted in several degrees less correction than patients without complications, but overall there was no clinically significant decompensation following complications. The study concluded that there are small changes in deformity measures after endoscopic anterior scoliosis surgery, which are statistically significant but not clinically significant.

Computed tomography evaluation of axial vertebral derotation in endoscopic anterior instrumentation for adolescent idiopathic scoliosis

Thoracoscopic instrumented anterior spinal fusion for adolescent idiopathic scoliosis (AIS) has clinical benefits that include reduced pulmonary morbidity, postoperative pain, and improved cosmesis. However, quantitative data on radiological improvement of vertebral rotation using this method is lacking. This study’s objectives were to measure preoperative and postoperative axial vertebral rotational deformity at the curve apex in endoscopically-treated anterior-instrumented scoliosis patients using CT, and assess the relevance of these findings to clinically measured chest wall rib hump deformity correction. This is the first quantitative CT study to confirm that endoscopic anterior instrumented fusion for AIS substantially improves axial vertebral body rotational deformity at the apex of the curve. The margin of correction of 43% compares favourably with historically published figures of 24% for patients with posterior all-hook-rod constructs. CT measurements correlated significantly to the clinical outcome of rib hump deformity correction.

A biomechanical study of top screw pullout in anterior scoliosis correction constructs

Study Design: Biomechanical testing of vertebral body screw pullout resistance with relevance to top screw pullout in endoscopic anterior scoliosis constructs. Objectives: To analyse the effect of screw positioning and angulation on pullout resistance of vertebral body screws, where the pullout takes place along a curved path as occurs in anterior scoliosis constructs. Summary of Background Data: Top screw pullout is a significant clinical problem in endoscopic anterior scoliosis surgery, with rates of up to 18% reported in the literature. Methods: A custom designed biomechanical test rig was used to perform pullout tests of Medtronic anterior vertebral screws where the pullout occurred along an arc of known radius. Using synthetic bone blocks, a range of pullout radii and screw angulations were tested, in order to determine an ‘optimal’ configuration. The optimal configuration was then compared with standard screw positioning using a series of tests on ovine vertebrae (n=29). Results: Screw angulation has a small but significant effect on pullout resistance, with maximum strength being achieved at 10 degree cephalad angulation. Combining 10 degree cephalad angulation with maximal spacing between the top two screws (maximum pullout radius) increased the pullout resistance by 88% compared to ‘standard’ screw positioning (screws inserted perpendicular to rod at mid-body height). Conclusions: The positioning of the top screw in anterior scoliosis constructs can significantly alter its pullout resistance.

Fusionless scoliosis correction using shape memory alloy staples

Severe spinal deformity in young children is a formidable challenge for optimal treatment. Standard interventions for adolescents, such as spinal deformity correction and fusion, may not be appropriate for young patients with considerable growth remaining. Alternative surgical options that provide deformity correction and protect the growth remaining in the spine are needed to treat this group of patients 1, 2. One such method is the use of shape memory alloy staples. We report our experience to date using video-assisted thoracoscopic insertion of shape memory alloy staples. A retrospective review was conducted of 13 patients with scoliosis, aged 7 to 13 years, who underwent video-assisted thoracoscopic insertion of shape memory staples. In our experience, video-assisted thoracoscopic insertion of shape memory alloy staples is a safe procedure with no complications noted. It is a reliable method of providing curve stability, however the follow up results to date indicate that the effectiveness of the procedure is greater in younger patients.

Development of patient-specific computer simulation tools for endoscopic scoliosis surgery

Endoscopic approaches for anterior correction of idiopathic scoliosis are a relatively new surgical technique. This paper describes the development of patient-specific finite element modelling techniques to investigate the biomechanics of single rod anterior scoliosis correction. Spinal geometry is obtained from pre-operative CT scans and material properties for osteo-ligamentous spinal tissues are based on existing literature. The techniques being developed will allow pre-surgical prediction of stresses, forces and deformations in spinal tissues, rods and screws under post-operative physiological loads.

Paediatric spinal deformity research at the Mater Children's Hospital, Brisbane, Australia.

The Paediatric Spine Research group was formed in 2002 to perform high quality research into the prevention and management of spinal deformity, with an emphasis on scoliosis. The group has successfully built collaborative bridges between the scientific and research expertise at QUT, and the clinical skills and experience of the spinal orthopaedic surgeons at the Mater Children’s Hospital in Brisbane. Clinical and biomechanical research is now possible as a result of the development of detailed databases of patients who have innovative and unique surgical interventions for spinal deformity such as thoracoscopic scoliosis correction, thoracoscopic staple insertion for juvenile idiopathic scoliosis and minimally invasive growing rods. The Mater in Brisbane provides these unique datasets of spinal deformity surgery patients, whose procedures are not being performed anywhere else in the Southern Hemisphere. The most detailed is a database of thoracoscopic scoliosis correction surgery which now contains 180 patients with electronic collections of X-Rays, photographs and patient questionnaires. With ethics approval, a subset of these patients has had CT scans, and a further subset have had MRI scans with and without a compressive load to simulate the erect standing position. This database has to date contributed to 17 international refereed journal papers, a further 7 journal papers either under review or in final preparation, 53 national conference presentations and 35 international conference presentations. Major findings from selected journal publications will be presented. It is anticipated that as the surgical databases grow they will continue to provide invaluable clinical data which will feed into clinically relevant projects driven by both medical and engineering researchers whose findings will benefit spinal deformity patients and scientific knowledge worldwide.

What aspects of the scoliosis correction are most important to the teenager who has keyhole scoliosis correction surgery? A prospective series of 100 patients

Introduction. Surgical treatment of scoliosis is assessed in the spine clinic by the surgeon making numerous measurements on X-Rays as well as the rib hump. But it is important to understand which of these measures correlate with self-reported improvements in patients’ quality of life following surgery. The objective of this study was to examine the relationship between patient satisfaction after thoracoscopic (keyhole) anterior scoliosis surgery and standard deformity correction measures using the Scoliosis Research Society (SRS) adolescent questionnaire. Methods. A series of 100 consecutive adolescent idiopathic scoliosis patients received a single anterior rod via a keyhole approach at the Mater Children’s Hospital, Brisbane. Patients completed SRS outcomes questionnaires before surgery and again at 24 months after surgery. Multiple regression and t-tests were used to investigate the relationship between SRS scores and deformity correction achieved after surgery. Results. There were 94 females and 6 males with a mean age of 16.1 years. The mean Cobb angle improved from 52º pre-operatively to 21º for the instrumented levels post-operatively (59% correction) and the mean rib hump improved from 16º to 8º (51% correction). The mean total SRS score for the cohort was 99.4/120 which indicated a high level of satisfaction with the results of their scoliosis surgery. None of the deformity related parameters in the multiple regressions were significant. However, the twenty patients with the smallest Cobb angles after surgery reported significantly higher SRS scores than the twenty patients with the largest Cobb angles after surgery, but there was no difference on the basis of rib hump correction. Discussion. Patients undergoing thoracoscopic (keyhole) anterior scoliosis correction report good SRS scores which are comparable to those in previous studies. We suggest that the absence of any statistically significant difference in SRS scores between patients with and without rod or screw complications is because these complications are not associated with any clinically significant loss of correction in our patient group. The Cobb angle after surgery was the only significant predictor of patient satisfaction when comparing subgroups of patients with the largest and smallest Cobb angles after surgery.

The measurement of applied forces during anterior single rod surgical correction of adolescent idiopathic scoliosis

INTRODUCTION. Following anterior thoracoscopic instrumentation and fusion for the treatment of thoracic AIS, implant related complications have been reported as high as 20.8%. Currently the magnitudes of the forces applied to the spine during anterior scoliosis surgery are unknown. The aim of this study was to measure the segmental compressive forces applied during anterior single rod instrumentation in a series of adolescent idiopathic scoliosis patients. METHODS. A force transducer was designed, constructed and retrofitted to a surgical cable compression tool, routinely used to apply segmental compression during anterior scoliosis correction. Transducer output was continuously logged during the compression of each spinal joint, the output at completion converted to an applied compression force using calibration data. The angle between adjacent vertebral body screws was also measured on intra-operative frontal plane fluoroscope images taken both before and after each joint compression. The difference in angle between the two images was calculated as an estimate for the achieved correction at each spinal joint. RESULTS. Force measurements were obtained for 15 scoliosis patients (Aged 11-19 years) with single thoracic curves (Cobb angles 47˚- 67˚). In total, 95 spinal joints were instrumented. The average force applied for a single joint was 540 N (± 229 N)ranging between 88 N and 1018 N. Experimental error in the force measurement, determined from transducer calibration was ± 43 N. A trend for higher forces applied at joints close to the apex of the scoliosis was observed. The average joint correction angle measured by fluoroscope imaging was 4.8˚ (±2.6˚, range 0˚-12.6˚). CONCLUSION. This study has quantified in-vivo, the intra-operative correction forces applied by the surgeon during anterior single rod instrumentation. This data provides a useful contribution towards an improved understanding of the biomechanics of scoliosis correction. In particular, this data will be used as input for developing patient-specific finite element simulations of scoliosis correction surgery.

Intrapleural analgesia following endoscopic scoliosis correction

Endoscopic (thoracoscopic) scoliosis correction plays an important part in the surgical options available for treating adolescent idiopathic scoliosis. However, there is a paucity of literature examining optimum methods of analgesia following this type of surgery. Intra-pleural analgesia has been successfully used following cardiothoracic procedures [1-3]. The role of intra-pleural analgesia after keyhole anterior selective thoracic scoliosis correction is examined and described.

Intrapleural analgesis following endoscopic scoliosis correction

Endoscopic scoliosis correction plays an important part in the surgical options available for treating adolescent idiopathic scoliosis. However, there is a paucity of literature examining optimum methods of analgesia following this type of surgery. The role of intrapleural analgesia is examined and described. In this study, local anaesthetic administration via an intrapleural catheter was found to be a safe and effective method of analgesia following endoscopic scoliosis correction. Post-operative pain following anterior scoliosis correction can be reduced to ‘mild’ levels by combined analgesia regimes. Surgeons may wish to expand its use into open or minimally invasive anterior scoliosis correction or anterior releases.

Inter-vertebral rotational deformity after endoscopic anterior scoliosis correction may contribute to rib hump recurrence after two years

Introduction. Endoscopic anterior scoliosis correction has been employed recently as a less invasive and level-sparing approach compared with open surgical techniques. We have previously demonstrated that during the two-year post-operative period, there was a mean loss of rib hump correction by 1.4 degrees. The purpose of this study was to determine whether intra- or inter-vertebral rotational deformity during the post-operative period could account for the loss of rib hump correction. Materials and Methods. Ten consecutive patients diagnosed with adolescent idiopathic scoliosis were treated with an endoscopic anterior scoliosis correction. Low-dose computed tomography scans of the instrumented segment were obtained post-operatively at 6 and 24 months following institutional ethical approval and patient consent. Three-dimensional multi-planar reconstruction software (Osirix Imaging Software, Pixmeo, Switzerland) was used to create axial slices of each vertebral level, corrected in both coronal and sagittal planes. Vertebral rotation was measured using Ho’s method for every available superior and inferior endplate at 6 and 24 months. Positive changes in rotation indicate a reduction and improvement in vertebral rotation. Intra-observer variability analysis was performed on a subgroup of images. Results. Mean change in rotation for vertebral endplates between 6 and 24 months post-operatively was -0.26˚ (range -3.5 to 4.9˚) within the fused segment and +1.26˚ (range -7.2 to 15.1˚) for the un-instrumented vertebrae above and below the fusion. Mean change in clinically measured rib hump for the 10 patients was -1.6˚ (range -3 to 0˚). The small change in rotation within the fused segment accounts for only 16.5% of the change in rib hump measured clinically whereas the change in rotation between the un-instrumented vertebrae above and below the construct accounts for 78.8%. There was no clear association between rib hump recurrence and intra- or inter-vertebral rotation in individual patients. Intra-rater variability was ± 3˚. Conclusions. Intra- and inter-vertebral rotation continues post-operatively both within the instrumented and un-instrumented segments of the immature spine. Rotation between the un-instrumented vertebrae above and below the fusion was +1.26˚, suggesting that the un-instrumented vertebrae improved and de-rotated slightly after surgery. This may play a role in rib hump recurrence, however this remains clinically insignificant.

2nd ESMO consensus conference on lung cancer : early-stage non-small-cell lung cancer consensus on diagnosis, treatment and follow-up

To complement the existing treatment guidelines for all tumour types, ESMO organises consensus conferences to focus on specific issues in each type of tumour. The 2nd ESMO Consensus Conference on Lung Cancer was held on 11-12 May 2013 in Lugano. A total of 35 experts met to address several questions on non-small-cell lung cancer (NSCLC) in each of four areas: pathology and molecular biomarkers, first-line/second and further lines in advanced disease, earlystage disease and locally advanced disease. For each question, recommendations were made including reference to the grade of recommendation and level of evidence. This consensus paper focuses on early-stage disease. © The Author 2014. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved.