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Minimally Invasive, Endoscopic, Internal Thoracoplasty for the
Treatment of Scoliotic Rib Hump Deformity
Praveen V. Mummaneni, M.D,*, Rick C. Sasso, M.D.**
*Department of Neurosurgery/The NeuroSpine Institute
Emory University
Atlanta, Georgia
**Indiana Spine Group
Indianapolis, IN
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Corresponding Author:
Praveen V. Mummaneni, M.D.
C/o Sherry A. Ballenger, Editor
Department of Neurosurgery, Emory University
1365B Clifton Road, NE, Ste. 2100
Atlanta, GA 30322
sherry_ballenger@emoryhealthcare.org
phone: 404-778-3183
fax: 404-778-2210
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Abstract
Object. Patients with idiopathic scoliosis often have a noticeable rib deformity that often persists
following corrective surgery. Open thoracoplasty has been the traditional method of reducing rib
deformity. Recently, however, video-assisted thoracoscopy (VATS) has been used to perform
thoracoplasty. There have been no long term follow-up studies on VATS thoracoplasty nor have
there been outcome scores to assess the results of thoracoplasty procedures. We present our
experience using VATS thoracoplasty with long-term follow-up and propose an outcome grading
system for thoracoplasty.
Methods. Between 1998 and 2000, four patients (ranging in age from 14 to 53 years) underwent
VATS thoracoplasty for significant rib hump deformity (mean 5 cm, range 4 to 6 cm of rib
deformity height) associated with idiopathic scoliosis. All patients had four rib segments
resected during the VATS thoracoplasty procedure. Three of the four patients also underwent
anterior thoracic release and discectomy during the procedure.
Results. Patients were followed for a mean of 40 months after surgery (range 33 to 50 mo).
There were no intraoperative or postoperative complications. All patients were pleased that they
had chosen to have VATS internal thoracoplasty. Outcomes were assessed by patient
questionnaire with our new thoracoplasty grading system. Two patients had an excellent
outcome, and two patients had a good outcome by our new grading system.
Conclusion. VATS provides an alternative, minimally invasive route to perform thoracoplasty.
VATS incisions are much smaller and more cosmetically appealing than open thoracoplasty
incisions. Long-term follow-up indicates good to excellent patient outcomes.
KEYWORDS: Scoliosis, Thoracoplasty, Minimally Invasive Surgery
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Introduction
Patients with idiopathic scoliosis often have accompanying rib deformities on the convex side of
their curves. These rib deformities may continue to pose cosmetic problems even after surgical
correction of the scoliotic curve (1,3,4,5,9,11,14,16). In addition, large rib deformities may
prevent patients from being able to sit comfortably in a hard backed chair.
Surgical correction of scoliotic rib hump deformities has been performed for over 100 years. In
1888, Volkmann was the first to attempt to correct a scoliotic rib hump deformity by performing
a thoracoplasty (removal of multiple ribs) (13). For a century after Volkmann, surgeons
performed thoracoplasties via an open posterior procedure through the same incision used for
posterior spine fusions or through a separate posterolateral skin incision (6,10,12,17). Over the
past decade, however, internal thoracoplasty (performed during a thoracotomy for anterior spinal
release) has gained popularity. In the past five years, a few authors have used video assisted
thoracoscopy (VATS) successfully to perform a more minimally invasive thoracoplasty (2,7).
We present our experience using this technique including long-term follow up of our patients.
There have been no published grading scales to evaluate the effectiveness of a thoracoplasty.
Since the procedure is often done for cosmetic reasons, patient satisfaction is very important in
evaluation of the outcome. We offer a new grading scale to measure the success of the
procedure.
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Methods
Technique
Prior to surgery, the patient’s chest x-ray is examined to count the number of ribs and decide
which ribs should be partially removed to reduce the rib hump.
Following intubation with a double lumen tube, the patient is positioned in the lateral decubitus
position with the rib hump side up. Single lumen ventilation is undertaken. Three ports are
established for the VATS (two working channel ports and one port for the thoracoscope) (FIG.
1). A fan retractor is used to mobilize the non-ventilated lung to allow access to the portion of
the ribs to be removed.
An anterior release is performed first in cases where it is planned (8). The anterior longitudinal
ligament and disc spaces are incised to decrease the rigidity of the spine and to allow for a
subsequent posterior correction of the scoliotic curvature.
Subsequently, the ribs to be removed are localized by rib counting via the thoracoscope and by
feeling the rib hump posteriorly. Intraoperative chest x-ray may also be used to confirm the
correct ribs for removal. (FIG. 2)
Rib dissection is then performed. Once the ribs are identified, a monopolar cautery is used to
expose the portion of each rib to be removed (from rib head to 4 cm lateral). A curved elevator
is then utilized to dissect the soft tissues from the ribs to be removed. We take care to avoid the
intercostal neurovascular bundle during this maneuver. (FIGS. 3A-3D)
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After rib dissection is complete, the rib head is disarticulated from the transverse process and
disc space and the rib is cut 4 cm lateral to the rib head with a rib cutter. The rib is then removed
with a grasping instrument through one of the working portals. This procedure is then repeated
for subsequent ribs. We avoid removing more than four short rib segments in order to avoid
decreasing pulmonary function and to avoid a flail chest (7,15).
Following the partial rib resections, we manually palpate the rib deformity posteriorly to ensure
that the deformity has been reduced. We then place a chest tube through one of the portals and
close the incisions in a standard fashion while the lung is re-inflated. We utilize the resected rib
segments for autograft bone (used either anteriorly by packing them into the disc spaces or for
the subsequent posterior fusion procedure).
Patients 1-4
Between 1998 and 2000, four female patients (ranging in age from 14 to 53 yrs.) with idiopathic
scoliosis underwent VATS thoracoplasty performed by a single surgeon (R.S.) for significant rib
hump deformity. All patients had right midthoracic curves (mean 55 degree curvature, range 45
to 66 degrees). Two of the patients had prior attempts at correction of their scoliosis that did not
adequately treat their rib deformities (Patients 1 and 3, see Table 1). The mean height of the rib
hump deformities in these patients was 5 cm (range 4 to 6 cm).
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All patients had four rib segments resected during the VATS thoracoplasty procedure. Three of
the four patients (patients 2, 3, 4 in Table 1) also underwent anterior thoracic release and
discectomy during the procedure.
Results
All patients underwent VATS thoracoplasty without intraoperative or postoperative
complications. Patients were followed for a mean of 40 months after surgery (range 33 to 50
mo). Since no previous outcome measures have evaluated thoracoplasties, we developed our
own grading scale to assess the success of the procedure.
Outcomes were assessed by patient questionnaire with the Mummaneni/Sasso criteria (Table 2).
Two patients had an excellent outcome, and two patients had a good outcome by the
Mummaneni/Sasso criteria. All patients reported that they were pleased with the results of the
procedure.
Discussion
Endoscopic thoracoplasty offers several potential advantages over traditional open techniques,
including decreased blood loss, decreased surgical morbidity to shoulder and chest wall
musculature, and more precise localization of the ribs to be addressed. It also serves as a natural
companion procedure to anterior release and interbody fusion. Endoscopic thoracoplasty as an
isolated procedure followed by posterior spinal fusion deserves further consideration. The
concept of endoscopic thoracoplasty for residual unacceptable rib hump after satisfactory
correction of scoliosis would appear to offer both physiologic as well as cosmetic advantages
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over conventional thoracoplasty techniques. (FIG. 4) One major potential complication seen
with open thoracoplasty is increasing pleural effusion from soft-tissue elevation, which has not
been experienced by our patients. With the inclusion of anterior release, discectomy, bone
grafting, and costoplasty, we believe that VATS offers all the advantages of thoracotomy except
for the ability to implant corrective instrumentation.
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References
1. Barrett DS, MacLean JGB, Bethany J, Ransford AO, Edgar MA: Costoplasty in adolescent
idiopathic scoliosis: objective results in 55 patients. J Bone Joint Surg Br 75:881–5, 1993.
2. Crawford AH, Wolf RK, Wall EJ. Pediatric spinal deformity. In: Regan JJ, McAfee PC,
Mack MJ (eds). Atlas of Endoscopic Spine Surgery. St. Louis, Quality Medical Publishing,
1995, pp 215-25.
3. Flinchum D: Rib resection in the treatment of scoliosis. South Med J 56:1378-80, 1963.
4. Geissele AE, Ogilvie JW, Cohen M, Bradford DS: Thoracoplasty for the treatment of rib
prominence in thoracic scoliosis. Spine 19:1636–42, 1994.
5. Harvey CJ, Betz RR, Clements DH, Huss GK, Clancy M: Are there indications for partial rib
resection in patients with adolescent idiopathic scoliosis treated with Cotrel-Dubousset
instrumentation? Spine 18:1593-8, 1993.
6. Lenke LG, Bridwell KH, Blanke K, Baldus C: Analysis of pulmonary function and chest
cage dimension changes after thoracoplasty in idiopathic scoliosis. Spine 20(12):1343-1350,
1995.
7. Mehlman CT, Crawford AH, Wolf RK: Endoscopic thoracoplasty technique. Spine 22:21782182, 1997.
8. Numberg SM, Crawford AH: Video-assisted thoracoscopic releases of scoliotic anterior
spines. AORN 63:561-79, 1996.
9. Shufflebarger HL, Smiley K, Roth HJ: Internal thoracoplasty: A new procedure. Spine
19:840-2, 1994.
10. Steele HH: Rib resection and spine fusion in correction of convex deformity in scoliosis. J
Bone Joint Surg 65-A:920-5, 1983.
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11. Thulbourne T, Gillespie R: The rib hump in idiopathic scoliosis: Measurement, analysis, and
response to treatment. J Bone Joint Surg 58-B:64-71, 1976.
12. Torto UD: Rib resection with Marino-Zuco-Harrington instrumentation. Clin Orthop Rel
Res 65:191-4, 1969.
13. Volkmann R: Resektion von Rippenstuker bei Skoliose. Berliner klin Wochenschr
26:1097-8, 1989.
14. Weatherley CR, Draycott V, O'Brien JF, Benson DR, Gopalakrishnan KC, Evans JH,
O’Brien JP: The rib deformity in adolescent idiopathic scoliosis. J Bone Joint Surg 69B:179-82, 1987.
15. Winter RB: Flail chest secondary to excessive rib resection in idiopathic scoliosis. Case
report. Spine 27:668-670, 2002
16. Winter RB, Hall HE: Kyphosis in childhood and adolescence. Spine 3:285–308, 1978.
17. Winter RB, Lonstein JE, Denis F. Technique of thoracoplasty. In: Atlas of Spine Surgery.
Philadelphia, Saunders, 1995, pp 538–47.
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Table 1
Patient
Age
(yrs.)
1
49
2
Symptoms
Hump
Size
Levels of
Thoracoplasty
Followup
Mummaneni/
Sasso Rating
Difficulty sitting &
cosmetic deformity
6cm
T5-8 rt
43 mo
good
53
Cosmetic deformity
4cm
T7-10 rt
50 mo
excellent
3
14
Cosmetic deformity
6cm
T6-9 rt
33 mo
good
4
28
Cosmetic deformity
4cm
T7-10 rt
33mo
excellent
Table 2: Mummaneni/Sasso Scores for Results of Thoracoplasty
Score
Excellent
Description
Rib hump absent, patient fully satisfied with cosmetic result of VATS thoracoplasty.
Minimal or no postoperative chest wall pain in area of rib removal (on NSAIDS only).
Good
Mild residual rib hump, patient satisfied with cosmetic result. Mild postoperative chest
wall pain in area of rib removal (requires occasional narcotics).
Fair
Rib hump diminished but still noticeable, patient equivocal about cosmetic results.
Moderate postoperative chest wall pain in area of rib removal (requires daily narcotics).
Poor
No change in rib hump, patient unsatisfied. Significant postoperative chest wall pain in
area of rib removal.
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Figure Legends
Fig 1. Illustration of scoliotic rib hump deformity.
Fig 2. Illustration of the three ports utilized for the video assisted thoracoscopy (two working
channel ports and one port for the thoracoscope).
Fig. 3A. The ribs to be removed are localized by rib counting via the thoracoscope.
Fig. 3B. Once the ribs are identified, a monopolar cautery is used to expose the portion of each
rib to be removed (from rib head to 4 cm lateral).
Fig. 3C. A curved elevator is then utilized to dissect the soft tissues from the ribs to be removed.
We take care to avoid the intercostal neurovascular bundle during this maneuver.
Fig. 3D. The rib is then cut and removed with a grasping instrument through one of the working
portals.
Fig. 4. Postoperative scars following VATS.