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Ann Thorac Surg 1996;62:822-823
© 1996 The Society of Thoracic Surgeons
DR ROHINTON K. BALSARA (Philadelphia, PA): Can you tell us how many disks you took out in each patient, and did you do posterior fusion at the same time or at a later stage?
DR POLLOCK: The number of disks was different depending on the patient and the amount of stiffness the spine had preoperatively. Four to six disks per patient was usual. All patients had concomitant posterior instrumentation in the same operative setting in both groups. Staged anterior release with later posterior fusion is a very unusual procedure at our institution and did not occur during the study.
DR BALSARA: And all patients went home in 4 days?
DR POLLOCK: Four days was the mean postoperative length of stay. The vast majority of patients had a cast placed on the third or fourth postoperative day and were discharged with outpatient follow-up.
DR RAPHEAL BUENO (Boston, MA): How low were you able to technically go; into what interspace?
DR POLLOCK: By taking down the diaphragm medially, you can actually get to L-1 and L-2 without much difficulty. There are techniques being developed for getting lower than this via a subcostal incision using balloon dissection to develop the extraperitoneal space. Approach to spinal levels L-4 and L-5 or L-5 and S-1 is done via a transabdominal laparoscopic approach.
DR JOHANN L. EHRENHAFT (Iowa City, IA): In our department of orthopedics, Dr Ignazio Poncetti has been working on scoliosis most of his life, and he approached me some time ago, about 20 years or longer, to do diskectomies on scoliotic adolescent people. We did not do thoracoscopy. We did open thoracotomies. The removal of intervertebral disk material must be complete, not only the nucleus pulposus, but all of the fibrous tissue as well. Furthermore, three segments are probably not enough. What you do is mostly over the convex surface. You must be able to reach all the way. Now, initially when we operated on the patients they were not fused posteriorly. It was an attempt to do a correction without posterior fusion. I see that all of your patients were fused, and some of the procedures had to be reverted to open thoracotomy. I wonder if you achieve complete disk removal, removal of all of the intervertebral material, with thoracoscopy. In ideal patients I am sure it is possible.
The interesting thing is that we submitted an abstract in 1973 to this Society and to The American Association for Thoracic Surgery with this particular problem and both societies rejected it. So maybe I have a chance to mention it anyway. The idea of disk removal is not that new. It does facilitate correction of adult/adolescent scoliosis. Thank you.
DR POLLOCK: With regard to the completeness of disk removal, I would make the following comments: (1) The technology available today (eg, three-chip cameras, 600-line resolution) is in no way comparable with that of thoracoscopy 15 years ago with regard to visualization of the disk space. (2) The removal of the disk is performed to increase the flexibility of the spine to facilitate straightening and also, as mentioned, to facilitate fusion. Both the results in terms of degree of correction and the lack of failed fusions in our series would attest to the adequacy of diskectomy. The impression from experienced orthopedic surgeons is that disk removal involving removal of both the caudad and cephalad end plates and the anterior longitudinal ligament is at least equivalent if not better with the video-assisted technique. It is my impression that the style of disk removal is really based on the stiffness, rotation, and degree of curvature of the spine and involves a fair amount of judgment by the orthopedic surgeon beyond just evacuating the disk space.
I believe the results of the study support the fact that disk removal is adequate. The real issue is to what extent this will change the indications for the operation and the approach for spinal fixation.
Related Article
Ann. Thorac. Surg. 1996 62: 818-822.
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