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Early Experiences With Video-Assisted Thoracoscopic Surgery: Our First 70 Cases

Al-Sayyad, Mohammed J. MD, FRCSC; Crawford, Alvin H. MD, FACS; Wolf, Randal K. MD, FACS

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Author Information

From the Department of Pediatric Orthopaedic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio.

Acknowledgment date: July 2, 2002. First revision date: November 27, 2002. Second revision date: May 29, 2003. Acceptance date: October 20, 2003.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work. Although one or more of the author(s) has/have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this manuscript, benefits will be directly solely to a research fund, foundation, educational institution, or other nonprofit organization with which the author(s) has/have been associated. One or more of the author(s) has/have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this manuscript: e.g., royalties, stock, stock options, decision-making position

Address correspondence and reprint requests to Alvin H. Crawford, MD, Division of Pediatric Orthopaedic Surgery, Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229-3039, USA; E-mail: alvin.crawford@chmcc.org

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Abstract

Study Design. Prospective consecutive series.

Objective. Analysis of the results and outcomes of patients treated with video-assisted thoracoscopic surgery for spinal pathology.

Summary of Background Data. Video-assisted thoracoscopic surgery is an alternative to open thoracotomy. It has been suggested that the learning curve is substantial. The authors present their early experience in treating a variety of spinal pathologies with this technique.

Methods. Seventy cases were available at the 2-year follow-up. Video-assisted thoracoscopic surgery with the goal of anterior spinal release and fusion was carried out on patients with the following diagnoses: idiopathic scoliosis, neuromuscular spinal deformity, Scheuermann kyphosis, congenital and infantile scoliosis, neurofibromatosis, Marfan syndrome, postradiation scoliosis, and repair of pseudarthrosis. Three patients had excision of the first rib to treat thoracic outlet syndrome. Two patients had excision of intrathoracic neurofibroma and a benign rib tumor. One had anterior fusion following thoracic spine fracture-dislocation.

Results. The average operative time for the thoracoscopic anterior release with discectomy and fusion procedure was 256 minutes (range 150–405 minutes). The average number of discs excised was 8 (range 4–11 discs). The average operative time per disc was 32.5 minutes (range 20–45 minutes). The average blood loss during the thoracoscopic anterior release with diskectomy and fusion was 285 mL (range 150–405 mL). Final postoperative scoliosis and kyphosis corrections were 68% (range 41–91%) and 90% (range 47–100%), respectively. Complications related to thoracoscopy occurred in 3 patients. All deformity patients had evidence of anterior fusion radiographically.

Conclusion. Video-assisted thoracoscopic surgery provides a safe and effective alternative to open thoracotomy in the treatment of thoracic pediatric spinal deformities. The procedure remains time consuming.

Thoracoscopic spine surgery is a new technique that allows for reaching and treating pathology of the spine and ribs with the same accuracy and completeness as is possible by the open approach but through smaller skin and muscle incisions. The body of knowledge currently available began with a single report in 19931 and progressed to 15 articles in the year 2000.2–16 Several animal studies have demonstrated endoscopic and open techniques to be equally effective in increasing spine flexibility in porcine and goat models.17,18 In December 1993, at Cincinnati Children’s Hospital Medical Center, the senior author (A.H.C.) began performing video-assisted thoracoscopic surgery (VATS).

Our indications for thoracoscopy in pediatric spinal deformities include: 1) rigid idiopathic scoliosis deformities at or about 75° in magnitude without correction to less than 50° on side bending radiographs; 2) to prevent crank shaft phenomena in the skeletal immature child with greater than 50° curvature; 3) kyphotic deformities of greater than 70° that do not correct to less than 50° on hyperextension films over a bolster; 4) progressive congenital deformities within the thorax requiring anterior epiphysiodesis; 5) patients with neuromuscular deformities with at-risk pulmonary status; 6) severe rib hump deformity not corrected by spinal instrumentation; 7) those patients with neurofibromatosis who had intrathoracic tumors in addition to a significant spinal deformity; 8) pseudarthrosis following anterior intervertebral fusion; 9) excision of first rib for thoracic outlet syndrome; 10) rib and intercostal nerve tumors; and 11) most recent, instrumentation of thoracic spinal deformities above the diaphragm. Our contraindications include: 1) inability to tolerate single lung ventilation; 2) severe or acute respiratory insufficiency; 3) high airway pressures with positive pressure ventilation; 4) pleural symphysis; and 5) empyema.19,20

The learning curve of VATS in the pediatric spine has been studied previously.10 The author’s purpose is to analyze their acquired experience during a consecutive series VATS with the majority of cases involving disc release and rib graft fusion.

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Materials and Methods

Seventy consecutive cases of VATS were carried out between December 1993 and May of 1999 and had a minimum of a 2-year follow-up. Video-assisted thoracoscopic surgery release of the anterior spine by disc excision and anterior fusion were carried out on patients with the following diagnoses: idiopathic scoliosis (n = 32), neuromuscular spinal deformity (n = 13), Scheuermann kyphosis (n = 9), congenital and infantile scoliosis (n = 3), neurofibromatosis (n = 4), Marfan syndrome (n = 1), postradiation scoliosis (n = 1), and repair of pseudarthrosis (n = 1). Three patients had excision of the first rib to treat thoracic outlet syndrome. Two patients had excision of intrathoracic neurofibroma and a benign rib tumor. One patient had anterior fusion following thoracic spine fracture-dislocation.

All cases were followed prospectively. Patient data collected from our computerized database included gender, age at the time of surgery, specific diagnosis, and indication for VATS. Perioperative data included the number of discs excised, anterior operative time, posterior operative time, anterior operative time per disc, anterior blood loss, posterior blood loss, and anterior blood loss per disc excised. Postoperative data included hospital stay (in days), days in the intensive care unit, days of chest tube use, chest tube output, chest tube output per disc, and complications.

Radiographic data were collected by the same author (M.J.A.) for all cases; the author was blinded to the functional and perioperative data at the time of the radiograph review. Deformities were measured on upright anteroposterior and lateral films using the Cobb method.21 Calculations for curve magnitude and percent correction were made using the worst deformity value that was recorded. Thoracic kyphosis was measured from T3–T12. Preoperative and postoperative films were measured. One-year and final follow-up radiographs were also measured and examined for fusion mass and implant failure. The presence of an anterior fusion mass was determined by the presence of a bridge of bone connecting the vertebral bodies in place of the old disc in the lateral view. The percent correction was calculated initially, at 1 year and at final follow-up. In calculating percentage correction for kyphosis cases, normal thoracic kyphosis was considered to be 40°. Percentage of kyphosis correction = {100 x [preoperative kyphosis – (postoperative kyphosis − 40°)]/preoperative kyphosis}. If correction was below 40°, the correction was considered 100%.10,22

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Surgical Technique.

In 65 of the 70 VATS cases, anterior release, endplate ablation, and grafting using autogenous rib graft were performed. Single-lung ventilation was performed with the use of a double lumen tube in all except 2 patients, who were 5 years old. Both patients had endotracheal intubation and a bronchial blocker (Fogarty catheter), allowing for collapse of the lung on the convex side of the curve in scoliosis cases and on the right side in kyphosis cases. The time for intubation was not included in the operative time.

The patient was placed convex side up onto the lateral decubitus position with kidney rest support. Although not draped out, the arm was hyperflexed at the shoulder to allow the placement of portals higher into the axilla. All pressure points were well padded. In all cases, an experienced access surgeon (R.K.W.) was present; we were fortunate enough that our access surgeon had experience with over 400 thoracoscopies before working with us. The first portal, i.e., the visual panorama portal, was most frequently placed at or about the T6 or T7 interspace in the midaxillary line. A 15 mm Trochar was used, through which a 10-mm 30° angled rigid telescope was placed. The lung was observed as it deflated. A panoramic assessment was then carried out to determine the topographical anatomy. The rest of the portals were done under direct visualization. Generally, 4 portals were used for spinal deformity cases. The ribs were counted in order to identify the levels to be treated. The parietal pleura was opened in a longitudinal fashion. Early in the series, electrocautery was used; however, after the first 20 cases, an ultrasonic device was used (ultracision LCS, Ethicon Endosurgery Inc., Piscataway, NJ). The harmonic scalpel produced less smoke, which improved visualization. The intervertebral discs were identified. A vessel sparing approach was used early in the series, but now because we consider transligation of the segmental vessels to be fairly safe, the segmental vessels were coagulated with the harmonic scalpel, incised, and retracted with the pleura.23 The pleura was further elevated and retracted using the harmonic scalpel, thoracoscopic periosteal elevators, and blunt dissectors. A transverse cut was made across the vertebral endplate parallel to the disc both rostral and caudal to it using electrocautery. An elevator was then used to elevate the vertebral endplate to isolate the disc. Rongeurs, curettes, and periosteal elevators were then used to assure complete removal of the disc material and the endplates. The anulus and disc space contents were excised; we strived to achieve an approximately 250° arc of release or from rib head to opposite posterolateral body (except in extreme levels like T2–T3, T3–T4, L1–L2, and L2–L3). In this series, ribs were harvested to perform intervertebral fusion. Early in the series (first 3 cases), the pleura were closed, but we no longer attempt to close it. A chest tube was then placed through the inferior most portal and observed thoracoscopically. The chest tube was then placed under water seal, and the anesthesiologist inflated the lung to determine whether there was an air leak. The patient was usually reintubated and turned prone for a posterior spinal fusion if one was planned.19,20,23,24 We now recommend routine suction of the inflated lung because of previous experiences in other centers with mucous plugs causing significant respiratory distress. We began routine suction after the fourth case, and we did not encounter mucus plugs with our current protocol.25

A total of 8 cases included in our study varied from the typical thoracoscopic release and fusion for spinal deformity. Case 25, a 16-year-old male with neurofibromatosis, had a large thoracic intercostal neurofibroma, which required thoracoscopic removal. Case 26, a 17-year-old male with neuromuscular scoliosis who underwent a previous spinal fusion and ended up with a painful pseudarthrosis at the level of T10–T11, had thoracoscopic rib grafting. Case 35, a 13-year-old female with adolescent idiopathic scoliosis of 54°, underwent thoracoscopic anterior instrumented fusion from T5–T11 with autogenous rib grafting. Case 37, a 17-year-old male patient, presented with a painful 10th rib mass, and the benign nature of the mass was determined radiographically and was excised thoracoscopically. Case 39, a 12-year-old boy with a T11–T12 spine fracture dislocation, underwent thoracoscopic decompression and fusion followed by posterior instrumented spinal fusion. Three patients (cases 40, 65, and 67) aged 31, 51, and 16 years old, respectively, had thoracic outlet syndrome. These patients had thoracoscopic first rib excision, the technical details of which can be reviewed in Minimal Access Cardiothoracic Surgery.26

All patients were given questionnaires (self-administered) at their latest postoperative visit to rate their satisfaction with surgery on a scale from 1 to 5 with 1 being extremely unsatisfied, 2 being somewhat dissatisfied, 3 being neither satisfied nor dissatisfied, 4 being somewhat satisfied, and 5 being extremely satisfied. Patients were also asked if they would have the same management again if they had the same condition, and this was graded as follows: 1 definitely not, 2 probably not, 3 not sure, 4 probably yes, and 5 definitely yes. These 2 measures were taken word for word from the Scoliosis Research Society outcomes instrument, questions 22 and 23, respectively.27

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Statistical Analysis.

Statistical analysis was done using SPSS for Windows version 9.0 (SPSS, Cary, NC). Descriptive statistics including mean and standard deviation of the results were calculated. Student t test analyses were used in the comparison between the halofemoral traction and nontraction groups and the group electrocautery versus the harmonic scalpel group. Statistical results at P < 0.05 were considered significant.

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Results

Of the seventy patients, 46 were females and 24 were males. Patients’ ages at surgery varied from 5.1 to 51.5 years with an average of 15 years. The average follow-up was 4.1 year (range 2–7 years). All patients had a minimum of 2 years follow-up. No patients were lost to follow-up.

Fifty-one of the 70 patients underwent same-day anterior thoracoscopic release and fusion followed by posterior instrumented spinal fusion. Eleven patients had an anterior thoracoscopic release and fusion followed by halofemoral traction for an average of 9 days (range 5–12 days) followed by posterior instrumented spinal fusion (Figure 1). The halofemoral traction group included 7 patients with idiopathic scoliosis, 3 neuromuscular scoliosis patients, and 1 patient with Scheuermann kyphosis (Figure 2). The mean scoliosis curve measurement in the halofemoral traction group was 89° (range 75–112°). Six patients had formal anterior thoracoscopic costoplasty with an average of 5 harvested ribs (range 3–7 ribs). Twenty-six patients had a posterior costoplasty. No cases were canceled or delayed because of failure to achieve single-lung ventilation, and no technical difficulties were encountered from the prospective of anesthesia.

Figure 1
Figure 1
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Figure 2
Figure 2
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Patient data including the number of discs released and operative time per disc were plotted, and a curve fit was performed. A straight line showed the proper fit as seen in Figures 3 and 4. Table 1 provides a summary of the operative and postoperative data. Data from case 35 (anterior thoracoscopic instrumentation) were excluded from the calculations, as surgical time and blood loss increased in instrumentation cases.

Figure 3
Figure 3
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Figure 4
Figure 4
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Table 1
Table 1
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There was no change in the number of discs released as the series progressed, as shown in Figure 4. The mean operative time per disc for discectomy alone averaged 13 minutes (range 8–18), but when considering the total procedure including rib harvesting, endplate ablation, and intervertebral fusion, operative time per disc was 32.5 minutes ± 7.8 minutes.

The mean hospital stay was 8.3 days ± 3.7 days (range 5–20 days). The halofemoral traction group had a mean hospital stay of 14.4 days ± 2.95 days. If the halofemoral traction group is excluded from these calculations, the mean hospital stay was 7.1 ± 2.4 days. A t test comparison of the hospital stay for the traction and nontraction groups showed that there was a significant difference between the traction and nontraction group, with P < 0.0001. The amount of chest tube drainage in the traction group (1087 mL ± 666 mL) was significantly greater than that of the nontraction group (716 ± 215 mL), with P < 0.0003. The amount of chest tube drainage per disc was also significantly different (P = 0.0114), with the drainage for the traction group being 104 mL ± 79 mL and the nontraction group was 64 ± 42 mL.

In this series, the anterior release and discectomy was done at levels between T2–T3 and L2–L3. The total number of discs released was 487 discs, and the frequencies of the particular discs released are shown in Table 2.

Table 2
Table 2
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There was no statistically significant difference (P > 0.05) between cases carried out using the electrocautery and the harmonic scalpel in the areas of anterior blood loss, anterior operative time, and anterior operative time per disc. The vessel-sparing approach was used in the first 4 cases of this series. The small number of cases in the vessel-sparing group limited the statistical analysis that could be carried out to compare operative time and estimated blood loss in both groups.

In patients treated for scoliosis, the mean preoperative scoliosis value was 72 ± 17° (range 42–120°), the mean 1-year postoperative scoliosis was 22 ± 13° (range 7–48°) and the mean final postoperative scoliosis was 24 ± 15° (range 7–50°). The mean initial scoliosis correction was 67 ± 16% (range 43–91%), the mean scoliosis correction at 1 year was 67 ± 17% (range 41–91%), and at final follow-up was 68 ± 18% (range 41–91%). For the kyphosis patients, the mean preoperative kyphosis value was 83 ± 6° (range 70–110°), the mean 1-year postoperative kyphosis was 43 ± 6° (range 39–55°), and the mean final postoperative kyphosis was 46 ± 6° (range 39–57°). The mean initial kyphosis correction was 92 ± 7% (range 48–100%), the mean kyphosis correction at 1 year was 90 ± 5% (range 50–100%), and at final follow-up was 90 ± 8% (range 47–100%). Solid anterior fusion mass was seen in all fusion cases, and Figure 1C shows a close-up of the anterior fusion mass at the T10–T11 level.

Case 25, the neurofibromatosis patient with a thoracic intercostal neurofibroma, had a successful thoracoscopic excision. Case 26, the painful pseudarthrosis at the level T10–T11, went on to have a successful painless fusion. Case 35 had a thoracoscopic anterior instrumented fusion from T5–T11 with autogenous rib grafting, was corrected to 25° after surgery, and had a successful fusion. Case 37, with the painful 10th rib mass, had the mass excised successfully, which proved to be a simple bone cyst. Case 39, with the T11–T12 spine fracture dislocation, had a solid anterior and posterior fusion. The thoracic outlet syndrome patients had a successful first rib excision and a successful clinical outcome.

Complications occurred in 8 patients, 3 of which were related to thoracoscopy. Case 20, a 13-year-old male patient with neuromuscular scoliosis, suffered from a left upper lobe atelectasis that was treated with Bipap. He also had a posterior spine wound infection that was treated with multiple debridements and retention of the spinal implant. Postoperative pneumonia occurred in case 34 an 11-year-old female with idiopathic scoliosis who underwent an anterior release to avoid the crankshaft phenomena; she was treated with antibiotics and recovered. The third patient (case 35), a 13-year-old girl with right thoracic scoliosis of 54°, underwent VATS discectomy and anterior spinal fusion with instrumentation from T5–T11 and developed an intraoperative tension pneumothorax. During surgery, overadvancement of a guide wire into the opposite (left) hemithorax resulted in a tension pneumothorax in the left hemithorax. This was treated with a chest tube inserted into the left hemithorax and had no long-term consequences.33

Other complications included a myelomeningocele patient (case 5) with severe kyphoscoliosis who suffered an iliac crest bone graft site infection. This patient had a chronic sinus that required multiple debridements. Fluid overload occurred in case 31, a 10-year-old male who was born with tetralogy of Fallot and had a 60° curve corrected to 18° by VATS discectomy and posterior instrumented fusion. He required reintubation and diuresis after surgery but fortunately was extubated in 48 hours and went back to his baseline function. Superior mesenteric artery syndrome occurred in case 38, a skeletally immature 11-year-old girl with idiopathic scoliosis of 55° that was corrected to 13°. This patient was treated by nasojejunal tube feeding and regained normal function following 2 weeks of treatment. A pulmonary embolus occurred in case 53, a 16-year-old female who had VATS discectomy and anterior spinal fusion followed by posterior instrumented fusion from T2–L3 for Scheuermann kyphosis of 85°. She was anticoagulated and has recovered completely. There were no chylothorax, incorrect levels of fusion, and no conversions to thoracotomy.

Results of the satisfaction questionnaire showed 48 of the 70 (68.57%) VATS patients to be extremely satisfied. Eighteen patients were somewhat satisfied (25.71%), and 4 patients were neither satisfied nor dissatisfied (5.72%). Fifty patients (71%) answered that they definitely would have the procedure again if they had the same condition. Eleven patients (16%) selected probably yes, 6 patients (9%) selected not sure, and 3 patients (4%) selected probably not (these 3 included 1 patient with tetralogy of Fallot with history of recurrent cardiac failures, 1 neurofibromatosis patient with scoliosis, and 1 patient with neuromuscular scoliosis).

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Discussion

In order to put VATS into perspective, the surgeon needs to be aware of the short-term results and outcome measures. In this series, we reported our results with VATS, beginning with the selection criteria, passing by evolution of the surgical technique, and progressing to spinal fusion.

In December 1993, at Cincinnati Children’s Hospital Medical Center, the senior author (A.H.C.) began performing VATS. He subsequently compared VATS patients to a thoracotomy group, the first group had 39 patients and the second had 40 patients respectively. Video-assisted thoracoscopic surgery was equally effective as thoracotomy in achieving adequate anterior spinal release with no difference in the adequacy of fusion as judged by osseous bridging across the disc spaces. Blood loss in the VATS group was significantly less than the thoracotomy group, being a mean of 412 mL compared to 804 mL in the thoracotomy group.28 Video-assisted thoracoscopic surgery patients in that presentation are included in this study.

This study includes the largest number of idiopathic scoliosis patients receiving anterior thoracoscopic release and fusion ever reported. The largest number of idiopathic scoliosis patients receiving anterior thoracoscopic release previously reported was 13 patients.2 This series also includes the longest follow-up to date on a thoracoscopic release, being an average of 4.1 years (with a minimum of 2 years follow-up) with the longest follow-up previously reported by Waisman and Saute (3 years in a report of 3 patients).23 Previous studies had a large number of neuromuscular scoliosis cases and lacked a follow-up that included achieving fusion and a maintained correction.10,13,29

The work of Landreneau et al and Mangione et al documented that the thoracoscopic procedure20 and thoracoscopic spinal procedures are less painful when compared to open thoracotomy.30–32 Arlet, in a meta-analysis and review of anterior thoracoscopic spine release in deformity surgery, made the comment that the quality of disc excision was rarely reported.2 In our series, we strived to obtain complete disc excision to an approximately 250° arc or from rib head to the opposite posterolateral body to the best of our visual and tactile judgment. In the series by Newton et al,10 no comment was made regarding the quality of the disc excision and utilization of allograft and posterior iliac crest bone graft. Specific numbers were not given to indicate how many patients received either type of graft, as the paper did not concentrate on comments regarding achieving fusion. The complication rate in this series compared favorably with previous thoracoscopic studies.10,33

Newton et al considered severe scoliosis, particularly in patients with neuromuscular disorders or small children, to be a relative contraindication to the thoracoscopic approach and may be best treated by open surgery; this has not been our experience.10 In this series, the authors treated 8 scoliosis patients with curves >90° (range 94−120°) with no need to convert to open thoracotomy.

Excellent final correction was obtained in the scoliosis and the kyphosis patient population, being 68 ± 18% and 90 ± 8%, respectively. Newton et al reported postoperative scoliosis correction of 56 ± 22% and postoperative kyphosis correction of 80 ± 17%, and in the meta-analysis by Arlet, the correction obtained in scoliosis cases varied from 55% to 63%.2,10 The satisfaction questionnaire showed 66 patients to be satisfied with the result of their surgery (94.28%), and 4 patients were neither satisfied nor dissatisfied (5.72%). These satisfaction questions were asked regarding the anterior thoracoscopic surgery specifically, the chance is still there that such a high satisfaction rate is partially or totally related to the achieved correction of the deformity.

Video-assisted thoracoscopic surgery clearly provides a safe and effective alternative to open thoracotomy for thoracic spinal deformities, as documented by our corrections obtained and fusion rates achieved. The time invested in training and the assistance of an experienced access surgeon made for a positive outcome with the procedure. The authors now use VATS for nearly every case previously requiring thoracotomy.

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Key Points

* Video-assisted thoracoscopic surgery provides a safe and effective alternative to open thoracotomy for thoracic spinal deformities.

* Time invested in training and assistance of an experienced access surgeon made for a positive outcome with the procedure.

* Excellent anterior fusion mass was observed in all of our deformity cases.

* The authors now use VATS for nearly every case previously requiring thoracotomy.

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References

1. Mack MJ, Regan JJ, Bobechko WP, et al. Application of thoracoscopy for diseases of the spine. Ann Thorac Surg 1993;56:736–8.

2. Arlet V. Anterior thoracoscopic spine release in deformity surgery: a meta-analysis and review. Eur Spine J 2000;9:S17–23.

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18. Wall EJ, Bylski-Austrow DI, Shelton FS, et al. Endoscopic discectomy increases thoracic spine flexibility as effectively as open discectomy. A mechanical study in a porcine model. Spine 1998;23:9–15.

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25. Picetti GD 3rd, Pang D, Bueff HU. Thoracoscopic techniques for the treatment of scoliosis: early results in procedure development. Neurosurgery 2002;51:978–84.

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27. Asher MA, Min Lai S, Burton DC. Further development and validation of the Scoliosis Research Society (SRS) outcomes instrument. Spine 2000;25:2381–6.

28. Durrani A, King E, Crawford AH. Anterior spinal release and fusion: video-assisted thoracoscopic surgery (VATS) vs. thoracotomy. Presented at: Scoliosis Research Society meeting; September 1999; San Diego, California.

29. Papin P, Arlet V, Marchesi D, et al. Treatment of scoliosis in the adolescent by anterior release and vertebral arthrodesis. Rev Chir Orthop 1998;84:231–8.

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31. Landreneau RJ, Wiechmann RJ, Hazelrigg SR, et al. Effect of minimally invasive thoracic surgical approaches on acute and chronic postoperative pain. Chest Surg Clin N Am 1998;8:891–906.

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33. McAfee PC, Regan JR, Zdeblick T, et al. The incidence of complications in endoscopic anterior thoracolumbar spinal reconstructive surgery. A prospective multicenter study comprising the first 100 consecutive cases. Spine 1995;20:1624–32. <artno;02448>

Keywords:

video assisted thoracoscopic surgery; scoliosis; kyphosis

© 2004 Lippincott Williams & Wilkins, Inc.

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