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Minimally Invasive Scoliosis Surgery Featuring George Picetti, III, M.D.

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  • #16
    Originally posted by jrnyc View Post
    very simply, i thought posterior approach requires less moving around of internal organs...no?

    jess
    I think the key issue is not having to deflate a lung with the posterior approach. I think the anterior approaches including the VBS procedures require deflating a lung but I could be wrong. I think someone here said it takes up to 2 years to get that lung back to full capacity? Am I remembering that correctly? It sounds wacky.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

    Comment


    • #17
      Here's the comment about the complications of endoscopic anterior scoliosis surgery:


      "iScoliosis.com: Are there any complications that you have had unique to thorascopic techniques that are different from standard posterior?

      Dr. Picetti: If the chest tube is not attended to appropriately, or it is pulled out too early, the chest can become filled with fluid. We have had some portal site numbness that has lasted up to six months. There have been several kids that have had a sympathectomy effect, where by the disruption of the normal sympathetic nerves that run along the front of the spine, they notice a difference in temperature of one leg from another. Their leg will be warm for a while and then that goes away. Those are probably the main ones."

      Comment


      • #18
        Here's the entire interview with Dr. Picetti, which is no longer found at the iScoliosis.com link. I'll post the entire interview in case the link I found it at disappears also. It's quite an interesting interview:

        http://sci.rutgers.edu/forum/showthread.php?t=5907


        Minimally Invasive Surgery for Scoliosis

        Scoliosis surgery can be scary for patients of any age, especially when faced with a five to seven day recovery, post-operative pain, and the anxiety caused by knowing you'll be left with a long scar. The idea of the scar can be the most frightening factor of the surgery, especially for young patients and their families. However, some new technology, created by Dr. George Picetti, is working to lessen the signs of scarring and make the entire scoliosis surgery easier on the patient.

        The technique is called thoracoscopic instrumentation. It uses video technology to correct certain types of curves "endoscopically." The procedure works by making several very small incisions while the surgeon corrects the scoliosis through an endoscope.

        We should emphasize that endoscopic instrumentation and correction of scoliosis is not for everyone, and only a small number of patients with scoliosis would be considered candidates for this type of surgical correction. Patients with a double thoracic curve, neuromusuclar curves, significant amount of kyphosis (hunching of the spine), or lung problems could have problems during this endoscopic procedure. However, as you will see the technique is a viable alternative and step toward the future of surgery.

        iScoliosis.com: How did you become interested in thorascopic instrumentation?

        Dr. Picetti: I first began to think about this when I was driving home from doing a case, an endoscopic case, where we did an anterior release through the endoscope followed by a routine posterior fusion. Although the endoscopic technique for doing the fusion on the front of the spine was intriguing, I just felt that it wasn't the end point. It seemed that I should be able to complete the rest of the surgery by inserting instrumentation into the spine endoscopically, and avoid the need to correct the deformity from the back. So, on the way home on the freeway, I started having ideas about how I could instrument the spine through the endoscopic portals. I pulled off the road several different times and wrote down my ideas. By the time I got home, I basically had drawn out the entire concept on scrap pieces of paper. We then went to the lab and continued to develop these ideas. So, actually, my whole idea of how to do this happened on my drive home from work!

        iScoliosis.com: What year was that?

        Dr. Picetti: I believe it was about 1993-1994, when we first started.

        iScoliosis.com: Since that time how many instrumented cases do you think you have done?

        Dr. Picetti: I have done over a 100 endoscopic scoliosis corrections so far.

        iScoliosis.com: From the patient's perspective, what are the advantages of thorascopic surgery over the more standard open, posterior approach?

        Dr. Picetti: In our experience, the advantages of thorascopic surgery are that the cosmetic result is significantly improved, the recovery time is much less, the amount of post-operative pain is significantly reduced, and the time to return to normal function is dramatically improved.

        iScoliosis.com: What is the average hospital length of stay after thorascopic compared to a standard posterior instrumentation and fusion?

        Dr. Picetti: The average length of hospital stay for thorascopic instrumentation in our institution is about three days compared to our posterior instrumentation patients, who tend to stay 5-7 days.

        iScoliosis.com: What is the ideal curve for thorascopic instrumentation?

        Dr. Picetti: I think that a very flexible, single right thoracic curve is the ideal curve for thorascopic instrumentation.

        iScoliosis.com: From the patient's perspective, what are the absolute contraindications to having their scoliosis corrected using the thorascopic approach?

        Dr. Picetti: I think that there are several curve patterns where correction using the thorascopic approach is extremely difficult, such as a double thoracic curve, for example. Someone who has a significant amount of kyphosis or hunching over of the spine makes it very hard to correct with this approach. Some patients with major lung problems may not tolerate the single lung ventilation that is necessary to do the procedure. Absolute contraindications, I think, would be someone who has a huge kyphosis, or a thoracolumbar junctional kyphosis where the kyphosis might get worse after the surgery. Neuromuscular curves, like those seen with Cerebral Palsy, would be difficult endoscopically.

        iScoliosis.com: How do the kids feel about their scars?

        Dr. Picetti: My favorite story is a patient who had her surgery around prom time. She was about 2 1â?„2 months out from her surgery and she went to the Mall to buy her dress for the prom. She was in her brace and trying on prom dresses. She happened to meet another girl there who had had a standard posterior surgery. The young girl took off her brace and tried on a long backless gown. When she went out and looked in the mirror, the other girl walks out and she says, "I thought you had scoliosis surgery"? She said, "yes I did," and showed her the little incisions on the side of her chest. The other girl went and got one of those high neck dresses and was in tears, asking why she had a big scar down her back when her new acquaintance had five small incisions that you can't even see when you are wearing this backless gown. So that meant a lot to me to hear that.

        iScoliosis.com: Do you brace kids after surgery?

        Dr. Picetti: Yes. I put them in a brace for three months.

        iScoliosis.com: What is the acceptance of your peers about the endoscopic technique?

        Dr. Picetti: I think initially that a lot of people thought what I was doing was voodoo. I got a lot of grief from many people, but I think that is changing significantly now. I think a lot of people are realizing it is not a fad or a passing trend. It is something that is not going to go away. Our early results show reasonably good outcomes, so it is no longer a technique that is up for debate.

        iScoliosis.com: What is your feeling about the learning curve for surgeons who
        want to start doing endoscopic instrumentation?

        Dr. Picetti: I think the learning curve for thorascopic instrumentation and fusion for scoliosis basically has to do with how well the surgeon can remove a thoracic disc. The instrumentation part of the procedure is actually fairly simple. Obviously, I think that surgeons who want to use this technique should have extensive experience doing the procedure using a standard thoracotomy incision and approach to the spine through the chest. They must have a thorough understanding of the normal and abnormal anatomy of the spine. If they have these skills, then they should be able to perform an excellent discectomy and obtain a solid fusion using the endoscopic technique.

        iScoliosis.com: How many surgeons do you think are doing endoscopic scoliosis corrections now in the U.S.?

        Dr. Picetti: We have had several courses and trained a lot of different surgeons, but there are probably somewhere between 10 and 20 surgeons who use this technique regularly, I think. Many surgeons are becoming more interested in the technique, obtaining the proper training and experience, but have not done many cases so far. There are many centers that are beginning to do lots of cases on a regular basis, however, and the experience is growing.

        iScoliosis.com: Are there any complications that you have had unique to thorascopic techniques that are different from standard posterior?

        Dr. Picetti: If the chest tube is not attended to appropriately, or it is pulled out too early, the chest can become filled with fluid. We have had some portal site numbness that has lasted up to six months. There have been several kids that have had a sympathectomy effect, where by the disruption of the normal sympathetic nerves that run along the front of the spine, they notice a difference in temperature of one leg from another. Their leg will be warm for a while and then that goes away. Those are probably the main ones.

        iScoliosis.com: Do you envision any new technology in terms of instrumentation in the immediate future?

        Dr. Picetti: There will probably not be a whole lot of new technology such as new instrumentation in the immediate future. We are expanding the indications for the endoscopic technique, such as developing an endoscopic double dual rod for adult thoracolumbar scoliosis, which produces a much stronger construct. There are kids who are hyperkyphotic that we may consider now using a dual rod with structural graft so that now we can get a better correction endoscopically.

        iScoliosis.com: Thank you.

        The information provided is not a substitute for professional medical advice. All of the content is educational in nature and for general information purposes only and is not a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of a qualified medical professional regarding any questions or medical conditions.

        Click here to find a doctor who performs this surgical procedure or read about a patient treated with this technology.

        http://www.iscoliosis.com/articles-i...ml?mastbox=yep

        Comment


        • #19
          Originally posted by jrnyc View Post
          how old is your daughter?...for some reason, i didn't think she was within pediatric doctor range...

          yes, i think minimally invasive will definitely be the future of scoli surgery and disc surgery! i wish more folks on forum were interested in watching videos on the subject...many here seem to be convinced that it can't work for large curves, can't work for lumbar curves, etc, when they haven't even investigated it!! i do not understand rejecting new procedures without knowing anything about them!

          i don't know what age Dr Neel Anand at Cedars Sinai goes down to for patients...he only uses minimally invasive approach now for ALL his scoli surgeries...he told me that a year ago January....& that is for ALL size curves, all locations of curves...he now considers "old" scoli surgery "unnecessary cutting and trauma to nerves and other tissue"

          best of luck with whatever you and your daughter decide, if/when it comes up for discussion...

          jess
          Jess...

          I don't think the issue is whether it can work, or whether it can work with large curves. I think the issue is people wanting to wait to see the real long-term results of of such surgeries.

          --Linda
          Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
          ---------------------------------------------------------------------------------------------------------------------------------------------------
          Surgery 2/10/93 A/P fusion T4-L3
          Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

          Comment


          • #20
            Originally posted by Pooka1 View Post
            That's an anterior procedure. They use one rod on one side.. As I understand it, they can fuse less levels so that is important in curves that go into the lumbar. I don't know why the posterior is considered the gold standard and not the anterior. Linda will know. So will Dr. K. Maybe you can ask him.
            I seem to recall several papers stating that anterior and posterior procedures had similar results in terms of correction, but anterior procedures resulted in more morbidity. I don't think there have been any comparison studies on the long-term results. Since most of the top scoliosis surgeons performed some number of anterior only procedures in the past, and have gone back to the gold standard of posterior procedures for most AIS patients, I'm guessing that they think they're getting better long-term results with the posterior procedure.

            --Linda
            Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
            ---------------------------------------------------------------------------------------------------------------------------------------------------
            Surgery 2/10/93 A/P fusion T4-L3
            Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

            Comment


            • #21
              Here's a link to some info for Montreal. It's on page 15. http://webversion.staywellcustom.com...spring/canada/

              and

              Info for BC Children's
              http://www.bcchf.ca/ckfinder/userfil...Spring2010.pdf
              CAmomof2

              July 07 - T 26*
              Aug 08 - curve now 22*
              Sept 08 - SpineCor Brace (in brace 17*) Ste. Justine
              March 09 - in brace 14*
              Aug 09 - in brace 14* / MRI normal
              Feb 10 - in brace 18* - had an oob xray - now 35*
              June 10 Considered VBS T 32*, L 27* , Stopped SpineCor brace
              Sept 10 T 38*, L 26*
              April 11 T 45*, L 31*
              July 11 T 51*, L 37*
              MIS SURGERY - NOV 28, 2011 / Age 12 / Fused T4 - T12

              Comment


              • #22
                Originally posted by LindaRacine View Post
                I seem to recall several papers stating that anterior and posterior procedures had similar results in terms of correction, but anterior procedures resulted in more morbidity. I don't think there have been any comparison studies on the long-term results. Since most of the top scoliosis surgeons performed some number of anterior only procedures in the past, and have gone back to the gold standard of posterior procedures for most AIS patients, I'm guessing that they think they're getting better long-term results with the posterior procedure.

                --Linda
                If the anterior procedure kept the fusion above L3 and therefore out of countdown range and the posterior did not then the anterior would be the gold standard in my book. I do know it is claimed to save levels but saving levels in the thorax is not worth the added risk because the patient will not notice. Staying above L3 arguably is probably worth the added risk.
                Sharon, mother of identical twin girls with scoliosis

                No island of sanity.

                Question: What do you call alternative medicine that works?
                Answer: Medicine


                "We are all African."

                Comment


                • #23
                  Minimally invasive threads

                  This might be of interest...

                  http://www.scoliosis.org/forum/showt...ht=dr+blackman

                  The search button here will reveal some interesting old threads.
                  Search;
                  Anand
                  Blackman
                  Picetti
                  Minimally invasive

                  Ed
                  49 yr old male, now 63, the new 64...
                  Pre surgery curves T70,L70
                  ALIF/PSA T2-Pelvis 01/29/08, 01/31/08 7" pelvic anchors BMP
                  Dr Brett Menmuir St Marys Hospital Reno,Nevada

                  Bending and twisting pics after full fusion
                  http://www.scoliosis.org/forum/showt...on.&highlight=

                  My x-rays
                  http://www.scoliosis.org/forum/attac...2&d=1228779214

                  http://www.scoliosis.org/forum/attac...3&d=1228779258

                  Comment


                  • #24
                    Thanks Ed. I had read that Blackman link which was quite interesting, especially about the loss of correction in some cases. He actually used fairly stiff, large curves for these procedures, and I had figured his study was one of the reasons they felt the moderately sized, very flexible curves were suitable for the endoscopic anterior procedures.

                    I'm finding more information now when I know the appropriate terminology. If I look for endoscopic or thoracoscopic scoliosis surgery, I find a lot more information on this procedure. There is lots of information on those other percutaneous minimally invasive procedures which is what pulls up if I simply use minimally invasive as a search term.

                    Thanks for your suggestions, I will give you in return a link you might find interesting as an engineer. I think you mentioned you might be interested in designing some of these scoliosis implants, so at this link you can find an orthopedic surgeon discussing all the nuts and bolts of an implant system. Enjoy, lol! (You can just click on the screens discussing the implant system itself if you're squeamish. Can't remember if you are or not).

                    http://www.orthopaediced.com/flash/deckey_01/
                    Last edited by Ballet Mom; 04-21-2011, 03:45 PM.

                    Comment


                    • #25
                      Okay, here are the conclusions of one of the latest studies (by Dr. Lonner) on this anterior thoracoscopic surgery:

                      "CONCLUSIONS: For single thoracic curves of <70 degrees in patients with a normal or hypokyphotic thoracic spine, video-assisted thoracoscopic surgery can produce equivalent radiographic results, patient-based clinical outcomes, and complication rates in comparison with posterior spinal fusion with thoracic pedicle screws, with the exception that posterior spinal fusion with thoracic pedicle screws may result in better major curve correction. The potential advantages of video-assisted thoracoscopic surgery over posterior spinal fusion with thoracic pedicle screws include reduced blood loss, fewer total levels fused, and the preservation of nearly one caudad fusion level, whereas the disadvantages include increased operative times and slightly less improvement in pulmonary function."

                      http://www.ncbi.nlm.nih.gov/pubmed/19181984


                      If it came to surgery, I would definitely get an evaluation by at least Dr. Newton in San Diego for my daughter to see what he felt, seeing as flexibility is important for my daughter and her ballet, even if only recreational in the future.

                      Comment


                      • #26
                        some doctors do both...and make the decision based on what the patient needs...and also considers if the patient makes a request...
                        Dr Lonner does both as far as the lst time i saw him....i requested MI approach, and he said he would do that for me...i havent done it ....yet...

                        Dr Anand believes strongly that MI is then only way to go now...and that it is an advance on fully open scoli surgery, whether posterior, anterior, or both...i do not for one moment believe he (or ANY surgeon, for that matter) will do a procedure because it is becoming "popular" or trendy....i think everyone with any ethics knows just how unethical that would be!

                        i will say again, every surgery was "new" at some point...arthroscopic surgery for ankles, knees, etc, was such a huge advance and makes such a huge difference with less damage to tissue and faster healing, it was amazing...i was a beneficiary of that advance...

                        i notice that "regular" surgery for scoli is not without it's problems...and there are enough people needing revision surgery...sometimes more than one revision...that it is not a perfect procedure

                        if/when i finally have spinal surgery for lumbar, i will not consider anything but MI...to me, it is the most advanced...
                        but...to each their own...people have choices now...and that is always a good thing!

                        jess
                        Last edited by jrnyc; 04-21-2011, 05:28 PM.

                        Comment


                        • #27
                          Originally posted by hdugger
                          I have zero information on whether the same dynamic is going on for minimally invasive - I don't think we've had enough years to evaluate it. But I think it's better to chose the best surgeon and let them choose the method.
                          Exactly. No matter how much research we read on our own, we'll never be able to understand the details as much as a good specialist.

                          --Linda
                          Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
                          ---------------------------------------------------------------------------------------------------------------------------------------------------
                          Surgery 2/10/93 A/P fusion T4-L3
                          Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

                          Comment


                          • #28
                            QUOTE by Dr. Lonner: "...and the preservation of nearly one caudad fusion level, ..."

                            Heh? So on average anterior saves "nearly" one caudal level?!? Not any distal levels and not even a whole caudal level???

                            How does it work to save a level above but not below??? What's the physics of that???

                            That would make it completely useless for trying to stay as much out of the lumbar as much as possible. I can't imagine how that justifies the almost three times risk of neuro injury over posterior (though still very low).
                            Sharon, mother of identical twin girls with scoliosis

                            No island of sanity.

                            Question: What do you call alternative medicine that works?
                            Answer: Medicine


                            "We are all African."

                            Comment


                            • #29
                              hi hdugger
                              i would expect to get at least 3 opinions on ANY major surgery for anything i ever may need done...
                              i am sorry there is a surgeon anywhere who didn't present all the pros and cons on breast cancer surgery! unfortunately, i think everyone needs to research any serious procedure they are facing...not all doctors think alike, no matter how ethical they may be....& since it is our own body and we will have to live with the results, we are the ones burdened with researching it all.....kinda "cant trust anyone completely" when it comes to major cutting and stitching, as it were....
                              i am very happy there are more and more choices coming in spinal surgery...i personally believe if the world is still here 50 years from now, spinal surgery will look a lot different than it does now...just my own speculation..

                              jess

                              Comment


                              • #30
                                is it the medicine, or the money..??
                                4 weeks is expensive, and so much of what insurance will pay for is driven only by that!!

                                jess

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