Minimally invasive scoliosis surgery: an innovative technique in patients with adolescent idiopathic scoliosis

Minimally invasive spine surgery is becoming more common for the treatment of multilevel pathology, including adult lumbar degenerative disorders [1-3]. The next logical step is to apply minimally invasive surgical techniques to the treatment of adolescent idiopathic scoliosis (AIS). However, there are significant technical challenges of performing minimally invasive surgery on this patient population. In contrast to adult degenerative scoliosis, the curves in AIS patients are much larger (usually 45-50° or more), the number of levels instrumented are longer (7-13), the deformity exists in three planes, and the vertebral rotation can be significant. Placement of pedicle screws (14-26 screws) also increases radiation exposure for both the patient and the surgeon [4-6]. In patients with double major curves, passing a rod that is contoured in the normal sagittal profile (thoracic kyphosis and lumbar lordosis) is a challenge in and of itself.The ultimate goal of the surgical management of AIS is to obtain an adequate fusion. In contrast to the adult population, an anterior approach is often not utilized in AIS patients, either for release or for fusion [7]. Thus, it is imperative that any surgical technique for AIS allows for adequate fusion at the facet joint. In the context of minimally invasive surgery, obtaining sufficient surface area for arthrodesis can be challenging. Bone morphogenic protein can be utilized, but is an off-label indication for this age group as well as for this type of surgery.Two other important issues in considering minimally invasive approaches to AIS are the length and type of skin incision as well as the reduction maneuvers employed for deformity correction. The standard stab incision for placement of minimally invasive or percutaneous pedicle screws cannot be utilized in adolescent patients, as fourteen to twenty six stab incisions in the back can be quite disconcerting for a young patient. Additionally, surgeons treating large spinal defor