Adolescent Idiopathic Scoliosis Surgery: A Comparative Study Of Anterior, Posterior, And Thoracic Approaches And The Role Of Project Management

Understanding Adolescent Idiopathic Scoliosis (AIS) and Its Treatment

The background for the investigation  

Scoliosis in patients aged between 10 and 18 years is known as adolescent scoliosis and the underlying causes of the same are multi-factorial. The most commonly occurring form of scoliosis in the adolescent period is adolescence idiopathic scoliosis (AIS), and what makes the condition stand out from other forms of scoliosis is that that the cause of this condition remains unknown. The condition is a three-dimensional health condition that corresponds to almost 80% of all spine deformity cases. The prevalence of AIS is described as 2-3% on a global scale. Around 0.5% of these cases are known to be progressive and require surgical treatment. The symptoms of the condition do not lead to neurologic conditions. However the visible symptoms related to the conditions are distinct (Lee et al., 2016). Treatment options to address concerns in adolescent idiopathic scoliosis is divided into three main categories; observation, bracing and surgery. The decision regarding treatment is based on the risk of curvature progression. The main objective of AIS surgery is to achieve a proper trunk and solid fusion. Nevertheless, it has been reported that though good radiological and clinical outcomes have been achieved, quality of life for patients as determined by self-evaluation is poor (Sudo et al., 2016).

The first aim of the research was to comprehend the usefulness and efficacy of the three forms of surgery, namely, anterior, posterior, and thoracic approach for treating AIS, and undertake a comparative study of the three surgical forms. The second aim was to understand the project management principles that can be applied for getting quick recovery in anterior surgery as compared to other surgical forms.

• To recognize the effectiveness of anterior surgical procedure for AIS
• To understand the effectiveness of posterior surgical procedure for AIS
• To identify the effectiveness of thoracic surgical procedure for AIS
• To highlight why anterior surgery is better than remaining two
• To assess the project management principles that can be applied for getting quick recovery in anterior surgery

The research questions that was addressed through the paper are

• Why anterior surgery is better than remaining two surgical forms?
• What are the project management principles to get quick recovery in anterior surgery compare to remaining surgery?

The hypothesis considered for the research was that “anterior surgery is better than remaining two surgical forms”.

Surgical treatment for patients with AIS is considered for those whose curves are greater than 45 degree with continual growth in this angle. The goal of such surgery can be understood to be two-fold. The first aim is to achieve prevention of curve progression. The second aim is to achieve curve correction. The three commonly used surgical methods to correct AIS are as follows-

• Posterior spine surgery
• Anterior spine surgery
• Thoracoscopic spine surgery

The results of the study would be elementary in indicating the form of surgery that is most appropriate for adolescence idiopathic scoliosis. Based on the research it would be easier to understand whether anterior adolescence idiopathic scoliosis surgery is better as compared to thoracic and posterior adolescence idiopathic scoliosis. The project management techniques that are useful and effective in this regard would also be highlighted.

A Comparative Study of Anterior, Posterior, and Thoracic Approaches for AIS Surgery

The significance of the study lies in the fact that on the  basis of the results of the study important changes can be brought about in practice of undertaking surgery for treating adolescence idiopathic scoliosis. Healthcare organizations can consider changes in project management practice in this regard and consider resource allocation accordingly.

Concept of management

Following a robust management method is pivotal in the successful completion of surgery in healthcare settings. The healthcare landscape is changing in a rapid manner and an increased focus is being given at present on access to quality care, reduction of care costs and prevention of surgical complications. Despite immense opportunities for healthcare professionals to engage in care techniques, varied constraints hamper progress to a considerable extent. Herein lays the need of a strong project management strategy that involves application of suitable tools, skills, knowledge and techniques for project activities for meeting the goal of care being provided. Project management reflects the domains of quality, scope, integration, cost, procurement, human resources, communications and risk management (Shirley, 2016).

Project management is referred to the practice of initiation, planning, execution, control and closing of a work to achieve a set of goals and to meet a set of criteria within a stipulated time. Such a management approach is needed for producing an end-result that suits the purpose of the task being done. Healthcare practices such as surgeries are a leading domain at the contemporary era and is growing effectively. With the shift towards need of safe practices the need of effective management is harnessed. Cost of healthcare practices is also an issue at present as a large number of advanced tools and aids are costly to be used at large (Ginter, 2018).

For effectively fulfilling their goals of better patient outcomes, surgeons treating adolescence idiopathic scoliosis choose to work in teams of clinician from different fields. Though teams augment the ability and skills of a surgeon in the care process, the added role of addressing group workflow and managing team dynamics might pose significant challenges. For surgeons carrying out vital surgeries, project management is a powerful tool for gaining maximum efficiency and efficacy in the setting (Chiocchio, 2015). Whether working in teams with professionals from different disciplines or independently, project management models can drive success.

Management of healthcare projects is a challenging task as a number of roles and responsibilities are to be fulfilled for gaining optimal results. Dividing the project into simpler efforts is crucial for giving the project a structure and ensuring manageable steps. The five phases of project management are project initiation; project planning; project execution project monitoring and control; project closure. Project initiation is the initial phase considering measurement of the feasibility and value of the project. Project planning refers to the thorough and detailed planning that provides guidance for securing the resources. Project execution is the key part wherein all the deliverables are fulfilled within a time frame. Monitoring of project involves understanding the needs of further improvements. Lastly, project closure is the ending of the project when the required task is completed. The primary challenge of application of such project management concept in healthcare is to achieve the complete set of goals within the constraints perceived. If the objectives and procedures of the project are ill-defined, it is likely that there would be a detrimental effect on the decision making process (Babineau&Lessard, 2015).

The Relevance of Project Management in Healthcare

Figure: project management concept

According to Shirley (2016), the concept of Project Management deals with the application of knowledge, tools, skills and techniques to execute project activities in order to satisfy the requirements of the projects. Shirley (2016) is of the opinion that the concerned project managers must not only strive to satisfy the specific scope, cost, time and overall quality requirements of the project, they must also assist the overall process of project management in order to meet the requirement and expectations of the people who are involved in or are affected by the project activities. The key elements of the project management framework include the project stakeholder, project groups, tools, knowledge and techniques, success of the project and required contribution of a project portfolio of project towards the success of the entire organization (Kerzner & Kerzner, 2017).

Figure: Different steps of project management

(Source: Kerzner & Kerzner, 2017)

Stakeholders: Stakeholders are the people are affected or involved by the activities of the project and mainly involve the project sponsor, project team, support staffs, suppliers, customers and opponents of the project. In case of the AIS and is subsequent treatment via surgery, the main stakeholders who are involved in the project management include the sponsors of the project that is the family members of the patients who make the complete payment for the surgery, the patient over whom the entire procedure will be undertaken and the care givers that is the healthcare professionals who are associated with the overall planning and the execution of the project (Kerzner, 2018). There may or may not be opponents of the project as in this case. Thus there are numerous stakeholders who are closely attached with the entire process of effective treatment of adolescence idiopathic scoliosis and hence effective success of the project of cure of the disease under the application of surgery is dependent on the expectations and needs of the stakeholders (Kerzner, 2018). According to Kerzner (2018), a successful project manager must develop healthy relationships with the concerned project stakeholders in order to understand and subsequently meet the requirement of the project.

The main five groups which are included inside the project management include initiating, planning, execution, monitoring, controlling and proper closing of activities (Kerzner & Kerzner, 2017). According to the theory of project management, Kerzner and Kerzner (2017) is of the opinion that for a successful health care project, it is the duty of a health care professional to develop key competencies towards that particular project in terms of knowledge and theories for proper execution of the project. The main areas of knowledge and skills that a project management managers must have as guided by the theory of project management include

1. Proper management of project integration
2. Proper management of the of the scope of the project via working with proper stakeholders
3. Proper management of the time of the project that is how long will it take in complete and how effective is this time in relation to the cost
4. Proper preparation and cost of the overall project
5. Proper quality management of the project
6. Proper management of the human resource associated with the project
7. Maintaining proper communication in order to make effective collection of data along with the dissemination and storing of the important project information
8. Procurement management of the project

Knowledge area/ Category	Tools and techniques
Integration management	Proper project management methodologies, project selection methods, charts and project management plan
Scope management	Proper break down of the structure via the use of mind maps
Time management	Gantt charts
Schedule management	Return on investment, total cost estimates, project portfolio management and overall cost management plans
Quality management	Quality metrics and fishbone diagrams
Human resource management	Motivational techniques, resource histograms and team building exercise
Communications management	Communication management plans, virtual communications and conflict management
Risk management	Risk management plans,  risk ratings
Procurement management	Contracts, source selection, requests for proposals
Stakeholder management	Stakeholder analyses, issue logs

Stakeholders Involved in Healthcare Project Management

Table: Different tools of project management techniques

(Source: Kerzner & Kerzner, 2017)

Thus from the above project management, theory, it can be stated that the overall success of as healthcare projects depends in the scope of the project, time span of the project and the cost goals of the project.

The main gaps in the study include there are different types of spine surgery, thoracic spine surgery, anterior spine surgery and posterior spine surgery. Different spine surgery has different advantages and disadvantages and thus drafting a successful project management plans over the spine surgery techniques is difficult. Previous studies have mostly highlighted over the advantages and disadvantages of the particular spine surgery and there are no comparative studies between all the three spine surgeries available. According to Kerzner and Kerzner (2017), performing a comparative study between inter-related techniques help in the elucidation of the proper basis of a particular health care project. In doing so it will help in the framing of the quick and effective projective management plan over the most effective and well-established techniques.

Thus from the above discussion it can be concluded that Robust management is the main role towards the successful completion of surgery under any healthcare settings. So effective project management technique willing mainly involved in the proper analysis of the stakeholder, overall understating of the process groups, understanding different aspects of knowledge areas, tools and techniques along with the project portfolio. Since there are numerous spine surgery techniques, developing effective project management plans over anyone particular techniques can be difficult. For the past decades there have been study of different spine surgery techniques in a separate manner and there is gap in research in the domain of the comparative study between all the three spine surgery techniques. Hence elucidation of the best spine surgery techniques among the other prevalent techniques will help in the successful framing of the project management plans.

Research philosophy      

The research was carried out following the Positivism research philosophy. The phenomena observed in relation to the research question to lead to the production of credible and valuable data (Taylor et al., 2015). As a research philosophy positivism revolves around the factual knowledge that is gained through measurement and observation. The role of the researcher in such a case is limited to data collection and interpretation in an objective manner.

The research was carried out with a secondary research design and a qualitative research approach was taken. A literature search on the topic was thought to be beneficial for addressing the research questions. There exists a rich pool of research carried out on the research topic and these were analysed in a comprehensive manner for understanding the key information. Secondary, qualitative research methods have the aim of identifying and evaluating the primary findings so that a concrete conclusion can be drawn (Panneerselvam, 2014).Assessing the present state of research on the concerned topic was the obvious value of the study. A critical evaluation of the literature was undertaken prior to synthesis of the information into the study for understanding implications for practice.

Project Management Groups and Tools

Databases used- The electronic databases that were used for the present review were PubmedOvid, Proquest, Web Search, CINAHL and others.

Keywords used- The search terms that have been used for the present research are adolescence idiopathic scoliosis, treatment, surgery, anterior, posterior, thoracic, anterior surgery, posterior surgery, thoracic surgery, project management, management, intervention

Boolean operation-The Boolean operations used for the present review were AND and OR. Application was done on the basis of the search methods for each database

• Articles published in English language
• Articles published after the year 2000

• Articles published in languages other than English
• Articles published before the year 2000

The study involved activities such as identification, recording, understanding, meaning-making, and transmitting information as the data collection tools. As a whole, the review of studies acted as the actual data collection. The review represented a formal data collection process wherein information was compiled and assessed in a comprehensive manner.

The research was carried out over a period of four weeks. The first week considered extensive literature search on the topic considering the selection criteria. The second week was dedicated to outline the important research findings. The third week was intended to carry out the main data analysis procedure. The report at the end of the project was written on the last week.

Ethical considerations are an important element of research. In the present research ethical principles were maintained by citing the sources used in a credible manner and acknowledging the contributions of the respected authors.

Due to time constraints, it was not possible to carry out primary data analysis through surveys. Therefore, the primary task for the research was to search for research article present on the respective topic.

According to Lykissas et al. (2013), Harrington rod construct was the basic instrument that is used for the management of the AIS via posterior spinal fusion. Iatrogenic “flatback deformity” at parts that is traversed by the Harrington rods, lead towards extremely poor results along with higher revision rates. Contrel and Dubousset designed the segmental hook-rod system in order to correct 3-dimensional deformity associated with AIS in different planes. However, at present, segmental fixation via hooks is replaced via pedicle screws that enable improved 3D correction along with the proper maintenance of spinal deformity. The results elucidated by Lykissas et al. (2013) showed long term adverse effect of Harrington rod instrumentation over the sagittal plane. Cortrel-Dubousset along with pedicle screw constructs had positive effect over the sagittal alignment. However, the technique of Cotrel-Dubousset technique has significantly high rate of corrections for both thoracic kyphosis and lumbar lordosis. The study also showed that post-oprative and peri-operative thoracic and lumbar curves did not differ from the patients with Harrington rod instrumentations and all-pedicle screw. Nevertheless, patients with pedicle screws have comparatively less postoperative curves. This difference is significant in the postoperative cure for the pedicle screw groups. Lykissas et al. (2013) further highlighted a significantly higher degree of corrections via patients with pedicle screw instrumentations in comparison to Harrington rods thereby suggesting that all-pedicle screw construct are more efficient for the correction of thoracic curve in both sagittal planes and coronal planes.

Key Competencies Required for Healthcare Project Management

Figure: Posterior Spinal Fusion Surgery

(Source: Spine Surgery Society of Australia, 2017)

The systematic review of literature conducted by Lykissas et al. (2013) highlighted that the chances of pseudarthrosis is higher following pedicle screw fixation in comparison to the Harrington rods and segmental tools. Again the group of patients operated with Harrington rods have higher rate of infection in comparison to the Cotrel-Dubousset construct and pedicle screw fixation. The study also found that the incidence of reoperation surgery is associated more frequently with Harrington rod instrumentation as compared with Cotrel Dubousset and all pedicel screw. Transient neurological complications were noted only under the test group of Cotrel Dubousset construct.

Complication	Rate (%)
Pseudo-arthrosis rate
Harrington rod	3.1
Cotrel – Dubousset	1.7
Pedicle Screw	…
Total	1.9
Infection rate
Harrington rod	5.5
Cotrel – Dubousset	4.3
Pedicle Screw	1.18
Total	3.6
Reoperation rate
Harrington rod	8.3
Cotrel – Dubousset	4.8
Pedicle Screw	…
Total	3.6
Neurological complication rate
Harrington rod	…
Cotrel – Dubousset	0.7
Pedicle Screw	…
Total	0.2

Table: Comparative study between different types of Posterior Spine fusion in Adolescent Idiopathic Scoliosis

(Source:  Lykissas et al., 2013)

According to the reports published by Smorgick et al. (2013), posterior spine fusion surgery is linked with significant loss of blood both in intra operative and in post operative conditions. Smorgick et al. (2013) further highlighted that single and multi-level posterior spine fusion carriers a significant amount of hidden loss in blood that is not recognised by the usual practice of analysing the intra-operative loss and post operative drainage. It is mainly believed that hidden blood loss occurs due to extravasations of blood inside the tissue during surgery, blood haemolysis and blood loss during postoperative hospitalization along with ongoing blood loss. Smorgick et al. (2013) found that an estimate value of 40% of hidden loss in blood during occurring during the posterior spine fusion is greater than most physicians would expect. This hidden loss of blood caused a substantial drop in the mean haemoglobin level. Ialenti et al. (2013) showed that this amount of mean hidden blood loss is different in different surgical techniques. Moreover, the total and hidden loss in blood is prominently greater among the re-infused patients in comparison to non-reinfused patients this is because the reinfused patients have high potential of greater among of blood loss (Smorgick et al., 2013).

Recent data published by Muhly et al. (2016) highlighted that the average lenghth of stay (LOS) for a pediatric idiopathic scoliosis patient, who is undergoing posterior spinal fusion (PSF) is 5 to 6 days. Evidence suggests that the administration of the nonopiod analgesics can improve the overall pain-management among the adolescents who are undergoing PSF for AIS (Muhly et al., 2016). Muhly et al. (2016)  further highlighted that strategies like early mobilization and dietary liberalization along with early stage discontinuation of intravenous opiods can decreases LOS along with overall treatment cost without increasing early of late complications among the adolescents who are undergoing PSF. However, there is little information in the domain of quality recovery while employing an accelerated recovery pathway (Muhly et al., 2016).

Thus from the above discussion of the posterior spine surgery in relation of the adolescent idiopathic scoliosis, it can be stated that the posterior spinal fusion in AIS is associated with numerous adverse outcomes. One of the main adverse outcome is the hidden internal bleeding which leads to sudden drop in the blood haemoglobin rate in intra and post-operative care and thereby increasing the length of the hospital stay along with increasing the rate of complications. The study also showed that there are different types of posterior spinal fusion and each of the three categories is associated with certain degree of complication either more or less. Some of the common complications associated with posterior spinal fusion in AIS is high peri-operate rate, high re-infection rate and high rate of Pseudo-arthrosis. However, the overall rate of complications in the neurological ground for all the three posterior spinal fusion is less.

According to de Kleuver et al. (2014), a thoracoscopic approach for the insertion of anterior instrumentation has been developed during the past 10 years in order to obviate the disadvantages of the open anterior thoracic approach. Kleuver et al. (2014) is of the opinion that the morbidity that is associated with the thoracotomy is comparatively less due to negligible dissection of skin and chest wall in this method. Employing numerous small incisions along with endoscope, visualization techniques and anterior spinal surgery have been made feasible via this less invasive procedure. It employed for over a decade in order to execute the anterior thoracic spinal release and fusion operations with escalating rate of success (Kleuver et al., 2014). However, Lonner et al. (2012) have highlighted that earlier reports in regards to this particular protocol have been mixed like reports of difficulties in visualization and adequate access into the disc space. Lonner et al. (2012) have questioned completeness of the process of disc excision in open surgery. Newton et al. (2004) conducted a study over single surgeon’s experience with a preliminary series of 50 consecutive patients who underwent thorasoscopic anterior thoracic instrument along with fusion in order to treat scoliosis. Their results revealed that the initial groups of the patient’s population and their carers suggest that the approach of thoracoscopic surgery as a viable options for treating AIS in comparison to the open anterior thoracic approach. () revealed that the corrections achieved 2 years after the surgery was 55% in the present day technique and 58% in historical open series. However, the implant failure rate was higher under the open series (31%) in comparison to the patients treated with smaller threaded rods Newton et al. (2004). However, in spite of the acceptance that the anterior thoracic scoliosis corrections can be done thoracoscopically, the question regarding, should this be done in this particular approach still prevails. Cahill et al. (2014) is of the opinion that the procedure is extremely demanding in technical ground and at the same time offers little or rather say no single room for error. According to Cahill et al. (2014), single anterior rod instrumentation is less resistant to fatigue failure in comparison to the posterior constructs thus demanding early fusion for the surgery to be a success. early fusion requires a technique of thorough discectomy which when done thoracoscopically demands substantial experience. The overall process of discectomy also plays heavily into the process of correction obtained via instrumentation. Three-dimensional thoracic scoliosis correction via anterior approach demands shortening of the anterior column that is only feasible when complete circumference of the annulus fibrosis along with the nucleus have been removed. Complete excision of the disc promotes transverse plane derotation, coronal plane correction along with restoration of thoracic kyphosis. The thoracic vertebrae are significantly large enough to adequately accommodate only one transverse screw. However, the placement inside the vertebra is important for both the purchase of the screw along with the placement of the rod. There is no good process to recover from the mishap of misplaced screw thereby making the selection of the starting point along with direction for the starting point which is critical to the overall success. Thus Cahill et al. (2014) is of the opinion that the proper refinement in patient selection along with surgical ability of the physicians is likely to decrease the overall frequency of these interlinked technical errors and complications. However, the question still remains that should thoracoscopic must be done for AIS. In regards to this, Cahill et al. (2014) further highlighted that the potentail advantage of this operation in comparison to the traditional, open posterior and anterior approach must be measured critically. The artificial nature of the scoliodid surgery cannot be overlooked altogether and the majority of the patients and their care givers are more interested in small and minimal scars that thoracoscopic approach bestows without any doubt. The potential functional benefit of this approach however still remains the main driving force behind the development of the technique. Capitalizing the overall advantage of the open anterior thoracic instrumentation with principally less fusions and without the chest wall morbidity or posterior muscle dissection have been the main goals of the thoracoscopic instrumentation (Cahill et al., 2014). The study of Cahill et al. (2014) also highlighted that the operative results along with health related quality of life after the surgery in AIS are significantly positively correlated with the experience of the surgeon.

According to Wong et al. (2008), the recovery time taken during the thoracoscopic spine surgery generally depends on the age of the patients, their physical state, the experience of the doctor and the time taken in order to execute the overall spinal fusion. However the amount of blood loss occurring during the thoracoscopic spine surgery increases the length of the hospital stay during certain complicated scenarios.

Figure: Thoracoscopic spinal fusion

(Source: Spine Surgery Society of Australia, 2017)

Thus from the above theme it can be derived that the thoracoscopic anterior instrumentation for AIS is one of the viable surgical operation. However, there lies certain technical challenges in this domain and overall success rate of the surgery is directly associated with the overall experience of the surgeons.

Thoracolumbar and lumbar adolescent idiopathic scoliosis (AIS) was treated by anterior spinal instrumentation. It was made popular by Dwyer and Zielke during the year 1970s (Suk et al., 2012). The anterior approaches have been preferred among the skeletally immature patients because it actively restricts the crankshaft phenomenon. Moreover, it is also found to generatebetter rib hum correction and better curve while saving the fusion levels distally (Tao et al., 2012). Anterior spinal instrumentation mainly encompasses unilateral segmental ligation of the vessel during the surgery. The spinal cord is supplied two arterial system: three longitudinal arterial trunks within spinal canal and segemental arteries arising from aorta (Helenius, 2013).

Numerous studies have showed that the dual rod system provide safe and effective correction of scoliosis among the patients who are suffering from thoracic, lumbar and thoracolumbar curves (Helenius, 2013). This improvement of the structural curve is linked with thoracic hypokyphosis correction along with a spontaneous correction in the non-structural thoracic or thoracolumbar curve. Juvenile individuals suffering from idiopathic scoliosis, the restriction of anterior spinal growth may cause overkyohosing effect. The act of horizontalization of the lowest instrumented vertebral body in the lumbar spine is astonishing under the anterior dual rod screw instrumentations (Helenius, 2013). According to Smith et al. (2011) the risk of failure of this implant of screw pull-out seems to be extremely low under the application of this instrumentation. Helenius, Serlo and Pajulo (2012) are of the opinion that correction in rip hump is better while using dual rod anterior instrumentation in comparison to posterior instrumentation. Additionally, the probability of the deep and superficial wound infection along with the risk if implant breakage is potentially lower in patients with anterior spinal instrumentation in comparison to the posterior instrumentation. Dobbs et al. (2006) conducted a radiographic correction test and found that patients with AIS, posterior-only surgery with comprehensive pedicle screw system provides identical radiographic corrections in comparison to the anterior-posterior surgery.

Tao et al. (2012) conducted a research with an aim to compare the effects of posterior pedicle screw instrumentation and anterior rod-screw instrumentation over sagittal balance of patients with Lenke type 5 AIS. Their retrospective study mainly included patients who have the indications for surgery with a Cobb angle of thoracolumbar lumbar curve > 40 degree along with no cardiac or pulmonary failure. Tao et al. (2012) measured lumbar scoliosis and thoracolumbar scoliosis via antero-posterior standing X-rays. Their results highlighted that sagittal vertical axis (SVA) is potentially better in anterior spinal fusion (ASF) in comparison to posterior spinal fusion (PSF). Tao et al. (2012) study also revealed that more number of segments below the fusion were preserved in ASF group in comparison to PSF group. This highlighted that there are no significant movable segements below the fusion level in ASF. They also discovered loss of lordosis among the ASF group in comparison to PSF group. Their study showcased similar results with Shufflebarger Geck and Clark (2004) who found that the angle of the lumbar lordosis varied from 20 to 70 degree before surgery conduction to 34 to 47 degree after surgery. There were no traces of infection, pseudarthrosis, and misplacement of pedicle screws or requirement for revision in the spinal balance in ASF. Tao et al. (2012) measured the quality of life via SRS-22 score and found that ASF group of patients have better quality of life in comparison to PSF group of patients and significant difference was mainly highlighted over the functional activities.

(Source: Tao et al. 2012)

According to Huitema et al. (2012), standard thoractomy for anterior fusion and instrumentation of thoracic spine in idiopathic scoliosis have hamrful effects over the pulmonary function. The study conducted by Huitema et al. (2012) aimed to describe a comparatively less invasive anterior surgical technique to show post and pre-operative pulmonary function under minimal follow-up for up to 2 years. Huitema et al. (2012) selected Lenke type 1 adolescent thoracic idiopathic scoliosis patients and treated them with anterior spinal fusion followed by instrumentation under 53 degree of Cobb angle thoracic curve. Their results revealed that Forced Expiratory Volume (FEV1) improved significantly after minimal invasive thoracotomy within two-years of minimal follow-up. Thus overall they concluded that in adolescent idiopathic scoliosis patients, comparatively less invasive anterior approach used for overall correction and then fusion of the thoracic spine is safe surgical procedure with minimal detrimental effects on the pulmonary functions (Huitema et al., 2012).

According to Bachy, Bouyer and Vialle (2012), Deep wound infection after the anterior spine fusion is a difficult yet challenging problem and has significant amount of morbidity, recovery time and cost for the patient. A rigorous approach towards deep wound infection providing importance towards early irrigation and debridement enabled preservation of instrumentation along with successful fusion in the majority of cases. Bachy, Bouyer and Vialle (2012) is of the opinion that patient can expect short to medium-term clinical outcomes in comparison to the similar patients in whom infectious complications did not occur.

According to Ialenti et al. (2013), excessive blood loss remains a risk in the domain of spinal fusion in AIS. Autologous blood predonation, anesthesia, controlled hypotensive anesthesia, normovolemic hemodilution and perioperative antifibrinolytics have been found to decrease the rate of the intra-operative blood loss and subsequent requirement for the allogenic transfusion at the time of execution of the spinal fusion surgery for AIS. As per the findings of Shah, Celerin and Stanton (2009), male sex, number of levels fused, tenure of surgery, major Cobb angle, application of pedicle screws and age are the major predictors of intraoperative blood loss. Meert, Kannan and Mooney (2002) is of the opinion that underlying neuromuscular disease, under-weight and numbers of levels fused are the major predictors for the requirements of transfusion in a heterogeneous cohort of children and adolescents. The findings of Ialenti et al. (2013) highlighted that the male, sex, weight, height, pre-operative T2 – T12 kyphosis, pre-operative lumbar Lenke modifier, pre-operative major curve magnitude, preoperative hematocrit, predonation of autologous blood, video-assisted thoracoscopic surgery release, bone graft harvesting, operative time and number of levels fused are the major factors which manipulate the amount of blood-loss among the AIS patients.

Source: Anterior Spinal Fusion

(Source: Spine Surgery Society of Australia, 2017)

Thus in summary, it can be said that the anterior spine fusion though associated with certain amount of blood loss can be regarded as one of the significant approach in treating AIS. The effective pulmonary restoration is one of the significant benefits highlighted in the anterior spine fusion in AIS.

The main goal of the spinal surgery of AIS is correction of the deformity along with prevention of pain and pulmonary squeal. Both posterior and anterior approaches along with thoracic spine surgery have been used successfully used in this regard for numerous curve types. According to Verma et al. (2011), anterior spinal fusion (ASF) is a viable option for the main thoracic (Lenke type 1) and thoracolumbar (Lenke type V) AIS deformity. It is found to provide benefit in the domain of release of large rigid thoracic curvatures along with scoliosis associated with the process of lordosis encompassing Lenke 2, 3, 4 and 6 curve types. Some of the reported benefits anterior over the posterior spine fusion surgery include reduced loss of blood, shorter fusions along with transfusion requirements. Anterior spine fusion also score high in the domain of ability of maintaining thoracic kyphosis, ability of saving on an average of one to three distal segments and spontaneous lumbar curve correction. Verma et al. (2011) highlighted that of lately there has been a trend to avoid anterior spine fusion approaches and to utilize posterior-only segmental pedicle screw techniques because of the radiographic equivalence. In the same context, Verma et al. (2011) is of the opinion that potential pulmonary impact of anterior procedures in comparison to the thoracic surgery approach is much less and thereby gaining prominence in the treatment of AIS. Verma et al. (2011) is of the opinion that thoracolumbar curves which is treated anteriorly have no detectable change in overall pulmonary function or have significant improvement in SRS-22 outcomes during the follow-up of 2 consecutive years. In agreement to this, Kim et al. (2008) stated a decrease in PFT scores during a follow of 2 consecutive years when the concerned patient is treated with open from of thoracotomy and not with a thoracoabdominal approach. Wang et al. (2008) argued that the reported equivalent correction in the coronal curve with either the PSF or ASF approach under thoracolumbar or lumbar deformities. They also reported notable reductions in the operative blood loss and hospital cost along with significant thoracolumbar/lumbar deformities. However, their study did not reported any significant pulmonary outcomes. For thoracic curves, Verma et al. (2011) have highlighted that the ASF approach imparts negligible impact over the pulmonary function over a follow-up of 2 years. The patients who gone through VATS-I showed identical correction in curve along with improved scores in the domain of SRS-22 in comparison to PSF. However, this group of patients have been found to progress through slightly decreased peak flow under a follow-up of 2 years.

According to Wong et al. (2004), there are numerous plus points of anterior fusion for idiopathic scoliosis. Anterior approach bestows certain mechanical plus points because a corrective force is utilised at the greatest distance from the approximate centre of the curve in both the lateral rotation and displacement. The present rigid fixation of segment deals with placing the bone screws via a staple over the lateral surface of the vertebral body. This enables higher manipulation along with holding power in comparison to anterior instrumentation dealing with two-end vertebra. The screws which are placed over the vertebral body have at least 30% greater moment arm for using corrective forces in comparison to that of the posterior hooks. The anterior procedure deals with fewer segments in correction. In the context of PSF and thoracoscopic spine fusion, Wong et al. (2004) stated that advantages of posterior segmental spinal instrumentation encompass stable level of fusion followed by proper sagittal control, low pseudarthrosis rates and other advantageous effects over the pulmonary function. In case of PSF, the patients are also able to stand and then simultaneously ambulate without any postoperative brace. However, Wong et al. (2004) stated that there were no potential differences between the two from of spinal fusion (posterior and thoracoscopic) in the domain of scoliosis correction. Moreover, both the form of spinal fusion identically exhibited loss of percentage corrections of scoliosis during the follow-up observation along with significant time trend (Wong et al., 2004).

(Source: Wong et al., 2004)

The study conducted by Lonner et al. (2006) showed that the thoracoscopic spinal instrumentation is favorably comperative with posterior spinal fusion in the context of coronal plane curve correction, saggital contour, balance, pulmonary function, the rate of complications and patient’s based outcomes. The advantage of PSF mainly include the requirement of fewer levels of spinal fusion, lower transfusion requirements, less operative blood loss and improved cosmesis due to small yet well-hidden incisions. However, the overall operative time taken for the thoracoscopic technique is nearly doubles that of the PSF technique (Lonner et al., 2006).

(Source: Lonner et al., 2006)

The research undertaken by Gatehouse et al. (2007) in order to study 100 consecutive endoscopic anterior scoliosis corrections undertaken during the tenure of April 2000 and February 2006 showed that ASF have gained significant statistical improvements along with increased consistency in the overall operative time, overall the entire operative settings, the time of the x-ray irradiation, total loss in blood, length in the hospital stay and time taken for spontaneous mobilization.

When a critical comparison is done between standard posterior approach, and thoracoscopic approach the anterior approach leads to more enhanced three-dimensional correction of adolescent idiopathic scoliosis (AIS). Though controversy exists regarding the usefulness of anterior approach in comparison to the other two approaches, there is a clear indication that it is better than the other two in significant and valid studies.

According to Franic and Kovac (2006) the anterior approach is best for three-dimensional correction of scoliosis. A study was carried out with 50 patients suffering from idiopathic scoliosis undergoing corrective spinal surgery. Anterior spinal fusion with the help of modified Zielke ventral derotation system (anterior approach to spine through thorax) carried out in 25 patients, and 25 patients underwent posterior approach. The average preoperative thoracic curve in coronal plane was 66.7 ± 9.9° and 65.0 ± 11.7° in the anterior and posterior correction groups, respectively. Measurement of Coronal and sagittal correction, rib hump, apical vertebral body rotation, and rib depression correction were first done and then the surgery was carried out (30 days after surgery). 2 years time was given before the second follow up. Cobb and Nash-Moe method was used for Posteroanterior and laterolateral radiographs of the erect spine. The aim was to assess coronal, sagittal, and horizontal plane corrections. Measurement of Rib hump and rib depression was done with Thulbourne-Gillespie measuring device. For statistical analysis the Student two-tailed ttest was used for understanding differences in scoliosis correction parameters in the two groups. The results were that the thoracic curve of 66.7 ± 9.9° before surgery in the anterior correction group was reduced to 14.8 ± 8.7° after surgery (78.1 ± 12.4% relative correction). Apical vertebral body rotation correction from 2.0 ± 0.4° to 0.8 ± 0.6° was achieved in the anterior correction group (62.0 ± 26.6% relative correction). Rib hump correction from 22.4 ± 15.5 mm to 5.4 ± 5.2 mm occured in the anterior correction group (70.9 ± 26.0% relative correction). It can be concluded on this basis that in relation to the preoperative values of the Cobb’s angle, patients would achieve highly appreciable correction in the coronal plane by anterior approach. A mild kyphotic effect can be expected to be found in the anterior correction group, which in the case of the posterior correction group is not there. Further, a minimally kyphogenic effect can be found due to the anterior thoracic approach. Better correction of rib hump is also a benefit.

From the study of Rioullan et al., (2016) anterior instrumentation produced both good functional outcomes and good correction in the coronal and sagittal planes. The researchers carried out a study with 35 patients. Mean pre-operative Cobb’s angle was 44°, mean SRS-30 score was 3.65/5, mean age at surgery was 14.7 years, and mean ODI was 14.9%. At last follow-up, mean Cobb’s angle was 14.7° and 25 patients exhibited coronal misalignment with a mean deviation of 12 mm. The functional outcome that was under assessment with the help of the SRS-30 score had a significant correlation with pelvic tilt and anterior SVA translation. Thus it can be concluded that anterior spinal fusion leads to substantial long-term functional outcomes in AIS. It can also be further said that correction is sustained and satisfactory. Anterior SVA translation with time is associated with improved functional outcomes.

Assessing further the benefits of anterior open scoliosis surgery it can be mentioned that the use of rod system is an effective and highly safe process to address scoliosis. The cosmetic outcomes have been good, as denoted by a number of studies (Jada et al., 2017). AIS patients who undergo anterior surgery have more chances of demonstrating a considerable and noteworthy decrease in percentage of predicted lung volumes at the time of follow up.

Table of comparison of anterior and posterior approach

Feature	Anterior approach	Posterior approach
Mechanical advantage	More	Less
Curve correction	More	Less
Kyphosis	Less	More
Loss of correction	Less	More
Number of motion segments  fused	Less	More
Cobb’s angle	Smaller increase	Larger increase
Lung volume at follow up	Less loss	More loss
Cosmetic outcomes	Very good	Good

Adolescent idiopathic scoliosis (AIS) can be successfully treated by surgery focusing in the correction of the curvature of the individual’s spine. Though it is a painful procedure carried out in surgical settings, the outcomes of the same are noteworthy. Experiences of patients undergoing surgeries and opinions expressed by them point out that surgical processes hold much potential to enhance the quality of life of patients within a short phase of time. From the above analysis, it is clear that anterior surgical approach is far better than the other two approaches, namely posterior and thoracoscopic surgery (Gatehouse et al., 2007).

While the utility of anterior approach has been well documented in literature, the need of proper driving factors to make the surgery successful has also been acknowledged. It can be said that healthcare facilities must consider proper resource allocation for making critical surgeries successful. This includes human resource allocation as well as materialistic resource allocation. The need of proper management of surgical procedure brings in the concept of project management into healthcare domain (Ericco et al., 2008). The concept of project management in surgical settings such as the one involving anterior approach in AIS emerges as one of the most significant skills at the contemporary era that can be highly useful for controlling costs, reducing risks and improving patient outcomes. Across the discipline, the underlying notions of project management would refer to the appreciable process of systematic planning, organizing and implementing steps for maximizing utilization of resources. The different aspects of project management pertaining to our area of concern include clear goals and objectives, cost effectiveness time, human resource allocation and appropriate engagement of stakeholders (Gopinatha, 2015).

Team formation is a crucial step in surgery process since the involvement of the capable professionals is very much essential for best patient outcomes. In surgical domain, projects would range from simple patient cases to highly complex ones.  Since AIS surgery might lead to certain undesirable changes in the body, it is essential that the team is formed as per the needs of the patient. For this, an accurate assessment of the patient condition is entailed. Each surgical group would be unique, and an experienced professional having leadership role has to take up the responsibility of setting up the team. The composition of the team might vary from members delegating tasks in an independent manner to a member of four to seven working in collaboration with each other. In each case, the ultimate outcomes are to be visualised well before the surgery (Shirley, 2016). It is to be highlighted that for ensuring that updated surgical techniques are considered for anterior approach in AIS, it is suggested that surgeons work in collaboration with health economists and clinical investigators. Though teams might augment the ability and skills of one surgeon in the process translating research into practice, the added task of managing appropriately the team dynamics might be challenging. What is learnt is that effective management of a surgical process cedes control to frontline professionals so that there is easy identification of problems and rapid resolve of the same. This entails that healthcare professionals are to report any issues arising while the surgery is being carried out and throughout the follow up in an adequate manner. Professionals are therefore to be empowered to define value from the perspectives of the patient (McLaughlin & Olson, 2008).

At this juncture it would be advisable to bring into limelight the concern of resource allocation for making anterior surgery approach a success for AIS across settings. Reflecting on the research of Govaert et al., (2015) it can be stated that resources are to be considered in light of the exact needs of the patients. Allocation can be done on the basis of the waiting times of the patients. The principle of integrity is also to be considered in the process of resource allocation. This implies that resource allocation is done as a process shared with the respective patient and family members. Further, allocation has to incorporate ‘systems thinking’, identifying a proper transfer of needed resources for supporting the processes. In this alignment, the opinion of Helenius, (2013) is to be brought into focus. A piece of caution lies in assigning resource allocation as the potential occurrence of trends not made a part of the audit might be influencing outcomes. Further, continuous development in the anterior technique might be possible.  Initiatives for quality improvements through resource allocation in particular hospitals might be a reason for overestimation of auditing results.

In light of the need of proper outcomes of anterior surgery approach in AIS, it can be stated that surgical auditing would be crucial for benchmarking and facilitating quality improvement. As opined by Laing et al., (2017) healthcare costs can be reduced by surgical auditing. Surgical auditing would act as the quality instrument responsible for collecting detailed information from care professionals to be further used for improving quality of care. This is to be done through regular feedback provided to the clinicians about the results of the surgeries undertaken. Further, surgical auditing would be useful for getting rich information of patients who did not have successful surgery outcomes. Surgical auditing has economic and societal importance, as pinpointed by (Bermudez et al., 2010).  As understood from literature, the main aim of healthcare through surgery is to maximize value for patients. The definition of value goes as the health outcomes achieved that are vital for the patients, relative to the costs behind the input given. One of the elements of healthcare is measurement of outcomes and costs for addressing needs of each patient. Through surgical auditing, results can be systematically measured. As a result, the consecutive surgical cases would eventually be better. The relation between surgical auditing and quality improvement is significant. 

It is recommended that surgeons must consider a thorough assessment of the history of the patient before processing with the surgery. Without an in-depth knowledge of the condition of the patient and the medical background, the spine surgeon would not be able to successfully understand the indications for surgery. In addition, the long term management of the condition would also not be possible (Wagner et al., 2015). Fundamental evaluation of the patient suffering from AIS would revolve around a comprehensive physical examination and understanding of patient history. It is also crucial that the applicable radiographic images are obtained within the stipulated time. For those in whom surgery is considered, a number of factors would drive treatment plan post surgery. The primate aim of surgery would be sufficient coronal and sagittal realignment, prevention of curve progression, and the preservation of motion. Vertebral-level selection, fixation strategies, curve-reduction techniques, postoperative protocols, and possible complications all are pivotal in the thriving surgical treatment of AIS. Thus, these factors are to be carefully reviewed by the surgeon (Lehman et al., 2015). When there is an in-depth understanding of all the variables, a spine surgeon is in a position to attain exceptional outcomes for his or her AIS patients.

Appropriate project management approaches would bring in good outcomes for patients undergoing AIS. The evident benefits would be reduced length of stay at hospital, improvement in peri-operative services as a result of suitable resource allocation, and improved timeline of surgery cancellations (Sudo et al., 2016). Further, the chances of adverse events are also less. Time management is crucial for achieving savings in cost and professionals must set up a robust plan prior to commencement of the surgery. It is further recommended that patients are to be made an active participant in the care process (Huitema et al., 2015).

Research in the field of AIS surgery is also highly demanded (de Kleuver et al., 2014). The key areas that need immediate attention are blood conservation techniques, use of pedicle screws, techniques for reducing curves, spinal cord monitoring and use of bone substitutes. AIS instrumentation strategies are to be considered for planning larger viability of surgical process. Diverse school of agreement for the present surgical management of the condition has been identified. There also exists empirical evidence for the same. The areas where little research has been done need further research. Though most of the results have been founded on high quality expert judgment, more robust quantitative research is needed for validating the same. Since patient care in AIS treatment is evolving, it is though necessary to deviate correctly from what is perceived to be the best among different approaches.

In conclusion, Adolescent idiopathic scoliosis (AIS) is a major 3D spinal deformity in the body that is found to affect children aged between 11 and 18 years. What is a striking feature of the condition is that it is without an identifiable etiology. AIS condition is the most common treated type of scoliosis where one or more segments of the thoracolumbar vertebral column is involved. The precise prevalent rate of AIS cannot be estimated accurately, and there exists differences across literature. The present body of literature comes up with varied possibilities for the cause of AIS, such as genetics, dorsal shear forces and axial rotational instability, biomechanical growth modulation,uncoupled spinal neuro-osseous growth, postural abnormalities and hindbrain dysfunction, motor control problems.

A deep insight into the benefits of the three surgery approaches, namely anterior, posterior and thoracoscopic, indicates that anterior fusion is considered as an effective procedure as the main advantages are larger number of levels left free caudad to the fusion and better correction of the rotational deformity. Anterior instrumentation also leads to better correction of the frontal and sagittal plane deformities while fusing shorter segments. Thus, anterior approach is the best among the three known approaches and further developments are needed in this regard. It is further to be noted that posterior techniques is a representation of the foundation of approaches. Anterior approaches might be reserved for patients who suffer thoracolumbar curves or those who are skeletally immature. Further investigations are however needed at the earliest. Studies have revealed that the reduction in pulmonary function is not permanent in case of anterior scoliosis surgery. Pre operative pulmonary function test can achieve a FEV1/FVC ratio of an average 88 and immediate post operative value can decrease by an average 5 (5.7%). Further, no research points out excess kyphosis, gross loss of correction or pseudoarthrosis or failure in implant when patients are subjected to follow up assessments. Lastly, there is a loss of mechanical advantage of using the corrective forces at site of deforming force if posterior approach is chosen.

The indication for surgical treatment in AIS is curved > 45 degree to 50 degree, and progressing curves. The ultimate aim of the surgical approaches is to bring a correction in the deformity and stabilization in the spinal curve. This is done with the help of instrumentation that has undergone rapid evolution in the recent past. In individuals suffering from AIS, the physical change that is suffered is curvature in the spine to one side and rotation along the long axis. As a result of this, unilateral prominence of trunk is noticed. Conventionally, idiopathic scoliosis had been treated with the help of posterior instrumentation and fusion which are still now considered to be gold standards. With the advancement of technology there have emerged a number of new techniques that give better results in shorter duration. Anterior spinal fusion carried out with Dwyer instrumentation is known to be the first generation of anterior implants used for correcting lumbar scoliosis. The next generation witnessed the use of Zielke rigid rod anterior instrumentation for saving fusion levels in the distal lumbar spine. Due to different concerns arising in relation to high rate of rod breakage as found in follow up studies, a new rod-screw-nut system was under development for a long time. The third generation posterior approaches provided three dimensional as well as powerful corrections in the body. However, these result in a number of complications like shoulder asymmetry, lumbar curve decompensation, recurrence of ribhump deformity, and trunk shift. Since such outcomes are not to be tolerated, alternative approaches such as the anterior approach is welcomed.

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