1. Surgical Treatment of Main Thoracic Scoliosis with Thoracoscopic Anterior Instrumentation by Peter O. Newton, Vidyadhar V. Upasani, Juliano Lhamby, Valerie L. Ugrinow, Jeff B. Pawelek, and Tracey P. Bastrom JBJS Essent Surg Tech Volume os-91(Supplement 2):233-248 October 1, 2009 ©2009 by The Journal of Bone and Joint Surgery, Inc.

2. The patient is positioned in a direct lateral decubitus position. Peter O. Newton et al. J Bone Joint Surg Am 2009;os- 91:233-248 ©2009 by The Journal of Bone and Joint Surgery, Inc.

3. Operating room setup. Peter O. Newton et al. J Bone Joint Surg Am 2009;os- 91:233-248 ©2009 by The Journal of Bone and Joint Surgery, Inc.

4. This intraoperative photograph shows the fan retractor placed on the lung, exposing the cephalad aspect of the spine. Peter O. Newton et al. J Bone Joint Surg Am 2009;os- 91:233-248 ©2009 by The Journal of Bone and Joint Surgery, Inc.

5. The ultrasonic scalpel is utilized to open the pleura longitudinally just anterior to the rib heads and to coagulate the segmental vessels. Peter O. Newton et al. J Bone Joint Surg Am 2009;os- 91:233-248 ©2009 by The Journal of Bone and Joint Surgery, Inc.

6. The ultrasonic scalpel is used to circumferentially expose the spine. Peter O. Newton et al. J Bone Joint Surg Am 2009;os- 91:233-248 ©2009 by The Journal of Bone and Joint Surgery, Inc.

7. This intraoperative photograph demonstrates the three portals utilized during spine exposure and discectomy. Peter O. Newton et al. J Bone Joint Surg Am 2009;os- 91:233-248 ©2009 by The Journal of Bone and Joint Surgery, Inc.

8. This intraoperative photograph demonstrates the pituitary rongeur being used to initiate the discectomy following incision of the anulus with the ultrasonic scalpel. Peter O. Newton et al. J Bone Joint Surg Am 2009;os- 91:233-248 ©2009 by The Journal of Bone and Joint Surgery, Inc.

9. Following discectomy and circumferential anular excision, the posterior longitudinal ligament can be seen in the depths of the disc space. Peter O. Newton et al. J Bone Joint Surg Am 2009;os- 91:233-248 ©2009 by The Journal of Bone and Joint Surgery, Inc.

10. Following discectomy at the caudad level, morselized cancellous graft and an allograft fibular strut can be seen filling the disc. Peter O. Newton et al. J Bone Joint Surg Am 2009;os- 91:233-248 ©2009 by The Journal of Bone and Joint Surgery, Inc.

11. Kirschner wires are placed to confirm proper posterior trocar placement. Peter O. Newton et al. J Bone Joint Surg Am 2009;os- 91:233-248 ©2009 by The Journal of Bone and Joint Surgery, Inc.

12. Confirmation with the image intensifier. Peter O. Newton et al. J Bone Joint Surg Am 2009;os- 91:233-248 ©2009 by The Journal of Bone and Joint Surgery, Inc.

13. The green 15-mm-diameter trocar used for screw insertion has been placed. Peter O. Newton et al. J Bone Joint Surg Am 2009;os- 91:233-248 ©2009 by The Journal of Bone and Joint Surgery, Inc.

14. The screw path is established with an awl (Fig. 11-A) and a tap (Fig. 11-B), placed from directly lateral in the middle of the vertebral body. Peter O. Newton et al. J Bone Joint Surg Am 2009;os- 91:233-248 ©2009 by The Journal of Bone and Joint Surgery, Inc.

15. The vertebral body screws have been placed at each level, and the contoured rod has been brought in from the caudad portal in preparation for being engaged from cephalad to caudad. Peter O. Newton et al. J Bone Joint Surg Am 2009;os- 91:233-248 ©2009 by The Journal of Bone and Joint Surgery, Inc.

16. After the rod has been engaged in the cephalad two screws and bone graft has been placed in the disc space, compression is applied between these levels. Peter O. Newton et al. J Bone Joint Surg Am 2009;os- 91:233-248 ©2009 by The Journal of Bone and Joint Surgery, Inc.

17. An endoscopic rod-approximating device is utilized to reduce the rod into the caudad screws. Peter O. Newton et al. J Bone Joint Surg Am 2009;os- 91:233-248 ©2009 by The Journal of Bone and Joint Surgery, Inc.

18. The endoscopic suturing device is utilized to reapproximate the pleura over the top of the instrumentation. Peter O. Newton et al. J Bone Joint Surg Am 2009;os- 91:233-248 ©2009 by The Journal of Bone and Joint Surgery, Inc.

19. Preoperative posteroanterior (Fig. 16-A) and lateral (Fig. 16-B) upright radiographs of a patient prior to thoracoscopic anterior spinal instrumentation and fusion. Peter O. Newton et al. J Bone Joint Surg Am 2009;os- 91:233-248 ©2009 by The Journal of Bone and Joint Surgery, Inc.

20. Radiographs made two years postoperatively demonstrate correction of the thoracic curve with a balanced spine. Peter O. Newton et al. J Bone Joint Surg Am 2009;os- 91:233-248 ©2009 by The Journal of Bone and Joint Surgery, Inc.