THE TREATM EN T OF SCOLIOSIS Page 4 P H Y S I O T H E R A P Y September, 1958. F. J. Ill 1)1)1 \ . B.Sc .. M.B., B.Cn. (W m ;M. I .R.C .S. (Em :.), F.R.C'.S. (E u in .) A c t in!; H o n . O rth op aed ic Surgeo n. O rth op aed ic D e p a rtm en t, A dd ington H o s p ita l, D u rb a n '1 J O H N C o b b o f A m e r i c a , r e c e n t ly s u u c d in a le c t u r e in L o n d o n , t h a t in o r d e r t o t r e a t s c o li o s is , ' Y o u d o n I h a v e to be c r a z y b i n il su r e h e l p s ' ! In rec ent ye ar s, h o w e v e r , the m a n a g e m e n t , a l t h o u g h s ti l l c o n t r o v e r s i a l , has g r a d u a l l y p r o ­ gressed a l o n g c e r t a i n sane a n d d e l i m i t lines. T h i s has been d u e , in p a r t i c u l a r , t o th e d e v e l o p m e n t o f a c c u r a l e m e a s u r e ­ m e n t o f i h e c u r v e s b y ihe m e t h o d o f F e r g u s o n , 1 l a l e r m o d i f i e d b y C o b b ; - ' s p in a l f u s i o n as a m e t h o d o f t r e a t i n g s c o li o s is b y H i b b s r ' 1 i h e use o f a c o r r e c t i n g t u m b u c k l e j a c k e t by K i s s e r 1 a n d , f i n a l l y th e e s t a b l i s h m e n t o f an a c c u r a t e p r o g ­ nos is in i d i o p a t h e t i c s c o li o s is b y P o n s c ti a n d F r i e d m a n . ’' Sco lio sis is a h ttcrid cu rvatu re of the \pinc a n d c o n s i s ts o f 2-4 c u r v e s . T h e c o m m o n e s t p a t t e r n is th e t r i p l e c u r v e w i l h a p r i m a r y o r m a j o r c u r v e in th e m i d d l e , a n t i t w o s e c o n d ­ a r y o r c o m p e n s a t o r y c u r v e s , o n e a b o v e a n d o n e b e l o w w h i c h d e v e l o p l a t e r in o r d e r t o ke ep i h e h ead d i r e c t l y a b o v e th e p el v is . T h e m a j o r c u r v e u n d e r g o e s s e c o n d a r y ch a n g e s , c o n s i s t i n g o f fi x e d r o t a t i o n o l the b o d i e s o l th e v e r t e b ra e s o t h a t th e s p i n o u s proces se s are r o t a t e d t o th e c o n c a v i t y o f the c u r v e , a n d o f w e d g i n g o f the v e r t e b r a e o n th e c o n c a v e side. In the s e c o n d a r y c u r v e s r o t a t i o n is m u c h less m a r k e d a n d d o c s n o t d e v e l o p u n t i l m u c h l a l e r (See Fi gs. I a n d 4.) O t h e r less c o m m o n p a t t e r n s m a y c o n s i s t o f 2 o r 4 c u r v e s (see b e l o w ) . C lin ic a l E x a m in a tio n Cas es o f s c o li o s is a r e best d e a l t w i t h in a sp ec ia l c l i m e so t h a t a d e q u a t e t i m e c a n be g iv e n t o a d e t a i l e d h i s t o r y a n d e x a m i n a t i o n o f ea c h case. It is u s ef u l t o r e c o r d the f i n d i n g s o n a s p e c ia l f o r m . T h e h i s t o r y s h o u l d i n c l u d e th e age o f o n s e t o f the s c o li o s is , past illnesses ( p a r t i c u l a r l y p o l i o m y e l i t i s ) , the r a p i d i t y o f p r o g r e s s o f th e c u r v e , a n d w h e t h e r th e re is a n y f a m i l y h i s t o r y o f s c o li o s is . T h e e x a m i n ­ a t i o n s h o u l d be c o n d u c t e d w i t h th e c h i l d s t a n d i n g a n d the b a c k s h o u l d be e x a m i n e d in er ect a n d b e n d i n g p o s i t i o n s . D e t a i l s o f th e d e f o r m i t y s h o u l d be r e c o r d e d , s u ch as e l e v a ­ t i o n o f th e s h o u l d e r , p r o m i n e n t s c a p u l a , list o f s p in e to o n e si de, p r o m i n e n t H ank crease a n d p r o m i n e n t h ip . T h e a p e x o f th e m a j o r c u r v e s h o u l d be d e l i n e d c l i n i c a l l y w i i l i i h e c h i l l i b e n d i n g f o r w a r d . A c o m p l e t e m u s c le c h a r t i n g s h o u l d be p e r f o r m e d , a n i l i h e h e i c l i t . w e i g h t a n i l leg le n g t h s r e c o r d e d . T h e chest d e f o r m i t y s h o u l d be n o t e d a n d th e v i i a l c a p a c i t y o f the l u n g s e s t i m a t e d . F i n a l l y a c a r e f u l s e ar c h s h o u l d be m a d e f o r ' t h e cafc-au-lait m a r k s o n th e s k i n f o u n d in n e u r o f i b r o ­ m a t o s i s , a n d c l i n i c a l p h o t o g r a p h ) , a r e t a k e n f o r r e c o r d p u rp o s e s . X - ra y E x a m in a tio n T h i s c o n s i s ts o f r o u t i n e l i l m s ta k e n o n 17 14 i n c h p l a i t s . T h e s e a re A P e re c t a n d s u p i n e o f i he w h o l e s p in e , a n d a l s o a l a t e r a l o f th e s p in e o n the l i r s l v i s i t o l th e p a t i e n t . Bend ing films a r e t a k e n w i i l i the p a t i e n t b e n d i n g l i r s l t o the r i g h t a n d t h e n t o i h e l ef t t o d e t e r m i n e th e r i g i d i t y o f the c u r v e s . In th e p a r a l y t i c c u r v e a f t e r p o l i o m y e l i t i s , a t i l t H im is a ls o t a k e n (see belo w'). T h e a n g l e s o f th e c u r v e s ar e m e a s u r e d a n d r e c o r d e d . T h e l i m i l o f e a c h c u r v e is d i s t i n g u i s h e d b y n o t i n g t h a t , w h e r e a s in the p r i m a r y c u r v e th e d is c is w i d e n e d o n o n e side , in the c u r v e a b o v e o r b e l o w it is w i d e n e d o n i h e o p p o s i t e side. A t e a c h j u n c l i o n th e r e is a n e u t r a l dis c e q u a l in w i d l h o n b o t h sides. L in e s are d r a w n p a r a l l e l to the l o w e r b o r d e r o f the l o w e s t v e r t e b r a a n d th e u p p e r b o r d e r o f i h e h ig h e s t v e r t e b r a o f ea ch c u r v e . F r o m these lin es p e r p e n d i c u l a r s are e r e c t e d , a n d the tin gles tit w h i c h these m e et a r c the ti n g le s o f th e c u r v e s . T h e d eg re e o f w e d g i n g a n i l r o l a l i o n o f th e v e r t e b r a is a ls o n o t e d . T h e r e s u lts s h o u l d be r e c o r d e d o n th e s p ec ia l S c o li o s is C h a r t . Figure 1. A t h orn c o - lu m liar i d i o p a t h i c c u r v e . 1 8 - LI 71 (maior curve) with upper secon­ dary curve, 12 17 39 , and lower secon­ dary eur\e, L2— SI 35 . F i n a l l y , i h e c h i l d s h o u l d be seen e v e r y 3 m o n t h s , o r l a l e r 6 m o n t h s , f o r c l i n i c a l e x a m i n a t i o n a n i l X - r a y , u n t i l s p i n a l g r o w t h has ceased a n d th e r e is n o t u r t h e r increa se o f th e c u r v e . C L V S S I I 1C V N O N B Y A l I I O L O C , Y T h e a e t i o l o g y o f the case m u s t n o w be a c c u r a t e l y d e t e r ­ m i n e d . In t h i s p a p e r th e s u b j e c t is c o n s i d e r e d in a c c o r d a n c e w i t h th e f o l l o w i n g a e l i o l o g i c a l c l a s s i f i c a t i o n : A . Fu n c tio n a l 1. P o s t u r a l 2. C o m p e n s a t o r y l i . S tru c tu ra l 1. I d i o p a t h i c S c o li o s is , i.e. s c o li o s is m w h i c h the e x a c t a e t i o l o g y is n o t k n o w n , c o n s t i t u t e s 8 0 - 9 0 " , , o f a ll cases. 2. P o s l - p o l i o m y e l i s 5 - I O " „ 3. N e u r o f i b r o m a t o s i s 2 ", , 4. C o n g e n i t a l cases less t h a n 2 " , , R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) S e p t e m b e r , 1958. P H Y S I O T H E R A P Y Page 5 5. T h o r a c o g e n i c cases ( p o s l - c m p y c m a . p o s t - t l i o i a - c o p l a s t y ) less l l i a n 2 6. O s t e o c h o n d r o d y s t r o p h y ( M o r q u i o ' s disea se ) les^ t h a n I 7. F r i e d r i c h ' s A l a x i a less I ha n I 8. S p a s ti c P a r a l y s i s a n d R i c k c t s \ c r y i a i c A. Functional 1. P o s m ra l Scoho\t\. In p o s t u r a l s c o li o s is t h e i c is a m i l d si ng le la t e r a l c u r v e , w i n c h d i s a p p e a r s o n s u s p e n s i o n o r o n b e n d i n g f o r w a r d . R o t a t i o n o f the v c i t e b r a e d o c s n o r o c c u r , a n d the c u r v e do e s n o t c h a n g e i n t o a s l r u c i u i a l one. 2. Com/’cn siiio ry Sco lio sis is d u e t o a s l io i I leg oi to d e f o r m i t y o f I he h i p j o i n t . It sliow-.s i w o curvc.s w i t h o u t r o t a t i o n , c o m m e n c i n g at th e level o f th e l u m b o - s a c r a l j o i n t . It d o e s n o t p r o g r e s s a n d o n l y r a i c l y , il c w ci . b e co m e s a fixe d s t r u c t u r a l c u i a c . B. Structural , S t r u c t u r a l S c o li o s is is a l a t e i a l c u i a u I u i c o f th e sp ine r i v i t h r o t a t i o n o f the v e r te b r a e 1. liHopm Uic Sco lio sis T h e n a t u r a l h i s t o r y a n d p r o g n o s i s o f the c u r v e l i . n e been d e s cr ib e d b y P o n s e l i a n d F n e d i n a n . ' ' o f A m c i i c a . a n d Ja mes o f L o n d o n . ' ' a n d are o f th e u t n i o s i i m p o i i a n c c in t r e a t m e n t . T l i e h i g h e r the sue o f the p n m a i y c u i a c a n d the e a r l i e r its o n s e t , th e w o r s e is i he p i o g n o s i s . T h e on se t m a y be at a n y age in c h i l d h o o d R is s c r's s i g n ' is u s e f u l in th e p i o g n o s i s l i is sa id to be p o s i ti v e w h e n the i li a c a p o p h y s i s a p p e a r s in i h c r a d i o g r a p h all the w a y r o u n d th e crests, f r o m th e a n t e r i o r t o th e p o s ­ t e r i o r s u p e r i o r sp ines . T h i s c o i n c i d e s w i i l i i h c f u s i o n o f the v e r te b r a l e p i p h y s e s , f o l l o w i n g w h i c h , as th e r e is n o f u r t h e r g i o w t h , n o tin thei d e i c u o r a t i o n in th e c u i ' . c w i l l o c c u i In g ir l s , [l ie o n se t o l m e n s n n a t i o n u s u a l l y p i c c c d c s th is sign by a l e w m o n t h s The sc'.cin i o f th e c u i a c ' s a rc ( I ) m i l d , i e. less th a n 70 . (2) s c \ e r e 7 0 - 1 0 0 . \ c r y s e \e r e o \ e r 100 I d i o p a t h i c s c o li o s is is e o m n m n c i in g ir l s t h a n b oy s a n d the c u i a c is c o m m o n c i t o th e l i g h t , w i t h tin e e x c e p t i o n o n l y (.see (a) t i n ) b e l o w ) [a ) Liiin h u i hliti/Hiihu Scoho\i'. o c c u r s in 2 6 11,, o f cases. 1 he a p e x is at I I u s u a l l y , a n d the c u r v e e x t e n d s f r o m T I I t o L. l) l a r c m i l d a n d the d e f o i m i i y is s l i g h t becau se n o l i b s a r e i n \ o l \ e d a n d th e s h o u l d e r s r e m a i n l e v e l . T h e p i o g n o s i s is g o o d , a n t i n o n e o! the cases need c o l l e c t i o n c m f u s i o n . T h e o n l y c o m p l i c a t i o n is l o w b a c k p a i n in m i d d l e lif e f r o m a r t l n i i i s o f the p o s t e r i o r i n i e r \ c r i e b r . i l j o i n t s d u e t o t h e i r e x t i e m e r o t a t i o n . (/>) rh o itn o - liin ’htii S o c c u i t s in (<"„ o f cases T h e a p e x o f th e c u i a c i s at T I I oi 12 a n d e x t e n d s f r o m T 6 o i 7 t o L I o r 2 I w o - i h i i d s a r c m i l d a n d o n l y o n e - t h i r d b e c o m e se v ei e . a n d d e f o i m i t y is n o t u s u a l l y m a i k e d e x c e p t in s e \ c r e cases, w l i c i e n h s a r c i m o h e d a n d th e s h o u l d e r s d i o p a n d th e h i p b e c o m e s p i o m i n e n i ( F i g . h (<) rh o m c u S io h o \ i\ o c c u r s in 43 ” n. T h i s is the m o s t i m p o r t a n t g i o u p . f o r in these cases the c u r v e s p r o g r e s s m o i e l a p i d l y th a n in o t h e r typ e s , g u i n g the lar ge st curvc.s a n d p r o d u c i n g th e w o r s t d c f b i m i n e s T h e a p e x o f ti le c u i a c is b e t w e e n 7 6 a n d T 10. a n d the \ c i t e b i a e sh o w m a i k e d w e d g i n g . l o t a t i o n a n d o s t e o p o i o s i s T h e y a i e c la s s ifi e d a c c o i d i n g t o the age oI o n s e t , a n d o c c u r m a i n l y in the ̂ p e u o d s o f r a p i d g i o w d i i i ) T h e titb lt'stc m g i o u p . c o m m e n c i n g a f t e i th e age o f 10 ye a r s (21 " „ ) t i l ) T h e ittw iu le g i o u p . c o m m e n c i n g b e t w e e n til e ages o f 5 a n d }■( ye a r s (5 T h e cases in g i o u p s t i ) Figure 2. Figure 3. Figure 4. Thoracic type paralytic scoliosis. Same ease showing the "razor back” Same case X-ra> curve 13— 110 meas- t\p e of deformity due to rib rotation, uring 104 . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 6 P H Y S I O T H E R A P Y September, 1958. and (ii) are com m oner in girls and the curves are mainly to the right in both groups. The prognosis is bad; 60% o f the adolescent cases and 85% o f the juvenile develop severe curves. (iii) The infantile thoracic group com m ences before 3 years o f age (11% ). It is com m oner in boys and the curve is more often to the left, making this a distinct pattern from the previous thoracic curves. The deformity is severe, rotation occurs early, and over 90% o f cases are severe by the age o f 10 years. The prognosis is very bad in the majority o f cases; although in a few the condition remains stationary or disappears, in the majority it progresses steadily. (d) C om bined Thoracic a n d Lum bar Scoliosis occurs in 23 %. This com bines the characteristics o f both lumbar and thoracic scoliosis, and has 4 curves— 2 primary in the middle with rotation, and 2 secondary. The upper primary curve is usually from T. 6 to T. 10, and the lower primary from T. 11 to L. 4. The two curves keep in step and balance each other, and the deformity is slight, for the shoulders remain level and the hips are covered. The prognosis is good. 2. P aralytic Scoliosis0 Scoliosis is com m on in a growing child after an attack o f poliom yelitis with paralysis o f the trunk muscles. There are two main groups (Fig. 5). (a) Firstly severe symmetrical paralysis, which causes a collapsing spine, as the spine is unstable in the erect position but does not give a severe curve. It is due to the force o f gravity. (b) Secondly, and more com m only, a curve develops from asymmetrical weakness o f the trunk muscles plus the force o f gravity, the convexity (jeveloping on the weaker side. The muscles which cause the scoliosis are the inter- costals, the lateral abdom inals and the quadratus lumborum. Even moderate inequality in these muscles on the two sides will produce a definite curve. A scoliosis may develop soon after the attack o f poliom yelitis, or it may be delayed 5-10 years; so a careful watch must always be kept o n the spine. The erector spinae, shoulder muscles, anterior abdominals and leg muscles do not cause scoliosis, although a co n ­ tracture o f the tensor fascia lata may cause pelvic tilting. The curve patterns have som e similarity to idiopathic scoliosis, but their prognosis is different (Fig. 6). The Lum bar (A pex at L. 1— L. 2) and Thoraco-lumbar (Apex T. 11 or T. 12) are due to weakness o f the lateral abdom inals and quadratus lumborum muscles, and the Thoracic are due to the additional weakness o f the lower intercostals (Figs. 2, 3, 4). These curves may progress and cause severe deformity, but they can be corrected surgically. H igh Thoracic curves starting at C. 1 or C. 2 are due to | paralysis o f the intercostals. This can be demonstrated by a cine-film, by the decrease o f m ovement o f the ribs on the convex side, and by their more vertical position. The head is stepped to one side and the rotated ribs make the trapezius prominent, causing severe deformity. This curve is very difficult or im possible to correct and has the worst prognosis o f all types o f paralytic scoliosis. Quadruple curves may occur with double primary curves in opposite directions and com pensatory curves above and below, and the primaries may not balance each other as in the idiopathic variety. - A s y n r t E T R ic n L Figure 5. Diagram showing the two main types o f paralytic curve (see text). Figure 6. Curve patterns in paralytic scoliosis due to asymetrical involvement o f muscle groups. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) September, 1958. P H Y S I O T H E R A P Y Page 7 Pelvic O bliquity may be caused by contracture o f the hip abductors and the tensor fasciae latae, paralysis o f the lateral abdom inals and quadratus lumborum, or a com ­ bination o f them, and may be associated with a short marked lumbar curve. The paralytic curve differs in appearance from the idio­ pathic and is typically a long C-curve with secondary com ­ pensatory curves. N o accurate prognosis can be given in paralytic curves, ow ing to the difficulty in accurate charting o f the affected muscles, but the earlier the onset and the higher the curves (as in idiopathic) and the greater the muscle imbalance, the worse the prognosis. However, unlike the idiopathic variety, the lumbar and thoraco-lumbar curves may cause great deformity. 3. N eurofibrom atosis A number o f cases o f neurofibromatosis develop scoliosis. The typical cases develop a short, sharp, acute angulating curve with wedging o f vertebrae in the thoracic region. They all progress rapidly, causing severe deformity, and have the worst prognosis o f any kind o f scoliosis. Para­ plegia may be a com plication in severe cases. 4. Congenital M any types o f abnormality may occur in the spine, such as hemi-vertebra, fused vertebra, spina bifida. The degree o f scoliosis varies from mild to severe, as one hemi-vertebra may cancel out another. N early all double curves (except compensatory) are congenital. Prognosis based on X-rays is often im possible, and the curves have to be watched carefully. K y p h o sc o lio sis10 In structural scoliosis, although there is often an apparent kyphosis due to the hump caused by rib rotation, there is no actual alteration in the anterior-posterior direction o f the vertebrae. H owever, very occasionally a true kyphosis is associated with a structural lateral curvature, when the condition is called kypho-scoliosis. T R E A T M E N T O F S C O L IO SIS A . Conservative Treatm ent J. P hysiotherapy. A great deal o f time and expense has been wasted in unnecessary treatment o f scoliosis. In paralytic scoliosis follow in g poliom yelitis, it is o f value to treat the weakened muscles by active exercises, as is carried out in limb paralysis, for the first 18 months. Jn an extensive follow -up o f cases treated by physiotherapy it has been shown by Sharrard o f London, in recent years, Ithat muscle exercises have very little value in paralytic scoliosis, and that where there are asymmetrical groups o f muscles paralysed, it is im possible to balance them by uni-lateral exercises. In other types o f scoliosis, especially the idiopathic, exercises whilst being o f assistance in improving posture and breathing, have unfortunately no affect on the progress o f the scoliosis. 2. Correcting p la ster ' beds a nd splints may be used in infants, such as the Merch-Jansen bed, or the D ennis Browne metal night splint, but neither is o f use in older children. 3. P laster ja c k e ts a n d spina! supports in older children should be avoided as far as possible, as they are only an encumbrance and fail to,control the progress o f the deformity. There are two exceptions, however: Firstly in a case where there is a rapidly progressing curve and the patient is too young to operate on, the M il­ waukee Brace o f Blount11 is o f great value and will control the curve or slow down the rate o f increase. Constant distraction o f the spine com bined with local pressure is obtained by means o f a moulded leather pelvic support connected to occipital and chin pieces by extensible anterior and posterior uprights. A lateral pressure pad exerts pressure at the apex o f the curve. Secondly, in paralytic curves, when there is a collapsing type o f curve without severe scoliosis, the patient in unable to sit up or stand, and the posterior spinal support with axillary crutches is necessary. B. O perative Treatm ent: Correction a nd Fusion The operative correction consists o f correction and fusion o f the major curve in a tum buckle plaster jacket. J. In Idiopathic Scoliosis, if the curve pattern and the age o f onset are considered together, an accurate prognosis is possible. Correction and fusion should be carried out fo r the prevention o f fu tu r e d e fo rm ity ; and, as there are no sym ptom s in the idiopathic variety, the indications are mainly cosm etic. Occasionally where there are severe chest deformities and a low vital capacity operation is indicated to prevent pulmonary and cardiovascular com plications. Less than 5 % o f cases o f idiopathic scoliosis need operation, and these consist alm ost entirely o f the thoracic group, where the prognosis is bad and severe deformity may de­ velop if untreated. When the deformity is established, the depression o f the shoulder and prom inence o f the hip can be corrected, but the projecting rib hump remains. In a mature child a curve o f 65-80° is ugly enough to warrant correction on clinical appearance alone. In a young patient before deformity is serious, correction is relatively easy and more com plete, but it is advisable to delay operation until the age o f approxim ately 10 years to avoid interference with spinal growth or the production o f a kyphosis, although in severe rapidly-progressing curves earlier operation may be necessary. Thus in a curve o f 55-60° in a child o f JO years, correction and fusion would be indicated because o f the bad prognosis. 2. In P aralytc curves 50% need operation. These curves are unstable and the treatment o f the stability of the spine is more important than the correction o f the deformity. , (a) In a fla il collapsing spine scoliosis may develop late owing to gravity and may also be indicated in order to give a rigid link between the trunk and leg. In the latter type, before fusion to the sacrum is performed it is important to establish that the patient has active hip flexors present. If these are absent and the patient has to rely on the lateral abdom inals to elevate the pelvis in order to swing the leg clear o f the groung in walking, fusion o f the spine to the sacrum will stop all walking. However, in a severe case with flail legs and spine, fusion to the sacrum may be in­ dicated to make the patient a good sitter, and allow working at a desk without back support. (b) Unstable p a ralytic curves need correction and fusion fir s tly if the curve is rapidly progressing in a young case and the prognosis is bad because o f severe muscle imbalance (the fusion should be left until the child is as old as possible but it may have to be done at an early age if there is rapid deterioration); and secondly if sym ptom s are produced such as pain from back fatigue or ribs pressing in the pelvis or if there is displacement o f abdom inal viscera or kinking o f the ureter. Unstable curves becom e stabilized after cess­ ation o f growth o f the spine, i.e. after the appearance o f Risser’s sign, and in som e cases this may occur even earlier. In stable curves, further deterioration does not occur, or if it does, is only slight, and operation is for cosm etic reasons. (c) In high thoracic paralytic curve correction is difficult, and fusion should be carried out early, before deformity arises. (d) The lum bar an d thoraco-lum bar paralytic curves, unlike the idiopathic, may becom e very severe and cause great deformity, but they are easy to correct, although difficult to fuse successfully. (e) P elvic obliquity. Soft-tissue stripping o f the con ­ tracted lateral abdominal muscles on the concave side, from the crest o f the ilium, may be necessary in severe R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 8 P H Y S I O T H E R A P Y September, 1958. Figure 7. Diagram i 1 lustra ting the use o f bending and tilt films in estimating tlie theoretical amount and correction possible. p a r a l y t i c c u r v e s , b e f o r e c o r r e c t i o n c a n be o b t a i n e d in a p la s t e r j a c k e t . T h e w e a k e r m u s c le s o n th e c o n v e x si de m a y be r e i n f o r c e d b y s t r i p s o f th e fa sc ia la t a f r o m th e i l i a c crest t o th e 9 t h o r 10th r i b b y M e y e r ' s m e t h o d , 1- o r b y th e m o r e re c e n t m e t h o d o f C l a r k ,1:1 in w h i c h th e t e n s o r fa s c ia e l a t a c a n d th e i l i o - t i b i a l b a n d is t u r n e d u p w a r d a n d a t t a c h e d to the 9 t h r i b t o g i v e a d y n a m i c r e i n f o r c e m e n t . Figure 8. Spinal fusion, showing wide de­ cortication of the laminae, tipping off of the apophyses of the trans­ verse processes, and removal of all soft tissue between the pro­ cesses. Figure 9. Risser jacket, showing correction o f curve by a turnbucklc. Figure 10. Kisser jacket: correction has been completed, and a window cut over spine for operation. 3. N e a r l y a ll cases o f iic iiro fib ro/iw iosis need o p e r a t i o n bec a u se o f t h e i r r a p i d l y d e v e l o p i n g t h o r a c i c c u r v e s . 4. C o itfn 'iiiia l Sco lio sis. U s u a l l y c o n s e r v a t i v e t r e a t m e n t is a d e q u a t e , b u t o c c a s i o n a l l y c o r r e c t i o n a n i l f u s i o n is i n ­ d i c a t e d . A l t e r n a t i v e l y , s t a p l i n g o f th e t h o r a c i c s p in e o r e x c i s i o n o f a h e m i - v e r t c b r a c in th e l u m b a r r e g i o n has been a t t e m p t e d , b u t these m e t h o d s a r e n o t g e n e r a l l y a d v i s e d . 5. K y p h o s c o lio s is . In k y p h o - s c o l i o s i s e a r l y c o r r e c t i o n a m i f u s i o n is i n d i c a t e d , b ec au se o f th e v e r y b a d p r o g n o s i s , a n i l here th e r e is n o f e a r o f p r o d u c i n g a l o r d o s i s b y e a r l y f u s i o n . M L I H O I) O I C O U U I C T IO N A N D F U S IO N T h i s c o n s i s t s o f f u s i o n o f th e w h o l e o f th e p r i m a r y c u r v e o r c u r v e s . B e f o r e c o r r e c t i o n a n d f u s i o n c a n be a t t e m p t e d th e M o b ilit y o f the curvc.s m u s t be d e t e r m i n e d in o r d e r to a s c e r t a i n the d e g re e t o w h i c h it is p o s s i b l e t o c o r r e c t the p r i m a r y c u r v e , s in c e it is e s s en tia l to m a i n t a i n the head o v e r the p e l v i s so as t o k e e p th e p a t i e n t w e l l b a l a n c e d . T h i s is d e t e r m i n e d f r o m th e b e n d i n g f i l m t a k e n o r i g i n a l l y , a n d d e t e r m i n e s th e a m o u n t o f s ti ff n e s s in th e s e c o n d a r y o r c o m p e n s a t o r y c u r v e s ( F i g . 7). I f . f o r e x a m p l e th e p a t i e n t has a 9 0 p r i m a r y c u r v e a n d a 45 u p p e r a n d a 45 l o w e r s e c o n d a r y c u r v e , th e b e n d i n g H im m a y s h o w t h a t th o s e t w o c u r v e s c o r r e c t t o o n l y 15 a n d 10 r e s p e c t i v e l y in b e n d i n g , o w i n g t o s ti ff ne s s. T h e p r i m a r y c u r v e c a n t h e n o n l y be c o r r e c t e d t o 15 + 1 0 i.e. 25 i f t h e h ea d is t o be k e p t o v e r th e p e l v i s . I f th e s p in e is o v e r - c o r r e c t e d , f o r e x a m p l e t o th e s t r a i g h t p o s i t i o n , as has been d o n e in th e p a s t , the r e s u l t m a y be d i s a s t r o u s ; the p a t i e n t w i l l l o o k l i k e th e l e a n i n g t o w e r o f Pisa. In a case o f p a r a l y t i c s c o li o s is , a t i l t f i l m w i t h a 3 - in c h b l o c k u n d e r th e b u t t o c k o n th e c o n v e x si de o f th e l o w e r s e c o n d a r y c u r v e m u s t a ls o be d o n e t o be su r e l h a t th e sp in e c a n be h e l d t o th e f u l l e x t e n t o f its m o b i l i t y , as s h o w n in th e b e n d i n g f i l m , b y the w e a k l a t e r a l a b d o m i n a l m us cle s R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) September, 1958. P H Y S I O T H E R A P Y Page 9 (in this particular case held over to a position 10° short o f the vertical). If this cannot be done the fusion must include all the secondary curves dow n to the sacrum. Technique o f Correction Correction o f the primary curve is achieved by means o f a Risser turnbuckle j a c k e t (Fig. 9). Felt pads are applied over the bony prom inences and over the apex o f the curve to prevent undue pressure on the skin. The jacket is applied standing, with head traction by means o f a halter to straighten out the secondary curves, and also to give a good fit for the jacket. It is a full spinal jacket with shoulder straps; the leg on the side o f the primary curve is included down to the knee. Anterior and posterior hinges are placed on the side o f the convexity, well lateral to and opposite the apex o f the curve, and the turnbuckle screw is placed on the concave side. When the plaster is dry it is cut transversally at the apex o f the curve. Correction by elongating the turnbuckle is rapid at first but will later become slower. N o discom fort should be produced at any time. A paralytic curve may correct in a few weeks, but an idiopathic may take up to 10 weeks, and in old patients full correction o f the promary curve o f the estimated degree may not be possible. When the end-point o f correc­ tion has been obtained it will be found that the patient tends to slip out o f the jacket, instead o f being further corrected. Com plications are rare with careful nursing, apart from minor pressure sores. When correction is finished the gap in the plaster is filled in, hinges and turnbuckle are rem oved, and a w indow is cut over the spine for operation (Fig. 10). A metal marker is placed over one sp inous process and an X -ray is taken to determine the vertebral level. The distraction ja c k e t designed by Stagnara, o f Lyons, is useful in correcting the high paralytic thoracic curves, which the Risser jacket fails to correct. It is also used in the combined lumbar and thoracic curve with a double primary curve, and also for correcting kypho-scoliosis. However, there are more risks o f pressure sores with this type o f jacket than a Risser. The localizer body cast has been developed by Risser in recent years as an alternative to the turnbuckle jack et.11 This is a plaster cast applied on a special frame with head and pelvic traction, whilst localised pressure is exerted postero-laterally over the rib angulation, forcing the apex o f the curve under the ends o f the curve and thereby pro­ ducing correction. It may be used for conservative treatment or for correction and spinal fusion, and its main advantage is early am bulation. Technique o f Fusion The method o f fusion advocated is that which has been developed by J. 1. P. James at the Royal N ation al O rtho­ paedic H ospital, London. The mechanical force which, after fusion, tends to cause relapse o f the curve is a lateral ungulating one, and so the aim is to produce a broad, wide fusion area o f the w h ole o f the primary curve to com bat this. This entails a com plete lateral exposure o f the spine as far as the apophyses o f the transverse processes and meticulous removal o f all intervening soft tissue. Profuse haemorrhage results, and it is essential to begin blood transfusion before the operation starts, or severe shock from blood loss may ensue. If possible the operation is done in one stage, and in a young patient 8 or 9 vertebra can be fused at one step, but occasionally 2 or even 3 stages are necessary. A large supply o f refrigerated stored bone must be available. Boiled bone may be used as an alternative, but it is believed, though this is not yet known for certain, that consolidation o f the graft may then take longer than when fresh bone is used. The operation area is towelled off and the site o f the original metal marker is preserved on the skin by means o f methylene blue, to act as an indicator o f the level o f spinal processes. A straight skin incision is used from top to bottom o f the curve, and the skin flaps are under­ mined with diathermy. Subperiosteal stripping o f the spinous processes, laminae and transverse processes is performed, and the apophyses o f the transverse processes are tipped off, to allow the spinal muscles to be retracted as far lateral as possible (Fig. 8). The spinous processes are then re­ m oved and the laminae and transverse prosesses are c o m ­ pletely decorticated with a rougine. In older children a power-driven burr may be used instead, and this diminishes shock. A deep, w ide raw bed is left and this is covered with a large mass o f bone chips from the bone bank. F inally silver clips are placed on the spinous processes above and below the fusion as a radiographic guide, and the w ound is closed in layers. The patient is kept recumbent for 6 months in the Risser jacket, and then is allow ed up in a polythene jacket. A l­ ternatively, a M ilwaukee brace may be used, particularly if relapse is feared, as in high thoracic cases. One year after the operation bending films o f the primary curve are taken to exclude a pseudo-arthrosis and, if satisfactory, all support is abandoned. Tw o other operative techniques have been introduced recently but, although they may be indicated in certain cases, as yet they are not recom m ended in routine work; Firstly, A llen ,15 o f Birm ingham , uses a jack which is inserted between the transverse processes on the concave side; the jack is opened, correcting the curve; and finally spinal fusion is performed w ithout post-operative plaster fixation. Secondly, R o a f,16 o f Oswestry, corrects the apex o f the curve by rem oving a wedge o f bone from the convexity o f the curve, including lam inae, pedicles, transverse pro­ cesses and adjacent portions o f tw o vertebral bodies and intervening disc. R e su lts o f Fusion The greater the curve, the greater is the force tending to cause relapse after operation. The average relapse follow ­ ing operation is about 25°. This is usually due to pseudo­ arthrosis o f the graft, which occurs in about 10% o f fusions or else to a too limited fusion o f the primary curve.17 The pre lim in a ry results o f fu sio n are encouraging, but final assessm ent o f this m ethod o f treatment cannot yet be made in a large enough group o f cases, until all these spines operated on have ceased to grow, but there is every indication that the present m ethod o f m anaging scoliosis will produce good results and prevent the developm ent o f the hideous deformities, which are still only too com m on. To S u m m a rize the T reatm ent o f Scoliosis.t8 1. Scoliosis should be dealt with in a special clinic where adequate facilities and time are available. The patients should be checked every 3-6 m onths until growth o f the spine has ceased. 2. In idiopathic scoliosis 5% o f the cases need early fusion and correction, mainly in the thoracic type at the age o f 10, in which the prognosis is bad. 3. O f paralytic curves 50% need operation because o f instability, production o f sym ptom s or deformity, and early fusion is specially indicated in the thoracic type. 4. N early all cases o f neurofibromatosis need early operation, but this is only rarely necessary in scoliosis o f the congenital type. I w ish to ex p ress m y th a n k s to M r. J. I. P. Ja m e s, o f th e R o y a l N a tio n a l O r th o p a e d ic H o s p ita l, L o n d o n , fo r his h elp a n d e n c o u ra g e m e n t, 'and to M r. G . T . du T o it, o f J o h a n n e s b u r g , a n d M r. R . C . J. H ill, o f D u rb a n , fo r a llo w in g m e to use th e ir clinical cases. In a d d itio n 1 w o u ld like to e x p ress m y th a n k s to th e e d ito r o f S . A frica n M e d ic a l J o u rn a l fo r his p erm issio n to re p r o d u c e th e illu s tra tio n s used in this a rticle. C o n tin u ed fin page 1 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 12 P H Y S I O T H E R A P Y September, 1958. G e n e r a l W O R LD C O N F E D E R A T IO N O F PH Y SIC A L T H ERAPY C opy o f a letter received from Miss N eilson, Secretary o f the World Confederation o f Physical Therapy. “A s a result o f a broadcast 1 gave on my return from East Africa, I have been able to put a com pletely paralysed polio patient in N airobi in touch with a young man in England similarly placed. This latter young man (Paul Bates) now wishes to have additional con ­ tacts with people w ho are also com pletely paralysed, and I am writing to ask whether you know o f any such patient in your country with whom I could put Paul Bates in touch. If any o f your members knows o f such a patient would they please send his name and address to Mrs. Levy, 105, A cacia R oad , Blackheath, Johannesburg. She will forward it to M iss Neilson. A t a C.E.C. m eeting held in Johannesburg on August 13th, a special w elcom e was extended to M iss Bodoano and Miss Savin both teachers o f Physiotherapy w ho have recently com e out to Pretoria Physiotherapy School from Britain. We all wish them every success and happiness in this country. APO LO G Y . The Article “ Som e uses o f Heat and Exercise in the Obstetric and G ynaecological U n it” which appeared in the June issue should have been attributed to D r. D. M. Lithgow, Specialist in G ynaecology at E D E N D A L E Non-European H ospital, not Edenvale N on-E uropean Hospital. J O U R N A L S RECEIVED 1. "Physiotherapy” Chartered Society o f Physiotherapy, London. 2. S.A . Medical Journal. 3. Medical Proceedings— S.A . Journal for advancement o f Medical Science. 4. Heilgymnastiek M assage en Physiotechniek— Neder- landsch Tijdschrift. 5. Sjukgymnasten— Kvinnliga Sjukgymnasters Riksfor- bund. 6. Tidsskrift for Dankse Fysioterapeuter. 7. Revue des Kinesitherapeutes— Organe de la Federation des M asseurs— Kinesitherapeutes de Franck et de L’Unoin Fran?aise. 8. K rankengymnastik— Offizielles organ des Zentralver- bandes Krankengym nastik. E.V. 9. Le Journal de K inesitherapie— Cercle d ’Etudes Kine- sitherapiques. 10. The Physical Therapy R eview — American Physical Therapy A ssociation. 11. World Veteran— World Veterans Federation. The above Journals may be borrowed on request from the editor, before being filed for reference. I n f H m o n a m It is with sorrow and regret we have to report that M iss Clara H opson died in Durban on July 4th, 1958, at the age o f 85 years. M iss Clara H opson trained, it is believed, at Kings C ollege H ospital, London, during the first World War, having previously done a nursing training. She passed the Exam ination o f Incorporated Society o f Trained M asseuses in massage in June 1916, her Electrical exam ination in D ecem ber, 1917. In 1921 she became a member o f the then recently formed Chartered Society o f M assage and M edical G ym nastics and received her L.E.T. Certificate in March, 1930. M iss H op son registered with the S.A . M edical and D ental Council in 1949. M iss Clara H o p so n ’s life has been bound closely with that o f the I.S.T .M ., C .S.M .M .G . and S.A .S.P. since their inception. During her very busy life, she treated soldiers in the 1914-1918 War and cam e to this country during that period and for the purpose o f treating the wounded o f that War. In 1922 she joined the S.A .S.P. in Durban. The Society was first founded in Durban in 1921. Later she became a Life Member. M iss H opson was in charge o f the Physiotherapy D epart­ ment at A ddington H ospital until she retired at the age o f 55 years. She then com menced private practice and learned to drive a car. She continued this work and to drive a car until as recently as five years ago. During the last year she was responsible for collecting the funds from Physiotherapists to send Brian Blankenberg overseas. M iss H opson lived for many years at the Y .W .C .A . in Durban, and was loved and respected by all w ho cam e in contact with her. She will be sadly missed by all o f us who knew her in Durban. M R . C H R IST O PH E R CELL. The sym pathy o f the Society is extended to Mrs. Norah Gell on the death o f her husband Christopher Gell in Port Elizabeth recently. In spite o f contracting polio in 1945 with severe generalised paralysis resulting in his spending most o f his last 13 years in an iron lung, he found the courage and the will to live H e married Norah G ell, M .C .S.P., M iddlesex Hospital, London, w ho nursed him, besides continuing her practice after his illness. She taught him to type thus enabling him to carry on with his writing. C o n tin u ed fr o m page 9 R E F E R E N C E S 1. F e rg u s o n , A . B. (1930): S th . M ed . J. (B g h am ., A la .). 23, 116. 2. C o b b , J . R. (1948): O utline f o r the S tu d y o f Scoliosis, A m erican A c a d e m y o f O rth o p a e d ic S u rg e o n s ’ I n s tru c tio n a l C o u rs e L e ctures, 5, 261. 3. H ib b s , R. A . (1924): J. B one J t. S u rg ., 6, 3. 4. H ib b s , R. A ., R isser, J . C . a n d F e rg u s o n , A. B. (1931): Ibid., 13, 91. 5. R isser, J • C . (1948): Im p o rta n t P ractical Factors in the T re a tm en t o f Sco lio sis , A m e ric a n A cad em y o f O rth o p a e d ic S u rg e o n s ’ In s tru c tio n a l C o u rs e L e c tu re s , 5, 248. 6. P o n se ti, I. V. a n d F rie d m a n , B. (1950): J . B one J t. S u rg ., 32A , 3 8 !. 7. J a m e s, J . 1. P. (1954): Ibid., 36B, 36. 8. Id em (1 951): Ib id ., 33B , 399. 9. Idem (1957): A n n . R oy. C oll. S u rg . V ol. 21— J u ly 1957. 10. Idem (1955): J. B o n e J t. S u rg ., 37B , 414. 11. B lo u n t, W . a n d S c h m id t. T he M ilw a u k e e S co lio sis Brace. W . C. C a m p b e ll (1956): In O p e ra tiv e O rth o p a e d ic s . S t. L o u is: C . V. M o sb y . 12. M a y e r, L. (1944): J. B o n e J t. S u rg ., 26, 257. 13. C la rk , J . M . P . a n d A n a to l A x er (1956): Ibid., 58B, 475. 14. R isser, J . C . (1955): T he A p p lication o f B o d y C a sts f o r the C or­ r ection o f Scoliosis. A m e ric a n A cad em y o f O rth o p a e d ic S u r g e o n s ’ I n s tr u c tio n a l C o u rs e L e ctu res, 12, 255. 15. A lla n , F . G . (1955): J . B one J t. S u rg ., 37B , 92. 16. R o a f, R . (1955): Ibid., 37B , 97. 17. J a m e s, J . I. P . (1957): P e rs o n a l c o m m u n ic a tio n . 18. H e d d e n , F . J . (1958): Ih e M a n a g em en t o f Scoliosis. S o u th A fric a n M e d ic a l J o u r n a l, V ol. 32, N o . 23, L. 582. * P a p e r re a d a t th e A n n u a l M eetin g o f th e S o u th A fric a n O rth o p a e d ic A ss o c ia tio n , D u r b a n 1956. * F o rm e rly S e n io r R e g is tra r, th e R o y a l N a ti o n a l O r th o p a e d ic H o s p ita l a n d th e H o s p ita l fo r S ick C h ild re n , G r e a t O rm o n d S tre e t, L o n d o n . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )