Page 6 P H Y S I O T H E R A P Y March, 1964 T h e T r e a t m e n t of S c o l i o s i s A PRACTICAL APPROACH By D A V ID R O U X , F .R .C .S ., O rthopaedic Surgeon. C o n tin u o u s e m p h a sis o n the difficulties a n d com plexity o f th e p ro b lem o f the tre a tm e n t o f scoliosis has w ith o u t ju stific atio n c re a te d in th e m in d s o f m o st O rth o p a e d ic S urgeons, co n fu sio n a n d a n u n w a rra n te d d e sire to leave the tre a tm e n t o f su c h cases in th e h a n d s o f th o se fo o lish e n o u g h to be inte rested in the p ro b le m . J o h n C o b b has o ften s ta te d th a t you d o n o t have to be m ad to tre a t sco lio sis— b u t it helps. T h e p u rp o s e o f th is p a p e r is a n a tte m p t to s tra ig h te n o u t o u r c oncepts. T h e g re at revival o f in te rest in Scoliosis in th e p a st d ecade, h as show n th a t c o rre c tio n a n d a d e q u a te p o s te rio r fu sio n , give g ra tify in g re su lts in th o se cases in w hich it is justified. U n fo rtu n a te ly , in te re s t in the subject now seem s to be w aning. M o re su rg e o n s a n d su rg e o n s in tra in in g sh ould tre a t scoliosis. I t is re w ard in g w o rk a n d the basic principles a r e easily le a rn t. E tio lo g ical C onsiderations: T h e o re tic a l d isse n ta tio n s as to the e tiology, fo r exam p le — is v e rte b ra l b o d y ro ta tio n a p rim a ry o r se c o n d a ry p h e n o m ­ e n o n , sh o u ld in itially be a voided. S p e c u la tio n as to w hich m u sc le is c au sin g the d e fo rm ity does n o t h elp the p a tie n t u nless the su rg e o n can d o so m e th in g a b o u t it. F o r exam ple, in p a ra ly tic sc o lio sis, fa c to rs such a s :— (1) C o m p e n s a tio n . (2) Im b a la n c e o f the e x tra -sp in al m uscles. (3) P rim a ry d is tu rb a n c e in v e rte b ra l g ro w th . (4) S e c o n d ary d is tu rb a n c e in v e rte b ra l g ro w th . (5) Im b a la n c e o f th e d e ep spinal m uscles. (6) F a sc ial c o n tra c tu re m a y be involved. T h ese f a c to rs m ay in te ra c t a n d e ith e r re -in fo rc e o r c o u n te ra c t o n e a n o th e r. T h e su rg e o n is now lik e A lice in W o n d e rla n d , P a ra ly tic Scoliosis: P a ra ly tic Scoliosis d e velops as a re su lt o f m u sc le im b a lan c e. I f recovery d oes n o t o c c u r, th e m uscle im b a lan c e becom es p e rm a n en t, the g row ing spine is affected, th e c u rv a tu re can a n d o ften d oes in crease. S e c o n d ary fa c to rs such as gra v ity , d isp a rity o f v e rte b ra l e p iphyseal g ro w th , e tc ., can m ak e it w orse. T h e age a t o n se t a n d the degree o f m uscle im b a lan c e a re th e decisive fa c to rs affecting th e p ro g n o sis. T h e c o n q u e s t o f P olio m y e litis will in five years, m ake this a ra re c o n d itio n a n d so e lim in a te 6 0 % o f a ll the Scoliosis cases re q u irin g surgery. P a ra ly tic c u rv es a re u su a lly m o re flexible th a n id io p a th ic curves, b u t w hen severe, can be e x tre m e ly rigid. Idio p ath ic S coliosis: Id io p a th ic Scoliosis is a diverse g ro u p , p ro b a b ly d u e to a m e ta b o lic d is tu rb a n c e w ith h e re d ita ry fa c to rs. O n set is u su a lly d u rin g ado le sc en c e b u t in a p a rtic u la rly m a g lig n an t g ro u p it s ta rts sh o rtly a fte r b irth . P ro g re ss io n o f the c urve is lim ited by th e c e s sa tio n o f sp in a l g ro w th . D e te rio ra tio n if it o c cu rs, is m o st ra p id d u rin g th e p u b e rta l g ro w th s p u rt. T h e cu rv es a re m o re rigid th a n p a ra ly tic curves. C ongenital Scoliosis: C o n g e n ita l Scoliosis is u su a lly d u e to hem i v e rte b ra e b u t c a n a lso be d u e to fa ilu re o f d iffere n tia tio n o f th e p o ste rio r e le m en ts o f th e spine o r d u e to co n g en ital fu sio n o f ribs. D e te rio ra tio n is u su a lly n o t significant e xcept in th o se w here th e p o s te rio r e lem ents have failed to differe n tia te a n d th o se a sso c ia te d w ith sp in a bifida oc cu lta. N eurogenic Scoliosis: N e u ro g en ic scoliosis is m o st o ften d u e to n e u ro fib ro m a ­ tosis. I t is c h a ra c te rise d by the cafe au lait p a tc h , th e o th e r stig m a ta o f n e u ro fib ro m a to sis a n d a s h o rt sh a rp a n g u la r c u rv e in w hich severe d e te rio ra tio n c a n occur. Spinal c o rd tu m o u rs o c ca sio n ally p re se n t as scoliosis. T horacogenic Scoliosis: N o w th a t em pyem a, p u lm o n a ry fibrosis a n d th o r a c o ­ p lasty have b e co m s u n c o m m o n , is ra re ly seen. A S S E S M E N T A N D S T U D Y : F o r th e a c c u ra te asse sm e n t a n d stu d y th e physical e x am ­ in a tio n m u st record d a ta o n p o stu re , g eneral physical d e v elo p m en t, m u sc u la tu re , s h o u ld e r level, sc a p u la r p ro m i­ nence, list, hip assym etry, leg len g th , cafe a u lait m arks, rib d e fo rm ity , ro ta tio n , flexibility a s well a s the d irection a n d e x te n t o f the m a jo r c u rv e a n d th e c u rv e p a tte rn . X -ra y s ta k e n o f th e spine sh o u ld c over th e 1st d o rsa l to iliac c re st a re a on a 17 x 14 casette . A .P . erect, sittin g a n d su p in e film s sh o u ld be d o n e . L a te ra l b e n d in g film s in the su p in e p o sitio n a re o n ly n ecessary p re -o p e ra tiv e ly . V ital c ap a c ity a n d p u lm o n a ry fu n c tio n stu d ies are m a n d a to ry in p a raly tic cases. E q u a lly im p o rta n t is a ro u g h c linical asse sm e n t o f th e p a tie n ts a b ility to c ough. I t is esse n tia l to th o ro u g h ly u n d e rs ta n d th e c o n c e p t o f a p rim a ry curve, a se c o n d ary curve, a s tru c tu ra l ^ u rv e , a fu n c tio n a l c u rv e a n d a co m b in e d stru c tu ra l-fu n c tio n a l curve. F e rg u so n defined a prim ary curve as o n e p ro d u c e d by a d e fo rm in g fa c to r o r force. A secondary curve is the re su lt o f the a c tio n o f th e law o f ba la n ce . M uscles a ct in v o lu n ta rily to b rin g th e head erect o ver the c e n tre o f th e pelvis w ith th e b o d y in balance, in the e asiest p o ssib le w ay a n d to th e e x te n t th a t the m uscles a re able. A structural curve is o n e w ith stru c tu ra l c h an g e s in bone, nerve, m uscle o r o th e r tissue a n d is a c u rv e w h ich the p a tie n t c a n n o t c o rre c t a n d m a in ta in c o rre c te d w hen he is e rec t. I ts c a rd in a l ro e n tg e n o g ra p h ic signs a re a b n o rm a l w edging, a n g u la tio n , ro ta tio n a n d p o sitio n o f th e v e rte b ra in th e curve. (C o b b ). A fu n ctio n a l curve is one w ith o u t s tru c tu ra l changes th at re su lts fro m th e n o rm a l a v a ila b le a n g u la tio n s betw een v e rte b ra e . I t is a c urve w hich th e p a tie n t c a n c o rre c t and m a in ta in c o rre c te d w hen he is erect. (C obb). A com bined structural-functional curve is o n e w hich has som e s tru c tu ra l a n d som e fu n c tio n a l c h a ra c te ristic s which th e p a tie n t can p a rtly c o rre c t w hen e rect. T h e c urve w ith the m o st s tru c tu ra l c h an g e is th e m a jo r stru c tu ra l (prim ary) curve. F u n c tio n a l (se co n d a ry ) a n d m in o r s tru c tu ra l (com ­ bined s tru c tu ra l-fu n c tio n a l) cu rv es a re re ad ily recognised. I T h e e x te n t o f th e c u rv e m u st be a c c u ra te ly d e te rm in e d by n o tin g th e m axim ally tilted e n d v e rte b rae . A c u rv e extends fro m th e to p o f th e u p p e rm o s t to th e b o tto m o f th e low er­ m o st v e rte b ra e in th e curve. I f in d o u b t, d ra w lines a lo n g the v e rte b ral b o d y m argins in o rd e r to d e te rm in e w hen th ese lines c ease converging in to th e con ca v ity o f a c u rv e a n d begin to diverge o n the convex side o f th e a d ja c e n t curve. T h e m ax im ally tilted end v e rte b ra is u su a lly c o m m o n to a d ja c e n t cu rv es u nless u n usual w edging is present. A fte r d e te rm in in g th e e x te n t a n d s tru c tu ra l c h anges in a curve, it c a n be m ea su re d by e ith e r C o b b ’s o r F e rg u s o n ’s m eth o d . B y C o b b ’s m eth o d , th e sc o lio tic a n g u la tio n is th e su p p le ­ m e n ta ry a ngle fo rm ed by th e in te rs e c tio n o f lines draw n p e rp e n d ic u la r to th e s u p e rio r su rfa c e o f th e to p v e rte b ra an d th e in ferio r su rfa c e o f th e b o tto m v e rte b ra . F e rg u s o n ’s m e th o d m e a su re s th e su p p le m e n ta ry angle fo rm e d by stra ig h t lines jo in in g th e c e n tra l p o in ts o f the a p ic a l a n d end v e rte b ra e . B o th have a m arg in o f e r ro r o f a p p ro x im a te ly three degrees. N o c o rre la tio n exists betw een th ese tw o m ethods. A given c u rv e w ill m e a su re differently by these tw o m ethods. 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. ) M a r c h , 1964 P H Y S I O T H E R A P Y page 7 C o b b ’s m eth o d c o n siste n tly gives a higher m ea su re m e n t. Y et a fte r c o rre c tio n , d u e to the fa ct th a t th e end v e rte b rae o f a curve u su ally c o rre c ts m o re th a n the a pical verte b rae , it in 50% ° f cases> 8 'ves a low er m ea su re m e n t. P e rc en tag e o f correction by C o b b ’s m eth o d , is th ere fo re m o re fa v o u ra b le. C o b b ’s m eth o d , because it ten d s to m agnify the p ro g re s­ sion o f a curve, is m o re useful in cases u n d e r o b se rv atio n . I have used C o b b ’s m eth o d exclusively. I believe it is m ore accurate, it can be ap p lie d se g m en tally in th e lo ca lisatio n o f pseu d o -arth ro sis a n d in m e a su rin g k yphosis. W ith F e rg u s o n ’s m ethod the c en tre p o in t o f th e a p ic al v e rte b ra e is difficult to find in hemi v e rte b ra , o r w here severe ro ta tio n is present. P o ss ib ly b o t h m e th o d s s h o u ld b e e m p lo y e d in a s se s s in g th e d e g re e o f c o r r e c tio n . C o n c e p t o f a n g u la r deviation o f a curve: L ist A curve convex to the rig h t p ro d u c e s a left a n g u la r d ev ia­ tion and vice versa. G iven a case w ith a trip le c urve p a tte rn where the oc cip u t is o n th e c e n tra l spinal axis, i.e. no list, the a n g u la r d e v ia tio n o f th e m a jo r c urve is b a lanced o r com pensated by th e su m to ta l o f the a n g u la r d e v ia tio n in the op p o site d ire c tio n o f th e m in o r cu rv es. In o th e r w ords scoliosis is n ot ju s t a n o th e r c ro o k ed spine. A p a tie n t w ith a m a jo r c u rv e convex to th e rig h t w ith o u t a d equate m in o r cu rv es, will list to th e left. In th is case the left a n g u la r d e v ia tio n o f the m a jo r c u rv e is g re a te r th a n the sum o f the right a n g u la r d e v ia tio n s o f the m in o r curves. It is u ncom pensated. Pelvic o b liq u ity alw ays c re a te s difficulties. A part fro m th o se cases o f pelvic o b liq u ity d u e to p rim a ry hip p a thology o r lo w e r e xtre m ity in eq u a lity , w hich m ay o ften not have s tru c tu ra l scoliosis, a d e fo rm in g fa c to r o r force has in co rp o ra te d th e pelvis in to a n d as p a r t o f a stru c tu ra l curve. T h e sa c ru m a n d its a tta c h e d pelvic rin g m u st be seen as the low erm ost v e rte b ra o f this stru c tu ra l curve. Betw een the sacrum a n d th e flo o r we m u st visualise a c o m p e n sa to ry curve in the o p p o site d irec tio n . W hen a s tru c tu ra l c u rv e e x te n d s d ow n to o r c lose to the lum bo-sacral ju n c tio n a n d insufficient c o m p e n sa to ry a n g u la r deviation is a v a ila b le in th e spine a b o v e this curve, then the pelvis will tilt in to this c u rv e so a s to c re a te c o m p e n sa to ry angulation below it. Tw o e x am ples: (1) T h e severe C type d o rs o -lu m b a r p a ra ly tic curve. (2) T he triple c u rv e w ith severe stru c tu ra l c h an g e s in all three curves in w hich th e su m o f the tw o m in o r curves is g re a te r th a n the m a jo r curve. Shoe raises to c o rre c t the pelvic o b liq u ity o b v io u sly m ake it m ore difficult fo r these p e o p le to sta n d erect. Secondary a b d u c tio n o r a d d u c tio n hip c o n tra c tu re can develop in these cases. T h e ir surgical c o rre c tio n will no alter the pelvic o b liq u ity th o u g h it d oes m ak e th e c o rre c tio n o f the scoliosis easier. Pelvic o b liq u ity c a n be o r h as to be m ain ta in e d by the _>atient in th e e rec t p o sitio n by e ith e r g oing o n to tip toe on one side o r by flexing the knee o n th e o th e r. Curve pa tte rn s: T here a re th ree flexible a re a s in th e spine, cervical, d o rsa l and lum bar. T h e d o rsa l c o m p rise s n e arly tw ice as m any segments as e ac h o f the o th e r. So lets say th e re a re fo u r regions by dividing th e d o rsa l in to tw o — an u p p e r a n d a lower d orsal region. A curve m ay h ave its a p ex a t th e ju n c tio n betw een tw o o l these regions. T h is allo w s fo r seven p o ssib le p rim a ry curves, i.e. cervical, c erv ico -d o rsal, high d o rsa l, m id d o rsa l, i? u ° rSa1, d o rs o -lu m b a r a n d lu m b a r. T h e c u rv e p a tte rn which develops d e p en d s o n th e n u m b e r o f p rim a ry curves (one o r tw o), th e situ a tio n o f the p rim a ry c u rv e a n d the relative flexibility a n d length o f spine a b o v e a n d below it ana the etiology o f the c u rv a tu re . C type, trip le q u a d ru p le a n d d o u b le m a jo r q u a d ru p le curve p a tte rn s m ay em erge. f n t0 reco gnise th e fo llow ing specifically. L he high d o rs a l o r c erv ico -d o ra sl p a ra ly tic c urve because o f its p o o r p ro g n o sis, cosm etic d e fo rm ity fy. ai?d the difficulties e n co u n tere d in c o rre c tio n . ) T he long C type p a ra ly tic c u rv e b ecause it is very ty p ic a l, fa irly flexible, easy to c o rre c t a n d m a in ta in s c o rre c tio n best. (3) T h e trip le curve p a tte rn o f id io p a th ic scoliosis because stra n g e ly e n o u g h th e m a jo r c u rv e is to th e right in o ver 8 0 % o f cases a n d it has a sex incidence o f fo u r girls to o n e boy. T h e m a jo r c urve is low d o rsa l. D 6 — D 12 a n d D 5— D l l a re by fa r the m o st freq u e n t. (4) T h e d o u b le m a jo r c urve p a tte rn o f id io p a th ic scolosis a n d oc ca sio n ally p a raly tic scolosis b ecause they b a la n ce e ac h o th e r so well th a t c o rre c tio n a n d fusion is n o t very o ften necessary b u t tire so m e w hen it is n ecessary because o f the d o u b le c o rre c tio n a n d length o f fusion. (5) T h e s h o rt sh a rp a n g u la r c u rv e o f N e u ro fib ro m a to s is b ecause o f its p o o r prognosis. (6) A n d lastly the c urve o f a n in tra spinal tu m o u r w ith its increased in te rp e d ic u la r distan c e a n d sc a llo p ed b o d y backs, because o f its p o o r p ro g n o sis fo r b o th p a tie n t a n d surgeon if n o t recognised. N ecessity for tre a tm e n t: W e m u st a p p re c ia te c le a rly th a t m an y c u rv es d o n o t get w orse, so m e even im prove, o th e rs resolve com p le te ly , o th e rs m ay sto p p rogressing even b efore sp in a l m a tu rity is reached. A ll id io p a th ic curves s to p g e ttin g w o rse w hen sp in a l m a tu rity is reach ed a n d th e iliac epiphyses a re co m p le te ly fo rm ed a n d fused m edially (R isse r’s sign). A p p ro x im a te ly a th ird o f c h ild ren will reach sp in a l m a tu rity a t 14^, 15i, a n d 1 6 i, U n fo rtu n a te ly a p p ro x im a te ly 4 0 % o f scoliosis cases have a p rogressive s tru c tu ra l c u rv e th re a te n in g u n sig h tly cosm etic defo rm ity . O b s e rv a tio n a n d experience increase o u r selectivity as to tim e a n d degree o f c a n d id a te s fo r c o rre c tio n a n d fu sio n . A b a la n ce m u st be s tru c k betw een R isse r’s e n th u sia sm a n d C o b b ’s c o n se rv a tism . F o rtu n a te ly in m o st cases, the decision is n o t in o u r h a n d s fo r even in a c o n se rv a tiv e clinic, 61 % o f the id io p a th ic cases th a t c om e to c o rre c tio n a n d fu sio n , w ere o f less th a n one y e ar d u r a tio n as fa r a s is k n o w n . T h e c u rv e a verage in th e ir g ro u p a n a ly se d w as 87 %. “ H o w ­ ever, th e e m p h a sis m u st be o n e a rly d e te c tio n . I t m u st be realised th a t d u rin g th e p e rio d o f m o st ra p id g ro w th o f the spine a t a n d preced in g p u b e rty , so m e sp in a l c u rv es m ay p ro g re s s very m ark e d ly w ithin a s h o rt tim e. C lose a n d c o n s ta n t o b se rv a tio n is re q u ire d in this p e rio d so th a t m ea su re m e n ts m ay be ta k e n to a rre s t a n d c o rre c t the d e fo rm ity befo re it is to o la te to achieve a sa tis fa c to ry re s u lt.” (de F o re s t Sm ith). P olio m y e litic cu rv es d o n o t a d h e re strictly to R isse rs ru le o f sp in a l m a tu rity . In c re a se in the c u rv a tu re th o u g h less ra p id , c a n o c cu r even a fte r sp in a l m a tu rity . I n this respect C o b b ’s ru le o f keeping a p a ra ly tic c u rv e u n d e r o b se rv a tio n fo r te n y ears o r u n t il th e age o f 16 years, w hich ever is th e lo n g e r is useful. P ro g re ssio n o f c urvatures: A c u rv e m a y increase in its degree o f a n g u la tio n , its n u m b e r o f segm ents, its stru c tu ra l c h an g e s a n d its rigidity. I n a p p ro x im a te ly tw e n ty per c e n t o f progressive curves, a d d itio n a l seg m en ts a re ad d ed to th e m a jo r c urve a t the e xpense o f th e m in o r curves. O n e o r every oc ca sio n ally tw o v e rte b ra e m ay be a d d e d to the m a jo r c u rv e a n d u su a lly fro m th e n o n flexible m in o r curve. I t a p p e a rs th a t a c urve d oes reach a p o in t w here the n u m b e r o f its c o m p o n e n t segm ents becom es c o n s ta n t a n d th a t fu rth e r increase in the d egree o f c u rv a tu re is a c c o m o d a te d by o r th e re su lt o f s tru c tu ra l c h anges in th e v e rte b ra l bodies. M o s t cu rv es how ever, re m a in c o n s ta n t a s re g a rd s to the n u m b e r o f th eir segm ents. B u t if fu sio n a t an e a rly age is c o n te m p la te d , th e p o ssib ility o f th e c u rv e in cre asin g in th e n u m b e r o f it’s segm ents, su b s e q u e n t to the o p e ra tio n , m ak e s a n a c c u ra te selectio n o f th e fu sio n a re a , difficult. In c re a se in th e n u m b er o f segm ents m ak es th e H a rrin g to n fa c to r less reliable. T h is fa c to r is d e te rm in e d by dividing th e n u m b e r o f degrees o f th e p rim a ry cu rv e, a s d e te rm in e d by th e C o b b ’s m eth o d , by the n u m b e r o f v e rte b ra e in the p rim a ry curve. F o r e xam ple, a typical id io p a th ic c u rv e o f 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 March, 1964 F i g u r e I. Po st P ol i o m y e l it i s S co l i o si s— P r e -o p e r a t i v e l y 30/1/57. 6 0 ; e x t e n d i n g f r o m D 6 — D 1 2 (i.e. 7 v e r t e b r a e ) will h a v e a H a r r i n g t o n f a c t o r o f 8- 5. S h o u l d this c u r v e in c r e a se by 5 C a n d a b s o r b a n o t h e r v e r t e b r a e , t h e H a r r i n g t o n f a c t o r will d e c r e a s e t o 8 • J in s p i i e o f t h e fact t h a t t h e c u r v e h a s i n c r e a s e d . H a r r i n g t o n st a te s t h a t if t h e f a c t o r is five o r m o r e , s u r g ic al t r e a t m e n t is u s u a l ly in d i c a t e d . In m y o p i n i o n , a f a c t o r o f se ven o r m o r e in a g r o w i n g ch il d w o u l d be safer. T h e i n c r e a s e in t h e n u m b e r o f v e r t e b r a e in a c u r v e po st- o p e r a t i v e l y , ev en in t h e p r e s e n c e o f a g o o d soli d fu sio n , is o n e o f the m o s t p o t e n t ca u s e s f o r loss o f c o r r e c t i o n in a g r o w i n g sp in e. Sig ni fic ant p r o g r e s s i o n o f a s t r u c t u r a l c u r v e d e f o r m s th e t h o r a x , d i m i n i s h e s vital c a p a c i t y a n d p u l m o n a r y f u n c t i o n a n d i n cr eas es the l i k e l i h o o d o f c a r d i o ­ p u l m o n a r y effects. It in cr ea se s fa t i g u e a n d r e d u c e s exer cise t ol e r a n c e . T h r e e d eg r es s o f sev erity a r e u s u a l ly r e c o g n i s e d : M il d c u r v e s — less t h a n 30° M o d e r a t e c u r v e s — 3 0 ° — 60° Severe c u r v e s — 60° C onservative T rea tm e n t: “ It m u s t be r e m e m b e r e d t h a t m a n y s p i n e c u r v e s a r e mild a n d few nee d a n y t r e a t m e n t . " ( C o b b ) . Seve re c u r v a t u r e w ith a well e s t a b l is h e d c o s m e t i c d e f o r m ­ ity in a ch il d o v e r t h e age o f t we lv e is best d e a l t w i t h by c o r ­ r e c t i o n a n d fu si o n. Less severe c u r v a t u r e s s h o u l d in itially be t r e a t e d co n s e r v a ti v e l y . Re le n tle s s d e t e r i o r a t i o n in sp it e o f a d e q u a t e c o n s e r v a t i v e t r e a t m e n t is a n i n d i c a t i o n fo r c o r r e c t i o n a n d fu si o n in a ch il d o v e r the age o f 8 years. R egular observation: A t f o u r m o n t h l y in t er v al s with a cli nical e x a m i n a t i o n a n d m e a s u r e m e n t o f the c u r v a t u r e o n a n er ect , si t t i n g a n d s u p i n e F i g u re II. P o st P o l i o m y el iti s -S co li os is — P r e - o p e r a t i v e l y 30/1/57. X - r a y film, i n s u r e s effective c o n t r o l . P l o t t i n g t h e c u r v a t u r e o n a g r a p h wit h de g re es o f c u r v a t u r e o n t h e a b s c i s s a ag a i n s t tim e o n the o r d i n a t e gives t h e best i dea o f p r o g r e s s a n d a tr e n d t o d e t e r i o r a t e is s o o n di sc o v er ed . A d e q u a t e j u st i f i c a ­ t i o n f o r t r e a t m e n t c o n s e r v a t i v e o r o t h e r w i s e , c a n o n l y be b a s e d , in mild cas es, o n f ac t u al e v i d e n c e o f d e t e r i o r a t i o n . D u r i n g this p e r i o d o f o b s e r v a t i o n the p a r e n t s f re q u e n tl y r e q u i re r e a s s u r a n c e . C o n f i d e n c e is g a i n e d w h e n t h e y realise t h a t t h e c h i l d ’s p r o b l e m is be i n g s t u d i e d scientifically. T h e y a cc e p t c o r r e c t i o n a n d fu si o n a n d all t h a t it implies m o r e re ad il y, s h o u l d d e t e r i o r a t i o n m a k e it ne ce s sa ry . Physiotherapy: P h y s i o t h e r a p y will neve r c o r r e c t a s t r u c t u r a l cu rv e. F u n c t i o n a l c u r v e s a n d p o s t u r e m a y be i m p r o v e d by it. It h elp s m a i n t a i n t h e flexibility o f the p r i m a r y a n d se c o n d a r y cu r v es . B r e a t h i n g a n d c o u g h i n g exer cis es a r e use ful in cases wi th r e d u c e d p u l m o n a r y f u n c t i o n . S w i m m i n g is excellent exercise. M o n e y s h o u l d n o t u n n e c e s s a r i l y be w a s t e d in the vain h o p e o f a cur e. Bed exe rcise s, t e n d o - a c h i l l e s a n d sole- s t r u c t u r e s t r e t c h i n g is i m p o r t a n t d u r i n g l o n g p e r i o d s of r e c u m b e n c y . Shoe raises: A t e m p o r a r y s h o e ra ise w hi ch i m p r o v e s a low cu rv e p r o b l e m h a s s o m e li m ite d valu e. R a d i o l o g i c a l c o n f i r m a t i o n o f t h e i m p r o v e m e n t is n ec es sa ry b e f o r e it is p r e s c r i b e d . Leg l eng th i n e q u a l i t y if it d o e s exist a n d is n o t merely a p p a r e n t be c a u s e o f a hi gh hip r e s u l t i n g f r o m t r u n k shift, s h o u l d be c o r r e c t e d . B uttock pads: I have f o u n d a sm a ll p ad s l i p p e d i n t o a p o c k e t in sid e the p a n t s , very use ful in i m p r o v i n g t h e s i t t i n g p o s t u r e o f a 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. ) March, 1964 P H Y S I O T H E R A P Y Page 9 child wi th a w a s t e d b u t t o c k . T h e s e lo w l u m b a r c u r v e s fre qu e nt ly d e v e l o p s t r u c t u r a l c h a n g e s . Recumbency: K e e p i n g a ch il d s u p i n e fo r u p t o 16 h o u r s a d a y h a s s o m e v alu e in s l o w i n g d o w n t he r a t e o f d e t e r i o r a t i o n bu t is difficult to enf orce. A d o l e s c e n t s d o no t t a k e eas ily t o it. 1 h av e ju st a b o u t given up. Braces: M a n y br a c e s ha v e bee n in v en t ed for th e t r e a t m e n t o f scoliosis. I have us ed t h e M i l w a u k e e b r ac e ex ten si vel y. A s far as I a m c o n c e r n e d it is th e o n l y b r a c e t h a t is o f a n y va lu e in t he t r e a t m e n t o f sc ol io s is . I t is in d i c a t e d in five i n s t a n c e s : (1) R a p id l y p r o g r e s s i v e s t r u c t u r a l c u r v e s in y o u n g ch i l d r en . It s lo w s d o w n p r o g r e s s i o n a n d g a i n s time. (2) C o l l a p s i n g sp i n e s in p a r a l y t i c cases. It p r o v i d e s sta b ili ty a n d i m p r o v e s b r e a t h i n g un t i l it c a n be r e p l a c e d by l on g a n d a d e q u a t e fu si on . (3) A m il d o r m o d e r a t e i d i o p a t h i c c u r v e w h i c h is s h o w i n g r a p i d p r o g r e s s i o n n e a r the e n d o f t he g r o w t h p er i o d . c a n *?e u n t l * g r o w t h is c o m p l e t e d . W C e r v i c o - d o r s a l c u r v e s p r i o r t o f u s i o n . (5) A f t e r sof t ti s s u e re lea se p r o c e d u r e s t o c o r r e c t pelvic o b li q u i t y . M a n y c u r v e s c o n t i n u e d e t e r i o r a t i n g in sp it e o f a well n t ti ng M i l w a u k e e br a c e . T h e s e c u r v e s p r o b a b l y r e q u i re •usio n. M y c a s e s d o n o t slee p in the bra ce. T h e best wa y t? ssess l ^ e ef fe ctiv en ess o f the b r a c e is a n X - r a y erect " h a n d w i t h o u t t h e b ra ce . If the pelvic piece d o e s n o t fit s n u g l y o r is lo o se ly f a st en ed , all t h e c o r r e c t i v e effect is lost. O r t h o d o n t i c s u p e r v i s i o n is n ec es sa ry. E n t h u s i a s m f o r th e M i l w a u k e e b r a c e s h o u l d be c a r e f u l ly c o n t r o l l e d a n d its l i m i t a t i o n s u n d e r s t o o d . T h e r e a r e few b e t t e r m e t h o d s o f a c h i e v i n g p r e - o p e r a t i v e c o r r e c t i o n , un l es s o f c o u r s e o n e is keen o n fu si n g mild flexible cu r v es . P l a s t e r C a s t s : M y e n t h u s i a s m f o r p r o c r a s t i n a t i o n j a c k e t s ei t h e r th e t u r n b u c k l e o r l o cal ise r c as t, is w a n i n g . I a m o f th e o p i n i o n t h a t if a M i l w a u k e e b r a c e is not h o l d i n g t he c u r v a t u r e it s h o u l d be fused. T h e M u r k J a n s e n p l a s te r bed h as very li m ite d v a l u e . O p e r a t i v e T r e a t m e n t : E v e r y n o w a n d th en we h e a r o f a ne w m e t h o d o f t r e a t i n g sc o lio s is w h i c h will d o the j o b b e t t e r a n d q u i c k e r . T h e y all ha v e a c a t c h - w o r d a n d a g i m m i c k a n d o u r l a n g u a g e is e n r i c h e d by it. T e r m s like “ l oc ali se r c a s t , ” “ s p r i n g p l a s t y , " " m u s c l e a r t h r o p l a s t y , ” “ i n s t r u m e n t a t i o n . ” c o m e t o m i n d , A h e a l t h y d e g r e e o f sc e p t i c i sm d e v e l o p s wit h ex pe r i e n c e . C a r e f u l l y d o c u m e n t e d e n d result s t u d i e s ha ve been p u b l i s h e d — M a c . Ri s se r, G u c k e r , Irwi n, R o u x . A n y ne w m e t h o d a d v o c a t e d c a n n o lo n g er get by w i t h o u t t w o y e a r p e r c e n t a g e c o r r e c t i o n m a i n t a i n e d figures. O n e o r t w o p h o t o g r a p h s o f a g o o d resul t no lo n g e r suffice. C l a s si f i c a t i o n o f re s u l t s as b e t t e r , s a m e o r w o r s e w h e n b e t t e r i m p l i e s : — “ if th e c u r v e w as d e c r e a s e d ; if p r o g r e s s i o n o f t he c u r v e in a ch il d w-as a r r e s t e d ; if f u n c t i o n w a s i m p r o v e d ; if fa t i g u e , p a i n a n d r e s p i r a t o r y d i st r e s s w er e r e d u c c d ; a n d if t h e p s y c h o s o c i a l effects o f th e d e f o r m i t y w er e r e d u c e d , " d o e s n o t suffice. C l e a r l y th e r e su l t s m a y be i n t e r p r e t e d a s p r o p o r t i o n a l to t h e 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. ) e n th u s ia sm o f p a tie n t a n d su rg e o n fo r th e m e th o d o f tr e a t­ m en t. I h ave a d h e re d to a n d advise o th e rs s ta rtin g to tre a t scoliosis to a d h e re to a m e th o d p ro v e d ov er 40 years. C a st c o rre c tio n p lus a n a d e q u a te , m a tu re p o ste rio r spine a r th r o ­ desis o f the w hole e x te n t o f th e c u rv a tu re . Indication: T he prim e in d ic a tio n s fo r c o rre c tio n a n d fusion a r e : — (1) T o c o rre c t u n sig h tly cosm etic d e fo rm ity . (2) S ta b ilisa tio n o f a w eak co lla p sin g spine. (3) P re v e n tio n o f fu rth e r defo rm ity . N o te the o m issio n o f p u lm o n a ry fu n c tio n . C a st c o rre c tio n a n d fu sio n d oes n o t im p ro v e v ita l c a p a c ity a n d p u lm o n a ry fu n c tio n , it m ay re d u c e it. Other indications: . (1) C urves o ver 60° u su a lly re q u ire c o rre c tio n a n d fusion. (2) H ig h p a ra ly tic curves. (3) P rogressive u n c o n tro la b le stru c tu ra l scoliosis in a y o u n g child. (4) C u rv e s d u e to N e u ro fib ro m a to s is . (5) A d u lts w ith p a in fu l s tru c tu ra l curves. Correction: T h re e ty p es o f c a s ts sh o u ld be used. T h e tu rn b u c k le c ast o f R isse r as m odified by C o b b , has sto o d th e te s t o f tim e. I t achieves c o rre c tio n if th e hinges a re p ro p e rly p lac ed ecc en tric to th e apex o f th e c urve by a c o m b in a tio n o f la te ra lb e n d in g , th ree p o in t p re ssu re a nd tra c tio n . I t will c o rre c t severe rigid cu rv es b e tte r th a n a n y o th e r type o f ja c k e t. I n n o single in stan c e have I fo u n d its leniency to e x aggerate th e se c o n d a ry cu rv es a p ra c tic a l disa d v an tag e . I t m u st be a p p lie d snugly a n d p ro p e rly . T h e h ead piece is alw ays n ecessary except in low lu m b a r cu rv es w hen p la ste r sh o u ld e r stra p s suffice. T h e th ig h o n th e side o f th e convexity is in c o rp o ra te d , th e a rm s a re free. F u ll c o rre c tio n can be achieved in less th a n six weeks. M ild er m o re flexible cu rv es can be c o rre c te d w ith the R isser lo ca liser cast. T h e S ta g n o ra d is tra c tio n ja c k e t is the m o s t effective cast fo r th e high d o rsa l a n d c erv ico -d o rsal curve. C heck X -ra y s ta k e n th ro u g h th e p la s te r a t re g u la r in tervals dete rm in e th e c o rre c tio n achieved. T h eo re tic ally , p e rm issab le c o rre c tio n in a trip le curve p a tte rn is th e su m o f th e re sid u a l a n g u la tio n o f th e m in o r cu rv es w hen the p a tie n t a tte m p ts to c o rre c t th em by la te ra l flexion. Sufficient a n g u la tio n m u st re m a in in th e m a jo r c u rv e a fte r c o rre c tio n a n d fu sio n , to b a la n c e the re sid u al a n g u la tio n in th e m in o r curves. I n p ra ctise, o v e r-c o rre ctio n a n d m a in te n a n c e o f o v e r­ c o rre c tio n is ra re ly e n co u n tere d . I t is alw ays wise to assess th e a b ility o f th e la te ra l tru n k flexors to m a in ta in th e c o rre c tio n o f the lu m b a r m in o r c urve T h e g re a te r th e degree o f c o rre c tio n o b ta in e d in a rigid curve, the m o re solid the fusion will have to be to m a in ta in it. I do n o t su b sc rib e to th e d e fea tist a ttitu d e o f lim iting c o rre c tio n to av o id su b s e q u e n t loss. O u r efforts sh o u ld ra th e r aim a t achieving a m assive fusion a n d a m o re careful p o st-o p e ra tiv e p ro g ram m e. P re ssu re so re s a re o c ca sio n ally e n c o u n te re d b u t can larg e ly be a v o id e d if fre q u e n t c h anges o f p o sitio n are e n co u ra g ed a nd if th e child is given full p e rm issio n to unscrew th e tu rn b u c k le , sh o u ld she b ecom e u n b e a ra b ly u n c o m fo rt­ able. C o rre c tio n o f rigid curves sh o u ld p ro c ee d slowly. F lexible c u rv es c an be c o rre c te d ra p id ly . P e rip h e ra l n e rv e lesions a re occa sio n ally e n co u n tere d d u rin g c o rre c tio n . T h e u ln a r nerve is m o s t co m m o n ly affected. W ea k n ess a nd n u m b n e s s in the u ln a r d istrib u tio n is u sually tra n s ie n t b u t c a n be p e rm a n e n t. A t first, like o th ers I asc rib e d it to d a m a g e to the ro o ts e ith e r by stre tc h in g or p inching. N o w I a m o f th e o p in io n th a t it is d u e to re p etitiv e tra u m a to th e n erve in th e g roove b e h in d th e m edial epicon- dyle fro m c o n tin u a lly re stin g on the elbow . T h is a re a sh o u ld be p ro te c te d a n d if the p a raly sis b eco m es p e rm a n e n t a n a n te rio r tra n s p o sitio n o f th e n e rv e m u s t be perfo rm e d . O th e r p o te n tia l sites o f nerve p re ssu re a re th e p o ste rio r Page 10 tria n g le o f th e n eck a n d th e u p p e r a rm o n th e edge o f the plaste r. Selection o f the Fusion area: O ne o f th e a rg u m e n ts in fa v o u r o f p o stp o n in g fusion u n til sp in a l m a tu rity is re ac h ed , is t h a t it sim plifies the se lection o f th e fu sio n a re a a n d re d u ce s th e incidence of s h o rt fu sio n s. I n a m a tu re spine, fuse th e w hole e x te n t o f an id io p a th ic p rim a ry c urve a n d to o ne v e rte b ra a b o v e and tw o b elow a p a ra ly tic p rim a ry curve. L eave a t lea st tw o m o b ile levels below th e fusion u nless the low n a tu re o f the p rim a ry c urve o r tr u n k m uscle w e ak n e ss re q u ire s th e fusion to e x te n d d o w n to th e sa c ru m . T h e ru le in an im m a tu re spine is to fuse to o n e v e rte b ra a b o v e a n d o n e v e rte b ra below a n id io p a th ic p rim a ry curve. I n a p a ra ly tic c u rv e th e fusion sh o u ld e x te n d to a t least two v e rte b ra a b o v e a nd tw o below . I f th e fu sio n a re a , so calcu ­ late d , e x tends to o r a b o v e th e 5 th d o rsa l v e rte b ra , it m u st be e x te n d ed u p to d o rsa l one. Operative Technique: I t w as m y privilege to sp en d a y e ar w ith J o h n C o b b and P h illip W ilson Jn r. a t th e H o s p ita l fo r S pecial Surgery. J o h n C o b b is a m eticu lo u s m a s te r o f th e a r t o f p o ste rio r sp in a l fusion. H is m o d ific atio n o f th e H ib b ’s tec h n iq u e , I will a tte m p t to d escribe. M a rk e r X -ray s a re ta k e n b e fo re th e o p e ra tio n . A m eth y ­ lene b lue skin ta to o m a rk a n d m e ta l X -ra y m a r k e t te c h n iq u e a re used. T h e o p e ra tio n is p e rfo rm e d u n d e r g eneral a n ae sth esia th ro u g h a w indow in th e tu rn b u c k le ja c k e t. A fte r tow eling a stra ig h t s c ra tc h in th e skin in th e line o f the p ro p o se d incision, the w h o le length o f th e incision is in filtrated intra- d e rm a lly w ith a \ % p ro c a in e s o lu tio n to re d u ce h a em o rrh ag e fro m skin vessels. T h ro u g h a sm all in cision th e spinous pro c ess o f b o th m a rk e r v e rte b ra e a re nicked fo r su b seq u e n t id entification. T h e incision is th e n m a d e in s h o rt easy stages to re d u ce b lo o d loss. Skin d ra p e s a re ap p lie d . T h e su rg e o n no w rem o v es the o u te r o f th e tw o p a irs o f gloves h e h a s o n . T h e su b c u ta n e o u s a re a l o r tissu e is scratch ed a p a rt. T h e m id lin e d e cu ssatio n o f the fascia c o vering th e p a ra v e rte b ra l m uscles is exposed. T h e c a rtila g e c a p o f each sp in o u s p ro c e ss to be e x posed is sp lit e x actly in th e m idline a n d b ro k e n off to e ach side. C o b b ’s p e rio ste al e le v ato r c a n n o w be slipped betw een the p e rio s te u m a n d the sp in o u s p ro c ess. B o th sides a re plugged a n d the next spine is exposed. W h en a ll the spines have been exposed th e in te rsp in o u s lig a m en ts a re split exactly in th e m idline. Perfect su b p e rio ste a l disse c tio n can n o w be achieved. T h e lam in a a re e xposed as fa r as th e b a se o f th e tran sv erse processes. T h e sp in o u s p ro c esses a n d lam in ae a re m eticu -, lously cleared o f a ll a tta c h e d so ft tissue sp a rin g o n ly th e ' y e llow fibres o f th e flavum . T h is c le arin g is d o n e m e th o d i­ c a lly fro m to p to b o tto m , a t no tim e sh o u ld m o re th a n tw o v e rte b ra e be e x posed to th e a ir. T h e rest o f the w ou n d is p a ck e d off. I f h a e m o rrh a g e is e n c o u n te re d it is p a ck e d off, th e n ext v e rte b ra is d e a lt w ith a n d la te r y o u re tu rn to th e tro u b le so m e a re a w hich by n o w is dry. T h is discipline saves tim e. I n th re e -q u a rte rs o f a n h o u r u p to tw elve v e rte b ra e c an be strip p e d a nd c leared a n d lo o k in g a s if th e jo b has been d o n e by a rm y a n ts . I t lo o k s slow b u t is re ally v ery m uch f a ste r th a n a n y o th e r m eth o d . D ia th e rm y is h a rd ly used. A fte r a c heck c o u n t o f th e v e rte b ra in th e fusion a re a , b ro a d d e c o rtic a tio n o f the exposed b o n e su rfaces is d o n e by r a is in g c u rls o f living bone. S ta r t in th e d e ep e st p a r t o f th e w o u n d a n d w o rk p ro g re s­ sively u p w a rd s. I n the d o rs a l a re a , a s h o rt la m in a r chip b a se d la te ra lly is ra ised fro m th e m id d le o f the la m in a on e ac h side. F o u r long c u rls a re th e n ra ised u tilising th e w hole o f th e sp in o u s pro cess a n d exte n d in g fa r o u t o n to the la m in a — tw o o n e ach side. O ne will be b e n t u p w a rd s to b rid g e th e in te r-la m in a r space a n d lo c k in u n d e r th e la m in a r ch ip o f th e v e rte b ra a b o v e a n d th e o th e r w ill be fo ld ed d ow n to lo ck in u n d e r th e la m in a r ch ip o f th e n ext c a u d a l March, 1964P H Y S I O T H E R A P Y 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. ) ,eb ra In the lu m b a r a re a a n a d d itio n a l c u rl is raised from M ch su p e rio r a rtic u la r process. In this way b ro a d d e c o rtic a tio n is a ch ie v e d a n d living curls o f bone in te rd ig ita te a cro ss th e in te rla m in a r spaces, form ing a b ro a d fu sio n bed. Sm all ju ic y pieces o f c an cellous h o m o g e n e o u s b a n k b one a re tu cked in to a ll th e crevices under these b one c u rls . A n d la te r w hen the fusion bed is com plete a large q u a n tity o f can c ello u s m a tc h stic k strip s of bone a re p a ck e d lo n g itu d in a lly o ver th e w h ole fusion area. Sufficient h o m o g en e o u s bone sh o u ld be a d d e d so th a t it is ju s t difficult t o close th e p a ra v e rte b ra l m u sc le s over the fusion. A c u sh in g c lip is le ft a t the u p p e r a n d low er lim it of the fusion as a n X -ra y guide. T he b one g ra ft is n ow encircled by a n in ta c t p e rio ste al tu b e . D u s tin g w ith penicillin a n d stre p to m y c in p o w d e r a n d p o st-o p e ra tiv e a n tib io tic cover, has e n ab led this series to be a cc om plished w ithout a single case o f significant sepsis. T he w ound is clo sed in layers w ith o u t d ra in a g e. T he window in the p la s te r is p a ck e d w ith w ool a n d covered with ela sto p last, to be filled in w ith p la s te r a fte r th e rem oval o f the sutures. The w hole d o rsa l spine c a n be fused in tw o h o u rs. B lood loss is a p p ro x im a te ly tw o p in ts a n d m u st be replaced. |I always have th re e p in ts on h a n d . W h en th e fusion extends into the lu m b a r sp in e th e ra te o f p ro g re s s is slow er. T he o p e ra tio n c a n be d o n e in tw o o r th re e stages a t fortnightly in te rv als d ep en d in g on th e p re -o p e ra tiv e c o n ­ dition o f the p a tie n t a n d his c o n d itio n d u rin g th e o p e ratio n . Particular a tte n tio n m u st th e n be given to ju n c tio n a l areas. I f the fusion is to e x te n d in to th e lu m b a r reg io n fo r th ree vertebra o r m ore, it is b e tte r to d o it in tw o stages. T racheotom y a n d m ech an ic al re sp ira to rs m ay be em ployed if required. 1 d o n o t fuse th e a r tic u la r facets. F acet fusion is w idely a d v o c a te d a n d in M a c ’s series a rticular facet fu sio n re d u ce d th e p se u d o -a rth ro sis incidence from 6 5% to 3 0 % in p a ra ly tic cases a n d fro m 5 6 % to 15% in idiopathic cases. T hese figures m a y a p p e a r to be very significant b u t m a n y fa c to rs a re involved. In th e C o b b series th a t I a n aly se d the incidence o f p se u d o -a rth ro sis was 20% in id io p a th ic cases. H e d oes n o t d o a fa ce t fusion. His arg u m e n t w hich seem s v alid is th a t d e stru c tio n o f the facets increases th e in te rse g m en tal m o b ility o f the spine. The incidence o f p se u d o -a rth ro sis is alw ay s h ig h er in paralytic cases th a n in id io p a th ic cases. S urely th e g re ater flexibility o f th e p a ra ly tic c urve m u s t be a p o te n t fa cto r. I like to see th e facets locked tig h tly by th e c o rre c tiv e force which has been ap p lie d . A u togneous b o n e is p ro b a b ly b e tte r th a n h o m o g en e o u s bone. T ibial g ra fts a re in m y o p in io n c rim in al a n d it is difficult to get sufficient a u to g n e o u s iliac c rest b o n e in [children. I a m q u ite h a p p y w ith h o m o g en e o u s b o n e e ith e r 'from the b a n k o r a w illing relative. Post-operative m anagem ent: A fter the lo st b lo o d has been rep la ce d , a n in tra v en o u s infusion is m ain ta in e d u n til th e p a tie n t p asses flatus. E arly in the series I lo st o n e case on th e th ird p o st-o p e ra tiv e d a y from a cu te d ilita tio n o f th e sto m ac h . T hese c h ild ren are prone to develop d ilita tio n a n d a g a stric su c tio n tu b e m u st M a rc h , 1964 be p a sse d if n a u se a a n d v o m iting p e rsist lo n g e r th a n th e 1st p o st-o p e ra tiv e day. C o u g h in g a n d b re a th in g exercises a re v e ry im p o rta n t. A d o rsa l fusion m ak es co u g h in g p a in fu l a n d a te lec ta sis is a re a l d a n g er. A fte r w ra p p in g in o f th e w in d o w the p a tie n t re m a in s re c u m b e n t fo r six m o n th s in th e tu rn b u c k le ja c k e t. T he c a s t is th e n re m o v e d a n d X -rays a re ta k e n a n d a sn u g h o ld in g ja c k e t a pplied, w ith sh o u ld e r stra p s. A fte r a fu rth e r f o u r m o n th s in bed, th e p la s te r is re m o v e d , X -ray s a re ta k e n a n d if sa tis fa c to ry , th e p a tie n t is allo w e d up in a full steel spinal brace. T h e fusion is p ro te c te d in this b ra ce fo r th ree to six m o n th s. I t is v irtu a lly im possible to re cognise a p se u d o -a rth ro sis on th e o b liq u e X -ra y ta k e n six m o n th s a fte r o p e ra tio n , as th e fu sio n m ass is still in a c o n g lo m e ra te s ta te . A fte r 10 m o n th s th e m ass is m o re u n ifo rm a n d a p se u d o -a rth ro sis can be seen on th e o b liq u e X -ray. Its im m e d ia te c o rre c tio n is m a n d a to ry . S h o rte r p e rio d s o f re c u m b e n c y can by a ll m e a n s be trie d . E xperience will te a c h th a t th e y lead to g re a te r loss o f c o rre c tio n a n d a hig h er p se u d o -a rth ro sis incidence. W ith in a m o n th o r tw o th e list re su ltin g fro m th e a c c e n ­ tu a te d m in o r curves c o rre c ts. T h e flat chest a s a re su lt o f rib p re ssu re fills o u t. C o rre c tio n o f e x tre m ity d e fo rm itie s m ay be u n d e rta k e n d u rin g the h o ld in g ja c k e t p eriod. C heck X -rays a re ta k e n a t th ree m o n th ly in tervals a n d a n y p se u d o -a rth ro sis th a t a p p e a rs m u st be d e alt w ith. U n d u e loss o f c o rre c tio n is a g oo d in d ic a tio n o f th e p resence o f a p se u d o -a rth ro sis. T w o years p o st-o p e ra tiv e ly w h en th e fusion is re a lly solid, a n y u n sig h tly rib h u m p can be im p ro v e d by rib re sec tio n . T h is is u su a lly a tw o stage p ro c e d u re to av o id m e d ia stin a l flu tte r. I t reduces th e v ita l c ap a c ity o n ly slightly. I t is o n ly to le ra te d w hen p u lm o n a ry fu n c tio n is re a so n a b le a n d sh o u ld be left to a th o ra c ic surgeon. In c erv ico -d o rsal curves, th e u n sig h tly p ro m in e n ce o f th e trap e ziu s c a n be v astly im p ro v e d by re sec tio n o f th e 1st a n d 2 nd ribs. Bone Growth after Spinal Fusion: I q u o te fro m J o h n s o n a n d S ou th w ic k . “ I t w as c o n c lu d e d fro m these cases th a t w hen a spine fusion is q u e stio n a b ly solid a n d fa irly m assive, th ere is little increase in le n g th o f th e fu sed a re a .” T h e stu d y o f H a llo c k , F ra n c is , a n d Jo n e s conveys a n in ac cu ra te a n d p e rh a p s u n in te n tio n a l im p re ssio n th a t c o n sid e ra b le g row th occu rs in a so lid ly fused sp in e segm ent. It does how ever, in d ic a te fro m th e p ra c tic a l c linical p o in t o f view w h a t will h a p p e n to th e a v era g e ch ild a fte r a n a verage fusion in e a rly c h ild h o o d . P seu d o -a rth ro s is in sp in e fu sio n s in c h ild ren a re m o re c o m m o n th a n generally suggested, th e y m a y be g ro ss o r m ic ro sc o p ic, b u t if th e fusion is m assive, th e less c h an c e th e re will be t h a t it will b re a k d o w n u n d e r th e stress o f gro w th a n d m o tio n . T his h a s been m y experience in tw o cases fu se d a t age 6 to 8 y ears respectively. V ery little g ro w th h a s o c c u rre d . T h e fu sio n s a re m assive a n d solid. T h e slig h t in cre ase in length o f the fu sed a re a can be ex p la in ed by in c re a sin g ra d io lo g ica l m ag nification a s t h s p a tie n t gets bigger. Page 11P H Y S I O T H E R A P Y Average age a t fusion. A verage degree o f c u rv a tu re p rio r to fusion. A v erag e c o rre c tio n ob tain e d . A verage c o rre c tio n m a in ta in e d for 2 years. A verage L ength o f p o st-o p e ra tiv e follow up. 13* 7 7% (in 28 cases w here know n) 89 % (in 25 cases w here it is re co rd e d ) I f 6 a d d e d a s zero c o rre c tio n d ro p s to 72% . 4 7 % (in 27 cases w here it is re co rd e d ) I f 4 cases w ith in­ c o m p l e t e r e c o r d s a d d e d as z ero , then it is 4 0 % 3 -4 years Pseudo-arthrosis r a te : — 2 5 % (8 cases). R e c o rre c tio n a n d fusion re q u ire d in th re e cases. Short fu sio n s:— T h re e cases, ages 12 years, 11 years, 12 years. 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 March, 1964 T h e in d ic a tio n fo r fu sio n in these tw o c h ild re n w ere c le ar c u t a n d d e m a n d in g a n d th e ir re s tric tio n o f sp in a l g ro w th will s tu n t th e m less th a n th e e v e n tu a l scoliosis w o u ld have. L o ss o f C orre ctio n : M o s t o f th e lo ss o f c o rre c tio n o c c u rre d d u rin g th e 1st y e a r a fte r th e o p e ra tio n a n d specifically b etw een th e 6th a n d 12th p o st-o p e ra tiv e m o n th . L oss o f c o rre c tio n o c cu rre d in sa m e case, u p to 16 m o n th s a fte r th e o p e ra tio n . C u ttin g th e w in d o w in th e tu r n b u c k le ja c k e t c au ses an im m e d ia te lo ss o f c o rre c tio n o f fro m 5° to 10°. In a d e q u a te fu sio n s, s h o rt fu sio n a n d p s e u d o -a rth ro s is are the m o st p o te n t c au ses o f lo ss o f c o rre c tio n . R E S U L T S . T o ta l 67 c ases c o rre c te d a n d fused. 32 c ases w ith tw o y ears fo llo w up. O n e d o u b le m a jo r e x clu d ed — 31 cases. 25 P o s t-P o lio 8 0 % 1 N e u ro fib ro m a to s is 4 % 5 Id io p a th ic 1 6% R E F E R E N C E S 1. B lo u n t, W . P .; S c h m iid t A . C .; a n d B idw ell, R . G . T h e M ilw a u k e e B race in th e O p e r a tiv e tr e a tm e n t o f S co lio sis. J . B one a n d Jo in t S u rg ery, 4 0 A , 51 1-525. J u n e , 1958. •2. B lo u n t, W . P .; S c h m id t, A . C .; a n d B idw ell, R . G . M a k in g th e M ilw a u k e e B race. J . B one a n d Jo in t S u rg e ry . 40A , 5 2 6 -5 2 8 , 624. J u n e , 1958. 3. C o b b , J . R .: O u tlin e f o r th e s tu d y o f S co lio sis. In In s tru c tio n a l C o u rs e L e c tu re s , T he A m e r ic a n A c a d e m y o f O rthopaedic Surgeons, 1948. V ol. 5, p p . 2 6 1 -2 7 5 . A n n A r b o r , J . W . E d w a rd s , 1948. 4. C o b b , J . R .: T e c h n iq u e , A fte r T r e a tm e n t, a n d R e s u lts o f S p in e F u s io n f o r S co lio sis. In I n s tr u c t io n a l C o u r s e L e c tu re s , The A m eric a n A c a d e m y o f O rth o p a ed ic S u r g e o n s , 1952, V o l. 9, pp. 6 5 -7 0 . A n n A r b o r , J . W . E d w a rd s , 1952. 5. C o b b , J . R .: E d ito r ia l, S co lio sis— Q u o V a d is ? J . B o n e a n d J o in t S u r g e r y , 4 0 A , 5 0 7 -5 1 0 , J u n e , 19^8. 6. C o b b , J . R .: T h e P ro b le m o f th e P rim a ry C u rv e . J . B one a n d J o in t S u r g e r y , 4 2 A , 1413-1425. 7. D e F o r e s t S m ith , A . : E d ito ria l— S co lio sis, J. Bone and Jo in t S u rg ery, 4 0 A , 5 0 5 -5 0 7 , J u n e , 1958. S. G a r r e tt , A . L . ; P e rry , J . a n d N ic k e l, V . L .; S ta b ilis a tio n o f th a c o lla p s in g s p in e . J . B o n e a n d J o in t S u r g e r y , 43A , 4 7 4 -4 8 4 , J u n e , 1961. 9. G e o rg e , K . a n d R ip p s te in , J .: A c o m p a ra tiv e s tu d y o f th e tw o p o p u la r m e th o d s o f m e a s u rin g s c o lio tic d e f o rm ity o f th e s p in e. J. B one a n d Jo in t S u r g e r y , 4 3 A , 8 0 9 -8 1 8 , S e p te m b e r, 1961. A. C. MILLER & CO. ORTHOPAEDIC MECHANICIANS M a n u fa ctu re rs a n d Suppliers o f: O R T H O P A E D I C A P P L IA N C E S , A R T I F I C I A L L IM B S , T R U S S E S , S U R G I C A L C O R S E T S , U R IN A L S , A R C H S U P P O R T S , C O L O S T O M Y B E L T S , E L A S T IC S T O C K IN G S , A N K L E G U A R D S , W R IS T G U A R D S , E L B O W G U A R D S , K N E E G U A R D S , L I G H T D U R A L C R U T C H E S F O R C H I L D R E N , W O O D E N C R U T C H E S , A N D M E T A L E L B O W C R U T C H E S . Phone 23-2496 P.O. Box 3412 312 Bree Street, Johannesburg 10. G r u c a , A .: T h e P a th o g e n e s is a n d T r e a tm e n t o f I d io p a th ic S coliosis. / . B one a n d J o in t S u rg ery. 40A , 5 7 0 -5 8 4 , J u n e , 1958. 11. G u c k e r , T . (iii): C h a n g e s in V ita l C a p a c ity in S co lio sis. / . Bone and J o in t S u r g e r y , 44A , 4 6 9 -4 8 1 , A p r il, 1962. 12. G u c k e r , T . 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B one and Jo in t S u rg ery. 4 0 b , 3 1 2 -3 3 2 . M a y , 1958. 29. R o a f, R . : P a r a ly tic S co lio sis. / . Bone and J o in t S u rg ery. 38B, 6 4 0 -6 5 9 , A u g u s t, 1956. 30. R o u x , D .: P re lim in a ry R e p o r t o f a n E n d R e s u lt S tu d y o f the T r e a tm e n t o f Id io p a th ic S co lio sis by C o rr e c tio n a n d F usion. Jo u r n a l o f the H o s p ita l f o r S p e c ia l S u rg ery. V ol. I., N o . 1. 31. S c o tt, J . C .: R e s o lv in g S co lio sis. / . o f B one a n d J o in t S u rg ery. 41B. 105-113. F e b r u a r y , 1959. B A R F 0 R D & J O N E S (SURGICAL SUPPLY CO.) Makers of: A R T I F I C I A L L IM B S and O R T H O P A E D IC A P P L I A N C E S SURGICAL INSTRUMENT REPAIRERS. P ER SO N A L ATTENTIO N GIVEN TO ALL CASES. 1 5 8 P R E S I D E N T S T R E E T Corner NUGGET STREET Phone 2 2 - 5 2 3 8 P.O. Box 5 4 8 4 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. )