management of - postgraduate medical journal · curvepatterns in idiopathic scoliosis...

THE MANAGEMENT OF SCOLIOSISBy J. I. P. JAMES, M.S., F.R.C.S.

From the Scoliosis Clinic, The Royal National Orthopaedic Hospital and Institute of Orthopaedics, London

In the early days of orthopaedic surgery, whenoperations were simple procedures and our pre-decessors were skilled in the design of surgicalappliances, scoliosis was one of the deformitieswhich occupied much of their attention. Assurgery improved, diseases more amenable tooperative treatment became the centre of interest.Though a few men continued their work onscoliosis along traditional lines, most orthopaedicsurgeons lost interest in a condition which seemedto respond so rarely, and scoliosis often went un-treated except for the most perfunctory measures.That this should happen was not unnatural;scoliosis had proved a hard nut to crack and themethods used did not appeal to the surgeon ofthe operative school. However, the real cause ofthis neglect lay deeper, for most men, thoughlacking proof, felt that the methods availablewere useless. In addition, there were no basicmethods of studying the disease. The position isnow altered and we may reasonably claim that*fter many years of attack certain types of scoliosisare showing signs of yielding, though with nothinglike unconditional surrender.One of the most important advances has been

the development of accurate measurement of thecurves, by the method of Ferguson (I930), latermodified by Cobb (I948). By this means it hasbeen possible to follow the evolution of the defor-mity and to assess the results of treatment. Onall conservative methods, such as plaster jackets,spinal braces, long continued head suspension,special systems of exercise, and so forth, the verdicthas been a striking one. In I941 the AmericanOrthopaedic Association published the report ofa committee investigating such conservative treat-ment in most of their large clinics: in not a singleinstance had a curvature decreased during treatment.

Spinal fusion as a method of treating scoliosiswas first employed by Hibbs. Risser, of the samehospital, later developed his correcting turnbucklejacket, still the most effective method of correction.Correction and fusion by their methods were used

with enthusiasm in the years after the first worldwar. Disquiet soon arose, however, becausecorrection was commonly lost on account ofpseudarthrosis; it was also sometimes found thatalthough the primary curve could be successfullycorrected, rigid compensatory curves remainedunable to ' decompensate' and the patient listedbadly to one side. Cobb, however, modified thetechnique of operation and thereby obtained ahigher fusion rate. At the same time he developedthe use of the ' bending film,' a fundamentalradiological investigation which enables us toestimate the maximum permissible correction ofthe primary curve in relation to the mobility ofthe compensatory curves. The use of this filmwill be detailed later.

It is interesting to pause a moment and see howthe influence of one hospital has transformed thetreatment of this disorder. As already stated,Hibbs, of the New York Orthopaedic Hospital,was the first surgeon to treat scoliosis by fusion.Risser, Ferguson, Von Lackum and Cobb haveall worked at the same hospital and it is thesemen who have so greatly advanced our knowledge.Up to the last few years, indeed, they wereresponsible for all the major advances.

Until quite recently, although some of the causesof scoliosis were understood, the natural historyof none of the types had been fully worked out,least of all in the commonest, the idiopathic type.Then in April I950, Ponseti and Friedman, ofIowa City, published an article of the greatestimportance, showing that in idiopathic scoliosis theprognosis is related to the site of the apex of theprimary curve. It is thus possible to predict howsuch a curve will behave and what problems maydevelop. Here is the key to the most importantvariety of this complex deformity.Armed now with a method of curve measure-

ment, a better understanding of prognosis anda means of correction and fusion, we may pro-ceed to discuss the management of scoliosis.

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JAMES: The Management of Scoliosis

As in all diseases, an exact diagnosis and anunderstanding of the aetiology are essential.

Clinical ClassificationScoliosis is a lateral curvature of the spine.

There should be little difficulty in decidingwhether it is present or not. When a lateralcurvature is discovered it is essential to decidewhether it is postural or structural.

FIG. I.-A girl with a triple curve primary thoracicidiopathic scoliosis. Note that only the primarycurve shows rotation and that this remains onforward flexion.

Postural ScoliosisPostural scoliosis is a single lateral curvature of

slight degree which disappears on suspension oron bending forward; in the latter position novertebral or rib rotation is seen. Postural scoliosisthen is a lateral curvature without rotation, thisdistinction from structural scoliosis being funda-mental. It disappears spontaneously or withsimple exercises and does not change to a struc-tural curve. It has long been a misconceptionthat it was the earliest sign of a curvature whichmight become serious.

Compensatory scoliosis, due to a short leg or toa deformity of the hip joint, can always be excludedby a careful initial examination. It shows twolong curves without rotation, commencing at thelumbo-sacral junction. Compensatory scoliosisdoes not appear to progress and has no greatpractical importance; it is rarely, if ever, a fixedstructural curve. The treatment is entirely thatof the primary cause.

Structural ScoliosisStructural scoliosis is characterized by the

presence of a lateral curvature with rotation. Thelateral curvature itself does not disappear onsuspension or with forward flexion of the spine,and the vertebral or rib rotation persists in allpositions (Fig. i).The primary cause of a structural scoliosis may

sometimes be identified with ease. Infantileparalysis, congenital abnormalities and neuro-fibromatosis are in this group. In addition thereare many rare causes, for example muscular dys-trophy, neuropathies such as syringomyelia, spasticparalysis and Friedreich's ataxia, rickets (a rarecause in Great Britain nowadays) and some otherconditions where the relationship is not clearlyunderstood. This leaves the main group ofidiopathic structural scoliosis for consideration.As the term implies, no reasonable explanationexists for this condition, and no published workhas advanced our knowledge of the possibleaetiology.

Idiopathic ScoliosisThe onset is at any age during childhood. The

deformity tends to increase rapidly during periodsof rapid growth, but does not always do so;many cases in fact become arrested before growthhas ceased, and for this there is no obviousexplanation. In general terms, the earlier the onsetthe more serious the prognosis, because the curvaturehas a longer time to progress and because boththe primary and compensatory curves in timebecome rigid, making correction difficult. Ininfancy males predominate, but in the early teens,the commonest age of onset, girls are affected aboutfifteen times more often than boys. The adoles-cent who develops scoliosis is usually a robustand otherwise normal child. As mentionedearlier, Ponseti and Friedman have recentlyfound that the site of the primary curve is ofgreat importance in prognosis; the higher thecurve, the worse the prognosis.

In idiopathic scoliosis there are either three orfour curves, best seen in the radiograph. Whenthere are three, the middle curve is primary,with a compensatory curve above and below.At first only the primary curve is accompanied byclinical rotation; later the compensatory curvesmay also acquire some fixed rotation. Whenthere are four curves the middle two are primary,with small compensatory curves above and below;both primary curves then show marked rotation.While considering aetiology and prognosis it

is convenient to discuss an observation made byRisser. He noted that idiopathic scoliosis ceases toprogress when the iliac apophyses appear in the

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FIG. 2.-Primary lumbar idiopathic scoliosis. Thecurve has ceased to progress at 540. Though thecurve is rather more severe than usual the deformityis slight.

radiographs all the way round the crests from theanterior to the posterior superior spines. Thiscomplete appearance of the iliac apophyses ispresumably an index of skeletal maturation andcoincides with fusion of the vertebral epiphyses.It is a variable event in terms of the age in years,but in practice it is a valuable end-point in thisdeformity of the growing child. In girls the onsetof menstruation usually precedes the full'develop-ment of the apophyses by some months.

Curve patterns in Idiopathic ScoliosisLumbar Idiopathic Scoliosis (Fig. 2)

In this common curve pattern the primarycurve is in the lumbar region with its apex atL.i, 2 or 3. Because the curvature is slight andbecause no ribs are involved in the rotation,deformity is always minimal. It never becomessevere and the curve is seldom as much as 800.This type therefore never requires correction andfusion, and this opinion may be confidently givenfrom the earliest stages of its development.

In later life, because of the rotation of theposterior joints in this mobile area, a degenerativeosteo-arthritis often develops and a fairly highproportion of patients with this pattern sufferbackache. Pain is not a common symptom inscoliosis and is largely confined to this group.It may be relieved by a corset, otherwise by fusionwithout correction.

Thoraco-lumbar Idiopathic Scoliosis (Fig. 3)This less common pattern has the apex'of the

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FIG. 3.-Primary thoraco-lumbar idiopathic scoliosis.The apex of the curve is at T.ii or 12 and theprognosis is good. This is a fairly typical endresult.

curve at T.ii or I2. As will be seen, it is inter-mediate in type between the lumbar and thoracicpatterns. The prognosis is good, with rare excep-tions which may require correction and fusion.

Thoracic Idiopathic Scoliosis (Fig. 4)This is a common and important pattern. Only

5 to io per cent. of all cases of idiopathic scoliosisbecome sufficiently severe to warrant correction andfusion, and it is almost exclusively in this thoracicgroup that such cases are found. The prognosis ispoor because of the severity of the curvature,which may reach I500, and because the involve-ment of the ribs in the rotation leads to an obviousdeformity. In adolescence, girls are more oftenaffected and the curve is more often to the right.

Infantile Idiopathic Thoracic Scoliosis. Whenidiopathic scoliosis starts in infancy, it occurspredominantly in boys and the curve is usually tothe left; except in rare instances the primarycurve is situated in the thoracic region. Thedeformity starts between six months and threeyears after birth, which suggests that it is unrelatedto moulding from intra-uterine position. Becauseof its early onset and thoracic location, the prog-nosis is serious. There are many exceptions,however; some cases remain static and a few ofminimal degree may even disappear spontaneously.

Combined Thoracic and Lumbar Idiopathic Scoliosis(Fig- 5)

This pattern is the only quadruple curveidiopathic scoliosis. The age of onset is some-what younger than the average. The adjacent

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FIG. 4. Thoracic idiopathic scoliosis of moderatedegree. This common pattem frequently has asevere prognosis. It leads to marked deformitybecause of the dropped shoulder and prominenthip.

lumbar and thoracic curves are both primarywith severe rotation, and the two curves progressat roughly the same rate. Despite the frequencyof severe curvature and of radiographs that lookgrotesque, this pattern has a good prognosis. Inmarked contrast with the thoracic pattern, theshoulders remain level and the hip is covered;because each posterior rotation balances the other,the clothes hang well.

Correction and fusion of this pattern is a for-midable procedure because two primary curves inopposite directions need correction and fusion.A Risser jacket is unsuitable and the Von Lackumtransection jacket is used. The problemfortunately is not a common one.

Paralytic ScoliosisAfter an attack of poliomyelitis with residual

paralysis of trunk muscles in a growing child, thedevelopment of a structural curve is a commonevent. These cases have characteristic curvatures,quite distinct from idiopathic scoliosis; moreover,the sex distribution is equal. Such observationsare sound arguments that the idiopathic varietyis not due to unrecognized poliomyelitis.

Paralytic curves fall into two main groups. Thecollapsing spine is associated with severe andsymmetrical paralysis; no severe fixed curvedevelops, but the spine collapses because it isunstable in the erect position. In the second andlarger group the curve develops from asymmetricalweakness of trunk muscles. The convexity of theprimary curve is on the weaker side; the curve

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1FIG. 5.-Combined thoracic and lumbar idiopathic

scoliosis. Two primary curves and two com-pensatory curves above and below are present.The primary curves are almost equal. Despite themarked radiographic changes the appearance isbetter than that of the patient shown in Fig. 4.

soon shows rotation and is usually progressive,often to a serious degree. Three types may bedefined, thoraco-lumbar, low thoracic and highthoracic, but these patterns are not so well definedas in idiopathic scoliosis because the paralysis isso variable.Thoraco-lumbar paralytic scoliosis is usually

associated with weak lateral abdominal and quad-ratus lumborum muscles, a low thoracic curvewith weak intercostals and lateral abdominals onthe one side. Being low and easy to hinge out,

FIG. 6.-A high thoracic paralytic curve of 82° extendingfrom T.i to T.7. The deformity is probably dueto paralysis of the intercostals on the left side.

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these curves are eminently suitable for correctionand, being paralytic in origin, the curves arerelatively mobile.The high thoracic curve is notoriously serious

(Fig. 6). It is associated with unilateral weaknessof the intercostals and extends caudally from thelevel of T.i. It produces a particularly uglydeformity, because the upper compensatory curveis in the neck; in consequence, the head seemsto be ' stepped sideways' on the trunk. It is toohigh for correction and requires early fusion beforea severe deformity develops.No accurate prognosis can be given in paralytic

scoliosis owing to the difficulty of grading theaffected muscles and because of the complexity ofthe curve patterns. As usual, an early onset ismore serious. Muscle imbalance is more signifi-cant than the actual severity of the paralysis.

Congenital ScoliosisMany types of bony abnormality may occur in

the spine, but they are so variable that a prognosisbased on the radiological picture is impossible.Frequently a spine with numerous abnormalities,for example several hemivertebrae, will show lesscurvature than one with a single abnormality,because the effect of one wedge may cancel theother. An abnormality occurring at the lumbo-sacral junction may cause severe curvature;because there is no room below for a compen-satory curve, a double curve develops, the lowerof which is primary. Apart from compensatoryscoliosis, nearly all double curves are congenital.

NeurofibromatosisA material proportion of cases of von Reck-

linghausen's neurofibromatosis develop scoliosis,sometimes with paraplegia. The curve is usuallyshort, thoracic and acute. In such cases a carefulsearch should be made for pigmented areas, whichare often overlooked in the examination of scoliosis(Fig. 7). The curvature is almost certain toprogress; no other type of scoliosis has sucha bad prognosis.

Case Records of ScoliosisIt is our practice at the patient's first visit to

make a thorough examination, including a com-plete check of muscle power; every effort is madeto determine the aetiology. Where the aetiologyhas been discovered, or by exclusion a diagnosisof idiopathic scoliosis has been made, the curvepattern is next established from radiographs taken,if necessary, in both the erect and the supinepositions. All the curves are measured and anassessment of the prognosis is recorded.The measurement of the angles of curvature is

quite simple (Fig. 3). The limit of each curve

FIG. 7.-A patient showing the typical caf6-au-laitpatches of neurofibromatosis over the left side ofthe chest.

can be distinguished by noting that, whereas inthe primary curve the disc is widened on one side,in the curve above or below it is widened on theopposite side. At each junction there is a neutraldisc equal in width on both sides. Lines aredrawn parallel to the lower border of the lowest

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JAMES: The Management of Scoliosis

FIG. 8.-Photographs of a girl with a right thoracicstructural scoliosis taken at an interval of one year.The earlier photograph shows a slight curvatureto the right with moderate but quite definiterotation of the ribs. A year later both the curvatureand the rotation are much more obvious. Notethat rotation is absent from the lower compensatorycurve in both views.

vertebra of each curve and from them perpen-diculars are erected. Similar lines are drawn atright-angles to the upper border of each highestvertebra. The angles at which each pair of per-pendiculars meet are the angles of curvature.The measurements for both primary andcompensatory curves are recorded.

Thereafter at intervals of three to six monthsthe patient, usually a child, attends for observationand radiographs. At each visit the curves aremeasured and any deterioration noted (Fig. 8).Occasionally the curve may have increased to sucha degree that correction and fusion is indicatedforthwith, but in the vast majority of cases regularobservation is all that is required. These recordsare of great value in accumulating data on thenatural history of the various types, of many ofwhich our knowledge is still very incomplete.

Treatment of Structural ScoliosisThe modern treatment of scoliosis is based on

the observed behaviour of the various types andpatterns of curvature. Some are known to havean excellent prognosis with or without treatment,whereas others present difficult problems. Withour knowledge of prognosis we can at the beginningeither warn parents of future trouble, or moreoften reassure them.We have already seen that structural curves are

not improved by conservative treatment, and itseems unlikely that we can even arrest the progressof the deformity by such measures. Though

suitable exercises may, of course, improve theposture and appearance and must help to retainthe mobility of the curves, we should not deceiveeither ourselves or parents into thinking that wecan obtain correction or even arrest by suchmeans. If exercises are to be used, their limitedvalue should be remembered and frequent atten-dance at hospital to the detriment of schoolingor at expense and inconvenience to parents shouldbe avoided.

Spinal supports, plaster jackets and plaster bedsshould be prescribed with caution. These un-pleasant encumbrances achieve very little andfavour rigidity of both primary and compensatorycurves. In general it is our practice to use noconservative treatment of this type, but in thetreatment of paralytic curvature certain exceptionsare made. Exercises to improve the power ofpartially paralysed muscles are logical, thoughphysiotherapy will seldom improve muscles afterthe first eighteen months or two years if theyhave been used in everyday activity. Spinalsupports, on the other hand, are occasionallyneeded. Often with partial symmetrical paralysisof the trunk muscles, and always with totalparalysis, there is a general collapse on becomingerect. Therefore some of these patients areunable to walk unless they wear an efficient spinalsupport.

Indications for Correction and FusionScoliosis becomes a crippling deformity in a

minority of cases; much of the disability iscosmetic, though this is not unimportant, especiallyin young girls. Correction may obviously beindicated when the deformity is ugly, or thedisability sufficient to justify a long and majorsurgical procedure. In deciding whether correc-tion is advisable for cosmetic reasons, it must berealized that while depression of the shoulderand prominence of the hip can be corrected, theprojecting rib hump responds only to a smalldegree. More important in practice is theyoung patient with moderate deformity in whomthe prognosis clearly indicates continued deteriora-tion. In our present state of knowledge correctionand fusion is unwise before the age of ten years,but the early case is easier to treat and morerewarding than the late neglected case withmarked bone changes and soft tissue contractures.

In idiopathic scoliosis almost the only patternrequiring correction is the thoracic triple curve. Inthe mature child it is generally found that a curveof 6S' to 800 is ugly enough to warrant correction,though the appearance of the patient is moreimportant than the radiographic measurement.For a girl aged ten years with a 550 or 600 curveof this pattern, correction would be indicated,

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having regard to the future rather than the presentcurvature.

Paralytic scoliosis is frequently severe and aconsiderable proportion of cases require correction.The thoraco-lumbar and low thoracic curves needcorrection when a severe deformity already exists,or when there is considerable lateral muscularimbalance in the young child and marked defor-mity can be expected. The upper thoracic curveis too high for correction and fusion is necessaryin the position of deformity at the earliest oppor-tunity. Its discovery before the age of ten yearsmay occasionally lead the surgeon to considerfusion at an earlier age; whether this may besafely done has still to be determined.The flail or collapsing spine due to severe

symmetrical paralysis presents different problems.Here we are not concerned with either the pre-vention or correction of severe scoliosis; it willnot occur. The aim is a rigid spine linking thelegs to the upper trunk in a stable fashion. Thisentails a fusion from sacrum up to perhaps themid-thoracic region. Before undertaking thisformidable procedure one point must be settledbeyond doubt. If the patient can walk it mustbe determined whether the hip flexors are strongenough to allow walking with the spine fixed tothe pelvis, or whether the lateral abdominalmuscles are used to elevate each side of the pelvisin turn, so that the legs can swing through. Ifthe latter method of progression is used, fusionof the lumbar spine to the sacrum will effectivelystop all walking. When in doubt, the applicationof a well-moulded plaster spinal jacket whichimitates the effects of arthrodesis will settle thematter.A few patients who can walk laboriously in

double calipers and a spinal support, and whocannot sit up without such a support, are worthyof fusion. Although walking may be impeded,they become ' good sitters.' The arthrodesis ofthe spine holds them rigidly upright, so that theycan sit at a bench or a typewriter and use bothhands.We have now briefly to consider the large group

of children under the age of ten years with severescoliosis of any aetiology other than anteriorpoliomyelitis. It must be emphasized that fromthe evidence available nothing can be done toarrest a progressing curve except operation. Ininfants, plaster beds are still under trial, butthe results to date are unimpressive. In general,therefore, the deformity is allowed to run itscourse until fusion is possible at the age of ten.

In the rarer types of scoliosis, the indicationsfor fusion vary considerably. In neurofibromatosisit is unusual for a case not to require correction,as the prognosis is exceedingly bad. In con-

genital curvature, the prognosis is not easilyassessed, but is frequently good; constantobservation with correction and fusion whenneeded is the present policy.

Mobility of the CurvesWhen correction is desirable, it must be seen

whether it is possible. This is determined bythe mobility of the various curves. Paradoxically,it is rigidity of the compensatory curves thatcontra-indicates the attempt more often thanrigidity of the primary curve. If a primary curveis to be completely straightened in a Risser jacket,the patient must be able to straighten both theupper and lower compensatory curves in orderto bring the head over the pelvis. If the com-pensatory curves are rigid, this will not be possibleand the patient will look like the leaning tower ofPisa. In earlier years over-correction of theprimary curve was often produced with suchdisastrous results.

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FIG. 9.-Line drawings to demonstrate the bendingfilm. The first drawing represents the antero-posterior view taken with the patient erect. Thesecond drawing illustrates the effect of bendingtowards the side of the convexity of the compen-satory curves; the lower compensatory curve hasstraightened completely, but the upper one onlyto 35'. The third drawing shows how aftercorrection and fusion of the primary curve to 35'the patient should be able to straighten the trunkand be left well balanced with two curves of 350in either direction.

The Bending Film. The amount of fixedrigidity of the compensatory curves is determinedby the bending film, which is an antero-posteriorview, taken with the patient standing and bendingto the side of the convexity of the compensatorycurves, usually to the left. If the primary curveis of recent origin, and particularly if paralytic,these compensatory curves may straighten outcompletely. It is then permissible to straightenthe primary curve completely. If the patient is

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Jyuly 1952 JAMES: The Management of Scoliosis 393

-. -11[] || |* ll I l. ... . . .FIG. Io.-The Risser frame. Stockinette is first applied over the patient's trunk and one thigh. The

patient lies on the long canvas strap which is detached at its upper end by sliding out the transverse rodand introduced under the stockinette from the back of the neck to the perineum. In certain cases thehead halter and the pelvic girdle are used to apply distraction to the trunk. Both the canvas belt andthe pelvic girdle may be removed with ease after application of the jacket.

an adult or the scoliosis is of long standing, how-ever, the compensatory curves may be virtuallyunaltered by bending. In this rather unusualcircumstance any correction is over-correction.The usual finding is somewhere intermediate

between the two (Fig. 9). For instance, in a triplecurve scoliosis with a primary curve of 900 andcompensatory curves above and below of 450each, it might be found that the lower curvestraightened out but that the upper curve straight-ened only to 350* It would then be permissible tocorrect the primary curve from 900 to 350, that isa correction of 550. In the end such a patientwould have a primary curvature of 350 to one sideand an upper compensatory curvature of 350 tothe opposite side; the head would therefore beover the pelvis and the patient well balanced.

The Tilt Film. One further examination of theparalytic curve is to determine whether or notthe lower compensatory curve can be held to thefull extent of its mobility by the weakened musclesacting against gravity. This is determined bya tilt film, the sitting patient being tilted off thevertical by a 3-in. block under whichever buttockis on the side of the convexity of the lower com-pensatory curve. From this position he attemptsto bring himself vertically in front of the X-rayscreen by actively obliterating the lower curve.If he cannot do so, the fusion may have to beextended down to the sacrum, provided of coursethat the flexors of the hips are adequate.

Technique of CorrectionCorrection of the primary curvature is achieved

by the use of the Risser turnbuckle jacket, the

most effective method yet devised. For the ' flail 'spine when no correction is required and for thehigh thoracic paralytic curve where none ispossible, the patient is simply put into a plasterbed or a plaster spinal jacket with a posteriorwindow before operation.The Risser jacket is applied on the special

frame of that name (Fig. io). It is a full spinaljacket with shoulder straps; the leg on the sideof the primary curve is included down to the knee;no head piece is now used (Fig. i I). Anteriorand posterior hinges are placed on the side of theconvexity, well lateral and opposite to the apex ofthe primary curve; on the concave side is theturnbuckle screw. When the plaster is thoroughlydry it is cut transversely at the level of the apexof the curve. A small horizontal ellipse is removedon the side of the convexity between the hinges.The jacket is then ready for correction to begin.

Correction by elongating the turnbuckle israpid at first, but slows as the more rigid partof the deformity is reached. Discomfort shouldnever be produced. A mobile paralytic curvemay correct in two weeks, whereas a rigid idio-pathic curve may take ten weeks. Radiographsare taken when correction is nearly complete andrepeated until the desired amount is obtained.In the younger age group it is nearly alwayspossible to achieve this, but in older patients orpatients with scoliosis dating from infancy, correc-tion may fall short of the degree thought possiblefrom the bending film. It is found that thisend-point of correction can be judged, becausethe patient tends to slip out of the Risser jacketinstead of being further straightened. Although

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FIG. I i.-A Risser jacket applied for the correction of a right thoraco-lumbar laralytic curve. In the second figurethe plaster has been closed after correction and a window cut posteriorly to allow access for spinal fusion.

it is possible that a primary curve might prove sorigid as to be uncorrectible despite a satisfactorybending film, this has not occurred in practice.In our personal cases operation has not yet beenrefused on account of a lack of correction in apatient with good bending films, though thecorrection has often been less than that desired.With careful nursing, complications seldom

arise, apart from minor pressure sores. Transientnerve paralysis is of two types. A ' Saturdaynight' paralysis is caused by the arm lying overan edge of the plaster cast during sleep. A fewtransient brachial plexus lesions have been of theupper trunk C.5 and 6, not traction lesions of thelower trunk as might have been expected. Theyare probably due to compression of the plexus

between the shoulder girdle and the side of theneck.When correction is finished, the wedge-shaped

space opened out in the plaster on the side of theturn-buckle is closed. Later a window is cut overthe spine to allow access for operation (Fig. i i).A marker is placed over one spinous process, aradiograph is taken and a known vertebral levelobtained.

Technique of Spinal FusionThe aim of the operation is to obtain a wide

and deep graft soundly fused to all the vertebrae;anything less than this leads to relapse. Themethod of fusion is simple in principle, butmeticulous- and tedious in practice. The extent of

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July I952 JAMES: The Management of Scoliosis 395

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FIG. I2.-A patient with a right idiopathic thoracic scoliosis. The primary curve measured 700. The final angle afterfusion waS 450, (see text).

the fusion is normally the primary curve, thoughthere are a few instances when more than this isnecessary. The operation may be done in one,two or even three stages. In the younger child,where periosteal stripping is easy, eight or ninevertebrae may be fused at one stage. The skinincision is straight, as a curved scar accentuatesthe remaining deformity. Subperiosteal strip-ping of the spines and laminae and of the articularand transverse processes is performed. Thespinous processes are then removed and thelaminae and transverse processes are completelydecorticated. This gives a deep, wide bed, thefloor of which is bleeding cancellous bone. Onthis base is packed a large mass of chipped bonefrom the bone bank; a store of refrigerated boneis essential for extensive spinal fusion operations.At the end of the operation silver clips are placedon the spinous process above and below the fusionas radiographic guides.

Blood transfusion is essential. Because a lowvital capacity is common in paralytic patients, theprolonged anaesthesia and the post-anaestheticcare may present special problems.The patients are kept recumbent in the Risser

jacket for six months. The spine is supported bya polythene spinal jacket for a further six months,during which time the patient is at home. Oneyear after the operation bending films of theprimary curve are taken to exclude pseudarthrosis,and if satisfactory all support is abandoned.Two cases showing satisfactory results are

illustrated in Figs. I2 and I3. The time-table forcorrection and fusion of the patient shown inFig. I2 was as follows:

26.6.5o Admitted Royal National Orthopaedic Hos-pital, Stanrmore. The primary curvemeasured 700.

27.6.50 Risser jacket applied.6.7.50 Hinges and turnbuckle applied.I 1.7.50 Risser jacket cut transversely.I4.7.50 Correction started.21.7.50 Small pressure sore; window cut.4.8.50 Correction from 700 to 22'.8.8.50 Plaster filled in.x iI.8.50 Posterior window cut. Marker film.I5.8.50 One stage fusion T.7 to I2. Three pints of

blood given.24.8.50 Wound healed, sutures removed.25.11.50 Appendicectomy.12.1.51 Plaster changed. Relapse from 22° to 340.28.2.5 I Cast taken for polythene spinal support.20,3,51I Patient discharged in polythene jacket.

Monthly visits to scoliosis clinic.Ii6.8.5I Jacket removed. Bending films to right and

left showed a variation of only I 0. Noevidence of pseudarthrosis.

14.2.52 Final angle is 450, i.e. correction of 250eighteen months after fusion. Iliacapophyses fully developed and furtherchange unlikely.

Complications and Results of FusionUp to date only 50 patients have come to

operation out of a total of over 700 under super-vision in our clinic. This proportion is low,because so many patients are quite unsuitable foroperation at the time of their first visit. Theresults mentioned here are only part of a pre-liminary report, because few of the patientsoperated upon have yet reached maturity.One death occurred from respiratory failure

several hours after operation; the patient wasa boy with severe paralytic scoliosis and a lowvital capacity. A positive pressure anaesthetic

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396 POSTGRADUATE MEDICAL JOURNAL July 1952

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FIG. 13.-An adult patient with a severe paralytic curve secondary to anterior poliomyelitis. The gain in height aftercorrection and fusion was 5 in. Note the altered relation between the right costal margin and the iliac crest. Thecurve was corrected from 124° to 780.

machine is now being used for this type of case.In six cases infection has led to partial loss of thebone graft, but in no case to failure of fusion.The single example of pseudarthrosis visible inthe radiographs occurred in a patient with apainful lumbar scoliosis, for which fusion withoutcorrection was performed. In four other patientsthe degree of relapse is such that failure of fusionis suspected, though radiographic evidence ofthis is lacking.

Correction up to 600 has been held successfullyin several instances. It is true, however, that it iseasier to correct such an amount than to hold it,though the relapse is usually only about onequarter to one third of the correction. Apartfrom the fatality mentioned above, no patient isworse as a result of the operation and no patienthas shown an increase of curvature during sub-sequent growth. This finding is most important,for it is likely that with more accurate prognosis,correction and fusion will in time become moreand more preventive of severe deformity, pro-vided of course that the long-term results of fusionremain satisfactory.

AcknowledgmentFigs. 3, 4, 5 and 8 have been reproduced by kind

permission of the Editor of the British Medical Journal.BIBLIOGRAPHY

AMERICAN ORTHOPAEDIC ASSOCIATION RESEARCHCOMMITTEE (I941), 'Report on End-Result Study of theTreatment of Idiopathic Scoliosis,' J7. Bone J7t. Surg., 23, 963.

COBB, J. R. (I948), 'Outline for the Study of Scoliosis,' AmericanAcademy of Orthopaedic Surgeons' Instructional Course Lectures,5, 26I.

FERGUSON, A. B. (1930), 'Study and Treatment of Scoliosis.'Sth. med. .7. Bgham., Ala., 23, iI6.

JAMES, J. I. P. (igsi), 'Two Curve Patterns in Idiopathic Struc-tural Scoliosis,'.7. Bone Jt. Surg., 33B, 399.

JAMES, J. I. P. (I95I), 'Common Spinal Deformities in Children,'B.M..7., 2, I270.

McELVENNY, R. T. (I94i), 'Principles Underlying the Treat-ment of Scoliosis by Wedging Jacket,' Surg. Gynec. Obstet.,72, 228.

PONSETI, I. V., and FRIEDMAN, B. (I950), 'Prognosis inIdiopathic Scoliosis,' 7. Bone Jt. Surg., 32A, 38I.

RISSER, J. C. (I948), 'Important Practical Factors in the Treat-ment of Scoliosis,' American Academy of Orthopaedic Surgeons'Instructional Course Lectures, 5, 248.

RISSER, J. C., and FERGUSON, A. B. (1936), 'Scoliosis: itsPrognosis,'.7. Bone Jt. Surg., I8, 667.

SMITH, A. DE F., BUTTE, F. L., and FERGUSON, A. B. (I938),'Treatment of Scoliosis by the Wedging Jacket and SpineFusion.' A Review of 265 Cases, Ibid., 20, 825.

VoM SAAL, F. (I94I), 'Management of Scoliosis,' Amer.J. Surg.,52, 433-

VON LACKUM, W. H. (1948), 'The Surgical Treatment ofScoliosis,' American Academy of Orthopaedic Surgeons' Instruc-tional Course Lectures, 5, 236.

RUTHIN CASTLE, NORTH WALESA Clinic for the diagnosis and treatment of Internal Diseases (except Mental or Infectious Diseases). The

Clinic is provided with a staff of doctors, technicians and nurses.The surroundings are beautiful. The climate is mild. There is central heating throughout. The annual

rainfall is 30.5 inches, that is, less than the average for England.The Fees are inclusive and vary according to the room occupied.

For particulars apply to THE SECRETARY, Ruthin Castle, North Wales.Telegrams: Castle, Ruthin. Telephone: Ruthin 66.

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