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Pre-Surgery

Scoliosis is a disorder that has plagued the human population for a large portion of recorded history as evidenced by ancient works of philosophy, religion, and myths that date back as far as 3500 BC describing people with spinal deformities.  Hippocrates was the first to explicitly describe scoliosis in the fifth century BC.  He wrote about the magnitude of deformity and knowledge of curve progression during the formation of the spine during human growth.  The cause he believed was chronic poor posture and proposed the first recorded treatment which included an extension apparatus to cause axial distraction which separates the joint surfaces without rupture of their binding ligaments and without displacement.

Hippocrates
Hippocrates [1]

Claudius Galen is credited with assigning the terms scoliosis, kyphosis, and lordosis to the disorder. In addition to the treatment advocated by Hippocrates, he experimented with chest binders and jackets in an effort to correct curvature of the spine.  He also believed that repeated exercise of the rib cage musculature through such methods as loud singing and respiratory exercises could correct some of the distortion.

Galen
Claudius Galen [2]

The Dark Ages stunted any further developments in the treatment of the disease and in fact saw the disease characterized as a curse of divine retribution as it seemed to be common among the heretics of the time.  Patients were put in a device called “the rack” which sought to correct the curvature through distraction.

Nicolas Andre, in 1741, coined the term “orthopedia” which means “straight child” literally translated.  He focused on the notion that scoliosis was due to muscle imbalance and poor posture.  He advocated for the proper ergonomic construction of tables and chairs in classrooms for children.  Frequent periods of recumbence as well as corsets and braces were his recommended treatment for the disorder.

Andre
Nicolas Andre
[3]

In 1768, Francois LeVacher described a “jurymast brace,” one of the first devices that allowed for axial distraction while upright, decreasing the amount of time that a patient would need to spend immobilized in bed.  The device was characterized by a tight-fitting cap suspended from a posterior bar arising from the back of the brace.

Jurymast Brace
Jurymast Brace [4]

The first orthopedic hospital specializing in the treatment of skeletal deformities was opened in 1780 in Switzerland by Jean–Andre Venel, who was considered by many to be the “Father of orthopedics.” The hospital specialized in the treatment of crippled children's skeletal deformities.  The opening of the institute vastly increased knowledge of muscular function and of the growth and development of bone in the 19th century.  The first brace that applied horizontal correction forces as well as extension forces was developed there.

Surgical Attempts

Surgical attempts to correct curvatures of the spine were not tried until the mid to late 19th century when Jules Guerin used percutaneous myotomies of the vertebral musculature in addition to bracing.  He claimed success with over 50 patients but was challenged by many of his colleagues who reexamined the results of the treatment and found that revisions were frequent.  He was subsequently banned from practice in France and forced into exile in Belgium.

Developments in the surgical aspects of correcting Scoliosis were not realized until the early 1900s but the development of casts and braces continued throughout the late nineteenth century.  Lewis Sayre popularized plaster of Paris casts in 1880 that were applied to patients while standing in vertical suspension devices.  This tried to correct the deformity in both lateral and rotational methods and held them with a cast.  In 1885, Bradford and Brackett developed horizontal distraction frames that utilized cast application to create a three-point fixation.

          Plaster of Paris Cast        Horizontal Distraction Frame
            Plaster of Paris Cast [5]                       Horizontal Distraction Frame [6]

1895 marked a vital development in medicine that allowed for a better understanding of what scoliosis treatments should attempt to accomplish; the roentgenogram or x-ray technique was developed allowing for an internal view without surgical risks to the spine.  With the new technology, several surgeons proposed the concept of spinal fusion.

X-ray
Internal View of Scoliosis Development with X-ray [7]

Spinal Fusion

As early as 1902 steel rods and wire anchored to the spine in conjunction with autographs were utilized in experimental procedures.  It was not until Robert Hibbs, in 1911, that a formal spinal fusion operation was performed.  Using a patient with tuberculosis, he performed the operation utilizing preoperative traction jackets, steel rods and hooks, and autographic bone segments to correct spinal curvature.  The patient was then immobilized in a cast for 6 months to maintain the correction.  By 1931, he had performed 360 cases and modified the technique slightly to create different results.  The results were promising but 50% of the cases saw no curve correction and 30% had an increase in the deformity because of improper selection of fusion areas. However, this work was vital in thrusting the procedure into public consciousness.  Many other surgeons picked up on the method with varying successes.

Hibbs
Robert Hibbs [8]

Successful outcomes in spinal fusion were not widespread through the 1930s and 40s.  In fact, the Research Committee of the American Orthopedic Association conducted a study in 1941 of 420 cases of patients who underwent various treatments for their scoliosis and found that 50% underwent spinal fusion and 29% had a complete loss of correction.  69% of patients rated their satisfaction with the results as fair or poor.  The conclusion was, however, that cast correction along with fusion did produce better results than most other types of treatments.  The 50s saw the advent of better techniques that improved rates of success in cast correction, fusion techniques, and postoperative immobilization such as the localizer cast developed by Joseph Risser, which consisted of a specialized frame where pressure was applied to the rib cage.  This allowed correction to be obtained immediately after surgery and also allowed for patients to be ambulatory after the operation.  Several other important inventions were made during this period including the Cobb method of measuring the scoliosis curve magnitude radiographically that is still used today. Another invention of the time period was the Milwaukee brace designed by Walter Blount and Albert Schmidt initially as a postoperative immobilization device as well as a non-operative treatment of the disorder.

At this time spinal fusion still required 6-9 months of bed rest after the operation, average hospital stays of 1 year, significant rates of fusion failure, infection and loss of correction. Many surgeons were looking at other internal methods to approach fixation.  1955 marked a milestone in scoliosis surgery when Paul Harrington developed the Harrington distraction instrumentation, which straightened the spine while holding it rigid while fusion took place.  The original was steel rod on a ratchet system attached to the spine with hooks at the top and bottom of the curvature that would distract the curve when cranked.  This was a momentous find yet it failed to properly align the skull with the pelvis or fix rotational deformity.  Nevertheless, it advanced the field into new territories, and was used up until the late 1980s. It is the basis a modern scoliosis correction.

Harrington Distraction Instrumentation
Harrington Distraction Instrumentation [9]

The techniques used during the fusion and insertion of Harrington rods evolved throughout the 60s and 70s and became the standard expectation in treatment of spinal curvature until Cortrel and Dubousset developed the segmental instrumentation system in 1984.  Their system use crosslinking of two rods in the back to provide three-dimensional correction of the scoliotic deformity and decrease the need for immobilization after the surgery.  This system and its subsequent modifications have become very popular replacing the Harrington instrumentation.

Segmental Instrumentation
Segmental Instrumentation System [10]

By:
Clayton Alonso
Alexander Pleet
Matthew Tann
Jamie Terran

Last updated:
April 25, 2008

References:
Left Banner Photo - http://www.spinesource.com/images/SCOLI3.jpg
Right Banner Photo - http://www.bee.qut.edu.au/graphics/research/themes/medical/rod_scoliosis_correction.jpg

[1] http://www.uab.edu/reynolds/IMAGES/Hippocrates.jpg
[2] http://content.answers.com/main/content/img/scitech/HSgalen.jpg
[3] http://www.ujaen.es/investiga/cts380/historia/fig-14.jpg
[4] http://www.uihealthcare.com/depts/medmuseum/wallexhibits/scoliosis/images/earlybrace.jpg
[5] http://www.uihealthcare.com/depts/medmuseum/wallexhibits/scoliosis/images/traction.jpg
[6] http://www.uihealthcare.com/depts/medmuseum/wallexhibits/scoliosis/images/jackets.jpg
[7] http://www.scoliosipadova.net/assets/images/immagini-sito/scoliosi/evoluzione/aggr_ferrarese.jpg
[8] http://cpmcnet.columbia.edu/dept/hibbs/hibbs.gif
[9] http://www.medscape.com/content/2003/00/44/83/448306/art-nf448306.fig2.jpg
[10] http://www.scoliosis.org/resources/medicalupdates/images/c-d.gif

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