Idiopathic Scoliosis E-Book

• Herausgeber: Thieme Medical Publishers
• Kategorie: Fachliteratur
• Sprache: Englisch

Veröffentlichungsjahr: 2021

Beschreibung

The definitive practical reference on managing idiopathic scoliosis from world-renowned experts

Idiopathic Scoliosis: The Harms Study Group Treatment Guide, Second Edition, edited by Peter O. Newton, Amer F. Samdani, Harry L. Shufflebarger, Randal R. Betz, and Jürgen Harms and written by an impressive group of experts reflects treatment advances made in the last decade. Greater understanding of the etiology and improved 3D anatomy has resulted in significant strides in clinical management of scoliosis. This richly illustrated book presents all facets of evaluation and treatment of abnormal curvature of the spine, supported by a solid foundation of evidence-based data culled from the prestigious Harms Study Group.

Divided into four sections and 31 chapters, this one-stop reference encompasses the full spectrum of surgical and nonoperative interventions—from early treatments to modern novel growth modulation techniques. In this second edition, each chapter has been updated and several new ones have been added, reflecting current literature, practice, and expert perspective. Throughout the book, masters share clinical pearls and firsthand knowledge on managing diverse types of adolescent idiopathic spinal deformity, with the common goal of improved patient outcomes.

Key Highlights

• Innovative topics include teamwork and safety in spine surgery, halo traction for large curves, anterior growth modulation, intraoperative neuromonitoring, and kyphosis restoration in scoliosis surgery
• Surgical chapters follow a consistent layout, encompassing rationales, techniques, and outcomes
• Postoperative chapters feature discussion of long-term clinical and radiographic outcomes, infections, complications, and rapid post-op recovery
• A wealth of illustrations enhance the reader's knowledge of specific techniques

This comprehensive textbook is essential reading for orthopaedic and neurosurgical residents, fellows, and researchers. Young spine surgeons embarking on their careers and senior surgeons who wish to remain up-to-date on new techniques for treating adolescent idiopathic scoliosis will also benefit from this illuminating resource.

This book includes complimentary access to a digital copy on https://medone.thieme.com.

Leseprobe

Idiopathic Scoliosis

The Harms Study Group Treatment Guide

Second Edition

Peter O. Newton, MD Chief of the Division of Orthopaedics & Scoliosis Rady Children’s Hospital-San Diego; Clinical Professor UC San Diego School of Medicine San Diego, California, USA

Amer F. Samdani, MDChief of Surgery Shriners Hospitals for Children-Philadelphia; Clinical Professor (Adjunct) of Neurological Surgery and Orthopaedic Surgery Sidney Kimmel Medical College of Thomas Jefferson University Philadelphia, Pennsylvania, USA

Harry L. Shufflebarger, MD Spine Surgeon Paley Orthopedic and Spine Institute West Palm Beach, Florida, USA

Randal R. Betz, MD Spine Surgeon Institute for Spine & Scoliosis Lawrenceville, New Jersey, USA; Voluntary Clinical Professor Department of Orthopaedics Icahn School of Medicine at Mount Sinai New York, New York, USA

Jürgen Harms, MD Professor Spine Surgery Ethianum Klinik Heidelberg, Germany

460 illustrations

ThiemeNew York • Stuttgart • Delhi • Rio de Janeiro

Library of Congress Cataloging-in-Publication Data is available from the publisher.

© 2022. Thieme. All rights reserved.

Thieme Publishers New York 333 Seventh Avenue, New York, NY 10001, USA [phone], [email protected]

Cover design: © Thieme Cover image source: Harms Study Group Typesetting by DiTech, India Printed in USA by King Printing Company, Inc.                                  5 4 3 2 1

ISBN 978-1-68420-055-9

Also available as an e-book:eISBN 978-1-68420-056-6ePub ISBN 978-1-63853-641-3

Important note: Medicine is an ever-changing science undergo- ing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowl- edge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

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This book, including all parts thereof, is legally protected by copy- right. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation without the publisher’s consent is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of micro?lms, and electronic data processing and storage.

We dedicate this second edition to our families and to our patients.

In Memoriam

We would like to honor a longtime Harms Study Group member and co-editor of the first edition of this textbook, Dr. Michael F. O’Brien.

Dr. O’Brien’s talent as a master surgeon was known around theworld, and his legacy lives on through his many patients whose lives improved through his care. His precision in the operating room and ability to execute made him one of the most respected spinal deformity surgeons of our time.

Dr. O’Brien’s knowledge and scientific contributions to the advancement of spinal deformity surgery were passed along to countless other surgeons through his personal teachings and extensive writings. He traveled the world to learn and share his expertise. He exuded generosity and compassion.

The first edition of this textbook was a passion project of Dr. O’Brien’s from the day it was conceived; it was an opportunity for him to collaborate with many of his mentors and even more of his mentees. We will all miss his insight and intellect, but will remember all he taught us as a true master of the field.

Contents

Foreword

Preface

Acknowledgments

Contributors

Section I Evaluation and Management

Editors: Patrick J. Cahill and Randal R. Betz

1 History of Scoliosis Treatment

Dainn Woo, Thomas J. Errico, and Harry L. Shu?ebarger

1.1 Introduction

1.2 Lewis Sayre, the Father of Orthopaedics

1.3 Operative Treatment

1.4 Russell A. Hibbs and Frederick H. Albee

1.5 John Robert Cobb and the Cobb Angle for Scoliosis

1.6 Fusion, Casting, and Prolonged Bedrest

1.7 Paul R. Harrington

1.8 Allen F. Dwyer and Anterior Instrumentation

1.9 Zielke Instrumentation Anterior Surgery..

1.10 Kostuik–Harrington Anterior Instrumentation Utilizing Harrington Screws

1.11 Luque Segmental Fixation

1.12 Cotrel–Dubousset Instrumentation and 3D Concepts of AIS

1.13 History of Pedicle Screws and Plates: King, Boucher, Roy-Camille

1.14 Polyaxial Screws in Spine Surgery

1.15 Segmental Application of Polyaxial Screw Constructs

1.16 Suk and Harms Thoracic Screws in Deformity

1.17 Spinal Instrumentation: Rods

1.18 Scoliosis Classification Systems

1.19 Osteotomies for Kyphosis and Scoliosis.

1.19.1 Thoracoplasty for Rib Prominence

1.20 3D Understanding of Scoliosis and the Future

1.21 History of Collaborative Research in Scoliosis

1.22 Tips/Pearls

2 Etiological Theories of Idiopathic Scoliosis

René M. Castelein and Jack C.Y. Cheng

2.1 Introduction

2.2 Biomechanics of the Upright Human Spine as Related to the Sagittal Profile, Dorsal Shear Loads

2.2.1 Evolution of the Human Pelvis, Pelvic Lordosis

2.2.2 Dorsal Shear Loads Acting on the Human Spine

2.2.3 Di?erences in Sagittal Spinal Alignment

2.2.4 Preexistent Rotation of the Nonscoliotic Spine

2.3 Animal Models.

2.3.1 Quadrupedal Animal Models

2.3.2 Bipedal Animal Models

2.3.3 Genetic Animal Models

2.3.4 Human Model

2.4 The Role of the Intervertebral Disc

2.5 Current Understanding of Genetics in AIS

2.5.1 Genome-Wide Association Studies

2.5.2 Di?erential Roles of Genetics and Environment Factors in Initiation/Progression of Deformity

2.5.3 Clinical Implications

2.5.4 Future Trends of Genetic Studies.

2.6 Bone Growth and Metabolism in Adolescent Idiopathic Scoliosis

2.6.1 Abnormal Skeletal Growth

2.6.2 Body Composition and Metabolic Dysfunction

2.6.3 Low Bone Mineral Density, Abnormal Bone Structure and Qualities

2.6.4 Abnormal Bone Turnover and Bone Cells Activity

2.6.5 Lifestyle Factors Associated with Low BMD and Poor Bone Quality

2.6.6 Bone Mass and Bone Qualities as Prognostic Factors of Curve Progression?

2.6.7 Potential Clinical Intervention and Lifestyle Modification Targeting Bone Health that Might A?ect the Curve Progression in Early AIS

2.7 Central Nervous System

2.7.1 Neurophysiological Dysfunction

2.7.2 Neuromorphological Changes (MRI-Based Studies).

2.8 Discussion

2.9 Tips/Pearls

3 Prevalence and Natural History

Kenny Kwan and Kenneth M.C. Cheung

3.1 Introduction

3.2 School Screening

3.2.1 Prevalence According to Genetic Factors.

3.2.2 Prevalence by Age

3.2.3 Prevalence by Gender

3.2.4 Prevalence by Curves

3.3 Natural History

3.4 Curve Progression

3.4.1 Curve Characteristics

3.4.2 Stage of Skeletal Growth

3.5 Back Pain

3.6 Cardiopulmonary Function

3.7 Psychosocial Issues and Cosmesis

3.8 Future Insights into the Natural History of Scoliosis.

3.9 Tips/Pearls

4 Clinical and Radiographic Evaluation of Patients with Scoliosis

Alvin H. Crawford, Patrick J. Cahill, and Jason B. Anari

4.1 Introduction

4.2 History and Clinical Presentation

4.3 Physical Examination

4.4 Radiographic Evaluation

4.5 Assessment of Skeletal Maturity

4.6 Conclusion

4.7 Tips/Pearls

5 Nonoperative Management of Adolescent Idiopathic Scoliosis.

Michael G. Vitale and Benjamin D. Roye

5.1 Introduction

5.2 Screening

5.3 History of Bracing

5.4 Types of Braces

5.5 Evidence for Bracing

5.6 BrAIST and Factors Impacting Brace Success

5.6.1 Factors Impacting Brace E?ectiveness

5.6.2 Psychosocial E?ects of Bracing.

5.7 The Authors’ Recommended Treatment Method

5.8 Bracing

5.9 Conclusion and Future Directions

5.10 Tips/Pearls

6 Classification of Adolescent Idiopathic Scoliosis for Surgical Intervention

Joseph M. Lombardi and Lawrence G. Lenke

6.1 Introduction

6.2 Classification

6.2.1 Historical Perspective

6.2.2 King Classification

6.2.3 Lenke Classification

6.2.4 SRS Three-Dimensional Classification System.

6.3 Conclusion

6.4 Tips/Pearls

7 Biomechanics and Correction of Scoliosis

Carl-Eric Aubin and David W. Polly, Jr.

7.1 Introduction: Three-Dimensional Morphology of Scoliosis and Spine Biomechanics

7.2 Deformity Correction Mechanics

7.3 Growth Modulation Instrumentation Mechanics

7.4 Multisegmental Correction Mechanics and Failure Modes

7.5 Bone Implant Interface Failure Mode (Pullout and Nonaxial Loads)

7.6 Long-Term Failure (Cyclic Loading)

7.7 Complex Deformity Correction Problems (Proximal Junctional Kyphosis and Proximal Junctional Failure)

7.8 Conclusion

7.9 Tips/Pearls

8 Benefits of Teams and Teamwork in Spine Surgery Quality, Safety, and Value

Kevin Wang, Michael G. Vitale, Elle MacAlpine, and John M. “Jack” Flynn

8.1 Introduction

8.2 Communication

8.3 Building Safety and Belonging

8.4 Team of Teams: Creating Shared Consciousness and Purpose

8.5 A Tale of Two Team Building E?orts: Children’s Hospital of Philadelphia and Children’s Hospital of New York

8.5.1 The CHOP Experience: The Value of Dedicated Surgical Teams: Bringing NASA and NASCAR Wisdom to Your Spine Operating Room

8.5.2 Improving Throughput at Children’s Hospital of New York: Leveraging a Comprehensive Unit-Based Safety Program

8.6 Tips/Pearls

9 Clinical Implications of Three-Dimensional Analysis

T. Barrett Sullivan and Peter O. Newton

9.1 Introduction

9.2 History of Radiographic Analysis

9.3 Three-Dimensional Reference Plane Definitions

9.3.1 Coronal Plane

9.3.2 Sagittal Plane

9.3.3 Transverse or Axial Plane.

9.3.4 Plane of Maximum Curvature

9.3.5 The Role of MRI and CT Imaging in AIS

9.3.6 Synchronized Biplanar Radiographic 3D Reconstruction

9.4 2D Radiograph to 3D Measurement Conversion Techniques

9.5 Conclusion

9.6 Tips/Pearls

Section II Surgical Considerations

Editors: Burt Yaszay, Firoz Miyanji, and Harry L. Shu?ebarger

10 Selective versus Nonselective Fusion for Adolescent Idiopathic Scoliosis

Daniel J. Sucato

10.1 Introduction

10.2 Indications and Criteria

10.3 Technical Aspects for Successful Selective Fusion.

10.3.1 Selection of Fusion Levels

10.4 Correction Mechanics and Desired Correction

10.4.1 Selective Thoracic Fusion.

10.5 Outcomes Following Selective Fusion

10.6 Complications

10.7 Conclusion

10.8 Tips/Pearls

11 Selection of Fusion Levels

Steven W. Hwang, Amer F. Samdani, and David H. Clements III

11.1 Background/Historic Context 114 11.2 History and Physical Examination

11.3 Radiographic Evaluation

11.4 Operative Algorithm/Goals

11.5 Anterior Spinal Fusion Level Selection

11.6 Posterior Spinal Fusion Level Selection

11.7 UIV Selection in Posterior Fusions

11.7.1 Upper Thoracic and Main Thoracic UIV

11.7.2 Thoracolumbar Upper Instrumented Vertebra

11.8 LIV Selection in Posterior Fusions

11.8.1 Main Thoracic Lower Instrumented Vertebra

11.8.2 Thoracolumbar Lower Instrumented Vertebra

11.9 Detailed Discussion of Lenke Curve Types

11.9.1 Type 1: Main Thoracic Curves.

11.9.2 Type 2: Double Thoracic Curves.

11.9.3 Type 3: Double Major Curves

11.9.4 Type 4: Triple Major Curves

11.9.5 Type 5: Thoracolumbar/Lumbar Curves

11.9.6 Type 6: Thoracolumbar/Lumbar Main Thoracic Curves

11.10 Other Considerations

11.11 Conclusion

11.12 Tips/Pearls

12 Posterior Correction Techniques in Adolescent Idiopathic Scoliosis.

Suken A. Shah and David H. Clements III

12.1 Introduction

12.2 Implant Properties.

12.3 Other Rod Materials

12.4 Correction Maneuvers

12.4.1 Compression–Distraction

12.4.2 Rod Derotation Maneuver

12.4.3 In Situ Contouring

12.4.4 Coronal and Sagittal Translation

12.4.5 En Bloc Vertebral Derotation

12.4.6 Segmental Vertebral Derotation

12.4.7 Derotation via Di?erential Rod Contouring

12.4.8 Cantilever Technique

12.4.9 Traction

12.4.10 Temporary Working Rods

12.5 The Authors’ Preferred Technique of Correction in Adolescent Idiopathic Scoliosis

12.6 En Bloc Spinal Derotation Technique

12.7 Segmental Spinal Derotation

Technique with Two Rods

12.8 The Authors’ Preferred Technique for Reducing Spinal Deformity

12.9 Conclusion

12.10 Tips/Pearls

13 Halo Traction in Large Idiopathic Scoliotic Curves Walter Klyce and Paul D. Sponseller

13.1 Introduction

13.2 Traction: The Risks and Benefits

13.3 Preferred Methods of Preoperative Traction

13.3.1 Halo-Femoral Traction

13.3.2 Halo-Gravity Traction

13.4 Complications and Contraindications.

13.5 Tips/Pearls

14 Indications and Techniques for Anterior Release and Fusion

Keith Bachmann and Peter O. Newton

14.1 Introduction

14.2 History and Evolution of Anterior Approaches

14.3 Complications

14.4 Pulmonary Function

14.5 Modern Approach

14.6 Crankshaft

14.7 Lack of Posterior Elements/Neuromuscular Scoliosis.

14.8 Techniques

14.9 Thoracotomy

14.10 Thoracoscopy

14.11 Thoracoabdominal Approach

14.12 Conclusion

14.13 Tips/Pearls

15 Posterior Releases: Pontes and Three-Column Osteotomies.

Michael P. Kelly, Ronald A. Lehman Jr., and Munish C. Gupta

15.1 Introduction

15.2 Classification and History.

15.2.1 Classification of Posterior-Based Osteotomies

15.2.2 History of Posterior Column Osteotomies (Schwab Type 2/Ponte/Smith-Petersen)

15.2.3 Pedicle Subtraction Osteotomies (Type 3/4)

15.2.4 Vertebral Column Resections (Type 5/6)

15.3 Surgical Techniques

15.3.1 Posterior Column Osteotomies/Schwab Type 2

15.4 Complications

15.4.1 Posterior Column Osteotomy/Schwab Type 2

15.4.2 Three-Column Osteotomy/Schwab Types 3, 4, 5, and 6

15.5 Conclusion

15.6 Tips/Pearls

16 Surgical Treatment of the Right Thoracic Curve Pattern

Peter O. Newton and Vidyadhar V. Upasani

16.1 Introduction

16.2 Deformity Classification

16.2.1 Three-Dimensional Analysis of the MT Curve

16.3 Decisions Relating to Surgical Treatment

16.3.1 Is a Surgically Instrumented Fusion Indicated?

16.3.2 The Inclusion of Minor Curves in the Fusion.

16.3.3 To What Extent Should the Thoracic Curve Be Corrected for Ideal Balance?

16.3.4 What Levels Should Be Included in the Fusion?

16.3.5 What Is the Best Approach?

16.3.6 When Is an Anterior Release Indicated?

16.4 Surgical Techniques

16.4.1 Posterior Spinal Instrumentation and Fusion.

16.4.2 Open Anterior Spinal Instrumentation and Fusion

16.4.3 Thoracoscopic Anterior Spinal Instrumentation and Fusion

16.5 Summary of Treatment

16.5.1 Recommendations for Lenke Type 1AR Curves

16.5.2 Lenke Type 1AL/1B Curves

16.5.3 Lenke Type 1C Curves

16.6 Conclusion 184 16.7 Tips/Pearls

17 Assessment and Management of Shoulder Balance

Joshua M. Pahys, Mark F. Abel, and Lawrence G. Lenke

17.1 Introduction

17.2 History and Relevance of Shoulder Balance

17.2.1 Shoulder Balance in Normal Adolescents

17.2.2 Relationship of Shoulder Balance with Outcome Scores

17.3 Assessment of Shoulder Balance

17.3.1 Clinical Evaluation of Shoulder Balance.

17.3.2 Radiographic Evaluation of Shoulder Balance

17.3.3 Authors’ Recommendation

17.3.4 Relationship of Clinical and Radiographic Shoulder Balance

17.4 Curve Patterns/Factors Associated with Shoulder Imbalance

17.4.1 Magnitude and Flexibility of the Proximal Thoracic Curve

17.4.2 Preoperative Shoulder Imbalance

17.4.3 Authors’ Recommendation

17.5 Strategies to Achieve/Correct Shoulder Balance

17.5.1 Upper Instrumented Vertebra Selection

17.5.2 Technique for Deformity Correction and Impact on Shoulder Balance

17.5.3 Relationship of Proximal Thoracic to Main Thoracic Correction

17.5.4 Intraoperative Shoulder Balance Assessment

17.5.5 Authors’ Recommendation

17.6 Postoperative Shoulder Balance

17.6.1 Postoperative Changes in Alignment

17.6.2 Patient-Reported Outcomes with Shoulder Imbalance

17.7 Conclusion

17.8 Tips/Pearls

18 Surgical Treatment of Lumbar and Thoracolumbar Curve Patterns (Lenke V).

Stephen G. George, Firoz Miyanji, and Harry L. Shu?ebarger

18.1 Introduction

18.2 Level Selection and Surgical Technique

18.2.1 Upper and Lower Instrumented Vertebrae

18.2.2 When Does Lenke 5 Become 6?

18.2.3 Ponte Osteotomy in Lenke 5 Curves

18.2.4 Correction Techniques in Lenke 5 Curves

18.2.5 Outcomes in Lenke 5 Curves.

18.3 Discussion

18.4 Tips/Pearls

19 The Surgical Treatment of Double and Triple Curves (Lenke Types 3, 4, and 6)

Umesh S. Metkar, Garrett R. Leonard, William F. Lavelle, Burt Yaszay, and Baron S. Lonner

19.1 Introduction

19.2 Curve Definitions

19.3 Treatment Principles.

19.4 Recent Trends in the Surgical Decision- Making Process

19.5 Surgical Approaches

19.6 Conclusion

19.7 Tips/Pearls

20 Thoracoplasty

Harry L. Shu?ebarger and Stephen G. George

20.1 Introduction

20.2 Indications

20.3 Operative Technique.

20.4 Complications

20.5 Postoperative Management

20.6 The Authors’ Institutional Experience with Thoracoplasty

20.7 Conclusion

20.8 Tips/Pearls

21 Kyphosis Restoration in Adolescent Idiopathic Scoliosis

Steven W. Hwang, Suken A. Shah, and Peter O. Newton

21.1 Introduction

21.2 Background

21.3 Importance of Sagittal Plane Correction

21.4 Surgical Restoration of Kyphosis

21.4.1 General

21.4.2 Curve Attributes.

21.4.3 Release of Spine: Posterior

21.4.4 Anterior Surgery/Video-Assisted Thoracoscopic Surgery

21.5 Posterior-Based Surgery

21.5.1 Type of Fixation

21.5.2 Implant Density

21.5.3 Rod Properties and Techniques

21.6 Conclusion

21.7 Tips/Pearls

Section III Postoperative Management

Editors: Steven W. Hwang and Amer F. Samdani

22 Long-Term Clinical and Radiographic Outcomes of Scoliosis

Tracey P. Bastrom, Michelle C. Marks, William F. Lavelle, and Peter O. Newton

22.1 Introduction

22.2 Long-Term Clinical Questions Answered

22.2.1 Maintenance of Radiographic Correction

22.2.2 Cosmesis.

22.2.3 Pulmonary Function

22.2.4 Spine Function, Mobility, and Health

22.2.5 Health-Related Quality of Life

22.2.6 Pregnancy and Childbirth

22.2.7 Reoperations at Long-Term Follow-Up

22.2.8 Comparison to Natural History

22.3 Long-Term Clinical Questions Remaining

22.4 Future Directions

22.5 Conclusion

22.6 Tips/Pearls

23 Infection in Adolescent Idiopathic Scoliosis

Michael P. Glotzbecker, Paul D. Sponseller, and Michelle C. Marks

23.1 Introduction

23.2 Background

23.3 Surveillance Periods for Surgical Site Infection

23.3.1 Early versus Late Surgical Site Infection

23.3.2 Deep versus Superficial Surgical Site Infection

23.4 Early Infections

23.4.1 Background and Incidence

23.4.2 Risk Factors and Prevention

23.4.3 Clinical Presentation and Evaluation

23.4.4 Treatment

23.5 Late Infections

23.5.1 Clinical Features

23.5.2 Evaluation and Initial Management

23.5.3 Surgical Management

23.5.4 Aftercare.

23.6 Conclusion

23.7 Tips/Pearls

24 Complications and Reoperations in Adolescent Idiopathic Scoliosis

Andrew C. Vivas, Amer F. Samdani, Joshua M. Pahys, and Steven W. Hwang

24.1 Introduction

24.2 Intraoperative Complications

24.3 Early Postoperative Complications

24.4 Late Postoperative Complications

24.5 Best Practice Guidelines

24.6 Conclusion

24.7 Tips/Pearls

25 Accelerated Pathways

Nicholas D. Fletcher and Robert W. Bruce Jr

25.1 Introduction

25.2 Background

25.3 Preoperative Considerations

25.3.1 Nutrition

25.3.2 Pulmonary

25.3.3 Gastrointestinal

25.3.4 Patient/Parent Expectations

25.4 Postoperative Management

25.4.1 Overview

25.4.2 Pain Management

25.4.3 Nutrition and Bowel Management

25.4.4 Mobilization

25.4.5 Care Pathways.

25.5 Conclusion

25.6 Tips/Pearls

26 Untreated Late-Onset Idiopathic Scoliosis and Revision Surgery in Adults

Kushagra Verma, Baron S. Lonner, and Thomas J. Errico

26.1 Introduction

26.2 Untreated Adolescent Idiopathic Scoliosis

26.3 Preoperative Assessment and Nonoperative Treatment

26.4 Complications an

26.5 Proximal and Distal Junctional Kyphosis

26.6 Revision Surgery, Alignment, and HRQOL

26.7 Flatback

26.8 Long-Term Follow-up after Adolescent Fusion

26.9 Tips/Pearls

Section IV Miscellaneous Topics

Editors: Paul D. Sponseller and Peter O. Newton

27 Osteobiologic Agents for Spinal Fusion Benjamin D. Roye and Stephen G. George

27.1 Introduction

27.2 The Biology of Spinal Fusion

27.3 Osteobiologic Products and Spinal Fusion

27.3.1 Autogenous Bone Graft

27.3.2 Allogenic Bone Graft

27.3.3 Cadaveric Allograft

27.3.4 Ceramics.

27.3.5 Demineralized Bone Matrix

27.3.6 Osteoinductive Proteins

27.3.7 Platelet Concentrates

27.3.8 Growth and Di?erentiation Factor-5

27.4 Conclusion

27.5 Tips/Pearls

28 Intraoperative Neuromonitoring

James T. Bennett, Joshua Auerbach, Amer F. Samdani, and John P. Dormans

28.1 Introduction

28.2 History.

28.2.1 Stagnara Wake-up Test

28.2.2 Ankle Clonus Test

28.3 Neuromonitoring

28.3.1 Somatosensory Evoked Potentials.

28.3.2 Transcranial Motor Evoked Potentials

28.3.3 Multimodality.

28.3.4 Triggered Electromyography

28.3.5 Descending Neurogenic Evoked Potentials

28.3.6 H-Reflex

28.3.7 D-Wave Monitoring

28.4 Anesthesia and Other Agents

28.4.1 Inhalational Agents

28.4.2 Total Intravenous Anesthesia

28.5 Other Considerations

28.5.1 Steroids.

28.6 Change in Intraoperative Neuromonitoring

28.6.1 Significant Change

28.6.2 Team Response to Intraoperative Neuromonitoring Alert

28.6.3 Timing of Change and Time to Return

28.6.4 Rate of Injury in Adolescent Idiopathic Scoliosis

28.6.5 Risk Factors for Changes in Intraoperative Neuromonitoring

28.6.6 Delayed Postoperative Neurologic Deficit

28.7 Case Examples

28.7.1 Case Example 1.

28.7.2 Case Example 2.

28.7.3 Case Example 3.

28.7.4 Case Example 4.

28.7.5 Case Example 5.

28.8 Conclusion

28.9 Tips/Pearls

29 Anterior Growth Modulation

Firoz Miyanji, Amer F. Samdani, Christine L. Farnsworth, and Peter O. Newton

29.1 Introduction

29.2 Clinical Application and Potential

Complications

29.3 Surgical Technique

29.4 Reported Outcomes

29.5 Conclusion

29.6 Tips/Pearls

30 Managing the Preadolescent Curve: Early Fusion versus Posterior Distraction

Muharrem Yazici and Burt Yaszay

30.1 Introduction

30.2 Spinal and Thoracic Growth

30.3 Surgical Alternatives.

30.4 Growth-Friendly Techniques.

30.5 Instrumented Fusion.

30.6 Conclusion

30.7 Tips/Pearls

31 The Development and Evolution of the Harms Study Group Registry.

Michelle C. Marks, Maty Petcharaporn, Peter O. Newton, Randal R. Betz, and Harry L. Shu?ebarger

31.1 Introduction

31.2 Development of a Study Group

31.3 Database Evolution

31.4 Research Study Development and Evolution

31.5 Surgeon/Site Participation.

31.5.1 Data Quality Assurance

31.5.2 Study Group Strategic Plan: Formation of a 501(c)(3) Nonprofit

31.6 The Power of Large Registries: Beyond the Research

31.7 Conclusion

31.8 Tips/Pearls

Index

Foreword

The understanding of the biology and architectural features of scoliotic spinal deformity has been revolutionized over the last 50 years, largely due to advances in computer chip technology that have been applied to the study of basic biology and engineering, as well as advances to the gathering of statistical data to better document scoliosis incidence, patterns, curve progression, and response to treatment methods.

Similar advances in understanding the three-dimensional aspects of spine deformity (UK, France), followed by the development of sophisticated spinal instrumentation methods to “normalize” spinal contour in three dimensions,were made possible by clear-headed thinking and computer technology, applied by both surgeons and PhD scientists.

The instrumented correction of scoliosis began with Harrington in the 1960s,whose straightforwardmethodwas both simple yet remarkably effective. Subsequent key advances include the technique of pedicle screwattachment to the spine by Roy-Camille (France) and the development of an “instrumentation system” that had the capacity to generate 3-D corrective forces (Cotrel and Dubousset).

As these advances were further developed throughout the world, the “German school” became prominent in deformity correction in the 1970s and 1980s through the work of Klaus Zielke and then Jürgen Harms. Harms’s comprehensive understanding of the nature of the spinal deformity aswell as his brilliant surgical techniques rapidly elevated him to the position of being considered as perhaps the best spine deformity surgeon of our generation (the subtitle of this text reflects this well-earned status).

The dynamic and innovative surgical methods of Harms and his colleagues quickly spread throughout Europe, North America, and Asia. The North American “penetration” began with Shufflebarger (Florida), followed by Betz (Philadelphia), Lenke (St. Louis/NYC), Newton (San Diego), and others.

As mentioned earlier, digital technology made data collection efficient, but someone had to do the work. The Scoliosis Research Society (founded in 1966) was key in starting the process, but over time, in the typical American way, smaller studygroups with funding from spinal implant manufacturers evolved and proved to be maximally efficient in gathering data to document the nature and efficacy of spine deformity correction. This development could be considered similar to the model of the AO Documentation Center in Bern and Davos, Switzerland.

This led to the evolution of the Harms Study Group, which has become a world-class information source for scoliosis treatment outcomes. The organization is dedicated to producing research that leads to presentations at international meetings and subsequent publications.

But finally, a textbook is required to gather, present, and illustrate the thinking and surgical techniques that have resulted from this remarkable organization. The first edition of Idiopathic Scoliosis: The Harms Study Group Treatment Guide published in 2010 to excellent reviews because of its comprehensive subject matter, including wellillustrated surgical techniques.

Now we are in 2021, over a decade further into the “deformity correction revolution,” and clearly the decade of advances since 2010 has been greater than a “half century” of improvements from just a generation ago.

Peter Newton and his co-editors, Samdani, Shufflebarger, Betz, and Harms, along with a world-class group of chapter authors, have assembled an extraordinary document of required reading for not only those “new to the game,” such as residents, fellows, and researchers, but also critical information for the young spine surgeon embarking on a career. The new information is also important for the sage, senior surgeon who wants to remain updated in all that is known about the scoliotic spine. I will not discuss the content in detail butwould note that access to topics such as “Teamwork and Safety in Spine Surgery,” “Halo Traction Techniques in Spine Surgery,” “Intraoperative Neuromonitoring,” “Kyphosis Restoration in Scoliosis Surgery,” and “Anterior Growth Modulation” (in addition to all the “expected topics”) makes this book an incredible asset.

This second edition will be a key reference for spine surgeons throughout theworld who treat spinal deformity.

Dennis R. Wenger, MDPediatric Orthopedic Training Program Director (Em)Rady Children’s Hospital San Diegoand Clinical Professor of Orthopedic SurgeryUniversity of California San DiegoSan Diego, California, USA

Preface

Several recent advances in the management of patients with adolescent idiopathic scoliosis spurred our desire to pursue a second edition of Idiopathic Scoliosis: The Harms Study Group Treatment Guide. These advances include novel growthmodulation techniques, a better understanding of the etiology of scoliosis, and improved 3D anatomy with its implications for treatment and outcomes, to name a few. This textbook serves as an invaluable repository of information, from recognized leaders in the field, on the comprehensive management of patients with adolescent idiopathic scoliosis. Each chapter has been updated from the first edition, and several newchapters have been added, reflecting the current literature, practice, and expert perspective.

Since its founding in 1995, the Harms Study Group has prospectively collected data on over 6,000 adolescent patients treated surgically for idiopathic deformities of the spine. Experience gained from these patients serves as a sound foundation for this book, and many of the facts addressed herein come from the analysis of this unique database.

The 31 chapters of this second edition are divided into four sections, which together provide the reader a one-stop comprehensive textbook on adolescent idiopathic scoliosis. The second edition spans all theway from the history of the earliest treatments of scoliosis to the modern, novel growth modulation techniques. All topics relevant to the optimal treatment of this unique patient population are included in this version, authored by renowned leaders in the field.

All the contributors to thiswork are recognized experts in the evaluation and treatment of spinal deformity. Specific surgical approaches to various types of adolescent deformity are presented in this book, along with the rationale, techniques, and results for each. This state-of-the-art work on idiopathic spinal deformity should be most useful to surgeons, fellows, and residents. It should also be valuable to all practitioners of nonsurgical care of spinal deformities and to all who work with patients who have such deformities.

Peter O. Newton, MDAmer F. Samdani, MDHarry L. Shufflebarger, MDRandal R. Betz, MDJürgen Harms, MD

Acknowledgments

The processes of writing and publishing this second edition of the book could not have been accomplished without contributions from many persons. We hope to give all of them the credit that is their due for helping to make this project possible.

This book would not have been completed without the diligent efforts of the section editors, Dr. Patrick Cahill, Dr. Steven W. Hwang, Dr. Firoz Miyanji, Dr. Paul D. Sponseller, and Dr. Burt Yaszay, and we thank them.We also thank the researchers at the Harms Study Group who have populated the database, and the contributors involved in writing the chapters for this book.We especially thank our patients and their caregivers, without whom therewould be no need for this book.

We thank Michelle Marks, multisite coordinator for the Harms Study Group, and the Setting Scoliosis Straight Foundation team, for their vital contributions, which included coordinating all inquiries related to the study group database, assisting in the analysis of these inquiries, and providing invaluable insight into the interpretation of the necessary data.

Carolyn Hendrix has been the driving force in pushing this text to completion. Without her devotion to the task and her firmguiding hand in dealing with all the editors and authors involved in it, the project would not have been completed. Her editorial and organizational skills are unparalleled, and we sincerely thank her for her time and talents.

Thieme Publishers, especiallyVandana Menon and Nidhi Chopra, have continually supported the publication of this book, and we thank Thieme for their support.

Peter O. Newton, MDAmer F. Samdani, MDHarry L. Shufflebarger, MDRandal R. Betz, MDJürgen Harms, MD

Contributors

Mark F. Abel, MD Charles Frankel Professor Emeritus Department of Orthopaedic Surgery University of Virginia Charlottesville, Virginia, USA

Jason B. Anari, MD Assistant Professor of Orthopaedic Surgery Division of Orthopaedic Surgery Children’s Hospital of Philadelphia Philadelphia, Pennsylvania, USA

Carl-Eric Aubin, PEng, PhD, ScD (h.c.), FCAE Full Professor, Department of Mechanical Engineering & Biomedical Engineering Institute, Polytechnique Montreal, Canada Adjunct Professor, Department of Surgery, Faculty of Medicine, University of Montreal Scientist, Sainte-Justine University Hospital Center, Montreal, Canada

Joshua D. Auerbach, MD Chief of Spine Surgery BronxCare Hospital Center Bronx, New York, USA

Keith R. Bachmann, MD Assistant Professor Orthopaedic Surgery University of Virginia Charlottesville, Virginia, USA

Tracey P. Bastrom, MA Orthopedic Research Program Manager Rady Children’s Specialists San Diego, California, USA

James T. Bennett, MD CSSG Pediatric Orthopaedic Surgery and Sports Medicine Assistant Professor of Pediatrics and Surgery Eastern Virginia Medical School Children’s Hospital of The King’s Daughters Norfolk, Virginia, USA

Randal R. Betz, MD Spine Surgeon Institute for Spine & Scoliosis Lawrenceville, New Jersey, USA; Voluntary Clinical Professor Department of Orthopaedics Icahn School of Medicine at Mount Sinai New York, New York, USA

Robert W. Bruce Jr, MD Orthopaedic Surgeon Children’s Healthcare of Atlanta Associate Professor of Orthopedics Emory University School of Medicine Atlanta, Georgia, USA

Patrick J. Cahill, MD Wyss/Campbell Chair of the Center for Thoracic Insufficiency Syndrome Associate Professor of Orthopaedic Surgery Division of Orthopaedic Surgery Children’s Hospital of Philadelphia Philadelphia, Pennsylvania, USA

René M. Castelein, MD, PhD Professor of Orthopedic Surgery University Medical Center Utrecht Utrecht, The Netherlands

Jack C.Y. Cheng, MD Emeritus Professor Department of Orthopaedics and Traumatology Faculty of Medicine The Chinese University of Hong Kong Prince of Wales Hospital Hong Kong, People’s Republic of China

Kenneth M.C. Cheung, MD Jessie Ho Professor in Spine Surgery Head, Department of Orthopedics and Traumatology University of Hong Kong Pok Fu Lam, Hong Kong

David H. Clements III, MD Professor of Orthopaedic Surgery and Neurosurgery Cooper Medical School of Rowan University Director, Orthopaedic Spine Surgery Cooper University Health Care Camden, New Jersey, USA

Alvin H. Crawford, MD, FACS, Hon Caus. Gr Emeritus Professor of Orthopaedics and Pediatrics University of Cincinnati College of Medicine Founding Director, Crawford Spine Center Children’s Hospital Medical Center Cincinnati, Ohio, USA

John P. Dormans, MD Orthopaedic Surgeon Riley Hospital for Children Professor, Indiana University School of Medicine Indianapolis, Indiana, USA

Thomas J. Errico, MD Associate Director of Pediatric Orthopedic and Neurosurgical Spine Nicklaus Children’s Hospital Miami, Florida, USA

Christine L. Farnsworth, MD Division of Orthopedics Rady Children’s Hospital San Diego, California, USA

Nicholas D. Fletcher, MD Pediatric Orthopaedic Surgeon Children’s Healthcare of Atlanta Associate Professor of Orthopaedic Surgery Emory University School of Medicine Atlanta, Georgia, USA

John M. “Jack” Flynn, MD Chief, Division of Orthopaedics Children’s Hospital of Philadelphia Philadelphia, Pennsylvania, USA

Stephen G. George, MD Pediatric Spine Surgeon Nicklaus Children’s Hospital Miami, Florida, USA

Michael P. Glotzbecker, MD Division Chief, Pediatric Orthopaedics Associate Surgeon in Chief George H. Thompson Distinguished Chair in Pediatric Orthopaedics Associate Professor, Case Western Reserve University School of Medicine University Hospitals, Rainbow Babies and Children’s Hospital Cleveland, Ohio, USA

Munish C. Gupta, MD Mildred B. Simon Distinguished Professor of Orthopaedic Surgery Professor of Neurological Surgery; Department of Orthopedic Surgery Washington University School of Medicine St. Louis, Missouri, USA

Steven W. Hwang, MD Spine Surgeon Shriners Hospitals for Children-Philadelphia Philadelphia, Pennsylvania, USA

Michael P. Kelly, MD Associate Professor, Orthopedic Surgery Spine Division;Washington University School of Medicine, St. Louis, Missouri, USA

Walter Klyce, MD Department of Orthopaedic Surgery Case Western Reserve University Cleveland, Ohio, USA

Kenny Kwan, BMBCh(Oxon) FRCSEd(Ortho) FHKCOS FHKAM(Orthopaedic Surgery) Clinical Assistant Professor, LKS Faculty of Medicine, Department of Orthopaedics and Traumatology, The University of Hong Kong Hong Kong Special Administrative Region of the People’s Republic of China

William F. Lavelle, MD Orthopedic Spine Surgeon Upstate Bone & Joint Center Associate Professor SUNY Upstate Medical University Syracuse, New York, USA

Ronald A. Lehman, Jr., MD Professor of Orthopaedic Surgery, Tenure (in Neurological Surgery); Chief, Reconstructive, Robotic & MIS Surgery; Director, Adult and Pediatric Spine Fellowship; Director, Athletes Spine Center; Director, Spine Research, The Daniel and Jane Och Spine Hospital NewYork-Presbyterian/The Allen Hospital New York, New York, USA

Lawrence G. Lenke, MD Surgeon-in-Chief The Daniel and Jane Och Spine Hospital New York-Presbyterian/Allen Hospital Professor of Orthopedic Surgery (in Neurological Surgery) Chief of Spinal Deformity Surgery Co-Director, Adult and Pediatric Comprehensive Spine Surgery Fellowship Columbia University Department of Orthopedic Surgery, New York, New York, USA

Garrett R. Leonard, MD Spine Surgeon Orthopaedic Institute Riverside Orthopaedics at Columbus Circle Assistant Professor, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell New York, New York, USA

Joseph M. Lombardi, MD Spine and Scoliosis Surgery Assistant Professor of Orthopedic Surgery (in Neurological Surgery) The Spine Hospital, Columbia University Medical Center New York, New York, USA

Baron S. Lonner, MD Chief of Minimally Invasive Scoliosis Surgery Mount Sinai Hospital Professor of Orthopaedic Surgery Icahn School of Medicine Mount Sinai Spine Center New York, New York, USA

Elle M. MacAlpine, BA Research Coordinator Division of Orthopaedics Children’s Hospital of Philadelphia Philadelphia, Pennsylvania, USA

Michelle C. Marks, PT, MA Executive/Research Director Setting Scoliosis Straight Foundation San Diego, California, USA

Umesh S. Metkar, MD Orthopedic Spine Surgeon Co-Director, Spine Center Beth Israel Deaconess Medical Center Instructor, Harvard Medical School Boston, Massachusetts, USA

Firoz Miyanji, MD, FRCSC Pediatric Orthopedic Surgeon BC Children’s Hospital Clinical Professor University of British Columbia Faculty of Medicine Vancouver, British Columbia, Canada

Peter O. Newton, MD Chief of the Division of Orthopaedics & Scoliosis Rady Children’s Hospital-San Diego Clinical Professor UC San Diego School of Medicine San Diego, California, USA

Joshua M. Pahys, MD Department of Orthopaedic Surgery Shriners Hospitals for Children-Philadelphia Philadelphia, Pennsylvania, USA

Maty Petcharaporn, BS Setting Scoliosis Straight Foundation San Diego, California, USA

David W. Polly, Jr, MD James W. Ogilvie Professor and Chief of Spine Surgery Catherine Mills Davis Endowed Professor Department of Orthopaedic Surgery Professor of Neurosurgery University of Minnesota Minneapolis, Minnesota, USA

Benjamin D. Roye, MD, MPH Pediatric Orthopedic Surgeon New York Presbyterian Hospital Morgan Stanley Children’s Hospital Associate Professor of Orthopedic Surgery Columbia University New York, New York, USA

Amer F. Samdani, MD Chief of Surgery Shriners Hospitals for Children-Philadelphia Clinical Professor (Adjunct) of Neurological Surgery and Orthopaedic Surgery Sidney Kimmel Medical College of Thomas Jefferson University Philadelphia, Pennsylvania, USA

Suken A. Shah, MD Division Chief, Spine and Scoliosis Center Clinical Fellowship Director Department of Orthopaedics Nemours/Alfred I. duPont Hospital for Children Wilmington, Delaware, USA Professor of Orthopaedic Surgery and Pediatrics Sidney Kimmel Medical College of Thomas Jefferson University Philadelphia, Pennsylvania, USA

Harry L. Shufflebarger, MD Spine Surgeon Paley Orthopedic and Spine Institute West Palm Beach, Florida, USA

Paul D. Sponseller, MD Professor and Head, Pediatric Orthopaedics Johns Hopkins University Hospital Baltimore, Maryland, USA

Daniel J. Sucato, MD, MS Chief of Staff, Texas Scottish Rite Hospital Professor, Department of Orthopaedic Surgery University of Texas Southwestern Medical Center Dallas, Texas, USA

T. Barrett Sullivan, MD Spine Fellow Rush University Chicago, Illinois, USA

Vidyadhar V. Upasani, MD University of California San Diego Rady Children’s Hospital-San Diego San Diego, California, USA

Kushagra Verma, MD, MS Adult and Pediatric Spine Surgeon Los Alamitos Medical Center Los Alamitos, California, USA; Clinical Assistant Professor of Surgery Western University of Health Sciences Pomona, California, USA

Michael G. Vitale, MD, MPH Director, Division of Pediatric Orthopaedics Chief, Pediatric Spine and Scoliosis Surgery New York-Presbyterian Morgan Stanley Children’s Hospital Ana Lucia Professor of Pediatric Orthopaedic Surgery and Neurosurgery Columbia University Medical Center New York, New York, USA

Andrew C. Vivas, MD Assistant Professor Department of Neurosurgery and Orthopedic Surgery UCLA David Geffen School of Medicine Los Angeles, California, USA

Kevin Wang, MHA Senior Director Performance Programs Center for the Advancement of Value in Musculoskeletal Care Hospital for Special Surgery New York, New York, USA

Dainn Woo, MD Orthopaedic Surgery Resident University of Pennsylvania Health System Philadelphia, Pennsylvania, USA

Burt Yaszay, MD Associate Clinical Professor Rady Children’s Hospital-San Diego University of California San Diego, California, USA

Muharrem Yazici, MD Children’s Orthopedic Center Cinnah Caddesi 112/2 Cankaya, Ankara, Turkey

Section I

Evaluation and Management

Editors: Patrick J. Cahill and Randal R. Betz

1 History of Scoliosis Treatment

2 Etiological Theories of Idiopathic Scoliosis

3 Prevalence and Natural History

4 Clinical and Radiographic Evaluation of Patients with Scoliosis

5 Nonoperative Management of Adolescent Idiopathic Scoliosis

6 Classification of Adolescent Idiopathic Scoliosis for Surgical Intervention

7 Biomechanics and Correction of Scoliosis

8 Benefits of Teams and Teamwork in Spine Surgery Quality, Safety, and Value

9 Clinical Implications of Three- Dimensional Analysis

1 History of Scoliosis Treatment

Dainn Woo, Thomas J. Errico, and Harry L. Shufflebarger

Summary

The history of scoliosis treatment can be traced to antiquity but has seen rapid development over the past 100 years. In the early 20th century, Russell A. Hibbs and Frederick H. Albee performed the first spinal fusion that eventually led to a wide variety of spinal instrumentation to optimally fuse, stabilize, and correct the spine. Fusion, casting, and prolonged bedrest remained the mainstay of treatment for several decades. Paul Harrington introduced the first implantable spinal implant, the Harrington rod, in the late 1950s. Future advances in segmental instrumentation with wires, hooks, and eventually pedicle screws decreased the need for casting and helped patients mobilize faster. The Dwyer method for anterior instrumentation and fusion introduced in the 1960s provided additional options for the treatment of scoliosis. Aside from advances in instrumentation, appropriately classifying patients with adolescent idiopathic scoliosis to guide treatment advanced their care. The future is bright as we improve our understanding of the three-dimensional deformity and how best to incorporate that information into daily practice.

Keywords: Harrington rod Dwyer method Lenke classification Cobb angle pedicle screw

1.1 Introduction

The roots of scoliosis recognition and treatment date back to antiquity. The oldest known documentation of spinal deformity correction was written between 3500 BCE and 1800 BCE in an ancient mythological Hindu epic called Srimad Bhagwat Mahapuranam. In this epic, Lord Krishna applies axial traction to correct a hunchback in one of his devotees, Kubja, by pressing her feet down and pulling her chin upward. The original Sanskrit translated to English reads:

“To shower the fruits of his blessings,

Happy Lord Krishna decided to straighten Kubja,

Who was deformed from three places.

He pressed her feet by his foot,

Held her chin by two fingers and pulled her up.

By the touch and pull of Lord

She became a beautiful straight woman.”1

Kubja’s spine was described as deformed in “three places,” likely indicating a form of kyphosis or kyphoscoliosis, treated by what may have been the first known use of spinal traction for deformity correction.

In the 5th to 4th century BCE, Hippocrates, the father of modern scientific medicine, was one of the first pioneers to thoroughly study the anatomy of the human spine as well as delve into specific pathologies including tuberculous spondylitis, posttraumatic kyphosis, scoliosis, vertebral dislocation, burst fractures, and fractures of spinous processes.2 In his book On the Nature of Bones, he describes in detail the components of the spine including intervertebral discs, ligaments, and muscles, and remarks the role of the spine in maintaining the erect posture of man.3 Hippocrates was also the first to divide the spine into cervical, thoracic, and lumbar sections and wrote about the natural lordosis of the cervical and lumbar spine and the kyphotic nature of the thoracic spine.4,5 Based on logical reasoning and close observation of athletes and cadavers on battlefields, he suggested possible ideas for the treatment of spinal deformities, including the Hippocratic ladder and board, both of which used traction and pressure to reduce spinal curvatures.

Centuries later in Ancient Greece, another distinguished physician, Galen (200-130 BCE), added to the works of Hippocrates through his own studies of the spine and its curvatures, which led to an accurate model of the vertebral column and spinal cord.6 He contributed significantly to the knowledge of spinal disease such as tuberculosis and injuries of the spinal cord, and his findings remained among the most thorough in the field for centuries until much more recent advances in technology were made.

One early example of nontuberculous scoliosis dates back to Medieval England.7 In 2012, archaeologists discovered the remains of King Richard III (1483–1485), whom Shakespeare had famously described as “hunchbacked” in his plays. On the contrary, computed tomographic reconstruction of Richard’s spine revealed a large right-sided scoliotic curve, which likely would have progressed throughout his lifetime. Further studies of his spine revealed that the curve probably first developed in early adolescence, confirming one of the earliest known cases of adolescent idiopathic scoliosis.

1.2 Lewis Sayre, the Father of Orthopaedics

The idea of using traction and suspension for spine correction continued in the 1800s. Orthopaedists in the days of the Civil War were considered primarily cast and brace makers, providing stability to fractures through indirect reduction and external stabilization techniques. Graduating with a medical degree from the College of Physicians and Surgeons in New York in 1842, Lewis Albert Sayre became one of the most prominent orthopaedic surgeons in the United States. Sayre established the first academic department of orthopaedics at Bellevue Medical College and served as its first professor of orthopaedics in 1853.8 Later in 1898, Bellevue Medical College merged with the New York University School of Medicine.

During his career, Sayre became well known for his successful resection of tuberculous arthritis of the hip and the invention of body casts, coined “Sayre jackets,” for the treatment of tuberculous spondylitis (Pott disease) and scoliosis.8 For the latter, patients were partially suspended by their shoulders and head from a hoist connected to the ceiling, lifted into the air to straighten the spine as far as pain would allow, then wrapped in plaster of Paris bandages that formed a rigid cast.9 The Sayre jackets paved the way for modern body casting and bracing for scoliosis.

In 1877, Sayre developed a mechanical model of scoliosis that demonstrated his three-dimensional (3D) understanding of scoliosis. The model consisted of a frame with several horizontal elastic bands holding up a makeshift spine by its spinous processes, and pressing on a brass knob on top of the frame would exert horizontal forces through the bands, creating a torsional result and spinal curves closely resembling those seen in adolescent idiopathic scoliosis.

1.3 Operative Treatment

Despite the widespread use of external stabilization techniques, only a limited effect was seen in scoliosis correction. More severe and sometimes life-threatening cases of spinal deformity required more invasive means of treatment. At the turn of the century, early luminaries attempted to stabilize the spine internally. While early surgeries were for trauma, they paved the way for deformity treatment.

Among the first was Berthold Ernest Hadra (1842–1903), a German surgeon who served in the Prussian army before immigrating to the United States to settle in Texas.10 In 1891, Hadra demonstrated the use of interspinous wiring for a case of an old unstable C6–C7 cervical fracture, where he reduced the dislocation and then interlinked the spinous processes with a silver wire.10 Although his first patient did not have tuberculosis, he believed that the same treatment could be used for patients with Pott disease and published a paper advocating its use in such cases, which he presented before the American Orthopaedic Association in September 1891.10

Two years later, the first internal fixation for Pott disease was performed in Paris by Antoine Chipault. He followed a similar method of using silver wiring through holes in the spinous processes for stabilization after reducing the deformity with traction and direct pressure and by 1896 had performed this procedure on five patients with Pott disease.10

1.4 Russell A. Hibbs and Frederick H. Albee

The idea of stabilizing the spine using a bony fusion was first proposed at the start of the 20th century by two surgeons working in New York City. Russell A. Hibbs was born in Kentucky, graduated from the University of Louisville School of Medicine, and then moved to New York City in 1893. He was appointed superintendent and house surgeon at the New York Orthopaedic Hospital in 1894 and became its surgeon-in-chief in 1900.11 During his career, Hibbs served as a major in the medical corps in the First World War, traveled weekly to give lectures to young surgeons in training at Walter Reed Hospital and the Columbia University College of Physicians and Surgeons, authored over 200 original research articles including 25 on spinal deformity treatment, and examined Franklin D. Roosevelt, pronouncing him fit to be president.11

During Hibbs’ time, tuberculosis was the leading cause of death in the western world, and he devoted much of his time tending to patients suffering from Pott disease.12 After successfully fusing a knee in a patient with poliomyelitis by mortising the patella, he set out to apply the idea to the spine.11 Working with George Huntington from the College of Physicians and Surgeons, Hibbs developed a method of spinal arthrodesis where he mobilized and longitudinally transposed spinous processes to the interspinous gap to create a continuous bony fusion. He believed the “bony bridge” would prevent kyphosis and provide cantilever support to the deformed spine.13 He first performed the procedure in 1911 on a 9-year-old boy with lumbar Pott disease, whose 3-month postoperative radiographs showed successful bony fusion.13 He further applied his method to idiopathic scoliosis in 1914, reasoning that a progressive curvature could be arrested if the vertebrae were fused to each other.14

At the same time and in the same city as Hibbs, Frederick H. Albee developed a similar method for spine fusion. Albee was born in Maine and grew up learning the principles of grafting from fruit trees on his family farm. After graduating from Harvard Medical School in 1903, he became the chief surgeon of the New York Postgraduate Medical School Clinic. He brought the concept of grafting to orthopaedic surgery. In 1906, he performed a successful bone grafting operation on a hip of a patient suffering from rheumatism. In 1911, simultaneous to Hibbs, he developed the Albee technique, performing a successful spinal fusion using the patient’s autologous tibial graft as a bridge after splitting the spinous processes.15 The following year, he invented the Albee bone mill, a tool that significantly decreased the time needed to obtain a bone graft.16 His bone mill and attachments evolved into the modern power equipment now commonly used in operating rooms around the world.

Albee was well known in his field and was sought after by many leading institutions. He demonstrated his methods in various military hospitals in France as well as in the Royal Medical Society of London.17 He set up the U.S. General Hospital Number 4 in Colonia, New Jersey, in 1918 where he served as the chief surgeon. During his career, which coincided with World War I, he treated thousands of orthopaedic injuries, implemented a rehabilitation program for wounded soldiers, and created the New Jersey Commission for Rehabilitation, where he served as chairman for 23 years.17 Throughout his life, Albee exemplified his motto: “Never train around a disability that can be removed.”18

1.5 John Robert Cobb and the Cobb Angle for Scoliosis

Not long after Hibbs' and Albee’s development of fusion techniques, John Robert Cobb became prominent in the field of scoliosis treatment. After graduating from Brown University with a degree in English literature, Cobb decided to pursue a career in medicine and received his MD from Yale University, after which he went on to complete his residency in orthopaedic surgery, drawn to the field by his strong interest in mechanics.19

In 1934, Cobb was appointed Gibney Orthopaedic Fellow at the Hospital for the Ruptured and Crippled in New York. Orthopaedics in its early years was mostly a nonoperative specialty. The “Ruptured” in “Ruptured and Crippled” represented the vast numbers of hernia surgeries performed at the hospital. In 1949, Philip Wilson Sr. merged the orthopaedic aspects of the hospital in Cornell Medical School, resulting in the Hospital for Special Surgery. During his career, Cobb headed the Margaret Caspary Scoliosis Clinic but is probably most remembered for the Cobb periosteal elevator.20 Cobb concluded that the best method for scoliosis treatment was with the use of turnbuckle plaster jackets in addition to spine fusion, which at the time were often performed with the child in a cast during the operation. Cobb also noted that not all children with scoliosis displayed curve progression, which led him to advocate for a period of observation before proceeding with surgical intervention.20

In 1948, Cobb developed a method of measuring the angle of curves in scoliosis, the “Cobb angle,” which is still widely used. In the coronal view, every scoliotic curve has an apical vertebra (most displaced from midline with the least tilted end plates) and superior and inferior end vertebrae, which have the most tilted endplates. Cobb measured the angle of curvature by drawing lines parallel to the upper border of the superior vertebral body and the lower border of the inferior vertebral body, then drawing perpendiculars from these lines to cross each other; the angle formed by the crossing lines was the Cobb angle.20,21 In an S-shaped curve, the lower end vertebra of the proximal curve would serve as the upper end vertebra of the distal curve. To be diagnosed with scoliosis, a patient must have a curvature with a Cobb angle of greater than 10 degrees.

1.6 Fusion, Casting, and Prolonged Bedrest

Similar to Dr. Cobb’s use of turnbuckle plaster jackets after fusion surgery, the idea of bracing, casting, and general immobilization techniques postoperatively was widely accepted in the mid-20th century. In 1946, Walter Blount and Albert Schmidt developed the Milwaukee brace, a full-torso cervicothoracolumbosacral orthosis (CTLSO).22 Though historically used to immobilize patients after surgery, it is used today to prevent progression of scoliosis in children who have not reached their growth spurts and are required to wear the brace 23 hours per day.22 The cervical component of these braces in growing children had an unfortunate side effect of deforming and impairing proper mandibular development.

In the late 1950s, Joseph C. Risser developed two different postoperative casts. His turnbuckle cast was a lighter, more contoured version of previous turnbuckle casts, which were cumbersome and heavy.23 He later developed the Risser localizer cast, which consisted of a rigid three-point mold and a pusher that applied posterolateral pressure to the rib angulation, intended for use immediately after surgery.24 The cast allowed patients to be ambulatory during the prolonged immobilization period. Risser is also known for his development of the Risser scale, which assesses spinal maturity by means of evaluating the ossification of the iliac apophysis, which coincides with that of the vertebral plates.25

1.7 Paul R. Harrington

Despite the development of novel fusion and external bracing techniques in the mid-20th century, successful treatment was limited by long periods of immobilization and frequent reports of infection, fusion failure, and loss of correction.26 Soon, the first implantable instrumentation allowing for stabilization of the deformed spine was introduced by Paul R. Harrington of Houston, Texas.

Dr. Harrington was born in Kansas and was known in his youth to be an outstanding athlete, serving as the captain of the University of Kansas basketball team and winning the regional championship in the javelin throw.27 After receiving his MD degree from the University of Kansas Medical School and completing his orthopaedic surgery residency in Kansas City’s St. Luke’s Hospital, he joined the U.S. army, where he served as chief of the orthopaedic service in the 77th Evacuation Hospital during World War II.28 Later in his career, he also helped found the Scoliosis Research Society and served as its president from 1972 to 1973.

In the post-war years, Harrington worked at Jefferson Davis County Hospital in Houston, Texas, where the majority of his scoliosis patients were victims of the poliomyelitis epidemic. He began to research new treatments to correct scoliosis in polio patients, who were unable to undergo physical therapy due to their illness.

After experimenting with various internal fixation methods, he finally developed the Harrington rod, a stainless-steel rod that would be attached to the spine at each end with hooks and then tightened with ratchets to straighten or distract the spine. The rod offered compression, distraction, and three-point bending forces that were good for both stability and correction. He presented his new implant to the American Academy of Orthopaedic Surgeons in 1958.

In 1963, John Moe presented his validation of the Harrington rod after recognizing that the technique would be successful only if it incorporated a solid bony fusion of the levels under the instrumentation. He used the Harrington rod plus fusion in 66 patients with favorable results, and within the next few years, fusion with instrumentation became regarded as superior to fusion without instrumentation. The Harrington rod grew in popularity and became the standard treatment for scoliosis until the late 1980s.29

The Harrington rod was not without fault. Early attempts to use the rod without fusing the spine failed due to movement of the unfused spine leading to rod breakage. However, when fusion was combined with instrumentation (even with failure of instrumentation over time), a successful fusion would maintain stabilization. The Harrington rod successfully treated curves without fusion in patients younger than 10 years, and this was the premise for the Food and Drug Administration (FDA) later approving growing rods and MAGEC devices.

Another issue after instrumented fusion for coronal deformity, especially in cases where the rod extended down to the lower spine, was “flatback syndrome.” This occurred where the natural lordosis of the lumbar spine was eliminated, causing pain, sagittal deformity, and difficulty with ambulation. It was not until the mid-1980s when new instrumentation techniques were developed that this event could be avoided.

1.8 Allen F. Dwyer and Anterior Instrumentation

Where Harrington instrumentation and fusion was suited to thoracic and double scoliotic curves, curvature of the lumbar spine was best corrected using the Dwyer method, developed by Allen F. Dwyer of Sydney, Australia.30 The Dwyer method was the first anterior spinal instrumentation for spine deformity, developed on the principle that scoliosis could be corrected by shortening the convex side of the curve.31

In 1964, Dwyer conducted a two-stage surgery in which he first performed posterior release, resecting the ligaments and capsular structures overlying the facet joints on the concave side, and excising any fibrous and bony ankylosis between the laminae, followed by corrective instrumentation via an anterolateral approach.32 He used titanium screws that were embedded into vertebral bodies on the convex side of the curve, which were then connected by a titanium cable. The cable would then be put under tension, allowing a stepwise correction of each vertebral body to the adjacent screw, ultimately straightening the convex curve. The intervertebral discs were removed to promote shortening of the convex side of the curve and to aid in spine fusion. Compared to Harrington instrumentation, the Dwyer technique required a shorter fusion length and produced better correction of the lateral curvature and rotation, especially in the thoracolumbar and lumbar spine.33

A drawback to the Dwyer technique was its contraindication in patients with a kyphotic spine. The instrumentation had a tendency to shorten the anterior part of the spinal column, thereby causing or worsening kyphosis. Also of note, a later study on 21 children who were followed up for 10 years after anterior instrumentation between 1972 and 1975 showed a frequent rate of pseudarthrosis, associated with failure of the cable and loss of correction.34 In complex cases, a posterior Harrington rod operation was performed as a planned staged component after the anterior scoliosis surgery.

1.9 Zielke Instrumentation Anterior Surgery

Improving on Dwyer’s anterior instrumentation to obtain better correction of the scoliotic spine, Klaus Zielke introduced his ventral derotation spondylodesis (VDS) instrumentation in 1976, which was aimed mainly at treating progressive, single, major lumbar or thoracolumbar curves in idiopathic scoliosis.35 Zielke’s method involved placing the screws more posteriorly through the vertebral bodies, which helped both derotate the spine and decrease the incidence of kyphosis.

Later, the VDS method was modified further to develop the Halm–Zielke instrumentation (HZI), which used a threaded VDS rod and a solid fluted rod that allowed for internal derotation and relordosation and improved rotatory stability and postoperative sagittal alignment.36 Halm–Zielke was a major improvement to the original Zielke VDS method in its ability to eliminate the kyphogenic effect and to provide primary stability.

Around the same time, in Japan, Kiyoshi Kaneda developed a two-rod anterior system that further sought to improve anterior surgery with minimal morbidity.

1.10 Kostuik–Harrington Anterior Instrumentation Utilizing Harrington Screws

In the case of kyphotic deformities, a different anterior instrumentation technique was developed by John P. Kostuik. Dr. Kostuik received his MD from Queen’s University in Kingston, Ontario, and then later served as the Chief of Spine and then Chief of Orthopaedics at Johns Hopkins School of Medicine. He was a past president of the Scoliosis Research Study and founding member and past president of the North American Spine Society.

Kostuik was interested in the biomechanics of spinal deformities and particularly focused on the kyphotic spine. Using a modification of Harrington’s technique, Kostuik relied on distractive forces on the anterior spine in combination with instrumentation.37 The anterior distraction helped resist compressive loads, and the use of segmental fixation helped minimize sagittal bending.

By 1990, Kostuik was able to report successful use of the technique in a wide variety of cases including burst fractures, posttraumatic kyphosis, Scheuermann disease, rigid round backs, congenital kyphosis, flatback syndrome, postlaminectomy kyphosis, kyphosis secondary to tumor, and osteoporosis-related kyphosis.36 Of the 279 cases reported, complications included 35 screw breaks and two fractures of distraction rods.36 In a publication in the Iowa Orthopaedic Journal, he described and illustrated in detail the specific surgical technique he used to treat each case. Kostuik’s method resulted in minimal morbidity, and “the wide range of application, ease of adaptability, and versatility”36 of his technique on kyphotic deformities of the spine were major steps for anterior spinal instrumentation.

1.11 Luque Segmental Fixation

In 1976, Eduardo Luque from Mexico City introduced a new, innovative concept in surgical scoliosis treatment: segmental spinal instrumentation. Luque saw spinal deformity as a multiplanar issue and developed a method that involved multiple points of fixation, which also had the advantage of stress load distribution. From a posterior approach, he used sublaminar wire loops to secure prebent stainless steel rods in place.38 Increasing the points of fixation in most scoliosis cases provided adequate and stable correction, and by doing so Luque hoped to reduce the need for external immobilization. This was especially important for patients in Mexico, where the hot climate would make brace compliance particularly difficult.

The Luque posterior technique was also used for severe kyphosis, as seen in three deformity cases of adolescents with myelomeningoceles that caused a thoracolumbar kyphosis between 90 and 120 degrees and a compensatory thoracic lordosis.39 These were corrected with wedge osteotomies of the gibbus deformity, segmental sublaminar wire fixation of the Luque rods, and spondylodesis with bone graft, all from the posterior aspect without requiring an anterior release. The spinal cord and dura remained intact in each case, and at 30-month postoperative follow-up, there was no notable progression of the curves. For further stabilization of the instrumentation, L-shaped rods were later devised to prevent rod migration.

Occasionally, the Luque method of sublaminar wiring would be used with Harrington rods, a technique sometimes referred to as “Tex-Mex” as a tribute to Harrington’s Texan background and Luque’s Mexican heritage. This method was popular, as both axial and transverse loading were used to correct the scoliosis, resulting in a very strong construct.40

Fixation of the lumbosacral spine and pelvis in the setting of pelvic obliquity was a particular challenge for which both Harrington’s and Luque’s methods were not quite suited. In 1976, Ben Allen and Ron Ferguson developed the Galveston technique, which involved inserting a long, contoured rod through the posteroinferior iliac spine into each ilium between the inner and outer tables, extending through the ilium to the area above the sciatic notch.41

An alternate technique for segmental fixation was later developed by Denis Drummond and his colleagues at the University of Wisconsin, which they named the “Wisconsin system.”42 The technique consisted of passing doubled closed-loop wires through holes drilled at the base of the spinous processes. The wires had steel buttons that were pulled against the spinous processes, creating a pullout strength just as strong as Luque’s sublaminar wires.41 Contoured rods would then be segmentally fixed to the spine, preserving sagittal curves. The Wisconsin system was easier to implant compared to Luque’s sublaminar wires and also had the advantage of being neurologically safer.41

1.12 Cotrel–Dubousset Instrumentation and 3D Concepts of AIS

The next advancement in segmental scoliosis correction came in 1983, when Yves Cotrel and Jean Dubousset introduced a new method of posterior instrumentation that would provide strong fixation and adequate reduction of the scoliotic curve, as well as derotation, while minimizing cord damage by avoiding the sublaminar space.

The Cotrel–Dubousset technique consisted of placing hooks on the lamina or pedicles of the spine and then independently inserting two parallel cylindrical rods in the convexity and concavity of the curve which would attach to the hooks and be locked by blockers, allowing for progressive straightening of the curve.42 The use of multiple hooks allowed the application of compression and distraction over different areas within the same rod and applied the principles of segmental fixation without the need for sublaminar wires. The rods could also be cross-linked by transverse rods creating a quadrilateral frame, which added further stability to the construct and allowed for correction of rotation, a powerful new step in the correction of scoliosis.

Cotrel and Dubousset correctly saw the scoliotic spine as a 3D structure and created their system to help improve the alignment of the spine in the coronal, sagittal, and axial planes. Untwisting the vertebrae allowed for natural reduction of the rib prominence, as the ribs associated with the deformity were attached to the vertebrae being derotated.43 External immobilization (cast or brace) was never required.

Cotrel and Dubousset’s method was later modified into several other similar devices that incorporated two rods and transverse connectors and multiple points of fixation, including Harry Shufflebarger's and Jurgen Harms' MOSS-Miami system, Asher’s Isola hybrid construct system, and the Texas Scottish Rite system.44

1.13 History of Pedicle Screws and Plates: King, Boucher, Roy-Camille

Spinal fixation by hook instrumentation was soon followed by the use of pedicle screw fixation, a technique that offers a secure grip on all three columns of the vertebrae. The use of screws in spine surgery began with many failures, but over time, modification and improvement of screws, rods, and plates led to a relatively safe and effective method for spinal stabilization in scoliosis, spondylolisthesis, pseudarthrosis, unstable fractures, postdecompressive instability, and tumor-associated instability of the spine.

The earliest use of bone screws for internal spinal fixation dates back to Jame Tourney in 1943 and Don King in 1944. King developed facet screws, 1 inch long for men and three-quarters of an inch for women, and described their placement as “parallel to the inferior border of the lamina and perpendicular to the facet joint.”