The History of Scoliosis Surgery
Scoliosis, a side-to-side curvature of the spine, most often becomes noticeable during adolescence and occurs more often in females than in males. Surgical treatment for scoliosis has seen many changes throughout its history. The basic premise, however, has remained the same: bring the spine to its straightest possible position, secure the straightened spine using one or more steel rods, and fuse all or part of the spine included in the surgical area. According to the Mayo Clinic, "Scoliosis surgery is one of the longest and most complicated orthopedic surgical procedures performed on children." The surgery is also performed on adults, although not as frequently.
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When is Surgery Required?
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When bracing is ineffective or the spinal curvature continues to progress after the patient's growth is complete, surgery may be necessary to stop the curve's progression. Surgery is usually recommended for adolescents and adults whose growth is complete and whose largest curve is at least 40 to 50 degrees. Patients typically develop a smaller, opposite curve below the large one, creating an "S" shape. Surgery may be recommended for an adult with a curve of less than 40 degrees if she is experiencing a great deal of pain.
Harrington Rod Surgery
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Very early scoliosis correction surgeries used a Harrington Rod and spinal fusion, developed by Paul Harrington in the 1950s. A single inflexible steel rod secured the straightened spine, with bone from the patient's own hip driven into the vertebral spaces to stimulate a fusion. This surgery was performed only posteriorly (from the back) and caused the patient to lose all flexibility the full length of the fusion. It was effective if the fusion was successful but didn't allow as much correction as current methods do. The surgery lasted between 8 and 12 hours, resulting in fairly large blood losses.
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Recovery Then
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Recovery was slow and difficult, with the patient confined to bed for up to three months, six months in a full body cast from the neck to below the hips, and another six months in a hard plastic jacket similar to today's Wilmington brace. Patients with large fusions experienced some difficulties due to lack of flexibility, and some had later problems with low back and leg pain due to degeneration of the discs below the fusion.
Two Rods
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By the mid-70s, the Harrington method was often performed using two rods rather than one to correct both upper and lower curves, allowing more flexibility due to the smaller fusions involved. Patients were encouraged to start walking just days after surgery and the body cast was much reduced in size.
C-D Rods
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In 1984, French surgeons Ives Cotrel and Jean Dubosset developed the C-D rods, or Cotrel-Dubosset instrumentation technique, also performed from the back. In this procedure, two metal rods and hooks or screws are attached to either side of the spine and adjusted to straighten it. Bony material for the fusion could be harvested from the hip, the iliac crest at the front of the pelvis, the patient's rib, or an allograft from a deceased donor. A number of patients had trouble with the original pedicle screws used with this technique but the problem was corrected with a relatively minor revision. This surgery is still in use today. Most patients require only six days of hospitalization, are allowed to walk almost immediately after surgery and don't require the use of any sort of post-surgical brace. Patients with few curved vertebra may not even have any noticeable reduction in their flexibility.
Other Approaches
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Variations of the C-D technique have evolved over time, including the use of anterior (from the front) surgery and combination anterior-posterior techniques. The anterior approach uses an incision that follows a rib and terminates in a north-south direction above the belly button, allowing surgeons easier access to vertebra near the waist. The most common method used is still the posterior approach, but surgeons have had great success with the anterior method for some curve types.
Recent Advances
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A technique is currently being used by Mayo Clinic surgeons to correct curves in young children who are still growing. It employs the use of two rods placed parallel to each other on either side of the spine, with adjustable center sections that can be lengthened in an outpatient procedure as the child grows. This procedure is designed to provide interim correction during the growing years for young children whose curves are severe enough to stunt the child's growth and/or possibly impact his heart and lungs. Additional approaches, such as endoscopic and video-assisted thoracoscopic surgery (VATS) are also in use in limited circumstances, as this surgery continues to evolve.
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