30845 Suppl Giot.pdf - Giornale Italiano di Ortopedia e Traumatologia

G.I.O.T. 2010;36(suppl. 1):S182-S184
Past, present and future for spinal deformities
Passato, presente e futuro delle deformità spinali
J. Dubousset
Before the era of the X rays from Hippocrates to Roentgen time,
clinical evaluation was the unique approach for external assessment
of spinal deformities, very close of the reality in the space,
people were really thinking 3D (nice description, drawings,
ingenious machines to measure). Of course the treatments were
very primitive despite multiples machineries working generally
by traction or pressure on the surfaces of the skin as bracing and
exercising. Some surgical attempts (percutaneous myotomies or
tenotomies: Jules Guerin, Paris 1842) were reported but quickly
abandoned!
The first revolution was given by the era of the X rays (Roentgen:
December 28, 1895) for assessment. It marked a so great advance
and was so attractive that the physician forgot in the analysis during
almost 70 years that the image obtained was only the projection
on one plane(the shadow) of the real deformity!
The treatments became more aggressive and safe thanks to the
development of anaesthesia and aseptic surgery, allowed spluttering
for surgical approaches directly on the spinal skeleton on
the back and on the front during the first half of the 20 th century.
Despite some localized attempts of minimal osteosynthesis (as
silver wiring of the spinous processes: Hadra, 1891; or rib resection
in adults: Von Volkmann, 1889), most of the time during the
following decades, the correction of the deformities was obtained
with external cast done before the surgery which was generally
performed from the back inside the correcting cast, and where
the major surgical technique was the fusion with or without
autogenous bone graft (Hibbs, 1914; Albee, 1917) of a more or
less extended number of vertebral segments. The cast being kept
post operatively until the fusion was obtained (several months
often recumbent).
The second revolution was the direct surgical correction of the
deformity thanks to adjunction of a more powerful internal spinal
instrumentation: Paul Harrington (1960) in Houston (TX, USA)
in the back, Alan Dwyer (1968) from Australia, in the front. They
were probably the major steps for correction of scoliosis during
the following 20 years. But these instrumentations were not sufficient
to suppress post op casting,and more important were not
addressing the real 3D deformity.
In fact they had forgotten the 3D aspect and especially the sagittal
plane (flattening of the back for Harrington, Kyphosing consequences
for Dwyer). It takes almost 20 years to recognize these
side effects.
Académie Nationale de Médecine, Paris, France
S182
We must also remember that simultaneously the development
of direct anterior approach for kyphosis (mainly Pott’s disease)
thanks to Arthur Hodgson (1955) and Arthur Yau in Hong Kong
was another important step forward, for spinal surgery.
During that period of time also, the refinements of the instruments
were also improved by the fortuitous discovery design and
use of the pedicular screw by my friend Raymond Roy Camille
in Paris (1977), as well as the use of laminar or sub laminar
wires attached segmentally to rods on each side of the vertebrae
all along the deformity as developed by Jacques Resina (1964)
and Alves Ferreira (1972) in Portugal and Eduardo Luque in
Mexico(1973) allowing to be “cast free” in post op, and to have
a better sagittal alignment.
So you have understood, it was a gradual improvement in the
management of the spinal deformities for the best benefit of the
patients.
The third revolution lies in 2 facets: the first one, was the
“re-discovery” (as it was before the era of the X rays) and the
understanding that every spinal deformity must be studied in 3D,
not only locally but re-established inside the entire spinal organ,
giving the facet: space.
The second facet was the great importance of that we can call the
4 th dimension: time.
We must remember that these two facets are always linked for the
life time of any human individual.
I gave for these two facets my personal contribution during all my
professional life, coming from multiple analysis, starting in 1972
by the paralytic pelvic obliquities were the 3D is obvious when
you compare X-rays and clinical aspect of the patient, the pathoanatomy
and evolution of the congenital vertebral anomalies, the
same for the basic idiopathic scoliosis curve with the Important
contribution of the rigorous anatomical analysis of specimens and
X-rays thanks to René Perdriolle (1979) from Montpellier.
It was also the introduction of the “computer era” allowing to
produce 3D reconstruction from simultaneous AP and lateral
standing X-rays thanks to the help of my friend Henry Graf and
of a brilliant engineer in computer Jérome Hecquet.
It is amazing to remember that when I suggest the main topic
of our GES meeting in Montreal in 1979: “Idiopathic scoliosis
seen from the lateral”, the scoliosis community was extremely
surprised because very very few lateral X-rays were founded in
the patient’s files! All over the world!
This new concepts and approaches of the deformities in 3D led
to understand much more clearly evidences such as progression
of congenital anomalies or of early fusion creating with time the
“crank shaft phenomenon”, giving clearly the major importance