Portal de Periódicos da CAPES

THE CLASSIC: An Operation for Progressive Spinal Deformities

2007; Lippincott Williams & Wilkins; Volume: 460; Linguagem: Inglês

10.1097/blo.0b013e3180686b30

1528-1132

RUSSELL A. HIBBS,

Medical Imaging and Analysis

Russell A. Hibbs (1869-1932) of the New York Orthopaedic Hospital and Fred H. Albee of New York Post-Graduate Hospital both worked independently to develop a technic of spine fusion at about the same time. Both published reports in 1911. The judgment of time has discarded the Albee technic of a cortical tibial strut graft and developed the operation of posterior spine fusion on the basis of Hibbs' procedure. This reprint of Hibbs' first report in the New York Medical Journal of May 27, 1911 remains the classic in the field. (See: History of Spine Fusion following in this issue.) E.M.B. The treatment of Pott's disease or humpback by immobilization of the diseased joints has long been the accepted method, and is accomplished by various mechanical means, braces, plaster of Paris, etc. That much success has been obtained in the prevention of deformity and the cure of the disease by these means, there is no question. That there is still much to be desired is equally unquestionable, because these various means do not secure absolute immobilization, and for this reason it is necessary to continue treatment for long periods of time, and in almost every case the deformity increases more or less. The treatment of lateral curvatures is still more unsatisfactory; the deformity is more complicated and its cause less definitely understood. In these, in spite of the best efforts by means of support to the column and the development of muscles, in a very large percentage of cases the increase of the deformity is progressive. In the spine affected by tuberculosis, it is the body of the vertebra which is destroyed, and, in consequence of this destruction of bone, the deformity appears, and is, in the very large percentage of cases, a purely kyphotic curve. It is very rarely that the spinous or lateral processes are affected. One of the reasons why the disease is so persistent in its destructive effect on the bodies of the vertebrae, is because of the motion which takes place between them, and while the various methods of treatment limit the motion, none absolutely prevents it. In the light of our present knowledge and experience, the greatest need in the treatment of this disease, both from the standpoint of shortening its duration and preventing deformity, is the perfection of a method which will absolutely immobilize the spine throughout the diseased area and make the development of deformity impossible. The writer has done an operation for stiffening the knee joint (1), which consists of removing the patella from its periosteum and putting it in the joint after a space is freshened in the bones to receive it, the periosteum then being stitched to that of the tibia and femur. In these cases the patella was not absorbed, but formed a bridge between the tibia and femur, and the periosteum reproduced in every case new bone sufficient to make a large bony bridge and a perfectly safe bony ankylosis. This operation led to the conception, that if the periosteum of the spinous processes was carefully removed, and the processes were divided at their base and placed longitudinally in the interspinous space touching with either end the base from which the processes were removed (see Fig. 1a)*, and then the periosteum brought back and sutured, a similar condition would be produced. That is, the process would become adherent to the base at either end, thus filling up the in-terspinous gap with solid bone, and the periosteum would reproduce more bone so that there would be secured a fusion of the posterior aspect of the vertebra by a bridge of bone which would increase in size and strength so that absolute ankylosis would be secured. It was thought that if a bony bridge could be established, its size and strength would gradually increase to meet the force exerted upon it, as is the case with the fibula when it is utilized to take the place of the tibia. This it seemed would be sufficient to prevent the kyphotic curve, while in the lateral curvature cases, in which the deformity is more complicated, it was thought necessary to do an arthrodesis in the articulation between the lateral processes, thus giving a cantilever support. Through the kindness of Professor George S. Huntington, of Columbia University, I was given the privilege of doing this operation three times on the cadaver, in the fall of 1910, and I am indebted to him as well for many helpful suggestions. I have since done it upon three patients, all with Potts' disease of the spine. A sufficient time has elapsed only in one case to give positive proof that the condition which we attempted has been produced. The x-ray pictures, Figs. 1b and 2, made by Dr. Caldwell, show the continuous bone formation between the vertebrae, three months after operation. One is a lateral view and the other an anteroposterior one. Of course the report of these cases, as stated before, is preliminary, as there are many questions which arise that cannot now be answered, for instance, the earliest age at which the formation of this mass of bone may be expected, its effect on the future progress of the deformity, etc. The youngest patient was seven years old. The processes in this case were sufficiently ossified and long enough to fill the interspinous space. It is believed that in still younger children it will be successful. The traumatism of the operation will hasten ossification and increase the activity of new bone formation from the periosteum. In the very young, however, I think it will be necessary to graft bone from the leg. This is a perfectly practical procedure. No case of lateral curvature has yet been done, but I propose to do exactly this same operation, and if it is not sufficient, to do an arthrodesis between the lateral processes, as already suggested. This operation was done through a longitudinal incision directly over the processes; the ligament was split, and the periosteum of the processes removed very carefully and retracted with the muscles. The processes were divided at their base, as closely as possible, without opening the canal, then they were placed longitudinally so that there was fresh bone contact, one end, the proximal, touching the lower part of the fresh base from which the process was removed, and the distal end in contact with the upper part of the base from which the next process was removed, and so on throughout the diseased area, so as to ankylose the diseased one to healthy vertebrae above and below. The periosteum was then brought back and sutured with chromic catgut, and the skin closed with silk, without drainage. Only in the first case were any bone sutures used, as it was thought unnecessary. The ordinary sterile dressings were applied. The wound in each case was found completely closed at the first dressing, on the eleventh day. The first patient got up at the end of five and a half weeks, and all support was removed after three months. Case I. E. Q., American, male, aged nine years. Entered ward of New York Orthopaedic Hospital, December 27, 1910. Lumbar Pott's disease. Patient had moderate kyphos involving last dorsal and upper four lumbar vertebrae. Disease was quite active as shown by intense spasm of muscles, occasional pain, protective gait. Indeed he was admitted for rest because of acute symptoms, as there was no thought at that time of operating on him. Patient was kept on back in bed, wearing a spinal assistant; under this treatment he became free from pain and had no night cries at the end of two weeks. General condition good. Temperature normal. X ray showed disease to have almost completely destroyed the bodies of the second and third lumbar vertebrae. January 9, 1911. Under gas and ether, an incision was made in the median line of the back from the eleventh dorsal to last lumbar vertebra, down to the periosteum. The periosteum was then divided over tips of spinous processes, and stripped down to base of spinous processes, the interspinous ligaments being split in median line, thus leaving a continuous layer of periosteum and ligament on either side of spinous processes. The last dorsal and three upper lumbar spinous processes were thus denuded. The four repective spinous processes were then fractured by means of a small bone chisel, close to their bases. The third lumbar spine was then placed longitudinally so that its apex rested on the upper part of the base of the spinous process of fourth lumbar spine; in this position a No. 2 chromic gut suture was passed through the end of the third and body of the fourth lumbar spines, thus fastening the two processes together. In like manner the second lumbar was fastened to the third, the first to the second, and the last dorsal to the first lumbar. The reflected periosteum was then brought together over the spinous processes and sutured with a running chromic suture, No. 1, and reinforced in three places with silk sutures. The skin wound was closed with silk. The wound was dressed and a plaster spica applied from knees to axilla, the spine being kept in slight overextension while plaster was applied. Patient was put to bed on back. On the first night after operation patient suffered severe pain which was difficult to control, even with opiates. January 11, 1911, pain still severe and plaster was amputated at groin; this gave him very little relief. January 13, entire plaster jacket was removed. Wound found to be in excellent condition, with primary union. The wound was dressed and a modified spinal assistant applied. At no time after this did the patient have the slightest pain. It is evident that the pain and discomfort were due to the over-extension of the spine, and the pressure of the plaster. The temperature rose to 100° F. on the day following the operation. On the third day after operation, the temperature dropped to normal and has remained so. Patient was kept in bed, until February 20th. At that time he was in excellent condition and seemed to have bony union in spine. He was allowed up on that date, wearing a brace, with no adverse effect. After getting up he continued to improve and on March 10, 1911, was transferred to the country branch. April 5, 1911, all support was removed. There was solid bony fusion of the posterior aspect of the vertebra. This is absolutely demonstrated by x ray pictures made by Dr. Caldwell. (See Figs. 1b and 2. Fig. 3 is a photograph after the operation.) Case II. W. M., Italian, male, aged seven years. Entered ward of New York Orthopaedic Hospital December 31, 1910, with dorsolumbar Pott's disease of two years' duration. Patient had moderate kyphos extending from tenth dorsal to fourth lumbar vertebra. Back was very painful, spasm of back muscles very acute. He also had double psoas spasm which caused flexion deformity of both thighs of about 90°. Slight thickening in left inguinal region. Patella reflexes exaggerated. Patient was put at rest on back and extension applied to both legs. General condition remained good and at the end of one week he had no pain and flexion of thighs was entirely reduced. Psoas spasm still present and patella reflexes +. Patient continued gradually to improve and by the middle of April, 1911, psoas spasm was very slight. Patella reflexes were normal. April 26th. Under gas and ether a spinal operation was performed. Incision was made over the kyphos from tenth dorsal to fourth lumbar inclusive. Periosteum and ligaments were stripped back as in Case I. Spinous processes were found to be quite large and almost completely ossified. The bases of the spinous processes (tenth dorsal to fourth lumbar inclusive) were then fractured with a small bone chisel, and placed so that the base of the fourth lumbar remained in contact with the lower part from which it was removed and the tip was placed in contact with the spinous process of the fifth lumbar, the third against the fourth, second against the third, etc., until the bridge was formed of continuous bone. The processes were not sutured in place as in the preceding operation, as it was thought that the close adjustment and suture of periosteum and muscle would hold them in place. The periosteum was then brought back over the bone and held with deep continuous chromic gut sutures. The skin wound was closed with silk without drainage. Having in mind the extreme discomfort that the preceding patient had experienced from the plaster jacket, a modified spinal assistant was applied with perineal straps. The patient was placed in bed on the back. Patient had some discomfort for the first twelve hours after operation, but not severe enough to require any attention. On the following day he was free from pain and at no time since has he had the slightest discomfort. General health good. Preceding the operation, temperature had never gone above 99.5° F., minimum being 97.5° F. Since operation the temperature has never gone above 98.6° F., minimum being 98° F. The wound was dressed on the tenth day and the sutures were removed, union being found perfect. (Fig. 4 is a photograph before, and Fig. 5 after operation.) A sufficient time has not elapsed to make a final report. This will be done later. Case III. Mrs. B., American, aged twenty-five years, mother of two children. Entered ward of New York Orthopaedic Hospital, March 13, 1911, with dorsolumbar Pott's disease, of five years' duration. Marked kyphos involving ninth dorsal to second lumbar vertebra inclusive. Patient had considerable pain when in erect posture and intense muscle spasm of back; psoas spasm on left side; large fluctuating abscess in left inguinal region, which had burrowed under Poupart's ligament, and extended down the anterointernal aspect of thigh about six inches. General condition good, temperature normal. Patient was kept at rest in bed until April 27, 1911, when it was decided to operate on her spine. The abscess during this time had remained about the same. April 27, 1911, under gas and ether an incision was made over the kyphos, down to spinous processes, the same technique being observed as in Case II. The last four dorsal and three upper lumbar spines were then fractured as in the preceding operations. The periosteum was then closed over the spines with continuous chromic gut sutures, reinforced at intervals with deep silk sutures. Skin was closed with silk, dressing applied, and the spine immobilized with modified spinal assistant with perineal straps. The patient being very heavy, she was put on a Bradford frame to facilitate moving her. She had very little pain after operation and slept during the first night without opiates. Since the first twenty-four hours after operation, the patient had no discomfort; temperature normal; the abscess had given her no discomfort and was slightly diminished in size. The wound was dressed on the tenth day, and sutures were removed; union by first intention. The most striking feature of the operation is the marked reduction in the kyphos. This patient is still in the recumbent posture. (Fig. 6 is a photograph before, and Fig. 7 after the operation.) It is too early in this work to reach any final conclusion as to its value. It seems, however, that this method may possibly do much in the prevention of kyphotic curves and shorten the duration of the disease, saving the patient at the same time the necessity of wearing an apparatus for years. In the lateral curvatures, it would seem to offer a means of preventing a progress of that distressing deformity.