Download rotation movements of the spine with special reference to scoliosis

ROTATION
MOVEMENTS
OF
THE
SPINE
WITH
SPECIAL
REFERENCE
TO
SCOLIOSIS
ROBERT
In
and
the
latter
half
anatomists
of the
studied
the
ROAF,
nineteenth
OSWESTRY,
and
movements
early
of the
cadaver
(Weber
and Weber
1836, Schulthess
Strasser
1913).
These
researches
culminated
the spine
is a tube of unequal
flexibilities,
linked,
occur
that
in the
with
the
rotation
thoracic
rotation
to the
concave
that
does
not occur
region.
Lovett
side.”
scoliosis
convex
He did
side.
not
part
spinal
of the
twentieth
column,
both
In extension,
ofa
normal
can
in the
surgeons
living
and
that side-bending
lateral
flexion
“
what
centuries
in the
1899, Lovett
1905, Virchow
1907, Fick
1910,
in the work of Lovett
(1905),
who concluded
that
that rotation
and lateral
bending
are inevitably
in the lumbar
region,
and
stated : in forward
flexion,
state
is an exaggeration
ENGLAND
lateral
happens
flexion
is associated
in the neutral
movement
and
that
does not
is associated
with
position.
rotation
Lovett
the mechanism
also
ofits
to
implied
production
be deduced
from a study of models
Frazer
(1940)
assumed
that the
From
this assumption
he concluded
exaggerating
one or other feature
of unequal
flexibilities.
axis of rotation
is in the centre
of the vertebral
body.
that the shape
of the articular
facets
prevents
rotation
in the
in the thoracic
region.
of the movements
of the
formalin-hardened
cadaver
lumbar
region
It will be clear
model
is necessarily
or side-bending
that observation
indirect.
In the
vertebral
bodies
the intervertebral
in the
disc
adult
loses
its normal
plasticity,
and the post-mortem
specimen
does not necessarily
the movements
of the living
spine.
Furthermore,
the older
investigators
a priori considerations
and had not accepted
the concept
of an inconstant
reproduce
exactly
were influenced
by
axis of movement
in joints.
With
reinvestigated
the
development
of radiology,
spinal
first, flexion,
extension,
and, more recently,
1931, Brailsford
1934, Steindler
1929, Tanz
has,
however,
been
comparatively
little
the living
re-examining
does,
subject
or in fresh,
flexible,
1) the normal
movements
in fact,
behave
as a tube
are inevitably
linked ; and
deformity
of scoliosis.
flexibilities
relationship
For
the
purpose
investigations
The
region
are
and
exaggeration
to four times
312
represented
young
spine
of the posterior
independently
region
rotation
rotation
of this
by freezing
of the
in Figures
screwing-down
there
whether
movements
on
the
were
two
therefore,
whether
side-bending
of the
sources
and then dissected
spines
of normal
1 to 9 and
opposite
and,
and
normal
spine
the
worth
spine
rotation
and
the
1) spines
of
STUDY
the thoracic
and lumbar
with a slight
screwing-up
movement:
range
and
been
have been studied
(Bakke
1949, Wiles 1935).
There
movements,
either
in
It seemed,
in particular
may
be summarised
side.
regions.
on the
Finally,
it is fundamentally
deserves
to be called
of material:
free of all muscles
after
children.
The
results
is a tube
of roughly
equal
flexibilities;
longitudinal
ligament;
lateral
flexion
and in both
is associated
of a normal
the normal
FOR
investigation
preserved
examination
and
between
MATERIAL
stillborn
babies,
first
and
2) radiological
have
necropsy
specimens.
of the spine,
noting
of unequal
2) the
movements
side-bending
movements
1950, Begg and Falconer
recent
work
on rotation
as follows.
the axis of rotation
is in the
and rotation
normally
occur
It is true that,
side away from
severe
an abnormal
a luxation,
THE
thawing;
of these
JOURNAL
in the cervical
the direction
of
scoliosis
is not
rotation-often
as the ancients
OF
BONE
AND
JOINT
just
an
three
called
it.
SURGERY
ROTATION
MOVEMENTS
OF
THE
SPINE
WITH
FIG.
Extension
of
normal
SPECIAL
REFERENCE
TO
1
infant’s
spine.
#{149}
r
FIG.
Flexion
VOL.
408,
NO.
2, MAY
1958
of normal
2
infant’s
spine.
SCOLIOSIS
313
314
R. ROAF
It will
be
realised
axis
about
which
the
degree
and
pulposus-for
the annular
and
to
except
nature
rational
to say
there
occurs
of
instance,
fibres and
rotation
between
This is not the
pain,
1) that
rotation
is a certain
may
shiftjust
intervertebral
movement
decompressing
extracting
the
the
place
that
degree
the
nucleus
pain
is usually
by
pulposus
causes
these
due
variation;
offlexion-extension
is affected
nucleus
pulposus
vertebral
bodies.
to discuss
the bearing
such
of individual
as the axis
the
turgidity
by making
a big increase
observations
to disorders
have
of rotation
and
of
the
the
3) that
nucleus
a tiny incision
in
in lateral
sliding
on
and
that
2)
does;
referred
that
this
spinal
is the key
treatment.
4
3
FIG.
Side-bending
To
return
flexibilities,
(Figs.
of normal
to scoliosis,
it cannot
10 to 15).
be
In order
even
made
if the
to
curve,
it must
an
uncommon
There
are
remains
and
be
two
to reproduce
(Fig.
in
mobile,
relatively
presents
anti-clockwise
types
type
minimal
rib
spine.
spine
is artificially
assume
the
of
scoliosis,
which
lateral
flexion
fairly
of rotation.
converted
deformity
deformity
lower
which
is
absence
of
one
into
easily
part
must
independently
is
dominant
the
has
it
is
an
less
of unequal
(Somerville
divide
most
1952)
of the spinal
(Figs.
16 to 19).
in the upper
part
of
etiology.
is
20).
occur
corrected,
basically
(Fig.
a tube
scoliosis
in positions
of forced
rotation
direction
of rotation
is clockwise
in the
deformity;
Note
usual
a scoliotic
ligaments
and then realign
the vertebrae
It is worth
noting
that if, say, the
the
infant’s
of
element.
tendency
exaggeration
The
The
curve
to relapse
of
a
after
normal
first
usually
fusion,
movement
21).
The
it soon
reasons.
other
becomes
Firstly,
type
rigid
there
of curve,
in which
and resistant
is an internal
rotation
to correction,
torsion
and
is the
main
feature,
tends
to be progressive;
and tends
to relapse
after
fusion
asymmetry
of the vertebrae
themselves
[Text
THE
JOURNAL
OF BONE
continued
AND
JOINT
for two
which
on page
323
SURGERY
ROTATION
MOVEMENTS
OF THE
SPINE
WITH
SPECIAL
REFERENCE
1’
V
‘p
I
FIG.
Rotation.
Note
4
absence
of side-bending.
/
FIG.
Rotation.
VOL.
408,
NO.
2,
MAY
1958
Note
5
absence
of side-bending.
TO
SCOLIOSIS
315
316
R. ROAF
wwi
/
-
iiiiTii
Rotation.
The axis
of rotation
are
FIG.
6
is in the region of the posterior
longitudinal
roughly
equal and evenly distributed
throughout
THE
ligament.
Note
the spine.
JOURNAL
OF BONE
that
AND
all movements
JOINT
SURGERY
ROTATION
MOVEMENTS
OF
THE
SPINE
WITH
SPECIAL
REFERENCE
TO
SCOLIOSIS
317
1
I
FIG.
of eight-year-old
boy,
in lateral flexion.
Spine
of eight-year-old
boy,
in rotation.
FIG.
VOL.
40 B,
NO.
2,
7
Spine
MAY
1958
Note
absence
of rotation.
8
Note
absence
of side-bending.
318
R. ROAF
FIG.
Spine
of eight-year-old
bending,
9
boy. If an effort is made to combine
rotation
the result is rotation and forward fiexion.
and
side-
kr
.
k
FIG.
Three
spinous
processes
have been
fastened
together.
10
In forced
flexion
THE
there
JOURNAL
is no tendency
OF BONE
AND
to rotation.
JOINT
SURGERY
ROTATION
MOVEMENTS
OF THE
SPINE
WITH
SPECIAL
REFERENCE
TO
SCOLIOSIS
319
A
c
FIG.
Same
spine
as in Figure
10, radiographed
11
in forced
flexion.
No
tendency
to
rotation.
I
44\
-
/‘Ii
‘V
1
J
FIG.
Same
VOL.
spine
40 B, NO.
as in Figures
2,
MAY
1958
10 and
11,
radiographed
12
in forced
lateral
flexion.
No
tendency
to rotation.
‘]J
320
R. ROAF
,t.
FIG.
Three
transverse
processes
have
been
fastened
tendency
spine
as in Figure
13.
In extension
In
side-bending
to
the
left
or
right
there
is no
to rotation.
FIG.
Same
13
together.
or fiexion
14
there
is no tendency
THE
to rotation
JOURNAL
OF
BONE
or lateral
AND
flexion.
JOINT
SURGERY
ROTATION
MOVEMENTS
OF
THE
SPINE
WITH
SPECIAL
REFERENCE
TO
SCOLIOSIS
I
FIG.
Same
spine
as in Figures
In order to reproduce
ligaments
VOL.
40 B, NO.
2,
MAY
1958
13 and
14 specimen
15
and
radiograph
with
the
FIG.
16
a deformity
resembling
scoliosis,
even in a neonatal
must
be divided
and a rotational
subluxation
produced.
spine
flexed.
spine,
many
321
R. ROAF
322
FIG. 17
FIG. 18
Figure 17-Reconstruction
of scoliotic
spine
by fastening
vertebrae
together
in forced
rotation
but no lateral flexion.
Figure 18-Radiograph
of the artificial scoliosis.
Shadows of plasticine
mark areas where oblique fibres of erector spinae muscles have a mechanical
advantage.
FIG.
1
FIG.
Reconstruction
of
scoliotic
Drawing
by
fastening
vertebrae
together
in forced
marks
areas where
rotation
but no lateral flexion.
Plasticine
oblique
fibres of erector
spinae
muscles
have
a mechanical
advantage.
THE
curve
an equal
rotation
in the
opposite
direction
in the
curve.
lower part of the
JOURNAL
that
in one direction
upper
part
of the
must bebalanced
by
rotation
in the
19
spine
20
to show
OF
BONE
AND
JOINT
SURGERY
ROTATION
MOVEMENTS
OF
THE
SPINE
WITH
REFERENCE
SPECIAL
TO
323
SCOLIOSIS
4
FIG
Lateral
is
largely
fiexion
type
confined
the convex
side
planes
between
to the
neural
arch.
are larger
so that
the superior
and
ends of the curve
the asymmetry
rotation,
six secondary
deforming
At
the
is reversed
factors
never
return
to the
mid-line
them
farther
asymmetrically,
concave
in the
from
the
causes
side
upper
(Figs.
part
forces
which
vertebral
surface
would
tends
of the
30);
be permanently
out
increases
the
lateral
flexion
408,
NO.
opponents
and
therefore
rib cage is both an obstacle
to increase
rotation
(Fig.
35).
have
a mechanical
to correction
and
Ffthly,
not usually
pa rallel,
the
(Figs.
36 and 37).
Lastly,
(Figs.
38 to 41).
0 ccasionally
occurs-that
i s, the rotation
increasing
MAY
since
effect
the
of rotation
if fusion
pedicles
Firstly,
on
the
normal
Secondly,
gravity
acts
checks
growth
on the
1958
advantage
itself creates
upper
and
is to
is performed
(Fig.
34).
a couple
of
lower
surfaces
direct
the
before
growth
lower
is
continued
growth
of the
of rotation,
increased
deviation
In this case
presence
one meets
is increased
patients
with scoliosis
on straightening
the
the curve
(Figs.
42 and 43).
Such patients
link bet ween rotation
and lateral
flexion.
inevitable
2,
and
laminae
of balance.)
lordosis
(Fig.
31).
and also possibly
mid-line
rotation”
VOL.
the
fibres
of the erector
spinae
muscle
is to advance
the vertebrae
at
This forward
movement
is normally
opposed
by gravity.
If the
movement
is unopposed,
so that every muscular
contraction
pushes
mid-line
and
a secondary
body
are
sideways
no
curve
is often
wrongly
interpreted
as a lateral
flexion
in fact, but for the lordosis,
the spine
could
from
the
“reverse
on
is easily
(Figs.
22 to 28).
Secondly,
in consequence
of the
come into action
which
inevitably
tend to increase
the graft
may act as a tether
at the back.
bodies
causes
increased
lordo sis and, in the
is
which
difference
in both sagittal
and longitudinal
facets
than
on the concave
side.
At the
complete
vertebral
decreased
that there
and after correction,
32 and 33). Thirdly,
the deep transverse
fibres of the erector
spinae
muscles
of the convexity
and lo wer part of the concavity
act more
directly
than
their
obliquely
placed
Fourthly,
the distorted
of the
vertebral
and
before
type.
centre
there is a bigger
inferior
articular
the deformity.
(The deformity,
incidentally,
when
it is really
a lordosis
(Figs.
29 and
action
of the longitudinal
the centre
of their
span.
vertebrae
are rotated
their
21
(with minimal rotation)
obtained
in this
of scoliosis
are
another
in whom
curve
and
illustration
324
R. ROAF
FIG.
22
FIG.
24
Views of scolioticvertebra. Figure 22-Posterior
view.
Lateral
view
on convex
Figure
25-Axial
showing
much
view.
more
hypertrophy
Note
marked
23
FIG.
F1G.
of pedicle
hypertrophy
than of body.
Note
hypertrophy
side.
of lamina
and
pedicle
Bulk
of erector
spinae
25
of Iamina
Figure
on
convex
muscle
THE
on convex
24-Lateral
side.
Asymmetry
is greater
JOURNAL
side.
view
OF
Figure
of concave
of
neural
23-
side.
arch
on convexity.
BONE
AND
JOINT
SURGERY
ROTATION
MOVEMENTS
OF
THE
SPINE
WITH
FIG.
Radiographs
illustrating
the
SPECIAL
REFERENCE
TO
26
features
shown
in Figures
21 to 24.
FIG.
FIG.
27
Transverse
section through
spine at apex
of scoliosis.
Note
lateral
broadening
of neural
canal
and spinal
cord
pressed
against
pedicles
on concave
side.
408,
VOL.
L
N3.
2,
MAY
1958
325
SCOLIOSIS
Drawings
of vertebral
mark
articular
facets.
28
body.
There
Dots
is a
greater
distance
in both
longitudinal
and sagittal
planes
between
the facets
on the convex
side.
326
R. ROAF
Figure
at
FIG. 29
29-Antero-posterior
radiograph
the apex of the scoliosis.
is really
of 75 degrees
The vertebrae
a lordosis.
are seen in profile
Figure
30-A
SHE
Wi
gravity
the
case.
bodies
lateral
flexion
example.
:
On
extension
rotated
moves
is
This
ttll
rIb
and apparent
similar
verre bra
the spine
by
FIG. 30
of the vertebral
of rotation
sideways
extended.
movement
and
vertebra
tends
when
is unopj,osec
to ‘r#{244}4ress
4’kroathe3’
the
On extend
verebrte
at
of the extending
[FFECTS
ROTAT
to
I
(I)
LON(ITUDINAL
MASS
SPIMAE
ERECTOR
which
that
contraction
are already
pointing
of
the
longitudinal
laterally,
move
of a normal
forwards
those
at the
relative
ends.
OF
MUSCIt
FIG.
Indicates
s1,ne,
centre
section
move
OF
ION
tn
the
fibres
farther
vertebra
31
of
the
laterally
erector spinae tend to make
unopposed
by gravity.
This
is opposed
scoliotic
forward
vertebrae,
movement
by gravity.
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
ROTATION
MOVEMENTS
OF
THE
SPINE
WITH
SPECIAL
REFERENCE
TO
SCOLIOSIS
FIG. 32
FIG. 33
Figure 32-Transverse
section of normal
thorax.
Figure
33-Transverse
section
of scoliotic
thorax.
1) line of centre of gravity (G) falls to one side of vertebral
column
causing
secondary
lateral flexion and
pressure on growing
epiphyses;
2) vertebral
body points sideways.
B’
EFFECTS
OF
ROTATION
(I)
In neutral
position
AB
the
rotar9
action
of the deep
oblique
fibres
of the erector
sinae
is
balanced
LSAO
= LSBO
In
L69
the rotated
L.ss’o’,
things
being
on the convex
advantage
p
there?ore,
ecjual,
eide
sition
the
act
A’ B’
other
muscles
at an
FIG.
34
Indicates
that the oblique
fibres of the erector
spinae,
which run
from a spinous
process
to a transverse
process
of a lower vertebra,
have a mechanical
advantage
on the convex
side in the upper part
of the curve and on the concave
side in the lower part of the curve.
Theseareasare
indicated
by plasticine
shadows
in Figures
l8and
19.
VOL.
408,
NO.
2,
MAY
1958
327
Note:
unequal
R. ROAF
328
FIG.
Photograph
of ribs on
increase
is equal
of model
spine
creates
of
35
distorted
a couple
rib cage.
Pressure
of forces
tending
to
rotation.
Normally,
pressure
of ribs on spine
and balanced.
Pressure
of ribs on convex side
is posterior
to axis of rotation.
Pressure
of ribs on
concave
side is anterior to axis of rotation. a) Pressure
on ribs in mid-axillary
line increases
vertebral
rotation.
b) Traction
on ribs
in mid-axillary
line
decreases
vertebral rotation.
c) Pressure
on ribs on concave
side
posteriorly
increases
rotation.
d) Pressure
on
rib hump,
i.e..
e) Superimposed
forward
pressure
pressure,
views
with
on ribs on
decreases
first traction
concave
side.
rotation.
and
then
e.
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
ROTATION
MOVEMENTS
OF
THE
SPINE
WITH
FIG.
Anterior
and
posterior
aspects
of a model
SPECIAL
REFERENCE
TO
SCOLIOSIS
36
of a scoliotic
spine.
Upper
and lower vertebral
surfaces
are not parallel:
therefore
rotation
alone will produce
lateral deviation
without
any element
of lateral flexion.
Note in model lordosis
at apex of curve (but for this, spine
would
not come back to the mid.line).
Series of nails and string represents
spinous
processes.
Line of drawing
pins represents
anterior
longitudinal
ligament.
V1EW
LAIERAL
A-P
V I EW
A-P
VIEW
OF
ROTATED
SPINE
FIG.
Illustrates
deviation
VOL.
40 B,
NO.
2,
MAY
1958
how
rotation
without
any
37
produces
lateral
lateral
flexion
in
vertebral
wedging.
inclination
the
presence
and
of
lateral
slight
329
330
R.
ROAF
I
/
FIG.
38
Figure
38-Antero-posterior
radiograph
of spine before
laminal
fusion.
Figure
39-Four
years later.
Continued
growth
of the vertebral
bodies
the tethering
action
of the laminal
fusion.
This gives a false appearance
antero-posterior
radiographs.
FIG.
39
FIG.
Note rotation
of vertebral
has caused
increased
lordosis
of increased
lateral
flexion
40
FIG.
bodies.
due to
in the
41
Figure 40-Antero-posterior
radiograph
of spine before laminal fusion. Note rotation of vertebral
bodies.
Figure 41-Six
years later. Continued
growth of the vertebral bodies has caused increased lordosis due to
the tethering action of the laminal fusion.
This gives a false appearance
of increased
lateral flexion in the
antero-posterior
radiographs.
(By
courtesy
of
THE
Mr
E.
N.
JOURNAL
Wardle.)
OF
BONE
AND
JOINT
SURGERY
ROTATION
MOVEMENTS
FIG.
Figure
42-In
OF
WITH
SPECIAL
REFERENCE
scoliosis
which
increases
of Occam’s
razor
proves
the
43
to the left in the thoraco-lumbar
lateral flexion there was rotation
to the right.
be expected
if the classical
theory were true.
direction,
331
TO SCOLIOSIS
FIG.
spine there was a slight lateral
When this was corrected
by right
direction
of rotation
which would
opposite
SPINE
42
this patient’s
in the
THE
deformity,
makes
the
region.
This is the opposite
Figure 43-Lateral
rotation
of the
flexion
disappear.
SUMMARY
The
principle
nothing.
Nevertheless,
it is possible
to explain
all the phenomena
of severe
scoliosis
on the basis
of a primary
rotation
deformity
alone.
The typical
rotation
type
of scoliotic
deformity
can be reproduced
artificially
by fitting
vertebrae
together
in an abnormal
rotatory
relationship
without
any element
of lateral
flexion.
From
this, certain
mechanical
factors
inevitably
come into
the deformity.
Above
all, the forces responsible
for progressive
not
just
passive.
The
such as a simple
and that correction
the
rotation
spine
deformity.
been insufficiently
Failure
to correct
readily
wedge
vertebra.
and control
I am
compensates
for
It is my belief
of severe
scoliosis
well
aware
that
a passive,
this
is an
cosmetic
improvement,
old
idea
but
out
of
deformity
the dominant
by concentrating
factor
on
its essential
truth
its full
reduction
implications.
in rotation
have not faced
even a slight
often
to increase
and active,
non-progressive
that rotation
is usually
can only be achieved
appreciated
in recent
years
and we
rotation
invites
recurrence.
Conversely,
usually
produces
a marked
radiographic
appearances.
play which
must tend
scoliosis
are dynamic
all
proportion
to
has
the
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