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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 REFERENCES BAKKE, S. N. (1931): Supplementum BEGG, A. Beobachtungen Rontgenologische C., and FALCONER, Intervertebral M. A. Disks. A Correlation with BRAILSFORD, J. F. (1934): The Radiology FICK, R. (1910): Handbuch der Anatomie Muskeln. Jena: G. Fischer. FRAZER, J. E. (1940): The Anatomy of the VOL. 40 B, #{252}ber die Bewegungen der Wirbels#{228}ule. Acta Radiologica, 13. NO. 2, MAY 1958 (1949): Operative of Bones Plain Radiography Findings. and Joints. und Mechanik Human Skeleton. in Intraspinal British Journal London: J. der Gelenke Fourth unter edition. &. Protrusion of Surgery, A Churchill of Lumbar 36, 225. Ltd. Ber#{252}cksichtigung der bewegenden London: J. & A. Churchill Ltd. 332 R. R. D. LOCKHART, Kodak Film Medical (1934): The Action Film Library, of Muscle, Anatomical Column, Vertebral Section, No. 238. Hip and Shoulder Joint in Living Subjects. (In British Medical Association Part 2, two reels. Library.) LovErr, W. (1905): R. Die Mechanik der 14, 399. f#{252}r Orthop#{228}discheChirurgie, W. (1899): Zur normalen f#{252}r Orthopadische Chirurgie, 6, 399. SOMERVILLE, E. W. (1952): Rotational Joint Surgery, 34-B, H. STRASSER, (1913): Diseases Lordosis. and Deformities Lehrbuch S. 5. (1950): To-and-fro Sinai Hospital, 16, 303. V1RCHOW, H. (1907): Ueber TANZ, zungsheft Wirbels#{228}ule und The Anatomic Development ihr Verh#{228}ltnis zur Skoliose. derjugendlichen of the Single Zeitschrift Wirbels#{228}ule. Zeitschrift Curve. Journal of Bone and 421. A. (1929): STEINDLER, normalen und pathologischen SCHULTHESS, WEBER, ROAF der of the Spine and Thorax. Muskel-und Motion Range die tiefen Gelenkmechanik, at Fourth and RUckenmuskeln des St Louis: Band Fifth 2. Lumbar Menschen. The C. V. Mosby Berlin: Company. J. Springer. Interspaces. Journal Anatomischer of the Mount Anzeiger, 30, Erg#{228}n- 91. W., and WEBER, E. (1836): Mechanik der menschlichen of the Lumbar Vertebrae Gehwerkzeuge. G#{246}ttingen:in der Dieterichschen Buchhandlung. WILES, Royal P. (1935): Society Movements of Medicine (Section of Orthopaedics), during Flexion and Extension. Proceedings of the 28, 647. THE JOURNAL OF BONE AND JOINT SURGERY