Posterior Technique:
Albee and Hibbs reported the first posterior fusions for spinal deformity independently in 1911. These were done to halt the progression of kyphosis in patients with spinal tuberculosis. In 1924 Hibbs(3) reported a series of 59 patients who had undergone posterior spine fusion for scoliosis. The technique he describes is very similar to what is done today with careful subperiostal dissection, obliteration of the facet joints, and elevation of flaps of bone with a gouge, which were then interdigitated. No internal fixation was used and the patients were placed in a well-molded cast until the fusion was firm. From his article it is difficult to tell the etiology of the curves; however, at a meeting in New York in the nineteen seventies a number of his cases were presented. The remarkable thing was how well these patients were doing 50 years after their surgery. I was fortunate to be present and some cases were clearly idiopathic. Their spines were balanced and non-painful and the patients had lived essentially normal lives.

POSTERIOR FUSION WITH INSTRUMENTATION
HARRINGTON SYSTEM
Following WWII, Paul Harrington(2) returned from the army and began practice in Houston. He took a job caring for polio patients at TIRR (Texas Institute for Research and Rehabilitation) and had many patients with significant spine deformities secondary to polio, some of who required a respirator. He recognized that these patients would not tolerate being in bed in a heavy cast for months and began working on a system of internal fixation. He developed the first successful system of internal fixation for scoliosis and published his work in 1962. I have many patients who have done very well using this system; however, it has two drawbacks.

• First, some external support is still needed.
• Second, the system tends to flatten the normal roundness or kyphosis of the thoracic spine and the normal sway or lordosis of the lumbar spine.

LUQUE SYSTEM
Eduardo Luque(4) in Mexico City was faced with the challenge of caring for a large number of patients from communities scattered throughout Mexico. These patients could not make regular trips to see him to have their cast changed. His challenge was to devise a system rigid enough so that no external support would be needed. A neurosurgical colleague showed him how to place wires beneath the lamina of a vertebrae, and then he tied the wires to a previously inserted Harrington rod. He came to recognize that the hooks were not needed and if two rods, which were subsequently connected, were used, this system was quite strong. Another advantage was that the rods could be contoured to provide normal thoracic kyphosis and lumbar lordosis. This system has become the standard of care for patients with neuromuscular scoliosis. Many of these patients with disorders such as cerebral palsy and muscular dystrophy have the pelvis included in the curve and the lower ends of the rod can be secured to the pelvis to provide stability.

COTREL & DUBOUSSET
This system(1), which utilizes multiple hooks and two rods connected together is strong enough so no external support is needed. Using this system, thoracic kyphosis and lumbar lordosis are preserved. This, or systems similar in design, are the most frequently used in adolescent idiopathic scoliosis.

1Cotrel, Y., Dubousset, J., and Guillaumat, M. New Universal Instrumentation in Spinal Surgery. Clinical Orthopaedics and Related Research 227: 10-23, 1988.

2Harrington, P. R. Treatment of Scoliosis. J. Bone and Joint Surg. 44-A (4): 591-634, 1962.

3Hibbs, R.A. A Report of Fifty-Nine Cases Treated by the Fusion Operation. J. Bone and Joint Surg. 6 (1): 3-37, 1924.

4Luque, E.R. Segmental Spinal Instrumentation for Correction of Scoliosis. Clinical Orthopaedics and Related Research. 163: 192-198, 1982.

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