Friday, December 13, 2013

SPINAL FUSION - A Brief But Loving Overview PART I

I had a comment to this blog (which I always welcome) requesting that I review the history of spinal fusion for deformity.  What follows is a vastly oversimplified yet still long review of the history of fusions and an overview of where the art has come from and where I think it is heading.  Please enjoy:

Scoliosis is an ancient problem and it is only in the last fifty or so years that we have started to engage in treatments beyond punishing braces and witchcraft.  Modalities ranging from bracing to electrical stimulation have been tried in an effort to reduce the curvature and stop its progression.  New vistas such as gene therapy are arising as we learn more about the genetic basis.  But for the last fifty plus years, the only tried and true method of actual correction of a curve was through surgical spinal fusion.

This does not mean to imply that spinal fusion is (or has ever been) a single monolithic procedure.  From the early onset of treatment, there has been controversy and change, some subtle, some drastic, in an effort to make the procedure safer and more reliable.  Even at our current sophisticated state, all surgeons recognize (or should) that we are just passing through this age with the “next great innovation” just over the horizon.  Ultimately, the key fact is that fusion surgery is a non-anatomic salvage.  It is a procedure that provides great benefit, but it is still a response to a process that we do not fully understand.  Until we understand the genetic or even the molecular level of the process, our efforts will be by necessity crude, regardless of how elegant they may be.

I marvel at the first few surgeons who undertook opening a spine for fusion.  Organized and scientific study of spinal fusion began in the late 1940’s, a time when antibiotics were just coming into their own and surgical infection rates were alarming by modern standards.  The exposure of a large portion of the spinal column must have seemed unbelievably daunting, but the truth of the matter is that younger   humans have incredibly robust immune systems.  As a result, infection in these cases was surprisingly low.  Early fusions did not have the benefit of internal fixation (the screws and rods that are commonly in use today).  Frequently, the child was corrected either by serial casting – a technique which is regaining some favor – or by a progressive brace hinged at the curve apex.  When the desired flexibility and correction had been obtained, the brace or cast was locked into position.  The child was taken to the operating room and the posterior bones of the spine were exposed and “shingled” – strips were cut and folded on themselves to provide a local graft material.  Later, graft from the hip/ pelvis area was use to supplement the local bone.  The incision was closed and then the child was left in the brace or cast in a corrected position until the bone had healed, for the most part a matter of months.  My father recalls rounding on pediatric floors during his early Orthopaedic years in Pittsburgh and following fifteen children wallowing in beds in large ward rooms over the course of entire summer.
The dreaded Turnbuckle Cast.  A child would live in this for months during healing of early fusions.

As has been often the case, it took the vision of one man to change the face of surgical treatment for scoliosis.  Paul Harrington from Baylor developed a fairly simple rod and hood complex which could act as an internal support for those children undergoing treatment.  The steel rod complex was threaded either with a fixed hook and a moving hook or two moving hooks.  By separating the fixed hooks in site, the convex side could be lengthened to allow what we term distraction of the curve.  The same type of local fusion was performed and patients still needed bracing for an extended course.  But casting was able to be put by the wayside and the children could be more mobile and released from hospital at a much earlier date after surgery.  Harrington rods rapidly became the gold standard and were used regularly as late as the late ‘70s.  Many operating room inventories still include Harrington sets on a shelf somewhere, although they are almost never used these days.

Harrington Rods - a distraction (lengthening) rod on the left and a compression (shortening) one on the right. 



As good as Harrington’s system was – and it had the benefits of ease of use and a simple elegance – there were several flaws in the design which needed to be overcome as fusion and instrumentation went forward.  The first and most obvious is in the mechanical design.  The Harrington device is ultimately a long rod with a hook at either end.  Each hook is secured into a bony bridge in the spine called the lamina.  Laminar hooks provide excellent fixation and were the basis of fixation for years to come until the advent of screws.  But a single lamina is a relatively thin strip of bone.  A single fixation at each end of a device which sees a tremendous amount of force over the course of a lifetime is bound to be prone to disruption, either by movement of the hook off the lamina or by breaking of the bone itself.   Another issue is that the linkage between the barrel and the screw of the rod proved to be a weak point, particularly if the bone fusion does not fully heal.  Breakage of Harrington rods was not an uncommon occurrence, usually at that transition point.

Various techniques were used to try to bolster the security of Harrington constructs.  Multiple rod constructs were attempted – necessary if the child had more than one curve.  I have seen constructs of two Harrington rods side-by-side along the spine.  Unfortunately rods continued to break and hooks to subside.

Around the same time that Dr. Harrington was developing his system, Dr. Eduardo Luque in Mexico City was working with a device that would stabilize if not fully correct a curve.  His device was predicated on a stainless steel rod placed alongside the spine and held in place with a series of wires wrapped around the lamina.  These Luque wires were individually flexible, but by wiring at each level the entire construct was made more rigid.  The inability to distract the device to allow curve correction ultimkately limited its use to patients with neuromuscular disease (such as Cerebral Palsy).  But the entire device could be placed safely and quickly and the concept and benefits of segmental fixation began to be evident.

Luque wiring and Galveston rods in the lower spine and pelvis of a child with cerebral palsy

The Luque wires were sometimes applied in hybrid to the Harrington Rod devices – creating a construct that was fondly called a Harri-Luque.  The application of this type of segmental fixation did seem to improve the strength of the constructs and disruption was diminished.  Added refinements, such as wires which went into the posterior elements of the bone rather than around the lamina (Drummond wires) helped as well.  But they could not overcome one of the main flaws of the Harrington design.

The human spine is mechanically based on the front to back curvatures, what is termed the sagittal alignment.  This allows the balancing of the centers of gravity in the body and facilitates all upright and most sitting posture in a normal person.  What the Harrington distraction did not take into account was the sagittal malalignment that makes up scoliosis.  Think about your high school geometry.  Simple lengthening of the convex side of a two-dimensional semicircle may straighten into a line, but in the third dimension it will decrease the necessary backward bend of the lower back, called the lordosis.  Patients who had Harrington fusion often developed severe pain and fatigue in their lower backs and an inability to sit unsupported for a long period of time.  This so-called Flat Back Syndrome was the long-term curse of the otherwise promising corrective ability of Harrington fusions.


As the science entered the late ‘70’s and early ‘80’s, it would take the French approach to the segmental fixation problem and the developing concept of a rotational model to advance the surgical art of scoliosis treatment.

To be continued...

Sunday, October 27, 2013

HOW I SPENT MY SABBATICAL

With the crisp air of fall settling in and the State Fair roaring to a close, it is time to review the long Spring and Summer and harvest whatever lessons life has offered me during my much needed break.  As my Sabbatical draws to a close, I can reflect on some of the ways my time off has changed me, as well as what about me has remained the same.

The constant is, and will always be, my interest in working with and I hope helping the children in my community.  I confess that I looked at other opportunities in other areas of the country.  But it was too difficult to leave the kids I already know and I could not escape the feeling of having unfinished business.  I have always felt loyalty is the strongest of virtues.

What has changed is my understanding of the need for full and clear communication, not only between myself and the children who are my patients, but also and especially with the parents and families of these kids.  I realize in retrospect that the pressures of being involved with such a busy practice did not allow me to spend as much time as I should have explaining my thinking and trying to understand the concerns and expectations of all involved.  I was able, during my break, to talk to a number of practitioners about how they maximize communication, and although I can tell you that no one has it down to a science, I came away with a number of new ideas that I think will help.  I also hope I never lose sight of the all-important trust factor that makes a successful doctor-patient relationship.

I, like many Americans, spent the summer trying to grapple with changes in policy as the Affordable Care Act begins to take effect.  I promise not to get overly political, but I find the ACA to be a tremendous opportunity to improve health care delivery, especially in the pediatric specialties.  For one thing, more children will have insurance and access to quality care.  For another, the law promotes communication and cooperation between specialty doctors and referrers and between doctors and hospitals.  And although it does not seem so right now, I think it will ultimately empower patients in the management of their own care.  Obviously, there is much more to see before anyone can make the final determination about the law.

Most importantly, my Sabbatical gave me an extended opportunity to spend time with my family and to relearn the importance of family ties.  This time enabled me to work with my son, a Second Year student at University of Virginia, on a number of creative outlets.  Through his encouragement, I sketched and wrote.  He even got me to start running regularly, which I would have bet could never happen.  I took voice lessons, which I had promised myself for a long time now.  I accompanied my wife on travel that I would never have been able to do had I been working – and so, I saw Brazil for the first time and attended the Gala Opening of the American Ballet Theater in New York City, among other adventures.  Throughout it all my family was a source of comfort and inspiration.

Perhaps most satisfying, I had the time to work with my father, Henry, an esteemed orthopaedist living in semi-retirement in Boston, on a book on Genetic Conditions in Orthopaedics, which has been published and is available to anyone who has absolutely nothing better to do.  We even included my son in the project as he designed the cover art (see below).



Overall the strength and support  of my family has reinforced the importance of engaging the families in my clinical endeavors.  And although I have enjoyed my time away, it is definitely time to return to work and try to put my new-found ideas into practice.

Thursday, June 27, 2013

185 Orthopaedists Walk Into a Bar...


I have a friend who does improv in New York City, and she told me about the traditional “walk into the bar…” joke or as they call them “185 jokes”.  The jokes are always along the lines of 185 something or other walking into a bar and being refused service.  The punchline, fast and furious, is generally groan-inducing.  A recent contribution from her goes like this:

185 Scoliscore tests (gene test for scoliosis) walk into a bar.  The bartender says “We don’t serve your kind here.”

              The Scoliscore tests respond, “Well, that sure threw us a curve!”

This month, June, has been Scoliosis Awareness month as always.  I have had the experience of giving four talks, writing three papers and two articles and being interviewed twice on media, always about scoliosis and mostly about Scoliscore, which I am championing.  Earlier articles in my blog have discussed the test which can determine the prognosis of a mild to moderate scoliosis with up to 99% accuracy, making it one of the most effective prognostic markers currently available in clinical medicine.

One of the reasons I have had this luxury is my self-imposed (and hopefully temporary) sabbatical from clinical care.  In three months, I have not seen a single patient (which has been unquestionably painful) and have not done a single surgical operation, which has been surprisingly refreshing.  Being out of the OR has allowed me to reflect on medical care from an entirely different perspective than my previous busy surgical practice allowed.

Doctors are an interesting lot.  We tend to define ourselves very strongly in terms of the composition of our practice.  We place ourselves by geography (“urban” vs. “rural”), by referral pattern (“primary” vs. “tertiary”), by complexity of the patient we see.  Surgeons, that most superstitious of groups, tend to define ourselves by surgical parameters – how busy are we, what is our caseload, what types of surgery are we comfortable with and what will we refer out?

The old adage from residency days is “a chance to cut is a chance to cure.”  But being outside of the surgical sphere made me realize that surgeries actually define a failure of a kind; the failure of non-operative treatment.  And in the bustle of being a busy surgeon, we run the risk of losing sight of the patient attached to the surgery.  No surgeon defines him or herself by the number of clinic patients seen, or the number of times that operative care was not invoked.

Humans also tend to define themselves in broad categories.  When it comes to medical care, they will often group themselves by their diagnosis, and will often carry the stigmata that go along with that diagnosis.  In adolescents and children, that is a particular issue, since placing yourself in a “diseased” category makes you somehow “other” or “different”.  Scoliosis is particularly pernicious in this regards.

Thinking, writing and speaking about Scoliscore through the eyes of a non-surgeon as much as I have over the past several months has led me to see the strengths of the test differently.  To be sure, a high score is very helpful.  It can define referrals and govern treatment plans.  It can give the doctor and patient a chance to explore more aggressive treatment options up to and including surgical intervention.  There is that surgical angle again (no scoliosis pun intended).

But the low score is inarguably most important to the patient.  With a 99% negative predictive value (only 1% or less of kids with the low scores will progress to need treatment) it will remove the fear and the stigma of having the diagnosis.  A child with a low score does not need to define herself as having “scoliosis” at all, since it so unlikely that there will be any consequence.  She can go on to other more congenial definitions like “preppy” vs. “Goth” or “athlete” vs. “artist”, and fit in more readily into the difficult vagaries of adolescent society.

 So, 185 low-risk Scoliscore tests walk into a bar.  The bartender says, “We don’t serve your kind here.”

The tests say, proudly, “We are not a kind.  We are as individual as anyone else in this bar. Serve up the drinks!”
That little effort would surely get me booed off the improv stage, but for a child with the diagnosis of scoliosis, it is surely a punchline to be cheered!

Tuesday, April 23, 2013

GRACE AND EMMA: The Interview

Not long ago, I had the pleasure of sitting down to sushi with two of my favorite patients, Grace B. (aged 15) and Emma B. (aged 13) along with their mother Victoria.  Both the girls have scoliosis to different degrees.  Grace's curve was severe and progressive and she required fusion at 12 years of age.  Her sister has a more mild curve, diagnosed after her sister already had progressed.  Both are avid performers and bubbly outgoing kids.  They readily agreed to talk about their experiences with curvature of the spine and its treatment.

What I couldn't capture or convey in words was the pleasure that these girls had in sharing there stories.  The interview was a delightful mix of laughter and excitement, with some surprisingly mature statements from both girls.  It was a long session, so I will divide it up in several posts.

Please note that their mother, who was present for the entire session gave full permission for use of the text and the picture.

I hope you enjoy.

Grace and Emma

KPM –So I thought it would be helpful for people to know what kinds of things go through your minds about scoliosis.  I think it’s a topic that Docs don’t seem to talk about much.

Grace – I guess when I first found out about scoliosis I was nine, so I didn’t really think anything of it.  I think we found out during a physical.  But at first I didn’t really know or really care what was going to happen.   I knew I wasn’t going to die.  I wasn’t told I was going to have surgery.  [The doctor visit] was a thing that I had to go to; I had to get x-rays and everything.  After  I moved here I sort of became more aware of what was happening, like I anticipated that I had to have surgery, so it wasn’t a complete shock to me.  I wasn’t scared, but it was kind of nerve-racking at first.

I did not want to go to Backtalk [spine support group] or the Spine Camp.  I didn’t want to be in one of those circles where you talk about your feelings and stuff.  But after my mom said she was going to go and everyone else was going to go, then I guessed I had to go.
 
I didn’t want to share.  Nobody knew at school.  I didn’t want to make it into a big thing.

I found it as like a limitation.  I didn’t want to be different from everyone else.  I didn’t want to tell everyone I couldn’t do this or this because of my scoliosis.  I thought it was a case where I wouldn’t be able to do something and that was why I didn’t want to tell everybody.

Mother – And you were afraid that you were going to cry.  This is a very extroverted kid that was able to sing on the steps of a cathedral, but she didn’t want to talk about something with kids who had the same thing.  It was shocking. You did want anyone to see you cry, was your quote.  I remember when you were doing everything at home - everything was very isolated, the crying whenever you wore the brace.  Like you were the only kid [who had the problem].

G – In a sense I was in my mind.

Nobody really understood the emotions I was going through.  I mean they got it but they couldn’t really understand.  And so it was kind of alone feeling.

K – Did you know anybody with scoliosis?

G – I didn’t know if I knew anybody.  People would tell me, like “I have scoliosis, but it’s only a 20 degree curve” so I was like, OK, why does that matter.  It wasn’t really significant to me.  I knew that they were trying to reach out to me, but I didn’t think they could understand what was happening to me.

K – Did you let the scoliosis define you?  Were you “a girl with scoliosis?”

G – Yeah, in a sense I was, I thought of myself that way.  I didn’t tell anyone at first that I had scoliosis.  I thought it was a limitation that I was determined not to let it make me who I am.  But in my mind it was.  It was like I couldn’t do this and I couldn’t so that.  It was almost like I was in the wheelchair of my mind.

K –What kind of limitations did you think you had? 

G – Well, I was in dance and I felt I couldn’t do the some of the modern dance and even in ballet there were things that were hard.  We’d have to square our shoulders and I couldn’t do that and I felt that I couldn’t say “I can’t do that because I have scoliosis.”  I didn’t want that to… but that’s sort of what it became in my mind of what I could and couldn’t do.

M – And then one particular day changed all that.  Do you remember what day it was?  I do.

G – Was it the Spine Camp?  (Mother nods) Yeah – I went to Spine Camp and it was where they have all the different activities and all these teaching stations.  Seeing everybody there was overwhelming, especially Mara [BackTalk founder Mara Howard-Williams].

K – I remember you at that Spine Camp.  You wouldn’t say a word – you just stood there glowering.

M – She was so mad at you she would barely even talk to you.  She said he can’t make me go, but we really wanted her to go since we knew it would help so much.  But by the end of it, and after Mara spent some time with her, it was like looking at someone who was in a type of recovery.  She found someone who had the same story, the same path – it was shocking.  Sad though I was about not being able to reach her, I felt that the Spine Camp people were such a gift.  You know, like a village raising a person. –
Even that night, the bracing was so much easier.  It was remarkable.  Because she had someone else who had gone through that experience.  And she never went back to the isolated whining.

K – Did you share things with Emma (your sister) when you found out how bad your curve was?  Did you try to talk with her about it?

G – Nah.

M – Emma would help her take the brace on and off.

G – Yeah, Emma was always there, like at the appointments and things.  But it wasn’t like I needed to share new info with her – she just sort of knew everything that was happening.

Emma is a significantly better dancer than I am, so it was kind of overwhelming to see her succeed where I couldn’t when she’s younger – so I didn’t really want to talk with her about it.  I felt I could talk to Mara and to a friend of mine – she had had spine surgery already.

M – They were in the same class. They didn’t even know they had the same issues.

K – You did know someone – you just didn’t know it.

You knew about your sister’s diagnosis, Emma, and you knew she was probably going to need surgery.  What did you think of it all?

Emma – Well, when she had surgery and was in the hospital, sometimes I had to sleep over at my friend’s house.  And I knew that surgery was serious – like when she was in the operating room.  I would do a lot of stuff for her when she was recovering in the hospital and at home.  I would go up and downstairs and fetch stuff.

G – I think after the surgery, there were certain people that I didn’t want there and Emma was one of them at first.  I know that sounds bad, but every time she came to the hospital I was like “Emma, get out!”  But in the end I was very grateful that she was there.

M – You were hurting.  I think you wanted her gone because you didn’t want her to see you hurting.

K – Emma’s so cheerful.  Maybe you just couldn’t deal with cheerful at that time.

M – Now Emma is relieved because every time we come her spine is still straight.

K – I’m sorry.  I don’t remember the exact timing.  Did we find Emma’s scoliosis before Grace’s surgery?

E – Yeah, we got the ScoliScore (gene test for scoliosis) on the day of her surgery.  You let me know then and that we would talk later.

K – So Emma, when you found out about the diagnosis, were you afraid that you were going to need surgery?  Are you still afraid you’re going to need surgery?

E – I’m afraid that if I did, I would have the same trouble with dance that Grace has and that’s kind of what I want to do with my life.  I want to be able to do certain things that I might not be able to do with back surgery. 

K – But Grace, you are performing now, aren’t you?  Theater- type dance?  (Grace nods)  Are there limitations that weren’t there before surgery?

G – Before I could do somersaults, bending back.  But before my balance was kind of off – it’s still off but it’s better.  My limitations were a lot different because I couldn’t bend my back.  It was a lot to adjust to.

M – What about your stamina?  Your ability to hang in there?  Is it better after or before surgery in terms of pain when things ache?

G – I don’t remember a lot of pain before surgery.

M – I love that that’s true for her.

G – Definitely more pain afterwards for a while.

M – You had to build your stamina up right after surgery.  Before the surgery, your hips would hurt you so much and also your shoulders.  Now that you’re fully recovered from surgery – your stamina is so much greater now.  And I would say that now you’re pain free.  You went through a couple of years… I’d say this is the first season you’re not having medicine every day – but before surgery, the aching would cause her to poop out and also she would get out of breath.

G – I remember that.

M – Now that you’re straight your lungs are working perfectly.  I notice as a mom that she can go for longer in physical activity than she could before.  Now the back muscles don’t ache as much.  She doesn’t even feel it is necessary to tell her director that she has rods in her back.

K – So Emma, do think about your scoliosis at all?  When you are dancing?

E – Yeah, I think about it.  I always think about it when I’m dancing.  But when I’m dancing, nothing really hurts.  It’s afterwards, and I think that’s really weird. 

K – Is your appearance an issue as a dancer?  I mean no one is as aware of their own appearance as a dancer.  Do you look in the mirror – does that factor into the way you think of yourself at all?

E – I don’t see a curve because it’s very little… very small.

G – I don’t think she sees a curve at all.  It’s the last thing on her mind.

M – We have a ballet barre and wall of mirrors in our dining room where they do their thing.  Emma is always inspecting her body.  I’m always wondering if she is looking at her back.

E – I don’t see it very much.

M – Emma used to look at Grace who was visibly crooked and so I think it disappeared from her consciousness.  And she’s been told by numerous people that they doubt she’ll express a curve and I think she believes that.

K – Grace, has your appearance been an issue to you, both before and after surgery?

G – Yeah, well I wasn’t taking vigorous ballet classes so I wasn’t so self-conscious about how I looked in a mirror.  Since I wasn’t in a class like Emma is.  I was self- conscious after about what everyone would think of my scar.  Going to the pool, like that.  But I think the scar now has pretty much faded away and nobody notices it.

K – So that’s something that I have no grasp of – the idea of what you see and how much the appearance affects you.

G – Yeah, I felt that after the surgery there was always the sense that when you stand up there’s a feeling of heaviness.  And what’s going to stay and what will go.  How you’ll feel in six months from now or even tomorrow.  What’s going to happen because you don’t have someone who’s parallel to you.  So in the beginning you look in the mirror and ask, is it always going to look this way or does anyone really even know?  Because the scar is kind of … it is the biggest scar I’ve had.  So yeah, you don’t really know how your body’s going to take scars so you don’t know what it’s going to look like 2 or 3 years or if it’s going to be significant or if you’re going to be like that girl who had to have the rods taken out – multiple surgeries.  There was always that mystery factor of what feelings were going to stay and what feelings were going to go, thinking of your appearance and what was going to remain.  It was kind of scary at first… but I’ve gotten over it now.

Tuesday, February 5, 2013

Hail To The Scoliotic King

Can the history of the world hinge on a back brace?

England is abuzz with the news today that a skeleton found beneath a Leicester parking lot is in fact that of the infamous King Richard III.  The king was slain during the Battle of Bosworth Field on August 22 (my birthday) in the year 1485 at the age of twenty-seven.  His short reign as the last Yorkist king of England at the very end of the Wars of the Roses was notorious for murders and family cabals, immortalized in a rather nasty and politically charged play by William Shakespeare.  Although there is a Richard III Society in England sworn to reclaim the reputation of a ruler they feel was unfairly maligned, there is no denying that his reign was shaded by mysterious deaths (his brother George, the Duke of Clarence, the Princes of the Bloody Tower and even his wife, Anne Neville) and by other percieved misdeeds.

One of the great mysteries about Richard, and a fact that seems to make him the perfect Pantomime villain is his appearance.  Shakespeare has the king describe himself as "rudely stamp'd" and "unfinished, deform'd."  Comment is made in the play and in other chronicles about his halting gait and deformed feet.  And his twisted back is probably his most notable feature.  In time he was known to the theater-going masses (and thus to posterity, such is the power of Shakespeare) as the Hunchbacked King.  However, contemporary portaraits show a troubled but well-appointed young man, with no evidence of rib prominence.  Of course who would paint the king with warts and all?

The findings in the Leicester parking lot are particularly breathtaking, largely because Richard's skeleton is unquestionably scoliotic.  The spine as reconstructed appears to have an unbalanced sixty or so degree right apex curve centered at the 7th Thoracic vertebrae.  There are modest rib anomolies, but no evidence of any significant chest wall deformity.  As for the rest of the skeleton, besides the obvious war wounds, there is not much in the way of other deformity.  The jaw is somewhat jutting, but this was not an uncommon trait in Europe's ruling families even at this early time.  Although Shakespeare and others would have us believe that Richard was clubfooted with a short limb, the remains of the legs seems proportional.  Although the feet are not seen in the reconstruction, the shin bones appear normal, with none of the secodary signs of untreated deformity.

Although I am aware of no pedigree regarding deformities in the English Royal family at this time, there does not seem to be any record of heritable spinal abnormality.  If there were, I think, Richard's curve would have been less remarkable even to the poison pen of the Bard.  Richard had one son, who as far as we know had no spinal curvature and no evidence of a syndrome.

In short, Richard did not seem to have any horribly deforming syndrome, but probably had an untreated idiopathic scoliosis.  His gait was probably disrupted by the trunk imbalance and the rotation of the spine which frequently leads to apparent leg length differences.

Obviously in the 1460s there were no orthopaedists lurking around the courts, least of the pediatric variety.  But from what I can see from the pictures, I think Richard's curve would have been very amenable to bracing, and if all else failed to a fairly straightforward corrective surgery.

It is hard for me not to imagine how life would have changed for the young and apparently dashing prince, brimming with the confidence of a corrected spine and straight stature that we often see after surgical correction.  Would his bitterness have softened, his ambitions been less brutally driving?  Would the poor princes of the tower have been spared and the many crimes which are associated with Richard's legacy never have occurred? 

What would Shakespeare have written about then?