The History of Spinal Surgery
The first fifty years: from Eisenhower to Bush
Spinal surgery today bears little resemblance to that practiced in 1950. The last fifty years have seen incredible change and improvement. The innovations can be attributed almost entirely to a group of visionary neurosurgeons.
The fifties saw the introduction of Barbie, Barcodes, the Brown vs. Board of Education verdict, the civil rights movement, commercial jets, credit cards, Disneyland, DNA, fast food, integrated chips, interstate highways, lasers, nuclear energy, the polio vaccine, rock ‘n roll, satellites, and the VCR.
As the fifties began, both neurosurgery and spinal surgery were in their infancy. Harvey Cushing, a general surgeon by training, set out to advance the science of cranial and spinal surgery. Considered one of the founding fathers of neurosurgery, he trained a generation of great doctors.
Spinal surgery in the early fifties included only a limited number of procedures and diagnostic tests. Surgeons did not even understand the cause of many common problems. Almost all spinal surgery was done through large posterior incisions. Plain X-rays and myelography, virtually the only available diagnostic tests, remained less reliable than the physical examination.
The pathology of lumbar spinal stenosis, central spinal cord injury and spondylolysis, three of the commonest spine problems requiring surgical treatment, was first described in the 1950’s.  Advances in spinal surgery in the 1950’s were revolutionary. Anterior cervical discectomies were first performed by Cloward and Robinson and Smith. Trauma surgery for spinal injuries was developed from lessons learned in the Korean conflict.
Apollo, the birth control pill, Black Power, the beginnings of the internet, Medicare, the microwave oven, pollution control, Sesame Street, the Surgeon General’s warnings about smoking and the Voting Rights Act all came to us in the sixties.
The sixties were the decade of technology. While the NASA worked to put a man on the moon, physicians developed the concepts that would lead to the first CT scanner and built the first microscope for use in the operating room. The first advances in bone fusion were made with the discovery of chemicals that cause bone to fuse. These were aptly called bone morphogenic proteins.
Surgical advances in the 1960’s included the introduction of instrumented lumbar fusion (with metal hardware) and the development of a number of new approaches for thoracic disc herniation. The first percutaneous (minimally invasive disc procedure), chymopapain injection was developed though it was soon abandoned.
Cable television, cell phones, hip-hop music, personal computers, Roe vs. Wade, Roots and Title IX all came from the seventies.
Perhaps the most significant medical advance of the decade was in the field of neuroimaging. Hounsfield, in 1972, developed and built the first CT scanner. MRI scanning was developed shortly thereafter in 1976. Simultaneously, minimally-invasive surgery advanced. The first percutaneous discectomy was completed and the use of the anterior approach for lumbar fusions was developed. Anterior and posterior cervical fusion techniques were perfected. The first national organization for spine and peripheral nerve surgery was formed by the Congress of Neurological Surgeons in 1979.
CNN, Cyclosporin, MTV and Prozac were introduced in the eighties.
In spine surgery, the improvements of the seventies continued into the eighties. The biomechanics of the spine were defined more rigorously. Spinal instrumentation technologies, based on the basic science research, were refined. A bewildering variety of types of rods and pedicle screws were developed for lumbar instability. Percutaneous approaches for osteoporotic fractures were also developed. Various biochemical graft materials were refined, including the introduction of a number of types of synthetic bone. Electrical bone growth stimulators were also developed. In addition to basic research in the science of medicine and surgery, the revolution in computer technology contributed greatly. Frameless stereotaxy was first proposed in 1982, even though it would be a number of years until the technology was fully implemented.
The 1990’s and beyond
The last decade of the millennium saw the introduction of genetically modified food and global positioning satellites.
The last decade of the twentieth century was also designated the “Decade of the Brain” by Congress. Advances in imaging benefited spine surgery as well. Intraoperative imaging became possible, even though still impractical. Artificial discs, developed in Europe in the eighties, entered into United States protocols in the nineties. Replacements of the disc nucleus were also described. Genetic defects responsible for a number of common syndromes were identified and the first genetic repair treatments were proposed. Endoscopic, laparoscopic, and thorascopic techniques were perfected. The bone morphogenic proteins, which were first described thirty years earlier, first became commercially available.
Perhaps the greatest advances involved a critical look at previously accepted innovations. The need for fusions was questioned. the need for many cervical disc surgeries was questioned and the concept of evidence-based medicine was introduced, not only to spine but to medicine in general.
The next decade will likely see great advances. The challenges may be even greater. All medical advances inevitably come at some cost. The cost of spine care in the United States exceeds $150 billion per year. Medicare and private payers are struggling to balance the need for new and innovative care with the cost of that treatment. The medical literature increasingly discusses cost effectiveness at the same time that it considers whether a procedure is safe or effective. Costs will increase as our population ages and as we increasingly expect technology to provide a cure to almost every ailment.
 Adapted from Barrow DL, Kondziolka D, Laws ER, Traynelis VC, eds. Fifty Years of Neurosurgery. Philadelphia: Lippincott, Williams & Wilkins, 2000.
 For more information on Dr. Cushing see http://www.whonamedit.com/doctor.cfm/980.html or http://www.uic.edu/depts/mcne/founders/page0020.html
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