The History of Spinal Neurosurgery

Spinal surgery today bears little resemblance to that practiced in 1950. The last fifty years have seen incredible change and improvement.[1] The innovations can be attributed almost entirely to a group of visionary neurosurgeons.

The 1950’s

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,[2] 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.[3]

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.[4]

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. [5][6][7][8] Advances in spinal surgery in the 1950’s were revolutionary. Anterior cervical discectomies were first performed by Cloward[9][10] and Robinson and Smith.[11] Trauma surgery for spinal injuries was developed from lessons learned in the Korean conflict.[12]

The 1960’s

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[13][14] and built the first microscope for use in the operating room.[15][16] 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.[17]

Surgical advances in the 1960’s included the introduction of instrumented lumbar fusion (with metal hardware)[18][19] and the development of a number of new approaches for thoracic disc herniation.[20][21] The first percutaneous[22] (minimally invasive disc procedure), chymopapain injection was developed though it was soon abandoned.

The 1970’s

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.[23] MRI scanning was developed shortly thereafter in 1976.[24] Simultaneously, minimally-invasive surgery advanced. The first percutaneous discectomy was completed[25] and the use of the anterior approach for lumbar fusions was developed.[26] Anterior[27] and posterior[28][29] 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.

The 1980’s

In spine surgery, the improvements of the seventies continued into the eighties. The biomechanics of the spine were defined more rigorously.[30] 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.[31][32][33][34][35][36][37][38][39][40] Percutaneous approaches for osteoporotic fractures were also developed.[41] Various biochemical graft materials were refined, including the introduction of a number of types of synthetic bone.[42][43] Electrical bone growth stimulators were also developed.[44] 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,[45][46] 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.[47] Artificial discs, developed in Europe in the eighties, entered into United States protocols in the nineties.[48][49][50][51][52][53] Replacements of the disc nucleus were also described.[54] Genetic defects responsible for a number of common syndromes were identified and the first genetic repair treatments were proposed.[55] Endoscopic, laparoscopic, and thorascopic techniques were perfected.[56] The bone morphogenic proteins, which were first described thirty years earlier, first became commercially available.[57]

Perhaps the greatest advances involved a critical look at previously accepted innovations. The need for fusions was questioned.[58][59] the need for many cervical disc surgeries was questioned[60][61] and the concept of evidence-based medicine was introduced, not only to spine but to medicine in general.

The Future

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.

[1] Adapted from Barrow DL, Kondziolka D, Laws ER, Traynelis VC, eds. Fifty Years of Neurosurgery. Philadelphia: Lippincott, Williams & Wilkins, 2000.

[2] 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

[3] Cushing H. Consecratio Medici and Other Papers. Boston: Little, Brown and Company, 1928.

[4] Semmes RE. In favor of simplicity: Applied to medicine in general and neurosurgery in particular. J Neurosurg 15:1-3 (1958).

[5] Schneider RC, Cherry G, Pantek H. The syndrome of acute central cervical spinal cord injury: With special reference to the mechanisms involved in hyperextension injuries of the cervical spine. J Neurosurg 11:546-577 (1954).

[6] Taylor AR. The mechanism of injury to the spinal cord in the neck without damage to the vertebral column. J Bone Joint Surg Br 33-533-537 (1951).

[7] Meyerding HW. Spondylolisthesis. Surg Gynecol 54:371-377 (1932).

[8] Taillard W. Le spondylolisthesis ce l’enfant et l’adolescent (etude de 50 cas). Acta Orthop Scand 24:115-144 (1954).

[9] See also http://www.cloward.com/pg_about.html , the web site of Dr. Cloward’s company.

[10] Cloward RB. The anterior approach for removal of ruptured cervical discs. J Neurosurg 15602-617 (1958).

[11]Robinson RA, Smith GW. Anterolateral cervical disc removal and interbody fusion for cervical disc syndrome. Bull Johns Hopkins Hosp 96:233 (1955).

[12] Wannamaker GT. Spinal cord injuries: A review of the early treatment in 300 consecutive cases during the Korean Conflict. J Neurosurg 11:517-524 (1954).

[13] Cormack AM. Representation of a function by its line integrals, with some radiological applications. J Appl Phys 34:2722-2727 (1963).

[14] Oldendorf WH. Isolated flying spot detection of radio-density discontinuities—displaying the internal structural pattern of a complex object. Trans Bio Med Elect 8:68-72 (1961).

[15] Yasergil MG. Microsurgical operation of herniated lumbar disc. Adv Neurosurg 4:81 (1977).

[16] Caspar W. A new surgical procedure for lumbar disc herniation causing less tissue damage through a microsurgical approach. Adv Neurosurg 4:74-80 (1977).

[17] Urist MR. The first three decades of bone morphogenetic protein research. Osteologie 4:207-223 (1995).

[18] Harrington PR. The history and development of Harrington instrumentation. Clin Orthop 93:110-112 (1973).

[19] Harrington PR, Dickson JH. Spinal instrumentation in the treatment of severe progressive spondylolisthesis. Clin Orthop 117:157-163 (1976).

[20] Ransohoff J, Spencer F, Siew F. Transthoracic removal of thoracic disc: Report of three cases. J Neurosurg 31:459-461 (1969).

[21] Perot PL, Munro DD. Transthoracic removal of midline thoracic disc protrusions causing spinal cord compression. J Neurosurg 31:4520458 (1969).

[22] Smith L, Garvin PJ, Jennings RB, et al. Enzyme dissolution of the nucleus pulposus. Nature 198-1311-1312 (1963).

[23] Hounsfield GN. Computerized transverse axial scanning (tomography). 1. Description of system. Br J Radiol 46:1016-1022 (1973).

[24] Hinkshaw WS, Bottomley PA, Hoilland GN. Radiographic thin-section of the human wrist by nuclear magnetic resonance. Nature 270:722-723 (1977).

[25] Hijikata S. Percutaneous nucleotomy: A new concept technique and 12 years experience. Clin Orthop 238:9-23 (1989).

[26] Freebody D, Bendall R, Taylor RD. Anterior transperitoneal lumbar fusion. J Bone Joint Surg Br 53:617-627 (1971).

[27] Robertson JT. Anterior removal of cervical disc without fusion. Clin Neurosurg 20:259-261 (1973).

[28] Hattori S. A new method of cervical laminectomy. Central Jpn J Orthop Traumatic Surg 16:792-794 (1973).

[29] Roy-Camille R, Saillant G, Mazel C. Internal fixation of the lumbar spine with pedicle screw plating. Clin Orthop 203:7-17 (1986).

[30] Denis F. The three column injury and its significance in the classification of acute thoracolumbar spinal injuries. Spine 8:817-831 (1983).

[31] Luque ER. The anatomic basis and development of segmental spinal instrumentation. Spine 7:256-259 (1982).

[32] Luque ER. Interpeduncular segmental fixation. Clin Orthop 203:54-57 (1986).

[33] Magerl F. External skeletal fixation of the lower thoracic andc lumbar spine. In, Ulthoff HK, Stahl E (eds). Current Concepts of External Fixation of Fractures. Berlin: Springer-Verlag, 1982.

[34] Roy-Camile R, Sailant G, Bertaux D, et al. Early management of spinal injuries, in McKibbin B (ed): Recent advances in Orthapedics. Edinburgh: Churchill Livingstone, 1979.

[35] Louis R. Fusion of the lumbar and sacral spine by internal fixation with screw plates. Clin Orthop 203:18-33 (1986).

[36] Louis R. Pars interarticularis reconstruction of spondylolysis using plates and screws with grafting without arthrodesis. Apropos of 78 cases [French]. Rev Chir Orthop Reparatrice Appar Mot 74:549-557 (1988).

[37] Dick W. The “fixatuer interne” as a versatile implant for spine surgery. Spine 12:882-900 (1987).

[38] Steffee AD, Sitkowski DJ. Reduction and stabilization of grade IV spondylolisthesis. Clin Orthop 227:82-89 (1988).

[39] Steffee AD, Biscup RS, Sitowski DJ. Segmental spine plates with pedicle screw fixation: A new internal fixation divice for disorders of the lumbar and thoracolumbar spine. Clin Orthop 203:45-53 (1986).

[40] Cotrel Y, Dubousset J, Guillaumat M. New universal instrumentation in spinal surgery. Clin Orthop 227:10-23 (1988).

[41] Bascoulergue Y. Percutaneous injection of methyl methacrylate in the vertebral body for the treatment of various diseases. 74th Annual Meeting of the Radiological Society of North America. Chicago, November 1988.

[42] Covey DC, Albright JA. Clinical induction of bone repair with demineralized bone matrix or a bone morphogenic protein. Orthop Rev 18:857-863 (1989).

[43] Herron LD, Newman MH. The failure of ethylene oxide gas-sterilized freeze-dried bone graft for thoracic and lumbar spinal fusion. Spine 14:496-500 (1989).

[44] Kane WJ. Direct current electrical bone growth stimulation for spinal fusion. Spine 13:363-365 (1988).

[45] Gildenberg PL, Kaufman HH. Direct calculation of stereotactic coordinates from CT scans. App Neurophysiol 45:347-351 (1982).

[46] Gildenberg PL, Kaufman HH, Murthy KS. Calculation of stereotactic coordinates from the computed tomographic scan. Neurosurgery 10:580-586 (1982).

[47] Dwyer AF, Newton NC, Sherwood AA. An Anterior Approach to Scoliosis: A Preliminary Report. Clin Orthop 62:192-202 (1969).

[48] Bao QB, McCullen GM, Higham PA, et al. The artificial disc: Theory, design and materials. Biomaterial 17:1157-1167 (1996).

[49] Cinotti G, David T, Postacchini F. Results of disc prosthesis after a minimum follow-up period of 2 years. Spine 21:995-1000 (1996).

[50] Cummings BH, Robertson JT, Gill SS. Surgical experience with an implanted artificial cervical joint. J Neurosurg 88:943-948 (1998).

[51] Enker P, SAteffee A, Mcmillin C, et al. Artificial disc replacement: Preliminary report with a 3-year minimum follow-up. Spine 18:1061-1070 (1993).

[52] Griffith SL, Shelokov AP, Buttner-Janz K, et al. A multicenter retrospective study of the clinical results of the LINK SB Charite intervertebral prosthesis: The initial European experience. Spine 19:1842-1849 (1994).

[53] LeMaire JP, Skalli W, Lavaste F, et al. Intervertebral disc prosthesis: Results and prospects for the year 2000. Clin Orthop 337:64-76 (1997).

[54] Nishimura K, Mochida J. Percutaneous reinsertion of the nucleus pulposus: An experimental study. Spine 23:1531-1539 (1998).

[55] Annunen S, Paassilta P, Lohiniva J, et al. An allele of COL9A2 associated with intervertebral disc disease. Science 285:409-412 (1999).

[56] Rosenthal DJ, Dickman CA. The history of thoracoscopic spine surgery , in Dickman CA, Rosenthal DJ, Perin NI (eds): Thorascoscopic Spine Surgery. New York: Thieme, 1999.

[57] Boden SD, Zdelblick TA, Sandhu HS, et al. The use of rhBMP-2 in interbody fusion cages. Definitive evidence of osteoinduction in human: A preliminary report. Spine 25:376-381 (2000).

[58] Fischgrund JS, Mackay M, Herkowitz HN, et al. 1997 Volvo Award winner in clinical studies. Degenerative lumbar spondylolisthesis with spinal stenosis: A prospective, randomized study comparing decompressive and arthrodesis with and without spinals instrumentation. Spine 22:2807-2812 (1997).

[59] Thomsen K, Christensen FB, Eiskjaer SP, et al. Volvo Award winner in clinical studies. The effect of pedicle screw instrumentation on functional outcome and fusion rates in posterolateral lumbar spinal fusion: A prospective, randomized clinical study. Spine 22:2813-2822 (1997).

[60] Dowd GC, Wirth FP. Anterior cervical discectomy: Is fusion necessary? J Neurosurg 90:8-12 (1999).

[61] Savolainen S. Rinne J, Hernesniemi J. A prospective randomized study of anterior single-level cervical disc operations with long-term follow-up: Surgical fusion is unnecessary. Neurosurgery 43:51-55 (1998).