Historical Evolution of Spinal Surgery1

Though surgery has been performed on the spine since prehistoric times it has been only in the last few decades that spinal surgery has evolved into a speciality in its own right. This has been entirely due to dedicated workers who have devoted their lives not only in attempting to understand the effects of disease on the spine and developing newer surgical techniques but also have worked hard to propagate this knowledge to others. From a time when general surgeons operated on the spine, now even within spinal surgery several subspecialites are developing. In this chapter the evolution of the speciality from prehistoric times down to the present time will be traced.

If one were to believe in Indian mythology the earliest spinal surgery would date back to prehistoric times when Lord Shiva transplanted the head of an elephant on his son Ganesha. The earliest documented spinal surgery however is found in the Edwin Smith Surgical papyrus which was written about 3000 to 2500 BC. In this era six cases of injuries to the spine (including dislocated and crushed vertebras) are listed. It was recognized that injuries and dislocation of the spine associated with cord damage caused paralysis of the arms and legs along with bowel and bladder incontinence and erection with seminal emissions.

Surgical history is very sketchy between the Egyptian and the Greek periods.

The comments of Anlus Cornelius Celsus on the treatment of spinal injuries are very brief. Like Hippocrates, he described fractures of spinous processes, not the bodies of vertebrae. For the treatment of dislocation of the vertebrae, he recommended extension as Hippocrates had described, but further 2remarked that this holds only for incomplete dislocations because complete dislocations caused death.

Galen's writings which are lengthy and numerous, were considered for centuries to be as unimpeachable as the Bible. However, Galen added nothing new to the treatment of spinal injuries. He merely commented on Hippocrates' methods.

For about two hundred years following Galen, there were no outstanding medical author. This was a period of compilers, whose chief merit lies in the fact that they preserved works that might otherwise have been lost. Oribasius was the first of these compilers to gain fame. He was a renowned Greek physician, when he came to the discussion of the treatment of dislocations of the spine, he again quoted Hippocrates. He added a practical attachment to Hippocrates' bench for reducing gibbosities. He had not found making a hole in the wall or driving a wide piece of wood in the ground very practical as a means of making leverage for a plank. Therefore he added, to one side of the bench, an iron attachment in which a plank could be inserted at the proper level. Although Oribasius made no discoveries for the treatment of spinal injuries, he did try to improve old methods.

Paul of Aegina was a Greek physician who not only described again Hippocrates' traction for dislocations but also added improvements employed by other physicians. He suggested that after the dislocation had been reduced, a thin sheet of wood be bound along the spine extending above and below the place of injury. If some gibbus persisted an emollient oil should be rubbed into this and a lead plate ‘bandaged on’ the vertebrae. Although Pauls remarks on dislocations of the spine were not original, as far as we know, his comments on the treatment of fractures were new. He originated the laminectomy. He said that when there is a fracture of the spinal column with compression of the cord, an incision should be made above the injury and that the piece of bone compressing the cord should be removed if possible. He also advised the removal of a fractured spinous process if it were causing pain. Although he did not describe the results of actual operations, he evidently fully appreciated the seriousness of the laminectomy because he admonished his reader to acquaint those concerned with the full danger of this operation before proceeding to perform it.

After the fall of the Western Roman Empire, civilization and culture in the West began to decline. Medicine and surgery, of course, followed the rest. At this time, however, the Eastern Empire was flourishing.

Avicenna a Persian followed Paul of Aegina's treatment of dislocations of the spine except with regard to the cervical vertebra. For reduction of the cervical vertebrae he said that the patient should be put on his back,” then he is extended head up with ease and made even in the vertebrae with compression and abstersion.” After reduction, the patient's neck should be bound with splints. He believed that fractures of the bodies of the vertebrae were fatal if accompanied by paralysis.

The school of Salerno did much to revive the medical profession during the eleventh and twelfth centuries. By the thirteenth century, medicine was pulling itself out of the dark ages and showing some signs of progress. Roland of Parma, a student and professor at Salerno, wrote his famous Chirurgia in 1210. His method of treating dislocations of the spine was different from Hippocrates' method. He discarded the use of the bench and used manual extension entirely. For reduction of the cervical vertebrae, Roland recommended bracing the patients shoulders and lifted his head rapidly by the hair or by a folded cloth passed under the lower jaw. For dislocations of the dorsal or lumbar vertebrae, the physician placed the patient in a supine position and pulled on his legs while an assistant held the upper part of the body. Another interesting point is that Roland emphasized that early treatment of these injuries is an important factor in their outcome. In principle, the methods of treatment employed by Roland of Parma were the same as those which were used the world over until the twentieth century.

In the fourteenth and fifteenth centuries, Guy de Chauliac was the most renowned surgeon and writer. He combined the works of serveral surgeons in his description of the treatment of spinal injuries. Like Lanfrank, he followed the method of traction introduced by Roland of Parma for the treatment of dislocations of the cervical vertebrae. For dislocation of the dorsal and lumbar spine, he preferred Hippocrates' bench equipped with windlasses for making traction. After reduction of the dislocation, the patient's back was bandaged and splinted. He was kept in a supine position for about twenty days. Guy de Chauliac's influence was very great because his work on surgery was translated into many spoken languages soon after it was written.

The fifteenth and sixteenth'centuries in Europe are known as the Renaissance, a period characterized by a revival of culture and learning. During this period, medicine and surgery began to have appearance of a modern science. Andreas Vesalius' De Fabrica Humani Corporis was too revolutionary to find immediate favor, but it received full appreciation from men like Pare. Of course, the invention of the printing press in the fifteenth century made books with their new ideas available to a much greater number of people.

Pare was one of the best known figures in the history of surgery since he was the first modern surgeon. Pare's greatness lay in his progressive attitude. He did not hesitate to cast tradition a side for new ideas. In Pare's Dix Livers de Chirurgie published in 1564 we find some interesting remarks on the treatment of fractures and dislocations of the spine. He went back to Paul of Aegina's work in reviving the laminectomy for fractures producing compression of the cord. He also thought that fractured spinous processes should be removed if they caused pain. But pare made one stipulation that Paul did not. He said that if the process were in any way attached to the periosteum, that the pieces should be set in their original position, splinted, and allowed to reunite. In the treatment of dislocation of the cervical vertebrae, Pare made some additions to the Roland of Parma technique.

The first spinal cord tumor was removed in 1887 by Victor Horsley himself although it was diagnosed by Gowers. It was an extramedullary tumor lying by the side of the spinal cord at the level of the 4th thoracic vertebra. The surgeon was assisted by Charles Balance and patient had made complete recovery from paralysis in the limbs. Victor Horsley was the first to remove successfully an intradural spinal cord tumor. Victor Horsley also described decompressive laminectomies for tuberculosis of the spine. He invented Bone wax so useful even today in spinal surgery to stop bleeding from the bone. That intradural spinal cord tumors could be removed was first suggested by pathologists. On 9th June 1987 Victor Horsley removed the first intradural spinal cord tumor.

A little earlier on 9th May 1883 Macewan had removed an extradural spinal lesion lying at the level of 5th, 46th and 7th thoracic vertebra. Patient had sensory and motor paralysis with bladder and bowel incontinence of two years duration. At operation the involved laminae were removed and an extradural fibrous neoplasm 1/8 inch in thickness firmly adherent to 2/3 circumference of the dura was carefully removed. Patient made complete recovery to be able to play football at the end of five years. Macewan was the first surgeon to successfully explore the spinal cord on the basis of localized neurological dysfunction.

He can rightly be called the father of modern spinal surgery. He trained himself as general surgeon and was influenced by Neurologists Sachs and Dana. In 1909 he joined the New York Neurological Institute. He performed the first spinal operation of the Institution on a female physician with intramedullary spinal cord tumor and she did well. He was also a prolific writer and wrote about 200 articles half of them on spine. He wrote three authoritative books on spinal surgery in 1916, 1925 and 1941. He also wrote the first definitive report on chordomas.

Myelography was developed in 1921 by Jean Sicard a French clinician and his pupil Jacques Forester who injected some substance into the back to treat low back pain. They noticed that the oil they used (Lipiodol) as carrier for the analgesic drug could be visualized on X-rays. This indirectly paved the way for the discovery of myelography giving the spinal surgeon a powerful diagnostic tool.

In 1932 Junghans made a milestone contribution to spinal surgery by describing “Motion segement” in the spinal. It was neither understood nor followed in those days. There was no appreciation of the statement. Now with better knowledge of biomechanics of spine we have realized how important it is to know the motion segment, preserve as much of it during surgery and stabilize it when there is instability in the motion segment. Junghans concept is an example of foresight of a person in the era when even prolapsed lumbar intervertebral disc was not understood. His textbook published in English in 1971.” The human spine in health and disease” with Schmorl G is an important document on spinal surgery.

A Neurosurgeon Dr William Jason Mixter and an orthopedic surgeon Dr Joseph S Barr Jr. wrote an article in the New England Journal of Medicine on 2nd August 1934 explaining prolapsed lumbar intervertebral disc as the cause of backache and sciatica and conclusively proved that the prolapsed disc could be removed by doing a laminectomy to produce relief from back and sciatic pain. The publication heralded the birth of modern scientific spinal surgery. In fact the impact of this publication was so great that for a long period it had dominated all thinking on the subject of backache and sciatica. It was only when faced with frequent failures after repeated surgery for prolapsed lumbar disc was any attention pain to alternative explanations and hypothesis.

His contribution to the understanding of lumbar canal stenosis remains a landmark in the development of spinal surgery. He developed an internationally known department of Neurosurgery in Utrecht in Netherlands. He studied at the University of Leiden in Netherlands. He did his neurological training under Prof GGJ Rademaker and Dr A Gans until 1937 and published several papers which attracted the attention of the world. For two years in 1938 and 1939 he trained himself under Dr Vincent Clovis in Paris. Second World War compelled Verbiest to return to Netherlands. He was appointed lecturer at the University of Utrecht in 1949 and full professor in 1963. He was the first one to describe lumbar canal stenosis. In absence of better technology he had developed techniques for measuring the diameter of the canal at the time of surgery. He described congenital and acquired stenosis and also emphasized the fact that the whole lumbar spinal canal could be developmentally narrow. His orginal paper on lumbar canal stenosis was rejected for publication by the editors of two internationally esteemed neurosurgical journals. He finally published his monumental paper in the journal of orthopedics. In the later part of this life he concentrated on the cervical spine and published several papers on more radical anterolateral approach to the cervical spine and decompression of 5the vertebral artery as it passed through the vertebral foramina. Although this approach has not become popular it certainly contributed to the advancement of surgery on the spine.

Harrington (1911–1980) was from Kansas in America. He was an outstanding basketball player and never had any idea of even going to college. However a basketball scholarship saw him at the university. His ambition was to become a physical instructor but his coach convinced him to become a doctor. He practiced in Houston in Texas and looked after the poliomyelitis patients at the city hospital. This is how he got interested in scoliosis and by trial and error he finally designed Harrington spinal instrumentation and Harrington rods for the treatment of scoliosis. Harrington rod instrumentation became extremely famous all over the world and remained popular for several years until pedicular screws appeared on the scene. These instruments he developed between 1950 and 1960 for which he received the most distinguished Alumnus award from Kansas University.

Dr Ralph B Cloward is considered as a craftsman par excellence and Michael Angelo of spinal surgery. His interest in spinal surgery was so great and intense that as neurosurgeon he only practiced spinal surgery. After his early training in USA during the Second World War he was recruited in 1939 in the US Army and posted in the Hawaiian Islands in the pacific for the duration of the war. However till today Dr Cloward has not left Hawaiian Islands and is settled in Honolulu. He is the father and originator of posterior lumbar interbody fusion (PLIF). The technique in fact was evolved as a necessity of the time. Pearl Harbor was attacked by Japanese on 7th Dec 1941. The Island defenses were built with furious pace of hard work against time. This resulted in many low back injuries with backache and sciatica. A method of treatment was needed which would return the man back to his job. In 1942 the operation of posterior lumbar interbody fusion was developed by him and in 1943 he presented a paper on his 100 cases to Neurosurgical audience. It was not well received and chairman was out to comment. The chisel and hammer should be left to orthopedic surgeons. Dr Cloward persisted and perfected his technique. He developed a bone bank and also devised instruments for his technique which were manufactured by Codman untill recently. Cloward technique of removing a dowel from the iliac crest and inserting it between too vertebrae became very popular and subsequently bank bone dowels'were introduced. Another aspect of spinal surgery to which Dr Cloward contributed was spinal stenosis. Although the condition was described much earlier the advent of CT scan brought better understanding of the symptoms resulting from alteration in the size and shape of the spinal canal. This led to the change in the surgical treatment and Cloward demonstrated that the spinal stenosis should be correctly treated by lateral rescess decompression and posterior lumbar interbody fusion.

Dr Crockard is the consultant neurosurgeon and head of the department of Neurosurgery at National Hospital for Nervous Diseases at Queen Square, London. He has special interest in the upper cervical spine. His work on rheumatoid arthritis causing atlantoaxial dislocation and spinal cord compression is respected all over the world. He used transoral excision of the odontoid along with posterior atlanto fusion using contoured metallic ring and Ransford loupes along with sublaminar wiring. He has used transoral route to remove tumors situated anteriorly in this region either intra or extradurally. Cloward transoral set of instruments are manufactured by Codman and Shurtlef Inc.6

He is an Indian neurosurgeon from Mumbai and has now settled in America where he is the Professor and Vice Chairman of the division of Neurosurgery at the Iowa University. At this University he has excelled himself as the spinal surgeon with special interest in the upper cervical spine and particularly craniovertebral anomalies, their detection, description and management. He has the largest series of management of such cases. He is of the opinion that subsequent to Bell's description of atlantoaxial dislocation in 1830 craniovertebral anomaly had remained a medical curiosity. But now it can be effectively managed and patient relieved of the symptoms of cord compression at this level. He has advocated transoral transpalatine approach to anterior clivus C1 and odontoid followed by posterior fusion with bone graft. He has not used contoured metallic loupes.

Professor R Roy Camille was the professor of Orthopedics at the Hospital de la Pitie in Paris in France. He can rightly be called father of European spinal stabilization procedures. He is the first to do pedicle screws and plates. He has invented (various) types of screws and plates and special right and left sides lumbosacral L shaped plates. He has advocated putting more than one screw in the sacral pedicle. He has devised various, instruments for fixing the screws and plates. He has described his own technique in finding the pedicle point which is slightly different from that described by Arthur Steffee and Weinstein. It may be noted here that although R Roy Camille is the first one to use pedicle screws and plates, he and Europe as a whole did not do posterior lumbar interbody fusion and he always did posterolateral fusion after fixing the spine with metallic implants. He has written several books. He has received the rare honor from Govt. of France “CHEVALIER DE LA LEGION d”HONEUR”. He died two years back due to malignancy.

Dr Arthur D Steffee is an orthopedic surgeon and he has his own spine and arthritis center in Cleveland in Ohio, in USA. Although he did not originally devise pedicle screw he has modified it and he has invented variable screw placement plate. He used screws and plates in conjunction with posterior lumbar interbody fusion. He had devised his own pedical point. Steffee pedicle point and Steffee technique of pedicle screw and plates has become most popular all over the world today for stabilizing an unstable spine. He has now established his own surgical firm “Acromed corporation” to manufacture 1: Pedicle screws and plates; 2: Steffee instrumentation for pedicle screws and plates and 3: Steffee set of instruments to perform the PLIF operation. Dr Steffee originally has been a hand surgeon but his interest in the spine made him give up hand surgery totally and he is now concentrating on doing only this type of surgery for various conditions of the spine resulting in instability. He has special interest in the treatment of cascading spines.

Dr Lin did his graduation and postgraduation at St. John's University in Shanghai China. Then he came to USA and studied at the Temple University in Philadelphia. In 1957 he received certification in neurological surgery from the American board of neurological surgeons. He continued as Instructor in Neurosurgery at the Temple University in 1957 and retired as Professor of clinical neurosurgery in 1990. His main interest was in the spinal surgery and eventually gave up altogether cranial neurosurgery and he has been practicing spinal surgery till his retirement in 1990. His main interest lay in posterior lumbar interbody fusion. It can rightly be said that Dr Lin popularized this surgery and created tremendous interest in the world in this surgery. He developed his own technique of doing this operation which had become extremely popular all over the world.

Dr Punjabi is an engineer (biomedical). He has received doctorate in the subject.

Evans is also a biomedical engineer. He has been working in USA but recently he has moved and settled in Hong Kong. He is remembered for his Flagpole concept in lumbar spinal instability. Many workers on posterior lumbar interbody fusion utilize this principle and preserve as much of the posterior motion segment. Evan's flagpole concept encompasses Junghan's concept of motion segment.

Dr Fred J Esptein is a neurosurgeon and is the Director and Professor of the division of neurosurgery (Pediatric) at the New York University School of Medicine. His name will go down in the history as a true modern spinal neurosurgeon' for his painstaking work on intramedullary neoplasms. He has given direction to modern spinal microneurosurgery. He is world renowned and has over 86 indexed publications. He has shown that with use of Cavitorn Ultrasonic Surgical Aspirator along with intraoperative monitoring of spinal functions an intramedullary tumor can be totally excised. He has published papers on intramedullary tumor intramedullary lipomas hydromyelia myelomeningoceles, etc.

Dr Ramani is the professor and head of the department of neuro and spinal surgery at LTMG Hospital in India. Following postgraduate qualification at the University of Mumbai he did neurosurgical training at the University of Newcastle upon Tyne in England and obtained MSc degree in neurosurgery from the university besides obtaining certificate of training from the Royal College of Surgeons-London. During the period of training at the University he published several papers on original work in spinal surgery and was recipient of David Dickson research prize of the year for research on spine. He demonstrated that the thickness of ligamentum flavum can vary but the term hypertrophy was a misnomer. He demonstrated that patient with prolapsed lumbar intervertebral disc coming for surgery has a narrow congenital canal. He demonstrated that Kiel bank bone used for anterior cervical fusion never assimilated with the host bone but was surrounded by a halo of fibrous tissue even after five years. He popularized PLIF surgery in India and is more known as PLIF doctor rather than Dr Ramani. He has evolved his own technique for PLIF which is very widely followed. During the last ten years his regular workshops help propagate the idea of PLIF in particular and spinal surgery in general among neuro and orthopedic surgeons. His textbook on PLIF is followed like postgraduate book in India. He was International President of PLIF Group from 1987 till 1989. He has been a member of World Federation of Neurosurgical Spine Society. His album on eight video cassettes on advanced techniques in spinal surgery and twelve books and textbooks on spine propagate the knowledge on spinal surgery in India. He has popularized microlumbar discectomy and has evolved a technique (IDSS) for the treatment of spinal stenosis. He has advocated three or four vertebral bodies cervical corpectomies for myelopathy.

Dr Mallis, a neurosurgeon from Mount Sinai Hospital in New York developed bipolar coagulation. Today spinal surgery cannot be considered without a bipolar coagulator. Although now obsolete he had developed “full column technique” of myelography for visualization of lesions in the spine.8

Several workers in Japan have contributed immensely for the development of spinal surgery in that country. Majority of the publications are in Japanese language. However their recent contribution in English language has made the world aware of their contribution, e.g. Dr Hijikata is the first man to start APLD, Dr Kiyoshi Hirabayashi has developed cervical spinal surgery including laminoplasty. His thoughts on the anterior approach to the lumbar spine are respected. Dr. Miyuki Takeda is remembered for his contribution to the stabilization of lumbar spine with preservation of posterior motion segment. He has developed a technique of PLIF. Dr Keiro Ono has been responsible for basic research on level diagnostic neurology specially with respect to cervical spine.

Shushruta described management of spinal injuries and showed great knowledge on this subject. For dislocations of the spine from neck downwards the surgeon was instructed to grasp the head at the nape of the neck and the angle of the jaw bone and tilt it upwards. Then the neck should be bandaged with splint and the patient ordered to lie on his back for one week. For fracture and dislocations of the lower section of the spinal column the patient should be placed on a board and tied with ropes to five pegs for immobilization of the spinal column. However, Shushruta believed that on the whole fractures of the spine were hopeless to treat.

Spinal surgery in India was started in early 1950s by neurosurgeon Dr R G Ginde and orthopedic surgeon Dr KT Dholakia, both of them in Mumbai. Dr RG Ginde popularized laminectomy for prolapsed lumbar intervertebral discs and cervical decompressive laminectomes for cervical spondylosis. Dr KT Dholakia routinely did laminectomies for prolapsed discs and cervical decompressive laminectomies for degenerative disorders. But he is remembered more for introducing surgery for scoliosis in Indian. He is still practising this surgery and is the only Indian to be a member of the prestigious Scoliosis Research Society of Northern America. Dr KV Chaubal, Orthopedic surgeon followed. He helped to put spinal surgery on a sound footing. Over the years he has pursued his interests doing traditional spinal surgery. Professor SM Tuli from Banaras, an orthopedic surgeon did lot of work on tuberculosis of spine. He also evolved a technique of preserving bone grafts. He followed the middle of the road path. He was neither too aggressive in surgery nor did he overemphasize conservative treatment. He has written a book on tuberculosis of the skeletal system. Dr PN Tandon practiced cervical discoidectomy without fusion in New Delhi. During early nineteen seven-ties Dr Gajendra Singh neurosurgeon from Mumbai did work on craniovertebral junction. Before this Dr NH Wadia, a neurologist had shown that abnormality in this area is more common in India than in the western world Dr A V Bavadekar, orthopedic surgeon helped to strengthen the spinal surgery by his two unique contributions. He excelled himself in spinal tumors. He advocated anterior approach to spine at a time when everyone did posterolateral decompression. Dr NS Laud, Orthopedic surgeon, fortified lumbar spinal surgery and along with Dr PS Ramani popularised anterior cervical spinal surgery in the orthopedic arena. In the early seventies Dr Balaparameshwara Rao and Dr I Dinaker published several papers in the neurology in India. Both of them are neurosurgeons practicing at that time in Vishakhapatnam. Dr MN Shahane, orthopedic surgeon took keen interest in traumatic spinal surgery and popularised use to Harrington instrumentation for treating spinal instability particularly at the dorsolumbar junction with neurological deficits. Dr DD Tanna orthopedic surgeon excelled himself in stabilizing the unstable spine with metallic implants and has advocated both anterior and posterior approach in the treatment of dorsolumbar junction fractures. He does PLIF along with pedicular screw and plate fixation. Dr PS Ramani, neurosurgeon from Mumbai set new standards for surgery in the lumbar and cervical spine. He innovated his own construct for PLIF and stressed the need to do anterior cervical fusion following discoidectomy. He established bone bank and convinced the spinal surgeons about the usefulness of this bone in spinal fusion. He popularized anterior approach to the thoracic spine, evolved an operation for lumbar lateral recess stenosis and advocated anterior sternotomy or claviculotomy for anterior approach to lesions of D1, D2 and D3 spine. He also 9popularized microlumbar discoidectomy and transoral surgery. Dr VT Ingalhalikar, orthopedic surgeon from Thane in Maharashtra was responsible for the birth of Associations of Spinal Surgeons of India (ASSI) a body that has remained primarily an orthopedic organ. More recently two orthopedic surgeons from Mumbai Dr VJ Laheri and Dr SY Bhojraj have dedicated themselves exclusively to spinal surgery. They are true spinal surgeons.