SURGERY
The evolution of spinal surgery has revolved around the following three basic surgical goals: (i) decompression, (ii) stabilization, and (iii) deformity correction. Although the main advances of spine surgery occurred in the 19th and 20th centuries, their roots actually go back several thousand years.
References to treatment of spinal pathology date back to ancient times. The earliest known description dates to the Smith Papyrus, the oldest known medical treatise on trauma, dating back to ancient Egypt, circa 1550 BC. A case of fractured cervical vertebrae with concurrent paralysis is described there; treatment was carried out by priests, involving rest with supplementary bandages and dressings on wounds.
However, according to the great Greek physician Hippocrates (460-377 BC), no real treatment options existed if a fracture was in fact accompanied by paralysis; he believed those unfortunate patients were destined to die without benefit from medical treatment. He instead described his methods for treating spinal fractures that were not immediately accompanied by paralysis, and employed non-operative methods to do so. To counteract a developing kyphotic deformity that could result from a spinal fracture, Hippocrates would employ a specially designed bed that would provide patients with spinal immobilization and traction to force kyphotic fractures back into normal positions, which became a foundational concept in management of spinal injury for subsequent centuries and to this day.
Interestingly, while Hippocrates thought those spinal fractures that were accompanied by paralysis were hopeless using the tools and methods of his day, he did speculate that therapy might be initiated by laying open the anterior side of the vertebrae to decompress the contents of the spinal canal—this was a thought that foresaw the potential to treat fractures by surgical methods. It was not until the seventh century AD, that the first operative repairs of injured spinal columns were carried out by Paulus of Aegina. Paulus of Aegina proposed that spinal fractures with accompanying paralysis could be handled by surgical removal of bony fragments that were causing irritation and leading to paralysis. It is documented that he himself attempted to perform the intervention to pull out loose bony fragments, but it is unclear what success he had.
It was then only in the early 1800’s where the thought of cutting into spinal vertebrae themselves was moving beyond a surgical dream and becoming a real surgical possibility. The British surgeon Henry Cline carried out the first much publicized trepanation of the spine, by laminectomy, in 1814. However, the patient died three days after surgery. Admittedly, surgical fatalities in this period were unfortunately too common, due as much to septic complications and anesthetic inadequacies, as they were to the still nascent surgical techniques.
Nevertheless, the first successful laminectomy was carried out by the American surgeon Alban Smith in Kentucky in 1828, on a patient who had fallen from a horse and sustained traumatic paraplegia. The patient not only survived the operation but achieved a partial neurological recovery.
Starting in the 1840’s on, surgeries were becoming systematically performed in aseptic conditions and with the patients in a state of general anesthesia, which began the successful era of spine surgery, whose success had previously been plagued by surgery-related infection or limited by patient pain sensitivity during surgery. Subsequently, with these developments, in the latter part of the 19th century, indications for laminectomy were extending from trauma to also tumor and infection. The first intraspinal tumor was resected through laminectomy by Victor Horsely in 1887; the patient who had had neurologic symptoms involving progressive dull back pain, urinary retention, paraplegia, and loss of sensation below the thoracic level, had a near full neurologic recovery at follow-up 1 year after surgery, walking without assistance and had returned to his premorbid work schedule, and eventually dying 20 years later from an unrelated cause. This success led to widening range of applications of laminectomy, such as in cases of tumor, trauma, infection, and congenital spine disease, which were first exhaustively reviewed and codified in 1916 in the textbook by Charles Elsberg, Diagnosis and Treatment of Surgical Diseases of the Spinal Cord and its Membranes.
As the laminectomy continued to become mastered, many more approaches to operating on the spine, advancements in instrumentation to restabilize the spine after surgical manipulations, and advancements to radiologic imaging for diagnosis and operative planning, have led to an accelerated advancement of indications for spinal surgery and optimizing its methods, such that the most common indication in the late 20th century, degenerative spine disease, was not even mentioned in Elsberg’s original classic text. Today, most of the spinal column has been mastered as far as operative technique itself is concerned; what remains as the most difficult questions are the decisions when an operation is indicated to the maximal benefit of the patient in order to avoid unnecessary surgeries.
-- Guest blogger Yosef Chodakiewitz, M.D. Candidate, Class of 2015
The Warren Alpert Medical School of Brown University
