History of Spine Surgery

HJ Cline, Jr. and the Argument Against Spine Surgery

At the beginning of the 19th century, the prospects for spine surgery appeared grim. The dismal results of a well-publicized operation for a traumatic spinal injury stimulated a heated debate over the “possibility” of spine surgery that persisted for nearly a century. At the center of this debate was HJ Cline, Jr., a little-known British surgeon.

In 1814, Cline performed a multilevel laminectomy for a thoracic fracture-dislocation associated with signs of a complete paraplegia ( Fig. 1.2 ). The patient was a 26-year-old man who fell from the top of a house. “He was bled previous to his admission” to St. Thomas’s Hospital in London, “and some imprudent attempts were made to relieve him by pressing the knees against the injured part, which only increased the pain and inflammation.” Upon admission to the hospital the patient was examined by Cline, who “ascertained that some of the spinous processes . . . were broken off and were pressing upon the spinal marrow . . . [and] who resolved to cut down and remove the pressure from the spinal marrow.”

The patient was observed overnight in the hospital, and on the day following admission, Cline performed his proposed operation. Although the operation was performed within 24 hours of injury, Cline was unable to reduce the dislocation or to achieve a complete decompression of the neural elements. The patient survived for 3 days after surgery, with increasing pain and a steadily increasing pulse. Following the patient’s death “on an examination of the body by Mr. Cline, it was found that the spinal marrow was entirely divided.” Despite the severity of the neural injury and the complexity of the fracture-dislocation, the untoward outcome of this unfortunate case would remain a topic of conversation for almost a century, providing ample ammunition for the opponents of spine surgery.

Cline’s case was not an isolated mortality. In 1827, for example, Tyrell reported 100% mortality for a small series of patients with surgically treated spinal dislocation and neurological injury. Other reports (e.g., Rogers in 1835) were often equally discouraging. Looking back on these early years of the debate about spine surgery, the early 20th century British surgeon Donald Armour described the controversy this way:

This [Cline’s operation] precipitated and gave rise to widespread and vehement discussion as to its justification. This discussion, often degenerating into bitter and virulent personalities, went on many years. Astley Cooper, Benjamin Bell, Tyrell, South, and others favored it, while Charles Bell, John Bell, Benjamin Brodie, and others opposed it. The effect of so eminent a neurologist as Sir Charles Bell against the procedure retarded spinal surgery many years—the operation was described with such extravagant terms as “formidable,” “well-nigh impossible,” “appalling,” “desparate [sic] and blind,” “unjustifiable,” and “bloody and dangerous.”

Of course, surgical fatalities in this period were caused as much by septic complications and anesthetic inadequacies as they were to surgical technique. The lack of an effective means of pain control during surgery intensified the problem of intraoperative shock and made speed essential. Furthermore, the problems of wound infection and septicemia were both predictable and frequently fatal. These hindrances to surgery were not ameliorated until the introduction of general anesthetic agents (i.e., nitrous oxide, ether, and chloroform) in the mid-1840s and the adoption of Listerian techniques (using carbolic acid) in the 1870s.

AG Smith and the First Successful Laminectomy

Despite these risks, a little-known surgeon named Alban G Smith from Danville, Kentucky performed a laminectomy in 1828 on a patient who had fallen from a horse and sustained a traumatic paraplegia. To Smith’s credit, his patient not only survived the operation but achieved a partial neurological recovery. The operative technique and surgical results were reported in the North American Journal of Medicine and Surgery in 1829 ( Fig. 1.3 ). Smith’s procedure comprised a multilevel laminectomy through a midline incision, involving removal of the depressed laminae and spinous processes, exploration of the dura mater, and closure of the soft tissue incision. Although the report of this landmark case appears to have attracted little attention at the time, it is a significant technical achievement and places Smith among the pioneers of the early modern period in spine surgery.

Laminectomy for Extramedullary Spinal Tumors

During the half century after Smith’s historic operation, the primary indication for laminectomy was spinal trauma. In the latter part of the 19th century, the indications for laminectomy were extended to tumor and infection. The first and most celebrated surgical case for spinal tumor in the 19th century, that of Captain Gilbey, was also the first successful one, and it played an important role in the rehabilitation of the laminectomy as a safe and effective procedure.

Captain Gilbey was an English army officer who suffered the misfortune of losing his wife in a carriage accident in which he also was involved. Although Gilbey himself escaped serious injury, he soon began to experience progressive dull back pain, which he attributed to the accident. As the pain became relentless, Gilbey sought the advice of a series of physicians, all of whom were unable to identify the source of his pain. Eventually, Gilbey was referred to the eminent London neurologist William Gowers, who elicited from the patient a history of back pain, urinary retention, paraplegia, and loss of sensation below the thoracic level ( Fig. 1.4 ).

The neurologist’s diagnosis was immediate and unequivocal: the cause of Gilbey’s symptoms was located in his spine, where a tumor was causing compression of the thoracic spinal cord. Although no intraspinal tumor had ever been resected successfully, Gowers referred the patient to his London surgical colleague, Victor Horsley ( Fig. 1.5 ). After all, Gowers had himself asserted, in his authoritative textbook, Manual of Diseases of the Nervous System , that removal of an intradural spinal cord tumor was “not only practicable, but actually a less formidable operation than the removal of intracranial tumors.”

Horsley acted quickly. Within 2 hours of the initial consultation, a skin incision was made at 1 pm , June 9, 1887, at the National Hospital, Queens Square, London. Despite his precipitous decision to undertake this dangerous operation, Horsley did not approach the operation unprepared. Although the Act of 1876 made it a criminal offense to experiment on a vertebrate animal for the purpose of attaining manual skill, Horsley had repeatedly practiced the proposed procedure in the course of his surgical experimentation. Despite some initial difficulty in locating the tumor, an intradural neoplasm in the upper thoracic spine causing compression of the spinal cord was identified and safely resected. The pathological diagnosis was “fibromyxoma of the theca.”

Follow-up 1 year later revealed almost complete neurological recovery. The patient was walking without assistance and had returned to his premorbid work schedule. He remained well, with no evidence of tumor recurrence, up to the time of his death from an unrelated cause 20 years later.

Laminectomy for Intramedullary Spinal Tumor

In 1890, Fenger attempted to remove an intramedullary spinal tumor in an operation that resulted in the patient’s death. In 1905, Cushing ^, also attempted to remove an intramedullary spinal cord tumor but decided to abort the procedure after performing a myelotomy in the dorsal column. To Cushing’s surprise, the patient improved after surgery. In 1907, von Eiselsberg successfully resected an intramedullary tumor.

The unexpected improvement that was observed in the patient reported by Cushing attracted the attention of New York surgeon Charles Elsberg. Elsberg described Cushing’s technique, which he aptly named the “method of extrusion.” The technique was intended to remove an intramedullary tumor by spontaneous extrusion of the tumor through a myelotomy made in the dorsal column. The rationale for this method was predicated on the theory that an intramedullary tumor was associated with an increase in intramedullary pressure. Release of this pressure by a myelotomy that extended from the surface of the spinal cord to the substance of the tumor was expected to provide sufficient force to spontaneously extrude the tumor. According to Elsberg, the advantage of this procedure over a standard tumor resection was that it required minimal manipulation of the spinal cord and therefore minimal spinal cord tissue injury.

Because the spontaneous extrusion of an intramedullary tumor occurred slowly, Elsberg performed these procedures in two stages. In the first stage, a myelotomy was fashioned in the dorsal column, extending from the surface of the spinal cord to the tumor ( Fig. 1.6A ).

When the tumor was identified and observed to begin to bulge through the myelotomy incision, the operation was concluded, the dura mater was left opened, and the wound closed. In the second stage of the procedure, which was performed approximately 1 week after the first stage, Elsberg reopened the wound and inspected the tumor ( Fig. 1.6B ). Typically, the tumor was found outside the spinal cord, and the few adhesions that remained between the spinal cord and the tumor were sharply divided. After the tumor was removed, the wound, including the dura mater, was closed.

Variations in Laminectomy Technique

By the last decade of the 19th century, after the case of Captain Gilbey, the possibility of safely performing a spinal operation was established in the collective surgical consciousness. Furthermore, new anesthetic techniques and aseptic methods had become available to most practicing surgeons. All of these factors increased the appeal of the laminectomy to surgeons and widened its range of application. For example, after Horsley’s widely publicized success for resecting a spinal tumor, many similar operations were soon described in the literature, and in 1896 Makins and Abbott reported 24 cases of laminectomy for vertebral osteomyelitis.

Although the safety and efficacy of the laminectomy had convinced many proponents of the utility of the procedure, toward the end of the century surgeons began to worry about postoperative instability. Advances in operative technique and perioperative management meant that more and more patients survived the operation and ultimately became ambulatory, which further heightened concern about stability.

In 1889, Dawbarn described an osteoplastic method of laminectomy that addressed this concern. Instead of a midline incision, Dawbarn described two lateral incisions that were carried down to the transverse processes. The lateral incisions were connected in an H-like fashion, and superior and inferior flaps—including skin, muscle, fascia, and bone—were then turned. In closing the wound, the intact flaps were reflected back and reapproximated in their normal anatomic positions.

Although not all surgeons subscribed to the osteoplastic method, many turn-of-the-century surgeons were largely preoccupied with modifications of this procedure. At the same time, however, a more important innovation in laminectomy technique, the hemilaminectomy, was developed independently in both Italy ^, and the United States.

In 1910, AS Taylor of New York described the hemilaminectomy: a midline incision, a subperiosteal paravertebral muscle takedown, and the removal of a hemilamina with a Doyen saw. The advantages of the hemilaminectomy over the cumbersome osteoplastic method were obvious, and Taylor argued that, compared with the laminectomy, the hemilaminectomy interfered less with the mechanics of the spine. Despite such detractors as Charles Elsberg, who responded that the field of view was narrow and the effect of laminectomy on spinal mechanics negligible, Taylor successfully championed its use.

Charles A Elsberg: The Laminectomy in Stride

Charles A Elsberg was one of the most influential writers on spinal decompression ( Fig. 1.7 ). Working at the Neurological Institute of New York, which he had helped to found, Elsberg published his first series of laminectomies in 1913. In 1916, he published his classic text, Diagnosis and Treatment of Surgical Diseases of the Spinal Cord and Its Membranes. Although this publication represents a landmark in the history of spine surgery, it constitutes more of a culmination than an innovation in spine surgery. Elsberg’s work on spine surgery, coming as it did at the end of a century of evolution of the decompressive laminectomy, effectively codified 19th and early 20th century developments.

In his textbook, Elsberg outlined the surgical indications and contraindications for laminectomy. He noted the beneficial effects in his own large series of laminectomies and puzzled over the benefits that may occur in the absence of evident increased intradural pressure, such as in patients with multiple sclerosis. He argued that the primary indications for operation were cases of tumor, trauma, and infection that were associated with symptoms localized to a spinal level. Patients with progressive symptoms should be operated on quickly, in the absence of contraindications such as metastatic cancer or advanced Pott disease.

Given the exhaustive scope of these early Elsberg publications—which, in addition to tumor, trauma, and infection, also review the management of congenital spine disease—conspicuously little is said about the most common late 20th-century indication for laminectomy: degenerative spine disease. The tardy development of a treatment for degenerative spine disease should be understood in the larger context of 19th and early 20th century knowledge of spinal pathology.

Unlike degenerative disease, tumor, trauma, and infection were already well known in antiquity. Although the concept of localization of function in the nervous system was undeveloped during the 19th century, the diagnosis and localization of tumor, trauma, and infection, particularly in their late stages, were not especially difficult. Degenerative disease, on the other hand, possessed a more subtle pathophysiology that was not as easily characterized, especially without the help of radiography. Thus, recognition of degenerative spine disease eluded the 19th-century surgeon. This tardy appreciation for the clinical, surgical, and pathological importance of degenerative spine disease deserves further mention.