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AANS Neurosurgeon | Volume 28, Number 3, 2019

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The World of Spinal Surgery

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Editor’s Note: One obvious way to think about the world of neurosurgery is that it is the culmination of all the care delivered across the subspecialties. Just a few decades ago, subspecialization (and the whole world of CAST, enfolded fellowships, post-residency fellowships, etc.) was the exception, limited to just a small number of academics. Today it plays a much larger role across the neurosurgical spectrum. In a series of pieces, AANS Neurosurgeon explores each of the subspecialties in neurosurgery’s orbit. 

The beginnings of spinal neurosurgery can be traced to ancient Egypt, where the great physician Imhotep documented early accounts of spinal injury around 2600-2200 BC.1 About two thousand years later, Hippocrates described treatments for spinal deformity, such as “succession”—suspending a patient upside down from a ladder and then dropping them from a height. While the efficacy of these treatments is unclear, it is apparent that spine-related problems have challenged physicians for millennia. In the past few decades, there has been a renaissance for spinal surgery, owing in equal parts to advances in material sciences, imaging technology and better understanding of spinal biomechanics.

Early Challenges and Progress

Early barriers to surgery included a lack of antiseptic and anesthetic techniques, but these deficiencies were rectified by the late 1800s through Lister’s description of germ theory and Morton’s work with ether as an inhaled anesthetic.2 At around the same time, advancements in radiographic visualization by Roentgen allowed for direct visualization of spinal pathology3. Development of a two-column and later the three-column biomechanical model of the spine by Denis4 allowed for improved treatment algorithms and outcomes.

The earliest successful spinal surgeries included laminectomies and epidural abscess evacuations in the late 1800s.5 For many subsequent decades, spinal fusion was done using the Hibbs technique6, which used decorticated spinous processes and articular surfaces to facilitate bony fusion as well as posterior wiring techniques. Berthold Hadra is credited with the first internal fixation of a C6-C7 fracture-dislocation using silver wiring in 1869.7 Vertebral body screw fixation was introduced in the 1940s8 and improved fusion rates to 50-60%. Fusion rates were further improved with the posterior lumbar interbody fusion (PLIF), first described in 1944 by Briggs and Milligan.9 The Harrington rod10 and the pedicle screw were first used in 1958-1959,11 primarily for correction of scoliotic deformity, but soon were utilized for other pathologies.

At around the same time, anterior approaches to the spine were evolving. In 1958, Cloward12 pioneered the most commonly used ventral approach to the cervical spine – exenteration of the disc space, followed by placement of a bone dowel to promote fusion between the vertebral bodies. Similar advancements were made in posterior cervical spine surgery a few decades later, with Magerl13 and Roy-Camille’s14 descriptions of C1-C2 transarticular screws and lateral mass screws, respectively. The anterior cervical plating system, as popularized by Caspar5 also shifted the paradigm for treatment of cervical spine pathology.

Further Evolution and Advancements

There has been a natural push by both surgeons and patients to develop less invasive techniques for spinal surgery. Beginning in 1931, with direct visualization of the spinal cord via myeloscopy15, improved technologies such as endoscopes and laparoscopes over the subsequent decades advanced the field of minimally invasive spinal surgery. Serially dilating tubular retraction systems allowing access to the spine through narrow corridors have greatly expanded the indications for minimally invasive surgery to include laminectomies, foraminotomies and discectomies.16 Minimally invasive interbody placement and fusions have also become common. More recently, lateral approach techniques have allowed surgeons to place larger interbody grafts and correct spinal imbalance.17 When combined with percutaneous posterior pedicle screw and rod placement, as well as minimally invasive iliac screws, large segment deformity corrections are now possible as well.18 With the increasing popularity of minimally invasive techniques among spinal surgeons, there is no doubt that the field of minimally invasive correction of maximal deformities will continue to rapidly grow.

Robots and the Next Generation

One of the most recent advances in the field of spine surgery has been the introduction of robotic-assistance as an extension of image-guided navigation. The first spine robot, the SpineAssist by Mazor Robotics™, gained FDA approval in 2004. Since then, additional systems have been created; there has been an explosion in robotics-related publications in the literature.19 Current use is generally limited to pedicle screw placement; data suggests increased accuracy and shorter length of hospitalization associated with robotic-assisted screws at the expense of higher operative time and cost.20 As with any new technology, a steep learning curve is to be expected. Advances in software and technique may expand the indications for robotic spine surgery, including tumor, deformity and infection. The world of spine surgery continues to grow. 

Spinal surgery is thousands of years old, reflecting the inherent need to understand the literal backbone of humanity. From archaic techniques to fix cosmetic defects to robotic arms assisting surgeons, the trajectory of spinal surgery has taken many interesting and unexpected turns. Leveraging technological advances and multidisciplinary collaboration is crucial to continuing this trend. Ultimately, this progress will not only improve the lives of the patients, but also help create new generations of efficient and capable spinal surgeons.

References

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1. Sanan, A., & Rengachary, S. S. (1996). The History of Spinal Biomechanics. Neurosurgery39(4), 657–668. doi: 10.1097/00006123-199610000-00001

2. Knoeller, S. M., & Seifried, C. (2000). Historical Perspective. Spine25(21), 2838–2843. doi: 10.1097/00007632-200011010-00020

3. Heary, R. F., & Madhavan, K. (2008). The History Of Spinal Deformity. Neurosurgery63(suppl_3). doi: 10.1227/01.neu.0000324520.95150.4c

4. Denis, F. (1983). The Three Column Spine and Its Significance in the Classification of Acute Thoracolumbar Spinal Injuries. Spine8(8), 817–831. doi: 10.1097/00007632-198311000-00003

5. Walker, C. T., Kakarla, U. K., Chang, S. W., & Sonntag, V. K. H. (2019). History and advances in spinal neurosurgery. Journal of Neurosurgery: Spine31(6), 775–785. doi: 10.3171/2019.9.spine181362

6. Hibbs, R. A. (2007). THE CLASSIC: An Operation for Progressive Spinal Deformities. Clinical Orthopaedics and Related Research460, 17–20. doi: 10.1097/blo.0b013e3180686b30

7. Hadra, B. E. (1975). The Classic Wiring of the Vertebrae as a Means of Immobilization in Fracture and Potts?? Disease. Clinical Orthopaedics and Related Research112(1). doi: 10.1097/00003086-197510000-00002

8. King, D. (1948). Internal Fixation For Lumbosacral Fusion. The Journal of Bone & Joint Surgery30(3), 560-578. doi: 10.2106/00004623-194830030-00003

9. Briggs, H., & Milligan, P. R. (1944) Chip fusion of the low backfollowing exploration of the spinal canal. The Journal of Bone & Joint 26(1):125-130.

10. Harrington, P. R. (1973). 1973 Nicoals Andry Award Contribution: The History and Development of Harrington Instrumentation. Clinical Orthopaedics and Related Research93, 110–112. doi: 10.1097/00003086-197306000-00013

11. Boucher H. H. (1959). A method of spinal fusion. Journal of Bone & Joint Surgery, 41-B(2), 248-259.

12. Cloward, R. B. (1958). The Anterior Approach for Removal of Ruptured Cervical Disks. Journal of Neurosurgery15(6), 602–617. doi: 10.3171/jns.1958.15.6.0602

13. Grob, D. & Magerl, F. (1987). [Surgical stabilization of C1 and C2 fractures]. Der Orthopäde, 16(1), 46-54.

14. Roy-Camille, R., Saillant, G., Judet, T., & Mammoudy, P. (1983). [Recent injuries of the last 5 cervical vertebrae in the adult (with and without neurologic complications)]. Sem Hop, 59(19), 1479-1488.

15. Burman, M. S. (1931). Myeloscopy or the direct visualitization of the spinal canal and its contents. Journal of Bone & Joint Surgery, 13(4):695–696.

16. Christie, S. D., & Song, J. K. (2006). Minimally Invasive Lumbar Discectomy and Foraminotomy. Neurosurgery Clinics of North America17(4), 459–466. doi: 10.1016/j.nec.2006.06.001

17. Deukmedjian, A. R., Ahmadian, A., Bach, K., Zouzias, A., & Uribe, J. S. (2013). Minimally invasive lateral approach for adult degenerative scoliosis: lessons learned. Neurosurgical Focus35(2). doi: 10.3171/2013.5.focus13173

18. Snyder, L. A., Otoole, J., Eichholz, K. M., Perez-Cruet, M. J., & Fessler, R. (2014). The Technological Development of Minimally Invasive Spine Surgery. BioMed Research International2014, 1–9. doi: 10.1155/2014/293582

19. Dsouza, M., Gendreau, J., Feng, A., Kim, L. H., Ho, A. L., & Veeravagu, A. (2019). Robotic-Assisted Spine Surgery: History, Efficacy, Cost, And Future Trends. Robotic Surgery: Research and Reviews, Volume 6, 9–23. doi: 10.2147/rsrr.s190720

20. Ghasem, A., Sharma, A., Greif, D. N., Alam, M., & Maaieh, M. A. (2018). The Arrival of Robotics in Spine Surgery. Spine43(23), 1670–1677. doi: 10.1097/brs.0000000000002695

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