Challenges in early operative approaches to intramedullary spinal cord tumors: Harvey Cushing's perspective.

Although Harvey Cushing was mostly known for his contributions to brain tumor surgery, he was also a pioneer in the development of spinal cord surgery. This lesser known facet of Cushing's career can provide a fresh and unique perspective into how the founders of neurosurgery surmounted early challenges in the field. The authors bring to light and examine for the first time Cushing's unpublished writing "Technique of Laminectomy" along with his first 3 documented intramedullary spinal cord tumor (IMSCT) cases at the Johns Hopkins Hospital. The authors draw lessons from the challenges in pathological classification, preoperative diagnosis, tumor localization, and surgical technique of that time. Although Cushing's attempts at exploration and resection of IMSCT as described here were of limited success, his ability to adapt his clinical and surgical technique to the challenges of the time, as well as develop skills to successfully manipulate the spinal cord during these exploratory procedures without the patients incurring neurological damage, postoperative infection, or complications, is a testament to his determination to advance the field and his meticulous operative technique. In spite of the limitations imposed on the pioneer neurosurgeons, Harvey Cushing and his contemporaries persevered through many of the challenges and built an essential part of neurosurgery's common story.

"No performance in surgery more interesting and satisfactory": Harvey Cushing and his experience with spinal cord tumors at the Johns Hopkins Hospital.

Although Harvey Cushing was a neurosurgical pioneer, his work on the spine remains largely unknown. In fact, other than his own publications, Cushing's patients with pathological lesions of the spine who were treated while he was at the Johns Hopkins Hospital, including those with spinal cord tumors, have never been previously described. The authors report on 7 patients with spinal cord tumors that Cushing treated surgically between 1898 and 1911: 2 extradural, 3 intradural extramedullary, and 2 intramedullary tumors. The authors also describe 10 patients in whom Cushing performed an "exploratory laminectomy" expecting to find a tumor, but in whom no oncological pathological entity was found. Cushing's spine surgeries were limited by challenges in making the correct diagnosis, lack of surgical precedent, and difficulty in achieving adequate intraoperative hemostasis. Other than briefly mentioning 2 of the 4 adult patients in his landmark monograph on meningiomas, these cases-both those involving tumors and those in which he performed exploratory laminectomies--have never been published before. Moreover, these cases illustrate the evolution that Harvey Cushing underwent as a spine surgeon.

Cervical spine surgery: an historical perspective.

BACKGROUND: Continued innovation in surgery requires a knowledge and understanding of historical advances with a recognition of successes and failures. QUESTIONS/PURPOSES: To identify these successes and failures, we selectively reviewed historical literature on cervical spine surgery with respect to the development of (1) surgical approaches, (2) management of degenerative disc disease, and (3) methods to treat segmental instability. METHODS: We performed a nonsystematic review using the keywords "cervical spine surgery" and "history" and "instrumentation" and "fusion" in combination with "anterior approach" and "posterior approach," with no limit regarding the year of publication. Used databases were PubMed and Google Scholar. In addition, the search was extended by screening the reference list of all articles. RESULTS: Innovative surgical approaches allowed direct access to symptomatic areas of the cervical spine. Over the years, we observed a trend from posterior to anterior surgical techniques. Management of the degenerative spine has evolved from decompressive surgery alone to the direct removal of the cause of neural impingement. Internal fixation of actual or potential spinal instability and the associated instrumentation have continuously evolved to allow more reliable fusion. More recently, surgeons have developed the basis for nonfusion surgical techniques and implants. CONCLUSIONS: The most important advances appear to be (1) recognition of the need to directly address the causes of symptoms, (2) proper decompression of neural structures, and (3) more reliable fusion of unstable symptomatic segments.

Sir Victor Horsley's 19th century operations at the National Hospital for Neurology and Neurosurgery, Queen Square.

Although he was not the first man to operate on the brain, Sir Victor Horsley was the world's first surgeon appointed to a hospital post to perform brain surgery, which happened in 1886 at the National Hospital for Neurology and Neurosurgery, Queen Square, London. The authors examined the patient records between 1886 and 1899 and found 151 operations performed by Sir Victor Horsley at the National Hospital, including craniotomies, laminectomies, and nerve divisions. The authors present the outcome data and case illustrations of cerebral tumor resections and laminectomies from the nineteenth century. Outcomes and notable pioneering achievements are highlighted.

Biographical sketch: George L. Walton, MD and Walter E. Paul, MD.

This biographical sketch on George L. Walton and Walter E. Paul corresponds to the historic text, The Classic: Contribution to the Study of Spinal Surgery: One Successful and One Unsuccessful Operation for Removal of Tumor (1905), available at DOI 10.1007/s11999-010-1664-2 .

Minimally invasive spine technology and minimally invasive spine surgery: a historical review.

The trend of using smaller operative corridors is seen in various surgical specialties. Neurosurgery has also recently embraced minimal access spine technique, and it has rapidly evolved over the past 2 decades. There has been a progression from needle access, small incisions with adaptation of the microscope, and automated percutaneous procedures to endoscopically and laparoscopically assisted procedures. More recently, new muscle-sparing technology has come into use with tubular access. This has now been adapted to the percutaneous placement of spinal instrumentation, including intervertebral spacers, rods, pedicle screws, facet screws, nucleus replacement devices, and artificial discs. New technologies involving hybrid procedures for the treatment of complex spine trauma are now on the horizon. Surgical corridors have been developed utilizing the interspinous space for X-STOP placement to treat lumbar stenosis in a minimally invasive fashion. The direct lateral retroperitoneal corridor has allowed for minimally invasive access to the anterior spine. In this report the authors present a chronological, historical perspective of minimal access spine technique and minimally invasive technologies in the lumbar, thoracic, and cervical spine from 1967 through 2009. Due to a low rate of complications, minimal soft tissue trauma, and reduced blood loss, more spine procedures are being performed in this manner. Spine surgery now entails shorter hospital stays and often is carried out on an outpatient basis. With education, training, and further research, more of our traditional open surgical management will be augmented or replaced by these technologies and approaches in the future.

History of thoracolumbar decompression and stabilization.

This article organizes the history of thoracolumbar spine surgery around its two major purposes: spinal decompression and spinal stabilization. Only select turning points of this history are addressed. Emphasis is given to important surgical obstacles and perioperative and anesthetic problems, as they have influenced the development of thoracolumbar spine surgery.

[Surgery of lumbar disk hernia: historical perspective]. / Chirurgia dell'ernia discale lombare: evoluzione storica.

Although the clinical picture of discogenic sciatica is well known already in the ancient world, it is not until 1933 that WJ Mixter and JS Barr provide the correct pathogenetic interpretation and suggest surgery as the treatment of choice. The work of the American Authors was however based on the knowledge acquired during the previous centuries starting with Domenico Cotugno, who first suggested the neurogenic nature of sciatica (1764) and later with the neurologists of the french school Valleix, Lasègue, Dejerine, Sicard who elucidated the semeiology and debated in detail the etiopathogenesis of the condition. The german pathologists Schmorl and Andrae (1927-29) are to be credited for their contribution to the pathology of intervertebral disc, recognizing the frequency and degenerative (not neoplastic) nature of nucleus pulposus herniation. Surgery of disc herniation starts with Oppenheim and Krause (1909). Mixter and Barr used laminectomy and a transdural route although a more limited approach to the spinal canal had already been proposed by the italian Bonomo (1902), unknown to many. Love, of the Mayo Clinic (1937-39) introduced the extradural/interlaminar approach while Caspar and Yasargil (1977) applied the concepts of microsurgery to the procedure. The latest advances are represented by percutaneous and endoscopic techniques.

The prone position for the surgical patient: a historical review of the principles and hazards.

Since the 1940s there has been an increase in the number of patients submitted for surgery of the spinal axis necessitating use of the prone position. Specifically designed operating tables were both rare and expensive, and probably only existed in a few highly specialized centres. Apparatus which could be easily made locally and used in conjunction with normal operating tables has been invented and generally used to good effect. The important historical landmarks in these developments are traced and a review of the methods and hazards is presented. Similar methods evolved almost simultaneously in differing centres. It is recommended that the Tarlov "seated prone" position should be widely used, in view of its physiological advantages and lack of adverse reports.

Spondylolisthesis: treatment by laminectomy and posterior interbody fusion.

Spondylolisthesis is a hereditary anomaly of the spine, often associated with intractable pain in the back and lower extremities. The diagnosis is commonplace. Approximately 5% to 7% of the population in the United States has the anomaly. This percentage varies with country and race. In patients who seek medical aid for symptoms of low back pain, 10% will have a pars defect. Laminectomy of the entire separate neural arch and a posterior interbody fusion is a superior operation for spondylolisthesis. It is a difficult operation, requiring a high degree of technical skill, but when properly performed, it is possible to attain a more rapid recovery with a lower morbidity and higher percentage of permanent cures.