1 History of Multidisciplinary Spine Surgery: Spinoplastics

Matthew J. Parham, Christopher Conlon, Caroline Bay, Edward M. Reece

1.1 Evolution of Spinal Surgery as a Multidisciplinary Endeavor

Spinal surgery encompasses a rich history of innovation and multidisciplinary collaboration. Spinal surgery has from the outset existed in the watershed between specialties as both orthopaedic surgery and neurosurgery have overlapping claims, and, before the days of subspecialization, the obligate general surgeons pioneered the field. Of note, the first posterior cervical laminectomy in the United States, a procedure previously considered to be uniformly fatal, was performed by a general surgeon, Alban Smith, in 1829. ▶ [1] This was a landmark achievement in spine surgery as the previous successful laminectomy was 1500 years prior, long before the specialization of surgeons.

Paul of Aegina, the first surgeon known to operate on the spine with success, is a remarkable historical figure—the sort of character about whom very little is known yet stands as a giant. He was a disciple of the Hippocratic tradition of medicine and his age of prominence is determined by those he quoted and those who quoted him. He authored the titleless text now known as Medical Compendium in Seven Books in the 600 s, with the sixth book devoted specifically to surgery. ▶ [2] In his opus magnum, he elaborates on all significant surgical knowledge of the time, including the innovative procedure of a laminectomy that would again elude western medicine until Alban Smith. ▶ [3] As previous attempts at spinal surgery were characterized by Hippocrates as disastrous, Paul of Aegina may be considered the father of spine surgery for this contribution.

Returning to the modern era of Alban Smith, prominent surgeons of the day continued to dabble in spine surgery. As antiseptic techniques improved, so did surgical outcomes, and the reluctance to operate on the spine gradually lessened. Sir William Macewen, a surgeon for the Royal Infirmary in Glasgow, reported several of the earliest cases of successful laminectomies, including five for granulomatous disease and one for traumatic paraplegia. ▶ [4] Though a general surgeon by training, his address in 1888 on “The surgery of the brain and spinal cord” set the stage for future neurosurgical advancement. ▶ [5] Building on Macewen’s work, Sir Victor Horsley registered the first oncologic laminectomy in London in 1887. A giant in his day and a testament to the variety in his practice, he is also credited with hemostatic bone wax and exogenous thyroid hormone supplementation. ▶ [6]

Harvey Cushing, while not renowned for his work in advancing spinal surgery relative to his overall contributions to the field, is nonetheless widely considered to be the first neurosurgeon—reasonably surmised to be minted in 1901 when he was charged with surgery of the central nervous system at Johns Hopkins—attributing Macewen and Horsley’s work as foundational to the establishment of neurosurgery as a distinct entity. In 1909, Fedor Krause, a German neurosurgeon, performed the first lumbar diskectomy. The laminae were removed in one piece, the lesion was resected transdurally, and the patient reported immediate, complete relief from pain. ▶ [7] That same year, Alfred Taylor carried out the first unilateral laminectomy. ▶ [8] These momentous achievements, in conjunction with the invention of X-ray by Wilhelm Conrad Röntgen in 1895 that allowed improved visualization of musculoskeletal structures, making diagnosis and management of spinal anomalies less daunting, set the stage for what would eventually become the modern era of spinal surgery. ▶ [9]

At the end of the 19th century, medicine continued to evolve toward specialization. As surgical specialties crystallized, orthopaedic surgeons carried the banner of progress in spine surgery. Orthopaedic surgery, the origins of which predate neurosurgery and long focused on fixing deformities (ortho coming from Greek for “straight”), began its foray into spinal procedures. ▶ [9] Interest and expertise in spinal surgery within both neurosurgery and orthopaedic surgery surged in the wake of World War II as lessons learned from treating wartime injuries were applied to civilian populations. This critical shift in the surgical treatment of spine deformities was heralded in the 1950s by Paul Harrington, an orthopaedic surgeon who introduced the Harrington instrumentation system, the first implantable system of rods for stability and deformational correction. ▶ [10] Two other orthopaedic surgeons, Fred Albee and Russell Hibbs, introduced bone grafting from the tibia and iliac crest, respectively, to facilitate fusion of vertebrae as a treatment for Potts’ disease, solidifying orthopaedic surgeons’ claim on the field of spinal surgery. ▶ [10] , ▶ [11]

Around the same time, an initially reticent community of neurosurgeons began to embrace the osseous spine in their scope of practice. In 1934, William Mixter and Joseph Barr published their famed paper on surgical correction of intervertebral disk lesions, now known as a diskectomy, fundamentally changing the management of sciatica and ushering in the period known as the “dynasty of the disk.” ▶ [12] , ▶ [13] Another central figure that increased the involvement of neurosurgeons in spinal surgery was Ralph Cloward. ▶ [14] Over the course of 30 years, his pioneering innovation in anterior cervical and posterior lumbar fusion techniques, once again, ushered in a new era for spinal surgery. ▶ [12] In addition, he designed over 100 surgical instruments, many of which are still used in neurosurgery.

Advances in technology, such as the magnetic resonance imaging (MRI) and surgical techniques allowing for minimally invasive surgeries, continued to advance the field of spinal surgery into previously uncharted surgical territory. These newer and more complicated procedures often required additional support from other surgical specialties. Namely, spine surgery was the exclusive domain of orthopaedic and neurosurgery specialists until the anterior approach required the expertise of the general surgeon. Later, the complication rates due to bony failure or soft tissue dehiscence would plateau and spine surgery found its next breakthrough in the grafts and flaps of the plastic surgeon.

Plastic surgery involvement in spinal surgery began with managing wound complications. Studies by Rohrich and Mathes in the 1980s outlined numerous techniques for management and coverage of complex spinal wounds secondary to complications using locoregional muscular flaps. ▶ [15] , ▶ [16] , ▶ [17] Applications of these methods soon became a mainstay in the management of complex spinal wounds. More recently, the value of plastic surgery closure in primary spinal surgery has become apparent with published data suggesting a 63% reduction in 30-day readmission rate. ▶ [18] This integration of plastic surgery, in conjunction with the introduction of vascularized bone grafts into spinal surgery, promises exciting new developments for this field.

1.2 Introduction to the Modern Era of Spinal Surgery

In the modern era, spinal surgery encompasses a vast array of surgical procedures to relieve the pain and physical limitations caused by injury and deformation of the cervical, lumbar, and thoracic spine. The procedures range from the more traditional reconstructive methods such as spinal fusion and laminectomies to a host of complex and minimally invasive spine surgery techniques.

As the population ages and the global burden of spinal pathologies continues to grow, numerous advances in technology, training, and surgical techniques have resulted in an era of unprecedented growth for spinal surgery. With an expected volume of 7.6 million procedures in 2022, spinal surgery is one of the fastest growing surgical...