Clinical and Health Affairs
Development and Growth of Anterior Spine Surgery in Minnesota
By Robert B. Winter, M.D., and Joseph J. Garamella, M.D.
ABSTRACT
Until the 1960s, it was not possible to directly access the thoracic vertebrae in order to correct conditions such as congenital kyphosis. Attempts to treat problems using traditional posterior spine surgeries often failed, leaving patients paraplegic. Using a procedure initially done in Hong Kong, surgeons from the University of Minnesota in 1966 became some of the first in the United States to access the thoracic spine from the anterior position, allowing for correction of deformities. This article highlights Minnesota surgeons’ contributions to the development of anterior spine surgery.
Today, anterior spine surgery is frequently performed for both complex and commonplace spinal disorders. It can be performed as a stand-alone procedure, but more often it is done in conjunction with a posterior spine procedure. Experience with thousands of cases all over the world has proved this to be a safe and relatively easy-to-perform procedure.
This was not always the case. Although exposure of the front of the lumbar spine through an extraperitoneal or “sympathectomy” approach had been done since the early part of the 20th century, access to the thoracic vertebrae anteriorly was not possible until advances were made in thoracotomy surgery. As a result, pathologies in the front of the thoracic vertebrae could not be accessed directly. Attempts to treat such problems using traditional posterior spine operations failed dismally, and patients often became paraplegic as a result.
A Radical Approach
In 1966, Robert Winter, M.D., one of the authors of this article, completed a study of 250 patients with congenital spine deformities under the guidance of John H. Moe, M.D., professor of orthopaedic surgery at the University of Minnesota, and reported the results to the American Orthopaedic Association at its national meeting in Hot Springs, Virginia. Although posterior spine fusion had proved highly successful for the treatment of congenital scoliosis, patients with congenital kyphosis consistently failed such treatment. The Minnesota researchers concluded that there appeared to be no good way to treat patients with kyphosis.
Following the presentation, Arthur Hodgson, M.D., a surgeon from the University of Hong Kong, described to Winter and Moe cases he had done using anterior transthoracic spine fusion with structural bone grafting. Hodgson was the pioneer of anterior transthoracic spine fusion, having developed it in Hong Kong in the 1950s to treat the hundreds of patients they were seeing with severe tuberculosis of the spine.1 Convinced that Hodgson’s approach would work, Moe and Winter agreed to try this surgery at the University of Minnesota.
A Brief History of Anterior Spine Surgery
The history of spine surgery dates back several hundred years to a time when courageous surgeons did laminectomies following trauma. Without the benefit of either antisepsis or anesthesia, their efforts seldom were of any benefit. It was not until the development of anesthesia in 1846 and antisepsis in 1867 that surgery of any kind truly became possible.
In the late 19th century, tuberculosis of the spine was a major problem that, when severe, often led to paraplegia. Efforts to deal with the paraplegia by laminectomy often failed because the pathology lay in the vertebral bodies anterior to the spinal cord and were inaccessible. In 1892, Vincent of Paris, described for the first time the evacuation of a tuberculous abscess using costotransversectomy, an approach to the vertebral bodies that involved removing segments of the ribs and transverse processes.1 In 1895, another French surgeon, Victor Menard, confirmed the benefits of Vincent’s approach. 2 These two were the true pioneers of anterior spine surgery.
In 1906, Muller of Germany described anterior debridement of tuberculosis of the lumbar spine by a transperitoneal approach.3 This was the first attempted anterior approach to the lumbar spine of which we are aware. Although Muller’s first patient did well, subsequent patients failed badly, and he abandoned the procedure. In 1921, Royle of Australia performed the first ever removal of a congenital hemivertebra in the lumbar spine using a retroperitoneal approach.4 In 1922, MacLennon of Glasgow described an anterior retroperitoneal approach for scoliosis treatment in children.5
During the 1930s, Chaklin of Russia wrote about an anterior retroperitoneal osteotomy of the lumbar spine,6 Burns of England described a transperitoneal approach for bone-grafting a lumbosacral spondylolisthesis,7 and Ito et al. of Japan discussed an anterior costotransversectomy approach to the thoracic spine and retroperitoneal approach to the lumbar spine that included thorough debridement of the tuberculous material as well as structural bone-grafting.8
In 1944, Iwahara of Japan became the first to describe the treatment of lumbar degenerative disease by an interbody fusion done using a retroperitoneal approach.9 This was followed by Lane and Moore, who used a transperitoneal approach to the lumbar discs.10
In 1956, Hodgson and Stock of Hong Kong described their extensive experience with anterior spine surgery for the treatment of tuberculosis.11 With the availability of antibiotics plus the surgery, they were able to successfully eradicate the disease in hundreds of patients. They also were the first to perform anterior thoracic spine surgery through an open thoracotomy. Once he became more comfortable with this approach, Hodgson began using it for treating nontuberculous pathologies in the thoracic vertebrae.
R E F E R E N C E S
1. Vincent E. Contribution a la chirurgie rachidienne du drainage vertebral dans le mal de Pott. Revue de Chirurgie. 1892;12:273-94.
2. Menard V. Traitement de la paraplegie du mal de Pott par le drainage lateral. Revue de Orthopaedie. 1895;6:134-8.
3. Muller W. Transperitoneale freilegung der wirbelsaule bei tuberkuloser spondylitis. Deutsche Zeitschrift für Chirurgie. 1906;85:128-35.
4. Royle ND. Operative removal of an accessory vertebra. Med J Australia. 1928;1:467-78.
5. MacLennon A. Scoliosis. Brit Med J. 1922;2:864-6.
6. Chaklin V. Anterior fusion of the lumbar spine. Paper presented at: Proceedings of the Scientific Research Institutes of Sverdlosk, 1933.
7. Burns BH. An operation for spondylolisthesis. Lancet. 1933;1:1233-5.
8. Ito H, Tsuchiya J, Asami G. A new radical operation for Potts disease: report of 10 cases. J Bone Joint Surg. 1934;16:499-515.
9. Iwahara T. A new method of vertebral body fusion, anterior retroperitoneal surgery. Surgery (Japan). 1944;8:271-9.
10. Lane JD, Moore ES. Transperitoneal approach to the intervertebral disc in the lumbar area. Ann Surg. 1948;127:537-44.
11. Hodgson AR, Stock FE. Anterior spine fusion. Brit J Surg. 1956;44:256-67.
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Early Cases
The first patient to undergo anterior spine surgery was an adult female with thoracolumbar kyphosis caused by achondroplasia. Her deformity was increasing and had produced pressure on the spinal cord to the point where she could no longer walk. Since the pressure on the spinal cord was on the front, a traditional laminectomy would have been useless. An anterior decompression via a costotransversectomy could have relieved pressure on the spinal cord, but could not have addressed the progressive kyphosis, which required an anterior bone-grafting procedure.
The procedure took place in June 1966 and was performed by a team that included general surgeon Arnold Leonard, M.D., neurosurgeon Shelley Chou, M.D., and Moe. The patient survived and her neurological situation improved significantly. Encouraged by this initial success, we eagerly awaited more patients who qualified for this new surgery.
In November 1966, we did our second case—a child with a progressive congenital kyphosis of 151 degrees and paraparesis. The outcome was not nearly as positive. The patient survived the surgery but died two weeks later because of an underlying severe pulmonary deficit caused by her deformity.
Surgeons at the university were not the only ones in Minnesota attempting anterior spine surgery during the 1960s. William Bickel, M.D., of the Mayo Clinic, had heard about our initial patient and was familiar with Hodgson’s work. Bickel performed multiple anterior osteotomies in the thoracic spine in a patient with a congenital kyphosis. This was followed two weeks later by a posterior fusion with instrumentation. Unfortunately, the implants failed and the correction was lost.2
In 1967, University of Minnesota general surgeons Arnold Leonard, M.D., Henry Sosin, M.D., and Ted Grage, M.D., assisted Moe and Chou in four more cases—three with congenital kyphosis and one with a giant cell tumor in a vertebral body with spinal cord compression. About the same time, Michael Goldner, M.D., of Mt. Sinai Hospital in Minneapolis was doing anterior disc excision and bone grafting in the lumbar spine. This operation had been developed long before Hodgson pioneered transthoracic surgery.
In 1968, four more anterior transthoracic spine surgeries were done at the University of Minnesota on three patients with congenital kyphosis (one with spinal cord compression) and one with a burst fracture of T12 with paraparesis. At this point, the surgeons and nursing staff had become comfortable with the procedure, and the aftercare was becoming more routine.
Gaining Acceptance
By 1969, we were off and running doing more and more of these anterior transthoracic procedures for patients with kyphotic problems or those needing anterior spinal cord decompression and fusion. The first such procedure done outside the university took place at St. Mary’s/Fairview Hospitals in Minneapolis in April 1969, with Joseph Garamella, M.D., as the thoracic surgeon. We also worked closely with his partner, thoracic surgeon Aydin Bilgutay, M.D. Our first case in St. Paul was at Gillette Children’s Hospital in 1971, with Lyle Tongen, M.D., as general surgeon.
With the 1978 publication of Moe’s Textbook of Scoliosis and Other Spine Deformities (W.B. Saunders) and scientific publications in a number of medical journals, Minnesota spine surgeons became known for their ability to manage patients with complex spine deformities. In 1995, one of our spine fellows published a paper on the surgical and medical complications in 1,223 adult patients;3 one of our residents published a second paper on the same subject in 599 children.4
Currently, all vertebrae from the skull to the sacrum can be safely approached anteriorly, posteriorly, or from both directions. For patients with severe scoliosis or kyphosis, the spine is first approached anteriorly by the thoracic surgeon. Then the orthopaedic spine surgeon does the disc removal and bone grafting. The thoracic surgeon closes the chest. If the patient’s general condition is satisfactory, he or she is turned over into the prone position and the posterior fusion and instrumentation are done by the orthopaedic spine surgeon.
Today, the anterior/posterior spine procedures are commonly done for problems that cause low back pain such as degenerative disc disease and spondylolisthesis. The combined procedure produces fusion success rates of 96% to 98%. With the evolution of technology, many of these anterior lumbar interbody fusions are being done from behind through the same incision as the posterior fusion.
Conclusion
Anterior spine fusion is now commonly used around the world. Spine surgeons have learned when it is indicated and when it is not. They know what complications to anticipate and how to manage them if they occur. Spine surgeons continue to work closely with cardiovascular/thoracic surgeons to achieve the best outcomes. Minnesota surgeons played a significant role in developing the tools, techniques, and knowledge base for successfully performing this surgery. We are proud to have been on the forefront of this exciting advance in spine surgery technology. MM
Robert Winter is clinical research director at Twin Cities Spine Center. Joseph Garamella is emeritus professor of surgery at the University of Minnesota.
References
1. Hodgson AR, Stock FE. Anterior spine fusion. Brit J Surg. 1956;44:256-67.
2. Bickel W. Personal communication.
3. Faciszewski T, Winter RB, Lonstein JE, Denis F, Johnson L. The surgical and medical perioperative complications of anterior spinal fusion surgery in the thoracic and lumbar spine in adults. A review of 1223 procedures. Spine. 1995;20(14):1592-9.
4. Grossfeld S, Winter RB, Lonstein JE, Denis F, Leonard A, Johnson L. Complications of anterior spine surgery in children. J Pediat Orthop. 1997;17(1): 89-95.