Spinal Reconstruction and Fusion

With the introduction of approaches to the spine and increasing surgical attempts to treat spinal tumors as well as spinal trauma and degenerative disorders, little concern existed for spinal stability among neurosurgeons - not to mention for the side effects of surgery on spinal stability. First attempts to reconstruct the vertebral column were met with great scepticism by many respected neurosurgeons because reconstruction and stabilization meant longer surgery, a risk of insufficient vascularization of the reinserted laminae, and a higher risk of infection at a time without sufficient anesthetic techniques and antibiotics [29, 30, 40, 50].

As early as 1889, Dawbarn performed an H-type opening with lateral transection over the transverse processes and a horizontal transection connecting the two. In this way he could reflect two flaps of soft tissue together with bony elements cranially and cau-dally [11]. Urban and Bickham used U-shaped incisions for the same purpose [3, 53]. Röpke described a similar technique to thin out the lamina with a chisel, transecting it in the midline and then retracting both lamina halves together with attached soft tissues laterally [43]. With closure of the soft tissues, these authors approximated the lamina sufficiently to allow fusion.

Spinal stabilization was first developed to treat patients with Pott's disease. Hadra used wiring of the spinous processes to prevent kyphotic deformities [21]. In 1910, Lange suggested steel bars for fusion of a spondylitic spine [31]. Albee, Hibbs, and Ito used bone grafts to achieve bony fusion [2, 25, 28]. However, it was not until the advent of better anesthetic techniques and antibiotic treatment, as well as a better understanding of spinal biomechanics, that stabilization techniques for the spine finally became practical. A major step was the pioneering work of Sir Frank Holdsworth, who classified spinal fractures according to the mechanism into pure flexion, flexion-rotation, extension, and compression fractures. He also introduced a two-column model of spinal stability [27]. This work provided an important background for the development of the first successful spinal instrumentation system for posterior spinal fusion by Paul Harrington in the 1960s [22, 23]. The first ventral instrumentation system was introduced soon thereafter by Dwyer et al. in 1969 [12].

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