Surg Neurol 1992;38:315-7
315
Historical Vignette Lumbar Disk Lesions in Retrospect and Prospect Eben Alexander, Jr., M.D.
So m u c h is w r i t t e n a b o u t r u p t u r e d disks. M a n y p e o p l e n o w b e l i e v e that t h e y w e r e d e s c r i b e d y e a r s b e f o r e , b u t in fact, m o s t g i v e c r e d i t to M i x t e r and B a r r for t h e o r i g i n a l d i s c o v e r y a n d p u b l i c a t i o n . Since this has n o t b e e n w i d e l y c i r c u l a t e d , a n d having k n o w n D r . M i x t e r briefly as w e l l as D r . J o e B a r r ' s son, J o e B a r r , Jr., I have b e e n a b l e to o b t a i n t h e actual d e s c r i p t i o n that D r . B a r r g a v e o f t h e d i s c o v e r y . W i t h this in m i n d , t h e f o l l o w i n g w o r d s w e r e a t a p e - r e c o r d e d a d d r e s s at a m e e t i n g o f t h e officer's club, San D i e g o N a v a l H o s p i t a l , o n M a y 15, 1961. It was p u b l i s h e d in Clinical Orthopaedics and Related Research ( N o v e m b e r / D e c e m b e r 1977, 1 2 9 : 4 - 8 ) .
Lumbar Disk Lesions in Retrospect and Prospect My first concepts with regard to lumbar disk lesions as causing clinical symptoms dates back to 1932. At that time I was just a little over 30 years old, had graduated from medical school, had a surgical internship, orthopedic residencies (children's and adult) and was in private practice. Those of you who are old enough to know about 1932 know that there wasn't much private practice at that time. It was scratch as scratch can. There wasn't a great deal of work and the work there was went to much older and much wiser doctors than I was at that time and perhaps ever will be. In any case I worked with Dr. Ober and those of you who know Dr. O b e r know that he is a unique sort of p e r s o n - - b l u n t , independent, a down-Maine Yankee who called his shots as he saw them. H e took his hat off to no man. H e said he was the only Democrat in the State of Maine. H e was just that sort of person. In any case in 1932 a young fellow came down to see Dr. Ober. I examined this fellow. His name was Kenneth Newton. H e was in his 30's. I don't have any notes except my recollections because I hadn't expected to talk tonight. So I can't verify what I have to say. You can consider these as reminiscences of a campaigner if you want to and discount as much as you choose. But this is the way I remember it. Kenneth Newton had what we now recognize as a classical disk syndrome. H e had hellish pain down his leg. H e had a list in his back and he was miserable. Plain © 1992 by Elsevier Science Publishing Co., Inc.
X-rays were negative. W e put him in a little hospital to cool off. H e stayed uncomfortable. Well, in those days we thought the cause o f this syndrome was either sacroiliac strain as exemplified by Smith Peterson or perhaps lumbosacral strain. Phil Wilson was a great person to defend the sacroiliac region as the cause of low back and sciatic pain. We knew that spondylolisthesis caused pain in the legs sometimes. We knew that infectious arthritis did also. We knew that tumors did and then we sort of stopped and we didn't know much more about it than that. Anyway, Kenneth Newton didn't do very well under conservative treatment so we considered manipulating his back. This was a standard form of treatment. I couldn't understand if it was strained, why it failed to be relieved by complete bed rest. It seemed to me very odd that this could be true. Any other strain of ligaments that I had ever heard of would be relieved by rest. It was also hard to understand why strain of any ligament could produce what appeared to be typical nerve pain, deepseated and agonizing. So I said to Dr. Ober, "Before we manipulate his back, isn't it possible that we are missing something?" Dr. Ober said, "Yes, he might have a tumor. Let's get Jason Mixter to see him." Jason Mixter was a neurosurgeon, of course, and the man in New England who knew most about the spine. N o t even Harvey Cushing, I think, had opened as many backs as Mixter had, and had looked in for a variety of tumors. So Jason saw the patient and said, "Well, it could be a tumor all right." H e had operated on a few chondromas of the spine and he advised that we do a lipiodol myelographic examination. We put in 2 cc of lipiodol to fill a big broad spinal sac and those 2 cc ran a little pencil line up and down the back. We didn't even know enough to do fluoroscopy. We just took a couple of films. These were negative as far as this was concerned. The patient was no better. Jason said he would be willing to explore the spine. So he did. Here I missed an excellent opportunity because I wasn't present at the exploration. I was busy doing some orthopedic examination or other and didn't see the surgery. But I was told the patient had a chondroma of the spine. I saw the operative note and in the clinical records at the M.G.H. is a very lovely pen-and-ink sketch that Mixter had made. H e found the tumor by opening the dura, doing a rather radical laminectomy, removing the 2 laminae and removing the tumor through the opening 0090-3019/92/$5.00
316
Surg Neurol 1992;38:315-7
in the dura. He found the first sacral nerve root under compression and removed it transdurally. The patient was much better, in fact was completely relieved of his back and leg pain. I wasn't so busy in those days and so on the next Sunday morning after the report had come back from pathology, "chondroma of the spine," I went over to the Pathology Department (Tracy Mallory was in charge), got the slides out and asked to see them. Here was this tumor but I couldn't see any cells. That seemed to me very odd. I asked Tracy about this chondroma that didn't have any cells. He said, "Well, that is a characteristic of chondromas of the spine. They don't have cells." Just about that time something happened which gave us a clue. I was sent a book by Schmorl and Junghanns. I wonlt give the German title of it but it was a book on the spine in disease and health and, as you all know, Schmorl was a German pathologist who spent his life, especially his later years, studying spines which had been removed at autopsy. He described these little posterior protrusions which he saw which he thought were of no clinical significance. "Nicht wichtig" they were called. I had been asked to review this book. My German was very bad. It took me about 3 or 4 weeks of hard slogging before I could make out just what this was all about. I asked Tracy Mallory if this could be a disk protrusion because from Dr. Mixter's description this had arisen from an intervertebral disk. Tracy said he didn't know. It might be. I went to the medical school and asked to see some slides of disk tissue and there were no pathological histological slides of normal intervertebral disk tissue at Harvard Medical School. This was extraordinary, but it was a fact. It was a tissue of no importance. So we made some disk tissue slides and compared them with this "tumor." O f course, it was the same sort of material. Fortunately, the Pathology Department had a very lovely index of all material they had ever examined at the M.G.H. since it was opened in 1812 or so. We were able to find about 20 or 30 cases ofchondromas of the spine. They ranged from the cervical spine on down to the lumbar spine with 1 or 2 in the dorsal spine. And of these "chondromas" of the spine, there were 3 or 4 of them that anybody, even a fourth year medical student, could tell were chondromas. They had cartilage cells in them. The rest of them all looked like normal disk tissue. So we were on the hunt then for other clinical cases with this same type of thing. Our first case in which we made the diagnosis preoperatively was a fellow by the name of John Andrade who was a Portuguese chap from down on Cape Cod. Phil Wilson and I operated on him. He had a severe forward and lateral list of his spine so he was cocked off to the side. Phil Wilson was sure that strain had a lot to do with this. So we took a massive tibial graft and did a fusion on him after the disk had been removed. He fused solidly but he fused with the list still present. John Andrade is living today with his spine bent off to the side about 30 ° and listed forward about 30 °.
Alexander
Then the struggle was on. We had a very difficult time getting the neurologists to accept the possibility that a tumor pressing on a nerve root could be present without producingobjective neurological changes. It just seemed to them incredible that such a thing could be true. If the ankle jerks were present and the knee jerks were present, the patient couldn't have this lesion. It took some doing and courage to operate on cases in which the neurologist had come out flatfootedly and said, "There is no use in doing one of these new-fangled lipiodal injections, because he hasn't got any neurological changes. He's all right." But we persisted and gradually we collected a number of cases. In 1934 Jason Mixter and I published our first paper. This paper included cases with lesions from the base of the skull down. We covered the waterfront. Cervical, dorsal and lumbar lesions are all included in this first article. But I couldn't get over this first case that I followed, severe sciatica with low back pain, and I finally collected 20 patients with characteristic lumbar and sciatic pain. I wrote a thesis for the AOA on this subject. It was accepted and published in about 1935 or 1936. But in any case I may say that these first 20 cases taught me 90% of what I have learned about disk lesions. There is a sort of pattern. Once you see a pattern, it is there and it doesn't take 100 or 200 or 300 cases to see what the pattern is. It is there for anyone to see. In 1933 I read my first paper. This was at a Peter Bent Brigham Hospital reunion of which I was a graduate. There were 42 cases. Elliott Cutler, who has since died, was there. He was a good surgeon and a good neurosurgeon. H e said it was very interesting but that he had never seen a case. He said that, if he ever had one, he would ask me to see it. That was the last I heard from the Brigham Hospital staff. I won't go into the history of it. At first it was very uphill. No one believed this, I think, practically at first. Yet the literature is strewn with references to it. If you start before our first paper in '34 and just collect the literature which was then in print, you would have a book shelf full of references. This has been known for many years. We didn't discover anything. We rediscovered something. Kocher was a famous Swiss surgeon, who described a case accurately in the 1800's. A fellow fell off a telegraphic pole or something like that and had a traumatic paraplegia. At post-mortem they found that disk tissue had transected the cord. And there were a couple of Scottish surgeons, Middleton and Teacher, who described this. Walter Dandy described it. Elsberg and Stukey described it. We didn't discover anything new. We rediscovered something that had been known. The point was that we were able to take what had been known in the pathology laboratory and what we could see clinically and had access to a group of cases which made a syndrome. And, of course, it is a marvelous thing because it is such a lovely neurological experiment in which you take a bit of tissue that isn't even 1.0 cm in diameter and produce excruciating pain. We all know
Lumbar Disk Lesions
that now but then it was incredible that such a little bit of tissue could do so much harm to an individual in the way of producing incapacitating pain. It is very easy to accept now but then was rather hard. We could scarcely believe it ourselves. It seemed too good to be true. We thought there must be something phony about this. And every case we did, there was always a very skeptical surgeon looking over our shoulders to see this little bit of tissue that was brought out and claimed to be the cause of the trouble. The surgery wasn't nearly as skillfully done then as it is now. We didn't have the tools you have now. We didn't even have the pituitary rongeur
Surg Neurol 1992;38:315-7
317
until finally Jason Mixter found that this was the proper tool to get into the disk space with. All the technique had to be developed the way it has been recently. EBEN ALEXANDER, Jr., M.D., Editor The author wishes to thank Joseph Barr, Jr., M.D., for the use of his father's speech which was tape-recorded at the meeting of the Officers Club, San Diego Naval Hospital on May 15, 1961. It is reprinted here with permission of Clinical Orthopaedics and Related Research 1977;129:4-8, published by J.B. Lippincott Company, Philadelphia, Petmsylvania.
315
Historical Vignette Lumbar Disk Lesions in Retrospect and Prospect Eben Alexander, Jr., M.D.
So m u c h is w r i t t e n a b o u t r u p t u r e d disks. M a n y p e o p l e n o w b e l i e v e that t h e y w e r e d e s c r i b e d y e a r s b e f o r e , b u t in fact, m o s t g i v e c r e d i t to M i x t e r and B a r r for t h e o r i g i n a l d i s c o v e r y a n d p u b l i c a t i o n . Since this has n o t b e e n w i d e l y c i r c u l a t e d , a n d having k n o w n D r . M i x t e r briefly as w e l l as D r . J o e B a r r ' s son, J o e B a r r , Jr., I have b e e n a b l e to o b t a i n t h e actual d e s c r i p t i o n that D r . B a r r g a v e o f t h e d i s c o v e r y . W i t h this in m i n d , t h e f o l l o w i n g w o r d s w e r e a t a p e - r e c o r d e d a d d r e s s at a m e e t i n g o f t h e officer's club, San D i e g o N a v a l H o s p i t a l , o n M a y 15, 1961. It was p u b l i s h e d in Clinical Orthopaedics and Related Research ( N o v e m b e r / D e c e m b e r 1977, 1 2 9 : 4 - 8 ) .
Lumbar Disk Lesions in Retrospect and Prospect My first concepts with regard to lumbar disk lesions as causing clinical symptoms dates back to 1932. At that time I was just a little over 30 years old, had graduated from medical school, had a surgical internship, orthopedic residencies (children's and adult) and was in private practice. Those of you who are old enough to know about 1932 know that there wasn't much private practice at that time. It was scratch as scratch can. There wasn't a great deal of work and the work there was went to much older and much wiser doctors than I was at that time and perhaps ever will be. In any case I worked with Dr. Ober and those of you who know Dr. O b e r know that he is a unique sort of p e r s o n - - b l u n t , independent, a down-Maine Yankee who called his shots as he saw them. H e took his hat off to no man. H e said he was the only Democrat in the State of Maine. H e was just that sort of person. In any case in 1932 a young fellow came down to see Dr. Ober. I examined this fellow. His name was Kenneth Newton. H e was in his 30's. I don't have any notes except my recollections because I hadn't expected to talk tonight. So I can't verify what I have to say. You can consider these as reminiscences of a campaigner if you want to and discount as much as you choose. But this is the way I remember it. Kenneth Newton had what we now recognize as a classical disk syndrome. H e had hellish pain down his leg. H e had a list in his back and he was miserable. Plain © 1992 by Elsevier Science Publishing Co., Inc.
X-rays were negative. W e put him in a little hospital to cool off. H e stayed uncomfortable. Well, in those days we thought the cause o f this syndrome was either sacroiliac strain as exemplified by Smith Peterson or perhaps lumbosacral strain. Phil Wilson was a great person to defend the sacroiliac region as the cause of low back and sciatic pain. We knew that spondylolisthesis caused pain in the legs sometimes. We knew that infectious arthritis did also. We knew that tumors did and then we sort of stopped and we didn't know much more about it than that. Anyway, Kenneth Newton didn't do very well under conservative treatment so we considered manipulating his back. This was a standard form of treatment. I couldn't understand if it was strained, why it failed to be relieved by complete bed rest. It seemed to me very odd that this could be true. Any other strain of ligaments that I had ever heard of would be relieved by rest. It was also hard to understand why strain of any ligament could produce what appeared to be typical nerve pain, deepseated and agonizing. So I said to Dr. Ober, "Before we manipulate his back, isn't it possible that we are missing something?" Dr. Ober said, "Yes, he might have a tumor. Let's get Jason Mixter to see him." Jason Mixter was a neurosurgeon, of course, and the man in New England who knew most about the spine. N o t even Harvey Cushing, I think, had opened as many backs as Mixter had, and had looked in for a variety of tumors. So Jason saw the patient and said, "Well, it could be a tumor all right." H e had operated on a few chondromas of the spine and he advised that we do a lipiodol myelographic examination. We put in 2 cc of lipiodol to fill a big broad spinal sac and those 2 cc ran a little pencil line up and down the back. We didn't even know enough to do fluoroscopy. We just took a couple of films. These were negative as far as this was concerned. The patient was no better. Jason said he would be willing to explore the spine. So he did. Here I missed an excellent opportunity because I wasn't present at the exploration. I was busy doing some orthopedic examination or other and didn't see the surgery. But I was told the patient had a chondroma of the spine. I saw the operative note and in the clinical records at the M.G.H. is a very lovely pen-and-ink sketch that Mixter had made. H e found the tumor by opening the dura, doing a rather radical laminectomy, removing the 2 laminae and removing the tumor through the opening 0090-3019/92/$5.00
316
Surg Neurol 1992;38:315-7
in the dura. He found the first sacral nerve root under compression and removed it transdurally. The patient was much better, in fact was completely relieved of his back and leg pain. I wasn't so busy in those days and so on the next Sunday morning after the report had come back from pathology, "chondroma of the spine," I went over to the Pathology Department (Tracy Mallory was in charge), got the slides out and asked to see them. Here was this tumor but I couldn't see any cells. That seemed to me very odd. I asked Tracy about this chondroma that didn't have any cells. He said, "Well, that is a characteristic of chondromas of the spine. They don't have cells." Just about that time something happened which gave us a clue. I was sent a book by Schmorl and Junghanns. I wonlt give the German title of it but it was a book on the spine in disease and health and, as you all know, Schmorl was a German pathologist who spent his life, especially his later years, studying spines which had been removed at autopsy. He described these little posterior protrusions which he saw which he thought were of no clinical significance. "Nicht wichtig" they were called. I had been asked to review this book. My German was very bad. It took me about 3 or 4 weeks of hard slogging before I could make out just what this was all about. I asked Tracy Mallory if this could be a disk protrusion because from Dr. Mixter's description this had arisen from an intervertebral disk. Tracy said he didn't know. It might be. I went to the medical school and asked to see some slides of disk tissue and there were no pathological histological slides of normal intervertebral disk tissue at Harvard Medical School. This was extraordinary, but it was a fact. It was a tissue of no importance. So we made some disk tissue slides and compared them with this "tumor." O f course, it was the same sort of material. Fortunately, the Pathology Department had a very lovely index of all material they had ever examined at the M.G.H. since it was opened in 1812 or so. We were able to find about 20 or 30 cases ofchondromas of the spine. They ranged from the cervical spine on down to the lumbar spine with 1 or 2 in the dorsal spine. And of these "chondromas" of the spine, there were 3 or 4 of them that anybody, even a fourth year medical student, could tell were chondromas. They had cartilage cells in them. The rest of them all looked like normal disk tissue. So we were on the hunt then for other clinical cases with this same type of thing. Our first case in which we made the diagnosis preoperatively was a fellow by the name of John Andrade who was a Portuguese chap from down on Cape Cod. Phil Wilson and I operated on him. He had a severe forward and lateral list of his spine so he was cocked off to the side. Phil Wilson was sure that strain had a lot to do with this. So we took a massive tibial graft and did a fusion on him after the disk had been removed. He fused solidly but he fused with the list still present. John Andrade is living today with his spine bent off to the side about 30 ° and listed forward about 30 °.
Alexander
Then the struggle was on. We had a very difficult time getting the neurologists to accept the possibility that a tumor pressing on a nerve root could be present without producingobjective neurological changes. It just seemed to them incredible that such a thing could be true. If the ankle jerks were present and the knee jerks were present, the patient couldn't have this lesion. It took some doing and courage to operate on cases in which the neurologist had come out flatfootedly and said, "There is no use in doing one of these new-fangled lipiodal injections, because he hasn't got any neurological changes. He's all right." But we persisted and gradually we collected a number of cases. In 1934 Jason Mixter and I published our first paper. This paper included cases with lesions from the base of the skull down. We covered the waterfront. Cervical, dorsal and lumbar lesions are all included in this first article. But I couldn't get over this first case that I followed, severe sciatica with low back pain, and I finally collected 20 patients with characteristic lumbar and sciatic pain. I wrote a thesis for the AOA on this subject. It was accepted and published in about 1935 or 1936. But in any case I may say that these first 20 cases taught me 90% of what I have learned about disk lesions. There is a sort of pattern. Once you see a pattern, it is there and it doesn't take 100 or 200 or 300 cases to see what the pattern is. It is there for anyone to see. In 1933 I read my first paper. This was at a Peter Bent Brigham Hospital reunion of which I was a graduate. There were 42 cases. Elliott Cutler, who has since died, was there. He was a good surgeon and a good neurosurgeon. H e said it was very interesting but that he had never seen a case. He said that, if he ever had one, he would ask me to see it. That was the last I heard from the Brigham Hospital staff. I won't go into the history of it. At first it was very uphill. No one believed this, I think, practically at first. Yet the literature is strewn with references to it. If you start before our first paper in '34 and just collect the literature which was then in print, you would have a book shelf full of references. This has been known for many years. We didn't discover anything. We rediscovered something. Kocher was a famous Swiss surgeon, who described a case accurately in the 1800's. A fellow fell off a telegraphic pole or something like that and had a traumatic paraplegia. At post-mortem they found that disk tissue had transected the cord. And there were a couple of Scottish surgeons, Middleton and Teacher, who described this. Walter Dandy described it. Elsberg and Stukey described it. We didn't discover anything new. We rediscovered something that had been known. The point was that we were able to take what had been known in the pathology laboratory and what we could see clinically and had access to a group of cases which made a syndrome. And, of course, it is a marvelous thing because it is such a lovely neurological experiment in which you take a bit of tissue that isn't even 1.0 cm in diameter and produce excruciating pain. We all know
Lumbar Disk Lesions
that now but then it was incredible that such a little bit of tissue could do so much harm to an individual in the way of producing incapacitating pain. It is very easy to accept now but then was rather hard. We could scarcely believe it ourselves. It seemed too good to be true. We thought there must be something phony about this. And every case we did, there was always a very skeptical surgeon looking over our shoulders to see this little bit of tissue that was brought out and claimed to be the cause of the trouble. The surgery wasn't nearly as skillfully done then as it is now. We didn't have the tools you have now. We didn't even have the pituitary rongeur
Surg Neurol 1992;38:315-7
317
until finally Jason Mixter found that this was the proper tool to get into the disk space with. All the technique had to be developed the way it has been recently. EBEN ALEXANDER, Jr., M.D., Editor The author wishes to thank Joseph Barr, Jr., M.D., for the use of his father's speech which was tape-recorded at the meeting of the Officers Club, San Diego Naval Hospital on May 15, 1961. It is reprinted here with permission of Clinical Orthopaedics and Related Research 1977;129:4-8, published by J.B. Lippincott Company, Philadelphia, Petmsylvania.
