The historical evolution of the management of spinal cord injury

M.D. Schiller*, R.J. Mobbs

• Faculty of Medicine, University of New South Wales, Sydney, New South Wales 2052, Australia
• Department of Neurosurgery, Prince of Wales Hospital, Randwick, New South Wales 2031, Australia

Article info

• Article history:
  Received 4 February 2010
  Accepted 7 March 2012
  Available online xxxx
• Keywords:
  History of neurology
  History of neuroscience
  History of neurosurgery
  Spinal cord injury

Abstract

The history of spinal cord injury (SCI) is long and fascinating. From Ancient Egypt to the current day, SCI has gradually shifted from being seen as an inevitably fatal condition, to one most amenable to treatment, albeit not yet cure. Several controversies have paved the path of this condition’s history, from the question of whether to treat, to the optimal timing of surgical intervention, to the potential of recent novel therapies. This article traces the major developments in the management of SCI, in addition to many broader historical developments relating to SCI.

© 2012 Elsevier Ltd. All rights reserved.

Surgical intervention, coupled with rehabilitation and complication- prevention, remains the mainstay of treatment for spinal cord injury (SCI). Future decades hold promise that this may give way to an actual cure. As several promising avenues of SCI research are pursued, it is a prudent juncture to review the historical development of this field. Table 1 provides a timeline of important milestones.

The history of the treatment of SCI is marked, more than anything else, by controversy. The question of whether SCI was at all amenable to treatment was contentious for millennia, whereas for the past two centuries the issue of contention has shifted heavily to whether it should be treated with aggressive surgical intervention or non-surgical medical management. More recently, the focus has begun to shift more towards the question of the ideal timing of surgical intervention, a controversy that remains alive today.

The known history of SCI can be traced into antiquity, to the earliest known record of medicine and surgery – the Edwin Smith Papyrus – which is thought to have been written in Egypt around 2500–3000 Before Common Era (BCE).1–3 Although it describes techniques of spinal surgery, the document expressly labels SCI as an ‘‘ailment not to be treated’’, a dogma that predominated for many centuries

The first references to SCI in classical antiquity come from the works of Homer.^4,5 The Greeks appear to have pioneered the treatment of SCI, with Hippocrates performing external reduction for the condition.^1,2,6,7 Hippocrates was also the first to raise the issue of preventing SCI-associated complications, describing techniques for ulcer prevention. SCI research had its genesis in Roman times, with Galen's pioneering experiments into spinal cord levels.^5,8

However, it was not until the time of the Byzantine Empire that surgical intervention for the condition was introduced, with Paul of Aegina first performing surgical decompression in the 7th Century Common Era (CE).^2,4,6,9 He also introduced a forerunner to spinal fixation in the form of splinting. Despite these advances, many remained resigned to the sentiments of the Edwin Smith Papyrus with regards to the ultimately fatal nature of SCI, including the great Persian physician Avicenna, as well as the Frenchman Ambroise Pare much later in the 16th Century.^2,4,6,9,10

The issue of the timing of intervention for SCI, one that dominates in the present context, first appears in the work of Roland of Parma, Italy, who identified the importance of prompt intervention in 1210 CE.⁶ The idea of open reduction of spinal fracture dislocation did not come until the 16th Century.^5,11 By the time of the late renaissance, knowledge of the spinal cord and SCI had advanced considerably, with Blasius publishing the first work with the spinal cord as its sole subject in 1666.^12,13 Surgery for patients with SCI became more widespread in the 18th Century, particularly in France,^5,6 although the hopeless prognosis still prevailed. This attitude came to prominence at the Battle of Trafalgar, in 1805, with the resigned death of Lord Admiral Horatio Nelson after suffering a SCI.¹

Not long after the Napoleonic age, arguably the most fierce and foundational debate in the treatment of SCI arose. From 1824, British surgeons Sirs Astley Cooper and Charles Bell bitterly argued over the merits of laminectomy for SCI.^1,7,9,14,15 Cooper boldly reasoned that, given the fatal nature of the condition, nothing could be lost by attempting surgery. However, Bell contended that such intervention unnecessarily risked death and further spinal cord damage, believing that continued pressure on the spinal cord was not a mediating factor in the nature of the injury, and his views were more in line with the mainstream.

* Corresponding author. Tel.: +61 2 9650 4855.
E-mail address: matt@unsw.edu.au (M.D. Schiller).

0967-5868/$ - see front matter  2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jocn.2012.03.002

Table 1

A timeline of important events in the history of spinal cord injury (SCI)

BCE = Before Common Era, c. = circa, CE = Common Era.

During the 19th Century, numerous advances in fields related to surgery would eventually render surgery for SCI a more appropriate treatment modality. These included blood transfusion,16 anaesthesia, ^17–19 antiseptic technique,^20–22 wound drainage,²³ and surgical gloves.²⁴ The end of the century also saw several developments in spinal fixation. In the United Kingdom, Burrell used a plaster jacket following surgery for SCI,^6,11,25,26 while in the United States, Hadra pioneered internal fixation.^27,28 The major spinal surgical advances were in the introduction of hemilaminectomy by Bonomo,^6,29 and the improvement of fixation technique by Lange^30–32 in the first decade of the 20th Century. Around this time, medical imaging had its genesis, with the discovery of X-rays in 1895.³³ Imaging would soon become pivotal in SCI diagnosis, particularly after the technique of myelography was developed in 1921.³⁴

Although spinal units arose transiently during the First World War along with the skyrocketing of patients with SCI at that time, it was not until 1936 that Donald Munro established the first permanent spinal cord unit in the United States. Ludwig Guttman did the equivalent in the United Kingdom as the Second World War drew to a close. On opposite sides of the Atlantic, these two men did much to revolutionise the treatment of, and attitude toward, SCI, developing multidisciplinary programs focused on holistic care and rehabilitation.^1,2,9 Novel techniques were developed to prevent SCI complications, such as tidal drainage to prevent urinary tract infection.^35,36 Also, by the end of the Second World War, antibiotics were available,³⁷ allowing this new breed of SCI physician to deal with the many infections associated with the condition. As well as revolutionising medical management, the advent of antibiotics meant that the prospects of surgical intervention were greatlyimproved. However, such interventional was still not seen as worthwhile by those such as Munro.

Not until this point did SCI begin to leave behind its reputation as an ultimately fatal condition. Before the 1940s, most patients with SCI in the United States and United Kingdom died within a few weeks of injury; however, their average life expectancy increased to around 10 years by the late 1940s. This would double by the 1950s.³⁸ With these increases in life expectancy, the population of patients with SCI increased steadily, as did their expectations about quality of life.^38,39 Affected patients became increasingly well organised, and structures soon developed around SCI care, including the American Paraplegia Society in the 1950s, the Australian Quadraplegia Association (now Australian Spinal Cord Injuries Australia) and the International Medical Society of Paraplegia in the 1960s, and SCI care traineeships and the American Spinal Injury Association (ASIA) in the 1970s.^6,40,41 The focus of SCI advocacy would slowly shift from the medical aim of achieving survival to the political aim of achieving social equality.

The concept of ''secondary injury'' in SCI was postulated by Allen in 1911.^5,42 Since then, progress in elucidating the precise pathology of this phenomenon has been slow, and our understanding remains very incomplete even today. Nonetheless, treatment modalities to date have focused on the limitation of this secondary injury.

It was in 1954 that a pioneering animal study by Tarlov first established the benefit of early decompression in improving neurological outcome after SCI,⁴³ lending some evidence for early surgical intervention. Paul Harrington, the man who would lend his name to probably the most well-known and widely used spinal instrumentation system, first presented that system in1958.^1,32,44–46 Over the following decades, advances in both anterior and posterior fixation systems came at a fast pace, with the Dwyer, Zielke, Luque, and CD systems being among the most prominent.^{32,45,47–50} With these new systems, successful and secure biomechanical fixation became increasingly feasible. Alongside these developments came a revolution in medical imaging, in CT scanning in the 1970s, and MRI in the 1980s.^13,51–53 While CT imaging remains the preferred method for assessing fractures and compressive bony fragments associated with traumatic SCI, it was not until the development of MRI that pathology of the spinal cord itself could be effectively visualised.⁵⁴ With much improved resolution in recent decades, MRI remains the definitive imaging modality for evaluating SCI. Despite surgical and radiological advances, the most recent systematic review of spinal fixation and decompression surgery concluded that there is insufficient evidence about the benefits and harms of such intervention, given a lack of well-designed, prospective controlled trials.⁵⁵ However, recently published results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) show that decompression within 24 hours is associated with a significantly improved neurological outcome.⁵⁶ Considering that surgery has been the mainstay of SCI treatment for many decades, it is surprising that the evidence for its effectiveness until now has been so limited. This is partly symptomatic of the condition's low incidence.

In 1969, Ducker and Hamit found that early pharmacological treatment with steroids in animals with SCI improved neurological outcome, presumably due to a limitation of secondary injury.⁵⁷ To the present, numerous animal and human studies have sought to confirm this phenomenon for both surgical and pharmacological interventions. The effect of methyprednisolone in humans was confirmed in a randomised trial by Bracken et al. in 1990.⁵⁸ However, methyprednisolone's merits have since been brought into question due to its complication profile and its use has diminished.⁵⁹

Several advanced functional treatments have become available to SCI sufferers in recent years, including tendon transfer to improve hand grasp, and functional electric stimulation (FES) to allow reactivation of limb, bowel and bladder muscles.⁵⁹ Additionally, recent developments in assistive technologies, particularly in the area of computing, have provided the potential for much improved quality of life.^60,61

As our understanding of the complicated pathophysiology of SCI has advanced exponentially in recent years, so the avenues for potential therapies have become numerous. These developments are the subject of a recent review,⁶² and are beyond the scope of this article. Of particular interest are those therapies involving cell transplantation. Olfactory ensheathing cells and human embryonic stem cells currently hold the most promise for a therapy based on enhanced regeneration, and trials involving both are currently underway.^63,64 Extensive reviews of the numerous completed, ongoing and planned clinical trials into SCI therapies have been published.^65,66

The epidemiology of SCI has only become well illuminated in recent decades. A recent review of international epidemiological studies since 1995 found reported incidences to range from 10.3 to 83 per million.⁶⁷ In the United States, this figure is estimated to be approximately 40 per million, with a prevalence of about 265,000 individuals.⁶⁸ In Australia, for the financial year 2007– 2008, 362 new patients with SCI were admitted to the country's six spinal units, with 385 of these being traumatic. This equates to an age-standardised incidence of persisting traumatic SCI of approximately 15 new cases per million population, with an estimated SCI population of about 9000 individuals.^69,70 Despite these small rates, the debilitating nature of SCI renders it one of the most costly medical conditions, both in terms of its effects on the lives of sufferers, and its associated economic costs. In the United States, the estimated direct lifetime costs for a person who becomes a ''high tetraplegic'' at the age of 25 years is US$4,373,912.⁶⁸ In New South Wales, the estimated annual personal care and equipment costs for a ventilator-dependent SCI sufferer is estimated to be approximately AU$300,000, while the ongoing costs of caring for the Australian SCI population is around AU$500 million per annum.⁷¹ The enormous personal, social and financial costs of SCI heighten the importance of achieving the next major advance in SCI treatment.

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  The historical evolution of the management of spinal cord injury

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