Spine surgery is an important branch of surgery and began in the early 20th century when Cushing reported a case of intramedullary tumor resection in 1905 and Openheim reported a case of L5/S1 discectomy in 1909. In 1909, Openheim reported a case of L5/S1 discectomy. After that, various surgical treatments for spinal diseases and various approaches were reported, and spinal surgery was gradually developed. In the early days, due to the backwardness of imaging and surgical techniques and the lack of understanding of the stability of the spine, the accuracy of diagnosis of spinal cord diseases in clinical work was poor, and surgical treatment was ineffective, and complications such as spinal cord injury and spinal deformity often occurred after surgery. It was not until 1973 that Hounsfield invented CT, which was the first major leap in the history of spinal surgery.
In 1977, the application of MRI in the field of neurology became the 2nd leap in spinal surgery. In 1983, Denis proposed the “three-column theory of the spine”, which became the mechanical basis for spinal surgery. On the basis of this theory, with the development and combination of engineering and materials science and the innovation of surgical instruments, new materials, techniques and methods have emerged and been applied clinically. “U”-shaped vertebral plates, cervical plates, Cagetechnology, transforaminal screws, transforaminal screws, CD systems, artificial discs, etc. have been widely promoted and applied, and spinal surgery has achieved rapid development, especially in the past 10 years or so, the development of spinal cord surgery can be described as a rapid development, the speed of development is amazing.
In many people’s conception of spinal cord disease, epidural lesions belong to orthopedic treatment and intradural lesions belong to neurosurgery. In fact, spinal surgery is a typical cross-discipline that includes both the bony structures of the spine and the central nerve and spinal nerve structures of the spinal cord. Because of the late start of neurosurgery in China, the treatment of spinal surgical diseases was basically undertaken by orthopedic surgeons in the past. Although there were neurosurgical predecessors who started spinal surgery at the beginning of the country, the proportion of them was very small, and the surgery was mainly focused on the removal of tumors within the spinal canal.
One of the main reasons is that neurosurgeons focus more on the protection of the spinal cord and nerves and give less consideration to the stability aspects of the spine, or have little understanding of the biomechanical structure of the spine and internal fixation techniques. In the past, it was mostly simple to bite off the vertebral plate, or even bite off multiple segments of the vertebral plate, and many of these patients were found to have spinal deformities years later.
So neglecting spinal stability became the biggest problem for neurosurgeons in the past in terms of spinal cord surgery. Neurosurgeons began to reflect on this and began to understand spinal cord disease from a comprehensive, holistic perspective and began to learn new techniques and theories about spinal fixation. Some major hospitals in China have now established spinal cord neurosurgery treatment centers, combining neuro-microsurgery techniques and internal fixation techniques, and have achieved excellent results in the surgical treatment of spinal cord diseases.
In Europe and the United States, spinal disorders are mostly attributed to neurosurgery, and neurosurgeons are dedicated to this field of spinal surgery. The volume of surgery for spinal cord disorders in many large neurosurgery centers accounts for more than 30-40% of the total volume of surgery, and in some cases, even 60%-80%. The history of spinal surgery is full of neurosurgeons, Cloward, Goel, Bryan In 2000, the Journal of the American Association of Neurological Surgeons, JNeurosurgery, officially published a spine subsection.
More than a decade ago in Taiwan, the situation is similar to that of our mainland now, spinal surgery is basically under the category of orthopedic treatment, but through the joint efforts of neurosurgeons, now in addition to spinal deformities, spinal cord tumors, herniated discs, spinal cord injuries and other surgeries are almost all undertaken by neurosurgeons, and the “Neurospinal Surgery Medical Association” has been established. “.
The main reason for the current status quo of spine surgery by orthopedic surgeons in China is because of the late start of neurosurgery in China, for a long time neurosurgeons have been committed to brain surgery to the world’s developed countries to learn and catch up, no time for spine surgery. Now, with the rapid improvement of the level of neurosurgery in China, the medical level of some large domestic neurosurgical units has been in line with international neurosurgery, neurosurgeons are gradually aware of the lack of spinal surgery, and began to pay attention to the research and treatment of spinal cord spinal diseases, dedicated to make up for this historical deficiency.
The Society of Neurological Surgeons has now established the Spinal Neurosurgery Section, which will greatly encourage neurosurgeons to engage in spinal surgery and ultimately play a positive role in promoting the development of spinal neurosurgery.
The American Association of Neurological Surgeons defines neurosurgery as the medicine that diagnoses and treats the central, peripheral and autonomic nervous system and its supporting structures. The Chinese Society of Neurosurgery also clearly states that the diagnosis and treatment of spinal cord disease is within the scope of the profession of neurosurgery. This has laid the foundation for neurosurgeons to perform spinal surgery. As we all know, the spine and spinal cord are inseparable and interdependent, just like the relationship between the skull and the brain.
The brain and spinal cord are both part of the central nervous system, and the skull is the support structure for the brain, which is the scope of neurosurgery. The spine, as the supporting structure of the spinal cord, should also belong to an important branch of neurosurgery. And based on the fact that neurosurgeons are more familiar with neuroanatomy and neurophysiology, they pay more attention to the protection of neural tissue. Especially with the widespread use of microscopic techniques in neurosurgery, neurosurgeons are able to operate more delicately and with greater surgical safety. As a result, most spinal cord surgeries in Europe and the United States are performed by neurosurgeons.
Spinal surgery mainly includes.
1, degenerative diseases of the spine, such as cervical spondylosis, lumbar disc herniation, etc., these most common diseases account for more than 80% of all kinds of spinal surgery;
2, spinal trauma;
3, spinal tumors;
4, spinal deformity.
In addition to spinal deformity surgery, other spinal surgery can be summarized into two aspects, namely decompression and fixation. It has been reported that incomplete decompression is the main reason for the poor outcome of cervical spine surgery, and the serious complications and even death caused by high cervical segment surgery are also mostly related to the surgical operation, and it is in this aspect that neurosurgeons can give full play to their specialties through microscopic operation techniques.
Neurosurgeons and orthopedic surgeons each have their own strengths in spinal surgery, with neurosurgeons specializing in spinal cord and nerve protection and orthopedic surgeons specializing in spinal stabilization. Chiropractic neurosurgery must be a perfect combination of both, analyzing and treating from a holistic perspective. You must have formal specialized training to practice spinal neurosurgery, and the difficulty of transitioning a neurosurgeon from microsurgery within the spinal cord to disc surgery is obviously different from the difficulty of transitioning an orthopedic surgeon from disc surgery to microsurgery of the spinal cord.
With microsurgical skills and a different training background, neurosurgeons have a deeper understanding of the anatomy and physiology of the spinal nerves and are uniquely positioned to handle spinal cord and nerve decompression.
In fact, neurosurgeons can not only maintain and restore spinal stability through internal fixation devices, but can also minimize the impact on spinal stability by reducing the extent of spinal canal openings and surgical trauma to the spine through microsurgical techniques. It can be argued that although neurosurgeons also need training in internal spinal fixation, it is not difficult compared to microsurgery, whereas the transition from orthopedics to spinal neurosurgery requires special training.
The few major neurosurgery centers in China have already established spinal neurosurgery specialties and have done a lot of work with very promising results. The Department of Neurosurgery at Tangdu Hospital established the Spinal Neurosurgery Treatment Center in 2010 and has abandoned the one-sided view and practice of focusing only on spinal nerves and not on spinal structures, on removing tumors and not on preserving the vertebral plates, and on spinal function and not on spinal stability.
We insist on the principle of combining minimally invasive microsurgery and spinal stability, and organically combine neurosurgical microsurgery and spinal internal fixation technology to achieve the perfect effect of relieving patients’ pain and maintaining spinal stability.
So far, we have performed a large number of spinal canal tumor surgeries, especially the difficult tumor surgeries of internal and external communication of the spinal canal and intramedullary tumor of the spinal cord, taking into account the stability of the spinal column. In order to minimize the damage to the stability of the spine, we use minimally invasive surgery with a hemi-vertebral plate as far as possible, without destroying the stability of the spine and eliminating the need for internal fixation, which simplifies the surgical procedure and saves the patient a great deal of money, but of course this is based on the application of microscopic techniques and locked-hole access techniques.
We have also done a lot of work in the treatment of skull base deformity, especially dentate deformity, because the dentate site is deep and the deformed dentate is displaced upward and backward to compress the medulla oblongata, so the operation is very difficult and the operation faces great risks.
In some cases, it is even possible to reposition and internally fix the dentate through the posterior approach, and dozens of cases have been completed, bringing new life to patients who had almost lost hope. Especially in cervical spondylosis and cervical disc herniation, the application of neurosurgical microtechnology has added countless colors to such surgeries. In China, cervical spondylosis has always been the domain of orthopedic treatment, but through the use of microscopy and microtechnology, under the guidance of minimally invasive concept, the anterior cervical spine not only has smaller surgical incision, less strain on the surrounding vital organs, clearer exposure of the structure of the posterior edge of the vertebral body, and gentler harassment of the cervical medulla, but also the use of microscopic grinding drill makes the decompression of the cervical medulla more complete, enabling safe and complete removal of the diseased The use of the microdrill also allows for a more complete decompression of the cervical medulla, allowing for the safe and complete removal of the diseased disc, thickened and calcified ligaments, and hyperplastic bones under direct vision.
It is important to note that spine surgery is a cross-discipline, and neurosurgery and orthopedics each have their own strengths. The relationship between the two disciplines should not be isolated, competitive or even antagonistic, but rather should learn from each other, complement each other’s strengths, promote each other and develop harmoniously. For neurosurgeons, they should take a positive attitude toward spinal surgery, but they must learn spinal fixation techniques from orthopedic surgeons with an open mind and be sure to undergo rigorous training in spinal fixation techniques, not to be blindly arrogant and eager for quick success.
At present, the scale of spinal neurosurgery in China is still far behind that of developed countries in Europe and the United States. Neurosurgeons in China should learn from each other and orthopedic surgeons with the idea of “everything for the patient”, implement the scientific concept of minimally invasive, give full play to the advantages of neurosurgical microscopy, and actively promote the development of spinal neurosurgery in China, ultimately bringing more help to patients. We will bring more help to the patients.