title: A history of lumbar disc herniation from Hippocrates to the 1990s.
abstract: In ancient times, a supernatural understanding of the syndrome of lumbar radiculopathy often involved demonic forces vexing the individual with often crippling pain. The ancient Greeks and Egyptians began to take a more naturalistic view and, critically, suspected a relationship between lumbar spinal pathology and leg symptoms. Relatively little then changed for those with sciatica until the classic works by Cotugno and Kocher arrived in the late 18th century. Early lumbar canal explorations were performed in the late 1800s and early 1900s by MacEwen, Horsley, Krause, Taylor, Dandy, and Cushing, among others. In these cases, when compressive pathologies were found and removed, the lesions typically were (mis-)identified as enchondromas or osteochondritis dissecans. To better understand the history, learn more about the first treatments of lumbar disc herniation, and evaluate the impact of the early influences on modern spine practice, searches of PubMed and Embase were performed using the search terms discectomy, medical history, lumbar spine surgery, herniated disc, herniated nucleus pulposus, sciatica, and lumbar radiculopathy. Additional sources were identified from the reference lists of the reviewed papers. Many older and ancient sources including De Ischiade Nervosa are available in English translations and were used. When full texts were not available, English abstracts were used. The first true, intentional discectomy surgery was performed by Mixter and Barr in 1932. Early on, a transdural approach was favored. In 1938, Love described the intralaminar, extradural approach. His technique, although modified with improved lighting, magnification, and retractors, remains a staple approach to disc herniations today. Other modalities such as chymopapain have been investigated. Some remain a part of the therapeutic armamentarium, whereas others have disappeared. By the 1970s, CT scanning after myelography markedly improved the clinical evaluation of patients with lumbar disc herniation. In this era, use of discectomy surgery increased rapidly. Even patients with very early symptoms were offered surgery. Later work, especially by Weber and Hakelius, showed that many patients with lumbar disc herniation would improve without surgical intervention. In the ensuing decades, the debate over operative indications and timing continued, reaching another pivotal moment with the 2006 publication of the initial results of Spine Patient Outcomes Research Trial.
authors.affiliation: Seton Spine & Scoliosis Center, A Program of the Seton Brain and Spine Institute, University Medical Center at Brackenridge, 1600 West 38th Street, Suite 200, Austin, TX, 78731, USA, etruumees@gmail.com.
authors.forename: Eeric
authors.initials: E
authors.lastname: Truumees
mesh_terms: D017586:Diskectomy / Q000266:history*; D049668:History, 15th Century; D049671:History, 18th Century; D049672:History, 19th Century; D049673:History, 20th Century; D049690:History, Ancient; D006801:Humans; D007403:Intervertebral Disc / Q000503:physiopathology / Q000601:surgery; D007405:Intervertebral Disc Displacement / Q000266:history* / Q000503:physiopathology / Q000601:surgery; D008159:Lumbar Vertebrae / Q000503:physiopathology / Q000601:surgery; D016896:Treatment Outcome
references.citation: Anesth Analg. 1996 Sep;83(3):559-64
references.pmid: 8780281
references.citation: Acta Orthop Scand Suppl. 1970;129:1-76
references.pmid: 5269867
references.citation: Spine (Phila Pa 1976). 1996 Dec 15;21(24 Suppl):45S-56S
references.pmid: 9112324
references.citation: Acta Neurochir (Wien). 1996;138(2):162-6
references.pmid: 8686539
references.citation: Spine (Phila Pa 1976). 1994 Jan 15;19(2):183-8
references.pmid: 8153828
references.citation: JAMA. 1964 Jan 11;187:137-40
references.pmid: 14066733
references.citation: J Bone Joint Surg Am. 2003 Jan;85(1):102-8
references.pmid: 12533579
references.citation: Spine (Phila Pa 1976). 1998 May 1;23(9):1029-34
references.pmid: 9589542
references.citation: Acta Orthop Scand. 1997 Apr;68(2):116-20
references.pmid: 9174445
references.citation: Spine (Phila Pa 1976). 1989 Jan;14(1):79-81
references.pmid: 2913673
references.citation: Spine (Phila Pa 1976). 1996 Aug 15;21(16):1893-7
references.pmid: 8875722
references.citation: J Spinal Disord. 1999 Aug;12(4):287-92
references.pmid: 10451043
references.citation: Spine (Phila Pa 1976). 1978 Jun;3(2):175-82
references.pmid: 663769
references.citation: Acta Orthop Scand. 1977;48(6):630-4
references.pmid: 607751
references.citation: Acta Neurochir (Wien). 1993;125(1-4):120-6
references.pmid: 8122535
references.citation: Neurosurg Clin N Am. 2001 Jan;12(1):173-9, x
references.pmid: 11175997
references.citation: Chir Organi Mov. 1999 Oct-Dec;84(4):367-73
references.pmid: 11569004
references.citation: Acta Neurochir (Wien). 1984;73(3-4):213-21
references.pmid: 6240194
references.citation: Acta Neurochir Suppl. 2011;108:117-21
references.pmid: 21107947
references.citation: J Neurol Neurosurg Psychiatry. 1988 Feb;51(2):169-73
references.pmid: 3346682
references.citation: Clin Neurosurg. 1968;15:343-51
references.pmid: 4945161
references.citation: Spine (Phila Pa 1976). 1980 Jul-Aug;5(4):366-70
references.pmid: 7455766
references.citation: Spine (Phila Pa 1976). 1988 Jun;13(6):690-5
references.pmid: 3175759
references.citation: J Spinal Disord. 1994 Apr;7(2):161-6
references.pmid: 8003834
references.citation: J Bone Joint Surg Am. 1990 Feb;72(2):230-7
references.pmid: 2303509
references.citation: J Bone Joint Surg Am. 1947 Apr;29(2):461-75
references.pmid: 20240207
references.citation: South Med J. 1983 Feb;76(2):232-8
references.pmid: 6337407
references.citation: Spine (Phila Pa 1976). 1978 Sep;3(3):256-9
references.pmid: 152469
references.citation: Orthop Clin North Am. 1991 Apr;22(2):223-34
references.pmid: 2014120
references.citation: Acta Chir Scand. 1957 Oct 12;113(6):436-7
references.pmid: 13507934
references.citation: Surg Technol Int. 2004;13:276-86
references.pmid: 15744701
references.citation: AJNR Am J Neuroradiol. 1983 May-Jun;4(3):609-10
references.pmid: 6410811
references.citation: J Spinal Disord. 1999 Jun;12(3):192-6
references.pmid: 10382771
references.citation: Spine (Phila Pa 1976). 1996 Aug 1;21(15):1777-86
references.pmid: 8855462
references.citation: Spine (Phila Pa 1976). 1999 Nov 15;24(22):2346-51
references.pmid: 10586459
references.citation: Cochrane Database Syst Rev. 2013 Aug 19;(8):CD003010
references.pmid: 23959683
references.citation: Arq Neuropsiquiatr. 2005 Sep;63(3A):701-6
references.pmid: 16172729
references.citation: Spine (Phila Pa 1976). 1987 Apr;12(3):264-8
references.pmid: 2954221
references.citation: Surg Neurol. 1992 Oct;38(4):315-7
references.pmid: 1440224
references.citation: JAMA. 2006 Nov 22;296(20):2441-50
references.pmid: 17119140
references.citation: J Bone Joint Surg Am. 2002 Nov;84(11):2022-8
references.pmid: 12429765
references.citation: Neurosurgery. 1991 Jan;28(1):78-86; discussion 86-7
references.pmid: 1994285
references.citation: Acta Neurochir Suppl. 2005;92:79-82
references.pmid: 15830973
references.citation: Spine (Phila Pa 1976). 1984 Jul-Aug;9(5):496-9
references.pmid: 6495014
references.citation: Spine (Phila Pa 1976). 1995 Feb 1;20(3):353-5
references.pmid: 7732472
references.citation: Acta Neurochir (Wien). 2010 Sep;152(9):1555-8
references.pmid: 19404576
references.citation: J Bone Joint Surg Am. 1947 Apr;29(2):429-37
references.pmid: 20240203
references.citation: Spine (Phila Pa 1976). 2014 Nov 15;39(24):E1448-65
references.pmid: 23970106
references.citation: Acta Neurochir (Wien). 1984;73(1-2):67-76
references.pmid: 6238507
references.citation: J Neurosurg. 1994 Sep;81(3):350-3
references.pmid: 8057141
references.citation: Neurosurgery. 1988 Jan;22(1 Pt 1):82-5
references.pmid: 3344091
references.citation: Spine (Phila Pa 1976). 1993 Jan;18(1):24-7
references.pmid: 8434321
references.citation: AJR Am J Roentgenol. 1985 Jun;144(6):1137-40
references.pmid: 3873792
references.citation: J Bone Joint Surg Am. 1990 Mar;72(3):403-8
references.pmid: 2312537
references.citation: J Bone Joint Surg Am. 2003 Sep;85(9):1749-56
references.pmid: 12954834
references.citation: Neurosurg Focus. 2004 Jan 15;16(1):E7
references.pmid: 15264785
references.citation: Acta Orthop Scand. 1990 Oct;61(5):399-403
references.pmid: 2239161
references.citation: Clin Orthop Relat Res. 1977 Nov-Dec;(129):22-45
references.pmid: 608279
references.citation: Clin Orthop Relat Res. 1989 Jan;(238):4-8
references.pmid: 2642775
references.citation: Neurosurg Focus. 2004 Jan 15;16(1):E6
references.pmid: 15264784
references.citation: J Spinal Disord. 1999 Feb;12(1):77-9
references.pmid: 10078955
references.citation: J Bone Joint Surg Br. 1998 Mar;80(2):201-7
references.pmid: 9546444
references.citation: Spine (Phila Pa 1976). 1994 Jun 1;19(11):1207-12; discussion 13
references.pmid: 8073311
references.citation: Spine (Phila Pa 1976). 1989 Apr;14(4):431-7
references.pmid: 2718047
references.citation: Spine (Phila Pa 1976). 1999 Nov 15;24(22):2358-62
references.pmid: 10586461
references.citation: Neurosurgery. 2002 Nov;51(5 Suppl):S123-8
references.pmid: 12234439
references.citation: Neurosurgery. 1988 May;22(5):837-41
references.pmid: 2967924
references.citation: Surg Neurol. 1977 Nov;8(5):331-6
references.pmid: 918830
references.citation: Eur Spine J. 1992 Sep;1(2):89-95
references.pmid: 20054953
references.citation: Neurosurgery. 1988 Mar;22(3):523-6
references.pmid: 3362318
references.citation: Clin Orthop Relat Res. 1996 Apr;(325):148-55
references.pmid: 8998867
references.citation: Spine (Phila Pa 1976). 1990 May;15(5):383-6
references.pmid: 1694599
references.citation: Spine (Phila Pa 1976). 1992 Dec;17(12):1457-61
references.pmid: 1471003
references.citation: Semin Roentgenol. 2004 Jan;39(1):52-67
references.pmid: 14976837
references.citation: Spine (Phila Pa 1976). 1996 May 1;21(9):1048-54; discussion 1055
references.pmid: 8724089
references.citation: Acta Neurochir Suppl. 2011;108:17-21
references.pmid: 21107933
references.citation: Spine (Phila Pa 1976). 1982 Nov-Dec;7(6):604-7
references.pmid: 7167834
references.citation: Acta Orthop Scand Suppl. 1993;251:45-6
references.pmid: 8451983
references.citation: Spine (Phila Pa 1976). 1994 May 15;19(10):1117-23; discussion 1123-4
references.pmid: 8059266
references.citation: Spine (Phila Pa 1976). 2011 Oct 15;36(22):E1477-84
references.pmid: 21217428
references.citation: Spine (Phila Pa 1976). 1983 Mar;8(2):131-40
references.pmid: 6857385
references.citation: Spine (Phila Pa 1976). 1995 Feb 15;20(4):460-8
references.pmid: 7747230
references.citation: J Bone Joint Surg Br. 1993 Nov;75(6):894-7
references.pmid: 8245078
references.citation: Spine (Phila Pa 1976). 1996 Mar 1;21(5):626-33
references.pmid: 8852320
references.citation: Clin Neurosurg. 1980;27:541-52
references.pmid: 6456105
references.citation: Spine (Phila Pa 1976). 1995 Jul 1;20(13):1500-5
references.pmid: 8623070
references.citation: Neurosurgery. 1981 Apr;8(4):422-7
references.pmid: 7242893
references.citation: Spinal Cord. 1997 Mar;35(3):139-46
references.pmid: 9076863
references.citation: Spine (Phila Pa 1976). 2000 Nov 1;25(21):2838-43
references.pmid: 11064533
references.citation: Spine (Phila Pa 1976). 1993 Nov;18(15):2206-11
references.pmid: 8278833
references.citation: Spine (Phila Pa 1976). 1999 Jul 1;24(13):1381-7
references.pmid: 10404583
references.citation: Spine (Phila Pa 1976). 1992 Aug;17(8):949-56
references.pmid: 1387977
references.citation: Anesth Analg. 1959 Mar-Apr;38(2):118-24
references.pmid: 13627523