REVIEW OF LITERATURE
HISTORY OF LUMBAR DISC HERNIATION AND MANAGEMENT:
Lumbar disc herniation is the most common cause of sciatica or low back pain which is most
common disabling spinal disorder recorded in history.
In the ancient literature there is no reference to surgical management of sciatic pain.
However, the use of traction, local cauterization, cupping, bloodletting, and
opioids was common in Arabic, Persian, and Islamic medicine and subsequently in
European medicine. Acupuncture has been practiced in Chinese medicine for centuries.
1. It was first with Hippocrates (460-370 B.C.), observations of nature in
combination with logic reasoning as the ground for diagnosis, was applied as method. Thus,
he has been called ‘the founder of scientific medicine’. He produced systematic, anatomical
and pathological reviews especially of the skeleton, joints and spine.
2. Galen of Pergamum (129-200 A.D.) was another Greek physician, but 500 years younger.
He was famous for his meticulous anatomic studies of the spinal cord, nerves and
neurological effects of injuries to these at different levels. He based his knowledge on apes
and pigs, and what remained of the gladiators’ bodies after their fights. He was the first to
describe the nervous system and its effects on muscles and skin sensation. As he also was
Christian and thought his remarkable findings reflected the wisdom of God, his knowledge
was accepted and survived into the Age of Enlightenment.
3. Caelius Aurelianus made a very well expressed clinical description of lumbago with
sciatica.
4. Domenico Cotugno, an Italian physician, introduced the term sciatica into the medical
vocabulary. Without having knowledge of the common
etiology of this disabling spinal disorder, he described some of the signs and symptoms
commonly seen in association with sciatic pain.
5. In the late nineteenth and early twentieth centuries, many investigators contributed to
the understanding of intervertebral disc anatomy.
In 1857, Virchow published autopsy findings on the intervertebral disc in a patient who was
injured and later expired.
In 1868, von Luschka described posterior disc protrusion in cadavers found in the course of
routine autopsy procedures.
In 1926, Schmorl’s contribution to anatomical structures of the intervertebral disc also
deserves recognition. He reported on autopsy findings on 5000 intervertebral discs, 15 of
which showed evidence of disc protrusion into the spinal canal. However, despite this
significant anatomical finding, he had not yet established the causal connection between disc
herniation and sciatic pain.
6. In 1911, Goldthwait described the management of a 39-yr-old male who underwent spinal
manipulation, and then he developed paralysis in the lower extremities. His conservative
management included plaster immobilization and rest. The patient failed to show
improvement, and 6 wk later he underwent extensive decompressive laminectomy, extending
from L1 to S2. The patient responded to the operative procedure and showed improvement.
Goldthwait attributed the patient’s neurological deficit to detachment and protrusion of the
fibrotic annulus into the spinal canal, slippage of the articular processes, and abnormality of
the transverse process of the lumbar segment.
7. In 1927, Putti reported laminectomy and facetectomy to decompress the L5 and S1 nerve
roots and relieve sciatic pain and elaborated on the contribution of Sicard, who performed
laminectomy from L3 to the sacrum to provide relief from sciatic pain.
5. Mixter and Barr are credited for establishing a clear causal connection between the
herniated disc and sciatica. They provided a detailed description of disc herniation and
popularized laminectomy and discectomy for surgical management of herniated lumbar
discs.
8. In 1972,Yasargil,a Turkish surgeon,later modified the traditional surgery described by
Mixter and Barr was later modified with the introduction of the microscope to the surgical
field making it less invasive.
9. In 1950 Hult, advocated an anterior retroperitoneal annular fenestrationfor decompression
of herniated lumbar discs in an article.
10. Lyman Smith should be recognized as a champion of the minimally invasive movement.
Learning from the experience of Lewis Thomas in rabbits, he introduced theconcept of
dissolving the nucleus pulposus by intradiscal injection of chymopapain.
11. in the early 1970s, Kambin initiated a feasibility study on the efficacy of mechanical
nuclear debulking for the treatment of herniated lumbar discs via a Craig cannula inserted
into the intervertebral disc dorsolaterally after approvel of role of chymonucleosis by
institution.
12. In 1975, Hijikata from the Toden Hospital in Japan independently experimented with
mechanical nucleotomy via a 2.6-mm-od cannula that was inserted into the center of the
intervertebral disc via a posterolateral access and reported successful outcomes
postoperatively.
13. Schreiber and Suezawa developed a series of cannulas that were telescoped one over
the other and placed in the center of the intervertebral disc via a posterolateral access.
The larger cannulas with a 7 to 8-mm internal diameter (id) permitted the insertion of
larger forceps and more rapid evacuation of nuclear tissue.
14. In 1985, Onick promoted the concept of central nucleotomy via a mechanical
tool called a nucleotomy.
15. In January 1990, with the permission of the Federal Drug Administration and Internal
Review Board of The Graduate Hospital,initiated a clinical study of the feasibility of
vaporizing disc fragments with laser light under arthroscopic illumination and magnification.
It was found that the wide arc of deflection of the laser fibers and concern about injury to
neural structures prevented adequate decompression and lysis of posterior herniated disc
fragments.
16. In 1807,Bozzini, an obstetrician from Frankfurt, is credited with introducing the concept of
visualizing internal organs,was originally introduced to a faculty in Vienna and was rejected.
17.In 1931,Burman from the Hospital for Joint Diseases in New York City described his
experience with the use of an endoscope for visualization of intracanalicular pathologies of
the cauda equina in cadaver specimens. However, owing to the size of the instruments, he
was unable to inspect the intrathecal structure.
18. Hausmann and Forst used an arthroscope to inspect the contents of the intervertebral disc
following open laminectomy and discectomy.
19. Schreiber et al.used an arthroscope via a second portal that was inserted into the
intervertebral disc dorsolateraly from the opposite side in order to inspect and resect nuclear
tissue under direct visualization.
20. In April 1990, the term minimally invasive spinal surgery was coined when a surgical
approach for the treatment of a variety of spinal disorders under arthroscopic or endoscopic
magnification and illumination became a reality, and the International Society for Minimal
Intervention in Spinal Surgery was established.
ANATOMY AND PATHOPHYSIOLOGY OF LUMBAR DISC HERNIATION
