GENERAL

Legacy

THE EVOLUTION OF INTRAMEDULLARY

SPINAL CORD TUMOR SURGERY
Daniel M. Sciubba, M.D.
Department of Neurosurgery,
The Johns Hopkins University,
Baltimore, Maryland
Daniel Liang, M.D.
Department of Neurosurgery,
University of Maryland,
Baltimore, Maryland
Karl F. Kothbauer, M.D.
Division of Neurosurgery,
Kantonsspital Luzern,
Lucerne, Switzerland
Joseph C. Noggle, B.S.
Department of Neurosurgery,
The Johns Hopkins University,
Baltimore, Maryland
George I. Jallo, M.D.
Department of Neurosurgery,
The Johns Hopkins University,
Baltimore, Maryland
OBJECTIVE: Resections of intramedullary spinal cord tumors were attempted as early
as 1890. More than a century after these primitive efforts, profound advancements in
imaging, instrumentation, and operative techniques have greatly improved the mod-
ern surgeon’s ability to treat such lesions successfully, often with curative results.
METHODS: We review the history of intramedullary spinal cord tumor surgery, as well
as the evolution and advancement of technologies and surgical techniques that have
defined the procedure over the past 100 years.
RESULTS: Surgery to remove intramedullary spinal cord tumors has evolved to include
sophisticated imaging equipment to pinpoint tumor location, laser scalpel systems to
provide precise incisions with minimal damage to surrounding tissue, and physiolog-
ical monitoring to detect and prevent intraoperative motor deficits.
CONCLUSION: Modern surgical devices and techniques have developed dramatically
with the availability of new technologies. As a result, continual advancements have
been achieved in intramedullary spinal cord tumor surgery, thus increasing the safety
and effectiveness of tumor resection, and progressively improving the overall outcomes
in patients undergoing such procedures.
KEY WORDS: History, Intramedullary, Spinal cord, Surgery, Tumor
Neurosurgery 65[ONS Suppl 1]:ons84–ons92, 2009 DOI: 10.1227/01.NEU.0000345628.39796.40

Reprint requests:
Daniel M. Sciubba, M.D.,
600 North Wolfe Street,
Meyer Building 8-161,
Baltimore, MD 21237.
Email: dsciubb1@jhmi.edu
Received, August 22, 2008.
Accepted, October 23, 2008.
Copyright © 2009 by the
Congress of Neurological Surgeons
F
rom the rather primitive beginnings of sur-
gery on the nervous system with Victor
Horsley to the current state-of-the-art with
sophisticated imaging, microsurgery, lasers, and
intraoperative neurophysiology, spinal cord
tumor surgery has evolved and benefited from
general progress of the special field of neurolog-
ical surgery and the clinical and scientific contri-
butions of a number of bold pioneers. The “two-
stage” technique of Elsberg and Beer (23),
Greenwood’s “two-point coagulation” (29), the
operating microscope, magnetic resonance
imaging (MRI), and the surgical laser are techni-
cal milestones in the advancement of knowl-
edge and practice as well as the improvement of
outcomes in patients with spinal cord tumors.
Surgical resection of intramedullary spinal
cord tumors currently remains one of the more
demanding procedures in neurosurgery. How-
ever, because of the techniques and techno-
ABBREVIATIONS: MEP, motor evoked potential;
MRI, magnetic resonance imaging; Nd:YAG,
neodymium:yttrium-aluminum-garnet; NMR,
nuclear magnetic resonance; US, ultrasound
logies developed over the past 100 years,
patients harboring such lesions may benefit
from curative resections yielding minimal neu-
rological deficits (Table 1).
THE BEGINNINGS
The first attempt to remove an intramedul-
lary tumor from the spinal cord is thought to
have been performed in the year 1890 by
Chicago surgeon Christian Fenger, who oper-
ated on a 38-year-old man with progressive
paraparesis at the T4–T5 level. The patient
remained paralyzed and died on postoperative
day 5 (9). Perhaps other attempts were made,
but never recorded. By the end of the 19th cen-
tury, Vienna, the capital of what was then the
Austro-Hungarian Empire, had become one of
the premier centers of medical excellence in
Europe. Anton von Eiselsberg, who chaired the
Department of Surgery at the University of
Vienna, was an innovative surgical generalist
who ventured into procedures involving the
nervous system (Fig. 1) (20). On November 13,
1907, he performed what is believed to be the

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 HISTORY OF INTRAMEDULLARY SPINE TUMOR SURGERY

first successful resection of ments, hemostasis with hot

an intramedullary tumor of saline packings, and then
the spinal cord. His patient multilevel laminectomies.
was a 27- year- old woman They found no epidural
with progressive paraparesis lesions, so they continued to
and back pain in the supine explore the intradural space.
position. Based on transla- While opening the dura, they
tion from the original report accidentally nicked the pos-
in German, he began with a terior aspect of the spinal
laminectomy of T7 and T8, cord in 2 areas. Upon closer
then extended the opening to examination, Elsberg noticed
T10, and eventually cranially abnormal-appearing tissue
to T6. Upon opening the extruding from the myelo-
dura in the upper portion of tomy incisions. He pro-
this exposure, he noted an ceeded to connect these 2
enlargement of the cord and defects and lengthen the
a blue oval tumor on the myelotomy. With an im - FIGURE 2. Portrait of Charles A.
right side covered by a thin proved view of the abnormal Elsberg. (Reprinted with permis-
translucent layer of spinal tissue, he concluded that it sion from Horwitz NH: Charles A.
cord. The tumor, measuring represented some sort of Elsberg [1871–1948]. Neurosurgery
4 ⫻ 1 cm, was removed with tumor within the cord. At 40:1315–1319, 1997.)
“blunt” dissection. The dura this point, the surgery was
was closed with catgut su- FIGURE 1. Portrait of Anton von interrupted by hemodynamic instability of the patient, so
tures and the wound closed Eiselsberg. (From the Clendening Elsberg ceased manipulating the spinal cord and closed the
with 4 drainage tubes in - Library Portrait Collection, The wound. It would be a week later before the patient would be
serted. The histology was University of Kansas Medical healthy enough to undergo reoperation.
described as “neurofibrosar- Center, Kansas City, Kansas.) During the second surgery, it turned out that Elsberg was sur-
coma.” A cerebrospinal fluid prisingly lucky. After reopening the wound and dura, he found
leak is described, but the patient apparently recovered, as it is that the tumor mass had “extruded itself.” The majority of the
noted that she was able to walk 22 months after surgery. The last tumor had pushed its way out of the cord, allowing relatively
follow-up evaluation noted, in September 1913, approximately easy separation from the cord with minimal manipulation. The
6 years after surgery, indicated that the patient was “well” and excised tumor was confirmed by pathology to be a gliosarcoma.
“able to go on long walks” (19). Thus, this has been credited as The patient did well and went on to regain most motor function
the first successful spinal cord tumor resection (21, 42). with the help of rehabilitation by 8 months postoperatively.
In the midst of various reports from the end of the first decade Elsberg’s second case with a similar history benefited from
of the 20th century (43, 63), the work of a pioneering New York the earlier experience. In this case, Elsberg did not hesitate and
City surgeon, Charles A. Elsberg (Fig. 2), stands out. He was decided to operate before the patient worsened to an even
2 years younger than Harvey Cushing and had also undergone greater degree. Using his standard approach, he noted an
the then-traditional training pattern of his American colleagues enlargement of the cord and made a midline myelotomy over
by traveling to Europe to apprentice under established general the most prominent area of spinal cord bulging. Similar to his
surgeons (33). By 1909, he had established himself as an expert other patient, he again witnessed an abnormally appearing
in cranial and spinal surgery and published several reviews mass immediately extruding itself through the myelotomy inci-
about his experiences. Then, several months later in 1910, he sion. Because the lesion appeared to be well encapsulated and
came upon 2 patients who would later become his first experi- had already delivered itself, he decided it would be amenable
ences with intramedullary spinal cord tumors. to immediate resection. He then proceeded to dissect the
These 2 patients were referred to him for evaluation because remaining attachments and removed the tumor en bloc. This
of their progressive back pain and deteriorating motor and sen- entire operation lasted less than 40 minutes. Unfortunately,
sory functioning, presumably caused by a spinal tumor. He shortly after surgery, this patient developed severe respiratory
believed the pathology was localized in or around the spinal distress and died a few hours later. Interestingly, the post-
cord and that the pathology was most likely a mass lesion, per- mortem examination revealed no wound or spinal cord
haps a tumor, which could be surgically removed to provide hematomas that could explain the rapid death of this patient.
improved clinical status.
Elsberg and his assistant, Edwin Beer, proceeded to explore THE “TWO-STAGE OPERATION”
the spinal canal and report their findings (23). They approached
the canal in their “usual fashion,” consisting of a midline incision After comparing his first 2 outcomes after intramedullary
over the spinous processes, dissection down to the bony ele- spinal cord tumor resection, Elsberg attributed the poor outcome

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SCIUBBA ET AL.
A B
C lar unit to power coagulation forceps. (Reprinted with
FIGURE 3. Illustrations of
Elsberg’s “two-stage operation” for
removal of spinal cord tumors, in
his 1913 manuscript entitled,
“Experiences in Spinal Surgery,
Observations upon 60 Laminec-
tomies for Spinal Disease” (23).
(From World Spine Journal.)
in his second patient to manipulation of the spinal cord sub-
stance during a more aggressive dissection. Thus, he concluded
that this operation would be safest if done in a “two-stage” man-
ner (Fig. 3). The following excerpt from an article on his initial
experiences summarizes “the method of extrusion” (23):
The above two operations for intra medullary
tumors of the spinal cord demonstrate that localized
growths of the cord substance must not be considered
as inoperable. They should be attacked by the neuro-
logical surgeon as readily as subcortical
Based on the anatomic grounds stated above, the writers
suggest the following method of treatment for intramedullary
tumors of the cord:
If after laminectomy and incision of the dura the
surgeon finds that he has to deal with a localized
intramedullary growth, he should make a small inci-
sion, about 1 cm long, in the posterior median col-
umn a few millimeters outside of the posterior
median fissure, at the spot where the growth seems to
be nearest the surface of the cord. The incision should
be deep enough to cut the pia and the substance of the
column down to the tumor. The tumor will then begin
to bulge through the incision. No matter how
markedly the tumor will seem to bulge, the surgeon
must not attempt to remove the growth, for he will be
ons86 | VOLUME 65 | OPERATIVE NEUROSURGERY 1 | DECEMBER 2009
FIGURE 4. Greenwood’s original setup using a monopo-
permission from Malis LI: Electrosurgery and bipolar
technology. Neurosurgery 58 [1 Suppl] ONS1–12,
2006.)
sure to cause grave injury to the cord. He must leave
it to nature to extrude the tumor. As the normal
intramedullary pressure will tend to readjust itself,
the growth, which has caused an increased pressure,
will be gradually pushed out of its bed. Nature will
do this by a slow and gradual process, and the tumor
will be slowly extruded, with a minimum of injury of
nerve fibers. Therefore, after the small incision into
the cord has been made, the muscles and skin must be
closed and the actual removal of growth left to a sec-
ond operation. After about one week the wound is
reopened and the tumor, which will in all probability
be found outside of the cord, can be removed by
dividing the few adhesions which remain. If the
manipulations are done with delicacy and care, no
injury should be done to the cord substance.
This was the very first real surgical concept for the resection
of intramedullary tumors. It can be regarded as a relatively
safe and conservative approach given the lack of specialized
equipment surgeons had at their disposal, and for today’s stan-
dards, amazing diagnostic uncertainty. Elsberg’s first book,
Diagnosis and Treatment of Surgical Diseases of the Spinal Cord and
Its Membranes, was published in 1916. It had a widespread
influence at the time and remains an impressive publication to
this day (33). The two-stage operation is still occasionally used
today under certain circumstances, such as unclear intraoper-
ative pathology or poor identification of a clear surgical plane
between tumor and cord (1).
BIPOLAR CAUTERY
In the late 1930s, James Greenwood, Jr., began using a tech-
nique at the Methodist Hospital in Houston that he termed the
“two-point coagulation forceps” (29, 30) (Fig. 4). This technology
was later refined by Leonard Malis, and eventually became what
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 HISTORY OF INTRAMEDULLARY SPINE TUMOR SURGERY

TABLE 1. Chronology of advancements in intramedullary spinal cord tumor surgerya

Year Surgeon Advancement
1907 Anton Freiherr von Eiselsberg First to resect an intramedullary spinal tumor and confer neurological improvement
1910 Charles A. Elsberg Two-stage technique
1940 James Greenwood, Jr. Two-point coagulation forceps
1954 Greenwood’s first series of intramedullary tumor resections showing long-term success
1957 Theodore Kurze First neurosurgeon to use a microscope in the operating room
1966 Hubert L. Rosomoff First to report use of a ruby laser for surgery on a brain tumor
1977 Raymond V. Damadian Demonstrated MRI of the whole body in a human
1978 Flamm and Ransohoff Ultrasonic ablator used for brain tumors
1982 Fred Epstein Ultrasonic ablator used for spinal cord tumors
1980–1983 Chandler and Knake, Rubin and Contemporaneously pioneered intraoperative use of ultrasound (imaging) for brain
Dohrmann, and Masuzawa et al. and spinal surgery
1983 MRI used commercially for imaging intramedullary spinal cord tumors
1986–1989 MEP monitoring used for neurosurgical operations on the spinal cord
1993 Fred Epstein Reports on plated bayoneted forceps to retract normal spinal cord when resecting an
intramedullary tumor
2002 George I. Jallo First report on Nd:YAG contact laser for intramedullary spinal tumors
a
MRI, magnetic resonance imaging; MEP, motor evoked potential; Nd:YAG, neodymium:yttrium-aluminum-garnet.

is now generally known as bipolar cautery (5, 46), an essential
microneurosurgical dissection and hemostasis technique. It was
far superior to older methods, such as saline hot packs, and it
decreased damage to surrounding tissue over monopolar elec-
trocautery. By allowing electric current to flow between the 2 tips
of the forceps, there was less transmission of electricity and its
associated heat to the surrounding tissue. This property greatly
facilitated Greenwood’s coagulation of tiny feeding vessels
specifically in removing tumors from the spinal cord.
Greenwood’s first series of intramedullary tumor resections
was reported in 1954 (31). Not surprisingly, in the 9 of 10 cases
involving gross total resections, 9 were found to be ependymo-
mas. He then reported a follow-up study in 1963 (32). Of the
8 patients who were still living at the time of follow-up, all
had preserved ambulation with or without crutch assistance.
From his experience, he concluded that gross total resection
should be attempted in tumors with clear cleavage planes, as
may be the case with ependymomas, because of the high
chance of neurological improvement and long-term control of
local recurrence. He emphasized the use of bipolar coagulation
to minimize trauma to surrounding neural elements and
stressed the importance of identifying and dissecting the cleav-
age plane to differentiate normal cord tissue from the tumor.
This was the first series of spinal cord tumor resections
reported that showed long-term beneficial results.
THE MICROSCOPE
Today, the surgical microscope seems to be an essential instru-
ment in the armamentarium of every neurosurgeon. However,
its evolution from the simple invention of Hans and Zacharias
Janssen, Galileo Galilei, and Anton von Leeuwenhoek to its cur-
rent form can be attributed to many pioneers who implemented
it not only for laboratory work but also for surgical use (44). In
1848, German machinist Carl Zeiss opened his microscope
workshop in Jena, Germany. Ernst Abbé, a physicist working
with Zeiss, derived new mathematical formulas, and the two
began to revolutionize lens making. For the first time, the opti-
cal qualities of a lens could be predicted and standardized,
allowing Zeiss to become the first mass producer of high-
quality microscopes. In 1893, he introduced the concept of stere-
opsis with the binocular telescope (44). By the early 1920s, oto-
laryngologists began using more advanced dissecting micro-
scope prototypes for otological dissection. Specifically, in 1921,
Maier and Lion published their observations of endolymph
movements in the ears of live pigeons (14). That same year,
Swedish otolaryngologist Carl Nylén built a monocular micro-
scope and was the first to use it clinically for treating a patient
with chronic otitis media (52).
In 1922, Holmgren attached a light source to an existing Zeiss
dissecting microscope, thus introducing the first binocular sur-
gical microscope (14). For the next few decades, otolaryngolo-
gists in Europe continued to expand and refine the use of the
surgical microscope. In the late 1950s, Howard and William
House made significant contributions to middle ear surgery
via highly successful microscopic temporal bone operations (6,
14, 34). After practicing dissection techniques with the micro-
scope in the House’s laboratory, Theodore Kurze became the
first neurosurgeon to use a microscope in the operating room
(44). In 1957, he removed a neurilemoma from the seventh
nerve of a 5-year-old patient (16). Kurze went on to introduce
many neurosurgeons to the operating microscope, including

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SCIUBBA ET AL.
Robert Rand, J. Lawrence Pool, and Charles Drake. In 1965,
J. Lawrence Pool became the first neurosurgeon to publish an
account of aneurysm surgery using the microscope (44). In the
late 1960s and the 1970s, M. Gazi Yaşargil and Hugo Krayenbühl
used the operating microscope for spinal cord pathology. In
1976, Yaşargil published a series involving 12 patients who
underwent “microsurgical” resection of intramedullary spinal
hemangioblastomas (66). Since that time, the operating micro-
scope has gone through many stages of evolution, now acting as
an indispensable tool for spinal cord tumor surgeons.
ULTRASONIC ASPIRATOR
Ultrasonic aspiration first entered medical use in 1947, orig-
inally developed for removal of dental plaques (35), and has
been adapted by various medical fields over the years. It was
eventually modified and, 30 years after its inception, intro-
duced into neurosurgical use by Flamm et al. (28) who docu-
mented successful removal of intracranial tumors. Shortly
thereafter, in 1982, Epstein and Epstein (24) published an arti-
cle on its use for spinal cord tumors.
The ultrasonic aspirator was found to be effective in localized
tissue removal via a combination of suction and high-frequency
vibration (28, 35). Via 2 mechanisms of tissue rupture, removal
of tumor could be accomplished with limited damage to neigh-
boring tissue (67). The first mechanism is based on suction.
Aspiration of the tissue brings it to the tip of the instrument
where transmission of acoustic energy leads to fragmentation.
The second mechanism is local cavitation. Acoustic energy
transmitted into neighboring tissue causes vapor pockets to
form around cells in tissues with high water content. Bonds
between tissue cells eventually rupture with collapse of these
pockets. Interestingly, tissues with weak intercellular bonds,
such as tumors and lipomas, have been found to be easy to
fragment, whereas tissues with strong bonds, such as nerves
and vessels, are more difficult to destroy (35). Current ultra-
sonic ablators confer precise localized tissue fragmentation and
aspiration to within approximately 1 mm of the tip. The small
working area of intramedullary spinal cord access makes the
ultrasonic ablator invaluable in seeking to minimize surround-
ing parenchymal injury.
INTRAOPERATIVE ULTRASONOGRAPHY
IMAGING
Intraoperative use of ultrasound (US) for brain and spinal
surgery was pioneered contemporaneously in the early 1980s
by Chandler and Knake (7), Chandler et al. (8), Knake et al.
(39–41), Dohrmann and Rubin (15), Rubin and Dohrmann (57,
58), Rubin et al. (59–61), and Masuzawa et al. (48). In 1980,
Rubin described intraoperative examination of the brain, and
from 1981 to 1983, all 3 groups described use of US for intra-
operative imaging of brain and spinal cord tumors. By the
early 1990s, US was being used consistently by Epstein et al.
(26) for all intramedullary tumor resections. In the report on
their series of 186 intramedullary spinal cord tumors, Epstein
ons88 | VOLUME 65 | OPERATIVE NEUROSURGERY 1 | DECEMBER 2009
et al. (26) proposed that intraoperative sonography had “per-
mitted more complete and better-guided radical resection of
spinal cord neoplasms, with improved postoperative quality
of neurological function,” (26, pp 732–733). This was achieved
by improved tumor localization, tumor and cyst characteriza-
tion, placement of myelotomy, and tumor resection monitor-
ing, all of which were influenced by the US visualization avail-
able during surgery.
Regarding tumor localization, extensive exposure of the
spinal cord beyond what is necessary to identify the tumor
had its drawbacks. First, a long laminectomy can potentially
increase the chance of postoperative spinal deformity. Second,
a long durotomy can increase contamination of the subdural
or subarachnoid space with epidural debris. Conversely, if
either opening is too limited rostrocaudally, an incomplete
resection is possible. US has permitted tailoring of exposure
before opening the dura. When MRI became available, the
ability to compare the intraoperative echographic image with
the preoperative magnetic resonance image further improved
exposure planning (59).
As an aid to myelotomy placement, US can be used to localize
the posterior midline via identification of spinal cord distortion,
the position of the dorsal root entry zone, and the location of the
dentate ligaments. The transverse image can then be used to
localize the midline, where the tumor is bulkiest and where the
surrounding cord is most splayed, and the sagittal image can be
used to define the cephalocaudal extent of the myelotomy.
Furthermore, if the lesion is associated with a cyst, the myelo-
tomy can be started at the cyst-tumor junction in the posterior
midline. Epstein et al. (26) proposed that limiting the myelo-
tomy to the extent of the neoplasm was particularly important at
the level of the conus, where cord segments are closely approx-
imated, because an unnecessarily long myelotomy could more
easily lead to postoperative deficits. Finally, US has allowed
intraoperative feedback of the extent of tumor resection, espe-
cially involving cases of astrocytoma in which the glial-tumor
interface is often difficult to identify visually as the resection
proceeds. The initial US image, which shows an echogenic
intramedullary mass can be sequentially compared with subse-
quent images, noting the magnitude of the residual echogenic
signal, the amount of lateral and ventral cord remaining, and the
presence of residual intratumoral cyst of calcification.
DEVELOPMENT OF MRI
MRI is now an indispensable tool for managing intra -
medullary spinal cord tumors. Its early development can be
attributed to a series of Nobel Prize laureates who have helped
to uncover the behavior of atoms in magnetic fields. Such indi-
viduals include Isidor Isaac Rabi (55), who developed the first
basic nuclear magnetic resonance (NMR) device in 1938, and
Felix Bloch (2, 3) and Edward Purcell (54), who conducted more
precise NMR experiments that eliminated the need to vaporize,
and thus destroy, the sample in 1945. By 1971, Raymond V.
Damadian (11) demonstrated in vitro that an NMR tissue
parameter (T1 relaxation time) of tumor samples was signifi-
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cantly higher than normal tissue; in 1973, Paul Lauterbur (45)
published “Image formation by induced local interaction:
Examples employing magnetic resonance.” By 1975, Richard R.
Ernst (27) proposed a method of obtaining NMR-tomographic
images using phase and frequency encoding and the Fourier
transform. By changing radiosignals, Ernst succeeded in mak-
ing the technology more sensitive and easier to interpret. This
technique formed the basis for current MRI techniques.
Perhaps one of the more serendipitous of the technological
developments of the 1970s was superconductors. These devices
helped to make possible the strong magnetic fields used in
MRI. In 1977, Damadian (12) demonstrated MRI of the whole
body in a human. In that same year, Mansfield (47) developed
the echo planar imaging technique. With his novel mathemat-
ical analysis of NMR signals, he improved imaging techniques
and showed how fast imaging could be achievable. In 1980,
Edelstein et al. (17, 18) demonstrated imaging of the body using
Ernst’s technique. A single image could be acquired in approx-
imately 5 minutes using this technique. Such capabilities would
be further developed in later years to produce images at video
rates (30 ms/image).
By 1983, published accounts of preliminary experience with
MRI of the spinal cord and intramedullary pathology were
becoming more widespread. Norman et al. (51) described their
results of 17 patients: “The ability to image the cord directly
rather than indirectly as in myelography, the absence of bone
artifact as in computed tomography, and the multiplanar capa-
bilities indicate that MRI will be the procedure of choice in the
examination of the spinal cord,” (p 1147).
Since that time, the use of MRI for preoperative diagnosis,
localization, and operative planning has been of paramount
importance in managing intramedullary spinal cord tumors.
INTRAOPERATIVE NEUROPHYSIOLOGICAL
MONITORING
In 1947, Dawson (13) recorded the first use of somatosensory
evoked potentials; in 1978, a description of the first use of
somatosensory evoked potentials during spinal surgery was
published (22). In 1980, the first successful transcranial electri-
cal motor cortex stimulation in humans was reported (49). With
these achievements, a wave of work emerged during the 1980s
to develop feasible techniques to continuously record motor
evoked potentials (MEPs). One of the early reports describes its
use in scoliosis surgery (4). In 1989, Zentner (68) reported on his
series of 50 patients who had undergone MEP monitoring dur-
ing neurosurgical operations on the spinal cord. He noted that
postoperative neurological complications coincided with per-
manent reduction in amplitudes of more than 50% of the base-
lines in every case.
Initially, motor pathway monitoring could use only one neu-
rophysiological modality, the D wave (53). The D wave results
from direct activation of large-diameter corticospinal axons
through transcranial cortical stimulation with an electric cur-
rent. The wave is recorded over the spinal cord distal to the sur-
gical site, and its amplitude is a measure of the number of
NEUROSURGERY
HISTORY OF INTRAMEDULLARY SPINE TUMOR SURGERY
intact axons. Thus, an amplitude decrease corresponds to a
similar decrease in the number of functioning axons. Using D
wave monitoring during intramedullary surgery, Morota et al.
(50) concluded that MEP monitoring provided a reliable predic-
tor of functional outcome intraoperatively.
The use of MEPs recorded from peripheral muscles became
possible, but it was not until the 1990s, when the “multipulse”
stimulation technique was developed, that it became a reliable
technique (64). With this development, the blockade of spinal
motor neurons by anesthetic mediation was overcome. The
muscle MEPs proved particularly useful in spinal cord surgery
because they have a unique “all-or-none” interpretation profile.
D wave and muscle MEPs together are the current standard of
intraoperative monitoring for spinal cord surgery, and provide
a safeguard for the surgeon to avoid functional deterioration in
the patient.
Today, this combination has even allowed surgeons to iden-
tify a “window of warning,” i.e., a neurophysiological correla-
tion to a temporary paraparesis. The loss of muscle MEPs dur-
ing surgery, with preservation of the D wave, correlates to a
temporary motor deficit. This allows the surgeon to change
course, even to stage a tumor resection before a definite irre-
versible deficit.
PLATED BAYONETED FORCEPS
Among technological advances, even those that are seem-
ingly small, specialized modifications to standard instruments
can have immense value. Many intramedullary tumors leave
only a thin mantle of spinal cord tissue surrounding the grow-
ing mass. Functional tracts stretched within this mantle can be
damaged with cord manipulation during surgery. In the early
1990s, surgeons began using bayoneted forceps with shovel-
like plates instead of tips to retract normal spinal cord when
resecting an intramedullary tumor. The modified “plated bay-
onet” forceps have rounded, flat tips measuring approximately
4 mm in diameter (25). This creates a larger tip profile, and the
distracting forces of the forceps are transmitted to the tissue
across a larger area compared with that of traditional cylindri-
cally tapered tips, leading to a lower and less focal pressure
transmission to tissue. Intrinsic prying action of the forceps
then allows gentle opening of the myelotomy, improving the
exposure without increasing spinal cord trauma.
SURGICAL LASER
In a laser scalpel system, energy is transmitted through a
flexible fiber cable to a coated sapphire crystal probe tip. The
laser beam resides only within the sapphire tip, and the ther-
mal energy is delivered to the tissue only on direct contact.
Use of the contact laser scalpel in neurosurgery was initially
described in experimental studies on rabbits (38). In these stud-
ies, carotid endarterectomy was performed using a contact
laser scalpel attached to an argon laser and the laser energy was
delivered through a sapphire crystal tip (37). This laser scalpel
system allowed for precise delivery of the laser energy to the
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SCIUBBA ET AL.
targeted tissue, producing minimal damage to adjacent healthy
structures. Furthermore, it provided tactile feedback on the
depth of laser penetration and the amount of pressure applied.
With these findings, the authors suggested that the laser
scalpel’s ability for producing fine, precise, hemostatic inci-
sions made it potentially useful for making spinal cord inci-
sions or removing tumors from adjacent critical structures.
In 1966, Rosomoff and Carroll (56) were the first to report the
use of a ruby laser for surgery on a brain tumor. In the 1970s, the
neodymium:yttrium-aluminum-garnet (Nd:YAG) laser was
introduced into the medical field (62). Nd:YAG and argon lasers
use a fiberoptic cable to transmit light. In 1984, sapphire tips
were attached to the quartz fiber of the Nd:YAG laser (10). As a
result, the laser beam resides entirely within the crystal, and
laser energy is only delivered to tissue on direct contact. In 2002,
the first report on the clinical use of the Nd:YAG laser scalpel in
contact mode as a surgical scalpel for dysraphic conditions and
intradural spinal tumors was published (36). Among the advan-
tages of the laser scalpel over freestanding, noncontact, laser
beam are the following: 1) beam alignment, 2) better energy uti-
lization with minimal loss of thermal energy, 3) tactile feedback,
4) control of movements as with other microinstruments, and 5)
minimal to no associated smoke and carbonization of tissue
edges. Possibly the greatest advantage of the laser scalpel is
that it can be used as regular microsurgical instrument.
Jallo et al. (36) thought that, compared with the bipolar
cautery and arachnoid knife, the laser scalpel provided a finer
and more precise incision with less bleeding when performing
the myelotomy for intramedullary spinal cord tumors. Once
inside the spinal cord, the scalpel also afforded effective, safe,
and precise dissection at the glial-tumor interface. During
debulking of these lesions, the laser scalpel may also poten-
tially minimize mechanical injury to normal spinal cord
parenchyma compared with the ultrasonic aspirator, which
relies on vibration and acoustic energy transmission. Further-
more, the scalpel may be particularly useful for coagulating
and vaporizing tumors with a firm texture by minimizing the
amount of manipulation and thermal injury to the surround-
ing spinal cord as typically observed with use of the bipolar
and scissors. Finally, the laser scalpel does not produce an
electrical artifact when used with electrophysiological moni-
toring; this benefit is especially important during the continu-
ous recording of MEPs used during the resection of an
intramedullary tumor.
CURRENT STATE OF THE ART
Neurosurgical pioneers early in the 20th century such as von
Eiselsberg and Elsberg proved that surgery within the spinal
cord was possible, not mere science fiction. However, the com-
plication rates of early techniques worried many neurosur-
geons into taking a conservative approach consisting of biopsy,
duraplasty, and adjuvant radiation therapy (65).
Throughout the 20th century, the advent of several key tech-
nologies sparked a revival in the movement toward more
aggressive resection of intramedullary tumors. Significant
ons90 | VOLUME 65 | OPERATIVE NEUROSURGERY 1 | DECEMBER 2009
advancements, which are now routinely used for surgical resec-
tion, have included the development of bipolar cautery (1940s),
operating microscope (1950s), the ultrasonic aspirator (1970s),
intraoperative US (1980s), MRI (1980s), MEPs for intraoperative
monitoring (1990s), plated bayoneted forceps (1990s), and the
Nd:YAG contact surgical laser (2000s). These tools together
with ever-increasing experience in microsurgical techniques
have enabled modern-day surgeons to provide more complete
resections while minimizing neurological damage. Patients
with intramedullary tumors can now receive an earlier diagno-
sis of their condition and benefit from lengthened progression-
free survival with less neurological injury.
Disclosure
George Jallo, M.D., has received educational grants from Codman and
Medtronics. The other authors have no personal financial or institutional inter-
est in any of the drugs, materials, or devices described in this article.
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COMMENTS
T his historical vignette is of great value for all neurosurgeons inter-
ested in spinal cord tumor surgery. We should never forget or
ignore the tremendous work of the pioneers who started such difficult
surgery without bipolar coagulation, the microscope, ultrasonic aspira-
tion, magnetic resonance imaging, evoked potentials, laser, or ultra-
sound. They succeeded to remove intramedullary tumors in spite of the
lack of all our modern tools, and they improved several of their
patients. I am in profound admiration with our pioneers. Thanks to
them, neurosurgery makes happen miracles today. But, one should not
forget that the best tools remain of no benefit in the hands of inexperi-
enced neurosurgeons and that experience remains the most important
condition to remove with success those tumors with preservation of
quality of life in spinal cord tumor surgery
Jacques Brotchi
Brussels, Belgium
T he origins of modern neurosurgery date to the end of the 19th cen-
tury when some very adventurous individuals developed the nec-
essary early skills and techniques for brain surgery. Surgery on the
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SCIUBBA ET AL.
spine for intramedullary tumors had to wait until the beginnings of
the 20th century with the pioneering works of von Eiselberg in Vienna
and Elsberg in New York City. The authors have provided a superb
overview of what evolved over time in both personalities and surgical
techniques to make spine surgery safer. Not only do we have a biog-
raphical review of some of the key characters, but also insight into the
various instrumentations and diagnostic techniques. As this group of
authors have been some of the key leaders in this field of intra-
medullary spinal surgery, whom better to accomplish this task. The
neurosurgical resident today is most likely little aware of these impor-
tant early accomplishments, so hopefully this review will alleviate
that ignorance for those who read this elegant article. My compli-
ments are offered to the authors for taking the time to put together this
important piece.
James T. Goodrich
Bronx, New York
S ciubba et al. have provided a wonderful review of the history of
intramedullary spinal cord tumor surgery. The management of
intramedullary spinal cord tumors has come a long way in the past sev-
eral decades, from the biopsy (“peak and shreak”) approach followed
A B
Anteroposterior/middle cerebral artery (MCA). A, view of a left carotid angiog-
raphy depicting an aneurysm arising proximal to the genu of the MCA, in the
distal half of the M1 and pointing superiorly in this projection. B, lateral projec-
ons92 | VOLUME 65 | OPERATIVE NEUROSURGERY 1 | DECEMBER 2009
by radiation therapy, to sophisticated surgical resections that simulta-
neously results in “cure” and in high quality neurological outcomes.
Hence, it is of paramount importance for all of us to understand how
we got here. We can then do a better job from where we stand and
strive to achieve more; much, much, more. For the insight provided, the
authors are to be heartily congratulated.
Edward C. Benzel
Cleveland, Ohio
T he authors have done a beautiful job recanting the history and evo-
lution of a classical neurosurgical operation. Because the original
documents of the early surgical procedures were not written in English,
this article will serve to immortalize some of those key initial observa-
tions and techniques that have since evolved into the safer methods
that we use today. Upon reading these accounts of spinal intra -
medullary tumor surgery performed a century ago, one cannot help
but be in awe of the courage, tenacity, and technical skills of our surgi-
cal forefathers. I thank Sciubba et al. for providing us with this hum-
bling and enlightening document.
Michael Y. Wang
Miami, Florida
C
tion of the same carotid angiography shown in A. Because of the superimpo-
sition of the vessels, it is difficult to visualize the aneurysm. C, Angiography-
computed tomographic depicting the aneurysm (arrow) shown in A.
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