fifth, sixth, and seventh cervical vertebra^ were removed. The dura was
exposed for two inches, but no tumor was found. The intervertebral
foramina .were then explored by a curved hook, and the sixth and
seventh cervical nerves were stretched so that a short loop of each was
raised. The operation was done between the dura and the bone, as the
dura had not been opened. The fifth nerve could not be raised by the
hoiik witiiout exciting considerable hemorrhage. The sixth and seventh
nerves were then cut across just outside the dura, both motor and sensory
roots thus being divided. The wound was packed with iodoform gauze,
but not closed. The neuralgia soon returned, and accordingly two days
later, without ether, the wound was exposed and the dura ojiened. It is
noticeal)lc tliat " the dura was scarcely at all sensitive to cutting," in con-
tradiction to Mr. Horslcy's statement that in sjtinal operations profound
anaesthesia is required when the dura is ilivided, on account of its extreme
sensibility. The posterior roots of the seventh and eighth cervical nerves
were now divided within the dura, the dura being then sutured with cat-
gut and the entire wound closed. The character of his })ain changed
some, and in January, 18;i;>, Dr. Abbe wrote mc that the i)atient "still
had consideral)lc neuralgia, if his statements can be taken for truth."
In tlie A'. ]'. Mcrl. Record, July 26, 1890, Abbe reports a second case,
which I had the jileasure of witnessing myself. The dura was opened,
and a portion of the posterior roots of the sixth, seventh, and eighth
cervical and first dorsal nerves was exsected. As in the former case, the
relief was only temporary. Tlie parts sup]ilied liy the divided nerves
' N. Y. Med. Rec, Feb. 9, 1S89.
THE SURGERY OF THE SPINE.
were persistently aiUL'sthc'tic, but the pain returned just as in so many
cases of neurectomy for tic douloureux, and the condition of the second
patient was ])ractically the same as that of the first.
The thinl case is re])orted hv I)t'nuett,' a man with cdnstitutional
sv])liilis, who had suffered afronizinti' ]iain in the left lej;-, and later in the
latissimus dorsi and erector spime muscles, with violent spasms. After
an incision over the tibia which gave no relief the leg was amputated at
the knee. The sciatic nerve was then stretched, and finally excised
without any benefit. By an incision six inches long, with its centre at
the eleventh dorsal spine, the lower four lumbar nerves were divided.
This division caused arrest of the ])ulse, which, however, returned u])on
gentle pressure upon the cord with a warm sponge. Then the first two
sacral nerves were divided, this also being followed by a similar effect
upon the heart. Bennett discovered later that he had not divided the
second lumbar, as he had thought at the time of operation. On the fifth
day the patient was comfortable and without any pain, though tlu' spasms
had returned. By the tenth day the wound was healed. Unfortunately,
on the eleventh day he suddenly died from cerebral apoplexy. The ]>ost-
mortem showed sclerosis of the posterior root-zone and tlie columns of (ioll.
Two other cases were reported by Horsley at the International Con-
gress of 1890 in Berlin." In one of them (the fourth case) the posterior
roots of the eierhth and ninth dorsal nerves on the riaht side were resected
with temporary relief, but the neur-
algia returned in other nerves. In
the other (the fifth case) the posterior
roots of the seventh and eighth cervi-
cal were resected, with " much relief."
Abbe has recently reported a sixth
case,^ a man forty years of age, who
had had spastic paralysis of the right
arm and leg since childhood, with
athetoid motion of the ujiper limb
and great j)ain, so that the arm had
been amputated at the shoulder-joint
five years before the resection of
the sjiinal nerve-roots, which Avas
done June 4, 1894. A quarter of
an inch of the fifth, sixth, seventh,
and eighth cervical and first dorsal
nerves was resected (Fig. 490), and
in addition to that, as the arm was
gone and secti(m of the anterior nerve-
I'oots would not involve loss of func-
tion, and might prevent the athetoid
movements, the anterior roots were
cut, excepting that of the fifth, which
was left intact on account of its relation to the jjhrenic nerve. " The
pain abated very much, and the spasms almost entirely disappeared after
' Med.-Chir. Tram., 1889, Ix.^ii. p. 329. = Sril. Med. Journ., 1890, ii. 1-2S9.
' Annals of Surgeri/, Jan., 1895, p. 53.
Diagram of intradural resection of posterior
roots of brachial plexus, witii section of
tlie anterior roots (Abbe).
DIVISION OF NERVE-ROOTS FOR INVETERATE NEURALGIA. 857
He also reports nt the same time on the condition of his two former
similar operations after an interval of tive and six years respectively :
" In both there had been very great, but not complete, relief from paiu
up to the present time."
MeCosh reported a seventh ease at the same time witli Al)l)e, in
whicli lie had cut two of tlie jiosterior dorsal roots, tiiouoh no ana;sthesia
followed, owinji' to the free anastomosis and overlap])ing of the branches
of these nerves.
One advantage of the operation was pointed out in the very first
case by Dana : that is, if a tumor or other lesion exi.st, it can be dealt
with during the operation, instead of division of the posterior nerve-
The result obtained in these cases is similar, of course, to that which
we obtained by neurectomy for tic douloureux. In both ojierations, if
the disease involves the peripheral nerves alone, the result is somewhat
unexpected, inasmuch as in sensory nerves the Wallerian degeneration
proceeds centrally, anil should have destroyed, therefore, the spinal ends
of the nervc-tibres. The pain of neurasthenics, or the " pain-habit," as
it has been called, seems to l)e so estaljlished by the long duration of
these cases that an earlier operation would appear to promise better
results. Abbe's own opinion is " that the operation is a safe one, and
if the hysterical element can l)e eliminated from any proper case, it
should be tried still further, inasnuich as it cannot disable the arm in
the slightest degree," the motor roots being left intact — an ojiinion in
wiiii'ii I fully agree. I have recently stretched first the bi'acliial jilexus,
then the ulnar nerve, then resected the ulnar nerve, and finally ampu-
tated at the shoulder-joint in a precisely similar case, in whicli I urged
the patient — inefFectually, however — to allow me to perform the intra-
spinal division of tlie posterior roots in the early stage of the disease.
The technique of the o])eration is that of an ordinary laminectomy
(p. 858) nj) to the disclosure of the dura. This is then opened, the
nerves identified, and the jiosterior nerve-roots alone divided. If, as in
Abbe's last case, the limb has been amputated, but the sjiasms persist in
the stump, the anterior nerve-roots should also be divided. In order to
identify the nerves one has to deal with, it is advisable to nick the skin
opposite the spine of any selected vertebra ; for instance, the seventh
cervical. When the cord and nerves are then exjiosed, one can count up
or down and readily fix upon the nerves which he is seeking. The
closure of the wound and the after-treatment are the same as after
The resemblance of this operation to that of neurectomy of the fifth
nerve in trigeminal neuralgia has alreadvbeen spoken of. The operation
is one of not a little mechanical ditliculty and nicety, Init not of excess-
ive danger, no one of the six cases having succMmbed to the o|H'ration.
The recent successful operations upon the Gasserian ganglion would lead
me to suggest that the ganglia on the posterior roots should be broken
up, as well as the posterior nerve-roots resected. It may be argued, of
course, that resection of the nerve-roots cuts off all connection between
the nerve and the ganglion on the one si<le and the cord on the other,
but we know the extraordinary jiowers of recuperation and re-estaljlish-
ment of peripheral nerves, as in the fifth, and hence the very small
858 THE SURdERY OF THE SPINE.
portion of the root which can he cxscc'ted within tlie (hira may possibly
allow the y^A\^ to be closed and the continuity of the nerve thns to be re-
established. I have seen in several instances the inferior dental nerve
reproduced in the entire lenj^th of the inferior dental canal. Hence
destruction of the ganglion, as well as resection of the nerve-root, may
possibly make the results of the operation more certain. Of course
care should be taken not to injure the mott)r root while breaking up the
ganglion. As in trigeminal neuralgia, the peripheral operations are less
dangerous than the central one, and for a time are etficacious. Hence it
is prolwble that jieripheral ojierations l>y stretching or resecti<m of the
nerves, or even amputation, might be justified before the posterior nerve-
roots are divided, but my own opinion is in favor of a primary resection
of the nerve-roots in view of the failure of rc])eated and serious opera-
tions, such as even amputation at the shouldci-JDint or in the tliigh.
When, therefore, we have to deal with such neuralgias, intraspinal resec-
tion should, in my opinion, be rather the first than the last operation.
Technique of Laminectomy.
The details of the various operations on the vertebrae and spinal cord
have been left till the present section Itecause they are all more or less
alike, and are almost always begun by the removal of the laminse of the
vertebrae. This operation is variously kno\\'n as lamnectomy, lamniec-
toray, and laminectomy. The former terms are, it is true, more correct
from the philological point of view, but the last, though a hybrid of Latin
and (jreek, has been so generally used that I have adopted it.
The back should be cleansed in the usual way ov(>r a very large area.
If the ]>crson be very hairy, of course the back sln)uid be shaved. The
preparation of the hands, instruments, dressings, etc. is that usual in any
ordinary aseptic or antiseptic operation.
The shock of a laminectomy is almost always severe ; hence every
precaution must be taken to avoid it. Hcreum has therefore very
properly proposed that it should be preceded l)y c(implcte restfulness of
mind and body; that a primary hyjiodcrmatic injection of strychnine
(gr. Jjj) be given ; that the patient shoukl be kept warm by a hot-water
bed or hot bottles and blankets ; and that atropine and caffeine be used
hypodermatieally, or a rectal injection of coffee be used.
Mr. Hoi-sley has called attention to five especial dangers : First, that
of hemorrhage. This is always considerable in amount, but with modern
methods, and especially by means of luemostatie fbrce]is and pressure by
sponges dipped in hot water, it is not a danger which any surgeon of
experience should fear.
Secondly, difficulty in clearing the neural canal. This, too, with
ordinary care, and especially after one has had experience in a few cases,
as a rule, can be dismissed.
Thirdly, physical ditticnlties in treating the fractured vertebrse. This
danger in part has already been considered. In a great many cases, of
course, the vertebrse are hopelessly fractured and displaced, and cannot
be dealt with satisfactorily. Unfortunately, we are not often able to
judge of the severity of the fracture, excepting after it has been revealed
by the operation.
TECHXiqUE OF L.iMIXECTOMY. 859
Fourthly, the hopeless nature of tlie damage to the spinal cord. In
a very large number, probably the majority, of eases of fracture-dis-
location tlie cord has suffered so severely that its regeneration is hope-
less. Even in a case, however, where the cord is almost diffluent, as in
Schede's case (p. 822), occasional benefit will result even to a striking
Fifthly, the danger of septic infection. Witli modern surgery there
should not be any considerable danger of septic infection, excepting in
those cases in which the fracture is compound and infection has taken
place before the surgeon sees it, or in those cases in which a fistula
results, especially from too prolonged use of a drainage-tube : as a
rule, therefore, this should be removed within twenty-four or forty-
Sixthly, to these dangers White has very justly added the danger of
ansesthesia in the prone position, the abdominal muscles being paralyzed.
This is a very real danger, and was well illustrated in one of my own
cases, in which the patient came very near dying from apnoea during
ansesthesia, even in the dorsal position and before I began to operate.
After lieing etherized, liowever, he bore the operation very well.
As the initial hemorriiage will be rather profuse, the surgeon should
not have less tlian two dozen haemostatic forceps. He should also have
rongeur and other bone forceps, raspatories, and, if a trephine is used, it
should be a half-inch in diameter.
The patient is placed in the Sims jiosition, requiring the administra-
tion tif the antestlietic in a most unfavorable position, cspeciallv if the
injury is iiigh up and has paralyzed the respiratory nnisclcs excepting
the diapiiragm. The face sliould be brought to the edge of the table.
The an:esthetizer's task is a most serious one, and this responsible post
should be occupied only by a man of large experience, quick observation,
and good judgment. Hy|)odermatic syringes, charged with strychnine,
digitalis, and atro]iinc, should be at hand. The patient should be well
protected from chilling by blankets and by hot-water bottles, or still
better by a table the top of which consists of steam-pij)iug, so that the
patient can be readily kept warm.
The incision is made in the middle line, four inches being the min-
imum, and as much longer as the extent of the operation demands. The
resection should not be limited to one or two arches, but should be a
large one, often involving tlie removal of five or six arches. I have
always found a single linear incision sufficient, though incisions in the
shape of T, V, or H have been proposed. Bullard, Eurrell, Abbe, Daw-
barn, and Urban ^ have proposed an osteojilastic resection ; that is to say,
that the spinous jirocesses or arches of the vertebrpe should be chiselled
or bitten away from the bodies, lifted with the muscles, and replaced
witii the fiap or flaps later. This of course requir"s an H or a i I incision
(Fig. 491"). I have never found it necessary to make such an osteoplastic
resection, and have been quite content with removing the arches. If an
osteoplastic I'esection is made and the arches are replaced, their edges
should be carefully rounded off, so that there would be no splinters to
wound the cord.
Chipault- has pointed out that in a normal s})ine tiie arches are of
' Archiv kliu. Chh:, xliv 1892. ■ Guz. rh-s Hop., Oct. 21, 1893.
THE SURCERY OF THE SPISE.
little value in producing solidity of the s])iiu>, hut tlint when the hodies
are gone, as in Pott'.s disease, the" arches re]>hiee tiie ho(Hes to some extent
in securing a stable spine. Pack ' lias noted a i-e-fracture bv slight effort
Osteoplastic resection (I'lliai
even a year after a laminectomy. Hence Chipault urges an osteoplastic
resection, and that the stability of the spine sliall be increased by suture
or ligature of the spine and laminse, and esj)ecially by a bilateral inter-
laminar ligature in a figure of 8. The osteo]>lastic operation being a long
and difficult one, he proposes that it should be replaced by a subperiosteal
resection, after the nietliod of Oilier, except in tubercular disease of the
arches, which is rare. He rejiorts (j such operations witii 3 autopsies, and
states that the operative result \\as very satisfactory.
Horsley has recommended that the lumliar ajioneurosis should be
divided by an incision at right angles to the first, l)ut I have never found
The muscles are fii'st sejiaratcd from tlie arches upon one side
(Fig. 492). In doing this I have been careful to follow the advice of
' Chipault, Inc. cit, p. 1145.
TECH ly QUE OE LAMINECTOMY.
Horsley, not to do it witli blunt raspatories, but by clean cuts of the knife.
This is the more important because the
spinal muscles consist lar>;ely of slips
running short distances, and any blunt
instrument leaves the tissue in tatters
which may readily undergo necrosis.
When the muscles have been well sejv
arated from the arches a raspatorv can
then be used with advantage to scrape
away the I'eniaining nuiscular tissue
which still adheres to the bone, and thus
to obtain a clear tield of operation.
During this dissection the licniorrhaoe
is very free, and I have foumi llorslcy's
method of dcalinir with it the best. Large
arteries may be seized by an assistant
with haemostatic forceps, but the operator
should not waste any time by attempting
to do so. The more quickly he exposes
the bone and packs the wound thoroughly
with sponges wrung out of very hot watci',
as hot as can be borne by the hands of the
operator, the less will be the amount of
blood lost. I have usually deferred the
final cleansing of the arches until after
the hemorrhage has been arrested. As
soon as one side has lieen packcil the
muscles are separated from the bones on the other side, and that in
turn is packed. By the time that the second dissection has been made
and the wound packed the first will be ready for the final clearing of the
To make an opening into the canal Mr. Horsley has devised some
excellent and powerful angular bonc-forccps. Other surgeons prefer to
use a trephine, but I have found the method described below so satisfac-
tory that I have never resorted to other means. If the trephine be used,
one edge should be placed close against the spinous processes, lest the
intervertebral nerves should be wounded by the penetration of the tre-
phine. I divide first the intcrs])inous ligaments by a knife. Care must
l)e taken, however, that the knife docs not penetrate the canal and wound
the membranes or even the cord. In the dorsal region the laniin;e so far
overlap each other that this is not practically a danger, but in the cervical
and lumbar region it is very possible to wound the cord by a slip or too
deep cut by the knife. It would seem almost ncetlless to caution a sui-
geon against a possil)le wound of the vertebral artery if the operation is
in the cervical region, but Ciiipault ' states that in at least three cases
speedy death has resulted from such a wound. I have not been able to
find any such recorded cases.
Having thus isolated one of the spinous processes by the knife, I
then ([uickly gnaw it away, together with a part of one of the arches, by
the double rongeur forceps (Fig. 493). As soon as an opening is effected
' Rev. lie Chir., 189-2, 685.
First stage in laminectomy : exposing
the muscles (Chipilult).
THE SURGERY OE THE SPL\E.
into the canal, T liave fonnd tlic Ix'st iiistrunient to be the rong'eur for-
ceps whicli I originally deviseil for linear craniotomy (Fig. 494). The
I.iiii > (hiiiiilc roiiiifur furet'i
chisel, of cour.se, can be u.sed, but I think that my rongeur forceps not
only effect removal of the arche.s more quickly, but are much safer, as
Keen's rongeur forceps for laminectomy, linear craniotomy, etc.
they avoid all jarring, and a .«lip of the chisel might wound the cord or
some of the nerves. I have often found rather sharp hemorrhage from
the vessels between the laminse or within the spinal canal, especially the
veins, but this is effectively controlled in a short time by pressure and
hot water. The arches being removed (Fig. 495), a moderately thick
layer of fatty tissue still oliscures the membranes of the cord. In it lies
a plexus of considerable veins which sometimes give temjiorary trouble,
but the bleeding is again easily controlled by jircssure and hot water.
This fatty tissue is l)est treated by dividing it carefully in the middle
line, pushing it to each side, and packing with small bits of sponge or
gauze to prt)duce pressure. Of course it must be carefully seen that
every one of these is removed before the operation is fini.sjied.
The dui'a should now be inspected to observe whetiier it pulsates.
If not, the absence of such jnilsation is generally due to adhesions,
swelling of the cord, or other cause of interference with the continuity
of the subdural space. If there is blood under the dura, the latter will
be bluish or purplish ; if ]nis, yellowish ; and if a tumor is present or
there is any inerea.se in the (piantity of cerebro-spinal fluid, the increased
tension and elasticity of the dura will be ])erce])til)le l)y touch. The
membranes and cord may now be carefully drawn first to one side and
then to the other by means of an aneurysm needle, the curved end of
AllLs's blunt dissector, a retractor, or any similar instrument, in order to
expose the bodies of tlie vertebrae for observation or, if necessary, for
TECHXIQCE OF LAMISECTOMY.
Mills has? proposed tluit if it is needful one ov two nerve-roots should
be ilivided, hut this would be an uiuisual necessity. If it is done, how-
ever, the nerve-roots should be .sutured before the operation is terminated.
In order to make such observation or operation on the vertebral bodies
Chipault places two cushions, some distance from each other, under the
abdomen of the patient, so that the spine will be concave posteriorlv,
which will facilitate the dis])laceinent of the cord (Fig. 476). The nerves
arc sufficiently elastic to allow of moderate stretching. If anv extradural
tumor, thickening- of the connective tissue between it and the bone, bony
growth, or pressure by dislocation of fracture of the laminae or bodies of
the vertebrae or carious or necrosed bone.
Fig. 495. is in Pott's disease, is discovered, suit-
able treatment can now lie instituted
(Figs. 496, 497).
AMiether the dura should be opened
is a more serious question in the spine
than in the brain. In the latter the
oj)ening can be closed without drainage,
Second stage in laminectomy: verte-
bral canal laid open (Clupault).
Pott's disease : the dark lines indicate the iiortion of
tlie bodies to be removed (Chipault,).
and thus we can prevent the continuous escape of the cerebro-spinal
fluid. After an operation upon the .-ipine, however, the injury to the
thick muscles will sometimes jirevent absolute primary union, and so
favor the formation of a fistula, and the wound is so extensive and deep
that a drainage-tube is usually required, and this tends in the .same
direction. The mere temporarv escape of the cerebro-.spinal fluid is not
in it.self so dangerous, (^n p. 795 a case of Robst>n's is referred to in
which <S5 ounces were intcntionallv removed by aspiration, and I have
not uncommonly .seen a large c|nantity lost at o])cration and continuously
escape for some days afterward without any ill efl'ects. But if a fistula
results and the cerebro-spinal fluid escapes continuou.sly, this is a source
of annoyance and irritation to the surrounding skin and requires constant
re-dressing, and has one far more serious source of ilangcr — namely, that it
is almo.st impossible in repeated dressings to avoid infection, with subse-
quent meningitis, myelitis, and often death. In spite of these objections,
THE SUBGEUY OF THE SPiyK
liowever, it is generally best to open the spinal dura, and, it" possible
when the operation is completed, to suture it with a continuous catgut or
Pott's disease: the dark line iiidieates the portion of the bodies to be removed (Urban).
tine silk glover's suture in order to obtiiin immediate union. If the dura
is not opened, we tail to learn the exact condition of the subdural space
and of the cord itself".
Having opened the dura, the subdural space can be explored carefully
by Horsley's dural separator or by an oi'dinary l)ent probe. It should
be explored ujiward and downward as far as is deemed necessary. So,
too, the extradural space between the dura and the laminae should be
explored, in order to determine whether there ai'e any irregularities or
obstructions, fracture, dislocation, etc. If there be a tumor on the sur-
face of the cord, it may now I)e removed. If it infiltrate the substance
of the cord, it is inojicralde.
If the cord has been crushed or injured by accident, any splinters of