The History of Anterior and Lateral Approaches to the Lumbar Spine

Anterior and lateral approaches to the lumbar spine are commonly used today for a variety of indications. These approaches can ultimately be traced back to early attempts to treat Pott’s disease. Evidence of Mycobacterium tuberculosis infection of the spine dates as far back as 2400 BCE, with ancient Egyptian mummies exhibiting lesions consistent with Pott’s disease. For many centuries, Pott’s disease was treated conservatively, and surgery came to be used when conservative therapy was ineffective, as medical therapy had yet to become available. In 1779, Percivall Pott recommended that peripheral paraspinal tuberculous abscesses be drained after noticing that patients’ lower limb function improved after the formation of spontaneous draining sinuses. Building on Pott’s ideas, Ménard described the first lateral approach to the spine via a costotransversectomy approximately 1 century after Pott’s theory. Most importantly, the surge in understanding anatomy with respect to developing safe corridors to the deeper structures of the human body brought together advances in technology, instrumentation, and visualization. Surgeons were thus emboldened to explore more complex anterior approaches to the spine. In 1906, Müller reported the first successful anterior approach to the spine in a patient with Pott’s disease. Over the next several decades, the efforts of surgeons such as Ito, Capener, Burns, and Mercer would lead to the development of the anterior lumbar interbody fusion. The costotransversectomy later evolved into the lateral rhachotomy and lateral extracavitary approach, which along with advances in the anterior lumbar interbody fusion paved the way for the oblique lumbar interbody fusion and lateral lumbar interbody fusion.

Introduction

As medicine and surgery have evolved over time, it is important to make note of the factors that have influenced the development of the innovations we utilize today. The anterior lumbar interbody fusion (ALIF), oblique lumbar interbody fusion (OLIF), and lateral lumbar interbody fusion (LLIF) are powerful approaches that are useful for a variety of indications. As these approaches are not necessarily intuitive, the pressure to innovate most certainly arose from the need to address complex disease processes for which treatment methods of that time were not optimal. Indeed, the severe limitations of the traditional posterior approach emboldened surgeons to explore alternative, although potentially more high-risk, approaches to effect a cure. In tracing the development of the ALIF, OLIF, and LLIF to their origins, one can identify a critical inciting disease serving as a stimulus for these novel approaches. Although rare in today’s medicine, the failure to adequately treat Pott’s disease over a century ago was, in part, a precipitating factor in the exploration of unique corridors to the spine.

As noted by Goodrich,¹ there is a relative paucity of literature regarding the development of spine surgery in antiquity. Despite this, there has long existed an understanding of the importance of the spine and the significance of its injury on the functioning of the human body. In one of the most ancient of medical treatises, the Edwin Smith papyrus, injuries to the spine were recognized as serious and typically fatal injuries.²

It would take several millennia after the writing of the Edwin Smith papyrus for a surgeon to publish a successful surgical intervention for spinal injury.³ That first surgery, a laminectomy to treat traumatic paraplegia resulting from a fall from a horse, would usher in an era of posterior approaches to the spine to treat a variety of conditions. This era culminated in the publishing of Elsberg’s Diagnosis and Treatment of Surgical Diseases of the Spinal Cord and Its Membranes, which established posterior decompression as one of the most important tools for the surgical treatment of many intrinsic and extrinsic spinal disorders.⁴

In the decades that would follow, it would take several pioneers to revolutionize the field of spinal surgery beyond posterior approaches. Not until the late 19th and early 20th centuries, with the wide acceptance of Louis Pasteur’s research in microbiology and Joseph Lister’s techniques of antisepsis, would surgeons feel comfortable with the routine exploration of the thoracic and abdominal cavities.⁵ In this article, we explore the role these early pioneering surgeons played in the development of anterior and lateral approaches to the lumbar spine.