see also:

• sciatica
• A History of Lumbar Disc Herniation From Hippocrates to the 1990s

• the first descriptions of sciatica go back to ancient times and often were given supernatural explanations involving demonic forces
  • Germans’ witch’s shot (Hexenschuß)
  • early British elf’s arrow
  • in ancient Hebrews, Jacob is renamed Israel after an all-night wrestling match with God (Genesis 32:25–32). God touches Jacob’s hip causing sciatica and from trhat time onwards, animals’ sciatic nerves are no longer kosher. The Talmud provides specific instructions for nerve removal from slaughtered animals
    • their treatment advised the painful area to be rubbed 60 times with fresh brine
• ancient India - if the kakundram marma in the lumbosacral area, is injured, lower extremity numbness or paralysis could be expected
• the ancient Greeks with Hippocrates,as well as the Egyptians started to develop a more naturalistic view connecting lumbar spine pathology with leg pain
  • sciatica was thought more prevalent during the summer and fall because the sun could “dry up” necessary joint fluid
  • Hippocrates prescribed rest, massage, heat, dietary changes, and music
• Galen (in 2ndC AD) produced several spinal pathoanatomy treatises
• Caelius Aurelianus (in 4thC AD) offered plate depictions of the spinal column and intervertebral disc spaces and advised that sciatica may occur after “a sudden jerk or movement during exercise, unaccustomed digging in the ground, lifting a heavy object from a low place, lying on the ground, a sudden shock, a fall, or continuous and immoderate sexual intercourse.”
  • Rx began with traditional bed rest, massage, heat, and passive ROM exercises
  • described the muscle wasting found in advanced cases and for these intractable cases leeches, hot coals, skin hooks, and blood-letting were instituted
• Paulus of Aegina (7thC AD) first suggested spine surgery, although his emphasis was on spine trauma
  • His description of sciatica included pain extending from the buttock and groin to the knee and “often as far as the extremities of the foot.” Like his predecessors, he recommended rest-based conservative treatments.
• 1764: De Ischiade Nervosa Commentarius, Domenico Cotugno ascribed radicular pain to the sciatic nerve
• perhaps in the 1860's, Ernest-Charles Lasègue (1816-1883) teaches his straight leg raise (SLR) sign of sciatica

• Paul of Aegina (625-690AD) advocated exploration and extraction of broken pieces of bone in spinal fractures
• Ambroise Pare (1510-1590) of the French Army, described the use of traction for spinal injuries
• Fabricus Hildain (1560-1634) perhaps gave the earliest description of laminectomy
• painless surgery commences in 1846 with use of chloroform and ether
• antiseptic surgery was introduced in 1867 by Lister although use of rubber gloves instead of bare hands was not introduced until Halsted (1852-1922) advised it for his scrub nurse who couldn't tolerate the carbolic acid
• 1887 - 1st excision of an intradural extramedullary spinal tumour by Horsley using the clinical localisation of William Gowers
• 1887: 1st “modern” lumbar laminectomy - variably attributed to William MacEwen or Victor Horsley
• 1888 - Bennet performs 1st section of posterior spinal roots to relieve pain
• Horsley invented bone wax in 1892 to reduce bleeding from bone
• local anaesthetic mixed with adrenaline introduced to reduce bleeding in 1909 by Brown
• electrocautery introduced by Cushing and Bovie in 1928 to control bleeding and bipolar forceps introduced in 1930 by Greenwood
• Gelfoam was introduced in 1945 for haemostasis by Correll and Wise

• in 1885, Corning was the 1st to use puncture of the subarachnoid space for therepeutic use - he injected cocaine
• in 1889, Walter Essex Wynter developed a crude cut down with cannulation in four patients with tuberculous meningitis to relieve raised intracranial pressure
• in 1891, Quincke described lumbar puncture for relief of raised intracranial pressure
• in 1893, Arthur H. Wentworth used the lumbar puncture as a diagnostic tool for meningitis by examining CSF but he was criticized by antivivisectionists for having obtained spinal fluid from children
• in 1908, it was realised that some patients with brain tumours died within a day of having a lumbar puncture ¹⁾

• Roentgen discoverd Xrays in 1896 and within a year its use in medicine was well established
• pneumoventriculography was discovered in 1918 by Dandy when he noticed air under the diaphragm of a patient with perforated viscus and decided to inject air into the CSF
• 1925: lateral lumbo-sacral spine Xrays 1st used (prior to this, only AP views were taken)

• radiographic myelography was introduced in 1921 by Jean Sicard, a French clinician, and his pupil, Jacques Forestier, when they discovered that the oil they used (lipiodol) to carry analgesics injected into the epidural space for treatment of low back pain was radiopaque
• for the next 3 decades myelography via the suboccipital route was utilised
• 1960s, myelography improved significantly with the introduction of new, hydrosoluble contrast media, including iodomethamate, which could be injected from a lumbar approach
• 1977, myelography correlated with intra-operative findings in 90% of cases
• in the 1980's plain myelography was largely replaced by CT myelography

• at the end of the pre-antibiotic era and before the disc herniation concept was popularized in the western world

• lesions closely related to the sciatic nerve (lumbosacral spine, sacro-iliac joints, hip joint, pelvis) such as:
  • infective arthritis
  • more rarely, TB or carcinoma
  • prostatitis or carcinoma of prostate
  • pelvic aetiology such as inflammatory exudate, tumour or varicose veins
  • less likely causes include neuritis from diabetes, syphilis or alcoholism
• individual attacks are often traceable to chilling of the body or to direct pressure by a hard object

• Lasègue's sign - severe pain when leg is extended while hip is flexed
• subjective sensations such as tingling and numbness may occur
• symptoms worse at night and on the approach of stormy weather
• chronic cases may result in muscle wasting

• recovery usually occurs in a few weeks or months unless the underlying condition is serious and irremovable
• relapses are common
• in some cases pain may become more or less continuous

• remove the cause
• bed rest is essential in acute cases
• in severe cases, limb should be immobilized by means of salt bags or a long straight splint
• free evacuation of the bowels to deplete the pelvic veins
• pain killers in full doses such as salycylates, acetphenetidine, cinchophen are often effective, but morphine may be needed
• high frequency electric currents may be of service
• counter-irritation by dry cups or small blisters along the course of the nerve is also useful
• very intense pain sometimes yields to injections of guaicol made deeply near the nerve
• arthritic cases will require removal of the primary infective focus and appropriate orthopaedic measures
• when no organic abnormalities outside of the sciatic nerve are found, epidural injections of novocaine are worthy of trial
• NB. the 1st commercial antibiotic, Prontosil (a sulphonamide) was introduced in 1935

• 1857, Virchow published a discussion of disc pathology that included a ruptured disc, which at that time was called “Virchow’s Tumor”
• 1858: Luschka further described disc ruptures but did not relate these pathologic findings to clinical symptoms

• 1908: Fedor Krause performed the 1st discectomy although the tissue was mistaken for an enchondroma
• 1909: Alfred Taylor performed the first unilateral laminectomy on a cadaver
• 1911, Goldthwait and Osgood interpreted a disc protrusion as the cause of lower extremity paresis
• Elsberg describes a case of central cervical disc herniation but misnamed as a chondroma and also described the use of spinal manometric studies to determine spinal tumour location

• 1920s, German pathologist Christian Georg Schmorl studied 10,000 spines. He described protrusions of disc material, including into the vertebral body and the spinal canal, as herniations which led to the term disc herniation becoming popular in the parts of Europe
• 1947: Inman and Saunders discovered pain fibers in the annulus ending the concept the disc was itself a painless structure
• 1960's - 1st use of chemonucleolysis, the injection of the enzyme chymopapain into the disc but over the next decade or two, reports of serious complications including anaphylactic shock and neurotoxicity diminished its popularity
• 1967: Yasargil - first use of an operating microscope in lumbar discectomy surgery
• 1968: concept of disc degeneration as a cause - Francis Murphey
• Studies in the 1980s and 1990s began to elucidate the mechanisms of pain generation from disc herniations and increasingly identified strong genetic susceptibility to both disc herniation and degeneration
• 1975: 1st endoscopic discectomy - Hijikata and Yamagishi
• rates of discectomy increased rapidly from 1979 to 1990
• mid 1980's more ready availability of CT scans to aid diagnosis
  • indications for surgery based upon crossed SLR, muscle wasting and decreased reflexes - sensory symptoms alone correlated poorly with good surgical outcomes
• 1988, concomitant fusion with discectomy was termed “wholly unnecessary”
• in the 1990's CT guided chemonucleolysis was developed and microdiscectomy was further refined
• 1996, microdiscectomy pioneer John A. McCulloch wrote, “long-term results of surgery are only slightly better than conservative measures and the natural history of lumbar disc herniation”
• late 1990's more ready availability of MRI scans to better aid diagnosis and guide surgery indications
  • MRI rapidly became sensitive enough that “absence of a clear cut abnormality on an MRI is a contraindication to surgery”
  • MRI also detected high rates of asymptomatic disc herniations and thus the presence of these may not be causing the patient's symptoms