1907 Journal of the American Medical Association (JAMA)  
From a fairly long training in the conservatism of orthopedic surgery, to which at one time I devoted practically all my efforts, I have developed a tendency to prefer, in general, those operative methods which conserve tissue, and especially if the tissue so saved can be expected to be of use to the patient. That the lamin\l=ae\ of the vertebr\l=ae\were orginally of use, to protect the cord and to give points of attachment for spinal muscles was obvious; that they would still be of use if,
more » ... r a laminectomy, they could be restored to position and function seemed good reasoning; that this could be done I believed had been demonstrated, and I was impressed somewhat with the description of the operation as given by Bickham.1 There was nothing new in this description, but it came at a time that was, or seemed, opportune, for Dr. Leo Newmark and I had been waiting and watching many years for a tumor of the spinal cord, and one presented itself just about the time when Bickham's paper was in my mind. The history of this tumor of the cord is not germane to this paper. It may suffice that symptoms of pressure on or involvement of the left side of the cord at about the level of the fourth cervical vertebra had gradually developed, that the pain had finally become unbearable and the disability was steadily increasing, so that the patient was ready to submit to the operation. TECHNIC. A priori, the ostéoplastie method, because of its more nearly restoring the integrity of the spine, should be especially preferable in the cervical, and perhaps, too, in the lumbar region, for in these regions the vertebras are not fortified and braced by the attachments of the ribs, as is the case in the dorsal region. It was, therefore, the operation I selected, and I rehearsed it on the cadaver, for, while laminectomy plain was not new to me, the ostéoplastie operation in the neck was new. The extensive incisions in the muscles and the great mobility of each individual cervical vertebra were the points for comment in this rehearsal, but my general impression was that the operation was practical, and so I decided to do it. It was done by turning up a quadrilateral flap containing skin, fascia, muscles and the laminae of the third and fourth cervical vertebra?. The outlines of this flap on the skin were broader than were the incisions as they approached the bone, so that the whole flap was practically beveled, getting narrower in the deeper parts. I found it impossible to cut the muscles of the deeper Read before the Western Surgical and Gynecological Association, August 31, 1906, at Salt Lake City, Utah. 1. Annals of Surgery, 1905, March. parts of the neck with the scalpel. They rolled up before the knife, or slipped to one side, or became spasmodically contracted and pulled out of the way. The latter part of the section of the muscles had to be done with scissors, the muscular tissue being caught with forceps so as to hold it still. In addition to this difficulty, there was a plentiful amount of hemorrhage from small and medium-sized vessels. The flap, when it was formed, seemed a most disorganized mass of tissue, for the areolar planes between the different anatomic layers permitted so much latitude of movement that the effect was as if the part had been mutilated. The section of the bones had been intended to have been made with the Doyen saw, but the wound was so deep that the saw was wholly inadequate, and so I used a pair of Liston bone forceps, curved on the edge that had served me before for this same purpose. The exposure of the cord, after splitting of the dura mater, was satisfactory and one could easily look up into the skull and see the under surface of the cerebellum, but the tumor, which was found as had been expected, extended down below the level of the fifth lamina, and so, without any attempt at more ostéoplastie work, the laminae of the fifth and sixth vertebras were resected by pushing the muscles away from them by blunt dissection, cutting the bones near the pedicles and removing the fragments. The tumor was a layer of sclerotic fibrous tissue closely attached to the surface of the cord and dipping down somewhat into its substance. It was impossible to remove it without serious damage to the cord, and so it was left in situ and the wound closed. As the flap was folded down the third and fourth laminae fell back easily in place and the muscles were then fastened by interrupted chromicized sutures. It was impossible, however, to make an anatomic union of the cut muscles. Never had the muscles of the neck seemed such a hopeless tangle. I had to be content with a few sutures at points where they seemed to be needed. The tendon of the trapezius was accurately closed and so was the skin. A small drain was put in to take away the serum that was sure to be the result of such an extensive incision in the muscles. PLAIN LAMINECTOMY AND THE OSTEOPLASTIC OPERATION. Prom this experience with this operation I can easily see that it would have been better had I done the ordinary laminectomy instead of doing this very difficult ostéoplastie operation. I should have saved time, and I should have saved tissue, and I think I should have saved function. I do not believe that the laminae of the third and fourth cervical vertebras, for the conservation of which the whole technic was planned, were worth the trouble: nor will they be worth it to the patient. A laminectomy in the cervical and perhaps in the lumbar region is very different from one in the dorsal region, for in the dorsal region the spine is convex posteriorly (kyphotic) and in the cervical and lumbar re-Downloaded From: by a University of Iowa User on 06/05/2015
doi:10.1001/jama.1907.25220360001001 fatcat:pzo7bldggfclda5a3nqymaju4a