Origins of Eponymous Instruments in Spine Surgery
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HISTORICAL VIGNETTE J Neurosurg Spine 29:696–703, 2018 Origins of eponymous instruments in spine surgery Morenikeji Buraimoh, MD,1 Azam Basheer, MD,2 Kevin Taliaferro, MD,3 Jonathan H. Shaw, MD,4 Sameah Haider, MD,2 Gregory Graziano, MD,3 and Eugene Koh, MD1 1Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, Maryland; Departments of 2Neurosurgery and 3Orthopedic Surgery, Henry Ford Hospital, Detroit, Michigan; and 4Wayne State University School of Medicine, Detroit, Michigan Every day, spine surgeons call for instruments named after surgical pioneers. Few know the designers or the histories behind their instruments. In this paper the authors provide a historical perspective on the Penfield dissector, Leksell rongeur, Hibbs retractor, Woodson elevator, Kerrison rongeur, McCulloch retractor, Caspar pin retractor system, and Cloward handheld retractor, and a biographical review of their inventors. Historical data were obtained by searching the HathiTrust Digital Library, PubMed, Google Scholar, Google Books, and Google, and personal communications with relatives, colleagues, and foundations of the surgeon-designers. The authors found that the Penfield dissectors filled a need for delicate tools for manipulating the brain and that the Leksell rongeur increased surgical efficiency during war-related laminectomies. Hibbs’ retractor facilitated his spine fusion technique. Woodson was both a dentist and a physician whose instrument was adopted by spine surgeons. Kerrison rongeurs were developed in otology to decom- press bone near the facial nerve. The McCulloch, Caspar, and Cloward retractors helped improve exposure during the emergence of new techniques, i.e., microdiscectomy and anterior cervical discectomy and fusion. The histories behind these eponymous instruments remind us that innovation sometimes begins in other specialties and demonstrate the role of innovation in improving patient care. https://thejns.org/doi/abs/10.3171/2018.5.SPINE17981 KEYWORDS eponymous instruments; history of orthopedic surgery; history of neurosurgery; history of surgery NUMBER of the instruments we employ in surgery communicated with relatives, colleagues, and foundations are eponymous. Nevertheless, their namesakes of the surgeon-designers. and the origins of the instruments remain obscure. ASurgeons have explored the origins of eponymous instru- Wilder G. Penfield (1891–1976) ments in the fields of hand surgery, plastic surgery, otolar- yngology, and general orthopedics.16,23,31,32 Although spine The Penfield dissectors comprise a set of 5 blunt-tipped surgery is one of the most innovative surgical fields, a his- dissectors designed for gently manipulating neural tissues. torical perspective on eponymous spine instruments has The No. 4 Penfield (Fig. 1 left) is the workhorse dissector not been written. in spine surgery. We aim to give a historical perspective on 8 spine in- Wilder Penfield (Fig. 1 right), one of the 20th century’s struments: the Penfield dissector, Leksell rongeur, Hibbs most influential brain surgeons, grew up in Spokane, Wash- retractor, Woodson elevator, Kerrison rongeur, McCulloch ington, and Hudson, Wisconsin. His father and grandfather retractor, Caspar pin retractor, and Cloward handheld re- were physicians. After matriculating from Princeton Uni- tractor. Our list of instruments is by no means complete, versity, Penfield studied physiology at Oxford on a Rhodes and merely reflects instruments commonly used by the au- Scholarship, and while there realized that neurophysiol- thors. We performed a nonsystematic search using the Ha- ogy was a “great unexplored field” primed for discovery.35 thiTrust Digital Library, PubMed, Google Scholar, Google Penfield obtained his medical degree at Johns Hopkins Books, and Google. Any non-English texts were translated University and interned at the Peter Bent Brigham Hos- into English with Google Translate (Google Inc.). We also pital in Boston, where he worked with Harvey Cushing. ABBREVIATIONS ACDF = anterior cervical discectomy and fusion; NYOH = New York Orthopedic Hospital; NYU = New York University. SUBMITTED September 7, 2017. ACCEPTED May 11, 2018. INCLUDE WHEN CITING Published online September 14, 2018; DOI: 10.3171/2018.5.SPINE17981. 696 J Neurosurg Spine Volume 29 • December 2018 ©AANS 2018, except where prohibited by US copyright law Unauthenticated | Downloaded 10/09/21 01:37 PM UTC Buraimoh et al. FIG. 1. Left: No. 4 Penfield dissector. Right: Photograph of Dr. Wilder G. Penfield. Photograph is in the public domain and was downloaded from https://commons.wikimedia.org/wiki/Wilder_Penfield#/media/File:Wilder_Penfield.jpg. Figure is available in color online only. He subsequently became a junior attending at Columbia changed.40 At the end of his career, Penfield saw himself Presbyterian Hospital in New York in 1921 under Allen as an explorer, except unlike his “predecessors who used Whipple. During this time, Penfield periodically observed compasses and canoes to discover unknown lands,” he neurosurgery clinics in Boston, Baltimore, and Philadel- used a scalpel and a small electrode to explore and map phia to continue learning his craft.11,35 the human brain.36 Penfield also traveled to Europe to study neurophysi- ology, neurology, and neurosurgery. His famed dissectors Lars G. F. Leksell (1907–1986) were created while he was in Breslau, Germany, in 1928, The Leksell laminectomy rongeur (Fig. 2 left) is used learning Otfrid Foerster’s technique for treating posttrau- 11,35 for spinous process removal, laminar thinning, and for matic epilepsy. While awed by Foerster’s techniques, some, central decompression during laminectomies. Lars Penfield noted a lack of gentle instruments for handling the Leksell (Fig. 2 right) was born in Fässberg Parish, Swe- brain. For example, he noted forceps and needles blunted den, in 1907. His father was a businessman and his mother by sponges being used to manipulate the brain, which he a talented porcelain decorator. As a teen, he liked gadgets found particularly vexing. Before returning to the US, he and enjoyed creating radio receivers. Leksell originally 35 enlisted a craftsman to make 5 “delicate dissectors.” intended to become a lawyer but turned to medicine after Penfield moved to Montreal in 1928, and in 1934 being impressed by orthopedic care he received after a founded the Montreal Neurological Institute.11 There, he motorcycle accident (D. Leksell, personal communication, perfected Foerster’s technique for excising epileptic foci 2017). Leksell completed his medical education at the using brain mapping and local anesthesia. This brain- Karolinska Institute in Sweden and began his neurosurgi- mapping technique led to Penfield publishing his map of cal training in 1935 under Herbert Olivercrona. Leksell’s the motor homunculus, which today remains relatively un- interest in neurosurgery stemmed from his interest in neu- FIG. 2. Left: Leksell rongeur. Right: Photograph of Dr. Lars Leksell, courtesy of the Leksell Gamma Knife Society. Published with permission. Figure is available in color online only. J Neurosurg Spine Volume 29 • December 2018 697 Unauthenticated | Downloaded 10/09/21 01:37 PM UTC Buraimoh et al. FIG. 3. Left: Hibbs retractor. Right: Dr. Russell A. Hibbs. Photograph by Doris Ullman-Jaeger. From The Faculty of the College of Physicians and Surgeons, Columbia University in the City of New York: Twenty-Four Portraits (New York: Paul B. Hoeber, 1919), courtesy Archives & Special Collections, Columbia University Health Sciences Library. Published with permission. Figure is avail- able in color online only. rophysiology (D. Leksell, personal communication, 2017). first and surgeons second, Hibbs was a pioneer in the use This interest resulted in his discovery of the gamma motor of arthrodesis for the management of appendicular tuber- neuron, which he presented as his PhD thesis in 1945.26 cular osteomyelitis.15 In 1909, he developed a technique In 1940, Leksell volunteered in the Finnish Winter War for knee arthrodesis. He learned from this the importance (1939–1945).26 The Leksell rongeur emerged during this of using bridging bone graft and meticulously preserv- time. Leksell designed the rongeur to improve the effi- ing periosteum to support new bone formation.19 He ap- ciency of laminectomy procedures for the removal of shell plied this principle in treating Pott’s disease in 1911.18 splinters from the spinal canal.12 The rongeur’s manufac- The original Hibbs spinal fusion was between the spinous turer, Stille, compared this elegant instrument to a prima processes; this was quickly extended to include the inter- ballerina, whose “form and balance are essential to artistic laminar spaces, and then the facet joints. Interestingly, achievement.” Unbeknownst to Stille, Leksell loved clas- Hibbs’ productivity was fueled by a professional rivalry sical ballet (D. Leksell, personal communication, 2017). with Dr. Fred Albee, another New York orthopedist who Leksell made many other contributions to neurosur- independently developed a spinal fusion technique. Spine gery. He developed a technique for ultrasound encepha- surgeons ultimately adopted Hibbs’ technique.33 The tim- lography for head trauma in 1954.12 He also advanced ra- ing of the development of the Hibbs retractor is unknown, diosurgery and invented the Gamma Knife.26 A desire to but the retractor was designed for interlaminar exposure, decrease the mortality rate associated with certain open where Hibbs performed fusion. Fittingly,