LEGACIES
HISTORY OF SPINE BIOMECHANICS: PART I—
THE PRE-GRECO-ROMAN, GRECO-ROMAN, AND
MEDIEVAL ROOTS OF SPINE BIOMECHANICS
Sait Naderi, M.D.
Department of Neurosurgery,
Yeditepe University
School of Medicine,
Istanbul, Turkey
Niteen Andalkar, M.D.
Department of Neurosurgery,
Cleveland Clinic Spine Institute,
Cleveland Clinic Foundation,
Cleveland, Ohio
Edward C. Benzel, M.D.
Department of Neurosurgery,
Cleveland Clinic Spine Institute,
Cleveland Clinic Foundation,
Cleveland, Ohio
Reprint requests:
Edward C. Benzel, M.D.,
Department of Neurosurgery,
Cleveland Clinic Spine Institute,
Cleveland Clinic Foundation,
9500 Euclid Avenue, S-80,
Cleveland, OH 44195.
Email: [email protected]
Received, February 20, 2006.
Accepted, October 13, 2006.
THE ROOTS OF spine biomechanics reside in the Antiquity and the Medieval and
Renaissance periods. A review of historical treatises reveals detailed information regarding this often historically neglected discipline. Ancient medical, philosophical, and
physical documents were reviewed, as they pertained to the historical foundation of
spine biomechanics. These included medical case reports and observations of nature and
motion by ancient philosophers and scientists. These documents heavily influenced
the portion of the scientific literature that we now regard as “spine biomechanics” up
through the Renaissance. The focus of Part I of this two-part series is placed on the
ancient and medieval biomechanics-related literature and on associated literature that
influenced the development of the field of modern spine biomechanics.
KEY WORDS: Biomechanics, Greco-Roman period, History, Medieval period, Pre-Greco-Roman period,
Spine
Neurosurgery 60:382–391, 2007
DOI: 10.1227/01.NEU.0000249276.94933.8D
S
pine biomechanics is the physical science
that forms a substantial portion of the
foundation of modern spine surgery. As a
discipline, spine biomechanics has enjoyed significant growth during the past two centuries.
Its roots, however, reside in the Antiquity and
the Medieval and Renaissance periods. An
assessment of these historical roots indicates
that an impressive understanding of the essentials and art of scientific investigation existed
in these periods. With such a strong scientific
background based in the physical, rather than
biological, sciences, it is appropriate to review
the true origins of this discipline. The portrayal
of the origins of spine biomechanics presented
herein has been drawn from medical case histories, medical treatises, and treatises concerning kinesiology and mechanics. Of note, the
historical periods have been variably defined.
Therefore, they have been arbitrarily chosen
and depicted as overlapping. These overlapping time periods are summarized in Figure 1.
PRE-GRECO-ROMAN
(ANCIENT) PERIOD
The first documentation of literature related
to spine biomechanics was drawn from preGreco-Roman case histories, including those of
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Egyptian and Indian origin. Many papyruses
from the ancient Egyptians have been discovered. Among them is the Edwin Smith papyrus
(2600–2200 B.C.), which is of great importance
from the perspective of spine biomechanics. A
copy of a copy, this papyrus is assumed to
have been written by Imhotep, the physician
for the court of Pharaoh Zoster of the Third
Dynasty. It was sold to Edwin Smith in 1869
and donated to the New York Historical
Society in 1906. The papyrus was not interpreted for many years; however, in the 1930s,
its transcription was published for the first
time (Fig. 2) (5). In 1992, the American
Association of Neurological Surgeons republished the Edwin Smith papyrus (23). In this
papyrus, 48 cases of trauma were reported,
including six cases of spinal trauma. Unfortunately, the portion containing thoracic and
lumbar spine trauma was missing. This papyrus reported vertebral dislocations (wenekh)
and burst fractures (sehem). It also presented
evidence in support of mechanisms of injury
(i.e., falling on one’s head [axial loading]
resulting in a burst fracture [5]).
The papyrus focused on the neurological
consequences of spinal fractures, emphasizing
that fracture-dislocations are associated with a
poor prognosis. Although the Egyptians
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HISTORY OF SPINE BIOMECHANICS: PART I
FIGURE 1. Timeline from the pre-Greco-Roman period through the Renaissance.
The use of spinal traction was reported in the ancient Indian
epic Srimad Bhagwat Mahapuranam, which is estimated to have
been written between 3500 and 1800 B.C. In this epic, one story
tells of Lord Krishna correcting the hunchback of one of his
devotees. This is the first known report addressing the correction of spinal deformity. Kumar (12) translated the original
Sankrit verse as follows:
To shower the fruits of his blessings,
Happy Lord Krishna decided to straighten Kubja,
Who was deformed from three places.
He pressed her foot by his foot,
Held her chin by two fingers and pulled her up.
By touch and pull of Lord,
She became a beautiful straight woman. (22, p 653)
Srimad Bhagwat Mahapuranam is, therefore, the oldest
known reference to the clinical application of a biomechanical principle (i.e., axial
traction) to optimize the care
of a patient with a spinal disorder.
FIGURE 2. The Edwin Smith papyrus was transcribed and published in the
1930s.
understood the importance of splinting for long bone fractures
and probably had a fundamental understanding of the underlying biomechanical principles, the use of such splints was not
addressed in the Edwin Smith papyrus.
Egyptian physicians, however, were aware of the spinal column. Much of the anatomic nomenclature terminology used
today was derived from these ancient physicians’ perspective
of the human body. For example, a derivative of the term
“spinal column,” the “djet column,” was used in ancient Egypt
(Fig. 3) (13).
The only other potential sources of information regarding
the ancient roots of biomechanics are of Indian and, possibly,
Chinese origin. Unfortunately, there is no known bona fide
information that documents ancient Chinese interest in spinal
disorders. However, some information does exist regarding the
interest of ancient Indians in this arena (12).
NEUROSURGERY
GRECO-ROMAN
PERIOD
Ancient Greek medicine
can be divided into two periods. The first period, known
as the mythological period,
began with the Trojan War
and lasted until the
Hippocratic period. The second period was the scientific
period, which began during
the time of Hippocrates and
ended with Paulus of Aegina.
The Mythological Period
The mythological period
was associated with much
FIGURE 3. A derivative of the
“spinal column,” the djet column was
known to the ancient Egyptian physicians (from, Lang JK, Kolenda H:
First appearance and sense of the term
“spinal column” in ancient Egypt.
Historical vignette. J Neurosurg 97
[Suppl 1]: 152–155, 2002 [13]).
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NADERI ET AL.
mysticism and the recognition of a number of gods, including
those of medicine and health. The predominant health centers
of this period were known as Asclepions. These were founded
for Aesculapius, the god of health. There were many
Asclepions in the major Greek settlements of Titan, Trika,
Rhodes, Kos, Epidauros, Athens, Alexandria, Tiber, and
Pergamon. The infrastructure of Asclepions resembled modern hospitals. Treatment modalities in the Asclepions included
hydrotherapy, physiotherapy, hygienic rule, diet, well-known
drug therapies, and minor surgical procedures. A priestphysician was responsible for examinations and treatments.
Interestingly, pregnant women and patients with severe,
untreatable disease were not accepted into Asclepions. It is
assumed, but not proven, that minor spinal disorders were
treated in these facilities. Ultimately, Asclepions were
destroyed by the Christians after Christianity achieved dominance in Rome in the second century A.D.
Although some important philosophers (e.g., Thales of
Miletus [625–585 B.C], Anaximenes of Miletus [556–440 B.C.],
Pythagoras of Samos [580–489 B.C.], and Alcamaeon of Crotona
[circa. 500 B.C.]) recorded their thoughts in the field of medicine, it seems that there is no documentation suggesting a contribution to kinesiology and biomechanics. The only information regarding the spine was reported by Empedocles, a
famous physician and philosopher in the 5th century B.C. He
thought that the vertebrae were initially unified, forming a
rigid spine, and that this solid osseous column subsequently
broke down (segmented) into pieces as a result of movements
of the body (1, 6).
Scientific Period
Modern scientific thought was first observed with
Hippocrates, who freed the art of medicine from the “influence” of supernatural spirits. Hippocrates was born on the
Island of Ceos, Greece, where he studied medicine and became
a priest-physician in Ceos Asclepion. Hippocrates founded an
open air school after he became prominent in the field of medicine. He wrote many treatises on a variety of medical issues.
Unfortunately, his original treatises were lost. They were, however, published in 12 books known as Corpus Hippocraticum. It
is thought that the books on prognostics and aphorisms were
authored by Hippocrates and the remaining books were written by other physicians from his school. Paul Emile Littre
(1801–1881), a French physician and a master of language and
medical history, translated the 12 books, which included discussions of spine pathologies and treatments, into French.
Therefore, information concerning spinal biomechanics in
ancient times can be drawn from the translated version of
Corpus Hippocraticum.
Hippocrates (460–377 B.C.)
Hippocrates (Fig. 4) focused on the anatomy and pathology
of the spine (6, 15, 23). As an anatomist, his contributions
were not remarkable. However, he realized that the spine was
held together by means of intervertebral discs, ligaments, and
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FIGURE 4. Among his other accomplishments, Hippocrates studied the
anatomy and pathology of the spine.
muscles, permitting him to describe the normal curvatures of
the spine.
He defined tuberculous, spondylitis, posttraumatic kyphosis,
scoliosis, spinal dislocation, and the spinous process fracture.
Hippocrates was the first physician to address the relationship
between spinal tuberculosis and gibbus formation. According
to Hippocrates, a spinous process fracture was not dangerous.
However, he observed that fractures of the vertebral body were
of greater clinical significance (15).
He described two frames for reduction of the dislocated
spine and associated deformities, including the Hippocratic
ladder and the Hippocratic board (Figs. 5 and 6) (14). He recommended simultaneous traction of the spine and the manual
application of focal pressure over the kyphotic area:
“But the physicians, or some person who is strong, and not
uninstructed, should apply the palm of the hand to the
hump, and then, having laid the other hand upon the former, he should make pressure, attending whether this
force should be applied directly downward, or toward the
head, or toward the hips . . . and there is nothing to prevent a person from placing a foot on the hump, and supporting his weight on it, and making gentle pressure . . . ”
(22, p 659).
If this maneuver did not work, Hipppocrates recommended
an alternative procedure:
”But the most powerful of the mechanical means is this; if
the hole in the wall, or in the piece of wood fastened into
the ground, be made as much below the man’s back as
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HISTORY OF SPINE BIOMECHANICS: PART I
FIGURE 5. The Hippocratic ladder was one method used for the reduction of
the dislocated spine and its associated deformities.
FIGURE 6. The Hippocratic board was one method used for the reduction of
the dislocated spine and its associated deformities.
may be judged proper, and if a board, made of lime-tree, or
any wood, and not too narrow, be put into the hole, then
a rag, folded several times or a small leather cushion,
should be laid on the hump . . . when matters are thus
adjusted, one person, or two if necessary, must press down
at the end of the board, while others at the same time make
extension and counter-extension along the body, as formerly described” (22).
clavicle. The C2 and the great vertebra (which corresponds to
either C1 or C7) were in this group. The second group included
the thoracic spine; the third group consisted of the five vertebrae between the chest and the pelvis. Hippocrates evidently
did not consider the sacrum and coccyx to be part of the spine.
However, he portrayed them as vertebrae when he described
the normal spinal curves.
Hippocrates used the term “ithioscoliosis” to indicate that
the spine is straight in the coronal plane, but curved in the
sagittal plane (15). He observed that the cervical and lumbar
lordoses were normal or natural and that the sacrum arches
dorsally and forms a cavity harboring the bladder and the
rectum. According to Hippocrates, the purpose of the spine is
to maintain the erect posture and to form the shape of the
human body.
Hippocrates categorized spinal disorders into five groups:
1) traumatic and nontraumatic (tuberculosis, congenital, agerelated-degenerative, those secondary to bilateral dislocation of
the pelvis, and rarely in epileptic patients) kyphosis; 2) scoliosis; 3) burst fractures; 4) vertebral dislocations; and 5) fractures
of the spinous processes (15).
According to Hippocrates, the most common cause of nontraumatic kyphosis is spinal tuberculosis. He classified tuberculous kyphosis into two main groups: those above the level of
attachment of the diaphragm and those below it. He observed
that spinal deformity is more prominent in patients before
puberty and that, after puberty, the course of the disease is
more benign.
Although Hippocrates practiced spinal manipulation, he
warned against the use of succussion to achieve spinal reduction. Succession was a practice in which a patient was secured
to a ladder in an upside down position. He was then suddenly
released, only to be abruptly suspended by the attached ropes.
It was thought that the rapid deceleration aided in achieving
spinal realignment. Hippocrates stated,
“Wherefore succussion on a ladder has never straightened anybody, as far as I know, but it is principally practiced by those physicians who seek to astonish the mobfor to such persons these things appears wonderful. For
example, if they see a man suspended or thrown down,
or the like; and they always extol such practices, and
never give themselves any concern whatever may result
from the experiment, whether bad or good. But the physicians who follow such practices, as far as I have known
them, are all stupid” (22).
Hippocrates emphasized the importance of acquiring knowledge regarding spinal anatomy: “One should first get a knowledge of the structure of the spine; for this is also requisite for
many diseases” (10).
He classified the spinal vertebrae into three groups. The first
group consisted of the vertebrae lying above the level of the
NEUROSURGERY
“When hump-back occurs in children before the body has
completed its growth, the legs and arms attain full size,
but the body will now grow correspondingly at the spine;
these parts are defective . . . when curvature comes on in
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persons whose bodily growth is complete, its occurence
produces an apparent crisis in disease then present. In
time, however, some of the same symptoms found in the
younger patients show themselves to a greater or lesser
degree, but in general they are all less malignant” (10).
Hippocrates observed that traumatic kyphosis was commonly caused by falling on the shoulder or buttock. He
addressed scoliosis associated with tuberculosis and also
described a case of cervical scoliosis. He observed that burst
fractures (sizis) resulted from vertical loading of the vertebra.
Vertebral dislocation, both ventral and dorsal, were recorded
and reported by Hippocrates. Ventral dislocation was observed
to be secondary to the falling of a heavy object on the spine or
by falling from a height. Dorsal dislocation was not commonly
observed and was noted to be associated with serious abdominal injury, often resulting from a high fall. Hippocrates
observed that dorsal dislocation was usually fatal. He identified fractures of the spinous process and observed that they
healed rapidly and usually without neurological deficit.
Hippocrates recommended diet and extension for the treatment of scoliosis. He favored the early management of dislocations because reduction was accomplished easily if attempted
before swelling occurred (15).
In addition to Hippocrates, this period was represented by
several other unique individuals, including Socrates, Plato, and
Aristotle. The most important aspect of this period was the
human inquiry into pathological processes and nature in general. Socrates taught that we could not begin to understand
the world around us until we understood our own nature (17).
Plato (427–347 B.C.)
Plato, a member of the Athenian aristocracy and 51 years
junior to Socrates, began the philosophical inquiries that have
influenced the disciplines of philosophy, psychology, logic, and
politics. He thought that mathematics, a system of pure ideas,
was the best tool for the pursuit of knowledge. Plato’s conceptualization of mathematics as the life force of science created
the necessary womb for the birth and growth of the science of
mechanics and spine biomechanics. Of note, however, he also
thought that divine intervention contributed to the creation of
the flexible spine (17).
FIGURE 7. Aristotle was the most prominent research scientist in ancient
Greece.
At that time, Greek culture, with a trend toward the investigation of the human body and mind, was at its peak. The Greeks’
enthusiasm for athletics, sports, and gymnastics was part of
their philosophy of developing the human being as a whole to
optimize functional capacity. Aristotle founded the first philosophy school in Assos (near Troy and Çanakkale, Turkey)
(Fig. 8) and was considered to be the most prominent philosopher of the time (11).
Herophilus of Chalcedon (335–280 B.C.)
Herophilus was educated under the influence of Hippocratic
philosophy in the Ceos Asclepion by the Greek physician
Praxagoras. He made significant contributions to the understanding of anatomy, particularly human neuroanatomy. However, there is no mention of spine anatomy and biomechancs in
his works. Nevertheless, he was aware of spinal cord injuries
and suggested that direct surgical intervention on the spinal
column should be avoided (1, 9, 20).
Aristotle (384–322 B.C.)
The most prominent research scientist in ancient Greece was
Aristotle (Fig. 7). He was born 7 years after Hippocrates’ death.
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FIGURE 8. Map showing the location of the the first philosophy school in
Assos (arrow) (near Troy and Çanakkale, Turkey).
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HISTORY OF SPINE BIOMECHANICS: PART I
Aristotle, the universal and consummate scientist, left his
mark in practically every major realm of science that was
known to man during this period, including physics, mathematics, chemistry, botany, zoology, physiology, and psychology. He had an extraordinary talent for observation and should
perhaps be considered the first biomechanist. He viewed the
animal’s body as a mechanical system and wrote the first book
on the subject, De Motu Animalium, or On the Movement of
Animals (4, 7, 8, 11, 17, 21).
His treatises, Parts of Animals, Movements of Animals, and
Progression of Animals described the action of the muscles and
subjected them to geometric analysis for the first time. He
recorded some practical observations: “…the animal that
makes its change of position by pressing against that which is
beneath it…hence atheletes jump further if they have weights
in their hands than if they have not; and runners run faster if
they swing their arms, for in the extension of the arms there is
a kind of leaning upon the hands and wrists” (3).
In the same treatise, he described the action of muscles and
used geometrical analysis. Aristotle defined the act of “muscular flexion” as a change from a straight line to an angle and
noted that without this “flexion,” there could not be forward
progression, such as walking and swimming. This implied, for
the first time, the thought or conceptualization of transformation of rotatory into translational motion (21).
Aristotle’s discussion regarding the problems of pushing a
boat under various conditions was, in essence, a precursor of
Newton’s three laws of motion. For his time, Aristotle demonstrated a remarkable understanding of the role of the center of
gravity, the laws of motion, and leverage (4, 21).
The writings of Aristotle mark the philosophical birth of
kinesiology, making Aristotle the father of this field. Although
Aristotle was a scientist, he performed no actual experiments
(4, 11). His numerous writings are the results of pure, logical
analysis. Aristotle obviously appreciated the existence of the
“center of gravity” in his writings: “The reason why an animal
which is to walk erect must be both a biped and also have the
upper part of its body lighter and the parts situated beneath
these heavier is obvious; for only if it were so constituted
would it be able to carry itself easily” (3). He stated that,
because of this fact, a man’s legs are stronger than his upper
limbs and that children have difficulty walking because the
upper part of their body is large in proportion to the lower
half. These findings can be related to the gravitational moments
effective at the axes of rotation of the joints of the weightbearing limbs (4). Although his studies were not directly
related to the spine, they were the first to discuss human kinesiology, and, in part, biomechanics.
In the third century B.C., the center of Greek civilization and
medicine shifted from the old Greek settlements toward the
new Egyptian city of Alexandria. In the cultural melting pot of
Alexandria, Greek science produced some of its greatest
achievements. Conversely, Eastern mysticism gained greater
influence on Greek thinking. Archimedes (287–212 B.C.), Euclid,
Praxagoras, Herophilus of Chalcedon, and Erasistratus of Ceos
(330–250 B.C.) are among the important figures of Alexandria
NEUROSURGERY
FIGURE 9. Archimedes studied the laws of leverage and problems related to
determining the center of gravity.
during this era. Among those figures, only Archimedes is of
significance from a biomechanics perspective.
Archimedes (287–212 B.C.)
Archimedes (Fig. 9) was born approximately 50 years after
the death of Aristotle. He was credited for his studies relating
to the hydrostatic principles associated with floating bodies.
Archimedes studied the laws of leverage and problems related
to determining the center of gravity. Hence, his treatises on the
latter have been described as the foundation of theoretical
mechanics. Before the time of Christ, he was the last of the
ancient Greeks to excel in the field of mechanics. Archimedes
identified our most fundamental scientific tools, deductive reasoning, and mathematical analysis (4).
Aulus (Aurelius) Cornelius Celsus (25 B.C.–50 A.D.)
There is controversy regarding the actual role of Aulus
Cornelius Celsus. Although some think he was a surgeon or
physician, he would probably be more accurately classified as
a medical encyclopedist. He wrote on observations in the field
of spine surgery. Celsus reported that cervical spine injury may
be associated with difficulty breathing and death; he also
reported that lower spine injury may cause paraparesis and
urinary incontinence. His recommendations included immobilization and external stabilization, but not surgery (9).
Galen of Pergamon (130–200 A.D.)
Galen of Pergamon (Fig. 10), another ancient Greek physician, was born in Pergamon, but later moved to Rome and
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FIGURE 11. In the Medieval period, Paulus of Aeginata collected ancient
data in his seven-volume encyclopedia.
FIGURE 10. Galen’s work as an official surgeon of the gladiators led to his
being considered the “father of sports medicine.”
became the physician to the emperor, Marcus Aurelius. He
is, therefore, considered by some to be a physician of the
Roman period. Galen worked as a surgeon and anatomist
and was the founder of experimental physiology and embryology. He described the muscular system as a “unified but
complex organ of locomotion” and demonstrated the physiological relationship between the nervous and muscular
systems (16).
Galen focused on the anatomy of animals and extrapolated
his findings to the human anatomy. His anatomic doctrines
affected medicine for more than 1200 years, until the studies
of Vesalius altered knowledge. It is of note that he worked as
an official surgeon of the gladiators in the amphitheaters,
leading to his being remembered as the “father of sports
medicine.” He confirmed the observations of Imhotep and
Hippocrates regarding the neurological sequences of cervical
trauma (2, 16, 24).
Galen made important contributions in anatomy and disorders of spine. According to Galen, if the spine was a single,
rigid bone, it would be invulnerable but also inflexible like a
statue. In that case, man would have been deprived of motion,
which is a vital feature of life. On the other hand, a spine consisting of many small parts would be more flexible, yet the
unavoidable consequence of this flexibility would have been its
vulnerability. The number of the existing vertebrae is ideal as it
allows the spine to bend in a circular, rather than angular, manner, thus avoiding injury of the spinal cord (16). He mentioned
that the vertebrae are bound ventrally and articulated dorsally.
The ventral parts provide for motion and the dorsal parts
ensure stability and prevent excessive extension.
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Galen classified spinal disorders as kyphosis, lordosis, scoliosis, and succussion. He addressed, in detail, tuberculosis of
the spine and spinal injury. He analyzed the mechanism and
the consequence of spine trauma and noted that spinal injuries
usually follow a fall from a height or from a violent force
applied to the vertebrae (16). The direction of the trauma affects
the type of the injury. Galen recommended the use of the
Hippocratic board for traumatic deformities and the Hippocratic ladder for kyphotic deformities. Unlike Hippocrates,
Galen was more liberal in advocating surgery to remove bone
fragments pressing on the spine (9).
Oribasius (325–400 A.D.)
Oribasius, a Byzantine physician, added a bar to the
Hippocratic reduction device and used it for reduction of both
spinal traumas and deformities.
BYZANTINE PERIOD
Paulus of Aegina (625–690 A.D.)
Although Paulus of Aegina (Fig. 11) lived during the
Byzantine period (330–1453 A.D.), he is recognized as a representative of ancient medicine because he collected doctrines of
the antique period in his seven-volume encyclopedia (Fig. 12).
Paulus of Aegina not only used the Hippocratic bed, but he
also worked with a red-hot iron (a cauterization device) to treat
painful maladies. He was credited with performing the first
known laminectomy in a case of spinal fracture resulting in
spinal cord compression and emphasized the use of orthoses in
spinal trauma (9).
Avicenna (981–1037 A.D.)
The Medieval age consists of two distinct periods, the Dark
Age and the Reconstruction Era. During the Dark Age, the
Church was dominant in the West, which had a tremendous
effect on scientific studies. During this age, most of the classics
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HISTORY OF SPINE BIOMECHANICS: PART I
FIGURE 12. The cover of Paulus of Aeginata’s encyclopedia.
were translated into Arabic, Syrian, and Persian. Islamic physicians recorded some of their observations and experiences
regarding the spine, spinal disorders, and spine anatomy.
Avicenna (Fig. 13) was one of the most prolific contributors in
this era. In his treatise, Al-Qanun fi al-Tibb, or The Canons of
Medicine, he wrote eight chapters on the functional anatomy of
the spine.
In his treatise, Avicenna sought an explanation for the
anatomic features of each spinal region. He emphasized that
the shape and the size of any given vertebra is determined by
its regional function. Therefore, he classified the spine into segments similar to those known today, such as cervical, thoracic,
lumbar, sacral, and coccyx. He then described anatomic features of elements of vertebra in any region, particularly regarding the anatomy of C2, T12, and the number of sacral vertebrae.
However, despite the aforementioned anatomic errors,
Avicenna described the biomechanical features of the vertebrae and the spine almost correctly. He described flexion, extension, and lateral bending aspects of the motion segments, as
well as the coupling phenomenon of the thoracolumbar spine.
The most interesting writings of Avicenna were on the biomechanics of the craniovertebral junction. Avicenna described
the characteristics of the atlas and the axis. He reported that the
cranial-atlas motion segment was responsible for lateral bending, whereas the C0–C2 segment makes anteroposterior motion
possible. According to Avicenna, the odontoid process has two
functions: 1) it is a protector of the high cervical spinal cord and
2) it prevents the displacement of the thinner first cervical vertebra. During anteroposterior and lateral movements of the
head, the C1 and C2 vertebrae act as a single bone and move
together (19). He also described the reduction technique for
spinal trauma cases (2, 12).
Albucasis (936–1013 A.D.)
Albucasis, also known as Al-Zahrawi, was undoubtedly the
greatest surgeon of the Middle Ages. He was born in Zahra, the
NEUROSURGERY
FIGURE 13. A physician and philosopher in the Medieval period, Avicenna
contributed to medical literature, including eight chapters on the functional
anatomy of the spine.
royal suburb of Cordoba, in southern Spain. Because he was a
prominent surgeon, he taught many students and treated many
patients from all over Europe. He was an inventor of surgical
instruments and described surgical techniques for the treatment of spine disorders, such as sciatica, low back pain, scoliosis, and spinal dislocations. He used cauterization for painful
maladies and described a device for reduction of dislocated
vertebrae (2). His treatise provided medical foundations for
both Arabic and European medicine. His techniques were used
and reported by the Turkish surgeon, Serefeddin Sabuncuoglu
(1386–1470). In the 15th century, Sabuncuoglu published these
works in his illustrated surgical atlas, Cerrahiyetul Haniye (18).
In this text, he described the treatment of spinal dislocations.
Loss of sphincter tone and motor function below the level of
injury was categorized as a complete dislocation. Less severe
injuries were described as partial. The reduction of partial dislocations was performed by placing the patient in the prone
position on a wooden frame. The chest and knees were tied
with ropes. The physician used both hands to apply manual
pressure over the dislocated segment until reduction was
achieved.
CONCLUSION
The foundations of modern spine biomechanics were laid in
the ancient and medieval periods by physicians, philosophers,
and scientists. Although each of these contributions, in and of
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themselves, often did not yield a true biomechanical breakthrough, each of them either enhanced the knowledge base of
the era or laid the groundwork for further investigation and
observation, setting the stage for a more accelerated acquisition
of knowledge in the upcoming centuries.
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COMMENTS
T
he authors extensively review the history of biomechanics in two
parts. For the most part, they have succeeded with this ambitious
390 | VOLUME 60 | NUMBER 2 | FEBRUARY 2007
undertaking. The understanding of spine biomechanics plays a vital
part in the management of spinal disorders. These two articles describing the history of biomechanics provide a good foundation for the
overall understanding of spine biomechanics.
Volker K.H. Sonntag
Phoenix, Arizona
T
he authors present a comprehensive overview of the history of
spine biomechanics. Dating back more than 2000 years, they have
detailed numerous vignettes which allow the reader to recognize that
many clinical problems present today also had to be tackled in the
early years of spine biomechanics. Furthermore, the primitive methods
available to healthcare providers at that time are described. The lack of
current spinal treatments obviously made successful management of
these afflictions much more difficult. Nonetheless, our predecessors
managed to effectively care for their patients in the great majority of
cases. The authors are to be lauded for specifically tracking down these
historic references and bringing them together to tell a cohesive story.
Robert F. Heary
Newark, New Jersey
T
he authors have put together an extensive review of the early medical and surgical writings in an effort to trace the heritage of spinal
mechanics. Looking at spinal mechanics and the literature this would
seem to be a most daunting task! The authors begin with the pre-GrecoRoman period and continue up through the medieval period. By focusing on personalities of the time and their writings, the authors have
been able to ferret out some pearls of history. The task is not an easy
one, as the literature from this era is sometimes quite scarce and sometimes confusing in translation. For the individual interested in the history of spinal mechanics, this article is an obligatory read.
James T. Goodrich
Bronx, New York
T
he first in a two-part series, this article summarizes the origins of
our knowledge and understanding of spinal disorders. While reading this article, one might be surprised by the ancient origins of many
of the concepts applied in modern spine management. As Bilroth, a
famous surgeon, once said “Only the man who is familiar with the art
and science of the past is competent in its progress in the future.”
In this first part of the series, some historical figures and epics lack
major contribution to our understanding of spine biomechanics.
However, they remain entertaining, especially in a period in which
mythology and medicine were interrelated. The authors mention how
the use of axial traction in Indian civilization transforms a kyphosed
woman into a beauty but omit to make reference to Homer’s Odyssey
in which several cervical injuries were described.
Although the Western world was plunged into darkness during the
medieval period, some important European figures thrived in this environment, especially in Italy where cadaveric dissections were permitted on a limited basis. One such man was Theodoric of Bologna
(1205–1298) who described in detail the examination of a patient experiencing a cervical injury and the nonsurgical treatment of his cervical
dislocation by reduction and stabilization.
It is interesting to note that most of the pathologies reported during
this ancient and medieval period were of traumatic lesions and infectious spinal deformities. Rarely were degenerative diseases described.
Paul Khoueir
Michael Y. Wang
Los Angeles, California
www.neurosurgery-online.com
HISTORY OF SPINE BIOMECHANICS: PART I
T
he authors provide an illuminating orientation to the accomplishments of Old World scientists and philosophers. These philosophers
and scientists made invaluable contributions to the medical sciences
under the most extreme and challenging conditions. It is regrettable that
some neurosurgeons today believe that the only means of achieving an
efficient surgery is through technology. While recognizing the importance of technology and the extraordinary medical advances that they
make possible, I firmly believe that without proper orientation to physiology, anatomy, and philosophy, we are depriving our patients of the
best treatment possible. I enjoyed reading this article immensely and am
grateful for the many new insights it contained.
Yucel Kanpolat
Ankara, Turkey
World Heavyweight champion Muhammad Ali’s (1942 –) knockout victory over Sonny Liston (1932–1971) happened less than two minutes into the
first round of their rematch on May 25, 1965 in Lewiston, Maine.
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