Spinal Vascular Malformations: An Historical Perspective
In this historical perspective, the author identifies three epochs in the development of the concepts and treatment of spinal vascular lesions: 1) early observations (1860s–1912), with the lesions during this time period recognized only at autopsy; 2) the "middle ages" (1912–1960), with surgical intervention sporadic and yielding dismal results; and 3) the modern era (beginning in the 1960s), coincident with parallel dramatic advances in radiology, microsurgical instrumentation, and anesthesiology. These advances resulted in a better understanding of the pathophysiological aspects and angioarchitecture of the lesions.

Whereas the nomenclature of the lesions in the past was confusing, a new understanding of these diseases that has emerged during the modern era has permitted refinement of the classification of the lesions as distinct biological entities. Modern diagnostic imaging has enabled identification of patients who may benefit from surgical or embolic occlusion, and treatment has become rationally based.

Future progress in the management of spinal vascular lesions may be anticipated, with improvement in noninvasive imaging for early detection of suspected abnormalities. Furthermore, advances in spinal cord neuroprotection may expand the range of future options for surgical or embolic intervention.

This study was undertaken in an effort to trace the historical development of surgery for spinal vascular lesions. These lesions encompass AVMs, AVFs, spinal cord aneurysms, and vascular neoplasms of the spinal cord. Although these terms are incorrect in a strict sense, they are commonly used interchangeably. In the course of the study, attention was directed to the interplay of contributions from other disciplines, notably radiology, and surgical instrumentation such as the operating microscope (Fig. 1). Three time periods or epochs were identified: 1) early observations: 1860s to 1912; 2) the "middle ages": 1912 to 1960; and 3) the modern era: 1960 to the present. These three epochs are linked to the evolution of the classification of spinal vascular lesions (see Appendix).



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Flow chart showing an overview of the historical evolution of developments in the early recognition of spinal vascular lesions up to the present. Parallel advances in radiology and in microsurgical instrumentation, beginning in the 1960s, are shown to interact with developments in the classification and treatment of spinal vascular lesions.