50 years ago in CORR: Anterior excision and vertebral body fusion for intervertebral disk syndromes of the lower lumbar spine: three- to five-year results in 224 cases. Paul H. Harmon, MD, FACS CORR 1963;26:107-127.

Most contemporary reports of the results of surgical procedures routinely describe complications. (A symposium in this issue—Volume 470 Issue No. 6 of CORR—is devoted to complications of spinal surgery.) Harmon, in 1960 [1] and 1963 [2], described in detail an anterior surgical approach for treating disc protrusion and degenerated discs, “utilizing a surgical approach that is free of the hazard of blood loss and where vision of the pathology is optimal” [1]. Complications were not always emphasized in reports from the literature of that time. In these two articles, Harmon mentions medical complications only several times, despite reporting large numbers of cases (250 in the 1960 article and 650 in the 1963 article): “…there has been only a single case (from a total of 550 cases) with neurologic complications…” and “The mortality has been nil, neurologic complications negligible, and the morbidity from all causes has been less than 1 per cent” [2]. He considered pseudarthrosis a “severe complication.” Harmon emphasized surgical techniques in both articles (the earlier article [1] contains two-parts, with the second devoted to technique). Figures 10 and ​and1111 from his 1963 article illustrate the types of grafts he considered essential to achieve fusion. “Definite trabecular osseous union has been observed in 95 per cent with autogenous grafts. A rate of union 10 per cent lower has been observed with frozen homogenous grafts.” He favored autogenous “sandwich grafts” consisting of alternate layers of tibial cortical and cancellous bone. Fig. 10 Halftone drawings, demonstrating a transvertebral grafting procedure on the anterior aspect of the lumbosacral joint. The lower right-hand figure shows insertion of full -thickness iliac graft, “coin” type. Two such grafts per level are ... Fig. 11 An alternative technique of preparation of graft bed and insertion of 2 rectangular grafts illustrated for the L-4 level: (A) incision in the anterior ligament; (B) preparation of graft bed; (C) completed grafting procedure. (Reprinted with permission ... Harmon used a characteristic categorical rating of the times: “Good and excellent results are both highly acceptable; in the former arc persons exhibiting only occasional and fleeting nonincapacitating reminders of their former disorder, while in the latter, the patients are entirely without symptoms. Fair results describe patients who are occasionally disabled with recurrent low back pains and/or radicular pain, but are improved as compared with their preoperative state. Unimproved (or poor) is self-explanatory.” In various subcategories, he reported 80% to 96% good or excellent results. “Considering all diagnostic subdivisions and all age groups, good and excellent results have been obtained in slightly more than 90 per cent of the cases.” Such categories are rarely used in contemporary reporting because they are subjective, various surgeons would rate patients differently, and because we emphasize validated patient-generated evaluations. Today, most reports give complications more attention, perhaps owing to the emphasis on patient safety. Harmon’s reports were characteristic for the time, but we wonder how rigorously complications, including the less severe complications, were recorded: certainly they were not always reported. Nonetheless, he seemed to improve most of his patients using meticulous techniques.