He began his practice of neurosurgery in the Territory of Hawaii in 1938. He designed over 100 surgical instruments which continue to be used today by practicing neurosurgeons.
Posterior Lumbar Interbody Fusion (PLIF) After William Mixter and Joseph Barr published their famed paper of disk herniation in 1934, discectomy to remove
stenosis became the routine procedure. Alternative attempts were to fuse the posterior arch of the spine. In cases of
spondylolisthesis, some surgeons had fused the interbody space, but only from an
anterior approach. During a posterior discectomy operation in 1940, Cloward noticed a large hole in the remaining
annulus fibrosis, and it occurred to him that this void could be filled with a piece of bone. But the patient suffered a pulmonary embolism on the tenth post-operative day, and died. Because disk herniation recurred in many cases, Cloward devised to reattempt his posterior interbody fusion procedure, which he did with success. However, as Cloward and later advocates argued, if performed successfully, the PLIF provided better
biomechanics and outcomes. Over time, after refining the technique and advocating its merits with publications and lectures, the PLIF became respected. With the help of a few other surgeons, including Paul Lin, the first PLIF Workshop was held at
Nazareth Hospital in Philadelphia in 1981 and the first PLIF Symposium was held in Temple Hospital in 1983. By this time, the procedure had garnered many advocates. When Cloward published his last paper on PLIF in 1985, he reported a successful fusion rate of over 92%. by Robert Robinson and George Smith at Johns Hopkins University, by Albert Dereymaeker and Joseph Mulier in France and by Cloward in Honolulu. None were aware of the work of the others at the time. Bailey, Badgely and Abbott had been the first to use the technique Cloward's technique differed from the other surgeon's in that he used a large dowel graft, as opposed to the strut graft that the others used. His idea for this dowel was taken from a modification made by Ben Wiltberger to Cloward's PLIF operation, who had used dowels in place of Cloward's bone pegs. Cloward published his work on the subject in 1958. Though not the first to perform or publish the procedure, his standing in the neurosurgical field at the time enhanced its early popularity. Like the PLIF, ACDF is now a popular method of spinal fusion.
Later career Throughout his career, he educated the international community of neurosurgeons in the performance of the operations he devised. Cloward was a member of the Western Neurosurgical Society for 40 years and served as its President in 1975. After his death in 2000, a number of Society members were desirous of creating an award in his name which would include a medal akin to the Cushing Medallion awarded by the AANS. It was felt that Ralph's innovative talents and pioneering efforts to establish anterior cervical and posterior lumbar interbody fusion plus the numerous instruments he devised was just cause to honor him in perpetuity by bestowing an award upon neurosurgeons from around the world who also exemplified such capacity for epochal innovation and pioneering application. In 2002, the Society established the award with the gracious assistance of the surviving Cloward family. ==References==