DISEASES OF THE VERTEBRAL COLUMN AND SPINAL CORD
POTT'S DISEASE: _Pathology_; _Clinical features_--Pott's disease as it
affects different regions of the spine--Disease of the sacro-iliac
joint; Syphilitic disease of spine; Tumours of vertebrae;
Hysterical spine; Acute osteomyelitis; Rheumatic spondylitis;
Arthritis deformans; Coccydynia; Tumours of cord and
membranes--Spinal meningitis; Spinal myelitis--Congenital
deformities: _Spina bifida_; _Congenital sacro-coccygeal tumours_.
Congenital sacro-coccygeal sinuses and fistulae.
TUBERCULOUS DISEASE OF THE SPINE--POTT'S DISEASE
Percival Pott, in 1779, first described a disease of the vertebral
column which is characterised by erosion and destruction of the bodies
of the vertebrae. It is liable to produce an angular deformity of the
spine, and to be associated with abscess formation and with nervous
symptoms referable to pressure on the cord. This disease is now known
to be tuberculous. It may occur at any period of life, but in at least
50 per cent. of cases it attacks children below the age of ten and
rarely commences after middle life.
#Morbid Anatomy.#--The tuberculous process may affect any portion of
the spine, and as a rule is limited to one region; several vertebrae
are usually simultaneously involved. The disease may begin either in
the interior of the bodies of the vertebrae--tuberculous
osteomyelitis--or in the deeper layer of the periosteum on the
anterior surface of the bones--tuberculous periostitis.
_Osteomyelitis_ is the form most frequently met with in children. The
disease commences as a tuberculous infiltration of the marrow, which
results in softening of the bodies of the affected vertebrae,
particularly in their anterior parts, and, as the disease progresses,
caseation and suppuration ensue, and the destructive process spreads
to the adjacent intervertebral discs. In some cases a sequestrum is
formed, either on the surface or in the interior of a vertebra. The
pus usually works its way towards the front and sides of the bones,
and burrows under the anterior longitudinal (common) ligament. Less
frequently it spreads towards the vertebral canal and accumulates
around the dura, causing pressure on the cord.
The compression of the diseased vertebrae by the weight of the head and
trunk above the seat of the lesion, and by the traction of the muscles
passing over it, produces angling of the vertebral column. The
anterior portions of the bodies being more extensively destroyed, sink
in, while the less damaged posterior portions and the intact articular
processes prevent complete dislocation. In this way the integrity of
the canal is maintained, and the cord usually escapes being pressed
upon. The spinous processes of the affected vertebrae project and form
a prominence in the middle line of the back. When, as is usually the
case, only two or three vertebrae are implicated, this prominence takes
the form of a sharp angular projection, while if a series of vertebrae
are involved, the deformity is of the nature of a gentle backward
curve (Fig. 210).
[Illustration: FIG. 210.--Tuberculous Osteomyelitis affecting several
vertebrae at Thoracico-lumbar Junction.]
The _periosteal form_ of vertebral tuberculosis is that most
frequently met with in adults. The disease begins in the deeper layer
of the periosteum on the anterior aspect of the vertebrae, and extends
along the surface of the bones, causing widespread superficial caries.
It may attack the discs at their margins, and spread inwards between
the discs and the contiguous vertebrae. Owing to the comparatively
wide area of the spine implicated, this form of the disease is not
attended with angular deformity, but rather with a wide backward
curvature which corresponds in extent to the number of vertebrae
affected. The accumulation of tuberculous pus under the periosteum and
anterior longitudinal ligament is the first stage in the formation of
the large abscesses with which this form of spinal tuberculosis is so
commonly associated.
_Effects on the Spinal Cord and Nerve Roots._--In some cases the cord
and nerve roots are pressed upon by an oedematous swelling of the
membranes; in others, the tuberculous process attacks the dura mater
and gives rise to the formation of granulation tissue on its outer
aspect--_tuberculous pachymeningitis_. Less frequently a collection of
pus forms between the bone and the dura, and presses the cord back
against the laminae. The cord is rarely subjected to pressure as a
result of curving of the spine alone, but occasionally, especially in
the cervical region, a sequestrum becomes displaced backward and
exerts pressure on it, and it sometimes happens, also in the cervical
region, that the cord is nipped by sudden displacement of diseased
vertebrae--a condition comparable to a fracture-dislocation of the
spine.
The severity of the symptoms is aggravated by the occurrence of
inflammation of the cord--_myelitis_--which is not due to tuberculous
disease, but to interference with its blood-supply from the associated
meningitis.
_Repair._--When the progress of the disease is arrested, the natural
cure of the condition is brought about by the bodies of the affected
vertebrae becoming fused by osseous ankylosis (Fig. 211). While this
reparative process is progressing, the cicatricial contraction renders
the angular deformity more acute, and it may go on increasing until
the bones are completely ankylosed; this reparative process can be
followed in successive skiagrams. An increase in the projection in the
back, therefore, is not necessarily an unfavourable symptom, although,
of course, it is undesirable.
[Illustration: FIG. 211.--Osseous Ankylosis of Bodies (_a_) of Dorsal
Vertebrae, (_b_) of Lumbar Vertebrae following Pott's disease. There is
marked kyphosis at the seat of the disease and compensatory lordosis
above and below.
(Museum of the Royal College of Surgeons, Edinburgh.)]
[Illustration: FIG. 212.--Radiogram of Museum Specimen of Pott's
disease in a Child; the disease is located at the thoracico-lumbar
junction.
(Dr. Hope Fowler.)]
In rare cases the disease affects only the articular or the spinous
processes, producing superficial caries and a localised abscess.
#Clinical Features.#--The clinical features of Pott's disease vary so
widely in different regions of the spine, that it is necessary to
consider each region separately. To avoid repetition, however, certain
general features may be first described.
_Pain._--In the earliest stages, the patient complains of a feeling of
tiredness, which prevents him walking far or standing for any length
of time. Later, there is a constant, dull, gnawing pain in the back,
increased by any form of movement, particularly such as involves
jarring or bending of the spine. If the patient is a child, it is
noticed that he ceases to play with his companions, and inclines to
sit or lie about, usually assuming some attitude which tends to take
the weight off the affected segment of the spine (Figs. 214, 217). If
he is going about, the pain increases as the day goes on, but may pass
off during the night. It is often referred along the course of the
nerves emerging between the diseased vertebrae, and takes the form of
headache, neuralgic pains in the arms or side, girdle-pain, or
belly-ache, according to the seat of the lesion. Tenderness may be
elicited on pressing over the spinous or transverse processes of the
diseased vertebrae, or on making pressure in the long axis of the
spine. These tests, however, are not of great diagnostic value, and
they should be omitted, as they cause unnecessary suffering. It is to
be borne in mind that in some cases the disease is not attended with
any pain.
_Rigidity._--The pain produced by movement of the diseased portion of
the spine causes reflex contraction of the muscles passing over it,
and the affected segment of the column is thus rendered rigid. If the
palm of the hand is placed over the painful area while the patient
attempts to make movements of stooping, nodding, or turning to the
side, it is found that the vertebrae implicated move _en bloc_ instead
of gliding on one another. This rigidity of the diseased portion of
the column with "boarding" of the muscles of the back is one of the
earliest and most valuable diagnostic signs of Pott's disease.
_Deformity._--The most common and characteristic deformity is an
abnormal antero-posterior curvature, with its convexity backwards. The
situation, extent, and acuteness of the bend vary with the region of
the spine affected, the situation of the disease in the bone, and the
number of vertebrae implicated. When the disease has destroyed the
bodies of one or two vertebrae, a short, sharp, angular deformity
results; when it affects the surface of several bones, a long, wide
curvature.
Lateral deviation is occasionally met with in the early stages of the
disease as a result of unequal muscular contraction, and in the later
stages from excessive destruction of one side of a vertebra, or from
partial luxation between two diseased vertebrae.
_Abscess Formation._--Spinal abscesses occur with greater frequency
and at an earlier stage in adults than in children, because in adults
the disease usually begins on the surface of the vertebrae. Pyogenic
infection of such abscesses after they have burst externally
constitutes one of the chief risks to life in Pott's disease.
_X-Ray Appearances._--These, when considered along with the clinical
signs, usually afford valuable information as to the exact seat and
nature of the lesion and the number of vertebrae involved. It is
recommended to compare the skiagram with that of the normal spine from
the same region and from a patient of approximately similar age. The
outlines of the bodies are woolly or blurred; in the early stage there
may be clear areas corresponding to cheesy foci. In progressive cases
the bodies may be altered in shape and in size, and from destruction
and collapse of the bones there is altered spacing, both of the bodies
and of the ribs. In the interpretation of skiagrams, help is often
obtained from an alteration in the axis of bodies, an angular
deviation often drawing attention to the lesion which is located at
the "angle." In children (Fig. 213) there is often a spindle-shaped
shadow, outlined against the vertebral column, which is due to a cold
abscess, and which extends above and below the bodies actually
involved in the tuberculous process. The fusion of the bodies by new
bone, which accompanies repair, can be followed in skiagrams taken at
intervals.
[Illustration: FIG. 213.--Radiogram of Child's Thorax, showing
spindle-shaped shadow at site of Pott's disease of fourth, fifth, and
sixth thoracic vertebrae.]
_Cord and Nerve Symptoms._--When the spinal cord is pressed upon, the
motor fibres are first affected as they lie superficially on the
antero-lateral aspects of the cord, and are more sensitive to
pressure. There is at first weakness or paresis of the muscles
supplied from the part of the cord below the seat of pressure. The
knee-jerks and plantar reflexes are exaggerated, and there is marked
ankle clonus. Later, there is paralysis of the spastic type, varying
in extent and sometimes amounting to complete paraplegia, and this may
come on gradually or quite suddenly. There is wasting of muscles from
disuse, and later a tendency to contracture and the development of
deformities, as a result of sclerosis or descending degeneration of
the cord.
The sensory fibres usually escape, although in some cases there is
partial anaesthesia and perversion of sensation. When there is also
myelitis, loss of sensibility to pain (analgesia) below the level of
the lesion is one of the most characteristic symptoms. In severe cases
there is incontinence of urine and of faeces, as the patient loses
control of the sphincters. Acute bed-sores are not uncommon.
The symptoms referable to pressure on the _nerve roots_ at their
points of emergence are pain and hyperaesthesia along the course of the
nerves that are pressed upon, and occasionally weakness and wasting of
the muscles supplied by them; girdle-pain is often a prominent symptom
in adults.
In the #diagnosis# of Pott's disease in young children, chief stress
is laid on the demonstration of rigidity of the affected portion of
spine; the child is laid prone and is lifted by the legs and feet so
as to hyper-extend the spine; in Pott's disease the spine is held
rigid, while in the rickety and other conditions that resemble it, the
movements are normal.
#Treatment of Pott's Disease.#--In addition to the general treatment
of tuberculosis, the essential factor consists in _immobilising
the spine in the recumbent posture and in the attitude of
hyper-extension_; this must be persisted in until the diseased
vertebrae become fused together or ankylosed by new bone, a result
which is estimated partly by the disappearance of all symptoms and
more accurately by observing the formation of the new bone in
successive skiagrams.
Under conservative measures it is estimated that this reparative
process entails an immobilisation of the spine of from one to three
years; the _operative procedures introduced by Albe and Hibbs_ bring
about a bony ankylosis of the vertebrae in as many months, and may be
accepted as reducing the period of spinal immobilisation in the
recumbent posture to one year at the most.
The immobilisation of the recumbent spine in the attitude of
hyper-extension is most efficiently carried out by an apparatus on the
lines of the _Bradford frame_; this is made of gas-piping covered by
canvas, and is easily bent as may be required in the progress of the
case towards convalescence. The frame does not interfere with such
_extension_ as may be necessary, to the head, for example, in recent
cervical caries, or to the lower extremities where flexion at the hip
from spasmodic contraction of the psoas muscle may be efficiently
relieved by weight-extension.
_Gauvain's "wheel-barrow" splint_ and the _double Thomas' splint_
(Fig. 215) are efficient substitutes, but _Phelps' box_ has been
discarded because it fails to secure immobilisation of the spine.
When the stage of _convalescence_ is arrived at, and recumbency is no
longer essential, the child is allowed to sit up, stand, and go
about, with the restraint, however, of some apparatus that will
prevent movement of the spine, except to a limited extent. The
_plaster-of-Paris jacket_, applied over a woollen jersey, as
introduced by Sayre of New York, is probably the best; the jacket is
accurately moulded to the trunk while the child is partly suspended by
means of a tripod and the necessary strings under the chin, occiput,
and armpits. Poroplastic felt, celluloid, papier mache, and other
materials, reinforced by strips of metal, may be substituted for the
plaster of Paris. Various forms of _jury-masts_ and _collars_ have
been employed to diminish the weight of the head in children with
cervical caries, but have been very properly discarded as failing to
perform the function expected of them.
_Correction of the Angular Projection._--In cases in which the angular
projection or gibbus, as it is called by continental authors, is of
recent origin, it may be corrected by the method so successfully
employed by Calot of Berck-sur-Mer--a plaster jacket is accurately
moulded to the trunk, and a diamond-shaped window is cut in the jacket
opposite the gibbus; a series of layers of cotton-wool are then
applied, one on top of the other, so as to exert firm pressure on the
gibbus, a plaster or elastic webbing bandage being employed to retain
them and reinforce the pressure. The padding is renewed at intervals
of three weeks or a month; in successful cases the projection may
ultimately be replaced by a hollow.
_Treatment of Abscess._--If a spinal abscess is causing symptoms or is
approaching the surface, and there appears to be a risk of mixed
infection, the abscess should be asperated and injected with iodoform
emulsion.
_Treatment of Cord-Complications._--Extension is applied, in the first
instance, to the head or to the lower limbs, or to both, while some
form of pillow is inserted at the seat of the disease; if the
condition is merely one of oedema, the symptoms usually yield with
remarkable rapidity; if they persist, in spite of extension, for three
to six weeks, recourse should be had to _laminectomy_; it is usual to
find evidence of mechanical pressure by granulation tissue, pus, or
displaced bone, the relieving of which is followed by disappearance of
the nerve symptoms. Some authors are lukewarm in their advocacy of
this operation, but we can cite a number of cases in which, after
laminectomy, an apparently hopeless paraplegia has been entirely got
rid of.
#Prognosis.#--As regards the _survival of persons who have suffered
from Pott's disease_, and as having an important bearing on prognosis,
it may be noted that surgical museums contain many specimens
illustrating the "cured" stage of the disease, in which the bodies of
the vertebrae, formerly the seat of tuberculous destruction or caries,
are represented by a ridge-shaped mass of new bone, forming a solid
union between the segments above and below (Fig. 211), or the remains
of the original bodies may still be identifiable, although they are
surrounded and fused together by new bone. The latter condition is the
more liable to a recrudescence of the tuberculous infection. Further,
it may be inferred from the number of "cured" cases of Pott's disease
met with in everyday life, that the malady is one from which recovery
may be expected.
The cervical cases are recognised by the "telescoping" of the neck,
the head and thorax being unduly approximated; the dorsal cases by the
well-known _hump_ or _hunch-back_, in which the spinous processes of
the collapsed vertebrae constitute the apex of the hump; the thorax is
telescoped from above downwards, the ribs are crowded together, the
lower ones, it may be, inside the iliac crests, and the sternum
projected forwards. The hunch-back from Pott's disease is often a
remarkably capable person, both physically and intellectually.
POTT'S DISEASE AS IT AFFECTS DIFFERENT REGIONS OF THE SPINE
#Upper Cervical Region, including Atlo-axoid Disease.#--When the
disease affects the first and second cervical vertebrae, the atlo-axoid
articulation becomes involved, and as a result of the destruction of
its component bones and ligaments, the atlas tends to be dislocated
forward. When this occurs suddenly, the odontoid process may impinge
on the medulla and upper part of the cord and cause sudden death. When
the displacement occurs gradually, the atlas and axis may be separated
to a considerable extent without the cord being pressed upon, and
recovery with ankylosis may ensue. When the third, fourth, and fifth
vertebrae are affected, the tendency to dislocation and compression of
the cord is not so great, but a portion of bone may be displaced
backwards and exert pressure on the cord.
The patient complains of a fixed pain in the back of the neck, and of
radiating pains along the course of the sub-occipital and other
cervical nerves. The neck is held rigid, and to look to the side the
patient turns his whole body round. As the disease advances the head
may be bent to one side as in wry-neck, or it may be retracted and the
chin protruded. To take the weight of the head off the diseased
vertebrae the patient often supports the chin on the hands (Fig. 214).
[Illustration: FIG. 214.--Attitude of patient suffering from
Tuberculous disease of the Cervical Spine. The swelling on the left
side of the neck is due to a retro-pharyngeal abscess.]
An abscess may form between the vertebrae and the wall of the
pharynx--_retro-pharyngeal abscess_--the pus accumulating between the
diseased bones and the prevertebral layer of the cervical fascia. The
abscess may project towards the pharynx as a soft fluctuating
swelling, and may cause difficulty in swallowing and breathing, and
snoring during sleep; if it bursts internally it may cause
suffocation. The abscess may bulge towards one or both sides of the
neck, and come to the surface behind the posterior border of the
sterno-mastoid muscle (Fig. 214). In some cases it comes to the
surface in the sub-occipital region.
If the cord is pressed upon by inflammatory products, there is
muscular weakness, beginning in the arms and extending to the legs,
and sometimes followed by complete paralysis. In the early stages
there is retention of urine and constipation; later the bladder and
rectum are paralysed, and there is incontinence.
Sudden death may result when dislocation of the atlo-axoid joint takes
place.
Cervical caries has to be diagnosed from rheumatic torticollis, and
from the effects of injuries, such as a sprain or twist of the spine.
When a retro-pharyngeal abscess points behind the sterno-mastoid, it
is apt to be mistaken for a cold abscess originating in tuberculous
cervical glands. Retro-pharyngeal abscess due to other causes is
described with diseases of the pharynx.
_Treatment._--Extension is applied to the head, preferably by means of
an elastic band fixed to the top of the bed, and the head of the bed
is raised on blocks so that the weight of the body may furnish the
necessary counter-extension. Lateral movements of the head are
prevented by means of sand-bags. After the acute symptoms have
subsided, the spine should be fixed by some rigid apparatus, such as a
double Thomas' splint prolonged so as to support the occiput (Fig.
215).
[Illustration: FIG. 215.--Thomas' Double Splint for Tuberculous
disease of Spine.]
When it is considered advisable to open a retro-pharyngeal abscess,
this should be done from the side of the neck by an incision along the
posterior border of the sterno-mastoid, as first recommended by John
Chiene. The abscess is evacuated, and the cavity filled with iodoform
emulsion, and closed without drainage. An opening made through the
mouth is attended with the risks of pus being inhaled into the
air-passages and of pyogenic infection.
When the patient is allowed to get up, a poroplastic collar and jacket
of the Minerva type which supports the head and controls the movement
of the cervical and thoracic vertebrae must be worn until the cure is
complete.
#Cervico-thoracic Region.#--When the lower cervical and upper thoracic
vertebrae are affected, in addition to the fixed pain in the diseased
bones, the patient complains of pain radiating along the distribution
of the superficial cervical nerves and down the arms. There is often
marked angular deformity. If an abscess forms, it may come to the
surface in the lower part of the posterior triangle, or may spread
into the posterior mediastinum or into the axilla. Sometimes the pus
burrows behind the oesophagus and trachea, and it may find its way
into the pleural cavity. The cord is not often pressed upon; when it
is, the cervical sympathetic is implicated.
#Thoracic or Dorsal Region.#--When the disease is confined to the
thoracic region, stiffness of the back and boarding of the vertebral
muscles are prominent features. On being asked to pick up an object
from the floor, the patient reaches it by bending his knees and hips,
while he keeps his back rigid. He refuses to make any movement that
involves jolting of the spine, such, for example, as jumping from a
chair to the ground. Children often attempt to take the weight off the
diseased vertebrae by placing the palms of the hands on the edge of a
chair so that the weight is borne by the arms.
Angular deformity is often well marked, and may implicate several
vertebrae. In order to maintain the head erect, the spine above and
below the seat of disease becomes unduly arched forward--compensatory
lordosis. In advanced cases the ribs become approximated, and the
lower end of the sternum is projected forward. The antero-posterior
diameter of the thorax is thus increased, while its vertical diameter
is diminished. These changes, together with the telescoping of the
vertebral bodies, lead to the deformity characteristic of the
tuberculous hunch-back (Fig 216). The alterations in the shape of the
chest may lead to functional disturbances of the heart and lungs.
[Illustration: FIG. 216.--Hunch-back Deformity following Pott's
disease of Thoracic Vertebrae.
(Photograph lent by Sir George T. Beatson.)]
_Dorsal Abscess._--As already mentioned, the earliest stage of abscess
is well seen in skiagrams (Fig. 213), especially in children. When
there is an extension of the suppurative process, the pus may pass
directly backwards along the posterior branches of the intercostal
vessels and nerves, and come to the surface behind the transverse
processes, or it may travel forward between the pleura and the ribs,
and, passing along the course of the lateral cutaneous branches of the
intercostals, come to the surface opposite the middle of the rib. In
the latter case, the abscess is liable to be mistaken for one
associated with tuberculous disease of the rib, particularly as the
rib is usually found to be bare. In rare cases the pus opens into the
pleura, giving rise to empyema. When the disease is on the anterior
surface of the bodies of the lower thoracic vertebrae, the pus may
spread down through the pillars of the diaphragm and reach the sheath
of the psoas muscle.
_Treatment_ is on the usual lines.
#Thoracico-lumbar Region.#--The symptoms are similar to those of
disease in the thoracic region. Children while standing often assume a
characteristic attitude--the hips and knees are slightly flexed, and
the hands grasp the thighs just above the knees (Fig. 217). In this
way the weight is partly taken off the affected vertebrae and borne by
the arms. If the child is laid on its back and lifted by the heels,
the spine remains rigid. By this test a projection due to tuberculous
disease may be differentiated from one due to rickets, as in the
latter case the projection disappears.
[Illustration: FIG. 217.--Attitude in Pott's disease of
Thoracico-lumbar Region of Spine.]
The patient often complains of pain in the abdomen--which in children
may be mistaken for a simple "belly-ache"--and of pain shooting down
the buttocks and into the legs. If the cord is pressed upon at the
level of the lumbar enlargement the anal and vesical sphincters are
paralysed, and the reflexes are exaggerated.
_Psoas Abscess._--When an abscess forms, it usually occupies the
sheath of the psoas muscle, in which it spreads down towards the iliac
fossa, and into the thigh, passing beneath Poupart's ligament,
posterior and lateral to the femoral vessels. The communication
between the pelvis and the thigh is often very narrow, so that the
abscess cavity has to some extent the shape of an hour-glass. The pus
may reach the surface in the region of the saphenous opening, or may
spread farther down the thigh under cover of the deep fascia. In some
cases it is liable to be mistaken for a femoral hernia, as the
swelling becomes smaller when the patient lies down, and has an
impulse on coughing.
_Lumbar Abscess._--Sometimes the pus travels along the posterior
branches of the lumbar vessels and nerves to the lateral border of the
sacro-spinalis (erector spinae) and comes to the surface in the space
between the edges of the latissimus dorsi and external oblique
muscles--the triangle of Petit.
In rare cases it passes through the sacro-sciatic foramen and forms a
swelling in the buttock (_sub-gluteal abscess_); or it may pass
through the obturator foramen and reach the adductor region of the
thigh or even the perineum.
#Lumbo-sacral Region.#--Pott's disease in the lumbo-sacral region
usually affects adults, and, on account of the breadth of the
vertebral bodies and the limited range of movement in this segment of
the spine, is seldom accompanied by marked symptoms or deformity. The
diagnosis, therefore, is often difficult, unless good skiagrams are
available. The disease may be associated with pain in the distribution
of the sciatic nerve, which is liable to be mistaken for sciatica.
Single or double _iliac abscess_ frequently forms without the patient
showing any characteristic signs of spinal disease. When the disease
begins in childhood it may induce a permanent deformity of the
pelvis, the conjugate diameter at the brim being increased, while the
transverse diameter at the outlet is diminished--kyphotic pelvis, and,
in females, this may lead to complications in parturition.
#Tuberculous Disease of the Sacro-iliac Joint.#--This condition may
occur as a primary affection, but is much more frequently secondary to
disease in the ilium, sacrum, or lower lumbar vertebrae, and is most
common in adolescents and young adults of the male sex. It is attended
with pain in the lumbar region, and sometimes in the buttock and along
the course of the sciatic nerve. The pain is aggravated by movements,
especially such as involve sudden and violent contraction of the
lumbar and abdominal muscles, for example, coughing, sneezing, or
straining during defecation. Tenderness is elicited on making pressure
over the joint, on pressing together the iliac bones, or on attempting
to abduct the limb while the pelvis is fixed. The muscles of the
buttock and thigh are wasted. As any attempt to bear weight on the
affected limb causes pain, the patient walks with a limp, and to save
the joint he assumes an attitude which is characteristic: he throws
his weight on the sound limb, leans forward, using a stick for
support, tilts the affected side of the pelvis downwards, and flexes
the hip and knee-joints of the diseased limb. The anterior superior
spine is unduly prominent on the affected side, and the limb appears
to be lengthened. Sooner or later, in most cases, an abscess forms,
and the pus may reach the surface over the posterior aspect of the
joint. When the pus forms in front of the joint, it may spread
laterally in the iliac fossa as an _iliac abscess_ or may gravitate
downwards in the hollow of the sacrum and emerge on the buttock
through the sacro-sciatic foramen--_sub-gluteal abscess_. Sometimes it
passes into the ischio-rectal fossa or into the perineum. The presence
of an abscess in the pelvis may sometimes be recognised on rectal
examination. The appearance of an abscess is sometimes the first thing
to draw attention to the condition.
As pain across the small of the back and along the course of the
sciatic nerve may be among the early symptoms of sacro-iliac disease,
the condition is liable to be mistaken for lumbago or for sciatica.
From hip disease it is recognisable by noting that the movements of
the hip-joint are not restricted. It is not always possible without
the aid of skiagrams to differentiate sacro-iliac disease from disease
of the lumbar spine, and the two conditions sometimes coexist.
The _prognosis_ is unfavourable, particularly in cases complicated by
extensive disease of the ilium with abscess formation and mixed
infection.
_Treatment._--In early cases the patient should use crutches and wear
a patten on the foot of the sound side; in more advanced cases he must
be confined to bed, and have absolute rest to the joint secured by
means of extension applied to both legs, or by other apparatus. In
children a double Thomas' splint or Stiles' abduction frame is a
convenient appliance. Counter-irritation by blisters or the actual
cautery may be had recourse to in dry cases in which pain is a
prominent feature. If operative treatment becomes necessary, as it
may, for removal of a sequestrum, access to the seat of disease is
obtained by removing the posterior portion of the iliac bone. Cold
abscess is treated on the usual lines.
#Syphilitic Disease of the Vertebrae.#--All the clinical features of
Pott's disease may be simulated by gummatous disease of the vertebrae.
This is usually met with in adults who have suffered from acquired
syphilis; it is most common in the upper cervical vertebrae, and begins
on the anterior surface of the bodies. The onset is more sudden than
that of tuberculous caries, and the progress more rapid. The bone is
early and extensively destroyed, but abscess formation is rare. Severe
nocturnal pains are complained of, and some degree of angular
deformity may develop. In almost all cases other evidence of tertiary
syphilis is present, and this, together with the history and the
effects of anti-syphilitic treatment, aids in diagnosis. The local
treatment is carried out on the same lines as for tuberculous disease.
#Malignant Disease of the Vertebrae.#--_Sarcoma_ is the most important
of the primary tumours met with in the vertebral column. It gives rise
to symptoms which are liable to be mistaken for those of Pott's
disease or of arthritis deformans. The pain, however, is more intense,
and the disease progresses more continuously, and is uninfluenced by
treatment. The changes in the vertebrae, as seen in skiagrams, are
helpful in diagnosis. The growth may encroach upon the vertebral canal
and cause pressure on the cord (p. 451). In the sacrum--the most
common site--the tumour implicates the sacral nerves, and causes
symptoms of intractable sciatica; and the real nature of the disease
is often only detected on making a rectal examination.
_Secondary cancer_ is a common disease, particularly in cases of
advanced scirrhus of the breast. It leads to extensive softening of
the bodies of the vertebrae, so that they yield under the weight of the
body, as in Pott's disease. Clinically it is associated with severe
pain in the region of the vertebrae affected, and along the course of
the nerves emerging in the neighbourhood. If paralysis occurs from
the cancerous bodies pressing upon the cord (_paraplegia dolorosa_),
it is of rapid development, often becoming complete in a few hours.
When the cervical cord is compressed all four limbs are paralysed, and
from interference with respiration, the condition is fatal within a
few days.
#Actinomycosis#, #Blastomycosis#, and #Hydatid Cysts# also occur in
the vertebrae, and are difficult to diagnose from tuberculous disease.
#Typhoid Spine.#--An acute infective condition of the vertebrae,
intervertebral discs, and spinal ligaments occasionally occurs during
convalescence from typhoid fever. The lumbar region is most frequently
affected, and the X-rays reveal inflammatory changes in the bones,
disappearance of the discs, and, in the later stages, deposits of new
bone leading to synostosis of adjacent vertebrae. The onset, which may
be gradual or sudden, is attended with intense pain, and tenderness
over the affected vertebrae. The temperature is raised, and other signs
of an acute infective process are present. In a few cases there are
symptoms of involvement of the membranes and cord. With prolonged rest
and immobilisation of the spine the inflammation usually subsides, but
sometimes it goes on to suppuration.
#Hysterical Spine.#--This term is applied to a functional affection of
the spine occasionally met with in neurotic females between the ages
of seventeen and thirty, and liable to be mistaken for Pott's disease.
The patient complains of pain in some part of the spine--usually the
cervico-thoracic or thoracico-lumbar region--and there is marked
hyperaesthesia on making even gentle pressure over the spinous
processes. As the patients are usually thin, the pressure of the
corset is apt to redden the skin over the more prominent vertebrae, and
give rise to an appearance which at first sight may be mistaken for a
projection. The general condition of the patient, the freedom of
movement of the vertebral column, and the entire absence of rigidity,
are sufficient to exclude tuberculosis. The condition is treated on
the same lines as other hysterical affections.
#Acute osteomyelitis# of the vertebrae is a rare affection, and is met
with in young subjects. It attacks the more mobile portions of the
spine--cervical and lumbar--and may begin either in the bodies or in
the arches. It is attended with extreme sensitiveness on movement,
severe localised pain in the region of the vertebrae attacked, and a
marked degree of fever. Pus usually forms rapidly, but, being deeply
placed, is not easily recognised unless it points towards the
surface. The infection is liable to spread to the meninges of the cord
and give rise to meningitis, particularly when the disease begins in
the arches. A milder form occurs, in which the main incidence is on
the periosteum; the symptoms are less severe, it does not tend to
suppurate, and is usually recovered from. The treatment consists in
applying extension to the spine and in opening any abscess that may be
detected. The suppurative form usually proves fatal, and, indeed, is
often only diagnosed on post-mortem examination.
#Arthritis Deformans.#--This disease usually begins between the ages
of thirty-five and forty, and attacks men who follow some laborious
occupation which involves exposure to cold and wet. It is met with,
however, in women who lead a sedentary life. There is sometimes a
recent history of gonorrhoea, rheumatism, or other toxic disease, and
occasionally the condition follows upon injury. The discs disappear,
osteophytic outgrowths develop at the margins of the bodies and in
connection with the transverse processes, and bridge across the space
between neighbouring vertebrae (Fig. 218). The articulations between
the ribs and the vertebrae show similar changes, and the ligaments of
the several joints tend to undergo ossification, so that the bones are
fused together.
[Illustration: FIG. 218.--Arthritis Deformans of Spine. The vertebrae
are fixed to one another by outgrowths of bone which bridge across the
intervertebral spaces, and there is a slight lateral deviation to the
left in the mid-dorsal region.
(Anatomical Museum, University of Edinburgh.)]
In the early stage the patient complains of pain and stiffness in the
back; later the spine becomes rigid, and gradually develops a
kyphotic curve, sometimes accompanied by lateral deviation. In some
cases, the curvature of the spine assumes an extreme type, the
shoulders are rounded, and the head depressed, the face approximating
the sternum, so that to see an object such as a picture on a wall, the
patient must turn his back to it. The chest is flattened and
restricted in its movements, with the result that respiration is
embarrassed and becomes almost entirely abdominal. The muscles of the
back, shoulders, and hips undergo atrophy, and may exhibit tremors,
and the deep reflexes become exaggerated. The nerves are liable to be
pressed upon as they pass through the intervertebral foramina, and
this gives rise to pain and other disturbances of sensation in their
area of distribution. These pains may simulate those associated with
renal or gastro-intestinal affections.
The disease may simulate tuberculous caries or malignant disease. The
changes in the bones are demonstrated by the use of the X-rays.
The treatment is carried out on general principles (Volume I., p.
530), but it is seldom possible to do more than arrest the progress of
the disease.
#Coccydynia# is the name applied to a condition in which the patient
experiences severe pain in the region of the coccyx on sitting or
walking, and during defecation. The pathology is uncertain. In some
cases there is a definite history of injury, such as a kick or blow,
causing fracture of the coccyx, or dislocation of the sacro-coccygeal
joint. These lesions have also been produced during labour. In other
cases the pain appears to be neuralgic in character, and is referable
to the fifth sacral and the coccygeal nerves, or to the terminal
branches of the sacral plexus distributed in this region. The
affection is almost entirely confined to females, and the patients are
usually of a neurotic type. On rectal examination the coccyx is
exceedingly tender, and it is sometimes found to be less movable than
normal, and unduly arched forward. When medicinal treatment fails to
give relief, the coccyx may be excised.
#Tumours of the Spinal Cord and Membranes.#--Tumours may develop in
the substance of the cord (_intra-medullary_), in the membranes
(_meningeal_), or in the tissues between the dura and the bone
(_extra-dural_); or the cord may be pressed upon by a tumour
originating in the vertebrae. It is seldom possible to diagnose the
nature of a tumour before operation, and it is often difficult to
determine in which of the above situations it has originated.
Tumours growing _in the substance of the cord_ are nearly as common
as extra-medullary growths, and as the growth is usually sarcoma,
glioma, tuberculoma, or gumma, and infiltrates the cord, it is seldom
capable of being removed by operation.
The great majority of _meningeal_ tumours are primary sarcomas, and in
about 25 per cent. of cases they are multiple. Hydatid cysts and
fibromas are also met with in this situation, and they too may be
multiple.
_Extra-dural_ growths are comparatively rare. The forms usually met
with are sarcoma and lipoma.
These extra-medullary tumours seldom infiltrate the cord; they simply
compress it, and should be subjected to operative treatment before
secondary changes are produced in the cord.
The _symptoms_ vary according as the tumour presses on the nerve
roots, on one half, or on both halves of the cord. Pressure on nerve
roots is a characteristic sign in extra-medullary growths. It gives
rise to pain, which, according to the level of the tumour, passes
round the trunk (girdle-pain), or shoots along the nerve-trunks of the
upper or lower limbs.
When the cord is pressed upon, intense neuralgic pain related to the
segment first involved is one of the earliest symptoms, particularly
in extra-medullary tumours. The pain is at first unilateral, but later
becomes bilateral--a point of importance in diagnosis. The painful
areas are anaesthetic, but the anaesthesia does not always reach to the
level of the lesion. There may be a zone of hyperaesthesia at the upper
limit of the anaesthesia, or in the area corresponding to the roots on
which the tumour is situated, but there is never diffuse hyperaesthesia
(V. Horsley). In intra-medullary tumours the pain is less severe, it
is rarely an initial symptom, and is seldom referable to individual
nerve roots.
The next symptom to appear is motor paresis, followed by complete
paralysis, and later by contracture of the paralysed muscles--_spastic
paraplegia_. In intra-medullary tumours the paraplegia is usually less
complete than in those that are extra-medullary. When only one lateral
half of the cord is pressed upon, the motor paralysis and loss of
ordinary sensation are on the same side as the tumour, and the loss of
the sense of pain and of the temperature sense is on the opposite
side. Retention of urine accompanies the onset of paralysis, and later
gives place to incontinence. The rectum becomes paralysed, and
cystitis and pressure sores develop.
Anti-syphilitic treatment should be employed in the first instance to
exclude the possibility of the lesion being of the nature of a gumma.
Radical operative treatment is contra-indicated in intra-medullary
and in metastatic growths, but decompressive measures may be employed
for the relief of pain. In meningeal and extra-dural tumours, however,
in view of the hopeless prognosis if the condition is allowed to take
its course, an attempt may be made to remove the tumour by operation.
It is to be borne in mind that the lesion may be two or three segments
higher than the complete anaesthesia would appear to indicate; the
vertebral canal, therefore, should be opened about four inches above
the level of the anaesthesia.
When the tumour is not removable, the patient's suffering may
sometimes be alleviated by resecting the posterior roots of the nerves
emerging in the vicinity of the lesion.
#Chronic Spinal Meningitis.#--Victor Horsley (1909) described by this
name a condition which gives rise to symptoms closely simulating those
of a tumour of the cord. He believes it to consist in a
pachymeningitis combined with a certain degree of sclero-gliosis of
the periphery of the cord. The theca is greatly distended over a
variable extent of the cord; the cerebro-spinal fluid is increased in
quantity and is under considerable tension; and the cord itself
presents a shrunken appearance. Sometimes there is thickening of the
arachno-pia and matting of the nerve roots. The condition appears to
begin in the lower part of the cord, and to spread up, usually as far
as the mid-thoracic region. There is frequently a history of syphilis,
sometimes of recent gonorrhoea, but in some cases no cause can be
assigned for the lesion.
_Clinical Features._--This affection is almost always met with in
adults, and the earliest symptoms are pain and weakness in the legs,
and sometimes a slight kyphotic projection of the spinous processes.
The loss of power, which is sometimes attended with spasticity,
usually manifests itself in one leg first, and later affects the
other; it is progressive, and ultimately ends in complete paraplegia.
The pain is not confined to the region supplied by any one nerve root,
but affects a diffuse area, and the patient complains also of a
sensation of tightness in the limbs. There is never absolute
anaesthesia, but there is relative anaesthesia for all forms of
sensation, which extends as a rule as far as the sixth or eighth
thoracic root.
There are no vaso-motor phenomena, and no tendency to the formation of
pressure sores. Sometimes the patient complains of pain in the spine,
but this is not aggravated by movement.
_Treatment._--The treatment recommended by Horsley consists in
performing laminectomy, opening the theca, and washing it out with 1
in 1000 mercurial lotion. After the wound has healed, mercurial
inunction over the spine is employed to hasten the absorption of
inflammatory products. The administration of anti-syphilitic drugs has
not proved beneficial.
#Acute Spinal Meningitis.#--The spinal membranes may become implicated
by direct spread in cases of acute intra-cranial lepto-meningitis, or
they may be infected from without--for example, in gun-shot injuries
or in cases of spina bifida.
When the infection spreads from the cranial cavity, the cerebral
symptoms dominate the clinical picture, but evidence of involvement of
the membranes of the cord may be present in the form of rigidity of
the cervical muscles with retraction of the neck; deep-seated pain in
the back, shooting round the body (girdle-pain) and down the limbs;
painful cramp-like spasms in the muscles of the back and limbs, with
increased reflex excitability, sometimes so marked as to simulate the
spasms of tetanus.
When the theca of the cord is directly infected the spinal symptoms
predominate at first, but as the condition progresses it involves the
cerebral membranes, and symptoms of acute general lepto-meningitis
ensue.
Once the condition has started little can be done to arrest its
progress, but the symptoms may be relieved by repeated lumbar
puncture.
#Spinal Myelitis.#--The term "myelitis" is applied to certain changes
which occur in the spinal cord as a result, for example, of haemorrhage
into its substance (_haemorrhagic myelitis_); or of pressure exerted on
it by fragments of bone, blood-clot, tuberculous material, or new
growths (_compression myelitis_).
In another group of cases myelitis is a result of the action of
organisms or their toxins. Syphilis is a common cause, but the
condition may follow on infections with ordinary pyogenic cocci,
pneumococci, the influenza bacillus or the bacillus coli.
In addition to the use of anti-syphilitic remedies, or of sera
directed to neutralise the toxins of the causative organism, attention
must be directed to the bladder, and steps taken to prevent cystitis
and the formation of bed-sores.
CONGENITAL DEFORMITIES OF THE SPINE
#Spina Bifida.#--Spina bifida is a congenital defect in certain of the
vertebral arches, which permits of a protrusion of the contents of the
vertebral canal. It is due to an arrest of development, whereby the
closure of the primary medullary groove and the ingrowth of the
mesoblast to form the spines and laminae fail to take place. The cleft
may implicate only the spinous processes, but as a rule the laminae
also are deficient. The defect usually extends over several vertebrae
(Fig. 219). While the protrusion varies much in size, there is no
constant ratio between the dimensions of the swelling and the extent
of the defect in the neural arches.
[Illustration: FIG. 219.--Meningo-myelocele of Thoracico-lumbar
Region.]
The condition is comparatively common, being met with in about one out
of every thousand births. It is most frequent in the lumbar and sacral
regions (Fig. 219), but occurs also in the cervical (Fig. 220) and
thoracic regions. It is not uncommon to find spina bifida associated
with other congenital deformities such as hydrocephalus, club-foot,
and extroversion of the bladder.
[Illustration: FIG. 220.--Meningo-myelocele of Cervical Spine.]
_Varieties._--Four varieties are usually described according to the
character of the protrusion. They are analogous, to a certain extent,
to the varieties of cephalocele (p. 387). (1) _Spinal meningocele_, in
which only the membranes, filled with cerebro-spinal fluid, are
protruded. (2) _Meningo-myelocele_, the form most commonly met with
clinically, in which the cord and some of the spinal nerves are
protruded, and spread out over the inner aspect of the sac (Figs. 219,
220). (3) _Syringo-myelocele_, in which there is a dilatation of the
central canal in the protruded part of the cord. In these three forms
the protrusion may be covered by healthy skin, or by a thin, smooth,
translucent membrane through which the contents are visible.
Frequently this thin covering sloughs or ulcerates, and permits the
cerebro-spinal fluid to drain away. (4) In the _myelocele_, this skin,
as well as the vertebral arches and membranes, is absent, and the cord
lies exposed on the surface. This form is comparatively common, but as
the infants are either dead born or die within a few days of birth, it
seldom comes under the notice of the surgeon.
_Clinical Features._--The presence of a swelling in the middle line of
the back, which has existed since birth, and which contains fluid and
increases in size and tenseness when the child cries, renders the
diagnosis of spina bifida easy. The defect in the bone may be seen in
skiagrams. The swelling is usually sessile, but may be pedunculated;
it is usually possible to palpate the edges of the gap in the bones.
It may be reduced in size by making gentle pressure over it, and in
young children this may cause a bulging of the fontanelles. This test,
however, must be employed with caution, as it is liable to induce
convulsions. A meningocele, as it contains no nerve elements, may be
translucent. In a meningo-myelocele the shadows of the cord and nerves
stretched out in the sac may be recognised. The presence of the cord
is sometimes indicated by a median furrow, and after withdrawal of
some of the fluid the cord can sometimes be palpated. It is, however,
often difficult to distinguish between a meningocele and
meningo-myelocele.
[Illustration: FIG. 221.--Meningo-myelocele in Thoracic Region.]
Sometimes there are no nervous disturbances, and this is especially
the case when the defect is in the lower lumbar and sacral regions
below the termination of the cord. In most cases, however, there are
paralytic symptoms referable to the lower extremities, the bladder,
and the rectum, and there may also be trophic disturbances in the
parts below. Paralytic symptoms may be absent during infancy, and
develop during childhood or adolescence.
_Prognosis._--Comparatively few children born with spina bifida
survive longer than four or five years. The great majority die within
a few weeks of birth, death being due to the escape of cerebro-spinal
fluid, or to spinal meningitis following on infection. The condition
in some cases remains stationary for years, but spontaneous
disappearance is rare.
_Treatment._--The more severe forms of spina bifida only call for
palliative treatment, which consists in protecting the protrusion
against infection and applying a sterilised dressing and a supporting
bandage. A meningocele may be tapped with a fine needle passed through
healthy skin, and the empty sac compressed by a pad of wool and an
elastic bandage.
Operative treatment is seldom to be recommended in a young child
unless it is otherwise viable and the swelling is increasing rapidly
and threatening to burst, and there is reason to believe that the
paralysis is due to pressure. The immediate results of operation are
usually satisfactory, but in a large proportion of cases the child
subsequently develops hydrocephalus, from which it ultimately
succumbs. The hope of improvement in the motor symptoms after
operation depends on the site of the spina bifida; above the twelfth
thoracic vertebra there is no prospect of improvement; below this
level, inasmuch as it is the tip of the conus or the cauda equina that
is involved, there may be regeneration of nerve fibres and return of
power in the lower extremities, and control of the sphincters may be
regained. Murphy has practised resection of cicatricial or atrophied
portions of the cauda, with end-to-end suture.
The term #spina bifida occulta# is applied to a condition in which
there is no protrusion of the contents of the vertebral canal,
although the vertebral arches are deficient. The skin over the gap is
often puckered and adherent, and is frequently covered with a growth
of coarse hair.
A mass of fat may project towards the surface, and when situated in
the lumbo-sacral region may suggest a caudal appendage or tail (Fig.
222).
[Illustration: FIG. 222.--Tail-like Appendage over Spina Bifida
Occulta in a boy aet. 5, and associated with incontinence of urine.
Operation was followed by temporary retention.]
The clinical importance of spina bifida occulta lies in the fact that
it is sometimes associated with congenital club-foot, and with nerve
symptoms, in the form of sensory, motor, and trophic disturbances
referable to the lower limbs, such as perforating ulcer, and to the
sphincters. These nerve symptoms usually result from the presence of a
tough cord composed of connective tissue, fat, and muscle, stretching
from the skin through the vertebral canal to the lower end of the
spinal cord. As this strand of tissue does not grow in proportion
with the body, in the course of years it drags the cord against the
lower border of the membrana reuniens, which closes in the vertebral
canal posteriorly. These symptoms may be relieved by the removal of
this strand of tissue from the gap in the vertebral arches, or by
incising the membrana reuniens.
#Congenital Sacro-coccygeal Tumours--Teratoma.#--Many varieties of
congenital tumours are met with in the region of the sacrum and
coccyx. The majority are developed in relation to the communication
which exists in the embryo between the neural canal and the alimentary
tract--the post-anal gut or neurenteric canal. Some are evidently of
bigerminal origin, and contain parts of organs, such as limbs, partly
or wholly formed, nerves, parts of eyes, mammary, renal, and other
tissues.
Among other tumours met with in this region may be mentioned: the
congenital _lipoma_--a small, rounded, fatty tumour which often
suggests a caudal appendage (Fig. 222); the _sacral hygroma_, which
forms a sessile cystic tumour growing over the back of the sacrum, and
is believed to be a meningocele which has become cut off _in utero_ by
the continued growth of the vertebral arch; dermoids, sarcoma, and
lymphangioma.
[Illustration: FIG. 223.--Congenital Sacro-coccygeal Tumour.
(Photograph lent by Sir George T. Beatson.)]
The _treatment_ consists in removing the tumour, as from its situation
it is exposed to injury, and this is liable to be followed by
infection. From the position of the wound, and the fact that many of
these tumours extend into the hollow of the sacrum and therefore
necessitate an extensive dissection, there is considerable risk from
infection, especially in young children. The risk is increased when
the tumour communicates with the vertebral canal.
#Congenital Sacro-coccygeal Sinuses and Fistulae.#--The _post-anal
dimple_, a shallow depression frequently observed over the tip of the
coccyx, may be due to traction exerted on the skin at this spot by the
remains of the neurenteric canal, or by the caudal ligament of
Luschka. Sometimes the integument is retracted to such an extent that
one or more _sinuses_ are formed, lined with skin which is furnished
with hairs, sweat, and sebaceous glands. The bursting of a dermoid, or
its being incised in mistake for an abscess, may result in the
formation of such a sinus, which fails to heal and may persist for
years.
In some cases the depression communicates with the vertebral canal,
constituting a complete _sacro-coccygeal fistula_, which may be lined
with cylindrical or ciliated epithelium.
From the accumulation of secretions and subsequent infection, these
conditions may be associated with a persistent offensive discharge,
and they are liable to be mistaken for ano-rectal fistulae. They are
best dealt with by complete excision, and as primary union cannot be
expected, the wound should be treated by the open method.