Manual of Surgery Volume II Part 45

In many cases there are no symptoms of damage to the cord or spinal nerves, but when both laminae give way the posterior part of the arch may be driven in and cause direct pressure on the cord, or blood may be effused between the bone and the dura. In such cases immediate operation is indicated. When there are no cord symptoms, the treatment consists in securing rest, with the aid of extension, if necessary, for several weeks until the bones are reunited.

The use of the X-rays has shown that one or more of the _transverse processes of the lumbar vertebrae_ may be chipped off by direct violence. The symptoms are pain and tenderness in the region of the fracture, and marked restriction of movement, especially in the direction of flexion. This lesion may explain some of the cases of persistent pain in the back following injuries in workmen. It is important to remember, however, that in a radiogram an un-united epiphysis may simulate a fracture.

#Isolated Fracture of the Bodies--"Compression Fracture."#--The "compression fracture" consists in a crushing from above downwards of the bodies--and the bodies only--of one or more vertebrae. It is due to the patient falling from a height and landing on the head, b.u.t.tocks, or feet in such a way that the force is transmitted along the bodies of the vertebrae while the spine is flexed.

If the patient lands on his head, the compression fracture usually involves the lower cervical or upper thoracic vertebrae. When he lands on his b.u.t.tocks or feet it is usually the lumbar or the lower thoracic vertebrae that are fractured (Fig. 207).

[Ill.u.s.tration: FIG. 207.--Compression Fracture of Bodies of Third and Fourth Lumbar Vertebrae. Woman, aet. 28, who fell three storeys and landed on the b.u.t.tocks.]

As a rule, there are no external signs of injury over the spine. The sternum, however, is often fractured, and irregularity and discoloration may be detected on examining the front of the chest. The recognition of a fracture of the sternum should always raise the suspicion of a fracture of the spine. On examination of the back a more or less marked projection of the spinous processes of the damaged vertebrae may be recognised. In the cervical and lumbar regions this projection may merely obliterate the normal concavity. The spinous process which forms the apex of the projection belongs to the vertebra above the one that is crushed. The cord usually escapes, but the nerves emerging in relation to the damaged vertebrae may be bruised, and this gives rise to girdle-pain.

Local tenderness is elicited on pressing over the affected vertebrae.

As might be expected from the nature of the accident producing this lesion, it is often a.s.sociated with serious injuries to the head, limbs, or internal organs which gravely affect the prognosis.

The _treatment_ consists in taking the pressure off the injured vertebrae in order that the reparative material may be laid down in such a way as to restore the integrity of the column. In the cervical region, extension is applied to the head, and a roller-pillow placed beneath the neck. In the lumbar region, the extension is applied through the lower limbs, and the pillow placed under the loins. The patient is confined to bed for six or eight weeks, and before he gets up a poroplastic or plaster-of-Paris jacket is applied. This is worn for a month or six weeks.

#Traumatic Spondylitis.#--This condition is liable to develop in patients who have sustained a severe injury to the back. It is believed to originate in a compression fracture which has not been recognised, and is probably due to the callus thrown out for the repair of the fracture being subjected to strain and pressure too early, or to a progressive softening of the injured vertebra and of the bodies of those adjacent to it. This leads to an alteration in the shape of the affected bones, which can be demonstrated by means of the X-rays. The usual history is that some considerable time after the patient has resumed work he suffers from pain in the back, and radiating pains round the body and down the legs. He becomes more and more unfit for work, and a marked projection appears in the back and may come to involve several vertebrae. While the condition is progressive, the prominent vertebrae are painful and tender. In course of time the softening process is arrested, and the affected bones become fused, so that the area of the spine involved becomes rigid and permanent deformity results. So long as the condition is progressive the patient should be kept in the rec.u.mbent and hyper-extended position over a roller-pillow and, when he gets up, the spine should be supported by a jacket.

#Dislocation and Fracture-Dislocation.#--It is seldom possible at the bedside to distinguish between a complete dislocation of the spine and a fracture-dislocation. _Fracture-dislocation_ is by far the more common lesion of the two, and is the injury popularly known as a "broken back." It may occur in any part of the column, but is most frequently met with in the thoracic and thoracico-lumbar regions. It usually results from forcible flexion of the spine, as, for example, when a miner at work in the stooping posture is struck on the shoulders by a heavy fall of coal. The spine is acutely bent, and breaks at _the angle of flexion and not at the point struck_. The lesion consists in a complete bilateral dislocation of the articular processes, together with a fracture through one or more of the bodies.

This fracture is usually oblique, running downwards and forwards. The upper fragment with the segment of the spine above it is displaced downwards and forwards, and the cord is crushed between the posterior edge of the broken body and the arch of the vertebra above it (Fig.

208). In almost every case the cord is damaged beyond repair.

[Ill.u.s.tration: FIG. 208.--Fracture--Dislocation of Ninth Thoracic Vertebra, showing downward and forward displacement of upper segment, and compression of cord by upper edge of lower segment.

(Anatomical Museum, University of Edinburgh.)]

_Total dislocation_, in which the articular processes on both sides are displaced and the contiguous intervertebral disc separated, is rare, and is met with chiefly in the lower cervical region.

_Clinical Features._--The outstanding symptoms of total lesions are referable to the damage inflicted on the cord. The diagnosis should always be made by a consideration of the mechanism of the injury and the condition of the nerve functions below the lesion. On no account should the patient be moved to enable the back to be examined, as this is attended with risk of increasing the displacement and causing further damage to the cord. On pa.s.sing the fingers under the back as the patient lies rec.u.mbent, it is usually found that there is some backward projection of the spinous processes, the most prominent being that of the broken vertebra. The spinous process immediately above it is depressed as the upper segment has slipped forward. Pain, tenderness, swelling and discoloration may be present over the injured vertebrae. It is usually possible to have skiagrams taken without risk of further damage to the spine. There is complete loss of motion and sensation below the seat of the lesion. The symptoms of total transverse lesions of the cord at different levels have already been described (p. 416).

_Treatment._--An attempt may be made to reduce the displacement under anaesthesia, gentle traction being made in the long axis of the spine by a.s.sistants, while the surgeon attempts to mould the bones into position. No special manipulations are necessary, as the ligaments are extensively torn, and the bones are, as a rule, readily replaced. A roller-pillow is placed under the seat of fracture to allow the weight of the body above and below to exert gentle traction, and so to relieve pressure on the cord. Operative treatment is almost never of any avail, as the cord is not merely pressed upon, but is severely crushed, or even completely torn across. Even when the cord is only partially torn, operative treatment is not likely to yield better results than are obtained by reduction and extension. The usual precautions must be taken to prevent cyst.i.tis and bed-sores.

Total fracture-dislocation between the _atlas_ and _epistropheus_ (axis), if attended with displacement, is instantaneously fatal (Fig.

209). This is the osseous lesion that occurs in judicial hanging.

Fracture of the odontoid process may occur, however, without displacement, the transverse ligament retaining the fragment in position and protecting the cord from injury. The patient complains of stiff neck and pain, and the lesion may be recognised in a radiogram.

A number of cases are recorded in which death took place suddenly weeks or months after such an injury, from softening of the transverse ligament and displacement of the bones.

[Ill.u.s.tration: FIG. 209.--Fracture of Odontoid Process of Axis Vertebra.]

#Penetrating Wounds.#--These result from stabs or gun-shot accidents, and are practically equivalent to compound fractures of the spine; their severity depends on the extent of the damage done to the cord, and on whether or not the wound is infected. In many cases the condition is complicated by injuries of the pleural or peritoneal cavities and their contained viscera, or by injury of the trachea, sophagus, or large vessels and nerves of the neck. When the membranes of the cord are opened, the profuse and continued escape of cerebro-spinal fluid may prove a serious complication.

_Treatment._--The wound of the soft parts is treated on the usual lines. When the spinous processes and laminae are driven in upon the cord, they must be elevated at once by operation. In injuries involving the lumbo-sacral region it is sometimes advisable to perform laminectomy for the purpose of suturing divided nerve cords.

When there is evidence that the spinal cord is completely divided, operation is contra-indicated. Attempts have been made to unite the two ends of the divided cord by sutures, but there is as yet no authentic record of restoration of function following the operation.

CHAPTER XVII

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 a.s.sociated 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 periost.i.tis.

_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 ca.n.a.l and acc.u.mulates 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 pa.s.sing 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 ca.n.a.l 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).

[Ill.u.s.tration: 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 acc.u.mulation 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 a.s.sociated.

_Effects on the Spinal Cord and Nerve Roots._--In some cases the cord and nerve roots are pressed upon by an dematous 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 a.s.sociated 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.

[Ill.u.s.tration: 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.)]

[Ill.u.s.tration: 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 repet.i.tion, 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 a.s.suming some att.i.tude 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 pa.s.s 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 pa.s.sing 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.