Manual of Surgery Volume II Part 47

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 ca.n.a.l 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 a.s.sociated 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 gonorrha, 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 s.p.a.ce 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.

[Ill.u.s.tration: FIG. 218.--Arthritis Deformans of Spine. The vertebrae are fixed to one another by outgrowths of bone which bridge across the intervertebral s.p.a.ces, 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 a.s.sumes 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 embarra.s.sed 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 pa.s.s 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 a.s.sociated 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, pa.s.ses 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 r.e.c.t.u.m becomes paralysed, and cyst.i.tis 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 ca.n.a.l, 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 quant.i.ty 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 gonorrha, but in some cases no cause can be a.s.signed 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 was.h.i.+ng 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 teta.n.u.s.

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 cyst.i.tis 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 ca.n.a.l. 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.

[Ill.u.s.tration: 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 a.s.sociated with other congenital deformities such as hydrocephalus, club-foot, and extroversion of the bladder.

[Ill.u.s.tration: FIG. 220.--Meningo-myelocele of Cervical Spine.]

_Varieties._--Four varieties are usually described according to the character of the protrusion. They are a.n.a.logous, 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 ca.n.a.l 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.

[Ill.u.s.tration: 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 r.e.c.t.u.m, 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.