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BACKACHE
846
Letters to the Editor BACKACHE wish to SIR,-I congratulate Burns and Young on their magnificent article of May* 10. They have done pioneer work in England on this difficult subject, andhave also shown great courtesy in explaining and demonstrating their technique to other orthopaedic surgeons. A visit to their department at St. George’s Hospital on a Thursday morning is most stimulating. From their article and subsequent letters it appears that, although removal of a damaged disk may become necessary, non-operative measures often give relief-at least for a time. -The forms of non-operative treatment recommended are : (1) Rest in bed for three weeks, followed by the wearing of a corset (Burns and Young). In their hands neither
physiotherapy nor epidural injections give lasting benefit. The wearing of a well-moulded plaster jacket for 2-3 months (Crisp). (3) Osteopathic manipulations (MacDonald). At a meeting of the British Orthopaedic Association last year Cyriax demonstrated the effect of epidural injections on a recent case of lumbago, and his method of gentle manipulations. Kenneth Stone suggests the possibility of the presence of a rheumatic state either preceding or coincident with a disk injury. The changes occurring in a torn or prolapsed intervertebral disk are in some respects similar to those seen in a torn internal semilunar cartilage. In the latter the flexors of the knee-the semimembranosus, semitendinosus, sartorius and gracilis-go into spasm. Full extension of the knee is impossible, partly through this spasm and partly through mechanical locking of the joint by the displaced torn piece of meniscus. When a tear is on the periphery, healing may take place if the knee is supported in plaster-of-paris and the muscles are moved isometrically (in contradistinction to isotonic contraction). If the knee is manipulated forcibly under an anaesthetic replacement may take place ; but often the damaged cartilage is further contused and little improvement is obtained. It can be seen that the contusion or tear causes (1) an inflammatory state of the joint, with (2) spasm of the surrounding muscles, which leads to (3) muscle imbalance (2)
between the flexor and extensor groups and muscle wasting. Each one of these factors must be treated separately, the first by rest and heat, the second by massage and gentle manipulation, and the third by graduated exercises and faradism. During the past fifteen years I have had to treat several thousands of cases of low back pain, with or without sciatica. It is my impression that :
(1) In some cases there is a state of tissue cedema, due to transudation of fluid, before the true attack. Copeman and Ackerman1 suggest that oedema of the tissues, especially the fatty tissues, may occur in fibrositis. (2) If the disk is torn or if the pulp protrudes, there is inflammation not only round the disk but in the surrounding vertebral articulations. This is one of the causes of limitation of movement. (3) The muscles of one side go into protective spasm, and the spasm accounts for the posture and for sciatic scoliosis, either homolateral, heterolateral, or alternating. The result in course of time is contracture of one group of muscles (with loss of extensibility), overstretching of the opposite group, muscle wasting, and all that goes to make for muscle imbalance. It was in such cases perhaps that successes were obtained in the past with forcible manipulation in the later stages, when the disk may have slipped back. (4) With faulty posture-e.g., in a person with a marked lordosis and a pendulous abdomen, or in a man sitting in a cramped position in a tank-there is loss of synergic action between the spinal extensors and flexors ; the front of the vertebral bodies are subjected to undue pressure and there is a tendency for the intervertebral disk to be squeezed backwards. Balanced synergic action between these groups must be restored by appropriate pelvic tilting exercises, so that the spine is straightened and the abdominal muscles are con1. Copeman, W. S. C., Ackerman, W. L. 13, 37.
Quart. J. Med. 1944,
tracted and elevated and the buttock muscles tightenedi.e., stand as if sitting on a shooting-stick. (5) Tender points occur in relation to the sacro-iliac joint, either at the origin of the glutei or in the insertion of the erector spinae. Sacro-iliac tests are usually found to be negative. It is suggested that these tender areas are the result of primary muscle strain of the glutei or erector spinse or the result of muscle spasm in cases of lumbago or sciatica (cf. tennis elbow). ,
Young2 describes two types of disks. In cases of prolapsed disk, giving rise to the compression syndrome, side bending towards the lesion is painful. In cases of
tear of the annulus fibrosus, giving rise to a stretch syndrome, side bending away from the lesion is painful. This does not tally with Burns and Young, who state that sideways bending is free. I have found cases vary with regard to side bending ; but where there is pain away from the lesion (stretch type, annulus tear) the condition might heal completely if the back was rested in a plaster jacket for three months. I suggest that cases should be placed in the following
groups : 1.-First attack, or patients refusing operation.-Treatment is directed to reducing inflammation, muscle spasm, and (if possible) prolapse. The patient lies prone on two pillows supporting the abdomen, his legs being supported by further pillows to flex the knees slightly. Each day he is given infra-red heat for ten minutes, friction massage for ten minutes, gentle faradism to the erector spinse and glutei for ten minutes, and anodal galvanism for ten minutes. We have had patients in severe pain coming in with a pronounced sciatic scoliosis, verified by X rays, and after the first treatment this has disappeared clinically and radiologically. The treatment must never be stimulating. If more than a subthermal dose of diathermy is given the symptoms are often made worse, and for this reason diathermy is not advised, especially in the’ early stages. If there is improvement gentle manipulation is added. The patient is told to rest as much as possible, but his back is supported by a felt pad and elastic webbing (a simple and practical method of giving support quickly, for often a corset, made to measure, takes weeks to obtain). In many cases he is almost symptom-free within a few days, and a great, deal of time has thus been saved. Some patients experience a feeling as if something has slipped back into position. A few have shown no improvement, and at the end of a week’s treatment have either been given three weeks’ rest in bed, using bedpans, or, when this was impossible, have been given .
plaster jacket. 2. Annulus fibrosus tears.-A plaster jacket for three months, with operation if there is aggravation at first or recurrence later. Recently we have had to operate on a patient, who had complete freedom from pain for eight months after wearing a plaster jacket for four months. At operation a large prolapsed disk was removed. 3. Patients over 45 showing spinal arthritis with disk prolapse.-Treatment should be as in group 1 and must be given a long and thorough trial before deciding on operation, since this type of case may require spinal grafting as well. All patients have pelvic tilting exercises, and many have told me that if they have felt pain in their backs and carried out these exercises at once the pain has disa
anneared in a short time. London, W.l.
W.
E.
TUCKER.
ON THE RECORD
SiR,-Readers of your leader of May 24 may also like to hear that during the past year discussions have taken place among a group of provincial hospital records officers as to how the many problems of their departments could be eased immediately and solved eventually. It is recognised that the standard of clinical records is primarily a medical responsibility, but this responsibility could be lightened, and time and expense saved, by the provision of trained lay assistants. America and Canada long ago recognised that this section of hospital administration was a specialty, and organised training in these two countries has achieved its objects. The standard of records is said tobe good, and experienced staff are available for the work. 2. Young, J. H.
Med. J. Aust. 1945, ii, 234.
,
Letters to the Editor BACKACHE wish to SIR,-I congratulate Burns and Young on their magnificent article of May* 10. They have done pioneer work in England on this difficult subject, andhave also shown great courtesy in explaining and demonstrating their technique to other orthopaedic surgeons. A visit to their department at St. George’s Hospital on a Thursday morning is most stimulating. From their article and subsequent letters it appears that, although removal of a damaged disk may become necessary, non-operative measures often give relief-at least for a time. -The forms of non-operative treatment recommended are : (1) Rest in bed for three weeks, followed by the wearing of a corset (Burns and Young). In their hands neither
physiotherapy nor epidural injections give lasting benefit. The wearing of a well-moulded plaster jacket for 2-3 months (Crisp). (3) Osteopathic manipulations (MacDonald). At a meeting of the British Orthopaedic Association last year Cyriax demonstrated the effect of epidural injections on a recent case of lumbago, and his method of gentle manipulations. Kenneth Stone suggests the possibility of the presence of a rheumatic state either preceding or coincident with a disk injury. The changes occurring in a torn or prolapsed intervertebral disk are in some respects similar to those seen in a torn internal semilunar cartilage. In the latter the flexors of the knee-the semimembranosus, semitendinosus, sartorius and gracilis-go into spasm. Full extension of the knee is impossible, partly through this spasm and partly through mechanical locking of the joint by the displaced torn piece of meniscus. When a tear is on the periphery, healing may take place if the knee is supported in plaster-of-paris and the muscles are moved isometrically (in contradistinction to isotonic contraction). If the knee is manipulated forcibly under an anaesthetic replacement may take place ; but often the damaged cartilage is further contused and little improvement is obtained. It can be seen that the contusion or tear causes (1) an inflammatory state of the joint, with (2) spasm of the surrounding muscles, which leads to (3) muscle imbalance (2)
between the flexor and extensor groups and muscle wasting. Each one of these factors must be treated separately, the first by rest and heat, the second by massage and gentle manipulation, and the third by graduated exercises and faradism. During the past fifteen years I have had to treat several thousands of cases of low back pain, with or without sciatica. It is my impression that :
(1) In some cases there is a state of tissue cedema, due to transudation of fluid, before the true attack. Copeman and Ackerman1 suggest that oedema of the tissues, especially the fatty tissues, may occur in fibrositis. (2) If the disk is torn or if the pulp protrudes, there is inflammation not only round the disk but in the surrounding vertebral articulations. This is one of the causes of limitation of movement. (3) The muscles of one side go into protective spasm, and the spasm accounts for the posture and for sciatic scoliosis, either homolateral, heterolateral, or alternating. The result in course of time is contracture of one group of muscles (with loss of extensibility), overstretching of the opposite group, muscle wasting, and all that goes to make for muscle imbalance. It was in such cases perhaps that successes were obtained in the past with forcible manipulation in the later stages, when the disk may have slipped back. (4) With faulty posture-e.g., in a person with a marked lordosis and a pendulous abdomen, or in a man sitting in a cramped position in a tank-there is loss of synergic action between the spinal extensors and flexors ; the front of the vertebral bodies are subjected to undue pressure and there is a tendency for the intervertebral disk to be squeezed backwards. Balanced synergic action between these groups must be restored by appropriate pelvic tilting exercises, so that the spine is straightened and the abdominal muscles are con1. Copeman, W. S. C., Ackerman, W. L. 13, 37.
Quart. J. Med. 1944,
tracted and elevated and the buttock muscles tightenedi.e., stand as if sitting on a shooting-stick. (5) Tender points occur in relation to the sacro-iliac joint, either at the origin of the glutei or in the insertion of the erector spinae. Sacro-iliac tests are usually found to be negative. It is suggested that these tender areas are the result of primary muscle strain of the glutei or erector spinse or the result of muscle spasm in cases of lumbago or sciatica (cf. tennis elbow). ,
Young2 describes two types of disks. In cases of prolapsed disk, giving rise to the compression syndrome, side bending towards the lesion is painful. In cases of
tear of the annulus fibrosus, giving rise to a stretch syndrome, side bending away from the lesion is painful. This does not tally with Burns and Young, who state that sideways bending is free. I have found cases vary with regard to side bending ; but where there is pain away from the lesion (stretch type, annulus tear) the condition might heal completely if the back was rested in a plaster jacket for three months. I suggest that cases should be placed in the following
groups : 1.-First attack, or patients refusing operation.-Treatment is directed to reducing inflammation, muscle spasm, and (if possible) prolapse. The patient lies prone on two pillows supporting the abdomen, his legs being supported by further pillows to flex the knees slightly. Each day he is given infra-red heat for ten minutes, friction massage for ten minutes, gentle faradism to the erector spinse and glutei for ten minutes, and anodal galvanism for ten minutes. We have had patients in severe pain coming in with a pronounced sciatic scoliosis, verified by X rays, and after the first treatment this has disappeared clinically and radiologically. The treatment must never be stimulating. If more than a subthermal dose of diathermy is given the symptoms are often made worse, and for this reason diathermy is not advised, especially in the’ early stages. If there is improvement gentle manipulation is added. The patient is told to rest as much as possible, but his back is supported by a felt pad and elastic webbing (a simple and practical method of giving support quickly, for often a corset, made to measure, takes weeks to obtain). In many cases he is almost symptom-free within a few days, and a great, deal of time has thus been saved. Some patients experience a feeling as if something has slipped back into position. A few have shown no improvement, and at the end of a week’s treatment have either been given three weeks’ rest in bed, using bedpans, or, when this was impossible, have been given .
plaster jacket. 2. Annulus fibrosus tears.-A plaster jacket for three months, with operation if there is aggravation at first or recurrence later. Recently we have had to operate on a patient, who had complete freedom from pain for eight months after wearing a plaster jacket for four months. At operation a large prolapsed disk was removed. 3. Patients over 45 showing spinal arthritis with disk prolapse.-Treatment should be as in group 1 and must be given a long and thorough trial before deciding on operation, since this type of case may require spinal grafting as well. All patients have pelvic tilting exercises, and many have told me that if they have felt pain in their backs and carried out these exercises at once the pain has disa
anneared in a short time. London, W.l.
W.
E.
TUCKER.
ON THE RECORD
SiR,-Readers of your leader of May 24 may also like to hear that during the past year discussions have taken place among a group of provincial hospital records officers as to how the many problems of their departments could be eased immediately and solved eventually. It is recognised that the standard of clinical records is primarily a medical responsibility, but this responsibility could be lightened, and time and expense saved, by the provision of trained lay assistants. America and Canada long ago recognised that this section of hospital administration was a specialty, and organised training in these two countries has achieved its objects. The standard of records is said tobe good, and experienced staff are available for the work. 2. Young, J. H.
Med. J. Aust. 1945, ii, 234.
,