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Causalgic backache
CAUSALGIC BACKACHE OTHO C. HUDSON, M.D., Attending Orthopedic Surgeon, Meadowbrook Hospital
CARL A. HETTESHEIMER, M.D. Chief Surgeon, Meadowbrook Hospital AND
PERCIVAL A. ROBIN, M.D. Attending RoentgenoIogist, Nassau HospitaI HEMPSTEAD,
J
UDOVICH and Bate? have caIIed our attention to the fact that low back pain may originate in the dorsoIumbar area. In osteopathic Iiterature the authors have mentioned that a peIvic tiIt may cause backache due to a primary short Iower extremity. This condition they treat by an eIevation within the shoe and by osteopathic manipuIation. One type of back pain invoIves the Iumbar muscIes and especiaIIy the quadratus Iumborum. Here, pain radiates along the tweIfth rib due to tweIfth dorsa1 and first Iumbar nerve irritation and a cIinica1 picture of asymmetrica muscIe imbaIance occurs. This group of cases comprises a definite cIinica1 entity which can be separated from the vast group of patients suffering from back pain. The treatment is simpIe and effective. This type of backache, produced by muscIe imbalance, causes subjective symptoms because the imbaIance, together with the muscIe spasm, increases the tension within the quadratus Iumborum fascia, producing direct pressure on the tweIfth dorsa1 and first Iumbar nerves. The irritation is manifested by pain with radiation aIong the course of these nerves. (Fig. I.) The trunk is maintained erect in equiIibrium by the abdominaIs and quadratus Iumborum muscIes in front and the sacrospinaIis muscIes behind. Overaction or weakness of any group of these muscIes wiI1 aIIow contractures to develop. The abdomina1 muscIes, due to Iack of use, become weakened and the overworked sacrospinaIis muscIes become contracted with an increase in the lumbar Iordosis. The
NEW
YORK
pelvis, Iacking the stabiIizing effect of the abdomina1 muscIes then incIines more anteriorIy. Injury, a toxic focus or chronic stress, may cause the quadratus Iumborum to become irritated, resuIting in spasm. Contraction of the quadratus Iumborum causes the Iast rib on the same side of the spine to deflect downward at a more acute angIe. As the tweIfth rib is drawn downward it aIso rotates forward, giving relativeIy a greater distance for the tweIfth dorsal nerve to traverse from the intervertebra1 foramen to the subcostal groove. As a direct resuIt of this shift there is produced increased tension in the nerve sheaths. In an effort to reIieve the pain thus produced, the patient wiI1 assume a position of asymmetrica muscle imbaIance and functiona scoIiosis appears. Following this uneven distribution of body weight a peIvic tiIt resuIts with abduction of the Iower extremity on the side of the Iow crest and adduction of the Iower extremity on the side of the high crest. Other muscle changes then occur. On the the abducted side, the thigh rotates internaIIy at the acetabuIum and the foot pronates with a vaIgus of the hee1. On the adducted side, the thigh shows Iittle or no internal rotation and the foot Iittle or no pronation. Another factor in maintaining the pelvic tiIt is the puI1 of the pronated foot and interna rotation of the femur of the abducted extremity. (Fig. 2.) We have chosen to IabeI this syndrome, for want of a more appropriate term, causaIgic backache. CausaIgia, or pain of a burning nature, describes brief3 y the sensation these patients experience.
298
Am&can Journal uf Surgery
EXPERIMENTAL
Hudson
PRODUCTION
OF
et al.-CausaIgic CAUSALGIC
BACKACHE
One of us, in an effort to prove the validity of this theory, made an experiment
Backache
MAY,
1941
this time definite tenderness was present paravert&braIIy in the dorsoIumbar area and aIong the-right tweIfth rib. The right sacrospinaIis muscIes were spastic.
TUCLFTH DoRSFiL NEW MT
LUt’lWR WERW
UTANEOU3 DI5TRIBUTION
RNrCluOR 5uRPACB FIG. I. Cutaneous
POSTLWOR3URFIKC
distribution of twelfth first Iumbar nerves.
dorsal
and
in an individua1 who had no history of previous back compIaints. PreIiminary cIinica1 and Roentgen examinations were negative. An eIevation of x inch was added to the heeI of the Ieft shoe, and was worn at a11 times. A cIinica1 examination was made with the adjusted shoes on. There was noted a peIvic tiIt with the right side incIined downward. The spine showed a right dorsa1, Ieft Iumbar scoIiosis. The right thigh was abducted and the Ieft thigh was adducted. On the first day of the experiment there was a sensation of waIking uphi on the adducted extremity. Most of the weight was borne on the abducted extremity (right), whiIe the patient was waIking and standing. (This was proved by having him stand with each foot on a separate spring baIance.) A notation in the diary on the third day discIosed that considerabIe aching was experienced deep in the buttocks. By this time it was impossibIe for the subject to walk with comfort unIess the entire right Iower extremity was internaIIy rotated. After one week, there was a sense of tightness and puIIing in the dorsoIumbar area on bending over; especially was this true on any attempt to straighten up. At
FIG.
2.
Diagrammatic ographic
representation findings.
of radi-
FoIIowing three weeks’ activity in this position, subjective pain was present radiating around the right side at the IeveI of the tweIfth nerve distribution. Hyperesthesia was present in the groin and aIong the right side of the chest. Night pain in these areas had been present for some time. After the elevation was removed and exercises instituted, the symptoms disappeared in two weeks. History. The history of these patients is quite characteristic. They have suffered for years with a pain in the low back area. They IocaIize it, however, by pIacing the hand over the crest of the iIium or midIumbar region. Pain is uniIatera1. If pain is right-sided, many of the patients have had appendectomies, gaII-bIadder surgery, or urologic instrumentation without reIief. The pain is described as aching, burning, tearing apart, boring, or stabbing in nature. These patients are unabIe to get comfortabIe on going to bed and they twist and turn for ten to twenty minutes to get reIief. This pain awakens the patient at
NEW SEMIS
VOL. L1 I. No.
Hudson
2
et aI.--~CausaIgic TABLE
Ci14C
_
A.G.. C.
1’. H.
L.
iv..
e or”
TY
Duration of Symptoms
ln:zid-
2 years
s/
4 years
Hravy
5 years
Slender
M.R..
..,
~.
Journal
Foci
OSSC2”US
Syndroms
of Surgery
End
Yes
None-
Tzz
Yes
Non?
None
No pa*n. to WPA Cured
Yes
None
Teett
CUPXI
None
Cured
I year
Slender
Physiotherapy, foci removed, S” port Kr .a ney studies, fracture 1st. lumbar vertebra, 193” Physiotherapy
1” years
Slender]
Foci
removed
299
NolIe
Yes Not
done
Yes
Result
Lesions
Physiotherapy
6 years
M.C..
A merican
I
Previous Treatment
I
A. R,
Backache
. None
Teett
Relieved
Non‘?
Cured
Returned work
I I. E.
?
Slender
None
?
Scoliosis
None
Cured
E.B....
4 months
Slender
Physiotherapy
?
None
Teeth
Relieved
L.. E.
3 years
Slender
Yes
None
None
Did not carry treatment
A. P.
8 months
Slender
Urological studies, physio. therap Physiot g erapy
Yes
None
None
Relieved
4 months
Slender
Physiotherapy
Yes
None
None
9 years
Slender
Yes
None
None
Relieved. to WPA Cured
Non.2
Unknown
A.A.. R.
B.
sl
I year
Slender
Physiotherapy, Ober o eration Physiot g erapy
44
/ P%$ight
I year
Slender
Physiotherapy
Refused
4”
/ P%$&kt
I year
Slender
Physiotherapy
?
~4
/ j;%I2I low back
15 weeks
Slender
None
Refused
7 months
Slender
Physiotherapy
?
3 monthr
Slender1
Physiotherapy
3 months
Slender
Physiotherapy
If....
A.T.... H. H.. M.
R. B...
.
E. J.
F.
M.
qr
P.
F.
24
A. B.
F.
2”
J.
G.
D.
M..
F.
39
G. L.
F.
33
H.
M.
4”
F.
36
R.
D.,
radiating to groin Pain left low back radiating to groin Pain right back radiating t, groin Pun right low back Pain left low back radiat,ing / t? grotn Pam left low back Pain right dorsolumbar area. Pjzs;_ght
Refused
.
.
None
Refused
Teett
Cured
None
Relieved
None
None
Relieved
?
Nont!
None
Relieved
Yes
None
None
Cured
None
None
Relieved
Non‘2
Unknown
None
Returned work
treatment
3 years
SIender
Physiotherapy
Yes
4 months
Slender
None
Refused
1 year
Slender
Physiotherapy
Yes
None
None
Cured
I year
Heavy
?
Congenital analomies
NOllC
Some
2 years
Slender
Lift
on heel
Yes
None
2 yelrrs
Slender
Physiotherapy
Yes
None
None
Cured
I year
Slender
Foci
None
None
NolIe
Questionable
!
M..
G.B....
,
1Physiotherapy
relief
lumbar
Dr.
M.
P. E.
39
F.
L.L
37
1 M.
H.C.B..
40
i area 1Pyrd_ght Iumbar area Pain right upper back radiating t< ‘n P% right
removed
Cured
yPP,e' C.
1M. i
R....
G.M
.
.(F.
M.
(37
Pain left low back PjgS;i_sht lumbar area Pain Ieft dorsolumbar
M.M.....
Dr.
DaCK
35
L..
4 weeks
Slender
Physiotherapy
None
Teeth
Questionable
I week
Slender
None
Yes
None
None
Questionable
3 years
SIender
Various
YCS
None
None
Cured
2 years
SIender
None
Yes
None
Teeth
Cured
I 0th”
C. Hudson.
M.D.. Carl
A. Hettesheimer,
M.D.
Per&vat
A. Robin,
M.D.. Hempstead,
ew York.
out
300
American Journal of Surgery
Hudson
et al.-CausaIgic
night, it begins near the midhne posteriorIy and usuaIly radiates anteriorIy when he arises. Lying on the hypersensitive skin area produces the night pain. Coughing, sneezing, or missing a step whiIe waIking gives severe pain that frequentIy doubIes the patient up. AIso, pain may be brought on by bending over the washbasin in the morning or bending over to do any type of work. In addition, there may be radiating pain into the thigh posterioIateraIIy, over the IumbosacraI area, or over the upper gIutea1 area. Examination of a11 paExamination. tients reveaIs spasm of the lumbar muscIes of varying degree, with limitation of motion of the spine in al1 directions. There is an increased Iumbar Iordosis. ScoIiosis is present on standing, but disappears on Iying down. The peIvis is tiIted and on the low side there is abduction of the Iower extremity, interna rotation of the thigh, and marked pronation of the foot. On the high side of the peIvic tiIt there is adduction of the Iower extremity, IittIe or no rotation of the thigh, and IittIe or no pronation of the foot. (The rotation of the thigh on the low side may be overIooked if the patient is examined with the thighs in externa1 rotation.) Hyperesthesia to pinching and poking of the skin is present over the cutaneous distribution of the tweIfth dorsa1 and first Iumbar nerves. There is tenderness along the twelfth rib, especiaIIy at exits of nerve trunks through fascia or muscIe. This can be elicited easily by pressing upward on the Iower edge of the rib. There is tenderness and hyperesthesia paraIIe1 to Poupart’s Iigament, on the upper inner aspect of the thigh, and over the tweIfth dorsa1 and first Iumbar transverse processes paravertebraIIy . Leg Iength should be measured. EIevations of varying thicknesses under the heel of the side of the Iow iIiac crest shouId correct the peIvic tilt and re@tabIish norma1 posture. The patients wiI1 immediateIy fee1 more secure in their baIance and comment on this fact without questioning.
Backache
May,,$I.$*
Treatment. If the heeI on the abducted extremity is raised by an eIevation sufhcient to overcome the peIvic tiIt the quadratus Iumborum is reIaxed, the rib returns to its norma position, the scoIiosis is corrected, and the interna rotation of the thigh disappears. Exercises are given to strengthen the abdomina1 muscles and weaken the sacrospinaIis group. Radiographic Examination. Roentgenograms are taken in the usua1 manner to ruIe out any abnormaIity such as structura1 scoliosis, arthritis, etc. When causaIgic backache is diagnosed cIinicaIIy, the routine x-ray fiIms are supplemented by specia1 examinations described in detai1 beIow. ConverseIy, this syndrome may be suspected if anteroposterior upright IiIms of the dorsolumbar spine and peIvis show an acute angIe of the tweIfth rib, Iow iIiac crest, and Iow femora1 head on the same side. (Fig. 3.) We perform the Roentgen examination as foIIows : I. A supine fiIm is made in the anteroposterior projection of the IumbosacraI spine incIuding the lower two dorsa1 vertebrae. It is important that the subject be adjusted on the tabIe so that the spine is straight. 2. A fiIm is made of the same region with the patient in the upright position, using the Potter-Bucky diaphragm. The position of the patient, here too, is important. The shoes are removed and the feet are pIaced 4 inches apart and paraIIe1. The patient is asked to stand with the weight equally distributed. 3. This examination is optional. The fiIm is taken with eIevations varying from M to g inch in thickness pIaced under the hee1 of the side of the Iow iIiac crest. This is done as in 2. Landmarks. I. Costovertebral Angle. To determine one side of this angIe, a Iine is drawn between the inferior articuIar margin and the inferior border of the tweIfth rib at the junction of the outer and middIe thirds. The other side of this angIe is formed by a Iine drawn between the inferior
NEW
SEINES VOL. LII, No.
2
Hudson
C
et al.-causalgic
Backache
American
~~~~~~~ of surgery
D
FIG. 3. Radiographic examination of typical case; female, aged 34, compIaining of left lower abdotnina pain and backache for five years. A, supine film, showing equa1 costovertebral angles, negIigibIe deviation of axis of Iumbar and IeveI crests and femora1 heads. B, upright fiIm showing acute Ieft costovertebral angIe, deviation of Iumbar spine towards the right, and low Ieft iliac crest and femoral head. c, upright fiIm with a ,+4 inch eIevation under the left hee1 showing a partia1 correction of the deformities. D, upright fiIm with a ?i inch eIevation under the left heel showing aImost compIete restitution to norma posture.
30 I
302
American Jourd
0f surgery
Hudson
et aI.-Causalgic
articuIar margin of the tweIfth rib and the superolateral margin of the second lumbar vertebra. 2. Angle of Deviation of the Axis of the Lumbar Spine. A vertica1 Iine is projected from the midpoint of the spinous process of the twelfth dorsal vertebra to the same point of the first sacra1 segment. A horizonta1 Iine is drawn paraIIe1 to the bottom of the fiIm through the spinous process of the first sacra1 segment. The angIes formed by these Iines are measured. The tiIt of the spine, either to the Ieft or right, is expressed in degrees by subtracting the smaIIer angIe from the Iarger. 3. Level of the Iliac Crests. Lines are drawn paraIIe1 to the base of the fiIm (or perpendicuIar to the side of the fiIm) passing through the highest point of each iIiac crest. The distance between these two paraIIe1 Iines is measured. 4. Level of the Superior Articular Margin of the Femora. The procedure here is identica1 with that of 3, the onIy difference being that the uppermost point of each femora1 head is seIected as a guide for the paraIIe1 Iines. 5. Other Points to Be Noted on the ExscoIiosis of the amination. (a) PosturaI dorsoIumbar spine; (b) rotation of the pelvis; (c) abduction and adduction of the femora; (d) interna rotation of the femur on the side of the Iow crest. REPORT
OF
CASES
We have treated thirty cases conservatively. The etioIogic factors were: injury to the back in ten; foca1 infection in eight; and no known cause in the remainder. The pain was right sided in twenty-two cases and left sided in eight. Ages varied from 20 to 48 years. There were fifteen females and fifteen maIes. The type of individual affected was the slender herbivorous type in twenty-eight cases and the stocky carnivorous type in two cases. The eIevation of the hee1 was usuaIIy 45 to 36 inch. The eIevation was worn for three to four months and then Iowered onehaIf for three to four more months. Some
Backache
r&Y,1gq.r
patients, on raising the hee1, develop pain in the thigh aIong the adductor muscIes on the opposite side and in the gIutea1 area on the same side. The pain is usuaIIy reIieved in two to three weeks and the hyperesthesia in six to eight weeks. Exercises are started when the pain begins to subside and are continued daiIy for six months. A typica case history foIIows: M. L., maIe, complained of pain of “raw” nature in the left back, radiating to the Iower abdomen just above the groin. This had existed two years. The pain awakened him in the morning. Examination reveaIed a peIvic tiIt to the left, scoIiosis of the spine, sIight increase of the Iumbar Iordosis, hyperesthesia over the cutaneous distribution of the tweIfth dorsa1 nerve, interna rotation of the Ieft femur with vaIgus of the Ieft hee1, and no muscIe spasm in the Iumbar muscles. SUMMARY
Another concept reIating to a specific phase in the backache probIem is presented. A mechanica theory based on muscIe imbalance is advanced to expIain the cIinica1 and roentgen findings. The patients compIain of an upper Iumbar backache that is aggravated at rest, awakens them at night, and is accompanied by pain that radiates aIong the Iast rib and to the groin. The cIinica1 examination reveaIs an increased Iumbar Iordosis, postura1 scoIiosis, a peIvic tiIt, abduction and interna rotation of the femur on the side of the Iow iliac crest, and adduction of the thigh on the side of the high iliac crest. There is tenderness and hyperesthesia over the cutaneous distribution of the tweIfth dorsa1 and first Iumbar nerves. The treatment consists of eIevation of the heeI on the side of the Iow crest and muscIe exercises. The roentgenographic examination confirms the cIinica1 findings when the upright firms reveal an acute costovertebra1 angIe and a peIvic tiIt. REFERENCES W. FauIty body mechanics a factor for causing diagnostic errors. Delaware State M. J.,
I. BATES,
7: 61, 1935.
NEW SERIES Var.. LII. No. 2
Hudson
et al.-Causalgic
2. BATES, W. ReIation of body mechanics to surgical diagnosis. Arch. Pbys. Therap., 16: 416, 1935. 3. BATES, W., and JIJDOVICH,B. D. Local treatment ot backache. Med. World, 55: 177. 1937. 4. CARNETT, J. B. Intercostal neuraIgia of abdominal waI1. Colorado Med., 27: 72, rg3o. 5. CARNETT, J. B., and BATES, W. Treatment of inter-
6. 7. 8.
g. IO.
I I. 12. 13_ 14.
I 5. 16.
17.
18.
19.
Costa1 neuraIgia of the abdominal wall. Ann. Surg., 98: 820, 1933. CLINTON, M. SubcostaI neuritis as a cause of abdomina1 pain. J. A. M. A., 83: go, rgq. GRANT, J. C. A Method of Anatomy. Baltimore, 1937. WiIIiam Wood. JUDOVICH, B. D., and BATES, W. The common back sprain; IumbodorsaI sprain with secondary first Iumbar neuraIgia. M. Rec., February 5, I 936. JUDOVICH, B. O., and BATES, W. Low back pain. C&n. Med. W Surg., 44: 245, 1937. KRAUS, E. R. CongenitaI anomaIies of the spine. J. Osleopatby, 1935. KRAC.S, E. R. Backache: a resume. J. Am. Osteopathic A., 1936. LOVE, J. G., and WALSH, M. N. Protruded intervertebra1 disks. J. A. M. A., I I I: 396, 1938. MASSIE, G. SurgicaI Anatomy. PhiIadeIphix, 1937. Lea & Febiger. TROSTLER, I. S. Radiology, 13: 3, 1938. MAYER, L. J. Bone @ Joint Surg., I 3: I, 193 I. BAUM. Chronic neuraIgia of Iowest intercostal nerves and its treatment. Deulscbe Ztschr. f. Cbir., 197: 74, 1926. Abst. J. A. 114. A., 7: I 522, 1926. CARNETT, J. B. Intercostal neuraIgia as a cause of abdominal pain and tenderness. Surg., Gynec. c Obst., 42: 625, 1926. CARNETT, J. B. Chronic pseudo-appendicitis due to intercostal neuraIgia. Am. J. M. SC., 174: 579, 1927. CARNETT, J. B. The simulation of gall-bIadder disease by intercosta1 neuralgia of the abdomina1 waI1. Ann. Surg., 86: 747, 1927.
Backache
A merican Journal of Surgery
303
20. CAKNETT, J. B. Acute and recurrent pseudoappendicitis due to intercostal neuraIgia. Am. J. M. SC., 174: 833, 1927. 21. CARNETT, J. B. The simulation of various intraabdominal lesions by intercostal neuraIgia of the abdominal waI1. M. J. Ed Rec., 129: 64, 1929. 22. CAKNETT, J. B., and BATES, W. The treatment of intercosta1 neuraIgia of the abdomina1 wall. Ann. Surg., 98: 820, 1933. 23. CARNETT, J. B. Chronic strain of the Iumbar spine and sacro-iIiac joints. Ann. Surg., 83: sag-518, 1927. 24. THOMAS, L. C., and GOLDTHWAIT, J. E. Body Xlechanics and Health. New York, Houghton MiflIin. 25. CARNETT, J. B., and BATES, W. Railway spine. S. C&n. N. America, 12: 1369, 1932. 26. COC:HRANE,W. A. Orthopaedic Surgery. Baltimore, WiIIiam Wood. 27. Livingston, E. M. Skin triangIe of appendicitis. Arch. Surg., 13: 63, 1926. 28. RORERTSON, G. Disturbed reflexes, their significance in acute abdomina1 diseases. Surg., Gynec. e? Obst., 43: 806, 1926. 20. KENDALL, H. O., and KENDALL, F. P. Study and treatment of muscIe imbaIance in cases of Iow back and sciatic pain. Private printing, BaIt.imore, 1936. 30. GOL.DTHWAIT, J. E., BHOWN, L. T., SWAIM, L. T., and KUHNS, J. G. Body Mechanics. PhiIadeIphia, 1934. Lippincott. 3 I. DICKSON, F. D. Posture. Everyday Practice Series. PhiIadeIphia, 1931. Lippincott. 32. GOL.DTHWAIT,J. E. An anatomic and mechanistic conception of disease. Boston M. Ed S. J., 172: 881, rgIs_ 33. GOL.DTHWAIT,J. E. Anatomic explanation of many of the cases of weak and painfu1 backs as we11 as many of the leg paraIyses. Boston M. e* S. J., 68: 128, 1913. 34. HULEON, 0. C., and HETTESHEIMER, C. A. Causalgia, a case of backache. Med. Times, 67: 21 I, 1939.
CARL A. HETTESHEIMER, M.D. Chief Surgeon, Meadowbrook Hospital AND
PERCIVAL A. ROBIN, M.D. Attending RoentgenoIogist, Nassau HospitaI HEMPSTEAD,
J
UDOVICH and Bate? have caIIed our attention to the fact that low back pain may originate in the dorsoIumbar area. In osteopathic Iiterature the authors have mentioned that a peIvic tiIt may cause backache due to a primary short Iower extremity. This condition they treat by an eIevation within the shoe and by osteopathic manipuIation. One type of back pain invoIves the Iumbar muscIes and especiaIIy the quadratus Iumborum. Here, pain radiates along the tweIfth rib due to tweIfth dorsa1 and first Iumbar nerve irritation and a cIinica1 picture of asymmetrica muscIe imbaIance occurs. This group of cases comprises a definite cIinica1 entity which can be separated from the vast group of patients suffering from back pain. The treatment is simpIe and effective. This type of backache, produced by muscIe imbalance, causes subjective symptoms because the imbaIance, together with the muscIe spasm, increases the tension within the quadratus Iumborum fascia, producing direct pressure on the tweIfth dorsa1 and first Iumbar nerves. The irritation is manifested by pain with radiation aIong the course of these nerves. (Fig. I.) The trunk is maintained erect in equiIibrium by the abdominaIs and quadratus Iumborum muscIes in front and the sacrospinaIis muscIes behind. Overaction or weakness of any group of these muscIes wiI1 aIIow contractures to develop. The abdomina1 muscIes, due to Iack of use, become weakened and the overworked sacrospinaIis muscIes become contracted with an increase in the lumbar Iordosis. The
NEW
YORK
pelvis, Iacking the stabiIizing effect of the abdomina1 muscIes then incIines more anteriorIy. Injury, a toxic focus or chronic stress, may cause the quadratus Iumborum to become irritated, resuIting in spasm. Contraction of the quadratus Iumborum causes the Iast rib on the same side of the spine to deflect downward at a more acute angIe. As the tweIfth rib is drawn downward it aIso rotates forward, giving relativeIy a greater distance for the tweIfth dorsal nerve to traverse from the intervertebra1 foramen to the subcostal groove. As a direct resuIt of this shift there is produced increased tension in the nerve sheaths. In an effort to reIieve the pain thus produced, the patient wiI1 assume a position of asymmetrica muscle imbaIance and functiona scoIiosis appears. Following this uneven distribution of body weight a peIvic tiIt resuIts with abduction of the Iower extremity on the side of the Iow crest and adduction of the Iower extremity on the side of the high crest. Other muscle changes then occur. On the the abducted side, the thigh rotates internaIIy at the acetabuIum and the foot pronates with a vaIgus of the hee1. On the adducted side, the thigh shows Iittle or no internal rotation and the foot Iittle or no pronation. Another factor in maintaining the pelvic tiIt is the puI1 of the pronated foot and interna rotation of the femur of the abducted extremity. (Fig. 2.) We have chosen to IabeI this syndrome, for want of a more appropriate term, causaIgic backache. CausaIgia, or pain of a burning nature, describes brief3 y the sensation these patients experience.
298
Am&can Journal uf Surgery
EXPERIMENTAL
Hudson
PRODUCTION
OF
et al.-CausaIgic CAUSALGIC
BACKACHE
One of us, in an effort to prove the validity of this theory, made an experiment
Backache
MAY,
1941
this time definite tenderness was present paravert&braIIy in the dorsoIumbar area and aIong the-right tweIfth rib. The right sacrospinaIis muscIes were spastic.
TUCLFTH DoRSFiL NEW MT
LUt’lWR WERW
UTANEOU3 DI5TRIBUTION
RNrCluOR 5uRPACB FIG. I. Cutaneous
POSTLWOR3URFIKC
distribution of twelfth first Iumbar nerves.
dorsal
and
in an individua1 who had no history of previous back compIaints. PreIiminary cIinica1 and Roentgen examinations were negative. An eIevation of x inch was added to the heeI of the Ieft shoe, and was worn at a11 times. A cIinica1 examination was made with the adjusted shoes on. There was noted a peIvic tiIt with the right side incIined downward. The spine showed a right dorsa1, Ieft Iumbar scoIiosis. The right thigh was abducted and the Ieft thigh was adducted. On the first day of the experiment there was a sensation of waIking uphi on the adducted extremity. Most of the weight was borne on the abducted extremity (right), whiIe the patient was waIking and standing. (This was proved by having him stand with each foot on a separate spring baIance.) A notation in the diary on the third day discIosed that considerabIe aching was experienced deep in the buttocks. By this time it was impossibIe for the subject to walk with comfort unIess the entire right Iower extremity was internaIIy rotated. After one week, there was a sense of tightness and puIIing in the dorsoIumbar area on bending over; especially was this true on any attempt to straighten up. At
FIG.
2.
Diagrammatic ographic
representation findings.
of radi-
FoIIowing three weeks’ activity in this position, subjective pain was present radiating around the right side at the IeveI of the tweIfth nerve distribution. Hyperesthesia was present in the groin and aIong the right side of the chest. Night pain in these areas had been present for some time. After the elevation was removed and exercises instituted, the symptoms disappeared in two weeks. History. The history of these patients is quite characteristic. They have suffered for years with a pain in the low back area. They IocaIize it, however, by pIacing the hand over the crest of the iIium or midIumbar region. Pain is uniIatera1. If pain is right-sided, many of the patients have had appendectomies, gaII-bIadder surgery, or urologic instrumentation without reIief. The pain is described as aching, burning, tearing apart, boring, or stabbing in nature. These patients are unabIe to get comfortabIe on going to bed and they twist and turn for ten to twenty minutes to get reIief. This pain awakens the patient at
NEW SEMIS
VOL. L1 I. No.
Hudson
2
et aI.--~CausaIgic TABLE
Ci14C
_
A.G.. C.
1’. H.
L.
iv..
e or”
TY
Duration of Symptoms
ln:zid-
2 years
s/
4 years
Hravy
5 years
Slender
M.R..
..,
~.
Journal
Foci
OSSC2”US
Syndroms
of Surgery
End
Yes
None-
Tzz
Yes
Non?
None
No pa*n. to WPA Cured
Yes
None
Teett
CUPXI
None
Cured
I year
Slender
Physiotherapy, foci removed, S” port Kr .a ney studies, fracture 1st. lumbar vertebra, 193” Physiotherapy
1” years
Slender]
Foci
removed
299
NolIe
Yes Not
done
Yes
Result
Lesions
Physiotherapy
6 years
M.C..
A merican
I
Previous Treatment
I
A. R,
Backache
. None
Teett
Relieved
Non‘?
Cured
Returned work
I I. E.
?
Slender
None
?
Scoliosis
None
Cured
E.B....
4 months
Slender
Physiotherapy
?
None
Teeth
Relieved
L.. E.
3 years
Slender
Yes
None
None
Did not carry treatment
A. P.
8 months
Slender
Urological studies, physio. therap Physiot g erapy
Yes
None
None
Relieved
4 months
Slender
Physiotherapy
Yes
None
None
9 years
Slender
Yes
None
None
Relieved. to WPA Cured
Non.2
Unknown
A.A.. R.
B.
sl
I year
Slender
Physiotherapy, Ober o eration Physiot g erapy
44
/ P%$ight
I year
Slender
Physiotherapy
Refused
4”
/ P%$&kt
I year
Slender
Physiotherapy
?
~4
/ j;%I2I low back
15 weeks
Slender
None
Refused
7 months
Slender
Physiotherapy
?
3 monthr
Slender1
Physiotherapy
3 months
Slender
Physiotherapy
If....
A.T.... H. H.. M.
R. B...
.
E. J.
F.
M.
qr
P.
F.
24
A. B.
F.
2”
J.
G.
D.
M..
F.
39
G. L.
F.
33
H.
M.
4”
F.
36
R.
D.,
radiating to groin Pain left low back radiating to groin Pain right back radiating t, groin Pun right low back Pain left low back radiat,ing / t? grotn Pam left low back Pain right dorsolumbar area. Pjzs;_ght
Refused
.
.
None
Refused
Teett
Cured
None
Relieved
None
None
Relieved
?
Nont!
None
Relieved
Yes
None
None
Cured
None
None
Relieved
Non‘2
Unknown
None
Returned work
treatment
3 years
SIender
Physiotherapy
Yes
4 months
Slender
None
Refused
1 year
Slender
Physiotherapy
Yes
None
None
Cured
I year
Heavy
?
Congenital analomies
NOllC
Some
2 years
Slender
Lift
on heel
Yes
None
2 yelrrs
Slender
Physiotherapy
Yes
None
None
Cured
I year
Slender
Foci
None
None
NolIe
Questionable
!
M..
G.B....
,
1Physiotherapy
relief
lumbar
Dr.
M.
P. E.
39
F.
L.L
37
1 M.
H.C.B..
40
i area 1Pyrd_ght Iumbar area Pain right upper back radiating t< ‘n P% right
removed
Cured
yPP,e' C.
1M. i
R....
G.M
.
.(F.
M.
(37
Pain left low back PjgS;i_sht lumbar area Pain Ieft dorsolumbar
M.M.....
Dr.
DaCK
35
L..
4 weeks
Slender
Physiotherapy
None
Teeth
Questionable
I week
Slender
None
Yes
None
None
Questionable
3 years
SIender
Various
YCS
None
None
Cured
2 years
SIender
None
Yes
None
Teeth
Cured
I 0th”
C. Hudson.
M.D.. Carl
A. Hettesheimer,
M.D.
Per&vat
A. Robin,
M.D.. Hempstead,
ew York.
out
300
American Journal of Surgery
Hudson
et al.-CausaIgic
night, it begins near the midhne posteriorIy and usuaIly radiates anteriorIy when he arises. Lying on the hypersensitive skin area produces the night pain. Coughing, sneezing, or missing a step whiIe waIking gives severe pain that frequentIy doubIes the patient up. AIso, pain may be brought on by bending over the washbasin in the morning or bending over to do any type of work. In addition, there may be radiating pain into the thigh posterioIateraIIy, over the IumbosacraI area, or over the upper gIutea1 area. Examination of a11 paExamination. tients reveaIs spasm of the lumbar muscIes of varying degree, with limitation of motion of the spine in al1 directions. There is an increased Iumbar Iordosis. ScoIiosis is present on standing, but disappears on Iying down. The peIvis is tiIted and on the low side there is abduction of the Iower extremity, interna rotation of the thigh, and marked pronation of the foot. On the high side of the peIvic tiIt there is adduction of the Iower extremity, IittIe or no rotation of the thigh, and IittIe or no pronation of the foot. (The rotation of the thigh on the low side may be overIooked if the patient is examined with the thighs in externa1 rotation.) Hyperesthesia to pinching and poking of the skin is present over the cutaneous distribution of the tweIfth dorsa1 and first Iumbar nerves. There is tenderness along the twelfth rib, especiaIIy at exits of nerve trunks through fascia or muscIe. This can be elicited easily by pressing upward on the Iower edge of the rib. There is tenderness and hyperesthesia paraIIe1 to Poupart’s Iigament, on the upper inner aspect of the thigh, and over the tweIfth dorsa1 and first Iumbar transverse processes paravertebraIIy . Leg Iength should be measured. EIevations of varying thicknesses under the heel of the side of the Iow iIiac crest shouId correct the peIvic tilt and re@tabIish norma1 posture. The patients wiI1 immediateIy fee1 more secure in their baIance and comment on this fact without questioning.
Backache
May,,$I.$*
Treatment. If the heeI on the abducted extremity is raised by an eIevation sufhcient to overcome the peIvic tiIt the quadratus Iumborum is reIaxed, the rib returns to its norma position, the scoIiosis is corrected, and the interna rotation of the thigh disappears. Exercises are given to strengthen the abdomina1 muscles and weaken the sacrospinaIis group. Radiographic Examination. Roentgenograms are taken in the usua1 manner to ruIe out any abnormaIity such as structura1 scoliosis, arthritis, etc. When causaIgic backache is diagnosed cIinicaIIy, the routine x-ray fiIms are supplemented by specia1 examinations described in detai1 beIow. ConverseIy, this syndrome may be suspected if anteroposterior upright IiIms of the dorsolumbar spine and peIvis show an acute angIe of the tweIfth rib, Iow iIiac crest, and Iow femora1 head on the same side. (Fig. 3.) We perform the Roentgen examination as foIIows : I. A supine fiIm is made in the anteroposterior projection of the IumbosacraI spine incIuding the lower two dorsa1 vertebrae. It is important that the subject be adjusted on the tabIe so that the spine is straight. 2. A fiIm is made of the same region with the patient in the upright position, using the Potter-Bucky diaphragm. The position of the patient, here too, is important. The shoes are removed and the feet are pIaced 4 inches apart and paraIIe1. The patient is asked to stand with the weight equally distributed. 3. This examination is optional. The fiIm is taken with eIevations varying from M to g inch in thickness pIaced under the hee1 of the side of the Iow iIiac crest. This is done as in 2. Landmarks. I. Costovertebral Angle. To determine one side of this angIe, a Iine is drawn between the inferior articuIar margin and the inferior border of the tweIfth rib at the junction of the outer and middIe thirds. The other side of this angIe is formed by a Iine drawn between the inferior
NEW
SEINES VOL. LII, No.
2
Hudson
C
et al.-causalgic
Backache
American
~~~~~~~ of surgery
D
FIG. 3. Radiographic examination of typical case; female, aged 34, compIaining of left lower abdotnina pain and backache for five years. A, supine film, showing equa1 costovertebral angles, negIigibIe deviation of axis of Iumbar and IeveI crests and femora1 heads. B, upright fiIm showing acute Ieft costovertebral angIe, deviation of Iumbar spine towards the right, and low Ieft iliac crest and femoral head. c, upright fiIm with a ,+4 inch eIevation under the left hee1 showing a partia1 correction of the deformities. D, upright fiIm with a ?i inch eIevation under the left heel showing aImost compIete restitution to norma posture.
30 I
302
American Jourd
0f surgery
Hudson
et aI.-Causalgic
articuIar margin of the tweIfth rib and the superolateral margin of the second lumbar vertebra. 2. Angle of Deviation of the Axis of the Lumbar Spine. A vertica1 Iine is projected from the midpoint of the spinous process of the twelfth dorsal vertebra to the same point of the first sacra1 segment. A horizonta1 Iine is drawn paraIIe1 to the bottom of the fiIm through the spinous process of the first sacra1 segment. The angIes formed by these Iines are measured. The tiIt of the spine, either to the Ieft or right, is expressed in degrees by subtracting the smaIIer angIe from the Iarger. 3. Level of the Iliac Crests. Lines are drawn paraIIe1 to the base of the fiIm (or perpendicuIar to the side of the fiIm) passing through the highest point of each iIiac crest. The distance between these two paraIIe1 Iines is measured. 4. Level of the Superior Articular Margin of the Femora. The procedure here is identica1 with that of 3, the onIy difference being that the uppermost point of each femora1 head is seIected as a guide for the paraIIe1 Iines. 5. Other Points to Be Noted on the ExscoIiosis of the amination. (a) PosturaI dorsoIumbar spine; (b) rotation of the pelvis; (c) abduction and adduction of the femora; (d) interna rotation of the femur on the side of the Iow crest. REPORT
OF
CASES
We have treated thirty cases conservatively. The etioIogic factors were: injury to the back in ten; foca1 infection in eight; and no known cause in the remainder. The pain was right sided in twenty-two cases and left sided in eight. Ages varied from 20 to 48 years. There were fifteen females and fifteen maIes. The type of individual affected was the slender herbivorous type in twenty-eight cases and the stocky carnivorous type in two cases. The eIevation of the hee1 was usuaIIy 45 to 36 inch. The eIevation was worn for three to four months and then Iowered onehaIf for three to four more months. Some
Backache
r&Y,1gq.r
patients, on raising the hee1, develop pain in the thigh aIong the adductor muscIes on the opposite side and in the gIutea1 area on the same side. The pain is usuaIIy reIieved in two to three weeks and the hyperesthesia in six to eight weeks. Exercises are started when the pain begins to subside and are continued daiIy for six months. A typica case history foIIows: M. L., maIe, complained of pain of “raw” nature in the left back, radiating to the Iower abdomen just above the groin. This had existed two years. The pain awakened him in the morning. Examination reveaIed a peIvic tiIt to the left, scoIiosis of the spine, sIight increase of the Iumbar Iordosis, hyperesthesia over the cutaneous distribution of the tweIfth dorsa1 nerve, interna rotation of the Ieft femur with vaIgus of the Ieft hee1, and no muscIe spasm in the Iumbar muscles. SUMMARY
Another concept reIating to a specific phase in the backache probIem is presented. A mechanica theory based on muscIe imbalance is advanced to expIain the cIinica1 and roentgen findings. The patients compIain of an upper Iumbar backache that is aggravated at rest, awakens them at night, and is accompanied by pain that radiates aIong the Iast rib and to the groin. The cIinica1 examination reveaIs an increased Iumbar Iordosis, postura1 scoIiosis, a peIvic tiIt, abduction and interna rotation of the femur on the side of the Iow iliac crest, and adduction of the thigh on the side of the high iliac crest. There is tenderness and hyperesthesia over the cutaneous distribution of the tweIfth dorsa1 and first Iumbar nerves. The treatment consists of eIevation of the heeI on the side of the Iow crest and muscIe exercises. The roentgenographic examination confirms the cIinica1 findings when the upright firms reveal an acute costovertebra1 angIe and a peIvic tiIt. REFERENCES W. FauIty body mechanics a factor for causing diagnostic errors. Delaware State M. J.,
I. BATES,
7: 61, 1935.
NEW SERIES Var.. LII. No. 2
Hudson
et al.-Causalgic
2. BATES, W. ReIation of body mechanics to surgical diagnosis. Arch. Pbys. Therap., 16: 416, 1935. 3. BATES, W., and JIJDOVICH,B. D. Local treatment ot backache. Med. World, 55: 177. 1937. 4. CARNETT, J. B. Intercostal neuraIgia of abdominal waI1. Colorado Med., 27: 72, rg3o. 5. CARNETT, J. B., and BATES, W. Treatment of inter-
6. 7. 8.
g. IO.
I I. 12. 13_ 14.
I 5. 16.
17.
18.
19.
Costa1 neuraIgia of the abdominal wall. Ann. Surg., 98: 820, 1933. CLINTON, M. SubcostaI neuritis as a cause of abdomina1 pain. J. A. M. A., 83: go, rgq. GRANT, J. C. A Method of Anatomy. Baltimore, 1937. WiIIiam Wood. JUDOVICH, B. D., and BATES, W. The common back sprain; IumbodorsaI sprain with secondary first Iumbar neuraIgia. M. Rec., February 5, I 936. JUDOVICH, B. O., and BATES, W. Low back pain. C&n. Med. W Surg., 44: 245, 1937. KRAUS, E. R. CongenitaI anomaIies of the spine. J. Osleopatby, 1935. KRAC.S, E. R. Backache: a resume. J. Am. Osteopathic A., 1936. LOVE, J. G., and WALSH, M. N. Protruded intervertebra1 disks. J. A. M. A., I I I: 396, 1938. MASSIE, G. SurgicaI Anatomy. PhiIadeIphix, 1937. Lea & Febiger. TROSTLER, I. S. Radiology, 13: 3, 1938. MAYER, L. J. Bone @ Joint Surg., I 3: I, 193 I. BAUM. Chronic neuraIgia of Iowest intercostal nerves and its treatment. Deulscbe Ztschr. f. Cbir., 197: 74, 1926. Abst. J. A. 114. A., 7: I 522, 1926. CARNETT, J. B. Intercostal neuraIgia as a cause of abdominal pain and tenderness. Surg., Gynec. c Obst., 42: 625, 1926. CARNETT, J. B. Chronic pseudo-appendicitis due to intercostal neuraIgia. Am. J. M. SC., 174: 579, 1927. CARNETT, J. B. The simulation of gall-bIadder disease by intercosta1 neuralgia of the abdomina1 waI1. Ann. Surg., 86: 747, 1927.
Backache
A merican Journal of Surgery
303
20. CAKNETT, J. B. Acute and recurrent pseudoappendicitis due to intercostal neuraIgia. Am. J. M. SC., 174: 833, 1927. 21. CARNETT, J. B. The simulation of various intraabdominal lesions by intercostal neuraIgia of the abdominal waI1. M. J. Ed Rec., 129: 64, 1929. 22. CAKNETT, J. B., and BATES, W. The treatment of intercosta1 neuraIgia of the abdomina1 wall. Ann. Surg., 98: 820, 1933. 23. CARNETT, J. B. Chronic strain of the Iumbar spine and sacro-iIiac joints. Ann. Surg., 83: sag-518, 1927. 24. THOMAS, L. C., and GOLDTHWAIT, J. E. Body Xlechanics and Health. New York, Houghton MiflIin. 25. CARNETT, J. B., and BATES, W. Railway spine. S. C&n. N. America, 12: 1369, 1932. 26. COC:HRANE,W. A. Orthopaedic Surgery. Baltimore, WiIIiam Wood. 27. Livingston, E. M. Skin triangIe of appendicitis. Arch. Surg., 13: 63, 1926. 28. RORERTSON, G. Disturbed reflexes, their significance in acute abdomina1 diseases. Surg., Gynec. e? Obst., 43: 806, 1926. 20. KENDALL, H. O., and KENDALL, F. P. Study and treatment of muscIe imbaIance in cases of Iow back and sciatic pain. Private printing, BaIt.imore, 1936. 30. GOL.DTHWAIT, J. E., BHOWN, L. T., SWAIM, L. T., and KUHNS, J. G. Body Mechanics. PhiIadeIphia, 1934. Lippincott. 3 I. DICKSON, F. D. Posture. Everyday Practice Series. PhiIadeIphia, 1931. Lippincott. 32. GOL.DTHWAIT,J. E. An anatomic and mechanistic conception of disease. Boston M. Ed S. J., 172: 881, rgIs_ 33. GOL.DTHWAIT,J. E. Anatomic explanation of many of the cases of weak and painfu1 backs as we11 as many of the leg paraIyses. Boston M. e* S. J., 68: 128, 1913. 34. HULEON, 0. C., and HETTESHEIMER, C. A. Causalgia, a case of backache. Med. Times, 67: 21 I, 1939.