Chronic sacroiliac sprain with attendant sciatica

CHRONIC SACROILIAC SPRAIN WITH ATTENDANT SCIATICA REGINALD

H.

JACKSON, M.D.,

F.A.C.S.

MADISON, WIS.

IRST, I wish to beg the induIgence of those who speciaIize in orthopedic surgery not onIy for my temerity in presentF ing a subject which inherentIy beIongs to them but aIso for the eIementary character of my presentation. I am not an orthopedic surgeon. My interest in the subject of chronic sacroiIiac sprain was awakened at the meeting of the Southern SurgidaI Association in 1929 when Baer, in discussing CampbeII’s paper on the fusion operation in certain of these cases, briefly described a non-open operative treatment which he had found wonderfuIIy efficacious in a very high percentage of cases. DirectIy on my return home a patient was admitted with a typica advanced type of this aflliction. (Case I.) The apphcation of the method of treatment as described by Baerl was so remarkabIy effective that I became greatIy interested in the subject. In the past three years we have had 28 simiIar cases in which we have used what I have chosen to designate as Baer’s maneuver. WhiIe there are aIIusions in the Iiterature to manipuIations of the affected Iimb, Kernig’s fIexion, dry stretching, etc., Baer’s description is most definite and precise. As a resuIt of our experience we are convinced that: I. This type of case is a distinct cIinica1 entity and the affliction is a reIativeIy common one. 2. The genera1 practitioner faiIs, as a ruIe, to comprehend the nature of the Iesion and is ignorant of the possibihty of prompt reIief in the majority of cases by the proper remedia1 measures. 3. It is a Iesion which the genera1 surgeon too often regards as beyond his ken. 456

CHRONIC SACROILIAC SPRAIN

457

4. WhiIe properIy beIonging to the orthopedic surgeon, it is a Iesion which, in reaIity, is not referred to him in appropriate numbers. 3. Those amicted with it become the wiIIing prey of the various c&s, drug addicts, and habitues of mud bath or hot spring estabIishments. 6. There are no more gratefu1, we&satisfied, appreciative patients in any fieId of surgica1 endeavor than the recipients of a curative treatment of chronic sacroihac sprain with attendant sciatica, suffering as they do with a11 gradations of pain and disabiIity cuIminating at times in the most protracted agony and despair. WhiIe a review of the Iiterature of sacroihac sprain reveaIs an ever-increasing interest in the subject on the part of orthopedic surgeons, one is impressed with the great variance of opinion that exists as to: I. Its actuaIity as a cIinica1 entity. 2. The mechanism producing it and the exact nature of this Iesion. 3. The appropriate type of treatment for the various gradations of the injury. 4. Its differentia1 diagnosis from Iesions such as IumbosacraI sprain, non-traumatic arthritis, early tubercuIosis of the joints, sciatica due to arthritis of the Iumbar spine, certain gynecoIogica1 Iesions, etc. It is not my purpose to enter upon or discuss the variou opinions extant upon these probIems but rather to confine myseIf to: I. EIementary remarks on the anatomy of the peIvis. 2. My persona1 experience with patients. 3. IIIustrations. ANATOMICAL

CONSIDERATIONS

The evoIutionary changes in the architecture of the bony peIvis and muscuIature attendant upon the transitional progress from a quadrupeda to the bipeda mode of Iocomotion

458

REGINALD

H. JACKSON

in the mammahan group, cuIminating in the highIy speciarized structure found in man, with his unique ability to spring sideways from not only a standing position but to do so on aIighting from a forward stride or jump, are interestingIy brought out by ReynoIds.2 As an exampIe of the process of gain in strength without an increase in weight, he cites the ability of the human peIvis to resist great strains in spite of its light weight. This end has been attained by such changes in the bones, Iigaments and muscuIar attachments as to vastIy increase through the Iaws of Ieverage their strength and power. SACROILIAC

JOINT

The conformation of the bony surfaces constituting this joint in man is such as to restrict to a minimum any cauda1 or cephaIad movement of either surface. They are aIso designed to Iimit or minimize rotary motions. This is apparent in the simpIe wooden mode1 (Fig. I) made for me by Professor Waiter SuIIivan of the anatomica department of the University of Wisconsin; an interIocking design presenting four phIange surfaces. In the upper portion of the joint, the joint cIeft runs from behind forward and inward; in the Iower part, forward and outward. This feature is aIso mentioned by Quain. This arrangement, together with the anterior and posterior Iigamentous system and the muscuIature, presents from the engineering standpoint an idea1 structure to Iimit or minimize rotary motion through a transverse axis. This function is admirabIy served under ordinary conditions of strain providing aIways that the muscIes which are aIso essentia1 to the proper functioning of this highIy deveIoped anatomica region are “on guard.” The histories of typica cases of chronic sacroiIiac sprain as a rule reveaI that the inception of the lesion occurred at a time when the patient, whiIe in an unusua1 muscuIar position, experienced either a sudden unforeseen additiona strain or a continued repetition of a moderate strain. Thus, in our cases the puIIing through the mud of a heavy hunting boat, the buiId-

CHRONIC

SACROILIAC

SPRAIN

459

ing of a pier by one unaccustomed to such work, the digging of a ceIIar, the opening of a window which, after starting to sIide open suddenIy stuck (Fig. 2) were cIearIy direct etioIogic factors

FIG. I. Wooden mode1 to show simpIe Iocking design of sacroiliac

in the production

joints.

of the Iesion. In some cases, the exciting

cause

is so trivia1 that without an appreciation of the Iaws of Ieverage it wouId be impossibIe to comprehend what takes pIace. If the hand and wrist of a strong man are voIuntariIy ff exed to the extreme Iimit (Fig. 3), the appIication of the index finger of a much weaker man to the back of the hand wiI1 effectuaIIy prevent the strong man from extending his wrist, the Ieverage of the muscIe is Iost. A very IittIe extra pressure of the index finger on the dista1 end of the mid-metacarpa1 bone which now serves as an actua1 Iever wiI1 cause acute pain in the back of the unguarded wrist. When the trunk is bent forward in a sIightIy twisted position with the Iower extremities braced, one more so than the

REGINALD

460

H. JACKSON

other, with the arms extended, the hands grasping a heavy weight (Fig. 4); if a foot unexpectedIy sIips, or the subject makes an extra effort fuIIy expecting to Iift the weight by using

FIG.

2.

Sudden sticking of a window and trivia1 exertions may result in acute sacroiliac sprain.

the trunk muscuIature and faiIs to do so, the acme of Ieverage force centers in the sacroihac joint. Unexpected Ieverage transmitted uniIateraIIy through the hamstring muscIes whiIe the body is sIightIy twisted and curved forward and down, is a most potent cause of sacroihac sprain. As stated by WaIker4 : “This joint supports the weight of the trunk and aIso absorbs the shocks from the Iower extremities. It hoIds the key position when one is Iifting, bending, stooping, and waIking.” If the traumatic injury resuhing from such a mishap

FIG. 3. To iIIustrate

FIG.. 4. Unexpected 643dy is slightly

(I) Ioss of muscuIar Ieverage; bony lever.

(2) effect of pressure

at distal end of

Ieverage transmitted unilateraIIy through hamstring muscles WIde twisted and curved forward is a common cause of sacroiIiac sprain U461ll

462

REGINALD

H. JACKSON

stretches and ruptures by a transverse rotary “shearing action ” the periostea1, capsuIar and Iigamentous support of the joint at the level of the third sacra1 vertebra, conceivabIy it wiI1 cause an acute pain with an immediate spasm of the muscuIature which protects the joint. PresumabIy this is foIIowed by injection of the synovia and increase of joint fluid. Whether the Iesion in an advanced state is a true arthritis is stiI1 under debate. PAIN

Smith-Petersen’ in speaking of the in Lesions of the sacroiIiac joint says:

characteristic

pains

Distribution of Pain. In regard to the patient’s description of the distribution of pain, this, of course, is subjective and cannot be anatomicaIIy accurate. It is distinctIy heIpfu1, however, when we consider the innervation of the sacro-iIiac joints. This is derived from the foIIowing sources: (I) AnteriorIy, from the IumbosacraI cord; (2) posteriorIy, from the first and second sacra1 nerves; (3) inferiorIy, from the superior gIutea1 nerve; (4) from the obturator nerve. There is some question as to the innervation derived from the obturator. The opinions of various anatomists differ on this point. BardeIeben and Morris, however, agree on the first three sources of innervation. On the basis of the innervation just described we may have pain referred aIong the fourth and fifth Iumbar and first and second sacra1 nerves. In other words, we may have pain referred aIong the posterior aspect of the thigh, anteroIatera1 and posterior aspect of the Iower Ieg and IateraI aspect of the ankIe. Because of the innervation from the superior gIutea1 nerve we are aIso apt to have pain referred to the sacrosciatic notch, extending in the anteroIatera1 direction aIong the distribution of the superior gIutea1 nerve to its termination in the tensor fascia femoris muscIe. FinaIIy, pain over the distribution of the interna obturator nerve, nameIy, the inferior, mesia1 aspect of the thigh. I have found pain referred to this area in two cases onIy; both cases were proven by operation to have a chronic inflammatory process in the sacro-iIiac joint.

In the type of case I am presenting, we have been impressed with two outstanding features; I. The severity and chronicity of the attendant sciatic pains.

CHRONIC

SACROILIAC

SPRAIN

463

2. The very marked contraction of the great group of hamstring muscIes. That the actua1 physica shortening of this group of mus-

FIG. 6.

FIG. 5. Actual

FIG. 5. physica

FIG. 6. LumbosacraI

shortening of hamstring muscles heIps maintain via sacroiliac ligament any imbaIance of joint surfaces. pIexus which is directIy irritated by any misaIignment of joint surfaces.

cIes, aIways apparent in the chronic type of Iesion, must exert a potent force in maintaining any imbaIance of the joint surface produced by the primary trauma is suggested by Figure 5, the puI1 exerted on the tuber ischii being extended to the vicinity of the sacroiIiac joint via the sacroiIiac Iigament. The conception of a rotary shearing traumatism which through repetition Ieaves the joint cIeft surfaces in permanent misaIign-

464

REGINALD

ment readiIy accounts present (Fig. 6).

H. JACKSON

for the intense

sciatic

pain

which

is

HISTORY

The typical history in our experience is one of persistent disabIing pain and tenderness over a sacroiIiac joint with attendant so-caIIed sciatica which has persisted over a period of months or years and faiIed to respond to many forms of treatment, in&ding remova of supposed foci of infection, wearing of specia1 beIts, braces, weight extension of the affected limb, epineura1 injections, etc. WhiIe many patients attributed the inception of their troubIe directIy to some remembered mishap, in others it was necessary to eIucidate by the taking of a very carefu1 history the fact that they had overexerted themseIves shortIy before the first onset of symptoms by “digging a ceIIar, ” “Ioading more hogs than the other feIIow,” “I oa d’mg b a I es of hay”-types of Iabor they were not hardened to. PHYSICAL

EXAMINATION

The majority of our patients were maIes (26 of 28 in oLr series) usuaIIy of an athIetic type, averaging thirty-five years of age, many of them bedridden when first seen. The faciaI expression is one df protracted pain and mentaI distress (Fig. 7). The posture in bed is usuaIIy a IateraI one with the affected Iimb flexed, both thigh and Ieg. On inspection there is a characteristic ffatness of the back in the IumbosacraI region. The skin of the posterior aspect of the Iimb from the buttock to the popIitea1 space, or Iower, presents the “marbeIcharacteristic of the repeated protracted use ized mottring” of hot water bottIes or eIectric pads. PaIpation of the affected joint eIicits marked tenderness; with the patient on his back, any effort on the part of the examiner to extend the Ieg on the thigh and then flex the Iower extremity on the trunk (Kernig’s test) meets with

CHRONIC

SACROILIAC

SPRAIN

464

marked resistance and resuIts in immediate exacerbation of pain in the affected sacroiIiac joint and intensifies the sciatic pain. GaensIein’s test is aIways positive.

FIG. 7. TypicaI facies and standing posture of patients afllicted with chronic sacroiIiac sprain with sciatica.

If abIe to stand the patient assumes a characteristic attitude, stooping forward from the hips, the affected Iimb somewhat flexed, the body weight resting on the unaffected extremity, the trunk tiIted to one side. Foci of infection may or may not be discovered by usua1 or specia1 methods of examination. X-RAY

EXAMINATIONS

In a11 our cases very thorough x-ray examinations were made. In no case was it possibIe to make a diagnosis by this

466

REGINALD

H. JACKSON

means per se. This diagnostic agent we found of vaIue IargeIy from the negative side, in ruIing out the possibIe presence of pathoIogica1 Iesions which might simuIate or compIicate a sacroiIiac sprain. CIinicaI Iaboratory findings are negative aside from their possibIe significance in associated Iesions. TREATMENT

I shaI1 confine my remarks to the one method of treatment used in our series of cases of typica chronic sacroiIiac sprain with attendant sciatica. The onIy modification which we have made in the method as described by Baer is in the substitution of a Iow spina anesthetic in pIace of a genera1 anesthetic. We beIieve that a spina anesthetic is a distinct improvement as : I. It produces an earIy compIete reIaxation of a11 the unaffected muscIes of the extremity, permitting the operator to concentrate on the contracted and physicaIIy shortened group. 2. The appIication of the plaster-of-Paris cast after the maneuver is compIeted is faciIitated by the cooperation of the patient. 3. It obviates the, at times, proIonged disagreeabIe aftereffects of a genera1 anesthetic. Our routine method of preparation of these patients is the same as that used in other patients to be operated upon under a spina anesthetic: I. One and one-haIf hours before going to the operating room IO grains of sodium barbita1 by mouth, one-haIf hour Iater >i grain pantopon and >gO0 to 31 5 ,, scopoIamine (dosage depending on age, weight of patient, and nature of operation) by hypodermic injection, and five minutes before the induction of the spina anesthetic, 50 to 125 mg. of ephedrin (dosage again depending on nature of operation and approximate IeveI of anesthesia desired) is injected into the muscIes of the back by a needIe Iong enough to insure its deposit and absorption in the muscIe.

CHRONIC

SACROILIAC

SPRAIN

467

We caII the method of administration we have developed the 1-2-3 (TabIe I, a copy of our anesthetic room chart of directions). If No. 2 is ordered it caIIs for the second IeveI of anesthesia, 200 mg. novocaine dissoIved in 2 C.C. spina fluid. This is the one we usuaIIy use in these cases. We have now used this method in about 6700 patients without a death which couId be, in any way, attributed to the spina anesthetic. We are convinced that the “sheet anchor of safety” is the administration and absorption of the proper amount of ephedrin five minutes before the spina anesthetic is given. It must be injected with a Iong needIe into the spina muscIes where it wiI1 be absorbed. If given by an ordinary hypodermic into subcutaneous fat it wiI1 not insure against the usua1 faI1 of bIood pressure, etc. TABLE 1 SPINAL ANESTHESIA--DOSAGE CHART Levels Anesth.-IeveI.

One

.

Ephedrin .........................

FLEXION

zo-40-mg.

609o-mg.

roe-r25-mg.

I oo-mg.

zoo-mg.

300-mg.

1.0

2.0-2.5

3.w3.5

s-sec. I- 1?4 hrs. OF

Three CIavicIe

....................

Length-anesth.....................

/

1 Costa1 margin

A ......................

Injection-rate.

Two

IIiac crests

Novocaine........................ C.c. spina

I

THE

EXTENDED

I$-sec.

1o-sec. I ‘,&I 52’ hrs.

/

IK

hrs.

LIMB

The flexion is carried to such a degree that the toes approximate the scaIp (Fig. 8). Th e average time consumed was about thirty-five minutes. As the word “Surgeon” is derived from two Greek words: Xier, the hand, and ergo, to work with, the compIete ffexion of the Iimb in one of these cases may we11 be designated as a surgica1 procedure. As noted in detai1 in the recita1 of Case I, the operator shouId not be in a hurry, the ffexion shouId be a SIOW, graduai

468

REGINALD

H. JACKSON

one, a step by step or “inching up” process. Assistants are necessary not onIy to hoId the peIvis flat on the tabIe by pressure on the anterior iIiac crests but also to keep the Iimb

FIG. 8. Baer’s maneuver compIeted. It requires thirty to thirty-five minutes to accompIish this. By an “inching up ” Aexion the contracted and physically shortened hamstring muscIes are freed. FIG. 9. Ready for cast. Note normal Iumbar lordosis.

extended by gentIe firm pressure over the anterior surface of the knee with one hand whiIe the ankIe or foot is grasped with the other. When the fIexion has passed 90 degrees, another assistant standing at the head of the tabIe reaches over and grasps the foot and ankIe and takes part in the ffexion under the direction of the operator who is at the foot of the tabIe exerting pressure against the caIf and kneading the contracted hamstring muscIes. When the foot has approached the point

CHRONIC

SACROILIAC

SPRAIN

4%

where the patient can grasp it (another advantage of spina anesthetic) he usuaIIy does so and is of some assistance in hoIding the Iimb whiIe the operator and assistants take occasiona1 rests. SeveraI times during the maneuver the extremity is pIaced upon the tabIe and vigorous kneading of the hamstring group practiced. In again taking up the process of ffexion it is done from the start in a SIOW, gentIe way, never rapidIy or forcibIy, unti1 the point is reached where ffexion again meets with marked resistance. As a ruIe, after ffexion has approximated an angIe of 120 degrees, the resistance rapidIy diminishes. In patients with a fourth degree (scaIe I to 4) contraction, we wouId advocate a two stage procedure with an interva1 of five to seven days, at the first sitting approximating IOO to I 15 degrees. DANGERS

ATTENDANT

UPON

MANEUVER

WhiIe there are occasiona aIIusions in the Iiterature to the possibiIity of (I) producing a fracture of the femur; (2) rupture of the sciatic nerve, I was not abIe to find any direct report of either of these accidents. ConceivabIy, if an operator endowed with great physica strength shouId exert it in a “hurry-up fashion” on a patient onIy partIy under a genera1 anesthetic, such an accident might happen. In onIy two of our patients were any postoperative effects noted which might be attributed to over-stretching. One patient noticed a narrow strip of paresthesia aIong the outer aspect of the Ieg between the knee and ankIe which persisted for six weeks. The other one compIained very bitterIy of daiIy repeated spasms of “ Iightning pains ” in the great toe and soIe of the foot associated with “cramps” in the caIf of the Ieg which required a hypodermic of morphine when the spasm came on. At the height of one of these speIIs during the third week, the resident surgeon injected novocaineyfreely into the caIf and the attacks ceased.

REGINALD

470

H. JACKSON

We aIways warn patients that there may be some transitory or permanent paresthesia or other residua1 effects but the pIight of patients afllicted with this chronicaIIy disabIing

FIG.

IO.

Same patient as shown in Figure 7, taken sever-d months after treatment.

and painfu1 condition is such that they invariabIy accept the risk without hesitation. APPLICATION

OF

PLASTER-OF-PARIS

CAST

After the maneuver has been compIeted and it is apparent not onIy to inspection but paIpation that the norma Iumbar Iordosis has been restored (Fig. g) the patient is transferred to a fracture tabIe and a pIaster-of-Paris cast appIied from the Costa1 margin to the lower part of the thigh (both limbs). At the end of two weeks this is removed and a properIy fitting sacroiIiac beIt fitted, and the patient aIIowed to graduaIIy

CHRONIC

SACROILIAC

SPRAIN

471

up and around. Physiotherapy measures, massage of the limb, etc., are given each day whiIe the patient remains in the hospita1 usuaIIy a week to ten days after the cast is removed. Ascertainable foci of infection are aIso given necessary attention. In order to give a cIear cross section of the experience which we have had in the past three years with this, to us, distinct cIinica1 entity, I am presenting brief histories of 6 typica cases, the record of Case I being more detaiIed than the others. It shouId be understood that for the sake of brevity onIy the outstanding and reIative points in the history, physica

get

fmdings,

Iaboratory

reports SYNOPSES

and treatment OF

are mentioned.

HISTORIES

Mr. K., No. 68181, maIe, aged forty-nine, commercia1 traveIer, admitted October 22, 1930. Chief Complaint: Severe sciatica right Ieg. Two and one-haIf years ago whiIe buiIding a pier at his summer cottage he had an acute attack of severe pain in the right sacroiIiac region. He was Iaid up for a few days and then tried to finish the buiIding of the pier. At his first effort to swing the heavy sIedge used in driving the pier posts the acute pain in the right sacroiIiac region returned. He attributed his troubIe to over-exposure in the coId water; he was confined to bed for a week and then began to hobbIe around. Three weeks Iater sciatic pain in the right Iimb appeared and has persisted more or Iess constantIy to the time of admission. Three months after the inception of the sciatica it was so severe he was compIeteIy incapacitated. At this time the epidura1 injection with novocaine was made by a surgeon in MinneapoIis. There was some reIief for three weeks, then the pain returned. He has tried mud baths, hot springs, sacroiIiac beIts, etc., but has not been abIe to carry on his work except for short periods. Six days ago an infected tooth was extracted. The next day he attended a footbaI1 game and was chiIIed. That night the sciatic pain was greatIy intensified and he has been confined to bed since then. He came in with the request that the sciatic nerve be injected with novocaine. Physical Examination. He was of the taI1, athIetic type. The facia1 expression was one of chronic pain and distress; he hobbIed into the examining room with a cane and sat on the first avaiIabIe chair, bending forward at the hips and flexing right Ieg. The posterior aspect of this Iimb shows the mottIec1 skin effect characteristic of the repeated protracted appIication of heat.

472

REGINALD

H. JACKSON

There is exquisite tenderness over the right sacroihac joint, normaI Iumbar Iordosis is repIaced by a definite ffatness. With the patient fiat on his back on the examining tabIe any effort to flex the extended right Ieg beyond a few degrees intensifies the pain in the sacroiIiac region and in the distribution of the sciatic nerve. Clinical Laboratory Reports: BIood, urine, etc., are practicaIIy normaI. X-Ray Laboratory Report: There is no evidence of any pathoIogica1 Iesion or deformed or dispIaced vertebrae. Diagnosis: Chronic sacroiIiac sprain with attendant sciatica. Treatment: The patient at first was most insistent on having an epidura1 injection of novocaine but consented, when the method was expIained to him, to have the Baer maneuver tried. October 23, 1930: Under Iow spina anesthesia an effort was made to fIex the extended right Iower extremity. Great resistance was encountered from the hamstring group of muscIes. After repeated efforts, the Iimb was brought to a flexion of about 90 degrees. At this time there was a sudden, quite Ioud, “pIopping” sound which was so aIarming that a11 further efforts to ffex the Iimb were abandoned. A radiograph of the femur was made and to our reIief showed no evidence of injury. The source of the sound was attributed to the giving away of adhesions or the rupture of the contracted sheaths of the hamstring muscIes. In subsequent cases we became accustomed to and Iearned to expect more or Iess of this sound phenomenon which varies in intensity and character, sometimes simuIating the peculiar “gerrunching” sound accompanying the parting of a stay Iine on a sai1 boat. This patient, being the first on whom this treatment was used, was watched with great interest for the next few days. He was given to understand that another treatment wouId probabIy be necessary. AIthough the intense sciatic pain which he had on admission was considerabIy aIIeviated, there was stiI1 marked tenderness on paIpation over the right sacroiIiac joint posteriorIy and a normal Iumbar Iordosis was not apparent. October 30, 1930: Under Iow spina anesthesia, the extended right Ieg was graduaIIy ffexed unti1 the great toe was touching the head, twentyfive minutes being necessary to accompIish this. The patient then requested that the other leg be treated in the same way, inasmuch as he had been having for severa weeks twinges of pain down the back of it and which he had negIected to teI1 us about when the history was taken. This was done, about fifteen minutes of manipuIation compIeting the maneuver. The patient was then transferred to the fracture tabIe for the application of the pIaster-of-Paris cast. It was immediateIy apparent that a norma Iumbar Iordosis was present.

CHRONIC

SACROILIAC

SPRAIN

473

The patient stated the day after the ConvaIescence was uneventfu1. Iast treatment that the pain had Ieft him, that he was quite comfortabIe, that he sIept Iast night on his back for the first time in two years. When the cast was removed at the end of two weeks and a properIy fitting sacroiIiac beIt put on, severa ecchymotic areas, the Iargest the size of the paIm of the hand, were noted on the back of the thigh but the patient did not compIain of any undue pain or soreness in this region. Subsequent History: Three years have eIapsed since this patient was treated. He states that he has had IOO per cent relief, that he has returned to his work, that he plays goIf, and that he is eternaIIy gratefu1 for the compIete change for the better the treatment brought in his attitude towards Iife which at the time of admission was one of such gIoom and despair due not onIy to his persona1 physica agony but to menta1 distress over the prospect that he wouId be permanentIy incapacitated and unable to support his famiIy and become a burden to them, that he had contempIated suicide as the onIy way out. CASE II. Mr. W., No. 68051, maIe, aged twenty-seven, nursery man, admitted November 12, 1930. Chief Complaint: Recurring attacks of acute sacroiIiac sprain sometimes on the right side, again on the Ieft; usuaIIy has to go to bed for a week or two when attacks occur, has had some reIief at times from strapping and wearing sacroiIiac beIt. Present attack came on yesterday whiIe he was Iifting some heavy cans. In great pain a11 night and today, requiring anodynes. Patient brought in by his brother, a physician. Physical Examination: We11 buiIt muscuIar man, suffering intense pain both sacroiliac regions and down into thighs (posterior aspect) to below knees. Lumbar Iordosis repraced by flattening of spine. Exquisite tenderness over both sacroiIiac joints posteriorly. Efforts to flex either Iower extremity in an extended position greatIy increases his pain and distress. X-Ray Laboratory Report: No evidence of pathoIogica1 Iesion is noted. anesthesia Baer’s Treatment: November 13, 1930, under Iow spina maneuver was carried out on both Iimbs, tota time one hour. Cast appIied, etc. Subsequent History: CompIete reIief, no recurrence of attacks in past three years. It is aIso of interest that this patient reports that he is now abIe to crouch and hop aIong the ground pIanting seeds, shrubs, etc., with compIete comfort hour after hour, a thing which he had not been abIe to do for severa years before treatment. CASE III. Mr. W., No. 70469, maIe, aged thirty-three, commercia1 traveIer, admitted June 22, I 93 I.

474

REGINALD

H. JACKSON

Cbiej Complaint: More or Iess constant sacroihac pain and sciatica right Ieg for past eight months. Inception of troubIe dates to lifting of a heavy weight last faI1; immediate treatment by an osteopath gave some reIief. In February another severe attack with radiation of pain down back of thigh and into caIf of Ieg. Has been in a Milwaukee hospita1 for severa weeks before admission. Various forms of treatment, weight extension, manipuIation of Ieg, etc., have not given reIief. Physical Examination: We11 buiIt muscuIar man, bedridden; refuses to get out of bed for examination. Marked tenderness over right sacroiIiac joint posteriorIy, Iumbar Iordosis gone, marbeIization of skin on posterior aspect of right thigh from buttock to beIow knee, very marked. Patient refuses to have extended right Iower extremity flexed; says he knows from past experience it wiI1 greatly aggravate his pain. He hoIds thigh in a flexed position with Ieg flexed to a point where he says he gets most relief. PaIpation of the hamstring group even in this position shows them to be markedIy contracted. Treatment: June 22, 1931, Baer’s maneuver, unti1 extended Iimb flexed to IOO degrees; many snapping sounds noted; thought best to compIete fuI1 Aexion at a second sitting. Contraction of hamstrings noted on record as fourth degree. June 27, 1931, flexion of Iimb compIeted unti1 toes touched head. Cast appIied, etc. ConvaIescence uneventfu1. Subsequent History: Returned to work and when Iast heard from’had had no recurrence. CASE IV. Mr. R. L., No. 74019, maIe, aged forty-seven, seed company manager, admitted May 18, 1932. Cbiej Complaint: Pain in Ieft sacroiIiac joint with sciatica. Duration two and one-haIf months. TroubIe began on day when patient heIped Ioad heavy bags of seed on a truck, an unusua1 type of work for him. Was confined to bed for severa days, then went back to offIce work. Distress in back continued more or Iess and sciatica appeared two weeks Iater and has continued with increasing severity. Has been confined to bed four weeks before admission. Physical Examination: SmaII, wiry type of man, examined in bed; marked tenderness over Ieft sacroiIiac posteriorly, muscIes protecting joint very rigid. MarbeIization of skin from buttock to popIitea1 space second degree. Kernig’s sign, grade II. X-ray Report: Negative. Treatment: May 20, 1932, Baer’s maneuver, both Iimbs. Time; one hour, ten minutes. Very IittIe sound phenomenon. Subsequent History: CompIete reIief of pain and disabiIity.

CHRONIC SACROILIAC SPRAIN

475

admitted CASE v. Mr. H. L., No. 52414, male, aged fifty, minister, January 2, x932. Chief Complaint: Bedridden past three months, intense sciatica and pain in right sacroihac joint. Four months ago, after hard day’s work in camp, had acute right scaroiliac pain; in bed a week. Sciatic pain developed in third week and has been more or Iess constant since, increasing in intensity. Physical Examination: Heavy muscular type, facial expression one of protracted pain and despair. Exquisite tenderness over right sacroiliac joint posteriorly. R/larbelization of skin from buttock to middle of calf, fourth degree. Kernig’s test: Fourth degree. X--ru~, Laboratory Report: Negative. Treulment: January 2, 1932, Baer’s maneuver; time, forty-five minutes; resistance of hamstring group grade III. Subsequent History: Patient stated the morning after treatment that he had slept on his back for the the reIief of his pain was “miracuIous”; first time in months. surgeon, referred CASE VI. F. B., No. 76191, male, aged thirty-seven, by Dr. C!arence Toland, Los AngeIes. Admitted February 13, 1933. Chief Complaint: Chronic right sacroihac sprain with sciatica. Duration two years. Trouble began while he was pIaying squash; acute sacroiIiac pain Iasting two weeks. A few weeks later had another attack whiIe pIaying squash. A few weeks later whiIe skiing had a bad tumble. Since then has had more or Iess constant disability and pain; bedridden for past severa weeks. Previous Treatment: Rest in bed, strapping, use of beIts and special braces, mud baths, hot springs, etc. Six months ago, under genera1 anesmanipuIation of affected Iimb, weight extension, thetic, tonsiIIectomy, etc. No relief. Comes in a state of desperation and despair. Physical Examination: We&developed, muscuIar type. FaciaI expression one of chronic pain and distress. TypicaI sacroiIiac syndrome, grade IV. Treatment: February 14, 1933, Baer’s maneuver; time fifty-five minutes. Subsequent History: CompIete reIief (Fig. I I).

CONCLUSIONS

ll,‘hiIe it is presumptious for one who is onI>- a genera1 surgeon and in no wise an orthopedist to present such a smaI1 number of cases of chronic sacroiIiac sprain with attendant

476

REGINALD

H. JACKSON

sciatica, the author feIt warranted in doing so for the foIIowing reasons : I. Since his attention was first awakened in the subject by Baer’s description of his method of treatment in 1929, he has treated 28 patients affEcted with this condition with eminentIy satisfactory resuIts. Two of this series were physicians who, on admission, were in a state of protracted agony and despair, a11 ordinary and usua1 methods of treatment having proved unavaiIing. 2. From his experience he beIieves that this type of case is a distinct cIinica1 entity and a reIativeIy common one; that the genera1 practitioner faiIs, as a ruIe, to comprehend its nature and is ignorant of the possibiIity of reIief through appropriate measures; that a better understanding by the genera1 practitioner of the nature of the mechanism producing the condition wouId resuIt in his insistence that every primary sacroiIiac sprain be regarded as a serious and potentiaIIy chronic Iesion unIess proper restraint and physioIogica1 rest of the injured part is instituted at once and persisted in for the time necessary for compIete repair to take pIace, a matter of at Ieast three weeks or Ionger. 3. It is a Iesion which the genera1 surgeon too often is prone to regard as beyond his ken. 4. WhiIe inherentIy beIonging to the orthopedic surgeon, in reaIity patients afflicted with it are not referred to him in appropriate numbers. As a resuIt of these conditions a host of such patients are wandering around ineffectuaIIy seeking reIief and many become the wiIIing prey of the various cuIts, drug addicts, and habit& of mud bath and hot spring estabIishments. In the author’s experience there are no more gratefu1, appreciative, satisfied patients in the whoIe fieId of surgica1 endeavor than the recipients of a curative treatment by Baer’s maneuver of chronic sacroiIiac sprain with attendant sciatica. The onIy modification of Baer’s method as described by him was the use of spina anesthetic in pIace of genera1 anes-

CHRONIC

SACROILIAC

SPRAIN

thetic. The author beEeves, from his experience, anesthesia offers many definite advantages.

477

that

spina

REFERENCES I. BAER, W. S. Sacroiliac strain. Johns Hopkins Hosp. Bull., 27: 159, ~917. 2. REYNOLDS, E. The evohrtion of the human peIvis in relation to the mechanics of the erect posture. Papers of Peabody Museum, Harvard University, vo1. 9, No. 5. 3. Quain’s Anatomy. VoI. 4, Pt. I, p. 253. 4. WALKER, F. H. The diagnosis and treatment of sacro-iliac strain. Clin. Med. @ Surg., 35: 655457, 1928. 5. SMITH-PETERSEN, M. N. CIinicaI diagnosis of common sacroiIiac conditions. Roentgenol. w Rad. Tberap., 12: 546-50, 1924. IFor Discussion see p. 483.1

Am. J.

FRACTURE entirely

destroyed,

but

fascia,

as from

ments

I have no faith,

OF

THE

no effort

my experience

TIBIAL

was

made

SPINE to

reconstruct

them

with

in whose

crucial

Iiga-

with the first case,

yet whose stabiIity

of the knee is sound, it seemed

unnecessary. In neither

case is there

any faIse motion

IateraIIy,

anteroposteriorly,

or in rotation.

In concIusion I beIieve prompt remova of the fractured spine is not onIy the shortest way to recovery, but the onIS way to prevent deformity; that the crucial Iigaments have onIy a sIight Iimiting function in knee stabiIity, and therefore the attempted repIacement of damaged crucia1 Iigaments with fascia is a useIess procedure; and finaIIy that earIy postoperative function, as in other joint injuries, is essentia1. DISCUSSION DR. spinal

ON

ROBERT anesthesia

anesthesia

PAPERS

OF

CAROTHERS,

Cincinnati,

in operations

such

JACKSON 0.:

as these.

is not used more often is because

horn--Ò to use it. I see it in various sequences in spina

DRS.

sometimes. anesthesia

I have

pIaces

I

am

I think badly

an

advocate

the

reason

of sacra1 troubles

I have no fear of it.

for some twenty-five

I know- much more about them now than

I started.

I fee1 that sacroiliac

Sometimes else. There

get out of order.

But

are so many if through

a cure and get these individuaIs

strains

things

are strains

in that

some process

I recaI1 2 cases particuIarIy, in a wreck.

lvith him and the roentgenogram one-third

lated it without a spica. that

one that

was nothing

showed separation

can

does it trouhIe

of a railroad

else the

matter

of the sacroiliac

joint

and we manipu-

much pain, gave him a long rest in bed and then put on

of a woman

FortunateIy,

There

of an inch. He had very few symptoms

He got entirely

an automobile

that

we effect

case? A real sacroiliac

is easily diagnosticated.

of about

and sometimes

neighborhood

of manipulation

fireman

had been

years,

I did \vhen

back on their feet what difference

make what has been wrong in that particuIar who

of just

used, and bad con-

and do not fee1 that something

of

spinal

I think there is no more danger

than other forms of anesthesia.

been a student

VENABLE

of fear and ignorance

very

If it is done properIy

AND

we11 and went back

who was seen within

on the right

to work. The other

the last year.

side and had a distinct

she had a small

fracture

case was

She had been hit h\ sacroiliac

diffIcultyi.

near the root of the sacraiIiac

and

following treatment she got entirely we11 and went back to work. sag- “fortunately” the fracture heIped to repair the sacroiIiac strain.

I

I

CHARLES

S. VENABLE

have done this manipuIation a good many times but never so successfuIIy as Dr. Jackson brought out, but it is effective. Another interesting thing is that these strains occur in persons not accustomed to hard work or great muscuIar strain. How much of this diffIcuIty may be muscuIar spasm and not sacroiIiac strain is diffIcuIt to say. MuscuIar spasm of the hamstrings often pIays a Iarge part in these cases and by reIieving that strain we get the resuIt Dr. Jackson has had. DR. FRANCIS R. HAGNER, Washington, D. C.: There is one point I wish to make. They always say the difference between speciaIists and genera1 practitioners is that the speciaIist puts his finger in the patient’s rectum. In such cases as here reported we aIways have to bear in mind maIignancy of the prostate. This possibiIity is not excIuded by finding no evidence of bone metastasis. I have seen patients with sciatica and sacroiIiac pain and no thought given to prostatic maIignancy and yet, on examination, carcinoma of the prostate wouId be easiIy recognized as the cause of the condition. DR. RALPH G. CAROTHERS, Cincinnati, 0.: I wouId like to know if Dr. Jackson uses this method in sacroiIiac strain when sciatica has not yet deveIoped, and in cases where there is shortening of one Ieg which has been present for years or some possibIe congenita1 abnormaIity of the leg, and foIIowing some strain the patient gets this sacroiIiac pain. It is we11 to remember that when the troubIe is caused or aggravated by automobiIe riding reIief is often obtained by riding in a car of different type or make. DR. W. BARNETT OWEN, Louisville, Ky.: Dr. Jackson has presented a number of very typica cases of what I shouId term sacroiIiac strain. I think he is quite right in his diagnosis. They are the extreme type, or the chronic type, and give the most troubIe. The methods empIoyed by Dr. Baer, that of extreme hyperff exion sIowIy and carefuIIy employed, foIIowed by a fixation pIaster spica for two or three weeks, wiI1 reIieve a very high percentage of the patients, but not aI1. We have had probabIy 5 per cent of cases that the procedure wouId relieve for a Iimited time and then suddenly there wouId be a recurrence and the patient wouId be as bad off as before. In those cases we have resorted to fusion of the sacroiliac joints. We know how diffIcuIt it is for the roentgenoIogist to give any definite information of many sacroiIiac conditions. As Dr. Jackson outIined, the roentgenograms are aIways negative in these cases of extreme sacroiIiac strain. Some of the miIder cases, which he did not touch on, can be reIieved by manipuIation, if it is properly done with the patient Iying on his face with the body pIaced in hyperextension and tremendous force empIoyed over the sacroiIiac joints.

FRACTURE

OF THE

TIBIAL

SPINE

485

These cases are not aIways confined to patients with poor muscuIar deveIopment or to those not accustomed to hard Iabor. I recaI1 a big, husky Negro, who was heIping to lift a piano; his assistant on the opposite side suddenIy slipped, Ieaving this man in a stooping position with the body hexed to one side, and it caught the hip on the side he was Ieaning on. This man couId not get out of bed at a11 and we empIoyed Dr. Baer’s methods. In three weeks he was out of bed with a support which heId him. He returned to work two months Iater. The sudden reIief of pain in these cases is astonishing. This procedure is not without danger; it is possible to disIocate or fracture the hip. DR. ROSSA. WOOLSEY,St. Louis, MO.: In the Iast twenty-five years we have had many dozens of cases of sciatica. In the oId days we wouId put on the big cast and extension; in others, under genera1 anesthesia, we wouId stretch the sciatic nerve with indifferent resuIts. Never until some six or eight years ago when we started spina anesthesia did we get the resuIts we get now. They are perfect. I wish to go one step further than Dr. Carothers and say we use spina anesthesia in everything beIow the diaphragm. I wish to go one step further than Dr. Jackson and say that in stretching these sciatic nerves he does not need the cast. We are getting perfect resuIts and are not using the cast. The rea1 thing is the thirty minutes he spoke of instead of mereIy a few short stretches. I beheve that with the proper anesthesia and the proper extension he does not need the pIaster cast in these cases. DR. REGINALD H. JACKSON, Madison, Wis. (closing): Dr. Carothers mentioned the differentia1 diagnosis; this is extremely important. Whenever I have been in doubt, I have sought the opinion of an expert orthopedic surgeon. As a ruIe, however, the properIy taken history and the cIinica1 findings constitute a distinct cIinica1 entity. Three of our cases had been diagnosed eIsewhere as idiopathic sciatica. In a11 three a carefuIIy taken history reveaIed a definite inception fohowing unusual occupational effort. Dr. Hagner mentioned carcinoma of the prostate as a cause of backache, which shouId not be overIooked. Of course, in a11 cases of backache in eIderIy men, we shouId think of carcinoma of the prostate and excIude it. The type of Iesion I am presenting usuaIIy comes in the third decade. RepIying to Dr. RaIph Carothers, we have used this method in some acute cases with exceIIent resuIts but I emphasized the chronic cases today for they are the ones commonIy passed by. I wouId not say we have IOO per cent good resuIts but we have found it a very usefu1 and gratifying method of treatment. WhiIe I reaIize my

CHARLES

486

S. VENABLE

presentation has not been of a high scientific grade of merit, I was encouraged to present it after reading Dr. Maes’ deIightfu1 editorial on the tradition of the Southern Surgical Association, 1which appeared in The American JournaI of Surgery. In speaking of the founders he said, in part, “They recognized the fundamental basis upon which surgery as a science is founded, but they realized with equa1 clarity that the uItimate aim of the surgica1 art is not the exhibition of scientific principles but the heaIing of the sick.” ‘Am. J. Surg., n.s.

20:

808,

1933.