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End results of certain procedures in the surgery of trauma
END RESULTS OF CERTAIN PROCEDURES IN THE SURGERY OF TRAUMA WILMER
C.
SMITH,
M.D.
Salem, Oregon
0
BSERVATIONS and accumuIated experience arising from association with disabiIity evaIuation should contain something of vaIue to the individua1 actively engaged in the practice of surgery, especiaIIy that surgery which concerns itseIf with the treatment of trauma. These observations are based upon a period of more than ten years of famiIiarity with disabiIity awards as given by the Oregon State IndustriaI Accident Commission. It is entireIy proper that one shouId ask at the outset what vaIidity concIusions so arrived at may carry and, therefore, what attention they actuaIIy warrant. There are three genera1 considerations which shouId be presented in answering this. In the Hurst place the number of cases handIed by this organization is quite Iarge, approaching some so,ooo claims per year and, hence, the number of exampIes of any particular condition or of any specia1 type of treatment is greater than that seen by aImost any singIe physician. Secondly when treatment has been concIuded and the condition has reached a stationary state, these patients are seen by medical examiners who are especiaIIy familiar with the recognition and evaluation of disability; this is estimated on a numerical basis. I believe that there are two advantages in such a method. In the first place the individua1 who estimates the end result is not the physician who treated the patient. This eliminates the pardonabIe pride in his end results which might inAuence the evaluation of the treating physician to some extent. In the second place, aIthough it is open to error, a numerical evaIuation in terms of percentage Ioss of function is in genera1 more dehniteIy expressive than is a rating based upon good, fair or poor, this Iatter method or some variation is often used by physicians in reporting their end results. LastIy, I think it is a fact that a more thorough foIIow-up system obtains in these cases. It is often true that the origina treating physician Ioses sight of patients who believe after a certain period of treatment or numNovember,
I 948
ber of calIs that little more is to be gained by further consuItation. However, in our cases the patients hope that further treatment will resuIt in more compIete physica restoration or that as a resuIt of aggravation disability evaluation will be revised; this tends to bring them back years after the Iast caI1 to the origina treating physician. As a matter of fact as Iong as there is any dissatisfaction with the resuIts of treatment or whenever aggravation appears, these patients invariabIy “come home to roost”; and atthough those of us connected with this type of work often wish it otherwise, the fact remains that our foIIow-up is most complete. It may, therefore, be said that observations made in this IieId recommend themseIves to the consideration of the practicing surgeon by virtue of muItipIicity of exampIe, impartia1, dehnitive evaIuation and thoroughness of foIIow-up. I am, of course, aware of certain arguments which are often advanced tending to impeach the vaIue of conclusions based upon compensation experience. The most common is that the patient fully reaIizes he is “before the cashier’s window,” and that every possible compIaint or objection to his end resuIt wiII be elaborated upon for the obvious reason that he believes his financia1 return wiI1 be based IargeIy thereon. WhiIe this criticism is true in many instances, it is also a fact that a great number of these patients do not engage in more than the usua1 amount of compIaining common to humanity in general. It should aIso be noted in this connection that examiners familiar with problems of disability evaIuation are more than usuaIIy astute in discounting compIaints without reasonable basis. StiII another fact which obtains in patients covered by an Industrial Accident Commission which is not generaIIy appreciated is the fact that these individuals as a rule are engaged in active physica Iabor and, therefore, surgica1 procedures performed upon them are generaIIy subject to greater strain than the same surgical procedure wouId be in the patient whose occupation is IargeIy sedentary. For example, in the case of a spina 6x9
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fusion the average private patient who is wiIling to suffer the consequent time Ioss and is able to finance the surgery and the subsequent inactivity is in general not an individua1 who, by reason of his occupation, is forced to put great stress upon the lower back. More often, indeed, he is a desk worker and for this reason his spinal fusion will never be subjected to the crucial tests that come with the daily Iifting and carrying of heavy weights so common among industrial workers. I, therefore, submit that procedures in the surgery of trauma are given a more severe trial in the case of the industrial worker who comes under an Accident Commission than in the instance of the average private patient and it is not unfair to state that, perhaps to some degree at least, the objection connected with “the cashier’s window” is met or even compIeteIy balanced by the fact that the industria1 worker subjects his surgery to a more rigorous test than does the private patient. SPINAL
FUSION
It has been our observation that in certain seIected cases spina fusion is indicated and in these cases its resuIts are generaIIy very good. At the same time it has been evident that in a Iarger group of patients in whom spina fusion was resorted to soIeIy because a11 other forms of therapy were unavaiIing, the resuIts were appaIIingIy bad. In our experience the greatest benefit from spina fusion, is found in those patients below the age of forty and preferabIy Iess than thirty who have a past history of frequent back injuries resuIting from minor trauma and who upon examination reveal we11 Iocalized pain and tenderness and especiaIIy whose x-ray examination reveaIs architectura1 defects Iimited to the area of compIaint. Even in these cases fusion shouId not be resorted to until an adequate period of conservative treatment has been tried or unIess the periods of disabiIity from minor back injuries have become suffrcientIy frequent to warrant more radica1 treatment even though the present attack might respond to conservative therapy. Our resuIts have not been so encouraging in patients above the age of forty, even though the patient may otherwise qualify; in like manner the patient whose pain and tenderness is diffuse and not Iocalized sharply does not appear to be nearIy so good a candidate for fusion as does the individua1 who presents a reIativeIy sharp
in Surgery
localization of complaints. As to the architectural defects which Iend weight to the indications for fusion, the most common are those of congenita1 or deveIopmenta1 origin. These usuaIIy consist of gross asymmetry of Iumbosacra1 articulating processes. This asymmetry may be either in size of the respective processes or in the pIane of their articuIations. The architectural defect prompting fusion should be of such nature that it can be obliterated by a fusion which includes the fewest possibIe vertebrae. We have noted aImost uniformly that the greater the number of vertebrae fused the higher is the disability, and the more frequent are compIications such as pain or pseudo-arthrosis. It is reaIIy doubtfu1 whether the resuIts ever warrant a fusion invoIving more than three vertebrae. Our experience with fusions done in the hope of aIIeviating symptoms resuIting from an uncorrected compression fracture deformity of a vertebral-body have been most unsatisfactory and it is my observation that the operation is not justified in these cases. The presence of any significant degree of arthritis, either osteo-arthritis or rheumatoid arthritis, has been one of the important contra-indications to fusions, even though the case may otherwise meet the requirements satisfactoriIy. If arthritis exists to any important degree, I am extremely doubtfu1 that fusion wiI1 prove worth-whiIe. We have found in these cases that disability after fusion is actually greater than that which existed before. It wouId seem reasonable to expIain this by the generaIIy accepted fact that arthritis invoIves numerous articuIations and is seldom limited to only one set. Moreover, it is commonly observed that an arthritic joint toIerates any forceabIe increase in its range of motion very poorIy; such a joint which is otherwise reIativeIy symptomIess may be quickly flared into acut? activity by increased stress and strain. Thus it may we11 be that when certain articuIations are deprived of motion by spina fusion, the contiguous articulations are subjected to a. greater range of motion and, consequently, a strain to which they are unaccustomed. Like any other arthritic joint subjected to the same stimuIus, they respond by acute inflammatory reactions. The frequency with which the pain and tenderness ascends to the region of the upper end of the fusion mass in these arthritic patients seems to Iend considerable support to
American
Journal of Surgery
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this assumption. I have seen cases in which, to combat the pain in its new location, another vertebra was subsequently included in the fusion with the result that the compIaints promptly rose one segment higher. One wonders in these cases just how far up the spinal column the source of discomfort could be pursued if both patient and surgeon were willing to continue fusions indefinitelv. Along with the arthritic patient another type of case in which our experience shows fusion to be of no value is the patient in whom there is no indication for fusion except failure of other forms of therapy. The classic example is the individual who may or may not be within the age group mentioned who usually has no history of former back injuries or if former injuries were suffered, these have been widely separated in time and have been the result of adequate trauma. Examination reveaIs a very poor localization of pain which may involve most of the lumbar area or may be entirely over the sacrum or sacroiliac articulations. Tenderness, aIso is apparently diffused rather than localized, or if localized, fails to correspond with spinal articulations, often being over the dorsum of the sacrum or in the sacrospinalis muscIe mass Iateral to the lumbar articulations. X-ray examination fails to reveaI any structural abnormahties or, at most, a narrowing of the intervertebral space between the fifth lumbar and first sacral vertebrae. Here one is confronted with a patient who presents none of the indications for fusion and is recommended only by the fact that all other forms of therapy have failed. The resuIts of fusion in this type of case have been uniformly without beneht or even disastrous. When examined for cIosure about tweIve months postoperatively, the patient wilI state that surgery resulted in no improvement and that if he had it to do over again knowing what he now knows, he would not submit to the operation. There is a sizeable group of these patients who will assert that they have been made decidedly worse as a result of the operation. Careful examination will disclose that a certain percentage are grossly exaggerating; however, in some instances examination will convince the impartial examiner that a considerable number are actually justified in this complaint. These patients wiII show greater limitation of motion, increased muscIe spasm and other evidence of acute discomfort. One is convinced that they
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are actuahy
considerably worse off than they were before spinal fusion, some of them being permanentIy and totally disabled whiIe their disability may have been only half this extent before surgery. I am totaIly unable to explain what has happened in these patients. The most painstaking x-ray examination may fail to reveal any evidence of pseudoarthrosis or other defects of fusion. I am, however, convinced of the reality of these occasional unfortunate results. In any large number of patients in which fusion has been done without real indications other than persistent back pain, our follow-up demonstrates most convincingly that the majority w-i11be unimproved while a very definite and important minority wiII have been made decidedly worse off as a result of the surgery. DISC
SURGERY
Our experience with partia1 hemilaminectomy for protruded intervertebral disc has on the whoIe been very satisfactory. In cases in which an actua1 protrusion of the disc was demonstrable and in which the symptoms and findings corresponded to what might be expected from root irritation at this point, removal of the offending protrusion has resulted uniformly in a reIativeIy short period of convalescence and in comparatively low permanent disability. In view of the fact that the symptoms and signs which underhe the diagnosis of herniated discs are IargeIy of a neurologic nature, we have made it a policy to restrict this operation to the neurosurgic field. An orthopedist does the fusion in instances in which this additional procedure is carried out. I believe that it is desirable to carry out contrast myelography for the purpose of demonstrating the protruded disc before surgery is decided upon. I am aware that it is not always possible thus to demonstrate the protrusion; however, these instances are relativeIy infrequent and the added assurance gained in those cases in which protruding discs are demonstrated is well worth the time and trouble required by the procedure. For some time the contrast medium used was lipiodol. This was removed with great difficulty and in time often proved very definitely irritating. Since the advent of pantopaque we have had no indications of any irritative phenomena and it has been uniformIy possible to remove almost all the contrast medium at the completion of the
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study. We do not beIieve that expIoration without previous demonstration of the presence of a disc is indicated unless the symptoms and findings are extremely typicaL THE
COMBINED
OPERATION
For the past few years I have been deepIy interested in the combined operation consisting of hemiIaminectomy with remova of the disc herniation and at the same time spina fusion carried out by an orthopedist. I realize that there are many who routineIy advise that fusion be done in a11 cases in which disc surgery has been performed. My own observations do not substantiate this view. A study of our records reveaIs that in cases in which the combined operation has been carried out permanent disability averages 40 per cent greater than in cases in which hemiIaminectomy alone has been done. The same study reveals that instances of recurrence of disc herniation have been infinitesima1. The reasons usually given for the combined operation are first, the possibiIityof recurrence; secondIy, the fact that an injury to a disc may be expected to change the intervertebra space and thus change the reIationships of the articuIar facets resulting in some pain from this source. Recurrences in our experience have been so rare as to warrant no consideration and whatever may be the virtue of the theoretic point concerning aItered reIationship of the articular processes, the fact still remains that permanent disabihty resuIting from hemiIaminectomy alone is increased by 40 per cent in those cases in which fusion is done. Those cases of oId compression fracture of a vertebra1 body which, as aIready stated, are not benefited by spinal fusion comprise another potent objection to the theory of altered reIations between articular processes resulting from disc injury constituting an indication for fusion. In these cases the compression of the vertebra1 body by aIIowing the body above to approach the body below the fracture aIters the reIationship between the inferior articuIating processes of the vertebra above with the superior articuIating processes of the fractured vertebra far more than does any nucleus pulposis herniation. There is no reason to beheve that the usual results of spina fusion wiI1 be in any way aItered by the fact that a protruded disc
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has been removed. In other words in a11 cases other than those which present indications for fusion as heretofore described there will be two groups; first, the Iarge group of patients who have gotten no benefit from operation; and secondly, the smaIIer group who are definitely made worse by spina fusion. Thus it can and. does happen that an otherwise successful operation upon a disc can be compIeteIy changed into a dismal faiIure by the addition of an unsuccessfu1 spina fusion. CASE
REPORT
On JuIy IO, 1946, J. G., a male, thirty-four years of age, suffered a severe Iifting injury of his Iower back. Pain forced him to stop work at once and consult his famiIy physician who for a period of some two months carried out conservative treatment. As a result of marked right leg radiation and when no improvement was seen on conservative regimen, a herniated disc was suspected. AccordingIy, the patient was referred to a neurosurgeon whose findings were suffrcientfy definite to convince him that right-sided disc protrusion actuaIIy existed. Since this man had to do heavy work, the neurosurgeon thought that fusion should be carried out at the time of the disc surgery and referred the patient to an orthopedist who upon x-ray examination discerned some narrowing posteriorly of the intervertebral disc between the fifth Iumbar and first sacra1 vertebrae. It was his opinion that an unstabIe Iumbosacral junction was present and he agreed that fusion shouId be done in addition to disc surgery. The combined operation was carried out on November 5, 1946. A herniated nucIeus puIposis was discIosed on the right side of the disc between L4 and L5. This was removed and foIIowed by a fusion L4 to SI. The orthopedist provided the postoperative foIIow-up, and in a report dated January rg, 1948, indicated that the patient’s condition was stationary and the cIaim ready for termination. On February 20, 1948, the patient was examined by one of the regular examiners of the Oregon Accident Commission. The patient compIained of marked pain and tenderness at the upper end of the fusion mass. There was extensive muscIe spasm and abundant confirmatory evidence that complaints were we11 founded. Leg radiation had remained absent since the compIetion of surgery but back compIaints were so severe that the examiner reported the patient as being, in his opinion, totaIIy disabIed. The patient was referred again to the orthopedist. After assuring himseIf that the present fusion was sound and no further pathoIogica1 condition had deveIoped, he suggested that another vertebra be added to the fusion in the hope of controIIing the obvious pain and disability.
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Results
This additiona surgery was authorized; and although the outcome is not yet evident, I fear the chances are better than not that no worth whiie improvement wilI be obtained. I believe the great McBurney is reported to have said “God deliver me from a surgeon
of but one case.” AIthough this is admittedly an extreme case, I have, nevertheless, seen enough variance of this result to convince me that such an outcome or some degree thereof is not uncommon. While one, of course, cannot say with certainty, I believe the preponderance of evidence indicates that disc surgery alone might have been quite successful but the addition of a fusion was disastrous. We, therefore, are forced to conclude on the present showing of our records that the additional benefit to be expected from the combined operation is far out-weighed by the increased disability consequent upon it, to say nothing of the greatIy lengthened convalescence resulting from the fusion. While I do not believe that the combined operation shouId be done routineIy in al1 disc cases, I do believe that our results cIearIy demonstrate that in those who present indications for spina fusion there shouId be no hesitancy in carrying out the combined operation. That is to say, if the findings are of such a nature as to indicate fusion, the fact that a protruded disc exists and is removed at the same time in no way alters the need for spinal fusion. I would, therefore, sum up our impressions by saying that, in general, operations for remova1 of a protruded intervertebral disc have proven quite satisfactory. It is our opinion that the remova of an intervertebra disc herniation is not, in itself, an indication for spina fusion. We beIieve spina fusion should not be done unIess the indications for this operation are present and exist independent of the disc injury. I beIieve it is better to perform only a hemilaminectomy in those cases in which spina fusion is not clearly indicated and, if necessary, to perform spinal fusion later rather than subjecting the whole group to the combined operation with its inevitabIe 40 per cent increase in permanent disabiIity and its occasional disastrousIy poor outcome. DISCUSSION ALEXANDER P. AITKEN (Boston, Mass.): TWO years ago I presented before this Society a paper
November,
1948
in Surgery
on a similar subject, the end resuIts of ruptured intervertebra disc in industry. Since the publication of that paper I have not been too popuIar with certain individuaIs in certain sections of the country. To evaIuate any operation we must have a compIete end resuIt study. Dr. Smith’s opinions are based upon long experience and a complete follow-up of these cases. This past February, before the American Academy of Orthopedic Surgeons, a paper was presented on the end resuhs of ruptured intervertebral disc by an author who reported that he had operated on 160 patients aIthough his end results were based upon the actuaI anaIysis of ninety cases. These ninety cases were either re-examined or answered questionnaires sent to them. As a result, he came to the conclusion that 86 per cent of his cases had exceIIent results. Seventy patients who did not answer his questionnaire and did not return for examination were simply forgotten. It seems to me that some of these seventy patients were not entireIy satisfied with their end results and that may explain why they faiIed to return for examination or to answer the questionnaires. I think the opinions expressed by Dr. Smith are important in that his opinions are based upon true end resuIt studies. In Dr. Smith’s experience the end results of the ruptured intervertebral disc were exceIIent. This is unquestionabIy true. However, in Oregon he is abIe to contro1 a good deaI of the surgery that is performed; he is able to see that these patients are pIaced in the hands of conservative and competent men. However, no such situation exists throughout the country. In states where we have free choice we stiI1 see rather promiscuous disc and back surgery being done. The end resubs throughout the country of this type of surgery are stiIl very poor. I think in the treatment of Iow back injuries we have got to develop some common sense program before we can obtain universaIIy good results. It is my behef that the ruptured disc does not occur spontaneously. I do not beheve a norma disc wilI rupture; before any disc can rupture, I beIieve it must first degenerate. That degeneration takes place over a Iong period of time and is the end resuIt of instability in the Iow back. Therefore, I beheve that in the treatment of this Iesion not onIy is it essentia1 to remove the offending disc but it is aIso essentia1 to remedy the instability in the Iow back. It may seem that I am taking issue with Dr. Smith. Actualiy, I am doing no such thing. I agree with everything he has had to say. I believe before any patient is subjected to disc surgery he shouId be examined not only by a neurosurgeon but aIso by an orthopedist; and it shouId be determined before any operation is performed whether or not
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that patient has an unstable type of back and whether spine fusion is indicated. If a patient gives a Iong history of-back pain and the x-rays show definite asymmetry in the facets, as pointed out by Dr Smith, and if that individua1 then deveIops Ieg pain as a resuIt of rupture of a disc, I believe simpIe removal of the ruptured disc may relieve that patient’s Ieg pain but it has done nothing for the disabiIity caused by his unstabIe back. I beIieve that type of back shouId be fused. I, therefore, am in favor of the combined operation. I believe if a patient has no abnormaIities in his low back, if he is a young individual and does not have a Iong history of back pain, his symptoms could then be entireIy due to a ruptured disc and I wouId agree that simpIe remova of the disc would effect a cure. However, if the patient has instabiIity in the Iow back and has a Iong history of back pain, I believe the combined operation should be performed. The end resuIts of spine fusions as seen in industrial cases are unquestionabIy poor. This is due IargeIy to poor technic. However, in our experience, if patients are carefuIIy studied and the cause of instability determined, and if a carefu1 fusion is performed followed by an adequate period of bed rest and immobiIization, good resuIts can be obtained. Such patients can then return to occupations of a reIativeIy heavy nature. The poor resuIts of fusion are usuaIIy due to poor seIection of patients, poor technic and after-care. JOHN E. RAAF (PortIand, Ore.): I agree with Dr. Smith that in a majority of instances a patient who is suspected of having a protruded intervertebra disc shouId have a pantopaque myeIogram. I am sorry I did not know Dr. Smith was pIanning to talk on this particuIar subject, otherwise some our
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76 discs.
the panto80 per cent
if we suppleinformation we are
in a
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better position to arrive at an accurate diagnosis than when we reIy on our cIinica1 opinion alone. The probIem of whether to limit the operation to remova of the protruded intervertebra disc or to remove the protruded intervertebra disc and then do a spinal fusion is a difhcub question to answer. SpinaI fusion was done in approximateIy 37 per cent of our 224 patients. Perhaps that figure is too high. Dr. Smith mentioned that by fusing the disability in disc patients is increased 40 per cent. I know from our studies that the time Ioss was increased. I also know that the various agencies, such as the State IndustriaI Accident Commission who are paying the workman’s compensation are out more money when a fusion is done. I beheve word has been passed around among workmen that if a fusion is done the patient automaticaIIy deserves a bigger disabihty award than if a protruded intervertebra disc is removed and no fusion done. The fact that a fusion has been done indicates to the workman that the back is in very bad condition as a resuIt of the injury. In the study of our cases we found we had obtained 60 per cent exceIIent resuIts, approximateIy 30 per cent good results and IO per cent poor resubs. By excellent results I mean those patients were abIe to go back to their originai occupations or occupations equaIIy as arduous. Good resuIts means that those patients were abIe to work but were Iimited in the amount of work they couId do. In other words they couId not carry on the heavy type of work they did originaIIy. WILMER C. SMITH (cIosing): I am aware of the fact that when disc surgery was first begun the disc alone was done without fusion, and it is true that over the years the baIance of opinion has swung IargeIy toward the combined operation. However, I wonder if this is not the result of many of those cases with architectural defects or long periods of back troubIe, coming from IittIe or no trauma, which gave a poor resuIt upon disc surgery aIone and later had to be fused. It seems to me that the penduIum has now swung too far the other way and that uItimateIy it wiI1 come to rest at a point where about onethird of the disc cases wiI1 have the combined operation done and the other two-thirds wilI be subjected to hemiIaminectomy onIy.
American
Journal of Surgery
C.
SMITH,
M.D.
Salem, Oregon
0
BSERVATIONS and accumuIated experience arising from association with disabiIity evaIuation should contain something of vaIue to the individua1 actively engaged in the practice of surgery, especiaIIy that surgery which concerns itseIf with the treatment of trauma. These observations are based upon a period of more than ten years of famiIiarity with disabiIity awards as given by the Oregon State IndustriaI Accident Commission. It is entireIy proper that one shouId ask at the outset what vaIidity concIusions so arrived at may carry and, therefore, what attention they actuaIIy warrant. There are three genera1 considerations which shouId be presented in answering this. In the Hurst place the number of cases handIed by this organization is quite Iarge, approaching some so,ooo claims per year and, hence, the number of exampIes of any particular condition or of any specia1 type of treatment is greater than that seen by aImost any singIe physician. Secondly when treatment has been concIuded and the condition has reached a stationary state, these patients are seen by medical examiners who are especiaIIy familiar with the recognition and evaluation of disability; this is estimated on a numerical basis. I believe that there are two advantages in such a method. In the first place the individua1 who estimates the end result is not the physician who treated the patient. This eliminates the pardonabIe pride in his end results which might inAuence the evaluation of the treating physician to some extent. In the second place, aIthough it is open to error, a numerical evaIuation in terms of percentage Ioss of function is in genera1 more dehniteIy expressive than is a rating based upon good, fair or poor, this Iatter method or some variation is often used by physicians in reporting their end results. LastIy, I think it is a fact that a more thorough foIIow-up system obtains in these cases. It is often true that the origina treating physician Ioses sight of patients who believe after a certain period of treatment or numNovember,
I 948
ber of calIs that little more is to be gained by further consuItation. However, in our cases the patients hope that further treatment will resuIt in more compIete physica restoration or that as a resuIt of aggravation disability evaluation will be revised; this tends to bring them back years after the Iast caI1 to the origina treating physician. As a matter of fact as Iong as there is any dissatisfaction with the resuIts of treatment or whenever aggravation appears, these patients invariabIy “come home to roost”; and atthough those of us connected with this type of work often wish it otherwise, the fact remains that our foIIow-up is most complete. It may, therefore, be said that observations made in this IieId recommend themseIves to the consideration of the practicing surgeon by virtue of muItipIicity of exampIe, impartia1, dehnitive evaIuation and thoroughness of foIIow-up. I am, of course, aware of certain arguments which are often advanced tending to impeach the vaIue of conclusions based upon compensation experience. The most common is that the patient fully reaIizes he is “before the cashier’s window,” and that every possible compIaint or objection to his end resuIt wiII be elaborated upon for the obvious reason that he believes his financia1 return wiI1 be based IargeIy thereon. WhiIe this criticism is true in many instances, it is also a fact that a great number of these patients do not engage in more than the usua1 amount of compIaining common to humanity in general. It should aIso be noted in this connection that examiners familiar with problems of disability evaIuation are more than usuaIIy astute in discounting compIaints without reasonable basis. StiII another fact which obtains in patients covered by an Industrial Accident Commission which is not generaIIy appreciated is the fact that these individuals as a rule are engaged in active physica Iabor and, therefore, surgica1 procedures performed upon them are generaIIy subject to greater strain than the same surgical procedure wouId be in the patient whose occupation is IargeIy sedentary. For example, in the case of a spina 6x9
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fusion the average private patient who is wiIling to suffer the consequent time Ioss and is able to finance the surgery and the subsequent inactivity is in general not an individua1 who, by reason of his occupation, is forced to put great stress upon the lower back. More often, indeed, he is a desk worker and for this reason his spinal fusion will never be subjected to the crucial tests that come with the daily Iifting and carrying of heavy weights so common among industrial workers. I, therefore, submit that procedures in the surgery of trauma are given a more severe trial in the case of the industrial worker who comes under an Accident Commission than in the instance of the average private patient and it is not unfair to state that, perhaps to some degree at least, the objection connected with “the cashier’s window” is met or even compIeteIy balanced by the fact that the industria1 worker subjects his surgery to a more rigorous test than does the private patient. SPINAL
FUSION
It has been our observation that in certain seIected cases spina fusion is indicated and in these cases its resuIts are generaIIy very good. At the same time it has been evident that in a Iarger group of patients in whom spina fusion was resorted to soIeIy because a11 other forms of therapy were unavaiIing, the resuIts were appaIIingIy bad. In our experience the greatest benefit from spina fusion, is found in those patients below the age of forty and preferabIy Iess than thirty who have a past history of frequent back injuries resuIting from minor trauma and who upon examination reveal we11 Iocalized pain and tenderness and especiaIIy whose x-ray examination reveaIs architectura1 defects Iimited to the area of compIaint. Even in these cases fusion shouId not be resorted to until an adequate period of conservative treatment has been tried or unIess the periods of disabiIity from minor back injuries have become suffrcientIy frequent to warrant more radica1 treatment even though the present attack might respond to conservative therapy. Our resuIts have not been so encouraging in patients above the age of forty, even though the patient may otherwise qualify; in like manner the patient whose pain and tenderness is diffuse and not Iocalized sharply does not appear to be nearIy so good a candidate for fusion as does the individua1 who presents a reIativeIy sharp
in Surgery
localization of complaints. As to the architectural defects which Iend weight to the indications for fusion, the most common are those of congenita1 or deveIopmenta1 origin. These usuaIIy consist of gross asymmetry of Iumbosacra1 articulating processes. This asymmetry may be either in size of the respective processes or in the pIane of their articuIations. The architectural defect prompting fusion should be of such nature that it can be obliterated by a fusion which includes the fewest possibIe vertebrae. We have noted aImost uniformly that the greater the number of vertebrae fused the higher is the disability, and the more frequent are compIications such as pain or pseudo-arthrosis. It is reaIIy doubtfu1 whether the resuIts ever warrant a fusion invoIving more than three vertebrae. Our experience with fusions done in the hope of aIIeviating symptoms resuIting from an uncorrected compression fracture deformity of a vertebral-body have been most unsatisfactory and it is my observation that the operation is not justified in these cases. The presence of any significant degree of arthritis, either osteo-arthritis or rheumatoid arthritis, has been one of the important contra-indications to fusions, even though the case may otherwise meet the requirements satisfactoriIy. If arthritis exists to any important degree, I am extremely doubtfu1 that fusion wiI1 prove worth-whiIe. We have found in these cases that disability after fusion is actually greater than that which existed before. It wouId seem reasonable to expIain this by the generaIIy accepted fact that arthritis invoIves numerous articuIations and is seldom limited to only one set. Moreover, it is commonly observed that an arthritic joint toIerates any forceabIe increase in its range of motion very poorIy; such a joint which is otherwise reIativeIy symptomIess may be quickly flared into acut? activity by increased stress and strain. Thus it may we11 be that when certain articuIations are deprived of motion by spina fusion, the contiguous articulations are subjected to a. greater range of motion and, consequently, a strain to which they are unaccustomed. Like any other arthritic joint subjected to the same stimuIus, they respond by acute inflammatory reactions. The frequency with which the pain and tenderness ascends to the region of the upper end of the fusion mass in these arthritic patients seems to Iend considerable support to
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this assumption. I have seen cases in which, to combat the pain in its new location, another vertebra was subsequently included in the fusion with the result that the compIaints promptly rose one segment higher. One wonders in these cases just how far up the spinal column the source of discomfort could be pursued if both patient and surgeon were willing to continue fusions indefinitelv. Along with the arthritic patient another type of case in which our experience shows fusion to be of no value is the patient in whom there is no indication for fusion except failure of other forms of therapy. The classic example is the individual who may or may not be within the age group mentioned who usually has no history of former back injuries or if former injuries were suffered, these have been widely separated in time and have been the result of adequate trauma. Examination reveaIs a very poor localization of pain which may involve most of the lumbar area or may be entirely over the sacrum or sacroiliac articulations. Tenderness, aIso is apparently diffused rather than localized, or if localized, fails to correspond with spinal articulations, often being over the dorsum of the sacrum or in the sacrospinalis muscIe mass Iateral to the lumbar articulations. X-ray examination fails to reveaI any structural abnormahties or, at most, a narrowing of the intervertebral space between the fifth lumbar and first sacral vertebrae. Here one is confronted with a patient who presents none of the indications for fusion and is recommended only by the fact that all other forms of therapy have failed. The resuIts of fusion in this type of case have been uniformly without beneht or even disastrous. When examined for cIosure about tweIve months postoperatively, the patient wilI state that surgery resulted in no improvement and that if he had it to do over again knowing what he now knows, he would not submit to the operation. There is a sizeable group of these patients who will assert that they have been made decidedly worse as a result of the operation. Careful examination will disclose that a certain percentage are grossly exaggerating; however, in some instances examination will convince the impartial examiner that a considerable number are actually justified in this complaint. These patients wiII show greater limitation of motion, increased muscIe spasm and other evidence of acute discomfort. One is convinced that they
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are actuahy
considerably worse off than they were before spinal fusion, some of them being permanentIy and totally disabled whiIe their disability may have been only half this extent before surgery. I am totaIly unable to explain what has happened in these patients. The most painstaking x-ray examination may fail to reveal any evidence of pseudoarthrosis or other defects of fusion. I am, however, convinced of the reality of these occasional unfortunate results. In any large number of patients in which fusion has been done without real indications other than persistent back pain, our follow-up demonstrates most convincingly that the majority w-i11be unimproved while a very definite and important minority wiII have been made decidedly worse off as a result of the surgery. DISC
SURGERY
Our experience with partia1 hemilaminectomy for protruded intervertebral disc has on the whoIe been very satisfactory. In cases in which an actua1 protrusion of the disc was demonstrable and in which the symptoms and findings corresponded to what might be expected from root irritation at this point, removal of the offending protrusion has resulted uniformly in a reIativeIy short period of convalescence and in comparatively low permanent disability. In view of the fact that the symptoms and signs which underhe the diagnosis of herniated discs are IargeIy of a neurologic nature, we have made it a policy to restrict this operation to the neurosurgic field. An orthopedist does the fusion in instances in which this additional procedure is carried out. I believe that it is desirable to carry out contrast myelography for the purpose of demonstrating the protruded disc before surgery is decided upon. I am aware that it is not always possible thus to demonstrate the protrusion; however, these instances are relativeIy infrequent and the added assurance gained in those cases in which protruding discs are demonstrated is well worth the time and trouble required by the procedure. For some time the contrast medium used was lipiodol. This was removed with great difficulty and in time often proved very definitely irritating. Since the advent of pantopaque we have had no indications of any irritative phenomena and it has been uniformIy possible to remove almost all the contrast medium at the completion of the
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study. We do not beIieve that expIoration without previous demonstration of the presence of a disc is indicated unless the symptoms and findings are extremely typicaL THE
COMBINED
OPERATION
For the past few years I have been deepIy interested in the combined operation consisting of hemiIaminectomy with remova of the disc herniation and at the same time spina fusion carried out by an orthopedist. I realize that there are many who routineIy advise that fusion be done in a11 cases in which disc surgery has been performed. My own observations do not substantiate this view. A study of our records reveaIs that in cases in which the combined operation has been carried out permanent disability averages 40 per cent greater than in cases in which hemiIaminectomy alone has been done. The same study reveals that instances of recurrence of disc herniation have been infinitesima1. The reasons usually given for the combined operation are first, the possibiIityof recurrence; secondIy, the fact that an injury to a disc may be expected to change the intervertebra space and thus change the reIationships of the articuIar facets resulting in some pain from this source. Recurrences in our experience have been so rare as to warrant no consideration and whatever may be the virtue of the theoretic point concerning aItered reIationship of the articular processes, the fact still remains that permanent disabihty resuIting from hemiIaminectomy alone is increased by 40 per cent in those cases in which fusion is done. Those cases of oId compression fracture of a vertebra1 body which, as aIready stated, are not benefited by spinal fusion comprise another potent objection to the theory of altered reIations between articular processes resulting from disc injury constituting an indication for fusion. In these cases the compression of the vertebra1 body by aIIowing the body above to approach the body below the fracture aIters the reIationship between the inferior articuIating processes of the vertebra above with the superior articuIating processes of the fractured vertebra far more than does any nucleus pulposis herniation. There is no reason to beheve that the usual results of spina fusion wiI1 be in any way aItered by the fact that a protruded disc
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has been removed. In other words in a11 cases other than those which present indications for fusion as heretofore described there will be two groups; first, the Iarge group of patients who have gotten no benefit from operation; and secondly, the smaIIer group who are definitely made worse by spina fusion. Thus it can and. does happen that an otherwise successful operation upon a disc can be compIeteIy changed into a dismal faiIure by the addition of an unsuccessfu1 spina fusion. CASE
REPORT
On JuIy IO, 1946, J. G., a male, thirty-four years of age, suffered a severe Iifting injury of his Iower back. Pain forced him to stop work at once and consult his famiIy physician who for a period of some two months carried out conservative treatment. As a result of marked right leg radiation and when no improvement was seen on conservative regimen, a herniated disc was suspected. AccordingIy, the patient was referred to a neurosurgeon whose findings were suffrcientfy definite to convince him that right-sided disc protrusion actuaIIy existed. Since this man had to do heavy work, the neurosurgeon thought that fusion should be carried out at the time of the disc surgery and referred the patient to an orthopedist who upon x-ray examination discerned some narrowing posteriorly of the intervertebral disc between the fifth Iumbar and first sacra1 vertebrae. It was his opinion that an unstabIe Iumbosacral junction was present and he agreed that fusion shouId be done in addition to disc surgery. The combined operation was carried out on November 5, 1946. A herniated nucIeus puIposis was discIosed on the right side of the disc between L4 and L5. This was removed and foIIowed by a fusion L4 to SI. The orthopedist provided the postoperative foIIow-up, and in a report dated January rg, 1948, indicated that the patient’s condition was stationary and the cIaim ready for termination. On February 20, 1948, the patient was examined by one of the regular examiners of the Oregon Accident Commission. The patient compIained of marked pain and tenderness at the upper end of the fusion mass. There was extensive muscIe spasm and abundant confirmatory evidence that complaints were we11 founded. Leg radiation had remained absent since the compIetion of surgery but back compIaints were so severe that the examiner reported the patient as being, in his opinion, totaIIy disabIed. The patient was referred again to the orthopedist. After assuring himseIf that the present fusion was sound and no further pathoIogica1 condition had deveIoped, he suggested that another vertebra be added to the fusion in the hope of controIIing the obvious pain and disability.
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Results
This additiona surgery was authorized; and although the outcome is not yet evident, I fear the chances are better than not that no worth whiie improvement wilI be obtained. I believe the great McBurney is reported to have said “God deliver me from a surgeon
of but one case.” AIthough this is admittedly an extreme case, I have, nevertheless, seen enough variance of this result to convince me that such an outcome or some degree thereof is not uncommon. While one, of course, cannot say with certainty, I believe the preponderance of evidence indicates that disc surgery alone might have been quite successful but the addition of a fusion was disastrous. We, therefore, are forced to conclude on the present showing of our records that the additional benefit to be expected from the combined operation is far out-weighed by the increased disability consequent upon it, to say nothing of the greatIy lengthened convalescence resulting from the fusion. While I do not believe that the combined operation shouId be done routineIy in al1 disc cases, I do believe that our results cIearIy demonstrate that in those who present indications for spina fusion there shouId be no hesitancy in carrying out the combined operation. That is to say, if the findings are of such a nature as to indicate fusion, the fact that a protruded disc exists and is removed at the same time in no way alters the need for spinal fusion. I would, therefore, sum up our impressions by saying that, in general, operations for remova1 of a protruded intervertebral disc have proven quite satisfactory. It is our opinion that the remova of an intervertebra disc herniation is not, in itself, an indication for spina fusion. We beIieve spina fusion should not be done unIess the indications for this operation are present and exist independent of the disc injury. I beIieve it is better to perform only a hemilaminectomy in those cases in which spina fusion is not clearly indicated and, if necessary, to perform spinal fusion later rather than subjecting the whole group to the combined operation with its inevitabIe 40 per cent increase in permanent disabiIity and its occasional disastrousIy poor outcome. DISCUSSION ALEXANDER P. AITKEN (Boston, Mass.): TWO years ago I presented before this Society a paper
November,
1948
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on a similar subject, the end resuIts of ruptured intervertebra disc in industry. Since the publication of that paper I have not been too popuIar with certain individuaIs in certain sections of the country. To evaIuate any operation we must have a compIete end resuIt study. Dr. Smith’s opinions are based upon long experience and a complete follow-up of these cases. This past February, before the American Academy of Orthopedic Surgeons, a paper was presented on the end resuhs of ruptured intervertebral disc by an author who reported that he had operated on 160 patients aIthough his end results were based upon the actuaI anaIysis of ninety cases. These ninety cases were either re-examined or answered questionnaires sent to them. As a result, he came to the conclusion that 86 per cent of his cases had exceIIent results. Seventy patients who did not answer his questionnaire and did not return for examination were simply forgotten. It seems to me that some of these seventy patients were not entireIy satisfied with their end results and that may explain why they faiIed to return for examination or to answer the questionnaires. I think the opinions expressed by Dr. Smith are important in that his opinions are based upon true end resuIt studies. In Dr. Smith’s experience the end results of the ruptured intervertebral disc were exceIIent. This is unquestionabIy true. However, in Oregon he is abIe to contro1 a good deaI of the surgery that is performed; he is able to see that these patients are pIaced in the hands of conservative and competent men. However, no such situation exists throughout the country. In states where we have free choice we stiI1 see rather promiscuous disc and back surgery being done. The end resubs throughout the country of this type of surgery are stiIl very poor. I think in the treatment of Iow back injuries we have got to develop some common sense program before we can obtain universaIIy good results. It is my behef that the ruptured disc does not occur spontaneously. I do not beheve a norma disc wilI rupture; before any disc can rupture, I beIieve it must first degenerate. That degeneration takes place over a Iong period of time and is the end resuIt of instability in the Iow back. Therefore, I beheve that in the treatment of this Iesion not onIy is it essentia1 to remove the offending disc but it is aIso essentia1 to remedy the instability in the Iow back. It may seem that I am taking issue with Dr. Smith. Actualiy, I am doing no such thing. I agree with everything he has had to say. I believe before any patient is subjected to disc surgery he shouId be examined not only by a neurosurgeon but aIso by an orthopedist; and it shouId be determined before any operation is performed whether or not
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that patient has an unstable type of back and whether spine fusion is indicated. If a patient gives a Iong history of-back pain and the x-rays show definite asymmetry in the facets, as pointed out by Dr Smith, and if that individua1 then deveIops Ieg pain as a resuIt of rupture of a disc, I believe simpIe removal of the ruptured disc may relieve that patient’s Ieg pain but it has done nothing for the disabiIity caused by his unstabIe back. I beIieve that type of back shouId be fused. I, therefore, am in favor of the combined operation. I believe if a patient has no abnormaIities in his low back, if he is a young individual and does not have a Iong history of back pain, his symptoms could then be entireIy due to a ruptured disc and I wouId agree that simpIe remova of the disc would effect a cure. However, if the patient has instabiIity in the Iow back and has a Iong history of back pain, I believe the combined operation should be performed. The end resuIts of spine fusions as seen in industrial cases are unquestionabIy poor. This is due IargeIy to poor technic. However, in our experience, if patients are carefuIIy studied and the cause of instability determined, and if a carefu1 fusion is performed followed by an adequate period of bed rest and immobiIization, good resuIts can be obtained. Such patients can then return to occupations of a reIativeIy heavy nature. The poor resuIts of fusion are usuaIIy due to poor seIection of patients, poor technic and after-care. JOHN E. RAAF (PortIand, Ore.): I agree with Dr. Smith that in a majority of instances a patient who is suspected of having a protruded intervertebra disc shouId have a pantopaque myeIogram. I am sorry I did not know Dr. Smith was pIanning to talk on this particuIar subject, otherwise some our
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accurate. ment gained
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and,
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our
approximately intervertebra
made were
on
we reviewed
before about that with
study,
76 discs.
the panto80 per cent
if we suppleinformation we are
in a
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better position to arrive at an accurate diagnosis than when we reIy on our cIinica1 opinion alone. The probIem of whether to limit the operation to remova of the protruded intervertebra disc or to remove the protruded intervertebra disc and then do a spinal fusion is a difhcub question to answer. SpinaI fusion was done in approximateIy 37 per cent of our 224 patients. Perhaps that figure is too high. Dr. Smith mentioned that by fusing the disability in disc patients is increased 40 per cent. I know from our studies that the time Ioss was increased. I also know that the various agencies, such as the State IndustriaI Accident Commission who are paying the workman’s compensation are out more money when a fusion is done. I beheve word has been passed around among workmen that if a fusion is done the patient automaticaIIy deserves a bigger disabihty award than if a protruded intervertebra disc is removed and no fusion done. The fact that a fusion has been done indicates to the workman that the back is in very bad condition as a resuIt of the injury. In the study of our cases we found we had obtained 60 per cent exceIIent resuIts, approximateIy 30 per cent good results and IO per cent poor resubs. By excellent results I mean those patients were abIe to go back to their originai occupations or occupations equaIIy as arduous. Good resuIts means that those patients were abIe to work but were Iimited in the amount of work they couId do. In other words they couId not carry on the heavy type of work they did originaIIy. WILMER C. SMITH (cIosing): I am aware of the fact that when disc surgery was first begun the disc alone was done without fusion, and it is true that over the years the baIance of opinion has swung IargeIy toward the combined operation. However, I wonder if this is not the result of many of those cases with architectural defects or long periods of back troubIe, coming from IittIe or no trauma, which gave a poor resuIt upon disc surgery aIone and later had to be fused. It seems to me that the penduIum has now swung too far the other way and that uItimateIy it wiI1 come to rest at a point where about onethird of the disc cases wiI1 have the combined operation done and the other two-thirds wilI be subjected to hemiIaminectomy onIy.
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Journal of Surgery