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THE SACRO-ILIAC PROBLEM.
66 examination, single-leg-lifting is difficult. but can be carriec, . out. Attempted double-leg-lifting produces no movement whatever of either leg-" no pain, just can’t do it." Grippitig BY C. B. HEALD, C.B.E., M.D. CAMB., the iliac crests, so as to close them up, immediately makes it M.R.C.P. LOND., possible to commence this movement. Pressing the iliac crests apart produces the same pain as coughing. PHYSICIAN TO THE ELECTRO-THERAPEUTIC DEPARTMENT, ROYAL rest in bed, anodal galvanism. T?’e6f
THE SACRO-ILIAC PROBLEM.
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"
"
just recovering there was very little difference between the sound (right) rather prolonged and debilitating attack of bronchitis. side and the painful side. One morning, when sitting at stool, I was seized with a . Treatment.--8trapping, accompanied by Bristow coil more than usually severe bout of coughing and suddenly treatment to all the muscles in the region of the left sacro’felt something give ’ in the region of the left sacro-iliac iliac joint, rapidly made the patient well, and by learning joint. There was no pain. Nor was there any pain to how to use the apparatus on herself she has been able to keep speak of on first standing, only a vague discomfort. Very well. shortly after I bent to pick up a small bag, weighing a I >The next case illustrates another aspect of this few pounds, and my return to the standing position was I accompanied by an almost intolerable hot and stabbing li interesting group. CASE 4.-A woman, aged 38, on trying to stand on her pain which radiated down from the original spot to the back of the knee and left the whole of the back of the left hands in January, 1924, " ricked her back " and ricked it thigh with a woolly, heavy feeling. Walking was not again the same evening while dancing ; this was followed painful, only uncomfortable, and a limp did not develop immediately by pain in the back, made worse by any until later. Work and duty could be carried out, though forward-bending movement. Coughing was painful except with a sense of insecurity. After some two weeks of this in the full knee-bend position, and pain could be diminished condition the stabbing attacks disappeared, leaving a by holding something in front of her (in effect fixing the continuouslumbago’ backache with the whole of the ribs, see later). On April 2nd, 1925, she caught a ’4 chill"left leg feeling heavy and somewhat unmanageable. At in church and then the pain returned, only worse, and went this stage the ilium, where it abuts on the sacro-iliac joint, down the legs in a spasm. A celluloid corset, partially felt morelumpy ’ than on the unaffected side. I was told, immobilising the sacro-iliac joints, was a great help. CASE 5.-A man, aged 22, strained his back wheeling a though personally I was unaware of it, that my trunk was The barrow in June, 1927. no longer erect, but bent forward and to the left. There was no slip or sudden nearest approach to a comfortable position was standing emergency and he went on working after the pain began. with the left leg behind and the shoulders thrown back. He got well, but when skipping in September, 1927, theDiathermy, ionisation, ultra-violet light, and radiant heat pain returned down the right leg and was also felt on sitting or coughing. On Dec. 20th, when first seen by me, this pain gave only temporary benefit." When examining this patient I noticed for the first was still present and prevented all games. The X rays were The double-leg-lifting sign was present and time a curious sign-namely, that while he could normal. of the thighs relieved the pain. In the hypertension lie on his back and lift each leg with the knee straight forward-lying the iliac side of the sacro-iliac joint position without difficulty or pain, he appeared to have on the affected side appeared to project more prominently absolutely no power to lift both legs together. It than on the healthy side. As this asymmetry largely was not a question of impending pain; he simply disappeared after treatment, it is worth noticing, particularly been noted in other cases. Treatment was carried might have been paralysed for this particular as it has movement. Passivemovements without an ansesthetic, out, as described below for the more severe and longradiant heat, and strapping effected a reasonably standing cases, and recovery has proceeded satisfactorily. CASE 6.-A woman. The original injury was caused rapid recovery. by turning to the left and leaning over to lift a coal scuttle ;;Since then I have come to recognise that the the right foot slipped on some grease and a feeling of somedouble-leg-lifting test is important in distinguishing thing that " went " in her back was followed some days all others. later by a disabling pain in the back and down the left one group of "backache" cases from It has been possible to collect a considerable number thigh. In this case, rest in bed. strapping, and jackets On examination of these cases, both in hospital and private practice, only effected temporary improvement. and they all conform so closely to the first that it in the forward-lying position the sacro-iliac joint on the side was so loose that Mr. J. Cunning considered will be sufficient to give brief notes of two or three. injured it justifiable, after all other methods had failed to fix a screw CASE 1.—A man, aged 26, was in a motor collision on through the joint. This he carried out successfully on May 4th, 1927, but was not turned over or thrown out ; Jan. 17th, 1923, and the patient was able to resume her he thinks he swung suddenly to save himself from impact. duties as cook-general and has carried on successfully ever He complains of pain deep in the left flank. Coughing hurts since. An X ray of the sacrum taken on Feb. 14th. 1rJ28, and shoots pain down the distribution of the left sciatic by Dr. Bertram Shires showed the screw in its original X rays show no bony injury or abnormality. On position. nerve.
67
Any anatomical theory to fit the common factors in these cases must take into consideration :(a) The comparatively minor nature of the original trauma. (b) The pain on coughing. (e) The pain in the back that tends to radiate either down the sciatic nerve, over the buttock, or towards the
groin. (d) The eccentricities of posture and movement that produce pain, including visceral discomfort. (e) The relief brought by manipulation, strapping, &c. (f) The mechanics that bring about the inability of the patient to lift both legs when lying flat. I sought the assistance of Prof. Lucas-Keene in the Anatomical Department of the School of Medicine for Women, and am indebted to her for the following
hypothesis :"
That the original injury is a comparatively minor tear of the inner portion of the quadratus lumborum muscle and of its anterior fascial covering commencing from the point where it becomes continuous with the ilio-lumbar ligament as this stretches, from the tip of the transverse process of the last lumbar vertebra, almost horizontally outwards to the inner lip of the iliac crest."
and then with the affected one. In the ordinary lying position these are usually found to be equal and full on both sides, but in the forward-lying position hyperextension of the thigh, with the sacrum fied.’. is generally less full, and it is this movement above all others that requires carrying out until it is full and free. The patient is then returned to bed and treated for two or three days as before, flat on back with a pillow under the upper part of the buttock to maintain slight hyperextension of the thighs, and with daily applications of direct current, (anode). Massage and passive movements are then commenced, and at the end of a week strapping is reapplied and the patient is allowed up, provided that the ability to begin double-leg-lifting has returned. The patient should now be warned that many weeks’ care will be necessary, and a list of the movements or strains to be avoided can be given him. In the less severe cases strapping without rest in bed sometimes effects all that is necessary, or a surprise hyperextension of the thigh in forward-lying position, without an anaesthetic, followed immediately by reapplication of strapping, is sufficient to initiate a satisfactory process of repair.
It is only necessary to glance at a dissection at that part of the quadratus lumborum which lies near the transverse process of the fifth lumbar vertebra to realise that a surprise contraction in an Summary. asymmetrical position might cause a tear more easily The group of cases described may, on account of the and with less force than in the well-recognised rupture exact similarity of signs and symptoms, be considered of the plantaris muscle. Pain on coughing would, as caused by one uniform anatomical injury. being with such an injury, be a certainty, as this muscle I A hypothesis of the possible nature of this anatomical must go into firm " holding " contraction to fix the is put forward which differentiates it from the injury lower ribs so that the diaphragm may carry out the ordinary cases of sacro-iliac -strain or rupture of the movements of coughing, and any pull on the external ilio-lumbar so clearly described by Mr. W. A. ligament arcuate ligament would be directly conveyed to the Cochrane,1 and a line of treatment is suggested which quadratus lumborum. Both the fourth and fifth is uniformly successful when the signs and symptoms lumbar roots of the lumbo-sacral plexus are in are limited to those described. immediate anterior relationship to the quadratus lumborum, and any effusion, such as would accompany a tear, would be bound, particularly in changing postures, to give rise to curious " freak " symptoms and pain radiating down the sciatic nerve distribution. Whether extension centrally of a tear of the fascial covering of the quadratus lumborum where this becomes continuous with the lumbar fascia could MALIGNANT PAPILLOMA OF THE LEFT satisfactorily account for the frequent association of KIDNEY IN A BOY. a variety of visceral symptoms in the chronic cases must be left for future investigation. It is sufficient BY O. W. ROBERTS, M.D. LOND., F.R.C.S. ENG., to note that there is anatomical proximity between ASSISTANT MEDICAL SUPERINTENDENT, ST. GILES HOSPITAL, CAMBERWELL. the inner border of quadratus lumborum and the sympathetic fibres passing to join the lumbo-sacral nerve roots. Finally, if we turn to Sherrington’s MALIGNANT papilloma of the kidney in a boy of 11 works on postural tonus we can see why the un- is uncommon, and the following case has some injured ilio-psoas muscles can individually work interesting features. and flex each thigh singly, but cannot do so when An puffy-faced boy had been suffering from an the more coordinated mechanism of double-leg- attackanaemic, of (?) which started with headache and nephritis," lifting is required. This necessitates balanced postural heematuria in May, 1927. He gave a history of a similar tonus in both quadratus lumborum muscles as a previous attack in May, 1926, and of measles and whoopingpreliminary to movement. I consider that this cough in infancy. His urine in May, 1927, was deeply but there was no history of the passage of hypothesis covers the majority of the symptoms so blood-stained, and his general well, and corresponds with the effective lines of blood-clots nor of any vesical symptoms, nephritis. After some days it was treatment so closely, that it may be accepted as a appearance suggested noted that the haematuria was inconstant and that the simple working description of a controversial condition. patient complained of vague hypogastric discomfort. This led to a thorough clinical investigation, and the urine on Treatment. examination was found to be free of casts, This naturally depends largely upon the duration microscopical to contain red blood cells, pus cells and Bacillus coli. and severity of the symptoms, but not a little upon Radiographic examination showed no obvious lesion of the the size, age, weight, and fatty covering of the patient. urinary tract, and the only clinical finding was a palpable In heavily built patients with severe pain and left kidney which, however, was painless. His condition temporarily improved, but in October. inability to begin double-leg-lifting, rest complete in bed completely flat, with a pillow under the 1927, the ansemia was more marked and the haematuria ; the urine contained red cells in large numbers buttocks, is the first essential. If, after a period pronounced of rest accompanied by daily applications of direct and pus cells, but no casts or organisms. Examination for He still, complained the tubercle bacillus was also current, the pain is not lessened on voluntary of headaches and occasional negative. vague hypogastric discomfort, movement, strapping should be put on, covering a but other signs or symptoms were absent. On cystoscopic wide area from below the level of both sacro-iliac the bladder mucosa was found to be congested joints to two or three inches above them, and extending and the left ureteric orifice suggested a lesion of the left outwards as far as the anterior superior spines. kidney ; but owing to the small size of the urethra a catheIf this strapping also fails to improve matters, some terising instrument could not be passed for examination form of manipulation is necessary. For this I remove of ureters or pyelography. Abdominal palpation under the a definitely enlarged left kidney, but the adhesive plaster and the patient is anaesthetised anaesthetic revealed on a mattress on the floor. mobilisation General 1 A Consideration of Backache from the Orthopædic Standmovements are carried out, first with the sound limb point, Edin. Med. Jour., April, 1927.
Clinical and
"
but
I examination
Laboratory Notes.
THE SACRO-ILIAC PROBLEM.
"
"
"
just recovering there was very little difference between the sound (right) rather prolonged and debilitating attack of bronchitis. side and the painful side. One morning, when sitting at stool, I was seized with a . Treatment.--8trapping, accompanied by Bristow coil more than usually severe bout of coughing and suddenly treatment to all the muscles in the region of the left sacro’felt something give ’ in the region of the left sacro-iliac iliac joint, rapidly made the patient well, and by learning joint. There was no pain. Nor was there any pain to how to use the apparatus on herself she has been able to keep speak of on first standing, only a vague discomfort. Very well. shortly after I bent to pick up a small bag, weighing a I >The next case illustrates another aspect of this few pounds, and my return to the standing position was I accompanied by an almost intolerable hot and stabbing li interesting group. CASE 4.-A woman, aged 38, on trying to stand on her pain which radiated down from the original spot to the back of the knee and left the whole of the back of the left hands in January, 1924, " ricked her back " and ricked it thigh with a woolly, heavy feeling. Walking was not again the same evening while dancing ; this was followed painful, only uncomfortable, and a limp did not develop immediately by pain in the back, made worse by any until later. Work and duty could be carried out, though forward-bending movement. Coughing was painful except with a sense of insecurity. After some two weeks of this in the full knee-bend position, and pain could be diminished condition the stabbing attacks disappeared, leaving a by holding something in front of her (in effect fixing the continuouslumbago’ backache with the whole of the ribs, see later). On April 2nd, 1925, she caught a ’4 chill"left leg feeling heavy and somewhat unmanageable. At in church and then the pain returned, only worse, and went this stage the ilium, where it abuts on the sacro-iliac joint, down the legs in a spasm. A celluloid corset, partially felt morelumpy ’ than on the unaffected side. I was told, immobilising the sacro-iliac joints, was a great help. CASE 5.-A man, aged 22, strained his back wheeling a though personally I was unaware of it, that my trunk was The barrow in June, 1927. no longer erect, but bent forward and to the left. There was no slip or sudden nearest approach to a comfortable position was standing emergency and he went on working after the pain began. with the left leg behind and the shoulders thrown back. He got well, but when skipping in September, 1927, theDiathermy, ionisation, ultra-violet light, and radiant heat pain returned down the right leg and was also felt on sitting or coughing. On Dec. 20th, when first seen by me, this pain gave only temporary benefit." When examining this patient I noticed for the first was still present and prevented all games. The X rays were The double-leg-lifting sign was present and time a curious sign-namely, that while he could normal. of the thighs relieved the pain. In the hypertension lie on his back and lift each leg with the knee straight forward-lying the iliac side of the sacro-iliac joint position without difficulty or pain, he appeared to have on the affected side appeared to project more prominently absolutely no power to lift both legs together. It than on the healthy side. As this asymmetry largely was not a question of impending pain; he simply disappeared after treatment, it is worth noticing, particularly been noted in other cases. Treatment was carried might have been paralysed for this particular as it has movement. Passivemovements without an ansesthetic, out, as described below for the more severe and longradiant heat, and strapping effected a reasonably standing cases, and recovery has proceeded satisfactorily. CASE 6.-A woman. The original injury was caused rapid recovery. by turning to the left and leaning over to lift a coal scuttle ;;Since then I have come to recognise that the the right foot slipped on some grease and a feeling of somedouble-leg-lifting test is important in distinguishing thing that " went " in her back was followed some days all others. later by a disabling pain in the back and down the left one group of "backache" cases from It has been possible to collect a considerable number thigh. In this case, rest in bed. strapping, and jackets On examination of these cases, both in hospital and private practice, only effected temporary improvement. and they all conform so closely to the first that it in the forward-lying position the sacro-iliac joint on the side was so loose that Mr. J. Cunning considered will be sufficient to give brief notes of two or three. injured it justifiable, after all other methods had failed to fix a screw CASE 1.—A man, aged 26, was in a motor collision on through the joint. This he carried out successfully on May 4th, 1927, but was not turned over or thrown out ; Jan. 17th, 1923, and the patient was able to resume her he thinks he swung suddenly to save himself from impact. duties as cook-general and has carried on successfully ever He complains of pain deep in the left flank. Coughing hurts since. An X ray of the sacrum taken on Feb. 14th. 1rJ28, and shoots pain down the distribution of the left sciatic by Dr. Bertram Shires showed the screw in its original X rays show no bony injury or abnormality. On position. nerve.
67
Any anatomical theory to fit the common factors in these cases must take into consideration :(a) The comparatively minor nature of the original trauma. (b) The pain on coughing. (e) The pain in the back that tends to radiate either down the sciatic nerve, over the buttock, or towards the
groin. (d) The eccentricities of posture and movement that produce pain, including visceral discomfort. (e) The relief brought by manipulation, strapping, &c. (f) The mechanics that bring about the inability of the patient to lift both legs when lying flat. I sought the assistance of Prof. Lucas-Keene in the Anatomical Department of the School of Medicine for Women, and am indebted to her for the following
hypothesis :"
That the original injury is a comparatively minor tear of the inner portion of the quadratus lumborum muscle and of its anterior fascial covering commencing from the point where it becomes continuous with the ilio-lumbar ligament as this stretches, from the tip of the transverse process of the last lumbar vertebra, almost horizontally outwards to the inner lip of the iliac crest."
and then with the affected one. In the ordinary lying position these are usually found to be equal and full on both sides, but in the forward-lying position hyperextension of the thigh, with the sacrum fied.’. is generally less full, and it is this movement above all others that requires carrying out until it is full and free. The patient is then returned to bed and treated for two or three days as before, flat on back with a pillow under the upper part of the buttock to maintain slight hyperextension of the thighs, and with daily applications of direct current, (anode). Massage and passive movements are then commenced, and at the end of a week strapping is reapplied and the patient is allowed up, provided that the ability to begin double-leg-lifting has returned. The patient should now be warned that many weeks’ care will be necessary, and a list of the movements or strains to be avoided can be given him. In the less severe cases strapping without rest in bed sometimes effects all that is necessary, or a surprise hyperextension of the thigh in forward-lying position, without an anaesthetic, followed immediately by reapplication of strapping, is sufficient to initiate a satisfactory process of repair.
It is only necessary to glance at a dissection at that part of the quadratus lumborum which lies near the transverse process of the fifth lumbar vertebra to realise that a surprise contraction in an Summary. asymmetrical position might cause a tear more easily The group of cases described may, on account of the and with less force than in the well-recognised rupture exact similarity of signs and symptoms, be considered of the plantaris muscle. Pain on coughing would, as caused by one uniform anatomical injury. being with such an injury, be a certainty, as this muscle I A hypothesis of the possible nature of this anatomical must go into firm " holding " contraction to fix the is put forward which differentiates it from the injury lower ribs so that the diaphragm may carry out the ordinary cases of sacro-iliac -strain or rupture of the movements of coughing, and any pull on the external ilio-lumbar so clearly described by Mr. W. A. ligament arcuate ligament would be directly conveyed to the Cochrane,1 and a line of treatment is suggested which quadratus lumborum. Both the fourth and fifth is uniformly successful when the signs and symptoms lumbar roots of the lumbo-sacral plexus are in are limited to those described. immediate anterior relationship to the quadratus lumborum, and any effusion, such as would accompany a tear, would be bound, particularly in changing postures, to give rise to curious " freak " symptoms and pain radiating down the sciatic nerve distribution. Whether extension centrally of a tear of the fascial covering of the quadratus lumborum where this becomes continuous with the lumbar fascia could MALIGNANT PAPILLOMA OF THE LEFT satisfactorily account for the frequent association of KIDNEY IN A BOY. a variety of visceral symptoms in the chronic cases must be left for future investigation. It is sufficient BY O. W. ROBERTS, M.D. LOND., F.R.C.S. ENG., to note that there is anatomical proximity between ASSISTANT MEDICAL SUPERINTENDENT, ST. GILES HOSPITAL, CAMBERWELL. the inner border of quadratus lumborum and the sympathetic fibres passing to join the lumbo-sacral nerve roots. Finally, if we turn to Sherrington’s MALIGNANT papilloma of the kidney in a boy of 11 works on postural tonus we can see why the un- is uncommon, and the following case has some injured ilio-psoas muscles can individually work interesting features. and flex each thigh singly, but cannot do so when An puffy-faced boy had been suffering from an the more coordinated mechanism of double-leg- attackanaemic, of (?) which started with headache and nephritis," lifting is required. This necessitates balanced postural heematuria in May, 1927. He gave a history of a similar tonus in both quadratus lumborum muscles as a previous attack in May, 1926, and of measles and whoopingpreliminary to movement. I consider that this cough in infancy. His urine in May, 1927, was deeply but there was no history of the passage of hypothesis covers the majority of the symptoms so blood-stained, and his general well, and corresponds with the effective lines of blood-clots nor of any vesical symptoms, nephritis. After some days it was treatment so closely, that it may be accepted as a appearance suggested noted that the haematuria was inconstant and that the simple working description of a controversial condition. patient complained of vague hypogastric discomfort. This led to a thorough clinical investigation, and the urine on Treatment. examination was found to be free of casts, This naturally depends largely upon the duration microscopical to contain red blood cells, pus cells and Bacillus coli. and severity of the symptoms, but not a little upon Radiographic examination showed no obvious lesion of the the size, age, weight, and fatty covering of the patient. urinary tract, and the only clinical finding was a palpable In heavily built patients with severe pain and left kidney which, however, was painless. His condition temporarily improved, but in October. inability to begin double-leg-lifting, rest complete in bed completely flat, with a pillow under the 1927, the ansemia was more marked and the haematuria ; the urine contained red cells in large numbers buttocks, is the first essential. If, after a period pronounced of rest accompanied by daily applications of direct and pus cells, but no casts or organisms. Examination for He still, complained the tubercle bacillus was also current, the pain is not lessened on voluntary of headaches and occasional negative. vague hypogastric discomfort, movement, strapping should be put on, covering a but other signs or symptoms were absent. On cystoscopic wide area from below the level of both sacro-iliac the bladder mucosa was found to be congested joints to two or three inches above them, and extending and the left ureteric orifice suggested a lesion of the left outwards as far as the anterior superior spines. kidney ; but owing to the small size of the urethra a catheIf this strapping also fails to improve matters, some terising instrument could not be passed for examination form of manipulation is necessary. For this I remove of ureters or pyelography. Abdominal palpation under the a definitely enlarged left kidney, but the adhesive plaster and the patient is anaesthetised anaesthetic revealed on a mattress on the floor. mobilisation General 1 A Consideration of Backache from the Orthopædic Standmovements are carried out, first with the sound limb point, Edin. Med. Jour., April, 1927.
Clinical and
"
but
I examination
Laboratory Notes.