CHAPTER XXVIII DIAGNOSIS OF DISEASES OF THE SPINE (Part 1)

CHAPTER XXVIII DIAGNOSIS OF DISEASES OF THE SPINE A SURGICAL examination of the spine should include investigation of the following seven points : 1. The state of the coverings of the spine, including the features of any tumour over it. 2. The curves of the spinal column. 3. The mobility of the vertebrae. 4. The condition of the spinal muscles. 5. The sensitiveness of the spine. 6. The condition of the vertebrte, as shown in a skiagram. 7. The evidence, if any, of pressure upon the spinal nerves or spinal cord. Where possible the patient should stand in a good light with heels together, arms hanging, and eyes directed straight forwards. An infant should be examined in the sitting posture. In all cases alike a couch or a bed should be at hand for the examination of the body in the prone and in the supine position. I. The coverings of the spine — Notice the condition of the skin, particularly the presence of hyperEemia or pigmentation, of ulceration or slouo-h- ing, of a dimple, sinus or fistula, of an abnormal growth of hair, or of a tumour or swelling over the spine. Redness, ulceration, and sloughing are usually the result of pressure from prolonged recumbency n" 393 394 SURGICAL DIAGNOSIS [chap. with neglect, the wearing of an ill-fitting instrument, or the projection of an unduly promment spine. Dimples, median sinuses, and fistulous communica- tions with the spinal cord or its membranes are met with in congenital malformations. Use a probe to find out the direction and length of a sinus, and by the microscope and chemical tests determine the nature of any discharge, whether pus or cerebro- spinal fluid. A growth of hair over the lumbar spine is often met with where the maderlymg spinous processes are defective— spina bifida occulta, .bor the diagnosis of tumours over the spme, see p. 4US. 2 The curves oS the spine.— The surgeon should first observe the natural antero-posterior curves of the spine, noting whether they are increased or diminished, replaced by a general curve of the spine backwards, or interrupted by an abrupt pro- iection of one or more spines. He should next ' determine whether there is any rotation of the verte- bree one upon another. For this purpose the prom- inence of the angles of the ribs, and of the lumbar transverse processes on the two sides, must be care- fully compared. The height and prominence of the scapute, the hollow of the waist on each side, and the apparent prominence of the iHac crests must be noted To determine the symmetry of the spme more accurately the patient should stoop for^^'cards while keeping the knees straight ; in this position the angles of the ribs are uncovered by the scapul*, and the lumbar transverse processes project back- wards, and the surgeon, standing behind the patient, or looking down along his back can see at once if the transverse processes of the vertj.br=iB a. o^^ the same level on the two sides. The diagnosis of scoliosis must depend upon the Pr^s^'^^^?^^/;'^^ degree, of rotation of the vertebra?, as shown by tlie xxviri] EXAMINATION OF SPINE 395 unsjmmetrical projection of the transverse processes and angles of the ribs, and not upon the lateral deviation of the tips of the spinous processes. Then, turning the patient round, the surgeon should notice whether one breast is more prominent than the other, or either side of the chest is flattened, and if the two anterior iliac spines are on the same level, or one is lower and more prominent than the other.' Having made this examination, carefully trace the tips of the spines from above downwards to notice whether they are all present and in line, or whether one or more is absent or deflected to one or other side ; a convenient way of doing this is to place an mk mark on the skin over each spine-tip and then connect the dots by a continuous line. _ A general rounded curve of the spine backwards is due to debibty or to posture ; an abrupt posterior curve is caused either by congenital absence of a vertebral body or by destruction of the anterior part of one or more vertebrae. An exaggeration of the umbar curve— lordosis— is to compensate either tor kyphosis above, or for tilting forwards of the pelvis as in fixed flexion of the hip or in congenital dislocation of the hip. It also occurs in obesity or wlien a large abdominal tumour is present. A lessen- ing of the lumbar curve is seen in early lumbar canes. Lateral deviation of the spine is caused in a few cases by congenital absence of one-half of a verte- bral body but more often by faulty posture, by tilting of the pelvis to compensate for mequality in the length of the lower limbs, or for abduction or adduction of one thigh, or by retraction of one side of the chest, or in conditions of general bone-softenine /t^f movemenls oi" (he spine— The sur- geon should first of all observe the patient's movemel, 396 SURGICAL DIAGNOSIS [chap. encouraging liim to walk, run, or pick things up from the floor etc., and notice whether these actions are performed easily and without restraint, or whether he keeps the spine rigid, and moves the hips and knees instead, or rotates the trmik on the thighs mstead of turning the head from side to side. The several parts of the spine can be examined by placmg the hand flat on the back and gettmg the patient to bend and extend the region, noticing whether the vertebrae move one upon another or are immov- ablv fixed In the cervical spine the movements ot nodding- the head, rotation of the head, and flexion of the spine should be separately investigated, as they occur at separate joints. Thus, if noddmg the head is free and painless, the occipito-atloid joint is nnaffected ; if the face can be turned without difc- cultv from side to side, the atlo-axoid joint is free ; and if flexion of the head is quite free and painless the lower cervical spine is unafiected : any one ot these movements may be impossible, or very bmited and painful, and this will point to disease of one or other of these regions. In all cases of alteration in the curves of the spine it is important to discover whether the deformity can be corrected or not, and whether the change in form is accompamed or not bv a loss of the natural mobility of the vertebra. Lhnitation of mobility of the spine may be caused -hv snasm of the spinal muscles, by changes m oi ^LXsrof the spinal articulations, by deformity or bf lyrstosis of L vertebral bodies or by extra- spinal conditions which interfere with the move- m nt of the trmik, such as thoracic and abdommal ^uBO irs The fact that the movements of the spiue TZ^. unrestricted and . unaltered is s^ong c^. denci of tlic absence of serious disease m the spmal column. xxviii] EXAMINATION OP SPINE 397 4. The comlition of the spiual muscles. — Notice whether these muscles are weak, or wasted, or rigid. Get the patient to beud forwards, aud, with the hand on his head or nape of his neck, observe how much resistance to extension of the spine his muscles can overcome : the strength of the extensor muscles of the spine can be thus tested. Peel the muscular mass on each side of the lumbar spines and judge whether it is wasted or unduly rigid. The best way of testing for muscular rigidity, however, is to notice the ease and freedom, or the re- verse, with which the various movements of the spine are made. The head may be supported in the hands to prevent any movement in the cervical spine ; in stooping to the ground the patient may only flex his hips and knees and further steady the spine by resting his hands on his thighs, while simi- larly all the turning or lateral bending movements of the trunk are made at the hip-joints. Spinal muscular rigidity is due either to some condition in which movement of the vertebrae is painful (caries, osteo-arthritis), or to ossification of the muscles (myositis ossificans), or to lumbago. Extreme wast- ing of the muscles is seen especially in anterior polio- myelitis, and when from any cause patients have been recumbent for a very long time. Weakness of spinal muscles is seen as a part of general debility, as in rickets, convalescence from acute illness, and in overgrown and ill-trained adolescents. 5. The sensitiveness of the spine should be tested m four ways : (1) Press with the fingers over the spinous processes. If the patient flinches and shows signs of pain, the surgeon should notice whether touching the skin very lightly or pinching It up without any pressure on the bone is equally pamful, whether the patient moves the apparently 398 SURGICAL DIAGNOSIS [chap. tender part of the spine in flinching away from the finger, and also whether, when attention is diverted, pressure on the same spot is tolerated. These signs indicate cutaneous hypersBsthesia, which is an important sign of " hysterical spine." Patients with active inflammation of the bodies of the yerte- brse can usually bear firm pressure over' the spinous processes. The sensibility of the skin to heat and cold may be tested, but this is of no value in de- termining the condition of the bones. (2) Press vertically down through the spine to see if there is any hypersensitiveness of the bodies of the vertebrae —a very frequent efiect of disease of these bones. The patient may be slp.nding or sitting, the surgeon standing facing him and ready to notice the least expression of pain. Pressure is best made upon the head ; at first it should be quite light, but if this fails to elicit pain it may be gradually m- creased up to heavy pressure, and, if this is borne without any evidence of pain, undue sensitiveness of the bodies of the vertebras is excluded. (3) Make firm pressure alternately on the two transverse pro- cesses of a vertebra, so as to rotate the bone slightly; where the joint between two bones is diseased, this movement is painful and is resented. (4) Ask the patient to make some movement which would cause a jar up the spinal column, such as to iump domi off a chair or to run downstairs, it instead of doing this freely he refuses to do it, or only does it slowly and with special precaution to avoid or to lessen the spinal jar— holding on to the chair and only letting himself down with great care and very slowly-it equally shows the presence ot undue sensitiveness of some part through which tne iar would pass. , . 6. The loudiUou oi nic spinal bones ami xxvin] EXAMINATION OF SPINE 399 joiuts can be determined by caiefidly feeling the spines to ascertain that none of them is absent or bifid, by noticing any grave deformity of the spine, such r.: an abrupt kyphosis, which can only occur when there is congenital absence of or acquired de- struction of the corresponding vertebral body or bodies, and by examining a skiagram of the spine. This is the most accurate method, for it shows changes in the bones unassociated with deformity, and also joint changes which cannot be felt. In examining the skiagram, look first of all at the neural arches (arcus vertebrse) and their processes, to make sure that they are intact and symmetrical. Then examine the bodies of the vertebrse, and notice any faintness of shadow or loss of distinctness in the structure of the bone, pointing to early tuberculosis ; or destruction of the bone, as in advanced tubercu- losis ; or synostosis, as in healed tuberculosis or in osteo-arthritis. Lastly, note any replacement of the bone by a tissue of different opacity to X-rays and without the structure of bone, as an aneurysm, an abscess, or a new growth. 7. Nerve phenomena — The symptoms to be investigated are pain, hyperassthesia, anassthesia, muscular spasm or paralysis, and the condition of the reflexes. The exact extent of sensory altera- tions, and the muscles affected, should be carefully determined. The diagnostic importance of these symptoms is that they enable us to judge whether there is an organic lesion of the nervous system the position of such a lesion, and whether it has an irritative or a destructive effect. An extensor reflex of the great toe when the sole of the foot is stimulated— Babinski's sign— -is con- clusive evidence of a lesion of the pyramidal tract (fasciculus cerebro-spinalis) ; it is never produced 400 SURGICAL DIAGNOSIS [chap. by a " neurosis." A true clonus in the ankle, where the movements of the foot increase with increased flexion of the ankle-joint, is another sign of organic lesion ; in a " neurosis " clonus is often observed, but it is arrested by firmer flexion of the ankle, and so is distinguished as " false clonus." An increased knee-jerk is a very common symptom in a " neu- .rosis " ; it is met with also in any disease interfering with the function of the upper motor neuron. The knee-jerk is lessened or lost in any organic lesion involving either afierent or efferent nerves, or the reflex centre ; it is entirely lost below a lesion which nearly or wholly destroys the conductivity of the spinal cord. Limitation of nerve disturbance to the area of distribution of a nerve or nerves indicates that the causative lesion afiects the nerve-trunk or trunks and not the spinal cord. As nerve-trunks, composed of meduUated nerve-fibres, are much more resistant to the effects of pressure and of inflammation than are the more delicate structures of the spinal cord, it follows that the symptoms of lesions of nerves are often, or for a long time, only irritative (pain, spasm), while those of lesions of the spinal cord almost im- mediately become paralytic (anaesthesia, paralysis). Having examined his patient, the surgeon can easily put any case into one or other of these groups: (1) cases of obvious deformity, (2) cases without obvious deformity, (3) cases of tumour of the spine or spinal cord. He should proceed with his diagnosis as follows : 1. Cases with Obvious Deformity of the Spine i. It the natural curves of the spine are lost and in their place there is a general convexity of tlie xxvni] DISEASES OF SPINE 401 spine backwards which disappears when the child lies down, and is altered by movement, it is due to spinal muscular debility. In young children this is usually caused by rickets, and if the long bones are bent, with swellings over their epiphyses, and the fontanelles are foimd open too late, etc., it is to be diagnosed as a rachitic spine. It is also met with in patients convalescing from severe illness which has kept them in the horizontal position for a long time. ii. In an adult a similar rounded ciu've of the cer\aco-dorsal region is met with as the result of faulty attitude. In young people the curve can be corrected ; in them it may be due to defect of vision : later in life it cannot be corrected, and changes in the outline of the bones and in the joints are found ; it is then known as an occupation curve. iii. If such a general posterior curve of the spine is a fixed curve, unaltered by recumbency or movement, and if the movements of the spine are greatly diminished or almost nil, and the chest is also fixed, _ breathing being entirely diaphragmatic, and the skiagram shows synostosis of the bodies of the vertebrae and lipping of the articular processes, it is due to spondylitis deformans. This condition is generally attended with severe pain. It may be met with in young adults, usually as a consequence of gonorrhcea, but is more frequent in later life. It is di.stinguished from caries of the spine by the less abrupt character of the curve, by the absence of tenderness to vertical pressure, in many cases by the pam bemg worse at night, and sometimes by the patient bemg conscious of a grating in his spine durmg movement. There is often osteo-arthritis in other jomts. If a similar general rounded curve of the spine m an elderly person is associated with en- 402 SURGICAL DIAGNOSIS [ciiAr. largeinent and curving of clavicles, femora, or tibia?, it is a part of osteitis deformans. iv. If there is an abrupt curve of the spine backwards, or a projection posteriorly of one or more of the spinous processes, and the skiagram shows destruction of the cancellous bone of the front of the spine, it is a case of Pott's disease or angular curva- ture, or, better, tuberculosis or caries of tlie spine. When the projection is great the evidence of fall of the upper part of the spine is obvious. When the deformity is of long standmg the spine above, or below, or in both situations will show a compen- satory curve forwards. In all cases of caries of the spme the sur- geon should carefully examine for abscess, and for evidence of nerve lesion. The abscess may be found at the back, but more frequently the pus travels down along the front of the spine. When the disease is in the neck the surgeon should examme the back of the pharynx, the posterior triangle, the axilla, and the suprasternal notch. In disease of the dorsal spine each psoas muscle should be examined; if no swelHng is detected, but either hip is flexed, it indicates inflammation of the muscle, and the formation of a tuberculous abscess will speedily follow. In disease lower down the ab- scesses' are' found in the sheath of the psoas or