Local tenderness is elicited on pressing over the affected vertebræ. As might be expected from the nature of the accident producing this lesion, it is often associated with serious injuries to the head, limbs, or internal organs which gravely affect the prognosis.
The treatment consists in taking the pressure off the injured vertebræ in order that the reparative material may be laid down in such a way as to restore the integrity of the column. In the cervical region, extension is applied to the head, and a roller-pillow placed beneath the neck. In the lumbar region, the extension is applied through the lower limbs, and the pillow placed under the loins. The patient is confined to bed for six or eight weeks, and before he gets up a poroplastic or plaster-of-Paris jacket is applied. This is worn for a month or six weeks.
Fig. 208.—Fracture—Dislocation of Ninth Thoracic Vertebra, showing downward and forward displacement of upper segment, and compression of cord by upper edge of lower segment.
(Anatomical Museum, University of Edinburgh.)
Traumatic Spondylitis.—This condition is liable to develop in patients who have sustained a severe injury to the back. It is believed to originate in a compression fracture which has not been recognised, and is probably due to the callus thrown out for the repair of the fracture being subjected to strain and pressure too early, or to a progressive softening of the injured vertebra and of the bodies of those adjacent to it. This leads to an alteration in the shape of the affected bones, which can be demonstrated by means of the X-rays. The usual history is that some considerable time after the patient has resumed work he suffers from pain in the back, and radiating pains round the body and down the legs. He becomes more and more unfit for work, and a marked projection appears in the back and may come to involve several vertebræ. While the condition is progressive, the prominent vertebræ are painful and tender. In course of time the softening process is arrested, and the affected bones become fused, so that the area of the spine involved becomes rigid and permanent deformity results. So long as the condition is progressive the patient should be kept in the recumbent and hyper-extended position over a roller-pillow and, when he gets up, the spine should be supported by a jacket.
Dislocation and Fracture-Dislocation.—It is seldom possible at the bedside to distinguish between a complete dislocation of the spine and a fracture-dislocation. Fracture-dislocation is by far the more common lesion of the two, and is the injury popularly known as a “broken back.” It may occur in any part of the column, but is most frequently met with in the thoracic and thoracico-lumbar regions. It usually results from forcible flexion of the spine, as, for example, when a miner at work in the stooping posture is struck on the shoulders by a heavy fall of coal. The spine is acutely bent, and breaks at the angle of flexion and not at the point struck. The lesion consists in a complete bilateral dislocation of the articular processes, together with a fracture through one or more of the bodies. This fracture is usually oblique, running downwards and forwards. The upper fragment with the segment of the spine above it is displaced downwards and forwards, and the cord is crushed between the posterior edge of the broken body and the arch of the vertebra above it ([Fig. 208]). In almost every case the cord is damaged beyond repair.
Total dislocation, in which the articular processes on both sides are displaced and the contiguous intervertebral disc separated, is rare, and is met with chiefly in the lower cervical region.
Clinical Features.—The outstanding symptoms of total lesions are referable to the damage inflicted on the cord. The diagnosis should always be made by a consideration of the mechanism of the injury and the condition of the nerve functions below the lesion. On no account should the patient be moved to enable the back to be examined, as this is attended with risk of increasing the displacement and causing further damage to the cord. On passing the fingers under the back as the patient lies recumbent, it is usually found that there is some backward projection of the spinous processes, the most prominent being that of the broken vertebra. The spinous process immediately above it is depressed as the upper segment has slipped forward. Pain, tenderness, swelling and discoloration may be present over the injured vertebræ. It is usually possible to have skiagrams taken without risk of further damage to the spine. There is complete loss of motion and sensation below the seat of the lesion. The symptoms of total transverse lesions of the cord at different levels have already been described ([p. 416]).
Treatment.—An attempt may be made to reduce the displacement under anæsthesia, gentle traction being made in the long axis of the spine by assistants, while the surgeon attempts to mould the bones into position. No special manipulations are necessary, as the ligaments are extensively torn, and the bones are, as a rule, readily replaced. A roller-pillow is placed under the seat of fracture to allow the weight of the body above and below to exert gentle traction, and so to relieve pressure on the cord. Operative treatment is almost never of any avail, as the cord is not merely pressed upon, but is severely crushed, or even completely torn across. Even when the cord is only partially torn, operative treatment is not likely to yield better results than are obtained by reduction and extension. The usual precautions must be taken to prevent cystitis and bed-sores.