Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

The symptoms referable to pressure on the nerve roots at their points of emergence are pain and hyperæsthesia along the course of the nerves that are pressed upon, and occasionally weakness and wasting of the muscles supplied by them; girdle-pain is often a prominent symptom in adults.

In the diagnosis of Pott's disease in young children, chief stress is laid on the demonstration of rigidity of the affected portion of spine; the child is laid prone and is lifted by the legs and feet so as to hyper-extend the spine; in Pott's disease the spine is held rigid, while in the rickety and other conditions that resemble it, the movements are normal.

Treatment of Pott's Disease.—In addition to the general treatment of tuberculosis, the essential factor consists in immobilising the spine in the recumbent posture and in the attitude of hyper-extension; this must be persisted in until the diseased vertebræ become fused together or ankylosed by new bone, a result which is estimated partly by the disappearance of all symptoms and more accurately by observing the formation of the new bone in successive skiagrams.

Under conservative measures it is estimated that this reparative process entails an immobilisation of the spine of from one to three years; the operative procedures introduced by Albe and Hibbs bring about a bony ankylosis of the vertebræ in as many months, and may be accepted as reducing the period of spinal immobilisation in the recumbent posture to one year at the most.

The immobilisation of the recumbent spine in the attitude of hyper-extension is most efficiently carried out by an apparatus on the lines of the Bradford frame; this is made of gas-piping covered by canvas, and is easily bent as may be required in the progress of the case towards convalescence. The frame does not interfere with such extension as may be necessary, to the head, for example, in recent cervical caries, or to the lower extremities where flexion at the hip from spasmodic contraction of the psoas muscle may be efficiently relieved by weight-extension.

Gauvain's “wheel-barrow” splint and the double Thomas' splint ([Fig. 215]) are efficient substitutes, but Phelps' box has been discarded because it fails to secure immobilisation of the spine.

When the stage of convalescence is arrived at, and recumbency is no longer essential, the child is allowed to sit up, stand, and go about, with the restraint, however, of some apparatus that will prevent movement of the spine, except to a limited extent. The plaster-of-Paris jacket, applied over a woollen jersey, as introduced by Sayre of New York, is probably the best; the jacket is accurately moulded to the trunk while the child is partly suspended by means of a tripod and the necessary strings under the chin, occiput, and armpits. Poroplastic felt, celluloid, papier mâché, and other materials, reinforced by strips of metal, may be substituted for the plaster of Paris. Various forms of jury-masts and collars have been employed to diminish the weight of the head in children with cervical caries, but have been very properly discarded as failing to perform the function expected of them.

Correction of the Angular Projection.—In cases in which the angular projection or gibbus, as it is called by continental authors, is of recent origin, it may be corrected by the method so successfully employed by Calot of Berck-sur-Mer—a plaster jacket is accurately moulded to the trunk, and a diamond-shaped window is cut in the jacket opposite the gibbus; a series of layers of cotton-wool are then applied, one on top of the other, so as to exert firm pressure on the gibbus, a plaster or elastic webbing bandage being employed to retain them and reinforce the pressure. The padding is renewed at intervals of three weeks or a month; in successful cases the projection may ultimately be replaced by a hollow.

Treatment of Abscess.—If a spinal abscess is causing symptoms or is approaching the surface, and there appears to be a risk of mixed infection, the abscess should be asperated and injected with iodoform emulsion.

Treatment of Cord-Complications.—Extension is applied, in the first instance, to the head or to the lower limbs, or to both, while some form of pillow is inserted at the seat of the disease; if the condition is merely one of œdema, the symptoms usually yield with remarkable rapidity; if they persist, in spite of extension, for three to six weeks, recourse should be had to laminectomy; it is usual to find evidence of mechanical pressure by granulation tissue, pus, or displaced bone, the relieving of which is followed by disappearance of the nerve symptoms. Some authors are lukewarm in their advocacy of this operation, but we can cite a number of cases in which, after laminectomy, an apparently hopeless paraplegia has been entirely got rid of.