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

by Alexis Thomson; Alexander Miles

Malignant Disease of the Vertebræ.—Sarcoma is the most important of the primary tumours met with in the vertebral column. It gives rise to symptoms which are liable to be mistaken for those of Pott's disease or of arthritis deformans. The pain, however, is more intense, and the disease progresses more continuously, and is uninfluenced by treatment. The changes in the vertebræ, as seen in skiagrams, are helpful in diagnosis. The growth may encroach upon the vertebral canal and cause pressure on the cord ([p. 451]). In the sacrum—the most common site—the tumour implicates the sacral nerves, and causes symptoms of intractable sciatica; and the real nature of the disease is often only detected on making a rectal examination.

Secondary cancer is a common disease, particularly in cases of advanced scirrhus of the breast. It leads to extensive softening of the bodies of the vertebræ, so that they yield under the weight of the body, as in Pott's disease. Clinically it is associated with severe pain in the region of the vertebræ affected, and along the course of the nerves emerging in the neighbourhood. If paralysis occurs from the cancerous bodies pressing upon the cord (paraplegia dolorosa), it is of rapid development, often becoming complete in a few hours. When the cervical cord is compressed all four limbs are paralysed, and from interference with respiration, the condition is fatal within a few days.

Actinomycosis, Blastomycosis, and Hydatid Cysts also occur in the vertebræ, and are difficult to diagnose from tuberculous disease.

Typhoid Spine.—An acute infective condition of the vertebræ, intervertebral discs, and spinal ligaments occasionally occurs during convalescence from typhoid fever. The lumbar region is most frequently affected, and the X-rays reveal inflammatory changes in the bones, disappearance of the discs, and, in the later stages, deposits of new bone leading to synostosis of adjacent vertebræ. The onset, which may be gradual or sudden, is attended with intense pain, and tenderness over the affected vertebræ. The temperature is raised, and other signs of an acute infective process are present. In a few cases there are symptoms of involvement of the membranes and cord. With prolonged rest and immobilisation of the spine the inflammation usually subsides, but sometimes it goes on to suppuration.

Hysterical Spine.—This term is applied to a functional affection of the spine occasionally met with in neurotic females between the ages of seventeen and thirty, and liable to be mistaken for Pott's disease. The patient complains of pain in some part of the spine—usually the cervico-thoracic or thoracico-lumbar region—and there is marked hyperæsthesia on making even gentle pressure over the spinous processes. As the patients are usually thin, the pressure of the corset is apt to redden the skin over the more prominent vertebræ, and give rise to an appearance which at first sight may be mistaken for a projection. The general condition of the patient, the freedom of movement of the vertebral column, and the entire absence of rigidity, are sufficient to exclude tuberculosis. The condition is treated on the same lines as other hysterical affections.

Fig. 218.—Arthritis Deformans of Spine. The vertebræ are fixed to one another by outgrowths of bone which bridge across the intervertebral spaces, and there is a slight lateral deviation to the left in the mid-dorsal region.
(Anatomical Museum, University of Edinburgh.)

Acute osteomyelitis of the vertebræ is a rare affection, and is met with in young subjects. It attacks the more mobile portions of the spine—cervical and lumbar—and may begin either in the bodies or in the arches. It is attended with extreme sensitiveness on movement, severe localised pain in the region of the vertebræ attacked, and a marked degree of fever. Pus usually forms rapidly, but, being deeply placed, is not easily recognised unless it points towards the surface. The infection is liable to spread to the meninges of the cord and give rise to meningitis, particularly when the disease begins in the arches. A milder form occurs, in which the main incidence is on the periosteum; the symptoms are less severe, it does not tend to suppurate, and is usually recovered from. The treatment consists in applying extension to the spine and in opening any abscess that may be detected. The suppurative form usually proves fatal, and, indeed, is often only diagnosed on post-mortem examination.

Arthritis Deformans.—This disease usually begins between the ages of thirty-five and forty, and attacks men who follow some laborious occupation which involves exposure to cold and wet. It is met with, however, in women who lead a sedentary life. There is sometimes a recent history of gonorrhœa, rheumatism, or other toxic disease, and occasionally the condition follows upon injury. The discs disappear, osteophytic outgrowths develop at the margins of the bodies and in connection with the transverse processes, and bridge across the space between neighbouring vertebræ ([Fig. 218]). The articulations between the ribs and the vertebræ show similar changes, and the ligaments of the several joints tend to undergo ossification, so that the bones are fused together.