In the early stage the patient complains of pain and stiffness in the back; later the spine becomes rigid, and gradually develops a kyphotic curve, sometimes accompanied by lateral deviation. In some cases, the curvature of the spine assumes an extreme type, the shoulders are rounded, and the head depressed, the face approximating the sternum, so that to see an object such as a picture on a wall, the patient must turn his back to it. The chest is flattened and restricted in its movements, with the result that respiration is embarrassed and becomes almost entirely abdominal. The muscles of the back, shoulders, and hips undergo atrophy, and may exhibit tremors, and the deep reflexes become exaggerated. The nerves are liable to be pressed upon as they pass through the intervertebral foramina, and this gives rise to pain and other disturbances of sensation in their area of distribution. These pains may simulate those associated with renal or gastro-intestinal affections.
The disease may simulate tuberculous caries or malignant disease. The changes in the bones are demonstrated by the use of the X-rays.
The treatment is carried out on general principles (Volume I., p. 530), but it is seldom possible to do more than arrest the progress of the disease.
Coccydynia is the name applied to a condition in which the patient experiences severe pain in the region of the coccyx on sitting or walking, and during defecation. The pathology is uncertain. In some cases there is a definite history of injury, such as a kick or blow, causing fracture of the coccyx, or dislocation of the sacro-coccygeal joint. These lesions have also been produced during labour. In other cases the pain appears to be neuralgic in character, and is referable to the fifth sacral and the coccygeal nerves, or to the terminal branches of the sacral plexus distributed in this region. The affection is almost entirely confined to females, and the patients are usually of a neurotic type. On rectal examination the coccyx is exceedingly tender, and it is sometimes found to be less movable than normal, and unduly arched forward. When medicinal treatment fails to give relief, the coccyx may be excised.
Tumours of the Spinal Cord and Membranes.—Tumours may develop in the substance of the cord (intra-medullary), in the membranes (meningeal), or in the tissues between the dura and the bone (extra-dural); or the cord may be pressed upon by a tumour originating in the vertebræ. It is seldom possible to diagnose the nature of a tumour before operation, and it is often difficult to determine in which of the above situations it has originated.
Tumours growing in the substance of the cord are nearly as common as extra-medullary growths, and as the growth is usually sarcoma, glioma, tuberculoma, or gumma, and infiltrates the cord, it is seldom capable of being removed by operation.
The great majority of meningeal tumours are primary sarcomas, and in about 25 per cent. of cases they are multiple. Hydatid cysts and fibromas are also met with in this situation, and they too may be multiple.
Extra-dural growths are comparatively rare. The forms usually met with are sarcoma and lipoma.
These extra-medullary tumours seldom infiltrate the cord; they simply compress it, and should be subjected to operative treatment before secondary changes are produced in the cord.
The symptoms vary according as the tumour presses on the nerve roots, on one half, or on both halves of the cord. Pressure on nerve roots is a characteristic sign in extra-medullary growths. It gives rise to pain, which, according to the level of the tumour, passes round the trunk (girdle-pain), or shoots along the nerve-trunks of the upper or lower limbs.