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

by Alexis Thomson; Alexander Miles

When the cord is pressed upon, intense neuralgic pain related to the segment first involved is one of the earliest symptoms, particularly in extra-medullary tumours. The pain is at first unilateral, but later becomes bilateral—a point of importance in diagnosis. The painful areas are anæsthetic, but the anæsthesia does not always reach to the level of the lesion. There may be a zone of hyperæsthesia at the upper limit of the anæsthesia, or in the area corresponding to the roots on which the tumour is situated, but there is never diffuse hyperæsthesia (V. Horsley). In intra-medullary tumours the pain is less severe, it is rarely an initial symptom, and is seldom referable to individual nerve roots.

The next symptom to appear is motor paresis, followed by complete paralysis, and later by contracture of the paralysed muscles—spastic paraplegia. In intra-medullary tumours the paraplegia is usually less complete than in those that are extra-medullary. When only one lateral half of the cord is pressed upon, the motor paralysis and loss of ordinary sensation are on the same side as the tumour, and the loss of the sense of pain and of the temperature sense is on the opposite side. Retention of urine accompanies the onset of paralysis, and later gives place to incontinence. The rectum becomes paralysed, and cystitis and pressure sores develop.

Anti-syphilitic treatment should be employed in the first instance to exclude the possibility of the lesion being of the nature of a gumma. Radical operative treatment is contra-indicated in intra-medullary and in metastatic growths, but decompressive measures may be employed for the relief of pain. In meningeal and extra-dural tumours, however, in view of the hopeless prognosis if the condition is allowed to take its course, an attempt may be made to remove the tumour by operation. It is to be borne in mind that the lesion may be two or three segments higher than the complete anæsthesia would appear to indicate; the vertebral canal, therefore, should be opened about four inches above the level of the anæsthesia.

When the tumour is not removable, the patient's suffering may sometimes be alleviated by resecting the posterior roots of the nerves emerging in the vicinity of the lesion.

Chronic Spinal Meningitis.—Victor Horsley (1909) described by this name a condition which gives rise to symptoms closely simulating those of a tumour of the cord. He believes it to consist in a pachymeningitis combined with a certain degree of sclero-gliosis of the periphery of the cord. The theca is greatly distended over a variable extent of the cord; the cerebro-spinal fluid is increased in quantity and is under considerable tension; and the cord itself presents a shrunken appearance. Sometimes there is thickening of the arachno-pia and matting of the nerve roots. The condition appears to begin in the lower part of the cord, and to spread up, usually as far as the mid-thoracic region. There is frequently a history of syphilis, sometimes of recent gonorrhœa, but in some cases no cause can be assigned for the lesion.

Clinical Features.—This affection is almost always met with in adults, and the earliest symptoms are pain and weakness in the legs, and sometimes a slight kyphotic projection of the spinous processes. The loss of power, which is sometimes attended with spasticity, usually manifests itself in one leg first, and later affects the other; it is progressive, and ultimately ends in complete paraplegia. The pain is not confined to the region supplied by any one nerve root, but affects a diffuse area, and the patient complains also of a sensation of tightness in the limbs. There is never absolute anæsthesia, but there is relative anæsthesia for all forms of sensation, which extends as a rule as far as the sixth or eighth thoracic root.

There are no vaso-motor phenomena, and no tendency to the formation of pressure sores. Sometimes the patient complains of pain in the spine, but this is not aggravated by movement.

Treatment.—The treatment recommended by Horsley consists in performing laminectomy, opening the theca, and washing it out with 1 in 1000 mercurial lotion. After the wound has healed, mercurial inunction over the spine is employed to hasten the absorption of inflammatory products. The administration of anti-syphilitic drugs has not proved beneficial.

Acute Spinal Meningitis.—The spinal membranes may become implicated by direct spread in cases of acute intra-cranial lepto-meningitis, or they may be infected from without—for example, in gun-shot injuries or in cases of spina bifida.

When the infection spreads from the cranial cavity, the cerebral symptoms dominate the clinical picture, but evidence of involvement of the membranes of the cord may be present in the form of rigidity of the cervical muscles with retraction of the neck; deep-seated pain in the back, shooting round the body (girdle-pain) and down the limbs; painful cramp-like spasms in the muscles of the back and limbs, with increased reflex excitability, sometimes so marked as to simulate the spasms of tetanus.