—The feasibility and propriety of forcibly reducing the deformities due to spinal caries was first suggested by Chipault, of Paris, who suggested wiring the spinous processes of the affected vertebra, and then, by Calot, who, in 1896, described a method of forcible reduction under an anesthetic. The first to actually wire the spine under these circumstances was Hadra, of Texas, who had actually done the operation four years before Chipault. The method has probably less to commend it in actual practice than in theory, and, attractive as it may be in respect to time and completeness of reduction, it is often followed by serious accidents, such as hemorrhage, rupture of abscess, fracture of the spine, etc. Bradford, in 1899, collected 610 cases performed by 29 different operators, with a record of 21 immediate deaths from local trauma and 15 cases in which there were at least alarming immediate symptoms. Of 229 of these cases complete correction was effected in 119, incomplete in 94, while no gain whatever was made in 16. Of results reported later, 66 showed some gain, there was no relapse in 17, while 49 showed more or less return of deformity. The claim has been made that the more or less wide gaps or bony defects which may result from forcible manipulation are filled in by new bone, but there do not seem to be any observations to confirm this statement. The amount of force which must be employed is a matter for the finest discrimination. The method includes complete anesthesia, traction upon the spine in each direction from the location of the deformity, and direct pressure force applied to the protection itself, as by a sling passed around the body and just beneath the projection, which can be used as a fulcrum upon which the rest of the spine can be applied as a double lever, with the application, at first, of gentle force, and, finally, sufficient to either satisfy the operator that he should go no farther or that the desired effect has been obtained. Immediately after completion of the maneuver a snugly fitting plaster jacket should be applied and the patient kept absolutely at rest in bed.
Fig. 259
Anteroposterior support: back view. (Lovett.)
Fig. 260
Anteroposterior support with head-ring for high dorsal caries: side view. (Lovett.)
The method seems most applicable in the presence of paralysis, even of long standing, and this feature has often been relieved.
Psoas contraction is best treated by traction, with the patient in bed, and with the maximum of weight and power applied which can be tolerated by the individual. If this seem impracticable, then the patient should be anesthetized and force applied until it is evident that more harm than good results. Should this harm appear, then open division of the tissues may be practised. Finally, as a last resort, in intractable cases, a subtrochanteric osteotomy may be made.
Pressure paralysis necessitates operative relief. This may be practised late and should consist of a laminectomy and exposure of the area compromised by bone pressure or that produced by pachymeningitis. The operation is done in the same way as for fracture, and will be described in the chapter on Surgery of the Spine.