COCCODYNIA; COCCYGODYNIA.
Under this name are included severe and chronic neuralgias of the coccygeal region, including its joint, which occur most often in women, and usually as the result of contusion or direct injury. Occasionally it results from an injury inflicted during parturition. It gives rise to a degree of pain and tenderness which sometimes is almost disabling. Because of the insertion of the levator ani into the tip of the coccyx defecation may become distressing, to an extent which leads to fecal impaction in the rectum from postponement of evacuation as long as possible. The symptoms are subjective, but the tenderness is frequently exquisite.
In regard to treatment subcutaneous division of the tissues around the bone may afford relief, but in most instances, particularly those of traumatic origin, an excision of the coccyx will afford the only cure. (See [below].)
OPERATIONS ON THE SPINE.
These are included under the general heading laminectomy, which is used in a comprehensive sense, as is also the term trephining.
In a general way the measure is about as follows: Through a long median incision over the spines of the region where the lesion is localized their tips are exposed, while the muscle groups on either side and posterior to the laminæ are separated by the knife and by retractors. Dense fibrous bands may be nicked. In this way the posterior aspect of the neural arches is exposed to the desired length. The exposed spines should be removed by cutting them off at their bases with bone forceps, although they may be left and later removed with the posterior bony arches. To clear them away, however, affords a better view of the field of operation. The ligamenta subflava are then divided transversely at their upper and lower margins, after which, either with cutting forceps, saw, or chisel, the laminæ are divided on either side, and the section which is loosened pried out from the bed in which it rests. More or less fatty tissue will be found outside of the dura and in this tissue veins, sometimes of considerable size, freely ramify. These may be seized and divided, those of considerable size being tied. Great care should be given during the procedure to avoid perforation of the spinal membranes by the points of the instruments used. The cutting forceps are preferable to the saw or chisel, except for work in the lower lumbar region, where the parts are stout and strong. Especially in case of fracture, and at the upper end of the spine particularly, care should be given, with the force used, that no loose fragment be so handled as to increase the damage already done to the cord.
The dura being thus exposed and the blood cleared away, inspection may or may not reveal the nature of the lesion. A probe, gently handled, passed upward and downward into the canal, will reveal whether the cause of the pressure has been cleared away or not. According to the nature of the lesion it can then be decided whether to open the dura. To open it is to pave the way for fatal infection, unless the strictest aseptic technique has prevailed. On the other hand, to leave it unopened is to fail to appreciate the actual condition of the cord and to leave an important matter still undetermined. The dura if opened should be closed by suture.
Reference has already been made, in three cases now on record, to suture of the cord as a whole. Such sutures may be applied, if necessary, in a manner to do the least possible damage to the structures of the cord. If cerebrospinal fluid escape too freely the patient may be operated in a position with the head lower than the trunk, avoiding leakage.
Osteoplastic methods of temporary resection of the posterior arches of the vertebræ have been devised and practised, but they offer no particular advantages, and are attended by disadvantages which have caused them to be almost abandoned, save in rare instances and by individuals of large experience. (See [Plate XLVII].)
In regard to wiring fragments of a fracture or displaced spine, Hadra, of Texas, was perhaps the first to carry out the measure. It comprises simply the fixation of fragments by wire sutures or ligatures which bind them together after they have been replaced through a more or less open wound, such as is included in the term laminectomy. But resort to wire is to be left to the judgment of the operator and the needs of the case. There is no reason, however, why it may not be used here, as in other fractures which are thus made compound, if there would seem to be prospect of benefit attaching to its use.