A system of practical medicine. By American authors. Vol. 5

by Unknown

The TREATMENT is the same as that for congestion of the spinal cord.

Acute Inflammation of the Spinal Dura Mater.

SYNONYM.—Acute spinal pachymeningitis.

Acute inflammation of the spinal dura mater is chiefly confined to the outer surface of the membrane (peripachymeningitis), and is almost always consecutive to either injury or disease of the vertebræ (fracture, dislocation, caries), to wounds penetrating the spinal cavity, or to suppurative disease in neighboring organs or tissues, which makes its way into the peridural space through the intervertebral openings. The symptoms are complex—in part caused by the original disease, and in part by the pressure of the products of inflammation exercised upon the nerve-roots, and even upon the cord itself. Pain in the back, corresponding to the seat of the disease, is rarely absent, and all movements of the trunk are extremely painful. When the exudation is sufficient to compress the nerve-roots, the pain will extend to the trunk and the limbs, and other signs of irritation, such as a feeling of constriction by a tight girdle, and tingling, numbness, and cutaneous hyperæsthesia in the limbs, will be observed, varying in situation according to the seat of the lesion. In some cases the compression of the cord may be sufficient to cause paraplegia. General symptoms will vary according to the complications of the case. Severe injury or extensive disease of the vertebræ will be accompanied with high fever; but if the external inflammation be moderate and the meningeal complication be limited in extent, the fever may be subacute.

MORBID ANATOMY.—The connective tissue between the dura and the bone is the seat of inflammatory exudation, usually purulent, of greater or less extent, and more abundant in the posterior than the anterior part of the spinal cavity, owing to the position of the patient. A more or less abundant exudation, either of pus or of dry caseous matter, is found upon the outer surface of the dura or infiltrating the connective tissue between it and the bony walls. The dura is thickened, and sometimes the exudation is seen upon its inner walls, but the pia is seldom involved in the inflammation. The cord may be compressed or flattened when the amount of exudation is large, and may in consequence show signs of inflammation in its vicinity. The spinal nerves likewise are sometimes compressed, atrophied, softened, and inflamed. The disease rarely occupies the cervical region, on account of the close union of the dura with the bones of that part; hence there is an absence of pain in the neck and of retraction of the head.

DIAGNOSIS.—The diagnosis is founded on the presence of general symptoms of spinal disease—pain in the back, but not extending to the neck, increased by movements of the trunk; cutaneous hyperæsthesia, tingling, or numbness in various parts of the surface of the body; paresis or paralysis of the lower extremities in severe cases; along with a history of vertebral disease or injury or of suppurative disease in the neighborhood of the spine. The history of the case will generally be sufficient to exclude myelitis, tetanus, or muscular pain (rheumatism, lumbago). From acute leptomeningitis the diagnosis must also be made by the history, but it should be borne in mind that the pia may be involved at the same time with the dura.

PROGNOSIS.—In complicated cases the prognosis is grave if the spinal symptoms are well marked and severe, especially when there is evidence of much pressure on the cord (paraplegia). If the signs of spinal irritation were moderate, the danger would depend upon the nature and extent of the external lesion.

TREATMENT.—This would be addressed mainly to the primitive disease. For the spinal symptoms the treatment would not differ materially from that of inflammation of the spinal pia mater.

Chronic Spinal Pachymeningitis.

This affection generally coexists with chronic inflammation of the pia. Like the acute inflammation of the dura, it is seen in connection with disease or injury of the vertebræ, and it may also arise from tumors of the membrane (chiefly syphilitic) and from myelitis. It is frequent among the chronic insane, and in them is sometimes associated with hemorrhagic effusions analogous to the hæmatoma of the cerebral dura mater. Chronic inflammation of the spinal dura is of unfrequent occurrence, and but little is known of its history and pathology. In a case reported by Wilks⁴ the membrane was thickened to nearly its whole extent, and in the cervical region presented numerous bony plates. The pia was also thickened at this part and adhered closely to the dura. The symptoms, which seemed chiefly due to disease of the cord from compression, were retraction of the lower limbs and violent jerking from excessive reflex action.