Page Four P H Y S I O T H E R A P Y September, 1957 THE PROBLEM OF TRAUMA IN THE LOW BACK By G. T. du Toit, F.R.C IN TE R EST in injuries to the low back was manifested in the writing o f H ippocrates 400 years B.C. It was recog­ nised then th a t dislocations o f vertebrae were fatal because o f injury to th e spinal cord. Lesser injuries were clinically diagnosed an d successfully treated. Celsus, in the second century A .D ., gave w arning th a t inexpert treatm ent o f dis­ locations o f th e spine could cause deterioration o f the condition and death. In A .D . 690 exploration o f th e injured spine'through an incision was advocated to remove pressure o f a bony frag­ m ent from the spinal cord. In G erm any in 1600 several surgeons advocated exploration o f the spine but not until 1762 was a successful operation quoted in France. Astley C ooper in 1826 advised against m anipulation o f a dislocated spine. Benjamin B rodie m anipulated fractures in the low back but thought it dangerous in the cervical spine. In England the attitude rem ained conservative and treatm ent was confined to rest in recumbency. In 1843 C row foot treated a coachm an who, while sitting on the box o f his coach, struck his head against an archway which doubled him up, so producing a dorsolum bar kyp­ hosis w ith paraplegia. W ith a belt under his arm s fixed to the head o f the bed and pelvic belt to which cords were attached over pulleys at th e foot o f the bed, the deformity gradually disappeared, paralysis recovered slowly and he eventually returned to work. W ith th e developm ent o f railways, th e term “ railway spine” covered a confused jum ble of orthopaedic and functional sequelae. D uring th e Crim ean W ar it was felt th a t all cervical bony injury cases died in the field and dorsolum bar injuries predom inated amongst those cases treated and studied. T reatm ent was mainly conservative im mobilisation on a w aterbed with general nursing hygiene. T he plaster jack et im mobilisation o f tuberculous spines lead to the sam e vogue for fractures o f the spine. X-ray developm ents in 1895 resulted in rapid progress in these studies. As a consequence, bony injuries assumed major im portance and in the absence o f neurological complications soft tissue injuries were largely forgotten o r ignored. In 1929, Davis drove hom e the point th at the anterior com m on ligam ent was very strong and could prevent over­ reduction when the p atien t’s feet were elevated and the spine extended to the limit. In 1940, W atson Jones advocated th e 2 table hyper­ extension cast. B ohler in 1935 showed the im portance of efficient routine, accurate casting and early organised active exercises to m aintain and regain muscle pow er. H e stressed the value o f segregation o f similar cases, fostered the spirit o f com petition in group exercises and accentuated the influence o f personal attention and practical psychotherapy in reducing the incidence o f traum atic neuroses. On his work is based the present attitude o f the physiotherapist tow ards this problem. ' In 1929, Schm orl’s pathological studies brought about intense interest in the subject o f ligamentous injuries and intervertebral disc damage. In 1934, M ixter and B arr pio­ neered the study o f herniated discs in relation to sciatica. • Since then', the study o f cervical discogenic pathology has advanced steadily. . N ow we recognise a num ber o f clinical pictures o f painful spinal disabilities associated with m echanical pressure on nerve roots and spinal cord and it is becoming increasingly clear th at many neuritic conditions such as brachial neuralgia and sciatica, as well as a num ber o f previously obscure spinal cord diseases with dam age to the tracts o f the spinal cord are the consequence of processes o f degeneration o f the spinal colum n due to com binations o f ageing and traum atic incidents. S., O rthopaedic Surgeon. STRU CTU RAL C O N SID ER A TIO N S: T he dorsal spine is relatively rigid and restricted by costovertebral and costotransverse joints and intertransverse and associated ligaments, as well as by th e configuration of th e paravertebral jo in ts and the narrow disc spaces. In the low dorsal area o f the false ribs m obility is great and, in the lum bar, even greater, where the discs increase relatively in thickness and the paravertebral joints are de­ signed to give greater mobility in all directions. Longitudinal compression can injure the m obile lum bar curve in the position assumed under stress, e.g. flexion. T he lum bar vertebral body has a compact, bony shell, containing soft cancellous bone perm eated by a blood sinus, the com pact bony end plates being alm ost bloodless. Posteriorly th e body is strengthened by articular processes and pedicles, so th at it is compressible anteriorly rather than posteriorly. , i T he intervertebral disc with fibrocartilagenous end plates, elastic annulus fibrosus and a semifluid nucleus pulposus is the essential mechanism o f th e am phiarthrodial jo in t between vertebrae. These positive fluid pressure joints distribute the stress evenly over the bearing surfaces. T he physico chemical processes keeping the disc in tension are not well understood. T he elastic annulus degenerates w ith increasing age. In the absence o f w eightbearing stress, two 'vertebral bodies are forced ap art with a pressure of ab o u t 32 pounds. In the erect posture this pressure is greatly increased and in forward flexion th e pressure reaches fantastic heights. T he efficiency o f this jo in t depends on internal fluid tension which intact cartilage plates and elastic annulus fibrosus are necessary. T he disc structure itself is avascular. V ariation in disc struc­ ture throughout life is considerable. Progressive change with advancing age is the key factor around which m ost spinal disabilities arise. These changes m ust be considered in relation to traum a. In youth, m ovem ent o f one vertebrae on the other is associated with accom m odation o f shape and redistribution o f the semifluid core to ad ap t to m ovem ent in all directions. In middle age, loss o f fluid, loss o f elasticity, fibrous replacem ent o f elastic tissues causes loss o f mobility o f the fluid core of the disc and consequently th e elastic bending of the spinal colum n as a whole is lessened and displacement o f vertebral bodies on each other becomes m ore o f a sliding o f one bone on the other. T he annulus tends to break, the endplates tend to crack and fissure, and there is loss o f height | and loss o f m obility o f the spine on the whole. However, there is a phase after substantial loss o f disc substance by prolapse, during which mobility a t an isolated disc level may be increased tem porarily before th e scarring and settling together o f vertebral bodies eliminates m ovem ent for practical purposes. These changes may be m ore specifically analysed as follow s:— Nucleuspulposus defects occur with loss of mucoid semifluid structure and fibrous replacement. The dem arcation between the nucleus and th e annulus becomes less distinct. Cavities and splits develop in the disc substance. T he residual semi­ fluid centre may be displaced from its anatom ical site and be incapable o f resuming norm al position. H erniation may occur through an endplate, through th e annulus backw ards or forwards. The cartilage endplates som etimes have em bryonic defects through which SchmorPs nodes push into th e vertebral body. T raum a may produce gross fracture o f the endplate and the body w ith escape o f the nucleus into the body, but lesser injuries may only produce cracks in the endplate with de­ layed consequences o f the sam e type. As the disc material escapes it becomes scarred and walled off by peripheral R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) September, 1957 P H Y S I O T H E R A P Y Page Five sclerosis, confining th e prolapse bu t by th at tim e the disc has lost substance and has becom e narrowed. fh e Annulus loses elasticity following degenerative changes associated w ith ageing > a n d ; traum a. T he m ost com m on prolapse o f the disc is through posterior developed defects in the annulus. , . In osteoporosis' from any cause th e positive pressure in 'th e disc causes expansion at the expense o f bony structure p ro ­ ducing biconcave vertebrae. T raum a can exaggerate this deformity. W ith age th e dorsal curve increases an d becomes l e s s resistant to compressive force. , ' , . The mobile lum bar spine being subject'to m ore wear and tear from m ovem ent, develops degenerative' changes m ore rapidly and traum a is often the culm inating factor giving rise to neurological dam age and symptoms. SOFT T ISSU E IN JU R IE S The condition o f “ sprung back” described by N ewm an in 1952, is now well recognised. It o ccurs.often in women suffering from lum bosacral pain, which is al dull ache, a nagging pain and n o t often a sharp pain. T he condition may come on after a fall, a blow or a strain while lifting a weight. Many o f the patients are young housewives, nurses or young men doing occasional heavy m anual w ork to which they are not accustomed. T he pain is m ade worse by sitting in a slouching position, lifting a weight a t arm ’s, length, bending or stooping w ith the knees straight, standing w ith a slight stoop as in washing, ironing, cooking, operating, gardening. Muscle spasm is not severe, active lum bar flexion is slightly restricted, other m ovem ents full. N eoruligical signs are absent. Straight leg raising is unim paired until the pelvis starts rotating. Tenderness is in the midline between L5-S1 or at the next higher level. Sometimes a definite depression can be felt when the spine is moderately flexed and contrasts markedly w ith th e resistance o f the intact supraspinous liga­ ment at other levels. Tilting X-rays may show mechanical instability in lateral films taken in full flexion and extension. Normally the supraspinous ligament acts as th e main check ligament to overflexion. Its tension is greatest when the knees are extended. If the ligament ruptures th e condition is a “ sprung back” . G reater violence would produce a compression fracture anteriorly. Occasionally th e pars inter- articularis breaks first to produce a traum atic spondylolysis. Rarely an articular facet m ay fracture. W hen the erector spinae muscles go into spasm, the torn structures often heal by close fibrous union, b u t the supraspinous ligament fails to heal adequately and may rem ain in an elongated and even an interrupted condition. T he dam aged paravertebral jo in t capsules would then also rem ain lax. T he affected vertebrae are unstable. In other cases the scar rem ains painful under strain especially when th e erector spinae becomes fatigued as in standing in a forw ard bent position. Newman follows up this finding w ith th a t o f more severe flexion strains causing dam age to annulus and posterior longitudinal ligament and disc prolapse. So he explains the years o f lumbago preceding prolapsed disc. Strain o f ligamentous attachm ents o f vertebrae are com­ mon and no different to those in o ther sites such as medial collateral ligament strain in the knee from one injury or typical tennis elbow from multiple repeated stresses. In more severe injuries it m ust be valid to assume partial rupture o f muscles, ligaments, capsules and their attach­ ments and, o f course, small bony processes such as trans­ verse processes which becom e avulsed by muscle action. These are similar to flake fractures o f the great tuberosity o f the humerus or an external malleolus in a severe sprain. The problem is related to th e severity o f traum a and recognition o f the necessity for healing to take place during rest and adequate splintage. Inadequate appreciation o f th e need for prolonged rest in the severe sprain, accounts for the developm ent o f many chronic disabling back conditions. By contrast, the minor strains respond dram atically to heat, gentle massage, local aneasthetic infiltration, hydrocortone and activity. T h at these injuries in the distribution o f the posterior prim ary, divisions o f the spinal nerves can become trigger points o f irritation w ith referred pain down the leg, is gener­ ally accepted and it is com m on practice to block these points w ith local aneasthetic w ith relief o f referred pain, to dis­ tinguish this type o f case from a genuine ro o t compression causing sciatica. T he next problem in our rath er empirical approach to clinical medicine, lands us in a quagmire, nam ely th at o f Congenital Anomalies. Ons is impressed by the recent analysis at the University o f H elsinki by Bistrom who analysed 151 cases o f men doing heavy m anual work a t all ages, and found Congenital Anomalies in 58; there were 13 cases o f Spondylolisthesis; 8 of Spondylolysis; 2 o f Spina bifida; num erous transitional vertebrae at L5 level; 25 cases o f Sacralisation o r lum barisation; an d 10 cases had a trans- versosacral jo in t on one side only. N one o f this series had backache o r any o th er symptoms. Such a finding justifies caution in th e evaluation o f back symptoms. Some loose thinking has crept into orthopaedic practice. T here is a tendency to assert th at once a w orkm an in th e third decade o f life develops a clinical aggravation of a pre-existing Spondylolisthesis o r pain in a transversosacral joint, th a t sym ptom s are likely to persist. In private practice, conservative treatm ent m ay restore the pre-accident state, but in industrial practice with the tardy response to tre a t­ ment, the surgeon not infrequently succumbs to th e desire to do- som ething drastic, even operation, in his wish to finalise a case with intractible symptoms. T he surgical approach to those cases o f Congenital Low Back Anomalies requiring treatm ent, is a com plicated one. We cannot genuinely assert th at our practice in this respect, a t present, is logical and based on an adequate analysis o f m aterial. Surgeons have preferences for different techniques and th e standard answ er for a problem such as Spondylolisthesis has no t yet been agreed upon. D ISC IN JU R IE S . T he degenerate changes in discs have already been des­ cribed. A t all stages traum a may precipitate, accelerate or aggravate th e condition. I t appears to be well-accepted th at degenerative changes appear at an early age but is not detachable clinically until the condition is advanced. Actual prolapse o r herniation o f a disc implies old o r pronounced degeneration as. a pre-existing condition in m ost cases. Massive acute prolapse after great violence m ay occur in young people under the age o f tw enty and is then usually associated with gross neurological signs even as extensive as paraplegia. Pathological studies ap p ear to indicate th a t in the upper spine the degenerative changes are diffuse but in the lower 2 spaces the weakness develops mainly posteriorly. A pparently increased pressure on th e posterior com m on liga­ m ent causes pain. D isc degeneration is a much m ore comm on cause o f low back pain than lum bosacral anomalies. Instability o r sliding m otion o f vertebrae bodies is an early sign o f disc degeneration and loss o f fulcrum function. T he differential diagnosis o f prolapsed disc includes con­ ditions such as ankylosing spondylitis, osteomyelitis o f spine, neoplasm o f any o f the related structures, chronic infections such as tuberculosis and a large variety o f soft tissue strains in the sprained back category. T he problem o f the coincidental occurrence o f a V ertebral body fracture and a traum atic prolapse o f a disc a t a different level, occurs occasionally. I t is clear that the responsibility of diagnosis in these cases is n o t always sufficiently appreciated. T he indiscretion o f subm itting such spines to treatm ent by physical m ethods is obvious. H ow interm ittent traction, o r head-halter traction o r m anipulation can have any perm a­ nent beneficial effect on pathology o f this type, is beyond understanding. A CCESSORY M E T H O D S O F IN V ESTIG A TIO N M yeolgraphy has inadequacies for diagnostic purposes under som e conditions and laterally placed prolapsed discs R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page Six P H Y S I O T H E R A P Y September, 1957 do no t necessarily indent the colum n o f pantopaque. In certain individuals the neural canal is narrow er than usual. A negative o r inconclusive myelogram need not be a deterrent to surgery in the face o f clear clinical findings. Patients, therapists, and doctors sometimes attach undue value to a negative myelogram . ■ Discography has certainly gained a place in preoperative diagnosis and will som etimes show a degenerative disc with diffused and dissipated opaque pyelosil a t the L4-5 level, and a norm al disc at the level L5-S1, when the reverse is expected on clinical grounds. W hen a tum our is suspected, a surgeon will usually prefer myelographic investigation. T here are technical difficulties in the interpretation o f discograms but greater experience is being acquired in this field. Surgical treatment: T rue perspective tow ards operation is developing as a result o f intensive study and statistical re ­ search. Surgical treatm ent is absolutely indicated only for sudden severe neurological disturbance. Even the worst cases, low back pain and sciatica, due to prolapsed disc, are am enable to conservative methods in any particular attack. R ecurrent severe incapacitation in relation to work and way o f life is the m ore usual justification for operation. Much harm is still done in disc surgery under circumstances where technical skill o r facilities are inadequate. B ut this statem ent m ay be true o f any field o f surgery. P R E -E M PL O Y M E N T EXA M IN ATIO N F o r many years it has been com m on experience in indus­ trial medical practice that one o f the m ost costly disabilities, from the point o f view o f loss o f time and perm anent dis­ ablem ent, is low back strain and its consequences. In recent years pre-em ploym ent radiological surveys o f the lum bosacral spine has been perform ed in some indus­ tries, especially in America. Examination o f this type reduces losses from the com pen­ sation point o f view just as aptitude testing has become an accepted technique in placem ent o f employment. By avoiding the placing in wrong em ploym ent, a weak spine can be saved from crippling strain. It is surely better for th e indi­ vidual with an architecturally weak spine to seek less arduous employment than to attem pt w ork beyond his pow ers and to become disabled to a severe degree. Even in the event o f a' man being accepted for employment with a defective back, the previous record of pre-existing defect would be valuable. It is not claimed that this procedure is a panacea for the problem o f com pensation claims due to injury o r strain o f the low back. A Study perform ed by the American L ocom o­ tive C om pany, New Y ork, on a series o f 4,654 cases, found 25.44 % which showed defects which the authors o f the paper regarded as o f actual or potential clinical significance. A bout 10% o f applicants were rejected for employment because of gross defects. The tendency is to adopt even m ore rigid standards o f acceptance. So many cases o f back injury fall within the field o f W orkm en’s C om pensation th at it is o f interest to discover that the C om pensation Act as it functions in New Y ork State, is m ore o f an economic detrim ent than a boon to the injured workman. In 160 cases which collected com pensation, th e review showed that 20% were consistent with degeneration of lum bar disc while in 80% an anxiety state was revealed by the presence o f multiple, unrelated complaints, failure to establish a firm clinical diagnosis and psychiatric findings o f intrinsic factors in the patient’s personality, extrinsic factors associated with litigation, all o f which resulted in failure to achieve rehabilitation up to the time o f the assessment o f the claim. O ur main hope appears to be in the field o f reducing the num ber o f cases where we are dependant upon subjective symptoms by greater accuracy in objective evaluation. It is hoped that in this field discography will assist in reducing guesswork and increasing the num ber o f cases in which' objective analysis is practicable. A positive, constructive, optimistic attitude is required for primary rehabilitation o f the man with the injured back. M ore workmen can be restored to activity, industrial m an­ power can be saved and the ascent o f C om pensation can be reduced. Fractures: Touching briefly on the problem o f compression fractures, it should be recorded .that m inor and moderate stable compression fractures are no longer immobilised in plaster caste but the probability exists th at cases requiring enough rest to consolidate and scar up, m ay be mobilised too soon by those who over-enthusiastically try to prove their dislike o f hyper-extension casts. Inadequate X-rays m ay fail to dem onstrate disruption of endplates and herniation o f discs into the vertebral body and lead to inadequate immobilisation, and a crop o f late, painful, unstable backs with subluxated paravertebral joints may be anticipated. . Disability evaluation: C omparatively few surgeons have the opportunity o f seeing large num bers o f injured backs, especially since the entire profession is now participating in this field o f medical service. It is one o f the doubtful benefits o f the “ free choice o f doctor” principle. Much attention in this field o f surgery is being devoted to the evaluation o f the effectiveness o f the p atient’s doctor in this role. In 1955, Kessler reviewed the work on 23,000 cases o f low back pain assessed under the W orkm en’s Com pensation ini New Y ork in one year, in 1952. Cases involving soft tissue only averaged 46 weeks o f tem porary total disability, as contrasted with six weeks in non-industrial cases. In cases of bone injury the tem porary total disability period averaged 232 weeks, i.e. 4 i years. In non-industrial cases the average was 6 months. I t is appalling to think th at the injured work­ m an was off ten times as long as the average private case. C O N C LU SIO N In this country the evils o f compensitis have only appeared occasionally. The im pact o f unfair claims on accident funds and insu­ rance carriers has been comparatively slight. There is need, however, for firm action to back injuries to prevent such eventualities. T he isolated practitioner who sees an occasional case of back injury, is handicapped in his attem pts at getting such a m an back to norm al activity in minim um time. Fortunately, there are developments in a num ber o f large centres in South Africa, which indicate a m ore realistic and effective approach to the problem o f the injured person. A team o f doctor, physiotherapist, occupational therapist, social worker, placem ent officer and others, can deal much m ore efficiently with these problems. T he establishm ent of th e R ehabilitation Association for Injured W orkm en by the D epartm ent o f L abour was a progressive move. T he pilot scheme, the W orkm en’s R e­ habilitation C entre, is a small beginning o f an im portant/ social service in this comm unity. f As the chronic crippling diseases and poliomyelitis are m ore effectively com bated, the accent will increasingly shift to traum atic work. GENERAL Miss E. Botting, the Journal Editor, is at present overseas. We would like to wish her a very happy stay, and wish Mrs. Botting a speedy recovery from her recent operation. Miss J. Blair, the Society C hairm an, has recently returned from a m onth’s to u r o f the Rhodesias. Miss M. Hinz, from Pretoria, and Mrs. H. B. H ope, from England, are welcomed on to the Physiotherapy Staff o f the University o f the W itwatersrand. M rs. J. Jooste and Miss J. Crewe Brown, both from Pretoria, are welcomed on to the staff o f th e Pretoria H ospital School o f Physiotherapy. We wish good luck to Miss M. M organ and Miss M. E. Rehfeld, who have left Pretoria for overseas, the latter to take her teaching diploma. Miss J. M uller, an ex Pretoria student who has been w ork­ ing at Stoke M andeville H ospital, is now proceeding to C anada for further experience. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )