LUMBAR DISC HERNIATION T H E E F F E C T O F T O R Q U E ON ITS C A U S A T IO N A N D C O N S E R V A T IV E T R E A T M E N T A P R E L I M I N A R Y R E P O R T Carl W . Coplan., M .R .C .S. (E n g.), L .R.C.P. (Lond.), D. Phy*. Med. (R.C.S. & P.)* Departm ent o f O rthopaedic Research, University o f Cape Town Reprinted by kind permission of the author, and the South A fric a n Medical Journal. Page Two ______ P H Y S I O T H E R A P Y __________ _________________ A p ril 1952 'T 'H E surgical approach to the problem of low back pain is o f comparatively recent origin and it is r-alutary, at thi.s time when laminectomy is becoming an increasingly common operation, to consider a new approach to the conservative treatment of lum bar disc herniation. Before the recognition of lum bar disc pathology as a common cause o f low back pain, ‘lum bago’ was treated by a succession of methods in which empiricism was the common denominator. One of these methods still sur­ vives topically and its use in most cases is just as empirical to-day as it was when the pathology of disc herniations was unrecognized. The patient with low backache inevitably submits himself to some form of manipulative procedure either by a registered or un­ registered practitioner. A consensus of standard works on m anipulation shows that the most commonly employed manoeuvre in the treatment of low back pain is the ‘pelvic twist’. Thi.s method is almost universally described and may be perform ed with or without anaesthesia. I'i;/. 1. The Pelvic Twist. The most commonly employed manoeuvre in m anipulation of the spine. The patient lies supine upon a suitably low couch and one shoulder is fixed by the operator’s hand while the homolatcral hip is forcibly rotated across the mid-line o f the body so that a twist is set up on the spine (F ig . 1). The operator moves to the opposite side of the patient and the same manoeuvre is performed using the contralateral hip and shoulder. This bilateral m anipulation is w ithout logical basis and is an empirical relic of the D a rk Ages of ‘lum bago’ when, w ithout critical diagnosis, m anipulation w'as performed for its blunderbuss effect. Most standard anatomy textbooks are emphatic that little or no rotation take place in the lum bar region of the vertebral column. *■’ These textbooks further point out that rotation is confined to the thoracic region. Brailsford,* however, follow ing the preparation of a cine X-ray film showing the movements of the spine, states that there i= a much greater degree of lum bar * Honorary Specialist in Physical Medicine to the Cape Town Free Dispensary and the Somerset Hospital. rotation than lias previously been ascribed to this j region. X-ray films taken by the author appear to con­ firm this statement. B la ir’ states that some pure rotation of the lum bar spine does take place, par­ ticularly in the lower part of the lum bar vertebrae owing to the laxity of the synovial joints. A series o f X-rays was taken to demonstrate thr amount of rotation possible in the lum bar vertebra^ joints. T w o are published in this preliminary com- i munication. Fig 2B represents the A-P view of a healthy male of 19 years. The pelvis was fixed and the lum bar region extended; the shoulders were then | passively rotated on the pelvis. There is some slight J latero-flexion, but it takes place high in the lumbar spine. It w ill be seen that rotation increases pro­ gressively from L 4, 3, 2 up to the thoracic vertebrae. 1 A stationary spine w ithout any attempt at movement is included for comparison (F ig . 2 A ). Fig. 3 represents the A-P view of the lum bar spine of a female dancer of 16 years. There is considerably more rotation than in the previous film. There is no latero-flexion. It was taken under the same conditions^ as Fig. 2, but latero-flexion was avoided by passively controlling the subject’s movement. I f free rotation takes place in the thoracic spine 1 alone, then it must be confined to the lower thoracic I spine, since the upper thoracic vertebrae are effectively, I splinted by the seven true ribs which, w ith their direct I attachment to the sternum, must lim it rotation to s o m e ! degree.'” It is accepted that the costo-transverse and costo-1 vertebral jo in t excursion is mainly concerned wittag respiratory movements. There exists, therefore, a group of 10 vertebrae I which link a relatively fixed portion o f the spine (the upper seven thoracic vertebrae) to an absolutely fixed I foundation, the sacrum. It is through this link of 10 vertebrae that the torsional forces of rotation must be distributed, the main burden of which is felt in the , lower lum bar spine where its firm anchorage to the I sacrum is encountered. The axis of rotation of the I lum bar spine is through the bodies of the vertebrae I and it is postulated, therefore, that the intervertebral I discs suffer distortion and sustain a great measure of I the torsional strain (hereafter referred to as to rq u e ).! It is interesting to conjecture, at this stage, on the 1 functional anatomy of the discs themselves. The in-1 ferior surface of one vertebral body is united to the I superior surface of the vetrebral body below it by the ( fibro-cartilaginous disc. The peripheral part of thisj structure is called the annulus fibrosus and is composed I o f dense fibro-cartilage. The fibres run obliquely be-j tween the two vetrebrae and are arranged in concentr'‘‘* 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. ) April- 1952 P H Y S I O T H E R A P Y Page Three Fig 2. (a) Resting spine, (b ) Lum bar vertebrae showing rotation. kF '9 3' Lum bar vertebrae l o w i n g rotation (dancer, ,«•/ 16) A creator degree of rotation i- demonstrated here. rings, the fibres in successive rings havinc: opposite obliquities.'1 The central part of the disc is called the nucleus pulposus and is contained in an envelope of fibro- cartilage which blends with the inner l a y e r s of the annulus. It is composed of mucoid material interlaced with fine fibres of fibro-cartilage. On each surface of the disc, above and below, there is a thin la\er of hyaline cartilage. The nucleus is under tension and bulges when the annulus is incised. It is believed that the tension is clue to pressure of the elastic fibres of the annulus and not to the expansile force w ithin the nucleus.'1 The disc distributes and transmits forces down the spine and allows segment mobility. It would seem from the mechanical design of the ~'sc ^ a t it is well able to adapt itself to the torque that is thrust upon it. As the force o f the torque mounts, the concentric laminae with their fibres run ­ ning in opposite obliquities would act as a circular Spring which winds and unwinds a< the torque varies m power and direction. It seems unlikely that the rotational clement in thoracolum bar vertrebrae, in view of the enormous forces that it has to sustain, could rease abruptly at an artificially delimited portion of the spine, hut rather that the mobile vertebral column would distribute its lorce= in relation to its entire archi­ tecture. Moreover, the 'shear’ forcc acting on the vertebral body tends to rotate the \ertebra causing a compression moment of this on the next lower disc.” It i> not the purpose of thi« paper to emphasize the degree of rotation that takes place in the lum bar spine, but rather to accentuate the torque that i> consequent, and which the author believes is the most important factor, in the production of disc herniation. If these mechanics of injury are accepted, then in­ creasing the traum atic torque (i e., the torsional force that has produced in ju rv ) will exaggerate pain and disability, the undermentioned clinical signs become understandable and aNo the principle may he applied in treatment. 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 Four P H Y S I O T H E R A P Y April, 1952 W h e r e the diagnosis of lum bar disc h e rnia tio n has been m ade, the fo llow in g two clinical signs should be elicited': .1. The p a tie n t lies supine and the m anoeuvre de­ scribed earlier in this paper as the ‘pelvic tw ist’ is perform ed gently, b u t w ith as full a range as the patient's pain perm its (F ig . 1). I t w ill be found th a t rotatio n of the pelvis w ith the h o m olateral s.houlder fixed is in v ariab ly m ore p a in ful to one side th a n to the other. T he direction of the m ovem ent causing pain is noted, e.g., rig h t hip rotated to left w ith rig h t shoulder fixed to the couch, more painful than vice versa. 2. T he p a tie n t'is now put in to the prone position an d asked to relax as m uch as possible. S tro n g lateral pressure is applied by the th u m b at rig ht angles to the lu m b a r spinous processes on one side, co m m encing at L I a n d w o rk in g caudally. A s the suspected level of herniation, is approached, it w ill ,be found th a t intense d iscom fort and an increase in root pain (if present) w ill take placc. - T he opposite side is now exam ined in an identical mariner. I t will be f o u n d t h a t .there is little o r no intensification of the local or referred pain. The force directed at the sides of the spinous processes sljould be. of. a m a g n itude such a s. the exam iner would- use if he was a tte m p tin g to elicit m ovem ent of the spinous process in the direction of the applied force. If the two signs are co-ordinated it w ill be found t h a t : 1. I f the rig h t hip rotated to the left w ith the rig ht shoulder fixed produces pain a n d vicc versa is painless t h e n : .. 2. Pressure along the left sides of the spinous pro ­ cesses a t the level o f the h e rnia tio n w ill produce pain, the spinous process im m e d iate ly above the herniate d disc b ^ in g the m ost p a in ful. I t isi im p o rta n t th a t this pain be d ifferentiated from paras.pinal tenderness. T his is due to pressure on the bellies of the erectores spinae w h ich ,are in reflex spasm fo llow in g disc he rniation . P a in produced by pressure on these muscles is of a more diffuse char­ acter and .root p ain is not increased. I t is postulated th a t pressure in the m an n e r de­ scribed on the sides of the spinous processes, produces a m o m e n t of torque upon the vertebra w h ich is in the same direction as the torque produced by the ‘pelvic tw ist.’ B o th these torsional forces are k n o w n as traum atic torque. T orsional force in the opposite direction to the above, is kn o w n as ‘counter torque’ and is utilized- in treatm ent. •T he auth o r w ishes to m ake it clear th a t he d o e s ’not hold th at the torsional stress is the o n ly factor in the production of lum bar disc he rniation . H e is well aware of the o ther stresses th a t exist, but he regards them as being ancillary to the traum atic torque. , It is intended to publish an analysis of the total forces acting on the lum bar spine in the m ore com pre­ hensive paper th a t w ill follow this p re lim in a ry report. T O R Q U E I N T R E A T M E N T A n im p o rta n t p re lim in a ry to tre atm e n t is the assess­ m e n t of the d irection of traum atic torque, w hich should be done in the m a n n e r described above. A broad padded canvas sling is placed under the p a tie n t’s chest a n d ' a sim ilar one under the knees. T he patie n t is then suspended some two feet above the p lin th by means of a G uth rie S m ith Suspension Apparatus'. T he position of the patie n t is sim ilar to th at which he w ould occupy if he was havin g a spinal plaster put on for a fracture of the dorsal vertebrae. I n this position ,the lum bar spine is in extension and conse­ quently, w hen counter torque is applied, rotation and torsional strain w ill be effective in this part of the spine. T he patie n t is now placed in counter torque, e.g., if in S ig n (1)— r ig h t .h ip rotated to left with rig ht shoulder fixed is p a in fu l; and if S ign (2)— pressure on the left side of the spinous processes at the suspected level of the disc is m ore p a in fu l than pressure a t the same level on the opposite side. Then the patie n t is slung in counter torque as follow s:— W it h the patient in prone suspension, the left shoulder is supported so th at it points upw ards and traction is applied to the left hip so th a t it is rotated* dow nw ards (F ig . 4). A special belt' has been designed for this latter purpose. I t is applied just above the level of the greater trochanters and buckles above the pubis. The body of the belt encloses a sheet of steel so devised th a t it allows a rigid rod to slide o bliquely from one -side to lth e o th e r; at the free end of this rod, a weight sufficient to produce rotation of the pelvis is attached (Figs. 4-6). T he p a tie n t’s h e a d ' is contained in a sling and the left ,arm is sim ilarly supported. The shoulder and knee slings are' now adjusted so that counter torque produces its m a x im um effect, e.g., left shoulder stay raised,, rig h t shoulder stay lowered; left knee stay lowered, rig h t knee stay raised. A n ultra-short wave d iath erm y d ru m is applied to the lum bar spine in order to dim inish muscle spasm, and the patie n t is left suspended Tor 20 m inutes. ,After com pletion of treatm ent the patient should be lowered to' the p lin th w ith the utm ost gentleness. T his form of therapy m ay be used for both acute and chronic lum bar disc herniations. A cute disc herniations are treated twice daily un til there is a, rem ission of sym ptom s and thereafter daily until sym ptom free. C hro nic disc herriiations are treated once daily u n til sym ptom free. U p o n cessation of treatm ent, counter torque and lum bar extension exer­ cises are advised and the patie n t is fitted w ith a shorl G old th w aite brace. This is w orn for a period of two m onths. I t w ill be noted that the purpose of this type of suspension is to produce the resultant of two forces upon the lum bar spine. These are': Engineering Terminology 1. A n extension force Tension 2. A rotational force Torque I t has been found th at counter torque suspension compares very favourabh- w ith other modes of con­ servative th e ra p y . Its success w ill be evaluated in a more com prehensive paper to be published. It' should be added th at in no case have any patients’ symptoms been increased. 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. ) April, 1952 P H Y S I O T H E R A P Y Page Five 1. The ellect of torque on the causation of lum bar disc herniations is discussed. 2. A ttention i-- draw n to the raitL’c of rotation that exists in the lum bar spine. 3. T raum atic torque is elucidated and two signs for the recognition of its direction are described. 4. .\ method of conservative and am b ulan t tre at­ ment known as ‘counter torque suspension’ is described. A traction table, em bodying these principles, is now being constructed. This work ha.-, been done in the D e p a rtm e nt of O rthopaedic Research of the U niversity of Cape Town and I wish to thank M r. A rth u r ]. Helfet. M.Cli. (O rth .). b .k .C .S . (E n g .) of that D epartm ent and also Dr. Noland Singer o f the D ep artm e nt of Anatom y for their collaboration. A more comprehensive paper on this subject will be published at a lalcr date in association w ith Mr. Helfet and Dr. Singer. I wish to thank Drs. H. and B. H irsc h o n for the many X-rays taken by them during the course of this work, Dr. A. R eichlin for his encouragem ent and a d ­ vice and M r. M c M a n u s of the D ep artm e nt of Surgcr\ at O roote S chuur H ospital for the p h o to ­ graphs. The torque belt was made to my design by A. H . Hodges & Co. ( I ’ty.) Ltd., 164 Sir T.owrv Road, Cape Town. R E F E R E N C E S 1 Ellis, John D. (1940): The In ju re d Hack and its Treatment. Springfield, Illin o is : Charles C. Thomas. 2. Mennel, Jam es B. (1945): I ’hysieal I rcatmeut by Movem ent, M anipulation and Massage. London ■ J. & A . C hurchill. Ltd. 3. Fisher, T im brell A. G. (1944): Treatment by M anipulation. 4th ed. L o n d o n : H . K. Lewis & Co,, Ltd. 4. M arlin, T. (1934): M anipulative 'Treatment Ja r the General I'raetilioner. L o n d on : Edw ard A rnold & Co. 5. Gray (1938): A natom y, 27th ed. L o ndon: Long­ mans, Green tk. Co. h. Frazer, Ernest J. (1933) : The .-Inalomy of the H um a n Skeleton. London: J. & A. Churchill, Ltd. 7. Buchanan (1950): M a n u a l o f A natom y, 8th ed. London: Bailliere, T indall &: Cox. X. B railsford, James F. (1935): The R adiology of Hones and jo in ts. O x fo rd University Press. 9. Blair, D . M. (1937): In Cunningham 's Text Rook o f A natom y. O x fo rd U niversity Press. 10. Blair, D. M. (1937) : Ibid. 1!. Blair, D . M. (1937) : Ibid. 12. Spurling, R. G. and B radfo rd , F. (1939): I. A n u r . Med. Assoc., 113, 2019. 13. Thieme, Frederick P. (1950): L u m b ar Breakdown Ca-uscd by T.recl Posture. A nthropological Papers No. 4. University of M ichigan P r e s s . S U M M A R Y Thj. 4. Counter T o iqu e Suspension. Xotc the opposite planes of the thorax, and p e k is . T orsion on the lum bai spine must be achiexcd if treatm ent is to he cllective. hi'!. 5. Counter Torque Suspension. Oblique \iew Tiit. (i Conntei Torque Suspension. Oblique view 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. )