June, 1 9 7 0 T have read this article carefully and agree with it entirely. T firmly believe that the pulmonary ventilation o f the normal pregnant woman is adequately served by normal snontaneous breathing and cannot accept that any special patterns of breathing will really improve on this state of affairs. The only possible advantage, that might accrue to the nreenant woman who has received special breathing exer­ cises is a psychological one. It may give her something to concentrate on in early labour and this may give her the feeling that she can do something active “to help” during the first stage of labour. Conversely, this may result in a feeling o f guilt towards her baby if in the later stages of labour she finds herself unable to maintain the pattern of breathing that she has been taught. In the second stage I agree that training does increase the ability o f the patient to co-operate with bearing down efforts—especially at the point o f crowning o f the foetal head. In my opinion Dr. Blankfield’s article is a well balanced and clear assessment o f the subject o f breathing in pregnancy and labour. It is an article that must be welcomed and is long overdue. It will help clarify a field that has, in recent years, become clouded and confused with unscientific methods and claims bordering on witchcraft. I am, Yours sincerely, L. van D on gen Professor o f Obstetrics and Gynaecology, University o f Witwatersrand. Page 5P H Y S I O T H E R A P Y C R O N IC L O W B A C K A C H E in the M ID D L E -A G E D W O M A N MICHAEL ADLER, M.B.Ch.B., F.R.C.S. (Ed.), F.R.C.S. (Glasgow) Department o f Orthopaedic Surgery and W ULF. H. U TIAN , M.B.B.Ch., M.R.C.O.G., Department o f Obstetrics and Gynaecology, Groote Schuur Hospital and University o f Cape Town Back pain may be described as a universal symptom. Almost everyone suffers from backache at one time or another in their lives, and some have it more or less con­ tinuously, but only a proportion o f those who suffer from it, complain o f it. Women are more prone to the condition than men because o f hormonal influences, changes o f posture during pregnancy and because gynaecological disturbances may cause backache. The complaint is often suffered in silence. Many people believe it is a normal sequel to childbirth or a natural accompaniment o f the menopause. It is a subject which is often dismissed lightly, but much discomfort and disability can be ameliorated. fre.quency w*th which long standing symptoms in the . a neurotic personality coincide is notorious, what u a Psych°somatic disturbance, and inevitably, ,„mi u , cause, it is very likely that sooner or later there w be psychological implications. ofTup treatment o f backache demands the time and patience e practitioner. Backache is seen in equal numbers by the gynaecologist and the orthopaedic surgeon. There is in fact an organic cause to nearly every complaint in the back. The assessment o f the severity o f pain, the cause o f it and the treatment best fitted to the individual patient remains one o f the more difficult problems in clinical medicine. It is by no means possible to arrive at a precise diagnosis, but the attempt must be made, for it is unusual to identify the specific structure causing pain in the back, even when X-ray changes are present. N ot many years ago, the concept o f the slipped disc came into vogue. Doctors jumped at this notion as a gift from heaven and the diagnosis was exploited so that slipped disc became the diagnosis for almost every backache. The subject is complex. Almost any structure in the spine can in fact cause pain. Furthermore, many abdominal or pelvic organs can cause pain referred to the back, that is, seeming as if it were coming from the back. Backache is a symptom and not a diagnosis. It presents frequently as an entity (as does headache). To simplify the matter therefore, it is useful to classify backache into a number o f clinical syndromes, since every 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 6 P H Y S I O T case can be so correlated with one o f these syndromes, making, both treatment and prognosis clearer. In practice also, it is far easier to recognise the syndrome to which a particular case belongs than to attempt to diagnose a complicated and usually controversial pathology. c A s mentioned above, the elucidation o f the nature o f the backache requires time. The history must be detailed enough to give a complete mental picture o f the onset o f backache and its course. General symptoms and complaints other than the backache must be asked for as they may be highly relevant to the diagnosis. Next o f importance is a detailed physical examination. This involves a general examination o f the patient as well as a local examination o f the spine in motion, standing, supine and prone, and a detailed examina­ tion o f the central and peripheral nervous systems. A gynaecological examination should be made if the symptoms point to it. A n X-ray examination is an essential accom­ paniment, and further modern and sophisticated investiga­ tions can be performed if indicated. THE SYNDROM ES OF BACKACHE IN THE OLDER WOMAN A. GYNAECOLOGICAL BACKACHE Backache that results from a gynaecological lesion is diffuse in nature. The pain results from involvement or extension o f pathological processes into the utero sacral ligaments and hence is always sacral or lumbo sacral in situation. The pain may be uni- or bilateral. Point tenderness is never a feature. The possible causes o f gynaecological backache are as follow s: 1. Menopausal backache and osteoporosis Recent research has shown a relationship to exist between ovarian endocrine function and the density o f bone. Osteo­ porosis is a metabolic disease o f bone characterised by a disturbance between bone formation and resorption. The main disturbance is an increased resorption o f bone which is related to production o f hormones. The osteoporosis com­ mences or accelerates in women soon after the natural or induced menopause and it does seem that osteoporosis is related to endogenous oestrogen deficiency. Recent work has tended to show that osteoporosis is more likely to develop when both calcium and sex hormones are deficient. Whatever the pathogenesis o f the disorder, the effect is a rarification o f the bone. Nevertheless, while reduced in quantity, the bone is essentially of normal chemical com­ position. Osteoporosis is probably the commonest cause o f chronic backache in the elderly patient. Although all parts o f the skeleton are affected, the spine and pelvis are more extensively involved than other parts. Radiologically there is rarification and collapsed vertebrae are often seen. The pain is characteristically worse when the patient is up and about or tired and is accompanied by rounding o f the back and loss o f stature. A t present it appears that removal o f normal ovaries from a female o f reproductive age will certainly result in osteoporosis. Administration o f exogenous natural oestrogens may prevent the development or extension o f this process. Unfortunately, there is no evidence as yet that such female hormones can cure or improve osteoporosis once it has developed. H E R A P Y June, 1970 2. Chronic Pelvic Sepsis as a cause o f low backache results from extension o f infection into the uterosacral ligaments. 3. Uterine prolapse: by dragging on the attached ligaments may cause pain in the lower back. Classically the pain is immediately relieved by lying down. 4. Tumours. Neoplastic lesions directly infiltrating the utero­ sacral ligaments may cause unilateral or bilateral low backache. The commonest tumour in this respect is advanced cancer o f the cervix. Endometriosis may also produce backache in this manner. Large abdominal tumours may cause backache purely as a result o f their weight and bulk and the subsequent strain on the back caused by a change in posture. 5. Gynaecological operations may cause pain in the back as a result o f incorrect positioning or handling o f the anaesthetised patient. TREATMENT The treatment o f backache o f gynaecological origin is that of the cause. This necessitates meticulous diagnosis. Prevention: A discussion such as this would be incomplete without some comment on prophylaxis. The following factors are important if backache is to be. minimised in the female. 1. Antenatal and postnatal care Incorrect management o f the pregnant female may be a cause o f ligamentous strain and subsequent backache in later life. This management includes advice with regard to correct posture, clothing and footwear, ante and postnatal exercises and avoidance during labour o f situations imposing excessive strain on the back. Postnatal exercises imply long term exercises. The patient should be advised and encouraged to perform a few basic abdominal and back muscle exer­ cises daily for years. Housework, irrespective o f how fati­ guing this may be, does not act as a substitution for a planned exercise programme. 2. Retention of ovaries at gynaecological surgery Premature removal o f the female ovary has been shown to result in a negative calcium balance and the subsequent development o f osteoporosis. It is therefore incorrect for the gynaecologist to remove ovaries o f normal appearance at the time o f hysterectomy on women o f reproductive age.1 B. ORTHOPAEDIC BACKACHE The causes o f orthopaedic backache are extremely numerous. For simplicity sake, it is convenient to arrange them into Mechanical and Pathological groups. In the first type, the bones and tissues themselves are normal, but there is some displacement o f the normal relationships. These include derangements o f the inter- vertebral disc, movement o f vertebrae one upon the other, injuries o f the back, and chronic postural strains. In the second type, there is some pathological process involving the bones themselves, be it biochemical, infective or neoplastic. I. Mechanical causes o f backache 1. Intervertebral disc displacements The intervertebral discs are situated between adjacent vertebral bodies. The disc itself is a jelly like substance 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. ) June, 1970 P H Y S I O T H E R A P Y Page 7 contained in a fibrous ring and under certain circumstances and especially in the lower lumbar spine, it may herniate anteriorly and press on emerging nerve roots, and stretch ligaments, and low back pain and sciatica result. The patient is generally well. There may have been previous episodes of low back pain and sciatica. The c la ssic a l attack starts acutely while the patient is bending forward and trying to lift a heavy weight, and the pain is usually felt in the back and down one leg; this pain is worse on coughing and straining. There are typical local signs o f tenderness, muscle spasm, and perhaps scoliosis. Neurou- logical signs from pressure on affected nerve roots may be found. X-rays may show no abnormality, a diminished disc space, or signs o f osteoarthritis. T r e a tm e n t consists o f strict and complete recumbent bed rest with traction to both legs for at least 10 days to three weeks. Afterwards, back strengthening exercises and pos­ tural training are important. A plaster jacket or a corset may be needed for a time when the patient gets up. Only in resistant cases is further special investigation necessary and laminectomy and surgical removal o f the disc necessary. 2. Acute traumatic injuries are usually followed imme­ diately by severe pain. Spinal injuries may be stable or unstable. The fracture is treated on its merits. If there is no X-ray abnormality, the soft tissue injury is generally not serious and with adequate rest, full recovery can be expected. Almost everyone at one time or another hurts or strains his back, either from a heavy fall or a blow, but only very rarely does the episode cause pain and disability. 3. Chronic postural strain. This is characterised by long­ standing aching pain in the back perhaps radiating to buttocks and thighs, aggravated by stooping, and punc­ tuated by remissions and exacerbations. The middle aged woman frequently complains o f low backache, especially after a day’s work, and worse on being tired. It does not usually keep her from her activities. The key to diagnosis is therefore the history, for both physical examination and X-rays are negative. 4. Spondylolisthesis: Slipping o f one vertebra on another is known as spondylolisthesis. It is a rather rare abnormality. It may cause episodes o f low backache and the diagnosis is established with the help o f X-rays. Immobilisation in plaster or a corset may provide relief but if displacement is narked, surgical fusion o f two vertebrae is usually lecessary. II. The pathological syndromes o f backache 1. Osteoporosis has already been mentioned as being one of the most prominent causes o f backache in the elderly female. The effects o f osteoporosis occupy a considerable portion of the practice o f an orthopaedic surgeon. 2. Osteoarthritis. This is a condition which involves the degeneration o f joints as a whole, especially articular cartilage, associated with advancing age. TTie involved joints become stiff and painfuL The spine is often the site for osteoarthritic changes, and many cases are diagnosed by the incidental finding o f osteoarthritis o f the spine on an X-ray when looking for some other pathology. 3. Acute and chronic infections These should always be excluded in any case o f low backache, as this may be the only symptom indicating the onset o f a disease process. 4. Primary and secondary neoplasms Severe backache in the elderly always raises the possibility o f a neoplastic deposit in the spine. The pain is usually continuous at rest and often worse at night. X-rays may indicate such a lesion, and common sites for a primary should be sought. 5. Rheumatic backache There is a group o f conditions which includes rheumatism, fibrositis, lumbago, sciatica and arthritis. Recent investiga­ tions have tended to deny the existence o f such conditions, but nevertheless there does appear to be a general condition o f rheumatism to which certain types o f people appear prone. The intricate complex o f joints, ligaments and muscles that constitute the lumbar and sacral spine provide infinite and varying possibilities for the source o f pain and the site o f a disease process. Sometimes tender nodules may be felt in the soft tissues, the exact nature o f which are poorly understood. The term fibrositis may well be applied to this condition. The nodules often act as trigger points from which backache may originate. TREATMENT With such a bewildering array o f possible causes for backache, it is not surprising that successful treatment can be so elusive. In general, treatment follows one o f two lines: 1. Conservative treatment Positive treatment often cannot be prescribed even for the more clearly defined conditions. In many cases o f long standing low backache which are not discogenic, treatment may take the form of: (a) Physiotherapy—exercises to strengthen the back and teach posture. Mobilisation exercises, massage, short wave diathermy and ultrasound and intermittent traction may all prove helpful in the appropriate case. (b) Local injections o f anaesthetic agents and hydro­ cortisone into tender areas may be extremely useful. (c) Braces or corsets, to relieve strain on ligaments; these should always be supplemented with exercises. In some cases, physical habitus and posture may suggest that defective posture is the cause o f backache, and postural exercises and training are indicated. 2. Surgery The place o f surgery in low backache should be reserved for the relatively few clear cut indications. Operations for removal o f discs and release o f pressure on nerve roots is already a well established procedure. This is usually under­ taken only after controlled and energetic conservative measures have been tried and have failed. Fusion o f the spine is seldom undertaken for low backache due to the lack o f precise indications for surgery, and to the technical difficulties in securing a sound fusion. It is one o f the fundamental principles o f orthopaedic surgery to fuse a painful joint. Few patients with low backache have a structural abnormality that can be detected radiologically. Even when X-ray changes are present, it is usually impossible to say that the causes o f such changes are the causes o f low back pain. Degenerative changes per se are no indication 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 8 P H Y S I O T H E R A P Y June, 1970 for surgery because conservative treatment will give satis­ factory results in more than half the patients. Indications for fusion are therefore clinical rather than radiological as studies have shown the similarity o f symptomatology no matter what the pathology. In a proportion o f cases therefore where there is persistant long standing low back pain that fails to respond to conservative measures and when the degree o f degeneration warrants it, fusion is indicated. CONCLUSIONS The problem o f low backache in the elderly female is thus seen to be a bewildering and difficult subject. An attempt has been made to explain the various causes o f low backache and to simplify the problem by classifying the various possible causes into a group o f clinical syndromes. Each group is described separately and the methods of examination, diagnosis and treatment are discussed. It is important to make a full assessment o f the individual patient including her mental makeup, her environment, and the physical lesion. A N A T O M I C A L FEATURES OF THE L U M B O S A C R A L SPINE By R. TREVOR-JONES An interesting collection o f abnormal lumbar vertebrae and sacra are housed in the Department o f Anatomy, Medical School, University o f Cape Town. This material inspired me to investigate the musculo-skeletal anatomy, as seen in the dissecting room, in an attempt to explain certain aspects o f backache. Clinical records o f the subjects dissected were too brief for any correlation o f findings and'symptoms. The lumbo-dorsal fascia varies in thickness and over the sacrum blends with the fascial origin o f the erector spinae muscle. From the erector spinae aponeurosis inter-muscular septa pass forwards to separate Multifidus completely from the sacro spinalis group o f muscles. . Multifidus arises from the dorsum o f the sacrum, the posterior medial edge o f the iliac crest between-posterior superior and posterior inferior iliac spines, the deep surface o f the combined lumbo-dorsal and erector spinae fascia and the medial surface o f the intermuscular septum which separates it from Longissimus. The intermuscular septum, in its upwards extension is attached to the inferior aspect of the mammillary processes while Multifidus arises from the superior aspect as well as the inter articular joint capsules. Careful dissection reveals that Multifidus can be separated into sagittal lamellae arranged segmentally although the muscle looks like a solid wedge. That portion medial to the posterior inferior iliac spine passes to the sacrum and lower four lumbar vertebrae while the portion from the posterior superior iliac spine passes to first lumbar and twelfth thoracic vertebrae. Longissimus and Iliocostalis have a common origin just lateral to the posterior superior iliac spine, from the erector spine, from the erector spinae fascia and from the lateral surface o f the intermuscular septum separating it from Multifidus. It can be divided into coronally placed musculo- tendonous lamellae passing to the accessory tubercles and adjacent laminae o f the lumbar vertebrae. Ilio-costalis is separated from Longissimus by a neuro­ vascular plane and an intermuscular septum. This muscle also can be separated into coronally placed lamellae passing to the transverse processes o f the lumbar vertebrae. The outer portions o f these lamella are formed into encircling loops which, with the erector spinae fascia and lumbar fascia firmly enclose the back muscles in the lumbo-sacral region. This segmental pattern is found in foetuses. Multifidus then has sacral segments. A six piece foetal sacrum was associated with incomplete muscle segmentation. This lack o f muscle differentiation was also found in an adult cadaver with a sacralisation o f the fifth lumbar vertebra on the left side. The muscle anomaly however occurred on the 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. )