BACKACHE FROM THE STANDPOINT OF THE ORTHOPEDIST”

NATHANIEL ALLISON, M.D., F.A.C.S. BOSTON

T HE physica compIaint known as backache is so common, so variable, and so incIusive in its nature, in its

causes, and in its effects, that it is difficult to assemble the facts, to arrange these facts in any kind of order, and to make any useful deductions from what seems to be, for the present at least, a hopeless mass of unclassifiable chnical observations.

Among others, the orthopedic surgeon is thought to be the person who should be able to heIp the patient with backache. The orthopedic surgeon is credited with possessing not only the requisite knowIedge for accurate diagnosis, but also with having at his disposal methods of therapy that bring about rapid and complete recovery. In the attempt to fuIfiI1 this obligation many- discouraging and difficult obstacles 2re met.

In the first place, accuracy in diagnosis is dificult and at times impossible. In the second place, without accurate diagnosis, clinical deductions as to the effect of therapy- are uncertain and in many in- stances \.alueless and misIeading.

CAUSES OF BACKACHE

It seems feasible to look upon backache from two points of view: first, those backaches that are the result of definite lesions of the bones and articulations of the spine and pelvis; second, the backaches that have their origin in troubIes that ha\-e no association with lesions of the bones and joints of the spine or pelvis. The first group beIongs to the surgeon, especiahv to him who is known as an orthopedic surgeon. The neurologic surgeon aIso has a role to play with certain serious backaches. The second group belongs to

the general physician, the gynecoIogist, the genitourinary surgeon, the neurologist, and the physical therapist.

It is not my purpose to bring up all of the various causes of backache, except to indicate that the great majority of backaches mean IittIe beyond a short period of physical unhappiness. That this is true is shown by the widespread use of the porous plaster which feels so good on the back, of the kidney pills, and of the more or less gentle mrnistra- tions of the osteopath and chiropractor. If backache were not a \.-ery common human ailment, easily cured, certain it is that much of charIatanism and nostrum vending and manipuIative quackery wouId cease to be profitabIe.

It is not possibIe for me to explain why it is that backache is so amenable to what seem to be illogica methods of therapy. The fact remains that it is so.

In this second group of backaches are the so-called Iumbagos. This sudden acqui- sition of a very breathIess kind of backache seems to be very common; indeed, medicaI men are frequentI>- thus incapacitated; we call it Iumbsgo or myositis. Again, there is the backache associated with renaI caIcuIus, and those who have experi- enced the passage of a stone from kidney peIvis to bladder may we11 claim the distinction of knowing v-hat is really backache. The gynecological backaches are we11 known to those who have them and to those who have to treat them. I have heard it said that the backache of acute infectious disease is hard to bear, and it must be true that the backache associated with parturition is not negligible in quantity or quality; also, there is- the

262 American Journal of Surgery AIIison-Backache

tired Iame back of industry, and of bad posture associated with penduIous abdo- men. These backaches are secondary. There is an infinite variety, and the methods of therapy are muItitudinous.

As an orthopedic surgeon, my interest in backache begins when it is more or Iess evident that the particuIar backache in question is not of the secondary variety, by which I mean that it depends upon causes Iying outside of the muscIes, bones, joints and mechanics of the spine. My interest is quickened when a demonstrabIe Iesion is discoverabIe. As one interested in medica diagnosis as an essentia1 to proper practice, my interest is engaged by what may we11 be termed the overIaps of medi- cine. In other words, it is necessary to seek counse1 and give the same in diffIcuIties of differentiat diagnosis in backache. It is essentia1 that a11 causes outside of the spine itseIf and the peIvis itseIf be estimated.

Having ruIed out by examination and carefu1 consuItation with others engaged in the overIap, the internist, the gynecoIo- gist, the neuroIogist and the genitourinary surgeon, it frequentIy works out that the individua1 backache is primary in char- acter and demands the type of surgica1 treatment that may be given by the ortho- pedic surgeon.

Before this treatment is undertaken, it is quite essentia1 to know what is the Iesion of the spine or peIvis. It may be taken for granted that Iesions of the bones, joints and muscuIature are what we are seeking to discover in the backache in question.

In brief, the causes are the foIIowing: I. Trauma 2. Bad attitude 3. CongenitaI anomaIies 4. Arthritis, acute and chronic 5. Maiignant disease In brief, the Iesions that resuIt from

these causes are: I. Fracture 2. Sprain 3. Strain 4. Bad mechanics 5. Deformity

6. Destruction of bone and joint tissue with abscess formation and with ankyIosis as resuIts.

DIAGNOSTS

It is not aIways easy to demonstrate definite Iesions in the structures of the spina coIumn and peIvis. On the contrary, most of the backaches eIude positive diag- nosis, and in consequence, the deductions made as to etioIogy are IikeIy to be erron- eous. AIso, the favorable resuIts of this or that type of treatment often Iead to ques- tionabIe concIusions. Confusion is added by the well-known fact that actua1 Iesions in the spine are signalized by pain eIse- where. For instance, gaI1 bIadders have been inspected when the cause of the pain was tubercuIosis of a vertebra1 body. Stom- achs have been opened for the persistent pain arising from malignant disease in the spina coIumn. The pain and discomfort caused by cervica1 ribs and cervica1 arthri- tis are not feIt in the spine but in the distri- bution of the cervical nerves. This truism is nowhere better shown than in the Iesions of the IumbosacraI junction where pain and discomfort are projected aIong the nerve trunks of the IumbosacraI pIexus.

It seems that what is needed for the advancement of our insight into the causes and the resuIts in backache is an ever-pres- ent reaIization of the part that the spina coIumn and the peIvic skeIeton may pIay in the production of the pain either in the regions themseIves or in areas distant from the spine, and it seems, aIso, that this reaIi- zation is frequentIy absent in the practice of medicine and surgery.

The backaches and aches in genera1 that faI1 to the orthopedic surgeon for diagnosis and treatment are, as above stated, due to injury, disease, strain and stress on the spina structures and the peIvic bones and articuIations.

Space wiII not aIIow me to point out but briefIy the significance of spina fractures, compression fractures, transverse process and spinous process fractures, and the backaches these injuries cause. Diagnosis

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is made by careful physica examination, and is confirmed by positive roentgeno- graphic findings. The same is true of the disease processes in the bones and joints, tuberculosis, syphilis, osteomyehtis, carci- noma and sarcoma. Space aIso demands that I pass by the attractive heId wherein lie the congenita1 anomalies of the spine as we11 as the backaches produced by faulty attitude. AI1 of these Iesions concern us greatly, but each group demands more carefu1 study than I can give it here.

I wiI1 discuss, rather, the Iumbar spine, the Iumbosacral junction and the sacro- iliac articulations, because about this region of the spine and its backaches much con- troversy has recently arisen.

In backache and sciatica it has become the vogue, especiahy in America, to suspect the sacroiliac articuIations as possibIe seats of the troubIe. In fact, the particuIar backache which is Iocated in the Iower spine, often near the IumbosacraI junction, demands carefu1 study in order to ruIe out the question of participation of injury or disease of the sacroiliac joints as causes of the painful back symptoms. It is only within recent years that the juncture of sacrum with the two ilia has been granted a position of cIinica1 significance. It is stiI1 open to serious question in many instances, whether an accurate interpreta- tion of physica signs and symptoms is possibIe when the nature of Iow back lesions is to be decided. Certain it is that clinica methods designed to reIieve the painful sciatica and Iow back discomfort associated with Iesions of the sacroiIiac joints have proved themseIves successfu1 in many instances. The confusion that exists as to the nature and cause of Iow back pain and sciatica arises from lack of definite cIinica1 understanding of the IumbosacraI junction and the sacroiIiac articuIations, and possibIe misinterpreta- tion of the resuIts of treatment.

A study of roentgenograms in painfu1 backs and sciatica, such as that made by O’ReiIIey, has not shown a definite cImica1 picture. On the contrary, it seems

that individuality is cIearIy expressed in the conformity of the Iower spina and peIvic articuIations, indeed to such an extent that no two persons have skeletons which are sufficiently similar to aIIow the type cIassifications so usefu1 in other regions of the human anatomy.

Painter1 has recentIy coIIected in admir- able fashion the anatomica facts which have to do with these articuk~tions. His paper deaIs most interestingly with the recent advancement of the notion that fusions of the sacroiIiac joint are demanded in a Iarge and increasing number of these questionabIe Iesions of the sacroiliac artic- uIations; the menace being the tendency to resort to serious surgica1 interference in Iesions which are not we11 understood, and which are often reheved or cured by so-called conservative treatment, such as protective measures, rest in bed and manipulation.

He states his beIief about as foIIows: Granting the fact that a movabIe sacro- iIiac joint exists in the norma individuai, this aIIows us to assume that this joint is subject to such Iesions as are the common Iot of the other joints of the body. The sudden pain and IocaI tenderness foIIowing excessive motion or strain in the region of the sacroihac articmations justify the beIief that these joints may be carried beyond their norma Iimits of motion and have a resuIting sprain. The acute sprain may be foIIowed by a chronic ar- thritis, with which are associated pain and stiffness and Iocal tenderness. Disease processes, notabIy tubercuIosis and pus infections, may IocaIize in these joints, producing destructive Iesions demonstrabIe by roentgenograms.

My own experience Ieads me to beheve that sciatica is one of the cardina1 signs of sacroihac disorder, and is due to the cIose proximity of the nerve roots to the sacro- iIiac articuIations. It seems warrantable to concIude that sciatica, especiaIIy when associated with scohosis of the Iumbar

’ Painter, C. F. Origin and spread of sacro-iliac idea and its menace. Boston M. &+ S. J., 1926, csciv, 613.

264 American Journal of Surgery AIIison-Backache

spine, the so-caIIed sciatic scoIiosis, has its origin in some definite Iesion of the sacro-

LumbosacraI arthritis wiI1 produce much

iIiac joint. On the other hand, manv Iesions the same cIinica1 picture as does sacroiIiac

of the Iumbar spine may cause simrIar cIin- arthritis, and yieIds to rest and protection,

ica1 phenomena. The diagnosis of the exact 0ccasionaIIy to manipuIation or operative

seat of the Iesion demands the greatest fusion of the Iumbar spine, in about the same percentage of cases as do Iesions of

care and painstaking study. the sacroiIiac joints. Too much reIiance must not be pIaced on

the roentgen-ray pIate in these lesions. Its vaIue Iies in the fact that destructive bone Iesions are at times demonstrabIe. The inter- pretation of abnormaIities and variations Ieads to considerabIe confusion, as a ruIe.

SUMMARY

A brief summary of the causes of back- ache, based upon our experience at the Massachusetts Genera1 HospitaI, is as foIIows :

THERAPY

It is diffIcuIt to estimate the resuIts of various methods of therapy, especiaIIy in the treatment of Iow back pain and sciatica. The methods used range from rest in bed, with sedatives and hot apphcations, to ankyIosing operations performed on the bones of the articuIations. Intermediate types of treatment include forcibIe manipu- Iations, stretchings under anesthesia, and the application of braces and pIaster-of- Paris jackets. The resuIts of these methods are suffIcientIy variabIe to suggest that treatment as a standard of correct diagno- sis is apt to Iead to confusion.

I. Genera1 debiIity, menta1 and physical fatigue.

2. GynecoIogicaI ahd genitourinary Iesions.

3. NeuroIogicaI Iesions, spina cord tumor, often overlooked.

4. Static and postura1 causes; body types (a Iarge industria1 company refuses to empIoy for hard Iabor men over 5 feet IO

inches. The Iong sIender back wiI1 not stand the strain of heavy Iabor), shortened ham- string and shortened tendo AchiIIis.

5. PartiaI or compIete spondyIoIisthesis, resuIting from bad position and heavy strain or injury.

In my own experience I have seen instances of protracted disabiIity due to chronic arthritis of the sacroiliac joints that have faiIed to respond to any type of con- servative treatment, and that finaIIy have been entireIy reIieved by surgery designed to obIiterate these joints, the so-caIIed “fusion” operation. On the other hand, I fee1 that conservative measures wiI1 resuIt in reIief from symptoms in the vast major- ity of cases.

The term “ conservative measures ” means a variety of things. ManipuIation under an anesthetic is regarded as a con- servative measure, though I must point out that as it is frequentIy done it seems far from conservative. The benefit that foIIows manipuIation is due, perhaps, to readjust- ment of the peIvic articuIations, but prob- abIy is due IargeIy to the stretching of shortened ham-string muscIes.

6. MetaboIic, toxic or infectious affection of the muscIes, Iumbago or myositis.

7. Acute trauma: strain, sprains, apo- neurotic or muscIe tears.

8. Fractures : transverse and spinous processes and compression fractures, often overIooked; also dislocations.

g. Arthritis, the ankyIosing type and the non-ankyIosing type.

10. Impinging spinous or transverse processes.

I I. CongenitaI variations, especiaIIy asymmetrica or sacraIized fifth Iumbar vertebra.

12. Spina bifida occuIta. I 3. TubercuIosis, syphiIis, typhoid,

0steomyeIitis. 14. NeopIasms: sarcoma, carcinoma and

non-maIignant giant-ceI1 tumor; muItipIe myeIoma.

15. Combinations of any of the above.

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A brief summary of the diagnostic methods necessary to identify these Iesions is diffIcuIt. It may be said, however, that a carefu1 examination of the spine is indi- cated in a11 types of physica examination, for any purpose whatsoever.

It is not possibIe to go into the question of treatment except in the most genera1 way. BroadIy speaking, treatment of back-

ache requires accurate diagnosis. The great diffIcuIty is to estimate the exact cause in many instances. Rest in bed is a good form of therapy for many tired backs. Support by appliances is needed in many; exercise and proper attitude by most. Once in a great whiIe, out of a great number of “ orthopedic ” backaches, operative inter- ference is demanded.

SURGICAL SUGGESTIONS

F OR padding between skin surfaces (e. g., in the

axiIIa) use foIds of gauze instead of absorbent

cotton. The Iatter “packs,” becomes odorous from skin

secretions and often causes the dermatitis it is intended

to prevent.

A S contrasted with spontaneous rupture of an uIcer,

traumatic perforation of stomach or intestine with

IittIe bIeeding is apt to give no symptoms unti1 the Ieak-

age assumes threatening proportions.

I N abdomina1 injuries there may rather suddenIy

deveIop symptoms of coIIapse from sIow Ioss of bIood

by a smaI1 vesse1, or from a fresh accession of bIeeding.

I N the treatment of shock arising from an abdomina1

injury do not administer fIuids ~ by rectum unIess

reasonabIy sure that there is no tear of the Iarge bowe1.