POSTGRAD. MED. J. (1966), 42, 36

INDUCED MUSCLE RELAXATION IN THETREATMENT OF LUMBAR INTERVERTEBRAL DISC

LESIONSROBERT H. V. HAFNER, ~F.R.C.S.

Consultant Orthopaedic Surgeon to St. Giles' Hospital,London, S.E.5

The Medway and Gravesend Group of Hospitals andthe Queen Elizabeth Hospital for Children, London.

CHARLES D. T. JAMES, F.F.A.R.C.S. RICHARD ROBERTSHAW, M.B., B.S., D.A.Consultant Anaesthetist, St. Giles' Hospital, London, Registrar, Department of Anaesthesia,

S.E.5 and the King's College Hospital Group. St. Giles' Hospital, London, S.E.5.

FOR many years it has been realised thatpatients suffering from lumbar intervertebraldisc lesions who are subjected to a generalanaesthetic for some unrelated disorder notinfrequently benefit.A method of treatment was instituted follow-

ing on this observation and was referred to as"Deep Sleep". We are not absolutely sure whoshould be credited with the original idea butit was used routinely by Burns and Youngfrom about 1948 onwards.MethodThe patient was premedicated with 'Omnopon' and

soopolamine and deep ether anaesthesia induced fora period of { to i of an hour. Post operative medica-tion was then igiven to maintain a drowsy conditionfor some hours. It was found -that this procedure onits own benefited the majority of patients sufferingfrom lumbar intervertebral disc lesions. A smallnumber were unaffected by it and approximately5% were made worse. The latter were affected in oneof several different ways. Sometimes the pain in theback was made worse and pain in one or other ofthe lower limbs exacerbated. Also some patients whobefore the treatment suffered only from low backpain began now to experience pain down one or otherlower limb. Fortunately, this worsening was usuallytransitory and after a few weeks even these patientswere usually better than they had been before theanaesthetic.After the introduction of muscle relaxants into

clinical anaesthesia the original technique was modi-fied, and the procedure now used is as follows:The patient is premedicated either with Omnopon

and scopolamine or morphine and atropine in theusual doses. Anaesthesia is induced with a sleep doseof thiopentone (2.5%) and maintained with nitrousoxide and oxygen. Sufficient muscle relaxant (usuallygallamine) is given intravenously to produce completemuscle paralysis, and respiration is maintained bymanual compression of the reservoir bag of theanaesthetic machine. As a result of the generalisedmuscle paralysis the normal lumbar lordosis flattensspontaneously and the lumbar region of the spinebecomes straighter. This can be confirmed by slidinga hand beneath the small of the patient's back.

Fig.l shows the lumbar region of the spine beforerelaxant anaesthesia and Fig. 2 the same area afterrelaxants. It will be seen that the lumbar lordosis hasbeen markedly decreased.

In addition, two other procedures are carried outwhilst the patient is anaesthetised. Straight-leg raisingis performed on each side followed by flexion of thehips to the abdomen with the knees flexed; Fig. 3shows the complete flattening of the lumbar lordosiswhen this is done. Complete muscle paralysis ismaintained for 15-20 minutes before reversal withatropine and prostigmine. It was discovered that thisprocedure is more successful than the original"Deep Sleep".MechanismWe look upon "Deep Sleep" as a type of

spinal imanipulation in which very little forceis used; perhaps it would be more accuratelydescribed as an auto-manipulation.We consider that the majority of the patients

we have treated by this Imethod are not sufferingfrom what is usually referred to as a prolapsedintervertebral disc, if one means by this a lesionin which part of the nucleus pulposus haspenetrated a ruptured or detached annulusfibrosus and entered the spinal canal. Webelieve that the majority of these patients aresuffering from disc protrusions or herniationsof part of the nucleus pulposus into an annulusfibrosus which is stretched but not ruptured orseparated from its attachment to the vertebralbodies.

The situation is demonstrated very diagram-atically in Figs. 4 and 5. In the former it willbe seen that part of the nucleus pulposus haspenetrated the torn annulus fibrosus and nowlies in the spinal canal. We consider it unlikelythat such a prolapse will revert spontaneouslyand although healing may occur over a longperiod of time by absorption or fibrosis, thisis the type of case best treated by laminectomy.

Fig. 5 shows part of the pulposus herniatinginto an annulus fibrosus which is not rupturedor separated from its attachments and thuscan still contain the protrusion.

It is this type of case which responds wellto conservative 'measures, such as those des-

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January, 1966 HAFNER, JAMES and ROBERTSHAW: Induced Muscle Relaxation 37:i':i:·l..::: ·:,:i·i:8

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FIG. 1.-Lumbar region of the spine before relaxantanaesthesia.

cribed above, because, given favourableconditions, the herniation can move back fromthe spinal canal and be held once more by theannulus fibrosus.The method is not used in isolation but is

part of a general system of conservative treat-ment of intervertebral disc lesions.The patients thus treated are those with

severe or moderately severe lumbar inter-vertebral disc protrusions which are consideredfrom the onset to be too severe for Out-patienttreatment, or who have failed to respond toit. The criteria of severity are the degree ofstiffness of the lumbar region of the spine andthe amount of limitation of straight leg raising

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FIG. 2.-Lumbar region after giving relaxants.

together with any abnormal neurological signswhich may be present.X-rays of the lumbar and sacral regions of

the spine are taken to exclude bony abnormalityor disease and the patient is kept at completerest in 'bed with fracture¢boards beneath themattress to produce a firm surface. Skin trac-tion is applied to the lower limbs with between5 and 15 lbs. pull on each side, depending onthe tolerance of the patient. It is the completeand uninterrupted rest in bed which is the mostvaluable method of treatment and we do notconsider that the traction itself has any verygreat 'benefit in the majority of cases but thereare two very important reasons for includingit.

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38 POSTGRADUATE MEDICAL JOURNAL January, 1966

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FIG. 3.-Complete flattening of the lumbar lordosisafter flexion of hips to abdomen with kneesflexed.

Firstly, it keeps the patients strictly confinedto bed and, secondly, it is good for morale;they feel thait something positive is being done.Analgesics and sedatives are given as required.At intervals of a few days progress is assessed

by the severity of symptoms and by the straightleg raising test. If the patient improves, treat-ment is continued for two or, if necessary, threeweeks after which the traction is removed andthe patient turned on to the face 3 to 4 timesdaily and instructed in hyperextension exercises.

After a few days of this treatment the patientis allowed gradually to sit up and then to startgetting out of bed wearing a surgical corset.He is then discharged to out-patient physio-therapy until fit to return to work.

.Nuoleuspulposus

-- Rupturedannulusfibrosus

C.

FIG. 4.-Part of ,the nucleus pulposus penetrating thetorn annulus fibrosus and lying in the spinalcanal.

The "Deep Sleep" technique as describedabove is used on those patients who fail toimprove at all or rapidly enough with the aboveregime. If necessary it is given on as many asthree occasions at weekly intervals. The resultsare shown in Table 1.

Whilst carrying out this technique one of us(C.D.T.J.) observed thaat it was sometimes im-possible, even with the patient completelyrelaxed, to achieve full straight-leg raising onthe more painful side. We could not understandthis completely, but we do know that relaxantanaesthesia does not completely relieve musclespasm in patients suffering from.trismus com-plicating dental sepsis With which a possibleanalogy can be drawn. Muscle relaxants acton the Imyoneural junction and not on themuscle fibres themselves.

It is sometimes observed that relaxants alone

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January, 1966 HAFNER, JAMES and ROBERTSHAW: Induced Muscle Relaxation 39

-Annulusfibrosus

FIG. 5.-Part of the nucleus pulposus herniating intoan annulus fibrosus which is not ruptured orseparated from its attachments.

do not completely relieve muscle spasm whileether which acts partially on the muscle fibresthemselves can produce total flaccidity. Is itthat the failure to achieve full straight-leg raisingis due to continuing muscle spasm because ofnerve root irritation?We consider that short or tight hamstring

muscles are an unlikely cause of this limitationnot only because it is unilateral but becauseprevious investigations have shed much doubton the existence of this syndrome (Hafner,1952).Case ReportsCase No. 1. An example of the dramatic type of

response.Mrs. B. aged 24 years. Teacher of dancing and

housewife. She developed sudden severe low backpain in February 1961 when teaching children danc-ing. With physiotherapy and a surgical corset sherecovered in a few months and suffered thereafteronly occasional transitory attacks of low back painuntil March 1962 when she developed an attack ofsevere low back pain radiating down her right lower

TABLE 1Cases

Total Manipu- CasesNo. of Male Female te NecessitatingMoreiCases MoeThan Laminectomy

Once81 45 Male 6

126 Average Average Male 15 (4.9%) 12 (15%)age age Female 8 Female 637 yrs. 35 yrs. (27%) J

limb to the foot and down her left lower limb as faras ithe knee. On examination her spine was held rigidand there was a fixed flexion deformity of about 20°Straight leg raising was right 20°, left 20°.She was admitted to hospital and given "Deep

Sleep" with dramatic improvement. The following dayshe had no pain and straight leg raising was right900, left 90°. A slight recurrence of pain occurredthree days later when she leaned back in a wheelchair and the chair back gave way. A second "DeepSleep" was carried out with equal success and whenshe was discharged from hospital a few days latershe was symptom free.She had her first baby in December 1962 without

incident and since then has had no further backtrouble.

Case No. 2. An example of a patient being madeworse by the procedure.

Miss T. aged 25 years. Medical Secretary. In 1954she began to experience attacks of low back painfollowing any strenuous activity.She was 'treated with a corset and physiotherapy

with some benefit but was still unable to engage inrowing or other strenuous physical exertion, neithercould she manage without her corset. She soughtfurther treatment in the hope that she would be ableto engage in more arduous activities or, at any rate,she would be able to discard her corset. She wastherefore admitted to hospital and a "Deep Sleep"procedure carried out 20.1.58. The following day herback pain was much worse and now radiated intoboth buttocks and lower limbs and was associatedwith a feeling of pins and needles in both feet. Shegradually improved over the course of the next fewweeks and she remained largely pain-free until 1962when she had a recurrence of pain in her back andlower limbs. This responded to a two months courseof physiotherapy as an outpatient, since when shehas been symptom-free and has discarded her corsetbut has not resumed rowing.

SummaryThis paper concerns 126 patients of whom

81 were males with an average age of 37 years,and 45 females with an average age of 35years. All were suffering from lumbar inter-vertebral disc lesions sufficiently severe towarrant inpatient treatment with the exceptionof Miss T. the second of Ithe two illustrativecases, who was on the staff of one of thehospitals and would not in the ordinary wayhave 'been considered severe enough to warrantin-patient therapy.

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40 POSTGRADUATE MEDICAL JOURNAL January, 1966

Of these 126 patients 4.9% of males requireda laminectomy, and no less than 27% offemales, giving a total of 15%. We feel that amajor factor in this surprising diisparity maywell be that there were so many fewer femalesthan males in the series.We do not wish to decry the value of lami-

nectomy in the treatment of severe lumbarintervertebral disc lesions and would advisesurgery in such cases if they failed to respondappreciably to a week or two of conservativein-patient therapy. Unfortunately, one of thelimitations of laminectomy is that one cannotgive the patient a guarantee of being able toresume heavy work thereafter and if a change

over to light work ,is obligatory then surgeryhas little, if anything, more to offer than amethod of conservative treatment which willrelieve pain.We feel that the procedure described above

has a place in the treatment of lumbar inter-vertebral disc lesions and in many caseslaminectomy can thereby Ibe avoided.We are indebted to Mrs. C. Moorhead Hamilton

for the diagrams.

REFERENCESHAFNER, R. H. V. (1952): The Relationship of theHamstring !Muscles to Movements of the Spine,Proc. roy. Soc. Med., 145, 139.

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