Dimensión 2: Recursos didácticos

Sphincter control is not usually disturbed in cervical mye­

lopathy. ' " Spondylotic change in the thoracic spine is fre­

quent, but not usually associated with alterations in (he sagittal diameter of the neural canal, or with spondylotic spurs which intrude sufficiently to compress the spinal cord.115

A case of thoracic stenosis has been described, 4)(l but the clinical description makes no reference to sphincter disturbance. Shaw ( 1 975) " " mentions that bladder

func-tion is sometimes impaired in prolapse of the thoracic intervertebral disc and in a series of 22 patients Benson and Byrnes (1975)" found that two-thirds of the patients had no urinary or bowel symptoms, only three of the group presenting with retention of urine. One patient had faecal incontinence. Most of the minority with urinary symptoms reported either hesitancy, urgency or a sense of incomplete evacuation.

A review'" of95 cases from the literature mentions that two-thirds of the cases showed abnormality of sphincters.

Lumbar spondylotic lesions of trespass into the neural canal are more likely to cause disturbance of voiding when they are multiple, and also when the prolapse is a massive central protrusion which completely blocks the canal,I062 although sphincter disturbance does not necessarily fol­

low (vide infra). High lesions are more likely to produce severe bladder dysfunction. Involvement of a single nerve root is unlikely to cause bladder problems.

Reports of patients with bladder symptoms, and little or no back pain or sciatica, have appeared in the literature during recent years, ^766, 61(l, 1268 and Sharr et aI. ( 1976) 1 1 1 3 observe that because definite abnormal neurological signs are often absent, the diagnosis may remain obscure for many years. Among 73 patients with chronic urinary symptoms, the authors found incontinence to be one of the commonest problems, the clinical diagnosis of neuro­

pathic incontinence depending particularly on the patient'S unawareness of bladder filling, emptying and urethral flow. Six of their patients, with minor myelo­

graphic irregularities commonly accepted as normal, were treated surgically because they fulfilled other diagnostic criteria, and were found at operation to have significant

lumbar spondylosis.

Emmett and Love ( 1 97 1 )" I also mention that in some of their worst cases the myelographic appearances were either negative or equivocal. Jennett ( 1 956)'" describes a patient admitted with complete double sphincter paralysis and a useless, numb right leg. The history in­

cluded backache and left-sided sciatica 20 years before, and during the 18 months before admission a further three or four bouts of right-sided sciatica, with a single attack of bilateral sciatica four months before admission.

Paralysis of the right leg was total below the knee a!ld there was distal wasting and weakness in the left leg. He had retention of urine with infection and a flaccid anal sphincter. After the patient's death from uraemia before operation, a small disc protrusion was found compressing the L3 root, but within the theca a dense and discrete band of arachnoid adhesions was observed exactly opposite the protrusion, firmly embedding the roots of the cauda equina, which could only be separated by sharp dissection.

Among the 25 cases of compression of the cauda equina by prolapsed intervetebral disc, Jennett mentions 4 cases whose onset of paralysis occurred while resting in bed.

Also described is the subsequent history of a patient with

PATHOLOGICAL CHANGES--COMBINED REGIONAL DEGENERATIVE 1 5 1

right-sided sciatica, for which she was manipulated under anaesthesia. On recovery from the anaesthetic she was un­

able to empty the bladder and both legs were numb and

Following myelography after some years of stress in­

continence, a 52-year-old man was operated on for an obstruction opposite the second lumbar disc. Only a small, calcified portion of the L2 disc was seen, until examina­

tion of the intrathecal space revealed a dense band of fibrous arachnoid thickening, thick and opaque enough to conceal the cauda equina. In I I of these cases there was profound paralysis, usually of anterior tibial, peroneal and calf muscles. Objective sensory loss of all modalities, typically in the whole sacral region, was present in 24 of the patients, but some had not noticed this until called to their attention by careful sensory testing,

Some degree of paralysis of the urethral and anal sphincters occurred in all but 2 of the patients and in 14 of them it was complete, with retention of urine and faecal incontinence.

Complete sphincter loss was always accompanied by complete bilateral sensory loss in the saddle area, often in the whole sacral distribution, In 1 7 cases there was a massive, loose fragment largely filling the vertebral canal, behaving like an extradural tumour. In the remaining 8 cases the protrusion was no larger than that in uncompli­

cated sciatica but focal thickening of the arachnoid was seen in each,

Jennett makes the important observation that while the persistence of a myelographic abnormality after surgery may be due to arachnoid adhesions, the possibility of there being two lesions must be borne in mind.

Love and Emmett ( 1 967)76' report three cases of urinary retention who had no evidence of radiculopathy on physi­

cal and neurological examination, although all were obese women and had been bed-wetters in their youth. The authors comment that this suggests their bladder innerva­

tion may have been abnormal or their cauda equinae un­

usually vulnerable, or both. At operation one had a cauda compressed by a 4th lumbar disc, and a congenitally short cul-de-sac. The second patient had protrusions of the 4th and 5th lumbar discs, and the third a 4th lumbar pro­

trusion. Two of the patients had been previously referred for a psychiatric opinion,

Ross and Jamieson (1971)"62 observe that large, central lumbar protrusions are likely to give rise to a lower motor neurone type of bladder paresis, whereas protrusions at higher spinal levels may compress the cord and produce upper motor neurone dysfunction,

Aho, et al. ( 1969)" reported their findings in 19 patients, of whom 18 were operated on, The cauda equina

syndrome began acutely without earlier sciatica in only one patient.

The disc trespass occurred at L5-S1 in I I cases, at L4-5 in 6 and at L3-4 in one. The protruded material excised was larger than 1 . 5 by I cm in 12 of the patients, and was centrally situated in 1 5 of them. The lesion was accom­

panied by rupture of the posterior longitudinal ligament in 1 1 cases. Severe disturbance of urethral function occurred in three patients with saddle anaesthesia on one side only.

As in sciatica unaccompanied by sphincter paralysis, it appears that the size of the neural canal remains the crucial factor. Small or lateral prolapses can produce cauda equina lesions when there is congenital stenosis, and the size alone of the prolapse does not dictate the degree of cauda equina compression. Even massive lumbar disc pro­

lapse need not produce cauda equina pressure. 1050 The authors mention that the incidence of degenerative changes on X-ray in their patients was no higher than the general incidence for patients with lumbar discs or a nor­

mal population.

While surgical opinion should be urgently sought in all cases of sphincter disturbance and saddle anaesthesia, a case is reportedl062 where acute lumbar pain, with right­

sided loss of ankle-jerk and a weak knee-jerk, accompanied by perianal anaesthesia and painless urinary retention, re­

covered full bladder function during a week of bed rest with traction and catheterisation. Six months later mic­

turition remained normal.

Sharr, et al. (1 976)^"1 3 mention that 39 of their 73 patients have not been treated surgically because of age, lack of progressive worsening and lack of clear diagnosis, but there has been improvement in some by conservative measures such as bedrest and lumbar support.

Jennett ( 1 956)'10 stressed the incompleteness of re­

covery after operation ' . . , recovery from cauda equina lesions is slow, but it is doubtful if it is realised just how unsatisfactory it can be'. Sphincter paralysis is the most serious factor, and although ambulant, pain-free and not inconvenienced by sensory loss a patient may have residual defective sphincter control. It may be three or four years before the end state of sphincter control is reached.

Aho, et a1. ( 1 969)1 2 reported that the majority of their 1 8 patients, i.e. I I , still showed abnormal bladder function on cystometry at follow-up examination, and their review of the literature indicates that only a small proportion of patients show signs of clearing of bladder symptoms.

THE PELVIS

It is gratifying to note the slowly increasing number of descriptions of pathological changes due to stress in the pelvic joints,284, 993, 1081, 1036, 1 157, 506, 505 particularly so since many erroneously believe that musculoskeletal

abnor-1 52 COMMON VERTEBRAL JOINT PROBLEMS

maiiries of these joints, unassociated with pregnancy and violent direct trauma, are virtually non-existent.

The pathological or radiological changes of, for example, tuberculosis, ankylosing spondylitis, rheuma­

toid arthritis or Paget's disease of the articulations are well documented, but since physical treatment directed spe­

cifically to the joint is most unlikely to be indicated in these clinical situations, there is little point in dwelling here on their pathology, other than in general terms and for com­

pleteness of information. It is morc difficult to describe the pathology of common, painful and disabling muscu­

loskeletal disorders of the pelvis, largely because of the comparative lack of reports providing surgical and necropsy evidence of joint changes acceptable as abnor­

malities probably underlying clinical features during the patient's lifetime.

For example, although there is more than one type of pathology underlying the condition of 'tennis elbow', it is universal clinical experience that a very common type of this malady has clear-cut signs, symptoms and functional restrictions, and responds very well to local in­

jection of hydrocortisone or triamcinolone and/or mobi­

lisation and manipulation ; yet an X-ray ofthe joint reveals nothing and the customarily tested ranges of movement are often normal. Although the upper limb is fruitful terri­

tory for pain referred from more proximal joint changes, confidence is justified that the site ofthat particular abnor­

mality of the elbow region has been identified, it has been correctly diagnosed and on a localised basis has been ade­

quately treated.

Precisely the same criteria of examination by a process of exclusion, identification of the site of the lesion causing the patient's current complaint, and localised treatment governs the management of common sacroiliac joint problems.

The former does not excite comment ; the latter seems to create unnecessary difficulties, and as the perennial sub­

ject of academic debate, the sacroiliac joint seems born to trouble as the sparks fly upwards. By virtue of a now reasonably large body of evidence,451 a basis for descrip­

tion may be summarised as follows : extreme of possible range

c. Irritability, sometimes severe

d. A tendency to hypermobility when adjacent articu-lations become stiff or ankylosed

e. Arthritis and arthrosis

f. I nvolvement in disease of adjacent bone g. Instability due to ligamentous insufficiency.

2. While bearing in mind its special characteristics, there is no good reason for doing other than dealing with its abnormalities according to the principles underlying the treatment of all other joints.

Because the sacroiliac joint is not immobile; it very fre­

quently bears multiples of the whole body-weight during functional activities ; it is the first weight-bearing joint between vertebral column and lower limb ; manifest asym­

metry of the two joints is nOt uncommon, considerations of postural asymmetry on an AP view, and their possible genesis, are of fundamental importance.

Postural asymmetry of the pelvis

This may reasonably be assumed present when, in the absence or presence of frank lateral pelvic tilt, there is apparent torsion of one ilium in relation to the other, so that for example the left anterior superior iliac spine is higher than the right, and the left posterior superior iliac spine is lower than its fellow.

On the basis of these findings, Lewit ( 1 970)7J6 observed the condition in almost 40 per cent of 450 schoolchildren.

In a further group of 72 children aged 6-7, the findings were as follows : pelvic torsions (28), slight scoliosis (1 3), difference in leg lengths (5). All of the latter group (72) were re-examined after a year. Not a single pelvic torsion had disappeared, and a 29th had developed. Of the slight sco­

lioses, 2 had recovered and 3 new cases appeared ; leg length differences had disappeared in three children.

The children were arranged as statistical twins ; one of each twin was treated, leaving the other as a control. After 7 years, the results were: Of 1 5 cases given gentle mani­

pulative treatment, 3 relapsed, 1 of whom recovered spon­

taneously. Of 1 4 untreated cases, 4 made a spontaneous recovery, 2 of these during the last year, and in both of these cases spasm of the iliacus muscle was still present.

Two of this group were lost to the trial. Four new cases developed during the period, I during the first year which was treated, and 2 others which recovered spontaneously.

The fourth appeared too late for inclusion.

Lewit makes the following interesting observations : 1 . The iliac crests themselves remained at the same horizontal level.

2. There was little correlation between scoliosis and pelvic {Orsion in his material.

3. Effective treatment of the asymmetry did not affect the development of scoliosis.

4. Sacroiliac asymmetry (or torsional fixation) is an ex­

tremely constant lesion.

5. There is increasing evidence that the asymmetry, however effectively treated by gentle manipulative pro­

cedures, is due mainly to muscle spasm.

6. If this iliacus spasm can be abolished by procaine, preferably to the sacroiliac joint itself, the pelvis straightens JUSt as permanently as after manipulation.

PATHOLOGICAL CHANGES--COMBINED REGIONAL DEGENERATIVE 153

These observations pose some important questions : 1 . What is the importance of psoas as well as iliacus spasm in the production of these torsional states?

2. What may initiate it; does it arise because of some irritative condition of the growing spine or in the growing sacroiliac joint?

3. How far into the future may this asymmetry be pro­

longed, unrecognised or ignored, by chronic unilateral muscle spasm?

4. Might reversible torsion, in the plane joints of the child's pelvis, be slowly 'frozen' after puberty, into later irreversibility by articular ridges and furrows as the physical stress of weight-bearing activity stimulates their development ?

5. Bearing in mind the functional interdependence of the vertebral column, what are the long-term prospects for cervical, thoracic, lumbar, lumbosacral, sacroiliac and hip-joint involvement in these children ?

6. In terms of degernative joint disease is the child, as in other respects, father to the man?

There is in medicine a natural law . . . that any single pathologi­

cal event is bound to project itself into a number of different clini­

cal manifestations (SreindJer, 1962). 1111

Cramer'" has provided an analysis (Fig. 6. 10) of dis­

tortion in the adult. If Ihe greal varialion of joint configura­

cion becween individuals ;s borne in mind, ic is probable chac chere is no one type or degree of asymmetry. Certainly, the abnormality illustrated seems to require a maniuplative correction of heroic complexity, should one believe cor­

rection feasible and choose to attack it so.

The aetiology of pelvic asymmetry in the adult is not easy to decide. Figure 6. I I(A) 1 6 January 1967, (8) 1 3 June 1969, and (e) 9 June 1975, shows the radiological appearances of a woman 39 years old in 1975 who at the age of5 was admitted to her local hospital for trouble with her right hip. While under more recent surgical care for the secondary osteoarthrosis which developed, the condi­

tion was retrospectively assessed as probably due to non­

articular Still's disease or possibly a synovial tuberculous infection ; Perthe's disease was considered unlikely. She had had several hospital admissions in the past, and at one time had the hip in plaster for 9 months. The notes at the time of her first admission 24 years before were un­

helpful, and X-rays were not available. The original diag­

nosis and subsequent surgical care of her hip condition need not concern us further, but the radiologically evident pelvic asymmetry, there when she presented in 1967, and still persisting, is of interest. Wasting of the right buttock may well have disturbed her pelvic posture when lying on the X-ray table, but this factor could not be responsible for the appearance of pelvic asymmetry. When did this asymmetry begin ? Why is it there? Is it a fairly long­

standing iatrogenic consequence, or was it there in early childhood ?

Fig. 6.10 A scheme of altered positional relationships in pelvic distortion or asymmetry. (After: Cramer A, quoted in Lcwit K 1969 The course of impaired function in the spinal column and its possible prevention. Proceedings of the Faculty of Medical Hygiene. Charles University, Prague.)

A 46-year-old man (Fig. 6. 1 2) presented on 30 April 1973 with pain in and around the left hip. There was a vague history of 'paralysis' as a child, but no definite details ; also pulmonary tuberculosis 12 years ago, now clear and under routine observation. He attributed a three-month history of the ache around the left hip area to a fall on that side three years previously. Retrospective radiological opinion was 'old Perthe's and early os teo­

arthrosis of the hip'. Confining our attention to the pelvic asymmetry, i.e. obturator foramen shadow, levels of pubis, width of ilia, etc., is this entirely due to an off­

centre view? Why is it there ? How long has it been there?

Was it produced by the fal l ?

Leg lengths (see p . 282)

Pregnancy

The hormonal influences resulting in softening and re­

laxation of the pelvic girdle and lumbar joints in preg­

nancy also occur to a lesser degree during menstruation and the menopause (Colachis, el ai., 1 963). '90 A number of postmortem specimens in various stages of pregnancy showed clearly that the increased range of movement is easily recognisable by the fourth month, and that at full term the range increased by about two-and-a-half times.

In one subject, the anterior margins of the joint could be separated by almost 2 cm (Brooke, 1924). ' }5

The normal 4 mm width at the symphysis pubis in­

creases more than twofold to 9 mm.

Obstetric and gynaecological surgery

Sacroiliac strains sometimes follow gynaecological and obstetric operations (Grieve, 1976).'" The lithotomy position is not above suspicion in causing some of [hese strains (Bankart, 1932) '7 Among 63 cases of backache in an average gynaecological service, there were 22 classed

Fig. 6.11 (A, B and c) Anteroposterior pelvic views of a 39-year-old lady with right hip involvement from the age of 5. (/0.) 16.1 .67, (8) 1 3.6.69, (c) 9.6.75. The asymmetry of symphysis pubis remains unaltered. (See text.)

PATHOLOGICAL CHANGES--COMBINED REGIONAL DEGENERATIVE 1 55

Fig. 6.12 Anteroposterior pelvic view of a 46-year-old man with an osteoarthrotic (L) hip. (see text.)

as 'traumatic'. All of these had received a general anaes­

thetic while in the lithotomy position and first suffered backache on discharge from hospital (Shafiroff and Sava, 1935). ^II.,.

In the course of two years, every woman who under­

went major gynaecological surgery at the Prague Clinic and subsequently complained of postoperative sacral area and neck pain was examined for musculoskeletal abnor­

malities (Novotny and Dvorak, 1971)."· The results were :

Table 6.2

Cervical spine Operations Number Sacroiliac disturbances disturbances Abdominal 449

Vaginal 539

TOlaJ 988

52 ( 1 1 .6°0) 51 (9.4°(1)

33 (7.3°",) 23 (4.2°0) 56 (5.6' ,)

Ankylosis or surgical fusion, and adjacent hyper­

mobility

Continuing evidence of the functional in terdependence of the vertebral column is provided by the frequency with which ankylosis or fusion of joints results in compensatory increase of movement in adjacent articulations. Brooke

Continuing evidence of the functional in terdependence of the vertebral column is provided by the frequency with which ankylosis or fusion of joints results in compensatory increase of movement in adjacent articulations. Brooke

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