Spinal Degenerative Disease

348 Pages·1981·9.007 MB·English

by  R. S. Maurice-Williams (Auth.)

SPINAL
enerative Disease
by R. S. Maurice-Williams MA, MB, Β Chir,
MRCP, FRCS
Consultant Neurosurgeon, The Royal Free Hospital
Formerly Consultant Neurosurgeon, South-East Thames
Regional Neurosurgical Unit
with a Foreword by
R. Campbell Connolly
Bristol
John Wright & Sons Ltd
1981
© R. S. Maurice-Williams, The Royal Free Hospital, Pond Street,
Hampstead, London NW3 2QG. 1981.
All Rights Reserved. No part of this publication may be repro­
duced, stored in a retrieval system, or transmitted in any form or by any means,
electronic, mechanical, photocopying, recording or otherwise, without the prior
permission of the Copyright owner.
Published by John Wright & Sons Ltd., 42-44 Triangle West, Bristol BS8 1EX.
British Library Cataloguing in Publication Data
Maurice-Williams, R S
Spinal degenerative disease.
1. Spine — Diseases
I. Title
616.7'3
ISBN 0 7236 0583 1
Printed in Great Britain by
John Wright & Sons Ltd., at The Stonebridge Press, Bristol BS4 5NU
PREFACE
During his neurosurgical training, the author was
surprised to discover that there appeared to be no book in existence which
dealt with the overall field of degenerative disease of the vertebral column.
There were indeed available monographs which dealt with various aspects
of the subject, such as cervical spondylosis or lumbar disc protrusions, but
none which provided, under a single cover, a critical brief general review of
current knowledge about, and methods of treatment of, this important
group of diseases.
This book is an attempt to fill that gap. That is, it sets out to provide a
guide to the subject of spinal degenerative disease in all its aspects rather
than provide new research data or promulgate novel theories. As far as is
possible, the author has tried to provide a balanced account of the more
controversial parts of the field, although it is hoped that his own personal
views on such topics are made fairly explicit.
By the term "spinal degenerative diseases'' is meant the disorders which
result from those changes in the tissues of the vertebral column which
occur to some extent in all individuals after early adult life. These changes
are thus part of the normal process of ageing, and they give rise to some
symptoms in virtually every person from time to time. In a small proportion
of the population, however, they may lead to a variety of painful and
disabling ailments which demand medical attention. Degeneration and
herniation of the substance of the intervertebral discs often play a major
part in the sequence of pathological events in these conditions, which are
of importance both socially and medically; socially because they are
widespread and are a common cause of serious disablement, medically
because their graver manifestations are very often amenable to specific
treatment.
An attempt has been made to cover not only the pathology, clinical
features and treatment of these disorders, but also certain topics related to
them, information about which is often difficult to obtain from a single
source. Amongst these may be mentioned the radiological techniques used
for spinal investigation, and the contrast media which are employed for
such investigations, the "whiplash syndrome" of the neck, and the
relationship between degenerative disease and spinal arachnoiditis. The
relevant aspects of normal spinal anatomy and physiology are briefly
outlined, but no attempt has been made to cover these subjects compre­
hensively, as this would have required the inclusion of much material of
little practical importance to the clinician. On the other hand, a chapter is
devoted to the practical assessment and investigation of patients with
spinal problems and another to the differential diagnosis of spinal pain and
sciatica. The latter necessarily involves the discussion in some detail of the
features of certain non-degenerative conditions which commonly give rise
to diagnostic difficulties.
ν
vi Preface
To a large extent the lack of a general guide to the degenerative dis­
orders of the spine is a reflection of the fact that it is a field which lies
legitimately within the province of several quite distinct groups of
practitioners, who tend to view spinal problems from quite separate (and
often incompatible) points of view. Each group has its own literature
about the spine which often makes little reference to what has been
written by those in other specialties. Amongst those with an interest in the
back may be mentioned orthopaedic and neurological surgeons, neuro­
logists, rheumatologists and physical medicine specialists, physiotherapists,
and the practitioners, both lay and medical, of the various heterodox
techniques of healing. In addition, many general medical practitioners have
acquired special experience and expertise in dealing with conditions which
inevitably occupy a considerable proportion of their working lives.
The spine tends to arouse strong feelings amongst interested parties.
Different factions adhere to firmly held views about the pathogenesis of
various spinal symptoms and the way in which they should be treated.
Sometimes it seems that such beliefs are based more on faith than on
objective scientific evidence and attempts to discuss the back with the
adherents of some schools of belief are liable to involve one in emotional
and acrimonious arguments that are almost theological in character.
No other sector of physical illness has permitted the growth of such
varied schools of thought as spinal degenerative disease. Indeed without
these conditions it is doubtful whether many of the heterodox branches of
medical practice would have come into existence. The natural history of
spinal degenerative disease could hardly have been more suitable for the
development of unorthodox or eccentric schools. The great majority of
persons afflicted with these disorders have symptoms which are trouble­
some and sometimes incapacitating, but which seldom lead to complications
which allow their pathological basis to be definitely established by surgical
exploration or post-mortem examination. The very high rate of early
spontaneous remission (although later relapses are common) means that a
wide range of therapeutic measures may appear to be effective, although
their true value, or lack of value, is extremely difficult to establish.
There can be no single book on the spine which satisfies every point of
view and it must be made clear that, inevitably, this book is written from a
particular standpoint, that of a clinical neurosurgeon. Several features
distinguish the neurosurgeon's experience of spinal conditions from that of
specialists in other fields. On the whole, he will be referred highly selected
cases. He will see a disproportionate number of cases in which serious
complications requiring major surgery have developed, and relatively few
of the milder and self-limiting ones which constitute the majority of cases.
Complex cases and those cases where earlier surgical treatments have
miscarried tend to be referred to a neurosurgeon as the "final court of
appeal", and he thus has the opportunity to learn from the mistakes of
others as well as those he may make himself. Such experience will tend
Preface
to make the neurosurgeon unusually cautious in his assessment and
management of patients and only too aware of the effects of precipitate
and injudicious treatment. Fortunately, the provision of facilities for
neurosurgical units in this country is sufficiently generous to permit a
relatively unhurried scrutiny of every case by the consultant in charge, a
state of affairs which is seldom the case in the other acute specialties.
The author's own prejudices about the spine are best made explicit,
although they cannot be said to be untypical ones for a neurosurgeon to
possess. First, he believes that surgery has only an occasional role to play
in the management of spinal degenerative disease, but that in the relatively
small number of cases where the indications are clear, the beneficial results
can be as gratifying as are ever achieved with surgical treatment of any
kind. The poor reputation that spinal surgery enjoys amongst the general
public is, he believes, because many operations are carried out as
"desperate last resorts", rather than because the defined indications for
surgery are present. All too often the patient is told that there is a chance
that surgery will help him rather than that there is an equal if not greater
chance that it will make him a good deal worse. Not surprisingly, the
patient will often leap at the chance of the former outcome, but find
himself left with the latter. Like many orthopaedic surgeons and virtually
all neurosurgeons, in this country at any rate, the author is virtually never
prepared to recommend fusion of the lumbar spine for a degenerative
condition. On a more purely neurological subject, he is sceptical as to
whether surgery is of much value in treating the spinal cord disorder which
is often found in association with cervical spondylosis.
As will be seen from the contents of the final chapter, the author
believes that a common error in the management of the less serious
manifestations of spinal degenerative disease (as with ailments affecting
other body systems) is to under-estimate the influence on the illness of
non-organic factors, both those which are a reflection of the patient's
personality and temperament and those which relate to more particular
circumstances in his life. Recognition of this aspect of clinical problems
means that the doctor has often to rely on his own initiative and personal
skills in managing cases rather than being able to fall back on a scheme of
well-laid out rules for treatment. It is hardly surprising that many doctors
prefer to adhere to a more mechanistic approach to the back. If this were
not frustrating enough, the doctor must also recognize that he is relatively
helpless in dealing with many of the spinal problems that are related to
degenerative change. Unfortunately, just as the term implies, spinal
degenerative disease is a reflection of the ageing process, and cannot itself
be arrested or reversed, although certain specific complications can be
dramatically alleviated. In their absence, it is probably best to try to be
honest both with oneself and the patient, and convey realistic expectations
of what can be achieved by those simpler symptomatic treatments that are
at least known to be free of any serious hazards.
viii Preface
Where it has seemed appropriate, brief case histories have been inserted
to illustrate various points. All the patients concerned either had been
under the care of the author or had been seen by him. Each case history is
identified by initials indicating the hospital concerned and its hospital
number. Thus BH represents the South-East Neurosurgical Unit at the
Brook Hospital; SBH, St Bartholomew's Hospital; GM, The Guy's-
Maudsley Neurosurgical Unit. Details of the patients from the latter two
hospitals are published by kind permission of Mr R. Campbell Connolly
and Mr Jeffrey Maccabe, the surgeons under whose care they were treated
at those two units respectively.
London, 1981 R.S.M.W.
ACKNOWLEDGEMENTS
This book was written while I was working at the South-
East Thames Regional Neurosurgical Unit at the Brook Hospital, and it
would have been impossible to complete without the help of several of my
colleagues there. I owe especial thanks to my secretary, Mrs Betty
Robinson, for the preparation of the manuscript; to Mrs Alison Bramley,
librarian of the Brook Postgraduate Library, for obtaining copies of large
numbers of papers in inaccessible journals, and to Mr Ray Leng and
Mr Girish Gosai of the Greenwich District Medical Photography Department
for their charactistic helpfulness and efficiency in the preparation of the
illustrations.
I am grateful to colleagues in other fields of medicine for reading and
commenting on those parts of the book which deal with contentious
matters which might be considered somewhat outside the province of a
neurosurgeon. They have helped me to avoid some embarrassing errors of
fact and emphasis. Mr Derek Porter read the section on low back pain and
spinal fusion, Dr the Honourable Christopher Penney the section on
neuroradiological techniques, and Dr John Miller gave invaluable help with
the passages on spinal manipulation and heterodox methods of treatment.
My senior registrar, Mr Hugh Coakham, read much of the manuscript
and gave great help and encouragement at a stage when morale was lagging,
before he left to become consultant neurosurgeon at Bristol. My registrar,
Mr Peter Richardson, gallantly volunteered to act as photographic model
for the illustrations demonstrating hysterical behaviour in Chapter 14. The
line figures were drawn by myself. Some of them are based on previously
published illustrations, and I am grateful to the copyright holders for
permission to reproduce them. Detailed acknowledgements are given with
the illustrations concerned. The photographs of the discograms and
the lumbar venogram were very kindly provided by Dr J. D. Irving
and Dr A. J. S. Saunders, consultant radiologists at Lewisham Hospital and
Guy's Hospital, respectively.
Lastly, I must express my thanks to Mr Campbell Connolly for writing
the Foreword to this book. I count myself fortunate in having been
trained by a neurosurgeon who must have an experience and expertise in
the surgery of the spine almost unrivalled at the present time, and who
first drew my attention to the complexity of many spinal problems, the
role played by non-organic factors in many cases, and the importance of a
careful, detailed and unhurried assessment of every patient.
ix
FOREWORD
by R. Campbell Connolly F.R.C.S.
Surgeon in Charge, Department of Neurosurgery
St. Bartholomew's Hospital, London.
Neurosurgeon, Royal National Orthopaedic Hospital,
London
Degenerative disease of the spine is responsible in many
people for intermittent or continuous symptoms throughout adult life. It
is one of the major causes of absenteeism from work. The degree of
disability varies very greatly but even comparatively minor symptoms are
often distressing to the patient, so that they may interfere with his normal
way of life or prevent him from undertaking heavy work, and they are a
potent trigger for neurosis. It is evident, therefore, particularly in the
younger age groups, that this is a disease which requires effective treat­
ment and merits the closest study. Only too often patients with aches
and pains due to this disorder are told that 'it is something which they will
have to live with\ On this account they sometimes turn for treatment to
someone who has little or no real understanding of the disease processes.
The treatment which is then given is rarely actually physically damaging
but it often tends to potentiate an underlying neurosis. Patients are
encouraged to continue with such treatment in the belief that they are
being helped, as in the natural history of the disease there is a strong
tendency to fluctuation in the severity of symptoms and spontaneous
remissions are common.
The disease, except in its most severe forms, is not lethal and autopsy
studies have therefore been infrequent. It is probably on this account that
the pathology has been so slow in coming to light. This is demonstrated
particularly by the delay until the early 1930s of the recognition of
intervertebral disc protrusion. However, with improved methods of investi­
gation and observations made at operation the pathology is now fairly clear.
With this knowledge of the pathology, combined with that of the anatomy
and the physiology, it should be more and more possible to formulate
treatment that will be effective in the long term, rather than to make
attempts merely to alleviate symptoms as they arise from time to time.
In this book Mr. Maurice-Williams has provided the necessary basic
knowledge. He has widely reviewed the literature, explained the pathology
and outlined the anatomy and the physiology. The management is discussed
in considerable detail and different methods of treatment are frequently
evaluated. The book thus indicates what modern treatment has to offer. It
should be valuable to all those, both surgeons and physicians, who are
concerned with the treatment of patients suffering from this disorder.
R. Campbell Connolly
xiii
chapter
Historical Review
1.1. Introduction
Although degenerative disease of the vertebrae is a common cause of
illness and disability, the clear identification of its various aspects has
occurred only relatively recently. This is surprising when one considers
that comprehension of the mechanism of the various spinal degenerative
disorders should have been possible from the mid-nineteenth century
onwards on the basis of the anatomical and physiological knowledge that
was then available. The history of the development of ideas in this field
exemplifies the statement that commonplace observations and concepts
only become obvious once they have been incorporated into the general
body of knowledge. Until that point has been reached extraordinary theories
may be brought forward to explain phenomena that subsequently appear
simple and straightforward.
The breakthrough in understanding spinal degenerative disease came in
the early 1930s with the discovery of the common occurrence of intra-
vertebral disc protrusions. Since then there have been three significant
phases in the growth of knowledge about these disorders. In the first
phase, following on for about 10 years after the definitive paper of Mixter
and Barr (1934)[328], there was an elucidation of the syndromes associ­
ated with disc protrusions at all levels. In the second phase, beginning
about 1945, attention was focused on the pathogenesis and treatment of
the myelopathy which is often found to be associated with spondylotic
change in the cervical spine. Interest in this field continues, for it is
probably fair to say that several of the basic problems associated with
spondylotic myelopathy have not been resolved to universal satisfaction.
The most recent period, from the mid-1950s onwards, has seen the
recognition of the various syndromes which can result from stenosis of the
lumbar spinal canal.
1.2. Lumbar Disc Protrusions
Sciatica has been recorded since antiquity and is mentioned by Shake­
speare [14]. Its association with backache and spinal deformity was well
described by the second half of the nineteenth century[58, 274], but
its relationship to lumbar disc lesions remained undiscovered for another 50
years. Until that time arrived a variety of conditions were invented or
invoked to explain sciatica. It had long been known that spinal tumours
1
2 Spinal Degenerative Disease
could give rise to it, but these were rare and most cases were designated as
idiopathic sciatica. Among the explanations for these cases that were put
forward were rheumatic neuritis, viral infections, diseases of the inter­
vertebral joints and venous ectasia along the course of the sciatic
nerve[51]. In 1914 Dejerine had attributed the common "sciatique radi-
culaire" to syphilis! 107].
However, all these explanations failed to account for certain common
and undeniable features of sciatica, namely, its remittant course, its
relationship to trauma, its association with spinal signs such as scoliosis,
and the fact that relapses often begin fairly abruptly.
An interesting instance of how cases of root compression from disc
protrusions were interpreted before the real mechanism was known is
provided by a case reported in detail in 1929 by Barker 126]. Barker
described a man 49 years old with what was, in retrospect, clearly a
lumbo-sacral disc protrusion causing compression of the first sacral root on
one side. After running through a wide range of possible causes of sciatica,
most of which would now be regarded as very rare, such as Paget's disease
or a varicocele, he came down to the diagnosis of neuritis affecting the
sciatic nerve or the lumbo-sacral nerve root. He correctly accounted for the
spinal deformity and the limitation of straight leg raising as attempts by
the body to reduce the tension on the inflamed nerve. Treatment, "which
usually yields gratifying results", included bedrest, the injection of local
anaesthetics into the sacral hiatus, and the removal of infective foci
elsewhere in the body. It is instructive to note that careful clinical obser­
vation was able to pinpoint the site of origin of symptoms, but was not
able to infer the mechanism by which they were initiated.
The anatomy of what was ultimately to emerge as the solution to the
problem, the intervertebral disc, had been known for some while. The
intervertebral discs had been described by Vesalius, and full accounts both
of their structure and of their pathological changes were published by
Virchow and von Luschka in the late 1850s. Indeed in 1857 Virchow had
described the autopsy findings in a case of traumatic disc rupture[270].
Kocher (1896) had reported a further example which occurred in a man
who had fallen 100 feet and died of visceral damage. At post-mortem a
ruptured L 1/2 disc was found but its relationship to neural structures was
not described[270].
What are probably the earliest clinical reports of disc protrusions were
published in the third volume of Guy's Hospital Reports by Aston Key in
1838[265]. He reported 2 men who died after the onset of spontaneous
paraplegia and who at post-mortem were found to have "hard protuberances
of the spinal ligaments'' lying anterior to the spinal canal and compressing
the cord and cauda equina. These protuberances were at D 11/12 and
L2/3 levels. Key describes some other cases of paraplegia of obscure
aetiology that he had encountered and he speculates that ligamentous cord
compression might have been the cause of some of these.