THE DIFFERENTIAL DIAGNOSIS OF A NUCLEAR LESION
In practice, the differential diagnosis of backache is a simple problem. The backache that results from a nuclear lesion is a clear and distinct entity which is easy to recognize. It is extremely common but no subject in medicine has been addled by a greater quantity of irrelevant and confused material.
The manner in which low back pain has been presented in textbooks, symposia, and to medical students causes despair in the mind of the student of ever making a diagnosis - and reflects the state of mind of the teacher. The analagous syndromes of nuclear lesions in the cervical and dorsal regions are not considered. As a rule, an orthopaedic surgeon, a neurosurgeon, a gynaecologist, a urologist, and sometimes a psychiatrist, give long lists of ailments with which low back pain is supposed to be associated. Valiant attempts are made to separate all these ailments from each other and from "herniation of an intervertebral disc". The end result is chaos. This regime causes many doctors in general practice to tell their patients that they "do not know anything about backs". We should consider - from a different viewpoint - the usual method of approach to the backache problem.
1. IN ORTHOPAEDIC SURGERY
One writer has listed one hundred and twenty-five causes of low back pain in the field of orthopaedic surgery alone, which presents the reader with a huge, amorphous and apparently insoluble problem. From these we can at once eliminate from consideration two great groups:
i. Febrile illnesses: Backache is a complaint in many acute febrile illnesses, but in these cases it is a minor concern of the attending physician. It may be found that after recovering from the illness the patient still has backache. If so, the patient probably has a nuclear lesion.
ii. Chronic infections: Chronic infections of the spine such as tuberculous or pyogenic osteomyelitis are now uncommon in civilized communities. These ailments almost always begin in childhood. In regions where tuberculosis is prevalent, the doctors are alert to the possibility of Pott's disease. Patients with chronic infections are ill. Patients with nuclear lesions of intervertebral discs, as a rule, are not ill.
II. SEVERE INJURIES
If the patient has suffered an injury that might have caused fracture or fracture-dislocation of the spine, the attending doctor is not primarily concerned with the possibility of an associated nuclear lesion. If such has incidentally occurred, which is likely, he will later become aware of it.
2. OTHER ORTHOPAEDIC CONDITIONS
I. SPRAINS (Minor tears of muscle or connective tissue).
Sprains or strains are uncommon in the powerfully constructed and heavily protected back. In any case, sprains are usually recognized by the patient for what they are. They heal progressively and quickly; and though they may come to the attention of an athletic trainer, a doctor is rarely consulted. Lumbo-sacral and sacro-iliac sprains are only labels for symptoms of nuclear lesions.
II. KISSING SPINES
Kissing spines is usually listed. It is a rare cause of back pain. Pain which is sharply localized occurs on extending the spine. X-rays usually show a pseudoarthrosis between two neighbouring spinous processes. Injection of local anaesthetic affords complete relief of pain for the duration of the anaesthetic. Permanent relief is secured by the simple procedure of excising the pseudoarthrosis.
III. SPRUNG BACK
Sprung back is another ailment usually included among the lists of causes of low back pain. It is reported that the complaint is of a dull or nagging ache in the low back which may radiate to the buttocks and thighs. The pain is made worse by bending or lifting or working in a stooping position. It is relieved by rest. The symptoms follow a fluctuating course. The physical signs vary with the severity of the pain at the time of examination.1 It is said that there may be spasm of the erector spinae muscles with limitation of spinal motion and pain on the extremes of movement. The only positive finding is reported to be tenderness of the interspinous ligament, most commonly between the fifth lumbar and first sacral spinous processes, less commonly between the fourth and fifth. The disability is attributed to a partial rupture of an interspinous ligament. On healing, “this leaves an attenuated ligament, which remains a permanent weakness.”
I have not seen a single one of these cases, and feel that if it exists at all, it must be very rare. The symptoms described are those of a nuclear lesion. Drawings illustrating the "sprung back" show a ruptured interspinous ligament with a transverse rupture of the posterior annulus, which would inevitably produce a herniation of the nucleus. Rupture of an intact posterior annulus does not (for all practical purposes) occur. The annulus is tough and resilient. It remains intact even after those violent injuries which cause fractures and fracture -dislocations of the spine. If the force applied has been great enough to tear through an intact annulus, the victim is unlikely to survive it.
At operations in which a spinal level is approached a second time, the interspinous ligament is found to be unusually thick, strong and firmly attached to the spinous processes above and below, even though at the previous operation, the ligament had been completely removed. It is inconceivable that an interspinous ligament which was partially ruptured would fail to heal completely. In my opinion the "sprung back" is a nuclear lesion of an intervertebral disc.
IV. HYPERTROPY OF THE LIGAMENTUM FLAVUM
This is an old favourite in the differential diagnosis of backache. I have never recognized it at operation.
V. CONGENITAL DEFECTS
Backache cannot be ascribed to congenital defects in the spinal column, which are, without exception, painless. Neither can backache be ascribed to static postural defects.
On securing x-rays of a patient with low back pain, the doctor, impressed by the dramatic appearance and spurred by the radiologist's report, may jump to the conclusion that such anomalies as sacralization of a lumbar vertebra, a hemi-vertebra, asymmetery of the posterior intervertebral joints, spina bifida, and spondylolisthesis, are the cause of the patient's complaints.
Examination of the patient will soon show that pain and tenderness are not related to the site of the unusual architecture. If the doctor wishes to go that far, and the site is accessible, he will find that injection of local anaesthetic into these defects has no effect on the patient's pain. The results of operations designed to modify these defects, including spinal fusion, are inevitably disappointing.
Bohart 2, Fullenlove and Williams 3 and Splithoff 4 between them x-rayed eighteen hundred patients with low back pain and compared them with eighteen hundred patients who had no history of low back pain. They found essentially the same incidence of congenital lesions of the spine in symptomatic as in asymptornatic patients.
These radiologists went to great trouble to prove what orthopaedic surgeons have known for ages, that the congenital anomalies of orthopaedic surgery are painless.
VI. FORAMINAL COMPRESSION
If a spinal nerve were to be compressed in the intervertebral foramen (or anywhere else) the result would be a painless paralysis attributable to that nerve. Pain cannot be ascribed to this cause.
Backache which might be attributable to osteoporosis of the spinal column from debilitating illness or advanced age should not cause any confusion. In any case it should be viewed with reasonable doubt as a cause of backache.
VIII. ANKYLOSING SPONDYLITIS
Ankylosing spondylitis is rarely seen by an individual doctor in general practice. The patient complains of spinal pain. The disease begins in the twenties. Progress of deformity of the spine leading to a marked increase in the dorsal kyphosis and elimination of the normal lumbar lordosis is usual. Chest expansion is minimal, The sedimentation rate is elevated. X-rays demonstrate the characteristic obliteration of the sacro-iliac joints and the pubic symphysis.
Osteoarthritis as a cause of pain in the spine is a myth, unless there has been an injury which has caused demonstrable incongruity of one or more posterior interarticular joints. In this case pain would be localized exactly to the involved joint or joints and as a diagnostic measure, could be relieved for two or three hours by the injection of local anaesthetic into that joint. The term "osteoarthritis" when applied to "lipping" of the vertebral bodies is an incorrect diagnosis. In any case it Is symptomless.
Sir Hugh Griffiths stated that:
“. . . osteoarthritis of the lumbar spine is a disease invented by the radiologists as an appellation for the new bone formation that decorates the bodies of the lumbar vertebrae . . . It is not a condition that causes pain, nor is it likely to be aggravated by indirect injury.” 5
X. PAGET'S DISEASE
Paget's disease is not a common condition. It occurs almost always in male patients beyond the age of fifty. Usually the complaint is of pain in many bones which is worse at night. Involvement of the spine occurs in the later stages. The appearance of the patient, in advanced cases, is usually characteristic, with the enlarged head, the recently acquired spinal curvature and bowed legs. The diagnosis is confirmed by the x-ray appearance and the raised plasma alkaline phosphatase.
Bone tumours are usually given a prominent place in discussions of the differential diagnosis of backache, but they are not considered from the viewpoint of the doctor who is faced with the realities of general practice; and this is the viewpoint from which all teaching in medical colleges should be critically examined.
A knowledge of bone tumours is essential to orthopaedic surgeons, radiologists and pathologists, but to a general practitioner such knowledge is, to put it delicately, of less practical value.
The question is - how often is a general practitioner likely to see a tumour of the spinal column in his own practice?
1. The incidence of all malignant tumours, both primary and secondary involving bone, is less than four per hundred thousand population per annum (1 bone tumour per 25,000 people per annum).
2. Of all bone tumours less than 1 in 20 occurs in the spine (1 tumour of the spinal column per 500,000 people per annum).
3. Most primary tumours of bone occur below the age of thirty. Most secondary bone tumours occur after the age of fifty. Of all bone tumours of the spinal column only 1 in 15 occurs in the age group of the nuclear lesion (i.e. thirty to fifty years), or 1 : 7,500,000 people per annum.
4. Now, let us say that a doctor in general practice cares for one thousand people. How often will he be confronted with the problem of making a differential diagnosis between a nuclear lesion of an intervertebral disc and a malignant tumour of the spinal column?
Answer: Once in every 7,500 years! 6
How often will he be confronted with, and baffled by a nuclear lesion of an intervertebral disc? About ten times a day.
If one should suspect a patient of having a malignant tumour of the spine, suspicion may be confirmed by remembering that a malignant tumour is insidious in onset and relentlessly progressive in its course. One cannot escape its eventual recognition.
The incidence of tumours in the contents of the spinal canal is about four per hundred thousand people per annum, or one case per twenty-five years in general practice.
Neuritis and neuralgia are loosely used and largely interchangeable terms. One wonders how often, if ever, inflammation of a nerve occurs as a result of the causes usually listed, such as generalized toxemia, arsenic, lead or alcohol poisoning, or as the result of syphilis or diabetes. "Neuritis" as a result of these causes is almost always a painless paralysis and the changes in the nerve tissue are degenerative, not inflammatory. When pain does occur as for example, in "diabetic neuritis" the pain is actually myalgia due to inadequate blood supply to the muscles, which in its turn is due to the early onset of arteriosclerosis in diabetics.
Neuritis and neuralgia are too often used as synonyms for "pain of unknown origin", i.e. the radiating pains of nuclear lesions.
Some time ago an obstetrician-gynaecologist began to refer his patients with low back pain for the relief thereof by means of traction and manipulation. So low back ache was separated from the symptoms of chronic pelvic infections, fibroids, and endometriosis such as menstrual disorders and a dragging sensation or pain in the lower abdomen and pelvis. It was further, and again, established that lumbago is not a normal symptom of pregnancy. Some of the patients so casually and confidently referred seemed to be alarmingly enceinte. It was suggested to the obstetrician-gynaecologist that it might not be regarded as good form for an orthopaedic surgeon to establish an emergency obstetrical service in his office. The reaction was that such an attitude revealed a weak character of a feebly conformist type.
The obstetrician- gynaecologist has now, for many years, applied traction and manipulation to his own patients. When it was suggested to him that a surgeon of his experience would find it an easy matter to remove the fibrous nuclei in his own obdurate cases another feebly conformist character was exposed.
Spinal pain should not be regarded as a symptom of pelvic disease in women or as a normal accompaniment of pregnancy.
The nuclear lesion with an acute onset and intense immobilizing pain has often been confused with ureteral colic. The distinguishing features are that in the nuclear lesion, if the patient lies down and remains motionless, he is relieved; but any spinal motion hurts. The pain of ureteral calculus is colicky in nature and is not relieved by the patient remaining motionless, even if he can be persuaded to do so. As a rule in his agony, the patient writhes ceaselessly; and the spinal motion has no influence on the pain. This is an example of the fact that pain of visceral origin is not affected by rest or by the patient's movements.
Spinal pain should not be regarded as a symptom of urogenital disorders.
A good deal has been written about the psychogenic aspects of backache. We believe that it is without foundation. The excruciating pain of the acute attack is terrifying to many patients. The patient who has had long continued and frequently exacerbating bouts of pain and disability and who feels that his useful life may be finished, is unquestionably a victim of anxiety and fear.
Too often the patient is told with authority that the pain is psychosomatic" or "all in your head". It is no wonder that some patients feel that they should be committed to a mental hospital. Sometimes on the first visit, they break down and weep helplessly at their plight and the fact that no one can do anything for them. A few indicate that they are considering suicide. When one considers the millions of people who are suffering from nuclear lesions one cannot escape the conclusion that this is a gigantic human tragedy. The tragedy is compounded by the fact that in all essential respects they are perfectly healthy people and that any doctor with occasional help from a consultant should be able to relieve almost all of them of their pain and disability. The patient's anxiety soon disappears when effective treatment with its accompanying relief, is instituted.
Backache in an evidently well person is more likely to cause amusement and good-natured contempt on the part of beholders than it is to arouse much sympathy. So it is unlikely to be selected as an ailment by the unstable person. If a patient complains of pain, he has pain, whether the doctor can find the cause or not. Disabilities with a psychogenic basis such as amnesia, aphonia, paralysis, blindness, and fits are spectacular. They impress the audience, but the patients do not complain of pain - unless they have pain.
On this point Richard Asher wrote:
“I do not think it likely that there are many cases of backache due purely to emotional or psychiatric causes. I also believe that quite a lot of alleged psychosomatic backache has some physical cause which has not yet been discovered. If psychosomatic backache expresses any hidden fear, the most probable fear to be expressed is that of the doctor who fears to admit he cannot make a diagnosis. Most doctors feel dissatisfaction when they cannot sort their cases into the neat diagnostic compartments provided by their teachers and their textbooks. Moreover, it must be remembered, that the detection of convincing psychic factors in the way of emotional strains and psychological stresses is no proof that they are the cause of an unexplained back pain.” 7
TENSION STATES: HEADACHES, BACKACHES, PAINS IN THE NECK AND SHOULDERS
In our grandfathers' time, constipation was regarded as the explanation of the inexplicable. Today "tension states" seems to have replaced it. Chronic anxiety apparently is a factor in the eventual production of hypertension, peptic ulcers, coronary artery disease, and spastic colitis. It may be a result of backache, and its radiating pain, but it is not a cause.
One wonders which is worse, the disorganization of the bowels by the administration of cathartics or the efforts to relieve "tension states" by the stupefaction of patients by tranquilizers, barbiturates and pain pills. "Tension" is a child of "stress". Asher wrote:
“Not only has the word 'stress' been allowed to run wild but its headstrong offspring, the adaptation syndrome has been given equal freedom to roam anywhere and lay claim to any unexplained illness that comes its way.” 8
Do people who are demonstrably under tension, such as athletes prior to an important contest, or nervous students before an examination, or people waiting to be executed, complain of pain? Rather, we think, they mention "butterflies in the stomach", loss of appetite, disturbed sleep and perhaps mild tremors.
Sir Hugh Griffiths wrote:
“At a recent conference held under the auspices of the British Council for Rehabilitation, this subject was debated throughout a day by members of the medical profession, the legal profession and the insurance business, with members from industry and trade unions. The majority opinion was that there had been much exaggeration in the statements attributing prolonged incapacity in cases of backache, to the delayed settlement of claims for damages or compensation. Malingering is a negligible factor in cases of lumbago.” 5
But it is still a broad highway of escape for insurance companies.
If malingering is suspected, particularly following automobile accidents, half a dozen treatments of heavy traction and manipulation, will help to settle the matter. The clicking or snapping sounds are elicited by the separation of the fibrous nucleus from the posterior annulus. They are diagnostic of nuclear lesions. If the patient reports that there has been no relief of pain and no change in his condition then we know that the sacral extra-dural injection (page 161) will relieve all pain, both spinal and radiating, from a low lumbar nuclear lesion. Similar relief can be obtained in cervical and dorsal lesions by an oblique extra-dural insertion of the needle into the spinal canal. If the patient reports there is no change whatsoever in his symptoms, then one must consider whether some other lesion is present. The doctor may then decide, after due deliberation and the exercise of caution, whether he is convinced that the patient is malingering.
A FEW ASSORTED AILMENTS
Perhaps we should mention, without enlarging on them, some other conditions that are usually included in discussions of the causes of backache, because at this point we do not believe that these possibilities will particularly alarm the reader. They are the backaches that are reputed to accompany gonnorrhea, typhoid, smallpox, actinomycosis, gumma, hydatid disease and one which was recently described in an august journal “Thrombosis of The Abdominal Aorta and its Branches”.
Backache is ubiquitous. Patients with any ailment may have a nuclear lesion as well.
THE HAPLESS LABELS
“Nor bring to watch me cease to live
Some doctor, full of phrase and fame
To shake his sapient head and give
The ill he cannot cure - a name.”
-- Matthew Arnold.
Many terms have crept into medical language in efforts to place diagnostic labels on the manifestations of nuclear lesions. There are no pathological findings to confirm any of them. They are not diagnoses based on etiology.
Before settling for any of the following diagnoses the patient should be given several treatments of manipulation of the cervical spine. Nocturnal neuralgia. Postural myoneuralgia. Acroparaesthesia. The shoulder-arm syndrome. The scapulo-costal syndrome. The carpal tunnel syndrome. In the last, of course, compression of the median nerve in the carpal tunnel would be shown by painless paralysis of the median nerve in the hand.
A variety of insupportable terms are applied to the spinal pains. Of these osteoarthritis is probably the most frequent. The radiating pains to the head and face are usually diagnosed as migraine, migrainous neuralgia, cluster headaches or neuralgia although "tension headaches" and other "tension states" are becoming increasingly popular. The radiating pains in the arms are often labeled brachial neuritis or brachial neuralgia. The radiating pains in the trunk are described as intercostal neuritis or abdominal neuritis. In the legs, sciatic, femoral and obturator neuritis are encountered. In all regions fibrositis, myositis, and myofascitis are diagnosed; bursitis too, applied to regions where there is no inflammation of a bursa or even the presence of a bursa. Psychosomatic pains, psychoneurosis and malingering are other convenient blankets. A horror diagnosis which seems to be exclusively North American is "pinched nerve" as in "pinched nerve in the shoulder". Obvious questions do not seem to arise. What nerve is being pinched? What is pinching it? What is the result of pinching a nerve?
THE MISTAKEN DIAGNOSES AND "MIRACULOUS CURES"
Let us consider the case of a patient who has a nuclear lesion in the cervical spine. His complaints are of severe pain at the back of the head which passes over the top of the head, pain at the bridge of his nose, pain over his frontal sinuses and discomfort in his eyes. 'When the pain is severe he is nauseated and vomits .
The diagnosis of migraine may be made, or a brain tumour may be suspected, and these possibilities are communicated to the patient. If the patient then proceeds to a lay manipulator and after a few treatments is relieved of pain, is it not likely that both he and the lay manipulator will believe that they have cured migraine or a brain tumour or frontal sinusitis or an eye ailment?
The patient with a nuclear lesion of the dorsal spine may complain of pain in the front of the left side of the chest which she attributes to an innocent irregularity in the breast. Her doctor suggests biopsy which, to the patient, means cancer. If she is treated by a lay manipulator and all pain disappears, is it not reasonable for them both to conclude that a cancer of the breast has been cured?
Similar results occur in patients with precordial pain and pain running down the left arm, when the pseudo-angina is diagnosed as angina pectoris and again is relieved by spinal manipulation.
The patient with excruciating pain from a nuclear lesion of the lumbar spine has often been confused with a sufferer from ureteral colic.
Here we may consider for a moment the state of mind of a doctor who has made a reasonably confident diagnosis in each of the above cases. Suppose, which is unlikely,that each patient tells the doctor that a lay manipulator has cured him. The doctor is outraged. He projects his annoyance on the lay manipulator rather than on his own ignorance and incompetence. Such a result, he believes, is inexplicable. It must be the result of suggestion on a susceptible patient or some baffling type of fraud or coincidence with spontaneous improvement. As a person with pretensions to scientific background he should have asked how the pain was relieved and why the pain was relieved.
An ameliorating factor is that most. patients do not tell their own doctor - to whom they are usually devoted - that they have consulted a lay manipulator. They feel, quite justifiably, that their doctor is a good doctor but that he cannot be expected to know everything.