CHAPTER X
BACKACHE IS A SIMPLE PROBLEM
THE DIAGNOSIS IS EASILY MADE
If the patient complains of backache, or of pain in his neck, the diagnosis is almost invariably a nuclear lesion of the appropriate part of the spine, and it is easy to decide that the pain is of spinal origin.
The history is of almost total importance in making a diagnosis of a nuclear lesion of an intervertebral disc. It is a striking fact that patient after patient after patient tells almost the same story, in almost the same words. The first attack, which may be mild to excruciating, is of pain in some part of the spine. The course of the disease is one of acute exacerbations and incomplete remissions. At a varying period after the first attack the radiating pains begin.
In the cervical spine the radiations are up the back of the head and maybe over the top of the head down to the eyebrows and the eyes, or it may be across one side of the face. Very commonly it runs from the neck to the shoulder and down an arm to the fingers. Sometimes the radiation runs down both arms.
The radiations from the dorsal spine are around the chest wall and sometimes pain over the sternum may be severe enough to cause nausea and vomiting. From the lower dorsal spine the radiations run around the abdominal wall.
From the lumbar spine the pain runs to the gluteal muscles and down the leg, occasionally down both legs, and sometimes into the toes.
There is no doubt that in these cases the pain arises from inside the intervertebral disc. Removal of the fibrous nucleus prior to its herniation is followed by complete relief of both the backache and the radiating pain.
The theory of the radiation of pain was evolved from discussions with electrical engineers. It is an elementary fact that a current of varying intensity running along a conductor causes a magnetic field around the conductor. This magnetic field will induce currents to run in the opposite direction from the original current in circults lying within it. From this we presumed that electric currents would behave similarly in a living body.
Now if we place the firm fibrous nucleus in contact with a partly eroded annulus, the fibrous nucleus is in a constant, if extremely slight, state of movement because slight spinal movements are constant in reaction to breathing, the heart beat and the interplay of muscles which maintain spinal posture. Thus a current of varying intensity runs along the nervus sinu vertebralis supplying the affected portion of the posterior annulus. Nerves inside the meninges lie within this magnetic field. We have presumed that the unmyelinated pain fibres are probably the most receptive tracts and currents are induced which run along them to the brain.
Occasionally one finds rather faint vascular symptoms associated with these lesions, such as the reputed vascular disturbances of migraine and sometimes a slight swelling of a hand or a foot, which are relieved by manipulation. This reminds us again that Luschka and subsequently many other investigators noted that each nervus sinu vertebralis is joined by a branch from the sympathetic.
The lack of physical findings to support the patient's complaints of pain is in itself almost diagnostic of a nuclear lesion. Therefore it is helpful to regard the various pains as pains without cause presenting symptoms without signs. The signs are found only in the uncommon cases in which the fibrous nucleus has eroded its way into the spinal canal and has compressed a nerve root, in which case painless paralysis attributable to that root will be demonstrated. However, in most cases in which the fibrous nucleus has wormed its way into the spinal canal a nerve root is not trapped and compressed. In a small proportion of cases of herniated discs rectal and bladder disturbances may occur, probable as the result of haemorrhage damaging the nerve supply (i.e. sacral nerves, 2, 3, and 4 bilaterally)
An illuminating exercise is suggested to the reader. He might ask his next twenty patients between the ages of thirty and fifty whether they have ever suffered from painful stiff neck or pains running up the back of the head, or running down an arm; whether they have ever had pain in the upper back or pain running around the chest, or pain in the front of the chest; and, whether they have ever had pain in the low back with pain running down a leg.
THE DIAGNOSIS IS CONFIRMED BY MANIPULATION OF THE SPINE
The diagnosis of a nuclear lesion is confirmed by manipulation of the spine. The snapping and clicking sound elicited by manipulation and the ensuing relief of pain do not occur in any other ailment. If the fibrous nucleus has herniated the snapping sounds are not elicited and there is no relief of pain. The posterior thrust test shows which intervertebral disc is involved. A marker taped over this spinous process shows in a lateral X7ray of the spine the exact level of the lesion. If operation has become necessary even the slightest indentation of the dural tube shown on the myelogram opposite this intervertebral disc is significant.
X-rays and other laboratory aids as a rule are not of any help in making a diagnosis of a nuclear lesion.
TRACTION AND MANIPULATION OF THE SPINE ARE PERFECTLY SAFE
It does not seem to be possible to rupture fibrillae in a normal nucleus by manipulation, at least I have never seen nor heard of the production of a nuclear lesion by manipulation. Rupture of fibrillae seems to occur only as the result of vigorous flexion plus rotation of some part of the spine. It may be that the relatively weak posterior annulus, unsupported by peripheral fibrous ligaments, allows some distraction of the posterior vertebral bodies. This distraction cannot occur in the powerfully constructed anterior and lateral parts of the intervertebral disc except as the result of extremely violent injury.
THE OPERATION IS A SIMPLE ONE
If one is familiar with the region to be traversed, the operation proves to be only the removal of a deeply placed foreign body and the patient should make a rapid recovery. Spinal fusion is not necessary.
The doctor who undertakes the practice of spinal manipulation will soon find that many patients whom he has regarded as tiresome hypochondriacs, psychoneurotics or victims of psychosomatic disorders will appear in a new and incredibly more favourable light and some of this light will be shed on himself. When doctors learn this ancient, simple and effective art, lay manipulators will vanish from the earth.