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RECURRENT SPONDYLOLISTHESIS, with Trouble. the Most Frequent Anomaly Is Probably in the Long Axis of the Joint Antero-Posterior

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RECURRENT SPONDYLOLISTHESIS, with Trouble. the Most Frequent Anomaly Is Probably in the Long Axis of the Joint Antero-Posterior syphilis. I have shown in every case, on making an injection and fell to the floor in a faint. When she awoke there was of tuberculous material into an animal, that the animal never a severe pain in the lower part of her back, but after a time, failed to develop tuberculosis. Among those cases which I with some assistance, she was able to walk home. For a call the hypertrophie, we found cases of inflammatory reac¬ week the pain continued, though less severe, and she was able tion, as well as the development of tubercle; and we believe to go to school, but on the eighth day her legs grew weak that these are cases of mixed infection. Dr. Fassett spoke and began to feel numb. A week later she was unable to concerning the rarity of the occurrence of tuberculosis in the walk at all. The pain radiated down the back of the thighs shaft, as a frequent occurrence in the epiphysis ; and he men¬ and legs, and for a time the family physician thought it tioned the work of Dr. Noyes of Edinburgh, who thinks that might be due to "sciatic rheumatism." As it did not respond it is entirely metaphyseal or epiphyseal. He does not believe to salicylates, a neurologist was called in consultation. that it occurs in the shaft. Yet it certainly does occur in the The knee-jerks were increased, a slight ankle-clonus was shaft. He does not say, however, that it is rare in the present, and the condition was one of spastic paraplegia. It epiphysis. That is the most common situation by far. He was thought that possibly a vertebral tuberculosis might be agrees that it occurs there. Dr. Steindler spoke of the work present, with pressure on the cord. A double Buck's extension of Friedländer on diaphyseal tubercle, and his classification, was applied to relieve the painful flexion of the knees. In including a purely periosteal form. If you search you will a few days the paralysis had disappeared, and the child was find in every case a central focus. Tubercle cannot occur sent to the orthopedic department of the Chicago Policlinic primarily in the periosteum. It used to be thought that it to have an artificial ankylosis of the vertebrae made by the occurred in the periosteum of the rib, but osteomyelitis occurs Albee method. in every such rib. Dr. Griffith spoke of the importance of Examination.—On examination, however, no evidence of eliminating bovine tuberculosis. That is the most important spinal tuberculosis could be found, and it seemed probable part of the work. If we can eliminate that we shall have that the condition was due to a mechanical cause rather than accomplished a great deal. Our system of milk inspection in to disease. An actual forward displacement of the fifth Edinburgh, at present, is shocking beyond words ; but we lumbar was not considered as likely as a protrusion of the hope to have this corrected. Dr. Griffith also asked how I intervertebral disk, although no history of a sideways bend¬ could explain the way in which, by retarding the blood¬ ing at the time of the accident could be elicited. stream, we can localize tubercle, and asked how I could Subsequent Course.—The patient was now apparently per¬ account for tuberculous infection without any interference fectly well, and after a week of observation in the hospital with the return circulation. I would ask him how he knows she was allowed to go home, in the belief that the trouble that retardation of the blood-stream does not occur in such would not recur without severe exertion. She was cautioned cases. The tubercle is always secondary to some focus in to avoid lifting any weights and to keep quiet for some the body; and with this primary focus you get a thickening weeks. For a week at home she remained well, but the next of the vessels, which produces a certain amount of retarda¬ day she stumbled over some obstacle on the floor and the tion of the blood-stream over the entire body. paralysis recurred. The Buck's extension once more rapidly relieved the paralysis and a plaster jacket was applied, fit¬ ting very low over the hips. A few days later an attack of and was RECURRENT WITH ptomain poisoning occurred, the jacket removed SPONDYLOLISTHESIS, by the family physician on account of the distention of the PARALYSIS; BONE-SPLINT abdomen. Now began a series of attacks of paralysis, aver¬ TRANSPLANTATION aging one every ten days, until January, 1914, when the child was confined to the bed all of the time. A small and ineffi¬ EDWIN W. RYERSON, M.D. cient commercial brace had been applied some time before, CHICAGO but it did no good. I saw her again Feb. 6, 1914, ten months after she had The fifth lumbar vertebra is subject to many abnor- passed from my observation. No paralysis existed, and the malities of development which may cause mechanical reflexes were normal. On bending her backward in bed, trouble. The most frequent anomaly is probably in exaggerating the lumbar lordosis, the spinous process of the the shape or size of the transverse processes. This fifth lumbar vertebra could be felt to move forward abnor¬ will not be considered here. mally far on the sacrum. This caused pain in the back and Next in is a variation in the articular a tingling and pricking sensation in the feet. On bending frequency the the lumbar processes, which may vary in size, in or in direc- body forward, obliterating lordosis, imme¬ shape, relief was tion. If the articulation be of the lumbar type, with diate felt and the child stated that this occurred the and the habitually on similar movements. She lies and sleeps with the long axis of joint antero-posterior, flat the spine in flexion for the sake of comfort. facets to the it is for the vertebra facing side, possible Treatment.—An opinion was now given that the trouble on sacrum is to slide forward the when the spine was due to the slipping forward of the fifth vertebra as a straight or extended, especially if the articular proc- whole, and that the best way to rectify it would be to implant esses be small and the ligaments weak. If the proc- a bone splint by Albee's method so as to immobilize the lower esses be of the dorsal type, and this is by no means lumbar spine. Accordingly, on March 11, 1914, this operation was rare, flexion of the spine, with violence, may cause performed at the Policlinic. A splint was cut from the left tibia, curved to fit the lumbar the facets to override; more easily, again, if these slightly lordosis and the facets be small and the be weak. sacrum, and long enough to reach from the third lumbar ligaments process to the third sacral. The lumbar The exhaustive work of Goldthwait1 and first two sacral explained spinous processes were readily split, but the third sacral was of class of but no clearly the mechanism this lesions, merely a small projection, so a groove was cut out lumbar vertebra bodily case of displacement of the fifth with in this region. The splint was sewed in with No. 12 braided paralysis has come under my observation until last silk sutures, boiled in mercuric chlorid solution and then in year: paraffin. These sutures were inserted deeply and strongly, CASE REPORT with large needles and a heavy needle-holder, and they were tied very tightly. A layer of the lumbo-sacral fascia was History.—In the latter part of February, 1913, a strong sewed over the whole both and silk and of 15 was another in her arms, splint, covering splint healthy girl carrying girl sutures. in the gymnasium, when she suddenly felt a pain in her back The girl was placed in an ordinary bed and kept recum¬ Read before the Section on Orthopedic Surgery at the Sixty-Fifth bent for three weeks, when against orders she began to Annual Session Medical Atlantic of the American Association, City, sit when the nurse was out the room. N. J., June, 1914. up of April 7 she 1. Goldthwait, J.: Boston Med. and Surg. Jour., 1911, clxiv, 365. went home, and April 21 began to walk about. Her back Downloaded From: http://jama.jamanetwork.com/ by a Georgetown University Medical Center User on 05/21/2015 felt perfectly well and strong and she remained in excel¬ «xposed and ultimately came out. As this was the thir¬ lent condition until June 4, a period of over six weeks. On teenth operation, it naturally would be expected to fail. this latter date something gave way in her back, causing That was the only graft that I lost in the twenty-six cases; severe pain but no paralysis. Examination June 11 showed and I think, from the experience I have had, that the attach¬ that the upper tip of the splint had become loosened from ing of the graft to the sacral region gives as good results as the third lumbar spinous process. The knee-jerks were nor¬ in any other region. Dr. Ryerson's paper is of immense mal, there was no ankle clonus and sensation and motion importance, as opening up a field for the treatment of that were undisturbed. There was easily perceptible grating and most troublesome of cases, the cases of spondylolisthesis. crepitus at the tip of the splint when the back was moved, In older patients, past 35 or 40, when it is possible by and the pain was said to be quite severe on such motion.
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