The Elbow
joint, resection of the radial head and partial Treatment
synovectomy give reasonably good results. If the Osteoarthritis of the elbow rarely requires more
entire joint is severely damaged, joint replacement than symptomatic treatment; loose bodies, however,
should be considered. The preferred operation is should be removed arthroscopically if they cause
a semi-constrained arthroplasty: stemmed metal locking. If stiffness is sufficiently disabling, removal
implants are cemented into the distal humerus and of osteophytes (by either open or arthroscopic
the proximal ulna; the protruding ends articulate surgery) can improve the range of movement. If
with each other on a polythene bearing. The there are signs of ulnar neuritis, the nerve may have
result is often excellent, at least compared to the to be transposed to the front of the elbow.
preoperative situation. With modern techniques
complications such as infection, instability and Loose bodies
implant loosening are much less common than in
the past. The commonest cause of a single loose body
in the elbow is osteochondritis dissecans of the
Osteoarthritis capitulum. Multiple loose bodies may occur with
osteoarthritis or synovial chondromatosis.
The elbow is an uncommon site for osteoarthritis.
When it does occur, it may be secondary to trauma. The cardinal clinical feature is sudden locking of
‘Primary’ osteoarthritis of the elbow should suggest the elbow. If this is troublesome, the loose bodies
an underlying disorder such as pyrophosphate can be removed arthroscopically.
arthropathy or congenital dysplasia, but usually
occurs spontaneously. Olecranon bursitis
The usual symptoms are pain and stiffness, The olecranon bursa sometimes becomes enlarged
but in late cases the joint may become unstable. as a result of pressure or friction. When it is also
Occasionally ulnar palsy is the presenting feature. painful, the cause is more likely to be infection,
The elbow may look and feel enlarged and gout or rheumatoid arthritis.
movements are somewhat limited.
Gout is suspected if there is a history of previous
X-rays show diminution of the joint space with attacks, if the condition is bilateral, if there are
subchondral sclerosis and marginal osteophytes; tophi, or if x-ray shows calcification in the bursa.
one or more loose bodies may be seen. Even then it is not easy to distinguish from acute
infection, unless pus is aspirated.
Rheumatoid arthritis causes both swelling and
nodularity over the olecranon. In almost all cases
this will be associated with a typical symmetrical
polyarthritis. In the late stages, erosion of the
elbow joint may cause marked instability.
14.4 Osteoarthritis This patient has osteoarthritis and 14.5 Olecranon bursitis The enormous red lumps
loose bodies in the elbow. over the points of the elbows are due to swollen
olecranon bursae; the patient’s ruddy complexion
completes the typical picture of gout.
188
‘Tennis elbow’ and ‘golfer’s elbow’
‘Tennis elbow’ and ‘golfer’s elbow’
Treatment pouring out tea, turning a stiff door-handle, shaking
The underlying disorder must be treated. Septic hands or lifting with the forearm pronated. The
bursitis may need local drainage. Occasionally a elbow looks normal and flexion and extension are
chronically enlarged bursa has to be excised. full and painless. Tenderness is localized to a spot
just in front of the lateral epicondyle, and pain is
‘Tennis elbow’ and reproduced by getting the patient to extend the wrist
‘golfer’s elbow’ against resistance, or simply by passively flexing the
wrist so as to stretch the common extensors.
The cause of these common disorders is unknown,
but they are seldom due to either tennis or golf. In ‘golfer’s elbow’, similar symptoms occur around
Most cases occur spontaneously as part of a natural the medial epicondyle and, owing to involvement
degenerative process in the tendon aponeuroses of the common tendon of origin of the wrist
attached to either the lateral or medial humeral flexors, pain is reproduced by passive extension of
epicondyle. Pain is probably due to a vascular repair the wrist in supination.
process similar to that of rotator cuff tendinitis
around the shoulder. Often there is a history of Treatment
occupational stress or unaccustomed activity, such Rest, or avoiding the precipitating activity,
as house painting, carpentry or other activities that may allow the lesion to heal. A splint and
involve strenuous wrist movements and forearm physiotherapy may help. If pain is severe, the area
muscle contraction. of maximum tenderness is injected with a mixture
of corticosteroid and local anaesthetic.
Clinical features
In ‘tennis elbow’, pain is felt over the outer side of Persistent pain which fails to respond to
the elbow, but in severe cases it may radiate widely. conservative measures may call for operative
It is initiated or aggravated by movements such as treatment. The affected common tendon on the
lateral or medial side of the elbow is detached from
its origin at the humeral epicondyle.
(b)
14.6 Tennis elbow
(a) Tenderness over the
lateral epicondyle. (b) Pain is
provoked by resisted wrist
extension. (c) Extensor carpi
radialis brevis origin may
(a) (c) have to be released.
189
CHAPTER 15
THE WRIST
■ Clinical assessment 190 ■ Ulnocarpal impaction and TFCC 196
■ Wrist deformities 192 degeneration 196
■ Tuberculosis 193 ■ Chronic carpal instability 196
■ rheumatoid arthritis 193 ■ Tenosynovitis and tenovaginitis 197
■ Kienböck’s disease 195 ■ Ganglion 197
■ Tears of the triangular fibrocartilage 195 ■ Carpal tunnel syndrome
clinical assessment deformity. If there is swelling, note whether it is
diffuse or localized to one of the tendon sheaths.
history Feel
■ Pain may be localized to the radial side (especially Undue warmth is noted. Tender areas must be
accurately localized and the bony landmarks
in tenovaginitis of the thumb tendons), to the compared with those of the normal wrist.
ulnar side (possibly from the radioulnar joint)
or to the dorsum (the usual site in disorders of (f)
the carpus). (e)
■ Stiffness is often not noticed until it is severe.
Loss of pronation or supination is more readily (a)
noticed and may be very disabling. (b)
■ Swelling may signify involvement of either the (c)
joint or the tendon sheaths. (d)
■ Deformity is a late symptom except after trauma.
■ Loss of function affects both the wrist and the 15.1 Tender points at the wrist (a) Tip of the radial
hand. Firm grip is possible only with a strong, styloid process; (b) anatomical snuff-box, bounded on
stable, painless wrist that has a reasonable range the radial side by (c) the extensor pollicis brevis and on
of movement. the ulnar side by (d) the extensor pollicis longus; (e) the
extensor tendons of the fingers; and (f) the head of the
ExAminAtion ulna.
Examination of the wrist is not complete without
also examining the elbow, forearm and hand. Both
upper limbs should be completely exposed.
Look
The skin is inspected for scars. Both wrists and
forearms are compared to see if there is any
Clinical assessment
(a) (b) (c) (d)
(e) (f) 15.2 Wrist movements (a) Flexion;
(b) extension; (c) ulnar deviation; (d) radial
Move deviation; (e) pronation; (f) supination.
Passive flexion and extension of the wrist can be
measured on each side in turn. To view both sides also on the condition of the elbow and movement
simultaneously and compare them, ask the patient between the forearm bones. The normal range is
first to place his or her palms together in a position 0–90 degrees in both directions.
of prayer, elevating the elbows, then to repeat the
manoeuvre with the wrists back-to-back. The Active movements should be tested against
normal range for both flexion and extension is 80– resistance; loss of power may be due to pain,
90 degrees. Radial deviation and ulnar deviation are tendon rupture or muscle weakness. Grip strength
measured in the palms-up position; ulnar deviation can be gauged by having the patient squeeze the
is normally about 40 degrees and radial deviation examiner’s hand; mechanical instruments allow
only about 15 degrees. Pronation and supination are more accurate assessment.
included in wrist movements, although they depend
Imaging
X-rays are routinely obtained; often both wrists must
be examined for comparison. Special oblique views
are necessary to show up difficult scaphoid fractures.
E G 15.3 X-rays (a) Note
D F the shape and position
of the bones which make
A C up the wrist:
B (A) scaphoid, (B) lunate,
(C) triquetrum overlain by
(a) (b) (b) pisiform, (D) trapezium,
(E) trapezoid,
(F) capitate, (G) hamate.
(b) Schematic section
showing the carpal
articulations and the
triangular
fibrocartilaginous
ligament (coloured
green).
191
The Wrist
Note the position of the carpal bones and look for (a) (b)
evidence of joint-space narrowing, especially at the
carpometacarpal joint of the thumb.
Magnetic resonance imaging (MRI) is useful for
demonstrating soft-tissue lesions or the early signs
of avascular necrosis in one of the carpal bones.
Arthrography, combined with computed
tomography (CT) or MRI, is a sensitive way to
diagnose ligament tears.
Arthroscopy
This is the most reliable way of diagnosing tears
of the triangular fibrocartilage complex (TFCC).
It will also reveal the early changes of osteoarthritis.
Wrist deformities
Congenital variations (c) (d) (e)
Embryonic abnormalities of the upper limb are
likely to affect more than one segment (or indeed the 15.4 Congenital deformities (a,b) Radial club-hand.
whole) of the limb; therefore, congenital anomalies (c–e) Madelung’s deformity.
often appear together in the forearm, wrist and
hand. Furthermore, other organs developing during If function deteriorates, centralization of the
the same period may be affected and thus there may carpus over the ulna is recommended, preferably
be associated congenital abnormalities. before the age of 3 years.
Madelung’s deformity
These are rare conditions; the overall In this deformity the lower radius curves forwards
incidence of upper limb anomalies is estimated (ventrally), carrying with it the carpus and hand
to be about 1 in 600 live births, but in only a but leaving the distal end of the ulna projecting on
fraction of those affected are the defects severe the back of the wrist. Although the abnormality
enough to require corrective surgery. A few of the is present at birth, the deformity is rarely seen
least unusual deformities affecting the wrist are before the age of 10 years, after which it increases
described here. until growth is complete. Despite the deformity,
function is usually undisturbed.
Radial dysplasia
The infant is born with the wrist in marked Treatment may be unnecessary, but if the
radial deviation, hence the common name radial deformity is severe, the lower end of the ulna can
club-hand; one-half of the patients are affected be shortened; this is sometimes combined with
bilaterally. There is absence of the whole or part of osteotomy of the radius.
the radius, and usually also the thumb.
Acquired deformity
Treatment in the neonate consists of gentle Physeal injuries can result in malunited fractures
stretching and splintage. Serious cases can be or subluxation of the distal radioulnar joint.
treated by distraction prior to a tension-free soft- Osteotomy of the radius or stabilization of the ulna
tissue correction which has less effect on growth of may be needed.
the carpus and distal ulna than the older technique
of ‘centralizing’ the carpus over the remaining Non-traumatic deformities are seen typically
forearm structures. Prolonged splintage is still in rheumatoid arthritis and cerebral palsy. These
required to avoid recurrence of the deformity. disorders are discussed in Chapters 3 and 10,
respectively.
Always examine the elbow: if the joint is stiff, a
radially deviated wrist can actually be advantageous,
as the child can then get the hand to his or her
mouth (for eating) and the perineum (for toilet
care). Surgical correction of the wrist in these cases
can be disastrous.
192
Rheumatoid arthritis
(a) (b) 15.5 Tuberculosis (a) Subacute
tuberculous arthritis; note the marked
osteoporosis in the distal radius and the
carpus. (b) A much more advanced case of
tuberculous arthritis giving rise to extensive
bone destruction.
Tuberculosis tendon sheaths. Sooner or later the whole wrist
becomes involved and tenderness is much more
Tuberculous arthritis sometimes occurs at the ill defined. In late cases the wrist is deformed and
wrist. Pain and stiffness come on gradually and unstable. Extensor tendons may rupture where
the hand feels weak. The forearm looks wasted; the they cross the dorsum of the wrist, causing one or
wrist is swollen and feels warm. Involvement of the more of the fingers to drop into flexion.
flexor tendon compartment may give rise to a large
fluctuant swelling that crosses the wrist into the X-rays show the characteristic features of
palm (what used to be called a ‘compound palmar osteoporosis and bony erosions. Tell-tale signs are
ganglion’). Movements are restricted and painful. usually more obvious in the metacarpophalangeal
In a neglected case there may be a sinus. joints.
X-ray examination shows localized osteoporosis (a) (b)
and irregularity of the radiocarpal and intercarpal
joints, and sometimes bone erosion. 15.6 Rheumatoid arthritis (a) The wrist is deviated
radialwards and the fingers ulnarwards; this is the typical
Diagnosis zig-zag deformity of established rheumatoid arthritis in
The condition must be differentiated from the wrist and hand. (b) X-ray of the same patient.
rheumatoid arthritis. Bilateral arthritis of the wrist Treatment
is nearly always rheumatoid in origin; when only
one wrist is affected, the signs resemble those of Management in the early stage consists of splintage
tuberculosis. X-rays and serological tests may help, and local injection of corticosteroids, combined
but sometimes a biopsy is necessary. with systemic treatment. Persistent synovitis
(usually affecting the extensor tendon sheaths) may
Treatment call for synovectomy and soft-tissue stabilization
Antituberculous drugs are given and the wrist is of the wrist. If the radioulnar joint is involved,
splinted. If an abscess forms, it must be drained. synovectomy can be combined with excision of the
If the wrist is destroyed, systemic treatment should distal end of the ulnar head. Flexor synovitis may
be continued until the disease is quiescent and the
wrist is then arthrodesed.
Rheumatoid arthritis
Clinical features
After the metacarpophalangeal joints, the wrist
is the most common site of rheumatoid arthritis.
Pain, swelling and tenderness may at first be
localized to the radioulnar joint, or to one of the
193
The Wrist
cause median nerve compression (carpal tunnel
syndrome), which should be treated by operative
release of the flexor retinaculum.
In the late stage, tendon ruptures at the wrist,
joint destruction, instability and deformity may
require reconstructive surgery, including either
arthroplasty or arthrodesis.
Osteoarthritis of the radiocarpal (a) 15.7 Osteoarthritis
joint of the wrist Severe
Osteoarthritis of the wrist joint proper is unusual symptoms may call for
except as a sequel to intra-articular injuries of
the distal radius or the carpal bones, or avascular either (a) total wrist
necrosis of the lunate (Kienböck’s disease). The
patient may have forgotten the old injury, but fusion or (b,c) total joint
some years later he or she begins to complain of
pain, progressive loss of movement and weakness replacement.
of grip. The appearance is usually normal, but the
wrist is tender and movements are restricted and
painful.
X-ray features are narrowing of the radiocarpal
joint, bone sclerosis and irregularity of one or more
of the proximal carpal bones. There may also be
signs of the old injury or Kienböck’s disease.
Treatment
Rest in a splint is often sufficient treatment. Painful
but limited osteoarthritis following a scaphoid
fracture can be alleviated by excision of the
radial styloid process. Widespread osteoarthritis
may require more extensive surgery, including
replacement or arthrodesis of the wrist.
Osteoarthritis of the FIRst (b) (c)
carpometacarpal joint
Osteoarthritis of the thumb carpometacarpal proximal end of the thumb metacarpal. Careful
joint is common in postmenopausal women. The examination will show that tenderness is sharply
patient complains of pain and swelling around the localized to the carpometacarpal joint, about 1 cm
distal to the radial styloid process. The condition is
(a) (b) (c) (d) (e)
15.8 Osteoarthritis of the first carpometacarpal (CMC) joint (a) Typical deformity: note the swelling over the
first CMC joint. (b) X-ray changes. Choice of treatment is between (c) trapeziectomy, (d) replacement arthroplasty and
(e) arthrodesis.
194
Tears of the triangular fibrocartilage
(a) (b) (c)
15.9 Kienböck’s disease (a) Typical x-ray features of avascular necrosis of the lunate. (b) Late changes – marked
distortion of the lunate. (c) Treatment, in this case, was first by osteotomy and shortening of the radius (the plate is still
present) and then, when this failed to relieve pain, by lunate excision and scaphocapitate fusion.
often bilateral, and Heberden’s nodes of the finger Treatment
joints are common. In late cases, fixed adduction During the early stage, while the shape of the lunate
of the first metacarpal produces a characteristic is more or less normal, osteotomy of the distal end
deformity. X-ray examination shows the usual of the radius may reduce pressure on the bone and
features of joint-space narrowing, sclerosis and thereby protect it from collapsing. Microsurgical
osteophyte formation. revascularization of the bone is also worth
considering if the necessary expertise is available. In
Treatment late cases, partial wrist arthrodesis or proximal row
Local injection of corticosteroid usually relieves excision or even joint replacement are considered.
pain, and movements may improve. If this fails,
operation may be advisable. The surest way of Tears of the triangular
abolishing pain and preserving function is to fibrocartilage
excise the trapezium. A more sophisticated, but
less reliable, option is joint replacement. Joint The TFCC fans out from the base of the ulnar
arthrodesis is difficult and causes stiffness. styloid process to the medial edge of the distal
radius, acting somewhat like a meniscus in the
Kienböck’s disease wrist joint (see Figure 15.3). Chronic pain in the
wrist may be related to an old ‘sprain’ in which a
After injury or stress, the lunate bone sometimes more serious injury to the TFCC was overlooked.
develops a patchy avascular necrosis. A predisposing In addition to pain, there may be loss of grip
factor may be relative shortening of the ulna strength and clicking on supination of the forearm.
(negative ulnar variance), which could result in The diagnosis can be confirmed by arthroscopy.
excessive stress being applied to the lunate where it
is squeezed between the distal surface of the (over- Central disc
long) radius and the second row of carpal bones. (Prone to degerative
tears)
The patient, usually a young adult, complains
of ache and stiffness. Tenderness is localized to the Peripheral attachment
centre of the wrist on the dorsum; wrist extension (Avulsion causes
may be limited. instability)
Imaging
The earliest signs of osteonecrosis can be detected Lunate fossa of
only by MRI. Typical x-ray signs are increased distal radius
density in the lunate and, later, flattening and
irregularity of the bone. Ultimately there may be 15.10 Triangular fibrocartilage complex.
features of osteoarthritis of the wrist.
195
The Wrist
Operative treatment may be needed if the Diagnosis
symptoms are marked. Peripheral tears can be re- The different types of carpal instability are
attached by either open or arthroscopic techniques; described on page 392. The most easily spotted
central tears, in the absence of ulnocarpal impaction example is a rupture of the scapho-lunate ligament,
(see below) are best managed by arthroscopic which appears on x-ray as an unusual gap between
debridement to remove the ragged fragments. the scaphoid and lunate and foreshortening of the
scaphoid image (Figure 15.11).
Ulnocarpal impaction and
TFCC degeneration Treatment
The best form of treatment is prevention. Acute
Chronic degeneration of the TFCC may be ‘wrist sprains’ should be carefully assessed for signs
associated with a relatively long ulna, impaction of of carpal displacement and instability (see page
the ulnar head against the ulnar side of the lunate 392). Carpal displacement must be reduced, the
and ulnocarpal arthritis (the ulnocarpal impaction ligament repaired and the bones held in position
syndrome). This may result when an impacted Colles with Kirschner wires (K-wires).
fracture leaves the radius relatively shorter than
usual. X-ray examination shows a relatively long ulna Patients with chronic instability can often
(‘positive ulnar variance’) and in late cases there may be treated by splintage, analgesics and specific
be arthritic changes in the ulnolunate articulation. physiotherapy. Occasionally operative treatment
is indicated, involving soft-tissue augmentation or
Treatment starts with simple analgesics, splintage partial fusion of the wrist.
and steroid injections. If the positive ulnar variance
is slight (less than 3 mm) arthroscopic excision of Tenosynovitis and
the distal dome of the ulnar head may be successful; tenovaginitis
otherwise the long ulna can be shortened using a
special jig and compression plate. The extensor retinaculum contains six compartments
which transmit tendons lined with synovium.
Chronic carpal instability Tenosynovitis can be caused by unaccustomed
movement; sometimes it occurs spontaneously.
The wrist functions as a system of intercalated The resulting synovial inflammation causes
segments (i.e. adjacent congruous bones) stabilized secondary thickening of the sheath and stenosis
by ligaments and by the scaphoid, which bridges the of the compartment, which further compromises
two rows of carpal bones. Following trauma to the the tendon. Early treatment, including rest,
carpus, there may be partial collapse of this structure, anti-inflammatory medication and injection of
a condition which is not always recognized at the corticosteroids, may break this vicious circle.
time. Some years later, the patient complains of
progressive pain and weakness in the wrist. The first dorsal compartment (enclosing
abductor pollicis longus and extensor pollicis
brevis) and the second dorsal compartment
(extensor carpi radialis longus and brevis) are the
ones most commonly affected.
De Quervain’s disease
Tenovaginitis of the first dorsal compartment is
usually seen in women between the ages of 30 and
50 years. There may be a history of unaccustomed
activity, such as pruning roses, cutting with scissors
or wringing out clothes. It is quite common shortly
after childbirth.
15.11 Carpal instability The scapholunate ligament Clinical features
has ruptured – the X-ray shows a large gap between the Pain, and sometimes swelling, is localized to the
radial side of the wrist. The tendon sheath feels
two bones and the scaphoid is foreshortened. thick and hard. Tenderness is most acute at the
very tip of the radial styloid.
196
Carpal tunnel syndrome
(a) (b) (c) (d)
15.12 De Quervain’s disease (a) There is point tenderness at the tip of the radial styloid process. (b,c) Finkelstein’s
test: ulnar deviation with the thumb left free is relatively painless (b), but if the movement is repeated with the thumb
held close to the palm (c), the pull on the thumb tendons causes intense pain. (d) Injecting the tendon sheath.
The pathognomonic sign is elicited by respectively (see Figure 15.1). Splintage and
Finkelstein’s test. Hold the patient’s hand firmly, corticosteroid injections are usually effective.
keeping the thumb tucked in close to the palm,
then turn the wrist sharply towards the ulnar side. Ganglion
A stab of pain over the radial styloid is a positive
sign. Repeating the movement with the thumb left The ubiquitous ganglion is seen most commonly
free is relatively painless. on the back of the wrist. It arises from cystic
Treatment degeneration in the joint capsule or tendon sheath.
In early cases, symptoms can be relieved by The distended cyst contains a glairy fluid.
ultrasound therapy or a corticosteroid injection
into the tendon sheath, sometimes combined The patient, often a young adult, presents with
with splintage of the wrist. Resistant cases need an a painless lump, usually on the back of the wrist,
operation, which consists of slitting the thickened but sometimes on the front. Occasionally there is a
tendon sheath. Care should be taken to prevent slight ache. The lump is well defined, cystic and not
injury to the dorsal sensory branches of the radial tender. It may be attached to one of the tendons.
nerve, which may cause intractable dysaesthesia.
Other sites of extensor The ganglion often disappears after some
tenosynovitis months, so there should be no haste about treatment.
Tenosynovitis of extensor carpi radialis brevis If the lesion continues to be troublesome, it can be
(the most powerful extensor of the wrist) or aspirated; if it recurs, excision is justified, but the
extensor carpi ulnaris may cause pain and point patient should be told that there is a 30% risk of
tenderness just medial to the anatomical snuffbox recurrence, even after careful surgery.
or immediately distal to the head of the ulna,
Carpal tunnel syndrome
15.13 Volar wrist ganglion
This is the commonest and best known of all the
nerve entrapment syndromes. In the normal carpal
tunnel there is barely room for all the tendons and
the median nerve; consequently, any swelling is likely
to result in compression and ischaemia of the nerve.
Usually the cause eludes detection; the syndrome
is, however, common in women at the menopause,
in rheumatoid arthritis, in pregnancy and in
myxoedema. The usual age group is 40–50 years.
Clinical features
The history is most helpful in making the diagnosis.
Pain and paraesthesia occur in the distribution of
the median nerve in the hand. Night after night the
patient is woken with burning pain, tingling and
numbness. Patients tend to seek relief by hanging
the arm over the side of the bed or shaking the arm;
197
The Wrist
(c)
(b)
(a)
(d) (e) 15.14 Median nerve compression (a) In the right
hand there is wasting of the thenar eminence. (b) Testing
for abductor power shows that it is weaker than that
in the normal hand. (c) Area of diminished sensibility.
(d) Tapping on the nerve may cause tingling in the
hand (Tinel’s sign), and holding the wrist flexed for 2
minutes may also produce tingling in the median nerve
distribution (e).
however, merely changing the position of the wrist Treatment
will usually help. Light splints that prevent wrist flexion can help
those with night pain or with pregnancy-related
Early on there is little to see, but there are two symptoms. Steroid injection into the carpal canal,
helpful tests: sensory symptoms can often be repro likewise, provides temporary relief.
duced by percussing over the median nerve (Tinel’s
sign) or by holding the wrist fully flexed for a minute Open surgical division of the transverse carpal
(Phalen’s test). In late cases there is wasting of the ligament usually provides a quick and simple cure;
thenar muscles, weakness of thumb abduction and this can usually be done under local anaesthesia.
sensory dulling in the median nerve territory. The incision should be kept to the ulnar side of
the thenar crease so as to avoid accidental injury to
Electrodiagnostic tests, which show slowing of the palmar cutaneous (sensory) and thenar motor
nerve conduction across the wrist, are reserved for branches of the median nerve. Endoscopic carpal
those with atypical symptoms. tunnel release offers an alternative with slightly
quicker postoperative rehabilitation.
Radicular symptoms of cervical spondylosis
may confuse the diagnosis and may coincide with
carpal tunnel syndrome.
198
CHAPTER 16
THE HAND
■■ Clinical assessment 199 ■■ acute infections of the hand 205
■■ Congenital variations 202 ■■ Rheumatoid arthritis 207
■■ acquired deformities 202 ■■ Osteoarthritis 209
CliniCal assessment Look
The skin may be scarred, altered in colour, dry or
The hand is (in more senses than one) the medium moist, and hairy or smooth. Wasting and deformity,
of introduction to the outside world. Deformity and the presence of any lumps, should be noted;
and loss of function are quickly noticed – and a crimped appearance of the skin in the palm is
often bitterly resented. characteristic of Dupuytren’s contracture.The resting
posture of the hand and fingers is an important clue
HiStory to nerve or tendon damage. Swelling may be in the
■■ Pain is usually felt in the palm or in the finger subcutaneous tissue, in a tendon sheath or in a joint
– typically the metacarpophalangeal (MCP) joints
joints. A poorly defined ache may be referred in rheumatoid arthritis or the interphalangeal (IP)
from the neck, shoulder or mediastinum. joints in osteoarthritis.
■■ Swelling may be localized, or may occur in
many joints simultaneously. Characteristically, Feel
rheumatoid arthritis causes swelling of the The temperature and texture of the skin are noted.
proximal joints and osteoarthritis the distal joints. Swelling or thickening may be in the subcutaneous
■■ Deformity can appear suddenly (due to tendon tissue, a tendon sheath, a joint or one of the bones.
rupture) or slowly (suggesting bone or joint If a nodule is felt, the underlying tendon should be
pathology). moved by flexing the finger to discover if the nodule
■■ Loss of function is particularly troublesome in the is attached to that tendon. Tenderness should be
hand. The patient may have difficulty handling accurately localized to one of these structures.
eating utensils, holding a cup or glass, grasping a
doorknob (or a crutch), dressing or (most trying Move
of all) attending to personal hygiene. Passive movements should be tested first, to see
■■ Sensory symptoms and motor weakness provide whether the joints are ‘movable’ before you ask
clues to neurological disorders affecting the the patient to move them actively. The range of
lower cervical nerve roots and their peripheral movement for each digit is recorded, starting with
extensions. the MCP joints and then going on to the proximal
interphalangeal (PIP) and distal interphalangeal
eXamination (DIP) joints.
Both upper limbs should be bared for comparison.
Examination of the hand needs patience and Active movements reflect, simultaneously, the
meticulous attention to detail. state of the joints, the integrity of the tendons and
motor nerve function in each digit.
The Hand
(a) (b) (c)
16.1 Examination – active movement (a) Extension. (b) Full flexion. (c) Testing finger abduction. The abducted
little fingers are forced against each other; the weaker one will collapse.
Ask the patient to place both hands with palms of both the first carpometacarpal (CMC) and the
facing upwards and the fingers extended, then to first MCP joint. With the hand lying flat, palm
curl the fingers into full flexion; a ‘lagging finger’ is upwards, five types of movement are recognized:
immediately obvious. ■■ Extension (sideways movement in the plane of
MCP flexion and IP extension are activated by the the palm).
intrinsic muscles (lumbricals and interossei). This is ■■ Abduction (upward movement at right angles to
tested by asking the patient to extend the fingers
with the MCP joints flexed (the ‘duckbill’ position). the palm).
■■ Adduction (pressing against the palm).
The interossei also motivate finger abduction and ■■ Flexion (sideways movement across the palm).
adduction (fingers together and then spread widely ■■ Opposition (touching the tips of the fingers).
apart). Active power can be roughly gauged by having Weakness of abduction (tested simply by pressing
the patient abduct the fingers while the examiner against the abducted thumb of each hand) is a
presses against the spread-out index and little fingers, cardinal feature of median nerve dysfunction. In
trying to force them back to the neutral position. A advanced cases there will also be obvious wasting
better way is to ask the patient to spread the fingers of the thenar eminence.
of both hands to the maximum; the examiner then
grasps the patient’s hands, pushes them towards each Pain, deformity and loss of motion at the base
other and forces the two little fingers against each of the thumb (the first CMC joint) are common
other; the weaker (non-dominant) side will normally symptoms of osteoarthritis.
give way first, but if the difference in one or other
hand is marked it signifies true abductor weakness, a Testing for musculotendinous function
sign of ulnar nerve or T1 root dysfunction. Flexor digitorum profundus (FDP) is tested by
simply immobilizing the PIP joint and then asking
Thumb movements (and their nomenclature) the patient to bend the tip of the finger.
are unusual, comprising the combined mobility
(a) (b) (c) 16.2 Thumb movements
(a) Hold the patient’s hand
flat on the table and ask
him or her to ‘stretch to the
side’ (extension); (b) ‘point
to the ceiling’ (abduction);
(c) ‘pinch my finger’
(adduction); and (d) ‘touch
your little finger’
(d) (opposition).
200
Clinical assessment
Flexor digitorum superficialis is more com Neurological assessment
plicated. The FDP must first be inactivated, If symptoms such as numbness, tingling or
otherwise one cannot tell which of the two tendons weakness exist – and in all cases of trauma – a
is flexing the PIP joint. This is done by grasping full neurological examination of the upper limbs
all the fingers, except the one being examined, should be carried out, testing power, reflexes
and holding them firmly in full extension; because and sensation. Further refinement is achieved by
the profundus tendons share a common muscle testing two-point discrimination, sensitivity to
belly, this manoeuvre automatically prevents all heat and cold, stereognosis and fine pressure (see
the profundus tendons from participating in Chapter 11).
finger flexion. The patient is then asked to flex
the isolated finger which is being examined; this Functional tests
movement must be activated by flexor digitorum Function can be measured subjectively using
superficialis. patient-completed scales, but objective tests are
more reliable. There are several types of grip,
There are two exceptions to this rule: first, the which can be tested by giving the patient a variety
little finger sometimes has no independent flexor of tasks to perform: picking up a pin (precision
digitorum superficialis; second, the index finger grip), holding a sheet of paper (pinch), holding a
often has a separate flexor profundus which cannot key (sideways pinch), holding a pen (chuck grip),
be inactivated by the usual mass action manoeuvre. holding a bag handle (hook grip), holding a glass
Instead, for these two fingers flexor superficialis is (span) and gripping a hammer handle (power
tested by asking the patient to pinch hard with the grip).
DIP joint in full extension and the PIP joint in full
flexion; this position can be maintained only if the Stereognosis is evaluated using Moberg’s pick-
superficialis tendon is active and intact. up test – asking the patient to pick up and identify,
with eyes closed, a number of objects from the
The long extensors are tested by asking the patient desk-top; the procedure is timed and the affected
to extend the MCP joints. However, inability to do hand is compared with the ‘good’ hand.
this does not necessarily signify paralysis or tendon
rupture: the long extensor tendon may have Each finger has its special task: the thumb and
slipped off the knuckle into the interdigital gutter index finger are used for pinch, but the index finger
(a common occurrence in rheumatoid arthritis). is also a sensory organ; slight loss of movement
matters little but if sensation is abnormal the
Flexor pollicis longus is tested by immobilizing patient may not want to use the finger at all. The
the thumb MCP joint and asking the patient to middle finger controls the position of objects
bend the single IP joint. in the palm. The ring and little fingers are used
essentially for power grip (e.g. wielding a hammer
Grip strength or a wrench); here stiffness is a real handicap.
Grip strength is assessed (rather crudely) by asking
the patient to squeeze the examiner’s fingers; it Dexterity is important in all these functions; it
may be diminished because of muscle weakness, may be lost in any type of nerve lesion – e.g. in
tendon damage, finger stiffness or wrist instability. a severe carpal tunnel syndrome (median nerve
Strength can be measured more accurately with a compression) because of the combination of thenar
mechanical dynamometer. Pinch grip also should weakness, reduced sensation and diminished
be measured. stereognosis and proprioception.
(c)
(a) (b)
16.3 Testing musculotendinous function (a) Flexor digitorum profundus (FDP) lesser
finger. (b) Flexor digitorum superficialis (FDS) lesser fingers. (c) FDP index. (d) FDS index. (d)
201
The Hand
Congenital variations Skin contracture
Cuts and burns of the palmar skin are liable to
The hand and foot are much the most common heal with contracture; this may cause puckering
sites of congenital deformities of the locomotor of the palm or fixed flexion of the fingers. Surgical
system; the incidence is about 1:1000 live births. incisions should never cross flexor creases. Established
Early recognition is important, and definitive contractures may require excision of the scar and
treatment should be timed to fit in with the Z-plasty of the overlying skin.
functional demands of the child. There are seven
types of malformation: Dupuytren’s contracture
■■ Failure of formation: total or partial absence This is a nodular hypertrophy and contracture of
the palmar aponeurosis. The condition is familial,
of parts may be transverse (‘congenital but there is a higher than usual incidence in people
amputations’) or axial (missing rays). with diabetes and acquired immunodeficiency
■■ Failure of differentiation: fingers may be partly syndrome (AIDS) and in patients with epilepsy
or wholly joined together (syndactyly). This receiving phenytoin therapy. Smoking and heavy
may be corrected by separating the fingers and alcohol consumption are also risk factors.
repairing the defects with skin grafts.
■■ Duplication: polydactyly (extra digits) is the most Clinical features
common hand malformation. The extra finger The patient – usually a middle-aged man –
should be amputated, if only for cosmetic reasons. complains of a nodular thickening in the palm.
■■ Under-growth: the thumb can be very small or Gradually this progresses distally to involve the
even absent. ring or little finger. Pain is unusual. Often both
■■ Over-growth: a giant finger is unsightly, but hands are involved, one more than the other.
attempts at operative reduction are fraught with The palm is puckered, nodular and thick. If the
complications. subcutaneous cords extend into the fingers, they
■■ Constriction bands: these have the appearance may produce flexion deformities at the MCP and
of an elastic band constricting the finger. In the PIP joints. Sometimes the dorsal knuckle pads are
worst cases this may lead to amputation. thickened.
■■ Generalized malformations: the hand may be
involved in generalized disorders such as Marfan’s Similar nodules may be seen on the soles of the
syndrome (‘spider hands’) or achondroplasia feet (Ledderhose’s disease). There is a rare, curious
(‘trident hand’). See Chapter 8. association with fibrosis of the corpus cavernosum
(Peyronie’s disease).
Acquired deformities
Diagnosis
Deformity may be due to disorders of the skin, Dupuytren’s contracture must be distinguished
subcutaneous tissues, muscles, tendons, joints, from skin contracture (where a previous laceration
bones or neuromuscular function.
(a) (b) (c)
(e)
(d) 16.4 Congenital variations (a) Transverse
failure. (b) Radial club-hand and absent thumb.
(c) Constriction rings. (d) Camptodactyly.
(e) Clinodactyly of both little fingers.
202
Acquired deformities
(c) (d)
(a) (b)
16.5 Dupuytren’s disease Contractures at (a) the palmar crease and (b) the proximal interphalangeal joint.
(c) Z-plasty shortly after operation and (d) 2 weeks later.
is usually obvious) and tendon contracture (where
the ‘cord’ moves on passive flexion of the finger).
Treatment (a)
If the deformity is static and there is no loss of
function, no treatment is needed. If the condition (b)
is marked, operative treatment may be called for.
The aim is reasonable, not complete, correction; a 16.6 Ulnar ‘claw-hand’ (a) High ulnar nerve paralysis
satisfactory outcome is more predictable at the MCP causing a partial claw-hand deformity: the paralysed
joint than the PIP joint, but there is still a risk of intrinsic muscles cause the loss of flexion at the MCP
recurrence or extension. If the disease is extensive, joints and loss of extension at the IP joints, but because
the affected area is approached through a Z-shaped flexor digitorum profundus (FDP) is also partially
incision that does not cross directly over a skin crease; paralysed the index and middle fingers are straight.
after carefully freeing the nerves and blood vessels, (b) Low ulnar nerve paralysis (lower than the innervation
the thickened part of the fascia is excised. Following of FDP), causing a total claw-hand deformity in which all
operative correction the hand is splinted for a few the long flexors are still active.
days and then active movement is encouraged,
but night splinting for a few months may reduce main causes are muscle scarring or shortening after
recurrence. An alternative to surgery is the injection trauma or infection. Moderate contracture can be
of a drug, collagenase, to dissolve the cord. treated by releasing the intrinsic muscles where
they cross the MCP joints.
Neuromuscular disorders Ischaemic contracture of the forearm
Ulnar ‘claw-hand’ (intrinsic-minus deformity) muscles
Ulnar nerve lesions characteristically cause hyper This follows circulatory insufficiency due to
extension at the MCP joints and flexion at the injuries at or below the elbow (see page 374).
IP joints. This is due to paralysis of the intrinsic There is shortening of the long flexors; the fingers
muscles which normally activate MCP flexion are held in flexion and can be straightened only
and IP extension. Thus it is sometimes called an when the wrist is flexed. Sometimes the picture
intrinsic-minus deformity. is complicated by associated damage to the ulnar
or median nerve (or both). If disability is marked,
Shortening of intrinsic muscles (intrinsic-plus
deformity)
Intrinsic muscle shortening produces flexion at
the MCP joints with extension of the IP joints
and adduction of the thumb – an intrinsic-plus
deformity. Anatomically this is the opposite of the
intrinsic-minus deformity described above. The
203
The hand
(a) (b) Dropped fingers
16.7 Contracture of the long flexors (a) When the The patient is unable to hold the fingers in extension
wrist is extended, the fingers involuntarily curl into tight at the MCP joints. The cause usually lies not at
flexion. (b) When the wrist is flexed, tension on the long the MCP joint but at the wrist, where the extensor
flexor muscles is relaxed and the fingers can uncurl to a tendons have ruptured (typically in rheumatoid
certain extent. arthritis). If only one finger is affected, direct repair
may be possible; otherwise the distal portion of the
some improvement may be obtained by releasing tendon can be attached to an adjacent finger extensor.
the shortened muscles at their origin above the
elbow, or else by excising the dead muscles and Boutonnière
restoring finger movement with tendon transfers.
This is a flexion deformity of the PIP joint, due
tenDon leSionS to interruption of the central slip of the extensor
tendon. The lateral slips separate and the head of
‘Mallet’ finger the proximal phalanx pops through the gap like a
finger through a buttonhole. It is seen after trauma
The patient suddenly cannot straighten the terminal or in rheumatoid disease. Post-traumatic rupture
joint, but passive movement is normal. This is due can sometimes be repaired; the chronic deformity
to injury at the attachment of the extensor tendon in rheumatoid disease usually defies correction.
to the terminal phalanx. The DIP joint should be
splinted for 8 weeks, with the proximal joint free. Swan-neck deformity
Ruptured extensor pollicis longus This is the reverse of boutonnière: the PIP joint is
hyperextended and the DIP joint flexed. It is due
The long thumb extensor may rupture after to imbalance of extensor versus flexor action in the
fraying where it crosses the wrist (e.g. after a Colles’ finger, and is often seen in rheumatoid arthritis. The
fracture, or in rheumatoid arthritis). Direct repair deformity may be corrected by tendon rebalancing.
is unsatisfactory and a tendon transfer, using the
extensor indicis, is needed. ‘triGGer finGer’
This common condition presents as an intermittent
‘deformity’, usually of the ring or middle finger,
sometimes of the thumb. The patient complains
(a) (b) (c)
(d) (e) (f)
16.8 Deformities due to tendon lesions (a) Mallet finger. (b) Dropped fingers due to extensor tendon ruptures at
the wrist. (c) Swan-neck deformities. (d) Rupture of extensor pollicis brevis. (e,f) Boutonnière deformities.
204
Acute infections of the hand
Acute infections of the hand
that, when the hand is clenched and then opened, sheath) may cause an increase in pressure to levels
the finger (or thumb) gets stuck in flexion; with at which the local blood supply is threatened. In
a little more effort, it suddenly snaps into full neglected cases tissue necrosis is an imminent risk.
extension. The usual cause is thickening of the Even if this does not occur, the patient may end up
fibrous tendon sheath: the flexor tendon becomes with a stiff and useless hand unless the infection is
temporarily trapped at the entrance to its sheath and rapidly brought under control.
then, on forced extension, it passes the constriction Clinical features
with a snap. A similar entrapment may occur due to Usually there is a history of trauma, but it may
a bulky tenosynovitis (e.g. in rheumatic disorders). have been so trivial as to pass unnoticed. A thorn
A tender nodule or thickened tendon can usually prick can be as dangerous as a cut. Within a day
be felt at the distal palmar crease. The condition is or two, the finger (or hand) becomes painful
more common in diabetes. and tensely swollen. The patient may feel ill and
feverish and the pain becomes throbbing. There
Infantile trigger thumb (‘snapping thumb’) is is obvious redness and tension in the tissues, and
usually misdiagnosed as a ‘dislocating thumb’; exquisite tenderness over the site of infection.
sometimes it goes completely undiagnosed and the Finger movements may be markedly restricted.
child grows up with the thumb permanently bent Principles of treatment
or the distal phalanx under-developed. Feel for the
tell-tale thickening on the palmar aspect at the base Antibiotics
of the thumb.
Treatment As soon as the diagnosis is made and specimens
The condition often improves spontaneously, so have been taken for microbiological investigation,
there is no urgency about treatment. However, if it antibiotic treatment is started – usually with
persists, or is particularly annoying, it can usually flucloxacillin and, in severe cases, with fusidic
be cured by an injection of corticosteroid carefully acid or a cephalosporin as well. This may later be
placed at the entrance of the tendon sheath. changed when bacterial sensitivity is known.
Refractory cases need operation: the fibrous Rest and elevation
sheath is incised, allowing the tendon to move
freely. In the case of the thumb, take particular In a mild case the hand is rested in a sling. In a
care to avoid injuring the digital nerve, which runs severe case the arm is elevated in a roller towel while
close to the sheath. the patient is kept in hospital under observation.
Analgesics are given for pain.
For children treatment (as above) can be deferred
until the child is 3 years old, as spontaneous c
recovery is quite common. a
Bone lesions dc b
Malunited fractures may cause metacarpal or
phalangeal deformity. Occasionally this needs ef
correction by osteotomy and internal fixation.
16.9 Incisions for infection The incisions for surgical
Acute infections of the drainage are illustrated here: (a) pulp space (directly
hand over the abscess); (b) nailfold (it may also be necessary
to excise the edge of the nail); (c) tendon sheath (two
Infection of the hand is frequently limited to one incisions, one distal and one proximal); (d) web space;
of several well-defined compartments: under the (e) thenar space; (f) midpalmar space.
nailfold (paronychia); the pulp space (whitlow);
subcutaneous tissues elsewhere; a tendon sheath;
one of the deep fascial spaces or a joint. Almost
invariably the cause is a Staphylococcus which has
been implanted by trivial or unobserved injury.
Pathology
Acute inflammation and suppuration in small
closed compartments (e.g. the pulp space or tendon
205
The Hand
Drainage Physiotherapy
If there are signs of an abscess (throbbing pain, Once the acute inflammation subsides, movements
marked tenderness and toxaemia), the pus should be are encouraged. Ideally this should be done under
drained. A tourniquet and either general or regional the direction of a physiotherapist specialized in
block anaesthesia are essential. The incision should ‘hand therapy’. The splint is re-applied between
be made at the site of maximal tenderness, but exercise sessions.
never across a skin crease. Necrotic tissue is excised
and the area thoroughly washed and cleansed. Specific types of infection
The wound is either left open or lightly sutured
and then covered with non-stick dressings. A pus Paronychia
specimen is sent for microbiological investigation.
Infection under the nailfold is common. The area is
Splintage swollen, red and tender. At the first sign of infection,
antibiotic treatment alone may be effective. If pus
After draining tendon sheath or fascial space is present, it can often be released simply by lifting
infections or if conservative treatment is likely the nailfold from the nail; otherwise the nailfold
to be prolonged, a removable splint should be must be incised. Occasionally a portion of the nail
applied – always with the joints in the position of needs to be removed.
safe immobilization, that is with the wrist slightly
extended, the MCP joints in 70-degrees flexion, Pulp-space infection (felon)
the IP joints extended and the thumb in abduction.
Pulp-space infection (usually due to a prick or
splinter) causes throbbing pain. The fingertip
is swollen, red and acutely tender. Antibiotic
treatment is started immediately. However, if pus
has formed, it must be released through a small
incision over the site of maximal tenderness.
(a) Other subcutaneous infections
(b) Anywhere in the hand, a blister or superficial cut
may become infected, causing redness, swelling
16.10 Position of safe immobilization (a,b) The and tenderness. A local collection of pus should be
metacarpophalangeal joints are 70 degrees flexed, the drained through a small incision over the site of
finger joints extended and the thumb abducted. This is maximal tenderness. It is important to exclude a
the position in which the ligaments are at their longest deeper pocket of pus in a nearby tendon sheath or
and splintage is least likely to result in stiffness. in one of the deep fascial spaces.
Tendon-sheath infection
Suppurative tenosynovitis is uncommon but
dangerous. The affected digit is painful and
swollen; it is held bent, is very tender and the
patient will not move it or permit it to be moved.
Unless treatment is swift and effective, there is a
risk of tendon necrosis and the patient may end up
with a useless finger.
Treatment must be started as soon as the diagnosis
is suspected. The hand is splinted and elevated
and antibiotics are administered intravenously –
initially a broad-spectrum penicillin or a systemic
cephalosporin, to be modified if necessary once
the organism has been cultured and tested for
antibiotic sensitivity. If there is no improvement
after 24 hours, surgical drainage is essential. Two
incisions are needed, one at the proximal end of
the sheath and one at the distal end; using a fine
catheter, the sheath is then irrigated with saline or
Ringer’s lactate solution (always from proximal to
206
Rheumatoid arthritis
(a) (b) from adjacent structures. At the onset, the clinical
features may be hard to distinguish from those of
(c) (d) acute gout. Joint aspiration will provide the answer.
16.11 Types of hand infection (a) Acute nailfold Intravenous antibiotics are administered and
infection (paronychia). (b) Chronic paronychia. (c) Flexor the hand is splinted. If symptoms and signs do not
tenosynovitis of the middle finger following a cortisone improve within 24 hours, open drainage is needed.
injection. (d) Septic human bite resulting in acute
infection of the fourth metacarpophalangeal joint. Bites
distal). The catheter is left in place for postoperative Animal bites are usually inflicted by cats, dogs or
irrigation during the next 2 days. farm animals. Many become infected and, although
the common pathogens are staphylococci and
Tendon-sheath infection in the thumb or little streptococci, unusual organisms are also encountered.
finger may spread proximally to the synovial bursa.
This has to be drained through a further incision Human bites and lacerations sustained during
just above the wrist. fist-fights are generally thought to be even more
prone to infection. A variety of organisms (including
At the end of the operation, the hand is swathed anaerobes) are encountered, the commonest being
in absorbent dressings and splinted in the position Staphylococcus aureus, Streptococcus group A and
of safe immobilization (Figure 16.10). Eikenella corrodens. All such wounds should be
assumed to be infected. X-rays should be obtained,
Deep fascial space infection to exclude a fracture or foreign body.
Infection from a web space or from an infected Treatment should be started immediately. Fresh
tendon sheath may spread to either of the deep wounds are carefully examined in the operating
fascial spaces of the palm. The palm is ballooned, theatre and swab samples are taken for bacterial
so its normal concavity is lost. There is extensive culture and sensitivity. If necessary, the wound
tenderness and the whole hand is held still. should be extended and debrided; search for a
fragment of tooth or a divit of articular cartilage
For drainage, an incision is made directly over the from the joint. The hand is then splinted and
abscess and sinus forceps inserted; if the web space is elevated and antibiotics are given prophylactically
also infected, it too should be incised. Postoperatively until the laboratory results are obtained.
the hand is dressed and splinted as described above.
Established infection in bite wounds will need
Joint infection debridement, wash-outs and intravenous antibiotic
treatment. The common organisms are all sensitive
Any of the joints may be infected, either directly to broad-spectrum penicillins and cephalosporins.
by a penetrating injury on injection, or indirectly With animal bites one should also consider the
possibility of rabies.
Postoperative treatment consists, as usual, of
copious wound dressings, splintage in the ‘safe’
position and encouragement of movement once the
infection has resolved. Tendon lacerations can be
dealt with when the tissues are completely healed.
Rheumatoid arthritis
The hand, more than any other part of the body, is
where rheumatoid arthritis displays its story. Early
on, there is synovitis of the proximal joints and
tendon sheaths; later, joint and tendon erosions
prepare the ground for mechanical derangement; in
the final stage, joint instability and tendon rupture
cause progressive deformity and loss of function.
Clinical features
Pain and stiffness of the fingers are early symptoms;
often the wrist also is affected. Examination may
show swelling of the MCP and PIP joints; both
207
The Hand
hands are affected, more or less symmetrically. (a) (b)
Joint mobility and grip strength are diminished.
(c) (d)
As the disease progresses, deformities begin to
appear (and are increasingly difficult to correct). 16.12 Rheumatoid arthritis (a) Typical deformities in
In the late stage one sees the characteristic ulnar established rheumatoid arthritis. The proximal joints are
deviation of the fingers and subluxation of the the ones most severely affected; there is subluxation of
MCP joints, often associated with swan-neck or the metacarpophalangeal (MCP) joints and the fingers
boutonnière deformities. When these abnormalities are deviated ulnarwards. (b) Severe rheumatoid
become fixed, functional loss may be so severe that deformities with dislocation of the MCP joints and
the patient needs help with washing, dressing and ulceration of the skin over the knuckles. (c) ‘Dropped
feeding. fingers’ due to rupture of extensor tendons where they
cross the back of the wrist. (d) Swan-neck deformities of
X-rays the fingers.
During the initial stages, x-rays show only soft-
tissue swelling and osteoporosis around the joints. requires synovectomy followed by physiotherapy.
Later there is narrowing of the joint spaces and Isolated tendon ruptures are repaired or bypassed
small periarticular erosions appear. In the last by appropriate tendon transfers. Joint instability
stage, articular destruction may be marked, with may require stabilization or arthroplasty.
joint deformity and dislocation.
In late cases with established deformities,
Treatment reconstructive surgery may be needed, but
In early cases, treatment is directed at controlling
the systemic disease and the local synovitis. In
addition to general measures, splints may reduce
pain and swelling.
Persistent synovitis may benefit from local
injections of methylprednisolone, but sometimes
surgical synovectomy is needed.
As the disease progresses, it becomes important
to prevent deformity. Uncontrolled synovitis
(a) (b) (c)
16.13 Rheumatoid arthritis – x-ray changes (a) Early on, the x-rays may show no more than soft-tissue swelling
and juxta-articular osteoporosis. (b) A later stage showing characteristic tiny punched-out juxta-articular erosions at the
second and third metacarpophalangeal (MCP) joints. The wrist is now also involved. (c) In the most advanced stage,
the MCP joints are dislocated and the hand is severely deformed.
208
Osteoarthritis
(a) (b)
(c) (d) 16.14 Rheumatoid arthritis – treatment (a,b)
Even with severe deformities, the patient may regain
good function. Why interfere if the disease is quiescent
and the hand works well? (c,d) If function is markedly
restricted, reconstructive surgery has a useful role.
X-rays before and after metacarpophalangeal (MCP)
joint replacement with Silastic spacers and fusion of the
thumb MCP joint.
treatment should be directed at restoring function and the CMC joint of the thumb may show similar
rather than merely correcting deformity. changes.
Osteoarthritis The distinction from rheumatoid arthritis is very
important. In both conditions, the finger joints are
Osteoarthritis of the DIP joints is very common swollen and stiff. However, whereas rheumatoid
in postmenopausal women and is usually a arthritis affects the proximal joints (particularly
manifestation of polyarticular osteoarthritis. It the MCP joints), osteoarthritis affects mainly the
often starts with pain in one or two fingers; the distal terminal IP joints.
joints become swollen and tender, the condition
usually spreading to all the fingers of both hands. Treatment is symptomatic; pain and tenderness
On examination, there is bony thickening around gradually subside and the patient is left with
the DIP joints (Heberden’s nodes) and some painless, knobbly fingers. Occasionally (if pain
restriction of movement. Not infrequently, some or deformity is particularly marked), fusion
of the PIP joints are involved (Bouchard’s nodes) of the DIP joint may be called for. If the PIP
joint or the MCP joint are involved they can be
replaced.
(a) (b) (c)
16.15 Osteoarthritis (a,b) Osteoarthritis affects mainly the distal interphalangeal joints. The knobbly joints are called
Heberden’s nodes. (c) Rheumatoid arthritis can look similar, but here it is mainly the proximal joints that are affected.
209
CHAPTER 17
THE NECK
■■ Clinical assessment 210 ■■ Pyogenic infection 216
■■ Deformities of the neck 212 ■■ Tuberculosis 217
■■ Vertebral anomalies 212 ■■ Rheumatoid arthritis 217
■■ Acute intervertebral disc prolapse 213 ■■ Ankylosing spondylitis 218
■■ Chronic disc degeneration (cervical
214
spondylosis)
clinical assessment eXamInaTIon
The entire upper trunk and both upper limbs
HIsTory should be exposed. Start the examination with the
The common symptoms of neck disorder are pain patient standing; neck posture and movements
and stiffness. are most easily observed in this position. The
■■ Pain is felt in the neck itself, but it can also be shoulders also are examined while the patient is
upright. The anterior structures (trachea, thyroid,
referred to the suprascapular areas, the shoulders oesophagus) are best felt with the patient seated
or the upper arms. It may start suddenly (as with and the examiner standing behind the chair. The
an acute intervertebral disc prolapse) or gradually third part of the examination is carried out with the
(as in chronic disc degeneration). Always ask if it patient lying down; it is easier (and more reliable)
is associated with paraesthesia in the arm or hand, to feel for muscle spasm and point tenderness
a particularly significant combination. with the patient lying prone with his or her neck
■■ Stiffness may be either intermittent or continuous. supported over a pillow. Neurological examination
Sometimes it is so severe that the patient can is performed with the patient lying supine.
scarcely move his or her head.
■■ Deformity usually appears as a wry neck, due Look
to muscle spasm; think of a disc prolapse or a Any deformity is noted. From the back, skin
previously undiagnosed fracture. blemishes, scapular abnormalities or muscular
■■ Numbness, tingling and weakness in the upper asymmetry can be seen. One shoulder may be
limbs may be due to pressure on a nerve root; higher and there may be muscle wasting in the arm
weakness in the lower limbs may result from or hand.
cord compression in the neck.
■■ Headache sometimes emanates from the neck, Feel
but if this is the only symptom other causes are The neck and shoulders should be carefully palpated
more likely. for tender areas, lumps and muscle spasm.
Always ask about previous neck injuries.
Clinical assessment
17.1 Examination (a) Look
for any deformity or
superficial blemish which
(a) (b) (c) might suggest a disorder
affecting the cervical spine.
(b) The front of the neck is felt
with the patient seated and
the examiner standing behind
him. (c) The back of the neck
is most easily and reliably felt
(d) (e) (f) (g) with the patient lying prone
over a pillow; this way muscle
spasm is reduced and the
neck is relaxed.
(d–g) Movement: flexion (‘chin
on chest’); extension (‘look up
at the ceiling’); lateral flexion
(‘tilt your ear towards your
shoulder’); and rotation (‘look
over your shoulder’).
(h) (i) (h,i) Neurological examination
is mandatory.
Move 17.2 Normal range of movement Flexion and
Flexion, extension, lateral flexion and rotation are extension of the neck are best gauged by observing
tested and the range of movements noted. Shoulder the angle of the occipitomental line – an imaginary line
movements, likewise, should be recorded. joining the tip of the chin and the occipital protuberance.
In full flexion the chin normally touches the chest; in full
Spurling’s test is helpful. The patient is instructed extension the occipitomental line forms an angle of at
to rotate the neck to one side with the chin elevated: least 45 degrees with the horizontal, and over 60 degrees
if this reproduces ipsilateral upper limb pain and in young people. Lateral flexion is usually achieved up to
paraesthesiae, it would increase the suspicion of a 45 degrees and rotation to 80 degrees each way.
disc prolapse with cervical nerve root compression.
Pain may be relieved by having the patient place paralysed, and some have lost their lives, because a
the arm overhead (the abduction relief sign). fracture–dislocation at C6/7 or C7/T1 was missed.
The normal cervical curve shows four parallel lines:
Neurological examination one along the anterior surfaces of the vertebral
Neurological examination of the upper limbs is bodies, one along their posterior surfaces, one
mandatory in all cases; in some the lower limbs
also should be examined. Muscle power, reflexes
and sensation should be carefully tested; even small
degrees of abnormality may be significant.
Imaging
X-ray examination should include all levels from the
base of the occiput to T1. The anteroposterior view
should show the regular, undulating outlines of the
lateral masses; their symmetry may be disturbed
by destructive lesions or fractures. A projection
through the mouth is required to show the upper
two vertebrae.
When looking at the lateral view, make sure that
all seven vertebrae are visible; patients have been
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The Neck
along the posterior borders of the lateral masses side is fibrous and fails to elongate as the child
and one along the bases of the spinous processes; grows. In some cases a well-defined lump is felt
any malalignment suggests subluxation. The disc in the muscle during the first few weeks of life,
spaces are inspected; loss of disc height and the but deformity may not become apparent until the
presence of osteophytic spurs at the margins of child is 2 or 3 years old. As the neck grows, the
adjacent vertebral bodies are features of chronic contracted sternomastoid tethers the skull on one
intervertebral disc degeneration, a common side, thus twisting the chin towards the opposite
finding in elderly people and not necessarily the side. Secondary facial deformities may occur.
cause of neck pain. The posterior interspinous
spaces are compared; if one is wider than the Treatment: if a child has a sternomastoid
rest, this may signify chronic instability of that ‘tumour’, subsequent deformity may be prevented
segment, possibly due to a previously undiagnosed by gentle, daily manipulation of the neck. Non-
subluxation. Flexion and extension views may be operative treatment is successful in most cases, but
needed to demonstrate instability, though after an if the condition persists beyond 1 year operative
acute injury such movements are best avoided! treatment is required to prevent progressive facial
deformity.The contracted muscle is divided (usually
Computed tomography (CT ) and magnetic at its lower end but sometimes at the upper end
resonance imaging (MRI) are essential for or at both ends) and the head is manipulated into
defining the intervertebral discs, the neural the neutral position. After operation, correction is
structures and the outlines of the spinal canal and maintained with a temporary orthosis followed by
intervertebral foramina. Remember, though, that stretching exercises.
20% of asymptomatic people show significant Secondary torticollis
abnormalities and the scans must therefore be Wry neck, due to muscle spasm, may develop as
interpreted alongside the clinical assessment. a result of acute disc prolapse (the most common
cause in adults), inflamed neck glands, vertebral
Deformities of the neck infection, injuries of the cervical spine or ocular
disorders.
Torticollis (‘wry neck’, ‘skew neck’)
In torticollis the chin is twisted upwards and Vertebral anomalies
towards one side. It may be either congenital or
secondary to other local disorders. Cervical vertebral anomalies are dealt with in
Infantile (congenital) torticollis Chapter 8. Odontoid dysplasia is particularly
Skew neck is sometimes seen in an infant or very important and the subject warrants repetition in
young child. The sternomastoid muscle on one this section.
(a) (b) (c)
17.3 Imaging – normal x-rays (a) Anteroposterior view – note the smooth, symmetrical outlines and the clear, wide
uncovertebral joints (arrows). (b) Open mouth view – to show the odontoid process and atlantoaxial joints. (c) Lateral
view – showing all seven cervical vertebrae.
212
Acute intervertebral disc prolapse
(a) (b) (c) 17.4 Torticollis Natural
history: (a) sternomastoid
(d) (e) tumour in a young baby;
(b) early wry neck;
Odontoid anomalies (c) deformity with facial
The odontoid may be absent or hypoplastic, an hemiatrophy in the
anomaly that should be suspected (and looked adolescent. Surgical
for even if the patient does not complain) in any treatment: (d) two sites at
case of skeletal dysplasia involving the spine. This which the sternomastoid
is especially important in patients undergoing may be divided; (e,f) before
operation; there is a risk that the atlantoaxial joint and a few months after
may subluxate under anaesthesia. Some patients
present with pain or torticollis, or neurological (f) operation.
complications such as transient paralysis or
sphincter disturbances. In the majority of cases may be sudden or gradual in onset, and with
the anomaly is discovered by chance in a routine trivial cause. The patient may complain of: (1)
cervical spine x-ray following trauma. Patients with pain and stiffness of the neck, the pain often
symptoms should have surgical stabilization. radiating to the scapular region and sometimes
to the occiput; (2) pain and paraesthesia in one
Acute intervertebral disc upper limb (rarely both), often radiating to the
prolapse outer elbow, back of the wrist and to the index
and middle fingers. Weakness is rare. Between
Cervical disc prolapse may be precipitated by local attacks the patient feels well, although the neck
strain or injury, especially sudden unguarded flexion may feel a bit stiff.
and rotation. It usually occurs immediately above
or below the sixth cervical vertebra; in many cases The neck may be tilted forwards and sideways.
(perhaps in all) there is a predisposing abnormality The muscles are tender and movements are
of the disc with increased nuclear tension. restricted. The arms should be examined for
neurological signs suggestive of nerve root irritation
The disc protrusion may press on the posterior or compression.
longitudinal ligament, causing neck pain and
stiffness as well as pain referred to the upper arm. Imaging
Even more suggestive are associated symptoms of X-rays may show narrowing of the disc space.
pain and paraesthesia in one or both arms. However, the diagnosis should be confirmed by
Clinical features MRI, which will show whether the disc protrusion
The original attack may occasionally be related is pressing on the adjacent nerve root.
to a definite and severe strain. Subsequent attacks
Differential diagnosis
Acute soft-tissue strain: acute strains of the neck can
cause pain and stiffness which may last for weeks
or months. The absence of neurological symptoms
and signs is significant.
Neuralgic amyotrophy (acute brachial neuritis):
pain is sudden and severe, and situated over the
shoulder, or the back of the shoulder, rather than
in the neck itself. Multiple neurological levels
are affected. Look for signs of serratus anterior
weakness (winging of the scapula).
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The Neck
(a)
(b) (c) (d)
17.5 Acute disc prolapse (a,b) Acute wry neck due to a prolapsed disc. (c) The intervertebral disc space at C5/6 is
reduced. (d) MRI in another case showing a large disc prolapse at C6/7.
Cervical spine infections: pain is unrelenting can also be performed using endoscopic
and local spasm severe. X-rays show erosion of the techniques.
vertebral end-plates.
Chronic disc degeneration
Cervical tumours: neurological signs are (cervical spondylosis)
progressive and x-rays or MRI may show bone
destruction. Intervertebral disc degeneration is common from
middle age onwards, even in people who have not
Treatment been aware of any acute episode in former years.
Heat and analgesics are soothing but, as with lumbar With time, the discs collapse and flatten, and bony
disc prolapse, there are only three satisfactory ways spurs appear at the anterior and posterior margins
of treating the prolapse itself: of the vertebral bodies on either side of the affected
■■ Rest: a collar will prevent unguarded movement; discs; those that develop posteriorly may encroach
upon the intervertebral foramina, causing pressure
it may be made of felt, sponge-rubber or on the nerve roots. Several levels may be affected
polythene. and the condition is then usually referred to
■■ Reduce: traction may enlarge the disc space, as ‘spondylosis’. The condition is not always
permitting the prolapse to subside. The head symptomatic, and many people go throughout life
of the couch is raised and weights (up to 8 kg) without experiencing anything more than slight
are tied to a harness fitting under the chin and stiffness.
occiput. Traction is applied intermittently for Clinical features
no more than 30 minutes at a time. Troublesome symptoms come on gradually. The
■■ Remove: if symptoms are refractory and severe patient, usually aged over 40 years, complains
enough, the disc may be removed through an of neck pain and stiffness. The pain may radiate
anterior approach; bone grafts are inserted to
fuse the affected area and to restore the normal
intervertebral height. Nowadays the operation
214
Chronic disc degeneration (cervical spondylosis)
widely: to the occiput, the scapular muscles and Differential diagnosis
down one or both arms. Paraesthesia, weakness Other disorders associated with neck or arm pain
and clumsiness are occasional symptoms. Typically and sensory symptoms must be excluded. Cervical
there are exacerbations of more acute discomfort, vertebral spur formation is very common in older
and long periods of relative quiescence. people and this can be misleading in patients with
other disorders.
The appearance is usually normal. There may
be tenderness in the soft tissues at the back of the Rotator cuff lesions: pain around the shoulder may
neck and above the scapulae; neck movements are resemble the referred pain of cervical spondylosis.
limited and painful at the extremes. However, features such as rotator cuff tenderness
and restricted shoulder movements should suggest
Careful neurological examination may show a local problem.
abnormal signs in one or both upper limbs.
Nerve entrapment syndromes: median or ulnar
Imaging nerve entrapment may give rise to intermittent
Typical x-ray features are narrowing of several disc symptoms of pain and paraesthesia in the hand.
spaces, bony spur formation at the anterior and Characteristically the symptoms are worse at night
posterior edges of the vertebral bodies and (in the or are related to posture. In doubtful cases, nerve
anteroposterior view) osteoarthritic changes in conduction studies and electromyography will
the tiny uncovertebral joints. Oblique views may help to establish the diagnosis. Remember, though,
show bony encroachment on the intervertebral that the patient may have symptoms from both a
foramina. MRI will show whether there is nerve peripheral and a central abnormality.
root compression.
Cervical tumours: with tumours of the vertebrae,
(a) (b)
17.6 Cervical spondylosis – x-rays (a) Degenerative features at one level, C6/7. Note the prominent ‘osteophytes’
at the anterior and posterior borders of these two vertebral bodies. (b) Marked degenerative changes at multiple
levels.
215
The Neck
spinal cord, nerve roots or lymph nodes the stay. However, it is too early to assess the long-term
symptoms are unremitting. Imaging studies should outcome of these procedures.
reveal the diagnosis.
Pyogenic infection
Treatment
During painful episodes, heat and massage are Pyogenic infection of the cervical spine is
soothing; some patients benefit from a period in uncommon, and therefore often misdiagnosed in
a restraining collar. Physiotherapy is the mainstay the early stages when antibiotic treatment is most
of treatment, patients usually being maintained effective. The organism – usually a staphylococcus
in relative comfort by various measures including – reaches the spine via the blood stream. Initially,
exercises, gentle passive manipulation and destructive changes are limited to the intervertebral
intermittent traction. disc space and the adjacent parts of the vertebral
bodies. Later, abscess formation occurs and pus
Surgical treatment is indicated if severe may extend into the spinal canal or into the soft-
symptoms are relieved only by a rigid and irksome tissue planes of the neck.
support, particularly if there are neurological Clinical features
changes due to nerve root compression. Vertebral infection may occur at any age. The
patient complains of pain in the neck, often
Foraminotomy associated with muscle spasm and stiffness. Neck
movements are severely restricted. Systemic
If the main problems are referred pain in the upper symptoms are often mild but blood tests may
limb and/or neurological symptoms and signs, and show a leucocytosis and an elevated erythrocyte
the MRI shows foraminal narrowing and nerve root sedimentation rate (ESR).
compression at one or two levels, foraminotomy
(through a posterior approach) may be indicated. X-rays at first show either no abnormality or
Only part of the facet joint is removed so this only slight narrowing of the disc space; later more
segment should not become unstable. However, obvious signs of bone destruction appear.
patients should be warned that pre-existing neck
pain may not be eliminated. Treatment is by antibiotics and rest. The cervical
spine is ‘immobilized’ by traction; once the acute
Anterior discectomy and fusion phase subsides, a collar may suffice. Operation is
seldom necessary; if there is abscess formation, this
This operation is particularly suitable if the will require drainage. As the infection subsides the
problem is primarily one of unrelieved neck
pain and stiffness. Through a transverse incision
at the front of the neck, the intervertebral disc
is removed without disturbing the posteriorly
situated neurological structures. After preparation
of the intervertebral space, a suitably-shaped
autogenous bone graft (usually taken from the
iliac crest) is inserted firmly between the adjacent
vertebral bodies. An anterior plate is added if there
is uncertainty about stability or if several levels
are being fused. Operative complications such as
injury to the recurrent laryngeal nerve or (worse)
the vertebral artery are unusual if sufficient care is
exercised. Graft dislodgement and failed fusion are
less likely with intervertebral plating.
Intervertebral disc replacement (a) (b)
Disc replacement operations are now being 17.7 Pyogenic infection (a) The first x-ray, taken soon
performed in several countries. This has the after the onset of symptoms, shows narrowing of the C5/6
(theoretical) advantage of removing the offending disc space. (b) Three weeks later there is destruction and
disc and preserving movement at the affected site. collapse of the adjacent vertebral bodies.
Short-term results appear to be as good as those
achieved with anterior spinal fusion, with added
benefits of lesser morbidity and shorter hospital
216
Rheumatoid arthritis
intervertebral space is obliterated and the adjacent Treatment
vertebrae usually fuse. Treatment is initially by antituberculous drugs
and ‘immobilization’ of the neck in a cervical
Tuberculosis brace or plaster cast for 6–18 months. Operative
debridement of necrotic bone and anterior cervical
Cervical spine tuberculosis is rare. The organism vertebral fusion with bone grafts may be offered as
is blood-borne and the infection localizes in the an alternative to such prolonged immobilization.
intervertebral disc and the anterior parts of the More urgent indications for operation are: (1) to
adjacent vertebral bodies. As the bone crumbles, drain a retropharyngeal abscess; (2) to decompress
the cervical spine collapses into kyphosis. A a threatened spinal cord; or (3) to fuse an unstable
retropharyngeal abscess forms and points behind spine.
the sternomastoid muscle at the side of the neck.
In late cases cord damage may cause neurological Rheumatoid arthritis
signs varying from mild weakness to tetraplegia.
Clinical features The cervical spine is severely affected in 30% of
The patient – usually a child – complains of patients with rheumatoid arthritis. Three types of
neck pain and stiffness. In neglected cases a lesion are common: (1) erosion of the atlantoaxial
retropharyngeal abscess may cause difficulty in joints and the transverse ligament, with resulting
swallowing or swelling in the posterior triangle instability; (2) erosion of the atlanto-occipital
of the neck. The neck is extremely tender and all articulations, allowing the odontoid peg to ride up
movements are restricted. In late cases there may into the foramen magnum; and (3) erosion of the
be obvious kyphosis, a fluctuant abscess in the neck facet joints in the midcervical region, sometimes
or a retropharyngeal swelling. The limbs should be ending in fusion but more often leading to
examined for neurological defects. subluxation. Considering the amount of atlantoaxial
displacement that occurs (often greater than 1 cm),
X-rays show narrowing of the disc space and neurological complications are uncommon.
erosion of the adjacent vertebral bodies.
Clinical features
The patient is usually a woman with advanced
rheumatoid arthritis. She has neck pain and
movements are markedly restricted. Symptoms
and signs of root compression may be present
17.8 Tuberculosis This child had been complaining of (a) (b)
neck pain and stiffness for several months. When she was
17.9 Rheumatoid arthritis (a) Atlantoaxial subluxation
brought to the clinic she had a large lump at the side of is common; erosion of the joints and the transverse
ligament has allowed the atlas to slip forward about 2
her neck – a typical tuberculous abscess. cm. (b) Reduction and posterior fusion with wire fixation.
217
The Neck
in the upper limbs; less often there are upper Treatment
motor neuron signs and lower limb weakness Despite the startling x-ray appearances, serious
due to cord compression. However, there may neurological complications are uncommon. Pain
be symptoms of vertebrobasilar insufficiency, can usually be relieved by wearing a collar.
such as vertigo, tinnitus and visual disturbance.
Some patients, though completely unaware of The indications for operative stabilization of
any neurological deficit, are found on careful the cervical spine are: (1) severe and unremitting
examination to have mild sensory or motor pain; and (2) neurological signs of root or cord
disturbance. Bear in mind that peripheral joint compression. Arthrodesis (usually posterior) is by
involvement and general debility can mask the bone grafting followed by a halo body cast, or by
signs of myelopathy. internal fixation (posterior wiring or a rectangular
fixator) and bone grafting. Postoperatively a
Imaging cervical brace is worn for 3 months; however,
X-rays show the features of an erosive arthritis, if instability is marked and operative fixation
usually at several levels. Atlantoaxial instability insecure, a halo jacket may be necessary. In
is visible in lateral films taken in flexion and patients with very advanced disease and severe
extension; in flexion the anterior arch of the atlas erosive changes, postoperative morbidity and
rides forwards, leaving a gap of 5 mm or more mortality are high.
between the back of the anterior arch and the
odontoid process; on extension the subluxation Ankylosing spondylitis
is reduced. Atlanto-occipital erosion is more
difficult to see, but a lateral tomograph shows Ankylosing spondylitis can affect the cervical spine,
the relationship of the odontoid to the foramen causing neck pain and stiffness some years after the
magnum. Normally the odontoid tip is less than onset of backache. The neck gradually becomes
5 mm above McGregor’s line (a line from the rigid and kyphotic, although some movement
posterior edge of the hard palate to the lowest point is usually preserved at the atlanto-occipital and
on the occiput); in erosive arthritis the odontoid atlantoaxial joints.
tip may be 10–12 mm above this line.
An unacceptable ‘chin-on-chest’ deformity, and
CT and MRI are useful for imaging ‘difficult’ inability to lift the head high enough to see more
areas such as the atlantoaxial and atlanto-occipital than ten paces ahead, are indications for cervical
articulations, and for viewing the soft-tissue spine osteotomy. The patient should be told that
structures (especially the cord). surgery carries a high complication rate.
218
CHAPTER 18
THE BACK
■■ clinical assessment 219 ■■ ankylosing spondylitis 235
■■ Scoliosis 224 (spondyloarthropathy) 235
■■ Idiopathic scoliosis 226 ■■ Intervertebral disc lesions 238
■■ kyphosis 230 ■■ Lumbar osteoarthritis 239
■■ Pyogenic infection 232 ■■ Spondylolisthesis 239
■■ Tuberculosis 233 ■■ Spinal stenosis 240
■■ The backache problem
cLinicaL aSSeSSment structure in a lumbar spinal segment can, if
irritated sufficiently, give rise to referred pain
hiStory radiating into the lower limbs. Unfortunately,
The usual symptoms of back disorders are with the passage of time, clinicians have taken
pain, stiffness and deformity in the back, and to describing all types of pain extending from
pain, paraesthesia or weakness in the legs. The the lumbar region into the lower limb as
mode of onset is very important: did it start ‘sciatica’. This is at best confusing and at worst a
suddenly (perhaps after lifting) or gradually? preparation for misdiagnosis! True sciatica, most
Are the symptoms constant, or are there periods commonly due to a prolapsed intervertebral disc
of remission? Are they related to any particular pressing on a nerve root, is characteristically
posture? more intense than referred low back pain, is
■■ Bachache, either sharp and localized or chronic aggravated by coughing and straining and
is often accompanied by symptoms of root
and diffuse, is the commonest presenting pressure such as numbness and paraesthesiae.
symptom. It is usually felt low down and on ■■ Stiffness may be sudden and almost complete
either side of the midline, but it may extend (after a disc prolapse) or continuous and
into the upper part of the buttock and even into predictably worse in the mornings (suggesting
the thighs. If there were no other symptoms arthritis or ankylosing spondylitis).
it would be difficult to tell whether the pain ■■ Deformity is usually noticed by others, but
originated in the intervertebral disc, the nerve the patient may become aware of shoulder
root, the vertebral facet joints or the soft-tissue asymmetry or of clothes not fitting well.
supports at that level of the lumbar spine. In disc prolapse, arthritis and ankylosing
■■ Sciatica is the term originally used to describe spondylitis, deformity is usually secondary to,
intense pain radiating from the buttock into and overshadowed by, pain and stiffness. In
the thigh and calf – more or less following structural disorders, such as scoliosis, it may be
the distribution of the sciatic nerve and the only complaint.
therefore suggestive of nerve root compression ■■ Numbness or paraesthesia is felt anywhere in the
or irritation. However, Jonas Kellgren (more lower limb, but can usually be mapped fairly
than 30 years ago) showed that almost any accurately over one of the dermatomes. It is
The Back
important to ask if it is aggravated by standing Feel
upright or walking and relieved by bending The spinous processes and the interspinous
forward or sitting down – a classic feature of ligaments are palpated, noting any prominence
spinal stenosis. or a ‘step’. Feel for tenderness at each interspinous
■■ Other symptoms important in back disorders are level.
urethral discharge, diarrhoea and sore eyes; these
are features of Reiter’s disease, one of the causes Move
of ‘reactive’ spondylitis. Flexion: ask the patient to bend forward and try
to touch the floor. Even with a stiff back he or she
Signs with the patient standing may be able to do this by flexing the hips; so watch
Adequate exposure is essential; patients must strip the lumbar spine to see if it really moves, or better
to their underclothes. still, measure the spinal excursion (see Figure 18.2).
Look The mode of flexion is also important; hesitant
Begin by standing face to face with the patient and movements, especially on regaining the upright
note his or her general physique and posture. Then position, may signify pain or segmental instability.
move round and stand behind the patient. Does
he or she stand upright or do they lean over to one Extension: ask the patient to lean backwards;
side? Is the pelvis level or is one leg shorter than with a stiff spine he or she may cheat by bending
the other? Does the spine look straight or curved the knees. The ‘wall test’ will unmask a disguised
(scoliosis)? Are there scars or other skin markings loss of extension: standing with the back flush
that may suggest a spinal disorder? against a wall, the heels, buttocks, shoulders and
occiput normally all make contact with the surface.
Seen from the side, the thoracic spine normally
has a gentle forward curve or kyphosis. An unduly Lateral flexion: ask the patient to bend first to
prominent kyphotic curve is sometimes called one side and then to the other; compare the range
hyperkyphosis; if it is sharply angulated, the of movement to right and left.
prominence is called a kyphos or gibbus.
Rotation: ask the patient to twist the trunk
By contrast, the lumbar spine is normally bent to each side in turn while the pelvis is anchored
slightly backwards (lordosis). In some conditions by the examiner’s hands; this is essentially a
the lower back may be unusually flat or excessively thoracic movement and should not be limited in
lordosed. lumbosacral disease.
If the patient consistently stands with one knee Chest expansion: rib excursion is assessed
bent (even though the legs are equal in length) this by measuring the chest circumference in full
suggests nerve root tension on that side; flexing the expiration and then full inspiration; the normal
knee relaxes the sciatic nerve and reduces the pull excursion is about 7 cm.
on the nerve root.
Muscle power: distal muscle power is conveniently
tested and compared by asking the patient to stand
up on their toes (plantar flexion) and then to rock
18.1 Examination With the patient standing upright, look at his general posture and note particularly the presence
of any asymmetry or frank deformity of the spine. Then ask him to lean backwards (extension), forwards to touch his
toes (flexion) and then sideways as far as possible comparing his level of reach on the two sides. Finally, hold the
pelvis stable and ask the patient to twist first to one side and then to the other (rotation). Note that rotation occurs
almost entirely in the thoracic spine and not in the lumbar spine.
220
Clinical assessment
(a) (b) (c)
18.2 Measuring the range of flexion Bending down and touching the toes may look like lumbar flexion but this is
not always the case. The patient in (a) has ankylosing spondylitis and a rigid lumbar spine, but he is able to reach his
toes because he has good flexibility at the hips. Compare his flat back with the rounded back of the model in Fig.
18.1(c). You can measure the lumbar excursion. With the patient upright, select two bony points 10 cm apart and mark
the skin (b); as the patient bends forward, the two points should separate by a least a further 5 cm (c).
back on the heels (dorsiflexion); small differences examined before testing for cord or nerve root
between the two sides are easily spotted. involvement. Also check the femoral and pedal
pulses.
Signs with the patient prone
Bony outlines and small lumps can be felt more The straight leg raising test: this is the classic test
easily with the patient lying face down. for lumbosacral root tension. With the patient’s
knee held absolutely straight, the leg is lifted from
Deep tenderness is easy to localize, but difficult to the couch until the patient experiences pain – not
ascribe to a particular structure. merely in the lower back (which is common and
not significant) but also in the buttock, thigh
Some neurological features are ideally elicited with and calf (Lasègue’s test). The angle at which this
the patient lying prone. Hamstring power is tested by occurs is noted; normally it should be possible to
having the patient flex the knee against resistance. raise the leg to 90 degrees without causing undue
The femoral stretch test is performed by bending the discomfort. In a full-blown disc prolapse with
patient’s knee with the hip flat against the couch; a nerve root compression, straight-leg raising may
positive sign is pain felt in the front of the thigh and be restricted to less than 30 degrees because of
the back, suggesting lumbar root tension. severe pain in the sciatic distribution. At the point
where the patient experiences discomfort, passive
Popliteal and posterior tibial pulses are dorsiflexion of the foot may cause an additional
conveniently felt in this position. stab of pain.
Signs with the patient supine A gentler way of testing straight-leg raising is
The patient is observed for pain and stiffness as to ask the patient to raise the leg with the knee
he or she turns over. Hip and knee mobility are straight and rigid – and to stop when he or she
feels pain.
(a) (b) (c)
18.3 Examination with the patient prone (a) Feel for tenderness, watching the patient’s face for any reaction.
(b) Performing the femoral stretch test. You can test for lumbar root sensitivity either by hyperextending the hip or by
acutely flexing the knee with the patient lying prone. Note the point at which the patient feels pain and compare the
two sides. (c) While the patient is lying prone, take the opportunity to feel the pulses. The popliteal pulse is easily felt
if the tissues at the back of the knee are relaxed by slightly flexing the knee.
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The Back
The bowstring sign is even more specific. Raise General examination: while the patient is lying
the patient’s leg gently to the point where he or undressed, a rapid examination is carried out to
she experiences sciatic pain; now, without reducing detect the presence of any suspicious lumps in the
the amount of lift, bend the knee so as to relax the breasts, abdomen or genitalia.
sciatic nerve. Buttock pain is immediately relieved;
pain may then be re-induced without extending Imaging
the knee by simply pressing on the lateral popliteal
nerve behind the posterolateral side of the knee, to X-rays
tighten the nerve like a bowstring.
In the anteroposterior view the spine should look
Sometimes straight leg raising on the unaffected perfectly straight and the soft-tissue shadows
side produces pain on the affected side. This should outline the normal muscle planes.
‘crossed sciatic tension’ is indicative of severe root Curvature (scoliosis) is obvious, and best shown
compression, usually due to a large central disc in erect views. Check the outlines of the pedicles,
prolapse, and warns of the risk to the sacral nerve which normally look like oval footprints near the
roots that control bladder function (the cauda lateral edges of each rectangular vertebral body:
equina syndrome – one of very few surgical a missing or misshapen pedicle could be due to
emergencies in spinal disorders). erosion by infection, a neurofibroma or metastatic
disease. Individual vertebrae may show asymmetry
Neurological examination: a full neurological or collapse. The sacroiliac joints may show erosion
examination of the lower limbs is essential. An or ankylosis, as in tuberculosis (TB) or ankylosing
absent ankle jerk on the side with sciatica, combined spondylitis, and the hip joints may show features
with paraesthesiae along the lateral border of the of osteoarthritis, not to be missed in the older
foot, suggests compression of the S1 nerve root; patient with backache. Don’t forget the soft tissues:
normal reflexes combined with paraesthesiae on bulging of the psoas muscle or loss of the psoas
the dorsum of the foot suggest compression of the ‘shadow’ may indicate a paravertebral abscess.
L5 nerve root.
(a) (b)
(c) (d)
18.4 Sciatic stretch tests (a) Straight-leg raising. The knee is kept absolutely straight while the leg is slowly lifted;
note where the patient complains of tightness and pain in the buttock – normally around 80–90 degrees – and
compare the two sides. (b) At that point, passive dorsiflexion of the foot causes an added stab of pain. (c) Sciatic
tension can also be shown by the bowstring sign. At the point where the patient experiences pain during straight leg
raising, relax the tension by bending the knee slightly; the pain should disappear. Then apply firm pressure behind the
lateral hamstrings (d); this tightens the common peroneal nerve and the pain recurs with renewed intensity.
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Clinical assessment
Intervertebral disc Scalloping (erosion) of
Facet joint vertebral bodies
Vertebral body
Pedicle Intervertebral disc
Spinous process
Facet joint
(a) (b)
18.5 Lumbar spine x-rays (a,b) The most important normal features are demonstrated in the lower lumbar spine. In
this particular case there are also signs of marked posterior vertebral body and facet joint erosions at L1 and L2,
features that are strongly suggestive of an expanding neurofibroma.
In the lateral view the normal thoracic kyphosis Computed tomography (CT)
(up to 40 degrees) and lumbar lordosis should be
regular and uninterrupted. Anterior shift of an CT is helpful in the diagnosis of structural bone
upper segment upon a lower (spondylolisthesis) changes (e.g. a vertebral fracture) and intervertebral
may be associated with defects of the posterior arch, disc prolapse. When combined with myelography
shown best in oblique views. Vertebral bodies, which it gives valuable information about the contents of
should be rectangular, may be wedged or biconcave, the spinal canal.
deformities typical of osteoporosis or old injury. The
intervertebral spaces may be edged by bony spurs Magnetic resonance imaging (MRI)
(suggesting long-standing disc degeneration) or
outlined by fine bony bridges (syndesmophytes – a MRI has virtually done away with the need for
cardinal feature of ankylosing spondylitis). myelography, discography, facet arthrography,
and much of CT scanning. The spinal canal and
disc spaces are clearly outlined in various planes.
L2
L3
L4
L5
(a) S1 (b) (c)
18.6 MRI and discography (a) The lateral T2-weighted MRI shows a small posterior disc bulge (arrow) at L4/5 and a
larger protrusion at L5/S1. (b) The axial MRI shows the disc prolapse encroaching on the intervertebral canal and the
nerve root on the left side. (c) Discography, showing normal appearance at the upper level and a degenerate disc with
prolapse at the level below.
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The Back
Scans can reveal the physiological state of the disc region the ribs on the convex side stand out
as regards dehydration, as well as the effect of disc prominently, producing the rib hump. Secondary
degeneration on bone marrow in adjacent vertebral (compensatory) curves nearly always develop to
bodies. counterbalance the primary deformity; they too
may later become fixed.
Scoliosis
Once established, the deformity is liable to
Scoliosis is an apparent lateral (sideways) curvature increase throughout the growth period (and
of the spine. ‘Apparent’ because, although lateral sometimes even afterwards).
curvature does occur, the commonest form of
scoliosis is actually a triplanar deformity with Most cases have no obvious cause (idiopathic
lateral, anteroposterior and rotational components. scoliosis); other varieties are congenital or osteopathic
Two broad types of deformity are defined: postural (due to bony anomalies), neuropathic, myopathic
and structural. (associated with some muscle dystrophies) and a
miscellaneous group of connective-tissue disorders.
Postural scoliosis
In postural scoliosis the deformity is secondary or Clinical features
compensatory to some condition outside the spine, Deformity is usually the presenting symptom:
such as a short leg or a pelvic tilt due to contracture an obvious skew back or a rib hump in thoracic
of the hip. When the patient sits (thereby cancelling curves, and asymmetrical prominence of one hip in
leg length asymmetry) the curve disappears. Local thoracolumbar curves. Balanced curves sometimes
muscle spasm associated with a prolapsed lumbar pass unnoticed until an adult presents with
disc may also cause a skew back. backache. Pain is a rare complaint and should alert
the clinician to the possibility of a neural tumour
Structural scoliosis and the need for MRI. A family history of scoliosis
In structural scoliosis there is a non-correctable is not uncommon.
deformity of the affected spinal segment, an
essential component of which is vertebral rotation. The spine may be obviously deviated from the
The spinous processes swing round towards the midline, or this may become apparent only when
concavity of the curve and the transverse processes the patient bends forward. The level and direction
on the convexity rotate posteriorly. In the thoracic of the major curve convexity are noted: e.g. ‘right
thoracic’ means a curve in the thoracic spine
and convex to the right; the hip juts out on the
concave side and the scapula on the convex. With
thoracic scoliosis, rotation causes the rib angles
to protrude, thus producing a rib hump on the
(a) (b) (c) (d)
18.7 Structural scoliosis (a) Slight curves are often missed on casual inspection but the deformity becomes
apparent when the spine is flexed (b). The young girl in (c) has a much more obvious scoliosis and asymmetry of the
hips but what really worries her is the prominent rib hump, seen best when she bends over (d).
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Scoliosis
convex side of the curve. In balanced deformities the patient erect. Structural curves show vertebral
the occiput is over the midline; in unbalanced (or rotation: in the PA x-ray, vertebrae towards the
decompensated) curves it is not. Side-on posture apex of the curve appear to be asymmetrical and the
should also be observed. There may appear to be spinous processes are deviated towards the concavity.
excessive kyphosis or lordosis.
The upper and lower ends of the curve are
The diagnostic feature of fixed (as distinct from identified as the levels where vertebrae start to
postural or mobile) scoliosis is that forward bending angle away from the curve. The degree of curvature
makes the curve more obvious. Spinal mobility is measured by drawing lines on the x-ray at the
should be assessed and the effect of lateral bending upper border of the uppermost vertebra and the
on the curve noted; is there some flexibility in the lower border of the lowermost vertebra of the
curve and can it be passively corrected? curve; the angle subtended by these lines is the
angle of curvature (Cobb’s angle).
Neurological examination is important. Any
abnormality suggesting a spinal cord lesion calls The site of the curve apex should be noted.
for CT and/or MRI. Right thoracic curves are the commonest, the great
majority in girls in adolescent idiopathic scoliosis.
General examination includes a search for the The primary structural curve is usually balanced
possible cause and an assessment of cardiopulmonary by smaller, compensatory curves above and below.
function (which is reduced in severe curves). Skin Lateral bending views are taken to assess the degree
pigmentation and congenital anomalies such as of curve correctability.
sacral dimples or hair tufts are sought.
A view of the upper part of the pelvis will show
Imaging whether the iliac apophysis has fully ossified and
Full-length posteroanterior (PA) and lateral x-rays fused (Risser’s sign of skeletal maturity) after which
of the spine and iliac crests must be taken with progression of the curve is minimal.
(a) (b) (c)
34
2 5
1
(d) (e)
18.8 Adolescent idiopathic scoliosis (a) Typical thoracic deformity. (b) Serial x-rays show how this curve increased
over a period of 4 years. (c) The angle of curvature is measured on the x-ray by Cobb’s method: lines projected from
the top of the uppermost and the bottom of the lowermost vertebral bodies in the primary curve define Cobb’s angle.
An AP view of the pelvis is needed to assess Risser’s sign (d,e). The iliac apophyses normally ossify progressively from
lateral to medial; when fusion is complete, we know that spinal maturity has been reached and further increase in the
angle of curvature is negligible.
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The Back
CT and MRI may be necessary to define a be needed before deciding between conservative
vertebral abnormality or cord compression. and operative treatment. At 4–9-monthly intervals
Special investigations the patient is examined, photographed and x-rayed
Patients with severe chest deformities should so that curves can be measured and checked for
undergo pulmonary function tests. A marked progression.
reduction in vital capacity is associated with
diminished life expectancy and carries obvious Non-operative treatment
risks for surgery.
If the patient is approaching skeletal maturity and
Patients with muscular dystrophies or the deformity is acceptable (less than 30 degrees and
connective tissue disorders require full biochemical well balanced), treatment is probably unnecessary
and neuromuscular investigation. unless x-rays show definite progression.
Treatment
Prognosis is the key to treatment: the aim is to Exercises have no effect on the curve but they do
prevent severe deformity. The younger the child maintain muscle tone and may inspire confidence
and the higher the curve the worse is the prognosis. in a favourable outcome.
Management differs for the different types of
scoliosis, which are considered below. Bracing has been used for many years in
treating progressive curves of 20–30 degrees.
Idiopathic scoliosis The Milwaukee brace consists of a pelvic corset
connected by adjustable steel supports to a cervical
This group constitutes about 80% of all cases of ring carrying occipital and chin pads; its purpose
scoliosis. The deformity is often familial and the is to reduce the lumbar lordosis and encourage
population incidence of serious curves (over 30 active stretching and straightening of the thoracic
degrees and therefore needing treatment) is 3 per spine. The Boston brace is a snug-fitting underarm
1000. The age at onset has been used to define brace that provides lumbar or low thoracolumbar
three subgroups: adolescent, juvenile and infantile. support. Corrective pads may be added to these
A simpler division now in general use is early- devices to apply pressure at a particular site. A well-
onset (before puberty) and late-onset scoliosis (after made brace does not preclude full daily activities,
puberty). including sport and exercises.
Late-onset (adolescent) idiopathic Although bracing is still being used, it is now
scoliosis (aged 10 years or over) recognized that it does not actually improve the
This is the commonest type, occurring in 90% of curve – at best it merely stops it from getting
cases, mostly in girls. Primary thoracic curves are worse. Many orthopaedic surgeons no longer
usually convex to the right, lumbar curves to the employ this method of treatment, arguing that
left. Progression is not inevitable; most curves of there is insufficient evidence of its benefits. Their
less than 20 degrees either resolve spontaneously preference now is to wait for the curve to progress
or remain unchanged. However, once a curve to the stage when corrective surgery would be
starts to progress, it usually goes on doing so justified.
throughout the remaining growth period (and,
to a much lesser degree, beyond that). Reliable Operative treatment
predictors of progression are: (1) a very young age;
(2) marked curvature; (3) an incomplete Risser The indications for surgery are: (1) curves of more
sign at presentation. In prepubertal children, rapid than 30 degrees that are cosmetically unacceptable,
progression is liable to occur during the growth especially in prepubertal children who are liable
spurt. to develop marked progression during the growth
Treatment spurt; and (2) milder deformity that is deteriorating
The aims of treatment are: (1) to prevent a mild rapidly. Balanced, double primary curves require
deformity from becoming severe; (2) to correct operation only if they are greater than 40 degrees
an existing deformity that is unacceptable to the and progressing.
patient. A period of preliminary observation may
The objectives are: (a) to halt progression of the
deformity; (b) to straighten the curve (including
the rotational component) by some form of
instrumentation; and (c) to arthrodese the entire
primary curve by bone grafting. Surgical options
include:
The Harrington system: in the original system a
rod was applied posteriorly along the concave side
of the curve; attached to the rod were movable
226
Infantile thoracic Idiopathic scoliosis
Adolescent thoracic
60% male.
Thoracolumbar 90% convex to left.
Lumbar Associated with ipsilateral
plagiocephaly.
May be resolving or progressive.
Progressive variety becomes severe.
90% female.
90% convex to right.
Rib rotation exaggerates the
deformity.
50% develop curves of greater than
70 degrees.
Slightly more common in females.
Slightly more common to right.
Features midway between adolescent
thoracic and lumbar.
More common in females.
80% convex to left.
One hip is prominent but no ribs to
accentuate deformity.
Therefore not noticed early, but
backache in adult life.
Combined Two primary curves, one in each
direction.
Even when radiologically severe,
clinical deformity is relatively slight
because always well balanced.
18.9 Patterns of idiopathic scoliosis Bracing is used far less than previously because of serious doubts as to its
effectiveness beyond natural history.
hooks that were engaged in the uppermost and levels and fixed to the rod on the concave side of the
lowermost vertebrae so as to distract the curve. If curve, thus providing a more controlled and secure
the curve is flexible, it will passively correct and fixation. By bending the rod and arranging the
bone grafts are then applied to obtain fusion over mechanism so that the wires pull backwards rather
the length of the curve. A major drawback is that than merely sideways, the rotational component of
this does not correct the rotational deformity the deformity can also be substantially improved.
and thus the rib prominence remains virtually However, the sublaminar wires are dangerously
unchanged. close to the dura and the risk of neurological
damage is increased.
Rod and sublaminar wiring (Luque): this is a
modification of the Harrington system. Wires are The Cotrel–Dubousset system: this mechanism
passed under the vertebral laminae at multiple combines a pedicle screw ‘box’ foundation at the
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The Back
(a) (b) (c)
18.10 Scoliosis – posterior instrumentation Idiopathic scoliosis treated by posterior double-rod fixation.
caudal end of the deformity, with multiple hooks (a) (b)
placed at various levels to produce either distraction
or compression. Using double rods one can distract 18.11 Scoliosis – anterior instrumentation (a) This
on the concave and compress on the convex side of 14-year-old girl had a very stiff lumbar curve. It was
the curve. It is claimed that this system can correct planned to correct this by two-stage anterior and
the rotational deformity as well. Moreover, it is posterior release and fusion. (b) X-ray taken after the
sufficiently rigid to make postoperative bracing Zielke anterior instrumentation.
unnecessary.
Anterior instrumentation (Dwyer; Zielke; Kaneda):
rigid curves and thoracolumbar curves associated with
lumbar lordosis can be corrected by approaching the
spine from the front, removing the discs throughout
the curve and then applying a compression device
along the convex side of the curve. Bone grafts are
added to achieve fusion. In some cases combined
anterior and posterior instrumentation is necessary.
Advantages of this system are: (a) that it provides
strong fixation with fewer vertebral segments having
to be fused; and (b) that overall shortening of the
deformed section (by disc excision and vertebral
compression) lessens the risk of cord injury due to
spinal distraction.
Warning: whatever method is used, spinal
cord function should be monitored during the
operation. Ideally this is done by measuring
somatosensory and motor evoked potentials during
spinal correction. If these facilities are not available,
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Idiopathic scoliosis
the ‘wake-up test’ is used: anaesthesia is reduced to may not need further treatment. If the deformity
bring the patient to a semi-awake state and he or continues to deteriorate, surgical correction may
she is then instructed to move their feet. If there be required.
are signs of cord compromise, the instrumentation
is relaxed or removed and re-applied with a lesser Osteopathic (congenital) scoliosis
degree of correction. Patients have no memory of The commonest bony cause is some type of vertebral
the wake-up procedure. anomaly – hemivertebra, wedged vertebra (failure
of formation) and fused vertebrae – sometimes
Rib hump: none of the instrumentation systems combined with absent or fused ribs. There may also
can completely eliminate the rib hump – and it be visceral abnormalities (e.g. in the patient with
is often this that troubles the patient most of all. spina bifida). While congenital scoliosis is often mild,
If the deformity is marked, it can be reduced some cases progress to severe deformity, particularly
significantly by performing a costoplasty, where those with unilateral fusion of vertebrae. Before any
short sections of rib are excised at multiple levels operation is undertaken, advanced imaging is needed
on the convex side. to exclude an associated dysraphism, particularly
Complications of surgery diastematomyelia and cord tethering, which must be
■■ Neurological compromise: with modern dealt with prior to curve correction.
techniques the incidence of permanent paralysis Treatment is more difficult and specialized than
has been reduced to less than 1%. that of idiopathic infantile scoliosis. Progressive
■■ Spinal decompensation: over-correction may deformities (usually involving rigid curves)
produce an unbalanced spine. This should be will not respond to bracing alone, and surgical
avoided by careful preoperative planning. correction carries a significant risk of cord injury.
■■ Pseudarthrosis: incomplete fusion occurs in These children should be treated in special units:
about 2% of cases and may require further the approach is to undertake staged resection of
operation and grafting. the curve apex, followed by instrumentation and
■■ Implant failure: hooks may cut out and rods may spinal fusion. If multiple segments of the spine are
break. If this is associated with a symptomatic involved, surgery may be too hazardous and should
pseudarthrosis, revision surgery will be needed. probably be withheld.
Early-onset (juvenile) idiopathic Neuropathic and myopathic
scoliosis (aged 4–9 years) scoliosis
This type is uncommon. The characteristics are Neuromuscular conditions associated with scoliosis
similar to those of the adolescent group but the include poliomyelitis, cerebral palsy, syringomyelia,
prognosis is worse and surgical correction may be Friedreich’s ataxia and the rarer lower motor
necessary before puberty. However, if the child is neuron disorders and muscle dystrophies. The
very young, a brace may hold the curve stationary typical paralytic curve is long, convex towards the
until the age of 10 years, when fusion is more likely side with weaker muscles, and at first mobile. In
to succeed. severe cases the greatest problem is loss of stability
and balance, which may make even sitting difficult
Early-onset (infantile) idiopathic or impossible. X-ray with traction applied shows
scoliosis (aged 3 years or under) the extent to which the deformity is correctable.
This is rare, perhaps because most babies nowadays
are allowed to sleep prone. Although 90% of Treatment depends upon the degree of functional
infantile curves resolve spontaneously, progressive disability. Mild curves may require no treatment
curves can become very severe and this may, in at all. Moderate curves with spinal stability are
addition, cause cardiopulmonary dysfunction. managed as for idiopathic scoliosis. Severe curves,
associated with pelvic obliquity and loss of sitting
Curves assessed as being potentially progressive balance, can often be managed by fitting a suitable
should be treated by applying serial elongation– sitting support; if this does not suffice, operative
derotation–flexion (EDF) plaster casts under treatment may be indicated. This involves
general anaesthesia, until the deformity resolves or stabilization of the entire paralysed segment by
until the child is big enough to manage in a brace. combined anterior and posterior instrumentation
From about the age of 4 years onwards, curve and fusion.
progression slows down or ceases and the child
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The Back
Scoliosis and neurofibromatosis other postural defects such as flat-feet. If treatment
About one-third of patients with neurofibromatosis is needed, this consists of postural exercises.
develop spinal deformity, the severity of which
varies from very mild (and not requiring any form Structural kyphosis is fixed and associated with
of treatment) to the most marked manifestations changes in the shape of the vertebrae. It may occur
accompanied by skin lesions, multiple in osteoporosis of the spine (the common round
neurofibromata and bony dystrophy affecting the back of elderly people), in ankylosing spondylitis
vertebrae and ribs. The scoliotic curve is typically and in Scheuermann’s disease (adolescent kyphosis).
‘short and sharp’. Other clues to the diagnosis
lie in the appearance of the skin lesions and any A kyphos (or gibbus) is a sharp posterior
associated skeletal abnormalities. angulation due to localized collapse or wedging
of one or more vertebrae. This may be the result
Mild cases are treated as for idiopathic scoliosis. of a congenital anomaly, a fracture (sometimes
More severe deformities will usually need combined pathological) or spinal TB.
anterior and posterior instrumentation and fusion.
Congenital kyphosis
Kyphosis Vertebral anomalies leading to kyphosis may be
due to failure of formation (Type I), failure of
Rather confusingly, the term ‘kyphosis’ is used to segmentation (Type II) or a combination of these.
describe both the normal (the gentle rounding of
the dorsal spine) and the abnormal (excessive dorsal Type I is the commonest (and the worst) type.
curvature). In the latter sense it signifies a well- Progressive deformity and posterior displacement
recognized deformity which may be progressive; of the residual vertebral segment may lead to cord
some people prefer the term hyperkyphosis. compression. In children younger than 6 years
with curves of less than 40 degrees, posterior spinal
Postural kyphosis is common (‘round back’ or fusion alone may prevent further progression.
‘drooping shoulders’) and may be associated with Older children or more severe curves may need
(a) (b)
18.12 Other types of scoliosis (a) This patient has a short structural curve plus multiple skin lesions – features
suggesting neurofibromatosis. (b) By contrast, the typical postpoliomyelitis ‘paralytic’ scoliosis shown in this x-ray is
characterized by a long C-shaped curve.
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Kyphosis
(a) (b) 18.13 Kyphosis and
kyphos (a) Kyphosis – a
generalized exaggeration of
the normal thoracic ‘rounding’
of the back, in this case due to
Scheuermann’s disease.
(b) Kyphos – a localized spinal
angulation, or gibbus, due to
collapse of one or two spinal
segments (here following
tuberculous spondylitis).
combined anterior and posterior fusion, and those these cartilaginous end-plates are weaker than
with neurological complications will require cord normal and the affected vertebrae in the thoracic
decompression as well. spine (which is normally mildly kyphotic) may
give way slightly and become wedge shaped. If
Type II (failure of segmentation) usually takes this happens, the normal kyphosis is exaggerated.
the form of an anterior intervertebral bar; as the In the lumbar spine the compressive forces are
posterior elements continue to grow, that segment more evenly distributed and deformity does not
of the spine gradually becomes kyphotic. The risk occur. Sometimes there may also be small central
of neurological compression is much less, but if herniations of disc material into the vertebral body;
the curve is progressive a posterior fusion will be these are called Schmorl’s nodes.
needed.
Adolescent kyphosis Clinical features
(Scheuermann’s disease)
This is a ‘developmental’ disorder in which there Thoracic Scheuermann’s disease
is abnormal ossification (and possibly some
fragmentation) of the ring epiphyses that appear The usual form of Scheuermann’s disease appears
on the upper and lower surfaces of each vertebral in the midthoracic vertebrae. The condition starts
body in the growing spine. As a consequence at or shortly after puberty and is more common in
boys than in girls. The parents notice that the child,
an otherwise fit teenager, is becoming increasingly
18.14 Scheuermann’s disease
– x-rays (a) X-rays of the young
girl in Figure 18.13(a). (b,c) In
lumbar Scheuermann’s there is
less wedging than in the thoracic
region. End-plate fragmentation
can be mistaken for a fracture of
the vertebral body. Arrows show
(a) (b) (c) typical Schmorl’s nodes.
231
The Back
‘round-shouldered’. The patient may complain anterior longitudinal ligament or outwards into the
of backache and fatigue. Examination reveals a paravertebral soft tissues. The spinal canal is rarely
smooth but well-marked thoracic kyphosis (or involved but when it is (in the form of an epidural
‘hyperkyphosis’) which does not improve with abscess) that is a surgical emergency! Despite rapid
changes in posture. surgical decompression, the patient is often left
with some degree of permanent paralysis.
X-ray features are typical: in the lateral views one
can see patchiness or irregularity of the vertebral Clinical features
end-plates and, in some cases, Schmorl’s nodes at Localized pain is often intense, unremitting and
several intervertebral levels. Later, the vertebral associated with muscle spasm and restricted
bodies become noticeably wedge shaped. movement. There may be point tenderness over
the affected vertebra. Enquire about any invasive
Treatment depends on the severity of the clinical spinal procedure or a distant infection during the
and x-ray changes. In some cases the early features preceding few weeks. Systemic signs such as pyrexia
are so mild that they go unremarked and it is and tachycardia are often present but not marked.
only when, as an adult, the person is x-rayed for In children the diagnosis can be particularly
some unrelated reason, that the features of an ‘old difficult; however, restricted back movement is
Scheuermann’s’ are recognized. If there is concern suspicious.
about back pain and/or deformity, an extension
brace worn for 1 year or 18 months will often allow X-rays may show no change for several weeks.
a return to normal vertebral growth. If this fails, or Early signs are loss of disc height, irregularity of
if the deformity is already marked when the patient the disc space, erosion of the vertebral end-plate
is first seen, operative correction and fusion may and reactive new bone formation. The early loss
be needed. of disc height distinguishes vertebral osteomyelitis
from metastatic disease, where the disc can remain
Thoracolumbar Scheuermann’s disease intact despite advanced bone destruction.
Thoracolumbar changes may appear together Radionuclide scanning will reveal increased
with thoracic kyphosis or may occur on their activity at the site but this is non-specific.
own. Compared to thoracic Scheuermann’s, this
condition is less common, tends to occur in late MRI may show characteristic changes in the
adolescence or early adulthood, does not give vertebral end-plates, intervertebral disc and
rise to local deformity and usually presents as paravertebral tissues; this investigation is highly
low back pain. X-ray changes are similar to those sensitive but not specific.
seen in the thoracic spine, but with little or no
vertebral wedging. Patients with low back pain
may respond to back-strengthening exercises.
Operative treatment is not indicated unless there
are associated features of discogenic disease.
Pyogenic infection (a) (b)
Acute pyogenic infection of the spine is uncommon; 18.15 Pyogenic infection (a) Typical x-ray features of
elderly, chronically ill and immunodeficient acute vertebral osyeomyelitis. (b) Progressive end-plate
patients are at greatest risk. erosion after 6 months.
Pathology
Staphylococcus aureus is responsible in 50–60%
of all cases, but in immunosuppressed patients
Gram-negative organisms such as Escherichia coli
and Pseudomonas are the most common. The usual
sources of infection are: (1) haematogenous spread
from a distant focus of infection; or (2) inoculation
during invasive procedures (spinal injections and
disc operations).
The infection usually begins in the vertebral
end-plates with secondary spread to the disc and
adjacent vertebra. It may also spread along the
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Tuberculosis
Special investigations should never be attributed merely to the irritant
The white cell count, C-reactive protein (CRP) effect of the injection. Systemic features are usually
level and erythrocyte sedimentation rate (ESR) are mild, but the ESR is elevated.
usually elevated, and antistaphylococcal antibodies
may be present in high titres. Agglutination tests In children the infection is assumed to be blood-
for Salmonella and Brucella should be performed, borne. The child complains of back pain, perhaps
especially in endemic regions and in patients who after a flu-like illness. Back movements are severely
have recently visited these areas. Blood culture may limited. X-rays, radioscintigraphy and MRI show
be positive; however, if it is negative a closed needle the same features as in pyogenic spondylitis.
biopsy is performed for bacteriological culture and
tests for antibiotic sensitivity. Prevention is better than cure: following an
injection into the disc, a broad-spectrum antibiotic
Treatment should be administered intravenously. Non-
Treatment is started on the basis of a clinical iatrogenic discitis is usually self-limiting.
diagnosis of infection and includes bed rest, pain
relief and intravenous antibiotic administration During the acute stage bed rest and analgesics
using a ‘best guess’ preparation that can be changed are essential. If symptoms do not resolve rapidly,
once the laboratory results and sensitivities are a needle biopsy is advisable. Only if there are signs
known. of abscess formation or cord or nerve root pressure
is surgical evacuation or decompression indicated.
Intravenous antibiotics are continued for This is rarely necessary.
4–6 weeks; if there is a good response (clinical
improvement, a falling CRP and ESR and a normal Tuberculosis
white cell count), oral antibiotics are then used for
a further 6–8 weeks and the patient is mobilized in The spine is the most common site of skeletal TB,
a spinal brace. The duration of antibiotic treatment accounting for 50% of all musculoskeletal TB.
depends on the further clinical, haematological
and radiological findings. Pathology
Blood-borne infection settles in a vertebral
Operative treatment is seldom needed. The body adjacent to the intervertebral disc. Bone
indications for an open biopsy and decompression destruction and caseation follow, with infection
are: (1) failure to obtain a positive yield from spreading to the disc space and the adjacent
a closed needle biopsy and a poor response vertebra. A paravertebral abscess may form,
to conservative treatment; (2) the presence of and then track along muscle planes to involve
neurological signs; (3) the need to drain a soft- the sacroiliac or hip joint, or along the psoas
tissue abscess. An anterior approach is preferred; muscle to the inner thigh. The affected vertebral
necrotic and infected material is removed and, if bodies may collapse to form a sharp gibbus (or
necessary, the cord is decompressed. If the spine kyphos). There is a major risk of cord damage
is unstable, internal fixation may be necessary. due to pressure by the abscess, granulation tissue,
Postoperatively the spine is supported in a brace sequestra or displaced bone.
until healing occurs.
With healing, the vertebrae re-calcify and bony
With prompt and effective treatment the fusion may occur between them. Nevertheless,
outcome is usually favourable. Spontaneous fusion if there has been much angulation, the spine is
of infected vertebrae is a common feature of healed usually ‘unsound’, and flares are common. With
staphylococcal osteomyelitis. progressive kyphosis there is again a risk of cord
compression.
Discitis
Infection limited to the intervertebral disc is Clinical features
rare and when it does occur it is usually due There is usually a long history of ill health and
to direct inoculation following discography, backache; in late cases a gibbus deformity is the
chemonucleolysis or discectomy. The vertebral dominant feature. Concurrent pulmonary TB
end-plates are rapidly attacked and the infection is a feature in most children under 10 years with
then spreads into the vertebral body. thoracic spine involvement. Occasionally the
patient may present with a cold abscess pointing
With direct infection there is always a history in the groin, or with paraesthesiae and weakness
of some invasive procedure. Acute back pain and of the legs. There is local tenderness in the back
muscle spasm following an injection into the disc and spinal movements are restricted. Neurological
examination may show motor and/or sensory
233
The Back
changes in the lower limbs. As spinal TB is found and decompression of the spinal cord will be
mostly in the thoracic spine, spastic paraparesis is a required. Patients with HIV infection should be
common presentation in adults. referred for appropriate management.
Differential diagnosis
In areas where TB is no longer common, the Spinal TB must be distinguished from other causes
infection may be confined to a single vertebral of vertebral pathology, particularly pyogenic and
body, symptoms may be mild and deformity can be fungal infections, malignant disease and parasitic
slight. It is important to be alert to the possibility infestations such as hydatid disease. Disc space
of this diagnosis, especially in patients who are collapse is typical of infection; metastatic lesions
human immunodeficiency virus (HIV)-positive. may cause vertebral body collapse similar to that
seen in TB but the disc space is usually preserved.
Imaging
The entire spine should be x-rayed, because 18.17 Spinal tuberculosis – MRI Sagittal MR
vertebrae distant from the obvious site may also images of advanced tuberculous infection with abscess
be affected. The earliest signs of infection are formation beneath the anterior longitudinal ligament.
local osteoporosis of two adjacent vertebrae and
narrowing of the intervertebral disc space, with Treatment
fuzziness of the end-plates. Progressive disease The objectives are: (1) to eradicate or arrest the
is associated with signs of bone destruction and infection; (2) to prevent or correct deformity; and
collapse of adjacent vertebral bodies into each (3) to prevent or treat the major complication –
other. Paraspinal soft-tissue shadows may be due paraplegia.
either to oedema or a paravertebral abscess. A
chest x-ray is essential. With healing, bone density Ambulant chemotherapy alone is suitable for early
increases, the ragged appearance disappears and or limited disease with no abscess formation or
paravertebral abscesses may undergo resolution, neurological deficit. Rifampicin 600 mg daily plus
fibrosis or calcification. isoniazid 300 mg daily plus pyrazinamide 2 g daily
are given in combination for 6–12 months or until
MRI and CT may reveal hidden lesions,
paravertebral abscesses, an epidural abscess and
cord compression. Myelography is appropriate
when these facilities are not available.
Special investigations
The Mantoux test may be positive and in the
acute stage the ESR is raised. In patients with no
neurological signs a needle biopsy is recommended
to confirm the diagnosis by histological and
microbiological investigations. If this does
not provide a firm diagnosis, tissue should be
obtained by open operation. If there are signs of
neurological involvement, operative debridement
(a) (b) (c) (d)
18.16 Spinal tuberculosis (a) Early x-ray changes with loss of disc space. (b) A child with a severe kyphotic
deformity. (c,d) X-rays before and after operative debridement and spinal fusion using a rib strut graft.
234
Intervertebral disc lesions
the x-ray shows resolution of the bone changes, but is AIDS defining. Patients with this condition are
stopping the pyrazinamide after the first 2 months. prone to developing opportunistic infections and
(The dosages listed are for adults of average weight.) atypical mycobacterial infections.
However, because TB is often a complication of
acquired immunodeficiency syndrome (AIDS), The tuberculous infection usually involves
resistant mycobacteria are an increasing problem. multiple vertebrae and results in severe deformity.
Ethionamide and streptomycin may have to be A primary epidural abscess is not uncommon.
substituted for isoniazid. Decompression and stabilization for neurological
deficit are performed through an extrapleural
Continuous bed rest and chemotherapy may be posterolateral approach with instrumentation to
used for more advanced disease when the necessary minimize pulmonary complications. A primary
skills and facilities for radical anterior spinal surgery epidural abscess is drained through a laminectomy.
are not available, or where the technical problems
are too daunting – provided there is no abscess that Postoperatively antituberculous therapy and
needs to be drained. antiretroviral treatment are commenced. Compliance
with treatment and regular monitoring of viral loads
Operative treatment is indicated: (1) when there and CD4/CD8 counts are essential to ensure a
is an abscess that can readily be drained; (2) for successful outcome.
advanced disease with marked bone destruction
and threatened or actual severe kyphosis; and (3) Ankylosing spondylitis
neurological deficit, including paraparesis, that (spondyloarthropathy)
has not responded to drug therapy. Through an
anterior approach, all infected and necrotic material This group of disorders is dealt with in Chapter 3.
is evacuated or excised and the gap is filled with
iliac crest or rib grafts that act as a strut. If several Intervertebral disc lesions
levels are involved, anterior or posterior fixation
and fusion may be needed for additional stability. About one-quarter of the length of the vertebral
Children who are growing and are seen to be at column is made up of fibrocartilaginous discs that
risk of developing severe kyphosis may need fusion are squeezed between adjacent vertebral bodies,
of the posterior elements to minimize the expected to which they are anchored at the cartilage end-
deformity. Antituberculous chemotherapy is still plates. It is the discs that lend limited flexibility to
necessary, of course. the spine.
Pott’s paraplegia In the lumbar region the discs are about 1 cm
Early-onset paresis (usually within 2 years of disease thick. Their posterior edges lie on the anterior
onset) is due to pressure by inflammatory oedema, boundary of the spinal canal and posterolaterally
an abscess, caseous material, granulation tissue or they skirt the right and left intervertebral canals
sequestra. The patient presents with lower limb close to the nerve roots that exit at successive
weakness, upper motor neuron signs, sensory levels. Little wonder that disc disorders are often
dysfunction and incontinence. The diagnosis is accompanied by neurological symptoms.
confirmed by MRI or myelography. The condition
is treated by early anterior decompression and Structurally the disc consists of a central
debridement followed by spinal fusion. The gel-like portion (proteoglycans in a collagen
prognosis for neurological recovery following latticework), called the nucleus pulposus, which
surgery is good. merges into surrounding lamellae of more fibrous
consistency – the annulus fibrosus. With ageing
Late-onset paresis is due to direct cord there is a gradual loss of proteoglycans and the disc
compression from increasing deformity, or becomes somewhat dehydrated and degenerate.
(occasionally) vascular insufficiency of the This is thought to be the underlying cause of two
cord. If MRI or myelography reveals direct cord important disorders that occur particularly in the
compression, operative removal of necrotic tissue lumbar and cervical regions and to a lesser extent
is probably still worthwhile. If there is no actual in the thoracic spine: intervertebral disc herniation
compression, operation is unlikely to be of use. and chronic intervertebral disc degeneration.
AIDS and spinal TB Intervertebral disc degeneration
One of the main reasons for the resurgence of TB, With increasing age, as the lumbar intervertebral
especially in the developing world, is the spread of discs gradually dry out, the nucleus pulposus
HIV. Spinal TB, which is an extrapulmonary focus, changes from a turgid bulb to a brownish,
235
The Back Imaging
X-ray examination typically shows flattening of the
Normal disc ‘disc spaces’ and spur formation at the borders of the
vertebral bodies, often accompanied by characteristic
Increased nuclear features of osteoarthritis in the small facet joints.
pressure causing bulging
MRI scans may show bulging of one or more
Ruptured annulus discs in both sagittal and axial projections. There
and ligament may also be subtle changes such as diminished
thickness and reduced signal intensity, or small
Degeneration and tears and fissures in the disc. Secondary changes,
joint displacement evidently arising from altered loading characteristics
of the degenerating disc, can usually be identified
18.18 Intervertebral disc prolapse and in the adjacent vertebral bodies.
degeneration Diagrammatic representation of
progressive stages in the development of disc prolapse. Treatment
At first there is only bulging of the posterior part of Asymptomatic lumbar disc degeneration does not
the disc; the annulus fibrosus may go on to rupture necessarily presage the future onset of symptoms
and the nucleus pulposus is extruded posteriorly to and does not need any treatment.
one or other side. In disc degeneration (lowest figure)
the disc becomes desiccated and collapses, causing Patients with chronic low-back pain and nothing
displacement of the posterior facet joints. more than x-ray signs of disc degeneration may
benefit from postural and muscle strengthening
exercises, as well as some modifications to their daily
activities. Their long-term progress is determined
mainly by whether they go on to develop any
associated features such as facet joint osteoarthritis,
degenerative spondylolisthesis or spinal stenosis. In
the absence of any such changes, treatment should
be conservative.
desiccated structure. The annulus fibrosus Acute intervertebral disc
develops fissures parallel to the vertebral end-plates herniation
running mainly posteriorly, and small herniations Intervertebral disc herniation or protrusion is a
of nuclear material squeeze into and through the bulging of the disc with the outer part of the
annulus. The discs flatten down and bulge slightly annulus intact, either directly posteriorly or to one
beyond the margins of the vertebral bodies. Where or other side of the posterior longitudinal ligament
they protrude against the surrounding ligaments, towards the intervertebral foramen. Acute disc
reactive new bone formation produces bony ridges herniation is usually initiated by mechanical stress –
(erroneously called ‘osteophytes’) and the adjacent a combination of flexion and compression – but even
vertebral end-plates ossify and become sclerotic. at L4/5 or L5/S1 (where stress is most severe) it is
The picture as a whole is referred to as spondylosis; unlikely that a disc would herniate unless there was
it occurs in over 80% of people who live for more some prior disturbance of the hydrophilic properties
than 50 years and, although characteristic changes of the nucleus pulposus. If the disc ruptures,
can be seen on x-ray examination (flattening of fibrocartilaginous material may sequestrate and lie
the disc ‘space’ and marginal spur foPrmrooaftiSotang)e,: t3he free iDnatteh: e26s.p01i.n2a01l4canal or the intervertebral foramen.
condition isefufesuctasllymaasyymenpstuoem: astliicg.hHt PodrwiosoepfvlSaetcra,egome:the2nert nerAvDeaptreoo:so1t2te.r0po1.lr2ao0tx1e4irmalalprtootriutssipooninctanof ceoxmitptrhesrsoutghhe
secondary the Dinatee:r1v2e.0r8te.2b01ra3l foramenF;igaNoh:e1r8n.1i8ation at L4/5
Title: Concise Soysftetmhoef Oprothsotpeareidoicrs vanedrtFerabcrtuarlesfacet jointPsr,ooffaScetatgej:oi1nt will compress the fifth lumbar nerve root, and
osteoarthritis and narrowing of the lateral recesses a herniation at L5/S1, the first sacral root; a
Ltd of the spinal canal and the intervertebral foramina. large central herniation or sequestration may
cause compression of the cauda equina. A local
It is then that patients experience the common inflammatory response and oedema may aggravate
and ill-defined symptoms of recurrent backache, this situation.
sometimes with pain radiating towards the
buttocks or thighs.
236
Intervertebral disc lesions
Acute back pain at the onset of disc herniation tension’). With a prolapse at L3/4 the femoral
probably arises from disruption of the outermost stretch test may be positive.
layers of the annulus fibrosus and stretching or
tearing of the posterior longitudinal ligament. If Neurological examination may show muscle
the disc protrudes to one side, it may irritate the weakness (and, later, wasting), diminished reflexes
dural covering of the adjacent nerve root causing and sensory loss corresponding to the affected
pain in the buttock, posterior thigh and calf level. L5 impairment causes weakness of big toe
(sciatica). Pressure on the nerve root itself causes extension and knee flexion, with sensory loss on
paraesthesia and/or numbness in the corresponding the outer side of the leg and the dorsum of the
dermatome, as well as weakness and depressed foot. S1 impairment causes weak plantarflexion
reflexes in the muscles supplied by that nerve root. and eversion of the foot, a depressed ankle jerk
and sensory loss along the lateral border of the
Clinical features foot. With cauda equina compression, urinary
The patient is usually a fit young adult, though retention is accompanied by loss of sensation over
children and old people can be affected. Typically, the sacrum.
while lifting or stooping (or perhaps merely
coughing) the patient is seized with back pain Imaging
and is unable to straighten up. Either then, or a X-rays are essential, not to show the disc space but
day or two later, pain is felt in the buttock and to exclude bone disease. However, after several
lower limb (sciatica). Both backache and sciatica attacks the disc space may indeed be flattened. A
are made worse by coughing or straining. Later myelogram or radiculogram outlines the disc well,
there may be paraesthesia or numbness in the leg but side-effects are unpleasant.
or foot, and occasionally muscle weakness. Urinary
retention – due to compression of the cauda equina CT and MRI are the best ways of identifying
– is uncommon but it signals an emergency and may the disc and localizing the lesion. Minor disc
lead to permanent dysfunction of sphincter control if bulges are common and unlikely to be the cause
treatment is unduly delayed. of neurological symptoms. See whether the disc
herniation is actually abutting against an adjacent
The patient usually stands with a slight list to nerve root.
one side (‘sciatic scoliosis’). All back movements
are severely limited, and during forward bending Differential diagnosis
the list may increase. The full-blown syndrome is unlikely to be
misdiagnosed, but with repeated attacks and with
There is often tenderness in the midline of the lumbar spondylosis gradually supervening, the
low back, and paravertebral muscle spasm. Straight features often become atypical. Three groups of
leg raising is limited and painful on the affected disorders must be excluded:
side; dorsiflexion of the foot and bowstringing of ■■ Inflammatory disorders, such as ankylosing
the lateral popliteal nerve may accentuate the pain.
Sometimes raising the unaffected leg causes acute spondylitis, cause severe and more generalized
sciatic tension on the painful side (‘crossed sciatic stiffness and typical x-ray changes.
(a) (b) 18.19 Prolapsed disc – clinical and
MRI (a) This patient presented with acute
low back pain and sciatica. He has the
characteristic sideways list (or tilt) due to
paravertebral muscle spasm. (b) MRI
showing the disc prolapse, with
posterolateral protrusion towards the
intervertebral foramen at L5/S1 (arrow).
237
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