Conservative treatment. Analgesics, rest, a collar and traction will usually produce a remission of symptoms but the pain may be so severe and intractable that disc excision is required as an urgent procedure.

Operative treatment. Disc excision may relieve pain and improve neurological function but it makes the cervical spine more unstable than the corresponding operation on the lumbar spine and the root can still be irritated even when the disc has been excised. To avoid this, operation is sometimes accompanied by a cervical fusion in which a block of bone is inserted between the adjacent vertebral bodies. The role of cervical fusion, which puts greater strain on the intact discs, is controversial.

The standard treatment consists of heat, rest, anti-inflammatory drugs, analgesics and a supporting collar. When the symptoms have subsided, mobilizing exercises to restore movement are important but it must be said that no properly conducted scientific study has ever shown that these exercises influence the natural history of the disease. Voltaire may have been right when he commented that ‘The efficient physician is the man who successfully amuses his patients while Nature effects a cure’.

Operation is seldom required for spondylosis but may be necessary if there is severe pain arising from a single identifiable level (Fig. 26.3).

A supporting collar is usually sufficient but atlantoaxial fusion may be needed if there is a neurological deficit or unremitting pain.

Treatment depends upon the cause. Most acute stiff necks settle with a collar, warmth and analgesia but serious injuries must be excluded first.

Excision may be necessary if radiographs demonstrate a complete or incomplete cervical rib; conservative treatment with physiotherapy to improve the power of the shoulder girdle muscles has been ineffective. The operation is straightforward but the root of the neck is ‘tiger country’ and the operation must only be done by a surgeon who is very familiar with this area.

No specific treatment is required but the scoliosis may need correcting.

Some improvement in position follows release of the muscles along its upper border if carried out at an early age.

The pain usually resolves without treatment over a period of weeks, but the weakness may take up to 2 years to recover. Apart from reassurance and excluding other disorders, no treatment is required.

The symptoms usually resolve spontaneously over a period of days or weeks. A supporting collar eases the pain and manipulation is sometimes helpful.

The ‘strain’ is usually the result of incorrect lifting and most can be avoided. Workers who have to lift heavy weights, including nurses who lift patients, should be taught correct lifting techniques (Fig. 26.8). Four principles are important:

In the workplace, lifting can be made easier by storing goods at waist height and avoiding the need for a twisting motion while lifting or carrying or by using lifting equipment and conveyor belts.

The following measures form the standard treatment for acute back injuries and are reliable; rest, analgesics and gradual mobilization are the most important:

Rest. The patient should rest in the most comfortable position possible, which is usually on the back or side with the knees flexed. If lying in bed is painful it is perfectly acceptable to rest in a comfortable chair.

Analgesics. Any analgesic or NSAID can be used. Narcotics such as pethidine should not be needed.

Heat, either from a hot water bottle or a heat pad, is very comforting for pains arising from muscles and ligaments and the diagnosis should be reconsidered if heat does not help. The mechanism of relief is obscure, but is probably nothing more than old-fashioned counterirritation. Even if unscientific, patients find warmth helpful.

Gradual mobilization. As the pain subsides, gradual mobilization can be started, but the patient must be prevented from lifting weights and risking further injury for at least 6 weeks. This may be difficult if the patient is a hardworking self-employed worker who needs to get back to work to earn a living. It is nevertheless essential if recurrent strains are to be avoided.

Mobilization of the spine is important. If a full range of spinal movement can be achieved, it is likely that the muscle or ligament has healed and the presence of a full range of movement ensures that loads can be borne equally throughout the spine.

If movement is limited, further injury is probable. The stiff areas of the spine are more likely to be injured by sudden stress and the mobile areas will be taking more strain than normal. A good range of movement should therefore be achieved before the patient returns to work, and the range of movement maintained by an exercise routine.

Lumbosacral brace. If the patient insists on returning to work before full movement has returned, a lumbosacral support will lessen the risk of recurrence. A brace will support the back when the patient is lifting and, perhaps more important, will ‘remind’ patients of their condition so that they lift correctly.

Spinal supports should be worn only for pain relief or to protect the back when it is at greatest risk. If they are worn permanently the spine will become stiff, the muscles will take less strain, and further injury becomes more likely.

Manipulation. Manipulating an acutely painful back is occasionally harmful if there is some underlying undiagnosed pathology but is sometimes dramatically successful, particularly if the sacroiliac joint is affected. Manipulation is a skill which takes much training and should not be attempted by the inexperienced. Both osteopaths and chiropractors are skilled manipulators.

There are two serious conditions that can masquerade as an acute back strain:

Operations have no place in the management of recurrent back strain. All the measures described for the management of acute back strains should be used, with special attention to prevention. Spinal fusion will make matters worse unless the disc is also unstable.

The discs are not solid lumps of inert gristle resembling rubber pads, as patients often think, but living structures which flatten slightly during the day and re-expand at night. They consist of a firm nucleus pulposus surrounded by the annulus fibrosus, a ring of fibrocartilage and fibrous tissue which links the two vertebrae together. The disc is a symphysis between each pair of vertebrae and, with the two posterior facet joints, allows movement between the vertebrae.

The tension within the disc is maintained by fluid imbibition at the cellular level. If imbibition fails for any reason, the pressure within the disc falls, the disc collapses, increased movement occurs between the adjacent vertebrae, the annulus fibrosus is exposed to increased stress and this is accompanied by vague low back pain. CT scans can demonstrate the lesion, and injection of saline or contrast medium may reproduce the back pain.

As degeneration proceeds, the annulus fibrosus softens and the degenerate disc bulges the annular ligament backwards, usually just lateral to the midline (Fig. 26.9). If this occurs in a tight spinal canal opposite a nerve root, the function of the root is affected.

Ninety per cent of lumbar disc protrusions involve the lowest two spaces, L4–5 or L5–S1. Lesions which press on the L5 root cause altered sensibility on the outer side of the calf and weakness of the peronei and ankle extensors, while those affecting the S1 root produce altered sensibility on the foot or back of the calf, weak ankle flexors and a depressed ankle jerk. The resting muscle tone of the glutei, hamstrings, calf muscles and other posterior muscle groups may also be reduced and these muscles may waste.

Unless there are neurological symptoms and signs below the knee, the patient probably does not have a true prolapsed intervertebral disc. Disc lesions seldom cause severe back pain and it is quite wrong to use the term as a synonym for acute back strain.

Straight leg raising, which stretches the nerve, is restricted by pain. Other tests which stretch the nerve are also positive (p. 17).

Be wary of patients with no straight leg raising; the nerve root is not stretched until the leg is lifted 30°, and pain before this level is reached is more likely to be caused by apprehension, hysteria, malingering, or one of the conditions listed below. Beware also of the patient who can lean forward and touch the toes on the couch yet has restricted straight leg raising. These features are not compatible with a simple organic disorder.

It is helpful to know the exact site of the lesion if operation is planned. MRI (Fig. 26.10) is the mainstay of treatment, but radiculography (Fig. 26.11) or CT (Fig. 26.12) can be used.

Any condition that causes root irritation or pain in the leg can be mistaken for a disc prolapse, including the following conditions:

Left untreated, the symptoms disappear spontaneously even if the protrusion remains. In other patients, the annulus fibrosis will rupture and disc material will be extruded into the spinal canal. This may make the symptoms either dramatically better or dramatically worse.

In patients over the age of 40 a plain radiograph should always be obtained and routine investigations carried out to exclude a spinal tumour and systemic disease before any treatment is started. The incidence of positive findings in patients between the ages of 20 and 40 is so low that some radiologists believe a preliminary radiograph is unnecessary until conservative treatment has failed, but most cautious doctors will wish to see a radiograph at some stage.

Conservative treatment. Because some natural recovery is likely, it is wrong to operate without a fair trial of conservative treatment unless there is a cauda equina lesion (p. 455). Treatment consists of two main measures:

Rest. The patient should stay in bed in the most comfortable position with adequate analgesia and, if necessary, muscle relaxants such as diazepam 5 mg twice daily. Bed rest should be total, in hospital if possible. Total bed rest at home is a formidable undertaking that places a great strain on the family. Most patients defy instructions and get up for meals and toilet purposes.

Traction helps to keep the patient in bed and some say that is all it does. It may also relieve muscle spasm and pain but it does not ‘replace the disc’.

‘Putting the disc back’. Manipulation of spines with acute disc prolapse is very dangerous. While osteopathic and chiropractic manipulations are excellent for chronic back problems, manipulation in the presence of neurological symptoms and signs can rupture the annulus fibrosus, extrude disc material and cause severe neurological damage. The concept of ‘putting the disc back’ by manipulation, as if it were a piece of jigsaw, is firmly rooted in the public mind and is quite wrong; a prolapsed disc is not a firm, rounded lump of gristle shaped like a ‘Smartie’, but looks more like a piece of soggy string (Fig. 26.14). Discs do not pop in and out like the cuckoo on a cuckoo clock (Fig. 26.15).

At operation, the disc will usually extrude itself from the disc space under pressure when the annulus fibrosus is excised, and to imagine that these discs can be replaced by manipulation is a fallacy.

Operative treatment. There are four indications for considering operation on prolapsed discs:

If operation is considered, a CT or MRI scan is needed to demonstrate spinal nerve roots and identify the disc protrusion. If the site of the disc protrusion matches the clinical signs, the disc can either be softened by chymopapain injection or excised surgically.

Chymopapain injection (chemonucleolysis). Injection with chymopapain, a proteolytic enzyme found in pawpaws and used commercially as a meat tenderizer, is suitable for discs that are also ideal for surgical excision. It is not helpful for patients with chronic disc lesions and no neurological signs. If the indications are correct, chymopapain injection is effective in about 70% of patients and in some centres has replaced surgical excision of the disc.

The injection must be done under image intensifier control on an inpatient basis and is accompanied by quite severe back pain. There is also a small incidence of anaphylactic reaction. Chymopapain injection is successful in the short term but there is some evidence that the long-term results are less satisfactory than surgical treatment; however, the morbidity is still less than that of disc excision.

Disc excision is done either by neurosurgeons or by orthopaedic surgeons. The disc is approached from behind after excising the ligamentum flavum and, if necessary, the inferior portion of the lamina overlying the root. This procedure is called fenestration (from the Latin fenestra, a window). All disc material should be removed, including any that has sequestrated into the spinal canal.

Disc excision relieves neurological symptoms in about 75% of patients, provided that it is done in the right patients and for the right indications; i.e. neurological symptoms that match the neurological signs and a radiologically proven disc protrusion. The physical signs of muscle weakness and loss of reflexes do not always return to normal after laminectomy and disc excision.

The operation disturbs the ‘triple joint’ between neighbouring vertebrae and their facet joints. Without a complete disc, the bodies move towards each other and put unnatural stresses upon the posterior facet joints, which then degenerate. This is an unavoidable problem and some degree of stiffness and back pain can be expected in 30–60% of patients after a disc prolapse, whether it is treated conservatively, surgically or by chemonucleolysis with chymopapain.

Microdiscectomy. Discs can be excised through small skin incisions or under endoscopic control. The technique is new and difficult but the results are encouraging. The recovery period is shorter and surgical trauma is minimized.

The treatment and indications for operation are the same as those for protrusions at lower levels, although excision is needed more often because the canal is relatively narrow in the upper part of the lumbar spine.

Untreated, the whole of the spine from coccyx to occiput can become a single rigid bar and it is important to maintain motion. Ankylosing spondylitis is best managed by a rheumatologist. Treatment of the acute attack is similar to rheumatoid arthritis, with rest and anti-inflammatory drugs followed by mobilization. In the longer term, regular physiotherapy to maintain motion is essential.

Unless there is a neurological deficit due to nerve root compression, surgery has no place in the management of lumbar spondylosis, which is best treated in a department of physical medicine.

Operation is not needed unless there is root entrapment. The following conservative measures are usually sufficient to relieve symptoms:

If the nerve root lesion can be localized, the root can be unroofed to decompress the nerve, but the osteophytes are likely to recur and decompression does not improve the underlying spondylosis and osteoarthritis of the facet joints.

CT scans and MRI demonstrate the constriction in the spinal canal very clearly.

Conservative treatment is often helpful and consists of weight reduction, a spinal support and physiotherapy to reduce hyperextension of the lumbar spine.

If these measures fail, operation to decompress the spinal cord is usually needed. A wide laminectomy will produce relief but symptoms can recur if soft tissue forms around the site of laminectomy.

Restriction of activity, a lumbosacral support for use when the back is painful and exercises to build up the extensor muscles of the spine are all helpful.

This is one of the few spinal conditions that may be helped by operation. Operation is indicated if conservative measures are not effective or there is progression of the slip in a growing child. An intertransverse fusion to link the two separated halves of the affected vertebra is simple and reliable.

If the kyphosis is severe, bracing may be effective, and in very severe cases a spinal fusion may be needed. It is not kind to keep urging the children to ‘stand up straight’ because they are unable to do so.

Patients with transitional lumbosacral vertebrae should be treated as if their radiographs were normal, using anti-inflammatory drugs and physiotherapy. Operation on the anomaly should be avoided.

Physiotherapy and analgesics are usually sufficient, but the hemivertebra may need to be excised if the deformity or the symptoms are severe.

The management of severe spina bifida in children is described on page 356.

Less severe manifestations are best treated conservatively unless there is evidence of tethering of the roots by bony bars or fibrous bands, which should be divided or excised by a neurological surgeon.

The commonest spinal tumour is a metastasis and the possibility of a tumour must always be remembered when treating any patient with back pain, even if the history is long. A history of back pain from other causes does not bring immunity to spinal tumours and it is quite possible for a patient with established back pain of many years standing to develop a bone tumour in addition to the original problem. Any painful back should be examined radiologically if a metastasis is suspected, even though making the diagnosis of a spinal tumour does not always help the patient. An ESR is useful: if normal, a metastasis is unlikely.

The commonest tumours to metastasize to the spine are those which usually spread to bone:

Metastatic tumours commonly go to the pedicles, which are destroyed. This can easily be recognized radiologically by looking for an owl in each vertebra on the anteroposterior view. The pedicles correspond to the eyes and the spinous process to the beak. If a pedicle is destroyed, its outline cannot be seen. Beware the winking owl!

Other bone tumours are seen in the spine, including osteoblastoma and giant cell tumour, but osteogenic sarcoma, which occurs typically around the growing end of long bones, is very rare. Tumours of the nervous system, such as neurofibroma and meningioma, also occur and multiple myeloma may cause vertebral collapse.

Apart from diagnosis and a spinal support, there is little to offer; the osteoporosis is usually too far advanced to be treatable by the time the patient is seen (p. 320).

Complications may be serious, with the formation of sinuses, which may become secondarily infected, and paraplegia (Pott’s paraplegia), which has three common causes: (1) pus and intracellular pressure; (2) mechanical injury to the cord from bony pressure; and (3) vascular embarrassment to the spinal cord where it crosses the gibbus.

Treatment is by oral antibacterials (p. 315), which are only effective if the patient actually takes them. The treatment must be continued for months or years. Alternatively, operation is needed to drain the pus, remove dead bone and fuse the affected vertebrae to prevent future bone collapse. If bone collapse has already occurred and the spinal cord is threatened, bone grafting and fusion is required.

If the organism can be identified, systemic antibiotics are effective, but exploration of the disc is sometimes necessary.

The condition usually resolves spontaneously and seldom requires decompression of the nerve.

Injection with hydrocortisone is often effective but if the pain is still present after three injections, denervation of the coccyx with ultrasound or a radiofrequency probe in a pain clinic should be considered.

Coccygectomy is sometimes done but should only be considered as the last resort. It may succeed in a few patients but in many the pain remains after the coccyx has been removed.