The dynasty of the disk

Vesalius (1543) described the intervertebral disk, but that was of purely anatomic interest. In the 19th century there were a number of postmortem reports of major trauma and disk damage causing paraplegia. Luschka (1858) first described two cases of prolapsed intervertebral disk with a connection from the nucleus pulposus through the posterior longitudinal ligament to the protrusion. Later Schmorl (1929) and Andrae (1929) made postmortem studies of large series of spines and described both posterior disk protrusions and protrusions into the vertebral bodies (Schmorl's nodes). They considered that most were asymptomatic in life! However, although pathologists saw these disk lesions, no one related them to the clinical symptom of sciatica.

Despite these reports, clinicians remained unaware of the disk. Middleton & Teacher (1911) then reported a case of fatal paraplegia from a central disk prolapse. They related it to the "sprains and racks of the back" and did a crude experiment to produce a disk prolapse. Goldthwait (1911) described a case of paresis after manipulation of the back for a "displaced sacroiliac joint." Harvey Cushing carried out a laminectomy and found nothing apart from "narrowing of the canal" at the lumbosacral junction. In an anguished search for the cause of this iatrogenic disaster, Goldthwait and Cushing considered compression of the nerve at the lumbosacral joint. They suggested the disk might be the cause of "many cases of lumbago, sciatica and paraplegia." Dandy (1929) gave the first complete account of disk surgery, a description of two cases with beautiful illustrations. They had paraplegia, myelographic evidence of complete block, a presumptive diagnosis of spinal cord tumor, and histologic proof of a sequestrated disk. Both cases recovered. Dandy probably deserves the real credit for the first description of disk prolapse. However, he only described the rare cauda equina syndrome and failed to recognize that disk prolapse was the common cause of sciatica. And so he missed his place in surgical history.

Mixter & Barr (1934) discovered "the ruptured disk" as the cause of sciatica. Mixter was a prominent neurosurgeon and Barr a young orthopedic surgeon. Barr had a patient with recurrent sciatica after a skiing accident. He had "several months in absolute recumbency on a Bradford frame" but his neurologic symptoms failed to improve. Barr thought he might have a spinal tumor and referred him to Mixter. A myelogram did not show a block

Mixter Barr
Figure 4.7 Surgery for "the ruptured disk." From Mixter 6t Barr (1934), with permission.

and so was reported normal. Despite that, Mixter went ahead with laminectomy and the operative diagnosis and pathology report were of enchon-droma. Barr was not convinced and wondered if this might not be similar to Schmorl's pathologic description of posterior disk protrusion. Mixter & Barr then reviewed the histology of previous cases and compared them with normal disks, having to make special sections as no one had looked at the disk before. Of 16 surgical specimens of "enchon-dromas," they found that 10 were normal disk cartilage. Mixter & Barr then began to look for patients, and on December 19, 1932 operated on the first patient with a preoperative diagnosis of disk prolapse (Fig. 4.7). Their classic paper (Mixter & Barr 1934) gave the first complete clinical, pathologic, and surgical description of disk prolapse as the cause of sciatica. It also showed that surgical treatment was possible.

Mixter & Ayer (1935) wrote a much more radical paper the following year. This was very influential, although few authors quote it now. It added several key ideas to the concept of disk prolapse. It suggested that disk rupture might cause back pain, even when there were no objective neurologic signs. It started modern myelography by describing the use of large quantities of dye and indentation of the dye column rather than a complete block. Even at that early stage, they admitted the results of disk surgery were less than ideal. Surgery cured leg pain in all but one case, but "some patients complain subsequently of lame back." Most important was their idea that the lesion was traumatic, although only 14 of their 23 cases reported even minor injuries. Disk lesions were now injuries to the spine, which the authors admitted "opens up an interesting problem in industrial medicine." This paper was the real start of the dynasty of the disk.

Disk rupture brought together the 19th-century ideas that back pain was an injury, an injury to the spine, and a mechanical problem that should be treated according to orthopedic principles. If all else failed, it could be fixed by surgery. Disk rupture made this into a marketable package. For the next 50 years the disk dominated medical thinking about back pain.

The first surgeons made the diagnosis of disk prolapse on hard neurologic signs. Their successors soon relied on symptoms alone, partly because of the risks and costs of early myelography. These moves away from the early strict criteria unleashed on an unsuspecting public a wave of surgical enthusiasm held back only by World War II. Key (1945) caused a furore at a meeting of the Southern Surgical Association in 1945 by claiming that "intervertebral disk lesions are the most common cause of low back pain with or without sciatica." Even the published discussion was heated. Magnuson retorted this was no more logical than saying that "all kittens born in an oven are biscuits!"

From the 1950s there was an explosion of disk surgery, closely related to the growth of orthopedics and neurosurgery. Indeed, it was claimed at one time that the average US neurosurgeon made half his income from disk surgery. But the rapid growth of disk surgery soon exposed its limitations. Even the enthusiasts admitted it was difficult to assess the results: "The question of liability, compensation and insurance loom large on the horizon and add complications compounded to an already knotty problem" (Love & Walsh 1938). By 1970, one authority on spinal surgery admitted that "no operation in any field of surgery leaves in its wake more human wreckage than surgery on the lumbar spine" (De Palma & Rothman 1970). Surgeons gradually came to realize that disk surgery only helps the few patients with a surgically treatable lesion and that success depends on careful selection.

Undaunted, orthopedic surgeons extended the concept of "disk lesions." If sciatica is caused by disk prolapse, then back pain might be caused by disk degeneration. They ignored the normal age-related nature of these X-ray changes and their poor rela tion to symptoms. They used biomechanical studies to support the hypothesis, despite the lack of clinica I correlation. Once again, they could blame the disk for most back pain. The answer was spinal fusion, and this re-established the role of surgery in back, pain. It also reinforced the influence of orthopedics in the management of ordinary backache This approach has gravely distorted health care for the 99% of people with back trouble who do not have a surgical condition. It caused us to see back pain as a mechanical or structural problem, and therefore patients expect to be "fixed." Just as when they take their car to a mechanic, it is the doctor or therapist's responsibility to fix their backs. By the time they discover there is no such magic cure for back pain, they are trapped. They no longer have ordinary backache, but have become patients with a serious back injury or irreversible degeneration. This has led to unrealistic expectations and has diverted resources from attacking the real problem of back pain.

Disk surgery has survived the test of time for more than half a century because 80-90% of carefully selected patients get good relief of sciatica. Sadly, this approach did not solve the problem of ordinary backache.

A HOLISTIC APPROACH

Since the ancient Greeks, most philosophers and many doctors have stressed the relationship between body and mind. It is fundamental to human existence and to medicine. Plato encapsulated this in the fourth century bc:

So neither ought you to attempt to cure the body without the soul ... for part can never be well unless the whole is well.

In 100 ad, Rufus of Ephesus saw the need for a complete clinical assessment:

And I place the interrogation of the patient first, since in this way you can learn how far his mind is healthy or otherwise; also his physical strengths and weaknesses, and get some idea of the part affected.

Stahl (1660-1734), writing at the time of the Renaissance, felt that the new physical sciences were not enough in themselves to explain human behavior. He was one in a long line of doctors since Hippocrates who took this view. His work has a surprisingly modern ring:

• the essential unity of the organism

• the personal element in liability to illness

• the part played by mental factors in mental and physical disease

• emotional life is important in treating patients and is independent of reason.

Sadly, the mechanistic approach of orthodox medicine soon swamped such holistic ideas. In the mind-body dichotomy, medicine dealt with the body, and pain was a simple signal of disease. Haller (1707-1777) founded modern physiology, so illness became a matter of disordered physiology. Pasteur (1822-1895) showed that infections are caused by microbes, and paved the way for modern treatment with antibiotics. The German pathologist Virchow (1858) proposed the concept of cellular pathology, which led to the disease model of human illness:

• Recognize patterns of symptoms and signs -history and examination

• Infer underlying pathology - diagnosis

• Apply physical therapy to that pathology -treatment

• Expect the illness to recover - cure.

The business of orthodox medicine was physical disease. We have already seen how the disease model changed medical thinking about back pain. Haller's concept of nerve excitability or irritability led to Brown's spinal irritation and Charcot's grande hystérie. So began our modern approach to the spine. But by concentrating entirely on physical disease it also introduced a bias that has continued to the present day. Brown (1828) described the syndrome of spinal irritation in young women. They had spinal tenderness, pain in the left breast, and many vague bodily symptoms. But these patients were unaware of their spinal tenderness until medical examiners drew it to their attention! The beauty of the diagnosis was that there was nothing physically wrong with the spine. But the more dramatic the treatment, the more effective it was for psychosomatic symptoms: "The ensuing orgy of blistering, leeching and cupping of the spine probably represents the first (unwitting) use of placebo therapy in modern surgery" (Shorter 1992). During the 1820s an increasing number of young women presented with spinal complaints augmented by medical suggestion.

Railway spine is one of the most distressing episodes in the history of back pain (see above). Erichsen (1866) brought together the spate of railway accidents, the new compensation laws, and Brown's concept of spinal irritation (Fig. 4.8). He suggested that minor railway injuries to the spine could have long-term effects. Controversy raged over the nature and indeed the existence of railway spine for many years in both medical and legal circles. In Europe, Valleix (1841) suggested that many

Figure 4.8 A railway spine victim. From Hamilton (1894), reproduced with permission from Spine.

of these symptoms were hysteric. In the USA, Page (1885) denounced railway spine as little more than traumatic lumbago, or a nervous disturbance with overtones of simulation or hysteria, combined with the deleterious effects of lawsuits. This view that the psychic shock of the accident produced "neurasthenia" gradually prevailed. "Exhaustion of the nervous system" or "disease of civilization related to industrialization" were in vogue by the end of the 19th century. At about the same time, the great French neurologist Charcot developed his theories of hysteria. Shortly before his death in 1896, Erichsen himself agreed that railway spine was probably a form of traumatic neurasthenia. As the diagnosis of railway spine fell into disrepute, so doctors, lawyers, and claimants shifted their attention to this new diagnosis. The condition spread from the railways to other work, road, and domestic accidents. With the acceptance of high-speed travel, better clinical examination, and the new X-rays, the diagnosis of railway spine faded. But Erichsen's railway spine caused a great deal of trouble before it was extinguished. And, like spinal irritation, some of its concepts endure to this day. Both medicolegal and lay circles came to accept that back pain is an injury and that minor trauma can lead to severe and permanent low back pain and disability.

The striking aspect of the stories of spinal irritation and railway spine is that vague clinical features gained such ready medical acceptance as physical diseases. This is not unique to back pain. Even today, many health professionals seem uncomfortable dealing with psychosomatic problems. They search desperately for a purely physical or neuro-physiologic explanation, however unlikely, for the vaguest symptoms.

Medicine's struggle with these problems coincided with the growth of psychology and psychiatry. Heinroth first coined the term "psychosomatic" in 1818. He did not imply a psychological cause but simply wanted to describe the mutual interaction between psychological and physical events. It is now nearly a century since Freud reaffirmed the importance of psychological factors in medicine. He showed how doctors could assess psychoneurotic symptoms and gain insight into emotional processes. Meyer, one of the founders of American psychiatry, recognized that psychological factors affect the course and outcome of every illness, physical as well as mental.

People have always had psychosomatic or stress-related symptoms, but the form they take varies depending on what each culture accepts as legitimate. Complaints must be acceptable to the patier t's family, health professionals, and society. What is acceptable changes over time and the history of psychosomatic disorders is of "ever-changing steps in a pas-de-deux between doctor and patient" (Shorter 1992). Up to the 18th century, psychosomatic symptoms were largely related to folk beliefs about external influences on health. In the 19th century, medical ideas focused on the nervous system and irritability. Psychosomatic symptoms changed to hysteric paralysis, then neurasthenia and traumatic neurosis. As medical ideas changed in the 20th century, so did psychosomatic systems. Now we focus cn pain and fatigue. They are not only symptoms, but have become accepted as syndromes. People are also now much more aware of their health. From 1928 to 1931, a survey of US adults reported 82 episodes of illness per 100 people per annum. By 1982, that had risen to 212 episodes. People are now much more likely to regard themselves as "ill" and to seek health care, despite vast advances in nutrition, health care, and public health. At the same time medicine has lost much of its authority, and patients develop their own fixed beliefs about disease.

MANUAL THERAPY

The value of massage to soothe pain has beer known since the fifth century (Schiotz & Cyriax 1975). It is still a common lay remedy today (Fig. 4.9).

Manual therapy is use of the hands to mobilize, adjust, manipulate, apply traction, massage, stimulate, or otherwise influence joints and muscles. In back pain, the basic idea is to influence spinal motion and so relieve pain and dysfunction. It may also produce change in neurophysiologic function and reduce muscle spasm. However, we still do not have a clear understanding of hou> manipulation works (McClune et al 1997).

Manual therapy includes manipulation and mobilization. Manipulation is generally defined as the application of a high-velocity, low-amplitude thrust to the spinal joint, slightly beyond its passive range of motion. Mobilization is the application of force within the passive range of the joint, without a thrust. However, different therapists use the term "manipulation" loosely to describe a wide range of procedures. There are striking similarities in the techniques developed by different health professions, yet it is surprising how unaware the various practitioners seem to be of these similarities.

Ancient medical texts, from Hippocrates and Galen to Paré in the 16th century, describe manipulation. These were powerful spinal manipulations usually combined with traction and were probably for fractures and dislocations, or deformities of the spine (Fig. 4.10).

Spinal manipulation for back pain appears in folk medicine over many centuries from places as far apart as Norway, Mexico, and the Pacific Islands. The most common form was "trampling" for lumbago. For several hundred years, professional bone-setters or "sprain rubbers" also developed manual

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Figure 4.10 Most old medical descriptions of manipulation from the time of Hippocrates to the 17th century were probably for fracture-dislocation or deformity. From Sculteti (1662), with thanks to Glasgow University library.

Bone Setting

Figure 4.10 Most old medical descriptions of manipulation from the time of Hippocrates to the 17th century were probably for fracture-dislocation or deformity. From Sculteti (1662), with thanks to Glasgow University library.

skills in manipulation. This was usually a family business handed down from one generation to the next by apprenticeship. St Bartholomew's Hospital in London had bonesetters on its staff in the 17th century, and one was even knighted.

They were called bonesetters because they attributed the pain to "a little bone lying out of place." Manipulation reset the bone to relieve the pain. The relationship between orthodox medicine and bone-setters varied from respect and cooperation to outright hostility. Paget gave a lecture to medical students in St Bartholomew's Hospital in 1866 on "cases that bonesetters cure." "Few of you are likely to practice without having a bonesetter as an enemy ..." He cautioned against "the mischief that they do," but also admitted that "it sometimes does some good," with lumbago as an example. "Learn then to imitate what is good and avoid what is bad in the practice of bonesetting." The success of bonesetters was partly due to their practical skill and experience, but also to medical ignorance and neglect of common musculoskeletal symptoms. (Oh, how little has changed today!)

Although orthopedics took over the manipulation of spinal fractures and dislocations, orthodox medicine in the 19th century rejected manual therapy for symptomatic relief. This reflected its focus on identifiable pathology and "science." As medicine struggled for professional status, it was happy to leave such hands-on therapy to others. In the UK, the Medical Act of 1858 registered medical practitioners and made it unethical to refer patients to unregistered practitioners. The result was to leave a vacuum, to be occupied by alternative health care, for people with spinal pain for whom orthodox medicine had little interest or help.

In the US, osteopathy and chiropractic developed to meet this need.

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