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4 POSTGRADUATE MEDICAL JOURNAL January I953
additional hazard after the disease has beenpresent for ten
years.
It is a radical concept which would connect thepersonality
disorder with the malignant change,but such speculation, though
idle, is of interest.
K. GURLING.
REFERENCESx. RICE-OXLEY, J. M., and TRUELOVE, S. (I950),
Lancet,
i, 663.2. ANDRESEN, A. F. R. (1942), Am. J. Digest. Dis., 9,
9I.3. MURRAY, C. D. (I930), J. Nerv. Ment. Dis., 72, 617.4. MURRAY,
C. D. (I930), Am. J. Med. Sci., I80, 239.5. SULLIVAN, A. J. (I936),
Am. J. Digest. Dis., 2, 65i.6. DANIELS, G. E. (x942), New England
J. Med., 226, 178.
7. WITTKOWER, E. (1938), Brit. Med. J., ii, I356.8. GRACE, W.
J., WOLF, S., and WOLFF, H. G. (195'),
'The Human Colon,' Heinneman, London.9. LIUM, R. (1939), Am. J.
Med. Sci., 197, 841.
Io. LIUM, R. (1939), Arch. Int. Med., 63, 2I0.11. FLEMING, A. B.
(1922), Proc. Royal Soc., S.B., 306.12. MEYER, K., and HAHNEL, E.
(1946), J. biol. Chem., 163,
723.I3. SAMMONS, H. G. (I95I), Lancet, ii, 239.I4. PAULLEY, J.
W. (1950), Gastroenterology, I6, 566.I5. HINTON, J. W., and
SHARIHOFF, B. P., cited by Grace,
Wolf and Wolff (8).i6. MORTON-GILL, A. (1944), Lancet, i,
536.I7. KIRSNER, J. B., and PALMER, W. L. (I95i), J. Ant. MVed.
Ass., 147, 541.I8. HARDY, T. L., and BROOKE, B. (1952), 'Modern
Trends
in Gastroenterology,' edited by F. Avery Jones; Butter-worth,
London.
19. LAHEY, F. H. (I950), Rev..Gastroenterology, 17, 723.20.
SLOAN, W. P., BARGEN, J. A., and CAGE, R. P., (I950)
Gastroenterology, I6, 25.
THE TREATMENT OF LUMBAR DISC-LESIONSBy JAMES CYRIAX, M.D.
Physician to the Department of Physical Medicine, St. Thomas's
Hospital
The discovery that the common cause of back-ache and sciatica is
a disc-lesion has caught themedical profession largely unprepared.
Forcenturies these symptoms had been considered areason for
instituting treatment by heat, massageand exercises. These methods
have now lost theirlast shred of theoretical justification but are
beingreplaced only very slowly by acceptable alterna-tives.
Nevertheless, a number of simple measuresexist, none a panacea,
each with its due proportionof successes. Few patients cannot be
relieved ifconservative treatment is intelligently used, andit is
for only a few of this remainder that surgeryneed be
considered.
ProphylaxisThe direction in which a damaged disc tends
to. move depends on the forces acting on it.During lordosis the
inclination of the joint sur-faces (Fig. I) is such that the
pressure of thebody weight on the joint pushes the disc
anteriorly.During kyphosis (Fig. 2) the tilt becomes reversedand
the disc is pushed backwards. Hence it isonly postures involving
flexion that are apt toresult in posterior displacement. The dura
materand the nerve roots lie posteriorly and are thesensitive
structures that make the patient awareof disc-protrusion, the
lumbar joints being inthemselves all but insensitive. The
importantmovement to avoid is stooping, especially when
weight-lifting increases the compression force onthe joint.
Industrial medical officers should teachworkers how to lift, using
their knees rather thantheir backs (Fig. 3), should see to it that
heavyobjects are presented at a suitable height and
.. .; '.' F · .1' ·jtf'7··, .·· ''... F I
t;;!f'::r·;4i."'.P.1F·! rlJ.·'
·, i :.C 5ii... t, ,, ,,
;." ...·:·. ::1. :r- .-·.. ;. .· r.··:··· ..t . 1..? · ·..5
i..r.:$:.C. I rIt ·· r.-.:"' '. c'f '" .·, .i·i?·rr!""l:r·
)'d·' rE
i:.I.·r 1 ;6·'.r·r 1.i ily.l :. I·I /**; -t-·
j. i: I I, 1·:i j··!·.:··! t ;
?:I.... I ..i i.FIG. I.-Jomnt space in extension. Tracing of
X-ray
photograph of the fourth lumbar intervertebraljoint in a normal
subject, bending backwards.Note that the front of the joint space
is i in.(I.2Z cm.) wide, but the back only 3/16 in. (0.5 cm.).In
this position backward movement of the inter-vertebral disc is
virtually impossible.
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January 1953 JAMES CYRIAX: The Treatment of Lumbar
Disc-Lesions
I)'.P1.I.. ·4.. "':
-.--.; ;r·n··....*'.ii ".;- ,
.I·.t.· 'I,.1 · ··. : rC, ib.
: .··.C.fl.p. ··. :;
,,P(: i E.ci :1·O ii·..· 31·1 ''' 7'.·.·Y'$· :
···'' ' I·
:i. ''"' t·.·'- ··1;.·. :.. '*?4I:.;.rJC.3.FiP.?a'.·'
·i.1LLi9y ·r Ir 2··
i: ,
I .·.·....'·B·:··.
;··!''. '.···;.r.;·..l
FIG. 2.-Joint space in flexion. The same subject asin Fig. I
bending forwards. The joint space isnow 5/I6 in. (o.8 cm.) wide
behind, and i in.(o.6 cm.) in front.
attend to the design of chairs and car seats.Patients in bed
should not be allowed to lie in' thenursing mother's position,'
i.e. half-sitting withmany pillows behind the thorax and no
supportfor the lumbar spine which droops into kyphosisall day. No
wonder the posterior longitudinalligament finally stretches and the
beginnings ofdisc-protrusion are laid down. The lithotomyposition
and the flexion that some patients aremade to maintain during
lumbar puncture areobvious offenders. Nurses require instruction
onthese points and it should be explained to gymnastsgiving
children postural training at school thatthe lordosis is not an
unsightly curve requiringobliteration but the chief mechanical bar
todisc-protrusion.Treatment
If something is out of place the most obviousapproach is to put
it back again. This conceptgoverns the orthodox immediate treatment
of mostfractures and of rupture with subluxation of themeniscus at
the knee. When it comes to thespinal joints an extraordinary hiatus
exists. Evenafter a doctor has arrived at a correct diagnosis
heregards active measures to promote reduction as sounorthodox that
he does not attempt them at all.This remarkable attitude has
brought into being agroup of laymen-variously called
bonesetters,osteopaths or chiropractors-who carry out to
ourrecurrent discomfiture the simple spinal manipula-tions that we
in general avoid. Lately we haveexplained away our neglect by
dilating on thedangers of manipulating the spinal joints-to
thegreat advantage of those laymen who, without
hi ii
rg
!Ul
III
FIG. 3.-A Canadian poster.
realizing it, have for years been reducing minorsubluxations of
part of the intervertebral annulus.The first decision that has to
be arrived at is
whether the displacement is likely or unlikely tobe reducible by
manipulation. The reason for thetwo different responses to
manipulation isanatomical. Displacements of the annulus (Fig.4)
consist of hard material that moves' under thestresses of
manipulation; protrusions of thenucleus 'usually do not for they
have the con-sistency of wet sand (Fig. 5). Burns and Young(I945),
analyzing cases coming to laminectomy,found that the primary lesion
in 56 per cent. oftheir cases to be cartilaginous, and in 44 per
cent.to be pulpy with an intact annulus. My impressionis that in
patients not requiring laminectomy theproportion is more like one
nuclear protrusion totwo annular. Thus the first major
decision-whether or not manipulation should be attempted-rests on
an evaluation of the symptoms 'andsigns differentiating a nuclear
from an annularprotrusion. These are set.out overleaf.
Differentiation of Cartilaginous from
PulpyProtrusionsHistory
This is often indicative. For example, a patient
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6 POSTGRADUATE MEDICAL JOURNAL January 1953nucleus pulposus
K annulus fibrosus
nerve roo.
d;dura matrs rl-or
longi'udinalW lijamenr
FIG. 4.-Cartilaginous protrusion causing lumbago. The annulusis
cracked and hinged. Reduction by manipulation shouldbe simple.
bends forwards and feels some aching in his backwhich gets worse
later in the day. Next morninghe finds himself unable to get out of
bed becauseof severe lumbago. This history indicates a pro-trusion
that has gradually increased in size--thatis, one-consisting of
nuclear material. By contrast,the patient who is subject to attacks
initiated by aclick in the back followe by agonizing lumbar
painfixing him in flexion has clearly suffered an
abruptcartilaginous displacement. Pulpy protrusions areuncommon in
the elderly, hence manipulative re-duction should always be
attempted for displace-ments, whether causing backache, gluteal
pain orsciatica in patients over 6o years old.
Primary postero-lateral protrusions causingsciatica are
irreducible by manipulation. This isindicated when a patient with a
low lumbar disc-lesion states that his pain began in the calf or
thighand does not reach the back. Naturally a centraldisplacement
impinges first against the dura mater,causing backache before it
sets up sciatica;primary postero-lateral protrusions never touchthe
dura at all, hence premonitory backache isabsent,
Another type of history' characterizes the self-reducing pulpy
disc-lesion; in such a casemanipulation is waste of time, achieving
no morethan the patient achieves for himself by
avoidingcompression. The patient wakes comfortable andas the'day
goes on backache appears and becomesslowly more severe, especially
if he stoops or lifts.A night's rest once more abolishes the
pain;Naturallyj if the posterior bulge at the joint re-cedes
spontaneously as soon as the stress on thejoint ends, only to recur
when the joint is made tobear weight again, the reduction brought
about bymanipulation is equally unstable and ephemeral.
Manipulation carried out at a time when no dis-placement is
present is, of course, quite pointless.A similar history
characterizes what I have
named the 'mushroom phenomenon' (Cyriax,1950). In an elderly
patient, backache soon fol-lowed by bilateral sciatica comes on
after about Iominutes' walking or standing and is abolished assoon
as he rests. It is often mistaken for inter-mittent claudication.
X-ray examination showsthat the joint space at, usually, the fifth
lumbarlevel has disappeared, the disc substance beingdisplaced
forwards and lying as a round ball be-tween two large osteophytes.
Since nothingsensitive is touched, anterior protrusion
proceedssilently, causing no symptoms until the disc hasbeen ground
to pieces and the compression ofweight-bearing causes capsular
bulging all the wayround the joint. The posterior component
thenirritates both the dura mater and the nerve roots.This lesion
does not respond to manipulation.A complaint of weakness of the
bladder, saddle
anaesthesia, paraesthesiae in the scrotum or numb-ness of the
labium shows that the fourth sacralroot is squeezed and provides an
absolute contra-indication to manipulation. The significance
ofreferred rectal, penile, or coccygeal pain is lessclear, but may
also indicate a protrusion im-perilling the fourth sacral root.
Since the im-portant danger of manipulation in an unsuitablecase is
lasting urinary incontinence, I regard thistype of referred pain as
contraindicating manipula-tion. Not having attempted it in such a
case Inaturally cannot be sure to what extent thisapparent danger
is real.SignsOf the physical signs the appearance of the
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January I953 JAMES CYRIAX: The Treatment of Lumbar Disc-Lesions
7
protrusion- dur& moar
verftbral body %r roo
neerve root
*IF (
FIG. 5.-Pulpy protrusion causing lumbago. The nucleus
hasprotruded backwards, the annulus remaining intact (afterR. H.
Young). Manipulation is unlikely to succeed; sus-tained traction or
recumbency is effective.
patient's back is the most informative. Lateraldeformity of the
lumbar spine when he is viewedstanding still, or apparent when he
bends forwards,indicates a protrusion that has reached a size
thatvisibly interferes with joint movement. Con-siderable lateral
deviation therefore indicatesirreducibility. I have also found that
reductionby manipulation is difficult, at times impossible,
inpatients whose lumbar movements (other thanflexion) hurt in the
thigh instead of the back orin whom the most painful movement is
side-flexion towards the painful side.Marked neurological signs
should be taken as
an indication of irreducibility, whether the lesionwas
originally of cartilage or pulp. Displacementof a fragment of
annulus may later be followed byextrusion of nuclear material along
the line of thefracture. This leads to severe compression of
thenerve root and proportionate interference withconduction. Thus
weakness of more than onemuscle in the leg, combined with, say,
loss ofankle jerk, cutaneous analgesia or much glutealwasting shows
that this secondary effect hassupervened.A disc-lesion at the
unstable joint resulting from
spondylolisthesis is treated in the same way as anordinary
disc-lesion.
ManipulationThis is the treatment of choice; for it can be
immediately effective. It is carried out in allsuitable cases as
soon as the diagnosis of anannular displacement is made.
General AnaesthesiaThis must be avoided, since it deprives
the
manipulator of the patient's co-operation, so vitalto effective
work. One manoeuvre is tried, where-upon the patient stands and by
repeating the move-
ments previously found painful assesses the resulon his
symptoms; the manipulator watches theeffect on his range of
straight-leg raising, postureand lumbar mobility. If this
manipulation hasdone good, it is repeated until no further
benefitaccrues. The next is then performed and theresult noted
again. In this way the manipulatorsees what results he is achieving
and knows whatto do next, when to go on and when to
stop.Anaesthesia denies him all this essential knowledgewith the
result that it is not difficult to make thepatient, at least
temporarily, worse. It is myexperience, too, that the muscular
relaxation in-duced by general anaesthesia is not of muchadvantage,
for displacements previously reducedunder anaesthesia have proved
equally easy toreduce without, and failure without anaesthesialeads
to failure with anaesthesia. It is not themanipulator or the
patient's relaxation that is atfault but the type of protrusion. If
it is large andpulpy no amount of manipulation has any chanceof
success.
TechniqueThe patient lies prone on a firm couch 15 in.
(38 cm.) high and various manual pressures areapplied at the
appropriate lumbar level. If thesefail, rotation strains should be
tried. Thesemethods have been described and illustrated(Cyriax,
1950). This treatment may require twoor three repetitions and an
adequate session maylast half an hour, hence it is my practice to
delegatemuch of this work to physiotherapists trained-as all our
students are-in these methods. Not alldoctors have time,
inclination or a suitable couchfor carrying out such manoeuvres
themselves;moreover these have in practice been found suitedto
delegation.
C
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8 POSTGRADUATE MEDICAL JOURNAL yanuary I953
Sustained TractionBy this means a patient can, as it were, be
put
to bed for several weeks in the course of a fewhours. Most pulpy
protrusions should be treatedby immediate traction, carried out
daily until re-duction is complete. They ooze out and are bythis
means squeezed back into place again. Trac-tion has two effects:
(i) Distraction of the vertebralbodies (Fig. 6). (2) Tautening of
the posteriorcommon ligament which exerts contripetal force onthe
nuclear protrusion and slowly pushes it back.The increased distance
apart of the vertebralbodies not only enlarges the space into which
theprotrusion can now return but creates suction.The couch is made
of steel and has a pillar with
a hook on it at each end. One hook canr bemade to travel
distally by rotating a wheel. Forpulpy lumbar herniations a band is
applied roundthe patient's lower thorax and fixed to the upperhook,
another about his pelvis passes to the lowerhook. Between ioo and
zoo lb. traction is appliedfor half to one hour-as long as the
patient cancomfortably stand it. In an emergency up to sixhours'
continuous traction can be borne. Thephysiotherapist stays with the
patient and adjuststhe tension, measured on a spring balance,
asrequired. This balance is important, not only toenable accurate
treatments to be given but it takesup slack should the belt slip
slightly and preventsall traction being temporarily lost.
Contra-indicationsCartilaginous displacements should be
manipu-
lated back into place. Elderly patients or thosewho have had
thoracic operations may find thatthe band round the chest
embarrasses respiration.Acute lumbago with twinges is unaffected or
madeworse. A patient with sciatica due to a pulpyprotrusion of
several months' standing is often inslight pain only, though the
signs are marked.Traction may effect reduction, but a
protrusionreduced may move again. By contrast if spon-taneous cure
is awaited, though it often takes ayear from the onset of root
pain, the tendency torecurrence is very slight. Hence there comes
atime in the evolution of a pulpy protrusion when itis better
policy to avoid even effective treatmentfor the sake of the
long-term result.
Epidural Local AnaesthesiaThe injection for epidural analgesia
is regarded
as difficult and dangerous by some authorities.During the last
I2 years I have used this methodon unprepared out-patients more
than Io,oootimes without ill effect, and have found it im-possible
to introduce the needle properly in lessthan I per cent. of all
cases. The patient can walk
*.X.:.
i:.· :.. ;·
FIG. 6.-Two radiographs have been superimposed, thesacra
coinciding. One was taken before, the otherduring, traction.
home about half an hour after the injection isgiven. There are
five main indications:
I. In acute lumbago the cause of the pain is acentral posterior
protrusion impinging on the duramater (Cyriax, I945). If this
membrane isanaesthetized by 50 ml. of o.5 per cent.
procaine,introduced extrathecally via the sacral canal,
theprotrusion presses on a membrane no longersensitive and all pain
ceases for the duration of theanalgesia-that is, one to two hours.
During thistime a patient can move freely, perform someessential
work, or go home to bed. He can withadvantage lie on the couch for
an hour in hyper-extension, thus initiating reduction. If this
isdone he usually experiences a large measure oflasting relief.
2. Persistent lumbar or sciatic aching after re-duction of a
prolapsed disc may prove trouble-some; it is apparently due to
persistent localbruising of the dura mater. One or two
epiduralinjections usually suffice to stop it.
3. Chronic backache, especially if it is moresevere at night
than by day, associated with onlyslight articular signs at the
lumbar spine can oftenbe lastingly abolished by one injection of
epidurallocal analgesia.
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January 1953 JAMES CYRIAX: The Treatment of Lumbar Disc-Lesions
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4. If a patient in whom spontaneous recoveryfrom sciatica is
being awaited continues too longto suffer marked limitation of
straight-leg raising,the nerve root can be painlessly mobilized by
fullstraight-leg raising after the induction of anepidural
block.
5. This is the treatment of choice in referredcoccygodynia.
Prolonged AnalgesiaThis is indicated in large irreducible
protrusions
especially at the fourth lumbar level. The patientoften suffers
little pain but has a gross lateraldeviation of the lumbar spine
which may havepersisted unaltered for weeks or months.He lies
supine in bed in his position of ease.
He is kept fully relaxed for four hours by a con-tinuous
intravenous infusion of procaine solution.At the end of the third
hour his position in bed isaltered to the reverse of that obtaining
previously,so that the lumbar spine is held in lateral deviationin
the opposite direction. Prolonged muscularrelaxation often results
in reduction.
Rest in BedThis is the old-fashioned treatment for lumbago
and sciatica. It acts by avoiding the compressionof standing;
the vertebral bodies finally move apartand reduction ensues. It is
a most successfultreatment, but very slow. It is apt to fail only
inthe elderly whose lumbar joints are so stiff as theresult of
capsular contracture that they cannotmove adequately. In such
patients a fragment ofannulus that weeks in bed have failed to
shift canoften be reduced easily by manipulation.
Rest in bed is an admission of defeat and oftentakes weeks or
months to become effective. It is,therefore, to be avoided as far
as possible. If thereis nothing else for it, the patient must lie
flat on afirm mattress, with a small pillow or a hot-waterbottle
maintaining his lordosis. He must not getout of bed nor sit up or
the relief from compressionat the joint is nullified. No sort of
physiotherapyis called for and all exercises, even towards
ex-tension lying prone, are contra-indicated, forcontraction of the
sacrospinalis muscle squeezesthe joints together and extends the
joints onlywhen this play has been taken up.
Awaiting Spontaneous CureBackache shows little tendency to
spontaneous
cure; it may last, or recur, during a patient'swhole lifetime.
Sciatica, however, nearly alwaysgets well of itself in about I2
months. The twoexceptions are: (a) after an unsuccesful
laminec-tomy this does not happen and sciatica may thenpersist for
years; and (b) after the age of 6o
spontaneous cure with the lapse of time isimprobable.Young
patients with sciatica are often seen who
show clear signs of a nuclear protrusion at a lowerlumbar level
of some months' standing. Thesymptoms amount to only an ache, the
patientlooks cheerful and sleeps well. Examinationstanding shows a
symmetrical lumbar spine withsome lateral deviation on attempted
flexion.Straight-leg raising is 45° to 60° limited andslightly
impaired conduction is noted, e.g. asluggish ankle-jerk and some
weakness of theextensor hallucis muscle. As already
mentioned,awaiting spontaneous recovery has a more per-manent
result than such treatments as bring aboutreduction, for the
protrusion becomes fixed in anew position from which it cannot
becomedislodged.The tendency to lumbago often ceases spon-
taneously between the ages of 50 and 6o. As ageadvances the
spinal joints stiffen and osteophytes,both cupping the disc and
limiting articular move-ment, make their welcome appearance.
Osteo-phyte formation at the lumbar spine is not apainful
condition, on the contrary it is beneficial.It is the mechanism
that prevents backache afteryears of wear and tear have damaged the
disc.
LaminectomyThis is to be avoided as far as possible, but
operation should not be unreasonably withheld.In the best hands
the results are not alwaysperfect; immediate cure may not be
secured andeventual recurrence is regrettably frequent evenin
patients who never go back to heavy work. Theintroduction of
sustained traction in I950 reducedmy laminectomy rate for all
disc-lesions fromI :40 to I :200. The five main indications
are;
I. Gross lumbar deformity. A young patientshould not be left to
recover spontaneously fromsciatica or, less often, backache causing
markedpersistent lumbar deformity. Though he mayrecover as regards
pain, the deformity remainspermanent.
2. Incipient drop foot. A patient who developsincreasingly
pronounced weakness of the dorsi-flexor muscles of the foot must be
warned so thathe must choose between laminectomy and thepossibility
of a permanently weak foot. In suchcases pressure atrophy,
doubtless from localischaemia, may result in complete insensitivity
ofthe sheath of the affected nerve root. As a result,pain quickly
ceases and straight-leg raising soonreaches full range at the same
time as the palsybecomes complete. The patient, chiefly
concernedwith his pain, is apt mistakenly to suppose that heis
getting better, an error that the physician shares
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'POSTGRADUATE MEDICAL JOURNAL Yanuary I953
unless he examines again the power of the musclescontrolling the
foot.
3. Intractable severe pain. Irreducible disc-lesions are caused
by complete erosion of theposterior ligament with extrusion of part
of theannulus into the neural canal. More rarely theend-plate
becomes detached and buckles over onitself. No amount of
conservative treatment canthen avail.The important point in such
cases is to make
sure that the allegations of pain are borne out bythe physical
signs. Patients with hysteria welcomeany operation the criterion of
whose success restsalmost entirely on the patient's own
statements.
4. Fourth sacral palsy. Weakness of thebladder, saddle
anaesthesia, paraesthesiae inscrotum or labium call for immediate
laminectomy.
5. Adherent root. If the symptoms warrant-they usually do
not-the adhesions can be dividedat laminectomy.Arthrodesis
Arthrodesis is the operation of choice inspondylolisthesis
causing sufficient local capsularpain or setting up traction on the
relevant lumbarnerve roots with consequent bilateral sciatica. Itis
the only effective treatment for anterior pro-trusion of the whole
disc (mushroom phenomenon),and is well worth carrying out in
patients under6o. It is also indicated in recurrence
afterlaminectomy if conservative measures fail. Fre-quent crippling
attacks of lumbago or sciaticaquickly recovering present a
difficult problem.Laminectomy cures less than half of all
suchcases. Arthrodr:sis is therefore to be preferred.Maintenance of
ReductionExplanationThe mechanics of lumbar disc-protrusion
must
be explained to the patient so that he understandswhy it is
essential that he should maintain hislordosis at all times. The
physiotherapist showshim how to stand, sit, lift and how to use
hisknees instead of his lumbar joints for getting hishands close to
the floor. Neurosis is prevented byemphasizing the purely
mechanical nature of hisdisorder-the analogy with the knee is
useful--and that it is not the precursor of arthritis likelyto
spread to other parts of the body. It is not somuch that he cannot
do this or that, he must doit in a different way. All exercises,
especiallytowards trunk flexion, must be avoided. Theymaintain
mobility and thus enable the movement
to take place that results in internal derangement.Active
prone-lying trunk extension exercises areless harmful than the
others, but are best avoidedsince the contraction of the
sacrospinalis musclescompresses the joint. Press-ups, where by
thetrunk is passively extended, are free from thisdefect.
SupportA Plaster Jacket
This is a method in great vogue at the moment,but I believe it
is seldom worth the discomfort itentails. It is usually wrongly
prescribed in thehope of achieving reduction rather than
main-taining it. One untenable reason for immobiliza-tion in
plaster has been expressed (Crisp, 1948)that rest in plaster allows
the broken cartilage tounite. Intra-articular cartilage has no
bloodsupply; therefore it cannot heal at a spinal jointany more
than at the knee joint. Immobilizationachieves a spurious
popularity when a patient, forwhom the proper treatment is to await
spontaneouscure, is put in plaster until he is well. He does
notknow that he would have recovered just as quicklywithout the
added discomfort of the plaster jacket.A Perforated Plastic
Jacket
This weighs a fifth as much as a plaster jacketand achieves a
much greater degree of immobiliza-tion; for it can be tightened at
will to any degree.It can be made in two days on a plaster cast
takenfrom the patient. Hence it supersedes a plasterjacket from
every point of view.A CorsetWhereas a plaster jacket cannot be worn
for
longer than some months and thus cannot providelasting
protection against recurrence, corsets, re-newed each year or two,
can be worn indefinitely,thus affording permanent security. If the
twosteels are accurately moulded to the lumbar curve,lordosis is
maintained and the joints steadied.Moreover, if the patient bends
too far forwards orsags as he sits, the front of the corset
pressesunpleasantly against his lower ribs-a salutaryreminder.
BIBLIOGRAPHYBURNS, B. H., and YOUNG, R. H. (1945), ' Protrusion
of Intra-
vertebral Disc,' Lancet, ii, 424.CRISP, E. J. (1948),
'Conservative Treatment of Lumbar Disc
Lesions,' Proc. Roy. Soc. Med., 26I.CYRIAX, J. (1945), '
Lumbago,' Lancet, ii, 426.CYRIAX, J. (1950),' Lumbar Disc Lesions,'
Brit. med. j., ii, I434.CYRIAX, J. (i95o), 'Orthopaedic Medicine,'
Vol. II, Cassell,
London.
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ostgrad Med J: first published as 10.1136/pgm
j.29.327.4 on 1 January 1953. Dow
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