THE AETIOLOGY, DIAGNOSIS, AND TREATMENT OF PROLAPSED INTERVERTEBRAL DISK, WITH A REVIEW OF 300 CASES OF SCIATICA

Abstract

1. An account is given of the symptoms, physical signs, and treatment of a number of patients suffering from sciatic pain.

2. Trauma plays an important part in the production of an intervertebral disk prolapse, but has little relevance to the myofascial type of sciatica.

3. The symptoms of intervertebral disk prolapse may be divided into two stages; the stage in which pain is confined to the back, and the stage in which pain is also present in the leg. Remissions are characteristic and are largely independent of treatment.

4. The symptoms of myofascial sciatica are less constant, but the diagnosis from pain due to a disk protrusion may be impossible in the early stages of the latter condition.

5. The characteristic physical signs of intervertebral disk protrusion are described. They fall into two groups, the mechanical and the neurological. The former are mainly due to changes in ligamentous and fascial structures in the lumbar spine, the latter are due to pressure upon the nerve root by the disk protrusion itself.

6. Surgical treatment of prolapsed disk is by no means certain to result in cure, certainly not immediate cure, and in some cases it is doubtful whether the slow improvement which results is directly attributable to surgery. From these results it would also seem justifiable to assume that removal of the protrusion itself will only relieve the symptoms of root compression, the relief of myofascial symptoms depending upon the removal of other affected structures in the course of the operation and perhaps upon the process of repair stimulated by the trauma incidental to the operation.

7. It is the writer's opinion that surgery should be reserved for those patients in whom prolonged rest has failed to give relief or for those in whom economic reasons render the prospect of a rather more speedy return to work desirable. Further, it is considered that a history of pain in the back and thigh without evidence of root compression does not alone constitute sufficient grounds for the performance of laminectomy; although a disk protrusion may be found in such cases, there is insufficient evidence to show that it is the primary cause of symptoms.

8. A comparison of the results of conservative and operative treatment of intervertebral disk prolapse leads to the suggestion that caution should be exercised in recommending the latter course. In addition there is reason to believe that sciatica, with the exception of the symptomatic variety, is a self-limiting disease, and that operation is practically speaking only a short cut in an otherwise tediously protracted disease.

The surgeons concerned in the operative treatment of these cases were: Mr. B. H. Burns, Mr. R. H. Young, Mr. Harvey Jackson, Mr. E. B. C. Hughes, Mr. H. L. C. Wood, aud Mr. R. H. Boggon, to all of whom the writer expresses thanks for permission to utilize their case notes and record their operative findings.