MEDICINE
Disc dilemma
JOHN ROWAN WILSON
It happened in a disconcertingly casual way. I was playing a rather sloppy game of tennis and felt a mild ache in one side of my back. Some kind of a strain, I thought vaguely. At first I thought it was going to get better on its own, but after a week it seemed to take a turn for the worse and I began to have pains down the front of my leg. Sitting down made it worse and I found it impossible to tie my shoelaces. At this point it became impossible to fool myself any longer. I had ruptured a disc.
1 suppose this must be one of the com- monest ailments of modern civilised man. Certainly that is the impression you get when you have one—it is really extremely difficult to meet anyone who hasn't already suffered from the condition, or at least had a wife or a close relative who has been struck down. It is said to be something to do with the erect posture. Animals don't have much trouble with their discs, except for dachshunds, with their deplorable tendency to sag in the middle.
Actually, when you look at the human spine, it is astonishing that it manages to hold up as well as it does. It is a very curvaceous affair; with a hefty backward curve in the chest region and a forward curve of the lumbar vertebrae just below. No self-respecting structural engineer would look at it for a minute. And between the vertebrae are the intervertebral discs, which act as shock absorbers. They are rather like stiff leather rings filled with wet sand.
In time, the pressure of modern sedentary life begins to tell on the disc. One day the ring cracks and the central soft nucleus gets squeezed out by the pressure of the verte- brae above and below. It pushes up against the ligaments at the back of the disc and causes pain in the back. Then, usually, it moves sideways. And in this position, behind the vertebrae and just to one side of the middle line, run the nerves down to the leg. When the pressure is exerted on them, the pain ceases to be localised to the back and begins to shoot down the leg. The pain, naturally enough, is governed by the pres- sure on the disc, which is squeezing out the nucleus through the hole in the ruptured
ring. When we sit down, the backward squeeze on the disc is at its maximum—and so is the pain. So it is usually more comfort- able either to stand up or lie down.
This is. of course, the same condition that was known for many years under the vague names of lumbago and sciatica. All the old fanciful explanations of the syndrome. such as muscle inflammation and fibrositis and locking of the joints of the back, have now been abandoned in view of our present knowledge of disc pathology. Unhappily, our increased understanding of a causation has not been matched by an equal agree- ment about the best method of treating it. The doctor who suffers a disc lesion finds himself confronted not only with a damn- ably painful leg but with a dilemma. To what particular method of treatment is he going to subject himself?
Within the medical profession there are two schools of belief about lumbar discs. The first is the conventional view of the orthopaedic surgeon. He advises, in the first instance, rest in bed. Boards must be put under the mattress and the patient should lie flat on his back. The length of time he stays in bed depends on the severity of the pain and how well it responds to rest. In a moderate case, he should be able to get up in a few weeks, when he is put in a plaster of Paris jacket or a plastic corset for several months. This is to prevent him carrying out the flexion movements of the spine which may cause recurrence of the pain.
If the pain does not respond to this so- called conservative treatment, operation to remove the offending disc material has to be considered. This is, in anybody's language, a major procedure and not one to be embarked on lightly. Surgeons differ considerably as to how often operation is necessary. Estimates have been made of as low as 2 per cent of cases and as high as 20 per cent. Opinions also vary about the results of operative treatment. Some surgeons claim 90 per cent satisfactory results, others no more than 60 per cent. Much obviously depends on the selection of patients for operation.
In opposition to this conventional wisdom are a group of medical men who may be called manipulative surgeons. They believe that it is possible to do something more positive than rest and less radical than operation. They use two main groups of treatment, varying according to the symptoms and their view of the state of the disc. The first of these is manipulation, designed to restore the disc to position. The other is traction, by which a leather cage is bound round the thorax and another round the pelvis, and the lumbar spine is stretched by weights. It is claimed by the manipulative surgeon that by one or other of these methods, almost all discs can be put back in place and the patient made pain-free, sometimes immediately, some- times after intermittent treatment over a week or two. The orthopaedic surgeons say this is nonsense.
Not being anxious to spend three weeks in bed, flat on my back, I personally chose the second method, and I'm glad to say it worked. But one cure doesn't necessarily prove anything.. As an orthopaedic surgeon pointed out to me, it might well have got better on its own. I suppose I could try to throw out the disc again and compare the way the orthopaedic men handled it. But this seems to be carrying science altogether too far. Incidentally, of course, there is a third school of thought about discs which doctors don't like to mention. This is the one held by the osteopaths. But perhaps they merit a separate article to themselves.
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