COMPRESSION OF THE SPINAL CORD BY CARIES OF THE VERTERRE (SPONDYLITIS) SpOildyritiS or Pott's disease is a frequent manifestation of tuber culosis in childhood and occurs chiefly in children with tuberculous inheritance. It is often accompanied by tuberculosis of the bones, glands, joints or lungs; but clinically, at least, it not rarely con stitutes the only demonstrable tuberculous lesion present. Boys are attacked somewhat more frequently than girls: not even infants escape; the period of greatest incidence of the disease is between three and five years of age.
The disease rarely attacks only one vertebra; as a rule, 2, 3, 4 or even as many as S vertebra. are involved (Hugelshofer, Beuthner, Bovier and others). The most frequent seat is in the lower dorsal, or upper lumbar portion of the cord, and in small children it is quite fre quently found in the cervical portion of the spinal column. Cases in which the lesion is confined to the first two cervical vertebrre have also been observed. So long as the vertebra chiefly involved retains its shape, spinal caries does not produce any demonstrable symptoms; but if the destructive process Is advanced, the bone collapses under the pressure of the superimposed vertebra- and is displaced backward, producing an acute angled deformity of the vertebral column. The spine of the vertebra, which is clisplaced backward, becomes visible externally, forming a so-called gibbosity. The collapse of the carious vertebra may be hastened by injury, which is then erroneously regarded as the cause of the spondylitis. Carious disease of bone frequently leads to the accumulation of pus, either in the neighborhood of the diseased focus or more frequently in the form of a deep abscess in the neighboring tissues. This complication, which affects the prognosis unfavorably, is specially apt to occur in dorsal and lumbar spondylitis, being tnore rare in the cases in which tpe cervical portion of the cord is involved.
Vertebral earies assumes neurological importance only- when the spinal marrow becomes involved in the morbid process. If pains pro duced by disease at the roots of the spinal nerves are also to be ascribed to involvement of the spinal cord, the ca.ses will be nnich more numer ous than if only cases with well-marked spinal symptoms are included.
The pathologic foundation of the spinal disease spondylitis is com pression of the vertebra, fiom lack of space. The cause of this lack of
space may be direct pressure of a diseased vertebra or a local abscess, but is much more frequently found in tt. proliferation of the granulation tissue at the carious site encroach ing upon the vertebral canal or local inflam mation with marked thickening of the dura.
The resulting disturbance of the circulation produces milema in the spinal marrow and finally softening. This softening of the mar row, in combination with the increasing pressure from without, ultimately produees marked contraction and sclerotic changes in the cord, so that the structure of the spinal cord may be completely destroyed at the point of angulation. Pronounced myelitis, however, occurs only in exceptional eases; hence the old designation compression-myelitis is not appropriate in the majority, of eases (tichinaus).
The spinal roots, especially the posterior roots, usually suffer much earlier f rom pres.sure or from the dural disease than the spinal marrow itself.
The most frequent symptom of spondylitis and one which is praeti cally never absent is pain. The pain is often the subject of bitter com plaint on the part of the patient; in other eases it must be elicited by tapping the vertebral column, concussion of the thoracic cage by sudden pressure on the shoulder, or by passing a hot sponge over the spine. If there is kyphosis, the hump is usually the seat of pain, either spon taneous or elicited by pressure. Rigidity of the vertebral column is the direct consequence of the pain. If the seat of the disease is in the cervical portion of the cord, the head is rigidly held in the same atti tude, sometimes inclined to one sicle as in torticollis; or the child sup ports the head with both hands and nervously resists any attempt at movement. In sprindylitis of the thoracic or lumbar portion of the cord the rigidity produces a lordosis, all the niovements of the body are tv—rt extremely cautious, and the patient makes every- effort to maintain the vertebral column in a condition of absolute rest. Direct spinal symptoms are a much more rare occurrence than pain in spondylitis (in 10.7 per cent., Hugelshofer; 12.7 per cent., Vulpius). The char acter and distribution of the various symptoms depend on the seat and intensity of the disease.