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Volume 36-B, Issue 2 May 1954

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Norman Capener

It is clear that in lateral rhachotomy we have a procedure which is appropriate for approach to the vertebral bodies in a variety of pathological processes including, besides the relief of Pott's paraplegia, the treatment of non-paraplegic tuberculosis, the exploration of spinal tumours, the relief of certain types of traumatic paraplegia and the drainage of suppurative osteitis of the vertebral bodies. For tuberculous disease we find in lateral rhachotomy a technical procedure which provides a meeting point for the solution of several ideas. These are the evacuation of tuberculous abscesses as enunciated by Pott and developed by Ménard, the revascularisation of avascular areas, the removal of necrotic material and the direct removal of the features causing spinal cord compression. It is to the latter only that I think I have made a small contribution. For all other purposes, between lateral rhachotomy and the classical costo-transversectomy, the differences if any are extremely small. The fact remains that the direct surgical approach to lesions of the vertebral bodies has a wide scope of usefulness.

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1. As a result of degenerative changes in the intervertebral disc, nuclear tissue often herniates through its confining structures. These lesions are common, even in children, and often lead to difficulty in diagnosis.

2. The radiological manifestations of nuclear herniations into the spongiosa of the vertebral body, through the anterior part of the annulus fibrosus, beneath the epiphysial ring, and through the posterior part of the annulus are described and illustrated. The clinical significance of these radiological appearances and their pathological basis is indicated.

3. An understanding of the significance of the radiological findings in herniation of the nucleus pulposus and a careful correlation with the clinical features of the case are necessary for accurate diagnosis.

1. The lesions chiefly responsible for persistent pain and weakness after acromio-clavicular dislocations are tears of the trapezius and deltoid muscles.

2. These tears cannot be adequately treated except by open operation.

3. There are often physical barriers making closed manipulative reduction impossible.

4. Open reduction and repair of torn ligaments and muscle is advocated for manual workers.

John C. Kennedy Howard Cameron

1. Screw fixation of clavicle to coracoid process, with subsequent calcification and ossification along the conoid and trapezoid ligaments, creates an extra-articular fusion of the acromio-clavicular joint.

2. Though the follow-up is admittedly early, excellent results can be obtained in the young healthy adult. It is possible to return an athlete to competitive sports and a heavy labourer to full work in a surprisingly short time.

3. The operation is of doubtful value in older patients.

4. A precise operative technique is most important in producing a successful result.

5. Screw fixation introduces a new movement into the abduction mechanism of the shoulder: synchronous scapulo-clavicular rotation.

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F. A. R. Stammers

1. The history of the development of the operation of sympathetic ganglionectomy for vasospasm is related.

2. A simple classification is given of the common diseases of the peripheral arteries.

3. The symptoms of peripheral arterial disease are described.

4. The investigations are discussed.

5. The treatment, both conservative and surgical, is discussed, with comments on arterial grafts.

6. Special points are made regarding poliomyelitis, acrocyanosis, Bazin's disease, cervical rib, vascular injuries and crutch arteritis.

7. The long-term results of sympathectomy are reviewed.

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J. S. R. Golding

1. The clinical features in twenty cases of osteoid osteoma have been analysed and compared with other cases reported in the literature.

2. The lesion is regarded as a benign neoplasm and its unusual clinical behaviour is attributed to its vascular nature.

3. The frequency with which an erroneous diagnosis of "neurosis" is made is stressed.

H. Verbiest

1. A clinical condition is described in which there are symptoms of compression of the caudal nerve roots on standing or walking, but not at rest. Seven cases are reported.

2. Myelography showed a block in the lumbar region in every case.

3. At operation narrowing of the spinal canal in part of its lumbar course was found.

4. The nature of the abnormality is discussed. It is suggested that the narrowing is due to encroachment on the spinal canal by the articular processes.

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G. D. Kersley H. S. Barber J. C. F. Cregan H. J. Gibson

1. Three cases of a degenerative type of rheumatoid arthritis, with large cystic cavities filled with pus-like material, are described. They may arise from bursae or breaking-down nodules.

2. Four cases in which necrosis and subluxation complicated rheumatoid disease of the cervical column are recorded.

3. The pathogenesis of necrotic and cystic areas in rheumatoid arthritis is discussed.

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C. M. C. Potter

1. Two cases of fracture-dislocation of the trochlea are described. One case was complicated by complete ulnar nerve palsy.

2. The injury is caused by direct force applied to the point of the elbow, or it may be associated with posterior dislocation of the joint.

3. Open reduction is recommended, the fragment being held in position by soft-tissue sutures alone.

4. Four other cases mentioned in the literature are reviewed.

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Raymond Farrow

A case of concealed run-over injury of the lower limb, complicated by delayed local gangrene and peripheral vascular involvement, is described and the mechanism of the lesion discussed.

A. Adam D. Ritchie

A case of parathyroid adenoma in a growing girl is described in which radiographs showed bands of increased density in the metaphyses in addition to the usual signs of osteitis fibrosa cystica. The literature is reviewed and the appearances are discussed.

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D. U. Bloor

A case of osteopathia striata in a girl aged three years is described. Similar cases are reviewed.

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R. Wheeler Haines A. McDougall

1. The anatomy of the forefoot in hallux valgus is compared with the normal, with a review of the literature and descriptions of anatomical preparations, observations at operation and radiographs.

2. The early and essential lesions are stretching of the ligaments on the medial side of the metatarso-phalangeal joint that attach the medial sesamoid and basal phalanx to the metatarsal, and erosion of the ridge that separates the grooves for the sesamoids on the metatarsal head.

3. In established hallux valgus a sagittal groove, formed where the cartilage is free from pressure by either the phalanx or the ligaments, cuts off a medial eminence, which articulates with the stretched ligaments, from a restricted area for the phalanx.

4. Apart from osteophytic lipping which squares off the outline of the eminence as it is seen in radiographs and a small amount of lipping of the ridge on the metatarsal there is no evidence of new bone growth. In chronic cases the eminence may degenerate or disappear.

5. The articular surfaces at the cuneo-metatarsal joint become adapted to the changed positions of the metatarsal without gross pathological change.

6. The four deep transverse ligaments that bind together the five plantar pads of the metatarso-phalangeal joints are not unduly stretched, so that as the metatarsals spread it is the ligaments that bind the pads to the heads of the metatarsals that give way.

7. The plantar metatarsal artery to the first space pursues a tortuous course between the two heads of the flexor hallucis brevis. In hallux valgus the course becomes still more tortuous and part of the pain experienced may be due to ischaemic effects.

G. N. C. Crawford

1. In young rabbits the muscle belly of the tibialis anterior was marked at intervals, either on its surface with indian ink, or in its substance by wires. The intervals between ink marks were measured directly, and those between wires by radiography. After four to seven months the measurements were repeated and the amount and site of longitudinal growth determined. The experiments showed that it occurred fairly evenly throughout the length of the muscle belly.

2. By transfer of the tibialis anterior in front of the crural ligament in young rabbits its course was reduced and the extent of contraction necessary to dorsiflex the foot was increased. The rabbits were killed when fully grown and the lengths of the tendons and muscle bellies of the tibialis anterior of the normal and experimental legs were compared. It was found that in every case the tendon of the experimental muscle was shortened and its belly lengthened in comparison with the normal. It is suggested that the increased length of the muscle belly was determined by the increased distance which it had to contract in order to dorsiflex the foot.

R. I. Harris Ian Macnab

One of the interesting aspects of spinal pathology having an important bearing on the treatment of backache is that the spine acts as an integrated whole and that damage sustained by one part frequently injures other structures in the spinal column. Thus disc degeneration may be associated with an extrusion of nuclear material; it may initiate degenerative changes in the posterior joints; it may predispose to tears of the posterior spinal ligaments; or it may give rise eventually to all of these lesions, any one of which may produce backache with or without sciatica. The sciatica may be referred pain or may be produced by nerve root pressure. Nerve root pressure in such instances is commonly due to an extrusion of nuclear material, but it may also be due to pressure on the nerve root within the foramen by a "squashed" disc or by a subluxated posterior joint.

Radiographs are of great value in the diagnosis of disc degeneration and they are of greater value in the assessment of the secondary effects that have taken place. With the use of bending films evidence of early degenerative changes may be obtained, tears of the supraspinous ligament can be detected, and abnormal movements of the posterior joints can be seen. Careful study of the antero-posterior and lateral projections will reveal evidence of subluxation of the posterior joints, chip fractures and degenerative arthritis in the zygapophysial articulations, and will clearly demonstrate overriding of the facets.

The investigation of subjective phenomena, such as backache, is fraught with many difficulties and it must be preceded by an investigation of the anatomy of the part and the anatomical variations, the normal and abnormal physiology and the pathological lesions that occur. Many of these changes of course may have no clinical significance, but it is only when armed with the knowledge of what may occur that we can tackle the problem of low back pain on a logical basis.

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F. Campbell Golding