Email mini-course; and, Back to 1911
Thanks for reading the 28th edition of my sciatica newsletter. This newsletter tracks my research as I write a book about lumbar radicular pain!
Free email mini-course
I recently asked on twitter what people would prefer I talk about at the upcoming Therapy Live conference: a big overview of sciatica, or a focused sub-topic. To my surprise, most people (well, only just most people) wanted to hear a big sciatica overview.
I was surprised because I feel like I’ve given a lot of ‘big sciatica overview’ talks, but of course it only seems like it from my point of view because, er, I’m the one giving them. There’s still a lot of demand out there for basic information about radicular pain!
I had the idea to make a free email mini-course so that anyone who wants to can ‘get up to speed’. It’s aimed at people who are fairly new to radicular pain; I’m imagining students or clinicians in their first year or two of MSK practice. Although, of course, anyone is welcome to sign up and see what they get from it!
There’s an email every three days and most take less than five minutes to read. The idea is that they are bitesize and digestable!
If you like, ⚡ you can sign up to the course here⚡
Please do share it with anyone you think would benefit.
A bit of history: back to 1911!
This week I’ve been writing another piece for In Touch Magazine (see my first one, from almost two years ago now, here).
It’s about the history of our understanding of disc herniations. You might know about the famous 1934 paper by Mixter and Barr which proved that disc herniations, and not, as was previously thought, cartilagenous tumours, are the most common cause of lumbar radicular pain.
But you might not have heard of a pair of equally interesting papers from 1911, one in the Glasgow Medical Journal by George Middleton and John Teacher, the other in The Boston Medical and Surgical Journal by Joel Goldthwait. These papers were important as they were the first time (in the English-speaking world, at least) that physicians began to guess that radicular pain could be caused by a disc herniation.
I’ll tell the story of those two papers now…
Remember, in 1911 physicians did know that radicular pain has something to do with the spine, and surgeons even performed laminectomies to remove disc herniations - but they didn’t know they were disc herniations! They thought they were removing cartilagenous tumours…
Let’s start with Middleton and Teacher. They described the case of a workman who, on lifting a heavy plate from the floor to a bench, felt a "crack" in the small of his back. That evening, the man felt "a sudden, agonising pain" in his legs, "with peculiar sensations as if the limbs were ‘sleeping’". Soon after, the man
"found he could not move either limb […] His bladder and bowels now became paralysed […] Two days later he was sent up to the surgical wards as a case of intestinal obstruction. His bowels moved in the ambulance van without his knowledge".
Since nobody at the time knew much about cauda equina syndrome or what causes it, the poor workman, whose name we do not know, was left in a hospital bed untreated. He developed bedsores, which became infected, and he died.
In the post-mortem examination, Middleton and Teacher found that a segment of the man's spinal cord had been compressed by "an irregular, roughly circular flat mass of firm white tissue, which looked rather like the pulp in the centre of the intervertebral discs". They performed further experiments to confirm that such an injury could be caused by bending and lifting, as the man had been doing when he felt a "crack" in his back. Middleton and Teacher concluded by guessing that this new kind of disc injury might explain a lot:
That same year, Goldthwait also noticed that radiculopathy could be caused by a herniated intervertebral disc. Goldthwait described the case of a man who, on lifting a heavy suitcase, felt a pain in his back. The next morning the man took a bath and, "on trying to get out of the tub, in leaning forward and straining to get up, something slipped in his back". The man developed a lateral shift and pain down both legs.
Goldthwait was sure the man had displaced his sacro-ilial joint, but a manipulation did nothing to relieve his symptoms. So the physician directed that a plaster of Paris jacket be applied to keep the patient's spine fixed.
As he was being moved in bed for the application of the jacket, the man "felt an intense pain followed by a quick relaxation". For a happy moment, Goldthwait thought the man’s sacro-iliac joint had been relocated and the story was over. But then, "gas escaped from the bowel, there being a complete paralysis of the rectal and bladder sphincters, as well as complete sensory and moror paralysis of the legs". Ah.
They turned the man on to his left side, and
"in a few moments power and sensation began to return in the legs so that within two hours the use was normal, and for the sensory disturbance there was left only a slight numbness in the dorsum of the right foot."
But, that night, as he was sleeping, the man rolled twice onto his back and exacerbated his radiculopathy again. All down his legs he felt "much pain of an explosive or lancinating character".
After six weeks of little improvement, the man underwent an exploratory spinal operation but nothing was found to explain his condition. Soon after, he started to improve and made a reasonable recovery.
Goldthwait pondered the case. The problem had clearly been in the spine. Perhaps because he was used to diagnosing and manipulating 'slipped' sacro-iliac joints, Goldthwait assumed that a joint in the man's spine must also have slipped. He thought perhaps the culprit was the facet joint, causing a kind of one-sided spondylolysthesis.
As a consequence, the disc too would seperate from the bone which, Golthwait summised, would allow the high-pressure nucleus to escape outward "and project beyond the edge of the vertebra [...] the result must be that the detached portion of the disk is crowded backward and must narrow the spinal canal".
Although the observations of Middleton and Teacher and Goldthwait were astute and their conclusions ~approximately~ correct, such isolated case studies proved little about sciatica or disc herniations generally. It would be another couple of decades until Mixter and Barr found that disc herniations are much more common than anyone had realised…
I’ll let you know when the full article is out!
That’s it for this edition! I hope you found something to suit your level of interest - whether it’s the beginners’ course or the advanced level history lesson!
Til next time,
Tom