Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 82

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189

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The most interesting question in connection with this sub- ject is the mode of production of the olisthesis, and numerous theories have been advanced in the attempt to solve it. Kilian in his original communication considered that the most import- ant etiological factor consisted in an inflammatory softening of the last intervertebral cartilage, as well as of the neigh- boring ligaments and vertebra. At the same time, he ad- mitted the possibility of spondylolisthesis developing as a result of retrogressive changes in the first sacral vertebra. Ritgen in 1854 expressed the belief that the anomaly might result from an œdematous condition of the spinal membranes, which had not led to the production of spina bifida (hydror- rhachis incolumnis).

Robert in 1855 was the first to resort to experiment in the hope of elucidating the etiology of lumbo-sacral spondylolis- thesis, and showed that it never followed mere section of all the ligamentous structures about the lumbo-sacral juncture, but readily occurred after the interarticular portions of the arch of the last lumbar vertebra had been sawed through, and the last intervertebral cartilage severed. From these observa- tions, he concluded that the development of lumbo-sacral spondylolisthesis is usually prevented by the articular proc- esses, and can only occur after their destruction. Or, it might follow luxation of the inferior articular processes of the last lumbar vertebra, or finally be due to a general softening of the ring of the last lumbar vertebra which permitted its articu- lar processes to become so far removed from its body that the latter could glide forward and downward, while its inferior

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articular processes still remained in contact with the superior articular processes of the first sacral vertebra.

The hydrorrhachis theory was generalized by Lambl in 1856 and in 1858. He held that such a condition could give rise to a pseudoarthrosis of the interarticular portion of the last lumbar vertebra, which would lead to the formation of a spondylolysis interarticularis. At the same time, he admitted the possibility of spondylolisthesis lumbo-sacralis developing as the result of luxation of the lumbo-sacral articular proc- esses, or from a fracture of the arch of the last lumbar verte- bra, as well as from the presence of a rudimentary accessory vertebra (Schaltwirbel).

Breslau, in 1861, in describing a new case, designated as caries sicca an inflammatory softening of the bony tissue of the last lumbar and first sacral vertebra, as well as of the last intervertebral cartilage; and stated that the lengthening of the vertebral arch in spondylolisthetic processes could there- fore be secondary in nature. In 1863 Hugenberger attributed a case of traumatic lumbo-sacral spondylolisthesis to forcible luxation or fracture of the articular processes; while Blake in 1867 considered that the development of the olisthesis might be due to excessive stretching of the ligaments at the lumbo-sacral juncture resulting from lipomatosis universalis. Blasius and Ender in 1868 and 1869, respectively, contended that their cases should be attributed to lumbar caries.

The idea that spondylolisthesis lumbo-sacralis might be the result of abnormal stretching of the interarticular portions of the last lumbar vertebra, dependent upon imperfect ossifica- tion, originated with Königstein in 1871, and was based upon experiments similar to those of Robert, to which reference had already been made. At the same time, he admitted the possibility of Lambl's theory, and of the part played by an accessory vertebra. Von Weber-Ebenhof in 1874 described two cases, which he considered followed luxation of the lumbo- sacral articular processes, and contended that this was the general rule. Caries of the lumbo-sacral articular processes was considered by Didier in 1874, and by Herrgott in 1877, as a satisfactory explanation for the development of spondylolis- thesis, and Van der Bosch expressed similar views in 1879.

In 1878 I contended that the cause of the olisthesis in the " kleines Wiener Becken " was to be found in a congenital anomaly of the sacrum, while in the " grosses Wiener Becken " the lesion in continuity in the interarticular portions of the last lumbar vertebra was due to fracture.

In 1882 Strasser believed that his case of lumbo-sacral olisthesis was the result of arthritis deformans of the lumbo- sacral joints, with the consecutive elongation of the arch of the last lumbar vertebra.

In the same year, appeared the highly important mono- graph of Neugebauer, in which he demonstrated that in lumbo- sacral spondylolisthesis only the anterior half of the last lumbar vertebra showed signs of displacement, and that the " dolicho-platy-kyrto-spondylus" which characterized it was the result of imperfect ossification of the interarticular por- tions of the last lumbar vertebra, or was due to their fracture. He accordingly defined spondylolisthesis as a mechanical de-

formity (Belastungs-difformitat) of the last lumbar vertelt developing gradually in extra-uterine life in the presence: certain predisposing conditions, as the result of the actics the body weight. Moreover, in 1852, Neugebauer stated c. the basis of Strasser's case that an originally normal last !: bar vertebra might develop this deformity secondarily, a = result of an olisthesis due to fracture of the superior artie. processes of the first sacral vertebra, should the former arrested by the posterior margin of the first sacral vero. and acquire an abnormal chronic inflammatory plastic: Under such circumstances, a further olisthesis could dev. only from the anterior half of the last lumbar vertebra.

Neugebauer reiterated similar views in 1883, 1884 & 1885, and laid particular stress upon the frequency of : terarticular spondylolysis, which he gradually came to : tribute more and more to a primary defect in developtur .= In 1884 and 1885 Arbuthnot Lane dissented from Neup- bauer's teaching concerning the great importance of congen:z spondylolysis interarticularis, and contended that spondyA: thesis was merely a manifestation of a deformity of the las lumbar vertebra, due to excessive pressure resulting from :2 continued carrying of heavy burdens by the individual. Tr. he held not only gave rise to the change in form of the very- bra, but also to the lesions in continuity in the interarticole portions.

Kruckenberg in 1885 pointed out that fracture of lumbo-sacral articular processes might also occur secondar .; in the course of an olisthesis; and H. von Meyer in 1877, atx: studying a case of spondylolisthesis of the first sacral vertebra stated that the condition might occur as the result of imperios development of the superior articular processes of the ts sacral vertebra, even without the presence of spondyloiysis i= terarticularis.

Neugebauer described a new spondylolisthetic pelvis in 1852. and demonstrated that it was certainly not attributable : hydrorrhachis, and clearly refuted the attacks of Laml! i that connection. In the following year he also adduced et- clusive evidence of the possibility of a separation in continuit; in the interarticular portion of the last lumbar vertelt: occurring as the result of trauma, and gave a very accur.s .: anatomical description of such a case.

In 1892 I attempted to bring together the various possible etiological factors concerned in the production of spondylolis- thesis, and based my conclusions upon a careful study of the literature, the investigation of a comparatively large persona. material, as well as upon experimental research. My in- vestigations led me to define spondylolisthesis lumbo-sacrali: as a gradual pushing forward of the last lumbar vertebra ove: the base of the sacrum, when the change might involve the vertebra in toto or only in its anterior half.

As a result of my studies, I held that any one of the follow- ing conditions might be considered a priori as etiological factors.

I. In olisthesis of the entire last lumbar vertebra.

1. Developmental anomalies of the lumbo-sacral articu- lar processes.

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2. Destruction by disease of the lumbo-sacral articular processes.

3. Fracture of the lumbo-sacral articular processes.

4. Luxation of the lumbo-sacral articular processes.

In olisthesis of the anterior half of the last lumbar vertebra.

1. Developmental anomalies of the arch of the last lumbar vertebra.

2. Softening or destruction by disease of the arch of the last lumbar vertebra.

3. Fracture of the arch of the last lumbar vertebra.

4. Changes in form resulting from carrying excessive burdens.

t that time I was able to adduce personal cases in support the correctness of several of these hypotheses, more par- larly for I, 1 and 3, and also for II, 1 and 3. As far as others were concerned, I was obliged to state that they had a advanced merely as hypothetical or probable causes he condition ; as for example I, 4, but that their actual occur- ce had not been demonstrated, nor did it appear likely conclusive evidence in their support could be adduced he future. Moreover, I was able to show in another speci- 1 of pronounced spondylolisthesis lumbo-sacralis that it impossible to determine which factors had been concerned ts production, when the synostosis at the displaced iumbo- al juncture was far advanced. Likewise it seemed im- tant to me to point out that, even when the existence of of the causal factors just mentioned could be demon- ted, it was necessary for excessive pressure on the part of body weight to come into play in order for an olisthesis evelop from the predisposing etiological condition.

1892 Neugebauer reviewed the entire literature upon the ect, and considered all cases which had been either clini- : or anatomically described up to that time. As a result, tated that the important etiological factors were spondyl- s, which might be either congenital or the result of fract- arthritis of the lumbo-sacral articular processes, and static mation in the sense of Arbuthnot Lane. In the following he was able to enlarge his previous list by 8 additional cal cases and ? anatomical preparations, and he referred cularly to the highly interesting communication of Ar- hot Lane in 1893, in which was described an attempt to spondylolisthesis, resulting from static deformation, by ring the spinous process and the arch of the fourth lum- ertebra. This case is of particular interest as it repre- the first attempt to treat spondylolisthesis by surgical tres.

ting the following years a number of casuistical publi- s appeared, and I would mention especially the work of ms, who, in 1899, described both anatomically and clini- a well-marked case of spondylolisthesis occurring in a 8 resulting from a spondylolysis interarticularis of trau- origin, and which he stated was the sixth case which en described in America up to that time. Morcover, I like to call attention to the publication of Lawrence in who, after excluding the possibility of a lesion in con-

tinuity in the interarticular portions of the last lumbar verte- bra being the etiological factor in his case, attributed it to imperfect development of the lumbo-sacral articular processes and of the arch of the last lumbar vertebra.

In 1900 Breus and Kclisko published their very thorough and systematic work upon spondylolisthesis, particularly from a pelikological point of view, to which I have already referred. Etiologically they considered that the typical factor in its production was spondylolysis interarticularis.

In 1905, I studied a new case of spondylolisthesis, in a 70-year-old woman, developing from congenital spondylolysis interarticularis of the last lumbar vertebra, and was able to demonstrate the presence of small accessory bones (Schalte- knochen) in the space between the fragments of the left in- terarticular portion, just as I had repeatedly observed in simple congenital spondylolysis interarticularis without olis- thesis. In 1901 Schwarte resuscitated the teachings of W. A. Freund, and contended that spondylolisthesis developing from congenital spondylolysis interarticularis was frequently due to the fact that the foetal form of the pelvis had persisted, and consequently that the deformity was frequently of peliko- genous origin.

As the result of the many investigations concerning the etiology and pathogenesis of lumbo-sacral spondylolisthesis, I consider that it has been shown beyond peradventure that the etiological factor most frequently concerned is congenital spondylolysis articularis of the last lumbar vertebra. It has also been satisfactorily demonstrated that fracture of the in- terarticular portions of the last lumbar vertebra may some- time play a causal part, while occasionally, an unusually scanty development or fracture of the lumbo-sacral articular processes, as well as their involvement by arthritis, may be the predisposing cause.

When the lesion in continuity is limited to the interarticular portion of the last lumbar vertebra, only its anterior half glides forward, whereas the entire vertebra undergoes dis- placement in the other conditions. Moreover, when the verte- bra becomes arrested in a certain location, the possibility must be considered that it may increase in length secondarily, in which event its body may later move further and further forward ; just as we must admit that the flattening and length- ening of the interarticular portions of the last lumbar vertebra may be due to the action of undue pressure, as advocated by Arbuthnot Lane; but, personally, I consider it improbable that a marked olisthesis can develop in this manner. Spondylolis- thesis occurring elsewhere than at the lumbo-sacral juncture is so very rare that it need not be considered at this time.

I believe that in the future our knowledge of spondyl- olisthesis will be advanced in great part by the study of pelves in which the anomaly is only slightly developed; as in them the etiological factors concerned can be much more clearly appreciated than in more advanced cases; since in the latter the presence of extensive synostoses may completely mask the underlying anatomical and etiological conditions. Such investigations will gradually place its etiology in a much clearer light, and will enable us to estimate more accurately

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the frequency with which the various factors come into play. They will also have to take into consideration, to a much greater extent than previously, the part played by trauma in the development of spondylolysis, as well as by the mode of life of the individual. Finally, they will teach us whether spondylolisthesis really occurs so much more frequently in females than in males, as seems to be indicated by the statis- tics thus far available.

In order to solve these problems, it will be necessary to search directly and systematically for spondylolisthesis in all pathological anatomical material. At every autopsy, whether upon male or female subjects, the region of the lumbo-sacral juncture should be carefully examined, and, whenever it ap- pears to be more prominent than usual, the pelvis should be removed and subjected to accurate preparation with a view of determining the existence of spondylolisthesis. Moreover, we should study all pelvic preparations, which are preserved in museums, with this point in mind.

In this manner I was enabled to discover three slight cases of spondylolisthesis lumbo-sacralis in my work in Prague prior to 1892, one of them being due to imperfect development of the lumbo-sacral articular processes, while in 1905 I de- scribed a fourth case. In about 4000 autopsies (25 per cent of which were upon children) performed under my supervision during the past four years in Strassburg, I discovered three additional examples of early spondylolisthesis. Etiologically they were quite ordinary, in so far as the causal factor was spondylolysis interarticularis; but on the other hand they were of especial interest in that they all occurred in males.

Up to 1893, out of a total of 115 cases, Neugebauer found only 7 examples of spondylolisthesis in males, an incidence of 6 per cent; Williams, in 1899, only 8 in 123 cases, 6.5 per cent; and, up to the time of this communication I could collect only 9 cases in 144, 6.2 per cent. If, however, I add to them the three cases to which I have just referred, we find 12 male cases in 147, and thus raise the incidence to 8.1 per cent. This being the case, it would appear permissible to predict that even in the male sex spondylolisthesis occurs much more frequently than is generally believed, and there- fore the male pelvis must be examined with particular interest in this regard.

In this connection it is important to note that up to the present time all cases of spondylolisthesis occurring in males were only of slight degree, but whether this is due to the greater strength of the ligamentous structures and the more pronounced development of the musculature in that sex I am not yet prepared to state.

I shall now pass on to the description of my three new cases.

CASE 1 .- Museum specimen 6769 (Figs. 1 and 2). This speci- men was obtained from a 70-year-old, very strongly built, peasant, 167 cm. in height, who died March 7, 1910, from embolism of the pulmonary artery. On removing the viscera from the abdominal cavity at autopsy, a marked protuberance was noted at the lumbo- sacral junction. Accordingly, after counting the normal number of cervical, dorsal and lumbar vertebrae, the pelvis was removed from the body and carefully prepared. On examination it was found that the spinous process of the 24th vertebra projected

about 1 cm. further posteriorly than those of the other lumix; vertebræ, while its body was pushed forward to the same erter beyond the body of the 25th vertebra. A somewhat flattere exostosis 4 to 5 cm. broad extended from the anterior surfs of the body of the 24th vertebra, principally to the left of th middle line, and was firmly united to a similarly formed : ostosis of the superior border of the 25th vertebra by maat of fibrous tissue. Moreover, a lip-like hyperostosis was pres on the adjacent antero-lateral margins of the 24th and #:| vertebræ, while the intervertebral cartilage between them TE markedly reduced in size.

On studying the relations of the 24th to the 25th vertebra : was seen that the body of the former had advanced 1 cm. 2 front of the posterior border of the upper surface of the late and that both interarticular portions of the 24th vertebra pr- sented a symmetrical spondylolysis interarticularis; the ends d the bone being smooth and about 1 cm. distant from one another while the intervening space was filled by ligamentous structure thus accounting for the increased length of the vertebra. T. 25th vertebra presented signs of lumbo-sacral assimilation at? was separated from the 26th by an intervertebral cartilage 8 uz in thickness, while its alæ were only very slightly develope: On the right side, a suture separated the ala of the 25th frez the normally developed ala of the 26th vertebra, while on : left side the two alæ were synostosed together; although a (- pression in the bone indicated their original union. Anterior'? and to the right, between the bodies of the 25th and 26th verte bræ, was a button-shaped exostosis, 4 cm. broad, 2 cm. long 1.5 cm. high, which served to bind the two bones together. spinous process of the 25th vertebra was split into a right ml left half. The 26th vertebra was otherwise normal; as were also the 27th, 28th and 29th vertebræ. The 30th, however, appeared to be entirely assimilated to the sacrum and below it were three well-marked coccygeal vertebræ. Either side of the sacrum pre sented 5 sacral foramina, while the sacral hiatus gaped from the 28th vertebra downward. The sacro-iliac joints were not syt- ostosed, and their anterior margins were lip-like. The inclinatic: of the pelvis appeared somewhat less than normal and its bones were all strongly built and the acetabula were of moderate depth.

The pelvis presented the following measurements: Distante between iliac crests, 27.5; between anterior superior spines, 25.5: and between superior posterior spines, 8.5 cm. Superior strait: Conjugata vera, 10.5 cm .; transverse diameter, 12.5 cm .; right oblique, 12.5 cm .; left oblique, 12 cm .; right and left sacro-cotyloid diameters 8.2 and 7.8 cm., respectively. Plane of greatest pelvic dimensions: Conjugata, 13 cm. (extending to the junction le tween the 27th and 28th vertebræ); transverse diameter, 11 cm. Plane of least pelvic dimensions: Conjugata, 11.5 cm. (extend- ing to the lower end of the 30th vertebra); distance between ischial spines, 9 cm .; distance between tubera ischii, 6.5 cm.

The sacral portion of the innominate bone was 8 cm. on each side (measured with a pelvimeter); the iliac portion was 6.4 cm. on the right and 5.5 cm. on the left side (tape measure). while the pubic portion measured 7.9 cm. on both sides. The sacrum measured 14 cm., from the upper margin of the 25th to the lower margin of the 30th vertebra, and 11.2 cm. in width.

From the study of this case, it appears that we have to do with a pelvis presenting a slight spondylolisthesis of the 24th vertebra resulting from an apparently congenital bilateral interarticular spondylolysis. This was combined with a lumbar assimilation of the 25th vertebra, and it is very interesting to note how this con- dition brought it about that the hypersynostotic processes. re- sulting from the olisthesis, involved not merely the junction be tween the 24th and 25th vertebra, but also that between the 25th and 26th. The development of olisthesis in this case from the spondylolysis interarticularis may be explained by the hard labor which the man was obliged to perform, while further slipping

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FIG. 2.

FIG. 1.

FIG. 4.

FIG. 3.

FIG. 7.

FIG. 5.

FIG. 6.

2 .- Spondylolisthesis lumbo-sacralis e spondylolysi interart. cong. vert. lumb. V. Assimilatio lumbalis vert. sacr. I. 1. 6709. Male 70a.

4 .- Spondylolisthesis lumbo-sacralis e spondylolysi interart. cong. vert. lumb. V. Strassburg. Mus. 6628. Male 55a. nd 7 .- Olisthesis vertebra lumb. IV e spondylolysi interarticulari fracturosa. Strassburg. Mus. 6651. Male 55a.

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FIG. Ia.

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FIG. Ila.

FIG. IIb.

FIG. IIIb.

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FIG. IV.

FIG. Ia, b .- Pero- et Syndactilia ligamentis amniotis effecta. Fœtus, 9 mens. Prag. Mus. 4943. FIG. Ila, b .- Perodactylia ligamentis amniotis effecta. Female 70a. Prag. Mus. 5543. FIG. III .- Ligamenta amniotica. Kind 3 hor. Prag. Mus. 5377.

FIG. IV .- Adhæsio amniotica interplacentam et caput foetus papyracei. Prag. Mus. 5105.

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FIG. VIII.

FIG. V.

FIG. VI.

FIG. VIIa.

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FIG. V .- Schizosoma cum defecta extr. s. d. Fœtus, 38 cm. Prag. Mus. 5610. FIG. VI .- Enkephalokele. Prosoposchisis. Ligamenta amniotica. Strassburg. Mus. 1922.

FIG. VIIa, b .- Schizosoma. Prosoposchisis. Ligamenta amniotica. Involucrum amnioticum thoracis. Prag. Mus. 5490. FIG. VIII .- Perobrachia sin. prob. amnio effecta. Male, 4 mens. Prag. Mus. 2417.

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"was arrested by the development of secondary ex- .t the bodies of the vertebrae.

-Museum preparation 6628 (Figs. 3 and 4). This ound in a 55-year-old laborer whose corpse was drawn Rhine, May 23, 1909. The body was very strongly lumbo-sacral junction was very prominent, particu- : right side, while the normal number of vertebra t in the cervical, dorsal and lumbar regions. On the sacrum presented four foramina and the first rtebra (the 30th), was typically caudal in character. ting the pelvis from behind, it was seen that the ess of the fifth lumbar vertebra projected 1 cm. more than the corresponding processes of the other lumbar he continuity of the interarticular portions of the vertebra was broken on either side, exactly mid- the upper and lower articular processes, and their gins gaped to the extent of 1 cm. The body of the had advanced to the same extent over the upper sur- body of the first sacral vertebra. Following the perostoses had developed upon the anterior and in- n of the body of the fifth lumbar, as well as upon and superior margin of the body of the first sacral he hyperostoses were 1 cm. high on the right side, it lower on the left, and a prolongation of the last I cartilage extended between them. The bodies of sacral vertebra were fused together in the usual

the sacral canal appeared to be closed as far as iddle of the 28th vertebra. The pelvic inclination ghtly diminished, while the bones of the pelvis ap- 'fully developed and free from any sign of injury. surements: Distance between iliac crests 25.7 cm .; erior superior spines 23 cm. and between superior nes 6.5 cm. The superior strait presented the fol- urements: Conjugata vera, 10.2 cm .; transverse 7 cm .; right oblique, 12.2 cm .; left oblique, 12 cm .; otyloid, 7.6 cm., and left sacro cotyloid diameter of greatest pelvic dimensions: Conjugata, 12 cm .; .. 3 cm. Plane of least pelvic dimensions: Conjugata, ance between ischial spines, 10.2 cm. Pelvic outlet: 'een tubera ischii, 11 cm. On either side, the sacral e innominate bone measured 6.7 cm .; the iliac por- nd the pubic portion 7 cm., while the sacrum was th and 11 cm. in width.

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Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 82

Author: Jacob Anthony Kimmell Publication date: 1910 Publisher: Number of Pages: 1189

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189