Mixter, N Engl J Med 1934 - Rupture of the Intervertebral Disc with Involvement of the Spinal Canal

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Rupture of the Intervertebral Disc with Involvement of the Spinal Canal

Mixter, Barr·N Engl J Med·1934·1,923 citations·Case series

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Mixter and Barr reviewed spinal masses previously labeled cartilaginous tumors of the intervertebral disc. They asked whether these lesions were true neoplasms or ruptures of the disc with herniated nucleus pulposus. The paper correlates the clinical picture of sciatica and cord compression with a mechanical disc lesion treatable by surgery.

Key Findings

Of 25 spinal masses reviewed, 19 were disc ruptures and only 6 were true cartilaginous tumor or unclassified, a 3:1 ratio. Lesions long called chondromata were, in most cases, herniated disc tissue.
Histology of 18 operative specimens confirmed the mechanical origin:
- 7 pure annulus fibrosus
- 4 pure nucleus pulposus
- 7 mixed annulus and nucleus
None showed the well-formed cartilage of a true chondroma.
Lumbar herniations clustered at the lower spine, with 10 of 19 cases at L4-L5 or L5-S1. Every one of these mimicked back strain with sciatic pain, stiff back, and limited straight leg raising.
Elevated CSF total protein with few cells was a key clue, using 40 mg as the upper limit of normal (Case 4 protein 52, Case 14 protein 108). Combined cistern and lumbar puncture localized the block.
A cervical disc at C5-6 produced cord compression with spasticity, clonus, and bilateral Babinski signs, while low lumbar lesions gave absent ankle jerks, showing how level dictates the exam.
Surgical laminectomy with excision gave satisfactory relief when compression was not prolonged, at an operative mortality of about 5% in this early series.

Board PearlMixter and Barr established that disc herniation, not cartilaginous tumor, causes sciatica and cord compression, and that laminectomy relieves it.

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|

Rupture of the Intervertebral Disc with Involvement of the Spinal Canal

Mixter, Barr·N Engl J Med·1934·1,923 citations·Case series

|

Mixter and Barr reviewed spinal masses previously labeled cartilaginous tumors of the intervertebral disc. They asked whether these lesions were true neoplasms or ruptures of the disc with herniated nucleus pulposus. The paper correlates the clinical picture of sciatica and cord compression with a mechanical disc lesion treatable by surgery.

Key Findings

Of 25 spinal masses reviewed, 19 were disc ruptures and only 6 were true cartilaginous tumor or unclassified, a 3:1 ratio. Lesions long called chondromata were, in most cases, herniated disc tissue.
Histology of 18 operative specimens confirmed the mechanical origin:
- 7 pure annulus fibrosus
- 4 pure nucleus pulposus
- 7 mixed annulus and nucleus
None showed the well-formed cartilage of a true chondroma.
Lumbar herniations clustered at the lower spine, with 10 of 19 cases at L4-L5 or L5-S1. Every one of these mimicked back strain with sciatic pain, stiff back, and limited straight leg raising.
Elevated CSF total protein with few cells was a key clue, using 40 mg as the upper limit of normal (Case 4 protein 52, Case 14 protein 108). Combined cistern and lumbar puncture localized the block.
A cervical disc at C5-6 produced cord compression with spasticity, clonus, and bilateral Babinski signs, while low lumbar lesions gave absent ankle jerks, showing how level dictates the exam.
Surgical laminectomy with excision gave satisfactory relief when compression was not prolonged, at an operative mortality of about 5% in this early series.

Board PearlMixter and Barr established that disc herniation, not cartilaginous tumor, causes sciatica and cord compression, and that laminectomy relieves it.

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