74 Robert H.
Wilkins
and pathological physiology of the nucleus pul-
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1932, n.s. 1~: 897-988.
14. KOCnER, T. Die Verletzungen der Wirbels~ule
zugleich als Beitrag zur Physiologic des mensch-
lichen Rtickenmarks. Mitt. Grenzgeb. Med. Chit.,
1896, 1: 415-480.
15. KRAUSE,F. Surgery of the brain and spinal cord
based on personal experiences. H. A. Haubold and
M. Thorek, Transl. New York: Rebman Co., 1909-
1912, 3 vols. (see 3: pp. 1041-1047).
16. MARKHAM,J . W . Surgery of the spinal cord and
vertebral column. In: A history of neurological sur-
gery. A. E. Walker, Ed. Baltimore: Williams &
Wilkins Co., 1951, xii, 583 pp. (see pp. 364-39~).
17. M A ~ I c , G. Le disque intervert6bral. Physiologic,
pathologie et indications th6rapeutiques. Paris:
Masson & Cie, 1933, 195 pp.
18. METTLER, C. C. History of medicine. A correla-
tive text, arranged according to subjects. F. A.
Mettler, Ed. Philadelphia: Blakiston Co., 1947,
xxix, 1215 pp. (see pp. 493, 813-814).
19. MIDDLETON,G. S., and TEACHER,J.H. Injury of
the spinal cord due to rupture of an intervertebral
disc during muscular effort. Glasgow med. J., 1911,
76: 1-6.
~0. MIXTF~, W. J., and BAR~, J. S. Rupture of the
intervertebral disc with involvement of the spinal
canal. New Engl. J. Med., 1934, 211: 210--o14.
~1. OPPENHEIM,H., and KRAUSE,F. Ueber Einklem-
mung bzw. Strangulation der Cauda equina.
Dtsch. reed. Wschr., 1909, 35: 697-700.
~2. PEET, M. M., and ECHOLS, D. H. Herniation of
the nucleus pulposus. A cause of compression of the
spinal cord. Arch. Neurol. Psychiat., Chicago, 1954,
32: 924-93~.
~3. PETIT-DuTAILHS, D., and ALAJOUANINE,W. Syn-
drome unilat6ral de la queue de cheval, laminec-
tomie exploratrice et ablation d'un fibrome du
disque intervert6bral. Bull. Soc. nat. Chit., 19s
54: 145~.
24. SASnIN, D. Intervertebral disk extensions into
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25. SANDERS, J. B. DEC. M., and INMAN, V.T. The
intervertebral disc. A critical and collective review.
Int. Abstr. Surg., 1939, 69: 14-~9.
26. SCHMORL, [G.] Die pathologische Anatomic der
WirbelsKule. Verb. dtsch, orthop. Ges., 1927, 21:
3-39.
~t7. SCHMORL, G. l~ber Chordareste in den Wirbel-
k~rpern. Zbl. Chit., 19~8, 55: 2805-2310.
28. SCnMORL, [G.] ~ber bisher nur wenig beachtete
Eigentiimlichkeiten ausgewachsener und kindlicher
Wirbel. Arch. klin. Chir., 1928, 150: 4~0-442.
~9. SCnMORL, G. Zur Kenntnis der WirbelkSrper-
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80. SCHMORL, G. Zur pathologischen Anatomie der
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3~. SCrIMORL, G., and JUNOnA~NS, H. Die gesunde
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logisch-anatomische Untersuchungen. Fortschr.
RSntgenstr., 193~, suppl. 43, xi, ~11 pp.
33. SPbn~LING, R. G. Lesions of the lumbar inter-
vertebral disc. With special reference to rupture of
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xi, 148 pp. (see pp. 3-8).
34. SPURLING, R. G. Lesions of the cervical inter-
vertebral disc. Springfield, Ill.: Charles C Thomas,
1956, xi, 134 pp. (see pp. 3-8).
35. STEINKE, C. R. Spinal tumors: statistics on a
series of 330 collected cases. J. nerv. inert. Dis., 1918,
47: 418--4~6.
36. STOOKEY,B. Compression of the spinal cord due
to ventral extradural cervical chondromas. Diagno-
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Chicago, 1928, 20: ~75-290.
37. VrETS, H . R . Domenico Cotugno: his description
of the cerebrospinal fluid, with a translation of part
of his De Ischiade Nervosa Commentarius (1764) and
a bibliography of his important works. Bull. Inst.
Hist. Med., 1935, 3: 701-738.
38. Vmcnow, R. Untersuchungen tiber die Entwicke-
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auf Schadelform, Gesichtsbildung und Gehirnbau.
Berlin: G. Reimer, 1857, 1~8 pp.+6 pl.
39. WALTOn,G. L., and PAUL, W.E. Contribution to
the study of spinal surgery. One successful and one
unsuccessful operation for removal of tumor. Boston
reed. surg. J., 1905, 153: 114-117.
40. WARTENBERG, R. On neurologic terminology,
eponyms and the Las~gue sign. Neurology, 1956, 6:
853-858.
41. WHITE J. C. Obituary. William Jason Mixter,
1880-1958. J. Neurosurg., 1958, 15: 581-584.
4~. WILKINS, W . F . Separation of the vertebrae with
protrusion of hernia between the same. Operation.
Cure. St. Louis med. surg. J., 1888, 54: 340-341.
RUPTURE OF THE INTERVERTEBRAL
DISC WITH INVOLVEMENT
OF THE SPINAL
CANAL*
BY WILLIAMJASONMIXTER, M.D.,~ AND
JOSEPH S. BARn, M.D.~$
UmNG the last few years there has been a
D good deal written and a large a m o u n t of
clinical work done stimulated
Schmorl's 1 investigation of the condition of the
by
intervertebral disc as found at autopsy. His work
* Read at the Annual Meeting of the New England
Surgical Society, September 30, 1933, at Boston.
Mixter, William Jason--Visiting Surgeon, Mas-
sachusetts General Hospital. Barr, Joseph S.--Ortho-
pedic Surgeon to Out-Patients, Massachusetts General
Hospital. For records and addresses of authors see "This
Week's Issue," page ~34.
:~ Reprinted from The New England Journal of
Medicine, 19S4, 211 : ~10-~14, with the kind permission
of the Editor.
 Neurosurgical Classic--XV
will stand as the most complete, painstaking and
authoritative t h a t has ever been done in this
condition. This work, however, is purely patho-
logical and it now remains for the clinician to
correlate it with the clinical findings and apply it
for the relief of those patients who are disabled by
the lesion.
I n the routine examination of spines from au-
topsy material he discovered t h a t the interverte-
bral disc is often involved in pathological changes,
the most common one being prolapse of the nu-
cleus pulposus into an adjacent vertebral body.
H e found one or more such prolapses (Knorpel-
knochen) in about thirty-eight per cent of the
spines examined. H e also discovered t h a t in about
fifteen per cent of the spines there were small
posterior prolapses beneath the posterior longi-
tudinal ligament, but concluded t h a t t h e y rarely,
if ever, produced clinical symptoms. H e attrib-
uted their presence to weakening of the annulus
fibrosus by degenerative changes, with mild
t r a u m a as a second factor, producing fissures in
the annulus and escape of the semifluid nuclear
material.
On the other hand, for a number of years clini-
cians have been reporting cases of spinal cord
pressure from intervertebral disc lesions. I n 1911
Goldthwait ~ reported a case of sciatica and para-
plegia which he attributed to a posterior displace-
ment of the intervertebral disc at the lumbosacral
junction and suggested t h a t such displacements
might be the cause of m a n y cases of lumbago,
sciatica, etc. Middleton and Teacher 3 report a
similar case confirmed at autopsy. Elsberg 4 in
1916 mentions chondroma of the vertebrae as
causing compression of the cauda equina and
states t h a t Oppenheim has described a similar
case. Mixter 5 in 19~1 mentions a similar case and
numerous other reports by Elsberg 6, Stookey 7,
Bucy s, Petit-Dutaillis and Alajouanine 9, and
others have come into the literature. Thus the
enchondroma, chondroma or ecchondroma arising
from the intervertebral disc has become, to the
neurosurgeon at least, a well-recognized lesion to
be treated by excision and with a distinctly favor-
able prognosis. D a n d y 1~ in 19~9 reported two
cases from which he had removed loose cartilagi-
nous fragments protruding extradurally into the
spinal canal. He considered t h e m "undoubtedly
t r a u m a t i c " in origin.
Our interest in this group of cases was stimu-
lated particularly by a case seen by us two years
ago in which the main symptoms were referable to
root pain and in which the tumor was situated in
the intervertebral foramen without cord or cauda
equina compression of any moment.
Investigation of the cases of spinal cord t u m o r
treated at the Massachusetts General Hospital
and in our own private practice has shown a sur-
75
prisingly large number of these lesions, classified
as chondromata, to be in t r u t h not tumors of
cartilage, but prolapses of the nucleus pulposus or
fracture of the annulus. We have a t t e m p t e d to
review these cases and differentiate true neoplasm
and masses caused by rupture of the disc. We find
as a result of this review t h a t nineteen of our
cases are rupture of the disc and six are true carti-
laginous tumor or unclassified.
Clinically these cases of disc rupture, particu-
larly the more recent ones, are of considerable
interest. Diagnosis has been made difficult and
operation has been delayed in t h e m on account of
the indefinite nature of the symptoms and signs
and their similarity to those found in various
conditions such as back strain, arthritis, sacro-
iliac disease, etc.
A summary of all cases of ruptured interverte-
bral disc is shown in table 1. For the purposes of
this article abstracts of two cases will suffice.
CASE 4: On February 6, 1933 a white married chauf-
feur, aged ~8, was admitted to the Massachusetts Gen-
eral Hospital. He gave a history of gradually increasing
stiffness of his legs, noticed chiefly in walking, and of
increasing numbness of the fourth and fifth fingers of
each hand. The onset was insidious about six months
before admission. He had been treated for cerebro-
spinal syphilis for three months.
P. H.: Essentially negative. There was no history of
serious trauma.
P. E.: Showed definite hypesthesia over the ulnar
distribution of each hand and very mild sensory dis-
turbance of the trunk extending downward from the
level of the nipples. There was definite spasticity of the
legs with hyperactive knee and ankle jerks, bilateral
ankle and patellar clonus, bilateral positive Babiuski
sign. Biceps and triceps reflexes were also increased.
Combined cistern and lumbar puncture was done.
There was alteration in the dynamics in the lower
needle indicative of a partial block. The total protein
of the fluid from the cistern was 17, and of the lumbar
fluid 5~. If 40 milligrams be considered the upper limit
of normal, then the lumbar fluid shows definite elevation
in total protein. By injection of ~ cubic centimeters of
iodized oil into the cisternal needle the block was
localized at the level of the intervertebral disc between
the fifth and sixth cervical vertebrae. Note that in the
lateral view (fig. 4) the block is shown, and that the
intervertebral disc is narrowed and there are hyper-
trophic changes present. After some delay the oil
passed the point of obstruction and descended into the
lower end of the dural sac. The patient was then placed
on a fluoroscopic tilt table, head down. Another x-ray
showed that the return of the iodized oil to the cistern
was blocked at exactly the same point as on its descent.
Cervical laminectomy disclosed a spinal cord com-
pression by an extradural encapsulated fibrocarti-
laginous mass 1.5X0.8X0.3 centimeters in size. The
tumor lay in the midline in front of the cord and was
exposed by rotating the cord and incising the anterior
dura. It was easily removed from the underlying inter-
vertebral disc.
 76 Robert H. Wilkins
TABLE 1

CASE AGE LOCATION IIISTORY OF TRAUMA SYMPTOMS SIGNS

NUMBER SEX OF LESION

1 H.L. 37 M C3-C4 Negative. Bllateral paresthesias in ulnar dis- Stiff neck. Hypesthesia to pinprick from
tribution, nipple llne downward and in ulnar distribu-
tion of bands.

W.A. 39 M C4-C6 Negative. Numbness and stiffness in legs. Mild spastic paraplegia. Hypesthesia to
Difficulty in urination and defeca- pinprick in ulnar distribution of both hands
tion. Pain in neck. and from manubrlum downward.
3 R.D. 50 M Ca-C6 Sudden onset while lifting a Numbness and tingling of fingers Spasticity of legs. Increased reflexes. No
weight, and legs. Stiffness of legs. Consti- definite sensory changes.
pation.

4 E.R. ~8 M Ca-C, Negative. Stiffness of legs. Numbness of Spasticity of legs. Increased reflexes. Posi-
fourth and fifth fingers, bilateral. tive Babinskl. Ulnar hypesthesia.

5 M.P. 53 F D*-D5 Negative. Numbness and stiffness of legs. Complete sens3ry and motor paraplegia.
Incontinence.

6 A.N. 63 F D B - D ~ Negative. Painl n legs and around abdomen. Hyperesthesla of legs and abdomen. Spasti-
Inability to walk. city of legs. Increased reflexes.

7 M.M. 4~ M Ds-D9 Negative. Numbness of legs. Increasing dif- Hypesthesia below umbilicus. Spasticity of
ficulty in walking. Back pain. legs. Increased reflexes in legs.

8 A.S. 56 M Du-D= Negative. Pain in back, thighs and legs. Un- Spasticity of legs. Increased reflexes. Hy-
steady gait Numbness of legs. In- pesthesia of feet and buttocks.
continence.

9 E.G. 2~ M I~L3 Sudden onset while lifting a Pain and stiffness in back and Inability to walk. Flaccid paralysis (partial)
weight. legs. Weakness of legs. of both feet. H~pesthesia of both legs over
sciatic distribution.
10 J.D. 37 M L4-L~ Fell fifteen feet at age of seven- Pain in lower back. Numbness Marked motor weakness of legs. Back mo-
teen, landing on feet and but- and weakness of legs. tions markedly limited. Ankle jerks absent.
tocks. In hospital one month. Saddle anesthesia.
11 T.D. 29 M L4-L~ Buried by shell explosion Numbness of perineum. Severe Generalized motor weakness of legs. Saddle
several years before entry. back pain. Incontinence of urine anesthesia. Incontinence.
and feces.

12 L.C. 20 M L4-L5 Severe fall of seventy-five feet Low back-ache. Pain down right Spine listed forward and to left. Lumbar
five years before present ill- posterior thigh and calf. k,vphos. Sensation normal. Reflexes normal.
ness.

13 P.P. 44 M L4-L~ Negative. Pain in lower back. Pain down Sensation normal. Weakness of muscles of
right posterior thigh and calf, both legs, right worse than left. Back mo-
worse on coughing. tions markedly limited. Ankle jerks absent.

14 K.N. 25 M L~-S1 Ski fall one month before pres- Pain in lower back, left posterior Lumbar kyphos, trunk listed forward. All
ent illness. thigh and calf. motions of lower back limited. Left ankle
jerk absent.
15 I.B. 36 F L6-$1 Ether manipulation for Urinary incontinence. Numbness Saddle anesthesia. Sural anesthesia of left
"slipped sacro-iliac." of buttocks. Pain down left pos- foot. Question of positive Babinski, left.
terior thigh. Urinary and rectal incontinence.

16 A.V. 48 M L-S1 Negative. Pain in lower back radiating down Tenderness over whole lower back. Trunk
left leg laterally and posteriorly. listed forward and to the right. Straight
leg raising limited. Sensation and muscula-
ture normal.
17 J.A. 41 M L5-$1 Twisted back by slipping off Midlower back pain radiating Stands with knees fexed, spine stiff and
runnin.g board of car. Immedi- down both posterior thighs. lumbar kyphos. Tenderness at lumbosacral
ate pain. junction. Left ankle jerk absent.

18 B.R. ? F L~-S1 Negative. Low back pain radiating down Sensory disturbance; hypesthesia of left side
left posterior thigh. of vulva, thigh and lateral aspect of foot,
Stiff back. Straight leg raising limited.

19 E.S. 35 F SI-S~ Negative. Paln in buttocks, anus, and vu]va. Saddle anesthesia of perineum and buttocks.
Pain down left thigh posteriorly. Sphincter paralysis. Legs essentially normal.
Incontinence of urine and feces.
 Neurosurgical Classic--XV 77
TABLE 1--Continued

SPINAL~LUID X-RAY EXAMINATION HISTOLOGYOF

OPERATION TISSUE END RESULT
Evidence of Total Local Lipiodol REMOVED
Block Protein Changes
Partial at first ex- 47 None of Block. Cervicallaminectomy. Remov- Annulus fibrosus. Back at work. Much improved.
amination; eont- consequence al of extradural mass from disc
plete at second between C.~and C4.
examination. 8~

Partial. 74 None of Block at Cervical laminectomy. Remov- Annulus fibrosus. Much improved.
consequence. C5. al of extradural mass from disc
between C, and Ca.
Partial? 33 Spur Not done Not done. Died at home. Autopsy showed
formation. tumor arising from disc between
C5-C~, compressing spinal cord
and causmg ascending and de-
scending tract degeneration.
Partial. 52 Narrow disc. Blockat Cervical lamineetomy. Remov- Annulus fibrosus. Much improved.
Spur Cs-C~. al of extradural mass from disc
formation, between C5 and C6.
Partial? 37 Calcification in Not done. Not done. Nucleus Died of pernicious anemia. Au-
disc between pulposus. topsy revealed a small posteri~Jr
D~ and Da. prolapse of the disc between D4
and De, which was degenerated
and contained calcium.
Partial. 67 Hypertrophic Block at Dorsal lam~nectomy. Removal Nucleus Complete motor and sensory
changes. D6-DT. of extradural mass from inter- pulposus. paraplegia. Unrelieved.
Narrow disc. vertebral disc, compressing
spinal cord.
Partial. 114 Nofilms. Notdone. Dorsallaminectomy. Piecemeal Annulusfibrosus Complete paraplegia. Unrelieved.
(Complete?) removal of mass from interver- and nucleus
tcbral disc, compressing spinal pulposus.
cord.
Partial. Increased. No films. Not done. Dorsolumbarlaminectomy.Re- Annulus fibrosus Died seven months after opera-
(Alcohol moval of tumor from disc be- and nucleus tion; cause unknown. Slight post-
and tween Dn and D12.compressing palposus. operative improvement in symp-
ammonium cord. toms.
sulphate
tests.)
Partial? 204 No films. Block at Lumbar laminectomy. Remov- Annulus fibrosus. Improved. Motor and sensory
In-L3. al of extradural mass from inter- changes are slowly disappearing
vertebral disc. pressing on cord.
None. 75 None? Block at Lumbar laminectomy Removal Annulus fibrosus Much improved. Slight residual
I~-L~. of extradural intervertebral disc and nucleus motor and sensory changes.
mass, compressingcauda equina. pulposus.
Complete. 70 ? Block at Lumbar laminectomy. Remov- Nucleus Much improved. Walks with a
L4-L6. al of extradural intervertebral pulposus, cane. Does light work.
disc mass, compressing eauda
equina
Partial? 75 Biconcave L4 Negative. Lumbar laminectomy. Remov- Annulus fibrosus Completely relieved.
and L verte- al of extradural intervertebral and nucleus
bral bodies, disc mass pressing on right L4 pulposus.
root.
None at L~, first 174 Block at Lumbar laminectomy. Free Annulus fibrosus. Relieved.
examination; al- L~-L~. mass found extradurally re-
most complete at moved. Probe could be passed
I~, second into the middle of the disc.
examination.
Partial. 108 None of Not done. Lumbar laminectomy. Extra- Annulus fibrosus. Completely relieved.
consequence. dural mass pressing on left L6
root removed.
Block at Lumbar laminectomy. Remov- Nucleus At first much relieved subjective-
L6-$1. al of mass compressing cauda pulposus, ly and objectively. Pyehtis fol-
equina, arising from the inter- lowed by uremia and death five
vertebral disc. months after operation.
Partial. 67 None of Negative. Laminectomy with removal of Annulus fibrosus Completely relieved.
consequence. pea-sized extradural tumor and nucleus pul-
compressing left L5 root. posus.

None. 83 Narrowing Not done. Laminectomy with removal of Annulus fibrosus Relieved.
of disc. small tumor pressing on eauda and nucleus
"Lumbosaeral equina. Spinal fusion. pulposus.
arthritis."
Partial at first ex- 62 Complete Laminectomy. Removal of ex- Annulus fibrosus? Completely relieved.
amination; com- block at tradural mass compressing left
plete at second Ls-S1. L5 and S1 roots.
examination.
None. 140 None of Negative. Lumbosacral laminectomy. Re- Annulus fibrosus Dead. Wound infection; septi-
consequence. moval of tumor arising between and nucelus eemia; pyemia.
Sl and S~, compressing lowest pulposus.
fibers of cauda equina.
78 Robert H. Wilkins

FIG. 1. A normal intervertebral disc. Note cartilage

plate, anterior and posterior longitudinal ligament,
annulus fibrosus, and the semifluid nucleus pulposus
which bears the superincumbent body weight and is
retained in place under pressure by the annulus.

FIG. 4. Lateral x-ray of cervical spine showing partial

lipiodol block at C 5-6 disc. CASE4. Note the narrowed
disc and early hypertrophic changes.

FIG. 2. Autopsy specimen. CAsE 5. Note small

posterior prolapse such as Schmorl describes.

FIG. 5. Photograph of specimen removed at operation.

CASE 4.

/////

(Fro. 17. Showing the usual location of a ventral

vertebral disc chondroma. [Legend in Surgery, Gyne-
cology and Obstetrics].)
Fro. 3. Illustration taken from article by Elsberg,
showing "chondroma "arising from intervertebral disc.
(Elsberg: S. G. & O.; 46: 19: 1928.)
 Neurosurgical Classic--XV
FIG. 6. A group of specimens taken from cases of this series.
Microscopic examination of the mass showed a
homogeneous matrix containing elastic fibers and occa-
sional cartilage cells. There was no evidence of malig-
nancy.
CASE 14: A twenty-five year old white man was ad-
mitted to the Massachusetts General Hospital June 15,
193~ complaining of pain and stiffness in his left leg of
two years' duration. A few months before the onset the
patient sustained a severe ski fall, but had no immediate
disability. He noticed at first only mild discomfort in
his back and the posterior portion of his left thigh, but
it increased gradually until he was unable to work. The
pain radiated down the posterior thigh, calf and into the
heel. There was a little discomfort in file other leg. He
finally consulted one of us, who treated him with ad-
hesive strapping and corset to support his back, with a
tentative diagnosis of low back strain. He spent several
months in absolute recumbency on a Bradford frame
without relief. On account of lack of improvement it was
decided to institute a complete neurological investiga-
tion.
On admission he presented the clinical picture of a
man suffering from an extremely acute back strain. He
stood with his knees flexed, the trunk listed forward and
to the right. The motions of the lumbar spine were
almost abolished by muscle spasm. Straight leg raising
was limited to ~5~ on the left and 80~ on the right.
Neurological examination was negative except for
absent ankle jerk on the left. There was tenderness along
the course of the sciatic nerve, especially in the sciatic
notch.
Lumbar puncture showed questionable partial block
and a definite elevation in the total protein to 108
milligrams. Lipiodol examination was negative.
On June ~9, 1939 an exploratory laminectomy from
79
the second lumbar to the first sacral inclusive was done.
After prolonged search a mass one centimeter in diame-
ter was found in the intervertebral foramen pressing on
the left fifth lumbar root and displacing the cauda
equina to the right. I t was removed piecemeal from the
intervertebral disc and the wound was closed. Recovery
was complete and uneventful. He had complete relief
from pain immediately after the operation and has re-
mained well since his recovery from the operation.
Pathological examination of the specimen showed it
to be composed almost wholly of dense eosin staining
fibrous connective tissue characteristic of annulus
fibrosus. The original report classified this specimen as
a ebondroma.
T h e s y m p t o m s a n d signs of these so-called
e h o n d r o m a t a , which we believe in m o s t instances
represent r u p t u r e of the i n t e r v e r t e b r a l disc, h a v e
been discussed a t length b y Elsberg a n d Stookey.
T h e s y m p t o m s d e p e n d entirely on t h e location
a n d size of t h e lesion. T h e r e is often a h i s t o r y of
t r a u m a n o t i m m e d i a t e l y related to t h e p r e s e n t
condition. N u m b n e s s a n d tingling, anesthesia,
partial or complete loss of power of locomotion,
are usually present. B l a d d e r a n d rectal sphincters
m a y be involved. T h e condition of t h e reflexes
varies w i t h t h e level of t h e lesion. If it is compress-
ing t h e e a u d a e q u i n a t h e t e n d o n reflexes m a y b e
a b s e n t ; if higher, compressing t h e cord, t h e legs
m a y b e spastic a n d t h e reflexes exaggerated w i t h
positive B a b i n s k i sign. I f t h e lesion is low in t h e
spine, t h e physical e x a m i n a t i o n m a y be suggestive
of low b a c k s t r a i n or saero iliae strain. X - r a y
e x a m i n a t i o n m a y be entirely negative, b u t nar-
80 Robert H. Wilkins
matter. I t frequently comes away without any
dissection and if not, section across its base or
removal with a curette is bloodless. Though we
have done it in only two cases, we believe that it
may be advisable to slip bone chips in between the
stumps of the laminae before closing the wound,
in order to facilitate fusion. Mter removal of the
torn piece of the disc one frequently finds an open-
ing through which a probe or half length may be
passed into the nucleus pulposus. All interesting
point is the appearance of the specimen before and
after removal. The tumor in situ usually has the
appearance of a half a pea with its flat side against
the intervertebral disc, but as soon as it is re-
moved it tends to unroll and can often be flattened
out like a crumpled bit of wet blotting paper or a
rolled up piece of fascia. The true chondromata on
the other hand are rounded or lobulated masses of
almost translucent cartilaginous tissue.
The microscopic picture of these chondromata
FIG. 7. Photomicrograph of specimen from CASE 1~ is quite at variance with that of the normal disc.
showing on the left, nucleus pulposus tissue; on the The chondroma is composed wholly of well-
right, tissue characteristic of normal annulus fibrosus. formed cartilage cells. The extruded portions of
the intervertebral discs on the other hand may
rowing of the intervertebral space is often present have occasional normal cartilage cells, but for the
and is of significance, as it ordinarily means escape most part are made up of the different elements of
of the nucleus pulposus, not necessarily but pos- the annulus flbrosus and nucleus pulposus, such as
sibly into the spinal canal. Lumbar or combined very poorly differentiated atypical cartilaginous
puncture and lipiodol examinations are of real
value. If the mass is large, a partial or complete
block is demonstrable at the level of the lesion.
The spinal fluid rarely contains more than one or
two cells, but the total protein in all of our cases
was elevated moderately.
I t so happens that most of the cases in this
group have been operated on by one of us
(W. J. M.) and not by a large number of surgeons;
therefore we have developed certain ideas as to
the operation when we suspect this lesion to be
present. Exposure of the spine and laminectomy
are performed as usual except that the laminec-
tomy is narrow and on the side where the lesion is
suspected, for we believe that a ruptured disc is a
weakened disc and the strength of the spine
should be preserved as much as possible. The dura
is opened and the spinal canal carefully explored,
particular attention being given to the interverte-
bral discs in front of the cord and the interverte-
bral foramina. If the lesion is found in the midline
it is approached by incising the dura over it as
suggested by Elsberg. If it is lateral, the dura is
closed and the dissection carried out to the side
between the dura and the bone. If a lesion is sus-
pected in the intervertebral foramen it may be
necessary to carry the removal of bone well out to
the side, even taking in part of the pedicle. One FIG. 8. Drawing of tumor in situ. CASF~10. This
must always remember that the tumor may be illustration is taken from Lewis' Surgery (Prior &
very small and extremely difficult to find on ac- Company) in the report of a case of "enchondroma" of
count of its position in the intervertebral foramen. the intervertebral disc (W. J. M). Reexamination shows
Mter the tumor is exposed removal is a simple the specimen to be normal intervertebral disc tissue.
 Neurosurgical Classic--XV
cells scattered irregularly in a very granular and
loose reticulum. T h e compactness of a true chon-
droma is not seen in this group.
We conclude from this study:
T h a t herniation of the nucleus pulposus into
the spinal canal, or as we prefer to call it, rupture
of the intervertebral disc. is a not u n c o m m o n
cause of symptoms.
T h a t this lesion frequently has been mistaken
for cartilaginous neoplasm arising from the inter-
vertebral disc.
T h a t in reality rupture of the disc is more com-
mon t h a n neoplasm; in our series in the ratio of
three to one.
T h a t this lesion should be borne in mind in the
study of certain orthopedic conditions, particu-
larly in those cases which do not respond to appro-
priate treatment.
T h a t a presumptive diagnosis m a y be made in
m a n y instances and t h a t operation whether for
this or for supposed spinal cord t u m o r should
always be planned with the possibility of finding
this lesion.
T h a t the t r e a t m e n t of this disease is surgical
and t h a t the results obtained are very satisfactory
if compression has not been too prolonged.
References
1. SCHMORL, G., and JUNGHANNS, H.: Archly und
Atlas der normalcn und pathologischen Anatomie
in typischen RSntgenbildern. Leipsig: Gcorg
Thieme, 1932.
2. GOLDTHWAIT,J. E.: The lumbo-sacral articulation;
An explanation of many cases of "lumbago,"
"sciatica" and paraplegia. Boston M. & S. J. 164:
365, 1911.
3. MIDDLETON, G. S., and TEACHER, J. H.: Injury of
the spinal cord due to rupture of an intervertebral
81
disk during muscular effort. Glasgow M. J. 76: 189,
1911.
4. ELSBERG. C. A.: Diagnosis and Treatment of
Surgical Diseases of the Spinal Cord and its
Membranes. Philadelphia: W. B. Saunders Co.
P. 288, 1916.
5. CLYMER, G.: MIXTER, W. J. and MELLA, HUGO:
Experience with spinal cord tumors during the past
ten years. Arch. Neurol. & Psychiat. 5: 213, 1921.
6. ELSBERG, C. A.: Extradural spinal tumors--pri-
mary, secondary, metastatic. Surg. Gynec. &
Obst. 46: 1, 1928.
7. STOOKEY,B.: Compression of the spinal cord due to
ventral extradural cervical chondromas. Arch.
Neurol. & Psychiat. 20: 275, 1928.
8. BucY, P. C.: Chondroma of intervertebral disk.
J. A. M. A. 94: 1552, 1930.
9. PETIT-DUTAILLIS, D., and ALAJOUANINE, T.:
Syndrome unilateral de la queue de cheval, lami-
nectome exploratrice et ablation d'un fibrome du
disque intervertebral. Bull. et Mere. Soc. Nat. de
Chir. 54: 1452, 19~8.
10. DANDY,W. E.: Loose cartilage from intervertebral
disk simulating tumor of the spinal cord. Arch.
Surg. 19: 660, 1929.
NOTE: Since the reading of this paper before the New
England Surgical Society in September, 1933 we have
obtained G. Mauric's monograph on the intervertebral
disc published in Paris by Masson et Cie in 1938.
This monograph covers many of the points touched
upon in this communication. It is a most complete and
exhaustive study of the subject and includes a volumi-
nous bibliography.
It is interesting to note that his deductions are drawn
from exhaustive studies and review of the literature
while ours are from a small group of personal cases.
Notwithstanding this difference of attack, our conclu-
sions are in substantial agreement. Anyone interested in
this subject is advised to read this monograph which is
too long and complete to be reviewed here.