522 THE THORAX AND VERTEBRAL COLUMN 



Abscesses in connection with the lower thoracic vertebrae 

 may enter the posterior mediastinum and gravitate downwards 

 behind the medial lumbo-costal arch (internal arcuate ligament, 

 p. 272). They subsequently descend under the fascial covering 

 of the psoas major (p. 271). 



When the disease commences in the lumbar region, 

 referred pain may be experienced in the back, in the lowest 

 part of the anterior abdominal wall, in the anterior, medial, or 

 lateral apects of the thigh, or in the medial aspect of the leg 

 (Figs. 118 and 124). Deep hyperalgesia may be found in any of 

 these areas and muscular spasm may also be present. 



Abscesses arising in connection with the lumbar vertebrae 

 may spread laterally and point in the loin (Fig. 83) ; or, they 

 may descend behind the fascial covering of the psoas major and 

 follow the femoral nerve into the thigh ; or, they may follow 

 the glut eal or sciatic nerves and enter the buttock (see also p. 415). 



Paraplegia may come on at any stage of tuberculous disease 

 of the vertebral column, but it occurs most frequently when 

 the upper thoracic region is involved. It is not as a rule due to 

 bony pressure, for, although the angular curvature may be so 

 marked that the spinal medulla is actually compressed, this 

 condition arises so gradually that it does not lead to paralysis. 

 Paraplegia is usually caused by a backward spread of the 

 disease into the vertebral canal. Tuberculous pachymeningitis, 

 or an abscess, or a sequestrum may compress the spinal medulla 

 and give rise to paralysis of the lower limbs. The signs of this 

 condition are outlined on p. 529. 



Examination of the Vertebral Column. In suspected 

 cases of tuberculous disease, the examination of the vertebral 

 column must be carried out systematically by means of both 

 active and passive movements. The active movements of 

 flexion, extension, rotation, and lateral flexion are first examined 

 and any limitation is observed. The patient is then placed face 

 downwards on the table and passive movements are carried out 

 by acting on the vertebral column through the lower limbs and 

 pelvis. A positive diagnosis depends, to a large extent, on the 

 discovery of abnormal rigidity due to muscular spasm. At an 

 early stage no local pain can be elicited by pressure over the 

 spines, as the disease originates in the anterior part of the 

 vertebral bodies. The sensitiveness to deep pressure should 

 always be tested, as areas of muscular hyperalgesia are frequently 

 present in the muscles supplied by the segment involved. 



