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Treatment of the patient with spinal cord injury
TREATMENT OF THE PATIENT SPINAL CORD INJURY JOHN
RAAF,
M.D.
Associate Clinical Professor of Surgery, University PORTLAND,
T
WITH
of Oregon Medica
School
OREGON
HAT injury to neuraI structures within the spina canal may resuIt in one of the greatest of human caIamaties is incontrovertibIe. Methods to obtain the maximum restoration of Iost functions are, however, subjects of much dispute. What to do about the numerous disabling effects of such an injury constitutes the subject of this paper. The opinions expressed are the resuIt of persona1 observations upon sixty-three patients with traumatic injury to the intraspina1 neura1 structures seen during the last seven years. Two of these patients gave clinica evidence of injury to cervical nerve roots onIy. NeuroIogicaI examinations reveaIed signs which indicated damage to the spina cord or cauda equina in a11 others. On the basis of time eIapsed from injury to examination by me, the sixty-three cases couId be separated into two groups. There were thirty-three acute conditions of the spina cord. The earIiest any of the patients in the acute series was examined foIIowing injury was one hour while thirteen days was the greatest Iength of time which eIapsed between injury and examination. Thirty cases were cIassified as chronic; the time interva1 from injury to examination ranged from one month to fifteen years. This Iatter group of cases is incIuded in the study, for even though the initia1 treatment was not under my supervision I had the opportunity of evaIuating the treatment which had been carried out by others during the acute stages. I performed Iaminectomy for decompression of the cord upon nine patients cIassified as acute and upon two cIassified as chronic. In addition, seven others in the chronic group had been operated upon by other surgeons before I saw them. Initial Treatment and Examination. CarefuI handIing of the patient with spina cord injury to prevent further damage to the cord is obvious. It has been suggested9 that patients with cervica1 spina cord injuries be transported in the face-down position, the argument being that this position forces the patient to keep his neck in III 1911
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hyperextension and faciIitates drainage of vomitus and secretions from the throat. If the patient is pIaced in this position, great care shouId be empIoyed to prevent turning of the head to the side.
FIG. I. Schrieber’s pneumatic coIIar for stabilization of the cervical spine (from Schreiber).
Better stiI1 in cases of cervica1 spine injury is the appIication at the scene of the accident of Schreiber’s pneumatic coIIar. (Fig. I.) This ingenious device can be deflated when not in use and, therefore, requires IittIe storage space. When inflated and appIied it hoIds the neck rigidIy in hyperextension, thus preventing motion and further damage to the cervica1 cord. As soon as possibIe after genera1 shock has been controIIed a neuroIogica1 examination shouId be done. A neuroIogica1 examination performed earIy is important since any change in neuroIogica1 signs may infIuence one’s decision regarding operation. DetaiIs of the symptomatoIogy produced by Iesions at various Ievels wiI1 not be presented since this paper deaIs principaIIy with methods of treatment. In case there is associated bone damage, the site of injury can usuaIIy be determined by discoloration, sweIIUI331)
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ing, acute tenderness, and many times deformity over the point of fracture. When the patient’s condition permits, roentgenograms of the spine shouId be taken, keeping in mind that severe cord damage may occur even though roentgenographic evidence of bony abnormaIity is absent. A spina puncture is done to determine whether there is blood in the spina ffuid and whether bIock in the cerebrospina1 ffuid pathway is present. The amount of bIood and degree of bIock are not necessariIy proportiona to the degree of loss of neuroIogica1 function. CompIete and permanent interruption of nerve impuIses fromIeveIs above the site of injury have been seen with no blood in the spina fIuid and no bIock. One must be on guard for hysterica paraIysis. One patient whom I frequentIy see has had no Iess than five hospita1 admissions with apparent paralysis of the Iegs and compIete Ioss of sensation from the iIiac crests down foIlowing minor faIIs. A few days rest aIways resuIts in compIete restoration of function and return to work. Norma1 reflexes, Iack of disturbance of bIadder function, and a tight anaI sphincter usuaIIy point to the true nature of the condition. Laminectomy for Decompression of the Spinal Cord or Cauda Equina. Sh oc k combated and examinations compIeted, the surgeon is faced with a most diffIcuIt question, nameIy, whether to decompress the damaged area of the spina cord. Some surgeons answer the question easiIy by operating upon none. Some assume the “nothing to Iose” attitude and advise operation on aI1. Others operate if there is a cerebrospina1 Auid block and refrain from operation if there is no bIock. It has never seemed to me that the question can be answered as easiIy as that. I beIieve that Iaminectomy for decompression of the spina cord is indicated under the foIIowing conditions : (I) Presence of neuroIogica1 signs indicating that the cord Iesion is progressing; (2) incompIete cord Iesion with evidence of pressure on the cord as indicated by roentgenogram or spinal Auid block; (3) d emonstration that the spina fluid pathway which was open foIIowing injury is becoming bIocked. The above criteria have, in my opinion, been Iisted in the order of their importance. Few wiI1 argue against operation when the first situation is present. In the face of progressive neurological signs certainly the spina cord shouId be expIored. The second criteria is appIicabIe to injuries in the dorsa1 and Iumbar areas but not appIicabIe to a cervica1 spine injury. UsuaIIy pressure upon the cervica1 cord can better be reIieved by traction with the CrutchfieId 1(12IR
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tongs than by operation. I agree with Munro and Wegner’o in their statement that patients with cervica1 cord injury shouId not be operated upon in the first few days after the accident. By the appIication of traction rather than resorting to surgery Munro and Wegner have been abIe to reduce their mortaIity for this type of injury by 30 per cent. If there is an incompIete cervica1 cord Iesion and the spina ffuid bIock persists after an adequate tria1 with traction, decompression of the cord is then justifiabIe. I present the third criteria with some doubt in mind. MayfieId and Cazan were convinced “that the resuIt of the Queckenstedt test shouId not inffuence one appreciabIy in seIecting cases for Iaminectomy.” However, I doubt that few surgeons couId resist the temptation to operate when repeated spinal punctures showed a progressive blocking of the spina fluid pathway. That operation under such circumstances may not bring improvement is demonstrated by the foIIowing case : CASE I. Mr. D. A. C., aged twenty-nine, was caught between a car and a truck whiIe riding a motorcycle on October 30, 1943. He sustained a back injury and his Iegs were immediately paralyzed. One hour after injury examination reveaIed a complete loss of motor power and sensation in the Iower extremities and roentgenograms showed a crushing fracture
of the tweIfth dorsa1 vertebra with no apparent bony encroachment on the cana1. SpinaI puncture immediateIy after admission to the hospita1 reveaIed cIear cerebrospina1 fluid with no cerebrospinar ffuid bIock on juguIar compression. Spina puncture was repeated on November 2, 1943, and this time there was no rise of cerebrospinar ffuid pressure on jugular compression. On November 3rd, a third spina puncture again showed a compIete bIock. At operation on November 4th, sIight pressure was found on the anterior side of the cord due to miId anguration of the spine. The cord was shghtly injected but appeared grossly in good condition. A catheter passed up and down the spina cana met no obstruction. Since the cord appeared almost norma it was hoped that function wouId return but seven months have eIapsed since injury and there has been practicaIIy no improvement.
In this case approximateIy thirty-six hours eIapsed between the demonstration of a compIete cerebrospina1 fIuid bIock and operation. Perhaps the operation shouId have been done earlier. The onIy purpose a Iaminectomy can accompIish is to reIieve pressure on the cord. Therefore, when dealing with dorsa1 or Iumbar injuries, the quicker the operation is done the better, provided the patient’s genera1 condition wiI1 permit surgery. UI22ll
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One must exercise great care whiIe performing a Iaminectomy upon a patient with spina cord injury. The foIIowing case iIIustrates the point. This patient fuIf3Ied the requirements of the second indication for Iaminectomy and we, therefore, beheved that she shouId be operated upon. FoIIowing surgery we regretted our decision. CASE II. Miss M. L. J., aged eleven, had a convuIsion on March I I, 1943. FolIowing the convuIsion she deveIoped sIight Ioss of motor power in the lower extremities but there was no complete paraIysis of any muscIe group. Touch and pain sensations were norma throughout the body. The abdomina1 reflexes were absent. The Babinski, Oppenheim, Gordon, and Schaeffer reflexes were biIateraIIy positive. Roentgenograms of the dorsa1 spine reveaIed compression fracture of the seventh dorsa1 vertebra. An attempt was made to improve the aIignment of the vertebrae by manipulation and traction. BIock in the cerebrospina1 fluid pathway persisted and operation was advised. The operation was performed on ApriI 7, 1943, with extreme care Iest the cord be further traumatized. The cord was found riding over an anguIation in the vertebra1 coIumn opposite the body of the seventh dorsal vertebra. There was puIsation above the point of anguIation but none below. When the dura was opened the edges had a sIight tendency to retract IateraIIy. The cord appeared normaI. The dura was easiIy cIosed and a spinal fusion performed. After the patient awakened from the anesthetic suffIcientIy we11 to co-operate, it was discovered that she had a complete Ioss of muscIe power in her lower extremities and a decrease in sensation as high as the eighth or ninth dorsa1 segment. She was taken back to the operating room and the wound reopened. A smaI1 bone chip was resting on the dura covering the cord. This was removed and the wound cIosed. FoIIowing reopening of the wound the condition of the patient’s Iower extremities improved gradually but she never did regain as much motion as she had before surgery. Pressure further
from
the bone
Ioss of function
and
cIosing
the
spina
the
dura
cord
the
chip
but
may
I am
was a more dura
shouId
have
incIined IikeIy not
been
to beIieve cause.
be opened
definite intradura1 hematoma which requires particuIarIy true when the dura is under slight Reduction
of Vertebral Dislocation
responsibIe that
In partia1 unIess
opening Iesions there
evacuation. tension.
and Stabilization
for the
This
of is a is
of the Spine.
Fracture, disIocation, or fracture-disIocation present the additional probIem of reduction, reahgnment, and stabiIization of the vertebrae. The site of fracture wiI1 IargeIy determine the method. If there is bony damage with or without neura1 invoIvement in the cervica1 I[1231
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region, the best method of reduction is by traction with the Crutchfield tongs. One shouId not be content with simpIy reducing the cervical disIocation; once reduction has been obtained the neck must
FIG. 2. Case III. Roentgenogram of the cervical spine taken the day following injury. The arrow points to a smaI1 chip fracture of the inferior articuIar process of the fifth cervica1 vertebra.
FIG. 3. Case III. Roentgenogram of the cervical spine taken two months folIowing injury. There is now a marked forward disIocation of the fifth on the sixth cervica1 vertebra.
be immobiIized for a period of five or six months to prevent Iocation. The foIIowing case history iIIustrates this point:
redis-
CASE III. Mr. J. M., aged seventeen, was in an automobile accident on August g, rgsg, at which time he sustained a head injury and was rendered unconscious. When examined approximately twelve hours folIowing the accident the patient was mentalIy confused. He had a Iarge scaIp laceration and bruises about the head. He moved a11 four extremities. Sensory examination was not possibIe in his confused menta1 state. The right Babinski reffex was positive, the Ieft negative. WhiIe the examiner was paIpating the back of the patient’s neck there was an audibIe pop. SpinaI fluid examination reveaIed a slightly bIoody fluid. The dynamics were normal. Roentgenograms of the cervica1 spine (Fig. 2) showed an exceIIent alignment of the cervica1 vertebrae, the onIy abnormality being
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a smaII chip fracture of the inferior articuIar process of the fifth cervica1 vertebra. During the next few days the patient remained mentally confused and diffIcuIt to handle. When he became mentally cIear, approximately a week foIIowing the a&dent, he complained of sIight numbness of the hands. The numbness subsided and he was dismissed from the hospital three weeks after injury. The patient was next seen on October Ioth, two months folIowing injury, at which time he came to the of&e complaining of stiffness in his neck and inability to retract his head as far as usual. Roentgenograms of the cervical spine showed a marked forward disIocation of the fifth cervica1 vertebra on the sixth. (Fig. 3.) With the redisIocation no new neurologica1 signs had deveIoped. The patient was advised to return to the hospital for appIication of traction but treatment was refused. ObviousIy the patient sustained a fracture-disIocation of the cervical vertebrae at the time of his injury which was accidentaIIy reduced by the examiner. When the roentgenograms taken the day foIIowing injury indicated norma aIignment of the vertebrae, attention was subsequentIy turned entireIy toward the cerebra1 injury. Measures shouId, of course, have been taken to stabiIize the cervica1 spine before he was dismissed from the hospita1. When accompanied by neura1 injury reduction of a fracture in the dorsa1 or Iumbar spine may be accompIished by gradua1 hyperextension. If the injury is in the dorsa1 region, the patient’s position in bed is reversed, that is, his head is pIaced at the foot of the bed and his back is pIaced across the convex surface which is formed when the knee rest is eIevated. GraduaIIy the convexity of the bed can be increased unti1 reduction is accompIished. If the fracture is in the Iumbar area there may not be room enough between the eIevated portion of the bed and the foot of the bed to accommodate the patient’s upper torso, head, and neck. In such a case hyperextension is accompIished by pIacing a bIanket roI1 underneath the mattress to form the convexity of the bed. If articuIar processes are Iocked so that reduction by hyperextension is not possible, an operation with unIocking of the processes as advocated by Barber becomes necessary. Once reduction has been accompIished, a pIaster of Paris jacket to hold the position might seem desirabIe but is definiteIy contraindicated in compIete transverse lesions of the cord or cauda equina because of the danger of bedsores. FoIIowing Iaminectomy for decompression of the cord one must be particuIarIy carefu1 to provide adequate support for the back
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before the patient which
have
fractured
CORD
INJURY
is aIIowed to sit up, for in these cases the Iigaments
been
torn
and
are stiI1 further
ing is an iIIustrative
the articuIar weakened
facets
which
by the Iaminectomy.
may
have
been
The foIIow-
case:
FIG. 4. Case W. Lateral roentgenogram of spine taken before Iaminectomy. There is compression fracture of the twelfth dorsaI vertebra.
FIG. 5. Case IV. Atiteroposterior
genogram of spine taken Iaminectomy.
roentbefore
CASE IV. Mr. W. N. W., aged twenty-eight, injured his back in an paraIyzed from automobiIe accident on May 2, 1943, and was immediately the waist down. Roentgenograms showed a fracture of the body of the twelfth dorsal vertebra. (Figs. 4 and 5.) A Iaminectomy was done. The dura was found to be torn and the spinal cord opposite the tweifth dorsal vertebra compIeteIy destroyed. The patient was kept flat in bed during the six weeks which he remained in the hospita1. Because of his compIete sensory paraIysis from the umbilicus down he was not pIaced in a cast nor was’he provided with any type of metal back brace. He wished to return home and was allowed to do so. He was seen on January 15, 1944, eight and one-half months after injury, when he returned complaining of pain in his back. Roentgenograms (Figs. 6 and 7) reveaIed marked displacement of the eIeventh dorsa1 vertebra on the tweIfth. This three
patient
months.
shouId
have
If roentgenograms
remained then
Aat in bed for approximateIy showed
adequate
bone repair,
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he couId have been provided with some type of back brace and aHowed up. In some of these cases spinal fusion may be desirabIe but I do not beIieve that fusion shouId be done at the time of the
FIG. 6. Case IV. LateraI roentgenogram of spine taken eight and one-haIf months after Iaminectomy. There is marked anterior displacement of the eleventh dorsa1 on the tweIfth.
FIG. 7. Anteroposterior roentgenogram of the spine taken at the same time as one shown in Figure 6.
laminectomy. ShortIy after injury when the Iaminectomy is done the tissues are usuaIIy so hemorrhagic and torn that spina fusion wouId be difficuIt and too time-consuming. General Care of the Patient. Every precaution must be taken to prevent bedsores. In my experience the best type of bed is an air mattress. Bradford frames and boards under the bed not onIy are unnecessary but are actuaIIy to be condemned. The air mattress must be inspected at Ieast twice daiIy to be certain that it is adequateIy inflated. The onIy bedsore I have ever seen deveIop while the patient was on an air mattress resuIted from the mattress being insufficientIy inffated to keep the hip off the hard bed underneath. PiIIows must be pIaced under the caIves of the legs to prevent sores from deveIoping on the ankles and heels. The prevention of footdrop is best accompIished in the foIlowing manner: Shave the Iower legs, put on a pair of women’s siIk or thin cotton stockings as high as
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the knee and appIy a coat of sheIIac, which sticks the stocking to the Ieg. Enough of the toe of the stocking shouId be Ieft projecting beyond the patient’s toes so a cord can be tied about it. The cords
.. FIG. 8. Method of preventing
footdrop.
from the toes of the stockings are attached to a crossbar from which another cord passes up over a puIIey on an overhead frame. (Fig. 8.) Weights at the head of the bed keep the feet in dorsiffexion. The patient shouId be turned in bed every two hours. WhiIe the patient is on his side or abdomen the cords to the toes of the stockings can be reIeased. A cradIe is necessary to prevent bed covers from resting on the toes. The patient’s skin shouId be gentIy massaged every three or four hours and passive exercises given the paraIyzed extremities. In case a reddened area appears on the skin it shouId be painted with tincture of benzoin. Cure of Paralyzed Bladder and Bowel.--The foIIowing methods have been empIoyed in caring for the acute neurogenic bIadder: (I) Non-interference with distention and overfIow, (2) manua1 expression of urine unti1 “automatic” bIadder deveIops, (3) interdrainage through an mittent catheterization, (4) continuous indweIIing catheter directIy into waste bottIe, (5) continuous drainage through indweIIing catheter with cIosed irrigator system or [I281
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tida1 wave apparatus, (6) suprapubic cystotomy, and (7) perinea1 urethrostomy. The method of non-interference with distention and overflow should not be used except for very short periods of time when other facihties are Iacking, for respiratory and cardiac action may be embarrassed and a bladder so overdistended may not regain its tone. I have not used manuaI expression of the urine because adequateIy trained personne1 who can be depended upon to carry out such a maneuver carefuIIy has usuaIIy been Iacking. AIso when this procedure is empIoyed there is a possibiIity of rupturing the bIadder2 and the wet bed which is usuaIIy present makes the occurrence of bedsores IikeIy. Intermittent catheterization is to be condemned because of trauma to the urethra and introduction of infection into the bIadder. Continuous drainage with an indweIIing catheter directIy into a waste bottIe has a11 the disadvantages of the inIying catheter and none of the advantages of the tida1 wave apparatus. As soon as possibIe after the patient’s arriva1 in the hospita1 a tidal wave apparatus is attached to an indweIIing catheter in the bladder. I have usuaIIy used the apparatus as described by Minro8 or as modified by Hesser, even though it is recognized that an indweIIing catheter may produce urethritis, baIanitis, and epididymitis. Another distinct disadvantage of this method is that for a tida1 wave apparatus to function properIy someone who understands its operation must check it frequently. If this type of drainage is to be used, the following suggestions are made: (I) The use of a FoIey catheter so that a11 bands encircling and constricting the penis may be eliminated; (2) a catheter smaII enough to aIIow urethra1 secretions to escape around it; (3) twice daiIy manual irrigation of the bIadder with boric acid to be certain the bIadder is washed out; (4) removal and resteriIization of the whoIe apparatus once a week; (3) the administration of smaI1 doses of urinary antiseptics such as methenamine or mandeIic acid, continuousIy given over a Iong period of time. A method of bIadder drainage which is very satisfactory and deserves more widespread use than it generally has been accorded is suprapubic cystotomy. This method of drainage is very easy to institute through a smaI1 supiapubic incision. The indications for its use are’ (I) oId or very iI patients, (2) marked urinary tract I[1291
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RAAF-SPINAL
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infection, (3) Iack of adequate personne1 which prevents carefu1 checking on tida1 wave apparatuses, (4) inabiIity to toIerate a urethral catheter and (5) transference of patients from one hospita1 to another which requires a period of several days. Hinman in discussing the probIem among soIdiers goes so far as to state that he beIieves a suprapubic cystotomy shouId be done at the outset of acute retention when the injury is severe, provided it wiI1 be days or weeks before the soIdier reaches a pIace where good management wiI1 be given. I have had no experience with perinea1 urethrostomy as advocated by Lewis. It is cIaimed that this method is advantageous because the patient can Iie on his abdomen part of the time and drainage is better than with a suprapubic tube. One wonders whether the disadvantages, nameIy, that the catheter passes through the posterior urethra and that for the average physician the insertion of the catheter wouId be more diffIcuIt than performing suprapubic cystotomy, would not outweigh the advantages. As time goes on the bIadder wiI1 either recover or become a chronic neurogenic bIadder. In the Iatter case, if the cord has been injured above the conus the bIadder wiI1 be governed by a simpIe spina reffex. Stretching of the bIadder waI1 is the stimuIus for bladder contraction and evacuation. The patient can usuaIIy adapt himseIf fai;Iy satisfactoriIy to this type of bIadder activity, but if the contractions are too frequent and the patient disIikes an incontinence bag, he may be more comfortabIe with permanent suprapubic drainage. If the injury is in the region of the conus or cauda equina, the bIadder has no spina reflex activity and high residua1 with dribbIing incontinence may resuIt. With this type of bIadder three. measures are avaiIabIe which may aid evacuation; (I) Evacuation may be accompIished by periodic manual suprapubic pressure with straining. (2) In those patients in whom the interna sphincter is spastic, transurethral resection of the interna sphincter is indicated. (3) FinaIIy, a certain number of patients may require permanent suprapubic drainage. FoIIowing a spina cord injury the patient may have fecal incontinence, but severe constipation is usual. Cathartics should be avoided and an enema given every second day. A recta1 examination should be done at Ieast once a week to check for feca1 impaction. Life for most patients foIIowing Rehabilitation of the Patient. spinal cord injury is extremeIy diffIcuIt and every avaiIabIe measure
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must be taken to make them more comfortabIe. Massage, warm baths, and underwater exercises shouId be administered. In some cases the reflex activity of the spastic Iimbs is such that massage cannot be administered. If the extremities become too spastic, the patient may be more comfortable folIowing intraspina1 section of the motor roots which suppIy the affected muscIes. The orthopedic surgeon may aid greatly by stabiIization of joints, transpIantation or Iengthening of tendons and appIication of braces. Some of these patients present the problem of nerve root pain. Cutting specific sensory roots may bring relief but frequently cordotomy (section of the anteroIatera1 spinothalamic tracts) is preferable. REFERENCES I. BARBER, C. GLENN. Open surgica1 reduction
7.
of fracture disIocation of the lumbar spine with cord or cauda equina involvement. Am. J. Surg., 52: 238-245, 1941. BROWDER, JEFFERSON and GRIMES, RICHARD. Treatment of fractures of the spine with and without neura1 injury. New York State J. Med., 42: 866873, 1942. CRUTCHFIELD, WM. G. Treatment of injuries of cervical spine. J. Bone @ Joint Surg., 36: 696703, 1938. HESSER, FREDERICK, H. Modification of the Munro apparatus for tida1 drainage of the urinary bladder. J. Ural., 47: 283-285, 1942. HINMAN, FRANK. The care of the bladder at the front when paraIyzed by injuries to the spina cord. J. Ural., 46: 4gg-504. rgq.1. LEWIS, LLOYD G. PerineaI urethrostomy for drainage of neurological bladders. Bull. U.S. Army Med. Dept., 36: 46-48, 1943. MAYFIELD, FRANK H. and CAZAN, GEORGE M. SpinaI cord injuries. Am. J. Surg.
8.
MUNRO,
2. 3. 4. 5. 6.
55: 317-326
1942.
DONALD. Tidal drainage and cystometry in the treatment of sepsis associated with spinaI-cord injuries. New England J. Med., 229: 6-14, 1943. g. MUNRO, DONALD. Cervical-cord injuries. New England J. Med., 229: 919-933, 194.3. 10. MUNRO, DONALD and WEGNER, WALTER. The bone Iesions accompanying cervical spinaI-cord injuries. New England J. Med., 222: 167-173, 1940. I I. SCHREIBER, FREDERIC. Persona1 communication. DISCUSSION
HARRY
E.
MOCK
(Chicago, III.): Lacking the opportunity
of reading
Dr. Raaf’s very exceIIent paper beforehand, I am Iimiting my discussion to the expression of certain persona1 opinions derived from the treatment of the average number of cord injuries coming to the hands of the surgeon with a fairIy extensive traumatic service. Back injuries of a11 descriptions are scattered throughout the land. In my experience Iess than 2 per cent of these back injuries give signs of
cord injury. Considering the country as a whole the genera1 physicians and surgeons Iocated in the County seats and the nearby towns see just as many and probabIy more cases of cord injuries than do the neurosurgeons in the great medica
centers.
The picture l[I3I)
presented
by immediate
paraIysis
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from the neck or waist downward in a healthy man or woman who has just sustained an accident is an overwhelming catastrophe. There are problems which must be met immediately by the physician or surgeon first seeing the case if the patient is to survive or is ever to walk again. The essayist has portrayed these steps of management so exceIIentIy that repetition is superfluous. However, there are certain points that are controversial or have not been sufficiently stressed. Otherwise, we would not see so many of these patients going practicaIIy untreated. If the paralysis develops immediately foIlowing the injury and is compIete and corresponds to that segment of the cord adjacent to the fracture or dislocation in the spine, one is justified in assuming that the cord has been injured. The x-ray will show the presence of the fracture or disIocation but it does not revea1 the amount of compression or the extent of compression of the cord by displaced fragments. A spinal puncture with cIear or bloody fluid obtained or with a Queckenstedt test for a block positive wiI1 not show the extent of cord injury. In such cases I believe it is IogicaI to assume that the cord may be crushed or transversely severed or it may be severeIy compressed by a depressed arch or other fractured fragment. If the first situation exists, the case is hopeIess so far as the paraIysis is concerned; but if the second situation only is present, reIief of this bony pressure on the cord may partiaIIy, although seldom compIeteIy, cure the paraIysis. Again, the earIier this mechanical constriction of the cord can be removed, the better chance has the patient to recover from his paralysis. Therefore, the only IogicaI procedure is to do a Iaminectomy, caI1 it an expIoratory Iaminectomy, to see if early relief from cord compression cannot be obtained. The Ionger such compression remains on the cord, the greater the degenerative reaction in the neura1 tissue. In my opinion, this is the view of the majority of genera1 surgeons, famiIiar with major trauma cases, especiaIIy interested in the surgery of trauma. It is not the view held by many neurosurgeons who in recent years have been preaching deIay in Iaminectomy especiaIIy if a spinal block is not demonstrated. If the paralysis develops sIowIy over a period of minutes or hours folIowing a back trauma, it is IogicaI to assume that concussion or contusion of the cord with edema or a hemorrhage is the condition present rather than pressure from a bony fragment. Bear in mind that this deIayed paralysis may be due to some accident folIowing lifting of the patient onto the x-ray tabIe or simiIar movement. Ruling this out, then one is justified in deIaying Iaminectomy; for in the majority of these cases, the edema wiI1 subside, the hemorrhage wiI1 absorb and recovery wiI1 foIIow within a few weeks or months. Every patient with paraIysis, whether subjected to Iaminectomy or not, shouId be pIaced upon an air mattress just as earIy as possibIe. Every II321
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effort must be made to avoid decubitous ulcers. Within the year I have seen a patient completely paralyzed due to a fractured eighth dorsa1 vertebra, encased in a body cast. When the cast was removed three weeks later, large decubitous ulcers were present over the knuckIe of the fracture, the sacrum and both ilia. For the same reason plaster or mechanical splints to the lower extremities to prevent foot drop or faulty positions should be avoided. Muslin hammocks, ropes, pulleys and weights and frequent exercises should be used to contro1 this situation. When an indwelling catheter for tidal drainage or otherwise is used, every precaution must be taken to avoid infection. The catheter should be self-retaining by means of a balloon or a mushroom on the bladder end, rather than retained by dirty adhesive applied about the glans penis. If cystitis develops and recurring attacks of ascending infection occur, c,ystotomy is the safest method of caring for the bladder. Finally, physical therapy started early and persisted in for months and even for two or three years will eventually reward the surgeon and the patient with a certain amount of function in many of these cases. E. P. PALMER (Phoenix, Ariz.): Any patient who has been involved in a serious accident should be treated as though he had an injury of the cord. The unconscious patient cannot tell you that he cannot feel or that he cannot move his extremities, yet he may have a serious involvement of the cord. Therefore, that patient shouId be handled with care, the same as a patient is handled who is known to have an involvement of the cord, transported carefulIy to the hospital and treated as though he had an injury of the cord, until it is proved otherwise. I cannot agree with the theory that these patients must have a delay of weeks or months before they are operated upon. Years ago I carried out a series of experiments on animals and we proved that compression of the cord carried on over six hours resulted in permanent injury. There is no regeneration of spina cord tissue. When it is destroyed it does not regenerate. Therefore, if you are going to have beneficial results after injury to the cord, and an operation is indicated, the operation should be done within the six-hour period. If you wait thirty-six hours, as Dr. Raaf did, or wait three weeks to six months, before operating upon these patients, you are going to have fatal results. JOHN CALDWELL (Cincinnati, Ohio): A few cases follow that illustrate some of the points that have been mentioned: We have observed at the Cincinnati General Hospital a series of six patients who have had spinal injuries with cord lesions, in which the x-rays have been entirely negative; they have shown nothing at all. Four of those patients had complete transverse lesions, yet the x-ray picture was entirely negative, and the picture was taken right awav.
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After death necropsy of these four patients showed there had been a complete transection of the cord by displacement of a vertebra, but in the handIing of the patients bringing them in, there had been immediate reduction. That, to my mind answers fairly concIusiveIy this question of immediate Iaminectomy to reIieve pressure. There is no surgeon who gives quite as prompt reIief as that. These patients are just dragged out from a wrecked automobire or moved about in an ambulance and have a dispIacement of the vertebra, which has been so compIeteIy reduced that the x-ray is entirely negative. Two patients survived, one with almost compIete symptoms. He was emaciated to a shadow; he could not Iift his arms. He wouId stand up and waIk with a shuflling gait if he was heIped to his feet. He couId not feed himseIf. He was in a most pitiabIe condition. That was present three years later. The other patient, a lineman, twenty-nine years ago, feI1 out of a tree and had an incompIete Iesion, probably a traumatic hematomyeIia. He had dissociation of sensation. Some years Iater he made a fairIy compIete recovery and couId get about. In fact, he went back to work as a Iineman, but the disassociation of the sensation persisted to such an extent that three years later he stood in front of a great fire and burned both of his shins without knowing it. His functional recovery, however, was fairIy good. The folIowing is another case iIIustrating a different phase: A young woman struck by a rapidIy moving automobiIe had a crushed chest, a IateraI dislocation of the sixth and seventh dorsal segment, a bad head injury and terrific shock. She was brought in in such shape that there was nothing to do; we could not even take an x-ray nor do a spinal puncture. Upon examination it was found that one leg was compIeteIy out, and within a few hours the other leg’s motion and sensation disappeared. She rapidIy deveIoped bIadder symptoms. On account of her genera1 condition nothing at a11 couId be done for her. The position of the vertebra showed that there was urgent demand for an attempt to reduce the dispIacement, but her condition wouId not permit that. Before the week was out she deveIoped a complete Iobar pneumonia from which she convaIesced. At the end of that time an attempt was made at reduction of her spina deformity, and nothing at a11 was accompIished. We pIanned a Iate laminectomy with her, but before we got started on it she began to improve. The final resuIt was that at the end of three months or so she regained complete bIadder function; she had quite a good gait finaIIy with slight spasticity. Severa years Iater she could dance and do practicaIIy everything she wanted to do, and she finished a university course. If I had done a iI34il
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Iaminectomy on her, I think I would have thought I had accomplished quite a surgical triumph. JOHN RAAF (closing) : My pIea is for the development of some rationaIe for Iaminectomy in these cases. I wish I could develop the attitude that all patients shouId be immediately operated upon because this attitude would take a terrific strain off my judgment. However, I do not believe a11 patients with spina cord injury shouId be indiscriminateIy subjected to surgery. As I stated previously, Munro found that in cervica1 cord injuries conservative treatment netted 30 per cent Iower mortality. In the dorsal and Iumbar regions if there is evidence of an incomplete Iesion of the spina cord, and if a bIock is present, I beIieve operation shouId be carried out.
RAAF,
M.D.
Associate Clinical Professor of Surgery, University PORTLAND,
T
WITH
of Oregon Medica
School
OREGON
HAT injury to neuraI structures within the spina canal may resuIt in one of the greatest of human caIamaties is incontrovertibIe. Methods to obtain the maximum restoration of Iost functions are, however, subjects of much dispute. What to do about the numerous disabling effects of such an injury constitutes the subject of this paper. The opinions expressed are the resuIt of persona1 observations upon sixty-three patients with traumatic injury to the intraspina1 neura1 structures seen during the last seven years. Two of these patients gave clinica evidence of injury to cervical nerve roots onIy. NeuroIogicaI examinations reveaIed signs which indicated damage to the spina cord or cauda equina in a11 others. On the basis of time eIapsed from injury to examination by me, the sixty-three cases couId be separated into two groups. There were thirty-three acute conditions of the spina cord. The earIiest any of the patients in the acute series was examined foIIowing injury was one hour while thirteen days was the greatest Iength of time which eIapsed between injury and examination. Thirty cases were cIassified as chronic; the time interva1 from injury to examination ranged from one month to fifteen years. This Iatter group of cases is incIuded in the study, for even though the initia1 treatment was not under my supervision I had the opportunity of evaIuating the treatment which had been carried out by others during the acute stages. I performed Iaminectomy for decompression of the cord upon nine patients cIassified as acute and upon two cIassified as chronic. In addition, seven others in the chronic group had been operated upon by other surgeons before I saw them. Initial Treatment and Examination. CarefuI handIing of the patient with spina cord injury to prevent further damage to the cord is obvious. It has been suggested9 that patients with cervica1 spina cord injuries be transported in the face-down position, the argument being that this position forces the patient to keep his neck in III 1911
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hyperextension and faciIitates drainage of vomitus and secretions from the throat. If the patient is pIaced in this position, great care shouId be empIoyed to prevent turning of the head to the side.
FIG. I. Schrieber’s pneumatic coIIar for stabilization of the cervical spine (from Schreiber).
Better stiI1 in cases of cervica1 spine injury is the appIication at the scene of the accident of Schreiber’s pneumatic coIIar. (Fig. I.) This ingenious device can be deflated when not in use and, therefore, requires IittIe storage space. When inflated and appIied it hoIds the neck rigidIy in hyperextension, thus preventing motion and further damage to the cervica1 cord. As soon as possibIe after genera1 shock has been controIIed a neuroIogica1 examination shouId be done. A neuroIogica1 examination performed earIy is important since any change in neuroIogica1 signs may infIuence one’s decision regarding operation. DetaiIs of the symptomatoIogy produced by Iesions at various Ievels wiI1 not be presented since this paper deaIs principaIIy with methods of treatment. In case there is associated bone damage, the site of injury can usuaIIy be determined by discoloration, sweIIUI331)
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ing, acute tenderness, and many times deformity over the point of fracture. When the patient’s condition permits, roentgenograms of the spine shouId be taken, keeping in mind that severe cord damage may occur even though roentgenographic evidence of bony abnormaIity is absent. A spina puncture is done to determine whether there is blood in the spina ffuid and whether bIock in the cerebrospina1 ffuid pathway is present. The amount of bIood and degree of bIock are not necessariIy proportiona to the degree of loss of neuroIogica1 function. CompIete and permanent interruption of nerve impuIses fromIeveIs above the site of injury have been seen with no blood in the spina fIuid and no bIock. One must be on guard for hysterica paraIysis. One patient whom I frequentIy see has had no Iess than five hospita1 admissions with apparent paralysis of the Iegs and compIete Ioss of sensation from the iIiac crests down foIlowing minor faIIs. A few days rest aIways resuIts in compIete restoration of function and return to work. Norma1 reflexes, Iack of disturbance of bIadder function, and a tight anaI sphincter usuaIIy point to the true nature of the condition. Laminectomy for Decompression of the Spinal Cord or Cauda Equina. Sh oc k combated and examinations compIeted, the surgeon is faced with a most diffIcuIt question, nameIy, whether to decompress the damaged area of the spina cord. Some surgeons answer the question easiIy by operating upon none. Some assume the “nothing to Iose” attitude and advise operation on aI1. Others operate if there is a cerebrospina1 Auid block and refrain from operation if there is no bIock. It has never seemed to me that the question can be answered as easiIy as that. I beIieve that Iaminectomy for decompression of the spina cord is indicated under the foIIowing conditions : (I) Presence of neuroIogica1 signs indicating that the cord Iesion is progressing; (2) incompIete cord Iesion with evidence of pressure on the cord as indicated by roentgenogram or spinal Auid block; (3) d emonstration that the spina fluid pathway which was open foIIowing injury is becoming bIocked. The above criteria have, in my opinion, been Iisted in the order of their importance. Few wiI1 argue against operation when the first situation is present. In the face of progressive neurological signs certainly the spina cord shouId be expIored. The second criteria is appIicabIe to injuries in the dorsa1 and Iumbar areas but not appIicabIe to a cervica1 spine injury. UsuaIIy pressure upon the cervica1 cord can better be reIieved by traction with the CrutchfieId 1(12IR
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tongs than by operation. I agree with Munro and Wegner’o in their statement that patients with cervica1 cord injury shouId not be operated upon in the first few days after the accident. By the appIication of traction rather than resorting to surgery Munro and Wegner have been abIe to reduce their mortaIity for this type of injury by 30 per cent. If there is an incompIete cervica1 cord Iesion and the spina ffuid bIock persists after an adequate tria1 with traction, decompression of the cord is then justifiabIe. I present the third criteria with some doubt in mind. MayfieId and Cazan were convinced “that the resuIt of the Queckenstedt test shouId not inffuence one appreciabIy in seIecting cases for Iaminectomy.” However, I doubt that few surgeons couId resist the temptation to operate when repeated spinal punctures showed a progressive blocking of the spina fluid pathway. That operation under such circumstances may not bring improvement is demonstrated by the foIIowing case : CASE I. Mr. D. A. C., aged twenty-nine, was caught between a car and a truck whiIe riding a motorcycle on October 30, 1943. He sustained a back injury and his Iegs were immediately paralyzed. One hour after injury examination reveaIed a complete loss of motor power and sensation in the Iower extremities and roentgenograms showed a crushing fracture
of the tweIfth dorsa1 vertebra with no apparent bony encroachment on the cana1. SpinaI puncture immediateIy after admission to the hospita1 reveaIed cIear cerebrospina1 fluid with no cerebrospinar ffuid bIock on juguIar compression. Spina puncture was repeated on November 2, 1943, and this time there was no rise of cerebrospinar ffuid pressure on jugular compression. On November 3rd, a third spina puncture again showed a compIete bIock. At operation on November 4th, sIight pressure was found on the anterior side of the cord due to miId anguration of the spine. The cord was shghtly injected but appeared grossly in good condition. A catheter passed up and down the spina cana met no obstruction. Since the cord appeared almost norma it was hoped that function wouId return but seven months have eIapsed since injury and there has been practicaIIy no improvement.
In this case approximateIy thirty-six hours eIapsed between the demonstration of a compIete cerebrospina1 fIuid bIock and operation. Perhaps the operation shouId have been done earlier. The onIy purpose a Iaminectomy can accompIish is to reIieve pressure on the cord. Therefore, when dealing with dorsa1 or Iumbar injuries, the quicker the operation is done the better, provided the patient’s genera1 condition wiI1 permit surgery. UI22ll
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One must exercise great care whiIe performing a Iaminectomy upon a patient with spina cord injury. The foIIowing case iIIustrates the point. This patient fuIf3Ied the requirements of the second indication for Iaminectomy and we, therefore, beheved that she shouId be operated upon. FoIIowing surgery we regretted our decision. CASE II. Miss M. L. J., aged eleven, had a convuIsion on March I I, 1943. FolIowing the convuIsion she deveIoped sIight Ioss of motor power in the lower extremities but there was no complete paraIysis of any muscIe group. Touch and pain sensations were norma throughout the body. The abdomina1 reflexes were absent. The Babinski, Oppenheim, Gordon, and Schaeffer reflexes were biIateraIIy positive. Roentgenograms of the dorsa1 spine reveaIed compression fracture of the seventh dorsa1 vertebra. An attempt was made to improve the aIignment of the vertebrae by manipulation and traction. BIock in the cerebrospina1 fluid pathway persisted and operation was advised. The operation was performed on ApriI 7, 1943, with extreme care Iest the cord be further traumatized. The cord was found riding over an anguIation in the vertebra1 coIumn opposite the body of the seventh dorsal vertebra. There was puIsation above the point of anguIation but none below. When the dura was opened the edges had a sIight tendency to retract IateraIIy. The cord appeared normaI. The dura was easiIy cIosed and a spinal fusion performed. After the patient awakened from the anesthetic suffIcientIy we11 to co-operate, it was discovered that she had a complete Ioss of muscIe power in her lower extremities and a decrease in sensation as high as the eighth or ninth dorsa1 segment. She was taken back to the operating room and the wound reopened. A smaI1 bone chip was resting on the dura covering the cord. This was removed and the wound cIosed. FoIIowing reopening of the wound the condition of the patient’s Iower extremities improved gradually but she never did regain as much motion as she had before surgery. Pressure further
from
the bone
Ioss of function
and
cIosing
the
spina
the
dura
cord
the
chip
but
may
I am
was a more dura
shouId
have
incIined IikeIy not
been
to beIieve cause.
be opened
definite intradura1 hematoma which requires particuIarIy true when the dura is under slight Reduction
of Vertebral Dislocation
responsibIe that
In partia1 unIess
opening Iesions there
evacuation. tension.
and Stabilization
for the
This
of is a is
of the Spine.
Fracture, disIocation, or fracture-disIocation present the additional probIem of reduction, reahgnment, and stabiIization of the vertebrae. The site of fracture wiI1 IargeIy determine the method. If there is bony damage with or without neura1 invoIvement in the cervica1 I[1231
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CORD INJURY
region, the best method of reduction is by traction with the Crutchfield tongs. One shouId not be content with simpIy reducing the cervical disIocation; once reduction has been obtained the neck must
FIG. 2. Case III. Roentgenogram of the cervical spine taken the day following injury. The arrow points to a smaI1 chip fracture of the inferior articuIar process of the fifth cervica1 vertebra.
FIG. 3. Case III. Roentgenogram of the cervical spine taken two months folIowing injury. There is now a marked forward disIocation of the fifth on the sixth cervica1 vertebra.
be immobiIized for a period of five or six months to prevent Iocation. The foIIowing case history iIIustrates this point:
redis-
CASE III. Mr. J. M., aged seventeen, was in an automobile accident on August g, rgsg, at which time he sustained a head injury and was rendered unconscious. When examined approximately twelve hours folIowing the accident the patient was mentalIy confused. He had a Iarge scaIp laceration and bruises about the head. He moved a11 four extremities. Sensory examination was not possibIe in his confused menta1 state. The right Babinski reffex was positive, the Ieft negative. WhiIe the examiner was paIpating the back of the patient’s neck there was an audibIe pop. SpinaI fluid examination reveaIed a slightly bIoody fluid. The dynamics were normal. Roentgenograms of the cervica1 spine (Fig. 2) showed an exceIIent alignment of the cervica1 vertebrae, the onIy abnormality being
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a smaII chip fracture of the inferior articuIar process of the fifth cervica1 vertebra. During the next few days the patient remained mentally confused and diffIcuIt to handle. When he became mentally cIear, approximately a week foIIowing the a&dent, he complained of sIight numbness of the hands. The numbness subsided and he was dismissed from the hospital three weeks after injury. The patient was next seen on October Ioth, two months folIowing injury, at which time he came to the of&e complaining of stiffness in his neck and inability to retract his head as far as usual. Roentgenograms of the cervical spine showed a marked forward disIocation of the fifth cervica1 vertebra on the sixth. (Fig. 3.) With the redisIocation no new neurologica1 signs had deveIoped. The patient was advised to return to the hospital for appIication of traction but treatment was refused. ObviousIy the patient sustained a fracture-disIocation of the cervical vertebrae at the time of his injury which was accidentaIIy reduced by the examiner. When the roentgenograms taken the day foIIowing injury indicated norma aIignment of the vertebrae, attention was subsequentIy turned entireIy toward the cerebra1 injury. Measures shouId, of course, have been taken to stabiIize the cervica1 spine before he was dismissed from the hospita1. When accompanied by neura1 injury reduction of a fracture in the dorsa1 or Iumbar spine may be accompIished by gradua1 hyperextension. If the injury is in the dorsa1 region, the patient’s position in bed is reversed, that is, his head is pIaced at the foot of the bed and his back is pIaced across the convex surface which is formed when the knee rest is eIevated. GraduaIIy the convexity of the bed can be increased unti1 reduction is accompIished. If the fracture is in the Iumbar area there may not be room enough between the eIevated portion of the bed and the foot of the bed to accommodate the patient’s upper torso, head, and neck. In such a case hyperextension is accompIished by pIacing a bIanket roI1 underneath the mattress to form the convexity of the bed. If articuIar processes are Iocked so that reduction by hyperextension is not possible, an operation with unIocking of the processes as advocated by Barber becomes necessary. Once reduction has been accompIished, a pIaster of Paris jacket to hold the position might seem desirabIe but is definiteIy contraindicated in compIete transverse lesions of the cord or cauda equina because of the danger of bedsores. FoIIowing Iaminectomy for decompression of the cord one must be particuIarIy carefu1 to provide adequate support for the back
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before the patient which
have
fractured
CORD
INJURY
is aIIowed to sit up, for in these cases the Iigaments
been
torn
and
are stiI1 further
ing is an iIIustrative
the articuIar weakened
facets
which
by the Iaminectomy.
may
have
been
The foIIow-
case:
FIG. 4. Case W. Lateral roentgenogram of spine taken before Iaminectomy. There is compression fracture of the twelfth dorsaI vertebra.
FIG. 5. Case IV. Atiteroposterior
genogram of spine taken Iaminectomy.
roentbefore
CASE IV. Mr. W. N. W., aged twenty-eight, injured his back in an paraIyzed from automobiIe accident on May 2, 1943, and was immediately the waist down. Roentgenograms showed a fracture of the body of the twelfth dorsal vertebra. (Figs. 4 and 5.) A Iaminectomy was done. The dura was found to be torn and the spinal cord opposite the tweifth dorsal vertebra compIeteIy destroyed. The patient was kept flat in bed during the six weeks which he remained in the hospita1. Because of his compIete sensory paraIysis from the umbilicus down he was not pIaced in a cast nor was’he provided with any type of metal back brace. He wished to return home and was allowed to do so. He was seen on January 15, 1944, eight and one-half months after injury, when he returned complaining of pain in his back. Roentgenograms (Figs. 6 and 7) reveaIed marked displacement of the eIeventh dorsa1 vertebra on the tweIfth. This three
patient
months.
shouId
have
If roentgenograms
remained then
Aat in bed for approximateIy showed
adequate
bone repair,
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he couId have been provided with some type of back brace and aHowed up. In some of these cases spinal fusion may be desirabIe but I do not beIieve that fusion shouId be done at the time of the
FIG. 6. Case IV. LateraI roentgenogram of spine taken eight and one-haIf months after Iaminectomy. There is marked anterior displacement of the eleventh dorsa1 on the tweIfth.
FIG. 7. Anteroposterior roentgenogram of the spine taken at the same time as one shown in Figure 6.
laminectomy. ShortIy after injury when the Iaminectomy is done the tissues are usuaIIy so hemorrhagic and torn that spina fusion wouId be difficuIt and too time-consuming. General Care of the Patient. Every precaution must be taken to prevent bedsores. In my experience the best type of bed is an air mattress. Bradford frames and boards under the bed not onIy are unnecessary but are actuaIIy to be condemned. The air mattress must be inspected at Ieast twice daiIy to be certain that it is adequateIy inflated. The onIy bedsore I have ever seen deveIop while the patient was on an air mattress resuIted from the mattress being insufficientIy inffated to keep the hip off the hard bed underneath. PiIIows must be pIaced under the caIves of the legs to prevent sores from deveIoping on the ankles and heels. The prevention of footdrop is best accompIished in the foIlowing manner: Shave the Iower legs, put on a pair of women’s siIk or thin cotton stockings as high as
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the knee and appIy a coat of sheIIac, which sticks the stocking to the Ieg. Enough of the toe of the stocking shouId be Ieft projecting beyond the patient’s toes so a cord can be tied about it. The cords
.. FIG. 8. Method of preventing
footdrop.
from the toes of the stockings are attached to a crossbar from which another cord passes up over a puIIey on an overhead frame. (Fig. 8.) Weights at the head of the bed keep the feet in dorsiffexion. The patient shouId be turned in bed every two hours. WhiIe the patient is on his side or abdomen the cords to the toes of the stockings can be reIeased. A cradIe is necessary to prevent bed covers from resting on the toes. The patient’s skin shouId be gentIy massaged every three or four hours and passive exercises given the paraIyzed extremities. In case a reddened area appears on the skin it shouId be painted with tincture of benzoin. Cure of Paralyzed Bladder and Bowel.--The foIIowing methods have been empIoyed in caring for the acute neurogenic bIadder: (I) Non-interference with distention and overfIow, (2) manua1 expression of urine unti1 “automatic” bIadder deveIops, (3) interdrainage through an mittent catheterization, (4) continuous indweIIing catheter directIy into waste bottIe, (5) continuous drainage through indweIIing catheter with cIosed irrigator system or [I281
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tida1 wave apparatus, (6) suprapubic cystotomy, and (7) perinea1 urethrostomy. The method of non-interference with distention and overflow should not be used except for very short periods of time when other facihties are Iacking, for respiratory and cardiac action may be embarrassed and a bladder so overdistended may not regain its tone. I have not used manuaI expression of the urine because adequateIy trained personne1 who can be depended upon to carry out such a maneuver carefuIIy has usuaIIy been Iacking. AIso when this procedure is empIoyed there is a possibiIity of rupturing the bIadder2 and the wet bed which is usuaIIy present makes the occurrence of bedsores IikeIy. Intermittent catheterization is to be condemned because of trauma to the urethra and introduction of infection into the bIadder. Continuous drainage with an indweIIing catheter directIy into a waste bottIe has a11 the disadvantages of the inIying catheter and none of the advantages of the tida1 wave apparatus. As soon as possibIe after the patient’s arriva1 in the hospita1 a tidal wave apparatus is attached to an indweIIing catheter in the bladder. I have usuaIIy used the apparatus as described by Minro8 or as modified by Hesser, even though it is recognized that an indweIIing catheter may produce urethritis, baIanitis, and epididymitis. Another distinct disadvantage of this method is that for a tida1 wave apparatus to function properIy someone who understands its operation must check it frequently. If this type of drainage is to be used, the following suggestions are made: (I) The use of a FoIey catheter so that a11 bands encircling and constricting the penis may be eliminated; (2) a catheter smaII enough to aIIow urethra1 secretions to escape around it; (3) twice daiIy manual irrigation of the bIadder with boric acid to be certain the bIadder is washed out; (4) removal and resteriIization of the whoIe apparatus once a week; (3) the administration of smaI1 doses of urinary antiseptics such as methenamine or mandeIic acid, continuousIy given over a Iong period of time. A method of bIadder drainage which is very satisfactory and deserves more widespread use than it generally has been accorded is suprapubic cystotomy. This method of drainage is very easy to institute through a smaI1 supiapubic incision. The indications for its use are’ (I) oId or very iI patients, (2) marked urinary tract I[1291
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infection, (3) Iack of adequate personne1 which prevents carefu1 checking on tida1 wave apparatuses, (4) inabiIity to toIerate a urethral catheter and (5) transference of patients from one hospita1 to another which requires a period of several days. Hinman in discussing the probIem among soIdiers goes so far as to state that he beIieves a suprapubic cystotomy shouId be done at the outset of acute retention when the injury is severe, provided it wiI1 be days or weeks before the soIdier reaches a pIace where good management wiI1 be given. I have had no experience with perinea1 urethrostomy as advocated by Lewis. It is cIaimed that this method is advantageous because the patient can Iie on his abdomen part of the time and drainage is better than with a suprapubic tube. One wonders whether the disadvantages, nameIy, that the catheter passes through the posterior urethra and that for the average physician the insertion of the catheter wouId be more diffIcuIt than performing suprapubic cystotomy, would not outweigh the advantages. As time goes on the bIadder wiI1 either recover or become a chronic neurogenic bIadder. In the Iatter case, if the cord has been injured above the conus the bIadder wiI1 be governed by a simpIe spina reffex. Stretching of the bIadder waI1 is the stimuIus for bladder contraction and evacuation. The patient can usuaIIy adapt himseIf fai;Iy satisfactoriIy to this type of bIadder activity, but if the contractions are too frequent and the patient disIikes an incontinence bag, he may be more comfortabIe with permanent suprapubic drainage. If the injury is in the region of the conus or cauda equina, the bIadder has no spina reflex activity and high residua1 with dribbIing incontinence may resuIt. With this type of bIadder three. measures are avaiIabIe which may aid evacuation; (I) Evacuation may be accompIished by periodic manual suprapubic pressure with straining. (2) In those patients in whom the interna sphincter is spastic, transurethral resection of the interna sphincter is indicated. (3) FinaIIy, a certain number of patients may require permanent suprapubic drainage. FoIIowing a spina cord injury the patient may have fecal incontinence, but severe constipation is usual. Cathartics should be avoided and an enema given every second day. A recta1 examination should be done at Ieast once a week to check for feca1 impaction. Life for most patients foIIowing Rehabilitation of the Patient. spinal cord injury is extremeIy diffIcuIt and every avaiIabIe measure
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must be taken to make them more comfortabIe. Massage, warm baths, and underwater exercises shouId be administered. In some cases the reflex activity of the spastic Iimbs is such that massage cannot be administered. If the extremities become too spastic, the patient may be more comfortable folIowing intraspina1 section of the motor roots which suppIy the affected muscIes. The orthopedic surgeon may aid greatly by stabiIization of joints, transpIantation or Iengthening of tendons and appIication of braces. Some of these patients present the problem of nerve root pain. Cutting specific sensory roots may bring relief but frequently cordotomy (section of the anteroIatera1 spinothalamic tracts) is preferable. REFERENCES I. BARBER, C. GLENN. Open surgica1 reduction
7.
of fracture disIocation of the lumbar spine with cord or cauda equina involvement. Am. J. Surg., 52: 238-245, 1941. BROWDER, JEFFERSON and GRIMES, RICHARD. Treatment of fractures of the spine with and without neura1 injury. New York State J. Med., 42: 866873, 1942. CRUTCHFIELD, WM. G. Treatment of injuries of cervical spine. J. Bone @ Joint Surg., 36: 696703, 1938. HESSER, FREDERICK, H. Modification of the Munro apparatus for tida1 drainage of the urinary bladder. J. Ural., 47: 283-285, 1942. HINMAN, FRANK. The care of the bladder at the front when paraIyzed by injuries to the spina cord. J. Ural., 46: 4gg-504. rgq.1. LEWIS, LLOYD G. PerineaI urethrostomy for drainage of neurological bladders. Bull. U.S. Army Med. Dept., 36: 46-48, 1943. MAYFIELD, FRANK H. and CAZAN, GEORGE M. SpinaI cord injuries. Am. J. Surg.
8.
MUNRO,
2. 3. 4. 5. 6.
55: 317-326
1942.
DONALD. Tidal drainage and cystometry in the treatment of sepsis associated with spinaI-cord injuries. New England J. Med., 229: 6-14, 1943. g. MUNRO, DONALD. Cervical-cord injuries. New England J. Med., 229: 919-933, 194.3. 10. MUNRO, DONALD and WEGNER, WALTER. The bone Iesions accompanying cervical spinaI-cord injuries. New England J. Med., 222: 167-173, 1940. I I. SCHREIBER, FREDERIC. Persona1 communication. DISCUSSION
HARRY
E.
MOCK
(Chicago, III.): Lacking the opportunity
of reading
Dr. Raaf’s very exceIIent paper beforehand, I am Iimiting my discussion to the expression of certain persona1 opinions derived from the treatment of the average number of cord injuries coming to the hands of the surgeon with a fairIy extensive traumatic service. Back injuries of a11 descriptions are scattered throughout the land. In my experience Iess than 2 per cent of these back injuries give signs of
cord injury. Considering the country as a whole the genera1 physicians and surgeons Iocated in the County seats and the nearby towns see just as many and probabIy more cases of cord injuries than do the neurosurgeons in the great medica
centers.
The picture l[I3I)
presented
by immediate
paraIysis
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from the neck or waist downward in a healthy man or woman who has just sustained an accident is an overwhelming catastrophe. There are problems which must be met immediately by the physician or surgeon first seeing the case if the patient is to survive or is ever to walk again. The essayist has portrayed these steps of management so exceIIentIy that repetition is superfluous. However, there are certain points that are controversial or have not been sufficiently stressed. Otherwise, we would not see so many of these patients going practicaIIy untreated. If the paralysis develops immediately foIlowing the injury and is compIete and corresponds to that segment of the cord adjacent to the fracture or dislocation in the spine, one is justified in assuming that the cord has been injured. The x-ray will show the presence of the fracture or disIocation but it does not revea1 the amount of compression or the extent of compression of the cord by displaced fragments. A spinal puncture with cIear or bloody fluid obtained or with a Queckenstedt test for a block positive wiI1 not show the extent of cord injury. In such cases I believe it is IogicaI to assume that the cord may be crushed or transversely severed or it may be severeIy compressed by a depressed arch or other fractured fragment. If the first situation exists, the case is hopeIess so far as the paraIysis is concerned; but if the second situation only is present, reIief of this bony pressure on the cord may partiaIIy, although seldom compIeteIy, cure the paraIysis. Again, the earIier this mechanical constriction of the cord can be removed, the better chance has the patient to recover from his paralysis. Therefore, the only IogicaI procedure is to do a Iaminectomy, caI1 it an expIoratory Iaminectomy, to see if early relief from cord compression cannot be obtained. The Ionger such compression remains on the cord, the greater the degenerative reaction in the neura1 tissue. In my opinion, this is the view of the majority of genera1 surgeons, famiIiar with major trauma cases, especiaIIy interested in the surgery of trauma. It is not the view held by many neurosurgeons who in recent years have been preaching deIay in Iaminectomy especiaIIy if a spinal block is not demonstrated. If the paralysis develops sIowIy over a period of minutes or hours folIowing a back trauma, it is IogicaI to assume that concussion or contusion of the cord with edema or a hemorrhage is the condition present rather than pressure from a bony fragment. Bear in mind that this deIayed paralysis may be due to some accident folIowing lifting of the patient onto the x-ray tabIe or simiIar movement. Ruling this out, then one is justified in deIaying Iaminectomy; for in the majority of these cases, the edema wiI1 subside, the hemorrhage wiI1 absorb and recovery wiI1 foIIow within a few weeks or months. Every patient with paraIysis, whether subjected to Iaminectomy or not, shouId be pIaced upon an air mattress just as earIy as possibIe. Every II321
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effort must be made to avoid decubitous ulcers. Within the year I have seen a patient completely paralyzed due to a fractured eighth dorsa1 vertebra, encased in a body cast. When the cast was removed three weeks later, large decubitous ulcers were present over the knuckIe of the fracture, the sacrum and both ilia. For the same reason plaster or mechanical splints to the lower extremities to prevent foot drop or faulty positions should be avoided. Muslin hammocks, ropes, pulleys and weights and frequent exercises should be used to contro1 this situation. When an indwelling catheter for tidal drainage or otherwise is used, every precaution must be taken to avoid infection. The catheter should be self-retaining by means of a balloon or a mushroom on the bladder end, rather than retained by dirty adhesive applied about the glans penis. If cystitis develops and recurring attacks of ascending infection occur, c,ystotomy is the safest method of caring for the bladder. Finally, physical therapy started early and persisted in for months and even for two or three years will eventually reward the surgeon and the patient with a certain amount of function in many of these cases. E. P. PALMER (Phoenix, Ariz.): Any patient who has been involved in a serious accident should be treated as though he had an injury of the cord. The unconscious patient cannot tell you that he cannot feel or that he cannot move his extremities, yet he may have a serious involvement of the cord. Therefore, that patient shouId be handled with care, the same as a patient is handled who is known to have an involvement of the cord, transported carefulIy to the hospital and treated as though he had an injury of the cord, until it is proved otherwise. I cannot agree with the theory that these patients must have a delay of weeks or months before they are operated upon. Years ago I carried out a series of experiments on animals and we proved that compression of the cord carried on over six hours resulted in permanent injury. There is no regeneration of spina cord tissue. When it is destroyed it does not regenerate. Therefore, if you are going to have beneficial results after injury to the cord, and an operation is indicated, the operation should be done within the six-hour period. If you wait thirty-six hours, as Dr. Raaf did, or wait three weeks to six months, before operating upon these patients, you are going to have fatal results. JOHN CALDWELL (Cincinnati, Ohio): A few cases follow that illustrate some of the points that have been mentioned: We have observed at the Cincinnati General Hospital a series of six patients who have had spinal injuries with cord lesions, in which the x-rays have been entirely negative; they have shown nothing at all. Four of those patients had complete transverse lesions, yet the x-ray picture was entirely negative, and the picture was taken right awav.
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After death necropsy of these four patients showed there had been a complete transection of the cord by displacement of a vertebra, but in the handIing of the patients bringing them in, there had been immediate reduction. That, to my mind answers fairly concIusiveIy this question of immediate Iaminectomy to reIieve pressure. There is no surgeon who gives quite as prompt reIief as that. These patients are just dragged out from a wrecked automobire or moved about in an ambulance and have a dispIacement of the vertebra, which has been so compIeteIy reduced that the x-ray is entirely negative. Two patients survived, one with almost compIete symptoms. He was emaciated to a shadow; he could not Iift his arms. He wouId stand up and waIk with a shuflling gait if he was heIped to his feet. He couId not feed himseIf. He was in a most pitiabIe condition. That was present three years later. The other patient, a lineman, twenty-nine years ago, feI1 out of a tree and had an incompIete Iesion, probably a traumatic hematomyeIia. He had dissociation of sensation. Some years Iater he made a fairIy compIete recovery and couId get about. In fact, he went back to work as a Iineman, but the disassociation of the sensation persisted to such an extent that three years later he stood in front of a great fire and burned both of his shins without knowing it. His functional recovery, however, was fairIy good. The folIowing is another case iIIustrating a different phase: A young woman struck by a rapidIy moving automobiIe had a crushed chest, a IateraI dislocation of the sixth and seventh dorsal segment, a bad head injury and terrific shock. She was brought in in such shape that there was nothing to do; we could not even take an x-ray nor do a spinal puncture. Upon examination it was found that one leg was compIeteIy out, and within a few hours the other leg’s motion and sensation disappeared. She rapidIy deveIoped bIadder symptoms. On account of her genera1 condition nothing at a11 couId be done for her. The position of the vertebra showed that there was urgent demand for an attempt to reduce the dispIacement, but her condition wouId not permit that. Before the week was out she deveIoped a complete Iobar pneumonia from which she convaIesced. At the end of that time an attempt was made at reduction of her spina deformity, and nothing at a11 was accompIished. We pIanned a Iate laminectomy with her, but before we got started on it she began to improve. The final resuIt was that at the end of three months or so she regained complete bIadder function; she had quite a good gait finaIIy with slight spasticity. Severa years Iater she could dance and do practicaIIy everything she wanted to do, and she finished a university course. If I had done a iI34il
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Iaminectomy on her, I think I would have thought I had accomplished quite a surgical triumph. JOHN RAAF (closing) : My pIea is for the development of some rationaIe for Iaminectomy in these cases. I wish I could develop the attitude that all patients shouId be immediately operated upon because this attitude would take a terrific strain off my judgment. However, I do not believe a11 patients with spina cord injury shouId be indiscriminateIy subjected to surgery. As I stated previously, Munro found that in cervica1 cord injuries conservative treatment netted 30 per cent Iower mortality. In the dorsal and Iumbar regions if there is evidence of an incomplete Iesion of the spina cord, and if a bIock is present, I beIieve operation shouId be carried out.