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Fracture of the fourth lumbar vertebra with paraplegia
FRACTURE
OF THE FOURTH LUMBAR VERTEBRA WITH
PARAPLEGIA
SIDNEY VERNON, M.D. WILLIMANTIC,
T
HE treatment of fracture of the spine by the surgeon is attended with neuroIogica1 considerations. On the basis of symptoms found one must surmise what is occurring in the spina cana and then decide what to do about it. It has been stated that if there is compIete Ioss of nervous function in the extremities after fracture of the spine, Iaminectomy is unnecessary and hopeIess. And yet there is no certainty that irreparabIe injury to the cord is present if complete Iower Iimb paraIysis occurs after such injury. The surgeon is compeIIed to consider whether symptoms are due to Iacerations of the cord or nerves, or pressure by dispIaced bone, or hemorrhage. AIso the aspect changes if injury is beIow the first Iumbar vertebra where the spina cord ends. Temporary pressure on the cord by absorbabIe exudate or edema can cause irrecoverabIe injury to the unsheathed fibers of the cord, whereas regeneration couId occur in the periphera1 nerves composing the cauda equina because they have neuriIemma sheaths from which regeneration of the axon wouId occur. This case is presented because it offered several interesting probIems and the solution of them is suggestive of a certain point in the treatment of injury to the Iumbar spine. CASE
REPORT
Mrs. 0. C., aged twenty-two, entered the W. W. Backus HospitaI September 28, 1931, having jumped from a second story window an hour before admission, Ianding on her feet. Family History: Father, mother, two brothers and three sisters Iiving and weI1, no famiIia1 diseases. Patient married three years, has had 178
CONN.
two children.
Husband died of pernicious anemia one year ago. Past History: Has had chiIdhood diseases, frequent coIds, tonsiIIectomy in chiIdhood, amenorrhea of two months’ duration, “rheumatic pains” in Iegs for three months. Physical examination reveaIs heart and Iungs negative, teeth in poor condition. She was suffering from back pain and compIete paraIysis and Ioss of sensation in the Iower extremities at the time of admission. No reflexes couId be eIicited. Her senses were apparentIy quite cIear. Roentgen ray examination showed compression fracture of the fourth Iumbar vertebra. A bed was prepared for her by putting boards under the mattress. A Bradford frame was put on the bed and three sand bags about 4 inches in diameter and 22 inches Iong, were placed across the frame to form a pyramid. Two piIIows were pIaced over this pyramid making a fairIy considerabIe mound. She was pIaced on the frame so that the lumbar spine rested over the sand bags, causing a marked arching of her back. It aIIowed both the upper and Iower parts of the body to be dependent from the Iumbar spine and thereby cause miId traction by the weight of her body. Twentyfour hours Iater she couId perceive duIIy a pin prick on her Ieg. On the second day after injury she couId move her toes and appreciate sharp sensation from pin prick on her leg. On the third day she could move her feet about and on the fourth move her knees. Knee jerks couId also be ehcited. The patient was kept on the Bradford frame with her back in this highIy arched position for about five weeks. Nursing care was quite simpIe under this arrangement. On November 9 she was placed in a she11 pIaster cast which was appIied to the posterior half of her body with her back in a highIy arched position. On December 2 the question of her amenorrhea was investigated. The uterus was found enIarged 4 cm. above the pubis. There were other
UF’X
SERIkS
\
01..
YYV.
No.
I
Vernon-Fracture
physical signs suggestive of pregnancy and a diagnosis of pregnancy was made. .4 brace was made for the patient with which she was aIIowed to get up on her feet during the later part of January. Numbness of the Iegs and weakness forced her return to bed and this reversa1 of improvement caused us to bIame the enlarging uterus as the offender. Consultation was held in order to determine the advisab&y of allowing pregnancy to continue with compIicating fracture of the spine. Interruption of pregnancy was decided upon but the operation was deIayec1 because of reIigious considerations. Cesarean section was performed on February 22, 1932, as it was feIt that by this date there was as much possibiIity of viabiIity of the child as the condition of the mother allowed waiting for. The patient was deIivered of a
seven months
fetus which IiGed about
five
hours after birth. After operation the patient was pIaced back on the Bradford frame using the same arrangement of sand bags as before to produce marked arching of the back, and was given the usua1 postoperative care. On March IO, 1932, ankIe cIonus and a diminished pateIIar reflex on the Ieft side were noted. She also dragged her Ieft foot on waIking at that time. These symptoms were interpreted as being due to pressure on nerve roots caused by caIIus formation at the site of the fracture. Patient was aIIowed up during the Iast week of March 1932, but pressure of the brace on the abdomina1 wound area caused such discomfort that it prevented her from continuing to wear the brace and forced her finaIIy to bed. Patient was removed to a state institution on ApriI IO. A follow-up Ietter from the superintendent of this institution stated that she “was abIe to walk without a Iimp, could dance and did practicalIy everything which a11 the girIs did there. She did compIain of pains in her back when first admitted but had no compIaints for some time before Ieaving. She was in exceIIent condition when she left on December 24, The state offIcia1 who visited her 1932." periodicaIIy reported that “in June, 1933 she had resumed her former occupation of factory work, was working six days a week and six hours a dav and apparently getting no bad results ph>&aIIy.”
of Vertebra
.4mcrica:i
Juurn;rl
01’Siirgrrr
‘“9
A foIIow-up of roentgen-ray examinations showed on September 28, 1931, a compression fracture of the fourth lumbar vertebra; on moderate absorption in October 13, 1931, fourth lumbar vertebra; on January- 16, 1932, CdUS formation. On 1larch 10, 1932, there was a larger deposit of calcium than noted on
previous examinations. This remarkabIy rapid return of function makes it probable that the nervous pathway had been interrupted by pressure of bone dispIacement which was readiIy corrected by earIy maximum arching of the back. The mechanism of this bony displacement is as foIIows: The crush of the body of the vertebra pushes it out of aIignment with the rest of the vertebra1 column rotating the bone on a horizontal axis so that the upper or lower edge of the posterior side of the vertebra1 body encroaches onto the spina cana pressing on its contents. Maximum early hyperextension causes quick reaIignment of the affected bone with reIief of pressure which is tantamount to safe manipuIation of the deformity. The forcibIe manipulation in hyperextension of Arthur Davis has some disadvantages among which is the need for The method of Rogers deep anesthesia. of Boston requires a specia1 apparatus and is not designed to attain an early correction of deformity. The method used here entails a minimum of equipment and a Iarge degree of safety. CONCLUSION
Complete paralysis and Ioss of sensation was foIIowed by compIete recovery of function without Iaminectomy and it is feIt that maximum earIy hyperextension was the most important therapeutic factor that contributed to this resuIt. This impeIs us to urge that where any period of watchful waiting is instituted before a contempIated Iaminectomy that this measure be generousIy apphed and make the operation unnecessary in some cases.
OF THE FOURTH LUMBAR VERTEBRA WITH
PARAPLEGIA
SIDNEY VERNON, M.D. WILLIMANTIC,
T
HE treatment of fracture of the spine by the surgeon is attended with neuroIogica1 considerations. On the basis of symptoms found one must surmise what is occurring in the spina cana and then decide what to do about it. It has been stated that if there is compIete Ioss of nervous function in the extremities after fracture of the spine, Iaminectomy is unnecessary and hopeIess. And yet there is no certainty that irreparabIe injury to the cord is present if complete Iower Iimb paraIysis occurs after such injury. The surgeon is compeIIed to consider whether symptoms are due to Iacerations of the cord or nerves, or pressure by dispIaced bone, or hemorrhage. AIso the aspect changes if injury is beIow the first Iumbar vertebra where the spina cord ends. Temporary pressure on the cord by absorbabIe exudate or edema can cause irrecoverabIe injury to the unsheathed fibers of the cord, whereas regeneration couId occur in the periphera1 nerves composing the cauda equina because they have neuriIemma sheaths from which regeneration of the axon wouId occur. This case is presented because it offered several interesting probIems and the solution of them is suggestive of a certain point in the treatment of injury to the Iumbar spine. CASE
REPORT
Mrs. 0. C., aged twenty-two, entered the W. W. Backus HospitaI September 28, 1931, having jumped from a second story window an hour before admission, Ianding on her feet. Family History: Father, mother, two brothers and three sisters Iiving and weI1, no famiIia1 diseases. Patient married three years, has had 178
CONN.
two children.
Husband died of pernicious anemia one year ago. Past History: Has had chiIdhood diseases, frequent coIds, tonsiIIectomy in chiIdhood, amenorrhea of two months’ duration, “rheumatic pains” in Iegs for three months. Physical examination reveaIs heart and Iungs negative, teeth in poor condition. She was suffering from back pain and compIete paraIysis and Ioss of sensation in the Iower extremities at the time of admission. No reflexes couId be eIicited. Her senses were apparentIy quite cIear. Roentgen ray examination showed compression fracture of the fourth Iumbar vertebra. A bed was prepared for her by putting boards under the mattress. A Bradford frame was put on the bed and three sand bags about 4 inches in diameter and 22 inches Iong, were placed across the frame to form a pyramid. Two piIIows were pIaced over this pyramid making a fairIy considerabIe mound. She was pIaced on the frame so that the lumbar spine rested over the sand bags, causing a marked arching of her back. It aIIowed both the upper and Iower parts of the body to be dependent from the Iumbar spine and thereby cause miId traction by the weight of her body. Twentyfour hours Iater she couId perceive duIIy a pin prick on her Ieg. On the second day after injury she couId move her toes and appreciate sharp sensation from pin prick on her leg. On the third day she could move her feet about and on the fourth move her knees. Knee jerks couId also be ehcited. The patient was kept on the Bradford frame with her back in this highIy arched position for about five weeks. Nursing care was quite simpIe under this arrangement. On November 9 she was placed in a she11 pIaster cast which was appIied to the posterior half of her body with her back in a highIy arched position. On December 2 the question of her amenorrhea was investigated. The uterus was found enIarged 4 cm. above the pubis. There were other
UF’X
SERIkS
\
01..
YYV.
No.
I
Vernon-Fracture
physical signs suggestive of pregnancy and a diagnosis of pregnancy was made. .4 brace was made for the patient with which she was aIIowed to get up on her feet during the later part of January. Numbness of the Iegs and weakness forced her return to bed and this reversa1 of improvement caused us to bIame the enlarging uterus as the offender. Consultation was held in order to determine the advisab&y of allowing pregnancy to continue with compIicating fracture of the spine. Interruption of pregnancy was decided upon but the operation was deIayec1 because of reIigious considerations. Cesarean section was performed on February 22, 1932, as it was feIt that by this date there was as much possibiIity of viabiIity of the child as the condition of the mother allowed waiting for. The patient was deIivered of a
seven months
fetus which IiGed about
five
hours after birth. After operation the patient was pIaced back on the Bradford frame using the same arrangement of sand bags as before to produce marked arching of the back, and was given the usua1 postoperative care. On March IO, 1932, ankIe cIonus and a diminished pateIIar reflex on the Ieft side were noted. She also dragged her Ieft foot on waIking at that time. These symptoms were interpreted as being due to pressure on nerve roots caused by caIIus formation at the site of the fracture. Patient was aIIowed up during the Iast week of March 1932, but pressure of the brace on the abdomina1 wound area caused such discomfort that it prevented her from continuing to wear the brace and forced her finaIIy to bed. Patient was removed to a state institution on ApriI IO. A follow-up Ietter from the superintendent of this institution stated that she “was abIe to walk without a Iimp, could dance and did practicalIy everything which a11 the girIs did there. She did compIain of pains in her back when first admitted but had no compIaints for some time before Ieaving. She was in exceIIent condition when she left on December 24, The state offIcia1 who visited her 1932." periodicaIIy reported that “in June, 1933 she had resumed her former occupation of factory work, was working six days a week and six hours a dav and apparently getting no bad results ph>&aIIy.”
of Vertebra
.4mcrica:i
Juurn;rl
01’Siirgrrr
‘“9
A foIIow-up of roentgen-ray examinations showed on September 28, 1931, a compression fracture of the fourth lumbar vertebra; on moderate absorption in October 13, 1931, fourth lumbar vertebra; on January- 16, 1932, CdUS formation. On 1larch 10, 1932, there was a larger deposit of calcium than noted on
previous examinations. This remarkabIy rapid return of function makes it probable that the nervous pathway had been interrupted by pressure of bone dispIacement which was readiIy corrected by earIy maximum arching of the back. The mechanism of this bony displacement is as foIIows: The crush of the body of the vertebra pushes it out of aIignment with the rest of the vertebra1 column rotating the bone on a horizontal axis so that the upper or lower edge of the posterior side of the vertebra1 body encroaches onto the spina cana pressing on its contents. Maximum early hyperextension causes quick reaIignment of the affected bone with reIief of pressure which is tantamount to safe manipuIation of the deformity. The forcibIe manipulation in hyperextension of Arthur Davis has some disadvantages among which is the need for The method of Rogers deep anesthesia. of Boston requires a specia1 apparatus and is not designed to attain an early correction of deformity. The method used here entails a minimum of equipment and a Iarge degree of safety. CONCLUSION
Complete paralysis and Ioss of sensation was foIIowed by compIete recovery of function without Iaminectomy and it is feIt that maximum earIy hyperextension was the most important therapeutic factor that contributed to this resuIt. This impeIs us to urge that where any period of watchful waiting is instituted before a contempIated Iaminectomy that this measure be generousIy apphed and make the operation unnecessary in some cases.