Paraplegia associated with hyperextension injury to the cervical spine

Paraplegia associated with hyperextension injury to the cervical spine

Paraplegia Associated with Hyperextension Injury to the Cervical Spine JAMES W . MILLER, M .D . AND LLOYD R . SCHULTZ, M .D ., [r] quotes from the...

873KB Sizes 7 Downloads 79 Views



Paraplegia Associated with Hyperextension Injury to the Cervical Spine JAMES W . MILLER, M .D . AND LLOYD R . SCHULTZ, M .D .,

[r] quotes from the Edwin Smith papyrus, the first recorded reference to cervical spine injuries with associated paraplegia, written some 4,000 years ago . The unknown author states briefly : "One having a crushed vertebra of his neck, he is unconscious of his two arms and two legs, and is speechless . An ailment not to be treated ." This pessimism is not entirely unfounded, for in spite of many notable contributions, including caliper traction, more than half of the patients with paraplegia die and those who survive are left with varying degrees of paralysis . The prognosis, however, is surprisingly good in the Type I hyperextension injury with simple therapy . It is most important in the Type I injury not to extend the cervical spine nor should a more radical approach, such as laminectomy, be performed . The prognosis is particularly poor in the Type ii and Type III hyperextension group in which death from an ascending spinal cord edema within two to ten days is the rule rather than the exception . The purpose of this paper is to report three patients with the three types of hyperextension injury outlined in Table I . Excellent papers [4-8] have been published on the subject in recent years, but because of the somewhat specialized nature of the problem the knowledge is not widely disseminated . Therefore, we believe the reporting of three additional patients with injuries of this kind seems worth while . The clinical and x-ray aspects of the problem will be stressed so that its recognition will be somewhat more widespread and the appropriate treatment may be more directly carried out . These patients demonstrate all the characteristics of the disorder . We believe our classification of hyperextension cervical spine injuries to be a logical and original one .

From the Department of Ortbopaedic Surgery, The Mason Clinic, Seattle, Washington .

to the cervical spine with associated spinal cord involvement constitutes one of our most serious accidents . The cervical cord may be damaged by both flexion and extension

I

NJURY

TABLE I TYPES OF CERVICAL SPINE INJURIES PRODUCING PARAPLEGIA

I . Flexion injuries A . Type I . Dislocation B . Type II . Compression fractures C . Type III . Retropulsion of intervertebral disc II . Hyperextension injuries A . Type I . Injury associated with arthritic spine B . Type it . Rupture of anterior longitudinal ligament C . Type III . Rupture of anterior longitudinal ligament with dislocation

types of injury . Much has been written about paraplegia associated with flexion injuries, but not so of extension injuries . It is extremely important to classify (Table I) all cervical spine injuries with paraplegia as both treatment and prognosis vary widely . Treatment of flexion injuries, reduced to its simplest terms, is in extension. By the same token, the hyperextension injuries are treated in flexion . This paper concerns only the second group, namely, hyperextension injuries . Barnes [r], in his classic article on the subject of paraplegia in cervical spine injuries, reports an incidence of approximately two-thirds of the patients having undergone a flexion force and one-third a hyperextension one . It is fairly commonplace to treat all patients with cervical spine injuries and associated paraplegia in hyperextension . This maneuver, however, may produce further cord damage and death . Barnes American Journal of Surgery, Volume 96, November, x958

Seattle, Washington

618

Paraplegia and Hyperextension Injury to Cervical Spine CASE REPORTS

R . S ., a fifty-two year old male farmhand, had been drinking and fell forward down a flight of steps on the night of June 15, 1946. The patient was seen at the site of injury in his employer's home approximately thirty minutes following the accident . He had facial and forehead abrasions and contusions . There was a sensory level of anesthesia below C5 and a complete motor paralysis of all four extremities . The patient was carefully transferred to an ambulance stretcher and taken to a nearby county hospital where head halter traction was applied in the neutral position . He was seen the following morning, approximately twelve hours later, and a truly miraculous recovery had taken place . The only residual weakness noted was in his left biceps, brachialis and deltoid muscles . X-rays of the cervical spine were unremarkable except for scattered degenerative changes . Lumbar puncture was not performed . His course was entirely uneventful and he left the hospital ten days later with some residual loss of strength in the left upper arm . No further follow-up is available . CASE 1 .

Comment : This is an excellent example of a patient who had a hyperextension injury to the cervical spine of the Type i variety with a transient quadriplegia . The skeletal-ligamentous system remains intact . There is a contusion of the cord and a hematomyelia which clears spontaneously . The outlook in general is good in this group if the patient's neck is not further hyperextended and if laminectomy is not performed . CASE 11 . C . T ., a fifty-six year old white man, was admitted to Virginia Mason Hospital on December 31, [950. He had received a "rabbit punch" (luring a friendly scuffle, falling forward face downward upon the floor . He was not unconscious at any time but noted immediate severe pain in his neck and inability to move his arms and legs . The past history revealed no previous neck injuries or spinal disease. Physical examination showed a large, middleaged man complaining of severe pain in the neck with all passive movements except flexion which was comfortable . There were multiple abrasions over the nose and forehead . A complete sensory loss below the level of the C4 dermatome along with a complete motor paralysis of the upper and lower extremities was noted . Routine cervical spine films showed a fusion of C5, C6 and C7 as a result of arthritis . There was a slight posterior subluxation of C4 on C5 . There was no evidence of fracture . Lumbar puncture was performed ; the spinal fluid was grossly bloody . The initial pressure was 270 mm . of water which rose rapidly to 380 mm . with

The cervical spine is relatively normal except for loss of cervical lordosis and minimal lower cervical degenerative changes . l1G . 1 .

jugular compression . The problem was recognized as a hyperextension injury producing quadriplegia, and a small pillow was placed beneath the occiput flexing the head forward . Sand bags were placed on each side of the head for immobilization . The patient became increasingly restless and five days following the accident the temperature rose to toy ° r . He was placed in a respirator because of difficulty in breathing . His condition continually degenerated and he died six days after his hospital admission . Postmortem examination showed the facial and forehead abrasions still evident . There was a contusion and associated edema of the right frontal area of the brain . The cervical spine showed a slight subluxation at the C4, C5 level with complete rupture of the anterior longitudinal ligament at this level . There was evidence of contusion and edema of the cervical cord . Comment : This is a typical example of a patient with a Type ii hyperextension injury . The anterior longitudinal ligament had been ruptured and there was instability of the cervical spine . The patient was only comfortable with the head flexed forward, closing the gap between the anterior cervical vertebral bodies and reducing the cord impingement posteriorly . The prognosis is generally poor in this group . CASE 1n . W . T ., a fifty-two year old Filipino man, was transferred to Virginia Mason Hospital on September 3, 1957, four days following an automobile accident . The car had apparently overturned and the patient was unconscious for eighteen hours immediately after the accident . The other details were not known . 61g

Miller and Schultz

FIG . 2. The cervical spine is dislocated posteriorly at the C4, C5 level following Crutchfield tong traction in extension.

FIG . 3 . The dislocation has been reduced by discon-

tinuing the traction and flexing the head forward . showed the dislocation had been reduced . (Fig . 3 .) The patient was placed upon an alternating pressure mattress to avoid decubitus ulcers . He was given a broad-spectrum antibiotic for prophylactic reasons . An indwelling catheter with intermittent irrigations was also utilized. The nursing care was excellent and his general condition remained good . There was some evidence of brachialis anticus return in both upper extremities . He was discharged one month following the accident, essentially quadriplegic, to a nursing home .

Physical examination showed an apprehensive, small man . A contusion of the forehead was present . Neurological evaluation showed the cranial nerves to be intact . There was a sensory level with anesthesia below C6 . A motor paralysis of the arms and legs was present . Routine cervical spine films showed a loss of the normal cervical lordosis with slight forward tilting of C4 on C5 . No fracture was evident . There were minimal lower cervical degenerative changes . (Fig . I .) Spinal puncture revealed grossly bloody fluid with no response to jugular compression on either side . The injury was regarded as the flexion type by his attending physicians . The neck was placed in slight hyperextension and Crutchfield tongs were inserted with 15 pounds of weight . Portable x-rays twenty-four hours later revealed a posterior dislocation of C4 on C5 . (Fig . 2.) We were asked to see the patient at this point, and it was suggested that the traction be discontinued and the head be placed in mild flexion with sand bags on each side of the head . This was done and the patient immediately became more comfortable . X-rays taken eight days later

Comment : This patient entered the hospital with, as far as we can tell, a Type ii hyperextension injury . By traction in hyperextension, i .e., continuing the mechanism of production, the problem was compounded by converting it to a Type iii injury or frank posterior dislocation . More or less spontaneous reduction occurred by flexing the head, and the patient immediately became more comfortable . The uliimate prognosis is poor, of course, in this patient and in this group . 62 0

Paraplegia and Hyperextension Injury to Cervical Spine

Fm . 5 . Normal cervical cord on the left . "Molding" of the cervical spinal cord by ligamcnta flavor and ostcophytic spurring that may occur with hyperextension force on the right .

FIG . 4.

Type i hyperextension injury showing impingement of the cervical cord by the forward bulging of the ligaments flava and osteophytic spurring of the posterior vertebral bodies . COMMENTS

patients may have central cord hemorrhage, producing the syndrome of acute central cervical cord injury or hematomyelia . A continuing hyperextension force to the head produces an increasing stretch on the interior longitudinal ligament with either partial or complete rupture in the mid-cervical region, a Type ii lesion . (Fig. 6 .) Occasionally a small piece of bone may be avulsed from an anterior cervical vertebral body . The spinal column may be literally opened up anteriorly like a book . The same stresses arc placed upon the cord as in the Type i injury but to a greater degree . Davis [3] found that the anterior longitudinal ligament has no elasticity or stretch but that it has a high breaking strength, averaging 337 pounds in autopsy specimens . Papers published a number of years ago frequently stated that the anterior longitudinal ligament was secure against severance by horizontal or hyperextension forces . It was believed that when the head was bent backward forcibly, the brunt of the force would he borne by the atlas and axis and that fractures would take place at this level . This, however, is not the case . In the cervical area it is believed that the cord injury occurs as a result of pressure or traction, or both . Crooks and Birkett [2] found the level of cervical cord injury was usually at a higher segment than the spinous injury, suggesting the importance of traction in the pathomechanics . Finally, if the hyperextension force either

Mechanism, Predisposing Factors and Patbogenesis . Hyperextension injuries to the cervical spine are produced either by a fall forward, landing on the forehead or face, or by a blow to one of these areas . People who fall downstairs face forward are particularly prone to sustain one of these serious injuries . The patients are, with few exceptions, fifty or more years of age . Advancing age with its normal increase in the dorsal kyphosis, plus compensatory increase in the cervical lordosis, predisposes the older individual to these disorders . These patients usually have cervical spine degenerative changes and accompanying relative lower cervical immobility . Type i hyperextension has been nicely shown by Schneider et al . [~] and Taylor and Blackwood [8] to produce extensive impingement of the cervical cord by bulging forward of the ligamenta flava posteriorly and osteophytic spurring of the posterior vertebral bodies on the anterior cord . (Fig . 4 .) The spinal cord occupies nearly all of the spinal canal in the cervical area and the squeezing force may actually produce indentations anteriorly and posteriorly in the cord . This has been aptly referred to by, Robson [S] as "molding" of the cord . (Fig . S .) Schneider et al . [7] have carefully worked out the stresses that occur upon the cord with this type of injury. The compressive, torsional and tensile stresses are well correlated with the neurological findings and recoveries in these patients . What is more, these 62 1

Miller and Schultz

FIG . 6. Type ii hyperextension injury with rupture of the anterior longitudinal ligament by severe hyperextension .

FIG . 7 . Type iii injury with stripping of the posterior longitudinal ligament from the vertebral bodies with dislocation and cord damage .

at the time of injury or later continues to act, the Type iii lesion is produced . The posterior longitudinal ligament is stripped from one or more of the mid-cervical bodies and a frank dislocation with inevitable cervical cord damage of irreparable nature occurs. (Fig . 7 .) Clinical Picture and Roentgen Evaluation . The patients are usually fifty years of age or more. They present with facial or forehead abrasions or lacerations . There is evidence of a mid-cervical para- or quadriplegia . All movements of the head except flexion are very painful. Spinal puncture ordinarily fails to reveal evidence of a block . The x-rays frequently show a lower cervical arthritic process, but may be strikingly unremarkable otherwise . If a fracture is present there is usually a small avulsion chip from an anterior vertebral margin . Management. A more or less routine program of treatment may be followed in this type of cervical spine injury . General physical examination to rule out other injuries, plus careful neurological evaluation, must be made . Concomitant frontal lobe injury is not unusual . A program which will make the patient comfortable is of cardinal importance . Caliper traction in extension is contraindicated since it reproduces the mechanism of the injury and may further aggravate the injury to the cord . The head should be slightly flexed with a small pillow and placed between sand bags, neutral as to rotation . Good nursing care is of the utmost importance . An alternating pressure mattress is most helpful in the prevention of decubitus

ulcers . An inlying catheter should be put in place early and intermittent bladder irrigations used . Suctioning of the respiratory passages must in some instances be utilized frequently . Tracheostomy may at times be necessary, as yvell as the respirator . Fluid intake must be watched and if the oral intake is not adequate, intravenous fluids are indicated . Constipation and fecal impaction can be avoided by judicial care and use of catharsis or enemas . Prophylactic polyvalent antibiotics are given to prevent pneumonia and urinary tract infections . Prognosis . These injuries are grave and the prognosis is by necessity guarded . Crooks and Birkett [2] reported on eight patients with complete paraplegia ; early death occurred in 6o per cent . Barnes [r] reported on six patients, with death in five . The mechanism of death is most commonly respiratory failure due to intercostal weakness or paralysis . Pneumonia and anoxia are a cgnstant and serious threat . The prognosis of the patient with a Type i lesion is often remarkably good if the neck is under no circumstances hyperextended . Surgery should assiduously be avoided as it may prevent normal spontaneous recovery .

622

SUMMARY

Three patients with severe hyperextension injuries to the cervical spine have been presented. The pathomechanics and clinical clues of forehead and facial abrasions or lacerations and quadriplegia have been stressed . The minimal roentgen findings in the initial films have

Paraplegia and Hyperextension Injury to Cervical Spine been mentioned . A simple classification of these injuries has been outlined . Middle-aged or older people who present these findings should not be hyperextended . The patient's head should be slightly flexed and further supported with sand bags on each side . Good nursing as well as other supportive therapy is important . The prognosis is good in the Type i lesion, ultimately poor in the Type ii and Type iii lesions, and early death is not unusual .

3. 4-

56.

locations of the cervical spine . Brit . J . Surg., 31 252- 265,1944 . DAVIS, A . G . New aspects of spinal injuries . Arch . Surg., 46 : 619-634, 1943 . KAPLAN, C . J . Cervical hyperextension injuries with paraplegia_ J . Bone e'N Joint Surg., 35B : 97 r00, 1953ROBSON, P . N . Hyperextension and haematomvelia . Brit . M . J., 1 : 848-852, 1956 . ROGERS, W . A . Fractures and dislocations of the cervical spine . J . Bone e- Joint Surg ., 3qA : 341-

376, 195 ; 7 . SCHNEIDER, R . C ., CHERRY, G . and PAUTEF, 14 . The syndrome of acute central cervical spinal cord injury . J. Neurosurg., 11 : 546-577, 1954 . 8 . TAYLOR, A . R . and BLACKWOOD, W. Paraplegia in hyperextension cervical injuries with normal radiographic appearances . J. Bone c'--' Joint Surg ., 3oB : 245--248, 1948 .

REFERENCES 1 . BARNES, R . Paraplegia in cervical spine injuries . J. Bone e^' Joint Surg ., 3oB : 234- 244, 1 948. 2 . CROOKS, F . and BIRKETT, A . N . Fractures and dis-

"Auguste Nelaton was born in 1807 in Paris. He presided with Malgaigne, who has been described as the greatest surgical historian and critic the world has yet seen, at the Hopital St . Louis. He comes down in history as an operator and teacher with a reputation as great as that of Dupuytren . We are told that he was a most modest man, quiet in his habits, of a friendly disposition and most considerate of the unfortunate . He was the first to devise a bullet-probe (this was used in Garibaldi's case) . The present-day flexible rubber catheter was his invention . In gynecology, he was the first to describe pelvic hematocele (1851-52), and due to his efforts, ovariotomy was established in France . His principal work is his `Elements de Pathologie Chirurgicale' (1844-59) . The surgeon is familiar with the Nelaton dislocation, the wedging of the astragalus between the widely separated tibia and fibula, usually complicated with fracture . The fibrous tumor or sarcoma lying between the peritoneum and the muscles of the abdominal wall is known as Nelaton's tumor . Nelaton's line is a line drawn from the anterior superior spine of the ilium to the tuberosity of the ischium ; normally the great trochanter lies in this line, but in cases of iliac dislocation of the hip or fracture of the neck of the femur, the trochanter is felt above the line . Auguste Nelaton died in 1873 ." (T . S . W ., Am . J. Surg ., 14 : 691, 1931 .)

62 3