- Email: [email protected]
Spinal Cord Injuries—Early Treatment
Spinal Cord InjuriesEarly Treatment 1. M. TARLOV, M.D., F.A.C.S.* FROM time to time we must take stock of therapy in certain fields of medicine because of current advances in clinic or laboratory. Our management of victims of spinal injuries must now be scrutinized in this light. Most spinal injuries result from indirect violence, where the direct force is received by the head, legs or buttocks. It is usually believed that in such cases the spine is abruptly flexed. Recent experiences, however, show that the spinal cord injury sometimes results from spinal hyperextension. This finding is of great significance in view of the well established practice of placing patients with spinal injury in the hyperextended position. Of course hyperextension, by reproducing the conditions of the injury, would only do further damage. Vertebral lesions most commonly occur at the sites of greatest spinal mobility (C5, C6, C7, D12 and L1). Probably many of the cervical lesions at the phrenic level are immediately fatal. Somewhat commoner are displacements of the atlas on the axis, usually forward and after fracture of the odontoid process or tears in its ligaments. Baldwin and ver Brugghen1 found that only 109 of 484 cases of vertebral fracture-dislocations were accompanied by severe spinal cord symptoms and signs. On the other hand, serious injury of the spinal cord or cauda equina may occur without gross bony damage. Browder and Grimes,2 for example, found that 16 of 88 patients with injury to the cervical spinal cord showed no demonstrable lesion of bone.
MECHANISM OF INJURY AND ITS BEARING ON POSTURAL TREATMENT
Sharp flexion of the spine results in fracture, often of a compression type, of one or more vertebral bodies, and sometimes in the forward dislocation of an upper upon a lower vertebra. The anterior surface of From the Department of Neurology and Neurosurgery, New York Medical College, Flower and Fifth Avenue Hospitals, New York, N. Y. * Professor and Director of the Department of Neurology and Neurosurgery , New York Medical College, Flower and Fifth Avenue Hospitals; Attending Neurosurgeon, Flower and Fifth Avenue Hospitals, and Metropolitan Hospital, New York, N. Y. 591
..,... 592
I. M. Tarlov
the spinal cord may thus be compressed over the edge of the lower vertebral body (Fig. 147). The upper vertebral body must therefore be extended to release the spinal cord from compression. It has been supposed that spinal cord injury without visible skeletal damage also results from acute hyperflexion involving vertebral dislocation immediately and spontaneously reduced by muscular action. This hypothetical series of events has been called "recoil injury" of the cervical spine. * This explanation, however, was shown to be improbable by Cramer and McGowan,3 who postulated acute flexion of the neck as
Fig. 147. A, Fracture-dislocation of C5-C6 before reduction by Crutchfield tongs. B, Fracture-dislocation of C4-C5 after reduction by Crutchfield tongs and fusion by parallel grafts taken from iliac crests. Fusion was done because of recurrence of fracture-dislocation. (Case of D~. Joseph Milgram.)
the cause of a supposed temporary disk displacement. Their evidence was a herniated intervertebral disk compressing the spinal cord as the result of an acute injury without vertebral fracture or dislocation, but they had no proof that a temporary prolapse of a disk could occur or injure the spinal cord. Barnes4 demonstrated that hyperflexion can cause cord compression only if it is sufficient to dislocate and lock the articular processes. Locking of this type proved insusceptible to spontaneous reduction. It is therefore probably not true that hyperflexion, without causing visible vertebral damage, can injure the spinal cord through temporary, self-reduced fracture-dislocation. TaylorD has recently shown that injury to the cervical cord without vertebral fracture or dislocation usually results from forcible extension of the neck rather than from hyperflexion. Such accidents are exemplified by diving with the head back into shallow water or by falling or being thrown forward while the head is arrested by a fixed object. Taylor has
* This series of events is thought to occur in some "whip-lash" injuries of the neck in which during a collision the head is snapped forward and back or back and forward on the neck as a pedicle.
Spinal Cord Injuries--,-Early Treatment
593
demonstrated by cadaver experiments that under these conditions the agent that impinges on the spinal cord is a forward bulge of the ligamentum flavum. Thus he very plausibly suggests that cases of cervical quadriplegia without radiographic evidence of bone damage or displacement should be regarded as injuries caused by forcible hyperextension and treated by immobilization in slight flexion without traction. To nurse patients with such hyperextension injuries in hyperextension is to cause further cord compression. Other traumatic vertebral lesions also call for avoidance of spinal hyperextension. Among these are odontoid fractures resulting from blows forcing the head backward, posterior dislocation, in which the upper vertebra is dislocated backwards upon the lower one, and intervertebral disk herniations alone or in combination with a vertebral fracture or dislocation or with both. Barnes has noted that elderly patients are predisposed to hyperextension injuries because age tends to develop kyphosis of the thoracic spine, usually compensated by cervical lordosis (extension deformity of the neck). Mobility of the spine is, moreover, often impaired by arthritic changes in joints and ligaments. "In the event of a fall, the neck cannot be flexed in the normal defensive manner, so that when the head strikes the ground powerful angular strain in extension is applied to the cervical region." Hyperextension fractures may follow falls from heights in which the body strikes an object crosswise in the lumbar region. "Thus the leverage of the weight of both ends of the body is directed against the middle .... " and "the anterior longitudinal ligament may rupture."6 In such cases treatment by hyperextension may cause immediate paralysis. The diagnosis of such hyperextension fractures may be apparent from the lateral x-rays in which the vertical height between the vertebral bodies is increased. "Pull in a straight line, using the posterior ligamentous investiture as a check strap . . . may serve to restore nearly normal conformation of the fractured body."6 TREATMENT AT THE SCENE OF THE ACCIDENT
The treatment of patients suffering from spinal injuries should begin at the scene of the accident, because mismanagement-faulty first aid or transportation-may produce or intensify cord injury or make a recoverable neural lesion irrecoverable. When spinallesions are suspected because of pain in the neck or back, paralysis or loss of sensation, the alignment of the spine must not be changed except judiciously on the basis of an understanding of 'the mechanism by which the injury was produced. By no means should the patient be allowed to flex his head, sit up, stand, walk, or make:any unnecessary movements. He should not be lifted from the ground by his shoulders and feet but should be allowed to lie in the neutral anatomic position on his back until ready to be transported.
I. M. Tarlov
594
If the mechanism of the force that produced the injury is known, the patient should be transported with his spine in an opposite position. Certainly everything possible concerning the production of the injury and the rapidity of onset of the neurological disturbance should be determined. An injury to the face is occasionally the clue that a cervical injury occurred in hyperextension. These patients should be transported supine on a rigid litter, board or other rigid surface with a small pillow, folded blanket or coat about 3 inches high under the head to produce slight flexion. Cervical hyperflexion injuries are at times associated with injury to the vertex. Such patients should be transported with the shoulders, rather than the neck, slightly raised to produce hyperextension of the neck. If there is a kyphos at the site of the injury, transportation in a position of hyperextension appears advisable. A patient with a herniated intervertebral disk (Fig. 148) or a fractured vertebral arch, if transported in hyperextension, would incur damage to the cord, or have the damage aggravated, by having the cord kinked over the disk protrusion or a part of the fractured vertebral arch. * In the past, massive extrusions of intervertebral disks caused by spinal injuries have probably been overlooked. When the mechanism producing spinal injuries is not known, it is safest to transport the patient in the supine position with the body held straight in the neutral anatomic position, the spine neither flexed nor extended. At least three persons are required to move the victim of a spinal injury: one person pulls on his feet, another on his head; or, if the lesion is thoracic or lumbar, the head-end traction may be applied under the armpits. One or two other persons gently lift or roll the patient into the desired position on a rigid litter. In cervical spine injuries folded blankets or clothing should be fixed at each side of the head to prevent lateral movement. Traction and countertraction should always be exerted when the patient is moved. Shouiders and pelvis must rotate in the same plane, and the spine must be kept in the same relative position, as though the patient were a rigid log. EXAMINATION IN HOSPITAL
The patient should not be moved from his litter until he has reached the x-ray table, the operating table; or the hospital bed. Clothing should be removed with minimum manipulation of the patient. At all times distorting the injured spine must be avoided. If the patient is in surgical shock, he should be placed in the shock position (lowered head), covered with blankets, and whole blood and * The writer recently treated a man who fell from a height and suffered almost complete paralysis of his feet caused by a herniated intervertebral disk. Hyperextension of the back markedly accentuated his pain, as is almost invariably true in cases of herniated intervertebral disks. Transporting this man in hyperextension would have increased the already marked compression of his cauda equina.
Spinal Cord Injuries-Early Treatment
595
other fluids and perhaps stimulants given. He should not be moved until he has been adequately treated for shock. The pulse, blood pressure, respiratory rate, and temperature should be frequently recorded.
Fig. 148. Photographs taken at operation upon a totally paralyzed patient in whom there was a fracture-dislocation of C5-C6 and also an extruded intervertebral disk shown by arrow in A. B, Photograph taken after removing the disk. C, Illustrating the fusion accomplished with a bank-bone graft. (Case of Dr. William V. Cone.)
For the relief of pain morphine sulfate in 16 to 32 mg. Oi to Y2 grain) doses subcutaneously may be given, but in -high cervical cord lesions respiration may be affected. In such circumstances the use of morphine is dangerous because it depresses respiration, and codeine sulfate in doses of 32 to 65 mg. (Y2 to 1 grain) should be used. Barbiturates are useful to relieve anxiety. The patient should be thoroughly examined as quickly as possible. When change of position is necessary, traction and countertraction
I. M. Tarlov
596
should be maintained; and the patient lifted or rolled like a log. Acute injuries elsewhere may of course require treatment before the spinal injury. The patient should be catheterized if necessary, and an indwelling urethral catheter should be introduced if there is evidence of severe spinal cord injury. At the earliest safe opportunity a neurological examination should be made with special emphasis on the degree of sensory and motor loss; Anteroposterior and lateral x-rays of the spine should be taken stereoscopically. In injuries to the atlas and axis additional views through the open mouth should be taken. Because vertebral lesions at C7, Dl and D2 are sometimes overlooked roentgenographically, one must obtain adequate x-ray views of these vertebrae before excluding fracturedislocations as a cause of spinal cord injuries referable to these levels. Great care is imperative when taking x-rays to avoid altering the alignment of the spine. If the patient has completely lost sensation and motor power below the level of the injury, whether or not x-rays show bony injury, a lumbar puncture should be made with the aid of a spinal fluid manometer and jugular compression (Queckenstedt test*). While this is done the patient should be placed on his side, and his spinal alignment should not be changed. If jugular compression reveals no evidence of spinal fluid block, operation would be pointless. If the patient does not show complete sensorimotor paralysis, then lumbar puncture and manometric examination are not immediately necessary. The Queckenstedt test should be carried out only as a preliminary procedure to a contemplated operation, which is not indicated as an emergency procedure under these conditi
The immediate reduction of fracture-dislocations is desirable to reduce pain and to secure a more stable and mobile spine. The primary object of such reduction in the paralyzed patient, however, is to relieve spinal cord compression. But indriven fragments of bone or soft tissue or other foreign bodies, or the presence of hemorrhage or edema around the spinal cord may maintain spinal cord compression even after the dislocation has been reduced. Is it possible to reverse the immediate complete paralysis, heretofore irrecoverable? Our animal experiments show 7 • 8. 9 that it is possible provided the compression is relieved within a relatively short time and
* Queckenstedt Test. Compressing the jugular veins digitally or with an inflated blood pressure cUff normally causes a prompt rise in cerebrospinal fluid pressure, which is transmitted throughout the subarachnoid spaces. Obliteration of the spinal subarachnoid spaces prevents transmission of these pressure changes below the level of the block. If pressure does not rise within the manometer attached to the spinal needle when the jugular veins are compressed, one may conclude that the spinal subarachnoid spaces are obstructed provided abdominal straining or coughing does raise pressure. If it does not, the needle is obstructed by a nerve root or meninges or other tissue, and its position must be changed and the test repeated.
Spinal Cord Injuries-Early Treatment
597
provided the compressive force is not too great. The magnitude of the compression, as well as the extent to which there has occurred irreversible damage to the spinal cord caused by laceration and other lesions, cannot be known in advance. One must assume that recovery of function can occur and treat these patients in the light of rational principles evolved from animal experiments as well as from clinical experience. A comparison of the effects of ischemia with those of spinal compression in our animals has shown that mechanical deformation rather than anoxia is the main cause of spinal compression paralysis. lo This is fortunate, because the capacity for recovery of spinal cord function is in general much greater with mechanical deformation than with ischemia. Our studies have shown, moreover, that when small compressive forces cause acute complete paralysis in dogs it may be totally reversed if the compression is removed within two hours. The cauda equina is much more resistant to compression, and even with great compressive forces total sensorimotor paralysis is reversible if the compression is released within five hours or even a longer time. 9 Hitherto the results obtained in treating acute total spinal cord paralysis caused by fracture-dislocationll have been dismal. Our analysis of 26 cases of complete spinal paralysis of traumatic origin in which laminectomy was done showed persistent complete paralysis. We have also reviewed a control series of nine surgically unexplored cases of spinal injuries in which there was immediate complete sensorimotor paralysis. Except for slight improvement in sensation and somewhat better activity of muscles supplied by nerve roots at or close to the level of the injury, there was no significant recovery in any case. In view of these uniformly dismal results it is now imperative to determine whether the outlook can be brightened by applying our experimental results to man. * Immediate total sensorimotor paralysis associated with a spinal fluid
* That recovery may occur in totally paralyzed patients after immediate decompressive laminectomy is shown by the experience of Tinsley12 and also of Cone.1I Tinsley reported 2 patients upon whom laminectomy was done for complete transverse lesions at C7 and Tn, 22 and 27 hours respectively after spinal injuries caused by high explosive shells. The first patient "was moving his toes and feet, position sense and touch were returning, there was a patchy return of sensation to pinprick.•.." when the last follow-up examination was made 14 days after operation. At the time of the last follow-up report of the other patient 22 days after operation, ''he was urinating spontaneously and moving his legs up to his knees. Sensation had returned to pinprick and touch although it was patchy and incomplete." W. V. Cone 11 did a laminectomy and fusion on a man aged 39 years approximately 24 hours after he sustained a fracture-dislocation of C5-C6, causing complete sensorimotor paralysis. An extruded intervertebral disk was also removed. Sensation began returning 14 days later. At the time of the last examination, 6 months after operation, there was moderately good power in all movements of the left lower limb. On the right side, slight hip flexion and extension of the knee were present. Pain sensation was normal over the right lower limb and impaired over the left. Touch sensation was present but vibratory sensation was absent over both lower limbs. It would be desirable to know the subsequent course of these patients, but the available data on them support the present writer's experimental results. Moreover, when we consider the utter hopelessness of such patients if not operated on,U it is clear that immediate decompressive laminectomy is justified.
598
I. M. Tarlov
block calls for immediate laminectomy to decompress the spinal cord and reduce any dislocation. The test for spinal subarachnoid space patency should precede the operation to exclude those rare cases of immediate paralysis resulting from spinal cord concussion, in which spontaneous recovery occurs. The next question that arises is whether the dura should be opened in such cases. The writer has seen two patients in whom the dura was opened. Immediately spinal cord tissue extruded itself through the opening. * It seems unwise, then, to open the dura, but it would appear desirable to split the outer layer of the dura to increase the decompressive effect. Whether it would be increased by removing cerebrospinal fluid above and below the traumatized cord segments would have to be determined by trial. Progressive functional spinal loss leading to serious spinal paralysis is another indication for immediate laminectomy. Hence, frequent neurologic examination should be made in patients suffering from spinal cord injuries. If neurologic signs improve, conservative treatment is the correct choice. If sensory and motor signs steadily advance, laminectomy should be considered. If total paralysis occurs or seems imminent, immediate laminectomy is urgently indicated. Total paralysis of gradual onset can be more readily reversed by decompression than total paralysis of sudden onset. The more gradual the course and the less complete the paralysis the more favorable is the outlook after compression is relieved. However, the more gradual the development of the paralysis and the less complete it is, the more justified is continuance of conservative treatment. If, in the presence of severe, handicapping neurologic signs, with or * Allena ,15 attempted to determine how long the spinal cord may be compressed without precluding functional recovery. He produced contusion of the spinal cord of dogs by dropping upon it known weights from known heights. The degree of impact was measured in gram-centimeters. Allen believed that the edema following the impact reached maximum about 4 hour after the injury. He concluded that if the spinal cord compression caused by the edema could be prevented, the spinal cord might recover some function. Accordingly, he advised midline posterior incision of the spinal cord through the contused segment to drain and release the intramedullary pressure. He made such incisions in dogs 2 hours after injury by a force known to produce complete paralysis. He reported that he could thus avert the disintegration of the cord tissue that invariably occurred in the control dogs in which the spinal cord was not incised. Similar experiments were recently carried out by Freeman and Wright,16 who made the same recommendations as Allen. A valid objection to Allen's interpretation of the changes which he described is well expressed by Thompson: "There is no doubt that the substance of the cord is clearer and better preserved in the incised than in the nonincised specimen but there is such a decrease in transverse area of the cord that we can't help feeling that the diffiuent tissue which escaped from the incision carried with it a considerable amount of nervous tissue which had not been seriously injured and which might have been expected reasonably to have recovered if it had not been disturbed. While it lies in the substance of the cord it acts as support to the uninjured tissue surrounding it. Evacuation removes this support and the walls of the cavity cave in like the sides of a sand pit or the banks of a river when the waters recede. On these grounds we believe that the evacuation is not without its drawbacks and its dangers."17
Spinal Cord Injuries-Early Treatment
599
without x-ray evidence of bony injury, improvement does not occur when the patient is conservatively managed for approximately a week, then laminectomy is in order if lumbar puncture with the aid of a manometer and jugular compression shows evidence of a spinal fluid block The less severe the neurologic signs the more justified is one in delaying laminectomy. A fourth indication for immediate laminectomy is the presence of fragments of bone or other foreign bodies in the spinal canal. Lumbar puncture is not necessary in these cases. CONSERVATIVE MANAGEMENT
For patients with cervical fracture-dislocation, skeletal traction is a simpler, more effective and more comfortable means of traction than a halter. Crutchfield tongs18 • 19 or some modification may be easily and quickly applied to the patient's skull in bed, permitting patients to be comfortably turned. These tongs have two prongs that enter drill holes made through small incisions on each side of the skull (Fig. 149). To avoid an uneven pull on muscles and tendons the tongs are applied in a vertical plane passing through the articulations of the cervical spine. The mastoid tips are approximately within this plane and serve as satisfactory landmarks. When the tongs are properly locked, the points will not bore in. If no tongs are available, traction can be applied by passing heavy steel wires through two close trephine openings on each side of the skull about an inch from the midline near the vertex.20 If there is x-ray evidence of an anterior dislocation of an upper on the lower vertebra (flexion injury, Fig. 150), the head should be moderately hyperextended by placing a small pillow under the shoulders. If x-rays show the relatively uncommon p05terior dislocation (hyperextension injury), the head may be somewhat flexed while traction is maintained. Hyperextension or flexion of the neck may also be obtained by applying the tongs somewhat in front of or behind their usual site of application to the skull. Traction should begin with about 5 pounds of weight and be increased by 2 pounds at a time up to 15 to 35 pounds. The head of the bed is elevated about 20 degrees for countertraction. X-ray studies should be made every few hours and just enough traction applied to reduce the dislocation. Reduction, often achieved within a few hours (Fig. 150), is maintained with a minimum of traction (5 to 10 pounds). The maintenance of greater traction may impede proper healing. Six weeks is allowed for healing of the ligaments that maintain spinal alignment and for firm fibrous union between the injured vertebrae. The patient may then get out of bed and be fitted with an adjustable brace (Fig. 149) to be worn for about three months. Because of the greater injury to spinal ligaments, traction is maintained for a longer time (8 to 12 weeks) in patients with atlanto-axial fracture-dislocations, and a support is worn for six months. Compression fractures of the atlas and axis require shorter periods of traction because
600
I. M. Tarlov
Fig. 149. A, Application of Crutchfield skull tongs. B, Traction correctly applied in line with the articulating facets. C, Light-weight adjustable brace. (Taken from Crutchfield. IS)
they "tend to remain in a satisfactory position... "19,20 If atlanto-axial or other dislocations tend to recur (Fig. 147, B), then fusion such as described by Cone and Tumer21* is indicated. • These authors consider fusion indicated in fractures of the odontoid and a.lso in multiple fractures of a vertebra. Even though this policy would probably prevent late spinal cord compression syndromes, it is not generally followed. However, this policy has yielded excellent results in the hanas of W. V. Cone21 who, using felt-lined boots, produces sufficient traction to reduce dislocated thoracic or lumbar vertebrae during laminectomy done on his ingeniously designed operating table. It is true that patients with satisfactory spinal fusions require shorter periods of bed rest and cast or brace immobilization than patients conservatively treated. These advantages, however, would appear to be offset by the disadvantages of a major surgical operation.
Spinal Cord Injuries-Early Treatment
601
Skeletal traction is usually ineffectual in reducing fracture-dislocations of the thoracic and lumbar spine. * In such cases hyperextension on a Bradford frame or on any convex surface centered at the point of the deformity should be tried provided the abnormal neurologic signs are not increased by this position. Gradually increasing hyperextension may be satisfactorily produced by using a reversed Gatch bed with the knee elevator coming up under the back at the site of the dislocation. Hyperextension may also be achieved by placing a blanket roll 18 inches in diameter transversely between a fracture board and a hard hair mattress over which is an air mattress. The patient remains in the hyperextended position for approximately two weeks, and then wears a bivalved plaster
Fig. 150. Fracture-dislocation of C4-C5 before (left) and after reduction (right) by skeletal (tong) traction.
cast extending from the top of the sternum to the symphysis pubis for two to three months. He is then allowed to get out of bed, but must wear a brace for four to six months. The bivalved plaster of Paris shells facilitate turning the patient and give easy access to the skin. Buckle straps meanwhile hold the shells firmly together. The hyperextended position often reduces thoracic and lumbar fracture-dislocations. The weight of the upper and lower parts of the body serves to bring the kyphosed and displaced spine back to its normal lordotic conformation. This method is simpler, often as efficient, and less of an ordeal for the patient than suspending him in a canvas hammock with his head and shoulders face down on one operating table and his pelvis on the other, t or by jacking up the Iilpine at the site of the injury. Perfect reduction of a spinal dislocation is desirable but fre-
* Attempts to directly force the vertebrae back into position while traction is being made are sometimes successful. A lateral force exerted at the level of the injury may reduce the uncommon lateral dislocation of a lumbar vertebra (Fig. 151). t The weight of the patient produces the necessary extension force and a close. fitting plaster of Paris jacket is then applied.
602
I. M. Tarlov
quently impossible. Moderate dislocation is compatible with recovery of spinal cord or cauda equina function and satisfactory spinal stability. If x-rays show no dislocation, traction is unnecessary. Such patients should be treated in the neutral anatomic position with the head neither flexed or extended. If closed methods of reducing dislocations fail and the patient is severely handicapped neurologically, he should be treated by open operative reduction provided the Queckenstedt test shows evidence of a spinal fluid block.
Fig. 151. Fracture-dislocation of I"3-L4 before (left) and after reduction (right) by longitudinal traction and lateral pressure at the level of the lateral dislocation. (Case of Dr. Joseph Milgram.) .
Occasionally in the lumbar region one encounters a complete fracturedislocation, with severe displacement encroaching on the neural canal. If there is severe paralysis, even though not complete, laminectomy and open reduction should be attempted. Fractures of the sacrum which may be associated with fractures of other parts of the pelvic ring are seldom accompanied by displacement of fragments. Therefore, bed rest is usually the only form of therapy required. Any severed nerve roots should be repaired. Primary nerve-root suture is hardly ever feasible because nerve substance is lost through the injury or through preparatory trimming of the frayed ends. Owing to anatomic limitations, the procedures for shortening gaps in peripheral nerves cannot be used on nerve roots. Grafting becomes necessary instead. Segments of severed posterior roots, which never regenerate, may be used to graft severed anterior nerve roots. If posterior roots have not been severed, segments of intercostal nerves may be used as grafts.
Spinal Cord Injuries-Early Treatment
603
It is impossible to suture these delicate roots satisfactorily with the conventional thread technique. Plasma-clot suture is ideal,22 however. Although clinical experience with the use of autologous nerve-root grafts sutured with plasma clot is "at present inadequate to assess the procedure, the excellent histological regeneration of the cauda equina in monkeys after such grafts23 makes it imperative to employ this technique in man. GENERAL CARE OF THE PATIENT
The paralyzed patient requires constant nursing care during the first few weeks. Pressure sores and urinary and pulmonary complications must be prevented and morale kept high. Bed sores are always pressure sores which can almost always be prevented by special nursing measures. The patient should lie on an air or sponge rubber mattress and a perfectly smooth bedsheet. Twice daily he should get an alcohol rub and then have his skin powdered to keep it dry. Every two or three hours his paralyzed muscles should be massaged, his extremities exercised, and his position changed. Minor adjustments of position should be made more often, and the skin over bony prominences should be massaged more often. A Stryker frame* facilitates turning and other care. Pressure on the heels should be prevented by resting them on soft cotton rings or by putting small pillows or blanket rolls under the calves. The knees should be kept slightly flexed over another pad under the lower thighs. The legs should always be separated by pillows. Bedclothes should be supported by a cradle or board at the foot of the bed to prevent their weight from causing foot drop. To keep the feet dorsally flexed, a pillow should be placed between them and the board. Hypostatic pneumonia is a postoperative hazard especially in cervical injury cases. Nasopharyngeal, intratracheal and bronchoscopic suction are used when indicated to remove excessive secretion. Frequent turnings lessen the hazard. The objective in managing the paralyzed urinary bladder is to establish adequate drainage with a minimum of urinary sepsis until automatic function resumes. An indwelling catheter with tidal drainage such as that described by Munro24 is employed. Early return of bladder tone and
* The Stryker frame (J.A.M.A. 119: 1731-1732, 1939) consists of 2 rectangular metal frames over which are stretched strips of canvas. These frames are like Bradford frames with openings in'-the canvas to facilitate use of the urinal or bed pan'. When the patient is to be turned a second frame is placed over him and securely fastened to one on which he is lying. The 2 frames are then locked together and with the patient pressed between them fastened to steel disks (turning devices clamped onto the head and foot of t.he bed) at each end. The disks can be rotated and locked in position. After the patient is turned, the frame on which he originally lay can be removed. This apparatus permits frequent and easy turning by a single nurse. When the patient is lying on the anterior frame his head is supported by a sponge-rubber face piece under the cheeks and forehead. His eyes a.re about 15 inches from the mattress so that he may read or write. A reading board may be suspended above him when be is on his back.
"'I
I. M. Tarlov
604
automaticity are best achieved by tidal drainage, which minimizes puddling of residual urine and provides for irrigation of the bladder and its regular emptying and filling at a predetermined level of intravesical pressure. The indwelling catheter is changed weekly, and all patients on constant urethral drainage are given systemic chemotherapy. Mechanical drainage is discontinued when automatic bladder function resumes, usually within 4 to 12 weeks. Patients who do not develop automatic bladder function must depend upon a receptacle strapped to the thigh. Bowels. Proper diet and mild laxatives usually keep the bowel contents semisolid and easily removable by enema or suppository. This avoids fecal impactions or stools so soft that soiling and maceration of the skin become troublesome. Occasionally atony of the bowel produces distressing distention which may usually be relieved by administering drugs such as prostigmine, pitressin, pilocarpine or Doryl, or by using a MillerAbbott tube. When on a bed pan the patient must be supported by pillows or folded blankets under his back and thighs so that his weight is not on the bed pan itself. Supportive Measures. Poor nutrition retards recovery of sensory and motor function and delays healing. Hence an adequate caloric, protein and vitamin intake is essential. Falling serum levels in early convalescence must be supported by transfusing whole blood or plasma. Postural Treatment. Covalt and his co-workers25 have stressed the importance of early standing in combating the fall of blood proteins, urinary tract infection and calculi, and osteoporotic changes as well as in promoting the healing of ulcers. They use the tilt board to which the patient is strapped. This treatment is started "10 to 14 days after ... the ordinary laminectomy.... The angle of inclination at the start should be around 30 degrees. The patient is watched closely for signs of discomfort, such as paleness, increased sweating, and increase of pulse rate .... This should be accomplished twice daily until the patient is standing in an upright position. Time of standing should be increased to a minimum of one hour daily." Rehabilitation. Paraplegic centers for the after-care of permanently paralyzed patients provide vocational training and offer considerable hope and encouragement to them. Thanks to modern rehabilitation techniques, control of urination and defecation, satisfactory sexual activity, ambulation with artificial aids-which is the best assurance against genitourinary tract stones or infection-complete self-care is frequently achieved by these patients, who may even beget children, become employable, and lead active social lives. SUMMARY
Injury to the spinal cord may result from forcible vertebral extension as well as flexion. The well established practice of placing patients with spinal injury in the hyperextended position is justified only in injuries
Spinal Cord Injuries-Early Treatment
605
resulting from sharp spinal flexion. To nurse patients with hyperextension injuries in hyperextension is to increase cord compression. When the mechanism producing spinal injuries is not known it is safest to transport and to treat the patient in the supine position with the body held straight in the neutral anatomic position, the spine neither flexed nor extended. Skeletal traction, usually ineffectual in reducing fracture-dislocations of the thoracic and lumbar vertebrae, is the safest and most effective method for reducing cervical fracture-dislocations. To reduce fracturedislocations of the thoracic and lumbar spine, hyperextension should be used provided the abnormal signs are not thereby increased. If dislocations tend to recur then spinal fusion is indicated. In spinal injuries with immediate complete sensorimotor paralysis no appreciable restoration of function occurs without operation. On the other hand, recent experimental, and clinical evidence too, shows that complete sensorimotor paralysis can be reversed in some cases provided the compression is relieved surgically within a relatively short time. It is therefore imperative in cases of immediate total paralysis associated with a spinal fluid block to do a laminectomy at the earliest possible time to decompress the spinal cord and to attempt to reduce any dislocation. Progressive loss of spinal function leading to serious paralysis or the presence of fragments of bone or other foreign bodies in the spinal canal also calls for immediate laminectomy. Moreover, if in the presence of severe handicapping neurologic signs, improvement does not occur when the patient is conservatively managed for approximately a week, then laminectomy is in order if the Queckenstedt test shows evidence of a spinal fluid block. ADDENDUM
After this paper was written there appeared a review by Wanamaker on the early treatment of 300 consecutive cases of spinal cord injuries sustained during the Korean conflict (J. Neurosurg., Nov., 1954, p. 517). He provided convincing evidence of the value of early laminectomy in treating patients with complete sensorimotor paralysis below the site of injury. Of 27 such patients with cervical injuries, 17 showed postoperative improvement. Twenty-nine of the 70 totally paraplegic patients suffering from injuries of the lumbar spinal cord, conus medullaris or cauda equina improved after laminectomy. Even in a group of 109 patients whose thoracic spinal injuries, producing complete sensorimotor paralysis of the lower limbs, were complicated by "concomitant lesions in the thoracic and abdominal cavities, often necessitating a delay in laminectomy," 17 showed improvement. Recovery, in all cases being referable to the long tracts of the spinal cord, was complete in seven patients. In only 28 per cent of the patients was the laminectomy done within 24 hours. In all likelihood the incidence of recovery would have been greater if it had been possible to operate on more of these patients sooner. At any rate, Wanamaker's data support the present writer's experimental and clinical evidence favoring emergency operation in patients with complete sensorimotor paralysis after a spinal injury. This recommendation is especially
I. M. Tarlov
606
urgent in view of the writer's experience that these patients do not recover without laminectomy except in cases of spinal cord concussion, in which the Queckenstedt test shows no evidence of a spinal block. Doubtless many victims of spinal injury can be saved from a life of paralysis by immediate laminectomy.
REFERENCES 1. Baldwin, R. and ver Brugghen, A.: Unpublished data cited in ver Brugghen, A.: Neurosurgery in General Practice. Springfield, Ill., Charles C Thomas, 1952. 2. Browder, J. and Grimes, R.: Treatment of Fractures of the Spine with and wi thout Neural Injury. New York State J. Med. 42: 866-873, 1942. 3. Cramer, F. and McGowan, F.: The Rule of the Nucleus Pulposus in the Pathogenesis of So-called "Recoil" injuries of the Spinal Cord. Surg., Gynec. & Obst. 79: 516-521, 1944. 4. Barnes, R.: Paraplegia in Cervical Spine Injuries. J. Bone & Joint Surg. 30B: 243244,1948. 5. Taylor, A.: The Mechanism of Injury to the Spinal Cord in the Neck without Damage to the Vertebral Column. J. Bone & Joint Surg. 33: 542-547, 1951. 6. Davis, A. G.: Injuries of the Spinal Column: In Military Surgical Manuals, National Research Council, Orthopedic Subjects. Philadelphia, W. B. Saunders Co., 1942, p. 97. 7. Tarlov, 1. M., Klinger, H. and. Vitale, S.: Spinal Cord Compression Studies. 1. Experimental Techniques to Produce Acute and Gradual Compression. Arch. Neurol. & Psychiat. 70: 813-819, 1953. 8. Tarlov, 1. M. and Klinger, H.: Spinal Cord Compression Studies. II. Time Limits for Recovery after Acute Compression in Dogs. Arch. Neurol. & Psychiat. 71: 271-290, 1954. 9. Tarlov,1. M.: Spinal Cord Compression Studies. III. Time Limits for Recovery after Gradual Compression in Dogs. Arch. Neurol. & Psychiat. 71: 588597,1954. 10. Gelfan, S. and Tarlov, 1. M.: Differential Vulnerability of Spinal Cord Structures to Anoxia. To be published in J. N europhysiol. 11. Tarlov,1. M. and Herz, E.: Spinal Cord Compression Studies. IV. Outlook with Complete Paralysis in Man. Arch. Neurol. & Psychiat., 1954. 12. Tinsley, M.: Compound Injuries of the Spinal Cord. J. Neurosurg 3: 306-309, 1946. 13. Cone, W. V.: Personal communication. 14. Allen, A. R.: Surgery of Experimental Lesion of Spinal Cord Equivalent to Crush Injury of Fracture-Dislocation of Spinal Column. J.A.M.A. 57: 878-880, 1911. 15. Allen, A. R.: Remarks on the Histopathological changes in the Spinal Cord Due to Impact: An Experimental Study. J. Nerv. & Ment. Dis. 41: 141-147, 1914. 16. Freeman, L. and Wright, T.: Experimental Observations of Concussion and Contusion of the Spinal Cord. Ann. Surg. 137: 433-443, 1953. 17. Thompson, J. E.: Pathological Changes Occurring in the Spinal Cord Following Fracture-Dislocation of the Vertebrae. Ann. Surg. 78: 260-293, 1923. 18. Crutchfield, W. S.: Skeletal Traction for Dislocation of Cervical Spine: Report of Case. South. Surgeon 2: 156, 1933. 19. Crutchfield, W. S.: Skeletal Traction in Treatment of Injuries to the Cervical Spine. J.A.M.A. 155: 29-32, 1954. 20. Hoen, T. 1.: Technical and Occasional Notes: A Method of Skeletal Traction for Treatment of Fracture Dislocation of Cervical Vertebrae. Arch. Neurol. & Psychiat. 36: 158, 1936. 21. Cone, W. and Turner, W. The Treatment of Fracture-Dislocation of the Cervical Vertebrae by Skeletal Traction and Fusion. J. Bone & Joint Surg. 19: 584602,1937. 22. Tarlov,1. M.: Plasma Clot Suture of Peripheral Nerves and Nerve Roots; Rationale and Technique. Springfield, IlL, Charles C Thomas, 1950. 23. Tarlov, 1. M., Berman, D., Kellerman, E. and Moldaver, J.: Cauda Equina
Spinal Cord Injuries-Early Treatment
607
Nerve Root Regeneration through Nerve Grafts. J. Neuropath. & Clin. Neurol. 1 (2): 111":'144 (April) 1951. 24. Munro, D. and Holm, J.: Tidal Drainage of the Urinary Bladder: A Preliminary Report. New England J. Med. 212: 229,1935. 25. Covalt, D., Cooper, I., Hoen, T. and Rusk, H.: Early Management of Patients with Spinal Cord Injury. J.A.M.A. 151: 89-94, 1953. 1249 Fifth Avenue New York 29, N. Y.
MECHANISM OF INJURY AND ITS BEARING ON POSTURAL TREATMENT
Sharp flexion of the spine results in fracture, often of a compression type, of one or more vertebral bodies, and sometimes in the forward dislocation of an upper upon a lower vertebra. The anterior surface of From the Department of Neurology and Neurosurgery, New York Medical College, Flower and Fifth Avenue Hospitals, New York, N. Y. * Professor and Director of the Department of Neurology and Neurosurgery , New York Medical College, Flower and Fifth Avenue Hospitals; Attending Neurosurgeon, Flower and Fifth Avenue Hospitals, and Metropolitan Hospital, New York, N. Y. 591
..,... 592
I. M. Tarlov
the spinal cord may thus be compressed over the edge of the lower vertebral body (Fig. 147). The upper vertebral body must therefore be extended to release the spinal cord from compression. It has been supposed that spinal cord injury without visible skeletal damage also results from acute hyperflexion involving vertebral dislocation immediately and spontaneously reduced by muscular action. This hypothetical series of events has been called "recoil injury" of the cervical spine. * This explanation, however, was shown to be improbable by Cramer and McGowan,3 who postulated acute flexion of the neck as
Fig. 147. A, Fracture-dislocation of C5-C6 before reduction by Crutchfield tongs. B, Fracture-dislocation of C4-C5 after reduction by Crutchfield tongs and fusion by parallel grafts taken from iliac crests. Fusion was done because of recurrence of fracture-dislocation. (Case of D~. Joseph Milgram.)
the cause of a supposed temporary disk displacement. Their evidence was a herniated intervertebral disk compressing the spinal cord as the result of an acute injury without vertebral fracture or dislocation, but they had no proof that a temporary prolapse of a disk could occur or injure the spinal cord. Barnes4 demonstrated that hyperflexion can cause cord compression only if it is sufficient to dislocate and lock the articular processes. Locking of this type proved insusceptible to spontaneous reduction. It is therefore probably not true that hyperflexion, without causing visible vertebral damage, can injure the spinal cord through temporary, self-reduced fracture-dislocation. TaylorD has recently shown that injury to the cervical cord without vertebral fracture or dislocation usually results from forcible extension of the neck rather than from hyperflexion. Such accidents are exemplified by diving with the head back into shallow water or by falling or being thrown forward while the head is arrested by a fixed object. Taylor has
* This series of events is thought to occur in some "whip-lash" injuries of the neck in which during a collision the head is snapped forward and back or back and forward on the neck as a pedicle.
Spinal Cord Injuries--,-Early Treatment
593
demonstrated by cadaver experiments that under these conditions the agent that impinges on the spinal cord is a forward bulge of the ligamentum flavum. Thus he very plausibly suggests that cases of cervical quadriplegia without radiographic evidence of bone damage or displacement should be regarded as injuries caused by forcible hyperextension and treated by immobilization in slight flexion without traction. To nurse patients with such hyperextension injuries in hyperextension is to cause further cord compression. Other traumatic vertebral lesions also call for avoidance of spinal hyperextension. Among these are odontoid fractures resulting from blows forcing the head backward, posterior dislocation, in which the upper vertebra is dislocated backwards upon the lower one, and intervertebral disk herniations alone or in combination with a vertebral fracture or dislocation or with both. Barnes has noted that elderly patients are predisposed to hyperextension injuries because age tends to develop kyphosis of the thoracic spine, usually compensated by cervical lordosis (extension deformity of the neck). Mobility of the spine is, moreover, often impaired by arthritic changes in joints and ligaments. "In the event of a fall, the neck cannot be flexed in the normal defensive manner, so that when the head strikes the ground powerful angular strain in extension is applied to the cervical region." Hyperextension fractures may follow falls from heights in which the body strikes an object crosswise in the lumbar region. "Thus the leverage of the weight of both ends of the body is directed against the middle .... " and "the anterior longitudinal ligament may rupture."6 In such cases treatment by hyperextension may cause immediate paralysis. The diagnosis of such hyperextension fractures may be apparent from the lateral x-rays in which the vertical height between the vertebral bodies is increased. "Pull in a straight line, using the posterior ligamentous investiture as a check strap . . . may serve to restore nearly normal conformation of the fractured body."6 TREATMENT AT THE SCENE OF THE ACCIDENT
The treatment of patients suffering from spinal injuries should begin at the scene of the accident, because mismanagement-faulty first aid or transportation-may produce or intensify cord injury or make a recoverable neural lesion irrecoverable. When spinallesions are suspected because of pain in the neck or back, paralysis or loss of sensation, the alignment of the spine must not be changed except judiciously on the basis of an understanding of 'the mechanism by which the injury was produced. By no means should the patient be allowed to flex his head, sit up, stand, walk, or make:any unnecessary movements. He should not be lifted from the ground by his shoulders and feet but should be allowed to lie in the neutral anatomic position on his back until ready to be transported.
I. M. Tarlov
594
If the mechanism of the force that produced the injury is known, the patient should be transported with his spine in an opposite position. Certainly everything possible concerning the production of the injury and the rapidity of onset of the neurological disturbance should be determined. An injury to the face is occasionally the clue that a cervical injury occurred in hyperextension. These patients should be transported supine on a rigid litter, board or other rigid surface with a small pillow, folded blanket or coat about 3 inches high under the head to produce slight flexion. Cervical hyperflexion injuries are at times associated with injury to the vertex. Such patients should be transported with the shoulders, rather than the neck, slightly raised to produce hyperextension of the neck. If there is a kyphos at the site of the injury, transportation in a position of hyperextension appears advisable. A patient with a herniated intervertebral disk (Fig. 148) or a fractured vertebral arch, if transported in hyperextension, would incur damage to the cord, or have the damage aggravated, by having the cord kinked over the disk protrusion or a part of the fractured vertebral arch. * In the past, massive extrusions of intervertebral disks caused by spinal injuries have probably been overlooked. When the mechanism producing spinal injuries is not known, it is safest to transport the patient in the supine position with the body held straight in the neutral anatomic position, the spine neither flexed nor extended. At least three persons are required to move the victim of a spinal injury: one person pulls on his feet, another on his head; or, if the lesion is thoracic or lumbar, the head-end traction may be applied under the armpits. One or two other persons gently lift or roll the patient into the desired position on a rigid litter. In cervical spine injuries folded blankets or clothing should be fixed at each side of the head to prevent lateral movement. Traction and countertraction should always be exerted when the patient is moved. Shouiders and pelvis must rotate in the same plane, and the spine must be kept in the same relative position, as though the patient were a rigid log. EXAMINATION IN HOSPITAL
The patient should not be moved from his litter until he has reached the x-ray table, the operating table; or the hospital bed. Clothing should be removed with minimum manipulation of the patient. At all times distorting the injured spine must be avoided. If the patient is in surgical shock, he should be placed in the shock position (lowered head), covered with blankets, and whole blood and * The writer recently treated a man who fell from a height and suffered almost complete paralysis of his feet caused by a herniated intervertebral disk. Hyperextension of the back markedly accentuated his pain, as is almost invariably true in cases of herniated intervertebral disks. Transporting this man in hyperextension would have increased the already marked compression of his cauda equina.
Spinal Cord Injuries-Early Treatment
595
other fluids and perhaps stimulants given. He should not be moved until he has been adequately treated for shock. The pulse, blood pressure, respiratory rate, and temperature should be frequently recorded.
Fig. 148. Photographs taken at operation upon a totally paralyzed patient in whom there was a fracture-dislocation of C5-C6 and also an extruded intervertebral disk shown by arrow in A. B, Photograph taken after removing the disk. C, Illustrating the fusion accomplished with a bank-bone graft. (Case of Dr. William V. Cone.)
For the relief of pain morphine sulfate in 16 to 32 mg. Oi to Y2 grain) doses subcutaneously may be given, but in -high cervical cord lesions respiration may be affected. In such circumstances the use of morphine is dangerous because it depresses respiration, and codeine sulfate in doses of 32 to 65 mg. (Y2 to 1 grain) should be used. Barbiturates are useful to relieve anxiety. The patient should be thoroughly examined as quickly as possible. When change of position is necessary, traction and countertraction
I. M. Tarlov
596
should be maintained; and the patient lifted or rolled like a log. Acute injuries elsewhere may of course require treatment before the spinal injury. The patient should be catheterized if necessary, and an indwelling urethral catheter should be introduced if there is evidence of severe spinal cord injury. At the earliest safe opportunity a neurological examination should be made with special emphasis on the degree of sensory and motor loss; Anteroposterior and lateral x-rays of the spine should be taken stereoscopically. In injuries to the atlas and axis additional views through the open mouth should be taken. Because vertebral lesions at C7, Dl and D2 are sometimes overlooked roentgenographically, one must obtain adequate x-ray views of these vertebrae before excluding fracturedislocations as a cause of spinal cord injuries referable to these levels. Great care is imperative when taking x-rays to avoid altering the alignment of the spine. If the patient has completely lost sensation and motor power below the level of the injury, whether or not x-rays show bony injury, a lumbar puncture should be made with the aid of a spinal fluid manometer and jugular compression (Queckenstedt test*). While this is done the patient should be placed on his side, and his spinal alignment should not be changed. If jugular compression reveals no evidence of spinal fluid block, operation would be pointless. If the patient does not show complete sensorimotor paralysis, then lumbar puncture and manometric examination are not immediately necessary. The Queckenstedt test should be carried out only as a preliminary procedure to a contemplated operation, which is not indicated as an emergency procedure under these conditi
The immediate reduction of fracture-dislocations is desirable to reduce pain and to secure a more stable and mobile spine. The primary object of such reduction in the paralyzed patient, however, is to relieve spinal cord compression. But indriven fragments of bone or soft tissue or other foreign bodies, or the presence of hemorrhage or edema around the spinal cord may maintain spinal cord compression even after the dislocation has been reduced. Is it possible to reverse the immediate complete paralysis, heretofore irrecoverable? Our animal experiments show 7 • 8. 9 that it is possible provided the compression is relieved within a relatively short time and
* Queckenstedt Test. Compressing the jugular veins digitally or with an inflated blood pressure cUff normally causes a prompt rise in cerebrospinal fluid pressure, which is transmitted throughout the subarachnoid spaces. Obliteration of the spinal subarachnoid spaces prevents transmission of these pressure changes below the level of the block. If pressure does not rise within the manometer attached to the spinal needle when the jugular veins are compressed, one may conclude that the spinal subarachnoid spaces are obstructed provided abdominal straining or coughing does raise pressure. If it does not, the needle is obstructed by a nerve root or meninges or other tissue, and its position must be changed and the test repeated.
Spinal Cord Injuries-Early Treatment
597
provided the compressive force is not too great. The magnitude of the compression, as well as the extent to which there has occurred irreversible damage to the spinal cord caused by laceration and other lesions, cannot be known in advance. One must assume that recovery of function can occur and treat these patients in the light of rational principles evolved from animal experiments as well as from clinical experience. A comparison of the effects of ischemia with those of spinal compression in our animals has shown that mechanical deformation rather than anoxia is the main cause of spinal compression paralysis. lo This is fortunate, because the capacity for recovery of spinal cord function is in general much greater with mechanical deformation than with ischemia. Our studies have shown, moreover, that when small compressive forces cause acute complete paralysis in dogs it may be totally reversed if the compression is removed within two hours. The cauda equina is much more resistant to compression, and even with great compressive forces total sensorimotor paralysis is reversible if the compression is released within five hours or even a longer time. 9 Hitherto the results obtained in treating acute total spinal cord paralysis caused by fracture-dislocationll have been dismal. Our analysis of 26 cases of complete spinal paralysis of traumatic origin in which laminectomy was done showed persistent complete paralysis. We have also reviewed a control series of nine surgically unexplored cases of spinal injuries in which there was immediate complete sensorimotor paralysis. Except for slight improvement in sensation and somewhat better activity of muscles supplied by nerve roots at or close to the level of the injury, there was no significant recovery in any case. In view of these uniformly dismal results it is now imperative to determine whether the outlook can be brightened by applying our experimental results to man. * Immediate total sensorimotor paralysis associated with a spinal fluid
* That recovery may occur in totally paralyzed patients after immediate decompressive laminectomy is shown by the experience of Tinsley12 and also of Cone.1I Tinsley reported 2 patients upon whom laminectomy was done for complete transverse lesions at C7 and Tn, 22 and 27 hours respectively after spinal injuries caused by high explosive shells. The first patient "was moving his toes and feet, position sense and touch were returning, there was a patchy return of sensation to pinprick.•.." when the last follow-up examination was made 14 days after operation. At the time of the last follow-up report of the other patient 22 days after operation, ''he was urinating spontaneously and moving his legs up to his knees. Sensation had returned to pinprick and touch although it was patchy and incomplete." W. V. Cone 11 did a laminectomy and fusion on a man aged 39 years approximately 24 hours after he sustained a fracture-dislocation of C5-C6, causing complete sensorimotor paralysis. An extruded intervertebral disk was also removed. Sensation began returning 14 days later. At the time of the last examination, 6 months after operation, there was moderately good power in all movements of the left lower limb. On the right side, slight hip flexion and extension of the knee were present. Pain sensation was normal over the right lower limb and impaired over the left. Touch sensation was present but vibratory sensation was absent over both lower limbs. It would be desirable to know the subsequent course of these patients, but the available data on them support the present writer's experimental results. Moreover, when we consider the utter hopelessness of such patients if not operated on,U it is clear that immediate decompressive laminectomy is justified.
598
I. M. Tarlov
block calls for immediate laminectomy to decompress the spinal cord and reduce any dislocation. The test for spinal subarachnoid space patency should precede the operation to exclude those rare cases of immediate paralysis resulting from spinal cord concussion, in which spontaneous recovery occurs. The next question that arises is whether the dura should be opened in such cases. The writer has seen two patients in whom the dura was opened. Immediately spinal cord tissue extruded itself through the opening. * It seems unwise, then, to open the dura, but it would appear desirable to split the outer layer of the dura to increase the decompressive effect. Whether it would be increased by removing cerebrospinal fluid above and below the traumatized cord segments would have to be determined by trial. Progressive functional spinal loss leading to serious spinal paralysis is another indication for immediate laminectomy. Hence, frequent neurologic examination should be made in patients suffering from spinal cord injuries. If neurologic signs improve, conservative treatment is the correct choice. If sensory and motor signs steadily advance, laminectomy should be considered. If total paralysis occurs or seems imminent, immediate laminectomy is urgently indicated. Total paralysis of gradual onset can be more readily reversed by decompression than total paralysis of sudden onset. The more gradual the course and the less complete the paralysis the more favorable is the outlook after compression is relieved. However, the more gradual the development of the paralysis and the less complete it is, the more justified is continuance of conservative treatment. If, in the presence of severe, handicapping neurologic signs, with or * Allena ,15 attempted to determine how long the spinal cord may be compressed without precluding functional recovery. He produced contusion of the spinal cord of dogs by dropping upon it known weights from known heights. The degree of impact was measured in gram-centimeters. Allen believed that the edema following the impact reached maximum about 4 hour after the injury. He concluded that if the spinal cord compression caused by the edema could be prevented, the spinal cord might recover some function. Accordingly, he advised midline posterior incision of the spinal cord through the contused segment to drain and release the intramedullary pressure. He made such incisions in dogs 2 hours after injury by a force known to produce complete paralysis. He reported that he could thus avert the disintegration of the cord tissue that invariably occurred in the control dogs in which the spinal cord was not incised. Similar experiments were recently carried out by Freeman and Wright,16 who made the same recommendations as Allen. A valid objection to Allen's interpretation of the changes which he described is well expressed by Thompson: "There is no doubt that the substance of the cord is clearer and better preserved in the incised than in the nonincised specimen but there is such a decrease in transverse area of the cord that we can't help feeling that the diffiuent tissue which escaped from the incision carried with it a considerable amount of nervous tissue which had not been seriously injured and which might have been expected reasonably to have recovered if it had not been disturbed. While it lies in the substance of the cord it acts as support to the uninjured tissue surrounding it. Evacuation removes this support and the walls of the cavity cave in like the sides of a sand pit or the banks of a river when the waters recede. On these grounds we believe that the evacuation is not without its drawbacks and its dangers."17
Spinal Cord Injuries-Early Treatment
599
without x-ray evidence of bony injury, improvement does not occur when the patient is conservatively managed for approximately a week, then laminectomy is in order if lumbar puncture with the aid of a manometer and jugular compression shows evidence of a spinal fluid block The less severe the neurologic signs the more justified is one in delaying laminectomy. A fourth indication for immediate laminectomy is the presence of fragments of bone or other foreign bodies in the spinal canal. Lumbar puncture is not necessary in these cases. CONSERVATIVE MANAGEMENT
For patients with cervical fracture-dislocation, skeletal traction is a simpler, more effective and more comfortable means of traction than a halter. Crutchfield tongs18 • 19 or some modification may be easily and quickly applied to the patient's skull in bed, permitting patients to be comfortably turned. These tongs have two prongs that enter drill holes made through small incisions on each side of the skull (Fig. 149). To avoid an uneven pull on muscles and tendons the tongs are applied in a vertical plane passing through the articulations of the cervical spine. The mastoid tips are approximately within this plane and serve as satisfactory landmarks. When the tongs are properly locked, the points will not bore in. If no tongs are available, traction can be applied by passing heavy steel wires through two close trephine openings on each side of the skull about an inch from the midline near the vertex.20 If there is x-ray evidence of an anterior dislocation of an upper on the lower vertebra (flexion injury, Fig. 150), the head should be moderately hyperextended by placing a small pillow under the shoulders. If x-rays show the relatively uncommon p05terior dislocation (hyperextension injury), the head may be somewhat flexed while traction is maintained. Hyperextension or flexion of the neck may also be obtained by applying the tongs somewhat in front of or behind their usual site of application to the skull. Traction should begin with about 5 pounds of weight and be increased by 2 pounds at a time up to 15 to 35 pounds. The head of the bed is elevated about 20 degrees for countertraction. X-ray studies should be made every few hours and just enough traction applied to reduce the dislocation. Reduction, often achieved within a few hours (Fig. 150), is maintained with a minimum of traction (5 to 10 pounds). The maintenance of greater traction may impede proper healing. Six weeks is allowed for healing of the ligaments that maintain spinal alignment and for firm fibrous union between the injured vertebrae. The patient may then get out of bed and be fitted with an adjustable brace (Fig. 149) to be worn for about three months. Because of the greater injury to spinal ligaments, traction is maintained for a longer time (8 to 12 weeks) in patients with atlanto-axial fracture-dislocations, and a support is worn for six months. Compression fractures of the atlas and axis require shorter periods of traction because
600
I. M. Tarlov
Fig. 149. A, Application of Crutchfield skull tongs. B, Traction correctly applied in line with the articulating facets. C, Light-weight adjustable brace. (Taken from Crutchfield. IS)
they "tend to remain in a satisfactory position... "19,20 If atlanto-axial or other dislocations tend to recur (Fig. 147, B), then fusion such as described by Cone and Tumer21* is indicated. • These authors consider fusion indicated in fractures of the odontoid and a.lso in multiple fractures of a vertebra. Even though this policy would probably prevent late spinal cord compression syndromes, it is not generally followed. However, this policy has yielded excellent results in the hanas of W. V. Cone21 who, using felt-lined boots, produces sufficient traction to reduce dislocated thoracic or lumbar vertebrae during laminectomy done on his ingeniously designed operating table. It is true that patients with satisfactory spinal fusions require shorter periods of bed rest and cast or brace immobilization than patients conservatively treated. These advantages, however, would appear to be offset by the disadvantages of a major surgical operation.
Spinal Cord Injuries-Early Treatment
601
Skeletal traction is usually ineffectual in reducing fracture-dislocations of the thoracic and lumbar spine. * In such cases hyperextension on a Bradford frame or on any convex surface centered at the point of the deformity should be tried provided the abnormal neurologic signs are not increased by this position. Gradually increasing hyperextension may be satisfactorily produced by using a reversed Gatch bed with the knee elevator coming up under the back at the site of the dislocation. Hyperextension may also be achieved by placing a blanket roll 18 inches in diameter transversely between a fracture board and a hard hair mattress over which is an air mattress. The patient remains in the hyperextended position for approximately two weeks, and then wears a bivalved plaster
Fig. 150. Fracture-dislocation of C4-C5 before (left) and after reduction (right) by skeletal (tong) traction.
cast extending from the top of the sternum to the symphysis pubis for two to three months. He is then allowed to get out of bed, but must wear a brace for four to six months. The bivalved plaster of Paris shells facilitate turning the patient and give easy access to the skin. Buckle straps meanwhile hold the shells firmly together. The hyperextended position often reduces thoracic and lumbar fracture-dislocations. The weight of the upper and lower parts of the body serves to bring the kyphosed and displaced spine back to its normal lordotic conformation. This method is simpler, often as efficient, and less of an ordeal for the patient than suspending him in a canvas hammock with his head and shoulders face down on one operating table and his pelvis on the other, t or by jacking up the Iilpine at the site of the injury. Perfect reduction of a spinal dislocation is desirable but fre-
* Attempts to directly force the vertebrae back into position while traction is being made are sometimes successful. A lateral force exerted at the level of the injury may reduce the uncommon lateral dislocation of a lumbar vertebra (Fig. 151). t The weight of the patient produces the necessary extension force and a close. fitting plaster of Paris jacket is then applied.
602
I. M. Tarlov
quently impossible. Moderate dislocation is compatible with recovery of spinal cord or cauda equina function and satisfactory spinal stability. If x-rays show no dislocation, traction is unnecessary. Such patients should be treated in the neutral anatomic position with the head neither flexed or extended. If closed methods of reducing dislocations fail and the patient is severely handicapped neurologically, he should be treated by open operative reduction provided the Queckenstedt test shows evidence of a spinal fluid block.
Fig. 151. Fracture-dislocation of I"3-L4 before (left) and after reduction (right) by longitudinal traction and lateral pressure at the level of the lateral dislocation. (Case of Dr. Joseph Milgram.) .
Occasionally in the lumbar region one encounters a complete fracturedislocation, with severe displacement encroaching on the neural canal. If there is severe paralysis, even though not complete, laminectomy and open reduction should be attempted. Fractures of the sacrum which may be associated with fractures of other parts of the pelvic ring are seldom accompanied by displacement of fragments. Therefore, bed rest is usually the only form of therapy required. Any severed nerve roots should be repaired. Primary nerve-root suture is hardly ever feasible because nerve substance is lost through the injury or through preparatory trimming of the frayed ends. Owing to anatomic limitations, the procedures for shortening gaps in peripheral nerves cannot be used on nerve roots. Grafting becomes necessary instead. Segments of severed posterior roots, which never regenerate, may be used to graft severed anterior nerve roots. If posterior roots have not been severed, segments of intercostal nerves may be used as grafts.
Spinal Cord Injuries-Early Treatment
603
It is impossible to suture these delicate roots satisfactorily with the conventional thread technique. Plasma-clot suture is ideal,22 however. Although clinical experience with the use of autologous nerve-root grafts sutured with plasma clot is "at present inadequate to assess the procedure, the excellent histological regeneration of the cauda equina in monkeys after such grafts23 makes it imperative to employ this technique in man. GENERAL CARE OF THE PATIENT
The paralyzed patient requires constant nursing care during the first few weeks. Pressure sores and urinary and pulmonary complications must be prevented and morale kept high. Bed sores are always pressure sores which can almost always be prevented by special nursing measures. The patient should lie on an air or sponge rubber mattress and a perfectly smooth bedsheet. Twice daily he should get an alcohol rub and then have his skin powdered to keep it dry. Every two or three hours his paralyzed muscles should be massaged, his extremities exercised, and his position changed. Minor adjustments of position should be made more often, and the skin over bony prominences should be massaged more often. A Stryker frame* facilitates turning and other care. Pressure on the heels should be prevented by resting them on soft cotton rings or by putting small pillows or blanket rolls under the calves. The knees should be kept slightly flexed over another pad under the lower thighs. The legs should always be separated by pillows. Bedclothes should be supported by a cradle or board at the foot of the bed to prevent their weight from causing foot drop. To keep the feet dorsally flexed, a pillow should be placed between them and the board. Hypostatic pneumonia is a postoperative hazard especially in cervical injury cases. Nasopharyngeal, intratracheal and bronchoscopic suction are used when indicated to remove excessive secretion. Frequent turnings lessen the hazard. The objective in managing the paralyzed urinary bladder is to establish adequate drainage with a minimum of urinary sepsis until automatic function resumes. An indwelling catheter with tidal drainage such as that described by Munro24 is employed. Early return of bladder tone and
* The Stryker frame (J.A.M.A. 119: 1731-1732, 1939) consists of 2 rectangular metal frames over which are stretched strips of canvas. These frames are like Bradford frames with openings in'-the canvas to facilitate use of the urinal or bed pan'. When the patient is to be turned a second frame is placed over him and securely fastened to one on which he is lying. The 2 frames are then locked together and with the patient pressed between them fastened to steel disks (turning devices clamped onto the head and foot of t.he bed) at each end. The disks can be rotated and locked in position. After the patient is turned, the frame on which he originally lay can be removed. This apparatus permits frequent and easy turning by a single nurse. When the patient is lying on the anterior frame his head is supported by a sponge-rubber face piece under the cheeks and forehead. His eyes a.re about 15 inches from the mattress so that he may read or write. A reading board may be suspended above him when be is on his back.
"'I
I. M. Tarlov
604
automaticity are best achieved by tidal drainage, which minimizes puddling of residual urine and provides for irrigation of the bladder and its regular emptying and filling at a predetermined level of intravesical pressure. The indwelling catheter is changed weekly, and all patients on constant urethral drainage are given systemic chemotherapy. Mechanical drainage is discontinued when automatic bladder function resumes, usually within 4 to 12 weeks. Patients who do not develop automatic bladder function must depend upon a receptacle strapped to the thigh. Bowels. Proper diet and mild laxatives usually keep the bowel contents semisolid and easily removable by enema or suppository. This avoids fecal impactions or stools so soft that soiling and maceration of the skin become troublesome. Occasionally atony of the bowel produces distressing distention which may usually be relieved by administering drugs such as prostigmine, pitressin, pilocarpine or Doryl, or by using a MillerAbbott tube. When on a bed pan the patient must be supported by pillows or folded blankets under his back and thighs so that his weight is not on the bed pan itself. Supportive Measures. Poor nutrition retards recovery of sensory and motor function and delays healing. Hence an adequate caloric, protein and vitamin intake is essential. Falling serum levels in early convalescence must be supported by transfusing whole blood or plasma. Postural Treatment. Covalt and his co-workers25 have stressed the importance of early standing in combating the fall of blood proteins, urinary tract infection and calculi, and osteoporotic changes as well as in promoting the healing of ulcers. They use the tilt board to which the patient is strapped. This treatment is started "10 to 14 days after ... the ordinary laminectomy.... The angle of inclination at the start should be around 30 degrees. The patient is watched closely for signs of discomfort, such as paleness, increased sweating, and increase of pulse rate .... This should be accomplished twice daily until the patient is standing in an upright position. Time of standing should be increased to a minimum of one hour daily." Rehabilitation. Paraplegic centers for the after-care of permanently paralyzed patients provide vocational training and offer considerable hope and encouragement to them. Thanks to modern rehabilitation techniques, control of urination and defecation, satisfactory sexual activity, ambulation with artificial aids-which is the best assurance against genitourinary tract stones or infection-complete self-care is frequently achieved by these patients, who may even beget children, become employable, and lead active social lives. SUMMARY
Injury to the spinal cord may result from forcible vertebral extension as well as flexion. The well established practice of placing patients with spinal injury in the hyperextended position is justified only in injuries
Spinal Cord Injuries-Early Treatment
605
resulting from sharp spinal flexion. To nurse patients with hyperextension injuries in hyperextension is to increase cord compression. When the mechanism producing spinal injuries is not known it is safest to transport and to treat the patient in the supine position with the body held straight in the neutral anatomic position, the spine neither flexed nor extended. Skeletal traction, usually ineffectual in reducing fracture-dislocations of the thoracic and lumbar vertebrae, is the safest and most effective method for reducing cervical fracture-dislocations. To reduce fracturedislocations of the thoracic and lumbar spine, hyperextension should be used provided the abnormal signs are not thereby increased. If dislocations tend to recur then spinal fusion is indicated. In spinal injuries with immediate complete sensorimotor paralysis no appreciable restoration of function occurs without operation. On the other hand, recent experimental, and clinical evidence too, shows that complete sensorimotor paralysis can be reversed in some cases provided the compression is relieved surgically within a relatively short time. It is therefore imperative in cases of immediate total paralysis associated with a spinal fluid block to do a laminectomy at the earliest possible time to decompress the spinal cord and to attempt to reduce any dislocation. Progressive loss of spinal function leading to serious paralysis or the presence of fragments of bone or other foreign bodies in the spinal canal also calls for immediate laminectomy. Moreover, if in the presence of severe handicapping neurologic signs, improvement does not occur when the patient is conservatively managed for approximately a week, then laminectomy is in order if the Queckenstedt test shows evidence of a spinal fluid block. ADDENDUM
After this paper was written there appeared a review by Wanamaker on the early treatment of 300 consecutive cases of spinal cord injuries sustained during the Korean conflict (J. Neurosurg., Nov., 1954, p. 517). He provided convincing evidence of the value of early laminectomy in treating patients with complete sensorimotor paralysis below the site of injury. Of 27 such patients with cervical injuries, 17 showed postoperative improvement. Twenty-nine of the 70 totally paraplegic patients suffering from injuries of the lumbar spinal cord, conus medullaris or cauda equina improved after laminectomy. Even in a group of 109 patients whose thoracic spinal injuries, producing complete sensorimotor paralysis of the lower limbs, were complicated by "concomitant lesions in the thoracic and abdominal cavities, often necessitating a delay in laminectomy," 17 showed improvement. Recovery, in all cases being referable to the long tracts of the spinal cord, was complete in seven patients. In only 28 per cent of the patients was the laminectomy done within 24 hours. In all likelihood the incidence of recovery would have been greater if it had been possible to operate on more of these patients sooner. At any rate, Wanamaker's data support the present writer's experimental and clinical evidence favoring emergency operation in patients with complete sensorimotor paralysis after a spinal injury. This recommendation is especially
I. M. Tarlov
606
urgent in view of the writer's experience that these patients do not recover without laminectomy except in cases of spinal cord concussion, in which the Queckenstedt test shows no evidence of a spinal block. Doubtless many victims of spinal injury can be saved from a life of paralysis by immediate laminectomy.
REFERENCES 1. Baldwin, R. and ver Brugghen, A.: Unpublished data cited in ver Brugghen, A.: Neurosurgery in General Practice. Springfield, Ill., Charles C Thomas, 1952. 2. Browder, J. and Grimes, R.: Treatment of Fractures of the Spine with and wi thout Neural Injury. New York State J. Med. 42: 866-873, 1942. 3. Cramer, F. and McGowan, F.: The Rule of the Nucleus Pulposus in the Pathogenesis of So-called "Recoil" injuries of the Spinal Cord. Surg., Gynec. & Obst. 79: 516-521, 1944. 4. Barnes, R.: Paraplegia in Cervical Spine Injuries. J. Bone & Joint Surg. 30B: 243244,1948. 5. Taylor, A.: The Mechanism of Injury to the Spinal Cord in the Neck without Damage to the Vertebral Column. J. Bone & Joint Surg. 33: 542-547, 1951. 6. Davis, A. G.: Injuries of the Spinal Column: In Military Surgical Manuals, National Research Council, Orthopedic Subjects. Philadelphia, W. B. Saunders Co., 1942, p. 97. 7. Tarlov, 1. M., Klinger, H. and. Vitale, S.: Spinal Cord Compression Studies. 1. Experimental Techniques to Produce Acute and Gradual Compression. Arch. Neurol. & Psychiat. 70: 813-819, 1953. 8. Tarlov, 1. M. and Klinger, H.: Spinal Cord Compression Studies. II. Time Limits for Recovery after Acute Compression in Dogs. Arch. Neurol. & Psychiat. 71: 271-290, 1954. 9. Tarlov,1. M.: Spinal Cord Compression Studies. III. Time Limits for Recovery after Gradual Compression in Dogs. Arch. Neurol. & Psychiat. 71: 588597,1954. 10. Gelfan, S. and Tarlov, 1. M.: Differential Vulnerability of Spinal Cord Structures to Anoxia. To be published in J. N europhysiol. 11. Tarlov,1. M. and Herz, E.: Spinal Cord Compression Studies. IV. Outlook with Complete Paralysis in Man. Arch. Neurol. & Psychiat., 1954. 12. Tinsley, M.: Compound Injuries of the Spinal Cord. J. Neurosurg 3: 306-309, 1946. 13. Cone, W. V.: Personal communication. 14. Allen, A. R.: Surgery of Experimental Lesion of Spinal Cord Equivalent to Crush Injury of Fracture-Dislocation of Spinal Column. J.A.M.A. 57: 878-880, 1911. 15. Allen, A. R.: Remarks on the Histopathological changes in the Spinal Cord Due to Impact: An Experimental Study. J. Nerv. & Ment. Dis. 41: 141-147, 1914. 16. Freeman, L. and Wright, T.: Experimental Observations of Concussion and Contusion of the Spinal Cord. Ann. Surg. 137: 433-443, 1953. 17. Thompson, J. E.: Pathological Changes Occurring in the Spinal Cord Following Fracture-Dislocation of the Vertebrae. Ann. Surg. 78: 260-293, 1923. 18. Crutchfield, W. S.: Skeletal Traction for Dislocation of Cervical Spine: Report of Case. South. Surgeon 2: 156, 1933. 19. Crutchfield, W. S.: Skeletal Traction in Treatment of Injuries to the Cervical Spine. J.A.M.A. 155: 29-32, 1954. 20. Hoen, T. 1.: Technical and Occasional Notes: A Method of Skeletal Traction for Treatment of Fracture Dislocation of Cervical Vertebrae. Arch. Neurol. & Psychiat. 36: 158, 1936. 21. Cone, W. and Turner, W. The Treatment of Fracture-Dislocation of the Cervical Vertebrae by Skeletal Traction and Fusion. J. Bone & Joint Surg. 19: 584602,1937. 22. Tarlov,1. M.: Plasma Clot Suture of Peripheral Nerves and Nerve Roots; Rationale and Technique. Springfield, IlL, Charles C Thomas, 1950. 23. Tarlov, 1. M., Berman, D., Kellerman, E. and Moldaver, J.: Cauda Equina
Spinal Cord Injuries-Early Treatment
607
Nerve Root Regeneration through Nerve Grafts. J. Neuropath. & Clin. Neurol. 1 (2): 111":'144 (April) 1951. 24. Munro, D. and Holm, J.: Tidal Drainage of the Urinary Bladder: A Preliminary Report. New England J. Med. 212: 229,1935. 25. Covalt, D., Cooper, I., Hoen, T. and Rusk, H.: Early Management of Patients with Spinal Cord Injury. J.A.M.A. 151: 89-94, 1953. 1249 Fifth Avenue New York 29, N. Y.