paraplegi 1

8/13/2019 paraplegi 1

1/11

F le xion in jur ies -Dis loca t ion . . . . . . 8 c ase sC rush frac tu re of ver teb ral b ody . . . 4Acute retropu lsion of in te rver teb ra l d isc . 3

Total . . . 15H vpe re xtens ion in jur ie s-

Dis loca t ion . . . . . . 1In ju ry to ar th r itic sp in e . . . . 6

Total . . . 7

23 4 T H E JO UR NA L O F B O NE AND JO INT SUR G E RY

PA R A PL E G IA IN C E R V IC A L SP IN E IN JU R IE SR O L A N D B A R N E S , G L A S G O W , S C O T L A N D

F rom the D epar tm en t o f O rth opa ed ic S urgery, U niv ersi ty o f G la sg ow

T he firs t record ed re fe rence to parap leg ia in cerv ica l sp ine in ju r ies is to be foun d in theE dw in S m ith p ap yrus , w ritten som e four thou sand years ago . T he unkn ow n au thor corn -m e n t s b rie fly upo n th e con d ition : O ne hav in g a crush ed ve rteb ra o f h is neck , he is uncon -sc ious (1 ) f h is tw o arm s and tw o legs , and is sp eech less. A n a ilm en t no t to be trea ted . Suchpessim ism w as n o t w ithou t ju stifica tion fo r in sp ite o f no tab le con tribu tion s by W altonand T ay lo r, and m ore recen tly the in trod uc tio n of ca lip er trac tio n b y C o lem an , M cK enz ie ,and C ru tch fie ld , cons ide rab ly m ore than ha lf the p a tien ts w ith parap j e from the o f sp ina l c ord in jpy, and m an y surv ivors a re le ft w ith vary ing degreesof paraly sis.

O ne of the m os t p uz zlin g featu res o f in ju ries o f th e cerv ica l sp ine is the lack of corre la -tio n be tw een the d eg ree of verteb ra l d isp lacem en t and the severity o f the sp ina l co rd lesion .T here a re cases w ith no rad iograph ic ev idence of bone in ju ry in w hich the cord is irre trievab lydam aged ; o thers, w ith g ross d isloca tio n , m ay have no parap leg ia . It is com m only b e lievedtha t th e sp ina l co rd is dam aged by the d is located neura l a rches, and in the absence o frad io graph ic ev idence of b one in ju ry it is assum ed tha t spon taneou s redu ction of thed is loca tion has taken p lace. T h is v iew is n o t, ho w ever, in accord w ith experim en ta l o rp ost-m o rte m ob servat ion s.

R ad iog rap h ic s tud y o f sp ec im e ns in w h ich the dural sac has been filled w ith lip iodo lshow s qu ite clea rly tha t the d is lo cated n eu ra l a rches do n o t p roduce a degree o f narrow in gof th e sp inal cana l w hich w ould co m press th e cord un til the re is lock ing of a t least on ear ticu la r p ro cess (F ig . 1 ). O nce th e articu lar p rocesses a re locked the d isloca tion is usua llystab le , and red uc tion canno t be secured w ithou t m an ipu la tion . F urthe rm ore , exam ina tion m e tha t sp in al co rd

occur in the absence of any verteb ra l d is1o caq p ,j and un less the re is c lea r id io - -gra ph ic e v id enc e o f fra ctu re of th e ar ticu lar p roc esses w h ich w ill p e rm it sp on taneo us red uc -tion of the d isloca tion w e shou ld lo ok fo r an alte rna tive ex p lana tion of the cord in ju ry .

T Y P E S O F C E R V IC A L IN JU R YD am age of th e cerv ica l co rd m ay be caused by flex ion in ju ries and h yperex tens io n

injuries. T he n um ber of cases o f each typ e of cerv ica l in ju ry in a se ries o f tw en ty -tw opa tien ts w ith parap leg ia is show n in T ab le I.

T A B L E I

T hree ty pes o f flex io n in ju ry m ay be recogn ised : 1 ) an te rio r d is location ; 2 ) c rushfrac tu re o f a verteb ra l bod y ; 3 ) acu te re tropu ls io n of an in te rverteb ra l d isc . T h ere a retw o ty pes of hyp erex ten sion in ju ry : 1 ) pos te rio r d isloca tion ; 2 ) in ju ry to an arth r itic sp ine .


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P A R A P L E G IA IN C E R V I C A L S P IN E IN J 1 R IE S 23 5

VO L . 30 B , NO . 2 , s iv 1948

B

FIG . 1E xper imen ta l d i s p lac emen t s of th e c erv ica l sp in e in w hic h the d ural s ac hasbe en fille d w ith lip io do l. A sh ow s the sp ecim en in ne u tral po sit ion a nd C , D , Esh ow de gre es o f flex ion d is loc atio n . B is a so ft tissu e rad io gra ph of th e s p in a lco rd fo r c om par iso n of size . In C the re is sub lux ation o f th e art icu lar p roc esses.In 1) on e articu lar pro ces s is loc ked . In E bo th articu lar pro ces ses are lo ck ed .T h e sp ina l cord is n o t co m p res sed by the d isp la ced n eu ral arch es u n til a t lea st

on e ar ticu la r p ro ce ss is locked .

It m us t be em phasised tha t th ese tw en ty - tw o cases w ere n o t an u nse lec ted grou p , fo rthe reason tha t som e w ere treated in a S p ina l In ju ry C en tre w h ich ten ds to rece ive th e m o reo bscure ty pes of in ju ry . It is like ly the re fo re tha t an un se lec ted ser ies w ould show a h igherp ro portion of d isloca tio ns. T he age in c id en ce o f th e various g roups is in te res ting (F ig . 6 ).A ll flex ion in ju ries , and the one d is lo ca tion in ex ten sion , occurred in p a tien ts und er fifty y earso f age ; n o hyp erex tens ion in ju r ies in a rth ritic sp ines w ere encoun te red in pa tien ts un der


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23 6 R . B A R N E S

fifty -seven years o f ag e. T h e m orta lity ra te in a ll types w as h igh ex cep t in the grou p ofth ree pa tien ts w ith d isc in ju ry , all o f w ho m su rv ived .

F L E X IO N IN JU R IE S O F T H E C E R V IC A L SP IN EC erv ica l d is lo ca tion s -In d is loca tion of the cerv ica l sp ine it is genera lly agreed tha t co rdin ju ry m ay b e due to a co m bina tio n of tw o facto rs : a ) p ressu re o n the dorsa l su rface o f theco rd b y the d islo ca ted n eura l arches ; and b often co -in c iden t co m pression of the v en tra lsu rface of the cord by re trop u lsed d isc m ate ria l. S ke le ta l trac tion by m eans of a sk u ll ca lipe ris the trea tm en t o f cho ice . T he d is lo ca tion can be red uced easily , w itho u t risk o f fu rthe rd am age to th e cord , and w ith be tte r p rospec t o f re liev ing the p ressu re of th e d isc than b yo the r m e tho ds. T he n ine d isloca tion s in th is ser ie s p re sen ted n o un usua l fea tu re s an d it w ou ldb e unp ro fitab le to d iscuss th em in fu rth er d eta il.A cute re tropu lsion o f d isc -T h ere w ere th ree cases o f th is ty pe , a ll due to fo rc ib leflex ion of the h ead on the trunk . In non e w as there rad iograp h ic ev idence of bone in ju ryb u t a ll the rad io graphs sh ow ed narro w ing of on e in te rverteb ra l d isc .

Ca se I. IV . 1., ag ed 34 e ars-F e 1 l ov er th e ha ndleba rs of h is cy cle o n to the b ac k of h is h ead . H ewas exam in ed w ith in an hou r of th e acc ide n t an d fou nd to h av e inc om ple te p ara lys is an d sen sory los sin th e lo w er lim b s, tru nk , an d up per l im b s. R ad iog rap h ic ex am ina tion sho w e d lipp ing o f th e an ter io rm arg in o f th e th ird an d fou rth ce rv ical v erte bra e and nar row ing of th e in terv erte bra l d isc (F ig . 2 ). T he rew as n o b on e in ju ry . O n th e da y a fte r in ju ry pa ralysis of th e legs h ad increased and th ere w as reten t iono f u rin e. T h e O uec ke nste d t te st sho w e d co m p lete sp in al b lock , a nd m ye log rap hy re vea led a n arresto f lip iod o l op pos ie th e d am age d in te rve rte bral d is c (F ig . 3 ). B y the th ird day there wa s comple tep ara lys is of bo th leg s. L am ine cto m y wa s pe rform e d , and a large p ro trusion of the d isc w a s ob servedb etw ee n th e th ird and fou rth ver teb rae. T h e co rd w a s c om pre sse d b etw ee n the d isc an d the lam ina e,a nd p ulsatio n d id no t retu rn to th e cord u nti l the th ird , fo urth , an d fifth la m inae ha d be en re m o ved .T h e r e wa s ste ady reco very of m oto r pow er a nd sen sat ion a fte r o peratio n , and tw o m on ths la ter the pa tien tw as a b le to w alk w itho u t sup po rt.(o rnn ien t-R ad iograph ic ev id en ce ind ica ted tha t th e d isc w as degenera ted befo re theacc iden t, and th is no d oub t p red isposed to m ass ive pro trus ion of d isc subs tance in to thesp ina l cana l as the resu lt o f flex ion in ju ry .

In the o ther tw o cases , cons id erab le recovery o f para lys is o ccu rred w itho u t op erativetrea tm en t (T ab le II), and th ere is the re fo re no pro of tha t th e cord in ju ry w as cau sed b yacu te d isc p ro trus ion . N everthe less the m echan ism of in ju ry , the narro w ed in te r-ve rteb ra l d isc , and th e absence of rad iograph ic ev idence o f bo ne in ju ry , m ake the d iag nos isreason ab ly certa in .

S im ila r cases h ave been reported b y B rook e (19 44) an d B row n and L ittle (19 39).A lth ough the Q ueckensted t tes t in B rook es pa tien t gav e norm al read in gs, pos t-m ortemexam ina tion revea led a la rge pro tru sion of the d isc w h ich w as cau sing severe co m press ionof th e cord .Trea tmen t-We have n ow to con sider th e treatm en t m o st lik ely to re lieve pressu re on theco rd in acu te d isc p ro tru sions . P rov id ing tha t th e d isc is no t degenera ted befo re in ju ry ,ca lipe r trac tion w ill resto re the norm al d isc h eigh t, and it is possib le th a t som e a t least o fthe d isc substance m ay find its w ay back in to the in te rverteb ra l space . E ven if th is d oesn o t happen trac tio n shou ld stra igh ten ou t th e k nuck le p ress ing on the co rd (Je fferson 19 40).I f p ar ap le gi a is in co m ple te , and the Q u eckens ted t te st g ives n orm al read in gs o f ce reb ro -sp ina lf lu id pressu re , th e cord is p robab ly no t under sev ere com press ion an d pre lim inary tr ia l o fsku l l traction is jus tified . If th ere is n o recov ery o f parap leg ia w ith in a few days of th eapp lica tion of sku ll trac tio n , lam in ectom y sh ou ld be consid ered ev en w hen the Q ueck ensted ttest is n eg a tive . F le iss an d Ingham (1943 ) an d B rooke (1944) have rep orted cases o f cordcom pression by a hern ia ted d isc w ith no rm al m anom etric read ing s.

T H E JO UR NAL O F B O N E AN D JO INT SUR G E RY


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F IG. 2 F IG. 3

F IG. 4 F IG. 5

P A R A P L E G IA IN C ER V IC A L S P IN E IN JU R IE S 23 7

VO L . 3 0 B , NO . 2, M AY 1948

C a se 1 . W . T. , a ge d 34 y ears . F lex io n in jury o f the cerv ic al sp ine w ith inco m p lete parap leg ia . F ig . 2sho w s tha t th e in terv erteb ra l d isc betw ee n th e th ird an d fourth c erv ic al v erteb rae is na rro w e d but

Lthere is no bo ne in jury . M ye lograp hy after in jectio n of lip iodo l in to the lum bar th eca (F ig . 3) showsc om plete b lo ck at th e leve l of the h ern ia ted disc.

C a se 4 . A . G ., aged 30 ye ars . F rac ture o f ce rv ica l sp in e w ith re sid ual pa raly sis o f uppe r an d low e tlim b s tw o ye ans after in jury . F ig . 4 sho w s crush fra cture of six th c erv ic al ve rtebra . F ig . 5 s h o w s

the m velo gram ; the re is a fillin g de fe ct opp osite the frac tured ver tebra .


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23 8 R . B A R N E ST A B L E II

P O S T E R IO R P R O T R U S IO N O F IN T E R V E R T E B R A L D isc

C a se A geN atu re of

in ju ryR a diogra phic

appearancesTy pe o f

parap leg iaQue c ke n-ste d t test

Ope ra t ivet reatmentL a m i n e c t -

om y

,

R e sul t

Consider -a b le re -covery

1\V . T .

34 Fhcb

eli ove ra nd leb ars ofv ie on toa ck o f h ead

N a rrow in g of d iscbetw ee n C .3 an d 4w ith a rth ritic l ipp ingof a d ja cen t v erte-brae. N o bon e in ju ry .M ve lograp h re vea ledco m p lete b loc k at

th e a bov e leve l

Inc om ple te C om ple teb lock

2W . S.

3 9 F ell fromc yc le andtu rn ed asome r sa ul t

M arke d na rrow in gof d isc be tw e en C .5a nd 6 w ith ar th r iticup ping of ad jac entve rte bra e. N o bo ne

Inc omple te N o blo ck N il A lm o stc on e terecovery

3 40 Fin jury

e li h ead lon g S ligh t n arrow ing of Incomplete . No block N il C on side r-B . R . dow ns tair s d is c betw ee n C .3 a nd

4 . N o o ther in ju ryB r o w n -

S#{233}quardsyndrome

a ble re -covery

T A B L E IIIC O P R E S S IO N F R A C T U R E S

C ase A g e N a ture ofin ju ryRadiograph ic

appearancesT y pe o f

parap leg la T reatm en t R esu lt

4 30 L o rry co l lid edA . G . w ith ano the r

v e h i c 1 e .T hro w n on toba ck o f he ad

C o m p res sio n fra ctu reof C .6 . M ye log rap hlater sh ow ed persist -en t an terio r fillingde fect a t leve l o f

f ractu re

Inc om ple te P laster ja cke t, Inco m p leteth ree a nd a rec ov eryh alf m o nth s

N il D e ath on th eda y of in ju ry .P o s t - mortem-hern iat ionofd isc i n a dd it io nto fra ctu re;severe c rush of

cord

5 40 F ell tw en ty C o m m inu ted fractu reJ. T . fee t on to dec k b ody o f C .5o f sh ip

Complete

6 18 P e r fo r m i n g\V . M cA . ha nd sp rin g ;

arm s g ave w a yan d fell heav ily

onneck

C o m p res sio n fra ctu reo f C .5 .

C om plete N il D e ath se con dda y . P os t -mortem - noev ide nce o fd islocat ion ;sev ere c rush in gof co rd at leve l

o f f ra ct ur e7 18J. R. R o ot o f treefel l on to bac k

o f he ad

C om pre ssio n f ractu reo f C .4 an d 5

IncompleteQ uecken-s te d t-no

b lock

C a lip er tra c-tion ten w e e k s

Incompleterecovery

\V hen there is stro ng p resum p tiv e ev idence of d isc p ro trusion , and sp in a l b lock isd em ons tra ted b y m an om etry , d eco m press ion of the cord is ind ica ted u rgen tly . In thesec ircu m stances lam inec tom y is like l to be m ore e ffec tive in reliev ing p re ssu re o n the co rdthan calipe r trac tion .

T H E J O UR NAL O F BO N E AND JO INT SU RG ER Y


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0 20 3 0 4 -3 5 0 60 70 8 0

P A R A P L E G IA IN C E R V IC A L S P IN E IN JU R IE S 23 9

VO L 30 B , NO . 2, MA Y 1948

C ru sh frac tu re o f cerv ica l ver tebra -Four pa tien ts su sta ined crush frac tu res o f thecerv ica l co lum n w itho u t rad io graph ic ev id ence of d isloca tio n of the articu la r p rocesses.T h ese cases a re su m m arised in T ab le III . Po st-m ortem ex am ina tion w as m ade in the tw ofata l cases (C ases 5 an d 6 ). In bo th , the sp ina l co rd w as severe ly c rushed b u t the re w as nod isloca tion of a rticu la r p rocesses . In C ase 5 there w as a la rge pro trusion of th e d isc in to thesp ina l cana l. T he tw o pa tien ts w ho surv ived had in itially in com ple te parap leg ia , and ve tthe re w as poor recovery of fun ction during a period of tw o years a fte r in ju ry .Ca se 4 . .-1 . G ., a ge d 3 0 rears-C ru sh frac ture o f the s ix th c erv ic al ve rte bra, trea ted in a plas terjac ke t fo r thre e an d a ha lf m on ths . H e w as ad m itte d to the S p inal In jury C entre tw o ye ars late r w ithres idu al para lys is of bo th uppe r and low e r lim bs . M velo gra hv sho w ed a con sta n t a n te rio r filling defe ctw hic h c ould h ard ly be exp lain ed b y th e re sid ual sp in al deform ity , a nd w as re sum ab ly c lue to (uscI)rotrusi n (F igs . 4 a nd 5).

T he ev idence of th is case s trong ly supp orts the v iew of C ram er and M cG ow an (19 44)th a t co rd in ju r\ in sim ple c rush frac tu res is due no t to p ressu re of the fractu red verteb ra lbody , o r to d is loca tion w ith sp on taneous red uc tion , b u t to c om pre ss io n of the ven tra l su rfaceof the cord by re tropu lsed d isc m ate ria l. T h e trea tm en t o f com pression frac tu re o f a cerv ica lve rteb ra com plicated by parap leg ia shou ld th erefo re b e o n s im ila r lines to th a t o f com p ress io nof the sp ina l co rd by a re tropu lsed in te rverteb ra l d isc .

H Y P E R E X T E N SIO N IN JU R IE S IN A R T H R IT IC SP IN E SI h av e been unab le to find an y re fe ren ce to in ju ries o f a rth ritic sp ines ex cep t in the

paper b y C ro oks an d B irk e tt (1 944). N everthe less th ese in ju ries a re by no m eans uncom m o n.In th e p re sen t se r ies th ere w ere six cases of th is type and th ey w ere respo nsib le fo r a ll sp ina lco rd in ju ries in pa tien ts over fifty years o f age (F ig . 6 ). A ll s ix pa tien ts had ar th ritic chang es

Age i ncidence of Hyper extensionInjurie s in Arthritic Spines ascompare d with remaini ng t ypes of

Cervical Injury. 6

Hyperextensi on injuries inarth ritic spi nes -

i Other types of cervica lIi injury

FIG. 6

in the cerv ica l sp ine of m odera te o r severe degree , an d th ere w as strik ing ly little rad io -g rap h ic ev idence of recen t verteb ra l in ju ry . T he in ju ry prov ed fa ta l in five of the six pa tien tsaltho ugh o n ly on e h ad com ple te parap leg ia . T w o cases se rve to illu stra te th e fea tu res:Ca se 12 . T . B ., ag ed 63 years-Fel l a dis tanc e o f ten fee t o n to h is foreh ea d , fo rc ib ly hype rextend ingth e ne ck . T here w as co m p lete m o tor paraly sis and sen so ry lo ss be low the fifth cerv ic al co rd seg m e nt.R ad iog rap hs sho w ed m ark ed o ste oar th r itic c han ge s in the cerv ica l sp in e w ith oss ific atio n o f the a n te rio rc om m o n lig am ent be tw een the fo ur th , fif th , and s ix th v erte bra e (F ig . 7 ) . A n o ste oph yte w as avu lse dfro m th e low er an ter io r m arg in o f th e th ird ce rv ical ve rteb rae ; the re w as no oth er bone in ju ry . F iv eho urs a fte r in ju ry he w as a b le to m ov e th e le ft leg , an d ta ctile se nsa tion h ad re tu rned to b oth low er lim bs .F ou r da ys af ter in ju ry the p atie n t w as ab le to m o ve bo th le gs and urine w as p asse d vo lun tar ily . T heQ u eck en sted t test sh ow e d no sp ina l b lo ck . F rom th e e igh th day h is c on dition d eter io rated stead ily an dh e died o n th e eleve n th d ay a fter in ju ry .


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8/11

I

,,. x .

24 1

V O L . 30 B , NO . 2, MA Y 1 9 4 8

P A R A P L E G IA IN C E R V IC A L S P IN E IN JU R IE S

IF IG. 9 F I G . 10

C ase 9 . T . N ., age d 58 yea rs. H y pere xte nsion in jury w ith inco m ple te pa ra ple g ia (F ig . 9 ). T he an terio rc om m on liga m e nt be tw e en . a nd 7 is rup ture d an d the d isc is av u lsed f rom the up per v erte bra .

F ig . 1 0 show s sligh t c ons triction of the sp inal c ord at th e le vel of v erteb ra l in ju ry .

o f ex trem e hyperex tens ion , and in these c ircum stances the upper leve l o f the cord les ionm igh t w ell be sev era l seg m en ts h igher than th e verteb ra l in ju ry .

N o pos t-m ortem exam ina tio n w as m ade in th e o th er th ree fa ta l cases b u t the na tu re o facc iden t, and the rad io graph ic appearances, leav e little room fo r dou b t tha t th ey too w ereh yperex tension in ju ries. A sum m ary of th e c lin ica l and rad iograp h ic fea tu res o f the sixcases is g iven in T ab le IV .

T A B L E I\H Y P E R E X T E N S IO N IN JU R IE S IN A R T H R IT IC S P IN E S

C ase A ge N atu re of R a diog ra phic T yp e (if R esulti n j u rv ap pea ranc es pa ra ple g ia

8 57J. S.

Fel l downstair s on M od erate os te oarthritis . In com plete R ec ove ry a pa rtto fa ce O ste oph yte avu lse d from from re sidu al

lo w e r m a rgin of C.6. No we akness indisp la c e me nt hands

9 58T . N .

F e ll th rou gh glass M od erate os teo arthritis . Inco m ple teroof N o frac ture or d islo ca tion

l)e ath sec ondda y

1 0 7 7M . C .

11 67J. M c.

K noc ke d dow n by A dva nce d spo ndyl itis. Inco m ple tem oto r c ar \erte brae ank ylosed be low

(.4 . F ra ctu re low er m arginof C .3 . B ackw ard d isp lace-m ent o f C .3 on 4 b y 5 cm .

D ea th fo urthda y

K no cke d dow n by G ross os teoa rthritis . N o C om pleteca r frac ture or d is loca tion

D ea th one w ee kafter in jury

12 63T . B .

F ell from lad der G ross os te oarthritis . Inc om p leted istanc e o f ten fe et F ra ctu re o f o ste oph yte on

on to hea d lo w e r an terior m arg in.3. No disloc ation

l ) e a th te n thda y

13 61 F ell seve n fe et from G ross osteoa rthritis . N o In com plete I)e ath sec ondG. B. sca fiolding on t o fore- frac tuce. Widening of in - lay

he ad terve rteb ra l spa ce b etw ee nC .4 and 5 ante riorly


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1 1G . 11\Iec ha nis ii f hvp erex tens ion in j u rv o f

ce rv ica l sp ine. lhe anterior com m onligam ent is torn or a vulse d with a honefrag m en t. T here is no (lis loc atio n of

a rticu la r

F io . 12

242 R . B A R N E S

T H E JO tR NA I. O F B O NE AN D JO IN T SU RG E RY

M ech an ism o f in jury -E lder ly pa tien ts are p red isposed to h perex tension in ju ry b y tw ofac to rs. \\ith advanc ing \ea rs the re is a ten dency to kvpho sis o f the thorac ic sp ine w hich

is usu a lly co m pensa ted by cerv ica l lo rdo sis (ex ten -s ion defo rm ity of the neck-F ig . 1 2). T h is is are la tive ly fixed pos ition , and any increase in thed eg ree of ex tension is liab le to cause stra in o r in -ju ry (B row n and K uhns 19 42 . T he r isk o f in ju ryb y hy perex ten sion v io lence is g reate r w hen m obilityo f the sp ine is im pa ired by arth ritic chang es injo in ts and ligam en ts. In th e even t o f a fa ll, theneck canno t be flexed in the norm al defens iv em anner, so tha t w hen th e h ead s tr ik es th e g roundp sT erfu l an gu la tio n s train in ex tens ion is app lied tothe cerv ica l reg io n . T he brun t o f th is v io lence fa llson the an te rio r co m m on ligam en t : it m ax rup tu re ;or a sm all flake o f bo ne m ay be av u lsed fromthe low er an te rio r m arg in of the u pper verteb ra(F ig . 1 1). T he tea r ex tends b ackw ards th rough th e

in te rverteb ra l d isc , o r the disc itself m ay b e to rnfro m the v er teb ra above . T h ere is no ten dency fo rthe d isc to hern ia te in to the sp in a l cana l as in thecase o f flex ion in ju ries. O nce the d isc has rup tu redthere is little resis tan ce to fu rthe r hvperex tens ion ,and consid erab le separa tion o f the v erteb ral bod iescan occur w itho u t rup tu re o f th e lax pos te rio r

com m on lig am en t o r the zvgapo physeal jo in t capsu les. Im m edia te ly the s tr ik in g fo rceis rem ov ed norm al a lig nm ent o f the verteb rae is resto red b y sp asm of the neck m usc lesand fo r th is reason the rad io -g raph ic appearances m a bedecep t ive . (C a se 9.N atu re o f th e sp in a l co rd in -ju ry -I h ave b een unab le to finda c m plete lv sa tis fac to ry explana-t ion of th e sp ina l cord lesion inthese hvpe rc xte ns ion in j u ri es .U n like flex ion in ju ries the re isne ithe r g ross d is lo ca tion of th ever tebrae, no r retropulsion of th ein te rver teb ra l disc. Th e C )r dda ma ge is no t usu ally severe , fo rthe parap leg ia w as in co m ple te infive of th e s ix pa tien ts. T w opo ss ib le ex plan ation s of the sjiina lco rd in ju ry have been cons idere (l:1 ) th at it m ay be caused by

spinal con cussion as th e re -s ult of mi nor d isplacement o f averteb ra l bod y ; or 2) tha t itm ay be due to traction in ju ry a t Tra cin g of rad io grap h o f e x te nsio n de form ity of cerv ic althe m om ent of ex trem e hv per- 5P1 1 com pen sa tory to se vere th orac ic kyp hosis. T he ang le

- be twe e n pedlicles an l body is more acute t han in a normalex tens ion . s pine an l the spinalcanal is therefor e narrowed.


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j IG. 1 3 11G . 14

P A R A P L E G IA IN C E R V IC A L S P IN E IN JU R IE S 24 3

v O L . 30 B , NO . 2, MA Y 1948

W hen there is ex tension d efo rm ity o f the n eck com pensa ting fo r thorac ic kvpho sis theang le be tw een the verteb ra l bod ies and the ped icles is decreased (F ig . I 2) , and co nsequ en tlythe sp ina l cana l is na rro w ed . M oreov er, in h ypertroph ic a rth ritis, o s teo phy tes m ay J)ro jec tfro m th e pos ter io r m arg in s o f the verteb ra l bod ies in to the sp ina l cana l and s till fu rthe rred uce the m arg in of sa fe ty . In th ese c ircum stan ces it is possib le tha t m inor d isp lacem en tsof the verteb rae m ay be su fficien t to co ncuss the sp in a l co rd .

W e have a lso observed tha t w hen the d isc is ru p tu red cons iderab le separa tion of verte -i)ra l b od ies is possib le and it is tem pting to pos tu late tha t the re m ax be traction in ju ry ofthe co rd . T he fac t th a t in som e pa tien ts the neuro lo g ical leve l o f co r(l in ju ry w as severa lsegm ents h igher than the v erteb ral in ju ry g av e supp ort to th is v iew .

S tee l m arke rs ha ve be en pla ce d in the spinal co rd throu gh the in te rverte bral (usci )e tween the th ird a nd fou rth , and fi fth and six th verte brae (F ig . 13) . F l ie a n te rio rco m m on liga m en t an d in te rverte bral d isc be tw e en th e fourth a nd fifth ve rtel)raehav e be en div ide d an d th e n eck h ype re xte nde d (F ig . 14). T he re is n o in crea se in

th e dis talc e betw ee n th e m a rkers an(I the refore no e vjd enc e th at trac tion forc e hasbee n a pplie(l to the sp inal c O r(i.

E x perim en ts w ere perfo rm ed on cad av ers to te s t the accu racy of th is hypo th es is. H o llown eed les w ere inser ted th ro ugh the in te rverteb ra l d iscs im m ediate ly abo ve and be low the o new hich w as to be d iv ided , and w ere pu shed on in to the sp ina l c ord . A fte r check ing the positionof the n eed les by rad iograph y a stee l m arker w as in trodu ced th roug h the lum en of eachn eed le in to th e sp in a l co rd and the nee(lles w ere rem ov ed . F urthe r X -ray film s e re takenand the d istance be tw een the m arkers m easured . T he an te rio r com m on lig am en t and in te r-v er teb ral d isc be tw een the tw o m arkers w as d iv ided . \V ith w edges p laced be tw een thesp in ous proce sse s abo ve and be low th e lev e l o f sec tion , in o rder to sim ulate the rig id ity ofan arth r itic sp in e, the neck w as fo rc ib ly hv perex tended un til the re w as a cons ide rab le g apb etw een th e verteb rae . Fu rthe r rad io graphs w ere taken in th is pos ition and the d istanceb etw een the m arkers aga in m easured . F ina lly the sp ina l co rd w as rem oved and the positiono f the m arkers rechecked by rad iograp hy . T hese tests fa iled to dem ons tra te any separa tiono f th e m arkers , and th e theory tha t parap leg ia m ay be du e to traction in ju ry of the cord isunsuppo rted . It m us t be adm itted , h ow ever, tha t the exp erim en ts w ere crude , and certa in lyd id n o t rep rodu ce accura te ly the cond itions of the liv ing sub jec t, SO tha t it w ou ld be un w iseto d ism iss fina lly th e possib ility o f m ild trac tio n lesions w hich s to p shor t o f neura l d isrup tion .


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24 4 R . B A R N E S

T rea tm en t-T h ere is n o ind ica tion fo r the use of ca lipe r trac tio n in hperex tens ion in ju ryof an arth r itic cerv ica l sp ine . T he in terverteb ra l d isc is n o t d isp laced backw ard s in to th esp ina l cana l, and any verteb ra l d isp lacem en t tha t the re m ay be is co rrec ted eas ily by m o dera teflex io n of th e n eck . It is n o t necessa ry to use ex te rna l sp lin tag e fo r it cann o t ass is t resto ra -tion of co rd fu nc tion , and e lderly pa tien ts a re so in to leran t o f p las ter jack ets o r co lla rs th a tth e ir app lica tion often has ten s the fa tal te rm in a tion .

S ince becom ing aw are of the true na tu re o f th ese in ju ries I have been co n ten t to do n om ore than u se a sm all p illow to keep the neck sligh tly flex ed , and to arran ge the u sua ln urs in g care o f a p arap leg ic pa tien t. It canno t be c la im ed tha t the resu lts a re anyim p rovem ent on m o re am bitious m eth ods , bu t a t least it has the m erit o f m ak ing m oreco m fortab le the few rem ain ing h ours o r days of the p atien ts life .

S U M M A R YT w enty -tw o cases o f p arap leg ia com p lica ting in ju ry o f the ce rv ica l co lum n have

been rev iew ed . T he verteb ra l in ju ry m ay be d ue to flex ion or h yperex tensio n v io lence .Flex ion in ju ry -T here a re th ree types of f lex ion in ju ry : 1 ) d isloca tio n ; 2 ) com pressionfrac tu re o f a verteb ra l b ody ; 3 ) acu te re tropu ls ion of an in te rverteb ra l d isc . E v id en ce isp resen ted in supp ort o f th e v iew tha t d isc p ro trusio n is the cau se o f the co rd les io n w henthere is n o rad io graph ic ev id en ce of bo ne in ju ry , an d in som e cases a t leas t w hen there is acom pression frac tu re . T reatm en t is d iscussed and the ind ica tions fo r ca lip er trac tio n andlam in ectom y are presen ted .H yp erex ten sion in jurv -T h ere are tw o ty pes of hyperex tens ion in ju ry : 1 ) d isloca tion ; 2 ) in ju ryto arth ritic sp ines. H yperex tens ion in ju ry of an ar th ritic sp ine is the usu al cause of p ara-p leg ia in p atien ts o ver fifty years o f age . T he m echan ism of hyperex tens io n in ju ry is d e-sc ribed . T he possib le causes o f sp ina l co rd in ju ry , an d its trea tm en t, a re d iscussed .

T he a utho r w ishes to th ank M r N ic hols for the clin ica l d eta ils o f C a se 1 w h ich w as unde r h is care in theN e urosurg ica l S erv ice at K ille arn H osp ital, a nd M r J. T u lloc h B ro w n for a ssis tan ce w ith the e xp erim en talobse rva t ions .

R E F E R E N C E SB R O O K E , W . S . (194 4): Jou rna l of th e A m erica n M e dica l A ssoc iatio n , 125 , 117 .B R O W N , L. T. , a nd K U H N S , J. G . (1942 ): Journa l o f B one a nd Join t S urge ry . 24 , 329 .B R O W N , M . M ., an d L IT TL E , N . (1939) : M e dica l Journa l of A ustralia , 1, 798 .C R A M E R , F ., a nd M cG oW A N , F. J. (1944 ): S u rg ery , G yne co logy, a nd O bstetric s, 79 , 516 .C R O O K S , F. , a nd B IR K E T T, A . N . 1944 : B ritish Journa l of S urge ry , 31 , 252 .F LEI5s , A . N ., and IN G H A M , H . (19 43) : Journa l o f the A m erica n M e dic al A ssoc iation , 123 , 759 .JEFFERSON , G . (1940 ): P ro cee din gs of the R oya l S o cie ty of M e dicin e, S e ctio n o f O rthopa ed ics , 33 , 6 57 .

TH E JO URN AL O F B O NE A ND JO IN T SURG ERY

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