Professional Documents
Culture Documents
ROLAND
From the Department
IN
CERVICAL
GLASGOW,
Surgery,
SPINE
SCOTLAND
University
INJURIES
BARNES,
of Orthopaedic
of
Glasgow
The
Edwin ments scious pessimism and and
of
first
Smith
recorded papyrus,
reference written
spine ago.
is to be unknown
found author
in
the cornSuch
four
briefly
(1)f his
upon
two was and
of
the
arms
condition and
two
One
and
having
for in
a crushed
An of patients survivors of caliper spite the
vertebra
ailment notable traction with are left
of his neck,
to be contributions Coleman, with parapjjie
he is uncon
is speechless.
treated. by
not more
without recently
cord
Taylor, Crutchfield,
paralysis.
McKenzie, degrees
considerably
spinal
varying
most
puzzling
features
is the cord in
lack
of
correlalesion. believed
between are
of the
spinal
cord
in which
by injury
evidence taken
observations. study
Radiographic
shows
of the
quite
spinal
clearly canal
the
cannot in
of
secured of any
the
fracture
absence
of
unless
there
graphic
evidence
the
articular
processes
which
will
permit
spontaneous
reduc-
tion
of the
dislocation
we
should
look
alternative
of the
and a series
hyperextension of twenty-two
The
with
number paraplegia
each
in Table
cervical
Flexion
injuries. . . . . . . . .
Dislocation
8 cases
Crush
Acute
fracture
retropulsion
of vertebral
of
body.
intervertebral
disc
. .
4 3 15
Total
Hvperextension
Dislocation Injury to arthritic
injuries. . . . . . . . . .
spine
1 6 7
Total
types
of
flexion body;
injury 3) injury:
may acute
be
recognised: of dislocation;
THE
1) an
dislocation; disc. to
BONE
2) There arthritic
JOINT
a vertebral of hyperextension
retropulsion
1) posterior
an
AND
JOURNAL
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PARAPLEGIA
IN
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INJ
1RIES
235
FIG.
displacements of the cervical spine in which the dural sac has filled with lipiodol. A shows the specimen in neutral position and C, D, E degrees of flexion dislocation. B is a soft tissue radiograph of the spinal for comparison of size. In C there is subluxation of the articular processes. In 1) one articular process is locked. In E both articular processes are locked. The spinal cord is not compressed by the displaced neural arches until at least one articular process is locked.
Experimental
be
these
were
not
an tends series
reason
in a Spinal age
which groups
flexion age;
injuries,
dislocation in
in patients encountered
30 B,
236 fifty-seven three patients years with of age. disc The injury, mortality all
R.
BARNES
rate
in
all
types
was
high
except
in
the
group
of
of whom
survived.
INJURIES dislocation
OF of the
THE cervical
SPINE it is generally on by easily, pressure the dorsal agreed surface that cord of the
a combination
of two
cord
surface is the damage
by
the
of the
dislocated
neural
retropulsed choice. and with The
arches
disc better
co-incident
traction reduced the
compression
means without of the
of the
of a skull risk disc of
ventral
caliper further than by
Skeletal of relieving
treatment to the
dislocation
presented
no unusual
features
and
it would
were none
of
this disc.
type,
all
due of
to bone
forcible injury
head
radiographic
evidence
the
radiographs
34
an
showed
ears-Fe1l
hour
the
cycle
on
to
the
of and
the upper
paralysis
in was of of
the no urine.
examination of the 3). a large compressed fourth, after and operation, legs block, had and By
the
margin
narrowing spinal
there revealed
retention
Oueckenstedt damaged
myelography
intervertebral vertebrae.
to
third
day
of the the
there
disc and had disc
complete
observed laminae, removed. the patient
cord power
until and
laminae months
steady to walk
of motor
able
(ornnient-Radiographic accident, spinal In treatment acute vertebral reasonably Similar Although examination of the cord. have disc will traction the of skull by now the disc disc, canal the and as other (Table and cases revealed this the no two II), the have doubt result and
indicated to injury.
the
disc protrusion
was
degenerated of disc occurred substance without injury the make and readings, severe was narrowed the
the the
of proof evidence
by inter-
protrusion. certain.
mechanism
injury,
Little
(1939).
Queckenstedt
Brookes of
post-mortem compression
Treatment-We cord caliper the not fluid disc happen pressure, traction is negative. in acute traction substance
to
treatment that height, into the under recovery should and be the knuckle the
likely not
to
relieve that
on least
the of does
protrusions. restore may should cord traction, Fleiss and find its
degenerated space. on the and within even have when reported cord
injury,
is possible
intervertebral
straighten
If paraplegia skull
test
is incomplete, is justified.
and
If
the
there
Queckenstedt
test
severe of Brooke
gives
normal
readings
of cerebro-spinal
preliminary a few the days cases of
application compression
Queckenstedt of cord
(1944)
readings.
THE JOURNAL
a herniated
manometric
OF
BONE
AND
JOINT
SURGERY
PARAPLEGIA
IN
CERVICAL
SPINE
INJURIES
237
FIG. Case
2
Flexion injury disc between after block at of the cervical the third and injection the level
FIG.
3
paraplegia.
is theca narrowed
1.
is
W. T.,
that
no the bone
shows Lthere
spine
fourth
with
cervical the
incomplete
vertebrae lumbar disc.
Fig.
but
Myelography complete
(Fig.
3)
shows
4
years. Fracture Fig. there of cervical spine with residual sixth the
4.
two
A. G., aged
yeans
30
of vertebra.
upper Fig.
and
lowet
5 shows
vertebra.
VOL.
30 B,
NO.
2, MAY
1948
238
R.
BARNES
TABLE
POSTERIOR PROTRUSION OF
II
INTERVERTEBRAL Disc
Case
Age
Nature
of
Radiographic
Type
of
Quecken-
Operative
appearances Narrowing of disc between C.3 and 4 with arthritic lipping of adjacent vertebrae. No bone injury.
Mvelograph revealed
Result
paraplegia Incomplete
test
1 \V. T.
34
complete the 2
W.
at
39 S.
Fell
cycle
from and
Marked of disc
Incomplete
No
block
Nil
Almost
conlete
C .5
bone
turned
somersault
and
upping
6 with
of
arthritic
adjacent
recovery
No
No
block
Nil
Considerable recovery
TABLE
CO!PRESSION
III
FRACTURES
Case
Age
Nature injury
of
Radiographic appearances Compression fracture of C.6. Myelograph later showed persistent anterior filling defect at level of fracture Comminuted body fracture of C.5
Treatment
Result
4 A. G.
30
Incomplete recovery
40 T.
J.
Fell feet
on
of
twenty to deck
ship
Complete
Nil
Death on the day of injury. Post mortem -herniationof disc in addition to fracture;
severe
crush
cord
of
\V.
6 McA.
18
P e r for m i n g hand spring; arms gave way and fell heavily onneck
Complete
Nil
Death second day. Post mortem no evidence of dislocation; severe crushing of cord at level of fracture tracIncomplete recovery
18 R.
J.
Root of fell on to
of head
tree back
Compression of C.4
fracture and 5
Incomplete
Caliper
Queckenstedt-no
tion
ten weeks
block
\Vhen demonstrated
there by traction.
is
strong
presumptive decompression
evidence of
of the
disc cord
protrusion, is indicated
and
spinal
block In these
is
manometry,
urgently.
circumstances
than caliper
laminectomy
is likelr
to
be
more
effective
in relieving
pressure
on the
cord
THE
JOURNAL
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239
crush of the crushed was fractures articular made but of the paraplegia, injury.
treated two anterior years in a later filling plaster with defect
of
patients evidence
.
dislocation
are (Cases
there disc
dislocation
survived
initially of two
sixth the
recovery
aged
and of a both 30 half
of function
rears-Crush months. upper
Centre
a constant was
which
I)rotrusin
could
hardly
(Figs.
be
explained 5).
)resumably
clue
to
(usc
4 and
of
evidence injur\ by in
view to
to
of
Cramer
and of the
pressure
compression
of the
spontaneous
fracture to that
of a cervical of compression
vertebra of the
therefore
a retropulsed
HYPEREXTENSION I have paper by injuries been Crooks unable and Birkett to find (1944). were over
fifty
SPINES spines by no had means arthritic responsible except for all in the
injuries these
In the
cord
present
series
in patients
there
of age
patients
Age incidence of Hyperextension Injuries in Arthritic Spines compared with remaining types Cervical Injury.
as of
6
Hyperextension arthritic
injuries spines
in
-
ii
Ii
Other
types of injury
cervical
FIG.
20
30
4-3
50
60
70
80
in
the
spine one
aged was
or
severe The
and proved
there fatal to
his
was illustrate
radiopatients
graphic although
Case the
of recent had
injury. paraplegia.
a distance
Two
of ten
serve
on to
forehead,
neck.
There
paralysis changes
loss cervical
fifth
cervical
urine condition
was
passed deteriorated
voluntarily. steadily
Queckenstedt
VOL
30 B,
NO.
MAY
240
R.
BARNES
FIG.
11G.
8 paraplegia.
is ossified and inter-
Case 12. T. B., aged 63 years. Hyperextension injury of osteoarthritic spine Fig. 7 shows an osteophyte avulsed from lower margin of C.3. The anterior between C.4, 5, and 6. Fig. 8 shows the autopsy specimen; the anterior vertebral disc between (.3 an(l 4 are ruptured.
of
the
anterior the
the
and
at
of
appearance
constriction
post-mortem Ossification
of
beyond ligament
and
that lower
localisation have
9. 7.
vertebrae,
anterior
not
imniediately
above recovered.
.V.,
cord
injury
aged
58
years-Fell sensation
from
a were
glass impaired
roof
on below
to
his the
head. fourth
There cervical
was cord
complete segment;
motor other
Radiographs
There was
showed no change
of the
moderate in the
anterior disc
arthritic neurological
common was avuisecl
changes hndings
ligament from hyperextension with on the both articular
in until
between
the he
cervical died
the of
spine eighteen
no
evidence
after
Post-mortem
showed
sixth
and
seventh
vertebra
cervical
but the
vertebrae
posterior injury;
(Fig. 9).
common the capsule upper of
the
body
of
the spine
upper was
acting
the
processes The
The
joint
was
sides.
spinal no
cord intra-
normal
appearances
aI)art from
observed
slight
on section
constriction
of the
opposite
cord (Fig.
the
10).
sixth
cervical
vertebra;
to four
those
in
12,
and than
to hyperextension
it is therefore
is possible,
PARAPLEGIA
IN
CERVICAL
SPINE
INJURIES
241
,,.
x.
I
FIG. Case 9. common T. N., aged 58 years. ligament between Fig. 10 shows slight
9
Hyperextension
(.
FIG.
10
injury
and
constriction
7 is ruptured
of the
with incomplete paraplegia (Fig. 9). The anterior and the disc is avulsed from the upper vertebra. spinal cord at the level of vertebral injury.
of
extreme well No
hyperextension, be and several the segments examination radiographic injuries. in Table IV. A post-mortem
and
in higher
circumstances the vertebral other little and in the leave the TABLE clinical I\
IN
of but that
might accident,
appearances, summary
radiographic
features
the
HYPEREXTENSION
INJURIES
ARTHRITIC
SPINES
Case
Age
Nature i nj urv
of
Radiographic appearances
(if
Result
57
Fell
downstairs
to face
on
J. S.
osteoarthritis. avulsed
of C.6.
from No
Recovery from
apart residual
displacement 9 T. 10 M. C. N. 77 Knocked motor 58 Fell through roof down car glass Moderate No fracture Advanced \ertebrae (.4. of Fracture osteoarthritis. or dislocation spondylitis. ankylosed lower on below margin Incomplete
weakness hands
l)eath day Incomplete Death day fourth second
in
by
C.3.
Backward
of C.3
displace4
by 5 cm. No Complete Death after one week injury
ment
11 J.
Mc.
67
Knocked car
down
by
12
T. B.
63
Fell
from
ladder
Incomplete
l)eathtenthday
distance
on to
of
ten
head
feet
Fracture
lower
of
anterior
osteophyte
margin
on
f
(.3. 13 G. B. 61
Fell seven head feet from Gross
No
dislocation
No Incomplete I)eath second
osteoarthritis.
scafiolding
on to fore-
fractuce.
tervertebral C .4 and
Widening
of in-
(lay
VOL.
30 B,
NO.
2,
MAY
1948
242
Mechanism factors. \\ith of injury-Elderly advancing \ears patients there
R.
BARNES
are is usually sion relatively degree jury by of joints neck manner, the
hperextension of the by neck-Fig. and liable 1942). by In the in the the head to any cause The arthritic event thoracic cervical
injury spine lordosis 12). increase strain risk when of normal strikes the a of This
by
two
is a tendency deformity
position,
injury in the
is greater
in extension brunt of this ligament : it be the itself is spinal the further of of of the the the the disc no may of backwards
disc
to falls from
the
anterior
small
lower 1 1). the
flake
anterior The vertebra tear disc,
of
bone
margin extends or the
upper may
intervertebral
to flexion little
herniate
canal
f hvperextension inj urv of spine. lhe anterior common is torn or avulsed with a hone There is no (lislocation of articular
or
the the ma
alignment
vertebrae
for
of have
the
cord
to
infind
mpletelv
of
satisfactory spinal
cord
explanalesion in
hvpercxtension
Unlike neither
vertebrae,
there
of
nor
is not
of the
C(
intervertebral
damage
the five
possible cord
the
sjiinal by reof a
been be
considere(l:
caused
1)
that
it
may
spinal sult of
the
body; to
of
or
2)
that
injury hvper-
it
at
Tracing of radiograph to of
Fio.
12 deformity
kyphosis.
traction extreme
extension
thoracic
of
The
cervical
angle
5P11
between
compensatory
severe
extension.
pedlicles an(l body is more acute than in a normal spine an(l the spinalcanal is therefore narrowed.
THE
JOtRNAI.
OF
BONE
AND
JOINT
SURGERY
PARAPLEGIA
IN
CERVICAL
SPINE
INJURIES
243 for (Fig. thoracic I 2) canal that minor separation be traction injury was cor(l
,
is extension vertebral is narrowed. margins of safety. may be and that the in observed
deformity bodies of In that some sufficient the these to when patients injury and
of the the in
neck
compensating is decreased arthritis, into the cord. considerable that to there level this spinal it is possible
the
and
Moreover, vertebral
osteophytes
J)roject further
the
vertebrae bodies
i)ral the
it is tempting vertebral
postulate
max of view.
cord.
segments
jIG.
13
11G.
14
markers have the third common ligament have been divided the distalce between
Steel
i)etween
been placed in the spinal cord through the intervertebral (usc and fourth, and fifth and sixth vertebrae (Fig. 13). Flie anterior and intervertebral disc between the fourth and fifth vertel)rae and the neck hyperextended (Fig. 14). There is no increase in the markers an(I therefore no evjdence that traction force has been applie(l to the spinal cOr(i.
were inserted
on cadavers the were intervertebral pushed a steel the markers two below was markers the forcibly radiographs Finally nee(lles
to
the spinal
accuracy
of
this above
hypothesis. and checking the below the lumen films ligament placed ere and between the and and any injury crude, of neural and the the of the be
immediately
cord.
one
After through
the
introduced Further anterior \Vith in order until taken spinal in cord failed be the living due to experiments subject, which stop The
needle and
spinous
X-ray
distance
processes
common wedges
to simulate
vertebral an arthritic
the
a considerable
gap
Further measured.
markers markers,
tests
the accurately
is
admitted,
that
it would
to dismiss
vOL.
possibility 1948
lesions
short
30 B,
2,
244 Treatment-There of an arthritic canal, of the of cord application Since more nursing improvement comfortable the than care becoming use of on a few and neck. function, often a small more cervical any spinal flexion tion their is no vertebral It is not and aware paraplegic ambitious remaining hours hastens pillow elderly the of the to indication The for
R.
BARNES
the
use that
traction is not
in
hperextension backwards easily jackets been to the merit or content arrange results of making by assist collars to the are
spine.
intervertebral
displaced
displacement necessary patients fatal true keep methods, or days nature the It to
be is corrected for of plaster I have flexed, claimed it has life. and that the
use are
splintage
it cannot
termination. of these neck cannot but at of the slightly be least patients injuries
patient.
SUMMARY Twenty-two been Flexion fracture presented there is no compression laminectomy Hyperextension to arthritic in The plegia scribed.
The author Neurosurgical observations.
paraplegia
injury three 3) view types acute that of bone
complicating
may of disc be flexion protrusion injury, and and due
injury
to injury: of an is the in some the flexion
of
1)
the
or
cervical
hyperextension 2) disc. of at for the least caliper cord
column
compression Evidence lesion there traction
have
violence. is when is a and
reviewed. injury-There of in
retropulsion
intervertebral
when
years
hyperextension discussed.
under
causes
thank Mr at Killearn
of spinal
Nichols Hospital,
treatment,
Case 1 which
wishes to Service
his
care
in
the
Tulloch
Brown
for
assistance
with
the
experimental
W.
S.
(1944):
and and
Journal
LITTLE,
of
the
125,
Surgery.
117. 24,
79,
L. T.,
M. F., M., and and
KUHNS,
J. G. (1942):
N. (1939):
F. A. N. H.
329.
516.
1, 798.
Obstetrics,
J.
(1944):
F., A.
(1944):
(1943):
31,
Medical
252.
Association, Section of
N., G.
123,
Orthopaedics,
(1940):
Proceedings
Medicine,
THE
JOURNAL
OF
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