Operation in Spinal-Cord Injuries

In lesions concealed from the surface involving a central nerve organization of extreme delicacy, the extent and precise nature of which are unknown without exploration, the after effects of such far-reaching importance, the parts reasonably accessible, and the possibilities so great of benefiting the patient, the operative stand-point in injuries to the spinal cord is found to be of special interest.This paper is based upon two cases of spinal-cord injury which Dr. Samuel J. Mi.xtcr permits me to report.Both cases were admitted upon Dr. Mixter's service at the Massachusetts General Hospital, Case I coming under my care while Surgical House Officer.In literature there are numerous valuable articles on in¬ juries of the spinal cord by Thomas,1 Courtney,2 Thorburn,8 Walton,4 Kocher,® Bastian,0 Lloyd,7 Lowenthal,8 Taylor,0 and others.Of recent papers that of Walton emphasizes the value of operation.Case I demands interest and attention for the following reasons: ist, Because there is high fracture of the spine, viz., in the cervical region; 2d, It was operated upon within twentyfour hours; 3d, Unusual length of life following the operation; 4th, Marked improvement in motion and sensation; 5th, Fol¬ lowing death there was preserved a complete series of sections of the cord from the pons to the coccyx, making it possible to reproduce sections at different levels showing degeneration, which I have been unable to find in previous literature; 6th, Its bearing upon the question of early operation, and the fact that 49S his head.Hearing and sight were normal; throat examination was negative.He complained of headache and pain in the neck.There were no external wounds.There was diaphragmatic breathing, complete loss of tactile sensation, flaccid paralysis below level of fourth rib in front, and below a line from the fourth to the seventh rib in the axillary line (Figs. 1 and2), loss of reflexes.No broken bones were palpable, and no deformity of spine de¬ tected.Motions of shoulders slow; arms could be drawn up to chest slowly, but not extended.Unable to put either hand on the opposite shoulder.Type of sixth cervical nerve irritation.Seen in consultation with Drs.Walton, Baldwin, and Paul, who considered the lesion to be in the region of the fifth and sixth cervical vertebra:.Operation by Dr. Samuel J. Mixter; Dr. H. M. Chase assisting.Patient on abdomen, head flexed over the end of the table; incision in median line of neck, spinous processes exposed and lamina: and spines of fourth, fifth, and sixth cervical vertebrae found fractured, depressed, and apparently lying against the cord.These were removed, exposing the dura, which looked normal.The dura was opened and cerebrospinal fluid escaped, no bloodclot under dura, small clot found under laminae.Dura not sutured, wick inserted, superficial sutures, and bandage.Good recovery from ether.Temperature gradually rose to 104.6° F.; pulse slow and good volume.June 25, 1902.No change in tactile sensation, arms are moved a little more deliberately.June 26, 1902.Tactile sensation returning slightly.June 30, 1902.Tactile sensation recovered over whole body except left hand (Figs. 3 and 4).Can locate accurately where one touches him, though sensation is not normal, as shown by the time required to locate the point of contact.Plantar reflexes, knee-jerks, and ankle clonus absent.Slight thoracic breathing.11 Soreness" of muscles of arms.Paralysis still complete below dotted line, and of extensors of arms.July 6, 1902.Slight plantar reflex and knee-jerk.No cre¬ masteric reflex.Improvement in motion of left arm.July 15, 1902.Ankle clonus present, tactile sensation normal except in left hand.July 26, 1902.Hamstring muscles can be contracted, but not November 30, 1902.Gaining in every way; can sit up in chair without assistance; can move wheel-chair a little with right hand.Disturbances of sensation mapped out in Figs. 5 and 6 on date of August 22, 1902, have nearly disappeared, and areas are blurred and indistinct.December 12, 1902.Occasional gastric disturbance.January i, 1903.Can pass urine voluntarily, but cannot empty bladder.Good control of sphincter ani.Flexor muscles gaining faster than extensor muscles.Can feed himself with right hand.January 17, 1903.Cannot hold anything in left hand.February 18, 1903.Can use both hands to wheel himself around in chair.Urine examination finds color normal, acid, sp.gr.1029, albumen slight trace, sugar absent.Rare hyaline cast with fatty renal cell adherent, considerable pus, few medium size and small round cells.March 6, 1903.Chill, vomiting, temperature, epigastric pain, distention.No abdominal spasm.Lungs negative.March 10, 1903.Chills, pain on left side of abdomen.Slight tenderness over left kidney.No plasmodia.White count, 9000.April 1, 1903.Out in chair apparently in good condition; can hold book in both hands for reading.Moderate cystitis.May 1, 1903.More improvement on right side than on left; can sit up and raise himself with his arms, but cannot stand.May 14, 1903.Urine examination, pale, clear, alkaline, sp.gr.1018, trace of albumen, sugar absent.Many triple phosphate crystals, much pus, considerable normal blood, rare caudate cell, several small and medium-sized round cells.May 20, 1903.Chill, fever, pain on left side of abdomen.No tenderness over kidneys.White count, 14,000.Increased to 20,500 in three days.May 21, 1903.Urine examination, color normal, acid, sp.gr.1012, trace of albumen, sugar absent.Many hyaline and fine granular casts, few with renal cells and blood-corpuscles adherent, considerable pus.May 25, 1903.Chills more frequent with pain in left side.More marked cystitis with renal complication.May 30, 1903.Suddenly became much worse, chills, great weakness and difficulty in breathing.Weakened rapidly, and died June 5, 1903.* Kit;.7.-Decent:ralion of motor (pyramidal) tracts.Second lumbar segment.1. Direct pyramidal linct.2. Crossed pyramidal tract.3. Substantia gelatinnsa of dorsal horn.4. Veutial Imru. 5. Dorsal root.6. Ventral root.