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Fig. 412
Every tumor of this general character and in this location should be removed
as early as possible unless it can be determined that it is not only cystic but
dangerously large. Of even these, however, it may be said that to leave them is
to expose the patient to more danger of infection than is incurred during a
legitimate surgical operation. There should be, then, about such a case serious
complications and perplexities, which would tend to make a competent surgeon
decline to operate (Fig. 412).
Fig. 413
The spinal column is so Fig. 414
strongly put together and its
bones so protected that
fracture of any one of its
component parts is
inconceivable except as a
result of violence. This may
occur by objects falling upon it
or by the body falling a
distance, or from violent
twisting or wrenching. These
injuries constitute but a small
percentage—about 3 per cent.
—of all fractures. They occur
more easily and commonly in
the upper portion than in the
lower, where the vertebræ are
larger. As a result of their
occupations adult males suffer
much more frequently than
women or children.
Diagnosis.—The diagnosis
of fracture of the vertebral
column is rarely difficult. The
disability produced is Crush of cord and its
instantaneous if the cord itself membranes. The result of a
be compressed. If the cord fracture of the spine.
escape pressure there may be (Erichsen.)
serious symptoms, but without
paralysis. The most serious feature, then, of any fracture of
the vertebræ is the amount of damage done to the cord
proper. The so-called gunshot fractures of the spine have
Fracture of body of
already been partially treated of above and in the chapter
the vertebra. on Gunshot Wounds. They constitute a somewhat different
(Warren Museum.) class of lesions, but have, in common with those above
alluded to, the actual fracturing of the bone and the
question of damage to the cord. In most respects they may be considered with
the non-penetrating injuries. Fractures of the spine, therefore, may be divided
into (a) fractures with injury of the cord, and (b) fractures without such injury. In
many cases it is difficult to state whether the cord is crushed or simply more or
less compressed by bone, fluid, or exudate, until the spinal canal has been
opened and explored.
When the cord is totally destroyed there will be total loss of reflexes, with
motor and sensory paralysis complete. (See Fig. 413.)
In some instances there is visible or palpable deformity. This is by no means
necessarily the case. It is more likely to be noted in the upper portion of the
column, where the vertebral spines are more easily palpated. If sufficient time
have elapsed there will often be ecchymosis. The principal feature, however, of
spinal fractures is the paralysis, which results in most instances as above. Its
careful study is requisite both for minute diagnosis and localization of the injury.
Paralysis, then, whether of motion or of sensation, along with the condition of
the reflexes, deserves careful consideration in each instance. It is of the
greatest importance, because by it, rather than by other causes, death is
brought about in the majority of cases which outlive the first twenty-four hours
after injury. Even injury low down, which causes paraplegia with loss of control
of the bowels and bladder, may terminate fatally in time, through an ascending
infection of the urinary passages, which may finally lead to pyelonephritis and
death. This has often occurred as the result of inattention to precautions in the
use of the catheter, and to carelessness on the part of the patient. Death, then,
may be caused by roundabout methods of infection which have only accidental
connection with the original injury. Other cases die of septic infection in
consequence of lack of proper attention to bed-sores. Again, with cord
involvement high up in the dorsal region there is very likely to occur a rapid
ascending degeneration, by which, one after another, the roots of the phrenic
nerves are involved in their order from below upward, until finally the patient
dies of asphyxia from paralysis of all the respiratory apparatus (Fig. 414).
Aside from such evidences as actual displacement of the vertebral spines
may afford the localizing diagnosis is made mainly by a study of the paralysis.
In regard to this paralysis it should be remembered how it is produced from the
very nature of the injury itself. That occurring within from a few minutes to a few
hours after the injury is due to hemorrhage; that which occurs still more slowly
is due to exudate or the presence of pus; while a late paralysis may result from
poliomyelitis. The first form of paralysis may be produced by hemorrhage either
within the central canal (hematomyelia) or hemorrhage within the membranes
or structure of the cord itself (hematorrhachis).
There is another form of paralysis due to embolism which, however, has but
little to do with the ordinary injuries. The following table, inserted by the
courtesy of Dr. Dennis, will assist in localizing the lesion by a study of these
paralyses and reflexes due to spinal injury:
Paralyses and Reflexes due to Spinal Injury.
Spinal
Nerve. Motor Paralysis. Anesthesia. Reflexes.
1. Death from pressure
of odontoid.
2-3. Death from paralysis
of diaphragm.
4. Deltoid muscles of Upper shoulder, outer arm. Pupil.
upper arm.
5. Supinators of hand. Outside of arm and forearm. Pupil, scapular,
supinator,
triceps.
Cervical. -
6. Biceps, triceps, Outer half of hand. Pupil, scapular,
extensors of wrist. triceps, post.
wrist.
7. Pronators of wrist, Inner side of arm and forearm. Pupil, scapular,
latissimus dorsi. post. wrist, ant.
wrist, palmar.
8. Flexors of wrist, Inner side of hand. Scapular, post,
hand, muscles. wrist, ant. wrist,
palmar.
Injuries low in the lumbar segments cause incontinence of urine and feces
because of the location of the centres for the rectum and bladder at this level.
Injuries higher up cause retention by paralyzing the expulsive muscles of the
abdomen. The reflexes which most interest the surgeon and which are of
importance to him in diagnosticating these and other traumatic conditions are
the following, with their method of detection (Bradford):
Pupillary: Dilatation produced by pinching side of neck.
Scapular: Scratching skin over scapula causes muscles to contract.
Supinator: Tapping tendon at wrist causes flexion of arm.
Triceps: Tapping tendon at elbow causes extension of arm.
Posterior wrist: Tapping tendons causes extension of hand.
Anterior wrist: Tapping tendons causes flexion of wrist.
Palmar: Scratching palm causes flexion of fingers.
Epigastric: Stroking mammæ causes retraction of epigastrium.
Abdominal: Stroking abdomen causes retraction.
Cremasteric: Stroking inner side of thigh causes retraction of scrotum.
Patellar: Striking patellar tendon causes extension of leg.
Gluteal: Stroking buttock causes dimpling in gluteal fold.
Plantar: Stroking sole of foot causes flexion and retraction of leg.
Ankle clonus: Forcible extension causes rhythmical flexion.
Much will depend upon the minute character of the injury, its location, and the
amount of displacement of fragments. Fracture of a spinous process causes
irregularity of the tips of the spines, with frequently the displacement of a
fragment which may be moved beneath the skin, with or without crepitus.
Fracture of one or both laminæ will permit mobility of the spinous process, with
perhaps displacement. It is difficult to elicit crepitus. The neural arch may thus
be broken without serious involvement of the body of a vertebra. On the other
hand, the body itself may be fragmented, compressed out of shape, or so
loosened as to permit of easy displacement.
Fig. 415
In the lower portions of the spine, which are both larger and more protracted,
are more frequent combinations of both injuries and fewer instances of the
single type of either. Except in the cervical region it is exceedingly difficult to
distinguish between these lesions, for the question of operation or no operation
is decided by other and more conspicuous features (Figs. 416 and 417).
Fig. 416 Fig. 417
Dislocation between the fifth and sixth cervical Dislocation of the spine forward (Bryant.)
vertebræ. (Erichsen.)
Fig. 418
In most cases it is impossible from the exterior to estimate either the damage
to the cord or the amount of fluid outpour until the spinal canal be opened. If
there be complete loss of reflexes, with absolute insensibility and motor
paralysis, then complete transverse destruction of the cord may be inferred. In
these instances it may be decided not to operate. On the other hand it may be
felt that unless the damage appear irremediable an open operation for
inspection and relief should be performed at the earliest possible moment,
since pressure on the cord allowed to persist even for a few hours causes
damage for which there is no compensation. These cases may then be viewed
in this light—if left to themselves they are almost hopeless. It therefore is a
question simply of what can be accomplished by operation. On one hand the
patient’s condition may be materially improved; on the other it is scarcely
possible to make him worse. The dangers of such operations inhere especially
in the anesthetic and in the possible introduction of sepsis; not that the
operation itself cannot be properly conducted, but that it is often difficult to keep
these cases free from contamination during the subsequent course of events.
To operate through bruised or infected skin would probably be fatal. These
operations, then, are begun as explorations intended to reveal deep conditions.
When one has freed the spinal cord from pressure and has removed the
products of hemorrhage he has done nearly all that can be accomplished in
such a case.
Until recently it has been supposed that complete transverse division or
crushing of the cord was necessarily hopeless and fatal. As previously
mentioned, Estes, Harte, and Fowler have reported instances of complete
division of the cord, with subsequent approximation by suture and with at least
partial restoration of function, that have lent an element of hope to cases
previously regarded as hopeless.
For my own part, although I regard these cases as discouraging, I do not feel
like withholding from patients the only possibility of improvement which can be
offered them, but I am more and more impressed with the necessity for prompt
intervention if this benefit is to be obtained. To wait a few days, then, until it has
been made evident that nothing can be done, save by operation, or until a tardy
consent is obtained, is to rob the patient of the hope which it may afford. The
operative treatment should be begun immediately after the diagnosis is made,
providing that this be promptly done. Delay is more than inexpedient—it is
absolutely dangerous. As Burrell has pointed out it is scarcely fair to decide
upon a course of treatment from a study of statistics alone, as lesions vary
within widest limits, as do also results of individual operators. Let each case,
then, be decided upon its merits, but let whatever is done be done promptly. If
there be excuse for delay it is in those cases where paralysis is incomplete and
where the cord apparently has not been seriously compromised. But these
would afford the most promising results after operation.
The operation itself will be described at the conclusion of this section, and in
connection with other operations practised for exposure of the cord when
involved in other lesions.
HEMATORRHACHIS AND HEMATOMYELIA (INTRASPINAL
HEMORRHAGES).
These occur, as do hemorrhages within the cranial cavity, with or without
serious other lesions of the investing structures. They are expressions, of
course, of transmitted violence, depending so far as known essentially upon
injury, whether the hemorrhage occurs within the central canal of the cord,
within its structure, or within the subdural or even extradural spaces.
Everywhere within these regions bloodvessels abound, from which may occur
sufficient outpour of blood to make pressure upon the cord to a degree
producing complete paralysis. The duration of time between reception of injury
and the occurrence of diagnostic paralysis will be to some degree a measure of
the rapidity of such outpour, while a study of the paralyses themselves will
permit of localizing the injury. The symptoms consist mainly of pain in the spine
radiating to some distance, often referred to the distribution of the nerves most
involved. This pain is often associated with muscular spasm, while paralysis
may be a very early or somewhat tardy symptom.
Treatment.—Once the fact of pressure upon the cord is established these
cases come under practically the same rule as above. While there is a
possibility that a moderate amount of bloody outpour might be absorbed there
is nearly as much danger of its organization and of permanent involvement of
the cord. In fact there is more reason for operating in cases of spinal
hemorrhage than in cases of fracture, since it may be possible to thereby
accomplish more.
The non-operative treatment of fractures or dislocations consists mainly in
external support, preferably by a plaster-of-Paris corset properly applied, and
by maintaining elimination and nutrition, while affording physiological rest for a
sufficient length of time. These cases will need massage and electricity, i. e.,
stimulation of the compromised muscles, and extreme care should be given to
the prevention of bed-sores, to which they are peculiarly liable. Every
precaution should be taken also against any possible retention of urine or
feces. The incontinence of an overdistended bladder should not be mistaken
for that of paralysis of its sphincter apparatus. The specimen of dislocation from
which Fig. 415 was taken was removed from a patient who almost completely
recovered from the effects of the injury, but who became careless about the
condition of his bladder and who suffered an ascending urinary infection that
terminated his life.
Of these cases it may also be said, then, that a much better prospect of
exact diagnosis and atonement for harm done is afforded by exploration, since
as between compression of the cord by clot or by bone there is little essential
difference.
The subjoined table may afford assistance in the diagnosis of the injuries
above considered:
Differential Diagnosis of Diseases and Injuries of the Spine and Spinal Cord.
Acute
Fracture. Dislocation. Hematomyelia. Hematorrhachis. Poliomyelitis.
Onset. Immediate. Immediate. Immediate. Progressive. Slow.
Anesthesia. Immediate. Immediate. Immediate. Incomplete. Absent.
Paralysis. (Is Hemiplegia Hemiplegia. Paraplegia. Hemiplegia or Paraplegia.
of or In partial paraplegia.
hemiplegic paraplegia. dislocation
type when may be
compression absent.
is unilateral,
paraplegic
when
bilateral,
and local
when single
nerve roots
are
involved.)
Deformity. Usually Present. Absent. Absent. Absent.
present.
Temperature. Rises after Same. Same. Same. Precedes the
second or paralysis of
third day. degeneration.
Bowels and Paralyzed. Paralysis Same. Affected late if No paralysis.
Bladder. usual. at all.
COCCODYNIA; COCCYGODYNIA.
Under this name are included severe and chronic neuralgias of the
coccygeal region, including its joint, which occur most often in women, and
usually as the result of contusion or direct injury. Occasionally it results from an
injury inflicted during parturition. It gives rise to a degree of pain and
tenderness which sometimes is almost disabling. Because of the insertion of
the levator ani into the tip of the coccyx defecation may become distressing, to
an extent which leads to fecal impaction in the rectum from postponement of
evacuation as long as possible. The symptoms are subjective, but the
tenderness is frequently exquisite.
In regard to treatment subcutaneous division of the tissues around the bone
may afford relief, but in most instances, particularly those of traumatic origin, an
excision of the coccyx will afford the only cure. (See below.)