Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

A classical instance is that of a late Governor-General of India, who on being thrown in the hunting-field was found to be paralysed in all four extremities; Paget diagnosed a total transverse lesion of the cervical cord with the necessary inference that it would inevitably have a fatal termination. The fact that the patient recovered completely, and was later able to fill two Viceroyalties, proved that the lesion must have been of the nature of a concussion of the cord.

The treatment consists in adopting the same measures as in crushing of the cord, while careful watch is observed for the signs of recovery of conduction. The usual order of recovery is first the reflexes, then sensation, and lastly, the motor functions.

Traumatic Spinal Hæmorrhage.—Hæmorrhage into the vertebral canal is a common accompaniment of all forms of injury to the spine, but the lower cervical region is the common seat of the severe type of hæmorrhage resulting from acute flexion of the spine such as occurs especially in a fall on the head from a horse or a vehicle in motion. The blood may be effused around the cord—between it and the dura—(extra-medullary), or into its substance (intra-medullary).

Extra-medullary Hæmorrhage—Hæmatorrachis.—The symptoms associated with extra-medullary hæmorrhage are at first of an irritative kind—muscular cramps and jerkings, radiating pains along the course of the nerves pressed upon, and hyperæsthesia. It is only when the blood accumulates in sufficient quantity to exert definite pressure on the cord that symptoms of paralysis ensue, and it is characteristic of extra-medullary hæmorrhage that the paralysis comes on gradually. When the effusion is in the cervical region—the commonest situation—the arms are more affected than the legs. The paralysis of the arms is of the lower neurone type, and the muscles are flaccid and undergo atrophy; the legs may exhibit a more complete degree of paralysis of the upper neurone type, with exaggeration of the knee-jerks. Blood may trickle down the canal and collect at a level lower than that of the lesion which causes the bleeding, and produce paralysis which slowly spreads from below upwards—gravitation paraplegia (Thorburn). There is blood in the cerebro-spinal fluid.

The treatment is on the same lines as in total transverse lesions. When there is evidence of progressive pressure on the cord, the blood is removed by spinal puncture if possible, or by laminectomy performed at the level suggested by the symptoms; operation is, however, rarely called for.

Intra-medullary Hæmorrhage—Hæmatomyelia.—Traumatic hæmorrhage into the substance of the cord occurs almost invariably in the lower cervical region, and results from forcible stretching of the cord by acute flexion of the neck. The blood is usually effused into the anterior cornua of the grey matter and into the central canal, and there is a varying degree of laceration of the nerve tissue, in addition to pressure exerted by the extravasated blood.

The severity of the clinical features depends upon the extent of the lesion. In contrast with what results in extra-medullary hæmorrhage, the symptoms are paralytic from the outset.

When the hæmorrhage is only sufficient to cause pressure on the cord, the paralysis is usually most marked in the lower extremities because the conducting fibres are pressed upon. This is associated with evanescent anæsthesia for temperature and pain, while tactile sensibility is preserved. There is retention of urine and fæces, and in young men, priapism. As the fibres which supply the dilator pupillæ are involved, the pupils are contracted. The symptoms gradually subside as the extravasated blood is re-absorbed, sensation being restored before motion, and recovery may be comparatively rapid.

When the blood extravasated in the cord causes disintegration of its substance, there is complete paralysis with atrophy, and anæsthesia in the area supplied by the segments of the cord directly implicated. The paralysis in the parts below the lesion assumes the spastic form. As the lesion is usually in the upper part of the cord, it is the arms that are most frequently affected. In less severe degrees of damage the paralysis of the most distant parts, e.g. the feet, may be transitory. Even in cases in which the loss of function below the level of the lesion has been complete, recovery may take place, but it is apt to be marred by a spastic condition of the muscles concerned, due to sclerotic changes in the cord.

Except that operative treatment is contra-indicated, the treatment is the same as for extra-medullary hæmorrhage, and at a later period measures may be employed to relieve the spastic condition of the muscles.