64. Spine
From Primary Surgery
64.1 Introduction
A fracture of the spine, like a fracture of the skull, is less important than the injury to the nervous system inside it. In a district hospital your main responsibilities are: (1) To see that patients with spinal injuries are not made worse unnecessarily. (2) To diagnose stable fractures of the cervical spine and put them into some kind of collar. (3) To apply neck traction to the occasional patient who has an unstable fracture of his cervical spine, with a normal or nearly normal cord. (4) To care for all injuries of the thoracic and lumbar spines conservatively. (5) To care for paraplegics in the manner we describe.
Unfortunately, there is almost nothing you or anyone else can do for a patient who is already totally quadriplegic (64.13). There are no indications for operations on spinal injuries in a district hospital, and few for referring a patient for them. Manipulation, whether under anaesthesia or not, is also contraindicated, because it is very dangerous, even in in the hands of most experts.
The common error is to fail to fit a collar when this is indicated. The only special equipment you will need is Gardner Wells tongs. If you don't have them you can apply Hoen's traction using a brace and burrs.
- TRACTION TONGS, Gardner Wells, one only. These expensive tongs are the most practical way of applying traction to an unstable fracture of the cervical spine. The alternative, Crutchfield tongs, is less
satisfactory, but they are easy to apply and will hold for about 6 weeks. Alternatively, you can make the halo in Fig. 64-12. Better still, these halos can be made centrally and distributed to all the district hospitals of a country. When you need a halo, you will need it urgently, and there will not be time to make it, so make one now.
64.2 Syndromes of spinal injury
The spinal cord, the bones, and the soft tissues of a patient's spine can be injured by accidents which compress, hinge, or shear them. Occasionally, in a hyperextension injury, his vertebrae only sublux momentarily at the time of the accident and then return to their normal places, so that a severe cord lesion can be combined with a normal X-ray, especially in the neck. The opposite is also true, and a patient with a gross bony injury can have a normal spinal cord. Luckily, most patients who injure their spines don't injure their cords. But if they do, this dominates their treatment, and their prognosis.
A patient's spinal injury can be stable or unstable. If his injury is stable, his spine was able to protect his cord from the forces of the original accident, and it will still be able to protect his cord from being harmed by ordinary movement. But if his injury is unstable, his spine cannot now protect his cord from the bony displacement that may follow normal movement. So, be safe and assume that: (1) any spinal injury is unstable, until you have proved it otherwise, and (2) make sure that a patient is moved with the greatest care, from the moment of his injury until you are sure, either that his spine is normal, or that its injury is stable. He has already received one injury, it would be tragic for him to receive another from careless mishandling. Any wrong movement may prevent the recovery that might otherwise have occurred. If a patient's spine is unstable, it must be protected from any movement, from the moment of the accident until it has stabilized several months later.
ALL SPINAL INJURIES ARE UNSTABLE UNTIL PROVED OTHERWISE
cord, (2) the tracts passing up and down it, and (3) the spinal nerve roots. Some or all of these can be injured, either completely or partly, at any level. The critical diagnostic steps are: (l) to find the patient's sensory level (to pinprick) and his motor level, (2) to find the bony level of his lesion, then (3) to compare these. If the bony level is below the sensory one, take more X-rays higher up his spine. You have probably missed a second injury there.
Here are some of the more common patterns of spinal injury. The further an injury is down the cord, the better the chances of the patient is being able to walk, but the worse the outlook for his bladder control.
Injuries above the level of T10 The important injury here is the complete or incomplete division of the tracts passing up and down the patient's spinal cord, destroying sensation and causing an upper motor type of paralysis. Great force is needed to fracture the thoracic spine, so that if it does fracture, the cord inside it is either normal, or completely transected. Lesions elsewhere are more often incomplete.
If a patient's cord injury is incomplete, as is common in the cervical region, some sensation and muscular power usually returns slowly over many months.
If a patient's cord injury is complete, it remains so. There is immediate flaccid paralysis in the lower part of his body, and he has no sensation whatever. If his anal or penile reflexes remain when he is like this, it is a further indication that transection is complete and he is unlikely to recover. Later, the reflex activity of his spinal cord below the lesion may recover, so that his bladder and bowel reflexes return. His knee and ankle jerks recover and then become exaggerated; his muscles become spastic and he may have severe spasms. If his bladder or bowel reflexes return without any sensation or motor power, this is an almost certain sign that his cord injury is complete.
Any lesion above C5 causes quadriplegia. At C5-T1 it causes quadriparesis. A common site of injury is the C5-C6 region. This may paralyse his hands, his intercostal muscles, and partly paralyse his diaphragm. Cord injuries at C3 or above may paralyse his respiration completely and kill him.
Injuries at the thoracolumbar junction (T10-L1) As Fig. 64-3 shows, an adult's first lumbar segment is at the level his tenth thoracic vertebra, and the end of his cord is at the lower border of his first lumbar vertebra. Trauma in this region can injure the nerve cells of his lumbar enlargement or the nerve roots of his cauda equina, or both. A severe fracture with marked displacement will sever his conus and his spinal nerve, roots down to T10, so that the fracture level and the dermatome level are not the same. Occasionally (especially at T12-L1) his nerve roots escape and his only conus is injured ('root escape').
An injury to a patient's spinal cord in this region makes his lower sacral segments anaesthetic (saddle anaesthesia) and destroys his central bladder reflex. It may however spare just enough of the nerve roots supplying his legs to allow him to walk. Apart from pain, which suggests a root rather than a cord injury, there is no way of telling which of the two have been injured. This is unimportant because the treatment of both is the same.
Injuries below the level of the first lumbar vertebra Trauma here can only injure the lumbar and sacral nerve roots of a patient's cauda equina. If they have only been bruised they recover slowly, so his prognosis is good. But if they have been cut, they isolate his bladder from the reflex centre in his cord, so that his bladder control is less satisfactory than it would be if his cord had been severed higher up. His paralysed legs remain permanently flaccid.
DOES THE PATIENT HAVE E MORE THAN ONE SPINAL JURY?
64.3 Caring for a spinal injury
Spinal injuries are often missed for two reasons:
(1) An injured patient may be unable to say that he has lost the feeling in part of his body. His other injuries may be so much more visible than his fractured spine that, unless you routinely exclude a spinal injury in all severely injured patients, you can easily miss one. You may save a patient's life by removing his spleen only to find bed sores developing because he is also paraplegic. A routine check is very quick. Can he move his legs? If you pinch one, does he move it away? If he cannot move his arms or legs, his cord is almost certainly injured.
(2) A patient with an unstable injury of his cervical spine may walk into hospital after a seemingly minor injury. So beware of anyone who complains of a painful neck after an accident. Immediately fit him with a soft collar and X-ray his neck. He may only have a minor soft tissue injury, or he may have an unstable fracture and be in danger of instant paralysis.
A spinal injury is terrifying for a patient because he may be completely paralysed and yet fully conscious. His prognosis and management are determined by the following facts: (1) If his injury is severe enough to cause immediate total paraplegia, or quadriplegia, his spinal cord is almost certainly damaged beyond repair, and no treatment, surgical or otherwise, is going to make it recover. (2) If any function remains immediately after the injury, his prognosis is completely unpredictable. He may make a substantial recovery or he may make none at all. So one of your first aims in.examining him should be to see if any function still remains. (3) If he shows any signs of recovery during the first few days, his outlook is much better, so don't give any prognosis for several days. The earlier and the more rapid his early recovery is, the more hope he has.
Should you refer a patient with a spinal injury? You will have to compare the care you can give him with the care he is likely to get in a referral hospital (1.8). Your care may be better-he is in much greater need of devoted nursing than of skilled surgery. There is seldom any advantage in referring a patient with a serious spinal injury immediately, because you can probably do as much for him, or more, than a referral hospital. Injured nerve cells cannot regenerate, so there is little to be gained by trying to decompress his spine in the hope that they will regenerate. Immediate laminectomy may do more harm than good. Some weeks later an operation to fuse an unstable spine may occasionally be useful. The only procedure that is practical in the acute phase is cervical traction. But although this needs only simple equipment, it needs great skill.
THE GENERAL METHOD FOR A SPINAL INJURY
This extends what has already been said about caring for a patient with multiple injuries in Section 51.3.
MOVING AND UNDRESSING A PATIENT When you move or turn a patient with a suspected spinal injury you will need at least 2 helpers, and preferably 4. Try to move him 'in one piece. Minimize the movement of his spine, especially its cervical region.
If he is on the ground, carefully turn him onto one side as you roll him onto a stretcher, or a stretched blanket, as in Fig. 64-4. As you turn him, take the opportunity to examine his back and his spine, as described below.
If you suspect that a patient has a neck injury, place one hand under his chin and the other under his occiput, as in A, Fig. 64-5, expert gentle traction on his neck, and lift and turn his head while you turn his body-don't let his head drop to one side. Holding his head is the task for the most skilled person in the team. When you have finished turning him onto his back, wedge his head between sandbags, or rolled up sheets or blankets, as in B, Fig. 64-5, or fit him with a collar as in C, in this figure.
CAUTION ! (1) Keep his spine stretched and as straight as possible. Don't move his head. Keep it in a neutral position at all times. Never let anyone carry an injured patient with his head hanging down as in B, Fig. 64-4. Unfortunately people often do. (2) If there is any possibility of a spinal injury, especially a cervical one, this careful handling must go on until you have made sure the patient's spine is rad!ologically stable. (3) Fit him with a temporary cervical collar as soon as possible and never transport him anywhere without one. Failure to do so may: (a) convert a patient with a normal cord i nto a quadriplegic, (b) convert a partial transection into a total one, or (c) deprive a partially quadriplegic patient of a few critically useful segments.
If you suspect that a patient has an injury of his thoracic or lumbar spine, transport him prone with a pillow under his shoulders and pelvis to hyperextend his spine at the site of the injury, unless he has multiple injuries or his airway is in doubt. If it is in doubt, transport him supine.
THE HISTORY AND EXAMINATION OF A SPINAL INJURY
Leave the patient on his stretcher until you have examined him. Enquire carefully about the circumstances of the accident. This will tell you what type of injury to suspect.
If he is conscious, ask him "Where is the pain?" He may be able to say that he has a pain in his back, pains round his body, or that his body feels dead below a certain level. Signs of injury on his face and skull may help you to decide the kind of force responsible.
SPINE Carefully slide your hand underneath the patient's
back, or turn him very carefully while an assistant holds his
head. (1) Feel for any local bruising, swelling, and tenderness
along his spine. Examine his spinous processes
systematically from his neck to his sacrum. (2) Look for any
break in the line. (3) Feel for any soft 'doughy' areas between
his spinous processes into which your fingers can sink. You
may feel a palpable gap. These last two signs indicate an
unstable fracture.
CAUTION ! Don't test the movements of his spine!
NEUROLOGICAL EXAMINATION This has two stages, and
if a patient has an associated head injury, interpreting either
of them may be difficult.
A rapid test to exclude a spinal injury Use this to exclude quickly a spinal injury in any severely injured patient (50.4). Can he move his legs? Are they equally strong? Can he feel anything when you pinch them?
A more extensive examination if you suspect a spinal Injury. Test the sensation on the patient's trunk with a pin, starting from below and working upwards. Find the sensory level, using the dermatome chart in Fig. 64-3. Can he recognize movements of his feet or knees? Test his knee and ankle jerks and his plantar responses. Test to find out if his sacral segments have been spared by pricking the skin beside his anus with a pin.
his neck to both occipital regions, suspect a fracture dislocation of his atlas on his axis.
Assess the level of a fracture dislocation like this: Dislocations between C1 and C2 cause severe continuous pain radiating from the neck to the occiput. Dislocations between C3 and C5 cause quadriplegia. If C5 is dislocated on C6, a patient's biceps is weak or paralysed. If C6 is dislocated on C7, his biceps is normal. In dislocations above C7 and T1 Horner's syndrome (ptosis, a constricted pupil, anhydrosis on the affected side of his face, and enophthalmos) may be present.
The lumbar nerve roots supply: (1) sensation to a patient's legs, except that supplied by his sacral segments, (2) the muscles of his hip and knee, (3) his cremasteric reflexes, his knee and his ankle jerks. Lumbar or sacral root pain suggests a root rather than a cord injury.
The sacral nerve roots supply: (1) sensation in his saddle area and a strip down the back of his leg and thigh, (2) the muscles controlling his ankle and foot, (3) his ankle and plantar responses, (4) his anal and cremasteric reflexes, (5) micturition.
The penile reflex Squeeze his glans penis, and feel his bulbocavernosus muscles. If they contract, the reflex is positive.
The anal wink reflex Scratch the skin round his anus. If his anus contracts and wrinkles, the reflex is positive. If either of these reflexes is positive immediately after the accident i n the absence of sensation in his legs, they indicate transection of his cord and are a poor prognostic sign.
X-RAYS Don't send him for an immediate X-ray. Find the level
of the lesion first. Some patients present with leg problems,
but have an upper thoracic fracture, so examine his spine with
care before you decide which part of it to X-ray. If you have
enough film, X-ray his entire spine routinely, because spinal
fractures are sometimes multiple. Otherwise, X-ray the relevant
area only. See him onto the X-ray table yourself.
IS THE PATIENT'S FRACTURE STABLE? This decision is
partly clinical and partly radiological. Make it by the criteria
i n Sections 64.4 and 64.5.
ASSOCIATED INJURIES About a third of patients have other
severe injuries, particularly of the head (63.1) and abdomen
(66.1), so look for them-this is critically important.
IMMEDIATE PROGNOSIS If a patient is paralysed with a
sharp line of anaesthesia, no reflexes, and no bladder control,
and with his anal and penile reflexes present, his cord
i s probably transected completely. Priapism (persistent, painful
erection of the penis) is another bad sign.
Firmly hyperextend his big toe. Test his toes, heels, and
perineum with a pin. If he is paralysed but can feel any of
these things, his cord is probably only shocked, and its function
will improve.
PROGNOSIS AT 24 HOURS If at this time he still has no
perianal sensation, no voluntary control of his toe flexors, or
rectal sphincters, he has a 90% chance of having a permanent
paraplegia or quadriplegia. If any of these things are
spared, or he shows any improvement in the first 48 hours,
significant recovery is possible. If there have been no signs
of improvement at 4 weeks, further recovery is very unlikely.
THE IMMEDIATE TREATMENT OF A FRACTURED SPINE
This varies with the level of the lesion.
Cervical spine Apply traction to all patients with: (1) any unstable fracture or any dislocation, (2) any patient with incomplete paralysis or impending paralysis, whatever the Xray findings. Use a halo or Gardner Wells tongs (5 to 7 kg), or a halter (3 to 4 kg), loosened periodically, to prevent the skin of his chin necrosing; a patient can only stand a halter for a few hours.
Lumbar and sacral spine Lie him in his most comfortable position.
THE INITIAL TREATMENT OF PARAPLEGIA AND QUADRIPLEGIA
If a patient is paraplegic, immediately start 2 hourly turni ng to prevent bed sores. They can start in the first few hours after the accident only too easily. Don't let his bladder fill up, start intermittent sterile catheterization, if you have the staff and committment to manage It (64.16).
If he is quadriplegic, also pass a nasogastric tube and remove his stomach contents, so as to prevent them being aspirated.
Transection of his cord interrupts his sympathetic pathways and causes immediate hypotension. His blood pressure will not return to normal for several days, so set up a drip meanwhile.
Watch for abdominal distension and absent bowel sounds caused by ileus. This is a common complication of a spinal cord injury and of a lumbar spine injury, even if there is no cord lesion. So give him only intravenous fluids, or sips of fluid by mouth, until you can hear persistalsis. On the fifth to seventh day he will need an enema, or manual removal of his faeces.
SHOULD YOU APPLY TRACTION YOURSELF, IF HE NEEDS IT, OR SHOULD YOU REFER HIM?
Transporting a patient with a spinal injury is never easy, even by air. If the roads are bad, the journey long, and the quality of care at the other end uncertain, he will probably be safer with you, especially in the earlier stages. If you decide to refer him (and you may be wise not to), start his initial care (see above) before he goes. Fit him with an efficient collar, and send a competent medical assistant or nurse with him, who must understand that his neck must be kept straight, and not flexed, extended, or rotated.
IF YOU SUSPECT A NECK INJURY, APPLY TRACTION OR FIT A TEMPORARY COLLAR IMMEDIATELY
64.4 Interpreting the X-rays
The important question in managing a patient's injured spine, and particularly his injured neck, is to decide if his injury is stable or not. One of the criteria for deciding this is his X-rays. Dislocations should always be considered unstable, so should bending or twisting injuries of the posterior elements of his spine. These include its pedicles, laminae, facets, and ligaments. It is injuries to these posterior elements that make an injury unstable. Compression injuries of a vertebral body are usually stable. In a flexion injury the posterior ligament is particularly liable to be ruptured, and in an extension injury, the anterior one. Both types of injury can damage the intervertebral discs.
The films should be good ones; those from a portable machine are usually useless. Even radiologists have difficulty interpreting X-rays of the spine, so you will probably have difficulty too.
The standard views in acute injuries are AP and lateral ones with the patient's head in its normal position. If these views are normal, take flexion and extension views yourself with the greatest care. They may show one vertebra moving abnormally on another when the standard films are normal. Finally, remember that a normal X-ray does not necessarily mean a normal spine.
IS A SPINAL INJURY UNSTABLE?
Take the patient to the X-ray room yourself. If possible X-ray him without moving him. If he has to be moved, supervise how this is done. An inexperienced X-ray assistant can make a partial cord lesion into a complete one.
Take one good AP view and two lateral views with the patient lying, one lateral view centred over his vertebral bodies at the site of maximal pain and tenderness, and another over his spinous processes at this level. Also take an open mouth view. You must see his whole cervical spine, so make sure his shoulders are well pulled down. Lesions at C6-C7 and C7-T1 are often missed. Don't try to take oblique views; they are difficult to take and interpret.
If possible, take a 'swimmers view'; this requires considerable experience and ability. Count the vertebrae in the lateral view to make sure that you have not missed C7. If necessary, take another view with traction to the patient's arm. You will see C7 and perhaps the upper border of T1.
As always with difficult films, sit down and look at them on a viewing box, or with an electric light bulb, while you have no other distractions. Start at the extreme edges of the film, and work in towards the middle. It is quite common for the i njury to be at the edge of the film. Use the signs which follow and Fig. 64-8 as a check list.
AP VIEWS OF AN INJURED CERVICAL SPINE
In the following section the numbers in brackets refer to Fig. 64-8.
Are any vertebral bodies displaced (1)? I f they are, the injury may be unstable.
Are any spinous processes out of line (2)? A rotational injury can twist them out of line, especially in the cervical spine, even though the vertebral bodies themselves are still inline. If they are out of line, the injury is probably unstable.
Are the pedicles on either side of the spinal canal aced laterally out of the line, compared with those above or below (3)? If they are, the injury is probably unstable. The vertebral arch forms a ring, so if part of the ring is to displacehas to fracture in two places. Either both pedicles are Isplaced, or neither of them.
Are the transverse processes of the patient's lumbar vertebrae broken (4)? If they are, they make no difference to his spine, but suspect that his abdominal organs may be njured, especially his kidneys, and that he may have a retroperitoneal haemorrhage.
LATERAL VIEWS OF AN INJURED CERVICAL SPINE
Take a good lateral film at the level of the lesion. Examine he vertebral bodies from top to bottom, they should have a normal box-like appearance.
Is the body of a vertebra wedge shaped? (5) If so, the patient has a compression fracture. These fractures are usually stable, so, if there are no other signs which indicate nstability, diagnose a stable injury confidently.
Has the body of a vertebra broken into many fragments 6)? If so, he has a burst fracture. This is more likely to be unstable and to have injured his spinal cord than a wedge racture.
Has one vertebra slipped forwards on another (7)? This s a serious sign of instability, particularly in the cervical region. It usually shows that the posterior longitudinal ligament has ruptured, perhaps with dislocation of the articular facets, or with fractures of the laminae and pedicles. The patient's posterior intervertebral joints may have subluxed or dislocated on one or both sides.
If displacement is equal to half the vertebral body, one ntervertebral joint has probably dislocated.
Do the posterior margins of all the vertebral bodies form a smooth curve? They should be smooth and continuous. Any abrupt change or step is a sign of subluxation and instability. Regard the odontoid as a vertebral body.
Is the space between the vertebral spines unequal? They may be widely separated at the site of the injury. If so, the injury is probably unstable.
Have any of the spinous process broken at the base, so that they are lying free? Have any of the articular facets fractured? These are difficult to see, and both indicate instability.
If there is a sharp angulation with widening of the spinous processes, this suggests an unstable injury.
Does a facet on an upper vertebra lie in front of the facet of a lower one? If it does, the facets are locked. Unilateral locked facets are difficult to be certain about, they are easier when they are bilateral. They are very rare indeed outside the cervical region. Locked facets, especially if they are bilateral, are not necessarily unstable.
Are the articular facets displaced? The first two facets in the cervical region are easily seen, but the third needs a very good X-ray.
Special signs in the lateral view in the cervical region. Examine the gap between the back of the patient's pharynx and the front of his vertebral bodies. Soft tissue swelling here suggests that he may have a spinal injury, probably an unstable one. Study every lateral view of the cervical spine you see carefully, so that you know what the normal soft tissue shadow looks like.
Look carefully at the base of the patient's odontoid, and at the arch of his atlas.
OTHER FINDINGS Fractures of the spinous and transverse processes are unimportant-they are essentially muscle injuries.
LATERAL VIEWS IN FLEXION AND EXTENSION
INDICATIONS These views are only indicated if you suspect a high fracture of a patient's neck, and the standard AP and lateral views, and an AP view through his mouth are normal. Some surgeons consider these much too difficult for most of our readers.
CAUTION ! (1) The manoeuvres necessary to take these views may be dangerous in acute lesions. (2) The patient must be conscious. (3) Always be present yourself when these views are taken, do them gently, and stop immediately if he has arm or leg symptoms.
Carefully flex his neck and take a film, then carefully extend his neck and take another one. Look for abnormal movement of one vertebra on another. In a flexion view look for the vertebral bodies slipping forwards over one another. In an extension view look for an abnormal gap between the front of two vertebral bodies, or for a posterior dislocation.
ATLAS AND AXIS See Section 64.8.
DIAGNOSTIC DIFFICULTIES WITH INJURIES OF THE CERVICAL SPINE
If you SUSPECT AN INJURY CLINICALLY BUT CANNOT SEE ONE IN THE FILMS, take more films higher up the spine. This is especially important if there are signs that the cord has been injured.
A NORMAL X-RAY DOES NOT NECESSARILY MEAN A STABLE SPINE
64.5 Managing injuries of the cervical spine
If a patient has injured his spine, the important factor in caring for him is whether his injury is stable or not. The diagnosis of stability is partly clinical and partly radiological, and is critically important in his neck. An injury of any part of the spine is unstable if any of the following conditions hold:
(1) The patient has any neurological signs (the only exception is an acute extension injury of his neck, as in Section 64.9.)
(2) He has any signs of instability on clinical examination. These are: (a) some break in the continuous line of spinous processes from his neck to his sacrum, or (b) any soft doughy areas between his spinous processes into which your finger can sink .
Such an area shows that the ligaments between the spines of his vertebrae have been ruptured, and that his spine is unstable at this point.
(3) He has X-ray signs of instability, in normal or flexion and extension views. Don't be misled by a normal X-ray, because his bones may have moved out of place at the time of the injury, and now be back place again. So, if a routine X-ray is normal, he can still have an table spine. You may need flexion and extension views to show instability.
If a patient has had no neurological signs at any time, no clinical signs of instability, and his X-rays are normal, treatment depends on his pain and stiffness. If this is mild, persuade him to ignore his injury and move his neck. If pain and stiffness are severe, put him to bed. If you cannot X-ray him or interpret his films, be safe and fit him with a collar.
If he has a stable injury radiologically and no neurological signs, fit a collar. Stable injuries are: (1) all anterior wedge fractures, (2) minor burst fractures (major ones are unstable), (3) fractures in which there is an anterior gap between two vertebral bodies in an extension film.
If he has an unstable injury and no neurological signs, put him in cuirasse. Traction is a preferable alternative, but if you are not expert and nursing care is less than perfect, he may be safer in a cuirasse. These injuries include all dislocations. These are rare precious patients.
If a patient has or has had neurological signs, his injury must be unstable, even if his X-ray looks normal. Treatment depends on their severity. If his neurological signs have now gone, give him a cuirasse, or better, apply traction. If his quadriplegia is only partial, apply traction. If his quadriplegia is complete, apply traction for a week. If it shows no sign of improving in a week, there is no point in continuing it, because it will hinder nursing care. Complete or partial recovery is more likely to occur with cervical than with thoraco-lumbar injuries.
If you are in doubt as to what to do, treat the injury as if it is unstable. Overtreat an injury of the cervical spine rather than undertreat it. This is the reverse of the advice for the lumbar spine. For example, if a patient has a painful neck after an injury, and you are not sure what to do, fit a collar. If you think traction might help, apply it.
PARTICULAR CERVICAL SPINE INJURIES
Wedge fractures ignore these, but fit the patient with a collar for comfort.
Burst fractures if he has no neurological signs, apply traction for 6 weeks, followed by a collar for 12 weeks.
Extension injuries don't usually cause fractures, but they may injure the anterior longitudinal ligament. Fit a collar for 2 to 3 months.
If he has a collar and if there are no other reasons for keeping him in bed, encourage him to get up.
IF IN DOUBT, OVERTREAT AN INJURED NECK
64.6 Collars and traction tongs
If an ambulant patient has an unstable or doubtfully stable fracture, there are several ways you can prevent the sudden sharp movements his neck that might injure his cord. In order of decreasing convenience but increasing security they are: (1) A home made collar. (2) A proper orthopaedic collar. (3) A plaster cuirasse, as in Fig. 64-10. (4) A Minerva cast.
A Minerva cast extends to a patient's iliac crests, and is sometimes advised, but it uses more plaster than a cuirasse and it is more difficult to apply. It is also very uncomfortable, especially in a hot climate, and it is totally contraindicated if he has any sensory defect, because it will cause ulcers. The marginally greater security of a Minerva cast is outweighed by all these disadvantages, so it is not described further here.
You can apply traction with: (1) Gardner Wells tongs, (2) Hoen's traction, (3) a halo, or (4) a halter. If you don't have tongs you can make a halo locally. A halter like that in Fig. 64-9 is useful for temporary traction only. It does not apply enough traction to reduce a dislocation, and it becomes very uncomfortable after a few hours. If you apply too much traction with a halter for too long, it can cause pressure sores. Use a halter to reduce muscle spasm until you can apply cervical traction or a cuirasse. You are unlikely to have a turning frame for paraplegic patients. The next best is a foam mattress.
- COLLAR orthopaedic, Zimmer pattern, two only of each of the three standard sizes. These are not expensive and should be standard equipment.
APPLIANCES FOR NECK INJURIES
A COLLAR MADE WITH TOWELS Fold a bath towel l engthwise so that it is 10 cm wide. Wrap it round the patient's neck, and pin its loose ends together, as in C, Fig. 64-5. i f neccessary, strengthen it with a few a turns of plaster.
A CARDBOARD COLLAR Take a length of stiff cardboard,
cut two curves in it as in Fig. 64-10, wind it round the patient's
neck, cut it to fit, damp it where necessary to mould it to
shape, pad it appropriately, and keep it together with adhesive
strapping. if necessary, strengthen it with a few plaster ban -
dages. It will work, but it will not be beautiful.
Or, take the top of a plastic bucket, if you can spare one,
and cut it to shape to make a plastic collar.
A CUIRASSE Use this for: (1) Stable fractures without
neurological signs. (2) Unstable fractures after a period in traction.
Some surgeons use a collar for both these indications.
(3) Unstable fractures if you do not feel competent to apply
traction.
Apply a layer of stockinette and pad the bony points over the patient's lower jaw, occiput, and clavicle. Apply a broad slab down the front of his neck from his chin to his upper sternum, and another down the back of his neck. Bind these slabs i n place with circular plaster bandages. Let the cuirasse set with his chin up as in Fig. 64-10. Finally trim it to shape, turn over the edges of the stockinette and bind them in place.
A HALTER Use this for temporary traction only. Don't apply
a halter for longer than 24 hours. Make one from canvas and
cord, as in Fig. 64-9. Don't apply more than 4.5 kg, and remove
it at least every 4 to 6 hours to rest his skin.
A LOCALLY MADE HALO Any good machine shop can make
this from 15x4 mm mild steel strip. Draw some 20 mm squares
on paper, and copy the pattern in Fig. 64-12 onto them. Give
this to the mechanic. The halo will fit any head except a very
small one. The space between the head and the halo is not
critical, provided the halo is not actually pressing on the
patient's skull. The type of hollow point shown will not
penetrate the inner table. if the mechanic cannot turn a hollow
point, a conical one will do. if he has no stainless steel rod to make the 6x50 mm screws, give him two Steinmann pins.
Or, he can use mild steel screws and inset a small piece of
stainless steel into the tips.
IF A PATIENT'S CERVICAL SPINE MIGHT BE INJURED, FIT A TEMPORARY CERVICAL COLLAR IMMEDIATELY
64.7 Skeletal traction
This is the best treatment for an unstable fracture of a patient's cervical spine. Surgeons differ in the method they like. Some like Hoen's traction, in which wires are passed through burr holes, while others prefer Gardner Wells tongs or a halo. The trouble with a halo is that it is difficult to align and may slip off, which is why Hoen's traction is gaining in popularity. This allows a patient to move his head freely, and you can leave it in position for months if necessary. It takes slightly longer than applying tongs, but is much more reliable. You will have to learn to make burr holes for head injuries anyway (63.4), so this is an additional use for them.
Traction is the surest way of stabilizing an unstable fracture or fracture dislocation, or occasionally of releasing locked facets. Be prepared to apply it yourself because: (1) patients with injured cervical spines travel badly, especially over bumpy roads, (2) the equipment is simple, (3) it may be the only way to prevent severe disability, (4) it can be used effectively. But it is not easy to apply and it requires expert nursing, so the indications we give for it differ from those of the experts. They always apply traction if a patient has a normal cord, because it is the best way of preserving it. But, if you are not expert and your nursing is less than perfect, a patient may be safer in a cuirasse. There is little point in anyone applying cervical traction if a patient is already quadriplegic.
If a patient has a fracture dislocation, traction will draw the fragments of his spine apart, restore the diameter of his cervical canal, and reduce the danger of pressure on his cord. When you apply traction, aim to draw the fragments apart with steadily increasing traction over a few hours, then maintain traction with a smaller weight for several weeks. Finally, protect the patient's neck with a cast or collar, so that his spine can heal and become stable in about 8 weeks. To be on the safe side it is desirable to protect it for 6 months.
If a patient has bilateral locked facets of his cervical spine (rare), they are usually associated with complete permanent quadriplegia. If so, traction is pointless. In the unlikely event that he has no neurological lesion, immobilization in a cuirasse or an efficient collar is a possible alternative to trying to unlock them, which is difficult.
When you apply traction to a fracture dislocation, apply only just enough weight to reduce it. If you apply too much too suddenly, you may increase the patient's soft tissue injury, and harm his cord. Adjust the traction to his build and don't exceed what is advised below.
SKELETAL TRACTION FOR THE CERVICAL SPINE
INDICATIONS (1) Unstable fractures or fracture dislocations of a patient's cervical spine, with partial quadriplegia, or early ( within a few days) complete quadriplegia, in whom there is still some hope of improvement. (3) Rupture of the posterior ligaments. (4) As a temporary splint for cervical fractures while a patient is being treated for his other injuries. i n more expert hands the most important indication for traction is an unstable fracture with no neurological signs. if you are less expert, he may be safer in a cuirasse.
CONTRAINDICATIONS (1) Complete permanent quadriplegia
in which traction is almost pointless. (2) Unstable fractures
in which there have been neurological signs, but in which these have now gone (fit a cuirasse). (3) Stable fractures in
which traction is unnecessary (fit a collar). (4) Signs of
i nstability which are only present in flexion and extension
views (fit a cuirasse). (5) Locked facets, unilateral or bilateral,
with or without neurological signs. Experts would apply traction.
if you cannot refer the patient, fit a cuirasse.
CAUTION ! You must be able to take bedside X-rays. if you cannot do this, don't try to apply traction - fit him with a coll ar or cuirasse.
HALTER Fit the patient with a halter temporarily while you
are organizing the traction device.
THE BED Apply traction on a bed with fracture boards (or
a door) covered with at least 10 cm of foam rubber, and large
castors. You should be able to adjust the height of the pulley
vertically.
NURSING Turn the patient 2 hourly-left side, supine, right
side. Alternate periods in which he is turned completely left
and right with periods in which he is turned partly left and
right. Take great care to move his head 'in one piece' with the
rest of his body. You will need 3 nurses while you do this, with
one to look after his head and neck. At 6 weeks, when traction
is replaced with a cervical collar, add the prone position
when he is turned. Rub his pressure areas 2 hourly.
X-RAYS Either apply traction in the X-ray department, or wheel
him there in traction for films to be taken.
SEDATION Give the patient diazepam with pethidine. Don't
give him a general anaesthetic. Intubating him may be difficult
and dangerous.
CAUTION ! (1) Monitor his neurological state carefully. if you apply too much traction too suddenly, you may injure his spinal cord or his medulla. (2) Never apply more traction than the maximum indicated. (3) if at any time there are signs that his neurological state is getting worse, reduce traction i mmediately. (4) If you are in doubt as to what to do, be safe and reduce the traction or take it down.
GARDNER WELLS TONGS FOR CERVICAL TRACTION
These grip a patient's skull a finger's breadth above his ears i n the line of his mastoid processes. Fit them in the ward. Apply them symmetrically without shaving his scalp. The pins should enter his skull just caudal to its maximum diameter, so that they don't slip. Sterilize the points. Dab iodine on the place where you want them to go, raise a wheel of lignocaine and anaesthetize his scalp right down to his periosteum. Apply iodine to the points of the screws.
One screw is spring loaded, so that as the tension is increased a small nipple protrudes. When it protrudes about 1 mm the tension is correct. Twist the screws so that their points go through his anaesthetized skin, and grip the outer table of his skull. Tighten them until the small nipple in one of the screws protrudes 1 mm from its hole, then tighten the lock nut.
A HALO FOR CERVICAL TRACTION
Fit this in the ward. Support the patient's head off the bed, try the halo for fit, and decide which screw holes to use. Shavi ng the skin in the areas where the pins will go is optional. Anaesthetize his skin, and apply the halo in the same way as for Gardner Wells tongs. Tighten the screws alternately, so that the halo is not pulled to one side. Tighten them as securely as you can, using only your thumb and three fingers on the screwdriver: more force is dangerous. After tightening, secure each pin with lock nuts on either side of the halo.
Thread cords through four of its unused holes, bring the cords together into two slings, and tie the main traction cord to them. Adjust them to determine the flexion and extension of his head.
CAUTION ! With both forms of traction device: (1) Make sure the points of the screws are needle sharp. (2) Try to keep them still, because this will minimize the risk of infection. (3) Tighten up the screws several times during the first 24 hours, then don't tighten them any more. Don't tighten them unnecessarily, or they may perforate his inner table. (4) if the traction sites become infected, move the pins on the halo.
HOEN'S TRACTION FOR CERVICAL TRACTION
ANAESTHESIA (1) If anaesthetic skills are good, consider general anaesthesia with intubation, taking due care of the patient's spine. (2) Or, use local anaesthesia, with intravenous diazepam if he is restless.
METHOD Make two linear 5 cm incisions in the parasagittal
plane centred on the patient's mastoid processes and 3 to
4 cm from the midline. Place these so as to straddle the
desired line of pull, which is usually in line with his cervical
spine.
Reflect the skin and make two burr holes (63.4) 3 cm apart, with a 2 cm bridge of bone between them.
Loop a pice of stainless steel wire into 4 or more strands, depending on its strength. Pass the blunt looped ends from one burr hole to another. You may need the help of the guide of a Gigli saw, or the the blunt end of a long slightly curved needle, with the wire in its eye.
CAUTION ! (1) Position the incisions and the burr holes away from the mid line, so as to avoid the patient's sagittal sinus. (2) Separate his dura very carefully, because infection may follow if you pierce it.
Pull the wires through until they are equal in length. When you have done the same thing on the other side, tension all four wires together to provide equal tension on all four.
Close the incisions. As you do so, make four slightly slanting nicks to prevent the medially slanting wires from pressing on the skin edges, where they would be uncomfortable, cause necrosis, and so promote infection. The wound will soon heal and a dressing is rarely needed.
Connect the wires to a rope passing over a pulley, apply a weight, and raise the patient's bed to apply counter traction.
APPLYING TRACTION FOR CERVICAL SPINE INJURIES
HOW MUCH TRACTION? This depends on: (1) The type of traction. With a halter 4 to 5 kg is the maximum, but with skeletal traction you will need 5 to 15 kg. (2) The build of the patient; large men need more than small women. (3) What you are trying to do. To begin with you may need 15 kg to reduce a dislocation. Later, you may only need 3 to 5 kg to maintain traction. (4) The position of the injury. Higher up the spine less traction is required (2 to 5 kg), than with the common C5 C6 injuries (5 to 15 kg).
Here is a rough guide, C1 2.5 to 5 kg, C2 3 to 5 kg, C3 4 to
7 kg, C4 5 to 10 kg, C5 and 6, 7 to 15 kg. Apply the weights
over a pulley. Raise the head of the bed about 4 cm for each
kilo, as for a fracture of the femur.
TRACTION FOR A FRACTURE DISLOCATION
The weights which follow apply to a large adult with a hyperflexion injury in his C4-C6 region, as A, Fig. 64-13. With other injuries adjust the weight appropriately. His X-ray may show: (1) a flattening, reversal, or distortion of the normal spinal curve, (2) displacement of the body of a vertebra forwards on the one below, (3) a compression fracture, (4) fracture of the pedicles.
Apply traction in a straight line, avoid flexion, extension or, rotation and start with 7 kg. Cautiously add 2 kg every 15 minutes, checking constantly for neurological changes.
When you have applied 15 kg for 30 minutes, x-ray him. The facets may begin to disengage (B), but you may have to wait longer.
If there is no disengagement, leave him with 15 kg traction for a maximum of 12 to 48 hours, taking X-rays every 6 to 12 hours.
As soon as: (1) the articular processes are completely disengaged, (2) overriding is corrected, and (3) the distance between the fragments of the pedicles is narrowed, reduce the weights and keep the patient's neck in a straight line. Usually, the facets will come into line.
At 2 to 3 weeks you can reduce traction to 3 to 5 kg. Take weekly lateral check X-rays for the first month, or after you have altered the weights.
At 6 weeks replace traction by a cuirasse ora collar (64.6). Leave this on for another 6 weeks. if immobilization is going to stabilise his spine, 3 months will do it.
At 3 months remove his cuirasse or collar. Take AP and l ateral X-rays. if these still show reduction, take flexion and extension views.
If the patient's vertebrae show no signs of slipping in normal or in flexion or extension views, advise Rim to increase the movements of his neck gradually, to avoid sudden movements, and to restrict his outdoor activities.
If he still has a painful unstable neck after 3 months, (6 weeks in traction followed by 6 weeks in a collar or cuirasse), refer him. This is rare. Fusion of his cervical spine may be indicated. if you cannot refer him, fit him with a collar.
If his injury is mainly bony, the fragments will probably fuse and his injury will become stable.
If his injury mainly involves the ligaments, stable union may not be achieved. He should be watchful for up to a year in case late displacement occurs.
DIFFICULTIES WITH CERVICAL TRACTION
If you have MADE THE DIAGNOSIS LATE, the patient's fracture may or may not be stable. Fit him with a collar for 3 months. If this does not relieve his symptoms in 2 weeks, apply traction for 2 weeks and then replace his collar.
If a patIent with a recent cervical Injury has OTHER SERIOUS INJURIES which make cervical traction impossible, fit him with a cervical cgilar.
If a FRACTURE REDISPLACES, Immediately traction is reduced, or later, or If a dislocation of the articular facets recurs as traction is reduced, reapply it, especially if nerve root symptoms recur. You may need more weight (up to 17 kg). The danger of quadriplegia is great, so refer him if you can.
FOLLOW UP THE PATIENT CAREFULLY
64.8 Fractures of the atlas and axis
no neurological symptoms, if he jerks his neck suddenly, he is in danger of serious paralysis. He may have fractured his atlas, or the odontoid process of his axis.
The atlas is seldom injured, except by downward blows on the skull, or in severe hyperextension. No treatment is required except immobilization in a soft collar and bed rest for comfort.
The odontoid process of the axis is its most vulnerable part, and is usually injured by a direct blow to the front of the patient's skull, which extends it sharply. So look for a fractured odontoid if a patient has had a severe hyperextension injury after a fall, or a car accident. As his skull moves backwards, it carries his atlas and his odontoid process backwards also. Either his odontoid process fractures, or, more seriously, the transverse ligament that retains it tears and allows his odontoid to press on his cord and kill him instantly. If he survives, his injury is probably stable enough to be treated in a cuirasse until there is bony or firm fibrous union.
The X-rays of most fractures of the upper cervical region are difficult to interpret. You should, however, be able to recognize a fracture of the odontoid. If you are in doubt, fit a patient with a collar, or preferably a cuirasse.
FRACTURES OF THE ATLAS AND AXIS
X-RAYS You need special views. If the films are bad, try again. You cannot make the diagnosis from poor films.
An AP view Take this through the patient's open mouth to avoid his teeth. Place a cork or a card between his teeth to hold them open while you do so. Place his head in moderate extension, so that the edge of his upper teeth falls in line with the base of his skull as it joins his cervical vertebrae. You will need an exact AP view, so that his palate does not obscure his atlas and axis.
Look for a fracture of his odontoid, especially a step at its base. The odontoid ossifies from a separate centre, so in a young person don't interpret the normal growth line as a fracture. This growth line sometimes persists into adult life. I f the lateral masses of the patient's atlas have spread significantly, he has a burst fracture, which has torn the transverse ligament.
Lateral view Focus the tube on the lobe of his ear which overlies his odontoid. A visible prominence of the soft tissues
at the back of the pharynx suggest an injury to his cervical
spine.
If you cannot refer a patient, treat him as follows.
FRACTURES OF THE ODONTOID PROCESS OF THE AXIS
The patient survived the original injury, so his chances of final
recovery are good. Take a good AP view through his mouth
and lateral views; diagnosis may be difficult.
If there is a neurological defect, use traction as for other fractures and dislocations of the cervial spine.
If there is no neurological defect, traction is best. It gives better stability and prevents backward displacement and angulation. An efficient collar or cuirasse for 12 weeks is a possible alternative, but is less reliable.
BURST FRACTURES OF THE RING OF THE ATLAS The ring
bursts at its weakest point where its posterior and lateral
masses join. The X-rays are particularly difficult to interpret.
If you cannot refer the patient, fit him with a collar.
IF AN INJURED PATIENT IS SITTING UP HOLDING HIS NECK, FIT HIM WITH A COLLAR
64.9 Cervical hyperextension injury ('porter's neck')
This is a common spinal injury in places where people carry large loads on their heads. Fortunately, the cord is not often, injured, and even if it is, there is some hope of recovery. The patient, who is usually a woman, stumbles and falls. The heavy load she is carrying falls backwards and extends or rotates her head violently. In hospital she is found to have a quadriparesis. X-rays may show no fracture. If she has narrowing of her cervical discs and osteoarthritic overgrowth, they are probably not responsible for her symptoms which are due to a sudden infolding of her ligamentum flavum pressing on her cord. The prognosis with this kind of paraplegia is usually good. Fit her with a soft collar, and care for her quadriparesis until she recovers.
64.10 Torticollis at birth
This is the end result of the birth injury known as 'Sternomastoid tumour'. Make every effort to try to turn the child's head the opposite way to his deformity. For example, if his head turns to the right,. have him nursed on the left. If the condition lasts more than 2 months, refer him for possible lengthening of his sternomastoid. This is an operation for the expert, because part of the sternomastoid is inserted behind the clavicle and is very close to the great vessels.
64.11 Torticollis in older children
A child's head may turn to one side, or slip forwards onto his chest, due to the softening of his transverse ligament, which normally holds his atlas to his odontoid (this ligament is shown in B, Fig. 64-14). Torticollis can follow a variety of neck or throat infections, such as peritonsillar abscesses, or it can follow an injury. Measure the distance between the child's odontoid peg and the back of the anterior arch of his axis. If this is more than 3 mm in adults or 4.5 mm in children, his transverse ligament has been stretched and the ring of his atlas has slipped forward. Atlanto-axial subluxation is serious, because paraplegia may follow, and because of the torticollis which may last weeks, or occasionally permanently, if you don't treat it. The differential diagnosis includes tuberculosis, but here collapse is much more usual than subluxation.
ATLANTO-AXIAL SUBLUXATION Exclude tuberculosis. if
necessary, treat the child's respiratory infection.
Treat him in gentle halter traction for 2 weeks, and then apply a soft collar, with his head turned slightly in the corrected position. Maintain this position by wrapping a few turns of plaster round the collar. Many patients will recover with this treatment, but not all of them.
64.12 Fractures of the thoracic and lumbar spine
The spinal cord ends at L1. A patient with a fracture at or above this level is usually either grossly injured and paraplegic, or has a stable fracture. Below this level he can have an unstable fracture and a normal cauda equina. If a patient has no cord injury, you can easily miss these fractures, especially if he has severe injuries elsewhere, or is unconscious. His spine can be injured by a force which compresses or flexes it, usually at T7-T8, the apex of his thoracic kyposis, at T12-'L1, the thoraco-lumbar junction, or at L4-L5. The result can be a wedge fracture, a burst fracture, or a fracture dislocation.
If a patient has a fracture especially a wedge fracture, after only a minor injury, suspect that it may be pathological, and the result of a secondary tumour or osteoporosis. If all you can see is a widened disc space, count his spinous processes, and see if they match his vertebral bodies. The widened disc space may be all that remains of a vertebral body.
If his fracture is stable by the criteria (1), (2), and (3) in Section 64.5, the active movements regime described below will give better results than a plaster cast and be cheaper.
If his fracture is unstable his accompanying paraplegia dominates his management. Fixation with interspinous plates is not established as better than conservative management which almost always leads to stable union in 6 to 10 weeks. The position in which the fracture unites is unimportant. He will probably be no better off in a referral hospital than in your hands.
FRACTURES OF THE THORACIC AND LUMBAR SPINE
Assess whether the patient's fracture is stable or not by the criteria already described (64.5). If you are in doubt, treat his injury as unstable.
STABLE FRACTURES Treat wedge fractures, minor burst fractures,
and laminar fractures in the same way. Treat the patient
in bed with fracture boards under a 10 cm foam rubber mattress.
Put a pillow between his legs and a pillow under his
back when he is lying on his side.
Keep him in bed until he can arch his back sufficiently for you to be able to put your hand underneath it, and until he i s sufficiently pain-free to walk, if necessary, with crutches. He can get up when pain allows him to, usually in about 3 weeks.
UNSTABLE FRACTURES are usually fractures of the posterior
elements with subluxation.
If the patient is not paraplegic, keep him in bed. Turn him 2 hourly in one piece, using at least 3 people. Use his right
and left sides, the supine, the lateral, and the prone positions.
At about 3 weeks he can start to turn himself using a balkan
beam and a handle.
When pain at rest has gone and light bouncing with a clenched fist causes little pain, usually at 6 to 10 weeks, mobilize him, at first with someone either side of him, and then using crutches.
If he is paraplegic, concentrate on his morale, his skin, his bladder, and his bowels, rather than on his fracture. Turn him 2 hourly and care for his skin as in Section 64.15.
When you turn him, put blocks of foam rubber underneath him, so as to minimize displacement of his spine. For example, put a block under the fracture when he lies on his back. This will encourage moderate extension and reduce the tendency of his spine to collapse. Change and adjust these blocks each time you turn him.
If you cannot get foam rubber blocks, or if adjusting them each time you turn him takes too long, forget about them and nurse him on a thick rubber mattress.
After 6 to 8 weeks in bed, when his spine is no longer painful or tender, mobilize him as effectively as his paraplegia will permit.
CAUTION ! Never apply a cast if he is paraplegic. It will rapidly cause ulcers in his anaesthetic skin.
IF IN DOUBT, UNDERTREAT A FRACTURED LUMBAR OR THORACIC SPINE
64.13 Paraplegia
because it means that a bed will be filled for a very long time. Can he be saved from bedsores, contractures, a small contracted bladder, and all the other miseries that are only too common? The answer most certainly is yes! There are some very simply equipped hospitals, with very dedicated workers, who can turn their patients every 2 hours, so that they do not get bedsores. So it can be done and it has been done! It is, however, so demanding that the care of paraplegia is perhaps the ultimate test of the real quality of a hospital, and of the morale and dedication of everyone in it. In paraplegia your aim must be-(1) no bedsores, (2) no contractures, (3) an uninfected bladder, with the early onset of reflex micturition in upper motor neurone lesions, and (4) the patient's ability to support himself with a craft. Ultimately, most paraplegics die from the uraemia that follows chronic urinary infection, but they may live many years.
The consequences of not managing paraplegia properly can be even worse than the patient shown in Fig. 64-16. Thus one patient was seen who had been admitted in quadriparesis (not quadriplegia) one year earlier in fairly good shape. In hospital he developed pressure sores over his sacrum, both hips, both knees, and both ankles. The joints under all these lesions were open and suppurating. He had more sores on his back and forearms, and flexion contractures of both his hips and knees. He had a urinary infection, a small contracted bladder, an indwelling catheter, and chronic urethritis. Mercifully he soon died.
Although quadriplegics should never reach this state, their outlook is much worse than for paraplegia, and is always hopeless in the end. However devoted your care, they will almost certainly develop severe pressure sores, hypostatic pneumonia, and die. Although you may be tempted to reproach yourself, you should not try to set yourself impossible targets. Paraplegics, on the other hand, are very well worth fighting for.
The key to success is to prepare your staff psychologically. Make the first patient you care for your top priority, and that of your ward team. The most critical days are the first ones, especially the first and second weeks of admission. The whole battle may be lost by careless treatment then. Leaving a patient unturned for only four hours may start a bed sore that leads to osteomyelitis, dislocation of a hip, contractures, and a series of surgical operations lasting years. Should he get a bed sore, you may be unable to refer him because no hospital will accept him.
THE FIRST 24 HOURS ARE CRITICAL
64.14 A paraplegic's morale
A severe spinal injury is so horrible that doctors and nurses are often too embarrassed to discuss it with the patient. Nevertheless, he is usually completely conscious and aware, and needs to be treated as a human being. He needs reassuring that his condition has been diagnosed, and is being urgently and carefully treated. He needs to be told that he has a serious injury, and that the people who care for him understand he is paralysed. If he asks whether his injury is going to be permanent, don't be too dogmatic too early.
During the entire course of treatment, keep his morale uppermost in your mind. Don't just pass by the foot of his bed say: "Ah, yes, the paraplegic. . .", and then pass on. Talk to him often. Manage him always with encouragement and hope, not necessarily hope that his cord will eventually recover, but hope that he will one day rejoin society, and find there a place for himself. His relatives need encouragement too. It is tragic for him when they stop coming, so make sure that someone explains your plans for him to them. Meanwhile, make his life as comfortable as possible. If he can read, make sure he has a reading board and something to read. If he ever stops eating from the effects of misery and chronic infection, his death is near. So make sure he is adequately fed, and watch for anaemia.
NEVER PASS BY WITHOUT SAYING SOMETHING TO THE PARAPLEGIC
64.15 A paraplegic's skin
Bedsores occur in sensory paraplegia and occasionally in any very sick or very old patient who is left in the same position too long without being moved. You can prevent them completely, even in complete paraplegia and quadriplegia, but, only provided you turn a patient every 2 hours day and night.
The cause of bedsores is clear. The pressure of the body on any part of the skin and subcutaneous tissue causes temporary ischaemia. In a normal person this causes mild discomfort, so that he turns about every 15 minutes to let another part of his anatomy bear his weight. Because a paraplegic patient cannot feel discomfort, or move, he cannot vary the skin on which he lies, so it remains ischaemic for hours at a time, it becomes necrotic, breaks down, and causes a bedsore. If only you can interrupt this period of ischaemia, you can prevent a sore forming. Explain the pathology of bedsores carefully to all your nurses, and to everybody who looks after paraplegic patients. Later, explain it to the patient too, so that he can play his part in preventing them. They are particularly likely to occur immediately after the injury, and during an intercurrent infection later.
TURN A PARAPLEGIC EVERY 2 HOURS AND CHART THAT YOU HAVE DONE SO
Bedsores can only be prevented if prevention has a high priority in the surgical ward. So, put a chart at the foot of a patient's bed, with the time marked on it every 2 hours. Ask the nurses to
sign this chart each time they turn him, and to record the side onto
which they have turned him-left side, back, front, etc. At least
2 people are needed, and three are better. During the night the
nurse on duty will need help, any help, even that of a relative,
a watchman, a porter, or another patient. Show them how to
turn him gently, so that they don't twist the patient's injured
spine and injure it further. This is especially important if his
fracture is unstable, when he must be 'moved in one piece'. Happily,
nurses very rarely injure a patient's cord when they turn
him.
ENORMOUS PRESSURE SORES CAN DEVELOP IN A FEW HOURS
The discipline of absolutely invariable 2 hourly turning is
difficult to introduce because most nurses have seen paraplegics
develop bedsores. Gloom and hopelessness thus pervades them
all. So take the initiative yourself. Turn a patient yourself the
first time, and next time, and perhaps the time after that. Ask
a nurse to help you. If you show yourself prepared to get up
a few times at 4 a.m. and help turn him (as some doctors have
done), your nurses will play their part. Come early into the ward
the next morning and inspect the pressure areas. If you find no
redness (in a Caucasian) or blistering, congratulate the nurses,
and help them with their plans for turning him during the rest
of that day. Even offer to help them to turn him at night, if
staff are short. If you are called, appear delighted, and conceal
your distress!
Inspect the pressure areas on every ward round, and if they are healthy, congratulate the staff. At the slightest sign of redness or blistering, help the nurses to prepare an alternative routine of turning that will spare the red areas from pressure for a few days.
If any important person visits the hospital, show him the paraplegics. If he asks the inevitable question, "Why are there no bedsores?" ask him to ask the nurses. They will be only too ready to explain that it is because they are turning the patient every 2 hours. They will soon realize that they are becoming experts in this exacting field.
After a month or two, the patient, and his relative between them can begin to work out their own routine for turning him, and plan how to manage him at home. After a few months it becomes almost reflex for him to be turning himself in bed at home. Once he is able to do this himself, he need only be readmitted to be turned by the nurses if he has an intercurrent infection, such as pneumonia.
Try to get him into a wheel chair or calipers quickly. When he is in them, teach him how to avoid getting pressure sores, as described below.
If he is only partly paraplegic and wears calipers, he must inspect where they press, so that he does not get pressure sores there. Let him see other patients with bedsores, so that he knows what he is trying to avoid.
| Dr NICKEL took over a chronic care hospital in California with the worst of reputations for poor nursing care. He made it a rule that at the begining of each shift, the new shift examined the back of each patient for pressure sores. If a bedsore developed, the senior nurse on the shift was dismissed. His hospital became a showplace. LESSON Good discipline can prevent pressure sores. |
SKIN CARE FOR PARAPLEGIA
Turn a paraplegic patient every 2 hours. This is by far the most important treatment. Each time you turn him, put his joints through a full range of passive movement, concentrating on hip and knee extension and dorsiflexion of his ankles.
BED Place a door on an ordinary hospital bed. On it place
two 10 cm foam mattresses covered with mattress ticking.
Put soft pillows or foam rubber cushions between the
patient's legs and under his back.
If you have only a hard mattress, pad the pressure points with cotton wool, gauze, or pieces of fleece. Keep them in place with adhesive strapping, but watch these pads carefully. Don't allow them to become creased. Remove them at least once a day and check the skin under them. Try to keep the patient's bottom sheet tight, dry, and free from creases, crumbs, and bits of food.
If his heels show any sign of pressure sores, put a pad under his ankles, or a ring pad around his heels.
PRESSURE POINTS Don't pad pressure points-pad round them.
Watch the skin over his sacrum, his iliac crests, his hips, the
sides of his knees, his heels, and his malleoli, and his penis
if a condom catheter is applied.
INCIPIENT SORES The first sign of a sore is redness of the
skin. Treat any red areas by careful massage and then apply
one of these solutions: (1) soap and water followed by careful
drying and powder, (2) hypochlorite('Eusol'), (3) borax in spirit,
(4) 1% formaldehyde.
ESTABLISHED SORES Keep pressure off a sore until it has
healed. Try to keep it clean. Use saline dressings or paraffin
gauze. Honey and the fruit of the papaya (paw-paw) have also
been used successfully. Small sores may heal slowly, if you
keep them clean and protected.
If a skin lesion is obviously necrotic, toilet i t and remove the necrotic tissue. You may find a much larger lesion under the surface. Large sores may need transposition, rotation, or myocutaneous flaps.
Keep the patient's haemoglobin above 12 g/dl.
TURNING A PARAPLEGIC NEEDS THREE PEOPLE
64.16 Paraplegic's bladder
If a patient has any significant degree of paraplegia, he will be unable to urinate voluntarily from the moment of the injury. His bladder will fill up slowly and will be full by about midnight on the day of admission. If you leave it, it will overflow, so anticipate this and prevent it. The best way of treating him is to use regular intermittent sterile catheterization. Infection is rare with this method. It imitates the natural cycle in which the bladder fills and empties. By leaving it almost empty for a significant period, this method relieves the pressure on its walls, both pressure of urine and pressure from the the balloon of a Foley catheter. This is important, because distension or pressure of any kind reduces the ability of the bladder to resist infection. It is also good training for student nurses. The disadvantage of this method is that it requires more nursing care, and if the patient is to do it himself, as described below, he must be cooperative. Some consultant surgeons in teaching hospitals say they cannot use this method, because they don't have the staff, and wonder that it can ever be done in smaller ones. In fact, some smaller hospitals can do it excellently. Don't use: (1) an indwelling catheter if you can possibly avoid doing so because infection is so common, or, (2) continuous suprapubic drainage, because it produces a small contracted bladder.
INTERMITTENT STERILE CATHETERIZATION
Use a 14 Ch soft rubber Jacques catheter. Boil it and use gloved hands or sterile forceps. Pass it every 4 to 6 hours from the moment of the patient's injury. Later it can be every 6 to 8 hours. Empty the patient's bladder completely by suprapubic pressure and then remove the catheter. Repeat the process 6 hours later, and again and again, four times a day. Record that catheterisation has been done on the chart which is used to record when he is turned.
CAUTION ! When you make rounds, check his bladder from ti me to time to make sure that it really is being emptied.
Continue, either until his cord recovers, or until an automatic bladder develops, usually in 2 to 3 months.
CATHETERIZE THE PATIENT WITH FULL STERILE PRECAUTIONS
Automatic bladder If a patient's spinal injury is above his lumbar enlargement, his bladder will eventually develop its own
micturition reflex. After 2 to 8 weeks of intermittent catheterization
he may discover a method of starting micturition himself.
Fit him with a condom catheter or a Paul's tube and encourage
him to try. He may be able to do this by stroking the side of
his thigh, or his penis, or by pressing suprapubically. Such training
may take a long time, it is not easy, and the nurses will
require considerable persistence. Although training him may be
difficult, it will save time in the end. When he has found a
method which works, encourage him, to use it more and more.
Let him do this before he is catheterized. Don't stop catheterising
him until his residual urine on catheterization after micturition
has fallen to 75 ml, or less. Even when it has fallen
to this volume, catheterize him once a week to make sure that
he is not partly retaining his urine. If you find that his residual
urine is more than 75 ml, consider referring him for resection
or division of the external sphincter of his prostatic urethra (external
sphincterotomy).
Intermittent clean but non-sterile self catheterization If a paraplegic's bladder is isolated from spinal control, emptying depends on a local reflex which is much less effective than a reflex arc via his cord. He does not develop an automatic bladder, and he has to catheterize himself. He can either boil up a catheter each time and try to pass it in a sterile manner, or he can catheterize himself regularly and cleanly, but without using sterile precautions.
Surprisingly, non-sterile self catheterization has many advantages. Because a patient does not need to boil up the catheter each time, he can catheterize himself more often, and does not allow his bladder to fill up. This reduces the incidence of infection, and in practice he is infected less often than if he waits and tries to sterilize a catheter. But for this method to succeed, he must empty his bladder as completely as possible with the help of suprapubic pressure continued until the moment that he pulls the catheter out. A bladder that is not emptied after catheterization will contain some organisms, but a bladder that is completely emptied will contain very few.
Many patients easily learn this method which has many advantages. For example, a patient can go to a football match, cheer widely, and in the interval go to the toilet, catheterize himself, and then return to the match! A patient who has been told to use sterile catheterization will either not be able to go to any such matches ever, or he will be inhibited from catheterizing himself in the toilet, so allowing pressure to build up in his bladder and running the risk of a urinary infection.
Some surgeons in the developing world say that they have never succeeded with this method; others are enthusiastic about it.
INTERMITTENT NON-STERILE SELF CATHETERIZATION
Give a man a Jacques rubber catheter. If he has difficulty, give him one with a small beak, such as an oliviary tipped Tieman catheter, or a coude catheter. Teach him which way to point the beak. Give a woman a small handbag mirror to help her find her urethral meatus.
Encourage the patient to catheterize himself cleanly. (1) He must keep the catheter clean. (2) He should if possible wash his hands and the tip of his meatus.
CAUTION ! Make sure he knows how important it is to empty his bladder completely.
INFECTION If his urine becomes infected and he has
symptoms:
(1) Encourage him to catheterize himself at more frequent
intervals. Usually, the reason for the infection is that he has
not been catheterizing himself often enough.
(2) Give him an appropriate antibiotic. He has not been on a prophylactic antibiotic, so his infection is usually easy to treat; sulphonamides may be enough. Don't try to prevent infection by giving antibiotics routinely.
(3) If the first two methods fail, admit him to hospital for continued, intermittent, non-sterile catheterization under supervision, together with bladder wash-outs.
64.17 A paraplegic's bowels
If a patient's bladder fills up after a spinal injury, so will his bowel, which quickly becomes loaded with brick-like faeces. Distension may become so severe that his sigmoid colon presses on his left iliac vein and may make it thrombose.
Give him an enema three times a week until his bowel function has returned, usually in 3 to 6 weeks. Glycerine suppositories later on may help him to develop a defaecation reflex. He may be able to start this reflex himself by inserting a suppository and sitting on the lavatory 15 minutes later. Even so, faecal impaction is always a danger, and either he or his relatives must be taught how to remove his faeces manually. This is so important that it should be part of the routine teaching of everyone who cares for paraplegics. Occasionally, remove them manually yourself and encourage the nurses to follow your example. Make sure that a patient has a high residue diet and give him laxatives if necessary.
64.18 The muscles and joints in paraplegia
From the very beginning of a patient's illness, ask some concerned person to move all his paralysed joints passively through a full range of movements several times a day. This will become more difficult as he becomes more spastic. If he is neglected, his hips, knees, and ankles will roll up like a hibernating hedgehog. Established contractures are a sign of total failure because they are readily preventable. Where possible, sit a patient up out of bed. Although physiotherapists are useful, they are not essential. Any doctor, nurse, or relative can be taught to put a patient's knees, ankles, and hips through a full range of movements every day, and so prevent contractures. Avoid force, because this may damage a joint. Encourage him to move his non-paralysed joints as much as he can, using his own muscles.
The hips of a paraplegic patient have a tendency to flex. Prevent this by following the regime below. If his hips have already started to flex, he will ask for a pillow to be put under his groins, so as to let them flex, even when he is lying on his front. This may be kind when you are starting to cure a hip deformity, but make the pillow thinner and thinner each day until there is no pillow at all. If, however, a patient has no deformity to start with, don't give him a pillow when he is lying on his face.
TURNING REGIMES FOR PARAPLEGIA
CERVICAL SPINE Start by turning a patient 2 hourly: left side-supine-right side-supine. When his fracture is relatively stable, usually at about 6 weeks when traction is replaced by a collar, add a period in the prone position. Later i ncrease the time in this position to reduce the tendency to develop flexion contractures in his hip and knee.
THORACO-LUMBAR SPINE Turn him 2 hourly: left sidesupine-
right side-prone. Later, increase time in the prone
position as above.
LET THE NURSES DO THE PHYSIOTHERAPY
64.19 Mobilizing and rehabilitating the paraplegic
after discharge, he is only too likely to die and waste all the care and attention he may have received while in hospital. This is especially likely to happen in the rural areas. So visit the patient's home, and try to make sure that he has a suitable bed and toilet. Often, money will be the major factor. If a patient was injured at work, the workmen's compensation fund may be able to support him.
Start to mobilize a patient when his fracture is reasonably stable and it is clear that his paralysis will be permanent. Stand him up regularly when his arms are strong enough to hold crutches. Use gutter plaster splints or walking calipers to support his knees and ankles.
Involve his whole family in rehabilitating him. He is going to need a wheel chair, and perhaps calipers and crutches to take home. Start thinking early about how to finance these. The first week of his illness is not too early for this. Early on during his stay in hospital, encourage him to develop extraordinary strength in the unparalysed parts of his body. Let him pull himself up with a Balkan beam, or give him weights to lift with his arms, so that they are strong enough to support him when he uses crutches or a wheel chair. Calipers may help him to keep his knees straight and his feet in neutral. Teach him some skill with his hands, such as making articles for sale, by basket making, weaving, or leather work. Encourage him to find markets for the things he is able to make, so that he can later earn his own living.
Aim for a date of discharge 4 or 5 months after his admission. Some caring member of the hospital staff should visit his home with a relative, to see if it is suitable for a paraplegic to live in. Is the floor flat, so that it can take a wheel chair? Are there any steps that cannot be managed with crutches? Sometimes, parallel bars can be put up outside his house so that he can exercise himself, as he did in the hospital. If his home is not like this, and many homes are not, his outlook is grim. He may have to live in a sheltered home and be found work in a sheltered workshop. Such workshops have been set up in many parts of the world, and it is a very uncaring community that cannot make some provision for its own handicapped.
Success in rehabilitating paraplegia is one of the best indicators of high quality care. Where it fails, a district hospital accumulates 3 or 4 paraplegics, and a provincial one perhaps 12, each with an average stay of perhaps 10 years, with all that this means for unnecessary expense, and for the other patients who might have been treated in their beds.
FURTHER CARE FOR PARAPLEGIA WHEEL CHAIRS
Start a patient in a wheel chair slowly, 2 hours once a day to begin with, then 2 hours twice a day. Teach him to lift up his buttocks a few times every 15 minutes. Sit him on two foam rubber cushions, or sit him on the blown up inner tube of the kind of motor cycle that has small wheels and big tyres. Cover this with a foam pad.
Give him a washable rubber bag for the time his bladder works unexpectedly.
If he develops skin sores or a urinary infection, he must return to the hospital rapidly.
AMPUTATION If a patient has grossly infected lower legs,
there may be a case for amputating both of them above his
knees. He can then move and be moved more easily, and some
possible sites of bed sores will have gone, but he will have
difficulty sitting. If you decide to amputate, don't remove both
legs on the same occasion.
PARAPLEGIA CAN BE TREATED IN A DISTRICT HOSPITAL
