FRACTURE-DISLOCATION OF THE THORACOLUMBAR SPINE

With Special Reference to Reduction by Open and Closed Operations

¹ NEWCASTLE-UPON-TYNE, ENGLAND

1. The site of the lesion determines, to some extent, the possibility and the degree of paraplegia. There is a higher relative incidence of paraplegia at the thoracolumbar junction than in the lower lumbar region. This presumably is due to (a) the larger size of the neural canal, and (b) the toughness of the cauda equina, as compared with the spinal medulla.

2. The extent of skeletal damage is no indication of the degree of cord trauma. For instance, in the thoracolumbar region, a simple interlocking of the articular facets, with a minimum anteroposterior shift, is often associated with complete paraplegia; yet at this site complete displacement must indicate complete transection of the cord. In the lower lumbar region, however, gross displacement may be present without paraplegia.

3. The method of reduction seems to play little or no part in the possibility of recovery. In the small series under discussion, closed reduction seemed to give better results timan open, but it would appear to be doubtful whether reduction matters at all.

4. The prognosis, if reasonable care is taken not to inflict further damage on the cord by careless handling, is surely decided at the time of the initial trauma.

5. The idea is disproved that stretching or attenuation of the cord may be an important cause in preventing recovery from paraplegia in cases of fracture-dislocation with interlocking facets.

6. The early appearance of the first signs of recovery of sensation or of motor power is no indication of the eventual prognosis.

7. Hyperextension, particularly with anaesthesia, which produces complete muscle relaxation, is to be condemned. In the present series, however, it has been tried in error on several occasions without anaesthesia, without disaster; and in one case it resulted in reducing the fracture-dislocation.

8. In the series examined, the dislocation, if reduced, has very often recurred, but without further signs of cord injury. Furthermore, this redisplacement is commonly associated with spontaneous anterior or lateral fusion of the vertebral bodies, giving rise to an excellent skeletal function.

One has not the courage, on the basis of such limited experience, to advise against reduction in timcse cases ; but an optimistic attitude must be adopted, whether reduction is performed or not. Careful nursing and physiotherapy are necessary from the beginning. These patients must no longer be discharged from busy surgical wards on the grounds that time outlook is hopeless.

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