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pedicles, pars articularis, or transverse processes, but gentle exion and extension of the injured areas must sometimes be undertaken and plain lms obtained in each position If a cervical spinal cord injury is associated with vertebral dislocation, traction on the neck is necessary to secure proper alignment and maintain immobilization This is best accomplished by use of a halo brace, which, of all the appliances used for this purpose provides the most rigid external xation of the cervical spine This type of xation is usually continued for 4 to 6 weeks, after which a rigid collar may be substituted Concerning the early surgical management of spinal cord injury, there have been two schools of thought One, represented by Guttmann and others, advocates reduction and alignment of the dislocated vertebrae by traction and immobilization until skeletal xation is obtained, and then rehabilitation The other school, represented by Munro and later by Collins and Chehrazi, proposes early surgical decompression, correction of bony displacements, and removal of herniated disc tissue and intra- and extramedullary hemorrhage; often the spine is xed at the same time by a bone graft or other form of stabilization The issue of acute decompressive surgery remains contentious to the present day The MRI scan has altered these empirical approaches by clearly demonstrating hematomas and other sources of compression that may be amenable to surgery With complete spinal cord lesions, most surgeons do not favor surgery The results of the conservative and aggressive surgical plans of management have been dif cult to compare and have not been evaluated with modern neurologic techniques Collins, a participant in the National Institutes of Health (NIH) study of acute management of spinal cord injury 20 years ago, concluded that the survival rate was increased as a result of early surgical stabilization of fractures and xation of the spine Other neurosurgeons, however, have not been able to document a reduction in neurologic disability as a result of early operation, and they have increasingly inclined toward nonoperative management of both complete and partial spinal cord lesions (see, for example, Clark; Murphy et al) Most American neurosurgeons take the less aggressive stance, delaying operation or operating only on patients with compound wounds or those with progression or worsening of the neurologic de cit despite adequate reduction and stabilization In any given case, the approach must be guided by the particular features of the patient s injuries A detailed description of the orthopedic and neurosurgical treatment of spinal fracture-dislocations is beyond the scope of a textbook of neurology but can be found in major textbooks of neurosurgery, and in the book on neurological intensive care by Ropper and colleagues listed in the References The greatest risk to the patient with spinal cord injury is in the rst 10 days when gastric dilatation, ileus, shock, and infection are threats to life According to Messard and colleagues, the mortality rate falls rapidly after 3 months; beyond this time, 86 percent of paraplegics and 80 percent of quadriplegics will survive for 10 years or longer In children, the survival rate is even higher according to DeVivo and colleagues, who found that the cumulative 7-year survival rate in spinal cord injured children (who had survived at least 24 h after injury) was 87 percent Advanced age at the time of injury and being rendered completely quadriplegic were the worst prognostic factors The aftercare of patients with paraplegia, in addition to psychologic support, is concerned with management of bladder and bowel disturbances, care of the skin, prevention of pulmonary embolism, and maintenance of nutrition Decubitus ulcers can be pre-
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vented by frequent turning to avoid pressure necrosis, use of special mattresses, and meticulous skin care Deep lesions require debridement and full-thickness grafting At rst, continual catheterization is necessary; then, after several weeks, the bladder can be managed by intermittent catheterization once or twice daily, using a scrupulous aseptic technique Close watch is kept for bladder infection, which is treated promptly should it occur Bacteruria is common and does not require treatment with antibiotics unless there is associated pyuria Morning suppositories and periodically spaced enemas are the most effective means of controlling fecal incontinence Chronic pain (present in 30 to 50 percent of cases) requires the use of nonsteroidal anti-in ammatory medication, injections of local anesthetics, and transcutaneous nerve stimulation A combination of carbamazepine or gabapentin and either clonazepam or tricyclic antidepressants may be helpful in cases of burning leg and trunk pain Recalcitrant pain may require more aggressive therapy, such as epidural injections of analgesics or corticosteroids or an implanted spinal cord stimulator that is applied to the dorsal columns, but often even these measures are ineffective Spasticity and exor spasms may be troublesome; oral baclofen, diazepam, or tizanidine may provide some relief In permanent spastic paraplegia with severe stiffness and adductor and exor spasms of the legs, intrathecal baclofen, delivered by an automated pump in doses of 12 to 400 mg/day, has also been helpful The drug is believed to act at the synapses of spinal re exes (Penn and Kroin) One must always be alert to the threat of pulmonary embolism from deepvein thrombi, although the incidence is surprisingly low after the rst several months Physical therapy, muscle re-education, and the proper use of braces are all important in the rehabilitation of the patient All this is best carried out in special centers for rehabilitation of spinal cord injuries
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