Injury, 11,39-42 Printedin GreatBritain
39
Clinical study of injuries of the lower cervical spinal cord J. Julow, I. Szarvas and A. S,~rvdry National Institute o f Traumatology. Budapest, Hungary The level involved was C5 in 18-5 per cent, C6 INTRODUCTION AMONG spinal cord injuries the number involving in 26-5 per cent, C7 in 35"8 per cent and C8 in 19.2 per cent. the cervical cord has increased considerably over Sixty-six per cent of vertebral fractures seen on the past few decades. the radiographs were at the level of C5 to C6. It is According to Guttmann (1973) the number of patients with cervical spine injuries amounted to remarkable that no direct relationship between 9 per cent of the total number of patients with the clinical condition and the gravity of the lesions spinal cord injuries in Great Britain in 1953 and was shown by X-ray examination (Table 1). Head injury was suffered by 56 patients (concussion in this percentage had reached 24 per cent in 1973. The same tendency has been observed all over the 47, contusion in 6 and intracranial haemorrhage in 3 cases). In 13 other cases the main injury was world, including Hungary. Spinal cord injuries raise several still unsolved complicated by rib fractures, in 2 cases by fracquestions, both from clinical and theoretical tures of the limbs and in 3 cases by abdominal points of view. These questions are also reflected injury. in literature published in Hungary (Kom~iromi, NEUROLOGICAL SYNDROMES 1964; Kiss and Viszt, 1967; B~ilint and Novoszel, 1970; Merei et al., 1973; T6th et al., 1975; There were 80 complete and 82 incomplete lesions. P~isztor, 1976). The appropriate literature differentiates between In the National Institute of Neurosurgery and the following syndromes of incomplete transverse the National Institute of Traumatology and in lesion. This differentiation is justified because of the Accident Service of P6terfy S,'lndor Hospital, the different lines of suitable treatment. Budapest from hundreds of cervical spine injuries, 162 patients (149 men and 13 women) Brown-S6quard syndrome have been studied in the last 10 years. This can nearly always be observed in an atypical Here we have chosen to analyse the most difficult and serious cases. We have not dealt form. According to Taylor and Gieave (1957) an with milder injuries like isolated fractures of asymmetrical paraparesis developing a few hours or days after the injury with analgesia on the less vertebrae, root injuries etc. paretic side can be regarded as an atypical Brown-Sdquard syndrome.
TIME, CAUSE AND NATURE OF INJURY
Forty-eight per cent of the patients were injured in June, July or August. The main causes of the injuries were falls in 38 per cent of cases, traffic accidents in 26 per cent and dives into shallow water in 17 per cent. Accidents at work accounted for 28 per cent of all the injuries.
Anterior cord syndrome As reported by Schneider (1951) and Taylor and Gleave (1962), below the lesion, bilateral complete flaccid paresis can be observed, with loss of the perception of temperature and pain but retaining the senses of touch, movement, pressure
40
Injury: the British Journal of Accident Surgery Vol. 11/No. 1
Table L The connection between the vertebral injury and neurological state Incomplete transverse lesion Distortion or negative X-rays Fracture without dislocation Fracture of arch Dislocation under ~ of vertebral width Dislocation between of vertebral width Dislocation between § and complete vertebral width Total dislocation
Table IlL
Table IL The connection between obstruction in the spinal canal, neurological state and vertebral fracture
Complete transverse lesion
10
2
99 11
4 7
30
22
20
22
2 0
15 8
Vertebral dislocation Less than ~- More than ,} 51 cases without obstruction* Incomplete transverse lesion Complete transverse lesion 30 cases with obstruction** Incomplete transverse lesion Complete transverse lesion
0
36
6
10
3
6
11
*Based on 24 Queckenstedt tests and 27 cisternal Myodil myelographies. **Based on 21 Oueckenstedt tests and 9 cisternal Myodil myelographies.
The comparison of the results of conservative and surgical treatment
Incomplete transverse lesion treated conservatively (58) Operated incomplete transverse lesion (24) Complete transverse lesion treated conservatively (60) Complete transverse lesion treated by operation (20)
Improved
Neurological state Unchanged
Worsened
45
35
9
1
10
14
14
0
0
33
27
6
16
5
19
1
0
1
0
Died
Survived acute period
13
and vibration. This s~,ndrome is mainly due to fracture, dislocation or ruptured disc. The clinical picture is almost identical to that of obstruction of the anterior spinal artery (Galibert, 1962; Benes, 1968). Central
9
cord syndrome
Besides serious bilateral paresis of the upper limbs this syndrome is accompanied by a much less serious paresis of the lower limbs, occasionally by disturbance of micturition but chiefly by disturbance of heat and pain sensation below the lesion (Thornburn, 1887; Schneider et al., 1954, 1958; Gros et el., 1960). It can be observed mainly with hyperextension of the cervical spine, but less frequently with fractures. Schneider et al. (1954 and 1958) and Gros et al. (1960) explained it as damage in the long tracts. The fibres of the corticospinal and spinothalamic tract from the
neck and the upper limbs suffer central damage, while the lateral thoracolumbosacral fibres are not damaged. Bailey (1900) and Rand and Crandall (1962) explain the paresis of the upper limbs as being due to damage to the anterior horn, the paresis of the lower limbs and the disturbance of micturition resulting from oedema compressing the corticospinal tract.
Posterior
cervical
contusion
It is characterized by symmetrical hyperaesthesia, paraesthesia from several cervical levels in the upper limbs and the trunk. It follows hyperflexion injuries without dislocation. The neurological signs are not serious and are reversible (Biemond, 1964; Braakman and Penning, 1971). It is often combined with paresis of the arms and hands and posterior tract signs.
Julow et al. : Spinal Injuries
It is caused by damage in the neighbourhood of the posterior horn. It is not identical with the posterior tract syndrome, described by Dejerine (1914) and rarely observed in practice. In our own patients we have observed the following types of incomplete transverse lesions: 15 atypical Brown-S6quard, 22 anterior, 18 central and 27 unclassifiable incomplete cervical cord syndromes. The damage of the roots accompanying these were observed in 11 cases. DETECTION OF SPINAL OBSTRUCTION This examination and its results are of great importance in judging indication for operation. It is most important in cases of incomplete transverse lesion without vertebral dislocation and in such cases decompression is indicated if the spinal block is complete. The examination is carried out by manometric measurement or by Myodil (Glaxo) myelography. Both procedures can establish the presence of spinal obstruction. A complete spinal block recorded by Queckenstedt's test is regarded by several authors as an absolute indication for decompression (Freeman, 1949; Bedbrook, 1959; Schneider, 1960, Beks and Oen, 1962; Taylor et al., 1962). O t h e r s d o n o t consider this procedure suitable to provide indications for operation because of the following possible errors. 1. It may give a false negative result in a case of anterior cord syndrome, as in a ruptured disc (Schneider et al., 1958). 2. If it is performed too early it may give a negative result. Braakman and Penning (1971) found a spinal block in 20 patients, with incomplete transverse lesion, in 3 cases on the first day, in 50 per cent at 2-4 days and then in steadily decreasing numbers day by day. 3. Re-examination may produce a false positive result in high cervical lesions due to venous congestion in the epidural veins of the neck. 4. In many cases there is no relationship between the gravity of the spinal lesion and the presence of spinal obstruction (Harris and Wu, 1965; Ruge, 1969). This view is also supported by our cases. 5. The improvement in the neurological signs and the resolution of the spinal block do not take place simultaneously. According to Braakman and Penning (1971) the spinal block cannot justify laminectomy in the first few days after the injury. If there is a spinal block, a positive cisternal myelogram is recommended first of all, as this is the only reliable procedure to indicate operation.
41
TREATMENT ]n selecting treatment there is no common standpoint even today. Bedbrook (1966), Benassy et al. (1967), Frankel et al. (1969), Guttmann (1973) and Meinecke (1964) recommended conservative treatment. Others perform a laminectomy in every case with an exploratory aim and proclaim the necessity of spinal fusion (Evans, 1956; Meirowsky, 1965; Kahn et al., 1969; Austin, 1973). As is evident from our results, we adopted therapeutic methods between these extreme standpoints. Traction, as recommended by Crutchfield, without spinal operation has been performed in 16 cases, and in 10 cases contributed to an improvement in both the neurological picture and the dislocation. The neurological symptoms were not altered in 6 patients. In Munro's report in 1943, 74 per cent of deaths were due to respiratory complications. Several years later this figure had dropped considerably. In cases of incomplete transverse lesion, respiratory complications were found by Heiden et al., (1975) in 12-16 per cent of patients treated by operation and treated conservatively; in 15 per cent after laminectomy for complete transverse lesions, in 32 per cent after anterior fixation and in 34 per cent with conservative treatment. The reduction of mortality can mainly be the result of prophylaxis against thromboembolic and other complications, by undertaking early tracheostomy, assisted respiration and giving Calciparin etc. The treatment of cervical transverse lesions continues to be a great therapeutic and ethical challenge. Though the chances of survival are better than generally known, up-to-date ambulance services and central, specialized facilities provided for the seasonal occurrence of these injuries are indispensable for a further improvement in results. Because of their different prognoses and therapy, incomplete transverse lesions should be classified according to syndromes. The C S F passage examination repeated several times is absolutely necessary. We should resort to operation only for definite indications. Treatment should also aim at the prevention of pneumonia, blood clotting disturbance and urinary infection. REFERENCES Austin G. (1973) The Spinal Cord. Basic Aspects and Surgical Consideration. Springfield, Ill., Charles C. Thomas.
42
Injury: the British Journal of Accident Surgery Vol. 11/No. 1
Bailey P. (1900) Traumatic hemorrhages into the spinal cord. Med. Rec. NY57, 573. l~lint J. and Novoszel T. (1970) A paraplegia rehabilitatio urologiai szempontjai. Orvosk~pz~s 45, 231. Bedbrook G. M. (1959) Spinal injuries: a challenge. Aust. NZ J. Surg. 28, 254. Bedbrook G. M. (1966) Pathological principles in the management of spinal trauma. Paraplegia 4, 43. Beks J. W. F. and Oen T. S. (1962) Les traumatismes cervicaux: operation postericuere avec fusion. Neurochirurgia 8, 327. Benassy J., Blanchard J. and Lecoq A. (1967) Neurological recovery in para- and tetraplegia. Paraplegia 4, 259. Benes V. (1968) Spinal Cord h~jury. London, Bailliere Tindall. Biemond A. (1964) Contusio cervicalis posterior. Ned. Tijdschr. Geneeskd. 108, 1333. Braakman R. and Penning L. (1971) Injuries of the Cerv&al Spine. Amsterdam, Excerpta Medica. Dejerine J. (1914) Semiologie des Affections du Systeme Nerveux. Paris, Masson et Cie. Evans J. P. and Rosenaur A. (1956) Spinal cord injuries: a 15 year survey. Arch. Surg. 72, 812. Frankel M., Hancock O., Myslop G. et al. (1969) The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. Comprehensive management and research. Paraplegia 7, 179. Freeman L. W. (1949) Treatment of paraplegia resulting from trauma to the spinal cord. JAMA 140, 1015. Galibert P. M. (1962) Une methode de traitment des luxations du rachis cervical condiqu~es de lesions m6dullaires on radiculaires. Lille Chir. 12, 172. Gros C., Vlachovitch B. and Mohasseb G. (1960) Une forme peu connue de t6trapl~gie traumatique. Presse Med. 68, 829. Guttmann L. (1973) Spinal Cord Injuries. Oxford, Blackwell. Harris P. and Wu P. M. T. (1965) The management of patients with injury of the cervical spine using Blackburn skull caliper and Stryker Turning frame. Paraplegia 3, 278. Heiden J. S., Weiss M. H., Rosenberg A. W. et al. (1975) Management of cervical spinal cord trauma in Southern California. J. Neurosurg. 43, 732. Kahn E. A., Crosby E. C., Schneider R. C. et al. (1969) Correlative Neurosurgery, 2nd ed. Springfield, Ill., Charles C. Thomas.
Requests for reprints should be addressed
to: Mr
Kiss J. and Viszt J. (1967) Gerincs6riiltek 16gz6szavarainak 6s t~d6sz6v~dm6nyeinek jelent~is6ge 6s kezel6se. Magy. Traumatol. Orthop. 10, 101. Kom~iromi L. (1964). A Gerincsdriildsek KezelEse. El~adds az OIT110 Eves Jubileumi OIEsdn. Budapest. Meinecke F. W. (1964) Early treatment of traumatic paraplegia. Paraplegia 1, 262. Meirowsky A. M. (ed.) (1965) Neurological Surgery of Trauma. Washington, p. 307. M6rei F. T., Kopa J. and Bodosi M. (1973) Nyaki gerincs6riil6sek kezel6se spinofuzi6val. Ideggydgy. Szle. 26, 359. Munro D. (1943) Cervical cord injury: a study of 101 cases. N. Engl. J. Med. 229, 919. P/tsztor E. (1976) ldegseb~szeti Alapismeretek. Budapest, Medicina. Rand R. W. and Crandall P. H. (1962) Central spinal cord syndrome in hypertension injuries of the cervical spine. J. Bone Joint Surg. 44A, 1415. Ruge D. (1969) Spinal Cord Injuries. Springfield, I11., Charles C. Thomas. Schneider R. C. (1951) A syndrome in acute cervical spine injuries for which early operation is indicated. J. Neurosurg. 8, 360. Schneider R. C. (1960) Surgical indications and contra indications in spine and spinal cord trauma in clinical neurosurgery. Proceeding of the Congress of Neurological Surgeons 8, 157. Schneider R. C., Cherry G. and Panthek M. (1954) The syndrome of acute central cervical spinal cord injury with special reference of mechanism involved in hyperextension injuries of cervical spine. J. Neurosurg. 2, 564. Schneider R. C., Thompson J. M. M. and Bebin J. (1958) The syndrome of acute central cervical spinal cord injury. J. Neurol. Neurosurg. Psychiatry 21,216. Taylor R. G. and Gleave J. R. W. (1957) Incomplete spinal-cord injuries with Brown-S6quard phenomena. J. Bone Joint Surg. 39B, 438. Taylor R. G. and Gleave J. R. W. (1962) Injuries to the cervical spine. Proc. R. Soc. Med. 55, 1053. Thornburn W. (1887) Cases of injury to the cervical region of the spinal cord. Brain 9, 510. T6th Sz., Gy~irfAs F. and Szalay Z. (1975) A nyaki gerinc s~riil6sei. Magy. Traumatol. Orthop. 18, 22.
J. Julow, National Institute of Traumatology, Budapest, Hungary.
39
Clinical study of injuries of the lower cervical spinal cord J. Julow, I. Szarvas and A. S,~rvdry National Institute o f Traumatology. Budapest, Hungary The level involved was C5 in 18-5 per cent, C6 INTRODUCTION AMONG spinal cord injuries the number involving in 26-5 per cent, C7 in 35"8 per cent and C8 in 19.2 per cent. the cervical cord has increased considerably over Sixty-six per cent of vertebral fractures seen on the past few decades. the radiographs were at the level of C5 to C6. It is According to Guttmann (1973) the number of patients with cervical spine injuries amounted to remarkable that no direct relationship between 9 per cent of the total number of patients with the clinical condition and the gravity of the lesions spinal cord injuries in Great Britain in 1953 and was shown by X-ray examination (Table 1). Head injury was suffered by 56 patients (concussion in this percentage had reached 24 per cent in 1973. The same tendency has been observed all over the 47, contusion in 6 and intracranial haemorrhage in 3 cases). In 13 other cases the main injury was world, including Hungary. Spinal cord injuries raise several still unsolved complicated by rib fractures, in 2 cases by fracquestions, both from clinical and theoretical tures of the limbs and in 3 cases by abdominal points of view. These questions are also reflected injury. in literature published in Hungary (Kom~iromi, NEUROLOGICAL SYNDROMES 1964; Kiss and Viszt, 1967; B~ilint and Novoszel, 1970; Merei et al., 1973; T6th et al., 1975; There were 80 complete and 82 incomplete lesions. P~isztor, 1976). The appropriate literature differentiates between In the National Institute of Neurosurgery and the following syndromes of incomplete transverse the National Institute of Traumatology and in lesion. This differentiation is justified because of the Accident Service of P6terfy S,'lndor Hospital, the different lines of suitable treatment. Budapest from hundreds of cervical spine injuries, 162 patients (149 men and 13 women) Brown-S6quard syndrome have been studied in the last 10 years. This can nearly always be observed in an atypical Here we have chosen to analyse the most difficult and serious cases. We have not dealt form. According to Taylor and Gieave (1957) an with milder injuries like isolated fractures of asymmetrical paraparesis developing a few hours or days after the injury with analgesia on the less vertebrae, root injuries etc. paretic side can be regarded as an atypical Brown-Sdquard syndrome.
TIME, CAUSE AND NATURE OF INJURY
Forty-eight per cent of the patients were injured in June, July or August. The main causes of the injuries were falls in 38 per cent of cases, traffic accidents in 26 per cent and dives into shallow water in 17 per cent. Accidents at work accounted for 28 per cent of all the injuries.
Anterior cord syndrome As reported by Schneider (1951) and Taylor and Gleave (1962), below the lesion, bilateral complete flaccid paresis can be observed, with loss of the perception of temperature and pain but retaining the senses of touch, movement, pressure
40
Injury: the British Journal of Accident Surgery Vol. 11/No. 1
Table L The connection between the vertebral injury and neurological state Incomplete transverse lesion Distortion or negative X-rays Fracture without dislocation Fracture of arch Dislocation under ~ of vertebral width Dislocation between of vertebral width Dislocation between § and complete vertebral width Total dislocation
Table IlL
Table IL The connection between obstruction in the spinal canal, neurological state and vertebral fracture
Complete transverse lesion
10
2
99 11
4 7
30
22
20
22
2 0
15 8
Vertebral dislocation Less than ~- More than ,} 51 cases without obstruction* Incomplete transverse lesion Complete transverse lesion 30 cases with obstruction** Incomplete transverse lesion Complete transverse lesion
0
36
6
10
3
6
11
*Based on 24 Queckenstedt tests and 27 cisternal Myodil myelographies. **Based on 21 Oueckenstedt tests and 9 cisternal Myodil myelographies.
The comparison of the results of conservative and surgical treatment
Incomplete transverse lesion treated conservatively (58) Operated incomplete transverse lesion (24) Complete transverse lesion treated conservatively (60) Complete transverse lesion treated by operation (20)
Improved
Neurological state Unchanged
Worsened
45
35
9
1
10
14
14
0
0
33
27
6
16
5
19
1
0
1
0
Died
Survived acute period
13
and vibration. This s~,ndrome is mainly due to fracture, dislocation or ruptured disc. The clinical picture is almost identical to that of obstruction of the anterior spinal artery (Galibert, 1962; Benes, 1968). Central
9
cord syndrome
Besides serious bilateral paresis of the upper limbs this syndrome is accompanied by a much less serious paresis of the lower limbs, occasionally by disturbance of micturition but chiefly by disturbance of heat and pain sensation below the lesion (Thornburn, 1887; Schneider et al., 1954, 1958; Gros et el., 1960). It can be observed mainly with hyperextension of the cervical spine, but less frequently with fractures. Schneider et al. (1954 and 1958) and Gros et al. (1960) explained it as damage in the long tracts. The fibres of the corticospinal and spinothalamic tract from the
neck and the upper limbs suffer central damage, while the lateral thoracolumbosacral fibres are not damaged. Bailey (1900) and Rand and Crandall (1962) explain the paresis of the upper limbs as being due to damage to the anterior horn, the paresis of the lower limbs and the disturbance of micturition resulting from oedema compressing the corticospinal tract.
Posterior
cervical
contusion
It is characterized by symmetrical hyperaesthesia, paraesthesia from several cervical levels in the upper limbs and the trunk. It follows hyperflexion injuries without dislocation. The neurological signs are not serious and are reversible (Biemond, 1964; Braakman and Penning, 1971). It is often combined with paresis of the arms and hands and posterior tract signs.
Julow et al. : Spinal Injuries
It is caused by damage in the neighbourhood of the posterior horn. It is not identical with the posterior tract syndrome, described by Dejerine (1914) and rarely observed in practice. In our own patients we have observed the following types of incomplete transverse lesions: 15 atypical Brown-S6quard, 22 anterior, 18 central and 27 unclassifiable incomplete cervical cord syndromes. The damage of the roots accompanying these were observed in 11 cases. DETECTION OF SPINAL OBSTRUCTION This examination and its results are of great importance in judging indication for operation. It is most important in cases of incomplete transverse lesion without vertebral dislocation and in such cases decompression is indicated if the spinal block is complete. The examination is carried out by manometric measurement or by Myodil (Glaxo) myelography. Both procedures can establish the presence of spinal obstruction. A complete spinal block recorded by Queckenstedt's test is regarded by several authors as an absolute indication for decompression (Freeman, 1949; Bedbrook, 1959; Schneider, 1960, Beks and Oen, 1962; Taylor et al., 1962). O t h e r s d o n o t consider this procedure suitable to provide indications for operation because of the following possible errors. 1. It may give a false negative result in a case of anterior cord syndrome, as in a ruptured disc (Schneider et al., 1958). 2. If it is performed too early it may give a negative result. Braakman and Penning (1971) found a spinal block in 20 patients, with incomplete transverse lesion, in 3 cases on the first day, in 50 per cent at 2-4 days and then in steadily decreasing numbers day by day. 3. Re-examination may produce a false positive result in high cervical lesions due to venous congestion in the epidural veins of the neck. 4. In many cases there is no relationship between the gravity of the spinal lesion and the presence of spinal obstruction (Harris and Wu, 1965; Ruge, 1969). This view is also supported by our cases. 5. The improvement in the neurological signs and the resolution of the spinal block do not take place simultaneously. According to Braakman and Penning (1971) the spinal block cannot justify laminectomy in the first few days after the injury. If there is a spinal block, a positive cisternal myelogram is recommended first of all, as this is the only reliable procedure to indicate operation.
41
TREATMENT ]n selecting treatment there is no common standpoint even today. Bedbrook (1966), Benassy et al. (1967), Frankel et al. (1969), Guttmann (1973) and Meinecke (1964) recommended conservative treatment. Others perform a laminectomy in every case with an exploratory aim and proclaim the necessity of spinal fusion (Evans, 1956; Meirowsky, 1965; Kahn et al., 1969; Austin, 1973). As is evident from our results, we adopted therapeutic methods between these extreme standpoints. Traction, as recommended by Crutchfield, without spinal operation has been performed in 16 cases, and in 10 cases contributed to an improvement in both the neurological picture and the dislocation. The neurological symptoms were not altered in 6 patients. In Munro's report in 1943, 74 per cent of deaths were due to respiratory complications. Several years later this figure had dropped considerably. In cases of incomplete transverse lesion, respiratory complications were found by Heiden et al., (1975) in 12-16 per cent of patients treated by operation and treated conservatively; in 15 per cent after laminectomy for complete transverse lesions, in 32 per cent after anterior fixation and in 34 per cent with conservative treatment. The reduction of mortality can mainly be the result of prophylaxis against thromboembolic and other complications, by undertaking early tracheostomy, assisted respiration and giving Calciparin etc. The treatment of cervical transverse lesions continues to be a great therapeutic and ethical challenge. Though the chances of survival are better than generally known, up-to-date ambulance services and central, specialized facilities provided for the seasonal occurrence of these injuries are indispensable for a further improvement in results. Because of their different prognoses and therapy, incomplete transverse lesions should be classified according to syndromes. The C S F passage examination repeated several times is absolutely necessary. We should resort to operation only for definite indications. Treatment should also aim at the prevention of pneumonia, blood clotting disturbance and urinary infection. REFERENCES Austin G. (1973) The Spinal Cord. Basic Aspects and Surgical Consideration. Springfield, Ill., Charles C. Thomas.
42
Injury: the British Journal of Accident Surgery Vol. 11/No. 1
Bailey P. (1900) Traumatic hemorrhages into the spinal cord. Med. Rec. NY57, 573. l~lint J. and Novoszel T. (1970) A paraplegia rehabilitatio urologiai szempontjai. Orvosk~pz~s 45, 231. Bedbrook G. M. (1959) Spinal injuries: a challenge. Aust. NZ J. Surg. 28, 254. Bedbrook G. M. (1966) Pathological principles in the management of spinal trauma. Paraplegia 4, 43. Beks J. W. F. and Oen T. S. (1962) Les traumatismes cervicaux: operation postericuere avec fusion. Neurochirurgia 8, 327. Benassy J., Blanchard J. and Lecoq A. (1967) Neurological recovery in para- and tetraplegia. Paraplegia 4, 259. Benes V. (1968) Spinal Cord h~jury. London, Bailliere Tindall. Biemond A. (1964) Contusio cervicalis posterior. Ned. Tijdschr. Geneeskd. 108, 1333. Braakman R. and Penning L. (1971) Injuries of the Cerv&al Spine. Amsterdam, Excerpta Medica. Dejerine J. (1914) Semiologie des Affections du Systeme Nerveux. Paris, Masson et Cie. Evans J. P. and Rosenaur A. (1956) Spinal cord injuries: a 15 year survey. Arch. Surg. 72, 812. Frankel M., Hancock O., Myslop G. et al. (1969) The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. Comprehensive management and research. Paraplegia 7, 179. Freeman L. W. (1949) Treatment of paraplegia resulting from trauma to the spinal cord. JAMA 140, 1015. Galibert P. M. (1962) Une methode de traitment des luxations du rachis cervical condiqu~es de lesions m6dullaires on radiculaires. Lille Chir. 12, 172. Gros C., Vlachovitch B. and Mohasseb G. (1960) Une forme peu connue de t6trapl~gie traumatique. Presse Med. 68, 829. Guttmann L. (1973) Spinal Cord Injuries. Oxford, Blackwell. Harris P. and Wu P. M. T. (1965) The management of patients with injury of the cervical spine using Blackburn skull caliper and Stryker Turning frame. Paraplegia 3, 278. Heiden J. S., Weiss M. H., Rosenberg A. W. et al. (1975) Management of cervical spinal cord trauma in Southern California. J. Neurosurg. 43, 732. Kahn E. A., Crosby E. C., Schneider R. C. et al. (1969) Correlative Neurosurgery, 2nd ed. Springfield, Ill., Charles C. Thomas.
Requests for reprints should be addressed
to: Mr
Kiss J. and Viszt J. (1967) Gerincs6riiltek 16gz6szavarainak 6s t~d6sz6v~dm6nyeinek jelent~is6ge 6s kezel6se. Magy. Traumatol. Orthop. 10, 101. Kom~iromi L. (1964). A Gerincsdriildsek KezelEse. El~adds az OIT110 Eves Jubileumi OIEsdn. Budapest. Meinecke F. W. (1964) Early treatment of traumatic paraplegia. Paraplegia 1, 262. Meirowsky A. M. (ed.) (1965) Neurological Surgery of Trauma. Washington, p. 307. M6rei F. T., Kopa J. and Bodosi M. (1973) Nyaki gerincs6riil6sek kezel6se spinofuzi6val. Ideggydgy. Szle. 26, 359. Munro D. (1943) Cervical cord injury: a study of 101 cases. N. Engl. J. Med. 229, 919. P/tsztor E. (1976) ldegseb~szeti Alapismeretek. Budapest, Medicina. Rand R. W. and Crandall P. H. (1962) Central spinal cord syndrome in hypertension injuries of the cervical spine. J. Bone Joint Surg. 44A, 1415. Ruge D. (1969) Spinal Cord Injuries. Springfield, I11., Charles C. Thomas. Schneider R. C. (1951) A syndrome in acute cervical spine injuries for which early operation is indicated. J. Neurosurg. 8, 360. Schneider R. C. (1960) Surgical indications and contra indications in spine and spinal cord trauma in clinical neurosurgery. Proceeding of the Congress of Neurological Surgeons 8, 157. Schneider R. C., Cherry G. and Panthek M. (1954) The syndrome of acute central cervical spinal cord injury with special reference of mechanism involved in hyperextension injuries of cervical spine. J. Neurosurg. 2, 564. Schneider R. C., Thompson J. M. M. and Bebin J. (1958) The syndrome of acute central cervical spinal cord injury. J. Neurol. Neurosurg. Psychiatry 21,216. Taylor R. G. and Gleave J. R. W. (1957) Incomplete spinal-cord injuries with Brown-S6quard phenomena. J. Bone Joint Surg. 39B, 438. Taylor R. G. and Gleave J. R. W. (1962) Injuries to the cervical spine. Proc. R. Soc. Med. 55, 1053. Thornburn W. (1887) Cases of injury to the cervical region of the spinal cord. Brain 9, 510. T6th Sz., Gy~irfAs F. and Szalay Z. (1975) A nyaki gerinc s~riil6sei. Magy. Traumatol. Orthop. 18, 22.
J. Julow, National Institute of Traumatology, Budapest, Hungary.
