Early Therapeutic, Social and Vocational Problems in the Rehabilitation of Persons with Spinal Cord

394 Pages·1977·34.33 MB·English

by  Bolesław Bielicki (auth.), Marian Weiss M.D. (eds.)

Early Therapeutic, Social
and Vocational Problems
in the Rehabilitation of Persons
with Spinal Cord Iniuries
Springer Science+Business Media, llC
The preparation and publication of this study was supported through the Special Foreign Currency
Program of the National Library of Medicine, National Institutes of Health, Public Health Service, U.S.
Department of Health, Education, and Welfare, Bethesda, Maryland, under an agreement with the Coordi-
nating Commission for Polish-American Scientific Collaboration, Scientific Council to the Minister of Health
and Social Welfare, Warsaw, Poland.
The research on the management of the acute phase of spinal cord injuries and the application of
springs to control fracture of the spine was supported by the Rehabilitation Services Administration,
Department of Health, Education, and Welfare.
The study was published pursuant to an agreement with the National Science Foundation, Washington,
D.C., by the Foreign Scientific Publications Department of the National Center for Scientific, Technical,
and Economic Information, Warsaw, Poland, 1977.
Early Therapeutic, Social
and Vocational Problems
in the Rehabilitation of Persons
with Spinal Cord Iniuries
edited by
MARIAN WEISS, M.D.
Chairman and Professor of the Rehabilitation Department
Warsaw Academy of Medicine, Konstancin, Poland
with a Preface by Paul R. Meyer, Jr., M.D.
and a Foreword by W.T. liberson, M.D., Ph.D.
Springer Science+Business Media, LLC
Translated by
Edwin Paryski, M. D.
ISBN 978-1-4684-2414-0 ISBN 978-1-4684-2412-6 (eBook)
DOl 10.1007/978-1-4684-2412-6
© 1977 Springer Science+Business Media New York
Originally published by Plenum Press, New York in 1977
Softcover reprint of the hardcover 1st edition 1977
Library of Congress Catalog Card Number 77-79008
International Standard Book Number 0-306-31075-9
All rights reserved. No part of this book covered by the copyright hereon may be
reproduced or transmitted in any form or by any means-graphic, electronic, or
mechanical, including photocopying, recording, taping, or information storage and
retrieval system-without written permission of the publisher.
T ABLE OF CONTENTS
Preface by P. R. Meyer, Jr., M.D., F.A.C.S. vii
Foreword by W. T. Liberson, M.D., Ph.]). xi
Introduction by M. Weiss, M.]) xiii
Part I (Clinical)
Boleslaw Bielicki, M. D. - Conservative Management of Paraplegia 3
.Tanusz Makowski, M.D. - Surgical Treatment of Injuries to the Dorsolumbar Spine . . . . . . . . . 17
Romuald Brzezinski, Surgeon Orthoppdist-Orthotic Equipment and Technical Aids for Paraplegics 51
Adam Szurek, Surgeon Orthopedist-Social Problems of Paraplegic Patients ......... . 63
Marian Weiss, M.D. _.- Social Rehabilitation of Paraplegics Treated at the Metropolitan Rehabilitation Center 84
Jolanta Walicka, Psychologist-Psychological Problems in Paraplegics ..... 86
Marian Weiss, M.D. - Sports in Therapy and Rehabilitation of Paraplegics . . . . 110
Mieczyslaw Kowalski, M. D. - Problems of Vocational Rehabilitation in Paraplegia 114
Part 2 (Laboratory Work)
Bogdan Wozniewicz. M.D.-Pathology of the Spine and Spinal Cord Injuries ........ . 133
Jerzy Kiwerski, M.D. -Problems of Spasticity in the Treatment of Spinal Cord Injuries .... . 166
Janusz Wirski, M.D.-Heflex Acti"ity in Spinal Shock in Man on the Basis of Hoffmann's Reflexes 189
Part 3 ,New Experimental Surgical Procedures)
Marian Weiss, M.D.-Our Experience with Treatment and Rehabilitation of Patients with Spinal Cord Injury 233
Marian Weiss, M.D. - Pathology of Spinal Cord Lesions in the Light of Dynamic Alloplasty 241
Marian Weiss, M.D.-Biomechanical Studies in Dynamic Alloplasty of the Spine 246
Marian Weiss, M,D.-Clinical Results 255
Marian Weiss, M.D.-General Evaluation of the Clinical Material, 368
Subject index . . . . . . . . . . . . . . . . . . . . . . . . 372
v
PREFACE
Dr. Marian Weiss' textbook reviewing the etiology, pathophysiology, philosophy and conservative vs.
surgical management of spinal and spinal cord injury is a significant contribution to the world literature.
The remarks which follow are intended to serve the reader as a surgeon's 'thumb nail' sketch of the text's
contents, along with brief comments on areas of agreement or mild variance of the opinions expressed.
Dr. \Veiss' statement that the average surgical team often becomes more emotionally involved with the
good or doubtful prognosis case at the expense of the victim with a hopeless prognosis, is totally valid. The
percentage number of surgical spinal cases are insignificant when compared with the number of surgical admis-
sions. As a result, little appropriate knowledge is amassed by the average surgeon to allow for competence
or confidence in the management of the spinal injured patient's total problems. The opinion is correct that
spinal trauma should be managed in Spinal Injury Centers where access to the entire array of specialists
required by quadriplegic or paraplegic victims is available. Such comprehensive programs are most appro-
priately affiliated with University Medical Centers.
The controversy over initial conservative vs. surgical care in the acute spinal cord victim still exists ill
the United States, as it does in other countries. The reason is an informational gap. In depth, structured
surgical data gathered by experienced 'neuroorthopaedists' is not yet available. Awareness of the importance
of loss of circulation to the spinal cord, how and why it occurs, and how it can be prevented or corrected does
not exist. As a result, surgical criteria have not yet been clearly drawn. The same is true for concomitant
injuries accompanying spinal injury: Ruptured spleen and bowel, joint dislocations, rib, pelvic and long
bone fractures. Understanding each of these will allow the development of management criteria and treatment
protocols which will include: An understanding of when there exists a need for relief of neural canal encroach-
ment; when there are requirements for spinal stability; what the consequences may be resulting from surgical
vs. conservative management; and what will be the influence of prolonged recumbency and delay in
active rehabilitation over the patient's vocational outcome. To this effort Dr. Weiss' book has appropriately
added a number of significant contributions.
SURGICAL MANAGEMENT OF FRACTURE DISLOCATIONS OF THE DORSOLUMBAR SPINE
Controversy exists in the area of surgical management of dorsal-lumbar vertebral injuries, as brought
to our attention by Dr. Weiss. The procedure 'laminectomy' began in the latter 1700's, while spine stabili-
zation techniques first began in 1891, using wire, plates and celluloid. In spite of wire fatigue, bone necrosis
and spine redisplacement, these procedures became increasingly more popular. They allowed early mobiliza-
tion of the spine injured victim without requiring massive external immobilization and/or prolonged recum-
bency. Wilson, Staub, Holdsworth and Hardy popularized the use of bone plates in the late 1940's. They also
noted that surgical reduction did not insure against instability. In the 1960's and early 1970's, other metal
devices came into use: The H-shaped metal plate of Daab: Harrington Compression and Distraction Rods;
and Weiss Springs. Also appearing in the literature was the experimental use of polymethylmethacrylate as
a method of achieving rapid spine stabilization. Anterior and anterolateral surgical approaches were advo-
cated as early as 1923, and more lately been popularized by Hodgson and others (1960-1970).
vii
It is quite universally agreed that if there is a single positive indication for early surgery, it most likely
is the presence of neurologic deterioration. A later indication for surgery is that of spinal instability. Although
Dr. Weiss stresses the decision of spine stabilization on the presence or absence of ligamentous integrity,
it is difficult to assess their damage where luxation or subluxation does not exist. The author speaks of the
ligamenta flava as being uf a lesser important structure when compared with rupture of the anterior
and posterior longitudinal ligament and associated possible disc extrusion. Some exception is taken. It
has been in my experience that rupture of the ligamentum flava is of equal importance. Without poste-
rior element stability to which these ligaments contribute greatly, surgical stabilization will almost surely
be required.
In reference to the vascular supply to the spinal cord, it is agreed that the most likely explanation ac-
counting for the not infrequent sudden extension of neurologic dysfunction, in the lower cervical or upper
thoracic spinl1 injured patient, in the absence of otherwise producing causes, is cord ischemia. This compli-
cation has been frequently observed. Regardless of follow-up care, surgical or conservative, where neurologic
function is rapidly lost, function is generally permanently lost. It bears repeating that the extent of trauma at
the time of injury is unobtainable by history, nor radiographically apparent when the patient is first seen
in the emergency area. Likewise, it is difficult to interpret the need for surgery as a 'preventative' measure
against further neurologic deterioration, when for vascular reasons, the neuropathology has resulted in the
first place. These two areas of anatomic importance (ligamentous instability and vascular injury) further
substantiate the value of the initial evaluation and management of the spine injured patient by an experienced
spinal traumatologist. Familiarity with like problems benefits greatly the early institution of the most appro-
priate management protocol.
The principal 'Prognosticators' of spinal cord injury outcome are: Early injury identification; exacting
patient extraction, splinting and transport; and prior to the institution of medical or surgical management,
early comprehensive neurological and radiological evaluation. The latter may include: Tomography, air or
contrast myelography, selective vascular angiography (for the vessel of Adamkiewicz between Ts and L2).
and where available and when indicated, 'computerized axial tomography' (CAT) at the level of injury.
The reliability and diagnostic value of cortical evoked potentials is still under study. Each of these areas are
discussed in varying detail in Dr. Weiss' book. What is not yet decided is the effectiveness ofthe early adminis-
tration of such agents as: Steroids, anti edema medications such as Mannitol, oxygen, or plasma expanders
R
and capillary flow accelerators such as Dextran • The use of hypothermia (spinal cord cooling) in combination
with steroids has been mentioned as a possible means of further reducing post-traumatic spinal cord edema.
Although this technique on the surface would appear to be beneficial, the procedure must be carried out
in the early hours fo.Jlowing injury (under four hours to be effective), and as a technique is cumbersome and
requires a sophisticated team. Patient selection is crucial. Clinical evidence does not yet demonstrate its
effectiveness.
Conversation relative to the indication for surgery on the traumatized spine always raises the question
and relationship of laminectomy (posterior decompression) to surgical stabilization. The indications for the
former are seldom; and the latter, more frequent. Most surgical anatomists are in agreement that the most
effective means of spinal cord decompression is spine reduction. Surgically, the anterior decompression pro-
cedure rather than posterior (unroofing) procedure is more often indicated. Manipulation of the dislocated
spinal column, during the early hours (one to three) following trauma, followed by an often repeated thorough
neurological evaluation, has been found an extremely effective means of attaining, in 70% of cases (15),
anatomic reduction. No patients on initial evaluation found to be incomplete demonstrated any increase
in neurologic deficit following manipulation. In fact, to add to the world literature a third case, one patient
with a fracture dislocation at L 3, and complete neurologic loss below L3 (absent perianal sensation and tone
by three examiners) had return of perianal sensation and progressive improvement in motor function in both
lower extremities beginning 12 hours post reduction. This case demonstrates the unpredictable nature
of cauda equina injuries.
Dr. 'Veiss expresses the opinion that laminectomy when accompanied by sectioning of the dentate liga-
ments provides further decompression of the cord. This is a neurosurgical procedure opposed to by some in the
field, but generally an unreliable procedure in producing neurologic return in the post-traumatic patient. It is
viii
also his belief that open wounds of the spine, regardless of etiology, require spinal canal surgical debridement.
Authoritative difference exists in these two areas. Certainly the latter group requires local debridement, but
rarely extensive exploration unless highly contaminated, or a wound produced by a high velocity missile
causing anticipated significant tissue damage. Dr. Weiss expresses other opinions, though logical, as yet are
not clinically substantiated, i.e. 'Psychological studies demonstrate that patients mobilized quickly after
stabilization of the spinal column achieve earlier acceptance of the disability.' To present this is not proven,
but there are indicators it is correct. The chapter delineating surgical indications and management of spinal
fractures is comprehensive. Brief discussion accompanies each consideration, with statistical information
where the author has such available. Noteworthy is the detailed review of muscle-tendon, nerve and spinal
cord physiology included in this text. Their inclusion compliments the academic thoroughness of the con-
sortium of authors. Several relevant excerpts are called to your attention.
Reference is directed to the 'H' Hoffmann reflex, found under 'Critical Evaluation of Studies Performed
and General Conclusions':
1) It is noted that a decrease amplitude of the 'H' reflex is the result of peripheral atrophic muscle
changes, rather than changes in excitability of the spinal cord. Muscle wasting results from functional
disuse, rather than denervation. In the peripheral lower motor neuron paralysis, wasting is more pro-
nJunced because no impulses reach the muscle. In upper motor neuron paralysis, it is less striking because
the reflex arc is maintained, and spasticity or hyperirritability (enhanced stretch reflex) maintains muscle
activity. It is the author·s opinion that this information places hope on the re-establishment of signal
transmission, and potential 'servo-electrical' control of motor activity in the high (cervical-thoracic)
spinal cord injured patient. In our present state, repair of central nervous system lesions is not possible.
'Regeneration is only known to occur exclusively in the fetal period of lower animals.'
2) According to Weiss and ~-irski, after extensive evaluation of the Hoffmann (H) reflex by EMG, it was
their opinion that this technique may allow establishment of a means of prognosticating the severity of
spinal lesions.
'With reference to spasticity, there appears to be general agreement that of the drugs acting on the spinal
cord, Valium is the most successful. Because of its permanency, alcohol is seldom used. On the other hand,
many have found for the severely spastic, the intrathecal instillation of phenol (1.25 gm. crystalline granules
diluted and mixed in 5cc normal saline and 5cc ofpanapaque) the treatment of choice because of its temporary
nature. Although occasional pain follows its use, the success of the procedure exceeds an attempt to surgically
relieve massive lower extremity contractures or spasticity. Normally, the effects of this technique extend
between two months and two years. Caution, however, must be taken, in the conversion of a sexually active
male spastic to a flaccid victim. Surgery, on the other hand, may provide a rapid and easy method of relieving
specific spastic muscle groups, such as the adductors. In such situations, it is agreed that intrapelvic obturator
neurectomy is the procedure of choice. Its safeguard is the maintenance of partial innervation to the adductor
muscle m!tss via the sciatic and femoral nerves.
Although little substantiating information exists relative to early sitting and standing and its influence
on extensor patterning, there is again absolute agreement with the authors that such is the case. Early
patient mobilization is seldom accompanied by flexor spasticity. Extensive review of personal alloplasty
patients undergoing early (two weeks post-operative; four to five weeks post-injury) mobilization, compromis-
ing flexor spasticity fails to appear.
Indications for surgery in the spastic-nonambulatory-paraplegic may be the performance of osseous
surgical procedures such as pan or triple arthrodesis at the ankle, to stabilize or prevent spastic equinovarus
deformities. In such patients, tendon transfer should not be considered. Either arthrodesis, or appropriate
balanced flexor and extensor tendon releases, followed by the use of an ankle foot orthosis for positioning.
In the hemiplegic or ambulatory paraplegic who will use an orthosis, release and tendon transfer procedures
find more use.
According to Dr. Weiss, under the section entitled 'Pathology of Spinal Injuries, Complete vs. Incomplete
Lesions·, 50% of all post-mortem dissections revealed complete cord lesions. Although like statistics are not
available by the reviewer, it is noted that of 108 quadriplegics in 1974-1975, 44% were complete, and 56%
ix
were incomplete. A similar review of llO thoracic-lumbar spine injuries in 1974-1975 revealed 57% were
complete and 43% were incomplete.
The 'Weiss Spring Dynamic Alloplasty' surgical procedure, as described by Professor Marian Weiss,
has been throughly investigated, evaluated and successfully utilized in the United States in over 200 cases
between 1972 and 1976. Dr. Weiss reports 154 cases between 1965 and 1974. The result has been, using
a similar surgical criteria to that of Dr. Weiss, to significantly shorten the patient's requirement for post-
traumatic recumbent care. This has reduced the period of acute hospital care, has accelerated the rehabilita-
tion process, and has brought about an overall reduction in rehabilitation costs (presently 136 days
- $32,424).
The expression of confidence in the "Veias' Spring procedure does not imply that there are not other
surgical techniques which might be used for post-traumatic spine stabilization. Depending upon the indica-
tions, these other procedures might include Harrington Compression or Distraction Rods. This latter proce-
dure is particularly indicated in the unstable flexion-rotation injury to the spine, where a unilateral pedicle-
facet fracture has resulted. These spines are prone to traumatic surgical scoliosis at the fracture site when
managed with the 'Weiss' Compression Springs. This problem can sometimes be counteracted by carefully
applying the increased contralateral tension on the alloplasty device, with lesser tension on the ipsilateral
device. This scoliosis is more easily prevented by Distraction Harrington Rods. Likewise, greater correction
of a comminuted vertebral body fracture, with bone in the neural canal, in the neurologically intact patient,
can be obtained using Distraction Rods. In the complete injury, this is not a consideration.
Although occasionally appearing, there are few, if any, indications for the use of Murig 'William spine
plates. They produce no correction and their ability to provide reliable internal spine stabilization is such
that they should not be used.
In conclusion, the greatest contribution which Dr. Weiss' textbook 'Early Therapeutic, Social and Voca-
tional Problems in the Rehabilitation of Persons with Spinal Cord Injuries' offers to the spinal cord medical
and surgical community is discussion based upon significant personal and literary investigation. The extensive
bibliography found in this text is outstanding and exceedingly well subject orientated. The book provides
to the physician interested in spinal cord injury a starting point for academic orientation, and a point of
departure from which to expand his interest in any of a number of different areas. The text contains very
few controversial areas. This is not by chance. The lack of such is the result of a book written by men of vast
experience having spent extensive time in the field observing and comprehending the requirements of total
spinal injury patient management. This has produced a comprehensive interpretation of both clinical and
research findings. This text is not fundamental. It is clinical. It will serve as an authoritative resource doc-
ument, and a new standard in the field of spinal cord injury.
PAUL R. MEYER, Jr., M.D., F.A.C.S.
Associate Professor of Orthopedic Surgery,
Northwestern University School of Medicine,
Director, Acute Spinal Cord Injury Trauma Center,
Co-Director, Midwest Regional Spinal Cord Injury Care System,
Chicago, Illinois
x