In the lower portions of the spine, which are both larger and more protracted, are more frequent combinations of both injuries and fewer instances of the single type of either. Except in the cervical region it is exceedingly difficult to distinguish between these lesions, for the question of operation or no operation is decided by other and more conspicuous features (Figs. 416 and 417).

Treatment.

—The injury having been localized, so far as deformity and careful study of its paralytic features will permit, the questions of prognosis and treatment become insistent. In the pure type of dislocation the prognosis will depend, first, upon whether reduction can be accomplished, and, secondly, upon the amount of damage suffered by the cord previous to such reduction. Every injury of the cervical spine is of most serious import because of the possible damage to the phrenic nerves. Rapidly ascending changes may terminate life in two or three days even though reduction be accomplished. The injuries to the lower part of the spinal column which produce paraplegia threaten life much less directly, but too frequently terminate fatally after the lapse of weeks or months, as the result of infections from spreading bed-sores, or infections through the urinary tract permitted by the constant necessity for and carelessness in the use of the catheter. The prognosis, then, in almost every case of these severe spinal injuries is unfavorable, at least if it be let alone (Fig. 415).

It becomes, then, a question of what can be done to improve the local conditions. Certain cases of cervical spinal dislocation have been reduced by forcible traction upon the head, assisted by rotation and manipulation with the hands in the direction indicated by the displacement of the patient’s head, as well as by such indications as may be secured in the pharynx. A considerable degree of traction may be necessary in this effort, and there is the possibility not only of failure but even of serious harm, and perhaps immediate death, since a fragment loosened may be made to produce promptly fatal pressure upon the cord. Such a measure, then, should be undertaken with the greatest care, and not without a complete understanding with those interested regarding its dangers (Fig. 418).

In most cases it is impossible from the exterior to estimate either the damage to the cord or the amount of fluid outpour until the spinal canal be opened. If there be complete loss of reflexes, with absolute insensibility and motor paralysis, then complete transverse destruction of the cord may be inferred. In these instances it may be decided not to operate. On the other hand it may be felt that unless the damage appear irremediable an open operation for inspection and relief should be performed at the earliest possible moment, since pressure on the cord allowed to persist even for a few hours causes damage for which there is no compensation. These cases may then be viewed in this light—if left to themselves they are almost hopeless. It therefore is a question simply of what can be accomplished by operation. On one hand the patient’s condition may be materially improved; on the other it is scarcely possible to make him worse. The dangers of such operations inhere especially in the anesthetic and in the possible introduction of sepsis; not that the operation itself cannot be properly conducted, but that it is often difficult to keep these cases free from contamination during the subsequent course of events. To operate through bruised or infected skin would probably be fatal. These operations, then, are begun as explorations intended to reveal deep conditions. When one has freed the spinal cord from pressure and has removed the products of hemorrhage he has done nearly all that can be accomplished in such a case.

Until recently it has been supposed that complete transverse division or crushing of the cord was necessarily hopeless and fatal. As previously mentioned, Estes, Harte, and Fowler have reported instances of complete division of the cord, with subsequent approximation by suture and with at least partial restoration of function, that have lent an element of hope to cases previously regarded as hopeless.

For my own part, although I regard these cases as discouraging, I do not feel like withholding from patients the only possibility of improvement which can be offered them, but I am more and more impressed with the necessity for prompt intervention if this benefit is to be obtained. To wait a few days, then, until it has been made evident that nothing can be done, save by operation, or until a tardy consent is obtained, is to rob the patient of the hope which it may afford. The operative treatment should be begun immediately after the diagnosis is made, providing that this be promptly done. Delay is more than inexpedient—it is absolutely dangerous. As Burrell has pointed out it is scarcely fair to decide upon a course of treatment from a study of statistics alone, as lesions vary within widest limits, as do also results of individual operators. Let each case, then, be decided upon its merits, but let whatever is done be done promptly. If there be excuse for delay it is in those cases where paralysis is incomplete and where the cord apparently has not been seriously compromised. But these would afford the most promising results after operation.

The operation itself will be described at the conclusion of this section, and in connection with other operations practised for exposure of the cord when involved in other lesions.

HEMATORRHACHIS AND HEMATOMYELIA (INTRASPINAL HEMORRHAGES).

These occur, as do hemorrhages within the cranial cavity, with or without serious other lesions of the investing structures. They are expressions, of course, of transmitted violence, depending so far as known essentially upon injury, whether the hemorrhage occurs within the central canal of the cord, within its structure, or within the subdural or even extradural spaces. Everywhere within these regions bloodvessels abound, from which may occur sufficient outpour of blood to make pressure upon the cord to a degree producing complete paralysis. The duration of time between reception of injury and the occurrence of diagnostic paralysis will be to some degree a measure of the rapidity of such outpour, while a study of the paralyses themselves will permit of localizing the injury. The symptoms consist mainly of pain in the spine radiating to some distance, often referred to the distribution of the nerves most involved. This pain is often associated with muscular spasm, while paralysis may be a very early or somewhat tardy symptom.

Treatment.

—Once the fact of pressure upon the cord is established these cases come under practically the same rule as above. While there is a possibility that a moderate amount of bloody outpour might be absorbed there is nearly as much danger of its organization and of permanent involvement of the cord. In fact there is more reason for operating in cases of spinal hemorrhage than in cases of fracture, since it may be possible to thereby accomplish more.

The non-operative treatment of fractures or dislocations consists mainly in external support, preferably by a plaster-of-Paris corset properly applied, and by maintaining elimination and nutrition, while affording physiological rest for a sufficient length of time. These cases will need massage and electricity, i. e., stimulation of the compromised muscles, and extreme care should be given to the prevention of bed-sores, to which they are peculiarly liable. Every precaution should be taken also against any possible retention of urine or feces. The incontinence of an overdistended bladder should not be mistaken for that of paralysis of its sphincter apparatus. The specimen of dislocation from which Fig. 415 was taken was removed from a patient who almost completely recovered from the effects of the injury, but who became careless about the condition of his bladder and who suffered an ascending urinary infection that terminated his life.

Of these cases it may also be said, then, that a much better prospect of exact diagnosis and atonement for harm done is afforded by exploration, since as between compression of the cord by clot or by bone there is little essential difference.

The subjoined table may afford assistance in the diagnosis of the injuries above considered:

Differential Diagnosis of Diseases and Injuries of the Spine and Spinal Cord.

COCCYGEAL OR PILONIDAL SINUS.

In the neighborhood of the coccyx, usually below its tip, between it and the anus, sometimes above the tip, a small depression or sinus mouth is occasionally seen. This is usually known as the pilonidal sinus. It is the persistent remnant of the original fetal termination of the spinal canal. It varies in size from a mere dimple to a cul-de-sac, in which sebaceous matter, with any other epithelial products, hair, etc., as well as foreign material and dirt from the skin, may collect and excite suppuration. In this way an abscess of considerable size may form. Sometimes its contents will be found to be principally hair; hence the name pilonidal. Frequently this sinus can be traced down to the periosteum and into the remains of the original neurenteric canal. When it is distended so as to give trouble it needs only to be freely incised and thoroughly cleaned.

CONGENITAL COCCYGEAL TUMORS.

In the region of the coccyx and lower part of the sacrum there appear tumors of congenital origin which are often present at birth or may not develop until later. These assume various sizes and aspects, varying from mere protuberances to large pendulous tumors. While covered with integument their internal structure varies within wide limits, and they are usually made of such a mixture of embryonal elements as to entitle them to be considered true teratoma. Even organized tissues or rudimentary organs may be found therein. They are rare and constitute practically surgical curiosities. Such a tumor, if troublesome, calls for removal, which should be accomplished with the strictest precautions, as the spinal canal may perhaps be opened during the procedure and most inflammable tissue thus exposed to infection from the perineum.

The sacrum, like the coccyx, is also the site of numerous congenital cysts and tumors which may appear posteriorly or anteriorly. Occasionally they form within the bone itself. Cysts that connect with the spinal canal will be found filled with cerebrospinal fluid, and some of them are essentially spina bifida occulta. The sacral region is also the site of predilection for those teratomas which consist in whole or in part of vestiges of an attached fetus. The advisability of operation must be determined for itself in each of these cases. (See Fig. 412, p. 627.)

COCCODYNIA; COCCYGODYNIA.

Under this name are included severe and chronic neuralgias of the coccygeal region, including its joint, which occur most often in women, and usually as the result of contusion or direct injury. Occasionally it results from an injury inflicted during parturition. It gives rise to a degree of pain and tenderness which sometimes is almost disabling. Because of the insertion of the levator ani into the tip of the coccyx defecation may become distressing, to an extent which leads to fecal impaction in the rectum from postponement of evacuation as long as possible. The symptoms are subjective, but the tenderness is frequently exquisite.

In regard to treatment subcutaneous division of the tissues around the bone may afford relief, but in most instances, particularly those of traumatic origin, an excision of the coccyx will afford the only cure. (See below.)

OPERATIONS ON THE SPINE.

These are included under the general heading laminectomy, which is used in a comprehensive sense, as is also the term trephining.

In a general way the measure is about as follows: Through a long median incision over the spines of the region where the lesion is localized their tips are exposed, while the muscle groups on either side and posterior to the laminæ are separated by the knife and by retractors. Dense fibrous bands may be nicked. In this way the posterior aspect of the neural arches is exposed to the desired length. The exposed spines should be removed by cutting them off at their bases with bone forceps, although they may be left and later removed with the posterior bony arches. To clear them away, however, affords a better view of the field of operation. The ligamenta subflava are then divided transversely at their upper and lower margins, after which, either with cutting forceps, saw, or chisel, the laminæ are divided on either side, and the section which is loosened pried out from the bed in which it rests. More or less fatty tissue will be found outside of the dura and in this tissue veins, sometimes of considerable size, freely ramify. These may be seized and divided, those of considerable size being tied. Great care should be given during the procedure to avoid perforation of the spinal membranes by the points of the instruments used. The cutting forceps are preferable to the saw or chisel, except for work in the lower lumbar region, where the parts are stout and strong. Especially in case of fracture, and at the upper end of the spine particularly, care should be given, with the force used, that no loose fragment be so handled as to increase the damage already done to the cord.

The dura being thus exposed and the blood cleared away, inspection may or may not reveal the nature of the lesion. A probe, gently handled, passed upward and downward into the canal, will reveal whether the cause of the pressure has been cleared away or not. According to the nature of the lesion it can then be decided whether to open the dura. To open it is to pave the way for fatal infection, unless the strictest aseptic technique has prevailed. On the other hand, to leave it unopened is to fail to appreciate the actual condition of the cord and to leave an important matter still undetermined. The dura if opened should be closed by suture.

Reference has already been made, in three cases now on record, to suture of the cord as a whole. Such sutures may be applied, if necessary, in a manner to do the least possible damage to the structures of the cord. If cerebrospinal fluid escape too freely the patient may be operated in a position with the head lower than the trunk, avoiding leakage.

Osteoplastic methods of temporary resection of the posterior arches of the vertebræ have been devised and practised, but they offer no particular advantages, and are attended by disadvantages which have caused them to be almost abandoned, save in rare instances and by individuals of large experience. (See Plate XLVII.)

In regard to wiring fragments of a fracture or displaced spine, Hadra, of Texas, was perhaps the first to carry out the measure. It comprises simply the fixation of fragments by wire sutures or ligatures which bind them together after they have been replaced through a more or less open wound, such as is included in the term laminectomy. But resort to wire is to be left to the judgment of the operator and the needs of the case. There is no reason, however, why it may not be used here, as in other fractures which are thus made compound, if there would seem to be prospect of benefit attaching to its use.

Laminectomy is practised also in Pott’s disease, with the hope of relieving pressure upon the cord, due to the deformity or to the presence of tuberculous foci. It is possible that in some of these cases an incomplete operation will serve the purpose. Sufficient should be done, however, to relieve pressure if such a measure be indicated.

When laminectomy is practised for the purpose of attacking a tumor of the spinal cord the exposure of the cord should be followed by the removal of the tumor. Some of these are so placed as to make the procedure simple, while at other times it will be exceedingly difficult, if not impracticable. If the growth has so extended as to involve the bones themselves, then the measure will be futile and should be abandoned; but an isolated tumor, either within or without the dural space, in or on the substance of the cord, can usually be removed by a process of blunt dissection. Sometimes the small wounds thus made will ooze considerably and hemorrhage may prove troublesome; it should be checked before the parts above it are closed. Pressure forceps and ligatures and the occasional use of adrenalin solution will afford the necessary means for combating bleeding.

For nearly all of these operations upon the spine the chisel and the cutting forceps will suffice. Some operators, however, prefer a small saw, like that suggested by Doyen, which has a guard that can be so set as to determine the depth to which the instrument may pass. No matter what instrument be used, great care should be taken lest it pass through and beyond the bone in such a way as to lacerate the dura or the plexus of veins outside of it.

The sacrum is rarely attacked except in connection with some of those tumors already described.

The coccyx is easily removed through a median incision, the parts around it being entirely separated and the bone thus freed removed at the joint with stout scissors or cutting forceps. The instruments used should be kept in contact with the bone and not allowed to injure the veins between it and the rectum. Such a wound should not be closed completely, as a cavity always remains, which it is better to pack and permit to heal by granulation. (See Coccodynia.)