War Surgery and Medicine
CHAPTER 8 — Spinal Injuries
THE history of the treatment of war wounds of the spine does not reveal any marked advances. In serious wounds surgery has not been able to reduce the mortality rate appreciably.
First World War
During the 1914–18 War the wound itself was treated on similar lines to wounds elsewhere in the body in the attempt to counteract infection. Excision, the application of antiseptics, and finally secondary suture, were carried out.
Operation on the spinal cord itself was recognised as of little or no avail and was seldom carried out, and that only for the relief of pain or for other special indications. Large metallic fragments were removed if possible. Suprapubic cystotomy was routinely carried out for bladder retention, and bladder lavage for urinary infection. Several patients are known to have survived for long periods, but urinary infection was a constant cause of death.
Spinal injuries were not uncommon in the Second World War. The lack of specialists in 2 NZEF made the Force largely dependent on British and American hospital facilities. In the Middle East the cases were mostly treated by the neurosurgical unit in Cairo. In the forward areas, in the early part of the war, operation was seldom performed, except when a large wound demanded attention. Supra-pubic cystotomy was generally carried out in the complete lesions. Stress was laid on the necessity to examine the wounded for signs of paraplegia, as there was a danger of the condition being overlooked in the presence of other serious wounds or when the patient was unconscious. On the other hand, there might be other more serious conditions, such as abdominal injury, present associated with paraplegia. There was fortunately little impairment of stability in gunshot wounds of the spine, quite different from the fracture dislocations. It was important, however, in every case of paraplegia to avoid extra damage during transport, and to have constant care of the paralysed bladder and bowel and the insensitive skin.page 163
Observations made during the Alamein battle showed that spinal injuries were unusually common. It was considered advisable not to operate on these cases till an X-ray was taken, so that foreign bodies in relation to the spine might, if possible, be removed. The patients stood transport very well, especially by air. These patients, when followed up at the Base, were observed to have done very well indeed, with only an occasional septic case.
In total lesions it was observed there was complete flaccid paralysis, absence of reflexes and rectovesical paralysis, which signs continued till death. Oedema of the legs and scrotum was also usually present. It was stated in 1942 that no cord lesion which had signs of a complete lesion after forty-eight hours would show any useful degree of recovery.
Recovery could be expected in partial lesions and was usually ushered in by a return of movement. Spastic paralysis also had a better prognosis. Pain was not commonly observed early, but was often intense in caudal lesions. Lumbar puncture and X-rays, except for the location of foreign bodies, were of little value. Complications were often associated with the urinary tract, and bed sores were very common. Meningitis was generally fatal within two to three weeks. Urinary retention was the usual accompaniment, but incontinence sometimes occurred. Surgical intervention was recommended only where there had been deterioration after an initial improvement, in caudal lesions, and for nerve root pain. Operation, if indicated, was best undertaken within ten days. It was not without its own serious dangers. Plaster casts for the treatment and transport of the spinal cases were found to be unnecessary, and they led to a multiplicity of bed sores as well as giving rise to abdominal distension and even vomiting.
Major Weinberger, US Army, who treated the New Zealand cases in the Cassino area (1944), operated as a prophylactic against infection, and removed the foreign bodies when they involved the spinal theca. He combined tidal drainage with the suprapubic. The foot of the bed was raised to relieve pressure on the back and legs. This lessened the incidence of bed sores, and assisted in their treatment. Plaster casts were not used during the transport of patients.
Major Shoreston, RAMC, in the British hospital at Lake Trasimene, dealt with New Zealand spinal casualties during the advance to Florence. He treated them on ordinary principles, removing damaged muscle, loose bone and foreign bodies, and repairing the dura, using grafts when necessary. He also carried out primary wound closure and used chemotherapy following operation. In all complete lesions he carried out a suprapubic cystotomy, but postponed operation, using expression of the bladder, in cauda equina lesions.page 164
During the same period several spinal cases were under treatment at 2 NZ General Hospital at Caserta. All were seriously ill and all had large sacral bed sores. Observations at the base neurosurgical unit at Naples confirmed the opinion that, under war conditions, sacral bed sores were inevitable and that no practicable measures of prevention seemed possible. The conditions of warfare involving frequent and prolonged evacuations of the wounded were largely responsible. There was insufficient medical personnel to ensure the constant movement and the meticulous attention necessary for the spinal cases. Perhaps in the future special rotary beds could be provided for- the spinal cases and thus enable constant change of position to be carried out. The Stryker frame would be suitable. The nursing of the cases was made more difficult by the attention required to dress the bed sores.
In the later stages of the war in Italy treatment was directed to the healing of the bed sores and to the urinary complications. The bed sores were closed, either by suture, by rotation flaps, or by using free skin grafts, after infection had been eliminated by penicillin. The closure of the bed sore led to marked improvement in the general condition of the patient. Bladder infection was dealt with by washing out the bladder and by chemotherapy. Regular bowel movement every two days was arranged and distention relieved by enemata and pituitrin. Urinary calculi and bladder stones were commonly met with later. Late exploration of the spine met with no success.
To sum up the position at the end of the war, little success was claimed in the treatment of these serious injuries. The prevention of infection was successful, especially in the latter part of the war. Infection had been largely eliminated in war wounds by early and efficient surgery and chemotherapy. Suprapubic cystotomy was the regular treatment for the paralysed bladder. Bed sores were inevitable, but were healed by plastic repair and skin grafting. The abolition of plaster jackets, especially for transport, reduced the number of bed sores, especially in the more serious cases.
The mortality was heavy and urinary complications frequent. Operation on the spinal cord was indicated only where there had been deterioration after an initial improvement in caudal lesions, and for nerve root pain, and it was best undertaken within ten days of wounding.
It is suggested that spinal injuries could be reduced by the wearing of metal shields for protection of the spine, just as the steel helmet is used for protecting the head.
|Concussion and paralysis, both arms||1|
|Fract transverse processes, cervical||1|
|Fract transverse processes, lumbar||1|
|Fract spinous processes||1|
|Fract cervical spine, simple 1 Fract cervical spine, compound||2|
|Fract cervical and spastic paraplegia||1|
|Fract cervical and brachial plexus injury||1|
|Fract dorsal vertebra||1|
|Fract dorsal vertebra and paraplegia||6|
|Fract lumbar vertebra||5|
|Fract lumbar vertebra and concussion cord||2|
|Fract lumbar vertebra and paraplegia||3|
|Fract lumbar vertebra and cauda equina lesion||9|
|Fract lumbar vertebra crush||1|
|Fract sacrum and cauda equina lesion||2|
|Fract sacrum and involg sacral nerves||1|
|Compression fract spine||1|
|Injury lumbar plexus||1|
|Lesion, 5 cervical nerve||1|
|Lesion, brachial plexus||1|
|Causalgia lumbar nerves||1|
|Paralysis cervical 4||1|
|Compression fracture cervical||6|
|Compression fracture dorsal||5|
|Compression fracture lumbar||13|
|Compression fracture dorsi-lumbar||2|
|Compression fracture vertebra (undef)||1|
|Fract transverse processes lumbar||3|
|Fract transverse processes and spondylolisthesis||1|
|Fract odontoid process||1|
|Fract neutral arch atlas||1|
|Other and undefined||11|
|admissions to hospital, 1941–45|
|Fract vertebra and lesion spinal cord||19|
|Fract vertebra without lesion||34|
K. Nissen Bulletin of War Medicine (MRC), February 1943.
H. PeiperAmerican War Medicine, January 1943.