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CHAPTER 12
All these methods employing plaster cases and prolonged recumbency proved to be
unsatisfactory in spinal fractures resulting in paraplegia. There is now general agreement
among those with experience of traumatic paraplegia that prolonged immobilization and
recumbency is detrimental in these patients, because of the tendency to promote stag
nation in the urinary tract resulting in pyelonephritis, stone formation and hydro- or
pyonephrosis. Furthermore, it leads to the development of pressure sores and articular
contractures. These dangers were greatly increased by plaster fixation, be it jacket or
plaster bed. Nissen (1941) advocated plaster beds in view of the disastrous effects of
plaster casts in traumatic paraplegia. The idea was that pressure was more evenly
distributed in a plaster bed. This concept did not prove to be correct. The volume of the
paralysed part of the body, especially the legs, does not remain constant, because there
are changes in the degree of vasodilatation as a result of interruption of the spinal vaso-
motor centres and pathways. In fact, in paraplegic patients who lay in a well-made
plaster bed for many weeks or months, not only did this method of fixation prove to be
no better than plaster casts, but it greatly promoted the development of sores of the most
frightful type. Moreover, this type of fixation caused profound fixed lordosis of the lum
bar spine, distortion of the pelvis and atrophy of the normal back muscles, which are so
vital for the physical readjustment and the later maintenance of the patient's upright
position. In spite of intensive physiotherapy it took many months, if one succeeded at
all, to overcome the fixed distortion of the pelvis in those paraplegic patients who were
admitted in plaster beds, let alone to heal the pressure sores which had developed as a
result of that treatment. This management has been strongly condemned (Guttmann,
1945, 1946; Watson-Jones, 1955; Holdsworth & Hardy, 1953) as utterly contrary to the
principles of rehabilitation of spinal paraplegics and as a result it is today hardly ever
used, apart from the occasional purpose of transport of traumatic paraplegics. It is fair
to say that Nissen himself has abandoned this method.
In contrast to the methods of forceful reduction and long-term recumbency, Sutcliffe
Kerr (1956) advocated restoring the vertical position of traumatic paraplegics following
fractures within a few days after the injury. He ignored, by this method, the injury to
the spine and accepted that there was no hope for recovery of the paraplegia if the paralysis
lasted longer than 48 hours after injury. Although this may be true in some injuries of
the upper and middle thoracic spine, it is certainly not so in injuries to the thoraco-
lumbar part of the spinal cord, where some degree of functional recovery may occur even
after weeks. This method, however, did not find acceptance.
Postural reduction combined with regular turning
In 1944 I introduced and developed the method of graduated reduction of fractures and
fracture-dislocations of the spine and immobilization on pillow-packs combined with
2-hourly turning of the paralysed patient, day and night. The original pillow-packs
were later replaced by the more suitable and more hygienic sorbo rubber packs. The
technique is as follows:
The patient is placed by three orderlies, under the supervision of a trained nurse,
on the prepared bed, consisting of four sorbo-rubber packs about 40 cm high, which
