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CHAPTER 12
4 If the answer is "No" the surgeon thereby goes on record as disagreeing with
virtually everybody else's opinion and perpetuates a deformity. He must, therefore,
hold himself responsible for any future disability despite any specious arguments or
reasons to the contrary.' I entirely agree with the views of Munro, who in the U.S.A.
certainly had the greatest experience in the treatment and rehabilitation of traumatic
paraplegics and tetraplegics, and McSweeney (1969) an experienced orthopaedic surgeon,
also condemned indiscriminate fusion of the cervical spine in the acute phase.
SURGICAL PROCEDURES IN LATER STAGES
The indications for late surgery on the spine and spinal cord following closed spinal
injuries are:
1
Persistent or recurring instability of the spine.
2 Restitution of neural function.
3 Treatment of spasticity and contractures.
4 Treatment of pain.
In the following, only items i and 2 are discussed as 3 and 4 are dealt with in the
respective chapters.
(1) As mentioned before, there are only selected cases where, following conservative
treatment of fractures and/or dislocations, late instability of the spine persists or may recur.
Although in the majority of these cases stability will be restored eventually by continuing
conservative methods, in those cases where neurological symptoms develop or existing
symptoms progress the risk of performing stabilizing operations is certainly justified,
provided the patients with incomplete lesions are properly informed about the risks. The
type of procedures naturally varies according to the type of pathology and the experience
and skill of the surgeon.
(2) Laminectomy has been repeatedly performed in both complete and incomplete
lesions in later stages in an attempt to restore or improve neural functions. In view of the
unsatisfactory results obtained during the Second World War (MacCravey, 1945;
Cutler, 1945) the American Army surgeons were instructed to abstain from performing
late laminectomies for restoring neural functions. Moreover, there is the danger of
increasing the existing deformity or producing instability of the spine as the result of
laminectomy.
In incomplete transverse lesions of the cord or cauda equina indiscriminate or routine
laminectomy should be condemned. This applies, in particular, to those cases who show
spontaneous recovery of neurological symptoms. The demonstration of displacement
of bone into the spinal canal (see Fig. 54) or partial or complete suparachnoidal block, as
suggested by Haynes (1946) and other surgeons, is in itself no indication for laminectomy
as long as there is progressive improvement of the neurological sumptoms. It is in the
patient's vital interest to wait at least until the clinical improvement stops. It cannot be
emphasized too strongly that the longer one observes such patients and provides them
with a fair chance of adequate management, the less one will take the great risk of inter
fering with the natural forces of repair and healing.
There is general agreement that in progressive increase of the neurological sympto-
