F- CLINICAL ASPECTS OF SPINAL CORD INJURIES
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described by E.Remark (1893), it was Babinski (1896) who realized the clinical signifi
cance of the phenomene du gros orteil which is generally accepted as Babinski's sign.
It is well known that the extent of its reflexogenic zone and the intensity of its motor
response varies. Sometimes the reflex response of the extensor hallucis longus either
alone or in combination with spreading of the toes (signe de Peventail) may show a
profound preponderance over any other muscles of the lower limbs, and in some patients
the contraction of this muscle may be very violent and permanent, resulting in subluxa-
tion of the terminal phalanx of the big toe, as described in a case of complete paraplegia
below T4 (Guttmann, 1953).
In the same group of reflex response belongs the tibialis anterior. The reflex contrac
tion of this muscle, either in combination with the extensor hallucis longus or isolated,
may become so preponderant that finally a contracture of the foot in dorsiflexion and
inversion occurs (spastic pes varus). This will be particularly profound if, during the
stage of spinal shock, a pressure lesion of the superficial branch of the external popliteal
nerve has occurred due to faulty position of the leg, resulting in peripheral paresis or
paralysis of the peroneal muscles. On the other hand, in the rare case of a peripheral
lesion of the anterior tibial branch of the external popliteal nerve leading to paralysis
of tibialis anterior and extensor hallucis longus the resulting unrestrained reflex activity
of the peronei will lead to profound eversion of the foot (spastic pes valgus).
2.
Preponderance of plantar flexors offeet and toes
In several patients with complete and also incomplete lesions resulting in marked
spasticity of the paralysed legs, a profound preponderance of the plantar flexors of the
feet and toes was found. Slightest stroking of the sole and tapping against the plantar
surface of the toes (Rossolimo's sign) or the capitulum of the 5th metatarsal (Mendel-
Bechterew's signs) produce brisk plantar contractions of the toes. This may occur in
one leg only, though it was usually seen bilaterally. This may become exaggerated as a
result either of keeping the feet and toes in plantar flexion during the stage of spinal
shock, instead of at the right-angle, or as a result of a pressure lesion of the external
popliteal nerve at the level of the head of the fibula through faulty position in the early
stages following transection of the cord, resulting in peripheral paralysis of the antag
onists of the plantar flexors, namely the dorsiflexors of foot and toes. This peripheral
nerve lesion additional to the upper motor neuron lesion of the cord, can be diagnosed
by the absence of any reflex response to cutaneous stimuli within the area of cutaneous
distribution of the external popliteal nerve—for instance by pricking or stroking with a
pin. Reflex responses to nociceptive cutaneous stimuli are obtained only at the border of
the cutaneous distribution of this nerve. Moreover, electrical examination of the muscles
in question and an electromyogram will reveal complete or incomplete R.D. of the
muscles supplied by the external popliteal nerve.
3.
Preponderance of crossed reflexes
These are very common in the spinal man but develop at a later stage of reflex return
following spinal shock, when excitability and responsiveness of the reflex arcs have
