F- CLINICAL ASPECTS OF SPINAL CORD INJURIES
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(c) Disturbances at and above the transverse lesion due to root or segmental
irritation
Nociceptive border zone reactions.
Patients with complete transverse lesions, especially
of the mid-thoracic and thoraco-lumbar cord, not infrequently develop an hyperpathic
zone at the border and above the lesion which may involve one or more dermatomes. In
some cases, this border zone hyperpathia may become a dominant clinical symptom, and
the patient usually complains of a feeling of band-like tightness and pain of burning
character. The slightest touch may become very unpleasant and the simplest pressure
of the bedclothes may elicit great discomfort. The irritation of the sensory elements in
these segments above the transection may lead to muscular reflex responses consisting of
irregular fascicular twitching or cramp-like contractions of the muscles supplied by the
border zone segments. It may also lead to hyperactivity of autonomic mechanisms in this
area, such as band-like vasodilatation, piloerection and sweating. Moreover, the triple
response as described by Lewis (1927) may be exaggerated in this hyperactive border
zone, which shows how the intensity of this local reflex response may be influenced by
the state of the segmental reflex activity of the spinal cord (see chapter on Vasomotor
Control).
Pain and paraesthesia occur frequently in cauda equina lesions, especially partial
ones. The root irritation is caused either by peri-radicular adhesions, as a result of post-
traumatic arachnoiditis, or by post-traumatic changes in the damaged roots themselves.
In these cases, the pain is often of a more spasmodic character described as Shooting
pain' and can be exaggerated by various extrinsic and intrinsic factors, such as atmos
pheric changes, noises, and acute infection of the body, especially of the urinary tract,
etc.
(d) Phantom sensations
Paraplegics and tetraplegics with complete transection of the cord or cauda equina may
complain of distressing burning and tingling sensation below the level of the lesion.
These sensations may be diffuse in character and are usually imperfectly localized. In
numerous cases, they are associated with phantom sensations and are referred either to
the lower limbs generally or to some specific area in the completely insensitive lower
limbs, such as feet, toes, or the ano-genital region.
During the First World War, Riddoch (1917) observed the occurrence of phantom
sensations in patients with transection of the spinal cord and, since the Second World
War, several reports on this subject have been published in traumatic paraplegics
(Schulte, 1947; Becker, 1959; Beck, 1949; Bors, I95ib; Pichler, 1954; Heye, 1956;
Pollock
et
a/., 1957; Guttmann, 1957, 1969). Phantom sensations are often experienced
immediately and in the initial stages following spinal cord injuries and are described as
'feeling as if my legs were blown off5, or 'swelling to twice their size'. However,
unlike phantom sensations after amputations, the phantom sensations in paraplegics do
not, as a rule, represent a dominant symptom and may gradually disappear, except in
cauda equina lesions where they can remain more or less permanent and troublesome.
