F- CLINICAL ASPECTS OF SPINAL CORD INJURIES
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result of gastric or duodenal ulcer, these sensations may persist or recur if the ulcer
becomes active again. The patient mentioned above actually experienced, on occasions, her
old ulcer complaints, though less intense, after she became a paraplegic with a high
thoracic lesion. In this connection, another case may be mentioned: a war pensioner with
a complete traumatic lesion below T5 had a duodenal ulcer before his injury, and recur
rence of this ulcer was accompanied by the same, though somewhat clouded, pain in the
anaesthetic upper abdominal region, mainly on the right side, which he had before his
injury. During one of his regular check-ups, a marked deterioration of his general
condition was noted. Detailed examination revealed that not only had his discomfort in
the upper abdominal region increased during the last two weeks before admission, but
there was no doubt whatsoever about a local tenderness to pressure in the right abdominal
region, appreciated as a dull ache. He deteriorated further in the following few days, and,
as the X-ray showed a small patch of air in the upper abdominal region, a slight perfora
tion was diagnosed and confirmed at operation. This patient's life, too, was saved. He
made a good recovery and returned home, where he continued his business.
In summarizing the pathways of conduction of the afferent impulses, arising from
abnormal, visceral activity in the anaesthetic area in complete spinal cord lesions, the
following routes may be considered:
Directly related to the affected viscera (such as urethra, bladder and colon):
a. Along autonomic nervous pathways, travelling extramedullary below the transection,
until the pathways connect with nerve fibres, which are themselves connected with
spinal segments above the transection.
b. First via posterior roots and spinal cord, as far as the level of the transection, and
continuing extramedullary, as described in (a).
Indirectly related to the affected viscera:
a. Along the phrenic nerve and referred as pain in the shoulder. This may occur in the
event of an abdominal catastrophe, caused by perforated gastric or duodenal ulcers,
affecting ramifications of the phrenic nerve in the diaphragm.
b. Along the perivascular nerve supply, in the form of ascending sensation in the midline
of the body, resulting in headaches, etc., and associated with vasodilatation, rise of
blood pressure, etc.
It may be assumed that, in patients with high spinal transection, who were suffering
from gastric or duodenal ulcers in their pre-paraplegic life, persistence or recurrence of
the local pain and the appreciation of localized tenderness to pressure are transmitted
(more or less distinctly) through the auxiliary, afferent, extramedullary pathways, once
the main route through the corresponding posterior roots and spinal segments is cut off
by the transection of the cord.
Control of pain
The analysis of the various patterns of painful sensations observed in paraplegics and
the better understanding of the underlying mechanisms naturally have their bearing on
the management of pain.
