F- CLINICAL ASPECTS OF SPINAL CORD INJURIES
513
POSTOPERATIVE CARE
A plastic operation, as any other major surgical procedure, may easily have an adverse
effect on the unstable vasomotor control of these patients, and pulse and blood-pressure
need careful attention in the first few days after operation. Blood transfusions are often
necessary to counteract prolonged surgical shock in these patients. Haematomas have to
be removed immediately and can be voided by suction through a fine multiperforated
polyethylene tube following operation. Flexion of the hips is not allowed for three weeks
after complete healing of the ischial and trochanteric sores, after which time passive
flexion is started and gradually increased to a right angle, until flexion produces no tension
of the skin whatsoever. The patient is usually not allowed out of bed until 4-5 weeks
after operation.
Pressure consciousness
Finally, no healing of a sore, whether by conservative or surgical procedures, will be
successful if the patient has not been instructed about the dangers of pressure and how to
avoid it. In other words, the patient has to be made absolutely 'pressure or sore con
scious', and this is the most important pre-condition in the prevention or recurrences of
sores and thus in the successful rehabilitation and industrial resettlement of paraplegics.
The paraplegic who is employed, must never forget to lift himself at regular intervals
even when sitting on a 4-in sorbo-rubber cushion, which should never be covered with
stiff rexine. Clothing and footwear has to be chosen carefully to avoid rubbing or pressure
to the tissues, especially to malleoli and toes. The urinal has to be in a proper position
to avoid pressure or friction in particular to the penis. As paraplegics with complete
lesions are insensitive in their paralysed limbs, they must take care not to knock their
legs against hard objects when transferring themselves from the wheelchair to the car
and vice versa. 'Look before you leap' means to a paraplegic more than a proverb,
especially for those with healed sores. Tetraplegics should avoid prolonged pressure on
the elbows when resting their forearms too long on the arm rest of the wheelchair or
on a mattress—when lying prone in bed. Tetraplegics below C6 who can propel them
selves in their wheelchairs should have a soft leather pad over the palm of the hand to
prevent pressure to the insensitive ulnar area of the hands.
Amputations
Not very long ago surgeons (Lindenberg, 1953; Street, 1958; Chase & White, 1959;
Felix, 1959) performed amputations on patients with transverse lesions of the spinal
cord as a preventive measure to the development of pressure sores, or these operations
were carried out indiscriminately in paraplegics suffering from sores in the paralysed
limbs which could have been healed by adequate conservative or surgical treatment or
even on the grounds, that without their 'useless' legs, they will be more mobile. During
the Second World War the writer saw such mutilated victims, amongst them a tetraplegic,
