F- CLINICAL ASPECTS OF SPINAL CORD INJURIES
517
the treatment of rigidity and spasticity, but toxic reactions such as haemoglobinuria and
thrombophlebitis at the site of the injection were observed (Pugh & Enderly, 1947).
We have used most of these drugs on our own patients but found that, while these drugs
may have a depressant effect on the spastic muscles, they also affect the muscles of the
normal part of the body as well as producing undesirable psychological effects. Amongst
the drugs examined, Tigloidine, a tiglic acid ester of the atropine series, advocated by
O'Rourke
et al.
(1960) in spastic paraplegics has proved quite useless in our own patients.
In recent years, Valium (Diazapem), an analogue of Librium (Chlordiazepoxide), has
been widely used in this and other countries (Dejak & Lowry, 1965; Neill, 1965; Wilson
& McKecknie, 1966; Kerr, 1966; Nathan, 1970; and others). In a discussion held at the
annual meeting of the International Medical Society of Paraplegia in 1966, there was
general agreement that Valium has definitely a relaxant effect on spasticity in small doses
without affecting too much the patient's general condition. However, it may lead to drug
addiction like Librium if used in prolonged medication and higher doses (Jousse, Frankel,
Guttmann & Walsh, 1966). Maglio (1966), who treated paraplegics, tetraplegics and
haemiplegics with Valium in doses of 40 to 50 mg, found that alcohol is an absolute
contraindication when Valium is used, and Kerr (1966) found, in doses of 16 to 24 mg
daily, drowsiness and a feeling of slackness of the limbs in incomplete lesions as the main
side effects. Corbett
et al.
(1972) carried out at Stoke Mandeville a double blind cross
over trial of Valium against Amytal and Placebo on 22 spastic paraplegics. Observations
were made by 6 independent observers. It was found that Valium was significantly more
effective than Amytal and Placebo and there was a low incidence of side-effects.
With regard to the effect of Prostigmin, there is no doubt that intrathecal injections
of Prostigmine 0-3 mg has a profound but only temporary relaxant effect on the skeletal
muscles (Kremer, 1941; Guttmann, 1953), and I have used this first in cases with intract
able spasticity combined with profound contractures of hip and knee joints to determine
the degree of contractures whilst the depressant action of this drug on the skeletal muscles
was at its height. With regard to its action on the reproductive organs, see chapter on
sexual function.
B. SURGICAL PROCEDURES
(i)
On the spinal cord or spinal roots
(a) Laminectomy and myelolysis—cordectomy
In the past, laminectomy and myelolysis has been performed by many neuro-surgeons to
relieve spasticity. However, there is no doubt that this procedure cannot be the answer,
having regard to the many factors involved in the pathophysiology of the isolated cord,
and, in fact, most surgeons with experience would now agree that this operation can only
achieve temporary, if any, relief.
Cordectomy (MacCarthy, 1954) represents a very destructive operation and would
be justified only in certain intramedullary tumours but not in traumatic lesions of the
spinal cord.
