T HIS report is based on the early phases of treatment of 300 consecutive

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1 SPINAL CORD INJURIES A REVIEW OF THE EARLY TREATMENT IN 300 CONSECUTIVE CASES DURING THE KOREAN CONFLICT MAJOR GORDON T. WANNAMAKER, M.C., U.S.A.* Section of Neurological Surgery, Tokyo Army Hospital, Tokyo, Japan (Received for publication June 7, 95) T HIS report is based on the early phases of treatment of 300 consecutive patients with spinal injuries at the Tokyo Army Hospital from September 950 to May 95~. t Of these patients ~5 were United Nations battle casualties from Korea with penetrating wounds of or about the vertebral column with neurological involvement (Table ). The remaining 6 had closed injuries similar to those encountered in civilian localities (Table ). All statistics herein presented were compiled in Tokyo and include a few casualties from Korea that were not treated at mobile neurosurgical units as well as some casualties from accidents in Japan. The patients who died in Korea on the battlefield or at medical installations there are not included. TABLE Vertebral level and type of injury Level Penetrating Wounds Injuries Cervical 86 9 Thoracic 35 7 Lumbar 7 0 Sacral 9 0 Total 25 6 TREATMENT The aim of treatment during this early phase of paraplegic care (average -6 weeks) was to salvage as much neurological function as possible and to prevent the formation of decubitus ulcers and other complications that may retard a rehabilitation program. The mortality rate in this series was per cent. As soon as the patient reached an equipped medical facility a complete physical examination was done, as penetrating wounds of the spinal cord * Present address: Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut. t The following officers were associated with the author in the care of the casualties on which this report is based: Lt. Col. Arnold M. Meirowsky, M.C., Neurosurgical Consultant, Far East Command, Samuel Atkins, Joseph C. Barnett, Edward J. Bishop, Robert A. Clark, Philip R. Dodge, Grifl]th R. Harsh, III, George J. Hayes, Milan Leavens, John B. Moyar, Jose Ninecurt, Richard R. Patterson and Paul R. Rosenbluth. 57

2 58 GORDON T. WANNAMAKER were frequently associated with damage to additional areas. Of the 25 patients with penetrating wounds of the spine 87 (3.25 per cent) had associated chest wounds with hemothorax and/or pneumothorax, 23 (9.05 per cent) had bowel perforations requiring colostomy, (.33 per cent) had retroperitoneal hematomas without bowel perforations, 0 (3.93 per cent) had perforations of the liver, and 9 (3.5 per cent) had lacerations of the kidney requiring unilateral nephrectomies. Other associated injuries and complications were also present, bringing the total to 9 associated injuries in 6 of the 25 patients who had penetrating wounds of the spine. It is to be noted that some patients had multiple associated injuries. Some of the complications were discovered at a later date, showing the value of an initial and repeated physical examination at frequent intervals. While an injury causing compression of the spinal cord may be considered a surgical emergency, other procedures of a life-saving nature take precedent, and laminectomy may of necessity be delayed several days. With few modifications the patients in this series received the same treatment as was advocated by many neurosurgeons towards the end of World War II. '6'7''2'~ In addition to performing laminectomies on all patients with penetrating wounds of the spine, early laminectomies in all cases of closed injuries with fracture-dislocation were also done. Decubitus ulcers were prevented by turning the patient every 2 hours, either by using the double-litter method L 9 or the Stryker frame. This turning was also continued during air evacuation of the patient back to his homeland. suprapubic cystostomies were done. Dietary restrictions were practically eliminated by starting early ambulation. 5 Most all of the patients with thoracic or lumbar injuries were fitted with metal long back-braces and started on a sitting-up program on the 0th postoperative day. Plaster of Paris or body casts of other material were not used because they were not deemed necessary for stability and their presence would have made temperature regulation and skin care practically impossible. Whole blood transfusions were given when indicated and no blood substitutes such as plasma were used. The availability of the newer mycin antibiotics and the disc method of culture and sensitivity studies made the treatment of infections much easier than in previous wars. We encountered practically no difficulty with wound healing or infection in those patients who received initial debridement, laminectomy and primary closure of the wound, even at 8-72 hours after injury. Bladder infections were the exception rather than a common finding. The 5/[cKenna type of tidal drainage apparatus was used? At times a chest tap for evacuation of a hemathorax or pneumothorax would be followed immediately by a laminectomy. NEUROSURGICAL INTERVENTION It may be seen in Table 2 that of the!~9 patients with penetrating wounds who had laminectomies, only (7.67 per cent) were operated upon within s hours of injury. Of the patients with closed injuries, 7 (56.66 per

3 SPINAL CORD INJURIES 59 TABLE Time interval from injury to laminectomy Time Interval Penetrating Wounds Injuries Within '2 hrs. 7 Over `2 hrs. `205 3 Total laminectomies `29 30 laminectomy 5 6 Total cases `25 6 cent) of the 80 operated upon had immediate laminectomies. These are overall statistics for the entire period covered in this report. Had neurosurgical teams reached more of the patients on the day of injury, their general condition permitting, the incidence of immediate laminectomies would have been higher. There were ~ patients (Table ~) who did not receive surgery. These were cases in which roentgenograms revealed no bony damage of the spinal canal. Most of these patients initially exhibited evidence of spinal cord damage (concussion) with transitory loss of function followed by remission of symptoms. Spinal manometrics were normal in all these cases. Two patients with fractures of the transverse processes who were treated by tongs and traction only had negative myelograms and persistent neurological deficit (Table ). At times, because of the large influx of casualties, serious penetrating wounds of the brain were given surgical priority over spinal cord injuries, particularly those below the cervical region. In general, spinal cord injuries were considered surgical emergencies and laminectomies were done immediately. In cases of closed injuries perhaps this was a departure from some of the current concepts of management, particularly in regard to cervical cord injuries?,3,~ In this series, believing that the time element was of considerable importance, immediate lamineetomy was deemed advisable prior to attempts to correct the bony deformity. Also, before doing a surgical decompression in the presence of a fracture-dislocation it seemed hazardous to the neural ele- TABLE 3 Summary ~results~treatmentinallcases Results Penetrating Wounds Injuries Improved `2 (`25 complete recovery) `26 (8 complete recovery) Unimproved 30 `20 Death* 3 0 Total 25 6 * Cause of death: () Pulmonary infarct; (2) ascending arachnoiditis; (3) bilateral kidney lesions.

520 GORDON T. WANNAMAKER ments to perform manipulations of the surrounding bone either manually ~ or by extending the manipulation over a longer period of time, as by traction.

4 520 GORDON T. WANNAMAKER ments to perform manipulations of the surrounding bone either manually ~ or by extending the manipulation over a longer period of time, as by traction. From this series of 279 laminectomies with no immediate operative deaths (Table 3) it would seem that the risk of a laminectomy is small and in careful hands may prove quite rewarding, as shown in Case below. Case illustrates the procedure of evaluation of a closed cervical cord injury during the time of this report. The same technique was also used with the substitution of the double-litter turning method by the teams in Korea. Case. Fracture-dislocation of C~-5. Immediate laminectomy. Regain of function. A ~l-year-old, white male private was brought in on a litter 2 hours after he had been injured in an automobile accident in Tokyo. Examination in the emergency room disclosed loss of motor function below C5, and a sensory level complete at C7 and below, with partial involvement of C5 and C6. There was contusion of the scalp in the occipital area. Respiration was by diaphragm only. Ileus and abdominal distension were present. A #6 French Foley catheter was inserted into the bladder and specimens were saved for culture and urinalysis. Because of the ileus and distended stomach a Levin tube was inserted into the stomach for deflation. The airway proved to be adequate. The patient was then placed face-up on a Stryker frame padded with five pillows laid crossways. An x-ray plate was slipped under the neck and upper chest by depressing the pillows and an A.P. film was taken. The top of the Stryker frame was then attached and the patient was turned face-down. Examination on the dorsal aspect of the patient was then completed. In this position a lateral x-ray of the cervical spine was taken with a portable machine. The wet films revealed a fracture-dislocation of C-5 with obvious narrowing of the vertebral canal. Blood count, urinalysis, and cross matching of blood were in the meantime performed. Course. The patient was taken to the operating room (remaining in the facedown position on the Stryker frame). preoperative medication other than sodium luminal gr. ~ intramuscularly was given. Operation. A wide decompression laminectomy o[ C3, C, and C5 was performed under local anesthesia. The Stryker frame was used in lieu of an operating table. There was a bilateral fracture of the facets between C and C5; the laminae, however, were intact. The dura mater was opened and the cord was found to be grossly intact with increased vascularity of the subpial vessels. There was marked angulation of the cord caused by deformity, and several dentate ligaments were therefore sectioned bilaterally. ~ The laceration in the left occipital region was dcbrided and closed. Crutchfield tongs with 5 lbs. traction were then applied. Postoperatively the patient regained normal sensation and the ability to void without residual, but generalized weakness persisted for the few weeks he was observed after operation. The strength in the lower extremities was greater than that in the upper extremities. RESULTS Cervical injuries (Table ) accounted for 55 cases (8.33 per cent of the 300 cases in this series). It has been previously stated by some authorities that in cases of acute closed injuries of the cervical spinal cord a complete loss of motor and sensory function is a contra-indication for immediate

5 55 SPINAL CORD INJURIES TABLE Treatment and results of cervical cord injuries* Treatment, and Results on Evacuation from Tokyo Neurological Deficit on Admission Laminectomy Surgery Type of. of Injury Patients Un- Imp. Deftimp. cit Tongs-Traction Only.Un Imp. Deft-.Un- Imp. Defi~mlc. cit imp. cit transitory long-tract signs or nerve root involvement Partial lesion ~ Complete loss of function below level of injury 3 l0 55 Total 0 6 s 2 * In Tables -7, Unimp.=unimproved; I m p. = improved; deftcit=no residual neurological deficit, complete recovery. laminectomy. In this series there were 9 patients with cervical spine fractures who had on initial neurological examination a complete deficit below the level of injury. Of these, 7 had laminectomies. The remaining ~ were TABLE 5 Treatment and results of thoracic cord injuries Treatment, and Results on Evacuation from Tokyo Neurological Deficit on Admission Pype of, of Injury Patients Surgery Un Lp. I[ )" D ~ c i t Laminectomy Unimp. Imp. Transitory long-tract signs or nerve root involvement 3 2 Partial lesion ~t Complete loss of function below level of injury Total * Negative myelogram and no fracture on X-ray. 8 Deficit

5~2 GORDON T. WANNAMAKER TABLE 6 Treatment and results of lumbar cord or conus injury Treatment, and Results on Evacuation from Tokyo Neurological Deficit on Admission l'ype of.

6 5~2 GORDON T. WANNAMAKER TABLE 6 Treatment and results of lumbar cord or conus injury Treatment, and Results on Evacuation from Tokyo Neurological Deficit on Admission l'ype of. oj Injury Patienl Surgery Lamineetomy Unimp. Imp. Deficit Unimp. Transitory long-tract signs or nerve root involvement 0 Partial lesion ~0 Complete loss of function below level of injury Total Imp. Deficit l 6 6 ~2 treated with tongs and traction only. Four of the 7 who had laminectomies showed improvement of the immediately adjacent cervical nerve roots and the long tracts of the spinal cord:. C-C5 fracture-dislocation (Case above). Regained normal sensation and ability to void but generalized weakness persisted for the few weeks he was observed postoperatively. 3. Compression fracture C5. Immediate operation with marked motor and sensory improvement to T. 3. Compression fracture-dislocation of C5-C6 with postoperative regain of partial function of all dermatomes and myotomcs.. Compression fracture C-C5 with signs of regaining sensation all the way down plus ability to move upper extremities. The patients with penetrating wounds of the cervical spine showed an even brighter picture. All 30 of those patients who had complete loss of motor and sensory function below the level of injury were operated upon and 3 showed improvement. One patient was ambulatory with slight weakness in the legs 3 weeks after injury. Even in the patients in whom no improvement was noted in the long tracts of the spinal cord, laminectomies and decompression of involved nerve roots in the cervical region frequently lowered the dermatome level by one or two segments. This allowed the patient some or better use of his upper extremities. While this series is too small to make any definite conclusion it appears to indicate that by an immediate laminectomy some patients may be saved from a life of quadriplcgia. There were no operative mortalities among the 3 cervical laminectomies of this series. Thoracic i~juries (Table 5) accounted for 37 cases (3.33 per cent). These wounds were frequently associated with concomitant lesions in the

7 5~23 SPINAL CORD INJURIES TABLE 7 Treatment and results of eauda equina injuries* Treatment, and Results on Evacuation from Tokso Neurological Deficit on Admission Fype of Injury. of Patients Surgery ~ - N~-o. /Unimp. Imp, Laminectomy ~ Deficit Unlmp. Transitory long-tract signs or nerve root involvement Partial lesion I l ~3 3 Completeloss offunction below level of injury Total 7 0 [ Deficit 5 7 ~ ll l 0 Imp. * Cauda equina without cord or conus involvement. thoracic and abdominal cavities, often necessitating a delay in laminectomy. To my knowledge none of these patients was wearing one of the armored vests which were issued during the later stages of the Korean conflict. Perhaps the delay in performing the laminectomies on 09 patients who had complete motor and sensory loss is one of the reasons why only ~ (.0 per cent) showed postoperative improvement. The above is in contradistinction to the ~7 cervical laminectomies (Table ) on patients with complete loss of function below the level of injury of whom 7 (6~.96 per cent) showed postoperative improvement in neurological function. Lumbar cord-conus injuries (Table 6) accounted for 7 cases (5.66 per cent). All except patient in this group had a laminectomy. Of the ~6 patients who had a complete loss of neurological function prior to laminectomy only 6 (~3.07 per cent) showed postoperative improvement. Cauda equina injuries (Table 7) represented 7 cases (~3.66 per cent) of the series. All except of the patients who had a closed injury with partial deficit and negative myelogram received laminectomy. Of the patients who had complete loss of neurological function below the level of injury ~3 (5~.ee per cent) showed improvement during the postoperative stay in Tokyo. Three were ambulatory. A survey of the over-all results of treatment of patients with a complete neurological deficit below the level of injury shows that improvement during the immediate postoperative period was best in the group of cervical cord injuries. This was followed in order by cauda equina, lumbar cord-conus, and thoracic groups. doubt the eventual recovery over a longer period of time would be best in the cauda equina group.

8 52 GORDON T. WANNAMAKER Factors in Mortality. While it has been stated above that there were no deaths in this series immediately attributable to the performing of a laminectomy, there were 3 patients who died during the course of hospital treatment and their deaths must be considered as operative mortalities. Their causes of death as determined by autopsy were:. Pulmonary infarct ~ days after laminectomy in a patient who had a penetrating wound of the spine at T2-L and multiple wounds of the back and arm with fracture of the left humerus. ~. Ascending adhesive arachnoiditis with respiratory paralysis month after penetrating wound of the spine at T~. 3. Bilateral kidney damage requiring the removal of one kidney with uremia 589months after sustaining a penetrating wound of the abdomen and spinal canal at TI~-L. SUMMARY A series of 300 consecutive patients with spinal cord injuries admitted to the Tokyo Army Hospital from September 950 to!y[ay 95~ are evaluated. The over-all mortality in this series was.0 per cent. REFERENCES. CAMPBELL,E., and MEmOWSKY, A. Penetrating wounds of the spinal cord. In: Surgery of trauma. W. F. Bowers, Ed. Philadelphia: J. B. Lippincott Co., 953, xxv, 605 pp. (see pp. ~-9). ~. CRUTCttFIELD,W.G. Skeletal traction in treatment of injuries to the cervical spine. J. Amer. med. Ass., 95, 55: ~9-3~. 3. DAVIDOFF,L.M. Spinal cord injuries. Surg. Clin. N. Amer., April 9, 2 : FREEMAN,L.W. Treatment of paraplegia resulting from trauma to the spinal cord. J. Amer. med. Ass., 99, 0: ; 05-0~. 5. FREEMAN,L. W. The metabolism of calcium in patients with spinal cord iniuries. Ann. Surg., 99, 29: KAHN, E. A. The r5e of the dentate ligaments in spinal cord compression and the syndrome of lateral sclerosis. J. Neurosurg., 97, : ~r A. A plea for exploration of spinal cord and eauda equina injuries. J. Amer. med. Ass., 95, 29: 5~ McKENNA, W. F. A simple, efficient, automatic tidal drainage apparatus. Urol. cutan. Rev., 98, 52: 8-~. 9. MEmOWSKY, A. M., and BARNETT,J. C. Mobile neurosurgical team. Ann. Surg., 953, 38: MunRo, D. Cervical-cord injuries. A study of 0 cases. New Engl. J. Med., 98, 229: MuNRo, D. The rehabilitation of patients totally paralyzed below the waist, with special reference to making them ambulatory and capable of earning their living. III. Tidal drainage, cystometry and bladder training. New Engl. J. Med., 97, 236: ~ ~. MUNRO,D. Rehabilitation of veterans paralyzed as the result of iniury to the spinal cord and cauda equina. Amer. J. Surg., 98, n.s. 75: PaXTT-THoMAs,H. R., and B~.aGER, K. E. Cerebellar and spinal injuries after chiropractic manipulation. J. Amer. reed. Ass., 97, 33: STarKER, H. A device for turning the frame patient. J. Amer. reed. Ass., 989, 3: 73-73~, 5. TINSLEY.M. Compound injuries of the spinal cord. J. Neurosurg., 96, 3:

T HIS presentation is a study of a consecutive series of 316 penetrating

INTRACRANIAL HEMATOMAS ASSOCIATED WITH PENETRATING WOUNDS OF THE BRAIN* JOSEPH C. BARNETT, M.D.,t AND ARNOLD M. MEIROWSKY, M.D.:~ (Received for publication September 29, 1954) T HIS presentation is a study