HYPEREXTENSION DAVID

C. BURKE,

Spiizal

Injuries

Ce,zt,’e

written

about

I’i#{149}o,iz tile

Little

has

been

INJURIES

OF

MELBOURNE,

for

Victoria,

SPINE

AUSTRALIA

Austin

hyperextension

THE

Hospital,

injuries

i’vlelbourne,

,liisi,’alia

in comparison

with

other

mechanisms

of’ injury to hyperextension proportionately

the spine. Probably the explanation for this is that in the cervical spine injuries are much more difficult to diagnose radiologically, and in consequence fewer of these injuries are diagnosed by surgeons and radiologists than are flexion and vertical compression lesions. It is also possible that because ofthe inherent stability that remains after most hyperextension injuries there has been little to excite controversy between the surgical and conservative schools as to the correct method of early management, or discussion on the relative injuries of the thoracic and

merits lumbar

ofdifferent spines

surgical approaches appear to be so rare

to the problem. Extension that they fail to excite much

comment. The

and to

varying

pattern

it is proposed the

Victorian

Spinal

1969,

December

of

hyperextension

hyperextension

to correlate

the

Injuries

and

to

injuries

the

and

Centre

discuss

of

injuries

clinical at

these

the

in

studied

over

findings

from

Hospital to

a

the

between

last

five

patients January

proposed

years,

admitted 1965

and

sub-classification

of

spine.

spine-Hyperextension

injuries

until Taylor and Blackwood in the presence of normal

been

Austin

relation

PREVIOUS

Cervical

has

pathological

(1948) radiological

REPORTS

of the

reported

cervical

spine

seem

who

sustained

a patient

appearances

of the

to have

been

thought

incomplete

cervical

spine,

and

rare

tetraplegia

postulated

that

the paralysis was caused by a hyperextension force. They showed that the spinal cord could be damaged by anterior compression by an intervertebral disc, and posterior compression by the ligamentum flavum. Taylor (1951) extended this theory with myelographic studies on cadaveric spines. Before Taylor’s work the only recognised cause of cervical lesions from hyperextension were those rare cases in which posterior dislocation was demonstrated. Another significant contribution came from Schneider, Cherry and Pantek (1954), who described

the

commonly evidence

the

acute

followed

concussion),

skeletal

of the

the mechanism in hyperextension

cervical

spinal

hyperextension

of cervical

importance

central

injury

history

or

of the

central (1966)

either

cord

central

anterior or posterior injury of the spine: to arthritic spines

NO.

cervical

Both or of clinical

displacement.

injury,

or

cord

oedema,

found

that

anterior

central vertical cord

I,

that

this

or without

syndrome

radiographic

and Schneider et a!. stressed of facial injury in proving

the full range cord syndrome

injuries whereas

showed with

Taylor evidence

haematomyelia,

compression syndromes,

They spine,

to and extension

of spinal (from

complete anterior

cord spinal

transverse dislocation

injuries

caused

injury cord cord caused either

cord syndromes. Barnes (1948) recognised two types of hyperextension I) posterior dislocation (one patient, under fifty years of age); and 2) injury (all more than fifty years of age). Later, Barnes (1961) stated that the

prognosis for the spinal cord was worse spondylitis and cervical spolidylosis than normal cervical spines. He emphasised might be present even though radiographs 53B,

syndrome.

of the

of these injuries. Schneider et al. described injuries, from the transient central

necrosis. Bedbrook

VOL.

cord

injuries

FEBRUARY

1971

in hyperextension injuries in patients with ankylosing it was with similar injuries sustained by patients with that rupture of the anterior longitudinal ligament appeared normal. 3

4

1). C’. BURKE

( 1963)

Holdsworth ruptured

or

detailed

five

but

cases

spondylitis,

of

understanding

rupture

anterior

Forsyth

(1964)

present the

of

bony

the

compression

Cornish coronal

(1968)

plane

thought

body

evidence

of the

patterns

of’

extellsion-rotation

affected

by

cervical

ligamentous group,

structures,

is complete

has

probably

sub-groups

which

they

of

called

a central

radiograph

of

lumbar,

and

a

in

lumbar

spines,

personal

experience

passing,

of

200

acting

of different

he

subdivided

2)

extension-

spine

of

a

cervical

an

forward

The

axis

presence

was

injuries

sometimes

in

spine

spines

but

classification

and

Forsyth of

bony

injury

injuries.

posterior

The

ligamentous

(1960).

cervical

spines

ankylosing

no

extension

four

and

by

affected

apparent

and

Whitley

recognised

normal

spondylosis,

by

(1954)

cited the

a case

fourth

They

spine

included

injuries,

the

twelfth

injury

region

spine.

of the at all,

refer

Bedbrook

(1969)

dislocations

of

in which

level.

of extension them

and

of Perardi’s

thoracic

of

rare.

fractures

some

one

of

extension”.

cases

as

by

injuries.

of all anterior

at

seven

the

in a

caused

vertebra. of

of

by

extension-disruption

in

cervical

to rupture

their

of which occurred in the thoraco-lumbar Most other writers, if they mention and

force

a fracture

were

caused

body

cervical

instability

and

eta!.

reported

the

of

of

foreshadowed

haematomyelia

severe

1966

in

third

lip

affected

due

flexion

spine-Schneider

of the in these

complete

injury

injury

body

was

mass

fracture

extension-disruption

instability

Thoraco-lumbar a

the

a spine

4)

been

which

postulated

basis

and

there

lateral

1) extension-disruption

2)

“combined

produced

on

mechanism

of

extension

that

structures,

in which

each

distinctive

classification

spondylosis:

that

of

injuries;

first.

spine, He

the

led not

if rotation

arch

injuries.

continuation

axis of

antero-inferior

and

cervical

vertebral

ofthe part

This

extension

disruption:

ofthe

On

column.

so easily

neural

direction.

posterior

fractures

axis the

injury

the

extension-rotation

posterior

injury:

3) extension

spondylitis;

four

many

in a detailed

(1969)

do

of the

as flexion

with

vertebral

and his results that he could

bilateral.

force.

from

the

could

injuries

(1966) ankylosing

with

spines, He found

but

forward

and I)

the

of the

fracture

Cheshire

last

that

through

of the

supporting

or

masses or

arc,

finally

groups:

compression

avulsion

in patients

fracture

ligament

Guttmann

through

masquerade

in an and

articular more

passing

displacement

an

force

unilateral

extension-vertical of

to

injuries,

occurs

ofextension

therefore

downward,

two

iI’ItO

that

spine

caused

group

and

extension

injury

injuries

fracture

as the anterior occurred.

by hyperextension,

another

in a backward,

patterns

gross

cervical

hyperextension

displacements, of

dislocation reduction

of the

ligament

Pure

introduced

continuation

successively these

to the

extension.

as forward

momentary

experimental work with fresh cadaveric of the mechanism of all spinal injuries.

longitudinal

with

was

spontaneous injuries

attention

to a greater applied

there

immediate

hyperextension

drawing

the

that

that

( 1 960) performed

Roaf

was

thought

stretched

thoracic

in

vertebra

ankylosing

to extension had the

a hyperextension (1963) showed

Guttmann

on

injuries

seen

the

first

spondylitis,

only

of the

one

such

two thoracic

case

in

a

spine.

MATERIAL

In the to

the

there

Spinal were

Of (29

live

per

nineteen

the

Of forty-six

between

Injuires

178

cervical extension

to

seventy-two)

for

154

all

for

of the

lesions,

Victoria

The

all

cervical

lesions

with

of the

thoracic

Austin 154

according

to age

an

332

Hospital

of the

spinal

thoraco-lumbar

of

was

were

admitted

cord

injuries:

region.

(1963),

patients

age

patients

with

Holdsworth

of these

average

(Table

there

were

forty-eight

thirty-one

fifty-one

years

years

(range

(range nine

to

I).

thoraco-lumbar spine.

1969,

December

the and

average with

admitted

and at

region

classified compared

other

1965

cervical

injuries.

patients

injuries,

Januai’y

Centre

injuries

cent)

sixty-seven)

extension

years

Their

injuries average

only age

four was

(2’S

per

cent)

fifty-four

years

BONE

JOINT

had (range

to sixty-two). THE

JOURNAL

OF

AND

SURGERY

IIYPEREXTINSION PATTERNS

OF

It is proposed spine

under

to

the

H’PEREXTENSION

discuss

following

the

OF

TABLE TRAUMATIC

332

Cervical

178

FOR

VICTORIA

1965

TO

Extension

154

rupture

as flexion

in apparent

injuries,

Posterior

a) in the

injuries

dislocation-Although

of hyperextension in this

presented

cervical

segment

forehead

and

suggested

the

after possibility

vertebra despite

that

time

function

the an

the

The

had

4 (2’S,)

the

fifth

of the

spinal

was

Extension-disruption

without

hyperextension

included

injuries

all those

of the

the

cervical

anterior

of

and

the

died

fourth

after

ten

but and

in

sensory Complete

observed

at

Schneider

et

compressed and

spine

the

necropsy

at the

invariably. spines

on

spines

show 53 B,

radiological obvious I.

ii Blv\iUi’

the

spinal

flavum

(and

posterior

may

this

grounds radiographic I 971

those

there

cord

is

posteriorly osteophytes) of

occur,

to subdivide and

but

This is the (1948) and by

subluxation

of injury

spondylosis

xii.

which

ligamentum

posterior

Attempts

cervical

,

site

in

group

or stretching

occurs,

of the vertebrae. and Blackwood

disc

Slight

rupture

ligament

the

this

(extension-rotation)

in which

(1954)

intervertebral

vertebra with

a!. between

anteriorly.

dislocation-Ill

longitudinal

is little or no displacement group described by Taylor

viii

maxilla

mechanism,

I).

are of

spine.

man

segment.

cord

masquerading

cervical

A lacerated

motor

cervical

injuries

upper

form

and

patient

some

hyperextension

b) in the

patient

management,

regained

1969

the fourth

accident.

dislocation

fifth.

5) and

one

mandible

respiratory

4) complete

150

classical

in only

extension

posterior on

in

transection (Fig.

of

intensive he

car

of

showed

days

is the

seen

a motor

fractures

radiographs cervical

it was

spine,

It occurred in a twenty-four-year-old with complete tetraplegia below

series.

who

this

injury

cervical

without

51 (29,)

injuries

injuries:

cervical

the

127

Extension

extension

lower

of

disruption

spondylitis:

DECEMBER

Other

ligamentous

injury

2) extension

Other Thoraco-lumbar

SPINE

I

JANUARY

Total

CERV1CAI

by ankylosing

CENTRE

ADMISSIONS,

THE

of’ hyperextension

affected

INJURIES

5

SPINE

dislocation:

of a spine

SPINAL.

OF

patterns

I) posterior

disruption

TIlE

INJURY

different

headings:

3) extension

dislocation:

INJURIES

but

is often changes.

FIG.

upper

by no means

group

with

the

normal

difficult,

into

those

Sagittal

showing

of the fIfth,

section complete

fourth causing

cervical

because

only

the

more

of

1

the cervical spine posterior dislocation

cervical complete the spinal

severely

vertebra cord.

on

transection

degenerated

the of

6

1). C. BURKE ILLUSTRATIVE

(SSE

REPORTS

Case

I-A sixty-nine-year-old man was admitted three hours after a motor car accident with complete tetraplegia below the fifth cervical segment. Bruises and lacerations of the forehead and a left perorbital haematoma suggested an extension mechanism. Radiographs showed a severely spondylotic spine with posterior subluxation of the fourth cervical vertebra on the fifth, and a fracture through an anterior osteophyte on the fifth cervical vertebra. He died on the twelfth day after injury. There had been return of only a little sensibility, in the legs. Examination of the spine at necropsy (Fig. 2) showed the classical central haematomyelia described by Schneider, suggesting that he probably would have made an incomplete neurological syndrome

recovery had he

longitudinal the fourth Case

and

2-A

jumping

and struck immediately three hours

and

and cervical

of

incomplete

with

and sixth widening

below

central showed

old compression

vertebrae of the disc

seventh

the of

central cord the anterior

the intervertebral vertebrae was also

tetraplegia

segment, showing the acute of Schneider. Radiographs

changes,

pattern of Rupture

disc seen.

between

fifty-nine-year-old man was riding a horse in a when the horse shied as it approached a hurdle him in the face with its head. He became tetraplegic and fell from the horse. On admission later he had an abrasion across the bridge of the

event

nose

ligament fifth

in the survived.

vertebrae,

fractures

(from space

and

a fall anteriorly

a flake

the

cervical moderate

sixth cord

cervical

syndrome degenerative

of the bodies

in

1931). between

fracture

of fifth

There was a the sixth and

from

the

antero-

superior lip of the body of the seventh cervical vertebra (Fig. 3). The deformity was corrected by flexion of the neck (Fig. 4); so it was considered that he had suffered an extension injury of the spine, causing rupture of the anterior longitudinal Case

FIG. 2 section text).

I -Sagittal

progressive neurological function, and normal same extent, and both four limbs, particularly significantly handicapped

It is probable

ligament between the sixth and seventh cervical vertebrae. The neck was immobilised in flexion in a collar. During the succeeding few days there was slight neurological deterioration, presumably due to oedema, but thereafter improvement occurred until the patient regained normal bladder and bowel power in the left leg. The right leg improved in power also, but not to the hands improved, but not to normal power. There was overlying spasticity in all in the right leg and the hands. He was able to walk quite well, but remained in hand function. of spine

that

the

(see

spinal

cord

in Case

2 suffered

similar

changes

to

those

in Case I: that is, central haematomyelia and rupture of the anterior ligament and intervertebral disc opposite this level. Of the fifty-one extension review twenty-three could be considered to have an area of central cord haemorrhage of varying extent, because the permanent neurological changes specimen

acute central cervical spinal cord syndrome. cervical spondylosis, but some radiological could be found in all but two patients. Three patients with similar radiological complete

which remained in a third (Fig. 5) if the patient had damage may occur if the degenerative in the

tetraplegia,

two At

cases

the

central

cervical

varying

from

described

opposite spinal forty-eight

Not evidence

in the

all had definite radiological evidence of of anterior longitudinal ligament damage

appearances

complete survived. changes-or

seen

longitudinal injuries under necrosis and were those of

to those

described

in two, and would have This case illustrates that the degree of injury-are

presented

with

remained complete greater spinal cord greater than as

above.

extreme

are

cord

syndrome, hours

to

those

patients but

two

weeks

who

who

suffered

made

a full

after

injury.

a transient

paralysis

neurological Ten

TilE

such JOURNAL

recovery patients OF

BONE

of the after

acute

a period

were

seen,

four

ANI)

JOINT

SURGERY

of

I IYPLREXTINSION

Case

2.

INJURIES

01

TIll

7

SPINE

3 Figure 3-Lateral radiograph of cervical spine (see text). Lateral radiograph of cervical spine with the neck flexed.

Figure

4-

Figure 5-Sagittal section of a cervical spine showing complete transverse spinal cord necrosis in a patient who suffered an extension injury to a markedly spondylotic spine. Note the upward and downward extension of the cord necrosis, in a central distribution, from the area of greatest damage opposite the fourth-fifth intervertebral disc level, where the disc and anterior ligament have ruptured. Figure 6-Sagittal section of a cervical spine showing rupture of anterior longitudinal ligament and intervertebral disc between fourth and fifth cervical vertebrae, but no macroscopic evidence of spinal cord injury. Viii..

53 B.

xii.

1,

ii BREARY

1971

8

C. BURKl

I).

whom

had

damage of’ one full

convincing

to the patient,

who

neurological

cord

was

radiological

anterior died

recovery

undamaged

According

to

changes

longitudinal from

a pulmonary

from

a central

et

al.

embolus

there

(1954)

spondylosis, Figure

cervical

demonstrated.

cervical

macroscopically

Schneider

of

ligament

two

spinal

were

there

weeks

cord

slight

after

cord

extension

injuries

injury,

syndrome.

changes

is a central

hut in only one was no 6 shows the spinal cord having

made

Although

to

be

oedema

seen

and

the

a

spinal

microscopically. recovery

occurs

as

it subsides. Thirty-six tile

of’ the

category

men

aged

twenty

rest,

with

an

to

in

the

cervical

with without

years

age

of

spine,

although

on

and

an

with

fifty-six

the intervertebral opinion that this

depends

examitiation

patients

twenty-six

average

degeneration of It is the author’s diagnosis

fifty-one

“Extension-disruption

of

dislocation”. normal

years

discs, lesion

cervical

(range

the the

cervical

to

may

history

and

not

general

demonstrate clinical

fell

of three

it seems

spines,

thirty-four

spine

exception

into young

probable

that

seventy-two

and also possibly degenerated rarely occurs without degenerative

radiographs

accurate

of With

the

years)

had

anterior ligaments. changes existing

cervical

examination,

spondylosis, precise

and

neurological

radiographs.

FiG. 7 FiG. 8 Figure 7-- Sagittal section of the cervical spie of a man suffering from severe cervical spondylosis. Note the anterior interbody fusions between the third and fourth, and sixth and seventh, cervical vertebrae. Figure 8-Lateral radiograph of cervical spine showing a fracture extending through the intervertebral disc between the fifth and sixth cervical vertebrae of a spine severely affected by ankylosing spondylitis.

It is a compression to

occur

in

ligamentum in

the flavum

Figures

2, 5 and

decompressions

of the

older

and

age and 6.

spinal

group

posteriorly Figure

fusions

cord with

that

causes

a spinal

protruding 7 shows

at

two

damage,

narrow for

by

and

canal

severe

and

narrowed

osteophytes

the

levels

tile

canal

in

this

is more

likely

a thickened

that

and

felted

intervertebral

a patient

cervical

discs

who

spondylosis

had causing

is shown

had

anterior

incomplete

tetraplegia. Extension-disruption through

force

in

a vertebral

and

never

ankylosing

column

with

flexion.

affected

There

spondylitis-According by ankylosing

were

four

such

to spondylitis

patients

occurs

in this series, THE

(1966)

Guttmann

only

JOURNAL

with

aged OF

BONE

disruption

a hyperextension

from AND

thirty

to sixty

JOINT

SURGERY

IIYPEREXTENSION years,

two

line

complete

with

extending

tetraplegia

horizontally

Of the

two

incomplete

a Brown-Sequard

and

at the

INJURIES

two

level

with

of an

tetraplegic

3--- The

incomplete

patients

one

disc

had

9

tetraplegia;

intervertebral

all four

(Fig.

8).

cord

syndrome

a central

had

a fracture

and

the

other

syndrome.

ILLUSTRATIVE

Case

OF THE SPINE

patient

with

the central

cord

CASE

hISTORY

syndrome

had

an interesting

onset

of paralysis.

After

a

road accident he felt pain in the neck, but did not develop any neurological signs immediately. An hour later at another hospital he was placed supine for radiography, after which he felt numbness; weakness gradually developing in his arms and legs. Because of this history and the radiographs which showed a fracture line extending through an ankylosed spine at the level of the sixth cervical intervertebral disc, the patient was sat up with the neck flexed slightly ; shortly afterwards he began to get some return of motor and sensory function in his legs. He was transferred to the Spinal Injuries Centre eint hours after the accident, when he had a classical central cord syndrome with slight weakness and spasticity in both legs, complete paralysis of the intrinsic muscles of both hands and marked weakness of finger flexors, finger extensors and triceps, particularly on the right side. He improved with conservative management and when last seen had only residual weakness in the intrinsic muscles of both hands and very slight weakness of the right finger extensors and triceps.

This patient illustrates very well the evolution of’ the spinal cord when the neck is extended. Complete

ligamentous

appeared

to present

antero-posterior one

The

became

patients

were

possible

to

by

(Burke

both

in apparent

with

ligamentous

which

of

rupture

primarily

be

sure

aged

later

from

whether

and

Two and

clinical

entity

but

cord

injury were

who

patients

then

to

central

injuries-There

injury,

of the

only

twenty-six this

Berryman

extension

an extension

rupture.

complete

of the

were

initially

was

the

fifty-eight is caused

had

by

As

four

shown

diagnosis

years.

by compression patients

to have

incomplete

of total stated

extension

tetraplegia,

instability

made.

elsewhere

or

who

complete

by

it

flexion

is not

forces,

or

1971).

ILLUSTRATIVE

CASE

HISTORY

Case 4-A forty-nine-year-old woman was ejected from a car when it struck a tree. She was admitted to the Spinal Unit seven hours after the accident with a complete tetraplegia below the sixth cervical segment. Other injuries included abrasions to the face and bruising around the right eye, an abrasion of the left vertex, multiple abrasions to both arms and the left leg and a fracture of the shaft of the right femur. Radiographs of the spine showed an extension injury of the fifth cervical vertebra on the sixth with no instability on limited movement (Fig. 9) and also compression fractures of the fifth and sixth thoracic vertebrae. The neck was merely immobilised in a collar. A radiograph the next day showed bilateral forward dislocation of the fifth cervical vertebra on the sixth (Fig. 10). Reduction was achieved and maintained by skull traction. She died suddenly on the eighteenth day after admission, probably from inhalation of vomitus. The only neurological change had been the return of some previously absent motor function to the sixth cervi3a1 segment. Sagittal section of the cervical spine showed a cleavage plane of complete anterior and posterior ligamentous rupture passing through the intervertebral disc between the fifth and sixth cervical vertebrae, with complete destruction of the spinal cord at this level (Fig. 11). Hyperextension described lower

had

had

supine

spine;

He with

had

patterns there

a soft-tissue

12).

masquerading

different

cervical

segment. (Fig.

injuries two

injury severe

were

as flexion of

extension

two

such

on his forehead forward

injuries. injury

patients

and

Lower which

in this

a complete

dislocation

of the

The rest of the cervical spine was the neck in the neutral position.

hyperextended Oblique

sixth

spine-Forsyth

cervical present

series.

as

(1964)

injuries

was

a young

tetraplegia

below

the

cervical

vertebra

although radiographs

One

flexion

of man

the who

sixth

cervical

the

seventh

on

the radiograph showed bilateral

was taken fractures

of the articular processes of the seventh cervical vertebra, with wide separation of the fragments. The other patient had a similar forward dislocation, of the fourth cervical vertebra on the fifth, with a fracture of the right articular mass of the fifth cervical vertebra. The lesion Viii.

53 B,

xii.

I,

FEBRUARY

1971

BURKE

I

4.

I

4-

1G.

10

FIG.

11

--te

:

showing marked spondylotic changes to the low.r spine. -‘f the sixth cervical vertebra suggests a ruptured anterior raph twenty-four hours later showing forward dislocation of -Sagittal section of cervical spine showing complete rupture Structures between the fifth and sixth cervical vertebrae, with ;verse cord section at this level.

;4

____

r --V

‘1

,,#{149}p#{149},

rIG.

13

14

e

showing bilateral forward dislocation of the sixthcervical )graphof a cervical spine showing bilateral fracture of the axis dening of the intervertebral disc spaces anteriorly between the and fifth cervical vertebrae, suggesting multiple anterior raph of a cervical spine showing a compression fracture of fifth cervical vertebra. 1 #{149} ,+

Till-

(if

JOURNAL

I

BON1

\Ni)

ftti

JOiNT

SURGI

RY

LIYPEREXTENSI()N was

complicated

posterior

only

ligaments

by

It is considered dislocation cervical

agrees

with

Cornish this,

it is worth

classifying

the

of

the

these

that

were

on the

aged

as described of

the

that

and

the

arch

of

vertebra.

the

The

axis

author

Figure

described

distinct

forward

Forsyth.

by hyperextension.

of

defined

nineteen

all

the

by

neural

cervical

caused

is a variant

operation

intact.

injuries,

arc

third

are probably it is a well

men

At

were

fractures

axis

syndrome

because

young

in an

with

injuries

this

separately

patients

twenty-nine, neurological Fractures

that

it seems

force

presented

of the

lesion.

vertebrae

extension-compression

of the

body

root

cervical

suffered

patients

of the

(I 968)

and

patients

motor

fifth

II

OF THE SPINE

cervical

and

continuation

displacement

illustrates

All

by

spine-Four

forward

fourth

these

caused

fifth

partial the

tllat

being

Upper

with

a

between

INJURIES

by

13

Forsyth,

clinical

but

entity.

to

all had transient or very incomplete lesions, and all survived. ofthe odontoid, with posterior displacement

atlas

on

hyperextension

the

axis,

injuries,

are

but

probably

there

caused

were

none

by in

this

series. According

only

to

Roaf

a compression

Ilot

dislocation.

in

this

has

the

arc

direction pushed

pure

the

of

of

force

to

that

body

of

the

hyperfiexion

a cervical

14 illustrates

Figure

case

opposite

(1960)

fracture

posteriorly

into

impression

of a posterior

such has

neural

by

fifth

canal.

and

an injury,

continued

described the

causes

vertebra,

the

Forsyth

and

cervical This

dislocation

but in

vertebra

could

from

give

an

the

extension

illjury.

HYPEREXTENSION OF

Only lesions were

THE

four presented

in necrosis

injury

and

cord

injury

spinal

The

in

has

occurred

indicates

that

was

cord

patients

spine.

changes

seen

levels

of

were

aged

abnormality

and

above

injury

the

level

ranged

from

forty-six severe

vertebral this

and In

necropsy

the to

FIG.

15

section

of

a

ninth

thoracic

thoracic

spine

in

third

two

one

thoracic

sixty-two

osteoporosis.

vertebrae.

spinal

compression. at

Sagittal

spinal

of of

than

all the

shows

Massive

transected,

from was

15

mechanism

rather be

thoraco-lumbar injuries, and

patient.

the

to

this

154

Figure

one

traction

was

SPINE

out of hyperextension

thoracic

pathological cord

patients with

the

INJURIES

THORACO-LUMBAR

to

only

four

patients

patients

in this

at laminectomy

disc

years; All

other

and

the one

tenth

thoracic

had

had

group

in the disc.

obvious

complete

the

other. The

pre-existing and

permanent

paraplegia.

DISCUSSION Tile all

subdivision

academic

combined

know

exercise. with

changes,

of extension

to

most

conservatively,

a more

potentially

unstable xii.

I,

in

injuries because many

hyperextension

FEBRUARY

1971

to

their

rational

particularly occur

53 B,

of

extension

extent-may

viii.

ability

The

a knowledge

leads

that

injuries

patients.

of

the

recognise

approach

clinical to

the

a number

in the

courses

and

treatment.

cervical

spontaneous

For

spine

are

neurological

However, lesions,

into

variations

varying

of

spine

and

it before

is

of

groups

pattern the

and

recovery-to equally they

become

merely

these

injuries,

pathological

it

is important

should

be

a greater

important have

of

expected

example,

stable

is not

to

or

recognise unstable.

to treated lesser the The

12

D. C. BURKE

treatment will for

of choice

give

for

a cautious

example,

in

ankylosing

the

a patient

spondylitis,

The

or

mortality

extension

after

injuries

neurological

people were

ten

who

had

patients

are

deaths

The

an

rarity

an

with

a total

unstable

able

series

injuries

of extension

low

incidence

in a large

the

prognosis

of the

1. 2.

The literature Such injuries

of

spinal

patients,

seven

disease.

This

forty-eight

injuries

series

of

extension

and

should

ofwhich

occurred a low

as,

disruption

with

usually

treatment was

spine,

so it is fortunate

lesions

common

lesions

the

in

1969).

is high,

stable

different fuse

are

that

most

an

incomplete

seen

in younger

it be required. in elderly

mortality

There

tetraplegics

rate,

especially

in

years.

of the

of patients.

cord

less

surgical

the to

(Cheshire

are

are

to stand

because

patients

people

of

a decision

rupture

tetraplegic

offifty-one

knowledge

allow

tetraplegia

older

cardiopulmonary age

also

ligamentous

in

more

but

it will

in aged

better

average

conservative,

incomplete

occur

The

pre-existing with

with surgery

usually in this

is still occasionally

which

lesion.

who

latter

approach;

thoraco-lumbar On

lesion

the

in these

spine

limited

has

experience

injuries

seems

been

emphasised

gained

from

by the

these

patients

to be poor.

SUMMARY

pathological

on hyperextension in the cervical

anatomy,

based

injuries spine can

on

the

of the spine is briefly be subdivided into

experience

of

Centre for Victoria over the past five years. 3. Extension injuries of the thoraco-lumbar poor

4.

are

groups

patients

discussed.

in

They

based

the

on

Spinal

are

rare

the

Injuries

and

have

a

prognosis.

The

importance

emphasised,

managed

of

treatment

particularly

in order

based that

on

stable

sound and

clinical

unstable

and lesions

pathological may

be

knowledge

recognised

early

is and

correctly.

I am grateful clinical

and

spine

fifty-one

reviewed.

five

material

to Dr D. J. E. Cheshire, and

Dr R. J. Riddell,

for technical

assistance

for

valuable

Director,

assistance

Surgical Pathologists, with the preparation

Spinal

in the

Injuries

preparation

Centre of

this

for their encouragement of pathological material.

for Victoria, paper;

and

also

for permission to

cooperation,

Professor

and

H.

to use the A.

Attwood

to Mr J. Christian

REFERENCES R. (1948): Paraplegia in Cervical Spine Injuries. Journal of Boiie and Joint Surgery, 30-B, 234. BARNES, R. (1961): Paraplegia in Cervical Spine Injuries. Proceedings of the Royal Societ,v of Medicine. 54, 365. BEDBROOK, G. M. (1966): Pathological Principles in the Management of Spinal Cord Trauma. Paraplegia, 4,43. BEDBROOK, G. M. (1969): Personal communication. BURKE, D.C., and BERRYMAN, D. (1971): Closed Manipulation in theTreatment of Flexion Rotation Dislocations of the Cervical Spine. In press. CHESHIRE, D. J. E. (1969): The Stability of the Cervical Spine Following the Conservative Treatment of Fractures and Fracture-Dislocations. Paraplegia, 7, 193. C0RNI5H, B. L. (1968): Traumatic Spondylolisthesis of the Axis. Journal of Bone and Joint Surgery, 50-B, 31. FORSYTH, H. F. (1964): Extension Injuries of the Cervical Spine. Journal of Bone and iou,,’ Surgery, 46-A, 1792. GUTFMANN, L. (1963): Initial Treatment of Traumatic Paraplegia and Tetraplegia. P. 80, Symposium on Spinal Injuries. Edited by P. Harris. Edinburgh: Royal College of Surgeons. GUT-FMANN, L. (1966): Traumatic Paraplegia and Tetraplegia in Ankylosing Spondylitis. Paraplegia, 4, 188. HOLDSWORTH, F. W. (1963): Fractures, Dislocations and Fracture-Dislocations of the Spine. Journal of Bone and Joi,,t Surgery, 45-B, 6. ROAF, R. (1960): A Study of the Mechanics of Spinal Injuries. Journal of Bone and Joi,zt Surgery, 42-B, 810. SCHNEIDER, R. C., CHERRY, G., and PANTEK, H. (1954): The Syndrome of Acute Central Cervical Cord Injury. Journal of Neurosurgery, 11, 546. TAYLOR, A. R. (1951): The Mechanism of Injury to the Spinal Cord in the Neck Without Damage to the Vertebral Column. Journal of Bone and Joi,,t Surgery, 33-B, 543. TAYLOR, A. R., and BLACKWOOD, W. (1948): Paraplegia in Hyperextension Cervical Injuries with Normal Radiographic Appearances. Journal of Bone and Joint Surgery, 30-B, 245. WHITLEY, J. E., and FORSYTH, H. F. (1960): The Classification of Cervical Spine Injuries. America,, Journal of Roentgenologv, Radiun, Therapt and Nuclear Medici,ze, 83, 633. BARNES,

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JOURNAL

OF

BONE

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JOINT

SURGERY