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The author has been asked to review the hospital records and X-rays of 12 patients from various regions of the United States who have sustained fracture dislocations of the cervical spine. In no instance was the initial care considered to be appropriate. No patient was significantly improved by treatment although only 17% had apparent complete transverse cord syndromes on admission. Sixty-seven per cent of the patients became worse. In the latter group there were three patients who were admitted with either no neurological deficit or only minimal pyramidal signs. All of these three patients became tetraplegic as a consequence of their not being immobilised or placed in traction during periods of many hours to several days after admission. There is little evidence that the treating physicians understood the need for immediate immobilisation, proper examination, steroid therapy, adequate safe radiological examination, expedited traction, postural adjustments, or follow-up examination. After-care was poor, leading to excessive complication. Two patients were transferred in deteriorating condition to other hospitals without safeguards and with adverse result. The availability and the performance of neurological surgeons during the first critical hours after injury was generally suboptimal. Although all of the patients were admitted within an hour of injury only three were seen by a neurosurgeon within 2 hours of admission. Three patients were seen between 36 hours and 8 days. The remaining six patients were examined between 4 and 36 hours and at an average of 12 hours. Skeletal traction was instituted on an average of 11 hours after admission excluding one case of delay for 9 days. Only two patients had adequate reduction within 28 hours. Steroids were given to eight patients at an average of 6 1/2 hours following admission but usually in inadequate dosage. Five laminectomies and six anterior fusions were eventually performed. Two patients had both operations. One patient subsequently expired. No patient had a surgically remedial lesion or showed postoperative favourable change in cord function. Five operated patients developed spine deformity, persistent dislocation, spinal canal stenosis or instability. This care was generally attested to meet proper standards and to represent the treatment ordinarily rendered when academic and qualified neurosurgeons gave testimony regarding it. Neither the funding of care and research, nor the adopted codes governing treatment in accredited hospitals, nor accepted teaching would appear to have influenced the substandard of care provided these patients. Other statistics confirm this to be a prevailing circumstance.
Paraplegia 1978 May
PMID:Proceedings of the Annual Scientific Meeting of the International Medical Society of Paraplegia held at Stoke Mandeville from 28-30 July 1977 (Part II). Fracture dislocation of the cervical spine: a critique of current management in the United States. 73 83

Between 1995 and 2000, 22 cases with low velocity missile injuries of the spine and spinal cord were treated in three service hospitals. All were adult males, with a mean age of 30.7 years. The wounds were caused by splinters in 18 (82%) and bullets in 4 (18%). Twelve patients received more than one splinter. The cervical and thoracic spines were most frequently involved. In 7 cases, there were injuries to other organs. There was extensive initial deficit (quadriplegia, paraplegia) in 18 (82%) cases, while 4 (18%) had partial deficits. The patients were evaluated by spine radiographs. Myelography was done in 4, CT myelography in 11 and MRI in 4 patients. Two patients had intramedullary hematoma without any skeletal injury, and were treated conservatively. Seventeen patients were treated operatively, and associated injuries of other organs received priority management. Surgery was in the form of debridement, exploration of the spinal cord, hemostasis, decompression and dural repair. Steroids and antibiotics were given routinely. Three patients (2 with cervical and 1 with thoracic spine injury) died preoperatively, and 1 (with dorsolumbar injury) died in the postoperative period due to multi-organ injury. Patients with complete injury remained completely paralyzed, while those with an incomplete injury showed improvement in their neurological grades. The initial neurological grade is the best prognostic indicator, and these injuries are often accompanied by multi-organ injuries. There was no instance of postoperative meningitis or CSF leak. These injuries should be explored for debridement and dural repair.
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PMID:Missile injuries of the spine. 1474 34