MEDICAL DEPARTMENT

UNITED STATES ARMY

IN WORLD WAR II

L

JTIt WALm INSPECTED 5
i
MEDICAL DEPARTMENT, UNITED STATES ARMY

SURGERY IN WORLD WAR II

NEUROSURGERY

Volume II

Prepared and published under the direction of

Major General S. B. HAYS

The Surgeon General, United States Army

Editor in Chief

Colonel JOHN BOYD COATES, Jr., MC

Editorsfor Neurosurgery

R. GLEN SPURLING, M.D. BARNES WOODHALL, M.D.

Associate Editor

ELIZABETH M. MCFETRIDGE, M.A.

OFFICE OF THE SURGEON GENERAL

DEPARTMENT OF THE ARMY

WASHINGTON, D.C., 1959
SURGERY IN WORLD WAR II

Advisory Editorial Board

MICHAEL E. DEBAKEY, M.D., Chairman

FRANK B. BERRY, M.D.

BRIAN BLADES, M.D.

J. BARRETT BROWN, M.D.

STERLING BUNNELL, M.D. (dec.)

NORTON CANFIELD, M.D.

B. NOLAND CARTER, M.D.

EDWARD D. CHURCHILL, M.D.

MATHER CLEVELAND, M.D.

DANIEL C. ELKIN, M.D. (dee.)

JOHN B. FLICK, M.D.

FRANK GLENN, M.D.

M. ELLIOT RANDOLPH, M.D.

ISIDOR S. RAVDIN, M.D.

ALFRED R. SHANDS, Jr., M.D.

HOWARD E. SNYDER, M.D.

R. GLEN SPURLING, M.D.

BARNES WOODHALL, M.D.

ROBERT M. ZOLLINGER, M.D.

Colonel JOHN BOYD COATES, Jr., MC (ex offlcio)

Colonel DOUGLAS B. KENDRICK, MC (ex officio)

Colonel JOSEPH R. SHAEFFER, MC (ex officio)

The Historical Unit, United States Army Medical Service

Colonel JOHN BOYD COATES, Jr., MC, Director

Colonel OTHMAR F. GORIUP, MSC, Executive Officer

Colonel R. L. PARKER, MSC, Special Assistant to Director

Lieutenant Colonel R. J. BERNUCCI, MC, Special Assistant to Director

JOSEPHINE P. KYLE, Special Assistant to Director

Lieutenant Colonel C. A. PENDLYSHOK, MSC, Chief, Special Projects Branch

Major RAYMOND H. WHITE, MSC, Chief, Promotion Branch

DONALD O. WAGNER, Ph.D., Chief, Historians Branch

WILLA B. DIAL, Chief, Editorial Branch

LUCY W. LAZAROU, Chief, Research and Archives Branch

HAZEL G. HINE, Chief, Administrative Branch

U. S. GOVERNMENT PRINTING OFFICE: 1959

For «ie by/V Sup^lr\ende)(\of Do/uVientytJ\S. Goynr^ent ^Tn^ngyifice^

\sMgtoVi 25TD.I
NEUROSURGERY

Volume II

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MEDICAL DEPARTMENT, UNITED STATES ARMY

The volumes comprising the official history of the Medical Department

of the U.S. Army in World War II are prepared by the Historical Unit, U.S.

Army Medical Service, and published under the direction of The Surgeon

General, U.S. Army. These volumes are divided into two series: (1) The

administrative or operational series; and (2) the professional, or clinical and

technical, series. This is one of the volumes published in the latter series.

VOLUMES PUBLISHED

ADMINISTRATIVE SERIES

Hospitalization and Evacuation, Zone of Interior

CLINICAL SERIES

Preventive Medicine in World War II:

Vol. II. Environmental Hygiene

Vol. III. Personal Health Measures and Immunization

Vol. IV. Communicable Diseases Transmitted Chiefly Through Respiratory and Alimentary Tracts

Surgery in World War II:

General Surgery, vol. II

Hand Surgery

Neurosurgery, vol. I

Ophthalmology and Otolaryngology

Orthopedic Surgery in the European Theater of Operations

Orthopedic Surgery in the Mediterranean Theater of Operations

The Physiologic Effects of Wounds

Vascular Surgery

Miscellaneous:

Cold Injury, Ground Type

United States Army Dental Service in World War II

VI
Contributors

BLDBIDGE H. CAMPBELL, Jr., M.D. (deceased)

Formerly Colonel. MC, AUS; late Professor of Surgery, Albany Hospital, Albany,

N.Y.

EDMUND JOHN CROCE, M.D.

Chief, Surgical Division, Worcester City Hospital, Worcester, Mass. Formerly Major,

MC, AUS.

FRANCIS ASBIIRY ECHLIN, M.D., CM., M. Sc, Med. Sc. D., F.A.C.S.

Professor of Clinical Neurosurgery, New York Universlty-Bellevue Medical Center,

New York, N.Y. Formerly Major, MC, AUS.

FREDERIC H. LEWEY, M.D. (deceased)

Formerly Lieutenant Colonel, MC, AUS; late Professor of Neuroanatomy and Associate Professor of Neuropathology, Graduate School of Medicine, University of Pennsylvania, Philadelphia, Pa.

WILLIAM R. LYONS, Ph. D., M.D.

Professor of Anatomy, University of California, School of Medicine, San Francisco,

Calif. Formerly Captain, MAC, AUS.

WILLIAM K. MASSIE, M.D.

Orthopedic Surgeon, Lexington, Ky. Major, U.S. Army Reserves.

DONALD D. MATSON, M.D.

Associate Clinical Professor of Surgery, Harvard Medical School; Neurosurgeon,

Children's Medical Center; Neurological Surgeon, Peter Bent Brigham Hospital, Boston, Mass. Formerly Major, MC, AUS.

FRANK H. MAYFIELD, M.D., F.A.C.S., A.B.N.S.

Assistant Professor of Clinical Surgery, College of Medicine, University of Cincinnati;

Director of Department of Neurosurgery, The Christ Hospital and Good Samaritan

Hospital, Cincinnati, Ohio. Formerly Lieutenant Colonel, MC, AUS.

WADE C. MYERS, Jr., M.D.

Chief of Surgery, Tampa General Hospital, Tampa, Fla. Formerly Captain, MC, AUS.

FRANK E. NULSEN, M.D.

Professor of Neurosurgery, Western Reserve University School of Medicine, Cleveland, Ohio; Chief of Neurosurgery, University Hospitals of Cleveland, and Senior Consultant in Neurosurgery, Crile Veterans' Administration Hospital. Formerly Captain, MC, AUS.

FREDERICK M. OWENS, Jr., M.D.

Clinical Associate Professor, University of Minnesota School of Medicine. Minneapolis,

Minn. Assistant Chief, Neurosurgery, McCloskey General Hospital, Temple, Tex.

Formerly Major, MC, AUS.

STANLEY E. POTTER, M.D.

Assistant Professor of Surgery, University of Nebraska College of Medicine, Omaha,

Nebr. Formerly Captain, MC, AUS.

GEORGE C. PRATHER, M.D., F.A.C.S.

Assistant Clinical Professor of Surgery, Harvard Medical School. Boston, Mass.

Head of Department of Urology, Beth Israel Hospital, Boston, Mass. Formerly

Lieutenant Colonel, MC, AUS.
VIII NEUROSURGERY

ROBERT T. ROSENFELD, M.D.

Attending Orthopedic Surgeon, Cedars of Lebanon Hospital, Mount Sinai Hospital,

Los Angeles County General Hospital, Los Angeles, Calif. Fellow, American College of Surgeons, International College of Surgeons, American Academy of Orthopedic

Surgeons. Formerly Major, MC, AUS.

R. GLEN SPURLING, M.D.

Professor of Neurosurgery, University of Louisville School of Medicine, Louisville,

Ky. Formerly Colonel, MC, AUS.

T. CAMPBELL THOMPSON, M.D.

Surgeon in Chief, Hospital for Special Surgery, Professor of Clinical Surgery (Orthopaedics), Cornell Medical Center, New York, N.Y. Formerly Colonel, MC, AUS.

WILLIAM P. VAN WAGENEN, M.D.

Associate Professor of Neurological Surgery, University of Rochester School of Medicine and Dentistry, Rochester, N.Y. Formerly Lieutenant Colonel, MC, AUS.

WARNER WELLS, M.D.

Assistant Professor of Surgery, University of North Carolina School of Medicine,

Chapel Hill, N.C. Formerly Consultant in Surgery to The Surgeon General, Department of the Army. Formerly Lieutenant Colonel, MC, AUS.

BENJAMIN BRADFORD WHITCOMB, M.D.

Visiting Neurosurgeon, Hartford Hospital, Hartford, Conn. Assistant Clinical Professor of Surgery (Neurology), Yale University, New Haven, Conn. Formerly Major,

MC, AUS.

BARNES WOODHALL, M.D.

Professor and Chairman of the Division of Neurosurgery, Duke University School of

Medicine, Durham, N.C. Formerly Lieutenant Colonel, MC, AUS.
Foreword

The first volume of the history of neurosurgery in World War II, which

was published in 1958, dealt with the administrative aspects of this specialty

and with the management of head injuries and their residua. This second

(and final) volume in the neurosurgical series deals with injuries and diseases

of the spine and peripheral nerve injuries.

The management of injuries of the spinal cord had been among the more

dismal chapters in the medical history of World War I. The management

of these injuries is, however, among the more brilliant chapters of the medical

history of World War II. The paraplegic program, which is described in

detail in this volume, was, and remains, an example of good medicine and

of perceptive and compassionate care of men who otherwise would have

been bedridden cripples all of their lives if, indeed, they had survived.

Without this program, most of them would probably have died, partly because of their injuries and partly because they would have had nothing to

live for. This program, which was instituted in Army hospitals during the

war, was, shortly after the war ended, taken over by the Veterans' Administration, in which it has been continued on much the same lines and with

much the same success.

The story of herniated nucleus pulposus (rupture of the intervertebral

disk) in World War II is an example of the flexibility which is possible by

the intelligent application of intelligently conceived administrative regulations. Most of the neurosurgery performed in the first year of United States

participation in the war was for this condition. By the end of the war,

surgery for lesions of the intervertebral disk was confined almost entirely

to those patients whose line of duty was "yes" and who desired the operation.

The reversal of the original policy occurred because it had been found that

few of the men operated on for this condition could be returned to full

military duty. The excellent results achieved by surgery in civilian life

were not being duplicated in military circumstances, chiefly because of the

physical requirements of military duty and because the protection of a locus

minoris resistentiae which is possible in civilian life is absolutely impossible

in service. The time and efforts of medical officers and other medical attendants, including physiotherapists, as well as the hospital bed space formerly devoted to herniated nucleus pulposus, were therefore wisely diverted

to those who would receive more benefit from them.

It had been expected, from the standpoint of the caseload, that head

injuries would furnish the outstanding neurosurgical problem in World

War II. As events turned out, the heaviest neurosurgical load was furnished

by peripheral nerve injuries.
X NEUROSURGERY

The management of these injuries represented a striking advance over

the methods used in World War I. Primary nerve suture was not attempted,

but, whenever possible, repair was instituted overseas, after debridement and

healing of the soft-tissue wound. The place of repair was not important.

What mattered was the timing. Nerves repaired within the optimum time

period of 21 to 90 days after wounding were restored to functional usefulness in countless cases in which the plan of delayed surgery usually

practiced in World War I would have left useless extremities.

The management of peripheral nerve injuries in the specialized neurosurgical centers described in the first neurosurgical volume had much to do

with making these successful results possible. This was partly because of

the concentration in the centers of a trained neurosurgical staff and specialized equipment. It was also because in these specialized centers there were

immediately available neurologists; orthopedic, plastic, and vascular surgeons;

and other specialists who were needed for the care of the numbers of patients with peripheral nerve injuries whose wounds required combined

management.

The record of these peripheral nerve injuries has been preserved in the

Peripheral Nerve Eegistry, which is described in detail in this volume. The

followup of a very large number of these cases is recorded in the volume on

peripheral nerve regeneration published in 1957 as a Veterans' Administration monograph. This monograph, of which Dr. Barnes Woodhall, coeditor

of the neurosurgical volumes in the World War II medical history, is also

a coeditor, is probably the most satisfactory followup of wartime injuries

that has ever been accomplished.

Neurosurgery furnished a particularly brilliant chapter of military

medicine in World War II. I should like to repeat here what I stated in

the foreword to the first of the neurosurgical volumes, that the editors of

this volume, Dr. Woodhall and Dr. R. Glen Spurling, and the authors of the

various chapters have added to their wartime service in the Medical Corps

by the time and effort which they have devoted to the preparation of this

permanent record of their work.

S. B. HAYS,

Major General,

The Surgeon General.
Preface

The first volume of the history of neurosurgery in World "War II,

published in 1958, was devoted to the administrative details without which

military medicine cannot function; the evolution of neurosurgical policies

in their broad aspects; and head trauma, including certain of its immediate

sequelae. This second and final volume of the neurosurgical history of

World War II is concerned with injuries of the spinal cord and peripheral

nerves. A chapter on lesions of the intervertebral disk is included.

Because of the classic work of Harvey Cushing on penetrating wounds

of the brain, the chapters on this subject in the history of the Medical

Department of the U.S. Army in World War I were exceedingly helpful in

setting up the program for the management of head trauma in World War II.

In sharp contrast, the World War I history was of little help to the clinician

in the management of peripheral nerve injuries and injuries of the spinal

cord incurred in combat in the Second "World War. It is true that the

invaluable laboratory experiments of Carl Huber on peripheral nerve suture

were printed in full in it, but the clinical sections did little more than discourage the neurosurgeon in his attempt to eliminate or reduce disability

from peripheral nerve injuries. As for major injuries of the spinal cord,

the few paragraphs, devoted to them are merely a depressing statement of

the futility of treatment for these casualties, most of whom, if they did not

die soon after wounding, died soon afterward, within weeks or months.

The most dramatic achievement of the entire neurosurgical program

in World War II was undoubtedly the new chapter which was written in

the management of paraplegia. Maj. Gen. Norman T. Kirk, USA (Eet.),

The Surgeon General of the Army when this program was put into effect,

has this to say of what was accomplished in this program:

This was a splendidly conceived program. Many new things were accomplished for

the paraplegic which had never been accomplished before in either military or civilian

medicine. Until this program was adopted, his life expectancy was measured in months,

chiefly because of ascending urinary tract infection and the loss of vital pints of blood

serum which leaked from decubitus ulcers. As paraplegics lost appetite, weight, and

strength, they also became susceptible to other infections.

All of this was changed by the paraplegic program, in which neurosurgeons, urologists, internists, orthopedic surgeons, plastic surgeons, nurses and ward attendants, dietitians, and physiotherapists worked as a team with a single-minded purpose and objective. Urinary tract infection was controlled. Automatic bladder function was established.

Bedsores were closed surgically, so that blood serum losses were ended. Plastic surgery

was also employed as necessary. Under an improved dietary regimen, the patients

gained weight and strength. With the help of orthopedic surgeons and physical therapists, many of them became ambulatory.
XI1 NEUROSURGERY

There would be little disagreement with General Kirk's concluding

statement, that more was achieved for the paraplegic in World War II in

comparison with his status in previous wars, than for any other type of

casualty.

In the early months of the war, the methods of management of the

intervertebral disk were carried over from accepted civilian practices which

had been developed in this relatively new entity before World War II. The

only new concept which arose from the Army experience was the futility

of attempting to rehabilitate most of these patients for field duty by any

means at our disposal.

Between the two World Wars, injuries to major peripheral nerve trunks

had been handled by orthopedic and industrial surgeons as well as by

neurosurgeons. These injuries are relatively uncommon, however, and, because of the scarcity of material, very few important clinical studies, and

even fewer important experimental studies, had been concerned with their

diagnosis, treatment, and prognosis.

When the United States entered World War II, it was fully realized

that large numbers of peripheral nerve injuries would be encountered. Reports from various sources had indicated the frequency of these injuries in

the experience of other belligerents during the first years of the war. Our

British colleagues, however, were the only ones who had laid down a

definite policy of management for them, and they had selected orthopedic

surgeons to do the job.

One of the first medicomilitary questions which Maj. Gen. James C.

Magee, USA (Eet.), then The Surgeon General of the Army, had to decide

was who should be responsible for these injuries in the U.S. Army. With

the advice and concurrence of his chief consultant in surgery, the late Brig.

Gen. Fred W. Rankin, it was decided to make the management of peripheral

nerve injuries a part of the neurosurgical program.

There were two compelling reasons for this decision. The first was that,

when the United States entered World War II, it had a more abundant

supply of trained neurosurgeons than any other country in the world. The

second reason, which proved eminently sound, was that orthopedic surgeons

would be so busily engaged in the treatment of enormous numbers of casualties with bone and joint injuries that they would have little time for

setting up an effective program in another field, particularly as the planned

program for peripheral nerve injuries envisaged not only the management

of peripheral nerve trauma but also preparations for a longtime study of

these injuries once the conflict had ended.

Throughout this second volume on neurosurgery in World War II, the

reader will encounter many references to the Peripheral Nerve Registry set

up in the Office of the Surgeon General in November 1944. It is ironical

to record that the 5-year study of peripheral nerve regeneration after
PREFACE XIII

repair,1 which was the outgrowth of this Eegistry, should have been completed and published before the volume of the World War II history which

tells the story of how the Registry came into being. The readers of this

second neurosurgical volume are urged to consult this monograph on nerve

regeneration. The two books, in a sense, complement each other, and to read

only one of them and ignore the other would leave the story of peripheral

nerve injuries in World War II only half told.

As in the first volume of the neurosurgical series, we wish to acknowledge

our debt of gratitude to the authors of the various chapters of this volume.

They produced them, often at a great sacrifice of time and energy, immediately after their separation from service. There is no better proof of

their devotion to duty than that, when the project was revived 10 years

later, they again gave freely of their time and effort to revise and correct

their manuscripts and thus help to produce this volume.

R. GLEN SPURLING, M.D.

BARNES WOODHALL, M.D.

1 Woodhall, Barnes, and Becbe, Gilbert W. (editors) : Peripheral Nerve Regeneration. A Followup Study of 3,656 World War II Injuries. Washington : U.S. Government Printing Office, 1957.
Contents

FOREWORD.

Page

IX

XI

PREFACE

Part I

INJURIES OF THE SPINAL CORD

Chapter

I Historical Note (Barnes Woodhall, M.D.) 3

II The Zone of Interior (Barnes Woodhall, M.D.) 5

Evolution of Policies *j

Personnel

Supplies and Equipment

Surveys of Paraplegic Centers

Causes of Death

Transfer of the Paraplegic Program to the Veterans' Administration_.. 13

III The Mediterranean (Formerly North African) Theater of Operations

(Eldridge H. Campbell, Jr., M.D.) l9

Incidence

Surgical Policies

Decubitus Ulcers

Management of the Cord Bladder 2Z

Hospital Management

Evacuation

IV The European Theater of Operations (R. Glen Spurting, M.D.) 25

Surgical Policies

Transportation ^

Decubitus Ulcers

The Cord Bladder 30

V The Management of Acute Compound Battle-Incurred Injuries of the

Spinal Cord (Donald D. Matson, M.D.) 31

Historical Note

Classification of Compound Injuries of the Spinal Cord 32

First Aid Treatment 35

Neurologic Examination

Lumbar Puncture

Roentgenologic Examination

Laminectomy

Postoperative Care

xv

36

38

39

41

57
XVI CONTENTS

Chapter p

V The Management of Acute Compound Battle-Incurred Injuries of the

Spinal Cord—Continued

Care of the Bladder __ g->

Care of the Gastrointestinal Tract _ 53

Nutrition __ „0

Evacuation fio

Factors of Mortality __ g«

VI Urologie Aspects of Spinal Cord Injuries (George C. Prather, M.D.) 67

The Status of the Bladder After Injury of the Spinal Cord 67

Progress of Recovery __ __ _ gg

Methods of Examination of the Bladder __ 72

Care of the Bladder __ gg

Surgical Measures nc

Bladder Training og

Comparison of Methods of Bladder Management 98

Status of the Upper Urinary Tract After Injury of the Spinal Cord.... 100

Status of the Sex Organs After Injury of the Spinal Cord 101

Genitourinary Complications of Injuries to the Spinal Cord 101

Results of Treatment 114

Spinal Cord Injury in the Female llg

Military Policies 119

A Suggested Program of Management 123

Conclusions __ 124

VII The Management of Paraplegic Patients in Zone of Interior Hospitals

{Barnes Woodhall, M.D.) 127

Analysis of Cases 127

Preliminary and Continuing Examinations 129

Decubitus Ulcers -jon

Nutrition and Diet j4g

Bladder Function '_ jrj

Bowel Function JJQ

Personal Hygiene i5y

Psychiatric and Emotional Considerations 15g

Physical Reconditioning J62

Ambulation 1 g^

Relief of Pain and Spasm _ jyg

Rehabilitation __ jg^

Results of Program __ igg

Physician and Patient __ _ jgg

The Problem of Morale 190

VIII Management of the Ruptured Intervertebral Disk (Herniated Nucleus

Pulposus) (R. Glen Spurling, M.D.) I93

Historical Note __ 193

Development of Clinical. Policies in the Zone of Interior 194

Development of Clinical Policies in Oversea Theaters 202
CONTENTS XVII

Part II

PERIPHERAL NERVE INJURIES

Chapter Page

IX Historical Note {Barnes Woodhall, M.D.) 207

Peripheral Nerve Injuries in World War I 207

X The Zone of Interior {Barnes Woodhall, M.D.) 211

Early Nerve Repair 211

Diagnostic Procedures 212

Nerve Grafting 218

Management of Causalgia 219

Neuropathologic Studies 219

Disposition 221

Peripheral Nerve Registry 225

XI The Mediterranean (Formerly North African) Theater of Operations

{Eldridge H. Campbell, Jr., M.D.) 231

Evolution of Policies 231

Primary Repair of Peripheral Nerve Injuries 231

Early Nerve Suture 233

Statistical Data 237

XII The European Theater of Operations {R. Glen Spurting, M.D.) 239

Evolution of Policies 239

Timing of Nerve Repair 239

Principles and Techniques 242

Combined Bone and Nerve Injuries 2-14

Physical Therapy 246

Statistical Data 247

XIII Standard Methods of Examination in Peripheral Nerve Injuries {Frederic

H. Lewey, M.D.) 251

General Considerations 251

Objectives of the Examination 252

Initial Investigations 253

Quantitative Examination of Sequence of Returning Motor Function^. 256

Quantitative Assessment of Strength of Muscles of Hand and Foot 256

Nerve Block To Eliminate Supplementary Movements 263

Handprints and Footprints 265

Electrodiagnosis 266

Sensibility Tests 266

Sensory Examinations 272

Qualitative Determination of Sequence of Returning Sensory Function^ 272

Qualitative Methods of Mapping Out Areas of Impaired Sensation 273

Quantitative Determination of Pain Sensation 273

Quantitative Determination of Superficial Pressure (Touch) 275

Estimation of Number of Pain and Touch Points 276

Nerve Block To Eliminate Overlap Sensation 277

Localization of Returning Sensation 277

Compass Test (Special Discrimination Test, Two-Point Test) 277

Sweat Tests "--- 279

Skin Temperature Test 280

Case Histories 283

49S991V—59 2
XVIII CONTENTS

Chapter Page

XIV Anatomic Approaches to the More Commonly Injured Peripheral Nerves

(Warner Wells, M.D., Frederick M. Owens, Ji., M.D., and Francis A.

Echlin, M.D.) 301

Historical Note 301

General Considerations 304

The Brachial Plexus 305

The Musculocutaneous Nerve 313

The Axillary Nerve 317

The Radial Nerve 318

The Median Nerve 328

TheUlnar Nerve 335

The Femoral Nerve 343

The Sciatic Nerve and Its Terminal Divisions 350

XV Techniques of Peripheral Nerve Repair (Benjamin Bradford Whitcomb,

M.D.) 363

General Considerations 363

Arrangement of Operating Room 364

Preoperative Preparation 365

Anesthesia 368

Incision and Exposure 369

Evaluation of the Status of the Nerve 372

Neurolysis 374

Techniques of Repair 375

Special Techniques 377

Steps of the Operation 382

Other Methods of Anastomosis 389

Regional Injuries 391

XVI Combined Bone and Peripheral Nerve Injuries (Wade C. Myers, Jr.,

M.D., and Robert T. Rosenfeld, M.D.) 415

General Considerations 415

Selection of Cases for Combined Operation 416

Preoperative Management 420

Operation 421

Analysis of Data 422

Postoperative Complications 426

Results 428

XVII Peripheral Nerve Injuries Complicated by Skin and Soft-Tissue Defects

(Stanley E. Potter, M.D., and Edmund John Croce, M.D.) 429

Evolution of Policies 429

Routine of Management 429

Special Techniques 430

Postoperative Management 431

Conclusions 431

XVIII Peripheral Nerve-Vascular Injuries (Barnes Woodhall, M.D.) 439

Incidence 439

Diagnostic Considerations 440
CONTENTS XIX

Chapter Page

XVIII Peripheral Nerve-Vascular Injuries—Continued

Injuries of the Neck 441

Injuries of the Upper Extremity 448

Injuries of the Lower Extremity 455

Peripheral Nerve Injury With Vascular Occlusion 458

Management of Combined Vascular-Nerve Inj uries 464

Other Associated Injuries 466

XIX Causalgia Following Combat-Incurred Injuries of the Peripheral Nerves

(Frank H. Mayfield, M.D.) 469

General Considerations 469

Incidence 470

Pathologic Process 473

Etiologic Considerations 474

Symptoms and Signs 478

Differential Diagnosis 485

Management 487

Results 489

XX Peripheral Nerve Grafts (Frank E. Nulsen, M.D., Frederic H. Lewey, M.D.,

and William P. Van Wagenen, M.D.) 493

General Considerations 493

Development of the Program 494

Materials and Methods 495

Indications 496

Technique 497

Evaluation of Results 499

Results 502

Summary and Conclusions 510

XXI Neuropathologic Changes in Battle-Incurred Injuries of Peripheral Nerves

(William R. Lyons, Ph. D., M.D.) 513

Materials and Methods 513

Time Lapse 514

Completely Severed Nerve Stumps 515

Severed Nerve Stumps in Fibrous Continuity 519

Neuromas in Continuity 519

Nerve Segment Eroded by Aneurysm 528

Suture Sites 531

Additional Studies 541

Comment 547

XXII Physical Therapy in the Management of Peripheral Nerve Lesions (William K. Massie, M.D.) 557

Changes in the Neuromuscular System Produced by Peripheral Nerve

Injuries 557

Diagnostic Aspects of Physical Therapy 559

Techniques of Physical Therapy 562

Psychologic Aspects of Physical Therapy 568
XX CONTENTS

Chapter page

XXIII Orthopedic Techniques for Use in Irreparable Nerve Injuries (T. Campbell

Thompson, M.D.) 569

General Considerations 569

Operations on the Upper Extremity 571

Operations on the Lower Extremity 578

Conclusions 584

APPENDIXES

A Army Service Forces Circular No. 25 587

B War Department Technical Bulletin 162 589

C Routine Procedure for Transverse Myelitis Cases 599

D Battle Wounds and Battle Injuries of the Spinal Cord and Vertebrae 609

E Peripheral Nerve Injury Study, All Nerves 611

F Peripheral Nerve Injury Study, Sciatic Nerves 633

INDEX 651

Illustrations

Number

1 Colony type of paraplegia ward 10

2 Wheelchair mess for paraplegic patients 11

3 Roentgenograms showing shell fragment wound of spinal canal 20

4 Roentgenograms showing bullet wound of spinal canal 21

5 Roentgenograms showing fracture-dislocation of fifth cervical vertebra 26

6 Roentgenogram showing crush fracture of third lumbar vertebra 26

7 Roentgenogram showing shell fragment wound of cauda equina 27

8 Roentgenograms showing shell fragment wound of spinal canal 27

9 Common varieties of compound spinal wounds due to high-explosive missiles- _ 34

10 Roentgenograms showing bullet wound of spine 40

11 Roentgenogram showing shell fragment wound of spine 41

12 Incisions for laminectomy 53

13 Surgical exposure of spinal wounds 53

14 Technique of laminectomy 54

15 Closure of wound of spine 54

16 Surgical exposure for hemilaminectomy 56

17 Position of paraplegic in bed 60

18 Position of paraplegic in bed 60

19 Cystometer 74

20 Cystometric curves of normal bladder 75

21 Cystometric curves of normal bladder 75

22 Cystometrogram of paraplegic bladder in first stage of recovery 76

23 Cystometrogram of paraplegic bladder in second stage of recovery 76

24 Cystometrogram of paraplegic bladder in third stage of recovery 77

25 Cystometrogram of paraplegic bladder with voluntary control 77

26 Cystometrogram of paraplegic bladder in third stage of recovery 78

27 Cystometrogram of paraplegic bladder with recovery still incomplete 78

28 Cystogram of paraplegic bladder in first stage of recovery 82

29 Cystogram of paraplegic bladder in stage of atony 83

30 Urethrogram of paraplegic in first stage of bladder recovery 84
CONTENTS XXI

Number Pa9

e

31 Urethrogram of paraplegic with complete cord transection 85

32 Urethrogram of paraplegic with good automatic bladder 86

33 Urethrogram of paraplegic with good bladder control 87

34 Urethrocvstogram of paraplegic with sufficient bladder control to permit

voluntary voiding öö

35 Diagram for closed system of bladder drainage and irrigation 92

36 Correct placement of suprapubic tube 96

37 Incorrect placement of suprapubic tube 96

38 Roentgenograms showing renal calculi in paraplegic 105

39 Intravenous urogram showing obstructing calculus in paraplegic 106

40 Roentgenograms showing ureteral calculi in paraplegic 107

41 Roentgenogram showing calculi in paraplegic 108

42 Multiple unilateral renal calculi in paraplegic 109

43 Roentgenogram showing bladder stone in paraplegic 110

44 Control record for paraplegic ward I

30

45 Decubitus ulcers in paraplegic 132

46 Decubitus ulcers in paraplegic 133

47 Care of paraplegic on Stryker frame 136

48 Care of paraplegic on Stryker frame 137

49 Decubitus ulcer treated by skin graft 139

50 Plastic repair of decubitus ulcers 141

51 Plastic repair of decubitus ulcers 142

52 Plastic repair of decubitus ulcers 143

53 Plastic repair of decubitus ulcers 144

54 Plastic repair of decubitus ulcers 145

55 Roentgenograms showing neurogenic ossifying flbromyopathies in paraplegics.- 148

56 Bedside setup for tidal drainage of bladder 152

57 Manometer used in typical tidal drainage of bladder 153

58 Instruction chart for use of tidal-drainage apparatus 154

59 Ward record for progress in genitourinary problems in paraplegics 155

60 Ward defecation record used in colony paraplegic care 156

61 Toilet guerney 157

62 Maximal physiologic position for defecation in paraplegia 157

63 Full sitting position on toilet seat achieved by paraplegic 158

64 Transfer from wheelchair to toilet by fully conditioned paraplegic 158

65 Toilet seat design for paraplegic 158

66 Washbasin arrangement for wheelchair-ambulant paraplegic 159

67 Bathing arrangements for wheelchair-ambulant paraplegic 159

68 Reconditioning at colony bed level by paraplegic 164

69 Mat exercises for paraplegics 16"

70 Advanced exercises for paraplegics ' 168

71 Chair exercises for paraplegics 168

72 Brace fitting of paraplegic 169

73 Details of long leg brace for paraplegic 170

74 Brace fitting of paraplegic 1'1

75 Thoracopelvic girdle for paraplegic 172

76 Step-through gait in paraplegia 173

77 Swing-through gait in paraplegia 174

78 Swing-through gait in paraplegia 174

79 Use of overhead suspension track in early stage of ambulation in paraplegia.-- 175

80 Advanced step-through ambulation by paraplegic 176

81 Walking record used in paraplegic colony 177

82 Roentgenograms showing shell fragment in spinal canal 179
XXII CONTENTS

Number D

rage

83 Roentgenogram showing fistula and exostosis after laminectomy for gunshot

wound of spine ^g

84 Surgery for relief of spasm and contracture in paraplegic 183

85 Recreation and occupational therapy in paraplegic colony 186

86 Special form used in ruptured intervertebral disk 19g

87 Serial Pantopaque myelograms in normal subject 197

88 Pantopaque myelograms in ruptured intervertebral disks 199

89 Form used for basic neurological examination _ 214

90 Form used for peripheral nerve examination 215

91 Charts used for mapping affected areas in peripheral nerve injuries 218

92 Form used in Peripheral Nerve Registry 227

93 Diagrams used in neurosurgical centers to show complete data in peripheral

nerve injuries 255

94 Specimen file card of patient with peripheral nerve injury 255

95 Forms for recording motor and sensory examinations 257

96 Forms for recording progressing regeneration in peripheral nerve injuries 258

97 Apparatus for measuring muscle strength 259

98 Technique for measuring muscle strength 262

99 Diagram used to record measured strengths of various motions 263

100 Handprints indicating paralysis of peripheral nerves of arm 266

101 Handprints indicating complete paralysis of ulnar and median nerves 267

102 Footprints indicating progress of recovery in injuries of tibial and peroneal

nerves 2fi8

103 Footprints of patient with tibial nerve injury 269

104 Diagrams showing areas of autonomous or isolated sensory supply of ulnar

and median nerves __ 270

105 Diagrams showing areas of autonomous or isolated sensory supply of sciatic,

peroneal, and tibial nerves 270

106 Diagrams showing quantitative estimation of pain and touch points 271

107 Head's algesimeter 274

108 Von Frey hair 274

109 Pattern of rubber stamp used in estimation of pain and touch points 274

110 Hyperhidrosis in skin distribution of injured ulnar nerve 281

111 Graphic record in injury of ulnar nerve 284

112 Graphic record in injury of median nerve 286

113 Progressive regeneration of injured ulnar nerve 287

114 Handprints in complete interruption of ulnar nerve 288

115 Handprints in injury of ulnar nerve 288

116 Graphic record in injury of ulnar nerve 290

117 Graphic record in injury of median nerve 292

118 Graphic record in injury of ulnar and median nerves 293

119 Graphic record in injury of radial nerve and fracture of humerus 295

120 Graphic record in injury of radial nerve and fracture of humerus 295

121 Graphic record in injury of sciatic nerve 297

122 Graphic record in injury of sciatic nerve (tibial and peroneal portions) 298

123 Graphic record in injury of tibial and peroneal nerves 299

124 Graphic record in injury of peroneal nerve 300

125 Schematic view of brachial plexus 306

126 Supraclavicular exposure of brachial plexus 307

127 Relation of brachial plexus to first rib and clavicle 307

128 Relation of brachial plexus cords to axillary artery 309

129 Relation between medial brachial plexus cord and axillary vein 309

130 Skin incision for exposure of brachial plexus 312
CONTENTS XXIII

i Paqe Number

131 Surgical anatomy of musculocutaneous nerve 315

132 Skin incision for exposure of musculocutaneous nerve 31o

133 Surgical exposure of musculocutaneous nerve 315

134 Skin incision for exposure of axillary nerve 319

135 Surgical anatomy of axillary space 319

136 Skin incision for exposure of axillary nerve 319

137 Surgical anatomy of axillary nerve 319

138 Surgical anatomy of radial nerve 321

139 Superficial cutaneous branches of radial nerve 321

140 Skin incision for exposure of radial nerve 323

141 Surgical exposure of radial nerve 323

142 Skin incision for exposure of radial nerve 324

143 Surgical exposure of radial nerve 324

144 Skin incision for exposure of radial nerve 324

145 Skin incision for exposure of radial nerve 327

146 Surgical exposure of deep radial nerve 327

147 Distribution of median nerve in arm 327

148 Terminal branches of median nerve 329

149 Course of median nerve 3jj

150 Skin incisions for exposure of median nerve 329

151 Cross section of arm showing relation of median nerve to neurovascular bundle.. 332

152 Surgical anatomy of antecubital fossa 332

153 Motor branches of median nerve 332

154 Surgical exposure of median nerve 334

155 Cross section showing anatomy of median nerve in forearm 334

156 Surgical exposure of digital nerve in index finger 334

157 Flexion technique of bridging gap in median nerve 334

158 Stripping technique of achieving length in injury of median nerve 336

159 Technique of repair of median nerve 336

160 Distribution of ulnar nerve 337

161 Skin incision for exposure of ulnar nerve 339

162 Surgical exposure of ulnar nerve 341

163 Skin incision for exposure of ulnar nerve 341

164 Technique of anterior transplantation of ulnar nerve 344

165 Surgical anatomy of femoral nerve 345

166 Superficial cutaneous branches of femoral nerve 345

167 Relation of femoral nerve to vascular structures at Poupart's ligament 347

168 Skin incision for exposure of femoral nerve 348

169 Surgical exposure of femoral nerve 348

170 Skin incision for exposure of femoral nerve 350

171 Surgical exposure of femoral nerve 35°

172 Schematic demonstration of origin, course, and main branches of sciatic nerve. 355

173 Anatomic approach to sciatic nerve 35^

174 Exposure of sciatic nerve to gain length 357

175 Anatomic approach to common peroneal and tibial nerves 358

176 Anatomic approach to tibial nerve 360

177 Anatomic approach to peroneal nerve 3°1

178 Instruments for peripheral nerve surgery 366

179 Instruments and apparatus for peripheral nerve surgery 368

180 Closure of incision in peroneal nerve injury 370

181 Scars of healing by granulation after debridement in peripheral nerve mjunes__ 371

182 Incision for repair of ulnar nerve 37

183 Scar tissue in typical missile wounds of peripheral nerves 37iJ
XXIV CONTENTS

Number Page

184 Nerve suture after extensive mobilization of proximal segment 377

185 Technique for repair of lateral neuroma 37g

186 Optimum positions for flexion-relaxation of sutured nerves 379

187 End-to-end nerve suture 003

188 Resection of scarred portion of damaged nerve _ 335

189 Injection of distal nerve segment to facilitate anastomosis 386

190 Suture techniques of nerve repair occ

191 Suture techniques of nerve repair 307

192 Nerve suture site after removal of tantalum foil 3gg

193 Tantalum foil cuff 3go

194 Postoperative roentgenogram showing tantalum sutures 390

195 Roentgenograms showing shortening of fractured humerus in repair of injury

of radial nerve ' 4f)r

196 Combined surgery in injury of humerus and radial nerve 424

197 Combined surgery in injury of humerus and radial nerve 425

198 Combined surgery in injury of radius, ulna, and median and ulnar nerves 426

199 Combined surgery in shell fragment wound of femur and sciatic nerve 427

200 Repair of injury of tibial nerve with soft-tissue loss 432

201 Repair of injury of tibial and peroneal nerves with soft-tissue loss 433

202 Repair of injury of tibial nerve with soft-tissue loss 434

203 Repair of injury of ulnar nerve with soft-tissue loss 435

204 Repair of injury of median nerve with soft-tissue loss 43g

205 Repair of injury of ulnar nerve with soft-tissue loss 437

206 Repair of injury of radial nerve with soft-tissue loss 43g

207 Paralysis of hypoglossal nerve 444

208 Paralysis of seventh nerve 444

209 Paralysis of spinal accessory nerve 447

210 Musculocutaneous and median nerve injury with axillary aneurysm 450

211 Paralysis of ulnar nerve with aneurysm of brachial artery 451

212 Aneurysm of brachial artery with ulnar and median nerve paralysis 452

213 Frozen hands after nerve-vascular injury 455

214 Popliteal aneurysm with sural nerve involvement 457

215 Frozen hand after nerve-vascular injury 460

216 Ischemic contracture of hand from nerve-vascular injury _ _ 4(51

217 Retention of function of hand after nerve-vascular injury 4g4

218 Patient with causalgia 4

219 Protection of causalgic hand 481

220 Serial demonstration of relief in causalgia 4g2

221 Oscillometric tracings in median nerve injury 4g3

222 Causalgic hand after median nerve injury 4g3

223 Oscillometric tracings in sciatic nerve injury _ _ 4g4

224 Method of keeping causalgic hand constantly moist 4g4

225 Roentgenograms showing spotty osteoporosis in causalgic limb 486

226 Successful frozen dried homograft applied to facial nerve 501

227 Successful frozen dried homograft applied to median nerve 504

228 Successful frozen dried homograft applied to median nerve 504

229 Successful frozen dried homograft applied to median nerve 505

230 Successful frozen dried homograft applied to median nerve 506

231 Unsuccessful application of frozen dried homograft to ulnar nerve 507

232 Unsuccessful application of frozen dried homograft to ulnar nerve 507

233 Unsuccessful application of frozen dried homograft to ulnar nerve 508
CONTENTS XXV

Number Page

234 Unsuccessful use of frozen dried homograft 509

235 Unsuccessful use of frozen dried homograft 510

236 Unsuccessful use of frozen dried homograft 511

237 Unsuccessful use of frozen dried homograft 511

238 Successful autogenous nerve graft 512

239 Complete severance of ulnar nerve 516

240 Cross section of severed musculocutaneous nerve 517

241 Cross section of severed branch of femoral nerve 518

242 Complete severance of posterior tibial nerve 520

243 Complete severance of radial nerve 522

244 Cross sections of degenerated distal nerve segments 524

245 Neuroma of ulnar nerve 525

246 Surgical exposure of median nerve 526

247 Longitudinal section through neuroma in continuity of ulnar nerve 527

248 Longitudinal section through neuroma in continuity of ulnar nerve 527

249 Cross sections of common peroneal and posterior tibial nerves 528

250 Contusion of sciatic nerve 528

251 Neuroma in continuity of common peroneal nerve 529

252 Fusiform neuroma in continuity of ulnar nerve 530

253 Neuroma in continuity of ulnar nerve 531

254 Neuroma in continuity of ulnar nerve 532

255 Erosion of radial nerve by aneurysm 534

256 Giant cell and fibrous reaction around silk sutures in ulnar nerve 536

257 Fibrous reaction around site of tantalum sling suture 537

258 Section through suture site of median nerve 538

259 Anastomotic zone of common peroneal nerve after tantalum wire suture 539

260 Temporary repair of radial nerve with silk sling stitches and fibrin film wrapping, 540

261 Cross section through fascicle of sutured radial nerve 542

262 Longitudinal section through fascicle of sutured ulnar nerve 542

263 Neuroma of ulnar nerve after repair with inadequate resection 544

264 Cross section through sutured median nerve 546

265 Complete severance of median nerve 548

266 Bulb suture of common peroneal nerve 550

267 Disruption of radial nerve after suture 551

268 Disruption of common peroneal nerve after suture 552

269 Stretch fibrosis of common peroneal nerve 553

270 Repair of radial nerve by sural autograft cables 554

271 Frozen dried homograft applied to posterior tibial nerve 555

272 Steindler technique of transplantation of flexor muscles 572

273 Steindler technique of transplantation of flexor muscles 572

274 Transplantation of flexors of forearm 575

275 Transplantation of flexors of forearm 575

276 Transplantation of flexor digitorum sublimis tendons in clawhand deformity. — 578

277 Transplantation of flexor sublimis tendon into thumb 578

278 Transplantation of flexor sublimis tendon into thumb 578

279 Lambrinudi operation to correct equinus and varus deformities 581

280 End result of Lambrinudi subastragalar arthrodesis 581

281 Transplantation of tibialis posticus for correction of equinovarus deformity 582

282 Transplantation of tibialis posticus for correction of equinovarus deformity 583

283 Transplantation of tibialis posticus for correction of equinovarus deformity 583

49S991V^59-
XXVI CONTENTS

Color Plates

Number page

1 Cross section through fascicle of severed ulnar nerve 518

2 Cross section through fascicle of severed median nerve 518

3 Cross section through fascicle of severed median nerve 518

4 Cross section through fascicle of severed ulnar nerve 518

5 Longitudinal section through fascicle of severed sciatic nerve 518

6 Cross section through fascicle of severed median nerve 518

7 Cross section through fascicle of severed sciatic nerve 518

8 Longitudinal section through fascicle of segment of neuroma in continuity in

posterior cord of brachial plexus 518

9 Longitudinal section through neuroma in continuity in common peroneal nerve- 518

10 Longitudinal section through neuroma in common peroneal nerve 518

11 Longitudinal section through neuroma in continuity in median nerve 518

12 Longitudinal section through frozen dried homograft in tibial nerve 518

Tables

Number

1 Status and disposition of paraplegics in December 1945 16

2 Distribution of 1,260 battle-incurred spinal cord injuries in United Kingdom

hospitals 28

3 Specimen case fatality rates in surgery of spinal cord injuries 65

4 Status in 1944 of 1943 admissions for herniated nucleus pulposus 198

5 Cases of herniated nucleus pulposus operated on in 1943 201

6 Status in 1945 of 1943 admissions for herniated nucleus pulposus 202

7 Anatomic distribution of 1,184 peripheral nerve injuries in Mediterranean

theater 237

8 Essential data in 6,245 peripheral nerve injuries in European theater 248

9 Average strength of motions of hospital population (in pounds) 260

10 Skin temperature 282

11 Summarized data in 36 combined bone-nerve operations 417

12 Incidence of causalgia in neurosurgical centers 471

13 Essential data in 60 cases of causalgia 491

14 Results of frozen dried homografts in 5 partial peripheral nerve defects 499

15 Results of frozen dried homografts in complete peripheral nerve defects 502
Parti

INJURIES OF THE SPINAL CORD
CHAPTER I

Historical Note

Barnes Woodhall, M.D.

The policies employed in injuries of the spine and the results secured

by them in World War I require no extended discussion. Only a few pages

were devoted to them in the official history of World War I,1and the section

dealing with their management in forward hospitals dismisses them m a

single paragraph, as follows:

SPINAL CASES

These did very badly throughout, as was anticipated. Most of them were immediately evacuated to base'hospitals and fully 80 percent died in the first few weeks in

consequence of infection from bed sores and catheterization. The conditions were such,

owing to pressure of work, as to make it almost impossible to give these unfortunate

men the care their condition required. No water beds were available, and each case

demands the almost undivided attention of a nurse trained in the care of paralytics.

Only those cases survived in which the spinal lesion was a partial one.

Wounds of the bony spine were classified into (1) those without perforation of the dura or injury to the cord, (2) those without perforation of

the dura but with injury to the cord, (3) those with perforation of the

dura and injury to the cord, and (4) those with injury to the cord without

external wounds (spinal concussion). Surgery was never considered for

spinal concussion, and spinal lesions in which a transverse injury was suspected were also considered inoperable if they were complicated by serious

wounds of the chest and abdomen.

The results of spinal injuries were described as extremely discouraging

and the mortality as very high. In one series of 32 cases reported by Col.

Harvey Cushing, MC, 8 were inoperable and there were 23 deaths (71.8 percent). Of the 24 patients operated on, 15 died (62.5 percent). All of these

patients were cared for in forward areas, and the followup was inadequate

because casualties with spinal cord injuries were evacuated promptly if they

were regarded as at all transportable. The implication is that more deaths

probably occurred in rear areas. Suture of the cord was stated to be "a vain

and harmful procedure, as the added handling produces more injury. An

injured cord can be cleansed, but not restored."

l (1) Cushing, Harvey: Organization and Activities of the Neurological Service, American

Expeditionary Forces. In The Medical Department of the United States Army in the World War.

Washington: Government Printing Office, 1927, vol. XI, pt. 1, pp. 749-758. (2) Hanson, Adolph

M • Management of Gunshot Wounds of the Head and Neck in Forward Hospitals, A.E.F. In The

Medical Department of the United States Army in the World War. Washington: Government

Printing Office, 1927, vol. XI, pt. 1, pp. 776-794.
NEUROSURGERY

The management of the bladder was never made a subject of specific

instructions, and it was never decided whether intermittent catheterization

or merely allowing the bladder to fill and overflow by dribbling was the

better policy. The principal objective was to avoid infection, and from this

standpoint there was something to be said for each of these plans. On the

whole, the "let alone" policy was most favored in evacuation hospitals.

The sad record of spinal cord injuries in World War I can best be

summed up in a paragraph from the official history which reads as follows:

* * * Many of these cases undoubtedly died soon after their evacuation to the rear.

It was rather common to have men with spinal cord injuries arrive dead or dying.

Injuries of the spine, perhaps, formed a much larger group than those computed from

hospital records would lead one to think, as the serious wounds involving the chest and

abdomen in which death occurred at the front, were undoubtedly in many instances,

complicated by spinal injuries.
CHAPTER II

The Zone of Interior

Barnes Woodhall, M.D.

EVOLUTION OF POLICIES

Although during the prewar years civilian neurosurgeons had had some

hopeful experiences in the treatment of paraplegia, it is lamentably true

that, during the early months of World War II, both casualties arriving

from overseas and those who had suffered their injuries in the Zone of

Interior had very little encouragement offered them. Two factors were responsible. The first was the feeling of hopelessness inherited from World

War I. The second was the administrative policy that these patients should

be passed through the Army general hospital system as rapidly as possible

and then discharged to the VA (Veterans' Administration) as inevitable

casualties of the war. There was a strong feeling among some of the officers

who had recently entered the Medical Corps from civilian practice that this

admission of failure was not justified. It is significant that the changes

which eventually produced one of the most striking advances in medical

history were instigated by Col. (later Brig. Gen.) Fred W. Eankin, MC,

Chief Consultant in Surgery, Office of the Surgeon General.

The recommendations which General Eankin made to The Surgeon

General concerning the care of paraplegics were formally implemented in

Circular No. 25, Headquarters, Army Service Forces, 22 January 1945 (app.

A, p. 587). This circular specified (1) that paraplegic casualties should be

retained in the Army general hospital system until maximum benefit had

been achieved (p. 13), and (2) that they should not be transferred to the

jurisdiction of the VA until their progress appeared to have leveled off and

until it was unlikely that further substantial improvement would occur.

TB MED (War Department Technical Bulletin) 162 (app. B, p. 589)

was issued in May 1945, after the neurosurgical centers designated for the

care of paraplegics had assumed their responsibilities and had begun to

assemble the diverse professional talent necessary for the management of

these patients. The bulletin covered all phases of the new program. Its

objectives were outlined in the first paragraph. After the warning that a

defeatist attitude was intolerable in the care of patients with transverse

myelitis, it was pointed out that the majority of these men could lead a

wheelchair existence, at least; that many of them could be taught to walk
NEUROSURGERY

with braces and crutches; and that practically all of them could achieve

self-support by means of some sedentary occupation, which should be regarded as the ultimate objective of all rehabilitation. It was further emphasized that it was the mission of general hospitals in the Zone of Interior

to effect, before the final discharge of a paraplegic, a degree of rehabilitation

for him "essential for the preservation of morale and human dignity."

The major problems encountered in the management of patients with

traumatic paraplegia included the prevention of decubitus ulcers, the maintenance of a satisfactory nutritional status, the control of neurologic complications, the establishment of bladder function, and, as has just been

described, the achievement of rehabilitation, a term which covered a variety

of objectives. The management of these problems and the techniques of the

new program are described elsewhere in this volume (p. 127). They were all

at Newton D. Baker General Hospital, Martinsburg, W. Va., on 11-12 May

1945; at Hammond General Hospital, Modesto, Calif., on 24-25 June 1945;

and at Halloran General Hospital, Staten Island, N.Y., and Thomas M'.

England General Hospital, Atlantic City, N.J., on 19-20 October 1945.

PERSONNEL

Organization.—An efficiently operated paraplegic program required the

support of practically every section in the hospital. More important, however, than securing the formal support of the various services was securing

the understanding help and cooperation of everyone associated with the

patients in any way at all and particularly those in constant, intimate

association with them.

At the inception of the program in each hospital, it was found useful

to assemble the ward personnel, including nurses, nurses' aides, wardmasters,

and ward attendants, and explain to them in detail the objectives and techniques of the program. The explanations covered the methods employed in

the restoration of bladder and bowel function, the care of decubitus ulcers,

the importance of adequate nutrition, and the other clinical responsibilities

which ward personnel must assume. The explanation also included the

mental and somatic approach to these patients and the extreme importance

of the psychologic encouragement which those who cared for them could

best supply.

Conferences betAveen ward officers and ward personnel were held thereafter at regular intervals as well as when special problems arose. All personnel were made to feel that suggestions were welcome. Initiative was thus

fostered, and many helpful changes in treatment or additions to the regular

ward routines were introduced in this way.

Selection and training.—Unfortunately, trained personnel were always

in short supply. At an occasional hospital, as Col. Loyal Davis, MC, mentioned in a survey of paraplegic centers which he made early in 1945,
ZONE OF INTERIOR

medical officers, physical therapists, nurses, orderlies, and social service personnel were so numerous that "there was an average of 1 such person for

each patient throughout the 24 hours."

This was not generally true. For one thing, personnel assigned to the

care of paraplegic patients had to be of a very special type. For another,

as all chiefs of services lamented, constant changes of personnel could undo

a program which had been carefully planned and in which there had been

every reason to anticipate success. As Col. Rüssel H. Patterson, MC, said

in discussing this phase of the program at the Hammond conference on

transverse myelitis in June 1945—

One group of corpsmen is uninterested in this type of patient and would rather not

take care of them. Another mixed group is untrained and it would take too long to

train them to be the kind of attendants who should be assigned to this job. You cannot

take corpsmen who have been field sergeants at Guadalcanal and Okinawa and put them

on a ward to take care of any sick patient, let alone paraplegics. They don't fit. Also

if you have a corporal who does wonderful work with these cases supervised by a top

sergeant who knows nothing about them, this tends to break morale.

The same thoughts were expressed by other chiefs of paraplegic services

at this conference and at others. There was general agreement that the

professional and nonprofessional personnel assigned to these wards must be

a select group, intelligent, well trained, and, above all, enthusiastic and interested. At the Hammond conference, there was serious discussion of the

possible necessity of establishing a school at some one of the paraplegic

centers for the training of personnel for this special work.

As Lt. Col. (later Col.) Ambrose H. Storck, MC, saw the problem, it

was one that would continue for many years. Work with these patients

could be done only by physicians who were genuinely interested and who

were willing to devote years of their lives to it. Even the reconditioning

and physical therapy requirements of this group differed from those of

"run-of-the-mill, short-term, less serious cases." Educational and vocational

planning and training must be on a long-term basis.

The end of the war in the Pacific and the transfer of paraplegic patients to the VA within the following months (p. 13) relieved the Army of

the responsibility for these patients. Otherwise, the increasing necessities of

the paraplegic program would probably have required the setting up of

such a training center as had been proposed and the recruitment of a greatly

increased number of personnel with special qualifications to staff the centers.

The efficient use of personnel required that nurses, nurses' aides, aidmen,

and civilian personnel must not only understand the program and its purposes but also must understand their own duties. When WAC's were first

assigned to the program in early 1945, they served competently, but in the

beginning there was considerable confusion because their duties and their

hours of work were not clearly specified by regulations. As Colonel Patterson said at the Hammond conference—
ö NEURO SURGERY

When WAG's began to replace corpsmen, the question arose as to how long they were

to work. The answer was 8 hours, the same as nurses. When you mentioned it to the

top sergeant, he said 12 hours, the same as corpsmen. It was some time before we got

all of this straight at Bushnell. Paraplegic wards are complicated, and things like this

cannot be left to chance.

Colonel Patterson, as well as others, also mentioned the effect on military

morale of the wages paid to civilian employees, sometimes more than twice

as much as WAC's and aidmen were receiving. Also under discussion was

the effect of blanket promotions of newly assigned personnel on individuals

who had given long and faithful service and who did not receive promotions.

In spite of the personnel difficulties which beset the paraplegic program

throughout the war and, indeed, as long as the Army was responsible for

it, the care which these patients received was of the highest type. It was

not only technically competent. It was also truly devoted.

SUPPLIES AND EQUIPMENT

Supplies in paraplegic centers were sometimes slow in arriving, but, on

the whole, they were excellent, efficient, and adequate. Because of the special

necessities of these patients, many of the items required for their care were

not in the supply catalog and had to be purchased as nonstandard items.

How rapidly the supplies could be secured depended chiefly upon the understanding and cooperation of the hospital commanders, most of whom were

sympathetic and helpful. In a surprising number of cases, lack of formal

equipment and temporary shortages were overcome by the ingenuity of professional and nonprofessional personnel, who devised ingenious substitutes.

To the end of the war, there was no general agreement on the type of

bed best for paraplegics. A hard bed, a bed with inner springs, and an air

mattress were all used with varying degrees of success.

Air conditioning was almost essential in the management of paraplegics

but was difficult to accomplish during wartime conditions. In May 1945,

General Bankin called this fact to the attention of the director of the Hospital Division, Office of the Surgeon General, and recommended that steps

be taken at once to provide it for the 20 paraplegic centers then in operation.

If this was impossible, he recommended that separate units be installed in

the paraplegic wards. If air conditioning could not be accomplished immediately by a general system or by local units, he recommended that first

priority be given to hospitals located in portions of the country in which

the summers were uncomfortably warm. As the result of this recommendation, air conditioning was installed in the paraplegic ward of Newton D.

Baker General Hospital and certain other centers.

SURVEYS OF PARAPLEGIC CENTERS

Visits to the various paraplegic centers by the Consultant in Neurosurgery, Office of the Surgeon General, revealed conditions ranging from
ZONE OF INTERIOR

o-ood to superb. No neurosurgical condition encountered in World War II

was handled with more technical competence, skill, and understanding than

paraplegia, as is shown by the following (summarized) reports, which are

entirely typical.

Newton D. Baker General Hospital

A visit to Newton D. Baker General Hospital in September 1945 showed

that the physical environment for the care of paraplegics was almost ideal.

The ward, which was without partitions, was air conditioned. There were

special wards for officers and a number of small rooms in which seriously

ill patients could be cared for. The beds were arranged around the periphery

of the ward in colony style (fig. 1). All were equipped with Balkan frames

and exercise bars. There were specially constructed bedside tables for the

patients' personal belongings. Wheelchairs and walkers were in generous

supply, so that the patients could be kept out of bed for large parts of the

day (fig. 2). Ward officers had their own office. The treatment rooms were

well equipped with the special equipment necessary for paraplegics. Excellent diets were served attractively from a well-equipped kitchen.

In addition to the urologic problems, all competently handled by Capt.

(later Maj.) Boris P. Petroff, MC, chief of the urologic service, there were

three other main problems, as follows:

1. Deculitus ulcers.—Initial attempts at secondary closure of these ulcers

had been so successful that a plastic surgeon, Capt. (later Maj.) Donald E.

Barker, MC, was assigned to assist in the management of these cases. At

the time of the inspection, every ulcer had been closed by secondary suture,

by rotation of skin flaps, or by skin grafts. This was a monumental accomplishment. The protein deficit which played such an important part in

decubitus ulcers was fully appreciated, and dietetic and other measures were

entirely adequate.

2. Control of pain—-In many cases, this was a problem which was hard

to overcome. The chief measures employed were removal of retained foreign

bodies, excision of scar tissue from lesions in the cauda equina, and spinothalamic cordotomy.

3. Control of spastic reflexes.—These were attacked by all known methods, including nerve crushing, the administration of curare in a few cases,

and in three instances, anterior rhizotomy.

McCaw General Hospital

Wren the paraplegic center at McCaw General Hospital, Walla Walla,

Wash., was visited in September 1945, there were approximately 50 patients

in it, about 45 of whom had been treated by laminectomy overseas. The

ward setup was excellent, and practically all the equipment necessary for

the competent management of these patients had been provided, including

a full supply of Stryker frames. The only real lack was a swimming pool.
10 NEUROSURGBKY

p

"-ift *i->M

FIGUKE 1.—Colony type of paraplegia ward equipped with Balkan

frames and exercise bars and typical of wards in all World War II

paraplegia centers.

Most of the patients had had extensive decubitus ulcers on their arrival,

and many of the lesions had presented real problems of management. Treatment had consisted of elevation on the Stryker frame, the application of

zinc peroxide, and the usual general measures, including a high-protein

component in the diet. Surgery was resorted to as indicated. The possibility of a secondary breakdown after the healing of extensive lesions was

fully appreciated, and, when healing had occurred spontaneously, it was the

rule to excise scars and perform sliding or undermining operations, to provide soft-tissue coverage for bony prominences. The stamp type of Thiersch's

graft proved most satisfactory for this purpose.

Pain and spasm were usually controlled by standard measures, but

curare in various preparations had been used in seven cases, in all of which

spasm was particularly troublesome. Belief was of varying duration. In

one instance it had lasted for 72 hours. Even when it lasted no longer than

6 or 7 hours, however, this interval provided an opportunity for physical

therapy, which could not be employed when spasticity was continuous. Attempts to develop an oil solution or a suspension, in order to prolong the

action of the curare, had not been successful. The best response to this

measure was observed in patients who had the most pain associated with

spasm. In one or two cases in which the dosage of curare had not been

sufficient to relax spasm notably, the relief of pain was quite pronounced.

With the enthusiastic cooperation of the orthopedic service, ambulation

was accomplished in most patients. Braces were fitted as necessary. Mass

sports, which were part of the reconditioning program, provided wholesome

recreation.
ZONE OF INTERIOR 11

FIGURE 2 —Wheechair mess for paraplegic patients in advanced

reconditioning group.

At this paraplegic center, there was a particularly praiseworthy attempt

to train the patients for future life. A number undertook courses at

Whitman College, Walla Walla, Wash., which was adjacent to the hospital,

or continued their previous scholastic training there. One soldier who had

been taking law before he entered the Army resumed his legal training.

Occupational therapy was directed to practical ends. It included typing,

watch repairing, key making, and other useful occupations.

As at all centers, the warm interest of the medical officers and other

personnel in their patients had much to do with this highly successful

program.

CAUSES OF DEATH

In spite of the serious condition of many paraplegics, fatalities in

paraplegic centers were remarkably few. Most of them were attributable to

urinary tract infection or its complications.

The report of six necropsies at the paraplegic center at Nichols General

Hospital, Louisville, Ky., by Capt. (later Maj.) Henry Rappaport, MC, may

be assumed to be typical. In these six cases, infection of the urinary tract

or complications of the infection were responsible for five of the deaths.

In the sixth case, death was caused by complications of a deep sacral decubitus ulcer.

There was a certain common pattern in these six cases. All the patients

were extremely emaciated. All had severe secondary anemia. Every post

mortem examination revealed a type of inflammation which had spread by
12 NEUROSURGERY

direct extension, without respect for such anatomic barriers as fascia, periosteum, or the serosal membranes or the capsules of viscera. The appearance

of the inflammation strongly suggested a pronounced decrease of general

and local resistance to infection. The lack of resistance was further evidenced

by the type of organisms found in three cases, in Avhich pure cultures of

gram-negative bacilli were recovered from blood taken at autopsy. The

same organisms were also found in the local lesions. In spite of the usual

low pathogenicity of the organisms of the coli-aerogenes group, these organisms were apparently able to cause continued suppuration and septicemia

in these debilitated patients.

Previous studies had shown that resistance to infection is considerably

decreased in hypoproteinemia and that, once infection develops, the regeneration of blood protein is much more difficult. In all of these fatal

cases, anorexia was pronounced, and the food intake was entirely inadequate.

Captain Rappaport therefore suggested that the type of inflammation found

in these necropsies was chiefly due to lack of resistance, particularly lack of

tissue resistance, caused by severe protein depletion of the tissues. He cited

the work of Elman and others to the effect that the reduction of tissue

protein is always more severe than is indicated by the plasma protein

values (p. 147).

The findings in these six cases suggested a causal relation between the

degree of protein deficiency and the extent and severity of the inflammatory

process. Captain Rappaport's suggestion was that a vicious circle was thus

established, whereby hypoproteinemia decreases resistance to infection, and,

once infection develops, the regeneration of body proteins becomes more

difficult, and a fatality may result.1

i Editor's Note : Dr. Harry Kessler wrote an article entitled "Traumatic Paraplegia, Rationale

of Therapy" which was published in the Annals of Internal Medicine, volume 40, pp. 905-923, May

1954. According to Kessler, writing from the central office of the VÄ in Washington, D.C., 2 949

patients with traumatic paraplegia (including quadriplegics) were admitted to hospitals 'of' the

VA system between 1 Jan. 1946 and 31 Dec. 1950. In this group, there were 226 deaths- 102

occurred in 1946, 31 in 1947, 46 in 1948, 24 in 1949, and 23 in 1950. It was cautiously concluded

that after the first year of his disability, the paraplegic, having come safely through the initial

period of spinal shock, has a better chance for survival. This report does not specify causes of

death, but Kessler was impressed with the frequency with which renal insufficiency appeared as

a precursor of the fatality. The extensive amyloidosis also apparent in some of these fatal cases

was not surprising, since the life of the paraplegic is punctuated by recurrent bouts of infection

and malnutrition.

Later (in September 1955), a survey was made of the 5,743 patients treated in VA hospitals

between 1 Jan. 1946 and 30 Sept. 1955 for traumatic injury of the spine resulting in paraplegia

or quadriplegia. It revealed that 590 paraplegic and 212 quadriplegic patients had died at some

time after their first episode of treatment in these hospitals.

When the survival experience was studied in relation to age, taking into consideration the time

elapsed between injury and the beginning of treatment in a VA hospital, it was found that the age

at the time of injury was an extremely important factor. Younger patients, whether their injuries

caused paraplegia or quadriplegia, had a better chance of survival. As might have been expected,

the paraplegic patient was found, in general, to have a better chance of survival than the quadriplegic. It was interesting to observe, however, that quadriplegics with partial lesions who were

under 25 years of age at the time of injury had about the same survival experience as the paraplegic with a partial lesion in the same age group. The 10-year survival experience of both paraplegics and quadriplegics showed a decrease in the percentage of survivors as the age of the patients

increased.

It is still not possible to determine whether the paraplegic or quadriplegic patient has a different mortality experience from that of the nonparaplegic veteran of similar age, but, by use of the
ZONE OF INTERIOR 13

TRANSFER OF THE PARAPLEGIC PROGRAM TO THE

VETERANS' ADMINISTRATION

Early Planning—1945

The policy set up in World War II that no patients should be discharged

from Army hospitals to the care of the VA until they had received maximum

hospitalization benefits introduced difficulties of interpretation in a number

of conditions, one of which was transverse myelitis. Army Service Forces

Circular No. 25, 22 January 1945 (app. A, p. 587) attempted to clarify the

requirement, as follows:

1. Wounds and pressure sores should be completely healed and no

further surgery should be anticipated.

2. Every attempt should have been made to establish an automatic

bladder, eliminate bladder infection, and establish satisfactory bowel function.

3. Every effort should have been made to achieve restoration of muscular

function in lower extremities by physical therapy, braces, crutches, and other

devices such as walkers.

4. Patients should be discharged to the jurisdiction of the VA only when

these requirements had been met as far as possible, when progress had leveled

off, and when no further substantial improvement could be anticipated.

On a number of occasions during the first part of 1945, The Surgeon

General further clarified the interpretation of maximum hospital benefits

by stating that patients with paraplegia who gave any promise of continuing

improvement should be retained in Army hospitals until no further substantial improvement could be expected.

At the paraplegic conferences held while the Avar was in progress, there

was considerable discussion about the future management of these patients.

Many of the medical officers who were caring for them envisaged paraplegic

centers especially built as well as especially equipped and staffed. The

discussions covered the location (in a temperate climate, within reasonable

proximity to an industrial center as well as near medical and educational

facilities) ; the type of building (one story, close to the ground or with

adequate elevators); specialized professional personnel (in neurosurgery,

urologic and orthopedic surgery, general surgery, and internal medicine);

other personnel (in sufficient numbers and qualitatively recruited); physical

1940-51 life tables for the white male population of the united States, certain observations were

possible. The differential mortality increased with advancing age. For example, for every 100

study patients under 25 years of age at the onset of the injury, 84 percent survived for 10 years,

as contrasted to an estimate of 98 percent for the general population of comparable age. The

differential, or added, risk of death is therefore 14 percent at the end of 10 years. This differential

was found to be 18 percent for paraplegics in the 25- to 34-year group, 24 percent in the next

decade, and 40 percent in the 45- to 59-year group. The mortality experience for quadriplegics was

similar except that the differentials were larger than those observed for paraplegics.

The VA has under consideration the preparation of a book covering all aspects of spinal cord

injury. Such a volume would be a fitting complement to the wartime experience, emanating, as^ it

would, from hospitals which have acquired a significant experience in the handling of patients with

this disability.—B. W.
14 NEUROSURGERY

reconditioning (requiring special personnel, special facilities, and braceshops) ; and research. The clue to the successful operation of such a center

would be its personnel, persons with interest in, and appreciation of, the

problems of the paraplegic, centering from the sympathetic, imaginative, and

understanding direction of the commanding officer.

By V-J Day, it had become clear that paraplegics then in Army hospitals were to become the responsibility of the VA. Numerous conferences

were held, participated in by the neurosurgical consultants, representatives

of the Hospital Division and other divisions of the Office of the Surgeon

General, and representatives of the VA.

At a conference of surgeons of the service commands on 27-29 September

1945, which was also attended by Maj. Gen. Paul R. Hawley, USA (ret.),

newly appointed medical director of the VA, it was agreed that an effort

would be made to concentrate all paraplegic patients into five Army hospitals and that the VA would take over these hospitals, thus insuring that

there would be no break in the operation of the program.

The hospitals selected (Birmingham General Hospital, Van Nuys, Calif.,

Vaughan General Hospital, Hines, 111., dishing General Hospital, Framingham, Mass., McGuire General Hospital, Eichmond, Va., and Kennedy General

Hospital, Memphis, Tenn.) were all near large cities in various sections of the

country, which would guarantee a continuance of the same high type of

medical care and the same industrial and educational facilities Avhich the

paraplegic program had previously offered. The plan was that, as the

hospitals in which they were then being cared for closed, the patients would

be placed in the hospitals nearest their homes. All of the details of this

planning appeared in Circular No. 440, Headquarters, Army Service Forces,

10 December 1945, which also contained a very detailed account of the

purposes and techniques of the paraplegic program.

Survey of Paraplegic Patients

On 10 December 1945, the Office of the Adjutant General, Headquarters,

Army Service Forces, issued instructions to the 19 general hospitals in the

Zone of Interior in which paraplegic patients were then concentrated for

a survey and comprehensive evaluation of these patients.2 A detailed questionnaire was attached, to be filled in for each patient hospitalized as of

15 December 1945. The survey was carried out by the Surgical and Neuropsychiatric Consultants Divisions, the Medical Statistics Division, and the

Resources Analysis Division, Office of the Surgeon General.

The reasons stated for the survey were as follows:

1. The cessation of hostilities presaged a reduction and consolidation in

the Army hospitalization system.

2 Memorandum, Maj. Gen. Edward F. Witsell, Acting The Adjutant General, to commanding

officers of general hospitals designated as neurosurgical centers, 10 Dec. 1945, subject: Survey ot

Paraplegia Patients.
ZONE OF INTERIOR 15

2. An effective demobilization program had to take into consideration

the requirements not only of the Army but also of the VA.

3. The exceptional success of the Army paraplegic program made it

essential to continue it with minimum disturbance, although there was full

recognition that the care of chronically ill patients was a responsibility of

the VA.

4. In spite of the great success of the Army in caring for paraplegic

patients, it was recognized that the long-term program could be further

improved if additional information could be obtained concerning the present

and prospective status of those who were still hospitalized.

Data secured.—Questionnaires were returned from 17 of the 19 paraplegic

centers to which they were sent. DeWitt General Hospital, Auburn, Calif.,

and McCaw General Hospital, which were on the point of closing, did not

participate in the survey. As of 15 December 1945, the date set for the

study, there were approximately 1,500 paraplegics in Army hospitals. The

smallest number of patients (5) were in Letterman General Hospital, San

Francisco, Calif., and the largest number (139) in Kennedy General Hospital. There were more than 100 paraplegics in each of six other hospitals.

On 5 February 1946, a summarized report of the survey3produced

the following information and predictions:

As of 15 December 1945, 63 paraplegics had reached maximum improvement. Four of these would have to continue to receive institutional care,

but 41 could be discharged to their own care and 18 to their homes if they

could be cared for in them.

Exclusive of these 63 patients and 27 others for whom classification was

not possible, 1,389 had not yet reached maximum improvement (table 1).

Of this number, it was expected that 739 (more than 50 percent), would

have reached maximum improvement by 30 June 1946 and 512 others by

the end of the year. This left 138 patients (10 percent), who would not

reach maximum improvement until after 31 December 1946.

Of the 1,389 paraplegics still to receive maximum improvement, 440

(about 30 percent), could be discharged to their own care, and 949 would

require continued care indefinitely. About two-thirds of this group could

receive such care in their homes if it could be provided; 348 would always

require hospitalization.

On the assumption that the VA could accept all the patients transferred

to it, there would remain, as of 1 July 1946, 650 paraplegics in Army hospitals. If the VA could not accept any patients, there would remain under

Army care 715 patients if only those requiring institutional care were considered and almost 1,000 if those who required continued care indefinitely

were taken into account.

At the time of the survey, 55 percent of the patients were classified

as completely paralyzed. Medical officers were uncertain about the degree

3 Memorandum for Maj. Gen. Raymond W. Bliss from Eli Ginzberg, Director, Resources Analysis

Division, Office of the Surgeon General, 5 Feb. 1946, subject: Paraplegic Patients.
16 NEÜROSURGERY

TABLE 1.—Report on status and probable disposition of paraplegia patients remaining as of

15 December 1945

Total Discharge

to own care

Will require continued care

indefinitely

Status

Total

Can be

discharged

to home

Will remain for

institutional care

Patients who have achieved maximum

improvement ' _ _____

2

90

1, 389

41

440

22

949

18

601

4

Patients who require further surgery or

therapy _ 348

Total 2

1, 479 481 971 619 352

Estimated time of maximum improvement:

Prior to 31 Deo. 1945 35

231

473

356

156

138

5

133

191

48

43

20

30

98

282

308

113

118

0

41

208

230

66

56

30

1 Jan. 1946-31 Mar. 1946

1 Apr. 1946-30 June 1946

57

74

1 July 1946-30 Sept. 1946

1 Oct. 1946-31 Dec. 1946

After 31 Dec. 1946

78

47

62

• As defined in sec. II, Army Service Forces Circular No. 25, 22 Jan. 1945.

2

Includes 27 patients not classified.

of ambulation likely to be achieved by the total group but ventured the

opinion that about 4 of every 10 men would be permanently nonambulatory.

They were willing to estimate that 71 percent of the entire group would have

full use of their remaining extremities and that about 16 percent would

have partial use of them.

It was estimated that approximately a quarter of the patients would

have a work tolerance of 6 hours daily or less, that an additional 25 percent

could work 6 to 8 hours, that about a third could work more than 8 hours but

less than 12 hours, and that about a sixth would have work tolerances

ranging to 13 or more hours per day. On the other hand, only 38 percent

of the completely paralyzed patients would have a work tolerance in excess

of 8 hours, compared to 63 percent of the incompletely paralyzed group.

Of the 1,399 patients for whom detailed questionnaires were returned,

it was estimated that 472 could probably be discharged to their own care,

612 to their homes if care could be provided in them, and 293 to institutions.

In 22 cases, no prognosis was possible.

Apparently medical officers took into consideration the ability of the

family to care for the patient when predicting the final disposition of these

men, although it was not the sole consideration. It was recommended that,

90 patients whose families could not care for them should be discharged to

home care or their own care, the disposition probably being predicated on the
ZONE OF INTERIOR 17

professional conviction that, from the emotional standpoint, these patients

would do better at home. Smaller percentages of the euphoric and depressed

groups would be discharged to their own care.

A higher percentage of less well educated patients would probably be

institutionalized. This fact, it was thought, might indicate a greater degree

of adaptability on the part of those with more education or merely the

superior economic status of the family, which was, of course, correlated with

the amount of schooling the patients had received. Only a small percentage

of students were likely to be hospitalized, while the farmer and clerk groups

would have a higher than average percentage in this category.

Fifty-seven percent of the families stated that they could care for the

patients; fourteen percent could not. In the remaining cases, this possibility

had either not been investigated or was not specified. Fourteen percent of

the patients had had no visits from their families during their hospitalization

and had not visited them; 18 percent had less than one visit per month,

23 percent one or two visits, and 27 percent four visits or more. In 14 percent, the number of visits was not specified, and in 2 percent there was no

information on this point. In 2 percent of the cases, the patients had gone

home on furlough but had had no visits from their families.

There was no correlation between the ability of the family to care for

the patient and the number of visits paid him per month; it was thought

reasonable to expect more frequent visits on the part of the wealthier families.

Later Preparations for Transfer of Patients—1946

Plans for necessary alterations of the five proposed paraplegic centers

to be transferred to the VA were drawn up by the Hospital Construction

Branch, Office of the Surgeon General. The necessary physical changes included air conditioning, covered passages between buildings, numerous ramped

exits, and other special construction required for the care of paraplegics with

their peculiar needs. These plans were reviewed and approved by representatives of the VA.

The problem of personnel loomed large from the first. In January

1946, The Surgeon General had pointed out to General Hawley that it was

imperative that the paraplegic program continue without interruption and

that the transfer in status from Army to VA control be accomplished with

the least possible difficulty. He suggested that representatives from the VA

visit the hospitals to be transferred, with the idea of studying the treatment

programs and recruiting necessary civilian personnel. He also suggested

that it would be highly desirable that the transfer be accomplished gradually, so that, as the Army patient load declined, the VA might take over

certain wards and buildings progressively, building up its staff as the transfers continued and eventually assuming operation of the entire hospital.

As the result of this suggestion, The Adjutant General, in February

1946, authorized the placing of VA personnel in Army hospitals which were
18 NEUROSURGERY

closing and also authorized the gradual transfer of portions of the hospital

as The Surgeon General had directed. Arrangements were made for feeding

of VA patients by Army messes during the phasing-out periods.

In March 1946, after it became evident that the civilian personnel employed by the VA did not fully understand the nature and techniques of the

paraplegic program, a number of officers and enlisted men from the Sixth

Service Command were detailed to the paraplegic center at Vaughan General

Hospital to assist VA personnel until civilians could take over the program

entirely. Similar arrangements were made in the Third Service Command at

McGuire General Hospital. Close contact was maintained by the VA with

the Personnel Division, Office of the Surgeon General, and physiotherapists

and other qualified personnel were employed by the VA hospitals as the Army

hospitals closed down.

In February 1946, representatives of the Office of the Surgeon General

attended a meeting at the VA at which there was a briefing of the officers of

the VA scheduled to go into the hospitals this organization was taking over.

Final Transfer of Program

The VA assumed control of Vaughan, Birmingham, and McGuire General Hospitals 31 March 1946 and of Kennedy General Hospital 30 June

1946. Cushing General Hospital passed into VA control 30 September 1946.

By the time Army control of these hospitals ended, almost all of the approximately 1,500 patients in 19 Army hospitals in December 1945 had been

brought together into these 5 hospitals.

At the end of December 1946, there were still 53 paraplegics in the Army

hospital system; 28 of these were at Percy Jones General Hospital, Battle

Creek, Mich., and were to remain there until necessary plastic surgery had

been completed. There were 4 each at Brooke General Hospital, Fort Sam

Houston, Tex., and McCornack General Hospital, Pasadena, Calif., 2 each

at Oliver General Hospital, Augusta, Ga., and Pratt General Hospital, Coral

Gables, Fla., 1 at the Army and Navy General Hospital, Hot Springs, Ark.,

1 at Fitzsimons General Hospital, Denver, Colo., and 11 at Walter Reed

General Hospital, Washington, D.C. These few patients were still receiving

necessary professional care before their final disposition. The transfer of

all the others from the Army hospital system to the VA system had been

effected expeditiously and without interruption of the planned paraplegic

program.

The neurosurgical procedures required by the patients still in Army

hospitals in December 1945 included 33 operations for pain and 61 for muscle

spasm. Of 432 patients who still had decubitus ulcers, 179 would need

surgery. Further treatment to achieve bladder control compatible with the

existing cord lesion was required in 298 patients, and 52 required treatment

for infection, stone, and other urinary tract complications.
CHAPTER III

The Mediterranean (Formerly North African)

Theater of Operations

Eldridge H. Campbell, Jr., M.D.1

INCIDENCE

Detailed information concerning deaths from battle wounds which occurred in Fifth U.S. Army hospitals in Italy during 1944 and 1945 is

available in the 1,450 fatalities analyzed in the massive study carried out

by Maj. (later Col.) Howard E. Snyder, MC, and Capt. (later Maj.) James

W. Culbertson, MC.2This analysis showed that injuries of the spine accounted for 0.94 percent of all battle casualties treated in these hospitals

during this period of time and for 1.9 percent of the 1,450 fatalities. This

is in contrast to all wounds of the chest and abdomen, which together accounted for 13.6 percent of all Fifth U.S. Army battle-casualty admissions

and for 52.2 percent of the 1,450 fatalities.

In another survey, Capt. Wolfgang W. Klemperer, MC, found that, in

a series of 115 missile injuries of the spinal cord, injuries of the chest, abdomen, or both were present in 19 of 82 injuries of the cervicothoracic cord

and in 11 of 33 injuries of the lumbosacral cord.3Thoracic injuries (18 cases)

predominated in the injuries of the cervicothoracic cord and abdominal or

thoracoabdominal (10 cases) in the injuries of the lumbosacral cord.

The bullet was retained in the spinal canal (figs. 3 and 4) in 4 of a

series of 68 cord injuries studied by Capt. William B. Weary, MC, and in

59 of a (second) series of 201 cases studied by Captain Klemperer. The

apparent discrepancy between the two series is easily explained; most of

Captain Klemperers cases were observed in forward hospitals before operation and most of Captain Weary's in rear hospitals after initial surgery.

Paralysis was complete in 27 of the 59 cases in which the missile was re1A consultant in neurosurgery was never formally appointed in the Mediterranean theater.

When the need arose, Dr. Campbell, then a lieutenant colonel in the Medical Corps, represented the

consultant in surgery to the Theater Surgeon. Gaps in this chapter are due to this fact; they

could not be overcome because of Dr. Campbell's death while the history was in preparation.

2 Snyder, Howard E., and Culbertson, James W.: Study of Fifth Army Hospital Battle Casualty

Deaths. An Analysis of Case Reports From Field and Evacuation Hospitals on 1,450 Fatally

Wounded American Soldiers. A Preliminary Report, in three volumes. Gardone Riviera, Italy,

September 1945. [Official record.]

3 Klemperer, W. W. : Statistical Report on Spinal Cord Injuries. M. Bull. North African Theat.

Op. 1 : 12-15, March 1944.

19
20 XEUROSURGERY

FIGURE 3.—Roentgenograms showing shell fragment wound of spinal

canal with paraplegia. A. Anteroposterior view showing irregular shell

fragment at level of third lumbar vertebra. B. Lateral view showing

shell fragment within dural canal.

tained in Captain Klemperer's cases, in comparison with complete paralysis

in 65 of the 104 cases in which the missile was definitely stated to have come

to rest outside of the canal. Complete paralysis was also more frequent in

the 94 thoracic and 47 cervical injuries than in injuries of other zones.

There were only 17 instances of complete paralysis in the 55 lumbar injuries

and none in the 5 sacral injuries. Variations in relative size, fixation, and

vulnerability of tissues to trauma probably account for these differences.

SURGICAL POLICIES

In the Tunisian campaign of 1942-43, the policy of management of

injuries of the spine was one of great conservatism. This attitude, which

was derived from previous civilian experience with similar injuries, continued throughout the Mediterranean campaign as far as fracture-dislocations

of the closed type were concerned. It was, however, considerably liberalized

for missile injuries. Anatomic disruption of the cord proved extremely

difficult to predict solely on the basis of neurologic or roentgenologic examination. While the great majority of patients with immediate and complete

paralyses could be expected to recover little if any function after operation,

there were numerous exceptions. For this reason, if the patient's general

condition were satisfactory and if other high-priority casualties with better

chances of recovery were not thereby denied operation, debridement and

laminectomy were performed even in apparently hopeless cases.

In general, there were two reasons for attempting decompression of the

cord: (1) The necessity for debridement of the wound, which was just as

valid in this region as anywhere else in the body, and (2) an attempt to
MEDITERRANEAN THEATER 21

FIGURE 4.—Roentgenograms showing bullet wound of spinal canal with

paraplegia. A. Anteroposterior projection showing rifle bullet at level

of second lumbar vertebra. B. Lateral view showing rifle bullet within

dural canal.

relieve pressure upon the cord. Debridement was regarded as particularly

essential if the wound of entrance or of exit was in the back. The danger

of infection was not so great if the missile had penetrated the spinal canal

from in front, though effective reparative surgery was then much more

difficult. Failure to debride or to close wounds of the lumbar and sacral

areas was always likely to lead to complications.

Persistent cardiorespiratory imbalance was regarded as a clear contraindication to laminectomy. Injuries of the chest and abdomen and major

injuries of the extremities usually demanded priority of surgery because they

presented a risk to life which the wound of the spine, for the moment, did

not. Thoracic injuries carried a particular hazard when the respiratory muscles were weakened or paralyzed, and in at least one instance death is known

to have occurred from tension pneumothorax because all the attention was

concentrated on the spinal cord injury.

The best results were achieved when debridement and laminectomy could

be performed within 24 hours of wounding. When concomitant wounds

were present, a double major operation was usually more than a recently

wounded casualty could tolerate, and debridement and exploration of the

spinal wound therefore had to be deferred until some recovery from the

first procedure had taken place. Improvement was the rule if debridement

was done for a missile wound of the spinal column which had caused only

partial paralysis, particularly if there was pressure on the cord or if a

foreign body had entered the canal. Even partial recovery was most unusual if paralysis had been immediate and complete.
22 NEUROSURGERY

DECUBITUS ULCERS

The prevention and treatment of decubitus ulcers in patients with

spinal cord injuries was a serious nursing problem. A paraplegic patient

left without attention for only a few hours inevitably developed pressure

sores. Because of delays in evacuation, many paraplegics arrived at general

hospitals with pressure sores already present. Once they had been hospitalized, the development of decubitus ulcers was the exception, though

the record was achieved only by unremitting care. An instance of what

such good nursing can accomplish is the record of the neurosurgical center

at the 33d General Hospital, in which only one bedsore developed after

admission in approximately 200 paraplegic patients.

MANAGEMENT OF THE CORD BLADDER

Suprapubic cystostomy was found to be the most satisfactory method

of managing the cord bladder when the care of the paraplegic patient had

to be carried out by any but the most experienced personnel. It was also

the most practical method in military hospitals during busy periods.

Tidal drainage was not used during the North African campaign because materials for it were not available in adequate quantities. Later, it

was found that this method w

Tas not practical under military circumstances,

partly because of the risk of leakage of air into the system and partly

because the frequent turning of the patients, which was necessary to prevent

bedsores, entailed constant readjustment of the apparatus and was prohibitively time consuming.

Urologie complications were fortunately uncommon. Sulfadiazine and

penicillin were not employed prophylactically, although many patients received sulfadiazine for other reasons. The deliberate use of these agents in

urinary tract complications was reserved for the treatment of acute infections.

HOSPITAL MANAGEMENT

Good nursing care of paraplegic patients proved, as always, to be

requisite for optimal convalescence. All departments of the hospital cooperated in the treatment of paraplegic patients. The genitourinary division

was responsible for the care of suprapubic cystostomies, indwelling catheters,

and bladder irrigations. The orthopedic division made the plaster shells

for immobilization when they were indicated and prepared the splints used

as a preventive or corrective measure in footdrop. Physiotherapists carried

out active and passive exercise to maintain joint function and assisted in

light (infrared) treatment of decubitus ulcers.

Psychotherapy was an important phase of treatment in many cases and

was indirectly aided by the services of American Red Cross aides, who

provided occupational therapy, reading matter, and recreation. The general
MEDITERRANEAN THEATER 23

attitude of all who came into contact with the patients was expected to be

one of cheerfulness and optimism.

It was the practice, as far as possible, to make few changes in nurses

and aidmen assigned to paraplegic wards. More nursing hours were required

for patients with these injuries than for any other patients in the hospital.

Because of the general use of catheters, however, the amount of linen used

was actually less than on the acute surgical wards, on which patients were

frequently incontinent of both urine and feces.

EVACUATION

Evacuation from the point of wounding to the forward hospital was

found to entail certain hazards in missile wounds of the spinal column,

though these were possibly not as great as in closed injuries, in which loss

of bony stability was sometimes considerable. Immobilization of an injured

part, which was often necessary, had to be carried out with the greatest care.

If local pressure and ischemia were permitted to last more than a very few

hours, the basis of the development of bedsores could be laid quite as well

in this period as in any later period. Since plaster and splints were impractical at the division level, paraplegic patients were usually transported

on well-padded litters, braced by folded blankets and straps. Attempts at

extension, even by experienced surgeons, were not recommended until the

forward hospital was reached.

Evacuation from the base hospital to the Zone of Interior was also

fraught with hazard. Nursing care was frequently inadequate during long

journeys, and unpredictable delays might impose a great burden on the skin

or the bladder.

If paralysis was complete, and particularly if the cord injury was high,

patients seemed to travel more comfortably in well-made plaster halfshells.

They felt more secure, and, if the shells were properly molded and adequately padded, pressure was evenly distributed and pressure sores were

unlikely to develop. Plaster body casts were not advisable, if only because

they prevented inspection and care of the skin. If a plaster shell was used,

it was neither necessary nor desirable to keep the upper half in situ.

It was found to be a wise plan to instruct each patient, before departure,

concerning his own needs and particularly concerning the intervals at which

he should be turned, so that, if the precaution was omitted by the attendants,

he could make the necessity known.

49S991V—59-
CHAPTER IV

The European Theater of Operations

R. Glen Spurling, M.D.

SURGICAL POLICIES

Injuries to the spinal cord accounted for a considerably greater number

of neurosurgical casualties 1in the European theater than had been anticipated, some 12 percent in all. About half of the injuries were gunshot

wounds. In the other cases, spinal cord damage resulted from fractures or

fracture-dislocations of the vertebrae, some of which were caused by traffic

accidents. These injuries required a much greater proportion of the neurosurgeon's time and effort than the percentage might suggest. In about half

of all combat-incurred injuries, severe associated injuries, particularly wounds

of the chest and abdomen, made the care of these patients doubly difficult.

Neurosurgeons, at least early in the fighting in the European theater,

were not in agreement about the value of surgical exploration of spinal cord

injuries. The dictum that very few injuries of the spine in which the cord

was involved would be improved by operation had been carried over from

civilian practice into military practice, and for a time it seriously handicapped military neurosurgeons. As a matter of fact, the attempt to correlate

the two types of injuries was as fallacious as it was misleading. The

"broken back" of civilian practice is usually a lesion which affects the

vertebral body primarily (figs. 5 and 6). The major lesion in a gunshot

wound of the spine was likely to be in the vertebral arches (figs. 7 and 8).

Paraplegia proved the most distressing of all military neurosurgical

conditions and the most difficult to benefit. It was fully realized that in

only a very small proportion of these cases could surgery improve the

patient's lot, but it was also realized, with equal clarity, that in an occasional case, particularly the type of case in which the bony injury was limited to the vertebral arches, debridement of the spinal canal might occasionally result in dramatic improvement.

The policy was therefore formulated before D-day in the European

theater and was disseminated to all neurosurgeons that, whenever there was

reasonable doubt concerning the complete destruction of the spinal cord,

the patient should have the benefit of prompt exploration, particularly if

i Neurosurgical conditions were defined early in World War II as surgical lesions of the brain,

spinal cord, peripheral nerves, and sympathetic nervous system.

25
26 NEUROSURGERY

FIGURE 5.—Fracture-dislocation of fifth cervical vertebra on sixth in

accident involving military vehicle. A. Prereduction roentgenogram.

B. Roentgenogram after reduction and fusion.

FIGURE 0.—Lateral roentgenogram

showing mild crush fracture of third

lumbar vertebra with paraparesis.

The injury was sustained during a

jump from a military vehicle under

enemy fire. This illustration, like figure 5, is typical of the so-called civilian type vertebral injury seen in

military personnel.

there was evidence of subarachnoid block by the Queckenstedt test. Operation was to be done under local analgesia, on the litter on which the patient

had been transported, unless circumstances made it imperative to move him.

The dura was not to be opened in the absence of definite indications.

Eeports of 1,260 battle-incurred wounds of the spinal cord (table 2)

made to the Senior Consultant in Neurosurgery, Office of the Chief Surgeon,

by 25 neurosurgeons in the European theater showed that operation was

performed in 479 (38 percent). Most of these operations were performed

at the level of the evacuation hospital on the Continent or in general hospitals

in the United Kingdom. Whenever possible, the operation was done in a

general hospital.

In about 15 percent of all patients operated on, according to these reports, the plan of management just outlined resulted in striking improvement

within 48 hours after operation. Other benefits were also accomplished.

Spinal fluid leaks were eliminated by closure of defects in the dura. Root

pain was eliminated by the removal of bony chips and foreign bodies about

the posterior nerve roots. Another advantage was that the prognosis in the
EUROPEAN THEATER 27

FIGURE 7.—Roentgenogram showing large shell fragment wound of cauda equina, with disruption of lateral components of fourth and fifth lumbar vertebrae.

This injury was associated with a major abdominal

injury.

FIGUKE 8.—Roentgenograms showing traversing shell fragment wound

of spinal canal. A. Anterior projection. B. Lateral view of same wound

showing fragmentation of vertebral body.

individual case could be made with greater certainty after inspection of the

anatomic damage to the spinal cord.

Manual of Therapy.—Instructions concerning fractures of the spine with

neurologic involvement, as given in the Manual of Therapy,2 which was

prepared in the European theater before D-day, were chiefly concerned with

diagnosis of the injury and with the prevention of further trauma. High

priority of transportation to evacuation or general hospitals was indicated.

2 Manual of Therapy, Office of the Chief Surgeon, European Theater of Operations, U.S. Army,

5 May 1944. Appropriate sections published in Medical Department, United States Army Surgery

in World War II, Neurosurgery, Volume 1. Washington: U.S. Government Printing Office, 1958,

appendix B, p. 403.
28 NBUROSURGERY

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EUROPEAN THEATER 29

When the manual was revised at the close of the active campaign in

Europe, it was found that the only major changes necessary in the neurosurgical section concerned the transportation and care of paraplegics. Their

entire management had become considerably more aggressive. "te^

TRANSPORTATION

Originally, a choice was permitted in the method of transporting patients

with spinal injuries in the thoracic and lumbar regions, either the recumbent

or the prone position being used. Experience promptly showed that the

prone or semiprone position was far superior to the supine position. It

eliminated the necessity for a cast. The patient traveled more comfortably.

Finally, there was less chance of the development of decubitus ulcers. The

prone position was therefore used routinely during the closing months of

the fighting in Europe unless an associated thoracic or abdominal wound

contraindicated it.

When the needs of paraplegic patients were realized, air mattresses were

authorized for immediate delivery to all general hospitals in which such

care was given, and their addition to the permanent table of basic allowances for all 1,000-bed hospitals was also recommended. Approval was

obtained from the Theater Chief Surgeon for placing air mattresses, suitably

sized to fit army field cots, field ambulances, hospital trains, and air ambulances in all field and evacuation hospitals. Recommendations concerning

these mattresses were forwarded to Lt. Col. (later Col.) Augustus Crisler,

MC, Chief Consultant in Surgery, First U.S. Army, who was enthusiastic

in his support of the project. High priority for the procurement of these

mattresses in suitable numbers was obtained from Col. (later Maj. Gen.)

S. B. Hays, MC, Chief, Medical Supply, Office of the Chief Surgeon, Headquarters, European theater, and they proved extremely useful.

It was recommended that all hospitals designated for the care of neurosurgical patients order from the nearest supply depot an operating table

pad (item 7162800) for every patient with transverse myelitis and that an

adequate supply of these pads be kept on hand to meet these calls. These

pads fitted the army stretcher and facilitated the evacuation of paraplegic

patients to the Zone of Interior after they were made available.

Patients were usually transported with indwelling catheters, with clamps.

The attendants who accompanied them were instructed to open the clamps

and drain off the urine every 2 hours.

DECUBITUS ULCERS

Decubitus ulcers occurred in some paraplegics in spite of every effort to

prevent them. Preventive measures included strict local cleanliness, turning

of the patients at regular intervals, maintenance of a high-protein intake,

and systemic chemotherapy and antibiotic therapy. When ulcers developed,
30 NEUROSURGERY

these same measures were useful. The experience with applications of

plasma locally was not encouraging. Every effort was made to get these

patients into condition for evacuation, so that skin grafting could be accomplished in Zone of Interior hospitals. Most patients were ready for

evacuation within 90 days after wounding.

THE CORD BLADDER

It was originally believed that the cord bladder could be handled successfully by tidal drainage through an indwelling urethral catheter for a

period of 4 or 5 weeks. Experience proved that this method, which required

a great deal of care and attention, was not suitable for use in wartime on busy

wards filled with paraplegic patients. During the latter half of the European

campaign, therefore, high suprapubic cystostomy Avas resorted to at once in

all patients with complete physiologic loss of cord function. It was constantly stressed, however, that even though tidal drainage had proved impractical in the immediate postwounding period, this was because of the

circumstances and not because of any inherent defect in the method. Tidal

drainage was a very valuable and entirely practical method later, because

it helped to maintain bladder capacity after the wound had contracted

around the suprapubic tube.

In a series of 100 paraplegics observed at one Army hospital in the

European theater between D-clay and 30 November 1944, tidal drainage was

used in 65 cases. On an average of 20 days, 31 patients had had a return

of bladder function, 18 patients were still on drainage when the survey was

made, and 16 had required suprapubic cystostomy because there had been

no bladder recovery. Suprapubic cystostomy was clone primarily in the

remaining cases. In 6 of these 100 patients, the injury was cervical, in

45 thoracic, and in 49 lumbosacral. In 69 cases there were associated major

injuries, including wounds of the chest in 30 cases, intra-abdominal wounds

in 16 cases, and fractures in 23 cases. In spite of the difficulties of managing

patients who were so seriously wounded, no gross urinary tract infections had

occurred.
CHAPTER V

The Management of Acute Compound

Battle-Incurred Injuries of the Spinal Cord

Donald D. Matson, M.D.

HISTORICAL NOTE

A great deal of information concerning the symptoms and signs of

compound wounds of the spinal cord, as well as the pathologic processes in

these injuries, was accumulated during World War I, particularly by British

neurologists.1The interpretation of this material from the point of view

of therapy was, however, scanty and inconclusive. As Tinsley2noted, the

Medical Research Council of Great Britain, in its review of World War I

spinal cord injuries, recommended laminectomy only for incomplete lesions

with progressive signs of functional loss and stated that a physiologically

complete transection of 48 hours' duration was a contraindication to surgery

because of the hopeless prognosis. This review also claimed that the gravity

of the initial injury was not increased by the presence of a foreign body or

of indriven bone in the cord.

In reviewing experiences with injuries of the spinal cord in the U.S.

Army in World War I, Cushing3stated merely that most of these casualties

were evacuated to base hospitals for therapy and that only those patients

survived whose lesions were partial. When there was immediate complete

loss of sensation and motor power, only debridement of the external wound

was performed. Hanson4noted that Cushing reported 32 cases of spinal

cord injury with a case fatality rate of 71.8 percent; 24 of these patients

were operated on, with a case fatality rate of 62.5 percent.

In World War II, compound wounds of the cord were among the most

difficult and in many ways the most discouraging of all wounds to treat.

1 (1) Holmes, G.: I. The Pathology of Acute Spinal Injuries. Brit. M.J. 2: 769-774, 27 Nov.

1915. II. The Clinical Symptoms of Gunshot Injuries of the Spine. Brit. M.J. 2 : 815-821, 4 Dee.

1915. III. The Sensory Disturbances in Spinal Injuries. Brit. M.J. 2 : 855-861, 11 Dec. 1915.

(2) Discussion on Gunshot Wounds of the Spine. Brit. M.J. 1 : 451-452, 25 Mar. 1916.

2 Tinsley, M. : Compound Injuries of the Spinal Cord. J. Neurosurg. 3 : 306-309, July 1946.

3 Cushing, Harvey : Organization and Activities of the Neurological Service, American Expeditionary Forces. In The Medical Department of the United States Army in the World War. Washington : Government Printing Office, 1927, vol. XI, pt. 1, pp. 749-758.

4 Hanson, Adolph M.: Management of Gunshot Wounds of the Head and Neck in Forward

Hospitals, A.E.F. In 'The Medical Department of the United States Army in the World War.

Washington : Government Printing Office, 1927, vol. XI, pt. 1, pp. 776-794.

498991v—59 5

31
32 NEUEOSUEGEEY

On the other hand, the overall case fatality rate in patients reaching field

and evacuation hospitals alive was reduced to around 15 percent, and the

postoperative case fatality rate for early laminectomy was reduced to between 5 and 12 percent, according to Tinsley and others.5

. One can only

speculate how much preservation of function was accomplished by treatment

during the acute phase of injury.

Many factors were responsible for this reduction in mortality. The

most important of these were (1) the rapid evacuation of patients with

spinal cord injuries to general hospitals in the rear, where adequate specialized equipment and neurosurgical personnel were available, (2) the presence

in forward hospitals of trained surgeons capable of performing early

laminectomy on nontransportable patients with serious injuries, (3) routine

systemic chemotherapy and antibiotic therapy in the treatment of all compound wounds as well as the prophylactic use of these agents in the prevention of urinary and pulmonary complications, and (4) the general

availability in the forward areas of large quantities of blood for replacement therapy.

Because of the widespread confusion which prevailed regarding therapy

of spinal wounds in the acute stage, a historical account of their treatment

in World War II is a difficult task. In this chapter, however, an attempt

has been made to describe the pathologic processes of these injuries as seen

in their early stages, the clinical problems which they presented, and the

consensus with respect to early operative and supportive treatment. No

attempt has been made to discuss final results.

CLASSIFICATION OF COMPOUND INJURIES

OF THE SPINAL CORD

Injuries to the spinal cord produced by high-explosive missiles may be

divided into three etiologic groups, as follows:

1. Direct injuries due to missiles.—This group includes wounds produced by the passage of bullets or shell fragments directly into, or through,

the substance of the cord or the cauda equina. Division of structural continuity produced in this fashion was permanent, since no regeneration of

nervous tissue within the central nervous system can occur. If only partial

anatomic transection was brought about by such a direct injury, the adjacent

nervous elements might be spared both anatomically and physiologically,

or they might be spared anatomically and interrupted physiologically, either

temporarily or permanently. The damage produced directly to the cord

occurred in two ways: (1) By destruction at the moment the metallic foreign

5

(1) Haynes, W. G. : Acute War Wounds of the Spinal Cord. Analysis of 184 Cases. Am. J.

Surg. 72 : 424-433, September 1946. (2) Matson, D. D. : Treatment of Compound Spine Injuries

in Forward Army Hospitals. J. Neurosurg. 3: 114-119, March 1946. (3) Pool, J. L. : Gunshot

Wounds of the Spine ; Observations from an Evacuation Hospital. Surg. Gynec. & Obst. 81 : 617-

622, December 1945.
COMPOUND INJURIES OF THE SPINAL CORD 33

body struck, or (2) by subsequent compression of nervous tissue caused by

the presence of the foreign body in the spinal canal.

2. Indirect injuries produced by bone.—In this group are included

wounds in which a missile fractured the vertebra and caused depressed or

comminuted fragments of bone to lacerate the cord or protrude into the

spinal canal and compress the cord. In this group, as in the first group,

the damage might be produced either at the moment of injury or by subsequent pressure or movement of the bony fragments within the spinal canal.

3. Indirect injuries due to concussion.—This group includes wounds in

which a loss of neurologic function occurred after passage of a missile in the

vicinity of the spinal column but not through the canal itself. Presumably,

the impairment of function resulted from disturbance of neuronal cytoplasm

due to transmission of a pressure wave from the path of the missile.

From a mechanical point of view, direct compound spinal injuries can

be divided into three common varieties (fig. 9), as follows:

1. Ricocheting wounds, in which a missile struck the vertebral body or

neural arch, fractured it, and drove bone fragments into the canal but

bounced off into the soft tissues at an angle to the direction of entry. These

wounds had the most favorable prognosis of all.

2. Perforating wounds, in which a missile passed completely through

the spinal canal or a portion of it. These wounds almost invariably carried

a poor prognosis.

3. Penetrating wounds, in which a missile lodged in the spinal canal

itself or in the bony vertebra and protruded into the canal. These wounds

sometimes had a favorable prognosis after early operation.

As noted by Scarff,0the loss of neurologic function immediately after

direct compound spinal cord injury may be due, from a pathologic point

of view, to any one of the following factors or to a combination of them:

(1) Edema of the cord, (2) hemorrhage into or about the cord, (3) compression of the cord by bone fragments or foreign bodies, and (4) anatomic

section of the cord.

Unfortunately, in the acute phase of injury, the surgeon's efforts toward

restoration of function could be directed effectively toward only one of these

etiologic factors; namely, localized, extrinsic compression of the cord. There

is no need to discuss anatomic section of the cord except to reiterate that

this is a hopeless injury, since neuronal elements within the central nervous

system never regenerate. Edema of the cord was extremely common and

was often severe, but surgical treatment was not effective in it either unless

persistent extrinsic compression was a factor in producing it. There has

never been reliable evidence that the function of a swollen, contused cord

could be improved by operative removal of normal laminae or incision of

intact dura.

6 Scarff, J. E. : The Surgical Treatment of Injuries of the Brain, Spinal Cord, anfl Peripheral

Nerves. Surg. Gynec. & Obst. 81 : 405-424, October 1045.
34 NEURO SURGERY

FIGURE 9.—Common varieties of compound spinal wounds due to highexplosive missiles. A. Ricocheting wound. The metallic foreign body

has struck the spine and been deflected at an angle on the same side

as the wound of entry. B. Through-and-through wound. The metallic

foreign body has passed completely through the spinal canal to lie in

the soft tissues on the side opposite the wound of entry. C. Penetrating wound. The metallic foreign body lies impacted in the spine or

free within the spinal canal.

As to hemorrhage, it was extremely uncommon to find extradural,

subdural, or subarachnoid bleeding in any significant amount. Serious local

compression of the cord by hematoma was not seen.7 As pointed out by

Pilcher,8there is adequate space both inside and outside the dura for

longitudinal infiltration of extravasated blood. Intramedullary hemorrhage,

on the other hand, undoubtedly contributed to cord destruction, but, like

edema of the cord, it was not responsive to surgical treatment.

' See footnote 5, p. 32.

8 Pilcher, C. : Injuries of the Spinal Cord and Cauda Equina.

November 1942.

South. Surgeon 11 : 755-764,
COMPOUND INJURIES OF THE SPINAL CORD 35

It becomes apparent, therefore, that, except for the relief of compression

due to indriven bone fragments and foreign bodies, the efforts of the neurosurgeon in the early treatment of injuries of the spinal cord were limited

to (1) prophylaxis against infection, (2) relief of pain, and (3) the prevention of urinary, gastrointestinal, and skin complications.

FIRST AID TREATMENT

Almost without exception, patients with spinal cord injuries became

helpless immediately. Also, with rare exceptions, the maximum extent of

the paralysis occurred at the moment of injury. The casualty lay where he

was injured until he could be moved by litter. External wounds were

usually dressed on the field or at the first battalion aid or clearing station

reached.

In the early months of the European campaign, it was customary to

sprinkle sulfanilamide powder into all wounds before dressings were applied.

Later, this practice was largely discontinued, and patients were given penicillin intramuscularly in doses of 20,000 to 40,000 units at the first medical

installation reached. Efforts were then made to continue regular systemic

antibiotic therapy without interruption throughout the preoperative and

postoperative periods.

Care in moving patients with closed injuries of the spine, especially

fracture-dislocations, was always extremely important because of the ease

with which additional cord damage could be brought about by mismanagement. In penetrating injuries of the spine, particularly in the cervical region,

this same danger Avas present, though perhaps not to the same degree.

Casualties with injuries of the lumbar spine traveled well either in the

prone position or on their backs, with a pillow or folded blanket under the

lumbar region. Those with thoracic injuries traveled satisfactorily in either

the supine or prone position. Those with injuries of the cervical spine

traveled satisfactorily only if lying on their backs with a small pillow or

folded blanket underneath the shoulders, so as to raise them 2 to 3 inches

and allow the head to fall back into slight extension.

In moving patients with cord injuries, flexion, extension, and torsion

of the spine were avoided. Aidmen (preferably two or three) were instructed to lift or roll the patient like a log when placing him on a litter.

Once he was on the litter, no further movement was permitted, except for

treatment of shock, removal of clothing, necessary first aid dressings, catheterization, and physical examination, until he had reached a field or evacuation

hospital or even, after transport by air or ambulance, to a general hospital.

Thus he often reached the destination for definitive treatment on the same

litter on which he was first placed immediately after wounding. No attempt

was made to hyperextend a patient unless there was evidence of a compressed

fracture of a vertebral body.
36 NEUROSURGERY

The early introduction of an indwelling urethral catheter was essential

(p. 61). If the tactical situation did not permit evacuation to a forward

hospital within a reasonable length of time (4 to 8 hours), catheterization

was often carried out as a first aid procedure. When this precaution was

neglected, distention of the bladder with overflow incontinence resulted.

Morphine sulfate, in doses of 16 to 32 mg. subcutaneously, was ordinarily

administered for pain, which frequently, however, was not an outstanding

feature of this type of injury.

Shock was often profound, especially when the spinal wounds were

associated with penetrating wounds of the chest and abdomen, as well as

in complete anatomic transection of the cord in the low cervical or high

thoracic region. Wet clothing was removed and warmth applied. Transfusions of plasma were given on the field or in battalion aid, collecting, or

clearing stations when it was necessary to support the patient for evacuation. On his arrival at a field or evacuation hospital, transfusions of whole

blood or additional transfusions of plasma were given as indicated. Small

doses of ephedrine sulfate at intervals were effective in combating hypotension.

NEUROLOGIC EXAMINATION

When a patient with a definite or suspected spinal cord injury arrived

at a hospital equipped for definitive operative treatment, a brief but careful

neurologic examination Avas carried out as soon as possible. This was done

as part of the initial examination unless shock was present. In such cases,

resuscitation took precedence over all other procedures. In addition to

those patients whose obvious paraplegia made the diagnosis of cord injury

immediately apparent, it soon became evident that, to rule out the possibility

of spinal cord damage, every patient with a penetrating wound of the neck,

shoulders, thorax, abdomen, and back must be checked briefly for sensation,

voluntary motion of the extremities, and urinary retention. Otherwise,

preoccupation with obvious penetrating wounds of the chest and abdomen

might result in unfortunate neglect of an associated spinal injury.

Symptoms

Except for the occasional patient with cervical damage, patients with

spinal cord injuries usually remained conscious and alert from the moment

of wounding. They could often give an accurate account of how they were

wounded and of any subjective changes observed from the time of injury

to the time of examination. It was extremely important to question each

patient carefully to obtain these details. Although there were no definite

symptoms which differentiated complete anatomic from complete physiologic

transection of the cord, clues could sometimes be picked up from the history

which would definitely establish the incompleteness, or at least suggest a

reasonable doubt of the completeness, of a cord transection.
COMPOUND INJURIES OF THE SPINAL CORD 37

If there was a history of abrupt and complete loss of motion and all

forms of sensation ("dead all over") from the instant of injury, with no

subsequent subjective change, then the presence of complete physiologic

transection of the cord, though not necessarily of anatomic transection, was

likely. The outlook under these circumstances was generally poor. If, on

the other hand, the patient stated that, after being hit, he was able to walk

or run for a short distance before he collapsed, or if he at any time had

experienced pain, sensations of warmth or cold, or paresthesias of any kind

in the lower extremities, or if he had been able to pass any urine spontaneously, then the lesion was considered an incomplete one until proved

otherwise, and the outlook was generally much more favorable.

Signs

Elaborate equipment was not necessary for satisfactory neurologic examination. In most instances, with a pin and a percussion hammer, an

adequate clinical appraisal could be made in a very few moments. Such an

examination, together with examination of the external wounds and of roento-enograms, gave sufficient information to localize the lesion and indicate

proper therapy. The early clinical picture often gave an impression of a

more severe injury than actually existed. The reverse was never true.

In complete transection of the spinal cord, whether anatomic or physiologic, there was absolute loss of sensation below a well-demarcated level

which corresponded to the known anatomic segmental configuration. Light

touch, pain, temperature sensations, position sense, vibration, and deep

pressure were all absent below the level of the lesion. It was important to

test all of these, particularly pain and deep pressure. Often there was a

band of hyperesthesia extending one to two dermatomes above the anesthetic

level. The upper level of anesthesia might move a segment or two up or

down, depending upon the extent of associated edema of the cord, but in

complete lesions, anesthesia always remained uniform throughout the anesthetic area. It was never spotty, and it never exhibited remissions and

exacerbations. If there was ever reliable appreciation of any type of sensation, even though transient, at some point below the level of injury, then the

lesion was considered partial. According to Haynes, a clinical level of

anesthesia and paralysis two to three segments higher than the level of bony

injury shown in roentgenograms usually indicated a complete transection.

In total transections, there was immediate complete flaccid paralysis of

all muscles innervated from cord levels below the site of the lesion. The

maintenance of any muscle tone or voluntary movement therefore indicated

an incomplete transection.

In total transections, immediate complete areflexia was observed below

the level of injury in almost every instance. Certain exceptions to this generally accepted finding were noted by Matson, Pool, and others. Occasionally,
38 NEÜROSURGERY

a bilateral atypical plantar response was obtained in complete lesions, in the

form of a delayed, weak, slow, vermicular type of plantar flexion. A slow,

widespread withdrawal type of response, similar to the mass reflexes observed

later on, was very seldom observed in the early period. With these exceptions, however, any type of reflex response in the acute phase of injury

indicated a partial lesion.

Vasomotor changes were often noted in the early period after injury.

The skin in the involved areas usually became cold and pale or mottled

immediately; later, it became flushed, dry, and warm. Priapism was very

infrequent, but lesser degrees of penile turgescence were commonly observed

with both complete and partial transections.

Patients with injuries of the lumbar spine often exhibited neurologic

findings which were incorrectly interpreted by the unwary examiner. The

error could usually be avoided if it was remembered that the conus medullaris lies opposite the body of the twelfth thoracic vertebra and the interspace

below it. Below this level, spinal injuries were associated with lesions of

the cauda equina, so that, depending on which roots were involved, asymmetrical and bizarre neurologic pictures were frequently seen.

Repeated brief neurologic examinations at frequent intervals and by the

same examiner were especially valuable in determining the exact level of a

lesion as well as the improvement or progression of an incomplete lesion.

It was extremely important to note on the patient's record the neurologic

status at the time of each examination, especially in the forward areas, where

movements of both patients and surgeons were frequent and often unforeseen.

LUMBAR PUNCTURE

Lumbar puncture to determine the character of the spinal fluid and

estimation of dynamics (Queckenstedt's test) proved of no particular value

in the early diagnosis or treatment of compound spinal injuries. In closed

spinal lesions, the presence of a block of the subarachnoid space can be determined readily by this method and may be of importance in deciding upon

laminectomy. In penetrating wounds of the spinal cord due to missiles,

the same criteria are not present, as indicated by the following observations:

1. A metallic foreign body or a depressed bone fragment often encroached upon the spinal canal, causing local compression of the long tracts

of the cord without producing demonstrable interference with the circulation

of the spinal fluid.

2. A complete block to the circulation of fluid was sometimes produced

in the first few days after injury by edema of the cord alone, in the absence

of any extrinsic compression that could be alleviated by surgical intervention.

3. Manometry proved unsatisfactory whenever there had been penetration of the dura resulting in a spinal fluid leak.
COMPOUND INJURIES OF THE SPINAL CORD 39

4. The finding of blood in the subarachnoid fluid on lumbar puncture

did not necessarily mean that dural penetration had taken place. Blood

was often present after simple concussion or contusion of the cord, without

direct involvement of the dural contents.

Lumbar puncture, therefore, did not help to differentiate anatomic from

physiologic transection, or complete from partial transection, of the cord,

nor did it aid in designating cases suitable for early laminectomy. For these

reasons, spinal fluid studies were largely abandoned in forward hospitals.

Lumbar puncture was, of course, indicated in patients who showed

clinical evidence of infection. If meningitis was established, lumbar punctures were continued for the intrathecal administration of penicillin one or

more times daily in doses of 10,000 to 20,000 units.

Postoperative lumbar punctures were indicated only for the diagnosis

and treatment of meningeal infection.

ROENTGENOLOGIC EXAMINATION

Even with the best equipment and technicians available, it is often

difficult to obtain good roentgenograms of the spine, particularly in the

thoracic and low cervical regions. In forward hospitals of combat zones, it

was even more difficult to obtain satisfactory films for one or more of the

following reasons:

1. Stereoscopic roentgenograms were not available; they would often

have been of great value in locating protrusion of bone fragments and

foreign bodies into the spinal canal.

2. The power available from portable generators varied considerably and

caused technicians infinite trouble in estimating the time of exposure necessary.

3. In the rush of casualties which followed any heavy engagement, there

was neither the time nor the personnel available to place patients in perfect

position for roentgenograms.

It was often possible, however, in spite of these difficulties, to obtain

fair, and even good, anteroposterior films. It was more difficult to obtain

satisfactory lateral films. Operations for spinal injuries were never acute

emergencies, and repeated roentgenograms often justified the additional time

and effort expended to secure them.

Roentgenograms were never made until patients had been adequately

treated for shock and until sufficient personnel were available to move them

onto the X-ray table. Eoentgenograms of the spine were always requested

in accordance with the level of injury estimated by clinical examination

rather than by the site of the external wound, since the spinal injury was

often found at a considerable distance from the wound of entry or exit.

Although roentgenograms often did not show accurate bony detail at
40 NEUROSURGERY

the point of injury, they were invaluable in permitting deductions concerning the course taken by a penetrating missile. Anteroposterior and lateral

films localized metallic foreign bodies well, and, when these films were

considered in conjunction with clinical examination of the wounds of entrance and exit, with evaluation of the neurologic signs, wound tracks could

usually be charted with considerable accuracy.

Metallic foreign bodies inside the spinal canal or impinging upon it

could be identified readily (figs. 10 and 11). It was always extremely important to determine whether a metallic foreign body lay on the same side

of the midline as the wound of entrance or on the opposite side. If it was

on the opposite side, the spine was examined carefully for fracture along

the calculated course of the missile (fig. 9B). When roentgenograms showed

FIGURE 10.—Roentgenograms showing bullet lying free within spinal

canal at Lx and fracture of pedicle and lamina of L2. Preoperative weakness of the left leg was relieved completely following removal of the foreign body and depressed bone fragments. A. Anteroposterior view. B.

Lateral view.

the foreign body on the same side as the wound of entrance, the surgeon

could never assume that the spine was uninjured because foreign bodies

very frequently ricocheted from the spine on the same side or bounced

directly backward after causing a depressed fracture (fig. 9A).

It was often possible to see actual protrusion of depressed fragments

of lamina or pedicle into the spinal canal. More often, however, these conditions were assumed to exist rather than actually visualized. It was the

rule to find much more extensive bony comminution and depression at operation than had been predicted by examination of the roentgenograms.
COMPOUND INJURIES OF THE SPINAL CORD 41

LAMINECTOMY

Indications

The indications for operative intervention in the management of spinal

injuries and the optimum time for it have always been controversial subjects.

The exigencies of war made these problems even more difficult, for, in addition to the purely clinical indications for laminectomy, such other factors

had to be considered as transportation and nursing facilities and the relative

priority of these patients in commanding the time of the neurosurgical

personnel available. It was necessary, therefore, to adopt some general

policy, which was, of course, subject to modification by particular problems

FIGUKB 11.—Anteroposterior roentgenogram showing shell

fragment on side of spinal canal opposite from wound of entry in neck. This roentgenologic observation, together with

the clinical findings of complete physiologic cord transection,

usually indicated a poor prognosis, although anatomic transection of the cord could be established only by laminectomy.

arising in unusual circumstances. In spite of the efforts of theater surgeons

and consultants to standardize the treatment of these wounds, there was

probably no type of war injury that received less uniform treatment at the

hands of different surgeons. As has already been pointed out, there was

considerable confusion after "World War I regarding early surgical treatment of compound spinal wounds; much of this confusion was carried over

to World War II. The actual difficulty in interpreting the clinical and

roentgenologic findings and the variable tactical situations which arose,

together with the existing confusion concerning the optimum form of

therapy, all contributed to the lack of standardization in early treatment.
42 NEÜROSURGERY

There were in reality two different problems, which, while separate,

were still dependent on one another. The first problem was purely clinical:

What were the actual indications for early laminectomy after compound

spinal injury? The second problem was administrative as well as clinical:

What was the level in the chain of medical evacuation at which laminectomy

was best performed?

In compound wounds of the spine, as well as in all other compound

injuries, some type of early operation was always indicated. Wounds of

entrance and exit required debridement, at least.

Prevention of infection.—When there were sizable wounds directly over,

or near, the spinal column, the only satisfactory way to perform an adequate

debridement was to excise the wound to its depths and perform a formal

laminectomy as widely as necessary to remove all comminuted and depressed

bone fragments. This was especially true if the dura was open and a spinal

fluid leak existed, as the following case history shows:

A U.S. Army sergeant was admitted to a field hospital in Belgium on 4 September

1945, alert, cooperative, and not in shock. He stated that immediately after wounding

he had become completely numb from the nipple line down and had fallen to the ground

at once.

Examination revealed a ragged 2.0- by 2.5-cm. wound of entrance directly over the

fourth dorsal vertebra in the midline posteriorly, with leakage of spinal fluid. There

was complete anesthesia below the fifth dorsal vertebra bilaterally, complete areflexia,

complete flaccid paralysis of the abdomen and lower extremities, and retention of urine.

Roentgenograms revealed a large metallic foreign body within the spinal canal at the

level of the fourth dorsal vertebra.

Under local procaine hydrochloride infiltration, the wound was excised and extended.

Comminuted fragments of the spine and laminae of the fourth dorsal vertebra were

removed. A 1.5- by 2.5-cm. metallic foreign body was found to have passed directly

through the spinal canal. It was dislodged from the body of the vertebra and removed.

There was a large gap in the dura, and the cord was completely transected. After

thorough debridement, a piece of fascia was placed over the gap in the dura, and the

paraspinal muscles were approximated tightly over the bone defect. Penicillin and sulfanilamide powder were dusted into the outer layers of the wound.

The postoperative course was uneventful, and the wound healed primarily. Constant

bladder drainage was maintained until evacuation. There was no change in the complete paraplegia.

When a spinal fluid leak persisted, it usually meant either that there

was a large laceration of the dura or that a spicule of bone or a foreign

body was protruding through the dura and thus maintaining the opening.

Such an injury is illustrated by the following case:

A U.S. Army officer was received in an evacuation hospital in Germany on 11 December 1944, 24 hours after injury. There was a 1.5-cm. wound of entry directly over

the midlumbar region, with gross leakage of spinal fluid. There was weakness of both

lower extremities, but all motions could be performed. There was hypesthesia below the

fourth lumbar vertebra bilaterally but no anesthesia. The patient was able to void spontaneously. His temperature was 101° F., and there was definite stiffness of the neck.

Roentgenograms revealed a 1.0- by 1.0-cm. metallic foreign body in the spinal canal at

the level of the third lumbar vertebra.
COMPOUND INJURIES OF THE SPINAL CORD 43

The patient was given penicillin and sulfadiazine systemically, and a large sterile

dressing was applied to the wound of entrance after thorough cleansing of the surrounding skin. Three days later, fever and stiffness of the neck had disappeared, but spinal

fluid still leaked from the wound. The weakness and sensory loss had almost completely

disappeared.

Under local anesthesia, the wound was excised widely, and the incision was extended

to expose the laminae of the second to the fourth lumbar vertebrae. A small metallic

foreign body was found protruding through the dura at the third lumbar vertebra. It

was removed, together with comminuted bone fragments. The dural opening was enlarged sufficiently to make certain there was no damage to the cauda equina. The dura

was closed tightly, and the rest of the wound was closed in layers after subdural instillation of 10,000 units of penicillin. The postoperative course was afebrile and uneventful.

If wounds involved infected or contaminated paraspinal tissues as well

as the dura, closure of the dura was essential to prevent meningitis. This

was particularly true when missiles passed through the bowel first and then

entered the spinal canal. The following case history illustrates this type

of injury:

A staff sergeant was seen in consultation at a field hospital in Belgium on 6 January

1945. Two days earlier, he had been admitted in shock with a wound of entrance in the

right anterior chest wall and with paraplegia. After shock therapy, a thoracoabdominal

operation had been performed, with suture of a laceration of the lower lobe of the right

lung, suture of two perforations of the small intestine, and suture of lacerations of the

liver and the diaphragm. Constant bladder drainage was instituted. The postoperative

course had been satisfactory, but the paraplegia had remained unchanged.

Examination revealed sensory and motor loss at the fourth lumbar vertebra on the

right and at the second lumbar vertebra on the left. Roentgenograms revealed a smallcaliber bullet in the region of the spinal canal at the third lumbar vertebra, with fractures of the bodies and pedicles of the second and third lumbar vertebrae on the right.

Approximately 72 hours after the thoracoabdominal operation, laminectomy was carried out under local procaine hydrochloride infiltration. The bullet was found protruding

into the dura, with gross leakage of spinal fluid into the paraspinal tissues. About half

of the roots of the cauda equina were divided, and half were intact. Several tiny pieces

of clothing and debris were removed from within the dura. All comminuted bone fragments were removed, and the dura was closed with a fascial graft. Penicillin and sulfanilamide powder were dusted into the wound, which was closed tightly.

Although the patient was not seen again by this particular surgeon, he was reported

convalescing satisfactorily 8 days after operation, though at this time there was no

change in the neurologic picture.

Relief of root pain.—Occasionally, a compound wound of the lumbar

spine or sacrum was observed, with involvement of the cauda equina, in

which the patient experienced severe raclicular pain. The presence of pain

was always evidence of an incomplete transection. The pain might even

grow more severe while the neurologic deficit receded. According to Pool,

in four out of five patients with root pain, pain was relieved by operation.

Since this type of pain was very severe and was usually untouched by ordinary medication, early operation was indicated. An example of such an injury follows:

A technical sergeant was admitted to a field hospital in Germany on 20 March 1945,

with a wound of entrance through the right side of the abdomen and a wound of exit in
44 NBÜKOSURGERY

the midlumbar region. There was partial paraplegia, with retention of urine. After

preliminary shock therapy, laparotomy was carried out with suture of one perforation

of the stomach and two of the duodenum and repair of a laceration of the liver. The

exit wound in the lumbar region was debrided superficially.

The postoperative course was satisfactory, and there was definite improvement in

the motor power of both lower extremities, as well as in sensation. The patient, however, complained increasingly of radiating pain down the back of the right leg and the

lateral aspect of the foot. When he was seen in consultation on the seventh day after

laparotomy, this pain was very severe. Roentgenograms revealed a comminuted fracture of the vertebral arch of the fourth lumbar vertebra. There was loss of function

below the fifth lumbar vertebra on the right and the first sacral vertebra on the left.

On the following day, under local procaine hydrochloride infiltration, the old wound

of exit in the midline was excised and extended. Severely comminuted fragments of the

spine, laminae, and pedicles of the fourth lumbar vertebra were removed from their

encroachment on the spinal canal. The dura was lacerated on the right side, and roots

of the cauda equina had herniated through the dural defect. They appeared badly contused and edematous but were intact. After replacement of the cauda equina, the dura

was sutured. Penicillin and sulfanilamide powder was dusted in all layers of the wound

after closure of the dura, and closure was effected in layers. Because this was a reopened wound, a slip drain was left beneath the fascia for 48 hours.

The patient was dramatically relieved of most of his pain immediately after operation and remained free of it up to the time of his evacuation 5 days later. There was

ho change in his neurologic status during this time. Constant bladder drainage was

maintained.

Decompression of the spinal cord and cauda equina.—The importance

of extrinsic pressure on the spinal cord by bone fragments or metallic foreign bodies has always been a subject of great controversy. For this reason,

it was difficult to define and establish a uniform policy of treatment. As

experience accumulated during the war, however, certain criteria for operation were adopted by most neurosurgeons and are worth presenting in some

detail.

In general, it was thought that laminectomy for purely decompressive

purposes was indicated early in certain types of cases but that these cases

did not constitute the surgical emergencies which they had often been considered. Pool stated that laminectomy could be postponed safely, to allow

cardiorespiratory stabilization, without jeopardizing the chances for subsequent neurologic improvement, and that the general condition of the patient

rather than the neurologic status should determine the optimum moment for

operation. Haynes, though he believed that the pressure of bone, debris, and

foreign bodies should be removed early, preferably within 48 hours, also

stated that the prognostic difference between operation at 48 hours and at

10 days was of minimal significance. Matson believed that operation purely

for purposes of decompression was probably the least urgent reason for early

laminectomy, but he thought that decompression should be carried out as

soon as feasible in all instances in which local compression of the spinal cord

was suspected or was actually demonstrable.

Early laminectomy for relief of local compression was considered particularly desirable for spinal injuries in the following types of patients:
COMPOUND INJURIES OF THE SPINAL CORD 45

1. Patients who exhibited a neurologic picture consistent with incomplete transection of the cord and in whom the picture had definitely altered

since the time of injury, especially if the neurologic deficit had increased.

These cases were extremely uncommon, which lends weight to the belief that

the greater part of the physiologic loss was due to damage produced at the

moment of injury rather than caused by subsequent compression. Even in

patients showing improvement, however, recovery might well stop short of

the maximum possible if cord compression remained, and it was therefore

the policy to relieve it as soon as possible.

2. Patients with a neurologic picture of fixed but incomplete cord transection, whose roentgenograms revealed clear-cut encroachment on the spinal

canal by a metallic foreign body or a definite fracture of the lamina or pedicle

with or without depression of bone fragments. It should be pointed out

again that detail was poorly visualized in these roentgenograms and that

almost invariably there was more comminution and depression of fractures than was evident in the roentgenograms. A Brown-Sequard type of

incomplete lesion was occasionally seen and appeared to indicate an especially favorable prognosis. The following case is an example of such an

injury:

A U.S. soldier was admitted to an evacuation hospital in Germany on 21 March

1945. He was alert, cooperative, and not in shock. There was a ragged wound of

entrance 2.0 by 3.0 cm. on the left arm just below the shoulder, with inability to use

this extremity. The man was also unable to move the left lower extremity, though

there was some tone present in the muscles. On the right side, there was absence of

pain sensation in the trunk and lower extremity and some weakness of the leg. Sensation on the left was normal.

Roentgenograms revealed comminuted fractures of the neck of the left humerus and

the left scapula, together with fractures of the spines and pedicles of the fifth and

sixth cervical vertebrae on the left. There was a metallic foreign body in the soft tissues

of the neck to the left of the midline.

Under local procaine hydrochloride infiltration, supplemented by intravenous thiopental sodium (Pentothal sodium) anesthesia, a midline incision was made from the

spines of the fourth to those of the seventh cervical vertebra. The fractured spines of

the fifth and sixth cervical vertebrae were removed, together with comminuted depressed

fragments of the sixth cervical lamina on the left. The dura was intact and did not

appear contused. Clear, colorless spinal fluid was aspirated from the subarachnoid space

through a hypodermic needle, and the dura was therefore not opened. The foreign body

was removed from the soft tissues of the neck, and the wound was closed in layers

without drainage. The wound of entrance was then debrided, and a thoracobrachial

plaster spica was applied.

By the time the patient reacted from the anesthesia, there was already improvement in the motion of the left leg, and by the time of evacuation, on the sixth day,

there was almost complete recovery of sensation on the right as well as of motion on

the left.

3. Patients with a neurologic picture of complete physiologic transection

of the cord, with roentgenograms showing the presence of a metallic foreign

body within, or protruding into, the spinal canal, as well as patients who

had demonstrable fractures with depression of bone fragments into the canal.
46 NEUROSURGERT

If a metallic foreign body lay on the same side of the spinal cord as the

wound of entrance, the prognosis was considered more favorable than if it

had crossed the midline. What appeared to be complete immediate physiologic transection was not necessarily a contraindication to early laminectomy,

provided that examination of the wound and of the roentgenograms indicated that a favorable situation might be present, While the presence of

such an immediate complete physiologic transection always carried an extremely guarded prognosis, it did not necessarily indicate a hopeless outcome;

an occasional patient showed significant improvement during a time interval

which made it reasonable to assume that operation had permitted, or at least

hastened, this course. Tinsley reported laminectomies on 19 patients with

complete physiologic transections, with early postoperative improvement in

two. Haynes also reported early improvement in patients with apparently

complete physiologic transections. Matson observed two patients who showed

some return of function following early laminectomy, although preoperatively they had been considered to have complete physiologic transections.

McCravey9reported that one out of six patients with complete immediate

physiologic transection exhibited subsequent improvement. At any rate, it

may be concluded from these observations that, if examination of the patient

and of the roentgenograms left any reasonable doubt in the surgeon's mind

that the cord had been severed, there was nothing to lose and there might be

much to gain by early relief of localized cord compression.

4. Patients with a history and neurologic picture of immediate complete

cord transection who had through-ancl-through wounds traversing the spinal

canal or patients whose roentgenograms showed gross fractures of one or

more vertebrae with obliteration of the spinal canal by bone fragments.

Lowest priority for early operation was given to these casualties. Even in

this group, however, complete physiologic transection did not necessarily

mean anatomic transection, as is illustrated by the following case:

A U.S. soldier was admitted to a field hospital in Belgium on 12 September 1944, in

good general condition. There was a 1.5-cm. wound of entrance in the right side of the

neck anteriorly and a 2.5-cm. wound of exit in the middorsal region opposite the fourth

and fifth dorsal vertebrae. There was complete flaccid paralysis of the abdomen and

lower extremities, complete loss of sensation below the nipple line, areflexia of the lower

extremities, priapism, and retention of urine. Spinal fluid leaked profusely from the

wound of exit. There was no evidence of penetration of any vital structures of the neck

or mediastinum.

Under procaine hydrochloride anesthesia, the wound of exit was excised and extended, so that the spine and fractured laminae of the fourth and fifth dorsal vertebrae

could be removed. A dural laceration on the right side was extended, so that intradural

exploration within could be carried out. The cord was markedly contused, hemorrhagic,

and edematous but was anatomically intact. The dura was sutured and the wound

closed in layers after being dusted with penicillin and sulfanilamide. The entrance

wound was then debrided.

9 McCravey, A. : War Wounds of Spinal Cord; A Plea for Exploration of Spinal Cord and

Cauda Equina Injuries. J.A.M.A. 129 : 152-153, 8 Sept. 1945.
COMPOUND INJURIES OF THE SPINAL CORD 47

This patient was evacuated 5 days after operation, at which time he showed no evidence of any return of function. His wound appeared well healed. Constant bladder

drainage was maintained.

5. Patients with wounds of the lumbar region of the spine which involved the cauda equina. Except in the presence of severe root pain, these

wounds were not considered to be as urgent as similar wounds of the cervical

and thoracic vertebrae with involvement of the spinal cord proper.

Exploration.—It must again be emphasized that in the acute stage of

injury, clinical findings, roentgenographic studies, and lumbar puncture did

not give a true picture of the pathologic changes, nor could they be relied

upon to determine the prognosis. Every patient with a demonstrable compound wound of the spine and abnormal neurologic findings therefore should

at some time have had the benefit of exploratory laminectomy.

Spinal cord concussion.—A temporary and reversible interruption of

physiologic function of the spinal cord may occur as a result of severe trauma

in the region of the spinal column, without actual mechanical pressure on the

cord or gross anatomic changes within its substance. This injury was recognized in World War I, as well as in civilian practice, and has become

known generally as spinal cord concussion. In World War II, it was observed frequently, usually following passage of a high-velocity missile close to

the spine, with or without production of a fracture of a spinous or transverse

process but always without direct involvement of the cord. It is assumed that,

in such cases, the interruption of function is due to a wave of pressure transmitted from the pathway of direct injury to the cytoplasm of neuronal

elements within the cord.

Eecovery from spinal cord concussion often began within a few hours.

Maximal if not complete recovery usually occurred within the first 1 to 3

weeks, but improvement was sometimes observed to continue for months.10

Decompression by removal of normal laminae of a cord that had sustained

concussion was thought to be of no avail. Any improvement which followed

such an operation undoubtedly would have occurred anyway in about the

same period of time. In the absence of any roentgenologic or other evidence

of vertebral fracture or of encroachment upon the spinal canal, there was

no indication for early laminectomy at the site of a clinical level of physiologic transection. This decision implied completely negative roentgenograms

or other definite evidence that the spinal column was not directly involved.

Administrative Considerations in Early Laminectomy

Unfortunately, it was not always possible during World War II to proceed with the management of cord injuries on the basis of purely clinical

judgment. Because of the rapid movements of the battlefront, it was neces10 (1) See footnote 5 (3), p. 32. (2) Baker, G. S., and Daniels, F., Jr.: Concussion of the

Spinal Cord in Battle Casualties. J. Neurosurg. 3: 206-211, May 1946. (3) Livingston, W. K.,

and Newman, H. W. : Spinal Cord "Concussion" in War Wounds. West. J. Surg. 54 : 131-139,

April 1946.
48 NEUROSURGERY

sary for medical units in forward areas to be mobile. It was often necessary

to transport patients long distances before fixed installations could be reached.

These considerations frequently played a necessary part in the decision to

carry out laminectomy at any given time or in any given hospital.

Particularly because of the problems involved in postoperative nursing

care of casualties with cord injuries, every effort was made to move these

patients to a fixed neurosurgical center in the rear as soon as possible,

whether or not operation was performed in a forward area. Although they

traveled fairly well during the first few days after laminectomy, provided

that there were no complicating injuries of the chest, abdomen, or head, in

general it was better to transport them to the rear before laminectomy if this

was practical within a reasonable length of time. If, however, the transportation facilities were so poor or the chain of evacuation was so uncertain as

to prohibit removal to a general hospital within 48 to 72 hours, then operation on patients in the categories just outlined was indicated in forward areas.

A considerable number of compound spinal injuries were associated with

penetrating wounds of the chest, abdomen, or pelvis. Patients with the latter injuries were considered nontransportable for 8 to 10 days after operation,

and they were held in field and evacuation hospitals for this period of time

unless the military situation required earlier evacuation. It was therefore

necessary to perform laminectomy on these patients in the forward areas

unless operation was to be delayed beyond the 10-day period. Laminectomy

was never carried out before, or at the same time as, an open chest or abdominal procedure. It was usually possible, however, to perform it within

48 to 72 hours after a chest or abdominal operation had been completed,

and certainly within the 10-day period. When spinal wounds were associated with massive hemothorax, laminectomy was delayed until respiratory

stabilization was achieved. Maintenance of systemic chemotherapy or antibiotic therapy permitted this delay without undue hazard of infection. The

following case history illustrates the management of such an injury:

A U.S. Army corporal was admitted to an evacuation hospital in Belgium on 20

September 1944, in moderate shock. He was alert and cooperative but had moderate

respiratory difficulty. There was a 1.5-cm. wound of entrance at the apex of the right

shoulder. There was an incomplete motor paralysis of the lower extremities, a sensory

loss at the ninth and tenth dorsal vertebrae, and retention of urine. Roentgenograms

taken after treatment of shock revealed a massive hemothorax on the right side and a

small-caliber bullet imbedded in the same side of the vertebral arch of the tenth dorsal

vertebra.

Oxygen was administered by the intranasal route, and 500 to 600 cc. of blood were

aspirated from the chest. These measures somewhat improved the respiratory status.

Several hours later, the patient was taken to the operating room and placed in the facedown position in preparation for laminectomy. In this position, however, his respirations

became more difficult, his pulse rapid, and his color slightly dusky. He was therefore

taken back to the shock ward and kept in Fowler's position while intranasal oxygen was

continued. During the next 24 hours, aspiration of the chest was repeated twice, with

removal of 600 to 800 cc. of blood each time, and two transfusions of whole blood were

given.
COMPOUND INJURIES OP THE SPINAL CORD 49

At the end of this time, laminectomy of the ninth and tenth dorsal vertebrae was

carried out satisfactorily under local procaine hydrochloride anesthesia. A 30-caliber

bullet was found protruding into the spinal canal, compressing the dura sharply toward

the left. Careful exploration after removal of this slug and several comminuted bone

fragments revealed the dura to be intact. The connection with the pleural cavity, which

had been sealed, was not reopened. The wound was closed tightly in layers.

Postoperatively, aspiration of the chest was repeated three more times. The patient's

convalescence was otherwise uneventful, and he showed definite neurologic improvement

at the time of evacuation on the tenth day. Constant bladder drainage was maintained.

Occasionally, patients with spinal injuries were considered nontransportable because of other injuries, such as extensive burns, compound fractures of the femur, penetrating wounds of the brain, or severe maxillofacial

injuries. Here too, if early laminectomy was indicated, it was performed

under appropriate anesthesia as soon as the patient's general condition permitted it.

Anesthesia

Three types of anesthetic agents were generally employed for early laminectomy, depending upon the character and location of the wound, the anesthetic facilities available, and the individual preference of the surgeon.

These included (1) local 1 percent procaine hydrochloride, (2) intravenous

2.5 percent thiopental sodium, and (3) intratracheal gas-oxygen-ether.

Premedication.—Morphine sulfate, in doses of 11 to 16 mg., was usually

given preoperatively to patients with injuries in the thoracic and lumbar

regions. It Avas given subcutaneously 45 to 60 minutes before operation, or,

more often, intravenously, just as the patient was placed on the operating

table. Morphine was never given preoperatively to patients with injuries

of the cervical region, nor was it given to patients with any respiratory

depression or irregularity.

Pentobarbital sodium (Nembutal) by mouth or amobarbital sodium

(Amytal sodium) subcutaneously, in doses of 0.1 to 0.2 gm., was often used

to good advantage 1 to iy2 hours before operation, to relieve anxiety and

restlessness. In the presence of injuries of the cervical portion of the spinal

cord or any evidence of respiratory depression, the barbiturates were either

withheld or were administered with extreme caution. Atropine sulfate, 0.45

to 0.65 mg., was given routinely before operation whenever general anesthesia was contemplated.

Since pain was seldom severe and often was completely absent, because

of the anesthesia produced by the cord injury itself, large amounts of drugs

for premedication were seldom necessary. Root pain at this stage was uncommon, though it was occasionally seen in cauda equina injuries. Severe

root pain responded poorly to ordinary medication and itself constituted an

indication for early operation.

Local anesthesia.—In most instances, local was the anesthesia of choice

for formal laminectomy. As long as the operation was carried out in the

midline, only small amounts of the anesthetic agent were needed. Often, the
50 NEUROSURGERY

area of operation was already partly or completely anesthetic. Sometimes,

however, it lay in the zone of hyperesthesia found just above the level of

anesthesia. If debridement of wounds of entrance or exit away from the

midline was also necessary, then local infiltration with procaine alone was

usually unsatisfactory, and thiopental sodium in small amounts was administered intravenously, as necessary, to supplement the local anesthetic.

One percent procaine hydrochloride (Novocain), to which epinephrine

(Adrenalin), 0.18 to 0.3 cc. per 30 cc. of 1:1,000 solution, had been added,

was routinely used. The skin along the line of incision was thoroughly

infiltrated, after which approximately 5 cc. of procaine was injected beneath

the fascia on each side of each spinous process. This anesthesia was usually

sufficient for the entire procedure unless manipulation of sensory nerve roots

at the level of injury was necessary..

Local procaine hydrochloride infiltration was used routinely by some

surgeons even when general anesthesia was employed, since it lessened the

amount of the general agent necessary and proved of substantial aid in local

hemostasis.

Thiopental sodium (Pentothal sodium).—Intravenous thiopental sodium

in 2.5-percent solution was widely used by many surgeons as the principal

anesthetic agent, as well as to supplement local infiltration for short periods.

It could also be given satisfactorily in a continuous intravenous drip of 0.5-

to 1-percent solution. Its use demanded the presence of a competent anesthetist to observe the patient's airway and vital signs, to administer oxygen

when necessary, and to insure an even level of anesthesia.

Thiopental sodium was contraindicated in injuries involving the soft

tissues of the neck or the cervical portion of the spine. It was also contraindicated in the presence of associated penetrating wounds of the chest and

in all instances of respiratory depression or irregularity, whatever the cause.

When thiopental sodium was employed, it was especially important that

correct positioning on the operating table be achieved, with the lower part

of the chest and the abdomen free from compression and the nasopharynx

and trachea free from obstruction. It was usually found desirable to induce

anesthesia to a satisfactory level with the patient on his back. Then he was

turned to the prone position, his head and shoulders were positioned, and his

airway, respirations, and color were observed in this position for a few

moments before he was covered with drapes and the operation was begun.

Thiopental sodium was especially valuable when soft-tissue wounds or

fractures elsewhere had to be debrided at the same time as the spinal wound.

Its principal use by Matson was for wounds in the lumbar region when no

respiratory complications were present.

Ether.—Inhalation anesthesia through an intratracheal tube was usually

the anesthesia of choice in penetrating wounds of the chest which involved

the thoracic region of the spine. During laminectomy on a patient with such

an injury, the operative wound could have been converted, necessarily or
COMPOUND INJURIES OF THE SPINAL CORD 51

inadvertently, into a sucking wound of the chest because of a pleural communication produced by the missile. The advantage of positive pressure

under such circumstances is self-evident.

Intratracheal gas-oxygen-ether anesthesia was also preferred for operations in the low cervical region when paralysis of the accessory muscles of

respiration was present, especially if large amounts of secretion had accumulated in the respiratory tree. This method allowed control of respirations

during possible periods of temporary arrest clue to operative manipulations

in the region of the cervical portion of the cord. It also permitted thorough

aspiration of the pharynx and trachea before and during operation.

Care of patient at operation.—Throughout all spinal operations, careful

observations of the pulse, respirations, and blood pressure were made whenever possible. An intravenous needle was inserted before operation, and

suitable fluid was continuously administered. Blood loss was replaced immediately by whole blood, and other supportive treatment was given as indicated.

Positioning

Patients with spinal injuries were routinely operated on in the prone

position. Considerable attention was devoted to proper adjustment of this

position, regardless of the anesthesia used. If local anesthesia was employed,

it was important that the patient be made as comfortable as possible, since

the operative procedures were usually fairly long. It was also essential to

make certain that prominent areas in the zone of anesthesia, such as the iliac

crests, shins, and dorsum of the ankles, did not rest against any hard surface

during operation.

Whenever it was available, a cerebellar type of headrest was used, thus

allowing the patient's head to be kept in the midline in a comfortable position. In laminectomies of the cervical and upper thoracic regions, this was

essential. In the absence of a cerebellar headrest, a support for the forehead

was improvised by making a sling between the handles of the standard army

litter.

The most important point in arranging the position of these patients,

however, was sufficient elevation of the shoulders from the operating table

or litter to permit easy respiratory excursion of the diaphragm. It was

essential to be able to slip the flat of the hand under the chest and upper

part of the abdomen at all times. This position was readily achieved by

placing a long, narrow sandbag, hard pillow, or tight small blanket roll

diagonally under each shoulder. Constant bladder drainage was maintained

throughout operation.

Preparation of the Surgical Field

With the patient in a satisfactory position, the operative area was

scrubbed thoroughly with soap and water, followed by alcohol and bichlo-
52 NEUROSURGERY

ride of mercury or by a 0.5-percent iodine solution or tincture of thimerosal

(Merthiolate), according to the surgeon's preference. Suitable drapes were

applied to isolate the operative site and any wounds requiring separate

debridement.

Technique

No attempt will be made to describe in detail the steps of a laminectomy,

since standard techniques were used in these operations.

Incision.—In cases which were suitable for early laminectomy, it was only

occasionally that more than one or two vertebrae were involved, so that,

provided the incision was properly placed, a large exposure was usually unnecessary. If, however, the external wound was even a short distance away

from the midline, it was debrided separately, and laminectomy was carried

out through a fresh exposure (fig. 12 A). If there was a wound of entrance

or exit directly in the midline, it was included in the operative incision, and

complete excision of the wound margins was carried out as the operative

exposure proceeded (fig. 12 B).

The skin incision was made with digital pressure on the wound edges

to minimize hemorrhage (fig. 13 A). Subperiosteal reflection of the muscles

from the spines, intervertebral ligaments, and laminae was carried out with

the aid of a broad, sharp periosteal elevator (fig. 13 B). Since this step is

the most shock-producing part of a laminectomy, it was limited, whenever

possible, to one vertebra above and one below the involved segments. Bleeding was controlled at each step with suction, pressure, and electrocautery,

and self-retaining retractors were introduced to maintain the exposure (fig.

13 C). It was usually necessary to remove one or more vertebral spines,

whether or not they were previously fractured, in order to gain adequate

exposure of the involved structures.

Removal of bone fragments and foreign bodies.—The most important

aim in early posttraumatic laminectomy was the visualization and complete

removal of all comminuted and depressed bone fragments and of all metallic

or other foreign bodies which encroached upon the lumen of the spinal canal.

In addition, contaminated and devitalized tissues were removed as thoroughly as possible.

The same principles were applied in the operative management of depressed fractures of the spine as in depressed skull fractures. The most

important was obtaining adequate exposure before attempting to remove

bony fragments or impacted foreign bodies. This was necessary to minimize

the danger of additionally injuring nervous tissue or of causing concealed

hemorrhage which would be difficult to control.

Laminectomy could sometimes be started easily and safely at the site

of the traumatic bony defect by gently teasing out loose fragments and then

enlarging the opening with suitable rongeurs (fig. 13 D). If the traumatic

defect was small or the fragments were impacted, it was usually easier and
COMPOUND INJURIES OF THE SPINAL COED 53

Metallic

foreign body

FIGUKE 12.—Incisions for laminectomy. A. Incision used for separate

debridement when wound of entrance

or exit was located at distance from

midline of back. Formal laminectomy

in this type of injury was carried out

through a fresh operative approach.

B. Incision used when wound of entrance or exit was located in midline.

In this type of injury, the wound was

excised in the surgical incision and

was extended sufficiently to permit adequate exposure of the spinal wound.

FIGURE 13.—Surgical exposure of spinal wounds. A. Midline incision carried down to vertebral spines, with

bleeding controlled by digital compression of wound margins. B. Reflection

of paraspinal muscles from spines and

laminae on left, revealing penetrating

wound of vertebral arch. Subperiosteal

reflection of paraspinal muscles on

right, beginning at tip of spinous process. Note broad, sharp periosteal elevator used for this step of the procedure. C. Exposure completed by

removal with heavy rongeurs of 3 spinous processes. In this type of impacted fracture, bony removal of 2

adjacent laminae was most easily and

safely begun at the distal margin of

the lower lamina. D. More extensive

spinal wound, in which debridement

has been begun by removal of loose,

comminuted fragments of lamina and

pedicle. The operation is completed by

rongeuring all contaminated bony margins until a smooth defect is obtained.
54 NEUROSURGERY

safer to begin removal of bone at an uninjured point, usually the distal edge

of an adjacent lamina (fig. 13 C). Every precaution was taken to protect

the dura and any exposed nervous tissue with moist cotton as the bone was

removed. Small amounts of extradural blood clot were frequently found

and removed, although it was never thought that enough extradural hematoma was present to produce significant local compression by itself. Wide

decompression of the spinal canal by removal of additional uninjured laminae was not believed to be necessary. An effort was always made, however,

to remove sufficient bone to permit assurance that displacement of the clural

envelope from every aspect had been relieved.

Number 8

FIGURE 14.—Technique of laminectomy. A. Exposure of dural wound

after removal of all depressed and

comminuted fragments and rongeuring of contaminated bony margins.

Traction sutures have been placed

through the edges of the dural laceration to facilitate exposure for debridement within the dura. A No.

8 soft rubber catheter is passed up

and down the subdural space to

make certain all extrinsic compression on the cord has been relieved.

B. Closure of dura by tacking fascial

graft to margins of defect with fine

silk sutures.

FIGUKE 15.—Composite picture illustrating careful closure of operative wound in layers. When complete closure of the dura was

impossible, tight approximation of

the paraspinal muscles and fascia

in the midline proved especially

important.

Muscle

Bone—EBB

Management of dura.—If the dura had been penetrated, exploration

within it was always carried out. Whenever possible, this was clone through

the laceration itself. If this was not possible, the dura was opened in the

miclline in the standard fashion. Intradural operation was limited to the

removal of bone chips, macerated tissue, foreign bodies, and blood clot.

Operative manipulation of the cord itself, which was not believed to be of
COMPOUND INJURIES OF THE SPINAL CORD 55

any value, was avoided. Xo subdural hematomas were of sufficient extent

to cause local compression in themselves. A small soft rubber catheter was

passed upward and downward to make certain that there was no unexposed

encroachment on the cord (fig. 14 A). The use of the electrocautery intradurally was avoided. Bleeding from the cord was controlled with pressure

by moist cotton pledgets and the application of tiny muscle stamps or of

fibrin foam when it was available. For the record, an attempt was made

to estimate the extent of contusion and laceration of the cord or cauda equina.

Every effort was made to obtain a tight closure of the dura. Small round

needles and fine silk facilitated this procedure. If dural defects remained, a

free graft of fascia was cut from the paraspinal muscles. Many times, such

a graft could not be sutured in a watertight manner, but it could usually be

tacked in position with a few fine silk sutures (fig. 14 B). When the dural

defect extended to the anterior aspect of the cord, a fascial graft was usually

necessary, supplemented by a tight approximation of the paraspinal muscles

above this area.

There was considerable difference of opinion in World War II, as there

had been previously, whether dura which had been depressed and contused

but not penetrated should be opened at operation. Since the spinal cord

itself does not respond to any operative manipulation and since bleeding in

the subarachnoid space is distributed longitudinally without local extrameclullary clot formation and compression, there would appear to be no therapeutic reason for opening the dura when it is certain that it has not been penetrated. It has been argued that it is of considerable prognostic importance

in subsequent management of the patient to inspect the cord at the point of

injury. This might be true when anatomic destruction of the cord could be

visualized directly, but this type of destructive injury was extremely infrequent in the presence of an intact dura. On the other hand, if the cord was

not divided, even direct inspection of the amount of edema, contusion, and

intramedullary hemorrhage present did not furnish a reliable indication of

what future function might be.

One reason for not opening the dura was the possibility of introducing

contaminated material into a previously clean subarachnoid space. There

was also the risk of additional damage by any manipulation of an edematous,

contused cord. There seemed, therefore, to be little indication for opening

the dura if it had not already been penetrated.

Closure of wound.—Careful approximation of the paraspinal muscles in

the midline in the region of the bony defect was always carried out. This

was necessary to obliterate dead space in the wound, as well as to prevent

the formation of a cerebrospinal fluid fistula when the dura could not be

closed accurately. Unless gross sepsis was present, laminectomy wounds

were closed in layers with silk sutures, without drainage (fig. 15). If a

contaminated wound had been excised through the operative incision, the

skin and subcutaneous tissues were sometimes left open, but the muscles and

498991^—59 6
56 NEUROSURGERY

fascia were carefully approximated. When wounds of entrance or exit were

debrided separately from the operative approach for laminectomy, they were

handled like all soft-tissue wounds except that, if the dura had been penetrated, the muscular and fascial layers were closed, to prevent spinal fluid

leakage.

Local chemotherapy.—There was considerable variation in the use of

local chemotherapy by individual surgeons. It became a common practice,

after closure of the dura, to dust all layers of the wound with a powder

made by mixing 1 gm. of sulfanilamide with 5,000 units of penicillin. Penicillin in liquid form, well diluted (1,000 units per cubic centimeter), was

sometimes introduced into the subarachnoid space. In some theaters, local

sulfonamide therapy was not used at all, and a sulfonamide was never introduced beneath the dura. The general conclusion was that, as in craniocerebral wounds, penicillin locally, plus penicillin and sulfadiazine systemically, provided the most satisfactory routine of chemotherapy.

Hemilaminectomy

Occasionally, a small spinal wound could be debrided satisfactorily

through a unilateral approach (fig. 16). The standard exposure for removal

Metallic

foreign

body

Dural

defect

FIGURE 16.—Surgical exposure for hemilaminectomy. A. Location and

size of wound suitable for management by hemilaminectomy. B. Reflection of paraspinal muscles subperiosteally from one side only of spinous

processes and laminae, to reveal the small spinal wound. C. Exposure

of small dural laceration after debridement of depressed fracture and

removal of metallic foreign body. This small laceration can be readily

sutured through this limited approach.

of a herniated intervertebral disk or for unilateral cordotomy was found

applicable in these cases. Subperiosteal dissection of the muscles from the

vertebral spines and from the laminae on one side only was carried out, and

a deep retractor was used to maintain the exposure (fig. 16 B). Kemoval

of one or more laminae could then be accomplished as necessary, followed by
COMPOUND INJURIES OF THE SPINAL CORD 57

debridement of the dural wound (fig. 16 C). If intradural exploration of

any extent proved necessary, it was usually more satisfactory to do a bilateral laminectomy than to attempt operation through this limited exposure.

The following case history illustrates the use of hemilaminectomy ;•

A U.S. soldier was admitted to an evacuation hospital in Germany on 17 March 1945,

with paralysis of both lower extremities. He was alert, cooperative, and not in shock!

There was incomplete sensory loss at the first lumbar vertebra bilaterally, areflexia of

the legs, and retention of urine. There was a ragged wound of entrance in the upper

himbar region on the right, about 1 inch from the midline. Roentgenograms revealed

a metallic foreign body lying opposite the body of the twelfth thoracic vertebra on the

right, in the paraspinal muscles. They also showed a comminuted fracture of the transverse processes, laminae, and pedicles of the twelfth dorsal and first lumbar vertebrae

on the right, with a fracture of the neck of the twelfth rib.

Constant bladder drainage was instituted by means of an indwelling catheter. There

was no blood in the urine. Under local procaine hydrochloride anesthesia, supplemented

by a small amount of intravenous thiopental sodium, the wound margins were excised

and extended in the midline. The paraspinal muscles were reflected from the spinous

processes and laminae from the eleventh dorsal to the second lumbar vertebrae on the

right side. The spines were not fractured, but comminuted and depressed fragments of

the transverse processes, pedicles, and laminae of the twelfth dorsal and first lumbar

vertebrae were removed, as well as the comminuted medial end of the twelfth rib.

A 2.0- by 1.5-cm. metallic foreign body and several small pieces of cloth were removed

from the bony defect, which was then made smooth by rongeuring the margins of the

adjacent laminae. The dura, which was explored carefully and found intact, was not

opened. The pleura was also intact. There was no evidence of injury to the kidney.

Penicillin and sulfanilamide powder were dusted into all layers of the wound, which

was closed tightly in layers with silk.

The postoperative course was uneventful. Definite improvement in sensation, without return of motor power or reflexes, was observed up to the time of evacuation on

the sixth day.

POSTOPERATIVE CARE

No less important than operation in the early management of spinal

injuries were nursing and supportive care. This was true whether or not

early laminectomy had been performed. In hospitals in the forward areas,

where personnel and facilities were necessarily limited, the care of these

patients provided an especially difficult problem. The general principles of

good postoperative care of any major surgical procedure applied to these

injuries.

Routine Measures

Fluid administration.—Fluids were administered orally and parenterally

to maintain normal hydration and an adequate urinary output; this usually

meant the administration of 2,000 to 3,000 cc. daily. Transfusions of whole

blood were given to replace depleted hemoglobin and red cells. Plasma and

whole blood transfusions were also used to bolster falling serum protein

levels.

Sedation and control of pain.—Barbiturates and paraldehyde were administered for restlessness and sleeplessness. Codeine and morphine in stand-
j-s NEUKOSUKGERY

ard doses were used for pain except in injuries of the cervical portion of the

cord and instances of respiratory depression. While the spinal injury itself

was not often painful, associated wounds frequently were.

Chemotherapy and antibiotic therapy.—Since nearly all spinal wounds

were compound fractures, casualties routinely received postoperative systemic

penicillin therapy. Penicillin was given in closes of 20,000 to 40,000 units

every 3 hours and was continued for at least 5 to 7 clays. If the dura had

been penetrated, it was usually administered for 7 to 10 clays. If a spinal

fluid fistula persisted, penicillin was continued for longer periods. If clinical signs of meningitis developed, penicillin was continued systemically and

was also injected intrathecally by the lumbar route in doses of 10,000 to

20,000 units once or twice daily. Intrathecal penicillin was introduced in a

solution of 1,000 units per cubic centimeter of spinal fluid or physiologic salt

solution.

During the early postoperative period, sulfadiazine also was given by

most surgeons, in doses of 4 to 6 gm. daily and was continued in smaller

doses as long as constant bladder drainage was continued.

When early postoperative evacuation became necessary, it proved especially important to arrange for uninterrupted chemotherapy during transportation.

Special Postoperative Problems

Certain specialized problems in the management of spinal cord injuries

must be considered in more detail.

Position.—Air and water mattresses were not available iii forward hospitals in the early fighting on the Continent. Some forward hospitals, in

fact, had no mattresses at all. Beds were not available, but the standard

army cots and litters were always provided. After operation, the patient

was transferred to a cot, with a mattress if it were available. If no mattress

was available, one was improvised by placing on the cot at least three folded

blankets covered by a tightly stretched clean, dry sheet.

Measures to prevent hypostatic pneumonia were imperative m the first

few days after operation, particularly in cervical injuries. Nasopharyngeal,

intratracheal, and bronchoscopic suction was employed as indicated for removal of excessive secretions. It was sometimes thought desirable to leave

the patient flat on his back for a few hours postoperatively, to promote early

sealing of the operative wound. Thereafter, he was to be moved at least

every \ hours, day and night. Unfortunately, this plan was not always feasible in active field and evacuation hospitals, though every effort was made

to alter the position at some regular interval. Alert, cooperative patients

could often be instructed to keep track of the time for movement themselves

and to notify the attendants.

A change of position did not necessarily mean moving from back to

abdomen every 2 hours, or even from side to side. The buttocks could be
COMPOUND INJURIES OF THE SPINAL CORD 59

raised alternately 2 or 3 inches with a small, soft pillow, a folded sheet, or

towel. The legs could be shifted a few inches or rotated a few degrees. The

legs were always kept separated by a pillow (fig. 17), and the points of

pressure on this pillow were changed frequently. This type of adjustment of

position could be carried out easily and safely by a single nurse or an aiclman.

For turning the patient from back to abdomen or from side to side, which

was necessary at less frequent intervals, additional attendants were needed.

At all times, when the paralyzed patient lay on his back an effort was

made to keep a pillow under his calves, so that his heels did not touch the

bed (fig. 18). No attempt was made to hyperextend the spine except in

fractures in the cervical region. In them, the head was allowed to fall back

slightly by placing a small pillow or folded blanket under the shoulders to

elevate them 2 to 3 inches (fig. 18 B). The prone position was well tolerated

by patients with thoracic and lumbar injuries.

Care of the skin.—It has often been pointed out,11 and it should be reemphasized here, that bedsores are always pressure sores; they are not trophic

disturbances of the skin. Every decubitus ulcer is preceded by a pressure

area in which subsequent ischemic necrosis takes place. In spite of general

knowledge of this fact, adequate care of the skin in spinal cord injuries

proved one of the most difficult tasks the personnel of medical units in forward areas were called upon to perform.

The sequelae of pressure necrosis over bony prominences were, however,

so distressing that all possible measures of prevention, no matter how laborious or time consuming, were attempted. Measures for the care of the skin

of patients who had been operated on were usually initiated immediately

after operation and were maintained as rigidly as the facilities and personnel permitted. An effort was made to give daily skin care to the area below

the level of the lesion, with special attention devoted to the sacrum, trochanters, and heels. This entire area was massaged with alcohol, carefully dried,

and powdered at least once daily and offener if possible. Every attempt was

made to keep the bed coverings dry at all times and as free from wrinkles

as possible. Wet sheets or blankets demanded immediate replacement. All

of these measures were feasible in hospitals in the forward areas except

under the most unusual circumstances. The efficiency with which they were

carried out determined, in large degree, the general status of the patient and

the speed of convalescence when hospitals in rear echelons were reached.

Psychiatric care.—The depression experienced by patients with spinal

cord injuries upon realization that paralysis might be permanent was often

profound. Every reassurance that could be given, therefore, to sustain a

' 11 (1) Davis, Loyal E.: The Principles of Neurological Surgery. Philadelphia : Lea & Febiger,

1946, 3d ed., pp. 321-322. (2) Kaaf, J. : Treatment of the Patient With Spinal Cord Injury.

Am J. Surg. 67: 263-279, February 1945. (3) Munro, D. : Thoracic and Lumbosacral Cord Injuries: A Study of 40 Cases. J.A.M.A. 122: 1055-1063, 14 Aug. 1943. (4) Munro, D. : Tidal

Drainage and Cystometry in the Treatment of Sepsis Associated With Spinal-Cord Injuries. New

England J. Med. 229 : 6-14, 1 July 1943.
60 NEUROSURGERY

FIGURE 17.—Proper position of paralyzed patient with either

thoracic or lumbar spinal wound. A soft pillow between the

knees keeps the legs from touching one another. Another small

pillow against the back allows frequent adjustment of the position of the trunk.

Sandbag

FIGURE 18.—Proper position for patient with compound fracture

through low cervical or upper thoracic spine. A. View from above

showing sandbags on both sides of head to prevent rotation and

lateral deviation. Note that the indwelling catheter is connected

to a tube which passes over the patient's thigh and is attached

to the mattress with sufficient slack to prevent any tensions on

the catheter. B. View from side. A broad pillow under the

calves prevents the heels from touching the mattress, and a pillow

under the shoulders allows the head to fall back in extension.

Sandbags hold the head steady, as shown in view A.
COMPOUND INJURIES OF THE SPINAL CORD 61

casualty through the long period before any visible progress toward selfsupport was achieved proved highly desirable. An early, detailed explanation to the patient of the possibilities for adequate living with his disability

often gave invaluable encouragement.

CARE OF THE BLADDER

Retention of urine, with a variable degree of overflow incontinence, was

an immediate result of injury to the spinal cord at any level. The condition

was not painful, because of the loss of sensation. It was of paramount

importance, therefore, that these facts be remembered, so that management

of the paralyzed bladder could be started at the earliest possible moment.

Usually, an indwelling urethral catheter was inserted under aseptic precautions as soon as feasible after the diagnosis of spinal cord injury had

been made. It was important not to wait to see how much retention there

would be, since, if marked distention of the bladder was once permitted,

subsequent recovery of bladder tone and the development of automaticity

were greatly delayed. Ideally, catheters should have been inserted at the

first battalion aid or clearing station in which the patient was treated. Actually, circumstances did not often permit this, and urinary drainage was not

usually instituted until after the patient's arrival at an evacuation or field

hospital.

There are several ways of managing urinary retention in spinal cord

injuries. All, however, were not practical in the forward areas.

1. Nonintervention, which simply means allowing the bladder to distend

and overflow intermittently, is disastrous. Retrograde dilation and infection

of the urinary tract invariably follow, and the constantly wet bedclothes

quickly lead to breakdown of the sacral skin.

2. Repeated catheterization is a method of management which is mentioned only to be condemned. Under any circumstances, it is undesirable,

and in the forward areas conditions did not permit the regularity and strict

asepsis necessary to make this method at all feasible.

3. Manual compression, consisting of firm pressure on the bladder

through the lower abdominal wall at 4-hour intervals, often produces satisfactory emptying of the bladder in the absence of obstruction. It obviates

the danger of introducing infection. It must, however, be carried out with

considerable care and with absolute regularity, and for these reasons it was

impractical in the treatment of patients in forward areas and during long

periods of transportation.

4. The use of an indwelling urethral catheter proved to be the most

widely adaptable and most satisfactory method of bladder management.

Foley type catheters were not available. A soft rubber catheter large enough

to fit the urethra snugly (No. 16 to No. 22 F.) was inserted into the bladder

under aseptic precautions and securely fastened to the penis with adhesive
62 NEUROSURGERY

strips. The indwelling catheter was attached to rubber tubing, which was

always led out over, rather than under, the patient's thigh and into a constant drainage bottle at the side of the cot. The tubing was fastened to the

side of the litter or cot in such a way as to permit turning the patient without tension on the catheter (fig. 18). Attention to the details of catheterization and to the arrangement for constant drainage was worthwhile and

did much to prevent catheters from leaking and coming out unnecessarily.

Indwelling catheters were irrigated at least once daily and were changed

weekly. Systemic chemotherapy was instituted in all patients in whom constant urethral drainage was employed, and a daily urine output of at least

1 000 cc. was maintained.

The studies of Munro12and many others have shown that early return

of bladder tone and automaticity is best promoted by the use of tidal drainage. In units in forward areas, however, where equipment, time, and personnel were all limited and where transfers from one hospital to another were

frequent and often unforeseen, tidal drainage proved entirely impractical.

When nontransportable patients remained in the forward areas for 10 to 14

days, it was occasionally used, but, ordinarily, simple, constant urethral

drainage was employed until the patients reached a general hospital in the

rear.

5. Suprapubic cystostomy was preferred by many surgeons in the forward areas. This method was always indicated in the presence of a purulent

urethritis or balanitis or in the presence of any injury or obstruction of the

urethra itself. It was employed by most surgeons only in nontransportable

cases and in other circumstances in which it was evident that it would be

10 to 14 clays before the patient would reach an installation where tidal

drainage could be established and continued satisfactorily. Suprapubic cystostomy was easily carried out under local anesthesia, or, in many of these

cases, under virtually no anesthesia, through a short miclline incision centered approximately halfway between the umbilicus and the pubis. It was

important not to bring the catheter out too close to the pubis because of the

clanger of osteomyelitis. Perineal urethrostomy, in the hands of some Urologie surgeons, proved to have some mechanical advantages over Guprapubic

cystostomy and was occasionally used in the forward areas.

In summary, the most satisfactory management of the paralyzed bladder

consisted of the earliest possible insertion of a sufficiently large, well-secured

urethral catheter, with maintenance of uninterrupted bladder drainage and

the use of systemic chemotherapy until tidal drainage could be established

at a fixed medical installation. Early suprapubic cystostomy was also satisfactory but was reserved by most surgeons for patients who presented local

12 (1) 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 England J. Med. 236: 223-235, 13 Feb. 1947.

(2) Munro, D., and Hahn, J. : Tidal Drainage of the Urinary Bladder: A Preliminary Report of

This Method of Treatment as Applied to "Cord Bladders" With a Description of Apparatus. New

England J. Med. 212 : 229-239, 7 Feb. 1935.
COMPOUND INJURIES OP THE SPINAL CORD 63

injury, obstruction, or infection and in whom constant urethral drainage was

impossible or undesirable.

CARE OF THE GASTROINTESTINAL TRACT

Retention of feces as well as of urine was the usual immediate response

to cord injury. For this reason, enemas were begun during the early postoperative period and were usually given every 2 clays to prevent fecal impaction and incontinence. In lesions of the cervical and thoracic regions, atony

of the bowel was frequently sufficient to produce distressing abdominal distention. Ileus was relieved by the administration of neostigmine bromide

(Prostigmin bromide) and vasopressin (Pitressin) or by the insertion of a

Miller-Abbott tube.

The use of the bedpan by paralyzed patients always introduced problems. It was necessary to raise the buttocks and thighs and the lower part

of the back on pillows or folded blankets, so that the weight was never carried on the bedpan itself. Pressure on the skin over the sacrum could thus

be avoided.

NUTRITION

It was found important, from the earliest possible moment, to devote

special attention to the nutrition of patients with spinal cord injuries. The

subsequent recovery of motor and sensory function, as well as the development of automaticity of the bladder and rectum, was shown to be markedly

retarded in the presence of poor nutrition. The nutritional factor was also

found to be extremely important in both the development and the healing

of pressure sores. It was therefore essential to maintain an adequate caloric,

protein, and vitamin intake from the beginning. Falling serum protein levels in the early period after injury were corrected by transfusions of plasma

and whole blood. If the oral intake was not sufficient, it was supplemented

by fluids and vitamins given parenterally, or by high-caloric, high-protein

feedings by tube.

EVACUATION

In perhaps no other type of injury was the desirability of early evacuation of the patient to a fixed medical installation so great as in spinal cord

lesions. Because the problems of nursing care in forward areas made satisfactory management so difficult, every effort was made to move these patients

as soon as possible to hospitals staffed with adequate medical and nursing

personnel and equipped with beds, mattresses, and facilities for tidal drainage of the bladder.

If no other complicating wound existed, casualties with spinal injuries

could be evacuated within 3 to 5 clays after laminectomy, or even earlier in

most instances. An attempt was always made to expedite transportation

to a neurosurgical center once evacuation had been decided upon.

49S99P'—59 7
64 NEUROSURGERY

Whether or not these patients had been operated on in a forward area,

evacuation was undertaken only after certain preparations could be made,

as follows:

1. The patient was placed on the litter on a mattress of folded blankets

covered by a dry, tightly stretched sheet.

2. Arrangements were made as far as possible to continue chemotherapy

without interruption en route.

3. A well-fitting, tightly secured urethral or suprapubic catheter was

in place.

4. Arrangements were made for the maintenance of continuous urinary

drainage and for adjustment of the patient's position at frequent intervals

during transportation.

Unavoidable delays in transportation due to the exigencies of warfare

occurred all too frequently and often contributed to the development of

pressure sores which might otherwise have been avoided. It was, therefore,

frequently a matter of individual judgment, depending upon the particular

circumstances, to decide the optimum time for evacuation. If transportation

facilities were poor but held promise of improvement, it was preferable to

keep the patient in a forward unit and carry out surgical and supportive

treatment there until rapid evacuation became available.

Because of its speed and comfort, air transportation proved the ideal

method of evacuation of patients with these injuries of the spinal cord, who,

therefore, were given the highest priority for movement by air. An effort

was made to route them from forward units directly to the nearest airstrip

for evacuation to a fixed neurosurgical installation in the rear.

FACTORS OF MORTALITY

Death in the acute stage of spinal cord injury occurred principally in

two groups of casualties: (1) Those with transections of the cervical part

of the cord, and (2) those with complicating injury to vital structures in the

chest. In both of these groups, shock was profound and was often lethal

in spite of treatment. The usual cause of death, however, was respiratory

failure due to (1) interruption of the innervation to the muscles of respiration, or (2) insufficient aeration brought about by accumulation of secretions

in the respiratory tree, by direct injury to the lungs themselves, or by

massive hemothorax. Occasionally, patients with injuries of the thoracic and

lumbar parts of the spinal cord succumbed although they might have survived but for associated injury to abdominal viscera. The actual early

mortality rate from spinal cord injury itself is, therefore, difficult to determine.

No attempt will be made here to report complete statistics, but the

results obtained in the early treatment of these wounds can be illustrated

in a general way. In 482 patients with spinal cord injury who reached
COMPOUND INJURIES OF THE SPINAE CORD 65

field and evacuation hospitals of the First U.S. Army alive during a 9-month

period, the overall mortality was 14.5 percent. This figure is almost identical

with that observed at two individual evacuation hospitals; 93 patients were

treated at the 45th Evacuation Hospital, with a case fatality rate of 16.1

percent, and 85 cases at the 128th Evacuation Hospital, with a case fatality

rate of 14.1 percent.

Accurate conclusions regarding postoperative case fatality rates in the

acute stage are even more difficult to ascertain because of the wide discrepancies in individual surgeons' indications for laminectomy and because

of the lack of uniformity in periods of postoperative observation in forward

hospitals. It was amply proved, however, that early laminectomy itself was

not a hazardous procedure in competent hands when the proper neurosurgical equipment and supportive therapy were available. Postoperative

meningitis without a persistent spinal fluid fistula was extremely uncommon

and was usually readily controlled by systemic and intrathecal penicillin

therapy. As in cord lesions that were not operated upon, early fatalities

were usually caused by pulmonary edema or occurred in the presence of

severe associated injuries of thoracic or abdominal viscera.

The figures in table 3, reported by individual surgeons, concern postoperative observations varying from 2 or 3 days up to 2 weeks, but it is

believed that they are of general significance:

TABLE 3.—Specimen ease fatality rates in surgery of spinal cord injuries

Surgeon Surgical

cases

Case fatality rate

Tinsley _

Haynes

Matson _

Pool

22

76

33

35

4.5

7.9

6. 1

11. 4
CHAPTER VI

Urologie Aspects of Spinal Cord Injuries

George C. Prather, M.D.

As a result of the cooperation of specialists in many fields, the outlook

for patients who sustained spinal corcl injuries in World War II was greatly

improved over that of patients with similar injuries in World War I. This

chapter is concerned with the role of the urologic surgeon in that cooperative

endeavor. The literature on the subject before 1941 is included, since most

of the diagnostic and therapeutic procedures employed in Army hospitals

had previously been tested in civilian clinics. World War II simply supplied

the opportunity for their trial on a mass scale.

THE STATUS OF THE BLADDER AFTER INJURY OF THE

SPINAL CORD

Historical Note

Severe injury of the spinal cord produces a profound effect on bladder

activity. Recorded observations in man and in animals show that, in the

absence of complications, time has an important, though variable, effect on

bladder physiology. The immediate disturbances and subsequent changes

in the bladder may be described as stages in the natural process of recovery.

Knowledge of these phenomena is essential for a proper interpretation of the

status of the bladder at a given time, as well as for the formulation of

opinions regarding the eventual results and the evaluation of various forms

of treatment.

Even though it was known that, in animals, bladder activity could be

resumed after spinal cord injury, Kidd,1in 1919, stated that before World

War I patients seldom recovered from paraplegia; that a bladder, once

paralyzed, was not likely to recover; and that an automatic bladder was a

rarity. He emphasized the importance of the demonstration by Head and

Riddoch2of the possibility of the establishment of an automatic bladder

in battle casualties.

1 Kidd, F.: The Treatment of the Bladder in Gunshot Injuries of the Spinal Cord. Brit. M..T.

1 : 397-399. 5 Apr. 1919.

2 Head, H., and Riddoch, G. : The Automatic Bladder, Excessive Sweating and Some Other

Reflex Conditions, in Gross Injuries of the Spinal Cord. Brain 40 : 188-263, November 1917.

67
68 NEUROSURGERY

Holmes,3in 1933, in a study by cystometric methods of the recovery of

bladder activity after spinal cord injury identified three stages which merged

into each other. Munro,4in 1936, recognized three stages in the recovery

process if the cord transection was above the sacral segment; when the

lesion was due to hematomyelia or edema at any level, he thought that four

stages could be recognized. J

to^

PROGRESS OF RECOVERY

Observations by cystometric methods in World War II pointed to three

stages of recovery, though the cystometric picture in the third stage depended

upon whether or not transection was partial or complete. These stages are

best conceived of as recognizable but merging phases of a gradual and continuous development. The duration of each stage varied in the patients

studied in World War II and was also subject to fluctuation according to

the presence or absence of complications, not only in the urinary tract but

in other parts of the body.

Spinal Shock

Before the three stages in the natural process of recovery are discussed,

it is necessary to consider the phenomenon which, in 1843, was termed

"spinal shock" by Marshall Hall (cited by Fulton and McCouch).5This

term has continued in good usage to the present time. Spinal shock, which

dominates the picture in the first stage of recovery, refers to the immediate

but usually temporary suppression of all reflexes caudal to the injured segment. It has been defined by Munro as "that condition which when caused

by spinal injury of any type produces suppression or alteration of segmental

reflex activity below the level of the cord injury."

Spinal shock occurs in all vertebrates, its intensity varying with cerebral

development. This is consistent with observations that the severity or duration of the phenomenon, or both, are progressively manifested in the cat,

dog, monkey, chimpanzee, and man. Fulton and his associates6demonstrated

that, in the cat, spinal shock does not occur unless the ventral quadrant of

the spinal cord is sectioned. Later, Fulton and McCouch pointed out that,

in man, section of the corticospinal tract leads to spinal shock. They

further suggested that the present concept of spinal shock indicates a suppression of reflexes caused by sudden withdrawal of continuous excitation

which normally occurs from suprasegmental levels via the descending pathways.

3 Holmes, G. : Observations on the Paralyzed Bladder. Brain 56 : 383-396, December 1933.

4 Munro, D. : The Activity of the Urinary Bladder as Measured by a New and Inexpensive

Cystometer. New England J. Med. 214 : 617-624, 26 Mar. 1936.

5 Fulton, J. F., and McCouch, G. P. : The Relation of the Motor Area of Primates to Hyporeflexia ('Spinal Shock') of Spinal Transection. J. Nerv. & Ment. Dis. 86: 125-146, August 1937

6 Fulton, J. F., Liddell, E. G. T., and Eioch, D. M. : The Influence of Experimental Lesions of

the Spinal Cord Upon the Knee Jerk. I. Acute Lesions. Brain 53 : 311-326, October 1930.
UROLOGIO ASPECTS OP SPINAL CORD INJURIES 69

First Stage of Recovery

After injury of the spinal cord, the bladder, as a reflex organ, is immediately affected and dominated by spinal shock, as shown by atonicity of

the bladder wall and loss of reflex contractions of the detrusor. The bladder

thus becomes distended to large capacity, reaching to, or above, the umbilicus.

Overflow incontinence, which may occur after a period of 24 to 48 hours,

is the only type of urination that can be expected. Cystometric studies

during this stage show a bladder of large capacity and low intravesical

pressure, without evidence of reflex detrusor activity (the so-called atonic

neurogenic bladder). Holmes found no pressure recorded until 4 to 8 oz.

of fluid had been introduced into the bladder. The pressure then rose slowly,

reaching a level of 8 to 10 cm. H20 when 20 oz. had accumulated. The

pressure curve repeated itself when the bladder was emptied. Cystitis caused

no change in the cystometric record, and the findings were the same for

injury at all levels of the cord and for injuries of the cauda equina. In

other words, the bladder, at this stage, presented only the property of

elasticity.

Holmes stated that the first stage of recovery lasted from a period of

days to one of weeks. According to Thomson-Walker,7it may last from

24 hours to 18 months.

Second Stage of Recovery

After a variable period of time, a return of mild reflex activity caudal

to the injured segment usually becomes evident and produces changes in the

activity of the vesical musculature. Progression from the first to the second

stage occurs gradually but can be demonstrated by cystometric study. The

bladder now has a smaller capacity, intravesical pressure is increased, and

the curve rises more rapidly. Although reflex contractions of the bladder

can be observed, they are of insufficient strength or duration to produce

efficient emptying. According to Munro,8these contractions are due to a

reflex arc that lies wholly within the bladder wall. The term "autonomous

cord bladder" is used to describe the status of the bladder at this stage.

Several observers9believe that the autonomous bladder may represent the

final stage of recovery in cases in which there has been complete transection

of the cord at the level of the sacral segments or cauda equina.

' Thomson-Walker, J.: The Treatment of the Bladder In Spinal Injuries in War. Brit. J. Urol.

9 : 217-230, September 1937.

8 Munro, D.: Treatment of the urinary Bladder in Cases With Injury of the Spinal Cord.

Am. J. Surg. 38 : 120-136, October 1937.

9 (1) Lewis, L. G.: Treatment of the Neurogenic Bladder After Acute Spinal Injury. S. Clin.

North America 23: 1505-1525, December 1943. (2) Munro, D.: The Cord Bladder—Its Definition,

Treatment and Prognosis When Associated With Spinal Cord Injuries. New England J. Med.

215: 766-777, 22 Oct. 1936. (3) Nesbit, E. M., and Gordon, W. G.: The Management of the

Urinary Bladder in Traumatic Lesions of the Spinal Cord and Cauda Equina. Surg. Gynec. & Obst.

72(2A) : 328-331, February 1941.
70 NEÜKOSURGERY

The clinical manifestation of the second stage of recovery is overflow

incontinence. The amount of residual urine is smaller than in the first stage,

perhaps because bladder capacity is not so great.

Third Stage of Recovery

Further recovery of the bladder beyond the second stage depends upon

several factors, including the extent of the injury of the spinal cord, the

level of the injury, the severity of bladder infection, and the general condition of the patient. The type of bladder to be reasonably hoped for in the

final stage of the recovery process depends upon whether transection of the

spinal cord has been partial or complete.

Complete transection of the cord.—Patients with complete transection

of the cord show complete functional interruption of the cord at a given

level for a long period of time. In some cases, this is demonstrable when

the cord is visualized at operation. If laminectomy has not been clone,

patients are regarded as falling within this category if they show no evidence

of voluntary motor power or return of sensation below the level of the

injury during a period of at least 6 months after injury.

It is expected that the bladder of the patient with complete transection

of the cord will progress to a final stage in which periodic, involuntary,

forceful, and efficient micturition is characteristic. The patient has no

voluntary control over the periodic reflex voiding, but during the 1-hour to

4-hour intervals between voidings, there is no leakage of urine. The patient

with this type of bladder becomes familiar with his individual time schedule

and learns to govern his activities accordingly. It was observed in patients

in World War II, though it was never explained, that the intervals between

voidings were frequently much longer when the patient was in the sitting

position than when he was recumbent in bed. Bladder capacity in this

final stage was found to vary between 150 and 400 cc. and residual urine

from 30 to 90 cc.

It was observed in Army paraplegic centers that emptying contractions

of the bladder usually created an intravesical pressure of 70 cm. H20 or

more. Holmes found oscillations of bladder pressure independent of reflex

contractions of the legs and did not regard bladder activity as part of a mass

reflex. Head and Eicldoch, on the other hand, had found that peripheral

stimuli often initiated automatic reflex evacuation of the bladder except in

cases of complete transection of the cauda equina.

The term "automatic reflex bladder" is used to describe the type of

vesical activity achieved by patients in the third stage of recovery. It is

the normal end of the path of recovery in patients who have had complete

transection of the spinal cord. Most with complete transection can be

expected to progress to this stage, although a few appear to remain in the

first or second stage; even when the nerve lesion is above T10, bladder in-
UROLOGIC ASPECTS OF SPINAL CORD INJURIES 71

fection is minimal, and the general condition is excellent. Limited recovery

is usually associated with flaccid paralysis of the lower extremities. The

cause of failure of progression to an automatic type of bladder is not

clear, but it is possible that lack of vascularity in the distal segment of the

spinal cord has led to necrosis and that insufficient tissue remains to permit

a suitable reflex arc.

Partial transection of the cord.—Patients with partial transection of the

spinal cord show some evidence of voluntary motor power and sensory

appreciation below the level of the lesion, although it may not be evident

for several months after injury. The expectation is that patients in this

category will progress to a third or final stage of bladder recovery characterized by voluntary micturition sufficient to produce efficient emptying of

the bladder. Control is voluntary, although during the act of voiding it

may be necessary to use manual pressure over the lower abdomen, or there

may be straining and diminished sensation over the bladder region. The

organ under these circumstances can be termed a "voluntary neurogenic

bladder." Bladder capacity is within normal limits, and residual urine

varies in amounts.

Although the terms "complete transection" and "incomplete transection"

have been emphasized because of their importance in predicting eventual

outcome and evaluating the results of treatment, it is often difficult to state

with assurance immediately after injury whether or not the lesion is complete.

During spinal shock, no reliable data can be secured about the degree of

nerve injury.10

Level of injury.—The level of injury in the cord may have some bearing

on the degree of recovery. Denny-Brownnand Head 12 recorded cases of

complete transection at the level of the conus or cauda equina in which an

automatic reflex type of bladder developed, but Lewis and Riches pointed

out that patients with complete lesions above the lumbar segments develop

an automatic type of voiding much more consistently than tnose whose

lesions are below that level.

Other factors.—Other factors of importance in the recovery process include a positive nitrogen balance; freedom from toxic and febrile states;

absence of decubitus ulcers; and absence of gross infection of the bladder

wall, this being essential for recovery of the organ, since infection of the

muscle layers followed by fibrosis would naturally militate against satisfactory bladder function. Experience with paraplegic patients in World

War II confirmed the importance of all these statements.

10 Kienes, E. W. : Methods and Results of Treatment in Cases of Paralysis of Bladder Following Spinal Injury. Brit. ,T. Surg. 31 : 135-146, October 1943.

11 Denny-Brown, D. E. : Nervous Disturbances of the Vesical Sphincter. New England J. Mod.

215 : 647-652, 8 Oct. 1936.

12 Head, Henry : Studies in Neurology. London : Henry Frowde, Hodder & Stoughton Ltd.,

1920, vol. II, passim.
72 NEUROSURGERY

METHODS OF EXAMINATION OF THE BLADDER

Study of the bladder and of the region of the bladder neck is essential

in every case to secure comparative data and to determine the method of

treatment necessary for optimum results. Not all methods of examination

are applicable in every case, nor, as was demonstrated in World War II,

are they all essential in the days or weeks immediately following injury,

but they should be used selectively, according to the needs of the individual

case. The most important of these methods are urinalysis, determination

of residual urine, cystometry, cystoscopy, and cystography.

Urinalysis

Examination of the urine in paraplegic subjects contributed the greatest

amount to knowledge of the condition of the bladder. Immediate examination of a freshly obtained specimen was stressed, and it was recommended

that, at intervals, the specimen be examined by the urologist himself, personal correlation of microscopic findings and clinical picture being preferable

to the usual formal data entered on a laboratory report.

The centrifuged urine sediment, when carefully examined under the

high-powered dry lens (or oil immersion if the specimen was stained), provided an approximate indication of the degree of infection in the bladder,

though it did not necessarily indicate the state of the bladder mucosa.

During an acute urinary infection, with pyuria, the bladder mucosa was

always infected and red and perhaps showed edema or hemorrhagic areas.

In patients with mild, chronic infection, there was usually no change from

normal, but when bacteria were present in bladder urine, potential cystitis

and pyelitis were also present.

Badal, Munro, and Lamb,13 in a careful cultural study of urines of

patients on tidal drainage, concluded that bacteria are always present in

the bladder 72 hours after the introduction of an indwelling catheter. The

most common organisms found in their studies were Proteus vulgaris. Escherichia coli, and alpha hemolytic streptococci. Prather's studies of routine

cultures taken from the distal ends of urethral catheters or suprapubic tubes

after several months of drainage showed staphylococci, Pseudomonas aeruginosa, P. vulgaris, and Esch. coli as the most common urinary inhabitants.

Predominating organisms changed from week to week.

There is no doubt that any kind of tube kept in the bladder for more

than 40 hours acts as a foreign body and gives rise to a foreign-body reaction which provides a locus for bacterial growth. Bacterial growth

ensues, as in other parts of the body, but, also as in other parts of the body,

if the region is properly drained and cleansed and if adequate body resistance

is maintained, clinical evidence of infection does not develop. A positive

13 Badal, D., Munro, D., ana Lamb, M. E. : Clinical Significance of Bacteriuria in Patients

With Spinal-Cord Injuries. New England J. Med. 230 : 688-693, 8 .Tune 1944.
UROLOGIC ASPECTS OF SPINAL COED INJURIES 73

urine culture with any type of bladder drainage therefore indicates potential, but not necessarily actual, clinical disease.

Cultures were also always desirable for another reason, to determine

proper medication should clinical evidence of sepsis occur.

David's14experimental studies can be correlated with clinical experience. After injection of Bacillus coli into the bladders of normal dogs, he

found that organisms remained in the urine for some time but that no

histologic evidence of cystitis or pyelitis appeared. If an animal had a

bladder residual, however, the introduction of bacteria into the bladder

caused ulcerative cystitis and renal infection. After section of the lower

dorsal spine of the experimental animal, infection in the wound in the back

was followed by bladder infection with the same organisms.

Cystometry

Cystometry is useful to determine bladder tone (the relation of the

volume of bladder content to intracystic pressure), the presence or absence

of reflex contractions of bladder muscle, bladder capacity, maximum voluntary pressure, and sensation to bladder distention. Although various

forms of instruments for cystometry are available, a simple model, which

is easily disassembled and sterilized, is entirely adequate. The model

shown (fig. 19) has no automatic recording device. More can always be

learned about the individual patient by close observation while the examination is in progress than can be gathered from a casual survey of a

completed record. In some models used for tidal drainage, cystometric

observations can be made without additional equipment.

Two features are important in any apparatus used for cystometry.

First, a water (or very sensitive aneroid) manometer is required to measure

small changes in intracystic pressure. In addition, a constant drip method

of filling the bladder during the procedure is to be preferred to the older

method of introducing 25-cc. to 50-cc. increments of fluid into the bladder

at intervals. By the constant drip method, the manometer is not shut off,

no reflex activity is missed, and there is no confusion or delay while one

awaits the downward stepladder changes in pressure so common immediately

following the sudden introduction of larger amounts of fluid.

Normal bladder activity.—There are some differences of opinion concerning normal bladder activity as demonstrated by cystometric studies. Munro

described three types, as follows:

1. Spaced, emptyinglike contractions occurred throughout the experiment.

2. Emptying contractions occurred toward the end of a 400-cc. fill in the

form of unspaced tetanic contractions.

3. No emptying contractions occurred until over 400 cc. of fluid had been

introduced into the bladder.

14 David, V. C.: The Management of the Urinary Tract of Paraplegic Patients. J.A.M.A.

76: 494-497, 19 Feb. 1921.
74 NEUROSÜRGERY

Calibrated infusion flask -__,

(750-1,000 cc.)

Rubber tube and

screw clamp ~~ "

Closed drip bulb

Rubber tubing -

Stand

'-- Board calibrated in cm.

Glass tubing

Bladder

FIGURE 19.—Simple cystometer using principle of constant drip filling of

bladder and indication of intravesical pressure in centimeters H20. The set

consists of an infusion bottle, rubber tubing, straight glass tubing, and board

calibrated in centimeters. It is autoclaved between individual studies.

Simeone and Lampson 15 reported that cystometric curves observed in

their studies of normal individuals could be divided into an initial rise, a

relatively flat area, and a final sharp rise. Spontaneous bladder contractions

were practically never seen until a steep rise in pressure had occurred.

Muschat, Carp, and Charny 16 were of the opinion that too much stress was

ordinarily laid on the pressure curve and emphasized, instead, the composite

picture consisting of (1) the first desire to void, (2) the pressure curve,

which gradually rose, and (3) the maximal voluntary pressure of 60-80 mm.

Hg. Examples of pressure curves in normal individuals17are shown in figures 20 and 21.

Cystometric findings after injury.—Cystometric findings are immediately altered after injury of the spinal cord. During the period of spinal

shock, in the first stage of recovery, with associated loss of reflexes below

the level of injury, the pressure curve is fiat and low, bladder capacity is

15 Simeone, F. A., and Lampson, R. S. : Cystometric Study of the Function of the Urinary

Bladder. Ann. Surg. 106 : 413-422, September 1937.

16 Muschat, M., Carp, J., and Charny, C. W. : The Normal Cystometrogram. J. Urol. 37 : 718-

720, May 1937.

17 WatMns, K. H.: Clinical Value of Bladder Pressure Estimations. Brit. J. Urol. 6: 104-118,

June 1934.
IJROLOGIC ASPECTS OF SPINAL CORD INJURIES 75

Pressure

(cm. H20)

40

20

0

0

A

/

7*4-

100 200 300 400 500 600 700

Volume (cc.)

FIGURE 20.—Cystometric curves in centimeters H20 of normal bladder at

rest. Curve A represents the highest, and curve B the lowest, curve in a

series of examinations. First sensation is at 100 cc. in curve A and at

150 cc. in curve B. (From Watkins.)

Pressure

(cm. H,0)

400

FIGURE 21.—Cystometric curve. Pressures recorded on bladder with normal innervation The vertical lines rising from the curve at rest indicate the result of attempted

urination. The first three attempts had very little effect. A marked increase of pressure

resulted at the next two efforts, after the man was requested to strain as hard as possible with his abdominal muscles. At the last attempt at urination, the micturition

reflex was released, and the high pressure which results from contraction of the detrusor

muscle is shown. First sensation was noticed at 250 cc. (From Watkins.)
' ° NEÜROSURGERX

increased to 500 to 600 cc. or more, no reflex contractions are evident, and

the sensation of distention is lacking except when the lesions are low in the

spinal cord; then, painful sensations may be felt in the lower part of the

abdomen. An example of a typical cystometric chart in this stage (atonic

neurogenic bladder) is shown in figure 22.

Pressure

(cm. H20)

60

50

40

30

20

10

0

VP•

M

•

1 ,^- »—

i

•——

\^../

•—

100 200 300

Volume (cc.)

400. 500 600

Pressure

(cm. H20)

60

50

40

30

20

10

0

FIGTJKE 22—Cystometrogram showing

atonic bladder at first stage of recovery

following severe spinal cord injury. In a

few cases, this stage may be permanent.

MVP

•

MVP /

'

MVP V

V

./

/

200 ' 300 400

Volume (cc.)

500 600.

1 Lower abdominal pain.

FIGTJKE 23.—Cystometrogram illustrating

second stage of recovery in patient with

complete transection of middorsal portion

of spinal cord. The rise in pressure is

rather steep, but there are no reflex voiding contractions. The lesion is too high to

permit more than a 10-cm. rise by maximum voluntary pressure.

As the bladder begins to show recovery from spinal shock and the

second stage develops (autonomous cord bladder), the cystometric chart

reflects certain changes, including increased initial tonus; a fairly steep pressure curve; a capacity limited to that of a normal bladder; minor rhythmic

detrusor contractions, seldom greater than 10 cm. H20 and insufficient to

empty the bladder; lack of definite desire to void; and, in some patients,

a feeling of lower abdominal discomfort when the bladder is full. A cystometrogram taken at this stage is shown in figure 23.

Cystometric findings in the third stage of recovery depend upon whether

or not transection has been complete. Instances of complete transection, when

the bladder is of the reflex or automatic type, the following findings are

characteristic: normal to increased initial tonus; variable pressure curve;

a capacity between 150 and 400 cc; forceful reflex detrusor contractions',

with urination when capacity has been reached; no sensation of bladder distention; and, frequently, variable flushing or sweating reactions in the

upper part of the body when the bladder reflex is about to act. The

cystometric chart of this type of patient is shown in figure 24.
tTROLOGIC ASPECTS OF SPINAL CORD INJURIES 77

When transection of the cord is partial, urination is voluntarily controlled and cystometric findings may be very close to normal, especially

if the lesion is in the upper part of the cord (fig. 25). Figures 26 and 27

show studies on patients with partial transection of the cauda equma.

Pressure

(cm. H,0)

20

M VP•

•

-•

.•^^

• ~

50 100 150

Volume (cc.)

200 ' 250

FIGURE 24.—Cystometrogram illustrating third

or final stage of recovery in patient with complete transection of upper thoracic portion of

spinal cord. Reflex contractions occur periodically during constant filling, but they are insufficient to produce voiding until 150 to 200

cc. has accumulated in the bladder. The patient has an automatic reflex type of urination

at fairly regular intervals with no leakage of

urine between voidings.

1 Leakage around catheter.

The data just listed were collected routinely on all military casualties

in World War II. In addition, Mullenix18advocated that, in traumatic

paraplegias, there should be determination of active or maximum bladder

pressure routinely throughout the entire process of bladder filling. This was

done in numerous instances and gave interesting information.

FIGURE 25.—Cystometrogram in patient with partial transection of cervical portion of spinal cord. Voiding is

now voluntary, with perfect control.

The cystometric data, which are essentially normal, represent the typical

third or final stage of recovery in partial transections in the upper segments

of the spinal cord.

Pressure

(cm. H20)

60

50

30

20

MVP

•

'

/

•

/

^

• '

•

50 100 150 i 200 250 300

Volume (cc.)

1 Desire to void.

18 Mullenix, R. B. : Cystometry in the Study of the Traumatic Neurogenic Bladder. J. Urol.

55 : 470-482, May 1946.
78 NEUROSURGERY

Pressure

(cm. H20)

w 1 M VP •

70

60

50

40

y

,•

/

*

l

l

20

10 f

^^. •

0

^^^. i^

FIGUHE 26.—Cystometrograin in

patient with partial transection of

cauda equina. Recovery to the third

stage of voluntary voiding has been

accomplished. Because the nerve

lesion is low, maximum voluntary

pressure is essentially normal.

0 50 100 150 ' 200 250' 300

Volume (cc.)

1 Leakage around catheter.

Pressure

(cm. H,0)

40

SO Pain in Bla< der reg on

90 ^.i

> i.

^^, -**^ ^

^^ ' -^^"^ ^~"

0

:

() 5 D K 0 If 0 2C 0 2f 0 i 3C 0 -3" 0 4f 0 4" 0 51 o 5: 0 60

Volume (cc.)

1 Desire to void.

FIGUHE 27.—Cystometrogram in patient with partial transection of

cauda equina. Recovery is not yet complete. The pressure curve is

somewhat flattened, but, soon after this examination, the patient developed voluntary voiding, which had to be supplemented by abdominal

pressure.
UROLOGIC ASPECTS OF SPINAL COED INJURIES 79

Mullenix used the term "expulsive force" for the difference between

voluntary pressure and the usual passive values recorded during filling. He

believed this factor important in any prognosis of the ability to void.

Prather's interpretation of maximum voluntary pressure is that it reflects

either paralysis or integrity of muscles of the abdominal wall, its value being

primarily dependent on the level (and perhaps the extent) of the spinal

lesion. In injuries of the conus or caucla equina, with no paralysis of the

abdominal muscles, the voluntary contraction of these muscles raises intravesical pressure and may, to advantage, augment the reflex contractions of the

detrusor. In injuries of the upper part of the spinal cord, since the abdominal muscles cannot be voluntarily contracted, there is little difference

between the passive pressure and the maximum voluntary pressure. Observations in military casualties bore out these observations.

Cystometric responses vary, and changes from one stage of recovery

to another do not necessarily occur rapidly. Repeated examinations are

frequently required to obtain an accurate impression of the functional

capacity of the bladder muscle. Effectiveness in voiding may also be influenced by conditions in the region of the bladder neck and the urethra.

It was the opinion of all concerned with the management of battleincurred paraplegias and other traumatic types in World War II that

cystometric studies were an integral part of the complete study of bladder

physiology.

Cystoscopy

Cystoscopy was not recommended routinely as part of the examination

of paraplegic patients in the early period of their disability. Used selectively, and with due care to avoid trauma, it supplemented other examinations and at times was invaluable in disclosing and dealing with bladder

stones and in explaining abnormal roentgenologic findings. Unless it was

employed for special studies, it was used only during the latter part of the

recovery period, to identify changes in the bladder neck which needed correction in order to improve bladder function. Its use was strictly limited

to medical officers who were experienced with it; injuries of the lower urinary

tract at the hands of untrained cystoscopists could readily occur because

of absence of normal sensation in paraplegic patients.

The cystoscopic picture in the paraplegic patient varied with the stage

of recovery. During the first (atonic) stage, the mucosa was usually smooth,

with fine trabeculation. During the second stage, moderately heavy trabeculation was frequently found. During the third stage, patients with complete

transection who had developed an automatic bladder showed moderate to

heavy trabeculation. Patients with partial transection who were voiding

effectively with voluntary control showed normal mucosa if the spinal lesion

was high and coarse trabeculation if the injury involved the caucla equina.

Trabeculation, which indicates a thickened bladder wall, could ap-
80 NEUROSURGERY

parently not be explained entirely by the effort of the bladder muscle to

overcome urethral or vesical neck obstruction as it was observed in patients

who were still on drainage. Hargrave,19 in 1852, had noted a similar finding

at autopsy in a patient who had been treated by intermittent catheterization.

No abnormality was observed in the appearance of the ureteral orifices

except for occasional edema, presumably caused by contact with the catheter

or with a suprapubic tube placed too low in the bladder.

Although it is generally believed that the bladder neck, prostatic urethra,

external sphincter, and membranous urethra relax or open after contraction

of the detrusor muscle has begun, these regions are closely linked to the

physiology of the bladder. In a complete study of bladder action following

spinal cord injury, the region of the bladder neck deserves study along with

the bladder. Information concerning it was obtained by cystoscopy with

the Foroblique lens system or by urethrocystography. Sphincterometry as

developed by Simons 20 was not used in paraplegic centers, though its possibilities have since been expanded.

Cystoscopic and cystographic observations had been made by Uhle,21 in

1913, to study methods of bladder closure. Burns,22 in 1917, had made

similar studies in a series of tabetic patients; but Plaggemeyer,23 in 1921,

seems to have been the first to make cystoscopic studies in patients with

spinal cord injuries. He described complete relaxation of the prostatic

urethra and bladder neck, elevation of the trigone in some cases, and atrophy

in others. Cumming,24 in 1922, made cystoscopic observations in paraplegics

and described a relaxed bladder neck and a normal or hypertonic external

sphincter. In further studies,25 he demonstrated dilatation of the bladder

neck during the stage of overflow incontinence and concluded that the internal sphincter is regularly dilated and presumably inactive soon after the

onset of paralysis but regains tone in periods of recovery.

Prather's observations on patients with spinal cord injuries in Army

paraplegic centers, which were made through a No. 20 F. panendoscope with

Foroblique vision, may be summarized as follows:

1. The prostatic urethra and bladder neck were definitely relaxed and

dilated in patients with complete transection of the spinal cord in the

upper and middle thoracic segments who had flaccid paralysis below the

19 Hargrave, Professor (reported by Mr. Arthur H. Taylor) : Fracture of the Spine—Hypertrophy of the Bladder Caused by Long-Continued Disease of the Spinal Cord. Dublin M. Press

27: 161-163, 1852.

20 Simons, I. : Advances in the Field of Cystometry Due to Clinical Studies With the Sphincterometer ; Studies in Bladder Function ; Preliminary Report. J. Urol. 36 : 88-97, July 1936.

21 Uhle, A. A. : Clinical Observations Upon the Mechanism of Bladder Closure. Tr. Am. A.

Genito-Urin. Surgeons 8 : 303-313, 1913.

22 Burns, J. E. : The Bladder Changes Due to Lesions of the Central Nervous System ; Their

Description and Treatment. Surg. Gynec. & Obst. 24: 659-668, June 1917.

23 Plaggemeyer, H. W.: Final Report on Fractures of the Spine in Relation to Changes in

Kidney and Bladder Function. J. Urol. 6 : 183-193, September 1921.

24 Cumming, R. E.: Shell Fracture of the Spine and Changes in Kidney and Bladder Function ;

Further Observations. J.A.M.A. 78: 335-339, 4 Feb. 1922.

25 Cumming, R. E. : Structural and Functional Changes in the Urinary Tract Following Focal

Cord Lesions. J.A.M.A. 99 : 1998-2004, 10 Dec. 1932.
UROLOGIC ASPECTS OF SPINAL CORD INJURIES 81

level of the lesion and who had, as yet, failed to develop any sign of reflex

activity of the bladder wall.

2. The bladder neck appeared normal for the age group in the majority

of patients with complete transection of the cord in the upper or middle

thoracic segments whose bladders had recovered to the third (final) phase

and who were voiding periodically (automatic reflex bladder). In others

in this group, there appeared to be slight dilatation of the prostatic urethra.

3. Patients with complete transection at D12 or below invariably showed

moderate to considerable relaxation of the bladder neck and prostatic

urethra.

4. Most patients with partial transection at these lower levels revealed

slight to moderate dilatation in the same region.

5. When partial transection had occurred in the higher segments of the

cord, the bladder neck usually appeared normal.

Bumpus, Nourse, and Thompson 20 reported various degrees of vesical

neck relaxation after cystoscopic examination. In some patients, they found

constriction in the region of the internal urethral orifice, so that the bladder

and prostatic urethra had an hourglass appearance. In other cases, they

observed a bar type of deformity.27

Cystography

Cystography, which permits indirect observation of the bladder, was

used to determine the general shape of the organ, the presence and size of

diverticula, spasticity, and approximate capacity. Roentgenographic studies

were made after the injection of sterile sodium iodide (3 to 4 percent) or

Skiodan (8 to 10 percent) through a catheter or suprapubic tube. Films

of the bladder region about 45 minutes after injection of a medium for

intravenous pyelography usually provided satisfactory data if the drainage

tube in the bladder was clamped off during examination.

During the first stage of recovery (the period of spinal shock), cystograms showed a large, smooth-walled bladder, which, if filled to capacity,

would occupy the whole bony pelvis (fig. 28). A similar picture was likely

to be found in severe lesions of the cauda equina. In the second stage of

recovery, cystograms showed irregularities in the periphery of a bladder of

normal size, caused by trabeculations. In the third stage, the cystogram

of the distended automatic bladder frequently revealed a rounded appearance

with an irregular border consistent with trabeculation. During the third

stage, in patients with partial transection, the cystogram appeared normal

except in lesions of the cauda equina, in which the bladder appeared slightly

dilated, with a slightly irregular margin.

20 Bumpus, H. C, Jr., Nourse, M. H., and Thompson, G. J. : Urological Complications in Injury

of the Spinal Cord. J.A.M.A. 133 : 366-369, 8 Feb. 1947.

27 Numerous postwar studies in Veterans' Administration hospitals have produced extensive data

on cystoscopic findings in paraplegic subjects.
82 NEUROSURGERY

Reflux up into one or both ureters was occasionally observed when the

cystographic medium had been introduced through the urethral catheter, but

this was an infrequent finding in the paraplegic patient, at least during the

early months after injury. It was more common after a considerable period

of time had elapsed (fig. 29). Reflux was assumed to be the result of an

inflammatory change involving the ureteral orifice rather than a direct

effect of the nerve lesion.

FIGURE 28.—Cystograrn through suprapubic tube in

patient with complete transection of dorsal portion of

spinal cord in first stage of recovery. The bladder is

atonic, and the bladder neck is dilated.

Cystourethrography and Urethrography

In 1933, Denny-Brown and Robertson 2S studied three cases of complete

transection of the cauda equina by cystometry, with the proximal tip of the

catheter in the bladder, in the prostatic urethra, and in the bulbous urethra.

In the absence of roentgenologic aid, however, it is difficult to see how these

observers could have been absolutely certain about the position of the proximal end of the catheter in the prostatic urethra, especially if the prostatic

urethra were dilated, as it should be in this type of lesion. They found

the degree of laxity of the internal sphincter directly proportional to the

degree of vesical contraction both during actual discharge and during vesical

contraction without discharge. They were unable to find any evidence of

a functioning external sphincter, though the pressure at which the discharge

28 Denny-Brown, D., and Robertson, E. G. : The State of the Bladder and Its Sphincters in

Complete Transverse Lesions of the Spinal Cord and Cauda Equina. Brain 50 : 397-463, December

1933.
UROLOGIC ASPECTS OF SPINAL CORD INJURIES 83

of urine began and terminated was much higher for the external than for

the internal sphincter.

Watkins,29 in 1936, found by cystography wide relaxation of the vesical

neck in 7 of 8 cases of partial transection of the cauda equina. He also

noted variations in the bladder neck at intervals of only a few minutes.

Even when the internal sphincter was widely dilated, there was no escape

of fluid. Watkins disagreed with the interpretation of Denny-Brown and

Robertson, according to which the internal sphincter should have been closed

in the interval between vesical contractions.

FIGURE 29.—Cystogram in patient with severe lesion

of cauda equina. The bladder is atonic, and the bladder neck is relaxed.

Denny-Brownsoreported additional cystographic observations on the bladder neck. He noted that in patients with automatic reflex urination, with

only 25 cc. of opaque solution in the bladder, the region of the internal

meatus had the shape of a small dimple. If distention was continued, the

dimple widened to a small funnel, and the urethra was dilated down to the

verumontanum. It was Denny-Brown's opinion that a funnel type of

The Bladder Function in Spinal Injury. Brit. J. Surg. 23: 734-759, 29 Watkins, K. H

April 1936.

30 See footnote 11, p. 71
84 NEUROSURGERY.

bladder neck is commonly found in lesions of the cauda equina, because the

procedure used to demonstrate it excites contraction of the bladder.

Urethrography by the injection of a small amount of opaque material

through the urethra from the external meatus should not produce sufficient

intravesical pressure to cause reflex detrusor activity and should disclose the

condition of the bladder neck in a resting state (figs. 30, 31, 32, 33, and 34).

Studies of changes in the bladder neck were made by Prather and

Petroff31in 129 cases of spinal cord injury at an Army paraplegic center.

FIGURE 30—Urethrogram showing dilated bladder neck

in patient in first stage of recovery. The dye in the

bladder surrounds a stone.

The bladder neck showed some degree of dilatation in 30 of 36 cases of

complete transection of the cord or cauda equina, a ratio of 5 dilated cases

to 1 normal case. In 93 cases of partial transection of the cord or cauda

equina, the ratio was 2.2 dilated cases to 1 normal case. In 29 cases of

complete transection of the thoracic portion of the cord, the ratio of dilated

to normal cases was almost 4 to 1, while all patients with complete transection of the cauda equina had some degree of dilatation at the internal

si Prather, G. C, and Petroff, B.: Spinal Cord Injuries : Urethrographie Study of the Bladder

Neck. J. Urol. 57 : 274-284, February 1947.
UROLOGIO ASPECTS OF SPINAL CORD INJURIES 85

urethral orifice. Dilatation of the neck was common in patients with partial

transection at various levels. It occurred with increasing frequency from

the level of the cervical region to the cauda equina.

In an effort to determine the significance of bladder tone or bladder

capacity in urethrographic changes at the bladder neck, Prather and Petroff

compared 10 patients with automatic bladders (the hypertonic type), with

a capacity of about 150 cc, with 12 patients with other types of bladders,

with a capacity of over 400 cc. Some degree of dilatation was common in

both groups.

FIGTJKE 31.—Urethrogram in patient with complete

transection in lower dorsal region. Pilling defect caused

by tip of suprapubic tube can be seen. Bladder neck is

dilated.

A selected group of patients who had had urethrographic studies during

a period of bladder drainage were reexamined 5 to 9 months later, when

they were voiding and not on drainage. Patients with both partial and

complete transection of the cord were included. While there might have been

some changes in the shape of the prostatic urethra and bladder neck, little

or no change in the degree of dilatation had occurred with the lapse of time

or with changes in the status of the bladder.
86 NEUKOSURGERX

FIGUKE 32.—Urethrogram in patient with complete

transection in lower dorsal region of the spinal cord. He

has good automatic reflex bladder with satisfactory capacity. The bladder neck is dilated.

Studies by various observers indicate that dilatation of the bladder

neck is a common finding in patients with spinal cord injury, but the correlation of the observation with detrusor action is difficult at this time for

three reasons:

1. The dilated bladder neck is common with both hypertonic and atonic

types of bladder.

2. There is no marked change in dilatation over a period of months during which changes in bladder activity occur.

3. The groups studied are not absolutely parallel.

CARE OF THE BLADDER

The objectives of care of the bladder in Army paraplegic centers can

be simply stated, as follows:

1. All patients should become ambulatory and free of urinary infection.

2. Patients who had sustained partial transection of the spinal cord

should attain voluntary control of urination and be capable of emptying

the bladder.
UROLOGIC ASPECTS OF SPINAL CORD INJURIES 87

3. Patients who had sustained complete transitions should attain involuntary, periodic reflex voiding at satisfactory intervals and should be

capable of emptying the bladder.

These objectives were considerably easier to express than to achieve.

Urinary drainage was provided during the first and second stages of recovery, or some arrangement was made to prevent overflow incontinence

from contributing to the development of, or aggravation of, pressure sores

over the sacral and trochanteric regions. That type of drainage was selected

W^Mi

«feu'

FIGURE 33.—Urethrogram in patient with partial transection of cauda equina. It shows no change from the

normal. The patient was voiding voluntarily with good

control.

which would keep bladder infection at a minimum, would not contribute to

infection of the upper urinary tract, would avoid genital sepsis, would not

interfere with ambulation, and would permit ultimate rehabilitation of the

bladder to a voiding state.

Nondrainage Methods

By the nondrainage program in paraplegia, the bladder is permitted to

distend and overflow, or manual expression of urine is accomplished by

49S901'-—59 S
NBUROSURGERY

oo

abdominal massage of the organ every 4 to 6 hours. A catheter is not used

in the hope that urinary infection may be avoided. Temporary distention

of the bladder for a matter of hours is not harmful and does not interfere

with the recovery process, but long-continued distention is harmful and

interferes with resumption of function.

F •fü* *t

FIGURE 34.—Urethrocystogram in patient with partial

transection of cauda equina. The bladder recovered sufficiently to permit voluntary voiding supplemented by

straining with abdominal muscles. The bladder neck is

dilated.

Over a period of years, various opinions have been expressed concerning

this method of treatment. Besley,32 in 1917, stated that infection seldom

occurred in the absence of catheterization and that distention of the bladder

was not harmful either to the bladder or the kidneys. In World War I,

Vellacott and Webb-Johnson 33 reported on 66 patients kept under observation

in a forward area for an average of 3 weeks each. Most of these patients

had been injured between 1 and 7 days earlier. Fifty had retention of

urine. Only 1 of 10 in this group who had not been cathetenzed was infected, while 31 of 40 who had been catheterized had become infected. The

preference of these observers was for a noncatheter program. Kidd, in 1919,

wrote that the Crede method of emptying the bladder had been used in

32 Besley F A • A Plea for Noncatheterization of the Urinary Bladder in Cases of Gunshot

Wounds of the Spinal Column. J.A.M.A. 69 : 638-639, 25 Aug. 1917. .

33 Vellacott, P. N., and Webb-Johnson, A. B. : Spinal Injury With Retent.on of Urme ; the

Avoidance of Catheterization. Lancet 1: 733-737, 3 May 1919.
UROLOGIC ASPECTS OP SPINAL CORD INJURIES 89

France by British surgeons in 1917 but that many patients had become infected; he did not favor a nondrainage program.

David, in 1921, recommended that the catheter should not be used in

patients seen early and without infection; if infection was present, this

advice would not hold. Cahill,34 in 1928, stated that, since World War I, he

had preferred to use the Crede method or permit overflow. He observed a

temporary rise in the nonprotein nitrogen of the blood but found that the

level improved after reflex bladder action returned. Connors and Nash,35

in 1934, reported on 54 patients (only 21 of whom had urinary retention)

treated Avithout catheterization; they maintained that urinary infection had

not occurred in any. They used the Crede method every 4 to 6 hours and

began treatment before maximum distention had been reached. Eupture

of the bladder was not encountered, and only one patient developed decubiti,

though an occasional patient required cystostomy. There is no mention in

the paper of the ultimate state of the bladder.

Wesson,30 in 1934, favored a noncatheter program and stated that overflow will occur in all cases and that conversion to an automatic bladder

will take place within 96 hours; no statistics are given. Munger,37 in 1937,

advocated the noncatheter program if catheterization had not previously

been employed and recommended suprapubic drainage in all infected cases.

Hinman3Srecommended a trial of manual expression of urine as the

best method, if it is effective, for the early development of an automatic

bladder, as well as the best method of avoiding urinary infection. Manual

massage of the bladder from above downward toward the symphysis pubis

by the palm of the hand must be performed every 4 hours by the clock.

This method, Hinman granted, is time consuming, is predicated on the

availability of conscientious personnel, and is applicable only when there

is no urinary infection and no mechanical obstruction.

Brock,39 in 1940, stated that the tendency to infection of the chronically

overdistended bladder when this method is used is nearly as great as when

catheterization and bladder irrigations are used, and Eiches, in 1943, after

only partial success with manual expression of urine, concluded that the

method was neither safe nor certain for routine use.

34 Cahill, G. F. : The Treatment of Bladder Paralysis Due to Non-Tabetic Spinal Cord Lesions.

Am. J. Surg. 5 : 442-444, November 1928.

35 Connors, J. F., and Nash, I. B.: The Management of Urologie Complications in Injuries to

the Spine; Keport of 54 Cases Without a Single Infection in the Urinary Tract. Am. J. Surg.

26: 159-167, October 1934.

36 Wesson, M. B.: Is the Use of a Catheter Ever Justified in Fractures of the Spine? Urol. &

Cutan. Eev. 38 : 572-579, August 1934.

37 Munger, A. D. : The Urologic-Orthopedic Viewpoint on the Cord Bladder. J. Urol. 37 : 54-59,

January 1937.

38 (1) Hinman, F.: The Treatment of Paralytic Bladder in Cases of Spinal Cord Injury.

Surgery 4 : 649-662, November 1938. (2) Hinman, F. : The Care of the Bladder at the Front When

Paralyzed by Injuries to the Spinal Cord. J. Urol. 46: 499-504, September 1941. (3) Hinman, F.:

Care of the Neurogenie Bladder; Abnormal and Genito-Urinary Injuries. Philadelphia: W. B.

Saunders Co., 1942.

39 Brock, Samuel (ed.): Injuries of the Skull, Brain and Spinal Cord: Neuro-Psychiatric,

Surgical, and Medico-Legal Aspects. Baltimore : Williams & Wilkins Co., 1940.
90 NEUROSURGBRT

A number of the earlier proponents of this form of treatment apparently

advocated it because of their poor results with a program of intermittent

catheterization. Unfortunately, there is no sizable series of cases on record

describing the ultimate bladder function and the extent of rehabilitation

achieved by the nondrainage technique. It is clearly not a method which

can be employed when large numbers of patients must be treated at the

same time or when transportation is involved in their management. Under

those circumstances, it is doubtful that the program could be safe for the

patient, from the standpoint of avoiding bedsores, or that it is best for the

bladder should urinary infection develop. Even before World War II,

there was a trend away from the method, and results obtained by other

methods during the war supply no cause for regret that it was not used,

nor have they led since to renewed interest in the noncatheter program.

Intermittent Catheter Drainage

It is generally agreed that in the management of spinal cord injuries,

intermittent catheter drainage is the worst form of treatment which can

be used. Thomson-Walker's report of the tragic English experience with it

in World War I, in which it was used routinely in certain installations,

should forever prohibit its further use. The estimated total death rate due

to urinary sepsis in his series was 80 percent. Of 339 patients whom he

personally observed 2 to 3 weeks after injury, 47 percent were dead within

8 weeks, and another 17 percent of those who survived to be transferred

to another hospital later died of urinary infection. It was a well-established

urologic principle before World War II that this type of drainage should

not be used for more than a few days.

Constant Drainage

Kidd, in 1919, in an effort to avoid overdistention of the bladder and

the severe infection which results from intermittent catheterization, recommended drainage with a "tied in" catheter. This form of therapy has now

been used in urologic cases for many years, and it was widely used in World

War II. Its chief advantage is that it obviates the necessity for surgery

(cystostomy or urethrostomy) and the time occupied by healing of a surgical

wound.

The chief objection to drainage of the bladder by a urethral catheter

is the possible occurrence of urethral or scrotal sepsis. Scrotal sepsis, although it may result in loss of part of the scrotal contents, is not dangerous

to life or likely to delay recovery materially if it is treated properly. Periurethral abscess, however, with fistula formation at the penoscrotal junction,

is a serious complication in the paraplegic patient. The opening heals only

slowly, and plastic surgery may be necessary. When voiding is reestablished,

it is often difficult, when the ordinary glass or metal ürinal is used, to pre-
UROLOGIC ASPECTS OF SPINAL CORD INJURIES 91

vent leakage of urine from the fistula onto the bed or the clothing. When

leakage occurs, complete rehabilitation of the bladder may be delayed for

weeks.

A practical consideration, which was particularly important in the

large numbers of paraplegics handled in oversea theaters, is the daily attention required by the catheter and the rest of the drainage system used.

Bladder irrigations are necessary to keep down infection, and, even if there

is no evidence of incrustation, the catheter must be changed, with a sterile

technique, at least every 7 to 10 days. The tactical situation often prevented

the use of constant drainage by this method, desirable as it was, in oversea

theaters in AVorld War II.

Whenever catheter drainage was employed, certain precautions, in addition to the use of a nontraumatic, sterile technique, were essential. The

catheter itself was always a No. 18 F. or a smaller size, since the urethra

of the paralyzed patient has no more tolerance to pressure than the sacral

and trochanteric regions. Either the two-holed (Robinson) soft rubber

catheter or the balloon (Foley) catheter was used.

It was possible to use the Robinson catheter effectively if penile adhesive strapping could be properly maintained. The balloon catheter, however, with a 5-cc. bag, required less daily adjustment and was desirable because it avoided the possible penile constrictions and abrasions caused by

adhesive tape. Repeated cystoscopic observations failed to reveal edema or

necrosis of the bladder neck caused by the distended bag of this type of

catheter. The balloon type of catheter is the only type which can be kept

properly adjusted in the presence of priapism. Since intravesical prostatic

enlargement is seldom present in men of the age group which made up the

bulk of casualties in World War II, there was seldom difficulty in keeping

the catheter in a satisfactory position for drainage within the bladder.

Methods of Irrigation

Syringe irrigation.—Facilities for syringe irrigation were always kept

available, since this is an effective method and is occasionally necessary

when the catheter becomes blocked by debris or clot. Its routine use, however, was impossible under military circumstances. It requires time and

effort on the part of nursing personnel, and it requires a fresh set of sterile

utensils for each irrigation on each patient. Moreover, since the catheter

must be disconnected and reconnected at each treatment, the chances of

cross infection are obvious.

Closed system with manual control.—This type of irrigation, which has

been commonly used in urologic practice for many years, was widely employed during World War II, by means of an apparatus (fig. 35) similar

to that used by Nesbit and Gordon.

This apparatus proved very satisfactory under military circumstances.

The unit, which was kept ready in sterile packs for immediate use, could be
92 NEÜROSURGERY

Sterile gauze sponge

Drainage jar

(1 gallon capacity)

FIGURE 35.—Diagram for closed system of drainage and irrigation of bladder, with

manual control. To irrigate bladder, clamp on A is opened while B is pinched off. After

the desired volume of fluid has entered the bladder, A is pinched off and B is released.

After this maneuver has been repeated several times, the clamp on A is reapplied.

easily sterilized in the autoclave. It was simple to set up and was quickly

disassembled for resterilization. Setting it up took no longer than connecting

the ordinary drainage tube, and, over a long period of time, the saving in

time and effort was considerable. The bladder was thoroughly cleansed at

each treatment because the irrigating fluid entered by force of gravity. As

long as the irrigating fluid was kept sterile, attendants could irrigate the

bladder easily, quickly, and without chance of contamination. The amount

to be run in at each bladder fill was readily seen on the calibrated irrigating

jar, and errors were practically impossible. The patient who had the use

of his arms could be taught to irrigate himself a certain number of times a

day and could do it quite as well as an attendant. With this system, there

was no difficulty with failure of drainage because of air in the tubing. There

was also no difficulty if drainage had to be reinstituted after a period of

ambulation. For these various reasons, it was the general opinion among

Army urologic surgeons that this system was simple, effective, compatible

with optimum functional activity of the bladder, and, in general, well

adapted to military use.

Closed system with automatic control (tidal drainage).—Tidal drainage (the nomenclature employed by Munro and Hahn40

) provides a closed

40 Munro, D., and Hahn, J. : Tidal Drainage of the urinary Bladder ; Preliminary Report of

This Method of Treatment as Applied to "Cord Bladders" With Description of Apparatus. New

England J. Med. 212 : 229-239, 7 Feb. 1935.
UROLOGIC ASPECTS OF SPINAL COED INJURIES 93

system of drainage and bladder irrigation in which periodic irrigation and

emptying occur automatically. Laver,41 in 1917, described an automatic

irrigator based on the principle of siphonage and on the observation that

water finds its own level. Munro and Hahn, in 1935, described a more

complicated apparatus for the same purpose, and Munro championed tidal

drainage after that time. Lawrie and Nathan,42 Bellis,43 Stewart,44 and

Cone and Bridgers45all described simplified devices for tidal drainage which

are effective and which permit cystometric studies without additional equipment. All models have the same objective, to provide automatic filling and

emptying of the bladder at a predetermined level of intravesical pressure.

To use any of them intelligently, previous cystometric studies are necessary,

so that the level of the siphon loop may be properly adjusted. The system

will not function properly if there is air in the rubber tubing leading to the

bladder, nor will the emptying of the bladder be effective if the opening

of the air vent is larger than a 22-gage needle.

Munro46is of the opinion that the early use of tidal drainage will

avoid urinary infection and has published statistics to prove the point.47

Hinman, whose experience, like Munro's, was civilian, advocated this method

in cases in which manual expression is contraindicated of impossible; he

believed that it hastens the development of an automatic bladder provided

that detailed attention is given to the care of the catheter and apparatus.

Military urologic surgeons were generally in favor of it. Stewart and other

English neurosurgeons48preferred tidal drainage to other methods when

facilities and trained personnel were available, and Riches was of the opinion

that the time requirement for the development of a reflex bladder was slightly

less when this form of treatment was used. American neurosurgeons thought

it an excellent method of treatment, but most of them did not consider it

essential for optimum recovery or rehabilitation of the paralyzed bladder.

The disadvantages of tidal drainage in both military and civilian practice are those common to all methods which require the use of urethral

catheters over long periods of time; that is, possible urethral or scrotal

sepsis. Munro, in his article on rehabilitation, found the incidence of complications less with tidal drainage than with other forms of treatment.

4iLaver, C. H.: An Automatic Bladder Irrigator. Guy's Hosp. Gaz. 21: 71-74, 1917.

42 Lawrie, R. S., and Nathan, P. W.: Automatic Tidal Drainage of the Bladder. Lancet 2:

1072, 18 Nov. 1939.

43 Bellis, C. J.: An Improved Apparatus for Tidal Drainage of the urinary Bladder and

Empyeme Cavities. Surgery 8 : 791-797, November 1940.

44 Stewart, O. W.: The Neurogenic Bladder ; Combined Tidal Irrigator and Cystometer. Lancet

1: 287-289, 7 Mar. 1942.

45 Cone, W. V., and Bridgers, W. H. : A Combined Tidal Irrigator and Cystometer for Management of the Paralyzed Bladder. Surg. Gynec. & Obst. 75 : 61-66, July 1942.

"(1) See footnote 9(2), p. 69. (2) Munro, D.: Rehabilitation of Patients Totally Paralyzed

Below the Waist, With Special Reference to Making Them Ambulatory and Capable of Earning

Their Own Living; Control of Urination. New England J. Med. 234 : 207-216, 14 Feb. 1946.

.«See footnote 9(2), p. 69.

48 Discussion on the Treatment of the Paralysed Bladder. Proc. Royal Soc. Med. 36 : 197-202,

26 Nov. 1942.
94 NEUROSURGERY

Certain objections have been raised to the apparatus itself. Lewis found

that the bladder was not always emptied, either because of a change in the

patient's position or because of air trapping; he and Thomas49both thought

that thorough bladder irrigation was necessary daily. Bumpus, Nourse, and

Thompson, who used tidal drainage at some stage of convalescence in most

of the naval casualties under their care, found supplemental irrigations

necessary to prevent puddling of infected urine and accumulation of calcium

debris in the bladder, in spite of their best efforts to maintain efficient

automatic drainage.

Irrigating solutions.—The solution used as an irrigating medium, regardless of the system of drainage used, was always sterile, antiseptic, nonirritating, and preferably of such quality as to delay or prevent phosphatic

deposits on glass and rubber tubing. Sterile water, saline solution, boric

acid, potassium permanganate, sulfanilamide, and solutions G and M proposed by Suby and Albright50 Avere all tried with varying degrees of success.

Solution G was found too irritating for long-continued use in the

bladder, as shown by bloody mucus in the return fluid. Solution M,51 which

did not have this undesirable feature, was readily autoclaved and proved

more effective than boric acid solution in delaying incrustations on tubing,

though the ingredients of the formula were not always immediately available

in the large quantities needed. Boric acid solution was a satisfactory substitute. Whatever solution was used, it was thought important to give it a

distinctive coloring (by the use of a small quantity of methylene blue) to

prevent errors and substitutions.

Drugs

The effect of drugs on reflex activity of the bladder after spinal cord

injury has perhaps not been fully exploited. Nesbit and Gordon found that

efforts to influence either sympathetic or parasympathetic activity by drugs

were without clinical benefit. Eiches found that drugs of the acetylcholine

type had no favorable influence on the bladder during spinal shock but

appeared to enhance reflex contractions once recovery had set in. The use

of atropine in an effort to lengthen the intervals between voidings in patients

with the reflex automatic type of bladder after complete transection was of

benefit in some ambulatory cases, but actual data are not available.

40 Thomas, W. H. : Tidal Drainage and Tidal Irrigation. Urol. & Cutan. Rev. 45: 147-149,

March 1941.

50 Suby, H. I., and Albright, F.: Dissolution of Phosphatic Urinary Calculi by Retrograde

Introduction of Citrate Solution Containing Magnesium. New England J. Med. 228 : 81-91, 21 Jan.

1943.

51 Citric acid (monohydrous) 32.35

Magnesium oxide (anhydrous) 3.84

Sodium carbonate (anhydrous) 8.34

Distilled water q.s.ad. 1 000.00
UROLOGIC ASPECTS OF SPINAL CORD INJURIES 95

SURGICAL MEASURES

Suprapubic Cystostomy

Suprapubic drainage of urine has been advocated for many years as

a method of avoiding urethral sepsis during paralysis of the bladder and

of protecting the upper urinary tract against infection. Thomson-Walker52

advocated this method during World War I, and 20 years later he was still

in favor of it if Crede methods failed. Boyd and Bailey53recommended it

as the logical method of primary treatment, and Munger favored it when

urinary infection was present. Hinman stated that it should be used in

civilian practice when other methods of treatment have failed and should

be used at once in battle-incurred spinal cord injuries of considerable degree.

Riches54advocated it at an early stage in the hope of preventing renal infection, though it has, of course, no influence on already established upper

urinary tract infection. The comprehensive reports of Thomson-Walker and

Riches and the large experience in the U.S. Army in World War II all

indicate that cystostomy does not adversely influence the rehabilitation of

the bladder to a voiding state or reduce bladder capacity even after months

of drainage if bladder infection is kept minimal. During World War II,

secondary closure of the suprapubic sinus was only occasionally necessary.

Suprapubic drainage did not interfere with ambulation in paraplegics

or with frequent changes of position in bed, although it proved troublesome

if a Stryker frame had to be used over a long period. The tube could be

connected to a closed system of drainage, and irrigation could be manually

controlled to avoid possible cross-contamination by personnel using syringe

irrigations. Patients could be taught to irrigate themselves as required, and,

if the cystostomy had been performed properly, cystometric determinations

could be carried out via the suprapubic tube.

The chief disadvantage of the method is that it is a surgical procedure

and that it takes 3 to 4 weeks for the sinus to heal during a period of

urethral catheter drainage, when rehabilitation of the bladder is at hand.

Like a urethral catheter, the bladder catheter requires periodic changing,

but the experience in World War II definitely refuted the assertion that

this type of drainage leads to shrinkage of the bladder capacity. The U.S.

experience also did not support either the contention that the tube is prone

to rot and break, that it fails to prevent puddling, and that it promotes

shrinkage and fibrosis of the bladder wall,55 or the complaint of leakage

about the catheter. The latter difficuly was not encountered in any properly

performed and properly maintained suprapubic cystostomy.

' 52 Thomson-Walker, J.: The Bladder in Gunshot and Other Injuries of the Spinal Cord. Lancet

1 : 173-179. 3 Feb. 1917.

53 Boyd, M. L., and Bailey, M. K. : Suprapubic Cystostomy in Bladder Paralysis. Tr. Am. A.

Genito-TJrin. Surgeons 21 : 305-315, 1928.

64 See footnotes 10, p. 71, and 48, p. 93.

E5 See footnote 9(1), p. 69.

498991"—59 9
96 NEUROSTJRGERY

Suprapubic incision

Penro.se drain

Pezzcr or Malecot lube 32° or 34° F.

Subcutaneous layer

Rectus muscle layer

FIGUKE 36.—Correct placement of suprapubic tube high in vertex of bladder.

This position avoids pressure on the trigone, permits easy surgical reentry

into the bladder, and leaves an oblique sinus when the tube is removed.

Penrose drain

Pezzer or Malecot tube 32° or 34° F. /

Suprapubic incision

Subcutaneous layer

Rectus muscle layer

Peritoneum

Bladder wall

FIGUEE 37.—Wrong placement of suprapubic tube, causing pressure on

trigone with possible edema around ureteral orifices. With the tube in this

position, it is difficult to obtain further surgical exposure of the bladder without opening the peritoneum. After removal of the suprapubic tube, the

residual sinus is short and may require a longer period to heal than an

oblique sinus.
UROLOGIC ASPECTS OF SPINAL CORD INJURIES 97

The placing of the tube was extremely important.56 It was introduced

high in the dome of the bladder (fig. 36) and was brought out through the

upper end of the skin incision. These precautions, which prevented riding

of the proximal end of the tube on the trigone and ureteral orifice, resulted

in an oblique sinus, which facilitated later closure. This technique also

avoided the possibility of infection of the pubic bone which might occur if

the tube were placed at the lower end of the incision adjacent to the pubic

bone (fig. 37).

Perineal Urethrostomy

Lewis'57suggestion that unrethrostomy in the bulbous urethra, with insertion of a Malecot tube to the bladder, was seldom used in U.S. paraplegic

casualties. The method seems to have numerous objections. It avoids periurethral abscess and fistula at the penoscrotal angle, it is true, but it does

not diminish the possibility of prostatic and scrotal sepsis. The necessary

proximity of the incision and the channel for the tube to an incontinent

anus invite urinary infection. The possible bad effect of pressure by the

tube on perineal structures when the patient is in the sitting position may

delay wheelchair activities. When there is delay in healing of the urethrostomy opening, prolonged urethral catheter drainage is required, because

the buttocks are wet each time the patient voids. Clearly, this is not a

satisfactory method for routine use.

Cystoscopic Procedures

Cystoscopic removal of bladder calculi, whenever they were present,

was necessary before satisfactory rehabilitation could be accomplished. Many

small stones could be removed through the sheath of the cystoscope or resectoscope with the aid of the Ellik evacuator. Larger calculi could be

crushed and removed by irrigation. These maneuvers were carried out

through the cystostomy wound or, if the bladder was intact, through the

urethra. The bladder was always inspected for possible calculi before the

patient was changed from a suprapubic to a urethral catheter program.

Eesection of the bladder neck, if used selectively, proved a useful

adjunct method in a small proportion of cases after it was believed^ that

maximum neurogenic activity had been attained. For an eventual satisfactory functional result in paraplegic subjects, reflex activity of bladder

musculature must be present, and sufficient sphincteric or urethral resistance

must remain to avoid continuous incontinence. Although, in many instances,

s

« (1) See footnote 48, p. 93. (2) Hamm, F. C.; Suprapubic Cystostomy. Mil. Surgeon 96:

241-244, March 1945. (3) Prather, G. C. : Suprapubic Cystotomy. Bull. U.S. Army M. Dept,

No. 81, pp. 96-98, October 1944.

57 Lewis, L. G.: Perineal Urethrostomy for Drainage of Neurological Bladders. Bull. U.b.

Army M. Dept., No. 69, pp. 46-48, October 1943.
98 NEUROSURGERY

a well-defined widening or relaxation of the bladder neck was revealed by

urethrographic and cystoscopic examination in paraplegic casualties, in the

great majority, the desired end result of functional control and efficient

emptying could be obtained without revision of the bladder neck. In instances of inefficient emptying of the bladder with demonstrable adequate

reflex activity on cystometry, resection of the bladder neck was sometimes

vital in the restoration of satisfactory bladder activity.

Bumpus, Nourse, and Thompson, as the result of experience in the

Navy in World War II, stated that dysfunction following low spinal

(cauda equina) lesions was most responsive to transurethral resection. Results were less spectacular but still worthwhile in patients with automatic

reflex voiding who had an appreciable bladder residue. Their practice was

to resect small amounts of tissue from the entire circumference of the bladder

neck, the total volume of the excised portions not exceeding 10 gm.

Experiences with resection of the bladder neck were not universally

successful in Army paraplegic centers, though some excellent results were

obtained. The method was probably most useful in patients whose natural

progress was not complete. To achieve the best results, as well as to avoid

doing harm, bladder neck resection was used selectively and only after it

was thought that maximum neurogenic activity had been attained.

BLADDER TRAINING

Bladder training for paraplegic patients with complete transection after

reflex bladder action had become reestablished was frequently very effective

when the plan devised by Munro58 was employed. The urethra! catheter

was clamped off at intervals of iy2 to 3 hours, in the expectation that the

bladder would accommodate itself to this time schedule, so that the patient

could void at regular intervals. When this had been accomplished, the

patient was given a trial on a similar schedule without the catheter.

COMPARISON OF METHODS OF BLADDER MANAGEMENT

It is difficult to compare the effects of some of the methods described

above, for the caliber of the attending personnel appeared to be as important

as the method, if not more important. Any method in the hands of unskilled individuals could end in disaster. Several of the methods in expert

hands could produce gratifying results.

In the description of a method of treatment, perfect technique in skilled

hands, experience with the method, availability of equipment, and knowledge

of potential complications are all assumed. In time of war, when treatment

often had to be started before a hospital for definitive care was reached, and

when problems of transportation were encountered, these ideal conditions

were unattainable. Furthermore, it was often difficult to compare effectivem

See footnote 46(2), p. 93.
UROLOGIC ASPECTS OF SPINAL CORD INJURIES 99

ness of methods except on a mass basis, and even then several methods might

have been employed in an individual patient.

Except in time of war, few individuals have a large experience with

paraplegic patients. Those who do usually have one method of treatment

which they believe the best. They therefore report the results of one method

instead of a comparative study of results of different methods with the

same skilled personnel. Neurosurgeons not trained in urologic surgery prefer

methods not involving detailed urologic procedures if they do not appear

necessary. Although neurosurgeons, principally Munro, have contributed

more to the rehabilitation of the bladder in civilian life than urologists, it

remains for the urologist with his various diagnostic and therapeutic procedures to make valid and conclusive comparisons of methods of treatment.59

The opportunity, however, is open only to the urologist who is interested,

ingenious, and skilled, and who has access to an appreciable number of

paraplegic patients.

The review of a number of reports on the treatment of the bladder

after spinal corcl injury, as well as observations of patients treated by

various methods during World War II, permit the following statements:

1. A program of intermittent catheterization is certain to lead to

disaster.

2. A nonclrainage program, with overflow voiding or Crede emptying

of the bladder, may be used in the individual case unless there is evidence

of urinary infection, though it is difficult to maintain a dry bed and avoid

decubitus ulcers. Nondrainage is not a feasible technique when large

numbers of patients are to be cared for or when attendant personnel is

limited. Eventual rehabilitation of the bladder is possible.

3. Drainage by urethral catheter, while it is an accepted method, must

be supplemented by bladder irrigations, under sterile precautions, with a

closed system that is either automatically or manually controlled. Careful

hygienic attention to the catheter and urethra is required, and a properly

working irrigating system is essential. Urethral sepsis and scrotal sepsis

are potential complications. The choice between manually controlled irrigation and tidal irrigation is open and depends upon the availability of equipment and training of the personnel. Eehabilitation of the bladder to a

voiding state is probable.

Suprapubic drainage with a properly placed tube is an accepted method,

perhaps the preferable method, if a long period of bladder drainage appears

necessary or if transportation problems make the urethral catheter program

difficult. A closed system of irrigation is advisable. Periodic change of the

tube is mandatory. This method, while it avoids a certain number of genital

complications, eventually requires a period of urethral drainage during

closure of the suprapubic sinus. Rehabilitation of the bladder to a voiding

50 Important studies have been made in Veterans' Administration hospitals since the end of

World War II.
100 NEUROSURGERY

state is probable but requires a slightly longer time than the urethral

catheter method.

Eemoval of bladder calculi is necessary for proper bladder function,

regardless of the type of drainage employed, and resection of the bladder

neck may be required in some cases to facilitate efficient emptying of the

bladder.

STATUS OF THE UPPER URINARY TRACT AFTER INJURY OF

THE SPINAL CORD

Numerous observations60indicate that the totally denervated kidney can

carry on all the renal function essential to life. There also appears to be no

anatomic physiologic change in the ureters directly attributable either to

injured nerve tissue or to the immediate altered bladder physiology.61 Other

observations indicate that ureteral reflux is not likely to occur62and that

there is no tendency toward hydronephrosis.63 Intravenous urography and

cystography in paraplegics studied in general hospitals confirmed these observations. In the absence of obstructive pathologic changes independent

of bladder dysfunction, urograms were normal, and reflux was observed in

only the occasional case, in which it could probably be explained by localized

changes in the ureteral orifice as the result of inflammation, edema, and

similar changes rather than by physiologic changes caused by the spinal

injury.

Observations on patients with spinal cord injuries sustained in World

War II confirm the observations made in World War I that, after such injuries, renal function is maintained satisfactorily in the absence of complicating renal infection or calculi formation.64 These observations covered

periods up to 2 years and included many patients whose bladders had been

rehabilitated to a voiding state. A much longer period of time must elapse

before the status of the upper urinary tract can be reported in a large series

of paraplegic patients, but at the time of writing there are some indications

of upper tract deterioration in patients with autonomous bladder function

over a period of many months. Sporadic case reportsG5and individual

observations suggest that a long-term study may reveal an increasing incidence of upper urinary tract dilatation, especially if bladder emptying is

incomplete or if inflammatory processes have permanently altered the vesi60 White, James C, and Smithwick, Reginald H. : The Autonomie Nervous System. New York :

The Macmillan Co., 1941.

61 Gruber, C. M. : The Autonomie Innervation of the Genito-Urinary System. Rev. 13: 497-

609, October 19S3.

02 (1) See footnote 24, p. 80. (2) Fullerton, A.: A Note on the State of the Ureters and

Their Orifices in Cases of Gunshot Wounds of the Spine. Brit. M..T. 1 : 124-125, 1 Feb. 1919.

(3) Plaggemeyer, H. W.: Shell Fractures of the Spine. J.A.M.A. 73: 1599-1604, 22 Nov. 1919.

83 See footnote 25, p. 80.

M See footnote 23, p. 80.

65 Hepler, A. B. : Late Results of Paralysis of the Bladder Following Fracture of the Spine;

Value of Excretory Urograms in Demonstrating These Changes. S. Clin. North America 13 : 1379-

1382, December 1933.
UROLOGIC ASPECTS OF SPINAL CORD INJURIES 101

coureteral junction. For a proper interpretation of upper urinary tract

observations years after spinal cord injury, earlier studies on each patient

must be available for comparison.60

STATUS OF THE SEX ORGANS AFTER INJURY OF THE

SPINAL CORD

After injury to the spinal cord and recovery from spinal shock, reflex

erection of the penis and priapism are not uncommon. Ejaculation has also

been described. Cobb and Coleman,67 in a study of 20 cases, found that

after injuries to the cervical portion of the cord, sexual function, as a rule,

was affected relatively more severely than urinary or rectal function. In

lower cord injuries, sex potency might return while there was still lack

of control over urine and feces. The World War II experiences were not

completely in accord with these findings. Some patients with partial transection of the cauda equina had satisfactory marital experiences, but others

found themselves impotent for a period of at least a year after injury.

Observations on this point are incomplete.68

GENITOURINARY COMPLICATIONS OF INJURIES TO THE

SPINAL CORD

Even before the age of Lister, thought had been given to changes in

the urine of paraplegic patients. Curling,69 in 1833 and in 1836, stated

that the alkaline state of the urine was produced primarily by morbid secretions of the bladder and secondarily by the debilitated state of the kidneys.

Burne,70 in 1833, took the same point of view, on the basis of finding foul

ammoniacal urine in the bladder and acid urine in the kidneys.

Renal Complications

Renal infection and calculus formation were the two serious urinary

tract complications encountered most frequently in World War II. Very

often they existed together, each condition enhancing the other at the expense

of the host.

Infections.—There was no attempt in World War II to differentiate

clearly between pyelonephritis and so-called cortical abscesses, of the kidney.

It is likely that a number of patients considered to have nephritis actually

had microscopic abscesses in the renal parenchyma.

66 Extensive studies along these various lines have been made in Veterans' Administration hospitals since the end of World War II.

61 Cobb, S., and Coleman, C. C.: The Course of Recovery Following Trauma of the Spinal Cord.

Arch. Surg.'3 :'132-139, July 1921.

68 Further studies have been made in Veterans' Administration hospitals.

69(1) Curling, T. B. : Essay on Affections of the Bladder, in Paraplegia. London M. Gaz.

13- 76-83, 1833. (2) Curling, T. B. : Further Observations on Affections of the Bladder in Paraplegia. London M. Gaz. 18 : 325-331, 1836.

TO Burne, J.: On the State of the Bladder in Paraplegia. London M. Gaz. 13 : 353-355, 1833.
102 NEUROSURGERY

The mortality rate from renal infection, both in World War I and afterward, was alarmingly high, chiefly because efficient urinary antiseptics were

not then available. Thomson-Walker's71report on a large series of patients

could not fail to create concern, since 47 percent died within 8 weeks and

still others at a later date. Vellacott and Webb-Johnson reported 10 percent

of deaths from urologic causes during the first month after injury, and it

may be assumed that other patients in their series later succumbed to the

same causes.

During World War II, intravenous urography, more effective medicinal

agents, and better handling of the paralyzed bladder helped to reduce the toll

of renal sepsis. Although there are no data for the first few weeks after

injury, those patients who were evacuated to the United States in general did

well.72

Eaines, at the conference on spinal cord injuries, reported no deaths

from urologic causes in a series of over 100 cases observed over a period of

months. Petroff T3 had only 1 death among 70 patients over a period of a

year or more, and Prather74reported only 1 death from urologic disease

in a series of 61 cases observed over a period of 18 months.

In patients who appeared to have renal infection after spinal cord injury, the diagnosis was usually made on the basis of fever and, perhaps,

pain, nausea, vomiting, and urinary findings, or on the exclusion of other

causes. The condition might be acute, recurrent, or chronic. In only the

acute and recurrent types did the temperature chart usually give a clue.

The mode of infection, just as in patients without spinal injuries, was

by the hematogenous, lymphatic, or ascending routes. It is difficult to prove

which route was most common. As pointed out previously, reflux could not

be demonstrated in the majority of cases, and it should not be assumed

that the ascending intraureteral path was the principal route. There were

many other possibilities, including transmission to the kidney via periureteral

lymphatics from an infected bladder; dissemination via the bloodstream

from septic foci in other parts of the body, including areas injured by

penetrating missiles and bedsores; and transmission from the intestinal

tract. Petroff found positive blood cultures in three cases.

The types of organisms responsible for renal infection are multiple.

Although the organisms found in urine from the bladder do not necessarily

mean that the same bacteria are causing the renal infection, they probably

offer the best general guide that is available without ureteral catheterization

or surgery. Eaines found Proteus, Aerobacter aerogenes, and Esch. coli the

most common bacteria in cases in which pure cultures of urine were ob71 See footnote 52, p. 95.

'2 Conference on Spinal Cord Injuries, Halloran General Hospital and Thomas M. England

General Hospital, 19-20 Oct. 1945.

73 Urological Conference and Symposium on the Paralyzed Patient, Newton D. Baker General

Hospital, 11-12 May 1945.

" Prather, G. C. : Spinal Cord Injuries: Care of the Bladder. J. Urol. 57: 15-28 January

1947.
UROLOGIC ASPECTS OF SPINAL CORD INJURIES 103

tained. In combination with these varieties, Raines frequently found nonhemolytic streptococci, Alkaligenes fecalis, and Sta-phylococcus aureus. Petroff found the bacilli just mentioned more difficult to eradicate than the

coccic forms. Prather found that cultural studies of urine specimens from

patients on drainage usually showed a mixed infection. The bacteria most

frequently encountered were staphylococci, Ps. aeruginosa, P. vulgaris, Esch.

coli, and B. cloacae.

The diagnosis of renal infection was usually made after an abrupt rise

in temperature, sometimes preceded by a chill. Pain was not present unless

the level of anesthesia was below the level of the upper abdomen. If the

patient was on drainage and had had a mild urinary infection, the urine

sometimes showed gross changes. This was not often a reliable sign.

Patients who were voiding clear urine usually developed cloudy urine with

the onset of an acute or recurrent infection.

The first important question raised by a temperature elevation caused

by renal infection was whether or not there was obstruction at some point

in the upper urinary tract. If there was no obstruction, medicinal measures

were pushed to the limit. If there was obstruction, these measures were

seldom sufficient. Since ureteral catheterization is not a satisfactory routine

procedure in this type of case, intravenous urography was used as a good

way of disclosing obstruction of the kidney. The value of periodic routine

studies during the afebrile period or normal convalescence was enhanced

by the ability to compare them with films taken later during febrile episodes.

Only by periodic examinations of this type could the upper urinary tract

be indirectly visualized and the correct interpretation given to an episode

of renal infection. There was no hesitancy about using intravenous urography during the first days of a febrile reaction.

Treatment of renal infections was far more effective during World

War II than it was some years ago, even though complete and permanent

sterilization of the urine was not always attained. Because of the everpresent necessity of forcing fluids to combat calculus formation, together

with the desirability of a high fluid output in renal infection, medicinal

agents which required restricted urinary output for their best effect were

not useful. Fortunately, the use of sulfonamides, penicillin, and streptomycin is not incompatible with a high urinary output. In addition to the

use of these agents, a high liquid intake and output, attention to the general

nutritional state, transfusions of whole blood, plasma, amino acids, and

vitamins played an important part in the treatment.

For renal infections caused by gram-negative bacilli, the sulfonamides

appeared to be the best agents for routine use except in patients who had

developed sensitivity to them. Sulfadiazine or sulfathiazole in 1-gm. doses

by mouth every 4 to 6 hours around the clock, with an equal quantity of

soda bicarbonate, was the customary treatment for the ordinary renal infection. Larger doses were seldom more effective, and even smaller quantities
104 NEUROSUBGERX

were sometimes just as useful. Once begun, medication was continued for

a period of 5 to 7 days; dosages of 1 gm. 4 times a day over a period of

several weeks could be given without untoward reaction. If these drugs

could not be used by mouth, sulfadiazine was utilized intravenously. Although there is no apparent reason why a patient with spinal cord injury

should be exempt from the renal complications of the sulfonamides, no

instance of this type of anuria seems to have occurred.

Streptomycin proved a valuable agent in the treatment of gram-negative

infections of the urinary tract, especially in relieving virulent febrile stages

which had not been controlled by the sulfonamides. It could be used simultaneously with sulfonamides or with penicillin. Although the optimum

dosage of streptomycin had not yet been agreed upon, it was evident that

large doses at the beginning of treatment helped to prevent the development

of resistance by the organism. With a standard of 1,000,000 units to the

gram, 300,000 to 400,000 units intramuscularly every 3 hours appeared to be

the average dose; 5 to 7 consecutive days of medication were necessary for

a fair trial. Alyea75found the drug most effective in an alkaline urine.

Penicillin seemed to be the most effective agent against coccic infections

in the kidney. The usual doses were 20,000 to 40,000 units intramuscularly

every 3 hours. Penicillin could be used simultaneously with streptomycin or

the sulfonamides. It was believed to be most effective in an acid urine.

Ureteral catheterization, drainage, and lavage were sometimes employed

in the treatment of renal infection. These methods were always used cautiously, but, on occasion, their heroic employment served to relieve obstruction, facilitate diagnosis, and prepare patients for operation. Very thorough

irrigation of the bladder was desirable before ureteral catheters were passed

through it on their way to the kidney.

Calculi.—Data accumulated during World War II showed a disturbingly

high incidence of renal calculi in paraplegics over a period of approximately

15 months after injury. Prather, by routine intravenous urography at intervals of 6 to 8 weeks, demonstrated calculi in 31.5 percent of patients with

complete transection and in 20 percent of patients with partial transection.

Other observers, who did not differentiate between complete and incomplete

lesions, also reported a high incidence. Petroff reported 20 percent; Bowie,

18.6 percent; Riba, 13 percent; and Malcolm, 9 percent.70

The frequent occurrence of renal calculi in the recumbent patient is a

well-established phenomenon. The three known etiologic factors are infection, stasis, and hypercalciuria.77 Patients with injury of the spinal cord

were necessarily confined to bed for periods of weeks or longer until stability

of bony structures permitted ambulation. It was not surprising, therefore,

to find a high incidence of stone in this group.

T5 Personal communication, E. P. Alyea to G. C. Prather.

'6 Transverse Myelitis Conference, Hammond General Hospital, 24-25 June 1945.

" Flocks, E. H.: "Early" Calcium Urolithiasis. J.A.M.A. 130 : 913-918, 6 Apr. 1946.
UROLOGIC ASPECTS OF SPINAL CORD INJURIES 105

According to Prather, routine intravenous urograms in a series of 60 patients, many of whom had been bedfast and on bladder drainage for several

months, showed no dilatation of kidney pelves or ureters. Similar studies,

several months later, when voiding had been reestablished, likewise revealed

no upper urinary tract dilatation. Calculus formation is probably not due to

any gross anatomic change that can be demonstrated by pyelographic study.

Calculi can form rather quickly. Large stones were found to develop

in a period of 5 months, and it was not unusual to see a definite increase in

size over an interval of 2 months. Bilateral stone formation was common,

but no more so than the unilateral distribution (figs. 38, 39, 40, 41, 42, and

43).

FIGUKB 38.—Roentgenograms showing renal calculi. A. Two left renal calculi in

paraplegic patient with high fever. At the time of operation, the left kidney contained

multiple cortical abscesses. Left pyelolithotomy was done rather than nephrectomy

because of a calculus in the upper pole of the opposite kidney. The patient made an

excellent recovery from operation. B. Postoperative intravenous urogram following surgical removal of left renal calculi from severely septic kidney. The kidney had excellent

function.

Symptoms were lacking in patients with transection in the upper part

of the spinal cord. Even those with a level of anesthesia below the kidney

area seemed to have less pain than the nonparalyzed patient. Gross hematuria occurred occasionally. It was seen more often in orthopedic patients
106 XEUROSüRGERY

confined to bed than in paraplegic patients. Nausea and vomiting, which

were common symptoms, were often thought to be due to a dietary upset

until the correct diagnosis was established.

Accurate diagnosis could be established only by roentgenologic studies.

Intravenous pyelography was preferred to the retrograde technique as a

routine. If proper treatment was to be given, it was imperative to determine

FIGURE 30.—Intravenous urogram showing small calculus in upper right ureter completely obstructing right

kidney. There is also a small stone in the right kidney.

Both calculi were removed surgically at the same operation.

the degree of obstruction caused by the stone. At times, retrograde examination was necessary to make the diagnosis, but this was done only after

painstaking irrigation of the bladder to prevent the introduction of organisms into a clean field or the introduction of new organisms into a locale

already infected. Stereoscopic and oblique films often aided in the localization of opaque shadows and were sometimes necessary to avoid mistakes in

interpretation.

Treatment was first directed against the known causative factors. The

incidence of renal infection could be reduced by proper treatment of the

bladder, by improvement in the patient's general condition, and by expert
ÜROLOGIC ASPECTS OF SPINAL COED INJURIES 107

FIGURE 40.—Roentgenograms showing ureteral calculi in patient with complete spinal

cord transection in middorsal region. A. Right ureteral calculus at level of lower border

of sacroiliac joint. B. Retrograde pyelogram showing abnormal kidney and ureter above

obstructing ureteral stone. The numerous filling defects are caused by inspissated pus.

Right ureterolithotomy was done, with prompt recovery. C. Postoperative intravenous

urogram demonstrating excellent anatomic and functional recovery by right kidney.
108 NEUROSURGERY

attention to foci of infection in other parts of the body, particularly pressure

sores. A routine daily liquid intake of 4,000 cc. was an aid in the prevention

of renal infection.

Stasis in the kidneys was combated by changes of body position every 2

hours. This could be accomplished without the use of a Stryker frame. A

program of forced fluids also helped to avoid urinary stasis in renal calyces

and pelves.

FIGUKE 41.—Roentgenogram showing bilateral single calculi

in patient with partial cauda equina transection. The stones

were removed surgically. There was no recurrence of calculi

during the next 6 months.

Hypercalciuria was very difficult to combat. There still appears to be no

specific method of correcting it by dietary, hormonal, or drug therapy.

If calculous disease became established in spite of every effort, it was

often possible to control it by surgery. The paralyzed patient tolerated

renal surgery surprisingly well. In addition, as time passed and he became

more ambulatory, if a clean removal of calculi had been done, the chances

of recurrence decreased.
ÜROLOGIC ASPECTS OF SPINAL CORD INJURIES 109

In the bedfast patient, calculi which were asymptomatic and not associated with fever or hydronephrosis were not considered immediately surgical.

It was wiser, if possible, to wait until the patient was ambulatory before

undertaking operative removal. Stones in the calyces do not require surgery.

Occasionally, however, calculi obstructed the kidneys of a bedfast patient

and operation was necessary for the patient's survival. The most efficient

urinary antiseptics were not adequate to control infection under these circumstances.

PIGUEE 42.—Roentgenogram showing multiple unilateral renal

calculi in paraplegic patient, which increased appreciably in

size over a period of 4 months.

In the ambulatory patient, surgery could be timed and planned to remove all calculi through one incision, before obstruction or dispersion of the

stones into the ureter had taken place.

Conservative renal surgery was paramount in the paraplegic patient

because of the greater than average possibility of stone formation in the

opposite kidney. Kidneys which were widely and grossly infected, with

multiple abscesses throughout the cortex, at times improved, and function

was maintained when obstruction was relieved. The presence of calculous

disease of the opposite kidney often contraindicated nephrectomy even when

the infected kidney appeared gravely damaged.
110 NEUROSURGERY

These statements do not imply that nephrectomy was never done. When

a normal kidney was opposite a large pyonephrotic kidney with a thin cortex,

surgical judgment took precedence over rules.

Nephrostomy and irrigation with Suby and Albright's solution G proved

helpful but was not universally successful. Prather's experience confirmed

Bowie's finding that irrigation treatment by means of ureteral catheters is

not successful.

FIGUEE 43.—Roentgenogram showing bladder stone in

paraplegic patient with complete spinal cord transection

in upper dorsal region.

Unless ambulation was enforced and strenuous efforts were made to

eradicate infection, there was an appreciable recurrence of calculus formation. Recurrence in series of cases observed over periods of 5 to 12 months

was otherwise not unduly large.

Calculous disease in combination with infection was a serious threat to

the welfare of the paraplegic patient. The obstructing stone had to be

removed if the urinary antiseptic agents were to exercise their full effect.
UROLOGIC ASPECTS OF SPINAL CORD INJURIES 111

Ureteral Complications

Calculi.—Ureteral stones descend from the renal pelvis and occur in the

paraplegic patient as they do in any other group of patients. The tendency

of renal calculi to increase in size fairly rapidly and thus become too large

to engage the ureter produced a higher ratio of renal stones to ureteral stones

in military practice than in ordinary urologic practice.

The pain of ureteral colic was often absent in the paralyzed patient with

a high level of anesthesia. Frequently, a febrile reaction called attention to

obstructive pathologic changes in the urinary tract. The diagnosis was

made by roentgenograms. Intravenous urography provided information

concerning the degree of obstruction. When there was uncertainty about the

nature of an opaque shadow in the course of the ureter, retrograde study,

especially in the oblique position, was often necessary.

Treatment of ureteral calculi became a matter of keen judgment. It

rested on estimating the probabilities of spontaneous passage versus manual

dexterity, not only with cystoscopic instruments but with surgical measures.

Calculi of passable size not causing a febrile reaction or more than minimal

dilatation proximally were treated expectantly, in the hope that they would

descend to the bladder spontaneously. Frequent roentgenologic examination

was required to watch their progress. Cystoscopic manipulation under these

circumstances was associated with a definite risk of infection above the

calculus if the procedure was not successful.

Calculi considered too large to have a good chance of passing spontaneously, as well as those of borderline size responsible for a febrile reaction

because of the infected kidney above, were removed by ureterotomy. Surgery, as already stated, was well tolerated by the paraplegic patient and

provided a certain method not only of removing the stone but also of relieving obstruction. Ureteral incisions, like those in the kidney, healed at a

normal rate, and fistula formation was uncommon. In an appreciable number of primary closures of the ureter, there was no urinary drainage from

the wound after operation.

Bladder Complications

Infection.—Long-continued severe cystitis was likely to lead to a reduced

bladder capacity, as observed by Head and Kiddoch in World War I. These

observers also found that any severe fever tended to disturb previously

established reflex action. As Ware 78 had noted in 1918, it is entirely possible for a hypertonic, small-capacity bladder to develop within 3 months

of injury.

Calculi.—Bladder stones were not a direct menace to the life of the paraplegic patient, but they interfered with establishment of satisfactory bladder

'8 Ware, M. W. : Contracture of the Bladder (Hypertonia Vesicae) Due to Spinal Injury. Ann.

Surg. 67 : 533-535, May 1918.
112 NBÜROSUKGERY

function and, by irritation of ureteral orifices, might be responsible for

reflux or ascending infection.

The incidence of bladder calculi in military personnel with spinal cord

injury was apparently uniformly high. Prather reported an incidence of 30

percent in patients with complete transection and of 14 percent in those with

partial transection. These figures are comparable to those of Raines and

Bowie, who reported, respectively, that 27 and 32 percent of their patients

showed bladder calculi.

Stone formation occurred irrespective of suprapubic urethral catheter

drainage and of tidal or manually controlled irrigation as well as during

the use of solution M as the sole irrigating medium. In most instances the

stones were small.

Symptoms were minimal, because the patients had little or no sensation

in the bladder. The diagnosis was usually made by roentgenograms or by

cystoscopy. Chemical analysis usually showed that the stones were chiefly

composed of calcium phosphate and calcium carbonate.

The treatment of multiple small calculi in the bladder did not prove

difficult. They could be crushed with the cystoscopic lithotrite and removed

through the resectoscope sheath with the aid of the Ellik evacuator, or, at

times, they could be removed through a suprapubic sinus.

Prostatic Complications

With the employment of urethral catheter drainage over a long period

of time, prostatitis of some degree was probably universal in the paraplegic

patient, but it seldom appeared to be of clinical significance. Since there

was no good reason to examine prostatic secretion in these patients, no data

are available.

Prostatic abscess was unusual even in patients on urethral catheter

drainage for many weeks. Perhaps this immunity might be explained, at

least in part, by the dilated prostatic urethra which is common in many of

these cases. If the bladder neck and prostatic urethra are relaxed, secretions

from the prostate emerging into the urethra would flow back easily into the

bladder.

Complications in the External Genitalia

Epididymitis.—Infection in the epididymis may occur whenever there is

urinary infection, presumably by retrograde extension via the ejaculatory

ducts and vas deferens. Bloodborne infection is also possible, but, in general,

it tends to cause abscess of the testis rather than of the epididymis. Epididymitis is more common during periods of bladder drainage by urethral

catheter than by a suprapubic tube. These observations were all confirmed

in paraplegic centers.

In the paralyzed patient, symptoms were negligible, but inspection of

the swollen scrotum revealed the disease. Fever was common.
UROLOGIC ASPECTS OF SPINAL CORD INJURIES 113

Treatment was the same as in the nonparalyzed patient. Elevation of

the scrotum, which is an accepted procedure, helped to relieve pain in the

patient who had sensory appreciation. Reverting to cystostomy drainage

simply for this infection was hardly advisable once the inflammatory process

had begun. Systemic use of sulfonamides and penicillin was logical and

useful. Surgical drainage was necessary only if a fluctuant abscess occurred.

In virulent infections, the process might cause extensive scrotal sepsis necessitating epididymo-orchidectomy.

Periurethral abscess.—Infection in the glands of the urethra might become severe enough in one area to lead to abscess formation. This occurred

most frequently during periods of drainage by urethral catheter and was

not uncommonly due to the use of too large a catheter. A large catheter was

also apt to produce pressure necrosis at angular portions of the urethra and

to cause abscess formation. In the paralyzed patient, catheters larger than

No. 18 F. were found to enhance the probability of periurethral abscess.

Abscess formation, which was most common at the penoscrotal angle, often

caused sufficient inflammatory reaction to be momentarily confused with

scrotal sepsis. Careful palpation led to the correct diagnosis.

The abscess itself was not serious, but if urethral fistula followed evacuation of pus, the recovery of the patient to a voiding state was delayed,

sometimes by many weeks. Treatment of the abscess was by systemic agents,

sulfonamides, and penicillin, with incision and drainage when required. A

small, urethral catheter permitted intraurethral discharge of pus. As in

epididymitis, cystostomy did not appear advisable once the process had

become full blown, since a change to suprapubic drainage at this point does

not prevent the formation of a fistula.

Urethral fistula.—Fistulas in the bulbous portion of the urethra tended to

close more quickly than those of the penile urethra provided that there was

no obstruction distal to the opening. They might close spontaneously in

either area. If the fistula was small and spontaneous closure did not occur,

fulguration of the sinus aided in the process. When the opening was_ larger,

surgical closure by plastic methods was sometimes required, as described by

Cordonnier.70

Priapism.—Priapism as a reflex mechanism was common in patients

with spinal cord injury, especially those with complete transection, after the

stage of spinal shock had passed. It was usually recurrent, each episode

lasting from a few minutes to several hours. The erection disturbed the

adjustment of urethral catheters if adhesive-tape fixation had been used.

Hartwell,80 in 1917, noted priapism in 27 of a series of 67 patients with

injury of the cervical or thoracic portions of the spinal cord; in all but 3 of

the 27 cases, the patients had suffered complete transection.

Cordonnier. J. J. : Fistula of the Penile Urethra: A Method of Repair utilizing Stainless

Steel "Pull-Out" Sutures. J. Urol. 55 : 278-286, March 1946.

so Hartwell, ,T. B.: An Analysis of 133 Fractures of the Spine Treated at the Massachusetts

General Hospital. Boston M. & S. .T. 177 : 31-41, 12 July 1917.
114 NEÜROSTJRGERY

There is no specific treatment. At times, neurosurgical advice was requested concerning possible nerve section or block to overcome the condition.

Impotence.—Few data are available on this question, but it is a subject

that needs study and evaluation. Cobb and Coleman found that, as a rule,

sexual function suffered relatively more than urinary or rectal function in

high lesions but that, in lower injuries, sex potency might return before

control of bladder and rectum was regained. Impotence might exist even

after partial transection and was of special concern to the male patient who

had made a good recovery in respect to ambulation and bladder and bowel

control. In Army experiences, the condition was more common following

partial transection of the cauda equina than after a similar injury at a higher

level. Further data are required to discover how much time is required for

optimum recovery.81

RESULTS OF TREATMENT

An accurate survey of results of urologic treatment is difficult because

in reported series, the distinction between partial and complete transection

of the cord has not always been maintained and because several methods of

treatment were often employed in one patient. The following statements

should therefore be accepted with these reservations in mind.

In 1917, Thomson-Walker, who did not differentiate between partial

and complete transection, found that 55 days was the average length of time

for the first two stages of bladder recovery. His cases were treated by intermittent catheterization, and the mortality rate, as already mentioned was

very high. Apparently, some of his patients later underwent cystostomy.

In a series of 100 patients whose injuries were more than 2 years old, 69

had resumed voiding with an automatic reflex bladder. In those patients

who had bladder capacities of 8 to 12 ounces, the residual urine varied

between 0 and 6 ounces. Patients with larger capacity had a larger residual.

Riches reported on 30 patients studied in World War II in whom no

single form of treatment was used. In injuries of the spinal cord, a period

of 4 to 20 weeks (an average of 12 weeks) elapsed before voiding was

resumed, while in injuries of the cauda equina, a period of 6 to 68 weeks

(an average of 26 weeks) passed before voiding took place. Periodic reflex

micturition developed best in supralumbar lesions, and the residual urine was

seldom over 2 ounces. Of 20 patients with incomplete transection, 9 recovered voluntary control after intervals of 1 day to 15 months. The presence

of a suprapubic tube for periods of 9 to 13 months did not prevent eventual

return of micturition which was clinically normal except for the presence of

infection and a 2-oz. bladder residual. Over a period of 2 years, the mortality rate was 28.5 percent, and half of the deaths were caused by urinary

tract infection.

81 Studies on this point have been made in Veterans' Administration hospitals.
UROLOGIC ASPECTS OF SPINAL CORD INJURIES 115

Dennis,82 writing in 1895, found that the higher the injury of the cord,

the higher was the mortality rate. He cited the death rate in the Civil War

for gunshot wounds of the cervical region as 70 percent, of the dorsal region

as 63.5 percent, and of the lumbar region as 43.5 percent. Cumston,83 in

World War I, found a mortality rate of 32 percent in lesions of the cauda

equina, considerably less than the death rate of 64 percent in injuries of the

spinal cord. Riches, in 1943, reported a mortality rate of 62.5 percent in

complete transection of the spinal cord and of 15.8 percent in complete

transection of the cauda equina. In cases of partial transection of the cauda

equina, the reported mortality rate was 12.5 percent as compared to 43.7

percent for partial transection of the spinal cord.

Up to the end of World War II, Munro84had reported the largest

number of spinal cord injuries observed in civilian life. In 1943, he reported an overall mortality rate of 57.5 percent in 40 thoracic and lumbosacral

cord and conus injuries. Deaths due to genitourinary sepsis were estimated

as representing about 17 percent of the total deaths. Some of these deaths,

however, were due to surgical accidents. In 100 cases of cervical cord injuries, the mortality rate was 46 percent, but genitourinary sepsis was responsible for only 6.5 percent of the total deaths.

Some interesting comparative data for tidal drainage were reported by

Munro85in 1946. Infection of the genitourinary tract developed in 24 percent of a group of patients who were completely paralyzed below the waist

while they were under treatment by this method, but it had cleared up in

all but 8 percent before discharge. Infection was present at discharge, however, in 20 percent of a group in whom this method was not employed until

other techniques had been used and was also present at discharge in 17 percent of a group of patients in whom it had not been employed at all. Sixtynine percent of Munro's patients who had been treated exclusively with tidal

drainage had no infection of the genitourinary tract at any time.

Functional results in 125 selected cases in Munro's series showed that

complete urinary control was attained in 58 percent of the patients when

tidal drainage was used from the start, in 45 percent when it was used after

an interval, and in 79 percent when it was not used. Munro does not specify

in what type of case the tidal apparatus was not used, nor does he state what

type of treatment was used instead. The reasons for failure in cases in which

tidal drainage was used were variable; they do not discredit this method and

would contribute to the failure of any method. In a selected group of 101

cases, only 1 patient in whom tidal drainage was properly used for a sufficient length of time failed to have infallible 21-hour control of urination at

the time of discharge.

82 Dennis, F. S. : The Treatment of Injuries of the Spine and Cord by Sayre's Plaster-of-Paris

Jacket. Ann. Surg. 21 : 268-278, 1805.

83 Cumston, C. G. : The Treatment of Cranio-Cerebral and Cord Injuries of Warfare. N. York

M.J. 109: 196-198, 1 Feb. 1919.

84 Munro. D.: Thoracic and Lumbosacral Cord Injuries ; A Study of 40 Cases. J.A.M.A. 122 :

1055-1063. 14 Aug. 1943.

85 See footnote 46(2), p. 93.
116 NEUROSTJRGERY

In 1936, after only a brief experience with tidal drainage, Munro86reported that the uninhibited normal cord bladder (automatic bladder) had a

storage capacity of less than 200 cc. in 90 percent of cases and that the average residual was about 6 percent of the fill. End points of progress were

reached between 17 months and 17 years after injury. There are no recent

data by this author on bladder capacity, amount of residual, and rate of

recovery in cases with complete transection of the spinal cord, now that many

years of experience with tidal drainage have been acquired. A larger capacity may be inferred from his statement that patients can go a minimum of

3 hours during the day and for the entire night without wetting themselves.

If one can assume a urinary output of 2,000 cc. per 24 hours, with 6 voidings

at 3-hour intervals during the day and none at night, bladder capacity would

be about 330 cc.

Petroff discussed the progress of patients injured in World War II at a

symposium on the subject in 1945.87 He had been able to transfer to tidal

drainage 42.5 percent of 40 patients with complete transection who had had

suprapubic cystostomy overseas. Eeflex urination had been developed within

a period of approximately 1 year from the time of injury. Patients with

partial transection could, in general, be rehabilitated to a voluntary voiding

status within 6 to 8 months from the time of injury.

Medler,88 at a similar conference, reported that in 122 cases of partial

and complete transection, two-thirds of the patients were free of catheters

at a time presumably averaging 8 to 15 months after injury. Prather studied

a series of 61 patients with spinal cord injuries. There were 2 deaths, in an

average period of nearly 15 months from the time of injury, in 20 patients

who had suffered complete transection of the spinal cord. One death was

caused by general sepsis that included the urinary tract and the other by

acute hepatitis. Periodic reflex voiding had been established in 62 percent

of the patients without the use of tidal drainage or resection of the bladder

neck. Micturition occurred at 1- to 4-hour intervals during the day, with a

longer interval during the night. There was no leakage of urine during the

interval between urinations. Bladder residual varied between 1 and 3 oz.

Several weeks after rehabilitation of the bladder had been accomplished, the

urine became grossly clear, but it still showed positive cultures in the majority of cases. These patients were ambulatory in wheelchairs or were on

braces outdoors and indoors. Some took trips to surrounding towns via

automobile.

Patients in whom voiding had not become reestablished either were in

poor general condition from associated injuries or had not sufficient reflex

bladder activity, as shown by cystometric study, to reestablish voiding.

Those who had developed periodic reflex micturition did so within 3 to 10

months from the time of injury (an average of 5.77 months). After con8G See footnote 9(2), p. 69.

87 See footnote 73, p. 102.

88 See footnote 72, p. 102.
UROLOGIC ASPECTS OF SPINAL COED INJURIES 117

version from suprapubic drainage, it was possible to develop an automatic

bladder, with the suprapubic wound healed, within a period of 4 to 8 weeks.

Most of these patients had had suprapubic cystostomy overseas. A manually

controlled system of irrigation was used during both suprapubic and urethral drainage in the majority of the cases. . ,.

Forty cases of partial transection of the cord or cauda equina caused by

war injuries were studied by Prather for periods up to 19 months from the

time of injury. His personal study began after the patients had been evacuated to the United States. There were no deaths in this series..: Thirty-nine

patients resumed voluntary voiding in normal quantities and with nearly

perfect control. Tidal drainage was used in only a few cases, and resection

of the bladder neck was necessary in only one case. In the patients who had

had urinary retention for 1 month or longer, the longest time from injury to

resumption of voiding was 11 months, and the average period was 3 months.

Fifteen percent had resumed voiding less than a month after injury.

Bumpus, Nourse, and Thompson's report on a series of 101 spinal cord

injuries concerned naval personnel. They found it advisable to resect the

bladder neck in 39 of 56 patients with injuries below the level of the eleventh

thoracic vertebra. Following this procedure, satisfactory urination was established in all but three. They believed that the operation facilitated emptying

of the bladder and contributed toward an eventual clear urine. They also

used vesical neck resection to diminish or eliminate bladder residual in 16

patients with lesions above the tenth thoracic segment. In their series, there

were two deaths. Of the surviving patients, 94 percent were free of catheter

drainage, and in the majority, the urine was grossly clear. Negative urinary

cultures were reported in 39 percent.

The data from these various sources indicate that urologic treatment of

spinal cord injuries was far more successful during the period just before

and during World War II than it had been 20 years earlier. Several factors

were probably responsible. Wider knowledge of the ability of the bladder

to recover its functional activity had led to more energetic and successful

attempts at rehabilitation to a state of satisfactory voiding. The greater

cleanliness of a sterile closed system of drainage and irrigation had helped

to reduce gross bladder infection and prevent a certain number of renal

complications. In addition, the more efficient urinary antiseptics saved

lives and contributed to eventual recovery. In World War II, the paraplegic

patient was justified in looking forward to bladder function that would permit a reasonable social existence.

Influence of Level of Treatment on End Results

The level as well as the extent of the spinal cord injury determines to

some degree the final status of the bladder and the success of the long-term

program of rehabilitation.

Patients with complete cervical transection present special difficulties in
118 NBUROSURGERT

rehabilitation of the bladder because they cannot use their hands. Since

they are unable to use a urinary receptacle, they are sometimes best left on

suprapubic drainage. If, however, a partial transection in the cervical region is unilateral, the patient can handle a urinal satisfactorily and should

look forward to a normally functioning bladder under excellent voluntary

control.

Patients with complete transection at the level of the upper and middle

thoracic segments have an excellent chance of developing an efficient, socially

compatible, reflex type of bladder as an end result. The intervals between

voiding may reach several hours, and, during the intervals, no leakage of

urine should occur. In the supine position, a bladder capacity of 4 to 8 oz.

is to be hoped for. In the sitting position, a larger amount of urine may

accumulate before a reflex contraction takes place. A bladder residual of

1 to 3 oz. is not uncommon. Patients with partial transection at this level

should attain an efficient bladder with voluntary control.

In cases of complete transection at the level of the lower thoracic or

lumbar segments, the establishment of an automatic bladder is less certain.

There are, however, a number of reported instances in which very satisfactory reflex function has become established. Bladder capacity is usually

greater than with complete lesions at a higher level, and a longer interval

between voiding can be anticipated if, at the time of reflex contraction,

supplementary effort by straining or suprapubic pressure is used. These

methods may help to avoid a tendency toward a larger bladder residual than

is commonly found in higher lesions.

Patients with complete transection at the level of the cauda equina are

unlikely to progress to an efficient type of automatic bladder, although

Denny-Brown89reported cases in which it had been achieved. Munro,90 however, found an inefficient autonomous bladder the typical end result. In such

instances, the bladder with an appreciable bladder residual is best cared for

by permanent drainage if voluntary straining and abdominal pressure do

not produce satisfactory emptying.

Partial lesions of the cauda equina may be associated with some incontinence when the patient is standing or engaged in physical activity. During

attempted urination, some straining may be necessary to empty the bladder.

SPINAL CORD INJURY IN THE FEMALE

Lack of wide experience with females with this type of disability prevents authentic statements for this group. The progress toward recovery

should be the same, however, and the chance for urethral and genital complications less. During the early phases of the illness, it would seem imperative to use a balloon-type catheter for drainage with either manual or auto88 See footnote 11, p. 71.

so See footnote 9(2), p. 69.
UROLOGIC ASPECTS OF SPINAL CORD INJURIES 119

matic irrigation to prevent overflow incontinence, a wet bed, and decubitus

ulcers. Eehabilitation to a satisfactory voiding state should be possible.

MILITARY POLICIES

Although complete data are not available, some information in regard

to the urologic problems of paraplegic patients can be summarized.

Historical Note

Not much information is available concerning spinal cord injuries in

World War I. Cushing set the mortality rate at 80 percent.91 There was no

definitive program of management (p. 4), and only casualties with partial

cord injuries seem to have survived.

According to Young,92 nonintervention was generally believed to be the

wisest course, and the Manual of Military Urology,93 for which he served as

chief editor, recommended this policy. He had no information on how

successful this policy had been, but he stated that, in many cases, it was

apparently desirable, or later became essential, to employ catheterization or

suprapubic drainage. Connors and Nash, in a survey of the policies of the

various combatants in World War I, found that the British, like the U.S.

forces, had never issued definite orders or instructions regarding treatment.

The French Army apparently used catheterization early and cystostomy later.

Inquiry of German and Austrian sources was unproductive, the replies stating that there were no statistics on the problem and no preferred method of

treatment.

Evolution of Policies in World War II

At the beginning of World War II, there was no official policy regarding the urologic management of spinal cord injuries. This is readily explained. Probably in no other type of injury were such divergent opinions

concerning the proper or best treatment so positively expressed by so many

authorities. Different methods of handling the bladder in civilian spinal

cord injuries had been championed and denied with equal vigor by recognized urologists and neurosurgeons. Experiences in World War I, while

they had failed to indicate any ideal form of treatment, had demonstrated

that the program of intermittent catheterization led to an appalling mortality. It is therefore understandable that, in this confusion, no official policy

could be honestly advocated. Tidal drainage had been the only new form

01 dishing, H. : Organization and Activities of the Neurological Service, American Expeditionary

Forces, In The Medical Department of the United States Army in the World War. Washington :

Government Printing Office, 1927, vol. XI, pt. 1, pp. 749-758.

92 Young, Hugh H., and Davis, David M. : Young's Practice of Urology. Based on a Study of

12,500 Cases. Philadelphia and London : W. B. Saunders Co., 1926, vol. II, p. 695.

03 Manual of Military Urology Including Venereal Diseases, Skin Diseases and Wounds of the

Genito-Urinary Organs. Published for the American Expeditionary Forces by the American Red

Cross. Paris : Masson et Cie., 1919, 2d ed.

49S991V—59 10
120 NEUEOSURGERY

of treatment prescribed in the previous 10 years, but care of war casualties

usually prohibited the use of this system until the patient reached a wellequipped fixed installation. Furthermore, relatively few physicians were

acquainted with this apparatus, its intricacies, and the cystometric studies

necessary for its correct use. In addition, associated wounds of the chest or

abdomen often prohibited the immediate use of this favored treatment.

Management overseas.—In spite of the known difficulties, much thought

was given to formulating a program of management of these casualties, particularly in the European theater, and long before D-day. Instructions were

issued just before the invasion date, specifying that tidal drainage should

be used. It was thought that rapid air evacuation from the Continent to

England would facilitate this plan, and, for some months, paraplegic patients

sent from France to England were all treated by tidal drainage on the

Continent.

Gradually, however, patients began to be returned with suprapubic tubes.

As reported by Scarff, this was due to several factors:

* * * primarily to the advent of new armies in the theater—for instance, the 7th,

the 9th, and the 15th. Parts of the 7th Army had fought in the African desert and in

the Italian mountains and their unique experience in these difficult terrains undoubtedly

justified their belief that the suprapubic drainage was the only safe method. Others

simply had not come under the persuasion of the Chief Surgeon's staff and had evolved

their own doctrines, in which the immediate safety of the patient completely obscured

the long-term objective of his later rehabilitation.

The lengthening lines of communication, delay in prompt evacuation

because of adverse weather, and changing personnel finally made continuance of the tidal drainage program impossible.

Between D-day and V-E Day, 1,260 paraplegic patients were treated in

general hospitals in the United Kingdom Base alone. The ideal care, according to the senior consultant in neurosurgery, consisted of transporting the

paraplegic patient from the battalion aid station to the nearest collecting

station, then sending him in an ambulance to the nearest evacuation hospital,

where his general condition could be evaluated and he could be prepared for

prompt air evacuation to a neurosurgical center. Insertion of an indwelling

catheter was the only urologic measure advised at this stage. For various

reasons, including other wounds, only about 50 percent of the casualties

could be handled in this manner. The remainder had to be cared for in

evacuation and field hospitals for the first 2 or 3 weeks after injury.

Once the patient arrived in a general hospital, he was placed in a

special ward, of which a urologist was in charge. The care of the bladder

was considered the most urgent problem. In some of the centers, tidal

drainage via the urethral catheter was used for several weeks. At the end

of that period, if there was no return of spinal cord function, a suprapubic

cystostomy was performed, to facilitate immediate treatment of urinary sepsis and to make the patient ready for evacuation to the United States in the

shortest possible time. When the wound had healed well around the supra-
UROLOGIC ASPECTS OF SPINAL CORD INJURIES 121

pubic tube and urinary sepsis had subsided, he was considered ready for

evacuation from a urologic point of view. It was not feasible to use tidal

drainage continuously in an active theater of war in a large group of casualties. Furthermore, it was completely impractical during the trip to the

Zone of Interior by any form of transportation.

The neurogenic bladder was one of the most common types of urologic

dysfunction that confronted the urologist in modern warfare, and its management remained a debatable subject to the end of hostilities. No conclusions could be drawn concerning whether or not tidal drainage irrigation

was essential because statistics on parallel groups of identical injuries were

not available. Nor could conclusions be drawn concerning the relative merits of various irrigating fluids used in tidal drainage, though acid mediums

appeared to be the most valuable. Of 117 patients observed by Maj. (later

Lt. Col.) John N. Robinson, MC, in whom the extent of the lesion was not

specified and who were treated with tidal drainage, 50 percent had some

degree of return of bladder function. Of a group treated by catheter drainage in which tidal irrigation was not used, 31 percent had a comparable

return of vesical function. Of another group of 294 patients, 199 required

suprapubic cystostomy either because of early recognition of a hopeless lesion

or because of failure to respond to urethral drainage. Robinson found that

patients who experienced marked or complete improvement showed it within

3 weeks. He believed that suprapubic cystostomy after that time appeared

to be the logical therapy either to insure safety during evacuation or because

of a poor ultimate prognosis. Lt. Col. J. Hartwell Harrison, MC, in the

Southwest Pacific Area, found that the best results were obtained when early

continuous tidal drainage was instituted by urethral, perineal, or suprapubic

catheter. It was not possible to use the urethral catheter in many patients

until an automatic bladder had been established, and a few, even with the

best of care, did not tolerate it. For transportation over long distances by

air or water, the suprapubic catheter proved to be the easiest to care for and

the safest method of drainage.

Suby and Albright's solution was used for irrigations. Progress toward

automaticity was followed by biweekly cystometrograms.

Additional personnel were assigned for handling spinal cord injuries,

and with the care thus made possible, patients under the regimen described

did not develop renal or vesical calculi, and automatic bladders were established before evacuation in one-third of the cases.

Management in the Zone of Interior.—After arrival in the United States,

which was usually 6 to 12 weeks after injury in the European theater, paraplegic patients were sent to neurosurgical centers located in Army general

hospitals. The trip from overseas, whether by air or by ship, had often

been an arduous one.

Thorough reevaluation of the urinary tract by roentgenography, intravenous urography, cystometry, and cystoscopy was instituted, and the general measures described were continued.
122 NEUROSURGERY

Capable representatives in various special fields, such as neurosurgery,

orthopedic surgery, plastic surgery, nursing, dietetics, physiotherapy, occupational therapy and recreation, Red Cross, and the Chaplain Corps, were

also enlisted for the welfare of these casualties. Their rehabilitation became

a challenge in many fields of medicine.

The urologic program was at first left to the ability, ingenuity, and

resourcefulness of the urologists at the centers designated for the care of

the paraplegic patient. Organized and improved urologic treatment became

increasingly necessary, however, as the number of patients increased. Sterile

closed systems of drainage and irrigation were instituted in some centers.

Cystometric studies disclosed that many bladders were capable of resuming

function, so that it was possible to institute urethral catheter drainage with

a closed system of drainage while the suprapubic wound healed. Attention

was also given to obtaining a renal condition as near normal as possible.

The final steps, removal of the catheter, a training period for the bladder,

and either reflex or voluntary voiding, proved successful in many cases.

This improvement was not accomplished overnight, but, during a period of

months, excellent results were obvious and stimulated further effort.

A survey of paraplegic patients in October 1945 revealed that 948 of

1,430 paraplegic patients had arrived in the Zone of Interior with suprapubic tubes in situ and that 236 of these, almost 25 percent, were voiding

on arrival. At the time of the survey, 635 patients, almost 44 percent, had

reestablished bladder activity and were voiding. Of 642 patients presumed

to have complete transections of the cord, 29 percent were voiding periodically with an involuntary reflex type of bladder activity, 32 percent were

on urethral drainage, and 39 percent remained on suprapubic drainage. Of

750 patients presumed to have partial transection of the spinal cord, 65 percent were voiding with voluntary control. These averages, which of course

do not represent the final accomplishment or the end point in the rehabilitation of the bladder, indicate that commendable progress had been made in

these cases within a period of months after the injury.

The survey produced further interesting clinical and statistical data.

Fifty-six cases of periurethral abscess were found, 48 of which occurred

during urethral catheter drainage. One hundred and seventy-nine instances

of epididymitis were recorded, 126 of which occurred during urethral catheter drainage.

Urinary tract calculi proved to be an important potential or actual complication. At the time of the survey, more than 12 percent of the patients

had renal calculi, and at least 20 percent had vesical calculi. ^

Drugs had not proved helpful in promoting bladder activity.

Resection of the presacral nerve was reported in two cases; both operations

were failures. Resection of the bladder neck to facilitate emptying of the

bladder had been tried in 33 cases up to this time, with good results in 19

and poor results in 14.
ÜROLOGIC ASPECTS OF SPINAL CORD INJURIES 123

Inquiry among the urologists on duty at neurosurgical centers yielded

the following opinions: Twenty believed it advisable to aim for resumption

of voiding in the paraplegic patient, and only two did not believe the effort

worthwhile. Nine believed tidal drainage was necessary for the eventual rehabilitation of the bladder, but sixteen disagreed with that opinion. Twentythree advocated cystometric study periodically to determine the status of the

bladder, although three did not believe this type of examination helpful.

The mortality rate in spinal cord injuries in active theaters of war was

not yet known at this time (October 1945), nor was the mortality rate known

in patients who had survived the initial shock of injury and had been returned to the Zone of Interior. Scattered reports from neurosurgical centers in the United States indicated a remarkably low mortality rate during

the first year, probably not over 6 percent, in this group; all the deaths,

furthermore, were not due to urologic causes. Patients who were not discharged to their homes would eventually be transferred to Veterans' Administration hospitals for further care, and statistical data must necessarily

come from that source (p. 12(n)).

A SUGGESTED PROGRAM OF MANAGEMENT

The following suggested program is based on an academic review of

contributions of many authors and on experiences in the rehabilitation of

patients during World War II. It is believed that it is as errorproof as

possible and that it will lead to a urinary tract as functionally efficient as

the extent of the injury allows. A successful result, as just indicated, depends as much on the skill and attention of those in immediate charge as

on the several possible methods of treatment.

There appears to be no reason to catheterize the bladder until urinary

retention has been demonstrated. When, however, it becomes evident that

the bladder will not immediately resume function, the patient should be

catheterized under strict aseptic precautions with a No. 18 F. two-holed soft

rubber catheter. The catheter should be arranged for constant drainage and

connected to a sterile closed drainage system with provision for closed irrigation controlled either manually or automatically.

If the neurosurgical survey indicates that a partial transection of the

spinal cord has occurred, plans can be made to continue the urethral catheter program with the hope that voluntary bladder action will be reestablished in a period of weeks. If the survey indicates that there is complete

transection of the spinal cord, the urethral catheter program can be continued unless contraindications appear, or suprapubic cystostomy can be done

and the tube connected to a closed drainage system. In cases of complete

transection, a number of weeks may elapse before a reflex type of bladder is

established. With either the urethral or suprapubic drainage program, frequent irrigations under aseptic conditions must be used, and catheters or
124 NEUßOSüRGERY

tubes must be changed periodically before they become obstructed or encrusted.

Fluid intake and output must be maintained at a high level and the

general state of nutrition watched carefully.

Koutine tests of renal function, as indicated by blood chemistry studies

and phenolsulfonphthalein excretion, should be made and repeated at intervals to be determined. Cystometric determinations should also be recorded

at intervals of 1 to 2 weeks to note progress of recovery of bladder musculature.

Urinary studies, including cultures, should be made frequently. Eoentgenologic study of the urinary tract by intravenous pyelography should be

done as soon as practicable and repeated at intervals of several weeks.

Sulfonamides and antibiotic agents need not be used routinely but are

helpful if upper urinary tract infection occurs. If urinary infection is

present, urinary antiseptics should be used vigorously after bladder drainage

has been terminated.

As soon as ambulation has been achieved or is in immediate prospect

and the bladder shows a satisfactory cystometric response, measures must

be undertaken to accomplish satisfactory voiding.

If voiding is not resumed as might be expected by the findings on

combined urologic and neurologic examination, cystoscopic study of the

bladder and bladder neck is justified. If there is evidence of vesical neck

obstruction when neurologic improvement has reached a maximum, resection

of this region should be considered.

A sincere interest in the welfare of the patient, strict attention to

aseptic conditions, and an understanding of the aims of treatment on the

part of the medical and nursing staff are essential for progress.

CONCLUSIONS

From the experiences in World War II, certain facts concerning urologic

care of spinal cord injuries in war become apparent, as follows:

1. The soldier with paralysis of the bladder should have constant

bladder drainage by means of a No. 18 F. urethral catheter connected to a

sterile closed drainage system during the early part of his illness. Frequent

irrigation of the bladder is important and can be accomplished by a tidal

apparatus or by manual control.

2. If neurosurgical survey indicates a partial transection of the spinal

cord, urethral catheter drainage can be maintained with hope of recovery

of bladder function in a period of weeks.

3. If neurosurgical opinion indicates a severe injury with probable

complete transection of the spinal cord, and if transportation over long

distances is necessary, a high suprapubic cystostomy with manual irrigation

by means of a sterile closed system offers a safe program.
ÜROLOGIC ASPECTS OF SPINAL CORD INJURIES 125

4. Tidal drainage is a good method of bladder irrigation but is not

necessary for rehabilitation of the bladder to a satisfactory voiding state.

5. Resection of the bladder neck may aid selected patients to reestablish

voiding.

6. Renal surgery is necessary at times to save life and to prevent deterioration of renal substance.

7. Roentgenologic study of the upper urinary tract by means of intravenous urography at intervals of several weeks is advisable to interpret

possible febrile episodes properly.

8. Cystometric study is necessary periodically to determine the proper

time to aim for rehabilitation of the bladder.

9. Penicillin, streptomycin, and the sulfonamides are helpful in controlling urinary infection.

10. Cleanliness, gentleness, and personal ability remain important factors

in urologic technique and treatment.

11. The aim of treatment should be reestablishment of the bladder as a

satisfactory functioning organ. This objective can be accomplished in the

majority of cases.
CHAPTER VII

The Management of Paraplegic Patients in

Zone of Interior Hospitals

Barnes Woodhall, M.D.

The care of paraplegics in civilian hospitals before World War II had

been conspicuously bad. In previous wars, the care provided for them had

been even worse, partly because of the circumstances and partly because

the care was based on an attitude of total defeatism (p. 3).

How completely the situation changed before World War II ended is

indicated in a statement by the consultant in neurosurgery, Office of the

Surgeon General, March 1945, as follows: "We have the problem of taking

care of broken backs in much better shape. Indeed, for all practical purposes, we have it mastered. We simply were not aggressive enough, either

mentally or physically, at first. Now we are."

The story of how this problem was mastered is contained in this

chapter, in which the practical details of the paraplegic program are described and the concept on which it was based is set forth. The material

is derived, unless otherwise indicated, from the reports of the conferences

held at Newton D. Baker General Hospital, Martinsburg, W. Va., on

11-12 May 1945; Hammond General Hospital, Modesto, Calif., on 24-25 June

1945; Halloran General Hospital, Staten Island, N.Y., and Thomas M.

England General Hospital, Atlantic City, N.J., on 19-20 October 1945; and

the special session on war wounds of the spinal cord held at Newton D.

Baker General Hospital on 20 June 1945 (p. 6).

ANALYSIS OF CASES

No comprehensive analysis of patients with paraplegia was undertaken

in the course of the war, but a great deal of information of a general

character was obtained in the questionnaire sent out from the Office of the

Surgeon General in December 1945 (p. 14). The detailed replies concerned

1,399 patients, probably more than 70 percent of all paraplegics treated in

Army hospitals in the Zone of Interior in World War II. The information

which follows was summarized from those replies.

Cause of injury.—No information was requested in the original questionnaire concerning the cause of injury, but a supplemental study included in

the report indicated that accidents were a more important cause of para127

498991T—59 11
128 NEUROSURGERY

plegia than of peripheral nerve injuries, the respective proportions being

21 percent and 4 percent. Shell fragments or shrapnel accounted for 40 percent of the spinal injuries against 62 percent of the peripheral nerve injuries

and gunshot wounds for 35 percent of the spinal injuries against 26 percent

of the peripheral nerve injuries. These figures were secured in an analysis

of 114 paraplegics at Halloran General Hospital. A survey of 26 paraplegics

at Percy Jones General Hospital, Battle Creek, Mich., showed that accidents

were chiefly caused by traffic accidents, falls, and dives into shallow water.

Branch of service.—In 64 paraplegics studied at Halloran General Hospital, 86 percent were in the Army Ground Forces, 11 percent in Army

Service Forces, and 3 percent in the Army Air Forces. About 80 percent

of Army personnel were in the infantry. According to the Adjutant General's Office, 89 percent of all men in service during World War II were in

the Army Ground Forces, 8 percent were in service forces, and 3 percent in

Army Air Forces. For the Army as a whole, the infantry accounted for

90 percent of all personnel.

Age.—The median age of paraplegics was 24 for enlisted men, and the first

quartile was 21. These age averages are about a year below the Army average. Only 17 percent were above 30 years of age, against 24 percent for the

entire Army. A survey of paraplegic officers gave about the same results,

except that the percentage of older paraplegics was less than the Army

proportion of older men. The explanation was assumed to be the high

proportion of paraplegics wounded in action, a group composed chiefly of

younger men.

Rank.—Officers composed 8.2 percent of the paraplegics surveyed. At

V-E Day, officer personnel accounted for 9.3 percent of Army strength. The

explanation, again, is the high proportion of younger men in the paraplegic

group and the very small number of Army Air Force personnel in it.

Marital status.—About a third of the paraplegic patients were married,

against 44 percent for the entire Army. The explanation was the high

percentage of younger paraplegics and their prolonged absence overseas.

About half of the married paraplegics had children; 70 percent had 1 child

each, and 2 percent had 4 children each.

Occupation.—In 3 percent of the paraplegics, no information was secured

about occupation. Mechanics made up 26 percent, farmers 14 percent, clerks

and students 11 percent each, salesmen 4 percent, and professional personnel

2 percent. The remainder represented a wide variety of other occupations.

Comparable Army data, which were incomplete, showed that 12 percent of

the personnel were farmers, 13 percent clerks, 13 percent salesmen, 5 percent

students, and 4 percent professional men. The youthful age of the paraplegics is, again, the explanation for the small percentage of professional

men in the paraplegic group. The high percentage of farmers might reflect

selective factors in their background which resulted in their greater utilization in the infantry than in other branches of service.
PARAPLEGIC PATIENTS IN ZONE OF INTERIOR 129

Educational level.—Only 2 of the 1,399 paraplegics analyzed in thissurvey

had had no schooling at all. In 3 percent, the educational level was not

specified. Of the remaining patients, 3 percent had had from 1 to 4 years

of schooling, 24 percent from 5 to 8 years, 56 percent from 9 to 12 years, and

11 percent from no college training at all to up to 3 years. The remaining

3 percent had had 4 years or more of education at and above the college

level. Twenty-seven percent of the paraplegic group had failed to reach

high school, against 35 percent for the entire Army, and 14 percent had

attended college, against 12 percent for the entire Army. The explanation

of these discrepancies is probably that paraplegics were both younger and

more competent, as shown by the fact that so many of them had qualified

for oversea service.

Army General Classification Tests.—No information was available on

the results of the AGCT (Army General Classification Tests) for 23 percent

of the paraplegics, including the 8 percent who were officers. In the order

of descending achievement, 5 percent of the remaining paraplegics were in

group I, 22 percent in group II, 24 percent in group III, 24 percent in

group IV, and 2 percent in group V. These are, on the whole, higher scores

than for the Army as a whole; on the basis of ten million examinations

given at reception centers, 5.8 percent of all selectees were in group I and

8.8 percent in group V. Many paraplegics who did not go beyond high

school had scores equal to, or superior to, the college group.

PRELIMINARY AND CONTINUING EXAMINATIONS

A complete history was taken, and a complete physical examination was

made as soon as paraplegic patients were received in Zone of Interior neurosurgical centers. Routine laboratory tests included urinalysis and urine

culture; blood studies, including a hematocrit determination; the Kahn test;

blood chemical determinations, including nonprotein nitrogen, urea nitrogen,

and creatinine; calcium and phosphorus determinations; determinations of

the serum protein; and roentgenograms of the chest, spine, and urinary tract.

Orthopedic and genitourinary consultations were requested when these

examinations were completed, and other consultations were requested on

special indications.

Urinalysis was repeated twice weekly. The pH of the urine was determined every second day. Cultures of the urine were taken routinely once

every 4 weeks, and oftener if necessary. Cystometric studies and sphincterometric studies were carried out at the same intervals. The blood chemistry was determined at least once every 6 weeks.

Roentgenologic practices differed from hospital to hospital. In one

sense, it seemed wasteful to repeat these examinations in the absence of

special indications. The general opinion was, however, that repeated roentgenograms were justified to determine bony changes and to guard against

the insidious development of calcification, calculi, and osteroporotic changes.
130 NEUROSURGERY

The simplest way for the ward officer to keep close track of his paraplegic patients was by means of a chart, in tabular form (fig. 44), showing

the name of the patient, the date and level of injury, and the dates of

laminectomy and of suprapubic cystostomy. Frequent entries on this chart

kept the medical officer responsible for the patient fully informed of his

status and progress.

28

FIGURE 44.—Control board in ward office for charting

all paraplegic patients on ward.

of data on

DECUBITUS ULCERS

The defeatist attitude toward gunshot injuries of the spine and their

residuals evident in World War I and in the early months of World War II

extended to all phases of their management, including the management of

decubitus ulcers. Maj. (later Lt. Col.) J. Lawrence Pool, MC, and Capt.

(later Maj.) Donald D. Matson, MC, who were among the first to adopt a

more hopeful attitude in regard to the entire problem, directed particular

attention toward this phase of it. These ulcers had been a serious problem

in World War I in the patients who had survived their acute injuries for

any length of time. In World War II, because of geographic considerations

and the long distances over which transportation of these casualties was

necessary, the problem was even more serious.
PARAPLEGIC PATIENTS IN ZONE OF INTERIOR 131

General Considerations

There was general agreement that the great majority of the paraplegic

casualties received from overseas in World War II arrived with decubitus

ulcers, which frequently were multiple as well as extensive. Of 21 patients

treated during one period by Capt. (later Maj.) Donald E. Barker, MC, at

Newton D. Baker General Hospital, 10 had 1 ulcer, 5 had 2, 4 had 3, and

1 had 5. The size ranged from a lesion 1 by 2 inches in extent to a lesion

6 by 8 inches, which covered the entire area of the sacrum.

Decubitus ulcers were observed in paraplegics on every body surface

subjected to ischemia for periods of time sufficient to initiate cellular necrosis.

At first, the upper limits of presumed safety were estimated rather liberally.

As the war progressed, these limits were set at a maximum of 4 to 6 hours,

with the shorter interval regarded as safer. It was also realized that the

presumed safety of these time limits depended upon a number of factors in

addition to the mere passage of time. Chief among these factors were

repetitive ischemia and the systemic changes brought about by malnutrition

and infection. Ulcers were occasionally observed in patients in good general

condition, who had been well handled, and in whom they had developed in

spite of every precaution. Most often, however, they occurred in cachectic,

very ill patients, in whom inept handling had often compounded the predisposing circumstances.

Decubitus ulcers were observed on the heels; on the dorsum of the

toes; and over the tibia, patella, sacrum, trochanteric region, ischial tuberosity, anterior superior iliac spines, spinous processes, alar scapulae, anterior

chest wall, and olecranon. They were also occasionally observed over the

forehead and malar prominences. Ulcers over the sacrum and in the

trochanteric region, in which they were frequently bilateral, were of the

greatest practical importance, both because of their frequency and because

their correct treatment often required complicated plastic procedures. Small

ulcers in these areas could often be closed by suture, but large ulcers might

require extensive plastic operations, which were the more difficult to perform because of various degrees of subcutaneous invasion by the ulcerative

process, and, in some cases, because of osteomyelitis of the sacrum or femur.

The pathologic process included engorged venules, thrombosis of the

smaller veins, and thickened arterioles. Capillary thrombosis was manifested

clinically by the absence of blanching on pressure. The bacteriologic flora

was similar to that of the feces and urine.

Care During Transportation

Paraplegic patients were evacuated from oversea theaters to general

hospitals in the Zone of Interior as soon as their condition permitted. The

global extent of AVorld War II made transportation necessary over great
132 NEUROSÜRGERY

distances, by whatever method of evacuation was available and practical,

including rail, sea, and air transport.

It is a distressing historical fact that during most of the war, paraplegic

patients arrived in the Zone of Interior considerably the worse for the

journey (figs. 45 and 46). No authentic observations are available covering

^

•V *•

FIGUEE 45.—Paraplegic patient showing wound of entry, oversea laminectomy scar, ill-defined level of cutaneous anesthesia,

indicated by area of skin discoloration, and decubitus ulcers secondary to transportation.

the period of transportation, but the general criticism may justifiably be

made that the high excellence of professional care behind the lines overseas

and the similarly high excellence of professional care of these patients in

Zone of Interior hospitals were not duplicated between these areas. Transportation, as far as paraplegics were concerned, was characterized by a

dismal hiatus in treatment. The circumstances were particularly unfortunate

for men with injuries of the spine, whose care must be incessant and unremitting.

In spite of the fact that in most gunshot wounds of the spine, the

bony skeleton was relatively stable, protection of the vertebral column during

transportation outweighed all other therapeutic considerations during the

first months of U.S. participation in World War II. Many additional

months were to pass before there was a full appreciation of the relevancy

of the already well-established fact that decubitus ulcers develop as the

result of ischemia of skin surfaces under pressure, whether or not analgesia

is present. The paraplegic patient, who was unable to recognize pressure

and unable to move even if he was aware of it, w

Tas naturally the better for
PARAPLEGIC PATIENTS IN ZONE OF INTERIOR 133

Y, >

FIGURE 46.—Extensive decubitus ulcers in cachectic paraplegic

patient. A. Posterior view. B. Oblique view. Note sequestration

of head of femur.

care during transportation. If lie did not receive it, lie was simply the

victim of adverse circumstances.

Eventually, it was realized that decubiti would inevitably occur unless

certain measures were employed during transportation, as follows:

1. The position of the casualty must be changed during transportation

at least every 4 hours and oftener if possible. This was mandatory.

2. During the intervals between changes of position, which were periods

of potential ischemia, pressure points must be protected.

3. Body surfaces must be constantly protected from the macerating

effects of body excretions.

The whole problem of the transportation of paraplegics was discussed

in detail at the paraplegic conferences. Particular attention was devoted to

it during the June 1945 conference at Hammond General Hospital, at which
134 NEÜROSURGERY.

it was pointed out that if ever casualties of the war deserved priority in

transportation, it was these paraplegics. It was also pointed out that rapid

transportation had other desirable effects in addition to the prevention of

decubitus ulcers. One of them was the elimination of the period of debilitation and muscle wasting almost inevitable when transportation was by sea

or by slow train.

On the other hand, every speaker at this and other conferences emphasized that air travel in itself was no solution to the problem, particularly

if patients brought from overseas by plane were transported by train across

the United States, as some of those in hospitals in the Ninth Service Command had been. In the absence of trained attendants, who understood the

care of these patients, bedsores would develop, no matter what mode of

transportation was employed. These attendants, whether they were nurses,

medical officers, or technicians, had to understand that these patients must

be turned regularly, that care of the bladder was necessary, and that the

skin must be kept clean and dry. Skin care offered special difficulties in the

tropics in patients who were in casts.

The entire problem of transportation of paraplegics had many ramifications. It was pointed out in discussions at the conferences, for instance, that

they traveled better in Stryker frames and could be turned in them much

more easily than in any other device. The use of these frames, however,

was not practical because they were cumbersome in the limited space of the

plane, and they added considerable extra weight. One proposal was that

engineers in the Army Air Corps devote some attention to the development

of a lightweight stretcher which could be used for the transportation of

paraplegics and in which they could be turned easily. It was suggested

that unless a Stryker frame was used, these patients should travel in the

prone position, in which less cord damage was likely. Another proposal,

that a number of specially built planes—up to a dozen—should be reserved

for paraplegics, was regarded as unrealistic because the total number of these

patients was very small. A more practical suggestion was that all paraplegics be tagged, just as patients receiving penicillin were tagged, with

the instructions that they be turned every 2 hours.

Prevention

The prevention of decubitus ulcers was an objective never fully achieved,

but the elements of prophylaxis were finally appreciated. The important

measures consisted of (1) rapid transportation, as soon after injury as

feasible, to a permanent hospital installation in the Zone of Interior, and

(2) the segregation of patients for transportation under the care of specially

trained air evacuation personnel, who were adept in turning paraplegics,

in the care of the bladder, and in the other prophylactic and therapeutic

measures of which paraplegics were in constant need.
PARAPLEGIC PATIENTS IN ZONE OF INTERIOR 135

In the last months of the war, when these principles had been realized

and implemented, paraplegics often were received in Zone of Interior hospitals 60 hours or less after injury, and without decubitus ulcers, because

they had been transported in appropriately padded casts, under the care

of specially trained aircrews. It was reported at the Hammond conference

in June 1945 that at DeWitt General Hospital, Auburn, Calif., patients who

had arrived within the past month were already ahead of patients with

equivalent lesions who had arrived a year earlier. One reason for the improvement of the patients who had recently arrived was that the hospital

was now more fully prepared for the management of these patients than

it had been then, but another, extremely important, reason was that they

were transported faster, before deterioration of their status could occur

and before bedsores, if they developed at all, could become extensive.

Management

While certain general principles of management were applied in all

cases of decubitus ulcer in paraplegics, individualization of the patients was

the rule in all centers, the regimen of therapy employed being fitted to the

necessities of the special case. Careful records were kept of all lesions,

including serial measurements and serial photographic records.

The protein deficit in decubitus ulcers, which played such an important

role in their perpetuation and the correction of which was an essential

phase of their management, is discussed under a separate heading (p. 147).

General care.—At many of the centers, it was the practice to nurse paraplegics on Stryker frames (figs. 47 and 48), which facilitated turning them.

Otherwise, they were cared for on soft beds, on soft sheets kept free of

wrinkles. There was no contact with rubber mattresses or other irritants.

The patient was turned every 2 hours. Daily baths were the rule,

with more frequent bathing if necessary. The skin was kept dry and free

of contamination from bodily excretions. AVashing with green soap followed by ether was satisfactory. Dressings were usually sufficient to isolate

the lesion from urine and feces. Alcohol rubs and massage were given at

least every 4 hours.

The skin was protected from pressure at points of predilection. Pillows

were more useful for this purpose than rings, which were usually made of

cotton batting or were inflated by air. In either event, their resiliency

promptly disappeared, and it was not very long before they were furnishing

no protection at all against pressure.

Local measures.—The first phase of active therapy in decubitus ulcers was

the institution of local measures, in addition to the general cleansing measures just described, to eradicate gross infection and prepare the bed of the

ulcer for skin grafting or for surgical incision and plastic restitution of

the defect.
136 NEUKOSÜRGERY

FIGURE 47.—Care of paraplegic on Stryker frame. A. Patient

in supine position. B. Patient in prone position after being

turned.

Debridement of all necrotic tissue was the first essential of management.

It was repeated as necessary until no more sloughing tissue was present.

Moist necrotic tissue was removed immediately, but mumified tissue was

left in situ. No debridement was done until a line of cleavage was evident.

There was general agreement on the necessity for initial debridement,

but thereafter there was no agreement at all on the local measures to be

employed to hasten preparation for surgery. Some observers thought that

pressure dressings, changed twice daily, were effective in lessening local

anemia and tissue anoxia. Others believed that more effective results were

achieved by controlled exposure of the ulcer to air and sunlight. Still others

believed that, when feasible, it was well to elevate the affected part, to improve the blood supply. Fluorescein studies, however, with observations

under light, paralleled the clinical impression that the blood supply to

decubitus ulcers was generally good.

Although no effort was made to secure bacteriologic sterility, numerous

local applications were used. Among the agents employed were sugar, min-
PARAPLEGIC PATIENTS IN ZONE OF INTERIOR 137

FIGURE 48.—Care of paraplegic on Stryker frame. A. Patient in

supine position. B. Patient in prone position after being turned.

eral oil, balsam of Peru, horse serum, gentian violet, tannic acid, chloramine-T

(Chlorazene), chloroazodin (Azochloramid), boric acid, acetic acid (which

was always used when Pseudomonas infection was present), castor oil,

iodoform, Dakin's solution, petrolatum-impregnated ointments, urea ointment,

and various solutions and ointments containing penicillin. At Cushing

General Hospital, Framingham, Mass., healthy granulations appeared rapidly after the use of a paste composed of concentrated reel blood cells,

thickened with agar and containing penicillin. Secondary closure was possible in 17 such cases, in all of which the bedsores were deep and penetrating;

those over the trochanter measured up to 5 cm. and those over the sacrum
138 NEUROSURGERY

up to 7 cm. in diameter. On the other hand, the experience with red blood

cell paste at DeWitt General Hospital was not such as to encourage its extensive use. The injection into the granulating surfaces of the ulcer of a

ground-up solution prepared from autogenous skin does not seem to have

been used at any of the paraplegic centers.

When Dakin's solution was used, normal adjacent skin frequently became irritated. The use of petrolatum-impregnated gauze or of tincture of

benzoin afforded protection and was particularly useful beneath adhesive

tape. At DeWitt General Hospital, adhesive strapping was found to be

remarkably useful in some cases in reducing the size of ulcers; it was reported to support the tissues, relieve local edema and anoxia, and keep

the edges mechanically approximated. Most observers, on the contrary, believed that adhesive tape should be used only to hold dressings in place and

then with great caution, because the skin irritation produced by the necessarily frequent changes of dressing often led to ulceration.

At McCaw General Hospital, Walla Walla, Wash., the policy was to

pack the cavity left after debridement of an ulcer with gauze saturated

with zinc peroxide. Packing was so effected that all wound surfaces were

in contact with the gauze, but it was sufficiently loose not to traumatize the

area and cause further undermining. This treatment, because it afforded

an oxygenated environment, was particularly efficacious when anaerobic

organisms were present. Similarly good results were obtained with the

use of Dakin's solution or chloramine-T. The proper use of either of these

solutions resulted in digestion of necrotic tissue and stimulation of granulations. Penicillin-saturated gauze was sometimes effective, but results with

chloroazodin were not good. If these methods proved inadequate, the

undermined pockets were incised and packed open.

This list of agents and techniques scarcely covers all the methods used

in the local management of decubitus ulcers. Their number and variety

indicate the generally unsatisfactory results accomplished with all of them.

In retrospect, it seems that the simpler methods, such as the use of penicillin

ointment, probably gave the best results.

Surgical Measures

Under a combination of the methods described, ulcers of small to

moderate size could be expected to heal eventually in most cases, but it was

a slow process, extending over many months. Moreover, the thin-based

scar which resulted could be expected to break down under the slightest

trauma. When this happened, new ulcers were likely to form.

The employment of surgical measures in the management of decubitus

ulcers was the result of evolution. There was little if any background of

experience with this plan when the United States entered World War II.

It was natural, therefore, that, following the observation that ulcers which

healed spontaneously were notoriously unstable, the first surgical efforts
PARAPLEGIC PATIENTS IN ZONE OP INTERIOR 139

should be directed toward skin grafting. The method was used chiefly

for sacral ulcers. Ulcers treated in this manner proved more stable than

those Avhich had healed spontaneously, but the thin, atrophic surface which

resulted showed tendencies toward erosion (fig. 49). In the meantime, conFIGURE 49.—Sacral decubitus ulcer in paraplegic patient. A. Ulcer after preparation for graft. B. Ulcer after application of split-thickness skin graft.

siderable success was being obtained by direct closure of small ulcers in the

sacral and trochanteric regions, and the success of these measures in small

ulcers led to more daring attacks upon larger trochanteric and sacral ulcers.

Rationale.—It was estimated that the time saved in treating ulcers in this

manner varied from 6 months in an ulcer an inch or less in diameter to

2 years or more in larger ulcers. Some sacral and trochanteric ulcers, it was

thought, would have taken as long as 5 years to heal by nonsurgical methods;

aggressive surgery in ulcers of this kind was lifesaving in some cases, and

eventually it was believed that the excision and closure of ulcers as small as

three-fourths of an inch in diameter which had penetrated to the subcutaneous tissue was good practice.

An additional reason for a prompt resort to surgery was that early

ambulation, which was the desideratum in all these patients, was impossible

until their decubitus ulcers were fully healed. Simply getting the patient

out of bed often effected an almost miraculous improvement in his morale.

Finally, nursing care was greatly decreased by closure of the ulcer by one

method or another.

Preoperative preparation.—A paraplegic patient was regarded as ready

for operative intervention (1) when he had been in positive nitrogen balance
140 NEUKOSURGEEY

for several weeks, as manifested clinically by an improvement in weight,

strength, and general well being (p. 151), and (2) when the ulcer showed no

evidence of acute inflammation; was free from sloughing fascia, muscle, and

other necrotic tissue; and presented a fixed margin invaded by vigorously

growing epithelium.

No surgery could be attempted until the decubitus ulcer appeared

healthy. Soft, fluffy, weeping granulations could not be expected to function

for the growth of epithelium. Even for simple closure, the apposing

granulating surfaces had to be smooth, firm, and relatively dry. If they

were not smooth, fluid pockets would form and would eventually dissect

away the proposed line of apposition. If skin grafts were used, they would

not adhere and would float off in the secretions from the wound.

Captain Barker, of Newton D. Baker General Hospital, who had a

particularly wide experience with the surgery of decubitus ulcers, preferred

to prepare his patients as follows: As soon as a definite line of demarcation

became evident, the necrotic tissue was dissected away by scissors. Then,

until the patient and his wound were both ready for surgery, the ulcers

were dressed with boric acid, urea ointment, or an emulsion made by mixing

4 cc. of penicillin with 1 ounce of petrolatum. In his experience, the appearance of the ulcer did not vary greatly with the kind of ointment used.

When the base was clean, the operation was clone; there was no attempt at

bacteriologic cleanliness.

Some surgeons used dressings saturated with physiologic salt solution

for 48 hours before operation. Others used no special immediate local

measures.

Since skin grafts do not take well in anemic subjects, blood studies

were made before operation, and transfusions were given as necessary.

Vitamin C was sometimes administered, on the ground that it plays a role

in tissue healing.

Penicillin was in general use when paraplegic patients began to be

received in large numbers in Zone of Interior hospitals, and it was frequently used before and after surgery on decubitus ulcers. At Cushing

General Hospital, for instance, it was given systematically for 48 hours

before operation and for 21 days afterward. At operation, the wound was

filled with penicillin solution, and the solution was also injected through the

suture line twice daily for 10 days after operation.

This plan was originally found very effective. As time passed, however,

some centers reported that when it was used, a high incidence of extensive,

destructive Pseudomonas infection occurred after skin grafting because other

organisms were being killed off. The use of penicillin in paraplegics to be

submitted to skin grafting was therefore discontinued at Dibble General

Hospital, Menlo Park, Calif., DeWitt General Hospital, and other centers

which had had the same experience.
PARAPLEGIC PATIENTS IN ZONE OF INTERIOR 141

Techniques.—The surgical techniques used in decubitus ulcers1varied

from hospital to hospital (figs. 50, 51, and 52).

Primary excision and closure was the method of choice in small ulcers.

The ulcer was completely excised, the excision including the scar tissue,

peripheral rim, and granulating base. Debridement was continued until a

firm, healthy base was reached unless the ulcer was so close to the bone that

a » »

-V*dto>:Ääi£tfJ&S *^S^^^^Pt."i" 'Mw*^

FIGUKE 50.—Plastic repair of decubitus ulcers. A. Simple

trochanteric ulcer involving skin and subcutaneous tissues.

B. Closure of ulcer by undermining of skin flaps.

no excision of granulation tissue was possible. The tissues about the ulcer

were then extensively undermined, usually for several inches, until closure

could be effected without tension. Closure was effected in layers, with one

1 (1) Croee, E. J., Schullinger, R. N., and Shearer, T. P.: The Operative Treatment of Decubitus Ulcer. Ann. Surg. 123: 53-69, January 1946. (2) Barker, D. E., Elkins, C. W., and Poer,

D. H. : Methods of Closure of Decubitus ulcers in the Paralyzed Patient. Ann. Surg. 123 : 523-

533, April 1946. (3) Gibbon, J. H., Jr., and Freeman, L. W. : The Primary Closure of Decubitus

Ulcers. Ann. Surg. 124 : 1148-1164, December 1946. (4) White, J. C, and Hamm, W. G. : Primary

Closure of Bedsores by Plastic Surgery. Ann. Surg. 124: 1136-1147, December 1946. (5) Barker,

D. E. : Late Results in Surgery for Decubitus Ulcers. Am. J. Surg. 74: 180-182, August 1947.

(6) Conway, H., Kraissl, C. J., Clifford, R. H., Ill, Gelb, J., Joseph, J. M„ and Leveridge, L. L.:

The Plastic Surgical Closure of Decubitus Ulcers in Patients With Paraplegia. Surg. Gynec. &

Obst. 85 : 321-332, September 1947.
142 NEUROSURGERY

FIGUKE 51.—Plastic repair of decubitus ulcers. A. Trochanteric ulcer involving skin, subcutaneous tissues, and fascia. B. Repair of ulcer by undermining of skin flaps and advance of gluteal skin.

suture line for the deep fascia and one for the skin, except in the trochanteric

area, where three layers of sutures were usually required, as the ulcer frequently extended through the fascia lata and the fascia of the gluteus

maximus. An extremely careful technique was necessary to secure satisfactory healing. Nonabsorbable sutures, preferably of tantalum or steel

wire, were used and were left in place for 21 days.

This technique gave excellent results, and at some centers virtually

superseded all other methods of closure. At dishing General Hospital, for

instance, of 52 operations analyzed over one period, 60 percent of the ulcers

closed by suture remained healed after the first attempt, though some of the

sacral ulcers were as large as 15 cm. in diameter. A number of these cases

had previously been managed by grafts of various kinds.

When simple closure with undermining of the adjacent skin was not

possible, full-thickness flaps of skin and subcutaneous tissues from adjacent

surfaces could be rotated to fill the defect. This method was particularly

successful in sacral ulcers and ulcers over the trochanteric region (in which

skin grafting was not desirable), because atrophy of the gluteus muscle, as

the result of malnutrition, had usually left an abundance of loose skin which

could be borrowed from the buttocks (fig. 53). If a large enough flap could

not be secured, split-thickness skin grafts could be used to supplement it.

In Captain Barker's experience, about 80 percent of ulcers managed by

primary closure with rotation flaps healed satisfactorily after the first operation. The technique he employed was very precise; the flap was in the exact

pattern of the ulcer and was usually transferred to it from an area ventral

to it. In the technique employed by Maj. William B. Scoville, MC, the

posterior surface of the trunk was extensively undermined after the ulcer
PARAPLEGIC PATIENTS IN ZONE OF INTERIOR 143

FIGURE 52.—Plastic repair of decubitus ulcers. A. Multiple sacral decubitus

ulcers. B. Repair of ulcers by undermining and advance of skin flaps.

was debrided, and an area of skin and subcutaneous tissue large enough to

cover the defect was shifted caudally.

In any comment on the results of skin grafting in decubitus ulcers, it

must be remembered that this technique was generally used in the more

unfavorable cases, in which the ulcers, practically always over the sacrum,

were very large and in which the patients were likely to be poor surgical

risks and unfit for extensive radical surgery.

Pinch grafts were not found very desirable, and split-thickness skin

grafts, twelve one-thousandths of an inch in thickness, were most often

used. The granulating area was shaved down to a firm, healthy base except

when the ulcer lay so close to the bone that this was not possible. The

graft was obtained from the patient, usually from the back. The donor area

practically always healed without difficulty, as did the surgical incision,

even though it was made in an anesthetic area.

At Halloran General Hospital, Capt. (later Maj.) Edmund J. Croce,

MC, described a method for the plastic closure of large sacral ulcers based

on the consideration that the skin from the iliac crest above to the trochanter

laterally is normally free and loose, and that this normal state is accentuated by the loss of subcutaneous fat and the atrophy of the glutei common

in paraplegics.

After the ulcer was excised, curvilinear incisions were made on each

side of the ulcer, extending along the iliac crests above and into the buttocks

below. The large flaps thus outlined were raised from the gluteal fascia.

When they were rotated toward the middle of the ulcer and approximated,

the defect could be completely closed with a layer of skin and normal sub-
144 NEUROSURGERT

FiGUKE 53.—Plastic repair of decubitus ulcers. A. Deep trochanteric

ulcer extending to femur. B. Repair of ulcer by rotation full-thickness

skin flap technique, supplemented by small split-thickness skin graft.

cutaneous tissue apparently capable of withstanding the abuse which the

skin in this area ordinarily receives. A fine silk technique (000000 black

silk) was used throughout. Originally, some of the larger ulcers were

closed in two stages. Later, iilcers from 10 to 12 cm. long and from 12 to

15 cm. wide were closed in a single stage. The end results of these techniques were apparently more durable than the use of split-thickness skin

grafts applied directly over the sacrum, some of which had broken down

repeatedly in patients in whom the Croce method proved entirely satisfactory (fig. 54).

In a few centers, the following technique of skin grafting was used:

Five cubic centimeters of whole blood, taken from the patient, was centrifuged,

and the serum was painted on the recipient site of the graft. The white-cell

layer was then taken off with a loop and mixed with Tyrode's grafts. Narrow

strips were used, no attempt being made to cover the entire area with a

single graft. The wound was covered with a strip of gauze, applied with
PARAPLEGIC PATIENTS IN ZONE OP INTERIOR 145

FIGUBE 54.—Plastic repair of decubitus ulcers. A. Extensive

decubitus ulcer of sacrum. B. Repair of ulcer by multiple

full-thickness flap technique.

slight pressure, to prevent bubble formation. Eesults with this technique

were apparently no better than those achieved by standard, less complicated

methods.

Postoperative care.—Postoperative care consisted of the standard routine,

usually supplemented by wet dressings for 3 or 4 days if grafts had been

employed. At Halloran General Hospital, postoperative dressings were

placed in charge of a single nurse. The medical officers had no time to

undertake them, and an interested nurse handled them very capably.

A major postoperative problem was to hold the dressings, and therefore

the grafts, in place in patients whose paraplegic state required that they be

moved constantly. No matter how careful ward personnel were, dressings

lost position, and the grafts were sometimes lost also. Captain Barker reported a case in which three unsuccessful operations were open to this

explanation. The patient had five large ulcers, from which there was a

daily protein loss of 50 gm., with a reversal of the albumin-globulin ratio.
146 NBUBOSURGEEY

NUTRITION AND DIET

Malnutrition and Protein Deficits

A chain of circumstances was responsible for the poor state of nutrition which was common to most paraplegics with battle-incurred. wounds

and which was far more severe than is the malnutrition likely to be encountered in the great majority of paraplegics treated in civilian practice.

When these patients were received in Zone of Interior hospitals, weight

losses were sometimes enormous. In one series of 82 patients reported by

Col. Robert H. Kennedy, MC, from Percy Jones General Hospital, the

average weight loss was 50 pounds.

Complicating conditions.—In addition to the complications which arose

more or less directly from the spinal cord injury, such as urinary tract

infection and decubitus ulcers, concomitant injuries were frequently present

in these paraplegic patients and assumed more than ordinary significance

because they added to the already grave burdens which they were carrying.

At one time, 32 paraplegics in the paraplegic center at Ashford General

Hospital, White Sulphur Springs, W. Va., also presented injuries of the

peripheral nerves and blood vessels; compound fractures; traumatic amputations; penetrating wounds of the chest; and penetrating wounds of the

abdomen, some of which had required colostomy. Three of these patients

presented the bizarre complications of cecal, urinary and biliary fistulas,

respectively, through the spinal wound. Another had an osteomyelitis of

the spine with a psoas abscess, and still another had chronic intermittent

meningitis, probably arising from a number of retained foreign bodies.

Some of these complicating wounds were themselves complicated by such

conditions as arteriovenous and arterial aneurysms and empyema.

Urinary tract infection was almost universal and almost invariably

produced a low-grade febrile response, sometimes interrupted by acute

episodes, lasting a week or more, of chills, sweats, and high fever. Pyelonephritis was the most usual cause of these episodes, though, in an occasional case, a patchy pneumonitis or a malarial attack might be responsible.

The frequent blood cultures taken in all febrile cases were practically always

negative.

The physical consequences of these wounds and the mental depression

associated with them frequently culminated in anorexia. This state, combined with the infections and draining wounds present, caused serious protein deficits, which were difficult to overcome because of the problem of

getting enough food into the patients, particularly the proteins which they

needed. Here, psychologic considerations also played a part. It was repeatedly found that these men would begin to eat only when they could

be convinced that the future still held something for them.

Active management of the paraplegic state was necessarily deferred

until complicating conditions were cleared up. Intensive treatment was
PARAPLEGIC PATIENTS IN ZONE OF INTERIOR 147

necessary. Infected and draining wounds had to be treated and closed.

Abdominal wounds with perforation of hollow viscera might require more

than one operation on the gastrointestinal tract. Enteric fistulas were sometimes almost intractable.

Disorders of calcium metabolism.—Disorders of calcium metabolism

were rather frequent in paraplegic patients.2 Capt. (later Lt. Col.) A. Bradley

Soule, Jr., MC, reported a number of such cases. At one of the paraplegic

conferences, he also described soft-tissue calcification about the hips and in

the lower extremities demonstrable by roentgenograms in 23 of a series of

62 patients with spinal cord lesions (fig. 55). It seemed a reasonable

assumption that the changes were the result of stasis of blood flow in patients with elevated blood calcium levels and that they were fostered by

recumbency. Other observers commented on the extensive osteoporosis often

observed in the bones of the lower extremities in patients who led a wheelchair existence. Pathologic fractures might follow even minor trauma.

A remarkable improvement occurred in these patients when they became ambulatory. Longitudinal pressure upon the long bones of the extremities apparently stimulated calcification and greatly reduced the possibilities

of both osteoporosis and of calculus formation in the urinary tract (p. 104).

Protein Deficits

The most serious of the nutritional deficiencies exhibited by paraplegic

patients concerned protein. Protein losses occurred from the so-called toxic

destruction which is a concomitant of all serious disease or injury, from the

ordinary wear and tear of daily living, and from decubitus ulcers, the

importance of which as a cause of protein deficits was recognized for the

first time in World War II.

Decubitus ulcers.—At almost every hospital in which paraplegics were

treated, a conspicuous and definite relation was established between the

plasma protein levels and the status of decubitus ulcers as well as their

actual development. In the presence of a protein deficiency, the tissues were

so changed in character that it apparently required a smaller amount of

pressure, or the same amount of pressure for a shorter period, to cause

necrosis. Wien malnutrition reached a certain point, even the amount of

pressure exerted by the recumbent body of ordinary periods of rest might

cause bedsores.

Studies by Mulholland and his associates3at the New York University

2(1) Herrmann, L. G., Eeinekc, H. G., and Caldwell, J. A.: Post-traumatic Painful Osteoporosis: A Clinical and Roentgenological Entity. Am. ,T. Roentgenol. 47: 353-361, March 1942.

(2) Sonle, A. B., Jr.: Neurogenic Ossifying Fibromyopathies : A Preliminary Report. J. Neurosurg.

2 : 485-497, November 1945. (3) Soule, A. B., Jr., and Stiff, D. W. S. : Changes in the Bones and

Soft Tissues in Paraplegia. Bull. U.S. Army M. Dept. 9 : 1018-1021, December 1949.

3 Mulholland, J. H., Tui, C, Wright, A. M., Vinci, V., and Shafiroff, B. : Protein Metabolism

and Bed Sores. Ann. Surg. 118 : 1015-1023, December 1943.
148 NEUROSÜRGERY

FIGUKE 55.—Roentgenograms showing neurogenic ossifying fibromyopathies in patients with traumatic paraplegia. A. Extensive ossifications

about knees 116 days after spinal injuries. B. Extensive and progressive ossifications about both hip joints, with virtual ankylosis, 6 months

after onset of paraplegia.

College of Medicine, established a number of useful and significant points,

as follows:

1. If patients had had large doses of hypnotics, which kept them lying

in one position for a long time, bedsores developed rapidly.

2. The same mechanism was set up by the use of casts in patients with

fractures.

3. When there was loss of nitrogen from the body, from toxic causes,

from undernutrition, or from a combination of these causes, the character

of the tissues was altered. In normal patients, who were able to change

their position frequently, bedsores did not develop at all. They developed

rapidly in malnourished patients.

4. In random studies of patients with bedsores, it was invariably found

that the plasma-protein concentration was below the lower limits of normal.

Studies of decubitus ulcers in the paraplegic centers practically always

showed large losses of protein. Various methods were used to demonstrate

this fact. 1st Lt. (later Capt.) Mark A. Jacobs, SnC, covered ulcers with
PARAPLEGIC PATIENTS IN ZONE OP INTERIOR 149

pads of cellucotton for 24 hours and then carried out micro-Kjeldahl determinations on the exudate recovered from the dressings. All the patients

whom he studied had some loss of protein from the ulcers, and 1 patient,

with 5 ulcers, had a total protein loss by this route of over 40 gm. in

24 hours. At other centers, losses up to 50 gm. in 24 hours were reported in

some cases.

Proof of the importance of protein loss from ulcers w

Tas furnished not

only by laboratory evidence but also by the improvement which resulted when

the ulcers were closed or skin grafts were applied. Once a good nutritional

balance had been attained, progressive, spontaneous healing of small ulcers

was frequently observed.

Evaluation of protein deficits.—The most severely malnourished paraplegics practically always revealed an increase in interstitial tissue fluid.

This increase was demonstrated by Maj. Helmuth Sprinz, MC, working at

Halloran General Hospital, to be characteristic of severe protein depletion.

In these cases, the plasma volume of the blood was normal or even slightly

higher than normal, but there was a decrease in the volume of circulating

red blood cells. The serum protein concentration and the albumin-globulin

ratio were not significantly altered except in patients with nutritional edema,

in whom a lowering of the serum-protein concentration and a reversal of the

albumin-globulin ratio were likely to be observed.

When this reversal had occurred, it had to be considered indicative of

an extensive depletion of protein stores, in view of the established fact that

each gram loss of plasma protein was accompanied by a loss of about 30 gm.

of tissue protein. In order to use a determination of the total plasma protein

as an index of the state of protein malnutrition, two important factors had

to be taken into consideration. The first was the effect of dehydration.

The second was the presence of decreased levels of albumin and increased

levels of globulin. As plasma protein diminished, the water-retaining power

of the blood was also decreased. Fluid was lost into tissue spaces, and there

was an increased concentration of plasma, with a consequent decrease in

total plasma volume. When this occurred, the quantity of protein which

would have been low when the plasma volume was normal might appear

normal or even higher than normal. Unless these considerations were borne

in mind, the plasma protein value would be likely to be regarded as normal

when actually protein depletion was present. To obviate these pitfalls, red

blood cell counts and hematocrit determinations were necessary, as well as

determinations of the plasma protein and of the albumin-globulin ratio.

Dietary Correction

The diet of paraplegics was always a subject of intensive discussion at

paraplegic conferences. Obvious points were stressed, such as the placing of

one dietitian in charge of paraplegics; the importance of serving the food
150 NEUROSURGERY

appetizingly; and observation of the amount of food which was not consumed. Curiously, there was a professional tendency to disregard the food

which was not eaten, though all the dietary planning in the world was perfectly useless if patients did not eat what was put before them.

It was a good plan to get the patients out of bed and send them to

their meals in wheelchairs as soon as possible. As their morale improved,

so did their appetites, though patients with colostomies and those with

malaria presented special problems which were not so readily solved.

The basic hospital diet in U.S. Army hospitals provided the patients

with about 2,800 calories daily. The protein content of this diet ranged

from 100 to 113 gm. per day. This provision, which amounted to about

1.5 gm. per kilo of body weight daily, was in excess of the National Eesearch

Council estimate that the daily requirement was 1 gm. per kilo. In paraplegic patients, the total caloric value of the diet- was stepped up to about

3,200 calories in most hospitals and the protein intake to 150 to 175 gm.

daily. In the face of special necessities, up to 300 gm. per day could be

administered by supplemental feedings.

The components of the diet were so planned as to supply as much

energy as possible, with the idea of sparing the protein to a maximum

degree for use in anabolic reactions. The fat content was moderate. A

certain amount was necessary, to aid in the absorption of fat-soluble vitamins,

though some observers thought that fats should be strictly limited because

they lengthen the emptying time of the stomach and so retard digestion.

Vitamin supplements were used on indications, in some instances probably more liberally than was necessary. The approximate vitamin A content

of the average hospital diet was 14,000 units daily, against an estimated requirement of 5,000 units daily. It was doubtful that patients whose utilization of vitamin A was normal and who had no hepatic disease and no

disorders preventing bile from entering into the intestinal tract required

any more. The thiamine, riboflavin, and niacin contents of the diet were

also far above normal. The average vitamin C content of the diet was

165 mg. daily, against a requirement of 75 mg.

The situation was somewhat different when mineral oil, which was the

laxative of choice in paraplegics, had to be administered, since it is knoAvn

to interfere with the absorption of the fat-soluble vitamins D and K. In

these cases, supplemental vitamin therapy was used, with the full recognition

that Peter was being robbed to pay Paul.

Adjunct measures.—When the patient was anemic, the deficiency had to

be corrected before satisfactory tissue and plasma protein regeneration could

occur; otherwise, most of the protein administered would be diverted to the

synthesis of hemoglobin. Whole blood was therefore used as liberally as

necessary to correct acute plasma protein deficiencies, especially when edema

of the tissues was obvious.

The use of plasma in chronic hypoalbuminemia due to malnutrition,
PARAPLEGIC PATIENTS IN ZONE OF INTERIOR 151

while logical, was entirely impractical. As already pointed out, for every

gram of plasma protein which remained in the blood, as much as 30 gm.

might be removed by the tissues. To supply 2,000 gm. of protein for the

entire body would require, it was estimated, 30 liters of plasma, which would

require 120 donors.

From the nutritional point of view, therefore, protein in excess amounts

had to be administered from other sources, chiefly from the protein concentrates or hydrolysates which were available commercially. These preparations were available for both oral and intravenous administration. A

hydrolysate of casein, the protein component of milk, was then available

for intravenous administration. A preparation of wheat, beef, and yeast

proteins, as well as of casein, was available for oral use.

When it was possible, it was always desirable to confine alimentation

to the oral route. This was partly because this is the physiologic method

of taking food and partly because of the risk, in intravenous alimentation,

of overloading the circulation of patients whose plasma protein levels were

dangerously low. To administer 100 gm. of protein, for instance, in the

form of a 5-percent Amigen solution required the introduction of 2 liters

of fluid. Such amounts could not be tolerated over a very long period.

The chief drawback to the oral administration of Amigen was that it

was extremely unpalatable, and ingenious ways had to be found to disguise

the taste. Another preparation, Aminoids, though it had less than half

the protein content of Amigen, was more generally useful because it was

more palatable. These hydrolysates, incorporated in food and put into

fruit juices and milk shakes, increased the protein intake by 50 to 100 gm.

of protein daily.

Results.—Evidence that protein deficits had been corrected was usually

prompt and convincing. It became progressively easier to restore and

maintain a normal nitrogen balance. The efficacy of all therapeutic agents

was enhanced. Chronic infection was more readily controlled. Wound

healing was faster and more satisfactory. Finally, as already noted, decubitus

ulcers healed more rapidly, and skin-grafting procedures were more successful.4

BLADDER FUNCTION

The paraplegic patient is the captive of the dead half of his body.

Bladder and bowl function and skin care are therefore extremely important

for his mere existence.

4 In July 1945, a research project on metabolic studies on patients with spinal cord injuries

was warmly approved in the Surgical Consultants Division, Office of the Surgeon General, and was

also approved by the Commanding General, Army Service Forces. It was to be conducted under the

direction of the surgical consultant, Fifth Service Command, and the chief of surgery, Wakeman

General Hospital, Camp Atterbury, Ind. This project, which was to be continued during the war

with Japan and which was to have urgent priority, did not come into existence because the war

with Japan ended about a month after it had been approved.

498991*—59 12
]52 NEUROSURGERY

The urologic aspects of spinal cord injuries are discussed in detail in

a separate chapter of this volume (p. 67), and no additional discussion of

them is required in this chapter.

The management of bladder function and the prevention of urinary

tract complications was a constant struggle in Zone of Interior paraplegic

centers. Typical tidal drainage setups are shown in figures 56, 57, and 58.

FIGUEB 56.—Bedside installation for tidal-drainage apparatus in paraplegia colony.

Calculi were a continuing problem,6sometimes being observed after only

a month of recumbency. Treatment, was basically acidification of the urine,

which required repeated, frequent determinations of the urinary pH. Repeated roentgenologic studies (films of the kidneys, ureters, and bladder,

and intravenous urograms) and inspections of the bladder were necessary,

because paralyzed patients do not experience pain and tenderness from

calculi as do normal patients. Similarly, diagnosis was likely to be delayed

even in such conditions as epididymitis and torsion of the spermatic cord.

The various paraplegic centers developed their own special technical

methods, such as the use of the suprapubic opening for inspection of the

bladder and removal of stones and encrustations of the mucosa; the reaction

by this method was less than after cystoscopy by the transurethral route.

Rolling the patient on his abdomen during irrigation was also found to

facilitate drainage by causing the gravitation of the exudate toward the

5 The importance of urinary calculi in paraplegic patients did not diminish with the passage

of time. In 1948, it was reported, in Veterans' Administration Technical Bulletin 10-503, pp. 15-27,

15 Dec. 1948, that they were present in 42.5 percent of the 458 paraplegics treated at the Veterans'

Administration hospital at Van Nuys, Calif. About a third of the stones were vesical.
PARAPLEGIC PATIENTS IN ZONE OF INTERIOR 153

FIGURE 57.—Detail of manometer in typical tidal-drainage apparatus.

suprapubic catheter. When irrigation was carried out in the supine position,

it was often found that only the supernatant exudate had been removed.

Eesults of using- stone-dissolving solutions were not encouraging, and

the best conservative method of treatment was found to be getting the

patient out of bed. Surgical procedures were always delayed until it was

clear that his condition would be jeopardized without them.

A special chart for recording urinary tract management and progress

was useful (fig. 59).

BOWEL FUNCTION

Bowel function was always a problem in paraplegics. The basis of

management was a complete knowledge of the individual patient's status and

needs, which implied careful recorclkeeping. A daily ward chart (fig. 60)

was useful for this purpose. From it, the ward officer could determine at

once, for all his patients, the type of cathartic necessary, the amount to be

administered, and the necessary frequency of medication. The objective

was to reduce the use of cathartics and the necessity for enemas to the minimum possible in each case. Frequent digital examinations were necessary

to rule out rectal impaction.
154 NEUROSURGERY

I

1.Ob irrigate bladder, remove

clamp from point O and attach

to point ©

2.When bladder fills,pressure and

bladder contractions are recorded

on Manometer.

3. <^Xb empty bladder, remote damp

from point © and apply clamp to

ßoint ©

A

QJb discontinue tidal drainage

to dllou; S^attettt out of bed.

1. Completely close clamp © and.

disconnect Gatketer at 0 and cla/np

tke- catAeter untk scrett» clamp.

B

FIGUKE 58.—Graphic chart and instruction sheet used to instruct ward personnel in

management of tidal-drainage apparatus. A. Bladder irrigation. B. Discontinuance of

bladder irrigation.
PARAPLEGIC PATIENTS IN ZONE OF INTERIOR 155

SPECIAL PROG BEES NOTES

P.T, „ «TIC CUL . en... = CY.TOSCOPIC l.v... » » .lOlOSCOPIC

FIGURE 59.—Ward chart depicting progress in genitourinary problems

in paraplegic patients.

Even before the patient was able to assume an upright position in bed,

bowel function could be improved by a number of mechanical measures.

There was considerable improvement, for instance, when Fowler's position

began to be used routinely, and, in some particularly favorable cases, spontaneous bowel movements occurred.

Experienced attendants often found the lateral recumbent position, with

the legs flexed, satisfactory for cleansing of the bowel manually or by enema.

Before limited ambulation was possible in the regimen of a paraplegic

patient, bowel management differed in only one detail from bowel management in any recumbent patient; every paraplegic needed constant observation and supervision when he was placed on a bedpan or over the

aperture of a toilet guerney or Stryker frame, in order to prevent further

skin necrosis or increased trauma to decubitus ulcers.

When the patient had progressed sufficiently, he was placed on a

padded toilet guerney or toilet seat, to which he was lifted by a tackle (figs.

61, 62, 63, 64, and 65). The advanced degree of Fowler's position that could

be attained on the toilet guerney allowed the patient full exercise of such
156 NEUROSURGERX

RESULTS OP ENEMAS

GIVEN EVERY OTHER

DAY.

ROUTIN'K: Mineral Oil 1 oz. daily; '/ > oz. PetrolaKar niyht before enema.

STUBBORN CASES: Mineral Oil 2 oz, daily; 1 oz. Petrolar or 1 cc Pill nicht before enema.

ATE ATE ATE DATE ATE DATE ATE DATE ATE DATE ATE

M H M S M H M S W H M s M H M s M H M s M H M s M H M s M H M s M K M s M H M s u M M s

PATIENT'S NAME:

FIGURE 60.—Ward defecation record used in colony paraplegic care.

ancillary aids as pressure on the abdominal wall. When he was on the toilet,

his bed could be given the necessary attention with far less expenditure of

effort than when he was in it.

Each patient was instructed in the importance of active defecation and

the prevention of overdistention of the bowel, which could further destroy

the functional response of the muscle fibers and the intrinsic nerves. He

was taught how to replace impaired abdominal pressure by proper movements

of the diaphragm and by manual support of the abdominal wall. He was

shown how to apply his hands flat against the abdomen, take deep breaths,

close the glottis, and then fix the diaphragm firmly. Instruction in certain

musical instruments proved of value in improving bowel function.

All patients received an ounce of mineral oil every day, never with their

meals. The night before an enema was ordered, the patient was given from

y% to 1 oz. of cascara petrolagar, or, in stubborn cases, a compound cathartic

pill.

Enemas were necessarily administered by ward attendants, but these

attendants were carefully instructed in the precautions necessary to avoid

damaging the bowel. The bowel in paraplegia is also involved in the disturbance of sensory function below the level of the lesion, and an exceptional

degree of care was necessary to prevent serious damage, including perforation, which might occur without any immediate reaction on the part of the

patient. Attendants who performed catheterization required the same warn-
PARAPLEGIC PATIENTS IN ZONE OP INTERIOR 157

FIGURE (51.—Detail of lightweight toilet

guerney, adjustable for Fowler's position or

upright position, and readily cleansed.

FIGURE 62.—Maximal physiologic position attained in adjustable toilet

guerney for bowel evacuation. Note

privacy obtainable for this purpose in

any typical paraplegia colony. Note

also self-administering enema apparatus.

ing. In the report of the enema, a special note was made of the consistency

of the feces.

When paraplegic patients became fully conditioned in terms of shoulderarm strength, had gained wheelchair ambulation, and were well versed in

the care of bowel function, toilet arrangements became much less complicated. Two efficient installations are presented in figures 64 and 65, showing how transfer from wheelchair to toilet seat could be facilitated by the use

of horizontal and vertical bars.

PERSONAL HYGIENE

Certain adaptations of facilities and equipment having to do with the

personal hygiene of the paraplegic patient, though apparently minor, were

most important. In these patients, the functions of washing and shaving

must be performed sitting, in the wheelchair subserving ambulation. Basins

and mirrors had to be lowered appropriately, and the undersurface of the

washbasin had to be open, to provide for entrance of the legs and the forward part of the chair (fig. 66).
158 NEUBOSURGERY

..I«**

{

A'" 4

I

Hi

«%r-

\ *> V-i.,

gps

FIGURE G3.—Full sitting position on toilet

seat achieved by shoulder-arm efforts of patient and overhead tackle. Strengthening of

the muscles of the shoulder and arm was an

important aspect of reconditioning and had

already started by use of the bed bar and

conditioning apparatus seen on patient's bed.

FIGURE 64.—Transfer from wheelchair

to toilet seat carried out by fully conditioned paraplegic by means of lateral horizontal bars.

FIGURE 65.—Another toilet-seat design,

utilizing vertical and horizontal bars, for

transfer of paraplegic from wheelchair to

toilet seat.

Bathing by the advanced paraplegic patient was easily mastered by the

technique of transfer from the wheelchair after adequate shoulder-arm conditioning. Overhead bars, as already mentioned for the toilet, were mandatory. The overhead multiple bar was fixed to the Avail and lowered to the

desired diagonal position above the tub (fig. 67).

PSYCHIATRIC AND EMOTIONAL CONSIDERATIONS

It was impossible to treat paraplegics simply as medical and physical

problems, without taking into consideration what had happened to them.
PARAPLEGIC PATIENTS IN ZONE OF INTERIOR 159

FIGURE 66.—Washbasin arrangement for wheelchair-ambulant paraplegic patient. Note low positions of washbasin and mirror and free

entrance of forward part of wheelchair under basin.

I

&&H

4b

m

FIGURE 67.—Double tubs and overhead adjustable horizontal bars for

use by wheelchair-ambulant paraplegic patients.

The spinal cord injury had usually occurred suddenly. Within a matter

of moments, the status of the individual had changed from complete independence to almost complete dependence on others for transportation,

nutrition, and bodily function. The adult, in effect, had abruptly returned

to what amounted to the infantile state. The paralyzed soldier was more

gravely affected physically than soldiers with deformities, amputations, and

even loss of sight and hearing;. He did not have to have a great deal of

498991»—59- -13
160 NEUROSURGERl7

intelligence and imagination to perceive what had happened to him in the

spheres of society, work, and sex.

Paraplegic Survey

Interesting data on the soldier's emotional state were secured in the

paraplegic survey conducted in December 1945 (p. 14). It was not clear,

the report stated, to what extent the reporting medical officers had adjusted

their concepts of normality to reflect the extreme disability from which

these patients suffered, but they classified only 15 percent as depressed, while

5 percent were euphoric, 12 percent indifferent, and 68 percent normal.

No significant correlation was found between the emotional status of

the patient and the level of his schooling, but the euphoric group contained

no individual who had had less than 5 years of formal schooling. There was

also no significant correlation between the emotional status and the AGCT

score. The indifferent group was composed chiefly of men with low test

scores who, in general, shared many of the characteristics of the depressed

group.

There was a high percentage of farmers and a low percentage of salesmen, students, and professional men in the depressed group. The normal

group contained a large percentage of salesmen, professional men, and

students.

There was a positive—perhaps understandable—correlation between the

emotional status of the patient and the ability of his family to care for him

after his discharge. The normal group contained a high percentage of

patients who could be cared for by their families, and the depressed group

contained the largest percentage of patients whose families could not care

for them. There was no significant correlation between the emotional

groups and the frequency of family visits; the 15 percent of patients who

had had no family visits at all manifested no special emotional reactions.

There was a large percentage of both euphoric and depressed patients in the

group of patients who received four visits or more a month. In the depressed group, the significant relationship was probably the large proportion

of completely paralyzed patients, though patients with complete paralysis

were on the whole no more depressed than those with incomplete paralysis.

The euphoric group was composed almost entirely of nonambulatory

patients, and a higher than average number of ambulatory patients appeared

in the depressed group.

Evolution of Policies of Management

Despondency and depression were the first inevitable consequences of

the paraplegic state. Some of the men were convinced that their span of life

would be measured in months. Others believed, or persuaded themselves

that they believed, that their paralytic state was transient and that in a
PARAPLEGIC PATIENTS IN ZONE OF INTERIOR 161

matter of time they would be completely normal again. Both groups, before

a great deal could be accomplished with them, had to be brought to terms

with the realities of the situation. This meant facing the fact that the

disability was permanent and that life must be lived with it.

Before any somatic rehabilitation could be attempted, the patient's selfconfidence had to be revived, and he had to be given hope for the future.

The medical officer explained to him in detail the specific aims of the rehabilitation program in its first phase; namely, to restore bowel and bladder

control, to get him out of bed, and to teach him to walk again. Along with

these physical objectives would go training for the future.

Opinions varied widely concerning the need for psychiatrists and psychologists. At some centers, consultation Avas asked at once. At others,

consultation was requested only when it was clearly indicated. At Hammond General Hospital, said Lt. Col. (later Col.) Mark Zeifert, MC, at the

paraplegic conference in June 1945, there had not been more than 2 or 3 requests for such consultations during the whole operation of the program.

"When a normal person has a fit of depression," he said, "he doesn't send

for a psychiatrist. His wife or his children or his friends help him out of

it." On a paraplegic ward, the ward officer should be the mental hygienist.

"If he isn't," Colonel Zeifert said, "get rid of him and get someone else who

is." Paraplegics need help, but it must be given to them casually, almost

unprofessionally, by all who come in contact with them.

Colonel Zeifert's approach throughout was bluntly matter of fact. Said

he:

We are directed not to use the swimming pool for these patients. Why not? If the

paraplegic had been swimming all his life, why shouldn't he use the pool to swim in?

He should learn to swim again in the hospital, while he knows someone is there to

protect him while he is learning again. If that kind of attitude is taken with respect to

all the other natural, normal activities of these men, you can provide them with a natural

life. Otherwise, you will end with a biological specimen on your hands.

As the war came to an end, there was a growing realization of the

wisdom of this attitude. Lt. Col. John J. Loutzenheiser, MC, stressed it at

the Hammond conference. The physical job, he said, was being very well

done, but the "song and dance element" should be taken out of it from that

time on, and every part of the program should be purposeful, profitable,

productive, and designed to fit these unfortunate men for prompt return to

a useful, independent life. Dr. Howard A. Busk's aphorism was more and

more quoted, that, "having added years to the lives of traumatic paraplegics,

we must now above all add life to their years."

Colonel Kennedy also stressed that rehabilitation of paraplegics should

be carried out with imagination as well as competence. Otherwise, he said,

quoting Douglas A. Thorn, these men would be "* * * * merely living

memorials to the skill of medical officers during World War II, but to no

good purpose. They must be given something besides just the privilege of

staying alive."
162 NEUßOSURGERT

To provide that "something" required discipline and a serious purpose

as well as solicitous kindness.

PHYSICAL RECONDITIONING

Physical reconditioning of paraplegics began immediately upon their

admission to Zone of Interior neurosurgical centers, while they were still

bedridden and on Stryker frames. All physical therapy and all exercises,

whether conducted in bed, in a wheelchair, or on the mat, were designed to

prepare them for the ultimate goal of ambulation. The establishment of

this goal was the natural outgrowth of the optimistic spirit which began to

characterize the paraplegic centers and the patients in them almost as soon

as the new program began to operate.

Physical therapy began with heat. Electrical therapy was not used

at all.

Because of the tendency in spastic patients to mass reflexes, all forms

of physical therapy were applied with extreme care, and all massage was

delicate, especially in patients who already presented these reflexes. The

smaller joints were attacked first, beginning with the big toe. If manipulation produced mass reflexes, it was discontinued at once. As experience

accumulated and physical therapy was applied with more and more skill,

it produced excellent results and was seldom responsible for undesirable reactions.

Physical therapy was always prescribed for paraplegic patients because

it was seldom possible to prophesy the outcome in any given case. Passive

exercise of the lower extremities was chiefly valuable for reeducation, but

there was sometimes a flicker in some muscles, and continued guided exercises

occasionally permitted the patient to use a brace for footdrop only instead

of a long caliper brace.

Whenever a swimming pool was available, patients were put into it as

soon as possible. One of the difficulties here was the practical one of bladder

and bowel control, a reasonable degree of which had to be achieved before

a common swimming pool could be used.

The widespread interest in reconditioning which had developed throughout the Army by the time the paraplegic problem had been appreciated was

adapted to meet the special needs of this group of patients. Experiences of

established civilian institutions, such as the New York Institute for the

Crippled and Disabled, proved of inestimable value and were fully utilized

in the large scale preambulation and ambulation programs finally put into

effect in the paraplegic centers.

Specimen Program

How intensive the reconditioning program was and how promptly it

was put into effect can be seen in the program set up at the center at Walter
PARAPLEGIC PATIENTS IN ZONE OP INTERIOR 163

Keed General Hospital, Washington, D.C. All paraplegics on Stryker frames

were assigned to the same ward. A single physical reconditioning officer

was responsible for these patients. The patients were turned a minimum of

6 times each day, and exercises were conducted in whatever position they

were when the instructor entered the ward.

The basic exercises were as follows:

1. Exercises in the supine position consisted of raise and push exercises; leg-stretching exercises; shoulder-blade squeezing exercises, which

might require modification for the individual patient; curl and twist exercises; hip-shrugger exercises; and breathing exercises. If bridge-raising

exercises, performed with the elbows braced at the sides, were forbidden,

chest-raising exercises were substituted. If paralysis was complete, pullups

were carried out on the overhead horizontal bar.

2. Exercises in the prone position consisted of raise and push exercises

and shoulder-blade squeezing exercises, as in the supine position; legstretching exercises, with head rotation substituted if the legs could not be

moved; curl and twist exercises, with muscle-testing exercises substituted if

arching of the back was contraindicated; and bridge-raising, hip-shrugger',

and breathing exercises, as in the supine position.

Group exercises were performed once daily, for 30 minutes at a time,

Monday through Friday. Patients were encouraged to perform the exercises

on their own initiative a second time each day, and twice daily on Saturdays

and Sundays. They were also encouraged to carry out remedial exercises

each hour, as prescribed by the physical therapist or the physical instructor.

After a patient had regained sufficient strength, he was encouraged to carry

out arm and shoulder exercises with dumbbells, to pull himself up on bars,

and to perform such other movements as he could (fig. 68).

Since the protective mechanism of pain was not present, great care had

to be taken that the exercises were not begun too early and that they were

not too vigorous. No patient began exercises until he had been pronounced

fit for them by the ward officer and until any precautions necessary had been

made a matter of record. The average patient was ready to begin exercises

within 3 to 5 months after injury.

Progress notes were maintained for all patients, and precautions were

noted on this form. The patients were encouraged to keep a record of their

own progress in terms of the number of repetitions performed and the

increase achieved in the range of motion.

All exercises prescribed for paraplegics were designed to increase the

strength of muscles of the shoulders, arms, hands, back, and trunk for the

achievement of balance and the final task of ambulation (figs. 69, 70, and 71).
164 NEUROSURGERY

FIGUKE 68.—Reconditioning at the colony bed level after control of

decubitus ulcers, bladder infection, and nutritional requirements had

been achieved in some substantial way in paraplegic patients. A. Simple progressive weight barbell exercises followed by, or carried out

simultaneously with, bed-bar exercises designed to further development

of shoulder-arm-hand musculature. B. Colony bed exercise allowing

full active movement of shoulder-joint musculature.

Results

The reconditioning program was remarkably successful. Under the

regimens specifically planned for them, the patients rapidly achieved a

considerable degree of physical stability, which fitted them for an out-ofbed existence, whether in a wheelchair or ambulatory. Most of them gained

weight. Their mental improvement was even more notable. They were

alert and hopeful, and most of them were prepared to go much farther in

rehabilitation than had seemed possible when the program was first conceived.

AMBULATION

The chief desire of every paraplegic patient was to be able to walk

again, and the first objective of the paraplegic program was to make this

desire come true. The entire exercise program, as just noted, was planned

with this end in view. Exercises begun in bed were continued in a wheel-
PARAPLEGIC PATIENTS IN ZONE OF INTERIOR 165

chair and on a mat. Functional activity, such as shaving himself and pulling

on his own socks and slippers, was required of each patient from the time

he was able to sit erect and balance himself. He was encouraged to take

shower baths as soon as possible, with as little help as possible.

In most centers, 70 percent or more of all patients attained some type

of eait on crutches and thus became free of a bed or wheelchair existence.

Patients and medical officers alike were responsible for the results secured,

and it is not too much to say that nowhere else during the war did an

earlier attitude of complete defeat meet a more resounding rout than in the

ambulation phase of the paraplegic program.

On the other hand, the program was not free from one important error,

that in some instances too much was promised. As Col. Loyal Davis, MC,

pointed out in one of the discussions of the paraplegic program, it was

essential that both profession and laity clearly understand that no paraplegic

patient could ever move about freely and that not all patients could be made

to walk again.0 What could be clone for them depended entirely on the level

and the nature of the spinal cord injury. It was unfortunate, Colonel Davis

said, that in some cases, the psychotherapy which was a necessary part of

the management of the paraplegic had been overemphasized and oversold

and that in these cases it might very well cause a disturbing and bitter reaction in both the patient and his family.

Braces.—Before the patient could stand and attempt to walk on crutches,

he had to be custom fitted with bilateral braces, extending to the upper

femoral region or higher (figs. 72, 73, and 74). These braces had to be light

enough not to be a drag on the patient, yet strong enough to give him confidence. The hip joint had to be immobilized so that the feet did not drag.

When there was little or no function in the abdominal musculature, a thoracopelvic girdle was also necessary (fig. 75).

At some hospital centers, standard braces, obtainable in three sizes, were

applied before individual braces were prescribed. In spastic types of

paralysis, the braces had to be supplemented by ankle and knee straps, and

fitting was, in general, much more rigid than in nonspastic types.

One of the difficulties encountered in the ambulation phase of the

paraplegic program had to do with securing and fitting proper braces.

There was constant competition with the provision of braces for orthopedic

casualties, who were numerous and whose needs were great. The braces

supplied were apt to follow the heavy, cumbersome pattern of protective

orthopedic devices. Light metals, which would have been ideal for braces,

were not available during most of the war, and ambulation was often delayed and was frequently made more arduous because of technical failures

in braces. Only in the last few months of the operation of the paraplegic

centers were braces of proper design received promptly and in sufficient

quantity to care for the paraplegic hospital population.

6 Many patients, after they had reached the point of ambulation and savored the satisfaction

of the achievement, wisely returned to their wheelchairs.
166 NEUROSURGERY

1st EXERCISE

^3 ($.

2nd EXERCISE 3rd EXERCISE 4th EXERCISE

A

5th EXERCISE 6th EXERCISE 6th EXERCISE - continued 7th EXERCISE 7th EXERCISE - continui

B

JiciJ .. FT

FIGUEE 69. (See opposite page for legends.)
PARAPLEGIC PATIENTS IN ZONE OP INTERIOR 167

Bih EXERCISE 6th EXERCISE - continued

9th EXERCISE 10th EXERCISE 11th EXERCISE 12th EXERCISE

FIGURE 69.—Mat exercises. After adequate shoulder-arm conditioning, ambulation

was possible by wheelchair, although bed-chair transport was not readily effected without further training. When ambulation was possible, group exercises could be conducted

on mats. The exercises illustrated here represent the fruit of expert supervision, much

hard work, and much personal anguish. A. Transport by chair to mat by means of

inclined plane or blocks, followed by trunk exercises (exercises 1-4). B. Turning, twisting of the neck, and abdominal exercises (exercises 5-7). These exercises were particularly valuable for patients with spinal transection at lumbar levels. G. Paraplegic patient

at exercise at fifth level of reconditioning, showing (1) preliminary position and (2)

guidance by trained rehabilitation experts as position is changed. D. Paraplegic patients

who have attained full control of shoulder-arm-trunk function after prolonged conditioning in mat exercises. E. Attainment of abdominal muscle and trunk control by paraplegic

with low-level lesion (exercise 8). The practical value of these more advanced exercises

in relation to personal paraplegic care is apparent, for instance, when the patient leaves

his bed. F. Final steps of mat conditioning exercises (exercises 9-12).

Education in Walking

Level of lesion.—The paraplegic patient was graduated as rapidly as possible from mat exercises for the upper extremities and trunk to standing

exercises at parallel bars and crutch balancing exercises. Patients with cord

lesions at or below the tenth dorsal vertebra were put into braces promptly,

without waiting for recovery of muscle function below the lesion. If their

upper extremities were intact, the hope of ambulation with crutches could
168 NEUROSURGERY

Ä, «^

FiGUitE 70.—Advanced

ABC

exercises. With the completion of the simpler

mat exercises, paraplegic patients advanced to crawling and modified

crutch exercises. These patients must use their arms for ambulation

when they transfer from bed to chair, from chair to toilet, from chair

to automobile (or even airplane), and when they fall, as they frequently

do. A. Arm-trunk lifting exercises, to assume the crawl position.

B. Abdominal-trunk exercises. Balancing exercises in anticipation of

actual crawling. C. Crawling exercises and first application of modified

crutch walking.

A B

FIGUEE 71.—Chair exercises. When paraplegics could begin chair

ambulation, group conditioning was facilitated. A. Continuing armshoulder play and early ambulation exercises. B. Important chair

transfer exercises.
PARAPLEGIC PATIENTS IN ZONE OF INTERIOR 169

FIGURE 72.—Brace fitting of paraplegic before efforts at ambulation.

A. Measurement of long leg brace with low pelvic girdle. B. First fitting of long leg brace for patient with lumbar vertebral injury.

be held out to them. Patients with lesions as high as the second dorsal vertebra, provided the upper extremities were intact, could frequently get about

with the aid of braces and crutches, but instruction and practice were likely

to be prolonged, and the prognosis had to be guarded. Patients with high

lesions, who were unable to use a walker, were promptly put into wheelchairs. They could not walk, but the simple change of posture and the additional exercise of moving the chair proved of great benefit to them.

Rationale of instruction.—Instruction in ambulation was based on certain

facts and principles. In transverse myelitis, there are three events, as follows: (1) Loss of motor power, or paralysis, (2) loss of sensation, including

loss of proprioceptive power, and (3) disturbance of the autonomic nervous

system. Manifestations of these losses are, in turn, (1) disturbances in powers of locomotion, (2) disturbances in the sense of balance, and (3) proneness to trophic changes, including fixation of the joints. The patient is most
170 NETJROSURGERY

FIGURE 73.—Detail of long leg brace with low pelvic girdle.

Note ankle and knee locks.

greatly handicapped who has lost control of his hip muscles, for with this

loss goes a loss of stability in this area.

These losses must be overcome by substitution factors. The first is the

use of the muscles of the upper extremity. The second is utilization of the

sense of vision. If this sense is used, it is usually possible to train the eyes

to achieve balance almost entirely, by teaching the patient to focus on his

environment and not on his paralyzed extremities. Once the lower extremities are properly stabilized by braces, the patient develops an awareness of

the position of the paralyzed parts and can use his eyes for other purposes.

Techniques of ambulation.—Normal walking is a complicated process,

and it was never a simple matter to reteach it to paraplegics. The paralytic

gait is fundamentally a succession of alternating movements as the nonweight-bearing extremity is swung forward like a pendulum. Propulsion is

obtained by the tripod action of the crutches and the braced lower half of

the body. Walking under these handicaps involves swinging the pelvis and

lower extremities forward, by action of the musculature of the thoracic cage

or the abdomen, with the force transmitted through the braces. Since the

gluteus muscle is paralyzed, the patient must lean far to one side or the other

to raise the opposite extremity off the ground. This makes for grotesque

overmovement at first, and it required long hours of practice to eliminate it.

Two gaits were taught in the paraplegic centers, the step through (fig.

76), which was much harder to learn but which gave the appearance of more

normal locomotion, and the swing through (figs. 77 and 78). The latter technique could be learned readily after the first had been mastered, and the

patient could then use whichever method best suited his need at the particular moment. The swing-through gait permitted more rapid progress but

was more difficult to achieve if taught first; it was best suited for open, unobstructed areas.
PARAPLEGIC PATIENTS IN ZONE OF INTERIOR 171

FIGURE 74.—Brace fitting of paraplegic before efforts at ambulation.

A. Final fitting of long leg brace. Note advanced conditioning of

shoulder-arm-trunk musculature. B. Transition from bed to the first

stages of ambulation.

Overhead suspension, which was always kept loose, was used only to

protect the patient from falling and to give him mental reassurance. It was

not intended to pull him up (fig. 79). It was used chiefly for paraplegics

with high thoracic transections and resulting loss of function of the lower

abdominal and hip musculature. Ambulation in these patients was better

achieved by the use of a wheelchair.

Walkers were useful because they provided a chance to exercise the same

muscle groups later used in walking with crutches. They were used chiefly

for balancing and stepping exercises and were not intended to replace parallel bars.
172 NEUROSURGERY

FIGURE 75.—Thoracopelvic girdle on paraplegic patient with midthoracic spinal cord transection and loss of function of abdominal

musculature.

Sidestepping and walking backward were taught to provide the patients

with free range of motion. Parallel bars were useful in teaching them to

go upstairs and downstairs; going downstairs was taught first (fig. 80).

Crutches were unpaclcled. Walking with crutches is fatiguing and

patients readily developed the habit, if the crutches were padded, of resting

on them in the axilla. These patients were going to have to use crutches for

the rest of their lives, and it was no kindness to them to permit them to get

into bad habits at the start. The way to use the crutches was to rotate them

in the axilla, not rest on them.

Walking with crutches was difficult to teach. It meant learning a new

and changed balance. Teaching a paraplegic to walk was quite different

from teaching a man with infantile paralysis, whose sensory tracts were

intact. The patient with infantile paralysis feels when he puts his legs

down. The man with a high lesion in transverse myelitis felt as if he were

walking on stilts. His point of gravity was completely altered, and he had

to be taught to use his crutches, and to think of them, as if they were prolongations of his upper extremities. This was no simple matter.

When the patient had learned to rise from bed to chair, from chair to

standing position, from standing position to parallel bars, and from bars to

crutches, he was taught to walk on a level surface and then to negotiate

stairs. The need for training patients in the use of public transportation
PARArLEGIC PATIENTS IN ZONE OF INTERIOR 173

FIGURE 76.—Details of step-through gait. A. Paraplegic patients

beginning instruction in step-through gait. B. First-stage instruction in step-through gait. C. Walking posture with step-through

gait, with gait achieved by alternating movements of ipsilateral

extremity and crutch.

ceased to be important when automobiles with hand controls were provided

for them. License bureaus in the various States readily granted licenses to

these men after they had been instructed in the use of their cars and had

passed the required examinations.

A surgical procedure was sometimes necessary before ambulation could

be undertaken. The feet had to be at right angles to the leg, and a patient

with a fixed equinus of 10° or 15° could not stand up until it was corrected.

Paralysis of the calf muscles sometimes remedied the situation, but deliberate lengthening of the heel cord was usually preferable.

Instruction was particularly difficult in spastic paralytics with the socalled scissors gait deformity. Neurectomies and tenotomies were used with

advantage in some of these cases, as in spastic children.

Records.—Throughout the whole exercise and ambulation program, it was

the custom at some centers to keep charts showing the achievement and time

of accomplishment of some 60 activities (fig. 81).
174 NEUROSURGERY

FIGUKE 77.—Paraplegic patients shown in figure 76 demonstrating

first phase of tripod or swing-through gait. Note detail of following

illustrations.

Pfc n^ >l/l~4-~.

?/e *a^ £ftviu„

FIGURE 78.—Details

ABC

of tripod or swing-through gait. A. First or preparatory stage, with tripod formed by feet together and crutches separated.

B. Body weight inclined forward over crutches with swing through of

paralyzed lower extremities. C. Finishing position of swing-through gait,

to be followed by placing crutches in position illustrated in view A.

The competitive aspect of the program improved the general morale, and

success in the ambulation program was of great aid in practically every other

problem which the paraplegic encountered.

Specimen Programs

Cushing General Hospital.—At the end of hostilities, in August 1945, Col.

Condict W. Cutler, Jr., MC, reported that there were 88 patients with cord
PAKAPLEGIC PATIENTS IN ZONE OP INTERIOR 175

FIGUKE 79.—Use of overhead suspension track in early stages of ambulation. A.

Patient lifted from transport guerney by means of overhead suspension. B. First stage

of ambulation, with use of paralytic walker in step-through gait with overhead suspension. C. Second stage of ambulation, with use of paralytic walker without aid of overhead suspension. D. Third stage of ambulation, with early use of crutches with aid of

overhead suspension by paraplegic patient with high thoracic, spinal cord transection.

injuries in the paraplegic center at Cushing General Hospital. They had

arrived emaciated, anemic, avitaminotic, incontinent of feces, and afflicted

with large decubitus ulcers. By means of transfusions, special alimentation,

and vitamin medication, their physical state was brought back to as nearly

normal as possible.
176 KEUROSURGERY

FIGURE 80.—Advanced ambulation with step-through gait in paraplegic patient with

low lumbar vertebral injury. A. Movement from chair to crutches. B. Ambulation with

step-through gait. C. Training in going upstairs and downstairs.

At first, it was thought necessary to keep paraplegics in bed during

treatment of their bladder condition, as well as to maintain the suprapubic

cystostomy for long periods. Later, it became apparent that they could be

got out of bed earlier than was previously thought possible, and that they

would be the better for it. The suprapubic tubes were therefore removed

as soon as gross infection of the bladder had cleared up under irrigation.

Suprapubic sinuses which failed to close after removal of the catheter were

closed surgically. Irrigations were continued at 2-hour intervals through

the urethral catheter until cystometric examinations had revealed increasing

capacity. Then tidal drainage was instituted and was continued until automatic bladder function had been established. Once this had been accomplished, ambulation could be begun.

Meantime, while the urinary condition was being cleared up, regular

exercise of the unparalyzed muscles of the upper body had been carried on,

and the patients had been given special instruction in self care.

The orthopedic section of the hospital collaborated in the construction

of appropriate braces. When these were applied, the patients attended

classes daily for guidance, assistance, and instruction in ambulation. They

were provided with special messing facilities. Thanks to the careful preparation for ambulation, the majority of these patients relearned to walk in a

remarkably short time.

Hammond General Hospital.—At Hammond General Hospital, Capt.

(later Maj.) Ernest H. J. Bors, MC, directed another remarkably successful

program (app. C, p. 599). As soon as the patient was admitted, roentgenograms of the spine and evaluation by orthopedic surgeons provided information concerning exactly how much the patient could undertake.
PARAPLEGIC PATIENTS IN ZONE OP INTERIOR 177

E- EXCELLENT WORW/O - WITH

G - GOOD OR WITHOUT OVERS-SPASTIC HEAD SUPPORT.

UP ON BRACES

PATIENT'S

NAME DATE DATE DATE DATE DATE DATE DATE

E

G

S

W OR W/O

FIGURE 81.—Walking record used to follow ambulation progress in paraplegic colony.

A table of measurements was charted, showing the vital capacity and

the circumference of the biceps, forearms, and thorax. Measurements were

taken every 6 weeks.

Exercises were directed toward strengthening the musculature, including

that of the upper extremities and of the thorax, abdomen, and back. They

were partly dynamic and partly carried out by squeeze pulleys. Projected

crutches (facsimiles) at the bedside were used to prepare the muscles for

future motion on real crutches. Other exercises consisted of pull-ups on

bars, lifting exercises for the hips and buttocks when the nerve supply of

the local musculature had not been impaired, and arching and sitting-up

exercises to take care of the back and abdominal muscles.

The patient was trained to become accustomed to a sitting position in

bed before he was put into a wheelchair. After he had been in a chair several times, each time for a longer period than the last, the first attempt was

made to apply braces and to bring him up into a walker with the aid of

the overhead suspension track. This overhead track proved very useful in

handling patients for various purposes, including placing them on the toilet

and giving them reassurance when they attempted to walk for the first time.

The overhead suspension track was kept on the side porch adjacent to

the ward. The patient was brought to it, clad in his corset and braces, and

was lifted from the transport guerney and placed in the upright position.

Two sizes of supporting belts, one large and the other small, were connected

with the tackle. Both were reinforced by supporting and straddle straps,

which permitted comfortable adjustment of the belt and at the same time

prevented its slipping. A suspension belt which was too tight simply created

respiratory embarrassment.
178 NEUROSUBGBBT

The patient was then aided by one or two attendants to get onto his

walker. As progress was made in ambulation, the overhead suspension was

made progressively looser until eventually it could be discarded altogether,

the patient then being forced to rely entirely upon the walker and his braces.

From the walker, the patient progressed to walking on crutches, at first with

the aid of overhead suspension.

When the patient began to try to walk, he was carefully taught how to

place his weight in the various motions of walking, and how to use his

crutches properly. The tripod position was explained, as well as the alternate use of the left foot and right crutch and the right foot and left crutch.

All phases of walking were supervised by the ward officer, with the

assistance of specially trained personnel. A record was kept on each patient

to show his progress.

RELIEF OF PAIN AND SPASM

Patients with combat-incurred injuries of the spinal cord practically

always had severe pain soon after wounding and for some time thereafter.

From a third to a half of all paraplegics had some form of sensory disturbance which was more or less persistent. The discomfort might take the form

of a tingling sensation. It might also be moderate or agonizingly severe root

pain of segmental distribution. It might also be of the causalgic type and

limited to one extremity. Patients with lesions of the conus or of the cauda

equina usually had more pain than those with lesions at a higher level;

causalgic pain was frequent in lesions at the lower level. Patients with

incomplete lesions usually had more pain than those with complete lesions.

The causation of the pain was perfectly obvious in some cases. In

others, it was never clarified. Retained foreign bodies in close proximity to

pain tracts of the posterior nerve groups explained some cases (fig. 82).

Bony overgrowth from healed fractures which impinged on nerve groups

was responsible for some cases (fig. 83). Arachnoiditis following trauma

to the cord might result in a generalized or girdle type of pain. Involvement of the sympathetic nervous system sometimes resulted in a most distressing type.

Spastic contractures, which were frequently painful, affected about 40

percent of all paraplegics. They usually appeared at intervals varying from

2 weeks to 7 months after injury of the cord.

As with pain, there was no universal explanation for these so-called

mass reflexes. The mechanism of the phenomenon was the entrance of sensory stimuli into the spinal cord through a posterior nerve root, and, after

their transmission to a large number of anterior horn motor cells, the emergence of these sensory stimuli as efferent stimuli to motor groups. This

theory, however, fails to explain why some patients exhibited these spasms

and others did not. Some patients with proved transection of the cord

might have a minimum motor response to strong sensory stimuli while others
PARAPLEGIC PATIENTS IN ZONE OF INTERIOR 179

FIGURE 82.—Roentgenograms showing shell fragment partly within spinal canal.

A. Anteroposterior view. The foreign body lies on the same side of the midline as the

wound of entry in the back, which is a favorable sign. B. Lateral view, showing fractures of vertebral bodies. This observation indicates that the shell fragment has passed

completely across the anteroposterior diameter of the spinal canal, which is an unfavorable sign. In this case, however, the dura was found intact at operation.

FIGURE 83.—Roentgenogram showing fistula and exostosis in healing gunshot wound following laminectomy. This patient suffered from persistent posterior nerve-root pain.

with partial transection might exhibit maximum motor response to minimal

stimuli.

Whatever the explanation, spasms of any severity in paraplegic patients

were incapacitating in the special sense that ambulation and rehabilitation

were impossible until they were controlled.
180 NEUROSURGERY

Nonsurgical Measures

Pain tended to decrease spontaneously with time, improvement in the

general condition, and increasing activity. In 10 percent or more of all

patients, it was persistent enough to require surgical measures for relief,

and in most patients, measures of relief were required until spontaneous

relief occurred.

Mild analgesics, hot baths, and the distraction and diversion of rehabilitative measures were useful in most cases in the interim. When they were

not, more radical measures had to be employed. Morphine could not be

used repeatedly for long periods because of the risk of addiction. If the

choice lay between it and surgery, there was no question that surgery was

better. On the other hand, while paraplegics did not tolerate pain well,

they also did not withstand extensive surgical procedures well.

Spontaneous relief of spasm occurred in many patients when they became

ambulatory. Physical therapy was always employed, and massage with

effleurage and gentle passive motion sometimes achieved good results. Traction was also successful in some cases.

At a number of centers, rather striking success was achieved in the

management of painful spasm by the use of the curare. By this time, this

agent could be used without fear of the toxicity which had for so long kept

it in ill repute, and preparations were becoming available which would hold

it in suspension for prolonged periods of time. Eesults varied from moderate to dramatic. Even the most severe spastics were likely to have periods

of relief for 15 to 18 hours or longer; during this time, physical therapy

could be carried out and other attempts made to reestablish muscle tone.

One patient at McCaw General Hospital who was relieved by this measure

had had such severe and persistent adductor spasm that he had developed

extensive decubitus ulcers on the knees and a similar ulcer in the groin.

Some striking successes were also achieved by the use of cobra venom

in dosages of 0.5 to 1 cc. twice daily. No results were usually observed for

4 or 5 days. Then, as pain diminished, the dosage schedule could be reduced. In 70 of 71 patients with pain and spasm at Bushneil General Hospital, Brigham City, Utah, the results of this measure were so good that no

additional medication was necessary except for aspirin and phenacitin. In

some hospitals, snake venom and curare were used interchangeably.

Paravertebral block with procaine hydrochloride was tried in some

patients with varying results. If adequate relief was obtained, sympathectomy was carried out in some cases, with resection of the first, second, and

third lumbar ganglia. The procedure was attended with little risk.

If the pain was segmental and the etiologic factors were obscure or the

chances of relief by more direct measures were slight, alcoholic injection of

the posterior nerve roots was employed. Paravertebral alcoholic injections

were also used in patients with draining wounds or with decubitus ulcers

whose location prevented surgical measures. Results were not impressive.
PARAPLEGIC PATIENTS IN ZONE OP INTERIOR 181

Alcoholic injection into the sub-arachnoid space and the low sacral region

was generally avoided because of the risk of interfering with bowel and

bladder function.

Surgical Measures

The neurosurgical task in the Zone of Interior was of diminishing magnitude in the management of paraplegics in comparison with the nonsurgical

problems presented by these patients. Surgery, however, was sometimes

necessary. Originally, a variety of procedures were employed, as the individual neurosurgeons desired. In TB MED (War Department Technical

Bulletin) 162, May 1945 (app. B, p. 589), only the following procedures were

authorized:

1. Decompression for excessive proliferation of bone at a fracture site

if the process was thought to be responsible for pain and progressive

paralysis.

2. Removal of retained foreign bodies or displaced bone fragments in

the cauda equina. Exploratory procedures intended only to identify pathologic neural changes were condemned.

3. Appropriate rhizotomy for the relief of radicular pain caused by

pressure on the nerve root at the site of injury.

4. Anterolateral cordotomy for the relief of intensive burning pain in

completely paralyzed extremities if the lesion was in the cervicodorsal region.

5. Sympathectomy for burning pain, interpreted as a true causalgia and

caused by injury to the cauda equina. Patients thought amenable to sympathectomy were to be selected, as already indicated, by preliminary paravertebral block of the lumbar sympathetic ganglia.

In this publication it was emphasized that while pain, progressive

paralysis, and mass reflexes associated with intractable flexor spasm and

ultimately with flexor contractures were common complications of injuries

of the spinal cord, care must be taken to differentiate true neurosurgical

difficulties from nonspecific and arthritic pain. It was recognized, however,

that the therapy of compound fractures and of amputation stumps of the

lower extremities could be severely comprised by the presence of flexor

spasm and that relief of spasm was therefore to take precedence over any

method of treatment directed at the other injuries.

Laminectomy.—There were a number of arguments in favor of exploratory

laminectomy in Zone of Interior hospitals and many regrets when it was

officially forbidden. For one thing, it could be done with a minimum risk

to life; there were very few deaths and few postoperative complications in

the cases in which it was performed.

Another argument in favor of exploratory laminectomy was that the

adoption of a conservative policy in regard to it meant that some patients

who might be helped by surgery would not have the benefit of operation.

Neurologic examination revealed only the extent of physiologic interruption,
182 NEUROSURGERY

not the extent of the anatomic lesion of the cord. The Queckenstedt test

as a criterion for surgery was discredited long before the end of the war;

the response was normal as long as the lumen of the subarachnoid space

was no smaller than the bore of the needle used.

Roentgenologic examination was also not reliable in the selection of

patients for laminectomy. Depressed bone fragments were often found in

the spinal canal after films had been reported as negative. Even when

careful stereoscopic views w

Tere made, the fracture of the laminae, the

pedicle, or both was often more extensive than the films had suggested.

Finally, partial compression of the dura and cord was sometimes found at

operation when it had not been revealed by roentgenologic or manometric

studies, and decompression often led to dramatic improvement.

Not much neurologic improvement could be expected if laminectomy was

unduly postponed. Improvement was evident in 57 percent of 36 patients

observed at Newton D. Baker General Hospital on whom laminectomy had

been performed within 3 hours to 5 days after injury, against a 10-percent

improvement in 386 patients in whom operation had been delayed beyond

this period. An occasional patient was benefited by late surgery, but the

circumstances were almost always out of the ordinary. In a patient at

DeWitt General Hospital, for instance, who had undergone laminectomy

because of a block and an incomplete lesion of the cauda equina, evacuation

of an absolutely sterile intradural abscess resulted in a moderate amount

of function.

All neurosurgeons, in their evaluation of surgery in paraplegia, pointed

out that a distinction must be made between operation on the cauda equina

and operation on the spinal cord. The cauda equina is essentially a group

of peripheral nerves, and its behavior is similar to that of peripheral nerves.

It can withstand surgery, and some degree of recovery or relief might be

expected after operation on it. Many surgeons noted that exploration of the

cauda equina produced about the same results as surgery in certain peripheral

nerve lesions. With injuries of the spinal cord proper, however, recovery

of function after operation is nothing like as probable.

Rhizotomy.—Experience, which accrued slowly, finally demonstrated that

anterior rhizotomy for the relief of mass reflexes in the completely severed

cord segment was often useful and sometimes lifesaving (fig. 84). It was

particularly useful in injuries of the cauda equina. At operation, the sensory

roots were often found glued to the cord or dura by dense adhesions, or

partly torn, or adherent to rough bony spicules or fractured bone.

Results were sometimes dramatic. At Newton D. Baker General Hospital, for instance, the operation was done on a patient with such pronounced

flexion contractures that he had suicidal ideas. Once his legs were straightened out, his rehabilitation was rapid and gratifying. It was often technically difficult to free the bound-down nerve roots, and scar tissue inevitably

re-formed after operation; but, at least while the patients were under observation, results were good in some cases and in some were dramatic.
PARAPLEGIC PATIENTS IN ZONE OP INTERIOR 183

_, '

A

FIGUKE 84.—Surgery for relief of spasm and contracture in paraplegic patients.

A. Spastic contractures of lower extremities. B. Relief of muscle spasm and contractures

after anterior rhizotomy.

Cordotomy.—Cordotomy, with section of one or both lateral spinothalamic

tracts, "was generally reserved for extreme cases of intractable pain in which

rhizotomy had failed. It was a relatively simple procedure technically, and

most observers believed that there was little to lose by it. The possible risk

of increasing motor involvement and urinary tract impairment was worth

taking, since cordotomy usually relieved pain. The operation cannot be

done under direct vision, since these tracts are not on the surface of the

cord, and some of the pain fibers were therefore sometimes left intact.

Other operations.—Until the limitations placed upon neurosurgical procedures in paraplegics by TB MED 162, a number of miscellaneous procedures were undertaken, and still others were discussed.

If adductor spasm prevented the patient from becoming ambulatory

promptly, obturator neurectomy w

ras performed in some hospitals. The results were sometimes poor, but this, it was pointed out, could be explained

by the anatomic fact that a small branch of the femoral nerve which supplies

the adductor group was frequently overlooked—some surgeons being ignorant

of its existence—and failure to cut it permitted spasm to continue.

Section of the cerebral sensory cortex for relief of pain was discussed

but was considered applicable only to the very occasional case. Since most

patients with transverse myelitis had bilateral pain, both posterior central

cortices would have to be exposed, the corresponding areas identified by

stimulation, and subpial resection performed. This would have been a very

formidable procedure indeed, and, as one observer remarked, it seemed an

excellent method of making a paraplegic into a triplegic and giving him

epilepsy besides.

Amputation.—Amputation of the legs was the subject of theoretical discussions at several of the paraplegic conferences but was never performed

unless the extremities were the site of extensive bone or vascular damage.

There were a number of arguments in favor of the procedure. The legs,

which were absolutely useless in complete transection of the cord, weighed

49S991V—59 14
184 NEUROSURGERY

40 to 50 pounds and were perfectly useless in ambulation. Actually, in the

new circumstances, they were harmful; they acted as stilts, elevating the

center of gravity from the ground for about 4 feet. Against these considerations was the fact that amputation is a mutilating procedure, which a

surgeon would not willingly undertake, and that it might merely superimpose a severe psychologic trauma on the severe physical trauma already

present. It was also pointed out that a patient with a lesion of the conus

could not be fitted with prostheses, for anything that touched the lower

extremities caused pressure sores. Amputation for the purpose of using any

kind of prosthesis would be defeated by the development of decubitus ulcers.

If amputation should be undertaken, disarticulation at the hip would

be more reasonable than midthigh amputation. The patient could then be

supplied with a platform, on which he could push himself along.

In these discussions, it was brought out that the literature was devoid

of any references to amputation in paraplegics. The sense of the discussions

on the subject at the paraplegic conferences was that this was a repugnant

procedure, for which there was no indication in paraplegic subjects. The

Council on Physical Medicine of the American Medical Association had

recommended the operation only if it offered a better prognosis in terms of

appearance, comfort, and function, and only if a sufficient part of the

extremities possessed enough useful function to work well in prostheses.

These criteria were unlikely to be met.

REHABILITATION

Recreation

When paraplegic patients were received in Zone of Interior hospitals,

there was a deliberate effort, during the first weeks of hospitalization, to keep

them occupied and interested all of their waking hours. A great deal of

time was necessarily occupied by medical matters, including attention to

decubitus ulcers and to the control of bowel and bladder function. Exercises accounted for another portion of the day, and when ambulation was

attempted, training and practice took up still more time. Distracting occupations and entertainment were especially necessary between dinner and

bedtime, but occupational therapy, reading matter, games, and other diversions had to be provided continuously. At Hammond General Hospital, it

was found most efficient to plan entertainment and occupational schedules

for the hours between 1300 and 2100 for a month at a time. Moving pictures,

band concerts, and entertainment by show units were particularly helpful.

From the first, an attempt was made to make the men feel that they

were still part of the outside world. At McCaw General. Hospital, even men

with severe decubitus ulcers being cared for on Stryker frames, who could

not be moved to wheelchairs, were taken outdoors, to the post exchange, and

even to the Saturday night, barbecues and the rodeo. Men with bedsores
PARAPLEGIC PATIENTS IN ZONE OF INTERIOR 185

which had cleared up were allowed 3-day furloughs or passes to visit their

families without any redtape at all; they merely told the administrative

officer that they wanted to go, and arrangements were made for them to go.

When patients revealed an active interest in music, this was encouraged,

particularly the playing of instruments which required strong movements of

the diaphragm and the abdominal muscles. The playing of saxophones,

trombones, and harmonicas often resulted in significant improvement, in

abdominal pressure. Music often helped to tide patients over the most trying period of their hospitalization.

The patient's special interests were investigated at almost the first personal interview with him by the ward officer. As soon as the information

was secured, it was distributed to those who would be concerned and who

could help. The post library produced books. The recreational officer

brought records. The special services officer played request pieces over the

loudspeaker and dedicated them to the patient. Everyone cooperated in

getting him what he was interested in and what he expressed a desire for

(fig. 85).

Occupational Training

On the more serious side, as soon as the patient was fit for it plans were

made for his reeducation and rehabilitation for a future occupation. At the

interview conducted for this purpose, he was questioned about what he had

done in the past and what he hoped to do in the future. The approach had

to be extremely careful. If a man had been a lumberjack and wanted to

return to his former occupation, this was obviously no moment to discuss

his future. It was no kindness to build up hopes which later had to be torn

down. All of the information thus obtained was used for guidance in the

rehabilitation of the patient.

At McCaw General Hospital, much importance was attached to psychologic testing. A profile was made of the patient's abilities as determined on

the basis of his performance while he Avas still on the Stryker frame. The

patient was told what these tests showed, and plans for his future were

made in accordance with them. It was always necessary to remember that

the paraplegic group represented all social and educational levels and that

the expression of interest in an occupation was very different from ability

to follow it.

Many patients expressed a desire to continue their education, but the

Army educational program did not prove useful in this connection. The

courses were difficult to obtain, and the few obtained were not suited to the

previous education and qualifications of the men who undertook them.

Centers which were located adjacent to colleges, such as McCaAv General

Hospital, were fortunate. Patients were able to attend classes in these colleges, and some of them did the preliminary work for medical and legal

training or began to study medicine and law.
186 NEÜROSURGERY

FIGURE 85.—Paraplegics engaged in various kinds of recreation and occupational therapy.

These are typical scenes.

The paraplegic survey (p. 14) showed that men who had had the most

schooling were most desirous of more schooling. Four out of every five of

those with previous college training desired to continue their education.

Younger patients more often desired additional schooling than older patients, and patients in the euphoric and normal groups more often desired

it than those in the depressed and indifferent groups.

As to occupational training, 70 percent of those who did not desire

further schooling also did not desire occupational training. Those with the

highest AGCT scores had the greatest interest in securing further occupational training. The euphoric and normal groups had an above-average

interest in additional training and the depressed and indifferent groups less

than average. Patients to be discharged to their own care or to their own

homes apparently had a slightly greater desire for occupational training than

those who would require institutional care.

RESULTS OF PROGRAM

The. end results of the paraplegic program could not be assessed during

the war and must be reported by the Veterans' Administration, to which

most of these patients were turned over within the 16 months after the war
PARAPLEGIC PATIENTS IN ZONE OF INTERIOR 187

ended, (p. 13).7 A few general comments may be made, however, and a few

special instances related.

In speaking of the program at Cushing General Hospital, Colonel

Cutler said that in one group of 67 paraplegics, 16 were eventually so improved that they were able to walk. It might be discouraging to reflect, he

continued, that the 51 others showed no neurologic improvement in the

periods (up to 12 months) in which they were under observation and treatment. On the other hand, all of the patients who remained unimproved

from this standpoint had been brought to a tolerable and even a useful

existence and all of them proved the entire justification of the new attitude

toward spinal cord injuries, as well as its great rewards.

The most successful results from the standpoint of occupational therapy

and training were accomplished in work that existed and was not created.

In one center, several of the paraplegics worked 4 hours a day, 2 hours in

the morning and 2 hours in the afternoon, doing precision work in a nearby

factory. They were paid by the hour, punched the timeclock, and lost pay

if they were absent or late. Their interest in what they were doing was

amazing. One of these men, his ward officer stated, did more to help the

morale of the other patients than anybody else, not excluding the Red Cross

workers and the Gray Ladies. He gave a practical demonstration that a

man with paralyzed legs could still lead a useful life and hold down a

paying job, and his determination and cheerfulness did more good than

medicine to the other patients.

Many of the men learned new occupations. A patient who thought he

wanted to be a rancher ended with a chicken farm. A former truckdriver

for a dairy company showed a real talent for leatherwork and was making

$45 a week from it when he left the hospital.

One particularly impressive case history was related by Captain Bors

at the paraplegic conference at Hammond General Hospital in June 1945.

In fact, the experience with this highly unpromising patient had provided

the chief stimulus for the whole plan of management of patients with

transverse myelitis at this institution.

This man, the first with transverse myelitis to be received, was a con1 Statistics of the Veterans' Administration are not available in such form as to permit a

followup of the paraplegics who were treated under the program in World War II, but Veterans'

Administration Technical Bulletin 10-503, dated 15 Dec. 1948, is of comparative interest. On this

date, 35 of 90 paraplegics were attending school and 29 were engaged in business, on-the-job training, or some remunerative hobby. The work tolerances of these 29 patients ranged from 15 to 40

hours weekly, and their monthly earned income ranged from $100 to $240. Two patients were

earning $130 and $155 per month, respectively, while training for future jobs.

As in other studies, this survey showed that patients with injuries at lower levels were more

likely to carry out plans for study and work than those with cervical and upper dorsal injuries.

Other facts also had to be taken into consideration in evaluating these results, chiefly the benefits payable to paraplegics at this time. Compensation was $360 per month. Each man was given

an automobile equipped for his driving needs. A home could be purchased at a low interest rate

after a small downpayment, and a subsidy could be secured for a specially equipped house, amounting to not more than $10,000 or not more than 50 percent of the cost. How far these benefits

influenced the desire to work cannot, of course, be determined, but their influence cannot be entirely

overlooked.
188 NEUROSURGERY.

scientious objector. He was rendering aid to casualties on Attu when he

was stabbed through the spinal cord by a Japanese soldier. When he arrived at Hammond General Hospital, he was completely paralyzed below

the eighth dorsal vertebra and had tremendous decubitus ulcers. He was

a depressed, complete invalid, "with no more activity than a jellyfish." He

was interested in nothing at all, and daily visits by the commanding officer

of the hospital had completely negative results until, after weeks of effort,

he became interested in the radio which had been placed by the side of his

bed. One thing led to another. Once his bowel and bladder function were

regulated and his ulcers cleared up, he was put into a wheelchair and then

fitted with braces and taught to walk. He learned to put on his own braces

and take them off. He learned to walk up and clown stairs.

Meantime, his interest in radio continued, and he became so adept a

mechanic that he was termed the "No. 1 radio instructor." He completed

his studies at Modesto Junior College, Modesto, Calif., securing the necessary (very high) credits to make him eligible for admission to Stanford

University, Palo Alto, Calif., where, when the war ended, he was studying

the scientific aspects of radio, with every prospect of a successful career in

this field.

The objective of the training phase of the paraplegic program, as 1st Lt.

(later Capt.) Edward B. Schlesinger, MC, expressed it, was to provide these

men with the complete economic security which they deserved of their

country. They were eligible for a pension (then $150 per month) and for

the pay of an attendant (then $100 per month), but this was not enough.

Before' they were dismissed from the hospital, they had to be provided with

a way to make a living in a dignified, grownup occupation, in some line

of work in which they would be given business on their merits and not just

because they were crippled.

The point of view of the patients was well expressed by a man treated

at McCaw General Hospital, after he had been taught to walk and had completed his first 6 months of legal training at a nearby college. He said:

"From the viewpoint of some persons, it seems that it would be more

merciful if the terribly handicapped should die. But believe me, living is

sweet, and so long as there is a glimmer of hope, there is a chance to live."

There was no better way of providing this "glimmer of hope"^ than

by teaching these paraplegic cripples once more to take their place in the

community of normal men.

PHYSICIAN AND PATIENT

The success of the paraplegic program depended fundamentally upon

the personal relations between the patient and those who cared for him,

particularly the medical officers who cared for him. The cooperation of the

patient—which usually had to be secured—was essential. The physician
PARAPLEGIC PATIENTS IN ZONE OP INTERIOR 189

needed tact and compassion almost more than lie needed medical knowledge

and skill.

The Relation Between Patient and Hospital Staff

The essence of this relation was well expressed at the paraplegic session

at the Newton D. Baker General Hospital in June 1945 by Lt. Col. (later

Col.) David H. Poer, MC, who spoke in substance as follows:

The basis of the everyday routine of care for paraplegic patients is the

purposeful development of a strong patient-doctor relationship. All matters

of every nature, all supervision, all details of management must be the

direct responsibility of a single medical officer, in whose charge the patient

is placed. This officer must be familiar with everything that happens to the

patient and everything that is done for him.8If the ward officer was not

interested, neither were the patients.

This relationship is of inestimable value to the patient. He finds that

he has a strong post to tie himself to and to spring back from on his road

to a reasonably satisfactory mode of life. The time and method by which

the officer establishes, builds up, and cements this relationship derive from

the daily ward rounds. They must be regular and systematic, and they

must be made at least once daily, including Sundays and holidays. Rounds

made in the evening are of immense value, since they are usually free from

the hurry, bustle, and rush of the average hospital day. During these periods, the patient will discover that the officer not only knows his problems

but can point the way to their solution. The complexity of the problems of

paraplegic patients requires an unusually time-consuming program, but it

pays rich dividends, and they cannot be obtained otherwise.

All personnel responsible for the care of the patients Avork directly

under the authority of the ward officer. The hospital corpsmen and ward

attendants are the most important members of the treatment team. Their

duties are concerned with the care of bowel and bladder function, with aiding the patients to become ambulatory, with feeding them, and with turning

them and caring for their beds. When attendants carry out their duties

properly and are sedulous in shifting areas of pressure, Stryker frames

promptly become unnecessary.

The work of the technicians who carry out physical therapy blends

into the reconditioning program, which is designed to give the man the

massive shoulder-girdle musculature required to substitute for motion of

the legs. Specially trained urologic technicians or male nurses carry out

the simple procedures necessary to keep the urinary tract free from infection.

s Detailed records head to be kept on all patients, and ward officers had different plans for keeping the overall picture of all of their patients immediately at hand. At Hammond General Hospital,

a control board in the office of the paraplegic ward informed the ward officer at a glance of the

special symptoms of each patient, his progress in the control of bowel and bladder function, his

status in regard to ambulation, his participation in ward activities, and all the other details which

provided a picture of the patient's mental and physical status at any time.
190 NEUROSURGERY

The Red Cross program is social as well as recreational. Red Cross

workers are particularly helpful in the family adjustments which the paraplegic requires. They concern the wife and the children most of all, but

they also involve other members of the family. Personal guidance and

counsel are provided to take care of all legal and business matters.

Educational and vocational instructors are also needed. The educational

program is set up to fit the needs of each patient and is directed toward

training him to earn a livelihood after he is discharged.

There is no ward in the hospital in which the chaplain can render more

useful service to patients and can be of more assistance to medical officers.

Chaplains of all faiths visit the wards daily, and efforts are made to take

all patients to chapel services.

Since the original injury is to the spinal cord, the first line of treatment is the responsibility of the neurosurgeon, though the urologist has the

chief daily contact with the patient until automatic function of the bladder

has been established and infection brought under control. The internist,

especially the internist trained in nutrition, has an important role on the

paraplegic ward. The results he achieves hasten, and are hastened by, closure

of decubitus ulcers. The orthopedic surgeon and the general surgeon also

play a part when there are associated conditions or complications.

Behind the medical staff stands the nurse in charge of the ward. She

shares with the medical officer responsibility for all details of treatment.

She is his listening post and intelligence department. She advises him and

supports him and shares with him the supervision of the work of attendants

and technicians.

Everything possible is done to convince the patient and his family that

he is receiving the most modern treatment possible, that bowel and bladder

control will be established, that he will be taught to walk again if this is

compatible with his injury, that he will be trained in a gainful occupation,

and that he will be dismissed from the hospital as soon as these things are

achieved or are achieved to the extent possible. When there is a serious and

determined effort to accomplish these results, Colonel Poer concluded, the

morale of a paraplegic ward and of the patients in it ceases to be a major

problem.

THE PROBLEM OF MORALE

A discussion by Colonel Kennedy at the paraplegic session at Newton

D. Baker General Hospital in June 1945 throws a great deal of light on

why the paraplegic program in Zone of Interior hospitals was a success. He

discussed the specialized personnel needed to deal with paraplegic patients,

personnel who had to be specialized not only in their training but in their

attitude and their compassion. He spoke of such practical matters as

securing special supplies; when ward and other personnel were told they

were not available, all of them "should take the attitude that there is no
PARAPLEGIC PATIENTS IN ZONE OF INTERIOR 191

such answer as 'No' to tlieir needs." He thought that officers might get

better treatment, and progress more rapidly, if they were put in the paraplegic wards along with enlisted personnel. He wondered whether it might

not be practical to keep in service certain paraplegics who could demonstrate to other patients what could be accomplished in this condition.

Then Colonel Kennedy spoke of the morale of paraplegic patients. He

said that originally, in his own hospital (Percy Jones General Hospital),

the patients had come in rapidly and their morale was poor. Since the

program had developed, the morale in the paraplegic ward was better than

in any other ward in the hospital and he thought the following story might

explain it:

Among the 600 patients in this neurosurgical center were 41 paraplegics,

39 of them enlisted men. A few days before Christmas, the officer on the

paraplegic ward went to the commanding officer of the hospital and said,

"We've got 39 men over there in the paraplegic ward. Christmas is coming

and many of these men have their families here. I don't know whether

they'll be alive next Christmas but they're here this Christmas and I want

every one of these men to have their families here for Christmas dinner."

The answer was "No." Said the young lieutenant, who had been in the

Army all of 4 months, "Sir, I demand that these men be allowed to have

their families here for Christmas. These men deserve it. They have given

everything to their country. They deserve to have their families here, and,

damn it, they're coming to dinner."

The end of the story is that there were 140 on the ward for dinner

Christinas day. The Eed Cross set up bridge tables at each bedside, with

gay tablecloths, candles, and comfortable chairs. Enlisted men, WAC's, and

nurses from other wards volunteered to serve the dinner. Presiding most

graciously over the affair, and the most pleased person on the ward, was the

commanding officer of the hospital.

One need not go beyond that story to know why, in that hospital center

and in others, the morale of paraplegic men was high and why the program,

founded on compassion as well as on technical competence, put courage and

hope into the hearts of soldiers who otherwise would have had no reason to

keep on living, let alone striving to create a new existence for themselves.

49S991V—59 15
CHAPTER VIII

Management of the Ruptured Intervertebral

Disk (Herniated Nucleus Pulposus)

R. Glen Spurling, M.D.

HISTORICAL NOTE

The condition known as rupture of the annulus fibrosus with herniation

of the nucleus pulposus (more commonly spoken of as ruptured intervertebral disk) furnished no problem in World War I, since at that time the

syndrome was unknown, at least as such. Its clinical importance began

many years later, with Mixter and Barr's 1first publication on the subject

in 1934. There is no doubt, of course, that, had this knowledge been available earlier, numerous obscure and puzzling complaints related to the back

would have been explained as ruptured disks in World War I.

By the time the United States entered World War II, the classical

clinical picture of the ruptured intervertebral disk was well established, and

diagnostic methods had become reasonably well standardized. The errors

inherent in air myelography had been pointed out, and the value of Lipiodol

studies, as well as their difficulties and dangers, had been clarified. The

introduction of iophenclylate (Pantopaque) in 1940, by Strain, Plati, and

Warren,2 Avas particulary well timed. Pantopaque was to prove a useful

and innocuous agent, and contrast myelography with it furnished the solution of numerous diagnostic problems. Finally, hemilaminectomy and interlaminar resection of disk tissue had become common practice following the

development of these operations by a number of neurosurgeons. In 1938,

Love and Walsh3had reported 100 surgical cases.

Followup studies on adequate numbers of surgical patients in civilian

practice had shown conclusively that, if the cases were properly selected and

if careful protection was provided for the lower lumbar region over a considerable period of time, half or more of all patients would be completely

relieved of their symptoms, while another large group would receive almost

1 Mixter, W. ,T., and Ban-, J. S. : Rupture of the Intervertebral Disc With Involvement of the

Spinal Canal. New England J. Med. 211: 210-215, 2 Aug. 1934.

2 Strain, W. L., Plati, J. T., and Warren, S. L. : Iodinated Organic Compounds as Contrast

Media for Radiographie Diagnosis. Iodinated Aracyl Esters. J. Am. Chem. Soc. 64: 1436-1440,

June 1942.

3 Love, .T. G., and Walsh, M. N. : Protruded Intervertebral Disks; Report of One Hundred

Cases in Which Operation Was Performed. J.A.M.A. Ill : 396-400, 30 July 1938.

193
194 NBUEOSUEGERY

complete relief. Perhaps most important of all, it had been shown that

eventual return to ordinary activities was possible in most of the successful

cases.

DEVELOPMENT OF CLINICAL POLICIES IN THE

ZONE OF INTERIOR

The management of herniated nucleus pulposus was to prove a major

responsibility of neurosurgeons in Zone of Interior hospitals in World

War II. From the standpoint of numbers, this lesion was exceeded only

by peripheral nerve injuries.4From the military standpoint, it accounted,

in the aggregate, for a very considerable loss of manpower-days.

Policies of management were arrived at by evolution as the importance

of the ruptured disk syndrome became clear and as it became apparent that

the methods of management which had proved correct and highly successful

in civilian practice could not be applied in military practice.

Classification of Patients

Patients with ruptured lumbar disk in Zone of Interior hospitals fell

into three categories, as follows:

1. Many men were inducted with the disability, in spite of the military

regulation that provided that no person was to be inducted with a history

or physical findings suggestive of such a lesion or with a history of surgery

for it.5 When questions of disposition arose, men in this group were considered Line-of-Duty-No.

2. Many men without a previous history of herniated nucleus pulposus

developed the condition under the wear and tear of routine military service.

At Kennedy General Hospital, Memphis, Tenn., special studies by Maj.

(later Lt. Col.) Fritz J. Cramer, MC, showed that it might be the result

of acute trauma. At post mortem studies, protruded intervertebral disks

were found directly opposite lesions present in the spinal cord, and violent

protrusion of the disk, due to compression of the nucleus pulposus or its

herniation, was proposed as a true mechanism for producing injuries of the

spinal cord with traumatic paralysis. When questions of disposition arose,

men in this group were considered Line-of-Duty-Yes.

3. A considerable number of men were returned to Zone of Interior

hospitals when the original policy which permitted surgery overseas was

altered and operation was no longer permitted in oversea theaters.

* This was true throughout the war and after the fighting ended. A report from Halloran

General Hospital dated 7 Dec. 1945 showed that in the preceding 6 months, 2,277 patients had been

admitted to the neurosurgical center ; 1,518 had peripheral nerve injuries, 229 craniocerebral wounds,

and 369 signs and symptoms indicative or suggestive of ruptured disks. During this period, 253

myelograms were performed, and 58 of the 908 operations were for ruptured disks.

5 War Department Mobilization Regulations No. 1-9, 19 Apr. 1944. Section X. Spine, Scapulae,

and Sacroiliac Joints.
MANAGEMENT OF RUPTURED INTERVERTEBRAL DISK 195

Early Policies of Management

The importance of herniated nucleus pulposus in young men subjected

to the unaccustomed rigors of Army life became evident early in the war.

A considerable number of operations for it were done by Maj. (later Col.)

E. Glen Spurling, MC, at Walter Eeed General Hospital, Washington, D.C.,

in which the first neurosurgical service in an Army hospital had been established in the spring of 1942. Almost at the same time, the Society of Neurological Surgeons discussed the problem in detail at its annual meeting, and

Dr. W. Jason Mixter, acting for the society, raised the question of their

management with Col. (later Brig. Gen.) Fred W. Eankin, MC, Chief

Surgical Consultant, Office of the Surgeon General. In his letter to Colonel

Eankin, Dr. Mixter pointed out that it was the sense of the society that it

was not possible to be dogmatic about the type of treatment to be given

to army personnel suffering from ruptured disks. Inquiries to Canadian

neurosurgeons had revealed the same indecision concerning the management

of army personnel.

Dr. Mixter proposed that certain Army (and Navy) hospitals be designated for the management and study of this condition; that patients be

referred to these hospitals only after careful selection and screening according to a specified routine; that the services be in charge of competent

neurosurgeons, with a special interest in herniated nucleus pulposus; and

that the myelographic and surgical management of these patients follow

the same standard technique in all hospitals. Special emphasis was placed

upon proper screening, to prevent the designated hospitals, as Dr. Mixter

expressed it, "from becoming a dumping ground for every lame back in

the Army."

Colonel Eankin was in general agreement with these proposals, except

that he believed it important that each neurosurgical center in which patients

with ruptured disks were to be treated should have a close relation with an

orthopedic service. The original suggestion, that a neurosurgeon and an

orthopedic surgeon examine each patient before he was sent to a neurosurgical

center, was not considered practical, and a form was drawn up (fig. 86)

which could be submitted to the center and on the basis of which the patient

would be accepted or rejected.

The establishment at about this time (the summer of 1942) of neurosurgical centers in several general hospitals made the establishment of

special services for the management of ruptured disks no longer the urgent

matter which it had been originally, but the plan which had been proposed

was, in general, followed, as is evident in the instructions contained in

Circular Letter No. 43, Office of the Surgeon General, 13 February 1943.

Selection of cases for surgery.—In this letter, it was pointed out that

herniated nucleus pulposus had become a major military problem, which

required the joint attention of orthopedic surgeons and neurosurgeons.
196 NEUROSURGERY

SPECIAL EXAMINATION OR ADDITIONAL DATA

LOW BACK PAIN CHART"

Grade Wald -

Line of Duty — - Civilian Compensation L

HISTORY: Traum*: No .... Yes Type _

Back Pain: Date of onset —

No. of in civil lite - — In Service -

Location

Character

Duration (No. of months)

Intensified by: Bending- Lifting ___ Coughing - So-aiming ..

Relieved by: Lying down Walking Immobilization (type)

Leg Pain: Date of onset — - - - -

No. of recurrences in civil life _ In terviee

Location: Right Left Bilateral —

Character

Pattern: Radiation to hip -__ Knee Calf Foot

Intensified by: Coughing Straining Bending Sitting..

Relieved by: Lying down - Flexing thigh Walking

Sensory disturbances:

Numbness

Tingling -—

Coldness !

ADDITIONAL HISTORY (Record any familial history of arthritis or back symptoms, el

In relation li

_ Limp (des<

helgnt - . and age _ EXAMINATION: Weight .

Gait: Smooth without litn]

Upper Extremity:

Signs of arthritis: Shoulder .. Elbow Wrist Fingers.

Atrophy __ Weakness Sensation Reflexes

Lumbar lordosis ., Reversal on forward bending

List: Right Left Pelvic tilt _

Muscle spasm

Percussion tenderness .. ...

Radiating percussiOH pain

Lateral bending test:

Toward painful side

Away from painful side

Hyperextension test

Spinal Mobility: Flexion Lateral -

Extension Rotation

Lower Extremity:

Length (A.S.S.-I.M.): — Right.

Circumference: Thigh __ — -- Right.

(Atrophy) . 10"

Knee - RightRight.

Right _

Call — -

Sensory changes: Hypesthesia

Paresthesias

Motor changes:

Reflexes:

Knee jerk

Ankle jerk —- ----- *&< - "•

Plantar response R'gn< — **''

Straight leg raising test Right Left

Lasegue lest -.— *fc* ^

Jugular compression test

Feet; Normal Relaxed arches

Pronation __ -- Circulation —

PERSONALITY APPRAISAL: Mental level Stoic Hypochondriacs] _

CLINICAL DIAGNOSLS:

EXTENT OF PATIENT'S DESIRE FOR RELIEF:

A B

FIGTTKE 86.—Special form developed for use in cases of ruptured intervertebral disk and

other cases of low back pain. A. Front of form. B. Reverse of form.

Prompt and appropriate treatment would permit the return to duty of these

patients within a few weeks.

Characteristic clinical manifestations were listed as low back pain;

unilateral sciatica; limitation of motion of the lower back; pain on percussion over the lumbar spine, with radiation into the hip and leg; increased

pain on hyperextension of the lumbar spine; hypesthesia and paresthesia

of the foot and leg on the affected side; absent or diminished ankle jerk

on the affected side; and a positive jugular compression test.

Great discretion was to be exercised in the selection of patients for

transfer to neurosurgical centers. Operation was to be performed only

in these centers, and the line-of-duty status of the patient was to be evaluated

before it was undertaken. If the man had had episodes of pain and disability referable to the lower back before induction, the condition was to be

considered Line-of-Duty-No, and operation was to be performed only in

exceptional circumstances. Low back pain or disability was considered an

indication for operation only under exceptional circumstances even in Lineof-Duty-Yes cases; the chief indication for disk surgery was intractable

sciatic pain.
MANAGEMENT OP RUPTURED INTERVERTEBRAL DISK 197

In Circular Letter No. 190, Army Service Forces, Office of the Surgeon

General, 17 November 1943, instructions were given for the careful selection

of patients with preinduction disabilities for elective surgery. Such operations were to be considered only for men with conditions which past experience had shown to be readily correctable and then only if return to

full military duty would be possible within a relatively short time. They

were not to be considered for defects which would require prolonged hospitalization or in which the liability of recurrence or failure was great.

This circular letter further pointed out that no individual with a preinduction disability was to be considered for elective surgery unless he gave

particular promise of being of future value to the Army from both the

mental and the physical standpoint. Herniated nucleus pulposus was listed

as among the preinduction defects in which surgery would not ordinarily

be justified.

Myelography.—Myelography was recommended for diagnosis and for localization of the disk lesion if clinical findings were not adequate for these

purposes. It was not to be performed, however, outside of neurosurgical

centers, to which patients were to be transferred for investigation and treatment only after a judicious selection.

Preliminary studies of the clinical reaction to Pantopaque had demonstrated its safety for clinical use, and subsequent experiences with it confirmed

the initial impression (fig. 87). The myelograms proved remarkably accurate in the more than 200 cases first investigated by this technique at the

FiouiiE 87.—Serial Pantopaque myelogram, with lumbar puncture

needle at L5, showing no abnormalities. Reading from left to right,

note smooth opaque column and symmetrical axillary pouches at L5, L4,

L4, and L3.
198 NEUROSURGERY

neurosurgical center at Walter Reed General Hospital. Spot films made

with a grid showed precise detail. Dural sleeves and axillary pouches were

usually completely outlined, and not infrequently the whole course of the

nerve root at each level could be shown. Use of this method therefore

became routine to verify the clinical diagnosis before operation was advised

and to localize the lesion accurately, so that, at operation, the removal of

the damaged disk could be accomplished with the least possible disturbance

of the weight-bearing mechanism of the spine (fig. 88).

Untoward reactions never followed the use of Pantopaque if it was removed immediately after the examination. If, for any reason, it could not be

completely aspirated, the reaction was no more serious than when Lipiodol was

used. The whole procedure, in the hands of an experienced neurosurgeon,

including the time necessary for the injection and aspiration of the Pantopaque, did not require more than 15 to 20 minutes.

It was the policy with Pantopaque, as with other contrast mediums,

not to attempt myelography until a week or more after diagnostic lumbar

puncture. Later, it became the policy not to remove the spinal fluid for

examination until after the myelogram.

Later Policies of Management

Statistical studies.—Statistical studies for the year 1943 indicated the

magnitude of the problem of herniated nucleus pulposus among Army personnel as well as the results of the policies then in effect (table 4). The

approximately 2,400 cases observed among enlisted and officer personnel in

the continental United States represented an admission rate of about 0.5 per

thousand strength for enlisted men and a slightly higher admission rate for

officers, who constituted about 11 percent of all patients hospitalized for

this cause.

TABLE 4.—Status, about 1 August 1944, of sample of patients admitted for herniated nucleus

pulposus in 1943

Enlisted personnel

Operations performed during 1943

Total cases in

sample

Still in service

1 Aug. 1944

Discharged

up to 1 Aug.

1944

Percent discharged

None _ _ _ __

Excision of herniated nucleus pulposus (including laminectomy) _

328

126

29

72

87

7

256

39

22

78

31

Miscellaneous or unknown 76

Total 483 166 317 66
MANAGEMENT OF RUPTURED INTERVERTEBRAL DISK 199

FIGUKE 88.—Pantopaque myelograms. A. Lateral view showing anterior defect in

opaque column at L4 and narrow lumbosacral disk. The lumbar puncture needle is at

L5. B. Serial myelogram showing defect characteristic of ruptured disk at L4 on left.

Lumbar puncture needle is at L5. C. Serial myelogram showing filling defect characteristic of lumbar ruptured disk at L5 on right. Lumbar puncture needle is at L4. D. Serial

myelogram showing minimal changes characteristic of lateral ruptured disk at L5. Note

that the axillary pouch at L5 is well shown on the right, while the one on the left fails

to fill. E. Myelograms showing large filling defect on left characteristic of tumor of

cauda equina. The neoplasm proved to be a neuroflbroma. F. Serial myelogram with

demonstration of filling defect (shown by arrow) at L3 as column progresses upward.

Note that the defect is obliterated when the third interspace is completely covered by

the opaque material. The lesion proved to be a ruptured intervertebral disk at L3.
200 NEUROSURGERY

The results of surgical treatment as analyzed in an approximately 20-

percent sample of these cases in August 1944 compared favorably with the

results of surgical treatment in civilian practice. The discharge rate of

31 percent for enlisted personnel treated by surgery compared very favorably

with the discharge rate of 78 percent for patients treated conservatively.

In a sample of 59 officers, 50 were still in service—32 who had been treated

surgically and 18 who had not. Nine (15 percent) had been discharged.

This separation rate corresponded quite well with the results at the neurosurgical center at Walter Reed General Hospital, Avhere less than 10 percent

of the officer personnel with ruptured intervertebral disks had been separated

from service for this reason.

These statistics seemed to indicate that the neurosurgical management of

herniated nucleus pulposus during 1943 had been effective in attaining the

major objective of all medical treatment of Army personnel, that is, rehabilitation of the patients for duty. On the other hand, although this

conclusion seemed fully justified, it had to be weighed in the light of two

highly favorable extraneous factors which were operative during 1943. The

first was the pressing need of the Army for manpower, as a result of which

there was considerable pressure on medical officers to expedite the return to

either full or restricted duty of all men capable of service. The second was

that the sample contained a relatively large group of officers, whose incentives for return to duty were greater than those of enlisted men and who

presented, therefore, few problems of rehabilitation.

The situation in respect to officers continued relatively favorable throughout the war. During the latter half of 1944, however, and the first months

of 1945, the whole picture of herniated nucleus pulposus underwent a considerable change. The story at the neurosurgical center at O'Reilly General

Hospital, Springfield, Mo., was typical. Early results of surgery were extremely encouraging. Later, they became less rosy. Some men who had been

returned to duty on a limited service status after a period of convalescence

were coming back with recurrent symptoms. Others who had been operated

on elsewhere were being referred to this center for evaluation. There was

no doubt, in short, that the results of surgery for ruptured disk in military

practice were by no means as good as they were in civilian practice. The

belief was also growing that practically all patients with ruptured disks,

whether or not the disability existed before induction, were likely to have

their symptoms aggravated by military service, and that line-of-cluty evaluation should therefore play practically no part in the decision for or against

operation.

War Department Circular No. 212, 29 May 1944, specified that if an

enlisted man could not "perform a reasonable day's work for the Army," his

retention was wasteful and he should be discharged. Many, if not most, of

the men operated on for herniated nucleus pulposus were covered by this

regulation, which was quickly reflected in the results of surgery. Increasing
MANAGEMENT OF RUPTURED INTERVERTEBRAL DISK 201

difficulty was experienced in accomplishing alleviation of symptoms, in contrast to the numerous good results formerly secured promptly.

An additional reason for the deterioration in surgical results was, paradoxically, the excellent reconditioning system which had been introduced.

However desirable it was in its general application, it proved ill adapted

to patients with low back disabilities. Practically all patients with disk

lesions responded unfavorably to it, and many of them had to be rehospitalized because their symptoms were reactivated. Similar observations were

made in the reconditioning centers in the United Kingdom Base.

To determine the then current status of patients with herniated nucleus

pulposus who had been operated on in 1948 (table 5), a reevaluation of an

approximately 20-percent sample was undertaken in March 1945 (table 6).

The proportion of discharges after surgery was found to have risen from

31 to 56 percent, while the total separations after surgery had risen from

66 to 83 percent. In all probability, these increases reflected not only the

influence of personnel requirements of the Army upon this special neurosurgical problem but also the actual inability of patients with this type of

lesion to Avithstand the difficulties and hardships of Army life.

Final Policy Changes

War Department Circular No. 209, 13 July 1945, took cognizance both

of the change in Army manpower requirements and of the long-term unsatisfactory results, at least from the military standpoint, of surgery for

herniated nucleus pulposus. In a more realistic approach to the problem,

the following policy was outlined for the management and disposition of

patients with this condition:

TABLE 5.—Cases of herniated nucleus pulposus {continental United States) operated on in

194S among approximately 20 percent of Army strength during that year

Total

Method of treatment

Cases admitted Excision or

laminectomy

No operation

450

62

8

133

39

4

3!7

23

4

Total -_ - - 520 176 344

1. All patients with a diagnosis of herniated nucleus pulposus established as not in line of duty were to be treated conservatively and then

separated from service in accordance with current military directives unless

they desired surgery for intractable pain or there was evidence of neural

paralysis.
202 NEUROSURGERY

TABLE 6.—Status, about February 1945, of cases, shown

in table 5 of herniated nucleus pulposus

Status Total

Enlisted men:

In service

Separated

Percent separated

Male officers:

In service

Separated

Percent separated.

Females:

In service

Separated

Percent separated.

Total:

In service

Separated

Percent separated.

90

360

80

44

18

29

5

3

38

139

381

73

Method of treatment

Excision or

laminectomy

No

operation

50

83

62

28

11

28

3

1

25

81

95

56

40

277

87

16

7

30

2

2

50

58

286

83

2. Military personnel who developed ruptures of the intervertebral disk

in line of duty were to be treated with the objective of achieving maximum

hospital benefit. Treatment was to be by conservative methods or, if the

patient desired it, by surgery. After maximum hospital benefits had been

attained, disposition was to be in accordance with current directives.

3. The "inherent repetitive character" of the syndrome of herniated

nucleus pulposus was to be closely examined in determining the line-of-duty

status in each individual case.

The Avar ended before the new policy could be put into effect and its

advantages and disadvantages tested.

DEVELOPMENT OF CLINICAL POLICIES IN OVERSEA THEATERS

The Mediterranean Theater of Operations

Early in the Tunisian campaign, it became apparent that operations

for ruptured intervertebral disk were, on the whole, not satisfactory in an

oversea theater. The immediate surgical results were usually good, but it

was difficult to get the men back to duty, and, if they could be returned,

difficult to keep them there. It therefore became the policy to evacuate men

with this condition to the Zone of Interior if they could not perform full or

limited duty in the theater. Operation overseas was permitted only in
MANAGEMENT OF RUPTURED INTERVERTEBRAL DISK 203

exceptional cases, and then only on written recommendation of the disposition

board of a general hospital.

In practice, this policy worked out so that operation was performed

overseas only in the following special circumstances:

1. The patient was in extreme pain, and the long delay entailed in a

return to the Zone of Interior would have worked considerable hardship on

him.

2. Pain, although intermittent and continuous, had not been relieved

by short periods of rest and was resulting in debilitation. The diagnosis of

ruptured intervertebral disk in this group of patients had to be absolutely

clear cut.

3. The patient was of particular value to the Army in the oversea theater.

4. The patient himself desired the operation, in order to be able to

return to his unit, in which his work would not be unduly strenuous.

When these various criteria were strictly observed, operation for ruptured disks in the Mediterranean theater usually gave good results.

The European Theater of Operations

It was originally the policy in the European theater to perform surgery

for ruptured intervertebral disk whenever it seemed likely that the patients

could be rehabilitated for duty. Operation was performed only in a general

hospital, only by a neurosurgeon, only after the chief of the orthopedic

service of the particular hospital had excluded (in a numerical listing)

all other conditions as possible causes of the symptoms, and then only after

approval by the theater senior consultant in neurosurgery or orthopedic

surgery.

Under these strict regulations, the number of surgical cases was small.

In June 1943, Col. Loyal Davis, MC, then senior consultant in neurosurgery,

reported that only 29 operations had been done in the theater up to that time;

11 patients had been returned to full duty and 5 to limited duty, but sufficient

time had not elapsed to determine end results. By March 1944, however,

it had become evident that only a small percentage of surgical patients

were likely to recover sufficiently, and within a reasonably brief time, to return to full duty.

Furthermore, as preparations for invasion of the Continent were intensified, the permitted period of convalescence for elective surgery was

reduced to 4 weeks at a maximum. Since disk lesions obviously could not

be handled under such a limitation, neurosurgeons in the theater were

instructed to operate for this condition only if the soldier was classified as

essential and then only if he could be expected to return to his former duties

without an unduly long convalescence. Patients who did not qualify for

surgery under these criteria were treated conservatively for a period of

about 2 weeks, and, if they had not responded satisfactorily to treatment by

the end of this time, were evacuated to the Zone of Interior.
Part II

PERIPHERAL NERVE INJURIES
CHAPTER IX

Historical Note

Barnes Woodhall, M.D.

PERIPHERAL NERVE INJURIES IN WORLD WAR I

The experiences of neurosurgeons with injuries of the peripheral nerves

in World War I were recorded at length and in a variety of ways. Although

the American experience was limited because of the relatively brief duration

of U.S. Army combat experience, there is a long, complete, and excellent

discussion of these injuries in the official history of the Medical Department.1

Huber's valuable neuropathologic studies are included in detail. The British

experience with peripheral nerve injuries appeared in the periodical literature

while the war was in progress, and an excellent and representative summary

by Platt and Bristow appeared in the British Journal of Surgery in 1924.2

The World War I experience and the lessons derived from it were also

recorded in a number of texts, the most important being those by Benisty,3

Tinel,4Stookey,5and Pollock and Davis.8Pollock and Davis' book was

well known to both general surgeons and neurosurgeons before the outbreak

of World War II, and during the war, it was destined to attain a high place

of respect and actual affection in the minds of military neurosurgeons.

It is extremely unfortunate that the official history of the U.S. Army

Medical Department in World War I was not made readily available to

military neurosurgeons in World War II. It should have been required

reading for them and for other military surgeons. It contains fundamental

information on peripheral nerve anatomy and on technical methods of

nerve exposure, mobilization, transplantation, and suture. Had they possessed

this fundamental knowledge, military surgeons untrained in neurosurgery

but required by the necessities of war to learn rapidly how to treat perii The Medical Department of the United States Army in the World War. Washington : Government Printing Office, 1927, vol. XI, pt. I, pp. 866-1283, passim.

2 Platt, H., and Bristow, W. R. : The End Results of Operations for Injuries of the Peripheral

Nerves. Brit. J. Surg. 11 : 535-567, January 1924.

3 Benisty, A. : Treatment and Repair of Nerve Lesions, edited by E. F. Buzzard. London:

university of London Press, Ltd., 1918.

4 Tinel, J. : Nerve Wounds. Symptomatology of Peripheral Nerve Lesions Caused by War

Wounds. Philadelphia : W. B. Saunders Co., 1922.

5 Stookey, Byron: Surgical and Mechanical Treatment of Peripheral Nerves. Philadelphia:

W. B. Saunders Co., 1922.

6 Pollock, Lewis J., and Davis, Loyal: Peripheral Nerve Injuries. New York : Paul B. Hoeber,

Inc., 1933.

207
208 NEUROSURGERY

pheral nerve injuries could have assumed these responsibilities more readily.

They could also have passed more readily to the more difficult problems of

nerve injuries associated with soft tissue, bone, and vascular injury; traction

palsy; the therapy of causalgia; and the perplexing management of neuromas

in continuity.

Policies of Nerve Repair

Theoretically, the advantages of prompt suture in peripheral nerve injuries had been fully recognized in World War I. Practically, because most

of these wounds were actually infected or there was good reason for believing that they would become infected, a policy of rather extreme conservatism had to be adopted. The majority of patients with peripheral

nerve injuries Avere treated in specialized centers in the Zone of Interior,

and definitive surgery was not, as a rule, performed until several months

after the injuries had been sustained, as will be pointed out shortly. An

additional reason for the postponement of definitive surgery was delay in

evacuation, which naturally was very much slower in World War I than

in World War II. The inevitably poor results of nerve suture under these

circumstances were reflected in numerous statements that battle casualties

with this type of injury were doomed, at best, to a mediocre functional

result. This feeling, which was essentially accurate for the period, persisted

well into the early years of World War II and was with difficulty replaced

by a more optimistic point of view.

Generally speaking, no important technical advances were made in the

surgery of peripheral nerve injuries in World War II with the possible

exception of the introduction of tantalum wire sutures and tantalum cuffs.

The striking improvement in results rested more upon a fuller appreciation

of the principles of nerve repair than upon mechanical or surgical advances

in technique.

Forward surgery.—During World War I, conditions in forward areas and

the pressure of work made it impossible to do more than emphasize the necessity of some sort of neurologic examination of every patient with a wound

of the extremities before any major debriclement was undertaken. When

this precaution was omitted, excision of presumably contaminated tissue in

the depth of the wound not infrequently led to accidental division of regional nerves.

If the neurologic examination produced evidence of nerve damage, it

was urged that the nerve be exposed in the wound; that a record be made

of the findings; and that, if the nerve were severed, it be sutured immediately. It was believed that this policy offered the best chances of restoration of function, but it could be employed only in isolated cases, in view of

the regulation forbidding primary wound closure during the active fighting

in the summer and fall of 1918.
HISTORICAL NOTE 209

Neurosurgical Centers

It was recognized in World War I that peripheral nerve injuries, by

reason of their complexity, demand the cooperation of the neurologist, the

"surgeon skilled in neurologic surgery," the orthopedic surgeon, and the

personnel of a well-developed physical therapy department. For this reason,

special centers were set up to which casualties with peripheral nerve injuries were to be sent. In all, 12 such centers were set up, though the

majority of patients were concentrated in 6.

Peripheral Nerve Registry

On 29 January 1919, in recognition of the complexities of peripheral

nerve injuries, The Surgeon General appointed a Peripheral Nerve Commission to correlate and study these injuries, which accounted for the majority

of neurosurgical casualties returned from overseas. In the confusion of their

return, many of these patients had been unavoidably scattered through general and base hospitals, and one of the first duties of the Peripheral Nerve

Commission was to see to it that they reached the specialized centers. On

the advice of the commission, the Section of Brain Surgery, Surgeon General's Office, printed and distributed blanks for a Peripheral Nerve Registry. Every patient with a peripheral nerve injury was examined and studied

according to this form, and duplicate copies were furnished to the Section

on Brain Surgery for the use of the commission as the patients were discharged. Commanding officers of all hospitals were instructed to recommend the transfer to specialized centers of all patients who were hospitalized

in nonspecialized hospitals.7

The 3,129 peripheral nerve registers which were filed in the Surgeon

General's Office represent between 80 and 90 percent of all the peripheral

nerve injuries for which surgery was done in U.S. Army hospitals in World

War I. It was hoped that the organization, which seemed ideal for the

purpose, could be maintained, so that a thousand or more neurorrhaphies

could be studied from the standpoint of long-term results. Unfortunately,

this hope was not realized.

Arrangements were not made for followup studies while the patients

were hospitalized. During 1919, the supervision of all patients who did not

require operative treatment was transferred to the U.S. Public Health Service, under the Bureau of War Eisk Insurance, and in 1921, the Veterans'

Bureau took over the care of the remaining patients who were then under

treatment or who were compensable.

The more than 3,000 operations recorded in the Peripheral Nerve Registry had been performed chiefly by skilled neurosurgeons, under almost

ideal conditions, with trained neurosurgical assistance and with supplemental physical therapy available. It is most unfortunate that these patients

7 Circular Letter No. 100, Surgeon General's Office, U.S. Army, 21 Feb. 1919.
210 NEUROSURGERY

could not be followed up, but dealing with three widely scattered governmental agencies proved an impossible task. The majority of followup examinations which were made were carried out by inexperienced personnel and

were correspondingly unreliable.

Timelag and End Results

It was the general practice at neurosurgical centers in World War I to

postpone operations for a minimum of 3 months after wound healing. Since

the majority of wounds were infected, the timelag was more nearly 4 to 8

months and sometimes even longer. A number of operations were performed after August 1919, in patients Avho for one reason or another, chiefly

overcrowding, had not passed through the neurosurgical centers. They were

discovered when they appeared for adjustment of compensation. At General Hospital No. 11, 31.5 percent of 400 patients were operated on by the

end of the fourth month, 41 percent by the end of the fifth or the sixth

month, and 15.5 percent by the end of the eighth month.

Only a few end results of peripheral nerve surgery were recorded in the

official history of the Medical Department in World War I.8In 496 operations, consisting of 350 neurorrhaphies, 132 neurolyses, and 14 transplants,

the best results were secured in surgery on the internal popliteal and mediun

nerves, in which there were, respectively, 92 percent and 86 percent of mediocre and good results. The highest percentage of failure, oddly, occurred in

operations on the musculospiral nerve, almost half of which were unsuccessful. The results in the ulnar and sciatic nerves were about midway between

these extremes, there being 70 percent good or mediocre results.

The generally poor results of neurolysis could be explained by the fact

that the military neurosurgeons of World War I had an insufficient knowledge of neuropathology.

8

See footnote 1, p. 207.
CHAPTER X

The Zone of Interior

Barnes Woodhall, M.D.

EARLY NERVE REPAIR

Principles and Rationale

The most important advance to come out of World War II in the management of peripheral nerve injuries in the Zone of Interior was, as elsewhere, the general application of the principle of early nerve repair. Even

before the entry of the United States into the war, experimental and histopathologic evidence had indicated that the optimum time for end-to-end

suture of severed nerves is between the third and the sixth week after injury.

Clinicians were slow to test these concepts on battle casualties, but eventually

the policy of extreme conservatism, which implies delay, was abandoned and

was replaced by a policy of prompt exploration, within a period of 21 to

90 days after wounding, of all nerve injuries in which there was the least

doubt that spontaneous regeneration was occurring.

This alteration in surgical principles and practice was based upon a

number of considerations, including (1) statistical evidence of a high incidence of nerve division in the early experience of the Mediterranean and

then the European theater, (2) absence of primary wound infection as the

result of the new plan of management of soft-tissue wounds, (3) pathologic

demonstration of what constitutes a neuroma in continuity, (4) the ease and

safety of nerve exploration in competent hands under local analgesia, and

(5) evidence that damaged nerves are likely to regenerate rapidly when they

are treated before degenerative changes occur in the distal nerve trunk.

Evidence substantiating the validity of early nerve repair continued to accumulate as studies of regenerating nerve injuries were recorded in the Peripheral Nerve Registry (p. 225).

Combined Injuries

A second major advance in the treatment of peripheral nerve injuries

in World War II resulted from a deeper appreciation of the influence of

soft-tissue, bone, and vascular injuries upon the timing of nerve repair and

the technical methods by which it was achieved. These injuries were frequent and serious, and it is surprising that so little attention was originally

paid to the possibility of improvement of results by their combined management.

211
212 NEUROSURGERY

In vascular injuries associated with nerve injuries, the factor of neural

ischemia, with its well-established pathologic sequelae, had to be considered

in relation to the usual crippling effect of the peripheral nerve injury alone.

The organization of three vascular centers in Zone of Interior general hospitals (Ashford General Hospital, White Sulphur Springs, W. Va., Mayo

General Hospital, Galesburg, 111., and DeWitt General Hospital, Auburn,

Calif.) was a partial solution of a problem which was never, unfortunately,

fully solved. The dramatic, lifesaving character of the therapy directed

toward the vascular component of the injury tended to submerge the real

significance of the less acute, but often more disabling, nerve injury. The

neuropathologic changes which occur in ischemia were well understood, but

this understanding, regrettably, was not translated, in any of the neurovascular centers, into a coordinated clinical study of these injuries. A real

opportunity was thus missed.

Combined bone and nerve injuries tended to progress satisfactorily and

rapidly when the professional talents of orthopedic surgeons and neurosurgeons were available on a combined ward. Coordination of effort along

these lines in Zone of Interior hospitals soon proved, beyond a doubt, that

nerve repair can be hastened and new approaches to joint problems discovered if a damaged limb is treated as a single structure rather than in terms

of its various isolated component parts. Progress in the coordinated attack,

it must be granted, was not as rapid as it should have been. It was sometimes confused, for example, by peering too closely at the femur and thus

losing sight of the gradual deterioration of muscle, nerve, and skin which

was occurring as the progressive result of nerve injury. Improvement was

eventually achieved by the enthusiastic pioneering of young orthopedic surgeons and neurosurgeons who worked as teams, as well as by constant emphasis upon the high priority of peripheral nerve injuries in neurosurgical

centers.

DIAGNOSTIC PROCEDURES

When the neurosurgeon deals with only a limited number of patients,

as he does in civilian practice, it is a relatively easy matter to carry out

deliberate and careful examinations and record the results. When, however,

the military neurosurgeon is confronted with the mass of peripheral nerve

injuries which are encountered in wartime and which must be treated under

military conditions, a very different situation exists. That is why there was

a steadily increasing tendency toward centralization of diagnostic methods

in so-called nerve laboratories in the Zone of Interior neurosurgical centers

in World War II (figs. 89 and 90).

An adequate heritage of knowledge concerning accepted methods of diagnosis of peripheral nerve injuries was available at the start of World War

II. Sensory patterns and supplementary motor movements had been thoroughly studied and were generally understood. The significance of Tinel's
ZONE OF INTERIOR

sign was fully appreciated. The techniques of simple manual examinations

were generally known, and possible errors and pitfalls based upon anatomic

variations were clearly recognized.

Not as much can be said for the more objective methods of neurologic

investigation. The reaction of injured peripheral nerve tissue to galvanic

and faradic stimulation was known, but this method cannot be considered

refined, and it was obviously not applicable to large numbers of casualties.

Moreover, testing had been officially made the responsibility of the physical

therapy departments in general hospitals, and examinations, as a result,

suffered from lack of standardization, as well as from the fundamental

defects inherent in a secondhand report of a study carried out by personnel

not responsible for the therapy to be based upon the results of the examination.

Other methods for recording electrical activity were still in the laboratory stage of development at the beginning of the U.S. participation in

World War II if they existed at all. These methods are all useful in identifying partial nerve lesions, detecting early regeneration, and permitting

quantitative estimations of recovery, and there was great need for them.

The war years were to see a steady (though individualistic and uncoordinated) effort in Zone of Interior hospitals to achieve progress in this

important field. Results were limited during the war, but they promised

to come to more complete fruition in the postwar era.1

One particularly important diagnostic effort was the determination of

the galvanic-tetanus ratio, which was developed and refined by Pollock and

his group,2under a National Research Council contract, and which was

studied intensively at the neurosurgical center at the Percy Jones General

Hospital, Battle Creek, Mich.

Another important advance was the observation by Richter3that, under

certain conditions, the area of increased skin resistance after section of a

peripheral nerve approximates the area of sensory loss. This observation

led to the development of a rapid and objective method for delineating

sensory patterns (fig. 91). A large number of studies by this method upon

1 The report of electrodiagnostic techniques and results in the followup study of 3,656 World

War II peripheral nerve injuries, edited by Barnes Woodhall, M.D., and Gilbert W. Beebe, Ph. D.,

and published in 1957, shows that this prophecy has been amply fulfilled.

2 (1) Pollock, L. J., Golseth, J. G., and Arieff, A. ,T. : The Use of Discontinuity of Strength

Duration Curves in Muscle in Diagnosis of Peripheral Nerve Lesions. Surg. Gynec. & Obst. 79:

133-141, August 1944. (2) Pollock, L. J., Golseth, J. G., and Arieff, A. J. : Use of Galvanic Tetanus

and the' Galvanic Tetanus Ratio in Electrodiagnosis. Arch. Neurol. & Psychiat. 54 : 317, October

1945. (3) Pollock, L. J., Golseth, J. G., Arieff, A. J., and Mayfleld, F. : Electrodiagnosis by Means

of Progressive Currents of Long Duration ; Studies on Peripheral Nerve Injuries in Man. Surg.

Gynec.°& Obst. 81: 192-200, August 1945. (4) Pollock, L. J., Golseth, J. G., Mayfleld, E., Arieff,

A. J., Liebert, E., and Oester, Y. T. : Spontaneous Regeneration of Severed Nerves. J.A.M.A.

134 : 330-333, 24 May 1947.

3 (1) Richter, C. P.: Sympathetic Innervation of the Skin: Experimental and Clinical Studies.

Arch. Neurol. & Psychiat. 48: 1028-1030, December 1942. (2) Richter, C. P., and Malone, P. D. :

Peripheral Nerve Lesion Charts. J. Neurosurg. 2 : 550-552, November 1945. (3) Richter, C P.,

and Woodruff, B. G. : Lumbar Sympathetic Dermatomes in Man Determined by the Electrical Skin

Resistance Method. J. Neurophysiol. 8 : 323-338, 1 Sept. 1945.
214 NEUROSURGERY

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ZONE OF INTERIOR 215

Form K8 K-10A

Date -I?...fee _1945 _

Name . Grade ..lY±1. Serial 1

Organization .Ui«.sgd.....J.nXt Date of injury .

1

.?..Juiy...l?44

Describe injury: Wound perforating moderate, middle l/3 of upper arm, caused by

shell fragment. (Right)

Debridement 7 hours

Secondary closure 15 August

Condition of wound:

"Wound healed 30 August 1944

Date of operation: 26 December 1944

Type of operation: Neurorrhaphy, radial nerve, right. Silk.

Name of surgeon: Lt. t. E. Cliffton, Vf.G.H.

Improvement since injury: No evidence of return of function radial nejrve. 10 Deo

(s«bj.m «id<w^UT.) jimp,. has b0(!r, no-j-etum 0f function since operation.

26 January 1945.

Definite return of function of the brechio-radialis

and Supinator and beginning function of the extensor carpi radialis. 30 Kay

, Definite return of function of muscles of Radial nerve

since operation. 26 June 1945.

Summary: VIA 17 July 1944 perforating noderate, middle 1/3 of upper arn,

caused by shell fragment. (Right) Debridement 7 hro. Secondary olosure 15

Aug. «ound healed 30 August 1S44. Neurorrhaphy 26 Dec. 1944, radial nerve.

There nas teen definite return of function of the brachio-radialis and Supinator end beginning function of the' extensor carpi radialis. 30 toy 1946.

There has been further return of function with definite contraction

of Extensors of the wrist. There is beginning return of sensation. 26 June

FIGURE 90.—Form used for examination of peripheral nerves (page 1).

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216 NEUROSURGERY

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ZONE OF INTERIOR 217

FIGURE 90.—Continued. Page 4 of form.

individual nerve divisions and the subsequent course of their regeneration

were carried out at the neurosurgical centers at Walter Keed General Hospital, Washington, D.C., Newton D. Baker General Hospital, Martinsburg,

W. Va., and Halloran General Hospital, Staten Island, JST.Y.

In the closing months of World War II, instruments for the determination of skin resistance were distributed to all neurosurgical centers, with

complete instructions for their use.4 At the same time, personnel from each

center were trained in the technique of electrodiagnosis at the neurosurgical

center at Percy Jones General Hospital.

The ideal of a simple, readily applicable battery of instruments for

objective nerve testing was an objective all through the war, but it had not

been completely achieved when hostilities ended. Hope that this effort would

continue in the postwar era was fostered by the ready acceptance by the

Army of a National Research Council project in this field, to be correlated

with the study of large numbers of regenerating nerve lesions in patients

under treatment in the hospitals of the Veterans' Administration.5

4 Richter, C. P.: Instructions for Using the Cutaneous Resistance Recorder or "Dermometer,"

on Peripheral Nerve Injuries, Sympathectomies, and Paravertebral Blocks. J. Neurosurg 3 181-

191, May 1946.

6 Woodhall, B., and Beebe, G. W. (editors) : Peripheral Nerve Regeneration. A Followup Study

of 3,656 World War II Injuries. Washington : U.S. Government Printing Office, 1957.
218 NEUROSURGERY

FIGURE 91.—Charts used in mapping areas of anesthesia or high electrical

skin resistance produced by peripheral nerve and other neurologic lesions

(modified from Richter and Malone). A. Upper extremity. B. Lower extremity.

NERVE GRAFTING

In the interim between World War I and World War II, nerve grafting had occasionally been carried out, but the only new and hopeful study

had been an experimental investigation of frozen dried homografts. Early

in World War II, plans were formulated for the development of a neurosurgical center at Walter Reed General Hospital, to which patients with

presumably irreparable nerve injuries should be referred for nerve grafting.

The experience at Cushing General Hospital, Framingham, Mass., to which

the program was transferred in 1944, is related elsewhere in this volume

(p. 493). At Walter Reecl General Hospital,6failure followed all eight homoG Spurting, E. G., Lyons, W. R., Whitcomb, B. B., and Woodhall, B. : The Failure of Whole

Fresh Homogenous Nerve Grafts in Man. J. Neurosurg. 2 : 79-101, March 1045.
ZONE OF INTERIOR 219

grafts. In the seven cases in which the grafts were later removed, the injury

was successfully repaired by end-to-end suture, supplemented by the methods of mobilization and transplantation which became standardized as the

war progressed. Among 26 nerve injuries referred to this center as irreparable, only 6 could not be repaired by the use of these techniques.7

Even at the end of the war, nerve grafting in man was still, for all

practical purposes, in the experimental stage. In no other field of peripheral nerve surgery had such auspicious results in the laboratory been followed by such dismal failures in clinical application. With the exception

of the successful autografting of small nerves, such as the facial and digital

nerves, and an occasional impressive instance of regeneration in frozen dried

homografts (p. 500), the record of nerve grafting in man was a practically

unbroken record of failures in World War II, as it had been in World War I.

MANAGEMENT OF CAUSALGIA

The syndrome of causalgia had been known since the Civil War, but

the successful therapy of this distressing condition dates from 1930, when

the first dorsal sympathectomy for causalgia of the upper extremity was

performed by Spurling.8The events of World War II proved that the

relief of causalgic pain secondary to combat-incurred peripheral nerve injuries can be achieved by an appropriate attack upon the sympathetic nervous system (p. 488).

NEUROPATHOLOGIC STUDIES

Very little knowledge concerning the intrinsic pathologic changes which

occur in peripheral nerve injuries was inherited from the experience of

World War I. A great deal of pertinent information was contained in the

protocols of Huber's animal experiments,9it is true, but it was not translated to human experience. The practical problem, therefore, which faced

neurosurgeons in neurosurgical centers in Zone of Interior hospitals in World

War II was the correlation of pathologic changes in damaged nerve segments with the extent of neural resection required before nerve suture could

be undertaken. There was also need for information concerning the effects

of traction and ischemia, as well as concerning changes characteristic of

lesions in continuity.

i Followup studios of peripheral nerve injuries by the Followup Agency of the National Research

Council developed by the Committee on Veterans Medical Problems in cooperation with the Veterans'

Administration, the Army, and the Navy, include 42 cases in which nerve grafting was performed.

In 12 instances, no secondary surgery was performed. In 10 instances, secondary surgery was

limited to exploration and lysis. In the remaining 20 cases, end-to-end anastomosis proved practical.

8 Spurling, R. G. : Causalgia of the Upper Extremity ; Treatment by Dorsal Sympathetic Ganglionectomy. Arch. Neurol. & Psychiat. 23 : 784-788, April 1930.

o Huber, G. Carl: Experimental Observations on Peripheral Nerve Repair. In The Medical

Department of the united States Army in the World War. Washington : Government Printing

Office, 1927, vol. XI, pt. 1, pp. 1091-1283.
220 NEUROSURGERY

Pathologic laboratories in Army general hospitals were too fully occupied with routine tasks to undertake special studies. The considerable mass

of gross material which was produced by an average of 6 neurosurgical

procedures daily at each of 19 or 20 neurosurgical centers could not possibly

be processed by available laboratory personnel in terms of frozen sections,

permanent sections, and photographic records. In addition, these laboratories

were not staffed or equipped for such highly specialized investigations.

The practical result of this combination of a deficit in fundamental

knowledge and a shortage of facilities and qualified personnel was reflected

early in World War II in a more or less total disregard by neurosurgeons

of intrinsic neural changes in damaged peripheral nerves, as well as by a

lack of comprehension of their significance. The statement can be made,

without qualification, that most neurosurgeons early in the war did not know

what they were suturing and whether the tissues they were uniting were

normal or damaged. In some centers, as a matter of fact, this fundamental

aspect of peripheral nerve surgery was not fully appreciated until the end

of the war. Operative notes mentioned "fibrous," "atrophic," or "normal

appearing" nerve ends, but correlation of clinical observations with adequately stained tissue specimens was for the most part missing.

In many neurosurgical centers, on the other hand, consistent efforts were

made as the war progressed to study the pathologic changes in nerve segments by one of two methods of approach. One was the use of frozen sections. The other was the more refined method of constant comparison of

gross findings with stained tissue slides. The potential as well as immediate value of permanent sections for comparative study during the course

of neural regeneration soon became evident. It also became equally evident

that only a trained histopathologist, devoting his entire time to the task and

furnished with special equipment, could possibly study the mass of material

available for investigation and thus increase the factual knowledge which

must underlie any clinical advance.

Tables of organization for general hospitals did not provide for a histopathologist with special training in neuroanatomy, and it was only by a

series of fortunate, entirely fortuitous circumstances that the services of Dr.

William E. Lyons, Associate Professor (now Professor) of Anatomy, University of California Medical School, Berkeley, Calif., could be obtained for

this purpose. In the spring of 1944, Dr. Lyons was commissioned captain

in the Sanitary Corps, U.S. Army. He had been admirably fitted by his

previous experience in high-altitude studies with the National Research

Council for his immediate mission, the application of the rapid freezingdehydration technique for the production and study of human nerve grafts.

His larger mission was the study of peripheral nerve injuries, particularly

the neuropathologic changes associated with them.

During the slow process of collecting the necessary equipment for the

nerve-graft studies, Captain Lyons began the study of correlating neuro-
ZONE OF INTERIOR 221

pathologic changes in damaged nerves with the progress of neural regeneration. The natural evolution of interest in this problem, as well as in nerve

grafting, inevitably led to the appearance of the neuroanatomist at the side

of the neurosurgeon in the operating room, to gather anatomic material and

to teach the neurosurgeon the facts of neuropathology. Data concerning

the history of the injury, the operative findings, and the gross and histologic

changes were assembled and were recorded by photography and photomicrography. Correlation of these observations with the progress of neural

regeneration was achieved through the Peripheral Nerve Eegistry (p. 225).

Eventually, a neuropathologic laboratory which approached the ideal in

organization was established at the Halloran General Hospital.

Early in the evolution of Captain Lyons' work, an accession number was

provided for his material, and the full facilities of the Army Medical

Museum were placed at his disposal by the director of the Army Institute

of Pathology. These facilities continued to be at his disposal even after

the transfer of his laboratory from its original location in Walter Reed

General Hospital to Halloran General Hospital. The clinical, pathologic,

and photographic source material derived from the nerve injuries studied by

Captain Lyons was later deposited in the Army Institute of Pathology (now

the Armed Forces Institute of Pathology) and was available for additional

and more detailed histologic study and for correlation with studies of clinical neural regeneration as it progressed in the patients followed up after

the war.

DISPOSITION

Evolution of Policies

It was recognized early in World War II that because convalescence

from peripheral nerve injuries is often prolonged, the efficient use of the

bed capacity of the general hospital system could quickly become impaired

if the hospitalization of these casualties were continued beyond the point of

definitive treatment. On the other hand, it was necessary to continue to

observe these patients beyond this time period. It was also desirable to

secure as much technical information as possible about these injuries during

the period of neural regeneration, when no active therapy was being carried out.

All of these considerations were reflected in the first directive issued

concerning the disposition of patients with peripheral nerve injuries. War

Department Circular No. 224, section IV, 21 September 1943, read as follows:

* * * Military personnel who have sustained injuries to the peripheral nerves will

not be discharged from the Army until the maximum degree of recovery has been

achieved. If otherwise qualified, such patients should be placed on a duty status which

permits them to perform work in accordance with their capabilities and be reexamined

at least every 3 months at the hospital where they were last treated for the nerve injury

until maximum recovery has been achieved and final disposition can be made.
222 NEUROSURGERY

Within a year after this directive had been issued, two very undesirable

situations had developed, as follows:

1. Although directives had been issued previously to the effect that

patients with peripheral nerve injuries should be treated in neurosurgical

centers in designated general hospitals, there still remained outside of these

centers a rather large number of patients whose nerve injuries had been

associated with bone or vascular injuries or both. Although these casualties

were given high priorities, at embarkation points, there had been a tendency

to concentrate on the vascular injury or the bone injury (p. 211) and a

failure to consider the injured extremity as a whole. Combined centers or

wards for the treatment of combined injuries had improved the situation

but had not solved the entire problem. Since the nerve injury was usually

basically responsible for the functional defect, it would have been wiser,

without delay, to have made the combined injury the responsibility of the

neurosurgeon.

2. War Department Circular No. 224 had apparently not been sufficiently explicit concerning the return of patients with peripheral nerve injuries to neurosurgical centers after 3 months of restricted duty status. As a

result, a considerable number of patients were being lost to observation.

War Department Circular No. 423, section II, 27 October 1944, made

mandatory the treatment of all patients with peripheral nerve injuries by a

neurosurgeon in a neurosurgical center. It also provided that—

* * * Military personnel who have sustained injuries to peripheral nerves will not,

if otherwise qualified, be discharged from the Army until maximum degree of recovery

has been achieved. Such patients will be placed on duty status which permits them to

perform work in accordance with their capabilities, and will be reexamined every 3

months until maximum recovery has been achieved and final disposition can be made.

In order to make sure that such patients actually appear for reexamination, they should,

at the time of disposition from hospital where they have received definitive treatment,

be ordered to return at the end of 3 months for reexamination at the nearest general

hospital specializing in neurosurgery. If, upon such reexamination, it is determined that

maximum recovery has not been achieved, they will again be ordered to present themselves at the end of another 3-month period for reexamination at the nearest general

hospital specializing in neurosurgery. This will be continued until maximum recovery

has been achieved.

This circular was later amended to provide that patients with peripheral

nerve injuries which required further surgical treatment should be returned

to the center in which definitive treatment had been initiated.

Final Disposition

The final disposition of patients with peripheral nerve injuries was

originally dependent in large part upon the need and demand for restricted

duty personnel. Few men who had suffered major nerve injuries could be

returned to full duty commensurate with the requirements of combat. During the year after the issuance of War Department Circular No. 423, on 27

October 1944, a large pool of men with peripheral nerve injuries was accu-
ZONE OF INTERIOR 223

mulated on a restricted duty status. They were of little value, since most

Army installations already possessed a sufficient number of restricted duty

personnel, and there were persistent demands from unit commanders to be

protected against the assignment of unusable personnel.

It was next thought that the disposition of these patients to the convalescent hospital system might provide a solution to the problem, but this

plan proved unsatisfactory from every standpoint. About the only justification for it was the enormous pressure for beds then being put upon the

neurosurgical centers. At one time, casualties with injuries of the peripheral nerves were sent directly to convalescent hospitals from debarkation

points, before their injuries had been evaluated. Their care was, of course,

inadequate, convalescent hospitals being totally unsuited for neurosurgical

care and observation. Moreover, since disposition of these patients was a

function of the convalescent hospital, all semblance of continuity of neurosurgical treatment was lost, and registration of these injuries in the Peripheral Nerve Registry was also ineffective.

Ninety-day work furlough.—The lack of demand for restricted duty personnel in the Army and failure of disposition of patients to the convalescent

hospital system to solve the problem of these casualties led to the introduction of the 90-day work-furlough plan. This plan, initiated at Cushing

General Hospital, was, as its name implied, a work furlough, during which

patients occupied themselves with useful civilian pursuits. The 90-day

period was sufficiently long for demonstrable changes in neuroregeneration

to occur and was also sufficiently long for the patient to perform some useful

labor and thus contribute to the solution of the manpower crisis then plaguing the country.

A patient with a peripheral nerve injury was regarded as eligible for

work under the following conditions: (1) If he did not require further

active or passive physiotherapy, (2) if he was able to use, in good measure,

some part of the injured extremity, (3) if there was indisputable evidence

of neuroregeneration, of either spontaneous or surgical origin, and (4) if the

patient was cognizant of possible injury to anesthetic areas and was able to

walk, for instance, for a reasonable distance without injury to such an area.

These criteria were applied in both postoperative cases and in cases in

which surgery was not required or was not planned within a month of the

beginning of the furlough.

A great deal of attention was paid to evaluation of the patient's temperament and of his attitude toward the prospective work before the furlough was granted. Psychoneurotics, neurasthenics, alcoholics, and other

emotionally unstable persons were promptly found to be unsuitable for this

kind of disposition. Their work record was irregular, they were sick the

greater part of the time, and they were a constant source of dissatisfaction

and actual irritation to their employers and in the organizations in which

they worked.

49S99r'—59 17
224 NEUROSURGERY

The process of granting the furlough after preliminary arrangements

had been made between the employer and the prospective employee was

carefully detailed. When the patient returned from the work furlough for

reexamination, every effort was made to expedite the general examination

and the evaluation of his neurologic status. If maximum hospitalization

benefits had not yet been achieved, he could often be returned to work on

the day of the examination. If, however, he was regarded as ready for some

type of final disposition, then he was admitted to the hospital, and disposition was carried outthrough the usual channels.

Postwar Disposition

With the ending of the war in Europe, the relation between the Medical

Corps officer and the neurosurgical patient assumed more and more of the

usual doctor-patient relation, quite uninfluenced by the pressure of emptying

hospital beds or of returning soldiers to duty in a fighting army. Under

the new circumstances, the previous definition of maximum hospital benefits

could no longer be considered realistic, since there was no longer any necessity to return men to limited service duty. The patients themselves were

eager to get back to their homes. The Army hospital system was in process

of reduction. Veterans' hospitals were in process of expansion.

To cover disposition to convalescent furloughs and to redefine the criteria of maximal hospital benefits in peripheral nerve injuries, Army Service Forces Circular No. 244 was issued 28 June 1945. In it the following

clinical criteria were outlined as guides for neurosurgeons in the management of patients with these injuries:

* ***** *

2. Eligibility of peripheral nerve injury cases for convalescent furlough or sick leave,

detached service, and transfer to convalescent hospitals is dependent upon the neurosurgeon's evaluation of the progress of regeneration, the necessity for supervised physiotherapy, and the patient's ability to care for himself without harm to his regenerating

nerve or jeopardy to his denervated extremity. The following points will be considered:

a. General condition of the extremity.

&. Requirement for further operation.

c. Necessity for physiotherapy other than that self-administered.

A. Favorable expectancy of nerve regeneration as evidenced by an intact suture

line, examined by X-ray when metallic sutures are used, descent in Tinel's sign, decrease

in muscle atrophy, alteration towards normal in electro-diagnostic tests, decrease in skin

resistance patterns, and the like.

e. Extent of the patient's insight into the potential hazards of his disability.

3. Maximal benefit of hospitalization is based on the following:

a. Those cases which have undergone operative repair or spontaneous resolution

must possess as a minimum, regeneration of the injured nerve to the point of innervation

of proximal musculature and to a steady diminution in the sensory loss of the involved

autonomous zone. In more distally placed injuries regeneration of the nerve to the sensory status described may be considered minimal evidence of regeneration.

&. No remediable deformity secondary to nerve injury should exist which can be

controlled or functionally corrected by physiotherapy and orthopedic or plastic rehabili-
ZONE OF INTERIOR 225

tation measures with the exception of distal deformities, such as opponens or extensor

hallucis longus paralyses which may require prolonged observation prior to reconstructive

surgery.

c. Irreparable nerve injuries must have been considered for orthopedic and plastic

rehabilitation measures and such measures completed or rejected.

d. In cases where other conditions are associated with peripheral nerve injuries,

the above criteria are the minimum to be met prior to disposition.

PERIPHERAL NERVE REGISTRY

For all practical purposes, as indicated elsewhere (p. 207), the knowledge relating to the biologic and technical factors of nerve repair and regeneration which might have stemmed from the experience of World War I

was almost completely lost. It was fortunately realized sufficiently early in

World War II that the great mass of military neurosurgical data concerning

peripheral nerve injuries would be similarly lost if an integrated effort were

not promptly made to preserve them. The outcome of this effort was the

formal establishment by The Surgeon General 22 November 1944 of the

Peripheral Nerve Registry.10

Early records.—In March 1943 Maj. (later Col.) R. Glen Spurling, MC,

then Consultant in Neurosurgery, Office of the Surgeon General, requested

The Surgeon General to authorize a form to be used by all hospitals overseas and in the Zone of Interior for the uniform recording of peripheral

nerve injuries. It was realized then that these injuries would be among the

major surgical problems of the war, and at that time no special arrangements

had been made to care for them. In October 1943, Major Spurling noted in

his official diary that the problem was still unsolved.

After consultation with Maj. (later Lt. Col.) Barnes Woodhall, MC,

on 1 March 1944, Colonel Spurling addressed a memorandum to Brig. Gen.

Fred W. Ranlrin, Chief Surgical Consultant, Office of the Surgeon General,

concerning the collection of neurosurgical data by means of central registries, similar in scope to the bone tumor registry and the Cushing brain

tumor registry, which had proved so effective in civilian life.11 The suggestion was made for two reasons: (1) That if new techniques of treatment

were developed, accurate and reliable conclusions could be more readily

drawn from accumulated material, and (2) that historical material would

thus become available to be recorded after the war. As an example, it was

suggested that all neurosurgical centers in the Zone of Interior should submit

once a month to the chief of neurosurgery at Walter Reed General Hospital

the identification and pertinent clinical data for all patients with peripheral

nerve injuries treated during the month. Eventually, all followup observa10 Letter, Brig. Gen. Edward F. Witsell, Acting The Adjutant General, to commanding generals,

all service commands and the Military District of Washington, 22 Nov. 1944, subject: Peripheral

Nerve Injury Eeport (Control Approval Symbol MCR-118), SG Form 941.

11 Letter, Lt. Col. R. G. Spurling, to Brig. Gen. Fred W. Eankin, Chief Surgical Consultant,

Office of the Surgeon General, 1 Mar. 1944, subject: Collection of Clinical Data of Neurosurgical

Interests Relative to War Casualties.
226 NEUROSURGERY

tions on all peripheral nerve injuries would find their way into this central

registry.

In the discussion of this plan, it was pointed out that the introduction

of tantalum as a suture and sheathing material was representative of the

type of advanced methods which required evaluation by regimented studies.

It was also pointed out that the data on the registry forms could be utilized

as a cross section of the technical dexterity of participating neurosurgeons,

many of whom were encountering for the first time the problems inherent

in combat-incurred peripheral nerve injuries and their repairs.

Establishment of Registry.—The directive setting up the Peripheral

Nerve Eegistry provided that forms be prepared for all patients with peripheral

nerve injuries treated by nerve suture or nerve grafting, a separate form

being prepared for each major nerve involved (fig. 92). The forms were

to be sent to the Surgical Consultants Division, Office of the Surgeon General

(1) immediately upon completion of the operative procedure; (2) as of the

90th, 180th, 270th, and 360th day of the patient's hospital stay, whether

during the course of the first admission or any readmission; and (3) upon

his final disposition from the hospital, whether on the first admission or a

readmission.

On 18 April 1945, additional instructions were issued to aid in clarification of assessments of these individual injuries.12

Originally, it had been planned to register new cases of peripheral nerve

injury only until 1 May 1945. In April 1945, the duration of the registry

was extended to 31 December 1945. With the end of the Japanese phase of

the war in August 1945, the necessity for an extension of such length disappeared, and on 12 September 1945, instructions were issued to end the

registration of new cases as of 1 October 1945.13 Assessments of nerve injuries already registered were to be continued until the 360th day of hospitalization, or until earlier discharge, for all patients for whom an original

Eegistry form had been submitted before this date.

At first, the Eegistry was maintained only in the general hospitals in

the Zone of Interior designated for the care of neurosurgical casualties.

Later, it was extended to oversea hospitals. The maintenance of the Eegistry was made the responsibility of the neurosurgical staffs of the participating hospitals, and approximately 85 neurosurgeons cooperated in the task.

Objectives of Registry.—The objectives of the Peripheral Nerve Eegistry

were limited. It was restricted to a compilation of nerve sutures and nerve

grafts. These operations were performed only in injuries which were complete and in which the study of regeneration would therefore be unqualified.

The Eegistry was designed for specialized studies going beyond the data

required by Medical Department requirements. Its accuracy depended upon

12 Letter, Maj. Gen. J. A. Ulio, The Adjutant General, to commanding generals, all service commands and the Military District of Washington, 18 Apr. 1945, subject: Peripheral Nerve Injury

Report (Control Approval Symbol MCR-118) SG Form 941.

13 Letter, Maj. Gen. Edward F. Witsell, Acting The Adjutant General, to commanding generals,

all service commands and the Military District of Washington, 12 Sept. 1945, subject: Peripheral

Nerve Injury Report (Reports Control Symbol MCR-118) SG Form 941.
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228 NEUROSURGERY

careful observations recorded by trained neurosurgical personnel. Often,

because of the pressure of work in combat areas and the large amount of

paperwork necessary in all military hospitals, there were omissions.

The special form used (fig. 92), although necessarily detailed, was kept

as simple as possible. A registry designed to record a potential reservoir of

many thousands of cases naturally could not be devoted to minutiae. The

recording of such very detailed data is a task for individual observers studying limited numbers of cases in personal series.

Analysis of Data

As cases were accumulated in the Registry,14 significant samples, ranging

in number from 450 to 469, were analyzed by various methods. The period

of observation in all cases analyzed ranged from 3 to 12 months. The results

secured in 649 cases analyzed by statistical methods were compared with

results of two groups of cases analyzed by a single individual (hand analysis). The first of these groups consisted of 450 cases. The second, which

included the 450 cases first analyzed, consisted of 602 cases. The results in

these hand-analyzed cases showed remarkably close correlation with the 649

cases analyzed by the statistical methods employed in the evaluation of all

Registry cases.

The following conclusions were drawn from these various analyses:

1. The proportion of failures was far greater when nerve suture was

performed at the time of debridement than when it was deferred until after

delayed wound closure. These data fully substantiated the directives which

had been issued during the war recommending that at debridement, surgery

on the damaged nerve should be limited to coaptation or simple protection

of divided nerve ends. The number of cases of primary nerve suture was

of course small, but the evidence clearly pointed to the dubious value of this

procedure.

2. Pathologic studies of Registry cases in which coaptation suture had

been performed showed without much doubt that if such a suture was properly applied, it did not increase neural damage at the point of severance or

in either segment, while, at the same time, it maintained the nerve in its

normal anatomic plane and prevented retraction of the ends.

3. Failures in nerve suture performed after delayed wound closure were

not frequent. They could be traced to two main causes, as follows: (1)

Inept surgical technique and (2) inadequate mobilization, or no mobilization

at all, of the extremity after nerve suture. In 9 of 16 suture-line disruptions

in one of these analyses, for instance, the failures were directly attributable

to improper mobilization of the extremity. In 17 neuromas of the suture

line encountered in this analysis, it was possible to demonstrate the adverse

effects of infection, intraneural sutures, tension on the suture line, unwise

w Woodhall, B., and Lyons, W. E.: Peripheral Nerve Injuries. I. The Results of "Early"

Nerve Suture : A Preliminary Report. Surgery 19 : 757-789, June 1940.
ZONE OF INTERIOR 229

selection of suture material, and inadequate resection of damaged nerve ends.

There were also several failures in which errors in identification of nerve

tissue again emphasized the importance of concentrating nerve injuries in

neurosurgical centers for care by well-trained neurosurgeons. Another significant finding in the 602 hand-analyzed cases was the far larger number of

failures in advanced units (22.4 percent) as compared with the number of

failures in general hospitals (5 percent).

4. These cases indicated that nerve grafting was still a laboratory procedure unless it was limited to small nerves, such as the digital or facial

nerves. It should not be regarded as a part of early nerve suture.

5. This analysis also clearly indicated the importance of detailed operative records and progress notes in peripheral nerve injuries. In the absence

of positive evidence of regeneration, lack of positive data concerning the

earlier procedure was a logical indication for secondary intervention.

6. In the first 450 cases analyzed by hand, 345 patients showed some

degree of regeneration over periods covering from 3 to 12 months after operation, while 53 showed no evidence of regeneration. In 17 of the 53 apparent

failures, the poor result could be explained by suture failure and in 2 others

by failure of the graft.

The period of investigation, with 12 months as the maximum, while it

was too short for the assessment of full nerve regeneration, was sufficient to

show the trend of normal nerve growth. It was also ample to make frank

failures manifest. From the standpoint of timing, the 44 failures which

occurred in 602 cases analyzed by hand fell into 3 groups, as follows:

In 16 cases, repair was done at the time of debridement.

In three cases, repair was done at the time of delayed wound closure.

In 16 cases, repair was done shortly after delayed wound closure.

In the remaining nine cases, the failures were ascribed to causes which

bore no relation to the time at which repair was done.

Addendum

By September 1945, 7,050 nerve sutures and 67 nerve grafts had been

recorded in the Peripheral Nerve Kegistry (apps. E and F, pp. 611 and 633).

The data varied greatly in detail and accuracy, chiefly because the Eegistry

was a hurriedly planned wartime project, without careful prewar planning.

Of the many difficulties inherent in the appraisal of neural regeneration in

these injuries, not the least was the prolonged time interval which must

elapse before regeneration can be fully assessed. The duration of the war,

however, as well as the duration of hospitalization in many of the cases

studied, permitted fairly adequate observation during the early months of

nerve regeneration.

The average period of observation, on the other hand, was only 12

months, a period entirely inadequate to determine the end results of surgery.

Had observation ended there, the World War II experience would have been
230 NEUROSURGERY

lost as hopelessly as the World War I experience was lost. Fortunately, the

situation was quite different. The Conference on Postwar Kesearch was

called by the National Kesearch Council in 1946 and was followed by a

Peripheral Nerve Conference in January 1947. The plan for a followup

project on peripheral nerve injuries was submitted to the Veterans' Administration, through the Committee on Veterans Medical Problems of the

National Eesearch Council and was recommended for financing in March

1947. Final planning was completed in November 1947.

The Veterans' Administration medical monograph entitled "Peripheral

Nerve Regeneration—A Follow-up Study of 3,656 World War II Injuries,"

was published in 1957. The 2,554 men in whom these injuries occurred were

followed up for a median period of 52 months. The cases are analyzed from

a wide variety of viewpoints, varying from the timelag between wounding

and operation to the training of the neurosurgeon who performed the

operation.

The author of one of the forewords to that volume, Doctor Spurling,

who served as Senior Consultant in Neurosurgery, Office of the Chief Surgeon, Headquarters, European Theater of Operations, U.S. Army, wrote as

follows concerning it:

Every man, woman, or child who has seen war and its aftermath will hope prayerfully that the opportunity to study such large masses of battle casualties as are represented in this volume will never again occur. But, should future generations be faced

by a similar catastrophe, this monumental work on peripheral nerve regeneration will

ease the task of those who must care for these injuries and will assure the victims of

another war better functional results than our generation of neurosurgeons has been

able to achieve.

In other words, the significance of this volume on peripheral nerve

regeneration is that the experience of World War II in the management of

peripheral nerve injuries, unlike the experience of World War I, has not

been lost.
CHAPTER XI

The Mediterranean (Formerly North African)

Theater of Operations

EldridgeH. Campbell, Jr., M.D.1

EVOLUTION OF POLICIES

At the beginning of the North African campaign, in the winter of 1942,

neurosurgical policies and practices in this theater were those recommended

by the National Research Council, which were essentially those in effect at

the end of World War I. These recommendations were to let severed peripheral nerves strictly alone and not to undertake repair until several months

after wounding. In line with this policy, the early repair of peripheral

nerve lesions was not encouraged in the Tunisian campaign of 1942-43.

Even had the burden of surgical work been less, no other program would

have been feasible at this time, for the management of soft-tissue wounds

had not yet been stabilized. By the spring of 1944, however, delayed primary

closure of soft-tissue wounds was an established policy in the theater and

was followed by sound healing in practically all cases.

In the meantime, the results of occasional neurorrhaphies performed soon

after wounding seemed highly promising. One such operation was performed

at the 26th General Hospital, Bizot, Italy, by Maj. Lyle A. French, MC,

in June 1943. At about the same time, Maj. (later Lt. Col.) Henry G.

Schwartz, MC, discussed his experiences at the 21st General Hospital with

four peripheral nerve injuries followed by causalgia and successfully treated

by neurolysis alone or by resection and suture with neurolysis. The first of

these operations was done in April 1943. In discussing them, Major Schwartz

said: "Granting that professional skill is available and the indications exist,

we raise the question whether any fixed time interval for nerve repair should

be laid down."

PRIMARY REPAIR OF PERIPHERAL NERVE INJURIES

The whole question of management of peripheral nerve injuries was discussed at a meeting of neurosurgeons called 23 May 1944 by Col. Edward D.

1A consultant in neurosurgery was never formally appointed in the Mediterranean theater.

When the need arose, Dr. Campbell, then a lieutenant colonel in the Medical Corps, represented the

consultant in surgery to the Theater Surgeon. Gaps in this chapter are due to this fact; they

could not be overcome because of Dr. Campbell's death while the history was in preparation.

231
232 NEUROSURGERY

Churchill, MC, Consultant in Surgery, Office of the Surgeon, Headquarters,

North African Theater of Operations, U.S. Army.

The advantages of primary repair of injured nerves, which was discussed in detail at this meeting, were fully recognized, but it was generally

agreed that they were outweighed by the disadvantages of this policy, among

which were the following:

1. Past experience had shown that primary nerve repair was entirely

impractical in military surgery during rush periods. It was a time-consuming operation, and it could be performed only by experienced neurosurgeons,

whose time, when high priority casualties were numerous, could be more

profitably occupied in lifesaving procedures.

2. Some patients were in such poor condition that they could not tolerate any but the most urgent procedures at the initial operation.

3. The results of primary repair were likely to be poor unless the operation was limited to wounds in which closure of the deep fascia would be

satisfactorily achieved. Closure of the skin was not necessary.

4. The incidence of infection was appreciably greater when immediate

suture was done in nerve injuries associated with compound fractures.

5. It was not easy at the first operation to determine how far pathologic changes might ultimately extend from the point of injury.

6. Lack of success was likely to be attended with serious consequences.

Neuromas were almost inevitable under the circumstances, and additional

length was lost by the additional resection necessary at secondary procedures.

Moreover, failure might not be detected for many months, during which time

all chances of successful repair might be lost.

In spite of these sound arguments, primary nerve suture was made permissive in certain carefully selected cases. The experience at the 15th Evacuation Hospital is probably typical of the small number in which it was

employed. Definitive repair was originally thought to be possible in 92 of

168 nerve injuries in 150 casualties. It proved feasible in only 52 of the 92;

23 of these injuries were complete. After painstaking debridement of each

wound, which consumed an average of 1% hours, the instruments were completely changed, and the damaged nerve was repaired. Local chemotherapy

was not employed, but all patients received sulfadiazine by mouth. Later,

when penicillin became available, it was used instead of sulfadiazine.

Immediate results were good. In the 10 to 14 days after operation

during which these patients were under observation, only 3 instances of

imperfect healing were described in the 52 injuries, all under the terms

"late type," "mild," "noninvasive infection." The first followup observations,

in 12 patients, were equally optimistic. Satisfactory recovery of function

was apparently occurring in every instance. The experience was cited as

showing what could be accomplished by primary nerve suture performed

under auspicious circumstances by experienced neurosurgeons. The first observations, however, were admittedly casual, and long-term results did not
MEDITERRANEAN THEATER 233

bear out the original optimism. Eventually, half of the operations were

classified as failures.

The general experience of the Mediterranean theater indicated that the

policy of primary nerve suture is unlikely ever to have a wide application

in military surgery. The most that can be said for it is that when evacuation hospitals have long periods of relative inactivity, as sometimes happened in World War II, competent neurosurgeons may be permitted to

employ the operation in favorable, carefully selected cases.

EARLY NERVE SUTURE

At the meeting called in May 1944 to discuss the management of peripheral nerve injuries, it was agreed that, under military conditions, the best

policy for general use would be inspection of the damaged nerve at the time

of initial wound surgery or delayed primary wound closure, with nerve

repair a few weeks later. This policy was at once disseminated to all neurosurgeons in the theater, and the new program was undertaken on as wide a

scale as the burden of work permitted.

Principles and Techniques

Certain aspects of the new program were promptly found to be important, as follows:

Records.—It was essential that records contain a concise but complete description of the observations made on the injured nerve at either initial or

reparative surgery, preferably supplemented by a diagram which made clear

whether the nerve was intact, partly or totally divided, wedged, or otherwise damaged. If a segment had been destroyed, the length of the defect

was to be estimated, to assist in planning for subsequent repair.

Accurate knowledge of the structural defect was prerequisite to sound

future treatment and accurate prognosis. If, for instance, a nerve which

was still paralyzed at the end of 1 or 2 months was exposed and found

intact, obviously another 4 to 6 months must be allowed to elapse before

hope for spontaneous recovery was abandoned. If, on the other hand, operation was withheld on the erroneous assumption that the nerve had not been

divided when it really had been, much valuable time would be lost and the

ultimate functional result might be seriously prejudiced.

Visualization at initial wound surgery.—It would, of course, have been

highly desirable to visualize the nerve lesion in all cases as promptly as possible; that is, at initial wound surgery. In spite of the interest and wholehearted cooperation of forward surgeons in the program, it proved impractical to identify the damage at this time, and therefore to describe it, in

more than half of all cases. In most instances, the omission was of no great

consequence, since the desired data could be obtained at the reparative operation in a general hospital 4 to 10 days later, usually with little additional

dissection or retraction.
234 NEURO SURGERY

Exploration at reparative surgery was not attended with any risk in

the absence of inflammation. If inflammation or infection were present,

exploration was obviously contraindicated. In 55 consecutive operations at

the 33d General Hospital in the early days of the new program, visualization

of the injured nerve was carried out at the reparative operation with no

lighting up of infection, and there was no evidence of increased fibrosis in

any of these cases when neurorrhaphy was performed several weeks after

the initial operation.

Management of nerve at initial wound surgery.—During World War I,2

it had been suggested that severed nerve stumps be stitched together at the

first operation, to prevent retraction, and this was done in a number of instances in the Mediterranean theater in the first months of the new peripheral nerve program. The value of this technique was highly debatable.

When the nerve ends were examined at neurorrhaphy 3 to 8 weeks later,

swelling frequently seemed to be more massive and more extensive than in

cases in which preliminary suture had not been done. Eetraction of the

ends had been prevented, it is true, but the impression was gained that, at

least in a number of cases, longer segments had to be resected before healthy

neural tissue was reached than was necessary in cases in which suture had

been omitted at the first operation. The result was that the gap to be overcome was not only no less than it might otherwise have been, which was one

of the objectives of preliminary suture, but was actually greater. Deeply

placed sutures, the resulting tension, and the drawing of the nerve into a

more exposed position within the wound may all have contributed to these

changes. Exposure of the nerve seemed to be particularly undesirable; it

was observed on numerous occasions that portions of nerve stump exposed

in the wound were considerably more reddened and swollen than other portions which, although they had been loosened within the wound bed, were

covered by muscle.

For these reasons, makeshift suturing of divided nerves was not recommended, though the use of one or two fine silk epineurial sutures to anchor

the nerve ends was permissible at debriclement. It was strongly recommended that the nerve be protected with adjacent muscle or subcutaneous

tissue at the first operation.

The local application of sulfonamide drugs was advised against, not

only because of their reputedly irritating effect upon neural tissue but also

because of the policy, which had by this time become general in the Mediterranean theater, of not introducing bacteriostatic or bactericidal substances

into wounds. Penicillin had become available by the time the program was

fully operative, and its routine administration was advised, in dosages of

25,000 units every 3 hours by the intramuscular route.

2 The Medical Department of the United States Army in the World War. Surgery. Washington : Government Printing Office, 1927, vol. XI, pt. 1, pp. 866-1283.
MEDITERRANEAN THEATER 235

A plaster splint, to include both adjacent joints, was also advised, to

secure maximum rest for the part and to reduce nerve retraction.

Timing.—The optimum time for the repair of the damaged nerve was determined by correlation of the pathologic process in the nerve with the

progress of healing in the soft-tissue wound. In the usual case, progress was

as follows:

1. When the nerve was visualized at initial wound surgery or at delayed

primary wound closure, 4 to 10 days after injury, the nerve ends were friable

and edematous.

2. By the end of the second or third week after delayed primary wound

closure, epithelization of the wound was complete, and organization of the

underlying cicatrix was well advanced. If for any reason the wound had

to be reopened during this period, vascularity was usually found to be rather

pronounced. If the wound was large, areas of induration and edema were

likely to be found both in it and about it. The nerve ends were usually

swollen and rather friable, as at the reparative operation.

3. By the fourth week after wounding, adjacent tissues had usually

become reasonably soft. Edema was likely to be minimal. Vascularity was

still somewhat excessive, but fibrosis within the wound had not progressed

to the stage at which dissection was difficult. Edema within the nerve trunks

had for the most part subsided if it had not actually disappeared.

On the basis of these observations, the fourth or fifth week after successful delayed primary wound closure was usually regarded as the optimal

time for nerve surgery. If, however, the nerve injury was complicated by a

fracture, operation was deferred until stability had developed as the result

of callus formation or had been achieved by internal fixation.

It would have been highly desirable to perform nerve repair in Zone of

Interior hospitals rather than in the theater, but this was not practical.

Because of associated injuries which made them nontransportable, as well as

because of delays in evacuation and for other reasons, many patients could

not have reached the United States until several months after wounding.

If, therefore, one of the important considerations of the new program, the

prompt performance of nerve surgery, was to be realized, nerve suture had

to be carried out overseas whenever it could be accomplished.

Resection of damaged neural tissue.—One of the first things that a military neurosurgeon had to learn was that the extent of resection of damaged

nerve tissue differed in civilian and military practice. In civilian practice,

it had long been established technique to cut the injured nerve ends back

to the point at which transected fasciculi stood out sharply. In wounds

produced by high-velocity missiles, however, conservative resection was not

sufficient. Early in the program, it became evident that epineurial fibrosis

appeared within a few days of wounding and was far more extensive than

in civilian-type injuries. It was most pronounced within the first centimeter

on either side of the injury, but it extended backward, although to a lesser
236 NEUROSURGERY

degree, for several additional centimeters. Careful inspection of the neural

tissue was necessary, for grossly normal nerve bundles were likely to be

encountered for a considerable distance before normal epineurium was

reached. On the other hand, if resection were carried back to normal epineurium, the surgeon might find himself confronted with a gap that seemed

insurmountable. The decision was often delicate, for many failures could

be attributed to clearly inadequate resection of damaged nerve tissue.

Nerve suture.—Approximation of the severed nerve ends was best accomplished by the well-established method of end-to-end anastomosis with epineurial sutures of fine silk, care being taken to avoid tension and rotation.

Transneural stay sutures were not used because of the risk of subsequent intraneural scarring. The placing of radiopaque sutures in the epineurium on

either side of the anastomosis was recognized from the beginning of the

program as a desirable and dependable method of facilitating detection of

postoperative distraction, but tantalum wire was not then available to carry

it out.

In the Mediterranean theater, anastomoses were not protected by either

tantalum foil or fibrin film. Convincing evidence of the effectiveness of these

techniques in preventing fibroplasia had not yet been adduced, and some

reports suggested that scar formation might actually be increased when they

were used. So far as was known at the time, the best bed for a sutured

nerve was a plane of clean, dry, scar-free, living tissue.

Management of extensive injuries.—Injuries in which there was extensive loss of nerve tissue presented special technical problems. Not infrequently, particularly in large avulsed wounds, long segments of nerve trunk

had been destroyed, and a large gap remained, even after extensive mobilization of the nerve ends above and below the lesion, flexion of adjacent

joints, or nerve transplantation. The use of nerve grafts was not regarded

as warranted; reports concerning them had been extremely disappointing.

In many instances, therefore, sufficient length for repair could be gained

only by bone shortening, a procedure which had been known for many years

but which had not previously been generally used. It proved practical and

not at all difficult. Observations on six patients at the 33d General Hospital

in the early phase of the nerve repair program indicated that the loss of 1

or 2 inches of the shaft of the intact humerus interferes only very slightly

with subsequent function. In any event, it was believed to be a small price

to pay for functional recovery in, for instance, a median nerve injury.

When compound comminuted fractures were associated with extensive

nerve injuries, shortening of the humerus was carried out either at the time

of delayed primary wound suture or 4 or 5 weeks later, when the nerve was

repaired.

Splinting.—While some support of the injured nerve was necessary after

wounding and after reparative nerve surgery, prolonged fixation was highly

undesirable and actually harmful; fingers and wrists readily became stiff and
MEDITERRANEAN THEATER 237

even frozen. Braces were of little or no value except in wristdrop or footdrop. Aside from the other undesirable features of more complicated apparatus, splints which combined simplicity of design with lightness and elasticity were the most useful kind for an oversea theater. An entirely desirable

splint did not become available during the war.

STATISTICAL DATA

Accurate determination of the incidence of peripheral nerve injuries in

the Mediterranean theater proved difficult. In forward areas, the heavy

burden of work, particularly the necessity for focusing attention upon the

salvage of life and limb, made it virtually impossible to record or even identify all cases, while the fact that many paralyses were transient possibly

vitiated some of the diagnoses made at the base. The incidence, however,

was thought to be somewhat higher than the 2-percent incidence estimated

for World War I.8 Data available during the war suggested that 5 to 8

percent was a more reasonable estimate for nerve injuries in World War II.

Peripheral nerve repair was more frequently applied to injuries of the

upper extremity than of the lower (table 7), one reason being the large

number of vascular injuries associated with nerve injuries in the lower extremity (p. 439).

TABLE 7.—Anatomic distribution of 1,184 peripheral nerve injuries in 1,121 casualties treated

in 3 hospitals in the Mediterranean Theater of Operations

Ulnar

Radial

Median

Perineal

Sciatic

Brachial plexus

Tibial

Femoral

Saphenous

Axillary

Musculocutaneous_

Not specified

Total injuries.

15th Evacuation Hospital

(150 casualties)

46

43

37

6

21

14

1

168

33d General

Hospital (592

casualties)

161

130

84

83

51

36

18

20

12

6

1

4

606

26th General

Hospital (379

casualties)

125

62

55

40

25

52

17

3

8

14

410

Total

injuries

332

235

176

129

97

102

36

29

12

9

9

18

1,184

Type of injury.—About half of all peripheral nerve injuries encountered

in the Mediterranean theater were incomplete. Capt. (later Maj.) Donald

H. Wrork, MC, in reporting on a series of 143 nerves inspected at initial

3 See footnote 2, p. 234.
238 NEUROSURGEKY

wound surgery, stated that 58 were completely severed, 34 were partly severed, and 51 were lesions in continuity. These observations are in substantial

agreement with observations at the 33d General Hospital.

The large proportion of incomplete nerve injuries, in which only neurolysis was necessary, further emphasized the importance of a clear record,

preferably supplemented by a diagram, of the status of the injury as surveyed

at primary debridement or reparative surgery (p. 223). It is easy to see that,

without such a record, a large proportion of unnecessary reoperations might

have been performed.

Multiple nerve injuries were frequent, the estimated incidence varying

from 8 or 10 percent up to 20 percent. In one series of 102 successive casualties observed at the 33d General Hospital, 18 patients had more than 1 nerve

injury. In 14 of these 18 cases, the injuries were in the upper extremities.

Concomitant injuries.—Compound fractures occurred in association with

nerve injuries in a third or more of all cases. Maj. (later Lt. Col.) Joe M.

Parker, MC, and Capt. Francis E. Crouch, MC, found that 40 percent of

271 compound fractures of the humerus managed at the 21st General Hospital were associated with injuries of the radial, ulnar, and median nerves.

In 243 battle fractures of the radius, ulna, or both bones, the incidence of

associated nerve injuries was practically the same, 39 percent. At the 33d

General Hospital, the incidence of combined bone-nerve injuries was about

36 percent.

Concomitant injuries of major blood vessels in which gangrene did not

develop occurred in 21 percent of 126 patients with nerve injuries studied at

the 33d General Hospital; of 18 patients with more than 1 injury, 9 also

had vascular injuries, bone injuries, or both.
CHAPTER XII

The European Theater of Operations

R. Glen Spurling, M.D.

EVOLUTION OF POLICIES

In the early spring of 1944, British neurosurgeons were still advocating

the policy of watchful waiting for a return of function in major nerve injuries, with late exploration if spontaneous recovery did not occur. This

policy was not in accord with recent experimental studies, or with the experience in U.S. Army hospitals in the Mediterranean theater. These data

had clearly indicated that early suture of severed nerve trunks yields the

most satisfactory end results. This did not, of course, mean primary nerve

suture. However applicable this policy may be in civilian-type nerve injuries, and however sound it may be in theory, it was realized that it was

both dangerous and illogical in war wounds. In these wounds, the contusion of the nerve ends which is inevitable after injury by a blunt missile

does not permit accurate resection and repair at the time of initial wound

surgery.

Experimental and histopathologic evidence, as well as the good results

obtained in the Mediterranean theater, indicated that the optimum time for

repair of a damaged nerve is between the third and the ninth week after

injury. Repair accomplished between the 21st and 28th clay was probably

productive of the best end results and could be carried out with the least

technical difficulty.

Still another reason for prompt exploration in every major nerve injury in which rapid clinical improvement was not occurring was the minimal

operative risk (p. 250). Surgical exploration was the final step in diagnosis.

If the nerve was found severed, valuable time was saved. If it was intact,

neurolysis often hastened recovery. If no surgery was indicated, the patient

was almost never the worse for the exploration.

TIMING OF NERVE REPAIR

In military practice, the selection and disposition of cases for operation

was often necessarily modified by factors not related to the professional welfare of the patient. The chief of these difficulties concerned transportation.

239
240 NEÜROSURGERY

Triage and Evacuation Overseas

The first phase of the peripheral nerve program of early repair was the

formulation of plans for the prompt triage and evacuation of these patients

from the Continent to neurosurgical centers in the United Kingdom. These

objectives were accomplished on the basis of three considerations:

1. Repair of peripheral nerve injuries was practically always an elective operation.

2. Casualties with peripheral nerve injuries therefore could not be given

a high priority for evacuation. In Circular Letter No. 81, Office of the Chief

Surgeon, Headquarters, ETOUSA (European Theater of Operations, U.S.

Army), 10 June 1944, neurosurgical priorities for evacuation from the Continent to the United Kingdom Base were assigned first to spinal injuries,

second to penetrating injuries of the brain, third to closed cranial injuries,

and last of all to peripheral nerve injuries.

3. Men with peripheral nerve injuries could seldom be returned to active

combat duty, but they were operated on overseas only if evacuation to the

Zone of Interior would be delayed.

From the standpoint of risk to life, the order of priority established for

neurosurgical casualties was obviously justified. From the standpoint of the

program of prompt repair of peripheral nerve injuries, it was very undesirable indeed. Even under optimum conditions of triage and evacuation in

the period immediately after D-day, patients with peripheral nerve injuries,

because of their low priority, seldom reached neurosurgical centers in the

United Kingdom until 2 or 3 weeks after wounding. In the interim, they

had passed through two or more general hospitals serving as transit installations, but, in spite of their delayed evacuation, many were arriving with

their soft-tissue wounds still open.

A concerted effort was therefore made to expedite early wound closure,

so that nerve exploration, with neurorrhaphy if it were found to be necessary, could be instituted promptly upon their arrival at neurosurgical centers. This objective was eventually accomplished, chiefly by means of conferences and personal contacts. When the program began to operate satisfactorily, the patient with a peripheral nerve injury, by the time he reached

the United Kingdom, was in excellent condition for early nerve repair at the

optimal time. His injuries had been debrided, in conformity with the regulations established for the management of soft-tissue wounds, and delayed

wound closure had usually been done at some one of the installations at

which he had halted temporarily in transit.

Evacuation to the Zone of Interior

Theoretically, because of the future unfitness of casualties with peripheral

nerve injuries for combat duty and because of the necessity for keeping

hospital beds in the combat zone and zone of communications free for other
EUROPEAN THEATER 241

casualties, it had been decided that most peripheral nerve repairs should be

done in the Zone of Interior. As in the Mediterranean theater, however,

military necessities did not always permit this ideal to be achieved, chiefly

because facilities for evacuation were frequently limited and those which

were available frequently had to be utilized for more urgent needs. If the

original plan had been adhered to inflexibly, by the time many of the patients

reached neurosurgical centers in the Zone of Interior, the optimal time for

nerve repair would have passed, and the functional results would have been

jeopardized, or at least would have been less good than they should have been.

The solution of the problem, then, was to correlate the optimal time for

surgery with the available transportation. This was accomplished by the

following methods:

1. Disposition proceedings were undertaken and completed in each case

as soon as possible after the patient reached a neurosurgical center in the

United Kingdom Base.

2. Patients with serious wound infections or with extensive soft-tissue

injuries requiring plastic repair were evacuated to the United States as soon

as transportation was available.

3. If transportation was available, other casualties with peripheral nerve

injuries were also evacuated to the Zone of Interior as promptly as possible.

4. If transportation was not available, or if, for any other reason, including complicating injuries, evacuation was undesirable, the waiting period

was utilized for the repair of peripheral nerve injuries. The patients were

then evacuated as soon after operation as their condition permitted and

facilities were available.

Neurosurgical Personnel

The shortage of neurosurgical personnel played a role in the timing of

repair of peripheral nerve injuries. The number of trained neurosurgeons

available to handle the heavy casualty load was always inadequate. The

deficit was met in two ways: (1) By the use of a number of general surgeons

who had had some training in traumatic surgery in the Zone of Interior,

and (2) by the use of general surgeons of sound training who were rapidly

instructed in fundamental neurosurgical principles. These two supplemental groups of surgeons were assigned to special neurosurgical centers, in

which they worked under chiefs of service who were formally trained in

neurosurgery and who had usually had considerable experience in this specialty in civilian practice. The centers were under the continuous supervision of regional consultants in neurosurgery, who in turn maintained intimate contact with the senior consultant in neurosurgery. The entire program

could thus be unified by standardization of diagnostic and therapeutic

methods.

It is not too much to say that it was the resourcefulness and energy of

the young general surgeons who were suddenly called upon to become profi-
242 NEUROSURGERY

cient in neurosurgery that made possible the handling of so many peripheral nerve injuries so well within the optimum period for repair.

PRINCIPLES AND TECHNIQUES

Initial Wound Surgery

The Manual of Therapy for the European Theater of Operations,1 which

was issued 5 May 1944, outlined the following plan of management for

peripheral nerve injuries. It is interesting to note that these general principles required no substantial alterations in the year of heavy fighting which

followed.

1. Injury to one or more of the major nerve trunks should be regarded

as a possibility in every wound of the extremities. Simple tests for motor

and sensory function should be used to determine which nerve (or nerves) is

involved.

2. The existence of a nerve injury does not warrant any departure from

the regulation management of soft-tissue wounds; that is, initial debridement

and delayed wound closure.

3. If the severed nerve ends are visualized when debridement is done,

they should be approximated whenever possible. If the gap does not permit

approximation, the ends should be snugly anchored to surrounding soft

tissue. Fine stainless steel or tantalum wire should be used for suture material, both being useful for later roentgenologic demonstration of the location

of the injury and the extent of the defect. The purpose of the initial suture

or temporary anchoring of the nerve ends is to prevent the retraction which

greatly complicates later end-to-end suture. Elaborate primary nerve suture

should not be attempted.

4. The soft-tissue wound should, as usual, be left open, to be closed at

an appropriate time in an installation farther to the rear. The muscles or

fascia should be approximated loosely over the exposed nerve trunk. A

pack should never be placed over an exposed major nerve trunk.

5. Splinting is usually a preliminary requirement for transportation.

About half of all nerve injuries are associated with injuries to one or more

of the long bones, but, even in the absence of bone injuries, the extremity

should be immobilized in the most favorable position to prevent deformity.

This can usually be achieved with bandages, blankets, or rolls of clothing;

casts and elaborate splints are seldom required for evacuation. Protection

of an extremity deprived of sensation is, however, essential.

6. An extremely important phase of preevacuation management is the

careful recording of the condition of the injured nerves at the first observation and a statement concerning exactly what was clone at debridement. The

i The sections of this manual devoted to neurosurgery are reproduced as app. B in Medical

Department, U.S. Army, Surgery in World War II. Neurosurgery, Volume I. Washington: U.S.

Government Printing Office, 1958, p. 403.
EUROPEAN THEATER 243

notes can be written either on the emergency medical tag or on the cast.

Lack of these data may delay subsequent surgery or result in unnecessary

nerve exploration.

Definitive Nerve Surgery

Every neurosurgeon who participated in the peripheral nerve repair

program was carefully instructed in the generally accepted principles of

nerve surgery, with particular emphasis upon the following points:

1. If the nerve was not divided, a policy of strict conservatism Avas

observed, the operation usually being limited to neurolysis.

2. The proximal and distal nerve ends were accurately trimmed back

until grossly normal neural tissue became apparent.

3. The transected nerve ends were approximated by a very carefully

performed interrupted epineurial suture.

4. The suture line must be free from tension. This objective was usually

accomplished by as extensive dissection as was necessary. Transplantation

of the proximal and distal nerve segments was preferable to excessive or

unphysiologic flexion of contiguous joints.

5. Tantalum wire (0.003 inch) swaged upon atraumatic needles was

recommended but was not mandatory for the sutures. If the surgeon preferred fine silk, he was at liberty to use it. The wire sutures, however, were

considered superior to other materials for several reasons. One was that

experimental studies had shown wire to be inert in human tissues. Another

was that, even at the beginning of the program, it was surmised that disruption of the repair might present a problem, which would be simplified

by early roentgenologic studies of a radiopaque suture line. When the necessity of later evaluation of large numbers of patients submitted to nerve

suture is borne in mind, the importance of this precaution is manifest. Preliminary surveys in the European theater testified to the validity of this

reasoning.

6. Strict hemostasis was mandatory. It was to be accomplished without

the use of a tourniquet unless an associated vascular injury made mechanical

control of the blood supply necessary.

7. A small cuff of tantalum foil (0.00025 inch in thickness) was placed

about the suture site in almost all nerve repairs carried out in the European

theater. In one center, a plasma clot sheath was used, the variation being

permitted because experimental studies had suggested that the method might

be valuable and a comparison of this technique with other methods of protecting the suture line seemed warranted.

Correspondence between the senior consultant in neurosurgery in the

European theater, Col. K. Glen Spurring, and the consultant in neurosurgery, Office of the Surgeon General, Lt. Col. Barnes Woodhall, indicated

that the use of tantalum cuffs was not harmful and was probably useful.

Followup studies indicated that regeneration had occurred rather consistently
244 NEUROSURGERY.

when they had been used in end-to-end sutures and that they had also been

useful when the scarred area of nerve was protected by a cuff after neurolysis.

A report from the neurosurgical center at Cushing General Hospital, Framingham, Mass., early in 1945 suggested that the use of these cuffs was harmful; many of them had had to be removed, and some of them had been found

to be fragmented when the secondary operation was undertaken. Neurosurgeons in the European theater were therefore instructed to be careful in

the application of these cuffs and to use no ties about them. The original

technique of annealing the foil was also altered, and it was merely curled

about a piece of rubber tubing, as one would roll a cigarette, in warm saline

solution. The report from Cushing General Hospital about the risks of

tantalum cuffs was the only such report received.

Postoperative Management

Casts were forbidden for the correction of deformities due to nerve injuries except during the immediate period of immobilization necessary after

operation.

Extension of the flexed joint was usually begun at the end of the second

week after operation and was completed by the end of the fifth week. The

timing was considered safe because of the comparative freedom from extensive flbrosis observed in patients treated by early nerve suture. It also had

the practical advantage of reducing the period of oversea hospitalization

and thus permitting evacuation to the Zone of Interior within the holding

policy of the theater.

There was no doubt that the prolonged use of any sort of cast or splint

was an obstacle to prompt and satisfactory functional recovery. On the

other hand, neuropathologic studies showed that suture-line disruption sometimes occurred when the policy of early mobilization was employed, and it

may be that discretion was not always used in its application. A followup

study of one series of 650 peripheral nerve injuries in the Zone of Interior

showed an incidence of rupture of the suture line of about 4 percent. This

was not regarded as unduly high; in fact, it compared very well with the

incidence noted when the suture line was protected from much longer periods

of time. The many variables which entered into the situation made definite

conclusions impossible, and the optimum time for joint extension was still

under debate when the war ended.

COMBINED BONE AND NERVE INJURIES

Wounds of the extremities with combined injuries of major nerve trunks

and fractures of the long bones comprised a considerable proportion of battle

wounds encountered in general hospitals. In the past, the functional results

of these injuries had been highly unsatisfactory. In the early part of the

European campaign, as in the North African and Mediterranean fighting,
EUROPEAN THEATER 245

they were handled on orthopedic services, with the primary objective of

securing correct alinement of bone fragments by the usual treatment for

fractures, including reduction, manipulation, and plaster immobilization or

skeletal traction. As a result of this policy, most casualties with combined

bone and nerve injuries were not sent to neurosurgical centers for treatment

of the nerve lesion until 8 to 16 weeks after injury. Then, because of the

theater holding policy, most of them had to be returned to the Zone of Interior for definitive treatment of the nerve injury. Many arrived with immobile joints and atrophied, paralyzed muscles, and end-to-end suture of the

severed nerve had proved impossible in about 20 percent of all cases.

Surgical management.—In December 1944, in cooperation with Col.

Mather Cleveland, MC, Senior Consultant in Orthopedic Surgery, Office of

the Chief Surgeon, ETOUSA, a program was instituted in the theater to

provide prompt combined treatment of nerve injuries associated with fractures of the long bones, as follows:

1. Early triage was the first consideration, so that patients with these

combined injuries could be transferred to neurosurgical centers while still in

the casts or splints in which they had been placed immediately after

wounding.

2. Once the patients reached the centers, every effort was made, through

the cooperation of orthopedic surgeons, plastic surgeons, and neurosurgeons,

to facilitate early repair of the damaged nerve.

3. The soft-tissue wound was closed by the usual routine.

4. The injured nerve was treated by suture or lysis as soon as possible

after healing of the soft-tissue wound, while, at the same operation, the

orthopedic surgeon carried out whatever procedure was indicated on the

fractured long bone.

5. The elective operation was performed, as a rule, within 3 weeks after

healing of the soft-tissue wound. In the interim, as soon as the original

plaster had been removed, the extremity was placed in balanced skeletal

traction.

This routine facilitated management of the fracture and also provided

the optimum conditions for dealing with the soft-tissue wound by simple

delayed closure or, if necessary, by an appropriate plastic procedure.

Adjunct therapy.—Penicillin or sulfadiazine was administered for 24

hours before, and for 72 hours after, the delayed wound closure. A booster

dose of tetanus toxoid was given before the combined bone-nerve operation.

Physical therapy, including daily electrical stimulation of paralyzed

muscles, was instituted as soon as the patient arrived at the neurosurgical

center and was continued throughout the period of hospitalization. Plaster

was used for immobilization after the bone-nerve operation, whether or not

internal fixation had been employed, but a window was cut in the cast over

the muscle belly to allow for electrical stimulation. During the postoperative period, every effort was made to encourage active and passive motion of

the joints, particularly the small joints.
246 NEUROSURGERY

Evacuation.—After V-E Day, when a holding policy of 60 days was instituted in the European theater, patients with complicated nerve and bone

injuries had to be evacuated to the Zone of Interior for treatment, Simpler

combined injuries continued to be handled in the theater. Attempts were

made, however, to complete the closure of all soft-tissue wounds before

evacuation.

Results.—Approximately 300 combined injuries of the major nerves and

long bones were treated according to this routine in the European theater,

within an average period of 6 weeks after injury. About 10 percent of the

patients required shortening or internal fixation of the fractured bone, and

about 60 percent required encl-to-end nerve suture. In the remaining patients, the nerve was found intact, and simple neurolysis was sufficient. In

a sample studied at one neurosurgical center, approximately three-quarters

of the combined bone-nerve injuries were in the upper extremities and

approximately a quarter in the lower. The incidence of complications, particularly wound infection, was negligible during the period the patients

remained under observation in the European theater.

So far as is known, this was the first time in the history of surgery that

a large series of patients with combined bone and nerve injuries were subjected to early, simultaneous operation.

PHYSICAL THERAPY

No opportunity was lost of emphasizing to all medical officers and all

others who participated in the peripheral nerve program that the surgical

procedure was only a single stage in the treatment of the paralyzed extremity. However satisfactory the nerve repair and subsequent regeneration

might be, an extremity would continue to be functionally useless if temporarily clenervated muscles were permitted to become irreversibly atrophied

or fibrosed or if joints of the wrist, hand, ankle, fingers, or toes became

irreversibly frozen.

The excellent results obtained in the peripheral nerve injury program in

the European theater were clue at least in part to the expansion of the physical therapy service proportionately with the neurosurgical load. The Chief

Surgeon's Office cooperated fully in this expansion, by the authorization of

additional space and equipment, by the assignment of available Army personnel in excess of Table of Organization specifications, and by permitting

the employment of trained British civilian personnel whenever possible. As

a result, the physical therapy service became one of the most important

departments of every neurosurgical center.

Experimental and clinical studies had indicated that daily galvanic

stimulation of denervated muscles would prevent atrophy and retard fibrosis.

This measure was therefore employed as a routine in all cases, beginning with

15 brisk contractions daily and progressing gradually to 30 contractions.

When casts were used for postoperative immobilization, windows were cut
EUROPEAN THEATER 247

in them over the bellies of the paralyzed muscle groups, and galvanic stimulation was begun the day after operation. Other measures included massage, active and passive motion, and the use of dry and moist heat as indicated. Particularly careful attention was given to the active and passive

motion of small joints. The excellent results obtained by this practice in

patients with combined nerve-bone injuries raised the interesting speculation

that it might be advisable to cut windows over the bellies of all muscle

groups in extremities immobilized for any considerable period of time and

to practice galvanic stimulation, regardless of the basic lesion.

Fixation by splints, as already indicated, was kept at a minimum. It

was considered of the greatest importance to give the patients detailed instructions concerning the care of their own joints. No patient was considered ready for evacuation until all his joints had been fully extended, which,

on the average, could be accomplished within 3 to 5 weeks after nerve repair.

If, however, he was not carefully instructed in constant movement of the

joints, passively as well as actively, he was likely to arrive in the Zone of

Interior with frozen joints, particularly the joints of the hand.

STATISTICAL DATA

Earlier in the war, during the fighting in the Mediterranean theater,

many neurosurgeons had been somewhat hesitant over applying the principles just outlined for the management of nerve injuries to battle casualties.

Even the most skeptical, however, were apparently convinced of their wisdom and safety by the demonstration during the Italian campaign that open

granulating soft-tissue wounds could be closed within 7 to 10 days after

wounding, with resulting primary healing, so that elective neurosurgical

repair could be undertaken within the optimum time period after wounding

without fear of serious wound infections. The European campaign presented an opportunity to test the program on a large scale.

Of 6,245 major peripheral nerve injuries treated in general hospitals in

the United Kingdom in the approximately 11-month period between D-day

and V-E Day (table 8), 2,873 (46 percent) were operated on overseas within

the period designated as early; that is, within 21 to 90 days after wounding.

The remaining injuries were treated in the Zone of Interior for a variety of

reasons, the most frequent of which was the inability of the neurosurgical

centers abroad to handle larger surgical loads within the optimum time limit

for surgery. The increase in the volume of patients operated on overseas

as time passed is noteworthy. In spite of the increasingly heavy patient

load, the proportion rose from just over 34 percent in the 8 weeks after

D-day to more than 50 percent in the 6 months before V—E Day.

In almost 47 percent of the cases in which surgery was done, the nerve

was found intact, and neurolysis, usually external but occasionally internal,

was done. In the remaining cases, the operation consisted of end-to-end

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EUROPEAN THEATER 249

suture, which is the most desirable method of treating divided nerves. The

fact that this technique could be applied in almost every case in the series

in which it was indicated is evidence of the soundness of the whole program of early nerve suture. The number of insurmountable gaps in the

group of cases under consideration from the European theater was less than

1 percent, whereas in a series of similar cases operated on in the Zone of

Interior after the North African campaign it was about 10 percent. The

improvement is significant, for the alternative of elective bone shortening

to facilitate end-to-end suture, while it is practical, is not a desirable procedure if it can be avoided, and most nerve grafts are clinical failures.

Early nerve suture, moreover, was proved to possess at least three major

advantages over delayed suture, as follows:

1. Mobilization of the proximal and distal nerve segments was much

more readily achieved.

2. Fibrosis in the wound, and particularly in the nerve stumps, was

greatly reduced.

3. Flexion of contiguous joints was more easily accomplished.

The timelag between wounding and neurorrhaphy in this series varied

from an average of 28 days in the period immediately after D-day to 42

days in the period between 1 February and V-E Day. The average of 39

days for the whole series is longer than the most desirable interval, which

is 21 to 28 days after injury, but is still well under the upper limit of 90

days. Associated injuries and late closure of the wound accounted for many

of the delays in definitive neurosurgery, but the most frequent reason was

the difficulties encountered in evacuation from the Continent, particularly

during the winter months when air evacuation was often hampered by bad

flying conditions.

On the other hand, the timelag does not seem unduly long when one

recollects that, in the interval, the patients had been removed from the frontline and transferred to various installations along the line of evacuation on

the Continent before they finally reached the neurosurgical centers in the

United Kingdom. On the whole, the 39-day average probably represents

the shortest practical period within which definitive neurosurgery can be

done on large groups of casualties under conditions of active warfare.

That primary wound healing occurred in more than 98 percent of the

cases is itself convincing testimony concerning the wisdom of delaying neurosurgery for 3 to 4 weeks after debridement of the initial wound. The policy

of early nerve stretching, however, was possibly somewhat overemphasized

(p. 244).

Many of the simpler injuries in the series were operated on under local

(procaine) infiltration analgesia, Operations on the sciatic nerve were

usually performed under spinal analgesia. AU brachial plexus injuries and

many combined injuries of the upper arm were handled under intratracheal

ether anesthesia.
250 NETJROSURGERY

The single death in the 2,873 operations followed local nerve block, in

preparation for exploration of a common peroneal nerve lesion, and was

presumably the result of a procaine hydrochloride (Novocain) reaction.

The fact that nearly 3,000 consecutive major neurosurgical operations could

have been performed with so low a case fatality rate is ample testimony to

the competence of the anesthesiologists, particularly when itis remembered that

neurosurgical procedures are necessarily complicated and prolonged, and that

as long as 5 hours may be required for a single operation.

At the beginning of the program, early nerve surgery was carried out

only in the injuries in which bone complications were not present. Later,

as already mentioned, combined injuries were brought under the same

program. The regimen included debridement and delayed wound closure,

balanced skeletal traction for immobilization, combined operation by the

neurosurgeon and orthopedic surgeon, antimicrobial therapy, and preoperative and postoperative physical therapy.
CHAPTER XIII

Standard Methods of Examination in

Peripheral Nerve Injuries

Frederic H. Lewey, M.D.

This chapter concerns methods of examination found useful in the neurologic-neurosurgical center at Cushing General Hospital, Framingham, Mass.,

in which, at times during World War II, large numbers of patients with

peripheral nerve injuries required immediate diagnosis and prompt decision

concerning treatment. The routine which was developed insured a thorough

and sufficiently complete workup by the use of a limited number of simple,

practical, rapid, and objective methods.

The aim of these methods was twofold: (1) To shorten the time of

hospitalization and (2) to express the results of the examination in numerical

terms. The latter objective was of special importance, since, in military

practice, each patient's motor power and sensibility frequently had to be

assessed by different investigators in subsequent followup studies.

GENERAL CONSIDERATIONS

The routine at Cushing General Hospital was established on the basis

of the following considerations:

1. The individual yardstick for what is designated as "good," "fair," or

"poor" function ahvays varies with the increasing experience of the same

physician and varies still more from one examiner to the next. The expression of one's estimate in percentage of the normal without a better basis

than an impression is never justifiable because it pretends an exactness which

is not warranted.

2. The presence or absence of improvement in such properties as muscular strength, sensitivity, and electrical irritability of muscles and nerves

determine the expected course of a nerve lesion.

3. The importance of reasonably exact and reproducible measurements

as criteria of the functional condition of a nerve cannot be overrated. The

slightest indication of motor or sensory improvement, if reliable, may prevent an unnecessary operation; if it is unreliable, it may delay nerve repair

and restitution of function for months.

4. It is well understood that no measurement in which human factors

enter will be truly exact; observational error is on the one side and the

251
252 NEUROSURGERY

patient's ability at judging his sensations, as Avell as his skill in demonstrating his true muscle power, is on the other. Standardization of the methods

of examination and adequate objective controls will minimize but cannot

completely nullify errors. Experiences at this neurosurgical center repeatedly

showed that the results of three independent observers, who used the methods

to be described and the same standardized techniques, were in reasonable

agreement and that the values obtained in subsequent examinations of the

same patient were sufficiently significant to permit sound judgment concerning further procedures.

5. Nerve regeneration is a slow process, often requiring years even under

favorable conditions. Every effort on the part of the neurologist and neurosurgeon was therefore directed toward shortening this period of restitution.

A correct appraisal of the initial findings contributed greatly to this task.

There was seldom doubt concerning the treatment of the small number of

patients returned from overseas with the definite statement that a nerve

had been seen to be interrupted and had not been repaired at the time of the

delayed primary closure of the wound, but in the majority of patients,

unfortunately, no reliable data were available concerning the anatomic condition of the paralyzed nerve. There was often doubt, therefore, whether

it was sufficiently injured to need surgical repair or, on the contrary, whether

it was capable of spontaneous recovery.

6. Clinical observation was always the best test of nerve regeneration,

but it had to be used judiciously, so that the examiner would not be deceived

by the host of trick movements which patients develop unconsciously. If motion is present in a muscle group, continued increase of strength should be

demonstrable. The same could be said for the sensory disturbance in the

distribution of the injured nerve.

Erroneous conclusions were easily drawn from correct observations and

recordings. One read frequently, for instance, in the chart of a patient

with an ulnar paralysis, followup statements extending over months to the

effect that strength and sensitivity had improved more and more until

eventually the absence of abduction and lack of sensation in the little finger

were the only residuals of the paralysis. Actually, these two signs represented

the only intrinsic deficit which had ever been present. All other initial

disturbances had been situated in the overlap area of the median and radial

nerves, which gradually assumed some of the ulnar functions. In other

words, the improvements, which were correctly recorded, had no bearing on

the ulnar nerve lesion, which was just as complete after months of observation

as in the beginning and which should have been repaired immediately.

OBJECTIVES OF THE EXAMINATION

Four basic questions had to be answered as early and as precisely as

possible concerning all peripheral nerve injuries in World War II, as follows:

1. Was the injured nerve completely or partially interrupted?
EXAMINATION IN PERIPHERAL NERVE INJURIES 253

2. Was the nerve in continuity, but with too many of its fibers interrupted intraneurally to permit spontaneous recovery?

3. Could a paralyzed nerve be left alone with the assumption that it

was only bruised and would recover spontaneously?

4. Had a nerve suture been successful?

All the methods of examination described in this chapter were selected

to provide material for the replies to these questions.

INITIAL INVESTIGATIONS

The Clinical History

All patients were seen within 24 hours of admission, although sometimes, when convoys brought groups of 20 or more patients at once, only

in a cursory way at this time.

Two of the younger ward officers were detailed for the first examinations.

They took the history of the injury and of previous treatment and abstracted

all pertinent data from the records accompanying or following the patient.

Deciphering of an oversea chart, scribbled with pencil in odd places,

was a tedious job. It was done so completely the first time that the task

did not have to be duplicated.

The checklist contained the following items:

1. Operative findings and procedures, copied verbatim, with reproduction of sketches and photographs.

2. Extent of the initial motor and sensory paralysis, as well as exact

dates and extent of each subsequent stage of improvement.

3. Whether or not the nerve had actually been seen or explored and,

if so, its appearance during primary treatment and secondary closure of the

wound.

4. Whether the nerve stumps had been tagged and how.

5. Injuries to, and ligation of, larger blood vessels.

6. Interruption of tendons and extensive loss of muscles and of other

soft tissue.

7. Bone or joint injuries.

8. The number and type of hospitals which the patient had passed

through, with the names of surgeons who had performed operations or made

pertinent statements. It was soon found that operations, statements, and

suggestions by certain neurosurgeons overseas could be taken at face value

even though the time elapsed was too short for confirmation or though they

seemed to be at variance with the current findings.

All dates and statements were checked with the patient. Any additional

information was characterized as such. Contradictory statements were also

recorded as such, though those made by patients were not overrated. It was

surprising how often intelligent men had not been interested enough to

inquire who had operated on them and what had been found or done.
254 NBÜROSURGERY

Data which were pertinent in the opinion of the examiner and which

could not be found in the chart or verified by the patient were specifically

noted.

Exploration.—Exploration of the paralyzed nerve proved to be the wisest

procedure in patients who had been observed or operated on by physicians

unfamiliar with neurosurgical work if no sign of recovery of function or

regeneration of nerve could be traced at the time of admission. In a certain

number of patients, the exploration was found to be unnecessary. More

often, the findings on personal inspection were in sharp contrast to the

description on the chart. Nerves reported to be intact were found completely interrupted. Other nerves were seen to be sutured to tendons or

blood vessels. Simple exploration in the hands of a competent neurosurgeon

is a minor and harmless procedure. It was not refused by any patient after

its implications had been explained to him.

Neurologic Examination

Plaster casts were removed at once unless they had been applied for

recent fractures. A qualitative motor and sensory examination followed,

for first orientation. Slips were filled out for all routine and special laboratory and X-ray examinations. Thereafter, the patient and his chart were

presented to the chief of section for discussion of the results. The examiner

filled out SGO Form 55-E-10A on the typewriter, with a carbon copy,

while the final motor and sensory examinations described later were performed by the specially trained personnel. A complete examination took

from 2 to 4 hours, and occasionally more, depending on the complexity of

the case and the number of required tests, and this plan saved time and

gave more reliable results. Ward officers, however, were urged to learn the

various special methods of examination.

Recording.—Experience in World War I had taughtthat many charts were

lost in the course of events through the chain of hospitalization or that,

at least, important forms disappeared from them. This fact was verified

in World War II. To make and keep a copy of each chart was small extra

work. Time was also saved by this plan when patients returned from work

furlough for a routine checkup. It took just a few minutes to get the

duplicate chart from the file cabinet, to examine the patient, and to add

the result to the chart. The copy was retained for his original chart,

which came through messenger mail from the registrar, often after the

patient had returned to his work.

The statisticians initiated a filecard (figs. 93 and 94) based on the prepared chart and checked it for completeness in both the original record

and the copy. The copy was retained in the department's file cabinet. The

original chart with the filecard clipped to it was delivered to the chief of

section for preparation of the weekly combined neurologic-neurosurgical,

orthopedic, and medical conference.
EXAMINATION IN PERIPHERAL NERVE INJURIES 255

+z <D k. +-

c ja Q.2 3

n

1

CO \~ in cfi CO e>

_l £ <D

FIGUEE 93.—Diagram showing method of indicating by type and position of riders

on filecard the particular nerve injured, the means of recovery (spontaneous versus

surgical), the treatment employed, and the immediate and ultimate disposition of the

patient. Immediate checking of the patient's total status was thus possible.

"B lSAuU L-July LJ

Age 27

Address:

I. DIAGNOSIS: Ulnar, left

Injury Section "by glass

Inj. 9 June

Prev. Oper. - Trf

OPERATION: Explor. Lyain. Suture. Graft. Cuff. Tantal .

Complete

9 July 'Ulf (Capt.Scoville) Resect.'of' • rem.5 Jan. 'k1?

small neuroma & gliomaj transposition,, end to

end sut. over 3/%" gapcaused by Fall on maneuvers

Atrophy ++ + + all ulnar muscles, see print

Electr. Exam.

Spont. Recov. 0

Sympath. Involv. 0

Other 0

2. TYPE & PLACE OF INJURY 2" ab.elbow,med.side

Interrupt.: y* Jt^

Scar — intraneur. extra

Bruiae _

Second Sect. ^/

16"->ABD. V.

Electr. Motor 1.5" "bel.sut.: Fl.p.IV.V , rest 0

Sens. " " " : Pain in 5th dig.

RECOVERY: g3-VIIl| 270(1.U-5 I I7-VI-U6

l8.V.lf5 mot. o

Atrophy 0

Intraneur.

CHR.msc 28

KCT.mA 20

5

16

17-!

Ad.p.20<Abd.V.Ad.p.30Al)dV:2C

! . Inteross.I:2CW

Dig.O Hg.V: Hypalg.

Abd.VjInteross.I: + +

2 I 20

3 ! 2

5 !

Other

First Signa uf: l6 July 'U5

Final Recov.:

Groflrth Rate: 3/V /m

Oper. Rep. V'

" Overseas 0

Ankyloaia 0

FIGURE 94.—Specimen filecard of patient with interruption of left ulnar nerve (first

rider, treated by suture (second rider, yellow on original card), sent on work furlough

(third rider, dark blue on original card), and eventually discharged (fourth rider, brown

on original card).

498991v—59- -19
256 NEUROSURGEItY

The methods of examination described were so selected that the necessary devices could be readily made by any mechanic or bought in any

hardware store. Graphic records were drawn on stencils and mimeographed.

In this way, blanks were prepared for sensory and motor recordings (fig. 95).

Large figures were found to be essential. Sensory entries were made with

black, blue, and red pencil, to give instantaneously a clear visual picture of

the condition. Verbal descriptions were given in unequivocal terms. To

give only one example, fingers were named, not counted; index, middle, ring,

and little fingers are specific terms.

QUANTITATIVE EXAMINATION OF SEQUENCE OF RETURNING

MOTOR FUNCTION

Figure 96 shows the forms used for ulnar, radial, median, sciatic-tibial,

and peroneal nerve injuries. They show the nerve branches to a few

muscles whose isolated function can be easily tested. The forms were blocked

on cardboard, on which the directions for their use were printed. As soon

as a muscle, previously paralyzed, showed beginning action, this date was

written in the corresponding space, together with a number indicating

whether motion resulted (1) from voluntary contraction, (2) electrical

stimulation on the intact skin, or (3) intraneural stimulation. If, for

example, in a radial paralysis concomitant with a fracture of the humerus,

only triceps function was present initially, but if the brachioradial was

found contracting at a later date and the extensor carpi radialis followed

in due time, it became clear that the nerve was regenerating and needed no

surgical intervention. Figures 113, 119, 121, and 123 show records of

patients with various nerve injuries. The figures were drawn true to scale,

as far as possible, and permitted ascertaining with sufficient accuracy the

ratio inches/months, meaning the distance from the lesion to the muscle

examined, over the number of months from the date of injury to the first

observation of muscle movement. This form, in contrast to figure 95, does

not reckon the degree of muscle strength, but checks the orderly progress

of the nerve regeneration from the place of injury to the most distant

muscle. It could be filled in without the use of any instrument.

QUANTITATIVE ASSESSMENT OF STRENGTH OF MUSCLES

OF HAND AND FOOT

Origin, meaning, and reliability of test.—The use of the spring scale (fig.

97) for measuring muscle strength seems to have been introduced into

medicine by Lovett1and developed on his instigation by Martin.2Pollock3

1 Lovett, Robert W. : The Treatment of Infantile Paralysis. 2d edition. Philadelphia: P.

Blakiston's Son & Co., 1917.

2 Martin, E. G., and Lovett, R. W.: A Method of Testing Muscular Strength in Infantile

Paralysis. J.A.M.A. 65: 1512-1513, 30 Oct. 1915.

3 Pollock, Lewis I., and Davis, Loyal: Peripheral Nerve Injuries. Hoeber's Surgical Monographs. New York : Paul B. Hoeber, Inc., 1933.
EXAMINATION IN PERIPHERAL NERVE INJURIES 257

RIGHT HAND

NAME

DATE

LEFT HAND

NAME

DATE

B

LEFT LEG

C D

FIGURE 95.—Mimeographed forms for recording of motor and sensory examinations.

A. Right hand. B. Left hand. C. Right leg. D. Left leg.
258 KEUROSURGBRY

NAME :

ASN:

DATE:

EXAMINER'.

nnc.carp.ciln.

Adduct. poll

Palm., dors, trrteross.

Ilex, digit profit*

Abd. digit. V

A

NAME:

ASN:

DATE :

EXAMINER:

^MEIWNM

Oppon.poll.

IMAMF:

ASN: J |

DATE : Deltoid ^

K itmDIßl N.

EXAMINER: X |

Triceps long.

}

Tricepsined.,brev.

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Ext A 1

carp.rad.lon<}.,brev. V.

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Ext. digit comm.^-

i 1

Ext carp. uln. )

flbd.poll long. ///

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t-f Tib. ant.

| 1 Datp

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Bet. d*4 long. .

1 K

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FIGURE 96.—Forms for recording progressing

regeneration of injured peripheral nerve. These

forms were blocked on cardboard, on which the

following directions were listed: Mark site of

injury and state distance from injury to muscle

examined in inches. Write date of first muscle

action in appropriate space. Indicate whether

method of examination was (1) voluntary contraction, (2) electrical stimulation on skin, or

(3) bipolar intraneural electrical stimulation.

A. Form for ulnar nerve. B. Form for radial

nerve. C. Form for median nerve. D. Form for

sciatic nerve. E. Form for common peroneal

nerve.
EXAMINATION IN PERIPHERAL NERVE INJURIES 259

l

?n

GRAMS

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A

PlGUEE 97

-a.ooo-

-Spring scales and appliances for measuring muscle strength.

See text for description.

used the technique in World War I, but no one seems to have followed his

example. The method does not always test single muscles, but rather

muscle groups active in a motion. The ability to resist the passive extension

of a voluntarily contracted muscle group is determined by means of a spring

scale and expressed in pounds.

The values so derived were recorded in the sensory form, either directly

in pounds or computed in percentages of normal. Table 9 gives the M

(computed mean) of the strength of various normal muscle groups participating in a motion, their SD (standard deviation), and their SE (standard error). The normal values were obtained from a hospital population

which, as a group, did not show the fitness of combat soldiers. The random

sample consisted of persons showing no nerve or muscle weakness and included studies on manual and clerical workers, as well as on both extremities of right-handed and left-handed individuals.

The reliability and limitations of the method were statistically evaluated

by plotting its values, expressed in percent of the normal, against the

voltage of the electromyogram on maximal nerve stimulation, also expressed

in percent of the normal. A high degree of relationship was found

(r — + .75 with an SE of 0.04). Ninety-four and a half percent of all

points of the scatter diagram fell within the limits of ±2 SD. The results

of the method may be called reasonably reliable, reproducible and comparable.

Materials.—Material (fig. 97) for thistest consisted of the following items:

1. A spring scale indicating up to 50 pounds and a smaller scale with

a 64-ounce capacity for measuring the first appearance of strength in hand

and finger muscles.

2. A wire about three-sixteenths inch thick and about 4 inches long,

one end of which was bent to hook into a ring of the scale; the other end

was bent into an open loop of about 1% inches in diameter and was covered

with a rubber tube.
260 NBUROSURGERY

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EXAMINATION IN PERIPHERAL NERVE INJURIES 261

3. Wire of the same type formed into an isosceles triangle of 4-inch

length, the base of which was padded with rubber; the opposite tip was

bent to hook into the scale.

4. A thin metal plate about 4 inches long and 1 inch wide with a hole

in one end for the scale. The plate was wrapped in tape to provide a

good grip.

Technique.—The patient was informed of the principles of the method and

was admonished energetically and repeatedly during the entire examination

to apply all possible force in resisting the pull of the scale. Hand, fingers,

or leg had to be fixed by the examiner in such a manner that the patient

was prevented from pulling with muscle groups other than those under

scrutiny. Figure 98 A, B, and C shows the procedure in testing the forearm,

hand, or finger muscles. In the foot, plantar and dorsal flexion of foot and

toes and eversion and inversion of the foot (fig. 98 D) were tested. This

same method could be applied for measuring other muscle groups in the

arm and leg.

It was important in this test to hold hand, fingers, and foot exactly as

demonstrated and to exercise traction in the given direction. Patients developed, unconsciously, innumerable trick movements and learned to use

auxiliary muscles. The positions of extremities, hook, and scale were so

chosen as to exclude, as far as possible, undesirable errors, such as the

contraction of the finger extensors in testing abduction of the index or little

fingers. Nevertheless, inspection and palpation of the muscles or muscle

groups under scrutiny were not omitted.

The duration of examination for each injured nerve was 25 minutes.

Recording.—Each figure which was secured was immediately noted in its

proper space in the form. Figure 99 indicates the points at which the

strength of each motion (adduction, abduction, opposition, and so forth)

was inscribed. The results were recorded either directly in pounds or in

percentages of the normal, depending on the purpose for which they were

to be used. The large figure (M) (fig. 98 A, B, C, and D) was used to

compute the percentage of deviation from the norm. The range (small figures, ±2 SD) provided a general idea of what strength could be expected in

a certain movement. The pounds given on figure 98 A, B, C, and D are

slightly at variance with those of table 9; they are rounded to a quarter of

a pound, in contrast to the calculated values of table 9.

The unit of measurement was noted on each patient's chart, with the

date, name of patient, and examiner. Special remarks were sometimes

useful, that the patient did or did not apply maximal force, for example,

that he seemed to be in good or poor condition, or that it was a very hot day.

Figures 111, 116, 117, 118, 120, 122, and 124 are examples of gradual

increase of muscle strength in injuries of the peripheral nerves, expressed

in percentage of the normal. The measured distance from the site of the

injury or suture to the muscle examined is given in inches (") in relation to
262 NEUROSÜRGERY

Flexion-llttl« fins Abductlon-llMleflnj

Adduction-tadct fins fldduction-llltle finger.

RADIAL NERVE

MEDIAN NERVE POSTERIOR TIBIflL, PERONEAL NERVE

C D

FIGUEE 98.—(See opposite page for legends.)
EXAMINATION IN PERIPHERAL NERVE INJURIES 263

Flex, distal phal.-

Tlex. middle phal:

Index abd

Thumb

ricx. dismalphalV. # \ /C

Flex, prox. pbair \

Adduct.^ \

Oppos. \-—> •

VoAar abd.—

Abduct,

fifth finger

FIGURE 99.—Diagram indicating exact spots on sensory form on which

measured strength of respective motions were recorded.

the time elapsed since injury or suture in months (m). The average growth

rate of all nerves, including the initial phase, was found in over 1,000 patients

to be 1.4 mm. per day or about one fifty-eighth inch per month.

NERVE BLOCK TO ELIMINATE SUPPLEMENTARY MOVEMENTS

Trick movements have already been mentioned as a source of erroneous

interpretation of recovery from nerve injuries. True trick movements, as

explained by Jones,4are passive movements. They are brought about by

tension on the paralyzed muscle by overaction of its antagonist, by recoil

phenomena, or by the action of gravity. Such faulty methods of examination

were carefully avoided.

Supplementary movements are performed by muscles so connected with

joints or tendons that these structures are able to take over the action of

the paralyzed muscle. In addition, there are true individual variations, as,

for instance, in the innervation of the thenar and flexor profundus muscles

by ulnar and median nerves. These movements are not sufficiently stressed

* Jones, Robert (editor) : Orthopaedic Surgery of Injuries. London: H. Frowde, 1921.

FIGURE 98.—Standard position, fixation of parts, and direction of traction for measuring strength of various characteristic movements. The technique was devised to prevent trick movements and minimize interference with supplementary movements. The

presence or absence of contraction of the corresponding muscles had to be verified by

inspection and palpation. The large figures on the form indicate the mean strength of

the hospital population surveyed and the smaller figures the range ( ± 2 SD) expressed

in pounds (450 gm.). A. Technique for testing ulnar nerve. B. Technique for testing

radial nerve. C. Technique for testing median nerve. D. Technique for testing posterior

tibial and peroneal nerves.
264 NEUROSURGERY

in many textbooks of anatomy and neurology. Well-known twigs—sometimes good sized, sometimes rudimentary—connect the two nerves on the

forearm. An extensive ulnar nerve overlap into the territory of the median

will greatly benefit a person with median paralysis but harm one with

ulnar paralysis.

In view of these facts, a block of the motor fibers of one or more

adjacent nerves was found to be the only safe way to obtain a correct

diagnosis. One patient, an officer, was observed with a complete interruption

(later confirmed) of the ulnar nerve at the elbow. His only motor deficit

was an inability to flex the tip of the little finger. He was not willing to

accept the diagnosis and the recommended suture of the nerve until block

of the median nerve convinced him of the loss of ulnar function.

This method was used before the war by a number of observers, including J. C. White in his investigation of peripheral vascular disorders and

Woollard in cases of sensory dissociation. Highet5availed himself of the

method systematically during World War II.

Materials.—The materials employed included the following items:

1. Hypodermic needles (No. 25).

2. Varnish M 473 (Sterling Varnish Co., Haysville, Pa.).

3. An electric stimulator.

4. A plate electrode (indifferent electrode).

5. Wires and alligator clips.

The needles were thoroughly cleaned, dipped into the varnish, and

dried hanging, with the tips downward, to obtain an even coating. They

were baked at a temperature of not less than 135° C. (275° F.) for 4 to

6 hours. The points of the needles were carefully pared with a sharp knife

to avoid chipping. The needles were sterilized by boiling or in alcohol.

Technique.—The needle was attached to a 5-cc. syringe filled with 2-percent procaine solution, to which adrenalin had been added (1:50,000). One

pole of the stimulator was fastened on the hub of the needle by means of

an alligator clip. The other terminal went to the indifferent electrode. The

needle was inserted into the nerve to be anesthetized, the correct position

being suggested by the motor and sensory effects of electrical stimulation.

Injection of 2 to 10 cc. of the procaine solution was necessary to produce

complete motor and sensory paralysis, including vasodilatation and anhydrosis, in 10 to 15 minutes. The block lasted for 2 to 4 hours. The method

could be used concurrently with bipolar intraneural stimulation of the

injured nerve and with a sweat test.

The duration of this test was 45 to 60 minutes.

Opposition of the thumb in a median paralysis, if prevented by anesthesia of the ulnar nerve, was not considered suggestive of regeneration of

the median nerve.

5 Highet, W. B.: Procaine Nerve Block in the Investigation of Peripheral Nerve Injuries.

J. Neurol. & Psychiat. 5 : 101-116, July-October 1942.
EXAMINATION IN PERIPHERAL NERVE INJURIES 265

HANDPRINTS AND FOOTPRINTS

The use of handprints and footprints was introduced into neurology by

Pollock,8in 1920, to record muscle atrophies and their gradual improvement

as well as trophic disturbances of the skin.

Materials.—The materials used in this test included the following:

1. A thick glass plate, or a sheet metal plate nailed on a board, 6 inches

wide and 8 inches long.

2. A squeegee roller 5 inches wide, as used for photographic prmtwork.

3. Printer's ink which comes conveniently in tubes for fingerprinting or

in bottles for mimeographing.

4. Mimeograph paper or any similar absorbing paper which is not glossy.

Technique.—The palm or the sole was scrubbed and cleaned with 70 percent

alcohol and dried with a hair drier. A drop of printer's ink was placed on

the glass or metal plate and distributed with the squeegee until the plate

was evenly inked. The squeegee was rolled over the palm and fingers or the

sole and toes. It was advisable to have an even, thick film of ink over the

entire surface at once. It was difficult to correct incomplete inking without

collecting stain at the seams, which reproduced as thick lines. Experience

taught how much ink was best for good prints.

The mimeograph paper was placed flat on a wrinkle-free, hard surface.

The hand, with thumb and fingers slightly separated, was placed flat, with

the arm strictly vertical, on the paper and was carefully pressed against it.

Each digit was cautiously rolled as for fingerprints. Here, again, experience

told the degree of pressure necessary to produce a good skin pattern without

distorting the picture.

The inked sole was similarly placed flat on the paper. Weight was put

on the foot, and the toes were slightly rolled over the paper. Foot and

toes were lifted simultaneously from the paper.

Two or three prints of decreasing density could be made with one inking, to be inserted into the copies of the chart. The signed prints were

covered with onion sheet paper. The ink was easily removed from the skin

by scrubbing with green soap and hot water. The ink plate was cleaned

every evening and freshly inked before use. Because of its changing quality,

each batch of ink required a few test prints.

The duration of the tests was 10 minutes.

Results.—Atrophy of muscles and clawing of fingers and toes were

clearly seen in the prints obtained by this technique. The gradual return

to normal could be followed by comparison with subsequent prints (figs. Ill,

114,115,116 B, and 117 B). Figures 100 and 101 indicate the site of atrophic

muscles in paralysis of the corresponding nerves. With some experience, the

diagnosis of a median, ulnar, or combined nerve lesion could be made from

the print.

6 Pollock, L. J.: Hand and Foot Prints as Kecords in Lesions of the Peripheral Nerves.

J.A.M.A. 74: 943-944, 3 Apr. 1920.
266 NEURÖSURGEKY

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14 AUG '44 I6 AUG. '44

A B

FIGURE 100.—Handprints indicating paralysis of peripheral nerves of arm. A. Print

of left hand of patient with mild ulnar paralysis. Note clawing of fourth and fifth

fingers and mild atrophy of abductor pollicis and of concavity of abductor digiti V, which

is normally convex. B. Print of right hand of patient with complete median paralysis.

The abductor pollicis shows a concave surface. The opponens pollicis is flattened. The

flexor pollicis brevis shows a defect in its median portion. All fingers are clawed, the

fourth and fifth chiefly because of ankylosis.

The prints in radial and peroneal nerve paralysis were not characteristic enough to be made routinely. The loss of the intrinsic foot muscles was

sometimes quite marked (fig. 102). The trophic changes of the sole in

tibial nerve injuries and their recovery could be easily demonstrated and

recorded (fig. 103).

ELECTRODIAGNOSIS

It was observed that the most careful measurements of motor function

were often inadequate in two types of patients: (1) Those with recently

neurotized muscles who had not yet learned their voluntary use and (2) those

in whom overlap injuries of a muscle gave a false notion of regeneration

through the nerve that normally supplies it. In both these instances, the

presence or absence of function of the nerve in question could be promptly

established by bipolar intraneural stimulation.

SENSIBILITY TESTS

Four main types of sensitivity were differentiated, as follows: (1) Pain

and temperature sensation; (2) deep pressure, joint, and position sense;

(3) superficial pressure (touch); and (4) vibratory sense.
EXAMINATION IN PERIPHERAL NERVE INJURIES 267

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FIGUKE 101.—Handprints of patient with complete paralysis of left ulnar and median

nerves. A. Print of left hand showing severe atrophy of all intrinsic hand muscles.

B. Print of normal right hand of same patient.

Experience showed that not all modalities of sensation are equally

important for judging lesions of the peripheral nerves. Temperature sensation ran fairly parallel with pain sensation. Quantitative temperature

measurements did not deliver sufficient additional information to warrant

the complicated apparatus required. Examinations of joint and position

sense were reserved for special cases. Vibration spread too widely over

the skin to normal parts to give reliable results in peripheral nerve injury.

Pain sensation to pinprick and perception of superficial pressure were

the modalities of sensation whose exact measurement gave the most useful

data. The question of the interpretation of pain response in deep pressure

to the terminal phalanges is still controversial. The isolated return of pain

sensation did not appear to afford positive evidence of regeneration.

A pin and a wisp of cotton wool were all that were needed for the

first orientation and for outlining the area of complete loss of sensation.

This field, if examined soon after complete interruption of a nerve, has

been called the maximal area of anesthesia. It includes the black and the

dotted areas of figures 104 and 105.

Within a few weeks or months, the anesthetic field gradually shrank

from its periphery toward the center until the dotted area eventually regained normal sensation. This area is called the overlap area of the

adjacent skin nerves. It was important to remember that recovery of
268 NEUROSURGERY

*

#'

<4Sfe

FIGURE 102.—Footprints of patient with contusion of left tibial and peroneal nerves caused by bullet wound through thigh 15 July 1944. A. Print

taken 29 September 1944, showing gross trophic disturbances of sole of foot.

Note scar across heel. B. Print taken 7 March 1945, when motor recovery

was full and sensory recovery 50 percent complete. Note beginning of transverse arch and partial return of normal skin pattern.

sensation in the overlap area was not a sign of regeneration in the interrupted nerve.

When the overlap area has regained full pain and touch sensation, the

black areas may remain void of sensation and mark the area which is exclusively innervated by the interrupted nerve. This area, the so-called

autonomous area or region of isolated sensory supply of a nerve, should not

be confused with the extension of the residual sensibility. This term,

which was used by Sherrington for the territory of a spinal root after

transection or full anesthesia of its two or three adjacent upper and lower

roots, has been applied to the sensitive area of a peripheral nerve after

anesthesia of its neighbors. This area, in the order of magnitude, is the

maximal functional field of a sensory nerve, including its overlap area into

the adjacent skin nerves. The isolated sensory supply (autonomous area),

on the contrary, represents the smallest sensory field. This area does not, in

most cases, regain sensation until the injured nerve has regrown into the

skin and made contact with its end organs.
EXAMINATION IN PERIPHERAL NERVE INJURIES 269

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FIGURE 103.—Footprints of patient with interruption of left tibial nerve 15 inches

above sole of foot 16 March 1944. A. Print of left foot showing clawing of toes, atrophy

of intrinsic muscles of foot, and loss of skin pattern 24 July 1944. B. Print of normal

right foot of same patient.

Some characteristics of decreased sensitivity might be explained by

a combination of physiologic and anatomic conditions. The function of a

sensory nerve might be so impaired that its threshold of irritability was

increased. A stronger stimulus was needed to produce a sensation. The

term "hypesthesia" was used for decrease of touch sensation and the term

"hypalgesia" for decrease of pain sensation.

On the other hand, only a certain number of nerve fibers might have

been injured or regenerated to their end organs in the skin. The end organs

which were present might have a normal threshold, but only a percentage

of the normal number of pain or touch points could be found. The terms

"penesthesia" and "penalgesia" were used for this condition, to imply scarcity

of end organs.

The importance of determining the number of pain points and of touch

points, or both, under certain conditions is best exemplified in a specific

case (fig. 106). The threshold for touch and pain sensation in a patient

with radial paralysis (8 gm.) had not improved during a period of 3 months.

The conclusion might have been drawn that regeneration had not progressed

and that the nerve was possibly scarred and should be explored. Determination of the number of end points, however, showed that a great number

of nerve fibers had arrived in the skin since the last examination. That
270 NEUROSURGERY

MEDIAN

FIGURE 104.—Diagrams showing areas of autonomous or isolated sensory

supply of ulnar and median nerves (black) and of fields of overlap from

adjacent nerves (dotted). Shrinkage of anesthesia in dotted field does not

indicate regeneration of injured nerve.

regeneration was progressing on schedule was borne out by later developments.

Pinprick is felt painfully only on stimulation of the end point of a

pain-sensitive nerve fiber. Its threshold was determined by measuring, in

grams, the pressure under which a pin had to be pressed against the skin

to produce soreness.

TIBIBL

C

FIGUKE 105.—Diagrams of areas of autonomous or isolated sensory supply

of sciatic, peroneal, and tibial nerves (black) and of fields of overlap from

adjacent nerves (dotted). Shrinkage of anesthesia in dotted field does not

indicate regeneration of injured nerve. A. Sciatic nerve. B. Peroneal nerve.

C. Tibial nerve.
EXAMINATION IN PERIPHERAL NERVE INJURIES 271

Complete anal

<Je»la ancsthesi

40 painpoints per cm-

.^.'""threshold ig.

."•l|p touch points per cmthreshold 3^. per mm.

IX touch point* per cm.1

threshold 0^. per mm.

Loss of Sensation afterBisection

of Radial Nerve.

Beginning Pain Sensation 6 Months

after- Suture of Radial Nerve.

f/o touch pointspresent

Parlia'l Retarn of Pain * Touch Sensitivity

9 Months after Suture of Radial Nerve.

A B C

FIGURE 106.—Diagrams showing quantitative estimation of pain and touch points

and their threshold after injury of radial nerve. A. Complete loss of sensation in radial

distribution after bisection of radial nerve. B. Beginning return of pain and touch sensation with 8-gm. threshold 6 months after nerve suture. C. Partial return of pain and

touch sensitivity 9 months after nerve suture. Although the threshold shows no further

improvement 3 months after the last test, as shown in B, the number of points has

increased from 1/cm.2to 20 and 12 respectively, indicating good nerve regeneration.

This is not the situation with the end organs for touch.7Touch, which

really means superficial pressure, produces a slight indentation of the skin

which becomes deeper with increased pressure. As this happens, a greater

number of end organs become involved and stimulated. The threshold is

expressed in terms of the tensile strength of the von Frey's hair which just

produces sensation. As a rule, therefore, touch sensitivity is expressed in

grams per millimeter.

The average threshold of pain sensation is one-half gram and of touch

sensation 1 gram per millimeter. There is little variation of threshold in

the various parts of the extremities.

The normal density of pain and touch points varies a great deal in

various parts of the body and undergoes great variations during life. End

organs are normally grouped in clusters, and numerous minimal lesions of

the skin in the course of life decrease the number of end organs and may

leave parts completely bare. Most neurologists have agreed to calling 50 pain

end organs and 30 touch points per square centimeter a normal number.

7 There are two types of touch end organs: (1) The basket-shaped nerve endings around the

root of each hair and (2) Meissner's end organs in hair-free parts of the skin. In hair-clad portions of the skin, the number of touch points is about equivalent to the number of hairs within the

same field.
272 NEUROSURGERY

This is far below the actual number of pain points, but there are practical

limitations to mapping out a larger number.

SENSORY EXAMINATIONS

Each sensory examination begins with the question of what type of

sensation, if any, the patient observes in the area of the injured nerve.

Numbness means absence of touch sensation in the skin and continues usually

for a while after pain sensation has returned. The term "paresthesia"

comprises many abnormal sensations and requires specification.

QUALITATIVE DETERMINATION OF SEQUENCE OF RETURNING

SENSORY FUNCTION

Tinel's Sign

Tinel first drew attention to the fact that the amyelinic nerve fibers at

the tip of a regenerating nerve are sensitive to gentle compression. The

sensation is that of formication and is usually likened to electricity by the

patient. It is not local but is projected into the skin distribution of the

compressed nerve.

This tingling sensation is not to be confused with pressure pain, which

is confined to the place of nerve compression or its immediate neighborhood.

The sensation is often elicited by compression of adjacent muscles and is

sometimes even more marked in them.

Tinel's sign, if present, is of great significance for the prognosis of

nerve regeneration, but its value depends on exact performance of the test.

Both Tinel and Woodhall stressed the importance of strict adherence to the

original definition of the phenomenon.

Three observations have to be secured before any conclusion can be

drawn, as follows:

1. From 4 to 6 weeks after partial injury or suture of a nerve, gentle

compression of its distal portion, about 1 or 2 inches below the lesion, must

produce a tingling sensation in the peripheral distribution of the compressed

nerve confined to its anatomic distribution.

2. This trigger point must become insensitive to pressure a few weeks

later.

3. The sensitive spot must travel down the nerve with a velocity of about

1.5 inches a month.

This sequence of events was found to be characteristic of nerve regeneration, but it indicated nothing about its degree. The absence of formication

on nerve compression, as well as failure of the trigger point to migrate down

the nerve, suggested a poor prognosis. These findings indicated that the

nerve was completely interrupted or that its fibers had not passed the suture

line or that they had met an obstacle and had not progressed beyond it.
EXAMINATION IN PERIPHERAL NERVE INJURIES 273

Tinel's sign was therefore regarded as of primary importance in the

evaluation of a nerve injury. It had a negative value in demonstrating

when the nerve was interrupted or had not regenerated or when a suture

was a failure.

QUALITATIVE METHODS OF MAPPING OUT AREAS OF

IMPAIRED SENSATION

Dragging a pin over the skin from the analgesic or hypalgesic area

toward the intact skin was found to be the simplest way of outlining an

area of lost or decreased pain sensation.

Pain sensation to unqualified pinpricks depended chiefly on sharpness

and thinness of the needle used and the changing degree of pricking.

Pollock suggested, to prevent the latter change, that the pin be inserted into

a 5-cc. or 10-cc. syringe and be weighted down by means of the piston.

Gentle touch with a wisp of cotton wool was used successfully over

hairless parts to determine qualitatively the perception of superficial pressure (touch), but it gave erroneous results over hair-clad portions. It was

inadvisable to draw a wisp of cotton or a hair over the skin; this practice led

to summation phenomena and wrong conclusions. Simultaneous stimulation of

skin and deep sense organs was done only with a camel's-hair brush. The borderline between denervated and intact skin was marked with a red pencil.

Recording.—It was found more difficult than is usually realized to transfer

correctly the outline of a determined skin area to a blank. For routine

clinical purposes, an approximate reproduction on the form was sufficient.

If greater exactness was desired, the skin drawing could be copied through

an onionskin sheet of paper, or, better, a photographic record, could be made.

QUANTITATIVE DETERMINATION OF PAIN SENSATION

Head's spring algesimeter (fig. 107) is a handy, easily manufactured

instrument sufficiently exact to determine the threshold of pain. It was

found practical to have one instrument to measure prick under a pressure

of 2 to 10 gm. (fig. 107 A) and another to measure it under a pressure of

10 to 40 gm. (fig. 107 B). Returning superficial pain sensation might need

values even up to 60 gm.

Materials.—Each of these instruments consists of a thin metal tube 10.5

cm. long and 6.5 mm. in the external diameter. Tube A (fig. 14 A) is closed

at the top, and the tip is screwed on. Tube B (fig. 14 B) is closed at the

tip and the top is screwed on. Tube A contains a thin metal rod ending in

a moderately thin needle. A small crossbar at the upper end of the rod

supports the needle at the blind end of the tube; another bar, at the lower

end, limits the protrusion of the needle from the tube. A fine spring scale,

soldered to the crossbar at the upper end of the rod, connects at its lower end

through a slot with a collar surrounding the tube. The spring is so cal-
274 NBUROSUKGERY

IO2 cm.

A B

FIGURE 107.—Structure of Head's algesimetei'. A. Algesimeter for prick under

pressure of 2 to 10 gm. B. Algesimeter for

prick under pressure of 10 to 40 gm.

Hair

FIGURE 108.—Graduated hair after von

Frey for measuring threshold of sensibility

to touch (superficial pressure).

• • • •

FIGURE 109.—Pattern of rubber stamp

used for estimation of number of pain and

touch points per square centimeter. Each

side of square measures 2 cm.

ibrated that the point of the needle, when applied vertically, bears only its

own weight. When the collar is slid down, increased pressure is exerted

on the needle. The degrees of pressure can be measured in grams by turning

the scales.

Tube B contains a longer and coarser spring with a crossbar, which

connects Avith the needle at the lower end only. A collar which glides inside

the tube is fixed to the spring at such a point that it exercises a pressure of

10 gm. when the upper end of the spring presses against the screw, closing

the tube, so as to bear only its own weight. A small button at the outer

circumference of the collar protrudes through a slot. This button can be

moved downward and fixed on 1 of 3 openings which are so placed that

they exert a pressure of 20, 30, and 40 gm., respectively.

Technique.—The patient was instructed to observe pain or soreness, not

degrees of sharpness, and to disregard the touch sensation accompanying

the prick. Pain had to be all or nothing. If the patient had to think over

what he felt, it was usually not pain. A preliminary test over a pain

sensitive area best explained what to expect. The pin was placed vertically

on the skin. The threshold was determined by gradually increasing the pressure until further increase did not augment the number of pain points in a

ai area.

The duration of this test was 20 minutes.

Recording.—The measured grams of pressure were noted with a red pencil

in the outlined area or were surrounded with a red square. The territory in

which prick under a load of 40 gm. was not felt as pain was considered

analgesic and painted red.
EXAMINATION IN PERIPHERAL NERVE INJURIES 275

QUANTITATIVE DETERMINATION OF SUPERFICIAL

PRESSURE (TOUCH)

Materials.—Materials required for this test were a set of von Frey's hairs,

prepared in the following way:

A great number of human hairs and horsehairs, about 1 to l)i inches long

were collected. The force (/) exerted by bending the hairs was measured in

milligrams by turning the scales. The force in the sets used at Cushing General

Hospital varied between 45 mg. and 1,800 mg. Hairs of equal force were

grouped together.

The next step consisted in measuring the length of the two axes of the

elliptic diameter of the hairs at their thick ends, which could be done in one

one-thousandth of a millimeter (M) with a thin slice of the hair. If the two axes

of the ellipse were called a and b, the radius of a circle of equal size was

r=-\/aXb. This radius varied in the sets used in these studies from 0.045 to

0 090 mm. The force (/) of the hair measured in milligrams, divided by r

1 . .

(radius) expressed in millimeters .—-r gave the tension of the hair in

grams per millimeter.

A complete test set after von Frey contained hairs of 1, 2, 3, 4, 5, 6, 8,

10, 15, and 20 gm./mm. tension. Deep sense organs might respond to hairs

of 8-20 gm./mm. when cutaneous sensitivity was absent. The hairs were

fixed with sealing wax to a piece of hardwood, the size of a kitchen match,

and their tension value was noted on the handle (fig. 108). The handles

were placed on a rack, which kept the hairs free from any contact, and the

set was protected against humidity in a tightly closed box.

Technique.—Examinations were made in a quiet room with the patient

seated comfortably and relaxed. The temperature was kept moderate because sweating as well as shivering impairs the accuracy of perception. The

patient was instructed to say "Touch" whenever he felt a touch. No questions were asked. A short demonstration over the intact skin preceded the

examination. During the examination, the patient kept his eyes closed.

Sixteen contacts of the skin were made per minute, following Head's

suggestion, in irregular time intervals to avoid rhythmic answers and to

detect the imaginary touch sensations so common in hypesthetic areas. The

test was usually begun with the strongest hair of 20 gm./mm. and was not

continued if this touch was not felt. If it was felt, the examiner then used

the finest hair, of 1 gm. tension, and jumped rapidly to 3, 5, 8, 10, and

15 gm./mm. until the number of touch points was not increased further by

use of a stronger hair. The examination was kept as short as possible because the test is trying and attention rapidly fails. Occasional touches over

an area of intact skin checked the patient's attention.

The duration of the test was 20 minutes.

Recording.—The measured tension was noted with blue pencil in the outlined area of hypesthesia or was surrounded by a blue diamond. The ter-
276 NEUROSURGERY

ritory in which superficial pressure with the hair of 20 gm./mm. tension was

not felt was considered anesthetic and painted blue (figs. Ill A, 113, 116 A,

117 A, 118, and 124). Completely analgesic and anesthetic areas were

blacked out.

ESTIMATION OF NUMBER OF PAIN AND TOUCH POINTS

Materials.—A rubber stamp was prepared, outlining a square whose sides

measured 2 cm. The borders of each centimeter were marked by thick dots.

Each square centimeter was subdivided by small dots which served as landmarks only (fig. 109). By touching or pricking each dot and interval, it

was easy to map out accurately 49 points per square centimeter.

An area of not less than 2 square centimeters was investigated because

of the normal tendency to grouping of touch and pain points and because

of their frequent loss following minimal skin lesions and the ensuing error.

Technique.—After delineation of the hypesthetic area, the inked rubber

stamp was so placed on the skin that half of it lay within the hypesthetic

field and the other half in the normal control area (fig. 106). The threshold

was measured as described. The landmarks on the upper border of each

centimeter were followed with pin or hair from left to right, each being

touched seven times serially. To avoid adaptation, the examiner then went

on to the lowest row of the same centimeter from right to left, continuing

in zigzag movements until a square centimeter was mapped out. The other

square centimeters were examined in the same way.

This method of examination was found to be the only exact one, because

it precluded the possibility of touching the same sensitive points several

times while bypassing insensitive ones. It was, however, time consuming

and tiring and was therefore reserved for special studies.

The duration of the full test was 1 hour.

A rapid simplified survey of the number of pain and touch points could

be obtained by touching the skin at random within the area of decreased

sensitivity with the predetermined pin or hair 50 subsequent times. The

patient was asked to register each sensation. The answers were tallied; a

correct answer was marked by a slant, failure by a zero, and hallucinatory

answers by a broken stroke. The relation of correct to missed answers,

possible hallucinatory ones being disregarded, gave the percentage of points

present directly. The method was inexact from a physiologic point of view

but gave an approximate idea for clinical purposes.

The duration of the simple test was 15 minutes.

Recording.—The patient's hand was placed on a sheet of paper, and its

contour was outlined. A print was made with the rubber stamp in the

same position on the skin. The places of positive answers were marked in

the corresponding spot on the paper (fig. 106). Pain points were marked

in red, touch points in blue.
EXAMINATION IN PERIPHERAL NERVE INJURIES 277

NERVE BLOCK TO ELIMINATE OVERLAP SENSATION

If it was doubtful whether an injured nerve had itself regenerated or

its sensitivity had been restored by fibers of the adjacent skin nerves, it was

helpful to anesthetize the fibers, as already described. If the original field

remained sensitive, the conclusion was that the interrupted nerve had reached

its skin distribution. Block of sensory nerves abolished, at the same time,

sweating in their skin distribution. The combined anesthesia and anhydrosis

following nerve block were often helpful in the frequent instances of an

unusually large overlap in one of the hand nerves. It might be important

to find out whether return of sensitivity was caused by shrinking in the

overlap area or through regeneration, or whether an unusually small area

should be interpreted as an individual variation or as the consequence of

a partial nerve lesion.

In this test, it was necessary to copy the original outline of the anesthetic region through onionskin paper, or better, to photograph it.

LOCALIZATION OF RETURNING SENSATION

In the beginning of returning sensation, localization is not yet possible

or may be incorrect or may show the phenomenon of split sensation. This

means that a sensation is felt simultaneously at the point of touch and at

another point or that it travels from the original point to a second one.

This phenomenon is a sign of returning function.

Technique.—The extremity to be examined was hidden from the patient

by a screen. The corresponding extremity of a helper was placed on the

other side of the screen, in view of the patient, in the same position as the

arm or leg to be tested. The patient was instructed to indicate with his

index finger on the helper's limb the point at which he felt the touch on his

own body. If the sensation radiated from the original point to another

area, or if it appeared at two points simultaneously, he was asked to follow

with his finger the course of the sensation.

The duration of the test was 30 minutes.

Recording.—The point touched was marked in black on the sensory form

and the place to which it was projected was marked in red. In the case of

split sensitivity, an arrow was run from the touched spot to the area of

point of radiation.

COMPASS TEST (SPECIAL DISCRIMINATION TEST,

TWO-POINT TEST)

The power of discriminating two points touched simultaneously or successively does not depend directly on the shortest distance between them.

It is rather a judgment, predicated upon the interference of several impulses

arriving in the cortex in very short intervals and integrated into peaks and
278 NEUROSURGERY

valleys of cortical activity. The distance of these peaks from one another

or their frequency in the time unit is considered the determining factor of

spatial discrimination. In reality, therefore, two-point discrimination is a

frequency discrimination in the brain wave pattern.

Materials.—A pair of compasses was used in this test, as the name

indicates. Head used a carpenter's compass, the legs of which were ground

down until they had lost their sharpness. A minimal droplet of solder was

sometimes affixed to the legs, but a piece of cork over the points was not a

practical solution. Commercial esthesiometers are manufactured with blunt

ivory points and have the advantage of a fine measuring scale and vernier,

but an ordinary slide gage with a vernier whose jaws had been rounded

was usually available and was easy to handle.

Technique.—All measurements were made in the longitudinal axis of the

extremities. The following tabulation gives an approximate idea of the

normal distance of two touch points in a given area as determined by

Weber and confirmed by von Frey:

Skin region: Millimetern Skin region—Continued Millimeters

Tip of tongue 1.1 Cheek 11.3

Volar surface of finger pulp 2.3 Dorsum of basal phalanx 15.8

Vola of middle phalanx 4.5 Lower part of forehead 22.5

Dorsum of finger and phalanx __ 6.8 Back of hand 31.5

Tip of nose 6.8 Forearm 40.5

Vola capit. ossis metacarpalia 6.8 Lower leg 40.5

Tip of toe 11.3 Back of foot 40.5

Dorsum of middle phalanx 11.3 Upper arm (middle) 67.5

Vola of hand 11.3 Thigh (middle) 67.5

This distance was selected for the first test. If the two points could not be

felt clearly as separate units, the distance was gradually enlarged until

threshold was obtained. With this distance, sometimes 2 points (and sometimes only 1) were applied to the area to be tested in irregular intervals

but in such a sequence that the patient was touched 10 times with 1, and

10 times with 2 points.

The duration of thistest was 30 minutes.

Recordings.—Sometimes only the measured distance was noted over the

standard value in the examined part of the body, for instance At other 1.5 cm.

times, McDougall's method of sampling was used. A correct answer was

marked by a slant, placed above the line when one point was touched, below the

line when two were touched. An error was marked with a cross placed above

the dividing line when one point was called two and below it when two points

were called one. The answers, whether right or wrong, were arranged in strict

sequence above and below the horizontal line. Such a record in a field with a

normal spatial discrimination distance of 1.5 cm. is shown before the return

of two-point discrimination:

1 5 cm I HI H / UM or short 1-5 cm. 1 9S.1 W. i.ü cm. 2 xx x xxx xxxx or snort - 2 0 R. 10 W.
EXAMINATION IN PERIPHERAL NERVE INJURIES 279

This record changed with gradually returning spatial discrimination to:

i.l /// // //X // 1 . 1 9 R. 1 W.

° °

m

- 2 J]X Wl m XX °

r L5 Cm

- 2 5R.5W.

In other words, there was no recovery of the two-point discrimination in the

first record and only 50 percent recovery in the second.

SWEAT TESTS

The skin area of an interrupted peripheral nerve does not sweat. The

autonomic (cholinergic) sweat fibers run along with the sensory branch of

the nerves. The area of lost or decreased sweating is similar to, though not

completely identical with, that of diminished sensitivity. The sweat test

could be used, therefore, as an objective means of verifying the patient's

statement about hypesthetic or anesthetic regions or to demonstrate them

if the patient was unconscious or otherwise unable to cooperate.

Sweat Tests of Hands

The simplest and cleanest method of recording sweating, though it is

limited to the palm of the hand, was described by Silverman and Powell.8

It is based on the fact that ferric chloride forms a black-blue ink with

tannic acid in the presence of sweat.

Materials.—Materials for this test included the following items:

1. Five-percent aqueous solution of tannic acid.

2. USP tincture ferric chloride, diluted 1:3 with alcohol (25 percent), to

be kept in a tightly closed brown bottle.

Technique.—The tannic acid solution was poured into a glass or enamel

(photographic) tray large enough to hold letter-sized paper. Ordinary

mimeograph paper was soaked in the solution for 3 minutes and then allowed to dry. The patient's palm was cleaned with alcohol and dried with

a blower or fan. It was painted with the ferric chloride by means of an

applicator and again dried.

One cubic centimeter of furtrethonium iodide (Furmethide iodide)

(containing 5 mg.) was injected intramuscularly. Profuse sweating began

within 3 to 5 minutes. The patient placed his wrist, flexed 90°, against the

edge of a table, the forearm hanging straight down. This position permitted

maximal flattening of the hand. The examiner pressed the hand firmly

down on the tannic acid paper and held it in position for about 3 minutes.

The hand was then lifted straight upward, to avoid smearing. If the first

print was too heavy, the hand was placed at once upon another sheet of

treated paper. The correct degree of printing was found after some experience. The reproduction thus secured was so delicate that often single sweat

glands could be demonstrated, especially on the pulp of the fingers.

The duration of the test was 10 to 15 minutes.

8 Silverman, J. J., ana Powell, V. E.: Studies on Palmar Sweating. Am.J.M. Se. 208 : 297-305,

September 1944.

49 8991T—59 20
280 NEUROSURGERY

Sweat Tests of Other Parts of Body

Chinizarin method.—To demonstrate sweating on other parts of the extremities than the hands and the trunk, sweating reagents had to be placed

directly on the skin.

Materials for the test included the following items:

1. Chinizarin 2-6 disulfonate (Burroughs Wellcome), a gray powder

which turns red when in contact with sweat.

2. A tube of greaseless jelly.

The part to be examined was anointed with the greaseless jelly and

allowed to dry. The patient was given 10 gm. of aspirin and hot fluids in

large amounts and was placed in a baker for 45 minutes. He was then

removed and wiped dry. Once he started to sweat, he always continued to

do so. The dyestuff was applied to the skin by cotton wool and was not

rubbed in. The powder turned to red in areas in which the patient sweated.

The duration of the test was 2 hours.

The color showed well on Kodachrome or on panchromatic black and

white film (fig. 110).

Iodine-starch method.—If Chinizarin was not available, the iodine-starch

method, although inconvenient, gave good results in experienced hands.9

Materials consisted of the following items:

1. Tincture of iodine 1.5 percent, 450 cc.

2. Castor oil, 50 cc.

3. Starch powder.

The part to be tested was painted with iodine. The skin was allowed

to dry without wiping. Starch was pressed into the skin with cotton

wool. When the patient was allowed to sweat, the sweat produced a dark

blue to black color. If too much sweating occurred, the black powder would

begin to flow.

Results were photographed on commercial film.

SKIN TEMPERATURE TEST

Painful coldness in fingers and toes was one of the commonest and most

distressing symptoms in paralysis of the peripheral nerves. Furthermore,

the possibility existed that the impaired circulation suggested by such evidence might impede recovery and that objective knowledge of the degree and

mechanism of the vasomotor paralysis might be helpful in an attempt to

alleviate it. The presence of paradoxical vasoconstriction might also call for

immediate sympathetic block to avoid subsequent ischemic contractures and

ankyloses.

9 The effect of Furmethide iodide in connection with the Chinizarin or starch methods was not

tested. The possibility of sensitization of denervated sweat glands to cholinergic drugs should not

be overlooked.
EXAMINATION IN PERIPHERAL NERVE INJURIES 281

FIGURE 110.—Hyperhidrosis in

skin distribution of ulnar nerve

after interruption, suture, and

beginning regeneration of nerve

(Chinizarin method). (Photograph taken with flashlight on

panchromatic film.)

Impairment of vasomotor function could often be diagnosed by simple

observation. The extremity was usually cyanotic, especially when dependent,

and might remain so after being elevated. It might, on the other hand, be

pale and fail to gain normal color when dependent. The effect of immersing

the hand or the foot in cold or hot water might indicate the nature of the

vasomotor disturbance.

These are all qualitative methods of examination. The only quantitative, accurate, and prompt method of judging the blood flow in the tissues is

measuring the skin temperature by means of a thermocouple. The temperature indicates vasospasm, vasoparalysis, and vascular reactions to direct and

indirect reflex stimuli.

Principle of test.—Since the interest is in the spot temperature rather than

in the average temperature over the skin, the method of choice is the potentiometric method. If wires of two dissimilar metals, such as iron and

constantan, are united by silver solder, a voltage is generated proportional

to the temperature difference between the two junctions. One junction is

used for measuring the skin temperature; the other is placed into ice water

in a thermos bottle, to serve as the temperature reference junction. The

increase or decrease of voltage is an accurate measure of the temperature on

the warm junction. A portable direct current null potentiometer with a slide

wire dial is calibrated in millivolts. The values in terms of degrees centigrade are read from a conversion table and added to or subtracted from the

temperature in the thermos bottle.

In Leeds and Northrup instruments, one junction is at room temperature

and the circuit compensated electrically. No ice bath is needed. Hence, the

reading of the potentiometer is independent of changes in the room temperature. The dial of the potentiometer is calibrated directly in degrees

centigrade. Point galvanometer, standard cell, battery, and galvanic keys

are included. An uncalibrated galvanometer is used to show when the dial
282 NEUROSURGERY

reading is correct within the limits of error of the instrument; that is,

±0.7° C.

Materials.—Materials used in the test consist of the following items:

1. A portable direct current null potentiometer with millivolt indicator.

2. A switch box with six or more outlets.

3. Thermocouples, which may be bought ready made for measuring skin

temperature or may be made. Constantan-iron wire can be bought by the

foot and the number of junctions prepared by uniting the two wires with

silver solder.

Technique.—The patient is placed on a bed in a constant temperature room

of about 20° C. The two binding posts of the potentiometer are connected

with the switch box from which go six leads, as follows: 1, for taking the

room temperature; 2, for taking the patient's mouth temperature; 3, 4, 5, and

6, to the pulp of the index and little fingers of each hand.

If the foot is to be examined, the latter electrodes are placed on the

plantar surfaces of the little toes and the dorsal interspaces between the

big and second toes. The thermocouples are securely fixed to the skin with

tape, which should not be wound around the fingers. Eeadings are taken

in intervals of from 5 to 10 minutes from all thermocouples, which are

connected in rapid sequence with the potentiometer by means of the switchbox.

After 30 to 40 minutes, heat pads are placed on the trunk, and the

patient is covered with 3 or 4 blankets. The hands remain uncovered.

When the temperature has leveled off after 1 hour, the heat pads and blankets

are removed, and the normal hand is immersed in ice water for 3 to 5 minutes.

After the temperature of both hands has leveled off, the hand on the

injured side is immersed in ice water for 3 to 5 minutes. Then the normal

hand is immersed in hot water, and, finally, the hand on the injured side

is similarly immersed.

A complete examination consumed about 4 hours but could be shortened

in individual cases. The method was, however, reserved for selected cases.

Recording.—Temperature readings were plotted against time. Examples

of results and of conclusions drawn from them are illustrated in figure 112

and table 10.

TABLE 10.—Skin temperature in degrees centigrade (case

Procedure

Heating whole body

Local ipsilateral icing (axon reflex)

Local contralateral icing (spinal reflex)

Lett index finger

-12 +9

- 7 -5.

- 4 -2

Eight index

finger

Percent

-25

-18

-50

Eight little finger

Percent

+ 10 (-16)
EXAMINATION IN PERIPHERAL NERVE INJURIES 283

CASE HISTORIES

The following case histories are presented in the form of summarized

progress notes from the hospital charts, to show convenient graphic presentation of motor and sensory signs and muscle atrophies. The final degree of

recovery was unknown in most of these patients when these summaries

were made.

As already indicated, the idea underlying these graphic presentations

was to demonstrate simultaneously, as concisely and as precisely as possible

the extent and severity of the initial motor and sensory defects, the type and

location of surgical treatment, the distance from the injury to the muscle

examined, the time factor, and the progress of recovery.

The key to the graphic records is as follows:

1. The numbers in the sets of unpainted hands and feet in the motor

forms represent percentages of full average strength in the respective motions.

2. The exact spots on the sensory form on which the measured strength

of the respective motions is recorded are indicated as in figure 99.

3. Blackout areas on the sensory forms indicate complete loss of all

modalities of sensation. On the colored charts, which could not be reproduced for reasons of economy, loss of pain sense was indicated by uniformly

red coloration and loss of touch sensation by uniformly blue coloration.

4. Figures framed by squares (red on the original charts) indicate the

percentage of return of pain sensation and those framed by diamonds (blue

in the original charts) indicate the percentage of return of touch sensation.

The areas to which these figures refer are slightly shaded.

Case 1. Injury of left ulnar nerve above elbow

9 June 1944. Pell on piece of glass during maneuvers. Complete sensory and motor

paralysis of left ulnar nerve below wrist flexor (figs. 94 and 111).

19 July 1944. The ulnar nerve was exposed 6 inches above and 12 inches below the

elbow. A neuroma (% inch) was resected 2 inches above the elbow. The ulnar nerve

was transposed and sutured end-to-end.

3 Jan. 1945. No return of motor or sensory function. Removal of tantalum cuff.

Electrical stimulation of the nerve 1% inches below the suture line resulted in flexion

of the end phalanges of the ring and little fingers and sensation radiating downward

to the little finger. Handprint shows clawing of little, ring, and index fingers, atrophy

of abd. dig. V, of 4th and 3d interossei, and of thumb adductor muscles. Hence, the

thumb has sunk down.

23 Aug. 1945. No motor improvement, slight shrinkage of analgesic area at wrist

(overlay). Has worked an average of 40 hours a week as maintenance man in a textile

mill during the last 7 months and improved the configuration of his hand slightly. The

index and ring fingers have straightened. The tone of the adductor has improved. No

more can be expected in 13 months with a distance of 16% inches to grow.

26 Nov. 1945. Pair strength in the thumb adductor and beginning motion in the

abd. dig. V. This means 16i4"/16 m. Both muscles have gained in volume; all fingers

straightened. Sensation still absent in the entire area of isolated ulnar supply.

17 June 1946. Good improvement of strength of all hand muscles except for adductor

of little finger. Return of pain and touch sensation down to tip of little finger 21"/23 m.

Summary.—Return of motor function of intrinsic hand muscles and sensitivity on time,
284 NEUROSÜRGERY
EXAMINATION IN PERIPHERAL NERVE INJURIES 285

following end-to-end suture and transposition of ulnar nerve. One may argue as to

whether 20 percent of the average represents adequate strength in the abd. dig. V.

Further improvement can be expected, but to all intents and purposes, this patient has

even now a perfectly useful hand as evidenced by the fact that he has earned a normal

livelihood in his trade as a mechanic.

Case 2. Injury of right median nerve near elbow

17 Jan. 1946. Complete motor and sensory paralysis of radial nerve, complete sensory

and partial motor paralysis of median nerve with mild causalgia following severe lesion

on radial side of volar aspect of right forearm near elbow (fig. 112).

16 and 19 Apr. 1946. Procaine blocks of right stellate ganglion with good result.

17 Apr. 1946. Complete analgesia and anesthesia in distribution of the radial,

median, and musculocutaneous nerves. No radial or ulnar pulses, no oscillometric readings at wrist.

Sweating is almost absent in thumb, index, and middle fingers, and on thenar and

metacarpal area of the index. It is poor over metacarpal area of middle finger and

adductor region of palm.

Skin temperature of right index finger is 3.5° C, while that of the left index finger

rises 11.8° C. In other words, there is reflex vasoconstriction in right index finger on

heating the body. The temperature of the right little finger rises but lags 2.5° C. (23

percent) behind that of the normal hand.

29 Apr. 1946. Operation. The radial nerve was found to be interrupted, the ends

so far apart that they were left alone for later tendon transplant. The median nerve

was embedded in dense scar tissue below the pronator muscle but in continuity. It was

freed from scar and injected with saline, which passed freely.

4 Sept. 1946. Sensation for touch and pain has partially returned over the palm

and for subcutaneous pressure in thumb, index, and middle fingers.

14 May 1947. Thirteen months after neurolysis, sensation was normal in the palm

and basal phalanges of index and middle fingers; touch sensation had returned in the

distal phalanges; analgesia continued. Sweating had returned to thumb and index finger

and to the basal phalanx but not yet to the distal phalanges of the middle finger. It

was decreased over the thenar.

Skin temperature is shown in table 10.

Summary.—The axon reflex has recovered—as is the rule—earliest and relatively best.

The vasomotor reaction of the little finger has improved compared with the figures of

a year ago (-23 percent) but still lags 16 percent behind the normal side, although the

ulnar nerve was at no time involved.

Case 3. Injury of right ulnar nerve above elbow

11 Dec. 1944. Wounded by shell fragments in right upper arm with severance of

the ulnar nerve 2 inches below the axilla (fig. 113).

7 Apr. 1945. Nerve sutured end to end overseas without transposition and under

considerable tension.

21 Sept. 1945. Patient's transfer to Cushing General Hospital requested because

there seemed to be no indication of returning function. X-ray suggested separation of

suture. At the time of his arrival at Cushing, intraneural stimulation at elbow 6 inches

below suture line gave acute sensation in finger. The tantalum cuff was removed and

an entirely satisfactory nerve suture found. Sensation on nerve stimulation was present

at all points in the distal portion of the freed nerve, though not as acute as in the

proximal portion. No motor reaction could be expected except in wrist and deep finger

flexors, which seemed to be intact.

10 Jan. 1946. No improvement of motility or sensation in hand, but intraneural

stimulation at wrist showed abduction of 5th finger, i.e., 18"/9 m.
286 NEUROSURGERY

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FIGUEE 112.—Graphic record of patient with complete sensory and partial motor

paralysis of right median nerve, managed by neurolysis. A. Sweat handprints taken at

13-month interval (tannic acid-ferric chloride method).' Second print shows gradual

return of sweating, which is still incomplete over middle and terminal phalanges of

middle finger. B. Skin temperature curves of same patient taken at 13-month intervals.

The first examination shows vasoconstriction of right index finger. The second shows

lagging of temperature increase on heating body of right index and little fingers in comparison with uninjured side. There is also lagging decrease of skin temperature in

injured side for direct cooling as well as cooling of opposite side (axon reflex and spinal

vasomotor reflex).
EXAMINATION IN PERIPHERAL NERVE INJURIES 287

FIGUEE 113.—Progressive regeneration of ulnar nerve interrupted

above elbow. Although the nerve

was not transposed and was sutured under considerable tension,

regeneration proceeded on schedule, as evidenced by intraneural

stimulation and returning sensitivity. Palm., dors, trctcross

18 Apr. 1946. Definite voluntary flicker in abd. dig. V and normal sensitivity in

overlay area of palm not yet in isolated supply area of little finger.

15 Aug. 1946. Intraneural stimulation gives strong contraction in short thumb flexor

and some in opponens. There is good recovery of pain and touch sensation down to

the tip of the little finger; this means 22"/161

/4 m. There is still a mild inability to

extend fully the last two fingers. This is so little disabling that patient rejected suggestion of transferring his sublimus tendon to the dorsal aponeurosis.

Summary.—Good regeneration despite tension on nerve scar, anticipated by intraneural

stimulation.

Case 4. Injury ofright ulnar nerve below elbow

31 May 1944. Wounded in upper third of right forearm by rifle bullet, with complete

sensory and motor ulnar paralysis below the wrist flexors. Patient insisted on existence

of considerable improvement, which delayed operation for 3% months (fig. 114).

12 Sept. 1944. The nerve was freed 3 inches both above and below elbow and fount*

completely interrupted. It was transposed and sutured end to end over a 5-cm. gap.

10 April 1945. Marked atrophy of thumb and of adductor and abductor of little.

finger with clawing.

6 July 1945. Although there is no motor or sensory improvement in the hand, its

configuration has much improved. The little finger has been limbered up and straightened and the thumb adductor has better tone.

25 Sept. 1945. Patient has improved to the degree that he is acceptable for reenlistment in the Regular Army. There is 70 percent strength in the deep flexor of the little

finger, 45 percent in the abductor dig. V, and 20 percent in the thumb adductor. There

is 75 percent return of touch sensation down to the tip of the little finger and practically

full pain sensation. The handprint shows good increase in the volume of the abd. dig. V

and reappearance of the thumb adductor.

Summary.—This man has used his right hand with unusual energy for 5 months

in his occupation as a tree surgeon. This may have contributed to the excellent final
288 NEUROSURGERY

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EXAMINATION IN PERIPHERAL NERVE INJURIES 289

result, despite a lapse of 16 months from the time of interruption of the nerve to the

reinnervation of the muscles. 14"/12 m.

Case 5. Injury of right ulnar nerve above wrist

11 Sept. 1944. Received laceration of right forearm with compound fractures of

distal ends of radius and ulna resulting in complete motor and sensory paralysis of right

ulnar nerve below wrist flexor and finger flexors when struck by tank during attack

(flg. 115).

There was bony union of radial fracture and no union of ulna when patient arrived

at Cushing General Hospital. The paralysis continued unchanged for 4 months. The

ring and little fingers showed clawing. The last two interossei and the abductor dig. V

were atrophied. It was therefore decided to explore the ulnar nerve.

12 Jan. 1945. Incision over course of the ulnar nerve extending 3 inches above and

6 inches below elbow joint. Dense scar found 2 inches distal to joint. A neuroma involved less than a third of the nerve, which felt moderately hard at this point. Saline

injected flowed slowly through the scar. The nerve branches to the flexor carpi ulnaris

and to the finger flexors came off proximal to the scar and reacted well on electrical

stimulation. There was no reaction in the intrinsic hand muscles but near-normal sensory response from a point 2 inches distal to scar. The nerve was transposed to a more

superficial level to provide a better bed but otherwise left alone.

22 May 1945. Beginning strength in abductor dig. V and thumb adductor. Can

innervate all interossei but without power. The fingers have straightened. The atrophy

of the interossei is receding but that of the abductor dig. V and thumb adductor has

progressed. Touch and pain sensations have markedly improved down to the fingertips.

24 Sept. 1945. Muscle strength and sensibility have continued to improve, though

very slowly, while the volume of the intrinsic hand muscles has returned to normal

except for the third interosseus.

Summary.—One is inclined to believe that the return of function was influenced by the

neurolysis. If this were not the case and regeneration had started soon after injury,

10"/8 m. and even 14"/8 m. would represent an average growth rate for a completely

interrupted sutured nerve. The completeness with which the marked muscle atrophy

was restored to normal within 4 months exceeds anything seen in complete interruption

of a nerve. The slow progress in regaining muscle strength, on the other hand, may be

due to the fact that the patient, a college student, could not be persuaded to do hard

manual work. This case is considered to be an example of partial intraneural interruption and scarring. Exploration and neurolysis were certainly indicated and possibly

helpful in hastening recovery.

Case 6. Injury of left ulnar nerve above elbow

I June 1944. Wounded by mortar shell at junction of middle and lower third of

upper arm. The left forearm and hand became immediately useless, the little and ring

fingers numb. The wound was debrided the same day and the ulnar nerve explored.

Its sheath was intact but the nerve appeared narrowed and felt as if about one-half

of its fibers were severed. The nerve was left alone (fig. 116).

II Oct. 1944. On the patient's arrival at Cushing General Hospital, the intrinsic

hand muscles were paralyzed and there was considerable atrophy, with clawing of last

two fingers. Sensitivity in little finger absent.

20 Nov. 1944. Nerve explored and found in perfect condition. Electrical stimulation

gave contraction of wrist and finger flexors but not of intrinsic hand muscles. Sharp

pain response in little finger from most distal part of incision.

29 Jan. 1945. Touch and pain sensation down to fingertip is first sign of returning

nerve function. 22%"/& m. This recovery rate of 2% inches per month suggests that

the sensory fibers had been spared in the intraneural injury.
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21 July 1945. Questionable flicker in abductor digiti V. Muscle atrophy, which had

increased until February, has begun to recede. The last fingers have been limbered up

and straightened.

1 Nov. 1945. All intrinsic hand muscles are innervated, though the adductor pollicis

reacts only to intraneural stimulation. The atrophy of abductor dig. V has markedly

improved. 18"/17 m. Only mild hypesthesia and hypalgesia present in little finger.

Summary.—This soldier, although a college student in civilian life, has worked his hand

hard, lacing and holding wire nets and cables 50 hours a week for 7 months. He has

limbered up perfectly his contracted last two fingers and increased the volume of his

paralyzed muscles better than expected. He was fortunate to be debrided the day of

injury by an experienced neurosurgeon, who explored and judged correctly the condition

of the nerve and gave a complete description of his findings. It would have saved the

patient the reexploration of 20 Nov. 1944—which did no harm anyway—had we known

the oversea surgeon at that time as we did shortly afterward. The time sequence of

recovery suggests that the motor fibers to the intrinsic hand muscles had been interrupted intraneurally and had to regenerate in the usual growth rate, whereas the sensory

fibers were only contused. A number of them regained function much earlier than could

be expected from regrowth, while others lagged as much as the motor fibers.

Case 7. Injury of left median nerve in forearm

28 Aug. 1944. Wounded by shell fragments in left forearm 2 inches above wrist with

complete motor and sensory median paralysis (fig. 117).

3 Dec. 1944. Median nerve mobilized, sutured, and encased in performed tantalum

cuff in general hospital overseas.

30 Jan. 1945. Clawing of index and middle fingers.

19 Mar. 1945. Cuff removed, revealing an indurated nerve. Electric stimulation

1% inches below suture line produced only sensory response in index and middle fingers.

4 Apr. 1945. Marked atrophy of opponens and abd. poll. br. muscles. Straightening

of index and middle fingers.

26 July 1945. Just beginning return of touch and pain sensitivity down to fingertips

and voluntary contraction of short thumb abductor.

20 Oct. 1945. Voluntary contraction of short thumb abductor and of opponens on

intraneural stimulation at wrist. Volume of opponens and abd. poll. br. muscles restored,

though not yet completely.

28 Jan. 1946. All intrinsic muscles are innervated. Sensation improved to degree

that remaining deficit does not impair earning capacity. Patient has worked in his prewar occupation, as plastic moulder, an average of 46 hours a week during the last 9%

months.

Summary.—The long delay of motor recovery, 4"/ll m., in a median or ulnar suture

close to the wrist is not unusual. The early return of pain sensation in the median

distribution of the palm is no sign of regeneration of the median nerve but of the returning overlap from radial and ulnar nerves. The eventual degree of strength, especially

in the opponens, cannot be predicted, but the good and rapid return of muscle volume

is promising. The crucial factor in a median nerve paralysis is the satisfactory return

of sensitivity in the fingertips, rather than of motor strength, which usually can be

compensated for by the adductor pollicis and the ulnar-innervated part of the short

thumb flexor or, in the worst cases, by transplantation of a tendon.

Case 8. Injury of right ulnar and median nerves above elbow

12 Nov. 1944. Wounded by shell fragment. Compound comminuted fracture right

humerus, lower third and complete paralysis of median and ulnar nerves (fig. 118).

24 Apr. 1945. Both nerves were found interrupted above the elbow and sutured

end to end over 8-cm. gap with mobilization of nerves between axilla and middle of forearm. Transposition of ulnar nerve. Humerus plated.
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6 Aug. 1945. Long thumb flexor innervated. Return of pain sensation in overlay

area of median and ulnar distribution of palm.

7 Nov. 1945. Wrist and long finger flexors of ulnar and median innervated.

8 Feb. 1946. Forearm flexors improved but intrinsic hand muscles absent. Returning pain sensation in fingers except for little finger.

13 May 1946. Intraneural stimulation of ulnar nerve at wrist gives contraction of

abductor V with 2 MA and of adductor pollicis at 4 MA. Intraneural stimulation of

median nerve at wrist gives no motor reaction.

9 Aug. 1946. Improvement of sensation but little of motion. Contracture of fourth

and fifth fingers is most distressing and tendon transplant will probably be needed.

Summary.—Patient has worked during the last year in his trade as fur cutter, averaging 40 hours a week, despite handicap caused by absence of thumb opposition and by

flexion contractions of ring and little fingers. Distance from suture to hand muscle is

13 inches, the time elapsed 13 months. However, the nerves were mobilized another

6 inches up to the axilla and may have to grow from this point down. This would mean

19"/16 m. at the time of discharge. Patient is discharged on his own request. The final

result remains to be seen. Tendon transplants may be eventually necessary.

Case 9. Injury of right radial nerve above elbow

9 Apr. 1945. Wounded by rifle bullet, sustaining compound comminuted fracture of

right humerus with complete radial paralysis below level of triceps muscle (fig. 119).

24 May 1945. Radial nerve suture with tantalum wire overseas. Tantalum foil.

No union of fracture.

10 July 1945. Arrival at Cushing General Hospital. Still complete motor and sensory radial paralysis. Good bony union of fracture.

9 Oct. 1945. First motion in brachioradial muscle. Beginning touch sensation on

back of hand.

4 Dec. 1945. Beginning dorsiflexion of hand and extension of fingers.

13 Feb. 1946. Thumb extension and abduction, improving touch and pain sensation.

Has worked a 50-hour week during last 4 months as a grocery store clerk.

Summary.—Excellent result of early end-to-end suture of radial nerve with fracture

of humerus 10"/83/i m.

Case 10. Injury of left radial nerve (at operation) above elbow

30 May 1944. Simple complete fracture of lateral condyle of left humerus (fig. 120).

13 June 1944. Open reduction with removal of fragment. Radial nerve retracted.

20 June 1944. Wristdrop, inability to extend thumb or fingers, and loss of sensitivity

on radial part of dorsum manus. Patient was transferred to Cushing General Hospital

for neurosurgical treatment when no improvement was apparent 3 months after operation.

10 Oct. 1944. Arrival at Cushing General Hospital. Wrist and finger extensors

showed fair strength and the long thumb extensor some motion. There was still complete analgesia. However, 40 percent touch sensation had returned in one-tenth of the

normal number of touch points.

23 July 1945. Thirteen months after operative traction paralysis, strength of finger

extensors was full, of wrist extensors and long thumb abductor 75 percent, of thumb

extensors about 50 percent. Pain and touch .sensitivities had returned 75 and 85 percent,

respectively; that is, 13"/13 m. Patient has worked in his own trade as hydraulic press

operator on a 48-hour week during the last 6 months.

Summary.—This is an example of a radial nerve contusion by the retractor during

operation. There was justifiable concern as to the degree of injury when no return of

function was observed in 3 months, with a distance of 3 inches from the site of injury

to the wrist extensor. However, improvement became apparent 1 month later and

progressed satisfactorily despite the delay.
EXAMINATION IN PERIPHERAL NERVE INJURIES 295

NaTne:L.M.

RSN. : 3125*766

Examiner: T.E.N.

FIGURE 119.—Graphic record of patient with interruption of right radial

nerve and fracture of humerus. Chart shows excellent motor and sensory

result of early end-to-end nerve suture.

FIGURE 120.—Graphic record of patient with contusion of left radial nerve by

traction during open reduction of fracture of humerus, with removal of lateral

condyle. A week later, complete radial paralysis was evident. Spontaneous

delayed recovery occurred.

498991—59 21
296 NEUROSURGERY

Case 11. Injury of leftsciatic nerve in upper third of thigh

7 July 1944. Wounded by shell fragments in upper third of left thigh with motor

and sensory sciatic paralysis below the knee. Pin and needle sensation, most marked

over dorsum of foot, had suggested returning function and delayed exploration (fig. 121).

7 Dec. 1944. Operation. Incision from gluteal fold to popliteal space and freeing

of nerve. The nerve was completely interrupted in the middle of the thigh, about 4

inches above its bifurcation. It was fully mobilized, and the tibial and peroneal portions

were isolated and separately sutured end-to-end after resection of neuromas and gliomas,

over a gap of 2 inches. The knee was flexed to 90°.

18 Jan. 1945. Cast removed and leg gradually stretched to 150° until February 1st.

8 Oct. 1945. First sign of returning function in gastrocnemius which is just in

time (10'VIO m.).

18 Mar. 1946. Good strength in gastrocnemius and trace in tibialis ant. Intraneural

Stimulation of peroneal at flbular head gave sensory radiation but no motion. 11"/15 m.

19 July 1946. Voluntary contraction of toe extensors and questionable reaction of

peroneal muscles to intraneural stimulation. No sensory improvement except for overlay

areas. No more can be expected for another year. Has worked as a punch press operator for over a year with a weekly average of 50 hours.

Summary.—This is an example of a high sciatic interruption, sutured after 5 months'

delay. Patient made a good motor recovery and was clearly going on to a satisfactory

end result, only slightly behind schedule. Began gainful employment 7 months after

suture.

Case 12. Injury of tibial and peroneal components of left sciatic nerve

25 June 1944. Wounded by mortar shell fragment involving the left sciatic nerve

3 inches below sciatic notch with complete paralysis (fig. 122).

4 Aug. 1944. Returning function of hamstrings and sensation in peroneal distribution. Complete motor paralysis in tibial and peroneal distribution.

20 Oct. 1944. Freeing and mobilization of sciatic nerve from gluteal crease to

popliteal space. Peroneal portion separated from tibial and found intact. Injected saline

passed freely. A neuroma and 5 cm. of scar were resected from the tibial portion and

the ends united, using tantalum wire. Separate preformed tantalum cuffs were placed

around each nerve. Knee splinted at 90° flexion.

14 Nov. 1944. Cast changed.

27 Nov. 1944. Cast removed and patient allowed to straighten leg gradually.

8 Jan. 1945. Cuffs removed. Electrical stimulation 6 inches below cuff gave sensation in peroneal nerve and 4 inches below suture in tibial; that is, a growth rate of

4"/3 m. No motor reaction.

27 Feb. 1945. Left on work furlough as truckdriver. Mild peroneal sensory disturbance at capit. fibul. following mobilization and handling of nerve.

5 May 1945. In motorcycle accident, fractured right and left radii below the heads.

Returned to hospital.

20 June 1945. Beginning motor function in both tibial and peroneal nerves. 13%"/

8y2 m. = 1%" p.m.

9 Aug. 1945. Good extension and flexion of foot, not of toes; good eversion and

inversion of foot.

15 Nov. 1945 and 16 Jan. 1946. Further improvement of mobility and sensitivity but

still complete analgesia and anesthesia of the sole.

19 Apr. 1946. Increase in strength of all muscles but toe flexors. Sensitivity of sole

still absent. Its return cannot be expected until end of 1946. Has worked the last

8 months on a farm about 40 hours a week without subjective or objective difficulties.

Summary.—This is an example of high sciatic injury with early return of hamstring
EXAMINATION IN PERIPHERAL NERVE INJURIES 297

Name-. E.S.

ftSN:32036 526

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1 Dec.'4-4 19 JuAtj '46

FIGURE 121.—Graphic record of patient with high interruption of left

sciatic nerve, managed by end-to-end suture of tibial and peroneal components. Operation was delayed for 5 months because of presumed sensory improvement. Good motor recovery is evident and is only slightly

behind schedule. In this case, no sensory improvement can be expected

for another year.

activity and peroneal sensitivity suggesting that the peroneal portion was at least partially preserved. Operative inspection and saline injection strengthened this assumption,

although electrical stimulation elicited pain only. The tibial portion was resected and

sutured over a 5-cm. gap. The almost simultaneous return of motor function in tibial

and peroneal nerves indicates that the nerve fibers had been interrupted also in the

grossly intact peroneal nerve and had to regenerate from the place of injury. Most of

the return of tibial sensitivity, if not all, is due to overlap, but return of sensation in

the sole cannot be expected in less than 21 to 30 months. Trophic disturbances and

pains have not been present at any time. Has worked on a farm, and the last 3 months

in his own profession as auto repairman in a garage, about 40 hours a week, without

difficulties. This is a satisfactory result in adequate time. It shows that a truckdriver

may be able to leave the hospital and return to commercial work 9 months after a high

sciatic injury with suture of its tibial portion.

Case 13. Injury of left tibial and peroneal nerves above poplitealspace

12 May 1945. Wounded on Okinawa by mortar shell 3% inches above popliteal space.

Complete motor and sensory sciatic paralysis in the leg. Evacuated to Zone of Interior

3 June 1945 (fig. 123).
298 NBUROSURGERY

8jflN'45(peron)

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pain insole.

15 NOV '45

FIGURE 122.—Graphic record of patient with high left sciatic injury, with complete •

interruption of tibial portion and contusion of peroneal poi'tion. The injury was managed by long mobilization of the sciatic nerve and resection and end-to-end suture of the

tibial portion. The peroneal portion was found intact and was left alone. Electrical

stimulation of the nerves 6 inches and 4 inches, respectively, below the injury gave sensation in the peroneal and tibial skin areas. Beginning motor function was observed in

both nerves 8 months after suture, with satisfactory progress.
EXAMINATION IN PERIPHERAL NERVE INJURIES 299

Name; J.H.P

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FIGURE 123.—Graphic record of patient with interruption of both the left tibial

and the left peroneal nerve above popliteal space, managed by early end-to-end

suture. Good progress of motor recovery restored the patient to full earning

capacity. Return of sensitivity could not yet be expected (15"/12 m.).

23 July 1945. Sciatic nerve freed from junction of upper and middle third of thigh

down to head of fibula. The nerve was almost completely interrupted. No sensory or

motor response to electrical stimulation was obtained in the tibial component, and very

slight sensory response in the peroneal. The nerve was mobilized throughout the length

of the incision, the scarred ends resected, and each component sutured separately end

to end over a 5-mm. gap with tantalum wire in 90° flexion of the leg. The leg was

gradually straightened after 7 months of immobilization and was straight on 6 Nov. 1945.

26 Nov. 1945. First sign of regeneration: voluntary contraction of gastrocnemius.

3%"/4 m.

27 Feb. 194G.

popliteal space.

31 May 1946.

8 July 1946.

peroneal muscles.

Contraction of tibialis ant. on intraneural stimulation of peroneal in

Voluntary contraction of foot and toe extensors.

Voluntary contraction of toe flexors. No innervation of long or short

No return of sensitivity. Is able to walk without brace. Has worked

as stock clerk for 8 months without difficulty.

Summary.—This is an example of early suture of tibial and peroneal nerves at the

level of the lower third of the thigh. Good functional recovery permitting gainful employment 6% months after injury and full working capacity in less than a year.
300 NEUROSURGERY

Scared.

u

20 JULY '45

U

20 HUG '45 28 JHN'46

FIGURE 124.—Graphic record of patient with partial interruption of right common

peroneal nerve, managed by suture. There has been satisfactory return of sensory

and motor function within the usual time limits.

Progress of motor reinnervation was on time in both tibial and peroneal nerves, with

the exception of the long and short peroneal muscles, which are often delayed. However, this did not much impair the gait. The shrinking analgesia and anesthesia are

due to overlap only. The distance from the lesion to the foot is 19 inches, and no real

improvement could be expected until 1947.

Patient had additional penetrating wounds of right upper arm and chest with hemothorax. Air transport nevertheless permitted nerve suture in Cushing General Hospital

10 weeks after injury on Okinawa.

Case 14. Injury of right common peroneal nerve

28 Feb. 1945. Wounded by shell fragments in popliteal space with complete paralysis

of right common peroneal nerve (fig. 124).

27 Apr. 1945. Exploration in which three-fourths of nerve was found interrupted

1 inch above bifurcation into superficial and deep branches. No motor response on electrical stimulation but sensory response from preserved filament. Suture (overseas) of

interrupted bundles and inclusion in preformed tantalum cuff.

20 July 1945. Complete motor and sensory paralysis in common peroneal.

20 Aug. 1945. Complete motor paralysis. Beginning return of sensation in lateral

sural and common peroneal distribution.

26 Nov. 1945. Beginning return of motor function in ant. tibial and peroneal muscles

(4"/7 m.), not yet in toe extensors. Hypalgesia, anesthesia in deep peroneal distribution.

The degree of motor return suggests that function began before present examination;

that is, within expected time.

28 Jan. 1946. Good progress in motor and sensory improvement. Has worked for

last 5 months as projectionist in movie theater without more difficulties than early

fatigue. Able to walk 2 miles without brace.

Summary.—Complete interruption of motor fibers and partial interruption of sensory

in common peroneal nerve with suture and return of motor function, as well as good

sensory return.
CHAPTER XIV

Anatomic Approaches to the More Commonly

Injured Peripheral Nerves

Warner Wells, M.D., Frederick M. Owens, M.D., and Francis A. Echlin, M.D.

An injured nerve that fails to recover spontaneously must be explored,

for its physiologic continuity is interrupted by constriction, scar, or severance. The success of the operation and the ultimate result are as dependent

on a correct anatomic approach as on a correct suture technique. The purpose of this chapter, therefore, is to present methods of approach to the

more commonly injured peripheral nerves based on the anatomy of that

portion of the extremity involved.

The techniques presented are an outgrowth of an experience in the

handling of over 3,000 peripheral nerve injuries at McCloskey General

Hospital, Temple, Tex., in World War II. No claim is made to originality.

With the exception of a greater awareness of the importance of flexion

creases, nothing fundamentally new was added in World War II to the

descriptions of Stookey 1and others published after World War I.

The procedures described are based on fundamental principles of surgical anatomy, on the unwritten store of surgical knowledge, and on the

writings of those pioneers in this field who created the obligation to do

nerve surgery through their studies in anatomy, physiology, and surgery.

The references give credit only to those most immediately concerned. There

are many more. It is hoped that the techniques subscribed to in World

War II will be improved as other surgeons, faced with the same problems

but equipped with new tools, bring to bear on them their ingenuity and

their imagination.

HISTORICAL NOTE

In an essay on the early history of practical anatomy, Keen 2 made the

following reference to Galen (b. 131 A.D.) : "Surgeons, however, not infrequently have been allowed to test operations on criminals, who were pardoned

if they survived. Galen thus operated in cases of nerve wounds * * *."

From his experience, Galen drew certain conclusions, as follows:

1. Section of a nerve produced paralysis in the region it supplied.

1 Stookey, Byron : Surgical and Mechanical Treatment of Peripheral Nerves. Philadelphia and

London : W. B. Saunders Co., 1922.

2 Keen, William Williams : The Early History of Practical Anatomy. In Addresses and Other

Papers. Philadelphia and London : W. B. Saunders Co., 1905, pp. 1-40.

301
302 NEUROSURGERY

2. This paralysis was incurable because nature was powerless to effect

regeneration of nerves.

This idea of Galen's traversed the Middle Ages, Guy de Chauliac in the

14th century to the contrary, and it was not until the year 1776 that

Cruikshank3contested Galen's doctrine by stating that paralysis was not

permanent after nerve section but that regeneration and resumption of

function occurred. Cruikshank reached his conclusions after observing regeneration in the unsutured pneumogastrics and vagi of the dog after their

deliberate severance. His study, however, was not reported until 1795.

Perhaps Druitt,4in 1852, was drawing on Cruikshank's observations

when he stated that, following complete nerve division, the nerve will readily

unite in the same manner as bone or tendon, and sensibility and motion will

return.

This idea of regeneration without suture has threaded its way through

the literature up to the present day. Ballingall,5in 1830, did, however, express a skeptical note when he stated: "The bulbous ends of a nerve which

had not united have been cut out, but without avail."

Nerve surgery is born of war. Interest in it waxes during periods of

hostility and wanes during the intervals of peace. For their knowledge of

peripheral surgery, neurosurgeons are chiefly indebted to surgeons faced

with the problem in military life. This was especially true in the Civil

War, the Sino-Japanese War, and the First World War.

Billroth,6in 1859, published a historical monograph on the nature and

treatment of gunshot wounds, but he did not mention nerve injuries. Billings'

Civil War journal describes fractures and amputations but makes no reference to nerve wounds.7

Philadelphia saw the opening, in 1863, of the Christian Street Hospital

and later the Turner's Lane Hospital, successively devoted to the diseases

and injuries of the nervous system, and probably the first Army hospitals

in this country devoted exclusively to a specialty. To these hospitals went

S. W. Mitchell, G. K. Morehouse, and W. W. Keen. Out of their experience

they published, in 1864, a book, the first of its kind, on gunshot wounds and

other injuries of nerves.8 Nerve surgery is not mentioned, although hope is

expressed that prostheses may benefit paralyzed extremities.

3 Cruikshank, W. : Experiments on the Nerves, Particularly on Their Reproduction; and the

Spinal Marrow of Living Animals. Philosoph. Tr. Koy. Soc. London, 85 : 512-519, 1795.

4 Druitt, R.: In The Principles of Surgery, by James Miller. Third American from second

and enlarged Edinburgh edition, revised with additions by F. W. Sargent. Philadelphia : Blanchard

and Lea, 1852.

5 Ballingall, George: Introductory Lectures to a Course of Military Surgery, delivered in the

University of Edinburgh. Edinburgh : A. Black, 1830.

6 Billroth, Theodor : Historical Studies on the Nature and Treatment of Gunshot Wounds From

the Fifteenth Century to the Present Time. Berlin : 1859. Translated by C. P. Rhoads. Yale J.

Biol. & Med. 4 : 3-36, October 1931 ; 4 : 119-148, December 1931 ; 4 : 225-258, January 1932.

"> Garrison, Fielding H. : John Shaw Billings ; A Memoir. New York : G. P. Putnam's Sons, 1915.

8 Mitchell, S. Weir, Morehouse, George R., and Keen, William W.: Gunshot Wounds and Other

Injuries of Nerves. Philadelphia : J. B. Lippincott Co., 1864.
COMMONLY INJURED PERIPHERAL NERVES 303

Mitchell described causalgia the same year, and 8 years later, in 1872,

he wrote his classic text on injuries of nerves and their consequences.9The

next year saw the publication of Leticvant's work entitled "Traite des Sections Nerveuses," 10 which, despite its emphasis on neurectomy, did employ

the physiologic principles underlying the experiments of Waller, Phillipeaux,

and Vulpian.

Baudens, a French Army surgeon, serving with the colonial forces in

Algiers, is credited with performing the first nerve suture; in 1836, he

sutured the median and ulnar nerves in the axilla by approximating adjacent

tissues. When the patient died a few days later, the ends were found to

have separated. Nelaton and Laugier each performed nerve suture in 1864,

and each claimed recovery within a few days of operation. Six more instances of nerve suture were recorded before 1870.

Nerve surgery did not pose a real problem until 1867, when Listeru

introduced "systematic and scientific antisepsis and asepsis for the treatment

of wounds and the performance of surgical operations." Lister's work was

based on Pasteur's experiments. When it became possible to salvage, rather

than amputate, badly wounded extremities, existing nerve injuries and their

treatment became significant. Waller's theory of nerve degeneration, advanced in 1852, then gave the physiologic basis for nerve suture.

By 1893, in an analysis of the collected records of 84 primary sutures,

Howell and Huber12stated: "The prognosis of cases of 'primary nerve

suture' is very favorable; in all probability function will be restored either

completely or partially."

Out of the First World War came careful and scholarly works on the

management of nerve wounds by Tinel13in 1918; Benisty14in 1918; Stookey

in 1922; Platt and Bristow15in 1924; the section on neurosurgery in The

Medical Department of the U.S. Army in the World War in 1927 ;

16 and

Pollock and Davis'17text in 1933. Bunnell's18book on the surgery of the

9 Mitchell, S. Weir: Injuries of Nerves and Their Consequences. Philadelphia : J. B. Lippincott Co.. 1872.

10 Letievant, J. J. E.: Traite des Sections Nerveuses. Paris: J. B. Balliere et Pils, 1873.

11 Lister, J. : On the Antiseptic Principle in the Practice of Surgery. A paper read before the

British Medical Association in Dublin on August 9, 1867. In the Collected Papers of Baron Joseph

Lister. Oxford at the Clarendon Press, 1909, vol. II, pp. 37-46.

12 Howell, W. H., and Hubcr, G. C.: A Physiological, Histological, and Clinical Study of the

Degeneration and Regeneration in Peripheral Nerve Fibres After Severance of Their Connections

With the Nerve Centres III. Critical Rfeume' of Surgical Cases of Primary and Secondary Suture.

J. Physiol. 14 : 1-51, 1893.

13 Tinel, J.: Nerve Wounds. Symptomatology of Peripheral Nerve Lesions Caused by War

Wounds. New York : William Wood & Co., 1918.

I* Benisty, A.: Treatment and Repair of Nerve Lesions, edited by B. Farquhar Buzzard. London : University of London Press Ltd., 1918.

15 Platt, H., and Bristow, W. R. : The Remote Results of Operations for Injuries of the Peripheral Nerves. Brit. J. Surg. 11 : 535-567, January 1924.

18 The Medical Department of the United States Army in the World War. Washington:

Government Printing Office, 1927, vol. XI, pt. 1, pp. 1081-1283.

i' Pollock, Lewis J. and Davis, Loyal: Peripheral Nerve Injuries. Hoeber's Surgical Monographs. New York : Paul B. Hoeber, Inc., 1933.

18 Bunnell, Sterling : Surgery of the Hand. Philadelphia : J. B. Lippincott Co., 1944.

498991v—59 22
304 NEUROSURGERY

hand, published in 1944, is a classic, not only for its treatment of nerve injuries, but for all phases of reconstructive surgery in the upper extremity.19

GENERAL CONSIDERATIONS

Certain general considerations are important if the surgeon is to combine good judgment with technical skill.

The extremity must be considered as a whole, with the recollection that

the arm is but a vehicle to support and provide range of motion for the

prehensile organ of sense, the hand, and that the foot is a hinged platform

adapted to the locomotor function of the leg. Skin, bone, muscles, tendons,

blood vessels, and nerves must be appraised collectively if the best functional

result is to be obtained.

Bunnell summarizes the problem as follows: "Usually in the same

traumatized limb with flexion contracture, injury to tendons, bones, joints,

and nerves, we must combine plastic, orthopedic, and neurologic surgery.

As the problem is composite, the surgeon must also be. It is impractical

for three specialists to work together or in series. There is no shortcut.

The surgeon must face the situation and equip himself to handle any and

all of the tissues in a limb."

There are two rules to be followed with respect to incision: (1) Excision of the skin and subcutaneous tissue scar as part of the planned incision,

and (2) delineation of the incision to conform to the course of the nerve

and possible extension in such a manner as to avoid contractures. Straight

lines should be avoided; flexion creases must not be crossed transversely or

in a straight line, and the linear course of lymphatics and blood vessels

must be respected. Sharp dissection to explore the injured nerve is preferred to blunt or scissors dissection. The plane of dissection should always

be in a direction parallel with the axis of the extremity, for all important

vascular, nervous, muscular, and tendinous structures are disposed in a

linear direction. Transverse dissection cuts rather than separates. Moreover, longitudinal dissection is less likely to injure the collateral blood

supply where the normal blood flow has been compromised.

The proximity of nerves to blood vessels should keep the operator ever

alert to the possibility of aneurysm or arteriovenous fistula even though the

condition is not diagnosed preoperatively.

The exploratory wound must be made large enough to expose normal

tissue above and below the lesion, to make it easier to follow the nerve into

areas in which scarring and distortion are considerable.

With few exceptions, the peripheral nerves have a meager intrinsic

blood supply. Their nutritional requirements are largely supplied from

small vessels that enter through the loose connective tissue investing them.

1!) Thp late Dr. Sterling Bunnell served as the special consultant in hand surgery to the Secretary of War during World War II and also as editor for "Medical Department, united States Army.

Surgery in World War II. Hand Surgery." Washington : U.S. Government Printing Office, 1955.
COMMONLY INJURED PERIPHERAL NERVES 305

If, therefore, a nerve is freed for a considerable distance, it becomes, in

effect, a nerve graft. Care should be taken, when a nerve is freed, to leave

it attached at intervals to its vascular connective tissue investment.

The mechanical difficulty experienced in obtaining end-to-end apposition

of the proximal and distal nerve stumps when large defects exist is perhaps

the chief obstacle to successful nerve suture. The technical maneuvers employed, which are discussed under the respective nerves, represent perhaps

the greatest contribution to nerve suture. Platt and Bristow, after World

War I, enumerated them in the order of their importance, as follows:

1. Wide anatomical exposure with free mobilization of the nerve.

2. Positioning of the extremity to afford maximum relaxation of the

nerve.

3. Transplantation of the nerve to a new position that will shorten its

course.

4. Stripping of the nerve branches in the proximal segment or, in very

occasional instances, the sacrificing of a branch to allow downward displacement of the nerve trunk.

5. Bone shortening, in the case of brachial plexus lesions in which the

clavicle is shortened or allowed to override and in which nonunion of

fractures requires the trimming of bone ends.

6. Preoperative exercises designed to stretch the nerve upward from

its site of attachment to the wound scar.

With increasing experience, the surgeon will find that the use of these

expedients for gaining length will decrease the number of lesions ordinarily

considered to be irreparable by direct suture.

THE BRACHIAL PLEXUS

General Anatomy

The brachial plexus is formed within the neck from the interlacing

fusion of the anterior primary divisions of the fifth, sixth, seventh, and

eighth cervical nerves and the first thoracic nerve, plus contributory twigs

from the fourth cervical and second thoracic nerves. Accurate localization

of the level of a nerve lesion requires that it be considered from the standpoint of its components, including the nerve roots that form it and its own

trunks, divisions, cords, and main branches (fig. 125).

Components.—The lower four cervical nerves, after crossing behind the

vertebral artery and between the anterior and posterior parts of the intertransverse muscles, enter tiie posterior triangle of the neck between the

contiguous borders of the anterior and middle scalene muscles (fig. 126).

The anterior primary division of the first thoracic nerve divides into two

branches, the smaller of which enters the first intercostal space as the first

intercostal nerve. The larger branch, after receiving a twig from the second

thoracic nerve, passes in front of the neck of the first rib and behind the
306 NBÜROSURGERY

a - To Phrenic

b= To Subclavius

c = Suprascap.

d= Lot. Thor.

e - Axill.

f.= Radial

q- Med. Thor.

, h = Pectoral

k = Subscap

m= Ant. Thor,

n = Subscap.

o= Subscap.

p = Dor. Scap.

r = Long Thor,

s = 1st Intercostal

ttu = Intercostobrach.

v = 2nd Intercostal

FIGURE 125.—Schematic view of brachial plexus, its roots components, and

its main branches (modified from Bunnell).

apex of the pleural sac. It continues upward and laterally into the posterior

cervical triangle, where, on the anterior surface of the scalenus medius, it

combines with the other nerves in the formation of the brachial plexus.

Three trunks are formed on the anterior surface of the scalenus medius

muscle to comprise the first portion of the brachial plexus. The fifth and

sixth cervical nerves fuse to form the upper trunk. The seventh cervical,

which is the largest nerve entering the plexus, crosses the muscle independently as the middle trunk. The eighth cervical and first thoracic nerves

form the lower trunk.

The upper, middle, and lower trunks each divide into anterior and

posterior portions to form the second portion of the brachial plexus.

The third portion of the brachial plexus begins near the first rib. It

consists of the lateral, medial, and posterior cords, which are so called because
COMMONLY INJURED PERIPHERAL NERVES 307

FiGuiiE 12G.—Supraclavicular exposure of brachial plexus.

FIGTJKE 127.—Relation of brachial plexus to first rib and clavicle.
308 NEUROSURGERY

of their relation to the axillary artery. The lateral cord is formed by the

anterior branches of the upper and middle trunk, the medial cord by the

anterior branch of the lower trunk, and the posterior cord by the posterior

branches of all three trunks. The lateral cord controls all flexor and pronator

motions of the upper extremity, and the posterior cord controls all extensor

and supinator motions. The medial cord controls the flexor muscles on the

ulnar side of the forearm and the intrinsic; muscles of the hand.

There are five main terminal branches in the brachial plexus, the musculocutaneous, radial, axillary, median, and ulnar nerves. The lateral cord

branches into the musculocutaneous for flexing the elbow and into the upper

branch of the median nerve for the sensory distribution of that branch and

for flexion of the wrist and pronation. The posterior cord branches to

form the axillary nerve for abduction of the shoulder and the radial nerve

for extension of the forearm, wrist, and fingers. The medial cord branches

to form (1) the lower branch of the median nerve, which supplies the

flexors of the digits, and (2) the ulnar nerve, which supplies the flexors

on the ulnar side of the forearm and all the intrinsic muscles of the hand

except the thenar muscles and the first two lumbricales. Two minor terminal

branches which arise from the medial cord, the medial antebrachial cutaneous

and the medial brachial cutaneous nerves, supply sensation down the medial

side of the arm.

Relations.—The brachial plexus begins in the posterior cervical triangle,

which is bounded anteriorly by the sternocleidomastoid, posteriorly by the

trapezius, and inferiorly by the clavicle (fig. 126). It extends from the

lateral border of the scalenus anterior, from beneath which the roots of its

constituent nerves appear, through the neck, and beneath the clavicle into

the axilla. Here, each of its three cords divides into terminal branches

near the lower border of the pectoralis minor.

In the posterior triangle, the brachial plexus is bounded posteriorly

by the scalenus medius, which it crosses, and anteriorly by the skin, superficial fascia, platysma, supraclavicular branches of the cervical plexus, and

the deep fascia. The levator scapulae and the trapezius muscles lie laterally.

In the root of the neck, the lower border of the plexus is in relation

with the pleura, the first rib, and the third part of the subclavian artery

(fig. 127). It is crossed by the lower part of the jugular vein, by the nerve

to the subclavius, by the transverse cervical and scapular veins, by the posterior belly of the omohyoid muscle, and by the transverse cervical artery.

In the axilla, the cords of the brachial plexus are arranged around the

axillary artery (fig. 128). The posterior cord lies dorsally, the lateral cord

laterally, and the medial cord medially to the artery. The medial cord is

overlapped anteriorly by the axillary vein (fig. 129).

The surgeon will be better oriented, and a lesion within the plexus can

be more accurately placed, if the nerve branches which arise within the
COMMONLY INJURED PERIPHERAL NERVES 309

FIGURE 128.—Relation of cords of brachial plexus to axillary artery.

FIGURE 120.—Relation between medial cord of brachial plexus and axillary vein.
310 NEUROSURGERY

plexus are grouped according to the components from which they arise

(fig. 125), as follows:

1. Branches from the nerve roots forming the plexus. Twigs supplying

the scaleni and longus colli muscles arise from the lower three or four

cervical nerves immediately after their exit from the respective intervertebral foramina. The dorsal scapular nerve arises primarily from the

fifth cervical nerve and crosses the scalenus medius parallel with, and

below, the spinal accessory nerve to the anterior border of the levator

scapulae. Here it disappears, to supply the rhomboids. The long thoracic

nerve (external respiratory nerve of Bell) arises by three roots from the

fifth, sixth, and seventh cervical nerves, respectively, the two upper roots

traversing the scalenus medius and the lower root crossing it anteriorly

before merging behind the brachial plexus. The nerve runs downward behind the first stage of the axillary artery, to supply the serratus anterior

muscle. A twig to the phrenic arises from the fifth cervical nerve. The

first intercostal nerve arises from the first thoracic nerve.

The sympathetic innervation to the upper extremity enters the brachial

plexus near the inner border of the scalenus medius before the nerves fuse

into the trunks. Because of its importance, both diagnostically and surgically, it is necessary to consider the sympathetic supply at this point. The

fifth and sixth cervical nerves each receive a gray ramus communicans from

the middle cervical sympathetic ganglion, and the seventh and eighth nerves

are supplied by the inferior cervical sympathetic ganglion. Two gray rami

communicans from the first thoracic ganglion supply the first thoracic nerve.

2. Branches from the trunks. The suprascapular nerve, the first conspicuously large nerve to leave the brachial plexus superiorly, arises from

the upper trunk near the lateral border of the scalenus medius and runs

across the posterior cervical triangle on the upper border of the posterior

belly of the omohyoid muscle to supply the supraspinatus and infraspinatus

muscles. The nerve to the subclavius makes its exit from the upper trunk

medial to the suprascapular nerve.

3. Branches from the cords. The lateral and medial anterior thoracic

nerves arise from the lateral and medial cords, respectively, and pass anteriorly to supply the pectoralis major and minor muscles. The subscapular

nerves, three in number, arise from the posterior cord as the upper, middle,

and lower nerves and pass posterior to the plexus to supply the subscapularis,

latissimus dorsi, and teres major muscles, respectively. The medial brachial

cutaneous and medial antebrachial cutaneous nerves arise from the medial

cord to supply, in succession, the medial surface of the arm and forearm.

4. Main branches from the plexus. These nerves will be considered

under separate headings.

Summary.—The brachial plexus may be considered as arising from five

nerves and terminating in five nerves. Intervening are three trunks and

three cords connected by three anterior and three posterior divisions. These
COMMONLY INJURED PERIPHERAL NERVES 311

divisions serve to separate the flexor and extensor nerve fibers which enter

the upper extremity. Fairly well defined and consistent nerve branches

emerge successively from different levels. These nerve branches, which are

the roots, the trunks, and the cords, together with the tissues which they

supply, serve as a means of identifying the level of a brachial plexus lesion.

Of additional aid is the knowledge that the lateral cord subserves all flexor

and pronator motions, the posterior cord all extensor and supinator motions,

and the medial cord the flexor muscles on the extreme ulnar border of the

forearm and the intrinsic muscles of the hand.

The surgeon will be better oriented at the operating table if he keeps in

mind that the trunks are formed on the anterior surface of the scalenus

medius muscle and that the cords begin at or near the level of the first rib.

Surface Anatomy

The brachial plexus itself has no direct superficial landmarks. There

is no difficulty, however, in localizing it accurately because of its relation to

easily seen and palpated superficial landmarks in the neck and axilla, as

follows:

1. With the head turned to one side, the sternocleidomastoid muscle of

the opposite side is thrown into strong relief.

2. The brachial plexus can be palpated deep in the neck as it crosses

the scalenus medius muscle immediately lateral to the middle third of the

sternocleidomastoid muscle.

3. The pulsation of the carotid artery can be felt just medial to the

plexus.

4. The cords of the plexus begin 2% inches lateral to this vessel.

5. The brachial plexus descends into the axilla beneath the middle third

of the clavicle (fig. 129).

6. The axillary artery can be palpated in the axilla.

7. The lower ends of the cords and the beginnings of the terminal

branches are disposed around this vessel (fig. 128).

Surgical Approach

Position.—The patient lies semirecumbent, with the head extended and

turned to the side opposite the lesion. An arm board affixed to the table

provides lateral support for the arm on the affected side. Preparation includes the neck, shoulder, anterior thorax, axilla, and the entire extremity.

The arm is wrapped in sterile stockinet but is readily accessible whenever it

is necessary to determine the effect of electrical stimulation. It is also left

free for any change in position necessitated in the course of the procedure.

Exposure.—The supraclavicular portion of the brachial plexus is exposed

through an incision that begins iy5 inches lateral to the middle third of the

sternocleidomastoid muscle and continues forward and downward toward

498991^—59 23
312 NEUROSURGERY

the sternoclavicular joint (fig. 130). Although this is not a collar incision,

it closely follows the creases present when the head is in neutral position.

If dissection below the clavicle proves necessary, the incision can be carried

downward and laterally across the upper chest toAvard the axilla, in line

with the course of the pectoral muscle. Deforming scars and keloid can

thus be avoided.

FIGUHE 130.—Skin incision for exposure of brachial plexus.

Dotted line represents extension.

The platysma is divided and widely undermined. The external cervical

fascia is incised lateral to the sternocleidomastoid, care being taken to avoid

injury to the external jugular vein and supraclavicular branches of the

cervical plexus. The sternocleidomastoid muscle is retracted medially. Incision of the deep fascia is then necessary to allow retraction of the omohyoid

muscle and exposure of the brachial plexus. The plexus stands out more

prominently and is exposed more easily if it is kept under tension by abducting, extending, and externally rotating the arm.

The scalenus anticus muscle lies medially and just lateral to the internal

jugular vein and carotid artery. The phrenic nerve crosses its anterior

surface obliquely (fig. 126). The brachial plexus emerges from beneath its

lateral border, crosses the scalenus medius, and runs obliquely downward

and laterally to lie in relation with the subclavian artery near the root of

the neck.

The topmost conspicuous nerve is the fifth cervical. The seventh cervical

nerve is also recognized by its large size. The eighth cervical and first

thoracic nerves are identified by their deep medial roots, which lie close to

the innominate vein, subclavian artery, and apex of the pleura. The cords

are well defined as the plexus crosses the first rib, and, from this point

downward, the posterior cord is behind the artery.
COMMONLY INJURED PERIPHERAL NERVES 313

If dissection must be prolonged below the clavicle, the incision is extended, as just described. The clavicle is severed in the middle in a dovetail

manner, and its ends are separated. It is not usually necessary to cut the

pectoralis major; lateral spread of its serrations from the breach in the

clavicle is sufficient in most cases. It may or may not be necessary to

divide the insertion of the pectoralis minor at the coracoid process (fig. 128).

If the brachial plexus lesion is infraclavicular, it may be exposed

through the axillary incision employed for the radial nerve (p. 322) or

through an incision parallel with the clavicle in front of the anterior axillary fold.

Exposure of the brachial plexus is a difficult and tedious procedure.

The surgeon who undertakes it must possess an accurate knowledge of the

regional anatomy as well as technical skill and judgment. When the injury

has been severe, the scar will be large and the tissues distorted and brittle.

It is essential that the injured area be approached from normal surroundings. Blind dissection could be fatal or crippling. The threat of serious

hemorrhage from large vessels is always present and must be anticipated

to be avoided.

Methods of Gaming Length

The brachial plexus is under greatest tension when the neck is extended,

the head turned and inclined to the opposite shoulder, the arm extended and

externally rotated, and the shoulder turned outward. Relaxation, on the

contrary, is maximal when the neck is flexed, the head turned and inclined

to the same side, the arm flexed and adducted, and the arm and shoulder

internally rotated. Gaps in the plexus up to 2*4 to 2% inches can thus be

overcome by the simple expedient of correct positioning. If great length

is required, the nerves can be freed down into the arm and the clavicle made

to override. Gaps up to 4 to 4% inches can thus be overcome.

Closure of the Wound

Severed muscles or tendons are reapproximated, and the subcutaneous

tissues and skin are closed separately. Loose approximation of the deep

tissues will eliminate dead space and lessen the chances of bleeding from

raw surfaces. If the clavicle has been divided, it will heal without internal

fixation if the dovetailed ends are approximated and the arm and shoulder

properly splinted.

THE MUSCULOCUTANEOUS NERVE

General Anatomy

The musculocutaneous nerve, one of the two terminal branches of the

lateral cord of the brachial plexus, is composed chiefly of fibers derived from
314 NEUROSURGERY

the fifth and sixth cervical nerves. In about half of all cases, it also receives fibers from the fourth and seventh cervical nerves. It originates deep

in the axilla, lateral to the axillary artery. It innervates the coracobrachialis,

the biceps, and the brachialis muscles, as well as the humerus and the elbow

joint. It also supplies sensation to the anterolateral and posterior surfaces

of the forearm (fig. 131).

After a short course in the axillary fossa lateral to the axillary artery,

the musculocutaneous nerve leaves the artery to pierce the substance of the

coracobrachialis muscle. Branches to this muscle are given off just before

the nerve enters it. In some instances, however, the nerve supply to the

coracobrachialis muscle comes directly from the seventh cervical nerve, the

musculocutaneous nerve not passing through the brachial plexus.

The musculocutaneous nerve then runs obliquely and laterally down the

arm between the biceps and brachialis muscles, which it supplies as it

descends. It also gives off twigs to the humerus and the nutrient artery. Its

deep terminal branch descends to provide the chief nerve supply to the elbow.

The lateral antebrachial cutaneous nerve begins below the branch to the

brachialis muscle and descends between this muscle and the biceps to the

anterolateral aspect of the elbow. Here it penetrates the deep fascia to

become superficial. It then divides into anterior and posterior branches,

which supply the anterolateral, posterior, and posterolateral aspects of the

forearm. The anterior branch extends as far as the thenar eminence, whose

midportion it supplies.

Only the axillary nerve has a shorter course proximal to its sphere of

innervation than the musculocutaneous nerve. Because of its short main

trunk, the latter nerve was therefore seldom the seat of isolated nerve injury,

while its close proximity to the brachial plexus and the muscles which the

plexus innervates accounted for the frequent association of injuries of these

structures and the musculocutaneous nerve.

Surface Anatomy

The course of the musculocutaneous nerve in the arm can be visualized

by drawing a line from the coracoid process to the lateral epicondyle of the

humerus. In its anteroposterior position, the nerve is in a plane with the

medial and lateral bicipital sulci. The two branches of the lateral antebrachial cutaneous nerve in the forearm are on each side of a line drawn

from the lateral epicondyle of the humerus to the thenar eminence.

Surgical Approach

Position.—The patient lies supine, with the shoulder elevated and the arm

abducted 90° on the affected side. The elbow is left free to move, and the

arm and axilla are included in the sterile field.
COMMONLY INJURED PERIPHERAL NERVES 315

FIGUHE 131.—Surgical anatomy of

musculocutaneous nerve.

FIGUHE 133.—Surgical exposure of

musculocutaneous nerve.
316 NEUROSURGERY

Exposure.—A curved incision, with its center over the medial bicipital

sulcus in the upper arm, is projected upward to the lower border of the

pectoralis major muscle at the point at which it crosses the axilla. It is

then continued downward across the axilla to the border of the latissimus

dorsi muscle, in line with the transverse skin crease (fig. 132). Branches of

the medial brachial cutaneous nerve lie in the subcutaneous tissue.

This incision affords adequate exposure of the brachial plexus in the

lower axilla and permits any necessary extension in the arm.

In the upper arm, the fascia investing the coracobrachialis is incised,

and the undersurface of the muscle is followed upward toward the coracoid

process. The musculocutaneous nerve will be seen between this muscle and

the neurovascular bundle lateral to the axillary artery (fig. 133). The nerve

pierces the coracobrachialis muscle just opposite the lateral third of the

pectoralis minor muscle. Branches to the coracobrachialis emerge at this

point. Just below the coracoid process, the musculocutaneous nerve becomes

part of the lateral cord of the brachial plexus.

Within the upper and middle thirds of the arm, the musculocutaneous

nerve lies between the biceps and the brachialis muscles. The motor branches

to these muscles arise soon after the nerve leaves the substance of the

coracobrachialis muscle. The terminal lateral cutaneous branch can be seen

descending obliquely and laterally between the biceps and brachialis muscles

toward the lateral epicondyle of the humerus.

The musculocutaneous nerve and its branches in the forearm were seldom deliberately explored unless one of them was the site of a painful

neuroma.

Methods of Gaining Length

The musculocutaneous nerve is under greatest tension when the head is

inclined to the side opposite the lesion; the shoulder and arm are externally

rotated; the arm is abducted; and the forearm is extended, with stretching

of the biceps and consequent traction on the nerve. Maximum relaxation

is obtained when the head is inclined to the side of the lesion, the

arm and shoulder are internally rotated, the arm is adducted, and the

forearm is flexed at the elbow. Positioning is thus used to advantage when

defects up to 2 inches must be overcome. Because the normal course of the

musculocutaneous nerve is in a straight line with the muscles it innervates,

nothing is gained by trying to reroute it.

Closure of the Wound

Closure of the wound consists simply of reapproximation of deep fascia,

subcutaneous tissues, and skin.
COMMONLY INJURED PERIPHERAL NERVES 317

THE AXILLARY NERVE

General Anatomy

The axillary nerve arises from the posterior cord of the brachial plexus.

It is composed primarily of fibers from the ventral division of the fifth and

sixth cervical roots. It runs in the sheath of the radial nerve, to form the

posterior cord of the brachial plexus. As it leaves the radial nerve, it passes

over the inferolateral third of the subscapularis muscle.

After the axillary nerve runs behind the axillary artery, it turns

posteriorly across the inferior border of the subscapularis muscle to enter

the quadrilateral space of Velpeau behind the surgical neck of the humerus.

It winds around the surgical neck of the humerus and courses forward and

laterally through the deltoid muscle, by which it is covered. Motor fibers

are supplied to the teres minor and the deltoid muscles, while sensory fibers

supply the skin of the lateral aspect of the shoulder.

Surface Anatomy

The axillary nerve is situated so deeply that it cannot be palpated at

any point, Posteriorly, it can be located in the space bounded above by the

teres minor, laterally by the humerus, and inferomesially by the long head

of the triceps muscle.

Surgical Approach

Like the musculocutaneous nerve, the axillary nerve was seldom injured

independently, both because of its short course and because of its intimate

relation to the brachial plexus. Injury to the axillary nerve in its muscular

bed was so frequently associated with crippling injuries to the shoulder joint

and deltoid muscle that only the exceptional patient could be benefited

by surgery.

Because of its intimate relation to the brachial plexus, the surgical

anatomy of that structure must be taken into consideration when axillary

exposure of the axillary nerve is necessary.

Exposure in the axilla.—The patient lies supine, with the arm abducted

and externally rotated. The shoulder is elevated by placing a small, hard

pillow beneath the medial portion of the scapula. The entire arm is so

draped that it can be moved freely.

The incision is made transversely across the axilla, beginning at the

lower third of the tendinous portion of the pectoralis major muscle and

extending posteriorly along the skin lines to the angle between the latissimus

dorsi and triceps muscles (fig. 134).

The deep fascia is divided, and the pectoralis major is retracted upward.

This maneuver exposes the neurovascular bundle and the axillary nerve,

which, with the radial nerve, lies posterior to the axillary artery. The
318 NEUROSURGERY

axillary nerve usually arises from the medial aspect of the radial nerve

(fig. 135). It extends distally on the subscapularis muscle to enter the

quadrilateral space just above the tendon of the latissimus dorsi muscle.

If exposure must extend farther in a proximal direction, the tendinous

portion of the pectoralis major muscle may be divided; if this is necessary,

the muscle must be carefully resutured when the wound is closed.

Considerable exposure can be gained from the approach just described,

including exposure of the nerve in the quadrilateral space.

Exposure at the surgical neck of the humerus.—The distal portion of

the axillary nerve can be exposed behind the humerus by employing a posterior extension of the axillary incision just described. The patient lies on

the unaffected side, with the arm flexed across the chest. The line of incision

(fig. 136) extends from the tip of the acromion process to the posterior

axillary line at the medial border of the long head of the triceps muscle.

The plane of dissection passes between the posterior border of the deltoid

muscle and the lateral border of the long head of the triceps. A layer of

fascia between these muscles is divided, after which the nerve is exposed as

it passes beneath the teres minor muscle. The motor branch to the teres

minor muscle arises at this point, but the remainder of the motor branches

originate as the nerve fans out beneath the deltoid muscle (fig. 137).

Injury to the nerve at the point at which it breaks up into its distal

branches usually defies repair. In such cases, the freshly cut ends of the

nerve bundles are implanted directly into the muscle. Irreparable injuries

in this region can be overcome by arthrodesis of the shoulder joint, provided

that the other muscles in the shoulder girdle are intact.

Methods of Gaining Length

The short course of the axillary nerve exterior to the muscles which it

supplies precludes the bridging of any large gap. Eelaxation is maximal

with the shoulder elevated, the arm externally rotated, and the head inclined to that side.

THE RADIAL NERVE

General Anatomy

The radial (musculospiral) nerve contains fibers from the sixth, seventh,

and eighth cervical nerves. It arises from the posterior cord of the brachial

plexus and mediates all extension to the elbow, wrist, and digits except for

the two distal joints of the fingers; these two joints are extended by the

intrinsic muscles of the hand.

After its beginning at the lower border of the pectoralis minor, the

radial nerve first traverses the axilla behind the axillary artery. Then it

continues down the upper arm, between the humerus and the brachial artery
COMMONLY INJURED PERIPHERAL NERVES 319

FIGUKE 134.—Skin incision for exposure

of axillary nerve.

FIGUKE 135.—Surgical anatomy of axillary space and exposure of axillary nerve.

FIGUHE 136.—Skin incision for exposure of distal portion of axillary nerve.

FIGURE 137.—Surgical anatomy of distal

portion of axillary nerve.
320 NEUROSURGERY

(fig. 138). Near the middle of the arm, the radial nerve, with the profunda

artery, passes obliquely behind the humerus through the musculospiral

groove to the external aspect of the arm. Near the lower third of the arm,

the nerve pierces the lateral intermuscular septum. Then, accompanied by

an anterior terminal branch of the profunda artery, it descends between the

brachioradialis and extensor carpi radialis longus to the elbow, where it

divides into its terminal branches. These branches are the motor or deep

radial and the sensory or superficial radial.

The superficial radial nerve courses downward, under cover of the

brachioradialis muscle, to the middle third of the forearm, where it lies

lateral to the radial artery. In the lower third of the forearm, it becomes

superficial to the brachioradialis tendon. Then it perforates the deep fascia

and descends along the radius to its terminal branches on the dorsum of

the first three digits.

The deep radial nerve leaves its bed between the brachioradialis and

extensor carpi radialis longus to pass through the substance of the supinator

muscle. It then crosses the abductor pollicis longus, in company with the

posterior interosseous artery, to become the dorsal interosseous nerve as it

dips beneath the extensor pollicis longus. Accompanying the volar interosseous artery and lying on the interosseous membrane next to the radius, this

nerve then descends through the groove for the extensor digitorum communis and the extensor indicis proprius to the wrist, where it ends in a

gangliform enlargement which gives branches to the carpal articulation.

Branches in the arm.—Motor branches from the radial nerve to the medial

and long heads of the triceps arise in the axilla. A sensory area behind the

arm is supplied from that level by the posterior brachial cutaneous nerve.

In the middle third of the arm, motor branches arise to the lateral and

medial heads of the triceps and to the anconeus. A sensory branch, the

dorsal antebrachial cutaneous nerve, also arises at this level. This nerve,

through upper and lower branches, supplies the skin over the lower lateral

and anterior aspect of the arm and the back of the forearm to the wrist

(fig. 139). After the radial nerve has pierced the lateral intermuscular

septum, motor branches are given off to the brachioradialis, the extensor

carpi radialis longus, and the lateral portion of the brachialis. An articular

filament passes to the elbow joint.

Branches in the forearm.—From above downward, the deep radial and

the dorsal interosseous nerves supply the extensor carpi radialis brevis,

supinator, brachioradialis, extensor digitorum communis, extensor digiti quinti

proprius, extensor carpi ulnaris, extensor indicis proprius, and the extensor

muscles of the thumb. The superficial radial nerve supplies sensation to the

skin over the dorsum of the first three digits and the radiodorsal aspects

of the hand.
COMMONLY INJURED PERIPHERAL NERVES 321

Rami

Cut. Brach.

S Cut. Anti Brach

Cut. Anti Brach.

Dors. 8 Rod.

FIQUKE 138.—Surgical anatomy of radial nerve.

ANTERIOR POSTERIOR

FIGURE 139.—Superficial cutaneous branches of radial

nerve in upper extremity.

Surface Anatomy

Since the radial nerve lies behind the axillary artery in the axilla, its

approximate position can be gaged by palpation of this vessel. In the upper

arm, the nerve lies deep in the medial bicipital sulcus beneath the brachial

artery. An oblique line drawn from the posterior axillary fold to a point

approximately 1 inch below the insertion of the deltoid muscle will define

the course of the nerve to the outside of the arm. From this point, the

nerve trunk runs forward through the lateral bicipital sulcus to the front

of the lateral epicondyle of the humerus. Here it divides into its deep

and superficial branches.

The superficial branch of the radial nerve lies beneath the brachioradialis muscle to the lower forearm. Here the branch becomes superficial and

continues downward, close to the radius, to the hand. The deep radial nerve

leaves the anterolateral aspect of the elbow to follow the radius in a gentle

spiral beneath the aUteroexternal bulge of the brachioradialis and radial

extensor muscles. In the lower forearm, the dorsal interosseous nerve descends to the wrist through the groove between the radius and ulna in

which the common extensor tendons lie. A line drawn between the lateral

condyle of the humerus to the tubercle of the radius generally corresponds

to the course of the radial nerve in the forearm.
322 NEUROSURGBRY

Surgical Approach

Positioning and preparation.—The patient lies supine on the operatingtable for all exposures of the radial nerve. Pillows or folded sheets are

placed beneath the body to raise the affected extremity 45°. With proper

draping, there are no lesions of the radial nerve which cannot be approached

from this position.

The entire arm, axilla, and shoulder are prepared. The hand is encased

in a sterile glove, and the extremity is wrapped in sterile stockinet. The

arm is extended on an arm board, and drapes are so applied that the entire

arm, axilla, and shoulder are in a sterile field. With such preparation and

draping, the extremity is allowed complete range of motion, and any change

in position necessary for fresh exposure or extension of the incision is easily

accomplished.

Exposure in the axilla.—With the arm held upright (fig. 140), a gently

curving incision is made in the groove between the biceps and deltoid and

is extended posteriorly across the axilla to the lateral border of the latissimus dorsi. The lines of Langer are thus followed, and the crossing of

flexion creases, which might later cause keloid or flexion contracture, is

avoided. When the subcutaneous exposure is completed, care must be

taken to avoid the intercostobrachial and thoracodorsal nerves.

In the center of the wound, between the short head of the biceps and

the latissimus dorsi, is a fascia-encased neurovascular bundle which contains

the lower reaches of the brachial plexus and the axillary artery and vein as

they blend into their respective components in the arm. The radial nerve

is on the opposite side of this bundle, behind either the axillary or the

brachial artery. It can be identified as the largest nerve going into the

arm (fig. 141).

If there is much scar tissue, its presence, together with the fragility of

the large, thin-walled veins, imposes great caution on the surgeon. Tissue

distortion may require identification of the posterior cord, from which the

radial nerve arises, above the lesion, as well as of the radial nerve in the

upper arm below the lesion. The posterior cord lies behind the axillary

artery and gives rise to the axillary nerve, which can be identified by

electrical stimulation. The radial nerve lies between the humerus and the

brachial artery in the arm. The motor branches to the medial and long

heads of the triceps which emerge from the radial nerve trunk at this level

should be identified for suture if they are severed or for their protection

if they are intact.

Closure of the incision in the axilla requires approximation only of the

subcutaneous tissues and skin. This exposure requires no severance of

muscular, tendinous, or retaining structures.

Exposure in the upper arm.—With the arm held upright (fig. 142), an

oblique incision is made from the apex of the axilla downward and laterally

to a point 1 inch below the insertion of the deltoid. The medial and lateral
COMMONLY INJURED PERIPHERAL NERVES 323

FIGURE 140.—Skin incision for exposure of proximal third of radial nerve.

FIGURE 141.—Surgical exposure of axillary portion of radial nerve.

brachial cutaneous nerves are avoided. The medial intermuscular septum

is incised at the upper limit of the wound, and the deep fascia is divided

downward and laterally. The neuromuscular bundle, which contains the

brachial artery and veins and the median, ulnar, radial, and medial antebrachial cutaneous nerves, lies in the sulcus between the biceps and the long

head of the triceps.

The radial nerve is identified behind the brachial artery. By separation of the fascia investing the long head of the triceps, it is possible to

trace the nerve downward and laterally between this head and the medial

head of the triceps. The long and lateral heads of the triceps can be

separated posteriorly in the lower end of the wound without cutting any

muscle fibers. When this has been done, the radial nerve will be found

close to the humerus in the musculospiral groove. The profunda artery

accompanies the nerve (fig. 143), and motor branches emerge to the lateral

and medial heads of the triceps and the anconeus. A sensory branch, the

dorsal antebrachial cutaneous nerve, also emerges at this point. All of these

structures must be respected.

Closure requires approximation of the deep fascia, the subcutaneous

tissues, and the skin.

Exposure in the arm.—The patient lies with the arm resting easily against

the body and the forearm flexed across the abdomen at an angle of 45° with

the arm (fig. 144).
324 NEUROSURGERY

FIGUHE 142.—Skin incision for exposure of radial nerve in upper third

of arm.

W>

FIGURE 143.—Surgical exposure of

radial nerve in upper third of arm.

FIGURE 144.—Skin incision for exposure of radial nerve in lateral

aspect of arm.
COMMONLY INJURED PERIPHERAL NERVES 325

The incision is begun in the midlateral portion of the arm, over the

lateral bicipital sulcus, 1 inch below the insertion of the deltoid. It is

carried downward and slightly forward toward the prominence of the

brachioradialis and extensor carpi radialis at the elbow. If the incision

must be carried below the elbow, it crosses the antecubital fossa transversely,

in order to prevent contracture or keloid at the bend of the elbow, and

then curves gently back to a straight course over the radius.

The deep fascia is incised, and a plane of cleavage is sought between

the brachialis and the lateral head of the triceps. The radial nerve lies

deep between these muscles. As the nerve courses upward, it pierces the

lateral intermuscular septum; this dense fascial investment must therefore

be divided to expose the upward passage of the nerve. In its downward

extension, the radial nerve lies deep between the brachialis and brachioradialis, dividing at the elbow into the superficial and deep radial nerves.

It is accompanied by an anterior terminal branch of the profunda artery,

and it gives off branches to the brachioradialis, the extensor carpi radialis

longus, the lateral portion of the brachialis, and the elbow joint. Precautions

must be taken to identify and avoid these structures. If separate nerve

branches should be cut, they must be repaired.

The frequency with which the radial nerve and humerus are both injured is due to their close proximity in this region, in which the nerve is

also particularly liable to compression or destruction by the formation of

callus. Moreover, the numerous and variable muscle branches, the proximity

of many muscles affecting refined movement, and the frequency with which

injuries to the middle and lower arm involve the elbow greatly increase the

difficulties attendant on exploration of the radial nerve in this region.

Closure requires approximation of the deep fascia, the subcutaneous

tissues, and the skin. It is not necessary to reapproximate muscle sheaths.

Exposure in the forearm.—The patient lies supine, with the affected extremity resting in midposition on an arm board. The line of incision corresponds to a line drawn between the external condyle of the humerus and

the tubercle of the radius. If exposure at the elbow is desired, a transverse

incision is used, to protect the flexion crease. Any extended exposure in the

forearm should be made through a curved or oscillating incision to prevent

contracture or keloid (fig. 145). Branches of the dorsal and lateral antebrachial cutaneous nerves course subcutaneously in this region. The deep

fascia is divided.

The deep radial nerve is approached at the elbow by separating the

loose areolar tissue between the biceps tendon and the brachioradialis

muscle. The extensor carpi radialis longus, which lies beneath the brachioradialis, is retracted laterally. The nerve, which runs between it and the

brachialis, is thus exposed. Near the capitellum of the humerus, the nerve

divides into deep and superficial branches. The deep radial branch passes

around the head of the radius to enter the substance of the supinator, while
326 NEUROSURGIORY

the superficial radial branch continues superficially, under cover of the

brachioradialis.

In order to expose the deep radial nerve in the upper forearm as it

traverses the substance of the supinator, it is necessary to make multiple

splits in the muscle or, in some cases, to sever part of it (fig. 146). The

utmost care is necessary in dissection to avoid injury of the emerging

branches of the deep radial nerve, which include those to the brachioradialis,

extensor carpi radialis brevis, supinator, extensor digitorum communis, extensor digiti quinti proprius, and extensor carpi ulnaris. It should be

emphasized that injury to the deep radial nerve is often impossible to repair

unless it was made with a sharp instrument or was associated with a

fracture of the upper end of the radius. This is because of the close

proximity of the nerve to the muscles it innervates, its numerous branches,

and the shortness of these branches. The superficial radial nerve, which

lies under cover of the brachioradialis muscle in the upper forearm, is

seldom explored independently for the purpose of deliberate suture unless

it is the site of a painful neuroma.

In the middle third of the forearm, the deep radial nerve can be found

by separating the extensor carpi radialis brevis and the extensor digitorum

communis. It accompanies the posterior interosseous artery across the dorsal

surface of the abductor pollicis longus. This nerve is small, and its motor

branches, which emerge in this area to supply the extensor indicis proprius

and the extensor muscles of the thumb, are smaller. When scarring is

present, therefore, identification and suture are both difficult. The deep

radial nerve terminates in the dorsal interosseous nerve, which passes through

the groove for the common extensors to the wrist. Here it supplies trophic

and sensory innervation to the carpal articulations.

AVound closure in the forearm includes approximation of the deep fascia,

subcutaneous tissues,=) and skin.

Methods of Gaining Length

The radial nerve is under greatest tension when the arm is fully

pronated, extended, and abducted at the shoulder. Conversely, maximal relaxation is achieved when the arm is fully adducted, externally rotated at

the shoulder, and flexed across the chest, with the forearm flexed on the

arm and supinated. As a rule, nerve suture can be effected with this positioning. If, however, repair cannot be accomplished even with optimum

positioning, the best plan is to transfer the nerve to an anterior position in

the arm and make it pass between the biceps and the brachialis, to rejoin

the divided nerve segments at the inner aspect of the arm, as recommended

by Bunnell. Since the branches of the nerve to the triceps anchor the nerve

trunk, they must be gently stripped upward until sufficient mobilization

is achieved.
COMMONLY INJURED PERIPHERAL NERVES 327

FIGURE 145.—Skin incision for exposure of radial nerve in forearm.

FIGURE 146.—Surgical exposure of

deep radial nerve.

FIGURE 147.—Distribution of median

nerve in arm. Skin incision for its

exposure is shown by dotted lines.
328 NEUROSURGERY

THE MEDIAN NERVE

General Anatomy

The median nerve originates in the medial aspect of the arm, deep in

the axilla, lateral to the axillary artery and near the lower border of the

pectoralis minor muscle (fig. 147). It is formed by fusion of components

of the lateral and medial cords of the brachial plexus. Its nerve fibers are

derived principally from the sixth, seventh, and eighth cervical nerves and

the first thoracic nerve (p. 310). It courses vertically through the medial

aspect of the arm, within the neurovascular bundle. It lies lateral to the

brachial artery in the upper arm but crosses it anteriorly in the middle of

the arm and lies medial to it from that point to the elbow.

The medial nerve is found anterior to the medial intermuscular septum.

It gives out no branches in the arm but occasionally receives a small branch

from the musculocutaneous nerve.

At the elbow, the median nerve assumes an anterior course which carries

it beneath the lacertus fibrosus and between the two heads of the pronator

teres muscle. In the upper forearm, it lies deeply bedded, between the

flexor digitorum sublimis and flexor digitorum profundus muscles, but, as

it approaches the wrist, it comes to lie superficially, between the flexor carpi

radialis and flexor digitorum sublimis tendons and beneath the tendon of the

palmaris longus. From the elbow dowmvard, branches are supplied successively to the elbow joint, pronator teres, flexor carpi radialis, palmaris

longus, flexor digitorum sublimis and profundus, flexor pollicis longus, and,

through the volar interosseous nerve, to the pronator quadratus.

At the wrist, except for the superficial palmar branch, the median nerve

passes between the anterior annular (transverse carpal) ligament superficial

to the flexor tendons. At the lower border of this ligament, it divides into

three common volar digital nerves that lie dorsal to the superficial volar arch

(fig. 148). These nerves, in turn, divide into the proper volar digital nerves

that lie on the volar side of the digital arteries and send motor and sensory

branches to the thenar eminence, the thumb, the index and middle fingers,

and the radial side of the ring finger. The motor branches innervate, respectively, the abductor and flexor pollicis brevis, the opponens pollicis,

and the first and second lumbrical muscles. Sensation to the medial border

of the eminence is supplied by the palmar branch of the median nerve.

Surface Anatomy

A line drawn from beneath the lower border of the pectoralis major at

the apex of the axilla along the medial aspect of the biceps brachii downward to the lacertus fibrosus conforms to the course of the median nerve in

the arm (fig. 149). From this latter point to the midvolar aspect of the

wrist, the median nerve descends in the forearm. The thenar crease marks
COMMONLY INJURED PERIPHERAL, NERVES 329

FIGURE 148.—Terminal branches of

median nerve below annular ligament. Dotted lines indicate skin incision for surgical exposure.

FIGURE 149.—Course of median nerve in upper extremity.

FIGURE 150.—Skin incisions for

exposure of terminal branches of

median nerve.
330 NEUROSURGERY

its course in the hand, although the nerve begins to divide near the proximal

transverse palmar crease (fig. 150). The digital nerves lie in a midlateral

position along each side of the fingers.

Surgical Approach

Positioning and preparation.—The patient lies supine, with an ether

frame so placed that drapes can extend to the shoulder girdle. This is to

make the entire arm accessible in the operative field. Experience has proved

this precaution a necessity except in exploration in the lower forearm and

hand. The drapes must cover the whole body, and movement of shoulder,

elbow, and wrist joints must be possible in a sterile field. The hand is encased in a sterile glove and the arm in sterile stockinet, in which windows

may be cut as necessary to correspond with the proposed skin incisions; if

they are required, the edges of the stockinet incised should be folded under,

to prevent entrance of lint into the wound.

The extremity prepared in this manner permits any necessary incision,

free range of motion, and freedom for examination on electrical stimulation

of the nerve.

Exposure in the arm.—The arm, resting on an arm board, is abducted and

externally rotated. The incision, which follows the medial bicipital groove,

is curved to prevent keloid or contracture. The medial brachial and antebrachial nerves are encountered in the subcutaneous tissue, the latter from the

lower third of the arm downward. The basilic vein likewise pierces the

deep fascia in the lower third of the arm, to pass from a superficial to a

deep position. The neurovascular bundle is identified by palpating the

brachial artery under the medial intermuscular septum between the bellies

of the biceps and triceps muscles. It is opened longitudinally under tension.

The median nerve lies anterior to the medial intermuscular septum,

lateral to the brachial artery in the upper arm. It crosses the artery

anteriorly in the middle third of the arm and lies medial to it in the lower

third. From the middle third of the arm downward, the ulnar collateral

artery and vein occupy a position lateral to the median nerve. Throughout

the arm, anastomosing branches of the venae comitantes enmesh the deeper

structures. The ulnar nerve, because it is smaller and situated more medially

and posteriorly, is unlikely to be confused with the median nerve. If, however, tissue distortion is great, electrical stimulation may be necessary to

identify the two nerves accurately.

Closure entails approximation of the deep fascia and suture of the

subcutaneous tissues and skin (fig. 151).

Exposure at the elbow.—The arm rests in supination. The incision

crosses the elbow transversely, in line with the flexion creases. The cubital

and basilic veins are spared. The medial antebrachial cutaneous nerve lies

near the medial reach of the incision and the lateral antebrachial cutaneous

nerve near the lateral. The deep fascia is divided; the lacertus fibrosus,
COMMONLY INJURED PERIPHERAL NERVES 331

which crosses the antecubital fossa obliquely, is used as a landmark (fig. 152).

The median nerve courses immediately beneath the midportion of the

lacertus fibrosus. Above it, the median nerve lies medial to the brachial

artery and biceps tendon and rests on the brachialis muscle along with the

inferior ulnar collateral artery. Below this fibrous band, the nerve is medial

to the ulnar artery and in lateral relation with the pronator teres, beneath

whose two heads it disappears. Articular branches to the elbow and branches

to the pronator teres arise from the median nerve as it passes through the

antecubital fossa. The nerve in this location lies relatively uncovered and

can be exposed merely by separating loose areolar tissue and fat.

Closure requires approximation of the deep fascia, subcutaneous tissues,

and skin.

Exposure in the forearm.—The patients lies with the forearm and hand

supinated. A curved incision is centered over the midvolar aspect of the

forearm. The medially and laterally placed antebrachial cutaneous curves

are avoided. The deep fascia is cut longitudinally.

To expose the median nerve in the upper forearm, the flexor carpi

radialis is retracted medially and the brachioradialis laterally. The humeral

head of the pronator teres is detached. The nerve is thus exposed as it

crosses the smaller ulnar head of the pronator teres. At this level, the

median nerve crosses the ulnar artery anteriorly and descends into the mid

forearm in company with the median artery. Branches to the flexor carpi

radialis, palmaris longus, and flexor digitorum sublimis are given off at this

level. The volar interosseous nerve arises at the lower border of the pronator

teres, on a level with the bicipital tubercle of the radius. This nerve supplies

the pronator teres and, in its course to the wrist along the interosseous

membrane, also supplies the two lateral divisions of the flexor digitorum

profundus and the flexor pollicis longus (fig. 153).

To expose the median nerve in the mid forearm, it is necessary to divide

the radial attachment of the flexor digitorum because the nerve lies between

this muscle and the flexor digitorum profundus. In some cases, however,

adequate exposure of a localized lesion can be secured merely by separating

the obliquely coursing fibers of this muscle. Since most of the branches of

the median nerve in the forearm arise in the upper third, they will not be

encountered in the mid forearm unless there is a variation in the mode of

origin.

The median nerve is quite easily exposed in the lower forearm. Here

it is centrally situated beneath the deep fascia and can be visualized by

retracting the flexor carpi radialis on the radial side and the palmaris longus

and flexor digitorum sublimis tendons on the ulnar si,de. The only branch

of the median nerve which arises in the lower forearm is the palmar branch

(palmar cutaneous nerve), which emerges just above the transverse carpal

ligament.
332 NEÜROSURGEKY

Brachiolis M

Triceps M

FIGURE 151.—Cross section of middle

third of arm showing relation of median nerve to neurovascular bundle.

Brachial A.8 V. Median N.

Basilic V.

Radio

Brachio

radialis M

Lacertus

fibrosus

Pronator teres M.

Biceps M.

Musculo-cut.N.

Median N.

Medial antibra-cut. N.

Basilic. V.

Intermuscular seplum

Brachial A.

Ulnar N.

FIGURE 152.—Surgical anatomy of

antecubital fossa.

FIGURE 153.—Motor branches of median nerve in forearm.
COMMONLY INJURED PERIPHERAL NERVES 333

Closure requires reapproximation of any muscles or tendons of origin

which have been cut. The deep fascia, subcutaneous tissues, and skin are

sutured in layers.

Exposure at the wrist.—The wrist is held with the hand supinated. A

transverse incision is made across the flexion creases of the wrist, with provision for extension if necessary (fig. 154).

When the deep fascia has been incised, the palmar cutaneous branch is

seen lying superficial to the transverse carpal ligament. This branch carries

sensation to the central depressed surface of the palm and to the medial

border of the thenar eminence. The median nerve lies beneath the transverse

carpal ligament, in front of the flexor tendons, in the middle of the wrist,

under the tendon of the palmaris longus. The palmaris longus is retracted

toward the ulna, and a linear incision is made between the tendons of the

flexor digitorum sublimis and the flexor carpi radialis. The median nerve

lies between these tendons, superficial to the tendons of the flexor pollicis

longus and the flexor digitorum profundus (figs. 154 and 155). It is unlikely to be confused with the ulnar nerve, which lies far off toward the

ulna, beneath the tendon of the flexor carpi ulnaris and the ulnar artery.

Closure requires suture of the deep fascia, subcutaneous tissues, and skin.

Exposure in the hand.—The incision in the hand conforms to the natural

creases (fig. 150).

The median nerve, at the point at which it divides into the common

volar digital nerves, lies in the middle of the palm, beneath the midportion

of the thenar or radial crease, in front of the flexor tendons, and behind

the superficial volar arch (fig. 148). The common volar digital nerves, in

turn, promptly divide into the proper volar digital nerves that extend to

their respective fingers and into a smaller branch to the thenar eminence.

This branch supplies the abductor pollicis, the opponens, and the superficial

head of the flexor pollicis brevis. Branches to the first and second lumbricales arise respectively from the first and second common volar digital

nerves. A branch which arises from the common volar digital nerve communicates with the ulnar nerve and may contribute a twig to the third

lumbrical muscle.

The proper volar digital nerves, which supply sensation to the pulp and

matrices of the nails of the thumb, index, and middle fingers, as well as to

the radial side of the fourth finger, lie along the respective sides of these

digits and may be explored as far as the distal digital creases. The incision

is made in a linear direction on the midlateral aspect of the finger (figs.

150 and 156). It is frequently necessary, to secure adequate exposure,

to divide the accompanying digital artery and vein. The lateral reflections

of the pulleys are to be avoided.

Buried sutures are seldom required to close an incision in the hand or

fingers. If they are necessary, they should be used sparingly. Closely

spaced interrupted sutures that approximate the entire thickness of the

skin eliminate the risk of painful subcutaneous foreign body reactions.
334 NEUROSURGERY

Flex, carpi rad. M,

Brachioradialis

Radius

Flex, carpi rad. M

Median N

Flex.digit. prof. M

Radial A.S V.-

Radius

Palmaris longus M.

Flex, digit, longus M.

Flex.carp.ulnaris M

Ulnar N.S vessels

Flex, digit.prof. M.

Ulna

Palmaris longus M.

Flex.digit.sublimus M.

Flex.carpi ulnaris M.

Ulnar A.

Ulnar N.

Head of ulna

FIGUKE 154.—Surgical exposure of

median nerve at wrist.

FIGUHE 155.—Cross section showing

anatomy of median nerve in forearm.

A. In mid forearm. B. Above annular

ligament.

FIGURE 156.—Surgical exposure of

digital nerve in index finger.

Palmaris longus M.

Median N.

Flex.carpi radialis M.

FIGURE 157.—Bridging of 2-cm. gap

of median nerve at wrist by flexion of

wrist.
COMMONLY INJURED PERIPHERAL NERVES 335

Methods of Gaining Length

The median nerve is under greatest tension when the arm is abducted

and externally rotated, the forearm is extended and pronated, and the wrist

and fingers are extended. Relaxation is maximal with the arm adducted

and internally rotated and the elbow, wrist, and fingers flexed; the hand is

in neutral position. Defects up to almost an inch in the hand can be overcome by flexing the fingers. Defects of iy2 to 2 inches at the wrist can be

bridged by sharply flexing the wrist and fingers (fig. 157). Defects of 2y2

to 3 inches in the arm and forearm can be overcome by stripping the nerve

branches in the forearm and flexing the elbow and wrist (figs. 158 and

159). Even larger defects can be bridged by detaching the humeral head

of the pronator teres and rerouting the nerve to a subcutaneous position

at the elbow, in combination with freeing the nerve high in the arm and

flexingx the elbow and wrist. b

THE ULNAR NERVE

General Anatomy

The ulnar nerve arises from the medial (inner) cord of the brachial

plexus, which itself originates in the anterior divisions of the eighth

cervical and first thoracic spinal roots. The nerve passes distally with, and

mesial to, the brachial artery and median nerve into the lower third of the

arm. Here it deviates posteriorly, piercing the medial intermuscular septum

to cross the medial head of the triceps muscle. After it crosses the biceps,

the ulnar nerve enters the ulnar groove posterior to the medial epicondyle

of the humerus. It is easily palpable in its superficial position as it lies

beneath the dense fascia between the olecranon and the medial epicondyle.

The branches to each head of the flexor carpi ulnaris muscle arise just

distally, followed by two branches to the flexor digitorum profundus of the

ring and the little finger (fig. 160).

The ulnar nerve enters the forearm beneath an aponeurotic arch formed

by the junction of the two heads of the flexor carpi ulnaris muscle. As the

nerve traverses the medial aspect of the forearm, it is covered in the upper

third by the flexor carpi ulnaris muscle. For the remainder of its course

in the forearm, it lies in close approximation to the ulnar artery and vein,

within the sheath of the common flexors of the fingers.

About 5 cm. above the wrist, the ulnar nerve divides into the dorsal

cutaneous and the volar branch. The dorsal cutaneous branch pierces the

deep fascia beneath the flexor carpi ulnaris and goes to the dorsum of the

hand. The volar branch enters the hand through an opening in the transverse carpal ligament on the radial side of the pisiform bone. Separation

into superficial and deep branches occurs at the lower margin of the ligament.

The superficial branch is sensory to the volar aspect of the hand, the

ulnar aspect of the ring finger, and the little finger. It sends small motor

408991*—59 24
336 NEUROSURGERY

FIGURE 158.—Stripping of muscular

branches of median nerve in upper forearm to attain additional length.

FIGURE 159.—Technique of repair of injured median nerve in arm.

A. Exposure of nerve. B. Proximal neuroma and distal glioma freed

and held with fine traction sutures. Note gap between nerve ends with

forearm extended. C. Overlapping of nerve ends achieved by flexing

forearm and abducting arm.
COMMONLY INJURED PERIPHERAL NERVES 337

FIGUEE 1G0.—Distribution of ulnar

nerve in upper extremity.

branches to the palmaris brevis muscle. The deep branch, which is principally motor, penetrates the depths of the palm, in company with the deep

volar arch of the artery. It then passes between the abductor digiti quinti

and the flexor digiti quinti brevis, to lie beneath the flexor tendons of the

fingers. It supplies the three short muscles of the small finger, the interossei,

and the third and fourth lumbricales, as well as the adductor pollicis and

the medial head of the flexor pollicis brevis. Small articular branches of

the superficial branch of the ulnar nerve pass to the wrist joint along its

course.

Surface Anatomy

The ulnar nerve can be rolled beneath the fingers as it lies in relation

to the brachial artery and the median nerve along the medial aspect of the

arm. At the elbow, it is readily identified in the ulnar groove. At the

wrist, it is immediately subjacent to the flexor carpi ulnaris tendon, just

proximal to the insertion of this tendon into the pisiform bone. In the

upper third of the forearm, the medial antebrachial cutaneous nerve crosses

the ulnar nerve obliquely, in a dorsomedial direction, on the external surface

of the fascia of the flexor carpi ulnaris muscle.
338 NEUROSURGERY

Surgical Approach

Positioning and preparation.—The patient lies supine, with the shoulder

at the edge of the table and the arm abducted on an arm board placed

high under the shoulder. After preliminary antiseptic preparation of the

skin from the axilla clown to, and including, the tips of the fingers, the

hand is encased in a sterile glove. Drapes are then so placed as to allow

exposure as far as the axilla. The probable lines of incision are delineated

on the skin by scratch marks made throughout the course of the nerve, after

which the arm is encased in sterile stockinet for skin coverage. Pads placed

beneath the arm facilitate exposure of the nerve.

Exposure in the axilla.—A transverse incision, already described (p. 316),

is employed for exposure of the ulnar nerve in the axilla. This incision

follows the skin lines but does not cross them. Incapacitating contracting

keloids form when incisions cross the skin lines in the axilla. A separate

incision can be started several centimeters below the axilla for mobilization

of the nerve (fig. 161). The subcutaneous tissues of the axilla and the

axillary fascia are divided to expose the neurovascular bundle.

With the arm abducted, the ulnar nerve lies dorsomedial to the axillary

artery, while the median nerve lies anterolateral to the artery and the radial

nerve lies dorsolateral. The medial antebrachial cutaneous nerve lies between the median and ulnar nerves, on the medial aspect of the axillary

vessels. The ulnar nerve is easily exposed in this region, in which, however,

it is seldom injured independently. Injury to it is usually associated with

injury to the median and radial nerves and to the axillary artery.

Exposure in the arm.—The patient lies supine, with the arm abducted on

an arm board and the forearm fully supinated. In the upper two-thirds

of the arm, the incision is the same as that used for the median nerve (p. 330);

that is, it roughly follows the course of the neurovascular bundle in a gently

oscillating curve. In the lower third of the arm, the incision deviates

posteriorly toward the medial epicondyle. It crosses the elbow anterior to

the epicondyle, however, to avoid an incision over the posteromesial aspect of

the elbow, which is an area subject to considerable trauma.

The deep fascia is divided, care being taken not to injure the medial

brachial cutaneous nerves. By retraction of the border of the coracobrachialis

in the upper part of the arm and of the biceps lower down, the neurovascular

bundle is exposed. If it is necessary to obtain exposure in the lower axilla,

the inferior fibers of the pectoralis major muscle may be cut. When the

neurovascular bundle is opened, the ulnar nerve is exposed in its posterior

portion. In the lower third of the arm, the nerve pierces the medial intermuscular septum and lies in close relation to the posterior surface of the

septum as far distally as the medial epicondyle.

Exposure of the ulnar nerve in the neurovascular bundle is a tedious

procedure. Dissection must be cautious, to avoid injury to the brachial
COMMONLY INJURED PERIPHERAL NERVES 339

FIGUKE 161.—Skin incision for exposure of ulnar

nerve in upper extremity. A. Exposure in axilla and

upper arm. B. Continuation of skin incision in lower

arm and region of medial epicondyle.

artery and veins. If there is much scarring, the procedure is particularly

time consuming.

Identification sutures, with due attention to the surface markings of the

ulnar nerve, are placed at the center of the mesial half of the nerve, both

above and below the lesion, to facilitate proper alinement of the nerve for

suture. These sutures are placed before the nerve is freed from its bed.

The nerve is mobilized as far as is necessary distally and proximally to

obtain length for overcoming the gap in it. Dissection is carried out with

as much sparing as possible of the vascular supply.

Frequently, in order to gain sufficient length for repair of the ulnar

nerve in the axillary area, it is necessary to transplant it anterior to the

medial epicondyle. When the nerve is in its normal position behind this

epicondyle, maximum relaxation is obtained by flexion of the wrist, extension of the elbow, and adduction of the arm. After transplantation of the

ulnar nerve, however, to a position anterior to the medial epicondyle, the

greatest relaxation is gained by flexion of the wrist, flexion of the elbow,

and adduction of the arm.

Exposure at the elbow.—In general, since almost any surgery on the ulnar

nerve in the elbow region requires its transplantation to the anterior position, considerable exposure of the nerve is necessary in both the arm and

forearm. The arm is abducted and externally rotated. The elbow is somewhat flexed, and the hand is supinated.

The incision begins in the region of the point of penetration of the intermuscular septum by the ulnar nerve. It extends distally along the septum

to a point about iy5 inches above the medial epicondyle. Here it sweeps

forward in a gentle curve anterior to the medial epicondyle. Then, after
340 NEUROSURGERY

crossing the antecubital space, the incision continues across the junction of

the two heads of the flexor carpi ulnaris about 1% inches below the epicondyle. From this point, the incision may be extended distally in a gently

oscillating curve to the wrist on the radial side of the pisiform bone.

The fascia is divided in the line of the uppermost part of the incision,

and the nerve is isolated. At the elbow, the posterior skin flap is dissected

free at the level of the fascia and displaced posteriorly, thus exposing the

region of the ulnar groove. The heavy fascia over the nerve is then divided.

Anastomotic vessels about the elbow joint may give considerable trouble,

but careful ligation will control bleeding.

As the nerve is exposed, the first (articular) branch of the ulnar nerve

comes into view on the inner aspect. The branches to the two heads of the

flexor carpi ulnaris muscle are distal to the articular branch. It may be

necessary, in order to expose the ulnar nerve after it passes between the two

heads of the flexor carpi ulnaris muscle, to split the muscle at the point of

junction of the heads.

In this region, the medial antebrachial cutaneous nerve crosses the forearm from a ventral position to a dorsomedial position. When it must be

divided, to facilitate exposure of the ulnar nerve, the ends should be marked

and the nerve resutured when skin closure is done; failure to resuture it

leads to anesthesia of the medial aspect of the forearm. The branches of

the ulnar nerve which supply the flexor digitorum profundus of the ring

and little fingers should be preserved, whenever possible, during transplantation of the nerve. They arise from the nerve trunk, just below the

olecranon and distal to the point of origin of the flexor carpi ulnaris branches.

Exposure in the forearm.—The ulnar nerve in the forearm lies along an

essentially straight line between the radial side of the pisiform bone and the

medial epicondyle. In the lower forearm, it lies to the radial side of the

flexor carpi ulnaris tendon, on the flexor digitorum profundus muscle. It

is contained within the thin enveloping fascial sheath of the flexor digitorum

muscles. The nerve is accompanied in its course by the ulnar vessels.

Exposure of the nerve is most easily begun at the wrist, the dissection

then being carried proximally into the forearm. When identification is

difficult at the wrist, the nerve may be exposed at the medial epicondyle and

traced distally between the two heads of the flexor carpi ulnaris muscle

(% 162).

The dorsal cutaneous branch arises from the main trunk of the ulnar

nerve near the junction of the middle and lower thirds of the forearm.

This branch should be carefully protected, for it supplies sensation to the

dorsum of the hand and fingers on the ulnar aspect of the hand; this portion

of the hand is particularly exposed to trauma, and serious trophic changes

can follow the division of the nerve.

Exposure at the wrist.—The arm is fully abducted on an arm board, with

the elbow extended and the hand fully supinated. The ulnar nerve can
COMMONLY INJURED PERIPHERAL NERVES 341

FIGURE 162.—Surgical exposure of ulnar nerve in lower forearm.

often be palpated just proximal to the flexion creases of the wrist; at this

point, it lies dorsolateral to the tendon of the flexor carpi ulnaris muscle.

The incision should follow the skin lines for some distance but should

not cross the flexion creases in a straight line (fig. 163). The nerve is

first exposed proximal to the lesion by dividing the fascia between the

flexor carpi ulnaris tendon and the flexor sublimis tendons. In the lower

FIGUKE 108.—Skin incision for exposure of ulnar nerve at wrist and

in hand.

third of the forearm, the nerve lies within the fascial sheath of the common

flexor tendons of the fingers; this sheath must be divided to expose it. In

this area, the nerve lies close to the ulnar artery and vein, and careful

dissection is required to avoid injury to the vessels. The dorsal sensory

branch of the ulnar nerve leaves the main trunk from 2 to 4 inches above

the wrist and pierces the deep fascia to pass around the ulna to the dorsum

of the wrist.
342 NEÜROSURGERY

Distally, the ulnar nerve is exposed as it lies beneath the annular

ligament to the radial side of the pisiform bone. The ligament may be

divided longitudinally over the nerve without causing any disturbance in

the function of the wrist. The nerve divides into superficial and deep

volar branches at the distal border of the ligament. Here, the deep branch

passes into the depth of the palm, in company with the deep volar vascular

arch, while the superficial branch runs directly to the ring and little fingers,

sending small motor branches to the palmaris brevis muscle.

Before the proximal and distal segments of the ulnar nerve are freed at

the wrist, identification sutures are placed in the sheath, to provide for

accurate approximation of the cut ends. The nerve is usually freed without

difficulty from the adjacent tendons, but some trouble may be encountered

in the region of the scar because of overgrowth of the cut ends of the

tendons and nerves. Great care must be taken to identify the proximal

and distal nerve ends, which are often difficult to distinguish from each other

in scar tissue. One valuable differential feature is the presence of blood

vessels within the nerve sheath and their absence in the tendons. Even when

the transected ends of tendons and nerves are remarkably similar, proximal

and distal dissection will serve to identify the nerve by its position, its

anatomic proximity to the artery and vein, and its nutrient vessels.

Repair of tendons should be carried out simultaneously with repair

of the nerve when there are severe injuries at the wrist or in the lower

forearm. Defects of 1% to 3% inches at the wrist can be overcome by flexion

of the wrist and proximal dissection of the nerve. At times, however, it may

be necessary to transplant the nerve at the elbow in order to gain sufficient

relaxation for satisfactory nerve suture.

Technique of Transplantation at the Elbow

Transplantation of the ulnar nerve is sometimes indicated for progressive neuritis resulting from trauma to the nerve in its normal position

behind the medial epicondyle, as well as to gain sufficient length for satisfactory anastomosis of a severed nerve.

The incision is begun over the medial intermuscular septum in the lower

third of the arm. It passes anterior to the medial epicondyle of the humerus

in a sweeping curve to the midportion of the belly of the flexor carpi ulnaris

muscle, about iy2 inches below the medial epicondyle. The skin and subcutaneous tissues anterior to the medial epicondyle are dissected radially

at the level of the deep fascia, to expose the ulnar side of the biceps tendon.

This usually cannot be accomplished without division of the medial antebrachial cutaneous nerve in the upper third of the forearm. This nerve

should be marked for suture at the time the skin is closed.

The ulnar nerve is then dissected proximally as far as the point at

which it pierces the intermuscular septum. The septum is divided and the
COMMONLY INJURED PERIPHERAL NERVES 343

nerve is placed anterior to the septum, to promote passage from the neurovascular bundle into the forearm in a straight line.

The nerve is next dissected away from the enveloping areolar tissue

with careful sharp dissection. Its articular branch is identified after the

dense fascia between the medial epicondyle and the olecranon has been

divided, and the branch is itself divided. The branches to the two heads

of the flexor carpi ulnaris, which leave the main trunk just distal to the

articular branch, are identified and mobilized proximally along the ulnar

nerve into the lower third of the arm. This is accomplished by carefully

cutting the nerve sheath at the junction of the branch and the main nerve

trunk and, by cautious dissection, separating the nerve bundle from the

main nerve to achieve maximum mobility. If necessary, dissection (fig. 164)

may be continued proximally for 3 or 4 inches.

Branches of the ulnar nerve to the flexor profundus muscles of the

ring and little fingers are identified as they leave the main trunk slightly

distal to the flexor carpi ulnaris branches. These branches, like the others,

are freed from the trunk to allow for anterior displacement of the main

nerve.

After satisfactory relaxation of tension has been obtained by dissection

of the branches, the ulnar nerve is placed on the deep fascia of the flexor

muscle group, which arises from the medial epicondyle in such a position

that the nerve follows a straight line down the forearm (fig. 164B). It is

a wise precaution, to prevent posterior displacement of the nerve on motion

of the elbow, to suture the overlying subcutaneous tissue to the fascia

posterior to the transplanted nerve trunk. In this position, the nerve is

covered by a pad of fat and subcutaneous tissue.

Some surgeons prefer to pass the ulnar nerve deep to the muscles

arising from the medial epicondyle. If the nerve is divided in the upper

third of the forearm, it may be passed through a tunnel made between the

flexor digitorum profundus muscle and the overlying flexor sublimis and

pronator teres muscles. On the other hand, if the nerve is intact, the flexor

sublimis and pronator teres muscles, which arise from the medial epicondyle,

may be divided close to their origin and resutured after the nerve trunk

lias been placed on the ventral surface of the flexor digitorum profundus

muscle.

THE FEMORAL NERVE

General Anatomy

The femoral nerve, which is the largest terminal nerve of the lumbar

plexus, is formed by the fusion of fibers from the second, third, and fourth

lumbar nerves and, sometimes, from the first. The fusion of these nerves

begins and is completed with the substance of the psoas muscle, above or

near the posterior brim of the pelvis, anterior to the transverse processes

of the lumbar vertebrae, and medial to the quadratus lumborum muscle.
344 NEUROSURGERY

FIGUKE 1C4.—Technique of anterior transplantation of ulnar nerve.

A. Surgical exposure of nerve in condylar groove. B. Anterior transplantation of nerve. Suture of fascia of flexor carpi ulnaris.

The nerve passes downward and laterally, making a visible entry into

the pelvis between the psoas and iliacus muscles a short distance above the

inguinal (Poupart's) ligament. Here it lies lateral to the external iliac

artery. It descends behind the inguinal ligament into the thigh, through

the groove between the iliacus and psoas muscles, where it lies lateral to

the femoral artery in the femoral trigone (Scarpa's triangle). Here it

divides into superficial and deep terminal branches that supply the muscles

and skin on the anterior aspect of the thigh. Collateral branches supply

the iliacus and femoral artery before the nerve enters the thigh (fig. 165).

Terminal branches.—The femoral nerve has three superficial terminal

branches, two motor and one sensory. A branch emerges from the femoral

nerve trunk just below the inguinal ligament and passes medially between

the femoral artery and the psoas muscle to the pectineus. Another twig

follows the middle branch of the anterior femoral cutaneous nerve laterally

to enter the sartorius. The anterior femoral cutaneous nerve, which is

composed of middle and internal branches (fig. 166), supplies sensation over
COMMONLY INJURED PERIPHERAL NERVES 345

FIGURE 105.—Surgical anatomy of

femoral nerve.

EiGuiiE ICO.—Superficial cutaneous

branches of femoral nerve.

the anterior and medial surfaces of the thigh down to the knee. One

branch, the posterior, after anastomosing with the obturator in the adductor

(Hunter's) canal, extends to the medial aspect of the mid calf.

The femoral nerve has six deep terminal branches, only one of which,

the saphenous, mediates sensation. This nerve follows the femoral artery

down to the adductor canal (fig. 165), which it traverses. Below the canal,

the nerve passes between the sartorius muscle and the gracilis tendon, supplying a branch to the patella, and then continues down the leg in company

with the great saphenous vein. At the ankle, the nerve courses anterior to

the internal malleolus and continues into the medial side of the foot as far

as the instep. The saphenous nerve supplies sensation to the medial side

of the leg and foot. The motor branches, which are arranged medially to

laterally, supply the vastus medialis, articularis genu (subcrureus), vastus

intermedius (crureus), vastus lateralis, and rectus femoris. All of these

motor branches branch promptly and frequently. Except for the branch to
346 NEUROSURGERY

the vastus medialis, which follows the saphenous nerve to the adductor

canal, they are quickly lost in the substance of their respective muscles.

Electrical stimulation is of great value in this region, in which easy anatomic

identification is impossible.

Accessibility.—Because of its origin, course, and termination, the femoral

nerve is the least accessible of the peripheral nerves. Arising as it does from

short interlocking nerve roots within the substance of the psoas muscle, its

first portion cannot be surgically exposed without grave damage to the

surrounding tissues. The second portion, which extends from its pelvic

appearance between the iliacus and psoas muscles down to the inguinal ligament lateral to the external iliac artery (fig. 167), is accessible through a

suprainguinal, retroperitoneal approach. The most easily exposed length of

the femoral nerve is its short third portion, which extends from the inguinal

ligament to its terminal branching in the femoral trigone. The fourth

portion consists of small terminal branches which, with the exception of

the saphenous nerve, lie almost wholly within the subcutaneous tissues and

muscles of the thigh. These branches are therefore difficult to expose except

near their point of origin.

Surface Anatomy

The femoral nerve emerges from the psoas muscle at a point level with

the anterior superior spine of the ilium. Its position in the thigh can be

ascertained by palpating the femoral artery; it lies immediately lateral to

this vessel, just beneath the inguinal ligament.

Surgical Approach

Positioning and preparation.—The patientlies supine for all exposures of

the femoral nerve. Skin preparation includes the entire lower abdomen

and the flank, groin, and thigh. Drapes are so applied that the entire leg

on the involved side is included in the operative field, to permit easy flexion

of the thigh. The thigh itself should be readily visible and palpable, to be

available for electrical stimulation if it is necessary for identification of

nerves. A folded pillow placed beneath the knee maintains relaxation of

the femoral nerve and the adjacent muscles.

Exposure in the pelvis.—An oblique incision is made in the loAver abdomen

with the center level with, and 1% inches inside, the anterior superior iliac

spine (fig. 168). The external oblique aponeurosis is divided longitudinally

about an inch medial to the inguinal ligament (fig. 169A). The ilioinguinal

and iliohypogastric nerves are identified and preserved. The fibers of the

internal oblique and transversalis muscles are now separated in succession,

exposing the parietal peritoneum (fig. 169B). By means of blunt dissection,

the peritoneum is separated from the deep transversalis fascia laterally and

posteriorly until the psoas muscle is reached.
COMMONLY INJURED PERIPHERAL NERVES 347

Lat. f em.cut. N.

Pectineus M.

FIGUHE 167.—Relation of femoral nerve to vascular structures at Poupart's ligament.

The femoral nerve will be found lying lateral to the external iliac artery

and vein in the lower end of the surgical field (fig. 169C). It courses upward in the groove formed by the iliacus and psoas muscles. If these muscles

are separated at the point, at which the nerve deviates medially and becomes

lost from view, an additional 2 to 2y2 inches of nerve can be exposed. There

is no objection to tracing the nerve as far as possible into the substance

of the psoas.

The ureter crosses the psoas in the upper end of the wound. The

genitofemoral nerve descends to the groin on the anterior surface of this

muscle. The inferior epigastric and deep circumflex iliac vessels are situated

anteriorly in the lower end of the wound. It is important to fix the position

of all of these structures at the beginning of the dissection.

The nerve can usually be traced into the thigh, if that is necessary,

without extending the incision. If, however, subinguinal incision is necessary,

it is better made through a second incision paralleling the first. The integrity of the groin is thus not compromised.

If scarring prevents a retroperitoneal approach to the intrapelvic portion of the femoral nerve, the exploration can be accomplished transperitoneally.
348 NEUROSURGERY

FIGTJKE 168.—Skin incision for exposure of intrapelvic portion of femoral

nerve.

FIGURE 169.—Surgical exposure of femoral nerve in pelvis. A. Division of external

oblique aponeurosis. B. Further dissection through fibers of transversalis muscle. C.

Relation between femoral nerve and lateral femoral cutaneous nerve in pelvis.
COMMONLY INJURED PERIPHERAL NERVES 349

Closure is effected in anatomic layers. The transversalis and internal

oblique muscles are loosely reapproximated unless they coapt naturally;

the sutures can be omitted. The external oblique aponeurosis is snugly

sutured; if its leaves are thin and weak, they should be imbricated. The

subcutaneous tissues and the skin are also sutured.

Exposure in the thigh.—The precise site of exposure of the femoral nerve

in the thigh will depend not only on the level of injury but also upon the

surgeon's judgment. As already pointed out, exploration of the femoral

nerve below the femoral trigone is of dubious value because of the intramuscular course of small, finely divided nerves. If, however, exploration of

isolated cutaneous or motor nerves is undertaken, the decision must be made

on the merits of the case. Operation is on general surgical principles.

Incision for repair of motor nerves is made with the recollection that their

position corresponds to that of the muscle involved. Incision for repair of

sensory nerves follows their anatomic course and is made with respect to

flexion creases and the lines of Langer, in order to prevent keloid contracture.

Exploration of the femoral nerve in the femoral trigone is not required

very frequently, at least for war wounds, probably because a wound of the

femoral nerve in this area is usually associated with a severe wound of the

femoral artery and vein, and the entire limb is lost. Exploration in this

area was necessary only once, for causalgia, in more than 1,500 consecutive

admissions to one neurosurgical ward in McCloskey General Hospital,

Temple, Tex.

The femoral nerve in the trigone is exposed through an oblique subinguinal incision, with its center over the femoral artery (fig. 170). The

lateral femoral cutaneous nerve may be encountered in the incision, and

branches of the lumboinguinal nerve lie medially in the subcutaneous tissue

(fig. 166). The great saphenous vein and its tributaries penetrate the cribriform fascia and enter the femoral vein through the fossa ovalis at the

median end of the incision.

The cribriform fascia is opened obliquely downward, exposing the

femoral trigone. The femoral nerve lies lateral to the femoral artery in a

groove between it and the iliopsoas (fig. 171). Branches of the superficial

epigastric and lateral circumflex arteries emerge from the lateral side of

the&femoral artery and cross the nerve. The terminal motor and sensory

branches of the femoral nerve show considerable individual variation; they

can be identified by the tissues they supply. If there is associated vascular

damage, special precautions must be taken to prevent injury to the collateral

blood supply.

Closure requires approximation of the cribriform fascia, the subcutaneous

tissues, and the skin.
350 NEUIiOSURGEBY

Methods of Gaining Length

The femoral nerve is under greatest tension when the back is arched

and the thigh extended. Relaxation is maximal when the back and thigh

are flexed. Gaps of 2y2 to 3 inches can be overcome by flexing the back

and thigh, with the knee flexed to relax the hamstring muscles. Subcutaneous rerouting of the nerve is of no value because the nerve would then

describe an arc rather than a straight line. Deepening the groove between

the iliacus and the psoas is of some little help because normally the nerve

is somewhat curved and each end is situated more posteriorly than is the

center. Branch stripping is of no help, with the possible exception of the

branches to the pectineus, sartorius, and iliacus, all of which are terminal

and emerge from the parent trunk in an almost straight line.

FIGURE 170.—Skin incision for /41F

exposure of femoral nerve in FIGURE 171.—Surgical exposure of terminal

thigh, branches of femoral nerve in thigh.

THE SCIATIC NERVE AND ITS TERMINAL DIVISIONS

The sciatic nerve, which is the largest nerve in the body, arises from

ventral and dorsal divisions of the fourth and fifth lumbar nerves and the

first, second, and third sacral roots (fig. 172). Its trunk contains a tibial

portion derived from the ventral divisions and a peroneal portion derived

from the dorsal divisions.

The sciatic nerve leaves the pelvis by passing through the great sacrosciatic foramen and usually beneath, but sometimes through, the piriformis

muscle. It then descends the posterior aspect of the thigh almost vertically
COMMONLY INJURED PERIPHERAL NERVES 351

to the apex of the popliteal space. Here it divides into the tibial and the

common peroneal nerves.

In its upper portion, the sciatic nerve lies approximately midway between the great trochanter and the tuberosity of the ischium. It is covered

by the gluteus maximus muscle. It lies first upon the posterior surface of

the obturator internus and gemelli muscles and then upon the quadratus

femoris. From just below the lower border of the gluteus maximus to the

popliteal space, the nerve lies upon the posterior surface of the adductor

magnus, lateral to the semimembranosus. Here it is covered by the obliquely

crossing belly of the long head of the biceps femoris muscle.

Division of the sciatic trunk into the tibia! and common peroneal nerves

most often occurs near the upper part of the popliteal space, but it may

also take place at a higher level. In a small percentage of cases, division

occurs within the pelvis itself. The sciatic nerve is then replaced by two

distinct nerves. Even when the tibial and common peroneal components are

incorporated in a single sheath, they are divided by a septum and can

usually be separated from one another. The tibial portion occupies a ventromedial position in the sciatic trunk and the peroneal portion a lateral and

somewhat dorsal position.

Branches in the thigh.—The nerve to the hamstrings, although at times it

is incorporated within the sciatic trunk, is usually separated from it and

should not be regarded as a branch of the sciatic. This fact explains why

the hamstring muscles are almost always spared in injuries of the sciatic

nerve, even in high lesions. The nerve to the hamstrings lies medial to the

tibial portion of the sciatic nerve and divides into branches which innervate

the semitendinosus, the long or ischial head of the biceps, the semimembranosus, and the dorsal portion of the adductor magnus. The short or

femoral head of the biceps is supplied at about the middle of the thigh by

a nerve which runs as a separate funiculus on the lateral border of the

peroneal division of the sciatic nerve. This nerve may or may not be regarded by anatomists as a collateral branch of the sciatic nerve, depending

upon the point of view. In any event, it must not be overlooked.

The tibial nerve.—The tibial nerve, after leaving the trunk of the sciatic

nerve, descends in the thigh and crosses the popliteal space near its midline

almost perpendicularly. At this level, it lies just beneath the fascia, dorsal

and somewhat lateral to the popliteal vein, which itself lies dorsolateral to

the popliteal artery. The tibial nerve then passes downward between the

two heads of the gastrocnemius to lie deep or anterior to this muscle on

the posterior aspect of the popliteus muscle. The nerve enters an arch in the

soleus in company with the popliteal artery and vein. From this point,

it descends in the leg as the posterior tibial nerve.

The tibial nerve gives off five muscular branches in the popliteal space.

These branches supply, respectively, the two heads of the gastrocnemius, the

plantaris, the soleus, and the popliteus muscles. Although they leave the
352 NEÜROSÜRGERY

nerve at different levels, they have a common intraneural course, through

a bundle which lies on the posterior aspect of the main nerve trunk. By

careful dissection, they may be separated from the parent trunk for many

centimeters above the points of their emergence.

The branches to the two heads of the gastrocnemius arise near the upper

part of the popliteal space and diverge to enter the medial and lateral heads

of the muscle. The nerve to the soleus arises at a lower level, passes deep

or anterior to the lateral head of the gastrocnemius, and enters the soleus

from its posterior aspect. This nerve sometimes emerges from the tibial

in common with the branch to the lateral head of the gastrocnemius. The

branches to the plantaris and the popliteus usually leave the main nerve

separately at about this level. Articular branches are also given off to the

knee joint, and vascular branches supply the anterior and posterior tibial

and peroneal arteries.

In the popliteal space, the tibial division gives off the medial sural

cutaneous nerve, which descends between the two heads of the gastrocnemius

to the mid calf. Here it pierces the deep fascia and anastomoses with a

communicating branch from the common peroneal nerve to form the sural or

short saphenous nerve. The nerve supplies the skin over the posterolateral

aspect of the lower third of the leg and the outer side of the foot and small

toe.

The posterior tibial nerve.—In the calf, the posterior tibial nerve lies in a

compartment in the intermuscular septum, deep to the soleus and on the

posterior surface of the tibialis posticus muscle. As the nerve approaches

the ankle, it occupies a groove between the flexor digitorum longus and the

hallucis longus. It passes behind the medial malleolus and divides into its

terminal branches in front of, and medial to, the tendo achillis. These

branches, the medial and lateral plantar nerves, enter the sole of the foot.

Throughout the leg, the posterior tibial nerve lies in close proximity to the

posterior tibial artery and vein; it is posterior to the vessels in the upper

calf and lateral to them from that point to the ankle.

Soon after its formation, the posterior tibial nerve gives off muscular

branches to the lower portion of the soleus, tibialis posticus, flexor hallucis

longus, and flexor digitorum longus. Articular branches are given off to

the ankle joint, and a medial calcaneal branch supplies the skin on <he

posterior medial surface of the heel and on the posterior part of the sole

of the foot.

The medial and lateral plantar nerves, which are the terminal branches

of the posterior tibial, supply the intrinsic muscles of the sole of the foot,

The medial plantar, which is the larger, gives branches to the flexor digitorum brevis, abductor hallucis, flexor hallucis brevis, and first lumbrical

muscles. It supplies the skin over the medial aspect of the sole of the foot

and over the dorsal surfaces of the medial three toes and the adjacent half

of the fourth.
COMMONLY INJURED PERIPHERAL NERVES 353

The kteral plantar nerve innervates the remaining muscles of the

sole of the foot and the skin over the lateral aspect of the sole and the

dorsal and plantar surfaces of the fifth toe and half of the fourth toe.

The common peroneal nerve.—The common peroneal nerve, when it

leaves the sciatic trunk, descends through the lateral aspect of the popliteal

space along the medial border of the biceps femoris muscle. It crosses the

dorsal surface of the lateral head of the gastrocnemius, passes behind the

head of the fibula, and then winds around its neck to enter a canal at the

origin of the peroneus longus muscle. Here it divides into its terminal

branches.

In the popliteal space, the common peroneal nerve gives off the communicating peroneal nerve, which descends on the posterior surface of the

lateral head of the gastrocnemius, perforates the deep fascia on the back

of the calf and unites with the anastomotic branch from the tibial to form

the sural (short saphenous) vein. The lateral sural cutaneous nerve also

arises from the peroneal nerve in the popliteal space, either as a separate

branch, or, in common with the communicating peroneal nerve, to supply

the skin over the posterior and lateral aspects of the leg.

As the common peroneal nerve passes through the peroneus longus

muscle, it divides into superficial and deep peroneal nerves, and it also gives

off the recurrent tibial branch. The superficial or musculocutaneous nerve

emerges from beneath the peroneus longus muscle and descends the leg along

the septum between this muscle and the extensor digitorum longus. It

innervates the peroneus longus and brevis muscles and remains deeply placed

to about the middle of the leg. Here it passes through the deep fascia and

supplies the skin on the front of the leg and the dorsum of the foot.

The deep peroneal (anterior tibial) nerve, after emerging from the

peroneus longus muscle, passes forward and downward, deep to the extensor

digitorum longus muscle, to the ventral surface of the interosseus membrane.

Here it descends in the leg in close apposition with the anterior tibial artery;

it is deeply placed between the tibialis anticus muscle medially and the

extensor hallucis and digitorum longus muscles laterally. The deep peroneal

nerve passes deep to the tendon of the extensor hallucis longus onto the

dorsum of the foot, where it divides into its lateral and medial terminal

branches.

In the leg, the deep peroneal nerve supplies muscular branches to the

tibialis anticus, extensor digitorum longus, extensor hallucis longus, and

peroneus tertius muscles. Its lateral terminal branch innervates the extensor digitorum brevis muscle, and its medial terminal branch sends dorsal

digital cutaneous nerves to the adjacent aspects of the great and second toes.

The tibial recurrent nerve, which is the smallest of the three branches

of the common peroneal nerve, is usually the first to leave the main trunk.

After passing beneath the peroneus longus muscle, it sends motor branches

to the upper portion of the tibialis anticus muscle and also sends articular

branches to the knee joint.
354 NEUROSURGERY

Surgical Exposure of the Sciatic Nerve

Positioning and preparation.—The patient lies prone. An attendant,

standing on a stool, elevates the foot and raises the thigh from the table,

to facilitate the skin preparation, which should include the skin of the

buttock and lower back if there is any chance that it may be necessary to

reflect the gluteus maximus muscle. The entire leg is also included in the

preparation.

A sterile sheet is passed beneath the leg and thigh. The foot and ankle

are wrapped in stockinet and then in a small sheet which is secured with

a bandage. The upper part of the leg is draped, provision being made for

exposure of the buttock on the affected side. A laparatomy sheet, with the

entire exposed limb thrust through the opening, can be used to advantage.

The draping described permits free mobility of the whole limb, which is

essential, especially if neurorrhaphy is necessary and the leg must be fixed

in flexion at the knee at the time of suture, to make up the nerve gap, and

maintained in this position after operation.

Exposure beneath the gluteus maximus muscle.—The question mark or

inverted question mark incision used in World War I is employed for exposure of the sciatic nerve beneath the gluteus maximus muscle (fig. 173A).

The objective of the incision is to expose the nerve throughout its course

from the sciatic notch into the thigh, with a minimum of injury to muscle

fibers and blood vessels. To accomplish this, it is necessary to divide the

tendon of insertion of the gluteus maximus muscle, so that the muscle can

be reflected medially with its nerve while the blood supply is left intact.

A curved incision, beginning at the posterior iliac spine, circles the

border of the buttock doAvnward and outward to the inner portion of the

greater trochanter. The incision then curves downward and inward along

the lower border of the gluteal fold to the midpoint of the thigh. It can

be extended vertically downward as far as is necessary. The deep fascia

is exposed and divided in the line of the incision (fig. 173B). A finger is

passed beneath the fascia, and the muscle is traced laterally to its insertion.

It is divided a few centimeters from its bony attachment. At the upper

limit of its insertion, the muscle is split in the direction of its fibers to the

upper medial angle of the skin wound. The whole muscle is now reflected

medially, care being taken to avoid injury to the inferior gluteal vessels

and nerves which lie on its deep surface. The small sciatic nerve, which

crosses the gluteal fold near its midpoint, must also be protected. Particular

care must be used in reflecting the muscle, as not infrequently it is adherent

to the underlying structures and even to the sciatic nerve trunk itself as

a result of penetrating wounds in this region.

When the muscle is reflected, the sciatic nerve, the small sciatic nerve,

and the nerve to the hamstrings are exposed as they emerge from the sacrosciatic foramen beneath the piriformis muscle. Since this muscle may be
COMMONLY INJURED PERIPHERAL NERVES 355

FIGURE 172.—Schematic drawing

of sciatic nerve- showing origin,

course, and main branches.

FIGURE 173.—Anatomic approach to sciatic

nerve. A. Outline of skin incisions in hip

and thigh. B. Division of gluteus maximus

at tendinous insertion to expose sciatic nerve

in buttock and upper thigh.
356 NEUROSURGP^RY

incorporated in the main sciatic trunk or lie to its medial side, an attempt

should be made to identify it at this stage by electrical stimulation. The

small sciatic nerve should also be identified by tracing it downward to its

superficial position beneath the gluteal fold. When the piriformis muscle is

retracted upward, the sciatic nerve can be traced higher for a short distance.

If further exposure is necessary, the tendon of the piriformis may be

divided and the muscle reflected medially.

The wound is closed in the usual fashion, care being taken to secure

firm suture of the tendon of insertion of the gluteus maximus. Particular

care is necessary, in closure of the wound of the thigh, not to incorporate

the small sciatic nerve in the suture line, since this error could give rise to

troublesome postoperative pain. This nerve lies in close relation to the deep

fascia and may easily escape notice.

In certain injuries to the sciatic nerve beneath the gluteus maximus, it

is not necessary to divide the tendon of insertion of this muscle. This is

particularly true when only a neurolysis is indicated. In injuries of the

nerve near the sacrosciatic notch, adequate exposure may be obtained by

utilizing the upper portion of the question mark incision, between the

trochanter and the posterior inferior iliac spine. The lower third of the

nerve beneath the gluteus maximus can be exposed by retracting the lower

border of the muscle upward and dividing only the lowermost fibers of its

tendinous attachment.

Exposure in the thigh.—The sciatic nerve can be exposed in the thigh by a

midline dorsal incision extending from the gluteal fold to the popliteal space

(fig. 174). An incision limited to this region may be adequate for lesions

in the upper third of the thigh. If a gap of several centimeters in the nerve

requires neurorrhaphy, length can be gained by exposing the nerve with its

tibial and common peroneal branches through a separate incision in the

popliteal space. In the upper third of the thigh, the incision is made

through the deep fascia, care being taken to avoid the posterior femoral

cutaneous nerve, which lies in close relation to the fascia.

Immediately below the inferior margin of the gluteus maximus muscle,

the sciatic nerve, which here is covered only by skin and fascia, lies along

the lateral border of the biceps. When this muscle is retracted medially, the

nerve is brought into view and can be traced downward to the mid thigh,

where it lies deep to the biceps. It can be followed into the buttock by

retracting upward the lower border of the gluteus maximus. During the

exposure of the sciatic nerve in the thigh, care must be taken to preserve the

branches to the hamstring muscles which lie to the medial side of the nerve.

A branch to the short head of the biceps, lying to the lateral side of the

nerve, must also be avoided.

Below the upper third of the thigh, the sciatic nerve is exposed by

retracting the biceps muscle laterally and the semimembranosus and semitendinosus muscles medially.
COMMONLY INJURED PERIPHERAL NERVES 357

FIGUEE 174.—Exposure of sciatic nerve in mid thigh and popliteal space

to show technique for gaming length.

Near the apex of the popliteal space, the nerve divides into the tibia!

and common peroneal portions. The common peroneal nerve is readily

identified by palpation as it passes along the medial border of the biceps

in the popliteal space. It constitutes the lateral portion of the sciatic nerve

and can easily be differentiated from the tibial portion, from which it is

separated by a fibrous septum. It is important to identify each component

when the sciatic nerve has been divided, so that there will be no crossing

of the components during suture. Technical considerations are discussed

elsewhere, under a separate heading (p. 362).

Surgical Approach to the Terminal Divisions of the Sciatic Nerve

Exposure of the tibial and common peroneal nerves in the popliteal

space.—In order to expose the tibial and common peroneal nerves in the popliteal space, the longitudinal midline incision used to expose the sciatic nerve

is extended directly downward through the politeal space to just above the

flexion creases. Here it is curved sharply laterally, to avoid crossing the
358 NEUROSURGERY

FIGUBE 175.—Anatomic approach

to common peroneal and tibial

nerves in popliteal space. A. Skin

incisions. B. Exposure of peroneal

and tibial nerves in popliteal space.

creases perpendicularly (fig. 175A). The incision is then continued downward to the neck of the fibula and is carried forward along the course of

the peroneal nerve as it enters the peroneus longus muscle.

The deep fascia is exposed and divided in line with the incision (fig.

175B). The common peroneal nerve can now be traced (1) upward to the

level at which it unites with the tibial nerve to form the sciatic trunk and

(2) downward to its entrance into the peroneus longus muscle. If it is desired, the tibial nerve may be exposed first. It can usually be found with

ease as it enters the apex of the popliteal space from beneath the biceps, or

as it leaves the space deeply between the two heads of the gastrocnemius

muscle.

In the popliteal space, the tibial nerve is surrounded by fat and is

crossed by several small vessels, which may be divided. This nerve lies

dorsal and slightly lateral to the popliteal vein, which has a similar relation

to the more deeply placed popliteal artery. The tibial nerve can be exposed

in the lower portion of its course by retracting the two heads of the gastrocnemius. This maneuver will expose the nerve as it lies upon the

popliteus muscle, just before it enters an arch in the soleus muscle to become

the posterior tibial nerve.

The muscular and sensory branches given off from the tibial and common

peroneal nerves at this level have been identified earlier in this chapter
COMMONLY INJURED PERIPHERAL NERVES 359

(pp. 352, 353). The individual branches are identified and preserved. By

careful dissection, they may be separated from the parent trunk for many

centimeters to gain length in overcoming large gaps in the nerves.

Exposure of the posterior tibial nerve.—A large gap in the posterior

tibial nerve may be overcome, even when it occurs at the ankle, by mobilizing

the tibial and posterior tibial nerves and their branches. Mobilization requires exposure of the tibial nerve in the popliteal space (p. 357), as well as

of the posterior tibial nerve throughout the greater part of its course. Free

mobilization of the posterior tibial nerve beneath the soleus muscle, which is

usually essential to gaining length at the ankle, requires division of the

lower half of the medial tibial attachment of the soleus muscle. For the

operation, the patient lies semiprone, with a pillow beneath the pelvis on

the side opposite the leg to be operated on (fig. 176A).

The posterior tibial nerve is exposed in the lower two-thirds of the leg

through a longitudinal incision that starts midway between the tendo achillis

and medial malleolus and ascends the leg parallel with, and about an inch

posterior to, the tibia (fig. 176B). Care must be taken to avoid the internal

saphenous vein and the medial sural nerve.

The deep fascia is divided in line with the incision. A fascial plane is

identified between the soleus, gastrocnemius, and flexor digitorum longus

muscles. Incision is made in this plane, and the gastrocnemius and soleus

muscles are retracted laterally. The neuromuscular bundle containing the

posterior tibial artery, with its venae comites and nerve, is brought into

view as it lies under the deep layer of the fascia cruris on the posterior

surface of the posterior muscle in a groove between the flexor digitorum

longus and flexor hallucis longus muscles. After the fascia has been opened,

the nerve is carefully dissected away from its vessels, and a wide elastic

band is placed about it to serve as a retractor. The nerve can now be

dissected downward to the ankle and upward to the level at which the attachment of the soleus interferes with further direct visualization. If there

is much scar tissue, venous bleeding is often troublesome and ligation may

be necessary to control it.

The incision to expose the posterior tibial nerve in its upper third is carried medially over the attachment of the soleus. The lower half or lower

two-thirds of the attachment is divided about 1 cm. medial to its tibial attachment and is retracted laterally, to bring the nerve into view. If local mobilization does not provide sufficient length, the incision can be extended upward to

expose the tibial nerve in the popliteal space. A separate incision for mobilization of the tibial nerve is frequently adequate. Whichever incision is used,

care must be taken to have it cross the midpopliteal space parallel to the

flexion creases and not at right angles to them.

Closure is accomplished in the usual fashion. The attachment of the

soleus muscle should be firmly sutured. In closure of the fascia, care must be

taken not to injure the medial sural nerve.

498091V—59 25
360 NEUROSURGERY

FiGuiiE 17G.—Anatomic approach to tibial

nerve in calf. A. Position of patient and

outline of skin incisions. B. Simultaneous

exposure of tibial nerve in lower calf and

ankle through window incision.

Exposure of the common peroneal nerve below the popliteal space.—

To expose the common peroneal nerve and its branches after the nerve leaves

the popliteal space, the incision used for exposure in the popliteal space is

continued downward and forward across the neck of the fibula and then

down the anterior aspect of the leg along the course of the extensor digitorum

longus muscle (fig. 177A). The nerve is identified by palpation along the

medial border of the biceps tendon as it crosses the lateral head of the

gastrocnemius. The deep fascia may be opened at this point and the nerve

traced downward as it passes posterior to the head of the fibula and winds

around its neck. As the nerve crosses the fibula, it is somewhat flattened

and is covered by a connective tissue layer consisting of deep fascia and

a lateral expansion of the biceps tendon. AVhen this layer of connective

tissue is opened, the nerve, which lies immediately beneath it, can be

traced downward and anteriorly to its point of entry into the peroneus

longus muscle. This muscle can now be opened to expose the nerve as it

passes through the muscle to divide into its terminal branches (fig. 177B).
COMMONLY INJURED PERIPHERAL NERVES 361

FIGUKE 177.—Anatomic approach to

peroneal nerve. A. Position of patient

and skin incision for exposure of peroneal nerve below knee. B. Surgical

exposure of motor branches of common

peroneal nerve.

The common peroneal nerve in the popliteal space consists of two large

bundles. The more dorsal and lateral bundle continues through the peroneus

longus muscle as the superficial peroneal (musculocutaneous) nerve. This

nerve descends the leg along the septum between the peroneus longus and

extensor digitorum longus muscles. In its upper third, it is deeply placed

and gives off branches to the peroneus longus and brevis muscles. At the

junction of about the middle and lower third of the leg, the superficial

peroneal nerve will be found lying upon the peroneus brevis muscle; immediately thereafter it passes through the deep fascia to supply the skin

of the front of the leg and the dorsum of the foot.

The other large bundle in the common peroneal nerve continues through

the peroneus longus muscle as the deep peroneal (anterior tibial) nerve.

As it passes through this muscle and forward, deep to the extensor digitorum

longus muscle, it gives off branches to these muscles and to the tibialis

anticus. It is usually impractical to follow the common peroneal nerve

beneath the extensor digitorum longus muscle unless the wound is in this

region and involves the muscular branches. It is only occasionally possible

to suture the terminal branches at this level.
362 NEUROSURGERY

In the lower third of the leg, both the deep and the superficial peroneal

nerves can be exposed through a longitudinal incision over the extensor digitorum longus muscle, about midway between the tibia and the fibula. The

deep peroneal nerve is exposed by incising the deep fascia and opening the

cleavage plane between the extensor digitorum longus and the tibialis anticus

muscles. The nerve lies deep between the latter muscle and the extensor

hallucis longus within the neurovascular bundle, in close apposition with the

anterior tibial artery. Exposure of the deep and superficial peroneal nerves

is seldom indicated except in certain instances in which pain in the foot

requires relief.

Methods of Gaining Length

The sciatic nerve and its major branches are under greatest tension when

the thigh is flexed, adducted, and internally rotated and the leg is extended.

Eelaxation is maximal when the thigh is extended, abducted, and externally

rotated and the knee is sharply flexed. Defects in the sciatic nerve up to 6

inches can be bridged by thus positioning the lower extremity. Gaps of

2% to 4 inches in the tibial or peroneal nerve can be closed at the knee by

simply flexing the knee, and additional length can be gained by transplanting

the nerve to a subcutaneous position. An additional % to % inch can be

gained in the peroneal nerve by removing the head of the fibula. Defects

up to 4% inches in the posterior tibial nerve at the ankle can be closed

by combining the advantages of wide mobilization, nerve stripping, and

positioning.

It was the general military experience that soldiers with injuries of the

lower extremity who practiced preoperatively until they were able to touch

their hands to the floor with legs extended were better prospects for suture

repair of the sciatic nerve and its branches than were those who had not

thus become supple and relaxed.
CHAPTER XV

Techniques of Peripheral Nerve Repair

Benjamin Bradford Whitcomb, M.D.

GENERAL CONSIDERATIONS

The techniques described in this chapter are chiefly those used in neurosurgical centers in the Zone of Interior and overseas during World War II.

They were arrived at by a process of evolution, it is true, but they were

based on classical, well-established principles of nerve repair. As is always

necessary in a military program, the procedures were standardized, but, so

long as the fundamental principles were followed, minor modifications, to fit

special circumstances, were both permitted and encouraged.

All operations at neurosurgical centers were performed by, or under

the supervision of, qualified neurosurgeons. Peripheral nerve surgery cannot

be undertaken lightly. The surgeons who perform it must be qualified technically, but they also must have a proper background of neuroanatomy,

neurophysiology, and neuropathology. With this knowledge, the timing of

repair of nerve injuries is on a rational basis and is related to the nature

and extent of the injury.

The categories of nerve injuries employed in World War II were as

follows:

1. Fresh wounds produced by some sharp instrument, such as a razor.

These wounds, which resembled the type of injury seen in civilian life, were

not combat incurred. Because they were generally clean, they could be

repaired at once, through a relatively small incision. When the nerve ends

were trimmed back a few millimeters to obtain flush surfaces for approximation, the delicate epineurium held sutures well, since tension was minimal

or absent.

2. Wounds similarly produced by some cutting agent, but grossly contaminated. In such injuries, extension of the incision was necessary to accomplish adequate repair. The best plan was to leave the wound open and

repair the nerve a week or so later, at the time of delayed primary wound

closure. In these circumstances and with this timing, extension of the incision was safer, and the epineurium was more suitable for suture.

3. Combat-incurred injuries from high-velocity missiles. Nerve injuries

of this kind were associated with more or less extensive wounds of the soft

tissues, to which first attention had to be given. These wounds were in no

way comparable with the nerve injuries generally observed in civilian prac363
364 NEUROSURGERY

tice. Even when the nerve was completely severed, it was not possible to

determine the precise extent of damage immediately after the injury. Furthermore, in the face of the contamination always present in a combatincurred wound, and, in many instances, the infection already established,

immediate nerve repair was not safe.

The policy was therefore developed of treating the soft-tissue wound by

the usual techniques of debridement and delayed primary wound closure and

deferring repair of the nerve injury until at least 3 weeks had elapsed. At

the end of this time, histopathologic processes were sufficiently established for

the surgeon to be able to demonstrate grossly the amount of proximal and

distal resection which would be necessary for satisfactory suture. In the

meantime, the soft-tissue wound would have healed successfully; antibiotic

therapy would have been used prophylactically or therapeutically; and the

epineurium would have become sufficiently strong to hold sutures, even if

some tension were present. At the preliminary operation, however, nothing

was done to the nerve except to investigate and record its status and, perhaps, approximate the severed ends with a tantalum sling suture.

A great deal was gained by the delay of 3 weeks or more after injury

before nerve repair was attempted. Delay, however, could not be indefinite.

If the repair operation was postponed more than 3 months, results became

progressively less good from loss of muscle substance and the accompanying

fibrotic process. According to Bowden and Gutmann,1detectable function

is still possible if nerve repair is delayed as long as 3 years, but it would be

unreasonable to expect it to be useful.

4. Combat-incurred wounds in which nerve trauma was associated with

serious bone, vascular, or soft-tissue loss. Special techniques of repair were

required in such injuries, though the general principles just outlined were

always followed; that is, adequate debridement, delayed primary wound

closure, and delayed nerve repair.

5. Closed injuries in which nerve damage was associated with fractures,

traction or stretch palsies, and paralysis resulting from ischemia. This category of injuries provided the most formidable problem which faced the military surgeon who was called upon to repair peripheral nerves.

ARRANGEMENT OF OPERATING ROOM

Operations for the repair of peripheral nerve injuries, particularly those

in which there were associated injuries and considerable scarring, often lasted

for several hours. A good deal of apparatus was required in addition to

the usual surgical instruments, and additional personnel were frequently

necessary. Ideally, peripheral nerve surgery was performed in a large operating room, not only to eliminate the discomforts of crowding but also to

avoid the risk of contamination almost inevitable with crowding.

1 Bowden, E. E. M., and Gutmann, E. : Degeneration and Re-Innervation of Human Voluntary

Muscle. Brain 67 : 273-313, December 1944.
PERIPHERAL NERVE REPAIR 365

The length of the operation meant that the comfort of the patient and

of the surgeon and his assistants was a practical consideration. The patient

was placed on a suitable mattress, and special attention was paid to making

such positioning as was required as comfortable as possible. When the injury was in the upper extremity, the arm was placed on a padded board,

which extended at about right angles to the table.

The surgeon and his assistants sat on stools of the proper height, and

the instrument tables and other apparatus were located with due regard for

their convenience.

Illumination was provided from fixed overhead lights, preferably supplemented by movable spotlights. These lights were almost essential for

operations in certain sites. For work on a flexed extremity, for instance, in

which precise approximation of the nerve ends was to be attempted, the

ordinary reflector type of overhead light did not provide sufficient illumination.

Instruments and apparatus.—The basic instruments of the usual dissecting set were suitable for peripheral nerve repair (fig. 178), with the proviso

that all of them be delicate and fine. Nerve hooks were essential. The finetoothed iris forceps was found to be an ideal instrument for handling delicate epineurium. Fine suture material was supplied on atraumatic needles.

The Greenwood bipolar electrocoagulation forceps was excellent for

achieving hemostasis near nerve trunks; when it was used, there was no

spread of heat to surrounding tissues, as there was when unipolar electrodes

were used in conjunction with a ground plate attached to the patient's body.

Only fine-pointed forceps were used, so that the mass of tissues to be coagulated between the points was held to a minimum.

Fibrin foam or Gelfoam with thrombin was of great value in accomplishing hemostasis in beds of scar tissue or in the nerve trunk itself, both

being areas in which ligatures were not practical and electrocoagulation was

contraindicated.

An essential piece of apparatus in peripheral nerve surgery was the

inductorium or electric nerve stimulator. Many models of this instrument

were available, some more complicated than others, but the only essential

was a weak faradic stimulation through a fine needlepointed bipolar electrode. Some types of stimulator could withstand sterilization by heat, and

others were sterilized by cold or wet sterilizing solutions. When wet sterilization was employed, the electrodes were thoroughly rinsed and the contacts

dried before use. Their terminals of application were kept in glass containers until they were needed; large test tubes were satisfactory.

PREOPERATIVE PREPARATION

No matter how thorough the preoperative study had been, it was always

a wise precaution for the surgeon, the day before operation was scheduled,

to make a second objective survey of the patient's status, with particular
I

366 NBUROSURGERY

,n>

FIGUKE 178.—Instruments for use in peripheral nerve surgery. Top row, left to right:

cord and applicator for electrosurgical unit; controlled suction tip with noncollapsible

rubber tubing; bipolar electrode with cord for nerve stimulation; sterile stockinet roll;

silver clip cartridge; clip applicator; large curved hemostat; Kocher forceps; Allis

forceps; small curved hemostat; mosquito hemostatic forceps towel clips (two sizes).

Middle row: cottonoid strips and small pledgets with suture attached; tantalum wire

size 0.005 and 0.003 swaged into fine curved needles; blades; metal rule; needles; Novocain and Novocain syringe; fibrin foam with thrombin and isotonic saline with syringe

and medicine glass for preparation. Bottom row: self-retaining retractor; blunt rake

retractor; Army retractor; vein retractor; nerve retractor; small rake retractor; nerve

hooks (large and small); curette scissors; iris scissors; bayonet forceps; small-toothed

forceps; dural forceps; fine-toothed iris forceps; long knife handle with assorted blades;

small needle holder.

reference to any paralysis present. In peripheral nerve injuries, particularly in early cases, the dramatic changes which sometimes occurred in the

course of a few days could radically alter the planned operation or even

eliminate the need for surgery.

Preoperative preparation followed standard practices, with special measures employed only if they were indicated. Some surgeons thought it advisable, in operations on the sciatic nerve, to have the plaster fixation cast

to be used after operation prepared beforehand. The cast was bivalved and
PERIPHERAL NERVE REPAIR 367

padded and was thus ready for immediate application at the end of the

operation.

Skin preparation.—Preparation of the skin, which began the night before

operation, included a wide area around the planned incision. If the wound

was in an extremity, as it usually was, the entire limb was shaved and

scrubbed with soap and water. Many surgeons preferred an orthopedic

preparation, in which, after the usual cleansing measures, the skin was additionally cleaned by alcohol and ether-and was then wrapped in sterile towels.

There was not universal agreement on the need for these additional measures,

except when a combined attack on nerve and bone was planned. On the

other hand, it was taught and practiced that the availability of effective

antibiotic and chemotherapeutic agents did not release the surgeon from the

necessity of painstaking skin preparation, in view of the extensive and prolonged exposure necessary in peripheral nerve surgery.

In the operating room, the extremity was thoroughly scrubbed with

soap and water, this cleansing, like all other measures, going well beyond

the area of the planned incision. Alcohol and ether were then applied, followed by some colored antiseptic with fat solvent properties. The phenol

coefficient in the antiseptic was regarded as of less importance than the coloring, which indicated the area of skin which had been prepared.

If the lower extremity had to be prepared, as in exploration of the sciatic nerve, it was usually held by an assistant or suspended from a standard

by means of a towel about the ankle. The patient himself frequently cooperated in maintaining the extremity in the desired position. If the operation was to be on the upper extremity, the prepared hand was usually covered by a rubber glove or sterile towel.

Draping.—After the extremity had been prepared, it was placed on sterile

drapes of waterproofed material or on several thicknesses of ordinary sterile

drapes. A roll of stockinet was then used to encase the limb like a stocking.

Certain general principles were followed in draping the patient. The

sterile field was completely isolated. The drapes were so arranged as to

permit free movement of the joints adjacent to the injury, with due regard

to the probable position of the extremity at the time of closure. The patient's

face was left exposed, so that there would be no interference with his breathing. An arm was left exposed, so that the anesthetist could determine the

blood pressure and pulse and administer intravenous fluids and medication

as necessary. Heavy drapes were supported on instrument stands or on

standards; a great deal of fluid could be lost from perspiration in the course

of the operation if this precaution were not taken.

The reflection of light from white drapes could become extremely trying

to the surgeon and his assistants during long operations, and colored drapes,

preferably dark green or gray, were used whenever possible (fig. 179).

498991v—-59 26
368 NEUROSURGERY

FIGUHE 179.—Arrangement of instruments and apparatus for peripheral nerve

surgery. Suction machine, inductorium, and electrocautery apparatus are on the

far side of the patient, with their respective leads available to the operative field.

ANESTHESIA

Regardless of the anesthetic used, an anesthetist was always present, not

only to administer anesthesia as necessary but also to follow the condition

of the patient by regular determinations of the blood pressure, pulse, and

respiration and to administer intravenous fluids and medications. With an

anesthetist present, the surgeon need not restrict himself to the use of any

single agent but could employ whatever combination he might wish to secure

balanced anesthesia.

Preoperative preparation included the administration of a barbiturate,

morphine, and atropine in the dosages appropriate to the individual case.

Local infiltration anesthesia.—Local infiltration anesthesia, achieved

with 0.5- to 1.0-percent solutions of procaine hydrochloride (Novocain) or

piperocaine hydrochloride (Metycaine hydrochloride), was the anesthesia

of choice in peripheral nerve surgery; it was essential until the status of the

affected nerve had been fully evaluated. It had many advantages. While

the nerve was being tested, the patient's cooperation, as just indicated, was

essential in recognizing sensory stimuli from the distal segment. If the

sheath was opened, the relative content of sensory and motor fibers in the

funiculi could also be recognized. Local anesthesia has a hemostatic effect

in the surgical field. It was always adequate when correctly administered.
PERIPHERAL NERVE REPAIR 369

The patient's postoperative condition was better after local than after general

anesthesia, and he could take fluid and food at once.

The chief disadvantage of local anesthesia was, as always, that it had

to be repeated at intervals during the operation, particularly into the subcutaneous tissues. Whatever agent was employed was given under direct

vision. No injection was made into the nerve until stimulation and evaluation had been completed.

Regional anesthesia.—Regional anesthesia was not employed in peripheral

nerve surgery. It had no real advantages over local or general anesthesia,

and it was useless in testing the sensory components of the damaged nerve.

Furthermore, unless it was administered by experts, brachial plexus and

sciatic nerve blocks sometimes damaged these nerve trunks, principally

because the trauma produced bleeding in or about them. Finally, if the

operation was prolonged, regional anesthesia was not sufficient and had to

be supplemented by local infiltration anesthesia.

Spinal anesthesia.—Continuous spinal anesthesia was ideal for repair of

peripheral nerve injuries in the lower extremity after the distal segments

had been stimulated and the status of the nerve evaluated. Since many

sciatic lesions were only partial, the importance of recognizing the intact

fibers is obvious. The status of motor fibers can be determined under any

variety of anesthesia, but intact sensory fibers, as already emphasized, can be

determined only with the cooperation of the patient. As soon as the status

of the nerve had been determined, a local anesthetic agent was instilled

through a needle already placed in the spinal canal. Ideal anesthesia was

thus assured for the remainder of the operation.

General anesthesia.—General anesthesia was achieved by the intravenous

or inhalation techniques. Intravenous anesthesia with thiopental sodium

(Pentothal sodium) was used as a supplement to local infiltration anesthesia

or spinal anesthesia when the patient became apprehensive or uncomfortable

from prolonged positioning. Inhalation anesthesia was chiefly used for the

same reasons, particularly when prolongation of the operation would require

the use of Pentothal sodium in amounts which exceeded safe limits.

INCISION AND EXPOSURE

Incision.—The operative incision was planned before operation, not after

the patient had been placed on the operating table. The fundamental approaches for each peripheral nerve employed during World War II were

based on previous developments and wartime experience. These standard

approaches were anatomically sound. Due regard was paid to anatomic

considerations as well as to the principles of plastic surgery. Flexion creases,

for instance, were not vertically crossed (fig. 180), and as far as possible

the cutaneous nerve and vascular distribution was always preserved.

The site of the incision in combat-incurred wounds was necessarily

affected by the location and extent of the scar of the original injury. The
370 NEUROSURGERY

^

l\\

W IT —

.V •. • iJ Mü5^...

FIGUKB 180.—Closure of lateral incision for injury of peroneal nerve.

Note that incision does not cross flexion crease of knee and this facilitates suture with the knee flexed.

distortion inevitable as the result of scarring frequently made exposure

difficult. The scar was usually attached to underlying tissues, and, if it did

not require removal because of its interference with the function of the

underlying muscles or vascular supply to a nearby incision, its excision was

usually indicated for cosmetic reasons. Whenever possible, the site of excision was incorporated into the surgical incision, in order to preserve maximum blood supply to the skin (fig. 181).

The incision was large enough to permit mobilization of the nerve segments under full vision. If the nerve defect was extensive, the incision was

extended to permit not only mobilization of the segment but also careful

dissection of the functioning branches (fig. 182). Blind stripping of these

branches by traction on the nerve segments through a small incision was

always harmful.

The margins of the incision were protected by towels, not only to protect

them against contamination and for hemostatic purposes but also to keep the

skin edges from drying during long neurosurgical procedures.

Dissection.—Dissection to expose the injured nerve was carried out gently

and carefully between the normal muscle planes of cleavage, with due regard

to protection of the muscle bellies and their nerve and blood supply. It was

occasionally necessary to split a muscle in the direction of its fibers or to

detach it from its insertion or tendinous point of origin by cutting through

the tendinous portion, but it was almost never necessary to cut across the

muscle fibers themselves.

The nerve involved was identified both above and below the point of

injury and the surrounding scar, in which recognition of structure was
PERIPHERAL NERVE REPAIR 371

^B* Sto* * £^Mm

iPIH

Jt^t^^8 IP

V

im

*WM

^H-

^^^^^3

FIGUKE 181.—Typical scars of healing by granulation following debriclement.

Resections of the entire scar must be planned for in incisions for nerve repair.

A. Wide scar overlying nerve injury in upper arm. Modified Z-plasty incision

is indicated. B. Contracted scar in median and ulnar nerve injury of upper

arm. This scar is easily resected and should not be extended proximally.

Note Tinel's irritative phenomenon in both the ulnar and the median distribution. C. Scar following tibial nerve injury and resulting palsy. This scar

might require modified Z-plasty to prevent constriction about the lower calf.

D. Long scar in injury of posterior tibial nerve with resulting palsy. This

scar can easily be adapted to the incision employed for nerve repair.

often difficult (fig. 183). Dissection toward and through the scar was done

cautiously and slowly, in order to preserve both large and small functioning

nerve branches and their accompanying vessels.

This stage of the operation was by far the most difficult and most timeconsuming part. The experienced neurosurgeon knew enough to proceed

cautiously. A direct primary attack on the structures in the area of greatest

scarring was evidence of inexperience and poor surgical judgment. Nerves

with good function or essential blood vessels were often incorporated in the

scar, and normal anatomic relations were distorted by the contraction of the

scar tissue. A hasty, careless approach might mean the needless severance

of these important structures and, possibly, the loss of the entire extremity.
372 NEUROSURGERY

The objective was full exposure of involved nerve tissue both above and

below the scar tissue until the area was visualized in which the appearance

of the nerve was normal and it was in normal relation with adjacent tissue.

Careful hemostasis was also essential. Satisfactory dissection could not be

accomplished rapidly. In fact, many experienced surgeons commented that

as their experience increased and the entire operation was performed more

rapidly, the period devoted to dissection was prolonged.

FIGURE 182.—Extensive incision for mobilization and repair of ulnar nerve.

EVALUATION OF THE STATUS OF THE NERVE

As the nerve was followed from each end into the area of maximum

scarring, the pathologic process gradually unfolded, and, in about half of

all cases, the extent of damage was immediately apparent. If gross continuity had not been lost, careful appraisal of the status of the nerve could

present many difficulties. A good idea of the condition of the nerve had

usually been obtained clinically by appropriate preoperative studies, and the

surgeon was able to say, before exposure, whether function had been partly

or entirely lost. At this stage of the operation, he proceeded to gather further information.

The nerve, once it was properly identified, was held by moist rubber

tapes. Great gentleness was essential, for a nerve is part of the nervous

system, not of the musculoskeletal system, and could not be handled as if it

were. If there was an obvious transection of the nerve, the proximal and

distal segments were grasped by the scarred ends and freed completely from

surrounding scar tissue, care being taken, as already mentioned, to preserve

any important regional branches.

Electrical Stimulation

The electrical stimulator (p. 365) was essential in all peripheral nerve

surgery. The bipolar electrode provided more information about lesions in
PERIPHERAL NERVE REPAIR 373

continuity than any other method. The surgeon who used it during the

course of his dissection was frequently able to avoid disaster to a functioning

nerve branch traversing the scar tissue which was being dissected.

Certain precautions had to be taken in the use of the electric stimulator,

as follows:

1. No matter how much confidence the surgeon might have in the apparatus which he was using, it was necessary to check every negative response

to stimulation by immediately testing an adjacent piece of functioning muscle, to be sure of the presence of an electric current. Contacts might work

>

FIGURE 183.—Scar tissue in gunshot wound of upper arm typical of missile

wounds of peripheral nerves.

loose or short circuits become established in the course of repeated use and

sterilization of the cord and electrodes, and without the precaution mentioned, a normally functioning nerve might be sectioned simply because it

did not respond to an electrode which was temporarily dead.

2. The stimulus to evoke a response was always minimal. Otherwise,

the patient was subjected to unnecessary discomfort, while contamination of

the operative field could occur because of uncontrollable flexion of the joints

affected by the stimulus.

3. Another reason for using a minimal stimulus was that a strong stimulus might spread to adjacent tissue and produce a false response.

Eesponses varied in intensity. Vague, unlocalized burning sensations

were occasionally encountered in complete lesions when the distal end was

stimulated. This phenomenon was considered as (1) the result of stimulation of wandering fibers which had reached the distal segments through circuitous routes through the scar tissue or (2) the result of impulses traveling

along accompanying vessels. It was usually regarded as of little significance.

Definite sensory responses, however, could usually be localized to definite

areas of nerve distribution. They were ordinarily present on light stimu-
374 NEUROSURGERY.

lation at varying distances distal to the lesion, even after the nerve had been

dissected from the scar tissue. The response was more difficult to detect if

the sensory stimulus in the distal segment was the result of stimulation of

regenerating nerves or intact fascicles. If nerves were regenerating and if

anatomic continuity at the level of the lesion was poor, the response probably represented spontaneous regeneration, and resection of the scarred area,

with end-to-end nerve suture, was often advisable. If, however, the fascicles

could be shown to be preserved, it was not wise to sacrifice their continuity

in order to facilitate end-to-end repair of the remaining fascicles; the function of preserved nerve fibers is always better than the function of repaired

fibers because of the cortical associations established in preserved fibers.

NEUROLYSIS

If preoperative investigation, gross appearance of the nerve, and electrical stimulation indicated that nerve function had been suspended only

because of pressure or ischemia from involvement of the nerve in the scar,

neurolysis was the procedure of choice. Extreme care was exercised in freeing the nerve from its surrounding bed of scar tissue, in order to inflict no

further injury upon it. The surrounding scar tissue, particularly if it was

excessive and was evidently restricting muscle function, was resected as far

as possible. If gross anatomic damage was slight and the nerve trunk appeared soft, this simple procedure alone often produced gratifying, and

sometimes dramatic, results. It was not uncommon, indeed, for a group of

muscles which had been paralyzed for months to respond actively to voluntary stimulus after the operation. At times, this postoperative result could

be anticipated from the nearly normal response to electrical stimulation at

operation.

More frequently, the traumatized area of the nerve was firm, and its

contour might show constriction or uniform swelling. Some surgeons recommended the injection of physiologic salt solution under the epineurium,

using the ease with which the solution dissected along the nerve trunk as a

diagnostic criterion. Other surgeons recommended this method as a therapeutic procedure. In such cases, however, particularly if the function of

the distal segment was seriously impaired, it was not thought wise to base

the fate of the nerve on either gross dissection of the nerve trunk by salt

solution or on the rate of diffusion of the solution. It was usually much

wiser to open the nerve sheath under direct vision and examine the fascicles.

Intraneural fibrosis, particularly if it involved the perineurium of the fascicles, was often dense enough to render sections of these seructures ischemic

even if their anatomic continuity was undisturbed. Extensive intraneural

dissection was not necessary. The procedure had to be performed with great

care, in order not to interrupt the continuity of the fascicles. It was best

performed under magnification by means of a loupe, with a fine-pointed

knife or needle.
PERIPHERAL NERVE REPAIR 375

When the continuity of the fascicles had evidently been lost in areas of

fibrosis or neuroma but possible early regeneration was suggested by a sensory response plus, perhaps, a feeble motor response on stimulation, it was

often difficult for the surgeon to decide whether neurolysis alone would be

sufficient or resection and suture would be the wiser course. The decision

was made on the basis of clinical evaluation, gross pathologic appearance,

and the results of stimulation, with due consideration of the time interval

since injury. If the sensory response was satisfactory, the lack of motor

response might be explained by the fact that the down-growing nerve fibers

had not yet had time to reach or innervate their muscles. In such casesv

particularly if the lesion was only weeks or a few months old, it was often

best to wait 6 to 8 weeks, in order to evaluate the results of neurolysis alone,

before resorting to end-to-end suture. If, however, the lesion was of long

duration, and particularly if a fusiform neuroma was present, resection with

direct suture was usually advisable without further delay.

Repeated neurolyses were done in some cases of moderate functional

deficits because good function had been transmitted by electrical stimulation

despite large neuromas in continuity. In such cases, if the persistent nerve

dysfunction was a real disability, subsequent resection of the neuroma, in

spite of its apparent function, often, surprisingly, produced no functional

loss which the patient could detect, and end-to-end suture promised more.

If neurolysis was decided upon as the procedure of choice, the involved

area of nerve was dissected from the scar tissue and was placed in a normal

muscle plane if that was feasible. In the past, a great deal of attention

had been given to techniques of protecting traumatized areas of nerves from

reinvolvement in scar tissue. Tantalum foil and fibrin film were used for

this purpose in many of these injuries in World War II. These methods

went the way of those which had preceded them, and there is little evidence

to suggest that such procedures are ever indicated.

TECHNIQUES OF REPAIR

Complete Nerve Suture

When the interruption of nerve continuity is complete, end-to-end

anastomosis of the segments is always indicated. The World War II experience left no doubt that the optimum results of nerve repair could be obtained only by this method and only after proper preparation of the segments.

Any other method of repair was a poor substitute or was merely one phase

of the repair procedure.

The wartime experience also left no doubt that experience was the most

important factor in the management of large nerve defects. Neurosurgeons

who were accustomed to performing peripheral nerve surgery only very occasionally encountered nerve injuries in which end-to-end anastomosis could not

be accomplished. These injuries are discussed under special headings (p. 416).

Inexperienced neurosurgeons rather frequently resorted to some type of nerve

49899.1T—59 27
376 NEUROSURGERY

graft to overcome relatively small defects. In some instances (p. 499), endto-end suture was done, with considerable ease, after the lapse of a few months

and the acquisition of more experience by the same surgeon.

There was considerable discussion in the course of the war over the wisdom and necessity of applying orientation sutures or identification markers

on the segments of the damaged nerve at debridement, to minimize their rotation and make end-to-end anastomosis of individual fascicles more likely.

When the injury was of short duration and the gap was short, these markers

were important. Only too frequently, however, when the nerve was inspected

after the two segments had been dissected free from scar tissue, considerable

rotation and displacement were observed, in spite of the markers. Furthermore, the marked disparity commonly present between the proximal and distal segments often made alinement of fascicle to fascicle a matter more of

chance than of skill.

A small suture of tantalum was always placed on the epineurium of the

divided segments at a measured interval from the anastomotic site, care being

taken that the markers were placed as nearly as possible at the same points

on the circumference of the nerve. The site could frequently be determined

by the proximity of a longitudinal vessel which might have been interrupted.

These markers were useful in the orientation of the nerve segments, but their

greatest value was in the postoperative roentgenograms taken to determine

the integrity of the suture site.

The nerve segments, after mobilization and dissection from the surrounding scar tissue, were followed proximally and distally until they appeared to

lie free in normal tissue, to be of normal size and consistency, and to be surrounded by loose areolar tissue. In the dissection, great care was taken to

preserve not only the muscle branches but also their blood supply, which contributes to the nutrition of the nerve trunk itself. Care was also taken during

mobilization of the nerve segments to maintain, at least intermittently, the

connection between the nerve tissue and the surrounding areolar tissue, so that

the circulation would not be cut off. Extensive mobilization with utter disregard of the vascular supply of the nerve segment frequently resulted in a

cyanotic appearance over a few centimeters of the distal mobilized segment

(fig. 184). Fibrosis of the nerve segment was increased in proportion to the

degree of ischemia produced by careless mobilization.

Partial Nerve Suture

In World War II, partial nerve suture was applicable to about 10 percent

of all injuries in which continuity had been interrupted. Its purpose was to

preserve all functioning fascicles and all which appeared to be in anatomic

continuity, so that no actual or potential function would be lost and an opportunity would be established for restoration of a reasonable degree of recovery

to fascicles which had been severed. Partial nerve suture required more dexterity and patience than complete nerve suture. Its proper execution de-
PERIPHERAL NERVE REPAIR 377

pended upon the complete cooperation of the patient while the stimulator was

carefully applied intraneurally to the individual fascicles. Operation was

performed under local anesthesia.

A lateral neuroma (fig. 185) was more easily managed than a central

neuroma. The lateral lesion, with the involved fascicles, was carefully dissected free from the adjacent fascicles which were still intact. Then the

fascicles which were contributing to the neuroma were stripped from the

adjoining normal nerve, as much epineurium being retained as possible. The

&fc*SS^'

FiGUKE 184.—Suture of nerve after extensive mobilization of proximal segment. Note cyanotic appearance of segment of nerve on left after extensive

mobilization which damaged blood supply.

proximal segments of the involved fascicles could be dissected proximally

much more easily than could the distal segments. This was partly because

they were attached to the definite neuroma which the regenerating fibers had

produced and partly because the distal segments of these fibers were atrophic

and smaller and could be identified by their negative response to electrical

stimulation.

SPECIAL TECHNIQUES

Certain procedures, many of them used in civilian practice, proved useful

in overcoming defects in the continuity of the damaged nerve. These techniques are discussed in order of their importance.

Flexion-Relaxation

Before resection of the neuroma and the glioma from the ends of the

severed nerve, the adjacent joints were flexed and the separated segments

brought toward each other and overlapped to the extent necessary to permit
378 NEUROSURGERY

approximation of normal nerve tissue after the damaged area had been cut

back. In many instances, it was immediately evident that end-to-end suture

could be accomplished without undue tension.

Positions of optimum relaxation were as follows (fig. 186) :

1. For injuries of the brachial plexus, the elbow was flexed and the arm

adducted. The arm was held in forward flexion during nerve suture and

closure of the wound. Afterward, the patient was most comfortable in a

Velpeau dressing, with the hand over the unaffected shoulder. In instances

of extreme tension, the position was modified by elevation of the shoulder.

2. For injuries of the neurovascular bundle or in the upper arm, the position recommended for injuries of the brachial plexus could also be used after

transposition of the ulnar nerve anterior to the humeral condyle. Flexion

of the elbow alone was often sufficient.

FIGURE 185.—Procedure for repair of lateral neuroma. Note that

the injured fascicles are split from the remaining normal nerve

before sectioning and suture.

3. For injuries of the radial nerve near the elbow, maximum relaxation

was secured by flexion and pronation of the forearm.

4. For injuries of the median and ulnar nerves after transposition, flexion

of the forearm with supination was most desirable. For injuries of the

median nerve in the forearm, maximum relaxation was secured by flexion of

the forearm and wrist, although, when possible, flexion of the wrist was

avoided because of the adverse effect of the traumatized muscles or tendons

which were almost inevitably involved. For injuries of the ulnar nerve in

the forearm after transposition of the nerve at the elbow, flexion of the elbow

and flexion and ulnar deviation of the wrist provided the best relaxation.

5. For all injuries in the leg, flexion of the knee was required, with hyperextension of the thigh. A double hip spica was necessary to maintain this

position with any degree of comfort to the patient. For injuries of the common peroneal nerve or its branches, additional relaxation was obtained by
PERIPHERAL NERVE REPAIR 379

FIGUEE 186.—Optimum positions for flexion-relaxation of sutured

nerves. A. Nerves in upper arm, axilla, and brachial plexus.

B. Radial nerve. O. Median and ulnar nerves. D. Axillary nerve

and brachial plexus.

combining this position with external rotation of the leg. Sufficient abduction of the leg had to be provided to make the patient comfortable and to

permit use of the bedpan.

Nerve Transposition

Nerve transposition had the objective of shortening the gap to be bridged

by transposing the damaged nerve to a more superficial plane in the region

of the flexed joint. To accomplish this, it was necessary to do a careful dissection of the branches of the nerve by opening the epineurium and splitting

the fascicles proximally from the nerve trunk for a distance of several centimeters. Great care had to be taken, as already mentioned, not to interrupt

the continuity of these fascicles, whether they were functioning, as they might

be when they were dissected from the proximal segment, or were nonfunctioning, as when they were dissected from the distal segment. Nerve transposition, combined with flexion-relaxation, was usually sufficient to overcome most

large defects.
380 NEUROSURGERX

Another technique, slight stretching of the nerve by traction on a neuroma

or glioma, also gave good results when it was used in the management of short

defects which were overcome by flexion-relaxation. It is, however, a very delicate procedure, whose abuse can produce irreparable nerve injury, and it was

never used to make up distance.

Bone Shortening

Bone shortening to overcome nerve defects was limited, for all practical

purposes, to injuries of the upper extremity and especially to shortening of

the humerus. Under exceptional circumstances it was employed in the lower

extremity, in high lesions of the sciatic nerve, when the knee joint was fixed

in extension, but it was not a desirable procedure because shortening of a

bone of the lower extremity severely affects body mechanics and influences

both standing and walking. It was frequently applied in defects of the

radial nerve, especially those associated with fractures of the humerus with

poor union or nonunion. An osteotomy was performed, with resection of the

deformed bone, or an oblique cut was made, with overriding of the severed

bone, which reduced the total length of the humerus by at least 2 inches.

Shortening of the bone permitted adequate repair of many large defects,

particularly when it was combined with flexion-relaxation of the adjacent

joints. There was no appreciable loss of function in the upper extremity, in

which the muscles appear able to adapt themselves readily to a limited degree

of shortening. If the bone was perfectly normal, the surgeon did not usually

consider resection of the humerus for a defect of the radial nerve alone; such

a defect could be managed better by tendon transplants. Resection of the

normal bone might be considered, however, when two or more nerves of the

upper extremity were separated by gaps too great to be overcome by more

conventional means. The amount of bone which could be resected without

impairing the function or cosmetic appearance of the extremity varied with

the size of the individual, but 2 inches was accepted as the upper limit, and

it was seldom necessary to attain this degree of shortening to produce the

desired result.

Two-Stage Repair (Suture of Neuroma)

Before resection of a neuroma or glioma, the surgeon estimated the gap

in the nerve to be overcome later. If it immediately became evident that

extensive contusion of the proximal and distal segments would make nerve

suture impossible after removal of the scarred ends, another procedure had

to be planned. If it was possible, after flexion-relaxation of the adjacent

joints, to bring the neuroma and glioma together, a two-stage procedure was

undertaken. The scarred ends were fastened together securely with metallic

sutures, or, if silk was used, radiopaque markers were placed on each segment.

Gradual extension of the adjacent joints was begun after operation. When

this had been accomplished, the second stage procedure was undertaken, in
PERIPHERAL NERVE REPAIR 381

the hope that sufficient lengthening of the nerve had occurred to permit good

end-to-end suture of satisfactory fascicles.

This procedure was not without risk. It was always possible that nerve

segments which might have been brought together by other means might

become irreversibly damaged by traction or stretch palsy. Neuroma suture,

however, was not without its merits. Operation was considerably facilitated

if, at debridement, the contused nerve ends were available and had been

brought together with a sling stitch.

Other Methods

In most cases, the results in the repair of severed nerves depended chiefly

upon the length of the gap to be overcome. If it was only a centimeter or

two, there was occasionally some regeneration with almost any method employed, or even in spite of the method employed. If all of the methods

described, even including dissection throughout the entire extremity for maximum mobilization, had failed to overcome a gap in a nerve ready to be

sutured, some one of the following procedures was occasionally attempted:

Suture ä distance.—This method, which was suggested by Assaky2in

1886, merely brought the nerve ends together as closely as possible by cables

of catgut running between the proximal and distal segments. In a few cases

of this kind recorded in the Peripheral Nerve Registry, gaps of 2 to 4 cm.

were overcome by regenerating fibers, and a certain amount of gross function

was achieved. Experimental work with scaffolding of nylon, glass, and plastic threads had been successful in the laboratory, but these techniques were

not employed clinically during World War II.

Tubulization.—Tubulization has been recommended with agents of almost

every conceivable material, both autogenous and extraneous. No clinical experiences were reported during World War II which indicated that results

were any better when this technique was used than when the gap was left

unprotected.

Nerve grafts (nerve transplantation).—Nerve grafts are discussed in

detail elsewhere in this volume (p. 493). In the opinion of many neurosurgeons, they have always received much more consideration than their clinical

success would warrant. Good results have been achieved with them in small

unmixed nerves, such as the digital and the facial nerves, but they have

invariably failed to deliver sufficient functioning fibers over a sufficient distance to make them of much practical value in the repair of major nerve

injuries.

Whole heterogenous or homogenous grafts, whether fresh or preserved,

proved worthless. Whole autogenous grafts secured from an amputation

stump and applied to the injured nerve in another limb sometimes transmitted

fibers through several centimeters, but these regenerating fibers were so feAv

and so inhibited by fibrosis that their failure was practically assured. The

2 Assaky, G.: De la suture des nerfs ä distance. Arch. gin. de miSd. 2: 529-553, November

1880.
382 NEUROSURGERY

failure of any autogenous graft, particularly a whole graft, inserted into a

nerve trunk was unquestionably due to the ischemia and fibrosis in its depth;

the graft was a free transplant completely removed from its blood supply.

The successes occasionally associated with cable grafting or the use of small

grafts for digital or facial nerves resulted from the fact that the fascicles in

these smaller structures, due to their proximity to an early blood supply, were

more likely to be viable.

STEPS OF THE OPERATION

Preparation of Nerve Ends for Suture

After the nerve segments had been completely mobilized and it had been

decided that end-to-end suture was feasible, scar tissue was excised from the

distal and proximal stumps until the fascicles seen in cross section appeared

normal and were as free as possible of surrounding fibrosis. The distal segment was usually appreciably smaller in diameter than the proximal segment,

this being the result, in part, of degenerative processes in the distal segment.

The glioma or scarring on the distal stump was usually much less extensive

than that on the proximal stump; it extended back only as far as the extent

of the contusion at the time of injury plus whatever area of fibrosis may have

followed the further extension of the intraneural hemorrhage.

Scarring of the distal stump did not cause the bulbous appearance produced in the proximal stump by regenerating nerve fibers; instead, the scar

tissue might be flattened or tapering or give evidence of slight swelling from

the sheath cells and from fibrosis, so that the term "glioma" was fully justified. The involvement was frequently not more than a centimeter in length.

To the naked eye, discrete fascicles appeared to pout from the cut end

of the nerve for a considerable time before the fibrosis had been eliminated by

serial section. At this stage of the procedure, it was therefore best to use a

sterile magnifying glass or loupe. On closer scrutiny, the surgeon frequently

found that, if an unsurmountable gap was not to be produced, a compromise

had to be made between theory and practice and that nerve ends with some

degree of fibrosis had to be used. As Lyons and Woodhall3demonstrated, the

condition of the distal segment was more important than that of the proximal

segment. Proximal fascicles, though not completely satisfactory, might still

give off an abundance of branching axons, while a fibrous distal stump would

transmit few if any. When a compromise was necessary, therefore, the sacrifice was made in favor of the distal segment, so that its fascicles might be

discrete and the interfascicular spaces be as free as possible of perineurial

fibrosis to receive the regenerating axons. For this reason, it was always

advisable to make serial sections of the stump of the distal segment before

the proximal segment was attacked.

The importance of precise, sharp cross sections in nerve repair had so

3 Lyons, William R., and Woodhall, Barnes ; Atlas of Peripheral Nerve Injuries. Philadelphia : W. B. Saunders Co., 1949.
PERIPHERAL NERVE REPAIR 383

impressed neurosurgeons that they have introduced many ingenious devices

to further this objective. Gross,4for instance, devised silver miter boxes of

assorted sizes to hold the nerve segments atraumatically and accurately while

a razor blade is carried down through the slot. Tarlov's 6nerve holder grips

the nerve end snugly in sponge rubber while the cross section is made.

Perhaps the commonest method employed during World War II was to

steady the nerve segment with cotton pledgets on a moistened tongue depressor. The advantage of this simple method was that it was carried out quickly

and that the entire nerve was well visualized while the section was made.

Serial sections were cut, about 1.5 to 2 mm. apart. Each section was left

attached to the nerve by a small part of the sheath until the final section,

showing a healthy cross section, had been made (fig. 187). A piece of fibrin

'III!If¥&. ^GBOTV "

N

"W»N,v\W

mmmß rnmmm

Armin Hemb&rdtr

FIGTJKE 187.—Classical method of end-to-end suture following

resection of scarred ends by serial section.

foam or gel was placed over the freshly cut nerve end to control bleeding.

Attention was then turned to the proximal neuroma. The proximal

stump of a severed nerve terminates in a bulb of regenerating neuraxes with

their numerous branchings and of proliferating sheath cells and connective

tissue. These regenerating nerve fibers frequently fold back upon themselves

and extend proximally on both sides of the epineurium and intrinsically

through the perineurial spaces to produce a typical expanding, bulblike appearance. The first few cuts might produce a rather dense, homogenous white

appearance. Then there might appear large, edematous fascicles, which an

inexperienced surgeon might consider suitable for approximation. They were

not. When a few more serial cross sections were made, these fascicles would

be seen breaking up into numerous smaller, discrete, softer fascicles unencumbered by perineurial fibrosis. At this point, the diameter of the nerve would

be almost normal.

During this procedure, as well as throughout the operation, the nerve

segments were handled with the greatest gentleness, by delicate iris forceps

placed in the epineurium. Sponging was usually done with moist cotton.

4 Gross, S. W. : Device for Accurate Approximation of Peripheral Nerves. Bull. U.S. Army M.

Dept. 75 : 118, April 1944.

5 Tarlov, I. M. : Autologous Plasma Clot Suture of Nerves. J.A.M.A. 126 : 741-748, November

1944.
384 NEUROSURGERY

Anastomosis

At this time, the extremity was positioned to facilitate nerve suture. If

the wound was at all extensive, it was closed except in the area of the nerve

suture. Some surgeons preferred to close it even before the neuroma and

glioma were removed. There were two principal advantages in closure of the

greater portion of the wound before nerve suture was accomplished. The first

was to eliminate the difficulties which might arise in closing the wound after

the necessary position of flexion had been employed. The second was that

it reduced the necessity for handling the extremity between the time the anastomosis was completed and the plaster cast applied and thus reduced the

opportunities for inadvertent stretching of the suture site.

Orientation sutures, previously applied, were now brought into line and

the opposing surfaces of the two segments were brought together by one of

several possible methods of anastomosis (fig. 188). If the distal end was very

much smaller than the proximal, so that approximation would be difficult,

the distal segment might be blown up by the injection of salt or procaine

solution through a fine needle (fig. 189). A less satisfactory way of overcoming the discrepancy in size was to make an oblique cut across the distal

segment at the last section, to increase its size.

If the nerve segments could be approximated without tension, fine epineurial anastomotic sutures were placed at once. Care was taken to place the first

two sutures in diametric opposition, to prevent distortion. These sutures were

left long and used to rotate the nerve as the remaining sutures were placed.

If moderate tension was present, traction sutures were placed at identical

points on the circumference of each segment, a few centimeters behind the

site of the sutures which would pass through the epineurium alone. These

two sutures were then crossed and held by an assistant with a hemostat over

the point of tension where the surfaces to be sutured came together without

tension. They were removed after the anastomosis had been accomplished.

Livingston and his associates6proposed still another method of anastomosis. At the same circumferential point in each segment, a small lip of the

sheath is left to extend distally. Small, matched mosquito clamps are placed

on these tabs adjacent to the cut surface of the nerve and are rotated 180°,

so that they can be held together and thus bring the surfaces to be approximated into apposition. The last two sutures are left long. The tabs are then

resected and their points of epineurial attachment closed.

When stay or sling sutures were applied (fig. 190), it was best to use

0.005 tantalum. The sutures were placed in the proper plane, about 1 to 1.5

cm. from the cut surfaces of the nerve, and were used to draw the nerve ends

into approximation. The ends of the suture were held at their point of

emergence from the nerve by two hemostats or were tied if correct tension

could be exerted and if their presence did not interfere with the approximation stitches to be placed in the epineurium later.

6 Livingston, K. B., Livingston, W. K., and Davis, B. W. : A Technique of Nerve Suture.

J. Neurosurg. 3 : 270-271, May 1946.
PERIPHERAL NERVE REPAIR 385

FIGURE 188.—Customary method of resecting scarred portion of nerve. A. Orientation

sutures in place. B. Fine tantalum epineurial sutures in place for demonstration purposes. They have not yet been tied. C. Fine epineurial approximation sutures used to

complete anastomosis.

There was no doubt that good results were accomplished by the use of

the transfixing or sling suture technique, but many surgeons thought its employment superfluous, and the introduction of these sutures necessarily meant

additional trauma to the transected fascicles. If, however, early mobilization

of the adjacent joints was particularly desirable and it was thought that the

strain on the suture site could not be borne by the delicate approximation

sutures alone, the transfixing sutures had their place.

Some surgeons preferred to secure the tension effect of transfixing stay

sutures by using mattress-type sutures for the epineurium. Two were placed

in diametrically opposite locations, each passing through a small bite of the

epineurium in both the proximal and the distal segments. A more satisfactory

type of epineurial tension suture was described by Learmonth and Wallace,7

who placed several small interlocking loops in the epineurium on each side

of the suture site. The delicate approximation sutures in the epineurium,

which were placed with a fine atraumatic needle, were so spaced as to bring

the epineurium together throughout its entire circumference and prevent the

exposure of aberrant fibers.

Apposition of the opposing surfaces of the cut nerve by suture practically

always controlled bleeding. If it did not, filbrin or Gelfoam soaked in throm7 Learmonth, J. E., and Wallace, A. B. : Certain Plastic Problems in the Surgery of Peripheral

Nerves. Surg. Gynec. & Obst. 70 : 106-109, January 1943.
386 NEUROSURGERY

bin was applied. Care was taken to see that all foreign material had been

removed before the nerve suture was completed.

Protection of Site of Anastomosis

Transplantation.—Some surgeons, after the nerve had been sutured,

thought it beneficial to transplant the site of anastomosis to a fresh muscle

plane free from scar tissue. The theory was good, but the plan was not pracäiMiiäiii iMawssitFIGURE 189.—Method of enlarging distal segment to facilitate anastomosis.

Novoeain or saline solution may be used.

tical. In extensive combat-incurred injuries, there was no such muscle plane

in the vicinity of the injured nerve. This practice also had its disadvantages,

in that it required dangerous lengthening of the nerve. It was frequently

possible, however, to transplant the suture site superficially to an adjacent

subcutaneous area in which it would be surrounded by viable fat and run

little risk of further fibrous fixation.

mwm_jiimm

MMfiiäim^imbiwwiiiMii &11MJH

c

FIGURE 190.—Suture techniques. A. Epineurial sling sutures, diametrically opposed,

which do not pierce fascicles. B. Through-and-through suture. Here the suture is passed

directly through both proximal and distal segments. The nerve is held in approximation

by means of hemostats on the stay suture at its level of emergence from the nerve.

The suture is tied after approximation stitches have been placed. C. Interlocking epineurial stay suture recommended by Learmonth and Wallace. Although this suture

requires a little more time, its holding power is greater, and the fascicles are not

pierced by it.
PERIPHERAL NERVE REPAIR 387

"^TiKtASKSE &&jMääßKtr <$$ im

m nrf1

- Jb? •--'"** 'llRWi "ill iT"K

.' •v* ''

r

'w5SSM yj^twf/J»

n

FIGURE 191.—Suture techniques. A. Suture of both components of sciatic

nerve. B. Protection of suture line with annealed tantalum foil.

Tantalum foil.—Early in World War II, when tantalum, which is relatively inert in tissues, began to be produced in thin foil, it was thought that

it might be useful as a protective wrapping for injured nerves (fig. 191). At

first, it was coiled as neatly as possible about the site of anastomosis and held

by restraining ligatures. The idea was that fibrous tissues would thus be

barred from invading the suture site and fixing it to adjacent tissues. The

further result, it was thought, was that the tension would be dispersed throughout the entire length of the nerve when the extremity was gradually permitted

to extend.

Some of these results were obtained, but there were also a number of

undesirable results. The distal ligature used to hold the foil against the nerve

was found to act as a constricting band which inhibited the downgrowth of

neuraxes into the distal segment and prevented it from attaining the diameter

of the remainder of the nerve. When the operative site was reexplored and

the constricting band was removed, the tissue enclosed within the foil presented as a smooth, glistening layer (fig. 192), which prevented adhesions

between the nerve and the surrounding tissue. The foil, however, was often

found broken and cracked, particularly when it had been placed near a joint.

To overcome this difficulty, slightly heavier foil (0.0005 inch) was annealed

into coils or tubes which were cut to the size of the nerve and which, when
388 NEUROSURGERY

\

V

FIGURE 192.—Appearance of nerve suture site after removal of tantalum

foil. Note glistening appearance with

surrounding membrane, but note also

scar limitation at each end.

FIGURE 193.—Small cuff of tantalum

foil illustrating size adequate to surround suture site only.

applied, it was thought would remain snugly against the epineurium by their

own spring action. When foil thus prepared was not placed in the region

of a joint and was not sufficiently overlapped to produce a constricting membrane, it seemed to fulfill the desired purposes. Surgeons who used this

method usually employed rather short cuffs, about 1 to 1.5 cm. in length, just

long enough to protect only the suture site (fig. 193).

Tantalum was misused by many surgeons, and trauma to the enclosed

nerve was often evident upon reexploration. As a result, it was rather generally condemned. Its use in selected cases to protect the anastomotic site had

obvious advantages, but the disadvantages attendant upon its employment,

and the harm attendant upon its misuse, warranted prohibition of its use routinely. It is entirely possible that the disadvantages associated with the use

of any material to be wrapped about a repaired nerve exceed the advantages

of its use even in occasional, carefully selected cases.

Selection of Suture Material

Almost every known suture material was used at one time or another for

the repair of peripheral nerves, including catgut, linen, silk, nylon, cotton,

stainless steel, human hair, and tantalum. All resulted in some degree of success. Before World War II, fine silk was most generally used, but experiences during the war indicated the definite advantages of tantalum.

Tantalum, like stainless steel, is more inert and therefore less irritating

to the tissues than silk or other organic suture materials. It is a more uniform element than steel. It is more malleable, which makes it easier to
PERIPHERAL NERVE REPAIR 389

handle and to apply to the fine atraumatic needles into which it may be

swaged. A tantalum thread of the same diameter as silk has equal tensile

strength on straight pull, but, after both are sterilized, tantalum has 40 percent more strength than silk on knot pull. The radiopacity of tantalum also

proved an enormous advantage. These metallic sutures (fig. 194) made it

possible to make serial roentgenologic studies of the integrity of the suture

line.

The more inert the material used for sutures, generally speaking, the less

the surrounding tissue reaction and the less the ultimate fibrosis. On the

other hand, with few exceptions, it is doubtful that the material used for

sutures was as important as its size.

OTHER METHODS OF ANASTOMOSIS

Removable Suture Technique

The pullout suture method devised by Bunnell for repair of tendons was

adapted by Potter8for repair of selected cases of peripheral nerve injuries.

This technique is carried out as follows: A wire loop brought through the

skin on one needle is placed through another wire loop formed by passing the

wire twice through the epineurium of each segment. The wire is then brought

through the skin and tied over a button. A similar procedure is carried out

with another wire suture, the loop in the epineurium being diametrically

opposite the first loop and the pull being on the opposite segment. After a

period of 2 to 3 weeks, each wire is cut and withdrawn. The advantage of

this method is that the anastomosis is left uninfluenced by any foreign material. The need for it, however, is scarcely sufficient to warrant the technical

difficulties. Occasional good results were reported, but the instances in which

the technique was feasible were not numerous.

Tube Technique

Weiss 9reported excellent experimental results in the repair of severed

nerves with segments of arteries and veins and with preformed tubes of

collagen or tantalum. The precise technique and special instruments required

make this method impractical for combat-incurred injuries. Furthermore,

all nerves of the human subject are apparently under some degree of tension,

and this is not a method applicable to injuries in which any degree of tension

is present.

Plasma Clot Anastomosis

The sutureless method of anastomosis proposed by Young and Medawar10

involved the use of a coagulated plasma cuff produced by adding chick embryo

8 Potter, S. E.: A Removable Suture Method of Nerve Repair. J. Neurosurg. 3: 354-357,

July 1946.

9 Weiss, Paul: Experiments on Nerve Repair. Tr. Am. Neurol. A., pp. 42-51, 1943.

I" Young, J. Z., and Medawar, P. B. : Eibrin Suture of Peripheral Nerves. Measurement of the

Rate of Regeneration. Lancet 2 : 126-128, 3 Aug. 1940.
390 NEUROSURGERY

FIGURE 194.—Postoperative roentgenogram demonstrating presence of

tantalum sutures. Note sutures in infraclavicular region. These are well

clustered and denote integrity of brachial plexus repair.

tissue to concentrated blood plasma and allowing a coagulum to form about

the nerve ends as they were held in apposition. This method has the disadvantage of all sutureless methods; namely, its limited tensile strength. Tarlov n modified the technique by holding the nerve ends together by a single

sling suture of tantalum wire. He also surrounded the anastomotic site with

a rubber mold into which the patient's chilled blood plasma was poured. The

improvement in results when this method was used did not compensate for

the technical difficulties attendant on it.

Another sutureless method, proposed by Singer,12 utilized fibrin film,

which is a byproduct of the preparation of plasma and serum albumin from

whole blood. Two pieces of film were cut into squares large enough to surround the nerve. They were then soaked in thrombin, and one side of each

square was dipped into fibrinogen. The treated sides were placed about the

suture site opposite each other. Coagulum formed immediately, and the pieces

of film adhered to the nerve and to each other. The technique of this method

was simple, but sterilization of the film frequently required sufficient denaturization to produce a considerable foreign-body reaction, and the resulting

fibrosis thus undid any possible advantage of this method as compared with

direct suture methods.

Nerve Grafting

As already mentioned, the technique of nerve grafting is described in

detail elsewhere in this volume (p. 493).

ii Tarlov, I. M.: Plasma Clot Suture of Nerves. J. Neurosurg. 1: 359, September 1944.

12 Singer, M.: The Combined Use of Fibrin Film and Clot in End-to-End Union of Nerves.

J. Neurosurg. 2 : 102-115, March 1945.
PERIPHERAL NERVE REPAIR 391

REGIONAL INJURIES

The Brachial Plexus

Injuries of the brachial plexus by penetrating missiles seldom involved

the entire structure, but the extent of the paralysis often greatly exceeded

what would have been expected from the fibers which were sectioned. The

explanation was undoubtedly the characteristically dense fibrosis which follows hemorrhage in this region. In one neurosurgical center, 5 percent of all

nerve sutures performed in the course of World War II were for injuries of

this plexus.

The anatomy of the important group of nerves constituting the brachial

plexus usually had to be remastered by military neurosurgeons before they

attempted the repair of nerve injuries in this region. With this knowledge,

it was usually possible to locate the site of the lesion clinically, and the location of the scar and the course of the missile were of further assistance in

localization when the injury was direct. In the indirect or traction type of

injury, the roots were usually involved, and, if the injury was severe, there

was some evidence of cord damage. Even when there was evidence of an

avulsion type of injury, it was the policy to explore the plexus and perform

a neurolysis, at least.

Operation was performed as follows:

With the patient lying supine, the neck, the shoulder, and the entire

upper extremity on the affected side were prepared and draped. A horizontal, supraclavicular incision was made, transecting the platysma and the

clavicular portion of the sternocleidomastoid muscle. This incision usually

provided adequate exposure of the upper portion of the brachial plexus. For

exposure of the divisions and cord, the outer angle of the incision was extended downward between the pectoralis major and deltoid muscles. If the

lesion was low lying, or if lower exposure was desired to permit more adequate identification, the tendon of the pectoralis major was sectioned close to

its insertion, the muscle was reflected, and the incision was continued posteriorly into the axilla as far as the neurovascular bundle. It should be

stressed that the incision for exposure of the lower portion of the brachial

plexus and the extension to disclose the axillary contents followed the course

of the cephalic vein, curving posteromedially over the neurovascular bundle

only after it had crossed the insertion of the pectoralis major bundle.

Other incisions proposed for exposure of the brachial plexus, such as

those curving medially along the lower border of the pectoralis major muscle,

provided adequate exposure of the axilla when the flap was reflected, but

upward extensions, which were frequently necessary, were awkward. The

transverse incision of the dome of the axilla proposed by Seletz 1S was difficult

to close, particularly after positioning to overcome nerve defects in this

is Seletz, E.: Peripheral Nerve Surgery: Review of Incisions for Operative Exposure. Preliminary Report. J. Neurosurg. 3 : 135-147, March 1946.

498991"—59 28
392 NEUKOSURGERY

region. It was sometimes possible to expose the infraclavicular portion of the

plexus merely by retraction of the pectoralis major, thus avoiding the removal of its insertion and its reflexion.

Whenever a nerve anastomosis was required, the exposure was always

extended to permit adequate mobilization and identification of the involved

segments. The pectoralis minor was then separated from the coracoid process

and the lower plexus visualized. If the lesion was retroclavicular, the clavicle

was transected. Experience showed that a subperiosteal resection of about

2 inches of clavicle improved the exposure without complicating the postoperative course or impairing the cosmetic results.

As in repair of the more peripheral nerves, it was always necessary, in

lesions of the brachial plexus, to isolate its components both above and below

the area of involvement. By careful neurolysis, identification of the various

components of the plexus was gradually established. The electric stimulator

was used repeatedly.

If the injury was restricted, neurolysis was all that was necessary, though

the surgeon could not be content to leave the plexus matted together by scar

tissue into a solid structure.

When the supraclavicular approach was used, the upper nerve trunk,

which lies most superficially and was most often involved in closed traction

or avulsion injuries, was most readily identified. Its roots of origin are quite

clear as it emerges from behind the scalenus anticus and lies on the scalenus

medius. The trunk itself, which is quite short, breaks up into three branches,

the supraclavicular nerve and the anterior and posterior divisions.

The middle trunk was readily identified as an extension of the seventh

root beneath the upper trunk. The lower trunk was more difficult to expose

in its proximal portion, but injuries in this area were rather infrequent;

because of the proximity of the subclavian artery, deaths from hemorrhage

often occurred.

Lesions of the divisions and cords of the brachial plexus were so intimately associated with injuries of the subclavian and axillary arteries that

aneurysms, which might not have been recognized before operation, were

sometimes encountered. When they were, it was always necessary to isolate

the vessel proximal to the lesion to be ready to control hemorrhage which

might occur.

The dissection of the normal plexus, with the branching of its trunks into

divisions and fusion of the divisions into cords, is a very difficult task. It is

therefore easy to understand the tedious and exacting dissection required when

the entire structure was embedded in scar tissue. Constant use of the stimulator, with isolation of functioning branches, was essential. Portions of the

plexus which had been divided and separated by small gaps in scar tissue had

to be dissected free and the proper associations established between their

proximal and distal segments. After these ends had been sectioned until satisfactory fascicles were seen, they could often be brought together simply by
PERIPHERAL NERVE REPAIR 393

raising the shoulder. If a portion of the clavicle had been removed, further

relaxation could be produced by bringing the shoulder forward and flexing

the arm.

After satisfactory reconstruction had been accomplished, the muscle tendons were reattached to their insertions, and the wound was closed. The arm

was put up in a Velpeau plaster bandage applied sufficiently snugly to prevent traction.

The Axillary Nerve

Surgery upon the axillary nerve has always given notoriously poor results,

primarily because of the difficulty in compensating for nerve defects by positioning of the arm.

The upper portion of the nerve was exposed through an anterior incision

similar to that employed for exposing the lower portion of the brachial plexus.

The incision was carried along the course of the cephalic vein, thus separating

the deltoid from the pectoralis major muscle. The pectoralis muscle was

divided at the insertion, the deep pectoral fascia was opened, and the overlying median nerve and axillary artery were retracted medially, disclosing

the radial nerve, which was followed upward to the origin of the axillary

nerve at the lower end of the posterior cord. Since the upper branch of the

triceps frequently comes off quite high, it was sometimes confused with the

axillary nerve, but its identity was readily established by electric stimulation.

The nerve could be followed well into the mid axilla by the exposure

described. Further exposure could be obtained, if necessary, through a dorsal

incision made along the posterior border of the deltoid muscle; when the

muscle was retracted upward, the nerve was observed coming through the

quadrilateral space to supply its undersurface.

Repair of the proximal third of the axillary nerve was accomplished

fairly easily, and results were often good; but repair of the distal portion

was extremely difficult, particularly if the gap was of any size, and results

were, in general, not satisfactory.

The Musculocutaneous Nerve

In contrast to the axillary nerve, which is the deepest and most inaccessible terminal branch of the brachial plexus, the musculocutaneous nerve is

the most superficial and most readily accessible of its terminations. For this

reason, and because of the gross function which it distributes, chiefly flexion

of the forearm, the results of repair of the musculocutaneous nerve were frequently gratifying.

Since this nerve arises from the outer cord of the brachial plexus along

with the lateral head of the median nerve, varying portions of the lateral

head of the median nerve may accompany the musculocutaneous nerve within

its sheath. The lateral head, in fact, may sometimes be entirely absent from

its usual location, the fibers joining the median nerve in the region of the
394 NEUROSURGERY

antecubital space. For this reason, paralysis which follows section of the

musculocutaneous nerve was sometimes far greater than would be expected

from this injury.

The approach to the musculocutaneous nerve, particularly in its upper

portion, was the same as the anterior approach to the axillary nerve. The

musculocutaneous nerve passes between the two heads of the coracobrachialis

muscle and lies upon it and upon the undersurface of the biceps, sending

branches to both of them. It then pierces the fascia between the brachialis

and the biceps to extend its sensory course to the lateral aspect of the forearm.

Injuries to the midportion of the upper arm may thus divide branches of the

nerve as well as the parent nerve, and careful search should be made for

them in the repair, since the branches to the biceps usually represent the

greatest function of the nerve. Because of the excellent compensatory function of the brachioradialis nerve in producing flexion of the forearm, early,

adequate repair of the musculocutaneous nerve was sometimes considered

unnecessary, and results of surgery were jeopardized by the delay.

Exposure for the lower portion of the musculocutaneous nerve was the

same as exposure of the neurovascular bundle as a whole, with retraction of

the anterior skin flap.

The Median Nerve in the Arm

From the point of view of function, the median nerve is the most important single peripheral nerve in the body. Injury to it usually involves the

ulnar nerve and the medial cutaneous nerve also, since all three nerves lie

in rather close association within the neurovascular bundle in the upper arm.

The musculocutaneous nerve and the radial nerve in the upper third of the

arm and in the axilla are also frequently involved in the same injury because

of their continued close association in this area. At the elbow, although the

three main trunks have become more evenly dispersed circumferentially about

the arm, it was still not at all unusual for a penetrating injury to affect two

or more of these structures simultaneously. As a rule, injuries to the neurovascular bundle were very grave, particularly if an artery were damaged.

If the collateral circulation was not promptly established, the traumatic lesion

was often complicated by a severe ischemic paralysis of the forearm, the end

result being a Volkmann's type of contracture which would militate against

the success of any surgical repair.

The incision was made with the patient positioned as for exploration of

a plexus injury, with the arm abducted and externally rotated. In the axillary area, the nerves are in such proximity to each other that their exposure

is similar to that for injuries of the lower plexus. The pectoralis major

tendon was reflected and the incision was extended downward over the course

of the neurovascular bundle. Sufficient exposure was thus provided to identify the damaged nerves and follow them upward through scar tissue to their

point of section.
PERIPHERAL NERVE REPAIR 395

Injuries above the nerve heads.—When the injury of the median nerve

was at or above the junction of its two heads, alinement of the proper

funiculi with each other was facilitated, and the correct radicular constituents were more likely to traverse their original fasciculi. This possibility

was somewhat overstressed in the older literature. It was often an impractical objective, particularly in some old, complete lesions. It was, however,

a possibility in the median and ulnar nerves, and every effort was made to

promote as precise an alinement of corresponding fascicles as could be obtained in them, since these nerves are not only important mixed nerves but

their ultimate function is extremely intricate.

Lesions at this level therefore required the exposure of the terminations

of the brachial plexus and of the nerves in the forearm. Due care was taken

to distinguish the median nerve from the ulnar and the musculocutaneous

nerves, as well as to distinguish the ulnar nerve from the medial brachial

cutaneous and the medial antebrachial cutaneous nerves. These nerves, which

are purely sensory terminations of the medial cord, were frequently all involved in the same injury which had affected other structures in this region,

particularly the ulnar nerve. The appropriate proximal stumps were often

difficult to recognize because of edema and distortion, especially if they arose

from the same cord. With correct knowledge of their distribution, however, they could be recognized by the sensory distribution perceived by the

patient upon electric stimulation.

Injuries in the upper third.—If the defect was in the axilla or the upper

third of the arm and was small, it could be overcome by flexion of the elbow

and adduction of the arm alone. If it was more extensive, and particularly

if it was in the ulnar nerve, it might be necessary to extend the incision

along the ulnar nerve into the forearm, mobilizing the nerve sufficiently to

transpose it anterior to the medial condyle of the humerus, in order to obtain

the additional benefits received by flexing the elbow.

Injuries in the middle third.—There are no branches of the median nerve

in the middle third of the arm, which greatly facilitated dissection in wounds

in this area involving the neurovascular bundle. Great care had to be taken

in dissecting the injured nerves from the surface of an intact brachial artery.

Irreparable damage to the forearm from ischemia could follow accidental

section of this vessel, and, when the accident happened, an immediate attempt was made to restore its continuity. If an aneurysm were present, no

apprehension usually had to be felt concerning the vascular supply because a

rich collateral circulation was probably already present.

It was frequently possible in the middle third of the arm to transpose a

sutured nerve into a muscle plane along the coracobrachialis or the biceps,

or, more superficially, into the subcutaneous area. Eepair of lesions of the

ulnar nerve at this level, even if the gaps were slight, was best supplemented

by transposition of the nerve anterior to the medial epicondyle for relief of

tension.
396 NEUROSURGERY

Injuries in the lower third.—Lesions of the median and ulnar nerves in

the lower third of the upper arm were less likely to be associated with each

other, and incisions for their exposure varied. When both nerves were involved, both could be exposed by following the incision along the course of

the ulnar nerve, carrying it to the midpoint of the forearm, and elevating a

flap of skin at the elbow. When this flap was retracted laterally, the median

nerve was exposed.

Combined or separate lesions of the median or ulnar nerve in the lower

third of the upper arm at any point proximal to the origin of the first muscle

branches frequently presented the problem, particularly if the gap was large,

of adequate mobilization of the distal segment before repair could be undertaken. This was because of the short length and the course of the muscle

branches.

If this difficulty arose in the median nerve, it was solved as follows:

The bicipital fascia, which was opened during exposure of the nerve, was

not closed after suture. The nerve was thus allowed to assume a more superficial location, which appreciably shortened its course. Next, the muscle

branches from the median nerve were carefully mobilized. Obviously, after

these nerves had been dissected back as far as possible into their muscles,

whatever restriction upon their free mobilization still existed was the result

of the shortness of the branches themselves rather than of the parent nerve.

It was therefore not necessary to transpose the median nerve superficial to

the pronator, since the trunk itself was not under tension. The restriction

upon mobilization of the distal segment was apparently due to the pull of

the branches in the order of their respective appearance. If further mobilization was essential, one or more of these branches therefore had to be

sacrificed.

Fortunately, the first two of these branches supply the pronator. Weakness of this muscle is not a serious handicap and was regarded as worthwhile

if the sacrifice would permit the regeneration of further strength and sensation to the hand.

Repair of the ulnar nerve by careful dissection of the branches to the

flexor carpi ulnaris, both along the nerve trunk and, in selected cases, into

the muscle itself, permitted the transposition of this nerve medially to a

point at which most defects in the area could be overcome when the elbow

was flexed. The great advantage of overcoming large nerve gaps by flexion

at the elbow introduced two considerations. First, when large defects were

overcome in this manner, the involved structures were seen to be under considerable tension when any extension at all was attempted. In these cases,

the wisest plan was to persuade the patient never to attempt complete extension and by all means to avoid forced extension; if there is sensation in the

hand and if there is useful associated motor function, it is always much more

satisfactory to have an arm in considerable flexion. The second consideration

was that lesions of these nerves anywhere in the extremity were also bene-
PERIPHERAL NERVE REPAIR 397

fited by flexion of the elbow if dissection had been adequate in the forearm,

in which the median and ulnar nerves were more likely to be injured independently.

The Median Nerve in the Forearm

Damage to the median nerve and its branches in the forearm was likely

to be disastrous because of its effect on the function of the fingers and hand.

This is a region in which knowledge of the detailed anatomy was essential

to the neurosurgeon confronted with such a situation. The results were often

disheartening, but it was nonetheless worthwhile to make every endeavor to

identify the branches and to cany out repair.

To expose the median nerve in the forearm, an incision was made along

the neurovascular bundle in the upper arm and brought down to the medial

portion of the flexion crease in the elbow. This crease was followed laterally to just beyond its midpoint. Here, a right-angled incision was made

and was carried down the mid forearm. This type of incision prevented the

unfortunate effects of any straight pull of a scar across the flexion crease.

The median nerve was isolated above and below the pronator teres, the more

distal exposure being accomplished by retraction of the flexor carpi radialis

and the flexor digitorum sublimis after separation of its radial attachment.

If the lesion was beneath the superficial head of the pronator teres, it was

usually necessary to reflect this muscle from its insertion into the radius to

promote adequate exposure.

Injuries of the upper forearm.—Lesions of the median nerve distal to the

lower border of the pronator teres have the same neurologic effects as lesions

of the median nerve at the wrist, and repair of even large gaps in this

region was possible without loss of motor function. In such cases, the

tendinous arch of the flexor sublimis was opened, and, by retraction of the

superficial head of the pronator, any motor branches emerging from the main

trunk could be carefully separated by opening the epineurium and carrying

the dissection upward. If the median nerve was transected above the point

at which these branches come off, sutures were placed with due recollection

of the fact that the motor supply to the muscles in the forearm comes from

the medial side of the nerve. If this fact were not borne in mind, confusion,

rotation, and interfunicular crossings were likely to result.

The phenomenon of axon splitting frequently overcame the surgeon's

best efforts to rearrange funicular topography, even in acute lesions, before

atrophy had occurred. When sensation first returned to an area, touch or

tactile stimulation might be localized not only in the area touched but in one

or more other areas, while, at times, sensation was referred entirely to other

areas instead of to the area stimulated. With the passage of time, this confusion tended to become less marked, and the patient, as the result of reeducation, experience, or both, came to find that distortion of sensation seemed

much less important than it had seemed originally.
398 NEUROSÜRGERY

The proximal segment was drawn proximally from beneath the pronator, which was then retracted downward and medially, and the motor branches

were farther dissected until they were found to compose a separate bundle.

The dissection could easily be carried upward as far as necessary to permit

transposition of the median nerve superficial to the pronator. When the

nerve was in this position and there was sufficient flexion of the elbow, all but

the most extensive gaps could be overcome. If loss of function to the deep

flexors was apparent upon faradic stimulation, an additional search was made

for the volar interosseous branch, which was repaired when possible.

Injuries of the mid forearm.—It was not unusual in wounds of the median nerve of the mid forearm to find a great deal of scar tissue and distortion.

In such cases, the nerve was picked up at the wrist, where it lies just medial

to the tendon of the flexor carpi radialis, and was followed proximally

through the scar tissue to its point of termination. It was easily identified

at the antecubital fossa, where it passes along the medial side of the biceps

tendon along with the brachial artery.

Injuries at the wrist.—At the wrist, injuries of the median nerve were

frequently associated with transection of tendons and sometimes of primary

vessels. In such cases, it was often advisable to repair both tendons and

nerves at the same operation.

The ends of the nerves were first isolated and were protected with packs

of moist cotton. The lacerated tendons were then identified, and, if there

was no considerable loss of substance, were sutured together. When loss of

substance was so great that direct suture was not practical, it was often possible to suture the distal segment into a proximal tendon which had the same

physiologic function.

The palmar cutaneous branch is the single branch of the medial nerve

proximal to the wrist which is of any importance. It leaves the median

nerve before it passes under the annular ligaments and usually travels with

the vessel into the palm. Since this branch of the medial nerve supplies

sensation to the palm and thenar eminence, time and effort to repair it were

warranted. If the median nerve had been severed at or near its origin, it

was sought for and incorporated into the repair whenever this was practical.

Small gaps could be overcome by flexion of the wrist alone. This nerve,

however, is of such importance to the hand that the surgeon did not hesitate

to take radical measures to restore it.

The best technique was to dissect it throughout the forearm, dissect the

proximal motor branches from the sheath under the pronator teres, and

transplant the nerve superficially, in order to achieve adequate suture repair

without tension. The disability associated with extreme flexion of the wrist,

particularly when tendons are involved, often justified overcoming the gap

principally from the relaxation accomplished by flexion of the elbow alone.

Physical therapy was then employed to prevent adhesions, with resulting

contractures, about the sites of tendon repair.
PERIPHERAL NERVE REPAIR 399

Injuries in the hand.—Injuries to the median nerve or its branches in the

palm are quite common in peacetime, when they are usually the result of

such accidents as falling on broken glass or lacerations from porcelain handles of faucets. In military practice, these wounds were of two types. The

first type resulted from the accidental or purposeful discharge of a rifle or

pistol. The second type was the combat-incurred injury, which was part of

an extensive injury from shell fragments or the explosion of boobytraps. The

true combat-incurred injury involved reconstruction of the whole hand and

was usually treated in a hand center equipped and staffed for this work.

When the nerve was the principal tissue damaged, it was essential that

it be thoroughly exposed and all its branches identified, so that proper

anastomoses could be performed. The skin was open by a Z-shaped incision

across the flexion crease of the wrist. The incision was extended along the

palm, along one of the flexion creases which turns about the thenar eminence of the head of the first metacarpal. When the palmar fascia was

opened, the median nerve was exposed as it emerges from under the annular

ligament and lies lateral to the flexor tendons. It was frequently possible

to produce enough relaxation in the nerve to bring a suitable stump, 2 to 3

cm. long, down into the palm and suture the distal segments of the primary

branches of the nerves in the hand into it.

Lesions in the digital nerves could be repaired by direct suture if the

gap was not too great and by nerve graft if it was. The most important

branches from this standpoint were those to the thumb and index finger.

The recurrent painful neuromas which were discouraging sequelae to some

of these procedures in the past were often successfully controlled by sympathectomy.

Functional results.-—Functional results of repair of the median nerve in

the upper arm or forearm were frequently good as far as return of gross

motor power was concerned. On the other hand, in spite of every effort at

correct funicular arrangement—at the best, this was crude in combat-incurred

injuries—and with the return of gross sensation, the intricate function necessary to form many of the simple acts performed with the thumb and

index finger was lacking. One patient whose medial nerve in the distal

forearm was repaired under highly favorable circumstances was reexamined

4 years after operation. Thenar atrophy, which is often persistent, had

completely disappeared, and tactile sensation was good throughout, even to

the point of reasonable two-point discrimination. The patient noticed no

handicap in his ability to play the piano, but he still could not wind his

watch with the affected hand. If the relatively extensive representation of

the thumb on the motor cerebral cortex is recalled, it is easy to understand

that it is completely unreasonable to compare the manifestations of regeneration in such a specialized nerve as the median with those of the radial

nerve, whose function is gross and almost completely that of extension.

498991V—59 29
400 NEUROSURGERY

The Ulnar Nerve

The ulnar nerve was the most frequently injured of all the peripheral

nerves in World War II. Its subcutaneous location and its proximity to

bone made it particularly susceptible to trauma in injuries about the elbow.

The ulnar nerve was exposed in the forearm by an incision which

roughly followed the course of the nerve from the distal third of the upper

arm downward and posterior to the medial condyle of the humerus. This

incision, which was curved slightly forward, was continued along the anteromedial aspect of the forearm just medial to the flexor carpi ulnaris muscle

and tendon in the distal half of the forearm and wrist.

Injuries at the elbow.—If the nerve lay in its normal position in the medial

aspect of the elbow, simple transposition out of this location to a subcutaneous

position anterior to the condyle was often all that was necessary to relieve

its fixation in callus, swelling, or a large fusiform neuroma. This procedure

was sometimes combined with external and internal neurolysis, the sheath

being left open.

In injuries at the elbow with complete section of the ulnar nerve, the

proximal segment was identified as it pierced the intermuscular septum, and

the distal segment could be identified just beneath the head of the flexor carpi

ulnaris muscle. When the lesion was located just proximal to the origin of

the muscle branches, it was frequently impossible to achieve sufficient mobility of the distal segment to overcome a large gap, though moderate transposition of the nerve anteriorly and flexion-relaxation of the elbow often overcame a defect of several centimeters. If necessary, the upper branches of the

flexor carpi ulnaris muscle were sacrificed; this procedure considerably increased the medial transposition of the nerve and, additionally, shortened its

course. By sacrificing all of the branches, gaps up to 12 to 14 cm. were

successfully repaired. Such a procedure, however, was not lightly undertaken. Much of the strength of the hand passes through the ulnar branches

of the flexor digitorum profundus, and return of gross function to this muscle usually occurred after nerve suture. On the other hand, return of function to the intrinsic muscles of the hand was more uncommon, particularly

if the nerve injury had been present long enough for extensive atrophy to

occur.

Injuries in the upper forearm.—Lesions of the ulnar nerve distal to the

branches of the flexor digitorum profundus were easily repaired, but dissection of the nerve was necessary from the level at which it pierces the

muscular septum in the upper arm to the wrist. By dissection of the branches

of the flexor carpi ulnaris and the flexor digitorum profundus, it was possible to reroute the nerve anterior to the humeral condyle, as well as medially, which accomplished extensive shortening of its course. The muscle

branches had to be separated from the parent nerve with great care; the

epineurial sheath was opened by delicate iris scissors or the point of a knife

blade. Such extensive dissections were not always successful, chiefly, it was
PERIPHERAL NERVE REPAIR 401

thought, because of anoxia caused by depletion of the blood supply of the

nerve in the course of the dissection and mobilization. This risk always had

to be borne in mind in operations on the ulnar nerve in this location, in

which it was usually necessary to separate the proximal segment, at least,

from its intimate connection with the ulnar artery.

Injuries in the lower forearm and wrist.—Management of lesions of the

ulnar nerve in the distal portion of the forearm and at the wrist required

preoperative knowledge of sensation to the dorsum of the ulnar aspect of

the hand and the fourth and fifth fingers. If sensation was absent, it was

necessary to identify the clorsocutaneous branch of the nerve. If the lesion

was proximal to the origin of this branch, correction was simple. This

branch, however, arises higher on the nerve than is sometimes realized, and

its independent section in injuries to the main division is not uncommon.

This is particularly true if the injury also involves the flexor carpi ulnaris

tendon, since these structures, throughout their course through the wrist,

are never more than 1 cm. apart. If both were injured, any gap present

had to be made up by transposition of the nerve at the elbow rather than

by flexion at the wrist. If the volar branch alone was involved, small gaps

could be overcome by flexion and ulnar deviation of the wrist itself.

Injuries in the hand.—In injuries to the ulnar nerve distal to the annular

ligament in the palm, exposure was secured through a modified Z incision

across the flexion crease of the wrist to the mid palm. After a flap had been

reflected medially, the nerve was isolated in the wrist and followed through

the carpal ligament in its compartment to its point of division into deep

and superficial branches. Up to this point, repair of the nerve could be

done quite readily, by treating the injury of the superficial branch and its

digital termination as injuries of the median nerve were treated (p. 399).

The deep nerve, however, could seldom be repaired beyond the proximal

centimeter.

From the standpoint of sensation alone, the dorsocutaneous branch of

the ulnar nerve is more important than the volar, since it supplies the medial

surface of the hand and the little finger. These are important areas of

contact, particularly when the hand is at rest.

Regeneration of the intrinsic muscles of the hand was most difficult to

obtain unless nerve suture was done early and postoperative physical therapy

was vigorous. When these criteria were met, results were generally good

and atrophy was minimal. It was frequently possible to demonstrate some

return of function in the hypothenar muscles and occasionally in the adductor pollicis, but, as always, the interossei and the two medial lumbricales were

notoriously poor in their response to surgery.

The Radial Nerve in the Arm

Injuries in the axilla.—The surgical approach to the radial nerve in the

axilla was the same as for the lower brachial plexus and the upper portions
402 NEUROSURGERY

of the other main nerve trunks in this area. As was true of other nerves in

the neurovascular bundle, lesions affecting the radial nerve at this level were

frequently accompanied by other nerve or vascular injuries.

If the lesion was high but below the origin of the upper large branch of

the triceps, this branch was always stimulated because it was frequently involved in the same lesion before it entered the muscle. Repair was not

difficult.

On the other hand, the axillary portion of the radial nerve was extremely difficult to repair, and its exposure was somewhat more difficult than

exposure of the median and ulnar nerves because these nerves, with the artery,

had to be retracted medially to permit adequate exposure.

If a gap of any size had to be overcome, it was necessary to adduct the

arm and rotate it externally as well as to raise it forward. Because of the

necessary approximation of the axilla, the nerve occupied a deep location in

the wound, and adequate exposure at this stage was sometimes achieved with

difficulty.

Injuries associated with fractures of the humerus.—Lesions of the

radial nerve in the next portion, as it passes through the musculospiral

groove of the humerus, are very common in peacetime and were also common

in war. They were usually associated with fractures of the humerus. An

injury at this level, in fact, was uncommon in the absence of bone damage.

Fractures of the humerus which were combat incurred were associated with

radial nerve paralysis in about 30 percent of all cases. In many instances,

the nerve was not completely severed, and recovery was spontaneous.

A radial nerve paralysis associated with a fracture of the humerus,

particularly a compound fracture, was an indication for visualization of the

nerve when the fracture was reduced, for a number of reasons, as follows:

1. The earliest possible repair of the nerve was desirable if it was severed, though it was always advisable to wait at least 3 weeks from the time

of wounding.

2. Investigation of the nerve along with the fracture made it possible

to extricate it from a fracture site in which it might be impinged upon by a

bony spicule.

3. It was desirable to place it in a new bed, away from the fracture site,

to prevent its encasement in callus.

Experience with these injuries in World War II soon showed the advantages of a combined neurosurgical and orthopedic attack, and this policy

became almost routine.14 Previously, the policy had been to delay surgical

exploration until the wound had healed sufficiently to permit open reduction

of the fracture if that was indicated. Then the attack on the nerve was

delayed until after bony healing had taken place, in the belief that sponM Attention is called to the excellent discussion of combined bone-nerve injuries in the volume

in this series of histories entitled "Medical Department, United States Army. Surgery in World

War II. Orthopedic Surgery in the Mediterranean Theater of Operations," pp. 116, 128-129, 132-

133, and 161.
PERIPHERAL NERVE REPAIR 403

taneous regeneration might occur in the interim and that, if nerve repair

was necessary, there would be less chance of derangement of the bony fragments. The later plan gave priority to the nerve injury.

Ideally, these combined injuries were treated as follows:

After primary debridement, followed by the administration of penicillin,

delayed primary wound closure was performed, preferably within 2 to 3 days

after the first operation. Combined bone-nerve surgery was carried out about

3 weeks after injury.

Although various incisions were recommended for exposure of the lesions,

the most universally satisfactory approach was through medial and posterolateral incisions, with the arm prepared and draped to facilitate freedom

of manipulation. The medial incision was made along the course of the

neurovascular bundle from the axilla to the mid arm. The contents of the

bundle were retracted downward into the area of trauma and scarring.

Electric stimulation determined whether the branches of the triceps were

intact.

The lateral incision began between the lower end of the biceps and the

origin of the brachioradialis and extended upward posteriorly over the

course of the radial nerve to a point at about the junction of the middle and

upper third of the arm. The nerve could be identified as it penetrated the

intramuscular substance and was followed upward into the area of trauma.

If the injury was produced by a shell fragment or was associated with a

comminuted compound fracture, the triceps muscle was sometimes completely destroyed or was so scarred and distorted that the normal anatomic

relations were of little use in guiding dissection.

When the muscle was relatively intact, it might be necessary to sever

some of the fibers of the lateral head of the triceps close to its origin in

order to preserve the nerve supply, although adequate exposure could sometimes be obtained by retracting these fibers or splitting them. In lesions of

longer standing, it might be necessary to use a chisel to free the nerve from

extensive callus. Sometimes the mere release of the nerve from such callus

was followed by satisfactory return of function.

In a combined bone-nerve injury, the radial nerve, although still in continuity, consisted of frayed, fibrous bands, indicating that a traction or stretch

palsy had been caused by displacement of the distal fragment and actual

tearing apart of the nerve substance. The damage often extended over several centimeters and resulted in a large defect, which was ordinarily difficult

to overcome at this level.

If the nerve was found completely separated and if the bone fragments

were in good position and alinement, the proximal and distal ends were mobilized, care being taken to preserve the branches of the triceps, if possible, by

stripping them up to the parent nerve. If the gap was small, it might be

possible to repair the defect directly by the relaxation produced by flexion

of the elbow. For this technique to be successful, the fibers of the triceps
404 NEUROSURGERY

muscle had to lie between the new suture site and the bone. If the gap was

large or the scar tissue in the proposed site of repair was excessive, it was

frequently advisable to reroute the nerve segment anterior to the humerus,

so that the repaired nerve could lie between the brachialis and the biceps.

Some observers believed that the extra length afforded by this rerouting

procedure was remarkable. Most believed that it was not. At Halloran

General Hospital, which had a particularly wide experience with such lesions

(p. 415), a gain of 1.0 to 1.5 cm. was thought the most that could be hoped for.

There were, however, two advantages inherent in transposing the radial

nerve anterior to the humerus as a technique of repair. One was the improved exposure produced by the transposition for the repair operation.

The other was the new bed, free from scar tissue, provided for the regenerating nerve.

In occasional lesions in continuity in which resection and sutures were

not required and which were not accompanied by complete fracture of the

humerus, the nerve might be brought through the fracture site to the anterior

location. The outlook for regeneration was then more promising.

In injuries in which both bone and nerve required surgical attention,

the nerve ends were mobilized, removed from the fracture site, and protected by moist cotton while the orthopedic part of the procedure was carried

out. Meantime, the site of probable resection of the neuroma and glioma

had been estimated, and, if the defect to be overcome was too great to be

made up by ordinary means, the additional distance was recovered in the

repair of the bony fragment. A shortening of not more than 3.5 to 5 cm.

was usually not difficult to attain. In some instances, it facilitated bony

repair and secured firmer union. The bone fragments were fixed in place by

a plate (fig. 195), a graft, or some other technique of internal fixation.

The nerve was then repaired, care being taken that the course selected

for it avoided irregularities and extraneous agents used in the repair of the

bone. Relaxation from flexion of the elbow could be further increased by

adduction of the arm. Fixation by a Velpeau dressing was satisfactory.

When more rigid fixation was required because of operation on the bone, a

plaster shoulder spica was frequently used.

Injuries in the distal third of the arm.—Lesions in the radial nerve in

the distal third of the arm were more readily accessible to surgical repair.

When the injury was associated with a fracture of the lower third of the

humerus, the bony injury was not likely to be as severe as in the injuries just

discussed.

In this part of the arm, the radial nerve lies between the brachioradialis

laterally and the biceps and brachialis medially. If it was necessary, it was

identified above the intermuscular septum and followed downward. Care was

taken to preserve the branches of the brachioradialis and the extensor carpi

radialis. These two nerves sometimes formed a large motor trunk. If it

was destroyed, along with the parent nerve, they could be repaired inde-
PERIPHERAL NERVE REPAIR 405

pendently. If it was necessary to suture them to the nerve, it had to be

remembered that these fibers arise from the fascicles on the lateral aspect

of this structure.

The distal segment could be found by identifying the superficial radial

nerve in the forearm and following it up to its junction with the posterior

interosseous to form the common trunk. The proximal segment had to be

mobilized thoroughly, since the course of the posterior interossei through

the supinator considerably restricts the mobilization of the distal segment

unless branches are sacrificed.

FIGUKB 195.—Roentgenograms of fracture of humerus. A. Nonunion.

B. Repair of fracture after 5 cm. shortening by use of bone plate. The

tantalum sutures employed to repair the radial nerve may be seen near

the head of the screw second from the elbow.

The Radial Nerve in the Forearm

In the forearm, the sensory division of the radial nerve (the superficial

radial nerve) lies under the brachioradialis. Because of its sensory distribution, the autonomous area of which is very small, this nerve is not of

surgical importance, though it was occasionally used in World War II as a

cable graft to other nerves in the arm. It was sometimes attacked surgically because of the annoyance produced by neuromas along its course.

The posterior interosseous nerve is important because of its function in

opening the hand. It was frequently injured during operations for removal

of the head of the radius after fracture. Its exposure and repair required

considerable dexterity.

Its exposure in the upper portion, before it enters the supinator muscle,

was accomplished by extension of the incision to expose the lower portion of

the radius in the upper arm. The incision was made to curve laterally, to
406 NEUROSURGERY

avoid crossing the flexion crease of the elbow in a straight line. By traction

on the brachioradialis and extensor carpi radialis, the nerve could be followed into the supinator. For additional exposure, a straight incision was

made over the dorsum of the forearm, between the extensor carpi radialis

and the extensor digitorum communis. After the fascia had been opened and

the plane followed between these two muscles in the upper portion of the

incision, the fibers of the supinator could be identified, and, after section of

the superficial portion, the nerve could be seen coming from the lower portion

of this muscle.

If the injury was within the muscle itself, the upper portion of the nerve

was identified through the exposure just described. The distal segment was

identified at the lower border of the supinator, where the nerve breaks up into

its numerous branches.

Defects in this region could be repaired quite readily by mobilizing the

proximal segment from above, at the point at which it was most often injured during surgical attack on the head of the radius. Because of the size

of the branches and the difficulty of repairing them, it was important to

remember the surgical significance of the two separate clusters (the proximal

branches to the extensor digitorum communis and extensor carpi ulnaris and

the distal branches to the abductor pollicis longus, extensor pollicis longus,

extensor pollicis brevis, and extensor indicis proprius). A lesion which

destroyed one cluster might spare the other, and a surgical repair might

salvage either one.

Disability of the hand was not only minimized but its physiologic restitution was more easily accomplished in this region by tendon splitting than

by transposition of flexor tendons. The technique recommended by Albritten,15 with intraneural dissection of the branches of the supinator and superficial extensors, permitted mobilization of the proximal segment distally

through the supinator by flexion of the elbow. The surgeon was thus enabled to overcome almost any reasonable gap that might occur in the dorsal

interosseous nerve.

In the past, the satisfactory results obtained from tendon transplants

somewhat dampened enthusiasm for extensive surgery to correct defects of

the posterior interosseous nerve. In World War II, the satisfactory results

which followed surgical repair of the nerve sufficiently outweighed the physiologic results from tendon transplants to warrant the more frequent use of

surgery.

The Femoral Nerve

The wartime experience with repair of the femoral nerve was not wide.

One reason was that few such injuries were seen because of the high fatality

rate attendant upon associated injuries of the accompanying femoral artery.

15 Albritten, F. F., Jr.: The Surgical Repair of the Deep Branch of the Kadial Nerve Sur"

Gynec. & Obst. 82 : 305-310, March 1946.
PERIPHERAL NERVE REPAIR 407

Another was the relatively short course of this nerve in the leg before it

breaks up into its numerous branches. Partial lesions were more likely to

be injuries of the branches in the mid thigh than injuries of the main nerve

in the groin.

Preoperative examination usually gave the surgeon some idea of the

portion of the quadriceps chiefly affected. Whenever localized atrophy was

present, surgical exploration usually revealed that suture was warranted.

The incision for repair of the femoral nerve or any of its branches was

made just lateral to the femoral artery. It extended downward over the

sartorius, along the medial border of the rectus femoris. When the sartorius

muscle was mobilized and reflected laterally, the principal branches of the

nerve were disclosed, and affected branches could be followed downward to

the point of injury. It was frequently possible to identify the distal segments of the branches, and anastomosis could be completed by mobilizing

the proximal segment and flexing the thigh until the patient was in a sitting

position. Plaster fixation in this position was well tolerated. A window

was left open over the anterior thigh to use for galvanic stimulation of the

quadriceps muscles, which atrophy rapidly from disuse. If the lesion was

only partial, quadriceps exercises within the cast were encouraged.

The Obturator Nerve

Injuries of the obturator nerve were even more uncommon than injuries

of the femoral nerve. This nerve, after passing through the obturator foramen, soon breaks into muscular branches, which explains why deficits of the

entire nerve were seldom seen.

Surgery upon the pelvic portion of this nerve was not uncommon in

military practice, particularly in the treatment of paraplegics, in whom

adductor spasm could be a disabling complication. The nerve could be isolated through a suprapubic incision as it enters the upper part of the obturator foramen after passing along the outer wall of the lesser pelvis. Its

identification was facilitated by the use of the electric stimulator. Simple

section was frequently accompanied by section of the pelvic adductor attachments.

The Sciatic Nerve

Surgery on the sciatic nerve was facilitated by the fact that it is by far

the largest nerve in the body. From the standpoint of surgical anatomy, it

was important to remember that the peroneal portion of the nerve occupies its posterolateral aspect and, because of its location, was particularly

vulnerable to trauma in certain areas, such as its course under the gluteus.

The lateral portion of the nerve was also frequently injured in dislocations

of the hip. It was not unusual for surgeons, in error, to assume that a

peroneal palsy which was present was the result of pressure on or trauma
408 NEUROSURGERY

to the peroneal nerve at its most exposed point over the head of the fibula,

especially since injuries which produced dislocations of the hip were likely

to be accompanied by trauma elsewhere in the leg.

Injuries in the upper portion.—The sciatic nerve was exposed in its upper

portion through a gluteal-reflecting incision and in its lower portion through

a vertical incision in the thigh, the location of the incision depending upon

the level of the lesion. If the injury was at the gluteal fold, the vertical

incision in the midline of the thigh could be extended laterally, following

the gluteal fold; only the lower fibers or the femoral attachments of the

gluteus were reflected. If, however, the gap in the nerve was great, it was

frequently necessary to combine the two exposures and mobilize the nerve in

its entirety.

To secure this exposure, the patient was placed prone, and the entire leg

and buttock, as well as the lower lumbar region, were thoroughly prepared.

Drapes were either stitched or clipped to the medial portion of the buttocks,

to prevent contamination, which was always a serious risk in this area.

The operation was begun under local anesthesia, which was continued

until the status of the nerve was evaluated. It was then continued under

continuous spinal anesthesia, administered through a malleable needle or

an ordinary spinal needle with a shield.

Exposure was secured by the ?-shaped curve recommended by Stookey.16

It extended from the level of the posterior iliac spine outward and downward to the trochanter of the femur. After passing downward over the

insertion of the gluteus maximus tendon, it curved medially again along the

gluteal fold to the midline of the thigh. It was then extended downward

over the course of the sciatic nerve as far as the requirements of the special

case indicated.

The fascia was opened, and the fibers were split above the trochanter

in the direction of cleavage. The muscle was followed to its termination in

the thick, tendinous band which passes across the greater trochanter over a

bursa and is inserted into the iliotibial tract of the fascia lata. This band

was cut along its tendinous portion. After the few fibers requiring transection in the attachment of the muscle to the femur and the few blood vessels

which required ligation had been cared for, the whole muscle could be reflected medially and held in retraction by an assistant. The inferior gluteal

vessels and nerves could then be seen on the undersurface of the muscle, and

measures were taken for their protection.

The sciatic trunk was now exposed. The injured portion was likely to

be encased in scar tissue which obscured the nerve through most of its

subgluteal course. When this condition was present, the nerve was isolated

at the lower border of the gluteus, where it is most superficial, and the

branches to the hamstrings were identified and stimulated. The nerve was

then followed upward into the region of maximum scarring. Dissection

16 Stookey, Byron: Surgical and Mechanical Treatment of Peripheral Nerves. Philadelphia and

London : W. B. Saunders Co., 1922.
PERIPHERAL NERVE REPAIR 409

was simplified by the fact that there are no branches given off by the sciatic

nerve in this region between the branches to the hamstrings and the inferior

gluteal nerve above.

The sciatic nerve was isolated in the region of the sciatic notch and was

followed downward. If the injury was in the region of the notch, the

piriformis muscle was likely to be involved in the scar tissue; if it was, it

was transected. Otherwise, it was separated from its insertion and reflected.

The inexperienced surgeon had to guard against a common error in this stage

of the procedure, identification of the greater trochanter and the ischial

tuberosity as the lower border of the sciatic notch. These structures are

at about the midpoint of the subgluteal exposure.

If the sciatic nerve injury was in the notch and the piriformis had to

be transected, care had to be taken not to injure the superior gluteal vessel

and nerve as they emerged above this muscle. Dissection of the piriformis,

neurolysis, and even nerve suture could be successfully accomplished at the

level of the sciatic notch. In dissection at this level, however, extreme care

had to be taken to isolate the gluteal vessels. Accidental opening of one of

these vessels at or slightly above the level of the notch might resist all efforts

at control of the bleeding from below and requires an anterior pelvic approach for ligation of the lower portion of the internal iliac artery. This

approach was frequently employed in aneurysms of the subgluteal artery

associated with sciatic palsy from pressure.

Gaps in the subgluteal region of the sciatic nerve could be overcome by

mobilizing the distal segment of the nerve, flexing the knee, and extending

the thigh at the hip. This maneuver, however, did not solve the problem

if the branches to the hamstrings were involved as they came off the common

trunk. Lesions in this area, as well as in the lower portion of the sciatic

nerve, were more likely to be partial than complete. Whether the primary

components of the nerve were involved totally or in part, the tibial and

peroneal portions of the nerve were separated from each other to facilitate

neurolysis through the neuromatous portion and to permit more accurate

approximation of the divided fascicles of each segment. The involved component of the nerve or the fascicles was painstakingly dissected from the

intact portion for a distance sufficient to permit approximation of the prepared

fascicles without causing too much kinking in the intact, relaxed segments.

Repair was best accomplished by metallic sutures. If they were not used,

metallic markers were placed at measured distances on each side of the

anastomotic site, to permit later roentgenologic studies of the integrity of

the suture line. In injuries of the sciatic nerve, it was always best to have

a spica plaster cast prepared and bivalved before operation, to minimize the

risk of loss of position during its application after operation.

Injuries in the lower portion.—Exposure and repair of the sciatic nerve

are less difficult in the lower portion of the thigh, in which no important

nerve branches are given off except those from the peroneal portion to the
410 NEUROSURGERY

short head of the biceps femoris. The nerve is readily exposed through a

midline incision.

In the upper thigh, the long head of the biceps femoris crosses the sciatic

nerve obliquely from the medial aspect above to the outer aspect below.

When the muscle was retracted medialward in the upper half of the thigh

and laterally in the lower thigh, the nerve was completely exposed. It facilitated the mobilization of the muscle belly to isolate it and place a tape

around it.

Special technical points.—In its course through the thigh, the sciatic

nerve lies on the adductor magnus, in a deep muscle trough between the

hamstrings. The lesser sciatic nerve lies in the fascia, which placed it under

the incision in the upper portion, near the gluteal fold. The fascia was

incised at a sufficient distance from it to avoid including it with the sutures

in the closure.

In all lesions of the sciatic nerve, whether partial or complete, suture

was preceded by complete separation of the two components for a distance of

several centimeters above and below the level of repair. The same procedure

was of definite advantage in neurolysis. If a line of division was not obvious,

it could usually be found by palpation of the nerve between the thumb and

fingers. If it was not identified by this means, the nerve was isolated at the

point of its bifurcation and was dissected upward, with due care to protect

the fascicles and blood supply of each component.

In complete transections of the sciatic nerve, there was frequently sufficient distortion and rotation present for the segments to be isolated sufficiently far from the injury to establish the normal dorsolateral position of

the peroneal component and the ventromedial position of the tibial component. Normally, the sciatic nerve under the gluteus is surrounded by a large

amount of loose areolar tissue, so little was usually gained by extensive

exposure of this portion. If a large gap had to be overcome, the popliteal

fascia was opened widely. If the tibial component was involved, it was

mobilized to a more superficial location in the popliteal space. If the peroneal

component was involved, it was freed to the head of the fibula; in some cases,

it was advisable to resect the neck of the fibula.

The nerve components were then repaired independently, to avoid the

risk of crossing fibers. Whenever the gap in the peroneal portion was more

than 4 to 5 cm., a relaxation stay or sling suture was placed through the parts

for additional support. Neuropathologic studies showed that tantalum or

stainless steel produced the least tissue reaction. A thread of 0.005 inch was

adequate. If the gap in each of the components was about the same in extent,

it was frequently possible to place the sling stitch through the septum dividing them, thus avoiding injury to any of the fascicles. This was a wise

precaution, for it was estimated that separation of the suture site could be

anticipated in about 25 percent of all cases.
PERIPHERAL NERVE REPAIR 411

The Peroneal Nerve

Independent injuries to the main components of the sciatic nerve were

more likely to occur above the popliteal space, just above which the two main

nerve trunks begin to diverge. The smaller, lateral component, the common

peroneal nerve, is quite simple and is easily accessible throughout its course.

Small gaps were readily overcome by simple flexion of the knee. Larger gaps,

although they might be overcome equally easily, were frequently prone to

disruption or to traction paralysis, with further tissue destruction. This was

because of the unusual mechanical stresses exerted on the nerve, which has

one fixed point over a bony prominence and then passes in an almost straight

line along the sciatic nerve to its point of emergence from the sciatic notch.

Any stretch here is not alleviated by any intervening soft tissue and must be

compensated for by the elasticity of the nerve itself. More favorable conditions were sometimes produced by resecting the neck of the fibula, which

permitted the nerve to assume a more medial position and provided it with

a more direct course from the popliteal space to its distribution in the anterior muscles of the leg. The course of the nerve was thus slightly shortened,

and the stretch pull was alleviated by the soft tissue of the muscle rather

than by the bone.

During the war, an incision for exposure of the peroneal nerve was developed which was a definite improvement over the incision formerly employed,

which followed the flexion crease of the knee. The limb was prepared and

so draped that the lower leg could be freely mobilized. Then the knee was

flexed acutely, and a line of incision outlined from the midpoint of the lower

thigh downward to a point well above the flexion crease of the knee. Here

the incision was swung laterally. Slight medial retraction of the skin flap

exposed the peroneal nerve satisfactorily, and the awkwardness and inconvenience attendant upon attempts to close the older type of incision after

flexion of the knee to obtain relaxation were eliminated.

Two other points were important in repair of injuries of the peroneal

nerve. The first was that the nerve be isolated after its bifurcation into

superficial and deep divisions and the distal segments be followed upward,

to correct any funicular distortion produced by trauma and permit appropriate fascicles to be approximated with each other. The second was that the

proximal segment be mobilized by incision of the deep fascia and further

separation from the tibial nerve.

Although the common peroneal nerve was most often injured in its

passage around the head of the fibula, injuries of the deep and superficial

peroneal nerves, either in combination or singly, were not infrequent. Gaps

in the upper portion of the superficial nerve could be overcome by mobilizing

the proximal segment, after splitting the two terminal portions of the peroneal

nerve for a distance of several centimeters.

Surgery was seldom performed below the branch of the extensor digitorum longus because of the extensive dissections necessary for mobilization
412 NEUE.OSURGERY

sufficient to overcome a gap of any length. Recovery of the extensor function

of the great toe was better accomplished by a split tendon transplant.

Injuries of the common peroneal nerve over the head of the fibula frequently required isolation of both the deep and superficial peroneal nerves

independently. They were then sutured into the common peroneal trunk,

which was brought down from the popliteal space.

The Tibial Nerve

In view of its size and importance, injuries of the tibial nerve were

neglected in a surprising number of cases. This was probably because they

were so often overlooked and undiagnosed, at least in some locations.

Injuries of the tibial nerve in the popliteal space, above the origin of the

branch of the gastrocnemius, were easily recognized and repaired. In this

location, mobilization of the distal segment was somewhat restricted because

of the limitations imposed by the branches to the gastrocnemius, but a considerable gap could usually be overcome by flexion of the knee. Also, it was

sometimes advantageous to separate the tibial from the peroneal portion of

the sciatic nerve for several centimeters, to afford better mobilization of the

proximal segment.

The surgical approach in this location was through a straight incision,

the continuation of the incision used for exposure of the sciatic nerve. Extension of the incision medially over the medial hamstrings, in the form of a

flap, greatly facilitated closure if the nerve suture required flexion of the

knee for relaxation.

If the injury was between the heads of the gastrocnemius but above the

origin of the soleus, the two heads of the gastrocnemius were divided to improve the exposure.

Injuries of the posterior tibial nerve below the level at which branches

are given off to the plantar flexors of the foot were frequently overlooked.

Experience in civil practice showed that a complete lesion at this level was

sometimes not recognized until years after the injury, when the patient presented himself with trophic ulcers on the ball of the foot, loss of intrinsic

muscles, and undue prominence of the metatarsal heads, which sometimes had

eroded through the anesthetized skin. Flexion of the toes was greatly diminished or completely lost, and ability to invert the foot, with stabilization of

the ankle, was also lost if the lesion was above the origin of the branch to

the tibialis posticus.

Lesions seen in military practice had not, of course, reached this stage,

and in several instances gaps of extraordinary length—several 10 cm. long

and another 16 cm. long—were repaired. The technique was as follows:

The patient lay prone on the table. The surgeon took his position on

the side of the table opposite the injured limb. The skin incision was an

extension of the incision used for an injury of the tibial nerve in the popliteal

space. It curved around the medial angle of the flexion crease of the knee,
PERIPHERAL NERVE REPAIR 413

extended slightly posteriorly, and then continued just posterior to the medial

border of the tibia downward to the ankle, where it passed midway between

the medial malleolus and the tendo achillis. Finally, the incision followed

the course of the nerve into the foot.

The saphenous vein and nerve were identified after the skin was opened

and were protected as much as possible; when the incision in the fascia was

closed later, care was taken not to strangle the nerve in the suture. The fascia

was opened in line with the skin incision. In the lower half of the leg, the

separation was between the soleus and gastrocnemius muscles posteriorly, as

they join to form the tendo achillis, and between the flexor digitorium longus

and the tibialis posticus anteriorly. Above this point, the narrow attachments

of the medial border of the soleus muscle were separated from the posterior

medial surface of the tibia. The upper attachment of the soleus was separated from the oblique popliteal lines of the tibia as far as the tendinous

arch, which was opened laterally. When this dissection had been completed,

the soleus and gastrocnemius muscles could readily be retracted laterally en

masse, with their nerve and blood supply. The neurovascular bundle was

thus exposed under the deep layer of the fascia on the posterior surface of

the tibialis posticus muscle, within the groove between the flexor digitorum

longus and the flexor hallucis longus muscles.

The main trunk of the posterior tibial nerve was picked up distally at

the anterior medial border of the tendo achillis, just above the internal malleolus. Stimulation of the nerve at this point usually indicated whether the

lesion was partial or complete. The nerve was identified proximally, either

at the popliteal space or at the level of the tendinous arch of the soleus, and

dissection of the segments was carried out proximally and distally through

the scar tissue until the proximal neuroma and distal glioma were encountered.

It was frequently possible to preserve the nerve supply to the deep

flexors as well as to the gastrocnemius and soleus, even though the lesion was

quite high, since these branches come off high in the calf or even in the

popliteal space. More often, the two lowest branches of the muscles of the

calf, the flexor hallucis longus and the flexor digitorum longus, were involved.

For adequate mobilization, these branches had to be separated from the

proximal portion of the posterior tibial nerve by careful intraneural dissection. If these branches were dissected after they came from a common

fasiculus and if the dissection was carried up to the popliteal space, the

branches to the soleus and the gastrocnemius were also exposed. At this

level, these branches were sometimes as large as the rest of the posterior

tibial nerve. During the dissection, great care was taken to protect the posterior tibial artery and its branches through the muscles of the calf.

In occasional injuries in which the gap to be overcome was excessive, a

few more centimeters could be obtained by withdrawing the proximal end

from between the heads of the gastrocnemius and extending it down the leg

superficially to the medial border of the soleus.
414 NBUROSURGERY .

When considerable dissection was necessary above the knee, it was a good

plan to close the upper part of the wound as far as possible before flexing the

knee to facilitate nerve suture.

After the nerve was repaired, the soleus was resutured to its attachment

at the tibia in the upper half of the leg with interrupted sutures of fine silk.

The wound was then closed in the usual manner.

It was generally agreed that the approach just described was less traumatic and sounder physiologically than the midline incision which requires

splitting of both the gastrocnemius and the soleus.

The posterior tibial nerve, like the median nerve, has an unusually large

number of sensory and autonomic fibers to the sole of the foot and the toes.

Causalgia was frequent after injuries to both nerves. It was always associated

with partial lesions in continuity and was therefore not regarded as an indication for resection and suture, since the function of the affected nerve was

often quite good and the symptoms could be well controlled by sympathectomy.
CHAPTER XVI

Combined Bone and Peripheral Nerve Injuries

JFade C. Myers, Jr., M.D., and Robert T. Rosenfeld, M.D.

GENERAL CONSIDERATIONS

When the problems of a combat-incurred peripheral nerve injury were

added to the problems of a serious bone injury in the same extremity, both

neurosurgeons and orthopedic surgeons were often confronted with a very

difficult situation. The original policy of treating the skeletal injury first and

relegating the nerve injury to second place gave unsatisfactory functional

results, and it is unfortunate that the policy eventually evolved of treating

the injured extremity rather than of treating the separate structural injuries

was not established earlier.

The experience at the neurosurgical center at Halloran General Hospital,

Staten Island, N.Y., with these combined injuries is typical of the general

experience. In February 1945, the policy of combined neurosurgical-orthopedic management of combined bone and nerve injuries was set up at this

center. Patients with these injuries were segregated in special wards, and

their care was made the joint responsibility of the orthopedic surgeon and

the neurosurgeon.

The new policy was based on the principle, by then thoroughly established, that nerve injuries must be sutured as soon as possible after wounding

if maximum functional recovery is to be obtained. In practice, this meant

that nerve repair was performed as soon as possible after healing of the softtissue injury. Primary repair of combat-incurred nerve injuries was never

considered practical in World War II.

Policies were completely flexible and depended upon the exigencies of the

individual case. In some instances, neurosurgical and orthopedic procedures

were carried out at the same operation. In some instances, nerve lesions were

repaired before the fracture had solidly united or before sufficient time had

elapsed after wound healing to permit a reconstructive bone operation. In

some instances, in which the bone injury had resulted in ankylosis, it was

necessary to perform reconstructive orthopedic surgery to permit flexion of

the joint before the severed nerve ends could be approximated. Whatever

the plan for the special case, the important consideration was that its management was the joint responsibility of the neurosurgeon and the orthopedic

415
416 NEUROSURGERY

This chapter is chiefly based upon the 36 combined bone-nerve injuries

which were repaired at single operations at the Halloran General Hospital

Neurosurgical Center in 1945 (table 11). Over the same period, several hundred patients with less serious injuries of the same kind recovered under conservative management, and in a smaller number of cases, which are briefly

discussed, surgery for the nerve injury and the bone injury was performed

at separate procedures. The important consideration, as already pointed out,

was that in all of these cases, no matter how they were managed, the approach

was total, and the treatment, no matter how it was carried out, was a joint

neurosurgical-orthopedic responsibility.

The combined treatment of neurosurgical-orthopedic injuries offered many

advantages, aside from the obvious one that there were no administrative

delays in transferring patients from one section to another. The neurosurgeon

was able to evaluate the nerve injury promptly and to perform early nerve

repair with the assurance that the bone injury was under competent supervision and management. Adequate fixation of the fracture not only expedited

bony union but also helped to prevent disruption of the suture site in the

nerve. When the bone injury also had to be managed surgically, the patient

was subjected to only one major surgical procedure instead of two, with a

resultant decrease in morbidity and shortening of hospital-stay days, and a

consequent increase in his morale. From the practical standpoint, the bone

shortening possible under the plan of combined operation often permitted

more satisfactory nerve repair. The experience at all neurosurgical centers

was that the plan of combined management offered the optimum chances for

satisfactory functional recovery in nerve injuries complicated by orthopedic

injuries.

SELECTION OF CASES FOR COMBINED OPERATION

Orthopedic and neurosurgical procedures were carried out at the same

operation when the following conditions existed:

1. When continuity of the bony structure was necessary to prevent separation of the repaired nerve. This was particularly necessary when the bony

defect was in the femur or the humerus and the nerve defect was in the

sciatic or in the radial, ulnar, or median nerves. Without effective stabilization of the bone by grafting, distraction of the bony fragments frequently

caused separation of the suture site.

2. When shortening of the humerus was necessary to permit suture of

the nerve because the gap in the nerve was too wide to permit union by any

technique of repair. In 10 cases thus treated at Halloran General Hospital,

all instances of radial nerve injury, pathologic changes in the humerus would

have required resection, regardless of the nerve injury. In another case, not

included in the series, a normal humerus was shortened 1.75 cm. because it

would otherwise have been impossible to approximate the severed ends of the

radial, median, and musculocutaneous nerves, all of which were completely
BONE AND PERIPHERAL NERVE INJURIES 417

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paralyzed. It was not the policy to shorten the normal humerus for injury of

the radial nerve alone; in this type of case, satisfactory results could be

obtained by tendon transplantation.

3. When reconstructive bone surgery was necessary and the interval

since wound healing was sufficient to make the combined bone-nerve procedure

safe. The combined procedures in this category were most often done in the

forearm, when the ulnar or median nerve required repair and the damaged

radius or ulna had to be managed by bone graft.

Timing of operation.—The neurosurgeon preferred to operate as soon as

possible after satisfactory healing of the soft-tissue wound. Theoretically,

the orthopedic surgeon considered a 3-month interval between wound healing and reconstructive surgery ideal. Practically, when there had been no

evidence of infection involving the bone, a 2-month interval proved entirely

adequate. If infection was present and of long standing, even a 3-month

interval was not sufficient.

In numerous instances, it was possible to perform the nerve repair

earlier than the orthopedic operation; reinfection was less likely in a softtissue wound, and, if it should occur, was of less consequence than when the

bone was involved. In such cases, the policy was to perform neurosurgery

at the earliest possible date and defer bone surgery until a later date;

because it was less urgent than early nerve repair, it could afford to wait

a more ideal time. This policy was particularly important in injuries of

nerves of the forearm, in which bone shortening was not considered advisable.

In the Halloran General Hospital series, the average time between

injury and complete wound healing was 2.5 months, the range being 10 days

to 6 months, and between injury and reconstructive surgery 5.1 months. The

shortest interval between wounding and reconstructive surgery was 1.5

months; in this case, only nerve surgery was done. The longest interval

was 9 months.

PREOPERATIVE MANAGEMENT

Immobilization.—Patients with compound fractures of the humerus were

usually received in Zone of Interior hospitals in shoulder spicas, which

had been found most satisfactory for transportation splinting. These casts

were removed, and hanging casts were substituted as promptly as possible.

The early use of an anterior molded splint, in place of a full plaster cast,

permitted the daily removal of the extremity from the splint for physiotherapy and muscle-stimulating exercises. The policy of early motion prevented excessive muscular atrophy and kept the skin in favorable condition

for operation. No instance of nonunion could be attributed to this form

of treatment.

Patients with fractures of the femur and the knee joint were usually

received from overseas in hip spicas. On their arrival in the Zone of Interior, these casts were removed, and traction suspension was substituted.
BONE AND PERIPHERAL NERVE INJURIES 421

Skin traction was satisfactory in most cases. Skeletal traction was used if

the fracture was markedly displaced or malalined. In limbs which presented a mere bowing deformity, it was usually possible to correct the bowing by vertical skin traction, with supplementary lateral traction by slings.

In the majority of cases of marked deformity, however, too great an interval

had elapsed between injury and admission of the patient to the Zone of

Interior hospital to permit correction of the deformity by traction, particularly when there was overriding. Surgical measures were usually required

in such cases.

Fractures of the tibia were treated by the application of a plaster posterior molded splint as soon as possible. As in fractures of the upper

extremity, the injured limb could be removed from the cast daily for physiotherapy, which included massage, mobilization of the joint, electrical stimulation, and skin conditioning. No instance of nonunion could be attributed

to this form of treatment.

Management of septic compound fractures.—Patients who arrived at

the hospital with draining wounds caused by bone infection were examined

and evaluated from the neurosurgical standpoint, but the primary problem

in these cases was orthopedic. Transportation casts were removed. Wounds

were inspected and cultures made. Eoentgenograms were also made.

Measures were then instituted to expedite healing of the fracture. Sequestrectomy, secondary wound closure, skin grafting, and revision of the

scar were employed as indicated. Penicillin was used as an adjunct to

surgery, and liberal plasma and whole blood transfusions were given according to the indications. Every effort was made to maintain a sound

nutritional status by a diet high in proteins and vitamins.

About 28 percent of all patients with orthopedic-nerve injuries were

received at Halloran General Hospital with draining wounds. The average

interval between wounding and their arrival at the hospital was 12 weeks,

the range being 2 to 23 weeks.

In septic compound fractures, operation was practically always deferred for 6 months or more after wounding; if the infection had been

particularly obstinate, a still longer delay was necessary.

Care of the skin.—Particular attention was paid to the condition of the

skin before operation. Dense and adherent scars were resected, and skin

grafting by means of pedicle flaps was employed if the wound could not

be closed satisfactorily after excision of the scar. The Potter and Croce

technique of performing a neurosurgical procedure and applying a pedicle

flap atthe same operation (p. 430) was sometimes very useful.

OPERATION

When combined nerve-bone reconstructive surgery was performed, operation was carried out according to a carefully planned routine, the steps

of which were as follows:
422 NEUROSURGERY

1. The neurosurgeon made the initial incision, isolated the nerve, mobilized it as freely as possible, and resected the ends as far back as necessary

to reach healthy nerve tissue. He also measured the defect which existed

with the joint flexed, to determine whether bone shortening would be required, and, if it were necessary, how much nerve tissue must be resected.

2. The orthopedic surgeon then initiated the orthopedic procedure. Experience showed that, because of the additional handling of the extremity

following the orthopedic operation, exceptionally firm fixation was necessary.

For this reason, both a plate and a graft were frequently used, tibial cortex

usually being employed for the latter purpose. The graft was fixed in place

with metal screws, and multiple bone chips and a generous amount of cancellous bone were packed around the fracture site.

3. The neurosurgeon, at the completion of the orthopedic procedure,

repaired the nerve lesion. In all instances of complete nerve section, end-toend neurorrhaphy was performed with interrupted epineurial sutures of

0.003-inch tantalum wire. The suture site was usually enclosed in a 2-cm.

length of tantalum foil. If nerve section was not complete, neurolysis was

performed.

4. After the neurosurgeon had closed the wound, the orthopedic surgeon

applied the plaster splint.

5. The nerve and orthopedic procedures were always performed through

different muscle planes, so that excessive scar formation would not endanger

the chances of nerve recovery.

Anesthesia.—The first neurosurgical phase of the operation was usually

performed under local anesthesia, secured with procaine hydrochloride (1-

percent solution), so that the results of stimulation of the exposed nerve

could be properly evaluated. General anesthesia was not begun until the

orthopedic stage was reached. Combined bone-nerve operations were frequently very long, but the plan described meant that there was no undue

prolongation of the anesthesia.

ANALYSIS OF DATA

Management of Regional Injuries

Upper arm.—Of 18 patients with compound comminuted fractures of the

humerus who underwent combined bone-nerve surgery, 17 presented paralysis

of the radial nerve and the other paralysis of the ulnar nerve.

In 10 cases, all instances of radial nerve injury, shortening of the

humerus was necessary, the average resection being 4.1 cm. and the lower

and upper limits 2.5 and 6.5 cm., respectively.

Neuromas in continuity were found in the single ulnar nerve injury and

in six of the radial nerve injuries. The average gap in the nerve after

excision of the neuroma was 6.1 cm., the range being 5 to 6.6 cm. These

(and all other) measurements of the nerve defects were made with the
BONE AND PERIPHERAL NERVE INJURIES 423

elbow in 90° flexion. In the remaining cases, the average gap after excision

of damaged tissue was 6.6 cm., the range being 5.2 to 10 cm. In many cases,

the character of the injury was responsible for the length of the defect. In

other cases, prolonged preoperative immobilization had resulted in considerable restriction of motion of the elbow.

The bone injury in all 18 cases consisted of nonunion, malunion, or

limited union; the fracture had united in many cases, but the bone mass was

insufficient to permit good function and assure safety from refracture under

moderate stress.

Neurorrhaphy was performed in 14 of the 17 radial nerve injuries and

in the single ulnar nerve injury. Neurolysis was adequate in one case, and

the damage in the two remaining cases was inoperable.

In seven instances of radial nerve involvement, the nerve was transplanted anteriorly (figs. 196 and 197). The usual lateral incision was made,

and the nerve was freed to the posterior aspect of the humerus in the musculospiral groove. An incision was next made on the medial aspect of the

arm over the neurovascular bundle in its upper portion, and the nerve was

dissected free from the medial aspect. It was then passed distally between

the brachialis muscle and the biceps. This technique provided a satisfactory

new bed for the radial nerve when there had been extensive soft-tissue

damage in the normal bed and also provided an additional 1 to 1.5 cm. in

the length of the nerve.

In the 10 cases of radial nerve injury in which shortening of the

humerus was necessary (p. 416), the average resection was 4.1 cm. In the

case (not included in this series) in which the normal humerus had to be

shortened (p. 416), resection of a neuroma left a gap of 1.75 cm. Of necessity, the humerus was shortened by the same length and then was fixed with

a Vitallium plate.

Forearm.—In the four median nerve injuries associated with fractures of

the humerus, the bone was repaired by grafting in all instances. The nerve was

managed by neurorrhaphy in one case and by neurolysis in the other three

cases. Neurorrhaphy was also necessary in the four ulnar nerve injuries

associated with fractures of the radius and in two of the four associated

with fractures of the ulna. Neurolysis was sufficient in the other two cases

(fig. 198). In all but one of the neurorrhaphies, the indication for repair

was a neuroma in continuity. In the other case, the indication was a 2.2-cm.

gap left after excision of damaged nerve tissue.

In the three cases, all median nerve injuries, in which the nerve was

involved at the elbow, it was possible to perform the neurorrhaphy with

the elbow in flexion, in the optimum position, though in one instance,

ankylosis with extension contracture required preliminary arthroplasty with

resection of bony fragments and scar tissue before the elbow could be flexed

to 90°. In the other two cases, the head of the radius was excised because

of severe comminution and displacement.

498991'—59 30
424 NEUROSURGERY

FIGURE 196.—Combined bone-nerve surgery in injury of humerus and radial nerve. A.

Preoperative roentgenogram. B. Onlay bone graft in place and nerve ends prepared for

suture. C. Rerouting of proximal nerve segment to avoid fixation in callus of healing

fracture site. D. Postoperative roentgenogram. Note tantalum sutures.

In the two remaining cases, the dorsal interosseous nerve was sutured

after resection of the synostosis of the radius and ulna; the mechanical

functional result was good in each case, but in neither was there any return

of function. The defect in the nerve after excision of the neuroma and of

the damaged tissue, respectively, was 10 cm. and 5 cm.

The problem in combined injuries of the ulnar and median nerves and

the bones of the forearm differed from the problem in combined bonenerve injuries of the upper arm in that shortening of the bones of the

forearm was not necessary for nerve repair; the advisability of shortening of

the bones of the forearm is, as a matter of fact, always questionable.^

The problem of timing also entered into the management of combined

bone-nerve injuries in the forearm. As already pointed out, it was usually
BONE AND PERIPHERAL NERVE INJURIES 425

FIGUKE 197—Combined surgery in injury of humerus and radial nerve. A radial

nerve defect 6 cm. long was found at operation approximately 7 months after injury by

shell fragments. After isolation of the nerve and anterior transplantation, the bone was

shortened 2.5 cm., and a bone plate was fixed with two Vitallium screws above and below

the fracture. Neurorrhaphy was then performed with tantalum wire. Recovery was

uneventful, and solid bony union ensued. A. Preoperative roentgenogram. B. Postoperative roentgenogram.

safe to repair injured nerves within 2 weeks after wound healing, but it was

never safe to repair bones in less than 2 months. In the forearm, therefore,

in which bone shortening was not done, it was often the practice to repair

the nerve alone within 2 to 2% months after wound healing and defer the

necessary bone surgery until later. The only combined bone-nerve cases in

this series were those in which healing had occurred sufficiently long before

to make bone surgery safe at the nerve operation.

Femur and hip.—The sciatic nerve was paralyzed in four cases in association with compound comminuted fractures of the femur (fig. 199). Bone

repair was accomplished by bone grafts in three cases, in one of which the

graft was employed only as a reinforcement. In the fourth case, in which

both a bone graft and plating were used, the femur was refractured when

the neurosurgical procedure was undertaken.

Flexion of the knee and mobilization of the nerve made repair feasible

in all four cases. Neurolysis was sufficient in one case. Neurorrhaphy was

necessary in the other three; in these cases, the defect ranged from 2.5 to

3.5 cm. initially and from 4 to 7.5 cm. after the necessary resection of the

damaged ends had been carried out. Early motion of the knee was instituted promptly after operation.

In 17 other cases in which the sciatic nerve was injured and the femur

was also fractured, suspension traction and orthopedic care proved adequate without bone surgery, and only nerve repair was necessary.
426 NEUROSURGERY

FIGUKE 198.—Combined surgery in injury of radius, ulna, and median and ulnar

nerves by machinegun bullet. The radial injury resulted in nonunion and a bone defect

and the nerve injuries in paralysis. Neurolysis of both nerves was performed 2 months

after injury; the application of a bone graft to the radius was deferred for 3 months

because wound healing was not complete. Smooth recovery and good bony union ensued.

Full return of median and ulnar nerve function was evident within 6 months after

neurolysis. A. Preoperative roentgenogram. B. Postoperative roentgenogram.

In one instance of complete sciatic nerve paralysis, chronic posterior

dislocation of the hip, associated with a fracture of the posterior lip of the

acetabulum, had been present for almost 3 months when the patient entered

Halloran General Hospital. Eeduction of the dislocation by skeletal traction

proved impossible. Eeduction and arthroplasty were therefore performed,

and a Smith-Petersen Vitallium cup was inserted. Neurosurgical exploration revealed no reason for the sciatic nerve paralysis other than nerve

stretch secondary to the dislocation.

Knee.—ln two instances, injury of the sciatic nerve was combined with

severe ankylosis at the knee. Motion could not be obtained in spite of intensive physiotherapy and traction by the Thomas splint and Pierson

attachment. Flexion to 90° was eventually possible after arthrotomy and

separation of the scar tissue; in both instances, resection of the patella was

also necessary because of the extensive lesions involving the articulating

surface. After operation, the patients were placed in suspension traction,

with removal pulleys and splints, and sufficient knee motion was thus obtained to permit repair of the sciatic nerve at later operations. Combined

operation was not performed in any case in which nerve injury was associated with damage to the bones of the knee.

POSTOPERATIVE COMPLICATIONS

Complications occurred in only 2 of the 36 cases of bone-nerve injury

managed by combined operation. In both instances, there had been a pre-
BONE AND PERIPHERAL NERVE INJURIES 427

FIGURE 199.—Combined surgery in shell-fragment wound of femur and sciatic nerve.

A bone graft was inserted 5 months after wounding, with a neurorrhaphy 7 weeks later.

A 4-cm. defect of the sciatic nerve existed after resection of the ends and was compensated for by flexion of the knee and mobilization of the nerve. In later cases of this

type (this being the first handled), the bone and nerve operations were performed simultaneously. Smooth recovery and solid bony union ensued. Ten months after operation,

Tinel's sign had advanced 55 cm. from the level of nerve injury, and the Pollock test

showed the tibialis anticus and gastrocnemius muscles in a regenerating phase. A. Preoperative roentgenogram. B. Postoperative roentgenogram.

operative infection, which was reactivated after operation. Both patients

had had penicillin before operation and for 7 days afterward, and both had

had a sterile 48-hour orthopedic preparation for surgery.

In the first case, infection was manifest by a temperature elevation on

the 10th postoperative day. Two days later, the cast was removed and

drainage instituted. The wound became quiescent under penicillin therapy,

but drainage continued, and removal of the metal plate was necessary.

Complete wound healing and solid bony union were then obtained, but regeneration of the radial nerve did not follow, and a tendon transplant was

necessary to accomplish extension of the wrist and fingers.

In the second case, the temperature elevation occurred and a draining

sinus developed on the fifth postoperative day, while the patient was still

receiving penicillin. The acute infection rapidly subsided when adequate

drainage was provided. At a later date, it was necessary to remove the

two screws which had been used, as well as a portion of the bone graft

which had separated by sequestration. Complete wound healing was obtained, as well as firm bony union. In this case, the infection did not interfere with nerve regeneration, and there was satisfactory return of function.
428 NEÜROSURGERY

RESULTS

Table 11 presents the results of assessment of nerve function, with the

time between the nerve operation and the last assessment, in the 36 cases of

bone-nerve injury in which combined neurosurgery and orthopedic surgery

were performed simultaneously at Halloran General Hospital. All of the

muscles supplied by each nerve are not mentioned, only those being included

which are checked routinely in postoperative nerve evaluations.

In 13 of the 15 cases of radial nerve injury in which neurorrhaphy was

done in combination with orthopedic surgery, regeneration was satisfactory.

In the other two cases, in which the nerve defect proved inoperable, surgery

was not entirely futile, since, in each instance, reinforcing bone grafts were

inserted through the incision made for exploration of the nerve.

Failure of union occurred in one case of supracondylar fracture of the

humerus associated with radial nerve injury. The fractured ends separated

either at the time of nerve suture or when the plaster cast was applied. A

second bone graft went on to full bony union. The radial nerve, which had

been transplanted anteriorly, was fortunately not separated, and the patient

had a satisfactory advance of Tinel's sign, with return of function of the

proximal muscles.

Satisfactory regeneration had also occurred or was in progress at the

last examination in the seven cases of ulnar nerve injury in which neurorrhaphy was done in combination with orthopedic surgery. Similarly good

results were obtained in the single neurorrhaphy done for median nerve

injury, and in the two neurolyses done for ulnar nerve injury and the three

done for median nerve injury in combination with orthopedic surgery; at

the last examination, the distal muscles showed voluntary function in all

of these cases.

The results were also satisfactory in the three neurorrhaphies and the

one neurolysis performed for sciatic nerve injury in combination with internal fixation of the femur. It might be added that satisfactory nerve

regeneration also occurred in the 17 other cases in which sciatic nerve surgery

had to be deferred until 90° flexion of the knee could be obtained by orthopedic treatment.
CHAPTER XVII

Peripheral Nerve Injuries Complicated by

Skin and Soft-Tissue Defects

Stanley E. Potter, MD., and Edmund John Croce, M.D.

EVOLUTION OF POLICIES

By the time a neurosurgical center was organized at the Halloran

General Hospital, Staten Island, N.Y., the problems inherent in combined

bone-nerve injuries were fully recognized, and a subsection was created for

their management. The value of the policy of segregation of these injuries

was proved by their subsequent expeditious and successful management.

The management of nerve injuries associated with soft-tissue damage

and loss of skin also presented special problems, which were promptly

recognized, but the patient load in this category was not large enough to

warrant the creation of a special subsection to handle them. Although there

was never any doubt of the importance of cooperation between the neurosurgeon and the plastic surgeon, the plans originally adopted were not satisfactory. The transfer of neurosurgical patients to plastic centers for

preliminary surgery meant postponement of the nerve repair, which, experience had shown, was always most satisfactory when it was performed

early. On the other hand, if neurosurgery were performed first, a successful

plastic repair might be compromised and the ultimate plastic result seriously

jeopardized. Because complicated plastic surgery, especially surgery requiring tube construction, was best undertaken at a plastic surgery center,

delayed nerve surgery was sometimes reluctantly accepted. In other cases,

nerve repair was performed as the first procedure, with split-thickness skin

grafts used as a temporary measure.

After all of these policies had been tested and had proved less than

successful or entirely unsuccessful, the policy was adopted of combining nerve

repair with the rotation of flaps or the construction of pedicle flaps or other

plastic procedures as indicated. Nerve repair was thus possible at a desirably early period after wounding, and the patient was subjected to a

single procedure. The prolongation of the operating time was not a major

difficulty, since local anesthesia was employed in most nerve repairs and was

also possible in the creation of smaller flaps.

ROUTINE OF MANAGEMENT

A preliminary survey of each patient was carried out jointly by the

neurosurgeon and the plastic surgeon. The plastic surgeon determined the

429
430 NEUKOSUKGBRY

type of plastic operation necessary, instructed the neurosurgeon in the pattern

of scar removal, and advised concerning the optimum placing of the neurosurgical incision at the angles of the skin defect. A consideration of the

possible posturing of the extremity required in nerve repair was always part

of the preliminary survey.

The neurosurgeon initiated surgery, under local anesthesia. The cutaneous scar or the split-thickness skin graft which had been employed in closure

was excised, and the incision was extended to provide adequate exposure.

The nerve was then repaired according to the technique necessary in the

special case. It was desirable, when possible, to transplant the suture site

from the area in which grafting was to be undertaken. If this was not

feasible, the suture site was placed in a fresh muscle plane. Tantalum cuffs

were not employed in cases in which plastic surgery and nerve surgery were

combined. If, however, the suture site could not be transplanted and had

to be left in a scarred bed at the site of the graft, a protective sleeve was

sometimes employed. It was so placed that it did not underlie the suture

line at the edge of the graft. Plastic repair was then proceeded with.

SPECIAL TECHNIQUES

Since skin grafts often became ischemic when they were mobilized in

operations for restoration of nerve function, the prophylactic policy was

adopted, as already indicated, of excising these areas of doubtful vitality

after the neurosurgical procedure had been completed. If this precaution

was omitted, there was always a chance that the nerve repair would be endangered and that secondary plastic procedures would also be required.

The pedicle flap used to cover the skin defect was usually raised from

the trunk when the wound was in the upper extremity. Sometimes, however,

the donor site was on the chest wall, because suture of the nerve defect

required immobilization of the extremity in varying degrees of flexion.

When circumstances permitted, the anterolateral aspect of the abdomen was

most desirable because the skin is loose in this area and subcutaneous tissue

is more abundant. For these reasons, the defect which remained after the

graft had been raised could often be closed primarily without distortion

of the regional topography.

A defect in one lower extremity was covered by a pedicle graft raised

from the other, though the optimum donor site could sometimes not be employed because the affected limb had to be immobilized in flexion. When

the posterior aspect of the upper or middle thigh was employed, moderate

postoperative discomfort was present for several days, but it was regarded

as justified; the use of this area as a donor site made it possible to close

the defect primarily, as in donor sites in the trunk, while the use of a

similar area on the calf required a split-thickness skin graft to effect closure.
PERIPHERAL NERVE INJURIES WITH SKIN DEFECTS 431

The recipient defect was accurately measured, and a pattern was made

of it upon gauze with methylene blue. The outline of the pedicle graft was

then drawn with methylene blue, with the aid of the pattern. In determining the length of the pedicle, allowance was made for the distance between

the abdomen and the base of the defect if juxtaposition of these areas was

not possible. The flap was raised to face the flexor or the extensor surface

of the extremity, depending upon the position of the defect, so that the

base of the defect and the abdominal wall would be as close as possible to

each other. The full-thickness graft was raised at the level of the deep

fascia. The size of the graft was often considerable; the largest in the

cases managed at Halloran General Hospital measured 15 by 10 cm.

The donor site was closed primarily whenever possible; this was usually

feasible. To facilitate closure, an incision was made on either side of, and

in line with, the base of the pedicle, and triangular flaps were raised and

were rotated toward each other. After transection of the pedicle, revision

of the wound of the donor area left a neat T-shaped scar. Silk sutures were

used throughout.

POSTOPERATIVE MANAGEMENT

It was the practice to transect the base of the pedicle in two stages, or

sometimes in three stages, over a period of 15 to 21 days, depending upon

the width of the pedicle, the size of the graft, and the circulatory status of

its apex. A preliminary test, by occlusion of the base with a rubber-covered

intestinal clamp, served as a useful guide in determining the vascular independence of the graft. A proper amount of pressure was applied to the

surface of the graft by means of a circular elastic bandage over mechanics'

waste.

The limb was immobilized in plaster of paris until the graft was freed

from its source.

CONCLUSIONS

The seven case reports related in the legends attached to the illustrations

in this chapter (figs. 200 through 206) are typical of the cases of combined

nerve and soft-tissue injuries treated at Halloran General Hospital and at

other neurosurgical centers in the Zone of Interior. From this total experience, the following general conclusions are believed to be warranted:

1. Peripheral nerve injuries accompanied by soft-tissue wounds which

have been allowed to heal secondarily or have been covered by split-thickness

skin grafts are best managed by a combined procedure. Definitive nerve

surgery can thus be performed at a desirably early period after wounding,

while the cooperation of the plastic surgeon at operation means that the

ultimate cosmetic result will not be jeopardized by the neurosurgery necessary.

2. Surgical defects resulting from removal of scar tissue or from inadequate split-thickness skin grafts should be covered with full-thickness

498991^—59 31
432 NEUROSURGERY

skin grafts from pedicle grafts mobilized concomitantly with the neurosurgical procedure.

3. For defects of the upper extremity, the abdominal or chest wall may

serve as the donor site, depending upon the necessities of the special case.

For defects of the lower extremity, the surface of the opposite thigh may be

used. The location of the donor site is often limited by the posturing

necessitated by the neurosurgical repair.

4. In most instances the defect created by raising the pedicle graft may

be closed primarily, by creation of sliding flaps.

FIGTJKE 200.—Repair of incomplete injury of right posterior tibial nerve, with avulsion of skin and soft tissues of lower third of right leg due to flak injury; wound healed

by granulation while patient was prisoner of war. Three-stage reparative procedure,

including (1) neurolysis of posterior tibial nerve and pedicle flap from posteromedial

aspect of left thigh 3% months after wounding; (2) partial section of pedicle 10 days

later; and (3) complete transection of pedicle, with revision of donor site 7 days later.

A. Preparation of pedicle. Note T-shaped closure of defect. B. Recipient site following

division and suture of base of pedicle. O. Donor site after division and suture of base of

pedicle. D. Medial aspect of right leg showing fully healed full-thickness graft.
PERIPHERAL NERVE INJURIES WITH SKIN DEFECTS 433

FIGURE 201.—Repair of incomplete injury of right posterior tibial and superficial

peroneal nerves, with avulsion of skin and soft tissues of lower third of right leg and

compound comminuted fracture of tibia, due to mortar shell fragments. Split-thickness

skin graft applied to defect 1 month after injury. Three-stage reparative procedure,

including (1) neurolysis of posterior tibial nerve and pedicle flap from posteromedial

aspect of left thigh 10 months after injury; (2) partial section of pedicle 7 days later;

and (3) complete transection of pedicle, with revision of donor site, 10 days later. A.

Medial aspect of right ankle, showing split-thickness graft overlying scar tissue. B. Operative site immediately following excision of scar and neurolysis. G. Medial aspect of

right ankle showing fully healed full-thickness graft.
434 NEUROSURGERY

FIGURE 202.—Repair of complete injury of left posterior tibial nerve, with loss of

skin and soft tissues of extremity and laceration of posterior tibial artery and vein, due

to shell fragments. Previous surgery included (1) approximation of nerve ends with

black silk 24 hours after injury and (2) split-thickness graft to wound site 17 days later.

Three-stage reparative procedure, including (1) left posterior tibial nerve repair and

pedicle graft from posteromedial aspect of right thigh 8% months after wounding; (2)

partial section of pedicle 10 days later; and (3) complete section of pedicle, with revision

of donor site, 7 days later. A. Skin defect after excision of split-thickness graft and

scar tissue. The neurorrhaphy has been completed and the sutured nerve lies exposed.

B. Recipient site after division and suture of base of pedicle. C. Medial aspect of left

ankle showing healed full-thickness graft.
PERIPHERAL NERVE INJURIES WITH SKIN DEFECTS 435

PIGUKE 203.—Repair of incomplete injury of right ulnar nerve, with massive skin

and soft-tissue loss, and compound comminuted fracture of distal end of humerus, due to

shell fragments. Split-thickness graft to right elbow 3 weeks after injury. Three-stage

reparative procedure including (1) neurolysis and transplantation of right ulnar nerve,

with pedicle graft from abdomen 10% months after injury; (2) partial section of pedicle

9 days later; and (3) complete transection of pedicle, with revision of donor site, 8 days

later. A. Right elbow showing extensive scar, in large part immediately overlying bony

structure; a split-thickness graft has been utilized to secure early healing. B. Operative

site following excision of scar, neurolysis, and transplantation of ulnar nerve. 0. Closure

of defect at donor site on anterolateral aspect of abdomen. D. Pedicle graft sutured to

skin defect after excision of scar and split-thickness graft. The ulnar nerve has been

transplanted anterior to the area of the pedicle graft. E. Posteromedial aspect of right

elbow showing healed full-thickness graft. The graft healed without infection, but there

was a spotty area of superficial necrosis in the distal third; this area cleared up

promptly, without in any way endangering the purpose of the graft. F. Healed donor

site on trunk.
436 NEUROSURGERY

FIGURE 204.—Repair of incomplete injury of right median nerve, with skin and softtissue loss, and compound comminuted fracture of radius and ulna, due to small arms

fire. Wounds healed by granulation after debridement. Three-stage reparative procedure

including (1) neurolysis of right median nerve, with pedicle flap from abdomen, 6 months

after injury; (2) partial section of pedicle 7 days later; and (3) complete transectlon

of pedicle, with revision of donor site, 2 weeks later. Improvement in sensory and motor

function was apparent 19 days after operation. A. Right forearm, showing extensive

adherent scar following healing of wound by secondary intention. B. Pedicle flap from

abdomen. C. Right forearm before partial section of pedicle flap. D. Volar surface of

right forearm showing healed full-thickness graft.
PERIPHERAL NERVE INJURIES WITH SKIN DEFECTS 437

FIGUEE 205.—Repair of incomplete injury of left ulnar nerve, with avulsion of skin

and soft tissues, due to small arms fire. Secondary closure and split-thickness graft 9

days after injury; exploration of ulnar nerve, without suture, 5% months later. Threestage reparative procedure including (1) neurorrhaphy and transplantation of left ulnar

nerve, with pedicle flap from left costal margin, 7 months after injury; (2) partial section of pedicle 10 days later; and (3) complete transection of pedicle, with revision of

donor site, 7 days later. A. Left wrist showing skin and soft-tissue defect. B. Skin

defect after excision of split-thickness graft and scar tissue after completion of neurorrhaphy. C. Healed full-thickness graft of left wrist. Superficial necrosis of a small area

did not interfere with healing. D. Healed donor site on trunk.
438 NEUROSURGBKY

FIGUKE 206—Repair of complete injury of right radial nerve, with avulsion of skin

and soft tissues of lateral aspect of lower third of arm, and compound comminuted fracture of humerus with loss of bone substance, due to shell fragments. Split-thickness

graft to skin and soft-tissue defect 2 months after injury. Four-stage reparative procedure, including (1) exploration of radial nerve, with reduction of 8.5-cm. defect to 4 cm.

by mobilization, with pedicle flap from abdominal wall 6 months after injury; (2 and 3)

partial section of pedicle 7 days, and again 14 days, later; and (4) complete transection

of pedicle, with revision of donor site, 8 days later. A. Right arm and elbow showing

extensive deformity after loss of soft tissue. B. Lateral aspect of right arm and elbow

showing extensive adherent scar overlying bone; split-thickness graft used to secure early

healing. 0. Skin and soft-tissue defect after nerve exploration. D. Pedicle flap from

anterolateral abdominal wall. B. Flap sutured into defect. F and G. Postoperative result.

A minor wound infection along the proximal suture line of the graft did not interfere

with healing. Note removal of scar tissue. H. Healed donor site.

This patient was later submitted to end-to-end suture of the radial nerve without

compromise of the graft. Bone shortening, which had been contemplated to permit

bridging of the nerve gap, did not prove necessary because of the gradual stretch of the

nerve by elbow extension after skin grafting.
CHAPTER XVIII

Peripheral ]N erve-Vascular Injuries

Barnes Woodhall, M.D.

INCIDENCE

Although complete statistics are not yet available, the indications are

that the incidence of combined vascular and peripheral nerve injuries in

World "War II will considerably exceed their incidence in any previous war.

Basic data secured from the Peripheral Nerve Eegistry showed that a major

vascular injury was present in 12.9 percent of peripheral nerve injuries in

which division of the nerve occurred and in which these data were stated.

The experience of World War II, like that of World War I, indicated that

neural complications were much more frequent in aneurysms of the upper

extremity than in those of the lower. The registry analysis showed 2.6 percent of combined injuries of the sciatic nerve and the regional vascular

supply but provided no other data on regional injuries.1

Combined vascular-nerve injuries are always fairly frequent in warfare

for the anatomic reason that, with very few exceptions, all large blood vessels

are accompanied in their course by peripheral nerve tissue. This is particularly true of the neck, where the great vessels lie in close proximity to

important cranial and cervical nerves, and is also true of the brachial,

femoral, and popliteal regions.

There were two reasons for the greater incidence of these combined injuries in World War II than in previous wars. The first was the excellence

of the initial medical care, including improved methods for control of

shock and infection, which kept many casualties alive who would formerly

have died of their injuries. The second reason is that, in addition to the

usual wounds caused by machinegun fire, rifle bullets, and shell fragments,

numerous multiple injuries were caused by the fragmentation of landmines,

i In the followup studies on peripheral nerve regeneration published as a Veterans' Administration medical monograph in 1956 (p. 230), it was found that arterial injury was associated with

peripheral nerve injury in 32.0 percent of median nerve injuries, 23.4 percent of ulnar nerve injuries, 15.1 percent of radial nerve injuries, 1.5 percent of peroneal nerve injuries, 3.9 percent of tibial

nerve injuries, and 3.0 percent each of sciatic-peroneal and sciatic-tibial injuries. In the upper

extremity, arterial injuries were associated with nerve injuries in 24.4 percent of all cases; the

largest proportion, 42.4 percent, was in injuries of the shoulder and the upper third of the arm,

and the next largest, 27.8 percent, in injuries of the middle third of the arm, with injuries of the

middle third of the forearm showing almost the same proportion, 26.8 percent. The smallest proportion, 12.3 percent, was in injuries about the elbow. In the lower extremity, arterial injuries

were associated with nerve injuries in only 2.8 percent of all cases, the largest proportions, 6.3

percent and 6.1 percent, respectively, being about the ankle and in the middle third of the leg.

No injuries of this sort were reported in the lower third of the leg or in the foot.

439
440 NEUROSURGERY

grenades, and aerial bombs. When as many as 50 small individual wounds

might be scattered over the body from the fragmentation of a landmine or

a grenade, the chances of a combined vascular-nerve injury were naturally

greatly increased.

DIAGNOSTIC CONSIDERATIONS

No very long military experience was necessary to show that diagnoses

made under battle conditions could not always be accepted at their face

value. Errors were particularly likely to occur in combined vascular-nerve

injuries, and, because of the conditions of military care in combat areas, they

might be carried by a wounded soldier for some time. These facts by no

means imply that initial management had been incorrect. On the contrary,

in the inception of any vascular injury, such as division of a major vessel,

the immediate care, quite correctly, was always directed toward the control

of hemorrhage. Surgeons working in frontline hospitals had neither the

time nor the facilities for elaborate investigation of individual patients when

the nature of their injuries seemed obvious.

In some vascular injuries, hemorrhage was slight, even though a major

vessel was involved, and bleeding could be controlled by simple measures or

was held in check by the natural pressure of the soft tissues. In this type

of injury, a pulsating hematoma or a false aneurysm might result. In still

other instances, vascular lesions developed slowly to the point of recognition.

An arteriovenous fistula, for example, though it was undoubtedly present

from the onset of injury, might not show characteristic signs until sometime

later, after edema and hemorrhage into the tissues had been absorbed.

As a general rule, the formidable nature of the vascular lesion at

first overshadowed the less dangerous but often more incapacitating neural

defect. In some instances, however, nerve lesions which produced motor and

sensory paralysis of the upper and lower extremities were so obvious, because

of their disabling consequences, that vascular injuries, at least in their early

stages, might be overlooked. It was therefore of the greatest importance

that patients with either nerve or vascular injuries be subjected to exhaustive investigation, including auscultation, in general hospitals distant

from the battlefield or in Zone of Interior hospitals, and that the examination

be conducted without prejudice by the previous diagnosis.

The chronology of the symptoms and signs was often a matter of considerable diagnostic importance, and the patient's history was therefore carefully reviewed. Excessive hemorrhage, repeated blood transfusions, and the

cold, gray pallor of an extremity in which an acute vascular occlusion had

occurred were unlikely to be forgotten by a patient who had retained consciousness after injury. Similarly, the history often suggested the extent

of the damage to nervous tissue. Even during the acute stage of injury, a

conscious patient was usually immediately cognizant of sensory and motor

loss. Paralysis of a peripheral nerve which became evident at the time of
PERIPHERAL NERVE-VASCULAR INJURIES 441

wounding might indicate severe trauma or even section of the involved nerve.

When it became apparent at a later date in a patient who also had an

aneurysm, the assumption that it was due to pressure was clearly justified,

and the observation was of both diagnostic and prognostic importance.

Vascular centers and neurosurgical centers were generally established in

the same hospitals in the Zone of Interior, and professional association was

close. Unfortunately, however, the potentialities of combined vascular-nerve

injuries for joint management and investigation were not realized as fully

as they might have been in World War II.

INJURIES OF THE NECK

For anatomic reasons, as already noted, combined vascular-nerve injuries were frequent in the neck. In the jugular foramen, the glossopharyngeal, vagus, and spinal accessory nerves lie in that order between the inferior petrosal sinus anteriorly and the internal jugular vein posteriorly.

The internal jugular vein, at its exit from the jugular foramen, lies external

to the nerves, while the carotid artery, with its accompanying sympathetic

plexus, lies closely anterior and medial to them. The hypoglossal nerve,

which leaves the skull through the adjacent anterior condyloid foramen, is

also in close proximity to them. All four nerves remain in close approximation to each other in their more peripheral courses, to a point slightly

below the tip of the mastoid, in the so-called retroparotid space. The fifth

and seventh nerves are more laterally placed, in the coronal plane of the head.

As Pollock and Davis2stated, the number of possible neurologic syndromes caused by wounds of the neck is limited only by the possible combinations of complete or incomplete paralyses of these several cranial nerves

and the descriptive ability of the various observers who write of them.

The syndrome described by Avellis,3for instance, long before World War I,

consists of unilateral paralysis of the soft palate and the larynx and is

caused by a lesion of the vagus and the internal branch of the spinal accessory nerve. The syndrome of Schmidt (cited by Pollock and Davis) simply

adds involvement of the external branch of the spinal accessory nerve to the

injuries of the vagus nerve and the internal branch of the spinal accessory

nerve. The syndrome of Jackson4acids involvement of the hypoglossal

nerve to these lesions.

During the course of World War I and in the years following, a number

of other observers added significant contributions to the literature of war

2 Pollock, Lewis X, and Davis, Loyal: Peripheral Nerve Injuries. Hoeber's Surgical Monographs. New York: Paul B. Hoeber, Inc., 1933.

3 Avellis, G.: Klinische Beiträge zur halbseitigen Kehlkopflähmung. Berl. Klinik 40: 1-26,

1891.

* Jackson, J. H.: Paralysis of Tongue, Palate and Vocal Cord. Lancet 1: 689-690, 10 Apr.

1886.
442 NEUROSTJKGERY

injuries involving these neural structures.3The nomenclature which they

employed was descriptive and denoted either the neurologic distribution of

the affected structures or the anatomic location of the causative wound.

Among these terms were syndrome of the posterior lacerated foramen;

glossolaryngoscapulopharyngeal hemiplegia; complete syndrome of the last

four cranial nerves; and syndrome of the posterior retroparotid space. Whatever the syndromes were termed, the resulting neurologic dysfunction depended upon the close anatomic continuity of the last four cranial nerves

in the early part of their extracranial courses.

Reports of combined injuries to the jugular vein and carotid artery in

association with injuries to the last four cranial nerves are extremely uncommon in the literature of World War I, although, for the anatomic

reasons just mentioned, such a combination must have occurred fairly frequently. Among the reports was Heyrovsky's description of the involvement

of the last four cranial nerves in association with a spurious aneurysm of the

vertebral artery. Aneurysmorrhaphy corrected the vascular lesion but had

no effect on the neural lesion.

In World War II, the number of combined vascular-cranial nerve injuries observed at the vascular centers in the Zone of Interior was also surprisingly small, although the congregation of vascular injuries at these

centers provided far more favorable circumstances for their recognition than

existed in World War I. Such injuries, for anatomic reasons, must be

fairly frequent, and their apparent infrequency is open to three possible

explanations, as follows:

1. These cranial nerves may be injured without concomitant vascular

injury, as observed by Vernet.

2. Vascular injuries may occur in association with the neural injuries

but may heal spontaneously.

3. The vascular injury may be so formidable that, even with modern

methods of controlling shock (methods which did not exist in World War

I), they are promptly fatal.

The vascular lesions observed in combined vascular-cranial nerve injuries in Zone of Interior vascular centers included arteriovenous aneurysms,

false aneurysms, and cicatricial occlusion. The extent and duration of the

vascular injury often bore no relation to the extent and duration of the

5

(1) Barbfi, A.: Le Syndrome nerveux de l'espace sous mastoi'dien. Progr. m<5d., Paris, 34 :

281-282, 19 July 1919. (2) Collet: Sur un nouveau syndrome paralytique pharyngo-larynge par

blessure de guerre. Hemiplegie glosso-laryngo-scapulo-pharynge'e. Rev. neurol. 22: 982-984, 1915.

(3) Körner, Von O.: Ueber Lähmungen der Nervi vagus, accessorius Willisii, hypoglossus und

sympathtcus durch Fernschädigung bei Halsschüssen. München, med. Wchnschr. 63 : 1429-1430,

3 Oct. 1916. (4) Pollock, L. J.: Extracranial Injuries of Multiple Cranial Nerves. Arch. Neurol.

& Psychiat. 4: 517-528, November 1920. (5) Sicard, J. A. : Syndrome du carrefour condylodgchir« posterieur (type pur de paralysie des qautre derniers nerfs craniens). Bull, et mem. Soc.

med. d. hop. de Paris 41 : 317-327, 16 Feb. 1917. (6) Vernet, M.. Syndrome du trou dechir«

posterieur (paralysie des nerfs glosso-pharyngien-pneumogastrique-spinal). Eev. neurol. 25: 117-

148, November-December 1918. (7) Villaret, M.: Le Syndrome de l'espace rStro-parotidien posterieur. Paris med. 23: 430-431, 1917. (8) Heyrovsky, J.: Nach Schussverletzung entstandenes

Aneurysma spurium der A. vertebralis operativ behandelt. Med. Klin. 11: 22, 3 Jan. 1915.
PERIPHERAL NERVE-VASCULAR INJURIES 443

neural injury. In other instances, the aneurysmal mass either caused the

neural lesion by its pressure or influenced it adversely, though it did not

necessarily follow that repair of the vascular lesion would favorably influence the neural lesion.

As the following case histories show, if vascular injuries were promptly

and correctly controlled at the time of wounding, the casualty's life could be

spared and some degree of rehabilitation could be accomplished even if there

was no improvement in the neurologic status after correction of the vascular

lesion.

Case Histories

Case 1.—This patient was wounded in the left malar region 10 November 1942, with a

French .44-caliber revolver bullet, which struck him at close range, traversed the face

and lateral aspect of the neck, and became embedded in the soft tissues of the left

occipitomastoid region. He staggered back under the impact of the bullet but did not

lose consciousness. He immediately noticed loss of sensation in the mouth and lower

left side of the face. His voice became hoarse, and he was unable to lift the left arm

fully from the side. The tissues of the neck swelled considerably, but there was no

extensive external hemorrhage. A few days afterward, he became cognizant of a loud

buzzing in the left ear, and, on occasion, his pulse rate became very rapid. The bullet

was removed from the left occipital region 22 December 1942, and the left common

carotid artery was ligated 22 February 1943. Neither operation produced any change

in his symptoms.

When the patient was admitted to Ashford General Hospital, White Sulphur Springs,

W. Va., 2 months after the second operation, examination revealed the following findings:

A small scar over the left malar region denoted the wound of entry and a short scar

4 cm. mesial to the tip of the left mastoid the operative wound. The tissues in this

region appeared full in comparison with those on the right. Palpation revealed a deeply

situated, pulsating mass, with a distinct systolic thrill. Auscultation revealed a continuous bruit, accentuated in systole, with maximal intensity over the occiput; it could be

obliterated by deep pressure over the sternomastoid muscle. Arterial pulsation was

absent over the left common carotid artery, the site of the earlier ligation.

The impression was that the lesion was an arteriovenous fistula of the cirsoid type,

probably involving the occipital artery and vein deep to the muscles and posterior to the

mastoid process, but possible involvement of the vertebral artery with the accompanying

veins in this region was also considered.

Significant findings revealed by neurologic examination were as follows: The pupils

were of equal size, and there was no enophthalmos. Analgesia and anesthesia were

present over the third branch of the left fifth nerve. There was loss of taste over the

anterior two-thirds of the left side of the tongue, which protruded to the left and was

atrophic and furrowed on this side (fig. 207). The soft palate was pulled to the right

upon phonation and the gag reflex was absent on the left side. The voice was hoarse,

and laryngoscopy disclosed a left abduction palsy. The left arm could not be abducted

beyond 90°. The left sternomastoid muscle was atrophied. The lower third of the

trapezius muscle was also atrophied, and the superior third was incompletely paralyzed.

The neurologic diagnosis was involvement of the fifth cranial nerve and of the special

visceral afferent (taste) fibers of the 7th nerve and the 9th, 10th, 11th, and 12th cranial

nerves (similar to the syndromes reported by Collet, Vernet, and Sicard), with the addition of the fifth and seventh nerve lesions.

Operation was performed 15 June 1943. A semicircular incision, beginning over the

left mastoid muscle, was carried upward over the base of the skull to the midline. The
444 NBUROSURGERY

FIGURE 207.—Paralysis of left hypoglossal

nerve following gunshot wound of face.

Tongue is atrophied and furrowed on the

left and protrudes to this side. An arteriovenous aneurysm of the occipital vessels resulted from the same injury.

FIGUEE 208.—Left seventh nerve paresis.

Note wound of entry on left lateral aspect

of nose, with development of arteriovenous

aneurysm of cavernous sinus and internal

carotid artery.

deep muscles were cut and retracted caudally. An arteriovenous aneurysm of the occiptal

vessels was then seen and felt at the base of the skull. Ligation of the external carotid

artery had little if any effect on it. The aneurysm was excised by ligating and cutting

the numerous arteries and veins seen to communicate with vessels entering the skull.

The considerable bleeding encountered was controlled by coagulation and by the use of

fine silk sutures. The bruit and thrill were no longer present at the conclusion of the

operation.

Two weeks later, after a friendly wrestling match, the wound opened, and a severe

secondary hemorrhage occurred. It was controlled by packing and by hemostats, which

were left in place. The vertebral artery was then ligated. This procedure apparently

controlled the bleeding at the source, since there was no further hemorrhage when the

packs and clamps were removed. The wound healed uneventfully, and the bruit and

thrill did not return, but there was no change in the neurologic findings when the patient

was discharged 3 months later, and also no change upon review examination 3 months

after discharge.

Case 2.—This soldier was injured 31 March 1943 by aerial bomb fragments which struck

the left frontal region of the scalp, the left side of the neck, and the left thigh. He was

unconscious for 2 hours. Severe hemorrhage persisted from the neck wound, and two

plasma transfusions were given during the first 24 hours after injury.
PERIPHERAL NERVE-VASCULAR INJURIES 445

Forty-eight hours after wounding, the wound in the neck was explored, and foreign

bodies were removed. At this time, the patient was unable to talk, move the left side

of his face, or shrug the left shoulder. He also had loss of feeling over the lower third

of the left side of the face. He had some difficulty swallowing fluids.

Three weeks after the injury, the aphonia cleared, and his voice became progressively

less hoarse. Both facial and shoulder movements improved slowly but steadily. From

this period in his convalescence until his admission to Ashford General Hospital on 10

May 1943, he noticed an intermittent singing noise in the left ear.

Examination revealed a small, stellate, puckered scar below, and anterior to, the

tip of the left mastoid. Palpation over the scar and in the anterosuperior cervical triangle disclosed a small, tubular, expansile mass. Auscultation over the mass revealed

the presence of a harsh, continuous bruit, accentuated in systole, which could be obliterated by compression of the common carotid artery.

Neurologic findings included an apparent enophthalmos on the left, moderate weakness of the musculature about the left angle of the mouth, and hoarseness, with an abduction paralysis of the left vocal cord. The tongue was atrophic and protruded to the left.

There was an area of hypalgesia and hypesthesia corresponding to the anterior fibers

of the second cervical nerve. Taste perception was normal. The superior third of the

left trapezius muscle was atrophic; there was weakness of shoulder elevation but normal

abduction of the left arm.

The neurologic diagnosis was involvement of the 7th, 10th, 11th, and 12th cranial

nerves and the 2d cervical nerve. With the exception of the seventh nerve disturbance,

this case was similar to the case just recorded; the more inferiorly and laterally placed

site of injury in this instance explained the lack of involvement of the glossopharyngeal

nerve.

Surgical exploration of the expansile mass in the cervical region disclosed a cicatricial, incomplete occlusion of the common carotid artery with proximal dilatation of the

vessel. The neurologic disturbance, with the exception of the abduction paralysis of the

left vocal cord, improved steadily until the patient was discharged 3 months later.

In this case, the release of scar tissue about the carotid artery led to complete disappearance of the bruit and thrill, a finding worthy of note, since scar tissue contracting

about a vessel may apparently produce the cardinal physical findings of an arteriovenous

fistula.

Case 3.—This soldier was injured 3 December 1942 by fragments from a 20-mm. shell

which struck the left mastoid region and left shoulder. The mastoid wound bled

profusely for a few seconds; then hemorrhage ceased spontaneously. Three days later,

this wound was explored, and a foreign body was removed.

On the following day, the patient noted a buzzing sound in the left ear and a swelling below the wound. For the first time, he complained of moderately severe generalized

headache. There was weakness in the muscles of the lower half of the left side of the

face, and his voice was hoarse. Solid food was tolerated without difficulty, but choking

followed the ingestion of fluids. When he became ambulatory, he realized that he could

not abduct the left arm beyond 90°.

On 3 April 1943, the left common carotid artery and left internal jugular vein were

ligated. On 11 June 1943, the arteriovenous aneurysm involving these vessels was

resected. Convalescence was without untoward incident.

Examination 9 July revealed a narrowing of the left palpebral fissure, enophthalmos,

some decrease in intraocular tension as compared to the right (normal) side, loss of the

ciliospinal reflex, and loss of sweating over the left side of the face. There was no change

in sensation over the domain of the fifth cranial nerve. A contracture of some muscle

fibers at the angle of the mouth caused inversion of this structure. There was weakness

of the risorius and triangularis and of the lower fibers of the orbicularis. There was

slight loss of the normal palatal arch on the left, and the soft palate pulled to the right
446 NEUROSURGERY

upon phonation. The voice was hoarse, and laryngoscopy revealed an abduction paralysis

of the left vocal cord. The left sternomastoid muscle was functionless, and the left arm

could not be abducted beyond 90°.

Examination at Ashford General Hospital 30 August 1943 revealed the following findings: The site of the operative procedure showed nothing abnormal, and there was no

evidence of recurrence of the arteriovenous aneurysm. The pupils were equal and reacted

to light stimulation and upon accommodation. There was intermittent conjunctival injection on the left. Vision in the right eye was 20/20; in the left eye, it was reduced to

hand movements, with fingers recognized in the temporal quadrants. The optic nerve

head of the right eye was normal. The left neuroretinal outline was clear, but the temporal half of the disk was pale. Adjacent to the temporal margin were two or three

hyaline deposits, and similar deposits were noted nearer the macula. An area just above

the disk was pale. The changes in the left fundus suggested an earlier papilledema with

subsequent atrophy.

The neurologic diagnosis at this time was incomplete involvement of the cervical

sympathetic chain and the 7th, 9th, 10th, 11th, and 12th cranial nerves. All components

of the neurologic picture had improved considerably over the previous examination except

those involving the 10th and 11th cranial nerves.

From the oversea clinical record, it was clear that this patient had had bilateral

papilledema of three diopters before the original operation. This would suggest an

increase in pressure in the venous circulation of the brain. Such a course is not incompatible with what is known of the physiology of an arteriovenous fistula, in which arterial blood enters the venous system at an increased pressure.

The syndrome in this case resembles that described by Villaret. Among six gunshot

wounds of the last four cranial nerves described by Vernet is a case identical with this

case; the postoperative course, unfortunately, is not described.

Case 4.—This officer was struck by a .30-caliber bullet 12 December 1942. The missile

entered 1 cm. mesial to the inner canthus of the left eye and made its exit beneath the

left mastoid region. He became unconscious at once and remained so for 24 hours. He

was confused and drowsy for the next 4 days. Debridement was carried out on the day

of injury, and sequestrectomy of a portion of the condyloid process of the mandible was

done 10 days later.

Soon after injury, the patient was aware of numbness along the lower half of the

left side of the face, weakness of the left facial musculature, and an inability to abduct

the left arm above 90°. From the time of adequate orientation, he had noted a protrusion of the left eyeball, which had never diminished in size. Occasionally, he reported

hearing a "roaring sound like the ocean" in his left ear.

The striking feature upon first examination of this patient was the moderate proptosis of the left eyeball. Conjunctival edema and vascular congestion were present.

There was a small, round scar on the lateral aspect of the nose 1 cm. from the inner

canthus of the left eye. Below the tip of the left mastoid was a 2- by 4-cm. scar, which

was adherent to the deep structures of the neck.

Neurologic examination disclosed normal direct and peripheral vision. The left

neuroretinal outline showed minimal blurring along its nasal margin. The retinal arterioles pulsated, and the veins were full. There was hypalgesia and anesthesia over the

third branch of the fifth cranial nerve. There was almost complete paralysis of the

circumoral musculature on the left side (fig. 208). There was pronounced atrophy of

the sternomastoid muscle on the left. The trapezius muscle was atrophic, with marked

winging of the vertebral border of the scapula and loss of abduction of the left arm

beyond 90° (fig. 209).

The supraorbital veins were engorged, and a distinct, continuous thrill could be felt

in both the upper and lower eyelids on the left side. This thrill was transmitted into

the neck over the carotid vessels. Over the left eye, the forehead, and the left side of

the neck, there was a harsh, continuous roaring bruit, accentuated in systole. The left
PERIPHERAL NERVE-VASCULAR INJURIES 447

FIGURE 209.—Paralysis of left spinal accessory nerve.

Note wound of exit beneath mastoid region.

eyeball pulsated slightly. The whole picture, which was one of pulsating exophthalmos,

was thought to be due to a communication between the cavernous sinus and the left

internal carotid artery.

On 26 May 1943, the left common carotid artery was partially compressed with an

aluminum band, which, it was thought, stopped about 80 percent of the blood flow through

this vessel. After this procedure, there was definite improvement in the exophthalmos.

On 23 June 1943, the carotid artery was again exposed, together with its terminal

branches. At this time, temporary occlusion of the common, internal, and external carotid

vessels did not obliterate the bruit previously described, and it was concluded that a large

blood supply to the fistula was coming from the other side and from the vertebral vessels.

At this time, the common carotid artery was doubly ligated with braided silk. After

this operation, there was additional improvement in the exophthalmos, although the bruit

and thrill were only slightly affected.

The neurologic diagnosis was involvement of the 5th, 7th, and 11th cranial nerves,

associated with an arteriovenous aneurysm of the left internal carotid artery and cavernous sinus.

COMMENT

The experience of World War II soon showed that the separation of

injuries to the cranial nerves of the neck into separate clinical syndromes

was of dubious neurologic value in spite of the close anatomic grouping of

these nerves. For one thing, any specific syndrome depended upon the unpredictable vagaries incident to trauma from gunshot wounds. For another,

the clinical picture and neurologic findings depended upon the time after

wounding at which the neurologic observations were made.

From a study of the cases just recorded and of other traversing wounds

of the face and neck in which there were no significant changes at the time

the neurologic study was made, several observations of prognostic import

may be made, as follows:
448 NEUROSURGERY

1. Injuries of the fifth and seventh nerves, whether transient or, as

was most unusual, permanent, might be engrafted upon the usual classical

syndromes of the last four cranial nerves. The superimposed neurologic defect exhibited a strong tendency toward spontaneous regression in the cases

observed at the vascular centers.

2. Lesions of the last four cranial nerves, whether they were acute or

of a chronic and perhaps regressive character, might incapacitate the patient

in only two important respects. The first was that some patients, soon after

injury, had a great deal of difficulty in swallowing fluids. The second was

that abduction paralysis of the vocal cord might be persistent. In two

instances at Ashford General Hospital (cases 2 and 3), the induction of

anesthesia, preliminary to the introduction of an intratracheal tube, precipitated respiratory collapse.

3. Involvement of the external branch of the spinal accessory nerve

usually showed some tendency toward improvement, but the loss of abduction of the upper extremity beyond 90° was likely to remain as a defect of

considerable magnitude. Direct exploration of the region of the jugular

foramen, with the objective of decreasing this neurologic disturbance, was

not carried out, or even contemplated, in any case observed at the vascular

centers.

INJURIES OF THE UPPER EXTREMITY

Neural complications, as already noted, have always been known to be

much more frequent in injuries of the upper extremity and their sequelae

than in those of the lower extremity. Thus Fromme,6in a long and carefully

documented article written in 1917, recorded 16 aneurysms of the upper extremity, 13 of which were associated with neural changes. In Maurer's7

World War I series of 71 aneurysms of the upper extremity, neural complications were present in 25 percent. In Makins's

experience, the brachial

plexus was involved in 25 percent of 28 subclavian aneurysms and in 43 percent of 54 aneurysms of the axillary artery. In this series, nerve injuries

occurred in 10 of 43 injuries of the brachial artery. It is of interest that

in it, there was only 1 arteriovenous aneurysm, in comparison with 12 arterial

aneurysms.

Case Histories

Case 5.—This soldier was wounded 28 March 1943 by a rifle bullet which struck the left

clavicular space, traversed the apex of the axilla, and made its exit lateral to the tip

of the left scapula. External bleeding was minimal, and there was no later evidence of

"Fromme, A.: Ueber Kriegsaneurysmen. Beitr. z. klin. Chir. 105: 293-323, February 1917.

7 Maurer, A., Note sur les plaies vasculaires recentes et leur traitement, d'aprfe 444 observations. Mem. Acad. de chir. 65 :1156—1164, 8 Nov. 1939.

8 Makins, George H.: On Gunshot Injuries to the Blood Vessels, Founded on Experience Gained

in France During the Great War, 1914-18. London: Simpkin, Marshall, Hamilton, Kent & Co.

Ltd., 1919.
PERIPHERAL NERVE-VASCULAR INJURIES 449

a massive subcutaneous hematoma. The left arm became paralyzed at the moment of

injury, and for 2 months, there were no signs of improvement. Return of function was

marked first by flexion of the forearm and then by extension of the wrist. Sensory loss,

which had been noted over the entire arm after injury, regressed slowly until eventually

it affected only the outer aspect of the forearm, the thumb, and the index, middle, and

ring fingers. After the patient was hospitalized in the Zone of Interior, an aneurysm

of the first portion of the axillary artery was found, and he was therefore transferred

to the vascular center at Ashford General Hospital.

Examination at this time revealed a small, well-healed wound of entry 4 cm. below

the outer third of the left clavicle and an irregular, larger scar, representing the wound

of exit, lateral to the tip of the left scapula. An oval, expansile mass, 3 by 2 cm., was

palpable in the left infraclavicular space. On auscultation, a faint systolic bruit could

be heard, which radiated into the distal third of the extremity. The radial pulse on the

left was weaker than on the right, and the ulnar pulse was absent. The blood pressure

in the right arm was 122/78 and in the left 110/76 mm. Hg.

Neurologic examination disclosed complete involvement of the musculocutaneous

nerve, an incomplete lesion of the median nerve, and minimal disturbance of the radial

nerve, with corresponding muscle dysfunction. An area of hypalgesia and anesthesia

corresponded to the sensory distributions of the lateral antebrachial cutaneous and

median nerves.

When operation was performed 16 August 1943, a false aneurysm of the first portion

of the left axillary artery was found and resected. There was an extensive gap in the

musculocutaneous nerve, and the mass of the aneurysm compressed the median nerve

chiefly. After operation, there was no demonstrable change in the vascular supply to

the extremity, but 3 months later beginning improvement in the neural defect was

detectable (fig. 210).

Case 6.—This soldier sustained a rifle bullet wound of the upper right chest 23 April

1943. He remained on the field under fire until the following day, when he was again

injured, this time by a shell fragment in the right shoulder. As the result of the second

injury, the right arm was paralyzed, and the hand and the fingers were in flexion spasm.

The hand and arm recovered normal function, as far as the patient could tell, in the

following 2 months. Chest pain persisted, and he was evacuated to the Zone of Interior.

On 25 October 1943, in the course of a routine physical examination, a rounded,

pulsating mass was palpated high in the right axilla. It appeared to be distinct from

the pulsation and course of the axillary artery. A nontransmitted systolic bruit was

present over the mass, and both pulsation and mass could be obliterated by compression

of the subclavian artery. A small scar was present on the anterior aspect of the right

shoulder. Neurologic examination disclosed atrophy of the triceps muscle with associated

weakness of extension of the upper arm. The muscle mass of the deltoid was diminished on the right, and the beginning abduction movement of the right arm was weak.

There was moderate flaring of the vertebral tip of the right scapula.

On 2 November 1943, exploration of the right axilla disclosed an arterial aneurysm

of the long thoracic artery 4 cm. in diameter. The long thoracic nerve curved around

the aneurysm and was embedded in the wall. After resection of the aneurysm, inspection of the axillary and radial nerves revealed no gross abnormality.

Case 7.—This soldier was injured by a rifle bullet 23 March 1943. The missile entered

the right forearm on the lateral aspect of the middle third, traversed the arm diagonally, and made its exit slightly above the medial condyle of the humerus. The wound

of exit bled so profusely that a tourniquet had to be applied. This wound became

infected, but the infection cleared up promptly.

As soon as he was wounded, the patient noticed weakness of the handgrip and loss

of feeling along the inner aspect of the forearm and the ulnar aspect of the hand, as

well as in the fourth and fifth fingers.
450 NEUROSURGERY

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FIGURE 210.—Musculocutaneous and median nerve

injury with axillary aneurysm. Note scar of operative approach.

Examination of the right upper extremity 7 May 1943 revealed a tubular swelling

of the proximal half of the forearm with a fluctuant area 4 cm. below the medial condyle of the humerus. A systolic pulsation and a systolic bruit were present over this

area. Elsewhere, the skin and subcutaneous tissues were firm and indurated. There was

no local heat or other change In the overlying tissues. Pressure in the region of the

ulnar nerve adjacent to the wound of exit caused a tingling paresthesia. Function had

been lost in the flexor carpi ulnaris, the two medial heads of the flexor digitorum profundus, and the intrinsic musculature of the hand innervated by the ulnar nerve. The

fifth finger and the ulnar aspect of the hand were analgesic and anesthetic, and a

narrow band of hypalgesia was present along the lateral margin of the lower half of

the forearm.

Obliterative endoaneurysmorrhaphy of the brachial artery IT May 1943 produced no

alteration in the peripheral nerve supply to the hand (fig. 211). At exploration 14 July,

the ulnar nerve was found divided in the thick scar tissue at the site of the aneurysmal

sac. End-to-end anastomosis was carried out with tantalum wire, but, at the end of

4 months, no return of function was evident.

Case 8.—This patient was injured by a .30-caliber rifle bullet on 3 July 1943. The missile entered the left forearm on its anterior and lateral aspect and emerged just above

and posterior to the medial epicondyle of the humerus. He noticed immediate numbness

and weakness of the hand. Within 2 hours of the injury, there was pronounced swelling

of the elbow, forearm, and hand, but there was no external hemorrhage. On the seventeenth day after injury, an incision was made below the antecubital space, and much

blood clot was evacuated.

On examination at Ashford General Hospital 16 August 1943, healed wounds of entry

and exit were noted, corresponding to the path of the missile. The left upper forearm

was swollen and indurated. An oval mass, 6 cm. in length, was palpable on the medial

aspect of the forearm below the antecubital fold. There was an expansile pulsation in

the mass, synchronous with cardiac systole. A loud systolic bruit was audible upon

auscultation. Compression of the brachial artery in the arm caused the mass to become

smaller and the bruit to disappear. The ulnar pulse was absent. The radial pulse was

weaker on the left side than on the right.

Motor examination showed disuse atrophy of musculature of the arm. Minimal radial

extension of the wrist was possible. Slight extension of the third finger at the metacarpophalangeal articulation was elicited. No other movements of the musculature of
PERIPHERAL NERVE-VASCULAR INJURIES 451

FIGURE 211.—Ulnar nerve paralysis with aneurysm

of brachial artery. Endoaneurysmorrhaphy has been

performed. Note obvious deformity caused by ulnar

nerve injury.

the hand were possible. There was extreme contracture of the flexor tendons to all

fingers. The entire hand showed cutaneous atrophy and loss of sweating. Analgesia

and anesthesia were present over the sensory distribution of the ulnar and median nerves

in the hand.

On 7 September 1943, the arterial aneurysm was resected. The median nerve was

found compressed by the mass of the aneurysmal sac, and the ulnar nerve was buried

in a mass of scarred, indurated muscle tissue medial to the aneurysm. It was observed

that widespread muscle damage was present in the bellies of the flexor musculature of

the forearm. Slight improvement in the neurologic status was evident after operation

(fig. 212).

Case 9.—A patient with an axillary aneurysm and involvement of the medial and lateral

branches of the median nerve was treated at Walter Reed General Hospital, Washington,

D.O., by excision of the axillary aneurysm and neurolysis, as follows:

An incision was made over the course of the cephalic vein in the upper arm and

extended medially toward the middle third of the clavicle. The tendon of the pectoralis

major muscle was reflected medially. The neurovascular bundle was identified, and the

median nerve was isolated and followed proximally to the point of injury at the level

of the lateral border of the pectoralis minor muscle. The medial antebrachial cutaneous

and ulnar nerves were then identified and isolated for a short distance. Stimulation of

these nerves revealed intact motor and sensation fibers in the ulnar nerve and intact

sensation of the medial antebrachial cutaneous nerve. Stimulation of the median nerve

revealed intact sensation and motor power except on the medial border, where the nerve

was insensitive and no motor response was evoked by stimulation.

To obtain adequate exposure, it was necessary to divide the pectoralis minor muscle

in part. The median nerve, at the point at which branches from the median and lateral

cords converge to form the nerve, seemed to be elevated over a 1.5-cm. tumor. This

tumor was soft, compressible, and pulsating; it was believed to represent an aneurysm

in the axillary artery.

Neurolysis was begun at this point, and, in attempting to separate the aneurysm

from the undersurface of the nerve, the aneurysm was broken into by a blunt hemostat.

Hemostasis was controlled by digital pressure of the artery over the first rib. An
452 NBÜKOSURGERY

attempt at suture of the rent resulted in tearing out of the suture material and increased

bleeding, so that, to secure hemostasis, it was necessary to isolate the artery superiorly

and place a constricting rubber cuff about it. When this had been done, it was possible

to separate the small aneurysm completely from the undersurface of the nerve. Very

little intrinsic damage was present in the branch from the lateral cord, but, in the

branch from the medial cord, there was some soft fusiform swelling.

FIGURE 212.—Preoperative photograph showing aneurysm of

brachial artery, with ulnar and median nerve paralysis. Note

drainage scar. Insert shows specimen of aneurysm removed at

operation.

A neurolysis of the branch from the medial cord was carried out, as well as a neurolysis of the musculocutaneous nerve, which was incompletely incorporated in soft scar.

Attention was then directed toward the aneurysm. To remove it in toto, it was

necessary to divide the axillary artery completely. At the site of the rent in the aneurysm, normal appearing intima was seen to merge into a purplish membrane which lined

the cavity. The artery was doubly ligated by a ligature and a suture ligature of heavy

silk both proximally and distally to the aneurysm, and the aneurysm was removed in

toto. The resultant defect in the artery measured about 1.5 cm.

Anatomic restoration of the pectoralis minor muscle and the tendon of the pectoralis

major was effected by interrupted sutures of heavy and fine silk. The axillary fascia

was closed by interrupted sutures of fine silk to obliterate dead space. The incision was

then closed in two layers with interrupted sutures of fine silk.

Sterile pressure dressings were applied, and the arm was put up in modified Velpeau

position. At this time, the extremity was Warm. The nail beds filled rapidly after

blanching, but the pulsations of the radial artery at the wrist could not be identified

with any certainty.
PERIPHERAL NERVE-VASCULAR INJURIES 453

Case 10.—A patient with an aneurysm of the brachial artery and involvement of the

left median and ulnar nerves was treated as follows at Walter Reed General Hospital:

Under satisfactory local anesthesia, with the patient supine, an incision was made

over the neurovascular bundle in the left upper arm, extending above and below the scar

of the old bullet wound. The incision was deepened until the median nerve was found

lying lateral to the artery below the scar. The nerve was picked up above the scar and

traced through this scarred area, in which it was found to pass over a bluish, pulsating

mass about 2 cm. in diameter. The ulnar nerve, which was picked up below and above

the scar, was likewise found to lie directly under the pulsating mass.

In the belief that this mass probably was an aneurysm of the brachial artery, it

was thought best to determine circulation of the hand and forearm after obliteration of

the artery, to decide whether it would be safe to remove the aneurysm. After an

Esmarch bandage had been placed around the hand and forearm, the artery was

occluded below the aneurysm. The bandage was then removed. In approximately 2

minutes, the color returned to normal in the hand. The artery was then occluded above

the aneurysm by a rubber-covered artery clamp. At the end of 15 minutes, there was

little appreciable change in the color, capillary pulsation, or temperature of the hand.

Oscillometric readings showed good oscillation in the artery. Therefore it was felt safe

to remove the aneurysm.

After the ulnar nerve had been dissected off from the aneurysm, little scarring was

found on the nerve itself, although there was considerable thinning out as it passed over

the pulsating mass. When the median nerve was similarly freed up, a small amount of

scar tissue was found on its later aspect. Stimulation of the median nerve above the

area of involvement resulted in some contraction of the long flexors of the fingers and

the pronator teres. Flexion of the flexor carpi nerve and the small muscles of the hand

was produced by stimulation of the ulnar nerve above the aneurysm. Stimulation below

the aneurysm produced a definite, characteristic sensory response. Division and suture

of the median and ulnar nerves was therefore not undertaken, in the belief that, when

the pulsating mass had been removed, the function of both nerves would probably return

to normal after a period of time.

With the brachial artery occluded above and below the aneurysm, the aneurysmal

tract was opened, and about a dram of old, brownish, organized blood clot was removed.

There was brisk bleeding from two or three small lateral communicating vessels which

entered the aneurysm on the lateral aspect of the arm. Each one of these vessels was

carefully closed at its entrance into the aneurysm from the interior of the aneurysm by

a purse-string silk suture. The brachial artery itself was occluded above and below by

a similar stitch inside the aneurysm. At the end of this procedure, there was no bleeding at all into the open aneurysmal sac. The sac was therefore closed by several interrupted silk sutures; it was not removed because of the danger of disturbing the collateral

circulation. The deep fascia, subcutaneous tissue, and skin were closed with silk. The

hand was warm at the conclusion of the operation.

Case 11.—The following case represents an uncommon instance of a combined vesselnerve injury in which an arterial aneurysm had not only compressed peripheral neural

tissue but had actually eroded the fascicles to such a degree that partial nerve division

ensued. There were only 2 such cases in 1,000 peripheral nerve operations at Walter

Reed General Hospital, and in both the pathologic process was discovered only at

operation.

The patient whose management is described herewith had a traumatic aneurysm of

the ulnar artery which was affecting the ulnar nerve. An incision was made over the

ulnar aspect of the forearm in about the midportion, and the previous scar was completely excised. The ulnar nerve was picked up proximal to the scarred area, dissected

out distally, and isolated in this position. When dissection was carried distally and

proximally from these points, it was found that the artery and nerve were densely bound
454 NEUEOSURGERX

together with adhesions. Further dissection revealed a bulbous area, about 1.5 cm. in

diameter, which was attached to the ulnar artery and which had apparently eroded the

ulnar nerve, except for two fascicles in the posterior lateral portion, which went to the

dorsal branch of the nerve. This swelling pulsated and appeared to be a traumatic

aneurysm of the artery.

Stimulation of the nerve proximally caused pain but no muscle response. Stimulation distally gave no response on the palmar branch, but pain was complained of when

the fascicles to the dorsal branch were stimulated.

When it had been definitely demonstrated that the pulsating swelling was an aneurysm, the ulnar artery was clamped above and below it, the ends were ligated, and the

vessel was divided. This area was then dissected out from the surrounding scar tissue.

A section of the ulnar nerve was cut out with a sharp razor blade until fairly normal

fascicles appeared. The defect measured 5.2 cm.

An incision was made upward over the medial epicondyle. The origin of the flexor

carpi ulnaris and the medial epicondyle were divided, and the nerve was dissected free

from the surrounding tissue. The fascicular dissection of the branches to the flexor carpi

ulnaris and the lateral portion of the flexor digitorum profundus permitted satisfactory

transplantation, and the nerve ends could be brought together without tension. After

bleeding had been controlled, the nerve ends were sutured with perineural sutures of

0.003 tantalum. The suture line was surrounded with a tantalum cuff. The wound was

closed in tiers with interrupted silk sutures, and the arm was put up in a cast to maintain the elbow at 90° flexion.

COMMENT

Peripheral nerve injuries visualized at operation in association with

vascular injuries as a rule differed grossly in only two respects from peripheral nerve injuries without associated vascular injuries, as follows:

1. The usual pathologic findings of complete or partial nerve section,

contusion, or compression by scar tissue were supplemented by the added

factor of compression by the mass of the aneurysmal sac. It was observed

in the cases in World War II, as in the few recorded in detail in the earlier

literature, that the neurologic defect apparently appeared full blown at the

moment of injury. Since spontaneous return of neurologic function seldom

occurred, operative repair of the neural lesion was mandatory in all cases.

2. The presence of a vascular lesion with the nerve injury, whether it

took the form of transection of the artery or of an aneurysm, tended to

exaggerate and make permanent the existing neural dysfunction because of

local and general alteration in the nutrition of muscle fibers, which occasionally, as just mentioned, amounted to their severance. The frozen, contracted hand resulting from acute arterial occlusion (fig. 213), which was

well recognized before World War II, might be beyond remedy if an uncorrected neural defect was superimposed on it.

In case 7 in this series, the diagnosis of abscess rather than arterial

aneurysm was considered, and, in case 8, an incision was actually made

for a presumed abscess. In two of the cases reported by Fromme, incision

for supposed abscesses caused very severe hemorrhages. In another of

Fromme's cases, which resembled cases 10 and 11, the diagnosis of abscess

was also entertained, but only briefly.
PERIPHERAL NERVE-VASCULAR INJURIES 455

FIGURE 213.—Examples of frozen hands after nerve-vascular injuries.

Note changes in nails and fingertips.

INJURIES OF THE LOWER EXTREMITY

It has already been pointed out that neural complications were considerably less frequent in injuries of the lower extremity than in those of

the upper. In Makins' series of 170 injuries of the femoral artery, nerve

involvement was described as "rare," and neural structures were involved in

only 5 of 85 injuries of the popliteal artery. The experiences of the vascular

centers in the Zone of Interior in World War II were in general accord with

these observations. The sciatic nerve was sometimes involved in traversing

injuries in the thigh, and its peroneal and tibial components were sometimes

involved in large open wounds of the popliteal space, but these complications

were infrequent compared to their incidence in wounds of the upper extremity.

Case Histories

Case 12.—This officer sustained a perforating wound of the thigh when he was struck

in the left femoral region by a machinegun bullet 29 April 1943. The wound of exit

was in the left buttock. The extremity was paralyzed and became anesthetic at the time

of impact, but motor and sensory defects cleared within a few hours. A profuse external

hemorrhage was controlled by pressure. Pain in the calf and the popliteal space developed early although there was no evidence of circulatory deficiency. The distress increased with the appearance of a harsh bruit over the femoral triangle, dilatation of the

veins of the leg, and some peripheral cyanosis. On 11 June 1943, the left femoral artery

and vein were ligated proximal to the fistula without alteration in the peripheral circu498991T—50 32
456 NEUROSURGERY

lation and without effect upon the aneurysm. At this time, cardiac studies were normal.

On 11 July 1943, examination at Ashford General Hospital showed induration in the

left femoral triangle. About 8 cm. below Poupart's ligament was a small wound of

entry beneath, and lateral to, a well-healed surgical incision. A second surgical incision

was situated lateral to the first. A scar representing the wound of exit was noted in

the left buttock. Beneath the larger incision, a loud, harsh bruit was audible throughout systole and diastole; it was accentuated during the systolic phase. Occlusion of the

femoral artery above the fistula diminished the bruit but did not cause it to disappear.

The occlusion caused a transitory slowing of the pulse rate. The peripheral pulses were

absent in the left lower extremity, and there was slight dependent cyanosis of the foot.

Definite enlargement of the heart to the left was confirmed by fluoroscopy. , Neurologic examination revealed only a diminution of the left knee kick and weakness in dorsiflexion of the left great toe. There were no sensory changes. The left

sciatic nerve was somewhat tender, and pressure over it increased the peripheral pain.

On 4 August 1943, quadruple ligation and resection of the arteriovenous fistula was

performed. Convalescence was uneventful, and the radiating pain slowly diminished.

Case 13.—This medical officer received multiple injuries of the trunk, abdomen, and

upper and lower extremities from the explosion of a landmine in April 1943. He remained

dazed and disoriented for several days as the result of blast concussion. At this time,

he recognized the presence of a right ulnar nerve paralysis and appreciated an area of

numbness over the lateral aspect of the right lower leg. He stated that there had been

profuse hemorrhage from a broad laceration of the right popliteal space at the time of

injury, which necessitated several plasma and whole blood transfusions. A month after

the injury, the ulnar nerve paralysis began to recede, and the patient became conscious

of a continuous thrill in the popliteal space. He was the first to recognize the presence

of an arteriovenous aneurysm of the popliteal vessels. He noticed no symptoms referable to cardiac strain except shortness of breath, and he did not feel that the peripheral

blood supply to the involved extremity was impaired.

Examination at Ashford General Hospital was noteworthy for the presence of 28

separate scars over the posterior surface of the trunk and lower extremities (fig. 214),

which is characteristic of multiple injuries from the explosion of an antipersonnel landmine. Over the inferior aspect of the right popliteal space was a broad, irregular scar,

extending laterally beneath the tibial tubercle. Above this scar, and rather high in the

popliteal space, the tissues appeared full. Upon palpation at this point, a strong continuous thrill could be felt. Upon auscultation, the bruit was continuous but was accentuated with systole. There was no evidence of cardiac damage, and the peripheral blood

supply of the foot was normal. Hypalgesia and hypesthesia were present over the sensory distribution of the sural nerve. There was no evidence of motor dysfunction in this

extremity. Neurologic study elsewhere had disclosed only hypalgesia over the cutaneous

area innervated by the ulnar branch of the medial antebrachial cutaneous nerve.

On 24 August 1943, the arteriovenous aneurysm was excised after quadruple ligation.

At operation, the peroneal nerve was found compressed by scar tissue, and an external

neurolysis was done. The neurologic defect improved steadily, and the patient was able

to return to duty.

Case 14.—When patients with peripheral nerve injuries present themselves relatively

early after injury, the concomitant edema and induration of tissue recently subjected to

trauma may hide the coexistence of an arterial aneurysm, particularly when investigation of the vascular lesion is difficult because of the protection of the lesion by the

muscular tissue of the thigh. The following operative note from Walter Reed General

Hospital in an injury of the sciatic nerve and profunda femoris artery should serve as

a warning to the inexperienced or unwary military neurosurgeon :

With the patient face down on the operating table, an incision was made, under

local anesthesia, from the edge of the gluteus maximus directly down the back of the
PERIPHERAL NERVE-VASCULAR INJURIES 457

thigh over the course of the great sciatic nerve. The fascia over the biceps was divided,

the two heads of the biceps separated, and the sciatic nerve identified and isolated

between the two heads of the hamstrings. Stimulation at this point produced pain in

all parts of the foot but no muscle response. Dissection was then carried upward between

the two heads to a point at which the sciatic nerve was apparently greatly thickened

and was densely bound down to all the soft tissues. There was extreme edema and

swelling of the tissues, which were quite dense.

The posterior femoral cutaneous nerve was picked up, dissected free, and retracted

laterally. It then became apparent that the gluteus had to be reflected, and a Naffziger

incision was therefore made. A curved incision was made from the posterior superior

iliac spine and was swung out laterally over the head of the femur.

FIGURE 214.—Popliteal aneurysm with involvement of sural nerve.

Note multiple injuries caused by explosion of landmine.

The incision was carried down to fascia. The insertion of the gluteus maximus was

then cut free from its insertion into the trochanter of the femur. All these tissues were

also greatly thickened and edematous and were bound together with adhesions. They

were yellowish.

When the insertion of the gluteus maximus was divided, there appeared to be a hole

in the underlying tissues, just medial to the head of the greater trochanter of the femur.

Old blood clots were coming through this hole. After it was slightly enlarged, it became

apparent that a tremendous hematoma underlay the gluteus muscle. A larger opening

was then made, and the hematoma was gradually evacuated. When it was being evacuated in the region of the posterior aspect of the femur, there was an immediate gush

of fresh blood. By the use of numerous retractors and two suckers, it was possible to

expose the bleeding point, which was apparently the profunda femoris artery; it was

tied with a silk suture. The hematoma appeared to contain about 1,500 cc. of blood

clots of varying ages; some were completely organized, and some consisted of black,

thick, fluid blood.

The sciatic nerve, which seemed to be intact, passed up superficially to the blood

clot on the undersurface of the gluteus muscle and then curved over the clot down

through the sciatic notch. There was great thickening, swelling, and adhesions of the

tissues surrounding the entire nerve, but it was apparently intact.

After the hematoma had been completely evacuated, a large piece of oiled silk was

placed gently into the cavity and was packed in lightly with a gauze roll. A perforated

tube led into the pack. The lower portion of the wound was closed by closing the fascia

over the hamstrings and by suture of the insertion of the gluteus maximus. The pack

was brought out under the lower edge of the gluteus maximus deep to the sciatic nerve

and then through a stab wound in the lateral posterior portion of the upper thigh; the
458 NEUROSURGERY

exit was kept as far from the anus as possible. The wound was closed in tiers with

interrupted silk sutures, and penicillin was injected locally.

The entire procedure was carried out under local anesthesia. The patient received

plasma and blood during the operation, when bleeding occurred, and he was in good

condition when he was taken off the operating table.

PERIPHERAL NERVE INJURY WITH VASCULAR OCCLUSION

As has already been pointed out and demonstrated by illustrative cases,

the neuropathologic process in combined vascular-nerve injuries differs in

only two respects from the process commonly seen in all peripheral nerve

injuries. First, there are the usual findings of nerve division, which, alone

or in combination, may be complete or partial, neuroma in continuity, and

transient block. To these neurologic findings is added the relatively pure

factor of compression, characteristically rapid, of an expanding aneurysmal

mass. Second, the arterial aneurysmal mass may produce various degrees

of distal tissue hypoxia. A third form of neural involvement, not yet

widely recognized, is a true division of nerve fibers through erosion of a

pulsating mass, a process similar to the classical vertebral erosion observed

in large aneurysms of the aorta.

When acute vascular occlusion was present, still another form of

neural pathologic process might occur from actual ischemia of peripheral

nerve tissue. The result might be a complete and possibly irreparable

peripheral nerve lesion, even though major nerve trunks remained intact.

If the vascular lesion was associated with nerve severance, nerve regeneration

was imperfect if it occurred at all, no matter how satisfactory the nerve

suture might be.

The original neural loss and the degree of subsequent regeneration depended quantitatively upon the initial deprivation of blood supply and the

intraneural changes which resulted. When failure of function in necrotic

muscle was combined with failure of nerve regeneration in residual undamaged muscle, with poor sensory return, the resulting clinical deformity

and dysfunction produced a gloomy picture indeed (fig. 213). The syndrome

described, which was much more common and disabling in the upper than

in the lower extremity, is illustrated in the following four case reports,

which also indicate possible methods of therapy.

Case Histories

Case 15.—This soldier sustained a compound fracture of the left humerus when he was

wounded by a shell fragment 17 July 1944. Debridement was done several hours later.

According to the surgeon, the median, ulnar, and radial nerves were affected, but he

found no evidence of vascular injury. A body cast was applied. On 26 July, delayed

primary wound closure was done, with the application of a hanging cast. The wound

drained purulent material until the middle of August. During this time, the fingers and

hand became very swollen, indurated, and stiff. Plaster fixation was maintained until

the patient was admitted to "Walter Reed General Hospital on 8 October 1944.

At this time, the extremity presented the classical picture of an ischemic contracture.
PERIPHERAL NERVE-VASCULAR INJURIES 459

The skin was shiny and smooth. There was woody atrophy of the musculature of the

forearm. The wrist was slightly flexed, with extension limited to 20°. The fingers were

flexed, and the thumb was held rigidly in adduction (fig. 215). No radial or ulnar arterial pulsation was present. There was weak action of the pronator teres and flexor

carpi radialis. All other muscles of the forearm and hand were paralyzed. Sensory

examination showed complete analgesia and anesthesia over the sensory domain of the

ulnar and median nerves, with hypalgesia over that of the radial nerve.

At operation, under local anesthesia, an incision was made over the course of the

neurovascular bundle in the left upper arm, extending into the axilla downward over

the course of the ulnar nerve behind the medial epicondyle. The scar on the medial

aspect of the upper arm was excised. All the tissues showed considerable fibrosis, induration, and rigidity. The elbow could not be extended beyond 90°.

The ulnar and median nerves were identified in the region of the wound. The

median nerve showed some scarring about it, but stimulation produced some motor

response in the forearm, and stimulation well distal to the wound produced a sensation

of pain over the median distribution. The ulnar nerve, however, showed a dense, scarred

fusiform neuroma, through which no satisfactory motor or sensory response could be

obtained. This neuroma was excised, which left a defect of about 3% cm. In order to

eliminate any possible tension, the nerve was dissected downward to the region of the

elbow and transposed anteriorly; the branches to the flexor carpi ulnaris were split to

provide sufficient mobility to bring the nerve anteriorly. This procedure provided sufficient length to permit suture in the upper portion of the arm in the region of the

wound. And end-to-end anastomosis of the ulnar nerve was done in this region, using

0.003 tantalum wire. A small cuff was placed around the suture site. The tantalum

foil held its position by its own tensile coil strength.

A very hard nodule occupied the greater portion of the lower half of the biceps

muscle. A biopsy revealed, instead of normal muscle, grayish-white fibrous tissue, indicative of severe vascular occlusion.

The wound was closed in two layers with interrupted silk sutures. No cast was

necessary, because of the inability of the patient to extend his arm because of fibrous

fixation.

Case 16.—This 24-year-old soldier sustained a complete, compound, comminuted fracture of the proximal third of the left ulna, with loss of approximately 5 cm. of the

substance of the bone, as the result of a shell fragment injury 6 March 1944. On the

same day, the wound was debrided, and the ulnar and radial arteries were ligated with

chromic catgut. The ulnar and radial nerves were dissected out and buried in muscle

tissue. Stellate block was performed immediately after operation and again on the

following day.

A draining sinus over the ulnar aspect of the left forearm developed and persisted.

Circulation to the left hand was always described as "good." On 17 March, the patient

could move his thumb and forefinger. There was loss of sensation to pinprick over the

ulnar nerve distribution.

On 20 September 1944, the left hand was manipulated under general anesthesia.

Soon after this procedure, the posttraumatic deformity returned, and the patient was

able to move his third finger only. After the injury, he noticed that exposure to a cool

environment, even with the hand adequately protected, gave rise to severe aching pain.

At times, even in a warm room, he suffered from intermittent aching of the left hand.

He described the pain as a diffuse, severe aching, which he could not localize. Exposure

to a cool environment, in addition to intensifying his pain, gave rise to deep cyanosis

and marked coldness of the hand. Exposure to extreme warmth likewise intensified the

pain. Partial relief was obtained by massage in cold water. On an average of two or

three times weekly, he was awakened from sleep, or he found it difficult to fall asleep,

because of pain in his hand. He noted no hyperhidrosis or involuntary twitching of the

muscles. Tapping the tips of his fingers produced electric shocklike sensations which
460 NEUROSURGERY

FIGUKE 215.—Frozen hand resulting from occlusion of brachial

artery and median-ulnar nerve injury.

radiated up the arm. He stated that he -would prefer to have the hand amputated, since

he thought a hook would be far more usable.

This patient had no history of frostbite, trenchfoot, cellulitis, lymphangitis, or

thrombophlebitis.

A draining sinus was present over the middle third of the ulnar aspect of the left

forearm. There was marked axillary adenopathy on this side. A firm, nontender nodule

was present over the medial aspect of the arm just above the medial epicondyle. The

radial and ulnar pulses were not palpable on the left but were normal on the right.

Normal brachial and axillary pulses were palpable bilaterally. Dorsalis pedis pulsations

were absent.

There was anesthesia over the ulnar distribution of the hand and forearm. A typical main d'accoucheur deformity (fig. 216) was present. There was hypesthesia over the

median nerve distribution of the palmar surface of the left hand. Muscle (faradic) testing revealed extreme diminution to complete loss of muscle function over the median

and ulnar nerve distribution. There was mild elevation pallor of the left palm and

intense dependent cyanosis.

Roentgenologic examination revealed marked bony atrophy with apparent soft-tissue

contraction.

Allen's test revealed marked delay in the left palmar flush following release of

proximal compression.

The first oscillometric readings were as follows:

Anatomical location:

Foot:

Right Vz

Left y2

Ankle:

Right 4

Left 4

Wrist:

Right 3

Left Vs

Anatomical location—Continued

Forearm just below elbow:

Right 5

Left 2

Arm just above elbow:

Right 9

Left 8
PERIPHERAL NERVE-VASCULAR INJURIES 461

FIGUKE 216.—Ischemic contracture of hand from ligation of median and

ulnar arteries with injury in continuity of median-ulnar nerves. A. Main d'accoucheur. B. Roentgenogram showing fracture of ulna.

Later oscillometric readings were as follows:

Anatomical location—Continued

Forearm:

Right 6

Left %

Anatomical location:

Palm:

Right %

Left y8

Wrist:

Right 3%

Left %

Arm:

Right 6%

Left 6%

The pulse waves recorded by oscillometer over the left palm, wrist, and forearm

showed slow ascending and descending limb characteristic of proximal arterial obstruction.

Dorsal sympathectomy improved this patient's subjective reactions of pain, but no

improvement in function was noted during the period of hospitalization.

Case 17."—This 30-year-old soldier had never suffered from any signs or symptoms

suggestive of peripheral vascular disease of the upper or lower extremities. He had

never had phlebitis, cellulitis, or lymphangitis. He smoked about 20 cigarettes a day,

drank only socially, and used no drugs.

On 10 September 1944, while in combat against the enemy, he sustained a shell fragment wound of the left elbow. No spurting from the wound occurred, and he immediately

applied a tourniquet, which controlled the bleeding. The tourniquet remained in place

for about 10 or 15 minutes. Immediately after the injury, the left upper extremity was

devoid of motor power and sensation from the elbow down.

The arm was placed in a cast, which was removed when the wound stopped draining. Upon removal of the cast, the left hand swelled considerably and became deep blue

in color. Shortly after, an operation was performed, as a result of which he was able

to flex his second and third fingers and extend his wrist partially. Apparently this

procedure was a nerve suture.

During the postoperative period, the patient suffered from drawing, aching pain that

"drove him crazy." This pain was constant and involved the entire left hand. It varied

in intensity and was aggravated by cold, damp, and rainy weather. Heat apparently

9 The oversea chart on this patient was not available, and the data recorded were secured by

questioning him.
462 NEUROSURGERY

did not influence it. On one occasion, the patient rested his hand against a hot water

bottle which did not seem extraordinarily warm to his normal right hand but which

caused blistering of the index and fifth fingers on the left hand. The blister over the

index finger healed rapidly, but an indolent ulcer formed at the tip of the fifth finger,

which was covered with a dry, brownish crust after that time. There was intermittent

hyperhidrosis of the left hand. Medication afforded little relief of the pain.

Examination revealed a well-developed, well-nourished white soldier, who appeared

to be suffering from pain in his left hand. He kept the hand shielded, moved it gingerly

and involuntarily retracted it when the examiner approached. There was a 3-cm. transverse scar just proximal and medial to the left olecranon. A 90° flexion deformity was

present at the left elbow. There was partial flexion contracture of all fingers, with

anesthesia of the entire palm and dorsum of the left hand. Percussion over the anatomic

snuffbox and over the pisiform bone gave rise to radiating paresthesias over the hand.

There was an indolent ulcer covered with a dry brown crust over the tip of the left

fifth finger.

The right hand was moister than the left. The left was cooler than the right. There

was dependent cyanosis and mild elevation pallor of the left hand. Allen's test revealed

a normal response on the right; there was a 2-second delay on release of radial and

ulnar compression on the left. All peripheral pulses were palpable and of normal aplitude with the exception of the radial and ulnar pulsations on the left and the brachial

pulsation in the left antecubital fossa. Axillary and brachial pulsations in the left arm

were normal. Blood pressure on the left was 138/96 and on the right 148/96 mm. Hg.

Good brachial pulsations were palpable in the left arm to a point about 2 cm. above the

flexor crease of the elbow. No bruits were audible in the antecubital fossa.

Actively pulsating collaterals outlined on the patient's skin were present over the

entire posterior aspect of the elbow and over the posteromedial, posterolateral portions

of the arm and forearm; they probably represented dilated superior and inferior ulnar

collaterals, radial collaterals, and radial and ulnar recurrent arteries. It was most

probably by means of these anastomoses with the unobstructed portions of the radial

and ulnar arteries in the forearm that circulation to the hand had been maintained.

At operation, an incision was made from the lower third of the left upper arm over

the region of the brachial artery, over the medial aspect of the antecubital fossa, and

down over the lateral upper third of the forearm. The incision was carried down to

the fascial plane, and skin flaps were reflected on either side. The cutaneous nerves and

the basilic vein were dissected out and retracted. Then the median nerve was isolated

about 4 cm. above the medial epicondyle and followed down to the upper border of the

pronator muscle. At this point, the nerve was closely and firmly bound down by the

bicipital fascia.

The brachial artery lying lateral and behind the nerve was pulsating vigorously at

the point of the first dissection, but as it was followed distally and began to divide,

pulsation stopped, apparently because of thrombosis.

The ulnar nerve was next isolated above the medial epicondyle. It too was firmly

bound down by the lateral border of scar tissue arising from the perforating wound.

It was freed from these tissues and also from its normal course in the epicondylar

groove. The nerve was slightly enlarged and slightly firmer than usual. Stimulation

gave good flexion of the hand. The motor branches to the flexor carpi ulnaris were

identified and reacted normally. Below this point, for a distance of 4 cm., normal sensory

responses were obtained.

Dissection was then carried out below the pronator, and various muscle branches to

the pronator, to the flexor carpi radialis, and to the flexor digitorum sublimus and profundus were isolated in this region. Stimulation of these branches gave normal responses.

At this point, a very interesting finding was noted. The lower third of the muscle

bellies was completely transformed, with a sharp demarcation point, into necrotic tissue
PERIPHERAL NERVE-VASCULAR INJURIES 463

which was rubberlike in consistency and almost pure yellow. Obviously the vascular

lesion had produced necrosis of the muscle bellies, and the peripheral sensory loss was

due to a similar vascular process. A biopsy was taken of normal and necrotic muscles.10

When the brachial artery was divided at the point of presumed thrombosis, it was

found completely thrombosed. A biopsy was taken of this tissue and also taken of a

small cutaneous nerve.

The median nerve, below its muscle branches, was somewhat soft but gave a good

sensory response. The entire nerve was thoroughly freed from surrounding scar tissue

beneath the pronator.

The incision was closed in tiers with interrupted fine silk sutures. A firm pressure

dressing was applied.

Case 18.—This patient sustained a wound from a pistol bullet on 29 September 1944.

The small wound of entry was near the right nipple, and the entire right firm became

numb and paralyzed at the moment of wounding. Examination a few hours later disclosed "an enormous swelling in the right pectoral region and the right axilla." There

was no overlying pulsation or bruit. The right hand was cooler than the left. The

blood pressure in the left arm was 120/80 mm. Hg. It could not be obtained in the right

arm. The right radial pulse was absent. There was diminution to pain perception over

the distribution of the median nerve. There was no record of motor involvement.

On 30!September 1944, a hematoma containing an estimated 1,000 cc. of blood was

evacuated, and a laceration of the axillary artery was visualized. The vessel was divided

and ligated. No Injury to adjacent nerve trunks was noted. At the end of this procedure, the right hand was cold and cyanotic. When block of the sympathetic nervous

system at Tt, T2, and T3 was done with 1 percent procaine, the hand became pink and

warm. Smaller blocks were done on T^ T2, and T6, on 4 and 28 October. On 6 October,

motion was noted in the fingers. On 14 October, sensation had returned to the arm but

not to the hand.

The patient was seen in Walter Reed General Hospital 28 January 1945. The radial

pulse was barely palpable. The musculature of the forearm, though spindly, exhibited

normal movements. The thumb was partially adducted, and there was minimal induration in the first interosseous muscle (fig. 217). There was incomplete extension of the

distal phalanges of the second and third fingers, with a tendency toward ulnar displacement of these digits. There was mild hypalgesia over the tip of the index finger and

the medial border of the thumb. The patient had no symptoms referable to this extremity

except clumsiness in fine movements of the fingers.

COMMENT

The eventual fate of these badly injured extremities in which a combination of peripheral nerve injury and tissue ischemia produced the socalled frozen hand could not be determined while the patients were under

treatment and observation in U.S. Army hospitals. Every attempt was made

to follow them up in the Peripheral Nerve Begistry.11

The proper treatment of these combined injuries immediately after

wounding was never clarified during World War II. Indeed, there is

considerable question whether they can be so controlled as to prevent func10 This case is described and illustrated In the "Atlas of Peripheral Nerve Injuries" by William

E. Lyons and Barnes Woodhall. Philadelphia : W. B. Saunders Co., 1949, case 160, p. 218.

11 As noted elsewhere, this task was accomplished in 3,656 of these World War II peripheral

nerve injuries by the Follow-Up Agency of the National Research Council developed by the Committee on Veterans Medical Problems in cooperation with the Veterans' Administration, the Army,

and the Navy (p. 230).

498991T—59 33
464 NEUROSURGERY

FIGUKE 217.—Facsimile of frozen hand following division of axillary artery

and partial injury of median nerve. Treatment with repeated sympathetic

blocks with procaine hydrochloride was instituted promptly, and useful function was retained.

tional sequelae, regardless of the methods used. One point, however, is clear,

that the use of firm casts and the failure to interrupt the sympathetic nerve

supply to the damaged extremity are factors in the production of this deformity.

MANAGEMENT OF COMBINED VASCULAR-NERVE INJURIES

The management of combined vascular-nerve injuries at the vascular

centers in the Zone of Interior was based on the principle that a single

inclusive surgical approach to the combined lesions was preferable to their

surgical repair at separate operations. Close cooperation between specialists

in diverse fields was essential in every case. In the management of the

individual lesions, the same principles of therapy were applied as if the

vascular and the nerve lesions had occurred independently.

Operation for neither arterial nor arteriovenous aneurysm was ever

regarded as an emergency unless there was rapid progress in the size of

the lesion, rupture had occurred or seemed impending, or heart failure

seemed impending. In the absence of these indications, time was allowed

for the collateral circulation to develop, which usually took 3 to 4 months.

In the meantime, artificial means to develop collateral circulation were

employed.

The choice of the surgical procedure depended upon the findings in the
PERIPHERAL NERVE-VASCULAR INJURIES 465

individual case. For arteriovenous fistulas, excision and quadruple ligation

soon became the preferred method, while for aneurysms, especially those of

the common femoral and other major arteries, in which nutrition to the

extremity was questionable, the encloaneurysmorrhaphy of Matas was most

generally used.

Although the majority of arterial aneurysms presented themselves as

palpable, pulsating masses lying over major vascular channels, they were

sometimes found quite unexpectedly during exploration of an extremity

for the repair of major injuries of the peripheral nerves. Even the most

careful preoperative examination occasionally failed to disclose the presence

of the vascular lesions, both because they were of small size and because

they might be imbedded in a mass of indurated scar and neural tissue.

The neurosurgeon, in the absence of more expert aid, had to be prepared

to deal with such lesions, since clinical evidence had made it clear that the

combined repair of nerve and vascular injuries was preferable to staged

operative procedures. Cases 11 and 19 describe the unexpected finding of

vascular lesions in the course of exploration for nerve injuries.

When the proper time had arrived for an attack upon the injured blood

vessel, the evidence of extensive nerve damage apparent when the patient

was first injured had sometimes resolved to a considerable degree, leaving

a residual neurologic defect which offered no serious problems. A conservative attitude was always taken toward all technical procedures, especially

in injuries in which nerve compression had occurred because of, or had been

increased by, the presence of an aneurysmal mass. The mass of a false

aneurysm often produced added nerve damage, but arteriovenous fistulas

were seldom large enough to have this effect unless the lesion was complicated

by the presence of a false sac on the arterial aspect of the injury. The

nerve damage, when this association was present, had apparently occurred

when the fistula was formed, as the result of the same inflicting force, and

took the form of concussion, contusion, or actual nerve section.

Although neurosurgeons had a fairly adequate working knowledge of

peripheral nerve injuries combined with the formidable vascular lesions

described in this chapter, not much can be stated authoritatively concerning

the therapeutic concepts and practices most effective in ischemic nerve injury. When the sequelae of vascular occlusion had become established in the

tissues of an extremity, the neurosurgeon was reduced, or elevated, to the

status of a neuropathologist and could do no more than visualize the irreparable changes in tissue sections. About the only hopeful approach to the

prevention of ischemic damage was prompt sympathetic denervation of the

affected limb. This technique is discussed in detail in the volume devoted to

vascular surgery in this series of histories.12

M Medical Department, United States Army. Surgery in World War II. Vascular Surgery.

Washington : U.S. Government Printing Office, 1955.
466 NEUROSURGERY

OTHER ASSOCIATED INJURIES

Fractures

Although fractures occurred in association with nerve injuries with

considerable frequency, they furnished only occasional problems in the Zone

of Interior vascular centers for the reason that they were usually healed,

or well on their way to healing, by the time the patients were received.

Even if healing was not complete, arterial lesions were seldom operated on,

except for special indications, under 3 months, which usually gave even

serious fractures ample time for recovery. In numerous instances, as a

matter of fact, the arterial and arteriovenous aneurysms became evident,

and presumably developed, while the patients were hospitalized for fractures.

An occasional combination of bone and nerve injuries gave rise to

diagnostic problems, as in the following case:

Case 19.—A 21-year-old American soldier was captured by the enemy shortly after he

had received an injury of the right forearm from machinegun fire. He was given first

aid in an enemy installation. Within 24 hours, he was released by American troops and

underwent debridement in a U.S. Army hospital. The arm was placed in a plaster cast.

Roentgenologic examination at this time showed lateral displacement of the fragments

of the radius. Delayed primary closure of the wound was carried out 20 days later, and

the cast was replaced. Thirteen days later it was changed, and traction was instituted

through the thumb for the correction of the lateral radial displacement.

The patient was received on the orthopedic service of Ashford General Hospital 9

weeks after he had been injured. Examination at this time showed a healed wound of

entrance on the ulnar aspect of the lower third of the right forearm and a healed wound

of exit on the radial aspect of the upper third. Flexion of the right index finger was

limited, and there was complete loss of pronation and supination of the right forearm.

Palpation revealed a firm, nontender swelling over the midportion of the radius. Hypesthesia was present along the distribution of the superficial radial nerve. Roentgenograms showed the same lateral displacement of the radial fragments as had been present

24 hours after injury.

At operation, which was undertaken with the intention of excising the deformity of

the radius and bridging the resulting defect with a tibial graft, a false aneurysm, about

5 cm. in diameter, was found between the radius and the ulna. When the tourniquet

was released, blood spurted from a small opening on the volar surface of the interosseous

artery. The vessel was ligated proximal and distal to the opening, and the false sac

was excised. The operation on the radius was carried out according to plan.

The postoperative course was entirely uneventful. Within 6 months, supination of

the right forearm was normal, and pronation was 60 percent of normal.

The aneurysm in this case was not suspected before its discovery at operation. The

circumstances prove again the importance of a deliberate search for a possible arterial

lesion in all combat-incurred bone injuries. They also suggest that the presence of an

aneurysm should be suspected when a bone deformity following a comminuted fracture

is uniform and persistent. In this case, the lesion apparently achieved its maximum size

immediately after injury. It should be noted that recovery was without complications

following a combined attack on the bone and nerve lesions and that the end results were

also satisfactory.
PERIPHERAL NERVE-VASCULAR INJURIES 467

Soft-Tissue Injuries

Soft-tissue injuries of considerable extent were less frequent in combination with vascular injuries than either nerve injuries or fractures. Only

seven were reported in combination with aneurysms and arteriovenous

fistulas in the vascular centers of the Zone of Interior. The explanation is

probably that when soft tissue was extensively lacerated, blood vessels were

completely severed, and under these circumstances aneurysms and arteriovenous fistulas obviously cannot develop.
CHAPTER XIX

Causalgia Following Combat-Incurred

Injuries of the Peripheral Nerves

Frank H.Mayfield, M.D.

GENERAL CONSIDERATIONS

Burning pain as a sequel of wounds of the peripheral nerves had been

recognized for some time before Mitchell, Morehouse, and Keen1applied

the term "causalgia" to it in 1864, in their text on injuries of the nerves.

In spite of its frequency, it does not appear in the index of the section on

neurosurgery in the official history of the U.S. Army Medical Department

in World War I or in the statistical volumes.

In 1922, Leriche2recommended interruption of the sympathetic nervous

system to control the pain, and his observations were subsequently confirmed

by many other observers, including, among others, Spurling,3 Ross,4 Kwan,5

White and Smithwick,6and Livingston.7 Until World War II, the literature

on the subject was limited to this and other methods of treatment and to

discussions of the etiology, for which many conflicting theories were advanced (p. 474).

The prompt establishment of neurosurgical centers in both British and

U.S. Army hospitals in World War II brought under the attention of experienced neurologists and neurosurgeons large numbers of casualties with

peripheral nerve injuries and provided unparalleled opportunities to study

the sequelae of these injuries. It soon became apparent that causalgia was

relatively common. It also soon became apparent that if certain criteria

were adhered to in the diagnostic routine, there was almost absolute assurance

that relief could be provided by interruption of the appropriate portion of

1 Mitchell, S. Weir, Morehouse, George K., and Keen, William W. : Gunshot Wounds and Other

Injuries of Nerves. Philadelphia : J. B. Lippincott Co., 1864.

2 Leriche R • A propos de la nature des troubles trophiques consecutifs ä la section du nerf

seiatique et de leur traitement. Bull, et mem. Soe. nat. de Chir. 28 : 1071-1073, 18 Oct. 1922.

3 Spurling, R. G. : Causalgia of the Upper Extremity, Treatment by Dorsal Sympathetic Ganglionectomy. Arch. Neurol. & Psychiat. 23.: 784-788, April 1930.

i Ross, J. P. : Symposium on Sympathectomy. Sympathectomy for Median Causalgia. St.

Barth. Hosp. J. 66 : 39, 1933.

5 Kwan, S. T.: . The Treatment of Causalgia by Thoracic Sympathetic Ganghonectomy. Ann.

Surg. 101: 222-227, January 1935.

«White, James C, and Smithwick, Reginald H.: The Autonomie Nervous System; Anatomy,

Physiology, and Surgical Application. 2d ed. New York : The Macmillan Co., 1941.

•> Livingston, W. K. : Pain Mechanisms. A Physiologic Interpretation of Causalgia and Its

Related States. New York: The Macmillan Co., 1943.

469
470 NEUROSÜRGERY

the sympathetic nervous system. There was, however, never sufficient uniformity of opinion concerning management to warrant the issuance of directives, and treatment was therefore left to the discretion of the chiefs of

the neurosurgical centers.

INCIDENCE

Pollock and Davis'sreport of 38 instances of causalgia in 1,020 peripheral

nerve injuries, 3.6 percent, provides the only figures available for this complication in World War I, and no statistics at all exist for previous wars.

In the absence of official data on the incidence of causalgia in World

War II, questionnaires were sent to a number of former medical officers who

had headed neurosurgical centers or served on neurosurgical services. The

13 replies received produced a total of about 500 cases. Only nine reports,

however, were received in sufficient detail for tabulation, and many specific

data are missing in them (table 12). A few other figures are available. For

the Navy, Capt. James C. White, (MC) USN, and his associates, in 1946,

reported 13 instances of causalgia in 400 nerve injuries, 3.25 percent. This

report was made before the Harvey Cushing Society.

It should be emphasized that none of the reports cited are really

definitive. They represent simply the experiences of individual medical

officers or consist of series of cases collected over varying periods of time.

The experience at the Percy Jones General Hospital, Battle Creek,

Mich., is probably typical. Early in the war, when only patients with

constant, severe pain were classified as suffering from causalgia, the incidence

was 2 percent (15 cases in 736 peripheral nerve injuries). Later, the incidence rose to 4.5 percent (105 cases in 2,318 nerve injuries). These 105

cases are exclusive of patients who had recovered spontaneously or who had

been relieved by sympathectomy before they were received at the Percy

Jones General Hospital Neurosurgical Center.

The increased incidence is open to two explanations, as follows:

1. Many cases were originally classified as mild which later proved to be

severe. When the patients were protected from noxious stimuli, as was

possible in the environment of the hospital ward, their complaints were

minor. Later, when they were transferred to reconditioning centers, it was

found that mass calisthenics, physical therapy, and the unprotected life in

barracks made the pain so severe that many patients had to be rehospitalized

for operation.

2. The increased incidence of causalgia later in the war may also be

explained by the increased speed of evacuation from oversea theaters as air

transportation was developed. In 1945, casualties were sometimes admitted to

neurosurgical centers in the United States within 2 weeks after woundino8 Pollock, Lewis J., and Davis, Loyal: Peripheral Nerve Injuries. Hoeber's Surgical Monographs. New York : Paul B. Hoeber, Inc., 1933.
CAUSALGIA AFTER PERIPHERAL NERVE INJURIES 471

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472 NEUROSURGERY

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CAUSALGIA AFTER PERIPHERAL NERVE INJURIES 473

and may have included patients who, earlier in the war, would have recovered

spontaneously while they were being held overseas.9

PATHOLOGIC PROCESS

Because causalgia notably occurs only with incomplete nerve lesions

(p. 476), specimens were seldom available for pathologic examination. In

the five such specimens studied at the Percy Jones General Hospital Neurosurgical Center, conventional stains revealed no appreciable differences between them and the neuromas secured from patients with nerve injuries

without causalgia. Gross inspection at operation also revealed no significant

8 This possibility has been interestingly discussed by Maj. Francis A. Eehlin, MC, as follows :

In a series of 1,500 peripheral nerve injuries treated at McCloskey General Hospital, Temple,

Tex., in 1945, 30 patients (2 percent) suffered from major causalgia sufficiently intractable to

require sympathectomy. Fifteen other patients, however, who had causalgia which was originally

quite as severe did not require sympathectomy ; they gradually improved under treatment by sympathetic blocks with procaine hydrochloride.

This observation suggested to Major Eehlin and his associates that the incidence of causalgia

at the various neurosurgical centers in the United States might be considerably higher than the

currently reported statistics indicated. The explanation of the discrepancy, in their opinion, was

the exclusion from these statistics of patients whose causalgia, as in their own patients, had

improved or disappeared before they reached these centers.

To test this assumption, these observers examined and questioned 310 patients with nerve

injuries who had not included or had not emphasized causalgia in their present complaints. They

found that 61 (19.6 percent) had originally suffered from causalgia, which in most instances seemed

to have been major. The course of the syndrome in most of the cases in which the diagnosis was

made chiefly or entirely on the history was identical with that of the 15 patients with major

causalgia who showed gradual improvement without sympathectomy while under observation at

McCloskey General Hospital. All of them had suffered for periods of weeks to months with severe

burning pain which, in time of onset, quality, severity and other characteristics, and distribution,

was indistinguishable from the pain described by the patients with causalgia who had been cured

by sympathectomy.

Of the 61 patients, 32 still had symptoms of mild or minor causalgia when they were examined. Gradual spontaneous improvement had occurred in the intense burning pain within 2

l

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months of the onset in 21 patients and within 6 months in 11 others. The pain had persisted,

however, for more than 3 months in 31 patients and for more than 6 months in 10 others.

Major Echlin's observation that patients with major causalgia may improve without sympathectomy and that the incidence of this complication following war wounds is probably much higher

than is usually reported is in keeping with the findings of Maj. (later Lt. Col.) Theodore B.

Easmussen (table 12). His incidence of 16.5 percent in 650 peripheral nerve injuries is probably

explained by the fact that these patients, all of whom were treated in Burma, were seen soon after

wounding.

It is interesting to note, Major Eehlin pointed out, that S. Weir Mitchell also observed that

spontaneous improvement is frequent in major causalgia. In his text entitled "Injuries of Nerves

and Their Consequences," published in 1872, Mitchell wrote: "In 1867, Dr. W. W. Keen was kind

enough to examine for me two of the worst of our former cases of causalgia. In both the injured

parts were still a fraction of a degree warmer than those on the well side. Both of these men

had improved considerably, and in both the pain had disappeared.

In the same text, Mitchell described the improvement in another case of major causalgia as

follows: "* * * The burning pain slowly lessened without any therapeutic aid, and within 4

months of the date of wounding he [the patient] was well, excepting some tenderness and slight

oedema of the foot."

Finally, Major Eehlin noted that Mitchell's observations on blisters in causalgia indicate conclusively that the pain of causalgia commonly subsides without sympathectomy. Under this heading Mitchell wrote as follows : "The curative treatment was simple. It consisted in blistering the

burning part repeatedly with Granville's lotion or enntharides. * * * In light cases two or three

blisters have answered ; in others, ten or twelve have been needed, and, in very rare examples, this

and every other method failed us, although such was never the case in any instance which was

treated early, only the oldest cases being thus obstinate."

It is unfortunate, as Major Eehlin said, that it is not possible to estimate the incidence of

causalgia in Weir Mitchell's cases of nerve injury.—B. W.
474 NEUROSURGERY

differences. The osteoporosis observed in some of these patients (p. 478, and

485) could not be distinguished from the same process observed in patients

with other nerve and bone diseases.

Capt. Byrl I. Kirklin, MC, and his associates were of the opinion, from

clinical observation and the gross findings at operation, that causalgia was

fairly frequent with complete nerve lesions. Microscopic examination of

their specimens, however, revealed that all but two lesions were obviously

incomplete, and, in these two, the pathologist regarded the findings as inconclusive.

ETIOLOGIC CONSIDERATIONS

Theories of Origin

Mitchell's10statement in 1872 that the mechanism of causalgia was obscure is still generally true. A large number of theories have been advanced,

but none of them is entirely satisfactory, and some of them can be eliminated

immediately. One illustration is Leriche's 11 theory that the pain is due to

ascending neuritis. Another is Tinel's 12 theory, advanced in 1919, that infection is a causative factor. The fact that the pain in many instances

occurs almost immediately after wounding, as Mitchell and his associates 13

noted during the Civil War, eliminates both of these theories from serious

consideration. The theory of infection is particularly inapplicable to World

War II cases, since, in most instances, healing occurred without gross infection. Lewis and Pickering'sli

theory that the pain can be attributed to

an accessory set of nerves, the so-called nocifensors, can also be eliminated;

these nerves, which they postulated, have been found not to exist.

That neither ischemia nor hyperemia is responsible for causalgia is

evident from two facts; (1) that vascular injury is infrequent in patients

with causalgia and (2) that the subjective symptoms are the same, regardless of the blood flow through the extremity. Of the first 75 patients with

causalgia observed at the Percy Jones General Hospital Neurosurgical

Center during World War II, 40 were in vasodilatation and 35 in vasoconstriction, as shown by skin temperature studies of the entire group,

supplemented by oscillometric studies of the first 15 patients observed.

Those in vasodilatation usually showed skin temperature readings from

1° to 4° F. higher than readings of corresponding areas of the normal extremities; those in vasoconstriction showed readings from 2° to 6° F. lower.

10 Mitchell, S. Weir : Injuries of Nerves and Their Consequences. Philadelphia : J. B. Lippincott Co., 1872.

li Leriche, Reng: The Surgery of Pain, translated and edited by Archibald Young. London :

Balliere, Tindall and Cox, 1939.

12 Tinel, J.: Parathfisies prfcoces aprfis suture on greffe nerveuse. Rev. neurol. 26: 521-

526, 5 June 1919.

13 See footnote 1, P. 469.

1* Lewis, T., and Pickering, G. W.: Vasodilatation in the Limbs in Response to Warming the

Body, With Evidence for Sympathetic Vasodilator Nerves in Man. Heart 11: 33-51, 7 Oct. 1931.
CAUSALGIA AFTER PERIPHERAL NERVE INJURIES 475

Subjective symptoms were identical in both groups. Interruption of the

sympathetic chain was successful in relieving the pain whether vasodilatation or vasoconstriction was present. It would therefore seem that alterations

in the blood flow in the affected limb can be excluded as a cause of the pain.

None of the patients at Percy Jones General Hospital were observed

for more than 2 months before sympathectomy, but it is probably significant

that, during the period of observation, there was no change in the vasomotor

state in any instance. In all of the cases observed by White, Heroy, and

Goodman15 in a naval hospital, the painful extremity was in vasoconstriction,

which led them to suggest that the brief duration of the condition might

explain the vasodilatation reported by other observers. This theory was not

borne out by the cases studied at Percy Jones General Hospital.

In 1943, on the basis of their laboratory experiments, Granit and his

associates16advanced the view that causalgia might result from cross-stimulation of sensory fibers as the result of interaction of these fibers with the

sympathetics within the injured nerve. In 1944, Doupe and his associates ir

published clinical studies which supported this premise, which was additionally supported by White and his group. Most of the well-documented

reports from Army neurosurgical centers in World War II also supported it,

although some data were not compatible with it. These conflicts seemed

to stem from two causes, differences in diagnostic criteria and variable interpretations of the term "minor causalgia" (p. 477). Another explanation of

the discrepancies was the tendency of some observers to overemphasize

features of the disorder which are different while discounting the overwhelming similarity of features common to all cases.

Analysis of data available from various reports on causalgia reveal

certain significant points, as follows:

1. The disease nearly always results from a penetrating wound of a

large mixed nerve. The incidence is considerably higher in the median and

the sciatic nerves, an observation of importance in view of the high proportion

of sympathetic and sensory fibers in these nerves.

2. The nerve injury, with very occasional exceptions, is incomplete.

3. The pain is usually exaggerated by emotional and environmental

stimuli (p. 479 and 482), which are known to cause increases in the efferent

impulses flowing from the hypothalamus over the sympathetic chain. This

point is strongly emphasized by White, Heroy, and Goodman.

4. The pain is reduced by agents which reduce the outflow of efferent

stimuli from the hypothalamus, such as cold in hyperemia, heat in ischemia,

sleep, and certain drugs. Interruption of the sympathetic chain provides

15 White, J. C, Heroy, W. W., and Goodman, E. N.: Causalgia Following Gunshot Injuries of

Nerves : Eole of Emotional Stimuli and Surgical Cure Through Interruption of Diencephalic Efferent

Discharge by Sympathectomy. Ann. Surg. 128: 161-183, August 1948.

16 Granit, R., Leksell, L„ and Skoglund, C. R.: Fibre Interaction in Injured or Compressed

Region of Nerve. Brain 67 : 125-140, June 1944.

IT Doupe, J., Cullen, C. H., and Chance, G. Q.: Post-Traumatic Pain and the Causalgia Syndrome. J. Neurol. Neurosurg. & Psychiat. 7 : 33-48, January-April 1944.
476 NEUROSURGERY

complete relief. Excision of the injured segment, which in effect converts

the incomplete to a complete lesion, is similarly effective.

The work of Granit, Leksell, and Skoglung, published in 1944, showed

that there is a constant interaction of impulses between various nerve fibers,

and that the sensitivity to this interaction, particularly when sensory fibers

are involved, is greatly increased when the nerve is injured. These data

lend strong support to the view expressed by these observers and by Doupe

and his associates to the effect that the pathologic mechanism of causalgia is

a shunting or short circuiting of impulses from the sympathetic into the

sensory fibers of the injured nerve. It would seem, therefore, if symptoms

take the form of burning superficial pain and hyperesthesia, that portions of

the distal segment of the nerve must be viable and must reach their normal

sensory end organ, as can happen when the nerve injury is partial, as it

practically always is. When this situation exists, the sensory end organs are

bombarded with impulses of frequency and amplitude which they are not

normally destined to receive.

The weak point in the theory advanced is obvious. If causalgia can

arise from a short circuiting of impulses, surely it could occur with complete

as well as incomplete lesions. There is general agreement, however, that it

is most common in patients with incomplete lesions. Furthermore, unless

some specific difference exists between complete and incomplete lesions, one

would expect causalgia to occur far more frequently in amputations than it

apparently occurs. The possibility must be considered that retrograde degeneration of the axis cylinder with transection of a nerve may set up

conditions unfavorable to the interaction of impulses.

Many observers have never encountered causalgia in complete nerve

injuries. In two instances at Percy Jones General Hospital in which the

surgeon, on gross inspection, interpreted the lesion as complete, it was later

proved to be incomplete by sensory and electrical examination; these studies

showed that both sensory and motor fibers of which the surgeon was not

aware had been divided by him at operation.

An instance of causalgia in a complete nerve lesion was, however, observed by Lt. Col. Barnes Woodhall, MC, at the neurosurgical center at

Walter Eeed General Hospital, Washington, D.C.:

A 24-year-old tank captain dated the onset of burning pain in his

upper arm to the fourth day after injury, when he first became cognizant of

his surroundings. There was no doubt that this was a major causalgia; it

fulfilled at the criteria (p. 485). The arm was amputated at the upper third

of the humerus shortly afterward, because of impending gangrene; the amputation was done just below the elbow, above the original point of nerve

injury. As soon as the patient reacted from anesthesia, it was found that

causalgia was still present. Immediate relief was obtained by sympathetic

block and complete relief by sympathectomy; in fact, the patient was caught
OAUSALGIA AFTER PERIPHERAL NERVE INJURIES 477

walking down the hall the day after operation (early ambulation was not

permitted in World War II).

This patient was seen by Dr. James C. White of Boston while his

symptoms were at the maximum. Dr. White agreed that this was an instance

of true causalgia in an amputated arm with a phantom limb. During the

period of pain, it was impossible to touch or examine the patient. After

relief of pain by sympathectomy, he disclaimed any interest in the phantom

limb, which was represented only by a lightly clenched fist in the intact arm

hanging at his side. This man had had four battle injuries and had been

decorated for bravery on two occasions, and he tried hard to get back into

active duty after the last operation.

Therapeutic Correlations

It is difficult to reconcile a number of observations with the theory just

advanced to explain the mechanism of pain in causalgia. One is the report

by Tinel that block of the nerve proximal to the site of injury failed to

provide relief of pain, which was, however, secured by section distal to the

injury. Doupe and his associates speculate that the relief which follows

injection of the nerve distal to the site of injury means that the site of

interaction is distal to the site of injury, often in the most distal part of the

extremity; failure to provide relief, on the other hand, by injection of the

nerve distal to the site of injury indicates that the site of interaction is at

the site of injury. The instances of failure to secure relief by section or

injection of the nerve proximal to the site of injury are too infrequent to

carry much weight. It is likely that they can be explained by technical

errors (p. 490).

It is possible that the spontaneous recoveries which sometimes occur in

causalgia can be explained by the redeposit of myelin at the areas in which

it has been fragmented.18 Such a process might also account for the relief

secured by patients who undergo repeated injections of the nerve over long

periods. It cannot, however, explain the cases in which there is permanent

relief of severe pain by a single injection of procaine into the sympathetic

chain.

Other Painful Posttraumatic Dystrophies

Homans,19 Herrmann and his associates,20 and Tinel take the position

that most painful posttraumatic dystrophies, such as Sudeck's atrophy and

painful osteoporoses, as well as painful phantom limb and the so-called

is Denny-Brown, D., and Brenner, C.: The Effect of Percussion of Nerve. J. Neurol. Neurosurg. & Psychiat. 7 : 76-95, July-October 1944.

19 Homans, J. : Minor Causalgia : A Hyperesthetic Neurovascular Syndrome. New England J.

Med. 222 : 870-874, 23 May 1940.

a> Herrmann, L. G., Eeineke, H. G., and Caldwell, J. A. : Post-Traumatic Painful Osteoporosis :

A. Clinical and Roentgenological Entity. Am. J. Koentgenol. 47 : 353-361, March. 1942.
478 NEUROSTJRGERY

minor causalgias, are all different manifestations of the same underlying

disorder. When Homans introduced the term "minor causalgia," he evidently intended it to apply to patients who were suffering from such conditions as Sudeck's atrophy. A few medical officers, however, applied the

term to patients with true causalgia resulting from penetrating wounds.

Most medical officers who worked in neurosurgical centers believed that

causalgia must be regarded as a clinical entity which may arise from the

same pain mechanisms as certain minor causalgias, using the term in the

generally accepted sense. Painful phantom limb and the psychoneuroses

have a different origin.

The mechanism just postulated to explain causalgia leads to conjectures

concerning the mechanism in Sudeck's atrophy and painful osteoporosis. If

these are, indeed, different clinical manifestations of the same underlying

disorder, a possible explanation is that, in the latter conditions, the injury is

to smaller nerves which supply tendons and ligaments. When shunting of

impulses occurs, the pain is then expressed as an aching sensation rather

than as burning hyperesthesia, as in causalgia, in which the more superficial

sensory organs are involved.

There is no doubt that, correctly, painful phantom limb and causalgia

must be considered as separate entities. More than 3,000 amputees were

admitted to the amputation center at Percy Jones General Hospital. The

first 200 were studied carefully from the standpoint of possible phantom

limb. In the remaining admissions, all patients who developed painful

phantom limb were studied on the neurosurgical wards. The incidence immediately after amputation was extremely high, probably 50 to 60 percent

of all cases. Pain subsided rapidly, however, and few casualties were left

with permanent residuals of painful phantom limb. From this study, it was

concluded that painful phantom limb is not a surgical problem, except for the

excision of locally painful scars and neuromas that interfere with weight

bearing and the application of prostheses. The transient relief which followed chemical block of the sympathetic chain in a few cases was interpreted

as the result of suggestion and not as evidence that sympathectomy would be

followed by permanent relief.

SYMPTOMS AND SIGNS

The description of causalgia by Mitchell, Morehouse, and Keen, based

on their observations of nerve injuries during the Civil War, is an unsurpassed example of clinical description. They wrote, in part, as follows:

The seat of burning pain is very various, but it never attacks the trunk, rarely the

arm or thigh, and not often the forearm or leg. Its favorite site is the foot or hand * * *.

The great mass of sufferers described this pain as superficial, but others said that it

was also in the joints, and deep in the palm. If it lasted long, it was referred finally

to the skin alone.

Its intensity varies from the most trivial burning to a state of torture, which hardly
CAUSALGIA AFTER PERIPHERAL NERVE INJURIES 479

can be credited, but which reacts on the whole economy, until the general health is

seriously affected.

The part itself is not alone subject to an intense burning sensation, but becomes

exquisitely hyperaesthetic, so that a touch or a tap of the finger increases the pain.

Exposure to the air is avoided by the patient with a care which seems absurd, and most

of the bad cases keep the hand constantly wet, finding relief in the moisture rather than

the coldness of the application * * *.

Later, in 1872, Mitchell wrote as follows:

Perhaps few persons who are not physicians can realize the influence which long

continued and unendurable pain may have on both body and mind. Under such torments

the temper changes, the most amiable grow irritable, the bravest soldier becomes a

coward, and the strongest man is scarcely less nervous than the most hysterical girl.

Nothing can better illustrate the extent to which these statements may be true than the

cases of burning pain, or, as I prefer to term it, causalgia, the most terrible of all

tortures which a nerve wound may inflict.

Symptoms

The cardinal symptom of causalgia was always burning pain, sometimes

throbbing, sometimes aching, but, in the experience of most observers, always

burning. On the other hand, a few reliable observers stated that some of

their patients did not interpret the pain as burning, and it may be that this

adjective has been somewhat overworked; it is significant that patients who

experienced the minor variety of causalgia never used the term. Some

patients felt as if their hands were being "squeezed in a vise." Others said

they felt as if the flesh of the affected part were "being torn off." Whatever

the description, there was little doubt of the severity of the pain in patients

suffering from major causalgias. In no instance did there seem any correlation at all between the severity of the nerve injury and the intensity of the

causalgia.

Mitchell, Morehouse, and Keen stated that some of their patients complained of pain almost as soon as the injury occurred. In most instances

in World War II, the onset of the pain was delayed, sometimes for several

weeks.

The pain was always referred to the distal portion of the affected limb

and was usually more intense in the autonomous zone of the injured nerve,

though it was not necessarily limited to it. The hands and feet were most

frequently affected. In the hand, the pain was referred chiefly to the palm

and the fingers. In the foot, it was referred chiefly to the instep, sole, and

toes.

The pain was always continuous but was not always of the same severity.

Extreme hyperesthesia of the involved part was characteristic of the more

severe cases. Equally characteristically, the pain was subject to exacerbation

by the slightest emotional or physical stimulus. Many times, jarring of the

bed, slamming of the door, even a draft of cool air, might induce severe

paroxysms. The patients apeared to be in a perpetual state of defense
480 NEUROSURGERY

against such stimuli. Some went to almost absurd extremes to protect the

injured part (fig. 218). They would grasp the painful limb just proximal

to the wrist or ankle and hold the protective posture for long periods of

time, even for hours. Meantime, the facial expression usually reflected

intense suffering.

FIGUKE 218.—Patient with causalgla. Note facial expression. He is protecting

the painful member by holding it immobilized with the other hand.

Some patients learned to protect the part with makeshift coverings of

soft cloth (fig. 219). Others, as Mitchell had observed, found comfort in

the application of moisture to the part, including the simple expedient of

carrying a tumbler of water in the painful hand. Some patients overseas

stated that they filled their boots with water to accomplish the same end.

The majority preferred that the water be cold, but a few stated that they

were more comfortable when it was hot.

At Percy Jones General Hospital, after a number of patients had made

the observation that they were relieved by the application of moisture, the

response to this measure became a routine test for causalgic patients.

Sixty-eight of the 75 who were surveyed for the preparation of this chapter

obtained some relief. Thirty-eight preferred cold applications, and 30 preferred warm. In several instances, the application of moist towels provided

relief for the first time, after weeks of continuous suffering. The change

in facial expression was remarkable (fig. 220), and the patients were almost

dramatically surprised that limbs which had heretofore been untouchable

because of pain could be touched and even moved without discomfort.

Objective Findings

Patients with causalgia were often malnourished because their food

intake was low. The facial expression, as already mentioned, usually reflected intense suffering, anxiety, and weariness.
CAUSALGIA AFTER PERIPHERAL NERVE INJURIES 481

Trophic and vasomotor changes were commonly observed in patients

who had severe pain. These changes were less striking when pain was of

lesser intensity. In severe cases, the changes occurred early.

Vasomotor and trophic changes were of two types; vasodilatation and

vasoconstriction. In vasodilatation, the temperature of the skin was usually

2° to 6° higher than that of the unaffected member (fig. 221). The skin was

dry and scaly (fig. 222). The hair was long and coarse, and the nails were

FIGUEE 219.—Makeshift covering of dry flannel, worn constantly to

protect causalgic member.

thick and ridged. In vasoconstriction, on the contrary, the skin was colder

by 2° to 5° F. than the skin of the opposite member (fig. 223) and was

thin and sometimes denuded. Often it was wet, glistening, and mottled

(fig. 224). The involved parts were likely to be hairless, and the fingers

were thick and tapering. In general, patients in vasodilatation found relief

from cold applications, while those in vasoconstriction preferred heat. Two

patients in vasoconstriction who were observed during attacks of malaria

(Plasmodium vivax) with intermittent chills were free from pain during the

temperature elevations, the pain returning soon after the fever subsided

(p. 487).

Trophic changes were generally similar to those observed in comparable

nerve injuries without causalgia.

Stiffness of the joints, particularly the small joints of the hands and

feet, was frequently excessive, but it was often more reasonably attributable

to disuse than to any specific reaction to the painful process. Splinting had

often been both incorrect and of unnecessarily long duration.
482 NEUROSURGERY

It was usually difficult to appraise the degree of motor paralysis because

of the unwillingness of the patients to permit a complete examination. Upon

relief of pain, many showed surprising degrees of recovery, sometimes within

a few seconds, the observation suggesting that there might be, at least m

part, a reflex paralysis of considerable degree of the type described by

Livingston.

FIGUEE 220.—Serial photographs of patient with causalgia showing extreme suffering,

mode of relief, and complete freedom from pain. A. Painful right hand protected by

sleeve of pajamas. Note facial expression. B. Relief of pain with immersion of hand

in cold water. Note change in facial expression. C. Appearance of patient with causalgia

after sympathectomy. Note unrestricted movement of hand and change in facial expression.

Capt. (later Maj.) Elmer C. Schultz, MC, reported that many of the

patients observed at the 55th General Hospital, Malvern, England, presented

contractures of the muscles. A characteristic deformity of the median nerve,

which often permitted diagnosis at a glance, was hyperextension of the

second and third digits, which bent dorsally.

Sensory losses were as difficult to determine as motor paralysis because

of the extreme hyperesthesia. Usually, it was possible to determine only

which nerve was involved and that the lesion was incomplete.

Psychogenic Factors

The disturbed emotional state of patients with causalgia was always

striking. Though most of them had been stable, valiant soldiers until their

injury, they were many times emotional derelicts afterward. They were

irritable and shut in. They were critical of attendants and found fault with

them captiously. They had no interest in family and friends, even though

they had been overseas for many months.
CAUSALGIA AFTER PERIPHERAL NERVE INJURIES 483

FIGURE 221.—Oscillometric tracings in causalgia of right hand caused by

injury of median nerve. A. Tracings on admission. The skin temperature

of the affected hand at this time was 37.5° 0. and of the normal hand

36.2° O. B. Tracings after preganglionic dorsal sympathectomy. The skin

temperature of the affected hand at this time was 35.4° C. and of the

normal hand 30° C.

AFIP HA-728-1

FIGUKE 222.—Causalgic hand after median nerve injury. Note dry, scaly

skin in the nerve distribution.
484 NBUEOSURGERT

FIGURE 223.—Oscillometric tracings in causalgia of left foot caused by

injury of sciatic nerve. A. Tracings on admission. The skin temperature

of the affected foot at this time was 31° C. and of the normal foot 35° 0.

B. Tracings after lumbar sympathectomy. The skin temperature of the

affected foot at this time was 37.9° O. and of the normal foot 33.6° C.

FIGUEE 224.—Method devised by patient with causalgia to keep hand

constantly wet.
CAUSALGIA AFTER PERIPHERAL NERVE INJURIES 485

Fear, anger, and other emotional stimuli disturbed and distressed them.

Sudden noises, lighting the room without warning, tearing paper, dragging

a chair across the floor, shaking the bed, or an attempt at examination of

the painful part set off such paroxysms of pain that some patients not only

reviled their attendants and physicians but even struck them. Many were

affected by sounds which recalled harrowing wartime experiences. One recalled a boat whistle. Another tried to wreck a dressing cart because the

squeak of the wheels reminded him of the squeaking hinges of the door of

his cabin on the ship on which he had gone overseas. One was particularly

disturbed by the high notes of the bugle call. White, Heroy, and Goodman

described patients whose pain was increased by drinking cold water, witnessing exciting moving pictures, and the act of urination or defecation.

Many patients with causalgia were unjustly classified as malingerers or

hysterical. Practically all of them, however, promptly recovered their emotional stability after relief of pain, and those subjected to psychiatric survey

afterward, in neurosurgical centers, showed no constitutional psychogenic

factors.

At the 55th General Hospital, many of the 63 patients with causalgia

observed over a 6-month period were found to have presented manifestations

of emotional instability before their injuries. These manifestations included

excessive worry; easy excitability; frequent headaches; cold, sweaty hands

and feet; and diarrhea after minor emotional stresses. Many of them also

admitted to a low pain threshold. These observations are contrary to the

usual experience in patients with causalgia.

Roentgenologic Observations

In 20 of the patients with causalgia observed at the neurosurgical

center, Percy Jones General Hospital, roentgenologic examination showed

spotty osteoporosis (fig. 225), somewhat more marked in those in vasodilatation. The demineralization, however, was no more pronounced than it was

in patients with comparable nerve injuries who did not complain of causalgia.

DIFFERENTIAL DIAGNOSIS

Causalgia must be distinguished from a number of other painful posttraumatic states in which burning pain is sometimes a complaint. The diagnosis of causalgia was therefore regarded as justified in most neurosurgical

centers only when the following criteria were met:

1. The pain occurred in an extremity which was the site of a peripheral

nerve injury which practically always was incomplete.

2. The pain was always of a burning character.

3. The pain was extremely severe and was exaggerated, often to a

paroxysmal degree, by environmental and emotional stimuli.

4. The pain was associated with certain vasomotor and trophic changes

(p. 481) and often with personality changes (p. 482).
486 NEUROSURGERY

5. The pain was temporarily relieved by procaine hydrochloride injection

of the sympathetic chain and was permanently relieved by sympathectomy.

Pain associated with neuromas, bony injury, and traumatic arthritis was

of a different quality from causalgic pain. Causalgic pain apparently occupies a much higher level of consciousness, and an experienced observer was

never in doubt of the organic origin and the extent of suffering of a patient

with it. He constantly protected himself from painful stimuli. Patients

with other conditions would frequently demand relief, but they would accept

delay quietly, even placidly. The patient with causalgia would not tolerate

delay.

FIGURE 225—Roentgenograms showing spotty osteoporosis in causalgic limb.

The pain associated with Sudeck's atrophy or painful osteoporosis lacked

the burning character of causalgic pain. It usually occurred in the deep

soft tissues about the smaller joints. The pain complained of in phantom

limb occurred under different circumstances, beginning with complete nerve

section. The pain of hysterical subjects and malingerers also had special

characteristics.

Therapeutic test.—In doubtful cases, the therapeutic test of sympathetic

block was of great value. In the general experience, relief thus secured

seldom exceeded the expected physiologic effect of the drug. Although there

were numerous reports of permanent relief from a single injection, the most

experienced observers came to believe that when this occurred, the patient's

complaints were likely to be psychogenic and not of organic origin. A number of these patients complained of burning pain which was not influenced

by emotional and environmental stimuli, as is characteristic of causalgia.

Some of them presented evidences of vasoconstriction. They obtained prolonged relief by sympathetic block, contrary to the experience of those with
CAUSALGIA AFTER PERIPHERAL NERVE INJURIES 487

causalgia, but were relieved only transiently or not at all by subsequent

sympathectomy; some of them, after the operation, complained of added pain

around the surgical wound. Some patients who underwent sympathectomy

for painful phantom limb had the same experience.21

MANAGEMENT

The wartime experience indicated that no measure except surgery could

be expected to provide permanent relief in causalgia. Symptomatic measures

could obviously not be continued for any length of time because of the very

real danger of drug addiction.

At Percy Jones General Hospital, after the observations made on patients

with malaria (p. 481), artificial fever therapy was tested on five patients.

One remained well after three treatments, but the other four, all of whom

were eventually completely relieved by sympathectomy, had relief only during the period of elevated temperature.

At the neurosurgical center at Kennedy General Hospital, Memphis,

Tenn., as well as at other centers, lysis of the affected nerve did not produce

relief in a single case. At this same center, another patient with burning

pain in the distribution of the radial nerve was apparently cured by repeated

doses of papaverine hydrochloride for 2 days, but similar treatment in other

cases produced no results.

At the 55th General Hospital, this same method was used in mild

causalgias; subcutaneous injections (gr. one-third to one-half) were given

several times daily for several days. It was thought that the improvement

in the capillary blood flow accounted for whatever relief was secured. In a

few other cases of mild causalgia treated at the same hospital, local injection

of the cutaneous nerves of the hand or foot with 1-percent Novocain solution afforded gradual and increased relief with each injection; treatment

could be discontinued permanently after three or four injections had been

given.

Though plans of management differed in the different neurosurgical

centers, as has just been indicated, there was rather general agreement that

patients suffering from causalgia of any appreciable degree should be treated

21 The writer of this chapter has observed only one patient with true causalgia who was not

completely relieved of pain by sympathectomy. This patient, encountered in civilian practice, was

a 55-year-old white woman who had the symptom for 3 years after traumatic amputation of the

fingers. She was addicted to morphine when she was first seen. She had complete relief for 4

days after sympathectomy. Then the pain began to return and soon reached its maximum intensity.

Psychiatric interview under thiopental sodium (Pentothal sodium) revealed that the patient's complaint of pain stemmed from her desire for morphine as well as for industrial compensation for

her injury.

There does not seem justification, in spite of this and similar cases, for the rather general

belief that patients with causalgia arising from civilian accidents which entail damage suits or

industrial compensation do less well than patients observed in military practice. In both military

and civilian practice, of course, long continued pain may lead to emotional instability, including

drug addiction, incompatible with industrial usefulness. Similarly, desire for compensation may

lead to malingering, but these motivations are the results, not the causes, of true causalgia.

4989911'—59 34
488 NEUROSTJRGERY

first by procaine hydrochloride injection of the sympathetic chain for diagnostic purposes. If relief was more than temporary, additional injections

were given, to the number of three or four. If relief was not permanent, as

it most usually was not, it was the general practice to perform sympathectomy, and, as a rule, to perform it promptly.

At the Percy Jones center, early in the war, some patients were injected

as many as eight times without permanent relief; in the later months of the

war, this procedure was employed only for diagnostic purposes.

In some centers, only patients with severe pain were considered candidates for prompt sympathectomy, on the ground that in the less severe cases

the pain would subside spontaneously. This did happen, in a fair percentage

of cases. According to Maj. Francis A. Echlin, MC, 16.6 percent of the

patients with causalgia admitted to McCaw General Hospital, Walla Walla,

Wash., had recovered before the first examination. There is, however, no

assurance of spontaneous recovery in any case, while in favor of prompt

sympathectomy is the sound argument that even if recovery should occur, it

may be so long delayed that the crippling effects of prolonged disuse of the

extremity and the psychic trauma of prolonged pain would be devastating.

The risk of the operation and its side effects are so slight, when the procedure is performed by an experienced neurosurgeon, that they are completely

outweighed by the hazards of delayed treatment.

When the nerve lesion was sufficiently severe to warrant excision of the

injured segment, the substitution of this operation for sympathectomy gave

good results. Periarterial neurectomy at the level of the injury was never

successful. Kecords of the neurosurgical centers reveal no instance in which

periarterial neurectomy of the more proximal portions of the vessels was

carried out by Leriche's technique. This does not seem a logical procedure,

in view of the fact that no fibers are believed to traverse the periarterial

sheath which do not also pass through the ganglionated chain.

Technique of Sympathectomy

The techniques employed at Army neurosurgical centers for both paravertebral block and subsequent removal of portions of the sympathetic

chain followed the practices of the individual surgeons. As a rule, preganglionic dorsal sympathectomy was done by the posterior approach through

the muscle-splitting incision developed by Smithwick.

In the later operations at Percy Jones General Hospital, precautions

originally taken for preventing regeneration of the sympathetic chain, including avulsion of the intercostal nerves and encasement of the proximal

stump with impervious material, were abandoned. It was believed that the

painful lesion would be corrected before regeneration occurred; apparently

this happened.
OAUSALGIÄ AFTER PERIPHERAL NERVE INJURIES 489

While a few surgeons approached the lumbar sympathetic chain transperitoneally, the majority accomplished exposure of the chain through a

unilateral retroperitoneal approach by means of the muscle-splitting incision

described by Shumacker. Others used a modification of the kidney incision,

which transects the muscles of the flank.

To denervate the arm, the rami connecting the second and third dorsal

ganglia were divided, and the chain was sectioned below the third dorsal

ganglia. In cases handled early in the war, this portion of the chain was

left in situ. In later cases, the second and third dorsal ganglia were removed.

In the lumbar region, removal of the second and third lumbar ganglia

was usually sufficient to denervate the leg. At times, however, it was necessary to remove the 11th and 12th thoracic ganglia as well, in order to

denervate the lower extremity satisfactorily.

RESULTS

There are few reliable followup statistics on patients with causalgia,

whether treated or untreated. John K. Mitchell's22report on his father's

patients showed that some of them were still suffering from the condition

20 years after their injuries. Pollock and Davis reported persistent pain

for 2 years or more.

Procaine injection of the appropriate sympathetic ganglia almost invariably gave immediate and dramatic relief of pain for periods ranging

from 1 to 3 hours. In a few instances, partial relief persisted for several

days, but, as a rule, the pain again reached maximum intensity within a short

time. During the period of remission, the patient became cooperative, and a

more thorough sensory and motor evaluation of the involved part was possible. Frequently, in cases in which no motor function had previously been

observed, the patient began to move the painful extremity immediately, which

suggested that in some cases, at least, the pain had initiated a reflex paralysis.

Doupe,23 White,24 and their associates also observed partial relief of pain

for several days after sympathetic block. At Schick General Hospital, Clinton, Iowa, permanent relief of pain was reported in some cases after single

or repeated blocks, and some similar results have been reported by civilian

observers.25 The reliability of the sources makes it impossible to challenge

these results, but, equally, they cannot be explained. In the Percy Jones

General Hospital, the only patients who showed any persistent improvement

after single or repeated sympathetic blocks were those who had been in the

most extreme pain, and their relief was relative, not absolute. One patient

22 Mitchell, John K.: Remote Consequences of Injuries of Nerves and Their Treatment An

Examination of the Present Condition of Wounds Received 1863-65, With Additional Illustrative

Cases. Philadelphia : Lea Bros. & Co., 1895.

23 See footnote 17, p. 475.

24 See footnote 15, p. 475.

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49Q NEUROSURGERY

admitted to this center required sympathectomy for recurrent pain after he

had been discharged from another center as cured after procaine injection.

This was probably not the only case of the kind in World War II.

All of the patients treated surgically at the Percy Jones General Hospital were followed up for at least 6 months after operation. During that

period, none of them had any recurrence of pain as is evident in the tabulated

histories of the first 60 patients treated at this center (table 13). The total

series numbered 105 patients.

Of the first 72 treated surgically, 24 answered questionnaires about their

condition from 3 to 5 years after operation. Fifteen of the 24 were still free

of persistent pain, but 14 complained of slight aching pain in the extremity

when they became fatigued. Many were still conscious of tingling, numbness,

or weakness in the affected limb. This was to be anticipated. Sympathectomy cannot be expected to relieve these manifestations of nerve injury, and,

if the burning pain is relieved, the operation should not be interpreted as a

failure.

An analysis of nine cases in which some pain persisted after sympathectomy showed that, in every instance, the sympathectomy had been incomplete.

In two cases in which the upper extremity was involved, the fourth rib had

been removed instead of the third. In one instance, completion of the

sympathectomy produced complete relief, and, in the other, the symptoms,

although still present, had been so much improved that the patient did not

wish further surgery.

In the seven instances in which the lower extremity was involved, the

second and third lumbar ganglion had been removed in all cases, and the

fourth lumbar ganglion, in addition, in some cases. Sweat tests showed that

sweating was preserved in certain areas of the involved extremity, and injection of the more proximal portion of the chain provided complete relief of

pain.

When the first lumbar ganglion was later removed in all seven of these

cases, three patients had permanent relief. In the four cases in which pain

was persistent after removal of the entire lumbar chain at the second operation, injection of the lower thoracic chain (D10, Dll5 and D12) with procaine

afforded relief of pain in the lower extremity and abolished excessive sweating. Complete relief was later secured by removal of the 10th, 11th, and 12th

thoracic ganglia. Removal of D12 or of Du and D12 might also have

afforded relief, but the magnitude of the necessary procedures did not seem

justified.

It seems highly probable that most instances of failure after sympathectomy can be explained as the failures just recorded were explained;

that is, by incomplete sympathectomy caused by inadvertent removal of the

wrong rib when the arm was involved or by anomalous innervation of the

leg when the lower extremity was involved.
CÄUSALGIA AFTER PERIPHERAL NERVE INJURIES 491

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CHAPTER XX

Peripheral Nerve Grafts

Frank E. Nulsen, M.D., Frederic H. Lewey, M.D., and

William P. Van Wagenen, M.D.

GENERAL CONSIDERATIONS

As casualties accumulated in World War II, it promptly became evident,

as it had been evident in previous wars, that the enormous number of wounds

of the extremities produced by high-velocity missiles would result in many

instances of damage to long segments of peripheral nerves. The first estimates were that about 5 percent of all nerve divisions incurred in combat

might be irreparable by the usual measures of mobilization and suture. As

this situation came to pass, the possibilities of nerve grafting were once

again seriously considered.

The World War I experience with nerve grafts had not been particularly

promising, and little work had been done in this field between the wars. The

type of nerve injuries encountered in civilian life seldom require a consideration of this technique, which is admittedly a last-resort procedure. Isolated

successes with homogenous nerve grafts have been reported in human subjects, it is true. On the other hand, surgeons who have had experience in the

early assessment of results after nerve grafting have remained properly skeptical about them; the reports of success are usually vaguely documented, and

it is generally realized that improvement in the function of an extremity is

more likely to be due to compensatory factors than to nerve regeneration.

That definite and useful regeneration can follow the use of autogenous

nerve grafts after certain injuries has been demonstrated by such observers

as Ballance and Duell1in repair of the facial nerve and by Bunnell2and

Seddon 3in the repair of digital nerves. Excellent results in the repair of

digital nerves were obtained by many surgeons during World War II;

reports of these successes are well documented. Some remarkable results in

autogenous grafting of the facial nerve were reported by Lathrop.4It is

1 Ballance, C, and Duell, A. : The Operative Treatment of Facial Palsy by the Introduction

of Nerve Grafts into the Fallopian Canal and by Other Intratemporal Methods. Arch. Otolaryng.

15: 1-70, January 1932.

2 Bunnell, Sterling : Surgery of the Hand. Philadelphia : J. B. Lippincott Co., 1944.

3(1) Seddon, H. J. : Peripheral Nerve Injuries. Glasgow M. J. 139: 61-75, March 1943.

(2) Seddon, H. J. (editor) : Peripheral Nerve Injuries. Medical Research Council Special Report

Series No. 282. London : Her Majesty's Stationery Office, 1954.

4 Lathrop, Frank D. : Facial Paralysis in Military Personnel. In Medical Department, United

States Army. Surgery in World War II. Ophthalmology and Otolaryngology. Washington : U.S.

Government Printing Office, 1957, pp. 525-548.

493
494 NEUROSURGERY

also well established that cross suturing is often successful; a centrally

divided facial nerve for instance, may be supplied with substitution innervation from the hypoglossal or the spinal accessory nerve trunk.

A careful distinction must be made, however, between the use of autogenous grafts in injuries of these relatively small nerves and the homogenous grafting of the extensive combat-caused nerve deficits of major

peripheral nerves considered in this chapter. The techniques just described

were not applicable to the vast majority of the injuries of such major nerve

trunks as the median, ulnar, radial, tibial, and peroneal nerves which were

encountered in World War II.

In extensive deficits in these nerves, it is impossible to find a comparable

nerve trunk for sacrifice for grafting purposes in the same patient without

imposing upon him an additional serious functional deficit. It was only

occasionally that irretrievable damage to another extremity permitted use

of one of its nerve trunks as a graft or that the loss of the fourth or fifth

fingers associated with extensive damage to the median nerve permitted the

use of the ulnar nerve in an attempt to restore all-important median nerve

function. Autografts of this kind have sometimes been satisfactory, especially

when the ulnar nerve has been employed as a pedicle to maintain the ulnar

blood supply, but these opportunities seldom arise.

Theoretically, it would seem possible that a long length of a dispensable

sensory nerve, such as the saphenous or the lateral femoral cutaneous nerve,

might be cut into shorter lengths and the lengths laid side by side as a

bridging cable graft to overcome a defect in a major nerve trunk. This

technique has been employed satisfactorily in grafts of the digital and facial

nerves, and occasional successes have been reported following its use in other

areas. When, however, one considers that the cross section of this type of

cable graft consists of perhaps 10 percent nerve tubules and 90 percent connective tissue and interstices between filaments, the success of such a bridge

seems unlikely, even as a theoretical possibility.

DEVELOPMENT OF THE PROGRAM

The first attempts at homogenous nerve grafting in World War II

centered around the use of fresh nerves obtained from patients who had

undergone amputation; these circumstances permitted the immediate use of

the graft under aseptic conditions. Seddon and Holmes5in England and

Spurling and the group working with him at Walter Reed General Hospital,

Washington, D.C., all employed this technique. By 1944, however, it had

become apparent that none of their patients were showing physiologic signs

of regeneration, and, on later histologic study, it was found that the best

regeneration had never proceeded more than 20 mm. into the proximal end

of the graft and that its extent even at this level was scanty.

5 Seddon, H. J., and Holmes, W.: The Late Condition of Nerve Homografts in Man. Surg.

Gynec. & Obst. 79 : 342-351, October 1944.
PERIPHERAL NERVE GRAFTS 495

The consistent failure of homogenous nerve grafts and the success reported by Weiss6

and his associates in the use of frozen dried homografts

in animals led to an extensive trial of this method in man. Hope that this

inert material might serve better than fresh grafts for nerve regeneration

was based on the theory that inert material would not continue to undergo

metabolic changes and necrosis and thus would not promote the degree of

foreign-body or inflammatory reaction which occurred with fresh homografts.

The results of 20 frozen dried homografts used by Lyons and Woodhall

at Walter Reed General Hospital did not bear out this hope.7 With a single

exception,8the results, whether full-thickness grafts were used or grafts

consisting of many separate fascicular cables, were comparable to the results

obtained with fresh homografts, in that only the most proximal portion of

the graft became neurotized.

The results in the 26 similar grafts employed at the Cushing General

Hospital Neurosurgical Center, Framingham, Mass., and reported in this

chapter were equally discouraging. Skepticism concerning their possible

value might have developed earlier except for two reasons. The first was the

long delay inevitable between the placement of a graft and the evaluation

of its capacity for permitting regeneration. The second was the hope, which

proved vain, that repeated alterations in technique, which were regarded as

improvements, might improve the results in the later cases of the series.

MATERIALS AND METHODS

In the 11-month period after this program was transferred from Walter

Reed General Hospital to Cushing General Hospital in August 1944, 26

frozen dehydrated homogenous nerve grafts were employed in 21 patients.

Of the injuries, 5 were incomplete and 21 were complete.

All the grafts were obtained from autopsies conducted at Boston City

Hospital and Peter Bent Brigham Hospital, Boston, Mass., both of which

kindly cooperated in the program. Cadavers were utilized for this purpose

only when the following criteria were met:

1. Autopsy could be performed within 4 hours of death.

2. Infection and chronic malnutrition had played no obvious part in the

fatality.

3. The patients were young men or were relatively young.

The nerves were removed under conditions of absolute sterility. The

blood group of the donor was rechecked. Separate cultures were made from

the heart blood and the donor site as an additional safeguard against pos6 Weiss, P. : Experiments on Nerve Eepair. Tr. Am. Neurol. A. 1943, pp. 42-45.

7 The results in these cases are discussed in the followup study of World War II peripheral

nerve injuries undertaken by the Veterans' Administration, the Army and Navy, and the National

Research Council (p. 230).

8 Although this patient "was operated on while the program was in progress at Walter Reed

General Hospital, he is included in this series because most of his followup period was spent at

the Cushing General Hospital Neurosurgical Center and because he had a later evaluation in 1949

by one of the authors of this chapter (F. E. N.). He is included in this series as case 1 (p. 500).

498991y—59 35
496 NEUROSURGERY

sible bacterial contamination. Other cultures were made at various stages of

preparation of the grafts, and any batch in which bacterial growth occurred

was discarded.

The material was prepared according to the technique of Weiss and

Taylor,9by quick freezing in sterile isopentane cooled by liquid nitrogen to

—175° C. The frozen grafts were then dehydrated in vacuo, at a temperature

between —30° and —40° O, in sterile tubes, which could be sealed when

drying had been completed. Each tube was plainly marked with the autopsy

source and the blood group of the donor and was stored in an antiseptic

solution with other tubes until it was used.

When it was decided, during an operative procedure, to bridge a defect

between nerve ends by grafting, a tube containing material of the appropriate

blood group was obtained. In the first cases at Cushing General Hospital,

rehydration was accomplished by breaking the vacuum tube in Ringer's solution. Later, after histologic study of resected grafts, it was found that

serum rehydration produced less distortion than rehydration accomplished

by Ringer's solution, water, saline solution, or spinal fluid. The patient's own

serum was therefore utilized in most of the later cases to accomplish

rehydration.

INDICATIONS

Frozen dehydrated homogenous nerve grafts were used on the following

indications:

1. Wien the extent of the defect seemed to make direct suture impossible.

2. Wien direct suture could not be accomplished without tension on the

suture line. In some cases,.in which the defect was less extensive than in the

group of injuries just mentioned, suture seemed technically possible after the

employment of extensive mobilization of the nerve trunk or after such radical

measures as bone shortening. In many of these cases, however, it was thought

that the degree of tension on the suture line would be so considerable that

physiologic regeneration and functional recovery would be unlikely to

parallel the anatomic feat of approximation and suture.

3. When the slack necessary for overcoming a defect between nerve ends

could not be obtained because of fixation of a joint, as, for example, fixation

of the knee in full extension.

4. When mobilization of nerve trunks could not be accomplished without

extension of the necessary dissection to areas of damaged skin and soft tissue

in patients with multiple points of injury.

5. When the injuries involved the median or ulnar nerve at the wrist or

the tibial nerve at the ankle to such an extent that direct suture could be

accomplished easily only if mobilization were carried above the elbow or the

knee. There was frank concern over how such extensive handling of long

9 Weiss, P., and Taylor, A. C. : Guides for Nerve Regeneration Across Gaps. J. Neurosurj:

375-389, September 1940.
PERIPHERAL NERVE GRAFTS 497

lengths of nerve, with consequent impoverishment of the blood supply, might

influence regeneration. In these circumstances, the necessary grafts were

relatively short, and it was hoped that a relatively short graft might behave

more favorably than a long graft. Finally, in this area, the means for early

recognition of failure was at hand, since the distance for growth to skin and

muscle was short. If failure occurred, therefore, there could be a prompt

resort to the more extensive mobilization procedure which would permit

direct suture.

6. When damage to a nerve trunk, although incomplete, was so extensive

that nearly half of the cross section of the nerve seemed implicated in stonyhard scar tissue which was so sharply delineated, at least grossly, that the

balance of the nerve seemed intact and capable of regeneration. In some

cases of this kind, the lesion involved a long segment of the nerve, and it did

not appear technically feasible, after the affected portion had been resected,

to approximate the portion in discontinuity. A graft was therefore inlaid

when it seemed that more might be lost than gained by sacrificing the segment in continuity in order to accomplish full-thickness resection and suture.

The graft was considered the best expedient for the patient but was undertaken with the full realization of the difficulty of attributing any part of

whatever recovery might occur to regeneration through the graft.

TECHNIQUE

Evolution of Surgical Methods

The first 15 grafts employed at Cushing General Hospital (this number

including the graft used in the patient operated on at Walter Eeed General

Hospital) were obtained from the sciatic nerve. In the first of these cases,

fascicles of large caliber were used, of such a size that two or three thicknesses corresponded to the defective areas in the recipient nerve trunks. In

later cases in which the sciatic nerve was used, it was broken down into

increasingly small filaments before processing, so that from 5 to 10 strands

were needed to match the size of the recipient nerve trunks.

Evidence suggested that these finer filaments fared better from the standpoint of both vascularization and neurotization, and the material for the last

11 of the 26 grafts in the series therefore consisted of the anterior roots of

cauda equina, which were secured by laminectomy in the cadaver. If smaller

filaments were preferable, as it was thought they were, these roots were

ready at hand and were free of the large connective tissue septa found in

peripheral nerve tissue. It was also thought that the uniformly large tubules

of these motor roots would afford a better bridge for axonal regeneration

than the scattered large and small tubules of the sensory roots.

The technique of placement of the grafts underwent a number of modifications, as follows:
498 NEUROSURGERY

1. In the cases which were handled during the first 3 months of the program at Cushing General Hospital, a tantalum sleeve was employed to

encompass the entire graft and the resected nerve ends for 5 to 10 mm. At

the end of this period, when the first reexplorations were conducted because

of obvious failures, it was found that, although good union of the proximal

nerve ends and grafts had occurred, the major portion of the grafts, which

had been insulated from any circumferential vascular supply, had a totally

inert appearance. The gross observations were confirmed by histologic study.

2. When these observations were made at the second operation, it was

also observed that the tantalum sleeve had created a cylindrical cavity of

fibrous tissue, within which fresh grafts could be easily approximated to the

freshened nerve ends and held in place by closure of the cavity with sutures.

In two of the early failures, regrafting was carried out in this fashion at the

end of 3 months.

3. In other cases, a two-stage procedure was employed. At the first

operation, a cavity was prepared to enclose the graft, by connecting the nerve

ends with an empty tantalum sleeve. From 4 to 6 weeks later, the sleeve

was removed, and the cavity which had been formed by it was utilized to

hold a cable graft in continuity with the freshened nerve ends.

4. In still other cases, after the technique of complete insulation by the

tantalum sleeve had been abandoned, the grafts were enclosed in collagen

sleeves as an alternative to the two-stage procedure.

5. In one instance, the graft was approximated to the nerve ends with

narrow tantalum bands, leaving its major portion exposed to the surrounding

tissue.

6. Toward the end of the program it was learned that the plasma glue

technique of Tarlov10 was being used routinely at St. Alban's Naval Hospital

in New York as a method for nerve-end approximation. This technique

permits the application of many nerve filaments, in good approximation, to

the face of large nerves, without resort to cuffs or sleeves, in instances in

which cable grafts are used and suture is not technically feasible. This

method was used in only one instance in this series (case 16, p. 501) to patch

grafts onto facial nerve filaments. The results were remarkably good.

7. All five partial nerve defects were filled in with graft inlays.

Postoperative Management

After operation, the injured extremity was immobilized in plaster for 3

to 4 weeks, as in the usual nerve repair. Small marking wires placed on the

sheaths of the nerve ends were repeatedly visualized by roentgenograms, to

be certain that the ends did not become widely separated during subsequent

mobilization of the joint.

10 Tarlov, I. M. : Plasma Clot Suture of Nerve—Illustrated Technique. Surgery 15 : 257-269,

February 1944.
PERIPHERAL NERVE GRAFTS 499

EVALUATION OF RESULTS

Incomplete Injuries

All of the five partial nerve defects filled in with graft inlays (table 14)

showed clear clinical evidence of varying degrees of regeneration. Three of

these grafts were reexposed when the tantalum sleeve was removed. At this

time, the graft could not be distinguished from the intact nerve, but electrical

stimulation applied to the inlaid nerve elements produced no sensation. No

method was available to determine what part the graft may have played in

the regeneration which was evident in all of these cases.

TABLE 14.—Results of use of frozen dried homografls in 6 partial peripheral nerve defects

Case

number Nerve

Location of

injury

Timelag,

injury to

grafting

Timelag,

insertion

to removal

Size of graft

Gross observations

at reexploration Clinical result

17

18 -

Tibial

. do

Mid thigh.--

Ankle.-- -

Wrist

Forearm

Mid thigh__.

Months

2

5

3

3

10

Months

13

13

14

3.5 cm., % cross

section.

2.5 cm., YL cross

section.

3 cm., Yz cross section.

2.4 cm., )4 cross

section.

4.5 cm., Ys cross

section.

White, insensitivePink, sensitive

do

Low-grade sensation.

Fair sensation, no

motor recovery.

Good sensation,

fair motor recovery.

Better than average recovery.

Minimal recovery.

19

20

Ulnar

do

21 Peroneal

1 Tantalum cuff removed.

Complete Injuries

When nerve grafts were applied to complete defects, the problem of

evaluation was simpler. A fair test of the potentials for nerve regeneration

would have covered many months if clinical evidence had been awaited, and

the policy, therefore, was to reexplore the injury within 3 to 4 months on the

suspicion of failure. The basis of the suspicion was the absence of Tinel's

sign just below the graft and the absence of paresthesias when the same

point was stimulated electrically with needles introduced percutaneously.

At operation, the graft was removed for microscopic study unless, in

addition to perception of paresthesias when the exposed graft was stimulated

electrically, there was gross evidence of some vascularization and viability.

When slight neurotization had occurred, as was subsequently demonstrated

histologically in the grafts removed, its extent was found to be closely

paralleled by the extent of the sensitivity of the graft to stimulation. Suture

by radical measures was usually possible in these cases, and the specimen

for study included the graft with the attached proximal and distal nerve

stumps.
500 NEUROSURGERY

Some grafts which proved to be failures were left in place longer than

was generally thought desirable because of apparent signs of regeneration,

which later proved to be misleading. Methods used to prove that regeneration had occurred unequivocally through grafts to complete nerve defects are

best described by the following case histories:

Case 1.—This patient, who was operated on at Walter Reed General Hospital by Maj.

Benjamin B. Whitcomb, MC, sustained a perforating wound of the left distal forearm,

with severance of the median nerve and a compound fracture of the radius. Because

of infection, operation on the nerve was not undertaken until 11 months later, in June

1944. A proximal neuroma of the median nerve was found in minimal continuity with

a bulbous distal nerve. Stimulation of the neuroma gave rise to paresthesias referred

to the median sensory zone.

The neuronal continuity was considered inadequate for function. The nerve ends

were therefore resected until grossly normal nerve tissue was obtained, the gap thus

created being 7 cm. By employing the degree of partial wrist flexion which the bone

injury permitted, plus the use of two tantalum stay sutures, the nerve ends could be

brought within 3 cm. of each other. This gap was filled with a full-thickness frozen dried

homograft from the sciatic nerve. The graft was anchored to the proximal and distal

ends by two sutures at each end. The graft and the nerve ends were wrapped in a

cylindrical sleeve of tantalum foil.

Six months later, in December 1944, the area was reexplored, to remove the tantalum

sleeve and examine the graft. Although the graft was narrowed in the central portion,

it appeared to be vascularized. The occurrence of paresthesias in the median area on

stimulation of the distal nerve indicated that some neurotization had occurred through

the graft into the distal nerve. Although there was no evidence of useful regeneration

at this time, it was decided to leave the graft in place for an additional period of

observation.

Three months later, this patient was transferred to Cushing General Hospital, with

a warning that the staff should not be misled by the scanty evidences of regeneration

through a graft which, if left in situ, was probably destined to give less adequate regeneration than might be obtained with its removal and extensive nerve mobilization and

direct suture.

Fifteen months after insertion of the graft proximal to the wrist, evidences of

median nerve function were unequivocal. Sensory examination revealed that 40 gm. pain

stimulus and 16 gm. touch stimulus could be felt throughout the median area. When the

area of the graft was infiltrated with procaine hydrochloride, and while ulnar and radial

sensation were intact, this sensation was absent in the two terminal phalanges of the

index and long fingers. Conversely, nerve blocks which were undertaken as a separate

maneuver and which produced total sensory loss in the radial and ulnar areas were without effect upon pain and touch perception in the median autonomous zone.

Sweating was assessed by skin resistance, as a further test of skin innervation. The

median area became dry when the graft was blocked. Later, it showed 80 percent of

normal sweating. Sweating in the median area was either unaltered or even increased

by the discomfort attendant upon total combined radial and ulnar blocks.

When motor function was tested, observers were agreed that the opponens pollicis

contracted during attempted thumb opposition and that slight rotation of the thumb was

evident. This component of thumb movement was lost when the graft was blocked.

The most convincing evidence of regeneration was afforded by electrical stimulation

delivered to two needles inserted in the vicinity of the graft; a definite contraction could

be seen in the opponens pollicis and was sufficient to roll the thumb over from its relaxed

position to a point opposite the middle finger. This movement was recorded cinemat-
PERirHERAL NERVE GRAFTS 501

FIGURE 226.—Successful use of frozen dried homograft by

plasma glue technique in injury of right facial nerve at mastoid

tip. The pictures were taken 8 months after operation. A. Face

in repose. B. Face on smiling.

ographically. When the test was repeated on several occasions, it was therefore possible to accept this evidence of an increasing volume of movement response, in spite of

the skepticism among the observers.

This patient was observed in October 1949, under the auspices of the peripheral

nerve regeneration study project supported by the Veterans' Administration, the National

Research Council, and the Army and Navy (p. 230). At this time, his sensory thresholds

in the median autonomous zone were 2 gm. for pain and 2 gm. for touch; occasional

points required 10 gm. of stimulus. Median nerve block abolished this sensation, while

radial and ulnar nerve blocks did not affect it.

Thumb opposition was rated at 25 percent of normal. The movement was produced

by median stimulation; ulnar stimulation produced only flexion. The patient could pick

up small objects blindly between his thumb and the tips of any of the last three fingers.

Impaired flexion of the index finger and the tip of the thumb were residuals of tendon

involvement.

The median motor and sensory functions were rated at a level close to the average found after median nerve suture at the wrist and above the average when suture

had been delayed, as in this instance, for 11 months after injury.

Case 16.—This graft, the last of the complete nerve severances in the series, was carried

out 4 months after the facial nerve had been injured at the mastoid tip. The central

end was found at operation, as were two distal filaments corresponding to the inferior

and middle facial branches. Two filaments of cauda equina were attached to the central

end with plasma glue. One of these filaments was glued to the middle branch for a

length of 4 cm. and the other to the inferior branch for a distance of 1 cm. The grafts

were left exposed to the tissues, which had been freely dissected.

Within 4 months, this patient began to show action at the angle of his mouth, and,

at the end of another 4 months, there was function in all of the lower facial musculature

up to the level of the orbicularis oculi. Needle stimulation of the facial nerve behind

the mandible reproduced the movements initiated voluntarily by the patient. The amplitude of action in the lower face, as well as the cosmetic result, was fully as satisfactory

as is usually seen after suture (fig. 226). Complete paralysis of the upper ocular musculature and of the forehead persisted because it was impossible to find a satisfactory

superior branch for inclusion in the graft.
502 NEUROSUKGERX

RESULTS

The two case histories just related represent the only two successes in 23

attempts to use frozen dried homografts to bridge complete nerve defects.

The remaining 16 cases, all of which ended in failure, are most conveniently

analyzed according to the procedures employed (table 15).

TABLE 15.—Results of use of frozen dried homografts in complete peripheral nerve defects

in 16 cases {21 operations)

Surgical tech- Nerve Location of

injury

Timelag,

injury to

grafting

Timelag,

insertion

to

removal

Length

of graft

Findings at reexploration

niques

Gross Histologie

Tantalum sleeve

technique: Months Months Cm.

Case 1 _-. . Median Wrist 11 3 Vascularized, sensi- Left in situ, regenertive. ation.

Case 2i —do ...do 3 2.5 3.5 Proximal 5 mm.

pink and sensitive.

Slight neurotization

and vasculanzation for 5 mm.

Case 3 .. Ulnar _ .. do— 2 5 5.2 Proximal 10 mm.

pink but insensiVascularization for 1

cm., questionable

tive. neurotization.

Case 4

l

. __.do ...do 4 2.5 5.5 Totally avascular,

insensitive.

No vascularization

or neurotization.

Case 5 —do ...do 3 4 2 Shrunken, avascular, insensitive.

Marked sterile inflammatory reaction; slight neurotization and vascu-

. larization for 7

mm.

Case 6 —do Forearm.. 3 2 10 Nccrotic, grossly

infected.

Inflammation, necrosis.

Case 7i Tibial Calf 3 4 5 Totally avascular,

insensitive.

No vascularization

or neurotization.

Case 8 . . Radial Axilla.. _ 5 6 3.5 Yellow, insensitive.. No tissue reaction.

Cased Median— Forearm. _ 4 3 6 Nccrotic, grossly infected .

Inflammation, necrosis.

Exposure technique:

Case 10 1 Ulnar Upper

arm.

9 2.5 6.5 Yellow, insensitive

in toto.

Vascularization and

resorption; neurotization for 2 mm.

Case 4

2

_-_ .. . .„do Wrist 7 11 7 Pink and sensitive

for 26 mm.

Vascularization, resorption; slight

neurotization at

periphery.

Case 2

2 Median.-. —do 5.5 9 5 Avascular, but

slightly sensitive

throughout.

Minimal neurotization extending to

distal-nerve.

Collagen sleeve

technique:

Case 10 2 Ulnar Upper

arm.

11.5 5 9.5 Totally insensitive

and inert.

Most of graft resorbed; neurotization for 2 mm.

Case 10' Median... ...do 11.5 5 10.5 Shrunken, fibrosed,

insensitive.

Neurotization for 3

mm.

Case 11 —do Forearm.. 8 5 10.5 Fibrosed, insensitive.

Graft largely resorbed; one nerve

bundle invaded for

I 1 5 mm.

See footnotes at end of tzible.
PERIPHERAL NERVE GRAFTS 503

TABLE 15.—Results of use of frozen dried homografts in complete peripheral nerve defects

in 16 cases {SI operations)—Continued

Timelag, Timelag, Findings at reexploration

Surgical techinjury grafting to of graft

removal Gross Histologie

Collagen sleeve

techniqueContinued Months Months Cm.

Casc72 Tibial Calf 7 9 8 Largely inert hut

slightly sensitive.

Severe fibrotic

change; minimal

neurotization for 5

cm.

Prepared bed

technique:

Case 12 ...do ...do 8 5 Not reexplored.

Case 13 Median.-- Forearm _ _ 10 9 4 Yellow, shrunken,

insensitive.

Slight vascularization, no neurotization.

Case 14 ...do Wrist 6 8

K Pink, sensitive

throughout, slight

contraction in

opponent.

Slight neurotization

throughout.

Case 15 Peroneal-- Above

knee.

12 7 3 Shrunken, inert,

insensitive.

Not removed. No

clinical recovery at

1 year.

Plasma glue

technique:

Facial Mastoid

tip.

4 4andl Not reexplored, obvious clinical

signs of regeneration at 4 months.

i First operation. 2 Secc nd operation a Thh d operatio n.

Tantalum Sleeve Technique

The technique employed in case 1 was generally followed in eight other

cases (table 15, cases 2 through 9). Either large or small fascicles obtained

from the sciatic nerve were enclosed, together with the nerve ends, in a tantalum sleeve except that, in most cases, the nerve ends were sutured to the

surrounding tissues rather than joined with wire stay sutures. The defects

bridged ranged from 2 to 10 cm. The time interval from injury to grafting

was more favorable in all the other cases than in case 1, but all the other

eight grafts were unequivocal failures.

There are various explanations for the failures. In cases 6 and 9, gross

infection ensued. In case 2, the median nerve lesion was in many respects

similar to the lesion in case 1. When the graft was reexamined at the end

of 2y2 months, after dissection of the tantalum sleeve, it was found firmly

attached to the nerve ends, with some bulbous enlargement at the proximal

junction. Except for the proximal 5 mm., most of the graft had either a

cadaveric appearance or the same gross appearance as when it was introduced.

The proximal area was pink, and stimulation limited to it produced median

paresthesia. More distally, both the graft and the distal nerve were insensitive to electrical stimuli.
504 NEUROSURGERX

FIGIIKE 227.—Successful use of frozen dried homograft by tantalum

sleeve technique in injury of median nerve at wrist. Note that the central portion of the graft retains its initial appearance. D, distal end

of graft. P, proximal end. G, graft occupying central portion.

swag» ,.__ ***&%*%&«!£KSWAT fewf^v. ^»>-. • -w ^'^L/-"•-•'a-Ä.^BiaBl^^^sssaSBa

ÜK3Är

fe

&lla«&flW^!^B%r»

FIGUKB 228.—Successful use of frozen dried homograft by tantalum

sleeve technique in injury of median nerve at wrist. This photomicrograph shows the best portion of the proximal nerve, well removed from

the graft. There is considerable fibrosis, with a minimum of amyelinic

fibers losing their direction in their progression toward the graft at

the left.

The graft was removed en bloc, with short lengths of proximal and

distal nerve ends. The histologic appearance of the graft in case 2 (figs. 227,

228, 229, and 230) may be summarized as follows:

1. In spite of good attachments of the graft at each end, vascularization

and organization were limited to a short zone, within 6 mm. of the nerve

junctions. More centrally, cadaveric preservation rather than necrosis was

evident.

2. The proximal nerve end consisted chiefly of connective tissue with a

paucity of axons, which were chiefly unmyelinized in any given area. It was

thought that this finding could reflect inadequate resection of the scarred
PERIPHERAL NERVE GRAFTS 505

rMiS'J

FIGURE 229.—Successful use of frozen dried homograft by tantalum sleeve technique

in injury of median nerve at wrist. The graft shows colliquation necrosis (N) but

preservation of fibroblasts and sheaths of Schwann (A and F).

graft bundles are also present (G).

Unattacked but dead

nerve end, though the frequency of similar observations throughout the series

suggested that the opposed graft might induce inflammation and fibrosis in

the nerve end.

3. A few amyelinic nerve fibers penetrated the graft for 3 to 5 mm., as

had been suggested by the sensory findings when the graft was stimulated,

but they were clishearteningly few in number, and they chose to drill their

way into the dense connective tissue of the perineurium rather than to seek

out the tubules of the nerve graft intended to attract them.

The case just described might be classified as a not quite complete failure.

More typical of the complete rejection of the graft as a vehicle for axonal

ingrowth was the histologic appearance of the graft in case 4 (figs. 231, 232,

and 233). This graft appeared to have induced the proximal nerve end to

wall itself off with a fibrotic cap Avhich permitted absolutely no neurotization

of the graft itself. There was much less vascularization of the graft at its

ends than in case 2, while the largest (central) portion apparently remained

insulated from any tissue reaction at all.

The wide differences in behavior in the grafts in the cases handled by

the tantalum sleeve technique (cases 1, 2, and 4, for instance) cannot reason-
506 NEUROSURGERY

SÖg»

«I

FIGUEE 230.—Successful use of frozen dried homograft by tantalum

sleeve technique in injury of median nerve at wrist. Necrosis is occurring nearer the center of the graft in the perineurium, while the fibers

of the graft themselves remain largely intact and inert.

ably be attributed to technical considerations. On the contrary, they suggest

an all-or-none acceptance of the graft by the host.

Exposure Technique

Because the technical measures of insulating the entire graft from the

surrounding tissues was thought to play a possible role in the failure of

frozen dried homogenous grafts, three grafts obtained from the sciatic nerve

were subsequently placed without such insulation. The most favorable degree

of neurotization occurred in case 2, the patient on whom the tantalum sleeve

technique had originally been employed. When the original graft was removed as a failure, a fresh graft was placed, after the nerve ends had been

freshened and the gap thus increased from 3.5 to 5.0 cm. The cavity left by

removal of the tantalum sleeve included the nerve ends, and it was possible

to suture it along its roof, so that nerve ends and graft filaments were held

in good apposition.

This graft was left in situ for 11 months, chiefly because sensory recovery

due to overlap and motor improvement by compensatory muscle functions

were assumed to be evidence of returning median function. At the next

(third) operation, the graft showed little change in the gross color to suggest vascularization, but both the graft and the distal nerve were sensitive
PERIPHERAL NERVE GRAFTS 507

G

SPSS«? SaSSS***

W®SM£\

FIGURE 231.—Unsuccessful use of frozen dried homograft by tantalum

sleeve technique in injury of ulnar nerve at wrist. Despite good attachment between nerve and graft, a solid cap of fibrous tissue divides the nerve

from the graft. G, graft. P, proximal nerve end.

PIGUKE 232.—Unsuccessful use of frozen dried homograft by tantalum

sleeve technique in injury of ulnar nerve at wrist. Disorganization is present to a surprising degree, and nearly all the nerve fibers are amyelinic,

although it would be reasonable to expect to find a nearly normal nerve in

this area, which is well removed from the graft.

to electrical stimulation. In spite of this finding, the graft was removed

because of the absence of motor response and the absence of, or reduction in,

skin sensation when the distal nerve was blocked with procaine.

Histologie examination (figs. 234 and 235) showed that, after case 2 was

operated on the second time, axons had penetrated through the proximal half

of the graft in fair numbers until the area of marked fibrotic reaction was

reached distally. In spite of this barrier, a few amyelinic nerve fibers were

discernible beyond the graft in the distal nerve.
508 NEÜROSURGBRY

FIGURE 233.—Unsuccessful use of frozen dried homograft by tantalum

sleeve technique in injury of ulnar nerve at wrist. Central portion of inert,

intactly preserved graft. The appearance is more nearly that of normal

nerve than the appearance of the section shown in figure 232.

In the other two grafts of this group, similar partial neurotization had

occurred, but to a lesser degree.

Collagen Sleeve Technique

At this time, as already mentioned, it seemed that abandonment of insulation of the graft by the use of a tantalum sleeve had improved the situation

by permitting vascularization of the grafts in all cases, with some minor

degree of neurotization. It was also thought, however, that vascularization

did not occur without a corresponding degree of fibrosis, which might seriously block the growth of nerve fibers.

As a compromise, therefore, a different type of insulation, with collagen

sleeves, was instituted in four cases, with the hope that humoral exchange

through these membranes, in the absence of fibroblastic ingrowth, might have

a favorable influence. These four grafts, however, fared no better than the

grafts originally encased in tantalum sleeves, whether judgment was by clinical standards or on the basis of the histologic appearance when the grafts

were removed 5 to 9 months after they had been placed.

Prepared Bed Technique

In addition to the four grafts already described which were placed in a

cavity preformed by the use of a tantalum sleeve which was discarded at the

time of grafting, four other grafts were managed by the same technique
PERIPHERAL NERVE GRAFTS 509

P

FiGUiiE 234.—Unsuccessful use of frozen dried homograft by exposure

technique, after removal of tantalum sleeve (figs. 227, 228, 229, and

230). There is good ingrowth of axons toward the left, to the point of

neuromatous formation, with slight continuity into the distal end. N,

graft. D, distal nerve end. P, proximal nerve end.

except that the material consisted, instead of sciatic fascicles, of many filajments of cauda equina motor roots laid side by side. f

Three of these grafts were entirely unsuccessful. The fourth (case 14)

showed more neurotization than any of the other grafts removed as failures.

In this case, the defect in the median nerve, after resection of damaged

nerve ends, was 5 cm. The frozen dried homograft was placed 6 months

after injury and was reexplored 8 months later in its location just proximal

to the wrist. Grossly, its appearance throughout was pink, and its caliber

was uniform except for a reduction at the distal junction with the nerve.

Both the graft and the distal nerve were sensitive to electrical stimulation,

and there was a barely visible contraction in the opponens pollicis. These

findings were considered inadequate evidence for regeneration 8 months after

grafting, and the graft was therefore removed and primary suture accomplished. Although the histologic picture (case 14) (figs. 236 and 237)

showed the persistence of many nerve bundles which had not been organized

and there was considerable neuromatous disorganization and fibrosis, amyelinic

regenerating fibers could be traced throughout the length of the graft and

were discernible in a photomicrograph of the distal nerve end.

Results of Autogenous Nerve Grafts

For purposes of comparison, another illustration is included in this chapter, a cross section of the distal end of an autogenous (ulnar) nerve graft

used to bridge a 9.8 cm. defect between the proximal end of the median nerve

and a digital nerve to the index finger (fig. 238). The injury was caused by

a shell fragment, which avulsed most of the soft tissues of the hand. The

section shown, at the distal suture line, was removed 6 months after operation, when the graft was found to be sensitive and the distal nerve was inert

to stimulation; a fresh suture was done at this point, The rich degree of

neurotization observed in this autograft is in striking contrast to the findings

in the homografts removed in this series.
510 NEÜROSÜRGERY

FIGURE 235.—Unsuccessful use of frozen dried homograft by exposure technique, after

removal of tantalum sleeve (figs. 227, 228, 229, and 230). In this section from the distal

end of the graft, some neurotization by regenerating amyelinlc fibers is seen to the right

of the areas marked A.

SUMMARY AND CONCLUSIONS

Definite success was achieved in only 2 of 26 frozen dried homografts

used to bridge defects in major peripheral nerves at the neurosurgical center

at Cushing General Hospital in 1944-45. Different techniques were used in

each of the successful cases. The single successful graft to a large mixed

nerve occurred through a short (3-cm.) defect. In general, insulation of any

greater length of nerve by a foreign body appeared to doom the procedure

to failure because the center of the insulated bridge apparently remained

inert and seemed actually to repel any attempt at axonal invasion, even when

the invasion had got off to a fair start in the proximal segment of the graft.

In two instances, exposure of the graft to surrounding tissues permitted

some neurotization, which was, however, inadequate to extend throughout the

length of the graft. The impression was received that neurotization was

interfered with by the fibrotic reaction that occurred in the exposed graft.

While this reaction did not interfere with the functional success of a facial

nerve graft, in this case, the situation was far more favorable because of the

use of fine filaments and the unusual regenerative capacities of this pure

motor nerve.
PERIPHERAL NERVE GRAFTS 511

FIGUHE 23G.—Unsuccessful use of frozen dried homograft by collagen

sleeve technique. The proximal end of the nerve is well attached to

the graft in minimal continuity with the distal end. Much of the graft

has not undergone organization, although some neurotization has occurred throughout. P, proximal end. D, distal end.

FIGURE 237.—unsuccessful use of frozen dried homograft by collagen

sleeve technique. Inert fibers of the graft as seen at the junction of

the graft with the distal nerve (A), while regenerating fibers are seen

in another area (F).
512 NEUROSURGERY

FIGURE 23S.—Successful autogenous (ulnar) nerve graft used to bridge

9.8 cm. defect between proximal end of median nerve and digital nerve

to index finger. Cross section of distal 1 mm. of this graft. Note the

high degree of neurotization by amyelinic fibers.

In the five instances in which homografts were inlaid into partial defects

involving from a third to two-thirds of the cross section of the nerve, it

seemed possible, and usually seemed probable, that the observed recovery

occurred through the intact portion of the nerve. In two cases (cases 19

and 20), recovery was better than might have been expected since half of

the nerve was missing. In two cases (cases 18 and 19), the graft appeared

to have some degree of function at reexploration. In a third case (case 17),

the graft looked like a foreign body at the second operation, although circumstances for its vascularization and neurotization were highly favorable. It

may be that only this last observation is of importance; it emphasizes the

possibility of complete rejection of the graft by the injured nerve in situations in which grafting could most logically be expected to be successful.
CHAPTER XXI

Neuropathologic Changes in Battle-Incurred

Injuries of Peripheral Nerves

William R. Lyons, Ph. D., M.D.

During the period between 19 February and 11 June 1945, inclusive, 105

external neurolyses and 228 neurorrhaphies (on 203 patients) were performed

in the neurosurgical section, Halloran General Hospital, Staten Island, N.Y.

The 228 specimens secured in the course of the nerve repair operations were

studied jointly by the surgeons and the pathologist attached to the service.

The collaborating neurosurgeons were Maj. John J. Lowrey, MC; Maj. Benjamin B. Whitcomb, MC; Capt. George T. R. Fahlund, MC; Capt. Wade C.

Myers, MC; Capt. William T. Muse, MC; Capt. Stanley E. Potter, MC; and

Capt, (later Maj.) Hugo V. Rizzoli, MC.

There were several reasons for making this study a cooperative endeavor

between neuropathologist and neurosurgeons, as follows:

1. To study each nerve specimen with the aid of special stains, in order

to accumulate information for use in the handling of future cases.

2. To determine the effect of the time element on the creation of adverse

and irreversible changes in distal segments and on the degree of fibrosis in

the nerve stumps in relation to the distance from the main point of injury.

3. To apply to each case the information gained previously in other cases

with the aid of the microscope and correlated with the appearance of the

lesion at surgery. Thus, it was not enough to ascertain that a good fascicular

pattern was exposed on each stump by fresh sections. Careful scrutiny with

the aid of a binocular loupe supplemented by discriminating palpation of

each nerve was necessary to detect any suggestion of fibrosis due to stretch

ischemia or time lapse.

4. To insure the direct collection of an adequate number of nerve ends

representative of the tissue finally coapted, so that, at a future elate, a correlation might be struck between the quality of the cross sections and the degree

of functional restoration.

MATERIALS AND METHODS

All 228 specimens were received directly by the pathologist from the

surgeon immediately after excision. After 24 hours' fixation in 10 percent

formalin, buffered with magnesium carbonate, the specimens were cut into

513
514 NBUROSURGERY

transverse and longitudinal sections and embedded in paraffin. They were

then cut at 8-10 micra, were impregnated by means of the Bodian Protargol

method, and were counterstained with a phosphomolybdic acid-aniline blue

mixture.

Of the 228 specimens, 152 were secured from the upper extremity and

76 from the lower extremity. In the upper extremity, 12 were secured from

the brachial plexus, 1 from the suprascapular nerve, 1 from the axillary nerve,

4 from the musculocutaneous nerve, 35 from the median nerve, 54 from the

ulnar nerve, 39 from the radial nerve, and 6 from the cutaneous nerve of the

forearm. In the lower extremity, 25 were secured from the sciatic nerve,

1 from the femoral, 22 from the posterior tibial, 26 from the common peroneal, and 2 from the sural nerve.

The number of specimens from the upper extremity was almost double

the number from the lower, and specimens from the ulnar nerve were in

excess of all others. Essentially the same distribution was noted in a series

of 163 consecutive neurorrhaphies at Walter Reed General Hospital, Washington, D.C., over an 8-month period just before this study was undertaken.

The specimens fell into two main groups, as follows: (1) Lesions in

continuity and (2) lesions with complete severance. These specimens were

further categorized as follows:

Specimens: Number

Completely severed nerve stumps 54

Severed nerve stumps In fibrous continuity 13

Partial neuromas in continuity 20

Complete neuromas in continuity 83

Nerve segment eroded by aneurysm 1

Sites of—

definitive neurorrhaphy 18

temporary neurorrhaphy 30

disrupted sutures 6

bulb sutures 3

Total 228

Because of their special interest, a fresh whole nerve homograft, a frozen

dried homograft, a fresh cable autograft, and a nerve showing fresh fibrosis

are included in the discussion, but, because they were collected after the other

specimens had been analyzed statistically, they are not included in the analysis.

TIME LAPSE

The following tabulation shows the distribution of the cases in this series

in relation to timelag between wounding and suture in 203 peripheral nerve

injuries:
NEUROPATHOLOGIC CHANGES 515

Timelag, in months : (number)

0-1 1

1-2 7

2-3 33

3-4 49

4-5 40

5-6 25

6-7 16

7-8 8

8-9 6

9-10 5

10-11 6

11-12 3

12-13 4

Total 203

It is probably true that the majority of the 203 patients were operated on as

early as possible, but it is also true that the surgeons concerned would rather

have performed the operation before, instead of after, the third month, as

was necessary in 80 percent of the cases.

COMPLETELY SEVERED NERVE STUMPS

Study of the completely divided nerves by means of routine application

of the Protargol technique of impregnation provided an abundance of information on all stages of wallerian degeneration as well as on the degenerative

and regenerative phases in the proximal stump. The whole series was sufficiently large and diversified to permit one to identify in the human all of

the main findings reported by Ramon y Cajal1in his classical work on nerve

degeneration and regeneration in experimental animals. Efforts were directed

toward evaluating and understanding each specimen on the basis of (1) the

nature of the traumatizing agent, (2) the observed trauma, and (3) time

relations.

Photographs were taken of the cross sections representing mirror images

of the nerve ends finally sutured and of longitudinal sections of all nerves

made after fixation. Figure 239A shows the typically enlarged and neuromatous proximal stump, surrounded by epineurial adhesions of fat, muscle,

and scar tissue, and the slightly shrunken distal stump, largely fibrotic and

also covered by adhesions. Even after resection of about 6 cm. of nerve, the

surgeon was still faced with considerable disparity in the cross sectional area

of the two ends. The topographic histology of these ends is shown in figure

239B and C. It should be noted that, while they represent a fair average of

all ends coapted in this series, they are, nevertheless, fibrotic between and

around the fascicles and show considerable edema within the proximal fascil Ramon y Cajal, Santiago : Degeneration and Regeneration of the Nervous System. Translated

and edited by Raoul M. May. New York : Oxford University Press, 1928.
516 NEUROSURGERY

FIGURE 239. (See opposite page for legends.)
NEÜROPATHOLOGIC CHANGES 517

FIGURE 240.—Cross section of proximal stump of severed musculocutaneous nerve

illustrating diffuse neuromatous proliferation involving the entire section and obliterating

most fascieular outlines. Great numbers of small neuromatous bundles have grown out

of the fascicles into the regions between the fascicles and beneath the epineurium. ( X 15)

cles. The pathologist learned to overlook such thickening of epineurium as

is seen here because it was highly respected and valued by the surgeon, not

only for better guidance of his needle, but also for more efficient maintenance

of his sutures.

Figures 240 and 241 are representative of cross sectional areas of proximal and distal nerve stumps taken from regions nearer the point of severance. They illustrate the types of reaction that the surgeon attempted to

avoid by cutting back the ends. The proximal section (fig. 240) consists of

large numbers of small regenerating nerve bundles growing in disarray amid

FIGURE 239.—Complete severance of ulnar nerve. A. TJlnar nerve completely severed

by mortar shell fragment 8% months previously. (Soldier was prisoner of war in Germany for 7 months.) Note the enlarged and neuromatous proximal stump surrounded

by fat, muscle, and scar tissue, and the slightly shrunken distal stump (D). The fascicles

shown in the proximal cross section are extremely edematous. (X 1.5) B. Proximal

cross section of nerve shown in A. Note intrafascicular edema and moderate interfascicular and epineurial fibrosis. (X 20) C. Distal cross section of specimen shown in A.

Note epineurial, perineurial, and interfascicular fibrosis. The small fascicle at the upper

Jeft has become almost obliterated. (X 20)
518 NEUROSüRGERY

FIGURE 241.—Cross section of distal stump of severed branch of femoral nerve showing marked generalized flbrosis around and between the shrunken, degenerated fasciclea

Note also fat and dense epineurial scar tissue. (X 22.5)

granulation tissue. These bundles illustrate the tremendous force delivered

by the nerve cell body to the peripherally damaged fibers, which may send

out as many as 40 fine fibrils from a single axis cylinder. The fascicular

sheaths are found obliterated for a distance of 1 centimeter or more proximal

to the point of severance, with neuromatous fibers escaping in all directions,

and usually through the epineurium into the surrounding tissue. The distal

section (fig. 241) shows atrophic nerve fascicles buried in dense scar tissue

and fat.

Figure 242 shows in longitudinal sections the improvement attained by

resecting the proximal and distal stumps as far back as seemed safe, with

due regard to subsequent tension. Figure 243 and color plates 1 through 7

are examples of the studies routinely made at higher magnifications of the

proximal and distal sections cut in the longitudinal and transverse planes.

The use of a Protargol and aniline blue combination permitted a study of

the degenerative and regenerative changes in axis cylinders on the one hand

and the degree of flbrosis on the other. It was possible to accumulate facts

on retrograde degeneration in the proximal stump nerve fibers, as well as to

witness the amount and nature of the regrowth of such fibers. The study of

intrafascicular flbrosis and tubular shrinkage in the distal stumps was deemed

of even greater practical importance than the study of regeneration, not only
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PLATE 1.—Cross section through proximal fascicle of ulnar nerve severed by mortar

shell fragment 5% months earlier. Resection of this stump was made approximately 20

mm. central to the severance point, and the histologic pattern shown here is essentially

that of a normal nerve. There is some edema, but very little Intrafascicular fibrosis and

no perineurial thickening. Some of the tubules have remained degenerated and appear

empty; others show regrowth of one or more nerve fibers. Most of the fibers appear

normal, with thick axons and wheelspoke neurokeratin patterns in their myelin sheaths.

(X 600)
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PLATE 2.—Cross section through proximal fascicle of median nerve severed by bullet

2% months earlier. Resection of the stump was made approximately 15 mm. central to

the severance point. The picture shown here is one of profuse regeneration of amyelinated and lightly myelinated fibers along and within the swollen, degenerated tubules.

Only a few of the tubules have remained empty, and even these show small fibers regenerating along their outer sheath surfaces. Some fibers appear to have taken isolated

pathways in the edematous endoneurium between the old tubules. Some of these, as well

as fibers within the tubules, show a narrow, clear area between the axon and neurilemma,

indicative of new myelination. (X 600)
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PLATE 3.—Cross section through proximal fascicle of median nerve severed by glass

1 week earlier. Resection of this stump was made approximately 10 mm. central to the

severance point. Here may be seen the various phases of myelin sheath and axonal

disintegration. In a few of the degenerating fibers, remnants of the neurokeratin network are still present. The axonal fragments have assumed bizarre shapes within the

distended neurilemmal sheaths. Some of the nuclei especially adjacent to the old sheaths

belong to the Schwann cells, while others, between the tubules, are flbroblastic. Macrophages with spheroidal nuclei have migrated into some of the tubules. Some of the fine

black dots in different regions of the section represent what was judged to be the early

phase of filamentous regeneration of a few of the least-injured axons (seen better in

long sections). (X 600)
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PLATE 4.—Cross section through proximal fascicle of ulnar nerve severed 3 months

earlier by bullet. This stump was resected at a point approximately 20 mm. central to

the severance point. The section was made through a region in which most of the nerve

fibers had undergone retrograde degeneration. Although a fair number of normal appearing, well-myelinated fibers are seen, the majority of the fibers represent regenerating and

thickening axons in clusters or isolated. Some of these show evidence of new myelination. (X 600)
PLATE 5.—Longitudinal section through proximal fascicle of sciatic nerve severed by

shell fragment 4 months earlier. In this region, the injured myelinated fibers had given

off many fine and ravelled filaments that had progressed distally for approximately 20

mm. to form a large neuromatous bulb. (X GOO)
PLATE 6—Cross section through distal fascicle of median nerve severed by shell

fragment 7 months earlier. Although many small collateral vessels had developed since

injury, this segment of nerve had remained relatively ischemic and presented a histological picture of marked endoneurial fibrous overgrowth with almost complete destruction of

the usual tubular pattern. (X 000)
PLATE 7.—Cross section through distal fascicle of sciatic nerve severed by steel fragment 2% months previously. The marked endoneurial flbrosis shown here was not seen

in all fascicles at this level (approximately 15 mm. distal to the severance point).

Medial parts of this outer fascicle showed large tubules with minimal fibrosis. The

variation in tubular shrinkage shown here indicates that the proximity to the point of

injury is .just as important a factor as the time interval in determining the degree of

endoneurial flbrosis. (X600)

498991*—59-
PLATE 8.—Longitudinal section through fascicle of proximal segment of neuroma in

continuity in posterior cord of brachial plexus severed by shell fragment S

1

^ months

earlier. Considerable fibrous replacement had taken place in this fascicle, and, within

this fibrous tissue, a well-thickened regenerated axon had formed two bulbs simulating

compound sensory corpuscles. In the distal bulb, the axon ends in a skeinlike growth,

within which Schwann cells may be seen. Below are seen clusters of regenerating

amyelinated fibers accompanied by Schwann cells. (X 600)
. \

PLATE 9.—Longitudinal section through proximal end of 70-mm. long neuroma in

continuity in common peroneal nerve injured by mortar shell fragment 2% months earlier.

A few degenerated tubules containing axonal debris, fat, and proliferating Schwann cells

are present; otherwise, this field, which is typical of the rest of the fascicle, is entirely

occupied by innumerable axonal sprouts attended by Schwann cells, growing in parallel

lines within, or sometimes on, the outer surface of the old tubules. (X 600)
PLATE 10.—Longitudinal section through neuroma in common peroneal nerve severed

by machinegun bullet 4% months earlier. The nerve ends separated, and a narrow

fibrous and neuromatous isthmus formed between them, made up of the types of tissue

shown here. Without the guiding aid of neurilemmal tubules, the regenerating axons

grew in all directions and formed intricate networks comparable to the diffuse nets that

some nerves form in the skin areas. Schwann cells can be seen closely applied to the

branching axonal filaments. Macrophages filled with globules and fibroblasts are present

in the intervening fibrous tissue. (X 600)
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PLATE 11.—Longitudinal section through midsegment of neuroma in continuity in

median nerve injured by bullet 3% months earlier. This section represents a later phase

of the same crisscross pattern of nerve fiber growth seen in plate 10. The small nerve

bundles have become more dense, due in part to a thickening of the individual filaments.

Communications could be traced between different nerve bundles, and the arrangement

shows some similarity to that of an autonomic nerve plexus. (X 600)
PLATE 12.—Longitudinal section through proximal segment of frozen dried nerve

homograft placed In defect of posterior tibial nerve severed 29 months earlier and

grafted 1 year earlier. Small bundles of amyelinated nerve fibers (black) had penetrated the graft for a distance of 15 mm. An ovoid structure simulating a compound

end organ is seen in the upper part of the field. Most of the graft has been replaced

by dense collagenous tissue (blue). (X 600)
NEUROPATHOLOGIC CHANGES 519

in regard to followup studies but in guiding and reemphasizing the policy

of early suturing of nerves.

Figures 243D, 244, and color plates 6 and Y show representative cross

sections taken from a large series of distal stumps resected from Y days to

Y years after nerve severance. It was learned from this study that the neurilemmal tubules usually remained unshrunken for a month or two after nerve

transection, with a gradual shrinkage accompanied by endoneurial fibrosis

during the following months. The extremely dense collagenization seen in

1 case (fig. 244D) after 25 months was sometimes seen as early as the sixth

month. The maintenance of patent though shrunken tubules, even after 2

years, provides partial evidence to explain the regeneration seen in the distal

parts of nerves sutured after long intervals of time, or in nerves sutured at

long distances from their terminations. Further studies will be required to

determine how well nerve fibers gaining access to the attenuated tubules or

the fibrotic intertubular regions are able to thicken and myelinate.

SEVERED NERVE STUMPS IN FIBROUS CONTINUITY

The 13 specimens in this group differed from those secured from completely severed nerves in that narrow strands of what appeared to be largely

fibrous tissue connected the severed stumps (fig. 245). Histologically, this

tissue was found to be the reinforced residue of a few shreds of nerve substance not cut through by the injurious agent. This type of specimen was

often found in conjunction with bone fractures, the association suggesting

that the jagged bone edges rather than the missile had been responsible for

the trauma. Although the isthmus was almost completely fibrotic (fig.

245C), it was usually possible to find microscopic evidence of fine nerve filaments regenerating through it to the distal segment.

It must be borne in mind that sparse regeneration of nerve fibers through

such attenuated connections—and indeed through the scarred bed of completely separated stumps—into the distal segment may be responsible for the

diagnosis of an advancing Tinel sign. This error leads to the conclusion that

a positive Tinel sign progressing distalward is not a valid reason, in the

absence of other favorable signs, such as resumption of function in muscle,

for postponing surgical exploration and neurorrhaphy. The possibility of an

advancing Tinel sign is no guarantee that sutured stumps have remained in

adequate continuity. This is why it was considered an advantage to use tantalum sutures and markers, which can be readily seen in X-ray films, to be

certain that sutured stumps had not become disrupted.

NEUROMAS IN CONTINUITY

The problem of deciding whether to resect or leave nerve lesions in continuity (fig. 246) was often very difficult. During the period of this survey,
520 NEUROSURGERY

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FIGURE 242. (See opposite page for legends.)
NEUROPATHOLOGIC CHANGES 521

as already mentioned, 105 lesions in continuity were explored and not resected.

Their appearance and their response to electrical stimulus suggested that

they required little more than a lysis from scar tissue and sometimes the

placement of a tempered tantalum sleeve. During this same period, 103

lesions in neuromatous continuity were removed and studied as specimens.

This figure indicates not only that the neurosurgeons were cognizant of the

formidable barriers to good nerve regeneration present in such lesions but

also that they had confidence in their ability to overcome these barriers by

neurorrhaphy. That they were amply justified has already been shown by

a microscopic study of the parts resected and by the rapid functional return

in the great majority of the sutured nerves.

Although the causes for the formation of neuromas in continuity are

many and varied, most of the lesions in this series appear to have been

caused by partial severance or severe contusion by missile fragments or by

fractured bones. Two-thirds were caused by artillery shell fragments and

about one-third by small weapon missiles; only three were due to landmines

and only two to aerial bombs. In a third of the cases, fracture of a neighboring bone accompanied the nerve injury, and the presence of bone fragments within some of the neuromas in continuity (fig. 247) seemed an adequate explanation for their formation. In other instances, a single small

fragment of steel, lead, or brass (fig. 248) would be found embedded in the

nerve, and, because it was often at some distance from the main wound, it

was assumed to be the sole contributing factor.

Depending upon the nature of the inflicting force, the lesions varied from

a small epineurial scar or wartlike excrescence to a large fusiform swelling

twice the normal diameter of the nerve (fig. 249). When it was possible for

the surgeon to separate whole and healthy fascicles from the neuromatous

part of the nerve, only the latter was resected (fig. 250) and a partial or

knuckle suture was performed. In some neuromas in continuity, only one or

two fascicles had remained intact (fig. 251), and these were often enclosed

in such dense scar tissue that the entire lesion had to be resected. In most

cases, however, all of the fascicles appeared to have been disrupted, and their

sheaths were so damaged and torn as to preclude the proper alinement of the

regenerating nerve fibers (figs. 252 and 253).

FIGURE 242.—Complete severance of posterior tibial nerve. A. Median longitudinal

section through neuromatous proximal stump of severed posterior tibial nerve. Fascicular

pattern is completely lacking. (X 9) B. Section just proximal to neuromatous bulb

shown in A. Regularly arranged fascicles are present, although there is still some interfascicular fibrosis, and the central fascicle is very edematous. (X 9) C. Median longitudinal section through distal stump of nerve shown in A, with point of severance (at

left) showing complete fibrosis. (X 9) D. Section just distal to fibrotic stump shown

in C. This section demonstrated the improvement attained by resecting approximately

1 cm. beyond the zone of contusion. Areas of fibrosis are interspersed between regular

fascicles and longitudinally directed blood vessels. Note clot at left formed at end of

artery following first transection. (x 9)
522 NEUROSURGERY

U '.- * "V1. v- *.. \-*V fitFIGUEE 243.—Complete severance of radial nerve. A. Longitudinal section through

proximal stump of radial nerve severed 41 days previously by machinegun bullet. Regenerating, amyelinated nerve fibers have grown along degenerated tubules. Note regions

of tubular distension. (X 600) B. Proximal cross section of nerve shown in A. Note

regenerating nerve fibers in walls and lumina of degenerated tubules and in zones of
NEUROPATHOLOGIC CHANGES 523

intertubular fibrosis. (X 600) C. Longitudinal section through distal stump of nerve

shown in A. Note degenerated Schwärm tubules containing debris and macrophages.

Excessive collagenization is seen between tubules. (X 600) D. Cross section through

same distal stump shown in C. Note that 41 days after section the tubular detritus is

still in process of being resorbed and that the tubules are slightly distended. (X 600)

49S991V—59 37
524 NBUROSUKGERY

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FIGURE 244.—Cross sections through fascicles of distal stumps showing changes in

size of Schwann tubules and replacement fibrosis which may be considered typical of

entire series of degenerated distal segments. A. Cross section resected from median nerve

severed 2% months earlier. B. Cross section from posterior tibial nerve severed 5 months

earlier. C. Cross section from median nerve severed 14 months earlier. D. Cross section

from posterior tibial nerve severed 25 months earlier. (All X 600)
NEUROPATHOLOGIC CHANGES 325

FIGUHB 245.—Neuroma of ulnar nerve. A. Median longitudinal and cross sections of

ulnar nerve incompletely severed by rifle bullet 2% months earlier. (P, proximal; D,

distal.) (X 1.5) B. Median longitudinal section through proximal segment from nerve

shown in A, showing region in which fascicles break up to form neuromatous bulb. (X 9)

C. Median longitudinal section through distal segment and fibrous isthmus connecting it

with proximal segment. Section is from nerve shown in A. A few nerve fibers had

grown through the isthmus and penetrated the degenerated distal tubules. (X 9)
526 NEUROSÜßGBRY

The neuromas in continuity were valuable in studying the regenerative

capacity of injured or severed axons (color plates 8, 9, and 10). In some

instances it was possible to compare, in the same section, axons that appeared

normal throughout the lesion and those that had undergone degenerative

changes for several centimeters proximal to the main site of injury and had

already sent regenerative sprouts through to the distal segment. With the

date of injury known, it was possible to evaluate the various phases of

degeneration and regeneration in relation to time.

FIGURE 246.—Surgical exposure of median nerve injured above elbow

by rifle bullet 2 months earlier. After removal of the neuroma in continuity and neurorrhaphy, nerve regeneration took place at a rate of

2.4 mm. per day, and within 6 months function had returned to all the

muscles supplied by this nerve except the opponens pollicis.

As in the cases of complete severance, a series of photomicrographs of

sections of distal fascicles was prepared and was used in two ways, as follows: (1) As a supplement to the other series in a study of the influence of

time on degenerative changes, and (2) to learn something about the fate of

numerous fibers regenerating through the main site of the lesion. In most of

the cases in which a complete neuroma in continuity was resected, electrical

stimulation of the nerve distal to the lesion elicited a painful, but never a

muscular, response. Histologically, all such distal segments showed varying

numbers of regenerating fibers, most of which were amyelinated and of very

small caliber.

Probably the most significant finding in these cases was the lack of any

appreciable myelination of the regenerating fibers, even after periods of

several months. The sections shown in figure 254A, B, and C were prepared

from an ulnar nerve that had been lysed 4 months after injury and then,

after an unavailing wait of 6 more months, reexplored with resection of the

neuroma in continuity. The lesion was near the wrist, and 10 months should

have been ample time for functional regeneration of nerve fibers. Fibers had

regenerated through the badly scarred zone of contusion, as is evident in

figure 254A and B. That these fibers had not myelinated is demonstrated

in a section through a distal fascicle (fig. 254C), in which fine axis cylinders
NEUROPATHOLOGIC CHANGES 527

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FIGUKE 247.—Longitudinal section through neuroma in continuity of ulnar nerve contused by bone splinters from fractured ulna. Besides the main fragment of bone, which

appears to have proliferated and which possesses a marrow, many smaller splinters were

found throughout the neuroma. (X 30)

FIGURE 248.—Longitudinal section through neuroma in continuity of ulnar nerve in

which small brass fragment was found. A dense fibrous capsule had formed around the

fragment, and beyond this, on all sides, the regular nerve fascicles had been replaced by

a neuroma made up of scar tissue and multiple small crisscrossing nerve fiber groups.

(X 62)
528 NEUROSURGERY

may be seen enmeshed in an endoneurial fibrosing process. In this case, it

seemed likely that the main factor contributing to the failure of distally

growing fibers to mature properly was fibrosis in the contusion zone. From

this and other cases, it was concluded that a densely collagenous envelopment of the regenerating axis cylinders in the neuromatous zone usually precludes functional development of such fibers even though they gain access to

patent distal tubules.

FIGURE 249.—Proximal (P) and distal

(D) cross sections and median longitudinal sections of common peroneal (upper)

and posterior tibial components of sciatic

nerve showing large neuromatous areas

contused by displaced end of femur fractured by shell fragment 4% months earlier. (X 1.1)

FIGURE 250.—Sciatic nerve contused 3%

months earlier by machinegun bullet.

Only the common peroneal component was

badly damaged. It was excised as shown,

and its ends were approximated by knuckling the posterior tibial component.

Attention is drawn to the better blood supply in the distal segments of

the neuromas in continuity as contrasted with that of the severed distal

stumps. In the former, the fascicles of both stumps appeared succulent and

there was little or no disparity in cross sectional areas when surgical sections

were made at the proper levels. In completely severed nerves, the distal

stump fascicles were always shrunken and never edematous, as in the proximal

stump, and thrombosed, sclerotic vessels were generally observed in them.

NERVE SEGMENT ERODED BY ANEURYSM

The finding of only a single nerve eroded by an aneurysm among a

group of 228 resected nerve specimens should not be construed as indicating

the true incidence of such associated lesions. The probable explanation is

that patients with combined nerve-vascular injuries were assigned to other
NEUROPATHOLOGIC CHANGES 529

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FIGURE 251.—Neuroma in continuity of common peroneal nerve. A. Median longitudinal and cross sections through neuroma in continuity of common peroneal nerve

partly severed by mortar shell fragment 2% months earlier. (X 1.5) B. Longitudinal

section through middle and distal parts of specimen shown in A. All but two fascicles

were destroyed, and they were found to be compressed between the hard fibrous neuroma

and dense epineuri.il adhesions. (X 0)
530 NEUROSURGERY

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FIGUKE 252.—Fusiform neuroma in continuity of ulnar nerve. A. Sections through

median longitudinal plane of fusiform neuroma in continuity resected from ulnar nerve

contused by mortar shell fragment 2% months earlier. B. Proximal section of specimen

shown in A. All fascicles are seen to have been torn or interrupted. C. Distal longitudinal section. All tubules are in process of resorption, and some show ingrowth of

nerve fibers regenerating at random through the neuroma. (X 9)

centers. This specimen of radial nerve (fig. 255A, B, and C), however, is

typical of the cases seen elsewhere. The sacculated aneurysm in the wall of

the axillary artery had deeply eroded the radial nerve and rendered it completely functionless. All but two fascicles in the lateral epineurial region

had been separated and destroyed by the erosional beat of the artery. The

nerve fibers in the main site of damage, and even in the two fascicles remaining in continuity, had undergone degeneration, and a futile attempt at

regeneration on the part of some of the nerve filaments (fig. 225C) was seen

in the scar tissue around the crater.
NBUROPATHOLOGIC CHANGES 531

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FIGUKE 253.—Neuroma in continuity of ulnar nerve. A. Median longitudinal and

transverse sections of ulnar neuroma in continuity resected 6% months after shell fragment wound. The ulna was also fractured. (X 1.5) B. Longitudinal section through

central part of neuroma shown in A. Fascicles have been replaced by small bundles of

regenerating nerve fibers growing at random amid the scar tissue, especially in the

epineurial regions in which muscle and adhesions are seen. (X 9)

Fifty-three days had elapsed since the injury was sustained, and it is

noteworthy that the patient came to surgery with a diagnosis of radial nerve

palsy and not of aneurysm, possibly because the radial pulse had always been

detectable, whereas bruit in the axilla had not been. Nerve ends showing

good fascicular pattern were obtained after resecting a 30-mm. specimen.

Evidence that such patients may be expected to show good progress is found

in the fact that within 3y2 months after suture, an 8-inch (20-cm.) advance

in Tinel's sign and beginning function in the triceps muscle were observed.

SUTURE SITES

Classification and timelag.—A group of 57 resected suture sites in a series

of 228 nerve specimens may seem disproportionately large, but about half

of the specimens should probably be classified as temporary coaptations.

Adequate histories available for 29 specimens permitted the following classifications :

1. Definitive suture was performed in seven instances within 2 days of

injury, and in seven within 20 days to 11 months.

49S991V—59 3S
532 NEUROSURGERY

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NEUROrATHOLOGIC CHANGES 533

2. Disruption occurred in seven other instances of definitive suture.

3. Temporary suture was performed in five instances from 1 to 10 clays

after injury.

4. Bulb suture was employed in three instances.

The remaining 28 specimens were obtained from cases in which there was

either no record of suture or insufficient data for determining whether the

suture was intended as temporary or definitive. By the use of such notes as

were available, as well as on the basis of gross and microscopic appearance

of the specimens, 4 of these 29 specimens were arbitrarily assigned to a

probably definitive class and 24 to a probably temporary class. In 8 of the 28

questionable cases, notations on the Field Medical Record were to the effect

that a nerve suture had been done (7 within 2 days of injury and 1 on the

11th day). The records in the remaining 20 cases contained no evidence that

neurorrhaphy had been done, and it was only an assumption that the suture

material found in these specimens had been placed there at the time of

debridement, or, less likely, at closure.

In 11 of the 28 cases without notes or adequate descriptions of procedure, the severances were found to be only partial, and it is possible that

the few approximating sutures used may have been considered adequate and

definitive at the time of debridement. This has not been assumed in classifying them. The single case in which a nerve was accidentally severed at

debridement was accompanied by a note indicating that temporary sutures

had then been placed.

Suture material.—From this heterogeneous group of 57 specimens of

suture sites, there was gleaned considerable information helpful in the general

problem of nerve suturing. Opportunities for observing the tissue reactions

to various types of suture material were particularly useful. The finest

available silk, nylon, cotton, or linen all caused the typical foreign body giant

cell and fibrous reaction (fig. 256); in specimens removed a year or more

after suture, extensive reactions were still very much in evidence. It was

learned that naming needles atraumatic and threading them with the finest

tantalum do not make them any less injurious to the tissues impaled upon

them (figs. 257 and 258). When suture material involved fascicles instead

of epineurium, nerve fibers were either destroyed by a severe fibrosing process

FIGURE 254.—Neuroma in continuity of ulnar nerve. A. Median longitudinal section

through neuroma in continuity resected from ulnar nerve contused by bullet 10 months

earlier. Neurolysis had been performed on this nerve 4 months after injury, without

effect. No intact fascicles were present in the midsegment, in which a hard fibrous

neuroma had formed. (X 9). B. Higher magnification of midsegment seen in A, showing disarray of fine nerve fibers attempting to regenerate through dense collagenous

tissue. (X 250) O. Longitudinal section through fascicle of distal stump of nerve

shown in A. Nerve fibers sparsely distributed among collagenous tissue are seen to have

grown through the zone shown in B. A few fibers have become thickened, and others

have formed braids, but, in the 10-month interval, none have properly matured. (X 600)
534 NEUROSURGERY

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FIGURE 255. (See opposite page for legends.)
NEUROPATHOLOGIC CHANGES 535

or were so altered as to form an intrafascicular neuroma (fig. 258). The

reaction around tantalum sutures as well as around foil (fig. 259A and B)

was largely one of fibroblastic proliferation and collagenation.

When properly prepared tantalum sleeves (rolled from 0.0005 inch

foil and tempered at 900° F. for 2 minutes in an oven were removed from

anastomotic sites several months after placement, it was noticed that a

smooth epineurium had sheathed the nerve and that a new, grayish-white

membrane had covered the outer surface of the sleeve (fig. 259A and B).

A few cases were included in this series in which fibrin film had been

placed around suture sites. The findings corroborated those of the Walter

Reed General Hospital series studied in 1944, when fibrin film had proved

to be a failure as a wrapping material for nerves. Extremely dense epinenrial scar tissue was always associated with the fibrin film used at that

time, and, as may be seen in figure 260A and B, the material remained in situ

and caused a typical foreign body reaction. In figure 260A, the complete

destruction of nerve fascicles by a temporary silk sling stitch is also shown.

Influence of timelag.—A study of the influence of the time lapse on the

endoneurial fibrosing process in the distal tubules of the sutured nerve stumps

repeatedly emphasized the importance of early neurorrhaphy. Many of the

specimens of suture sites were obtained 5 months or longer after the original

neurorrhaphy, and although most specimens showed some neurotization of the

distal stump, the gradual fibrous replacement was very much in evidence after

the longer intervals (figs. 261 and 262). The regenerating fibers in these

cases remained fine in caliber or degenerated after being choked by collagenous tissue.

Even greater significance was attached to the more pronounced, diffuse

fibrosis in the midst of the neuromatous proliferation in the suture zone.

This was considered to be the main reason for the failure of regenerating

fibers to gain access to patent distal tubules and for the failure of most of the

fibers that had penetrated the distal tubules to maintain themselves.

Somewhat similar pictures were seen in the central regions of the sutureline neuromas that developed in nerves sutured at the time of injury and in

those sutured secondarily, but with inadequate resection. Figure 263A, B,

C, D, and E are illustrations of a typical suture-line neuroma resected from

FIGURE 255.—Erosion of radial nerve by aneurysm. A. Specimen of radial nerve

eroded by aneurysm. External view (above) shows craterized portion and fibrous adhesions around the point of injury. Below are seen the proximal (P) and distal (D) cross

sections showing good fascicular pattern and a median longitudinal section with portions

of the destroyed fascicles. (X 1.2) B. Longitudinal section through the eroded region

seen in A. Peripheral to the central scar tissue are the ends of segments of fascicles

surrounded by fibrous reaction. (X 9) G. Higher magnification of portion of midsegment shown in B. Pine anastomosing or braided nerve fibers have attempted to

regenerate in the midst of scar tissue and old tubular remnants. Large macrophages

filled with fat and other debris are also present. (X 600)
536 NEUROSURGERY

FIGURE 256.—Giant cell and fibrous reaction around fibers of silk (S) used in suture of

severed ulnar nerve. (X 600)

an ulnar nerve sutured within 24 hours of severance. It was concluded from

a study of these early sutures that it must have been almost impossible for

the surgeon to foretell, on the day of injury, how far the pathologic process

would extend along the nerve stumps. In the case illustrated, another 5 cm.,

at least, should have been excised at the first operation, in order to have

excluded most of the contused nerve from the suture site. That a good

proximal cross section was not attained even at the second neurorrhaphy is

shown in figure 263E.

Observations have proved that the granulation and scar tissue response

to nerve contusion becomes fairly well demarcated within 3 weeks. Microscopic examination of a series of transections of the stumps of nerves damaged 3 weeks or more earlier usually revealed that intraneural changes such

as fibrosis, edema, hemorrhage and thrombosis, neuromatous proliferation

within or between fascicles, and sheath distortion had extended for at least

1 cm. above and below the points of obvious gross pathology. From this,

it would seem to follow that surgeons who advocate the urgency of immediate suture should be prepared to resect as much stump above and below

the main site of injury as would be compatible with a good coaptation

without undue tension after transplantation, rerouting, complete mobilization, and joint posturing. This is mentioned because it is one of the common
NEUROPATHOLOGIC CHANGES 537

FIGURE 257.—Fibrous reaction around site from which tantalum sling stitch was

removed. The tantalum had been placed in the ulnar nerve at suture 4 months earlier.

Note small bundles of regenerating nerve fibers above and to the left. (X 480)

questions asked a pathologist, who is just as helpless as the surgeon in

predicting on the clay of injury how far the effects of the trauma will

eventually extend.

Failure of neurorrhaphy.—The reason for failure of some of the secondary neurorrhaphies in this series was not so much the inability to recognize

the extent of the lesion as the lack of other methods of obviating it, after

all of the usual maneuvers had been resorted to. There were only a few

cases, however, in which, at a previous secondary neurorrhaphy, the surgeon

had been unable to avail himself of all of the accepted methods of gaining

nerve length in order to resect adequately, and, in consequence, had been

faced with the task of suturing a large edematous neuroma to a shrunken,

fibrotic distal stump. One of the results of such a suture is shown in figure 264, in which a neuromatous rind has grown over a distal stump that

had been coapted to a proximal neuromatous stump with over 100 percent

greater cross sectional area. The region shown was enclosed within a

tantalum cuff, and, beyond this point, the distal stump had a cross sectional

area equivalent to the central fasciculated region.
538 NEUROSURGERT

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.

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is.-:

FIGURE 258.—Median longitudinal section through suture site of median nerve severed

by gunshot wound and sutured on day of injury, 11 months before reexploration and

resection. The scar tissues around the site from which the tantalum suture was removed

had replaced about half of the fascicle shown here. Small bundles of regenerating nerve

fibers are seen below. (X 115)

Three of the specimens obtained from nerves in which secondary neurorrhaphy had failed were somewhat the worse for ill-placed sutures, and, in

each instance, a tantalum sling stitch was found in the middle of the nerve

surrounded by dense scar tissue (fig. 259A).

Temporary suture.—A typical case in which temporary suture was done

in a severed median nerve at the time of debridement and in which secondary

neurorrhaphy was performed 2 months later is illustrated in figure 265.

Upon resection of the 35-mm.-long specimen (fig. 265A) representing the

neuromatous bulb (fig. 265B) and the glioma in continuity, it was possible

for the surgeon to attain relatively good ends (fig. 265C and D). Both cross

sections showed a moderate amount of interfascicular fibrosis and thickened

epineurium.

Sections through the proximal segment showed that the nerve had been

resected to a region in which well-myelinated and regenerating axis cylinders

were in evidence (fig. 265E and F). Distally, the fascicles were found to be

slightly edematous, and most of the tubules had remained unshrunken.
NEUROPATHOLOGIC CHANGES 539

FIGURE 259.—Anastomotic zone of common peroneal nerve after suture with tantalum

wire. A. Median longitudinal section through anastomotic zone of common peroneal

nerve sutured 2 months earlier by tantalum sling stitch. The rents in the tissue were

made in removing the tantalum wire. The dark central areas represent the fibrous

reaction around the sling stitch. Note that smooth fibrous epineurium has formed under

tantalum sleeve placed around anastomoses. (X 8) B. Section of new fibrous membrane

formed over tantalum sleeve used around anastomotic zone shown in A. (X 30)

Macrophages were still engaged in clearing out the products of degeneration,

and finely braided regenerating nerve fibers had succeeded in penetrating a

few of the tubules for a distance of at least 17 mm. beyond the point of

severance (fig. 265G and H).

Influence of position.—Some of the bulb-suture specimens provided opportunities to study the effects of suturing uncut nerve stumps with the limb

in flexion and subsequently extended. This positioning represents the first

phase of a two-stage stretching procedure designed to allow the surgeon to

resect the pathologic segments and finally bring together fairly satisfactory

nerve ends. The specimen shown in figure 266 was obtained from a common

peroneal nerve and is an example of the stretch fibrosis that may develop in

the region of the nerve immediately involved. This is seen to be especially

true of the proximal stump, in which extremely dense fibrosis was found instead of the usual neuromatous proliferation.

Disruption of suture site.—Two nerve disruptions after suture were of

particular interest. In the first case, a neuroma in continuity had been

resected from a radial nerve 2% months after injury, and the arm had been
540 NEUROSURGERY

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NETJROPATHOLOGIC CHANGES 541

flexed in a cast for only 16 clays, when, due to an accident, the elbow was

extended and the suture zone disrupted. Figure 267A shows the gross

specimen obtained from this nerve, and figure 267B and C shows the topographic view of the distal and proximal stumps, respectively. At surgery, a

badly distorted tantalum sleeve was removed from the fibrous isthmus connecting the greatly enlarged and neuromatous bulb to the shrunken and

fibrotic distal segment.

In the second case, the common peroneal nerve had become separated

after neurorrhaphy, with maintenance of fibrous strands between the stumps

(fig. 268A). In the 36-day interval between the first and second operations,

fine nerve filaments had grown from the region of neuromatous disarray in

the proximal stump (color plate 11) through the fibrous isthmus and into a

narrow portion of a distal fascicle (fig. 268B). The rate of growth, about

30 mm. in slightly over a month, is considerably less than that observed in

many favorable cases (2.5 mm. per day) but is an example of a growth rate

under extremely adverse conditions.

ADDITIONAL STUDIES

Stretch Fibrosis

Supplementary to this series of cases, a specimen was obtained that was

considered to be typical, nonseverecl, stretch lesion (fig. 269A). It was obtained from a soldier who had experienced a knee injury when a log fell

across his leg. Other specimens diagnosed as stretch lesions were seen at

surgery, with densely fibrotic changes over distances too great to be made up

if adequate resection were done. In such cases, it was usually possible to

demonstrate by electrical stimulation that some sensory fibers had remained

in continuity or had regrown through the fibrotic segment. Since it was

impossible, however, without biopsy, to diagnose the precise extent of the

damage, the nerve was merely lysed from the bed of scar, tissue in preference

to inserting a graft. It was realized, from previous histologic studies of

resected stretched nerves, that little hope could be entertained for good

regeneration through these palpably fibrotic segments.

Other specimens were obtained from nerves showing what appeared to

be stretch fibrosis associated with severed, or partially severed, and contused

nerves. Kather extensive fibrotic lesions in continuity were found in radial

FIGURE 260.—Temporary repair of radial nerve with silk sling stitches and wrapping

of fibrin film. A. Cross section through distal stump of severed radial nerve sutured

temporarily with silk sling stitches and wrapped with fibrin film. Fascicles have been

replaced by scar tissue in left half of section through which silk passed. On the right,

fibrin film fragments are embedded in a dense epineurial fibrous reaction. (X 16) B.

Higher magnification of fibrous and giant cell reaction around fibrin film in nerve shown

in A. (X 230)
542 NEUROSURGERY

FIGURE 2(51.—Gross section through fascicle of distal stump of radial nerve sutured

6 months earlier, 4 months after severance. Tubular shrinkage and fibrous replacement

are marked. Some of the small black dots in the tubules represent regenerated, amyelinated nerve fibers. (X 600)

FIGURE 262.—Longitudinal section through fascicle of distal stump of ulnar nerve

sutured 10% months earlier, at time of injury. Most of the regenerated axis cylinders

surrounded by collagenous tissue show granular degeneration. The suture site was also

fibrotic. (X 600)
NEUROPATHOLOGIC CHANGES 543

nerves apparently lacerated and impinged upon by the edges of fractured

humeri. The fibrosing effect of excessive stretch was also observed in segments of nerves in which bulb sutures had been done, with the limb flexed

during the month following temporary stump union and then extended.

As shown in figure 269B and C, the typical histologic finding in a

stretched nerve was the mass replacement of normal structures by fibrous

tissue. The injurious force was sufficient to cause rupture of sheaths, nerve

fibers, and blood vessels. There was evidence of intraneural hemorrhage and

of a diffuse granulation reaction that subsequently changed to dense scar

tissue. Nerve fibers remaining in continuity, as well as those attempting

regeneration after disruption at different levels of the lesion, became choked

in granulation and scar tissue, and many showed granular degeneration.

The fibrous reaction surrounding such fibers as*had escaped degeneration

appeared to be sufficient to defeat myelination, and it seemed unlikely in such

cases that any functions except those subserved by fine, amyelinated fibers

would return.

Ischemia

No example of pure ischemia of a peripheral nerve was encountered in

this series. From examples of peripheral nerve injury associated with

vascular occlusion of the main vessel of an extremity studied at the Ashford

General Hospital, White Sulphur Springs, W. Va., and from biopsy of

ischemic nerves embedded in necrotic muscle, it is clear that considerable

variations in the pathologic changes may exist. The process is easily studied

experimentally as well. In minor degrees of ischemia, axonal and myelin

degeneration will occur as simple nerve division. In the most severe degree

of ischemia, with all tissues of the extremity affected, the involved nerve may

show total cellular necrosis, particularly when it is studied from an area of

necrotic muscle. Diffuse endoneurial collagenization may develop in less

severe grades of ischemia; it is not unlike that visualized in distal tubule

denervation of long duration. Such changes appear incompatible with any

degree of functional nerve regeneration.

It was interesting to note, in a median nerve severed by gunshot simultaneously with the ipsilateral subclavian artery, that, after 9 months, the

fascicular pattern was maintained throughout the nerve trunk; that a uniform and extreme degree of tubular resorption with dense fibrous replacement had taken place; that end organs had persisted with atrophic Schwann

cells in their centers; and that revascularization had progressed well, as shown

by the presence of many small collateral vessels.

Nerve Grafts

No specimens of nerve grafts were obtained during the period of the

4-month survey. Shortly after the series was completed, however, three
544 NEUROSURGERY

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FIGUKE 263.—Neuroma of lunar nerve after repair in which resection was inadequate.

A. Proximal (P) and distal (D) cross sections and median longitudinal section of ulnar

nerve sutured 3% months earlier, 24 hours after severance. (X 1.5) B. Median longitudinal section through proximal end of nerve shown in A. Note greatly thickened

epineurium containing muscle fibers and adhesions. These stumps were not adequately

resected at primary suture, and a hard, fibrous neuroma developed in the suture zone.

C. Median longitudinal section through distal end of same specimen. (X 9) D. Longi-
NEUROPATHOLOGIC CHANGES 545

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Hi

tudinal section through suture zone shown in 'A, B, and C. Small nerve bundles have

grown in disorderly fashion into the scar tissue of the anastomosis. (X COO) E. Transverse section through proximal stump of nerve shown in A. It is evident from the

amount of epineurial and interfascicular fibrosis that it was not possible to resect all of

the contused segment even at secondary neurorrhaphy. (X Ü2.5)
546 NEUROSURGERY

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EIGUKE 264.—Cross section through first part of distal stump of severer! median nerve

sutured 9 months earlier. An enlarged and edematous proximal stump was sutured to

a small, fibrotic, distal segment, and the union was enclosed in tantalum foil. The

proximal outgrowth overflowed the anastomotic zone and formed the epineurial neuroma

shown here. (X 30)

lesions which had been grafted came to surgery. Specimens of three different

types of nerve graft were obtained, as follows: (1) A whole fresh homograft,

taken from an amputated limb, which had been used to bridge an 80-mm.

deficit in a posterior tibial nerve; (2) a frozen dried homograft taken from

the sciatic nerve 12 hours after death and placed in an 85-mm. deficit in a

posterior tibial nerve; and (3) the anastomotic site between a cabled sural

autograft and the distal stump of a severed radial nerve.

In the last case, 33 mm. of a 75-mm. deficit had been overcome by the

usual methods of mobilization and elbow flexion, and four cables of the sural

and median sural nerves were used to complete the union. The specimen

was removed at a second operation in which the distal anastomosis was

freshened. At this time, it was learned by electrical stimulation that nerve

fibers had traversed the graft and entered the distal stump. This finding

was confirmed by microscopic study, but the graft cables (fig. 270A), as

well as the distal nerve segment (fig. 270B), had undergone a marked, diffuse, fibrosing process that seemed sufficient to prevent anything approaching
NEUROPATHOLOGIC CHANGES 547

a normal functional return. In the 4 months following the freshening of the

distal anastomosis, nerve fibers had grown approximately 150 mm., as judged

by the advance of the Tinel sign. In the 4%-month interval between the

placing of the graft and the second operation, nerve fibers had grown through

the degenerating graft and as far as the extremely fibrotic distal union, a

distance of only 42 mm.

In a series of approximately 20 fresh and frozen dried homografts

previously studied at the Walter Eeed General Hospital, no evidence of success was obtained beyond the finding of neurotization of the first 10 mm. of

most grafts and the complete neurotization of a small 30-mm. frozen

dried graft in a median nerve. The fresh homograft and the frozen dried

homograft (fig. 271) mentioned above and recovered at Halloran General

Hospital showed essentially similar pictures, consisting of the usual signs:

of tubular disintegration, with dense replacement fibrosis in most of the graft,

and clusters of amyelinated nerve fibers penetrating the dense connective

tissue of the first centimeter of the graft (color plate 12).

COMMENT

No acute injuries were included in this study of the neuropathologic

processes in 228 injuries in which neurorrhaphy was performed. The majority of the 203 patients were seen between the third and sixth months after

wounding. The series included the following groups:

1. Patients awaiting definitive care, who had been evacuated from overseas because peripheral nerve centers in the theater had a capacity load.

2. Patients who required reexploration after having had definitive treatment at oversea or Zone of Interior neurosurgical centers.

3. Patients in whom neurorrhaphy had been delayed because of spurious

or temporary signs of spontaneous recovery.

4. Patients in whom nerve repair had been delayed for other reasons,

such as the presence of residual infection or the necessity for orthopedic

surgery.

Exclusive of 13 lesions in essentially fibrous continuity, and 57 suture

sites, 103 lesions in neuromatous continuity were resected. These formed the

largest group of the series. About half that number of complete severance

cases were studied. The resection of 103 neuromas in continuity may be

contrasted with the decision, over the same period, to allow 105 unqualified

lesions in continuity to continue to recover spontaneously without further

intervention other than external neurolysis and an occasional transposition or

enclosure in a tantalum sleeve.

A nerve which was the site of stretch palsy, a nerve eroded by an

aneurysm, and three nerve grafts of separate types were also studied and

reported.
548 NEUROSURGERY

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FIGUHE 265.—Complete severance of median nerve. A. External view (above) and

transverse and median longitudinal sections (below) of median nerve sutured 2 months

earlier, at time of injury. (P, proximal; D, distal.) B. Median longitudinal section

through proximal neuromatous parts of nerve shown in A. Sutures were found in the

region at the extreme right. The surgeon's first trial section is seen on the left. (X 6)

O, D. Cross sections through proximal (C) and distal (D) stumps of median nerve

shown in A. These sections represent the mirror images of the ends sutured at secondary neurorrhaphy. Slight epineurial and interfascicular fibrosis is present. (X 15)

E. Longitudinal section through proximal end of suture site shown in A. Most of the

nerve fibers are well myelinated, and clusters of regenerating, amyelinated fibers are also
NEUROPATHOLOGIC CHANGES 549

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present. F. Transverse section of same specimen. (X 500) G, H. Longitudinal and transverse sections through distal end of specimen shown in A.

Fine, intertwining nerve fibers have regenerated through the suture site and

have grown along the vacuolated distal tubules, some of which still contain

detritus. (X 500)
550 NEUROSTJRGERY

FIGURE 266.—Bulb suture of common peroneal nerve.

Upper: fibrotio segment of bulb-sutured common peroneal

nerve, proximal to, and at site of, heavy silk sutures. Lower,

left to right: proximal cross section, first distal cross section,

distal longitudinal section, and last distal cross section. The

first distal cross section is completely fibrotic, and the last

shows marked fibrosis; only after resecting 4 cm. of it was a

regular fascicular pattern attained. (X 1.5)

From direct observation and electrical stimulation of the lesions in situ,

from gross and microscopic study of the resected specimens, and from clinical

evaluations of some of the cases postoperatively, it was concluded that the

main obstacle to good nerve regeneration was fibrosis. This is stated with

due respect for the all-important fibrosis of the suture line that must be kept

at a minimum and encouraged to be as orderly as possible by very careful

surgery.

The main forms of fibrosis to be prevented or overcome were as follows:

1. Fibrous replacement within the tubules undergoing degeneration,

whether distal to the zone of severance or retrograde along the proximal

stump. This process eventually obliterated most of the cross sectional area

available to regenerating nerve fibers, and, as it progressed, it minimized the

chances of the regenerating fibers to thicken and myelinate. This endoneurial

fibrosis could be obviated by bringing the degenerating distal tubules into

contact with the greatly proliferated nerve fibers of the proximal stump as

soon as possible after the extent of the lesion had become demarcated (usually

about 3 weeks after injury).

2. Scar tissue that formed in the region of nerve severance, contusion, or

stretch. This form of fibrosis might be so extensive as to make difficult its

complete radication from the suture site, even though resection of several

centimeters proximal and distal to the main point of injury were resorted to.

3. Scar tissue of the surrounding bed of a contused or repaired nerve.

This tissue might sometimes enclose a nerve within dense, constricting bands

and render it functionless, even though no axons were severed. It was usually

possible to remove this scar tissue without endangering the nerve, which then

could be wrapped in a tantalum sleeve or transposed.
NEUROPATHOLOGIC CHANGES 551

./

m

FIGUKE 267.—Disruption of radial nerve after suture. A. Median longitudinal and

transverse sections of radial nerve which disrupted after suture. The proximal (P)

neuroma and distal (D) glioma were joined by a fibrous isthmus. (X 1.5) B. Median

longitudinal section through distal stump shown in A. Fragments of a tantalum sleeve

used in wrapping the anastomosis were removed from the indented areas at the left.

(X 9) C. Median longitudinal section through proximal neuroma shown in A. The

neuroma tapers off to the fibrous isthmus distally. In the upper left, a fascicle has transformed into typical neuromatous whorls. Degenerated muscle fibers and adhesions cover

the epineurial surface. (X 9)
552 NEUROSURGERY

FIGURE 268.—Disruption of common peroneal nerve after suture. A. Transverse

median longitudinal sections of proximal (P) and distal (D) stumps of sutured and

disrupted common peroneal nerve. The 15-mm. tail on the proximal stump represents

the fibrous tissue found joining the stumps. (X 1.5) B. Longitudinal section through

fibrotic fascicle of distal stump shown in A. In 1 month, the fine nerve filaments shown

here had penetrated the degenerated Schwann tubules after growing through about 30

mm. of the connecting fibrous tissue. (X 600)

FIGUEB 269.—Stretch fibrosis of common peroneal nerve. A. Proximal (P) and distal

(D) cross sections and median longitudinal section through common peroneal nerve

showing stretch fibrosis. B. Longitudinal section through distal end of specimen shown

in A. A few isolated remnants of fascicles are seen among the dense scar tissue and

the crisscrossing small regenerating nerve fiber groups. (X 9) C. Longitudinal section

through fascicle of nerve shown in A. Some of the nerve fibers that have persisted in

the dense collagenous reaction show granular degeneration, (x 600)
NEUROPATHOLOGIC CHANGES 553

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554 NEUROSÜRGERY

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FIGUKE 270. (See opposite page for legends.)
NEUROPATHOLOGIC CHANGES 555

During the period of this survey, seven severed nerves presented gaps

too extensive to be overcome by the usual methods. Three of these were

cutaneous nerves; three were substituted for by tendon transplantation; and

one was managed by a sural, cabled autograft through which nerve fibers

regenerated.

Nerves repaired in such a manner as to minimize fibrosis regenerate at

the rate of approximately 2.5 mm. per day as judged by the Tinel sign and

resumption of function in the parts supplied.

FIGUKE 271.—Cabled, frozen dried nerve homograft inserted between proximal and distal stumps of posterior tibial nerve (shown

here) 18J,4 months earlier.

FIGURE 270.—Repair of radial nerve defect by sural autograft cables. A. Cross section through 4 fused sural autograft cables placed in radial nerve defect 4% months

earlier. Note diffuse fibrosis and matting together of the cables by adhesions. Regenerating nerve fibers had grown along some of the degenerated fascicles to the distal nerve

stump. (X 20) B. Cross section through distal stump to which autograft shown in A

1

was sutured. Note extreme generalized fibrous and fascicular atrophy. Nerve fibers

from the graft had grown into the fascicles and the extrafascicular fibrous areas. (X 20)

498991v—59 39
CHAPTER XXII

Physical Therapy in the Management of

Peripheral Nerve Lesions

William K. Massie, M.D.

At the beginning of World War II, a not inconsiderable number of

medical officers, including some neurosurgeons, believed that physical therapy

was of little value in many conditions except for its palliative aspects. This

attitude did not persist. During the war, both experimental studies and overwhelming clinical evidence showed that the application of this modality to

many varieties of war wounds was fully justified from every standpoint. In

peripheral nerve injuries, physical therapy came to be regarded as an integral

part of the total therapy, and it also came to be an important phase of all

plans of rehabilitation.

In all U.S. Army hospitals, physical therapy was conducted under the

supervision of the orthopedic sections. This was an essentially correct arrangement. General policies affecting the somatic system could best be

prescribed under the direction of orthopedic surgeons. The transfer of

patients from one center to another, which was necessary for various reasons,

at times seriously interfered with continuity of treatment. Fortunately, uniformity of recordkeeping as well as, to some extent, uniformity of methods

in the various hospitals did much to overcome this obstacle.

Physical therapy, as it related to peripheral nerve injuries in World

War II, had three aspects; namely, diagnostic, therapeutic, and psychologic.

Unless, however, the basic physiologic-pathologic changes produced by injuries of the peripheral nerves were clearly understood, neither logical prescription nor competent management of these injuries was possible, and the

best results were not likely to be obtained.

CHANGES IN THE NEUROMUSCULAR SYSTEM PRODUCED BY

PERIPHERAL NERVE INJURIES

Muscle changes.—After denervation caused by injury, atrophy of the

affected muscles begins promptly and progresses rapidly for 4 to 6 weeks.

The rate is then appreciably retarded.1

Interstitial fibrosis is minimal during the first 3 months after injury.

For the next 4 to 12 months, muscle fibers decrease in size, lose definite

1 Bowden, R. B. M., and Gutmann, E. : Denervation and Re-Innervation of Human VoluntaryMuscle. Brain 67 : 273-313, December 1944.

557
558 NEUROSUKGERY

striation in some portions, and show an increase in interstitial fibrosis, particularly in perivascular areas. Intact nerve end-plates are progressively more

difficult to demonstrate. At the end of 3 years, fibrous tissue has almost

completely replaced muscle fibers, and such fibers as persist undergo changes

generally interpreted as irreversible.

The effects of tension demonstrated by Hipps2in biopsies of muscle from

patients with poliomyelitis may be appropriately cited here. Transverse lines

of fibrosis, interpreted as healed muscle tears resulting from overstretch,

could be seen extending across fasciculi. In other sections, fasciculi, though

apparently innervated, were undergoing degeneration because they were

embedded in masses of fat which obliterated all muscle tension. These observations were partly substantiated by functional tests on denervated

muscle.3

Prolonged rigid immobilization in nerve injuries also played its part

in muscle changes in combat casualties. Under these circumstances, muscle

changes were often observed in the atrophy associated with fractures. As

long as a muscle remained innervated, the process which has been described

was largely reversible, and no permanent weakness due to fibrosis and

muscle replacement occurred. When, however, denervated muscle was immobilized, the process of fibrous replacement was greatly enhanced.4

Joint changes.—The most serious sequelae of immobilization after injury

occur in the joints, which may be left irreparably stiff. There is sound evidence that a normal joint, without associated vascular disturbances, may be

immobilized for prolonged periods without becoming permanently stiff,5but

joints distal to a peripheral nerve lesion cannot be considered normal. They

are affected by the peripheral vascular changes common to all such injuries.

Periarticular edema, if it is not combated by active muscle contractions, will

result in organization of the edema, with resulting permanent disability.

Nerve changes.—The pathologic changes in nerve trunks which occurred

after combat-caused injury were of three principal types, depending upon

the severity of the causative trauma,6as follows:

1. Contusion or neurapraxia.7This process is a transitory interruption

of nerve impulses, the mechanism of which is not completely understood.

It closely simulates the paralysis which follows the use of a tourniquet, in

2 Hipps, H. E. : The Clinical Significance of Certain Microscopic Changes in Muscles of Anterior Poliomyelitis. J. Bone & Joint Surg. 24 : 68-80, January 1942.

3 (1) Eisenhauer, J., and Key, J. A.: Studies on Muscular Atrophy: A Method in Recording

Power in Situ and Obseryations on Effect of Position of Immobilization on Atrophy of Disuse and

Denervation. Arch. Surg. 51 : 154-103, October 1945. (2) Hipps, H. E. : Muscle Behavior Following Infantile Paralysis. Am. J. Surg. 53: 314-318, August 1941. (3) Hines, H. M. : Effects of

Immobilization and Activity on Neuromnscular Regeneration. J.A.M.A. 120 : 515-517, 17 Oct. 1942.

4 Huddleston, O. L.: Recent Experimental Studies on the Effects of Immobilization of Denervated Muscle. South. M..T. 37 : 72-77, February 1944.

5 McMurray, T. P. : Uses and Abuses of Splints and Other Instruments in the Treatment of

Nerve Lesions. Brit. J. Phvs. Med. 5 : 20-25, February 1942.

« Bunnell, Sterling : Surgery of the Hand. Philadelphia : J. B. Lippincott Co., 1944.

i Seddon, H. J. : Peripheral Nerve Injuries. Glasgow M..T. 139 : 61-75, March 1943.
PHYSICAL THERAPY IN PERIPHERAL NERVE LESIONS 559

which there is temporary intermittent thinning of the axis cylinders and loss

of myelin.8

2. Partial severance or axonotmesis. This process is a rupture of the

axis cylinders in which, however, their supporting structure is preserved.

Later, the distal segment undergoes degeneration, but regeneration occurs

down the original sheaths.9

3. Complete severance or neurotmesis. In this process, the supporting

structure of the nerve trunk is interrupted, and, as a result, it is practically

impossible for any axis cylinder to regenerate down to its original sheath.

In the first and second of the processes just described, regeneration of

the damaged nerve is inevitable. In the third, eventual recovery depends,

in large part, on early alinement of the nerve tubules. If they are alined

promptly, axis cylinder regeneration is possible. If they are not promptly

alined, the tubules become fibrosed.10 Marked alterations occur in the nerve

end-plates as time passes, and these changes greatly prolong reinnervation,

though regeneration of axis cylinders from proximal segments to end-plates

does not appear to be greatly inhibited by the delay. The rate of regeneration differs according to the nerves affected. It occurs most rapidly in the

radial, musculocutaneous, and external popliteal nerves, and most slowly

in the median and ulnar nerves.11 Reinnervation at the end-plate is profoundly affected by delay, most probably because a gradual fibrosis of the

sarcolemma of the muscle fiber presents penetration of axoplasm to the

end-plate.12 The axoplasm is forced to run between muscle fibers and

eventually forms incomplete new end-plates. Obviously, muscle changes

progress until the fibers actually respond to nerve impulses.

Vascular changes.—Vascular changes resulting from nerve injury are of

two types, as follows:

1. Primary changes, which are the result of loss of the sympathetic nerve

supply to the area and which are gradually compensated for by overlap from

surrounding nerves.

2. Secondary changes, which result from a lack of muscular activity.

DIAGNOSTIC ASPECTS OF PHYSICAL THERAPY

The diagnostic aid afforded by the techniques of physical therapy

proved essential in World War II in processing large numbers of patients

with peripheral nerve injuries and thus making it possible for them to

8 Chamberlain, E. D. : Some Aspects of Physical Therapy In Relation to Peripheral Nerve Injuries. Arch. Phys. Therapy 24 : 603-609, October 1943.

" Cooksey, F. S. : Cö-Ordination of Physical Methods im the Treatment of Peripheral Nerve

Injuries. Brit. J. Phys. Med. 5 : 25-27, February 1942.

10 Spurting, Ki. G., and Woodhall, B. : Experiences With Early Nerve Surgery in Peripheral Nerve

Injuries. Ann. Surg. 123 : 731-748, May 1946.

11 Kovacs, R. : Physical Therapy in Peripheral Nerve Injuries. New York State J. Med. 43:

1403-1408, 1 Aug. 1943.

u

Gutmann, E., and Young, J. Z. : Re-Innervation of Muscle After Various Periods! of Atrophy.

J. Anat. 78: 15-43, January 1944.
560 NEUROSURGERY

receive early definitive treatment. Periodic muscle testing provided information essential for management and not obtainable in any other way.

Muscle testing, if it was to be relied upon, had to be carried out

thoroughly and precisely. A careless observation or a record completed on

assumption could mean the difference between prompt exploration and

watchful waiting. Great care also had to be exercised in correctly interpreting the so-called trick or substitution movements. The techniques of

muscle testing are described in detail elsewhere.13

The basic muscle chart used in neurosurgical centers was used in its

original form in some neurosurgical centers. In a number of others, it was

revised so that the muscles were listed in the order of origin of their branches

from the parent nerve trunk. By the use of these charts, a trained observer

could localize a lesion accurately at a mere glance, and, by comparison of the

recorded results of the examinations carried out every 10 days, he could

ascertain even minimal progress just as quickly.

Electrodiagnosis

Galvanic-faradic testing.—Electrodiagnosis proved of definite value in

differentiating neurapraxia from other, more serious lesions if more than

3 weeks had elapsed since wounding. During the first 3 weeks after injury,

the degenerative process is not complete (p. 557), and the galvanic-faradic

response is not useful.

Physical therapy units sent overseas were equipped with the portable

Mclntosh machine, on which measurements of current strength were known

to be accurate. The current strength required to produce a response was

entered on the chart opposite the muscle tested. On successive tests, a decrease in the rheobase or the disappearance of a faradic response which had

previously been present was a sufficiently accurate indication of degeneration.

These observations were in many instances the deciding factor in bringing

patients to exploration during the optimum time for nerve suture. As time

passed, the operative findings, which generally confirmed the preoperative

observations, made the surgeon more and more confident of the accuracy

of the electrodiagnostic method. When nerve trunk destruction was incomplete, however, or when a muscle was doubly innervated, the results were

sometimes confusing.

Galvanic-faradic testing continued to be used by the great majority of

physical therapy units in the European theater during the war. In the

Zone of Interior, other methods of determination came into use. The continued use of this technique, however, was regarded as justified in a communications zone, in which muscle testing had but a single objective, to help

the surgeon diagnose a degenerative nerve reaction at the earliest possible

1

3

(1) War Memorandum Series No. 7: Aid to the Investigation of Peripheral Nerve Injuries.

British Medical Research Council, reprinted 1945. (2) Spurling. R. G., and Matson, D. D.: Simple

Tests of Nerve Trunk Injuries. Bull. U.S. Army M. Dept. No. 75, pp. 71-76, April 1944.
PHYSICAL THERAPY IN PERIPHERAL NERVE LESIONS 561

moment. A second reason for continuing to use this technique was that

technicians were more familiar with it than with other methods.

Chronaxie determinations.—Strength duration or chronaxie determinations were used to supply information not only about the process of degeneration and the period it covered but also about the beginning of

regeneration. The curves for normal muscles were established by Ritchie,14

and the machine employed was so calibrated that the voltage did not vary

with changes in resistance between electrodes. Rectangular waves of 1 millisecond were found to stimulate a normal muscle at a voltage considerably

lower than is required by a denervated muscle. This type of stimulus approached normal some weeks before other signs of regeneration were evident,

and these findings were interpreted to mean that the axoplasm had joined

the end-plate but was not yet able to conduct an impulse throughout its

Avhole length.

Galvanic-tetanus ratio.—The progressive current measurement advocated

by Pollock and his associates,15 which was of prognostic value in determining

the presence of nerve regeneration, was also found to be quite accurate in

the determination of the period of degeneration. Its action depends upon

the phenomenon that a denervated muscle will respond to a much lower

current than a normal muscle if the current is allowed to increase very

slowly over a given period of time. The normal muscle seems to accommodate

to the gradual change. The denervated muscle apparently cannot. The

gradient increase of current required to produce a response during the period

of degeneration (the first 14 days after wounding) must be steeper than is

required during the period of regeneration. When regeneration begins, the

increase suddenly (within a period of 2 or 3 days) jumps to a much steeper

gradient than at any other time. The gradient then gradually returns to

normal long after muscle function has returned.

The galvanic-tetanus ratio is the ratio between the minimal current

required to produce tetanus divided by the minimal current required to produce a single contraction (rheobase). The usefulness of the observation is

based on the fact that, in denervated muscle, the current required to cause

tetanus very closely approaches the rheobase, while in a normal muscle the

ratio is approximately 6 :1. The increased sensitivity is considered by the

proponents of the therapy of chemical transmission of nerve impulses to

indicate the normal sensitivity of the cells without the constant inhibition

provided by intact nerves.16

14 Ritchie, A. E. : Electrical Diagnosis of Peripheral Nerve Injury. Brain 67 : 314-330, December 1044.

15 (1) Pollock, L. J., Golseth, J. G., Arieff, A. J., Sherman, I. C, Schiller, M. A., and Tigay,

E. L. : Electrodiagnosis by Means of Progressive Currents of Long Duration ; Studies on Cats With

Experimentally Produced Section of the Sciatic Nerves. Arch. Neurol. & Psychiat. 51 : 147-154,

February 1044. (2) Pollock, L. J., Golseth, J. G., Arieff, A. J., and Mayfleld, F. : Electrodiagnosis

by Means of Progressive Currents of Long Duration ; Studies on Peripheral Nerve Injuries in Man.

Surg. Gynec. & Obst. 81 : 102-200, August 1045.

10 Loewi, O. : Aspects of the Transmission of the Nervous Impulse. J. Mount Sinai Hosp.

12 : 851-865, September-October 1945.
562 NBUROSUKGERY

As regeneration occurs, the ratio becomes higher than normal, and

tetanus eventually cannot be produced because the current required to demonstrate it is too high to be tolerated without anesthesia.

The galvanic-tetanus ratio, before the war ended, had largely replaced

the galvanic-faradic test in Zone of Interior hospitals because it was found

to be more accurate as well as productive of more information. Another

advantage was that it did not require the intricate equipment needed for the

progressive current or strength duration current tests.17

Dermometer.—Although a great deal was written about the use of the

dermometer toward the end of the war,18 it was not found to be as accurate

a diagnostic method as the other techniques described, because of the uncertainty of nerve overlap. This machine, however, is quite simple to operate,

and it was found useful in some oversea units in which large numbers of

patients had to be tested in a short time. Its action depends upon the fact

that skin resistance is greatly increased when normally acting sweat glands

are sparse or absent and, in peripheral nerve lesions, when sympathetic

fibers to the area are also sectioned.

TECHNIQUES OF PHYSICAL THERAPY

When physical therapy was employed as a modality of treatment, the

methods used depended upon the stage of the lesion.

First Stage

The first stage of management of a nerve injury covered the period

from wounding to wound healing and the control of edema resulting

from the vasomotor imbalance caused by autonomic nerve interruption plus

muscular inactivity. During this period, the wound received the principal

attention. As long as it remained open, adjunct therapy was greatly inhibited

or could not be employed at all.

It was generally agreed that 90 percent or more of all wounds in which

peripheral nerves were involved could be closed by delayed primary wound

closure within 14 days after wounding; actually, the timelag was usually

considerably less.

Early motion.—Motion of joints distal to the injury necessarily depended

upon the location of the wound, but, in general, the principles of early

active motion, elevation of the distal part, and provision of continued

pressure by means of elastic dressings proved the best treatment for both

healing of the wounded area and maintenance of normal joint motion. A

17 (1) Dillin, E. L. : Physical Therapy in the Treatment of Neurosurgical Conditions. Physiotherapy Rev. 26: 309-315, November-December 1946. (2) Pollock, L. J., Golseth, J. G., and Arieff,

A. J. : Galvanic Tetanus and Galvanic Tetanus Ratio in Electrodiagnosis of Peripheral Nerve

Lesions. Surg. Gynec. & Obst. 81 : 660-666, December 1945.

is (1) Hyman, I., and Beswick, W. F.: Measurement of Skin Resistance in Peripheral Nerve

Injuries. War Med. 8: 258-260, October 1945. (2) Jasper, H., and Robb, P.: Studies of Electrical

Skin Resistance in Peripheral Nerve Lesions. J. Neurosurg. 2 : 261-268, July 1945. (3) Pollock,

L. J. : Diagnosis of Peripheral Nerve Lesions. Clinics 4 : 240-262, August 1945.
PHYSICAL THERAPY IN PERIPHERAL NERVE LESIONS 563

joint uselessly immobilized or allowed to become immobile because of the

collection of edema in the extremity distal to the wound added a new and

preventable disability, the correction of which often proved more difficult

than the management of the nerve injury itself. Unfortunately, circumstances beyond the control of the neurosurgeon had often produced just such

changes before the patient reached an installation in which unified medical

management was possible.

Splinting.—During the first stage of a peripheral nerve injury, splinting—

unless a fracture was present—was used for a single purpose, to maintain

the part in a comfortable, neutral position which would prevent the overpull

of unapposed normal (uninjured) muscles.

The part was splinted immediately after delayed primary wound closure,

to prevent stress on the recently sutured wound. The splint used at this

time was usually of plaster and, since continuous immobilization might be

necessary for a short period, was not of the removable type used later. Joints

whose motion would not seriously interfere with wound healing or cause

the patient constant discomfort were left free to move, though positions of

contracture had to be prevented.

If a fracture was present in association with the nerve injury, a more

stable type of cast was, of course, necessary.

Galvanic stimulation.—It was not usually feasible to begin galvanic stimulation before delayed primary wound closure. When it was feasible and

could be carried out without causing the patient undue discomfort, it was

employed daily, with a careful sterile technique, even in the presence of open

wounds. This was sound practice, since maximum atrophy of muscles, as

already pointed out, occurs within the first 30 days after wounding. This

practice w

Tas useful in cases in which nerve injuries were complicated by

fractures; these patients received maximum benefits from such pseudoactive

exercise.

Casualties whose peripheral circulation was extremely poor and who

resisted ordinary means of treatment were sometimes greatly benefited by

repeated sympathetic blocks with procaine hydrochloride (Novocain).

Exercises.—About three-quarters of all peripheral nerve injuries occurred

in the upper extremity,19 and the majority of these patients could be ambulatory. This group therefore participated in rehabilitation classes, conducted under the supervision of sergeants in the physical therapy section,

almost from the beginning of their hospitalization.

Bed patients were segregated, so that they could be given group exercises.

A bulletin, with diagrams, prepared in the European theater and distributed

to each patient, described and illustrated the simple but comprehensive

exercises which could be carried out in the prone and supine positions.20

is» Spurling, E. G. : Early Treatment of Combined Bono and Nerve Lesions. Bull. U.S. Army

M. Dept. 4 : 444-446, October 1945.

20 Taylor, G. M., McFarland, J. W., and Bond, A.: Exercises for the Convalescent Bed Patient.

Arch. Phys. Med. 27 : 82-89, February 1946.

498991^—59 40
564 NEUROSURGERY

Associated fractures.—In a series of 621 nerve injuries studied at the

neurosurgical center at Halloran General Hospital, Staten Island, N.Y., in

1946, fractures were also present in 21.7 percent.21 The percentage is typical.

The objective of management in these cases of bone-nerve injury was essentially the same as the objective in cases without associated fractures. The

treatment of the nerve injury was the principal concern, and physical therapy

played an even greater role than in uncomplicated cases because the reaction

to injury with associated edema was much more severe than in uncomplicated cases.

When skeletal traction was employed in combined bone-nerve cases, it

was so applied that muscle points could be reached through the bandages

and stimulated by portable machines brought to the bedside. When cast

fixation was sufficient, the motor points were accessible through appropriately placed windows. In a small number of cases of combined bonenerve injury, such as injuries of both bones of the forearm associated with

radial nerve lesions, immobilization was provided by special methods. External skeletal splints of the Roger Anderson type, for instance, or intramedullary pins were used for the sole purpose of making the extremity

available for muscle stimulation.

Massive soft-tissue losses.—In the cases of nerve injuries reported from

the neurosurgical center at Halloran General Hospital, massive soft-tissue

losses occurred in only 1.1 percent. The small percentage was fortunate,

for this complication was far more difficult to manage, from the standpoint

of physical therapy, than associated fractures. Primary or delayed flaps

were almost always necessary for wound closure, and their chances of survival were not enhanced by the motion incident to muscle stimulation. Even

in these cases, however, elastic dressings were used, and flaps were designed

with subsequent muscle stimulation in mind.

Second Stage

Heat and massage.—The second stage of management of nerve injuries

from the standpoint of physical therapy began with the completion of wound

healing and continued until the reinnervation of the end-plate and the first

return of voluntary motion. During this period, for the first time, heat and

massage were of practical value. The whirlpool bath was particularly useful

if it was not contraindicatecl by associated fractures or for other reasons.22

Experimental evidence suggested that it played no part in decreasing the

rate of muscle atrophy, but it seemed to allay the discomfort of galvanic

stimulation and encourage active movements of all points.23 In addition, it

was of potent psychologic value.

21 Woodhall, B., and Lyons, W. R. : Peripheral Nerve Injuries. I. The Results of "Early"

Nerve Suture : A Preliminary Report. Surgery 19 : 757-789, June 1946.

22 See footnote 3(3), p. 558.

23 Mennell, J. : Massage, Movements and Exercises in the Treatment of Nerve Suture and

Repair. Brit. J. Phys. Med. 5 : 40-47, March 1942.
PHYSICAL THERAPY IN PERIPHERAL NERVE LESIONS 565

Galvanic stimulation.—During the second stage of management, galvanic

stimulation played a major role if it was administered regularly, with current sufficient to elicit strong contractions, and systematically distributed to

each denervated muscle. Experimentally, galvanic stimulation begun soon

after denervation neither produced hypertrophy nor maintained the normal

size of the muscle fibers, but it unquestionably decreased the rate of atrophy.24

There were certain prerequisites for preventing atrophy, as follows:

1. Treatment had to be begun early, at the most within a month of

injury.

2. Treatment had to be continued until the return of voluntary contractions.

3. Current strength had to be accurate. It was applied either as separate

stimuli, gradually increased to 30 per minute for 3 minutes for each muscle,

or in equivalent sinusoidal current.25

When muscles were treated daily according to these criteria, a clear-cut

decrease in interfascicular adhesions was demonstrable histologically.26 Clinically, patients who were similarly treated almost invariably presented pliable

distal joints and a circulation approaching normal. It was regarded as

possible, at least by some observers, that untreated muscle, if not denervated

for longer than 18 months, might eventually attain a strength equal to that

of treated muscle after reinnervation, though the rate of increase would

admittedly be slower.27

The maintenance of normal joint action in itself justified prolonged

electrical treatment during the second phase of the nerve injury. Joint

mobility cannot be obtained by passive motion. This form of therapy, in

fact, often leads to stiffness of the joint, since there is a great compulsion

to force it slightly beyond its free range of motion and thus initiate adhesions. Active motion, on the other hand, stimulates the peripheral circulation ; reduces local tissue edema, which is the precursor of adhesions; and

carries the joint through its full range of motion.28 The possibility that

strong contractions might cause stretch tears was not overlooked when

electrical treatment was employed in neurosurgical centers. It was, in fact,

a strong argument for delegating this work only to experienced personnel

who could accurately evaluate early muscle fatigue.

Splinting.—Splinting in the second stage of management of nerve injuries

was used to counteract two forces, as follows: (1) That of the normally

contracting antagonistic group, and (2) the effect of gravity. It was there24 Jackson, E. C. S., and Seddon, II. J. : Influence of Galvanic Stimulation on Muscle Atrophy

Resulting From Denervation. Brit. M.J. 2 : 485-486, 13 Oct. 1945.

25 Grodins, F. S., Osborne, S. L., Johnson, F. R., Arana, S., and Ivy, A. C. : Effect of Appropriate Electrical Stimulation on Atrophy of Denervated Skeletal Muscle in the Rat. Am. J. Physiol.

142 : 222-230, September 1044.

26 Jackson, E. C. S., Bowden, R. E. M., and Seddon, H. J. : Galvanic Stimulation of Denervated

Muscle. Brit. M.J. 1 : 65-66, 12 Jan. 1946.

2f Gutmann, E., and Guttmann, L. : The Effect of Galvanic Exercise on Denervated and Re-Innervated Muscles in the Rabbit. J. Neurol. Neurosurg. & Psychiat. 7: 7-17, January-April 1044.

28 Watson Jones, R. : Adhesions of Joints and Injury. Brit. M.J. 1 : 925-929, 9 May 1936.
566 NEUROSUßGERY

fore more effective in instances of extensor muscle paralysis, in which both

these factors operate, than in the flexor paralysis.

The optimum position for muscle recovery after denervation was a

disputed question during the war, as it had been for years before. Experimental evidence could be cited to support the idea that the risk of

overstretching by opposing muscles had been greatly exaggerated as a detrimental factor29

and that holding the muscle in complete relaxation was not

an innocuous procedure.30 There was much to prove the contention that the

momentary overstretching which might be required of denervated muscles

when normal muscles were allowed to contract forcefully was less harmful

than that of overzealous splinting, which kept joints in fixed positions and

reduced active motion and the consequent increase in circulation.

On the basis of this reasoning, splinting was applied with the following

principles in mind:

1. Maintenance of both joints and muscles at either extreme is harmful.

2. Complete immobility in any position is to be avoided over long

periods of time.

3. Active motion should be encouraged, while, at the same time, denervated elements must be protected from the constant overpull of both

gravity and opposing normal muscles.

4. Whatever method of splinting is selected, it must be so applied as

not to embarrass further a circulation which is far from normal.

With these criteria in mind, an operator of normal ingenuity could

devise an appropriate splint for any part. A useful rule of thumb was to

reproduce the position assumed by the extremity when the denervated muscles

were moderately (not forcibly) relaxed and to endeavor to maintain this

position by mild elastic action; the spring pickup was used for paralysis

of the common peroneal nerve, and the various elastic splints devised by

Bunnell and others31 were used for the hand and the wrist.

Immediately after nerve suture in which gaps in the trunk were overcome by appropriate positions of adjoining joints to permit increased length,

plaster splints were applied and were maintained for from 2 to 3 weeks.

During the next 3 weeks, the joint was extended daily for an additional

one-half inch daily, which permitted active and passive motion within the

range permitted by the splint.32

Occupational therapy and work.—A patient might remain in the second

stage of nerve management for periods ranging from 12 to 18 months.

During this time, when he was not actually receiving physical therapy, he

29 See footnote 3(1), p. 55S.

30 (1) See footnotes 2 and 3(1). (2) Heyman, C. H. : When Should the Poliomyelitis Patient be

Splinted? Ohio State M.J. 41 : 432-436, May 1945.

31 (1) See footnote 6, p. 558. (2) Highet, W. B. : Splintage of Peripheral Nerve Injuries.

Lancet 1 : 555-558, 9 May 1942. (3) Wilson, H. C. : Physical Therapy in a Plastic Surgery Unit.

Physiotherapy Eer. 25 : 3-21, January-February 1945. (4) Elastic Splint for Foot Drop. Bull. U.S.

Army M. Dept. 4 : 374, October 1945.

32 See footnote 10, p. 559.
PHYSICAL THERAPY IN PERIPHERAL NERVE LESIONS 567

was being guided in preparation for work of his own choice. If his progress

was satisfactory, he might even assume a full-time job.

The more severely wounded, of course, could undertake only diversional

occupational therapy in addition to physical treatment.

At this phase of management, the psychologic aspects of treatment were

most important (p. 568). As the patient lost the protective environment of

many companions affected as he was and began to compete on equal terms

with normal individuals, he often required advice.

Periodic testing.—During the second stage of nerve injuries, periodic electrodiagnostic tests were carried out to determine as soon as possible the

progress of regeneration. These tests were of value to the surgeon, who

had to consider exploration if progress was not noted, and were also a

morale-building factor to the patient when progress was encouraging.

Third Stage

Management in the third stage of a nerve injury was a gradual extension

of the measures used in the latter part of the second stage except that, by

this time, partial muscle reinnervation had occurred, and attention was concentrated on active stimulation of the involved fibers. As a guide to therapy,

it was found useful to apply the criteria suggested by Dillin,33 as follows:

1. When a muscle can develop less than 10 percent of normal tension,

passive motion is necessary, with the patient attempting to contract it.

2. When the muscle can develop from 10 to 50 percent of normal tension,

the patient can be assisted through a full range of motion.

3. When muscle strength is over 50 percent, resisted motion is necessary

for full development of its power.

Muscles had to be made to work against resistance in order to develop

strength. More could be accomplished in a few minutes of resistance exercises than in hours of free-swinging exercises, as suggested by the proponents of the Danish school of gymnastics. In fact, clinical differences were

apparent in the muscles treated by these different methods. A system of

exercises designed to furnish constant resistance through muscle excursion

was far more efficient than a system designed to furnish gradually increasingresistance. At first, these exercises could not be left to the patient's discretion, because fatigue, which it was necessary to prevent, was not easily perceived. A swimming pool proved the best single adjunct to treatment at

this phase of recovery.

Galvanic stimulation was continued until voluntary muscle twitches were

observed. At this time, if elastic splints had been required, they were gradually abandoned, since the patient was able to maintain the part in neutral

position, without support.

33 See footnote 17(1), p. 502.
568 NEUROSURGERY

Most patients, as the result of occupational therapy during the second

stage, were now able to pursue some occupation, either full time or part time.

Their progress was followed periodically with repeated muscle tests until

maximum recovery had been attained. By this time, they had learned to

substitute the actions of some muscles which had recovered rapidly for the

actions of muscles which had recovered more slowly. This was not desirable, though it could not be entirely prevented. When, however, a substitute motion was depriving of adequate exercise a muscle in which signs

of reinnervation were evident, the patient had to be guided to use the reinnervated muscles. Once it was evident that maximum regeneration had

occurred, all possible substitutions were encouraged. Only when this possibility had been exhausted was tendon transplantation or other reconstructive

measure considered.

PSYCHOLOGIC ASPECTS OF PHYSICAL THERAPY

The psychologic aspects of physical therapy were important in every

phase of management, including the diagnostic phase. Casualties with

peripheral nerve injuries of the upper extremities uncomplicated by other

injuries either were ambulatory when they were received in neurosurgical

centers both overseas and in the Zone of Interior, or they rapidly became

ambulatory. It was explained to them immediately that, while rehabilitation

of the injured extremity was possible, it would require a prolonged effort,

in which they themselves must participate most earnestly.

The concentration of patients with peripheral nerve injuries in neurosurgical centers played an important part in the psychologic benefits of

physical therapy. When the single patient associated with so many others

in the same predicament as he was, or even in worse predicament, his individual problem was comparably reduced. The daily progress of other

patients, both those with more serious injuries and those in more advanced

stages of recovery, was always encouraging.

Trained enlisted personnel could be assigned the full-time duty of keeping the patient with a peripheral nerve injury constantly occupied with

medically outlined and supervised activity. The responsibility for recovery,

however, as was made clear to the patient, rested upon him and not upon

the physical therapist. Competitive activity was encouraged and was made

as attractive as possible, but the individual patient clearly understood that,

in the last analysis, he was the one who determined just how much benefit

he would derive from the therapist's efforts.
CHAPTER XXIII

Orthopedic Techniques for Use in Irreparable

Nerve Injuries

T. Campbell Thompson, M.D.

GENERAL CONSIDERATIONS

During World War II, a number of casualties were seen at all neurosurgical centers who had sustained irreparable nerve damage associated with

loss of sensation and musclepower. As a rule, the injury which had caused

the nerve lesion had also caused extensive damage to the bones, muscles,

blood vessels, and skin of the affected extremity. The loss of sensation and

the muscular paralysis caused by the nerve injury was sometimes of less

importance in the patient's total disability than the damage to other soft

tissues or to bone.

From the time such an injury occurred, it had to be borne in mind that

the retention of function in the entire extremity was the objective of treatment and was much more important than the restoration of power in a

certain group of muscles or of sensation in a certain area of skin. The

viewpoint of the orthopedic surgeon in such cases was completely realistic,

which means that it was a combination of pessimism and optimism. He

realized that a soldier who was crippled to such a degree could practically

never be completely restored functionally, but he also comprehended that

almost all of these patients could be improved and that any treatment which

offered a reasonable chance of improvement should be carefully considered

and undertaken.

In the management of irreparable nerve injuries, certain practical considerations had to be borne in mind, as follows:

1. In the upper extremity, loss of sensation in the median nerve constitutes a major disability and is just as great a handicap as is loss of power

in the muscles supplied by this nerve. In lesions of other peripheral nerves,

however, the patient can soon learn to disregard numbness and often forgets

it entirely.

2. Absence of sensation seldom produces serious trophic changes. Even

when the weight-bearing area of the foot is completely without sensation,

the patient seldom experiences difficulties unless there is an associated de569
570 NEUROSURGERY

formity, such as equinovarus, which causes the body weight to be borne upon

one small area instead of upon the entire plantar surface. After complete

sciatic paralysis, one might have expected to find ulcers on the sole of the

foot or a Charcot joint, but they were seldom observed.

3. In the lower extremity, difficulties due to malalinement were probably

more important to the patient than those due to loss of sensation or musclepower. This is because proper alinement of the various weight-bearing segments of the lower extremities is absolutely essential for both standing and

walking. In the attempt to restore normal stance and gait, therefore, in a

patient with a severe injury of the lower extremity, correction of bony

deformity and of soft-part contracture always took precedence over nerve

repair or muscle transplantation.

4. In the upper extremity, mobility and musclepower are more important than alinement, though, even here, the usefulness of the hand depends

to a great degree upon the position of the shoulder, elbow, and wrist. A

normal hand with the wrist fixed in flexion or the forearm completely supinated was much less useful to the battle casualty than a partially stiff hand

in good position.

Every battle casualty presented a specific problem and often several

problems. The final selection of the procedure to be used in any single case

was made only when the surgeon had convinced himself that the procedure

or combination of procedures which he proposed to use would more nearly

restore normal function than any other procedure or combination of procedures. The occupation of the patient as Avell as his physical and emotional

makeup were also taken into consideration when the decision was made.

Whatever the procedure selected, the following general principles were

observed:

1. No transplanted muscle can be expected to overcome a fixed deformity.

2. The production of a deformity in an effort to restore function in

muscles supplied by a paralyzed nerve is almost never justified. This principle is particularly applicable to injuries of the lower extremity.

3. In the treatment of fractures, the prolonged immobilization required

to ensure solid bony union promotes fibrosis in the muscles, stiffness in the

joints, and atrophy in the bones. These changes occur even though weight

bearing in plaster is permitted. Prolonged immobilization to support paralyzed muscles while regeneration after nerve repair is awaited also promotes

fibrosis, not only in the paralyzed muscles but in normal structures as well.

If the chances of success from nerve suture or nerve graft are not good,

prolonged splinting of any part, especially in a poor functional position,

cannot be justified. Again it must be borne in mind that the function of

the extremity as a whole is more important than the partial restoration of

power in any group of paralyzed muscles.
ORTHOPEDIC TECHNIQUES IN NERVE INJURIES 571

OPERATIONS ON THE UPPER EXTREMITY1

In irreparable nerve injuries of the upper extremity, the operative

procedures employed were designed to restore the balance of power between

antagonistic muscles. These procedures not only reduced the tendency toward

deformity but also produced marked improvement in coordinated muscular

activity. They could not be expected to correct deformities which already

existed or to restore completely normal function.

Fusion Operations

If paralysis was extensive, fusing operations produced more complete

and more permanent correction of deformity than operations on soft tissue

and also made additional active muscles available for transplantation to take

the place of the paralyzed muscles. This was especially true in the hand

and wrist. When any two of the three major nerves in the upper extremity

were permanently paralyzed, wrist fusion was usually considered indicated.

This operation, in addition to improving the appearance of the hand, fixed

the wrist in a good functional position and made available for use as motors

of the fingers whatever wrist flexors or extensors were still functioning.

Arthrodesis of the elbow or shoulder could be performed if the paralysis

about either of these joints was of such magnitude that the joint could not

be maintained in a good functional position.

A claw-hand deformity caused by section of the median and ulnar

nerves at the wrist could be overcome quite effectively by fusion of the

interphalangeal joints of one of the fingers. The long flexor muscles then

could flex the entire finger at the metacarpophalangeal joint. Anatomic

correction of the hyperextension deformity at one metacarpophalangeal joint

produced similar improvement in the other fingers, and the entire claw-hand

deformity was thus overcome to a remarkable degree.

Correction of the position of the thumb with fixation of the first metacarpal bone to the second by means of a bone graft was probably the best

method of restoring opposition of the thumb when the median nerve had

been destroyed high in the forearm or above the elbow.

Transplantation Operations

After paralysis of a single muscle or group of muscles in the upper

extremity, transplantation of an active muscle often produced remarkable

improvement in function.2In order to restore active abduction of the

shoulder after deltoid paralysis, the short head of the biceps and the long

1 Attention is called to the many ingenious operations for repair of injured hands described in

the volume in this series devoted to hand surgery (Medical Department, united States Army.

Surgery in World War II. Hand Surgery. Washington: U.S. Government Printing Office, 1955).

2 (1) Ober, F. R., and Barr, ,T. S. : Brachioradialis Muscle Transposition for Triceps Weakness.

Surg. Gynec. & Obst. 67: 105-107, July 1938. (2) Ober, F. R. : Transplantaciones de tendones en

las extremidades snperiores en la poliomielitis. Cir. Ortop. y traumatol. 3 : 7-23, January-March

1935.
572 NEUROSURGERY

head of the triceps could be transplanted to the acromion.3 Another procedure employed was the Mayer operation,4

in which the trapezius is extended

downward by means of a piece of fascia lata, thus permitting active abduction

of the humerus by this muscle.

Operations for Axillary Nerve Paralysis

In pure axillary nerve paralysis, the remaining active muscles of the

shoulder take over the function of the deltoid very well, and operative measures were therefore seldom necessary. When there was extensive paralysis

about the shoulder joint, arthrodesis of the shoulder was usually the operation of choice.

Complete loss of flexor power at the elbow was seldom seen because

the various muscles which produce flexion of the elbow are supplied by four

different nerves. When surgery was necessary, remarkable improvement

could be secured by Steindler's operation of transplanting the origins of the

flexors of the wrist and fingers upward on the humerus (figs. 272 and 273).

FIGUKE 272.—Steindler technique of transplantation of flexor muscles

at elbow. The common origin of the flexor muscles from the internal

epicondyle is freed and transplanted upward on the humerus to restore

active flexion of the elbow.

FIGURE 273.—Steindler technique of transplantation of flexor muscles.

After the flexor muscles of the wrist and fingers have been transplanted proximally on the humerus, they act as strong flexors of the

elbow as well as flexors of the wrist and fingers.

3 Ober, F. E. : An Operation to Relieve Paralysis of the Deltoid Muscle, J.A.M.A. 99: 2182,

24 Dec. 1932.

4 Mayer, L.: Transplantation of the Trapezius for Paralysis of the Abductors of the Arm.

J. Bone & Joint Surg. 9: 412-420, July 1927.
ORTHOPEDIC TECHNIQUES IN NERVE INJURIES 573

Even when the elbow joint could be flexed against gravity without surgery,

this procedure was often regarded as justified, to increase the power of

flexion.5It was in the forearm and hand, however, that muscle transplantation produced the most gratifying results.

Operations for Radial Nerve Paralysis

Because of the winding course of the radial nerve around the shaft of

the humerus and the exposed position of the dorsal interosseous branch on

the outer aspect of the elbow, many injuries which caused a fracture of the

shaft of the humerus or a fracture of the elbow joint also caused serious and

often irreparable damage to this nerve. The sensory loss was of no importance. The loss of extensor power in the fingers and thumb if the lesion

was below the elbow, or the complete wristdrop which could result from

injuries above the elbow, often produced most unsightly and crippling deformities. As the nerve supply to the extensor carpi radialis longus comes

off well above the elbow, this muscle Avas usually still active when the injury

was confined to the dorsal interosseous branch. When the injury was to the

radial nerve in the upper arm, wristdrop was complete.

The loss of power to fix the wrist and extend the fingers rendered the

hand almost useless, and the wrist had to be firmly fixed in dorsiflexion if

the flexor muscles of the fingers and the intrinsic muscles of the hand were

again to perform their many and finely controlled movements.

The prognosis for recovery of the radial nerve after injury was fairly

good, but the time required for regaining motor function was always long,

and recovery was often incomplete. In injuries near the elbow associated

with extensive scarring about the head of the radius, there was often loss of

considerable substance in the dorsal interosseous branch, and recovery of

active power in the extensors of the fingers and thumb therefore seldom occurred.

Transplantation operations.—Extension of the fingers, thumb, and wrist

does not need to be as accurately controlled as do the motions of flexion

and opposition. This is fortunate. For this reason, muscle transplantation

for restoration of motor function after irreparable damage to the radial

nerve was almost uniformly successful.

Some procedure of this kind was applied early in all instances of gross

loss of substance in the radial nerve if it was thought that recovery after

nerve suture or nerve grafting would be uncertain or was likely to be long

delayed. An injury involving the dorsal interosseous branch of the nerve

could seldom be repaired unless it was only a simple laceration which was

seen shortly after wounding. The satisfactory results obtained from tendon

transplantation encouraged the performance of this operation without delay

5 Steindler, Arthur: Musclo and Tendon Transplantation at the Elbow. In The American

Academy of Orthopaedic Surgery Presents Lectures on Reconstruction Surgery. Ann Arbor:

Edwards Bros., Inc., 1944, pp. 276-283.
574 NEUROSURGERY

when it was impossible to obtain a perfect nerve suture in an unscarred

field. Function in the extremity could usually be restored to almost normal.

The exact type of procedure used seemed to make no great difference.

Excellent results were secured with a variety of techniques, provided certain

requirements were met, as follows:

1. The transplanted muscles must be strong enough to hold the wrist

and fingers in extension without tiring. The palmaris longus is often weak

and is sometimes missing, and, for this reason, it is unwise to count upon it

to provide strong extension of any finger or of the thumb. The flexor carpi

radialis and the flexor carpi ulnaris, on the contrary, are strong muscles,

which can be freely mobilized without disturbing their nerve and blood

supply. They can therefore be brought around the radial and ulnar aspects

of the forearm, respectively, to provide strong extension of the fingers and

thumb (fig. 274). The palmaris longus is left intact to provide flexion of

the wrist.

2. Occasionally, after muscle transplantation, function returns in a

radial nerve which has been considered permanently paralyzed. This usually

results in a hyperextension deformity of the wrist with the fingers flexed,

and the transplanted flexor muscles must be replaced in order to restore

muscle balance. This is not an unduly difficult procedure, and the remote

possibility of spontaneous recovery is therefore not a valid reason for

delaying transplantation of the flexors into the extensors.

3. Normally, the thumb and index finger function together. When the

thumb rotates and flexes in the position of opposition, the index finger flexes

to meet it. When the hand is spread out, the thumb and index finger extend

simultaneously. For these reasons, it is advisable to use the flexor carpi

radialis to provide extension of both the thumb and the index finger as well

as abduction of the thumb. The tendon is threaded through the abductor

pollicis longus, the extensor pollicis brevis, the extensor pollicis longus, and

the extensor indicis proprius.

4. The remaining fingers usually flex together in the position of grasp

or are extended simultaneously when the hand is spread. For this reason,

the flexor carpi ulnaris is transplanted into the common extensors of the

fingers and the extensor digiti quinti proprius (fig. 275).

5. If the nerve injury is below the elbow, the extensor carpi radialis

longus will still be functioning, and there will be adequate power to dorsiflex

the wrist. When the damage has been above the elbow, the lost power of

dorsiflexion of the wrist can be restored by freeing the pronator radii teres

from its insertion into the radius and threading it into the extensor carpi

radialis longus and the extensor carpi radialis brevis.6It was the practice

of some orthopedic surgeons to supplement the transplantation of the two

flexors of the wrist by transplantation of the pronator radii teres into the

a (1) Jones, E. : Tendon Transplantation in Cases of Musculospiral Injuries Not Amenable to

Suture. Am. J. Surg. 35 (o.s.) : 333-335, November 1921. (2) Tubby, A. H. : Deformities Including Diseases of the Bones and Joints. New York : Maemillan & Co. Ltd., 1912, vol. 2, pp. 740-764.
ORTHOPEDIC TECHNIQUES IN NERVE INJURIES 575

FIGURE 274.—Transplantation of flexors of forearm to extensors of finders

and thumb for radial nerve paralysis. The strong flexor carpi radial is

and flexor carpi ulnaris muscles are freely mobilized through incisions on

the flexor surface of the forearm.

üii***

FIGURE 275.—Transplantation of flexors of forearm to extensors The

flexor carpi radialis is inserted into the extensors of the thumb and into

the extensor proprius of the index fingers. The flexor carpi ulnaris is

inserted through the extensor proprius of the little finger and into the

common extensors of the other fingers. Strong extension of the fingers

and thumb will result. If the nerve injury is above the elbow, transplantation of the pronator radii teres into the extensor carpi radialis brevis will

provide strong active extension of the wrist.

radial extensors. If the radial nerve paralysis has persisted for some time,

there is often a pronation deformity as well as a wristclrop, and this additional procedure will not only reinforce the paralyzed wrist extensors but

also may correct the pronation deformity. Capt. (later Maj.) Vincent J

Turco, MC, demonstrated at Lawson General Hospital, Atlanta, Ga, that

it was better to insert the pronator radii teres into the extensor carpi radialis

brevis only, instead of into both the brevis and longus, as in the technique

described by Tubby. Because the extensor carpi ulnaris is paralyzed, the

hand goes into radial deviation during dorsiflexion of the wrist when the

pronator teres is inserted into both radial extensors. Because the insertion

of the extensor radialis brevis is into the base of the third metacarpal bone,

radial deviation of the hand does not occur when the pronator teres is

transplanted only into this muscle.

Operations for Ulnar Nerve Paralysis

Although loss of function of the ulnar nerve produces a characteristic

deformity, it does not represent a major disability. Many soldiers with
576

NBUROSURGERY

complete ulnar nerve paralysis could perform full duty. A partial lesion

of this nerve, however, could cause so much pain in the ulnar distribution

that the patient protected the entire extremity and used it only when he

was forced to. If paresthesia and dysesthesia persisted m the unar distribution after transplantation of the ulnar nerve to the front of the elbow

or after neurolysis or nerve graft, the same situation occurred; the man would

not use the extremity and therefore had a much greater handicap than a

person with a complete ulnar lesion. _

In some instances in which there had been extensive soft-tissue damage

and the nerve lay embedded in a mass of scar tissue, the prognosis tor

restoration of ulnar nerve function was thought to be so poor that section

of the nerve well above the site of injury was considered justified, Ihis

simple procedure, which is so successful in relieving pain when any purely

sensorv nerve is hopelessly involved in scar tissue, was always kept in mind

in the management of partial lesions of the larger nerves. After severance

of this nerve, accommodation to the absence of sensation in the little finger

and to lack of power in some of the intrinsic muscles of the hand was so

complete that the loss of ulnar function was not complained of. I his has

repeatedly been observed in civilian practice when complete severance of this

nerve has occurred in childhood.

In neurosurgical centers, prolonged hospitalization and complicated

surgical procedures for correction of paralysis of the ulnar nerve were

considered of doubtful value and seldom justified. It was much more sensible to convince the patient that his handicap was minor and to induce him

to eno-age in some gainful occupation in which he would learn to compensate

for the loss of ulnar function and cease to concentrate upon it. Orthopedic

operations designed to correct ulnar nerve paralysis were seldom regarded

as indicated unless there had been associated damage to the median nerve

and flexor tendons.

Operations for Median Nerve Paralysis

Irreparable damage to the median nerve, because it produces loss of

sensation and power in the thumb and the index finger, renders the hand,

and the entire upper extremity along with it, almost useless. If the ulnar

nerve had been spared in a battle-incurred injury, considerable useful function could be reestablished. When attempts to restore sensation m the

median distribution had failed, not much functional improvement could

be expected. .

Development of a claw-hand deformity of some degree was almost inevitable following any lesion of the median or ulnar nerve; the deformity

was most unsightly and was completely disabling when the injury was

combined. If the injury had been low enough to spare the innervation to

the flexor muscles in the forearm, the most satisfactory way of overcoming

the deformity was to use the sublimis tendons as substitutes for the paralyzed
ORTHOPEDIC TECHNIQUES IN NERVE INJURIES 577

lumbricales and interossei, as described by Bunnell.7These tendons could be

sectioned near their insertions, brought up through a palmar incision, and

threaded down through the lumbrical canals. If they were split well up

into the palm, eight slips of tendons were available for reinsertion into the

extensor aponeuroses of the fingers (fig. 276). When their courses were

altered, these tendons would no longer flex the middle phalanx on the

proximal phalanx, but they would produce flexion at the metacarpophalangeal

joints and extension of the distal phalanges. It was sometimes possible to

arrange the insertions so that a certain amount of adduction and abduction

of the individual fingers was also accomplished. Appropriate muscle transplantations were employed for injuries of individual branches of the ulnar

and median nerves.

The most important function of the hand is opposition of the thumb to

the fingers. It is therefore not strange that numerous complicated procedures devised to restore this function8 were employed during World War II.

One technique, the use of a graft between the first and second metacarpal

shafts, has already been mentioned (p. 571). Another technique9sometimes

employed was simple posterior dislocation of the base of the first metacarpal,

to put the thumb in a position of moderate opposition. Another very simple

method employed in some neurosurgical centers was the Thompson modification of the Royle operation 10 (figs. 277 and 278). By this technique, the

flexor sublimis tendon of the middle or ring finger is brought out through

the palm and run subcutaneously across the thenar eminence. The lower

border of the transverse carpal ligament forms a smooth pulley for the

transplanted tendon, which is split and inserted into the distal end of the

first metacarpal bone and the base of the proximal phalanx of the thumb.

The transplanted tendon thus runs in the same direction as the fibers of the

paralyzed opponens pollicis.

If the transplanted muscle was strong enough and all fixed deformity

had been corrected, one or another of these procedures restored almost normal

opposition of the thumb and first finger. Moreover, since opposition of the

thumb and flexion of the fingers normally take place together, as two parts

of a pinching action, little or no reeducation of the transplanted muscle was

needed. It was absolutely essential, however, that the deformity be completely corrected and that an osteotomy be done at the base of the first metacarpal if the thumb did not readily rotate into a position of real opposition.

1 Bunnell, Sterling : Surgery of the Hand. Philadelphia : J. B. Lippincott Co., 1944.

s (1) Bunnell, Sterling: Opposition of the Thumb. J. Bone & Joint Surg. 2o': 260-284, April

1938. (2) Irwin, C. B. : Transplants to the Thumb to Restore Function of Opposition': End

Results. South. M.J. 35: 257-262, March 1942. (3) Ney, K. Winfleld : A Tendon Transplant for

Intrinsic Hand Muscle Paralysis. Surg. Gynec. & Obst. 33: 342-348, October 1921. (4) Royle,

N. D. : An Operation for Thenar Paralysis. M.J. Australia 2: 155-156, 1 Aug. 1936. (5) Roylei

N. D. : An Operation for Paralysis of the Intrinsic Muscles of the Thumb. J.A.M.A. Ill : 612-613,'

13 Aug. 1938. (6) Steindler, A. : Plexor Plasty of the Thumb in Thenar Palsy. Surg Gynec &

Obst. 50 : 1005-1007. June 1930.

»Fitch, Ralph R. : An Operation To Improve the Condition of Hands Disabled by Paralysis

of the Opponens Pollicis. J. Bone & Joint Surg. 12 : 190, January 1930.

10 Thompson, T. C. : A Modified Operation for Opponens Paralysis. ,T. Bone & Joint Surg

24: 632-640, July 1942.
578 NEUROSURGERY

FIGURE 276.—Transplantation of

flexor digitorum sublimis tendons for

claw-hand deformity. Following median or ulnar paralysis, the transplantation of flexor digitorum sublimis

tendons through the lumbrical canals

into the extensor expansions will, in

a large measure, restore active flexion

of the metacarpophalangeal joints.

FIGURE 277.—Transplantation of flexor

sublimis tendon into thumb to restore

power of opposition (Thompson modification of Royle operation). The flexor sublimis tendon to the ring or middle finger

is sectioned at the base of the finger and

brought out through a palmar incision.

The distal margin of the transverse carpal ligament acts as an excellent pulley

for the transplanted tendon as it runs

subcutaneously across the thenar eminence.

FIGURE 278.—Transplantation of flexor

sublimis tendon into thumb to restore

power of opposition. The thumb is first

rotated into a position of full opposition.

An osteotomy at the base of the first

metacarpal bone is performed if necessary. Good active opposition is then

maintained by threading one segment of

the transplanted sublimis tendon through

a hole in the distal end of the metacarpal

and the other through a subperiosteal tunnel at the base of the first phalanx.

OPERATIONS ON THE LOWER EXTREMITY

Orthopedic procedures in irreparable nerve injuries in the lower extremities are directed primarily toward correction of deformity, with elimination of the muscle imbalance which has caused the deformity second in

importance. Only in the occasional case is it possible to improve muscle

function, eliminate limp, and increase endurance. The situation is not as

hopeless as it sounds. A person can walk quite well upon a completely

paralyzed extremity or upon an artificial leg if the joints are so locked that

the parts are in a good weight-bearing position.
ORTHOPEDIC TECHNIQUES IN NERVE INJURIES 579

The extensors of the hip and knee and the flexors of the foot and ankle

are of great assistance in accomplishing this objective. Muscle transplantation to reinforce these muscle groups was therefore sometimes considered,

but the procedure was not usually practical, for muscles with strength great

enough to justify transfer were seldom available in a badly damaged limb.

In paralysis of the quadriceps, one or more of the hamstrings were

sometimes transplanted forward. The improvement which resulted was

chiefly due to correction of the slight flexion contracture of the knee which

had developed as a result of shortening of the unopposed hamstring muscles.

Since all the muscles in the thigh contract simultaneously to stabilize the

knee in the first part of the weight-bearing phase of gait, no special reeducation of the transplanted muscle was necessary.

Operations for Paralysis Below the Knee

In any attempt to restore function in the lower extremity, the foot was

considered first, since it is a stable pedestal during stance and a strong lever

during walking.

Relief of pain.—Pain in the foot or referred to the foot was usually aggravated by weight bearing and represented a major disability. Severe pain on

walking was frequently the result of contractions of tendons or muscles,

particularly if the nerves were adherent. A painful partial lesion was much

more disabling than a complete lesion.

Radical excision of scarred muscle, lengthening of contracted tendons,

and, above all, freeing of nerves from scar tissue in the foot and leg were

undertaken whenever an injured extremity continued to be painful. If

scarring was intraneural or if the nerve had to be replaced into a bed of

scar tissue, high section of the nerve often resulted in more functional improvement than could be accomplished by neurolysis or nerve suture.

When purely sensory nerves were involved, section of the nerve above

the area of scarring was practically always preferable to suture. Even in

the larger nerves, section was usually the operation of choice if it was thought

that the injured nerve trunk was apt to remain painful. Section of the

sciatic nerve, however, like section of the median nerve, was not the proper

treatment for causalgia.

Correction of clawing.—After section of the posterior tibial nerve in the

calf, there was usually a tendency toward cavus deformity of the foot and

clawing of the toes. It was seldom severe enough, however, to warrant any

procedure more radical than correction of the deformities of individual toes

by arthrodeses of the interphalangeal joints, capsulotomy, or transplantation

of the long flexor muscles into the extensors. If clawfoot was severe, transplantation of all the extensor tendons into the necks of the metatarsals, together with plantar fasciotomy, was sometimes necessary to flatten the foot

and correct the deformities of the toes.
580 NEUROSTJRGERY

Stabilization of the foot.—When musclepower was completely lost below

the knee, every effort was made to produce in the foot a stable pedestal for

standing and a lever for walking. An amputee who has a well-fitted

prosthesis can walk without any appreciable limp, and, similarly, a carefully

planned foot-stabilizing procedure could produce the same result in a limb

with irreparable nerve damage. Which one of the numerous operations

designed to correct paralysis and deformity of the foot was selected in the

individual case was not important provided that the following criteria

were met:

1. The plantar surface of the foot must be smooth and must be in such

a position that the weight of the body is distributed over the entire plantar

area.

2. There must be good lateral stability when the foot is placed upon the

ground, even though the inverting and everting muscles are paralyzed.

3. The foot must be in such a position beneath the leg that the normal

pushoff from the metatarsal heads is reestablished.

4. The foot must be painless. Complete anesthesia is preferable to

paresthesia or dysesthesia.

5. Whenever possible, ankle joint motion should be retained within a

limited range. If this is not practical and ankle fusion is necessary, the

alinement of the extremity upon the foot should be such that good function

is still possible.

6. The foot should fit into an ordinary shoe, and supporting braces

should be unnecessary.

Of the numerous operations devised for foot stabilization,11 posterior

bone blocks,12 tenodeses, and tendon transplantations 13 were frequently used

and gave good results. In the equinus and equinovarus deformities which

followed peroneal or complete sciatic nerve paralysis, the Lambrinudi procedure 14 (figs. 279 and 280), which involves removal of appropriate bone

wedges in the subastragalar and micltarsal joints, accomplished correction

of the deformity with mathematical precision.

11 (1) Dunn, N. : Stabilizing Operations in the Treatment of Paralytic Deformities of the Foot.

Proc. Roy. Soc. Med. (Sect. Orthop.) 15: 15-22, 6 Dec. 1921. (2) Hoke, M. : On Operation for

Stabilizing Paralytic Feet. J. Orthop. Surg. 3: 494, October 1921. (3) McCarroll, H. Relton:

Foot Deformities Resulting From Irreparable Nerve Lesions. In The American Academy of Orthopaedic Surgeons Presents Lectures on Reconstruction Surgery. Ann Arbor: Edwards Bros., Inc.,

1944, pp. 149-108. (4) White, J. Warren: Disorganization of the Foot. In The American Academy

of Orthopaedic Surgery Presents Lectures on Reconstruction Surgery. Ann Arbor : Edwards Bros.,

Inc., 1944, pp. 129-136.

12 (1) Campbell, W. C. : An Operation for the Correction of "Drop-Foot". J. Bone & Joint

Surg. 5: 815-825, October 1923. (2) Wagner, L. C. : Modified Bone Block (Campbell) of Ankle

for Paralytic Drop Foot. With Report of Twenty-Seven Cases. ,T. Bone & Joint Surg. 13 : 142-148,

January 1931.

13(1) Mayer, L. : The Operative Treatment of Paralytic Deformities of the Foot. Am. J. Surg.

7 (n.s.) : 80-88, July 1929. (2) Mayer, L. : The Physiological Method of Tendon Transplantation.

Surg. Gynec. & Obst. 22: 182-197, February 1916. (3) Mayer, L.: The Physiological Method of

Tendon Transplantation in the Treatment of Paralytic Foot-Drop. J. Bone & Joint Surg. 19 : 389-

394, April 1937.

1* Lambrinudi, C. : New Operation for Drop Foot. Brit. J. Surg. 15 : 193-200, October 1927.
ORTHOPEDIC TECHNIQUES IN NERVE INJURIES 581

Operations for Peroneal Nerve Paralysis

In the lower extremity, any direct injury in the region of the knee

may produce peroneal nerve paralysis. As the nerve winds around the head

of the fibula, it is practically subcutaneous, and it was therefore even more

vulnerable to combat injuries than the radial nerve in the upper extremity.

The injury often involved a considerable extent of the nerve, and suture

was difficult or entirely impossible.

FIGURE 280.—End result of Lambrinudi subastragalar arthrodesis. After

correction of the deformity by removal

of subastragalar and midtarsal bone

wedges, the foot is in a stable, weightbearing position. As the astragalus

remains in equinus, a physiologic bone

block is established. Recurrence of the

deformity is prevented by impingement

of the posterior tip of the astragalus

against the posterior tip of the tibia.

FIGURE 279.—Lambrinudi operation

to correct equinus and varus deformities. Removal of an appropriate bone

wedge through the subastragalar joint

corrects the equinus and inversion of

the heel. Removal of a wedge of bone

through the calcaneocuboid joint corrects adduction of the forepart of the

foot and the cavus deformity of the foot. ~~" -^

In the arm, this problem could be solved by flexing the elbow to permit

end-to-end suture, since flexion is the usual position of the elbow when the

hand is active. In the lower extremity, acute flexion of the knee was scarcely

ever justified in an attempt to obtain a good end-to-end suture, since even

slight flexion deformity of the knee entirely upsets the weight-bearing function of the leg; the patient has to walk Avith the limb flexed and becomes

fatigued on standing. Another factor that discouraged the use of such a

procedure was the notoriously poor results of suture of the peroneal nerve.

In soldiers who had had extensive injuries of the leg, it was usually

possible to prevent the development of equinovarus deformity by immobilization of the limb in plaster in good position, followed by constant

support in a well-designed brace. As soon, however, as it was recognized

that the injury of the peroneal nerve was likely to be permanent, some

operative procedure was undertaken to eliminate the use of a brace. When
582 NEUROSURGERY

all the extensors and evertors of the foot are paralyzed, the constant pull

of the strong, unopposed tibialis posticus is the chief cause of the varus

deformity. Early transplantation of this muscle was therefore undertaken,

not only to prevent development of varus but also to help overcome the

tendency toward equinus. If necessary, the transplantation operation was

supplemented by subastragalar and micltarsal arthrodesis.

It was entirely feasible to transplant the tibialis posticus muscle

directly forward through a large opening in the interosseous membrane.

This method was generally used by Captain Turco, at the neurosurgical

center at Valley Forge General Hospital, Phoenixville, Pa., with superior

results.

At the Thomas M. England General Hospital, Atlantic City, N.J., the

technique devised by Maj. E. Nelson Hatt, MC, also gave good results. The

operation (figs. 281, 282, and 283) is performed as follows:

A 5-cm. incision is made over the middle cuneiform, and the dissection

is carried down just lateral to the dorsalis pedis vessels. A drill hole 0.625

FIGUBE 281.—Transplantation of tibialis posticus to dorsum of foot for

correction of equinovarus deformity. This strong muscle can be used to

overcome the varus and equinus deformities which usually follow peroneal

nerve paralysis. The muscle is freely mobilized to allow it to function

well in its transplanted position.

cm. in extent is made obliquely downward and inward, drilling being continued until the point of the drill can be felt at the inner border of the foot,

approximately opposite the inferior aspect of the first cuneiform bone.

A short curved incision is next made over the insertion of the tibialis

posticus muscle.

A third incision begins at a point just posterior to the medial malleolus

and extends upward approximately 12 to 15 cm.
ORTHOPEDIC TECHNIQUES IN NERVE INJURIES 583

The tendon of the tibialis posticus muscle is detached at its insertion,

and the aponeurotic portion is dissected forward (fig. 281). Without this

dissection, it is a little short when transposed.

The tendon is then pulled up through the third incision, and the muscle

belly is stripped upward until the tendon can be swung forward in a straight

line with the dorsal incision on the foot.

FIGUKE 282.—Transplantation of tibialis

posticus to dorsum of foot for correction of

etminovarus deformity. A strong suture is

inserted into the end of the transplanted

tendon, and the tendon is drawn firmly down

with it into a hole drilled through the second cuneiform bone.

FIGUEE 283.—Transplantation of tibialis posticus to dorsum of foot

for equinovarus deformity. With the foot held in valgus and dorsiflexion, the ends of the suture are tied over a small roll of gauze. The

action of this tendon in its transplanted position largely restores muscle

balance in the foot and prevents recurrence of the deformity.

A tunnel is made through the subcutaneous fat by passing a hemostat

up from below, and the tendon is brought down through this tunnel to the

dorsal incision. With the foot in full dorsiflexion, an estimate is made of the

amount of tendon to be drawn down through the drill hole, and the section

to be used is denuded of epitendon and peritendon.

A through-and-through suture of No. 12 cotton is begun at the end of

the tendon. The ends of the suture are threaded on a long Keith needle,
584 NEUROSURGERY.

guided through the drill hole by means of a grooved director, and brought

out through the skin at the medial aspect of the foot (fig. 282). By grasping

the ends of the suture, it is possible to pull the tendon well down into the

drill hole with the estimated degree of tension on the muscle belly. The

ends of the suture are tied over a rolled sponge placed between them, the

tendon thus being anchored in the correct position. A possible modification

of the technique is to bring the needle out through the second incision and

suture the ends of the cotton through the fascia over the first cuneiform.

Two small stay sutures of No. 80 cotton are placed through the tendon and

periosteum at the entrance to the tunnel. For further security, a slip of

the tibialis anticus tendon is split off and sutured into a small slit in the

transplanted tibialis posticus (fig. 283).

The three incisions are closed, and a plaster boot is applied, with the

foot at a right angle and in slight valgus. The plaster is bivalved at the end

of 4 weeks. The suture in the tendon is removed by cutting the thread on

one side and pulling on the other end.

At this time, a toe drop brace is applied, and physiotherapy is begun.

A split plaster cast is worn at night for 4 to 6 weeks. At the end of this

period, the brace is also discarded.

Injuries of the external popliteal nerve were often associated with

fractures of the upper end of the fibula or with both bones of the leg. In

such cases, the treatment of the fracture usually required prolonged immobilization of the leg and foot. In the upper extremity, such a situation

was extremely serious; the resulting stiffness of the fingers, hand, and wrist

caused permanent, often extreme, disability, and it was therefore avoided,

even at the risk of insufficient splinting of fractures of the bones of the

forearm or inadequate support of paralyzed muscles.

In the lower extremity, however, the stiffness that occurred in the foot

and the fibrosis that developed in the paralyzed extensor muscles were

really assets; they prevented the development of the severe equinovarus deformity to be expected in complete paralysis of the peroneal nerve. When

this deformity developed, it was necessary to perform an arthrodesing

operation in the subastragalar and midtarsal region, to correct supination and

adduction of the foot and limit downward motion at the ankle. This operation, although it did not restore active dorsiflexion, did produce a very

satisfactory weight-bearing foot. It was most important, however, that

alinement be perfect.

CONCLUSIONS

1. It should be clearly understood that, whenever a peripheral nerve has

been damaged so severely that its function cannot be restored, orthopedic

procedures, while they are frequently useful, cannot be expected to restore the

patient to his normal functional status.
ORTHOPEDIC TECHNIQUES IN NERVE INJURIES 585

2. The procedures described in this chapter had a definite field of usefulness in World War II, but they did not restore normal sensation or motor

power to muscles supplied by nerves which had been irreparably injured.

3. The chief value of these orthopedic procedures was to restore some

balance between the remaining active muscles, thus correcting or preventing

deformity and generally improving function in the injured extremity.
APPENDIX A

ASF Circular] HEADQUARTERS ARMY SERVICE FORCES

No. 25 j Washington 25, D.C., 22 JANUABY 1945

PART ONE. Section

PATIENT IN HOSPITAL—Sec. II, ASF Cir. 374, 1944, amended I

PART TWO.

PATIENT IN HOSPITAL—Sec. IX, ASF Cir. 374, 1944, clarified II

WAR DEPARTMENT FILM—For civilian initiative, incentive, and morale

purposes in

ARMY SPECIALIZED TRAINING PROGRAM—Report on former dental and

veterinary trainees IV

PART THREE.

INSTALLATION—Redesignation, Armed Forces Radio Service School, Los

Angeles, California V

SHIPMENT—Replacement of shipments lost at sea VI

PART ONE

(General application—complete distribution)

I—PATIENT IN HOSPITAL.—1. Paragraph lc (1) and (2), section II, ASF Circular

No. 374, 1944, is rescinded and the following substituted therefor:

(1) White enlisted men.

(a) Armored: Armored Replacement Training Center, Fort Knox,

Kentucky.

(Ö) All other personnel of the arms and services, and personnel without

arm or service, with the AGF, Infantry advanced replacement

training centers—

Camp Howze, Texas

Camp Livingston, Louisiana

(2) Colored enlisted men.—All colored enlisted personnel reassigned under the

provisions of this paragraph, including armored, will be ordered to the

Infantry Advanced Replacement Training Center, Camp Livingston,

Louisiana.

2. Section I, ASF Circular No. 390, 1944, is rescinded.

(SPX 220.3 (19 Jan 45)SPGAC)

PART TWO

(Limited application—special distribution)

II—PATIENT IN HOSPITAL.—1. Reference is made to paragraph 2a, section IX,

ASF Circular No. 374, 1944.

2. In view of the present lack of uniformity in interpretation of the provisions of

this paragraph, the following clinical criteria are submitted as guides in ascertaining

maximum benefit of hospitalization in cases of paraplegia or transverse myelitis:

a. Wounds and pressure sores.—Wounds and pressure sores should be completely

healed. No further surgery should be anticipated.

b. Bladder and bowel -function.—Every attempt should be made to establish an automatic bladder and eliminate bladder infection. Satisfactory bowel function should also

be obtained.

587

498991v—59 41
588 NEUROSURGERY

c. Extremity function—Every effort should be made to achieve restoration of muscular function in the lower extremities by utilizing physical therapy, proper braces, crutches,

and other devices, such as "walkers."

a. Taking into consideration a, 6, and c ,above, these patients should be discharged

to Veterans Administration jurisdiction under current directives when progress appears

to have leveled off and no further substantial improvement can be anticipated.

(SPX 220.8 (16 Jan 45)SPMCR)

(Minimum distribution: Regional, station, and general hospitals.)

HI—WAR DEPARTMENT FILM;—l.-Distribution will be made, upon a circuit basis,

of prints of selected films for exhibition to civilian employees in Army Ground Forces,

Army Air Forces and Army Service Forces installations, beginning with the release for

the month of February 1945, due to begin its circuit during the latter part of January

1945, this release being a film entitled "Suggestion Power" referred to in section I, ASF

Circular No. 420, 1944. Initially, distribution will be made upon a basis of one subject

per month.

2. The films to be so circuited will be used primarily for the purpose of developing

civilian morale, incentive, and initiative, and may also be made available for information

and education purposes to such military personnel of Army Ground Forces, Army Air

Forces and Army Service Forces as may be determined by the commanding officers of

field installations. Films so distributed will previously have been approved for such

showing to military personnel by the Director, Information and Education Division, Army

Service Forces. Circuits will be operated by the various numbered service commands

and the Military District of Washington, the circuits to include all military installations

within the commands, including those of the Army Air Forces, as may desire bookings.

All bookings, control of the circuits, and the notification of circuits will be accomplished

by the central film library of each service command, to which all requests for bookings

and all correspondence from field installations relative to exhibition of these films should

faß addrGssGd.

3. Notification of circuit bookings will be given by the central film library of each

of the commands concerned approximately 2 weeks in advance of the showing date.

* * * * * * *

BY COMMAND OF LIEUTENANT GENERAL STYER:

OFFICIAL:

J. ATJLIO, LER. LUTES,

Major General, Mai°r General'

G

-

8

-

G

"

The Adjutant General. Acting Chief of Staff.
APPENDIX B

War Department Technical Bulletin (TB Med) 162

CONVALESCENT CARE AND REHABILITATION OF PATIENTS WITH

SPINAL CORD INJURIES

War Department, Washington 25, D.O. MAY 1945

1. PURPOSE. A defeatest attitude is intolerable in the care of patients with traumatic

transverse myelitis. Rehabilitation can and must establish a wheel-chair life for the

majority and walking with aid of braces or crutches for many. Self-support at a sedentary occupation is the ultimate objective. Maximal rehabilitation is essential for the

preservation of morale and human dignity. It is the function of general hospitals in

the zone of interior to effect this degree of rehabilitation prior to final discharge of the

patient. It is the purpose of this bulletin to summarize experience and establish policies

for professional care during the rehabilitation of patients with irrevocable spinal cord

injuries.

2. GENERAL CONSIDERATIONS. The emergency management and initial surgical

treatment of spinal cord injuries are beyond the scope of this bulletin. Transportation

splinting and preparation for evacuation are the responsibilities of oversea installations.

a. Spinal cord injuries are generally of two types: simple vertebral fracture with

cord compression or transection; and penetrating wounds with direct injury of the cord.

(1) Major vertebral fractures usually require splinting and support for 3 months.

They are properly evacuated in well-fitting plaster jackets.

(2) Penetrating wounds of the spinal cord with minimal bone damage rarely require

plaster splinting. The use of plaster jackets for the evacuation of these patients has

been discouraged.

Ö. Experience in the care of patients during evacuation has established the need for

suprapubic cystostomy. Most of the objections to this procedure can be overcome by

placing the tube as nearly as possible in the dome of the urinary bladder. (See TB

MED 147, March 1945.)

c. The paralyzed patients present immediate and continuing problems in special

nursing care. Even before the stability of the vertebral fracture is assured, a rigorous

program must be instituted to teach the patient to care for himself. This requires the

constant attention and integrated industry of medical officers, nurses, physiotherapists,

and hospital corpsmen.

d. The morale of patients is sustained by group care on large open wards. Air conditioning is desirable during the warm months. The observed progress of a fellow

casualty is a powerful stimulus to continued cooperation in a long and arduous program

of rehabilitation. Group care facilitates the recognition of common difficulties and

methods of adaptation from patient to patient. Group care encourages group instruction,

collective occupational therapy, and the institution of training programs for self-support

in sedentary jobs. The ward diversion and decoration should be the assigned responsibility of one or more Red Cross workers educated in the special problems of the paraplegic patients.

e. Intelligent coordination of diverse professional interests is essential to the successful administration of the program. The integration and effective execution of this program should be the sole responsibility of one medical officer. This officer should be

chosen on the basis of enthusiasm, diligence, and broad experience. He need not be

589
590 NEUROSURGERY

primarily a neurosurgeon or urologist. The specialized character of care and the importance of patient-personnel friendship demand semipermanent assignment of specially

selected nurses and corpsmen.

3. NURSING CARE. Special attention must be devoted to the care of the skin and the

prevention of decubitus ulcers. The anesthetic skin has no inherent vulnerability to

trauma but in the absence of pain is more severely traumatized than normal skin. Sustained pressure over a bony prominence produces absolute ischemia of the skin in that

area. It is believed that maintained pressure for 3 to 4 hours may be sufficient to

produce skin necrosis. The subcutaneous tissues are more vulnerable than skin to this

trauma. Consequently, when skin erosion and slough occur, the decubitus lesion is often

undermined.

a. There is only one way to prevent ulceration of the anesthetic skin. The position

of the patient should be changed, at regular intervals of 2 hours. In addition, the skin

overlying such bony prominences as the sacrum, hips, ankles, heels, and elbows should

be protected by pillows, pads, or rings. A surgical pad should be placed over the

perineum to minimize soiling from fecal incontinence. The perineal and pelvic pads

should be secured by a binder around the entire midriff. The binder should be of material of sufficient thickness to protect the skin from friction burns during the process of

turning the patient. The perineum should be promptly and thoroughly washed with

soap and water, dried, and powdered after each escape of feces.

&. The standard Army felt mattress supported by fracture boards is the bedding of

choice. Air, "foam" rubber, or other special soft mattresses are not to oe used. Such

mattresses make it difficult to change the patient's position and are conducive to muscle

contractures. Pillows may be used to increase postural comfort in the hard bed.

c. The bed linens should be kept clean and smooth. Sheets should be tightened

after each change of the patient's position.

d The Stryker frame is an excellent device for the care of the patient during the

period of spinal instability. Seriously ill or uncomfortable patients may be turned and

handled expeditiously even in the absence of trained personnel. It may also be used to

facilitate indicated surgical procedures.

4 NUTRITION. Patients with spinal cord injury frequently show evidence of malnutrition Blood loss from associated wounds at the time of injury may have been severe.

Lowered morale, difficult self-feeding, ileus, and persistent urinary tract infection are

factors further favoring reduced caloric intake and ineffective utilization of ingested

foodstuffs.

a. Whole blood transfusions are more desirable than infusions of plasma or ammo

acids' Persistent urinary tract infection may retard erythropoiesis. Correction of persistent secondary anemia by transfusion facilitates the flow of new food protein mainly

to the synthesis of needed tissue protein. It should be remembered that the quantitative

estimation of the concentration of hemoglobin does not necessarily reflect the true quantity of total circulating hemoglobin. The minimally acceptable levels for convalescence

are an hematocrit of 40 percent (copper .sulfate method) or an hemoglobin of 14 grams

percent (photelometer determination). It is essential to establish these red blood cell

values before attempting to interpret the significance of observed plasma protein concentration.

b The caloric intake should be maintained at 3,500 calories daily. This may require

feeding by ward personnel at first. Interval nourishment should be given between meals

and at bedtime. The dietitian should supervise the preparation of meals and check on

consumption by individual patients. Special feeding problems should be given skilled

consideration.

c. The protein intake should be at least 125 grams per day.

d. The vitamin intake should be adjusted, by supplement if necessary, to provide a

minimum of 5,000 I. U. vitamin A, 2 mgm thiamin, 3 mgm riboflavin, 20 mgm niacin,
APPENDIX B 591

75 mgm ascorbic acid, and 400 I. U. vitamin D. The routine use of mineral oil as a

laxative interferes with the absorption of fat-soluble vitamins and is not recommended.

e. A fluid intake of 3,500 to 4,000 cc. is a desirable supplement to the treatment of

the urinary tract.

5. CARE OF BOWEL. Intestinal tone and peristalsis are diminished after spinal cord

injury. Ileus and obstipation are followed by constipation and sluggish fecal evacuation.

Fecal incontinence and impaction are to be expected until autonomic function of the

bowel is established.

a. Enemata should be given at regular intervals, at least every 3 days. Complete

evacuation of the rectum should be ascertained by digital examination after each enema.

&. Regular bowel habits should be fostered. The laxative effects of various articles

of the diet should be utilized to encourage regularity. Other laxatives and cathartics

are not recommended. Regular bowel habits are to be expected as part of maximal

recovery.

6. MANAGEMENT OF SUPRAPUBIC CYSTOSTOMY. Immediately after severe injury

of the spinal cord the bladder becomes atonic or hypotonic, presumably because of

detrusor paralysis. Atonicity may prevail for an unpredictable period of days or months.

Ultimately, there is to be expected an automatic phase of micturition characterized by

periodic vigorous contractions of the detrusor muscle with evacuation of several ounces

of urine at one time. Such voiding is involuntary and without sensation, usually at

intervals of 1 to 3 hours. There is no leakage of urine during the interim. Complete

emptying of the bladder is not assured but evacuation is reasonably efficient. In complete

transverse lesions of the cord, the automatic phase of micturition is permanent. Return

of voluntary control is possible with incomplete section of the cord. Every effort should

be made to recognize the automatic phase which permits the removal of drainage tubes

and catheters and encourages intermittent voiding. Morale is raised, ambulatory existence is more comfortable, and rehabilitation is accelerated after bladder function is

resumed.

a. The suprapubic tube may be held in place by adhesive after sutures have been

removed from the wound. No available drug, administered internally or introduced into

the bladder, will sterilize the urine under the conditions of tube drainage of the bladder.

Control of bladder infection depends upon the mechanical efficiency and cleanliness of the

drainage system, avoidance of contamination during the change of catheters or equipment, and the maintenance of general nutrition and an adequate urine volume.

b. Routine Madder irrigations must be done at least 4 times each day. A closed

system of drainage and irrigation is recommended. The equipment for the closed system,

including the irrigation jar and tubing, should be sterilized by boiling or autoclaving

before use. The apparatus should be cleaned and sterilized once each week.

(1) The manually controlled closed system (fig. 1) is the simplest and most foolproof. The equipment for the assembly may be obtained from the Medical Supply

Catalog:

Item No. 4048500—Bottle, infusion, Kelly.

Item No. 4180800—Clamp, shut-off, screw adjustment.

Item No. 4464000—Tubing, rubber, special, 340-inch inside diameter, l^g-inch wall,

acid-cured.

Item No. 4002000—Adapter, Y tube, glass, 5-mm bore.

Item No. 4458000—Tubing, glass, 6-mm outside diameter.

The stem of the Y tube is connected to the suprapubic tube. The limbs of the Y tube

are connected to rubber tubing leading on one side to the irrigation bottle and on the

other to the collecting bottle. Most patients can be taught to irrigate their own bladder.

The system may be disconnected to allow the patient up in a wheel chair. Air in the

tube line does not interfere with function.
592 NEUROSURGERY

,ST£RILE GAUZE SPONGE

CATHETER OR SUPRAPUB1C TUBE

FIGURE 1.—Manually controlled closed system.

22 GAUGE

NEEDLE STUCK j

THRU AIR

BOTTLE, WfUSION, K€LlV

SCRW CUMP

TU»S,CRIP, SUSS (MURPHV)

•TUBING,RUBBCB •

%' DIAMETER' INSID6

-CORK.TW) HOLES

-TUBINCjOLASS

-GALLON JUGFIGURE 2.—Automatically controlled or tidal system.
APPENDIX B 593

(2) The automatically controlled or tidal system of closed drainage (flg. 2) requires

for efficient operation the constant attendance of trained personnel. Knowledge of the

individual dynamics of each paralyzed bladder is necessary for its correct use. Air in

the tubing impairs the mechanical efficiency of the system—an inconvenience in the care

of ambulatory patients. There are several systems of "tidal irrigation," and the essential equipment is available in the Medical Supply Catalog.

(3) A 2 percent solution of boric acid is a satisfactory irrigating solution. Solution

"M" of Suby and Albright has the advantages of being mildly bacteriostatlc and of dissolving phosphatic concretions on catheters and tubing. The formula for solution "M" is:

Citric acid 32.35 gm.

Sodium carbonate (anhydrous) 8.84 gm.

Magnesium oxide 3.84 gm.

Distilled water q.s.ad 1000 cc.

The solution should be autoclaved before use and may be tinted distinctively by the

addition of methylene blue or other dye.

c. The suprapubic tube may be removed as soon as it appears that reflex bladder

action would be adequate for automatic micturition. Prompt recognition of this phase of

recovery is not always easy. Modified cystometric studies through the suprapubic tube

and specific interrogation of patients as to bladder function should be undertaken regularly at intervals of 2 weeks to facilitate recognition of reflex bladder action. Removal

of the suprapubic tube is warranted when the cystometric studies show a bladder capacity of 400 cc. or less, a normal or hypertonic curve, an atonic curve with maximal voluntary pressure of at least 60 cm of water, or urethral voiding. After removal of the

suprapubic tube, there is likely to be continued leakage of urine with delayed closure

of the cystostomy wound and maceration of the surrounding skin. For these reasons, the

removal of the suprapubic tube is an indication for the insertion of an urethral catheter,

sizes 18 F or 16 F, soft rubber, with two holes. Larger catheters are a source of complications and should be avoided. A self-retaining catheter may be used. The catheter

should be fastened in place by adhesive tape to the skin of the penis. The tip of the

catheter should be adjusted to give effective dependent drainage of the bladder. Urethral

catheters should be changed and adjusted at intervals of 1 week.

d. Healing of the suprapubic wound is likely to be delayed. Excision of exuberant

granulations and efficient urethral drainage of bladder urine are helpful adjuncts. Surgical closure of the cystostomy is rarely necessary.

e. Removal of the urethral catheter may be considered after the suprapubic wound

is healed. Cystometric study showing evidence of good reflex activity, high maximum

voluntary pressure, or both, or voiding around the catheter are features warranting a

trial at voiding. No set cystometric values appear to be a completely reliable guide for

the proper time to remove the catheter. Close observation of bladder efficiency is important during the period of trial at voiding. A residual urine of more than 100 cc is an

indication for further catheter drainage. Overdistention of the urinary bladder should

not be allowed. The efficiency of automatic bladder action fluctuates with the general

condition of the patient. Constant vigilance to prevent overdistention is necessary even

though reflex action appears satisfactory for the first few days after removal of the

catheter.

/. Periodic X-rays for urinary tract calculi are suggested in patients immobilized in

recumbency for several months. Intravenous urograms may be helpful in the explanation

of obscure febrile reactions. Cystoscopy has no place in the routine care of the neurogenic bladder.

7. TREATMENT OF DECUBITUS ULCERS. Bed sores and decubitus ulcers are the

late consequence of ischemic gangrene of the skin and subcutaneous tissue. They are

preventable. Topical applications of antiseptic drugs and healing ointments have no

demonstrable value.
594 NEUROSURGERY

a. Superficial cutaneous abrasions may be healed by the avoidance of pressure, frequent postural changes, and the maintenance of nutrition.

b. Deeper ulcerations should be treated by surgical excision of the necrotic slough

with primary or delayed skin closure or skin grafting. Undermining of skin to facilitate

closure, when feasible, is preferable to skin grafting. Systemic penicillin therapy and

whole blood transfusions are legitimate adjuncts to this surgical program.

8. PHYSIOTHERAPY. The objective of physiotherapy is to maintain tissue vascularity

and joint mobility until such time as physical reconditioning may be instituted. This is

usually the period of spinal instability; that is, 6 weeks to 3 months for penetrating

wounds of the cord, and 3 to 6 months for major vertebral fractures. Pain on attempted

motion should be investigated by X-ray to identify periarticular calcification.

a. Massage and passive exercise help retain tissue turgor and joint motion.

&. Heat lamps and ultraviolet lamps are of questionable value.

c. Hot water tub treatments are not recommended. They are, in general, more

debilitating than helpful.

9. PHYSICAL RECONDITIONING. An aggressive policy of physical reconditioning is

the cornerstone of successful rehabilitation of paraplegic patients. Didactic instruction

and personal supervision by a skilled and enthusiastic physical instructor are essential

to the success of the program.

a. The objectives of physical reconditioning are—

(1) To maintain, as nearly as possible, the level of physical fitness present when

disability was incurred.

(2) To promote recovery and restore function of weakened and affected muscles.

(3) To restore and actually increase the strength of the muscles of the shoulder

girdle in anticipation of increased dependence upon the upper extremities during ambulatory convalescence.

(4) To instill self-confidence into the patient. Increased appetite, improved nutrition, and heightened morale contribute to a general sense of well-being.

ö. There should be a definite administrative organization for the program:

(1) The medical officer should advise the physical reconditioning instructor and confer with him from time to time as to the progress of individual patients. No patient

should be exercised before the medical officer has completed the diagnosis and noted the

precautions to be observed. The absence of the protective pain mechanism dictates an

initial restraint in prescribing exercises. After tolerance has been established, graded

exercises are prescribed to the limit of ability consistent with common sense. (See TB

MED 137, January 1945.)

(2) One physical reconditioning instructor should be assigned the responsibility of

conducting the exercise program for paraplegic patients. Additional personnel, if needed,

should be designated as assistants. A roster of patients with records of individual

progress should be maintained. New patients require orientation as to the objectives and

requirements of the program.

(3) The patients take the exercises in the position they are in at the selected time

for calisthenics. Patients are encouraged to keep personal records of their progress,

measurements beings in terms of times and numbers of exercises or increase in range

of motion. It has been found helpful to maintain competitive charts with weekly records

of body weight, circumference of arms, and the number of the various exercises performed.

c. The schedule of exercises should provide for conducted and voluntary periods.

(1) Group exercises under supervision and instruction "by the numbers" should be

held for a 30-minute period each day Monday through Friday.

(2) Patients should perform the group exercises "on their own" at a time announced

by the ward nurse for a second period of 30 minutes each day Monday through Friday,

twice daily on Saturdays and Sundays.
APPENDIX B 595

(3) Special exercises may be prescribed for voluntary performance at hourly intervals throughout the day. Pull-ups on a trapeze, dumb-bell exercises, and the like may

be given in this fashion.

d. It has been demonstrated that the ambulatory phase of convalescence is dependent

upon preliminary physical reconditioning. If this is neglected or ineffective, patients are

unable to move freely, suffer from arthritic and radicular pains, and cannot tolerate

even a wheel-chair existence.

10. AMBULATORY TREATMENT. The two greatest drawbacks to the establishment

of an ambulatory regime are: persistence of the mass reflex; and persistence of atony

of the urinary bladder. These complications require special consideration. (See pars.

11 and 12.)

a. The use of a wheel chair is possible for the great majority of patients as soon

as there has been sufficient development of the arm and trunk muscles. Occupational or

vocational therapy may be begun in earnest.

b. Attempts at walking should be instituted under the guidance of a consulting orthopedist. Use of the tripod training walker is a matter of election. Crutches, braces, and

splints usually have to be fitted. Tendon transplants and joint fusions may be indicated.

Flexor spasm is a neurosurgical problem. Each case should be treated in accordance

with individual needs. In general, corrective procedures of this sort should be allocated

to the final stages of convalescence.

c. Most patients retaining function of the upper extremities can be made ambulatory

and may enjoy life within the limits of their intelligence. They can carry on ordinary

daytime activities without urinary or fecal incontinence or having to evacuate the bladder

offener than every 3 hours. They can sleep through the night without involuntary soiling or having to get up. These objectives should be the visualized goals of every patient.

11. UROLOGIC COMPLICATIONS. Infections, calculi, and the persistently hypotonic

bladder are the most frequent and serious urologic complications. Urinary retention

from improper bladder drainage leads to back-pressure and stagnation of the urine as

etiologic factors in many instances. Bacterial contamination of bladder urine is an

inevitable accompaniment of tube or catheter drainage. Loss of retroperitoneal fat as

part of the generalized nutritional depletion permits obstructive kinking of the ureters

as they pass over the pelvic promontory. General demineralization of bone as part of

the atrophy of disuse contributes to the excretory burden of the kidney. A broad concept

of the etiologic factors is essential to successful management of urologic complications.

Cystoscopic maneuvers through an infected bladder carry an excessive incidence of severe

reactions. Observation cystoscopy of the urinary bladder, when indicated, may be performed through the cystostomy tract. X-ray and intravenous urography are the preferred diagnostic aids.

a. Urinary tract infection should be considered as a possible explanation of any

obscure febrile reaction in a paraplegic patient.

(1) Pyelonephritis or cortical abscesses may be relatively "silent" except for fever

and X-ray evidence of obstructive changes in the upper urinary tract. Treatment is

frequently empirical. Systemic treatment with penicillin, sulfonamides, or both, is useful

unless B. proteus or B. pyocyaneus are the only etiologic bacteria. A high urine volume

should be maintained. Whole blood transfusions are necessary to prevent anemia.

(2) Epididymitis is readily recognized. It is chiefly a complication of urethral drainage. Removal of the catheter and institution of suprapubic drainage is reserved for

persistent or repeated infection. Systemic chemotherapy and scrotal support suffice for

the average case. The surgical drainage of pus is rarely necessary.

(3) Periurethral abscess may occur at the peno-scrotal angle. Early incision and

drainage is the treatment of choice. If the abscess is large, it may be necessary to

remove the urethral catheter and institute suprapubic drainage.

Ö. Calculi, once formed, present the same problems in treatment established for the

49S991T—59 42
596 NEUROSURGERY

nonparalyzed patient. After indicated surgical procedures, a temporary loss of bladder

tone should be anticipated.

c. The persistently atonic or hypotonic bladder is largely an unsolved problem. Tidal

drainage is indicated for all or most of the time. During ambulatory periods, the catheter

may be allowed to drain in a urinal. The purpose of continued tidal drainage is to

prevent ultimate fibrosis and contracture of the bladder wall.

12. NEUROSURGICAL COMPLICATIONS. Pain, progressive paralysis, and mass reflexes

associated with intractable flexor spasm and ultimately flexor contractures are the most

common neurosurgical complications. It is important to differentiate nonspecific and

arthritic pains from true neurologic difficulties. The proper management of neurosurgical

complications may tax the judgment and ingenuity of the most skilled specialist. The

decision for operative intervention should entail wide consultation.

a. Excessive proliferation of bone at the fracture site may be responsible for progressive paralysis or pain. Decompression is helpful.

b. Retained foreign bodies or displaced bone fragments in the cauda equina should

be removed. Purely exploratory procedures for the identification of pathologic neural

change are condemned.

c. Radicular pain due to pressure on the nerve roots at the site of injury may require

appropriate rhizotomy.

d. Certain patients complain of intense burning pain in completely paralyzed extremities. If the lesion is in the cervico-dorsal region of the spine, anterolateral cordotomy

may be necessary for relief. If the lesion is at the dorsolumbar junction or below, the

burning pain may evidence a true causalgia due to injury of the cauda equina and

amenable to sympathectomy. Paravertebral novocain block of the lumbar sympathetic

ganglia will indicate the cases in which sympathectomy is warranted.

e. Massed reflexes, or reflex motor spasm in response to minimal stimuli, may be so

severe as to handicap the entire program of rehabilitation. They may be associated with

the involuntary discharge of urine and feces. Many patients show this massed motor

activity during the convalescent phase. Massed reflexes are not necessarily an indication

of complete section of the cord. As purely spinal reflexes, they tend to become exhausted

with the passage of time with reduction of power and excitability. Appropriate rhizotomy

will abolish the reflex but operation is justified only after all hope of spontaneous recovery has been abandoned.

13. DISPOSITION OF PATIENTS. Perhaps in no other group of patients is successful

rehabilitation so dependent upon a continuous and integrated program of convalescence.

Changes of environment and professional assistance are damaging to the loyalty, morale,

and self-confidence of patients. The road to maximal recovery is long and arduous, beset

with many discouragements. There is a high moral obligation upon medical officers to

provide continuous and uninterrupted treatment to the point of maximal rehabilitation

for these soldiers. Disposition by certificate of disability, discharge, or retirement to

home or veterans facility will be accomplished only after maximal hospital benefit has

been obtained.

[AG 300.5 (16 May 45)]
APPENDIX B 597

BY ORDER OF THE SECRETARY OF WAR :

OFFICIAL :

J. A. ULIO, G. C. MARSHALL,

Major General, Chief of Staff.

The Adjutant General.

DISTRIBUTION :

AAF (5) ; AGF (5) ; ASF (2) ; T of Opn (25) ; Dept (5) ; Base Comd (5) ; Island

Comd (5) ; Arm & Sv Bd (1) ; Def Comd (5) ; S Div ASF (1) ; Tech Sv (2)

except SGO; SvC (10); GH (Named) (60) ; EH (40); SH (Named) (40)

Gen Disp (ZI) (10) ; Gen & Sp Sv Sen (5) ; USMA (2) ; ASTU (1) ; ROTC (2)

Tng C (2) except Tng C 8 (60) ; Repl Tng C (2) ; Ind Sta (10) ; Sv C Lab (5)

A (5) ; OHQ (5) ; D (55) ; T/O & E 8-510S (35) ; 8-550 (60) ; 8-550S (45)

8-560 (40) ; 8-580 (40) ; 8-581 (30) ; 8-590 (20) ; 10-95 (7) ; One (1) copy to

each of the following: T/O & E 3-25; 4-45; 4-145; 4-232; 5-55; 5-72; 5-95;

5-275; 6-35; 6-55; 6-65; 6-75; 6-95; 6-175; 6-325; 6-355; 6-365; 6-395; 7-85;

9-12; 11-25; 17-55; 17-125; 18-25; 19-35; 20-42; Two (2) copies to each of the

following: T/O & E 2-22; 4-152; 4-260-1; 5-386; 5-535S; 6-12; 6-45; 8-22

8-26; 8-520; 9-35; 9-76; 10-22; 10-165 ; 10-217; 11-15; 17-15 ; 18-10-1; 18-35

19-55; 20-46; 44-15 ; 44-25 ; 44-75 ; 44-115 ; 44-125 ; 44-225 S, 44-315 ; 55-120-1

Three (3) copies to each of the following: T/O & E 5-192; 7-95; 8-27; 10^5

10-175; 17-115; 44-135; 44-325; 55-110-1; Five (5) copies to each of the following: T/O & E 5-21; 8-534; 8-572S; 8-780; 8-790; Six (6) copies to each of the

following: T/O & E 5-21; 10-125; Ten (10) copies to each of the following:

T/O & E 8-28; 8-595T ; 8-750 ; 8-760; Fifteen (15) copies to each of the following:

8-150; 8-537T ; 8-591T.

Refer to FM 21-6 for explanation of distribution formula.
APPENDIX C

Routine Procedure for Transverse Myelitis Cases1

I. ORDERS ON ALL NEW ADMISSIONS

1. Complete blood count.

2. Blood chemistry: (to include NPN, urea, creatinin, phosphorus, calcium, protein,

A/G ratio, hematocrit.)

3. Kahn.

4. Urinalysis.

5. Urine culture.

6. Neurological consultation. (New injury cases.)

7. Orthopedic consultation. (New injury cases.)

8. X-ray of chest.

9. X-ray of spine. (As indicated by the ward surgeon.)

10. KUB X-ray.

11. Body weight.

II. UROLOGICAL CARE

1. Tidal drainage to be applied only in cases where no reflux occurs. (Tested by

cystogram.)

2. On the bedside table of each patient who has any type of tube, there will be a

jar of alcohol sponges. The patient will be instructed to cleanse the rubber tube and

glass tube after disuniting and before uniting them.

3. On each patient's bedside table there will be an alcohol jar of submerged finger

cuts. The patient will be instructed to protect the disunited system between the drainage and catheter, and he will be instructed to protect the end of the catheter or end

of the glass connecting tube after he has disunited them so that he may leave his bed.

4. All glass tubing on tidal drainages or direct drainages will be kept clean. This

will be the duty of the GU man assigned to the respective ward. The tidal drainage

will be changed once each week. Catheters will be changed once a week in suprapubic

cases, once a week in intraurethral cases without complications, and every 48 hours in

cases of epididymitis with intraurethral catheter.

5. Irrigation fluid will be routinely: Acetic acid one-quarter percent, or boric acid

2 percent, or sulfanilamide solution 1 :1000. Solution G, G-2, or M will be used only

if indicated by the ward surgeon.

G. Despite tidal drainage, all catheter cases will be irrigated by hand syringe twice

daily. Solution G will be used in cases who have a tendency to form calculi around the

catheter, or in those cases who have had real bladder or kidney stones.

7. Sterile bottles will be used for urinary drainage.

8. In all bed patient cases, intake and output will be registered daily.

9. The intake of each patient will be around 3,000 cc. or more daily.

10. A pH determination by nitrozine paper should be done once a week on each

patient, and a weekly report submitted to the ward surgeon. Care should be exercised

that no irrigation fluid is being tested.

11. Urinalyses will be taken weekly on all patients. Urinalyses will be taken more

often if indicated by the ward surgeon. Urine cultures will be taken once in 0 to 8 weeks.

1 The very valuable material in this appendix, which describes the routine employed in the

paraplegic center at Hammond General Hospital, Modesto, Calif., during World War II, was prepared by Capt. (later Maj.) Ernest Bors, MC. Captain Bors was one of the pioneers in the development of the program for the care and rehabilitation of paraplegic patients. Coming to his duties

after training as a urologist, he proved one of the most competent and dedicated of all medical

officers in developing a specific regimen of care for the rehabilitation of paraplegics. He has made

many original contributions in this field, in which he is still actively engaged in the Veterans'

Administration hospital system.—B. W. and R. G. S.

599
600 NEUROSURGERY

12. Concentration and dilution tests will be taken on all patients once in 3 months.

13. KUB pictures will be taken routinely once in 3 months, providing patients have

never shown calculi of the kidneys or bladder.

14. IV pyelograms will be taken once in 6 months provided there has never been

any calculosis.

15. In cases of calculosis, KUB's and/or IV pyelograms and/or retrograde pyelograms will be done once in 4 weeks.

16. A weekly report will be submitted by the GU man to the ward surgeon, listing

cases as suprapubic, intraurethral, no catheter, dribbling, or clamping off. The latter

refers to suprapubic cases which are in the process of clamping off.

17. In cases without catheter, the following procedures will be observed by the GU

man and will appear on his weekly report:

(a) Urine clear, residual 2 to 3 ounces, test residual every 2 weeks.

(b) Urine hazy, no residual, test residual every 2 weeks.

(c) Urine hazy, residual 2 to 3 ounces, test residual every week.

(d) Urine hazy, residual 3 to 8 ounces, test residual twice a week.

Each testing for residual is to be followed by irrigation with boric acid solution,

2 percent.

18. The GU man is to be instructed to take the specimen for urine culture according

to the following rules:

(a) If patient voids normally, he is to void in two or three test tubes, and last

tube to be for sterile culture.

(b) If the patient has a suprapubic or indwelling catheter, the catheter is to

be discontinued for a sufficient time to rule out irrigation fluid.

(c) If patient has an automatic bladder, catheterized specimen will be obtained.

19. In cases with suprapubic tubes, it is permissible to start clamping off for 1 hour

at first, and later for 3 hours if patient has observed that urine is escaping freely

through the urethra. (This is usually first observed during bowel movements.)

20. After removal of the suprapubic catheter, attempt should be made to apply a

butterfly to the suprapubic sinus without insertion of a urethral catheter.

21. The patient should be admonished to void every hour on the hour at first, and

later every 2 hours, if automatic bladder has developed.

22. If the suprapubic sinus does not close within 10 to 15 days, intraurethral catheter

and fulguration of the suprapubic sinus are indicated.

23. If the above measures fail, the suprapubic sinus will be closed surgically.

24. Sphincterometric and cystometric examinations should be done on patients where

no automaticity of the bladder has occurred, at approximately 6- to 8-week intervals.

According to the outcome of the sphincterometric and cystometric examinations, therapy

will be devised with a trial given to Furmethide in atonic or hypotonic bladders, one-half

.tablet twice a day. Trasentine should be given three times a day, two tablets, in hypertonic bladders; pudendal nerve blocks in cases of good intravesical tone but simultaneous

hyperactivity of sphincteric systems, tested by sphincterometric examinations and verified

by a strong bulbocavernosus reflex. The latter should be tested routinely in each patient.

(Execution: rectal examination of patient; squeezing of glands produces contraction of

the anal sphincter.) Sympathetic block to be tried in cases with hypertonicity of internal

sphincter only.

25. Oral urinary antiseptics will be:

(a) Calcium mandelate, three times a day, two tablets, for at least 10 days.

(b) Sulfonamides: sulfadiazine routine: first day, 1 gram sulfadiazine plus 20

grains of soda bicarbonate, q4h. Following this, 4 x 24 hours, one-half gram sulfadiazine

plus 10 grains soda bicarbonate q4h. During this routine, urinalysis should be done

every second day in order to check for sulfa crystals. WBC in blood to be determined,

with hemoglobin, every other day. Sulfa level will be taken after the first 48 hours.
APPENDIX C 601

Forcing of fluids will be strictly observed in these cases, with a minimum intake of

3,000 cc. per day.

26. Sulfadiazine intravenously will be given as an intravenous Murphy drip, 5 grams

(20-cc. ampules) mixed with 80 cc. of triply distilled sterile water, slowly dripping

(1 hour). The same precautionary measures will be taken as observed during oral sulfonamide therapy.

27. Penicillin routine will be 25,000 units every 3 hours.

28. From the WBO count in the urine and the bacteriological report, the ward surgeon should evaluate which therapy he considers to be suitable.

29. Streptomycin therapy should be used as follows:

(a) In cases without residual, but with persistent infection without calculosis,

in order to clear up the infection. (Susceptibility to streptomycin must be demonstrated

prior to therapy.)

(b) Vitally indicated in acutely, seriously ill patients in the presence of calculosis, after drainage has been established and blockage bypassed.

30. If WBG's in the urine persist in high numbers, or if slight macroscopic hemorrhage occurs, or if RBC's persist in sediment, cystoscopy appears indicated.

III. BOWEL REGULATION

Bowel regulation will be best achieved when the patient is brought into the proper

position (Fowler's position) on either a gurney, if the patient is seriously ill, or the

toilet seat, or directly on the latrine toilet bowl. In addition, impaction should be prevented by not letting the fecal matter dry out. Overdistention by too large quantities

of enema fluid should be prevented. The patient should eventually be taught to press

with flatly applied palms to substitute for the absent abdominal muscles.

1. Routine application of mineral oil, one-half to 2 oz., at bedtime with or without

the addition of bulk-forming Imbicoll, 1 to 2 teaspoons.

2. A weekly report is to be given by the ward attendant in charge of bowel evacuation, as to the efficiency of the above mentioned routine. He is to report cases of impaction and of loose bowel movements, which eventually might lead to involuntaries. This

report should be submitted through the ward nurse to the ward surgeon who will take

corrective measures.

3. Cathartics such as licorice powder or cascara will not be used routinely except

with the consent of the ward surgeon, and in specially selected cases, as in preparation

for KUB pictures or IV pyelograms.

4. It is permissible that the patient use a rubber gloved finger to initiate defecation

while on the toilet in the latrine.

5. It is not permissible that the patient dig out bowels with rubber gloved finger;

he should, instead, report the condition present to the ward nurse or doctor.

6. If the finger does not suffice to initiate bowel movements, glycerine suppositories,

one or two, should be introduced by the patient.

7. If glycerine suppositories do not suffice, small enemas consisting of 90 cc. water,

30 cc. glycerine and 30 cc. mineral oil should be used. The patient is to be taught to

apply these enemas himself, if both of his upper extremities are not impaired.

8. If this procedure does not suffice, then the ward doctor should be informed before

further steps are taken.

9. It is highly desirable that the ward surgeon and the ward nurses instruct patients

on their wards upon the necessity of becoming independent of assistance by attendants

for their bowel habits.

IV. DIET

1. The diet may be a mixed diet in the average case.

2. Acid ash diet is desirable, in order to change the pH determination of the urine.

The patient is to be instructed as to the detrimental effect of any addition to this diet

purchased in the PX, because of lack of medical control.
602 NEUROSURGERY

3. Use of vitamins A, B, and 0:

(a) Vitamin A should be used in all cases of calculosis and recurrent calculosis.

(b) Vitamin B should alternate with vitamin O every other week.

(c) Vitamin C should be chiefly used in all inflammatory exacerbations, but it

is desirable that it be given in large doses without any other vitamins.

V. BLOOD ROUTINE

1. A WBC count and hemoglobin should be done routinely every 6 weeks. Complete

blood count to be taken only if pathology is encountered by the aforementioned method,

or in case of acute illness.

2. NPN should be done routinely once in 6 weeks unless otherwise indicated by the

ward surgeon because of acute illness.

3. Under emergency conditions, all the blood chemical analyses should be done which

appear justified by the ward surgeon.

VI. BEDSORE ROUTINE

1. Culture of bedsore to be taken prior to closure or grafting.

2. Photographs with ruler and name card in place to be taken before closure or

grafting (or an admission of new patients).

3. Protein level with A/G ratio to be done preoperatively.

4. Wet dressings, preoperatively, are to start routinely, 3 days prior to skin graft or

closure. (Dakin, Domeboro, or saline.)

5. Routine sulfa and penicillin to be started 24 hours prior to operation if so indicated by the culture.

6. Postoperatively, patient is to be kept off the operative region, and in selected cases

he is to be put on a Stryker frame for from 4 to 5 days. Dressings will be changed by

the operator or ward surgeon if he has been designated to do so.

7. Following buried type of epidermis graft, dressing to be changed daily. Domebromo solution wet dressings to be applied for the first week, by the ward surgeon.

8. When the bedsore closure or graft has become healed, another photograph will

be taken.

9. General outline for therapy: Mummification and dry crust will be handled differently from moist, gangrenous sore:

(a) In mummification, demarcation should take place before the crust is

attacked. Exposure to air and dry protection for the crust is desirable. In cases where

mummification is accompanied by a strong inflammatory reaction, with reddening and

infiltration of the margins surrounding the crust, softening of the crust and consequent

debridement is most quickly achieved by local application of cod liver oil ointment.

(b) Moist, gangrenous sore to be debrided at once. Permissible treatment according to the judgment of the ward surgeon:

(1) Sulfa and sugar, and exposure to air.

(2) Dakin wet dressings.

(3) Domeboro or acetic acid wet dressings.

(4) Saline wet dressings.

(5) Local penicillin jelly or ointment or wet dressing (1,000 units/1 cc).

(c) If the wound is clean, zinc diapheresis is permissible. Bathing is permissible if concurrent induration and inflammatory condition has subsided. Exposure to air

and sunshine is permissible and recommended. Exposure to ultraviolet lamp is permissible in combination with local application of cod liver oil ointment; contact ultraviolet

lamp is preferable in this procedure.

10. Ointments recommended for epithelialization are:

(a) Scarlet Red ointment.

(b) Silver Peruvian ointment (1 :10 :100, 70 percent cod liver oil as base).

(c) Cod liver oil ointment, 70 percent.

(d) Desitin ointment.
APPENDIX C 603

11. Bedsores are not a contraindication to walking unless recently operated. Many

sores will improve if the patient does walk.

12. Prevention of bedsores:

(a) Routine turning of patients every 2 hours.

(b) Routine protective treatment of the skin by alcohol rubs.

(c) Patient to be kept completely dry at all times.

(d) Use of Stryker frames in recent injuries will also contribute to prevention

of sores.

(e) Prevention of pressure by application of rubber rings and doughnut pads.

13. Where superficial pressure or excoriation appears, paint with tincture of benzoin

and expose to air.

14. Recurrent decubitus ulcers are to be considered a symptom indicating that the

patient is not making wanted progress. He should be checked for urinary complications,

malaria, bowel disturbance, or other sources.

15. Persistent decubitus ulcers at ischial bone or trochanteric regions should be evaluated as to secondary osteomyelitis activity, by X-ray of the respective region.

VII. SPASTICITY

1. Patient to be checked for interference with walking such as adductor or hamstring spasms.

2. If interference with walking by scissoring is obvious, obturator neurectomy and

severing of adductor muscles is indicated. Procedure should not be carried out prior

to 12 months following injury unless severe progress of spasm has been observed.

3. Routine application of curare intramuscularly, 0.05 milligram per pound weight

of patient. The course will include three injections of 3 successive days followed by a

3-day interval and repeated twice. Change of treatment or statement of efficiency will

not be considered until the above complete routine has been followed.

4. A report on all curare patients will be submitted to the ward surgeon at the conclusion of the first course.

5. During application of curare, a resuscitator will be on the ward, and prostigmine,

1 : 4000, 1 cc, will be ready for intravenous injection, if indicated.

6. Curare records will be kept by the physiotherapists.

7. If curare has been found inefficient, the doses can be stepped up to 50 percent

for the next course and, if no results are obtained, it may be further increased doubly

for the third course.

8. Curare in beeswax will be requested because of its reported higher efficiency.

9. In connection with curare, all patients will be weighed once in 6 weeks, and a

record kept of their weight.

10. Spasticity will be counteracted by the physiotherapists through gentle stretching,

carefully avoiding all spinal reflexes, and also by application of the Hubbard tank

treatment.

11. Heat treatment is permissible for relaxation and will be used in selected cases

as indicated.

12. Grading in curare therapy is done according to:

(a) Spontaneous spinal or mass reflexes: Grade I.

(b) Mass reflexes induced by touching lightly with swab: Grade II.

(c) Mass reflexes induced when pricked by pin or sharp stick: Grade III.

(d) Mass reflexes induced when struck a sharp tap: Grade IV.

VIII. PAIN (so-called root pain)

1. Root pains occur on the trunk, bilaterally in extremities, or unilaterally in extremities.

2. Root pains might be caused by another underlying pathology such as kidney calculi which therefore should be ruled out prior to therapy.

3. In order to alleviate root pains, venom therapy is permissible: one-half cc. twice

a day to start, eventually increasing during the first week to 1 cc. twice a day.
604 NEUROSURGERY

4. Causalgia with hyperhidrosis is to be differentiated from conditions encountered

in lower extremities where the temperature is raised and sweating is absent.

5. Causalgia might respond to Depropanex, 2 cc. intramuscularly, four times a day,

or to sympathetic block. If so, and if it does not level off by itself, the case is amenable

to sympathectomy.

6. If the dry, hot condition exists, the case might be treated with gynergen, onequarter to 1 cc. intramuscularly per day for 3 to 4 days. If the slightest paresthesia

occurs or numbness in the fingertips, therapy must be discontinued at once.

IX. CLASSIFICATION OP PATIENTS

Three classes of patients are differentiated as shown on the following chart:

CLASS I

WALKING AND INDEPENDENT PATIENTS

CLASS

WHEELCHAIR PATIENTS

PREPARATION FOR WALKING

CLASS III

BED PATIENTS
APPENDIX 0 605

Class I.—Walking and independent patients: All activity is focused around educational and vocational timetable. Walking, physiotherapy, physical recreation, and outdoor activities take second and third place.

Class II.—Wheelchair patients (preparation for walking) : All activities will focus

around physical education; then follows physiotherapy and eventually educational and

occupational therapy.

Class III.—Bed patients: All activities will focus around occupational therapy, education, entertainment, symptomatic physiotherapy, and finally physical education in the

lightest form will be subordinated.

X. SURVEYS

Surveys as attached are to be completed on each patient, and kept up to date with

each new complication arising:

1. General information (to be kept as a roster on each ward).

2. Desirable final bladder condition.

3. Incidence of calculosis.

4. Sexual condition.

5.

*******

Gynecomastia.

XI. WALKING

1. Prior to walking, a patient's torso and arm musculature must be prepared by

regular physical exercise, outlines for which are on the files of the Physical Reconditioning Branch.

2. Before a patient walks, he must be up in a wheelchair daily for at least 2 weeks.

3. Painting can be avoided in cases with paralyzed abdominal musculature, by abdominal binders prior to getting up, or by adrenalin in oil, 1 cc. intramuscularly. This

will be given one-half hour prior to getting up.

4. Adrenalin in oil is indicated only when a severe drop in blood pressure has been

found between the supine and erect position.

Walking School Procedure

Parallel bars:

Before a patient begins walking procedure, he should be up in a wheelchair for at

least 2 weeks, and his musculature should have been prepared to support him on the

parallel bars, by regular physical exercises.

1. Balance exercises: Patient is put in braces and placed between parallel bars, his

feet slightly apart, side-straddle position, with both hands on the bars. He is then to

release one hand after the other, keeping his balance. Once he has mastered this, he

is to release both hands from the bars, still maintaining his balance. In all these exercises, a slight forward leaning position is desirable; however, the patient will have to

find out, according to the level of his lesion, where his point of gravity lies.

2. Leg-swinging exercises: With both hands on the parallel bars, the patient is

requested to lift one leg after the other, and to swing his leg forward and backward.

The patient will increase the number of swings with practice.

3. Forward-stepping exercises: Patient is placed in a slight forward-leaning position, similar to the tripod position, on crutches, with his legs approximately 4 to 5 inches

apart. He is then instructed to use his right hand and left in the following manner:

Patient releases grasp of right hand from the bar and places it approximately 3 inches

forward. By leaning on outstretched right arm and pushing against outstretched left

arm, with a rotating motion from the hips, he pushes the left leg forward. After patient

has done this, taking a step of about 2 to 3 inches, he repeats the same procedure, using

the left arm and right leg.

4. Backward-stepping exercises: These exercises are done in the same manner as

the forward-stepping exercises, using opposite arm and leg, with even shorter steps.
606 NEUROSURGERY

5. Sidestepping exercises: Patient faces the bar, side-straddle position, legs 3 to 4

inches apart. Sidestepping to the right, he advances his right arms 3 to 4 inches to the

right, and pulls his left leg to his right leg, and then advances the right leg 3 to 4 inches.

The maneuver is then repeated, grasping in a new position.

Caution:

Patient should be closely watched during his first exercises to prevent his fainting,

as far as possible. Pulse rate should be controlled and sweating watched. Patient

should not exercise to the point of fatigue.

Crutches:

Only after a patient has become experienced and confident on the parallel bars, with

or without a transitional period on the walker, should he be put on crutches. During

the crutch exercises, the attendant should stand behind the patient, always ready to

grab him, and encouraging him to fall forward instead of backward.

1. Tripod position: Patient leans forward in front position without hanging his

axilla in the crutches. By holding the crutch handles in a firm grasp with outstretched

elbow, patient stands in a side-straddle position with feet 3 inches apart, and learns to

keep his balance.

2. Swinging exercises: Crutches will be placed apart, permitting a firm grip, and

then patient is instructed to sway his body to the left and right, supporting himself

chiefly on the left or right crutch. Once he has finished the swaying exercises and is

confident to perform them on both crutches, he will lift his right crutch while swaying

to the left side, etc.

3. Equilibrium exercises: After patient has completed the above exercise, he will

take a side-straddle position with feet approximately 12 inches apart. He will then

attempt to shift his equilibrium slowly, relying chiefly upon one crutch. This crutch

will eventually form a triangle; in the apex of the triangle, crutch will be in front of

patient and the base of the triangle will be formed by the two feet. This will enable

the patient to stand slightly leaning forward on one crutch, with the other crutch lifted.

Crutches (walking positions)

1. Four-point step walk: Tripod position: right crutch, left leg, left crutch, right

leg. Execution: Right crutch placed 2 to 3 inches forward to start with. Equilibrium

shifted to right leg at the same time the outstretched left arm pushes away from the

left crutch, permitting rotating motion forward of left leg. Same procedure is repeated

with left crutch and right leg. During this procedure the patient is encouraged to support his weight entirely on the supporting standing leg, thereby permitting the opposite

swaying leg to be carried without touching the floor, through a hip-lifting motion originating in the shoulder of the side from which the leg is swung.

2. Quick four-point or ski-ivalk: This is basically the same type of step as described

under "four-point walk" except that this is executed in a quick manner which permits

the motion of right crutch, left leg (and vice versa) to occur almost simultaneously, and

also permits a sliding walk as used on skis.

3. Side, backstepping, and turning around exercises should be taught similar to those

performed and executed on the parallel bars.

4. Swing-to walk: This exercise is advocated for patients with a lesion of D-10 or

higher (i.e., from the line of the umbilicus or higher level). The swing-to walk consists

of tripod basic position. Then the patient is instructed to move both crutches forward,

which in the beginning he will probably accomplish by moving each crutch individually

and not both at the same time. He then pulls his legs forward 2 to 3 inches until he

gets back into a tripod position. This maneuver repeats itself, thus enhancing locomotion

5. Swing-through walk: Same procedure as swing-to walk except that the legs will

be swung to a position exceeding the tripod position whereby patient will always have
APPENDIX C 607

to lean forward in order to prevent dropping backward. This will have to be done rather

quickly in order to maintain balance.

Walker exercises:

1. The walker may be utilized by those patients who wish to use it as a transitional

stage between bar exercises and crutch exercises. High-level lesion cases are not encouraged to use the walker unless they so desire in order to do the hop-walk, rather than

individual stepping.

2. The execution is as follows: Patient in walker faces the attendant, and takes the

tripod position. The walker is then swung to the left, whereby the patient shifts his

equilibrium to the left, standing on the left leg. He then pushes his body away from the

right side by stretching his right arm and pushing it against the handle of the walker,

thus permitting the right leg to swing forward. The maneuver is then executed to the

right side.

Sit down exercises:

1. Patient walks to chair on crutches, turns sideways with leg nearest chair slightly

forward and leaning against the chair. Patient lays down crutch nearest to chair, grasps

chair arm, unlocks brace nearest chair, regrasps chair arm, using remaining crutch as

support, rolls backward and into chair seat.

Stair-stepping exercises:

1. Steps of the parallel bars may be utilized to instruct the patient in stepping

upstairs and downstairs. Downstair stepping preferably executed in a backward position.

2. Curb stepping could be taught by removing one of the parallel bars and teaching

the patient to step up on side of bar platform.

3. Stair-stepping exercises will be executed by using the shallow steps first, one hand

on the banister and the other hand on the crutch. Steep steps to be attempted only

when patient has graduated from the shallow steps with confidence.

uneven ground, and ramp exercises:

1. Patients will first try shallow ramps and progress to steep ramps, when he has

become proficient at the other walking exercises. Eventually uneven ground exercises

on the lawn should be executed routinely.

XII. WORKING SCHEDULE

1. The ward surgeon will check at least once a week on all general surgical questions

such as bedsores, gynecomastia, etc.

2. The ward surgeon will check on all urological problems once each week. Use of

the abbreviated GU progress sheet form is recommended.

3. All problems referable to bowel regulation will be checked every 2 weeks, and

recorded on the attached bowel movement progress form.

4. The ward surgeon will check on the neurological condition once each week, using

the attached form as progress notes.

5. The ward surgeon will observe patients in their walking progress each week, and

check his bracing problems, etc.

6. Each Monday, all X-rays taken the previous week will be on hand on the ward

and will be shown to the conference of all ward surgeons and the chief of the paraplegic

service. This will be followed by rounds on that particular ward, where all problems

and necessary consultations or operative procedures will be discussed. It is contemplated

that, in order to make a thorough study, 1 ward of 48 patients should be seen that day.

7. It is desirable that all patients of the service who can walk be seen once in 3

weeks by the chief of the paraplegic service.
APPENDIX D

Battle Wounds and Battle Injuries of the Spinal

Cord and Vertebrae

The statistical data presented in tables 1 and 2 were prepared by the Medical Statistics Division, Office of the Surgeon General.

The term "admission," as used in these tables, refers to cases in which a battle

wound or a battle injury of the specified site was reported as the primary cause of

admission to hospital or quarters. With respect to multiple wounds recorded on admission, only one, the more serious, would have been recorded as the admission diagnosis.

Data pertaining to patients who incurred spinal injuries but were admitted to treatment

primarily for wounds or injuries of other sites are not available. With respect to KIA

(killed in action) data, the anatomical region indicated is that associated with the

primary cause of death. The variables, causative agent, nature of traumatism, and

anatomical location pertain to the primary diagnosis for admissions and CRO (carded

for record only) cases and to the principal cause of death for the KIA.

TABLE 1.—Battle wounds and battle injuries of the spinal cord and vertebrae in the U.S. Army,

by causative agent, combined years 1942, 1948, and 194-5

[Preliminary data based on tabulations of individual medical records]

Causative agent KIAi

Bomb and bomb fragments

Shell, shell fragment, and flak

Bullet, maehinegun, rifle, etc

Landmine, boobytrap

Grenade and grenade fragments

Explosion of ammunition, weapon, etc

Firearms, mechanism or effects of discharge of

Aircraft, excluding aircraft weapons

Parachute jump

Boat sinking and accident

Tank, tractor, caisson

Motor vehicle, passenger and cargo

Vehicle, other and unspecified

Cutting or piercing instruments

Fall or jump, twisting, turning, listing, slipping, etc...

Other and unspecified

Total..

Number

3

30

36

7

3

5

1

12

1

107

Nonfatal

CEO

cases 2

Admissions 3

Number

2

15

4

1

1

1

1

11

Number

69

1,408

750

189

32

51

8

130

123

20

46

4

412

126

Deaths

among

those admitted i

Number

3

157

153

10

3

1

337

Case

fatality

ratio

Percent

4.3

11.2

20.4

5.3

9.4

2.0

2.3

25.0

4.8

9.8

i KIA for whom a wound or injury of the spinal cord and vertebrae was reported as the primary cause of death. The

number of KIA cases is markedly affected by the lack of detail in describing the anatomical location. This accounts for

the relatively small number of KIA. cases shown.

' CRO cases with a wound or injury of the spinal cord and vertebrae as the primary diagnosis.

' Due to the wounds or injuries of the spinal cord and vertebrae.

i Consists of all cases which ended in death, not necessarily due to a wound or injury of the spinal cord and vertebrae

nor necessarily occurring during the years indicated.

NOTE—The low case fatality ratios are probably due to the relatively minor nature ofmany of the cases which reached

medical treatment facilities; many serious cases are killed instantly or die before arriving at a treatment facility.

609
610 NEÜROSURGERY

TABLE 2.—Admissions for battle wounds and battle injuries

of the spinal cord and vertebrae, by location of traumatism,

U.S. Army, 1943-43

[Preliminary data based on tabulations of individual medical records]

Anatomical location

Nonfatal

CEO

cases

Admissions

Deaths

among

those admitted i

Spinal cord __ __

Number Number

16

594

68

Number

19

4

31

Vertebral joints ___ _. ... __ _„ _ „

Total 23 678

i Not necessarily due to the wound or injury causing admission nor necessarily

occurring during 1942-43.
APPENDIX E

Peripheral Nerve Injury Study (All Nerves)1

NATURE OF THE DATA

The present study of peripheral nerve injuries is based on 6,336 individuals. Of

these, 5,748, or slightly over 90 percent, showed only 1 nerve injury on which surgery

was performed; 588, or about 10 percent, were reported as having been operated on for

two or more nerve injuries.

The total number of nerves on which reports were received was 7,050. The ulnar

was by far the most frequent nerve encountered, accounting for almost one-third of the

total number of injuries. Next in order of frequency of occurrence were the median

(with 19.5 percent of the total number of injuries), the sciatic (16.9 percent of the total),

and the radial (14.1 percent of the total).

Throughout the entire study, the reports of these 7,050 nerve injuries have been

divided into two categories:

1. OS (oversea) cases: Those cases on which the first report attempt at definitive

treatment was performed overseas.

2. ZI (Zone of Interior) cases: Those cases on which the first reported attempt at

definitive treatment was performed in the Zone of Interior.

On the basis of this division, the 7,050 nerve injuries were broken down into 1,390

OS cases (19.7 percent of total) and 5,660 ZI cases (80.3 percent of total).

Graft procedure as the original definitive treatment was used in only 1 percent of

the total number of injuries. End-to-end anastomosis was performed as initial treatment

on the remainder.

The total number of operations performed on these 7,050 nerves was 7,327.

i This analysis was prepared by the Medical Statistics Division, Office of the Surgeon General,

and submitted to the Historical Unit, U.S. Army Medical Service, on 22 August 1956. The data

were derived from material in the World War II Peripheral Nerve Registry from the date of the

Registry's establishment up to the date of 1 November 1945.

611
612 NEUROSURGERY

TABLE 1.—Involved nerve and type of operative procedure (total cases)

End-to-end anastomosis as original definitive

procedure

Graft as

original

definitive

procedure

Total cases

Nerve involved Primary

Other Total Actual

No previous bulb

suture

With previous bulb

suture

Percent

132

1,240

2,095

904

81

28

1,101

219

520

19

17

106

6

59

90

33

3

138

1,362

2,248

985

87

28

1,186

242

557

21

17

l 112

1

14

13

12

139

1,376

2,261

997

37

29

1,191

252

558

21

25

114

2.0

Median _______

Ulnar _____ _ _ ___

Radial. _

63

63

48

3

19.5

32.1

14.1

1.2

1

5

10

1

.4

36

12

11

1

49

11

26

1

16.9

Tibial

Peroneal- _

3.6

7.9

.3

3

«2

.4

1 5 1.6

Total nerve injuries 6,462 238 '283 6,983 67 7,050 100.0

* Includes antebrachial cutaneous (49), sural (34), axillary (20), brachial cutaneous (3), spinal accessory (3), plantar (3).

2

Includes axillary (1), cauda equina (1).

s Includes cases with—

Secondary as first report received — 77

Primary after graft as first report received _ 4

Only bulb suture report received _ - - 76

Primary, etc., section reported as "unknown" __ 126
APPENDIX E

613

TABLE 1 (a).—Involved nerve and type of c peralive procedure, OS and ZI

End-to-end anastomosis as or

procedure

lginal definitive

Graft as

original

definitive

procedure

Total cases

Primary

Other Total Actual Pert Nerve involved

No previous bulb

suture

With previous bulb

suture

OS ZI OS ZI OS ZI OS ZI OS ZI OS ZI OS ZI

16

223

394

178

12

1

238

34

113

3

3

13

116

1,017

1,701

726

69

27

863

185

407

16

14

93

4

26

40

12

2

2

33

50

21

1

20

253

441

195

15

1

266

36

130

4

3

116

118

1,109

1,807

790

72

27

920

206

427

17

14

2 96

2

1

1

14

11

11

20

253

443

196

15

2

267

37

130

4

7

16

119

1,123

1,818

801

72

27

924

215

428

17

18

98

0.3

3.6

6.3

2.8

.2

3.8

.5

1.8

.1

.1

.2

1.7

4

7

5

1

59

56

43

2

15.9

25.8

11.3

1.0

1

1

1

4

9

1

.4

4

1

32

12

11

24

2

17

25

9

9

1

13.1

3.1

6.1

.2

4 4

2

.3

1 3 2

1.4

Total nerve injuries. 1,228 5,234 22 216 3 130 3 153 1,380 5,603 10 57 1,390 5,660 19.7 80.3

i Includes antebrachial cutaneous (11), sural (2), axillary (1), brachial cutaneous (1), plantar (1).

2 Includes antebrachial cutaneous (38), sural (32), axillary (19), brachial cutaneous (2), spinal accessory (3), plantar (2).

3 Includes cases with— Oo Zi 1

Secondary as first report received 6

Primary after graft as first report received * J>

Only bulb suture report received... — 2'*

Primary, etc., section reported as "unknown".- — 122

Total - -- -

130 153
614 NEUROSURGERY

TABLE 2.—Single and multiple nerve injuries (total cases)

Type of injury OS ZI

Total

Actual Percent

1,154

111

4,894

477

5,748

588

90 7

Total number of individuals

with nerve injuries. . 1,265 5,071 6,336 100.0

1

Individuals with only 1 nerve injury requiring end-to-end anastomosis or graft procedure.

2

Individuals with 2 or more nerve injuries requiring end-to-end anastomosis or graft

procedure.

TABLE 3.—Postoperative nerve condition (total cases)

Nerve condition' OS ZI Total

19

13

44

26

1 As shown either on assessment or report of reoperation.

NOTE.—Though there were 4 times as many ZI cases as OS cases, there were only

about 2 times as many individuals on whom either suture-line separation or infection after

suture were reported. The number of the latter cases, however, is so small as to make any

generalization on this difference subject to some doubt.
APPENDIX E 615

TABLE 4. —Dispositions and lime lost from duty (total cases)

Time lost from duty (weeks)

Type of disposition

Less

than

30

30-39 40-49 50-59 60-69 70-79 80-89 90-99

100

and

over

Total

Average

weeks

lost

Full duty:

1

1

1 1

2

1 4

3

45.3

43.0

2 1 3 1 7 44.3

Limited duty on account of

nerve injury:

6

6

10

11

2

7

4

6

2

2

1 25

35

41.0

ZI 2 1 43.5

12 21 9 10 4 2 1 1 60 42.5

ODD or retired on account of

nerve injury:

OS .- 7

13

33

37

29

53

45

62

18

56

2

12

1

6

1

18

136

264

47.9

ZI 7 56.9

20 70 82 107 74 14 7 7 19 400 53.8

ODD for other reasons:

2

2

1 3

7

43.6

ZI -. - - 1 1 1 1 1 67.4

Total . 1 4 1 1 1 1 1 10 60.3

Other dispositions:'

1 4 1 6 49.5

1 4 1 6 49.5

Total dispositions:

OS

ZI

14

21

43

49

34

66

51

70

21

59

2

14

1

7

2

20

168

315

46.7

9 55.4

Total -- 35 92 100 121 80 16 8 9 22 483 52.4

i Other dispositions include 1 accidental death, 2 cases separated by sec. VIII, and 3 transfers to plastic or orthopedic

sections.

NOTE.—483 cases in the present study received dispositions after an average duration of treatment of 52.4 weeks. Of

these total dispositions, 400 cases, or about 83 percent, had been given ODD (certificate of disability for discharge) or retirement because of the nerve injury.

Men who were returned to duty (either full or limited) had significantly less time under treatment than those whose

disposition involved separation from service. The explanation may be (1) doubtful cases could be returned to limited

duty and still be kept under observation, and (2) men who were to be CDD'd were kept in the service until recovery was

fairly complete or until further treatment was inadvisable.

On the average, patients who received their first definitive treatment in a ZI installation were retained under treatment about 9 weeks longer than those who were first operated on overseas.
616 NEUROSURGERY

TABLE 5.—Causative agent (total cases)

Causative agent

Battle wounds:

Battle wound (unspecified) '

Gunshot wound or bullet. -

Shell or bomb fragment, shrapnel.

Landmine, boobytrap, grenade...

Aircraft crash (combat)

Other battle wounds

TotalAccidental wounds:

Aircraft crash (noncombat)

Motor vehicle

Accidental gunshot wound or bullet..

Accidental shell-fragment wound, etc.

Knife or glass (cut or stab)

All other accidents2

Total

TJnreported or unknownTotal number of individuals with nerve injuries.

54

341

767

35

1,265

ZI

110

1,560

2,972

115

4

21

4,782

244

45

5,071

Total

164

1,901

3,739

150

4

24

5,982

4

32

49

16

119

81

i The group classified as "battle wound (unspecified)" consists of cases reporting cause of injury as "wounded in

action," "caused by enemy fire," etc.

2 "All other accidents" includes—

OS: Accidental laceration (5), fall (4), falling or moving object (2), previous surgery (1).

ZI: Accidental laceration (15), fall (14), falling or moving object (10), explosion (6), previous surgery (11),

crushed by machinery (6), other (7).

NOTE.—Gross classification of the total number of cases shows the following percentage breakdown: 94.4 percent of

the total injuries were caused by battle wounds, 4.8 percent were caused by accidental injury, and 0.8 percent of the cases

showed cause either as unknown or unreported.

The most important single cause of injury was shell or bomb fragments, accounting for 59 percent of the total injuries.

Small arms fire (gunshot wound or bullet) was next in importance, with 30 percent of the total number of nerve injuries.
APPENDIX E 617

TABLE 6.—Bone, vascular, or soft-tissue injury (total cases)1

Type of damage

No bone, vascular, or soft-tissue damageBone injury only

Vascular injury only

Soft-tissue injury only

Bone and vascular injury

Bone and soft-tissue injury

Vascular and soft-tissue injury

Bone, vascular, and soft-tissue injuryTotal cases with bone, vascular, or soft-tissue injury

Total reportedNumber of cases

OS

244

92

12

25

10

385

ZI

2,238

1,744

409

92

200

112

19

14

Total

2,952

501

104

225

122

19

16

2,975

Percentage of total reported

OS

65.0

22.1

8.4

1.1

2.3

35.0

ZI

36.1

8.5

1.9

4.1

2.3

.4

53.6

Total

33.4

8.5

1.8

3.8

2.1

.3

.3

100.0

i Soft-tissue injury includes only those cases requiring plastic procedure, showing marked loss of soft-tissue substance

or severe infection.

NOTE.—Reports on the presence or absence of bone, vascular, or soft-tissue damage were received on 5,927 cases (93.5

percent of the total number of individuals under study), as against only 409 (166 overseas and 243 in the Zone of Interior)

cases which failed to report this item or reported it as unknown. All calculations of percentage distribution, therefore,

have been based on the total number of cases on which definite information on this item has been received.

About lA (49.8 percent) of the cases in this latter group stated that no complicating injury was encountered. The

remaining half (50.2 percent) showed either bone, vascular, or soft-tissue damage or some combination of the three.

Bone injury was the greatest single complication, appearing either alone or in conjunction with some other type of

damage in 39.6 percent of the total cases reported. Vascular injury was present in 12.9 percent of the cases. Soft-tissue

damage appeared in 4.5 percent of the total cases reported.

A comparison of OS and ZI cases shows that bone, vascular, or soft-tissue damage was present in only 35 percent of

the cases operated on overseas, while 53.6 percent of the ZI cases reported 1 or more of these conditions. This difference

may be accounted for by the fact that the more seriously complicated cases were probably sent back to this country and

definitive treatment postponed until these conditions had been at least partly relieved.
618 NEUROSURGERY

TABLE 7.—Interval from injury to first operation (primary or graft), (total cases)1

Interval (tenths

of months)

Actual

number

of cases

Cumulative

number

of cases

Cumulative

percent

Interval (tenths

of months)

Actual

number

of cases

Cumulative

number

of cases

Cumulative

percent

146

29

12

13

13

8

15

26

31

36

40

57

65

64

67

75

70

65

64

146

175

187

200

213

221

236

262

293

329

369

426

491

555

622

697

767

832

896

2.1

2.5

2.7

2.9

3.1

3.2

3.4

3.8

4.2

4.7

5.3

6.1

7.0

7.9

8.9

10.0

11.0

11.9

12.8

19 68

78

62

54

61

56

76

93

72

100

86

1,015

1,082

929

701

446

313

697

22

964

1,042

1,104

1,158

1,219

1,275

1,351

1,444

1,516

1,616

1,702

2,717

3,799

4,728

5,429

5, 875

6,188

6,885

6,907

13.8

1 20 14.9

21-. 15.8

3 22- 16.6

4 23 17.5

5 24 18.3

6 25. _ 19.4

7 _ 26

27

20.7

8 21.7

9 28.

29

23.1

10 24.3

30-39 39.1

40-49 55.0

13 50-59 68.5

14 60-69 78.6

70-79 85.1

16 80-89 89 6

17 99.7

18 100.0

i Exclusive of bulb sutures (214), secondary or tertiary operations (191), and primary after graft (15).

NOTE.—This table shows the length of time which elapsed between the date of injury and the first attempt at actual

nerve repair. The table includes only those cases (6,907) on which reports of primary operation or initial graft were received. Thus, 146 cases (2.1 percent of total) received definitive treatment within the same tenth of a month as the injury;

175 received treatment either within the same tenth or the following tenth of a month after injury, and so forth.

Within 1 month after injury (the same interval as the injury plus the following 9 intervals) 329 cases, or 4.7 percent

of the total, had received reparative surgery. At the end of 2 months, 13.8 percent of the cases had been treated and so

forth. (Compare with table 7(a) for difference between OS and ZI cases.)

On 22 cases, either the date of injury or the date of operation was reported as unknown.
APPENDIX E

619

TABLE 7(a).—Interval from injury to first operation {primary or graft) OS and 7A '

Interval

(tenths of

months)

0_

1.

2.

3.

4.

5.

6.

7_.

8_.

9_.

10

11.

12,

13.

14.

15.

16.

17.

18.

Actual

number of

cases

OS

119

29

11

9

12

7

15

24

30

31

39

52

60

61

62

64

59

50

53

ZI

Cumulative

number of

cases

OS

119

148

159

168

180

187

202

226

256

287

326

378

438

499

561

625

681

734

787

ZI

27

27

28

32

33

34

34

36

37

42

43

48

53

56

61

72

83

98

109

Cumulative

percent

OS ZI

8.7 0.5

10.8 .5

11.6 .5

12.2 .6

13.1 .6

13.6 .6

14.7 .6

16.4 .6

18.6 .6

20.8 .7

23.6 .7

27.3 .8

31.6 .9

36.0 1.0

40.5 1.1

45.1 1.3

49.4 1.5

53.0 1.8

56.8 2.0

Interval

(tenths of

months)

19....

20

21

22

23

24

25

26

27

28

29

30-39..

40-49..

50-59..

60-69..

70-79..

Actual

number of

cases

OS

Cumulative

number of

cases

ZI

90 and over.

Unknown...

46

49

39

29

27

23

35

34

20

25

10

102

52

24

19

9

14

28

9

22

29

23

25

34

33

41

69

52

75

70

913

1,030

905

682

437

299

669

13

OS

131

160

183

208

242

275

316

375

427

502

572

1,485

2,515

3,420

4,102

4,539

4,838

5,507

5,520

Cumulative

percent

OS

60.1

63.6

66.4

68.5

70.4

72.1

74.6

77.1

78.5

80.3

81.5

89.0

92.7

94.4

95.8

96.4

97.4

99.4

100.0

ZI

2.4

2.9

3.3

3.8

4.4

5.0

6.7

6.8

7.7

9.1

10.4

26.9

45.7

62.1

74.4

82.3

87.7

99.8

100.0

1 Exclusive of—

OS ZI

Bulb sutures 18 i%

Secondary or tertiary operations 56 135

Primary after graft 1 14

Total 75 345

NOTE.—See table 7 for explanation of data and procedure.

About 20 percent of the OS cases received the first attempt at surgical repair within the first month after injury 40

percent during the second month, and 20 percent during the third month. Thus, a total of over 80 percent of the OS

cases received definitive treatment within the first 3 months after nerve injury.

The comparable figure for ZI cases for the same period was only 10 percent. The great bulk of ZI cases (about 90 percent) did not receive the first primary or graft operation until 3 months or more had elapsed after injury. The period of

greatest activity on ZI cases was in the 3-month interval from the 4th through the 6th month after injury, with over onehalf of the total cases receiving first definitive treatment in that period.

498991T—59- -43
620 NEUROSURGERY

TABLE 8.—Operative procedure end-to-end anastomosis (total cases)1

End-to-end anastomosis

Complete

Partial

Information unavailable

With tantalum wire

With other suture material

With tantalum wire and other suture materialNo entry or information unavailable2

With stay suture

Without stay suture

Information unavailable

Wrapped in tantalum foil

Wrapped in other cuff material

No entry or Information unavailable

With mobilization

With transplantation

With mobilization and transplantation

No entry or information unavailable

Bone resection

No entry or information unavailable

Number of cases

OS

1,237

136

60

958

313

17

145

398

601

434

738

13

682

628

108

147

550

13

1,420

ZI

5,127

476

2

3,294

1,822

463

26

973

4,599

33

1,610

33

3,962

3,405

287

1,293

620

104

5,501

Total

6,364

612

62

4,252

2,135

480

171

1,371

5,200

467

2,348

46

4,644

4,033

395

1,440

1,170

117

6,921

Percentage of total reported

OS

90.1

74.4

24.3

1.3

98.3

1.7

71.2

12.2

10.6

59.0

32.7

8.3

17.5

82.5

98.0

2.0

68.3

5.8

25.9

Total

61.9

31.1

7.0

20.9

79.1

98.1

1.9

68.7

6.7

24.6

i Excluding all bulb sutures. .,,,*

2 "No entry" signifies items were left blank; "information unavailable" signifies that the reporting hospital lacked

information on the items.
APPENDIX E 621

TABLE 9 —-Rate of advance in TineV s sign , by interval aft tr operation (total coses)

Interval after operation to assessment (in months)

Tinel's sign (in cm.)

0-1.9 2-2.9 3-3.9 4-4.9 5-5.9 6-6.9 7-7.9 8-8.9 9-9.9 10-

10.9

11-

11.9

12-

12.9

13+ Total

0 121

18

30

12

14

9

11

2

108

27

69

51

42

28

51

44

15

10

5

13

5

313

36

198

239

221

152

186

213

100

134

47

89

27

20

21

11

22

5

6

26

80

8

28

42

58

26

41

42

17

45

9

33

9

JO

12

3

8

3

1

9

53

2

16

17

23

22

48

63

14

37

10

48

24

5

20

8

22

4

5

6

94

6

26

33

36

45

57

108

34

79

37

97

84

34

67

37

120

26

15

17

32

1

12

7

8

9

16

29

4

24

5

32

12

9

11

5

25

2

8

5

21

2

6

6

3

8

10

15

7

17

7

23

14

3

11

5

34

10

7

3

28 16 10 11 34

1

5

5

2

6

1

3

4

2

5

7

2

4

2

35

16

12

15

921

101 0.1-2.9

3.0-5.9 2

4

11

13

12

25

13

27

13

39

26

16

25

17

57

36

13

5

1

5

1

7

2

2

3

7

4

11

14

3

7

6

12

8

6

4

6.0-8.9 1

2

1

1

1

2

3

1

12

7

3

7

17

5

2

1

2

1

2

5

1

7

3

6

13

9

10

1

31

15

8

418

426

323

443

550

213

395

143

408

242

114

196

96

385

130

85

101

9.0-11.9

12.0-14.9

15.0-17.9

18.0-20.9

21.0-23.9

24.0-26.9 1

27.0-29.9

30.0-32.9

33.0-35.9

36.0-38.9

39.0-41.9 __ 1

2

42.0-44.9- 1

45.0-59.9

60.0-98.9

2

18

Unknown or

unreported 3

Total assessments

Average ad222

8.3

491

13.0

2,066

16.7

484

19.6

447

24.7

1,052

30.4

256

27.9

212

33.3

382

37.8

119

35. S

75

40.2

126

43.9

151

42.8

6,083

23.9

1

Includes 1 case on which date of operation is unknown.

NOTE.—This table was based on the total number of assessments received on 4,137 oncrations. The assessments were

distributed by the interval, in months, between each operation and its corresponding assessments, and, within each time

interval, by the reported advance of Tinel's sign distally from the suture line. Thus, 2,066 cases were assessed during

the 4th month after operation; the distribution of these cases according to the distal advance of Tinel's sign as of that

time is shown in column 3-3.9.

The average advance of Tinei's sign for each time interval, based on the assessments within that interval, is shown

at the bottom of the table. Cases reporting Tinel's sign as "none," "unknown," or "completed" were excluded from the

calculations of these figures.
622 NEUROSURGERY

TABLE 9(a) —Rate of advance of Tinel's sign, by interval afier operation (OS cases)

Interval after operation to assessment (in months)

Tinel's sign (In cm.)

0-1.9 2-2.9 3-3.9 4-4.9 5-5.9 6-6.9 7-7.9 8-8.9 9-9.9 10-

10.9

11-

11.9

12-

12.9

13+ Total

0 48

14

19

5

11

6

9

2

32

8

28

18

18

11

14

9

6

3

1

8

1

62

6

47

50

42

31

40

43

27

21

4

14

10

7

6

3

6

1

3

6

39

6

10

23

18

10

13

17

8

13

2

16

4

4

4

2

2

1

1

4

15

2

5

10

8

9

21

22

5

7

3

20

6

1

4

4

3

1

2

2

23

5

9

11

13

15

17

26

11

33

12

22

24

11

21

12

34

4

7

6

9

1

5

2

3

3

7

14

3

14

19

6

2

5

1

9

2

4

2

8

1

4

3

1

4

5

9

3

7

2

13

6

2

7

4

12

2

2

1

11 7 2 5 8 269

43

1

1

4

6

4

11

6

16

5

25

13

4

12

3

22

19

3

2

1

2

5

2

1

1

2

2

8

8

2

3

2

3

3

1

1

3 132

125

9.0-11.9 2 2

1

2

122

101

15.0-17.9 1

1

1

3

136

18.0-20.9 .

158

70

1 2

1

6

5

4

119

27.0-29.9-- -- -

1

4

8

2

6

1

4

2

2

1

9

4

3

12

33

30 0-32.9 -

156

33.0-35.9. - -

95

36 0-3S.9 37

39.0-41.9 _ . 1 75

32

45 0-59.9 - 1 12

2

1

16

7

6

129

60 0-98 9

46

33

Unknown or unre1 7

34

Total assessments --

Average ad116

8.3

166

12.9

429

16.8

197

18.9

150

22.2

316

28.9

111

27.9

96

30.7

168

38.0

54

32.8

39

40.3

59

46.3

44

40.0

1,945

24.6

i Includes 1 case on which date of operation is unknown.
APPENDIX E 623

TABLE 9(b) .—Rate of advance of Tinel's sign, by interval after operation (ZI cases

Interval after operation to assessment (in months)

Tinel's sign (in cm.)

0-1.9 2-2.9 3-3.9 4-4.9 5-5.9 6-6.9 7-7.9 8-8.9 9-9.9 10-

10.9

11-

11.9

12-

12.9

13+ Total

0

0.1-2.9

73

4

11

7

3

3

2

76

19

41

33

24

17

37

35

9

7

4

5

4

251

30

151

189

179

121

146

170

73

113

43

75

17

13

15

8

16

4

3

20

41

2

18

19

40

16

28

25

9

32

7

17

5

6

8

1

6

2

5

38

11

7

15

13

27

41

9

30

7

28

18

4

16

4

19

3

3

4

71

1

17

22

23

30

40

82

23

46

25

75

60

23

46

25

86

22

8

11

23

7

5

5

6

9

15

1

10

5

13

6

7

6

4

16

4

3

13

1

2

3

2

4

5

6

4

10

5

10

8

1

4

1

22

8

5

2

17 9 8 6 26

1

2

3

1

4

1

3

4

2

4

3

2

1

26

12

9

3

652

58

3.0-5.9 1

3

7

7

8

14

7

11

8

14

13

12

13

14

35

17

10

3

6.0-8.9 3

1

2

1

1

1

2

1

1

2

1

7

2

2

5

7

4

1

15

8

2

9.0-11.9 304

12.0-14.9 .

15.0-17.9..-

18.0-20.9 1

2

5

2

3

6

1

4

4

9

5

5

3

2

1

6

2

3

3

5

3

1

21.0-23.9

24.0-26.9

27.0-29.9

30.0-32.9

33.0-35.9

36.0-38.9

39.0-41.9

42.0-44.9 . 1

45.0-59.9 1

60.0-98.9 .

2

11

Unknown or unrcported _. . 2 67

Total assessments

Average advance

106

8.3

325

13.0

1,637

16.6

287

19.9

297

26.0

736

31.1

145

27.8

116

35.6

214

37.7

65

38.6

36

40.2

67

42.1

107

44.1

4.138

23.6

TABLE 10 —-Rale of m itor recovery, by interval after operation (total cases)

Motor recovery code

Interval after operation to assessment (in months)

0-1.9 2-2.9 3-3.9 4-4.9 5-5.9 6-6.9 7-7.9 8-8.9 9-9.9 10-10.9 11-11.9 12-12.9 13+ Total

0 _ 198

14

6

1

409

51

18

5

1

2

5

1,598

273

125

21

4

6

38

330

91

49

8

1

5

261

108

61

12

1

2

2

490

271

226

41

6

7

12

115

63

53

18

3

79

66

42

17

4

139

108

104

26

3

1

1

34

23

37

20

4

16

21

24

11

2

33

36

44

10

2

154

29

45

17

2

3,756

1,154

834

207

32

l._

2_

3

4 _

No loss

Unknown or un3 4 5 1 1 4 81

Total assessments.. _ 222 491 2,065 484 447 1,053 256 213 382 119 75 125 '151 6,083

i Includes 1 case on which date of operation was unknown.
624 NETJROSURGERY

TABLE 10(a).—Rate of motor recovery, by interval after operation {OS cases)

Interval alter operation to assessment (in months)

0-1.9 2-2.9 3-3.9 4-4.9 5-5.9 6-6.9 7-7.9 8-8.9 9-9.9 10-10.9 11-11.9 12-12.9 13+ Total

0 102

6

5

140

IS

5

2

324

60

29

6

1

1

8

133

35

21

4

90

33

19

7

140

78

78

12

2

4

2

52

28

18

9

1

30

33

23

7

1

54

50

49

12

1

1

1

16

5

17

11

4

6

11

13

7

2

15

18

19

6

1

Ul

6

14

11

1,113

1 . 378

2 - --

310

3 - 94

4 13

2

2

1

3

1 10

Unknown or unre3 3 2 1 2 27

Total assessments.» 116 166 429 197 150 316 111 96 168 54 39 59 144 1,945

i Includes 1 case on which date of operation was unknown.

TABLE 10(b).—Bate of motor recovery, by interval after operation {ZI cases)

Motor recovery code

Interval after operation to assessment (in months)

0-1.9 2-2.9 3-3.9 4-4.9 5-5.9 6-6.9 7-7.9 8-8.9 9-9.9 10-10.9 11-11.9 12-12.9 13+ Total

0 96

8

1

1

269

36

13

3

1

1,274

213

96

15

3

5

30

197

56

28

4

2

171

75

42

5

1

1

2

350

193

148

29

4

3

10

63

35

35

9

2

49

33

19

10

3

85

58

55

14

2

18

18

20

9

10

10

11

4

18

18

25

4

1

43

23

31

6

2

2,643

1 . -.

776

2

524

3 113

19

9

Unknown or unre3 1 3 1 2 54

Total assessments -- 106 325 1,636 287 297 737 145 117 214 65 36 66 107 4,138

TABLE 11.—Bate of sensory recovery, by interval after operation {total cases)

Interval after operation to assessment (in months)

Sensory recovery code

0-

1.9

2-

2.9

3-

3.9

4-

4.9

5-

5.9

6-

6.9

7-

7.9

8-

8.9

9-

9.9

10-

10.9

11-

11.9

12-

12.9

13+ Total

0 202

10

4

423

36

13

3

4

1

11

1,674

267

55

18

7

4

40

340

91

34

4

3

1

11

265

111

45

19

7

520

331

139

46

6

2

9

109

74

47

20

2

70

75

36

26

2

118

156

67

26

10

28

39

29

20

3

13

23

16

15

6

28

48

27

17

5

147

43

27

28

6

3,837

1

1,304

2

539

3 -

242

4 .

54

8

Unknown or

6 4 3 5 2 1 99

Total

assessments-- 222 491 2,065 484 447 1,053 256 212 382 119 75 126 1 151 6,083

i Includes 1 case on which date of operation was unknown.
APPENDIX K 625

TABLE 11(a)-—Rate of sensory recovery, by interva after operation (OS cases)

Interval after operation to assessment (in months)

Sensory recovery code

0-

1.9

2-

2.9

3-

3.9

4-

4.9

5-

5.9

6-

6.9

7-

7.9

8-

8.9

9-

9.9

10-

10.9

11-

11.9

12-

12.9

13+ Total

0 .- 102

8

2

144

14

7

338

59

21

5

2

136

36

17

3

1

86

37

18

9

133

109

47

21

4

41

33

23

13

28

32

18

17

41

70

34

11

7

7

19

17

9

2

6

12

8

10

2

10

19

15

12

3

'7

14

8

13

2

1,079

1 462

2 235

3 123

23

Unknown or unre4 1 4 4 2 1 1 5 1 23

Total assessments lie 166 429 197 150 316 111 96 168 54 39 59 144 1,945

1

Includes 1 case on which date of operation was unknown.

TABLE 11(b)-—Rate of sensory recovery, by interval after operation (ZI cases)

Interval after operation to assessment (in months)

Sensory recovery code

0-

1.9

2-

2.9

3-

3.9

4-

4.9

5-

5.9

6-

6.9

7-

7.9

8-

8.9

9-

9.9

10-

10.9

11-

11.9

12-

12.9

13+ Total

0 100

2

2

279

22

6

3

4

1

10

1,336

208

34

13

S

4

36

204

55

17

1

2

1

7

179

74

27

10

7

387

222

92

25

2

2

7

68

41

24

7

2

42

43

18

9

2

77

86

33

15

3

21

20

12

11

1

7

11

8

5

4

18

29

12

5

2

50

29

19

15

4

2,758

1 842

2

304

3 119

4 _ ...

31

8

Unknown or unre2 3 2 1 1 76

Total assessments. 106 325 1, 636 287 297 737 145 116 214 65 36 67 107 4,138
626 NEUROSURGERY

TABLE 12.—First appearance of Tinel's sign in operations

with assessment, by time after operation (total cases)

With appearance of Tinel's sign J

Interval after operation

to assessment (months) With previous

assessment

showing Tinel

sign as 0

No previous

assessment

Total

No appearance of

Tiners

sign 2

0-1.9 96

357

1,670

345

220

267

79

71

77

25

11

17

43

96

360

1,691

360

242

350

97

88

102

33

16

23

48

86

2-2.9. _ 3

21

15

22

83

18

17

25

8

5

6

5

67

3-3.9- _ 231

4-4.9 57

5-5.9... 32

6-6.9. 59

7-7.9 24

8-8.9 17

9-9.9 IS

10-10.9 10

11-11.9 8

12-12.9 8

13

1

Total - . 228 3,278 3,506 631

i Distributed by first assessment which showed a positive Tinel's sign.

2 Distributed by latest assessment received.

3 Date of operation unknown.

NOTE .—Table 12 consists of 2 separate sections. The firstshows 3,506 operations

on which Tinel's sign has appeared, broken down into those cases (3,278) which

reported a definite value for Tinel's sign on the first assessment, and those cases

(228) on which Tinel's sign did not appear until after a previous assessment which

had reported the sign as "none" or "unknown." For each of these subgroups,

the table shows the distribution according to the interval between operation and

the assessment on which Tinel's sign first appeared.

The second major group, 631 cases with no appearance of Tinel's sign on any

assessment, was tabulated by the interval between operation and the last assessment report. The intention in this section is to show the length of time which has

elapsed since each operation with still no evidence of recovery.

For example, during the 4th month after operation (3-3.9 months) 1,691 cases

reported the presence of Tinel'ssign for the first time, 21 of them having previously

reported it as absent or unknown. During the same period, the last report

received on 231 cases showed a continued absence of the Tinel.
APPENDIX E 627

TABLE 12(a).—First appearance of Tinel's sign in operations

with assessment, by time after operation (OS and ZI)

With appearance of Tinel's sign '

Interval after operation to assessment

(months)

With previous

assessment

showing Tinel

sign as 0

No previous

assessment

Total

No appearance of

Tinel's sign2

OS ZI OS ZI OS ZI OS ZI

0-1.9 67

121

329

124

78

121

40

33

39

13

2

8

12

29

236

1,341

221

142

146

39

38

38

12

9

9

31

67

122

335

133

85

149

47

42

50

18

5

8

13

29

238

1,356

227

157

201

50

46

52

15

11

15

35

22

22

36

28

9

12

6

6

8

4

1

4

8

1

64

2-2.9 1

6

9

7

28

7

9

11

5

3

2

15

6

15

55

11

8

14

3

2

6

4

45

3-3.9 195

4-4.9 - - 29

5-5.9 23

6-6.9

7-7.9

47

18

8-8.9 11

9-9.9 10

10-10.9 6

11-11.9 . _ 7

12-12.9 4

1 5

Total 87 141 987 2,291 1,074 2,432 167 464

1 Distributed by first assessment which showed a positive Tinel's sign.

2 Distributed by latest assessment received.

3 Date of operation unknown.

NOTE.—At first inspection, the total columns of the cases on which Tinel's

sign has appeared seem to indicate that ZI cases recovered the Tinel earlier than

did OS cases. By the end of the 4th month after operation, for example, 66.7 percent (1,623 cases) ofthe total of 2,432 ZI cases in this column had reported the initial

appearance of Tinel's sign. For the OS cases, the corresponding percentage is

only 48.8 percent (524 of the total of 1,074 cases). This percentage lead of the ZI

cases continues with a gradually decreasing differential with the inclusion of succeeding intervals until, at the end of the 9th month, the comparable percentages

are practically equal at about 96 percent.

Any conclusions drawn from this comparison, however, must be severely

modified by 2 facts: (1) Assessments on OS cases did not fall into the regular

3-, 6-, 9-, 12-month pattern as well as ZI cases; (2) on the average, the first assessments on ZI cases were made sooner after operation than were those on OS cases,

thus tending to distort the first reports of Tinel recovery in favor of the ZI cases.

498991T—59- -44
628 NEUROSURGERY

TABLE 13.—First evidence of motor recovery in operations with

assessment, by time after operation (total cases)

With evidence of recovery i

No

Interval after operation

to assessment (months) With previous

assessment

showing recovery as 0

No

previous

assessment

Total

evidence

of

recovery *

0-1.9 14

67

341

110

96

165

66

57

60

25

12

13

48

14

67

350

127

160

442

109

96

139

53

20

34

60

121

2-2.9 -- 237

3-3.9 _ - 9

17

64

277

63

39

79

28

8

21

12

1,051

4-4.9 203

6-5.9 -. - -- 208

6-6.9 - 381

7-7.9 --

79

8-8.9 - - -- 49

9-9.9 80

10-10.9 16

11-11.9 12

12-12.9 . 20

18

Total -- 607 1,054 1,661 2,476

' Distributed by first assessment reporting evidence of recovery,

s Distributed by latest assessment received.

' Date of operation unknown.

NOTE.—As in table 12, this table should be considered as composed of 2 separate

sections. The first consists of those operations (1,661) on which motor recovery

has been reported positively, with the cases broken down according to whether

the recovery was reported on the first assessment or on a later assessment after an

earlier report showing no recovery: both types of cases are tabulated by the time

interval between operation and the assessment which first showed some degree

of motor recovery. The second section is made up of those operations (2,476)

whose assessments have shown no indication of motor recovery at any time; these

cases are tabulated by the interval between the operation and the latest assessment on each operation.

Thus, during the 4th month after operation (3-3.9 months) 350 cases reported

for the first time that motor recovery was beginning; in 9 of these the report

followed a previous report showing motor recovery as 0. In the same interval,

1,051 cases, according to their latest assessments, had never shown evidence of recovery.
APPENDIX E 629

TABLE 13(a).—First evidence of motor recovery in operations

with assessment, by time after operation (OS and ZI)

With evidence of recovery l

Noev

Interval after opera- of re«

tion to assessment

(months)

With previous

assessment

showing recovery as 0

No previous assessment

Total

idence

very2

OS ZI OS ZI OS ZI OS ZI

0-1.9 - 10

21

81

43

41

82

29

24

34

15

2

6

14

4

36

260

67

55

83

27

33

26

10

10

7

34

10

21

87

53

58

156

51

42

68

30

7

15

20

4

36

263

74

102

286

58

54

71

23

13

19

40

43

81

183

74

59

83

30

19

25

5

5

7

8

1

78

2-2.9 156

3-3.9 6

10

17

74

22

18

34

15

5

9

6

3

7

47

203

31

21

45

13

3

12

6

868

4-4.9 129

5-5.9 149

6-6.9 298

7-7.9 49

8-8.9 - - 30

9-9.9 55

10-10.9 - 11

11-11.9 7

12-12.9 ... .. 13

10

Total 216 391 402 652 618 1,043 623 1,853

1 Distributed by first assessment reporting evidence of recovery.

' Distributed by latest assessment received.

3 Date of operation unknown.

NOTE.—As was the case on Tinel's sign (table 12(a)), the initial reports of motor

recovery on ZI cases fall more heavily into the early intervals after operation than

do those on OS cases. On the surface, this seems to indicate an earlier appearance

of motor recovery on ZI as compared to OS cases. 2 weaknesses in the data,

however, make the validity of such a conclusion doubtful: (1) The interval between an OS operation and the first assessment report is, on the average, longer

than on a ZI operation; and (2) the early assessments on OS cases are made at more

irregular intervals than those on ZI cases. (See note on table 12(a).)

The above objections to the reliability of the data seem to be borne out by the

fact that those cases which have never reported recovery show the same type of

relationship between the distributions of OS and ZI groups as do the cases on

which recovery has appeared. The conclusion seems to be that the seemingly

favorable results in the ZI group are due more to the nature of the basic data than

to actual earlier recovery.
630 NEUROSURGERY

TABLE 14.—First evidence of sensory recovery in operations

with assessment, by time after operation (total cases)

With evidence of recovery i

No

Interval after operation

to assessment (months) With previous

assessment

showing recovery as 0

No

previous

assessment

Total

evidence

of

recovery 2

0-1.9 1 20

77

421

130

105

152

48

50

45

17

12

13

41

21

77

427

145

159

426

101

91

124

47

25

44

57

2-2.9 225

3-3.9 6

15

54

274

53

41

79

30

13

31

16

1,014

4-4.9

6-5.9 _

6-6.9

7-7.9

8-8.9

9-9.9

10-10.9 ...

11-11.9 14

12-12.9

21

1

Total 613 1,131 1,744 2,393

' Distributed by first assessment reporting evidence of recovery.

2 Distributed by latest assessment received.

3 Date of operation unknown.

NOTE.—The data on sensory recovery were handled and tabulated in the

same manner as the data on motor recovery. (See notes on table 13.) Cases

showing evidence of sensory recovery at any time after operation (1,744 cases)

were tabulated by the interval between operation and the first assessment which

reported the beginning of recovery; the 2,393 cases showing no recovery on any

assessment were tabulated by the interval between operation and the latest

assessment.

This table may be read in the same manner as table 13. During the 4th

month after operation, 427 cases showed signs of sensory recovery for the first

time. Of these, 421 were cases on which the first assessment fell within this

period; 6 had previously reported sensory recovery as 0 on earlier assessments.

During the same interval, the last assessment on 1,014 cases showed no sensory

recovery as of that time.
APPENDIX E 631

TABLE 14(a).—First evidence of sensory recovery in operations

with assessment, by time after operation (OS and ZI)

With evidence of recovery '

Interval after operation to assessment

(months)

With previous

assessment

showing recovery as 0

No previous assessment

Total

No evidence

of recovery 2

OS ZI OS ZI OS ZI OS ZI

0-1.0 1 11

24

94

48

33

74

24

23

21

11

2

5

14

9

53

327

82

72

78

24

27

24

6

10

8

27

11

24

97

58

53

139

43

45

51

25

10

20

22

10

53

330

87

106

287

58

46

73

22

15

24

35

40

80

187

80

53

82

32

21

31

13

5

10

8

1

74

145

827

122

132

264

44

39

56

10

9

15

13

2-2.9

3-3.9 3

10

20

65

19

22

30

14

8

15

8

3

5

34

209

34

19

49

16

5

16

8

4-4.9

5-5.9

6-6.9

7-7.9

8-8.9

9-9.9

10-10.9

11-11.9

12-12.9

Unknown'

Total.... 214 399 384 747 598 1,146 643 1,750

1 Distributed by first assessment reporting evidence of recovery.

2 Distributed by latest assessment received.

3 Date of operation unknown.

NOTE.—The cases on which sensory recovery has been noted show the same

pattern of relationship between the OS and ZI groups as was observed on Tinel's

sign and on motor recovery (tables 12(a) and 13(a)). Because of a greater proportion of reports of first recovery in the early months after operation, the ZI

cases apparently show earlier sensory return than do the OS cases. However, the

reliability of the basis data is open to the same objections which were brought out

in the comments on the tables mentioned above. (See notes on tables 12(a) and

13(a).) Here again, the comparatively unfavorable position of OS operations

seems to be due largely to the longer interval between operation and first assessment report and to the irregular intervals between the early reports of assessment.
APPENDIX F

Peripheral Nerve Injury Study (Sciatic Nerves)1

NATURE OF THE DATA

In this study, a case was considered to be a sciatic nerve injury only when the location of injury was in the knee or thigh. The cases included in this section are those on

which the involved nerve was reported as "sciatic," "peroneal component of the sciatic,"

or "tibial component of the sciatic." Injuries to the peroneal or tibial nerves below the

knee are not included in this group.

Sciatic nerve injuries, as defined above, were reported on 1,109 individuals. On 82

of these patients, both components of the nerve were injured and were reported as separate cases. Thus the total number of nerve injuries reported was 1,191, of which 585

were reported as injuries to the sciatic nerve, 392 as injuries to the peroneal component,

and 214 as injuries to the tibial component.

As in all nerves combined, the sciatic cases were divided into an OS (oversea)

group and a ZI (Zone of Interior) group, depending upon the location of the first

attempt at actual repair. On this basis, 267 cases (22.4 percent of the total) were classified as OS, while 924 cases (77.6 percent of the total) fell into the ZI group.

Only four cases of sciatic nerve injury received graft procedure as first definitive

treatment.

The total number of operations performed on the 1,191 sciatic injuries was 1,234.

TABLE 1.—Sciatic nerve by type of operative procedure (total cases)

End-to-end anastomosis as original definitive

procedure

Graft as

original

definitive

procedure

Total cases

Location Primary

Other Total Actual

No previous bulb

suture

With previous bulb

suture

Percent

238

863

4

32

24

25

266

920

1

4

267

924

3.8

13.1

Total 1,101 36 149 1,186 5 1,191 16.9

' Includes cases with—

OS ZI

Secondary as first report received 1 14

Primary alter graft as first report received 1

Only bulb suture report received- 9

Primary, etc., section reported as "unknown" 23 1

Total 24 25

l This analysis was prepared by the Medical Statistics Division, Office of the Surgeon General,

and submitted to the Historical Unit, U.S. Army Medical Service, on 22 August 1956. The data

were derived from material in the World War II Peripheral Nerve Eegistry from the date of the

Registry's establishment up to the date of 1 November 1945.

633
634 NEUROSURGERY

TABLE 2.—Single and multiple sciatic nerve injuries (total cases)

Type of injury OS ZI

Total

Actual Percent

231

18

786

64

1,027

82

92 6

Multiple nerve injuries !

7.4

Total 249 860 1,109 100.0

i Tibial and peroneal components in thigh reported separately.

TABLE 3.—Postoperative nerve condition (total cases)

Nerve condition • OS ZI Total

9

2

16

11

25

13

1 As shown either on assessment or report of reoperation.
APPENDIX F 635

TABLE 4.—Disposition and time lost from duly (total cases)

Time lost from duty (weeks)

Type of disposition

Less

than

30

30-39 40-49 50-59 60-09 70-79 80-89 90-99

100

and

over

Total

Average

weeks

lost

Limited duty on

account of nerve

injury:

OS.. 2 1 3

1

38.3

ZI 1 69.0

Total. 2 1 1 4 46.0

ODD or retired on

account of nerve

injury:

OS 1 1

2

1

4

4

3

4

4

1

1

12

23

54.3

ZI 1 1 7 74 7

Total 1 3 5 7 8 2 1 1 7 35 67.7

Other dispositions: ]

OS 0

ZI 1 1 2 67.0

Total. 1 1 2 67 0

Total dispositions:

OS 3 1

2

1

5

5

3

4

5

1

1

15

26

51 1

ZI 2 1 7

Total 3 3 6 8 9 2 2 1 7 41

i Include 1 accidental death and 1 transfer to orthopedic section.

NOTE.—The average duration of treatment for the 41 sciatic cases on which disposition was reported was 65.6 weeks,

approximately 13 weeks longer than the average for all nerves combined. (See table 4, app. E.) As in the study of the

combined nerves, the great bulk (85 percent) of the dispositions were ODD (certificate of disability for discharge) injury.

In spite of the small number of disposed sciatic cases, the comparison of the OS and ZI groups seems to show a significantly greater difference in the sciatic nerves than in all nerves combined. The average length of treatment on the

ZI sciatic group was almost 22 weeks longer than on the corresponding OS cases. The comparable difference for the

combined nerves was only 9 weeks.
636 NEUROSURGERY

TABLE 5.—Causative agent (total cases)

Causative agent OS ZI Total

Battle wounds:

17

65

157

4

17

275

518

17

34

340

675

21

1 5 6

Total --. --. - - 244 832 1,070

Accidental wounds:

2

2

4

2

3

5

2

2

4

2

3

2 7

Total - -- --- - 2 18 20

3 10 13

Total - -- 249 800 1,109

1 Consists of cases reporting cause of injury as "wounded in action" "causes by

enemy Are," etc.

2 "All other accidents" includes—

OS: Fall (1), falling or moving object (1).

ZI: Fall (2), falling or moving object (2), fracture (1).

Note.—Of the total number ofsciatic nerve injuries, 97 percent were caused by

battle wounds, while only 1.8 percent were caused by accidental injuries; in 1.2

percent of the cases the cause of injury was unknown or unreported.

As in all nerves combined, shell or bomb fragments caused about 00 percent of

the sciatic nerve injuries, while small arms fire (gunshot wound or bullet) was the

causative agent in an additional 30 percent of the total number of cases.
APPENDIX F 637

TABLE 6.—Bone, vascular, or soft-tissue injury (total cases)1

Type of damage

Number of cases Percentage of total reported

OS ZI Total OS ZI Total

170 570 740 82.9 71.3 73.7

21

7

3

3

1

186

8

17

7

10

1

207

15

20

10

11

1

10.2

3.4

1.5

1.5

.5

23.3

1.0

2.1

.9

1.3

.1

20.6

1.5

2.0

1.0

1.1

.1

Total cases with bone vascular or soft-tissuo injury. 35 229 264 17.1 28.7 26.3

205 799 1,004 100.0 100.0 100. 0

i Soft-tissue injury includes only those cases requiring plastic procedure, showing marked loss of soft-tissue substance

or severe infection. Bone, vascular, or soft-tissue injury was unknown or unreported in 105 of the 1,109 patients with

sciatic nerve injuries.

NOTE.—Of the sciatic cases reporting on the item of bone, vascular, or soft-tissue damage, only H (26.3 percent) indicated the presence of complicating injuries; in contrast, H of the reports on all nerves combined reported this condition.

(See note on table 6, app. E.)

Bone injury was again the most important single factor, being present alone or in combination with other injuries in

22.7 percent of the total sciatic cases reporting. Vascular damage was present in 2.6 percent and soft-tissue damage in 3.2

percent of the total cases.

As in the study of the combined nerves, the percentage of OS cases reporting bone, vascular, or soft-tissue damage

was less than in the ZI cases. Only 17.1 percent of the OS group of sciatic cases reported 1 or more types of concomitant

injury, as compared to 28.7 percent of the ZI group.

TABLE 7 —Interval from injury to first operation (primary or graft) (total cases)1

Interval

(tenths of months)

Actual

number

of cases

Cumulative

number

of cases

Cumulative

percent

Interval

(tenths of months)

Actual

number

of cases

Cumulative

number

of cases

Cumulative

percent

14

7

4

6

1

1

2

6

10

11

7

16

13

7

15

15

19

16

15

14

21

25

31

32

33

35

41

51

62

69

85

98

105

120

135

154

170

185

1.2

1.8

2.1

2.6

2.7

2.8

3.0

3.5

4.4

5.3

5.9

7.3

8.4

9.0

10.3

11.6

13.2

14.6

15.9

19 22

16

4

8

14

16

15

18

16

21

17

190

181

129

90

59

44

122

3

207

223

227

235

249

265

280

298

314

335

352

542

723

852

942

1,001

1,045

1,167

1,170

17.8

20 -- 19.2

21 19.5

22- —- 20.2

23 21.4

24 22.8

25 24.1

26 --- 25.6

27... 27.0

28 28.8

29 30.3

30-39 46.4

40-49 61.8

50-59 72.8

60-69 80.5

15 70 -79 85.5

80-89 89.3

90 and over 99.7

Unknown _.. 100.0

' Exclusive of bulb sutures (26), secondary or tertiary operations (37), and primary after graft (1).

NOTE.—See table 7, app. E, for explanation of data and procedure.
638 NEUROSURGERX

TABLE 7(a) —-Interval frow, injury to first operation {primary suture or graft), OS and 7A i

Interval (tenths

of months)

Actual

number

of cases

Cumulative number of

cases

Cumulative

percent Interval (tenths

of months)

Actual

number

of cases

Cumulative number of

cases

Cumulative

percent

OS ZI OS ZI OS ZI OS ZI OS ZI OS ZI

0 11

7

3

5

1

1

2

6

9

11

7

13

11

6

15

13

17

15

12

3

1

1

1

3

2

1

2

2

1

3

11

18

21

26

27

28

30

36

45

56

63

76

87

93

108

121

138

153

165

3

3

4

5

5

5

5

5

6

6

6

9

11

12

12

14

16

17

20

4.1

6.7

7.8

9.7

10.1

10.5

11.2

13.4

16.8

20.9

23.5

28.4

32.5

34.7

40.3

45.2

51.7

57.3

61.8

0.3

.3

.4

.5

.5

.5

.5

.5

.6

.6

.6

.9

1.1

1.2

1.2

1.4

1.6

1.7

2.0

19 14

8

2

3

8

5

7

6

4

7

1

19

9

1

3

1

8

8

2

5

6

11

8

12

12

14

16

171

172

128

87

58

44

118

3

179

187

189

192

200

205

212

218

222

229

230

249

258

259

262

263

263

267

267

28

36

38

43

49

60

68

80

92

106

122

293

465

593

680

738

782

900

903

67.0

70.0

70.7

71.8

74.8

76.7

79.3

81.5

83.0

85.6

86.0

93.2

96.6

97.0

98.1

98.5

98.5

100.0

100.0

2.9

3.8

4.0

4.6

5.3

6.5

7.4

8.7

10.1

11.7

13.5

32.4

1— 20

2 ____ 21

3 ___. 22

4 23

5 24

6 25

7 „ 26

8- 27

9 28

10 29

11 __ 30-39

12 40-49-

13 50-59... 65.7

75.3

81.7

86.6

99.7

14 60 69

15 70 79

16 80-89

17 90 and over. . 4

18

1 Exclusive of—

OS

Bulb sutures... _ ___ 2

Secondary or tertiary operations 10

Primary after graft

ZI

24

27

1

Total. 12

NOTE.—This table on sciatic nerve injuries shows approximately the same pattern of relationship between OS and ZI

cases as was observed for all nerves combined (table 7(a), app, E). Most of the OS cases (86 percent) received the first

attempt at surgical repair within 3 months after injury; during the same period, operations were performed on only 13.5

percent of the ZI group. As in all nerves combined, the majority of the ZI cases (52.2 percent) received first definitive

treatment during the 3-month interval from the 4th through the 6th month after injury.
APPENDIX F 639

TABLE 8.—Operative procedure, end-to-end anastomosis (total cases)1

End-to-end anastomosis

Number of cases Percentage of total reported

OS Zl Total OS ZI Total

214

50

12

205

39

5

27

105

94

77

169

2

106

154

744

181

540

297

83

5

202

715

8

311

4

610

798

4

13

110

1

924

958

231

12

745

336

88

32

307

809

85

480

6

715

952

4

14

231

1

1,200

81.1

18.9

80.4

19.6

80.6

19 4

82.3

15.7

2.0

58.7

32.3

9.0

63.8

With other suture material- _. . . __ 28.7

7.5

52.8

47.2

22.0

78.0

27.5

72 5

98.8

1.2

98.7

1.3

98 8

1.2

99.4 97.9

.5

1.6

98.2

.4

1

121

.6 1.4

276

1 Excluding all bulb sutures.

2

"No entry" signifies items were left blank; "information unavailable" signifies that the reporting hospital lacked

information on the items.
640 NEUROSURGERY

TABLE 9.—Rate of advance of Tinel's sign, by interval after operation {total cases)

Interval after operation to assessment (in months)

Tinel's sign (in cm.)

0-

1.9

2-

2.9

3-

3.9

4-

4.9

5-

5.9

6-

6.9

7-

7.9

8-

8.9

9-

9.9

10-

10.9

11-

11.9

12-

12.9

13+ Total

0 18

3

3

1

1

21

4

7

9

11

2

12

7

4

2

1

6

1

56

2

23

26

21

22

20

37

17

30

14

29

6

10

7

3

16

4

1

3

9

5

2

8

2

8

7

7

2

7

2

4

5

1

7

2

1

1

6

1

2

2

2

5

5

5

2

5

1

7

6

1

6

2

8

3

1

1

5 4 3 1 3 2 2 130

0 129 10

3.0-5.9 4

2

3

3

3

14

1

15

5

18

12

5

22

6

61

17

3

44

60 89 42

9.0-11.9 1 1 48

12 0 14 9 1

3

4

1

3

9

2

4

6

2

12

2

1

1 36

15 0-17.9 1 1

1

1

5

1

1

6

1

18

8

1

2

1

1

1

9

4

5

8

4

26

29

1

2

54

18 0 20 9 77

21 0-23 9 1

1

1

1

27

24.0-26.9_-. 1 1 2 68

27.0-29.9 26

30 0 32 9 2

3

1

5

1

4

6

93

33.0-35.9 1 1 39

38 0-38.9 31

39.0-41.9 1 2 3 2 73

42 0-44 9 20

45.0-59.9 2 6

5

12

13

1

15

13

1

187

60.0-98.9 102

7

Unknown or unre1 11

Total assessments

Average ad28

7.8

91

16.2

347

22.6

80

27.0

71

30.9

199

41.1

54

38.0

46

50.3

96

53.5

25

51.7

18

54.2

32

60.3

38

57.7

1,125

35.0

NOTE.—This table shows all sciatic assessments distributed by the interval between operation and assessment, with

the assessments in each interval broken down by the extent of advance of Tinel's sign. Tor each time interval, the average

advance of the sign is shown at the bottom of the table. Cases reporting Tinel's sign as "none," "unknown," or "complete" were excluded from the calculation of these average figures.

In almost every interval the sciatic cases show a greater average advance than do all nerves combined (table 9, app.

E). However, this difference is readily explained by the comparatively great length of the sciatic nerve and the consequent higher probability of long advances. The resultant weighing in the high advance groups would necessarily cause

the calculated average to be higher than for the combined nerves. (Compare line 60.0-98.9 on table 9, app. E, with line

60.0-98.9 above.)
APPENDIX F 641

TABLE 9(a).—Rate of advance of Tinel's sign, by interval after operation (OS cases)

Interval after operation to assessment (in months)

Tinel'ssign (in cm.)

0- 2- 3- 4- 5- 6- 7- 8- 9- 10- 11- 12- 13+ Total

1.9 2.9 3.9 4.9 5.9 6.9 7.9 8.9 9.9 10.9 11.9 12.9

7

3

8

9

16 i 3

1

1 1 39

6

6 2 1 1 17

5 9 2 2 19

6 2 1 14

1

5

7

6

1 4

2

2

3

1

3

16

20

3 13

1

2 2

2

4 2

1

1 2 29

6

1 2 6

1

2 1 6

2

3 21

3

3 5 2 5 6 3 5 2 36

33 0-35.9 1 1

2

2 5

1

1

1

1 3 1

1

1 1 18

6

39.0-41.9 1 1

1

1

1

7

3

5

1

4

1

3

1

3

1

1 3 30

10

45.0-59.9 1 3

1

2

1

19

2

4

2

7

1

7

16

1

2

3

2

6

6

5

4

59

60.0-98.9 38

1 1 3

Unknown or unre2 1 1 4

Total assessments 15 46 84 27 28 62 30 19 39 12 7 16 9 394

Average ad8.6 17.0 19.9 27.0 25.8 38.0 35.9 44.5 56.9 46.5 55.9 59.3 64.9 34.5
642 NEUROSURGERY

TABLE 9(b) .—Rate of advance of Tinel's sign, by interval after operation {Zl coses)

Interval after operation to assessment (in months)

Tinel's sign (in cm.)

0-

1.9

2-

2.9

3-

3.9

4-

4.9

5-

5.9

6-

6.9

7-

7.9

8-

8.9

9-

9.9

10-

10.9

11-

11.9

12-

12.9

13+ Total

0 11 13

2

1

4

7

1

7

4

2

41

2

17

17

15

15

14

24

16

24

13

26

5

8

6

2

13

3

1

1

5 3 5 4 2 1 2 2 2

0.1-2.9 4

3.0-5.9 2 3 1 3

2

2

1

27

6.0-8.9 23

9.0-11.9 6

1

8

5

2

1

3

3

1 1 34

12.0-14.9 1 20

15.0-17.9 1 1 34

18.0-20.9 10

1

9

3

13

7

4

15

3

42

15

2 48

21.0-23.9 1

1

1

4

1

5

5

3

19

13

1

1

1

1

21

24.0-26.9 5

2

2

1

3

4

6

1

4

1

5

4

1

5

1

6

2

1 2 47

27.0-29.9 1

1 3

1

3

1

1

8

1

1

2

1

2

11

7

23

30.0-32.9 57

33.0-35.9 2 21

36.0-38.9 25

39.0-41.9 2 1 2 43

42.0-44.9 10

45.0-59.9- 1 3

4

3

3

6

7

1

10

9

1

128

60.0-98.9 64

Complete 4

Unknown or unre1 1 1 2 1 7

Total assessments.- - _.-

Average ad13

4.5

45

15.3

263

23.4

53

27.0

43

34.1

137

42.6

24

41.3

27

54.4

57

51.2

13

56.9

11

52.8

16

61.5

29

55.4

731

35 3

TABLE 10 —-Rate of m otor recovery, by interval after operation (total cases)

Motor recovery code

Interval after operation to assessment (in months)

0-1.9 2-2.9 3-3.9 4-4.9 5-5.9 6-6.9 7-7.9 8-8.9 9-9.9 10-10.9 11-11.9 12-12.9 13+ Total

0 27

1

85

6

305

25

15

2

58

16

4

1

1

55

8

5

3

147

30

21

1

39

12

3

33

6

4

2

1

61

21

8

5

1

11

6

7

1

8

8

2

16

9

7

15

11

12

1

2

3 15

4 3

Total assessments 28 91 347 80 71 199 54 46 96 25 18 32 38 1,125
APPENDIX F 643

TABLE 10(a).—Rate of motor recovery, by interval after operation (OS cases)

Motor recovery code

Interval after operation to assessment (in months)

0-1.9 2-2.9

42

4

3-3.9

70

6

7

1

4-4.9 5-5.9 6-6.9 7-7.9 8-8.9 9-9.9 10-10.9 11-11.9 12-12.9 13+ Total

0 14

1

16

6

3

1

1

21

3

2

2

40

12

10

22

7

1

14

1

3

1

21

10

4

3

1

8

2

2

4

2

1

10

4

2

2

2

5

1 60

40

8

2_„_

3

4_ 2

Total assessments 15 46 84 27 28 62 30 19 39 12 7 16 9 394

TABLE 10(b) —Rate of motor recovery, iy interval after operation (ZI cases)

Motor recovery code

Interval after operation to assessment (in months)

0-1.9 2-2.9 3-3.9 4-4.9 5-5.9 6-6.9 7-7.9 8-8.9 9-9.9 10-10.9 11-11.9 12-12.9 13+ Total

0- 13 43

2

235

19

8

1

42

10

1

34

5

3

1

107

18

11

1

17

5

2

19

5

1

1

1

40

11

4

2

3

4

5

1

4

6

1

6

5

5

13

9

7

1

2 48

3 7

4

Total assess13 45 263 53 43 137 24 27 57 13 11 16 29 731
644 NEUROSURGERX

TABLE 11.—Rate of sensory recovery, by interval after operation (total cases)

Sensory recovery

code

Interval after operation to assessment (in months)

0-1.9 2-2.9 3-3.9 4-4.9 5-5.9 6-6.9 7-7.9 8-8.9 9-9.9 10-10.9 11-11.9 12-12.9 13+ Total

0 ..... 27

1

86

2

3

329

10

2

60

10

3

1

59

7

3

2

150

36

11

2

38

12

4

26

12

5

3

51

34

9

1

11

7

0

1

8

5

2

3

12

15

3

1

1

13

11

8

6

876

1

168

2 . .

59

3

20

1

Unknown or unre1 1

Total assessments 28 91 347 80 71 199 54 46 90 25 18 32 38 1,125

TABLE 11(a)--Rat e of sensory recovery, by interva aftei operation (08 cases)

Sensory recovery

code

Interval after operation to assessment (in months)

0-1.9 2-2.9 3-3.9 4-4.9 5-5.9 6-6.9

46

8

8

7-7.9

20

7

3

8-8.9

10

5

2

2

9-9.9

18

14

5

1

10-10.9 11-11.9 12-12.9 13+ Total

0 14

1

42

1

3

78

4

2

22

3

1

1

23

2

2

1

5

5

2

3

1

2

1

6

7

2

1

1

3

3

2

288

1

61

2

35

8

1

Unknown or unre1 1

Total assessments. 15 46 84 27 28 62 30 19 39 12 7 10 9 394

TABLE 11(b).—Rate of sensory recovery, by interval after operation (ZI cases)

Sensory recovery

code

Interval after operation to assessment (in months)

0-1.9 2-2.9 3-3.9 4-4.9 5-5.9 6-6.9

104

28

3

2

7-7.9 8-8.9 9-9.9 10-10.9 11-11.9 12-12.9 13+ Total

0 13 44

1

251

12

44

7

2

36

5

1

1

18

5

1

16

7

3

1

33

20

4

6

2

4

1

5

4

2

6

8

1

1

12

8

5

4

588

107

24

12

Total

assessments-. 13 45 263 53 43 137 24 27 57 13 11 16 29 731
APPENDIX F 645

TABLE 12.—First appearance of Tinel's sign in operations

with assessment, by time after operation (total cases)

With appearance of Tinel's sign '

No

Interval after operation

to assessment (months) With previous

assessment

showing Tinel

sign as 0

No

previous

assessment

Total

appearance

of Tinel's

sign !

0 19 10

66

277

65

36

63

20

17

16

3

3

3

13

10

66

279

67

42

81

27

21

18

6

4

3

15

9

2-2.9 - - 13

3-3.9 - 2

2

6

18

7

4

2

3

1

38

4-4.9 -

6

5-5.9 .._ - 1

6-6.9 ... -. - 5

7-7.9 _ 2

8-8.9 - — 3

10-10.9 - 3

11-11.9 2

2

Total ... -. 47 592 639 82

i Distributed by first assessment which showed a positive Tinel's sign.

2 Distributed by latest assessment received.

NOTE.—Of the 721 sciatic operations on which at least 1 assessment has been

received, 639 reported that Tinel's sign had made its appearance, either on the

first assessment or on an assessment later than one which had shown the sign

as "none" or "unknown." In the table above, these cases were distributed

according to the interval between operation and the first report which showed

recovery. The remaining 82 operations showed no appearance of Tinel's sign

on any assessment; these cases were tabulated by the interval between operation

and the latest assessment, so as to show the length of time which had elapsed

since operation with no evidence of recovery.

Thus, during the interval 3-3.9 months after operation, 277 cases showed the

Tinel present at the time of the first assessment; 2 cases reported it for the first

time, after previously reporting it as absent or unknown. During the same

period, the most recent reports on 38 operations showed the Tinel still absent.
646 NEUROSURGERY

TABLE 12(a).—First appearance of Tinel's sign in operations

with assessment, by time after operation (OS and ZI)

With appearance of Tinel's sign '

Interval after

operation to

assessment (months)

With previous

assessment

showing Tinel

sign as 0

No previous

assessment

Total

No appearance of

Tinel's sign 2

OS ZI OS ZI OS ZI OS ZI

0-1.9 8

35

62

20

15

34

11

7

6

1

2

2

2

31

215

45

21

29

9

10

10

2

3

1

11

8

35

62

22

17

38

15

9

6

2

2

3

2

31

217

45

25

43

12

12

12

4

4

1

12

3

5

13

1

1

1

6

8

25

5

2-2.9

3-3.9 2

4

14

3

2

2

2

1

4-4.9 2

2

4

4

2

5-5.9

6-6.9 5

2

2

7-7.9

8-8.9.._

9-9.9

10-10.9 1 1 2

11-11.9 2

12-12.9

13 and over .... 1 1

Total 16 31 203 389 219 420 25 57

i Distributed by first assessment which showed a positive Tinel's sign.

2 Distributed by latest assessment received.

NOTE.—This table shows the status of Tinel recovery on all sciatic operations,

broken down into OS and ZI groups. Comparison of this table and table 12(a),

app. E, reveals that the pattern of relationship between OS and ZI cases of operation on the sciatic nerve is very similar to that observed on all nerves combined.

Here again a higher proportion of ZI cases report the presence of the Tinel in the

early months after operation, apparently indicating quicker recovery on sciatic

cases which were operated on in this country. However, as seen in the note on

table 12(a), app. E, the greater irregularity of reports of assessment on OS cases

operates to weaken the reliability of such a conclusion.
APPENDIX F 647

TABLE 13.—First evidence of motor recovery in operations with

assessment, by time after operation (total cases)

With evidence of recovery i

Interval after operation

to assessment

(months)

With previous

assessment

showing recovery as 0

No previous assessment

Total

No evidence of recovery 2

0-1.9 _ 1

5

18

14

8

23

7

8

9

1

3

2

11

1

5

18

14

11

47

14

13

31

10

6

8

15

16

2-2.9 49

3-3.9 187

4-4.9 37

5-5.9 3

24

7

5

22

9

3

6

4

41

6-6.9 96

7-7.9 24

8-8.9 16

9-9.9 34

10-10.9. 6

11-11.9 8

12-12.9 8

6

Total 83 110 193 528

i Distributed by first assessment reporting evidence of recovery.

2 Distributed by latest assessment received.

NOTE.—Using a procedure similar to that used in table 12, all sciatic operations were divided into 2 groups: Those on which recovery of motor function was

reported, with distribution by the interval between operation and the first assessment showing recovery; and those on which no motor recovery was ever

reported, distributed by the interval between operation and the latest assessment received.

Thus, at each interval, the status of reporting cases in respect to motor recovery can be read. Tor example, during the 4th month after operation (3-3.9

months) 18 cases reported for the first time that motor recovery was noted; in this

instance all reports were first assessments received on the operations. In the same

period, the last assessments received on 187 cases reported that no motor function

was or had been recorded since the operation.
648 NEÜROSURGERY

TABLE 13(a).—First evidence of motor recovery in operations

with assessment, by time after operation (OS and ZI)

"With evidence of recovery 1

Interval after operation to assessment

(months)

With previous

assessment

showing

recovery as 0

No previous assessment

Total

No evidence of

recovery 2

OS ZI OS ZI OS ZI OS ZI

0-1.9— 1

4

6

5

3

11

5

2

6

1

2

1

12

9

5

12

2

6

3

1

3

1

9

1

4

6

5

4

16

8

5

16

5

1

5

5

1

12

9

7

31

6

8

15

5

5

3

10

6

24

45

8

14

22

14

8

11

3

3

4

1

10

2-2.9 25

3-3.9 142

4-4.9. 29

5-5.9 1

5

3

3

10

5

1

4

3

2

19

4

2

12

4

2

2

1

27

6-6.9 „ 74

7-7.9 10

8-8.9 8

9-9.9 - 23

10-10.9 3

11-11.9 5

12-12.9 4

5

Total 35 48 46 64 81 112 163 365

1 Distributed by first assessment reporting evidence of recovery.

2 Distributed by latest assessment received.

NOTE.—This table is based on the same data shown in table 13, with an additional breakdown of each column into OS and ZI cases.

The comparison of the distribution of the OS and ZI cases here is subject to

the same weaknesses of the basic data which were brought out in table 13(a),

app. E. (See table 13(a): Note.)
APPENDIX F 649

TABLE 14.—First evidence of sensory recovery in operations

with assessment, by time after operation (total cases)

With evidence of recovery '

Interval after operation

to assessment

(months)

With previous

assessment

showing recovery as 0

No previous assessment

Total

No. evidence of recovery »

1

6

42

21

9

21

6

6

3

2

3

1

8

1

6

42

21

14

39

12

10

18

6

8

9

14

15

2 29 50

3 39 --- - 174

4-4 9 34

6-5.9 _._ 5

18

6

4

15

4

5

8

6

34

6-6 9 ---

94

7 79 ._ 24

8-8.9 -

23

9-9.9 37

10-10.9 8

11-11.9 - ---

8

12-12.9 12

8

Total 71

129 200 521

i Distributed by first assessment reporting evidence of recovery.

2 Distributed by latest assessment received.

NOTE.—The data on sensory recovery after sciatic operations was handled and

tabulated in the same manner as the data on motor recovery. For the explanation

of data and procedure see note on table 13.
650 NEUROSURGERY

TABLE 14(a).—First evidence of sensory recovery in operations

with assessment, by time after operation (OS and ZI)

With evidence of recovery 1

Interval after operation to assessment

(month)

With previous

assessment

showing

recovery as 0

No previous assessment

Total

No evidence of

recovery 2

OS ZI OS ZI OS ZI OS ZI

0-1.9 1

4

14

10

4

13

4

2

1

2

2

28

11

5

8

2

4

2

2

3

1

6

1

4

14

10

6

19

6

4

8

1

1

3

5

2

28

11

8

20

6

6

10

5

7

6

9

6

25

41

6

11

20

13

10

11

6

4

7

2

9

2-2.9 _

3-3.9 133

4-4.9 28

5-5.9__„ 2

6

2

2

7

1

1

3

3

3

12

4

2

8

3

4

5

3

6-6.9—

7-7.9

8-8.9

9-9.9

10-10.9

11-11.9

12-12.9

Total 27 44 55 74 82 118 162

' Distributed by first assessment reporting evidence of recovery.

2 Distributed by latest assessment received.

NOTE.—The above table shows the data of table 14 with each of the columns

in this table divided to show OS and ZI cases separately.

Comparisons between the 2 groups of cases are open to the same objections

which were raised in the note on table 14(a), app. E.
INDEX

abdomen, wounds of, 19, 21, 25, 29, 30, 36,

48, 120, 146, 147

as cause of death in—

acute spinal cord injuries, 64

meningitis, 65

in World War I, 3, 4

Abduction, absence of, in ulnar nerve paralysis, 252

Abduction paralysis, of vocal cord, 448

Abductor—

digiti quinti, 337

hallucis, 352

pollicis brevis, 328

pollicis longus, 320, 326, 406, 574

spasm in paraplegia, 407

Abscess, diagnostic confusion of brachial

aneurysm with, 454

Abscess formation, in epididymitis, 113

Accessory nerves, as cause of causalgia after

peripheral nerve injuries, 474

Accidents, as cause of paraplegia, 127-128

Acetabulum, fracture of, 426

Acetic acid, in decubitus ulcers, 137

Acetylcholine drugs, in cord bladder, 94

Acromion process, 318

Acromion, transplantation of biceps and

triceps heads to, 571-572

Acute spinal cord injuries, 3-191

adjunct therapy in, 32, 36, 63

antibiotic therapy in, 29, 39

antimicrobial therapy in, 32, 48, 56

bone fragments in, 42, 44-47

calculus formation after, 101

care of gastrointestinal tract in, 63

causes of death in, 115, 116

chemotherapy in, 29, 32

concomitant wounds in, 36, 120, 146

decubitus ulcers in, 61

debridement in, 42-43, 50

diagnosis of, 26, 36-40

effect of level of, on bladder status, 117-118

evacuation in, 26, 47-49, 63-64

factors of mortality in, 64-65

foreign bodies in, 44-47

genitourinary complications in, 101-114

hyperesthesia in, 50

in ETOUSA, 25-30

in female, 118-119

in MTOUSA, 19-23

laminectomy in, 9, 25, 27, 33, 41-57

498991T—59- -45

Acute spinal cord injuries—Continued

loss of sensation in, 169

lumbar puncture in, 38-39

management of, 31-65

meningitis in, 39, 43

neurologic examination in, 36-38

nursing care in, 23

nutritional status in, 63

orthopedic care in, 22

pain after, 36, 178-184

physiologic pathology in, 169-170

plasma transfusion in, 36

priority of evacuation in, 26

prognosis in, 26-27, 33, 37, 46, 47, 55

prophylactic antimicrobial therapy in, 22

pulmonary complications in, 32

records in, 38

renal infection after, 101-104

respiratory depression in, 50, 58

resuscitation in, 35, 36, 39

roentgenologic examination in, 37, 39-40,

45, 46, 47

root pain in, 47, 49

sedation in, 36

shock in, 36, 39, 64

signs in, 37-38

skin changes in, 38

statistics of, 31-32, 64-65

status of sex organs after, 101

suppression of reflexes after, 74

surgery in, 25-27, 33, 41-57

symptoms of, 36-37

transfusion in, 36

transportability in, 47-49

transportation in, 35, 47-49

upper urinary tract function after, 100-101

urinary tract infection after, 70

urologic complications in, 22, 32, 101-119

urologic management in, 22, 36, 61-63,

119-125

vasomotor changes in, 38

See also Paraplegia, Spine, injuries of.

Adductor—

magnus, 351, 410

pollicis, 357, 401

spasm in paraplegia, 180, 183

Adjunct nutritional measures, in paraplegia,

150-151

Adjunct therapy—

after laminectomy, 57

651
652 NEUROSURGERY

Adjunct therapy—Continued

during spinal operations, 51

in acute spinal cord injuries, 32, 36, 63

in combined bone-nerve injuries, 415-416,

421

See also Blood replacement, Fluid balance,

Replacement therapy, etc.

Adjutant General, 17

Adjutant General's Office, 128

Administrative considerations, in—

early laminectomy, 47-49

physical therapy, in peripheral nerve injuries, 557

Administrative policies, in paraplegia, 5-8

Adrenalin, 50

Aerobactei aerogenes renal infections, in

paraplegia, 102-103

Age factor, in survival, in paraplegia, 12-13n

Age incidence, in paraplegia, 128

Air conditioning, in paraplegic centers, 8, 9,

17

Air evacuation, in—

acute spinal injuries, 35

ETOUSA, 120

paraplegia, 64, 120, 132, 134

peripheral nerve injuries, 249

Air mattresses, 8, 29, 58

Air myelography, 193

ALBRIGHT, F., 94, 110, 121

ALBKITTEN, F. F., Jr., 406

Albumin-globulin ration, in paraplegia, 145,

149

Alcoholic injections, for segmental pain, in

paraplegia, 180-181

Alcoholism, as contraindication to work furlough, in peripheral nerve injuries, 223

Alkaligenes fecalis renal infections, in paraplegia, 103

Alpha hemolytic streptococcic infection, in

paraplegia, 72

ALTEA, E. P., 104

Ambulation:

in paraplegia, 5-6, 10, 15-16, 86, 87, 95,

110, 124, 139, 147, 153, 163, 164-173,

176, 179

in prevention of renal calculi, in paraplegia, 108, 110

relation of, to—

emotional status, 160

level of cord injury, 165

results of instruction in, 172-173, 176, 178

techniques of, 170-173

American Red Cross, 22, 122, 187, 190, 191

Amigen, 151

Amino acids, in renal infection, 103

Aminoids, 151

Amobarbital sodium. See Amytal sodium.

Amputated limbs, procurement of nerve

grafts from, 494, 546

Amputation:

associated with spinal cord injuries, 181

causalgia after, 476-477, 478

in paraplegia, 183-184

Amyloidosis, in paraplegia, 12n

Amytal sodium, before laminectomy, 49

Analgesia, in etiology of decubitus ulcers, 132

Anatomy, of—

axillary nerve, 317

brachial plexus, 305-311, 391

common peroneal nerve, 353, 361-362

femoral nerve, 313-346, 347, 349

median nerve, 328, 397, 398

musculocutaneous nerve, 313-314, 393-394

neck, 441

obturator nerve, 407

peripheral nerves, 207

peroneal nerve, 407, 409-410, 581

posterior tibia] nerve, 352-353

radial nerve, 318-321, 404-405, 573

sciatic nerve, 350-353, 407, 409-410

tibial nerve, 351-353

ulnar nerve, 335-337, 401

See also Surface anatomy.

Anastomotic vessels, about elbow, 340

Anatomic approaches, to peripheral nerves,

301-362

See also Incision.

Anconeus, 320-323

Anemia in paraplegia, 11

Anesthesia:

after acute spinal injuries, 37, 50

after perineal nerve injuries, 223

sweat tests in, 279

after ulnar nerve injuries, 340

combined with anhydrosis, after nerve

block, in peripheral nerve injuries, 277

for combined nerve-plastie surgery, 422,

430

for laminectomy, 31, 49-51

for peripheral nerve surgery, 249, 368-369

for sciatic nerve surgery, 408

for vascular-cranial nerve surgery, 448

maximum area of, in peripheral nerve

injuries, 267

of foot, in irreparable nerve injuries, 580

of skin, in posterior tibial nerve injuries,

412

zones of, after spinal cord injury, 51
INDEX 653

Aneurysms:

associated with—

bone-nerve injuries, 466

brachial plexus injuries, 392

peripheral nerve injuries, 304, 439, 448,

454, 458, 464-465

peripheral nerve-soft tissue injuries, 467

peripheral nerve-vascular injuries, 441

erosion of peripheral nerve by, 519,

528-530

in paraplegia, 146

of aorta, 458

of brachial artery, 395

of subgluteal artery, 409

rupture of, 464

Aneurysmorrhaphy, 442

anhydrosis, after nerve block, 277

Ankle:

frozen joint in, 246

fusion operations on, 580

Ankylosis—

after prolonged immobilization of upper

extremity, 584

in combined bone-nerve injuries, 415, 423

in combined sciatic nerve-knee injuries,

426

in combined vascular-nerve injuries, 280

in peripheral nerve injuries, 558, 563, 565

in preventing nerve suture, 496

Annular ligament, 342

Annulus fibrosus, rupture of, 193

Anomalous innervation of leg, 490

Anoxia—

during dissection of ulnar nerve, 401

in paraplegia, 12, 146

Antecubital fossa,-325, 331

Antecubital space, 340

Anterior annular ligament, 328

Anterior condyloid foramen, 441

Anterior femoral cutaneous nerve, 344

Anterior horn motor cells, 178

Anterior rhizotomy, 9

Anterior tibial artery, 352, 353, 362

Antibiotic therapy, in—

combined radial nerve-humerus injuries,

403

peripheral nerve injuries, 364, 367

urinary track infection, 103-104, 124

Antimicrobial therapy—

after laminectomy, 58

in acute spinal cord injuries, 29, 32, 35,

48, 56

in combined bone-peripheral nerve injuries,

245, 250

Antimicrobial therapy—Continued

in cord bladder, 117

in epididymitis, 113

in periurethral abscess, 113

Anuria, after sulfonamide therapy, 104

Aorta, aneurysm of, 458

Arachnoiditis, 178

Areflexia, in acute spinal cord injuries, 37

Arm:

causalgia in, 478, 490

combined bone-nerve injuries in, 422-423

exposure of—

median nerve in, 330-333

radial nerve in, 322-325

ulnar nerve in, 339-340

Armed Forces Institute of Pathology, 221

Army Air Forces, 134

paraplegia in, 128

Army educational program, 185

Army followup, of peripheral nerve grafts,

219n

Army General Classification Tests, rating

of paraplegics in, 129, 160, 186

Army general hospital system, paraplegics

in, 5

Army Ground Forces, paraplegia in, 128

Army Institute of Pathology, 221

Army Medical Museum, 221

Army Service Forces:

Circular No. 244, 28 June 1945—224

paraplegia in, 128

Arterial tubes, in peripheral nerve repair,

389

Arteriovenous aneurysms—

associated with peripheral nerve injuries,

442, 464-465

of upper extremity, 448

in paraplegia, 146

Arteriovenous fistulas, 304, 440, 466, 467

Arthrodesis—

after tibialis posticus transplantation, 582

in subastragalar region, 584

of elbow, 571

of interphalangeal joints, 579

of shoulder joint, 318, 571, 572

Arthroplasty, in combined—

bone-peripheral nerve injuries of forearm,

423

sciatic nerve-acetabular injuries, 426

Arthrotomy, in combined bone-peripheral

nerve injuries, 426

Articularis genus (subcrureus), 345

Artificial fever therapy, in causalgia, 487

Ascending infection, in vesical calculi, 112
654 NEUROSURGERY

Ascending route, of renal infection, 102 Axillary nerve—Continued

ASSAKY, G., 381 orthopedic surgery for repair of, 317-318,

Assessments, of motor power, in peripheral 393, 572-573

nerve injuries, 251-252 study of specimens from, 514

Assessments, of peripheral nerve regenera- surface anatomy of, 317

tion, in Peripheral Nerve Registry, techniques of gaining length in, 318

226-230 Axillary vein, 308, 322

Assignment, of neurosurgical personnel, 241 Axon splitting, in median nerve injuries, 397

Associated injuries. See injuries of specific Axonotmesis, 559

structures. Azochloramid, in decubitus ulcers, 137, 138

Atlas of Peripheral Nerve Injuries, 463n

Atonic neurogenic bladder. See Cord Bacillus cloacae infections, in paraplegia, 103

bladder. Bacillus coli infections, in experimental paraAtonic stage, of cord bladder, 79, 86 plegia, 73

Atrophie sulfate: Back, wounds of, 36

before laminectomy, 49 Bacteriology, of—

in cord bladder, 94 bladder infections, in paraplegia, 72, 73

preoperative administration of, in periph- decubitus ulcers, 131

eral nerve surgery, 368 infection, in paraplegia, 12

Atrophy, in— renal infection, in paraplegia, 102-103

peripheral nerve injuries, 565 BADAL, D., 72

ulnar nerve injuries, 400 BAILEY, M. K., 95

Attu, 188 Balanced skeletal traction, in combined

Auscultation, in combined peripheral nerve- bone-nerve injuries, 245, 250

vascular injuries, 440 Balanitis, 62

Austrian management, of cord bladder, in Balkan frames, 9

World War I, 119 BALLANCE, C, 493

Autogenous nerve grafts, 219, 381, 494-499, BALLINGALL, G., 302

509 Balsam of Peru, in decubitus ulcers, 137

Autogenous skin solution, in decubitus Barbiturates:

ulcers, 138 after laminectomy, 57

Autografting, of small nerves, 219 contraindications to, in acute spinal inAutografts. See Autogenous nerve grafts. juries, 49

Automobiles, for paraplegics, 173 preoperative administration of, in periphAutonomie nervous system, 169 eral nerve surgery, 368

Autonomous area, in peripheral nerve in- BARKER, Maj. D. E., 9, 131, 140, 142, 145

juries, 224, 268, 405 BARR, J. S., 193

Autonomous bladder. See Reflex automatic Basilic vein, 330

bladder. Battalion aid stations:

Autonomous zone in causalgia, pain in, 479 acute spinal cord injuries in, 36

AVELLIS, G., 441 management of cord bladder in, 61

Avulsed wounds, of brachial plexus, 391 BAUDENS, 303

Avulsion injuries, involving peripheral Beds, for paraplegics, 8

nerves, 236 BELLIS, J. C, 93

Axilla: BENISTY, A., 207, 303

exposure of ulnar nerve in, 338 BESLEY, P. A., 88

repair of radial nerve injuries in, 322, Biceps, 314, 322, 323, 326, 330, 335, 338,

401-402 394, 395, 404, 423

Axillary aneurysms, 448 brachii, 328

Axillary artery, 308, 310, 311, 317, 318, 320, femoris, 343, 351, 410

322, 338, 392 tendon, 325, 331, 362

Axillary nerve: transplantation of short head of, to acroanatomy of, 313 mion, 571-572

exposure of, 317-318 Bicipital tubercle, of radius, 331
INDEX 655

Biliary fistula, in paraplegia, 146

BILLROTH: T., 302

Bipolar intraneural stimulation, 266

Bladder:

capacity, in paraplegia, 70, 74-79, 116

See also Cystometry.

complications, of cord bladder, 111-112

drainage of—

after laminectomy, 58

during laminectomy, 51

function, in—

acute spinal cord injuries, 37

paraplegia, 6, 13, 18, 151-153

irrigations, in—

catheter drainage, of cord bladder, 99

catheter management, of cord bladder,

91, 99

renal infection, 104

suprapubic cystostomy, 95

neck:

in cord bladder, 79, 80-81, 83-86, 91

resection of, 97-98, 99, 117, 122, 124, 125

physiology of, 80

pressure, in paraplegia, 77-79

status, effect of level of cord injury on,

117-118

training, in paraplegia, 98, 122

wall:

fibrosis of, 95

infection of, 71

trabeculation of, 79, 80

See also Cord bladder, Reflex automatic

bladder, Urologie, Vesical, etc.

Blisters, in causalgia, 473n

Blood chemical studies, in paraplegia, 124,

129

Blood cultures, in urinary tract infections,

102, 146

Blood replacement—

after laminectomy, 57

during laminectomy, 51

in acute spinal cord injuries, 36, 63

in combined bone-peripheral nerve injuries,

421

in combined peripheral nerve-vascular

injuries, 440

in decubitus ulcers, 140

in paraplegia, 150, 175

in renal infections, 103 ,.

Blood serum, applications of, in decubitus

ulcers, 144

Blood studies, in paraplegia, 129, 149 150

Blood supply:

in decubitus ulcers, 136

in peripheral nerve injuries, 304

protection of, at sciatic nerve repair, 410

Bodian Protargol technique, 514, 515, 518

Bone chips, in combined bone-peripheral

nerve surgery, 422

Bone fragments:

in cauda equina injuries, 181

in spinal cord injuries, 26, 31, 33, 35, 38,

42, 44-47

management of, at laminectomy, 52-54

roentgenologic demonstration of, in acute

spinal cord injuries, 39, 40

Bone grafting, 404, 416, 420

Bone grafts, in—

combined bone-peripheral nerve injuries,

422, 428

combined sciatic nerve-femoral injuries,

425

fusion operations on thumb, 571

irreparable median nerve injuries, 577

Bone injuries, associated with:

incomplete peripheral nerve injuries, 519,

521, 543

peripheral nerve injuries, 211-212, 232,

235, 238, 244-246, 304, 364, 367,

414-428, 519, 521, 543, 558

in World War I, 208

orthopedic techniques in, 569-570

role of, in peripheral nerve injuries, 519,

521

shortening of bone in, 236, 249, 305,

380, 496

Bone-peripheral nerve-vascular injuries, 222

Bone-radial nerve injuries, 564

Bone Tumor Registry, 225

Boobytraps, 399

Boric acid—

applications, in decubitus ulcers, 137, 140

solutions, for bladder irrigation, 94

BORS, Maj. E. H. J., 176, 187

BOWDEN, R. E. M., 364

Bowel function, in paraplegia, 6, 13, 151,

153-157

BOWIE, Maj. C. F., 104, 112

BOYD, M. L., 95

Braces—

after peripheral nerve suture, 237

in irreparable peripheral nerve injuries of

lower extremity, 580

in paraplegia, 10, 13, 116, 162, 165, 167-

168, 176, 177

in peroneal nerve injuries, 581
656 NEUROSURGERY

Braceshops, in paraplegic centers, 14 Branches—Continued

Brachial artery, 318, 320, 321, 323, 330, 331, of ulnar nerve, 335-337

335, 337, 338, 398 BBIDGERS, W. H., 93

protection of, at median nerve surgery,395 BEISTOW, W. R., 207, 303, 305

Brachial plexus, 322 British civilian personnel, use of, in physical

anatomy of, 305-311, 391 therapy, 246

branches, from—• British experience, in peripheral nerve innerve roots of, 310 juries, in World War I, 207

trunks of, 310 British Journal of Surgery, 207

components of, 305-308 British management, of—

cords of, 310, 311, 316, 317, 318, 322, 335, cord bladder, in World War I, 89, 119

392 peripheral nerve injuries, 239

division of clavicle in injuries of, 313 British neurosurgical centers, 469

formation of, 305-308, 310-311, 335 BROCK, S., 89

formation of median nerve, from cords of, Bronchoscopic suction, after laminectomy,

328 58

injuries of, 249, 303-313 Brown-Sequard incomplete spinal cord leassociated with aneurysms, 448 sions, 22-24

closure of wound in, 313 Bulb sutures, in peripheral nerve injuries,

exposure in, 311-313 519, 533, 543

neurolysis in, 391, 392 Bulbous urethra, in cord bladder, 82

pathologic process in, 391 BUMPUS, H. C, 81, 94, 98, 117

positioning at operation for, 311, 313, BUNNELL, S., 4, 5, 303, 304, 326, 289, 493,

378, 391 566, 577

repair of, 391-393 Bureau of War Risk Insurance, 209

shortening of clavicle in, 305 Burma, 473n

study of specimens from, 514 BURNB, J., 101

techniques of gaining length in, 313 Burns, 49

nerve block, 369

physiology of, 308, 311 Cable frozen dried homografts, 495

relations of, 308-310 Cable grafts, in peripheral nerve injuries,

relations of axillary nerve to, 317 381, 382, 405, 494, 498, 514

roots of, 305-306/311 Cable sural autografts, 546, 555

surface anatomy of, 311 Cachexia in etiology of decubitus ulcers, 131

surgical approach to injuries of, 311 -313 Cadavers, procurement of nerve grafts from,

trunks of, 311 495-496

veins, 323, 338 CAHILL, G. F., 89

Brachialis, 314, 320, 325, 326, 331, 394, 404, Calcification of soft tissues, in paraplegia, 147

423 Calcium—

Brachioradialis, 320, 321, 325, 326, 331, 403, debris, in cord bladder, 94

404, 406 metabolism, disorders of, in paraplegia,

involvement of, in radial nerve injury 258 129, 147

nerve, compensatory function of, 394 Calculi, in cord bladder, 14, 97, 100, 121, 122

Branches— Calculus formation, in paraplegia, 101, 129,

from brachial plexus cords, 310 147, 152-153

from nerve roots forming brachial plexus, CAMPBELL, Col. E. H., Jr., 231n

308-310 Canadian policies, in herniated nucleus

from trunks of brachial plexus, 310 pulposus, 195

of femoral nerve, 344-346 Cantharides, 473n

of posterior tibial nerve, 352-353 Capillary thrombosis, in decubitus ulcers, 131

of radial nerve, 320, 321 Capitellum, of humerus, 325

of sciatic nerve in thigh, 351 Capsulotomy, of toes, 579

of service, paraplegia in, 128 Cardiorespiratory imbalance, in acute spinal

of tibial nerve, 351-352 cord wounds, 21
INDEX 657

Carotid artery, 441

CARP, J., 74

Case fatality rates, in—

acute spinal cord injuries, 31-32, 65, 115

in Civil War, 114-115

in civilian life, 115

in forward hospitals, 64-65

in World War I, 3, 31, 114, 115, 119

combined peripheral nerve-vascular injuries, 439, 442

cord bladder, 114-115, 117

in World War I, 114

incomplete transections of spinal cord, 115

intermittent catheter drainage, 90

laminectomy, 65, 181

paraplegia, 12-13n, 123

peripheral nerve surgery, 250

renal infection in paraplegia, 102

See also Statistics.

Case histories:

autogenous nerve grafts, 509

cable sural autografts, of radial nerve,

546-547

causalgia, in complete nerve injuries, 476-

477

combined bone-peripheral nerve-vascular

injuries, 466

of lower extremity, 455-458

of upper extremity, 448-454

combined sciatic nerve-bone injuries, 426

combined skin-soft tissue-peripheral nerve

defects, 432-438

combined vascular-cranial nerve injuries,

443-447

common peroneal nerve injuries, 300

disruption of suture line, in peripheral

nerve injuries, 539-541

erosion, of radial nerve, by axillary

aneurysm, 528-531

failure, of sympathectomy, in causalgia,

487, 487n

frozen dried homografts, 495-512

hemilaminectomy, 57

injury, of tibial and peroneal components,

of sciatic nerve, 296-297

injury, of tibial and peroneal nerves, above

popliteal space, 297-300

laminectomy:

accociated thoracoabdominal and spinal

cord injuries, 43

cerebrospinal fluid fistula, 42-43

compression, of spinal cord, 45

hemothorax, 48-49

Case histories—Continued

laminectomy—continued

through-and-through wounds, of spinal

canal, 46-47

wound of oauda equina, root pain, 43-44

median nerve injury—

in forearm, 291

near elbow, 285

peripheral nerve injury, combined with

vascular occlusion, 458-463

radial nerve injury, above elbow, 294-295

radial nerve paralysis, 269-270

rehabilitation, in paraplegia, 187-188

repair of median nerve, in distal forearm,

399

sciatic nerve injury, in upper thigh, 296

successful frozen dried homografts, 500-

501

surgical radial nerve injury, above elbow,

294

ulnar and median nerve injuries, above

elbow, 291-294

ulnar nerve injury^-

above elbow, 283-287, 289-291

above wrist, 289

below elbow, 287-289

unsuccessful frozen dried homograft, 503

Caster oil applications, in decubitus ulcers,

137

Casts—

after peripheral nerve repair, 244, 246-247

Catgut sutures, in peripheral nerve surgery,

388-389

Cathartics, in paraplegia, 153

Catheter drainage:

as cause of periurethral abscess, 113, 122

epididymitis during, 122

in cord bladder, 122

in female, 118-119

in perineal urethrostomy, 97

management of cord bladder, 89, 90-91

Catheterization—

in acute spinal cord injuries, 36, 123

in World War I, 3, 4, 119

of ureters, in renal infection, 104

Cauda equina:

bladder neck, in complete transection of,

84-85

bladder pressure, in wounds of, 79

bone fragments in, 181

case fatality rates for wounds of, in World

War I, 115

complete transection of, 71
658 NEUROSUßGERY

Cauda equina—Continued

cord bladder, in wounds of, 69, 70, 98, 114,

118

cystography, in wounds of, 81

cystometry, in—

complete transection of, 82-84

incomplete transection of, 77

wounds of, 69

cystoscopy, in wounds of, 79

decompression of, 44-47

foreign bodies in, 181

frozen dried homografts from, 497-509

laminectomy, in wounds of, 182

pain, in wounds of, 43-44, 49

rhizotomy, in wounds of, 182

sex function, after incomplete transection

of, 101, 104

wounds of, 9, 32, 38, 47, 55, 178

Causalgia:

after femoral nerve injuries, 349

after injuries of posterior tibial nerve, 414

after median nerve injuries, 414

after peripheral nerve injuries, 178, 208,

219, 231, 303, 469-492

clinical picture in, 479-485

contractures in, 482

contraindications to nerve section in, 579

diagnosis of, 469, 475, 488

differential diagnosis of, 485-487

effect of environment on, 470

effect of malaria in, 487

emotional stimuli in, 482-485, 486, 488

environmental stimuli in, 485, 486

etiology of, 469, 474-478

followup studies in, 490

hyperesthesia in, 476, 478, 479, 482

in Civil War, 478-479

incidence of, 469, 470-473, 473n

in special nerves, 475

malnutrition in, 480

management of, 487-489

mechanism of pain in, 475-477

motor paralysis in, 489

nerve resection in, 488, 579

neurolysis in, 487

osteoporosis in, 477-478, 485

pain in, 470-473, 473n, 474-475, 476,

478-480, 485-487, 488, 489-490

papaverine hydrochloride in, 487

pathologic process in, 473-474, 476

personality changes in, 482, 485

physical stimuli in, 485

preexistent psychogenic factors in, 485

Causalgia—Continued

after peripheral nerve injuries—continued

psychogenic factors in, 482-485, 486, 488

recurrence of, 490

results in, 489-490

roentgenologic examination in, 485

section of ulnar nerve in, 576

sensory losses in, 482

sensory paralysis in, 489

skin temperature readings in, 474-475

spontaneous recovery in, 470, 473, 477

statistics of, 470-473, 473n, 490

sympathectomy in, 470, 473n, 475-477,

486-489, 490

sympathetic block in, 473n, 476-477,

486-490

therapeutic testing in, 486-488

trophic changes in, 481

vasoconstriction in, 485, 486-487

vasomotor changes in, 481, 485

in paraplegia, 181

Causes of death, in—

acute spinal cord injuries, 115, 116

brachial plexus injuries, 392

combined peripheral nerve-vascular injuries, 442

femoral nerve injuries, 406

paraplegia, 11-12, 90

peripheral nerve surgery, 250

Cavus deformity, 579

Central neuroma, 377

Cephalic vein, 391, 393

Cerebral sensory cortex, 183

Cerebrospinal fluid:

circulation of, 38

fistula, 38

after laminectomy, 55, 65

closure of, 26

penicillin therapy in, 58

Cervical laminectomy, 51

Cervical nerves, 312

formation of—

axillary nerve from, 317

brachial plexus from, 305-308, 310, 335

median nerve from, 328

musculocutaneous nerve from, 314

radial nerve from, 318-320

Cervical plexus, 312

Cervical spinal cord:

anesthesia, in wounds of, 50, 51

case fatality rates, in wounds of, 115

cord bladder in, 118

factors of mortality, in wounds of, 64
INDEX 659

Cervical spinal cord—Continued Civil War—Continued

priapism, after transection of, 38, 91, 101, peripheral nerve injuries in, 302-303

113, 173 sympathectomy in, 489

roentgenograms of, 39 Civilian management, of—

wounds of, 20, 30, 35, 36, 47, 49, 50, 58, 59, cord bladder, 67, 98-99

63,64 paraplegia, 127, 146

in Civil War, 115 Civilian policies, in—

Cervicodorsal spinal cord, wounds of, 181 acute spinal cord injuries, 25

Cervicothoracic spinal cord, wounds of, 19 rehabilitation in paraplegia, 162

Changes of position— Civilian practice:

after laminectomy, 58-59 causalgia in, after peripheral nerve induring evacuation of paraplegics, 23, 131— juries, 487n

135 spinal cord concussion in, 47

in paraplegia, 22, 29, 108, 135 Civilian results, of surgery for herniated

Chaplain Corps, 122 nucleus pulposus, 193-194, 200

Chaplains, in paraplegic program, 190 Civilian-type injuries of—

Charcot joint, 570 median nerve in hand, 399

Charny, C. W., 74 peripheral nerves, 239, 363-364, 493

Chemotherapy, in— posterior tibial nerve, 412

acute spinal cord injuries, 29, 32, 64 spinal cord, 115-116

cord bladder, 62 ulnar nerve, 576

renal infection, 103-104 Classification, of—

Chest wall, decubitus ulcers of, 131 acute spinal cord injuries, 32-35

Chest, wounds of, 19, 21, 25, 29, 30, 36, 48, in World War I, 3

50, 51, 64, 120, 146 peripheral nerve injuries, 363-364

as cause of death, in acute spinal cord inju- recovery stages, of cord bladder, 68-71

ries, in World War I, 3, 4 suture sites, in peripheral nerve injuries,

Chief of Medical Supply, Office of Chief 531-533

Surgeon, ETOUSA, 29 Clavicle:

Chief Surgical Consultant, OTSG, 195, 225 boundary of posterior cervical triangle by,

Chills, in urinary tract infection, 103, 146 308

Chinizarin sweat test, in peripheral nerve division of, in brachial plexus injuries, 313

injuries, 280 overriding of, in brachial plexus surgery,

Chloramine-T, in decubitus ulcers, 137 313

Chlorazine, in decubitus ulcers, 138 shortening of, in brachial plexus injuries,

Cholinergic drugs, 280n 305, 392

Chronaxie determinations, in peripheral Claw hand, 265, 571, 576-577

nerve injuries, 561 Clawing, of toes, 579

Churchill, Col. E. D., 231-232 Clearing stations:

Cicatricial vascular occlusion, associated acute spinal cord injuries in, 36

with peripheral nerve injuries, 442 management of cord bladder in, 61

Circular No. 25, ASF: Cleveland, Col. Mather, 246

22 Jan. 1945—5, 13 Clinical picture, of herniated nucleus pulpo10 Dec. 1945—14 sus, 193, 196

Circular Letters: Closed drainage, in cord bladder, 122, 123,

No. 43, OTSG, 13 Feb. 1943^195 124

No. 81, Office of Chief Surgeon, ETOUSA, Closed injuries, of spine, 20, 23, 35, 38

10 June 1944—240 Closed system, of irrigation, in cord bladder,

No. 190, OTSG, 17 Nov. 1943—197 91-92, 99

Civil War: Closure, of—

case fatality rates for acute spinal cord cerebrospinal fluid fistula, 26

injuries in, 114-115 decubitus ulcers, 139-145, 149, 190

causalgia after peripheral nerve injuries donor site in combined peripheral nervein, 219, 473n, 474, 478-479 plastic surgery, 431

49S9,9,1T—«9i 46
660 NBUROSURGERY

Closure, of—Continued

dura at laminectomy, 55

incision in brachial plexus injuries, 313

in femoral nerve injuries, 349

in musculocutaneous nerve injuries, 316

in peripheral nerve surgery, 384

in posterior tibial nerve injuries, 359

in radial nerve injuries, 323, 325, 326

in sciatic nerve injuries, 356

laminectomy wound, 55-56

suprapubic cystostomy, 176

Coaptation sutures, at debridement in peripheral nerve injuries, 228, 234, 242

Cobb, S., 101, 114

Cobra venom, 180

Codeine, after laminectomy, 57-58

Coleman, C. C, 101, 114

Coli-aerogenes infection, in paraplegia, 12

Collagen sleeve technique, in frozen dried

homografting, 498, 508

Collagen tubes, in peripheral nerve repair,

389

Collagenization, in peripheral nerve injuries,

519, 528, 543

Collateral circulation, in—

combined vascular-peripheral nerve injuries, 464

median nerve injuries, 394

peripheral nerve injuries, 304

Collecting stations, acute spinal cord injuries

in, 36

Colony-type paraplegic wards, 9

Color changes, in combined vascular-peripheral nerve injuries, 440

Colostomy, in paraplegics, 146, 150

Combined arterial-peripheral nerve injuries,

439n

Combined bone-peripheral nerve injuries,

211-212, 222, 235, 238, 242, 244-246,

250, 253, 364, 415-428

orthopedic techniques in, 569-570

physical therapy in, 564

statistics of, 246, 422-428

Combined bone-peripheral nerve surgery,

technique of, 421-422

Combined bone-peripheral nerve-vascular injuries, 466

Combined injuries. See special combinations.

Combined median nerve-arterial injuries,

439n

Combined median nerve-bone injuries, 428

Combined median nerve-humerus injuries,

423-425

Combined neurosurgical-orthopedic management of bone-peripheral nerve injuries,

245-246, 250, 367, 380, 415-428

Combined peripheral nerve-femoral artery

injuries, 455

Combined peripheral nerve injuries, study of

footprints and handprints in, 265

Combined peripheral nerve-jugular veincarotid artery injuries, 442

Combined peripheral nerve-popliteal artery

injuries, 455

Combined peripheral nerve-skin injuries,

429-438

Combined peripheral nerve-skin-soft tissue

injuries, 211-212, 364, 564

Combined peripheral nerve-soft tissue-bone

injuries, 569-570

Combined peripheral nerve-soft tissue-vascular injuries, 467

Combined peripheral nerve-vascular injuries,

211-212, 222, 237, 238, 243, 253, 280-

281, 364, 439-467

diagnosis in, 440-441

incidence of, 439-440, 439n

in neck, 441-448

prognosis in, 442-443

Combined peripheral nerve,vascular-bone injuries, 569-570

Combined peroneal nerve-arterial injuries,

439n

Combined plastic-neurosurgical management

of peripheral nerve injuries, 429-438

Combined radial nerve-arterial injuries, 439n

Combined radial nerve-bone injuries, 428

Combined radial nerve-humerus injuries,

256, 325, 402-404, 422-423, 573

Combined sciatic nerve-femoral injuries,

425-426, 428

Combined sciatic nerve-knee injuries, 426

Combined sciatic-peroneal nerve-arterial injuries, 439n

Combined sciatic-tibial nerve-arterial injuries, 439n

Combined tendon-nerve injuries, 253, 398,

401

Combined tibial nerve-arterial injuries, 439n

Combined ulnar nerve-arterial injuries, 439n

Combined ulnar nerve-bone injuries, 428

Combined ulnar nerve-humerus injuries,

422-423

Combined ulnar nerve-radius injuries, 423-

425

Combined ulnar nerve-ulna injuries, 423-

425
INDEX 661

Combined vascular, cranial nerve injuries,

441-448

Combined vascular-radial nerve injuries, 402

Committee on Veterans Medical Problems,

National Research Council, 219, 230

Common flexors of fingers, 335

Common flexor tendons of fingers, 341

Common peroneal nerve, 352, 356

anatomy of, 353, 361-362

exposure of, 357-362

formation of, 351, 357

injuries of, 250, 378-379

repair of injuries of, 411-412

stretch fibrosis of, 539

study of specimens from, 514

transplantation of, 411

Common volar digital nerve, 328, 333

Communicating peroneal nerve, 353

Compass test, in peripheral nerve injuries,

277-279

Complete peripheral nerve injuries:

causalgia in, 476-477

response to electrical stimulation in, 372

Complete syndrome, of last four cranial

nerves, 442

Complete transection, of—

cauda equina, 71, 118

cystometry in, 82-84

cystoscopy in, 80-81

spinal cord:

at level of conus, 71

bladder neck in, 84-85

bladder function in, 87

case fatality rates in, 115

cord bladder in, 69, 70-71, 94, 116,

117-118, 123-124

cystometry in, 76

in World War I, 3

priapism after, 38, 91, 101, 113, 173

renal calculi after, 105-106

Dakin's solution, in decubitus ulcers, 137,

138

Danish school of gymnastics, 567

David, V. C, 73, 89

Davis, Col. Loyal, 6, 165, 203, 207, 303,

441, 470, 489

Debilitation, in—

herniated nucleus pulposus, 203

paraplegia, 12, 131, 134

Debridement:

accidental nerve severance at, 533

at hemilaminectomy, 56

at laminectomy, 52-54, 55

Debridement—Continued

coaptation sutures at, in peripheral nerve

injuries, 234

in acute spinal cord injuries, 20-21, 25,

42-43, 50

in combined bone-nerve injuries, 250

in combined radial nerve-humerus injuries, 403

in decubitus ulcers, 136, 141-142

in peripheral nerve injuries, in World War

I, 208

in spinal cord injuries, in World War I, 31

in wounds of extremities, 208

management of peripheral nerve injuries

at, 233-237, 242-243, 250, 304-305,

364, 376, 403

primary nerve suture at, 228, 232

de CHAULIAC, G.

Decompression—

in paraplegia, 181

of spinal cord, 20-21, 54

of spinal cord and cauda equina, 44, 47

Decubitus ulcers:

as cause of death, in paraplegia, 11

as result of adducter spasms, 180

associated with renal calculi, 110

closure of, 139-145, 149, 190

debridement in, 136

development of, during transportation, 23,

29, 64, 130-135

dietary management in, 9

dressings in, 137-138

etiology of, 131-134, 147-148

fluorescein studies in, 136

healing in, 138-139

in paraplegia, 6, 9, 10, 13, 22, 29-30, 61,

71, 87, 89, 90, 99, 119, 130-145, 146

in World War I, 3, 130

infrared treatment of, 22

local measures in, 135-138, 140

management of, 29-30, 135-145

nitrogen balance in, 139-140

nursing care in, 145

nutritional factor in, 63

of sacral region, 11, 61, 87, 131, 137-138,

139, 142, 143

over trochanters, 87, 135, 137, 139, 142 *

pathologic process in, 131

plastic surgery in, 9, 10, 131, 135

prevention of—

after laminectomy, 59

at operation, 51

in paraplegia, 6, 134-135, 155
662 NEUROSURGERY

Deoubitus ulcers—Continued

protein deficit in, 9, 10, 63, 135, 145, 146,

147-150

recordkeeping in, 135

renal infection from, 102

skin grafting in, 135, 143-145, 149, 151

spontaneous healing of, 10

statistics of, 22, 137, 142

surgery in, 10, 18, 138-145

techniques of surgery in, 141-145

D-day, 25, 26, 120

Deep circumflex iliac vessels, 347

Deep peroneal (anterior tibial) nerve, 353,

361

Deep pressure sense, in peripheral nerve injuries, testing of, 266-272

Deep radial nerve, 321

Definition, of neurosurgical conditions, 25n

Deformities, in causalgia, after peripheral

nerve injuries, 482

Degenerative changes, in peripheral nerve

injuries, 211

Delayed management of nerve component,

in combined bone-nerve injuries, 245

Delayed primary wound closure, 231

in combined bone-peripheral nerve injuries, 246, 250

in combined radial nerve-humerus injuries, 403

in MTOUSA, 247

in peripheral nerve injuries, 242, 252, 364,

562, 563

in soft-tissue wounds, 240

Deltoid, 317, 318, 321, 322, 325, 391, 393

Deltoid function, in axillary nerve injuries,

572

Deltoid paralysis, 571

Dennis, F. S., 115

Denny-Brown, D. E., 71, 82, 83, 118

Depressed fracture, of spine, 40

Depression, in paraplegia, 17

Dermometry, 562

Detrusor, reflex contractions of, 76, 79, 80,

84, 86

Development, of—

paraplegic program, 5-18

policies, in—

herriated nucleus pulposus, 194-203

peripheral nerve injuries, 211-230, 231-

237, 239-247

Diagnosis, of—

acute spinal cord injuries, 26, 36-40

causalgia, after peripheral nerve injuries,

469, 475, 488

Diagnosis, of—Continued

combined peripheral nerve-vascular injuries, 440-441, 454, 465

epididymitis, 112

herniated nucleus pulposus, 193

peripheral nerve injuries, 251-300

periurethral abscess, 113

renal calculi, 104, 105-106

renal infection, 102-103

ureteral calculi, 111

urinary calculi, 152

urinary tract infection, 125

vesical calculi, 112

See also Differential diagnosis.

Diagnostic aspects, of physical therapy, in

peripheral nerve injuries, 557, 559-562, 568

Diagnostic errors, in peripheral nerve injuries, 213

Diagnostic procedures, in peripheral nerve

injuries, 212-217

Diagrams, in peripheral nerve injuries, 233-

238

Dietary management, in—

acute spinal cord injuries, 63

combined bone-nerve injuries, 421

decubitus ulcers, 9

paraplegia, 9, 175

renal calculi, 108

Dietitians, in paraplegic program, 122

Differential diagnosis of causalgia, 485-487

Digital arteries, 328

Digital nerves:

cable grafts from, 494

grafting of, 219, 229, 381, 399, 493

Digits of hand, loss of extensor function of,

573

DILMN, E. L., 567

Dislocation of hip, in—

combined bone-nerve injuries, 426

peroneal nerve injuries, 408

Disorders of calcium metabolism, in paraplegia, 147

Disposition, in—

herniated nucleus pulposus, 200-201

peripheral nerve injuries, 221-225, 241

Disruption of suture site—

after peripheral nerve repair, 228, 243,

244, 416, 519, 533, 539-541

in combined bone-nerve injuries, 416

in peroneal nerve repair, 411

in sciatic nerve repair, 410

Diverticula of bladder, 81

Donor sites, in combined peripheral nerveplastic surgery, 430-431, 432
INDEX 663

Dorsal antebrachial cutaneous nerve, 320, ECHLIN, Maj. F. A., 473n, 488

323, 325 Economic considerations, in paraplegia, 17

Dorsal cutaneous branch, of ulnar nerve, 335 Edema—

Dorsal interosseous nerve, 320, 326, 406, 424, after debridement, in peripheral nerve in573 juries, 235

Dorsal scapular nerve, 310 in combined bone-peripheral nerve inDorsal sensory branch, of ulnar nerve, 341 juries, 564

Dorsal spinal cord: in combined peripheral nerve-vascular

case fatality rates in wounds of, 115 injuries, 440

cystoscopy in complete transection of, in median nerve injuries, 395

80-81 in peripheral nerve injuries, 515, 528, 536,

Dorsal sympathectomy, in causalgia, after 538, 558, 562, 563, 564

peripheral nerve injuries, 219 of bladder neck, in paraplegia, 72, 91

Dorsiflexion of wrist, after radial nerve of foot, in causalgia, after peripheral nerve

injury, 574 injuries, 473n

Dorsocutaneous branch of ulnar nerve, 401 of spinal cord, 33, 34, 37, 38, 55, 68

DOITPE, J., 475, 477, 489 of urethral orifices, in cord bladder, 80, 100

Drainage, in renal infection, 104 Education, continuation of, by paraplegics,

Draping, in peripheral nerve surgery, 367 7, 185-186

Dressings, in decubitus ulcers, 137-138 Educational considerations, in paraplegia, 17

Drug addiction, in causalgia, 487 Educational level, of paraplegics, 129

Drug therapy, in renal calculi, 108 Efferent impulses, from hypothalamus, 475

Drugs, effects of, in cord bladder, 94, 122 Effleurage, 180

DRTJITT, R., 302 Ejaculation, after acute spinal cord injuries,

DUELL, A., 493 101

Dura: Ejaculatory duct, retrograde extension of incompression of, 182 fection by, 112 ;• '

defects of, in spinal cord injuries, 26 Elastic dressings, in combined peripheral

exploration of, in acute spinal cord in- nerve-soft tissue injuries, 564

juries, 26 Elastic splinting, in peripheral nerve ininvolvement of, in acute spinal cord in- juries, 566

juries, in World War I, 3 Elbow:

management of, at laminectomy, 54-55 arthodesis of, 571

penetration of, in acute spinal cord in- exposure of median nerve at, 330-331

juries, 38 exposure of ulnar nerve at, 339-340

wounds of, 42-43 limitation of extension of, in ulnar nerve

Duration, of peripheral nerve operations, injuries, 396-397

250, 364-365 orthopedic surgery, in nerve injuries about,

Duty status, after peripheral nerve injuries, 572-573

221, 222, 223 Elective surgery:

Dysesthesia, in— holding period for, in ETOUSA, 203

irreparable nerve injuries of foot, 580 in peripheral nerve injuries, 240

ulnar nerve injuries, 576 Electrical stimulation—-

Dysphagia, in vascular-cranial nerve in- after femoral nerve surgery, 407

juries, 448 at ,6bturator nerve surgery, 407

at operation, for—

Early nerve suture: • axillary nerve injuries, 393

failures of, 228-229 brachial plexus injuries, 392

in combined bone-nerve injuries, 415 femoral nerve injuries, 346

in MTOUSA, 231, 233-237 median nerve injuries, 395, 398

principles of, 211-212, 233-237 obturator nerve injuries, 407

rationale of, 210-211 peripheral nerve injuries, 311, 330, 346,

timing of, 211, 231, 233, 234, 235, 239-242, 356, 365, 368, 369, 372-374, 375, 377,

363-364, 375, 515, 519, 531-533 392, 521, 526, 541
664 NEUROSURGERY

Electrical stimulation—Continued

at operation, for—continued

radial nerve injuries, 403

at reexploration, after frozen dried homografting, 503, 505, 506-507, 509

at reoperation, after nerve grafting, 499,

503

in assessment of returning motor function,

256

in combined bone-nerve injuries, 421

Electrocoagulation, at peripheral nerve surgery, 365

Electrodiagnosis, in peripheral nerve injuries,

213-217, 213n, 224, 251, 266, 560-562, 567

See also Faradic, Galvanic, etc.

Electrodiagnostic techniques, in peripheral

nerve injuries, 213-217, 213n

Ellik Evacuator, 97, 112

ELMAN, R., 12

Emaciation, in paraplegia, 11

Emotional considerations, in paraplegia, 158-

162

Emotional instability—

as contraindication to work furlough, in

peripheral nerve injuries, 223

before causalgia, after peripheral nerve

injuries, 485

in causalgia, 479, 487n

Emotional status, in irreparable nerve injuries, 570

Emotional stimuli, in causalgia, 475, 479,

482-485, 486

Empyema, in paraplegia, 146

Endoaneurysmorrhaphy, 465

Endoneurial fibrosis, in peripheral nerve injuries, 517

End organs, in peripheral nerve injuries, 269,

271

Endotracheal anesthesia, for laminectomy,

50-51

Endotracheal suction, after laminectomy,

58

End-to-end anastomosis—

after nerve grafts, 376

in peripheral nerve injuries, 242, 244, 305,

375-390

in combined bone - peripheral nerve

injuries, 246

in ETOUSA, 249

Enemas, in paraplegia, 153, 155, 156-157

England. See United Kingdom Base.

Enlisted men, herniated nucleus pulposus

in, 198-201

Enteric fistula, in paraplegia, 146, 147

Environmental stimuli, in causalgia, 470,

475, 485, 486

Ephedrine sulfate, in acute spinal cord

injuries, 36

Epididymitis, 112-113, 122, 152

Epididymo-orchidectomy, 113

Epilepsy, induced by section of cerebral

sensory cortex, 183

Epinephrine. See Adrenalin.

Epineurial fibrosis, in peripheral nerve

injuries, 235

Epineurial sutures, in peripheral nerve

injuries, 243, 364, 384-385

Epineurium, injection of, with physiologic

salt solution, 374

Equinovarus deformity, in peripheral nerve

injuries, 570, 580, 581, 584

Equinus deformity, in paraplegia, 173

Equipment, for—

chronaxie determinations, 561

compass test, in peripheral nerve injuries,

278

estimation of pain and touch points, in

peripheral nerve injuries, 276

footprints and handprints, 265

galvanic-faradic testing, in peripheral

nerve injuries, 560-561

galvanic-tetanus ratio, 561

nerve block, in quantitative testing of

muscle strength, 264

paraplegic program, 8, 9

peripheral nerve surgery, 365

peripheral nerve testing, 217

quantitative assessment, of muscle

strength, 259-261

quantitative assessment, of pain sensation, 273-274

quantitative determination, of superficial

pressure (touch), 275

resection of damaged nerve ends, 372, 383

skin temperature testing, 281-282

spinal surgery, in forward hospitals, 32

sweat tests, in peripheral nerve injuries,

279

testing of pain sensation, in peripheral

nerve injuries, 267

Erosion, of peripheral nerves, by aneurysms,

519, 528-530

Escherichia coli infection, in paraplegia, 72,

102-103

Esthesiometer, 278

Ether anesthesia, for laminectomy, 50-51

Etiology, of—

acute spinal cord injuries, 25, 32-33
INDEX 665

Etiology, of—Continued Evaluation, of—Continued

causalgia after peripheral nerve injuries, progress, in peripheral nerve injuriel,

469, 474-478 224-225

decubitus ulcers, 59, 131-134, 147-148 Excision and quadruple ligation, in arterioherniated nucleus pulposus, 194 venous fistulas, 465

pain in paraplegia, 178 Exercises—

paraplegia, 127-128 for paraplegics, 163-164

renal calculi, 104-105 in peripheral nerve injuries, 563

spastic reflexes, in paraplegia, 178-180 Expectant management, of peripheral nerve

Euphoria, in paraplegia, 17, 160, 186 injuries, 211, 231

Europe. See Continent. Experimental studies, in—

European Theater of Operations: cord bladder, 67, 68, 73

acute spinal cord injuries in, 25-30 frozen dried homografts, 218, 495

electrodiagnosis in, 560-561 peripheral nerve injuries, 239, 381, 566

herniated nucleus pulposus in, 203 in World War I, 207, 219

holding policy in, 244, 245 peripheral nerve regeneration, 302, 515

management of cord bladder in, 120-121 peripheral nerve repair, 211, 243

management of peripheral nerve injuries physical therapy in peripheral nerve

in, 211, 239-250 injuries, 246, 557, 564

physical therapy for peripheral nerve Exploration—

injuries in, 563 in acute spinal cord injuries, 25-57

Evacuation— in peripheral nerve injuries, 211, 234, 243,

after laminectomy, 58 254

after peripheral nerve repair, in ETOUSA, after use of tantalum foil, 287-288

244 through dura, at laminectomy, 55

in acute spinal cord injuries, 3, 26-27, Exploratory laminectomy, in—

47-49, 63-64 acute spinal cord injuries, 47

in paraplegia, 30, 131-135 paraplegia, 181-182

in MTOUSA, 23 Exposure, at operation—

in World War I, 31 for peripheral nerve injuries, 207, 369-370

timing of, 30 in axillary nerve injuries, 317-318

to Zone of Interior, 120-121 in brachial plexus injuries, 311-313

in peripheral nerve injuries, 235, 240-241 in musculocutaneous nerve injuries, 316

in World War I, 208 in radial nerve injuries, 322-326

of casualties with combined bone-pe- in ulnar nerve injuries, 338-342

ripheral nerve injuries, 246 of common peroneal nerve, 360-362

of casualties with herniated nucleus pul- of femoral nerve, 346-349

posus, 202, 203 of median nerve—

priorities of, 222, 240 at elbow, 330-331

See also Air evacuation, Transportation. at wrist, 333

Evacuation hospitals: in arm, 330-333, 394, 395, 396

acute spinal cord injuries in, 32, 35, 36 in forearm, 331-333

in ETOUSA, 26, 29 in hand, 333

management of cord bladder in, 61 of posterior tibial nerve, 359

management of acute spinal cord injuries of radial nerve—

in, 120

in World War I, 4

in arm, 323-325

postlaminectomy care in, 58 in axilla, 402

primary nerve suture in, 233 in forearm, 325-326

of sciatic nerve, 354-357 Evaluation, of—

patients for work furloughs, 223 of terminal divisions, of sciatic nerve, 357-

peripheral nerve injuries, at operation, , . , 362

372-376 of tibial nerve, 357-359
666 NEUROSURGERY

Exposure, at operation—Continued

of ulnar nerve—

in arm, 339-340

in axilla, 338

in forearm, 340-342

Exposure technique, of frozen dried homografting, 506-508

Extension contracture, in combined bonejierve injuries in forearm, 423

Extension deformity, of metacarpophalangeal joints, 571

adjacent joints, after peripheral nerve

surgery, 244, 247, 380

elbow, limitation of, in ulnar nerve injuries, 396-397

spine and head, in acute injuries, 23, 35

Extensor carpi—

radialis, 256, 325, 404, 406

radialis brevis, 320, 326, 574

radialis longus, 320, 325, 574

ulnaris, 320, 326, 406

Extensor digiti quinti proprius, 320, 326

Extensor digitorum—

brevis, 361

communis, 320, 326, 406

longus, 353, 361, 362, 411

Extensor function, of digits, loss of, 573

Extensor hallucis longus, 225, 353, 362

Extensor indicis proprius, 320, 326, 406, 574

Extensor muscle paralysis, in peripheral

nerve injuries, 566

Extensor pollicis—

brevis, 406, 574

longus, 320, 406

Extensors, of thumb, 320, 326

External condyle, of humerus, 325

External fixation, in combined bone-nerve

injuries, 564

External genitalia, complications in, in cord

bladder, 112-114

External iliac artery, 344, 346, 347

External jugular vein, 312

External oblique aponeurosis, 346, 349

External popliteal nerve injuries, associated

with tibial-fibular injuries, 584

Extradural hemorrhage, in acute spinal cord

injuries, 34, 54

Extramedullary hematoma, 55

Extremities, wounds of, 21, 30

Facial nerve grafts, 219, 229, 381, 493, 494,

498, 510

Facies, in causalgia, after peripheral nerve

injuries, 480

FAHLTJND, Capt. G. T. R., 513

Failures—

of early peripheral nerve suture, 228-229

due to inadequate resection of nerve

ends, 236

of peripheral nerve grafts, 381-382, 494-

495

of primary nerve suture, 228, 232-233

False aneurysm—

associated with peripheral nerve injuries

442, 465

in combined peripheral nerve-vaseular

injuries, 440

Family care, of paraplegics, 15, 16-17, 160

Faradic stimulation—

at peripheral nerve surgery, 365, 368, 369

in peripheral nerve injuries, 213

Fascial graft, for dural closure, at laminectomy, 55

Fascicles:

fibrosis of, 558

ischemia of, 374

loss of continuity of, 374-375

management of—

at peripheral nerve surgery, 376-377,

379, 381, 395

in peripheral nerve grafts, 382

of sciatic nerve, as frozen dried homografts, 497

Fat content, of diet, in paraplegia, 150

Fat-soluble vitamins, in paraplegia, 150

Fecal impaction—

in acute spinal cord injuries, 62, 63

in paraplegia, 153

Feet, quantitative assessment of muscle

strength in, 256-263

Female, acute spinal cord injuries in, 118-119

Femoral aneurysms, 465

Femoral artery, 344, 346, 349, 406, 455

Femoral nerve: ..

anatomy of, 343-346, 347, 349

formation of,. 343-346

injuries of, 343-350

closure of wound in, 349

electrical stimulation at operation for,

346

exposure of, 349

positioning at operation for, 346, 350

study of specimens from, 514

techniques of gaining length in, 350

physiology of, 344-345

surface anatomy of, 346

surgical approach to, 346-349

terminal branches of, 344-346, 349, 350
INDEX 667

Femoral vein, 349

Femur:

fractures of, associated, with peripheral

nerve injuries, 49, 416, 420-421 internal

fixation of, 428

Ferric chloride sweat tests, in peripheral

nerve injuries, 279

Fever, in—

cystitis, 111

epididymitis, 112

renal infection, 102, 103

ureteral calculi, 111

urinary tract infection, 146

Fibrin film, 385-386

Fibrin film technique, of peripheral nerve

repair, 236, 375, 390, 535

Fibrin foam, 55, 365, 382

Fibroplasia, after peripheral nerve suture,

236

Fibrosis:

after debridement, in peripheral nerve

injuries, 235

after frozen dried homografting, 505, 508,

509, 510, 546-547

after peripheral nerve surgery, 386

development of, in relation to suture

material, 389

effect of, on nerve regeneration, 550

in brachial plexus injuries, 391

in peripheral nerve grafts, 381-382

in peripheral nerve injuries, 234, 244, 246,

249, 382, 513, 515, 519, 528, 533-534,

539, 541, 543, 555, 557-558, 584

of bladder wall, in paraplegia, 95

production of, by prolonged immobilization, 570

relation of ischemia to, 376

See also special types of fibrosis, Histopathologic process in peripheral nerve

injuries, etc.

Fibula:

fractures of, associated with peripheral

nerve injuries, 584

resection of head of, 362, 410

resection of neck of, 411

Field hospitals, management:

of acute spinal cord injuries in, 32, 35,

36, 120

of cord bladder in, 61

postlaminectomy care in, 58

Field Medical Record, 533

Fifth Service Command, 151n

Fifth U.S. Army, 19

Fifteenth U.S. Army, 120

Fingers:

ankylosis of, 584

clawing of, 265, 571, 576-577

extension function of, 574

function of, after sublimis tendon surgery,

in median nerve injuries, 577

orthopedic procedures on, 572-573, 577

pain in, in causalgia, 478-480

First aid, in acute spinal cord injuries, 35-36

First intercostal nerve, 310

First thoracic ganglion, 31.0

First U.S. Army, 65

Fistula formation—

after ureterotomy, 111

at penoscrotal junction, 90-91, 97

See also specific types.

Fixed hospitals, acute spinal cord wounds

in, 19

Flaccid paralysis, in acute spinal cord

injuries, 37

Flap closure, in combined peripheral nervesoft tissue injuries, 564

Flexion contractures—

in median nerve injuries, 330

in radial nerve injuries, 322, 325

of knee, 579

Flexion creases:

avoidance of—

at peripheral nerve surgery, 301, 304,

322, 338, 341, 369

in median nerve surgery, 397

in popliteal space, 359, 411, 412

in radial nerve surgery, 325

in sciatic nerve surgery, 357-358

in hand, 401

in thigh, 349

of elbow, 406

Flexion of »contiguous joints, in peripheral

nerve injuries, 236, 243, 249, 377-379

Flexion-relaxation—

combined with bone shortening, 380

in ulnar nerve injuries, at elbow, 400

Flexor carpi—

radialis, 328, 331

radialis tendon, 328

ulnaris, 333, 335, 337, 340, 343, 396, 400

transplantation of, 574

ulnaris tendon 337, 340, 341

Flexor digiti quinti brevis, 337

Flexor digitorum—

brevis, 352

longus, 352, 359, 413

muscles, 340
668 NEUROSURGERY

Flexor digitorum—Continued

profundus, 328, 331, 333, 335, 340, 343,

400

sublimis, 328, 331, 397

sublimis tendon, 328, 331

Flexor hallucis—

brevis, 352

longus, 352, 359, 413

Flexor paralysis, in peripheral nerve injuries,

566

Flexor pollieis—

brevis, 328, 333, 337

longus, 328, 331, 333

Flexor profundus digitorum, 343

Flexor profundus, innervation of, 263

Flexor, spasm, in paraplegia, 181

Flexor sublimis, 343

Flexor sublimis tendons, 341

Flexor tendons, of fingers, 337

injuries of, associated with ulnar nerve

injuries, 576

transplantation of, 406

Fluid balance, after laminectomy, 57

in cord bladder, 124

in renal calculi, 108

in renal infection, 103

Fluid infection, of distal peripheral nerve

segment, 384

Fluorescein studies, in decubitus ulcers, 136

Foley catheter, 91

Footdrop, in paraplegia, 162

Forearm, exposure of:

median nerve in, 331-333

radial nerve injuries in, 325-326

Followup—

in causalgia, after peripheral nerve injury,

490

in herniated nucleus pulposus, 193-194

in peripheral nerve injuries, 213, 221-230,

243-244

See also Peripheral Nerve Registry.

of paraplegics

in VA, 12-13n

in World War I, 3

Foot:

causalgia in, 478, 479, 481, 4.87

cavus deformity of, in peripheral nerve

injuries, 579

stabilization of, irreparable nerve injuries,

580

Footdrop, in—

paraplegia, 22, 162

peripheral nerve injuries, 237

Footprints and handprints, in neurologic

testing, 265-266

Forearm:

causalgia in, 478

combined bone-nerve injuries in, 423-425

exposure of—

median nerve injuries in, 331-333

radial nerve injuries in, 325-326

ulnar nerve injuries in, 340

Forehead, decubitus ulcers on, 131

Foreign bodies, in acute spinal cord injuries,

9, 19-20, 21, 26, 31, 32-33, 35, 38, 44-47,

146

causation of pain by, 178

in cauda equina, 181

management of, at laminectomy, 52-54

roentgenologic demonstration of, 39, 40

See also Bone fragments.

Foreign body reactions, after—

homogenous nerve grafting, 495

peripheral nerve repair, 390, 533-535

Formation, of—

axillary nerve, 317

brachial plexus, 305-308, 310-311

common peroneal nerve, 351, 357

musculocutaneous nerve, 313-314

radial nerve, 318-320, 328

sciatic nerve, 350

tibial nerve, 351, 357

ulnar nerve, 335-337

Formication, 272

Foroblique lens system, 80

Forward hospitals:

deaths from acute spinal cord injuries in,

64-65

management of acute spinal cord injuries

in, 19, 64

nursing care of acute spinal cord injuries

in, 63

postlaminectomy care in, 57

Fossa ovalis, 349

Fowler's position, for defecation, in paraplegia, 155

Fracture-dislocations, of spine, 20, 25, 35

Fractures—

associated with peripheral nerve injuries,

232

associated with spinal cord injuries, 50,

146, 178, 181

of femur, 49

of long bones, 244-246

of vertebrae, 25, 33, 47

See also special bones.

France, 89, 120
INDEX 669

FRENCH, Maj. L. A., 231

French management, of cord bladder, in

World War I, 119

FROMME, A., 448

Frozen dried homografting, technique of,

497-498

Frozen dried homografts, 218-219, 220-221,

493^512

histopathologic process in, 514, 546

results of, 499-512

statistics of, 495, 502-512

Frozen hand, 454, 463-464

Frozen joints, in peripheral nerve injuries,

236-237, 245, 246, 247

Fulguration, of urethral fistula, 113

FULTON, J. F., 68

Furloughs, in—

paraplegia, 185

peripheral nerve injuries, 223, 224

Furmethide iodide, in peripheral nerve

testing, 279, 280n

Fusiform neuroma, 375, 400

Fusion operations—

in irreparable nerve injuries, of upper

extremity, 571

on ankle, 580

GALEN, 301, 302

Galvanic-faradic testing, in peripheral nerve

injuries, 560-561

Galvanic stimulation, in peripheral nerve

injuries, 213, 246-247, 565, 567

Galvanic-tetanus ratio, in peripheral nerve

injuries, 213, 561-562

Gangrene, after peripheral nerve-vascular

injuries, 238

Gas-oxygen-ether anesthesia, for laminectomy, 51

Gastrocnemius, 351, 352, 353, 358, 359, 362,

412, 413

Gastrointestinal complications, in acute

spinal cord injuries, 35

Gastrointestinal tract, care of, in acute

spinal cord injuries, 63

Gastointestinal wounds, 147

Gelfoam, 365, 385-386

Gemelli, 351

General anesthesia, in —

combined bone-peripheral nerve surgery,

422

peripheral nerve surgery, 369

General Hospitals:

ETOUSA, 26, 29

General Hospitals—Continued

overseas, management of acute spinal cord

injuries in, 31, 32-65

serving as transit hospitals, 240

Gentian violet, in deoubitus ulcers, 137

Genitourinary complications, in acute spinal

cord injuries, 101-114

Genitourinary consulations, in paraplegia,

129

German management, of cord bladder, in

World War I, 119

Girdle pain, 178

Glioma:

management of, at peripheral nerve

surgery, 384

resection of, 377, 380-381

traction on, 380

Glioma formation, in—

common peroneal nerve injuries, 413

peripheral nerve injuries, 382, 538

radial nerve injuries, 404

Glossolaryngoscapulopharyngeal hemiplegia,'

442

Glossopharyngeal nerves, 441

Gluteus maximus, 142, 143, 351

exposure of sciatic nerve beneath, 354-356

Gluteus maximus tendon, 408

GOODMAN, E. N., 475, 485

GORDON, W. G., 91, 94

Gracilis tendon, 345

Grafts. See specific types.

GRANIT, 475, 476

Granville's lotion, 473n

Graphic records, in—

deoubitus ulcers, 135

peripheral nerve injuries, 253, 256, 273,

275-276, 277, 282

Gray Ladies, 187

Great sacrosciatic foramen, 350

Great saphenous vein, 349

Greater trochanter, 351, 354

Greenwood bipolar electrocoagulation

forceps, 365

GROSS, S. W., 383

Guadalcanal, 7

Gunshot wounds—

as cause of paraplegia, 128

of spine, 25

GUTMANN, E., 364

HAHN, J., 93

HALL, M., 68

Hallucinatory answers, in neugologic testing,

376
670 NEUROSURGERY

Hamstrings, 351, 354, 356, 408, 409, 410, 412

transplantation of, in quadriceps paralysis,

579

Hand:

ankylosis of, after prolonged immobilization, 584

oausalgia in, 478, 479, 480, 481, 487

exposure of median nerve injuries in, 333

frozen joints in, 246, 247

quantitative assessment of muscle strength

in, 256-263

sweat test of, 279

Hand center, management of median nerve

injuries in, 399

Handprints and footprints, in neurologic

testing, 265-266

HANSON, A. M., 31

HARGRAVE, Prof., 80

HARBISON, Lt. Col. J. H., 121

HARTWELL, J. B., 113

Harvey Cushing Society, 470

HATT, Maj. R. N., 582

HAWLEY, Maj. Gen. P. R., 14, 17

HAYNES, W. G., 37, 44, 46, 65

HAYS, Maj. Gen. S. B., 29

HEAD, H., 67, 70, 71, 111, 273, 278

Head injuries, priority of evacuation in, 240

Head's spring algesimeter, 273-274

Healing—

after delayed primary wound closure, 235

in decubitus ulcers, 10, 138-139

in peripheral nerve injuries, 249

Heat therapy, in peripheral nerve injuries,

247, 564

Heel cord, lengthening of, in paraplegia, 173

Heels, decubitus ulcers on, 131

Hematocrit determinations, in paraplegia,

129, 149

Hematogenous origin, of—

epididymitis, 112

renal infection, 102

Hematoma formation, in acute spinal cord

injuries, 34

Hematomyelia, 68

Hematuria, in renal calculi, 105-106

Hemilaminectomy, in—

acute spinal cord injuries, 56-57

herniated nucleus pulposus, 193

Hemorrhage—

at operation, for brachial plexus injuries,

313

for ulnar nerve injuries, 340

from gluteal vessels, in sciatic nerve surgery, 409

Hemorrhage—Continued

in brachial plexus injuries, 391, 392

in combined peripheral nerve-vascular injuries, 440

in peripheral nerve injuries, 536, 543

into (about) spinal cord, 34

Hemostasis:

at laminectomy, 52, 55

at peripheral nerve surgery, 243, 365, 372,

385-386

effect of local anesthesia on, 368

Hemothorax, 48-49

Hepatitis, 116

HERMANN, L. G., 477

Herniated nucleus pulposus, 56, 193-203

classification of patients with, 194

clinical picture of, 193, 196

diagnosis of, 193

disposition in, 200, 201

etiology of, 194

historical note on, 193-194

in MTOUSA, 202, 203

incidence of, 194, 194n, 198

indications for surgery in, 200-201

line-of-duty status in, 200-201

management of, in Zone of Interior, 194-

202

results of surgery in, 200-203

statistics of, 198-201, 203

HEROY, W. W., 475, 485

Heterogenous nerve grafts, 381

HEYROVSKY, .]., 442

High velocity missiles, as cause of peripheral nerve injuries, 235, 363-364

HIGHET, W. B., 264

HINMAN, F., 89, 93, 95

Hip, dislocations of, in combined bone-nerve

injuries, 408, 426

Hip spica, for transportation splinting, in

peripheral nerve injuries, 420-421

HIPPS, H. E., 558

Histopathologic-neurosurgical cooperative

study, in peripheral nerve injuries, 219-

221, 513-555

Histopathologic process, in peripheral nerve

injuries, 364, 513-555

See also Pathologic process, Fibrosis,

Neurotization, etc.

Histopathologic studies—

in frozen dried homografts, 499, 504-505,

507-509

of nerve grafts, 543-555

Historical note:

acute spinal cord injuries, 3-4
INDEX 671

Historical note—Continued Hospitals, general—Continued

causalgia, 469 named—continued

herniated nucleus pulposus, 193-194 McCaw, 9-11, 18, 138, 180, 184, 185,

peripheral nerve injuries, 207-210, 301-304 188, 488

History taking, in— McCloskey, 301, 349, 473n

acute spinal cord injuries, 36 McCornack, 18

combined peripheral nerve-vascular in- McGuire, 14, 18

juries, 440-441 Mayo, 212

paraplegia, 129 Newton D. Baker, 6, 8, 9, 127, 131,

peripheral nerve injuries, 253-254 140, 182, 189, 190, 217

Holding policies, in ETOUSA, 203, 244, 246 Nichols, 11

Hollow viscera, perforating wounds of, 147 Oliver, 18

HOLMES, G., 68, 69, 70 O'Reilly, 200

HOLMES, W., 494 Percy Jones, 18, 127, 128, 146, 191, 213,

HOMANS, J., 477, 478 217, 470, 474, 475, 476, 478, 480, 485,

Homogenous nerve grafts, 218-219, 381, 493, 487, 489, 490

494-495, 546 Pratt, 18

procurement of, from amputated limbs, Schick, 489

494 Thomas M. England, 6, 127, 582

Hormone therapy, in renal calculi, 108 Valley Forge, 582

Horse serum, in decubitus ulcers, 137 Vaughan, 14, 18

Hospital conferences, on peripheral nerve Walter Reed, 18, 162-163, 195, 198 200,

injuries, 254 217, 218, 221, 225, 477, 494, 495 497,

Hospital Construction Branch, OTSG, 17 514, 535, 547

Hospital Division, OTSG, 8 numbered:

Hospital organization, in paraplegic pro- 21st—238

gram, 6, 22-23 26th—231

Hospitalization policies, in peripheral nerve 33d—22, 234, 236, 238

injuries, 221-225, 244 55th—482, 485, 487

Hospitals. See specific types. Hospitals, various:

Hospitals, evacuation: Boston City Hospital, 495

15th—232 Christian Street Hospital, 302

45th—65 General Hospital No. 11—210

128th—65 New York Institute for the Crippled and

Hospitals, general: Disabled, 162

named: Peter Bent Brigham Hospital, 495

Army and Navy, 18 St. Alban's Naval Hospital, 498

Ashford, 146, 212, 448, 456, 543 Turner Lane Hospital, 302

Birmingham, 14 HOWELL, W. H., 303

Brooke, 18 HUBEB, G. C, 207, 219, 303

Bushnell, 8, 180 Human hair sutures, in peripheral nerve

Cushing, 14, 18, 137, 140, 142, 174, 175, surgery, 388

187, 218, 223, 244, 251-300, 495-512 Humerus:

DeWitt, 18, 135, 138, 140, 182, 212 abduction of, by trapezius transplantation,

Dibble, 140 572

Fitzsimons, 18 capitellum of, 325

Halloran, 6, 127, 128, 143, 145, 149, exposure of axillary nerve at surgical neck

194n, 217, 221, 404, 415-428, 429-438, of, 318

513-555, 564 external condyle of, 325

Hammond, 6, 7, 127, 133, 161, 176, 184, fractures of—

187, 188, 189n combined with peripheral nerve in; uries,

Kennedy, 14, 15, 18, 194, 487, 488 238, 416-420

Lawson, 575 combined with radial injuries, 256,

Letterman, 18 402-404, 573
672 NEUROSURGERY

Humerus—Continued

fractures of—continued

lateral condyle (epicondyle) of, 321

medial epicondyle of, 335, 338, 339, 340,

342, 343, 395

shortening of, in combined bone-nerve

injuries, 236, 380, 416-420, 422-423

shortening of, in radial nerve injuries,

404

supracondylar fractures of, associated

with radial nerve injuries, 428

surgical neck of, 317

transplantation of origins of wrist and

finger flexors on, 572-573

Hunter's canal, 345

Hydronephrosis, 100, 109

Hypalgesia, in peripheral nerve injuries, 269,

273

Hypercalciuria, 104, 108

Hyperemia, as cause of causalgia, after peripheral nerve injuries, 474-475

Hyperesthesia, in—

acute spinal cord injuries, 37, 50

causalgia, after peripheral nerve injuries,

476, 478, 479, 482

Hyperextension, in—

compression fractures of vertebrae, 35

fractures of cervical spine, 59

Hyperextension deformity, of wrist, after

muscle transplantation, 574

Hypertonie bladder, 85, 86

Hypesthesia:

in herniated nucleus pulposus, 196

in peripheral nerve injuries, 269

sweat test in, 279

Hypnotics, role of, in development of

decubitus ulcers, 148

Hypoglossal nerve, 441, 494

Hypoproteinemia. See Protein deficit.

Hypostatic pneumonia, after laminectomy,

58

Hypotension, in acute spinal cord injuries, 36

Hypothalamus, 475

Hypothenar muscles, 401

Hysteria, 485, 486

at debridement in peripheral nerve injuries, 253, 364, 376, 384, 519

at ulnar nerve surgery, 339, 342

in frozen dried homografts, 498

Ileus, in acute spinal cord injuries, 63

Iliac spines, decubitus ulcers over, 131

Iliacus, 344, 346, 350

Uiohypogastric nerve, 346

Ilioinguinal nerve, 346

Iliopsoas, 349

Uiotibial tract of fascia lata, 408

Immobilility, effect of, in development of

decubitus ulcers, 148

Immobilization:

after peripheral nerve surgery, 366-367,

384

in acute spinal cord injuries, 23

of vertebral fractures, during evacuation,

132

risk of, in peripheral nerve injuries, in

upper extremity, 584

Impotence, in paraplegia, 114, 114n

Improvised equipment, in paraplegic program, 8

Improvised transportation splinting, in peripheral nerve injuries, 242

Incidence of—

acute spinal cord injuries, 19-20

brachial plexus injuries, 391

causalgia after peripheral nerve injuries,

469, 470-473, 473n, 475

combined bone-peripheral nerve injuries,

564

combined humerus-radial nerve injuries,

325, 402

combined peripheral nerve-soft tissue injuries, 564

combined peripheral nerve-vascular injuries, 439n, 439-440

disruption of suture line, after peripheral

nerve repair, 244

femoral nerve injuries, 406

herniated nucleus pulposus, 194, 194n, 198

irreparable gaps in peripheral nerve injuries, 249

multiple peripheral nerve injuries, 238

peripheral nerve erosion by aneurysms, 528

peripheral nerve injuries, 128, 211, 212,

225, 493, 514

in ETOUSA, 247-250

in MTOUSA, 237

in World War I, 237

peroneal nerve injuries, 411

phantom limb, 478

renal calculi in paraplegia, 104-105

ulnar nerve injuries, 400, 514

vascular-cranial nerve injuries, 442

vascular peripheral nerve injuries of—

lower extremity, 455

upper extremity, 448

vesical calculi, 112
INDEX 673

Incisions— Indications for—Continued

for hemilaminectomy, 56-57 surgery, for—

for laminectomy, 52 causalgia in posterior tibial nerve infor sympathectomy, 488-489 juries, 414

in axillary nerve injuries, 317-318, 393 decubitus ulcers, 139

in brachial plexus injuries, 311-313, 391, herniated nucleus pulposus, 196-197,

392, 403 200-201, 202-203

in femoral nerve injuries, 346-347, 349, 407 peripheral nerve injuries, 252

in median nerve injuries, 330-331, 333, spinal cord wounds, 20-21

394, 395, 396, 397-398, 399 transfer of paraplegics to VA, 5, 13-14

in musculocutaneous nerve injuries, 316, use of frozen dried homografts, 496 -497

394 Incontinence of feces, in acute spinal cord

in obturator nerve injuries, 407 injuries, 63

in peripheral nerve injuries, 304, 305, 369- Inductorium, 365, 372-374

372 Industrial compensation, in causalgia, after

in peroneal nerve injuries, 411 peripheral nerve injuries, 487n

in posterior tibial nerve injuries, 359, 412- Indwelling catheter—

413, 414 during evacuation, in acute spinal cord

in radial nerve injuries, 322-326, 405, 406 injuries, 29, 64

in sciatic nerve injuries, 354-356, 408, 410 in acute spinal cord injuries, 22, 30, 36, 61

in tibial nerve injuries, 412-413 in management of cord bladder, 61-62, 120

in ulnar nerve injuries, 338-342, 400, 401 Infantry, paraplegia in, 128

See also Anatomic approaches, Exposure. Infection:

Incomplete peripheral nerve injuries, 252- after early nerve suture, 228

253, 547 as cause of death in paraplegia, 11-12

association of bone injuries with, 519 at reparative surgery, for peripheral nerve

causalgia after, 473, 475, 476 injuries, 234

frozen dried homografts in, 495, 499, 512 in acute spinal cord injuires, 21

histopathologic process in, 514, 519 in combined bone-nerve injuries, 420-421,

stretch fibrosis in, 541-543 426-427, 439

Incomplete neuroma, 519 in cord bladder, 115

Incomplete transection of cauda equina, 77 in etiology of—

cord bladder in, 118, 123 causalgia after peripheral nerve injuries,

sex function after, 101, 114 474

Incomplete transection of spinal cord, 16, decubitus ulcers, 131

19-20, 21, 32, 37, 39, 45-46 renal calculi, 104

case fatality rates in, 115 in frozen dried homografting, 503

cord bladder in, 71, 86, 114, 116, 117, 124 in peripheral nerve injuries, 211, 241

cystography in, 81 in World War I, 210

cystometry in, 77 in primary nerve suture, 232

cystoscopy in, 79 of bladder wall, in acute spinal injuries, 71

in World War I, 3, 31 of cord bladder, 72-73

pain in, 43-44, 178 in World War I, 4

vesical calculi in, 112 of prostate, in peroneal urethrostomy, 97

Incomplete ulnar nerve injury, 576 of pubis, in suprapubic cystostomy, 97

Indications for— of urethra, in catheter drainage of cord

amputation in paraplegia, 183 bladder, 99

emergency surgery in combined aneurysm- prevention of, in acute spinal cord inperipheral nerve injuries, 464 juries, 35, 42-43

intradural exploration at laminectomy, 55 relation of, to hypoproteinemia in paralaminectomy, 41-47 plegia, 12

myelography, 197 Inferior cervical sympathetic ganglion, 310

resection of neuromas, 375 Inferior epigastric vessels, 347

selection of anesthesia for laminectomy, 49 Inferior gluteal vessels, 354
674 XEÜROSURGERY

Inferior petrosal sinus, 441 Intrinsic musculature of foot, loss of, in

Inferior ulnar collateral artery, 331 posterior tibial nerve injuries, 412

Inframedullary hemorrhage, in acute spinal Iodine-starch sweat test, in peripheral nerve

cord injuries, 34 injuries, 280

Infrared treatment, of decubitus ulcers, 22 Iodoform, in decubitus ulcers, 137

Infraspinatus, 310 Iophendylate. See Pantopaque.

Initial wound surgery. See Debridement. Iris forceps, in peripheral nerve surgery, 384

Innominate vein, 312 Irreparable peripheral nerve injuries, 225,

Interaction of nerve fiber impulses as cause 569-585

of causalgia, 476 incidence of, 249

Intercostobrachial nerve, 322 Irrigations, in—

Interfunicular crossings, in median nerve cord bladder, 91-94, 123-124

surgery, 397 renal calculi, 110

Interlaminar resection, of intervertebral suprapubic cystostomy, 95

disk, 193 Ischemia—

Intermittent catheterization, in— after damage to brachial artery, 395

cord bladder, 90, 99 as cause of causalgia, after peripheral

World War I, 114, 119 nerve injuries, 474-475, 476

Internal fixation— effect of, in peripheral nerve injuries, 219,

in combined bone-peripheral nerve in- 543

juries, 235, 246, 404, 422, 425 in autogenous nerve grafts, 382

infection after, 427 in combined vascular-peripheral nerve inof femur, 428 juries, 212, 465

Internal iliac artery, 409 in etiology of decubitus ulcers, 23, 59, 131,

Internal jugular vein, 441 132, 133

Internal malleolus, 413 in peripheral nerve injuries, combined with

Internal oblique muscle, 346, 349 vascular occlusion, 458, 463

Internal saphenous vein, 359 of fascicles, 374

Internists, in paraplegic program, 190 of peripheral nerves, from careless mobiliInterosseus membrane, 353 zation, 376

Interosseus muscles, 337, 401 of peripheral nerves, from scarring, 37

use of, in irreparable median nerve injuries, Ischemic contractures, in vasomotor-pe577 ripheral nerve injuries, 280

Interphalangeal joints: Ischemic paralysis, in—

arthrodesis of, 579 median nerve injuries, 394

fusion of, 571 peripheral nerve injuries, 364

Intertransverse muscles, 305 Ischial tuberosities, decubitus ulcers over,

Intervertebral disk, interlaminar resection of, 131

193 Ischium, tuberosity of, 351

Intestinal origin of renal infection, in para- Italy, 19

plegia, 102

Intradural exploration, at hemilaminectomy JACKSON, J. H., 441

(laminectomy), 55, 57 JACOBS, Capt. M. A., 148

Intramedullary hemorrhage, in acute spinal Joint changes, in—

cord injuries, 55 causalgia, 481

Intramedullary pins, 564 peripheral nerve injuries, 558, 562-563

Intraneural fibrosis, 374 Joint-peripheral nerve injuries, 253, 304

Joint sense, testing of, in peripheral nerve

Intratracheal anesthesia, in peripheral nerve

repair, 249

injuries, 266-272

Joints, effect of galvanic stimulation on, in

Intrathecal penicillin therapy, 39, 58, 65 peripheral nerve injuries, 565

Intravenous pyelography, 81, 106, 124 Joints:

Intravenous urography, 100, 102, 103, 104, extension of, after peripheral nerve repair,

111, 121, 125 244, 247, 380
INDEX 675

Joints—Continued Laminectomy, in acute spinal cord

flexion of, after peripheral nerve repair, injuries—Continued

236, 243, 249 for exploration, 47

movement of, after combined bone-pe- in cadaver to secure nerve grafts, 497

ripheral nerve surgery, 245 indications for, 41-47

pain in, in causalgia, 478, 486 in forward hospital, 32

JONES, R., 263 in World War I, 31, 41

Jugular compression test, 196 postoperative care in, 57-61

Jugular foramen, 441, 448 preoperative medication in, 49

Jugular vein, 308 special problems after, 58-61

statistics of, 182

Kahn test, 129 technique of, 52-57

KEEN, W. W., 301, 302, 469, 473n, 478, 479 timing of, 44, 47-49, 182

Keloid formation, after— LAMPSON, R. S., 74

femoral nerve injuries, 349 Larynx, paralysis of, 441

medial nerve injuries, 330 Lateral antebrachial cutaneous nerve, 314,

radial nerve injuries, 322, 325 325, 330

ulnar nerve injuries, 338 Lateral anterior thoracic nerve, 310

KENNEDY, Col. R. H., 146, 161, 190, 191 Lateral bicipital sulcus, 321, 325

KESSLER, H., 12 Lateral brachial cutaneous nerve, 322-323

KIDD, F., 67, 68, 90 Lateral circumflex artery, 349

Kidney, cortical abscess of, 101, 109 Lateral condyle of humerus, 316, 321

Kidney function, after acute spinal cord Lateral epicondyle of humerus, 314, 321

injury, 100-101 Lateral femoral cutaneous nerve, cable graft

KIRKLIN, Capt., B. I., 474 from, 494

KLEMPERER, Capt. W. W., 19, 20 Lateral neuroma, 377

Knee joint, fractures of, associated with Lateral plantar nerves, 352

peripheral nerve injuries, 420-421 Lateral sural cutaneous nerve, 353

Knee, orthopedic surgery on, for paralysis Lateral traction, 421

below, 579, 580 LATHROP, F. D., 493

KWAN, S. T., 469 Latissimus dorsi, 310, 317, 318, 322

LAUGIER, 303

Laboratory examinations, in— LAVER, C. H., 93

cord bladder, 124 LAWRIE, R. S., 93

paraplegia, 129 LEARMONTH, J. R., 385

peripheral nerve injuries, 254 Leg:

Laboratory personnel, shortages of, for pe- anomalous innervati on of, 490

ripheral nerve studies, 220 bone-peripheral nerve injuries in, 384

Laboratory studies, in protein deficits, in causalgia in, 478

paraplegia, 148-149 LEKSELL, L., 476

Lacertus fibrosus, 328, 330 LERICHE, R., 469, 474, 488

Lambrinudi operations, for equinus (equinovarus) deformities, 580

Lethality of acute spinal cord wounds, 21

LETIEVANT, J. E. F., 303

Laminectomy, in acute spinal cord injuries,

9, 20-21, 33, 38, 39, 41, 57, 70

adjunct therapy after, 57

administrative considerations in, 47-49

anesthesia for, 49-51

antimicrobial therapy after, 58

Levator scapulae, 308, 310

Level of spinal cord injury:

effect of, on work capacity, 187n

relation of, to ambulation, 165

LEWIS, L. G., 71, 87, 94

bladder drainage after, 58 LEWIS, T., 474

case fatality rates in, 65, 181 Limited duty, after peripheral nerve inchanges of position after, 58-59 juries, 222, 223, 224

contraindications to, 21 Linen sutures, in peripheral nerve surgery,

evacuation after, 63 388, 533
676 NETJROSURGERY

Line-of-duty classification, of herniated nucleus pulposus, 194, 196, 201-202

Lines of Langer, 322, 349

Lipiodol myelography, 193, 198

LISTER, J., 101, 303

LIVINGSTON, K. E., 384, 469, 482

Local analgesia, for—

combined peripheral bone-nerve surgery,

422

laminectomy, 26, 49-50, 51

peripheral nerve repair, 211, 249, 368-369

sciatic nerve surgery, 408

suprapubic cystostomy, 62

Local chemotherapy—

at laminectomy, 56

in acute spinal cord injuries, 35

in primary nerve suture, 232

Local injection of Novocain, in causalgia,

487-488

Local measures in decubitus ulcers, 135-138,

140

Local sulfonamide therapy, in peripheral

nerve injuries, 234

Localization, of—

foreign bodies in spinal cord injuries, 39-40

peripheral nerve injuries, 305-308

returning sensation, in peripheral nerve

injuries, 277

Long bones, fractures of, associated with peripheral nerve injuries, 244-246

Long thoracic nerve, 310

Longus colli, 310

LoUTZENHEISER, Lt. Col. J. J., 161

LOVE, J. G., 193

LOVETT, R. W., 256

Lower extremity:

bone shortening in, 380

combined peripheral nerve-vascular injuries in, 439n, 455-458

incidence of peripheral nerve injuries in 514

irreparable peripheral nerve injuries in,

578-584

LOWREY, Maj. J. J., 513

Lumbar spinal cord, wounds of, 20, 38, 118

case fatality rates in, 64, 115

Lumbar nerves, formation of—

femoral nerve from, 343

sciatic nerve from, 350

Lumbar plexus, 343

Lumbar puncture—

in acute spinal cord injuries, 38-39

with myelography, 198

Lumbar spine, pain on hyperextension of, in

herniated nucleus pulposus, 196

Lumbar spine, wounds of, 21, 29, 35, 47, 50,

59

Lumboinguinal nerve, 349

Lumbosacral spinal cord, wounds of, 19, 30,

115

Lumbrical muscles, 328, 333, 337, 352, 401

paralysis of, in median nerve injuries, 575-

576

Lungs, wounds of, 64

LYONS, Capt. W. R., 220-221, 382, 495

Lymphatic route of renal infection, 102

MAKINS, G. H., 448, 455

Malalinement, in irreparable peripheral

nerve injuries of lower extremity, 570

Malaria:

effect of, in causalgia after peripheral

nerve injuries, 481, 487

in paraplegia, 146, 150

Malar prominences, decubitus ulcers over,

131

MALCOLM, Maj. D. C, 104

Malecot tube, 97

Malingering, suspicion of, in causalgia, 485,

486, 487n

Malleolus, 252

Malnutrition, in—

causalgia, 480

decubitus ulcers, 131, 142

See also Nutritional status.

Malunion, in combined bone-peripheral

nerve injuries, 423

Management, of—

acute spinal cord injuries, 31-65

in ETOUSA, 25-30

in general hospitals overseas, 32-65

in MTOUSA, 20-23

in World War I, 31, 304

of catheter, in cord bladder, 91

of causalgia, after peripheral nerve

injuries, 487-489

combined bone-peripheral nerve injuries,

245-246, 415-428

cord bladder, 22, 30, 61-63, 86-100, 114-

117, 119-125, 176

in World War I, 3, 4, 90, 119

decubitus ulcers, 6, 9, 10, 22, 29-30, 135-

145

epididymitis, 113

fasiclesat operation, 376-377, 381, 382, 395

foreign bodies (bone fragments), at laminectomy, 52-54

herniated nucleus pulposus, 194-202
INDEX 677

Management, of—Continued MCCOUCH, G. P., 68

indwelling catheter, 6, 22, 62 MCCBAVEY, A., 46

neurologic complications, in paraplegia, 6 McDougall's sampling technique, 278

paraplegia, in ZI, 5-18, 127-191 Mclntosh galvanic-faradic testing machine,

peripheral nerve injuries— 561

at debridement, 228, 233-237 Mechanism, of—

in ETOUSA, 239-250 pain in causalgia, after peripheral nerve

in MTOUSA, 233-237, 247 injuries, 475-477

in World War I, 208-210, 231, 234 spinal cord concussion, 35

on Continent, 249 spinal cord injuries, 32-33

peripheral nerve injuries, principles of, Medial antebrachial cutaneous nerve, 310,

304-305 323, 330, 337, 340

periurethral abscess, 113 Medial anterior thoracic nerve, 310

priapism, 114, 173 Medial bicipital groove, 321, 330

peripheral nerve-vascular injuries, 464- Medial brachial cutaneous nerve, 308, 310,

465 322-323, 338, 395

renal calculi in paraplegia, 106-110 Medial calcaneus nerve, 352

renal infection in paraplegia, 103-104 Medial condyle, 342, 343

soft tissue-peripheral nerve wounds, 211, Medial cutaneous nerve, 394

242 Medial epicondyle of humerus, 335, 338,

soft-tissue wounds, 231 339, 340, 395

ureteral calculi, 111 Medial plantar nerve, 352

urethral fistula, 113 Medial sural nerve, 359

urinary calculi, 152-153 Median nerve, 323, 335, 337

vesical calculi, 112 anatomy of, 328, 398

Manometry, in paraplegia, 38, 182 assumption of ulnar nerve function by, 252

Manpower, losses, from herniated nucleus autogenous grafting of, 493

pulposus, 194 causalgia after injuries of, 414, 475

Manual compression, in cord bladder, 61 contraindications to section of, in causalManual examination, in peripheral nerve in- gia, 579

juries, 213 deformity in causalgia, 482

Manual expression of urine, 61, 89, 93, 124 formation of, 308, 328

Manual of Military Urology, 119 injuries, 236, 328-335, 397, 398

Manual of Therapy, ETO, 26-27, 242 clawhand deformity after, 571

Marital status, of paraplegics, 128 closure of wound in, 330, 331, 333

MARTIN, E. G., 256 combined with bone injuries, 238, 416,

Massage, in peripheral nerve injuries, 247, 420

564 combined with radial and ulnar nerve

Mass reflexes, in— injuries, 338

acute spinal cord injuries, 38 combined with ulnar nerve injuries, 576

paraplegia, 162, 181 flexion-relaxation at operation for, 378

MATAS, R., 465 frozen dried homografting in, 503

MATSON, Maj. D. D., 37, 44, 46, 50, 65, 130, positioning at operation for, 335

389 repair of, 303, 394-399, 496-497

Maxillofaeial wounds, 49 repair of, in World War I, 210

Maximum area of anesthesia, in peripheral study of, by handprints, 265

nerve injuries, 267 study of specimens from, 514

Maximum hospital benefits, in— techniques of gaining length in, 335

paraplegia, 5 inner vation of thenar and flexor profundus

peripheral nerve injuries, 221-222, 223- muscles by, 263

224 orthopedic surgery in irreparable injuries

Maximum voluntary pressure, in cord of, 569, 571, 576-578

bladder, 79 overlap of ulnar nerve into area of, 263-

Mayer transplantation operation, 572 264
678 NEUROSURGERY

Median nerve—Continued

physiology of, 328, 333, 394, 396, 399

regeneration, 264

subclavian arterial involvement, in injuries of, 543

surface anatomy of, 328-330

surgical approach to injuries of, 330-333

transplantation of, 335, 395, 396

Medical care, in paraplegia, 13

Medical corpsmen, in paraplegic program,

7,8

Medical Department of the United Slates

Army in the World War, 207, 210, 469

Medical Department, United States Army,

Surgery in World War II, Hand Surgery,

571n

Medical Director, VA, 14

Medical Statistics Division, OTSG, 14

Mediterranean Theater of Operations:

acute spinal cord injuries in, 19-23

herniated nucleus pulposus in, 202-203

peripheral nerve injuries in, 211, 231-

238, 239, 241, 244-246, 247, 249

MBDLEB, Capt. R. E., 116

Meissner's end organs, 271n

Membranous urethra, in cord bladder, 80

Meningitis—

after laminectomy, 58, 65

in acute spinal cord injuries, 39, 43

in paraplegia, 146

Merthiolate, 52

Metallic sutures, in peripheral nerve injuries,

224, 409

Metatarsals, transplantation of extensor

tendons of, 579

Metycaine hydrochloride, 369

Micro-Kjeldahl test, 149

Middle cervical ganglia, 310

Midtarsal arthrodesis, 582, 584

Midtarsal joints, Lambrinudi operation on,

580

Miller-Abbott tube, 63

Mineral oil, effect of—

in decubitus ulcers, 136-137

in paraplegia, 156

on fat-soluble vitamins, 150

Minor causalgia, 473n, 475, 478, 479, 487

MITCHELL, J. K., 489

MITCHELL, S. W., 302, 303, 469, 473n, 474,

478, 479

Mixed nerves:

causalgia in, 475

grafting of, 510

MIXTEK, W. J., 193, 195

Mobilization, of—

peripheral nerves, 207, 219, 305, 376

radial nerve, 326

ulnar nerve, 338, 339

Modesto Junior College, 188 . .-•

Moisture, relief of causalgia by, 479, 480, 481

Morale, of—

casualties with combined bone-peripheral

nerve injuries, 416

paraplegics, 6, 150, 164, 190-191

personnel in paraplegic program, 7, 8

MOBEHOUSE, G. R., 302, 469, 478, 479

Morphine:

for pain in paraplegia, 180

in laminectomy, 49, 57-58

preoperative administration of, in peripheral nerve surgery, 368

Mortality, factors of, in acute spinal cord

injuries, 64-65

Motor cerebral cortex, 399

Motor examinations, in peripheral nerve

injuries, 254, 256

Motor function, testing of, at debridement,

242

Motor paralysis, in—

causalgia after peripheral nerve injuries,

482, 489

combined peripheral nerve-vascular injuries, 440

peripheral nerve injuries, 253

Motor branches, of femoral nerve, 349

Motor power, assessment of, in peripheral

nerve injuries, 251-252

Motor testing, at —

debridement, 242

peripheral nerve surgery, 369, 375

MULHOLLAND, J. H., 148

MULLENIX, R. B., 77, 79

Multiple nerve injuries, incidence of, 238

MUNGER, A. D., 89, 95

MIISCHAT, M., 74

Muscle activity, in relation to peripheral

nerve regeneration, 256

Muscle atrophy:

in combined bone-peripheral nerve injuries, 420

in peripheral nerve injuries, 224, 245, 246

test of, by handprint and footprint,

265-266

Muscle contractures, in causalgia, 482

Muscle deterioration, in peripheral nerve injuries, 272

Muscle stamps, 57
INDEX 679

Musole strength, quantitative assessment of, > Nerve block—Continued

in peripheral nerve injuries, 256-263 in quantitative testing, of muscle strength,

Muscle testing, in peripheral nerve injuries, 263-264

559-562 to eliminate overlap sensation, in periphMuscle tissue, management of, at peripheral eral nerve injuries, 277

nerve surgery, 370 Nerve crushing, in paraplegia, 9

Muscle transplantation, in irreparable nerve Nerve regeneration:

injuries, 570, 579 after frozen dried homografting, 497, 499,

Musculocutaneous groove, 320, 323 512

Musculocutaneous nerve, 328, 353 after homogenous nerve grafting, 493,

anatomy of, 313-316, 393-394 494-495, 497

course of, 314 after neurorrhaphy, 496

exposure in injuries of, 316, 395 after sympathectomy, 488

formation of, 308, 313-314 in median nerve injuries, 264, 397

injuries of, 313-316, 416-420 in peripheral nerve injuries, 220-221, 223,

closure of, wound in, 316 224, 243-244, 251-252, 256, 559

positioning at operation for, 314, 316 combined with vascular occlusion, 458

repair of, 393-394 criteria of, 224-225

study of specimens from, 514 experimental studies on, 302

techniques of gaining length in, 316 studies on, 219-221

involvement of, in median nerve injuries, NESBITT, R. M., 91, 94

394 Neurapraxia. See Contusion.

physiology of, 314 Neurasthenia, as contraindication to work

surface anatomy of, 314 furlough, in peripheral nerve injuries, 223

surgical approach to injuries of, 314-316 Neuraxes, downgrowth of, into distal nerve

MUSE, Capt. W. T., 513 segment, 387

Myelography, 193, 194, 195, 197-198 Neurectomy, in—

MYERS, Capt. W. C, 513 paraplegia, 173

peripheral nerve injuries, 303

Nail changes, in causalgia, 481 Neuritis—

NASH, I. E., 89, 119 after ulnar nerve injury, 342

Nasopharyngeal suction, after laminectomy, as cause of causalgia, 474

58 Neuroanatomy, in peripheral nerve injuries,

NATHAN, P. W., 93 220, 363

Nausea, in— Neurologic complications, in paraplegia, 6

renal calculi, 106 Neurologic examination, in—

renal infection, 102 acute spinal cord injuries, 20, 36-38

Naval casualties, cord bladder in, 94, 117 peripheral nerve injuries, 254-256

Navy followup, of peripheral nerve grafts, wounds of extremities, 208

219n Neurolysis, 231, 238, 239, 243, 244, 247,

Neck: 374-375, 513

anatomy of, 441 after nerve grafting, 219n

posterior triangle of, 305 in brachial plexus injuries, 391, 392

wounds of, 36 in causalgia after peripheral nerve inNELATON, 303 juries, 487

Nembutal, before laminectomy, 49 in combined bone-peripheral nerve inNeostigmine bromide. See Prostigmin. juries, 245, 246, 422, 423, 425, 428

Nephroctomy, 109-110 in incomplete peripheral nerve injuries,

Nephrostomy, 110 541, 547

Nerve block— in neuroma in continuity, 521

as test of regeneration, of frozen dried in sciatic nerve injuries, 409, 410

homografts, 507 in ulnar nerve injuries, 400

in peripheral nerve injuries, 563 in World War I, 210

in priapism, 114, 173 repetitions of, 375
680 NEUROSURGERY

Neuroma:

in combined bone-nerve injuries, 422-423

in continuity, 208, 211, 519-528, 538, 539,

547

of suture line, 228-229

pain in, 486

resection of, 377, 380-381

surgical management of, 375, 384

suture of, 380-381

traction on, 380

See also Pathologic process, Histologie

process, etc.

Neuroma formation—

after amputation, 478

after frozen dried homografting, 509

after median nerve repair, in hand, 399

after primary nerve suture, 232

in causalgia, 473

in common peroneal nerve injuries, 413

in complete peripheral nerve injuries, 518

in musculocutaneous nerve injuries, 316

in peripheral nerve injuries, 536, 537

in radial nerve injuries, 326, 404, 405

in sciatic nerve injuries, 409

Neuromuscular changes, in peripheral nerve

injuries, 557-559

Neuronal cytoplasm, effect of pressure wave

on, 33

Neuropathologic studies—

in peripheral nerve injuries, 207, 211, 219-

221, 244, 363, 513-555

in World War I, 207, 219

on tantalum sutures, 410

Neurophysiology, 363

Neuropsychiatric Consultants Division,

OTSG, 14

Neurorrhaphy, 240, 375-390

after frozen dried homografting, 499, 509

in combined bone-peripheral nerve injuries, 422, 423-426, 428

in combined skin-soft tissue-peripheral

nerve injuries, 77, 429-438

in painful injuries of lower extremities, 579

timelag in, 514-515

See also Early nerve suture, End-to-end

anastomosis, etc.

Neurosurgical centers, 469, 568

causalgia in, 437n, 487

in ETOUSA, 120

in United Kingdom Base, 240, 241, 247

in World War I, 208, 209

in Zone of Interior, 123, 212, 221, 441,

470, 547

management of paraplegics in, 127-191

Neurosurgical centers—Continued

oveiseas, 547, 568

training of personnel in electrodiagnosis

in, 217

See also named and numbered general

hospitals.

Neurosurgical conditions, definition of, 25n

Neurosurgical personnel:

assignment of, 32, 241

in paraplegic program, 122

shortages of, 241-242

training of, 241-242

Neurotization—

after frozen dried homografting, 499, 505,

506, 508, 509, 510

in nerve grafts, 547

See also Pathologic process, Histopathologic process, etc.

Neurotmesis, 559

Neurovascular bundle, in—

arm, 330, 338, 343, 378, 394, 395

axilla, 317, 322, 323, 338, 391, 402

New York University College of Medicine,

147

Niacin, in paraplegia, 150

Ninety-day work furlough, in peripheral

nerve injuries, 223-224

Ninth Service Command, 134

Ninth U.S. Army, 120

Nitrogen balance, in—

decubitus ulcers, 139-140

paraplegia, 71

Nitrogen losses, effect of, in development of

decubitus ulcers, 148-149

Nocifensors, 474

Nondrainage management of cord bladder,

87-90, 99

Nonhemolytic streptococcic renal infections,

in paraplegia, 103

Nonintervention method, in cord bladder, 61

Nonprotein nitrogen levels, in paraplegia, 129

Nonsurgical control, of pain in paraplegia,

180-181

Nonsurgical management, of spastic reflexes

in paraplegia, 180-181

Nonunion, in combined bone-peripheral

nerve injuries, 423

North African Campaign, 231

North African Theater of Operations. See

Mediterranean Theater of Operations.

NOURSE, M. M., 81, 94, 98, 117
INDEX 681

Novooain analgesia, in—

combined bone-peripheral nerve surgery,

422

laminectomy, 50

peripheral nerve repair, 249, 368

Novooain block, in peripheral nerve injuries,

563

Novocain reaction, death after, 250

Novooain sympathetic block, in causalgia,

473n, 486, 488-490

Numbness, in peripheral nerve injuries, 272

Numerical expression of examination results,

in peripheral nerve injuries, 251-253

Nurses, in paraplegic program, 7

Nursing care—

after laminectomy, 48, 57

in acute spinal cord injuries, 22, 23, 63

in decubitus ulcers, 145

in paraplegia, 6, 122, 124, 135, 139, 190

during evacuation, 23, 134

in World War I, 3

Nutritional edema, in paraplegia, 149, 150

Nutritional status, in paraplegia, 6, 12,

146-151

Nylon sutures, in peripheral nerve surgery,

388, 533

Objectives, of—

diagnostic routine, in peripheral nerve injuries, 251, 252-253

paraplegic program, 5-6

Peripheral Nerve Registry, 226-227

Objective techniques of testing, in peripheral

nerve injuries, 213-217

Obstruction, as cause of—

renal calculi, 109

renal infection, 103

Obstruction, caused by calculi, 111

Obstruction, of vesical nock, 124

Obturator, 345

Obturator internus, 351

Obturator nerve:

anatomy of, 407

injuries of, 407

Obturator neurectomy, 183

Occupational therapy, in—

paraplegic program, 11, 22, 122, 187

peripheral nerve injuries, 566-567, 568

Occupational training, in paraplegia, 185-186

Occupations of paraplegics, 128

Office of the Adjutant General, 14

Office of the Chief Surgeon, ETOUSA, 29

Office of the Surgeon General, 8, 14, 17, 18,

151n, 195, 197, 225, 226

Consultant in Neurosurgery in, 127, 243

Officer personnel, herniated nucleus pulposus

in, 198-201

Ointments, in decubitus ulcers, 137

Okinawa, 7

Olecranon process, 335, 340, 343

decubitus ulcers over, 131

Omohyoid, 308, 310

Operating room setup, for peripheral nerve

surgery, 364-365

Operation :

electrostimulation at, in peripheral nerve

injuries, 19, 20, 311, 330, 346, 356, 365,

368, 369, 372-374, 375, 377, 392, 393,

395, 398, 403, 407, 521, 526, 541

positioning at, in—

axillary nerve injuries, 317, 318, 393

brachial plexus injuries, 311, 313, 391,

392-393

combined bone-peripheral nerve injuries, 423, 425

femoral nerve injuries, 346, 350

median nerve injuries, 330, 331, 346,

355, 394, 395, 395-397

peripheral nerve injuries, 305, 365, 367,

384, 536, 539

peroneal nerve injuries, 411

posterior tibial nerve injuries, 359

radial nerve injuries, 322, 323, 325, 326,

402, 404

sciatic nerve injuries, 362, 408, 409, 425

tibial nerve injuries, 412, 414

ulnar nerve injuries, 338, 339, 340

use of identification sutures at, 253, 364,

376, 384, 519

Opponens paralysis, 225

Opponens Pollicis, 328

Orthopedic consultation, in—

herniated nucleus pulposus, 195

paraplegia, 22, 129

Orthopedic management, of combined bonenerve injuries, 244-246, 415-428

Orthopedic preparation, in—

combined bone-nerve surgery, 427

peripheral nerve surgery, 367

Orthopedic surgeons:

direction of physical therapy by, in peripheral nerve injuries, 557

role of:

in paraplegic program, 122, 176, 190

in peripheral nerve injuries, 209, 212,

224, 244-246, 415-428
682 NEUROSURGERY

Orthopedic surgery, in—

irreparable peripheral nerve injuries, 569-

585

paraplegia, 13

Oscillometry, in causalgia, 474-475

Osteomyelitis—

associated with deeubitus ulcers, 131

in paraplegia, 146

of pubis, 62

Osteoporosis, in—

causalgia, after peripheral nerve injuries,

474, 477-478, 485, 486

paraplegia, 129, 147

Osteotomy of metacarpals, 577

Overflow bladder incontinence, in acute

spinal cord injuries, 36, 61, 69, 70, 87-

90, 99

in female, 119

Overlap areas, in peripheral nerve injuries,

252, 267-268

Overlap compensation, in peripheral nerve

injuries, 559

Overlap muscle injuries, 266

Overlap of ulnar nerve, into median nerve

area, 264

Overlap sensation, in peripheral nerve injuries, 277

Overriding, of—

clavicle, in brachial plexus injuries, 305,

313

humerus, in peripheral nerve injuries, 380

Oversea hospitals, Peripheral Nerve Registry

in, 225, 226

Pacific Ocean Areas, 7

Pain and touch points, estimation of, in

peripheral nerve injuries, 276

Pain, in—

acute spinal cord injuries, 35, 36, 49, 178-

184

causalgia, after peripheral nerve injuries,

470-473, 473n, 474-475, 476, 478-480,

485-487, 488, 489-490

mechanism of, 475-477

relation of trophic changes to, 481

relation of vasomotor changes to, 481

herniated nucleus pulposus, 196, 203

incomplete peripheral nerve lesions, of

lower extremity, 579

paraplegia, 9, 10, 18, 178-184

renal calculi, 105, 152

renal infection, 102, 103

Pain sensation, in peripheral nerve injuries,

273, 280

quantitative estimation of, 273-274

testing of, 266-272

Pain threshold, in causalgia, 485

Palmar cutaneous nerve, 331

Palmaris—

brevis, 337, 342

longus, 328, 331, 574

longus tendon, 328, 331, 333

Pantopaque myelography, 193, 197-198

Papaverine hydrochloride, in causalgia, 487

Paradoxical vasoconstriction, in peripheral

nerve injuries, 280

Paraldehyde, after laminectomy, 57

Paralysis:

below knee, orthopedic surgery for, 579-

580

onset of, in spinal cord injuries, 35

Paraplegia:

according to branch of service, 127

adjunct nutritional measures in, 150-151

administrative policies in, 5-8

age factor in survival in, 12-13n

air evacuation in, 120, 134

albumin-globulin ratio in, 149

ambulation in, 5-6, 10, 15-16, 86, 87, 95,

110, 124, 139, 147, 152, 163, 164-173,

176, 179

amputation in, 183-184

amyloidosis in, 12n

anemia in, 11

anorexia in, 12, 146

blood chemical studies in, 129

blood replacement in, 150, 175

blood studies in, 149, 150

bowel function in, 6, 13, 151, 153-157

braces in, 10, 13, 116, 162, 165, 167-168,

176, 177

calculus formation in, 122, 129, 147, 152-

153

case fatality rates in, 12-13n, 123

cathartics in, 153

causes of death in, 11-12, 90

changes of position in, 22, 23, 29, 108,

130-135

civilian management of, 127

crutches in, 13, 167-168

cystometry in, 98

cystoscopy in, 98

debilitation in, 12, 131, 134

deeubitus ulcers in, 6, 9, 10, 13, 18, 22,

29-30, 71, 87, 89, 90, 99, 108, 119, 130-

145, 146
INDEX 683

Paraplegia—Continued Paraplegia—Continued

depression in, 17 rehabilitation in, 11, 61, 160, 184-186

dietary management in, 9, 149-151, 175 renal calculi in, 104-110

economic considerations in, 17 renal infection from decubitus ulcers in,

emaciation in, 11 102

emotional considerations in, 158-162 renal insufficiency in, 12n

epididymitis in, 112 research in, 14

etiology of, 127-128 roentgenologic examination in, 129, 182

euphoria in, 17 septicemia in, 12

evacuation in, 23, 27, 29, 30, 50-51, serum protein levels in, 149

120-121, 131-135 skin care in, 134, 135

family relations in, 16-17 social factors in, 128-129

followup studies on, in VA, 187n somatic approach in, 6

footdrop in, 22 spastic reflexes in, 18, 178-184

furloughs in, 185 statistics of, 18, 30, 122-123, 127-129, 165,

general medical care in, 13 187, 187n

hematocrit determinations in, 149 in VA hospitals, 12-13n

history-taking in, 129 studies on, in VA hospitals, 81n, 152n

impotence in, 114 surgery in, 9, 13, 18

in civilian practice, 146 urethrography in, 98

laboratory examinations in, 129 urinalysis in, 72-73

lack of resistance to infection in, 12 urinary tract complications in, 13, 18, 30,

mass reflexes in, 162 70, 71, 86, 87, 146

neurologic complications in, 6 as cause of death, 114-115

nitrogen balance in, 71 urologic management in, 6, 9, 13, 18, 29,

nursing care in, 122, 124, 135, 139 30, 67-125, 134, 151-153, 189

during evacuation, 134 vitamin supplements in, 150, 175

in World War I, 3 vocational training in, 7

nutritional edema in, 149, 150 weight loss in, 146

nutritional status in, 6, 12, 146-151 wheelchair existence in, 5, 116

obturator nerve surgery in, 407 work tolerance in, 16

occupational therapy in, 11, 12, 187 See also Acute spinal cord injuries, injuries

occupational training in, 185-186 in special parts of spine, etc.

orthopedic surgery in, 13 Paraplegic centers:

pain in, 9, 10, 18, 36, 178-184 physical specifications for, 8, 9, 13-14, 17

personal hygiene in, 157-158, 165 recordkeeping in, 153, 163, 173, 177, 178,

physical examination in, 129 189n

physical reconditioning in, 7, 10, 13-14, surveys of, 6-7, 8-11

162-164, 177 Paraplegic program, 5-18, 127-191

physical therapy in, 7, 13, 32, 163, 180 chaplains in, 190

plasma protein levels in, 12, 147, 148, 149 conferences on, 6, 7-8, 13-14, 127, 133-

plasma transfusions in, 150-151 134, 161, 184

plastic surgery in, 18 equipment for, 8, 9

post mortem examination in, 11-12 hospital conferences in, 6

prewar management of, 5 hospital organization in, 6, 163

priapism in, 38, 91, 101, 113, 173 medical corpsmen in, 7, 8

prognosis in, 15-17 nurses in, 7

protein deficits in, 12, 145, 146, 147-150 objectives of, 6

protein replacement in, 29, 150 personnel in, 6-8, 11, 13-14, 17-18, 122,

psychiatric factors in, 6, 146, 158-162, 186 189-190

psychologic considerations of amputation physical therapists in, 7, 189

in, 184 physician-patient relations in, 188-190

psychologic testing in, 185 results of, 186-188

psychotherapy in, 22-23 transfer of, to VA, 5, 7, 13-18, 123

^(lOOftlv Kf\ A-7 fiHoyji —ow ^t 1
684 NEUROSURGERY

Paraplegic program—Continued Pathologic process, in—Continued

vocational instructors in, 190 See also Histopathologic process, Fibrosis,

WAC's in, 7-8 Neurotization, etc.

Paraplegics: PATTERSON, Col. R. H., 7, 8

beds for, 8 Pectineus, 344, 350

continuation of education by, 17, 185-186 Pectoralis—

educational level of, 7, 17, 129 major, 310, 317, 328, 338, 391, 392, 393

family care of, 15, 16-17, 160 minor, 310, 392

indications for transfer of, to VA, 5, 13-14 Pedicle flaps, in combined peripheral nervemanagement of, in ZI hospitals, 127-191 skin-soft tissue injuries, 421, 429, 430-

morale of, 6, 150, 164, 190-191 432

previous occupations of, 128 Pelvis, exposure of femoral nerve injuries in,

rating of, in AGCT, 129, 160, 186 346-349

recreation for, 184—185 Penalgesia, 269

survey of, in ZI hospitals, 14-17, 127-129, Penetrating wounds—

160, 186 as cause of causalgia, 475

Paravertebral block, in paraplegia, 180, 181 in gluteal area, 354

Paresthesia— of spine, 33, 35, 38-39

after frozen dried homografting, 503 Penicillin, in—

in acute spinal cord injuries, 37 acute spinal cord injuries, 35, 39

in herniated nucleus pulposus, 196 combined peripheral nerve-bone injuries,

in irreparable peripheral nerve injuries, 580 254, 421, 427

in peripheral nerve injuries, 272 decubitus ulcers, 137, 138, 140

in ulnar nerve injuries, 576 epididymitis, 1J3

PARKER, Lt. Col. J. M., 238 peripheral nerve injuries, 234

Partial nerve suture, 376-377 periurethral abscess, 113

Partial spinal cord injuries. See Incomplete postlaminectomy meningitis, 58, 65

transection of spinal cord. primary nerve suture, 232

PASTEUR, L., 303 renal infection, 103, 104

Patella: urinary tract complications, of spinal indecubitus ulcers over, 131 juries, 22, 125

resection of, in combined injuries, 426 Penile turgescence, 38

Pathologic anatomy, in peripheral nerve Penoscrotal abscess, 113

injuries, 370-372 Penoscrotal fistula, 90-91, 97

Pathologic fractures, in paraplegia, 147 Pentobarbital sodium. See Nembutal.

Pathologic physiology, in— Pentothal sodium anesthesia, for—

cord bladder, 67-71 laminectomy, 50

peripheral nerve injuries, 269 peripheral nerve surgery, 369

spinal cord injuries, 32-33 Perforating wounds, of—

Pathologic process, in— hollow viscera, 147

acute spinal cord injuries, 32-34 spine, 33

brachial plexus injuries, 391 Periarterial neurectomy, 488

causalgia, after peripheral nerve injuries, Perineal urethrostomy, 62, 97

473-474 Perineurial fibrosis, 374

combined peripheral nerve-vascular in- Peripheral nerve-bone injuries, 232, 242, 244-

juries, 465 246, 247, 304, 415-428, 558, 563, 564

combined radial nerve-humerus injuries, in World War I, 208

403 physical therapy in, 563, 564

decubitus ulcers, 59, 131 Peripheral Nerve Commission, in World War

infection, in paraplegia, 11 1,209

median nerve injuries, 394 Peripheral nerve concussion, 465

peripheral nerve injuries, 304, 557-559 Peripheral Nerve Conference, 230

combined with vascular occlusion, 458 Peripheral nerve contusion, 253, 454, 465,

peripheral nerve-vascular injuries, 454 550, 588-589
INDEX 685

Peripheral nerve ends:

preparation of, for suture, 382-383

visualization of, at debridement, 242

Peripheral nerve fibers, interaction of impulses between, 476

Peripheral nerve grafts, 218-219, 229, 236,

375-376, 381-382, 390, 493-512, 547

end-to-end anastomosis after, 219n, 376

histopathologic studies on, 543-555

In World War I, 219, 493

plaster fixation after, 570

registration of, in Peripheral Nerve Registry, 226-228

statistics of, 218-219, 219n

Peripheral nerve injuries, 207-585

administrative considerations in physical

therapy in, 557

assessment of sensory status in, 251-252

bone shortening in, 305, 496

causalgia after, 469-492

civilian type of, 363-364

classification of, 363-364

combined with vascular occlusion, 458-464

compass test in, 277-279

complicated by other injuries, 241

delayed primary wound closure in, 242,

252, 562, 563

determination of superficial pressure in,

275-276

diagnosis of, 251-300

diagnostic procedures in, 212-217

disposition in, 221-225, 241

early motion in, 562-563

edema in, 562, 563, 564, 565

electrodiagnosis in, 251, 266, 560-562, 567

evacuation of casualties with, 240-241

evaluation of, at operation, 372-374

evolution of, management of, 211-230,

231-237, 239-247

experimental studies on, 207, 211, 218,

219, 239, 243, 246, 302, 381, 495, 515,

557, 564, 566

followup in, 221-230

in Peripheral Nerve Registry, 225-230

histopathologic process in, 239, 513-555

historical note on, 207-210, 301-304

history-taking in, 253-254

hospitalization policies in, 221-225

in Civil War, 302-303

in civilian practice, 239

in ETOUSA, 211, 239-250

in MTOUSA, 211, 231-238, 239, 241

in paraplegics, 146

in Sino-Japanese War, 302

Peripheral nerve injuries—Continued

in World War I, 207-210, 225, 231, 301,

302, 303-304

incidence of, 128, 194, 194n, 211, 212, 225,

493

initial wound surgery in, 31, 208, 233-237,

242-243, 250, 304-305, 364, 376, 403

joint changes in, 558, 562-563, 565

late exploration in, 239

localization of, 305-308

localization of returning sensation in, 277

management of, 251-585

muscle testing in, 559-562

neurologic examination in, 254-256

neuromuscular changes in, 557-559

objectives of examination in, 252-253

occupational therapy in, 566-567, 568

orthopedic surgery in irreparable types of,

569-585

pathologic process in, 219-221, 239, 304,

513-555, 557-559

physical therapy in, 1, 5-9, 209, 223, 224,

245, 246-247, 250, 557-568

physiologic pathology of, 557-559

postoperative management in, 244, 426-

428, 431, 498

preoperative preparation in, 365-367

primary suture in, 222, 228, 231-233, 239,

242, 303, 415

principles of management of, 208, 211-212,

233-237, 242-244, 304-305

priority of evacuation in, 222, 240

psychologic factors in, 567

records in, 242-243, 253-256, 259, 261-263,

273, 274, 275-276, 277, 278-279, 282,

364, 557, 560

at Cushing General Hospital, 254-256

regeneration in, 219-221, 223, 224-225,

243-244, 251-252, 256, 264, 302, 397,

458, 488, 493, 494-495, 496, 497, 499,

512, 559

roentgenologic examination in, 224, 242,

243, 254, 376, 389

sensory patterns in, 212, 213-217

sensory testing in, 266-272

skin temperature tests in, 280-282

splinting in, 235, 236-237, 242, 246, 420-

421, 563, 565-566

spontaneous regeneration in, 211, 224,

239, 253, 301, 373-374, 448

statistics of, in—

ETOUSA, 237-238

MTOUSA, 247-250

Peripheral Nerve Registry, 228-229
686 NEUROSüRGERY

Peripheral nerve injuries—Continued

stretch fibrosis in, 541-543, 558

supplementary motor movements in, 212

suture material in, 388-389, 533-535

sweat tests in, 279-280

symptoms of, 280

techniques of—

examination in, 251-300

physical therapy in, 562-568

repair in, 242-244, 246, 249, 301-467

timing of surgery in, 211, 231, 233, 234,

235, 239-242, 363-364, 375, 515, 519,

531-533

Tinel's sign in prognosis of, 212-213, 224,

272-273, 428, 519, 531, 547, 555

trick movements in, 261, 263-264, 568

unnecessary exploration in, 243

vascular changes in, 558, 559

vasomotor disturbances in, 562

work furloughs in, 223-224, 254, 268

wound infections in, 241, 246

See also special nerves, special injuries,

special combinations of injuries, etc.

Peripheral nerve-joint injuries, 304

Peripheral nerve laboratories, 212

Peripheral nerve lesions, in continuity,

219, 237-238

Peripheral nerve regeneration. See Pathologic process, Histopathologic process,

Neurotization, etc.

Peripheral Nerve Regeneration, 213n, 230,

439, 495n

Peripheral Nerve Registry, 211, 221, 223,

225-230, 381, 439, 463

in World War I, 209-210

Peripheral nerve repair:

disruption of suture line after, 228, 243,

244, 416, 519, 533, 539-541

techniques of, 363-428

Peripheral nerve resection, in causalgia, 488,

579

Peripheral nerve-soft tissue injuries, 211,

242, 253, 429-438

in World War I, 208

Peripheral nerve surgery:

anesthesia for, 368-369

setup of operating room for, 364-365

positioning at, 305, 311, 313, 314, 316,

317, 318, 330, 331, 335, 346, 350, 354,

359, 393, 394, 395, 402, 404, 408, 409,

411, 412-414, 423, 424, 430, 536, 539

Peripheral nerve suture, failures of, 228-229,

236

Peripheral nerve-tendon injuries, 304

Peripheral nerve transplantation, 207, 219,

236, 243, 305, 379-380, 536, 547, 550, 551

Peripheral nerves:

anatomic approaches to, 301-362

erosion of, by aneurysms, 519, 528-530

mobilization of, 207, 219, 305

Periurethral abscess, 90, 97, 113, 122

Peroneal artery, 352

Peroneal component, of sciatic nerve, 410

Peroneal nerve:

anatomy of, 407, 409-410, 581

autogenous grafting of, 494

injuries of:

equinus (equinovarus) deformity after,

580

failures of suture of, 581

Lambrinudi operation after, 580

orthopedic surgery after, 581-584

study of, by footprints, 266

irreparable injuries of, 581-584

Peroneal nerve-vascular injuries, 455

Peroneal palsy, 407-408

Peroneus—

brevis, 353, 361

longus, 353, 358, 362

tertius, 353

Personal hygiene, in paraplegia, 157-158,165

Personality changes, in causalgia, after

peripheral nerve injuries, 482, 485

Personnel Division, OTSG, 18

Personnel, in—

paraplegic program, 6-8, 11, 13-14, 17-18,

122, 189-190

shortages of, 7

training of, 6-8

peripheral nerve program:

in physical therapy sections, 568

training of, in electrodiagnosis, 217

PBTEOFF, Maj. B. P., 9, 84, 85, 102, 103, 104,

116

Petrolatum-impregnated ointments, in decubitus ulcers, 137, 138

Phantom limb, 477-478, 486, 487

Phenolsulfonphthalein test, in cord bladder,

124

PHILLIPEAUX, 303

Phosphomolybdic acid-aniline blue mixture,

514, 518

Phosphorus blood levels, in paraplegia, 129

Photomicrography, in peripheral nerve injuries, 221, 515-516, 526

Phrenic nerve, 312

Physical examination, in paraplegia, 129
INDEX 687

Physical stimuli, in causalgia, after peripheral

nerve injuries, 479, 482-485

Physical therapists, in paraplegic program,

7, 18, 122, 189, 568

Physical therapy:

after tibialis posticus transplantation, 584

diagnostic use of, in peripheral nerve injuries, 1, 5-9, 213, 557, 559-562, 568

effect of, in causalgia, 470

in combined bone-peripheral nerve injuries, 245, 250, 420, 421, 426

in median nerve injuries, 398

in paraplegia, 7, 13, 22, 163, 180

in peripheral nerve injuries, 223, 224, 246-

247, 557-568

in World War I, 209

psychologic factors in, 557, 564, 568

techniques of, in peripheral nerve injuries,

562-568

Physician-patient relations, in paraplegic

program, 188-190

Physiologic basis, of—

compass test in peripheral nerve injuries,

277-278

nerve suture, 303

Physiologic pathology, in—

acute spinal cord injuries, 45, 169-170

median nerve injuries, 576-577

peripheral nerve injuries, 1, 2-4, 557-559

radial nerve injuries, 573-575

Physiologic salt solution, injection of, into

distal nerve segment, 374, 384

Physiology, of—

axillary nerve, 317

bladder, 80

brachial plexus, 308, 311

cauda equina, 182

deep peroneal nerve, 353

femoral nerve, 344-345

lateral plantar nerve, 353

medial plantar nerve, 352

median nerve, 328, 333, 394, 396, 397, 399

musculocutaneous nerve, 314, 353

proper volar digital nerve, 333

radial nerve, 320, 326, 399

sural nerve, 352

ulnar nerve, 340

upper extremity, 304-305

PICKERING, G. W., 474

PILCHEB, C, 34

Pinch grafts, in decubitus ulcers, 143

Piperocaine hydrochloride. See Metycaine

hydrochloride.

Piriformis, 350, 356, 409

Pisiform bone, 335, 340, 342

Pitressin, 63

PLAGGEMEYEB, H. W., 80

Plantar fasciotomy, 579

Plantar response, in acute spinal cord injuries, 38

Plantar ulcers, 570

Plantaris, 352

Plasma:

local application of, to decubitus ulcers, 30

protein levels, in paraplegia, 12, 147, 148,

149

replacement, of protein deficits, in paraplegia, 150-151

transfusion after laminectomy, 57

in acute spinal cord injuries, 36, 63

in combined bone-peripheral nerve injuries, 421

in paraplegia, 150-151

in renal infection, 103

Plasma clot anastomosis, in peripheral nerve

surgery, 389-390

Plasma clot sheath, in peripheral nerve surgery, 243

Plasma glue technique, of nerve grafting, 498

Plaster fixation:

after combined bone-peripheral nerve

surgery, 422, 564

after combined peripheral nerve-plastic

surgery, 431

after femoral nerve surgery, 407

after combined peripheral nerve-tibial

surgery, 421

after frozen dried homografting, 498

after peripheral nerve surgery, 366-367,

384, 563, 566

after peroneal nerve surgery, 581

after sciatic nerve surgery, 409

after tibialis posticus transplantation, 584

muscle changes caused by, in peripheral

nerve injuries, 558

risks of, in combined peripheral nervevascular injuries, 464

Plaster shells, in evacuation of paraplegics,

22,23

Plaster shoulder spicas, in combined boneperipheral nerve surgery, 404

Plastic repair, of soft-tissue injuries, 241

Plastic surgeons, cooperation of, in peripheral

nerve injuries, 224-225, 429-432

Plastic surgery, in—

combined bone-peripheral nerve injuries,

246
NEUROSUKGERY

Plastio surgery, in—Continued

combined peripheral nerve-skin-soft tissue

injuries, 429-438

deeubitus ulcers, 9-10, 131, 135

paraplegia, 18

peripheral nerve injuries, 304

periurethral abscess, 113

PLATI, J. T., 193

PLATT, H., 207, 303, 305

Pneumonitis, in paraplegia, 146

POEK, Col. D. H., 189

Poliomyelitis, 558

POLLOCK, L. J., 207, 213, 256, 265, 273, 303,

441, 470, 489, 561

POOL, Lt. Col. J. L., 37, 43, 44, 65, 130

Popliteal nerve injuries, in World War I, 210

Popliteal space, 351, 353, 357-359, 361

combined peripheral nerve-vascular

injuries in, 455

exposure of common peroneal nerve

below, 360-362

exposure of common peroneal nerve in,

357-359

exposure of tibial nerve in, 357-359

Popliteal vessels, 351, 358

Popliteus, 351, 352, 358

Position sense, in peripheral nerve injuries,

testing of, 266-272

Positioning, after laminectomy, 58-59

Positioning, at operation for—

axillary nerve injuries, 314, 317, 3i8, 393

brachial plexus injuries, 311, 313, 391,

392-393

combined bone-peripheral nerve injuries,

423, 425

combined peripheral nerve-plastic surgery,

430

combined sciatic nerve-femoral injuries,

425

femoral injuries, 346, 350

median nerve injuries, 330, 331, 335, 394,

395, 396-397

musculocutaneous nerve injuries, 316

peripheral nerves injuries, 305, 365, 367,

378-379, 536, 539

peroneal nerve injuries, 411

posterior tibial nerve injuries, 359

radial nerve injuries, 322, 323, 325, 326,

402, 404

sciatic nerve injuries, 354, 362, 408, 409

spinal cord injuries, 50, 51

tibial nerve injuries, 412, 414

ulnar nerve injuries, 338, 339, 340

Positioning of paraplegics, for—

transportation, 29, 35

defecation, 155

Positive pressure anesthesia, 51

Posterior bone blocks, in irreparable

peripheral nerve injuries, 580

Posterior brachiocutaneous nerve, 320

Posterior cervical triangle, 308, 310

Posterior femoral cutaneous nerve, 356

Posterior interosseous, 405

Posterior interosseous artery, 320, 326

Posterior interosseous nerve, 405

Posterior tibial artery, 352, 413

Posterior tibial nerve, 325, 353

anatomy of, 352-353

causalgia after injuries of, 414

closure of wound in injuries of, 359

exposure of, 359

grafting of, 546

repair of injuries of, 412-414

study of specimens from, 514

Posterior tibial vessels, 352, 359, 413

Posterior triangle of neck, 305

Post mortem examinations, in paraplegia,

11-12

Post mortem studies, in herniated nucleus

pulposus, 194

Postoperative case fatality rates, in acute

spinal cord injuries, 65

Postoperative complications, in combined

bone-peripheral nerve injuries, 426-428

Postoperative management—

after combined peripheral nerve-plastic

surgery, 431

after frozen dried nerve grafting, 498

after laminectomy, 48-49, 57-61

after peripheral nerve surgery, 244

in deeubitus ulcers, 145

Posttraumatic dystrophies, 477-478

Potassium permanganate solutions, for bladder irrigations, 94

Potentiometric skin temperature test, 281

POTTER, Capt. S. E., 389, 513

Potter-Croce technique, in combined boneperipheral nerve injuries, 421, 430-431

Poupart's ligament, 344, 346

POWELL, V. E., 279

PBATHEB, Lt. Col. G. C, 72, 79, 80, 84, 85,

102, 103, 104, 110, 112, 116, 117

Preganglionic dorsal sympathectomy, 488-

489

Preinduction herniated nucleus pulposus,

194, 196-197, 200
INDEX 689

Preoperative evaluation, of— Prognosis, in—Continued

femoral nerve injuries, 407 combined peripheral nerve-vascular inperipheral nerve injuries, 365-366 juries, 442-443, 458, 463

Preoperative exercises, in— combined vascular-cranial nerve injuries,

peripheral nerve injuries, 305 447-448

sciatic nerve injuries, 362 herniated nucleus pulposus, 197

Preoperative infection, in combined bone- incomplete transection of spinal cord, 45

peripheral nerve injuries, 426-427 paraplegia, 15-17

Preoperative management, of combined peripheral nerve injuries, 272-273

bone-peripheral nerve injuries, 420-421 radial nerve injuries, 573

Preoperative medication, before— sciatic nerve injuries, 362

laminectomy, 49 spinal cord concussion, 47

peripheral nerve surgery, 368 ulnar nerve injuries, 575-576

surgery, in decubitus ulcers, 139-140 Pronation deformity, in radial nerve injuries,

Preoperative preparation, in peripheral nerve 575

injuries, 365-367 Pronator—

Preparation of surgical field, for laminecto- quadratus, 328

my, 51-52 radii teres, 574

Prepared bed technique, in frozen dried teres, 328, 331, 335, 343, 397

homografting, 498, 508-509 Prone position, in transportation of paraPresacral nerve, resection of, in cord bladder, plegics, 29

122 Proper volar digital nerves, 333

Pressure points, protection of: Prophylactic antimicrobial therapy, in—

after laminectomy, 59 acute spinal cord injuries, 22

in acute spinal cord injuries, 63 cord bladder, 32

in decubitus ulcers, 131 Proprioceptive power, 169

Pressure waves, effects of, in concusssion Prostatic complications of cord bladder, 97,

spinal cord injuries, 33 112

Prevention of— Prostatic urethra, in cord bladder, 80-81,

complications, in acute spinal cord injuries, 82, 85

35 Prostigmin bromide, 63

decubitus ulcers, 6, 23, 29-35, 51, 59, Protection, of—

134-135, 155 flexion creases at operation, 328, 401, 406,

Priapism, 38, 91, 101, 113, 173 411

Primary nerve suture, 228, 231-233, 242, suture line after peripheral nerve repair,

303, 415 243, 386-388

in civilian injuries, 239 Protein deficit, in—

in World War I, 208 decubitus ulcers, 9, 10, 63, 135, 145, 146,

statistics of, 232-233 147-150

Primary wound healing, in peripheral nerve paraplegia, relation of infection to, 12,

injuries, 249 144-149

Principles of early nerve suture, 208, 211- Protein hydrolysates, 151

212, 233-237, 242-244, 304-305 Protein replacement, in paraplegia, 29, 150

Priority of evacuation, in— Protein-sparing diet, in paraplegia, 150

acute spinal cord injuries, 26, 240 Protein supplements, in combined bone-nerve

head injuries, 240 injuries, 421

paraplegia, 133, 134 Proteus vulgaris renal infections, in paraperipheral nerve injuries, 222, 240 plegia, 72, 102-103

Procaine hydrochloride. See Novocain. Proximal segment, management of, in peProfunda artery, 320, 323, 325 ripheral nerve surgery, 382-383

Prognosis, in— Pseudomonas aeriiginosa infection, in paraacute spinal cord injuries, 21, 25, 26-27, plegia, 72, 103

31, 33, 37, 55 Pseudomonas infection, in decubitus ulcers,

ambulation in paraplegia, 169 137, 140
690 NEUROSURGERY

Psoas, 343, 344, 346, 347, 350

Psoas abscess, in paraplegia, 146

Psychiatric care, after laminectomy, 59-61

Psychiatric factors, in paraplegia, 158-162

Psychogenic factors, in causalgia, after peripheral nerve injuries, 482-485, 486, 488

Psychologic factors, in—

paraplegia, 6, 146, 184, 186

peripheral nerve injuries, 567

physical therapy, in peripheral nerve injuries, 557, 564, 568

Psychologic testing, in paraplegia, 185

Psychoneurosis:

as contraindication to work furlough, in

peripheral nerve injuries, 223

relation of, to causalgia, 478

Psychotherapy, in paraplegia, 22-23

Pubis:

infection of, in suprapubic cystostomy, 97

osteomyelitis of, 62

Pulmonary complications, in acute spinal

cord injuries, 32

Pulmonary edema, as cause of death, in

acute spinal cord injuries, 65

Pulsating hematoma, in combined peripheral

nerve-vascular injuries, 440

Pyelitis, in paraplegia, 72, 73

Pyelography, 106

Pyelonephritis, 101, 146

Pyonephrosis, 110

Pyuria, in paraplegia, 72

Quadratus lumborum, 343

Quadriceps—

exercises, after femoral nerve surgery, 407

paralysis of, 579

Quadrilateral space of Velpeau, 317, 318, 393

Quadrirjlegia, 12-13n

Qualitative determination, of—

areas of impaired sensation, in peripheral

nerve injuries, 273

returning sensory function, 272-273

Qualitative examinations, in peripheral nerve

injuries, 254

Quantitative assessment, of muscular

strengtti, in peripheral nerve injuries,

256-263

Quantitative determinations, of—

pain sensation, in peripheral nerve injuries, 273-274

superficial pressure (touch), in peripheral

nerve injuries, 275-276

Quantitative estimation, of recovery, in peripheral nerve injuries, 213

Quantitative examinations, of motor function, in peripheral nerve injuries, 256

Queckenstedt test, 26, 38, 182

Radial crease, 333

Radial extensor muscles, 321

Radial nerve: 317, 323

anatomy of, 318-321, 404-405, 573

assumption of ulnar nerve function by 252

branches of, 320, 321

cable sural autograft of, 546-547

course of, 318-320

formation of, 308, 328

injuries of, 318-327, 541-543

associated with bone injuries, 238, 256,

416-420, 573, 574

bone shortening in, 380, 404

closure of incision in, 322, 323, 325, 326

flexion-relaxation at surgery for, 378

positioning at operation for, 322, 323,

325, 326

prognosis in, 573

repair of, 401-406

study of, by handprints, 266

study of specimens from, 514

surgical approach to, 322-326

techniques of gaining length in, 326

irreparable injuries of, 573-575, 581

physiology of, 320, 326, 399

surface anatomy of, 321

transplantation of, 326, 403-404, 423, 428

Radiopacity of tantalum, 380, 389

Radius:

bicipital tubercle of, 331

fracture of head of, 405

fractures of, associated with—

peripheral nerve injuries, 328, 420

radial nerve injuries, 326

resection of head of, in combined bonenerve injuries, 423

Radius and ulna, peripheral nerve, injuries

associated with fractures of, 238

RAINES, Maj. S. L., 102, 103, 112

RAMON Y CAJAL, 514

Rank, relation of paraplegia to, 128

RANKIN, Brig. Gen. F. W., 5, 8, 195, 225

RAPPAPORT, Capt. H., 11, 12

RASMUSSEN, Lt. Col. T. B., 473n

Reaction, to—

Pantopaque myelography, 198 sutures,

in peripheral nerve injuries, 533-535

Reconditioning centers, causalgia in, 470

Reconditioning, in paraplegia, 7, 10, 13-14,

164, 177
INDEX 691

Reconditioning system, effect of, in herniated

nucleus pulposus, 201

Records, at spinal operations, 51

in acute spinal cord injuries, 38

in decubitus ulcers, 135

in paraplegic centers, 130, 153, 163, 173,

177, 178, 189n

in peripheral nerve injuries, 299, 233, 238,

242-243, 253, 256, 259, 261-263, 273,

274, 275-276, 277, 278-279, 282, 364,

560, 557

at Cushing General Hospital, 254-256

of Peripheral Nerve Registry, 225-228

in World War I, 209

Recreation, for paraplegics, 184-185

Recumbency, as cause of renal calculi,

104-105

Recurrence of—

causalgia, after peripheral nerve injuries,

490

renal calculi, in paraplegia, 108, 110

Recurrent tibial nerve, 353

Red blood bell paste, in decubitus ulcers,

137-138

Reduction of fractures, in combined boneperipheral nerve injuries, 245

Reeducation of transplanted muscles, 577

Reexploration, after—

definitive peripheral nerve surgery, 547

frozen dried homografting, 498, 499-501

Reflex arc, in bladder wall, 69, 71

Reflex automatic bladder, 13, 63, 67, 69, 70,

71, 79, 121, 123, 176

after intermittent catheterization, 114

after tidal drainage, 115-117

cystography in, 81-82, 83-84

development of, 61-63, 76-79, 93

effect of drugs on, 94

effect of level of injury on, 117-118

noncatheter achievement of, 89

renal function in, 100

resection of bladder neck in, 97-98, 99,

117, 122, 124, 125

urethrography in, 85

Reflex paralysis, in causalgia, after peripheral

nerve injuries, 489

Reflex responses, in acute spinal cord injuries, 38

Reflexes, suppression of, after acute spinal

cord injuries, 68, 74

Refracture, in combined peripheral bonenerve injuries, 423, 425

Regional anesthesia, in peripheral nerve

surgery, 369

Regional consultants in neurosurgery, in

ETOUSA, 241

Regional distribution, of combined peripheral

nerve-vascular injuries, 439

Regional incidence—

combined bone-peripheral nerve injuries,

246

peripheral nerve injuries, 237

Regrafting with frozen dried homografts, 498

Rehabilitation of paraplegics, 6, 11, 61, 160,

184-186

Rehydration of frozen dried homografts, 496

Removal suture technique, in peripheral

nerve surgery, 389

Renal calculi in paraplegia, 104-110

management of, 106-110

recurrence of, 108-110

surgery in, 108-110

Renal complications, of cord bladder, 101-

110

Renal function studies, in cord bladder, 124

Renal infection:

antimicrobial therapy in, 103-104

associated with calculi, 106-108, 110, 111

diagnosis of, 102-103

in acute spinal cord injuries, 101, 104

surgery in, 125

Renal insufficiency, in paraplegia, 12n

Repair, of—

axillary nerve injuries, 393

brachial plexus injuries, 391, 393

combined bone-nerve injuries, 245, 415-

428

digital nerve injuries, 399

femoral nerve injuries, 406-407

median nerve injuries, 394-399

in World War I, 210

musculocutaneous nerve injuries, 393-394

obturator nerve injuries, 407

peripheral nerve injuries, in relation to

type of wound, 363-364

peroneal nerve injuries, 411-412

popliteal nerve injuries, in World War I, 210

radial nerve injuries, 401-406

sciatic nerve injuries, 407-410

in World War I, 210

tibial nerve injuries, 412-414

ulnar nerve injuries, 395, 396-397, 400-401

in World War I, 210

Replacement therapy, in—

acute spinal cord injuries, 36

peripheral nerve surgery, 367

renal infection, 103
692 NEÜROSURGERY

Resection, of—

bladder neck, in paraplegia, 97-98, 99, 117,

122, 124, 125

clavicle in brachial plexus injuries, 392

damaged nerve ends, 220, 221, 229, 234,

235-236, 239, 243, 364, 374, 382-383,

421, 425

at primary nerve suture, 232

Resection, of—

gliomas, 277, 380-381

head of fibula, 362, 410

head of radius, 405, 423

incomplete nerve lesions in causalgia, 476,

488

neck of fibula, in peroneal nerve surgery,

411

neuromas, 377, 380-381

patella, in combined sciatic nerve-knee

joint injuries, 426

presacral nerve, in cord bladder, 122

synostosis, of radius and ulna, 424

Resectoscopic removal of vesical calculi,

97-98, 112

Residual urine. See Cystometry.

Resistance exercises, in peripheral nerve injuries, 567

Resistance to infection, in paraplegia, 12

Respiration, during laminectonry, 51

Respiratory collapse, in vascular-cranial

nerve surgery, 448

Respiratory depression, in acute spinal cord

injuries, 49, 50, 58

Respiratory failure as cause of death, in

acute spinal coid injuries, 64

Results, of—

axillary nerve repair, 393

closure of decubitus ulcers, 142-143

combined bone-peripheral nerve surgery,

427, 428

frozen dried homografts, 499-512

initial orthopedic surgery in 'combined

bone-peripheral nerve injuries, 245

instruction in ambulation, in paraplegia,

172-173, 176, 178

median nerve repair, 399

musculocutaneous nerve repair, 373

nerve grafts, in peripheral nerve injuries,

218-219, 236

nerve suture, in World War I, 208, 210

orthopedic surgery, in irreparable peripheral nerve injuries, 584-585

paraplegic program, 186-188

primary nerve suture, 232-233

protein replacement, in paraplegia, 151

Results, of—Continued

radial nerve repair, 406

radial nerve transplantation, 404

reconditioning program, in paraplegia, 164

rhizotomy, in mass reflexes, 182

spinal cord injuries, in World War I, 3-4

surgery, in acute spinal cord injuries, 26-27

in combined bone-peripheral nerve injuries, 424

in herniated nucleus pulposus, 193-194,

200-201, 202, 203

in peripheral nerve injuries, 301

sympathectomy in causalgia, 489-490

ulnar nerve repair, 396, 400, 401

Urologie management, in paraplegia, 114-

117

Resuscitation, in acute spinal cord injuries,

35, 36, 39

Retroclavicular injuries, of brachial plexus,

392

Retrograde pyelography, 106

Retrograde urography, 111

Retroparotid space, 441

Retroperitoneal approach, in—

femoral nerve injuries, 346, 347

sympathectomy, 489

Rhizotomy, 9, 181

Rhomboids, 310

RIBA, Lt. Col. L. W., 104

Riboflavin, in paraplegia, 150

RICHES, E. W., 71, 89, 93, 94, 95, 114, 115

Richocheting wounds of spine, 33

RICHTER, C. P., 213

RIDDOCII, C, 67, 70, 111

Ringer's solution for rehydration of frozen

dried homografts, 496

RITCHIE, A. E., 561

RIZZOLI, Maj. H. R., 513

ROBERTSON, E. C, 82, 83

Robinson catheter, 91

ROBINSON, Lt. Col. J. N., 121

Roentgenologic examination—

after frozen dried homografting, 498

after peripheral nerve surgery, 376, 389,

519

after sciatic nerve surgery, 409

in acute spinal cord injuries, 20, 37, 39-40,

45, 46, 47

in causalgia, after peripheral nerve injuries, 485

in combined bone-peripheral nerve injuries, 421

in cord bladder, 121, 124
INDEX 693

Roentgenologic examination—Continued Scarring—Continued

in peripheral nerve injuries, 224, 242, 243, in combined radial nerve-humerus injuries,

254, 376 403

in renal calculi, 103, 106, 152 in combined vascular-peripheral nerve inin uroteral calculi, 103 juries, 454, 465

in urinary tract infection, 125 in common peroneal nerve injuries, 413

in vesical calculi, 112 in femoral nerve injuries, 347

Roger Anderson splints, 564 in median nerve injuries, 398

Root pain, in— in peripheral nerve injuries, 236, 301, 304,

acute spinal cord injuries, 26, 47, 49 305, 322, 364, 369-372, 373-374, 375,

paraplegia, 181 380, 382, 497, 505, 521, 526, 528, 543,

wounds of cauda equina, 43-44 550

Roots of brachial plexus, 305-306, 311 in posterior tibial nerve injuries, 359

Ross, J. P., 469 in radial nerve injuries, 326

Rotation of skin flaps, in—, in sciatic nerve injuries, 408-409

combined peripheral nerve-skin-soft tissue in ulnar nerve injuries, 339, 342

injuries, 429 SCHLESINGEK, Capt. E. B., 188

decubitus ulcers, 9-10, 142-143 School for training of personnel, in paraRupture, of— plegic program, 7

aneurysms, 464 SCHULTZ, Maj. E. C, 482

annulus fibrosus, 193 Schwann cells, 543

cord bladder, 89 SCHWARTZ, Lt. Col. H. C, 231

Ruptured intorvertebral disk. See Herni- Sciatic nerve:

ated nucleus pulposus. anatomy of, 350-353, 407, 409-410

RUSK, H. A., 161 block of, 369

branches of, in thigh, 351

Sacral nerve roots, formation of sciatic nerve causalgia in, 475, 579

from, 350 course of, 350-351

Sacral spinal cord, wounds of, 20, 21, 67 exposure of, 354-362

Sacrifice of peripheral nerve branches, at formation of, 350

operation, 396, 400, 405 frozen dried homografts from, 497, 503,

Sacrosciatic foramen, 354 505, 509, 554

Sacrum, decubitus ulcers over, 11, 61, 87, high lesions of, 380

131, 137-138, 139, 142, 143 injuries of, 249, 350-362, 367, 407-410

Saphenous nerve, 345, 346, 413 association of, with bone injuries, 416

cable grafts from, 494 association of, with vascular injuries,

Sarcolemna, 559 455

Sartorius, 344, 350, 407 equinus deformities after, 580

Scaleni muscles, 310 in World War I, 210, 354

Scalenus anticus, 305, 392 plaster fixation after surgery for, 366-

Scalenus medius, 308, 310, 311, 392 367

Scapula, decubitus ulcers over, 131 positioning at operation for, 354, 362

Scapular vein, 308 prognosis in, 362

Scar tissue, pain caused by involvement of repair of, 354-356, 369

nerves in, 579 study of specimens from, 514

SCARFF, Lt. Col. J. E., 33, 120 surgical approaches to, 354-362

Scarpa's triangle, 344, 346, 349 transplantation of, 362

Scarring: Sciatic neurolysis, 356

about elbow, in radial nerve injuries, 573 Sciatic notch, 354

after combined bone-peripheral nerve Sciatic palsy, 409

surgery, 421, 422, 423 Sciatic paralysis, trophic changes after, 570

in brachial plexus injuries, 312, 392 Scissors gait deformity, 173

in combined peripheral nerve-skin-soft Sclerosis, in peripheral nerve injuries, 528

tissue injuries, 430 SCOVILLE, Maj. W. B., 142
694 NEUROSURGERY

Scrotal sepsis, in paraplegia, 90, 93, 97, 99,

112, 113

Secondary closure, of—

decubitus ulcers, 9, 137

suprapubic sinus, 95

Secondary neurorrhaphy, 537-538

Secondary sympathectomy, in causalgia, 490

Secondary wound closure, in infected boneperipheral nerve injuries, 421

Section on Brain Surgery, SGO, 209

Section of cerebral sensory cortex, 183

Sedation—

after laminectomy, 57-58

in acute spinal cord injuries, 36

SEDDON, H. J., 493, 494

Segmental distribution of paraplegic pain,

178

Segmental reflex activity, suppression of,

in acute spinal cord injuries, 68

Segregation of patients, with combined boneperipheral nerve injuries, 415-416

Selection of personnel, for paraplegic program, 6-8

SELETZ, E., 391

Semimembranosus, 351, 356

Semitendinosus, 351, 356

Senior Consultant in Neurosurgery, Office

of Theater Chief Surgeon, ETOUSA,

26, 120, 230, 241, 243

See also Davis, Col. L.; Spurling, Col.

R. G.

Sensation:

localization of return of, in peripheral

nerve injuries, 277

loss of, in acute spinal cord injuries, 36-37,

169

Sensory branches of femoral nerve, 349

Sensory examination, in peripheral nerve

injuries, 254, 266-272

Sensory fibers, cross stimulation of, as cause

of causalgia, 475

Sensory function, qualitative determination

of return of, in peripheral nerve injuries,

272-273

Sensory loss, in—

causalgia, after peripheral nerve injuries,

482

peripheral nerve injuries, 212, 224, 253,

569-570

Sensory paralysis, in—

causalgia, 449

combined peripheral nerve-vascular injuries, 440

Sensory patterns, in peripheral nerve injuries, 212, 213-217

Sensory status, assessment of, in peripheral

nerve injuries, 251-252

Sensory testing, in peripheral nerve surgery,

242, 272, 368, 369, 375

Sepsis, as cause of death, in spinal cord

injuries, 116

Septicemia, in paraplegia, 12

Sequestration, after bone grafting, 427

Sequestrectomy, 421

Serratus anterior, 310

Serum protein levels—

after laminectomy, 57

in acute spinal cord injuries, 63

in paraplegia, 129, 149

Serum rehydration of frozen dried homografts, 496

Seventh U.S. Army, 120

Sex function, in paraplegia, 101, lOln

SHERRINGTON, C. S., 268

Shock—

during laminectomy, 52

in acute spinal cord injuries, 35, 36, 39,

64, 123

in combined peripheral nerve-vascular

injuries, 439, 442

Short saphenous (sural) nerve, 352

Shortages, of—

equipment, for paraplegic program, 8

laboratory personnel, for peripheral nerve

studies, 220

neurosurgical personnel, 241-242

personnel in paraplegic program, 7

Shortening, of—

bone, in combined bone-peripheral nerve

injuries, 246, 249, 305, 380, 496

clavicle, in brachial plexus injuries, 305

humerus, in combined bone-peripheral

nerve injuries, 416-420, 422-423

normal bone, in peripheral nerve injuries, 380

Shoulder joint, arthrodesis of, 318, 571, 572

Shoulder spica, for transportation splinting,

420

Shoulder, wounds of, 36

SHUMACKER, H. B., Jr., 489

Shumacker technique of sympathectomy,

489

Shunting of sympathetic-sensory nerve impulses, as cause of causalgia, 476, 478

Signs, in—

acute spinal cord injuries, 37-38

causalgia, 479, 480-482
INDEX 695

Silk sutures, in peripheral nerve surgery, Sodium iodide, in cystography, 81

243, 388-389, 533, 535 Soft palate, paralysis of, 441

SlLVERMAN, J. J., 279 Soft tissue-bone-peripheral nerve injuries,

SlMBONB, F. A., 74 569-570

SIMONS, I., 80 Soft tissue-peripheral nerve injuries, 50, 241,

SINGER, M., 390 429-438

Sino-Japanese War, peripheral nerve injuries in World War I, 208

in, 302 Soft tissues, calcification of, in paraplegia,

Sixth Service Command, 18 147

Skeletal traction, in combined bone-peri- Soleus, 352, 358, 359, 412, 413, 414

pheral nerve injuries, 245, 421, 564 Solution G, 94, 110

Skin care— Solution M, 94, 112, 121

after laminectomy, 59 Solutions, for irrigations of cord bladder, 94,

in combined bone-peripheral nerve in- 121

juries, 421 Somatic approach, in paraplegia, 6

in paraplegia, 134, 135, 151 SOULE, Capt. A. B., 147

Skin changes, in— Southwest Pacific Area, 121

causalgia, 481 Spastic reflexes, in paraplegia, 9, 10, 18, 178-

peripheral nerve injuries, 272 184

Skin complications, in acute spinal cord in- Special discrimination test. See Compass

juries, 35, 38 test.

Skin grafting, in— Specifications for facilities, in paraplegic procombined bone-peripheral nerve injuries,

421

decubitus ulcers, 30, 135, 139, 143-145,

gram, 13-14, 17

Spermatic cord, torsion of, 152

149, 151 Sphincterometry, 80, 129

Skin-peiipheral nerve injuries, 429-438 Spinal accessory nerve, 310, 441, 448

Skin preparation, in peripheral nerve sur- innervation of facial nerve by, 494

gery, 367 Spinal anesthesia, in peripheral nerve surSkin resistance determinations, by dermome- gery, 249, 369, 408

try, 562 Spinal cord:

Skin resistance patterns, in peripheral nerve anatomic transeetion of, 33, 36

injuries, 213-217, 224 bladder function in complete transeetion

Skin temperature, in causalgia, 474-475, 481 of, 87

Skin temperature tests, in peripheral nerve bladder neck in complete transeetion of,

injuries, 280-282 84-85

Skin, trophic disturbances of, 265-266 case fatality rates in transeetion of, 115

Skiodan, in cystography, 81 classification of injuries of, 32-35

SKOGLCJNG, C. R., 476 compression of, 33, 34, 35, 38, 44-47, 182

Sliding-flap closure of donor sites, for pedicle concussion of, 3, 35, 39, 47

grafts, 432 in World War I, 3

Sliding operations, in decubitus ulcers, 10 contusion of, 39, 55

Sling-suture techniques, in peripheral nerve cord bladder, in—

surgery, 384-3S5, 410 complete transeetion of, 69, 71, 86, 94,

Small sciatic nerve, 354-356 116, 117, 122, 123-124

Smith-Petersen Vitallium cuff, 426 incomplete transaction of, 71, 86, 94,

SMITHWICK, R. H., 469, 488 114, 116, 117, 122

Smithwick technique of sympathectomy, decompression of, 44-47

488-489 edema of, 33, 34, 37, 38, 55, 68

SYNDER, Col. H. E., 19 effect of level of injury of, on work capacSocial factors, in paraplegia, 128-129 ity, 187n

Social service personnel, in paraplegic pro- hemorrhage into (about), 34

gram, 7 injuries of, 3-191

Society of Neurological Surgeons, 195 antimicrobial therapy in, 35
696 NEUROSURGERY

Spinal cord—Continued

injuries of—continued

association of, with other wounds, in

World War I, 3, 4

foreign bodies in, 19-20

gastrointestinal complications in, 35

in civilian life, 115-116

in ETOUSA, 25-30

in MTOUSA, 19-23

in World War I, 3-4, 18, 31, 47, 67, 119

incidence of, 19-20

management of, 31-65

pain in, 35

pathologic process in, 32-34

prevention of infection in, 35

priapism after, 38, 91, 101, 113, 173

priority of evacuation in, 26, 240

prognosis in, 21, 25, 31

shock in, 35, 36, 39, 64, 123

statistics of, 25, 120

statistics of, in World War I, 31

urologic aspects of, 67-125

suture of, in World War I, 3

See also Acute spinal cord injuries, Paraplegia, Spine, spinal injuries in special

locations, etc.

Spinal fluid rehydration of frozen dried

homografts, 496

Spinal shock, 53, 68, 69, 71, 74, 76, 81,

Spine:

case fatality rate for injuries of, 31-3294

in Civil War, 115

in World War I, 31, 114, 115

closed injuries of, 23, 35, 38

depressed fractures of, 40

etiology of injuries of, 25, 32-33

first aid in wounds of, 35-36

fractures (fracture-dislocations) of, 20, 25

penetrating wounds of, 33, 38-39

perforating wounds of, 33

ricocheting wounds of, 33

roentgenologic examination in wounds of,

20

through-and-thorough wounds of, 46-47

See also Acute spinal cord injuries, Paraplegia, Spinal cord injuries, spinal injuries in special locations, etc.

Spinothalamic cordotomy, 9

Splinting:

after debridement, in peripheral nerve

injuries, 235

after peripheral nerve surgery, 236-237

effect of, in causalgia, 481

Splinting—Continued

in peripheral nerve injuries, 242, 246, 420-

421, 563, 565-566

See also Transportation splinting.

Split thickness skin grafts, in—

combined peripheral nerve-skin-soft tissue

injuries, 429, 430-432 decubitus ulcers,

143

Spontaneous improvement, in causalgia,

470, 473, 473n, 477, 488

Spontaneous regeneration, in peripheral

nerve injuries, 211, 224, 239, 253, 301,

373-374, 448

Spring scale, in peripheral nerve testing,

256-263

SPRINZ, Maj. H., 149

Spurious aneurysm, of vertebral artery, 442

SPTJRLINO, Col. R. G., 195, 219, 225, 230,

243, 469, 494

Stabilization of foot, in irreparable peripheral

nerve injuries, 580

Staged frozen dried homografting, 498

Staged surgery, in combined vascular-peripheral nerve injuries, 465

Stainless steel sutures, in peripheral nerve

surgery, 242, 388

Stamp grafts, in decubitus ulcers, 10

Stanford University, 188

Staphylococcic infections, in paraplegia, 72,

103

Staphylococcus aureus renal infections in

paraplegia, 103

Stasis, as cause of renal calculi, 104, 105

Statistics:

acute spinal cord injuries, 19-20, 25, 26,

31-32, 64-65, 120 in World War I, 31,

119

ambulation in paraplegia, 165

causalgia after peripheral nerve injuries,

470, 473, 473n, 480, 490

combined bone-peripheral nerve injuries,

246, 422-428

cord bladder, 30, 88-89, 114-117, 121,

122-123 in World War I, 114

decubitus ulcers, 22, 137, 142

disruption of suture line after peripheral

nerve repair, 244

exploratory laminectomy, 182

frozen dried homografts, 495, 502-512

herniated nucleus pulposus, 198-201, 203

intermittent catheter drainage of cord

bladder, 90

paraplegia, 30, 122-123, 127-129, 187,

187n in VA hospitals, 12-13n
INDEX 697

Statistics—Continued

paraplegics in ZI hospitals, 14-17

peripheral nerve grafts, 218-219, 219n

peripheral nerve injuries, in—

ETOUSA, 237-238

MTOUSA, 237-238

World War I, 209-210

Peripheral Nerve Registry, 228-230

peripheral nerve surgery at Halloran General Hospital, 513

priapism, 113, 173

primary nerve suture, 232-233, 303

renal calculi in paraplegia, 104-105

renal infection in paraplegia in World

War I, 102

sex function after acute spinal cord injuries, 101

timelag in early nerve suture, 247-249

transfer of paraplegics to VA hospitals,

18

vesical calculi, 112

Steel wire sutures, in decubitus ulcers, 142

Steindler transplantation operation, for

peripheral nerve injuries about elbow,

572-573

Step-through gait, 170

Stereoscopic roentgenograms, in spinal cord

injuries, 39, 182

Sternocleidomastoid, 308, 311, 312

STEWART, O. W., 93

Stone-dissolving solutions, in renal calculi,

152

STOOKEY, B., 207, 301, 303, 408

STOBCK, Lt. Col. A. H., 7

STBAIN, W. L., 193

Streptomycin, in urinary tract infections, in

paraplegia, 103, 104, 125

Stretch fibrosis, in peripheral nerve injuries,

541-543, 558

Stretch ischemia, in peripheral nerve injuries, 513

Stretch palsies, in peripheral nerve injuries,

364, 381, 404, 526, 547

Stretch paralysis, in peripheral nerve injuries, 566

Stripping of nerve branches, in peripheral

nerve surgery, 305, 326, 350, 403-404

Stryker frame, 9, 10, 95, 108, 134, 135, 155,

162, 163, 184, 185, 189

Subarachnoid alcoholic injection, 181

Subarachnoid block, 26, 38

Subarachnoid hemorrhage, in acute spinal

cord injuries, 34, 55

Subastragalar arthrodesis, 582, 584

Subastragalar joint, Lambrinudi operation

on, 580

Subclavian aneurysm, association of brachial

plexus injuries with injuries of, 448

Subclavian artery, 308, 312, 392

injury of, associated with median nerve

injury, 543

Subclavius, 308, 310

Subdural hematoma, in acute spinal cord

injuries, 54

Subdural hemorrhage, in acute spinal cord

injuries, 34

Sublimis tendons, use of, in median nerve

paralysis, 576-577

Subscapular nerve, 310

Subscapularis, 310, 317, 318

Substitution movements, in peripheral nerve

injuries. See Trick movements.

SUBY, H. I., 94, 110, 121

Sucking wounds of chest, 51

Sudeck's atrophy, 477-478, 486

Sulfadiazine—

after laminectomy, 58

in acute spinal cord injuries, 56

in combined bone-peripheral nerve injuries, 245

in primary nerve suture, 232

in urinary tract complications of spinal

cord injuries, 22, 103-104

Sulfanilamide solutions, for bladder irrigations, 94

Sulfathiazole, in renal infections, 103-104

Sulfonamide therapy—

at laminectomy, 56

in epididymytis, 113

in periurethral abscess, 113

in renal infections, 103-104

in urinary tract infections, 124, 125

Summation phenomena in peripheral nerve

testing, 273

Superficial epigastric artery, 349

Superficial pressure (touch) sensation in peripheral nerve testing, 275-276

Superficial volar arch, 333

Supinator, 320, 325, 326

Supplementary motor movements in peripheral nerve injuries, 212

Supplies. See equipment.

Suppression, of—

reflexes in acute spinal cord injuries, 74

supplementary movements in testing

muscle strength, 263-264

Supraclavicular approach, to brachial plexus

injuries, 392
698 NEUROSüEGERY

Supraclavicular branches, of—

brachial plexus, 308

cervical plexus, 312

Supracondylar fracture of humerus, associated with radial nerve injury, 428

Suprapubic cystostomy, in cord bladder, 22,

30, 62-63, 89, 95-97, 99-100, 112, 117,

118, 120, 121, 122, 123-124, 176

in World War I, 119

Suprapubic drainage, of periurethral abscess,

113

Suprascapular nerve, 310, 514

Supraspinatus, 310

Sural nerve autograft, in cutaneous nerve

injury, 546-547

Sural nerve injuries, 514

Sural vein, 353

Surface anatomy, of—

axillary nerve, 317

brachial plexus, 311

femoral nerve, 346

median nerve, 328-330

musculocutaneous nerve, 314

radial nerve, 321

ulnar nerve, 337

Surgeon General, The, 5, 13, 17, 18, 225

See also Office of the Surgeon General.

Surgeon General's Office, in World War I, 209

Surgical approach, to—

axillary nerve injuries, 317-318

brachial plexus injuries, 311-313

femoral nerve injuries, 346-349

median nerve injuries, 330-333

musculocutaneous nerve injuries, 314-316

radial nerve injuries, 322-326

sciatic nerve injuries, 354-362

ulnar nerve injuries, 338-342

Surgical Consultants Division, OTSG, 14,

151n, 226, 277

Surgical neck of humerus, 317, 318

Survey of paraplegics, in ZI hospitals, 14-17,

127-129, 160, 186

Surveys of paraplegic centers, 6-7, 8-11

Survival in paraplegia, age factor in, 12-13n

Suture ä distance, 381

Suture line, disruption of, after peripheral

nerve surgery, 244, 519, 533, 539-541

Suture material, in peripheral nerve surgery,

229, 243, 365, 388-389, 533-535

Suture, of—

neuroma, 380

spinal cord, in World War I, 3

Suture sites, classification of, in peripheral

nerve surgery, 531-533

Sutureless technique of peripheral nerve

surgery, 389-390

Sweat tests, in—

causalgia, 490

peripheral nerve injuries, 279-280

Swimming pools, in—

paraplegia, 9, 161, 162

peripheral nerve injuries, 567

Swing-through gait, 170

Sympatheetomy:

in causalgia, 414, 470, 473n, 475-477,

486-487, 488-489, 490

in combined peripheral nerve-vascular

injuries, 464

in management of pain in paraplegia,

180, 181

in median nerve injuries in hand, 399

in phantom limb, 478

technique of, 488-489

Sympathetic innervation, of upper extremity,

310

Sympathetic nerve block, in—

causalgia, 473n, 476-477, 486-488, 489-490

paradoxical vasoconstriction, 280

phantom limb, 478

Sympathetic nerve supply, loss of, in peripheral nerve injuries, 559

Sympathetic nervous system, in—

causalgia, 219

spinal cord injuries, 178

Symptoms, in—

acute spinal cord injuries, 36-37

causalgia, 479-485

combined peripheral nerve-vascular injuries, 440-441, 448

peripheral nerve injuries, 280

urinary tract complications in paraplegia,

102, 103, 112, 146, 152

Syndrome, of posterior retrocarotid space,

442

Synostosis of radius and ulna, resection of,

424

Syringe irrigations, in catheter management

of cord bladder, 91

Tabes, bladder function in, 80

Tables of organization, of general hospitals,

220

Tactile stimulation, in median nerve injuries,

397

Tannic acid, in—

decubitus ulcers, 137

sweat tests in peripheral nerve injuries, 279
INDEX 699

Tantalum band technique of frozen dried

homografting, 498

Tantalum cuffs, 208, 226, 236, 243-244, 375,

387-388, 422, 430, 521, 535, 537, 547, 550

Tantalum sleeve technique of frozen dried

homografting, 498, 503-506, 508

Tantalum sutures, in—

decubitus ulcers, 142

peripheral nerve surgery, 208, 226, 242,

243, 253, 339, 342, 364, 376, 384, 388-

389, 395, 410, 422, 519, 533-535, 538

Tantalum tubes, in peripheral nerve repair,

389

TARLOV, I. M., 383, 390, 498

TAYLOB, A. C, 496

Technical errors in sympathectomy, in

causalgia, 490

Technique, of—

ambulation, in paraplegia, 170-173

bladder irrigations, 91-94

catheter drainage, in cord bladder, 91

combined bone-peripheral nerve surgery,

421-422

compass test, in peripheral nerve injuries,

278

cystometry, in cord bladder, 73

estimation of pain and touch points, in

peripheral nerve injuries, 276

evacuation, in paraplegia, 64, 132-135

examination, in peripheral nerve injuries,

251-300

exposure of peripheral nerves, 311-313,

316, 317-318, 322-326, 330-333, 338-

342, 346-349, 354-362

femoral nerve repair, 407

footprint and handprint testing, in peripheral nerve injuries, 265

frozen dried homografting, 497-498

gaining length in peripheral nerve surgery,

236, 305, 313, 316, 318, 326, 335, 350,

356, 359, 362, 381-382, 537

galvanic stimulation, in peripheral nerve

injuries, 565

hemilaminectomy, 56-57

history-taking, in peripheral nerve injuries,

253-254

laminectomy, 52-57

localization of returning sensation, in

peripheral nerve injuries, 277

management of cord bladder, 22, 30,

61-63, 86-100, 119-125

median nerve repair, 396-399

nerve block in muscle testing, in peripheral

nerve injuries, 264

498991''—59 48

Technique, of—Continued

neurolysis, 374-375

nerve transplantation, 342-343, 379-380,

400, 423

orthopedic surgery, in irreparable peripheral nerve injuries, 569-585

peripheral nerve repair, 236, 242-244,

247-249, 363-482

peroneal nerve repair, 411-412

physical therapy, in peripheral nerve

injuries, 245, 246-247, 562-568

plasma clot anastomosis, in peripheral

nerve surgery, 389-390

posterior tibial nerve repair, 412-414

preparation of—

frozen dried homografts, 495

peripheral nerve specimens, for histopathologic study, 513-514

procurement of nerve grafts, from cadavers, 495-496

qualitative (quantitative) peripheral nerve

testing, 261, 273, 274, 275

radial nerve repair, 62-64

sciatic nerve repair, 409-410

skin temperature testing, in peripheral

nerve injuries, 266-272, 282

suprapubic cystostomy, 62, 97

surgery, in decubitus ulcers, 141-145

sympathectomy, 488-489

sweat tests, in peripheral nerve injuries,

279, 280

tantalum sleeve method of frozen dried

homografting, 503

tibialis posticus transplantation, 582-584

transplantation of flexor carpi radialis, 574

ulnar nerve repair, 400-401

use of inductorium, 372-374

Temporary suture, in peripheral nerve

injuries, 533, 538-539

Tendo achillis, 359, 413

Tendon contraction, in paralysis below knee,

579

Tendon injuries, associated with peripheral

nerve injuries, 253, 304, 398

Tendon repair, with ulnar nerve repair, 342

Tendon splitting, in hand injuries, 406

Tendon transplantation, in peripheral nerve

injuries, 380, 411, 427, 555, 568, 573-574,

579, 580

Tenodeses, in irreparable nerve injuries of

lower extremity, 580

Tenotomy, in paraplegia, 173

Tension pneumothorax, 21

Teres major, 310
700 NEUROSURGERY

Teres minor, 317, 318

Terminal branches, of—

brachial plexus, 308

common peroneal nerve, 353, 361

femoral artery, 350

femoral nerve, 344-346, 349

posterior tibial nerve, 352

sciatic nerve, 357-362

Test:

for measurement of muscle strength, in

hands and feet, 256-263

of motor function, at initial wound

surgery, 242

of sensory function, at initial wound

surgery, 242

See also specific tests.

Theater Chief Surgeon, ETOUSA, 29, 246

Thenar crease, 328, 333

Thenar eminence, 314, 328, 333, 399

Thenar muscle, innervation of, 263

Therapeutic test, in causalgia, 486-488

Thermocouple, 281

Thiamine, in paraplegia, 150

Thiersch grafts, in decubitus ulcers, 10

Thigh, exposure of sciatic nerve in, 356-357

Thigh pain, in causalgia, 478

Thimerosal, tincture of. See Merthiolate.

Thiopental sodium. See Pentothal sodium.

Third Service Command, 18

Thoracic laminectomy, 51

Thoracic nerves, formation of brachial

plexus from, 305-308, 312, 328, 335

Thoracic spinal cord:

priapism, after transection of, 173

wounds of, 20, 29, 30, 35, 36, 39, 47, 59,

63, 64, 80-81, 115, 118, 171

Thoracoabdominal wounds, 19

Tboracodorsal nerve, 322

THOM, D. A., 161

THOMAS, W. H., 94

THOMSON-WALKER, J., 69, 90, 95, 102, 114

Thompson-Boyle operation in median nerve

paralysis, 577

THOMPSON, G. J., 81, 94, 98, 117

Thrombin, for hemostasis, at peripheral

nerve surgery, 365, 385, 386

Thrombosis, in peripheral nerve injuries, 528,

536

Through-and-through wounds of spinal canal,

46-47

Thumb-finger opposition, operations for, 577

Tibia:

decubitus ulcers over, 131

Tibia—Continued

fractures of, associated with peripheral

nerve injuries, 421

Tibial component of sciatic nerve, 410

Tibial nerve, 356

anatomy of, 351-353

autogenous grafting of, 394

branches of, 351-352

exposure of, in popliteal space, 357-359

formation of, 351, 357

injuries:

combined with vascular injuries, 455

repair of, 412-414, 496-497

Tibial recurrent nerve, 353

Tibialis anticus, 353, 361

Tibialis posticus, 352, 412

transplantation of, in irreparable peroneal

nerve injuries, 582-584

Tidal drainage of bladder, 22, 30, 62, 63, 72-

73, 92-94, 99, 115-116, 117, 119-121, 123,

124, 125, 152, 176

Timelag, in peripheral nerve injuries, 230,

514-515, 531-533, 535-537, 547

in World War I, 210

Timing, of—

Assessments of nerve regeneration, 226

changes of position, in paraplegia, 131, 135

combined bone-peripheral nerve surgery,

236, 245, 402-403, 415-416, 420, 424-

425

combined peripheral nerve-plastic surgery,

429, 431

combined vascular-peripheral nerve surgery, 464

evacuation—

in acute spinal cord injuries, 63-64

in paraplegia, 30

joint extension after peripheral nerve repair, 244

laminectomy, in acute spinal cord injuries,

21, 41, 44-47, 48, 49, 182

operation—

in infected bone-peripheral nerve injuries, 421

in irreparable nerve injuries of lower

extremity, 570

in renal calculi, 109

peripheral nerve surgery, 211, 231, 233,

234, 235, 239-242, 247, 249, 363-364,

375, 515, 519, 531-533, 560

in World War I, 208, 210

reexploration after frozen dried homografting, 499

sympathectomy, in causalgia, 488
INDEX 701

TiNBL, J., 207, 272, 303, 474, 477

Tinel's sign, in peripheral nerve injuries,

212-213, 224, 272-273, 428, 519, 531, 547,

555

TINSLEY, M., 31, 32, 46, 65

Toe drop brace, after tibialis anticus transplantation, 584

Toes:

clawing of, 265, 579

decubitus ulcers on, 131

frozen joints in, 246

pain in, in causalgia, 478-480

Touch and pain points, estimation of, in

peripheral nerve injuries, 276

Touch sensation, in peripheral nerve injuries, 269, 273, 275-276

Touch stimulation, in median nerve injuries,

397

Tourniquet, in peripheral nerve repair, 243

Trabeculations, of bladder wall, 79-80, 81-

82

Traction:

effect of, in peripheral nerve injuries, 219

in combined bone-peripheral nerve injuries, 420-421, 425, 426

Traction injuries of brachial plexus, 391

Traction management of spastic reflexes, 180

Traction on neuroma, 380

Traction palsies, in peripheral nerve injuries, 208, 364, 381, 403

Traction paralysis, after peroneal nerve repair, 411

Traction suspension, 420

Training of neurosurgical personnel, 241-242

for paraplegic program, 6-8

in electrodiagnostic techniques, 217

TraiU des Sections Neroeuses, 303

Transfusion. See Blood replacement, Replacement.

Transit hospitals, 240

Transperitoneal approach—

in sympathectomy, 489

to femoral nerve injuries, 347

Transplantation, of—

anastomosis, in peripheral nerve surgery,

386

common peroneal nerve, 411

flexor tendons, 406

median nerve, 335, 395, 396

peripheral nerves, 207, 219, 236, 243, 305,

379-380, 550, 551

in World War I, 210

radial nerve, 326, 403-404, 423, 428

sciatic nerve, 362

Transplantation, of—Continued

ulnar nerve, 339, 340, 342-343, 378, 395-

396, 400, 401, 576

wrist and digital flexors, 572-573

Transplantation operations, in irreparable

nerve injuries, 571-572, 573-575, 582-584

Transplanted muscles, reeducation of, 577

Transportability, in acute spinal cord injuries, 48-49

Transportation, in—

acute spinal cord injuries, 35

paraplegia, 27, 29, 130, 131-135

Transportation splinting, in—

combined bone-peripheral nerve injuries,

246, 420-421

peripheral nerve injuries, 137, 242, 246,

420-421

Transurethral resection of bladder neck, 98

Transversalis muscles, 346, 349

Transverse carpal ligaments, 328, 331, 333,

335

Transverse cervical vessels, 308

Transverse myelitis. See Acute spinal cord

injuries, Paraplegia.

Trapezius, 308

Mayer transplantation operation on, 572

Traumatic amputations, in paraplegia, 146

Traumatic arthritis, 486

Traumatic division of peripheral nerves, at

operation, 208

Triage, in peripheral nerve injuries, 240, 246

Triceps, 317, 318, 320, 322, 323, 325, 326,

330, 335, 393, 403

transplantation of long head of, to

acromion, 571-572

Trick movements, in peripheral nerve injuries, 252, 261, 263-264, 560, 568

Trigger point in tests of sensory function, 272

Trigone in cord bladder, 80

Triplegia, 183

Trochanters, decubitus ulcers over, 87, 131,

137, 139, 142

Trophic changes, in—

causalgia, 481

peripheral nerve injuries, 340, 569, 570

tests of, 265-266

spinal cord injuries, 169

Trophic ulcers, 412

Trunk, causalgia in, 478

Trunks of brachial plexus, 306, 311

branches from, 310

TUBBY, A. H., 575

Tube feeding, in acute spinal cord injuries, 63

Tuberosity of ischium, 351
702 NEUROSURGERY

Tubulization technique, in—

combined peripheral nerve-skin-soft tissue

injuries, 429

peripheral nerve injuries, 381, 389

Tunisian campaign, 20, 202, 231

TUECO, Maj. V., 575, 582

Two-point test. See Compass test.

Two-stage repair, of peripheral nerve injuries, 380-381

Tyrode's grafts, 144

UHLE, A. A., 80

Ulna, fractures of, associated with peripheral

nerve injuries, 238, 420

Ulnar artery, 331, 333, 335

Ulnar collateral artery, 330

Ulnar groove, 335, 337, 340

Ulnar nerve, 323, 333

anatomy of, 335-337

assumption of functions of, by median and

radial nerves, 352

autogenous grafting of, 494

branches of, 335-337

course of, 335-337

differentiation of, from median nerve, 330,

333

exposure of, 338, 342, 395

formation of, 308, 335-337

injuries of, 335-343

clawhand deformity after, 571

combined with bone injuries, 238, 410

flexion-relaxation at operation for, 378

incidence of, 514

positioning at operation for, 338, 339,

340

repair of, 303, 395-397, 400-401, 496-

497

study of, by handprints, 265

study of specimens from, 514

surgical approach to, 338-342

innervation by, of thenar and flexor profundus muscles, 263

involvement of, in median nerve injuries,

394, 395, 396-397

mobilization of, 338, 339

orthopedic surgery, in irreparable injuries

of, 575-576

overlap into median nerve area, 263-264

paralysis of, 252

physiology of, 340

surface anatomy of, 337

transplantation of, 339, 340, 342-343, 378,

396-397, 400, 401, 576

Ulnar vein, 335

Undermining technique, in closure of decubitus ulcers, 10, 141

United Kingdom Base, 120

general hospitals in, 26

herniated nucleus pulposus in, 201

neurosurgical centers in, 240, 241, 247

United States. »See Zone of Interior.

Upper extremity:

bone shortening in, 380

combined bone-peripheral nerve injuries

in, 584

combined peripheral nerve-vascular injuries in, 439n, 448-454

incidence of peripheral nerve injuries in,

514

irreparable peripheral nerve injuries in,

569, 571-578

physiology of, 304-305

prognosis of combined peripheral nervevascular injuries in, 458

Urea nitrogen levels, in paraplegia, 129

Urea ointment, in decubitus ulcers, 137

Ureteral calculi, 111

Ureteral colic, 111

Ureteral complications, of cord bladder, 111

Ureteral reflux, 82, 100, 102, 112

Ureterotomy, 111

Ureters:

relation of, to femoral nerve, 347

status of, after acute spinal cord injuries,

100-101

Urethra, status of, in cord bladder, 79

Urethral fistula, in cord bladder, 113

Urethral infection, during drainage of cord

bladder, 90-91, 93, 99

Urethral obstruction, in cord bladder, 80

Urethritis, 62

Urethrocystography, 80, 82-86, 98

Urethrostomy, 90

Urinalysis, in paraplegia, 72-73, 101, 124, 129

Urinary calculi, in cord bladder, 152-153,

152n

Urinary tract infection:

as cause of death, in spinal cord injuries,

11-12, 90, 114-115

blood cultures in, 146

in acute spinal cord injuries, 35

in nondrainage management of cord

bladder, 88, 89

in paraplegia, 13, 30, 60, 70-71, 86, 87,

95, 146

in perineal urethrostomy, 97

roentgenologic examination in, 125
INDEX 703

Urinary tract infection—Continued

See also Urologie, special structures of

urinary tract.

Urologie aspects, of spinal cord injuries,

67-125

Urologie care, of paraplegics, during evacuation, 29

Urologie complications, of spinal cord injuries, 18, 22, 32, 101-114

Urologie management, of spinal cord injuries, 67-125

Urologists, in paraplegic program, 190

U.S. Public Health Service, 209

Vagus nerve, 441

Vascular centers, in Zone of Interior, 212,

441, 455, 464, 467

Vascular changes, in peripheral nerve injuries, 558, 559

Vascular injuries—

as cause of causalgia, 474-475

combined with peripheral nerve injuries,

211-212, 222, 237, 238, 243, 253, 280-

281, 364, 398, 439-467

in World War I, 208

in paraplegics, 146

Vascular occlusion, combined with peripheral

nerve injuries, 458-464, 543

Vascular-peripheral nerve-bone injuries,

combined orthopedic techniques in 569-

570

Vascular supply, protection of, at peripheral

nerve surgery, 376

Vascular theory, of causalgia, 474-475

Vascularity, after debridement, in peripheral

nerve injuries, 235

Vaseularization, after frozen dried homografting, 497, 504, 505, 506, 508, 512

See also Pathologic process, Histopathologic process, etc.

Vas deferens, retrograde extension of, infection by, 112

Vasoconstriction, in causalgia, after peripheral nerve injuries, 474-475, 481, 486-

487

Vasodilatation, in causalgia, 474-475, 481-

485

Vasomotor changes, in—

acute spinal cord injuries, 38

causalgia, after peripheral nerve injuries,

481, 485

peripheral nerve injuries, 562

Vasomotor reactions, in activity of bladder

reflex, 76

Vasomotor symptoms, in peripheral nerve

injuries, 280, 562

Vasopressin. See Pitressin.

Vastus intermedius, 345

Vastus medialis, 345

V-E Day, 120, 246

VELLACOTT, P. IN., 88, 102

Velpeau dressing, after—

bracial plexus surgery, 378, 393

radial nerve surgery, 404

Venae comitantes, 330

Venous tubes, in peripheral nerve repair, 389

VERNT, 442

Vertebrae, fractures of, 33, 35, 47, 132

See also Spine.

Vertebral artery, spurious aneurysm of, 442

Vertebral erosion, by aortic aneurysms, 458

Verumontanum, 83

Vesical calculi, 14, 97, 99, 111-112, 122

Vesical neck obstruction, in cord bladder, 80

Veterans' Administration:

care of paraplegics in, 186-187

followup of paraplegics in, 12-13n, 187n,

219n, 230 "

transfer of paraplegic program to, 5, 7, 13-

18, 123

Veterans' Administration hospitals:

postwar expansion of, 224

studies of—

cord bladder in, 81n, 9fln, lOln

paraplegia in, 152n

peripheral nerve regeneration in, 217

sex function in, lOln, 114n

Veterans' Bureau, 209

Vibrator}' sense, testing of, in peripheral

nerve injuries, 266-272

VILLARET, 442

Visualization, of peripheral nerve injuries,

at debridement, 233-234, 235, 242

Vitamin supplements, in—

acute spinal cord injuries, 63

combined bone-peripheral nerve injuries,

421

paraplegia, 140, 150, 175

renal infection, 103

V-J Day, 14

Vocal cords, abduction paralysis of, 448

Vocational instructors, in paraplegic program, 190

Vocational training, of paraplegics, 7

Volar branches, of ulnar nerve, 335, 342

Volar interosseous artery, 320
704 NBUROSUEGERT

Volar interosseous branch, of median nerve,

398

Volar interosseous nerve, 328, 331

Volkmann's contracture, in median nerve

injuries, 394

Voluntary neurogenic bladder, 71

Vomiting, in—

renal calculi, 106

renal infection, 102

von Frey's hairs, 271, 275-276

VULPIAN, 303

WAC's, in paraplegic program, 7-8, 191

Walkers, in paraplegia, 9, 13, 169, 171

WALLACE, A. B., 385

Wallerian nerve degeneration, 303, 515

WALSH, M. N., 193

War Department Circular:

No. 209, 13 July 1945—201

No. 212, 29 May 1944—200

No. 224, 21 Sept. 1943—221, 222

No. 423, 27 Oct. 1944—222, 223

War Department Technical Bulletin (TB

MED) 162, May 1945—5, 181, 183

Ward attendants, in paraplegic program, 6

Ward officers, in paraplegic program, 6,

189-190

Wardmasters, in paraplegic program, 6

WARE, M. W., Ill

WARBEN, S. L., 193

Water mattresses, in paraplegia, 3, 58

WATKINS, K. H., 83

WEARY, Capt. W. B., 19

WEBB-JOHNSON, A. E., 88, 102

Weight loss, in paraplegia, 5, 116

WEISS, P., 389, 495, 496

WESSON, M. B., 89

Wheelchair existence, in paraplegia, 5, 116

Whirlpool bath, in peripheral nerve injuries,

564

WHITCOMB, Maj, B. B., 513

WHITE, Capt. J. C, (MC) USN, 264, 469,

470, 475, 477, 485, 489

Whitman College, 11

WOODHALL, Lt. Col. B., 225, 243, 272, 382,

476, 495

Work capacity, after ulnar nerve injury,

575-576

Work furloughs, in peripheral nerve injuries,

223-224, 566-567, 568

Work tolerance, in paraplegia, 16

World War I:

acute spinal cord injuries in, 3-4, 31,

67, 119

World War I—Continued

case fatality rate of —

renal infection in, 101

spinal cord injuries in, 114, 115

causalgia in, 469

combined peripheral nerve-vascular injuries in, 439, 442, 448, 455

cord bladder in, 119

decubitus ulcers in, 130

experimental studies on peripheral nerve

injuries in, 207, 219

followup on peripheral nerve injuries in,

230

herniated nucleus pulposus in, 193

incidence of peripheral nerve injuries in,

237

laminectomy in, 41

management of—

cord bladder in, 88, 89, 90

peripheral nerve injuries in, 234

nerve grafting in, 219

neuropathologic studies on peripheral

nerve injuries in, 219

neurosurgical centers in, 208, 209

peripheral nerve injuries in, 207-210, 225,

231, 301, 302

quantitative testing of muscle strength in,

256-259

records of peripheral nerve injuries in, 254

sciatic nerve injuries in, 354

spinal concussion in, 47

urologic complications of paraplegia, 114

wounds of—

abdomen in, 3, 4

chest 3, 4

Wound infection. See Infection.

Wounding agents, in—

combined peripheral nerve-vascular injuries, 147, 439-440

peripheral nerve injuries, 235, 399, 521

spinal cord injuries, 25, 32-33, 35, 102,

128

Wounds. See specific types and areas.

Wrist:

ankylosis of, after prolonged immobilization, 584

exposure of—

median nerve injuries at, 333

ulnar nerve injuries at, 340-342

frozen joint in, 246

fusion operations on, in irreparable peripheral nerve injuries, 571

median nerve injuries at, 397, 398
INDEX 705

Wrist—Continued

transplantation of origins of humeral

flexors on, 572-573

Wristdrop, in peripheral nerve injuries, 237,

573

WKOCK, Maj. D. H., 237

YOUNG, H. H., 119

YOUNG, J. Z., 389

ZEIFERT, Col. M., 161

Zinc peroxide, in decubitus ulcers, 10, 138

Zone of Interior:

definitive nerve surgery in, 246, 247, 363

electrodiagnosis in, 560-561

evacuation of—

casualties with peripheral nerve injuries to, 240-241, 246

paraplegics to, 63-64, 123, 131-134

Zone of Interior—Continued

evacuation of—continued

patients with herniated nucleus pulposus to, 202-203

evacuation to, after peripheral nerve repair, 244, 247

galvanic-tetanus ratio studies in, 562

management of—

cord bladder in, 121-123

herniated nucleus pulposus in, 194-202

paraplegics in, 5-18, 127-191

neurosurgical centers in, 9, 212, 219, 441,

470, 547, 568

neurosurgical centers, in World War I, 208,

209

policies on peripheral nerve injuries in,

211-230

skin grafting of decubitus ulcers in, 30

survey of paraplegics in, 14-17, 127-129,

160, 186

vascular centers in, 212, 441, 455, 464, 467
History of the Medical Department, U.S. Army, in World War II

OSD (1)

OSA (1)

ASA (CMA) (1)

ASA (FM) (1)

ASA (LOG) (1)

ASA (MP & RF) (1)

ASA (1)

CofS (1)

AFSWP (1)

DCSPER (1)

ACSI (1)

DCSOPS (1)

DCSLOG (1)

ACSRC (1)

CAMG (1)

CUSARROTC (1)

CofF (1)

CINFO (1)

CNGB (1)

CLL (1)

DRD (1)

CMH (2)

OCSpWar (1)

TIG (1)

TJAG (1)

TPMG (1)

TAG (1)

CofCH (1)

CofEngrs (1)

CmlC (1)

CofT(l)

CSigO (1)

TQMG (1)

CofOrd (1)

Technical Svc Bd (1)

Chaplain Bd (1)

CAMG Bd (1)

TAG Bd (1)

USA Intel Bd (1)

DISTRIBUTION LIST

NEUROSURGERY, VOLUME II

Army Maint Bd (1)

USA Arty Bd (1)

USA Armor Bd (1)

USA Armor Test Bd (1)

USA Inf Bd (1)

USA Air Def Bd (1)

USA Air Def Test Sec (1)

USA Abn & Elct Bd (1)

USA Avn Bd (1)

. USCONARC (2)

USARADCOM (1)

USARJ/UNC/EA(R) (1)

MAJ/OS COMDS (3)

SHAPE (3)

Southern European TF (1)

OS Base Comd (1)

*Log Comd (1)

MDW (3)

Armies (2)

Corps (1)

Corps (Res) (1)

Bat Gp (1)

*#Div (2)

USATC (1)

Brig (1)

Regt/Gp (1)

Bn (1)

Med Bn (Sep) (1)

Med Co (1)

Med Co (Sep) (1)

Med Det (Sep) (1)

Ft & Camp (2)

USMA (2)

CGSC (3)

ARWC (3)

Svc Colleges (3)

Br Svc Sch (3)

Jpint Sch (3)

Specialist Sch (2)

Med Sec, Gen Depot (1)

AH (6)

USA Hosp 1-100 beds (1)

USA Hosp

*#100-500 beds (3)

*#500 up (5)

WRAMC (10)

WRAIR (5)

BAMC (20)

Pers Cen (1)

Army Terminals (2)

ATTC (1)

GTTC (1)

PTTC (1)

RC (1)

PG(l)

AFES (1)

Arsenals (1)

Med Fid Maint Shops (1)

AFIP (5)

DB(1)

Disp

Named or Numbered (1)

General (2)

Industrial (1)

MAAG (5)

Mil Mis (3)

JBUSMC (1)

Units organized under following TOE's:

*#8-22 (1)

8-571 (1)

*#8-581 (1)

8-590 (2)

*Med Lab (2)

*RA units and USAR.

#RA units and NG.

4!)8<J«1V—5!) U.S. GOVERNMENT PRINTING OFFICE; 1959