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The application of a paper strip screening test for urinary infection in the management of paraplegic patient is described. In acute injuries cultures are carried out daily on specimens of urine. A hundred consecutive patients admitted between 15 April 1971 and 17 March 1973 are reviewed. There were 51 cervical, 38 thoracic and 11 lumbar lesions. Fifty-nine were admitted within 7 days of injury. On admission 59 patients had sterile urine, 41 had infected urine. Two patients died during the study. At the end of the period or on discharge 86 patients had sterile urine. Half the patients with sterile urine acquired their first infection by 10 days. It was acquired on a Sunday or Monday in the majority of cases and eliminated in 2 days. The advantages of this technique in the speed of elimination of the infection and the maintenance of the urine in a sterile condition are discussed and comparisons made with other series.

The management of the respiratory problems of acute traumatic tetraplegia has been discussed in previous papers. This paper presents a modification and extension of the same subject and, in addition, attempts to correlate the respiratory and metabolic facets of management into a pattern of treatment which will maintain adequate alveolar ventilation and nutrition and a normal fluid and electrolyte balance.The maintenance of adequate alveolar ventilation may be threatened by:(1) increasing paralysis of the muscles of respiration;(2) the supervention of either pulmonary consolidation or collapse. These complications are related to the aspiration of vomitus, the inability to deliver sputum to the mouth, and the inspissation of sputum;(3) pulmonary oedema, due to over-hydration of the patient.Arising from a knowledge of these potential complications, a respiratory regime is presented, which includes the timely use of tracheostomy and intermittent positive pressure respiration. In the management of a patient with a tracheostomy, the importance of the humidification of the inspired air, and frequent and adequate bronchial suction is stressed.The effect of body temperature or the oxygen requirements of the tetraplegic patient is also discussed, and the suggestion is made that there may be advantages in nursing such a patient at 34 to 35°C.The patient with acute traumatic tetraplegia may show one or more of a number of disturbances of function, each of which may stress homeostatic mechanisms for fluid and electrolyte. In particular, shock, paralytic ileus, vomiting and acute renal failure are common and gastric aspiration and intravenous infusion are almost always required. Among the more common disturbances of fluid, electrolyte and acid-base balance which must be prevented are:(1) Respiratory acidosis.(2) Alkalosis associated with loss of gastric hydrochloric acid.(3) Acidosis associated with loss of small intestinal secretions. This loss may be external or into dilated gut.(4) Acidosis associated with starvation—this may be made worse by coexisting hypoventilation or acute renal failure.(5) Hypokalaemia.The final pattern which may require correction by intravenous therapy could be the resultant of any combination or all of these disturbances. The principles of intravenous therapy are discussed.

This paper has presented a preliminary estimate of the benefits of a ‘systems’ approach to the treatment of spinal cord injury. The preliminary cost-benefit ratio exceeds six. For a variety of reasons, this is probably a severe underestimate of the benefits because possible reductions in medical and attendant costs after discharge have not been included nor have any potential increase in earnings. In addition, the definition of ‘system’ and ‘non-system’ patients also tends to underestimate the benefits.The accumulation of follow-up data will permit an estimate of post-discharge medical and attendant costs and increase in earnings. A large number of patients will also permit additional statistical analysis.

Twenty-six patients with paraplegia and scoliosis have been reviewed. Thirteen of these patients have been instrumented and fused with Harrington or Dwyer Instrumentation. It is felt that Harrington Instrumentation is the surgery of choice in the spinal cord injury patient with scoliosis and Dwyer Instrumentation is the surgery of choice in the myelomeningocele patient without posterior elements and scoliosis. However, one must also consider fusing the myelomeningocele patient from L4 or L5 to the sacrum by the posterior route as well as Dwyer Instrumentation.Dwyer Instrumentation has also successfully been used in myelomeningoceles with kyphosis by reflecting the cord and meninges and instrumenting the spine with the Dwyer apparatus posteriorly. This will be the subject of a forthcoming paper.

Associated severe injuries in patients with traumatic paraplegia or tetraplegia are common and in different reported series, including that mentioned in this paper, occur in some 25 per cent. of patients with closed spinal injuries, and up to 65 per cent. with open wounds of the spine.The diagnosis of the injuries in these patients presents particular difficulties and the important points are detailed, along with commoner sites and the frequency of these injuries. Head injury is the commonest severe associated injury with a cervical cord lesion, and chest injury with a serious injury to the dorsal spine.Complex clinical problems often ensue, requiring intelligent first aid and rapid transportation to the accident service of a comprehensive hospital, where routine resuscitative measures are applied and investigations and special surgical medical treatments instituted. Priorities of treatment are discussed.

This paper deals with the results of the observations made in the German Federal Republic on 50 spinal cord lesions with complete, irreversible paraplegia. To obtain comparable results, the results were assessed in two fixed stages: one at the end of the accepted average time of treatment and the other at twice the time.As all paraplegics had been paralysed in the years 1952-58, specialised early treatment in special wards or departments was not available in 86 per cent. of our paraplegics. A combination of inadequacy in medical and nursing personnel, facilities and organisation very often prevented a competent early medical treatment. The reported figures about frequency and extent of complications in paraplegia confirm this experience.The inadequacy of early treatment had a markedly negative effect on the later standards of training and the occupational rehabilitation of our paraplegics. We hope very much to help our paraplegics more effectively in the near future by completing and enlarging those departments which were recently started in our country.

This paper deals with the effects of spinal cord transection on the reflex function of the isolated cord in the spinal man in relationship to these effects following cord transection in animals.Details are presented of latent period, intensity and duration of the reflex depression of skeletal muscles during the period of spinal shock caudal and cephalad of the cord transection.Factors influencing the patterns of reflex recovery are described and special attention is drawn to the effect of posture during spinal shock on the development of flexion and extension synergies.Varieties of reflex pattern due to preponderance of individual muscles occurring after cessation of spinal shock are discussed and special mention is made of the phenomenon of synchronous rhythmic muscle contractions.

This paper concerns a study of the morbidity and mortality of venous thrombosis and pulmonary embolism in 431 cases of acute spinal cord injury.The incidence is related to age, sex, year of injury, level and type of lesion, type of onset and site of thrombosis, associated injuries and major operations.The commonest time of occurrence was about three weeks after the initial trauma.Dorsal lesions had the highest rate of venous thrombosis and its occurrence was higher in complete lesions than in incomplete lesions.The mortality rates were similar at all levels of spinal cord injury. Variations and anomalies are briefly discussed.The disability arising from venous thrombosis has been much reduced by the use of anticoagulant therapy. The prophylactic use of anticoagulants is not recommended.

This paper deals with the management of the paralysed bladder during an 11-year period in 476 traumatic paraplegics and tetraplegics—409 male and 67 female—who were admitted to Stoke Mandeville within the first 14 days, most of them within the first 48 hours, after injury. The patients were followed up after discharge from the Centre at least yearly but often more frequently.In 370 patients, the urine was sterile on admission; of these 278 had either intermittent catheterisation (174) or no catheterisation (104) before admission. One hundred and six patients were infected on admission, the majority of them following previous indwelling catheter drainage by Foley catheters (81).The method of choice employed at Stoke Mandeville in the management of the paralysed bladder was the non-touch technique of intermittent catheterisation (Guttmann, 1949, 1953). This method has proved highly effective in preventing infection of the paralysed bladder, especially in male patients where the catheterisation was carried out exclusively by the medical officer in charge of the case. 64.8 per cent. male and 49.3 per cent. female patients (62.2 per cent. of the total of the 476 patients) had sterile urine on discharge from hospital. 70.4 per cent. of the 186 incomplete lesions and 56.9 per cent. of the 290 complete lesions were sterile on discharge.Details of late complications are given and attention is drawn to the low incidence of hydronephrosis, vesico-ureteric reflux and calculosis, and in particular to the complete absence of urethral fistulae in patients with sterile or infected urine.The non-touch technique of intermittent catheterisation has proved superior to any other form of early management of the paralysed bladder hitherto described and has disproved the prejudice held against intermittent catheterisation for so many years by urologists and other workers in the field of spinal paraplegia.

This paper concerns the treatment of paraplegia due to bony injuries of the spine at the dorso-lumbar level. The observations made are based on the experiences gained in the early treatment of 156 patients of whom 61 had had bony injuries at the D.V.11/12 level and 95 at the D.V.12/L.V.1 level.The anatomical relationships of the spinal cord and its nerve roots to the bony levels are detailed. The mechanism of the different types of fracture and fracture-dislocation is outlined and shown to have a bearing on the type of spinal cord and root injury at the dorso-lumbar junction.The importance of the nursing routine is emphasised and the method used at the Spinal Injuries Unit in Sheffield is described.The patterns of neurological recovery are listed. The cases showing most recovery were those with the preservation of some sensory or motor activity from the time of the accident. The speed and quality of recovery was inversely proportional to the time taken for any one new feature to appear.There was no great difference between the results in the operative and non-operative groups of cases. True comparison of the two groups was not possible because of the biased selection of cases for each group. The non-operative group tended to include the cases with the lesser degrees of bony injury while the operative group included the major degrees of bony displacement and instability.The ease of handling of this latter group of cases was greatly improved by the operative procedures.

A review and analysis of the records of 583 patients who had been admitted to my private care at the Boston City Hospital over 30 years are analysed and classified in the light of a previous paper dealing with the part played by the spinal ligaments in the maintenance of stability and weight-bearing. Traction and Fusion-with-internal splinting therapies are analysed and my experience with a small series of the latter as well as a large series of 506 patients treated by traction therapy are presented for the reader's information. No statistical comparison is offered. Attention is particularly drawn to the importance of fractures of the posterior, lateral walls of the spinal canal, tension hemo-pneumothorax and hematorachis, and to the significance of the shape of the spinal arches in determining the frequency and site of fractures and dislocations and their effect on weight-bearing. The conclusion is reached that fusion may be useful in certain instances but no sooner than a year after the injury, and that in all other instances the preferable and indeed the only treatment that offers any hope of recovery and the avoidance of morbidity is traction therapy supplemented by the judicious use of laminectomies for diagnosis and treatment or both.

This paper deals with surgical procedures for relief of foot spasticity which include division of tendons (Pan-tenotomy) and resection of the sciatic nerve.At present, it is impossible to say which method is the best procedure. The advantage of tenotomy is that there is no muscular atrophy or cutaneous risk, while neurectomy has the advantage of being simple, resulting in a better scar and producing paralysis of short flexors and suppression of the reflexogenic area.