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Spinal cord injuries will not disappear, but the incidence can be reduced. A reduction of up to 50% of spinal cord injury cases is, in the opinion of Menzies' seminar participants, practical and possible but will only occur if the subject is accepted as a major challenge in the surgical world. Great advances in spinal cord injury care were made by surgeons. Prevention is a programme already targeted in other surgical areas. As a multidisciplinary medical and surgical area, spinal cord injury prevention now needs the effective activity of groups of health professionals. Primary prevention must therefore be a target for surgical communities. Surgeons should be among the leaders in the field ensuring good overall management of prevention programmes.

The work of two Australian surgeons using the same techniques for anterior lumbar interbody fusion operations in 150 patients has been analyzed by an independent observer (A.F.). Used as a primary procedure in 84 cases, only four patients failed to return to work. Time off work varied between 3.3 to 11.8 months, depending on the patients' occupations. Used as a salvage procedure in 38 cases, only five patients failed to return to work. Time off work varied between 24 and 5.6 months depending on the patients' occupations. In 28 cases, supplementary operations were performed following interbody fusions. Even in this difficult group only nine patients failed to return to work.

Facilities providing a co-ordinated 'system' of care to the spinal cord injured are now more accepted as being preferable to fragmented 'non-system' facilities. Data reflecting the incidence of selected complications common to spinal cord injury were collected over a 2-year period from a system located outside the United States and from 'non-systems' within the United States. The latter was defined as care provided in community facilities prior to entry into one of 14 model United States spinal cord injury centres. All complications occurred more frequently in the American group, particularly decubitus ulcers and urinary tract infections. The data suggest that system care is preferable to non-system care in its capacity to prevent costly complications and the sooner the spinal cord injured patient is referred to a spinal cord centre capable of meeting all his needs, the less likely will he be exposed to complications that could slow the rehabilitation effort.

Ten patients with idiopathic scoliosis underwent electromyographic (emg) examination before and after Harrington instrumentation and fusion. Each patient had a normal emg preoperatively. At 3 weeks all 10 demonstrated spontaneous activity consistent with denervation, and voluntary activity was absent or markedly reduced. By 3 months and in some cases 6 months, denervation was significantly reduced or absent; voluntary activity had also reappeared and in most cases was equal to preoperative intensity. This rapid reversal of denervation after surgery within the paraspinal muscles in a young female population with no underlying disease suggests that interpretation of any postoperative emg should include considerations such as the time since surgery, the age of the patient, and the extent of preoperative pathology. No evidence was gained from this study that extensive posterior spinal surgery itself interfered significantly with paraspinal muscle function after 3 to 6 months.

At the present time our preventive methods do not fully prevent the occurrence of scoliosis subsequent to juvenile paraplegia. The methods of management must be: (a) preventive; (b) early non-operative correction, such as braces; and by (c) operative correction. The operative correction must be both an anterior and posterior procedure to give good spinal alignment. Further follow-up over many years will be necessary to watch these cases, but the initial results are satisfactory re correction. Function has been improved in both (a) respiration and (b) mobility, but at the 'expense' of reduction in some areas of recreation.

In the last decade, by application of detailed methods of care, the previously accepted complications of urinary infection, pressure sores and motor skeletal problems of contractures and spasm, have largely been eliminated from the clinical picture of patients with spinal paralysis. Many professionals in medicine have contributed to these advances. Long-term or extended care in the area of tetraplegia and paraplegia need further stimulation, with continued application of all those methods used in acute rehabilitation in properly organized spinal units.

Clinical interest in spinal compression and resultant paraplegia due to metastases has mounted in recent years. This has stimulated attention to the neuropathology of the condition. 14 cases of spinal cord compression due to vertebral metastases are compared with over 100 traumatic cases. In the traumatic lesions there is central haemorrhagic necrosis leading to cavitation and gliosis with nerve root regeneration in the late stages. In the metastatic cases, lesions are often peripheral, pie-shaped and are related to vascular factors. The neuropathology of cord necrosis due to metastatic spinal disease is therefore different from that caused by trauma. These observations have clinical importance in planning treatment.

Fifty patients with chronic low-back pain were subjected to extensive medical, psychiatric, and psychosocial assessment by a comprehensive Low Back Pain Clinic. Most patients were found to have easily identifiable environment factors which influenced the persistence of the symptomatology. All patients were significantly functionally impaired, and whilst neurologic findings were uncovered in only 12 patients, most had restricted movement of the lumbar spine. The initiating cause of the low-back pain was usually from a minor injury or no injury at all. Thirty-two patients were given psychiatric diagnoses, but only one patient was thought to warrant psychiatric treatment. Whilst some were considered to be candidates for limited further conservative treatment, only two were subjected to further surgery (one fusion, one posterior facet rhizotomy). Only nine were admitted to an inpatient behavior modification program, and the results of this effort were modest. The major benefit was seen to be the definitive diagnosis, prognosis, and medical and social planning which was given to all 50 patients upon conclusion of the assessment. The assessment proved to be of benefit to the patient, the referring doctor, the team itself, as well as all other interested parties, such as his family, insurance company, and lawyer.

The authors have studied 193 cases of cervical injury with tetraparesis or paralysis in a similar way to a previous study completed in 1973 (Bedbrook 1973). Comparison with three other centres, Stoke Mandeville, Tokushima and South West Region has shown similarities and regional dissimilarities--for example in aetiology. Only in cases with bilateral facet dislocation was reduction considered to have any effect on neurological recovery in all four geographical areas. The observations recorded strengthen the view that the result of the neurological injury is largely determined at the time of the accident.

Clinical interest in spinal compression and resultant paraplegia due to metastases has mounted in recent years. This has stimulated attention to the neuropathology of the condition. Fourteen cases of spinal cord compression due to vertebral metastases are compared with over 100 traumatic cases. In the traumatic lesions there is central haemorrhagic necrosis leading to cavitation and gliosis with nerve root regeneration in the late stages. In the metastatic cases, lesions are often peripheral, pie-shaped and are related to vascular factors. The neuropathology of cord necrosis due to metastatic spinal disease is therefore different to trauma. These observations have clinical importance in planning treatment.

Acute spinal injury with paresis or paralysis is an increasing problem in modern communities. The corrdinated efforts of many are necessary for its management. The expertise developed by various disciplines through work with nonparaplegic patients should be coupled with the specific expertise of those responsible for total care. Generally, operative techniques have only a limited application, whereas basic medical and nursing techniques give good results.

From previous papers from five separate Spinal Injury Centres, namely Perth, Western Australia, Stoke Mandeville, U.K., Heidelberg, Germany, Tokushima, Japan and South West Region, U.S.A., a total of 665 patients with cervical spine injuries have been extracted. These were grouped according to the Frankel classification on neurological status on admission and again on discharge. This has been used to assess the prognosis on the initial classification of the ultimate neurological recovery, as is indicated by the tabulated results. A small group of Perth patients have been further reviewed, the Frankel B group were sub-divided into B1, posterior column sparing only, and B2, fuller sensory sparing, to assess any difference in ultimate outcome. With only small numbers available at present, no major prognostic significance has been demonstrated by using such a division.

A patient who survived for 50 years after two cervical injuries is described. Among other effects he showed remarkable compensatory changes in the vertebrae above and below a cervical fusion operation. He also developed a meningeal pseudocyst following lumbar laminectomy. The history and pathological findings are considered to be instructive.

This review paper surveys historical aspects and then proceeds to examine major considerations in the management of spinal injuries. These include neurological sequelae, functional disabilities and expectations, pathology, spinal cord injury in children, management complications (genitourinary, bone, neurological, skin respiratory, cardiovascular, and gastrointestinal), and social aspects. The paper concludes by highlighting the need for comprehensive spinal injury services, noting the bleak future for a reduction in incidence, and emphasizing the goal of care in the community at large, not just in hospital.