Surgical ©relations 
FOR THE 
Relief of Pressure Paralysis 
IN CARIES OF THE SPINE. 
BY 
WILLIAM N. BULLARD, M. D., 
AND 
HERBERT L. BURRELL, M. D. 
Reprinted from the Boston Medical and Surgical Journal of 
October 24, 1889. 
BOSTON: 
DAMRELL & UPHAM, Publishers, 
283 Washington Street. 
1889. S. J. PARKHILL & co., PRINTERS 
BOSTON SURGICAL OPERATIONS FOR THE RELIEF OF 
PRESSURE PARALYSIS IN CARIES OF THE 
SPINE.1 
The advances in surgery, which have been so rapid 
and so extensive within the last few years, have at 
length reached a point where operations of a serious 
nature upon the spinal column, involving the removal 
of portions of several vertebrae and the opening of the 
spinal canal, may be performed with success, so far as 
the operation itself is concerned, and it now becomes 
the duty of the physician to be able to give, so far as 
is consistent with our present knowledge, an intelligent 
opinion in regard to the benefit likely to be derived 
from such operation in any given case, and the risks 
which are to be encountered apart from those of a 
purely surgical character. 
We wish then to point out as distinctly as possible 
what cases of spinal caries are, in our opinion, suita- 
ble cases for operation, and on what factors we depend 
to form an opinion in any special case. 
The symptoms for which operations on spinal ca- 
ries have been undertaken are those of compression 
with or without irritation of the spinal cord, and the 
direct object of these operations has been the relief of 
pressure on the spinal cord. This compression is 
usually produced in caries of the vertebrae either by 
the collection and accumulation of inflammatory pro- 
ducts between the dura mater and the bone and by the 
thickening of this latter membrane with an increase of 
DRS. WILLIAM N. BULLARD AND HERBERT L. BURRELL. 
1 Read before the American Orthopedic Society, September 19,1889. 2 
fibrous or connective tissue formation, or by the direct 
pressure of displaced bone. The first cause is by far 
the most common. In a very large proportion of 
cases, it is probable that compression once produced 
does not materially diminish and that the improvement 
in the symptoms, which so frequently occurs, is due 
principally to the adaptation of the cord itself to its sur- 
roundings ; in a smaller number of cases the compres- 
sion may be more or less acute, and may diminish or 
disappear spontaneously. These latter cases are 
usually connected with abscess formation. Apart 
from the general condition of the patient and the or- 
dinary surgical considerations, there are three elements 
especially to be weighed in determining the advisabil- 
ity of an operative procedure on the spine. First, the 
actual condition of the spinal cord; secondly, its pros- 
pects of recovery (of function), if not operated upon, 
under rest and other suitable treatment; thirdly, its 
prospect of recovery (of function) if the pressure be 
removed. 
ACTUAL CONDITION OF THE CORD. 
The amount of injury suffered by the cord depends 
upon various factors, some more or less easily esti- 
mated, others extremely difficult to judge of. The 
principal ones are (1) the degree of pressure; (2) 
the time throughout which it has been exerted; (3) 
the liability of the cord to inflammation or degenera- 
tion. 
Our means of determining the condition of the cord 
in general are well-known, and we will only say that 
the symptoms to be principally relied upon are the loss 
of motion and of sensation and the condition of the 
reflexes below the diseased area. It is evident that 
the greater the loss of motion and sensation below the 
diseased point, the greater must be the obstruction to, 3 
or the destruction of the cord conduction. If the inhi- 
bition or destruction of the conduction through the 
cord were proportional to the amount and duration of 
the compression, our problem would be much simpli- 
fied. As it is, however, we have to deal with an inde- 
terminate factor, the spreading of the disease in the 
cord. It is still a disputed question in what pathologi- 
cal form this extension of the disease ordinarily occurs, 
whether, as maintained by Striimpell, it is a degenera- 
tive process, or whether, as held by Gowers, it is 
inflammatory. However this may be, there is no 
doubt that, in addition to the ordinary spreading of 
the disease in certain cases, a spontaneous myelitis may 
occur, and the possibility of this must always be borne 
in mind. 
PROSPECT OF RECOVERY WITHOUT AN OPERATION. 
The prospect of, at least, a partial recovery is in the 
large majority of cases, especially in the earlier stage, 
a very good one. Even in cases of total loss of mo- 
tion and sensation, recovery, at least partial, may 
occur. Incontinence of urine and faeces are very seri- 
ous symptoms (Lauenstein's formula), yet we have 
seen both disappear after several months duration and 
the patient become practically well. The duration of 
the symptoms is a most important element in the prog- 
nosis, though even this is not so determining as might 
at first seem probable. We all know cases in which 
paralysis has existed for years and which finally com- 
menced to improve and recover motion and sensation. 
The recuperative power of the spinal cord, at least as 
regards function, is much greater than would be sup- 
posed a priori. The cases of caries of the spine are 
comparatively few, in which, aside from causes de- 
pendent on the general health of the patient, it is not 
possible or even probable that some improvement in 4 
the symptoms, directly referable to the cord, will occur, 
if the active advance of the disease can be checked. 
So long as we have reasonable or even moderate 
chances of recovery without operation, we do not be- 
lieve it advisable or justifiable, in the present condition 
of spinal surgery, to perform so serious an operation 
as resection of the lamina of the spinal vertebra. 
This consideration at once reduces the proportion of 
these cases, suitable for operation, to a very small one, 
as we all know how prone these cases are to, at least, a 
partial recovery ; on the other hand, when spontaneous 
recovery has become otherwise well nigh hopeless, this 
procedure offers us a prospect of success which should 
not be neglected. At present, it seems probable that 
this prospect is greater in the case of children than of 
adults. 
PROSPECT OF RECOVERY FROM PARAPLEGIA AND 
OTHER CORD SYMPTOMS BY MEANS OF OPERATIVE 
REMOVAL OF COMPRESSION. 
We have thus far been able to collect only eleven 
published cases in which an operation for the removal 
of compression has been performed upon the spinal 
cord, omitting Abbe's case, which, though counted by 
White, seems doubtful. (These are Macewen, five ; 
Horsley, Duncan, Lane, Dercum and White, Wright, 
Thompson, each one.) To these we add our own case, 
making twelve in all. 
Three cases (Macewen's) were successful, four were 
much benefited, and some of these, notably Duncan's, 
should probably be classed as successful. One 
(Wright's) had recurrence of the former symptoms in 
two months. Four died, one in thirty hours, one in 
thirty-six hours, one in a week and one in a few 
months; the two latter of general tuberculosis. 
Of these the age is given in only seven. Five were 5 
children under fourteen years of age. Two were adult 
males. Of the children one became well, three were 
at least much benefited, in one the symptoms recurred. 
Both the adults died of shock. 
The results of these cases are, on the whole, favor- 
able, and we are warranted in looking forward to 
much better ones as progress is made in surgical 
technique. 
The principal contra-indication, besides the obvious 
ones existing in the general condition of the patient 
and his surroundings, is the presence of tuberculosis 
in some other portion of the body. In such cases the 
prognosis is necessarily serious, and the operation 
should not be attempted unless there exists some 
symptom thought to be due to pressure and immedi- 
ately threatening life, as in the case of Thompson. 
Macewen's view that the presence of continued high 
temperature is of itself a contra-indication, aside from 
the possibility of its pointing to tubercular disease in 
other parts of the body, has not been borne out by 
later cases, notably by that of Lane, where, in spite of 
high temperature, the operation was successfully per- 
formed. The presence of an abscess is a contra-indi- 
cation to resection if the pus can be evacuated in any 
other manner. 
The occurrence of acute symptoms referable to the 
cord, other than those due to abscess is not an indi- 
cation for operation unless they appear to threaten 
life through compression of the cord. On the other 
hand, in many cases where acute symptoms occur, we 
have to deal with processes in the cord which may not 
be specially aided by the removal of the compression, 
and where again there is a tendency to partial recov- 
ery. Thus a sudden paraplegia or increase of loss of 
motion or sensation is a contra-indication to immediate 
operation, though the time may come later when the 
operation will be desirable. 6 
When, however, in any case the health of the 
patient is gradually failing, when cystitis is becoming 
chronic, and when obstinate bed-sores are beginning 
to form without obvious cause in a case of some 
standing, operation should be resorted to early in 
order that the chances may be in our favor. 
To sum up in short: 
Contra-indications'. - (1) General health and gen- 
eral surgical considerations; (2) The presence of 
tuberculosis in other parts of the body; (3) The 
presence of an abscess connected with the caries which 
can be otherwise evacuated; (4) Acute exacerbation 
of symptoms referable to the cord, and not threaten- 
ing life. 
Indications in favor of an operation are : -(1) Gen- 
eral good condition and favorable surroundings ; (a) 
when the disease is gradually and slowly progressing 
to an unfavorable termination; (b) when the patient 
has more or less complete loss of motion and sensa- 
tion in the portions of the body below the level of the 
lesion, and incontinence of urine and faeces, and where 
these conditions have lasted for a sufficient length of 
time to render spontaneous recovery improbable, and 
not so long as to have produced permanent destruc- 
tion of all recuperative power in the cord. (2) Where 
acute symptoms threatening life appear, and where 
there is reasonable expectation that they may be re- 
lieved by the removal of compression. 
We now come to the consideration of our own 
special case. 
The patient, a strong butcher, forty-six years old, a 
native of Ireland, entered the Carney Hospital on the 
29th of December, 1888, in the service of Dr. V. Y. 
Bowditch. His family history was good and he him- 
self had never been ill previous to his present trouble. 
About three months ago, he began to suffer from 7 
pains in the back, sides and abdomen, and from a sen- 
sation of constriction around the body. Three weeks 
ago the pain extended to his lower extremities, they 
became weak and he was unable to walk without as- 
sistance. 
December 30th. To-day an examination of the 
patient was made by Dr. Bullard at the request of 
Dr. Bowditch, as follows: Patient well developed and 
in excellent condition as regards general health. 
Nothing abnormal detected about head, face, chest, 
upper extremities, or in any of the internal organs. 
Distinct prominence in the back, involving the fourth, 
fifth and sixth dorsal vertebrae, and over these there is 
some tenderness. There is a decided weakness of 
both lower extremities, but he can walk with the aid 
of a stick. Sensation is somewhat diminished every- 
where in front below the seventh intercostal spaces; 
behind there is decided diminution below the level of 
the lower dorsal vertebra and slight diminution up to 
the level of the sixth dorsal. Thoracic reflexes nor- 
mal as low as sixth or seventh ribs, below this and 
over the abdomen, the superficial reflexes are di- 
minished. Over the back they are more marked in 
the upper portion than below, and are not marked 
over the glutei. Cremasteric reflexes slight; plantar 
cannot be obtained; triceps reflexes not remarkable. 
Knee jerks' much increased on both sides. Para- 
doxical contraction obtained on both sides, left more 
marked than right (this disappeared in a day or so). 
February 1st. From change of service the patient 
enters to-day under the care of Dr. Bullard. Has 
grown steadily worse since entrance. Paraplegia in- 
creasing, some difficulty in micturition and considera- 
ble pain. 
February 6th. Complete paraplegia. Sensation 
as before. 8 
February 19th. The question of operation has 
been considered, but it has been decided to place the 
patient on a Bradford frame. 
March 1st. Not comfortable on frame. Girdle 
pains very severe. 
March 15th. Removed from frame. Very serious 
bed-sores. Has been in great pain most of the time, 
partially relieved by morphine. 
May 13th. Patient growing rapidly worse, bed-sores 
increasing, and pain being intolerable. General con- 
dition has been rapidly failing, and is now poor. For 
the last fortnight every means has been used to im- 
prove his general condition. 
Transferred to care of Dr. Burrell. (Patient was 
seen by Dr. Burrell, in consultation, for the first time 
in February, and several times later. For more than 
a fortnight before his actual transfer, he was practi- 
cally under his care.) 
On May 14, 1889, the condition of the patient was 
truly pitiable. He was suffering intense pain, which 
morphia could hardly make bearable; he had a large 
bed-sore, which exposed the sacrum and which ex- 
tended onto either buttock. Sloughs had already 
occurred at various points on the heels and over the 
heads of the fibulae. Cystitis existed in a marked 
form. The patient urgently begged for some relief 
to his condition, and the uncertainties of the suc- 
cess of the operative procedure having been explained 
to him, it was undertaken. 
The patient was etherized and an incision was made 
in each vertebral groove extending from the second to 
the seventh dorsal vertebra; these incisions were car- 
ried down to the laminae. Considerable oozing of 
blood ensued, which was arrested by sponge pressure. 
A transverse incision was made uniting the two in- 
cisions in the vertebral grooves, just below the spine 9 
of the fifth dorsal vertebra. This made an II incision. 
Two flaps were raised from the laminae and the spin- 
ous processes by means of a heavy knife and scissors, 
and thus were made musculo-cutaneous flaps which 
were reflected upward and downward; then by means 
of a Bon well surgical engine, which was run at a low 
rate of speed, the laminae of the third, fourth, fifth and 
sixth dorsal vertebrae were divided. Unfortunately 
the engine, the saw of which was kept constantly wet 
by a stream of water broke down when the laminae 
were two-thirds divided and the operation had to be 
completed by the aid of an osteotome. The osteotome 
was then driven in directly over the spinous process 
of the second dorsal vertebra, breaking off its over- 
hanging point. A separation was accomplished be- 
tween the spines of the sixth and seventh dorsal ver- 
tebrae by means of a knife and scissors ; this allowed 
the block of the spines and laminae of the third, fourth 
fifth and sixth dorsal vertebrae to be raised up, hinge- 
ing at the divided point of the spine of the second 
dorsal vertebra. The turning up of this block of 
spines and laminae was not directly but it was 
thrown a little to the right. This allowed a full, free 
exposure of the cord, which was seen in the bottom of 
the wound, seemingly normal in appearance, except 
opposite the fifth dorsal vertebra, where it was per- 
ceptibly flattened and did not pulsate. The veins of 
the cord were somewhat congested. The cavity was 
irrigated, and a small roughened portion of the lamina 
of the sixth dorsal vertebra was removed. The block 
of the spines and laminae was turned down into posi- 
tion, and held by sutures to the adjacent muscular 
structure. Wound closed with catgut sutures, and 
dressed with baked gauze. Time of operation one 
hour and forty-five minutes. 
The haemorrhage which we expected would be quite 10 
severe was easily controlled ; it was not greater in 
amount than usually occurs in a breast amputation 
and a clearing out of the axillary contents. 
At the completion of the operation the patient was 
very cyanotic, and breathing was somewhat difficult. 
Stimulation was resorted to with partial success. The 
patient was put to bed reclining in prone position. 
Patient continued to improve very slowly throughout 
the day, and six hours after the operation took brandy 
per mouth, pulse very rapid and feeble. Eight hours 
after the operation patient was placed in a recumbent 
dorsal posture, and soon fell asleep. Respiration 36, 
pulse 144. Twenty four hours after the operation 
it was noticed that he breathed with more difficulty 
and took less nourishment. Thirty-six hours after 
the operation the patient became cyanosed, his respira- 
tion became shallow, and he died of shock. 
In commenting on this case we would say that it 
was undertaken as an experimental effort, with the 
distinct understanding with the patient that such was 
the case; and we both feel confident that had it been 
undertaken at an earlier period in the patient's illness, 
and at a time when his recuperative powers were 
stronger, it would not have ended fatally. 
Dawbarn (New York Medical Journal, June 29) 
has reported a case where he resected for traumatic 
paraplegia. His operation occurred on December 20, 
1888, and from his description we should judge that 
he attempted the same operative procedure that was 
undertaken in our case. His patient recovered, and 
some slight improvement in the symptoms ensued. 
One of the advantages of the operation of " resection 
and reimplantation " is, that it lays bare a given por- 
tion of the spinal cord and restores the bony structures 
with a possibility, at least, of their re-uniting ; but at 
present, if we were asked to undertake this operation, 11 
we should decline, and should resort to the use of a 
trephine and bone-cutting forceps for the removal of 
the laminae. 
The key to the success of any operative procedure 
on the spine will be the securing of an efficient means 
for dividing the bony structures with ease, speed and 
accuracy. 
Boeckel. Schmidt's Jahrbuch, 1882, No 196, page 269. Phila- 
delphia Med. News, September 8, 1883. 
Israel. Berl. klin. Woch., March 6, 1882. 
Halstead. Med. News, January 3, 1885. 
Lidell. International Encyclop. of Surgery. 
Morris. Annals of Surgery, June, 1886. 
Lauenstein. Centr. f. Chir., No. 51, 1886. 
Wright. Lancet, July 14, 1888. 
Keetley. Br. Med. Jour., 1888, II, 421. 
Thorburn. Br. Med. Jour., 1888, II, 665. 
Macewen. Br. Med. Jour., 1888, II, 254. 
Abbe. N. Y. Med. Record, February 9, 1889. 
Travers. Br. Med. Jour., January 12, 1889. 
Duncan. Edinb. Med. Jour, March, 1889, 
Allingham. Br. Med. Jour., April 13, 1889. 
Lane. Br. Med. Jour , April 20, 1889. 
Dawbarn. N. Y. Med. Jour., June 29, 1889. 
Dercum and White. Annals of Surgery, June, 1889. 
White. Annals of Surgery, July, 1889. 
Thompson. Lancet, August 17, 1889. 
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