Incomplete spinal cord injury

Incomplete spinal cord injury

Acampora et al: Intracranial Chondroma plished only by a piecemeal removal. T h e C T scans taken one year later revealed no evidence of recurrence. ...

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Acampora et al: Intracranial Chondroma

plished only by a piecemeal removal. T h e C T scans taken one year later revealed no evidence of recurrence.

References 1. Alpers BJ: Cerebral osteochondroma of dural origin. Ann Surg 101:27-37, 1935 2. Aronson HA, Otis RD: Intracranial chondroma involving the cerebello-pontine angle. J Neurosurg 19:529-531, 1962 3. Berkmen YM, Blatt ES: Cranial and intracranial cartilaginous tumors. Clin ILadiol 19:327-333, 1968

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4. Bonnet (1891): cited by Chorobski [51. 5. Chorobski J, JarzymskiJ, Ferens E: Intracranial solitary chondroma. Surg Gynecol Obstet 68:677-686, 1939 6. Dutton J: Intracranial solitary chondroma. J Neurosurg 49:460-463, 1978 7. Geuna F, Gori G: Condroma della volta cranica. Minerva Neurochir 6:62, 1962 8. Hardy RW, Benjamin SP, Gardner WJ: Prolonged survival following excision of dural chondroma. J Neurosurg 48:125-127, 1978 9. Ramamurthi B, Iyer CGS, Vedachalam SP: Intracranial meningeal chondroma. J Neurosurg 18:826-828, 1961

Letters to the Editor Incomplete Spinal Cord hijury The article in Sur~cal Neurology, "Surgery in Incomplete Spinal Cord Injury" ( 17:12-15, 1982), by Mr. O'Laoire and Mr. Thomas, has been drawn to my attention. I should like to make the following comments: 1. Sir Ludwig Guttmann and his many pupils have never said that open surgery had no role to play in the treatment of spinal cord injuries, and this is therefore an error by the authors which I hope will be corrected. The authors, in my opinion, have not understood much of Guttmann's material. 2. The case which they so well describe does fall into the indications which Sir Ludwig Guttmann made clear in his book, i.e., progressive paralysis in incomplete lesions and the development of paraplegia after a free interval. I would also like to indicate that from my reading of the article, the authors have not clearly tLnderstood the specific pathology of injuries of the vertebral colunm associated with incomplete cord lesions. There is the most important factor of time. If the incomplete cord lesion is discovered immediately after the accident, surgery has very little to offer, for in contradistinction to what the authors say, anterior cord lesions are not due to continuing posterior displacement and compression by fragments of bone and the intervertebral disc. Such occurs only at the moment of impact, and the pathodynamics of the injury indicate that the momentary compression is relieved by the elastic recoil of the bony vertebral tissue confined, as it usually is, within the longitudinal ligaments. Thus, incomplete paresis discovered immediately after a bony injury of the vertebral column is not usually helped by either anterior or posterior surgery. Fortunately the era of posterior surgery seems to be almost over. As yet no authors have really reviewed a satisfactory series of cases in which anterior compression has been undertaken for proper pathological reasons, as was clescribed in the case presented by O'Laoire and Thomas. Indeed the references quoted by the authors have not led me to believe that anterior surgery is indicated in incomplete cord lesions where bony injury has been sustained. However, in the type of case described by these two authors, there is no doubt that anterior decompression and anterior surgery is urgently indicated, and thus i1: fits into one of the rare indications for such early surgery.

Sir George Bedbrook, O.B.E., O.St.J., Hon. M.D. (WA), M.S. (Mdb), D.P.R.M., F.R.C.S., F.R.A.C.S., Hort. F.R.C.S.E. Royal Perth (Rehabilitation) Hospital Shenton Park, Western Austra/Ja

Incomplete Spinal Cord I n j u r y I have read with much interest the article written by Mr. O'Laoire and Mr. Thomas, "Surgery in Incomplete Spinal Cord Injury" (Surg Neurol 17:12-15, 1982). As a pupil of Sir Ludwig Guttmann, I was greatly disturbed to read the authors' incorrect statement that "Guttmann and his pupils and followers claim that open surgery has no role to play." The authors seemed to misrepresent the Guttmann school of spinal cord injury management. It is tree that the Guttmann school strongly advocates conservative postural reduction; however, it does not claim that "open surgery has no role to play." It was Guttmann who established the classic "indications for surgery" in the management of acute spinal cord injury. The case described by O'Laoire and Thomas definitely falls into at least one category of the "classic indications" described by Sir Ludwig Guttmann in his book: (1) progressive paralysis in incomplete lesions; and (2) the development of paraplegia after a free interval. The authors presented an interesting case that was somewhat unusual in that it involved the upper thoracic cord. However, considering the findings reported, I think that any competent spinal cord injury specialist (including Guttmann's pupils) would have immediately performed neuroradiological investigations, followed by open surgery, if necessary.

Paul DoUfus Mulhouse, France

Reply Dr. Bucy has transmitted to us the letters, regarding our article "Surgery in Incomplete Spinal Cord Injury" (Surg Neurol 17: 12-15, 1982). Regarding the letters pertaining to our article, it was not our intention to suggest that the Guttmann method of treating closed spinal injuries allowed for no exceptions to the conservative approach it advocates. However, among neurosurgeons and orthopedic surgeons, there is a widely held belief that the Guttmann teaching allows little exception to conservative treatment, and, indeed, I should say that the patient whom we described was refused surgical treatment by another specialist before being referred to us. Our purpose in reporting this case was to increase awareness among our surgical colleagues that some cases of spinal cord injury require surgical treatment rather than rehabilitation.

S. A. O'Laoire, F.R.C.S.I., F.R.C.S., and D. G. T. Thomas, M.R.C.P., F.R.C.S. Wimbledon, England