THE NECK

MECHANISM WITHOUT

OF

INJURY TO

TO

THE THE

SPINAL VERTEBRAL
SCOTLAND

CORD

IN

THE

DAMAGE A. R.
Fro;n TAYLOR,

COLUMN

EDINBURGH, of Surgical

the Department

Neurology,

Edinburgh

The cervical without dysfunction, The spine it was during by cervical McGowan disc of as the supposed adduce contusion. sufficient of spontaneous

discrepancy injuries vertebral are commonly that hyperfiexion action. spine.

between has been column recognised. observed spinal

,

damage the subject and injury, This

to of

the vertebral

spinal by

cord many fracture

and and the in by skeletal vertebral

,

to authors.

the

vertebral Both cord

column damage without of the was injury by Cramer intervertebral cause they for spinal only susceptible cord damage extension with

in cord

comment

dislocation group. injuries displacement reduced

communication and without series of this acute of can cord occur, processes. temporary

concerns displacement it is caused persistent dislocation of events explanation intraspinal forcible flexion they compression nor can that was as

former hyperfiexion.

anatomical in hyperflexion, cord damage

cervical caused of the and of the findings did not cord if it is

is fracture-dislocation supposed acute

Not

unnaturally

involving hypothetical

temporary

immediately designated demonstrated displacement of the relied after it could cord of this causing upon

spontaneously

muscular

This The They disc

recoil an as the but

improbability suggested and disc postulated as a cause prolapse that the displacement.

(1944). explanation, temporary

of neck the injury, account compression type

As evidence,

occasional

a prolapsed proof Barnes

cervical that (1948) and out reduction. pointed

a temporary showed lock Taylor

hyperfiexion

cause Locking

to dislocate

articular and

is not

As was

by

Blackwood

(1948),

injuries

cervical

in the

absence

of vertebral

fracture

or dislocation

are

usually

sustained

by forcible

of the neck rather than head back into shallow

while Blackwood temporary They of the suggested cases in the head dislocation that is probably is described

by hyperfiexion. water, by falling

by in be a fixed a case which

Such accidents are forwards downstairs

object, rupture occurred, of common observations, of damage to as the leaving in anterior no

exemplified by diving or by being thrown

accidents. longitudinal detectable and indicate The findings might by that ligament

the and and many

forwards

arrested

motoring trace

Taylor radiography. explain a suggest

in hyperextension this question. the might Subsequent common cause on

a relatively

occurrence however, the cord.

simpler that

mechanism

the and

injury that

is caused the agent

by which

hyperextension impinges

of the the cord

cervical is the

spine

without

temporary ligamentum

dislocation, flavum.

forward-bulging

CASE A man kicking aged sixty-seven a golf ball along years gave a roadway, a clear

REPORT

was

history of injury by forcible hyperextension. He both hands in his pockets, when he fell forward on to his face. He was unable to free his hands quickly enough to break his fall. He sustained a large bruise on his forehead. He was immediately paralysed in both arms and legs, retaining only shoulder movements, and had anaesthesia below the segmental level of C.6-7. Radiographs of the spine showed no abnormality except senile degenerative changes. After a spirited resistance, he died from urinary infection nine weeks after the injury.
with

Necropsy-The Radiographs
VOL.

cervical spine of the specimen

NO.

was removed showed no

1951

en bloc, abnormality

after laminectomy (Figs. 1 and

and
2).

removal

of

the
rupture

cord.
of

There

was

no

33 B,

4,

NOVEMBER

543

544

A. it.

TAVLOR

11G.

FIG.

FIG.

Case I. Figures 1 and 2-Radiographs of the cervical and upper thoracic spine removed a case of traumatic contusion of tile spinal cord with quadriplegia. There is 110 evident Figure 3-Microscopic section through tile spinal cord in tile area of the lesion. Fragmentation fibres extends from the posterior aspect of tile cord almost to the central canal

at

necropsv
bone of the lesion.

in nerve

(<

9).

the to be

anterior undamaged.

longitudinal

ligament,

and

careful

dissection

showed

all of

discs, softening
of tile

joints

and

ligaments

ihe
Microscopically,

spinal

cord
at

showed,
the site of

at
this

vertebral
softening,

level
there

C.4-5,
was

a small
gross

area
destruction

in there

its was

dorsal
columns,

half. marked
were

posterior

with gliosis. also

interruption The seen, but damage with

and

fragmentation extended
into the of

of the
anterior gliosis

nerve

fibres
columns, DO gross

(Fig.
where

3)

At its edges
of

well fibres.

compound

granular

corpuscles

a lesser

degree

and

interruption

the first,

nerve that

\Ve for that the the

felt spinal cord

justified cord had

in drawing to be been damaged struck

two b from

conclusions

from

these

findings:

it

was
; and

possible second,

hvperextension behind.

of an

intact

cervical

spine

ANATOMICAL

INVESTIGATIONS

lo determine
which made was opposite the outline adult and is radio-opaque vith
undisturbed
a

the
oil spine
in
series

impinging
had
various

agent
injected
positions.

radiographic
into The and 6). in
appeared

studies
the cervical neutral
on

were
spinal outline position

undertaken
canal. of the (Fig. surface by findings was a lumbar In like removed did by in the on
OF

on cadavers
Radiographs fluid But of inward that were on the the on column forced
column,

in
were

been (Fig.

the

in

smooth the

opaque 5).

flexion
of

4) (Fig.

the

hyperextensli)n

indentations

posterior to be caused the

the

interlaminar interlaminar by on who showed on cadavers. had five was

spaces as much cadavers undergoing spine indentations It been was

These It can cent Fig. and

appeared be of its 7). in the full seen total The from

bulging thecal a young Figures seen from an in constant

of

compressed
narrowed

ligaments. as 30 per (see in moderate also

radiographs These repeated

width. experiment for spaces spine

in experiments patient 9 show

contrast opposite confirmed, out, in the no the

investigations laminar a cervical hyperextension manner head of indentation

THE

lesion. full those intact, fact cause flexed anterior

AND JOINT

8 the

his cervical

hyperextension.

hyperextension which inward so surface

SURGERY

radiographs experiments the cord Figure the chin and and of the bulging

on that

dura

stripped ligaments that were when apposed

interlaminar the sternum

suggested a cadaver appeared

JOURNAL

radiographs. that of the

4 demonstrates

was

maximally

BONE

MECHANISM

OF

INJURY

TO

SPINAL

CORD

IN

NECK

WITHOUT

DAMAGE

TO

VERTEBRAL

COLUMN

545

the

oil column

opposite formation in

the

discs.

However, spines can

the be

significance seen in Lying Figure

of disc 7. The anteriorly,

degeneration fixed they act

and protrusions as counter

adjacent which points

osteophyte

senile

they

cause

further

reduce

the

margin

of safety.

FIG.

5
cervical spine of a space. Figure Figure 6-Spine in forward-bulging

FIG. cadaver after injection 4-Spine in full flexion. hyperextension, showing ligamenta fiava.

6
of opaque Figure notches oil into 5-Sl)ine opposite

Radiographs the cervical in neutral

of the subarachnoid position.

to

the

pressure

of of Barnes

the

forward-bulging (1948)
1951

ligamenta high incidence

flava. of these

This injuries

accords in the

with elderly.

the

clinical

observations
VOL.

on

the

33 B,

NO.

4,

NOVEMBER

546

A.

R.

TAYLOR

FIG. (ervical Ilava lesions show spine are

ill

7
The
i)ostr10r

of a cadaver
shown.

in

hvperextension.

notches

well this
increased

Anterior
risk

notches

at
notches in

C.4,

elderly

t lie

subject. These of hvperextension is caused l)\

5 and 6 are caused h were present in all positions

spine. ihe vessels.

tilling

of

the arthritic tile vertebral

caused b iiganienta degenerative disc of tile Siil, and anterior linear shadow

ii
FIG. itadiographs in moderate
few degrees

8 subject
showing

FIG. after the have

subarachnoid beginning of illJcctioIl posterior of

9 11111(1. Figure Figure 9---;

as iii

of a living
extension,

opaque

8-

-Spine
furtller

notching. notching

of

extension

produced

fuli

developed

the

cadaver.

DISCUSSION It maligned many recall bracliial takes most not its The attempt that pain place seems, otherwise the now again
produces

after

all, unexplained

that

the

projection has was agent and injury

which already the blamed but in

bruises

the more days role. that Those

cord

in

these its share

cases of is of

is

not

the
for to

intervertebral ligamentum rightly

disc-which flavum attributed injurious cord

to

hear earlier

than flavum. for

blame interest

symptoms-but to lesions sportsmen a rabbit,

ligamentum intervertebral

It much disc. of

the the

sciatic ligament force

and

of the in a new suggest

Now

as an spinal the

observations to break

of farmers neck

hvperextension with experience

is the

that do

readily

in animals.

of livestock

of a lien,

or a fIsh
THE

by
JOURNAL

flexion.
OF BONE AN!) JOINT SURGERY

IMECHANISM

OF

INJURY

TO

SPINAL

CORD

IN

NECK

WITHOUT

DAMAGE

TO

VERTEBRAL

COLUMN

547 flava
without

It are falling, caught of and the the themselves

is stated only to on between posterior (Fig. 6). The seen that

in markedly

Cunninghams elastic of the of the column, they can during contrast level at lesion damage press studies at laminae they

Text-book ligaments laminae into connect. on the showed which cord level in

of in Man. forward folds It theca

Anatomy By their flexion might that the point bulging occurs that

(1937) elasticity of the press they of in do

that

the
can

ligamenta
accommodate mater folds, approximation column,

they vertebral upon not the fall greatest

separation the arches The segmental

extension

which is true and is at greatest damage dictum

dura into curvature, flava

or but namely,

be by

compression-bulging C.4-5

its contents.

The greatest this

hyperextension

of ligamenta type with vertebral

between case hypothesis.

C.3 It lesions

C.6. 6 or 7. be

of our

is usually cord

.c.5,
will

Neural this

a vertebral to the

of C. 4, 5, 6 accords traumatic

conforms

and

occur

at the

sites

of greatest

spinal

mobility.
TREATMENT

From
cervical regarded in slight whether

the
paraplegia

evidence
without caused

here
by

adduced
radiographic forcible is

we would
evidence hyperextension necessary

venture
of bone and because is intact

to draw
damage treated there or not.

the
or is no

conclusion
displacement by has means of

that

cases
should

of
be

as injuries flexion. the anterior

as such Traction

immobilisation determining no value and

Immobilisation longitudinal

ligament

should The
recoil \Ve ischaemia. enlargement cause primary is from the cord.

not

be employed. of cord
relationships especially normal anywhere to the flow is dislocation of ligamenta

conception
urge Under than injury projection

injury
that conditions else. by to

by skeletal
and nurse the The extension, cord such cord

displacement
should has swells fluid no longer in a smaller after as judged re-forms patients

in hyperfiexion
influence hyperextension margin contusion, by causes the of safety sometimes Queckenstedts practical

with
is to at

spontaneous
management. cause the test. If cord cervical to If the injury

to normal would

is untenable

sufficiently

obstruction

of cerebrospinal flava,

hyperextension

redislocation. projection and

hyperextension

compresses

SUMMARY A case damage may reasons are extension

I should of this like paper,

of

cervical by inward

traumatic discs or bulging bulging of

paraplegia ligaments. of may such the occur, cases

is

described

in which evidence flavum during

there suggests of the

was that

no

evidence such injuries

of The

to be why discussed.

vertebrae, this inward

Experimental ligamentum despite is the considered

caused

h\perextension. ligamentum of importance

elasticity and the

flavum, avoiding

Treatment emphasised.
to express and to
my gratitude

to

Professor

Norman

Dr

R.

Saffley

and

Mr

R.

White

for

M. Dott for advice and criticism in the preparation their assistance with the radiological studies.

REFERENCES BARNES,
CRAMER,

R. F.,

(1948): and Injuries D. London: R., and

Paraplegia MCGOWAN, F. of the Spinal

in Cervical

Spine Role

Injuries. of the Gynecology

Journal Nucleus and

of Bone Pulposus Obstetrics, edition.

and

Joint

Surgery,

30-B,

234.

J.

Recoil CUNNINGHAM,

(1944): The Cord. Surgery, of

Press.

in the Pathogenesis 79, 516. Edited by

of so-called Brash with and E. Normal B.

J.

(1937):
Oxford

Text-book
University

Anatomy. Paraplegia and Joint

Seventh in

J. C.
Injuries

J arnieson,
TAYLOR,

A.

BLACKWOOD, Journal

W. of

(1948): Bone

Hyperextension

Cervical

Radiographic

Appearances.

Surgery,

30-B,

245.

VOL.

33 B,

NO.

4,

NOVEMBER

1951