The results of the conservative and aggressive surgical plans of management for incomplete cord injuries have been difficult to compare and have not been evaluated with modern neurologic techniques. Collins, a participant in the National Institutes of Health (NIH) study of acute management of spinal cord injury 20 years ago, concluded that the survival rate was increased as a result of early surgical stabilization of fractures and fixation of the spine. Others, however, have not been able to document a reduction in neurologic disability and have increasingly been inclined toward nonoperative management of both complete and partial spinal cord lesions (e.g., see Clark; Murphy et al). Many North American neurosurgeons take the less aggressive stance, delaying operation or operating only on patients with compound wounds or those with progression or worsening of the neurologic deficit despite adequate reduction and stabilization. In each case, the approach is guided by the specific aspects of the injuries; ligamentous disruption, presence of hematoma, misalignment-displacement of spinal segments, instability of the injury, and fracture type.
The greatest medical risks to the patient with spinal cord injury occur in the first 10 days when gastric dilatation, ileus, shock, and infection are threats to life. According to Messard and colleagues, the mortality rate falls rapidly after 3 months; beyond this time, 86 percent of paraplegics and 80 percent of quadriplegics will survive for 10 years or longer. In children, the survival rate is even higher according to DeVivo and colleagues, who found that the cumulative 7-year survival rate in spinal cord–injured children (who had survived at least 24 h after injury) was 87 percent. Advanced age at the time of injury and being rendered completely quadriplegic were the worst prognostic factors.
The aftercare of patients with paraplegia, in addition to substantial psychological support to allow accommodation to new limitations while encouraging a productive life, is concerned with management of bladder and bowel disturbances, care of the skin, prevention of pulmonary embolism, and maintenance of nutrition. At first, continual catheterization is necessary; then, after several weeks, the bladder can be managed by intermittent catheterization once or twice daily, using a scrupulous aseptic technique. Bacteriuria alone is common and does not require treatment with antibiotics unless there is associated pyuria. Morning suppositories and periodically spaced enemas are effective means of controlling fecal incontinence. Chronic pain (present in 30 to 50 percent of cases) requires the use of nonsteroidal anti-inflammatory medication, injections of local anesthetics, and transcutaneous nerve stimulation. A combination of carbamazepine or gabapentin and either clonazepam or tricyclic antidepressants may be helpful in cases of burning leg and trunk pain. Remaining pain may require more aggressive therapy, such as epidural injections of analgesics or corticosteroids or an implanted spinal cord stimulator that is applied to the dorsal columns or an analgesic pump, but often even these measures are ineffective. Fentanyl transcutaneous patches may be tried. Spasticity and flexor spasms may be troublesome; oral baclofen, diazepam, or tizanidine may provide some relief. In permanent spastic paraplegia with severe stiffness and adductor and flexor spasms of the legs, intrathecal baclofen, delivered by an automated pump in doses up to 400 mg/d, has also been helpful. The drug is believed to act at the synapses of spinal reflexes (Penn and Kroin). Selective injection of botulinum toxin may provide relief of some spastic deformities and of spasms. One must be alert to the threat of pulmonary embolism from deep-vein thrombi, although the incidence is surprisingly low after the first several months.