Glottic and tracheal stenosis in spinal cord injured patients - Hsu S.; Dreisbach J.N.; Charlifue S.W.; English G.M. (Paraplegia, 1987)
Between 1965 and 1985, 47 cases of glottic and/or tracheal stenosis were diagnosed at the Rocky Mountain Regional Spinal Cord Injury System. A retrospective review of medical records identified associated injuries, pulmonary and other medical complications in this patient population. Radiographic and endoscopic reviews utilised a grading system to classify the severity of stenosis. The clinical symptoms of stenosis were multiple, including dysphonia, aspiration, dysphagia, odynophagia, dyspnea and excessive secretions. The wide spectrum of treatment modalities included endoscopy with excision and/or dilation, general medical management, steroids, radiation therapy, intubation, stent insertion and surgical repair of the stenotic area. Outcome status was reviewed and suggestions provided for the early diagnosis and treatment of this potentially life-threatening condition.
Keywords: central nervous system; clinical article; diagnosis; etiology; glottis stenosis; human; injury; larynx; management; respiratory system; spinal cord injury; therapy; trachea stenosis; tracheotomy

Management of airway trauma. II: Combined injuries of the trachea and esophagus - Kelly J.P.; Webb W.R.; Moulder P.V. (Annals of Thoracic Surgery, 1987)
Twenty-four consecutive patients with combined injuries of the trachea and esophagus were operated on at the Tulane University Hospital and the Charity Hospital of New Orleans between 1967 and 1983. Only 3 of the injuries resulted from blunt trauma, and 1 of these patients had a total transection of both the trachea and esophagus; the remaining injuries were due to penetrating trauma (20 gunshot wounds; 1 stab wound). The combined lesions involved the cervical region in 20 patients and the thoracic esophagus and trachea or bronchus in 4. All patients underwent bronchoscopy; in recent years all have had esophagoscopy, because our experience indicates that esophagrams, which patients also underwent, have a high rate (12.5%) of false negative results. Operative techniques included a two-layer closure of all esophageal injuries, closure of the trachea with non-absorbable monofilament suture, and transthoracic or cervical drainage. Muscle flaps were used for suture line reinforcement. Associated operative procedures included tracheostomy (5), laparotomy (4), vascular procedures (5), neurologic procedures (2), and close-tube thoracostomy (6). Five patients (21%) died in the perioperative period, 4 of 20 with combined cervical injuries, and 1 of the 4 with combined thoracic injuries. Deaths resulted from missed injuries to the esophagus (2 patients), a missed tracheal injury (1), associated vascular injury (1), and associated thoracoabdominal injury (1). Two patients experienced cervical esophageal suture line leaks, both of which sealed with conservative therapy. Clinical follow-up showed good results in 90% of the patients who survived. One patient had late neurologic sequela of the injury, including spinal cord trauma and recurrent nerve paralysis, and 1 had pharyngeal paralysis from extensive neurologic damage in the neck. No patient had esophageal or tracheal stenosis.
Keywords: blunt trauma; bronchoscopy; clinical article; diagnosis; esophagoscopy; esophagus; human; injury; priority journal; respiratory system; therapy; thorax penetrating trauma; thorax surgery; trachea

Postextubation airway obstruction after anesthesia for posterior fusion of occipital bone and cervical spine - Kainuma M.; Yamada S. (Japanese Journal of Anesthesiology, 1985)
A 53-year old female suffering from atlanto-axial subluxation due to advanced rheumatoid arthritis was scheduled for posterior fusion of the occipital bone and cervical spine. The trachea was transnasally intubated with a spiral tube, using the fiber-optic bronchoscope because of being unable to open the mouth caused by temporo-mandibular joint ankylosis. under nitrous oxide-oxygen-enflurane anesthesia, the surgery was finished uneventfully after 8 hours, resulting in the spine completely fixed at the severe flexion position. After recognizing that she awoke by opening eyes and grasping hand following the anesthetist's orders, the trachea was extubated, without removing her Halo-vest. Although she could speak easily to the anesthetist just after extubation, her upper airway was rapidly obstructed, followed by general cyanosis and severe hypotension. Emergency tracheostomy was carried out maintaining her airway. This airway complication was considered to be attributed to the severe flexion fixation of the spine resulting from the surgery and wearing the Halo-vest, and the worsening of the already compromised cricoarytenoid joint by the stimulus of the fiber-optic bronchoscope.
Keywords: airway obstruction; bone; case report; cervical spine fusion; extubation; fiberoscope; human; joint; postoperative complication; priority journal; respiratory system; rheumatoid arthritis; therapy

Odontoid upward migration in rheumatoid arthritis. An analysis of 45 patients with 'cranial settling' - Menezes A.H.; VanGilder J.C.; Clark C.R.; El-Khoury G. (Journal of Neurosurgery, 1985)
Lack of correlation between the severity of rheumatoid subluxation of the upper cervical vertebrae and supposed absence of neurological damage has led to erroneous supposition that this finding is innocuous. Incomplete autopsy studies in rheumatoid arthritis have failed to recognize the cause of death, despite previously proven dramatic occipito-atlanto-axial dislocations. The most feared entity of rheumatoid basilar invagination, namely 'cranial settling', is poorly understood. Between 1978 and 1984, the authors treated 45 rheumatoid arthritis patients who were symptomatic with 'cranial settling'. This consisted of vertical odontoid penetration through the foramen magnum (9 to 33 mm), occipito-atlanto-axial dislocation, lateral atlantal mass erosion, downward telescoping of the anterior arch of C-1 on the axis, and rostral rotation of the posterior arch of C-1 producing ventral and dorsal cervicomedullary junction compromise. Cervicomedullary junction dysfunction has mistakenly been called 'entrapment neuropathy', 'progression of disease' or 'vasculitis'. Occipital pain occurred in all 45 patients, myelopathy in 36, blackout spells in 24, brain-stem signs in 17, and lower cranial nerve palsies in 10. Four patients had prior tracheostomies. Four previously asymptomatic patients with 'cranial settling' presented acutely quadriplegic. The factors governing treatment were reducibility and direction of encroachment determined by skeletal traction and myelotomography. Transoral odontoidectomy was performed in seven patients with irreducible pathology. All patients underwent occipitocervical bone fusion (with C-1 decompression if needed) and acrylic fixation. Improvement occurred during traction, implying that compression might be the etiology for the neurological signs. There were no complications. Thus, 'cranial settling' is a frequent complication of neurological signs. There were no complications. Thus, 'cranial settling' is a frequent complication of rheumatoid arthritis; although it is poorly recognized, it has serious implications and is treatable.
Keywords: basilar impression; bone; bone fusion; brain stem compression; central nervous system; cervical myelopathy; cervical spine; clinical article; cranial nerve paralysis; diagnosis; human; joint; myelography; occipital pain; odontoid process; peripheral nervous system; priority journal; rheumatoid arthritis; spinal cord compression; spinal cord disease; therapy; tomography; tooth; traction therapy; vertebral artery compression

Fracture of the cervical spine complicating bilateral fractures of the mandible: a case report. - Hemmings K.W. (The British journal of oral & maxillofacial surgery, 1985)
A case reported of a 21-year-old male who sustained a fracture of the body of the second cervical vertebra, a bilateral fracture of the mandible and a deep laceration on the left side of his neck. The importance of excluding cervical spine fractures in cases of severe trauma to the head and neck is emphasised, and the airway management problems are discussed.
Keywords: adult; article; second cervical vertebra; case report; fracture; fracture fixation; human; immobilization; injury; male; mandible fracture; tracheotomy

Atelectasis in spinal cord injured people after initial medical stabilization. - Sugarman B. (The Journal of the American Paraplegia Society, 1985)
Two hundred and forty-three spinal cord injured people were evaluated during 271 consecutive admissions to a spinal cord injury service over four years. These patients all had received initial medical stabilization after spinal cord injury prior to admission. Atelectasis with or without apparent pulmonary infiltrate or pleural effusion was documented in six quadriplegics, all on the left side. Five out of the six had tracheostomies. Atelectasis occurred days to months after injury and initial medical stabilization. The patients often had symptoms and findings suggestive of other illnesses and may have had more invasive diagnostic and therapeutic procedures if the diagnosis of atelectasis was not provisionally made. Associated dyspnea delayed the rehabilitation of several patients. Response to vigorous pulmonary therapy and bronchoscopy, if necessary, was prompt, with complete resolution in less than 24 hours. The inability to clear secretions that caused this problem was responsible for recurrences in three patients. Preventive and therapeutic modalities such as assisted coughing, deep breathing, incentive spirometry, chest percussion, and suctioning, if necessary, should be practiced. Atelectasis may still occur after the original injury.
Keywords: aged; article; atelectasis; case report; female; human; male; quadriplegia; spinal cord injury; thorax radiography

Respirator-dependent quadriplegics: problems during the weaning period. - Lamid S.; Ragalie G.F.; Welter K. (The Journal of the American Paraplegia Society, 1985)
During a two-year period we admitted 13 respirator-dependent quadriplegic patients to the spinal cord injury service at Wood VAMC for weaning from a mechanical ventilator, and rehabilitation. The patients were sent to the Spinal Cord Injury Center because initial weaning attempts from the respirator at other medical centers were unsuccessful. We successfully weaned them from the respirator, and at the time of discharge, only two patients required an indwelling tracheostomy tube for suction. The time required for weaning off the respirator varied from two days to 14 months. Most of the patients were discharged and many of them could independently perform the activities of daily living. We conclude that are four main factors which influence the successful weaning of dependent quadriplegics from the mechanical ventilator: alleviation of patient's anxiety and depression; family support; close working relationship between staff; prevention of complications such as pneumonia and urinary tract infections.
Keywords: action potential; adult; anxiety; article; artificial ventilation; case report; female; human; injury; male; middle aged; phrenic nerve; psychological aspect; quadriplegia; respiratory failure; stimulation

Cefoperazone in the treatment of postsurgical wound infection, sepsis, and abscess of the spinal cord and brain - Jung Hyun Woo; Jae Kwang Ryu (Clinical Therapeutics, 1984)
Cefoperazone was used in the treatment of 23 cases of serious bacterial infection in 20 patients. Ten postoperative scalp wound infections, five infections at the site of tracheostomy, four cases of extradural spinal cord abscess, three cases of sepsis, and one abscess of the cerebellopontine angle were treated with cefoperazone (1 to 2 gm BID, usually for seven to 27 days). There were excellent or good clinical responses in 87% (20/23) of the cases (14 of the 15 postsurgical wound infections, three of the four cases of spinal cord abscess, and all three cases of sepsis). Most of the organisms isolated from the patients' cultures were sensitive to cefoperazone. Excellent or good responses occurred in ten of the 12 infections due to Staphylococcus aureus, in all three infections due to Pseudomonas sp, all three due to Citrobacter freundii, the two due to Serratia marcescens, one of the two due to Klebsiella sp, and the one due to Escherichia coli. Two patients with ventriculitis were clinically improved by three 1-gm infusions, via a shunt, of cefoperazone. No adverse effects of the antibiotic therapy were reported.
Keywords: cefoperazone; adverse drug reaction; bacterial infection; brain abscess; central nervous system; clinical article; drug efficacy; drug therapy; human; intramuscular drug administration; intravenous drug administration; methodology; postoperative infection; priority journal; prophylaxis; sepsis; spinal cord abscess; therapy; wound infection

Microscopic decompression of the anterior upper cervical spine: A case of odontoid malunion to the atlas - Miller J.; Parent A.D. (Neurosurgery, 1984)
For the past 20 years, the transoral approach to the upper cervical spine has been utilized for odontoid fractures, the removal of an abnormal odontoid process, decompression of basilar impression, and biopsy or resection of nasopharyngeal or metastatic tumors. The effectiveness and safety of this procedure is well documented. Use of the surgical microscopic adds to the efficiency and safety of the procedure. We are reporting a case of fusion of the odontoid base to the anterior arch of the atlas. To our knowledge, this entity has not been described previously. The spinal cord was protected by an initial posterior fusion of C-1, C-2, followed in 10 days by a tracheostomy and the transoral removal of the anterior C-1 arch and the abnormal dens. Because the medical history did not reveal a source of trauma, it is supposed that the patient had malunion of the odontoid process to C-2, with subsequent migration and fusion of the dens to the C-1 arch.
Keywords: first cervical vertebra; bone; case report; central nervous system; cervical spine; computer analysis; computer assisted tomography; diagnosis; human; odontoid process; spinal cord compression; therapy

Transoral operations for craniospinal malformations. - Gilsbach J.; Eggert H.R. (Neurosurgical review, 1983)
The transoral approach to the lower third of the clivus and to the ventral aspect of the upper cervical spine is used in craniospinal malformations with or without dislocation as well as in basilar aneurysms, ventrally situated cranio-spinal tumours, fractures of the odontoid process, and in rheumatoid arthritis compressing the spinal cord. In consideration of the literature and ten personal cases the indications and techniques of the transoral approach in craniospinal malformations are discussed. According to our own experiences and those of other authors it is possible to expose the lower clivus and the cervical spine down to C2 by a midline incision of the pharyngeal wall using a mouth retractor and oral intubation. Splitting of the soft palate or resection of the hard palate are not necessary, a tracheotomy should be performed only in exceptional cases. In congenital craniospinal malformations without dislocation or instability causing a ventral compression of the spinal cord, for instance by the odontoid process, the transoral decompression is preferable to dorsal decompressing operations. In cases of pure instability without any space-occupying lesion the transoral and posterior approach are possible in order to perform a fusion. The last one seems more advantageous in these cases. In craniospinal malformations with dislocation causing a ventral and dorsal narrowing of the spinal canal, apart from the decompression a stabilization has to be achieved. In these usually complex malformations individual treatment is necessary. According to the rare cases in the literature and to our own experience a primary anterior decompression, followed by a most careful posterior stabilization seems to produce the most favourable results.
Keywords: adult; article; atlantoaxial joint; second cervical vertebra; basilar impression; bone dysplasia; cervical spine; congenital malformation; dislocation; female; human; Klippel Feil syndrome; male; middle aged; radiography; skull; procedures

Respiratory complications of achondroplasia - Stokes D.C.; Phillips J.A.; Leonard C.O. (Journal of Pediatrics, 1983)
Nine patients with achondroplasia who were seen over a three-year period developed significant respiratory complications. Eight had sleep-disordered breathing, including obtructive sleep apnea in five, for which two required tracheostomy. Of the seven patients with significant hypoxemia, five had clinical evidence of cor pulmonale and recurrent pulmonary infiltrates. Two patients died, one with autopsy findings of compression of the medulla at the level of the foramen magnum and one with respiratory and cardiac failure. Appropriate therapy for our patients depended on recognition of the mechanisms that led to the respiratory complications, including (1) chest deformity, (2) upper airway obstruction and sleep-disordered breathing, (3) neurologic complications, and (4) coincidental chronic pulmonary conditions such as asthma.
Keywords: achondroplasia; asthma; bone; breathing disorder; central nervous system; congenital disorder; diagnosis; etiology; heart; heart failure; human; hypoxemia; infant; lung infiltrate; major clinical study; newborn; respiratory system; sleep disordered breathing; spinal cord compression; thorax malformation

Anaesthetic considerations in patients with muscular dystrophy undergoing spinal fusion and Harrington rod insertion - Milne B.; Rosales J.K. (Canadian Anaesthetists Society Journal, 1982)
Charts of nine patients with Duchenne and one with Becker's muscular dystrophy who had undergone spinal fusion and Harrington rod insertion for scoliosis were reviewed retrospectively. The mean age was 15 years and mean angle of scoliosis was 69 degrees. Preoperative pulmonary function studies showed a restrictive defect with a mean vital capacity of 1.3 ± 0.69 litres, 35 ± 20 per cent of predicted value, 33 ± 20 ml.kg-1 and a mean inspiratory capacity of 0.99 ± 0.5 litres, 23 ± 13 ml/kg-1. There were no anaesthetic complications during operation and obstructive cardiomyopathy, hyperpyrexia, hyperkalaemia and rhabdomyolysis were not problems. Succinylcholine was avoided. One patient developed an arrhythmia postoperatively and one patient whose postoperative problems included tracheostomy, pneumonia and sepsis could not be weaned from the ventilator and died 11 weeks after operation. As assessing risk and survival of the operation depends on objective pulmonary function, a vital capacity of at least 20 ml/kg-1 in the range of 30 per cent of predicted volume with an inspiratory capacity of at least 15 ml/kg-1 would appear to be adequate in patients with muscular dystrophy requiring Harrington rod insertion. Other factors including the rapidity of progression of the muscular disease, other respiratory and cardiovascular problems, and disease such as obesity should also be considered.
Keywords: anesthesia; bone; case report; harrington technique; lung function; muscle; muscular dystrophy; respiratory system; scoliosis; spine fusion; therapy

Respiratory problems encountered in appliance fitting, orthopedic correction and surgical treatment of trunk-muscle paralyses in children and adolescents - Barois A.; Estournet B.; Harountunian A.; Adrien A. (Annales de Medecine Physique, 1982)
After birth the pulmonary alveoli multiply up to the age of 4 to 8 years, then they increase in size. The respiratory paralyses and the thoracic deformations that they entail have a repercussion on this pulmonary growth. Study of 66 children in whom the paralytic disease commenced before 4 years and some of whom were submitted to an intermittent or permanent artificial ventilation, enabled the authors to confirm the efficacy of pulmonary mobilisation to promote the alveolar growth. In a second part are specified the most appropriate ways of giving artificial ventilation in the paralytic respiratory insufficiency of the little child. The orthopedic correction and the surgical treatment of paralytic scolioses should avoid all impairment of the ventilatory function. Above all, vertebral arthrodesis should be followed by a systematic endotracheal ventilation for at least 8 days to avoid a considerable restriction of the immediate and later vital capacity which would run the risk of leading to a definitive tracheotomy for respiratory aid.
Keywords: adolescent; central nervous system; lung ventilation; major clinical study; muscle; muscle disease; musculoskeletal system; nervous system; paralysis; poliomyelitis; preschool child; respiratory system; school child; spinal cord injury; therapy

A simplified alternative to orthogonal field overlap when irradiating a tracheostomy stoma or the hypopharynx - Pezner R.D.; Findley D.O. (International Journal of Radiation Oncology Biology Physics, 1981)
Orthogonal field arrangements are usually employed to irradiate a tumor volume which includes a tracheostomy stoma or the hypopharynx. This approach may produce a significantly greater dose than intended to a small segment of the cervical spinal cord because of filed overlap at depth from divergence of the beams. Various sophisticated approaches have been proposed to compensate for this overlap. All require marked precision in reproducing the fields on a daily basis. We propose a simplified approach of initially irradiating the entire treatment volume by anterior and posterior opposed fields. Opposed lateral fields that exclude the spinal cord would then provide local boost treatment. A case example and computer-generated isodose curves are presented.
Keywords: case report; hypopharynx cancer; larynx; methodology; pharynx; radiation field; radiotherapy; respiratory system; therapy; tracheostomy

Associated injuries in patients with spinal injury - Silver J.R.; Morris W.R.; Otfinowski J.S. (Injury, 1980)
The associated injuries found in 100 consecutive spinal injuries are described. Fifty-one of the patients had injuries of the cervical cord, 31 per cent complete. A total of 75 per cent of the patients had associated injuries, the commonest being a head injury. Chest injuries were the next most frequent. The management of these injuries in the presence of a severe spinal injury is described. The importance of early tracheostomy and prophylactic anticoagulant therapy is stressed in reducing the mortality to the order of 2 per cent. The value of spinal injury units is emphasized.
Keywords: central nervous system; injury; major clinical study; musculoskeletal system; spinal cord injury; spine injury

Unilateral diaphragmatic paralysis in spinal cord injury patients - Carter R.E. (Paraplegia, 1980)
Since the inception of the Spinal Cord Injury Center of The Institute for Rehabilitation and Research in 1961, over 1600 spinal cord injury patients have been admitted. Of these patients, approximately 51 per cent or 821 are tetraplegics. A review of the medical records shows that 22 patients had unilateral diaphragmatic paralysis. All but one of these patients are male, and they range in age from 15 to 73 years of age at onset. All cases with unilateral diaphragmatic paralysis are reviewed as to side of paralysis, incidence of tracheotomy, initial vital capacity, final vital capacity, and estimation as to the duration of diaphragmatic paralysis.
Keywords: central nervous system; diaphragm; diaphragm paralysis; injury; major clinical study; muscle; paraplegia; quadriplegia; respiratory system; spinal cord injury; tracheotomy; vital capacity

Neurogenic respiratory failure: A 5-year experience using implantable phrenic nerve stimulators - Oakes D.D.; Wilmot C.B.; Halverson D.; Hamilton R.D. (Annals of Thoracic Surgery, 1980)
During the past 5 years, 20 phrenic nerve stimulators have been implanted in 11 patients who were ventilator dependent because of neurogenic respiratory failure. Ten patients had traumatic spinal cord lesions; the remaining patient suffered from a progressive demyelinating disease. There was no operative mortality. Complications included 1 stimulator malfunction and 1 pneumothorax. In spite of adjacent tracheostomies, there were no infections or wound complications. Of the 20 stimulators implanted, 13 initially produced good diaphragmatic function, 2 had fair function, and 5 had little or no function. Three patients became completely independent of their ventilators; 6 became partially independent, thus simplifying nursing care. There were no late complications. As of December 1979, 7 patients had benefited or were continuing to benefit from phrenic nerve stimulation.
Keywords: artificial ventilation; central nervous system; demyelinating neuropathy; diaphragm; major clinical study; methodology; nervous system; neuromuscular disease; peripheral nervous system; phrenic nerve pacing; respiratory failure; respiratory system; spinal cord injury; therapy

Myelopathy in mucopolysaccharidosis type II (Hunter syndrome) - Ballenger C.E.; Swift T.R.; Leshner R.T. (Annals of Neurology, 1980)
A 24-year-old man with Hunter syndrome has spastic quadriparesis due to impingement of thickened meninges upon the cervical spinal cord. Tracheal narrowing due to submucosal deposits (presumably mucopolysaccharide) produced serious ventilatory complications during induction of anesthesia and necessitated tracheostomy before surgical decompression of the spinal cord could be attempted. Recognition of compressive myelopathy and tracheal compromise as late complications of Hunter syndrome may promote early therapy and prevent respiratory catastrophe.
Keywords: case report; central nervous system; Hunter syndrome; spastic tetraplegia; spinal cord disease

Clinical study of injuries of the lower cervical spinal cord - Julow J.; Szarvas I.; Sarvary A. (Injury, 1979)
The number of injuries of the spinal cord is increasing (from 9 to 24%). If there is a spinal block, a positive cisternal myelogram is recommended, as this is the only reliable procedure to indicate operation. The treatment is not uniform. Some authors prefer the conservative method; others perform laminectomy. 74% of deaths are due to respiratory complications. A prophylactic tracheostomy may reduce them. The prevention of blood clotting and urinary infection are no different from the well known methods. (Pap - Debrecen)
Keywords: Brown Sequard syndrome; central nervous system; cervical spine; injury; major clinical study; neck injury; spinal cord injury

Paraplegia and tetraplegia in spinal injuries - Lepisto P.; Harkonen M.; Paakkala T. (Acta Orthopaedica Scandinavica, 1979)
The series consisted of 29 patients operated on in 1968-75, 25 of whom were followed up until 1978. In 12 cases the indication for operation was severe radicular symptoms which did not respond to conservative treatment and which were connected with considerable degeneration of the corresponding spinal segment only. Seventeen patients were operated on for instability of the cervical spine caused by traumatic injury. The injury had been dislocation and radicular or medullary symptoms which persisted in spite of conservative treatment with skull traction or a collar. The late result was evaluated with a view to objective neurological improvement, subjective improvement, present symptoms and working capacity. All fusions were radiologically successful. The late result was fair or better in 7/11 in the degeneration group and in 12/14 in the traumatic injury group. An age of over 35 years and a preoperative motor defect were statistically significant factors for a poor prognosis in the traumatic injury group. Preoperative sick-leave and preoperative symptoms lasting over 6 months were prognostic factors for a poor result in the degeneration group.
Keywords: case report; central nervous system; diagnosis; injury; nervous system; paraplegia; quadriplegia; respiratory system; spine; therapy; thrombosis; tracheostomy; urinary tract infection

Spinal cord injuries associated with vertebral fractures and dislocations. Clinical and radiological results in 30 patients - Harkonen M.; Lepisto P.; Paakkala T. (Archives of Orthopaedic and Traumatic Surgery, 1979)
During the period 1968-1975, 11 patients with paraplegia and 19 with tetraplegia were treated at the Central Hospital of Tampere. The mean age of the patients was 33 years. The spinal cord injury was sustained in a traffic accident in 11 cases, at work in 6 and at home or during leisure hours in 13. The injury was due to fall or to hitting the bottom in diving in 17 cases. Reduction and osteosynthesis (Williams) were performed on 4 paraplegic patients. The tetraplegics were treated by skull traction and an orthopedic brace. The average duration of primary hospital treatment was 69 days for the paraplegics and 72 days for the tetraplegics. Tracheostomy was performed on 7 tetraplegic patients. Tracheal stricture, which developed in 2 cases, was conservatively treated. A catheter a demeure was applied primarily in all cases, and urinary infection developed in all patients. Four paraplegics and 4 tetraplegics developed deep venous thrombosis, which led to pulmonary embolism in 1 paraplegic and 2 tetraplegic patients. All these patients recovered. During primary hospital treatment 3 paraplegics and 5 tetraplegics developed bed sores, which were operatively treated in 4 cases. Two paraplegic and 8 tetraplegic patients died during primary hospital treatment; three of these patients had also sustained a severe brain injury. In addition, 1 paraplegic and 2 tetraplegic patients died of pulmonary infection during the five-year follow-up period. At the time of follow-up examination 7 paraplegics were nursed at home and 1 was in institutional care; the corresponding figures for the tetraplegics were 3 and 6. Five of the paraplegics were ambulant in a wheel-chair, 2 walked with the aid of crutches, and 1 was a bed-patient. Of the tetraplegics, 6 were ambulant in a wheel-chair and 3 were nursed in bed. All surviving patients, 1 paraplegic excepted, had a disability pension.
Keywords: central nervous system; diagnosis; injury; major clinical study; musculoskeletal system; paraplegia; quadriplegia; spinal cord injury; spine fracture dislocation

Acute respiratory insufficiency in traumatic tetraplegia - Hachen H.J. (Minerva Anestesiologica, 1979)
The author reviews the case-histories of 188 patients with acute traumatic tetraplegia who were admitted to the National Spinal injuries Centre over the past 20 years. Since the introduction, in 1968, of a highly specialized, nation-wide helicopter rescue-system and the immediate transfer (within 1 1/2 hours) of all polytraumatized patients to an intensive-care unit attached to the Paraplegic Centre, the mortality rate for complete tetraplegics (n = 117) has dropped from 32,5% in 1966 to 6,8% in 1976. For the 71 patients with incomplete lesions the numbers are 9,9% and 1,4% respectively. Most early deaths were found to be related to pulmonary complications. Due to paralysis of the thoracic muscles, the existence of severe hypoventilation and absence of the cough reflex, severe respiratory insufficiency may develop within a few hours after injury and this in the absence of any direct trauma to the chest. Tracheotomy had to be performed in 22,2% (= 26) of the patients with complete and in 5,6% (n = 4) of the ones with incomplete lesions. In 33,5% of all tetraplegics temporary nasotracheal intubation for periods of up to two weeks proved entirely sufficient. No complication arose from this procedure. On the other hand 4 patients with tracheostomy developed severe local infection with resistant gram-negative germs, 2 showed posterior tracheomalacia, 1 was found to have distal tracheal stenosis and another one required surgical care for acute local hemorrhage. In view of this relatively high rate of complications (26,7%) 'prophylactic tracheostomy' does not seem advisable. Facilities for continuous monitoring of central venous pressure, arterial pressure, pulse rate, breathing pattern, pO2, pCO2, pH, electrolytes and blood and urine osmolality must be available for all patients with neurological levels above C6.
Keywords: central nervous system; injury; major clinical study; quadriplegia; respiratory failure; respiratory system; therapy

The management of tumors of the upper cervical spine - Dunn E.J.; Anas P.P. (Orthopedic Clinics of North America, 1978)
Tumors of the atlas and axis are exceedingly uncommon lesions. A review of the literature provided 28 cases, of which two-thirds were the result of metastatic processes. Benign endoplasms in this region may cause serious sequelae resulting from impingement upon the lower brainstem, upper cervical cord, and vertebral arteries. Vigorous therapeutic endeavors should be undertaken with the aim of achieving complete amelioration of pain, reversal of neurologic impairment, and attainment of cervical stability. Although the underlying disease process in the majority of patients may be a terminal condition, improved longevity combined with the presence of disabling pain and neurologic compromise demands carefully planned treatment. Important points discussed include: It is necessary to establish tissue diagnosis by the appropriate method. The transpharyngeal needle biopsy of Ottolenghi is a safe and dependable method for obtaining tissue from the anterior elements of C1 and C2. Cord compression may result from two basic mechanisms, and it is necessary to resort to cervical myelography to distinguish between the two. Flexion and extension views, cineradiography, angiography, and tomography may assist in patient evaluation. Guidelines for planning the surgical approach are offered, as well as preferred exposure techniques. Anterior surgery in this region is a major undertaking and should be reserved for patients with benign anterior tumors or cancer patients with a good prognosis and specific indications. Tracheostomy should be carried out to avoid postoperative complications after anterior surgery. Whenever possible, bone grafting should be used to establish cervical fusion. Several drawbacks to succesful bone grafting exist in the case of metastatic disease. Some of these factors may be circumvented with the use of methyl methacrylate alone or in combination with a bone graft. Acrylic also allows early postoperative ambulation without the need for cumbersome external immobilization devices.
Keywords: bone; spine tumor; therapy

Vertebrectomy and fusion in the cervical spine - Karaguiosov L.; Andreeff I. (Orthopadische Praxis, 1978)
Total replacements of cervical vertebrae are relatively rare and are occasionally indicated in tumors and inflammations, as this report of 8 cases demonstrates. In case the third cervical vertebra is affected, the approach according to Stevenson is given preference to the transoral approach. Intubation necessitates, however, preoperative tracheotomy. For surgical interventions below the third cervical vertebra the ventral or ventrolateral approach is used. If the tumor has already affected the dorsal part of the cervical spine, bilateral operative treatment may become necessary.
Keywords: bone; bone resection; cervical spine; major clinical study; methodology; spine fusion; spondylodesis; therapy; vertebra

Intra medulla oblongata and cervical ependymoma (surgery, apnea for two months and improvement) - Banayan A.; Guerin J.; Boulard G. (Neurochirurgie, 1978)
A 17-year-old female was first seen in a neurology department in December 1975. She was running a low grade fever; her general status was not good. At the physical examination she presented with an amyotrophy of both arms, mainly proximal, a thermo analgesic dissociation which was complete from C1 to C5 and incomplete from C5 to D4, and a spastic quadriparesis (with a posterior spinal syndrome). The first physical disabilities had appeared 15 months before. Myelography revealed an enlarged spinal cord in the upper part of the cervical region and the contrast media could not pass through the foramen magnum. At surgery a mass localized on the right side, inside the medulla oblongata and the spinal cord, with a cyst at each extremity, reaching C4 in the lower part and the recessus lateralis in the upper part. During surgery the patient was breathing spontaneously. After the removal of the mass, she presented with apnea. The quadriplegia following surgery was very brief. She rapidly recovered normal motor activity in both legs and in the right arm. Respiratory paralysis remained complete for 2 months. The right diaphragm recovered completely in 4 months, the left one only partially. 4 Months after surgery, she was discharged and returned home. One year later, to ensure security, she still has a tracheotomy. The distal paralysis of the left superior arm is still present.
Keywords: adolescent; apnea; case report; central nervous system; diagnosis; ependymoma; quadriplegia; spine surgery; therapy

Stabilization of the collapsing spine in Duchenne muscular dystrophy - Sakai D.N.; Hsu J.D.; Bonnett C.A.; Brown J.C. (Clinical Orthopaedics and Related Research, 1977)
Of 41 patients with Duchenne muscular dystrophy, no ambulatory patient had scoliosis greater than 19°. Non-ambulatory patients were prophylactically placed in body jackets, which kept the spine flexible and provided adequate support for sitting in the majority of patients. Ten patients had posterior spine fusion for progressive spinal collapse. The procedure was extensive with significant blood loss but bony fusion was achieved in every case. Pulmonary complications were minimized by performing preoperative tracheostomy on all patients who had vital capacities less than 40% and or non-functional coughs. Spinal fusion permitted long-term sitting stability despite the progression of the disease.
Keywords: diagnosis; Duchenne muscular dystrophy; etiology; major clinical study; methodology; radiography; scoliosis; spine fusion; spine lesion; spine stabilization; therapy

Idealized care of the acutely injured spinal cord in Switzerland - Hachen H.J. (Journal of Trauma, 1977)
Case histories of 188 patients with acute traumatic tetraplegia who were admitted to the National Spinal Injuries Centre over the past 10 years are reviewed. Since the introduction, in 1968 of a highly specialized nationwide helicopter rescue system and the immediate transfer of all patients with multiple trauma to an intensive-care unit attached to the Paraplegic Centre, the mortality rate for complete tetraplegic (n = 117) has dropped from 32.5% (1966) to 6.8 (1976), and for the 71 patients with incomplete lesions from 9.9% to 1.4%. Most early deaths were found to be related to pulmonary complications: paralysis of the thoracic muscles, severe hypoventilation, and absence of the cough reflex may lead to severe respiratory insufficiency within a few hours after injury even in the absence of any direct trauma to the chest. Tracheotomy had to be performed in 22.2% (n = 26) of our patients with complete and in 5.6% (n = 4) of those with incomplete lesions. In 33.5% of all tetraplegics temporary nasotracheal intubation for periods of up to 2 weeks proved entirely sufficient with no complications. Four patients with tracheotomy developed severe local infection with resistant Gram-negative germs, two showed posterior tracheomalacia, one had distal tracheal stenosis, and one required surgical care for acute local hemorrhage. In view of this relatively high rate of complications (26.7%), 'prophylactic tracheotomy' does not seem advisable. Facilities for continuous monitoring of central venous pressure arterial pressure, pulse rates breathing pattern pO2, pCO2, pH, electrolytes, and blood and urine osmolality must be available for all patients with neurologic injuries above C6.
Keywords: central nervous system; injury; intensive care; major clinical study; mortality; multiple trauma; nasotracheal intubation; quadriplegia; spinal cord injury; Switzerland; therapy

Malignant astrocytoma of the pons and left cerebral peduncle: report of a case - Rosman *Roberson *Richardson Jr. N.P.G.H.E.P. (New England Journal of Medicine, 1977)
A 15-yr-old boy was admitted because of unresponsiveness and quadriparesis. 2 wk after entry repeated neurologic examination revealed nystagmus in all directions of gaze. There was bilateral facial weakness, more marked on the left side; tongue movement was diminished; the left corneal reflex was absent, and the right decreased. The gag reflex was diminished. Right hemiparesis was still present, with increased right-sided reflexes. There were bilateral Babinski signs. Cerebellar ataxia was observed in the left upper extremity. 12 days before admission a tracheostomy had been performed. Spastic quadriplegia was present. The differential diagnosis is amply discussed because during life (he died on the 19th hospital day) there was no certainty in this reapect. The list of possibilities is a long one, but finally 2 diagnoses were suggested: acute multiple sclerosis (?) and pontine glioma (?), while the chief neurologist thought it to be a case of Leigh's disease (subacute necrotizing encephalomyelopathy). The post-mortem examination showed an infiltrating malignant tumor of the brainstem, located mainly in the pons, where it occupied the entire basal portion on the left side and much of it on the right; at the mid-pontine level it involved most of the tegmentum as well. The tumor extended upward into the midbrain, compressing and distorting it, although it was largely confined to the left cerebral peduncle. The cerebral hemispheres were otherwise intact, and the microscopical examination did not show diffuse infiltration of cerebral structures above the midbrain level. So the process was not cerebral gliomatosis. The neoplasm extended downward to the level of the junction between the pons and the medulla oblongata, with no evidence of tumor in the medulla itself or in the spinal cord. Sections of the brainstem revealed a malignant astrocytoma that permeated the fiber tracts and nuclei. In the fiber tracts the cells assumed an elongated bipolar configuration conforming to the polarity of the tracts. The tumor was anaplastic and there were large areas of coagulation necrosis. The tumor cells were undifferentiated, with hyperchromatic nuclei and scanty cytoplasm. In many fields there were tumor giant cells with large, irregular nuclei. Mitoses were numerous, and atypical and multipolar mitoses could be identified readily.
Keywords: astrocytoma; autopsy; brain tumor; cerebellar ataxia; child; diagnosis; histology; major clinical study; nystagmus; quadriplegia

Management of craniocerebral trauma - Lecuire J.; Bret Ph. (Lyon Chirurgical, 1976)
In this short article the authors outline a plan for the management of severe craniocerebral injuries that begins at the scene of the injury. Initially the patient is to be protected from further injury. If he appears moribund or in severe vascular collapse, immediate life saving measures are required. Hemorrhage from large vessels must be controlled by compression bandages or even the application of hemostat forceps. In patients with multiple injuries, cardiovascular collapse may require intravenous fluid cortico steroids, vasopressors and revival of cardiac action. At the same time respiratory distress demands that an adequate airway be established by tracheal intubation, aspiration of the tracheal tube, oxygen therapy, assisted respiration and possibly tracheostomy. They admit that all of these measures at the scene of the injury imply the availability of necessary trained personnel and equipment in ambulances, helicopters and first aid posts. If associated spinal injuries are present special care in resuscitation measures and transportation are necessary. Transportation to a center for definitive treatment is essential within a maximum of three hours after injury. This should be possible in Europe except in unusual situations such as accidents in high altitudes, at night, or in bad weather. At admission to a hospital equipped for definitive treatment of injuries, the injured patient should be put in the care of a multidisciplinary team of anesthesiologists skilled in resuscitation techniques and general trauma, neurological and orthopedic surgeons. The clinical and neurological examination should be supported by radiological examinations, echoencephalography, electroencephalography and carotid angiography as required. The objective should be 1) continuous and complete surgical resuscitation, 2) performance of urgent surgery, and 3) the urgent neurosurgical procedures that are necessary. Some extracranial injuries take precedence over the craniocerebral trauma. They include ruptured viscera, major arteries, and some major extremity injuries. When neurosurgical intervention is required in the patient with multiple injuries, a competent experienced neuroanesthesiologist is necessary. Constant monitoring of the patient will indicate the necessity for angiography to determine whether an intracranial hematoma is present. Theoretically, within three days the patient can usually be transferred to a neurosurgical service. If assisted respiration is still necessary he will have to be in a semi intensive care unit of the neurosurgical service. As a rule highly specialized care will not be required for more than three weeks. Certain patients with continued deep coma or persistent unresponsiveness (vegetative state) will require continued neurosurgical care. After the patient has stabilized from his initial injury (usually in three days) other necessary extracranial injuries can be attended to. The authors further suggest that after three weeks of neurosurgical care, patients should be transferred to hospitals or centers that specialize in rehabilitation. Their care there should prepare them for return to their families and eventually to their previous social and economic status. This concise paper covers the subject well but the order of presentation is not as logical as it should be. It is still a valid plan for management of the severe craniocerebral injury with associated multiple injuries.
Keywords: brain injury; head injury; injury; therapy

Critical notes on the transport of patients with cervical cord injuries - Nechwatal E. (Chirurg, 1975)
Patients with a cervical spine injury who cannot be taken to a special centre immediately after the accident should be transferred to such a centre only when one is sure that no additional transportation trauma will be produced. The fractured cervical spine must be adequately stabilized during transportation. The partial oxygen pressure must not be lower than 60 mm Hg and one should wait at least 1 wk after removal of tracheostomy tube. An acute stress ulcer (melaena) also has to be excluded. 13 fatal cases are described.
Keywords: ambulance; cervical spine fracture; injury; patient transport; spinal cord injury; stress ulcer; therapy

Severe injury to the neck region by seat belt - Petersen H.; Lenz W. (Aktuelle Traumatologie, 1975)
The problem of multiple injuries to the neck region by improper use of seat belts is discussed. The diagonal seat belt is an important factor in such injuries. Similar to whip lash injuries of the neck it results in hyperflexion fractures of the cervical spine, ruptures of the esophagus and trachea can be observed even without severe laceration to the skin, so that they are difficult to diagnose. Hemoptysis, mechanical airway obstruction and cervical emphysema are typical signs of damage of the upper airway. Difficulties in diagnosis are found with esophageal lacerations. Severe pain and dysphagy may point to it. The urgent problem is to clarify the lacerations by laryngo bronchoscopy, esophagoscopy and X ray examinations. The purpose of treatment is maintenance of free airway, early operative reconstruction, if possible, and sufficient immobilisation of cervical spine fractures.
Keywords: bronchoscopy; carotid arteriography; cervical spine; diagnosis; emphysema; esophagoscopy; esophagus injury; etiology; injury; laryngoscopy; major clinical study; neck; neck injury; necrosis; radiodiagnosis; seatbelt injury; spine fracture; trachea injury; tracheitis; tracheoesophageal fistula; tracheotomy

Treatment of respiratory failure in cases of cervical spine injury - Cape J.; McAslan L.; Manson S. (Physiotherapy Canada, 1974)
The authors present a brief survey of the relevant information available on the external support system or adjuncts utilized in the acute treatment of patients in respiratory failure, as a result of traumatic injury to the cervical spine. The study is based on the contention that the physiotherapist, to contribute effectively to the total program, must become familiar with all equipment and treatment procedures essential to the life support techniques of the intensive care unit and the medical team.
Keywords: artificial ventilation; cervical spine; injury; intensive care; intermittent positive pressure ventilation; lung ventilation; respiratory failure; spinal cord transverse lesion; spine; therapy; tracheotomy

Handbook of spinal medicine. - Burke D.C.; Murray D.D. (The Australasian nurses journal, 1974)
Keywords: article; homeostasis; human; lung embolism; lymphedema; neurogenic bladder; respiratory failure; spinal cord disease; thrombophlebitis; tracheotomy

Respiratory complications in traumatic quadriplegia. Analysis of 20 years' experience - Bellamy R.; Pitts F.W.; Stauffer E.S. (Journal of Neurosurgery, 1973)
A 20 year series of 531 patients with cervical spine fractures or dislocations is reviewed, and the records of 54 quadriplegic patients are analyzed in detail. Tracheostomy, surgery, overhydration, advanced age, severity of neurological injury, and corticosteroid therapy are discussed as factors in pulmonary complications.
Keywords: breathing; injury; lung edema; lung function; quadriplegia; spine fracture; therapy; tracheostomy; tracheotomy

The early management of cervical spin injuries. - McKibbin B.; Brotherton B.J. (Resuscitation, 1973)
Keywords: article; catheterization; cervical spine; dislocation; fracture; human; injury; radiography; spinal cord compression; spinal cord injury; spine injury; time; tracheotomy; traction therapy

The sensation produced by threshold resistive loads to breathing - Noble M.I.M.; Frankel H.L.; Else W.; Guz A. (Eur.Clin.Invest. (Berl.), 1972)
The ability to detect resistances added to the tracheostomy tubes of ENT patients was improved by allowing the pressure changes to be transmitted to the upper airways (by deflating the tracheostomy tube cuff). This suggests that the upper airways are sensitive detectors of added airway resistance and that this sensitivity masks impaired thoracic mechanisms of detection. Patients with chronic obstructive airways disease were able to detect added resistances less well than those with minimal airway disease. Patients with cervical cord transections from spinal level C3 to C6 were able to detect threshold resistive loads normally. It is concluded that receptors in the chest wall and diaphragm are not essential for the normal sensation of threshold resistive loads.
Keywords: receptor; airway; airway resistance; breathing; cervical spinal cord; cuff; diaphragm; otorhinolaryngology; patient; respiratory tract disease; sensation; thorax wall; tracheostomy; tube; upper respiratory tract

Necrotizing encephalomyelopathy. report of a case with manifestations resembling behr's syndrome - Dunn H.G.; Dolman C.L. (Kur Neurol., 1972)
A boy was first noted to have partial optic atrophy, strabismus, cerebellar ataxia and delayed behavioural development after the age of 4 yr. Subsequently he developed kyphosis and mild pes cavus; spasticity first became apparent in the legs, and a diagnosis of Behrs syndrome was entertained. However, the disease progressed in a series of relapses with subsequent partial recovery. At 12 1/2 yr he was shown to have bilateral depression of labyrinthine function attributable to a lesion of central vestibular pathways. He had high normal levels of blood Iactate and plasma alanine and somewhat high urinary alanine output. A diagnosis of necrotizing encephalomyelopathy was made and was confirmed when the urine was shown to inhibit thiamine pyrophosphate adenosine triphosphate phosphotransferase. During a further relapse with increased weakness impaired conduction in limb nerves was demonstrated. After slight improvement the boys condition deteriorated and he required respirator care and tracheostomy. I.v. infusion of thiamine hydrochloride and thiamine propyl disulphide (15 mg/kg daily) failed to arrest the downward course. He died at 12 yr 10 1/2 mth. Autopsy showed the characteristic changes of Leigh s disease which involved not only diencephalun and brain stem but also the optic nerves and chiasm, cerebellum, and cervical and thoracic portions of the spinal cord. The importance of considering necrotizing encephalomyelopathy in the differential diagnosis of hereditary ataxias in childhood is emphasized.L.
Keywords: adenosine triphosphate; alanine; cocarboxylase; phosphotransferase; propane; thiamine; autopsy; blood; boy; brain stem; cerebellar ataxia; cerebellum; childhood; diagnosis; differential diagnosis; hereditary ataxia; infusion; kyphosis; leg; limb; male; nerve; optic nerve; optic nerve atrophy; plasma; relapse; seasonal variation; skin; spasticity; spinal cord; strabismus; tracheostomy; urine; ventilator; vestibular system; weakness

Osteomyelitis of the cervical spine after neck injuries. - Altman M.M.; Joachims H.Z. (Archives of otolaryngology (Chicago, Ill. : 1960), 1972)
Keywords: antiinfective agent; adult; article; blast injury; cervical spine; foreign body; human; immobilization; male; myelography; neck injury; osteomyelitis; radiography; tracheotomy

Major abdominal and thoracic trauma associated with spinal cord injury: problems in management - Bricker D.L.; Waltz T.A.; Telford R.J.; Beall A.C. (J.Trauma, 1971)
When injuries to the abdomen or thorax are associated with injuries to the spinal cord, the problems of management are greatly magnified. Eighteen patients with such injuries were seen during the past 3 years in Texas, and the problems and lessons learned during their management constituted the basis for this report. Preoperative, intraoperative, and postoperative problems were considered from the viewpoint of the general and thoracic surgeon, the neurosurgeon, and the anesthesiologist. The inadvisability of hasty laminectomy in these patients was stressed. The greatest challenge was found in the postoperative period, where respiratory insufficiency was the most prominent complication. Tracheostomy and assisted ventilation were frequently necessary, and the advent of the volume cycled respirator has proved a great advance. The effect of autonomie dysfunction on the cardiovascular, gastrointestinal, and genitourinary systems was evident in this group of patients, and some of the diagnostic and therapeutic pitfalls associated with such dysfunction were elucidated with select case presentations. The physiologic bases for the functional disturbances in these patients were discussed. Application of the principles outlined should minimize mortality and morbidity in this extraordinarily complex and challenging group of patients.
Keywords: abdomen; abdominal injury; anesthesist; assisted ventilation; diagnosis; injury; laminectomy; morbidity; mortality; parkinsonism; patient; physiotherapy; postoperative period; respiratory failure; spinal cord; spinal cord injury; spinal cord lesion; thorax; thorax injury; thorax surgery; thorax wall; tracheostomy; United States; urogenital system; ventilator

Penetrating wounds of the larynx and cervical trachea - Le May S.R. (Archives of otolaryngology, 1971)
Twenty five cases of penetrating missile wounds involving the larynx and trachea are reported. Penetrating injuries of the anterior portion of the neck may have associated wounds of the larynx, pharynx, trachea, esophagus, major vessels, or spinal cord. Missiles crossing the midline of the neck are suspected of injuring the midline structures. Signs, symptoms, and diagnostic procedures are discussed. All neck wounds were debrided and explored to rule out deep structure injury. Surgical exploration of laryngotracheal injuries was directed toward open reduction and stabilization in position of function. The unfortunate complication of chronic stenosis of the larynx and trachea can be avoided in most penetrating missile wounds of the larynx and trachea.
Keywords: diagnostic procedure; esophagus; injury; laryngoscopy; larynx; larynx injury; larynx stenosis; missile wound; neck; open reduction (procedure); penetrating trauma; pharynx; spinal cord; stenosis; trachea; trachea injury; trachea stenosis; tracheotomy; wound

The cervical spine: Some clinical and practical considerations - England R.W. (J. Amer. Osteopath. ass., 1971)
Review of some of the basic techniques for treatment of problems of the cervical spine by the osteopathic family physician in his office, including a review of the anatomic and structural factors and the clinical approach. The method of taking the history, the physical examination, and the radiologic examination are outlined. The approach to be utilized in evaluation of somatic dysfunction of the cervical spine is detailed. The basic approaches to treatment and technique are presented.
Keywords: assisted ventilation; cervical spine; endotracheal intubation; esophagus burn; general practitioner; medical decision making; physical examination; radiodiagnosis; tracheotomy; tube

Some problems of surgical tactics in complicated spinal fractures - Lebedev V.V.; Isakov I.V. (Vestnik khirurgii imeni I. I. Grekova, 1971)
Keywords: article; endotracheal intubation; fracture; human; osteosynthesis; spine injury; procedures; tracheotomy

The ability of man to detect added resistive loads to breathing. - Noble M.I.; Frankel H.L.; Else W.; Guz A. (Clinical science, 1971)
Keywords: adult; airway resistance; article; human; male; mechanical stress; pathophysiology; sensation; sensory receptor; spinal cord injury; tracheotomy

Spinal cord injuries. an analysis of 300 new lesions - Key A.G.; Relief P.J.M. (Paraplegia, 1970)
An analysis of 300 new lesions admitted to u spinal injuries centre. Statistics given relate to the following: (1) mode of transport to the centre; (2) age and sex distributiv;., (3) cause and frequency of spinal cord lesions; (4) neurological classification - incidence and extent; (5) general nursing care; (6) plastic repair of sores; (7) incidence of automatic and autonomous bladders and treatment; (8) orthopaedic procedures; (9) tracheostomy; (10) death rate; (11) discharges, and (12) out patient attendance.
Keywords: plastic; bladder; classification; mortality; nursing care; outpatient; spinal cord injury; spinal cord lesion; spine injury; statistics; tracheostomy

Tracheal stenosis following tracheostomy. - Frankel H.L. (Paraplegia, 1970)
Keywords: adolescent; adult; article; cauda equina; female; human; injury; male; paraplegia; positive end expiratory pressure; spinal cord injury; trachea stenosis; tracheotomy

The problems presented in a reanimation service by fractures of the cervical spine during the first few months - Goulon M.; Bigot B. (Les problemes poses dans un service de reanimation par les fractures du hachis cervical pendant les premiers mois, 1969)
The authors discuss 8 cases of fractures of the cervical spine with quadriplegia, admitted for problems connected with resuscitation. Among the most important complications were: Polyuria up to 5 liters per day, with polydipsia, in the early weeks after injury; psychological disorders in 2 patients; temperature disturbances (hypo- or hyperthermia), though whether the basis on those was central or infective was not established; respiratory difficulties, which were among the most important. In this series 7 patients were tracheotomised, 5 in the first 48 hr, and 5 were on artificial respiration. In the authors' view, tracheotomy is preferable to intubation in these cases, and it is better to perform tracheotomy too often than to submit the patient to risk by omitting this precaution. In the discussion, Professor Gabibert was surprised at the low incidence of hypothermie complications. Professor Grossiord emphasized the problems involved in the indications for tracheotomy, and Dr. Dollfus stressed the risk of cardiac arrest during tracheotomy. (Paradystal - Lidkoping).
Keywords: artificial ventilation; breathing; cardiovascular system; cervical spine; cervical spine fracture; digestion; fracture; heart arrest; hyperthermia; injury; intubation; mental disease; patient; polydipsia; polyuria; psychology; quadriplegia; resuscitation; risk; spinal cord lesion; temperature; tracheotomy; urology

Radical treatment of cervicodorsal spinal tuberculosis - Fang H.S.Y.; Ong G.B. (Journal of the Royal College of Surgeons of Edinburgh, 1969)
28 patients with cervico dorsal spinal tuberculosis have been treated by means of radical surgery during the last 10 years. The approach adopted was one first described by Cauchoix and Binet (1956). There were 2 postoperative deaths from aspiration of blood into the lungs through a tracheostomy tube. In fact, tracheostomy is not necessary. After debridement of the diseased vertebrae, anterior spinal fusion was carried out in each instance. As many as 6 vertebrae had been fused successfully.
Keywords: anterior spine fusion; aspiration; blood; death; debridement; lung; patient; spine surgery; surgery; tracheostomy; tube; tuberculous spondylitis; vertebra

The problems presented in a reanimation service by fractures of the cervical spine during the first few months - Goulon M.; Bigot B.; Lougovoy Vistonti J. (Annales de Medecine Physique, 1969)
The authors discuss 8 cases of fractures of the cervical spine with quadriplegia, admitted for problems connected with resuscitation. Among the most important complications were: Polyuria up to 5 liters per day, with polydipsia, in the early weeks after injury; psychological disorders in 2 patients; temperature disturbances (hypo- or hypertheimia), though whether the basis on those was central or infective was not established; respiratory difficulties, which were among the most important. In this series 7 patients were tracheotomised, 5 in the first 48 hr, and 5 were on artificial respiration. In the authors' view, tracheotomy is preferable to intubation in these cases, and it is better to perform tracheotomy too often than to submit the patient to risk by omitting this precaution. In the discussion. Professor Gabibert was surprised at the low incidence of hypothermic complications. Professor Grossiord emphasized the problems involved in the indications for tracheotomy, and Dr. Dollfus stressed the risk of cardiac arrest during tracheotomy.
Keywords: artificial ventilation; bradycardia; cervical spine; cervical spine fracture; fracture; heart arrest; hypotension; injury; intubation; mental disease; paralysis; patient; polydipsia; polyuria; quadriplegia; respiratory failure; resuscitation; risk; temperature; tracheotomy

Radical treatment of cervico-dorsal spinal tuberculosis. - Fang H.S.; Ong G.B. (Journal of the Royal College of Surgeons of Edinburgh, 1969)
Keywords: adolescent; article; child; female; human; male; postoperative care; preschool child; spine fusion; tracheotomy; tuberculous spondylitis

The early management of associated injuries in the presence of coincident damage to the spinal cord - McSweeney T. (Paraplegia, 1968)
Tracneostomy is seldom necessary in dorsal or lumbar paraplegia, except in the presence of a severe chest injury. In cervical cord injury there is the risk of over-transfusion. In dorsal and lumbar paraplegia the risk of over-transfusion is not so great. Soft tissue wounds and compound fractures of limbs are thoroughly cleaned, devitalised tissue excised and simple closure undertaken as soon as the patient's general condition will permit. For single bone injuries, it may be possible to dispense with splints and make use of a pillow and crepe bandage to support the limb. Uncomplicated dislocations are promptly and gently reduced. Absolute indications for surgery are fractures accompanied by gross pressure on vessels or nerves, or where an attempt at closed reduction may increase the neurovascular hazard; such cases require exploration and reduction. It is not advisable to accept gross angular deformity in an anaesthetic limb because of the difficulty of fitting appliances at a later stage. Open reduction of fractures should be considered when these are irreducible, unstable or where the fragment is so small that it cannot be manipulated. Operation is required only in a minority of head injuries. The author recognises three indications for urgent cranial surgery:(1) Compound fracture of the skull. (2) Expanding lesions within the skull. (3) Certain fractures involving the sinuses. The need for exploration is obvious by open wounds of the abdomen associated with spinal injuries. Inspection, percussion, palpation and auscultation may throw little light on the problem of injuries of abdomen when the spinal cord is damaged. An accurate history, careful clinical investigation frequently repeated and X- ray studies including the use of contrast media will help in deciding about laparotomy. In tétraplé gie patients with severe associated chest injuries, tracheostomy is vital. By chest injuries five basic principles must be remembered: (1) The relief of tension pneumothorax by a lollow needle. (2) Immediate closure of a sucking meumcthorax. (3) Correction of paradoxical respiration due to flail chest. (4) Frequent onchoscopic toilet. (5) Aspiration of the pleural cavity is often advisable and when intercostal lrainage is necessary, it should be carried out hrough a wide-bore tube with an under-water seal. Mastny - Brno (19, 8A, 9B*).
Keywords: anesthetic agent; contrast medium; water; abdomen; aspiration; auscultation; bandage; bone injury; cervical spinal cord injury; open fracture; deformity; flail chest; fracture; fracture reduction; general condition; hazard; head injury; injury; laparotomy; limb; needle; nerve; open reduction (procedure); palpation; paraplegia; patient; percussion; pleura cavity; pneumothorax; risk; skull; skull surgery; soft tissue injury; spinal cord; spine injury; splint; sucking; surgery; thorax injury; tissues; tracheostomy; transfusion; tube; wound; X ray

Fatal road accidents. Injuries, complications, and causes of death in 250 subjects - Sevitt S. (British Journal of Surgery, 1968)
An analysis has been made of the injuries, complications, and causes of death of 250 road-accident victims comprising 125 pedestrians (507.)i 41 motor-cyclists, 18 pedal cyclists, 30 vehicle drivers, 26 vehicle passengers, 6 bus passengers, and 4 other subjects. Pre-existing disease was responsible for the accident in 4 car drivers and caused the death of 2 of them. Head and chest injuries predominated, affecting 70 and 45% respectively, of all subjects, followed by lower-limb fractures (34%)l fractures of the pelvis (237.). abdominal injuries (19*4 fractures and dislocations of the spine (14%) and upper limb (14%). Multiple injuries were the rule and two or more body regions were involved in two-thirds of the cases, the head and chest together in 28%. The main difference between the different road users was a high frequency of pelvic and lower-limb fractures in pedestrians (36% and 48%, respectively); a very high rate of head injuries in motor-cyclists and vehicle passengers (80%); and in vehicle drivers a high and equal frequency of head injuries (63%) and chest injury (67%} commonly with abdominal trauma (37%) and spinal injuries confined to the neck. Sixteen per cent of the subjects died soon after the accident and 44% of those reaching hospital alive died within 24 hours of injury (28% within 6 hours). At this time the main causes of death were cerebral injury and severe hemorrhage - generally hopeless cases. Head, chest and abdominal trauma were divided into major and minor types. Early death after head injury was usually due to a direct contusion of the brain-stem or third ventricular region, but many deaths during the first hours and subsequent days were from the complication of tentorial herniation ol the midbrain. following subdural hemorrhage and the associated frontal or temporal coup or contrecoup lesions. Theoretically this is preventable and requires fuller study. Many deaths were attributable to chest injuries but few to abdominal trauma. Fourteen patients had a ruptured aorta, most of them just beyond the arch. Some burst hours or days after injury and might have been amenable to surgery. The mechanism of most' aortic ruptures seems to be aortic elongation, following deceleration from a cephalically directed body movement. Most chest injuries had multiple unilateral or bilateral rib fractures and were due to compression, but some resulted from hyperflexion of the upper on the lower chest or vice versa and then the dorsal spine was also fractured Sternal fractures or subluxation were either inwardly directed injuries from compression or outward bucklings from forced chest hyperflexion. Lung lacerations were either peripheral tears from penetrating ribs or central disruptions, probably a burst type of injury. Injuries to the cervical spine (20 patients) were mainly hyperextension subluxations of hyperflexion fracture-dislocations, but a few patients had axis or odontoid fractures. A dislocated cervical spine was found in 7% of those major head injuries. Complications were either specific to trauma or were of àmore general nature,- they were frequent and numerous, and not infrequently two or even three occurred in the one subject. Numerically the most important were tentorial herniation, severe hemorrhage, and respiratory infection which form the lethal triad after injury, each contributing to or causing between 2OX and 25*4 of the deaths; then came pulmonary embolism, pulmonary edema, pneumothorax, cerebral fat embolism, and inhalation of vomit, followed by septicémie, acute renal failure, pneumococcal meningitis, air embolism, and a variety of other general and local complications. No evidence of so-called irreversible shock after adequate transfusion was found. The relatively low frequency of acute renal failure is attributable to a clinical policy of early and adequate blood transfusion,- and the rate of pulmonary embolism might have been higher were it not for a hospital policy of anticoagulant prophylaxis with oral drugs. A few patients might have been saved from death from hemorrhage and others from death from embolism. The problem of bronchopneumonia and its relationship to tracheostomy and cross-infection in hospital needs solution.
Keywords: anticoagulant agent; abdominal injury; accident; acute kidney failure; air embolism; aorta; aortic rupture; arm; bacterial meningitis; bleeding; blood transfusion; body movement; body regions; brain injury; brain stem; bronchopneumonia; car driver; cervical spine; compression; contusion; cross infection; cycling; death; deceleration; embolism; fat embolism; fatality; fracture; fracture dislocation; head injury; hernia; hospital; hospital policy; inhalation; injury; laceration; lacrimal fluid; leg; limb fracture; lung; lung edema; lung embolism; mesencephalon; multiple trauma; neck; odontoid process fracture; patient; pedestrian; pelvis; pneumothorax; policy; prophylaxis; respiratory tract infection; rib; rib fracture; spine; spine injury; subdural hematoma; subluxation; surgery; thorax; thorax injury; tracheostomy; traffic accident; transfusion; victim

Associated chest injuries - Frankel H.L. (Paraplegia, 1968)
Thoracic lesions, often seen in transverse lesions at the thoracic and thoracolumbar level, and rarely in cervical lesions, should be diagnosed and treated as soon as possible. The following are discussed: costal fractures, hemothorax, pneumothorax, lesions to the diaphragm or phrenic nerve, lesions to the lung tissues, pulmonary vessels and mediastinum including the heart, tracheotomy and the unavoidable frequent complications thereof.
Keywords: diaphragm; heart; hematothorax; injury; lung blood vessel; lung parenchyma; mediastinum; phrenic nerve; pneumothorax; rib fracture; spinal cord lesion; spinal cord transverse lesion; thorax injury; thorax wall; tracheotomy

Emergency measures in the treatment of patients with cervical vertebro-medullary injuries - Merli G.A.; Gritti G.; Manani G.; Manzin E. (Acta anaesthesiologica, 1968)
Keywords: adult; article; artificial ventilation; bladder disease; cervical spine; decubitus; dislocation; enteropathy; female; first aid; fracture; fracture fixation; human; male; middle aged; quadriplegia; respiratory tract disease; spinal cord injury; spine injury; tracheotomy; traction therapy

Tracheostomy in acute injury and acute vascular pathology of the central nervous system - Panchulidze I.A. (Khirurgiia, 1968)
Keywords: article; artificial ventilation; brain injury; cerebrovascular disease; human; paralysis; respiratory failure; spinal cord injury; tracheotomy; wound drainage

Thoracic trauma and associated injuries - - Proye C. (Lille chirurgical, 1967)
Thoracic injury is often associated with severe trauma to other organs, e. g. in 121 out of the presented 313 cases. Common mistakes made in handling such injuries are: to attribute the respiratory symptoms to the associated cranial or facial injuries; to attribute the shock to a moderate hemothorax; to regard cases of thoracic injury as 'untouchable' and omit a lifesaving laparotomy. or fraction fixation; to carry out a laparotomy for spasm which is due merely to rib injury. To avoid such errors a thorough examination is necessary i. e. a systematic clinical examination; X-ray examination should include the skull, spine, chest and pelvis; no lesion should be ignored, but the thoracic lesion is the most urgent; no general anesthetic should be given until respiration has been controlled by tracheostomy. pleural drainage and rib fixation. Faciomaxillary injuries only occurred in 8 cases and jaw fractures in 134 during 15 yr. Their treatment may be delayed for 6 hr up to 3 days, but not for a week without danger. Intracranial injuries occurred in 126 out of 730 cases. In Uusee lhe cerebral edema, anoxia and electrolytic balance are upset by the associated thoracic injury, which may induce pulmonary edema and CheyneStokes respiration. The assessment of the relative importance of these features may be difficult. Respiratory control must be attained before any move to a brain-surgery unit. The only urgent cerebral emergency is extra-dural hemorrhage. Cervical spinal injuries also require early operation in the prone position.
Keywords: anesthetic agent; anoxia; bleeding; body position; brain edema; brain surgery; cervical spine injury; clinical examination; electrolyte balance; emergency; error; examination; face injury; hematothorax; injury; jaw fracture; laparotomy; lung edema; muscle spasm; pelvis; radiodiagnosis; respiration control; rib; skull; spine; thorax; thorax injury; tracheostomy

Recent developments in the treatment of tetraplegics - Walsh J.J. (Physiotherapy, 1966)
The increasing number of tetraplegic patients admitted to spinal injuries centers throughout the world demand the need for a very high standard of physiotherapy. This paper deals in some detail with the problem of prophylactic and curative physiotherapy for chest complications in tetraplegics, and also discusses the indications for tracheostomy and its management. The place of electrotherapy in tetraplegia is discussed. Reference is made to some of the recent advances in designing special apparatus including powered chairs, selector mechanisms and the Egerton Stoke Mandeville bed.
Keywords: electrotherapy; patient; physiotherapy; quadriplegia; spine injury; thorax; tracheostomy

Infectious mononucleosis: neurologic and eeg findings - Schnell R.G.; Dyck P.J.; Bowle E.J.W.; Klass D.W.; Taswell H.F. (Medicine, 1966)
From 1950 through 1963, a diagnosis of infectious mononucleosis was made in I, 285 cases. Of 44 patients, 12 met the authors' criteria for the diagnosis of infectious mononucleosis and had nervous-system involvement secondary to the mononucleosis. These patients, 11 male and 1 female, ranged in age from 13 to 27 years. Eight of the 12 had acute meningoencephalomyelitis of short duration. This was characterized by headache, fever, stiff neck, delirium, and confusion. Additional manifestations, in some cases included combative and irrational behavior, seizures, papilledema, and signs of cerebellar dysfunction. The electroencephalograms of 7 cases were abnormal. The changes were predominantly diffuoe and of uillu degree but occasionally wer? ,evere and localized. Of the remaining patients, one had predominantly spinal cord'involvement, two had polyradiculopathy, and one had mononeuritis. The findings indicate that when the nervous system is affected by infectious mononucleosis, the neurologic symptoms and signs may predominate and obscure the usual presenting symptoms. Such cases may present as an acute psychosis or a convulsive disorder, as men ingoen cephalitis, as myelitis, or as peripheral neuropathy or mononeuropathy. A striking feature of these cases was the good prognosis and lack of neurologic residua even when marked neurologic abnormalities had been present during the acute phase of the illness. Tracheostomy and mechanical respiration were important in the treatment of those patients who had respiratory failure due to brain-stem or peripheralnerve involvement. Steroids, used in two of the cases, may have been helpful in the treatment of these severely ill patients. Although patients with neurologic involvement from infectious mononucleosis can be critically ill, in the authors' opinion, the improved methods of symptomatic treatment have favorably altered the previously grave prognosis,.
Keywords: steroid; acute psychosis; artificial ventilation; brain stem; convulsion; critically ill patient; delirium; diagnosis; electroencephalogram; female; fever; general aspects of disease; headache; infectious hepatitis; mononucleosis; male; mononeuropathy; mononucleosis; myelitis; neck; nervous system; neurologic disease; palliative therapy; papilledema; patient; peripheral neuropathy; prognosis; radiculopathy; respiratory failure; seizure; spinal cord; tracheostomy

Clinico-pathological study of devic's optic neuromyelitis with artificially prolonged course. terminal septic encephalitis - Tommasi M.; Lecuire J.; Masquin A.; Buffat J.J. (Revista de Neurologia, 1966)
Eight days after developing angina with arthralgia in the right elbow a 28-yr-old woman presented symptoms of acute bilateral 'retrobulbar neuritis' with complete blindness, paralytic mydriasis and slight hemiparesis on the right side. A few days later a sensory motor flaccid quadriplegia of Cg-C7 level localization developed rapidly after PEG. The CSF contained 35 cells/ mm3, proteins 0.45 g/1 and glucose 1.03 g/1. The optic disks showed soft nasal borders. Because of important respiratory disturbances tracheotomy was performed allowing assited respiration during a few weeks. Antibiotics, hydrocortisone, ACTH and vitamins were administered. A slight improvement occurred but pyocyanic infection of bedsores, bronchopneurnonitis and purulent pleuritis were responsible for the death of the patient 4.5 mth after the onset of the disease. Examination of the CNS revealed atrophy of the chiasma and both optic nerves, cerebral edema and a large necrotic focus in the cervico-thoracic segment of the spinal cord. Only parts of the later alnd dorsal column were spared in the affected segment. Similar necrotic foci were also observed in the medulla and under the floor of the 3rd ventricle. These necrotic lesions were characterized by numerous macrophages without macroglial and lymphocytic reactions. The cerebral edema was explained by numerous micro-abscesses with predominant polmorphonuclear cells. These disseminated nodular inflammatory lesions due to a preterminal septicemia are to be distinguished from the inflammatory reactions in perivenous encephalomyelitides and similar demyelinating diseases. (B, 8a).
Keywords: antibiotic agent; corticotropin; glucose; hydrocortisone; protein; vitamin; abscess; angina pectoris; arthralgia; atrophy; blindness; brain edema; central nervous system; cerebrospinal fluid; death; decubitus; demyelinating disease; elbow; encephalitis; examination; female; hemiparesis; infection; inflammation; macrophage; mydriasis; myelooptic neuropathy; optic disk; optic nerve; patient; pleura empyema; quadriplegia; respiratory failure; retrobulbar optic neuropathy; septicemia; spinal cord; spine; tracheotomy

CARDIOVASCULAR COMPLICATIONS during ANESTHESIA for a CERVICAL SPINALCORD INJURY (Japanese) - Uchida M.; Ishitani H.; Okuda Y.; Kiyohara R. (Japanese Journal of Anesthesiology, 1966)
A 24-yr. -old male was hospitalized with a dislocation of the 6th cervical vertebra and a spinal cord injury in the associated area. There was complete paralysis of the sensory and most of the motor area below C 5-6 segments on the 50th day after the injury. Thoracic respiration had deteriorated. After atropinization, he was induced with 150 mg. of thiopentone which gave rise to muscletwitching in the pectoral area. SCC infusion produced peripheral ischemia for 3 min. The addition of fluothane with N2O oxygen, caused the cardiovascular system practically to collapse within 3 min. Carnigen was injected and successfully restored cardiac function, but the operation had to be postponed until the 75th day. The patient was then tracheotomized and anesthesia was maintained with N2O oxygen and a local anesthetic. The operation and anesthetic were uneventful. Thiopentone induced twitching and hypersensitivity to ACh in denervated patients are discussed. SCC-induced ischemia must be caused by a dominant nicotinic action. Nakayama - Tokyo.
Keywords: anesthetic agent; halothane; local anesthetic agent; oxilofrine; oxygen; thiopental; anesthesia; cardiovascular system; cervical spine; denervation; heart; heart arrest; heart function; hypersensitivity; infusion; injury; ischemia; Japan; male; paralysis; patient; peripheral ischemia; spinal cord injury

Emergency surgical care of injuries in mass accidents. Initial medical help at the accident site in facial injuries, penetrating injuries of the body cavity, injuries of the vertebral column involving the spinal cord - Berthold H.; Reichmann J.; Zeumer G. (Zeitschrift für ärztliche Fortbildung, 1966)
Keywords: abdominal injury; accident; adult; article; artificial ventilation; child; emergency; endotracheal intubation; face injury; first aid; foreign body; head injury; heart injury; human; injury; patient transport; preschool child; rib fracture; spinal cord injury; spine injury; thorax injury; tracheotomy

Cardiovascular reflexes in tracheostomjsed tetraplegics - Dollfus P.; Frankel H.L. (Paraplegia, 1965)
A patient with acute traumatic tetraplegia associated with severe bleeding from multiple peptic 'stress ulcers' is described. He was treated with blood transfusions (35 pints in 1 week) but his condition deteriorated after a pulmonary embolism and a tracheostomy was performed. Subsequently he had periods of cardiac arrest every time his tracheostomy was sucked out. Atropine prevented this, and the mechanism of the cardiac arrest is assumed to be vago-vagal. The patient died the next day. Seven patients with high traumatic spinal cord lesions and tracheostomies (6 cervical, 1 upper dorsal) had ECGs performed before, during and after endotracheal suction. No arrhythmias developed. The mechanism of the cardiac arrest in this case is discussed with particular reference to the association with 'stress ulcers' and pulmonary embolism.
Keywords: atropine; bleeding; blood transfusion; cardiovascular reflex; heart arrest; heart arrhythmia; lung embolism; patient; quadriplegia; spinal cord lesion; stress ulcer; tracheobronchial toilet; tracheostomy; tracheotomy

Cardiovascular reflexes in tracheostomised tetraplegics - Dollfus P.; Frankel H.L. (Paraplegia, 1965)
A patient with acute traumatic tetraplegia associated with severe bleeding from multiple peptic 'stress ulcers' is described. He was treated with blood transfusions (35 pints in 1 week) but his condition deteriorated after a pulmonary embolism and a tracheostomy was performed. Subsequently he had periods of cardiac arrest every time his tracheostomy was sucked out. Atropine prevented this, and the mechanism of the cardiac arrest is assumed to be vago-vagal. The patient died the next day. Seven patients with high traumatic spinal cord lesions and tracheostomies (6 cervical, 1 upper dorsal) had ECGs performed before, during and after endotracheal suction. No arrhythmias developed. The mechanism of the cardiac arrest in this case is discussed with particular reference to the association with 'stress ulcers' and pulmonary embolism.
Keywords: atropine; bleeding; blood transfusion; cardiovascular reflex; heart arrest; heart arrhythmia; lung embolism; patient; quadriplegia; spinal cord lesion; stress ulcer; tracheobronchial toilet; tracheostomy; tracheotomy

CARDIOVASCULAR REFLEXES IN TRACHEOSTOMISED TETRAPLEGICS. - Dollfus P.; Frankel H.L. (Paraplegia, 1965)
Keywords: article; drainage; electrocardiography; heart arrest; lung embolism; paraplegia; quadriplegia; reflex; spinal cord injury; stomach ulcer; tracheotomy; wound drainage

AN ALTERNATIVE TECHNIQUE FOR BRONCHIAL ASPIRATION THROUGH A TRACHEOSTOMY. - Cheshire D.J.; Foster K.M. (Paraplegia, 1964)
Keywords: article; bronchus; drainage; endotracheal intubation; geriatrics; lung disease; paralysis; respiratory failure; spinal cord injury; tracheotomy; wound drainage

Anterior spinal fusion: The operative approaches. - Fang H.S.; Ong G.B.; Hodgson A.R. (Clinical orthopaedics and related research, 1964)
Keywords: anesthesia; article; cervical spine; child; human; postoperative care; premedication; preoperative care; spine fusion; procedures; tracheotomy; vertebra

ASPECTS OF MAJOR INJURY IN THE JOHANNESBURG AFRICAN--A REVIEW OF 300 CASES. - Froman C. (South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde, 1964)
Keywords: abdominal injury; amputation; article; blood vessel; cardiovascular disease; emergency; face injury; fracture; head injury; heart injury; injury; kidney disease; Black person; Black person; shock; South Africa; spinal cord injury; statistics; thorax injury; tracheotomy; urology

RESPIRATORY MANAGEMENT IN ACUTE TRAUMATIC TETRAPLEGIA. - Cheshire D.J. (Paraplegia, 1964)
Keywords: chloramphenicol; penicillin derivative; penicillin G; trypsin; article; artificial ventilation; bronchoscopy; paraplegia; RESPIRATORS; respiratory failure; spinal cord injury; tracheotomy; ventilator

Diagnosis and treatment of closed head trauma - Nishimoto S.; Hirose S.; Miyatake S.; Onoda O. (Surgery, 1963)
Out of 86 patients hospitalized and treated for head injury in 1 yr, 17% complained of a heavy feeling of the head and 16% complained of an impaired memory. According to Araki's classification of the sequelae of head trauma, 50% belonged to type II and 34.9% to type III. Six patients complained of retrograde amnesia, which lasted several minutes in 4 cases and over 3 hr. in 1 severe case. The traumatic force was most frequently directed to the anterior or posterior part of the skull and was applied to the frontal and occipital region. The cerebral nerves were paralysed in 12 patients. The degree of cerebral damage was marked in types I, II, VI and VII of head trauma, especially in type II. The onset of cerebral damage was markedly delayed in patients without intracranial hemorrhage. The curability of late trauma was better than that of recent trauma. Spinal puncture was performed 3 hr. after trauma in 44 patients, but the general condition was not markedly disturbed in any of them. The severity of the head trauma was related to the red blood cell count of the CSP, but not to the pressure of the CSF. The CSF pressure started to increase and its color became xanthochromic, as seen after craniotomy, 3 days after trauma. The clinical symptoms were effectively improved after the aspiration of the hemorrhagic CSF. Generally, the body temperature was elevated to a level of 37-39° C. on the first postoperative day and then gradually decreased. Six patients with type IH head trauma and bronchial stenosis were successfully treated by tracheotomy and 3 died of respiratory paralysis.
Keywords: aspiration; body temperature; brain damage; brain hemorrhage; bronchus stenosis; cerebrospinal fluid; cerebrospinal fluid pressure; classification; color; craniotomy; diagnosis; diaphragm paralysis; erythrocyte count; general condition; head injury; injury; memory; nerve; patient; puncture; retrograde amnesia; skull; tracheotomy

Anaesthesia for operations on the spinal cord and the vertebral column - Kapustin S.M.; Raevskii V.P. (Vopr. Neirokhir., 1963)
For operations of the vertebral column and the spinal cord, general anesthesia was used in 83 patients and local anesthesia in 17. There were no complications from the anesthesia. For endotracheal anesthesia, nitrous oxide and oxygen were used in combination with intravenous relaxants and controlled breathing. In patients with injury to the cervical spine a tracheotomy was carried out, through which the endotracheal anesthesia was administered. The premedication included antihistaminies, analgesics and parasympathicolytic drugs. In operations on the thoracic part of the spine, the ECG is an important method of control. Tachycardia and slight changes in the T-wave were frequently observed. When the patient's condition deteriorated, the S-wave became deeper, which pointed to increasing cardiac weakness. Marked changes in the venous pressure, especially its rise, were regarded as signs of incipient haemodynamic disturbances. The venous pressure remained most stable when operation was carried out under endotracheal anesthesia. Good results were achieved in the postoperative period by using anesthesia in the analgesia stage.
Keywords: analgesic agent; cholinergic receptor blocking agent; nitrous oxide; oxygen; analgesia; anesthesia; breathing; cervical spine; electrocardiogram; general anesthesia; injury; local anesthesia; patient; postoperative period; premedication; spinal cord; spine; T wave; tachycardia; tracheotomy; venous pressure; weakness

Tracheostomy in wounds and diseases of the brain and spinal cord. - Kalitkin K.N. (Voprosy neǐrokhirurgii, 1962)
Keywords: article; brain injury; BRAIN INJURY, ACUTE; spinal cord; spinal cord injury; tracheostomy

Tracheostomy in wounds and diseases of the brain and spinal cord. - Kalitkin K.N. (Voprosy neǐrokhirurgii, 1962)
Keywords: article; brain injury; BRAIN INJURY, ACUTE; spinal cord; spinal cord injury; tracheostomy

The epidemic of poliomyelitis in croatia in 1960 - Fališevac J.; Rulnjević J.; Hirzler R. (Lijecnicki vjesnik, 1961)
Of 234 paralytic cases, 79.4% were in children under 4 yr. of age. In the Zagreb area, where since 1958 the majority of young children have been immunized with Salk vaccine, the percentage of cases was much lower than in the previous epidemic (1953) and the incidence had shifted to the older children and adult age groups, in which the percentage of immunized subjects was lower. The patients included 19 children, who had been immunized with combined DPT vaccine 4-30 days previously; in 10 of them only the inoculated limb was paralysed. 183 cases had spinal (28 with respiratory failure), 20 bulbar and 31 bulbospinal form of poliomyelitis. Bulbar involvement occurred in adults and young children. It was not possible to estimate the number of cases with 'aparalytic' or encephalitic forms of poliomyelitis, since the polio epidemic was accompanied by high incidence of serous meningitis and meningoencephalitis syndromes caused by other enteroviruses and other agents; for the same reason it is not possible to say whether in all cases the paralytic disease was due to polioviruses. Specific diagnostic methods were used in only a small number of cases; they revealed that all but one of the isolated and identified cytopathogenic agents were polioviruses, mainly type 1. Serological tests were in agreement with these findings. Treatment was along generally adopted lines. In 26 of cases with life-threatening poliomyelitis artificial respiration was applied, in 2 tracheotomy was performed and in a further 18 cases both methods were used. Of the 234 patients 23 died, twice as many as for Croatia as a whole. The reason for this high fatality rate was the concentration of almost all severe cases from Croatia and a part of Bosnia in the respiratory centre of this hospital. In the majority of fatal cases death occurred within the first 5 days after the onset of paralysis. In 21 cases necropsy was performed. In 6 of them the cause of death was probably damage to the vital centres of the CNS, in 7 extracerebral complications, and in 8 both causes acting together, were responsible. At necropsy the spinal cord and medulla oblongata were involved in all 21 cases, the cerebellum in 14, the basal ganglia in 17, the cerebrum in 11 and the leptomeninges in 20 cases. Lesions of the higher regions of the CNS were found in this epidemic more frequently than in the previous one, in 1953, the only epidemic in Croatia studied in more detail from the pathological point of view. Myocarditis was found in 4, and pneumonia in 7 necropsies, much less frequently than in the epidemic of 1953.
Keywords: diphtheria pertussis tetanus vaccine; poliomyelitis vaccine; adult; artificial ventilation; autopsy; basal ganglion; brain; cause of death; central nervous system; cerebellum; child; Croatia; death; diagnostic procedure; Enterovirus; epidemic; epidemiology; fatality; groups by age; hospital; limb; medulla oblongata; meningitis; meningoencephalitis; myocarditis; paralysis; patient; pneumonia; poliomyelitis; Poliomyelitis virus; respiratory failure; serology; spinal cord; tracheotomy

Three rare cases of respiratory stenosis (Russian) - Katsnelson E.N. (Vopr. Obshch. Klinicheskoi Otorinolarlngo Logii (Sborn.Trud. Kaf.Oto-Rino-Laring. Len.Inst.Usoversh. Vrach.), 1961)
Three cases of stenotic breathing of unusual aetiology are cited: (1) A 54-year-old male patient suffered from a small polypus of the larynx, not manifested clinically and not causing embarrassment to breathing. Renal disease and cardiac insufficiency brought about the development of laryngeal oedema. A secondary inflammatory process and necrosis appearing in the area of the polypus caused laryngeal stenosis which necessitated tracheotomy. (2) A 25-year-old male patient developed stenotic breathing following azotaemia, caused by disease of the kidneys (secondary granular kidney, right-sided hydronephrosis, nephrolithiasis). (3) A 30-year-old male patient was troubled with stenotic breathing caused by a lesion of the spinal cord, with paralysis of the muscles of thorax and diaphragm (traumatic origin).
Keywords: breathing; diaphragm; etiology; heart failure; hydronephrosis; inflammation; kidney; kidney disease; larynx; larynx edema; larynx stenosis; male; muscle; necrosis; nephrolithiasis; paralysis; patient; spinal cord; stenosis; thorax; tracheotomy; uremia

The circulatory effects of acute respiratory failure: With special reference to acute cor pulmonale - Lee G.D.J. (Postgraduate Medical Journal, 1961)
The causes of acute respiratory failure may be classified as: (1) those due to extra-pulmonary causes (injuries to the brain, intoxications), interference to nerve supply to the muscles of respiration (polio, high spinal cord lesions) and various disorders of the chest wall (fractures, deformities); (2) those caused by parenchymal disorders of the lung; and (3) obstructive pulmonary vascular disease. The functional results are hypoxia, hypercapnoea or both. These changes in gases result in changes in peripheral circulation, with increased cerebral blood flow, contraction of capillaries of the periphery with increased central venous pressure and pulmonary arterial vasoconstriction. The exact effects on renal circulation are more obscure. Hypoxia produced increase both in heart rate and in stroke volume. Fall in cardiac output in relation to failure from cor pulmonale signifies a late stage of the process. The author relates a steep rise in hospital admissions and in mortality to the influenza epidemic of 1957-1958 which precipitated both respiratory failure and acute cor pulmonale in patients with emphysema. Twenty per cent of all patients admitted with emphysema or related conditions died; 39% of those showing evidence of right heart failure died, and 74% of all deaths occurred within 7 days of admission. Treatment consists of oxygen (usually no higher than 25-30%), broad spectrum antibiotics, tracheostomy in bad cases, digitalization. Sedation is harmful; phlebotomy in patients with well-maintained cardiac output is often dangerous. Intermittent positive pressure devices are apt to raise the general intrathoracic pressure and hence impede venous return to the heart. Tracings from patients indicate that this is a real result of the (improper) use of such devices.
Keywords: antibiotic agent; oxygen; acute respiratory failure; brain; brain blood flow; capillary; central venous pressure; cor pulmonale; death; deformity; devices; digitalization; emphysema; epidemic; epithelium; fracture; gas; heart; heart output; heart rate; heart right ventricle failure; heart stroke volume; hospital admission; hypoxia; influenza; injury; innervation; intoxication; kidney circulation; lung; mortality; muscle; patient; peripheral circulation; phlebotomy; poliomyelitis; respiratory failure; sedation; smoking; spinal cord lesion; thorax pressure; thorax wall; tracheostomy; vascular disease; vasoconstriction; venous return

Stabilization of the collapsing spine - Garrett A.L.; Perry J.; Nickel V.L. (J. Bom Jt Surg., 1961)
The purpose of the paper is to demonstrate the value of stability of the spine in patients with paralysed trunk muscles. Scoliosis deformity as such is stated not to be the essential factor decreasing functional ability. The operative procedure was a Hibbs type fusion with excision of the facet joints and with the addition of bone. For immobilization a body cast connected with a halo device fixed to the skull bones was applied in many instances. All fusions involved at least thirteen segments, the longest reaching from the occiput to the fourth lumbar vertebra. The series includes only patients with considerable trunk instability, the muscles of the back rating between poor and zero. The safety of these major surgical operations on patients with major respiratory deficit is striking. Thirty-one patients had vital capacities below 60%. Tracheotomy was performed prior to operation. The operative mortality was nil. Follow-up results 1 to 1.5 yr. after operation on 38 patients, ranging in age between 4 and 48 yr., are given. Extremity function endurance and respiratory function were tested and generally found to be improved. Patients with poor body balance but with preserved function of the lower extremities had the greatest benefit from fusion. Some patients, before the operation unable even to sit and stand without assistance, got stability enough from fusion of the spine to be capable of performing that function unaided.
Keywords: bone; deformity; devices; endurance; excision; follow up; forced expiratory volume; immobilization; leg; lumbar vertebra; muscle; paralysis; patient; respiratory function; safety; scoliosis; skeletal muscle; skull; spine; surgery; surgical mortality; tracheotomy; vital capacity

Total cervical-spine fusion for neck paralysis - Perry J.; Nickel V.L. (J. Bone Jt Surg., 1959)
The cases concerned were cases of severe paralysis, mostly as a sequela of poliomyelitis. Among the 22 cases considered, fixation with inclusion of the skull was carried out 10 times. The indication as to how far the fusion has to be extended depends on an accurate examination of the 4 muscle groups and the degrees of preserved function: The flexors and extensors of the head and the flexors and extensors of the neck. The procedure is particularly indicated for those patients,who in addition to the instability of the head,suffer from disturbances of breathing, swallowing and speech. The operation is carried out with the aid of a particular extension apparatus, the halo traction apparatus, which is attached to the cranial bones with screws and head band. Intubation anaesthesia is administered via a tracheotomy. Particular difficulties are attached to the stabilizing of the suboccipital region. The technique consists in decortication of the vertebral arches and the small vertebral articulations using the chip technique of Hibbs. If the fusion area did not extend proximal to the second cervical vertebra, no additional bone was used. Suboccipitally. autoplastic chips from the posterior portion of the ilium were used. The traction is maintained for 3 months.
Keywords: anesthesia; bone; brace; breathing; cervical spine; decortication; examination; iliac bone; intubation; muscle; neck; paralysis; patient; poliomyelitis; scoliosis; skull; speech; spine fusion; swallowing; thorax surgery; tracheotomy; traction therapy

Injuries to the cervical cord. fundamental factors in treatment and rehabilitation - White J.C. (J. Bone Jt Surg., 1959)
The first essential in injuries to the cervical vertebrae is protection against increasing damage to the spinal cord. Cranial traction by means of tongs should be applied in every quadriplegic patient, even if no fracture of dislocation is apparent. To prevent critical respiratory embarrassment, oxygen administration, tracheotomy, and a snug swathe applied to the lower ribe can be helpful. It ia recommended to delay operation until the patient ia recovering from spinal shock, with a systolic blood pressure over 100 and a vital capacity of over 1000 ml. While complete spinal recovery rarely results, when it would not have taken place spontaneously, experience has shown that operation performed after the first critical days is relatively safe and has the following advantages: (1) protection in penetrating wounds against meningitis resulting from septic fistulae; (2) reduction of radicular pain from compression of emerging roots of the brachial plexus; (3) recovery of compressed plexus roots above the level of spinal tranaection. Spinal fusion allows earlier movement and institution of the rehabilitation programme. During the first critical month, expert nursing is required in order to help prevent bed-sores, hypostatic pneumonia, hypoproteinaemia, and malnutrition. Tidal drainage and affective bowel training can restore satisfactory automatic evacuation through spinal reflex mechanisms. Also helpful are orthopaedic surgical procedures for stabilizing the thoracolumbar spine, and the transplantation of tendons to finger flexors and extensors.
Keywords: bladder and bowel management; brachial plexus; cervical spinal cord; cervical spine; compression; decubitus; fistula; forced expiratory volume; fracture; hypoproteinemia; injury; malnutrition; meningitis; nursing; oxygen therapy; patient; penetrating trauma; pneumonia; protection; radicular pain; rehabilitation; spinal cord; spinal reflex; spine fusion; surgical technique; systolic blood pressure; tendon; thoracolumbar spine; tracheotomy; traction therapy; transplantation; vital capacity

Neurosurgery in old age and modern anaesthesia - Wüllenweber R. (Anaesthesist, 1958)
In the above clinic, 165 major neurosurgical interventions were performed during the period 1956/1957 on patients aged 60-75. Death within 4 weeks was recorded as early death; this group included secondary causes of death such as embolism, infection, etc. The best results were obtained in extradural operations on the spinal cord (i i% mortality), on the cranium (trigeminus, aneurysms, angiomata, 5-7% mortality) and in intradural operations on the spinal cord (about 10% mortality), but intradural operations on the brain were considerably less favourable (tumours, haematomata, abscesses, 33-40% mortality). The least favourable results were obtained in hypophyseal adenoma and craniopharyngeoma; these conditions are at present given only palliative therapy, the former with radioactive gold seeds, and the latter by puncture evacuation of the cysts, both under X-ray control. Cerebral oedema is of decisive importance as a factor leading to complications and death (postoperative incarceration !). Other such factors include intradural haemorrhage and circulatory collapse. The over-all mortality very closely approaches that in younger patients. Only modern anaesthesia has been used since 1952 (this means: block of the ANS and controlled hypotension). The results remained unaltered, but indications were considerably extended (81 cranial interventions as against 18 previously; 7.2% over 6p yr. old as against 1.5% previously). Local anaesthesia was entirely abandoned in view of frequent cerebral oedema. The trachea was invariably intubated, as this is no longer possible once the operation has commenced (position, asepsis). Muscle relaxation interferes with respiratory control unless intubation is performed. All cases were given anaesthesia using the half-open system, to avoid the necessity of breathing against resistance. In N1O anaesthesia, the O1 supply is often insufficient for aged subjects; this is improved by 'forced expiration', particularly in patients with emphysema. Postoperative oxygen administration is always continued for several days. Controlled hypotension is indispensable in the case of angiomas or highly vascularized tumours. An arterial pressure decrease to below 70 mm. Hg in hypertensive subjects should be avoided. Postoperative hypotension against cerebral oedema is effective only if sustained (in which case it is hazardous in old age). Hypotension to the point of a decrease in venous pressure may cause circulatory collapse. It is therefore impossible to control cerebral oedema by hypotension in the aged. After-haemorrhage, however, can be readily controlled by mild hypotension for a maximum of 32 hr. Hibernation is only too often followed by circulatory collapse in the aged. Tracheotomy is becoming increasingly important as an aid in the prevention of hypostatic pneumonia.
Keywords: gold 198; abscess; aged; anesthesia; aneurysm; angioma; arterial pressure; asepsis; bleeding; brain; breathing; craniopharyngioma; cyst; death; edema; embolism; emphysema; forced expiration; hibernation; hypophysis adenoma; hypotension; induced hypotension; infection; intubation; local anesthesia; mortality; muscle relaxation; neurosurgery; outpatient department; oxygen therapy; palliative therapy; patient; plant seed; pneumonia; prevention; puncture; respiration control; senescence; shock; skull; spinal cord; trachea; tracheotomy; trigeminal nerve; venous pressure; X ray

INDICATIONS and TECHNIQUE of TRACHEOSTOMY in RESPIRATORY SYNDROMES - Despons J. (Revue de laryngologie, d'otologie et de rhinologie (1919), 1958)
After an historical outline, an extensive study is made of the indications of tracheotomy, which at present should not be considered as a palliative operation, a make shut in cases of asphyxia, but as a veritable method of treatment taking its place among the modern methods of resuscitation. The principal indications studied include the following: (1) Respiratory syndromes of nervous origin, which comprise: bulbar poliomyelitis, Guillain-Barre syndrome, various forms of polioencephalitis, comas, cerebrovascular syndromes and tetanus. (2) Respiratory syndromes of traumatic and surgical origin: cranial and spinal traumatisms, thoracic traumatisms, accidents due to anaesthesia, drowning, sequelae of thoracic operations, etc. A very complete clinical and physiopathological study of the respiratory syndromes precedes the detailed description of the technique of tracheotomy, its possible complications and its results. Decroix Paris (XV, 50).
Keywords: accident; acute respiratory tract disease; anesthesia; asphyxia; cerebrovascular disease; coma; drowning; France; general aspects of disease; Guillain Barre syndrome; poliomyelitis; resuscitation; tetanus; thorax surgery; tracheotomy

Bulbar spinal poliomyelitis complicating pregnancy at term - Pvatt H.M.; Yim B.; West W.L. (New England journal of medicine (Print), 1958)
The first case reported in this article is that of a 26-year-old paia-1, gravida-2, with progressing bulbar respiratory paralytic poliomyelitis. Admission date was 3 weeks before expected delivery. Tracheotomy was performed and the patient was placed in a Drinker respirator. Within 12 hr. all extremities and the chest were paralysed. Twenty-four hours after admission a low-segment caesarean section was performed. A viable but cyanotic male infant was delivered. The mother had a stormy convalescence, and she was gradually weaned away from the respirator into the rocking bed. The quadriplegia did not improve. The second case was that of a 23-year-old para-3, gravida-4, who was 35 weeks pregnant. She was admitted with paralysis of one arm and leg. Three days after admission, respiratory difficulty developed. Tracheotomy was performed and the patient was placed in the respirator. The following day, a caesarean section was performed, and a 2,230 g. viable infant was delivered. The mother did well and 12 days later weaning from the respirator was started and she began to tolerate plugging of the tracheotomy. It is emphasized that with paralysis of the intercostal, diaphragmatic and abdominal muscles, an intra-abdominal mass, such as a foetus, actually reduces ventilation when the patient is in the tank respirator Thus early delivery enhances mechanical ventilation by the lank and contributes to the survival of mother and infant.
Keywords: nitrogen; abdominal mass; abdominal wall musculature; air conditioning; arm; artificial ventilation; boy; cesarean section; convalescence; diaphragm paralysis; fetus (anatomy); infant; leg; mother; paralysis; patient; poliomyelitis; pregnancy; quadriplegia; survival; thorax; tracheotomy; ventilator; weaning

Recovery from a severe asthmatic state following tracheotomy, endotracheal respiration, procaine block of spinal nerve roots & curarization. - Mollaret P.; Turiaf J.; Bastin R.; Goulon M.; Lissac J.; Cophignon J.; Liozon F. (Bulletins et mémoires de la Société médicale des hôpitaux de Paris, 1958)
Keywords: article; asthma; ASTHMA/therapy

Emergency features of head injury - Reed H.L. (Journal of the International College of Surgeons, 1957)
The unconscious patient needs immediate attention for recognition and prompt treatment of tracheal obstruction, preferably with tracheotomy if this unconsciousness is expected to be prolonged. The unconscious patient equally needs immediate evaluation of the likelihood of injury to the neck, with or without involvement of the spinal cord, and proper diagnostic measures and immediate immobilization with traction if this is present. The extradural haematoma is an early and rapidly killing lesion that requires critical serial observation of the slightly or seriously injured person, and prompt diagnosis and surgical treatment are necessary to effect recovery, in contrast to the uniformly fatal outcome when treatment is delayed. Patients with compound fractures of the vault, although they merit early attention, are less urgently needed in the operating room and are better served by early general supportive measures and an opportunity to react to trauma. Chronic subdural haematoma is an elusive lesion, often occurring in alcoholic persons, with obscure symptoms requiring a high index of suspicion. When it is diagnosed early, definitive surgical treatment is indicated and usually brings gratifying results.
Keywords: alcoholism; child; open fracture; diagnosis; emergency; epidural hematoma; fatality; head injury; immobilization; infant; injury; neck; operating room; patient; spinal cord; subdural hematoma; surgery; trachea obstruction; tracheotomy; traction therapy; unconsciousness

Safeguarding of the airway in cases of spinal poliomyelitis with respiratory insufficiency - Barani J.C.; Roncagliolo A.; Vera G.; Gomez L.; Nuñez C.; Ferreira E.; Perez Lagrave E.; Berterretche J.; Somma R. (Archivos de Pediatria del Uruguay, 1957)
A report on 17 cases with affection of the respiratory muscles. Therapeutic measures used were Trendelenburg position, manual compression of the abdomen, positive pressure in a tank respirator and tracheotomy.
Keywords: abdomen; airway; book; breathing muscle; compression; poliomyelitis; rehabilitation; respiratory failure; tracheotomy; ventilator

Respiratory care of patients who have suffered from spinal poliomyelitis with respiratory insufficiency - Barani J.C.; Roncagliolo A.; Vera G.; Gómez L.; Nuñez C.; Ferreira E.; Pérez Lagrave A.; Berteche J.; Somma R. (Otolaringologica, 1957)
Patients who have suffered from spinal poliomyelitis have a functional insufficiency of the diaphragm and of the intercostal muscles. They are very susceptible to acute diseases of the respiratory apparatus and cannot get rid of their sputum. In such cases, the Trendelenburg position, manual compression of the abdomen, iron lung and tracheotomy are indicated.
Keywords: iron; abdomen; acute disease; book; compression; diaphragm; intercostal muscle; lung; patient; pneumothorax; poliomyelitis; respiratory care; respiratory failure; respiratory system; sputum; tracheotomy

Acute medical care in poliomyelitis (Systemic treatment of the acute stage) - Russell W.R. (Third Intern. Poliomyelitis Conf., 1954)
The effect of treatment in the acute stage is difficult to assess and the fate of the spinal nerve cells is often decided before medical care is established. Paralysis is caused by destruction by the virus of spinal cord cells, and changes in muscle are not important. The virus-cell struggle is decided within a few days. Experimental attempts to influence this critical stage should be tested carefully on animals before using on patients. Complete physical rest after the onset of the major illness reduces the amount of paralysis and suitable sedation is helpful when this can be used safely. In bulbar cases, however, full sedation may precipitate the need for assisted respiration. In 80% of paralytic cases there is no serious danger to life, but in the remainder a very high degree of medical and nursing supervision may be required if life is to be saved. It is suggested that special respiration units should be established to which cases of special difficulty can be transferred from smaller hospitals receiving cases of poliomyelitis. Anaesthetists play a vital part in such units and for this reason a regional respiration unit should be present in the largest general hospital in the region. Cases requiring special supervision must be transferred under continual care of an anaesthetist using if necessary the apparatus required for controlled respiration. Cases with pharyngeal paralysis often preserve sufficient power of the muscles of respiration provided that the lungs can be kept healthy and atelectasis avoided. The supine position should be avoided even in the ambulance, as the inhalation of vomit must be avoided at all costs, for it often leads to irrecoverable changes in the lungs which cause death within a few hours. Frequent changes of bodily posture are essential if the lungs are to be kept healthy and the principles of postural drainage must be fully understood and applied. When failing respiration is due to spinal paralysis treatment in a tank-type of respirator should not be delayed, but when there is also pharyngeal paralysis, the method advocated by Ibsen and Lassen of positive pressure respiration through a tracheotomy tube is the method of choice. Care of the lungs takes priority over all else while life is in danger, but attention to the paralysed muscles must not be neglected. Continual relaxation of paralysed muscle is harmful as the resultant shortening makes the muscle tight and vulnerable to later stretching. Frequent passive movements are the most important need of paralysed muscles. Hot packs are sometimes useful but are not vitally important. Too many different methods of treatment are used and all should now be compared by measuring with graduated springs the strength of muscle groups during the period of recovery for a period of at least a year. Only by doing so can clarity emerge from the present confusing variety of methods of treatment in use.
Keywords: ambulance; artificial ventilation; assisted ventilation; atelectasis; autopsy; body position; death; emergency care; general aspects of disease; general hospital; hospital; inhalation; lung; medical care; muscle; nursing; paralysis; passive movement; patient; poliomyelitis; positive end expiratory pressure; postural drainage; rest; sedation; spinal cord; spinal cord nerve cell; spinal paralysis; stretching; supine position; systemic therapy; tracheotomy; tube; ventilator; virus

Epidemiology of acute anterior poliomyelitis. III. Frequency of bulbar and spinal localizations in the above-mentioned hospital in 1951-1953 - Di Nola F.; Angela G.C. (Minerva medica (Testo stampato), 1954)
No shift towards the adult age-group was noted, nor was any increased virulence of the virus. Tracheotomy is indispensable in acute bulbar forms.
Keywords: adult; epidemiology; groups by age; hospital; poliomyelitis; tracheotomy; virulence; virus

Care of the patient with multiple injuries - Mathewson Jr. C. (Surgical Clinics of North America, 1954)
Proper initial aid and transportation may obviate the production of further complications such as converting an unparalysed victim with a spinal injury to a permanent or complete paraplegic. Transportation with proper splints of fractures is elementary but should be continually emphasized. The extent of the initial injuries should be established by the initial physician and a base line recorded for progressive changes in signs and symptoms often are the key to correct diagnosis. Particularly is this true in intra-abdominal and head injuries. If there is question of asphyxia, a tracheotomy should be utilized early. Haemorrhage and shock, of course, should be corrected. It is pointed out that needless trauma from multiple laboratory procedures should be prevented if the clinical signs and symptoms are sufficient for diagnosis. When combined thoraco-abdominal injuries are encountered, the thoracic portion of the procedure usually is undertaken first in an attempt to restore normal cardiovascular physiology. In crush injuries of the chest, skeletal traction is a valuable and effective method of stabilizing the chest wall. Tracheotomy, of course, is mandatory. Penetrating wounds of the abdomen should, of course, be explored as soon as the general condition of the patient permits. Blunt injuries of the abdomen present a different but nonetheless serious problem. Ruptured spleen or bladder, lacerations of the liver and bowel, mesenteric haemorrhage and injuries to the pancreas all present difficult diagnostic problems. The presence of blood in the urine indicates injury to some level of the urinary tract. In head injuries, the importance of a recorded early and complete neurological examination should be recognized. Changes in the state of consciousness and in the neurological findings may be the only clues to the extent and progress of a brain injury. Initial management of specific types of injuries influenced by surgical judgment and proper timing of procedures may be life-saving.
Keywords: abdomen; abdominal injury; asphyxia; bladder; bleeding; blood; blunt trauma; brain; brain injury; cardiovascular function; consciousness; crush trauma; decision making; diagnosis; fracture; general condition; head injury; injury; intestine; laboratory test; laceration; liver; multiple trauma; neurologic examination; pancreas; paraplegia; patient; penetrating trauma; physical disease by body function; physician; skeleton traction; spine injury; spleen; splint; thorax; thorax wall; tracheotomy; traffic and transport; urinary tract; urine; victim

Treatment of respiratory (spinal; bulbar and bulbospinal) types of poliomyelitis and radiculoneuritis (14 cases) - López Clares F. (Gaceta Medica de Mexico, 1954)
Tracheotomy was performed (with success) in 9 of the 14 cases. Clinically, 3 cases were of bulbar type, 2 of bulbospinal radiculoneuritis, 4 of quadriplegia with muscular involvement, 3 of bulbospinal-type quadriplegias and 2 of diffuse (facial and bulbopontine) involvement with respiratory disturbances. The classical considerations on the treatment of these forms of poliomyelitis are reviewed.
Keywords: neuritis; poliomyelitis; quadriplegia; respiratory failure; tracheotomy

A study of spinal fluid pressures in operations requiring removal of both internal jugular veins - Schweizer O.; Leak G.H. (Annals of surgery, 1952)
Removal of both internal jugular veins, either at one operation or in 2 stages, did not result in a consistent rise in spinal fluid pressure. Clinical experience showed that removal of both jugular veins could be performed with minimal risk. An occasional patient did experience signs and symptoms of increased intracranial pressure, but these were transient and subsided spontaneously in the majority of cases. Tracheostomy is done routinely when the 2nd jugular vein is removed, and the 'head up' position is helpful.
Keywords: anesthesia; cerebrospinal fluid; internal jugular vein; intracranial hypertension; jugular vein; ligation; patient; physical disease by body function; risk; tracheostomy; vein

Tracheotomy in spinal respiratory paralysis. - Ohler R.L.; Provost P.E. (The Journal of the Maine Medical Association, 1952)
Keywords: article; poliomyelitis

The mechanism of suffocation in bulbo-spinal poliomyelitis and some primary experiences from surgical treatment - Sjöberg A. (Svenska Laekartidningen, 1949)
Eleven cases with respiratory difficulties were treated by tracheotomy and bronchoscopic drainage. Ten survived. Four different types of suffocation mechanism are distinguished depending on the involvement of the central nervous system. The indications for surgical procedures are discussed. (I) In patients with intercostal and diaphragmatic paralysis without bulbar involvement, bronchial secretions may necessitate bronchoscopic drainage with or without preceding tracheotomy. (II) In bulbar cases with pharyngeal paralysis, aspirated secretions often make the above-mentioned procedures inevitable. (III) In bulbar cases with pharyngeal paralysis and laryngeal abductor paralysis tracheotomy is always necessary. Paralysed, paramedially situated vocal cords, if tracheotomy is not performed, cause the respirator to lead to suffocation. (IV) In 6 out of the II cases there was a simultaneous bulbar and spinal involvement. When C1 and C2 are affected and there is at the same time a pharyngeal paralysis, the antagonists force the larynx upwards and backwards. The dislocation of the laryngeal entrance contributes to suffocation. When the patient is recumbent, the acute angle formed by the lower part of the mouth and the anterior contour of the neck is clearly observable (normally this is a right or obtuse angle). Tracheotomy must be immediately performed (often with the patient in the respirator). In many such cases the author found no mucus in the bronchi. It is therefore evident that the dislocation and not the secretions are in such cases responsible for death.
Keywords: asphyxia; bronchus; bronchus secretion; central nervous system; death; diaphragm paralysis; larynx; mucus; neck; paralysis; patient; poliomyelitis; bodily secretions; surgery; surgical technique; tracheotomy; ventilator; vocal cord

Bulbar poliomyelitis. Its mechanism and treatment - Baker A.B. (American Journal of Medicine, 1949)
Observation of 183 cases within a few months. Involvement of cranial nerve nuclei often led to difficulty in swallowing and obstruction of the airway. Suction, postural drainage and sometimes tracheotomy are advised. Lesions of the autonomic centres in the medulla are sometimes due to hypoxia. Treatment consists in oxygen therapy. Combined involvement of the bulb and the upper spinal cord makes respiratory treatment necessary.
Keywords: airway; cranial nerve; hypoxia; obstruction; oxygen therapy; poliomyelitis; postural drainage; spinal cord; suction; swallowing; tracheotomy