Pathological studies and pathological principles on the management of extension injuries of the cervical spine

Extension injury to the arthritic spine of elderly individuals involves rupture of the anterior longitudinal ligaments and disks at several levels, but no bony injury can be observed on X-ray. There are many small focal haemorrhages in the central portion of the spinal cord and the injury is often accompanied by incomplete paresis. As the injury is a stable injury with the posterior ligament complex being intact, it is only necessary to immobilise the cervical spine conservatively. Laminectomy is not indicated. In hyperextension injury of the rigid cervical spine and in momentary posterior dislocation observed in middle aged individuals, rupture of the anterior longitudinal ligament and disk is observed at a single site, but being spontaneously reduced, traumatic findings cannot be observed on X-ray. The spinal cord is crushed at the site of injury to bring about severe neural damage. When this type of injury is diagnosed or suspected, further damage may be inflicted on the spinal cord if skull traction is made with calipers in the extended position and the condition at the time of injury is reproduced. Therefore, the patient should be nursed in a shell or between sandbags in a neutral position or even in a position of slight flexion. In extension fracture dislocation with compression which resembles on X-ray a flexion injury, all of the three columns of the spine are destroyed to bring about an extremely unstable condition. As the spinal cord is extensively injured to involve several segments, decompression surgery for relief of neuroparalysis should not be performed when complete paralysis develops simultaneously with fracture dislocation. Therefore, it should be first treated conservatively with skull traction, and in cases where stability cannot be restored, surgical fixation of the spine should be performed.