The value of more aggressive management in traumatic paraplegia

In the last decade, operative decompression of cord and cauda, internal fixation with rods, bony fusion and early ambulation, have become more popular in the management of thoracolumbar injuries with neurological deficit. Computer-tomography, CT myelography and peroperative ultrasonography provided direct evidence, that, without surgical decompression, reduction of displaced bone and disc fragments, propelled into the spinal canal, is often incomplete, not only after postural reduction, but also after rod instrumentation. The percentage of patients with incomplete paraplegia who show improvement of neurological deficit after surgical reduction and stabilization, is probably greater than that noted with postural management. There are, however, shortcomings in the classification of neurological deficit, which hamper adequate comparison. Further research in this field is necessary. The value of the surgical approaches is mainly in immediate stabilization, which diminishes pain, facilitates nursing care and allows more rapid mobilization. This results in a shorter stay in hospital and earlier active rehabilitation. That decompression of the neural elements provides improved neurological recovery seems likely, but has so far not been proven. Management of these patients, preferably admitted to specialized units, should be carried out by an orthopedic surgeon and a neurosurgeon in cooperation. The orthopedic surgeon is mainly concerned with management of the spine; the neurosurgeon with management of the paraplegia, operations being carried out by both.