By Dr. Brett Greenky
It was August 1990, the days when beepers simply beeped and cell phones housed a whole suitcase. I sat in the emergency room waiting for the inevitable consequence of a smoldering Syracuse summer day. The sunset is especially appreciated in our city of long winters and gray skies. A cooling breeze arose as the heavy sun drifted lower, dragging a shadow across the cityscape. The desire to be outside was irresistible.
A 19-year-old girl, home from work in the third floor apartment she shared with three friends, watched the sun’s descent as she waited for her roommates to arrive. The last beads of the day’s perspiration evaporated as a new convertible drove up below her and she lingered on the fire escape. A boy she knew distantly from school had stopped below her with a new red sports car.
“ You want to go for a ride?” he asked.
“No, I better not. My roommates are coming home soon and we’re gonna go out tonight,” she replied.
“Come on, we’ll just go for a quick spin. I’ll have ya back in 20 minutes. I just got my first car, isn’t it slick?”
“Yea it’s really nice,” she admitted. “I have to wait for my roommates.”
“Come on, you will be back before they even get home. Leave a note,” he gestured with a waving hand.
“Ok, but really quick cause I gotta be back in 20 minutes.”
The stairs are always faster in the hospital; less competition than the elevator, and no unscheduled stops.
She lay on a stretcher, quite calmly actually, IV in place as I watched from the doorway. The ER Physician softly whispering to me the situation:
o No nerve function in either leg.
o Hemodynamically stable.
o Neck pain only, collar in place.
o Foley catheter in and no blood in the urine.
o Spine and pelvis X-ray being developed
No reason to go in there until I see the X-ray’s I thought, since questions will be asked, and the answers will depend on the films. I wandered to the X-ray display and startled. The films were all fine except the cervical spine. She had bilaterally jumped facets at C5/6.
The boney spine is like articulating armor around the spinal cord. Think of a concrete embankment around a highway, protecting the traffic. There are a lot of entrances and exits in certain areas like downtown and long stretches of highway with few exits. The spine is best protected in the long thoracic area (the part from your shoulders to your waist) by the stiff facet joints and the presence of the ribs. As a consequence, traumatic injury in the middle of the thoracic spine is rare. The cervical (neck) and lumbar (low back) parts of the highway have lots of exits and entrances for the nerves to the arms and legs. In addition these areas need a lot of flexibility for motion. These areas are much more vulnerable to trauma. The most risk exists at the junctions between stiff and flexible spine segments. Where the flexible cervical spine meets the stiffer thoracic spine is especially at risk.
Bilaterally “jumped” facets result in a 50% reduction of the spine diameter at that level. Usually that pitches the spinal cord so much that permanent loss of nerve function below the level of injury is inevitable: quadriplegia.
“Hi, I’m doctor Greenky, one of the bone doctors here at the hospital. Do you have pain?”
“My neck hurts but that’s it. Why can’t I move my legs?”
“You have an injury to your spine and your spinal cord in your neck. It’s too early to tell about improvement right now,” I responded.
“OK, but I have to work on Monday so I have to be out of here soon.”
“I understand. Can we call your parents and let them know you are here.”
“I don’t want to call them. They will be mad I went for a ride in that car. I will tell them later next week when I’m all better and back to work.”
The nurse and I checked the “bulbocavernous reflex” using the Foley catheter. This presence of the reflex represents the end of spinal cord shock. If the spinal cord is in shock and not recovered then reversal of some, and in rare cases most, of the nerve deficit is possible. The presence of the reflex means no recovery will occur. Her reflex was present. Our hearts fell. Her quadriplegia was going to be permanent. I knew it immediately and felt a wave of nausea. I smiled and held her hand.
“We need to stabilize your spine with an operation. We need to talk to your parents now.”
“Ok, but they are going to be mad,” she reluctantly responded.
“I know. My parents have been mad at me lots of times but they got over it,” I said.
“How about moving my legs?”
“It’s too soon to know for sure,” I answered again. “Lets take one thing at a time.”
As I walked to the OR to book the case, a glimpse of the red sun slipping below the horizon left me with the feeling that a long dark night had just only begun.