Sympathetic Ramisection in Spastic Paralysis

Abstract

Influenced by the clinical results and the very plausible explanation of sympathetic release, reported by Royle 1 and supported by Hunter,2 my colleagues and I have performed ramisection for spastic paralysis in a sufficient number and variety of cases to make a report of them of some value in arriving at a proper estimate of the operation.Included in this study are eighty-three ramisections: twenty-three cervical and sixty lumbar, with twenty-five left, fifteen right and eleven bilateral. The first analysis was based on the comparative study of a group of operations done in 1925, including twenty lumbar and four cervical operations; another in 1926 and 1927 with sixteen lumbar and six cervical, and a third group in 1928 with twelve lumbar and thirteen cervical operations.In 1925 the indications specified by Royle in selecting cases were followed closely and only those patients were operated on who had fair cortical control, definite increase in plastic tone, with slow joint position change and hang up reflexes. The average age was greater than in the 1927 or 1928 group. In the latter two groups the mental requirement remained the same, but the state of the muscle tone was not given consideration in the selection of cases. The operative technic was alike in the three groups and the final results were so nearly the same that grouping in this manner offers only one conclusion ; namely, that increased plastic tone has no value in selecting cases for operation. This is in accord with the experience of Von Lackum.3In our series there are seventeen left and fifteen right hemiplegias, eleven paraplegias, fifteen tetraplegias and two triplegias. The cervical operations were done through exposing the brachial plexus and cutting the sympathetic rami to the fifth, sixth, seventh, eighth, and first dorsal nerve roots. The stellate ganglion was not exposed at any operation. Increased warmth was noted in 40 per cent, but was never so much as present in the lumbar cases.For the lumbar sympathetic, the trunk was exposed through a lumbar incision and the gray rami from the second through the fifth, and the trunk divided below this point. Postoperative increase in the temperature of the leg was recorded in 100 per cent of the cases. In some an increase in warmth and circulatory tone was present four years after operation. In one case, twelve months later there was an increase of one-half inch in circumference of the calf on the limb that had been operated on and, incidentally, relief during the entire period from a troublesome constipation, existing for several years, by purposely dividing the trunk at the first lumbar enlargement.Great difficulty has been experienced in making an accurate estimate of the actual effect of ramisection on the final result when a combination of measures has Clinical cases from the Texas Scottish been followed in treatment of the patients. Primary interest, naturally, was in improving the function of an arm or a leg and frequently the opportunity for watching the effect of ramisection alone was sacrif...