"No clinical puzzles more interesting": Harvey Cushing and spinal trauma, the Johns Hopkins Hospital 1896-1912

Abstract

Although Harvey Cushing played a central role in the establishment of neurosurgery in the United States, his work on the spine remains largely unknown. This article is not only the first time that Cushing's spinal cases while he was at Johns Hopkins have been reported, but also the first time his management of spinal trauma has been described. We report on 12 patients that Cushing treated from 1898 to 1911 who have never been reported before, including blunt and penetrating injuries, complete and incomplete spinal cord lesions, and both immediate and delayed presentations. Cushing performed laminectomies within 24 hours on patients with immediate presentations-both complete and incomplete spinal cord lesions. Among those with delayed presentations, Cushing did laminectomies on patients with incomplete spinal cord injuries. By the end of his tenure at Hopkins, Cushing advocated nonoperative treatment for all patients with complete spinal cord lesions. Four patients died while an inpatient, with meningitis and cystitis leading to the death of 1 and 3 patients, respectively. Cystitis was treated with intravesicular irrigation; an indwelling catheter was placed by a suprapubic cystostomy in four. Cushing was one of the first to report the use of x-ray in a spine patient, in a case that may have been one factor leading to his interest in the nervous system; Cushing also routinely obtained radiographs in those with spinal trauma. These cases illustrate Cushing's dedication to and rapport with his patients, even in the face of a dismal prognosis.

FIGURE 1

Case 9: A 34-year-old man presented 2.5 hours after an accident with difficulty moving his right leg, paresthesias in his lower extremities, and severe back pain. Although there is no note of “saddle” or perineal anesthesia, Cushing made drawings of this presentation from the dorsal lithotomy (A) and lateral (B) views. Twelve hours after presentation, Cushing performed a laminectomy and exploratory durotomy. He has depicted the fracture-dislocation (C), specifically noting the “area of fracture-disloc”; he has also sketched the exposure (D), labeling the “area of fracture anterior” between T12 and L1, and “posterior curve” of the spinal cord. The patient was discharged with no residual motor symptoms

FIGURE 2

Case 3: A 38-year-old African American man presented after having been accidentally struck in the neck while digging graves. The patient's sensory examination was drawn on a template of the human body. The shaded areas in (A) and (C) demarcate areas of intact sensation; the line in (B) shows the line above which sensation was intact, and below which sensation was lost, consistent with a lesion at C7.

FIGURE 3

Case 10: A 25-year-old miner who had been crushed by falling coal 1 year earlier presented with difficult walking and bowel and bladder dysfunction. Examination was remarkable for bilateral paralysis of dorsiflexion and numbness involving the L5 and sacral dermatomes. Cushing often depicted where the deficits of his spinal patients on an embryonic model (A). Not only are the areas of sensory impairment shaded for this patient (B), but the individual dermatomes are also labeled. Intraoperatively there was “considerable displacement, [with] the first lumbar being dorsally much more prominent than the other vertebrae,” and he sketched the kyphotic deformity (C) in his operative note.

FIGURE 4

Case 2: A 38-year-old man presented 2 months after a coal mine injury with deficits in a Brown-Séquard pattern, including right leg weakness and loss of sensation of pain and temperature on the left leg. Cushing has drawn the spinal cord as he envisioned the lesion in a histological section, depicting the crossing of pain and temperature fibers upon entering the spinal cord (A). On the right side, he has written “sensory OK, Motor (pyramidal) paralysis”; on the left side, he has written “Motor (pyramidal) OK, sensory pain (thermic) paralysis.” Cushing performed a laminectomy and exploratory durotomy and he sketched a diagram of the patient's compression fracture from a sagittal view (B).

FIGURE 5

Case 3: A 32-year-old miner presented to the Johns Hopkins Hospital 8 days after having been crushed by coal with bilateral lower extremity paralysis and paresthesias. Three days later, Cushing performed a laminectomy that revealed a fracture-dislocation with anterior subluxation. He sketched his depiction of the injury from a sagittal view (A) and drew the intraoperative view after the 3-level laminectomy (B).