Spinal Cord Injury Level and Function

Home , C5 (classification), Dermatome (anatomy)

Dr Wunna Aung SCI rehabilitation Consultant The Spinal Cord

• Anatomy • Function Anatomy Spinal segment Spinal cord segment level relative to vertebral bodies Function

Major conduit through which information travels between brain and body. – Sensation – Motor – Blood Pressure – Bladder – Bowel – Sexual Function Assessment of SCI

• AIS (American Spinal Injury Association ASIA Impairment Scale) – Level of injury – Completeness of injury- A, B, C, D, E • Dermatome=area of the skin innervated by the sensory axons within one segmental nerve (root) • Myotome=collection of muscle fibers innervated by the motor axons within one segmental nerve( root) Dermatomes Myotomes Sensory testing

• Soft touch and pin prick • Dermatomes • Sensory Scoring – 0 Absent – 1 Altered – 2 Normal

ASIA Chart

? ? ? ? ? ASIA Chart

C4 T4 (nipples) T6 (xiphisternum) ? ? ASIA Chart

C4 T4 T6 (xiphisternum) T10 (umbilicusicus) ? ASIA Chart

C4 T4 T6 (xiphisternum) T10 (umbilicusicus)

T12 (Inguinal ligament) Motor examination

• Motor power of key muscles • MRC Motor Scores – 0 None – 1 Flicker – 2 Movement, gravity eliminated – 3 Movement, against gravity – 4 Movement, against resistance – 5 Full Power

Key muscles

• C5 - Elbow flexion (biceps) • C6 - Wrist extension (extensor carpi radialis) • C7 - Elbow extension (triceps) • C8 - Finger flexion (flexor digitorum profundus) • T1 - Small finger abductors (abductor digiti minimi) • L2 - Hip flexion (iliopsoas) • L3 - Knee extension (quadriceps) • L4 - Ankle dorsiflexion (tibialis anterior) • L5 - Great toe extension (extensor hallucis longus) • S1 - Ankle plantar flexion (gastrocsoleus complex) Per rectal examination

• Deep anal sensation • Bulbo-carvernosus reflex • Voluntary anal contraction ASIA Chart Upper Limb and Trunk

Date Time Motor Touch Pain MOTOR R L R L R L Shoulder Elevators C3, 4 2 2 2 2 C2 Abductors C5, 6 2 2 2 2 C3 Adductors C5-T1 2 2 2 2 C4 Elbow Flexors C5,6 5 5 2 2 2 2 C5 Elbow Extensors C7, 8,T1 3 3 2 2 2 2 C6 Wrist Flexors C6,7,8 2 1 1 1 C7 Wrist Extensors C6, 7,8 5 5 0 0 0 0 C8 Finger Flexors C7, 8,T1 0 0 Finger Extensors C7,8 0 0 0 0 T1 Hand Intrinsic C8,T1 0 0 0 0 T2 Thumb Flexors C7,8,T1 0 0 0 0 T3 Thumb Extensors C7,8 0 0 0 0 T4 ABD. DIG. MIN C8,T1 0 0 0 0 0 0 T5 Abdominal Muscles: Upper 0 0 0 0 T6 Lower 0 0 0 0 T7 ASIA Chart Lower Limb

Time Motor Touch Pain MOTOR R L R L R L Hip Flexors L2, 3 0 0 0 0 0 0 T8 Extensors L5,S1,2 0 0 0 0 T9 Abduct. L4,5,S1 0 0 0 0 T10 Adduct. L3,4 0 0 0 0 T11 Knee Flexors L4,5,S1,2 0 0 0 0 T12 Knee Extensors L2, 3,4 0 0 Ankle DF L4, 5,S1 0 0 0 0 0 0 L1 PF S1,2 0 0 0 0 0 0 L2 Toe Flexors L5, S1,2 0 0 0 0 L3 Extensors L4,5,S1 0 0 0 0 0 0 L4 0 0 0 0 L5 REFLEXES 0 0 0 0 S1 ASIA SCORE 0 0 0 0 S2

Total ASIA score 26 /100 0 0 0 0 S3

0 0 0 0 S4-5 ASIA Chart Upper Limb and Trunk

Date Time Motor Touch Pain MOTOR R L R L R L Shoulder Elevators C3, 4 2 2 2 2 C2 Abductors C5, 6 2 2 2 2 C3 Adductors C5-T1 2 2 2 2 C4 Elbow Flexors C5,6 5 5 2 2 2 2 C5 Elbow Extensors C7, 8,T1 3 3 2 2 2 2 C6 Wrist Flexors C6,7,8 2 1 1 1 C7 Wrist Extensors C6, 7,8 5 5 0 0 0 0 C8 Finger Flexors C7, 8,T1 0 0 Finger Extensors C7,8 0 0 T1 Hand Intrinsic C8,T1 0 0 T2 Thumb Flexors C7,8,T1 Level ? 0 0 T3 Thumb Extensors C7,8 0 0 T4 ABD. DIG. MIN C8,T1 0 0 0 0 0 0 T5 Abdominal Muscles: Upper 0 0 0 0 T6 Lower 0 0 0 0 T7 ASIA Chart Upper Limb and Trunk

Date Time Motor Touch Pain MOTOR R L R L R L Shoulder Elevators C3, 4 2 2 2 2 C2 Abductors C5, 6 2 2 2 2 C3 Adductors C5-T1 2 2 2 2 C4 Elbow Flexors C5,6 5 5 2 2 2 2 C5 Elbow Extensors C7, 8,T1 3 3 2 2 2 2 C6 Wrist Flexors C6,7,8 2 1 1 1 C7 Wrist Extensors C6, 7,8 5 5 0 0 0 0 C8 Finger Flexors C7, 8,T1 0 0 Finger Extensors C7,8 0 0 0 0 T1 Hand Intrinsic C8,T1 0 0 0 0 T2 Thumb Flexors C7,8,T1 C6 0 0 0 0 T3 Thumb Extensors C7,8 0 0 0 0 T4 ABD. DIG. MIN C8,T1 0 0 0 0 0 0 T5 Abdominal Muscles: Upper 0 0 0 0 T6 Lower 0 0 0 0 T7 Level of injury

• Sensory level-the most caudal, intact dermatome for both pin prick and light touch sensation. • Motor level-lowest key muscle function that has a grade of at least 3 , providing the key muscle functions represented by segments above that level are judged to be intact (graded as a 5). • neurological level of injury- the most cephalad of the sensory and motor levels

Zone of Partial Preservation

• Only applies in Complete Injuries – No sensation or motor function in S4/S5 • Levels below neurological level with some motor or sensory function ASIA Scale

A Complete. No sensation or motor function in S4/S5 B Incomplete. Sensation but no motor C Incomplete. Motor, > 50% < 3 D Incomplete. Motor, > 50% > 3 E Normal

Neurological level and clinical significance • C3 or above- diaphragm palsy- ventilatory support • Injury at T6 or above will interfere with blood pressure control- autonomic dysreflexia, orthostatic hypotension • Above T10- reflexogenic penile erection • Supraconal vs conal /infra conal injury

Level of injury in paraplegia

Spastic paraplegia Flaccid paraplegia • Supraconal injury • At or below conus injury • Increase muscle tone • Reduced muscle tone,(no (spasm), reflexes, spasm issue) , absent of • Spastic bladder reflexes • Reflexic bowel • Flaccid /atonic bladder • Reflexic erection • Flaccid /atonic bowel • No reflexic erection Functional outcome following SCI • Level of injury • Completeness of injury ( AIS ) • Other – Age, gender and body shape – comorbidities – Motivation – Values, roles and lifestyle – Environment

Spinal Cord Injury

C1,C2,C3 • Ventilated • Neck Movement, Shoulder shrug • Power chair sip / puff • Eye Gaze

C4 ASIA -A

C4 • Breathes • Neck Movement, Shoulder shrug • Power chair sip / puff or chin control • Normal communication • Assistive technology • Hoist transfer

C5 ASIA-A C6 ASIA A C7 ASIA A C8/T1 ASIA A Paraplegia ASIA A

• Manual chair • Self caring • Independent transfer • Normal activities • Driving adapted car T10

Ambulation according to ASIA Grade

ASIA GRADE BASELINE EXAM RATE OF AMBULATION at discharge ASIA -A <72 hrs 0% ambulate ASIA -B <72 hrs 48% household ambulation ASIA -C <72 hrs <50 yrs 91% household ambulation >50 yrs 42%household ambulation ASIA -D <72hrs >95% community ambulate • Determine the potential functional outcomes • Formulate functional goals during inpatient rehabilitation programme. THANK YOU