SPINAL CORD INJURY (SI)

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A Spinal Cord Injury (SCI) is a catastrophic, life-changing event that results in an impairment in a person’s sensory, motor, and autonomic function. Individuals experience diminished physical capacities and face lifelong challenges such as pain, fatigue, depression, and anxiety, all of which influence their ability to lead healthy and fulfilling lives. Some people will have the ability to achieve a high level of independence while others, limited by their physical ability, will only be able to achieve a level of independence through directing their care and by using technology.

Grading SCI
SCIs are graded according to the American Spinal Injury Association (ASIA) grading scale, which describes the severity of the injury.

The scale is graded with letters:
ASIA A: injury is complete spinal cord injury with no sensory or motor function preserved.
ASIA B: a sensory incomplete injury with complete motor function loss.
ASIA C: a motor incomplete injury, where there is some movement, but less than half the muscle groups are anti-gravity (can lift up against the force of gravity with a full range of motion).
ASIA D: a motor incomplete injury with more than half of the muscle groups are anti-gravity.
ASIA E: normal.

Vertebral vs. Cord Segmental Levels

The vertebral column is made up of 24 segments with 7 cervical, 12 thoracic, and 7 lumbar segments. However, the spinal cord terminates approximately between lumbar vertebrae L1 and L2. Therefore, spinal vertebral and spinal cord segmental levels do not necessarily correlate. i.e. The spinal cord itself has “neurological” segmental levels which are defined by the spinal roots that enter and exit the spinal column between each of the vertebral segments, and the spinal roots are not always situated at the corresponding vertebral levels.
For example:
• C8 cord segment is situated in the C7 vertebra, and the C8 root exits between C7 and T1.
• T12 cord is situated in the T8 vertebra.
• The lumbar cord is situated between T9 and T11 vertebrae.
• The sacral cord is situated between the T12 to L2 vertebrae.
• The tip of the spinal cord or conus is situated at L2 vertebral level.
• Below L2, there are only spinal roots, called the cauda equina.

SCI Mnemonic for cervical levels

C1-C3 I turn my head so I can see

C4 Breathe more, shrug my shoulders to ignore

C5 Arms up high, bend my elbows, pretend to fly

C6 Pick up sticks, tenodesis helps me exist

C7 I’m in heaven, transfer myself, independent livin’

C8 This is great – now my thumb can manipulate

The cervical spine consists of seven distinct vertebrae, two of which are given unique names:
• The first cervical vertebrae (C1) is known as the atlas.
• The second cervical vertebrae (C2) is known as the axis.
The spinal nerves extend from above their respective vertebrae, through the intervertebral foramen.
C7 is an exception – it has a set of spinal nerves extending from above (C7) and below (C8) the vertebra. Therefore, there are eight spinal nerves associated with seven cervical vertebrae.

FOCUS ON ABILITIES AND FUNCTIONAL GOALS

Level	Key muscles innervated	Abilities	Functional Goals	Equipment needed to gain function/independence
C1–C3	• Sternocleidomastoid • Cervical Paraspinal • Neck accessories . No motor innervations to diaphragm; ventilator dependent.	Limited movement of head and neck.	Breathing: Depends on a ventilator for breathing. Communication: Talking is sometimes difficult, very limited or impossible. If ability to talk is limited, communication can be accomplished independently with a mouth stick and assistive technologies. Effective verbal communication allows the individual with SCI to direct caregivers in their ADLs -bathing, dressing, personal hygiene, transferring as well as bladder and bowel management. Daily tasks: Assistive technology allows for independence in tasks such as turning pages, using a telephone and operating lights and appliances. Mobility: Can operate an electric wheelchair by using a head control, mouth stick, or chin control, and can tilt wheelchair for independent pressure relief.	• Electric Trendelenburg Hospital Bed • Ventilator and back-up generator • Mechanical Lift • Power wheelchair with tilt and recline, and sip-and-puff • Environmental control unit • Head pointer • Computer access: Integra Mouse with sip/puff select (can operate with tongue or lips), morse code with switch operated by tongue, eye movement or other facial muscles, single switch scanning, limited voice recognition for commands and using macros/shortcuts, eye gaze technology.
C3–C4	C4 • Diaphragm • Upper trapezius • Cervical paraspinal muscles	Usually has head and neck control. May be able to shrug their shoulders (C4 level).	Breathing: May initially require a ventilator for breathing, usually adjusts to breathing full-time without ventilator assistance. Communication: Communication devices may be needed or may be normal. Daily tasks: Environmental controls are often needed. Dependent for feeding, dressing, and bowel and bladder care. Can independently operate an adjustable bed with an adapted controller. Mobility: Dependent for bed mobility and transfers, independent in electric wheelchair and with pressure relief by reclining wheelchair.	• Electric Trendelenburg Hospital Bed • Mechanical Lift • Power wheelchair with tilt and recline • Computer access: Mouthstick and holder/mini keyboard, trackball mounted at chin, onscreen Keyboard, separate switch and interface for L/R click (operated by sip/puff, cheek, shoulder shrug, eye movement, mouse devices designed to be mounted at chin, mouth, “Hover” or “dwell” software for automatic selection of icons/controls, single or double switch scanning, morse code/switch activation, voice recognition • Other: call systems, environment controls, mouthstick for page turning and computer operation with use of lap trays, book holders, and mouthstick docking stations.
C5	Elbow Flexion Biceps Brachii Biceps Brachialis	Typically has head and neck control, can shrug shoulder and has shoulder control. Can bend his/her elbows and turn palms face up.	Daily tasks: With setup and use of adaptive equipment, independent in self-feeding. Needs help with dressing. Dependent for bowel and bladder care. Health care: Can manage their own health care by doing self-assist coughs and pressure reliefs by leaning forward and moving side-to-side. Mobility: Moderate to maximum assistance needed for bed mobility. Maximum assistance needed for sliding board transfers. Independent in electric wheelchair with hand drive/controls. Independent in manual wheelchair with quad pegs for indoor mobility.	• Electric Trendelenburg Hospital Bed • Power wheelchair with arm drive control for outdoors • Manual wheelchair for indoors (level and non-carpeted surfaces) • Padded shower bench • Splints: Day- Wrist cock up and Night- Intrinsic Plus. Air splints to maintain elbow extension for home exercise program for increasing shoulder/scapula strength. • Universal-cuff with right angle pocket for feeding, long straw, plate guard, mobile arm support or offset feeder, long wanchik brace for writing, caduceus stylus or stylus in u-cuff, with proper setup of phone or tablet on lap tray or clasp on holder • Computer Access: Typing aids ( with/ without wrist support), mouthstick as back up, or if UE pain is present, mini-keyboard, laptray, trackball /joystick / touchpad for mouse movement, separate switch and interface for L/R click, keyboard shortcuts (Sticky Keys, Hotkeys, etc.), word prediction/completion software for rate enhancement, voice recognition for ease and efficiency
C6	Wrist Extension – Tenodesis Extensor Carpi Radialis Longus Extensor Carpi Radialis Brevis	Has movement in head, neck, shoulders, arms and wrists. Can shrug shoulders, bend elbows, turn palms up and down and extend wrists.	Daily tasks: Independent in self-feeding with use of adaptive equipment. Independent with upper body dressing and needs assistance with lower body dressing. Dependent for bowel and bladder care. Health care: Can independently do pressure relief (side-to-side), skin checks and turn in bed. Mobility: Independent bed mobility and transfers but often requires a sliding board and may need minimal help with transfers that are not level. Independent with lightweight manual wheelchair on level ground, gentle slopes, and 2-inch curbs. Can take off armrests and footplates independently. Drives adapted car independently. ** Individuals with C6 tetraplegia will require to modify their technique of transferring due to paralysis of the triceps. Gravity-assisted movements of the trunk while locking their arms, by passively extending their elbows, allows the patient to slide along the board. When triceps function is impaired, C6 SCI patients learn to externally rotate their shoulders and lock their elbows in extension. They can maintain forward sitting balance by using shoulder depression, protraction and external rotation and, full elbow and wrist extension. Patients with C6 tetraplegia have added difficulties rolling because paralysis of the triceps muscles limits their ability to maintain elbow extension. By using an arm swinging motion, the patient builds up momentum and rolls from side to side. By externally rotating the shoulders, minimizing shoulder flexion, and performing the whole task with sufficient speed to ensure the elbows have little opportunity to flex. Contrary to what some may intuitively think it is not possible to roll with the elbows fully flexed. The shortened upper limbs cannot generate sufficient angular momentum to roll the body, and hand position limits arm swing. Patients unable to roll in bed can use bed rails or loops attached to the side of the bed to pull themselves from side to side. Alternatively, they must rely on assistance from others.	• Power wheelchair with arm drive control for outdoors •Manual wheelchair for indoors (level and non-carpeted surfaces) • Postural support devices: Hydraulic standing table, w/c pressure relief cushion, power/mechanical lift • Tenodesis splint • Transfer board • Built-up handles • Writing: short wanchik, u-cuff with right angle pocket, build-up foam or other custom writing utensils. • Grooming: adapted makeup and makeup stand, adapted nail clippers, u-cuff for oral care, large top toothpaste with rubber bands. • Dressing: elastic shoe laces, dycem gloves, loops in pants, sock aid, maternity clothes. • Bathing: adapted sponges, bath mitts, adapted long-handled sponges with splinting material, grab bars, padded shower/commode chair • Driving: vehicles adapted for driving with hand control. • Computer Access: Typing aids ( with/ without wrist support), mouthstick as back up, or if UE pain is present, mini-keyboard, laptray, trackball/joystick/touchpad for mouse movement, separate switch and interface for L/R click, keyboard shortcuts (Sticky Keys, Hotkeys, etc.), word prediction/completion software for rate enhancement, voice recognition for ease and efficiency. .
C7-C8	C7 C7 Elbow Extension Triceps Brachii C8 Flexion of Middle Finger Flexor Digitorum Profundus	Has similar movement as an individual with C6, with added ability to straighten his/her elbows.	Daily tasks: Independent with all self-care. Needs some assistance for bowel care. Able to perform household duties. Need fewer adaptive aids in independent living. Health care: Able to do wheelchair pushups for pressure reliefs. Mobility: Daily use of manual wheelchair. Can transfer with greater ease. Independent in uneven transfers. May be able to transfer floor to wheelchair. Independent in manual wheelchair on slightly uneven ground, low curbs, and standard ramps. May be able to stand in parallel bars with braces. C8: Independent bladder function with intermittent catheterization. Independent bowel function with digital stimulation. Independent car transfers and may be able to get wheelchair loaded.	• Wheelchair: Manual rigid or lightweight folding W/C with modified rims • Transfer board as needed • Adaptive devices similar as with someone at a C6 level
T1	Abduction of Little Finger Abductor Digiti Minimi	Has added strength and precision of fingers that result in limited or natural hand function.	Daily tasks: Can live independently without assistive devices in feeding, bathing, grooming, oral and facial hygiene, dressing, bladder management and bowel management. Mobility: Uses manual wheelchair. Can transfer independently.
T2–T6	Finger abduction and adduction of the IP joint Dorsal and Palmar Interossei Thumb abduction Abductor Pollicis Brevis MCP joint flexion with IP joint extension Full Lumbrical function Thoracic spine extension Erector Spinae of upper back Abdominal strength begins at T6. Abdominals	Has normal motor function in head, neck, shoulders, arms, hands and fingers. Has increased use of rib and chest muscles, or trunk control.	Daily tasks: Should be totally independent with all activities. Mobility: Independent in all transfers and pressure relief. Independent with manual wheelchair on curbs, ramps, wheelies, and uneven ground. Able to load wheelchair into car and drive with hand controls. Able to walk short distances with leg braces locked straight and crutches or walker.
T7–T12	Partial to full innervation for trunk flexion and rotation Abdominals	Has added motor function from increased abdominal control.	Daily tasks: Able to perform unsupported seated activities. Mobility: Walking with leg braces and walker possible Walking a long distance may be hard, and wheelchair use is still needed due to the high energy needed.
L1–L5	L2 Hip Flexion Iliopsoas L3 Knee Extension Quadriceps L4 Ankle Dorsiflexion Tibialis Anterior L5 Long Toe Extensors Extensor Hallucis Longus	Has additional return of motor movement in the hips and knees.	Mobility: Walking can be a viable function, with the help of specialized leg and ankle braces. L1 to L2: Independent transfers from bottom of tub. Walking with leg braces and crutches possible, but wheelchair use still needed due to high energy needed. L3 to L5: Walking with leg braces and straight canes. May use wheelchair for sports or long distances.
S1–S5	S1 Ankle Plantarflexion Gastrocnemius Soleus	Depending on level of injury, there are various degrees of return of voluntary bladder, bowel and sexual functions.	Mobility: Increased ability to walk with fewer or no supportive devices. S1 to S3: Walking without leg braces possible, but may be needed due to muscle imbalances

Quick guide to equipment needed to gain function / independence-

SCI levels C1- C6

ADDITIONAL RESOURCES

Thomas Jefferson University Hospital and Magee Rehabilitation. Regional Spinal Cord Injury Center of the Delaware Valley, Susan. 

* Activities of Daily Living-Spinal Cord Injury Manual – addresses basic ADLs including dressing techniques 
https://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1009&context=spinalcordmanual_eng

* Mobility-Spinal Cord Injury Manual – addresses all aspects of transfers
https://jdc.jefferson.edu/cgi/viewcontent.cgi?referer=https://www.google.com /&httpsredir= 1&article =1011 &context=spinalcordmanual_eng

RECOMMENDED VIDEOS

References: 
https://www.sci-info-pages.com/spinal-cord-injury-functional-goals/
https://uihc.org/health-topics/appendix-ii-functional-ability-level-spinal-cord-injury
https://www.travisroyfoundation.org/sci/resources/spinal-cord-injury-levels-classification/
http://www.wheelessonline.com/ortho/spinal_shock https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6218357/
https://www.sciencedirect.com/topics/neuroscience/neurogenic-shock
https://www.nature.com/articles/3101603