Category Archives: Hospital Admission and Treatment

Examinations and treatment for spinal cord injury upon admission to a hospital spinal care unit.

Spinal Injury Fracture and Dislocation

Spinal Cord Injury Radiology X-rays

Radiological investigations are crucial to medical professionals in determining an accurate diagnosis of spinal injury. Once a patient’s condition is stable, plain x-ray radiographs are generally taken in the hospital radiology department. When symptoms of nerve damage exist a doctor should be in attendance to ensure any spinal movement is kept to a minimum. Sandbags, collars and tapes are not always radiolucent, and clearer radiographs may be obtained if these are removed after preliminary films have been taken. Emergency departments may use mobile radiographic equipment for seriously ill patients, and those unable to be moved, but the quality of these films are usually inferior.   

Computed Tomography (CT) scans and Magnetic Resonance Imaging (MRI) are used for further evaluation. When x-rays prove no fracture, dislocation or other bony abnormalities exist it is important to remember, it does not mean no spinal cord injury exists. A central disc prolapse, ligamentous damage, or cervical spondylosis may have occurred. Common amongst children and the elderly these render a spinal cord vulnerable to further damage, especially in cases of cervical hyperextension injuries.   

Spinal Injury Fracture and Dislocation

Diagnosis of Spinal Injury Fractures and Dislocation X-rays

Cervical Spinal Cord Injury Radiology X-Rays

The most telling and important spinal x-ray when cervical spinal cord injury is suspected the lateral view of the neck obtained with the x-ray beam horizontal consistently offers the best possible insight to spinal damage and can be taken in the hospital emergency department without moving a supine (face up) patient. In a best case scenario lateral and anteroposterior (taken from directly above) x-rays should be thoroughly scrutinized before open mouth views of the odontoid process are taken as the latter normally requires removal of the collar and some adjustment of position.   

Lateral View Spinal Injury X-rays

Lateral Spinal Injury X-rays

 The initial lateral view x-ray should be repeated if the radiograph does not show the whole of the cervical spine and the upper part of the first thoracic vertebra. Failure to embody this often results in injuries of the lower cervical spine being missed.   

Lower cervical vertebrae are generally obscured by the shoulders unless depressed by applying traction to both arms. This traction must be stopped if it produces pain in the neck or exacerbates any neurological symptoms. If the lower cervical spine is still not seen, a supine “swimmer’s” view where the near shoulder is depressed and the arm next to the cassette abducted can show abnormalities as far down as the first or second thoracic vertebra. The interpretation of cervical spine radiographs may pose problems for the inexperienced who overlook the fact a spine consists of bone (visible) and soft tissue (invisible).   

Thoracic and Lumbar Spinal Cord Injuries

The thoracic spine is often demonstrated well on the anteroposterior chest radiograph that forms part of the standard series of views requested in major trauma. This x ray may be the first to reveal an injury to the thoracic spine.  

Radiographs of the thoracic and lumbar spine must be specifically requested if a cervical spine injury has been sustained (because of the frequency with which injuries at more than one level coexist) or if signs of thoracic or lumbar trauma are detected when the patient is log rolled. In obtunded patients in whom the thoracic and lumbar spine cannot be evaluated clinically, the radiographs should be obtained routinely during the secondary survey or on admission to hospital. Unstable fractures of the pelvis are often associated with injuries to the lumbar spine.   

A significant force is normally required to damage the thoracic, lumbar, and sacral segments of the spinal cord, and the skeletal injury is usually evident on the standard anteroposterior and horizontal beam lateral radiographs. Burst fractures (8), and fractures affecting the posterior facet joints or pedicles (3), are unstable and more easily seen on the lateral radiograph. Instability requires at least two of the three columns of the spine to be disrupted. In simple wedge fractures (4), only the anterior column is disrupted and the injury remains stable.   

A detailed demonstration of the thoracic spine can be extremely difficult to obtain, particularly in the upper four vertebrae, and CT scans are often required for a clearer definition. Instability in thoracic spinal injuries may also be caused by sternum or bilateral rib fractures as the anterior splinting effect of these structures will be lost.   

One particular type of fracture, the “Chance” fracture, is typically found in upper lumbar vertebrae. It runs transversely through the vertebral body and usually results from a shearing force exerted by the lap component of a seat belt during severe deceleration injury. These fractures are often associated with intra-abdominal or retroperitoneal injuries.   

Haematoma (blood pooling – bruising) in the posterior mediastinum (rear mid chest cavity region) is often seen around a thoracic fracture site, particularly in the anteroposterior view of the spine and sometimes on the chest radiograph requested in the primary examination. If there is any suspicion that these appearances might be due to traumatic aortic dissection, an arch aortogram will be required.   

Reading X-Ray Films Bone and Soft Tissue Damage

In addition to cervical, thoracic, lumbar, and sacral sections a spinal column is divided into three basic column sections; anterior (front), middle, and posterior (back). When deciphering spinal x-rays keep an ABC’S approach in mind as described in The ABC of Spinal Cord Injury (see references).   

Four Lines of Cervical Alignment

Four Lines of Cervical Alignment

A – Alignment

Follow four lines on the lateral x-ray (2) (5);   

  • 1. The fronts of the vertebral bodies — anterior longitudinal ligament.
  • 2. The backs of the vertebral bodies — posterior longitudinal ligament.
  • 3. The bases of the spinous processes.
  • 4. The tips of the spinous processes.

 
B – Bone

Follow the outline of each individual vertebra checking for any steps or breaks.   

C – Cartilage

Examine the intervertebral discs and facet joints for displacement. The disc space may be widened if the annulus fibrosus (outer wall of disc, comprising numerous layers of organic material crisscrossing each other at angles for structural strength which contain the core of the disc, the nucleus pulposus) is ruptured or narrowed as in degenerative disc disease.   

S – Soft Tissue

Check for widening of the soft tissues anterior to the spine on the lateral radiograph, denoting a prevertebral haematoma, and also widening of any bony interspaces indicating ligamentous damage—for instance separation of the spinous processes following damage to the interspinous and supraspinous ligaments posteriorly.   

Diagnosing Spinal Cord Injury X-Rays

Any evidence of either anterior or posterior displacement (1) between vertebrae greater than 4mm on a lateral cervical radiograph is considered abnormal. Anterior displacement of less than half the diameter of the vertebral body suggests unilateral facet dislocation, displacement greater than this indicates bilateral facet dislocation. Atlanto-axial subluxation (dislocation) may be identified by an increased gap (of more than 3mm in adults and 5mm in children) between the odontoid process and the anterior arch of the atlas on the lateral radiograph.   

On the lateral radiograph, widening of the gap between adjacent spinous processes (9) following rupture of the posterior cervical ligamentous complex denotes an unstable injury which is often associated with vertebral subluxation (9) and a crush or compression fracture of the vertebral body. The retropharyngeal space at C2 should not exceed 7mm in adults or children whereas the retrotracheal space at C6 should not be wider than 22mm in adults or 14mm in children (the retropharyngeal space widens in a crying child).   

Fractures of the anteroinferior margin of the vertebral body otherwise known as “teardrop” fractures are often associated with an unstable flexion injury and sometimes retropulsion of the vertebral body or disc material into the spinal canal. Similarly, flakes of bone may be avulsed from the anterosuperior margin of the vertebral body by the anterior longitudinal ligament in severe extension injuries.   

On the anteroposterior radiograph, displacement of a spinous process from the midline (2) may be explained by vertebral rotation secondary to unilateral facet dislocation, the spinous process being displaced towards the side of the dislocation. The spine is relatively stable in a unilateral facet dislocation, especially if maintained in extension. With a bilateral facet dislocation, the spinous processes are in line, the spine is always unstable, and the patient therefore requires extreme care when being handled. The anteroposterior cervical radiograph also provides an opportunity to examine the upper thoracic vertebrae and first to third ribs: severe trauma is required to injure these structures.   

Oblique radiographs are not routinely obtained, but they to help to confirm the presence of subluxation or dislocation and indicate whether the right or left facets (apophyseal joints), or both, are affected. They may elucidate abnormalities at the cervicothoracic C7-T1 junction and some authorities recommend them as part of a five-view cervical spine series. The 45 degree supine oblique view shows the intervertebral foramina and the facets but a better view for the facets is one taken with the patient log rolled 22.5 degree from the horizontal.   

Flexion and extension views of the cervical spine may be taken if the patient has no neurological symptoms or signs and initial radiographs are normal but an unstable (ligamentous) injury is nevertheless suspected from the mechanism of injury, severe pain, or radiological signs of ligamentous injury. To obtain these radiographs, flexion and extension of the whole neck must be performed as far as the patient can tolerate under the supervision of an experienced doctor. Movement must cease if neurological symptoms are precipitated.   

CT Scans – Computed Tomography

If there is any doubt about the integrity of the cervical spine on plain radiographs, CT scans should be performed. These provide much greater detail of the bony structures and will show the extent of encroachment on the spinal canal by vertebral displacement or bone fragments. It is particularly useful in assessing the cervicothoracic junction, the upper cervical spine and any suspected fracture or misalignment.   

Helical (or spiral) CT scans are now more available. These allow for a faster examination and clearer reconstructed images in the sagittal and coronal planes. Many patients with major trauma will require CT scans of their head, chest or abdomen, and it is often appropriate to scan any suspicious or poorly seen area of the spine at the same time rather than struggle with further plain films.   

MRI Scans – Magnetic Resonance Imaging

MRI gives information about the spinal cord and soft tissues and will reveal the cause of cord compression, whether from bone, prolapsed discs, ligamentous damage, or intraspinal haematomas. It will also show the extent of cord damage and oedema (swelling) which is of some prognostic value. Although an acute traumatic disc prolapse may be associated with bony injury, it can also occur with normal radiographs, and in these patients it is vital that an urgent MRI scan is obtained.   

These scans can also be used to demonstrate spinal instability, particularly in the presence of normal radiographs. MRI has superseded myelography, both in the quality of images obtained and in safety for the patient, allowing decisions to be made without the need for invasive imaging modalities. Its use may be limited by its availability and the difficulty in monitoring the acutely injured patient within the scanner.   

Pathological changes in the spine — for example, ankylosing spondylitis or rheumatoid arthritis — may predispose to bony damage after relatively minor trauma and in these patients further radiological investigation and imaging must be thorough.   

Conclusion

Fractures of the spine are often complex and inadequately shown on plain x-ray films. X-rays of the lower cervical, thoracic and lumbar spine are commonly obstructed by other bones and organs. CT scans display bony detail more accurately. MRI scans best demonstrate the extent of spinal cord and soft tissue damage.   

An accurate reading and diagnosis of spinal injuries and subsequent spinal cord injuries through means of x-rays, CT and MRI scans requires specialized training, expertise and experience. Never be afraid to ask for a second opinion when it comes to your spine.   

My Personal Experience

spinal skeleton x-ray eyeLocked in the vice grips of Gardner-Wells tongs staring up at the fluorescent bulbs a doctor came by interrupting my torturous “nose toilet” routine, a nurse fishing for boogers with a cue tip. Almost boasting he proudly held up an x-ray of cervical vertebra 4-5 at right angles to each other. I can’t recall what he said or what condition the patient was in but that image has always stuck in my mind. I guess it did help lessen the shock value of seeing my own x-ray films but such horrendous injuries usually result in death. A macabre trophy to some spinal injury specialists I’m sure. Back then the bedside manner of many doctors and nurses left a lot to be desired.   

Recently I clean broke my left leg Tibia and Fibula. I didn’t realize turning from my desk the tip of my shoe caught the table leg, it went off like a firecracker. I looked down to see my foot pointing backwards, not good Graham, I thought to myself. My carer and girlfriend sat glaring jaw open silent at the kitchen table. I said, “Oops.” In a very stern voice my girlfriend replied, “What have you done now!”   

We splinted my leg with two football socks bandages and a plastic anti-foot drop splint. After a shower seven days later hoisting me back to bed I noticed my lower leg bend. I admitted myself to hospital. They put a full lower leg cast on then cut a two inch gap down the front in order to periodically check for pressure areas. The next morning prepped for surgery they removed the cast outside the surgery doors. When the guy cut the two inch gap he also cut my skin. Unable to operate as the cuts were red and infected they kept me in another 10 days.   

Without a spinal unit stuck in the main ward I was constantly surprised how many nurses had no idea how to care for a quadriplegic. One snarled at me, “You should have taken these meds an hour ago.” I said, “Lady, if my hands worked I would have.” They tucked my drain bag and tubing under the mattress with clean sheets, took several hours to figure out that’s why I was sweating. A urologist who clamped off my catheter to take a sample neglected to remove the clamp, sweating again, we discovered it a little faster this time. There were many more errors made but you get the idea, it was not a pleasant stay.    

Broken left leg tibia fibula, screwdiver securing screws, two ankle screws, one knee screw

Broken left leg tibia fibula, screwdiver securing screws, two ankle screws, one knee screw

 
Six weeks post-op I returned for progress radiograph x-ray results. Quite impressed they not only managed to x-ray the correct leg, the clarity and resonance of the x-ray films was excellent. I had the doctor take these photos. You can see the surgical steel rod they call a nail and the screws top and bottom keeping it in place. It was all done through keyhole surgery. Like most images on our website you can click to enlarge.   

While I may have strayed from the subject a little with my personal story I want to point out that if you do encounter doctors or nurses, anyone for that matter, who is not aware of your special needs be patient polite and educate them. Your efforts will benefit all of us living with spinal cord injury in the future.  

Resources 

  • David Grundy, Honorary Consultant in Spinal Injuries, The Duke of Cornwall Spinal Treatment Centre, Salisbury District Hospital, UK. Andrew Swain, Clinical Director Emergency Department, MidCentral Health, Palmerston Hospital North, New Zealand: ABC of Spinal Cord Injury: BMJ Books, 2002.
  • Gary L. Albrecht. 2006. Encyclopedia of Disability. University of Illinois, Chicago.
Chronic Spinal Pain

Partial Spinal Cord Injury And Syndromes

Neurological symptoms don’t always follow a classic pattern or demonstrate a clear neurological level. For this reason, spinal cord injuries are sometimes misdiagnosed and become attributed to hysterical or conversion paralysis. Neurological symptoms indicating spinal cord injury and spinal cord syndromes should never be dismissed until spinal cord injury has been proven to not exist by means of thorough examinations and appropriate clinical investigations.

When a spinal cord injury has been confirmed through comprehensive primary and secondary hospital examinations a clinical diagnosis of spinal cord injury can be made. The diagnosis comprises of a level, completeness, and is often attributed to a type of syndrome, before a prognosis of expected long term outcomes is delivered. Given any spinal cord injury syndrome where lesions display as complete from the outset, recovery is far less likely than for incomplete lesions.

Spinal Pain

Spinal Pain

Most spinal cord injury syndromes are considered a rare disease by the United States National Institute of Health as the incidence rates for each number less than 200,000 people in the American population. In total approximately 250,000 Americans are living with some form of SCI.

At an incidence rate of 10,000/year many are classed under a syndrome. And while we do offer detailed statistics throughout this website it is important to remember spinal cord injury is about people’s lives not numbers or expectation. A full life is lived when you make the most of what you have got, not what you have lost. Where there is life there is hope and where there is a wheel there is a way.

Anterior Cord Syndrome

Damage to the anterior (front) of the spinal cord is usually caused by a compression fracture, or by a flexion-rotation force on the spine producing an anterior dislocation. There is often anterior spinal artery compression so that the corticospinal (between spinal cord and brain cortex) and spinothalamic (between spinal cord and thalamus) tracts are damaged by a combination of direct trauma and inadequate blood flow. This results in loss of power as well as reduced pain and temperature sensation below the lesion.

Brown Sequard Syndrome

The signs of Brown-Sequard syndrome are hemisection (cutting) of the spinal cord resulting from stab injuries but also common in lateral mass fractures of the vertebrae. Power is reduced or absent but pain and temperature sensation are relatively normal on the side of the injury because the spinothalamic tract crosses over to the opposite side of the cord. The uninjured side therefore has good power but reduced or absent sensation to pin prick and temperature.

Central Cord Syndrome

The most common spinal cord syndrome, an incomplete spinal cord injury is also known as, “inverse paraplegia” because the hands and arms are paralyzed while the legs and lower extremities work correctly. Typically seen in older patients with cervical spondylosis central cord syndrome is a hyperextension injury often from relatively minor trauma to the cervical regions of the spinal cord. The more centrally situated cervical tracts supplying the arms suffer the brunt of the injury resulting in a flaccid (lower motor neurone) weakness of the arms and relatively strong but spastic (upper motor neurone) leg function. Sacral sensation and bladder and bowel function are often partial. The ability to walk is regained in most cases with some residual disability.

Conus Medullaris Syndrome

Resulting from injury to the tip of the spinal cord, located at vertebra L1 the effect of injury to the sacral cord (conus medullaris) and lumbar nerve roots is usually loss of bladder, bowel and lower limb reflexes. Lesions high in the conus may occasionally represent upper motor neurone defects and function may then be preserved in the sacral reflexes, for example the bulbospongiosus and micturition reflexes.

Posterior Cord Syndrome

This syndrome is most commonly seen in hyperextension injuries with fractures of the posterior (rear) elements of the vertebrae. Contusion of the posterior columns may cause the patient to have good power, pain and temperature sensations, but poor perception of movement and spatial orientation, making walking very difficult.

Tethered Spinal Cord Syndrome

Tethered spinal cord syndrome (also known as occult spinal dysraphism) is a condition arising from an abnormally stretched spinal cord. The sensory and motor symptoms of lower back pain and leg weakness can usually be relieved by surgery that may involve the cutting of spinal cord nerve roots. Tethered spinal cord damage affecting bowel or bladder function however is typically non-treatable and permanent.

Conclusion

Spinal cord injuries resulting in paraplegia and quadriplegia (tetraplegia) are permanent debilitating conditions of paralysis involving much more than loss of limb function and sensation. Thorough primary and secondary hospital examinations are essential in forming an accurate early diagnosis and long term prognosis of spinal cord injury classification and outcomes.

Given the same neurological examination and findings, neurologists and physiatrists may not assign the same spinal cord injury level. For example, a patient with fractured C5 vertebrae who has normal C4 sensation and absent C5, a physiatrist may call a C4 level injury whereas a neurologist or neurosurgeon may call it C5. Most orthopedic surgeons will refer to the bony level of injury C5 as the level of injury.

Outside of clinical environments it matters little if C4 or C5. Both require use of a wheelchair for life. Many of the rights and opportunities afforded to able-bodied people are not afforded to wheelchair users with spinal cord injury.

Resources

 
Kind Regards
Graham Streets

Spinal Reflex Hammer

Testing Reflexes Redefining Spinal Shock

Vital information on the nervous system is gathered by testing reflexes after spinal cord injury. The path reflex neurons follow (the reflex arc) do not rely on intact nerve paths to the brain. They synapse (jump a small gap between nerve ends) in the spinal cord returning along motor nerves to quickly trigger muscles. Impulses travel along these refex arc nerves at 127 mph.

Stimulus to a reflex tendon creates an impulse that travels along sensory nerve axons (long middle section of nerve) to the spinal cord where it returns along motor nerves to trigger a muscle response, without the delay of routing signals via the brain, although (in a healthy spinal cord) the brain will receive motor (muscle) sensory feedback when the reflex arc fires.

spinal cord reflex arc

Basic Reflex Arc

There are two types of reflex arc — autonomic (affecting inner organs) and somatic (affecting muscles), — an accurate assessment of reflex arc function determines the location and severity of spinal cord injury, resulting amount of paralysis, and formulates expected long term outcomes. Testing reflexes also gives strong indications whether a spinal cord injury is incomplete or complete.

After severe spinal cord injury paralysis and limited to no sensation below the level of injury is typical, but it is rare to present no reflexes – spinal shock. Almost one third of patients examined within 1-3 hours of injury do present some reflexes. Describing spinal shock as the period following injury during which all spinal reflexes are absent is being phased out.

The evolution of reflexes over several days following spinal cord injury are now considered more relevant to prognosis than the use of the term spinal shock and the presence or absence of reflexes on the actual day of injury.

Reflexes and Corresponding Spinal Cord Nerve Supply Level

spinal cord injury reflex testing hammer with retractable pin prick

Reflex testing hammer with pin prick

  • Biceps jerk C5, C6
  • Supinator jerk C6
  • Extensor digitorum reflex C7
  • Triceps jerk C7, C8
  • Abdominal reflex T8-T12
  • Knee jerk L2-L4
  • Ankle jerk L5, S1, S2
  • Bulbospongiosus reflex S2-S4
  • Anal reflex S5
  • Plantar reflex L5-S2

 

Delayed Plantar Response Reflex

Delayed Plantar Response (DPR) is a reflex present in all patients with complete spinal cord injury. DPR is demonstrated by pressing a blunt instrument firmly from the heel along the lateral (outer) sole of the foot and continuing slowly across the metatarsal heads (where foot bones connect to toes). Following this stimulus the toes flex and relax in delayed sequence. Caution should be taken to not misinterpret the flexion component as a normal plantar response.

Deep Tendon Reflex

Deep tendon (stretch) reflexes provide information on the integrity of the central and peripheral nervous system. Generally, decreased reflexes indicate a peripheral problem and lively or exaggerated reflexes a central one. Deep tendon reflexes are usually absent in complete spinal cord injuries as both peripheral and central nervous systems have been compromised, and conversely are present in the majority of patients with incomplete spinal cord injuries.

Anal and Bulbospongiosus Reflex

Understanding the usefulness of sacral reflex arcs in determining the location and severity of spinal cord injury requires definition of the term bulbospongiosus. Imagine a diamond between your legs (no girls, not that kind of diamond lol), the perineum, a diamond shaped erogenous zone that includes the anus and penis or vagina.

Bulbospongiosus muscles are superficial (surface) muscles of the perineum. In males that includes the base of the penis to halfway up the penis shaft. Its function is to empty the urethra and contributes to erection, ejaculation, and the feelings of orgasm. In females, residing either side of the vagina, bulbospongiosus muscles are responsible for clenching the vagina closed and contribute to clitoral erection and the feelings of orgasm. Both anal and bulbospongiosus reflexes rely on intact sacral reflex arcs.

Anal reflex is an externally visible contraction of the anal sphincter triggered by pin prick. The bulbospongiosus reflex is a similar contraction of the anal sphincter in response to firmly squeezing the penis head or clitoris.

Testing anal and bulbospongiosus reflex arcs aid in distinguishing between upper motor neuron lesions in which the reflex may not return for several days, and lower motor neuron lesions in which the reflex remains abaited unless neurological recovery occurs.

  • Upper motor neuron lesion; injury of upper motor neurons are common because of the large amount of cortex occupied by the motor areas, and because motor pathways extend all the way from the cerebral cortex to the lower end of the spinal cord.
  • Lower motor neuron lesion; injury of lower motor neurons are less common as they are typically secondary injuries. Lower motor neurons relay the movement instructions provided by upper motor neurons, from spinal cord to the relevant muscles. When the lower motor neurons are damaged the result is muscle weakness, twitching and atrophy.

Conclusion

As a part of primary and secondary initial hospital assessments the testing of reflexes delivers conclusive information relevant in determining the level and completeness of a spinal cord injury. The term spinal shock is being phased out. The evolution of reflexes over several days to weeks following spinal cord injury are considered significant factors in determining long term outcomes.

Resources

chest sensation

Incomplete vs Complete Spinal Cord Injury

A key component of initial hospital examinations and treatment is the diagnosis of a spinal cord injury as incomplete or complete. Incomplete means some sensory (feeling) or motor (muscle) function exists below the neurological level of injury, including the lowest sacral segment (S4-S5). Complete means no sensory or motor function exists below the neurological level of injury, including the lowest sacral segment (S4-S5).

  • Incomplete means some
  • Complete means none

Diagnosis of a spinal cord injury as incomplete verses complete is made by locating the neurological level of injury and determining which myotomes and dermatomes remain intact. We covered this in the previous article and move on here to explore some real life examples and the long term outcomes of incomplete verses complete spinal cord injury.

It may not seem a big difference but the outcomes certainly are. To understand the broader implications of incomplete verses complete spinal cord injury we first need to consider the following real life examples. Incomplete and complete translate into being able to achieve a sustainable erection or not, having sensation in forearms or not, having wrist extension or not, to name but three examples.

While at first, the difference between some and none may seem subtle, after further consideration the full impact upon relationships, employment, health and independence become more obvious.

Real Life Examples of Incomplete vs Complete

Taking our first real life example, the inability to achieve a sustainable erection and satisfy your partner sexually is self demoralizing and can place a huge strain on an existing relationship or marriage. Impotency drastically reduces the number of potential partners interested in forming new sexual and intimate life-long relationships and greatly suppresses ones sexual self awareness, sexual development and sexual expression. Testosterone levels, impotency and virility have long been proven to have widespread influence upon the male psyche.

sexual imperfection

Sexual expression and sustainable erection following spinal cord injury

Hence, the inability to achieve a sustainable erection following spinal cord injury vastly reduces the opportunities available to men in finding a life partner, getting married, and fathering children. These undeniably huge life events are keenly sought by most men, and as such, they are possibly the greatest example of difference between an incomplete and complete spinal cord injury.

As a C4 incomplete quadriplegic I have no sensation from the nipples down or elbows out, though I feel compelled to state, I can achieve sustainable erections. I can only imagine the dent, the blow to ego and self becoming impotent a man. That said, there are many ways to sexually please a person and we advocate these throughout our website.

In our second real life example, having no forearm sensation makes it virtually impossible to determine by leaning on an object if it’s hot or cold, acidic, dirty, sharp, sticky, wet etc. Often clothing that cuts off circulation to hands goes unnoticed. Void of forearm sensation it’s impossible to estimate the weight of an object by holding it. Likewise, it’s impossible to sense when a limb is under so much pressure it’s about to break. Absolutely any area of skin or body part void of sensation is vulnerable to many forms of harm.

chest sensation

Chest sensation

As an incomplete quadriplegic I have limited forearm sensation, areas of my body void of sensation seem to have a way of eventually getting the message through. Technically I am paralyzed and void of sensation from the chest down but as I’m incomplete my legs and feet spasm frequently. I experience warm or buzzing sensations in my lower limbs in response to pain. Typically those with complete spinal cord injury do not spasm or “feel” any sensation whatsoever below the neurological level of injury.

While eating dinner one night a complete quadriplegic friend of mine realized his roast pumpkin was missing, totally unaware it had fallen onto his bare foot causing third degree burns. Had that been my foot, I most likely would have noticed a dull sensation after five minutes and/or noticed increased spasm in that leg. Being incomplete is not always good however. I once calculated my feet spasm approx 8640 times per day.

Our third real life example of wrist extension means moving the back of the hand toward the back of the forearm (upward). Wrist flexion is moving the palm of the hand toward the front of the forearm (downward). When no wrist function exists and a diagnosis of incomplete is given there is small chance of regaining some wrist extension. Usually this would occur within 3 to 12 months of injury. When no wrist function exists and a diagnosis of complete is given, change is extremely rare.

disability friendly vehicle hand controls

Disability friendly vehicle hand controls

In many countries to legally operate a vehicle on a public road requires wrist extension. When “some” wrist extension exists, bending the wrist upward automatically closes the hand and fingers, fashioning a grip sufficient enough to operate the standard hands controls of a disability friendly vehicle. The ability to drive (or not) has universal impact on employment opportunities, independence, freedom of travel, maintaining friendships, living in rural and remote areas, participation in the community, outings and social integration in general.

I have no wrist extension and cannot legally drive a car (not because my injury is incomplete). My spinal cord was damaged above the neurological section responsible for wrist extensors – C6. Having held A and C class, omnibus, motorcycle, forklift, cherry picker, scissor lift, and speedboat licenses, being active and adventurous driving is something I miss terribly.

“Losing my legs was hard to deal with but losing my hands is a real bitch.” –Graham Streets

Outomes of Incomplete vs Complete Spinal Cord Injury

professor wise young

Professor Wise Young

Professor Wise Young, Ph.D., M.D. who co-chaired the committee defining the currently accepted ASIA (American Spinal Injury Association) classification suggests many doctors today frequently become confused when determining spinal cord injury levels, the definition of complete and incomplete, and the classification of spinal cord injury.

“In the end, the whole issue of complete versus incomplete injury may be a moot issue. The absence of motor and sensory function below the injury site does not necessarily mean that there are no axons that cross the injury site. Many clinicians equate a complete spinal cord injury with the lack of axons crossing the injury site. However, much animal and clinical data suggest that an animal or person with no function below the injury site can recover some function when the spinal cord is reperfused (in the case of an arteriovenous malformation causing ischemia to the cord), decompressed (in the case of a spinal cord that is chronically compressed), or treated with a drug such as 4-aminopyridine. The labeling of a person as being complete or incomplete, in my opinion, should not be used to deny a person hope or therapy.” —Professor Wise Young, Ph.D., M.D.

I agree, my GP admitted he knew about spinal cord injury in general but would assist in finding a local spinal injuries specialist with concise knowledge and experience if I wish. I see specialists annually so kept my GP who has been brilliant in learning with me the intricacies of quadriplegia and spinal cord injury.

Incomplete or complete many of the challenges in life after spinal cord injury are being met through advances in medicine, assistive devices and education. Research and studies highlight the need of improved therapies and treatments for spinal cord injury. Technology such as computers and disability schemes are broadening employment opportunities after spinal cord injury. Laws for wheelchair friendly buildings and environments are increasingly becoming legislated. And greater sexual awareness and rights for wheelchair users are being established globally.

Conclusion

Spinal cord injury is a life changing event. Stem cell research and advances in medicine are narrowing the differences between incomplete verses complete spinal cord injury. Still, the differences are significant and should be considered on an individual and whole basis. A diagnosis of complete is not absolute, some will regain function. A complete spinal cord injury does not mean an incomplete life. Emphasis is best placed on life after diagnosis rather than the diagnosis itself.

People with complete spinal cord injury may not be able to achieve a sustainable erection but many enjoy healthy active sexual relationships. Many are getting married and fathering children. Many are furthering their education and gaining meaningful employment. Incomplete verses complete spinal cord injury does not affect a person’s ability to love, respect, achieve and live a full satisfying life.

Resources

SCI Info Pages; http://www.sci-info-pages.com/levels.html

Dermatomes are areas of the skin

Neurological Examination and Assessment

During spinal cord injury primary and secondary examinations neurological examinations are carried out to assess the severity and location of damage to the spinal cord. These examinations aim to provide information on the neurological level of spinal cord injury, extent of injury to the spinal cord, and the resulting degree of impairment. Performed upon initial hospitalization and repeated periodically during rehabilitation, the collated results assist in determining how much support may be required upon discharge from hospital. For initial assessment purposes a typical neurological examination where spinal cord injury is suspected will include the following tests;

  • Cranial nerve function: There are 12 cranial nerves which are nerves that originate in the head, coming off the brain and brain stem. The examination of these nerves and their functions is complex but includes areas such as smell, vision and eye movements, facial sensation, reflexes and movement, hearing, taste, tongue and palate movements and even movements of the head, neck and shoulders.
     
  • Power of muscle groups according to the Medical Research Council scale: This part of the examination tests the motor function, or movement, of the major muscle groups, most notably in the shoulders, arms, hips and legs. The muscles are tested for mass, muscle tone, and strength.
     
  • Reflexes including abdominal, anal, and bulbospongiosus: Various reflexes are tested throughout the body. While these can indicate problems with sensation and/or motor function, they can also reveal other aspects of nervous system dysfunction as well.
     
  • Sensation to pin prick, fine touch and joint position sense: The sensory exam part of the neurological exam evaluates the sensation of the patient. This includes not just normal touch but also pain and temperature and sensation of limb position and movement.

 
Detailed neurological examinations may include CAT, IVP and MRI scans, a cerebral angiogram, electroencephalogram, electromyogram, and nerve conduction study.

Myotomes and Dermatomes

Dermatomes are regions of the skin

Dermatomes – last region of skin with healthy sensation indicates neurological level of injury

Each myotome (muscle) and dermatome (region of skin) of the body is supplied by a particular level or section of the spinal cord and by its corresponding spinal nerve. There are eight cervical nerves, twelve thoracic nerves, five lumbar nerves and five sacral nerves. Each of these nerves relays sensation (including pain) from a particular muscle or region of skin to the brain. By examining the dermatomes and myotomes this way, a motor score, level and completeness of a spinal cord injury can be determined.

According to the American Spinal Injury Association (ASIA) standard neurological classification guide the last dermatome or region of skin with healthy intact sensation displaying normal spinal cord function is considered the neurological level of injury. This does not necessarily correspond with the vertebral (spinal column bone or disc) level of injury. Therefore both neurological and vertebral diagnoses are recorded. Additionally while the following muscles grades are not included in determining the ASIA motor score and level they should still be assessed and noted.

  • Diaphragm – C3,4,5
  • Shoulder abductors – C5
  • Supinators/pronators – C6
  • Wrist flexors – C7
  • Finger extensors – C7
  • Intrinsic hand muscles – T1
  • Hip adductors – L2,3
  • Knee flexors – L4,5 S1
  • Toe flexors – S1, S2

Neurological Level of Spinal Cord Injury

A significant proportion, 55% of cases admitted to spinal units involve the cervical segments C1-C7. This type of impairment is referred to as tetraplegia (or quadriplegia). Injury at the thoracic, lumbar or sacral levels, are referred to as paraplegia. In Australia over the past eight years cervical spine injuries have accounted for between 50% and 59% of all SCI. The most common cervical spine injuries involved C4-C5. This group accounted for 61% of cervical SCI cases and 32% of all 241 documented neurological injuries reported in 2007-08.

Neurological levels of spinal cord injury

Neurological levels recorded for 241 spinal cord injury patients

The next most common neurologic level of spinal cord injury is the thoraco-lumbar junction with 11% of cases reporting neurological impairment at T12-L1. Injuries to the thoracic spine accounted for 32% of all injuries reported. The number of thoracic spinal injuries ranged between 64 in 2003-04 to a high of 93 in 2004-05 in Australia. Reports from 2000 to 2010 show an annual average of 31% of all SCI occurred at the thoracic levels T1-T12. Lumbar and sacral injuries make up the remaining cases.

Neurological Category of Spinal Cord Injury

The overall severity of spinal cord injury is measured by a combination of the neurological level of injury (tetraplegia or paraplegia) and extent of injury (complete or incomplete). These are divided into five neurological categories;

  • Complete Tetraplegia
  • Incomplete Tetraplegia
  • Complete Paraplegia
  • Incomplete Paraplegia
  • Complete Recovery

 
Approximately 65% of all spinal cord injury cases are diagnosed as incomplete injuries. In 2007-08 a study group of 241 Australian patients with permanent spinal cord injury were diagnosed under the following categories;

  • Incomplete Tetraplegia 38%
  • Incomplete Paraplegia 27%
  • Complete Paraplegia 20%
  • Complete Tetraplegia 15%

 
This distribution of neurological injury is relatively consistent from year to year. Similar results have been found in Europe although a slightly different model appears in the United States where reports show greater proportions of complete SCI cases, mostly attributed to a higher proportion of penetrating gunshot injuries.

Spine Board for patient transport

Primary and Secondary Hospital Examinations

Admission to hospital with spinal cord injury is for most a hazy memory of frantic doctors and nurses testing one thing or another. Whether you’ve been through the process or are interested in what’s happening to a loved one, we take a closer look at primary and secondary clinical examinations. From a quadriplegic patient point of view I share my thoughts and feelings experienced at the time.

On average 350 people require hospitalization and treatment for spinal cord injury in a specialized spinal unit in Australia each year. That is 15 per million of the population (aged 15 years and older). Ongoing costs associated with long-term care are estimated to be more than $500 million AUD per year. International incidence rates for spinal cord injury range from 10 to 40 cases per million population.

AUSTRALIAN SPINAL INJURY UNITS

Australia has six hospitals with specialized spinal units that care for SCI patients. They are located in the following five States:

  • Queensland (Princess Alexandra Hospital)
  • NSW (Royal North Shore Hospital & St James Hospital)
  • Victoria (Austin Hospital)
  • South Australia (Royal Adelaide Hospital)
  • Western Australia (Royal Perth Rehabilitation Hospital)

 
Tasmania, Northern Territory and the A.C.T. do not have Spinal Units and SCI patients are sent to the closest interstate Spinal Unit.

PRIMARY EXAMINATION AND TREATMENT

When a spinal cord injury patient arrives at the nearest major emergency department, a detailed history is sought from paramedics, witnesses, and if conscious the patient while transferring quickly and smoothly to a trauma trolley. A spinal board is an ideal transfer device as resuscitation can continue with little interruption. A scoop stretcher is also adequate but a slower process. In the absence of either device, trained personnel can perform a coordinated spinal lift. Correct lifting and transfer techniques are essential to avoid further damage to the spinal cord and greater paralysis.

Spinal Board for patient transport and transfer

Spinal Board for patient transport and transfer

Full general and neurological assessments are undertaken in accordance with the principles of Advanced Trauma Life Support (ATLS). The examination must be quick yet thorough because spinal cord injury is frequently associated with multiple injuries. The patient’s airway, breathing and circulation — ABC n that order — are the first priorities as the spinal injury itself can directly affect the airway (for example by producing a retropharyngeal haematoma or tracheal deviation) as well as the respiratory and circulatory systems. The cervical spine (C1-C7 neck) is then secured in the neutral position, a central nervous system assessment is undertaken, and any clothing removed.

Spinal Cord Injury can be accompanied by:

  • Head injury (coma of more than 6 hours duration, brain contusion or skull fracture) 12%
  • Chest injury (requiring active treatment, or rib fractures) 19%
  • Abdominal injury (requiring laparotomy) 3%
  • Limb injury 20%

SECONDARY EXAMINATION AND TREATMENT

Having addressed any immediate life-threatening injuries, a secondary examination (head to toe) aims to identify and treat other serious injuries. The patient should be kept covered as much as possible and body temperature monitored while conducting the secondary examination. In the supine (face up) position, cervical and lumbar abnormalities of the spine may be detected by gently sliding a hand under the patient. If neurological symptoms present, a senior doctor or spinal specialist may direct a partial log roll to examine the back for specific signs of injury. Signs include local bruising or deformity of the spine (e.g. increased interspinous gap) and vertebral tenderness.

The entire length of the spine must be inspected, as about 10% of patients with an unstable spinal injury have another secondary spinal injury at a different level. Priapism (an erect penis or clitoris not returning to flaccid state within four hours) and diaphragmatic breathing (abdominal breathing) are signs of a high spinal cord lesion. Warm limbs are indicative of good circulation but should not negate the possibility of neurogenic shock attributable to spinal cord injury. A good secondary examination includes a thorough assessment of the peripheral nervous system.

Diagnosis of intra-abdominal trauma is made difficult amongst those with high spinal cord lesions (above T7). Lack of abdominal sensation together with diaphragmatic breathing can mask the classic symptoms of abdominal swelling, bruising and pain. Signs of peritoneal irritation do not develop however the pain may be referred to the shoulder from the diaphragm and this is an important symptom. When blunt abdominal trauma causing internal bleeding is suspected a peritoneal lavage (flexible plastic tube inserted into abdomen) or computed tomography may be performed unless clinical concern justifies an immediate laparotomy. Abdominal bruising from seat belts, especially isolated lap belts in children, is associated with injuries to the bowel, pancreas and lumbar spine.

The log roll during secondary examination provides ideal opportunity to remove the spinal board. While necessary to restrict any flexion or rotation of the spine, these rigid boards create pressure points on the occiput, scapulae, sacrum, and heels. Abnormal spinal column alignment and broken bones are also highly susceptible to pressure area marks, poor circulation and skin degradation. It is generally recommended the spinal board be removed within 30 minutes of its application whenever possible. Should a spinal board be required for longer than 30 minutes use of a pressure relieving mattress is recommended. In the field these typically include memory foam (tempura) and vacuum bead types. Interface pressures are much lower when a vacuum mattress is used and patients report the device is much more comfortable than a spinal board.

EMOTIONAL CATHARSIS

If you are still awake having covered the clinical primary and secondary assessment key points above, let me tell you as someone who has endured this process, this is where I experienced sheer heartbreak. My life was over. All those swarming around me connecting monitors, delivering injections, setting cannula’s and installing catheters, essentially placing me on life support, faded into the background. I crawled so far inside myself I sometimes wonder if I will ever truly return. Anxiety subsided, fear evaporated and with a single cold tear trickling past my temple I slipped into the darkness.

internal reflectionsI had always said, the scariest place to leave me is alone in my own head, and here I was, at the gates of my own demons residence. Curled up in a ball my life flashed before my eyes. Like so many old projector slideshows on a fibro wall in Brighton, my boyhood memories from pedal cars to last sweet kiss flickered by all scratched and torn, then faded away.

A voice was calling my name, I was reluctant to look. My eyes cracked open to see a huge surgical steel hammer pass within inches of my face, You may feel a bump here the doctor said, as a spike was driven into my skull just above my right ear. The left was just as bone crunching loud but also painless.

The drugs had kicked in clawing me back from the abyss. My fight had just begun. Exaltation to deep depression would persist over the next three months but drawing on this emotional catharsis gave me great peace despite the gravity of my situation and in time would come to fast-track my acceptance of quadriplegia.