Correlation between level of spinal cord lesion and eventual deficits has been discussed before. This article concentrates on functional disabilities after spinal injuries at the different levels which means what the patient is expected to do and what she would be unable to do after the injury.
In the absence of medical complications, the most important factor in functional disability is the amount of muscle power remaining to the individual.
However, there are certain factors which can affect the functional outcome. The most important factors are spasm, decubitus nature, insufficient motivation, deformity, urinary and fecal incontinence.
We would discuss seven critical levels of injury which are
- T 12
We would begin with C5 and move downward.
The level mentioned denotes the spared level
Chart of Activities Possible at Different Levels
C5 Functional Abilties
The patient below C5 [C5 is spared] has full innervations of trapezius, sternocleidomastoid and upper paraspinal muscles.
Patient can stabilize and rotate his neck.
Patient can also elevate and externally rotate the scapulae.
Rhomboids, deltoids and all of the major muscles of the rotator cuff are still functional though these are partially innervated [from C6].
These muscles can provide scapular adduction, glenohumeral joint abduction, internal and external rotation, flexion and extension of the shoulder.
However shoulder is not able to perform strong depression, flexion, protraction and adduction.
But it has been seen, that in absence of prime movers of shoulders [latissimus, pectoralis and serratus muscles] and incomplete innervation of stabilizers prevent remaining from becoming functional.
Elbow flexion is present as biceps and brachioradialis remain partially innervated.
There is no muscular function in hand or wrist.
The patient is unable to roll over or come to sitting position in the bed.
She may in certain cases may eating using special hand devices.
Patient is unable to push the wheelchair.
Endurance is low due to reduced respiratory reserve.
Patient cannot ambulate and is confined to a wheelchair. She requires an attendant for life who would assist in selfcare, to lift and transport to back chair.
Removable arm rests, swinging removable foot rests and detachable back make shifting easier.
A gatch bed for bedcare. It is a bed with a frame in three movable sections equipped with mechanical spring parts that permit raising the head end, foot end, or middle as required.
Tilt board is used for a hour daily to maintain vascular tone and bone density for compensating inability to stand.
Patient with C% injury is not able to earn a living by use of his hands.
C6 Functional Abilities
As compared to C5, asubstantial functional increase occur at C6 level. Rotator cuff of the shoulder becomes fully innervated whereas serratus, latissimus and pectoralis major receive partial but significant innervations. Nerve supply to biceps becomes complete. Muscles appear at the wrist particularly externsor carpi radialis and sometimes flexor carpi radialis.
There is good rotation and abduction of glenohumeral joint.
As prime movers are working, true adduction, flexion, extension and scapular protaction is possible.
However, as the nerve supply of prime movers is partial only, the strength varies.
Respiratory reserve would still be low.
Biceps and brachioradialis provide strong flexion. Extensor and flexors of the wrist work and extensors of the wrist could utilize the remaining elasticity of the flexors to provide a weak closure of the hand.
However, more elaborate hand devices are required.
Even with absent grasp, the patient may take advantage of elbow flexors to sit up independently.
Rolling over in the bed is permitted by shoulder strength.
But the patient cannot move in the bed while recumbent without help.
An attendant is essential in lifting the patient to and from the wheel chair.
Patient may be able to feed himself with help of hand devices. She can perform part of his toilet and dressing activities.
But the patient cannot be termed as independent in self care. Use of Gatch bed and tiltboard is recommended.
Ambulation is not possible and patient is confined to wheel chair but can propel his own wheel chair on a smooth leveled floor.
The grasp is absent but she uses elbow flexors and shoulder adductors for this.
The patient is not able to do any job with hands though some may develop sufficient skill to use specially
some may use the specially adapted machinery.
C7 Functional Abilities
The patient with spared C7 has three important additions
- Common finger extensors
- Long finger flexors
Primary innervation for each of these groups varies between C7 and C8.
Triceps is especially strong as the innervations comes as high as C6.
This enables the patient to stabilize the elbow in extension and can assist in lifting the body weight.
Finger extensors and flexors offer grasp and release but not powerful.
As the intrinsic muscles of the hand are not yet significantly innervated , the hand lacks the strength and dexterity.
The patient is more independent in bed and wheelchair than C6 patients.
Exceptional individuals may be able to make the transition to wheelchair independence.
These patients can roll over, sit up in the bed, and move about in sitting position.
Assistance is required to lift the pelvis while recumbent, as in putting the trousers.
Most of the patients require help in transferring to and from the wheelchair but the help is just an assistive push than real lift.
Some assistance is required for toileting and dressing activities.
Eating can be done independently.
If adequately braced, some C7 lesions are able to ambulate with crutches to some extent. The fingers permit grasping the crutches and triceps provides stability to the elbow.
To maintain the upright posture, the patient needs long leg braces with pelvic band and a high spinal attachment.
The only independent gait possible is the “drag to” gait.
As applying braces and attaining the erect position cannot be done without a great deal of assistance, this kind of ambulation cannot be considered functional.
C7 quadriplegic is still confined to wheelchair, needs a part time and in many cases, full time attendant. Endurance is affected by low respiratory reserve.
Occupations requiring use of hands are more feasible since finger flexors and extensors are functional.
The type of work is limited by weakness of grasp. The activities involving tight grasp such are not recommended.
Possible vacations include book keeping, telephone services and mimegraphing or typing.
T1 Functional Abilties
The patient in whom T1 is spared by a complete lesion as full innervations of the upper extremity musculature, including essential intrinsic muscles of the hand.
This patient would have strength, dexterity and fully innervated proximal musculature.
As ulnar side of wrist has full blood supply now, crutch walking is better controlled.
The patient still lacks trunk stability, respiratory reserve of intercoastal origin and trunk fixation [required for prime movers of upper extremity]
Patient is functional in bed activities. She is able to transfer to and from wheelchair without aid, requiring assistance sometimes.
T1 patient is independent in all activities of self care, excluding those of requiring lifting of body while recumbent.
Patient is able to carry himself with help of crutches with a drag to or swing to gait.
Because of full body bracing , attaining an erect position is laborious requiring help. Ambulation, therefore, cannot be considered functional and a well adapted wheelchair is essential.Patient is able to carry home bound jobs requiring use of hand. Some patients develop sufficient sitting balance to drive a hand controlled car though in and out transfer from car may require assistance.
T6 Functional Abilities
T6 paraplegic has complete control of thoracic and upper extremity musculature, stabilized against a well coordinated pectoral girdle including intercostals, long muscles of upper back and transverses throracis.
The patient has tight grasp, supported by proximal musculature which in turn is stabilized against thorax.
Added intercostals innervations hels increment in respiratory reserve..
All these factors translate into better self care, enough to provide independence in all phases of self care.
Even application of full body bracing becomes possible as patient can adequately stabilize his upper extremities to use them to lift pelvis in applying braces..
Patient can independently transfer in and out of wheel chair by using strong pectoral girdle and triceps.
The patient usually needs no attendant but adaptation and customization of wheel chair may be required.
The patient is braced with low spinal attachment, pelvic band and double long leg braces.
With these braces, the patient is able to stand erect for indefinite periods. She is also able to ambulate with swing through gate. Ambulation gets restricted by slow and laborious attainment of erect position.
Door –bars, parallel or stall bars are prescribed for assisting in getting to erect position.
Even if the ambulation is not very functional the patient is encouraged to stand for at least one hour daily. The use of tiltboard is not required.
For those who are comfortable while standing, special standing apparatus of work equipments may be considered.
Patient is unable to do elevation activities as hip and knee are locked and all the elevation activities must be accomplished by pure push-up in the shoulder girdle.
This push up is adequate in most of the patients only for ascent of very low stairs with a handrail but not the standard 20 cm stairs, thus making public transportation impossible.
Work outside the home could be reached by private hand controlled or chauffeured car. Most of T6 patients have sufficient sitting balance to drive a hand controlled car.
The patient is able to transfer from wheel chair to car.
T12 Functional Abilties
This patient has full innervations to rectus abdominis, oblique muscles of the abdomen, the transverses abdominis and all muscles of thorax.
As lumbar innervations is absent, lower back muscles are weak. So are primary hip lifters i.e. quadratus lumborum and lower erector spinae muscles. Hip hiking can be accomplished by secondary hip hikers namely internal and external obliques and latissimus dorsi.
For ambulation patient is braced with bilateral long leg braces and may or may need a pelvic band, depending on his skill. The patient may use a two point alternate or four point or swing through gait as suits her convenience. Using these gaits, she can ambulate freely on reasonably rough surfaces, negotiate curbs as well negotiate 200 mm [achieved by pelvic tilt] stairs with hand rails. This would also enable use of public transportation.
T 12 patients have very few limitations in sedentary or semisedentary jobs away from home.
The patient’s wheelchair should be customized as per needs.
L4 Functional Abilties
The patient with a lesion below L4 has functional assistance of quadratus lumborum, erector spinae, quadriceps and primary hip flexors. Ankle remains flail.
Long leg brace becomes unnecessary as quadriceps extension is present. Flail ankle can be supported by short leg brace.
The patient’s gait is bilateral maximus-medius gait with added disability of flail ankles. Lumbar lordosis and genu recurvatum may develop as extended pelvis and extended knee becomes necessary during ambulation.
Crutches are prescribed to prevent long-term effects though patient may be able to walk without them.
Patient is independent in all phases of self care and ambulation. A wheelchair may be a convenient addition at home or work.