Spinal Cord Injury Levels

Spinal cord injury levels can be expressed in many ways and it is important to understand the correlations.

This has an important beearing in marking the level of injury and correlating with the anatomy. For example if an injury occurs at T10-11 vertebral level, it is going to damage her lower thoracic as well lumbar spinal segments.

Few definitions first

Neurologic level

The most caudal segment with normal sensory and motor function on both sides

Sensory level

The most caudal segment with normal sensory function on both sides

Motor level

The most caudal segment with normal motor function on both sides

Skeletal level

Radiographic level of greatest vertebral damage

Spine

The spine consists of a series of vertebral segments. The spinal cord itself has neurological segmental levels marked by the spinal roots. A spinal root is named after the vertebra it exits from. When traced back to cord spinal cord segmental levels do not necessarily correspond to the bony vertebral level.

different spinal cord injury levels

Let us have a look at vertebrae and nerve root numbers

  • Cervical – 7  vertebrae and 8 cervical roots. This discrepancy is because there ar total 8 nerve roots exiting from the cervical vertebrae
  • Thoracic 12 vertebrae and 12 roots
  • Lumbar – 5 vertebrae and 5 nerve roots
  • Sacral – 5 vertebrae and 5 nerve roots

The spinal cord segments are not necessarily situated at the same vertebral levels. This has been caused by difference in vertebral height and height of spinal segment. Thus while  first cervical spinal segment is within C1 vertebra, the T12 cord comes to lie at the T8 vertebra.

Similarly the entire lumbar spinal segment lies between T9 and T11 vertebrae and the the sacral cord is between the T12 to L2 vertebrae.

Course of  Spinal Roots

C1 spinal root exit the spinal column at the atlanto-occiput junction. C2 root exits at the atlanto-axis. The C3 roots exit between C2 and C3. The C8 root exits between C7 and T1.

The first thoracic root or T1 exits the spinal cord between T1 and T2 vertebral bodies. The T12 root exits the spinal cord between T1 and L1. The L1 root exits the spinal cord between L1 and L2 bodies. The L5 root exits the cord between L1 and S1 bodies.

Relation of Spinal and Vertebral Segments

  • First two cervical cord segments roughly match the first two cervical vertebral levels.
  • C3 – C8 segments of the spinal cords are situated between C3 through C7 bony vertebral levels.
  • Likewise, in the thoracic spinal cord, the first two thoracic cord segments roughly match first two thoracic vertebral levels.
  • However, T3 through T12 cord segments are situated between T3 to T8. The lumbar cord segments are situated at the T9 through T11 levels while the sacral segments are situated from T12 to L1. The tip of the spinal cord or conus is situated at L2 vertebral level. Below L2, there is only spinal roots, called the cauda equina.

A rough calculation can be done as follow to obtain a relation between vertebral and segmental level.

  • From C2-C6 vertebra add 1 to obtain the spinal segment level
  • From T1-T6 vertebra add 2 to obtain the spinal segment level
  • From T7-T9 vertebrae add 3 to obtain the spinal segment level
  • T10-T12 vertebrae have whole of lumbar segments
  • L1 vertebra has  sacral & coccygeal segments
  • L2 onwards is cauda equina

Spinal Cord Injury Levels Regionwise

High-Cervical Injury (C1 – C4)

  • Most severe of the spinal cord injury levels
  • Leads to quadriplegia and trunk paralysis, may affect respiration too
  • Patient may have speaking problems, bladder and bowel incontinence and would always require assistance if no recovery occurs.

Low-Cervical Injury(C5 – C8)

 

  • This spinal injury level involves C5 to C8 nerve roots.
  •   There would be no breathing or speech problems
  • The disability depends on spinal injury level
    • C5 injury  has to have some or total paralysis of wrists, hands, trunk and legs, will require assistance with most activities of daily living, but  can move from one place to another independently in wheelchair.
    • C6 injury –  Paralysis in hands, trunk and legs, should be able to bend wrists back, can move in and out of wheelchair and bed with assistance/aid, No voluntary control of bowel/bladder, but may manage on their own with special equipment
    • C7 injury-    Most have normal movement of their shoulders, can do most activities of daily living , but need assistance with more difficult tasks, may be able to drive an adapted vehicle,  no voluntary control of bowel or bladder but, may be able to manage on their own with special equipment
    • C8 injury – Able to grasp and release objects, can do most activities of daily living by themselves, but may need assistance with more difficult tasks, may also be able to drive an adapted vehicle, little or no voluntary control of bowel or bladder, but may be able to manage on their own with special equipment

Upper Thoracic Injury (T1 – T5)

This spinal cord injury levels affect affect muscles of upper chest, mid-back and abdomen.   Arm and hand function is usually normal,  paraplegia is present. Patients are able to use  manual wheelchair. Some can stand in a standing frame, while others may walk with braces.

Lower Thoracic Injury(T6 – T12)

This spinal cord injury level affects muscles of the trunk , usually results in paraplegia and there is normal upper-body movement, there is little or no voluntary control of bowel or bladder but can manage on their own with special equipment, can use a manual wheelchair, learn to drive a modified car, stand in a standing frame, while others may walk with braces.

Lumbar Injury(L1 – L5)

These generally result in some loss of function in the hips and legs.    Little or no voluntary control of bowel or bladder, but can manage on their own with special equipment.     Depending on strength in the legs, may need a wheelchair and may also walk with braces

Sacral Injury(S1 – S5)

Injuries generally result in some loss of functionin the hips and legs.    Little or no voluntary control of bowel or bladder, but can manage on their own with special equipment.   Most likely will be able to walk

Note: For all practical purposes whenever lesion in the spine is examined, it is always good to mention injured vertebral and spinal levels sparately.

If they roughly match, the level has been ascertained. if they grossly mismatch something might have been missed. There might be another lesion or cord edema.

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Comments

  1. boubou says

    si je me base sur la relation vertebre-segments,une fracture de la vertebreL1 leserait les segments sacrees et pas les segments lombaires.Sauf que personnellement ,j'ai eu une fracture en L1,et j'ai eu une lesion au niveau du segment L4.Et que ca m'empeche melheureusement de marcher.

    y at'il erreur de votre part?

  2. Dr Arun Pal Singh says

    This is what Google translated for me from your text
    if I look at the relationship vertebra-leg, a fractured vertebra L1 segments would prejudice the sacred and not lombaires.Sauf segments that personally, I had a fracture of L1, and I had a lesion at the segment L4.Et melheureusement that I could not walk.
    Are there errors on your part?

    Here is answer
    No! There are no errors. The extent of vertebral injury and spinal injury may vary. Moreover there are individual variations.

    The level correlation is an approximation. It works well but it should not be strictly adhered to like mathematics.

    I hope that helps.

    Here is the translation
    Non! Il n'y a pas d'erreurs. L'étendue de la lésion vertébrale et lésion de la moelle peut varier. En outre il ya des variations individuelles.

    La corrélation de niveau est une approximation. Il fonctionne bien, mais il ne devrait pas être strictement respectées, comme les mathématiques.

    J'espère que cela

  3. winnie says

    thank you, dr arun! i have been trying to understand the relation of spinal and vertebral level and you made it so much easier !! :) may i know which book you referred from?

  4. winnie says

    thank you, dr arun! i have been trying to understand the relation of spinal and vertebral level and you made it so much easier !! :) may i know which book you referred from? thanks!

  5. Dr Arun Pal Singh says

    @winnie,

    Welcome. I do not remember but this is mentioned in many a text books.

  6. Samia says

    Dr. Arun, please explain:

    I have been studying neuroanatomy from Snell’s, it says:

    T1 to T6 Add 2

    T7 to T9 Add 3

    T10 L1 L2

    T11 L3 L4

    T12 L5

    In one of the clinical questions, a patient suffered from T9 fracture. Applying the above calculation, shouldn’t it be corresponding to T12 segment. Instead, it says T9 segment. Please shed some light.

  7. apsingh1975 says

    To avoid the confusion, there are two levels mentioned in diagnosis of injury. Vertebral level and spinal level. If T9 fracture is there the level, as you rightly stated should be T12. But in case there is an concomitant injury higher up for example T6 too, it could be T9 because the clinical presentation would correspond to injured higher segment.

    Otherwise it could be printing mistake. If there is a doubt let me see the clinical question.

  8. Harpreet60 says

    Dear sir, the 2 methods u have told…m getting different ans frm them
    above 1 say- c1 and c2 of cord and vertebrae corresponds
    lower 1 say – add 1 to c2 to get spinal cord level = c3 ??
    i am confused…

  9. Arun Pal Singh says

    Apparently there is a discrepancy but it is not. Both the methods are seen together and it must be remembered that it is human body and variations exist. One cannot treat absolute and like mathematical equation.

    As the text says C1 and C2 roughly correspond to the respective vertebral level. The catchword is :rough:

    The confusion does exist for C2. It could correspond to C2 and C3 according to your calculations and it is rightly calculated. When you add :roughly: to your calculation C2 might span over an area C2-C3.

    This is what I can say from my knowledge. If you come across a better explanation, please do share with us.

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