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 bearing 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.

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 – Spinal Level vs Vertebral Level

• 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 and patient may require ventilator.
• Patient may have speaking problems, bladder and bowel incontinence and would always require assistance if no recovery occurs.
• Patients may be able to use a power wheelchair controlled with the chin or the breath.
• Patients are also able to control adaptive devices for light switches, bed controls, televisions and so with the help of adaptive devices. They will require a caregiver’s assistance for most or all of their daily needs.

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

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.

These patients are able to flex their elbows. They can learn to feed and groom themselves with help of assitive devices.

With some supervised help they can dress their upper body and change positions in bed. These patients are able to use power wheelchair equipped with hand controls.

These patients require help in transfers from bed to chair and so forth, and for assistance with bladder and bowel management. Bathing and dressing , especially in lower part also requires assistance.

They are able to drive to drive a vehicle equipped with hand controls.

C6

This results 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.

These people can use elbows and writs and are able to grasp objects with support.

Some are able to transfer themselves without help using a slide board.

They can learn to feed, groom, and bath themselves with the help of assistance devices, are able to operate special vehicles.

C7

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

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.