- Ventilator independent- Has biceps, deltoid, and can flex elbow, but lacks wrist extension and supination needed to feed oneself- Independent ADL’s; electric wheelchair with hand control, minimal manual wheelchair function
- Various return of B/B and sexual function- Walking with minimal or no assistance
Please rate topic.
Average 4.4 of 65 Ratings
A 32-year-old man is brought to the Emergency Department after cervical spine trauma. Physical examination has classified his injury as ASIA B at the C6 level. All of the following exam findings are expected in this patient EXCEPT?
Sensation intact in the long finger
Sensation intact over the medial aspect of the forearm
5/5 strength in deltoid function
2/5 strength in triceps function
0/5 strength in the instrinic hand muscles
Select Answer to see Preferred Response
Because this patient is a ASIA B, you would expect sensory to be preserved on some level distal to the injury level, but all motor distal to the injury level would be lost.
The American Spinal Injury Association (ASIA) defines the "Level" the lowest segment with intact sensation and antigravity. Therefore, a C6 level would have intact C6 function (brachioradialis, wrist extension), but everything distal (C7-triceps) would not be functional. Because this patient is a ASIA B, although he has an incomplete spinal cord injury, you would still not expect any motor function distal to the level (ASIA B = sensory intact but no motor function).
The American Spinal Injury Association (ASIA) classification system helps to determine the level and severity of spinal cord injury. The "Level" is defined as the lowest segment with intact sensation and antigravity. The degree is determined by an A-E scoring system.
ASIA A: injuries are complete spinal cord injuries.
ASIA B: are incomplete injuries and have preserved sensory but no motor function.
ASIA C: are incomplete injuries characterized by greater than half of the key muscle groups below the neurological level with muscle grade less than 3.
ASIA D: are incomplete injuries characterized by at least half of the key muscle groups below the neurological level with muscle grade greater than 3.
ASIA E: implies normal motor and sensory function..
Schouten et al. reviewed initial assessment and management of the patients with spinal injury. Approximately one half of patients with ASIA B injuries, 3/4 of patients with ASIA C injuries, and nearly all patients with ASIA D injuries recover enough lower extremity strength to ambulate. They also advocate for decompression within 24 hours, citing the STASCIS study.
Hadley et al. reviewed clinical assessment of acute cervical spine injury. Their review suggests that the ASIA classification is the most consistent and reliable scoring system for neurological assessment while the Spinal Cord Independence Measure (SCIM III) is best for determining functional abilities and impairment.
Illustration A outlines the ASIA classification system.
Answer 1: Describes sensation in C7 dermatome, expected to be intact with this injury because he is an ASIA B and sensation is preserved distal to the injury.
Answer 2: Describes sensation in C8 dermatome, expected to be intact with this injury because he is an ASIA B and sensation is preserved distal to the injury.
Answer 3: Describes motor function from C5 nerve root, expected to be intact with this injury it is at or above the injury level.
Answer 5: Describes motor function from C8 and T1 nerve roots, expected to be lost with this injury because he is an ASIA B and motor distal to the injury is lost.
Schouten R, Albert T, Kwon BK.
J Am Acad Orthop Surg. 2012 Jun;20(6):336-46. PMID: 22661563 (Link to Abstract)
Schouten, JAAOS 2012
Hadley MN, Walters BC, Aarabi B, Dhall SS, Gelb DE, Hurlbert RJ, Rozzelle CJ, Ryken TC, Theodore N.
Neurosurgery. 2013 Mar;72 Suppl 2:40-53. PMID: 23417178 (Link to Abstract)
Hadley, NEUROS 2013
Please rate question.
Average 3.0 of 9 Ratings
An 18-year-old male is evaluated for a suspected spinal cord injury. His neurological exam shows diminished sensation below the T7 level. His bulbocavernosus reflex is intact. Which physical finding of motor function, below the affected neurological level, would classify this injury as an ASIA B according to the American Spinal Injury Association impairment scale?
More than half of the major muscles demonstrate palpable or visible muscle contraction
At least half of key muscles have a muscle grade of 5.
More than half of key muscles have a muscle grade less than 3.
At least half of key muscles have a muscle grade of 3 or more.
No motor function preserved below affected neurological level
The American Spinal Injury Association (ASIA) impairment scale allows for categorization of spinal cord injuries. Maintained sensory but no motor function below the affected neurological level is consistent with an ASIA B category injury.
There are 5 categories of spinal cord injuries according the ASIA impairment scale. ASIA A is a complete spinal cord injury. There is no preserved sensation or motor function below the affected neurological level. ASIA B-D are incomplete spinal cord injuries ASIA B is described above. ASIA C is defined by preserved sensation and a motor function grade of less than 3/5 below the level of injury. ASIA D is defined by a motor function grade of greater than 3 below the injury level. ASIA E describes a normal neurological examination.
Stevens et al. reviewed the critical care and perioperative management in traumatic spinal cord Injury. They state that the neurologic level of injury is determined as the most caudal segment of the spinal cord with normal bilateral motor (strength >3/5) and sensory (light touch and pinprick) function.
Illustration A is an summary chart of the ASIA impairment scale. Illustrations B and C are the front and back pages of the ASIA examination sheet.
Answer 1: 50% or more muscles show grade 1/5 power. This is consistent with ASIA C.
Answer 2: 50% or more muscles show grade 5/5 power. This is consistent with ASIA D.
Answer 3: Less than 50% of muscles show grade 0-2/5 power. This is consistent with ASIA C.
Answer 4: 50% or more muscles show grade 3-5/5 power. This is consistent with ASIA D.
Stevens RD, Bhardwaj A, Kirsch JR, Mirski MA.
J Neurosurg Anesthesiol. 2003 Jul;15(3):215-29. PMID: 12826969 (Link to Abstract)
Average 4.0 of 10 Ratings
A 36-year-old male involved in a high speed motor vehicle accident is found on exam to have Grade 2 of 5 motor strength in 80% of his key muscle groups in his lower extremity. His perianal sensation and rectal tone are intact. A bulbocavernosus reflex is present. His sensation is decreased from a point at the intersection of the mid-clavicular line and the 4th intercostal space at the level of the nipples distally. Based on the American Spinal Injury Association (ASIA) classification system, what ASIA grade is he?
This patient is presenting with an ASIA C high thoracic level injury.
The ASIA classification is used to determine severity of injury. ASIA A is a complete spinal cord injury. ASIA B is characterized by preserved sensory function but no motor function below the neurological level. ASIA C is characterized by preserved motor function below the neurological level, but more than half of key muscles below the neurological level have a muscle grade less than 3. ASIA D is characterized by preserved motor function below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more. ASIA E is a normal exam.
Waters et al. followed 148 patients prospectively and demonstrated that no individual presenting with a complete neurologic level of injury above T9 ever regained any lower extremity motor function. Patients with a complete neurologic level below T9 had some return of function. One fifth of patients with complete injuries below T12 were eventually able to ambulate using conventional orthoses and crutches.
Harrop et al. reviewed 150 patients treated over a 10 year period with a spinal cord injury between T4 and S5. Patients were stratified based on level of injury, initial American Spinal Injury Association (ASIA), age, race, and etiology. A total of 92.9% of lumbar (conus) patients neurologically improved one ASIA level or more compared with only 22.4% of thoracic or thoracolumbar spinal cord-injured patients.
Illustration A is the ASIA worksheet that helps to classify a spinal cord injury. Illustration B shows the ASIA classification in chart format.
Harrop JS, Naroji S, Maltenfort MG, Ratliff JK, Tjoumakaris SI, Frank B, Anderson DG, Albert T, Vaccaro AR
Spine. 2011 Jan;36(1):21-5. PMID: 21192220 (Link to Abstract)
Harrop, SPINE 2011
Waters RL, Yakura JS, Adkins RH, Sie I.
Arch Phys Med Rehabil. 1992 Sep;73(9):784-9. PMID: 1514883 (Link to Abstract)
Average 2.0 of 21 Ratings
A 23-year-old man falls down a flight of stairs while intoxicated and is brought to the emergency room the following morning. On physical exam he has no motor function in his upper and lower extremities. Sensory exam shows diminished but present sensation in the perianal area and in the lower extremities. Reflex exam shows his bulbocavernosus reflex is intact. The inital CT and MRI are seen in Figures A and B. According to the American Spinal Injury Association (ASIA), how would this injury be classified?
This patient has some sensory function but no motor function below the injury level. His bulbocavernosus reflex is intact so we know he is no longer in spinal shock. Therefore, he would be classified as an ASIA B.
The imaging studies show a type II odontoid fracture, a congenital fusion at C2/3 and C4/5, and a large soft disc herniation at C3/4 with spinal cord compression and myelomalacia.
The ASIA system describes the exam below the level of the injury.
ASIA A: Complete. No motor or sensory
ASIA B: Incomplete. No motor function but some remaining sensory
ASIA C: Incomplete. 50% or more of muscles below injury are less than Grade 3.
ASIA D: Incomplete. 50% or more of muscles below injury are equal to or greater than Grade 3.
ASIA E: Normal
Furlan et al reviewed the ASIA classification in the assessment of motor and sensory function in patents with spinal cord injury (SCI). Although many studies suggest convergent and divergent construct validity, they determined that the ASIA classification is an adequate instrument to evaluate patients with SCI.
Illustration A outlines the ASIA classification. The complete ASIA assessment chart is in Illustration B.
Furlan JC, Fehlings MG, Tator CH, Davis AM.
J Neurotrauma. 2008 Nov;25(11):1273-301. PMID: 19061373 (Link to Abstract)
Average 4.0 of 19 Ratings
A 49-year-old male fell from a height of 10 feet while cleaning his roof. He sustained the isolated injury shown in Figures A and B. Upon transfer from the outside hospital 10 hours later, he has 0/5 motor strength in bilateral lower extremities, no sensation distal to umbilicus, and an intact bulbocavernosous reflex. He has no perianal sensation or rectal tone. He received no medical management at the outside hospital. Which of the following is the most appropriate use of methylprednisolone in this patient.?
Initiate high-dose methylprednisolone with a loading dose of 30mg/kg and a drip of 5.4 mg/kg/hr
Initiate high-dose methylprednisolone, without a loading dose, at 5.4 mg/kg/hr
Do not initiate treatment with methylprednisolone
Initiate high-dose methyprednisolone if his neurologic status does not improve over the next 14 hours
Administer a one-time dose of methylprednisolone at a dose of 30 mg/kg
The clinical presentation describes a lower thoracic spine burst fracture with a complete neurological spinal cord injury. Since the patient's injury occurred ten hours prior to presentation, the original studies did not support initiation of high-dose methylprednisolone. In fact, more recent studies than the ones they quoted when this question first appeared in 2011 have suggested that steroids are no longer indicated for spinal cord injury regardless of timing.
High-dose corticosteroid administration following spinal cord injury was thought to work by stabilizing neuronal membranes and reducing inflammation. While there is much controversy regarding this topic, recommendations from the most recent Cochrane review when this question was asked was to give a 30mg/kg bolus followed by a 5.4 mg/kg drip if the injury occurred less than 8 hours prior to presentation. If the injury was sustained less than 3 hours prior to presentation, the methylprednisolone drip was to continue for 23 hours. If the injury occurred from 3-8 hours prior to presentation, the steroid drip was to be continued for 48 hours. Contraindications to steroid therapy include injuries that occur greater than 8 hours prior to presentation, pregnancy, gunshot wounds, patients under the age of 13, and brachial plexus injuries.
Ito et al. performed a prospective study in which they gave high-dose methylprednisolone (30 mg/kg bolus, then 5.4 mg/kg/hr for 23 hours) to all patients with a cervical spinal cord injury that occurred less than 8 hours prior to presentation. They compared this to a similar group that did not receive methylprednisolone. All patients underwent decompression and stabilization as soon as possible after the injury. They found an increased risk of pneumonia in the group treated with steroids, highlighting the potential side-effects of such therapy.
Kwon et al. provide a review on subaxial cervical spine trauma. They discuss the importance of making the correct diagnosis upon initial presentation and discuss that the treatment algorithm should take into account stability, neurologic status, and patient-related factors such as DISH. They comment that corticosteroids should be considered.
Bracken provides the most recent Cochrane review on the use of steroids in acute spinal cord injury. Methylprednisolone sodium succinate was shown to improve neurologic outcome up to one year post-injury if administered within eight hours of injury and in a dose regimen of: bolus 30mg/kg over 15 minutes, with maintenance infusion of 5.4 mg/kg per hour infused for 23 hours. One trial showed a benefit to extending the duration of treatment to 48 hours if starting between 3 and 8 hours after injury.
Figures A and B are the sagittal and axial CT cuts that show a T9 burst fracture with rotational malalignment and moderate anterolisthesis.
Answers 1,2,4,5: Data does not support the administration of high-dose methylprednisolone if the injury occurs greater than 8 hours before presentation.
Ito Y, Sugimoto Y, Tomioka M, Kai N, Tanaka M
Spine. 2009 Sep;34(20):2121-4. PMID: 19713878 (Link to Abstract)
Ito, SPINE 2009
Kwon BK, Vaccaro AR, Grauer JN, Fisher CG, Dvorak MF
J Am Acad Orthop Surg. 2006 Feb;14(2):78-89. PMID: 16467183 (Link to Abstract)
Kwon, JAAOS 2006
Cochrane Database Syst Rev. 2012;1:CD001046. Epub 2012 Jan 18. PMID: 22258943 (Link to Abstract)
Bracken, COCHD 2012
Average 3.0 of 24 Ratings
A 52-year-old male is involved in an altercation where his neck was twisted and extended with force. Upon presentation he complains of neck pain, and loss of ability to stand or ambulate. On physical exam, he has Grade 3 motor strength in the majority of his muscles groups in his upper and lower extremities. His sensory is intact in all four extremities, and his bulbocavernosus reflex is intact. Sagittal and coronal computed tomography are shown in Figure A and B respectively. The patient's neurologic condition is best classified as?
This patient has a spinal cord injury as a result of a rupture to his transverse ligament. This is evidenced by the increased atlanto dens interval on his computed tomography. Motor and sensory function are preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more. His bulbocavernosus reflex is intact, so we know he is no longer in spinal shock. Therefore, he would be classified as an ASIA D.
The ASIA system describes the exam below the level of the injury and can be broken into the following five categories.
ASIA A: Complete. No motor or sensory
ASIA B: Incomplete. No motor function but some remaining sensory
ASIA C: Incomplete. 50% or more of muscles below injury are less than Grade 3.
ASIA D: Incomplete. 50% or more of muscles below injury are greater than or equal to than Grade 3.
ASIA E: Normal
Furlan et al. evaluated whether the American Spinal Injury Association (ASIA) standards are sensitive enough to discriminate neurological recovery. They found the ASIA Standards represent an appropriate instrument to discriminate and evaluate patients with SCI in a longitudinal manner.
Illustration A details the ASIA motor function grading, ASIA Impairment (AIS) Scale, and steps in classification of individuals with spinal cord injury. Illustration V depicts what an ASIA D injury looks like in the lower extremity on physical exam.
Average 3.0 of 30 Ratings
What percentage of patients with a spinal cord injury suffer from Major Depressive Disorder?
Less than 5%
5 to 20%
20 to 50%
50 to 75%
Greater than 75%
Approximately 11% of patients with spinal cord injuries meet the criteria for Major Depressive Disorder (MDD). Therefore, in patients with spinal cord injuries who show symptoms of depression, such as suicidal ideation, it is important to screen for major depression and consult for psychological care.
Bombardier et al found 11.4% of participants with spinal cord injuries met criteria for MDD. They found MDD was associated with poorer subjective health, lower satisfaction with life, and more difficulty in daily role functioning.
Kishi et al found that both acute and delayed-onset suicidal ideation was strongly associated with the existence of major depression and impaired social functioning in patients with spinal cord injury. They argue that the detection and appropriate treatment of depressive disorders and social isolation may be the most important factor in preventing suicide both during the acute and chronic period following spinal cord injuries.
Bombardier CH, Richards JS, Krause JS, Tulsky D, Tate DG.
Arch Phys Med Rehabil. 2004 Nov;85(11):1749-56. PMID: 15520969 (Link to Abstract)
Kishi Y, Robinson RG, Kosier JT.
J Nerv Ment Dis. 2001 Sep;189(9):623-8. PMID: 11580007 (Link to Abstract)
Average 1.0 of 126 Ratings
All of the following are attributed to the loss of supraspinal control of the sympathetic nervous system that commonly occurs in patients with spinal cord lesions at T-6 or higher EXCEPT
Spasticity is unrelated to the sympathetic system and usually occurs after the acute phase of spinal cord injury (SCI), when spinal shock has resolved. Furlan et al states that sympathetic decentralization leads to altered regulation of the autonomic function, despite the presence of intact parasympathetic (vagal) afferent and efferent pathways in patients with SCI. Hypotension (supine and orthostatic), cardiac arrythmias, and autonomic dysreflexia are all the result of loss of supraspinal control of the sympathetic nervous system. Autonomic dysreflexia is defined as “an increase in systolic blood pressure of at least 20% associated with a change in heart rate and accompanied by at least one of the following signs (sweating, piloerection, facial flushing), or symptoms (headache, blurred vision, stuffy nose)” due to a stimulus such as overdistended bladder or bowel impaction. Guidelines for treatment of autonomic dysreflexia include 1) patient immediately placed in a sitting position if the person is supine. 2) clothing or constrictive devices need to be loosened 3) troubleshoot etiologies for bladder distention or bowel impaction 4) a SBP >150 mmHg may need to be treated with nifedipine or nitrates 5) close monitoring of symptoms, blood pressure, and heart rate for at least 2 hours.
Furlan JC, Fehlings MG.
Neurosurg Focus. 2008;25(5):E13. PMID: 18980473 (Link to Abstract)
Functional electrical stimulation is used in the rehabilitation of patients with spinal cord injuries. This rehabiliation method has the greatest functional effect on which of the following?
Dorsal root ganglion
Functional electrical stimulation is a technique that rehabilitates patients with spinal cord injuries by using electrical stimulation of skeletal muscles. Mulcahey et al. studied the benefits of implanted functional electrical stimulation systems for hand function in adolescents with tetraplegia secondary to spinal cord injuries and found in five patients that the combination of functional electrical stimulation and surgical reconstruction of the hand provided improved active palmar and lateral grasp and release. In a follow-up study, Davis et al. evaluated the self-reported usage via patient survey of a functional electrical stimulation system that stimulated lateral pinch and palmar grasp again in adolescents with C-5 or C-6 tetraplegia. They found patients performed better ADLs (eating, grooming, brushing teeth) but had difficulties donning the system independently between uses.
Mulcahey MJ, Betz RR, Smith BT, Weiss AA, Davis SE.
Arch Phys Med Rehabil. 1997 Jun;78(6):597-607. PMID: 9196467 (Link to Abstract)
Davis SE, Mulcahey MJ, Smith BT, Betz RR.
J Spinal Cord Med. 1998 Jul;21(3):220-6. PMID: 9863932 (Link to Abstract)
Davis, JSCM 1998
Average 2.0 of 28 Ratings
A 30-year-old male is involved in a motor vehicle accident and sustains a fracture-dislocation of the cervical spine. On physical exam he has absent distal motor function, absent sensation, absent rectal tone, and an intact bulbocavernosus reflex. Which term best describes this spinal cord injury pattern?
Central cord syndrome
Incomplete spinal cord injury
Complete spinal cord injury
This patient has a complete spinal cord injury which is defined as no voluntary anal contraction (sacral sparing) AND 0/5 distal motor AND 0/2 distal sensory scores (no perianal sensation) AND an intact bulbocavernosus reflex. The key to answering this question is understanding the meaning of an intact bulbocavernosus reflex. If the bulbocavernosus reflex is intact then the patient is no longer in spinal shock and we can determine a final classification of their spinal cord injury pattern. If the bulbocavernosus reflex is absent, then it is possible the patient is in a state of spinal shock, and therefore we can not classify his final spinal cord injury pattern.
Average 4.0 of 39 Ratings
A 16-year-old male is involved in a diving accident six months ago that leads to a spinal cord injury. On physical exam he has 5 out of 5 deltoid and biceps strength. He has good brachioradialis muscle tone and 5 out of 5 bilateral wrist extension. He has 0 out of 5 wrist flexion and triceps strength. He has no anal sphincter tone, absent perianal sensation, absent lower extremity sensation, and an intact bulbocavernosus reflex. He has no motor tone in his lower extremities. How would you define this patients neurologic deficit.
Incomplete C5 spinal cord injury (ASIA A)
Complete C5 spinal cord injury (ASIA E)
Complete C6 spinal cord injury (ASIA A)
Complete C7 spinal cord injury (ASIA A)
Incomplete C7 spinal cord injury (ASIA B)
According to the ASIA Classification of Spinal Cord Injuries, this patients neurologic deficit would be best described as a Complete C6 spinal cord injury (ASIA A).
There are three general steps to define a spinal cord injury using the ASIA classification system.
Step 1: Identify the neurologic level, which is described as the lowest segment where motor and sensory function is normal on both sides. Because this patient has normal function at C6 (brachioradialis and wrist extension), and no function at C7 (triceps and wrist flexion), his last normal functional level is C6. Therefore his neurologic level is C6.
Step 2: Determine if injury is complete or incomplete. Complete injuries are defined as no voluntary anal contraction (sacral sparing) AND 0/5 distal motor AND 0/2 distal sensory scores (no perianal sensation) AND intact bulbocavernosus reflex (patient not in spinal shock). Therefore, this patient has a complete injury.
Step 3: Assign ASIA impairment score. Because this patient has a complete injury, his ASIA impairment score is ASIA A.
Kirshblum SC, Memmo P, Kim N, Campagnolo D, Millis S.
Am J Phys Med Rehabil. 2002 Jul;81(7):502-5. PMID: 12131176 (Link to Abstract)
Average 4.0 of 49 Ratings
Which of the following best describes a patient's functional level with a complete C5 spinal cord injury?
Electric wheelchair with only head or chin control
Electric wheelchair with hand control
Limited use of manual wheelchair, can drive car with manual controls
Long-distance use of a manual wheelchair
Fully independent transfers
Patient with a C5 tetraplegia require an electric wheelchair with hand control for extension mobilization.
Individuals with C5 tetraplegia have functional use of deltoid and elbow flexion (biceps). A power wheelchair with hand controls will probably be required for most of their mobility needs, although a manual wheelchair with grip enhancements (rim projections) may be used for short-distance mobility on level surfaces. With the help of specialized assistive devices (such as wrist or hand orthotics to allow them to hold objects), these persons can achieve independence in feeding and grooming. Patients with a C5 injury can assist with upper extremity dressing and bed mobility.
They would not have functioning wrist extension/supination (C6) or triceps (C7) so patients require assistance for most other self-care (eg, lower extremity dressing, bathing), for transfer mobility, and for bladder and/or bowel tasks. They would not be able to drive a car.
The functional outcome of different levels of injury are described below. Remember the injury level is defined as the most caudal level of the spinal cord that has normal motor and sensory function.
C1, C2, C3: Ventilator dependent with limited talking, electric wheelchair with head or chin control.
C4: Ventilator independent, electric wheelchair with head or chin control.
C5: Ventilator independent, electric wheelchair with hand control, unable to live independently.
C6: Manual wheelchair, able to live independently.
C7: Improved use of a manual wheelchair.
Average 3.0 of 37 Ratings
Following an acute spinal cord injury a patient presents with systemic hypotension and relative bradycardia. His bulbocavernosus reflex is present. This is characteristic of what type of response in acute spinal cord injuries?
Traumatic spinal cord injury is frequently associated with alterations in respiratory and cardiovascular function that require critical care management. Spinal shock and neurogenic shock are two conditions that can occur in the acute phase.
Stevens et al review traumatic spinal cord injury management. Neurogenic Shock is characterized by hypotension & relative bradycardia in a patient with an acute spinal cord injury. It is potentially fatal. Treatment includes Swan-Ganz monitoring for careful fluid management and pressors to treat hypotension. Spinal shock is defined as temporary loss of spinal cord function and reflex activity below the level of a spinal cord injury. It is characterized by bradycardia & hypotension (due to loss of sympathetic tone) and an absent bulbocavernosus reflex. The concept of spinal shock is important because one cannot evaluate the neurologic deficit until spinal shock phase has resolved. The end of spinal shock is indicated by return of the bulbocavernous reflex.
Average 4.0 of 32 Ratings
A 2-year-old child falls down a flight of stairs and is found to have spinal cord injury without radiographic abnormality (SCIWORA). What is the most important predictor of her neurologic outcome?
Mechanism of injury
Severity of initial neurologic injury
Injury pattern of fracture or dislocation
Location of spinal cord injury
Age of patient
Spinal cord injury without radiographic abnormality (SCIWORA) is common in children under 10 years of age and is associated with more complete neurologic injuries than in cases where the injuries can be seen on radiograph.
Pang discusses in a Level 5 review that the increasing use of MRI in SCIWORA has yielded ample evidence of damage in surrounding soft tissues of the juvenile vertebral column. These findings provide the structural basis for the postulated "occult instability" in the spine of a patient after SCIWORA. MRI also demonstrated five classes of post-SCIWORA cord findings: complete transection, major hemorrhage, minor hemorrhage, edema only, and normal. These "neural" findings are highly predictive of outcome: patients with transection and major hemorrhage had profoundly poor outcome, but 40% with minor hemorrhage improved to mild grades, whereas 75% with "edema only" attained mild grades and 25% became normal. All patients with normal cord signals made complete recovery. Therefore, the severity of initial neurologic injury is the most important predictor of outcome.
Neurosurgery. 2004 Dec;55(6):1325-42; discussion 1342-3. PMID: 15574214 (Link to Abstract)
Pang, NEUROS 2004
Which of the following scenarios would be most appropriate for posterior deltoid-to-triceps transfers?
Axillary nerve injury
C6 ASIA A Spinal Cord Injury with 5/5 biceps and 4/5 brachioradialis
Erb's palsy with waiters tip deformity
C5 ASIA C Spinal Cord Injury with 3/5 deltoid and 2/5 biceps
C5 ASIA D Spinal Cord Injury with 4/5 deltoid and 4/5 biceps
Posterior deltoid-to-triceps transfer is considered for COMPLETE spinal cord injuries at C5 or C6 with 5/5 delt/biceps, but 0/5 triceps. Only Answer 2 would provide this function.
Activities such as dressing, controlling a power wheelchair and supporting oneself while sitting are dependent on the balanced forces provided by the triceps muscle. The transfer involves detaching the posterior deltoid muscle and anchoring the tendon sutured into the triceps muscle. It is the best choice as it will allow for opposing elbow extension to his maintained bicep function - which will help patients to perform reaching movements and improve level of functional independence.
Hamou et al. looked at a systematic review of literature of elbow extension restoration in people with tetraplegia. They concluded that mean MRC score for elbow extension strength improved from 0 to 3 with deltoid to triceps transfer.
Netscher et al. reviewed the surgical techniques of deltoid to triceps transfers. They concluded that reinforcing the central triceps tendon and posterior deltoid with palmaris longus, provides a very secure fixation.
Illustration A shows a schematic image of a posterior deltoid transfer to the central tendon that has been reflected proximally.
Answer 1: Axillary nerve injuries are a contraindication for this procedure as you wouldn't have deltoid function for transfer.
Answer 3: In Erb's palsy, the arm will be adducted, internally rotated, at shoulder; pronated, extended at elbow (“waiter’s tip”). This results from deficiency in the axillary and musculocutaneous nerves.
Answer 4 and 5: Insufficiency in deltoid strength is a contraindication for this procedure, assuming a loss of one grade of strength with tendon transfer. Also, this muscle transfer is for not appropriate for INCOMPLETE spinal cord injuries (transfer is for COMPLETE only) and that with weakness of the involved muscles the transfer would not be as useful.
Hamou C, Shah NR, DiPonio L, Curtin CM.
J Hand Surg Am. 2009 Apr;34(4):692-9. PMID: 19345872 (Link to Abstract)
Hamou, JHS 2009
Netscher DT, Sandvall BK.
J Hand Surg Am. 2011 Apr;36(4):711-5. PMID: 21463732 (Link to Abstract)
Netscher, JHS 2011
Average 3.0 of 22 Ratings
HPI - Three days prior, patient was admitted due to a gunshot wound through the thorax. The pulmonary artery was transected while entering the spinal canal without damaging the vertebral body.
On imaging the T8 posterior structures are seen damaged with the bullet doing a traumatic laminectomy through the level. The disc material and vertebral body was spared, however the bullet trajectory can be seen crossing the spinal canal.
How would you treat this SCI given limited resources?
HPI - tetraplegic pt - Heterotopic ossification of both hip joints...
what is the preferred treatment choice for this patient?
HPI - The patient is a 39-year-old male immigrant that become intoxicated and fell down the stairs. He was found the following morning, unable to move any of his extremities. He was brought to the emergency room via ambulance.
Would you have done anything differently with the odontoid fracture?