Social, Occupational, and Medical
Aspects of Spinal Cord Injury
Samuel Grissom, MD
Medical Director
Spinal Cord Injury Program
Methodist Rehabilitation Center
Incidence of Traumatic SCI


Average nationally 40 per million
population per year (11,000 per year)
Varies by state


25 per million in West Virginia
59 per million in Mississippi
Estimated National Prevalence: 253,000
Incidence of Traumatic SCI




Average age 38
About 53% between 16 – 30 years old
78% male
Greatest frequency on weekends



19.3% Saturdays
17.2% Sundays
Seasonal variation: greatest frequency
during summer
Etiology of Traumatic SCI

Vehicular (car, motorcycle, ATV) 47%


Leading cause until age of 45 yo
Falls 24%

Leading cause after age of 45 yo
Violence 14%
 Sports 9% (diving #1 > 50%)
Variability by region

Etiology of Nontraumatic
SCI/dysfunction





Degenerative: spinal stenosis, herniated
disc
Tumors
Infections
Vascular
Multiple Sclerosis
More common in patients over 40 years old
Classification of Spinal Cord Injury
ASIA Impairment Scale

A = Complete: no motor or sensory
function preserved in the sacral
segments S4-5 (ie. NO perianal
sensation, deep anal sensation, or
voluntary anal contraction)

B = Incomplete: Sensory but no
motor function preserved in the
sacral segments (may not be normal,
but is present!)

C = Incomplete: Motor function is
preserved below the neurologic level,
& > ½ of the key muscles below the
NLI have a muscle grade of < than 3

D = Incomplete: Motor function is
preserved below the neurologic level,
& ≥ ½ of the key muscles below the
NLI have a muscle grade of ≥ than 3
Definitions

Neurologic Level of Injury: the most distal
level where both motor & sensory are intact
Level of Injury


Overall, most common NLI: C5
51% Cervical level injury: tetraplegia
NLI
16
14
12
10
8
6
4
2
0
C1
C5
T1
T5
T9
L1
L5
Incomplete Syndromes




Central Cord Syndrome
Brown-Sequard Syndrome
Anterior Cord Syndrome
Posterior Cord Syndrome
Central Cord Syndrome
Greater weakness in the upper
limbs than in the lower limbs,
occurs in cervical region

The most common of the
incomplete syndromes

Frequently seen in elderly patients
with cervical stenosis

Good prognosis for recovery but
age a predictor:
<50 yo >50 yo
Ambulation
97%
41%
ADLs
77%
12%
Bowel
63%
24%
Bladder
83%
29%

Brown-Sequard Syndrome
Hemi-section injury of the
spinal cord producing greater
ipsilateral proprioceptive &
motor loss with contralateral
loss of pin & temperature
sensation
 Overall best prognosis for
recovery
Ambulation 75%(40% if >50 yo)
ADLs
70%
Bowel
82%
Bladder
89%

2 - 4 % of all traumatic SCI
Anterior Cord Syndrome


Injury involving anterior 2/3 of
spinal cord with variable loss
of motor function, pain &
temperature, with preserved
proprioception and light touch
Poor prognosis for recovery
only 10 – 20% have any
motor recovery and it’s almost
always non-functional
Posterior Cord Syndrome



Least frequent
Preserves pain,
temperature, and light
touch with varying
degrees of motor
preservation and loss of
proprioception
Prognosis for ambulation
is poor
Recovery Prognostication Determinants




Complete vs Incomplete injury
Initial level of injury
Initial strength of muscles
Age
* Primary determinant of motor recovery is
completeness of injury at one month
Complete Tetraplegia


Most patients regain 1 motor level during
1st year after injury
Most upper extremity recovery occurs in
1st 6 months, greatest rate in 1st 3 months
Incomplete Tetraplegia


Poor prognosis for community ambulation if
no lower extremity motor strength at 1 month
Poor prognosis for ambulation if >50 years
old
Complete Paraplegia


Most recovery in 1st 6 months
Poor prognosis for community ambulation

<5% overall
Incomplete Paraplegia


Greatest rate of recovery in 1st 3 months
50% recover community ambulation
Levels of Injury and Outcome
Cervical paraspinal, sternocleidomastoid, neck accessory muscles,
partial innervation of diaphragm
C1 – 3 Levels
Expected Functional Outcomes
Equipment
Respiratory
• Ventilator dependent
• Inability to clear secretions
• 2 ventilators (bedside, portable)
• Suction equipment
• Generator/battery backup
Bowel
Total assist
• Padded reclining shower/commode chair
(if roll-in shower available)
Bladder
Total assist
Bed Mobility
Total assist
• Full electric hospital bed with Trendelenburg
feature
• side rails
Transfers
Total assist
• Transfer board
• Power or mechanical lift with sling
Pressure relief
Total assist; may be independent
with equipment
• Power recline and/or tilt W/C
• W/C pressure-relief cushion
• Postural support and head control devices as
indicated
• Hand splints may be indicated
• Specialty bed or pressure-relief mattress may
be indicated
Eating
Total assist
Dressing
Total assist
Grooming
Total assist
Cervical paraspinal, sternocleidomastoid, neck accessory muscles,
partial innervation of diaphragm
C1 – 3 Levels
Expected Functional Outcomes
Equipment
Bathing
Total assist
• Handheld shower
• Shampoo tray
• Padded reclining shower/commode chair
(if roll-in shower available)
W/C propulsion
Manual: Total assist
Power: Independent with
equipment
• Power recline and/or tilt W/C with head, chin,
or breath control
• Manual recliner W/C
• Vent tray
Standing/
Ambulation
Standing: Total assist
Ambulation: Not indicated
Communication
Total assist to independent,
depending on work station setup
and equipment availability
• Mouth stick, high-tech computer access,
environmental control unit
• Adaptive devices everywhere as indicated
Transportation
Total assist
• Attendant-operated van (e.g. lift, tie-downs) or
accessible public transportation
Homemaking
Total assist
Assist Required
• 24-hour attendant care to include
homemaking
• Able to instruct in all aspects of
care
Further innervation of diaphragm & paraspinal muscles
C4 Level
Expected Functional Outcomes
Equipment
Respiratory
May be able to breathe without a
ventilator
If not ventilator free then same equipment as for
C1-3
Bowel
Total assist
• Padded reclining shower/commode chair
(if roll-in shower available)
Bladder
Total assist
Bed Mobility
Total assist
• Full electric hospital bed with Trendelenburg
feature
• side rails
Transfers
Total assist
• Transfer board
• Power or mechanical lift with sling
Pressure relief
Total assist; may be independent
with equipment
• Power recline and/or tilt W/C
• W/C pressure-relief cushion
• Postural support and head control devices as
indicated
• Hand splints may be indicated
• Specialty bed or pressure-relief mattress may
be indicated
Eating
Total assist
Dressing
Total assist
Grooming
Total assist
Further innervation of diaphragm & paraspinal muscles
C4 Level
Expected Functional Outcomes
Equipment
Bathing
Total assist
• Handheld shower
• Shampoo tray
• Padded reclining shower/commode chair (if
roll-in shower available)
W/C propulsion
Manual: Total assist
Power: Independent
• Power recline and/or tilt W/C with head, chin,
or breath control
• Manual recliner W/C
• Vent tray
Standing/
Ambulation
Standing: Total assist
Ambulation: Not indicated
• Tilt table
• Hydraulic standing table
Communication
Total assist to independent,
depending on work station setup
and equipment availability
• Mouth stick, high-tech computer access,
environmental control unit
Transportation
Total assist
• Attendant-operated van (e.g. lift, tie-downs) or
accessible public transportation
Homemaking
Total assist
Assist Required
• 24-hour attendant care to include
homemaking
• Able to instruct in all aspects of
care
Biceps (elbow flexors), deltoids, rhomboids, partial innervation of
serratus anterior (shoulder flexion, extension, & abduction)
C5 Level
Expected Functional Outcomes
Equipment
Respiratory
May require assist to clear secretions
Bowel
Total assist
• Padded shower/commode chair or transfer
tub bench with commode cutout
Bladder
Total assist
• Adaptive devices may be indicated (electric
leg bag emptier)
Bed Mobility
Some assist
• Full electric hospital bed with Trendelenburg
feature
• side rails
Transfers
Total assist
• Transfer board
• Power or mechanical lift with sling
Pressure relief
Independent with equipment
• Power recline and/or tilt W/C
• W/C pressure-relief cushion
• Postural support and head control devices as
indicated
• Hand splints may be indicated
• Specialty bed or pressure-relief mattress may
be indicated
Eating
Assist for setup, then independent
with equipment
• Long opponens splint
• Adaptive devices as indicated
Dressing
Lower extremity: Total assist
Upper extremity: Some assist
• Long opponens splint
• Adaptive devices as indicated
Grooming
Some to total assist
• Long opponens splint
• Adaptive devices as indicated
Biceps (elbow flexors), deltoids, rhomboids, partial innervation of
serratus anterior (shoulder flexion, extension, & abduction)
C5 Level
Expected Functional Outcomes
Equipment
Bathing
Total assist
• Handheld shower
• Padded tub transfer bench or
shower/commode chair
W/C propulsion
Manual: Independent to some assist
indoors on noncarpet, level surface;
some to total assist outdoors
Power: Independent
• Power recline and/or tilt W/C with arm drive
control
• Manual lightweight rigid or folding W/C with
handrim projections
Standing/
Ambulation
Standing: Total assist
Ambulation: Not indicated
• Hydraulic standing frame
Communication
Independent to some assist after
setup and equipment availability
• Long opponens splint
• Adaptive devices as indicated for page
turning, writing, button pushing
Transportation
Independent with highly specialized
equipment; some assist with
accessible public transportation; total
assist for attendant-operated vehicle
• Highly specialized modified van with lift
Homemaking
Total assist
Assist Required
• Personal care: 10 hours/day
• Homecare: 6 hours/day
• Able to instruct in all aspects of care
Wrist extensors
C6 Level
Expected Functional Outcomes
Equipment
Respiratory
May require assist to clear
secretions
Bowel
Some to total assist
• Padded shower/commode chair or transfer
tub bench with commode cutout
• Adaptive devices as indicated
Bladder
Some to total assist with
equipment; may be independent
with leg bag emptying
• Adaptive devices may be indicated
Bed Mobility
Some assist
• Full electric hospital bed
• side rails
Transfers
Level: some assist to independent
Uneven: some to total assist
• Transfer board
• mechanical lift
Pressure relief
Independent with equipment
and/or adapted techniques
• Power recline and/or tilt W/C
• W/C pressure-relief cushion
• Postural support devices
• Pressure-relief mattress or overlay may be
indicated
Eating
Assist for setup (cutting), then
independent
• Adaptive devices as indicated (e.g. u-cuff,
tenodesis splint, adapted utensils, plate guard)
Dressing
Lower extremity: some to total
assist
Upper extremity: independent
• Adaptive devices as indicated (e.g. button
hook, loops on zippers, Velcro on shoes)
Grooming
Some assist to independent with
equipment
• Adaptive devices as indicated (e.g. u-cuff,
adapted handles)
Wrist extensors
C6 Level
Expected Functional Outcomes
Equipment
Bathing
Lower body: some to total assist
Upper body: independent
• Handheld shower
• Padded tub transfer bench or
shower/commode chair
• Adaptive devices as indicated
W/C propulsion
Manual: Independent indoors;
some to total assist outdoors
Power: Independent
• May require standard upright power or
recline
• Manual lightweight rigid or folding W/C with
modified rims
Standing/
Ambulation
Standing: Total assist
Ambulation: Not indicated
• Hydraulic standing frame
Communication
Independent
• Adaptive devices as indicated for page
turning, writing, button pushing
Transportation
Independent driving from W/C
• Modified van with lift and tie-downs
• Sensitized hand controls
Homemaking
Some assist with light meal prep;
total assist for other homemaking
• Adaptive devices as indicated
Assist Required
• Personal care: 6 hours/day
• Homecare: 4 hours/day
Triceps (elbow extensors), finger flexors
C7 – 8 Levels
Expected Functional Outcomes
Respiratory
May require assist to clear secretions
Bowel
Some to total assist
• Padded shower/commode chair or transfer
tub bench with commode cutout
• Adaptive devices as indicated
Bladder
Independent to some assist
• Adaptive devices may be indicated
Bed Mobility
Independent to some assist
• Full electric hospital bed or full to king
standard bed
Transfers
Level: independent
Uneven: independent to some assist
• May need transfer board
Pressure relief
Independent
• W/C pressure-relief cushion
• Postural support devices as indicated
• Pressure-relief mattress or overlay may be
indicated
Eating
Independent
• Adaptive devices as indicated
Dressing
Lower extremity: independent to
some assist
Upper extremity: independent
• Adaptive devices as indicated
Grooming
Independent
• Adaptive devices as indicated
Equipment
Triceps (elbow extensors), finger flexors
C7 – 8 Levels
Expected Functional Outcomes
Equipment
Bathing
Lower body: independent to some
assist
Upper body: independent
• Handheld shower
• Padded tub transfer bench or
shower/commode chair
• Adaptive devices as indicated
W/C propulsion
Manual: Independent indoors and
level outdoor terrain; some assist
uneven terrain
• Manual lightweight rigid or folding W/C with
modified rims
Standing/
Ambulation
Standing: Independent to some
assist
Ambulation: Not indicated
• Hydraulic or standard standing frame
Communication
Independent
• Adaptive devices as indicated
Transportation
Independent car if independent with
transfer and W/C loading/ unloading;
independent driving modified van
from captain’s seat
• Modified vehicle
Homemaking
Independent light meal prep and light
housecleaning; some to total assist
for complex meal prep and heavy
housekeeping
• Adaptive devices as indicated
Assist Required
• Homecare: 2 hours/day
• Personal care: 6 hours/day
T1 – 9 Levels
Expected Functional Outcomes
Equipment
Bowel
Independent
• Elevated padded toilet seat or tub bench with
commode cutout
• Adaptive devices as indicated
Bladder
Independent
Bed Mobility
Independent
• Full to king standard bed
Transfers
Independent
• May need transfer board
Pressure relief
Independent
• W/C pressure-relief cushion
• Postural support devices as indicated
• Pressure-relief mattress or overlay may be
indicated
Eating
Independent
Dressing
Independent
Grooming
Independent
Respiratory
T1 – 9 Levels
Expected Functional Outcomes
Equipment
Bathing
Independent
• Handheld shower
• Padded tub transfer bench or
shower/commode chair
W/C propulsion
Independent
• Manual lightweight rigid or folding W/C
Standing/
Ambulation
Standing: Independent
Ambulation: Typically not functional
• Standard standing frame
Communication
Independent
Transportation
Independent in car, including W/C
loading/unloading
• Hand controls
Homemaking
Independent complex meal prep and
light housecleaning; some to total
assist for heavy housekeeping
• Adaptive devices as indicated
Assist Required
• Personal care: 6 hours/day
• Homecare: 2 hours/day