Thursday, April 11, 2013

Spinal Cord Injury


Spinal Cord Injury
By Alyssa Flake and Kari Durrant
Winter 2013
RECM 470

Table of Contents
  1. Spinal Cord and Column
  2. Facts and Statistics
  3. Levels and Classification of Injury
  4. Functional Goals
  5. TR Implications
  6. Adaptive Technologies
  7. Resources
  8. Associations and Organizations
  9. Glossary










Spinal Cord & Column Information


The spinal column, more commonly called the backbone, is made up primarily of vertebrae, discs, and the spinal cord. Acting as a communication conduit for the brain, signals are transmitted and received through the spinal cord.
When an injury to the spinal cord occurs the flow of information from that point down is stopped. This break in instructions to the arms, legs, and other parts of the body will prevent the individual from moving, sometimes breathing, and obstructs or stops any sense of feeling or touch.


General Overview


Spinal Cord & Column
The spinal column is separated into 5 specific functional areas.
  • Cervical / C 1-7
  • Thoracic / T 1 - 12
  • Lumbar / L 1 - 5
  • Sacral
  • Coccyx

The spinal cord is a bundle of nerve cells and fibers wrapped together extending down from the brain stem to the lower back. The cord is protected by a kind of bone tunnel made up of vertebrae which are separated by membranes called discs. The brain sends electrical signals through the spinal cord, giving instructions to the legs, arms, and other areas of the body.


Vertebrae


There are 33 vertebrae that make up the bone structure of the spinal column, with the last four being fused together to make the tailbone.


Discs


Each vertebrae is separated by a soft bone substance, called a disc, which acts as a cushion and a seal at the same time.
Complete & Incomplete SCI
An SCI is categorized as either "complete" or "incomplete". A "complete" SCI means a total loss of function and sensation below the affected vertebrae, and an "incomplete" SCI means only partial loss of function or
sensation.


BONY ANATOMY


Cervical Spine
There are seven cervical bones or vertebrae. The cervical bones are designed to allow flexion, extension, bending, and turning of the head. They are smaller than the other vertebrae, which allows a greater amount of movement.
Each cervical vertebra consists of two parts, a body and a protective arch for the spinal cord called the neural arch. Fractures or injuries can occur to the body, lim pedicles, or processes. Each vertebra articulates with the one above it and the one below it.


Thoracic Spine


In the chest region the thoracic spine attaches to the ribs. There are 12 vertebrae in the thoracic region.
The spinal canal in the thoracic region is relatively smaller than the cervical or lumbar areas. This makes the thoracic spinal cord at greater risk if there is a fracture.
The motion that occurs in the thoracic spine is mostly rotation. The ribs prevent bending to the side. A small amount of movement occurs in bending forward and backward.


Lumbosacral Spine


The lumbar vertebrae are large, wide, and thick. There are five vertebrae in the lumbar spine. The lowest lumbar vertebra, L5, articulates with the sacrum. The sacrum attaches to the pelvis.
The main motions of the lumbar area are bending forward and extending backwards. Bending to the side also occurs.


NEUROANATOMY


Just like the spinal column is divided into cervical, thoracic, and lumbar regions, so is the spinal cord. Each portion of the spinal cord is divided into specific neurological segments.
The cervical spinal cord is divided into eight levels. Each level contributes to different functions in the neck and the arms. Sensations from the body are similarly transported from the skin and other areas of the body from the neck, shoulders, and arms up to the brain.
In the thoracic region the nerves of the spinal cord supply muscles of the chest that help in breathing and coughing. This region also contains nerves in the sympathetic nervous system.
The lumbosacral spinal cord and nerve supply legs, pelvis, and bowel and bladder. Sensations from the feet, legs, pelvis, and lower abdomen are transmitted through the lumbosacral nerves and spinal cord to higher segments and eventually the brain.


Nerve Pathways


There are many nerve pathways that transmit signals up and down the spinal cord. Some supply sensation from the skin and outer portions of the body. Others supply sensation from deeper structures such as the organs in the belly, the pelvis, or other areas. Other nerves transmit signals from the brain to the body. Still others work at the level of the spinal cord and act as "go betweens" in the signal transmission process.


The Motor Neuron


The upper motor neuron refers to injuries that are above the level of the anterior horn cell. This results in a spastic type of paralysis. Conversely, the lower motor neuron injury refers to an injury at or below the anterior horn cell that results in the flaccid type paralysis. The terms neurogenic bowel and neurogenic bladder are used to describe abnormal bowel and bladder function and can be classified as either an upper motor neuron or lower motor neuron type of problem. In general, those patients with an upper motor neuron paralysis will have an upper motor neuron bowel and bladder, and those with lower motor neuron injuries will have a lower motor neuron picture of the bowel and bladder. Adequate bowel and bladder management is critical for adequate reintegration of the patient/client into the community and hopefully into the work place.


Sensory Pathways


Feelings from the body such as hot, cold, pain, and touch, are transmitted to the skin and other parts of the body to the brain where sensations are "felt". These pathways are called the sensory pathways.
Once signals enter the spinal cord, they are sent up to the brain. Different types of sensation are sent in different pathways, called "tracts". The tracts that carry sensations of pain and temperature to the brain are in the middle part of the spinal cord. These tracts are called the "spinothalamic". Other tracts carry sensation of position and light touch. These nerve impulses are carried along the back part of the spinal cord in what are called "dorsal columns" of the spinal cord.


Autonomic Nerve Pathways


Another type of special nerves are the autonomic nerves. In spinal cord injuries, they are very important. The autonomic nerves are divided into two types: the sympathetic and parasympathetic nerves.
The autonomic nervous system influences the activities of involuntary (also known as smooth) muscles, the heart muscle, and glands that release certain hormones. It controls cardiovascular, digestive, and respiratory systems. These systems work in a generally "involuntary" fashion. The primary role of the autonomic nervous system is to maintain a stable internal environment within the body. The heart and blood vessels are controlled by the autonomic nervous system. The sympathetic nerves help to control blood pressure based on the physical demands placed on the body. It also helps to control heart rate. The sympathetic nerves, when stimulated, cause the heart to beat faster.


Sympathetic Nerves


The sympathetic nerves also cause constriction of the blood vessels throughout the body. When this happens, the amount of blood that is returned to the heart increases. These effects will increase blood pressure. Other effects include an increase in sweating and increased irritability or a sensation of anxiety.
When spinal cord injury is at or above the T6 level the sympathetic nerves below the injury become disconnected from the nerves above. They continue to operate automatically once the period of spinal shock is over. Anything that simulates the sympathetic nerves can cause them to become overactive. This over-activity of the sympathetic nerves is what is called autonomic dysreflexia.


Parasympathetic Nerves


The parasympathetic nerves act in an opposite manner to the sympathetic nerves. These nerves tend to dilate blood vessels and slow down the heart. The most important nerve that carries parasympathetic fibers is the vagus nerve. This nerve carries parasympathetic signals to the heart to decrease heart rate. Other nerves supply the blood vessels to the organs of the abdomen and skin.
The parasympathetic nerves arise from two areas. The fibers that supply the organs of the abdomen, heart, lungs, and skin above the waist begin at the level of the brain and very high spinal cord. The nerves that supply the reproductive organs, pelvis, and leg begin at the sacral level, or lowest part of the spinal cord. After a spinal cord injury, the parasympathetic nerves that begin at the brain continue to work, even during the phase of spinal shock. When dysreflexia occurs, the parasympathetic nerves attempt to control rapidly increasing blood pressure by slowing down the heart.


Spinal Cord Injury Facts & Statistics


Who Do Spinal Cord Injuries Affect in the United States?


  • 250,000 Americans are spinal cord injured.
  • 52% of spinal cord injured individuals are considered paraplegic and 47% quadriplegic.
  • Approximately 11,000 new injuries occur each year.
  • 82% are male.
  • 56% of injuries occur between the ages of 16 and 30.
  • The average age of spinal cord injured person is 31.
  • SCI injuries are most commonly caused by:
    • Vehicular accidents 37%
    • Violence 28%
    • Falls 21%
    • Sports-related 6%
    • Other 8%
  • The most rapidly increasing cause of injuries is due to violence; vehicular accident injuries are decreasing in number.
  • 89% of all SCI individuals are discharged from hospitals to a private home, 4.3% are discharged to nursing homes.
  • Only 52% of SCI individuals are covered by private health insurance at time of injury.




What Do Spinal Cord Injuries Really Cost?


  • Length of initial hospitalization following injury in acute care units: 15 days
  • Average stay in rehabilitation unit: 44 days
  • Initial hospitalization costs following injury: $140,000
  • Average first year expenses for a SCI injury (all groups): $198,000
  • First year expenses for paraplegics: $152,000
  • First year expenses for quadriplegics: $417,000
  • Average lifetime costs for paraplegics, age of injury 25: $428,000
  • Average lifetime costs for quadriplegics, age of injury 25: $1.35 million
  • Percentage of SCI individuals who are covered by private health insurance at time of injury 52% - Compare health insurance atprivatemedicalhealthinsurance.org.uk
  • Percentage of SCI individuals unemployed eight years after injury 63%. (Note: unemployment rate when this article was written was 4.7%)
Source: The University of Alabama National Spinal Cord Injury Statistical Center - March 2002
 


Spinal Cord Injury Statistical Information - NSCIA, 8/95


Although there is more information available about people who have a spinal cord injury than ever before, much of it is incomplete. Some of the statistical data is summarized below per 8/95.


Number of New Injuries Per Year


32 injuries per million population or 7800 injuries in the US each year
Most researchers feel that these numbers represent significant under- reporting. Injuries not recorded include cases where the patient instantaneously or soon after the injury, cases with little or no remaining neurological deficit, and people who have neurologic problems secondary to trauma, but are not classified as SCI. Researchers estimate that an additional 20 cases per million (4860 per year) die before reaching the hospital.
Total Number of People with SCI
  • 82% male, 18% female
  • Highest per capita rate of injury occurs between ages 16-30
  • Average age at injury - 33.4
  • Median age at injury - 26
  • Mode (most frequent) age at injury 19
  • Motor vehicle accidents are the leading cause of SCI (44%), followed by acts of violence (24%),falls (22%) and sports (8%), other (2%)
  • 2/3 of sports injuries are from diving
  • Falls overtake motor vehicles as leading cause after age 45
  • Acts of violence and sports cause less injuries as age increases
  • Acts of violence have overtaken falls as the second most common source of spinal cord injury
  • Marital status at injury:
    • Single 53%
    • Married 31%
    • Divorced 9%
    • Other 7%
  • 5 years post-injury:
    • 88% of single people with SCI were still single vs. 65% of the non-SCI population
    • 81% of married people with SCI were still married vs. 89% of the non-SCI population
  • Employment status among persons between 16 and 59 years of age at injury:
    • Employed 58.8%
    • Unemployed 41.2%
      (includes: students, retired, and homemakers)
  • Employed 8 years post-injury:
    • Paraplegic 34.4%
    • Quadriplegic 24.3%
People who return to work in the first year post-injury usually return to the same job for the same employer. People who return to work after the first year post-injury either worked for different employers or were students who found work.


How are spinal injuries caused?


Until the most recent figures were released by NSCIA in August, 1995, these were considered as the major causes of spinal cord injuries. See Answer to # 4 and Dr. Wise Youngís statistics in Section 2 for all the most recent demographics. One of the most surprising findings is that acts of violence have now overtaken falls as the second most common source of spinal cord injury,  as of the 1995 findings.
Previous To 1995:
  • Motor vehicles 48%
  • Falls 21%
  • Sports 14% (66% of which are caused in diving accidents)
  • Violence 15%
  • Other 2%




The Injury


Since 1988, 45% of all injuries have been complete, 55% incomplete. Complete injuries result in total loss of sensation and function below the injury level. Incomplete injuries result in partial loss. "Complete" does not necessarily mean the cord has been severed. Each of the above categories can occur in paraplegia and quadriplegia.
Except for the incomplete-Preserved motor (functional), no more than 0.9% fully recover, although all can improve from the initial diagnosis.
Overall, slightly more than 1/2 of all injuries result in quadriplegia. However, the proportion of quadriplegics increase markedly after age 45, comprising 2/3 of all injuries after age 60 and 87% of all injuries after age 75.
92% of all sports injuries result in quadriplegia.
Most people with neurologically complete lesions above C-3 die before receiving medical treatment. Those who survive are usually dependent on mechanical respirators to breathe.
50% of all cases have other injuries associated with the spinal cord injury.


Most Frequent Neurological Category


Quadriplegia, incomplete 31.2%
Paraplegia, complete 28.2%
Paraplegia, incomplete 23.1%
Quadriplegia, complete 17.5%


Hospitalization


(Important: This section applies only to individuals who were admitted to one of the hospitals designated as "Model" SCI centers by the National Institute of Disability and Rehabilitation Research.)
Over 37% of all cases admitted to the Spinal Cord Injury System sponsored by the NIDRR arrive within 24 hours of injury. The mean time between injury and admission is 6 days.
Only 10-15% of all people with injuries are admitted to the NIDRR SCI system. The remainder go to CARF facilities or to general hospitals in their local community.
It is now known that the length of stay and hospital charges for acute care and initial rehabilitation are higher for cases where admission to the SCI system is delayed beyond 24 hours. Average length of stay (1992):
Quadriplegics 95 days
Paraplegics 67 days
All 79 days
Average charges (1990 dollars) Note: Specific cases are considerably higher.
Quadriplegics $118,900
Paraplegics $ 85,100
All $ 99,553
Source of payment acute care:
Private Insurance 53%
Medicaid 25%
Self-pay 1%
Vocational Rehab 14%
Worker's Comp 12%
Medicare 5%
Other 2%
Ongoing medical care: (Many people have more than one source of payment.)
Private Insurance 43%
Medicare 25%
Self-pay 2%
Medicaid 31%
Worker's Compensation 11%
Vocational Rehab 16%


After the Hospital


Residence at discharge
Private Residence 92%
Nursing Home 4%
Other Hospital 2%
Group Home 2%
There is no apparent relationship between severity of injury and nursing home admission, indicating that admission is caused by other factors (i.e. family can't take care of person, medical complications, etc.) Nursing home admission is more common among elderly persons.
Each year 1/3 to 1/2 of all people with SCI are re-admitted to the hospital. There is no difference in the rate of re-admissions between persons with paraplegia and quadriplegia, but there is a difference between the rate for those with complete and incomplete injuries.
Survival


Overall, 85% of SCI patients who survive the first 24 hours are still alive 10 years later, compared with 98% of the non-SCI population given similar age and sex.


Causes of Death


The most common cause of death is respiratory ailment, whereas, in the past it was renal failure. An increasing number of people with SCI are dying of unrelated causes such as cancer or cardiovascular disease, similar to that of the general population. Mortality rates are significantly higher during the first year after injury than during subsequent years.
 http://www.sci-info-pages.com/facts.html




Spinal Cord Injury Levels & Classification

Wise Young, Ph.D., M.D.W. M. Keck Center for Collaborative Neuroscience
Rutgers University, Piscataway, NJ
When people are injured, they are often told that they have an injury at a given spinal cord level and are given a qualifier indicating the severity of injury, i.e. "complete" or "incomplete". They may also be told that they are classified according to the American Spinal Injury Association (ASIA) Classification, as a ASIA A, B, C, or D. They may also be told that they have a bony fracture or involvement of one or more spinal segments or vertebral levels. What most people do not know is doctors are frequently confused about the definition of spinal cord injury levels, the definition of complete and incomplete injury, and the classification of spinal cord injury. In the early 1990's, when I co-chaired the committee that helped define the currently accepted ASIA Classification, there was no single definition of level, completeness of injury, or classification. In this article, I will briefly address the issue of spinal cord injury levels, the definition of "complete" spinal cord injury, and the ASIA Classification approach towards spinal cord injury.

Vertebral vs. Cord Segmental Levels

The spinal cord is situated within the spine. The spine consists of a series of vertebral segments. The spinal cord itself has "neurological" segmental levels which are defined by the spinal roots that enter and exist the spinal column between each of the vertebral segments. As shown in the figure the spinal cord segmental levels do not necessarily correspond to the bony segments. The vertebral levels are indicated on the left side while the cord segmental levels are listed for the cervical (red), thoracic (green), lumbar (blue), and sacral (yellow) cord.


Vertebral segments. There are 7 cervical (neck), 12 thoracic (chest), 5 lumbar (back), and 5 sacral (tail) vertebrae. The thoracic vertebrae are defined by The spinal cord segments are not necessarily situated at the same vertebral levels. For example, while the C1 cord is located at the C1 vertebra, the C8 cord is situated at the C7 vertebra. While the T1 cord is situated at the T1 vertebra, the T12 cord is situated at the T8 vertebra. The lumbar cord is situated between T9 and T11 vertebrae. The sacral cord is situated between the T12 to L2 vertebrae.


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


The Cervical Cord. The first and second cervical segments are special because this is what holds the head. The lower back of the head is called the Occiput. The first cervical vertebra, upon which the head is perched is sometimes called Atlas, after the Greek mythological figure who held up earth. The second cervical vertebra is sometimes called the Axis, upon which Atlas pivots. The interface between the occiput and the atlas is therefore called the atlanto-occiput junction. The interface between the first and second vertebra is called the atlanto-axis junction. The C3 cord contains the phrenic nucleus. The cervical cord innervates the deltoids (C4), biceps (C4-5), wrist extensors (C6), triceps (C7), wrist extensors (C8), and hand muscles (C8-T1).


The Thoracic Cord. The thoracic vertebral segments are defined by those that have a rib. These vertebral segments are also very special because they form the back wall of the pulmonary cavity and the ribs. The spinal roots form the intercostal (between the ribs) nerves that run on the bottom side of the ribs and these nerves control the intercostal muscles and associated dermatomes.


The Lumbosacral Cord. The lumbosacral vertebra form the remainder of the segments below the vertebrae of the thorax. The lumbosacral spinal cord, however, starts at about T9 and continues only to L2. It contains most of the segments that innervate the hip and legs, as well as the buttocks and anal regions.


The Cauda Equina. In human, the spinal cord ends at L2 vertebral level. The tip of the spinal cord is called the conus. Below the conus, there is a spray of spinal roots that is frequently called the cauda equina or horse's tail. Injuries to T12 and L1 vertebra damage the lumbar cord. Injuries to L2 frequently damage the conus. Injuries below L2 usually involve the cauda equina and represent injuries to spinal roots rather than the spinal cord proper.
In summary, spinal vertebral and spinal cord segmental levels are not necessarily the same. In the upper spinal cord, the first two cervical cord segments roughly match the first two cervical vertebral levels. However, the C3 through 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.

Sensory versus Motor Levels



A dermatome is a patch of skin that is innervated by a given spinal cord level. Figure 2 is taken from the ASIA classification manual, obtainable from the ASIA web site. Each dermatome has a specific point recommended for testing and shown in the figure. After injury, the dermatomes can expand or contract, depending on plasticity of the spinal cord.


C2 to C4. The C2 dermatome covers the occiput and the top part of the neck. C3 covers the lower part of the neck to the clavicle (the horizontal bone that goes to the shoulder. C4 covers the area just below the clavicle.


C5 to T1. These dermatomes are all situated in the arms. C5 covers the lateral arm at and above the elbow. C6 covers the forearm and the radial (thumb) side of the hand. C7 is the middle finger, C8 is the lateral aspects of the hand, and T1 covers the medial side of the forearm.


T2 to T12. The thoracic covers the axillary and chest region. T3 to T12 covers the chest and back to the hip girdle. The nipples are situated in the middle of T4. T10 is situated at the umbilicus. T12 ends just above the hip girdle.


L1 to L5. The cutaneous dermatome representating the hip girdle and groin area is innervated by L1 spinal cord. L2 and 3 cover the front part of the thighs. L4 and L5 cover medial and lateral aspects of the lower leg.


S1 to S5. S1 covers the heel and the middle back of the leg. S2 covers the back of the thighs. S3 cover the medial side of the buttocks and S4-5 covers the perineal region. S5 is of course the lowest dermatome and
represents the skin immediately at and adjacent to the anus.




Ten muscle groups represent the motor innervation by the cervical and lumbosacral spinal cord. The ASIA system does not include the abdominal muscles (i.e. T10-11) because the thoracic levels are much easier to determine from sensory levels. It also excludes certain muscles (e.g. hamstrings) because the segmental levels that innervate them are already represented by other muscles.


Arm and hand muscles. C5 represents the elbow flexors (biceps), C6 the wrist extensors, C7 the elbow extensors (triceps), C8 the finger flexors, and T1 the little finger abductor (outward movement of the pinky finger).


Leg and foot muscles. The leg muscles represent the lumbar segments, i.e. L2 are the hip flexors (psoas), L3 the knee extensors (quadriceps), L4 the ankle dorsiflexors (anterior tibialis), L5 the long toe extensors (hallucis longus), S1 the ankle plantar flexors (gastrocnemius).


The anal sphincter is innervated by the S4-5 cord and represents the end of the spinal cord. The anal sphincter is a critical part of the spinal cord injury examination. If the person has any voluntary anal contraction, regardless of any other finding, that person is by definition a motor incomplete injury.
It is important to note that the muscle groups specified in the ASIA classifications represent a gross over simplication of the situation. Almost every muscle received innervation from two or more segments.


In summary, the spinal cord segment serve specific motor and sensory regions of the body. The sensory regions are called dermatomes with each segment of the spinal cord innervating a particularly area of skin. The distribution of these dermatomes are relatively straightforward except on the limbs. In the arms, the cervical dermatomes C5 to T1 are arrayed from proximal radial (C5) to distal (C6-8) and proximal medial (T1). In the legs, the L1 to L5 dermatomes cover the front of the leg from proximal to distal while the sacral dermatomes cover the back of the leg.
 

Spinal Cord Injury Levels



Differences between neurological and rehabilitation definitions of spinal cord injury levels. 


Doctors use two different definitions for spinal cord injury levels. Given the same neurological examination and findings, neurologists and physiatrists may not assign the same spinal cord injury level. In general, neurologists define the level of injury as the first spinal segmental level that shows abnormal neurological loss. Thus, for example, if a person has loss of biceps, the motor level of the injury is often said to be C4. In contrast, physiatrists or rehabilitation doctors tend to define level of injury as the lowest spinal segmental level that is normal. Thus, if a patient has normal C3 sensations and absent C4 sensation, a physiatrist would say the sensory level is C3 whereas a neurologist or neurosurgeon would call it a C4 injury level. Most orthopedic surgeons tend to refer to the bony level of injury as the level of injury.


EXAMPLE. The most common cervical spinal injuries involve C4 or C5. Take, for example, a person who has had a burst fracture of the C5 vertebral body. A burst fracture usually indicates severe trauma to vertebral body that typically injures the C6 spinal cord situated at the C5 vertebrae and also the C4 spinal roots that exits the spinal column between the C4 and C5 vertebra. Such an injury should cause a loss of sensations in C4 dermatome and weak deltoids (C4) due to injury to the C4 roots. Due to edema (swelling of the spinal cord), the biceps (C5) may be initially weak but should recover. The wrist extensors (C6), however, should remain weak and sensation at and below C6 should be severely compromised. A neurosurgeon or neurologist examining the above patient usually would conclude that there is a burst fracture at C5 from the x-rays, an initial sensory level at C4 (the first abnormal sensory dermatome) and the partial loss of deltoids and biceps would imply a motor level at C4 (the highest abnormal muscle level). Over time, as the patient recovers the C4 roots and the C5 spinal cord, both the sensory level and motor level should end up at C6. Such recovery is often attributed to "root" recovery. On the other hand, a physiatrist would conclude that the patient initially has a C3 sensory level, a C4 motor level, and a C5 vertebral injury level. If the patient recovers the C4 root and the C5 cord, the physiatrist would conclude that both the sensory and motor levels are C5.


Discrepant lower thoracic vertebral and cord levels. The spinal vertebral and cord segmental levels become increasingly discrepant further down the spinal column. For example, a T8 vertebral injury will result in a T12 spinal cord or neurological level. A T11 vertebral injury, in fact, will result in a L5 lumbar spinal cord level. Most patients and even many doctors do not understand how discrepant the vertebral and spinal cord levels can get in the lower spinal cord.


EXAMPLE. The most common thoracic spinal cord injury involves T11 and T12. A patient with a T11 vertebral injury may have or recover sensations in the L1 through L4 dermatomes which include the front of the leg down to the mid-shin level. In addition, such a patient should recover hip extensors, knee extensors, and even ankle dorsiflexion. However, the sacral functions, including bowel and bladder and many of the flexor functions of the leg may be absent or weak. As in the case of cervical and thoracic spinal cord injury, it is important to assess both sensory and motor function.


Conus and Cauda Equina Injuries. Injuries to the spinal column at L2 or lower will damage the tip of the spinal cord, called the conus, or the spray of spinal roots that are descending to the appropriate spinal vertebral levels to exit the spinal canal or the caudal equina. Please note that the spinal roots for L2 through S5 all descend in the cauda equina and injury to these roots would disrupt sensory and motor fibers from these segments. Strictly speaking, the spinal roots are part of the peripheral nervous system as opposed to the spinal cord. Peripheral nerves are supposed to be able to regenerate to some extent. However, the spinal roots are different from peripheral nerves in two respects. First, the neurons from which sensory axons emanate are situated in the dorsal root ganglia (DRG) which are located just outside the spinal column. One branch of the DRG goes into the spinal cord (called the central branch) and the other is the peripheral branch.
Thus, a spinal root injury is damaging the central branch of the sensory nerve whereas peripheral nerve injury usually damages the peripheral branch. The sensory axon must grow back into the spinal cord in order to restore function and they generally will not do so because of axonal growth inhibitors in the spinal cord and particular at the so-called PNS-CNS junction at the dorsal root entry zone. Second, the cauda equina contains the ventral roots of the spinal cord, through which the motor axons of the spinal cord pass to innervate muscles. If the injury to the ventral root is close to the motoneurons that sent the axons, the injury may damage the motoneuron itself. Both of these factors significantly reduce the likelihood of neurological recovery in a cauda equina injury compared to a peripheral nerve injury.
 

Complete versus Incomplete Injury



Most clinicians commonly describe injuries as "complete" or "incomplete".
Traditionally, "complete" spinal cord injury means having no voluntary motor or conscious sensory function below the injury site. However, this definition is often difficult to apply. The following three example illustrate the weaknesses and ambiguity of the traditional definition. The ASIA committee considered these questions when it formulated the classification system for spinal cord injury in 1992.
  • Zone of partial preservation. Some people have some function for several segments below the injury site but below which no motor and sensory function was present. This is in fact rather common. Many people have zones of partial preservation. Is such a person "complete" or "incomplete", and at what level?
  • Lateral preservation. A person may have partial preservation of function on one side but not the other or at a different level. For example, if a person has a C4 level on one side and a T1 level on the other side, is the person complete and at what level?
  • Recovery of function. A person may initially have no function below the injury level but recovers substantial motor or sensory function below the injury site. Was that person a "complete" spinal cord injury and became "complete"? This is not a trivial question because if one has a clinical trial that stipulates "complete" spinal cord injuries, a time must be stipulated for when the status was determined.
Most clinicians would regard a person as complete if the person has any level below which no function is present. The ASIA Committee decided to take this criterion to its logical limit, i.e. if the person has any spinal level below which there is no neurological function, that person would be classified as a "complete" injury. This translates into a simple definition of "complete" spinal cord injury: a person is a "complete" if they do not have motor and sensory function in the anal and perineal region representing the lowest sacral
cord (S4-S5).


The decision to make the absence and presence of function at S4-5 the definition for "complete" injury not only resolved the problem of the zone of partial preservation but lateral preservation of function but it also resolved the issue of recovery of function. As it turns out, very few patients who have loss of S4/5 function recovered such function spontaneously. As shown in figure 3 below, while this simplifies the criterion for assessing whether an injury is "complete", the ASIA classification committee decided that both motor and sensory levels should be expressed on each side separately, as well as the zone of partial preservation.
In the end, the whole issue of "complete" versus "incomplete" injury may be a moot issue. The absence of motor and sensory function below the injury site does not necessarily mean that there are no axons that cross the injury site. Many clinicians equate a "complete" spinal cord injury with the lack of axons crossing the injury site. However, much animal and clinical data suggest that an animal or person with no function below the injury site can recover some function when the spinal cord is reperfused (in the case of an arteriovenous malformation causing ischemia to the cord), decompressed (in the case of a spinal cord that is chronically compressed), or treated with a drug such as 4-aminopyridine. The labeling of a person as being "complete" or "incomplete", in my opinion, should not be used to deny a person hope or therapy.

Classification of Spinal Cord Injury Severity

Clinicians have long used a clinical scale to grade severity of neurological loss. First devised at Stokes Manville before World War II and popularized by Frankel in the 1970's, the original scoring approach segregated patients into five categories, i.e. no function (A), sensory only (B), some sensory and motor preservation (C), useful motor function (D), and normal (E).




The ASIA Impairment Scale is follows the Frankel scale but differs from the older scale in several important respects. First, instead of no function below the injury level, ASIA A is defined as a person with no motor or sensory function preserved in the sacral segments S4-S5. This definition is clear and unambiguous. ASIA B is essentially identical to Frankel B but adds the requirement of preserved sacral S4-S5 function. It should be noted that ASIA A and B classification depend entirely on a single observation, i.e. the preservation of motor and sensory function of S4-5.
The ASIA scale also added quantitive criteria for C and D. The original Frankel scale asked clinicians to evaluate the usefulness of lower limb function. This not only introduced a subjective element to the scale but ignored arm and hand function in patients with cervical spinal cord injury. To get around this problem, ASIA stipulated that a patient would be an ASIA C if more than half of the muscles evaluated had a grade of less than 3/5. If not, the person was assigned to ASIA D.
ASIA E is of interest because it implies that somebody can have spinal cord injury without having any neurological deficits at least detectable on a neurological examination of this type. Also, the ASIA motor and sensory scoring may not be sensitive to subtle weakness, presence of spasticity, pain, and certain forms of dyesthesia that could be a result of spinal cord injury. Note that such a person would be categorized as an ASIA E.
These changes in the ASIA scale significantly improved the reliability and consistency of the classification. Although it was more logical, the new definition of "complete" injury does not necessarily mean that it better reflects injury severity. For example, is there any situation where a person could be an ASIA B and better off the ASIA C or even ASIA D?
The new ASIA A categorization turns out to be more predictive of prognosis than the previous definition where the presence of function several segments below the injury site but the absence of function below a given level could be interpreted as an "incomplete" spinal cord injury.
The ASIA committee also classified incomplete spinal cord injuries into five types. A central cord syndrome is associated with greater loss of upper limb function compared to the lower limbs. The Brown-Sequard syndrome results from a hemisection lesion of the spinal cord. Anterior cord syndrome occurs when the injury affects the anterior spinal tracts, including the vestibulospnal tract. Conus medullaris and cauda equina syndromes occur with damage to the conus or spinal roots of the cord.

Conclusion

Much confusion surrounds the terminology associated with spinal cord injury levels, severity, and classification. The American Spinal Injury Association tried to sort some of these issues and standardize the language that is used to describe spinal cord injury. The ASIA Spinal Cord Injury Classification approach has now been adopted by almost every major organization associated with spinal cord injury. This has resulted in more consistent terminology being used to /describe the findings in spinal cord injury around the world.
 


Sci-info-pages.com/levels.html


Functional Goals

Level

Abilities

Functional Goals
C1-C3
 Limited movement of head and neck
 Breathing: Depends on a ventilator for breathing.
Communication: Talking is sometimes difficult, very limited or impossible. If ability to talk is limited, communication can be accomplished independently with a mouth stick and assistive technologies like a computer for speech or typing. Effective verbal communication allows the individual with SCI to direct caregivers in the person's daily activities, like bathing, dressing, personal hygiene, transferring as well as bladder and bowel management.
Daily tasks: Assistive technology allows for independence in tasks such as turning pages, using a telephone and operating lights and appliances.
Mobility: Can operate an electric wheelchair by using a head control, mouth stick, or chin control. A power tilt wheelchair also for independent pressure relief.


C3-C4
 Usually has head and neck control. Individuals at C4 level may shrug their shoulders.
 Breathing: May initially require a ventilator for breathing, usually adjust to breathing full-time without ventilator assistance.
Communication: Normal.
Daily tasks: With specialized equipment, some may have limited independence in feeding and independently operate an adjustable bed with an adapted controller.


C5
 Typically has head and neck control, can shrug shoulder and has shoulder control. Can bend his/her elbows and turn palms face up.
 Daily tasks: Independence with eating, drinking, face washing, brushing of teeth, face shaving and hair care after assistance in setting up specialized equipment. 
Health care: Can manage their own health care by doing self-assist coughs and pressure reliefs by leaning forward or side -to-side.
Mobility: May have strength to push a manual wheelchair for short distances over smooth surfaces. A power wheelchair with hand controls is typically used for daily activities. Driving may be possible after being evaluated by a qualified professional to determine special equipment needs.


C6
 Has movement in head, neck, shoulders, arms and wrists. Can shrug shoulders, bend elbows, turn palms up and down and extend wrists.
 Daily tasks: With help of some specialized equipment, can perform with greater ease and independence, daily tasks of feeding, bathing, grooming, personal hygiene and dressing. May independently perform light housekeeping duties.
Health care: Can independently do pressure reliefs, skin checks and turn in bed.
Mobility: Some individuals can independently do transfers but often require a sliding board. Can use a manual wheelchair for daily activities but may use power wheelchair for greater ease of independence.


C7
 Has similar movement as an individual with C6, with added ability to straighten his/her elbows.
 Daily tasks: Able to perform household duties. Need fewer adaptive aids in independent living.
Health care: Able to do wheelchair pushups for pressure reliefs.
Mobility: Daily use of manual wheelchair. Can transfer with greater ease.


C8-T1
 Has added strength and precision of fingers that result in limited or natural hand function.
 Daily tasks: Can live independently without assistive devices in feeding, bathing, grooming, oral and facial hygiene, dressing, bladder management and bowel management.
Mobility: Uses manual wheelchair. Can transfer independently.


T2-T6
 Has normal motor function in head, neck, shoulders, arms, hands and fingers. Has increased use of rib and chest muscles, or trunk control.
 Daily tasks: Should be totally independent with all activities.
Mobility: A few individuals are capable of limited walking with extensive bracing. This requires extremely high energy and puts stress on the upper body, offering no functional advantage. Can lead to damage of upper joints.


T7-T12
 Has added motor function from increased abdominal control.
 Daily tasks: Able to perform unsupported seated activities.
Mobility: Same as above.
Health care: Has improved cough effectiveness.


L1-L5
 Has additional return of motor movement in the hips and knees.
 Mobility: Walking can be a viable function, with the help of specialized leg and ankle braces. Lower levels walk with greater ease with the help of assistive devices.


S1-S5
 Depending on level of injury, there are various degrees of return of voluntary bladder, bowel and sexual functions.
 Mobility: Increased ability to walk with fewer or no supportive devices.










TR Implications


Stress reduction - Reducing  stress can improve physical and mental well-being.
Overall well-being - People with spinal cord injuries who participate in active recreational activities have fewer SCI-relatedhealth problems,  such as skin breakdown.
 
Social contacts 
-Participation  in community based and group activities can help a person with a spinal cord injuryovercome feelings of social isolation and self-consciousness.
 
Increased endurance 
-Participation  in active recreational activities increase your cardiovascular endurance, which cangive you more energy for returning to work or school.
 
Skill development 
-Participation in recreational activities can enhance skills, such as fine motor use and sitting balance, which are used in other areas of life, such as dressing.
 
Increase confidence and self-esteem  Independence in recreational activities can increase independence in other activities.

interpersonal skills Communication skills, such as assertiveness, can be practiced in the non-threatening environment ofrecreational activities.

Community reintegration Independence in mobility and social interaction, which can be achieved through recreationparticipation,  leads to increased self confidence and self reliance








Adaptive Technologies




Assistive Technology




Resources for SCI


Hospitals and Rehabilitation Centers
Support and Financial Assistance
State Resources
Medical, Rehabilitation and Nurses Aids
















Spinal Cord Injury Associations & Organizations (USA)



American Spinal Injury Association (ASIA)
Group of medical and other professionals engaged in treatment of spinal cord injury: to promote and establish standards for health care, education, to foster research and to facilitate communication between members.


Canadian & American Spinal Research Organization
An alliance of the CSRO and ASRO to help us maximize research and the fund raising efforts. Dedicated to the improvement of the physical quality of life for persons with a spinal cord injury through targeted medical and scientific research.


Center for Paralysis Research
The Center for Paralysis Research at Purdue University was founded to both develop and test promising methods of treatment for spinal cord injuries.


Christopher & Dana Reeve Foundation
A merger of the American Paralysis Association and the Christopher Reeve Foundation. Supports research to develop effective treatments and a cure for paralysis caused by spinal cord injury. Includes the Paralysis Resouce Center which provides a comprehensive, national source of information for people living with paralysis and their caregivers to promote health, foster involvement in the community, and improve quality of life.


Darrell Gwynn Foundation
Exists to prevent, provide for and ultimately cure spinal cord injuries and other debilitating illnesses. To expedite specific cures, the Foundation assists in the funding of targeted research. Also helps improve the quality of life for those already afflicted with injury or illness, by providing necessary equipment or special services.


Facing Disability
A web resource with more than 1,000 videos drawn from interviews of people with spinal cord injuries, their families, caregivers and experts.


Foundation for Spinal Cord Injury Prevention, Care & Cure
FSCIPCC is a non-profit educational group dedicated to the prevention, care and cure of spinal cord injuries through public awareness, education and funding research.


International Campaign for Cure of Spinal Injury
An affiliation of organizations working to fund research into cures for paralysis caused by spinal cord injury. This site has been created as an information resource for interested individuals, organizations and governments who wish to understand more about, and perhaps, contribute to spinal cord injury research.


Life Rolls On
A subsidiary of the Christopher & Dana Reeve Foundation, dedicated to improving the quality of life for young people affected by spinal cord injury, and utilizes action sports as a platform to inspire infinite possibilities despite paralysis.


Miami Project to Cure Paralysis
University of Miami School of Medicine, is the world's largest, most comprehensive research center dedicated to finding more effective treatments and, ultimately, a cure for paralysis that results from spinal cord injury.


Mike Utley Foundation
Committed to providing financial support of selected research, rehabilitation and education programs on spinal cord injuries. The Foundation seeks financial assistance through special events, fund-raising, and corporate and individual support throughout the United States and Canada.


Morton Cure Paralysis Fund
Organization dedicated to finding a cure for spinal cord injuries by raising money for spinal cord injury research. In its brief history, it has raised over $1 million despite being in all-volunteer organization. Because of that efficiency, nearly 100% of every dollar donated goes directly to research. The MCPFuses a peer review process of experts to allocate its funds to the projects that offer the most potential for moving science forward.


National Spinal Cord Injury Association
Mission is to enable people with SCI to make choices and take actions to achieve their highest level of independence and personal fulfillment. Includes current articles/news, injury information, chat, message boards, a quarterly publication and other areas.


Paralyzed Veterans of America (PVA)
This site is a resource center for veterans and for all American with a spinal cord injury or disease, as well as their families and the professional communities who serve them.


Rehabilitation Research Center (RRC)
Involved in research activities to enhance the lives of those affected by SCI and TBI. Part of the Santa Clara Valley Medical Center.


Roman Reed Foundation
Provides support and funding for the research in the field of spinal cord injury and regenerative medicine — being conducted by leading universities, scientists and institutions — in the quest for a cure for paralysis.


Sam Schmidt Paralysis Foundation
Helps individuals overcome spinal cord injuries and other neurological disorders by funding scientific research, medical treatment, rehabilitation and technological advances.


Spinal Cord and Brain Injury Research Center
Located at the University of Kentucky College of Medicine,SCoBIRC was established in 1999 to promote both individual and collaborative studies on injuries to the spinal cord and brain that result in paralysis or other loss of neurologic function.


Spinal Cord Injury Information Network
Provides news and events, research projects, general information and statistics.


Spinal Cord Injury Network International (SCINI)
SCINI is a non-profit organization dedicated to facilitating access to quality health care by providing information and referral services to spinal-cord-injured individuals and their families.


Spinal Cord Society (SCS)
An international organization for cure research and treatment of spinal cord injury paralysis and related problems. Site includes headlines from the SCS newsletter on cure research, current SCS research projects, and other information on SCS. 100% of its research funding goes for research!


United Spinal Association
Formerly the Eastern Paralyzed Veterans Association, a nonprofit that provides information and services to individuals with spinal cord injury and disease regarding benefits, disability rights advocacy, wheelchairs and barrier-free design.


W. M. Keck Center for Collaborative Neuroscience
The Center is situated at Rutgers, the State University of New Jersey. The SCI Project encompasses the research program devoted to care and cure of spinal cord injury. This site describes the people, the research programs, and the mission of the Center. Also provides support and information for the community, including the forum.




Spinal Cord Injury Glossary

Abdominal Binder - Wide elastic binder use to help prevent a drop in blood pressure or used for cosmetic purposes to hold in abdomen. A rigid (non-elastic) binder is used to help empty the bladder in some patients.


Aces - Elastic bandage used to wrap extremities to help support and prevent blood pressure from lowering.


Acute rehabilitation program - Primary emphasis on the early rehabilitation phase which usually begins as soon as a person is medically stable. The program is designed to be comprehensive and based in a medical facility with a typical length of stay of 2-3 months. Treatment is provided by and identifiable team in a designated unit.


Adipose tissue - Fatty tissue.


ADL - Activities of daily living: eating, dressing, grooming, shaving, etc. Nurses, occupational and physical therapists are the main coaches for ADL, which is sometimes called DLS or daily living skills.


Afferent - Sensory pathway proceeding toward the central nervous system from the peripheral receptor organs.


Ambulation - "Walking" with braces and/or crutches.


Ankylosis - Fixation of a joint leading to immobility, due to ossification or bony deposits of calcium at joints.


Anterior - The front of anything. Before or toward the front.


Anterior Cord Syndrome -An incomplete spinal injury in which all functions are absent below the level of injury except proprioception and sensation.


Anterior Spinal Artery Syndrome - (also known as Anterior Cord Syndrome) Anterior spinal artery syndrome refers to the anterior spinal artery that originates from the vertebral arteries and basal artery at the base of the brain and supplies the anterior two-thirds of the spinal cord to the upper thoracic (chest) region. The lesion produces variable loss of motor function and of sensitivity to pinprick and temperature, while preserving proprioception (position sense).


Anterio-lateral - To the front and to the side.


Antero-posterior - To the front and to the back.


Antibody - A protein, carried in the blood, produced by the immune to system which will attack germs, viruses, and other invading agents.


Anticholinergic - A drug often prescribed for those with indwelling catheters to reduce spasms of smooth muscle, including the bladder. Anticholinergics block certain receptors (acetylcholine), resulting in inhibition of certain nerve impulses (parasympathetic). Brand names include Daricon, ProBanthine, Urispas, Ditropan, and Cystospaz. Side effects may include constipation, nausea, dry mouth, and blurred vision. Caution: combined with alcohol, anticholinergics can cause extreme drowsiness.


Antidepressant - A drug prescribed to treat depression; standard tricyclic antidepressants include Tofranil, Imvate, Elavil, Norpramin, and Adapin.


Aphasia - The change, or loss, in language function due to an injury.


Apraxia - The inability to produce voluntary speech due to a deficit in motor (muscle) programming caused by brain damage.


Arachnoid Membrane - The middle of three membranes protecting the brain and spinal cord.


Arachnoiditis - Inflammation and scarring of the membranes covering the spinal cord.
ASIA Score - A measure of function after spinal cord injury, used by physicians. "A" means complete injury; "E" means full recovery.


Astrocyte - Star-shaped glial cells which provide the necessary chemical and physical environment for nerve regeneration.


Ataxia - Failure or irregularity of muscle coordination.


Atelectasis - Loss of breathing function characterized by collapsed lung tissue.


Atrophy - A wasting away or decrease in size of a cell, tissue, organ, or part of the body due to lack of nourishment.


Augmentative and Alternative Communication (AAC) - Forms of communication that supplement or enhance speech or writing, including electronic devices, picture boards, and sign language.


Autoimmune Response - The body produces a response against itself.


Autonomic Dysreflexia (Hyperreflexia) - A syndrome attributed to interruption of spinal cord sympathetic pathways. It is a condition that can occur in anyone who has a spinal cord injury at or above the T6 level. It is related to disconnections between the body below the injury and the control mechanisms for blood pressure and heart function. It causes the blood pressure to rise to potentially dangerous levels.


Autonomic Nervous System - The part of the nervous system that controls involuntary activities, including heart muscle, glands, and smooth muscle tissue. The autonomic nervous system is subdivided into the sympathetic and parasympathetic systems.


Axon - The nerve fiber that carries an impulse from the nerve cell to a target, and also carries materials from the nerve terminals back to the nerve cell. A long, slender part of a neuron that carries the electrochemical signal to another neuron. It's the main or core nerve fiber which generally conducts impulses away from the cell body.


Bacterial infection - Infection by minute, one-celled organisms which multiply by dividing in one or more directions.


Balkan Frame - A rectangular frame which may be placed over a hospital bed to position or increase mobility. Loops or a trapeze are often hung from the Balkan frame to assist a patient in bed activities and wheelchair transfers to and from the bed.


Bilateral - Refers to using both sides of the body or extremities on both sides.


Bilateral sensory stimulation - Stimulation of both sides of the body simultaneously, using touch, hearing, or vision, in order to determine whether an individual imperceives the stimulus on one side or the other.


Bilateral transfer - Facilitation of performance of a task by one hand as a result of having practiced the task with the other hand.


Biofeedback - A process that provides sight or sound information about functions of the body, including blood pressure, muscle tension, etc. The use of sensory feedback to help provide some self-control over autonomic functions, such as blood pressure.


Biotechnology - In the most general terms, biotechnology describes guiding natural occurrences to develop useful products. More specifically, it involves using living organism to make products and solve problems.


Bladder Training - Method by which the bladder is trained to empty (micturition) without the use of an indwelling catheter. Involves drinking measured amounts of fluid, and allowing the bladder to fill and empty at timed intervals. See intermittent catheterization.


Body Jacket (TLSO) - A support made of plastic that fits over the chest, abdomen and upper pelvis, used to support an unstable or recently fused spine.
Bowel program - The establishment of a "habit program" or a specific time to empty the bowel - also known as a "dil" - so that regularity can be achieved.


Bradycardia - Slow pulse (< 60 beats per minute)


Brain stem - Composed of midbrain, pons and medulla.


Brown-Sequard Syndrome - An incomplete spinal cord injury where half of the cord has been damaged. The Brown-Sequard syndrome is caused by a functional section of half of the spinal cord. This results in motor loss on the same side as the lesion and sensory loss on the opposite side. This syndrome is very often associated with fairly normal bowel and bladder function and does not prevent the person from being able to walk, although some functional bracing or ambulatory device such as a cane or crutch may be necessary.


Calculi - Stones that may form in either kidney or bladder.


Carpal Tunnel Syndrome - A painful disorder in the hand caused by inflammation of the median nerve in the wrist bone.


Catheter - A flexible rubber or plastic tube for withdrawing or introducing fluids into a cavity of the body, usually the bladder.


CT Scan - Computerized axial Tomography is a cross-sectional X-ray enhancement technique that greatly benefits diagnosis with high-resolution video images.


Cauda Equina - The collection of spinal roots descending from the lower part of the spinal cord.


Cauda Equina Syndrome - Injury to the nerves still within the spinal cord as they form a "horse's tail" to exit the lumbar and spinal regions. This usually occurs with fractures below the L2 level and results in flaccid-type paralysis. The type of bladder and bowel impairment that results from such an injury depends on the level of the injury and can be problematic, particularly for women, who may have difficulty with urinary drainage and incontinence.


Central Cord Syndrome - A lesion, occurring almost exclusively in the cervical region, that produces sacral sensory sparing and greater weakness in the upper limbs than in the lower limbs. A central cord syndrome indicates there is an injury to the central structures of the spinal cord. This is most commonly seen in older patients with cervical arthritis and may occur in the absence of spinal fracture. 


Central Nervous System (CNS) - The CNS includes the brain and spinal cord.


Cerebrospinal Fluid (CSF) - A colorless solution similar to plasma protecting the brain and spinal cord from shock. A lumbar puncture (spinal tap) is used to draw CSF.


Cervical - The upper spine (neck) area of the vertebral column. Cervical injuries often result in quadriplegia (tetraplegia).


Collateral sprouting - Intact axons located near damaged areas may sprout to reestablish connections with, and in place of damaged areas; cannot be assured that the new connections function exactly as their damaged neighbors did.


Complete Lesion - An injury with no motor or sensory function below the area of the spinal cord that was damaged.


Contracture - The stiffening of a body joint to the point that it can no longer be moved through its normal range.


Condom Catheter - External urine collecting device used by males.


Conus Medullaris Syndrome - Injury of the sacral cord (conus) and lumbar nerve roots within the neural canal, which usually results in an areflexic bladder, bowel and lower limbs. Sacral segments may occasionally show preserved reflexes with higher lesions.


Creatinine Clearance - A 24-hour urine collection test to assess how the kidneys are functioning.
Crede - A technique of pressing down and inward over the bladder to facilitate voiding. Pronounced "cruh-day."


Cyst (post traumatic cystic myelopathy) - A collection of fluid within the spinal cord, which may increase pressure and lead to increased neurological deterioration, loss of sensation, pain, and dysreflexia.


Cystogram (CG) - X-ray taken after injecting dye into bladder.


Cystometric Examination - An exam measuring the pressure of forces to empty, or resisting to empty, the bladder.


Decubitus Ulcer - See pressure sore.


Demyelination - The loss of nerve fiber "insulation" due to trauma or disease, which reduces the ability of nerves to conduct impulses (as in multiple sclerosis and some kinds of SCI).


Denial - Avoiding physical or emotional conflict or loss; many rehab professionals over-ascribe denial to their patients. Hoping for functional improvement should not be misunderstood as denying disability.


Dendrite - Microscopic tree-like fibers extending from a nerve cell (neuron). They are receptors of electrochemical nervous impulse transmissions. A fine branching process of the nerve cell which conducts a nerve impulse from the cell body to the structure(s) supplied by the nerve, or toward the cell body.


Depression (dysthymia) - An abnormal lowering of mood of psychologic or physiologic origin which is more prolonged than mourning and is time-limited and related to a specific loss.


Dermatome - A map that shows typical function for various levels of spinal cord injury. May also refer to the area of the skin innervated by the sensory axons with each segmental nerve (root). 


Derotational Splints - Long splints on legs and feet used to prevent foot drop and external rotation of the hips. These splints are used when a patient is supine.


Disability - Any restriction or lack (resulting from an impairment) of ability to perform an activity in a manner or within the range considered normal for a human being.


Discharge Planning - Planning and preparation for life rehab. has been completed.


DLS (Daily Living Skills) - See 'ADL".


Dorsal Root - The collection of nerves entering the dorsal section (on the back) of a spinal cord segment.


Dura Mater - The outermost of three membranes protecting the brain and spinal cord, it is tough and leather-like. The fibrous outer sheath surrounding the brain and spinal cord.


Dysphagia - Difficulty in swallowing.


Edema - Swelling; most commonly present in legs and feet. Edema occurs when the body tissues contain an excessive amount of fluid (plasma), increasing skin sensitivity and risk of pressure sores.


Egg-crate Mattress - Foam mattress, resembling egg cartons, that helps distribute pressure and prevent pressure sores.


Effector neuron - The output nerve component of the reflex arc which transmits a reaction to the end of the organ to which the effector neuron connects.


Efferent - Motor pathway proceeding from the central nervous system toward the peripheral end organs.


Electromyogram (EMG) - A test that records the responses of muscles to electrical stimulation.


Electro-ejaculation - A means of extracting sperm from men with erectile dysfunction by using an electrical probe in the rectum. The sperm can be used to fertilize eggs in the uterus or in a test tube.


Environment - The context in which development takes place, including physical properties of stimuli.


Exacerbation - A recurrence or worsening of symptoms.


Extension - Movement which brings the body or limbs into straight position. Outward movements of body parts away from the center of the body (straightening).


External Continence Device (ECD) – Male external urine control device that attaches to tip of penis.


Fairley Test - A urine test to determine the site of infection. For instance, it can determine whether infection exists in the bladder only or in a kidney as well.


FES (Functional Electric Stimulation) - The application of low-level, computer-controlled electric current to the neuromuscular system, including paralyzed muscle.


Flaccidity - A form of paralysis in which muscles are soft and limp.


Flexion - Movement which brings body or limbs into a bent position. Inward movements of body parts toward the center of the body (bending).


Foley Catheter - A rubber tube placed in the urethra, extending to the bladder, in order to empty the bladder. It is held in place with a small fluid-filled balloon.


Functional - The ability to carry out a purposeful activity.


Gait Training - Instruction in walking, with or without equipment.


Ganglioside - Complex, carbohydrate-rich lipids found in cell membranes, most concentrated at the surface of brain cells.


Glial Cells - From the Greek for "glue," glial cells are supportive cells associated with neurons. Astrocytes and oligodendrocytes are central nervous system glial cells. In the peripheral nervous system the main glial cells are called Schwann cells.


Glossopharyngeal breathing (GPB) - A means of forcing extra air into the lungs to expand the chest and achieve a functional cough. Also called "frog breathing."


Halo Traction - The process of immobilizing the upper body and cervical spine with a traction device. The device consists of a metal ring around the head, held in place with pins into the skull. A supporting frame is attached to the ring and to a body jacket or vest to provide immobilation.


Hand Splint - See "tenodesis".Handicap - A disadvantage that limits or prevents fulfillment of a role that is normal (depending on age, sex, and social and cultural factors).


Handicap dimensions - Physical independence, mobility, roles and activities, social integration, and economic self-sufficiency.


Harrington Rods - Metal braces fixed along the spinal column for support and stabilization.


Hemiparesis - Partial paralysis of loss of movement on one side of the body.


Heterotopic Ossification (HO) - The formation of new bone deposits in the connective tissue surrounding the major joints, primarily the hip and knee. A disorder characterized by the deposition of large quantities of calcium at the site of a bone injury. Often the result of prolonged immobilization. [heterotopic bone].


Hubbard Tank - A large full-body tank of water used for wound care and range of motion.


Hydronephrosis - A kidney distended with urine to the point that its function is impaired. Can cause uremia, the toxic retention of blood nitrogen.


Hyperreflexia - See "autonomic dysreflexia".


Hyperesthesia - Grossly exaggerated tactile stimuli.


Hypothermia - An extreme lowering of the body temperature. A technique used to cool the spinal cord after injury.


Hypoxia - Lack of blood oxygen due to impaired lung function.


Immune Response - The body's defense function that produces antibodies to foreign antigens. It is important in organ and tissue transplantation since the body is likely to reject new tissues.


Impairment - Any loss or abnormality of psychological, physiological, or anatomical structure or function.


Incomplete Injury - Some sensation or motor control preserved below spinal cord lesion.


Incomplete Lesion - A spinal cord lesion in which some sensation or muscle function below the level of injury is preserved.


Incontinence - Lack of bowel and/or bladder control.


Indwelling Catheter - A flexible tube retained in the bladder, used for continuous urinary draining to a leg bag or other device.


Informed Consent - A patient's right to know the risks and benefits of a medical procedure.


Intermittent Catheterization (ICP) - Using a catheter for emptying the bladder on a regular schedule. See self-catheterization.


Intrathecal Baclofen - Administration of the anti-spasm drug Baclofen directly to the spinal cord by way of a surgically implanted pump.


Intravenous Pyelogram (IVP) - An X-ray of the kidney to determine function.


Ischemia - A reduction of blood flow that is thought to be a major cause of secondary injury to the brain or spinal cord after trauma.


KUB - An X-ray of the abdomen, showing the kidneys, ureters, and bladder.


Laminectomy - An operation used to relieve pressure on the spinal cord, or used to examine the extent of damage to the cord.


Late Anterior Decompression - Surgical procedure to reduce pressure on the spinal cord by removing bone fragments.


Lateral - Side.


Leg Bag - External bag which is strapped to the leg for collection of urine.


Lesion - An injury or wound, any pathologic or traumatic injury to the spinal cord.


Lipid Peroxidation - Lipids are the backbone of nerve cell membranes.


Lithotripsy - A non-invasive treatment for kidney stones. Shock waves, generated under water by a spark plug, crumble stones into pieces that will pass with urine.


Log Roll - Method of turning a patient without twisting the spine, used when a person's spine is unstable.


Lower Motor Neurons - These nerve fibers originate in the spinal cord and travel out of the central nervous system to muscles in the body. An injury to these nerve cells can destroy reflexes and may also affect bowel, bladder and sexual function.


Lower Motor Neuron Lesion - Any damage to the lower motor neuron or its axon (peripheral nerve) that separates the lower motor neuron from control of its muscle fibers. This type of lesion leads to flaccidity and muscle atrophy.


Lumbar - Pertaining to that area immediately below the thoracic spine; the strongest part of the spine, the lower back.


Malingering - Faking or conscious deception; voluntary production of symptoms for a rationally considered goal, such as financial recompense, avoidance of responsibility, etc.


Medicaid - A state-funded insurance program that varies by state, and may vary within a state if a managed care product is present. Individuals are eligible and can receive the insurance for free if they meet maximal income limits, are pregnant, are <21 years of age, or have sufficient enough medical bills. Pays for all rehabilitation care, equipment, custodial and skilled nursing home care, home personal care services, and medications (a co-pay is usually needed for medications). All Medicaid in Virginia is managed care (as of 4/99).


Medicare - A Federally-funded insurance program that offers standard services nationwide, that may vary if a managed care product is present. Individuals are eligible and can receive for free Part A (pays for inpatient care, all rehabilitation care, equipment) if they have been employed for 10 or more years and are either 65 and older, disabled for 2 years or more, or have end-stage renal disease. Individuals are eligible for Part B (pays for physician services) if they have Part A, but must pay a monthly fee (around $50). Medicare does not pay for medications, personal care services at home, or custodial nursing home care, but does provide for skilled nursing facility (rehabilitation or medical) in a nursing home for 100 days (per each medical or rehabilitation incident separated by 60 days).


Molecular genetics - The study of how genes function to control cellular activies. (Genetic engineering involves the application of knowledge about molecular genetics in order to change living things by modifying their DNA, so they will produce desired strains).


Motoneuron (motor neuron) - A nerve cell whose cell body is located in the brain and spinal cord and whose axons leave the central nervous system by way of cranial nerves or spinal roots. Motoneuron supply information to muscle. A motor unit is the combination of the motoneuron and the set of muscle fibers it innervates.


Motor- Referring to nerves that give signals to muscles or glands in the body.


Motor development - The gradual acquisition of full control of all voluntary motor movements common to the species.


MRI (Magnetic Resonance Imaging) - A high-tech diagnostic tool to display tissues unseen in X-rays or by other techniques.


Multiple Sclerosis (MS) - A chronic disease of the central nervous system where myelin, the insulation on nerve fibers, is lost. MS is thought to be an autoimmune dysfunction in which the body turns on itself for some unknown reason.


Myelin - A white, fatty insulating material for axons which produced in the peripheral nervous system by Schwann cells, and in the central nervous system by oligodendrocytes. Myelin is necessary for rapid signal transmission along nerve fibers, ten to one hundred times faster than in bare fibers lacking its insulation properties. It insulates axons giving the "white matter" of the central nervous system its characteristic color.


Myelogram - A diagnostic test in which an opaque liquid is injected into the spinal canal, producing an outline of it on X-rays or fluoroscope.


Myoclonus - Involuntary, sharp, jerking muscular contractions, often painful.


Myotome - The collection of muscle fibers innervated by the motor axons within each segmental nerve (root).


Neurapraxia - The first level of nerve injury. The large motor fibers are predominately affected and anatomic continuity of the nerve is preserved. The prognosis for recovery is excellent and usually complete within a few days to weeks.


Nerve Growth Factor (NGF) - A "vitamin" for nerve cells. NGF, a protein, supports survival of embryonic neurons, and regulates neurotransmitters.


Nerve Impulse - An electrical current is carried along the plasma membrane (outer skin) nerve, and it may "start" in one of three ways: a) spontaneous "ignition" of the nerve cell body, b) removal of a suppressor impulse, and c) reception of an electrical impulse from other nerve cells.


Neurogenic Bladder - Any bladder disturbance due to an injury of the nervous system.


Neurological Level - Refers to the lowest segment of the spinal cord with normal sensory and motor function on both sides of the body. In fact, the segments at which normal function is found often differ by side of body and in terms of sensory vs. motor testing. Thus, up to four different segments may be identified in determining the neurological level. In cases such as this, generally each of these segments is separately recorded and a single "level".


Neurolysis - Destruction of peripheral nerves by radio frequency, heat, cutting or by chemical injection. Used to treat spasticity.


Neuron - A nerve cell that can receive and send information by way of synaptic connections consisting of the cell body and extensions of the nerve called axons and dendrites.


Neuropathic / Spinal Cord Pain - Neuropathic (nerve-generated) pain is a problem experienced by SCI patients. A sharp, almost electrical shock, type of pain will be felt to the left of the injury and is the result of damage to the spine and soft tissue surrounding the spine. Phantom limb pain or radiating pain from the level of the lesion is related to the injury or sysfunction at the nerve root or spinal cord.


Neurotmesis - The most severe form of nerve injury. There is complete disruption within the nerve and/or an actual severing of the nerve. This injury needs surgical repair. There is wallerian degeneration of the nerve distal to the site of the injury and the prognosis for recovery is far poorer than in the case of neurapraxia or axonotmesis (the other 2 classes of nerve injuries). A nerve may not always have only one type of injury. It is possible to have combined types of injuries within a given nerve.


Neurotransmitter - A chemical released from a neuron ending, at a synapse, to either excite or inhibit the adjacent neuron or muscle cell. A chemical synthesized within the nerve cell body, characteristic for this type of nerve, and stored at the nerves in pods as granules. Release of these chemicals into the synaptic cleft between axons facilitates nerve transmissions.


Nucleic acid - Complex organic acids found in the nucleus of all living cells that contain the genetic code essential to life.


Occupational Therapist (OT) - The member of the rehabilitation team who helps maximize a person's independence.


Occupational Therapy (OT) - Structured activity focused on activities of daily living skills (feeding, dressing, bathing, grooming), arm flexibility and strengthening, neck control and posture, perceptual and cognitive skills, and using adaptive equipment to facilitate ADL’s.


Oligodendrocyte - A central nervous system glial cell. Oligodendrocytes are the site of myelin manufacture for central nervous system neurons (the job of Schwann cells in the peripheral nervous system).


Omentum - Well-vascularized tissue of the gut.


Osteoporosis - Loss of bone density, common in immobile bones after SCI.


Ostomy - An opening in the skin to allow for a suprapubic cystostomy (catheter drainage), for elimination of intestinal contents (colostomy or ileostomy) or for passage of air (tracheostomy).


Papavarine - A drug injected into the penis to produce an erection which acts by increasing blood flow.
Paralytic Ileus - Loss of movement in the small intestine, resulting in gas and fluid build-up. It usually lasts a few days after injury.


Paraplegia - Refers to impairment of loss of motor and/or sensory function in the thoracic, lumbar or sacral (but not cervical) segments of the spinal cord, secondary to damage of neural elements within the spinal canal. WIth paraplegia, arm functioning is spared, but, depending on the level of injury, the trunk, legs, and pelvic organs may be involved. There are some types of paralysis involving the legs that are described by the impairment they cause (see Clinical Syndromes).


Paraplegic - One who has loss of function below the cervical spinal cord segments, wherein the upper body retains most function and sensation.


Paresis - Weakness in voluntary muscle or slight paralysis.


Passive Standing - Standing on one's feet while being propped up in a standing frame or other device. It is said to benefit bone strength.


Percussion - Forceful tapping on congested parts of the chest to facilitate postural drainage in persons with people with high-level tetraplegia.


Peripheral -Nerve tissue not found in the brain or spinal cord.


Peripheral Nervous System - Nerves outside the spinal cord and brain (not part of the central nervous system). If damaged, peripheral nerves have the ability to regenerate.


Personal Care Services - Non-skilled assistance (bathing, dressing, light housework) provided to individuals in their homes.


Phrenic Nerve Stimulation - Electrical stimulation of the nerve that fires the diaphragm muscle, facilitating breathing in people with injury at the C1 or C2 level.


Physiatrist - A doctor whose specialty is physical medicine and rehabilitation.


Physical Therapist (PT) - A key member of the rehabilitation team.


Physical Therapy (PT) - Structured activity focused on mobility skills (bed, transfers, wheelchair use, walking), leg flexibility and strengthening, trunk control and balance, endurance training, and using adaptive equipment to facilitate mobility.


Piloerection - "goose bumps"


Plasticity - Long-term adaptive mechanism by which the nervous system restores or modifies itself toward normal levels of function.


Posterior - Back.


Postural Drainage - Using gravity to help the clear lungs of mucus by positioning the head lower than chest.


Postural Hypotension - The reduction of blood pressure resulting in light-headedness.


Preservation - The repetition of an idea or activity without an appropriate stimulus.


Pressure Release - Relieving pressure from the ischial turberosities (bones on which we sit) every 15 min. in order to prevent pressure sores.


Pressure Sore - Also known as decubitus ulcer. A potentially dangerous skin breakdown due to pressure on skin resulting in infection, tissue death.


Priapism - A dangerous condition where the penis remains erect due to retention of blood.


Prone - Lying on stomach.
Proprioception - The sense of movement and position.


Prosthesis - Replacement device for a body part, for example an artificial limb.


PVR (Post Void Residual) - The volume left in bladder after the patient voids (urinates).


Quad - Generally, a high quad is someone with an injury at C1, C2, and C3. some doctors also group c4 quads into this category. Mid-level quads are those injured at C5. Low-level quads are those injured at C6 & C7. This isn't written in stone, and some doctors consider C4, C5, and C6 all as mid-level, with C7 being low-level.


Quad Cough - A method of helping a patient with tetraplegia cough by applying external pressure to diaphragm, thus increasing the force and clearing the respiratory tract.


Quadriparesis - Partial loss of function all four (4) extremities of the body.


Quadriplegia - Loss of function of any injured or diseased cervical spinal cord segment, affecting all four body limbs. Outside the U.S. the term tetraplegia is used (which is etymologically more accurate, combining tetra + plegia, both from the Greek, rather than quadri + plegia, a Latin/Greek amalgam).


Range of Motion (ROM) - The normal range of movement of any body joint. Range of Motion also refers to exercises designed to maintain this range and prevent contractures.


Receptor (afferent) neuron - The input nerve component of the reflex arc which conducts stimuli from the environment toward the CNS.


Reciprocating Gait Orthosis (RGO) - A type of long-leg brace used for ambulation by paralyzed people. Uses cables across the back to transfer energy from leg to leg, thereby simulating a more natural gait.


Reflex - An involuntary response to a stimulus involving nerves not under control of the brain.


Reflex arc - In its simplest form, three components. Receptor, association, and effector (efferent) neurons facilitate one-way transmission of nerve impulses in a repetitive manner.


Reflux - The backflow of urine from the bladder into the ureters and kidney.


Regeneration - The regrowth of a cell or nerve fiber.


Rehabilitation - Retraining to normal functionality or training for new functionality.


Residual Urine - Urine that remains in the bladder after voiding. Too much left can lead to a bladder infection.


Restorative Nursing (NRS) - Replication of activities initiated by PT, OT, and SLP performed by nursing staff (range of motion, dressing, hygiene, walking, feeding).


Retrograde Pyelogram (RP) - Insertion of contrast material directly into the kidney through an instrument.


Rhizotomy - The cutting, or interruption, of spinal nerve roots.


Sacral - The fused vertebrae and spinal cord below the lumbar level.


Schwann Cells - Responsible in the peripheral nervous system for myelinating axons they also provide trophic support in injury situation.


Secondary Injury - The biochemical and physiological changes that occur in the injured spinal cord after the initial trauma has done its damage.


Self-Catheterization - Intermittent catheterization, the goal of which is to empty the bladder as needed, on one's own, minimizing risk of infection.
Sensory Level and Motor Level - When the term "sensory level" is used, it refers to the lowest segment of the spinal cord with normal sensory function on both sides of the body; the motor level is similarly defined with respect to motor function. These "levels" are determined by neurological examination of (1) a key sensory point with in each of 28 dermatomes on the right and 28 dermatomes on the left side of the body, and (2) a key muscle within each of 10 myotomes on the right and 10 myotomes on the left side of the body.


Shunt - A tube used to drain a cavity. In the spinal cord, a shunt is used to treat a syrinx by equalizing pressures between the syrinx and the spinal fluids. In spinal bifida, it is used to reduce pressure of hydrocephalus.


Skin Breakdown - Skin breakdowns (also termed "decubitus ulcers") occurs as a result of excessive pressure, primarily over the bones of the buttock.


Social Work (SW) - Supportive service for psychosocial adjustment and intervention, financial resources, and discharge planning.


Space Boots - Plastic boots with foam linens worn on the feet when lying on your side.


Spasticity - Hyperactive muscles that move or jerk involuntarily. There are some benefits to spasticity:
  1. Warning mechanism to identify pain or problems in areas of no sensation.
  2. Helps in spotting an oncoming urinary tract infection.
  3. Helps to maintain muscle size and bone strength.
  4. Helps to maintain circulation.
  5. Helps to prevent osteoporosis.


Speech and Language Pathology (SLP) - Structured activity focused on communication skills, perceptual and cognitive skills, and swallowing.


Sphincterotomy - The cutting of the bladder sphincter muscle to eliminate spasticity and related voiding problems.


Spinal accessory nerve - Cranial Nerve XI. Largely motor, this nerve supplies sternomastoid and trapezius muscles.


Spinal nerves - Sensory and motor nerves which connect the spinal cord to the periphery of the body.


Spinal Shock - Similar to a concussion in the brain, spinal shock causes the system shuts down.




Subluxation - Complete or partial dislocation (as in shoulder).


Suctioning - Removal of mucus and secretions from lungs. It is important for people with high-level tetraplegia who lack ability to cough.


Suprapubic Catheter - A catheter surgically inserted into the bladder by incision above the pubis.


Suprapubic Cystostomy - A small opening made in the bladder and through the abdomen, sometimes to remove large stones, more commonly to establish a catheter urinary drain.


Synapse - The specialized junction between a neuron and another neuron or muscle cell for transfer of information such as brain signals, sensory inputs, etc., along the nervous system. These are the junctions between the "sending" fibers of one nerve cell, to the "receiving" fibers of other nerve cells. The axon (sending fiber) ends in multiple branches, each of which has a button-like enlargement that nearly touches the "receiving" fibers of the other nerve cell bodies. Nerve cells "talk" to each other via synapses. Basically the connection between the end of a nerve and the adjacent structure, such as a muscle cell or another nerve ending. Various transmitter chemicals liberated into the synapse make nerve transmissions possible.


Syringomyelia - The formation of a fluid-filled cavity (a syrinx) in an injured area of the spinal cord, which is a result of nerve fiber degradation and necrosis. It sometimes extends upward, extending also the neurological deficit. Treatment often includes surgery to insert a shunt for drainage of the cavity.
Syringomyelocele - A congenital neural tube defect which can cause spinal bifida in which spinal fluid fills a sac of spinal membrane.


Syrinx - A cyst; a cavity.


Tendon Lengthening - A procedure, usually involving the Achilles tendon, to treat contractures caused by spasms.


Tenodesis (Hand Splint) - Metal or plastic support for hand, wrist and/or fingers. Used to facilitate grater function to a disabled hand by transferring wrist extension into grip and finger control.


Tetraplegia - (Quadriplegia) Refers to impairment or loss of motor and/or sensory function in the cervical segments of the spinal cord due to damage of neural elements within the spinal canal. Tetraplegia results in impairment of function in the arms as well as in the trunk, legs, and pelvic organs. It does not include brachial plexus lesions or injury to peripheral nerves outside the neural canal.


Thoracic - Pertaining to the chest, vertebrae or spinal cord segments between the cervical and lumbar areas.


Thrombophlebitis - A clot in a vein due to diminished blood flow which can occur in a paralyzed leg. Symptoms include swelling and redness.


Tilt Table - A table which is used to gradually increase patients tolerance to being in a standing position. Also used to teach partial weight bearing and to give prolonged stretch in each position.


Tracheostomy - Opening in windpipe to facilitate breathing.


Upper Motor Neurons - Long nerve cells that originate in the brain and travel in tracts through the spinal cord. Any injury to these nerves cuts off contact with brain control. Reflex activity is still intact, however resulting in spasticity. For men with upper motor neuron injuries, reflex erections are possible.


Urinary Tract Infection (UTI) - Bacterial invasion of the urinary tract, which includes bladder, bladder neck and urethra. Symptoms of UTI include urine that is cloudy, contains sediment and smells foul, and fever. UTI involving the kidneys is preventable but dangerous. Medications often prescribed for UTI include Keflex, Macrodantin, Furadantin, Septra, Bactim, Mandelamine, penicillin, and amoxicillin. Side effects vary, and may include nausea and vomiting, skin rash or hives.


Ventilator - Mechanical device to facilitate breathing in persons with impaired diaphragm function.


Vertebrae - The bones that make up the spinal column.


Vital Capacity - The measure of air in a full breath. It is an important consideration for people with high-level tetraplegia who also have impaired pulmonary function.


Vital Signs - Consist of taking blood pressure, pulse, respiration and temperature.


Weaning - Gradual removal of mechanical ventilation, as patient's lung strength and vital capacity increases.


Zone of Partial Preservation - Refers to those dermatomes and myotomes below the neurological level that remain partially innervated. When some impaired sensory and/or motor function is found below the lowest normal segment, the exact number of segments so affected make up the ZPP. The term is used only with incomplete injuries.
 


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