C6 Spinal Cord Injury Case Study

As with all trauma patients, initial clinical evaluation of a patient with suspected spinal cord injury (SCI) begins with a primary survey. The primary survey focuses on life-threatening conditions. Assessment of airway, breathing, and circulation (ABCs) takes precedence. A spinal cord injury must be considered concurrently. [31, 32, 6]

Perform careful history taking, focusing on symptoms related to the vertebral column (most commonly pain) and any motor or sensory deficits. Ascertaining the mechanism of injury is also important in identifying the potential for spinal injury.

The axial skeleton should be examined to identify and provide initial treatment of potentially unstable spinal fractures from both a mechanical and a neurologic basis. The posterior cervical spine and paraspinal tissues should be evaluated for pain, swelling, bruising, or possible malalignment. Logrolling the patient to systematically examine each spinous process of the entire axial skeleton from the occiput to the sacrum can help identify and localize injury. The skeletal level of injury is the level of the greatest vertebral damage on radiograph.

Complete bilateral loss of sensation or motor function below a certain level indicates a complete spinal cord injury.

Pulmonary evaluation

The clinical assessment of pulmonary function in acute spinal cord injury begins with careful history taking regarding respiratory symptoms and a review of underlying cardiopulmonary comorbidity such as chronic obstructive pulmonary disease (COPD) or heart failure.

Carefully evaluate respiratory rate, chest wall expansion, abdominal wall movement, cough, and chest wall and/or pulmonary injuries. Arterial blood gas (ABG) analysis and pulse oximetry are especially useful, because the bedside diagnosis of hypoxia or carbon dioxide retention may be difficult.

The degree of respiratory dysfunction is ultimately dependent on preexisting pulmonary comorbidity, the level of the spinal cord injury, and any associated chest wall or lung injury. Any or all of the following determinants of pulmonary function may be impaired in the setting of spinal cord injury:

  • Loss of ventilatory muscle function from denervation and/or associated chest wall injury

  • Lung injury, such as pneumothorax, hemothorax, or pulmonary contusion

  • Decreased central ventilatory drive that is associated with head injury or exogenous effects of alcohol and drugs

A direct relationship exists between the level of cord injury and the degree of respiratory dysfunction, as follows:

  • With high lesions (ie, C1 or C2), vital capacity is only 5-10% of normal, and cough is absent

  • With lesions at C3 through C6, vital capacity is 20% of normal, and cough is weak and ineffective

  • With high thoracic cord injuries (ie, T2 through T4), vital capacity is 30-50% of normal, and cough is weak

  • With lower cord injuries, respiratory function improves

  • With injuries at T11, respiratory dysfunction is minimal; vital capacity is essentially normal, and cough is strong.

Other findings of respiratory disfunction include the following:

  • Agitation, anxiety, or restlessness

  • Poor chest wall expansion

  • Decreased air entry

  • Rales, rhonchi

  • Pallor, cyanosis

  • Increased heart rate

  • Paradoxic movement of the chest wall

  • Increased accessory muscle use

  • Moist cough

Hemorrhage, hypotension, and hemorrhagic and neurogenic shock

Hemorrhagic shock may be difficult to diagnose, because the clinical findings may be affected by autonomic dysfunction. Disruption of autonomic pathways prevents tachycardia and peripheral vasoconstriction that normally characterizes hemorrhagic shock. This vital sign confusion may falsely reassure. In addition, occult internal injuries with associated hemorrhage may be missed.

In a study showing a high incidence of autonomic dysfunction, including orthostatic hypotension and impaired cardiovascular control, following spinal cord injury, it was recommended that an assessment of autonomic function be routinely used, along with American Spinal Injury Association (ASIA) assessment, in the neurologic evaluation of patients with spinal cord injury. [33]

In all patients with spinal cord injury and hypotension, a diligent search for sources of hemorrhage must be made before hypotension is attributed to neurogenic shock. In acute spinal cord injury, shock may be neurogenic, hemorrhagic, or both.

The following are clinical "pearls" useful in distinguishing hemorrhagic shock from neurogenic shock:

  • Neurogenic shock occurs only in the presence of acute spinal cord injury above T6; hypotension and/or shock with acute spinal cord injury at or below T6 is caused by hemorrhage

  • Hypotension with a spinal fracture alone, without any neurologic deficit or apparent spinal cord injury, is invariably due to hemorrhage

  • Patients with a spinal cord injury above T6 may not have the classic physical findings associated with hemorrhage (eg, tachycardia, peripheral vasoconstriction); this vital sign confusion attributed to autonomic dysfunction is common in spinal cord injury

  • The presence of vital sign confusion in acute spinal cord injury and a high incidence of associated injuries requires a diligent search for occult sources of hemorrhage

Cord syndromes and nerve root injury

A careful neurologic assessment, including motor function, sensory evaluation, deep tendon reflexes, and perineal evaluation, is critical and required to establish the presence or absence of spinal cord injury and to classify the lesion according to a specific cord syndrome.

The presence or absence of sacral sparing is a key prognostic indicator. Sacral-sparing is evidence of the physiologic continuity of spinal cord long tract fibers (with the sacral fibers located more at the periphery of the cord). Indication of the presence of sacral fibers is of significance in defining the completeness of the injury and the potential for some motor recovery. This finding tends to be repeated and better defined after the period of spinal shock.

Determine the level of injury and try to differentiate nerve root injury from spinal cord injury, but recognize that both may be present. Differentiating a nerve root injury from spinal cord injury can be difficult. The presence of neurologic deficits that indicate multilevel involvement suggests spinal cord injury rather than a nerve root injury. In the absence of spinal shock, motor weakness with intact reflexes indicates spinal cord injury, whereas motor weakness with absent reflexes indicates a nerve root lesion.

ASIA has established pertinent definitions (see the following image). The neurologic level of injury is the lowest (most caudal) level with normal sensory and motor function. For example, a patient with C5 quadriplegia has, by definition, abnormal motor and sensory function from C6 down.

American Spinal Injury Association (ASIA) method for classifying spinal cord injury (SCI) by neurologic level.

Sensory function testing

Assessment of sensory function helps to identify the different pathways for light touch, proprioception, vibration, and pain. Use a pinprick to evaluate pain sensation.

Sensory level is the most caudal dermatome with a normal score of 2/2 for pinprick and light touch.

Sensory index scoring is the total score from adding each dermatomal score with a possible total score of 112 each for pinprick and light touch.

Sensory testing is performed at the following levels:

  • C2: Occipital protuberance

  • C3: Supraclavicular fossa

  • C4: Top of the acromioclavicular joint

  • C5: Lateral side of antecubital fossa

  • C6: Thumb

  • C7: Middle finger

  • C8: Little finger

  • T1: Medial side of antecubital fossa

  • T2: Apex of axilla

  • T3: Third intercostal space

  • T4: Fourth intercostal space at nipple line

  • T5: Fifth intercostal space (midway between T4 and T6)

  • T6: Sixth intercostal space at the level of the xiphisternum

  • T7: Seventh intercostal space (midway between T6 and T8)

  • T8: Eighth intercostal space (midway between T6 and T10)

  • T9: Ninth intercostal space (midway between T8 and T10)

  • T10: 10th intercostal space or umbilicus

  • T11: 11th intercostal space (midway between T10 and T12)

  • T12: Midpoint of inguinal ligament

  • L1: Half the distance between T12 and L2

  • L2: Midanterior thigh

  • L3: Medial femoral condyle

  • L4: Medial malleolus

  • L5: Dorsum of the foot at third metatarsophalangeal joint

  • S1: Lateral heel

  • S2: Popliteal fossa in the midline

  • S3: Ischial tuberosity

  • S4-5: Perianal area (taken as 1 level)

Sensory scoring is for light touch and pinprick, as follows:

  • 0: Absent; a score of zero is given if the patient cannot differentiate between the point of a sharp pin and the dull edge

  • 1: Impaired or hyperesthesia

  • 2: Intact

Motor strength testing

Muscle strength always should be graded according to the maximum strength attained, no matter how briefly that strength is maintained during the examination. The muscles are tested with the patient supine.

Motor level is determined by the most caudal key muscles that have muscle strength of 3 or above while the segment above is normal (= 5).

Motor index scoring uses the 0-5 scoring of each key muscle, with total points being 25 per extremity and with the total possible score being 100.

Lower extremities motor score (LEMS) uses the ASIA key muscles in both lower extremities, with a total possible score of 50 (ie, maximum score of 5 for each key muscle [L2, L3, L4, L5, and S1] per extremity). A LEMS of 20 or less indicates that the patient is likely to be a limited ambulator. A LEMS of 30 or more suggests that the individual is likely to be a community ambulator.

ASIA recommends use of the following scale of findings for the assessment of motor strength in spinal cord injury:

  • 0: No contraction or movement

  • 1: Minimal movement

  • 2: Active movement, but not against gravity

  • 3: Active movement against gravity

  • 4: Active movement against resistance

  • 5: Active movement against full resistance

Neurologic level and extent of injury

Neurologic level of injury is the most caudal level at which motor and sensory levels are intact, with motor level as defined above and sensory level defined by a sensory score of 2.

Zone of partial preservation is all segments below the neurologic level of injury with preservation of motor or sensory findings. This index is used only when the injury is complete.

The key muscles that need to be tested to establish neurologic level are as follows:

  • C5: Elbow flexors (biceps, brachialis)

  • C6: Wrist extensors (extensor carpi radialis longus and brevis)

  • C7: Elbow extensors (triceps)

  • C8: Long finger flexors (flexor digitorum profundus)

  • T1: Small finger abductors (abductor digiti minimi)

  • L2: Hip flexors (iliopsoas)

  • L3: Knee extensors (quadriceps)

  • L4: Ankle dorsiflexors (tibialis anterior)

  • L5: Long toe extensors (extensor hallucis longus)

  • S1: Ankle plantar flexors (gastrocnemius, soleus)

Perform a rectal examination to check motor function or sensation at the anal mucocutaneous junction. The presence of either is considered sacral-sparing.

The sacral roots may be evaluated by documenting the following:

  • Perineal sensation to light touch and pinprick

  • Bulbocavernous reflex, S3 or S4

  • Anal wink, S5

  • Rectal tone

  • Urine retention or incontinence

  • Priapism

The extent of injury is defined by the ASIA Impairment Scale (modified from the Frankel classification), using the following categories [3, 4] :

  • A = Complete: No sensory or motor function is preserved in sacral segments S4-S5 [5]

  • B = Incomplete: Sensory, but not motor, function is preserved below the neurologic level and extends through sacral segments S4-S5

  • C = Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have muscle grade less than 3

  • D = Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have muscle grade greater than or equal to 3

  • E = Normal: Sensory and motor functions are normal

Thus, definitions of complete and incomplete spinal cord injury, as based on the above ASIA definition, with sacral-sparing, are as follows [3, 4, 5] :

  • Complete: Absence of sensory and motor functions in the lowest sacral segments

  • Incomplete: Preservation of sensory or motor function below the level of injury, including the lowest sacral segments

With the ASIA classification system, the terms paraparesis and quadriparesis have become obsolete. Instead, the ASIA classification uses the description of the neurologic level of injury in defining the type of spinal cord injury (eg, "C8 ASIA A with zone of partial preservation of pinprick to T2").

Differential Diagnoses


1. Yıldırım K, Şengel K. Spinal kord yaralanmaları ve rehabilitasyonu (Spinal cord injury and rehabilitation) Klnk Akt Tıp Derg. 2004;(4):26–38.

2. Yip PK, Malaspina A. Spinal cord trauma and the molecular point of no return. Mol Neurodegener. 2012;7:6.[PMC free article][PubMed]

3. Cantu RC, Li YM, Abdulhamid M, Chin LS. Return to play after cervical spine injury in sports. Curr Sports Med Rep. 2013;12:14–17.[PubMed]

4. Mahan ST, Mooney DP, Karlin LI, Hresko MT. Multiple level injuries in pediatric spinal trauma. J Trauma. 2009;67:537–542.[PubMed]

5. Sipski ML, Richards JS. Spinal cord injury rehabilitation: state of the science. Am J Phys Med Rehabil. 2006;85:310–342.[PubMed]

6. Kirshblum SC, Burns SP, Biering-Sorensen F, Donovan W, Graves DE, Jha A, Johansen M, Jones L, Krassioukov A, Mulcahey MJ, et al. International standards for neurological classification of spinal cord injury (revised 2011) J Spinal Cord Med. 2011;34:535–546.[PMC free article][PubMed]

7. Gibson KL. Caring for a patient who lives with a spinal cord injury. Nursing. 2003;33:36–41; quiz 42.[PubMed]

8. Fries JM. Critical rehabilitation of the patient with spinal cord injury. Crit Care Nurs Q. 2005;28:179–187.[PubMed]

9. Barbin JM, Ninot G. Outcomes of a skiing program on level and stability of self-esteem and physical self in adults with spinal cord injury. Int J Rehabil Res. 2008;31:59–64.[PubMed]

10. Paker N, Soy D, Kesiktaş N, Nur Bardak A, Erbil M, Ersoy S, Ylmaz H. Reasons for rehospitalization in patients with spinal cord injury: 5 years’ experience. Int J Rehabil Res. 2006;29:71–76.[PubMed]

11. Hitzig SL, Tonack M, Campbell KA, McGillivray CF, Boschen KA, Richards K, Craven BC. Secondary health complications in an aging Canadian spinal cord injury sample. Am J Phys Med Rehabil. 2008;87:545–555.[PubMed]

12. Yuen HK, Hanson C. Body image and exercise in people with and without acquired mobility disability. Disabil Rehabil. 2002;24:289–296.[PubMed]

13. Chen SC, Lai CH, Chan WP, Huang MH, Tsai HW, Chen JJ. Increases in bone mineral density after functional electrical stimulation cycling exercises in spinal cord injured patients. Disabil Rehabil. 2005;27:1337–1341.[PubMed]

14. Pickett GE, Campos-Benitez M, Keller JL, Duggal N. Epidemiology of traumatic spinal cord injury in Canada. Spine (Phila Pa 1976) 2006;31:799–805.[PubMed]

15. DeVivo MJ, Chen Y, Mennemeyer ST, Deutsch A. Costs of care following spinal cord injury. Top Spinal Cord Inj Rehabil. 2011;16:1–9 [DOİ: 10.1310/sci1604-1].

16. Munce SE, Wodchis WP, Guilcher SJ, Couris CM, Verrier M, Fung K, Craven BC, Jaglal SB. Direct costs of adult traumatic spinal cord injury in Ontario. Spinal Cord. 2013;51:64–69.[PubMed]

17. Mehrholz J, Elsner B, Werner C, Kugler J, Pohl M. Electromechanical-assisted training for walking after stroke. Cochrane Database Syst Rev. 2013;7:CD006185.[PubMed]

18. Berlowitz DJ, Tamplin J. Respiratory muscle training for cervical spinal cord injury. Cochrane Database Syst Rev. 2013;7:CD008507.[PubMed]

19. Domingo A, Al-Yahya AA, Asiri Y, Eng JJ, Lam T. A systematic review of the effects of pharmacological agents on walking function in people with spinal cord injury. J Neurotrauma. 2012;29:865–879.[PMC free article][PubMed]

20. Wessels M, Lucas C, Eriks I, de Groot S. Body weight-supported gait training for restoration of walking in people with an incomplete spinal cord injury: a systematic review. J Rehabil Med. 2010;42:513–519.[PubMed]

21. Taricco M, Adone R, Pagliacci C, Telaro E. Pharmacological interventions for spasticity following spinal cord injury. Cochrane Database Syst Rev. 2000;28:CD001131.[PubMed]

22. Hitzig SL, Craven BC, Panjwani A, Kapadia N, Giangregorio LM, Richards K, Masani K, Popovic MR. Randomized trial of functional electrical stimulation therapy for walking in incomplete spinal cord injury: effects on quality of life and community participation. Top Spinal Cord Inj Rehabil. 2013;19:245–258.[PMC free article][PubMed]

23. Astorino TA, Harness ET, Witzke KA. Effect of chronic activity-based therapy on bone mineral density and bone turnover in persons with spinal cord injury. Eur J Appl Physiol. 2013;113:3027–3037.[PMC free article][PubMed]

24. Sadowsky CL, Hammond ER, Strohl AB, Commean PK, Eby SA, Damiano DL, Wingert JR, Bae KT, McDonald JW. Lower extremity functional electrical stimulation cycling promotes physical and functional recovery in chronic spinal cord injury. J Spinal Cord Med. 2013;36:623–631.[PMC free article][PubMed]

25. Gorgey AS, Dolbow DR, Cifu DX, Gater DR. Neuromuscular electrical stimulation attenuates thigh skeletal muscles atrophy but not trunk muscles after spinal cord injury. J Electromyogr Kinesiol. 2013;23:977–984.[PubMed]

26. Karimi MT. Robotic rehabilitation of spinal cord injury individual. Ortop Traumatol Rehabil. 2013;15:1–7.[PubMed]

27. Karimi MT. Functional walking ability of paraplegic patients: comparison of functional electrical stimulation versus mechanical orthoses. Eur J Orthop Surg Traumatol. 2013;23:631–638.[PubMed]

28. Savaş F, Üstünel S. Omurilik yaralanması sonrası rehabilitasyon prensipleri (Principles of rehabilitation after spinal cord injury) In: Hancı M, Erhan B (eds): omurga ve omurilik yaralanmaları (spine and spinal cord injuries). İntertıp; 2013. pp. 585–588.

29. Tander B. Nörolojik hasarlı hastanın rehabilitasyonu (Neurological injured patients of rehabilitation) In: Şenel A, Çaylı S, Dalbayrak S, Temiz C, Arslantaş A(eds): Omurga travmalarında tedavi prensipleri (Principles of rehabilitation after spinal cord injury). Türk nöroşirürji derneği; 2011. pp. 297–308.

30. Şahin E. Omurilik yaralanmaları ve üst ekstremite ortezleri (Spinal cord injuries and upper extremity orthoses) In: Hancı M, Erhan B (eds): omurga ve omurilik yaralanmaları (spine and spinal cord injuries). İntertıp; 2013. pp. 603–615.

31. Chi JH. Combination therapy improves walking in spinal cord transaction. Neurosurgery. 2009;65:N10–N11.[PubMed]

32. Diong J, Harvey LA, Kwah LK, Eyles J, Ling MJ, Ben M, Herbert RD. Incidence and predictors of contracture after spinal cord injury--a prospective cohort study. Spinal Cord. 2012;50:579–584.[PubMed]

33. Jia X, Kowalski RG, Sciubba DM, Geocadin RG. Critical care of traumatic spinal cord injury. J Intensive Care Med. 2013;28:12–23.[PubMed]

34. Jacobs PL, Nash MS. Exercise recommendations for individuals with spinal cord injury. Sports Med. 2004;34:727–751.[PubMed]

35. Curtis KA, Tyner TM, Zachary L, Lentell G, Brink D, Didyk T, Gean K, Hall J, Hooper M, Klos J, et al. Effect of a standard exercise protocol on shoulder pain in long-term wheelchair users. Spinal Cord. 1999;37:421–429.[PubMed]

36. Kruger EA, Pires M, Ngann Y, Sterling M, Rubayi S. Comprehensive management of pressure ulcers in spinal cord injury: current concepts and future trends. J Spinal Cord Med. 2013;36:572–585.[PMC free article][PubMed]

37. Patwardhan AG, Li SP, Gavin T, Lorenz M, Meade KP, Zindrick M. Orthotic stabilization of thoracolumbar injuries. A biomechanical analysis of the Jewett hyperextension orthosis. Spine (Phila Pa 1976) 1990;15:654–661.[PubMed]

38. Mehrholz J, Kugler J, Pohl M. Locomotor training for walking after spinal cord injury. Spine (Phila Pa 1976) 2008;33:E768–E777.[PubMed]

39. Hastings JD. Seating assessment and planning. Phys Med Rehabil Clin N Am. 2000;11:183–207, x.[PubMed]

40. Guest RS, Klose KJ, Needham-Shropshire BM, Jacobs PL. Evaluation of a training program for persons with SCI paraplegia using the Parastep 1 ambulation system: part 4. Effect on physical self-concept and depression. Arch Phys Med Rehabil. 1997;78:804–807.[PubMed]

41. Audu ML, Nataraj R, Gartman SJ, Triolo RJ. Posture shifting after spinal cord injury using functional neuromuscular stimulation--a computer simulation study. J Biomech. 2011;44:1639–1645.[PMC free article][PubMed]

42. Kirshblum SC, rehabilitation of spinal cord injury. In: Physical medicine and rehabilitation, principle and practice. Philadelphia: Lippincott Willams&Wilkins; 2005. pp. 1715–1751.

43. Hawran S, Biering-Sørensen F. The use of long leg calipers for paraplegic patients: a follow-up study of patients discharged 1973-82. Spinal Cord. 1996;34:666–668.[PubMed]

44. Jaspers P, Peeraer L, Van Petegem W, Van der Perre G. The use of an advanced reciprocating gait orthosis by paraplegic individuals: a follow-up study. Spinal Cord. 1997;35:585–589.[PubMed]

45. Massucci M, Brunetti G, Piperno R, Betti L, Franceschini M. Walking with the advanced reciprocating gait orthosis (ARGO) in thoracic paraplegic patients: energy expenditure and cardiorespiratory performance. Spinal Cord. 1998;36:223–227.[PubMed]

46. Kantor C, Andrews BJ, Marsolais EB, Solomonow M, Lew RD, Ragnarsson KT. Report on a conference on motor prostheses for workplace mobility of paraplegic patients in North America. Paraplegia. 1993;31:439–456.[PubMed]

47. Yozbatiran N, Berliner J, O’Malley MK, Pehlivan AU, Kadivar Z, Boake C, Francisco GE. Robotic training and clinical assessment of upper extremity movements after spinal cord injury: a single case report. J Rehabil Med. 2012;44:186–188.[PubMed]

48. Schwartz I, Sajina A, Neeb M, Fisher I, Katz-Luerer M, Meiner Z. Locomotor training using a robotic device in patients with subacute spinal cord injury. Spinal Cord. 2011;49:1062–1067.[PubMed]

49. Stiens SA, Kirshblum SC, Groah SL, McKinley WO, Gittler MS. Spinal cord injury medicine. 4. Optimal participation in life after spinal cord injury: physical, psychosocial, and economic reintegration into the environment. Arch Phys Med Rehabil. 2002;83:S72–81, S90-8.[PubMed]

50. Baslo M. Omurilik yaralanmalı hasta için konut ve çevre düzenlemeleri ‘evrensel tasarım’ (Housing and environmental regulations for spinal cord injured patients’ universal design’) In: omurga ve omurilik yaralanmaları (spine and spinal cord injuries), editörler; Hancı M, Erhan B. İntertıp; 2013. pp. 645–668.

51. Lee Y, Mittelstaedt R. Impact of injury level and self-monitoring on free time boredom of people with spinal cord injury. Disabil Rehabil. 2004;26:1143–1149.[PubMed]

52. Loy DP, Dattilo J, Kleiber DA, Exploring the influence of leisure on adjustment: Development of the leisure and spinal cord injury adjustment model. Leisure Scie. 2003;25:231–255.

53. Youngstrom MJ. The Occupational Therapy Practice Framework: the evolution of our professional language. Am J Occup Ther. 2002;56:607–608.[PubMed]

0 Replies to “C6 Spinal Cord Injury Case Study”

Lascia un Commento

L'indirizzo email non verrà pubblicato. I campi obbligatori sono contrassegnati *