Cervical (neck) injuries usually result in four limb paralysis.
This is referred to as Tetraplegia or Quadriplegia. Injuries above
the C-4 level may require a ventilator or electrical implant for
the person to breathe. This is because the diaphragm is controlled
by spinal nerves exiting at the upper level of the neck. The well
documented horse riding accident of Christopher Reeve (Superman)
resulted in a 'complete' spinal cord injury above C3 and he now
has to use a mechanical ventilator via a hole in his throat to breathe.
You can also have an
incomplete quadriplegic injury too
C-5 injuries often result in shoulder and biceps control, but no
control at the wrist or hand. C-6 injuries generally yield wrist
control, but no hand function. Individuals with C-7 and T-1 injuries
can straighten their arms but still may have dexterity problems
with the hand and fingers.
Quadriplegia is far more debilitating than paraplegia as the arms
are paralysed too. The descriptions below detail what is likely
to be expected functionally with the different levels of tetraplegia.
It is only intended as a guide and should be read as such.
C1-4 Quadriplegia: Patients with C-1 and C-2 lesions may have functional phrenic nerves.
In these cases, implanted phrenic nerve pacemakers can be used,
and pacing of the diaphragms may be simultaneous or alternating.
If secretions are not a problem, tracheostomies may be plugged or
discontinued. Less equipment may be needed for C-1 and C-2 patients
than for C-3 and C-4 patients.
Patients with C-3 lesions have impaired breathing and may be ventilator-dependent.
They can shrug their shoulders and they have neck motion, which
permits the operation of specially adapted power wheelchairs and
equipment, such as tape recorders, computers, telephones, page turners,
automatic door openers, and other environmental control units with
mouth control (sip and puff), voice activation, chin control, head
control, eyebrow control, or eye blink. Patients with C-4 lesions
may be free of respiratory equipment beyond the initial acute care
stage, but may have the same functional equipment needs as ventilator-dependent
In addition to powered wheelchairs, C1-4 t Quadriplegics require assistance
for all personal care, turning, and transfer functions. Head rests,
troughs or a lapboard, for the upper extremities, and lifts may
be necessary. Bed surfaces with two or more segments that are alternately
inflated and deflated may be indicated for patients who do not have
assistance for turning. Functional electrical stimulation (FES)
may restore elbow flexor function in patients with C-4 lesions.
For patients with lesions at C-5 or higher, power recliners to achieve
pressure relief while sitting are recommended. Patients with partial
C-4 lesions and inadequate elbow flexors and patients with C-5 lesions
may initially require a balanced forearm orthosis, for enhanced
arm placement, or a long opponens orthosis with utensil slots and
pen holders, for wrist stability, during activities such as feeding,
writing, and typing.
C-5 Quadriplegia: C-5 Quadriplegics have functional deltoid and/or biceps musculature.
They can internally rotate and abduct the shoulder, which causes
forearm pronation by gravity. Wrist flexion is similarly produced.
They can externally rotate the shoulder and cause supination and
wrist extension. They can bend the elbow, but elbow extension can
only be produced by gravity, or by forceful horizontal abduction
of the shoulder and inertia or shoulder external rotation.
C-5 patients require assistance to perform bathing and lower body
dressing functions, for bowel and bladder care, and for transfers.
With the use of balanced forearm orthoses, long opponens orthoses,
or universal cuffs and adaptive equipment, C-5 patients can feed
themselves, perform oral facial hygienic and upper body dressing
activities, operate computers, tape recorders, telephone, etc. and
participate in leisure activities. They can propel manual wheelchairs
short distances on level surfaces, although the hand-hand rim interface
should be modified with vertical or horizontal lugs (or plastic
tubing can be wrapped around the rims), and gloves should be worn
to protect the hands. Powered wheelchairs, propelled with a hand
control, are needed for community distances and outdoor terrain.
C-6 Quadriplegia: C-6 patients have musculature that permits most shoulder motion,
elbow bending, but not straightening, and active wrist extension
which permits tenodesis, opposition of thumb to index finger, and
finger flexion. Wrist extensor recovery is common in C-6 patients,
but its return can be delayed. Tenodesis orthoses support tenodesis
training early in recovery. Wrist-driven flexor hinge splints permit
pinching strength, needed for catheterization and work skills. Short
opponens orthoses with utensil slots, writing splints, Velcro handles,
and cuffs permit feeding, writing, and oral facial hygiene.
C-6 patients can perform upper body dressing without assistance
and may also perform lower body dressing without assistance. They
can catheterize themselves and perform their bowel program with
assistive devices. They can perform some transfers independently
with a transfer board, turn independently with the use of side rails,
and relieve pressure by leaning forward, alternating sides, or possibly
by push-ups. Water mattresses can lower pressure sufficiently to
eliminate the need for turning during the night. They can propel
a manual wheelchair short distances on level terrain, operate power
wheelchairs, and may drive with a van and special equipment. They
can cook, perform light housework, and live independently with limited
Upper extremity reconstructive surgery, or functional neuromuscular
stimulation of the upper extremity, or surgery and stimulation in
the same patient can improve function in C-6 patients. Surgery is
recommended only for patients who are neurologically stable and
without spasticity. Stimulation can be provided by external, percutaneous,
or implanted electrodes, by shoulder motion utilizing an external
system, or by key and palmar grip and release, or by a bionic glove,
an electrical stimulator garment that provides controlled grasp
and hand opening.
C7-8 Quadriplegia: C-7 patients have functional triceps, they can bend and straighten
their elbows, and they may also have enhanced finger extension and
wrist flexion. As a result, they have enhanced grasp strength which
permits enhanced transfer, mobility, and activity skills. They can
turn and perform most transfers independently. They can propel a
manual wheelchair on rough terrain and slopes, and may therefore
not need a powered wheelchair. They may drive with a van and specialized
equipment. They can perform most daily activities, they can cook
and do light housework, and therefore they may live independently.
They may, however, require assistance for bowel care and bathing.
C-8 patients have flexor digitorum profundus function which permits
all arm movement, with some hand weakness. They can propel a manual
wheelchair community distances, including in and out of a car and
over curbs, and may even become wheelchair independent. They can
drive with a van or car and special equipment. They can perform
all personal care and daily activities, except heavy housework.
Incomplete Quadriplegia -
Complete SCI -
Causes of SCI -