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
tetraplegic 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.
Tetraplegia 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
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 patients.
In addition to powered wheelchairs, C1-4 tetraplegics
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 tetraplegics 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
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 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 attendant care.
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.
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.
Tetraplegia - Paraplegia
of SCI -