Positive findings & PG level Physiotherapy assessment for Spinal cord injury & explain anatomy ,types & pathology of disease

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Spinal Cord Injury (SCI): Anatomy, Types, Pathology & PG-Level Physiotherapy Assessment

1. ANATOMY OF THE SPINAL CORD

Vertebral Column & Cord Levels

The vertebral column consists of:

Cervical (C1-C7), Thoracic (T1-T12), Lumbar (L1-L5), Sacrum, Coccyx

Vertebral column regions from cervical to coccyx

Vertebral column: cervical (C1-C7), thoracic (T1-T12), lumbar (L1-L5), sacrum, and coccyx - Campbell's Operative Orthopaedics 15e

Key anatomical points:

The spinal cord is shorter than the vertebral column, terminating as the conus medullaris at L2 in adults (L3 in neonates)
Below the conus, the filum terminale (a fibrous cord) connects the cord to the first coccygeal segment
The cord is enclosed in three meninges: pia, arachnoid, and dura mater; the subarachnoid space contains CSF
The cord has cervical and lumbar enlargements corresponding to the brachial plexus and lumbar plexus
Spinal nerves C2-C7 exit above the named pedicle; C8 and below exit below the named pedicle

Internal Tracts (Cross-Sectional Anatomy)

Tract	Location	Function
Dorsal Columns (Fasciculus gracilis/cuneatus)	Posterior	Ipsilateral fine touch, proprioception, vibration
Spinothalamic Tract (STT)	Anterolateral	Contralateral pain and temperature
Corticospinal Tract (CST)	Lateral (posterior)	Ipsilateral voluntary motor control
Anterior CST	Anterior	Ipsilateral proximal motor

Somatotopic arrangement: Cervical tracts are located centrally; thoracic, lumbar, and sacral tracts are progressively more peripheral. This explains the clinical findings of central cord syndrome and syrinx.

Dermatomal and sensory nerve distribution - anterior and posterior views

Dermatomal and cutaneous nerve distribution - Campbell's Operative Orthopaedics 15e

2. TYPES OF SPINAL CORD INJURY

A. Based on Completeness

Complete SCI (ASIA A)

No motor or sensory function preserved in sacral segments S4-S5
Complete transection or physiological disruption below the lesion level

Incomplete SCI (ASIA B, C, D)

Some sensory or motor function is preserved below the neurological level, including in S4-S5

B. Spinal Cord Syndromes (Incomplete Patterns)

Syndrome	Cord Region Affected	Key Clinical Features
Central Cord Syndrome	Central gray + central white matter	Upper extremity weakness > lower; bladder dysfunction; cervical hyperextension injury in elderly
Anterior Cord Syndrome	Anterior 2/3 (STT + CST)	Loss of motor + pain/temperature below level; dorsal column (proprioception, vibration) PRESERVED
Brown-Sequard Syndrome	Hemisection	Ipsilateral motor loss + proprioception loss; contralateral pain + temperature loss
Posterior Cord Syndrome	Dorsal columns	Loss of proprioception, vibration, fine touch; motor PRESERVED
Conus Medullaris Syndrome	L1-L2 (conus)	Mixed UMN + LMN features; bladder/bowel/sexual dysfunction prominent
Cauda Equina Syndrome	Below L2 (nerve roots)	Pure LMN: flaccid paralysis, areflexia, saddle anesthesia, bladder/bowel incontinence

C. By Level

Level	Designation	Primary Deficit
C1-C4	High Cervical	Quadriplegia, diaphragm paralysis (C4+), ventilator dependent
C5-C8	Low Cervical	Quadriplegia; C5: shoulder abduction; C6: wrist extension; C7: elbow extension
T1-T12	Thoracic	Paraplegia; T1-T6: respiratory impairment; Below T6: trunk control intact
L1-L2	Conus	Mixed UMN/LMN
L3-S2	Cauda equina	Flaccid paraplegia/paresis

3. PATHOPHYSIOLOGY

Primary Injury

The initial mechanical insult results from:

Contusion (most common) - vertebral fracture-dislocation
Laceration / transection - penetrating trauma
Distraction - flexion-extension
Compression - burst fractures, disc herniation

Mechanisms produce: direct axonal disruption, neuronal death, hemorrhage into gray matter

Secondary Injury Cascade

This extends damage over hours to days:

Phase	Mechanism	Timing
Vascular	Ischemia, microhemorrhage, vasospasm	Minutes-hours
Ionic	Na+ influx, Ca2+ overload, K+ efflux	Hours
Excitotoxicity	Glutamate release, NMDA receptor activation	Hours
Inflammatory	Neutrophils, macrophages, microglia activation	Hours-days
Free radicals	Lipid peroxidation, oxidative stress	Days
Apoptosis	Programmed cell death in neurons and oligodendrocytes	Days-weeks
Cystic cavitation	Glial scar + syrinx formation	Weeks-months

Increased autophagy activity is detected in neurons, astrocytes, and oligodendrocytes at the lesion zone.

Spinal Shock

Immediately after SCI: marked reduction in all spinal reflex activity below the lesion
Results in areflexic acontractile bladder (urinary retention lasting 6-12 weeks in complete SCI)
Ends when the bulbocavernosus reflex returns
Below-level reflexes then transition to spasticity (detrusor overactivity, DSD)

4. PG-LEVEL PHYSIOTHERAPY ASSESSMENT

A. Subjective Assessment

History:

Mechanism of injury (trauma type, direction of force)
Time since injury, surgical intervention, precautions
Premorbid functional level and comorbidities
Presenting complaints: pain, spasticity, pressure areas, bowel/bladder status
Autonomic symptoms: sweating, flushing, headache (autonomic dysreflexia screening)
Social history, home environment, prior aids/appliances

B. Objective Assessment - Positive Findings

1. Neurological Level Assessment (ISNCSCI / ASIA)

The International Standards for Neurological Classification of SCI (ISNCSCI) is the gold-standard tool:

Motor Testing - Key Muscle Groups (graded 0-5 MRC scale):

Level	Key Muscle	Movement
C5	Elbow flexors (biceps)	Elbow flexion
C6	Wrist extensors (ECRL)	Wrist extension
C7	Elbow extensors (triceps)	Elbow extension
C8	Finger flexors (FDP, middle finger)	Grip
T1	Finger abductors (DI)	Small finger abduction
L2	Hip flexors (iliopsoas)	Hip flexion
L3	Knee extensors (quadriceps)	Knee extension
L4	Ankle dorsiflexors (tibialis anterior)	Ankle dorsiflexion
L5	Long toe extensors (EHL)	Great toe extension
S1	Ankle plantarflexors (gastrocnemius)	Ankle plantarflexion

Sensory Testing - Key Dermatomes (light touch + pinprick):

Tested bilaterally at 28 key points per the ASIA standard form
Graded: 0 = absent, 1 = altered/impaired, 2 = normal

ASIA Impairment Scale (AIS) Grade:

Grade	Definition
A - Complete	No motor or sensory in S4-S5
B - Sensory Incomplete	Sensory but no motor function below neurological level including S4-S5
C - Motor Incomplete	Motor function below neurological level, majority of key muscles grade < 3
D - Motor Incomplete	Motor function below neurological level, majority of key muscles grade ≥ 3
E - Normal	Motor and sensory normal

Positive finding: ASIA motor score, sensory score (light touch/pinprick), neurological level of injury (NLI), zone of partial preservation (ZPP)

2. Tone & Spasticity Assessment

Positive signs of spasticity (UAMS SCI Guidelines 2024):

Clonus (sustained rhythmic contractions)
Rigidity
Increased cutaneous and muscle stretch reflexes (hyperreflexia)
Spasms (flexor/extensor)
Preserved muscle mass / increased muscle activity

Negative signs (also assessed):

Weakness, easy fatigability, loss of selective control

Tools used:

Modified Ashworth Scale (MAS) - grades 0, 1, 1+, 2, 3, 4
Pendulum Test (Wartenberg pendulum test for lower limbs)
Spinal Cord Assessment Tool for Spastic Reflexes (SCATS): clonus (0-3), flexor spasms (0-3), extensor spasms (0-3)
Penn Spasm Frequency Scale

3. Muscle Strength

MRC grading (0-5) for all accessible muscle groups
Compare bilateral symmetry
Document zone of partial preservation (ZPP)
Note any voluntary anal contraction (sacral sparing)

4. Range of Motion (ROM)

Passive ROM: all joints, note contractures
Active ROM: against gravity and resistance
Joint integrity: subluxation, heterotopic ossification (HO)
Document capsular tightness, especially shoulder (rotator cuff) in tetraplegics

5. Sensory Assessment

Superficial sensation: light touch, pain/pinprick, temperature
Deep sensation: proprioception, kinesthesia, vibration, deep pressure
Sacral sensation (S4-S5): perineal sensation, voluntary anal contraction
Map sensory level for dermatomal pattern

6. Reflexes (Positive Findings)

Reflex	Level	Positive Finding in SCI
Biceps (C5-C6)	Cervical	Hyperreflexia (above lesion)
Triceps (C7)	Cervical	Hyperreflexia
Knee jerk (L3-L4)	Lumbar	Hyperreflexia (UMN) or Areflexia (LMN/shock)
Ankle jerk (S1-S2)	Sacral	Hyperreflexia or Clonus
Babinski's sign	Pyramidal	Positive (extensor plantar response) - pathological
Oppenheim's	Pyramidal	Positive in UMN lesion
Clonus	UMN	Sustained - positive
Bulbocavernosus reflex	S3-S4	Absent in spinal shock; return = end of shock
Anal reflex	S4-S5	Absent = complete; present = incomplete
Cremasteric reflex	L1-L2	Absent in UMN lesion

Positive UMN signs (above/at level): spasticity, hyperreflexia, Babinski, clonus, Hoffman's sign (upper limb) Positive LMN signs (at level/cauda equina): flaccidity, areflexia, atrophy, fasciculations

7. Postural & Balance Assessment

Sitting balance: static and dynamic (Function in Sitting Test - FIST)
Standing balance: Berg Balance Scale (BBS), Functional Reach Test (FRT)
Mini-BESTest (Mini-Balance Evaluation Systems Test)
Timed Up and Go (TUG) in ambulatory incomplete SCI
T-Shirt Test for upper limb function
Note: A 2025 meta-analysis (PMID 39111646) confirmed balance interventions significantly improve upright balance in motor-incomplete SCI (BBS improvement MD = 4.22, 95% CI 1.78-6.66)

8. Functional Assessment

Spinal Cord Independence Measure (SCIM III):

Self-care: 0-20 points
Respiration and sphincter management: 0-40 points
Mobility (room + toilet): 0-40 points
Total: 0-100 (higher = more independent)

Functional Independence Measure (FIM):

18-item scale; motor and cognitive subscales
7-point scale (1 = total assist; 7 = complete independence)

Wheelchair Skills Test (WST) - for wheelchair users

9. Respiratory Assessment

Vital Capacity (VC) and FEV1 - significantly reduced in high cervical/thoracic injuries
Diaphragm function (C3-C5 via phrenic nerve)
Accessory muscle recruitment (sternocleidomastoid, scalenes)
Cough effectiveness (peak cough flow)
Positive findings: reduced VC, paradoxical breathing pattern, absent cough, SPO2 <95%
ABG analysis in ventilator-dependent patients (C4 and above)

10. Autonomic Assessment

Blood pressure: orthostatic hypotension (common at acute stage)
Autonomic Dysreflexia (AD): lesions at or above T6
- Triggers: bladder distension, pressure sores, constipation
- Positive signs: paroxysmal hypertension (>150 mmHg systolic), bradycardia, flushing/sweating above lesion, pallor/piloerection below lesion, headache
- Emergency: sit upright, remove trigger, sublingual nifedipine if SBP >150 mmHg
Thermoregulation: poikilothermia below lesion level
Heart rate variability

11. Skin & Pressure Injury Risk

Braden Scale / WATERLOW Score for pressure injury risk
Inspect all bony prominences: sacrum, ischials, greater trochanter, malleoli, heels
Note skin breakdown, maceration, redness, Stage I-IV pressure injuries
Assess sensory impairment over pressure areas

12. Pain Assessment

Neuropathic pain (at-level / below-level): burning, shooting, dysesthetic
Nociceptive pain: musculoskeletal (shoulder overuse in wheelchair users)
Numeric Rating Scale (NRS) / Visual Analogue Scale (VAS)
International SCI Pain Basic Data Set classification

13. Gait & Locomotion (Incomplete SCI)

10-Metre Walk Test (10MWT): walking speed
6-Minute Walk Test (6MWT): endurance
Timed Up and Go (TUG)
Walking Index for SCI (WISCI II): 0-20 scale incorporating use of assistive device, bracing, and physical assistance
Lower Extremity Motor Score (LEMS): Patients with LEMS ≥ 10 at 1 month become community ambulators; LEMS ≥ 30 allows near-normal walking speed (Bradley and Daroff, cited in Dobkin et al. 2006)

14. Upper Limb Function (Tetraplegia)

Grasp and release: key pinch, palmar grasp, lateral pinch
Jebsen-Taylor Hand Function Test
Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP)
Box and Block Test
Manual wheelchair propulsion capacity

C. Outcome Measures Summary (PG Level)

Domain	Tool
Neurological classification	ISNCSCI / ASIA
Spasticity	MAS, SCATS, Penn Spasm Scale
Functional independence	SCIM III, FIM
Ambulatory function	WISCI II, 10MWT, 6MWT, TUG
Balance	BBS, FIST, Mini-BESTest
Pain	NRS, VAS, SCI Pain Basic Data Set
Quality of life	SF-36, WHOQOL-BREF
Respiratory	Spirometry, Peak Cough Flow
Upper limb (tetraplegics)	GRASSP, Jebsen-Taylor
Fatigue	FSS-SCI, MFI (2026 Systematic Review, PMID 41047092)

D. Functional Prognosis (Evidence-Based)

ASIA A at onset: ~4% recover any walking ability; almost never recover normal bowel/bladder
ASIA B at onset: ~40% regain walking by 26 weeks
ASIA C at onset: ~70% recover unlimited walking (Geisler et al., 2001 trial of 760 patients)
ASIA C - no motor gains by 16 weeks markedly reduces likelihood of useful motor recovery
With C5 intact: self-feeding possible with assistive devices; power wheelchair with hand control
With C6 intact: wrist extension allows tenodesis grip; manual wheelchair propulsion, sliding board transfers possible
With C7 intact: more efficient ADLs, suppository use for bowel program feasible
Patients with education beyond high school are far more likely to return to work (Bradley and Daroff's Neurology in Clinical Practice)

E. Key Precautions During Assessment

Maintain spinal precautions until cleared
Screen for autonomic dysreflexia before any assessment in T6 and above injuries
Check skin before and after positioning
Monitor blood pressure for orthostatic hypotension during position changes
Ensure bowel/bladder has been attended to before assessment (to prevent AD)
Screen for deep vein thrombosis (DVT) - Homan's sign, limb swelling

5. QUICK REFERENCE: LESION LEVEL vs. EXPECTED FUNCTION

Level Intact	Expected Function
C4	Diaphragm breathing; power wheelchair (chin/sip-puff control); dependent for all ADLs
C5	Shoulder shrug, elbow flexion; BFO-assisted feeding; power wheelchair
C6	Wrist extension, tenodesis grip; self-catheterization, UE dressing, manual wheelchair
C7	Elbow extension; independent transfers, most ADLs from wheelchair
C8-T1	Finger control; full wheelchair independence
T1-T9	Paraplegia; independent with wheelchair; therapeutic ambulation only
T10-L1	Household ambulator with KAFO and walker
L2-S1	Community ambulator with AFO/crutches

Sources:

Campbell's Operative Orthopaedics 15e (2026) - Anatomy of Spinal Cord and Nerves
Bradley and Daroff's Neurology in Clinical Practice - SCI Rehabilitation, Neurological Level, Prognosis
Bailey and Love's Short Practice of Surgery 28e - Spinal shock, Autonomic Dysreflexia
StatPearls - Spinal Cord Injuries (NIH, 2024) - Classification, Pathophysiology, ASIA
UAMS IDHI SCI Guidelines 2024 - Spasticity Assessment, MAS, SCATS
Benn et al., 2025 (PMID 39111646) - Meta-analysis: Balance interventions in motor-incomplete SCI
Lahuerta-Martin et al., 2026 (PMID 41047092) - Fatigue outcome measures in SCI

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