So, this concludes the first half of the focused review for spinal cord injury. There are a couple of case scenarios that I'd like to review with you. The first is that of a 26-year-old man who was involved in a motor vehicle crash 24 hours or before this exam. His exam will be shown on the next slide. Another challenge is to classify his sensory, motor, and neurologic levels, the Asian impairment scale, and the zone of partial preservation. So the motor exam is as illustrated here. At C5, he has normal strength on the right and the left. At C6, he has less than anti-gravity strength on the right and moderate resistance on the left. At C7, he has a trace of movement bilaterally. At C8 and T1, he has a trace of movement on the right, but not on the left. There is no movement in the lower extremities, and he has no volitional anal contraction. His sensory exam shows normal sensation in the dermatomes from C2 to C6 bilaterally in both light touch and pinprick, and present but not normal sensation at C7 on both right and left with light touch and pinprick. There's no sensory function below and no anal sensation. What is his sensory level on the right, on the left? What is his motor level on the right, on the left? And what is his neurologic level of injury, the last completely normal level bilaterally? What is his Asia grade, and what is his zone of partial preservation for sensory and motor on the right and the left? The next slide includes the answers. Because this patient has normal strength in his C5 muscles bilaterally, we then are able to look at the C6 muscles, determine whether or not he has, quote, intact strength in that myotome. Intact is defined by a grade 3 or better in a key muscle with the level above it being normal. So in this case, he has a 2 in the right C6 with the C5 being normal. Therefore, he does not get credit for that C6 on the right, but on the left, because he has a 4 out of 5 on the right, or on the left, C6, and the one above it is normal, he gets credit for C6. Therefore, his motor level on the right is C5, and his motor level on the left is C6. His sensory level is normal at C6 bilaterally at both pin and light touch on left and the right. But what is his neurologic level of injury? This would be C5. You have to back up to the level of injury where everything is normal, and that only occurs at C5 at this point. If you repeat the exam in a month, and he has gained strength in that right C6, so that is now at least a 3, then his motor level will change, and his neurologic level of injury will change based on the current neurologic exam. His Asian impairment scale grade is A, motor and sensory complete, because he has no voluntary anal contraction and no anal sensation. His zone of partial preservation on the right is C7, because he has some sensory activity there, and likewise C7 on the left, because there is some sensation there, even though it's not normal. The motor zone of partial preservation on the right goes to T1, because he has some preservation as low as T1 on the right, but on the left, it only goes to C7. Over time, as his neurologic exam changes, his neurologic injury classifications will change as well, and this will have an important impact on his functional expected activity, because we expect everybody to gain at least one level segmentally, and maybe more, and if they are incomplete, likely to gain more motor function distally. So that leads us to the second question, what is this patient's most likely mobility-specific functional outcome at one year? A, power wheelchair with joystick, B, manual wheelchair with push-rim projections, C, manual wheelchair without push-rim projections, D, household ambulation with bilateral KAFOs and a walker, or E, community ambulation with bilateral AFOs and forearm crutches. The answer to this is likely C, a manual wheelchair without push-rim modifications. Because he's likely to recover one or more levels over the first year, he should be able to propel a manual wheelchair. He will be at least a C6 on the right and a C7 on the left, which should allow him to propel a manual wheelchair. However, it is unlikely for him to walk, as he has an Asia A complete injury at this time. A third question, the same patient, now one week after injury, complains of chest tightness, shortness of breath, heart rate increases to 100 to 120 beats per minute, his blood pressure increases from his standard 90 over 60 to 110 over 80, and his oxygen saturation on room air drops to 88%. What is the most likely diagnosis? A, autonomic dysreflexia, B, pulmonary embolism, C, respiratory failure due to ascending spinal cord injury, D, myocardial infarction, or E, gastroesophageal reflux. In this case, the greatest risk for pulmonary embolism is within the first two weeks following spinal cord injury. Signs and symptoms of PE, chest tightness, shortness of breath, tachycardia, hypoxemia are classic, and any blood pressure elevations are likely due to the stress and anxiety. Although he may have some degree of autonomic dysreflexia, this would be likely secondary to the pulmonary embolism, and the PE needs to be addressed first. A 58-year-old woman with a history of diabetes, breast cancer, comes in with complaints of acute onset of mid-thoracic back pain without any associated trauma. She has difficulty walking and reports numbness in her feet and a new onset of urinary incontinence. What is your primary concern? Is this an osteoporotic spine fracture? Is this a diabetic peripheral neuropathy? Is there a metastatic extradural spinal cord compression, a herniated disc with lumbar radiculopathy, or cauda equina syndrome? And in this case, spine metastases must be considered and evaluated urgently in any patient with a history of cancer and new onset back pain weakness and sensory changes, with or without bladder symptoms.

spinal cord injury

motor vehicle crash

sensory levels

functional outcome

metastatic extradural spinal cord compression