National Spinal Cord Injury Statistical Center (2021) Facts and figures at a glance

- road traffic accident 40%

- falls 30%

- sports 10%


Chen et al Arch Phys Med Rehab 2016

- 80% male

- cervical (60%), thoracic (30%), lumbar (10%)


van der Berg et al Neuroepidemiology 2010

- bimodal age distribution

- 15 - 29 - motor vehicle accidents and sports

- > 50 - falls


Natural History


Khorasanizadeh et al J Neurosurg Spine 2019

- systematic review of 114 studies

- improvement of one ASIA grade

- grade A: 19%

- grade B: 74%

- grade C: 87%

- grade D: 47%


Mechanism of injury



- mechanical

- contusion / compression / stretch / laceration



- ischemia

- pro-inflammatory state

- additional neuronal death

- microcystic cavitations




Neurological level

- lowest level at which motor and sensory function is normal


Complete lesion / no sacral sparing

- absence of sensory and motor function in the lowest sacral segment

- no sacral sparing


Incomplete lesion / sacral sparing

- presence of sacral and motor function in the lowest sacral segment

- indicates preserved function below the defined neurological level


Spinal shock


Refers to initial flaccid paralysis of all motor, sensory and reflexes absent below level of injury


An accurate assessment of spinal cord function can only be made when spinal shock has resolved (48 hrs in 99%)


Resolution of spinal shock

- return of cord mediated reflexes below the anatomic level of the injury

- bulbocavernosus reflex is the lowest and thus the first to return


Bulbocavernosus Reflex

- squeeze glans / clitoris or pull on urinary catheter

- causes anal contracture

- if present indicates S2-S4 region firing

- spinal shock resolved

- can prognosticate about level of neurological injury


Spinal Cord Injury Grading


Medical Research Council (MRC) Power Grading


0 - no visible movement

1 - palpable or visible contraction

2 - active movement with gravity eliminated

3 - active movement against gravity

4 - active movement against some resistance

5 - active movement against full resistance


ASIA Myotomes/Dermatomes (American Spinal Injury Association)


Upper Limb Motor Sensation Lower Limb Motor Sensation
C5 Elbow flexor Lateral arm L1   Inguinal ligament
C6 Wrist extension Dorsal thumb L2 Hip flexion Middle medial thigh
C7 Elbow extension Dorsum middle finger L3 Knee extension Anterior knee
C8 Finger flexion Dorsum little finger L4 Ankle dorsiflexion Medial malleous
T1 Interossei Medial arm sensation L5 Toe extension First webspace
T2   Armpit sensation S1 Ankle plantarflexion Heel
      S2   Back of knee

Sensory Levels


T4 - nipple

T7 - xiphisternum

T10 - umbilicus

T12 - groin


American Spinal Injury Association Impairment Scale (AIS)


A (complete): no motor or sensory

B (incomplete):  no motor, some sensory intact

C (incomplete):  > 50% muscle groups strength < grade 3

D (incomplete):  > 50% muscle groups strength > grade 3

E (normal) motor and sensory




Cremasteric Reflex T12-L1

- stroke thigh & scrotal contraction


Anal Wink S2-4

- stroke cleft for anal contract



- upgoing = upper motor neuron injury



- stroke tibial crest & toes go up