SCI Prognostic Factors Practice Flashcards

Functional Innervation Profile for Complete (AIS A) Spinal Cord Injury

• High Tetraplegia ($C1-C4$) Innervation:

  • Facial muscles.

  • Partial scalenes ($C3-C8$).

  • Levator scapulae.

  • Sternocleidomastoid ($SCM$).

  • Trapezius.

  • Partial diaphragm ($C3-C5$).

• $C5$ Level Innervation:

  • Partial rhomboids ($C5-C6$).

  • Partial pectoralis major ($C5-C7$).

  • Partial teres minor ($C5-C6$).

  • Partial deltoid ($C5-C6$).

  • Partial elbow flexors ($C5-C6$).

• $C6$ Level Innervation:

  • Partial latissimus dorsi ($C6-C8$).

  • Partial extensor carpi radialis ($C6-C7$).

  • Partial serratus anterior ($C6-C8$).

  • Clinical Feature: Utilization of a Tenodesis Grip.

• $C7-C8$ Level Innervation:

  • Flexor carpi radialis.

  • Extensor digitorum.

  • Triceps.

  • Partial flexor digitorum ($C8-T1$).

  • Partial lumbricals ($C8-T1$).

  • Partial interossei ($C8-T1$).

• Paraplegia Level Innervation:

  • Full Upper Extremity ($UE$) innervation.

  • Abdominal muscles innervated to the level of injury.

  • Erector spinae muscles innervated to the level of injury.

  • Hip flexors: ($L1-L4$).

  • Quadriceps ($Quads$): ($L2-L4$).

  • Hamstrings: ($L4-S2$).

  • Anterior Tibialis ($Ant. Tib$): ($L4-L5$).

  • Extensor Hallucis Longus ($EHL$): ($L5-S2$).

  • Gluteus Medius ($Glute Med$): ($L4-S1$).

  • Gluteus Maximus ($Glute Max$): ($L5-S1$).

  • Gastrocnemius ($Gastric$): ($S1-S2$).

Functional Activities and Mobility Prognosis for Complete (AIS A) SCI

• Sitting and Out of Bed ($OOB$) Tolerance:

  • All levels ($C1$ through Paraplegia): Waking hours.

• Communication and Writing:

  • High Tetra ($C1-C4$): Will need assistive technology and assistance with setup for all tasks.

  • $C5$: Modified Independent ($Mod(I)$) to set up with assistive technology.

  • $C6$: Modified Independent ($Mod(I)$).

  • $C7-C8$: Modified Independent ($Mod(I)$).

  • Para: Independent ($I$).

• Feeding:

  • High Tetra ($C1-C4$): Dependent, but able to verbalize.

  • $C5$: Setup/SBA – Minimal Assistance ($Min(A)$).

  • $C6$: Modified Independent ($Mod(I)$).

  • $C7-C8$: Modified Independent ($Mod(I)$).

  • Para: Independent ($I$).

• Grooming (Face Washing, Hair Care, Oral Care):

  • High Tetra ($C1-C4$): Dependent, but able to verbalize.

  • $C5$: Minimal Assistance ($Min(A)$).

  • $C6$: Modified Independent ($Mod(I)$).

  • $C7-C8$: Modified Independent ($Mod(I)$).

  • Para: Independent ($I$).

• Bathing and Dressing:

  • High Tetra ($C1-C4$): Dependent, but able to verbalize.

  • $C5$: Dependent, but able to verbalize.

  • $C6$: Minimal Assistance ($Min(A)$) for upper body; Minimal to Moderate Assistance ($Min-Mod(A)$) for lower body.

  • $C7-C8$: Modified Independent ($Mod(I)$); may need Minimal Assistance ($Min(A)$) if dressing in wheelchair.

  • Para: Independent ($I$) to Modified Independent ($Mod(I)$).

• Bowel and Bladder Management:

  • High Tetra ($C1-C4$): Dependent, but able to verbalize.

  • $C5$: Dependent, but able to verbalize.

  • $C6$: Male: Minimal Assistance ($Min(A)$). Female: Moderate Assistance ($Mod(A)$).

  • $C7-C8$: Modified Independent ($Mod(I)$).

  • Para: Modified Independent ($Mod(I)$).

• Bed Mobility:

  • High Tetra ($C1-C4$): Dependent, but able to verbalize.

  • $C5$: Dependent to Maximum Assistance ($Dep-Max(A)$), but verbalizes all care.

  • $C6$: Minimal Assistance ($Min(A)$) to Modified Independent ($Mod(I)$).

  • $C7-C8$: Modified Independent ($Mod(I)$).

  • Para: Modified Independent ($Mod(I)$).

• Transfers:

  • High Tetra ($C1-C4$): Dependent, but able to verbalize.

  • $C5$: Dependent to Maximum Assistance ($Dep-Max(A)$) and able to verbalize; may assist with parts of some transfers.

  • $C6$: Minimal to Moderate Assistance ($Min-Mod(A)$) for most level surfaces; Moderate to Maximum Assistance ($Mod-Max(A)$) to car; Maximum Assistance to Dependent ($Max(A)-Dep$) for floor transfers.

  • $C7-C8$: Modified Independent ($Mod(I)$) for most; may need Minimal Assistance ($Min(A)$) for w/c loading in car and Moderate to Maximum Assistance ($Mod-Max(A)$) for floor transfers.

  • Para: Modified Independent ($Mod(I)$).

• Power Wheelchair ($w/c$) Mobility:

  • High Tetra ($C1-C4$): Modified Independent ($Mod(I)$) on indoor surfaces and ramps with sip and puff, chin drive, or head array; Dependent for curbs.

  • $C5$: Modified Independent ($Mod(I)$) on indoor surfaces and ramps with hand-drive power w/c; Dependent for curbs.

  • $C6$: Modified Independent ($Mod(I)$) on indoor surfaces and ramps with hand-drive power w/c; Dependent for curbs.

  • $C7-C8$: Modified Independent ($Mod(I)$) on indoor surfaces and ramps with hand-drive power w/c; Dependent for curbs.

  • Para: Only likely to utilize if comorbid conditions or older age are present; should be Modified Independent ($Mod(I)$) with all, but still Dependent for curbs.

• Manual Wheelchair ($w/c$) Mobility:

  • High Tetra ($C1-C4$): Dependent, but able to verbalize.

  • $C5$: Dependent, but able to verbalize.

  • $C6$: Modified Independent ($Mod(I)$) on smooth surfaces; Minimal to Moderate Assistance ($Min-Mod(A)$) on ramps; Maximum Assistance to Dependent for curbs.

  • $C7-C8$: Modified Independent ($Mod(I)$) on smooth surfaces and ramps; Minimal to Moderate Assistance ($Min-Mod(A)$) for curbs.

  • Para: Modified Independent ($Mod(I)$); may need Minimal to Moderate Assistance ($Min-Mod(A)$) for stairwells.

Continued Functional Maintenance and Community Integration

• Skin Care (Weight Shifts, Positioning, Skin Checks):

  • High Tetra ($C1-C4$): Modified Independent ($Mod(I)$) for weight shifts in power w/c; Dependent for all others, but verbalizes care.

  • $C5$: Modified Independent ($Mod(I)$) for weight shifts in power w/c; Dependent for all others, but verbalizes care.

  • $C6$: Modified Independent ($Mod(I)$) for weight shifts in power or manual w/c; Minimal to Moderate Assistance ($Min-Mod(A)$) for positioning and skin checks.

  • $C7-C8$: Modified Independent ($Mod(I)$) for weight shifts in power or manual w/c; Minimal Assistance ($Min(A)$) to Modified Independent ($Mod(I)$) for positioning and skin checks.

  • Para: Modified Independent ($Mod(I)$).

• Community ADLs:

  • High Tetra ($C1-C4$): Will need assistance when in the community.

  • $C5$: Dependent to Moderate Assistance ($Dep-Mod(A)$) depending on the situation; will likely need assistance in community.

  • $C6$: Minimal Assistance ($Min(A)$) for light ADLs; Moderate Assistance ($Mod(A)$) for heavy ADLs; Modified Independent ($Mod(I)$) for driving with hand controls.

  • $C7-C8$: Modified Independent ($Mod(I)$) for light ADLs; Minimal to Moderate Assistance ($Min-Mod(A)$) for heavy ADLs; Modified Independent ($Mod(I)$) for driving with hand controls.

  • Para: Modified Independent ($Mod(I)$) for light ADLs; Minimal to Moderate Assistance ($Min-Mod(A)$) for heavy ADLs; Modified Independent ($Mod(I)$) for driving with hand controls.

• Home Exercise Program ($HEP$):

  • High Tetra ($C1-C4$): Independent ($I$) to Minimal Assistance ($Min(A)$) for respiratory and cervical exercises; Dependent for all others but can verbalize care.

  • $C5$: Independent ($I$) to Minimal Assistance ($Min(A)$) for respiratory and cervical exercises; Dependent for all others but can verbalize care.

  • $C6$: Minimal Assistance ($Min(A)$).

  • $C7-C8$: Modified Independent ($Mod(I)$).

  • Para: Modified Independent ($Mod(I)$).

Summary Takeaways by Injury Level

• High Tetraplegia ($C1-C4$):

  • Physically dependent for all tasks.

  • Goal: Patient must be able to verbalize all care requirements.

• $C5$ Injury Level:

  • Acquires the ability to bring hands to mouth/face for feeding and grooming with assistance ranging from SBA to Moderate Assistance ($Mod(A)$).

  • Otherwise physically dependent, but must be able to verbalize all care.

• $C6$ Injury Level (Most Variable Outcomes):

  • Considered the most variable functional outcome group.

  • Features significantly more innervation in the scapula, shoulder, elbow, and wrist, though not fully innervated.

  • Hand function remains limited with no finger intrinsics.

  • Mobility: Some utilize manual wheelchairs, while others still require power wheelchairs.

  • Independence: Increased ability for independent feeding, grooming, dressing, bathing, and transfers.

  • Driving: Capable of driving with hand controls, but likely needs assistance loading/unloading the wheelchair into the vehicle.

  • Variability Factors: A young, strong, healthy individual with $C6$ AIS A may achieve Modified Independence with most activities, whereas older individuals or those with comorbidities may remain Maximum Assistance to Dependent.

• $C7-C8$ Injury Level:

  • Scapulae, shoulders, elbows, and wrists are fully innervated.

  • Addition of hand and finger intrinsics allows for functional speed and efficiency.

  • Generally Modified Independent ($Mod(I)$) with feeding, grooming, dressing, bathing, and transfers to most surfaces.

  • Mobility: Most can use a manual wheelchair and navigate the community with no more than Minimal Assistance.

  • Driving: Can drive with hand controls and may be independently able to load/unload a manual wheelchair.

• Paraplegia Injury Level:

  • Ease and efficiency in tasks vary based on trunk innervation (higher innervation correlates with better balance, function, and trunk strength).

  • Mobility: Standing and gait may be possible for lower paraplegia levels depending on the degree of Lower Extremity ($LE$) function.

  • General Outlook: Should be Independent or Modified Independent ($I/Mod(I)$) with all daily tasks, driving, employment outside the home, and community navigation.

Prognostic Factors for Ambulation Post-SCI

This section summarizes factors for walking and is NOT limited to complete injuries.

• Ambulation Recovery by One Year Post-Injury (Completeness of Injury):

  • Complete Paraplegia: $5\%$

  • Incomplete Paraplegia: $76\%$

  • Complete Quadriplegia: Very unlikely (statistical data is difficult to locate).

  • Incomplete Quadriplegia: $46\%$

• Ambulation Recovery by SCI Syndrome Classification:

  • Central Cord Syndrome: $77\%$

  • Brown-Sequard Syndrome: Similar to Central Cord Syndrome ($\sim 77\%$), though sources vary.

  • Anterior Cord Syndrome: Poor prognosis for walking.

  • Posterior Cord Syndrome: Functional ambulation is unlikely due to the loss of sensation and proprioception.

  • Cauda Equina / Conus Medullaris Syndrome: Some form of ambulation is considered likely.

Additional Positive Prognostic Factors for Walking

• Motor Function: Quadriceps strength greater than $3/5$ on at least one side within the first $2$ months post-injury.

• Sensory Sparing: Pin prick sensation spared at segments $S4/S5$ one week post-injury.

• Key Muscle Sparing: Pin prick sensation spared at key Lower Extremity ($LE$) muscles required for walking.

• AIS Classification: Classification as AIS C or D (motor incomplete injury).

• International Standards for Neurological Classification of Spinal Cord Injury ($ISNCSCI$) Scores: Lower Extremity Manual Muscle Test ($LE MMT$) scores greater than or equal to $30/50$.

• Age Factor: Being under the age of $50$ at the time of injury.