Level of Injury Question

[Carl R]

I have been doing more and more research trying to find out exactly what happened when I was injured and what level I am. I have been saying for 2 years that I was a C5 incomplete. I asked Dr Donovan last week on my visit and he was rather vague on the complete or incomplete part. As it turns out, I am a C3 sensory, C5 motor at present. I found a letter from 2 years ago which describes my injury as follows:

"Injuries included a burst fracture of C5, fracture of C6 vertebral body, retropulsion of C5, minimally displaced left laminar fracture at C5 and a left laminar fracture at C6. "

What does the above mean in laymans terms and is it rather typical for my level of injury? Also, any clue as to why my sensory is at C3?

[Shawn]

I have the exact same question and just when i logged on to post it, i read this post and decided to include here so:

Dr Young, SCI-Nurse or anyone else that might know. Please explain the following to me. When i was injured in MVA on the 26/10/96, i was only told that i was an incomplete paraplegic and today, almost five years later, my orthopedic surgeon informed me that: "you had an aorto rupture with a spinal infarct at T10 level". He also mentioned that, although i made partial recovery, i still have loss of muscle power in the L5, S1 & S2 groups. Please explain what this all means and what are my chances of a full recovery? Thank you in advance. [img]/forum/images/smilies/wink.gif[/img]

[Wise Young]

Originally posted by Carl R:


I have been doing more and more research trying to find out exactly what happened when I was injured and what level I am. I have been saying for 2 years that I was a C5 incomplete. I asked Dr Donovan last week on my visit and he was rather vague on the complete or incomplete part. As it turns out, I am a C3 sensory, C5 motor at present. I found a letter from 2 years ago which describes my injury as follows:

"Injuries included a burst fracture of C5, fracture of C6 vertebral body, retropulsion of C5, minimally displaced left laminar fracture at C5 and a left laminar fracture at C6. "

What does the above mean in laymans terms and is it rather typical for my level of injury? Also, any clue as to why my sensory is at C3?

Carl R,

Let me begin with a general statement and then get down to specifics, concerning how levels are determined in spinal cord injury.

Until the ASIA classification system was established, there was considerable confusion in the literature concerning how levels should and are being expressed by doctors. Many people do not know that doctors do not agree on the way that spinal cord injury levels are specified. In the early 1990's, we did a survey of some 400 patients that had been seen at Bellevue Hospital and on which we had detailed neurological examinations. We then went through the charts and identified what different doctors thought the levels of injury were. We found, in general that surgeons (neurosurgeons and orthopedic surgeon) tended to express the level of injury by the findings from the bony level of injury seen on CT and MRI. Neurologists and neurosurgeons tend to identify the level of injury as the first neurological level that shows a deficiency. On the other hand, physiatrists (and physical therapists) tend to define the level of injury as the lowest "normal" or functional level. Since bony and neurological levels differ (particularly in the lower spinal cord levels) and the rehab people differ from surgical and neurologists in defining the level of injury as the lowest normal or the highest deficient neurological level, this led to discrepancies of as much as 3 segmental levels in the identification of the injury site.

The American Spinal Injury Association (ASIA) classification system decided to hew to the physiatry definition, i.e. the lowest "normal" level. But, this was, in itself not as straightforward, particularly for determinations of motor levels because any given muscle may receive innervation from more than one segmental level. For example, if a person has slightly weak deltoid (C3/4), very weak biceps (C4/5) on the left, normal deltoids (C3/4), and weak wrist extensors (C6/7) and triceps (C7), what is the motor level? According to ASIA definition, this would be identified as a C3 motor level on the left since C3 is the lowest normal level. A neurologist would classify this as C4 since C4 is the first neurological segment with abnormalities.

In your particular case where you have a burst fracture at C5 which should affect the C4 spinal cord. What you should remember, however, is that the physiatrist's definition of spinal cord injury level is the lowest "normal" segment. So, if you have a C3 sensory level, that means that it is normal and that C4 is the first level to show significant deficits. This would be consistent with a C5 fracture that affected the C4 root.≥

Wise.

[SCI-Nurse]

Spinal cord infarct

Spinal cord infarction can often occur in cases of either aortic aneurysms, either repair or rupture. The cord depends not only on a blood supply from the spinal arteries, but on additional blood flow directly from the aorta. This occurs at several key spots, T-10 being an important one.

It is common to have fairly significant return after spinal cord infracts, depending on how much of the cord was deprived of blood supply and for how long. Some traumatic injuries are really due to damage to the circulation rather than direct damage to the cord.

If you have at this time only weakness in the levels you describe (L5, S1 & S2 groups) then this would be primarily in the muscles that cause knee extension (straightening) and movement of the ankles and toes. Hip muscles are innervated a little higher. How is your sensation? Do you still have bowel and bladder effects? The latter is primarily innervated from S2-4 so it would make sense if you still have some involvement there.

After 4 years it is less likely that you would continue to get more significant return, but it is certainly not totally impossible. I am not aware of any current legitimate therapies that would help this process. You might want to explore 4-AP to see if it helps you at all in these weak muscles.

(KLD)

[Shawn]

Thank you for replying SCI-Nurse. It's really great having people like yourself, Dr. Young and others on this message board. I just want you know that, we really appreciate having all of you here. Now, to answer your questions. I do have fairly good sensation below the level of injury and my bowel movements are normal most of the time. In some instances when it becomes irregular and i can't control it, i just take two immodiums and i'm fine. As far as my bladder goes, i can feel when i need to go but, if i don't reach the toilet in time, i start to leak. My bladder also doesn't empty completely so, i visit the toilet almost every hour. I'm currently using Ditropan for this but, it doesn't seem to be working very well. I can straighten both my legs and i walk with crutches by locking my knees. [img]/forum/images/smilies/smile.gif[/img]

[SCI-Nurse]

Bladder management

Shawn, Ditropan will not help your bladder empty better. It can help to keep you dry if the cause of your leakage is bladder spasm, but not if it is due to "overflow" incontinence. I suspect at your level that you may have a flaccid or areflexive bladder and that when you urinate you may be doing this by straining and increasing your intra-abdominal pressure rather than by controlled bladder contraction. If this is the case, Ditropan will not help you and could make it worse. Generally intermittent catheterization is recommended for this type of problem to assure complete emptying on a regular basis.

The only way to know what is happening with your bladder is to get a complete urodynamics study done. Have you done this? What were the results?
(KLD)

[Shawn]

SCI-Nurse: Yes, i did go for a full urodynamic study way back in July 1999. My Urologist indicated that, i have a very unstable bladder and i have difficulty in emptying my bladder completely. He also mentioned that i have a dangerously high pressure bladder. In order to treat this, he said the first step would be to give me Ditropan and make me to intermittent catherization. I have been taking my Ditropan but, i haven't been catherizing myself at all because, it also doesn't empty my bladder completely. At the time, my Urologist mentioned that, if this did not work, there were two other options, i.e. to do a type of bladder enlargment procedure or, to insert a nerve stimulator. I haven't given either of these options any thought and neither have i seen my Urologist since but, i intend making an appointment with him soon for a check up. [img]/forum/images/smilies/smile.gif[/img]

[Wise Young]

Shawn,

Some of the people who have taken 4-AP have reported better ability to control their urine after they feel urgency. In general, they can hold it longer until they can get to a bathroom. This was not originally something that was looked for in the clinical trials but several post-trial interviews revealed this as a potential beneficial effect of 4-AP.

Wise.

[Shawn]

Thank you for the advise on 4-AP Dr. Young. If it can help me with my bladder problem, that would be really great. Where can i get more information on it because, if my medical insurance agree's to pay for my SCI Rehabilitation, i intend talking to the physio and occupational therapist there about it. [img]/forum/images/smilies/smile.gif[/img]

[Wise Young]

Shawn, there is a lot of information on these forums concerning 4-AP. If you do a search for 4-AP, it should pop up dozens of long postings on the subject. I am working on putting an updated article on 4-AP on the carecure server. I will post that in a few days. Wise.

[Shawn]

Thank you Dr. Young. I found a lot of information and i'm looking forward to your updated article on 4-AP. [img]/forum/images/smilies/wink.gif[/img]