Frankel’s five-level rating method (1969) A B C D E
A: Loss of sensation and movement below the level of injury;
B: Presence of sensation below the level of injury (only some sensation in the sacral region), loss of movement;
C: sensation below the level of injury exists, ineffective movement (i.e., no useful function exists), muscle strength less than grade 3;
D: sensation exists below the plane of injury, effective movement, muscle strength is greater than level 3, can walk with crutches;
E: normal sensation and movement, good bowel function, pathological reflexes exist.
Grade A (complete injury): spinal cord injury below the plane, including S4-S5 (saddle area) without any motor and sensory function preservation;
Grade B (incomplete injury): below the level of spinal cord injury, including S4-S5 (saddle area) with preservation of sensory function, but without any preservation of motor function;
Grade C (incomplete injury): below the level of spinal cord injury, there is preservation of motor function, but more than half of the key muscles below the neurological level of spinal cord injury have muscle strength less than grade 3;
Grade D (incomplete injury): below the level of spinal cord injury, with motor function preserved, and at least half of the key muscles below the level of spinal cord injury are greater than or equal to grade 3;
Grade E (normal): normal sensory and motor function.
Incomplete injury definition: incomplete sensory injury, and the retention of the anal sphincter autonomic contraction or spinal cord injury motor plane below three segments above the residual motor function.
1, the upper cervical spinal cord injury (C1-4)
The upper end of this segment of the spinal cord is connected to the medulla oblongata, so some patients can be combined with clinical manifestations of medulla oblongata or even brainstem injury after injury. When the upper cervical spinal cord is injured, there is often pain in the cervical-occipital region and limited neck movement. c1-2 injury, most patients die immediately. c2-4 segment has a phrenic nerve center, and after the injury, there is mostly paralysis of the diaphragm and other respiratory muscles, and patients show progressive respiratory distress and incomplete paralysis of the upper motor neurons of the extremities below the plane of injury.
2, the lower cervical spinal cord injury (C5-8)
Injury to this segment mostly causes intercostal nerve paralysis, diaphragm paralysis, quadriplegia, flaccid paralysis of both upper limbs, spastic paralysis of both lower limbs, loss of sensation below the plane of injury, C8 to T1 injury can appear claw-shaped hand of ulnar nerve paralysis and Horner’s sign of sympathetic ganglion damage.
3, thoracic spinal cord injury
There is often radicular pain, hyperalgesia or loss of sensation below the level of the lesion, urinary and fecal impairment, motor impairment manifested as upper motor neuron paresis of both lower extremities, and respiratory distress may occur in injuries above Te. Sympathetic block syndrome can occur during the spinal shock period, that is, the loss of vascular tone, that is, a slow decline in pulse, body temperature changes with the external temperature, the overall reflex can appear after the spinal shock period.
4, lumbosacral segment spinal cord injury (L1 ~ S2)
According to its clinical manifestation, it is divided into three parts: lumbar medullary, conus and cauda equina injury. when spinal cord injury is caused by vertebral injury below T10, it shows flaccid paralysis of both lower limbs, disappearance of testicular reflex and knee tendon reflex, presence of abdominal wall reflex, positive Babinski sign; conus injury does not cause motor paralysis of lower limbs, no muscle atrophy of lower limbs, no change in muscle tone and tendon reflex, reduced or lost anal reflex, perianal area including vulva Saddle-type sensory impairment, non-tensile neuronal bladder, often accompanied by sexual dysfunction such as impotence, rectal sphincter relaxation and gluteal muscle atrophy; fracture or dislocation of vertebrae below Lz, damaging the cauda equina nerve, mostly incomplete, manifesting as spontaneous pain in the lower back, thighs, calves and perineum, often asymmetric on both sides, weakness of both lower limbs, often accompanied by muscle atrophy, loss of Achilles tendon reflex, weakened knee tendon reflex. Sphincter and sexual dysfunction and nutritional disorders are often not obvious.
The most important clinical manifestations after spinal cord injury
Various causes of direct or indirect spinal cord injury produce a series of symptoms, but the clinical manifestations are different in the early and late stages. In transverse spinal cord injury, the muscles innervated by the section below are paralyzed, and there is dysfunction of the random motor, sensory and sphincter muscles. Complete damage to the spinal cord either manifests as spinal shock or as complete spastic quadriplegia or paraplegia, the former occurring acutely and the latter developing gradually to form. It may also manifest as incomplete transverse damage of the spinal cord.
I. Spinal cord shock
In acute transverse spinal cord damage, immediately after spinal cord injury, there is flaccid paralysis of the limbs below the plane of damage, hypotonia or loss of muscle tone, hypotonia or loss of all kinds of reflexes, complete loss of deep and superficial sensation below the level of the lesion, inert bladder, urinary retention, fecal incontinence, and atonic (filling) urinary and fecal incontinence.
In addition to various factors related to the spinal cord injury itself, the length of the period of spinal shock is also related to the patient’s age, whether there is infection (such as decubitus ulcer, urinary tract infection), whether there is severe anemia, malnutrition, etc. Especially, the loss of protein caused by decubitus ulcer, and bladder and rectal insufficiency can prolong the period of shock. Usually from 3 to 4 days to 6 to 8 weeks, with an average of 2 to 4 weeks.
Second, complete spinal cord damage
After spinal cord shock, the muscle tone below the plane of injury is increased, tendon reflexes are hyperactive, pathological reflexes are positive, but various senses are not restored, and the general reflexes may appear early, that is, when the skin or mucous membrane below the injury is stimulated, hip and knee flexion, ankle plantarflexion, both lower limbs inversion, abdominal muscle contraction, reflex urination and penile erection, etc., but motor and various senses and sphincter function are not restored. This type of flexion paraplegia is usually indicative of complete transverse spinal cord damage. In contrast, extension paraplegia is now incomplete transverse spinal cord damage.
Incomplete spinal cord damage
Complete transverse spinal cord lesions are relatively rare, and more often incomplete transverse spinal cord damage occurs, either acutely or chronically. In acute lesions, although the damage is incomplete, the physiological function is completely suppressed in the early stage, i.e., spinal shock, so it is difficult to distinguish it from complete transverse spinal cord damage in the early stage, and the real lesion and signs can be revealed only after the spinal shock is gradually eliminated. In the case of chronic lesions, there is no spinal shock, but as the lesion progresses, the manifestations of spinal cord damage gradually appear and worsen: 1.
1.Motor impairment
The extent and degree of motor impairment depends on the nature and location of the lesion. The degree of limb paralysis is usually less than that of a complete transverse injury, and the degree of increased muscle tone and the appearance of pathological reflexes are not as significant as those of a complete transverse injury, and the hyperactivity of tendon reflexes is also less, and the retraction reflex can appear at an early stage.
2.Sensory impairment
The type and degree of sensory impairment depends on the damage to the sensory conduction tracts. Perianal sensation is often intact and painful symptoms may appear.
3.Bladder and rectal dysfunction
The appearance of these disorders is related to the degree of spinal cord lesions and usually parallels the severity of limb paralysis. In mild cases, there may be no bladder and rectal dysfunction, but there is often difficulty in urination. In severe cases, there is often urinary frequency, urgency and even incontinence, the bladder cannot be emptied, the stool is often constipated, and incontinence is less common.