Cervical Injuries - Tetraplegia

C1-4 Tetraplegia

     Patients with C-1 and C-2 lesions may have functional phrenic nerves. In these cases, implanted phrenic nerve pacemakers can be used, and pacing of the diaphragms may be simultaneous or alternating. If secretions are not a problem, tracheostomies may be plugged or discontinued. Less equipment may be needed for C-1 and C-2 patients than for C-3 and C-4 patients.

     Patients with C-3 lesions have impaired breathing and may be ventilator-dependent. They can shrug their shoulders and they have neck motion, which permits the operation of specially adapted power wheelchairs and equipment, such as tape recorders, computers, telephones, page turners, automatic door openers, and other environmental control units with mouth control (sip and puff), voice activation, chin control, head control, eyebrow control, or eye blink. Patients with C-4 lesions may be free of respiratory equipment beyond the initial acute care stage, but may have the same functional equipment needs as ventilator-dependent patients.

     In addition to powered wheelchairs, C1-4 tetraplegics require assistance for all personal care, turning, and transfer functions. Head rests, troughs or a lapboard, for the upper extremities, and lifts may be necessary. Bed surfaces with two or more segments that are alternately inflated and deflated may be indicated for patients who do not have assistance for turning. Functional electrical stimulation (FES) may restore elbow flexor function in patients with C-4 lesions (Chen, 1997).For patients with lesions at C-5 or higher, power recliners to achieve pressure relief while sitting are recommended (Formal, et al 1997). Patients with partial C-4 lesions and inadequate elbow flexors and patients with C-5 lesions may initially require a balanced forearm orthosis, for enhanced arm placement, or a long opponens orthosis with utensil slots and pen holders, for wrist stability, during activities such as feeding, writing, and typing.

C-5 Tetraplegia

     C-5 tetraplegics have functional deltoid and/or biceps musculature. They can internally rotate and abduct the shoulder, which causes forearm pronation by gravity. Wrist flexion is similarly produced. They can externally rotate the shoulder and cause supination and wrist extension (Formal, et al 1997). They can bend the elbow, but elbow extension can only be produced by gravity, or by forceful horizontal abduction of the shoulder and inertia or shoulder external rotation (Formal, et al 1997).

     C-5 patients require assistance to perform bathing and lower body dressing functions, for bowel and bladder care, and for transfers. With the use of balanced forearm orthoses, long opponens orthoses, or universal cuffs and adaptive equipment, C-5 patients can feed themselves, perform oral facial hygienic and upper body dressing activities, operate computers, tape recorders, telephone, etc. and participate in leisure activities. They can propel manual wheelchairs short distances on level surfaces, although the hand-hand rim interface should be modified with vertical or horizontal lugs (or plastic tubing can be wrapped around the rims), and gloves should be worn to protect the hands (Formal, et al 1997). Powered wheelchairs, propelled with a hand control, are needed for community distances and outdoor terrain.

C-6 Tetraplegia

     C-6 patients have musculature that permits most shoulder motion, elbow bending, but not straightening, and active wrist extension which permits tenodesis, opposition of thumb to index finger, and finger flexion. Wrist extensor recovery is common in C-6 patients, but its return can be delayed. Tenodesis orthoses support tenodesis training early in recovery. Wrist-driven flexor hinge splints permit pinching strength, needed for catheterization and work skills. Short opponens orthoses with utensil slots, writing splints, Velcro handles, and cuffs permit feeding, writing, and oral facial hygiene.

     C-6 patients can perform upper body dressing without assistance and may also perform lower body dressing without assistance. They can catheterize themselves and perform their bowel program with assistive devices. They can perform some transfers independently with a transfer board, turn independently with the use of side rails, and relieve pressure by leaning forward, alternating sides, or possibly by push-ups. Water mattresses can lower pressure sufficiently to eliminate the need for turning during the night (Formal, et al 1997). They can propel a manual wheelchair short distances on level terrain, operate power wheelchairs, and may drive with a van and special equipment. They can cook, perform light housework, and live independently with limited attendant care.

     Upper extremity reconstructive surgery, or functional neuromuscular stimulation of the upper extremity, or surgery and stimulation in the same patient can improve function in C-6 patients. Surgery is recommended only for patients who are neurologically stable and without spasticity. Stimulation can be provided by external, percutaneous, or implanted electrodes, by a neuroprosthesis (Degnan, et al 2002), by shoulder motion utilizing an external system, or by key and palmar grip and release (Formal, et al 1997), or by a bionic glove, an electrical stimulator garment that provides controlled grasp and hand opening (Prochazka, et al, 1997).

C7-8 Tetraplegia

     C-7 patients have functional triceps, they can bend and straighten their elbows, and they may also have enhanced finger extension and wrist flexion. As a result, they have enhanced grasp strength which permits enhanced transfer, mobility, and activity skills. They can turn and perform most transfers independently. They can propel a manual wheelchair on rough terrain and slopes, and may therefore not need a powered wheelchair. They may drive with a van and specialized equipment. They can perform most daily activities, they can cook and do light housework, and therefore they may live independently. They may, however, require assistance for bowel care and bathing.

     C-8 patients have flexor digitorum profundus function which permits all arm movement, with some hand weakness. They can propel a manual wheelchair community distances, including in and out of a car and over curbs, and may even become wheelchair independent. They can drive with a van or car and special equipment. They can perform all personal care and daily activities, except heavy housework.