🚨 Spinal Cord Injury (SCI): Classification (ASIA) and Phased Rehabilitation

Spinal Cord Injury (SCI) involves traumatic or non-traumatic damage to the cord, causing neurological deficits below the lesion. This critical guide focuses on the gold standard ASIA Impairment Scale (AIS), the pathology of spinal shock, and the stage-specific physiotherapy interventions essential for managing motor, sensory, and life-threatening autonomic complications.

1. 📚 Classification: Level and Completeness

A. Based on Anatomical Level

• Tetraplegia (Quadriplegia): Injury in the Cervical Spine (C1–T1), resulting in motor and/or sensory impairment in all four limbs and the trunk.
• Paraplegia: Injury in the Thoracic, Lumbar, or Sacral Spine (T2 and below), resulting in impairment in the lower limbs and trunk (spares the upper limbs).

B. Based on Completeness (ASIA Impairment Scale - AIS)

The ASIA scale is universally used to grade the severity and completeness of SCI. It relies on sensory and motor function at the S4–S5 dermatomes (Sacral Sparing).

Grade	Name	Definition
A	Complete	No motor or sensory function preserved in S4–S5 segments.
B	Sensory Incomplete	Sensory but no motor function preserved below the neurological level and extending through S4–S5.
C	Motor Incomplete	Motor function preserved below the neurological level, and less than half of key muscles below the level have grade $\ge 3/5$.
D	Motor Incomplete	Motor function preserved below the neurological level, and at least half of key muscles below the level have grade $\ge 3/5$.
E	Normal	Motor and sensory function is normal.

2. 🔬 Pathophysiology: Primary vs. Secondary Injury

Primary Injury (Mechanical)

The initial mechanical trauma (contusion, laceration, compression) at the moment of impact. This damage is immediate and irreversible.

Secondary Injury (Ischemia and Edema)

Secondary Injury: This delayed, progressive destruction occurs hours to days after the initial trauma. It is driven by ischemia, local hemorrhage, inflammation, excitotoxicity, and edema. The resulting edema expands the lesion area, making secondary injury the primary target for acute medical and surgical interventions (e.g., decompression).

3. ⚡ Spinal Shock (The Initial Flaccid Stage)

Spinal shock is the immediate, temporary loss of all neurological function, including reflexes, motor power, and sensation, below the level of the injury.

• Clinical Presentation: Flaccid paralysis, Areflexia, absence of sacral reflexes.
• Duration: Lasts days to weeks.
• End Point: The shock state resolves when reflexes return, starting with the Bulbocavernosus Reflex (BCR). The return of reflexes signals the start of the chronic phase, often marked by the emergence of Spasticity (UMN sign).

4. 🚩 Clinical Features and Autonomic Emergencies

A. Motor and Sensory Deficits

• Motor: Initial flaccidity $\rightarrow$ later Spasticity (in lesions above the conus medullaris). Weakness/paralysis below the lesion.
• Sensory: Loss of sensation with a clear Sensory Level demarcating the intact and impaired dermatomes.

B. Autonomic Dysfunction (T6 Rule)

Lesions above $T6$ risk severe autonomic instability:

• Autonomic Dysreflexia (AD): A life-threatening, massive sympathetic response to a noxious stimulus (e.g., full bladder, pressure sore) below the level of injury. Symptoms: sudden, severe Hypertension, pounding headache, flushing above the lesion. Immediate action is required (sit patient up, remove stimulus).
• Orthostatic Hypotension: Severe drop in blood pressure when moving to an upright position due to loss of sympathetic control (vasoconstriction).
• Respiratory: High cervical injuries (C1-C4) affect the phrenic nerve $\rightarrow$ Ventilator Dependence. Poor cough increases pneumonia risk.

5. 🛑 Complications and Long-Term Sequelae

• Musculoskeletal: Contractures, Heterotopic Ossification (HO - bone formation in soft tissue), Scoliosis.
• Integumentary: Pressure Sores (due to sensory loss and immobility) $\rightarrow$ requires constant education and pressure relief.
• Vascular: Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) risk is extremely high in the acute phase.
• Pain: Chronic neuropathic pain (burning, phantom sensations) is common.

6. 🏥 Medical, Surgical, and Pharmacological Management

• Emergency Management (ATLS): Maintaining the airway and breathing while protecting the spine (C-spine immobilization).
• Surgical: Decompression (removing bone/disc fragments compressing the cord) and Stabilization (using rods/screws).
• Pharmacological: Antispastic drugs (Baclofen, Tizanidine), DVT prophylaxis, and aggressive pain control.

7. 🛠️ Physiotherapy Management: Phased Approach

A. Acute Phase (Immobilization & Life Support)

Goals: Respiratory maintenance, joint protection, pressure relief.

• Respiratory: Chest physiotherapy, glossopharyngeal breathing (Frog Breathing) for high SCI.
• Protection: Gentle Passive ROM (avoiding hip flexion/adduction if HO risk is high). Splinting to prevent contractures and preserve tenodesis grip (C6 injuries).
• Positioning: Log-rolling for turning, bed elevation for respiratory effort/ICP (if concurrent TBI).

B. Subacute/Functional Phase

Goals: Strengthening, functional mobility, spasticity management.

• Strengthening: Maximize strength in preserved muscles (grade $3/5$ and above). Strengthen the upper body for transfers (e.g., functional push-ups).
• Balance & Transfers: Mat activities, sitting balance training (dynamic stability). Progression to tilt-table standing (for orthostatic hypotension and bone density).
• Gait Training (ASIA C & D): Use of parallel bars, BWSTT (Bodyweight-Supported Treadmill Training) to encourage locomotor rhythm and weight-bearing. Orthotics (AFO/KAFO) may be fitted.
• Spasticity: Prolonged stretching, positioning, inhibitory casting, and NMES.

C. Chronic Phase (Community and Independence)

• Wheelchair Skills: Advanced mobility, floor-to-wheelchair transfers, pressure relief techniques (every 20 minutes).
• ADL/Adaptive Skills: Training in functional transfers, dressing, and using assistive technology.
• Fitness: Arm ergometry (UE ergometer) for cardiovascular health.

8. 💡 Patient Education and Essential Long-Term Care

Education is central to survival and quality of life in SCI.

• Skin Checks: Daily self-inspection of all skin surfaces (using mirrors).
• AD Management: Training the patient and family to recognize and manage AD swiftly.
• Bladder/Bowel Programs: Teaching intermittent catheterization and bowel management routines.
• Assistive Devices: Selection and proper use of wheelchairs, adaptive equipment, and orthoses (AFOs or KAFOs).

9. 📈 Prognosis and Predictors

Recovery potential is determined by the completeness of the injury:

• ASIA A (Complete): Very low chance of meaningful motor return below the injury. Functional independence relies on compensatory strategies and assistive devices.
• ASIA D (Motor Incomplete): Excellent prognosis for community ambulation (walking).
• Sacral Sparing (S4–S5 function): The single most important clinical predictor of potential neurological recovery and ambulation.

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❓ Frequently Asked Questions (FAQs)

Q: What is the significance of the Bulbocavernosus Reflex (BCR)?

A: The BCR is a sacral reflex ($S2–S4$) tested by squeezing the glans penis or tugging on a catheter, eliciting a contraction of the anal sphincter. Its return signals the end of Spinal Shock and that neurological function below the lesion will transition from flaccid to spastic (if the lesion is UMN).

Q: In a C6 tetraplegia patient, how is hand function managed?

A: C6 injury typically retains wrist extension. This allows for a functional tenodesis grip. The hand should be splinted/positioned to prevent overstretching of the wrist flexors while allowing the finger flexors to shorten, enabling a passive grasp when the wrist extends.

Q: What is Heterotopic Ossification (HO) and how is it managed by PT?

A: HO is the pathological formation of bone in soft tissue, often around the hips or knees, usually beginning 1–4 months post-injury. Management involves maintaining a pain-free passive range of motion. Vigorous, forced stretching is contraindicated as it can increase inflammation and accelerate bone growth.

Q: What are the target goals for managing Orthostatic Hypotension (OH)?

A: OH is managed by gradual verticalization (using a tilt table), abdominal binders/compression stockings (to centralize blood volume), and timed pharmacological intervention if needed. The goal is to slowly acclimate the cardiovascular system to upright posture.

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🎯 10 Practice MCQs for SCI Exam

Q1. A patient with an ASIA D classification means motor function is preserved below the lesion and:

Answer: B). ASIA D is Motor Incomplete with preserved strength that is functionally useful ($\ge 3/5$).

Q2. Spinal shock ends clinically with the return of which reflex?

Answer: A). The BCR is the first sacral reflex to return, signaling the end of spinal shock.

Q3. A lesion at the C7 level would typically result in which condition?

Answer: A). Any injury C1–T1 causes Tetraplegia (impairment in all four limbs).

Q4. The most critical intervention for preventing death during an episode of Autonomic Dysreflexia is:

Answer: B). Sitting the patient up rapidly lowers the blood pressure, reducing the risk of cerebral hemorrhage.

Q5. Secondary injury following SCI is caused primarily by:

Answer: C). Secondary injury is the progressive, delayed, and potentially preventable destruction of neural tissue.

Q6. In the acute phase of SCI, passive stretching should avoid full range hip flexion and knee extension if there is a high risk of developing:

Answer: C). Aggressive stretching around major joints can increase inflammation, accelerating HO formation. PROM should be pain-free.

Q7. The sensory level in SCI is useful for:

Answer: B). The sensory level is determined by the caudal-most dermatome with intact sensation and defines the neurological level.

Q8. For an ASIA A patient with a T10 lesion, what is the most appropriate long-term orthotic device for ambulation?

Answer: A). Complete lesions above L3-L4 generally require a wheelchair for community mobility, as walking devices are too energy-intensive for routine use.

Q9. The preservation of motor or sensory function in the S4–S5 segment is known as:

Answer: A). Sacral sparing is crucial as its presence classifies the injury as Incomplete (ASIA B, C, or D).

Q10. Orthostatic Hypotension in SCI is caused by the dysfunction of:

Answer: B). Loss of sympathetic outflow, particularly in $T6$ and above injuries, prevents the blood vessels from constricting to return blood to the heart upon standing.

📚 Important Academic References

• Kirshblum, S. C., et al. (2011). International Standards for Neurological Classification of Spinal Cord Injury (revised). The Journal of Spinal Cord Medicine, 34(6), 535–546. (The ASIA Classification).
• Ditunno, J. F., et al. (2009). Spinal cord injury: Functional changes after rehabilitation. Archives of Physical Medicine and Rehabilitation, 90(7), 1083–1092. (Functional outcome prediction).
• McKinley, W. O., et al. (2007). Central cord syndrome: analysis of functional and neurological outcomes. Spinal Cord, 45(3), 184–192. (Clinical Syndrome Analysis).
• O’Sullivan, S. B., & Schmitz, T. J. (2019). Physical Rehabilitation (7th ed.). F.A. Davis Company. (For comprehensive Physiotherapy Assessment and Management).