Tetraplegia


Definition/Description[edit | edit source]

Tetraplegia is a paralysis caused by an injury of the cervical spinal cord. This can result in a partial or total sensory and motor loss of the four limbs and torso[1]. The injuries that occur above level C4 often result in respiratory deficiency.[2]

Epidemiology /Etiology[edit | edit source]

In the United States, there is an estimated incidence of tetraplegia or paraplegia of 230,000 persons a year.[3][4]
Eighty percent of the tetraplegic cases are men and almost 60 percent of the cases arise from traffic accidents. Almost 50 percent of the patients were between 18 and 25 years old at the time of the accident. The most often affected levels are C4 - C7. Half of the patients have physiotherapy, with an average of 3 times a week.[5]

Characteristics/Clinical Presentation[edit | edit source]

Patients with tetraplegia have different clinical presentations, depending on the level of the injury. In general, all patients have motor and sensory deficits in the arms, trunk and legs.[1]
The spinal cord can be crushed (e.g. due to compressing forces caused by translation of a vertebra or segment) or torn (e.g. due to extreme tension caused by an extreme movement of the spine causing trauma of multiple tissues). In case it is torn, it will likely have a better prognosis. When the spinal cord is crushed, the decompression is urgent within 2-3 hours, otherwise the prognosis will worsen.[6]
In the case of a high tetraplegic lesion (above C3), the patient may experience a locked-in syndrome. This means that he or she is aware of everything, but there is no communication possible or communication is reduced to vertical eye movements and blinking.[7]

The most common complications are: [3] [8]

  • respiratory problems such as atelectasis, hypersecretion, bronchospasms, pulmonary edema and pneumonia.
  • pulmonary thromboembolism and other embolisms (blood clots).
  • urinary and pulmonary infections
  • pressure sores
  • spastic muscles
  • loss of bladder and bowel control
  • pain

Differential Diagnosis[edit | edit source]

There is no differential diagnosis, the American Spinal Injury Association (ASIA) classification excludes other disorders. Frankel or ASIA classification: Only grade A is a para- or tetraplegia.
We can differentiate between tetraplegia and paraplegia, and between tetraplegia and tetraparesis. We speak of tetraparesis if the paralysis is not complete.
The difference between tetraplegia and paraplegia lies in the affected levels, we say everything above level T1 is in the category of tetraplegia. Below C8 until the cauda equina is paraplegia.[9]

Diagnostic Procedures[edit | edit source]

An early and accurate diagnosis of lesions of the spine and cervical spinal cord in tetraplegic patients is important. To find out which part of the spine is damaged they could use imagining studies such as computed tomography (CT) and magnetic resonance imaging. Sometimes they use CT or MRI scan with contrast for a more accurate diagnosis. In case of diseases of the spinal cord they do a blood test and/or spinal tap to investigated the blood and/or spinal fluid.[10] [11]

Examination[edit | edit source]

The initial assessment of individuals with acute spinal cord injury should include a complete history, physical, and neurologic examination to determine the level of injury as accurately as possible. Physical assessment should include an evaluation of breathing pattern and effectiveness of cough. The most common abnormal breathing pattern is an isolated diaphragmatic breathing with chest wall retraction during inspiration.[8]
The neurologic examination, more specific the motor and sensory examinations, of tetraplegia includes:

  • The International Standards for Neurological Classification of Spinal Cord Injury (ISCSCI)
  • Electrophysiological measures: stimulated muscle testing, strength-duration (SD) testing, evoked-potential testing, nerve conduction velocity (NCV) testing, and needle and dynamic electromyography (EMG) testing
    These motor and sensory examinations could be used for the assessment of muscles strength and sensation.
    For the assessment of upper limb in tetraplegia, the Sollerman hand function test, Capabilities of the Upper Extremity instrument (CUE), the Motor Capacity Scale and the Tetraplegia Hand Activity Questionnaire are useful instruments. At least, one or a combination of these tools should be used for the assessment of the hand function and to collect evidence for interventions.[12]

In the systematic review, Julio C. Furlan et al., they collect eight different outcome measures that were used to assess disability in the spinal cord injury population:[13]

  • Functional Independence Measure (FIM)
  • Spinal Cord Injury Measure
  • Walking Index for Spinal Cord Injury (WISCI)
  • Quadriplegia Index of Function (QIF)
  • Modified Barthel Index (MBI)
  • Timed Up & Go (TUG)
  • 6-min walk test (6MWT)
  • 10-m walk test (10MWT)

Medical Management[edit | edit source]

The medical management of tetraplegia could be the treatment of the cause, an invasive technique might be used to release pressure or attempts can be made to repair damage. Most of these techniques are still in an experimental stage (eg. use of stem cells).[14]
More often, the treatment is aimed at functional recovery. The ability to use the upper limb(s) has an important influence on the independence of the patient (use of a wheelchair, pressure relief manoeuvres, independent transfers, etc). Therefore, procedures such as the transfer of the teres minor motor branch for triceps reinnervation and biceps-to-triceps transfer for elbow extension could give the patient an improvement in function. Most physicians believe these procedures are beneficial, but unfortunately, they are often not used since the risk/benefit ratio is still unknown. The known literature consists of small case reports.[15] [16] [17]
Patients that lost their ability to breathe autonomously are ventilated through a tracheotomy and are more likely to get a respiratory infection and/or disease. A better technique is the use of a diaphragm pacing system, which electrically stimulates the phrenic nerve to pace the diaphragm. This technique has promising results but, more trials are necessary to evaluate the impact on the patients. [18]

Physical Therapy Management[edit | edit source]

As mentioned above, the ability to use the upper limbs is considered crucial to regain independence. A review of several studies showed that different training techniques may improve arm and hand functioning after cervical spinal cord injury, with tetraplegia as a consequence. There is some evidence that suggests that task-specific training (with functional electrical stimulation if the grasp function is too weak) is ideal to improve the hand function. Almost all studies showed an improvement in arm and hand function and/or activity level. Therefore a physical therapist should set individual goals for each patient and use a specific (suitable) training program to gain success. [19][20][1]
If the surgeon and physician decide to use a procedure as mentioned above, the physiotherapist’s task will be to reinforce the muscle and teach the patient to control his muscle individually.

Furthermore, the lack of physical activity which is often paired with chronic spinal cord injury should be one of the key points a physical therapist should address. Innovative techniques such as the use of functional electrical stimulation lower extremities cycling [21] , treadmill gait and electrical stimulation during gait are used to regain/maintain muscle mass in the legs , strengthen the bones and to gain many other benefits from physical activity (cardiovascular). [22][23] Hypotension and orthostatic hypotension is often seen in these patients; a patient should be instructed to get up (from a lying or seated position) gradually and slowly. Circulatory exercises before standing up might be helpful to stimulate the blood flow. Furthermore, medication, a special diet (with enough water and salt) and regular exercise therapy should be given to prevent hypotension.

For the respiratory problems that can come with tetraplegia, secretion removal techniques, use of expiratory flow devices are recommended and the improvement of various components of cough (Vital capacity, flow rate, maximum respiratory pressures) are recommended. Intermittent positive pressure breathing (IPPB) can be used as a treatment or to prevent atelectasis.
Studies have shown that inspiratory muscle training with a threshold trainer at low loads increases the strength of the respiratory muscles in quadriplegic patients. The efficacy for quadriplegics has not been proven but, it is suggested that this will help the respiration as it does for COPD patients.[24]

Clinical Bottom Line[edit | edit source]

Patients with tetraplegia have different clinical presentations, depending on the level of the injury. An injury of the cervical spinal cord can result in a partial or total sensory and motor loss of the four limbs and torso.[25] An early and accurate diagnosis of lesions of the spine and cervical spinal cord in tetraplegic patients is important.
The initial assessment of individuals with acute spinal cord injury should include a complete history, physical, and neurologic examination (CT-scan) to determine the level of injury as accurately as possible.
Physical assessment should include an evaluation of breathing pattern and effectiveness of cough.
A physical therapist should set individual goals for each patient and use a specific (suitable) training program to gain success.[26] The lack of physical activity which is often paired with chronic spinal cord injury should be one of the key points a physical therapist should address. In case of respiratory problems the proper treatment (see Physical Therapy Management) should be applied.

Case Studies[edit | edit source]

Two case reports of cervical spinal cord injury in football (soccer) players P Silva1, S Vaidyanathan1, B N Kumar1, B M Soni1 and P Sett1

https://www.icf-casestudies.org/en/case_studies.php?id=13&cat_id=16&k=0

References[edit | edit source]

  1. 1.0 1.1 1.2 Spooren AI, Janssen-Potten YJ, Kerckhofs E, Seelen HA. Outcome of motor training programmes on arm and hand functioning in patients with cervical spinal cord injury according to different levels of the ICF: a systematic review. Journal of rehabilitation medicine. 2009 Jun 5;41(7):497-505.
  2. Reid WD, Brown JA, Konnyu KJ, Rurak JM, Sakakibara BM, SCIRE Research Team. Physiotherapy secretion removal techniques in people with spinal cord injury: a systematic review. The journal of spinal cord medicine. 2010 Jan 1;33(4):353-70.
  3. 3.0 3.1 Firsching R. Moral dilemmas of tetraplegia; the 'locked-in' syndrome, the persistent vegetative state and brain death. Spinal cord. 1998 Nov;36(11):741-3.
  4. Hamou C, Shah NR, DiPonio L, Curtin CM. Pinch and elbow extension restoration in people with tetraplegia: a systematic review of the literature. The Journal of hand surgery. 2009 Apr 1;34(4):692-9.
  5. . Enquête 1995 sur le devenir des tétraplégiques par AFIGAP 4
  6. CTR Brugmann, Jean-François Dinant, Coordination Paramedicale.5
  7. Firsching R. Moral dilemmas of tetraplegia; the 'locked-in' syndrome, the persistent vegetative state and brain death. Spinal cord. 1998 Nov;36(11):741-3.
  8. 8.0 8.1 Berlly M, Shem K. Respiratory management during the first five days after spinal cord injury. The journal of spinal cord medicine. 2007 Jan 1;30(4):309-18.
  9. http://www.apparelyzed.com/quadriplegia.html
  10. Chin KR, Seale J, Cumming V. “White cord syndrome” of acute tetraplegia after anterior cervical decompression and fusion for chronic spinal cord compression: a case report. Case reports in orthopedics. 2013 Mar 4;2013.
  11. Pinheiro DF, Fontes B, Shimazaki JK, Bernini CD, Rasslan S. Diagnostic value of tomography of the cervical spine in victims of blunt trauma. Revista do Colégio Brasileiro de Cirurgiões. 2011;38:299-303.
  12. Mulcahey MJ, Hutchinson D, Kozin S. Assessment of upper limb in tetraplegia: Considerations in evaluation and outcomes research. Journal of Rehabilitation Research & Development. 2007 Jan 1;44(1).
  13. Furlan JC, Noonan V, Singh A, Fehlings MG. Assessment of disability in patients with acute traumatic spinal cord injury: a systematic review of the literature. Journal of neurotrauma. 2011 Aug 1;28(8):1413-30.
  14. Li J, Lepski G. Cell transplantation for spinal cord injury: a systematic review. BioMed research international. 2013 Oct;2013.
  15. Bertelli JA, Ghizoni MF, Tacca CP. Transfer of the teres minor motor branch for triceps reinnervation in tetraplegia: case report. Journal of neurosurgery. 2011 May 1;114(5):1457-60.
  16. Kozin SH, D'Addesi L, Chafetz RS, Ashworth S, Mulcahey MJ. Biceps-to-triceps transfer for elbow extension in persons with tetraplegia. The Journal of hand surgery. 2010 Jun 1;35(6):968-75.
  17. Curtin CM, Hayward RA, Kim HM, Gater DR, Chung KC. Physician perceptions of upper extremity reconstruction for the person with tetraplegia. The Journal of hand surgery. 2005 Jan 1;30(1):87-93.
  18. Tedde ML, Vasconcelos Filho P, Hajjar LA, Almeida JP, Flora GF, Okumura EM, Osawa EA, Fukushima JT, Teixeira MJ, Galas FR, Jatene FB. Diaphragmatic pacing stimulation in spinal cord injury: anesthetic and perioperative management. Clinics. 2012 Nov;67(11):1265-9.
  19. Harvey LA, Dunlop SA, Churilov L, Hsueh YS, Galea MP. Early intensive hand rehabilitation after spinal cord injury (" Hands On"): a protocol for a randomised controlled trial. Trials. 2011 Dec;12(1):1-9.
  20. Spooren AI, Janssen-Potten YJ, Kerckhofs E, Bongers HM, Seelen HA. Evaluation of a task-oriented client-centered upper extremity skilled performance training module in persons with tetraplegia. Spinal cord. 2011 Oct;49(10):1049-54.
  21. Dolbow DR, Gorgey AS, Moore JR, Gater DR. Report of practicability of a 6-month home-based functional electrical stimulation cycling program in an individual with tetraplegia. The journal of spinal cord medicine. 2012 May 1;35(3):182-6.
  22. de Abreu DC, Cliquet A, Rondina JM, Cendes F. Electrical stimulation during gait promotes increase of muscle cross-sectional area in quadriplegics: a preliminary study. Clinical orthopaedics and related research. 2009 Feb;467(2):553-7.
  23. Carvalho DC, Garlipp CR, Bottini PV, Afaz SH, Moda MA, Cliquet Jr A. Effect of treadmill gait on bone markers and bone mineral density of quadriplegic subjects. Brazilian journal of medical and biological research. 2006 Oct;39(10):1357-63.
  24. Silveira JM, Gastaldi AC, Boaventura CD, Souza HC. Inspiratory muscle training in quadriplegic patients. Jornal Brasileiro De Pneumologia. 2010;36:313-9.
  25. Spooren AI, Janssen-Potten YJ, Kerckhofs E, Seelen HA. Outcome of motor training programmes on arm and hand functioning in patients with cervical spinal cord injury according to different levels of the ICF: a systematic review. Journal of rehabilitation medicine. 2009 Jun 5;41(7):497-505.
  26. Harvey LA, Dunlop SA, Churilov L, Hsueh YS, Galea MP. Early intensive hand rehabilitation after spinal cord injury (" Hands On"): a protocol for a randomised controlled trial. Trials. 2011 Dec;12(1):1-9.