Functional Outcomes per Level of Spinal Cord Injury

Updated: Aug 30, 2023
  • Author: William McKinley, MD; Chief Editor: Stephen Kishner, MD, MHA  more...
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Functional outcomes are strongly associated with the neurologic level of a patient's spinal cord injury (SCI). The objectives of rehabilitation after an individual has sustained an acute SCI include maximizing the person's medical, functional, and psychosocial outcomes. Providing education to the patient and his/her family is also essential. Rehabilitation should begin as soon as possible after injury in order to optimize outcomes and reduce complications.

An interdisciplinary team approach is needed and typically involves specialists from many disciplines, including rehabilitation medicine, nursing, various therapists (physical, occupational, speech, recreational, vocational), psychology, social work, and/or case management, who can individualize the program to meet the patient's needs and abilities. The SCI rehabilitation physician, often a specialist in physical medicine and rehabilitation (physiatry), must be able to predict the potential functional outcomes of individuals who have had an acute SCI. This information assists the physician in appropriately informing the patient and his/her family and helps these individuals to set realistic functional goals.

Functional outcomes may vary by individual, depending on such factors as the level and completeness of the injury, neurologic recovery (or loss), associated medical complications (pain, spasticity, contractures, cardiac disease, musculoskeletal injury), the amount of rehabilitation training that the patient receives, and the rehabilitation team's level of expertise, as well as the patient's motivation, age, and family and financial resources.

The use of orthotics and assistive devices (some of which are mentioned below) can sometimes facilitate the patient's functional abilities. [1] Advances in surgical reconstruction and functional electrical stimulation (FES) also may enhance the patients' functional abilities.

A study by Hatch et al of 759 individuals with SCI found that in such patients, neither the severity nor the level of injury was related to decreased survival in the 10 years after injury, although older age, male sex, and a lower dismissal Functional Independence Measure (FIM) score were. [2]


Neurologic Level and Completeness of Injury

The neurologic level and completeness of injury are important factors in predicting neurologic recovery and, therefore, functional outcome after SCI. The International Standards for Neurological Classification of SCI (ISNCSCI), including the American Spinal Injury Association (ASIA) Impairment Scale (see below), is a standardized assessment and classification scale used for SCI. The more incomplete the injury is, especially on initial examination at 72 hours to 1 week after the injury has occurred, the more favorable the potential for neurologic recovery. [3, 4, 5, 6, 7]

Neurologic recovery usually plateaus in the first 3-6 months (although changes have been reported >1 year after injury). Individuals with motor-complete injuries are usually expected to recover 1 motor level of function distal to the lowest motor level observed during their initial examination. [8]

Comprehensive and detailed neurologic examinations that are performed early and are repeated often form an important component of patient assessment and of neurologic and functional outcome prediction. Key elements of the examination include motor and sensory testing, which allows for the designation of a neurologic level of injury (NLOI) and of the completeness of injury. In addition, rectal examination is required to assess motor and sensory functions.

A study by Macklin et al suggested that electrical perceptual threshold (EPT) tests are more sensitive than ISNCSCI exams for determining the level of SCI at which sensory function still exists in patients with chronic incomplete cervical SCI. The investigators reported that the spinal segment at which sensory function was found to be maintained was lower in EPT testing than in ISNCSCI evaluation in 15 of 17 individuals with this sort of SCI. [9]

Neurologic level of injury

The NLOI is defined as the most caudal (ie, lowest) level of the spinal cord that has normal motor and sensory function. The motor level, which is a better predictor of the patient's functional abilities, is determined by the manual testing of key muscle groups on both sides of the body. These groups represent neurologic levels, and findings are graded 0-5, as follows:

  • Grade 5 - Normal; muscle movement through the complete range of motion (ROM) against gravity and full resistance

  • Grade 4 - Good; muscle movement through the complete ROM against gravity and moderate resistance

  • Grade 3 - Fair; muscle movement through the full ROM against gravity alone

  • Grade 2 - Poor; muscle movement through the full ROM with gravity eliminated

  • Grade 1 (Trace) - Palpable muscle contraction or joint movement, but not through complete ROM, even with gravity eliminated

  • Grade 0 - Zero; no muscle movement or palpable contraction

Motor levels representing upper and lower extremity function (and key muscles) are as follows:

  • C5 - Elbow flexion (biceps)

  • C6 - Wrist extension (extensor carpi radialis)

  • C7 - Elbow extension (triceps)

  • C8 - Finger flexion (flexor digitorum profundus)

  • T1 - Small finger abductors (abductor digiti minimi)

  • L2 - Hip flexion (iliopsoas)

  • L3 - Knee extension (quadriceps)

  • L4 - Ankle dorsiflexion (tibialis anterior)

  • L5 - Great toe extension (extensor hallucis longus)

  • S1 - Ankle plantar flexion (gastrocsoleus complex)

Sensory function is determined by examining 28 key sensory points on both sides of the body. These points are designated within dermatomes for light touch and pin prick. They are graded as follows: 2 = normal, 1 = impaired, and 0 = absent.

Sensory levels are designated as follows:

  • C2 - Occipital protuberance

  • C3 - Supraclavicular fossa

  • C4 - Top of acromioclavicular joint

  • C5 - Lateral antecubital fossa

  • C6 - Thumb

  • C7 - Middle finger

  • C8 - Little finger

  • T1 - Medial antecubital fossa

  • T2 - Apex of axilla

  • T3 - Third intercostal space (IS)

  • T4 - Fourth IS (nipple line)

  • T5 - Fifth IS (midway T4-T6)

  • T6 - Sixth IS (xiphisternum)

  • T7 - Seventh IS (midway T6-T8)

  • T8 - Eighth IS (midway T6-T10)

  • T9 - Ninth IS (midway T8-T10)

  • T10 - Tenth IS (umbilicus)

  • T11 - 11th IS (midway T10-T12)

  • T12 - Inguinal ligament (midpoint)

  • L1 - Half the distance T12-L2

  • L2 - Midanterior thigh

  • L3 - Medial femoral condyle

  • L4 - Medial malleolus

  • L5 - Dorsum of foot (third metatarsophalangeal joint)

  • S1 - Lateral heel

  • S2 - Popliteal fossa (midline)

  • S3 - Ischial tuberosity

  • S4-5 - Perianal area

ASIA Impairment Scale

The ASIA Impairment Scale classifies the completeness of SCI on a scale from A-E, as follows [3, 4, 5, 6] :

  • A - Complete; no sacral motor or sensory sensation in segments S4-5

  • B - Sensory incomplete; preservation of sensation below the level of injury, extending through sacral segments S4-5

  • C - Motor incomplete; voluntary anal sphincter contraction or sensory sacral sparing, with sparing of motor function distal to 3 levels below the motor level of injury and with the majority of key muscles having a strength grade of less than 3

  • D - Motor incomplete; voluntary anal sphincter contraction or sensory sacral sparing, with sparing of motor function distal to 3 levels below the motor level of injury and with the majority of key muscles having a strength grade of 3 or greater

  • E - Normal; normal motor and sensory recovery (hyperreflexia may be present)

Functional Outcome Measures

Several functional outcome measures are reliable and valid for use in SCI. Outcome measures need to be standardized and validated so that clinicians know how to perform them, are clear on their measuring characteristics, and are capable of providing information about clinically meaningful outcome changes. A common scale for the measurement of functional ability is the Functional Independence Measure (FIM), which uses a 7-point scale to measure 18 items in the following 6 categories:

  • Mobility

  • Locomotion

  • Self-care

  • Continence of the bowel and/or bladder

  • Communication

  • Social cognition

On the FIM scale, a score of 1 indicates total dependence on a caregiver, and a score of 7 indicates independence. Numbers between 1 and 7 represent different levels of assistance required from a caregiver or assistive device to perform a specific skill. [1]

Additional functional assessment scales are as follows:

  • Quadriplegic Index of Function (QIF) - Designed to detect small, but clinically relevant, changes in individuals with tetraplegia, in 9 categories of activities of daily living (ADL)

  • Modified Barthel Index (MBI) - A 15-item assessment of self-care and mobility skills

  • Walking Index for SCI (WISCI and WISCI II) - A scale that has demonstrated validity and responsiveness to change in neurologic/walking function after SCI [10]

  • Capabilities of Upper Extremity Instrument (CUE) - A 32-item measure for assessing upper extremity function with tetraplegia

  • Spinal Cord Independence Measure (SCIM) - Designed as an alternative to the FIM to assess 16 categories of self-care, mobility, and respiratory and sphincteric function [11]

  • Canadian Occupational Performance Measure (COPM) - Used to assess outcomes in the area of self-care, productivity, and leisure

  • Grasp and Release Test (GRT) - Designed to assess hand function in people with C6-7 level injuries

  • Six-Minute Walk Test (6MWT) - Measures the distance a patient can walk on a flat, hard surface in 6 minutes

  • Ten-Meter Walking Test (10MWT) - Assesses short duration walking speed


C1-C4 Tetraplegia (High Tetraplegia)

Individuals with complete C1-C4 (high) tetraplegia have little or no movement of upper and lower extremity muscles. They have movement of the head and neck, as well as, possibly, shoulder elevation (shrug). Persons with an injury at the C4 level have innervation of the diaphragm (the primary muscle for respiratory inspiration). They should not require long-term ventilatory assistance, although it is not uncommon to require ventilation initially after injury.

Patients with C1-C3 injuries are likely to require long-term mechanical ventilatory support because of the loss of innervation to the diaphragm. These individuals may be candidates for FES of the phrenic nerve (or diaphragm) to reduce their need for mechanical ventilation, if their lower motor innervation to the diaphragm remains intact. [12] Swallowing and phonation functions are preserved.

Individuals with injuries at the C1-C4 level will likely depend on others for help with almost all of their mobility and self-care needs, although they may be able to use a power wheelchair with chin or pneumatic (sip and puff) controls. If their elbow flexion and shoulder movement are suboptimal (muscle grade 2 or 3), a balanced forearm orthosis (BFO) or mobile arm support (MAS) may assist them with feeding and grooming activities. The use of a long bottle or straw can allow these individuals to drink independently.

Patients should be able to communicate with caregivers (and provide direction) about their mobility needs, as well as about self-care and bladder and/or bowel care. Assistive technologies, such as electronic aids to daily activities (EADLs, previously referred to as environmental control units), may be accessed by using a mouth stick or switch or by employing voice activation. Assistive devices transmit signals by means of radio waves, infrared light, or ultrasonographic waves to facilitate an individual's control of his/her environment. In this way, the person can accomplish such tasks as answering phones, adjusting bed height, and controlling computers, lights, and televisions.

Brain/Computer Interface (BCI) methods, using noninvasive electroencephalography (EEG), are being trialed in order to bridge the disconnection between the brain and muscle. [13] With BCI, it is necessary to interpret brain activity and interface brain signals with a computer, and this may enable a person with tetraplegia to control a computer, operate devices such as an EADL, or control a power wheelchair. Individuals using BCI systems indicate it gives them an increased sense of independence and improves their quality of life. This technology needs further refinement before it can be clinically implemented.

Some patients with high tetraplegia experience, to varying degrees, spontaneous motor recovery, especially in the first year following the SCI. A study by Javeed et al found that in a cohort of patients with C1-C4 tetraplegia, the likelihood of achieving functional independence (with regard to feeding, bladder management, and transfers [bed/wheelchair/chair]) was 11 times greater when elbow extension (C7) and finger flexion (C8) were regained. The likelihood of functional independence was seven times higher when wrist extension (C6) returned. [14]


C5 Tetraplegia

Individuals with C5 tetraplegia have functional use of elbow flexion. With the help of specialized assistive devices (such as wrist or hand orthotics to allow them to hold objects), these persons can achieve independence in feeding and grooming. It is important to prevent contractures of elbow flexion and forearm supination caused by unopposed biceps activity. Patients with a C5 injury can assist with upper extremity dressing and bed mobility.

For persons with C5 tetraplegia, a power wheelchair with hand controls will probably be required for most of their mobility needs, although a manual wheelchair with grip enhancements (rim projections) may be used for short-distance mobility on level surfaces. Patients require assistance for most other self-care (eg, lower extremity dressing, bathing), for transfer mobility, and for bladder and/or bowel tasks.

As with persons who have sustained injuries at higher cervical levels than this one, assistive technology (eg, EADLs) can play an important role in maximizing the individual's control of his/her environment, helping the patient to adjust bed height, answer phones, and use computers, lights, and televisions. Driving a specially modified or adapted van is possible.


C6 Tetraplegia

Individuals with C6 tetraplegia have the added function of wrist extension. This permits tenodesis, or passive thumb adduction on the index finger during active wrist extension, which assists with grasp and release. A wrist-hand orthosis (tenodesis splint) can be used to facilitate these abilities. The patient should avoid overstretching the finger flexors, which limits the tenodesis action. [15]

C6 is the highest level at which patients can have a complete injury and still function independently without the aid of an attendant, although this situation is not common. Individuals with injuries at this level can achieve functional independence in terms of feeding, grooming, bathing, and bed mobility by using assistive devices. They can dress their upper body and assist with lower-body dressing, as well as with the bladder and bowel program. With the use of a slide board, persons with C6 tetraplegia may become independent in performing transfers from a bed to a chair, although they usually require assistance with these. Intermittent catheterization for bladder care may be possible with set-up and assistive devices, although this is not common and is technically more difficult for women than for men. [16]

Manual wheelchairs with enhancement for gripping the wheel rims may be used for community mobility, although patients may prefer a power chair. Driving a vehicle with adaptations, such as a custom lift and hand controls, is an option. Patients with C6 injuries can be independent in using a phone, turning pages, and writing and typing (with assistive devices).


C7 Tetraplegia

Individuals with C7 tetraplegia have the functional ability to extend their elbow, which greatly enhances their mobility and self-care skills. C7 is usually the highest level at which patients can have an injury and still be able to live independently. They may achieve independence in feeding, upper extremity dressing, bathing, bed mobility, transfers (although they may require assistance with moving over uneven surfaces), and manual wheelchair propulsion in the community (with the exception of going over curbs).

With the use of assistive devices, patients may also become independent with regard to grooming, lower extremity dressing, and bowel care. Individuals with a C7 injury, especially women, may need help with bladder care (eg, intermittent catheterization). Patients may be able to independently drive an adapted van or a car that has been adapted with hand controls. Patients with C7 tetraplegia can be independent, with or without assistive devices, in writing, typing, turning pages, answering phones, and using computers.


C8 Tetraplegia

Individuals with C8 tetraplegia have functional finger flexion, which improves their independence in terms of hand grasp and release. They can achieve independence in feeding, grooming, upper and lower extremity dressing, bathing, bed-mobility transfers, manual wheelchair propulsion, and bladder and bowel care, as well as in typing, writing, answering phones, and using computers. These persons can also drive independently using an adapted van or a car that has been adapted with hand controls.


Thoracic Paraplegia

Individuals with T1-T12 paraplegia have innervation and function of all upper extremity muscles, including those for hand function. They can achieve functional independence in self-care (including light housekeeping and meal preparation), in bladder and bowel skills, and, at the wheelchair level, in all mobility needs. Individuals should receive advanced wheelchair training so that they can move over uneven surfaces, rough terrain, and ramps and curbs, as well as do "wheelies" and make transfers from the floor to the wheelchair. Like patients with an injury to the low cervical levels, persons with thoracic paraplegia can drive independently by using an adapted van or a car adapted with hand controls.

Individuals with a T2-T9 injury have variable trunk control (of the paraspinal and abdominal muscles), and they may be able to stand by using bilateral knee-ankle-foot orthoses (KAFOs) along with a walker or crutches. Persons with a T10-T12 injury have better trunk control than do patients with a higher injury, and they may be able to walk household distances independently with KAFOs and assistive devices; they may even attempt to walk up and down stairs. Unfortunately, these maneuvers can require extreme energy expenditure, and many individuals may prefer wheelchair mobility.


Lumbar Paraplegia

Individuals with lumbar or sacral paraplegia can achieve functional independence for all mobility, self-care, and bladder and bowel skills. Advanced wheelchair training (as mentioned above) should be undertaken.

Patients with this injury can drive independently by using a car adapted with hand controls. In addition, individuals with an injury at the lumbar level can become functionally independent in terms of household and community ambulation, which is often defined as unassisted ambulation for distances of greater than 150 feet, with or without the use of braces and assistive devices. Orthotic devices (KAFOs and ankle-foot orthoses [AFOs]) are often prescribed to assist patients with lower extremity standing and walking. Full- or part-time use of a manual wheelchair is often necessary.


Community Ambulation After SCI

Neurologic examination can assist in determining the patient's prognosis for ambulation. Those with incomplete SCI have a possibility for community ambulation. Factors associated with more favorable outcomes include younger age, ASIA impairment scale, and level of injury. The prognosis for recovery of lower-extremity function and eventual walking is better in patients with pinprick sparing in association with sensory-only incomplete injuries than in those with preservation of light touch alone.

Strength in the key muscles of the lower extremities is important. The ambulatory motor index (AMI) is used to grade the lower extremity muscles and is reported to be a reliable clinical indicator of community ambulation. The lower extremity motor score (LEMS) at 1 month is predictive of ambulation at 1 year. It is important to be aware that SCI community ambulators are at higher risk for falls due to spasticity as well as decreased trunk strength, leg strength, balance, and proprioception.

An NLOI below T11 is associated with an increased potential for ambulation. Important considerations in whether an individual can achieve community ambulation are the presence of functional hip flexion (to advance the hip) and knee extension (to avoid buckling at the knees), which begin at the L2 and L3 neurologic levels, respectively. Orthotic assistance with KAFOs and/or AFOs, along with a walker or crutches, may be necessary.

In individuals with incomplete spinal cord injury (SCI), intensive overground mobility therapy and body-weight–supported treadmill training (BWSTT) are accepted standards of care in gait rehabilitation. [17, 18] Manual BWSTT can be labor intensive for the therapy team (involving multiple therapists and time). Robotic-assisted gait training (eg, Lokomat system) is being used more commonly in formal SCI therapy, in order to optimize the body’s rhythmic generations of stepping movements. [19]

Most often, successful brace-assisted community ambulation is accomplished by individuals with an injury at or below the L3 level. Success also depends on factors such as intact hip and knee proprioception, an ability to tolerate the high-energy requirements of such ambulation, the patient's motivation and age, his/her cardiopulmonary stability, the severity of spasticity, the presence of joint contractures (especially of the hips, knees, and ankles), and the presence of pain. Several orthotic options and assistive devices are available; these vary according to the level and degree of muscle weakness. In addition, FES can be used in patients with injuries at even higher levels than this to achieve community ambulation.



Neuroprostheses are devices that use electrodes to interface with the nervous system to restore function. They hold great potential, and, although there are few commercially available devices, they represent an area of emerging technology. [20] There are functional electrical stimulation (FES) devices that can be used for both upper and lower extremities, diaphragm, and bladder. Patients work closely with therapists at first, but then can transition to using the device at home on a regular basis. FES can help reduce disability and improve function and quality of life, if used on a consistent basis.

Lower extremity neuroprostheses can be used to provide mobility in individuals with low cervical or thoracic spinal cord injury (SCI). These devices can give a patient capabilities, such as standing, performing transfers, and walking, that were previously unobtainable with injuries at these levels. The Parastep device one of the commercially available, portable FES system in which surface electrodes are placed over the quadriceps, peroneal nerve, and gluteal muscles to stimulate movement and allow the person to stand and walk. Use of this device is usually indicated for individuals with a T4-T12 neurologic level of injury. Factors limiting its use may include upper extremity strength, lower extremity joint ROM, pain sensation in the lower extremity, ability to tolerate high energy requirements, cardiac disease, clinically significant spasticity, lower motor neuron (LMN) injury of the lower extremity muscles, and severity of osteoporosis.

There are also implantable devices that place electrodes to bilateral erector spinae, gluteus maximus, semimembranosus, and vastus lateralis muscles. These can be for both assistance with trunk control as well as lower extremity function.

Upper extremity neuroprostheses enhance the potential for upper extremity movement (especially hand grasp and release) in individuals with a C5 or C6 injury. The Ness H200 neuroprosthesis uses five surface electrodes (integrated into a wrist-hand orthosis) to activate finger and thumb flexors and extensors. [21]

In a study of 15 arms in 13 patients with motor level C5 or C6 tetraplegia, Kilgore et al reported that an implanted, myoelectrically controlled neuroprosthesis permits “considerable flexibility in the control algorithms that can be utilized for a variety of arm and hand functions.” According to the investigators, such prostheses can permit highly motivated persons with cervical SCI to attain arm and hand function that orthotics or surgery alone could not restore. [22]

Indeed, the use of implantable FES systems, such as the FreeHand System, in combination with surgical reconstruction (discussed below), provides the greatest opportunity for long-term function. The FreeHand System consists of 8 implanted electrodes and an implanted receiver-stimulator unit. It is controlled by activating an external joystick worn on the patient's chest or shoulder. [21]

Surgical transfer of the brachioradialis to enhance wrist extension in patients with C5 or C6 tetraplegia and/or transfer of the posterior deltoid to triceps to enhance elbow extension in patients with C6 tetraplegia are often employed in combination with FES to further improve upper extremity movement, as well as hand grasp and release. Special considerations include C5 and C6 levels, ASIA classes A or B, LMN innervation of key forearm and hand muscles, neurologic stability, expertise in postsurgical rehabilitation, and patient motivation. There are also second-generation implantable devices, which use 12 stimulating electrodes and electromyographic signals controlled by voluntary muscles, that are used to perform various functions.

Bladder neuroprostheses have been used in patients with suprasacral SCI to improve their bladder and bowel function, though results have been variable. Available devices apply FES to sacral nerve roots (which carry parasympathetic efferents) and include the VOCARE Brindley-Finetech bladder system and the Medtronic InterStim. Stimulation causes contraction of the detrusor bladder muscle (for bladder emptying) and facilitates stool transport through the colon. This technique is usually used in combination with posterior rhizotomy, or surgical ablation of the sacral sensory nerve roots, to reduce detrusor hyperreflexia and incontinence. Potential candidates are persons who are neurologically stable and who have viable function of the sacral nerve.

FES of respiratory muscles by using implantable phrenic-nerve or diaphragmatic pacemakers reduces the need for mechanical ventilation in individuals with tetraplegia at C1-3; these persons would otherwise be ventilator dependent. [12] Potential benefits include increased ease in patient transfers, improved speech, reduced anxiety, improved sense of well-being, reduced need for nursing care, and reduced overall costs. Candidates must have an intact phrenic nerve and be free of clinically significant lung disease.

Robotic exoskeleton devices (eg, ReWalk, Ekso) have been designed to allow standing and ambulation for patients with paraplegia and are still undergoing clinical trials. They use backpack battery–powered mechanical joints and have emerged as the next step in the technological evolution of exoskeleton devices. [23, 24]


Surgical Reconstruction To Aid Upper-Extremity Function

Surgical reconstruction can improve upper extremity function in individuals with tetraplegia. [25] Tendons from proximal, functioning muscles can be surgically transferred to enhance distal, nonfunctioning parts, often improving an individual's motor function by one level. In patients with an injury at the C5 level, tendon transfers may enable wrist and elbow extension. In persons with an injury at the C6 level, tendon transfers may provide for elbow extension and tenodesis, allowing these patients to grasp and release. When the injury is at the C7 level, tendon transfers can restore active grasp and improve hand dexterity.

In a functional magnetic resonance imaging (fMRI) study of patients with a high cervical SCI who underwent a procedure to adapt an elbow flexor muscle (the brachioradialis) for thumb flexion (via tendon transfer), Wester et al found evidence that the muscle, originally controlled by the portion of the brain typically related to elbow movement, came under the control of the brain region normally linked to wrist movements. According to the investigators, the results indicate that such arm-to-hand tendon transposition can lead to cortical reorganization. [26]

Careful patient selection and the use of experienced hand surgeons and therapists are essential for successful outcomes in reconstruction surgery. Appropriate candidates for these procedures must be neurologically stable and well motivated to participate in postoperative rehabilitation (immobilization, edema and scar management, mobilization, functional skills training, and strengthening).

A study by Dengler et al indicated that in patients with C5-C8 traumatic SCI, those with strong finger flexion have greater independence with regard to feeding, urinary function, and bed-to-wheelchair transfer ability. Surprisingly, however, patients in the study with strong elbow extension were not uniformly able to transfer independently. The investigators concluded that restoration of finger flexion in persons with midcervical-level SCI should be a reconstructive priority. [27]


SCI Clinical Syndromes and Outcomes

The prognosis for enhanced functional outcomes is most favorable for patients with incomplete spinal cord injury (SCI). Six clinical syndromes resulting from anatomically distinct SCIs are often discussed.

Central cord syndrome

Central cord syndrome, which is a relatively common cervical incomplete injury, is characterized more by weakness of the upper extremities (especially of the hands) than of the lower extremities. Individuals with central cord syndrome may also have sensory and bladder dysfunction. This syndrome is frequently seen in elderly individuals with degenerative spinal stenosis and is associated with hyperextension injuries.

In general, patients with central cord syndrome have a favorable prognosis for functional ability in ADLs, bladder and bowel control, and ambulation. Residual upper extremity weakness may persist and can affect basic self-care. Moreover, the patient may need to use assistive devices for ambulation. Favorable prognostic factors are age younger than 50 years (at the time of injury), good initial hand or lower extremity motor score, education, decreased comorbidities, decreased spasticity, and rapid early improvement. [28]

Brown-Sequard syndrome

Often attributed to spinal cord hemisection, Brown-Séquard syndrome is characterized by relative ipsilateral paresis, along with proprioception and/or vibratory loss and contralateral loss of pain or temperature sensation below the level of injury. The prognosis for functional independence in ADLs and ambulation, as well as for bladder and bowel continence, is good. [29]

Anterior cord syndrome

Anterior cord syndrome, which is characterized by a variable loss of motor and pinprick sensation, has relatively little effect on proprioception and vibration. Lesions result from damage to the anterior two thirds of the spinal cord, but the posterior columns are spared. In comparison with the other 5 syndromes discussed here, the prognosis for neurologic recovery in anterior cord syndrome is diminished. Functional outcomes in terms of ADLs and mobility depend on the level of injury.

Posterior cord syndrome

The least common of the SCI clinical syndromes, posterior cord syndrome results from a selective injury to the posterior columns in the spinal cord, leading to a loss of proprioception and vibration sensation below the level of injury. Motor strength, as well as pain and temperature sensation, is relatively spared. Functional outcomes for mobility and self-care, as well as for bladder and bowel continence, are good, although individuals may require the use of assistive devices (walker, cane) for ambulation.

Conus medullaris syndrome

Conus medullaris syndrome is characterized by injury to the sacral cord and to the lumbosacral nerve roots. The result is symmetrical and (often) complete saddle anesthesia, bladder and bowel dysfunction, and lower-extremity motor weakness. The functional prognosis for mobility and ADLs is good, although bladder or bowel function is less likely than in other conditions, and neurologic recovery is limited.

Cauda equina syndrome

Because cauda equina syndrome is characterized by injury to the lumbosacral nerve root, it is not truly an SCI. It causes saddle anesthesia, bladder and bowel dysfunction, and variable motor weakness of the lower extremity. Cauda equina syndrome is often less complete and symmetrical than is conus medullaris injury. Because axons of the peripheral nerve root can regenerate (unlike spinal cord axons) and because these injuries are often incomplete, neurologic recovery may continue for many months or years. The functional prognosis for mobility and self-care skills is good, although bladder and bowel continence vary.