The Injury Level – Understanding The Facts is One Key in Good Decision Making.

As we all know a child with Spina Bifida has a spinal cord injury due to how the spinal area formed before birth. Spina Bifida is not exactly like a spinal cord injury; However the best place I found to figure out what my child could or would not be able to do came from learning about the spine and how the injury level can affect the child’s ability to control parts of the body. The best places I found were: http://www.spinalinjury101.org/details/levels-of-injury and http://www.waisman.wisc.edu/~rowley/sb-kids/wbwsb.html

A few simple statements that are known.

  1. The higher the injury on the spinal cord, the more dysfunction can occur.
  2. Your child’s physical therapist and neurologist should be able to tell you what general area the injury is and  what nerves are and are not working.
  3. It is important to ask about  functional level as well as injury level. There is a difference
  4. It is always best to ask several times, at different times in a young child’s life, as very young infants  sometimes just do not cooperate during testing.
  5. The most important factors that determine the ambulatory status of a child with myelomeningocele, besides the level of the lesion, are the motor power (the muscle strength) within a given neurosegmental level (part of the spinal cord) and the extent and degree of orthopaedic deformities (how are the hips)  . Article –      http://www.ncbi.nlm.nih.gov/pubmed/794072
  6. Realize this can be a scary thing to  talk about and that’s ok.

The cervical vertebrae are those that start the spinal cord start where the head sits on the spine

High-Cervical Nerves (C1 – C4)

  • Most severe of the spinal cord injury  levels
  • Paralysis in arms, hands, trunk and legs
  • Patient may not be able to breathe on his or her own, cough, or control bowel or bladder movements.
  • Ability to speak is sometimes impaired or reduced.
  • When all four limbs are affected, this is called tetraplegia or quadriplegia.
  • Requires complete assistance with activities of daily living, such as eating, dressing, bathing, and getting      in or out of bed
  • May be able to use powered wheelchairs with special controls to move around on their own
  • Will not be able to drive a car on their own
  • Requires 24-hour-a-day personal care

Low-Cervical Nerves (C5 – C8)

  • Corresponding nerves control arms and hands.
  • A person with this level of injury may be able to breathe on their own and speak normally.
  • C5 injury
    • Person can raise his or her  arms and bend elbows.
    • Likely to have some or total paralysis of wrists, hands, trunk and legs
    • Can speak and use diaphragm, but breathing will be weakened
    • Will need assistance with most activities of daily living, but once in a power wheelchair, can move  from one place to another independently
  • C6 injury
    • Nerves affect wrist extension or moving the hand up while arm rests on the table.
    • Paralysis in hands, trunk and legs, typically
    • Should be able to bend  wrists back ie move it down or toward the body when side of arm is resting on the table and pinky is down and index up
    • Can speak and use  diaphragm, but breathing will be weakened
    • Can move in and out of  wheelchair and bed with assistive equipment
    • May also be able to drive an adapted vehicle
    • Little or no voluntary  control of bowel or bladder, but may be able to manage on their own with  special equipment
  • C7 injury
    • Nerves control elbow extension (straighten) and some finger extension (straighten).
    • Most can straighten their arm and have normal movement of their shoulders.
    • Can do most activities of daily living by themselves, but may need help with more difficult tasks
    • May also be able to drive an adapted vehicle
    • Little or no voluntary  control of bowel or bladder, but may be able to manage on their own with  special equipment
  • C8 injury
    • Nerves control some hand  movement.
    • Should be able to grasp and release objects
    • Can do most activities of  daily living by themselves, but may need assistance with more difficult tasks
    • May also be able to drive an adapted vehicle
    • Little or no voluntary control of bowel or bladder, but may be able to manage on their own with special equipment

Thoracic vertebrae are located in the mid-back.

Thoracic Nerves (T1 – T5)

  • Corresponding nerves affect muscles, upper chest, mid-back and abdominal muscles.
  • Arm and hand function is usually normal.
  • Injuries usually affect the trunk and  legs(also known as paraplegia).
  • Most likely use a manual wheelchair
  • Can learn to drive a modified car
  • Can stand in a standing frame

Thoracic Nerves (T6 – T12)

  • Nerves affect muscles of the trunk (abdominal and back muscles) depending on the level of injury.
  • Usually results in paraplegia
  • Normal upper-body movement
  • Fair to good ability to control and balance trunk while in the seated position
  • Should be able to cough productively (if abdominal muscles are intact)
  • Little or no voluntary control of  bowel or bladder but can manage on their own with special equipment
  • Most likely use a manual wheelchair.
  • Can learn to drive a modified car
  • Some can stand in a standing frame, while others may walk with lots of bracing. It will be slow and take lots of effort

Lumbar vertebrae are the five vertebrae between the ribs and the pelvis. They are the largest segments of the spine. They are designated L1 to L5, starting at the top.

Lumbar Nerves (L1 – L5)

  • Injuries generally result in some loss of function in the hips and legs.

L2 – some hip movement, household ambulation a possibility with bracing and walker/cruthes

L3 – some knee movement,

L4 – some ankle movement,

L5 – some toe movement, may walk with or without crutches in home

  • Little or no voluntary control of  bowel or bladder, but can manage on their own with special equipment
  • Depending on strength in the legs i.e.   what they can move, may need a wheelchair and may also walk with braces.    May need both as effort required to walk may interfeer with school learning

The sacrum is a large, triangular bone at the base of the spine.

Sacral Nerves (S1 – S5)

  • Injuries generally result in some loss of function in the hips and legs.
  • Little or no voluntary control of bowel or bladder, but can manage on their own with special equipment
  • Most likely will be able to walk in he community. May need short braces in the shoes or around the ankles

It is important to realize that some children may experience paralysis and lack of sensation above or below their defect level. This can be referred to as their “functional level.” An individual may have a lesion level at L4 but may have a functional level of L1, because that is the highest level where paralysis and lack of sensation occur. It is also important to know that the lesion level is rarely a “straight line.” This means that the area of paralysis (what does not work) and lack of sensation maybe higher or lower on different sides of the body. Sometimes, the level of sensation (where they feel) may be different then the level of paralysis.

Mel’s injury is L1, L2. She initially walked with very high braces (RGOs) and a walker, her hips were never stable and popped in and out all the time; especially when she was walking. I read somewhere that most kids with her level will use a wheelchair by 3rd grade. I looked around. I saw no kids as teenagers walking with braces as high up as Mel’s.  I’m still not sure of the advantage of all that therapy for walking when all the data said by 3rd grade she would be in a wheelchair.  (30min 2xweek + 60 min drive) Time is valuable is it not?  Was functional walking possible, not for Mel but that is for a different post.  For the longest time my wish was for her to just be able to walk down the aisle at her wedding.  You have to wish and dream.  It’s ok to wish.

My wish, for you, is that this life becomes all that you want it to, your dreams stay big, and your worries stay small, you never need to carry more than you can hold, and while you’re out there getting where you’re getting to, I hope you know somebody loves you, and wants the same things too. – Rascal Flatts

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