Tetraplegia

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Not to be confused with Spastic quadriplegia.
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Quadriplegia

Other names Tetraplegia

Specialty Neurosurgery

Types Complete, incomplete

Causes Damage to spinal cord or brain by illness or

injury;

Diagnostic method Based on symptoms, medical imaging

Tetraplegia, also known as quadriplegia, is paralysis caused by illness or injury

that results in the partial or total loss of use of all four limbs and
torso; paraplegia is similar but does not affect the arms. The loss is usually
sensory and motor, which means that both sensation and control are lost. The
paralysis may be flaccid or spastic.

Contents

 1Signs and symptoms

 2Causes
 3Diagnosis
o 3.1Classification
 3.1.1Complete spinal-cord lesions
 3.1.2Incomplete spinal-cord lesions
 4Treatment
 5Prognosis
 6Epidemiology
 7Terminology
 8See also
 9References
o 9.1Citations
o 9.2Journals
o 9.3Web sources
 10External links

Signs and symptoms[edit]

Although the most obvious symptom is impairment of the limbs, functioning is
also impaired in the torso. This can mean a loss or impairment in
controlling bowel and bladder, sexual function, digestion, breathing and
other autonomic functions. Furthermore, sensation is usually impaired in affected
areas. This can manifest as numbness, reduced sensation or
burning neuropathic pain.[citation needed] Secondarily, because of their depressed
functioning and immobility, people with tetraplegia are often more vulnerable
to pressure sores, osteoporosis and fractures, frozen joints, spasticity, respiratory
complications and infections, autonomic dysreflexia, deep vein thrombosis, and
cardiovascular disease.[1]
The severity of the condition depends on both the level at which the spinal cord is
injured and the extent of the injury. An individual with an injury at C1 (the highest
cervical vertebra, at the base of the skull) will probably lose function from the
neck down and be ventilator-dependent. An individual with a C7 injury may lose
function from the chest down but still retain use of the arms and much of the
hands.
The extent of the injury is also important. A complete severing of the spinal cord
will result in complete loss of function from that vertebra down. A partial severing
or even bruising of the spinal cord results in varying degrees of mixed function
and paralysis. A common misconception with tetraplegia is that the victim cannot
move legs, arms or any of the major function; this is often not the case. Some
individuals with tetraplegia can walk and use their hands, as though they did not
have a spinal cord injury, while others may use wheelchairs and they can still
have function of their arms and mild finger movement; again, that varies on the
spinal cord damage.[citation needed]
It is common to have movement in limbs, such as the ability to move the arms
but not the hands, or to be able to use the fingers but not to the same extent as
before the injury. Furthermore, the deficit in the limbs may not be the same on
both sides of the body; either left or right side may be more affected, depending
on the location of the lesion on the spinal cord.

Causes[edit]
Tetraplegia is caused by damage to the brain or the spinal cord at a high level.
The injury, which is known as a lesion, causes victims to lose partial or total
function of all four limbs, meaning the arms and the legs. Typical causes of this
damage are trauma (such as a traffic collision, diving into shallow water, a fall, a
sports injury), disease (such as transverse myelitis, Guillain–Barré
syndrome, multiple sclerosis, or polio), or congenital disorders (such as muscular
dystrophy).
Tetraplegia is defined in many ways; C1–C4 usually affects arm movement more
so than a C5–C7 injury; however, all tetraplegics have or have had some kind of
finger dysfunction. So, it is not uncommon to have a tetraplegic with fully
functional arms but no nervous control of their fingers and thumbs. It is possible
to suffer a broken neck without becoming tetraplegic if the vertebrae are
fractured or dislocated but the spinal cord is not damaged. Conversely, it is
possible to injure the spinal cord without breaking the spine, for example when a
ruptured disc or bone spur on the vertebra protrudes into the spinal column.

Diagnosis[edit]
Classification[edit]
Spinal cord injuries are classified as complete and incomplete by the American
Spinal Injury Association (ASIA) classification. The ASIA scale grades patients
based on their functional impairment as a result of the injury, grading a patient
from A to D. This has considerable consequences for surgical planning and
therapy.[2]

American Spinal Injury Association Impairment Scale[2]

A Complete No motor or sensory function is preserved in the sacral segments S4–S5.

Sensory function preserved but no motor function is preserved below the neurological
B Incomplete
level and includes the sacral segments S4–S5.

Motor function is preserved below the neurological level; more than half of key
C Incomplete
muscles below the neurological level have a muscle grade less than 3.

Motor function is preserved below the neurological level; at least half of key muscles
D Incomplete
below the neurological level have a muscle grade of 3 or more.

Complete spinal-cord lesions[edit]

Pathophysiologically, the spinal cord of the tetraplegic patient can be divided into
three segments which can be useful for classifying the injury.
First, there is an injured functional medullary segment. This segment has
unparalysed, functional muscles; the action of these muscles is voluntary, not
permanent and hand strength can be evaluated by the Medical Research Council
(MRC) Scale. This scale is used when upper limb surgery is planned, as referred
to in the 'International Classification for hand surgery in tetraplegic patients'. [3]
A lesional segment (or an injured metamere) consists of denervated
corresponding muscles. The lower motor neuron (LMN) of these muscles is
damaged. These muscles are hypotonic, atrophic and have no spontaneous
contraction. The existence of joint contractures should be monitored. [3]
Below the level of the injured metamere, there is an injured sublesional segment
with the intact lower motor neuron, which means that medullary reflexes are
present, but the upper cortical control is lost. These muscles show some
increase in tone when elongated and sometimes spasticity, the trophicity is good.
[3]

Incomplete spinal-cord lesions[edit]

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Incomplete spinal cord injuries result in varied post injury presentations. There
are three main syndromes described, depending on the exact site and extent of
the lesion.

1. Central cord syndrome: most of the cord lesion is in the gray matter of the
spinal cord, sometimes the lesion continues in the white matter. [4]
2. Brown-Séquard syndrome: hemisection of the spinal cord.[4]
3. Anterior cord syndrome: a lesion of the anterior horns and the
anterolateral tracts, with a possible division of the anterior spinal artery. [4]

For most patients with ASIA A (complete) tetraplegia, ASIA B (incomplete)

tetraplegia and ASIA C (incomplete) tetraplegia, the International Classification
level of the patient can be established without great difficulty. The surgical
procedures according to the International Classification level can be performed.
In contrast, for patients with ASIA D (incomplete) tetraplegia it is difficult to assign
an International Classification other than International Classification level X
(others).[4] Therefore, it is more difficult to decide which surgical procedures
should be performed. A far more personalized approach is needed for these
patients. Decisions must be based more on experience than on texts or journals.
[4]

The results of tendon transfers for patients with complete injuries are predictable.
On the other hand, it is well known that muscles lacking normal excitation
perform unreliably after surgical tendon transfers. Despite the unpredictable
aspect in incomplete lesions, tendon transfers may be useful. The surgeon
should be confident that the muscle to be transferred has enough power and is
under good voluntary control. Pre-operative assessment is more difficult to
assess in incomplete lesions.[4]
Patients with an incomplete lesion also often need therapy or surgery before the
procedure to restore function to correct the consequences of the injury. These
consequences are hypertonicity/spasticity, contractures, painful hyperesthesias
and paralyzed proximal upper limb muscles with distal muscle sparing. [4]
Spasticity is a frequent consequence of incomplete injuries. Spasticity often
decreases function, but sometimes a patient can control the spasticity in a way
that it is useful to their function. The location and the effect of the spasticity
should be analyzed carefully before treatment is planned. An injection
of Botulinum toxin (Botox) into spastic muscles is a treatment to reduce
spasticity. This can be used to prevent muscle shorting and early contractures. [4]
Over the last ten years, an increase in traumatic incomplete lesions is seen, due
to the better protection in traffic.

Treatment[edit]
See also: Upper-limb surgery in tetraplegia
Upper limb paralysis refers to the loss of function of the elbow and hand. When
upper limb function is absent as a result of a spinal cord injury it is a major barrier
to regain autonomy. People with tetraplegia should be examined and informed
concerning the options for reconstructive surgery of the tetraplegic arms and
hands.[5]

Prognosis[edit]
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relies too heavily on primary sources. Please review the contents of
the article and add the appropriate references if you can. Unsourced
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Delayed diagnosis of cervical spine injury has grave consequences for the victim.
About one in 20 cervical fractures are missed and about two-thirds of these
patients have further spinal-cord damage as a result. About 30% of cases of
delayed diagnosis of cervical spine injury develop permanent neurological
deficits. In high-level cervical injuries, total paralysis from the neck can result.
High-level tetraplegics (C4 and higher) will likely need constant care and
assistance in activities of daily living, such as getting dressed, eating and bowel
and bladder care. Low-level tetraplegics (C5 to C7) can often live independently.
[citation needed]

Even with "complete" injuries, in some rare cases, through intensive

rehabilitation, slight movement can be regained through "rewiring" neural
connections, as in the case of actor Christopher Reeve.[6]
In the case of cerebral palsy, which is caused by damage to the motor cortex
either before, during (10%), or after birth, some people with tetraplegia are
gradually able to learn to stand or walk through physical therapy. [citation needed]
Quadriplegics can improve muscle strength by performing resistance training at
least three times per week. Combining resistance training with proper nutrition
intake can greatly reduce co-morbidities such as obesity and type 2 diabetes. [7]

Epidemiology[edit]
See also: List of people with quadriplegia
There are an estimated 17,700 spinal cord injuries each year in the United
States; the total number of people affected by spinal cord injuries is estimated to
be approximately 290,000 people. [8]
In the US, spinal cord injuries alone cost approximately US$40.5 billion each
year, which is a 317 percent increase from costs estimated in 1998 ($9.7 billion).
[9]

The estimated lifetime costs for a 25-year-old in 2018 is $3.6 million when

affected by low tetraplegia and $4.9 million when affected by high tetraplegia.[8] In
2009, it was estimated that the lifetime care of a 25-year-old rendered with low
tetraplegia was about $1.7 million, and $3.1 million with high tetraplegia.[10]
There are about 1,000 people affected each year in the UK (~1 in 60,000—
assuming a population of 60 million).

Terminology[edit]
The condition of paralysis affecting four limbs is alternately
termed tetraplegia or quadriplegia. Quadriplegia combines the Latin root quadra,
for "four", with the Greek root πληγία plegia, for "paralysis". Tetraplegia uses the
Greek root τετρα tetra for "four". Quadriplegia is the common term in North
America; tetraplegia is more commonly used in Europe. [11]

See also[edit]
 Clearing the cervical spine
 Hemiplegia
 Locked-in syndrome
 Sexuality after spinal cord injury
 Spinal cord injury research

References[edit]
Citations[edit]
1. ^ Schurch et al. 2011.
2. ^ Jump up to:a b Roberts et al. 2017.
 3. ^ Jump up to:a b c Coulet et al. 2002.
4. ^ Jump up to:a b c d e f g h Hentz & Leclercq 2008.
5. ^ Fridén & Reinholdt 2008.
6. ^ Burkeman 2002.
7. ^ Gorgey et al. 2012.
8. ^ Jump up to:a b NSCISC 2018.
9. ^ Christopher & Dana Reeve Foundation.
10. ^ NSCISC 2009.
11. ^ Apparelyzed.

Journals[edit]

 Coulet, B.; Allieu, Y.; et  al. (2002). "Injured metamere and functional surgery of the tetraplegic
upper limb".  Hand Clin.  18  (3): 399–412, vi.  doi:10.1016/s0749-0712(02)00020-3.  ISSN  0749-
0712.  PMID  12474592.

 Fridén, J.; Reinholdt, C. (2008). "Current concepts in reconstruction of hand function in

tetraplegia".  Scand. J. Surg.  97  (4): 341–346.  doi:10.1177/145749690809700411. ISSN 1457-
4969.  PMID  19211389.

 Gorgey, A.; Mather, K.; et al. (2012).  "Effects of resistance training on adiposity and
metabolism after spinal cord injury".  Med. Sci. Sports Exerc.  44  (1): 165–
174.  doi:10.1249/MSS.0b013e31822672aa.  ISSN  0195-9131. PMID 21659900.

 Hentz, V.R.; Leclercq, C. (2008). "The management of the upper limb in incomplete lesions of
the cervical spinal cord". Hand Clin. 24 (2): 175–184. doi:10.1016/j.hcl.2008.01.003. ISSN 0749-
0712.  PMID  18456124.

 Roberts, T.T.; Leonard, G.R.; et  al. (2017). "Classifications in Brief: American Spinal Injury
Association (ASIA) Impairment Scale".  Clin. Orthop. Relat. Res.  475  (5): 1499–
1504.  doi:10.1007/s11999-016-5133-4. ISSN 1528-1132.  PMC 5384910. PMID 27815685.

 Schurch, B.; Knapp, P.A.; et  al. (2001). "Does sacral posterior rhizotomy suppress autonomic
hyper‐reflexia in patients with spinal cord injury?".  Br. J. Urol. 81 (1): 73–82. doi:10.1046/j.1464-
410x.1998.00482.x.  ISSN  1464-4096. PMID 9467480.

 Taylor-Schroeder, S.; LaBarbera, J.; et  al. (2011). "Physical therapy treatment time during
inpatient spinal cord injury rehabilitation".  J. Spinal Cord Med.  34  (2): 149–
161.  doi:10.1179/107902611X12971826988057.  ISSN  1079-0268. PMC  3066500.  PMID  21675
354.

Web sources[edit]

 Burkeman, O. (2002). "Man of steel". The Guardian. Retrieved 4 September  2018.

 National Spinal Cord Injury Statistical Center, Facts and Figures at a Glance  (PDF),
Birmingham, AL: University of Alabama at Birmingham, 2009

 National Spinal Cord Injury Statistical Center, Facts and Figures at a Glance  (PDF),
Birmingham, AL: University of Alabama at Birmingham, 2018

 "Quadriplegia and Tetraplegia". Apparelyzed – Spinal Cord Injury Peer Support. n.d. Archived
from the original on 5 Jan 2014. Retrieved 4 September  2018.
 "Stats about paralysis".  Christopher & Dana Reeve Foundation. 2016. Retrieved  4
September  2018.