Quadriplegia classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]


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. (see table 1 for criteria) This has considerable consequences for surgical planning and therapy.[1]

Table 1: ASIA impairment scale[1]

A Complete no motor or sensory function is preserved in the sacral segments S4-S5.
B Incomplete sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5.
C Incomplete Incomplete: motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3.
D Incomplete Incomplete: motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more.
E Normal motor and sensory function are normal.

Complete Spinal Cord Lesions

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 strength can be evaluated by the British Medical Research Council (BMRC) scale. This scale is used when upper limb surgery is planned, as referred to in the 'International Classification for hand surgery in tetraplegic patients' (see table 2).[2]

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.[2]

Below the level of the injured metamere there is an injured sublesional segment with 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.[2]

Incomplete Spinal Cord Lesions

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. The 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.[3]
  2. The Brown–Séquard syndrome: hemi section of the spinal cord.[3]
  3. The anterior cord syndrome: a lesion of the anterior horns and the anterolateral tracts, with a possible division of the anterior spinal artery.[3]

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).[3] 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.[3]

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.[3] 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.[3] 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.[3]

Over the last ten years an increase in traumatic incomplete lesions is seen, due to the better protection in traffic.


  1. 1.0 1.1 "American Spinal Injury Association (ASIA)".
  2. 2.0 2.1 2.2 Coulet B, Allieu Y, Chammas M (2002). "Injured metamere and functional surgery of the tetraplegic upper limb". Hand Clin. 18 (3): 399–412, vi. PMID 12474592. Unknown parameter |month= ignored (help)
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Hentz VR, Leclercq C (2008). "The management of the upper limb in incomplete lesions of the cervical spinal cord". Hand Clin. 24 (2): 175–84, vi. doi:10.1016/j.hcl.2008.01.003. PMID 18456124. Unknown parameter |month= ignored (help)

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