Physical Examination

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Physical examination of all patients suspected of having a spinal-column and/or cord injury should include documentation of spinal-cord neurological function according to the American Spine Injury Association (ASIA) classification system. The ASIA system includes grading of at least 1 muscle group in each upper and lower extremity myotome on a standard 5 point scale, and grading sensory function in each dermatome as normal, abnormal or absent. Presence of spared sensation in the sacral dermatomes (perineum and scrotum or labia) establishes the presence of incomplete spinal-cord injury, which has a significantly better prognosis than complete injury.

Table 6. Spinal level by muscle group

Spinal

Predominant

Associated

Level

Muscle Group

Reflex

C3-5

Diaphragm

C4

Rhomboids, trapezius

C5

Supraspinatus, infraspinatus, deltoid

C6

Biceps, brachioradialis, extensor carpi radialis

Biceps

C7

Triceps, extensor digitorum

Triceps

C8

Flexor pollicis longus, flexor digitorum

T1

Abductor pollicis brevis, lumbricals, interossei

T10

Abdominal wall

Umbilical cutaneous

L2

Iliopsoas

L3

Adductors

L4

Quadriceps femoris

Patellar

L5

Extensor hallucis longus, tibialis anterior

S1

Gastrocnemius, hamstrings

Achilles

S2

Flexor digitorum longus, small muscles of foot

S2-4

Urinary and anal sphincters

Anal wink, cremasteric

Lower cranial nerve function, which is often abnormal after craniocervical junction injury, should be examined. The spinal trauma examination should include:

• Palpate entire spine for deformity, crepitus or step-off (3 team log roll with neck in collar and held in neutral position).

• Assess lower cranial nerve function. Loss of facial sensation from damage to the spinal nucleus of the trigeminal nerve may be found in any upper cervical spinal-cord injury. Atlanto-occipital dislocation is commonly associated with bilateral sixth nerve palsy, facial weakness, respiratory distress and/or absent gag and swallowing reflexes.

• Strength examination for each myotome bilaterally (by ASIA classification) (see Table 6).

• Sensory examination for each dermatome, including sacral dermatomes, bilaterally (by ASIA classification).

• Examination of proprioception at index fingers and great toes bilaterally (to assess dorsal column spinal function).

• Deep tendon reflexes in upper and lower extremities.

• Cutaneous reflexes including abdominal, cremasteric and Babinski (to help determine spinal-injury level and completeness).

• Digital rectal examination to assess tone and voluntary contraction (which will be absent in complete spinal-cord injury). Placement of bladder catheter to assess and treat acute urinary retention after spinal-cord injury.

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