SPINAL CORD INJURY & ITS ORTHOTIC MANAGEMENT

SPINAL CORD
INJURY & IT’S
ORTHOTIC
MANAGEMENT
RAHUL KANNA M
MPO 8TH BATCH
PDUNIPPD,DELHI

TABLE OF CONTENTS
1. Introduction
2. Nervous System Overview
3. Introduction to Spinal Cord
4. Gross Anatomy of the Spinal Cord
5. Internal Anatomy of the Spinal Cord
6. Meninges and Spaces
7. Vertebral Column & Spinal Cord
Relations
8. Arterial Supply of the Spinal Cord
9. Spinal Cord Cross Section
10. Spinal Cord Pathways/Tracts
11. Ascending Tracts
12. Dorsal Column–Medial Lemniscal
Pathway
13. Anterolateral (Spinothalamic)
Pathway
14. Spinocerebellar Tracts
15. Descending Tracts
16. Pyramidal Tracts
17. Corticospinal & Corticobulbar
Tracts
18. Extrapyramidal Tracts (Ipsilateral &
Contralateral)
19. Dermatomes and Myotomes
20. Classification of SCI
21. ASIA Classification (ISNCSCI
System)
22. Incomplete Injury Syndromes
23. Autonomic Dysreflexia
24. Orthotic Management Overview
25. Upper Limb Functional Levels &
Equipment (C1–C8)
26. Lower Limb Functional Levels &
Equipment (T1–S1)
27. Spinal Trauma, Fracture Types &
Orthotic Management
28. References

Introduction
❖ A spinal cord injury (SCI) means damage to the spinal cord, the bundle of nerves and nerve fibers
that carries signals between the brain and the rest of the body. This damage can lead to temporary or
permanent changes in feeling, movement, strength, and other body functions below the injury level .
❖Annual Incidence: Approximately 250,000 to 500,000 new cases of SCI occur worldwide each
year.
❖Incidence Rate: Estimated at 40 to 80 cases per million population per year globally.
❖Prevalence: As of 2021, an estimated 15.4 million people were living with SCI worldwide.
❖Primary Causes: Up to 90% of SCI cases are due to traumatic events, including road traffic
accidents, falls, and violence.
❖Demographics: Males are more commonly affected than females, with higher prevalence observed
in the 20–29 and 70+ age groups.
❖Mortality Risk: Individuals with SCI are 2 to 5 times more likely to die prematurely compared to
those without SCI, particularly in low- and middle-income countries.

NERVOUS SYTEM
❖The nervous system enables the
body to react to continuous changes
in its internal and external
environments. It also controls and
integrates the various activities of the
body, such as circulation and
respiration.
❖The nervous system is divided
Structurally into the central nervous
system (CNS), consisting of the brain
and spinal cord, and the peripheral
nervous system (PNS) .
❖Functionally into the somatic
nervous system (SNS) and the
autonomic nervous system (ANS) .

Introduction to spinal cord
❖Long, cylindrical structure made of nervous tissue — part of
the central nervous system (CNS).
❖Located within the vertebral canal and extends from the
medulla oblongata to approximately L1–L2 in adults.
❖Surrounded and protected by vertebrae, meninges, and
cerebrospinal fluid (CSF).
❖Functions as a conduction pathway for transmitting signals
between the brain and body.
❖Serves as a reflex center — mediates reflexes without brain
involvement.
❖Contains both ascending (sensory) and descending (motor)
nerve tracts.
❖Internally composed of gray matter (butterfly-shaped center)
and white matter (outer region).

SPINAL CORD INJURY & ITS ORTHOTIC MANAGEMENT

Gross Anatomy of the
Spinal Cord
❖The spinal cord is a cylindrical structure, about 42–45 cm long in adults,
extending from the foramen magnum to around the L1–L2 vertebral level.
❖Spinal cord enlargements occur at regions where nerves supplying the
limbs arise: the cervical enlargement (C4–T1) for upper limbs and the
lumbosacral enlargement (L2–S3) for lower limbs.
❖The conus medullaris is the tapered end of the spinal cord located around
L1–L2, and below it lies the cauda equina, a bundle of spinal nerves.
❖The cauda equina, named for its horse’s tail appearance, is a bundle of
lumbar, sacral, and coccygeal nerves located below the spinal cord proper.
❖The filum terminale is a thin fibrous extension from the conus to the
coccyx, functioning to anchor the spinal cord in place.
❖The spinal cord is organized into 31 segments—8 cervical, 12 thoracic, 5
lumbar, 5 sacral, and 1 coccygeal—with each segment giving rise to a pair
of spinal nerves.

Internal Anatomy of the
Spinal Cord
❖ Gray Matter of the spinal cord consists mainly of neuronal cell
bodies and is divided into the dorsal horn, ventral horn, and lateral
horn.
❖ White Matter of the spinal cord consists mainly of neuronal fibers
and is divided into the dorsal funiculus, ventral funiculus, and lateral
funiculus.
❖Ventral Median Fissure is a distinct surface indentation present at all
spinal cord levels and is related to the anterior spinal artery.
❖ Dorsal Median Fissure is a less distinct surface indentation present at
all spinal cord levels.
❖Dorsal Intermediate Septum is a surface indentation present only at
and above T6 that distinguishes ascending fibers within the gracile
fasciculus (from the lower extremity) from ascending fibers within the
cuneate fasciculus (from the upper extremity).

Contd..
❖F. Conus Medullaris is the end of the spinal cord,
which occurs at vertebral level L1 in the adult and
vertebral level L3 in the newborn.
❖G. Cauda Equina consists of the dorsal and ventral
nerve roots of L2 through coccygeal 1 spinal nerves
traveling in the subarachnoid space below the conus
medullaris.
❖H. Filum Terminale is a prolongation of the pia mater
from the conus medullaris to the end of the dural sac at
vertebral level S2 where it blends with the dura. The
dura continues caudally as the filum of the dura mater
(or coccygeal ligament), which attaches to the dorsum
of the coccyx bone .

Meninges and Spaces
❖Epidural Space is a potential space located between the vertebra and dura
mater. This space contains fat and the internal vertebral venous plexus.
❖Dura Mater is the tough, outermost layer of the meninges.
❖Subdural Space is a potential space located between the dura mater and
arachnoid.
❖Arachnoid is a thin, cellular layer that consists of arachnoid barrier cells
connected by tight junctions. In addition, various-shaped fibroblasts in close
contact with collagen fibers bridge the subarachnoid space forming the spider-
like arachnoid trabeculae
❖Subarachnoid Space is located between the arachnoid and pia mater and
contains cerebrospinal fluid (CSF), arachnoid trabeculae, and cerebral arteries
and veins.
❖Pia Mater is a thin layer that is closely applied to the spinal cord and has
lateral extensions called denticulate ligaments, which attach to the dura mater
and thereby suspend the spinal cord within the dural sac .

Vertebral Column and Its
Relation to the Spinal Cord
❖The vertebral column protects the spinal cord by enclosing it in
the vertebral canal, running from the skull base to the coccyx.
❖Although the vertebral column has 33 vertebrae, the spinal cord
only has 31 segments, ending at the L1–L2 vertebral level in adults.
❖The spinal nerves continue beyond the cord as the cauda equina,
exiting through respective intervertebral foramina.
❖Due to the length mismatch, spinal segments are positioned higher
than their corresponding vertebrae, which is important for clinical
localization of injuries.

Arterial Supply of the Spinal Cord
Anterior Spinal Artery and Posterior Spinal Arteries
❖ There is only one anterior spinal artery, which arises from the
vertebral arteries and runs in the anterior median fissure. The anterior
spinal artery gives rise to sulcal arteries, which supply the ventral two-
thirds of the spinal cord.
❖There are two posterior spinal arteries, which arise from either the
vertebral arteries or the posterior inferior cerebellar arteries. The
posterior spinal arteries supply the dorsal one-third of the spinal cord.
❖The anterior and posterior spinal arteries supply only the short
superior part of the spinal cord. The circulation of the rest of the spinal
cord depends on the segmental medullary arteries and radicular
arteries.
and other arteries such as Anterior and Posterior Medullary Segmental
Arteries , Great Anterior Segmental Medullary Artery (of
Adamkiewicz) ,Anterior and Posterior Radicular Arteries .

Spinal cord cross section
❖ The spinal cord cross-section shows inner gray matter (H-
shaped) surrounded by outer white matter.
❖ Gray matter contains:
Dorsal (posterior) horns: Receive sensory input
Ventral (anterior) horns: Contain motor neuron cell bodies
Rexed’s laminae: The gray matter is subdivided into 10 layers (I–
X) based on cytoarchitecture — important for understanding tract
synapses.
White matter is organized into funiculi (columns):
Anterior funiculus: Mostly motor tracts
Posterior funiculus: Mostly sensory tracts (e.g., DCML)
Lateral funiculus: Contains both motor and sensory tracts

Spinal cord pathways/tracts
❖The spinal cord contains organized bundles of
axons, known as tracts or pathways, that transmit
information between the body and brain.
❖Ascending pathways carry sensory information
such as touch, proprioception, pain, and temperature
from the body to the brain, through tracts like the
dorsal column–medial lemniscus, spinothalamic, and
spinocerebellar systems.
❖Descending pathways transmit motor commands
from the brain to the body, controlling voluntary
movements, posture, and balance via tracts such as
the corticospinal, rubrospinal, vestibulospinal, and
reticulospinal systems.

Ascending tracts – sensory pathways
❖The ascending tracts refer to the neural pathways by
which sensory information from the peripheral nerves is
transmitted to the cerebral cortex. It is also known as
somatosensory pathways or systems.
❖Functionally, the ascending tracts can be divided into the
type of information they transmit – conscious or
unconscious:
Conscious tracts – comprised of the dorsal column-medial
lemniscal pathway and the anterolateral system.
Unconscious tracts – comprised of the spinocerebellar
tracts

Dorsal Column–Medial Lemniscal
Pathway (DCML/PCML)
The DCML pathway transmits fine touch, vibration, and proprioception. It is
named for the two main structures it involves: the dorsal columns (in the spinal
cord) and the medial lemniscus (in the brainstem).
It consists of three-order neurons:
◦ First-order neurons carry sensory input from the periphery to the medulla:
◦ Upper limb signals (T6 and above) travel via the fasciculus cuneatus to
synapse in the nucleus cuneatus.
◦ Lower limb signals (below T6) travel via the fasciculus gracilis to synapse
in the nucleus gracilis.
◦ Second-order neurons arise from the cuneate or gracile nuclei, decussate in
the medulla, and ascend via the contralateral medial lemniscus to the
thalamus.
◦ Third-order neurons extend from the ventral posterolateral nucleus of the
thalamus through the internal capsule to the primary sensory cortex.

Anterolateral (Spinothalamic) Pathway
The anterolateral system consists of two tracts: the anterior spinothalamic
tract (carrying crude touch and pressure) and the lateral spinothalamic tract
(carrying pain and temperature). Both follow a three-order neuron system.
First-order neurons originate from peripheral sensory receptors. They enter the
spinal cord, ascend 1–2 levels, and synapse in the substantia gelatinosa of the
dorsal horn.
Second-order neurons decussate within the spinal cord and ascend to the
thalamus:
◦ Fibers for crude touch and pressure enter the anterior spinothalamic
tract.
◦ Fibers for pain and temperature enter the lateral spinothalamic tract.
These tracts run close together and functionally act as a single unit.
Third-order neurons project from the ventral posterolateral nucleus of the
thalamus to the primary sensory cortex, passing through the internal capsule.

Spinocerebellar Tracts – Unconscious
Proprioception
Unlike the DCML and anterolateral systems which transmit conscious sensations,
spinocerebellar tracts carry unconscious proprioceptive input from muscles to the
cerebellum. This information helps the brain refine and coordinate motor activity without
conscious awareness.
These tracts convey signals ipsilaterally and are divided into four pathways:
◦ Posterior spinocerebellar tract: Transmits lower limb proprioception to the ipsilateral
cerebellum.
◦ Cuneocerebellar tract: Carries upper limb proprioception to the ipsilateral cerebellum.
◦ Anterior spinocerebellar tract: Transmits lower limb signals, decussates twice, and still
ends in the ipsilateral cerebellum.
◦ Rostral spinocerebellar tract: Sends upper limb proprioception to the ipsilateral
cerebellum.

Descending Tracts – Motor Pathways
❖Descending tracts carry motor commands from the brain to the
body, where they synapse with lower motor neurons that directly
innervate muscles to produce movement.
❖These tracts are divided into two functional groups:
◦ Pyramidal tracts originate in the cerebral cortex and mediate
voluntary control of facial and body musculature.
◦ Extrapyramidal tracts originate in the brainstem and control
involuntary and automatic movements, such as posture, tone,
and locomotion.
All neurons within these tracts are considered upper motor
neurons (UMNs). They do not synapse until reaching lower motor
neurons, and their axons remain entirely within the central nervous
system (CNS).

Pyramidal Tracts
The pyramidal tracts derive their name from the medullary
pyramids of the medulla oblongata, which they pass
through.
These pathways are responsible for the voluntary control of
the musculature of the body and face.
Functionally, these tracts can be subdivided into two:
Corticospinal tracts – supplies the musculature of the
body.
Corticobulbar tracts – supplies the musculature of the
head and neck.

Corticospinal Tracts – Voluntary Motor
Control
The corticospinal tracts originate in the primary motor cortex, premotor cortex,
and supplementary motor area, with additional input from the somatosensory
cortex for feedback regulation.
Fibers converge and descend through the internal capsule, a key white matter area
between the thalamus and basal ganglia. Lesions here (e.g., capsular stroke) can
cause severe motor deficits due to tract damage.
The descending axons pass through the crus cerebri of the midbrain, the pons, and
reach the medulla, where the tract splits into two branches:
◦ Lateral corticospinal tract: Fibers decussate in the medulla, descend in the
contralateral spinal cord, and terminate in the ventral horn at all levels,
supplying limb muscles.
◦ Anterior corticospinal tract: Fibers remain ipsilateral, descend to cervical and
upper thoracic levels, then decussate near their termination and supply trunk
muscles.

Corticobulbar Tracts – Motor Control of Face
& Neck
The corticobulbar tracts originate from the lateral portion of the primary motor
cortex, receiving inputs similar to the corticospinal tracts. Fibers descend via the
internal capsule to the brainstem.
These neurons terminate in the motor nuclei of cranial nerves, where they synapse
with lower motor neurons that control the muscles of the face, jaw, pharynx,
larynx, and neck.
Most cranial nerve nuclei receive bilateral innervation from both hemispheres. For
example, the trochlear nucleus receives upper motor input from both sides of the
cortex.
Exceptions include:
◦ Facial nerve (CN VII): The lower facial muscles receive only contralateral
input, which explains why a unilateral UMN lesion causes lower facial droop
sparing the forehead.
◦ Hypoglossal nerve (CN XII): Receives contralateral input only, affecting
tongue movement in UMN lesions.

Extrapyramidal Tracts – ipsilateral tracts
The extrapyramidal tracts originate in the
brainstem and carry motor fibers to the spinal cord.
They are responsible for involuntary and automatic
control of muscles — including tone, posture,
balance, and locomotion.
There are four main extrapyramidal tracts:
◦ Ipsilateral: Vestibulospinal & Reticulospinal
◦ Contralateral: Rubrospinal & Tectospinal
Vestibulospinal Tracts :
Arise from vestibular nuclei (which receive balance
input).
Convey signals to the ipsilateral spinal cord to
control balance and posture.
Activate anti-gravity muscles — arm flexors and
leg extensors
Reticulospinal Tracts :
Arise from the reticular formation in the brainstem:
◦ Medial (pontine) tract: Facilitates voluntary
movements and increases muscle tone.
◦ Lateral (medullary) tract: Inhibits movements
and reduces muscle tone.

Extrapyramidal Tracts – Contralateral Tracts
Rubrospinal Tract :
❖Originates in the red nucleus of the midbrain and decussates
immediately.
❖Descends into the spinal cord, providing contralateral innervation.
❖Function is unclear but likely aids in fine motor control of the upper
limbs, especially the hands.
Tectospinal Tract :
❖Starts in the superior colliculus of the midbrain, which receives visual
input.
❖Neurons decussate quickly and descend to cervical spinal levels.
❖Coordinates reflexive head and neck movements in response to visual
stimuli.

Dermatomes
❖ Dermatomes are strips of skin extending from the posterior midline to the
anterior midline which are supplied by sensory branches of dorsal and ventral
rami of a single spinal nerve. A clinical finding of sensory deficit in a
dermatome is important in order to assess what spinal nerve, nerve root, or
spinal cord segment may be damaged.

Myotomes
❖A myotome is a group of muscle fibers innervated by motor axons
from a single spinal nerve root.
❖Most muscles receive input from multiple nerve roots, and most
nerve roots supply more than one muscle.
❖When a muscle scores 3/5 (movement against gravity), it’s
assumed the more rostral (higher) nerve root is intact. If the next
key muscle above is 5/5, both involved segments are considered
normal.
❖To avoid confusion in assessment, ISNCSCI designates one “key
muscle” per spinal segment for consistent clinical testing.
❖This standardization helps clinicians accurately determine the
motor level of spinal cord injury.

Classification
Spinal cord injuries are divided into two broad functional
categories:
Tetraplegia and Paraplegia
Tetraplegia:
◦ Motor and/or sensory impairment in all four limbs and
trunk
◦ Includes respiratory muscles
◦ Results from cervical spinal cord lesions
Paraplegia:
◦ Motor and/or sensory impairment in trunk and both
lower extremities (LEs)
◦ Results from thoracic, lumbar spinal cord, or cauda
equina lesions

Introduction to ASIA
Classification (ISNCSCI System)
•Accurate designation of lesion level is essential to assess
motor and sensory loss in SCI
•The extent of neurological impairment determines medical
and rehab needs
•The American Spinal Injury Association (ASIA) developed
the
International Standards for Neurological Classification of
Spinal Cord Injury (ISNCSCI)
•ISNCSCI provides a standardized examination to
document:
•Sensory loss (light touch & pinprick)
•Motor loss (key muscle group testing)
•Ensures consistent communication, supports prognosis, and
enables clinical research trials

Terms & definitions
Term Definition / Description Key Points / Notes
Dermatome
Area of skin innervated by sensory axons
of a spinal nerve
Key test points designated for ISNCSCI
standardization
Myotome
Muscle group innervated by a motor nerve
root
Often has dual root innervation(more then
one spinal root ); tested using MMT
Key Muscle Functions
10 key muscles tested bilaterally in
ISNCSCI
Scored 0–5, used to define motor level
Non-key Muscle Functions Other muscles not routinely tested
Used only when needed to differentiate
AIS B/C
Sensory Level
Most caudal dermatome with normal
sensation (light touch and pinprick) on
both sides
Score of 2/2 needed; differs L vs R
Motor Level
Lowest key muscle with ≥3/5 strength and
all above are 5/5
Side-specific; based on MMT in supine
Neurological Level of Injury (NLI)
Most caudal level with normal sensory &
motor on both sides
May differ from skeletal level; one final
NLI is defined

Contd..
Skeletal Level Level of vertebral damage on imaging Not part of ISNCSCI; may not match NLI
Sensory Scores
Sum of sensory scores for light touch &
pinprick
Max: 112 per side (28 dermatomes × 2
modalities × 2 pts)
Motor Scores Sum of MMT scores of key muscles Max: 50 per limb (UE 25, LE 25)
Sacral Sparing
Preservation of function at S4–S5 (sensory
or motor)
Defines incomplete injury; includes DAP,
VAC
Complete Injury (ASIAA) No sensory or motor function in S4–S5 No sacral sparing (no DAP, no VAC)
Incomplete Injury (ASIA B–D) Any preservation of function in S4–S5 Sacral sparing present
Zone of Partial Preservation (ZPP)
Segments below NLI with some preserved
function (only used in complete injuries)
Noted for each side (R-sensory, L-sensory,
R-motor, L-motor)
Not Determinable (ND) Used when exam is not possible (e.g., NT) Must be documented with explanation

Incomplete injury syndromes
Syndrome Definition
Cause /
Pathophysiology
Key Clinical Features Prognosis / Notes
Brown-Sequard
Syndrome
Hemi-section (one side) of
the spinal cord, usually
from trauma
Penetrating injuries like
stab or gunshot wounds
- Ipsilateral: Paralysis, loss of
proprioception, vibration, and
light touch- Contralateral:
Loss of pain and temperature
starting a few segments below
good functional recovery
Anterior Cord
Syndrome
Damage to the anterior
2/3 of the cord sparing the
dorsal column
Flexion injury; anterior
spinal artery infarct;
disc herniation
- Bilateral motor loss- Bilateral
loss of pain & temperature-
Preserved: Proprioception,
vibration, light touch
Poor motor recovery;
rehab takes longer

Central Cord
Syndrome
Damage to the central
cervical spinal cord,
affecting arm tracts
Hyperextension injury in
elderly or cervical stenosis
- Motor loss > in UEs than
LEs- Variable sensory loss-
Bowel/bladder may be spared
Most common incomplete
SCI,Good ambulation
recovery; fine motor UE
deficits remain
Cauda Equina
Syndrome
Injury to lumbar/sacral
nerve roots below the
conus medullaris
Lumbar spine trauma,
herniated discs, tumors
- Flaccid LE paralysis-
Areflexic bowel & bladder-
Saddle anesthesia
LMN lesion → Partial
nerve regeneration
possible
Conus Medullaris
Syndrome
Injury to the very end of
the spinal cord at T12–
L1
Trauma, tumors, ischemia
at the conus
- Mix of LMN & UMN signs-
Early bladder/bowel/sexual
dysfunction- Variable LE
weakness
Prognosis varies
depending on extent of
conus and nerve root
involvement
Syndrome Definition
Cause /
Pathophysiology
Key Clinical Features Prognosis / Notes

Autonomic dyreflexia
Component Details
Definition
A life-threatening condition seen in individuals with SCI
at or above T6, characterized by sudden uncontrolled
hypertension due to reflex sympathetic overactivity.
Cause/Mec
hanism
Triggered by noxious/non-noxious stimuli below lesion
level (e.g., bladder distension), leading to reflex
vasoconstriction below the injury and loss of
supraspinal regulation.
Clinical
Features
- Systolic BP rise ≥ 20 mmHg from baseline (≥15
mmHg in children) - Pounding headache, flushing above
lesion, sweating, bradycardia or tachycardia, nasal
congestion, anxiety
Complicati
ons &
Notes
If untreated → risk of cerebral hemorrhage, seizures,
MI, pulmonary edema. Common in chronic SCI, though
rarely may appear early.

Orthotic management
❖Orthotic management involves the prescription and use of spinal,
upper limb, or lower limb orthoses to assist in the rehabilitation of
individuals with spinal cord injury (SCI).
❖To stabilize joints, prevent muscle shortening or joint
contractures, and promote functional motion. In some cases,
orthoses may be used to induce controlled contractures.
❖Orthoses help achieve rehabilitation goals such as mobility,
posture, joint protection, and independence. Proper fit and
alignment are essential for optimal function and comfort.
❖Orthotic intervention is a core element of SCI rehabilitation,
tailored to the patient’s neurological level, motor capacity, and
recovery phase. Designs are adjusted as progress occurs.

Upper Limb Functional Levels and
Equipment (SCI Levels C1–C8)
Neurological
Level
Key Muscles Available Movements
Functional
Capabilities
Equipment, Assistance, and
Orthotic Intervention
Complications
C1–C4
Face and neck
muscles, cranial
nerves, diaphragm
(partial at C3–C4),
trapezius
Talking, mastication,
sipping, blowing,
scapular elevation,
breathing
Totally dependent
in ADL; directs
care; uses
environmental
control
Full-time attendant, mouth/head
stick, power wheelchair with
sip-and-puff or head control,
portable ventilator if needed,
head support, cervical collar,
ventilator support if diaphragm
weak
Respiratory
insufficiency,
pressure sores
C5
Biceps, brachialis,
brachioradialis,
deltoid, infraspinatus,
rhomboids, supinator
Elbow flexion and
supination, shoulder
abduction and flexion
to ~90°, shoulder
external rotation
Assistance with
ADLs using
adaptive equipment
Mobile arm support, wrist-hand
orthosis, universal cuff, part-
time attendant, dorsal wrist-
hand orthosis, mobile arm
support
Elbow flexion
contractures,
impaired balance,
ADL dependence

C6
Extensor carpi radialis,
infraspinatus, latissimus
dorsi, pectoralis major
(clavicular), pronator teres,
serratus anterior, teres minor
Wrist extension
(tenodesis grasp),
shoulder
flexion/extension/interna
l rotation/adduction,
forearm pronation,
scapular
abduction/protraction/up
ward rotation
Independent feeding
and grooming with
devices; dressing with
assist
adapted utensils,
manual wheelchair
on level surfaces,
tenodesis orthosis,
universal cuff, WHO
with ratchet or
dynamic assist
Limited grip strength,
skin breakdown,
tenodesis fatigue
C7
Triceps, extensor pollicis
longus and brevis, finger
extensors, flexor carpi
radialis
Elbow extension, wrist
flexion, finger extension
Independent in most
ADL with equipment;
transfers with assist
Power/manual
wheelchair, adaptive
driving controls,
transfer board,
adapted keyboard,
wrist and hand
orthosis for support,
transfer board
Joint contractures,
shoulder overuse
syndrome, spasticity

Contd …
C8
Finger flexors,
flexor carpi ulnaris,
flexor pollicis
longus and brevis,
intrinsic hand
muscles
Finger flexion,
thumb movement
Independent in all
ADLs with minimal
aids
Adaptive equipment
(e.g., reacher,
shower chair);
manual wheelchair
independent
indoors/outdoors,
short opponens
orthosis, finger
flexor assist splints,
adaptive grips
Fine motor
limitations, risk of
carpal tunnel,
fatigue

Lower Limb Functional Levels and Equipment
(SCI Levels T1–S1
Neurological
Level
Key Muscles
Available
Movements
Functional
Capabilities
Equipment, Assistance, and
Orthotic Intervention
Complications
T1–T12
Intercostals, long back
muscles (sacrospinalis,
semispinalis), abdominal
musculature (T7 and
below)
Improved trunk
control, increased
respiratory reserve
Independent with
manual wheelchair, all
ADLs; improved
efficiency with caudal
levels
Manual wheelchair, pressure
relief cushion, adaptive
driving, transfer board, TLSO
(thoracolumbosacral orthosis)
during early rehab, abdominal
binder for posture and
respiration
Poor sitting
balance (upper
T), spasticity,
bowel/bladder
issues
L1–L3
Gracilis, iliopsoas,
quadratus lumborum,
rectus femoris, sartorius
Hip flexion, hip
adduction, knee
extension
Short-distance
ambulation with aids
KAFO or AFO based on quad
strength, forearm crutches,
Scott-Craig KAFOs, RGOs or
HKAFOs for exercise
ambulation, gait training
orthoses, abdominal binder
Gait fatigue,
hip/knee
instability, falls
risk

L4–S1
Quadriceps (L4),
tibialis anterior (L5),
hamstrings (L5–S1),
gastrocnemius (S1),
gluteus
medius/maximus
(L5–S1), extensor
digitorum, posterior
tibialis, peroneals,
toe flexors/extensors
Knee and ankle
motions, toe
movements, hip
stability
Independent
ambulation in home
and community (may
use wheelchair for
long distances)
AFO, crutches/cane,
FES devices (e.g.,
WalkAide, Bioness),
minimal orthoses as
needed, AFO (solid
or hinged), Swedish
knee cage, functional
electrical stimulation,
posterior leaf spring
AFO
Ankle instability,
foot drop, fatigue on
slopes/uneven
surfaces
S2–S3 and below
Gluteus
maximus/medius,
intrinsic foot muscles
Full lower limb
control
Independent in all
mobility; minimal
assistance
No orthoses unless
orthopedic issues
present; may need
foot orthoses or
taping, custom foot
orthotics or ankle
taping for
stabilization if
needed
Bladder/bowel
dysfunction, sexual
dysfunction, sensory
loss

Spinal Trauma and Fracture Types with
Mechanism and Orthotic Management
Spinal Level Fracture Type Injury Mechanism Remarks Orthotic Management
Upper Cervical (C1) Jefferson Fracture Axial load Triplanar instability Halo vest
Upper Cervical (C2) Hangman Fracture
Hyperextension,
distraction
Traumatic spondylolisthesis;
triplanar instability
Halo vest
Odontoid Fracture
(Type I–III)
Flexion/extension
injuries
Type I: Stable; Type II & III:
Unstable
Halo vest
Lower Cervical (C3–
C7)
Anterior Compression Hyperflexion
Common at C5; may involve
brachial plexus
Rigid collar
Whiplash
Hyperextension +
distraction
Soft tissue injury; long-term
risk of forward head posture
Soft collar (contraindicated in
structural injury), rigid collar if
ligamentous involvement
Shear + Compression
Severe flexion-
compression trauma
Requires evaluation for
instability
Rigid collar or CTO depending on
instability
Cervicothoracic
Junction (C7–T1)
Various
High mechanical
stress transition zone
Often requires more rigid
control
CTO or CTLSO

Contd..
Upper Thoracic (T1–T8)
Denis I (Compression
Fracture)
Flexion + compression
Most common type;
anterior column damage
TLSO, Jewett brace (for
milder cases), corset
Denis II (Burst Fracture) Compression + flexion
Anterior and middle
column injury;
retropulsion risk
Custom TLSO or
prefabricated TLSO
Lower Thoracic (T9–T12)
Denis III (Chance/Slice
Fracture)
Flexion + distraction
(e.g., seatbelt injury)
Posterior and middle
column failure; often
requires surgery
TLSO or postoperative
bracing
Thoracolumbar Junction
(T12–L2)
Common site for burst
and fracture-dislocation
High biomechanical stress
zone
Combined instability;
surgical intervention often
required
TLSO, postoperative
spinal orthosis

Contd..
Upper Lumbar (L1–L2)
Denis IV (Fracture-
dislocation)
Translation, rotation,
shear
Disruption of all 3 spinal
columns; surgical case
Post-surgical TLSO or
rigid LSO
Lower Lumbar (L3–L5)
Spondylolysis /
Spondylolisthesis
Repetitive hyperextension
(e.g., gymnastics)
Common at L4–L5, L5–
S1; adult low back pain
Custom LSO, TLSO with
posterior pelvic tilt
control
Lumbosacral (L5–S1)
Degenerative / Traumatic
listhesis
Chronic strain or trauma
Often needs pelvic
stabilization
Custom LSO, may
include pelvic band or hip
spica if needed

References
1. Magee, D. J., & Manske, R. C. (2021). Orthopedic Physical Assessment. Elsevier.
2. Cifu, D. X., & Lew, H. L. (2017). Braddom’s Rehabilitation Care: A Clinical Handbook. Elsevier.
3. O'Sullivan, S. B. (2019). Physical Rehabilitation (Philadelphia: F.A. Davis Company).
4. Lusardi, M. M., & Nielsen, C. C. (Latest Ed.). Orthotics and Prosthetics in Rehabilitation. Elsevier.
5. Murphy, D. P. (2015). New Atlas of Limb Orthoses (5th ed.).
6. American Academy of Orthopaedic Surgeons (AAOS). Atlas of Orthoses and Assistive Devices (4th ed.).
7. Louis, T. M., & Dudek, R. W. (2015). High-Yield Gross Anatomy. Wolters Kluwer.
8. Agur, A. M. R., Dalley, A. F., & Moore, K. L. (2018). Clinically Oriented Anatomy. Wolters Kluwer.
9. Drake, R. L., Vogl, A. W., & Mitchell, A. W. M. (2019). Gray’s Anatomy for Students (4th ed.).
10. ASIA–ISCOS (2019). International Standards for Neurological Classification of Spinal Cord Injury
(Worksheet).
11. Ko, H-Y. (2022). Management and Rehabilitation of Spinal Cord Injuries. Springer.
Web Sources
TeachMeAnatomy
Physiopedia
Kenhub

SPINAL CORD INJURY & ITS ORTHOTIC MANAGEMENT

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