Assessing range of movement in the neck
- Be aware that range of movement in the neck when there is clinical suspicion of a cervical spine injury can only be assessed safely before imaging in people with a head injury if they have no high-risk factors
- Only do the assessment if they have at least 1 of these low-risk features
- They were in a simple rear-end motor vehicle collision
- They are comfortable in a sitting position
- They have been ambulatory at any time since injury
- There is no midline cervical spine tenderness
- They present with delayed onset of neck pain.
Neurological assessment
Relationship between the bony spinal canal and the spinal cord and nerves
- Since there are 8 pairs of cervical nerves and only 7 cervical vertebra
- Cervical nerves 1 through 8 exit above the pedicles of their like-numbered vertebra
- Thoracic, lumbar and sacral nerves exit below the pedicles of their like-numbered vertebra
- Due to disproportionately greater growth of the spinal column than the spinal cord during development, the following relationships of the spinal cord to the vertebral column exist
- To determine which segment of the cord underlies a given vertebra
- From T2 through T10: add 2 to the number of the spinous process
- For T11, T12 and L1, remember that these overlie the 11 lowest spinal segments (L1 through L5, S1 through S5, and Coxygeal-1)
- The conus medullaris in the adult lies at about L1 or L2 of the spine
Motor level assessment general information
Segment/Level | Muscle | Action to test |
C4 | Diaphragm | Tidal volume (TV), FEV1, and vital capacity (VC) |
C5 | Biceps | Flex elbow |
C6 | Wrist extensors | Cock up wrist |
C7 | Triceps | Extend elbow |
C8 | Flexor digitorum profundus | Flex middle distal phalanx |
T1 | Hand intrinsics | Abduct little finger |
T2–9 | Intercostals | Sensory level, abdominal reflexes, Beevor’s sign |
T9-T10 | Upper abdominals | Sensory level, abdominal reflexes, Beevor’s sign |
T11–12 | Lower abdominals | Sensory level, abdominal reflexes, Beevor’s sign |
L2 | Iliopsoas | Flex hip |
L3 | Quadriceps | Straighten knee |
L4 | Tibialis anterior | Dorsiflex foot |
L5 | EHL | Dorsiflex big toe |
S1 | Gastrocnemius | Plantarflex foot |
Segment | Muscle(s) | Action to test | Reflex |
C1-4 | Neck muscles | ㅤ | ㅤ |
C3-5 | Diaphragm | Inspiration, TV, FEV1, VC | ㅤ |
C5, 6 | Deltoid | Abduct arm > 90° | ㅤ |
C5, 6 | Biceps | Elbow flexion | Biceps |
C6, 7 | Extensor carpi radialis | Wrist extension | Supinator |
C7, 8 | Triceps, extensor digitorum | Elbow and finger extension | Triceps |
C8, T1 | Flexor digitorum profundus | Grasp (flex distal phalanges) | ㅤ |
C8, T1 | Hand intrinsics | Abduct little finger, adduct thumb | ㅤ |
T2–9 | Intercostals | ㅤ | ㅤ |
T9, 10 | Upper abdominals | Beevor’s sign | Abdominal cutaneous reflex |
T11, 12 | Lower abdominals | Beevor’s sign | Abdominal cutaneous reflex |
L2, 3 | Iliopsoas, adductors | Hip flexion | Cremasteric reflex |
L3, 4 | Quadriceps | Knee extension | Infrapatellar (knee jerk) |
L4, 5 | Medial hamstrings, tibialis anterior | Ankle dorsiflexion | Medial hamstrings |
L5, S1 | Lateral hamstrings, posterior tibialis, peroneals | Knee flexion | ㅤ |
L5, S1 | Extensor digitorum, EHL | Great toe extension | ㅤ |
S1, 2 | Gastrocs, soleus | Ankle plantarflex | Achilles (ankle jerk) |
S2, 3 | Flex digitorum, flex hallucis | ㅤ | ㅤ |
S2–4 | Bladder, lower bowel, anal sphincter | Clamp down during rectal exam | Anal cutaneous reflex, bulbocavernosus & priapism |
- Beevor sign
- This sign was an indication for rectus abdominis weakness or paralysis due to spinal cord lesions between T10-12.
- The patient should be in a supine position. To elicit the sign, the patient is asked either to flex his neck or to sit up from the recumbent position without using the arms (the patients can keep their arms across their chest).
- Once the umbilicus moves upward, it is a positive Beevor sign.
- It is negative if the umbilicus remains in its position.
- NB: most muscles receive innervation from two adjacent spinal levels, the levels listed in
Sensory level assessment (dermatomes and sensory nerves)
- ASIA standards 28 key points identified in
- Pinprick
- Light touch
- NB: regarding the “C4 cape” AKA “bib” region across the upper chest and back: sensory segments “jump” from C4 to T2 with the intervening levels distributed exclusively on the UEs . The location of this transition is not constant from person to person.
- Key sensory landmarks
- Additional sensory exam
- The following elements are considered optional but it is recommended that they be graded as absent, impaired, or normal
- Position sense: test index finger and great toe on both sides
- Awareness of deep pressure/deep pain
Level | Dermatome landmark | Level | Dermatome landmark |
C2 | Occipital protuberance | T7 | Seventh IS (midway between T6 & T8) |
C3 | Supraclavicular fossa | T8 | Eighth IS (midway between T6 & T10) |
C4 | Top of acromioclavicular joint | T9 | Ninth IS (midway between T8 & T10) |
C5 | Lateral side of antecubital fossa | T10 | Tenth IS (umbilicus) |
C6 | Thumb, dorsal surface, proximal phalanx | T11 | Eleventh IS (midway between T10 & T12) |
C7 | Middle finger, dorsal surface, proximal phalanx | T12 | Inguinal ligament at mid-point |
C8 | Little finger, dorsal surface, proximal phalanx | L1 | Half the distance between T12 & L2 |
T1 | Medial (ulnar) side of antecubital fossa | L2 | Mid-anterior thigh |
T2 | Apex of axilla | L3 | Medial femoral condyle |
T3 | Third intercostal space (IS) | L4 | Medial malleolus |
T4 | Fourth IS (nipple line) | L5 | Dorsum of foot at 3rd MTP (metatarsal phalangeal) joint |
T5 | Fifth IS (midway between T6 & T8) | S1 | Lateral heel |
T6 | Sixth IS (xiphoid process) | S2 | Popliteal fossa in the mid-line |
Rectal exam
- External anal sphincter
- Method
- Insertion of the examiner’s gloved finger
- Perceived sensation is recorded as present or absent.
- Any sensation felt by the patient indicates that the injury is sensory incomplete
- Record resting sphincter tone and any voluntary sphincter contraction
- Bulbocavernosus (BC) reflex
- Absence suggests the presence of spinal shock, and it may not be possible to declare a suprasacral SCI as complete because there might be spinal shock which could transiently suppress spinal cord function
- A polysynaptic spinal cord mediated reflex relayed via S2–4 nerve roots.
- Method: Contraction of anal sphincter in response to
- Squeezing the glans penis in males, OR
- Tugging on the Foley catheter in either sex is a normal response
- Must be differentiated from the movement of the Foley catheter balloon
- Loss of reflex can occur with
- Spinal shock: the BC reflex may be lost with spinal shock as can occur with suprasacral injuries. Reportedly, the return of the BC reflex may be the earliest clinical indicator that spinal shock has subsided
- Injuries involving the cauda equina or conus medullaris
- Presence of BC reflex used to be taken as an indication of an incomplete injury, but its presence alone is no longer considered to have a good prognosis for recovery.