F- CLINICAL ASPECTS OF SPINAL CORD INJURIES
239
The patient has difficulty in talking and speaks with a low and nasal voice in a rather
staccato fashion. He also has difficulty in swallowing. The respiratory rate is increased
and the patient uses the few remaining auxiliary respiratory muscles, trapezius, sterno
mastoid, platysma and alae nasi. The vital capacity may be practically nil or as low as
50-100 ml. The patient is unable to cough and even with a tracheostomy tube
in situ
cannot bring up mucus; his respiration becomes bubbly if the mucus is not removed by
suction or tilting the patient down. His colour may become cyanotic owing to obstruction
of the air passage resulting from accumulated secretion and collapse of a lung may occur.
He may become increasingly irrational and finally lose consciousness as a result of anoxia.
The sensory loss in complete lesions involving C2 and 03 segments affects the whole
body, including the occipital area, the ear and submental region of the face. In lesions
at 04 the sensory loss reaches up to the middle of the neck but leaves the ear and sub-
mental area free.
Until recently, tetraplegics with transverse upper cervical lesions were doomed to
death within a few hours or days, but with the modern means of management they can
survive for a considerable time and can even become wheelchair bound. There is an
improvement in the vital capacity of the lung, due to strong compensatory action of
trapezius and sternomastoid, the latter sometimes becoming hypertrophic. They are able
to move about in an especially adapted electrically driven wheelchair, which they control
by movements of the head. However, these patients will remain liable to lung collapse
and, particularly, pneumonia, especially in the age group over 40. As a rule, the life
expectation of these very high tetraplegics is greatly shortened.
C5 SEGMENT
In the acute stage of a complete transverse lesion at €5, the function of the diaphragm
is greatly impaired if not completely abolished as a result of post-traumatic oedema.
Moreover, meteorism as a result of the initial intestinal paralysis will aggravate the
respiratory distress, as described in upper cervical lesions, and tracheostomy may become
imperative. However, in due course the diaphragm will regain its full function, once the
segmental innervation of the phrenic nerve has fully recovered from its initial shock.
Moreover, as levator scapulae (03-05) and rhomboids (04-05) are only partially dener-
vated and trapezius and sternomastoid are intact, the vital capacity of the lung will, in
due course, be definitely better than in the upper cervical lesions. Supra- and infraspinatus
(04-05) will also be only impaired and some outward rotation of the arm will be possible.
The muscles deprived of their segmental innervation are deltoid, biceps, brachialis
internus, brachioradialis and supinator brevis. The deltoid, biceps and supinator reflexes
are either abolished or greatly diminished. The arms lie motionless alongside the body
(Fig. in). The shoulder may be markedly elevated due to the uninhibited action of
levator scapulae and trapezius, as a result of the paralysis of the depressors of the
shoulders. In recent years, it has been suggested that the segmental innervation of the
biceps is somewhat higher than that of the deltoid (Grossiord
et
a/., 1963). I cannot
confirm this from personal experience. The reflexes below the level of the lesions become
exaggerated and this applies also to the spastic finger flexion reflex. Moreover, a tap on
