F-CLINICAL ASPECTS OF SPINAL CORD INJURIES
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position has difficulty in keeping his balance. The higher the transection of the cord the
more profound is the disturbance of posture, and this applies in particular to upper
thoracic and cervical lesions. In the past, such a person was, as a rule, confined to bed or
had to be transported in lying position in a spinal carriage. If the upright position in
such cases was attempted, it was achieved by propping them up with artificial aids such as
heavy leather and steel corsets. Moreover, the postural disturbances in lesions above T5
are greatly aggravated by the loss of vasomotor control as the result of the interruption of
the splanchnic innervation (see chapter on Vasomotor Control).
Experience in the last 25 years on the spinal man has shown that the sensory discon
nection between the paralysed and normal parts of the body does not remain permanent
(Guttmann, 1946, 19533, 1967, 1969). In later stages of complete transverse lesion,
afferent impulses arising from paralysed parts of the body are mediated centrally and
new connections with afferent pathways above the cord transections are established and
thus some reorientation of sensory function and a reorientation of the postural control
take place. Such transformation of function of afferent mechanisms in the human body
is of immense importance for the rehabilitation of the spinal man.
In analysing the pathways conducting afferent impulses arising from paralysed parts
of the body, the following routes have to be considered:
It must be remembered that in all transections of the lumbar, thoracic and up to the
middle cervical cord, there still exists a bridge between the paralysed parts of the body
and the central nervous system above the level of the transection, provided for by nature
through the anatomical arrangements of certain muscle groups, which have their seg-
mental supply above the cord transection but their anatomical insertion points are attached
to areas below the transection such as the lower part of the spine, and, most important
of all, to the pelvic girdle. These are, in particular, the trapezius (supplied by the acces
sory nerve as well as the upper cervical segments), which has its insertion points distally
to the 12th dorsal vertebra, and, especially, the latissimus dorsi (supplied by C6,
Cj
and C8), with its anatomical attachments on the lumbar fascia and posterior rim of the
pelvis. In more distal lesions, say below Tio, these connections of the back muscles are
intensified by the rectus abdominis (segmental supply T5~Ti2) which is also attached
to the pelvis. Through their attachment to the pelvis, these muscle groups, innervated
above the level of transection, play an essential part in the reconditioning of the afferent
system in complete transverse lesions in restoring postural control in the spinal man. For,
proprioceptive impulses arising from any movement of the pelvis are transmitted centrally
along the afferent nerve fibres of these normally innervated muscles and thus reconnect
the insensitive part of the body with the cerebral and cerebellar centres and their connec
tions with the labyrinths and their arcs subserving postural control, promoting appro
priate efferent postural responses to the paralysed area. Eventually, a new pattern of
postural sensibility develops along the nerve supply of the trunk muscles, which enables
the paraplegic even of higher level to regain his postural control and restore his upright
position without the aid of artificial support by corsets. This is first accomplished under
visual guidance by balancing exercises in sitting position in front of a mirror, during
which the patient raises his arms in various directions, whereby he learns to compensate
by visual control for the unsteadiness of the trunk resulting from the loss of postural
