I made these 'learning posts' in June for Spina Bifida Awareness month, but thought I'd make a stand-alone blog so that if anyone is interested, all of the information is here. And I can add as I learn more about spina bifida as well!

Spina Bifida is the most common birth defect in North America. My son Nickolas was born November 13, 2009 with spina bifida and I have chronicalled our journey here, in my personal blog.

I hope you enjoy and learn something!


The information from this blog has been collected by myself to share what I have learned. It should in no way replace medical recommendations or consultation. This is for educational and information purposes only.

Start by picking a topic below:

Monday, June 18, 2012

Lesions, Levels, Sensory and Mobility

It's all about the letters and numbers.

For those not in the spina bifida world there are actually 2 sets of numbers and letters to work with (actually maybe 4), which represent that lesion (where the spine was damaged) or level. One is motor ability and the other is sensory ability. Then there is actual level and functional level. Am I confusing you yet?

Some basics: The spine is made up of vertebrae (bones) that have letters and numbers. From the top down we have 8 cervical vertebrae (C1-C8), 12 thoracic vertebrae (T1-T12), 5 lumbar vertebrae (L1-L5) and 5 sacral (S1-S5).


The spinal cord and nerves are protected by the bony vertebrae. The nerves send messages back and forth to/from the body and brain.
Sensory lets your brain know what different parts of your body is feeling
Motor function lets you brain tell your body, muscles what to do.

 

The lesion means that the protecting bony part of the spine did not develop and the nerves are exposed and damaged. Unlike a spinal cord injury - where there is usually a clear line of function versus no-function, spina bifida can be patchy with lesion levels that might not equal functional level.

So what does it mean?

Sensory level is easy to determine, it just means what does someone actually feel.
Does an infant, child or adult feel when you touch? When you tickle?

  

 You can see from both these pictures that it is not a straight line.
The nerves feed into different muscles and part of the body and it is different at the front and the back of the legs.
With Nickolas, I feel that he can feel down the front of his legs, and up the back of his calf, but nothing at the back of his thigh. So... that would give us about a S1 sensory level.

 Functional level is a little tricky.
Muscles get messages from different nerves - this is called innervation.
When I ask someone to give me a number and letter, they always tell me that it's their best guess. And with infants and children, it will take time to determine. There is also no clear-cut answer.

When scientists all got together in a room and drew all of these charts they had to draw a line in the sand and say 'this muscle = this vertebrae/nerve'
To get an idea of what I mean you can look at this medical illustration linked here.




The Spinal Hub website outlines exactly what function spinal nerves do to muscles. Also a powerpoint presentation here.

Vertebrae
Muscle
Function
C1


C2


C3
Diaphragm
Breathing
C4
Diaphragm/ Shoulder
Breathing/Shoulder shrug
C5
Deltoid/ Biceps
Lift arms, sideways/Bend elbow
C6
Wrist extensors
Lift wrist back
C7
Triceps
Straighten elbow
C8
Hands/Fingers
Grip object

Thoracic

T1
Hands/Fingers
Splay fingers apart
T2
Chest (intercostal)
Allow ribcage move/breathe
T3
Chest (intercostal)
Allow ribcage move/breathe
T4
Chest (intercostal)
Allow ribcage move/breathe
T5
Chest (intercostal)
Allow ribcage move/breathe
T6
Chest/ Abdomen
Ribcage move/Cough
T7
Chest/ Abdomen
Ribcage move/Cough
T8
Chest/ Abdomen
Ribcage move/Cough
T9
Abdomen
Cough, balance
T10
Abdomen
Cough, balance
T11
Abdomen
Cough, balance
T12
Abdomen
Cough, balance

Lumbar


L1
Hip
Bends hips
L2
Hip
Bend, flex hip joint
L3
Quadricep/Hip adductors
Straighten leg at knee
L4
Knee/Ankle
Bend ankle, draw foot back (dorsi-flexion)
L5
Ankle/Toe
Lift ankle/Lift big toe

Sacral


S1
Ankle/Toe
Bend ankle/Point toe (plantar flexion)
S2
Toes/Anal, bladder sphincter

S3
Anal, Bladder sphincter

S4
Anal, Bladder sphincter

S5
Anal, Bladder sphincter


When you start looking up things like this, it is almost like you need a separate textbook to understand what these pictures are telling you! One site that was very interesting in the amount of depth of information came from medical school notes, found here.
I love medical students that put their studying online like flashcards here.


Plain English please!

All of those muscles get confusing!



Especially when your physio talks about 'oh I think there is definitely ____ muscles, not sure about ____ mucles' and you are trying to remember grade 12 biology. So Glutes, quadracepts, and hamstrings are the ones that stick out for me on those pictures.

Muscle Ability
Muscle Group
Nerve Innervation
Thigh flexion

L1, L2, L3, L4
Thigh adduction

L2, L3, L4
Thigh abduction

L4, L5, S1
Extension of leg at hip
Gluteus maximus
L5, S1, S2
Extension of leg at knee
Quadriceps
L2, L3, L4
Flexion of leg at knee
Hamstrings
L4, L5, S1, S2
Dorsiflexion of foot

L4, L5, S1
Extension of toes

L4, L5, S1
Plantar flexion of foot

L5, S1, S2
Flexion of toes

L5, S1, S2
Anal wink

S2, S3, S4

Some sources for this chart here and here.

Muscles receive messages from a number of nerves. Can't anything be easy?!
So trying to determine what a level is by what someone can do or feel is not as easy as the colourful pictures lead you to believe. If you are trying to determine the functional level that your child has, I am just repeating what I found online as well as what our physiotherapist explained to us. I used alot of this information to try to decode or translate what we were told - not to diagnose. (OK maybe I tried to diagnose a little bit when I didn't like what I was being told)

I looked at a bunch of articles that talked about flexion and extension and abduction/adduction. Then I had to look up what all of those meant, and then I had to look up pictures.

Abduction


 Adduction


Knee extension

 
Knee flexion


Hip flexion




This is one of the most frustrating part when you are trying to imagine what you child will be able to do. All of this information and pictures and illustration will not let your child do something that their nerves will not allow them to do.
Labelling your child as a number and letter will not help anything (I can say this from experience and from fighting with myself about wanting a letter and a number). Being aware of what information is out there, and celebrating the achievements and abilities of your child and trying to educate yourself  is what I hope people get out of this information post.

8 comments:

  1. Finally I'm less confused! It feels great.

    ReplyDelete
  2. Hi, Nice post! Would you please consider adding a link to my website on your page. Please email me back.

    Thanks!

    Harry
    harry.roger10@gmail.com

    ReplyDelete
  3. Very nicely done. Thank you.
    Just one note: Knee flexion (bending up against gravity) and knee extension (straightening the knee out in front of you when sitting) should be reversed in your labeling, which you have done Above each photo, not below. Cheers!

    ReplyDelete
  4. My doctor had told me that my spina bifida is S1 L1.... So im still confused... I just found out that I had this about 6 months ago.... but my mother has always said my entire life I have complained... but my doctor says its nothing... Should I be considering finding a new doctor?

    ReplyDelete
  5. I was found to have an open S5 in 1998 at age 43, but it didn't bother me until my bladder nerve function diminished so much that I was diagnosed with neurogenic bladder in 2011, and since then I'm unable to urinate and must remain with a foley catheter...

    ReplyDelete
  6. Hi, thank you so much for posting this blog. This indeed is quite helpful. We incidentally discovered yesterday that our son, 13 years, have spina bifida at T1 level. We wish to consult an expert but are split between Neurologist and Neurosurgeon. Kindly share your understanding on this. Just to reaffirm, we discovered this incidentally and have not witnessed any kind of trouble with our son till date.

    ReplyDelete
  7. Hi everyone,
    I updated this post and removed old links. I also updated the knee extension and flexion from the comment above. So as of Feb 2014 this is correct.
    If you get a diagnosis of spina bifida as an old child/adult then it would be spina bifida occults. Which has less nerve damage. I recommend talking to your doctor. If surgery is not indicated, I do not know what information a neurosurgeon could give you. But neurosurgery is who we have had all of our contact with.

    I am glad everyone has found this helpful.\Thanks

    ReplyDelete
  8. Hi I was diagnosed at birth 41 yrs ago after birth, my scar is S1-S5 and I have bowel, bladder, sexual and some sensation and mobility probs in the legs but atm not severe. My question is which SB I am cause what has been suggested could go both ways. At that level my wound was open and nerves severed and exposed, but I am wondering if it was open due to rupture from a natural birth which then would make me a different level SB.

    ReplyDelete