In the conscious individual, a systematic neurological assessment should identify the level of the injury and the extent of neurological disability. It is important to remember that sensory preservation over the manubrium sterni may be due to C4 innervation (supra-clavicular nerves) rather than from the intercostal nerves at T3/4. Sensory assessment should follow specific well established landmarks which include the axilla (T2),the umbilicus (T10), anterior superior iliac spine D12/L1).

In the unconscious individual, paralysis can be suspected by neurogenic paradoxical respiration with indrawing of the intercostals during inspiration. It may also be seen with patients with cervical spinal cord injury where there is an absence of response to painful stimuli that might arise from movement of an injured extremity and the presence of pseudo priapism in the male.

Hyperpathia in a dermatomal fashion in the upper extremity may also be elicited.


Action of deltoid and/or biceps in a C5 tetraplegic could result in abduction of the shoulder and flexion of the elbow with passive movements of the wrist and fingers. If voluntary reproducible finger movements could not be demonstrated, such incidental passive movements of fingers should not be interpreted to indicate normal power.

Involuntary twitching of the paralysed lower extremity may be seen in the A & E Department soon after cord injury, for a varying period of time. These do not indicate preservation of voluntary power in the lower extremities.

The tone in the lower extremity may be partly preserved soon after the accident. Plantar stimulation may result in reflex withdrawal of the lower extremity. Again these do not suggest preservation of function in the lower extremities unless it is voluntary and reproducible.

Neurological charting such as “grade 1/5 in upper and lower limbs” is not meaningful documentation but can result in unnecessary litigation against Health Authorities, should these “neurological chartings” be assumed to represent true function. Medical documentation should clearly identify what was actually observed during neurological assessment and whether it was reproducible, in a conscious patient.