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Hyun-Yoon Ko and Sungchul Huh
Handbook of Spinal Cord Injuries and
Related Disorders
A Guide to Evaluation and Management
1st ed. 2021
Hyun-Yoon Ko
Department of Rehabilitation Medicine, Rehabilitation Hospital, Pusan
National University Yangsan Hospital, Pusan National University
College of Medicine, Yangsan, Korea (Republic of)
Sungchul Huh
Department of Rehabilitation Medicine, Rehabilitation Hospital, Pusan
National University Yangsan Hospital, Yangsan, Korea (Republic of)
ISBN 978-981-16-3678-3 e-ISBN 978-981-16-3679-0

https://doi.org/10.1007/978-981-16-3679-0
© The Editor(s) (if applicable) and The Author(s), under exclusive

license to Springer Nature Singapore Pte Ltd. 2021
This work is subject to copyright. All rights are solely and exclusively
licensed by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in
any other physical way, and transmission or information storage and
retrieval, electronic adaptation, computer software, or by similar or
dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks,

service marks, etc. in this publication does not imply, even in the
absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general
use.
The publisher, the authors and the editors are safe to assume that the
advice and information in this book are believed to be true and accurate
at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the
material contained herein or for any errors or omissions that may have
been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer

Nature Singapore Pte Ltd.
The registered company address is: 152 Beach Road, #21-01/04
Gateway East, Singapore 189721, Singapore
To my mother and to the memory of my father, who gave me everything
and made me have a faithful mind.
To my mentors, who taught me with incredible generosity, shared their
advanced knowledge, gave me opportunities to learn a lot from them, and
inspire and motivate me.
To my special colleagues in the Department of Rehabilitation Medicine at
Pusan National University College of Medicine for their passion and
support.
To the most important person, my wife Insun, Dr. Park, for her
understanding and support.
Hyun-Yoon Ko, MD, PhD
My greatest thanks go to all of my patients throughout the years with
spinal cord injury.
To my wife, Sung Eun Lee, my little son, Junwoo Huh, and my parents for
all their sacrifices for me and for teaching me the meaning of my life.
I greatly appreciate my teacher and mentor, Dr. Hyun-Yoon Ko, for taking
the opportunity to participate in the writing.
Sungchul Huh, MD
Preface
Spinal cord medicine, which encompasses the diagnosis, treatment, and
rehabilitation of patients with spinal cord injuries, has developed
remarkably since World War II. Technology for the prevention and
treatment of complications that cause death after spinal cord injuries
such as cardiopulmonary and urinary complications and pressure
injuries associated with spinal cord injuries has also been developed,
and mortality and morbidity after the acute phase of spinal cord injury
have become almost similar to that of people without spinal cord injury.
In addition, it is good news that spinal cord injuries related to traffic
accidents and accidents at work are on the decline. However, the
lengthening of life expectancy after spinal cord injury over the past 20
years has been in a state of stagnation, and as the health age and
lifespan of the general population increase overall, the difference in life
expectancy between people with spinal cord injuries and the general
population is gradually increasing.
Spinal cord injury is a very devastating event as it can directly or
indirectly have negative effects on the person affected by spinal cord
injury and their family and friends, including the urinary system,
gastrointestinal system, sexuality, and psychosocial problems, as well as
motor and sensory functions below the level of injury. Fortunately,
however, most patients with spinal cord injuries can improve their
quality of life and social participation through personal effort,
rehabilitation, and medical assistance through spinal cord medicine.
Successful rehabilitation after spinal cord injury can be achieved
through a very comprehensive and well-planned effort by physicians
and medical personnel involved in spinal cord medicine, physical
therapists, occupational therapists, speech therapists, social workers,
and psychologists. Despite significant advances in spinal cord medicine,
physicians who are not involved in the treatment of patients with spinal
cord injuries or who do not specialize in spinal cord medicine may not
understand patients medically and may not provide proper primary
care. Physicians or primary care providers have to make continuous
efforts to be able to appropriately cope with medical situations and
emergencies of people with spinal cord injuries.
Various medical problems of people with spinal cord injuries can be
solved through a joint effort of internal medicine such as cardiology,
respiratory medicine, infections, and endocrinology, neurology,
orthopedic surgeon, neurosurgeon, urology, radiology, laboratory
medicine, and physiatry. Therefore, physicians involved in spinal cord
medicine must learn and acquire knowledge in a wide variety of fields
such as functional anatomy, neuroanatomy, neurology, urology,
orthopedics, and cardiopulmonary medicine, and strive to apply that
knowledge appropriately. Medical infrastructure is required for the
successful treatment and rehabilitation of patients with spinal cord
injuries. Medical professionals practicing spinal cord medicine should
endeavor to disseminate medical knowledge of spinal cord medicine
and medico-social movement in order to achieve successful
rehabilitation of our patients.
The knowledge of spinal cord medicine has been acquired from the
knowledge of various fields mentioned above, and many kinds of
specialized books related to spinal cord medicine are introduced. Some
books were biased to deal with surgical issues, while others were
quotes and descriptions from too many references, making it difficult to
easily acquire knowledge about spinal cord injuries. The authors wrote
this book with the intention of concisely presenting universal
knowledge that can be applied clinically throughout the book, and as a
book that can be easily referenced in the medical field. In addition, we
have tried to keep up-to-date knowledge while dealing with various
issues of spinal cord injury. Hopefully, if this book has an opportunity to
lead to another edition in the future, it can make up for the lack of
parts. The authors believe that this book can serve as a good reference
as it can be easily read by physiatrists involved in the treatment of
patients with spinal cord injuries, neurologists, urologists, internists,
orthopedic surgeons, and neurosurgeons in the medical field of spinal
cord medicine.
Hyun-Yoon Ko
Yangsan, Korea (Republic of)
April 2021
Contents
1 Clinical and Functional Anatomy of the Spinal Cord
1.1 Development of the Spinal Cord
1.2 Metamerism
1.3 Myelination
1.4 Anatomy of the Spinal Cord
1.4.1 Overview of Anatomy of the Spinal Cord
1.4.2 White Matter and Tracts
1.4.3 Gray Matter
1.5 Spinal Nerves and Roots
1.6 Meninges, Subarachnoid Space, and Cerebrospinal Fluid
1.7 Vascular Anatomy of the Spinal Cord
1.7.1 Arteries
1.7.2 Veins
References
2 Extremity Kinematics and Muscles for Functional Training of
Tetraplegics and Paraplegics
2.1 Potential Functions
2.2 Relevant Kinematics
2.2.1 Movement and Kinetic Chains
2.2.2 Muscle Contraction
2.2.3 Muscle Substitution
2.3 Contributing Muscles to Mobility Depending on the Motor
Level
2.3.1 Neurological Level of Injury:C4
2.3.6 Neurological Level of Injury:T1–9
2.3.7 Neurological Level of Injury:T10–T12
2.3.8 Neurological Level of Injury:L1
2.3.10 Neurological Level of Injury L3
2.3.13 Neurological Level of Injury:S1
2.4 Functional Anatomy of the Extremity Muscles
2.4.1 Muscles of the Upper Extremity
2.4.2 Muscles of the Lower Extremity
References
3 Physical and Neurological Differentiation of Spinal Cord Lesions
3.1 Neurological Assessment
3.1.1 Clinicoanatomical Considerations
3.1.2 Neurological Classification of Spinal Cord Injury
3.1.3 Upper Motor Neuron and Lower Motor Neuron Lesion
3.1.4 Muscle Bulk
3.1.5 Muscle Tone
3.1.6 Muscle Strength
3.1.7 Reflexes
3.1.8 Sensory Assessment
3.2 Functional Assessment
References
4 Laboratory Tests Commonly Encountered in Care of Spinal Cord
Injuries
4.1 Simple Blood Tests
4.1.1 Complete Blood Cell Counts
4.1.2 Electrolyte Disorders
4.1.3 Liver and Kidney Functions
4.2 Urinalysis
4.2.1 Physical Tests
4.2.2 Biochemical Tests
4.3 Infection/Inflammatory Markers
4.3.1 Erythrocyte Sedimentation Rate
4.3.2 C-Reactive Protein
4.4 Nutrition Markers
4.4.1 Serum Visceral Protein
4.4.2 Non-visceral Protein Markers
4.5 Bone Turnover Markers
4.5.1 Bone Formation Markers
4.5.2 Bone Resorption Markers
4.6 Coagulation Markers
4.6.1 Prothrombin Time and International Normalized
Ratio
4.6.2 Activated Partial Thromboplastin Time
4.6.3 Fibrinogen
4.6.4 D-Dimer
4.7 Metabolites
4.7.1 Glucose
4.7.2 Lactate
4.7.3 Urea
4.8 Arterial Blood Gas
4.8.1 pH
4.8.2 Partial Pressure of Oxygen
4.8.3 Partial Pressure of Carbon Dioxide
4.8.4 Bicarbonate
4.8.5 Base Excess
4.8.6 Anion Gap
4.8.7 Oxygen Saturation
4.9 Lipid Profile
4.9.1 Total Cholesterol
4.9.2 HDL Cholesterol
4.9.3 LDL Cholesterol
4.9.4 Triglycerides
4.10 Cardiac Markers
4.10.1 Cardiac Troponins
4.10.2 Creatine Kinase
4.10.3 Myoglobin
4.10.4 Homocysteine
4.11 Hormonal Markers
4.11.1 Antidiuretic Hormone
References
5 Pharmacotherapy in Spinal Cord Injuries
5.1 Basic Clinical Pharmacology
5.1.1 Pharmacokineticsand Drug Metabolism
5.1.2 Therapeutic Drug Monitoring
5.2 Altered Pharmacokineticsin Spinal Cord Injuries
5.2.1 Altered Pharmacokinetics
5.3 Medication Categories Commonly Prescribed in Spinal Cord
Injuries
5.3.1 Autonomic and Cardiovascular Drugs
5.3.2 Medications for Respiratory Dysfunction
5.3.3 Anticoagulants for Deep Venous Thrombosis and
Pulmonary Embolism
5.3.4 Medications for Bladder Dysfunction
5.3.5 Medications for Bowel Dysfunction
5.3.6 Medications for Spasticity
5.3.7 Pain Medications
5.3.8 Medications for Hypertension and Coronary Heart
Disease
5.3.9 Medications for Depression
5.3.10 Medications for Anxiety
5.3.11 Medication for Sleep Disorder
5.4 Polypharmacy in Spinal Cord Injuries
References
6 Imaging Assessment of Spinal Cord Injuries
6.1 Guidelines of Imaging Studies of Spinal Cord Injuries
6.2 Imaging Modalities
6.2.1 Plain Radiographs
6.2.2 Magnetic Resonance Imaging
6.3 Cervical Spine Imaging Study
6.4 Thoracic and Lumbar Spine Imaging Study
6.5 Imaging for Ankylosing Spondylitis or Diffuse Idiopathic
Skeletal Hyperostosis (DISH)
References
7 Functional Assessment and Expected Functional Outcomes
Following Spinal Cord Injuries
7.1 Initial Neurological and Functional Assessment After Spinal
Cord Injury
7.2 Factors Affecting Neurological and Functional Outcomes
7.3 Recovery of Ambulatory Function
7.4 Functional Assessment Measures for Spinal Cord Injuries
7.5 Expected Functional Outcomes of Spinal Cord Injuries
7.5.1 C2-C4 Tetraplegia
7.5.2 C5 Tetraplegia
7.5.3 C6 Tetraplegia
7.5.4 C7 and C8 Tetraplegia
7.5.5 Thoracic Paraplegia
7.6 Quality of Life After Spinal Cord Injury
References
8 Standard Neurological Classification of Spinal Cord Injuries
8.1 History of the ISNCSCI
8.2 Overview of the ISNCSCI
8.3 Two Major Changes with the Eighth Edition of ISNCSCI in
2019
8.3.1 General “*”-Concept
8.3.2 New Definition of Zone of PartialPreservation (ZPP)
8.4 Definitions of the Terms
8.4.1 Tetraplegia
8.4.2 Paraplegia
8.4.3 Tetraplegia and Paraplegia Vs.Tetraparesis and
Paraparesis
8.4.4 Dermatome
8.4.5 Myotome
8.4.6 Key Muscle Functions
8.4.7 Non-Key Muscle Functions
8.4.8 Sensory Level
8.4.9 Motor Level
8.4.10 Neurological Level of Injury (NLI)
8.4.11 Skeletal Level
8.4.12 Sensory Scores
8.4.13 Motor Scores
8.4.14 Sacral Sparing
8.4.15 Complete Injury
8.4.16 Incomplete Injury
8.4.17 Zone of Partial Preservation (ZPP)
8.4.18 Not Determinable (ND)
8.5 Neurological Examination
8.5.1 Sensory Examination
8.5.2 Motor Examination
8.5.3 Sensory and Motor Scores/Levels
8.5.4 Neurological Level of Injury (NLI)
8.6 ASIA Impairment Scale (AIS)
8.7 Zone of Partial Preservation (ZPP)
8.8 Clinical Syndromes
8.9 Expedited ISNCSCI
References
9 Spinal Shock:Definition and Clinical Implications
9.1 Definition of Spinal Shock
9.2 Pathophysiology
9.3 Clinical Implications of Spinal Shock
9.4 Clinical Observations of Reflex Evolution During Spinal
Shock
9.5 Changing Phases of Reflexes after Spinal Cord Injury
References
10 Acute Phase Management of Traumatic Spinal Cord Injuries
10.1 Initial Management of Spinal Cord Injuries
10.2 Neurological Assessment of Spinal Cord Injury
10.3 Decision of Surgery
10.4 Neuroprotective Medication
10.5 Polytrauma in Spinal Cord Injury
10.6 Acute Cardiovascular Management
10.7 Acute Pulmonary Management
10.8 Venous Thromboembolism
10.8.1 Prophylaxis of Deep Vein Thrombosis
10.8.2 Diagnosis of Venous Thromboembolism
10.8.3 Treatment of Venous Thromboembolism
10.9 Bladder Management
10.10 Bowel Management
10.10.1 Stress Ulcer Prophylaxis
10.10.2 Swallowing Dysfunction
10.11 Hyponatremia
10.12 Autonomic Vascular Dysfunction
10.13 Noninfectious Fever and Abnormal Temperature
Regulation
10.14 Pressure Injuries
10.15 Contractures
10.16 Pain
10.17 Nutritional Support
10.18 Psychological Adaptation
References
11 Clinical Syndromes of Incomplete Spinal Cord Lesions
11.1 1.Anatomy of the Relevant White Matter Tracts to
Incomplete Spinal Cord Syndromes
11.1.1 Corticospinal Tract
11.1.2 Posterior Columns
11.1.3 Spinothalamic Tract
11.2 Incomplete Spinal Cord Syndrome
11.2.1 Central Cord Syndrome
11.2.2 Brown-Séquard Syndrome (Unilateral Cord
Syndrome)
11.2.3 Anterior Cord Syndrome
11.2.4 Cauda Equina and Conus Medullaris Syndrome
11.2.5 Posterior Cord Syndrome
11.2.6 Subacute Combined Degeneration Myelopathy
(Posterolateral Column Syndrome)
11.2.7 Cruciate Paralysis
11.2.8 Anterior Horn Syndrome
References
12 Posttraumatic Syringomyelia and Chiari Malformations
12.1 Posttraumatic Syringomyelia
12.1.1 Epidemiology
12.1.2 Pathogenesis
12.1.3 Classification
12.1.4 Clinical Presentation
12.1.5 Diagnosis
12.1.6 Management
12.2 Chiari Malformations
12.2.1 Classification
12.2.2 Pathogenesis of Chiari I Malformation and
Syringomyelia
References
13 Cauda Equina and Conus Medullaris Lesions
13.1 Cauda Equina Syndrome
13.1.1 Development and Anatomical Features of the Cauda
Equina
13.1.2 Etiology
13.1.3 Pathophysiology
13.1.5 Physical Examination
13.1.6 Management
13.1.7 Prognosis
13.2 Cauda Equina Vs.Conus Medullaris Lesions
References
14 Nontraumatic Spinal Cord Lesions/Diseases
14.1 Degenerative Cervical Myelopathy
14.1.1 Epidemiology
14.1.3 Physical/Neurological Examination and Clinical
Presentation
14.1.4 Imaging Study
14.1.5 Differential Diagnosis
14.1.6 Management
14.2 Cauda Equina Lesion
14.3 Adjacent Segment Disease
14.4 Spine and Spinal Cord Tumors
14.4.1 Symptoms and Signs
14.4.2 Diagnosis
14.4.3 Management
14.5 Multiple Sclerosis
14.6 Neuromyelitis Optica Spectrum Disorder
14.7 Idiopathic Transverse Myelitis
14.8 Amyotrophic Lateral Sclerosis
14.8.1 Prognostic Factors
14.8.2 Clinical Presentations
14.8.3 Diagnostic Criteria
14.8.4 Management
14.9 Vascular Disease and Ischemic Injury
14.9.1 Vascular Disease of the Spinal Cord
14.9.2 Arteriovenous Malformations
14.10 Ossification of the Posterior Longitudinal Ligament
14.11 Arachnoiditis
14.12 Poliomyelitis
14.13 Spine and Spinal Cord Infection
14.14 Nutritional Myelopathy
14.15 Myelopathy Due to Electrical or Lightning Injuries
14.16 Myelopathy Due to Decompression Sickness
14.17 Radiation Myelopathy
References
15 Autonomic Nervous System in Spinal Cord Injuries
15.1 Anatomy of Autonomic Nervous System
15.1.1 Sympathetic Nervous System
15.1.2 Parasympathetic Nervous System
15.2 Neurotransmitters
15.3 Evaluation of Autonomic Function
15.3.1 Tests of Autonomic Cardiovascular Reflexes
15.3.2 Heart Rate Variability
15.3.3 Testing of Sudomotor Function
15.4 Autonomic Nervous System Dysfunction in Spinal Cord
Injury
15.4.1 Cardiovascular Dysfunction
15.4.2 Abnormal Response to Hypoglycemia
15.4.3 Impairment of Gastric Motility
15.4.4 Disorder of Temperature Regulation
References
16 Cardiovascular Dysfunction in Spinal Cord Injuries
16.1 Cardiovascular Consequences as Autonomic Dysfunction
16.1.1 Pathophysiology of Cardiovascular Consequences as
Autonomic Dysfunction
16.1.2 Neurogenic Shock
16.1.3 Resting Blood Pressure
16.1.4 Bradycardia
16.1.5 Orthostatic Hypotension
16.1.6 Autonomic Dysreflexia
16.2 Cardiovascular Consequences as Metabolic Disorder
16.3 Deep Venous Thrombosis
16.4 Peripheral Arterial Disease
16.4.1 Assessment and Management of Peripheral Arterial
Disease
References
17 Orthostatic Hypotension and Associated Supine Hypertension
17.1 Orthostatic Hypotension
17.1.1 Epidemiology
17.1.2 Precipitating Factors
17.1.4 Clinical Presentations
17.1.5 Symptom Grading of Orthostatic Intolerance
17.1.6 Diagnosis
17.1.7 Management
17.2 Supine Hypertension
References
18 Autonomic Dysreflexia
18.1 Epidemiology and Etiology
18.2 Pathophysiology
18.3 Clinical Presentation
18.4 Assessment
18.5 Management
18.6 Prevention and Education
References
19 Venous Thromboembolism in Spinal Cord Injuries
19.2 Diagnosis
19.2.1 Deep Vein Thrombosis
19.2.2 Pulmonary Embolism
19.3 Prevention of Deep Vein Thrombosis
19.4 Treatment of Deep Vein Thrombosis and Pulmonary
Embolism
19.4.1 Unfractionated Heparin
19.4.2 Low Molecular Weight Heparin
19.4.3 Warfarin
19.4.4 Direct Oral Anticoagulants (Non-Vitamin K Oral
Anticoagulants)
19.4.5 Inferior Vena Cava Filter
19.4.6 Others
References
20 Respiratory Dysfunction in Spinal Cord Injuries
20.1 Respiratory Anatomy
20.1.1 Respiratory Muscles
20.1.2 Inspiratory Muscles
20.1.3 Expiratory Muscles
20.2.1 Respiratory Muscle Weakness
20.2.2 Altered Compliance of the Thorax
20.2.3 Altered Coordination of the Thoracic Cage and
Abdomen
20.2.4 Effect of Altered Airway
20.2.5 Effect of Position
20.3 Assessment
20.3.1 Pulmonary Function Test
20.3.2 Maximum Inspiratory Pressure (MIP) and Maximum
Expiratory Pressure (MEP)
20.3.3 Peak Cough Flow (PCF)
20.3.4 Arterial Blood Gas Analysis
20.3.5 Chest Measurement
20.4 Management of Respiratory Dysfunction
20.4.1 Secretion Management
20.4.2 Management of Respiratory Muscle Weakness and
Breathing Fatigue
20.4.3 Mechanical Ventilation in the Acute Phase
20.5 Rehabilitation of Ventilated Patients During the Acute
Phase
20.5.1 Tracheostomy and Tracheostomy Tube
20.5.2 Communication and Mobilization
20.5.3 GlossopharyngealBreathing
20.5.4 Weaning of Mechanical Ventilator
20.5.5 Weaning of Tracheostomy
20.5.6 Long-Term Mechanical Ventilation
20.5.7 Noninvasive Ventilation
20.5.8 Alternatives for Long-Term Mechanical Ventilation
20.6 Respiratory Complications
20.6.1 Atelectasis
20.6.2 Pneumonia
20.6.3 Ventilator-Associated Pneumonia
20.6.4 Sleep Apnea
References
21 Electrolyte Disorders and Management in Spinal Cord Injuries
21.1 Sodium
21.1.1 Hyponatremia
21.1.2 Hypernatremia
21.2 Potassium
21.2.1 Hypokalemia
21.2.2 Hyperkalemia
21.3 Calcium
21.3.1 Hypercalcemia
21.3.2 Hypocalcemia
21.4 Hormonal Changes
21.5 Chronic Dependent Edema
References
22 Metabolic Disorders in Spinal Cord Injuries
22.1 Disorder of Glycemic Regulation
22.2 Bone Loss After Spinal Cord Injury
22.2.1 Assessment
22.2.2 Management
22.3 Fractures
22.4 Metabolic Syndrome
22.4.1 Changes in Body Composition After Spinal Cord
Injury
22.4.2 Diagnosis
22.4.3 Treatment
22.5 Nutrition
22.5.1 Nutritional Problems in the Acute Phase of Spinal
Cord Injury
22.5.2 Nutritional Support
22.6 Coronary Heart Disease
22.6.1 Diagnosis
22.6.2 Management
References
23 Voiding Dysfunction and Genitourinary Complications
23.1 Anatomy of the Urinary Tract
23.2 Innervation of the Lower Urinary Tract
23.3 Functions of the Lower Urinary Tract
23.3.1 Storage
23.3.2 Emptying
23.4 Physical and Neurological Examination
23.5 Neurogenic Bladder Dysfunction
23.5.1 Lower Motor Neuron Lesion Bladder Dysfunction
23.5.2 Upper Motor Neuron Lesion Bladder Dysfunction
(Suprasacral Lesion)
23.5.3 Assessment
23.6 Medical and Social Concerns
23.7 Voiding Methods
23.7.1 Intermittent Catheterization
23.7.2 Credé and Valsalva Maneuver
23.7.3 Reflex Voiding
23.7.4 Indwelling Catheter
23.7.5 Sacral Root Stimulation and Rhizotomy
23.8 Management
23.8.1 Neurogenic Bladder Management Routines
23.8.2 Pharmacological Management
23.9 Urinary Tract Infection
23.9.1 Diagnosis
23.9.2 Treatment of Urinary Tract Infection
23.9.3 Recurrent Urinary Tract Infection
23.9.4 Prevention of Urinary Tract Infection
23.10 Vesicoureteral Reflux
23.11 Urinary Stones
23.12 Malignancy
23.13 Nocturnal Polyuria
23.14 Epididymitis
23.15 Follow-Up Evaluation
23.16 Special Considerations of the Urological Management in
Elderly Patients with Spinal Cord Injuries
23.16.1 Upper Urinary Tract Changes with Aging
23.16.2 Lower Urinary Tract Changes with Aging
References
24 Bowel Dysfunction and GastrointestinalComplications
24.1 Functional Anatomy and Physiology of the Bowel
24.1.1 Colon and Anorectum
24.1.2 Neural Innervations
24.1.3 Colonic Reflexes
24.1.4 Defecation
24.2 Neurogenic Bowel Dysfunction
24.2.1 Upper Motor Neuron Neurogenic Bowel
24.2.2 Lower Motor Neuron Neurogenic Bowel
24.2.3 Assessment
24.2.4 Management of Neurogenic Bowel Dysfunction
24.3 Other GastrointestinalProblems
24.3.1 Fecal Impaction
24.3.2 Constipation
24.3.3 GastroesophagealReflux
24.3.4 Acute Abdomen and GastrointestinalBleeding
24.3.5 Gallbladder Disease
24.3.6 Clostridium difficile Infection
24.3.7 Superior Mesenteric Artery Syndrome
24.3.8 Hemorrhoids
24.4 Lifespan Care of Neurogenic Bowel Dysfunction
References
25 Sexuality Changes after Spinal Cord Injuries
25.1 Neurophysiology of Sexual Arousal
25.2 Physical Examinations on Sexual Dysfunction in Spinal
Cord Injuries
25.3 Psychological Considerations
25.4 Male Sexuality
25.4.1 Erection
25.4.2 Ejaculation
25.5 Female Sexuality
25.6 Erectile Dysfunction and Management
25.6.1 Phosphodiesterase Type 5 (PDE-5) Inhibitors
25.6.2 Intracavernosal Injections
25.6.3 Vacuum Erection Device
25.6.4 Intreurethral Alprostadil (Medicated Urethral System
for Erection, MUSE)
25.6.5 Penile Prosthesis
25.7 Sexual Arousal in Males and Females with Spinal Cord
Injuries
25.7.1 Sexual Dysfunction in Males with Spinal Cord Injuries
25.7.2 Sexual Dysfunction in Females with Spinal Cord
Injuries
25.8 Fertility in Patients with Spinal Cord Injuries
25.8.1 Male Fertility
25.8.2 Menstruation, Birth Control, and Female Fertility
25.9 Sexual Activity of Spinal Cord Injuries in Practice
References
26 Spasticity
26.1.1 Evolution of Reflexes and Spasticity After Spinal Cord
Injury
26.1.2 Upper Motor Neuron Syndrome and Function
26.2 Assessment
26.2.1 Clinical Scales to Quantify Spasticity
26.3 Treatment
26.3.1 Positioning
26.3.2 Physical Therapy
26.3.3 Orthoses
26.3.4 Medications
26.3.5 Chemoneurolysis
26.3.6 Botulinum Toxin
26.3.7 Intrathecal Baclofen
26.3.8 Surgical Procedures
26.4 Contracture
26.4.1 Common Sites of Contractures
26.4.2 Beneficial Contractures
26.4.3 Prevention of Disadvantageous Contractures
26.4.4 Treatment of Contractures
References
27 Pressure Injuries
27.2 Staging and Assessment of Pressure Injuries
27.2.1 Additional Pressure Injury Definitions
27.3 Beds for Pressure Injuries
27.4 Pressure Injury Prevention
27.5 Treatment of Pressure Injuries
27.5.1 Basic Nonsurgical Care:Cleaning, Debridement, and
Dressing
27.5.2 Pressure Injury Management in Practice
27.5.3 Surgical Management
27.6 Marjolin’s Ulcer
References
28 Heterotopic Ossification
28.1 Pathogenesis
28.2 Clinical Features
28.3 Diagnosis
28.4 Classifications of Heterotopic Ossification
28.5 Prophylaxis
28.6 Management
References
29 Pain Types and Taxonomies
29.2 Pain Terminology and Classification of Spinal Cord Injury
29.2.1 Nociceptive Pain
29.2.2 Neuropathic Pain
29.3 Diagnosis and Screening of Pain
29.4 Treatment
References
30 ThermoregulatoryImpairment
30.1 Anatomy and Physiology of Thermoregulation
30.2 Disorder of Thermoregulationin Spinal Cord Injuries
30.3 Management of Poikilothermia
References
Index
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021
H.-Y. Ko, S. Huh, Handbook of Spinal Cord Injuries and Related Disorders
https://doi.org/10.1007/978-981-16-3679-0_1
1. Clinical and Functional Anatomy of the

Spinal Cord
Hyun-Yoon Ko1 and Sungchul Huh2
(1) Department of Rehabilitation Medicine, Rehabilitation Hospital, Pusan
National University Yangsan Hospital, Pusan National University College
of Medicine, Yangsan, Korea (Republic of)
(2) Department of Rehabilitation Medicine, Rehabilitation Hospital, Pusan
National University Yangsan Hospital, Yangsan, Korea (Republic of)
Keywords Spinal cord – Development – Metamerism – Myotome –

Dermatome – Myelination – Descending tracts – Ascending tracts
The spinal cord controls the voluntary muscles of the trunk as well as the
upper and lower extremities and receives sensory information from the areas
of the body. It is anchored to the dura mater by denticulate ligaments and
extends from the cervicomedullary junction to the tip of the conus medullaris
at the lower border of the first lumbar vertebra, which is individually variable
(Bican et al. 2013). There are 20 or 21 pairs of denticulate ligament attached to
the anterolateral segment of the spinal cord. The spinal cord is anchored
caudally by filum terminale: filum terminale internum in the dural sac and
filum terminale externum outside the dural sac up to the coccyx. Basic
knowledge of anatomy and embryologic development, including metamerism
of the myotomes and dermatomes is very important for the interpretation and
understanding of the pathological findings of the spinal cord, as well as for the
diagnosis and lesion localization of the lesions.
1.1 Development of the Spinal Cord

The mantle layer of the neural crest between the ventricular zone and the
marginal zone is located around the primitive spinal cord and arises from
multiple neuroepithelial cell divisions. The mantle layer becomes the gray
matter of the spinal cord. The marginal zone eventually becomes the white
matter of the mature spinal cord. Two distinct paired regions can be observed
in the mantle layer: the dorsal thickening is called the alar plate (future
sensory areas of the spinal cord), and the ventral thickening is the basal plate
(future motor area of the spinal cord).
Development of motor neurons that form the nuclei of the ventral gray
columns progresses in the caudal direction and reaches the site of the cervical
enlargement at about 30 days. The subdivisions of the ventral gray column
begin to appear apparent before the end of the 6th week. The neurons of the
ventral horn arise from five different columnar subpopulations. The lateral
motoneurons located in the cervical and lumbosacral enlargement of the
spinal cord will later innervate the muscles of the extremities (Tomlinson et al.
1973). The medial motor neurons, which are found in the entire spinal cord,
will later innervate axial muscles. The visceral motor neurons occur in the
intermediolateral column in the thoracic and upper lumbar segments.
The development of skeletal muscle fibers from myotomes and limb bud
mesenchyme is parallel to the development of neural structures. Myofibrils
appear in human myoblasts during 5 weeks, and the cross striations are visible
at 7 weeks. Figure 1.1 shows both quantitative and qualitative changes in the
developing spinal cord of a GW 4.5 embryo. The quantitative change is the
growth of the lateral neuroepithelium. The formation of the cluster of
differentiating cell signals the onset of the exodus of postmitotic cells from the
ventral neuroepithelium and the onset of differentiation of the earliest spinal
cord neurons, the ventral horn motor neurons. Nerve fibers enter the
primordial muscles, and simple nerve endings are present among myoblasts in
human embryos at 7 weeks (Fig. 1.2). There are neurons in the spinal ganglia
of the human embryos before the beginning of the fifth week. The ganglion
cells are initially bipolar, and their central processes reach the spinal cord,
where they initiate the posterior funiculi. Interneurons are born both in the
areas of the dorsal root plate as well as the ventral root plate. The posterior
spinal cord forms six distinct progenitor pools (dp1–dp6). Interestingly, most
of these early subtypes develop into commissural interneurons projecting to
the contralateral side of the spinal cord. In the mature central nervous system,
these commissural interneurons are essential components of left-right
locomotor coordination and are major components of central pattern
generators playing a fundamental role in the rhythmic, coordinated movement
of the limbs and trunk (Vallstedt and Kullander 2013).
Fig. 1.1 GW 4.5. The cluster of differentiating cells that flank the ventral neuroepithelium
(red outline) is the earliest motoneurons of the incipient ventral horn. From Altman and
Bayer (2001)
Fig. 1.2 GW 7.0. The cervical spinal cord in a GW 7.0 embryo. The ventral canal and the
ventral neuroepithelium are disappearing, and the ventral horn motoneurons have grown
considerably, but the population of dorsal interneurons (yellow) is small. From Altman and
Bayer (2001)
Regression is the process of formation of the filum terminale and the cauda
equina and the migration of the conus medullaris to its adult level at the L1/L2
vertebral body. On days 43–48 of gestation, the future site of the conus
medullaris, known as the ventriculus terminalis, develops. Initially, it is located
at the level of the second coccygeal vertebra. At 3 months, the appearance of
the spinal cord is similar to that of the adult, but unlike the adult, it occupies
the entire spinal canal. Until then, the mantle layer has a shape that
characterizes mature gray columns, and the posterior and anterior horns are
connected by an isthmus, including the central canal lined by ependymal cells.
The nerve fibers of the marginal layer are unmyelinated and, until the middle
of the gestation period, the myelination begins to produce white matter in the
spinal cord. The caudal neural tube may then regress, and the ventriculus
terminalis around the spinal canal is obliterated, thus allowing the ventriculus
terminalis to rise within the spinal canal. This is 18 weeks at the level of L4
vertebral body because it is relatively fast at the beginning. Then, the rise is
slowed down and the tip of the spinal cord is at the L2–L3 interspace at birth
and reaches the adult level of the L1–L2 interspace by the first 3 postnatal
months. When the neural tube rises, there remains a fibrous band between the
ventricularis medullaris and the tip of the coccygeal vertebrae, which becomes
the filum terminale. During this ascent, the nerve roots that originally leave the
spinal canal opposite to their segmental origin of the spinal cord must be long
to be cauda equina (Keegan and Garrett 1948).
The discrepancy between the position of spinal cord segments with their
nerve roots and corresponding bony structures due to differences in growth
rates during embryonic development becomes more evident in the more
caudal spinal cord segments so that the nerve roots connected to the lower
lumbar, sacral, and coccygeal spinal cord segments have to travel longer
distances before reaching appropriate intervertebral foramina to pass. As the
nerve roots descend to their corresponding vertebral level, they become more
oblique from rostral to caudal so that the lumbar and sacral nerves descend
almost vertically to reach their exit points. These long spinal nerve roots
surrounding the filum terminale form the cauda equina, in which most caudal
segments are most centrally located. The three vertebrae (T11–L1) usually lie
over all ten lumbosacral spinal cord segments (L1–S5) (Fig. 1.3). From C5 to C8
spinal cord segment level is 1 level higher than the corresponding vertebral
body. Thus, the C5 cervical vertebral body corresponds to the level of the C6
spinal cord segment. In the upper thoracic region, the vertebral body is two
segments above the corresponding cord segment. In the lower thoracic and
upper lumbar regions, the difference between the vertebral level and spinal
cord segment level is two or three segments so that a spinal cord sensory level
at T9 would correspond to a pathologic abnormality at the T6 or T7 vertebral
body. The levels of the lumbar and sacral spinal cord segments correspond to
vertebral T12–L1 levels (Table 1.1).
Fig. 1.3 Diagrammatic representation of spinal cord segments in their relations to vertebral
bodies and spinous process, and levels of the emergence of spinal nerves. From Windle (1980)
Table 1.1 Vertebral bodies in their relations to corresponding spinal cord segments
Vertebral body Corresponding spinal cord segment

Upper cervical (C1–C4) Same spinal cord segment
Lower cervical (C5–C7) Add 1 segment
Upper thoracic (T1–T6) Add 2 segments
Lower thoracic (T7–T10) Add 3 segments
T11–T12 Lumbar segments
T12–L1 Sacral segments (conus medullaris)
Below L1 Cauda equina
The cord is an approximately cylindrical structure of average length 45 cm
in the male and less than 43 cm in the female. The spinal cord has an uneven
contour due to the presence of cervical and lumbar enlargements associated
with the spinal nerves for the upper and lower extremities. The enlargements
appear first in the embryo at the time of formation of the limbs. The size of the
spinal cord in adults is four times longer than at birth. Its weight increases
from 7 to 90 g or more, and its volume in adults increases from 6 to nearly
80 mL.
1.2 Metamerism
The spinal cord is a segmental organ. Each of the 31 pairs of spinal nerves
supplies a metamere or body segment derived from an embryonic somite.
Metamerism is more evident in the thoracic than in other regions of the adult
body, and the fields of sensory innervation are easier to identify than those of
motor innervation. The outgrowth of limb buds in the embryo causes
complicated metameric patterns.
The body surface areas supplied by the nerve fibers from a single dorsal
root ganglion are defined as a dermatome. The dermatomes are orderly in the
embryo, but they are distorted by outgrowth of the limbs so that the C4
dermatome is above T2 at the level of the sternal angle. Finally, the C5
dermatome is located next to the T1 dermatome (Biller et al. 2017; Vanderah
and Gould 2016) (Fig. 1.4). The junctions are marked by “axial lines” in the
diagram. A similar relationship exists in the lower extremities. At the 8th week,
medial rotation of the lower limb reverses the preaxial and postaxial borders,
creating a spiral arrangement of dermatomes (Fig. 1.5). Spinal nerve segments
on the anterior surface of the lower extremity extend medially and inferiorly.
The great toe is supplied by nerves from a more rostral dermatome (L4) rather
than the little toe (S1). The lower extremity is an extension of the trunk, and
most caudal dermatomes supply the perineum, not the foot (Felten et al.
2016). Cervical dermatomes maintain a relatively orderly distribution in the
upper extremity with minimal rotation. Within the same spinal cord segment,
the region of the sensation is also determined by the typical topographic
organization (Altman and Bayer 2001) (Fig. 1.6). Most dermatomes overlap
one another to a varying extent, but there is less overlap with pain and
temperature than with touch. An overlap of sensory fibers, which can reach
25–40 mm, occurs along the midline (Kellgren 1939).
Fig. 1.4 Development of dermatomes of the upper extremity of human embryos. Outgrowth
of limb buds in the embryo results in complications of the metameric patterns. Finally, the C5
dermatome lies next to the T1 dermatome due to outgrowth of the upper extremities carrying
the intervening dermatomes. From Biller et al. (2017)
Fig. 1.5 Changes in ventral dermatome pattern during limb development with limb rotation.
Rotation of the lower limb results in a reversal of the preaxial and postaxial borders,
producing a spiral arrangement of dermatomes. Spinal nerve segments on the anterior surface
of the lower extremity extend medially and inferiorly; the great toe (hallux) is supplied by
nerves from a more rostral dermatome (L4) than the little toe (S1). The lower extremity is an
extension of the trunk, and the most caudal dermatomes (sacral and coccygeal) supply the
perineum, not the foot. Cervical dermatomes maintain a relatively orderly distribution to the
upper extremity with minimal rotation. From Felten et al. (2016)
Fig. 1.6 Somatotopic organization of cutaneous afferents in laminae II-III of the cervical and
upper thoracic spinal cord of the cat. Sensory fibers from the dorsal skin, arm, forearm, and
hand are arranged in a lateral to medial order. Digit II, III, and IV are represented in a rostral-
to-caudal order. From Altman and Bayer (2001)
Metamerism also occurs in the innervation of skeletal muscles. Few
muscles have been derived from a single somite. The adductor pollicis and
some of the small deep muscles of the back may have a monosegmental
innervation. Other muscles receive nerve fibers from two to five ventral roots,
especially in the upper and lower extremities (Keegan and Garrett 1948).
1.3 Myelination
Myelin formation on nerve fibers of the spinal cord occurs only in the middle of
fetal life. It is then thought to be associated with differentiation of glioblasts
into oligodendrocytes. The first myelination of axons in the human is observed
in the early fetal spinal cord at less than 16 weeks of gestation. Although not
many mammals, myelination in the human is part of the postnatal
developmental period. The earliest structure to myelinate is the medial
longitudinal fascicles in the upper cervical spinal cord at 20 weeks, with the
corticospinal tract being the last, and myelination during the first year after
birth (Armand 1982; Weidenheim et al. 1996). The process of myelin
formation continues for several years, but the exact time of its completion is
unknown (Fig. 1.7).
Fig. 1.7 Schematic summary of the myelination of the corticofugal tract. A corticospinal
tract that descends through the internal capsule, the cerebral peduncle, the pontine gray, and
crosses in the pyramid is the absence of myelin at birth. At 1 month of age, a small
complement of myelinating corticofugal fibers reaches the pontine gray. But the bulk of the
corticofugal tract remains unmyelinated. There is an increase in the proportion of myelinated
fibers in the upper corticofugal tract between 2 and 3 months. The myelination of the bulk of
the lower corticospinal tract occurs between 4 and 8 months of age. From Altman and Bayer
(2001)
1.4 Anatomy of the Spinal Cord

The spinal cord consists of outer white matter with ascending sensory and
descending motor tracts and inner gray matter with nerve cell bodies. The
Another random document with
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si el gobierno hubiera atropellado las leyes para castigar los
atropellos de otros, debería haber empezado por embarcarse él
para Canarias, y decir: Marchemos todos francamente, y yo el
primero, por la senda de presidio? Vaya, Andrés, que eso ni
suponerse puede, y si te cuentan que tal caso ha sucedido, puedes
decir que el que lo cuente es un malévolo de ésos que traen la
anarquía en el bolsillo. Diría el gobierno y diría bien: «Yo no hice tal
cosa, y si la hiciera, ¿qué diferencia habría entre los atentados del
pueblo y los míos? Porque en fin, mientras que la ley no le ha
declarado reo, el condenado es asesinado: en ese caso no habría
entre mi atentado y el del pueblo más que una diferencia, á saber:
que el pueblo asesinó malamente carlistas y yo asesino malamente
liberales».
Asesinatos por asesinatos, ya que los ha de haber, estoy por los del
pueblo.
Puedes estar seguro de que hay causa; y si no se les ha formado,
es porque andamos de prisa, ó por mejor decir, lo que ha ido á
Canarias no ha sido una cadena de culpables, sino una comisión
artística compuesta de liberales, que van á costa del gobierno á
acabar de descubrir aquellas islas, y escribir una memoria de las
alturas del globo, y á dar testimonio al mundo sobre todo de la altura
á que estamos, tomando el meridiano del pico de Tenerife.
También te habrán contado posteriormente otra pequeña
arbitrariedad ejecutada oficialmente en una vieja, en virtud de un
cúmplase de un héroe. ¡Dios nos libre de caer en manos de héroes!
Sólo te diré que á lo menos en Barcelona tuvieron que acometer una
fortaleza y exponerse á ser rechazados. Bueno es remontarse á las
causas de las cosas, al tronco, y no á las ramas. Es así que la
primera causa de que existen facciosos fueron las madres que los
parieron; ergo quitando de en medio á las madres; lo que queda.
Los teólogos dicen: sublata causa tollitur efectus. Es lástima que no
haya vivido el abuelo, porque mientras más arriba más seguro es el
golpe. Pero hemos tenido que contentarnos con la madre. Está
probado que así como Sansón tenía la fuerza en el pelo, los
facciosos tienen el veneno en la madre, que viene á ser la hiel de
ellos; en quitándosela se vuelven como malvas: así lo ha probado la
experiencia, porque de resultas el otro no ha fusilado más que á
treinta. ¿Quién sabe los que hubiera fusilado si hubiera tenido
madre todavía? Luego, las mujeres son las que están impidiendo la
felicidad de España, y hasta que no acabemos con ellas no hay que
pensar en tener tranquilidad. En cuanto á las hermanas, como
estaban casadas con guardias nacionales, les tocaba fusilar la mitad
á los de allá, y la otra mitad á los de acá; pero nosotros, más
desprendidos, no quisimos perdonar ni la mitad que nos tocaba, y lo
fusilamos todo. ¡Bienaventurados en tiempos de héroes los
incluseros, porque ellos no tienen padre ni madre que les fusilen!
Pasadas estas etiquetas de recíproca cortesía, dieron en correr
voces de que el ejército estaba descontento, y que la guerra de
Navarra no iba lo ligera que debía. Felizmente para todos, algunos
amigos tuyos y míos, que así saben mover la pluma como esgrimir
la espada, enderezaron la opinión en artículos luminosos, probando
lo que ninguno debía tener olvidado, que las guerras civiles son
largas, á pesar de todos los programas del mundo; que éstos son
por el contrario los que tienen corta vida; que así las civiles como las
demás se sostienen con dinero y con soldados; que un gobierno en
lucha con una facción pierde más cuando pierde una batalla, que
adelanta cuando la gana, y que una derrota nuestra nos quita más
honra que gloria da á la facción; que por lo tanto es fuerza no
aventurarse sino á ciencia cierta; que la guerra no se hace en el
ministerio, sino en Vizcaya; que de real orden se llevan y se traen
jueces, se envían buques á Canarias, y se conquistan votos, pero
de real orden no se ganan batallas; que algunos descalabros
nuestros han sido debidos á reales órdenes; que para hacer la
guerra se necesita un plan; que para tener plan es preciso que el
general sólo sea responsable; y que Córdoba, en fin, sin que haya
necesidad de llamarle héroe, tiene un plan, el cual es forzoso dejarle
llevar á cabo, siquiera porque no ha habido hasta ahora otro mejor
que el suyo.
Tales razones no convencieron, fué bien acogida la representación
del ejército, y si bien ninguno de los que hablaban fué á dar su brazo
en vez de su voto, al fin no se admitió la dimisión, y sigue el general,
y su plan, y la guerra de Navarra, en el mejor estado posible.
Mientras todo esto pasaba echáronse encima las próximas
elecciones, hoy ya pasadas, y porque digo se echaron encima, no
vayas á pensar alguna tontería. Dijeron muchos si habría amaños ó
si no habría amaños; que se escribió largo y se intrigó más. Lo
primero solo prueba cultura en el país, lo segundo arguye talento.
¡Vaya usted á impedir que hablen las gentes! Para que no fuesen
las elecciones muy populares bastante amaño era ya la propia ley
electoral, en virtud de la cual debían elegir los electores nombrados
por los ayuntamientos y los mayores contribuyentes. No hay cosa
para elegir como las muchas talegas: una talega difícilmente se
equivoca; dos talegas siempre aciertan, y muchas talegas juntas
hacen maravillas. Ellas han podido decir á su procurador por boca
de los mayores contribuyentes la famosa fórmula aragonesa: «Nos,
que cada una de nos valemos tanto como vos, y todas juntas mucho
más que vos, os hacemos procurador».
Luego, los elegidos habían de tener doce mil reales de renta: gran
garantía de acierto: por poco que valga un real en estos tiempos, no
hay real que no valga una idea, sin contar con las muchas que hasta
ahora hemos visto que no valían un real, y con los varios casos en
que por menos de real daría uno todas sus ideas: bueno es siempre
que haya reales en el Estamento por si acaso no hubiese ideas.
Tanto mejor si hay lo uno y lo otro.
No es menos importante lo de los treinta años; no es menos
simbólico ni cabalístico el número de treinta que el de tres tan
citado, y de que es décuplo; treinta días tiene el mes, treinta minutos
cada media hora, por treinta dineros vendió Judas á un Dios, treinta
años representa la vida de un jugador, y treinta años, en fin, la
capacidad de un procurador. Muchos filósofos han creído que
cuando el hombre nace, el Ser Supremo, que esta atisbando, le
sopla dentro el alma por medio del mismo procedimiento que usa un
operario en una fábrica de cristales para dar forma á una vasija;
pero eso es el alma, mas no la capacidad y la facultad de procurar:
esta tal otra quisicosa se la infunde el Criador el día que cumple
treinta años, por la mañanita temprano, así como la aptitud legal y la
mayoría se la comunica á los veinte y cinco. Oh tú, Andrés, que no
los has cumplido, está con cuidado el día que los hayas de cumplir,
y escríbeme para mi gobierno lo que sientas en ese día: dime por
dónde entra la capacidad, y hacia dónde se coloca en tu persona:
prevenido de esa suerte de los síntomas que la anuncian podré yo
hacer á la mía, el día que me baje, el recibimiento que se debe á tan
ilustre huésped. ¿Cuándo tendremos treinta años? Aquel día
seremos ya unos hombrecitos.
Bien ha habido hombres que han discurrido antes de los treinta
años, pero ésos son fenómenos portentosos, raros ejemplos de no
vista precocidad; y en cuanto á Pitt y otros de su especie, ministros
ya mucho antes, ni siquiera es posible considerarlos como
monstruos de naturaleza; es fuerza inferir error de cálculo y mala fe
en la de bautismo.
El haber nacido en la provincia, ó tener en ella arraigo, no es de
menos importancia, si recordamos que las primeras impresiones se
graban para siempre en la cabeza del niño, y deciden de lo que ha
de ser después cuando grande: ni es posible que un hombre
conozca su provincia, y se interese por ella, si no ha nacido por allí
cerca. Puede suceder que una provincia tenga más confianza en la
reputación, en el saber de un forastero; pero páselo en paciencia la
buena de la provincia, que más pasó Cristo por ella.
Dicen sin embargo que todos los electores no han tenido presentes
todas esas verdades; así que, unos procuradores no han nacido,
otros no tienen la renta, ¡qué sé yo! Esto tiene compostura habiendo
comisión de poderes, y en todo caso se aplica la renta de unos á
otros, como hacen los buenos cristianos con los méritos de nuestro
Señor Jesucristo, que valen mucho más que las rentas; y así
poniendo de aquí y quitando de allí tengo para mí que se ha de
remediar. Y aun yo diría más. Don Juan Álvarez Mendizábal fué
elegido por ejemplo por Barcelona, siendo natural de Cádiz, y no
habiendo residido en Cataluña. Decían: «Pero no tiene nada suyo
en Cataluña, sino los electores:» ¿pues eso no es tener?, ¿no valen
tanto por lo menos los electores como una casa, ó una tapia, ó unas
cuantas fanegas de pan llevar? ¡Sino que poniéndose á hablar las
gentes!...
Por lo demás es sabido que el gobierno no ha influido
absolutamente nada en las elecciones, y desde luego se dijo que
eran á pedir de boca. Para que formes una idea, han salido elegidos
los sugestos siguientes:
Por Barcelona, como llevo dicho, don Juan Álvarez Mendizábal.
Por Cádiz, don Juan Álvarez Mendizábal.
Por Gerona, don Juan Álvarez Mendizábal.
Por Granada, don Juan Álvarez Mendizábal.
Por Madrid, don Juan Álvarez Mendizábal.
Por Málaga, don Juan Álvarez Mendizábal.
Por Pontevedra, don Juan Álvarez Mendizábal, etc., etc., etc.
Que es el cuento de pasó una cabra, y volvió y pasó otra, y volvió á
tornar y á pasar otra cabra, y así sucesivamente.
Si oyes decir que se abre el Estamento, di que es broma, que quien
se abre es don Juan Álvarez Mendizábal.
No habrás olvidado que los ministros de estado y de hacienda, y el
presidente del consejo, son don Juan Álvarez Mendizábal, y que los
otros ministros no son sino una manera de ser, distinta sólo en la
apariencia del don Juan Álvarez Mendizábal. Ahora figúrate el día
que el Estamento don Juan Álvarez Mendizábal pida cuentas al
ministro don Juan Álvarez Mendizábal...; aquí llaman esto un
gobierno representativo: sin que sea murmuración, confieso que yo
llamo esto un hombre representativo.
Una vez conocida la buena índole de las elecciones y la idoneidad
de esos diversos señores procuradores, ocurrió la duda de si estas
Cortes que iban á reunirse vendrían sólo para hacer una ley
electoral mejor que la que les confiere su derecho; ó si podrían
constituirse revisoras. Quiénes se agarraron á la legalidad, diciendo
que esto último sería ilegal; quiénes intentaron probar que lo de
menos era la legalidad, y que lo que importaba era la conveniencia.
Por fin salimos del atolladero, y parece que no tratarán de
constituirse por varias razones. Porque no han sido convocadas
para eso. Porque siendo su objeto principal hacer una ley electoral,
en virtud de la cual puedan convocarse luego las revisoras, es claro
que los demás asuntos que á ellas se sometan, por importantes que
sean, habrán de ser subalternos al principal. La nación tiene un
cimiento, y necesita una casa: en estas Cortes va á decidir cuáles
han de ser las circunstancias del arquitecto que se la puede hacer á
su gusto. Por consiguiente, todo lo que sea proceder á construir el
que sólo está comisionado para designar el constructor, es hacer la
casa y dejar para después el arquitecto: equivale á blanquear
después de pintar; es dejar al que venga detrás el derecho de poner
en duda la validez de la construcción.
En estas disputas andábamos, cuando otro run run más terrible vino
á poner nuevo espanto en nuestro corazón. He aquí que una noche
corre la voz de que se va á poner la constitución del año 12. ¡Bravo!,
dije yo: esto es lo que se llama andar camino. Aquí no se sabe
multiplicar, pero restar á las mil maravillas. Vamos á quién puede
más. El año 14 vino el rey y dijo: quien de catorce quita seis, queda
en ocho. Vuelvan pues las cosas al ser y estado del año 8. El año
20 vienen los otros y dicen: quien de veinte quita seis, queda en
catorce: vuelvan las cosas al ser y estado del año 14. El año 23
vuelve el de más arriba y dice: quien de veinte y tres quita tres,
queda en veinte; vuelvan las cosas al ser y estado de febrero del
año 20. El año 1836 asoman los segundos, y éstos quieren restar
más en grande: quien de treinta y seis quita veinte y cuatro, queda
en doce; vuelva todo al año 12. Éstos han pujado, si se exceptúa el
del Estatuto, que más picado que nadie cogió y lo restó todo, y nos
plantó en el siglo xv.
¡Diantre!, ¡si volveremos todavía á la venida de Túbal! Sepamos
primero cómo se entiende nuestro progreso. ¿Hacia dónde vamos?
¿Hacia atrás, ó hacia adelante? Tengamos el cuento del cochero,
que, montado al revés, arreaba al coche.
Ya te lo he dicho: tejedores; tejer y destejer. Nadie vende su tela, y
nadie hace tela nueva.
Decían ellos que el volver atrás no era más que tomar carrera. ¡Dios
los bendiga, y qué larga la toman!
Vamos claros. La constitución del año 12 era gran cosa en verdad,
pero para el año 12: en el día da la maldita casualidad de que
somos más liberales que entonces: si te he de hablar ingenuamente,
á mí me parece poco.
Las circunstancias del año 12, la guerra que sosteníamos apoyada
en el fanatismo popular, y el mayor atraso de la época, exigieron
concesiones en el día no necesarias, ridículas.
En ellas hablan las Cortes en nombre de Dios Todopoderoso, Padre,
Hijo y Espíritu Santo: gran principio para una novena: buena es la
devoción, pero á su tiempo: eso es adoptar, heredar de la
monarquía el derecho divino: la sociedad puede servir á Dios en
toda clase de gobiernos. El Supremo Hacedor no delega facultades
temporales ningunas, ni en un soberano, ni en un congreso; la
sociedad se hace ella misma por derecho propio sus reyes y sus
asambleas. Cristo vino al mundo á predicar, no á redactar códigos.
Á Dios daremos cuenta de nuestras creencias, no á los hombres:
reflexión igualmente aplicable al capítulo II, artículo 12, porque el
Salvador quiso convencer, no obligar, porque no quiere más
homenajes que los voluntarios.
Ítem más: en la constitución del año 12 no está consignada la
libertad de imprenta, sino para las ideas políticas, y eso es decirle á
un hombre: Ande usted, pero con una sola pierna.
En cambio nos impone como ley fundamental el amor á la patria y la
obligación de ser justos y benéficos... en cambio... Andrés mío,
callemos, porque, repito, que la venero, y tengo por indigno de un
liberal poner en ridículo el paladión de nuestra independencia
nacional, y la cuna de nuestra libertad, por fácil que eso sea. Pero la
respeto, como Cristo respetó el testamento viejo, fundando el nuevo.
Veneremos el viejo código, y venga no obstante otro nuevo más
adecuado á la época.
Parécense los hombres del año 12, amigo Andrés, al cura que no
sabía leer más que en su breviario: ó mejor al gastrónomo en Vista-
Alegre, que viendo su mesa puesta, pugna por sentarse á ella en
cuanto le dejan un momento libre, en cuanto ve un resquicio por
donde acercarse á la mesa. El caso es el mismo: todos les hacemos
cumplimientos, pero no les dejamos sentarse. Unas veces se lo
impidió el poseedor don Pascual de la Rivera, otras los mozos de su
fábrica... Convengo en que es una desesperación; pero culpen, no á
nosotros, sino á ellos mismos, que tantas veces se dejaron
interrumpir antes de llegar el bocado á la boca.
Aténgome á su artículo, que dice:
«La nación española es libre é independiente, y no es ni puede ser
patrimonio de ninguna familia, ni persona».
Esto digo yo: entre á gobernar, no éste ni aquél, sino todo el que se
sienta con fuerzas, todo el que dé pruebas de idoneidad. Basta de
ensayos. Á eso nos responden ellos: «¿Y dónde están esos
hombres?» ¿Dónde han de estar? En la calle, esperando á que
acaben de bailar los señores mayores, para entrar ellos en el baile.
«¿Cómo no salen esos hombres?», añaden. ¿Cómo han de salir?
De Calomarde acá, ¿qué protección, qué ley electoral ha llamado á
los hombres nuevos para darles entrada en la república? Cuenta sin
embargo con ella, y llámelos la ley presto: ¡¡¡déjese entrar
legalmente á los hombres del año 1836, ó se entrarán ellos de
rondón!!!
En conclusión, hombres nuevos para cosas nuevas: en tiempos
turbulentos hombres fuertes sobre todo, en quienes no esté cansada
la vida, en quienes haya ilusiones todavía, hombres que se paguen
de gloria, y en quien arda una noble ambición y arrojo constante
contra el peligro.
«¿Qué saben los jóvenes?», exclaman. Lo que ustedes nos han
enseñado, les responderemos, más lo que en ustedes hemos
escarmentado, más lo que seguimos aprendiendo. ¡Y qué eran
ustedes el año 12! Nosotros fundaremos nuestro orgullo en ser sus
sucesores, en aprovechar sus lecciones, en coronar la obra que
empezaron. Nosotros no rehusamos su mérito; no rehúsen ellos
nuestra idoneidad, que el árbol joven es la esperanza del jardinero,
si el viejo ya le da sombra.
Según el miedo que tienen de que la juventud entre en los puestos,
no parece sino que es posible hacerlo peor que ellos.
Para el año 1836 la única constitución posible es la constitución de
1836.
Una idea te diría, si no la hubieras de contar; y sólo á ti te la diría,
porque ellos la tomarán á personalidad, si de ella hiciese un artículo,
y sabe Dios que no lo digo por tal. Mucho venero á los hombres de
otra época, Andrés mío; mucho saben, sobre todo en no hablándose
de gobernar, para lo cual ya nos han manifestado repetidas veces
hasta donde rayan: mucho saben, y tanto que no sólo no los
lanzaría yo de la república, sino que los guardara muy guardados
como guardaban los romanos los libros sibilinos, para consultarlos
con el mayor respeto: de ellos armaría una biblioteca viva, donde
vueltos de espaldas en muy pulidos estantes, leyese el estudioso
encima Fulano, de Economía Política; Mengano, de Reformas
Constitucionales; Zutano, de la Guerra de la Independencia;
Perengano, de Metáforas y del Espíritu del Siglo, etc., etc.; de suerte
que no hubiese más que volverlos y ojearlos en un apuro, cuidando
mucho de quitarles antes y después el polvo, y de tornarlos á volver
hasta otra duda, como pergaminos preciosos.
Ahí verás tú si los respeto, y si los tengo en estima.
Hasta aquí de la constitución y de los hombres del año 12. Pasó el
susto, y la noticia, como habrás visto, no tuvo consecuencia. Sin
duda el ruido que metió fué el último cumplimiento de despedida que
nos hizo.
No ganamos para sustos. Posteriormente se cruzaron de palabras el
pueblo de Valencia y su capitán general. Éste tomó una porción de
providencias, entre otras las de Villadiego; con cuyo ingenioso
arbitrio no le pudieron haber los valencianos, que es decir que ha
podido más que ellos, que se ha burlado de ellos. Tiene mucho
talento. Buen chasco se han llevado. Así, así: á los alborotadores
hay que jugarles esas pasadas; con eso escarmientan. Á buen
seguro que si Basa hubiera hecho otro tanto, no le hubieran
deshecho á él, y el pueblo de Barcelona se hubiera llevado el mismo
chasco que el de Valencia. ¿No queréis capitán general? Pues
tomad capitán general. ¿No te figuras tú al pueblo de Valencia
buscando á su capitán general por todas partes, como quien busca
una sanguijuela extraviada, y él trota que trota para Madrid? Á mí
me hace morir de risa. Es lo que él dice: «¿Pues qué, querían
ustedes que me mataran?» ¿Qué habíamos de querer?
Conque ahora está aquí bueno, gordo y tranquilo; no ha sido poca
fortuna el poderlo contar.
En Zaragoza fué por otro estilo: salieron unos carlistas sentenciados
á qué sé yo qué bobería: se levantó el pueblo, sitió á los jueces, y
dieron en quererlos juzgar. Al maestro cuchillada. Pero no les da el
naipe para esos pasajes á los jueces de Zaragoza, como á los
capitanes generales de Valencia.
Entre tanto el ministerio de gracia y justicia sigue siempre de
mudanza, y hace bien, porque el juez que no da fruto en una tierra,
lo da en otra. El juez ha de ser como el zapato, hecho al pie; por eso
el que no le viene bien al uno, le viene al otro.
Para eso el de la gobernación no se mete con nadie, ni habla mal de
nadie. Es un excelente señor; á su oficina y no más. Da lástima
hacerle daño, y sería completo si se le volviese C la H de su
apellido; pero llámalo h.
En cuanto al de la guerra nadie sabe una palabra de él.
En mi última te pintaba en globo la confusión que en el Estamento y
fuera de él había causado la ley electoral, y te añadía:
«Yo por el pronto sólo veo clara una cosa, y es que para el 22 de
marzo se reunirán de nuevo en Madrid otras Cortes... que para
entonces es probable que empecemos á entendernos... y que
seguramente no tendremos facción, porque estarán al caer los seis
meses de la promesa, ó no tendremos ministerio, si no la cumple,
porque estará caído, etc.».
De todas esas profecías sólo en la primera acerté; porque en cuanto
á entendernos da gusto. Unos dicen que Mendizábal es el primer
hombre del mundo; otros que no es tal, sino el último; que el primero
es Istúriz y Galiano; te advierto que éste son dos: otros que ni Istúriz
ni Mendizábal: no sé qué te diga: quién asegura que esto puede
durar unos quince días, quién defiende que durará más que un
constipado mal curado: éste no ve más que el prestigio que tiene
todavía en las provincias, el cual no se destruye tan fácilmente,
sobre todo cuando no deja de tener algún fundamento; aquél no
atiende más que al descrédito en que ha caído en sus corros y
cafés, y cree que toda la nación puede juzgarle con igual talento, y
tan de cerca como él. Éstos disputan que no hay hombres aquí;
aquéllos que sí hay hombres; los de la izquierda que hay dinero; los
de la derecha que no hay un cuarto; estoy por éstos. Quién opina
que la guerra es inacabable; quién la da por acabada; añadiendo
que no falta más que tirar una línea: uno dice que el mal de España
no tiene remedio; otro que ésa es la mejor señal, que empieza la
revolución, y que en Francia sucedía lo mismo, á pesar de que todo
era diferente; varios juzgan que el rigor es de justicia, y que el árbol
de la libertad se riega con sangre: algunos creen que la humanidad
repugna tales horrores: no falta quien piensa que es guerra de
empleos, y sobra quien no piensa ni eso ni nada. Pero todos somos
liberales y vamos á una: eso sí. Por lo cual esto se acabará pronto
de un modo ó de otro: en prueba de ello te puedo decir que se
empiezan ya á acabar dos cosas: el dinero y la paciencia.
Pero son tantas las opiniones en fin y los hechos que se acumulan,
y tantas las cosas que van á suceder, sin contar las que han
sucedido desde la apertura de las Cortes, que me es indispensable
reservarlas para otras cartas: me limito en ésta á ponerme al
corriente, saliendo del atraso de noticias en que te tenía. En lo
sucesivo aprovecharé todas las ocasiones posibles de escribirte, y
al siguiente correo para Francia recibirás la inmediata, salvo
extravío, golpe de mano airada, ó caso fortuito.
Si en el ínterin, y en medio de este conflicto de opiniones
encontradas, me pides la mía, te contaré un caso que juzgo
oportuno.
Sitiaban los Franceses al mando del mariscal Moncey esa misma
Valencia, que en distintas épocas han mandado el Cid y Carratalá.
Reuniéronse en tan grave apuro el ayuntamiento y las personas
más ricas del pueblo, entre las cuales quedóse dormido de
confusión y pesadumbre un confitero, que entendía más de
ramilletes que de disturbios políticos. Iba diciendo cada uno en la
asamblea su opinión como mejor lo entendía. Llegada que le fué su
vez á nuestro hombre,—y usted, le dijo sacudiéndole del brazo el
que á su lado tenía, ¿qué piensa?—Sí, ¿cuál es su opinión de
usted?, preguntaron todos á un tiempo; á cuya pregunta contestó
despertando y todo despavorido el confitero: ¡¡¡mi opinión, sí, mi
opinión, señores, es de que Dios nos asista!!! En cuyo voto imitaba
el confitero la rara discreción del padre Froilán Díaz, confesor de
Carlos II.
Eso mismo opino yo, Andrés mío, por ahora, y mientras no vea
levantarse en masa á la nación para ahogar de una vez y para
siempre el monstruo que en el norte nos devora, en vez de
entretenerse en cuestiones secundarias y en rencillas personales,
de las cuales debiera el país hacer justicia, como del orgullo
mezquino y de la loca vanidad de sus dueños.—Tu amigo,—Fígaro.
FIN DEL TOMO SEGUNDO
PARIS.—ÉDOUARD BLOT, IMPRIMEUR, RUE BLEUE, 7

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