1131 - Walking Despite Weakness: Unexpected Ambulation in a patient with C1 AIS C tetraplegia with Minimal Lower Extremity Motor Scores

Thursday, February 19, 2026

5:00 PM - 6:30 PM AST

Presenting Author(s)

MM

Meela Mehdi, MD

Resident
UC Davis
Sacramento, California, United States

Co-Author(s)

AB

Ashar Brar, BA

Medical Student
UC Davis
Sacramento, California, United States
SS

Shane Stone, MD

PM&R Director of SCI
UC Davis
Sacramento, California, United States
DD

Dayken Dawson, MD

Resident Physician
UC Davis
Sacramento, California, United States

Submitter(s)

MM

Meela Mehdi, MD

UC Davis
Sacramento, California, United States

Case Diagnosis: A healthy 50yo female presented with full body weakness and paresthesias after a 10-foot fall from a ladder. MRI demonstrated acute compressive myelopathy at C6-7 and compressive deformity of T3 vertebral body. She underwent a C5-7 ACDF without complications.

Case Description: Upon inpatient rehabilitation arrival, she required maximal assistance for transfers and ISNCSCI exam demonstrated C1 AIS C (lower extremity motor scores of 5 bilaterally). After 8 weeks of rehabilitation, including locomotor training, her ISNCSCI improved to C1 AIS D and she could ambulate with a front-wheel-walker and AFOs despite unchanged LEMS and no evidence of spasticity on exam.

Discussions: Recovery of ambulation after SCI can be variable. Ambulation is typically associated with antigravity strength in lower extremity muscle groups, particularly hip flexors and knee extensors, however some studies have argued against this. Kim et al. found that individuals with incomplete SCI and < 3/5 strength in at least one muscle group could still walk in the community, although average strength in hip flexors, hip extensors, and ankle dorsiflexors were greater than in our patient. Wirz et al. demonstrated that walking progression often outpaced LEMS improvements suggesting gait recovery also depends on factors such as spasticity, motor control, and bracing rather than isolated strength. Possible explanations for this patient's ability to ambulate are her relatively increased adductor strength (2/5) for enhanced pelvic stabilization and facilitation of hip circumduction during swing phase, and improved trunk control with antigravity upper extremity strength allowing balance maintenance and weight stabilization on a walker.

Conclusions: This case highlights the heterogeneity of motor recovery after SCI and challenges traditional motor strength thresholds for ambulation. It also suggests clinicians should broaden considerations of gait prognosis and incorporate factors beyond LEMS. Recognizing these contributors can guide gait training and change information given to patients about functional expectations.