3/3/2016. International Standards for the Neurologic Classification of Spinal Cord Injury (ISNCSCI)

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1 International Standards for the Neurologic Classification of Spinal Cord Injury (ISNCSCI) American Spinal Injury Association International Spinal Cord Society Presented by Adam Stein, MD Chairman and Professor Department of Physical Medicine and Rehabilitation Hofstra Northwell School of Medicine 1

2 Educational Objectives Utilize terminology relevant to SCI classification. Master sensory and motor scoring systems. Utilize examination results to determine levels of injury, Asia Impairment Scale (AIS) and zone of partial preservation (ZPP). Describe key features of common clinical syndromes seen after SCI. Introduce INSTeP e learning program Introduce 2013 additions to ISNCSCI Tetraplegia Impairment of motor and/or sensory function in the cervical segments of the spinal cord due to damage of neural elements within the spinal canal. Must result in at least some impairment of function of the upper limbs. Usually involves impairment in trunk, legs and pelvic organs. Does not include brachial plexus lesions. Avoid quadriplegia Paraplegia Impairment of motor and/or sensory function in the thoracic, lumbar or sacral segments of the spinal cord due to damage of neural elements within the spinal canal. Arm function is spared. Depending on level of injury, trunk, legs and pelvic organs may be involved. Does not include lumbosacral plexus lesions. 2

3 Neurological Level Most caudal segment of the spinal cord with normal sensory and motor function on both sides of the body denotes single neurologic level. Can specify a sensory level and a motor level for each side of body for more complete clinical description. Skeletal Level Spinal level with greatest degree of vertebral damage Determined by imaging Complete Injury Absence of sensory and motor function in the lowest sacral segments (S4 5) No voluntary anal sphincter contraction No perirectal sensation to pin, light touch or pressure 3

4 Incomplete Injury Sensory and/or motor function is found below the neurological level and MUST include the lowest sacral segment (S4 5). Sacral sensation includes sensation at anal mucocutaneous junction as well as deep anal pressure. Test of motor function at S4 5 is presence of voluntary contraction of the external anal sphincter upon digital rectal examination. Zone of Partial Preservation (ZPP) Used only with complete injuries. Specifies dermatomes and myotomes caudal to the sensory and motor levels which remain partially innervated. The most caudal segment with some sensory/motor function defines the extent of the ZPP. Sensory Examination Required elements sensitivity to pin prick and light touch in each of 28 dermatomes on each side of the body. Scoring: 0=absent 1=impaired 2=normal NT=not testable 4

5 Deep Anal Pressure Technique: insert distal index finger to anal canal and apply pressure to anorectal wall between examiners thumb and index finger. Motor Examination Required elements testing of key muscles, each representing one of 10 paired myotomes, and the external anal sphincter. Scoring: use 0 5 scale as for other muscle testing. Do not use + or grades Rectal exam graded yes/no Key Muscles C5 Elbow flexors C6 Wrist extensors C7 Elbow extensors C8 Long finger flexors to middle finger T1 Small finger abductors L2 Hip flexors L3 Knee extensors L4 Ankle dorsiflexors L5 Long toe extensors S1 Ankle plantar flexors External anal sphincter 5

6 Determining Sensory Level Most caudal level where both pin prick and light touch scores are normal (2) Specify a sensory level for each side of the body Determining Motor Level Most caudal level with motor grade of 3 or better where next most rostral key muscle has grade of 5 Specify level on each side of the body If next most rostral level does not have a key muscle, use sensory level If no key muscle available use sensory level 6

7 Determine Single Neurologic Level Single neurologic level is the most caudal level where BOTH sensory AND motor function is normal. ASIA Impairment Scale (AIS) A=Complete.No sensory function at S4 5 key points, no deep anal pressure sensation, no voluntary anal sphincter contraction. B=Incomplete. Sensory preservation below neurological level, including at S4 5. No motor function more than three levels below the MOTOR LEVEL on each side of the body. C=Incomplete. Motor preservation below neurologic level(>3 levels) and >1/2 key muscles below SINGLE NEUROLOGIC LEVEL graded less than 3. ASIA Impairment Scale (AIS) D=Incomplete. Motor preservation with >1/2 key muscles below SINGLE NEUROLOGIC LEVEL graded 3 or better. E=Sensory and motor exams are normal, though may have other neurologic abnormalities (tone, proprioception, etc). 7

8 Prognosis after SCI Significance of spinal shock Timing of examination: acute vs 72 hour Complete vs. incomplete AIS B importance of pin sparing AIS C and D Clinical Syndromes Central Cord Syndrome Brown Sequard Syndrome Anterior Cord Syndrome Conus Medullaris Syndrome Cauda Equina Syndrome Central Cord Syndrome Incomplete lesion in cervical region that produces greater weakness in the affected upper limbs than the lower limbs. Tends to occur in older individuals with preexisting cervical spondylosis who suffer relatively low velocity extension injuries. 8

9 Brown Sequard Syndrome Cord lesion producing relatively greater ipsilateral motor and proprioceptive loss with contralateral loss of sensitivity to pain and temperature. Clinically common, though not in pure form (cord hemisection). Do not describe as hemiparesis Anterior Cord Syndrome Cord lesion producing variable loss of motor function and of sensitivity to pain and temperature, with relative preservation of proprioception and light touch. Lesion usually vascular in origin Conus Medullaris Syndrome Injury to distal spinal cord. Typically produces areflexic bladder and bowel and lower limbs sensorimotor deficits. May have preserved sacral reflexes if injury high in conus with intact reflex arc. 9

10 Cauda Equina Syndrome Injury to lumbosacral nerve roots resulting in areflexic bowel, bladder and lower limbs. INSTeP International standards e learning program Interactive online educational tool for teaching standards. Learner works at own pace Multimedia/multiple learning tools Six modules Anatomy Sensory Motor Rectal exam Scoring and classification Additional topics INSTeP Certificate of completion available Became available June, 2009 Cost : Free without certificate of completion; $40 with certificate. Competency tool for residency/fellowship. WeeSTeP (Peds) and ASTeP (autonomic standards) also available. 10

11 Recent Publicatons Related to ISNCSCI S Kirshblum, et al. International Standards for Neurologic Classification of Spinal Cord Injury (Revised 2011). J. Spinal Cord Med 2011, Nov 34(6), S Kirshblum, et al. International Standards for Neurologic Classification of Spinal Cord Injury: Cases with Classification Challenges. J Spinal Cord Med 2014, March 37(2), Revision: Identification of Non Key Muscles Movement Shoulder: Flexion, extension, abduction, adduction, internal and external rotation Elbow: Supination Elbow: Pronation Wrist: Flexion Finger: Flexion at proximal joint, extension. Thumb: Flexion, extension and abduction in plane of thumb Finger: Flexion at MCP joint Thumb: Opposition, adduction and abduction perpendicular to palm Finger: Abduction of little finger Hip: Adduction Hip: Ext rotation Hip: Extension, abduction, int rotation Knee: Flexion Ankle: Inversion and eversion Toe: MP and IP extension Hallux and Toe: DIP and PIP Flexion and abduction Hallux: Adduction Root level C5 C6 C7 C8 T1 L2 L3 L4 L5 S1 11