Clinical Case of the Month. Neurological issues. Introduction

Transcription

1 Spinal Cord (997), International Medial Soiety of Paraplegia All rights reserved 6 9/97 $. Clinial Case of the Month Neurologial issues William H Donovan, Douglas J Brown, John F Ditunno Jr, Paul Dollfus, and Hans L Frankel Department of Physial Mediine and Rehabilitation, University of Texas Houston Medial Shool, Moursund, Houston, Texas 7796, USA; Spinal Injuries Unit, Austin Hospital, Heideberg, Vitoria, Australia; Thomas Je erson University Hospital, Philadelphia, PA 97, USA; 7 rue des CarrieÁres, 68, Mulhouse, Frane; National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, Buks HP 8AL, UK The ase histories of two patients who had had a spinal ord injury (SCI) were seleted by the senior author and sent to four experts in the eld of SCI. Based on the 99 Amerian Spinal Injury Assoiation (ASIA) and International Medial Soiety of Paraplegia (IMSOP) standards, the four partiipants plus the senior author reorded the motor and sensory sores, the ASIA impairment sale (AIS), the neurologial level (NL) and the zone of partial preservation (ZPP). Several minor soring errors ourred among the partiipants, espeially with motor sores when key musles ould not be tested due to pain, or external immobilization devies. Di ulties with interpretation ourred with the motor levels and the ZPP for the patient with a omplete injury. This exerise points to the need for all examiners of SCI patients to thoroughly familiarize themselves with the standards and to use the motor and sensory sores to arrive at a NL and ZPP. They also indiate a need to revise the standards to larify the determination of sensory levels and how to sore musles whose strength is inhibited by pain. Keywords: spinal ord injury; neurologial examination; standards for lassi ation of spinal ord injury Introdution In 98, the Amerian Spinal Injury Assoiation (ASIA) published a booklet entitled, Standards for Neurologial Classi ation of Spinal Cord Injured Patients. In 989, the Standards were revised in response to onerns raised by liniians and researhers, who were onerned about removing as muh ambiguity as possible when olleting and reording data. The standards were next revised in 99 and published in Paraplegia. For the rst time, the standards inluded a disability measure by inorporating the funtional independene measures (FIM) as part of the standards. These standards were formally adopted by the International Medial Soiety of Paraplegia (IMSOP) at its 99 annual meeting in Barelona. In response to ongoing feedbak, the standards have again been revised in 996 and will ontinue to be updated from time to time. Despite the wide aeptane of the standards, little investigation has been done to test their reliability. Donovan reported signi ant problems existed with interrater reliability, partiularly with the parameters Correspondene: Dr William H Donovan of neurologi level, what was then alled the Frankel grade, and the zone of partial preservation (ZPP) for both physiians and therapists. Subsequently, Priebe found similar problems in a test, retest study espeially with the determination of sensory levels at T and L and motor levels in inomplete patients. They supported the all for the revisions whih followed in 99. In a study aimed at assessing the e ay of Omental Transposition in the treatment of hroni spinal ord injury, Clifton et al 6 tested the intrarater reliability of the 99 standards and found the motor sore to be very reliable (r=.99) and the sensory sores less so but still aeptable for their study. Cohen et al 7 assessed the interrater and intrarater reliability of the 99 standards in a test onduted at the 99 Amerian Spinal Injury Assoiation (ASIA) annual meeting. She found that partiipants had the greatest di ulty with soring an inomplete SCI patient, establishing a motor level, and determining the ZPP of a omplete patient. These were areas that needed still further re nement. 7 Sine the interrater reliability still remains to be established, it seemed that this rst exerise in the assessment of linial ases, a series whih appears for the rst time in this issue of `Spinal Cord', should

2 76 survey a group, reognized as experts in the eld of spinal ord injury, provide them with the same two ases and determine how they would sore and interpret them using the 99 standards. 8 Materials and methods Two patients whih the senior author personally examined, are desribed below. The ase reports were then sent to four expert volunteers who agreed to read the ases, read the standards, interpret the narrative, omplete the motor and sensory sore hart following the diagram (Figure ) 8 and along with the author, interpret the ndings to arrive at a neurologial level, an ASIA Impairment Sale (AIS) and a ZPP, if appliable. The partiipants were not asked to omment on the treatment or prognosis, only to interpret the information as reported so that they ould sore and lassify eah patient. Two were from the United States, and one eah was from Australia, Great Britain and Frane. All four volunteers and the author, speak uent English. Case A year-old omputer programmer was involved in a motor vehile aident and sustained a left C/6 unifaetal disloation and a right perhed faet at the same level. Following resue and transport to a trauma enter, he underwent losed redution by ervial tration, and 8 h later had an operation with internal xation and fusion via a posterior approah. His postoperative ourse was uneventful. A follow-up examination weeks following the injury revealed the following: Sensation Pinprik: Right: From the oipital protuberane to the top of the aromiolaviular joint normal. From the lateral side of the anteubital fossa to the perianal area absent. Left: From the oipital protuberane to the top of the aromiolaviular joint normal. From the lateral side of the anteubital fossa to the medial side of the anteubital fossa absent. From the apex of the axilla to the perianal area, the sensation was desribed as sharp but not as sharp as the fae but nevertheless was aompanied by an unpleasant hyperpathia. Light Touh: Right: From the oipital protuberane to the top of the aromiolaviular joint normal. At the lateral side of the anteubital fossa diminished. At the thumb and middle nger absent. From the little nger to the perianal area diminished. Left: From the oipital protuberane to the top of the aromiolaviular joint normal. From the lateral side of the anteubital fossa to the perianal area diminished. Deep anal sensation was present. Figure

3 77 Motor Musle strength was graded from to as follows: Right/Left: Elbow Flexors /, Wrist Extensors /, Elbow Extensors /, Finger Flexors /, Small Finger Abdutor /, Hip Flexors /, Qudrieps /, Ankle Dorsi exors /, Long Toe Extensor /, Ankle Plantar exors /. Voluntary Anal Contration present. Request Using the aompanying `Standard Neurologial Classi ation of Spinal Cord Injury' hart, please omplete the motor sore, the pinprik sore, the light touh sore, the neurologial levels (sensory and motor), left and right the Impairment Sale, and the Zone of Partial Preservation. Please insert the ASIA impairment sale based upon the revised 99 edition in the box whih says omplete or inomplete. Case A year old biylist was struk by a ar. Following resue and transport to a trauma enter, he was found to have a L ompression frature with retropulsion of the body into the neural anal. Two days later, he underwent L vertebretomy, anterior interbody fusion from T to L using a left ilia rest strut graft and Z- plate instrumentation via a lateral approah. He also underwent posterior Cotrel-Dubousset instrumentation and fusion. He had also sustained a left Colles frature whih was treated with losed redution and immobilization in a ast. His examination h after the injury, and prior to the operation was as follows: Sensation Pinprik: Right: From the oipital protuberane to the medial femoral ondyle normal. From the medial malleolus to the lateral heel diminished. From the popliteal fossa to the perianal area absent. Left: From the oipital protuberane to the medial malleolus normal. The dorsum of the foot and the lateral heel diminished. From the popliteal fossa to the perianal area absent. Light Touh: Right: From the oipital protuberane to the lateral (si) femoral ondyle normal. From the to (si) the popliteal fossa diminished. The ishial tuberosity and the perianal area absent. Left: From the oipital protuberane to the medial malleolus normal. The dorsum of the foot diminished with aompanying sensation of hyperpathia. From the lateral heel to the perianal area absent. Deep anal sensation absent. Motor All musles in the upper extremities were normal, however, the left wrist extensors ould not be tested. Lower extremities: Hip exors Right: the patient was unable to lift the leg due to pain. When the right thigh was supported by the examiner and elevated degrees, a strong isometri ontration was palpated. Left: The patient was able to lift the leg ( exed at the knee) to 9 degress. A strong ontration was palpated but the patient ould o er no resistane against extension due to pain. Knee Extensors: Right and Left: Able to o er full resistane: Ankle Dorsi exors: Right: Full range of motion is possible but only with gravity eliminated. Left: Able to o er moderate resistane. Extensor Halluis Longus: Right: A minimal ontration is palpable. Left: Full range of motion against gravity is possible but no resistane an be provided. Ankle Plantar Flexors: Right: No ontration is palpated or seen. Left: A slight ontration is appreiated by palpating over the Ahilles tendons. Voluntary anal ontration absent. Request Using the aompanying `Standard Neurologial Classi ation of Spinal Cord Injury' hart, please omplete the motor sore, the pinprik sore, the light touh sore, the neurologial levels, the impairment sale, and the zone of partial preservation. Please insert the ASIA impairment sale based upon the revised 99 edition in the box whih says omplete or inomplete. Results Case The motor sores are shown in Table a. The sensory sores are shown in Table b and while Table d displays the neurologial level, impairment sale and zone of partial preservation for all ve partiipants. As shown in Table a, there was omplete agreement in the motor soring. Sorer number, however, failed to indiate whether any anal ontration was present. Table b shows the omplete agreement for light touh among all partiipants. Number omitted the anal sensation also. Table reveals that the pinprik sores were idential with regard to totals despite the fat that sorer number sored T on the left as a instead of a. As shown in Table d, sorer number did not submit a sensory or motor level. Sorers and stated that the motor level was bilaterally while sorers and stated that the motor level was C bilaterally. All sorers stated that the ASIA impairment sale was `D' exept sorer number who left this out. Likewise all sorers exept sorer number who left it out, reported the zone of partial preservation as non-appliable beause the lesion was inomplete. Case As shown in Table a, all sorers reognized that on the left was not testable exept sorer number who reversed the sores left to right. Sorer number delared the L musle as not testable. Sorers and gave the hip exors a grade bilaterally while and gave them grade bilaterally. There was omplete agreement for. For L, all sorers gave the right ankle dorsi exors a grade exept sorer who gave it a grade. For the extensor halluis and the ankle plantor exors, the sorers were in omplete agreement. Sorers and treated the total as not sorable. Sorer 's total was 8, sorer put down 7 over 9 and

4 sorer sored 7. All agreed on the absene of anal ontration. As shown in Table b, there was total agreement from C through. Despite the typographial error in the light touh setion of the ase desriptions, sorers through were able to agree on the soring from L to S. Sorer however did not interpret the information and left a question mark for L, L and S on the right. S and S/ were uniformly sored. Sorers,, and plaed 9 as the total. Sorer reported. For pinprik (Table ) the sorers were in omplete agreement exept for the total where sorer number again summed the values as instead of 9. As shown in Table d, there was agreement between sorers and as to the motor and sensory levels, ie left and L right. Sorer did not ommit to a motor level but gave the sensory level as bilaterally. Sorer also gave the sensory level as bilaterally and the motor level as L on right and L on the left. Sorer simply gave an overall sensory level of L and a motor level of L. All ve sorers gave the ASIA impairment sale as A. Under zone of partial preservation, again Sorers and were in agreement, reporting the ZPP for sensory as S on the right Table Case a Motor C T L L L S T CO Y Y Y Y b Sensory light touh C C C C T T T T T T T T L L L L S S S S/ T Y Y Y Y Sensory pin prik C C C C T T T T ont. Table ontinued Sensory pin prik T T T T L L L L S S S S/ T d Neurologial level MOT C C C C C C C C C C C C ASIA impairment sale D D D D Zone of partial preservation N/A N/A N/A N/A 78

5 and S on the left and for motor L on the right and S on the left. Sorer number again did not give a motor ZPP but reported sensory on the right as S and on the left as L. Sorer reported the sensory ZPP as S bilaterally and the motor ZPP as L on the right and S on the left. Sorer gave the sensory ZPP as S (presumably bilaterally) and the motor ZPP as L on the right and S on the left just as Sorers, and. Disussion It beomes apparent when analyzing the data from an exerise suh as this, that soring and interpreting are two di erent proesses. Auray is neessary for the former and reliability is needed for the latter before an instrument like the International Standards an be optimally utilized in multienter studies. This projet was designed to examine the 99 Standards' usefulness to seasoned students of the topi of spinal ord injury by allowing them to uniformly sore and interpret two representative patients with a SCI. If suh uniformity were not reahed, then at least the study ould point the way to further re nements and Table Case a Motor C T L L L S T 8 7/9 7 CO N N N N N b Sensory light touh C C C C T T T T T T T T L L L L S S S S/??? T N N N N N Sensory pin prik C C C C T T T T ont. Table ontinued Sensory pin prik T T T T L L L L S S S S/ T d Neurologial level MOT L L L L L L L L ASIA impairment sale A A A A A Zone of partial preservation S S S L S S S S S MOT L S L S L S L S 79

6 8 the ASIA Neurologial Standards Committee ould see whether these had been made in the 996 revision, whih was not available at the time of this study. Case The following were regarded as soring and reording problems: (a) examiner number omitted the information regarding anal ontration and sensation (Table a,b); (b) examiner number gave segment T on the pinprik sore (Table ) a `' on the left yet the total reorded was, not as expeted, if the sums had been orret. The text of Case stated the patient had absent pinprik sensation at `the medial side of the anteubital fossa'. This is the key area for T on the dermatome hart (Figure ); () examiner number took segments of the sore sheet provided and had them enlarged but the enlargements did not ontain the boxes for the neurologial level (NL) nor the ZPP. These two piees of information were missing from the results submitted; (d) examiner number omitted the AIS; (e) as an aside, examiner number expressed onern about the use of the lateral anteubital fossa representing C. However, the key point for C is learly shown on the dermatome hart as loated in this area (Figure ). All of the foregoing (a d) were lassi ed as soring errors that would likely disappear with more pratie. The interpretation of the data for Case is to be found in Table d. Even though this was a ase of inomplete SCI, there was near unanimous agreement as to the sensory level, AIS and ZPP (exeptions as noted above). The motor level posed a problem, however. The 99 standards state that `... the motor level (the lowest normal motor segment whih may di er by side of body) is de ned by the lowest key musle that has a grade of at least, providing the key musles represented by segments above that level are judged to be normal...' Sine the C musles were Grade (normal strength) and the musles were Grade, while the musles were less than Grade, the musles were the lowest ones that tested `at least ' (atually ) while the musles `above that level' (C) were Grade (normal). Following the guidelines then, is the motor level. The ASIA standards ommittee has already reognized that further lari ation of the standards regarding the determination of the motor level is needed and this has been addressed in the 996 revised standards. Case The following were interpreted as soring and reording problems: (a) while all examiners reognized the wrist extensors in this ase were not testable (), examiner number reversed the sides (Table a). Examiners, and gave a total sore while numbers and did not. Number gave the musle a value of by summing the sore as 8. Number sored the total as 7 out of 9 while number simply indiated 7; (b) examiner number gave a sum of 7 but the atual sum should have been 7, if the sores were added orretly as reported (Table a). The ASIA standards say when a dermatome or myotome annot be tested, should be reorded for that segment, for the a eted side of the body and for the total sensory and/or motor sores (as appliable) sine they `annot be generated with respet to the injury at that point in treatment'. Other soring and reording problems noted were: () number graded the L musle as Grade even though the ase text stated `full range of motion is possible with gravity eliminated'. In Case it was purposely deided to use the names of the musles and words to desribe the strength grades rather than numbers as were used in Case. This was the only error that appeared to result from that deision; (d) examiner number summed the sensory sores for pinprik and light touh both as (Tables b,); (e) despite the typographi error in the ase text desribing the light touh ndings on the right, examiners through assumed that medial rather than lateral femoral ondyle was intended and that light touh was diminished from L to S. Examiner plaed a `?' in L, L and S but gave these three dermatomes a summed value of to arrive at a total of 9 (Table b); (f) examiner number reorded only one level and one sensory ZPP. This may also have resulted from enlarging the sore sheets and separating their omponents (Figure ). Problems relating to interpretation are more evident in this ase. The most signi ant is posed by the hip exors. Case had a signi ant injury to his upper lumbar spine. The psoas portion of the iliopsoas musle originates from this area and the onomitant injury to the musle makes testing it in the way desribed in the ASIA standards manual 9 problemati. It ould be argued that all ve examiners were orret in the way they sored these musles, even though they gave three di erent answers (Table a). Sine so muh depends upon the examiner's judgement and experiene as to how to grade the iliopsoas under these onditions, the use of would likely result in a more uniform, albeit unsorable response. Examiner gave no motor level (Table d) but this was onsistent with the motor sore (Table a). Numbers and also gave motor levels onsistent with their assumption of Grade iliopsoas musles. They sored the left L musle as `less than Grade ' (atually ), while the right one was `at least ' (atually ). Sine they sored both the L and musles as Grade bilaterally, they followed the standards by giving their motor levels as right and left L. While the typographial error seemed to have reated only minor problems with respet to sensory soring, it may have a eted the interpretation of a sensory level (Table d). Nevertheless, when studying

7 8 the sensory sores (Table b,), all examiners reorded the lowest normal segments as being on the right and L on the left. However, the sensory levels were not unanimous. The 99 standards 8 do not de ne the requisite onditions for arriving at the sensory level as expliitly as they do for the motor level. They say `when the term sensory level is used, it refers to the most audal segment of the spinal ord with normal sensory funtion on both sides of the body.' This is an area for the ASIA Neurologial Standards Committee to address. All examiners reognized the AIS as `A' or omplete. The larity with whih the NL is de ned beomes ritial when reording the ZPP. The segments inluded in the latter are alulated based upon the former. Nevertheless, despite the di erenes among the examiners for the sensory and motor levels, numbers,, and all agreed upon the most audal level to whih the motor ZPP extended ie, right L, left S (number, onsistently, did not give a motor ZPP as there was no motor NL reorded). The sensory ZPP was a problem area however. Examiners, and agreed on the right side (S) while examiners, and agreed on the left side (S). Yet, if Tables b and are examined arefully, all agreed that the lowest segment with any sensation at all was S on the right and S on the left. The 99 standards de ne the ZPP as `... those dermatomes and myotomes audal to the neurologial level that remain partially innervated. When some impaired sensory and/or motor funtion is found below the lowest normal segment, the exat number of segments so a eted should be reorded for both sides as the ZPP. The term is used only with omplete injuries.' The disrepanies in the NL and ZPP interpretations seem to relate to inexat appliations of the standards and lak of utilization of the soring sheets by all examiners. When allowane for the di ulty related to the hip exors, the urrent de nition of a sensory level and the typographial error whih appeared in the light touh setion is made, overall, the standards ontained most of the information needed to sore and interpret these two ases. It is reognized that asking multiple examiners to sore and interpret a ase report is not the same as having them examine, sore and interpret the examination of a real patient. The former was the only means of onduting this exerise. Comparing the results of a ase report of a `standardized patient' with the examination of that patient would be an interesting study. The senior author has deliberately refrained from listing `the right answer' for eah ase, allowing the reader to deide individually based upon the 99 standards. Now that the 996 standards have just been released, in months, this exerise will be repeated to see if the di ult areas of interpretation have improved. Referenes Standards for Neurologial Classi ation of Spinal Cord Injured Patients. Amerian Spinal Cord Injury Assoiation 98, Chiago. Ditunno JF, Young W, Donovan WH, Creasey G. The International Standards Booklet for Neurologial and Funtional Classi ation of Spinal Cord Injury. Paraplegia 99; :7 8. Hamilton BB, Devoe MJ. 99 Funtional Enhanement in Spinal Cord Injury. The Model. Proeedings of a National Consensus Conferene on Catastrophi Illness and Injury, Georgia Regional Spinal Cord Injury Care Sysem, Shepherd Center.Atlanta,GA. Donovan WH, Wilkerson MA, Rossi D, Mehoulam F, Frankowski RF. A test of the ASIA Guidelines for Classifiation of Spinal Cord Injuries. Journal of Neurologi Rehabilitation 99; : 9. Priebe MM, Waring WP. The Interobserver Reliability of the Revised Amerian Spinal Injury Assoiation Standards for Neurologial Classi ation of Spinal Injury Patients. Amer J PM&R 99; 7: Clifton GL et al. Omental Transposition in Chroni Spinal Cord Injury. Paraplegia 996; : 9. 7 Cohen ME, Ditunno JF, Donovan WH, Maynard FM. A test of the International Standards for Neurologial and Funtional Classi ation of Spinal Cord Injury. J Spinal Cord Med 996; 9: 7. 8 Standards for Neurologial Classi ation of Spinal Cord Injured Patients. Amerian Spinal Cord Injury Assoiation 99, Chiago, Il. 9 Referene Manual for the International Standards for Neurologial and Funtional Classi ation of Spinal Cord Injury. Amerian Spinal Injury Assoiation/International Medial Soiety of Paraplegia 99, Chiago, Il.