INTERNATIONAL STANDARDS

for NEUROLOGICAL

CLASSIFICATION of SPINAL

CORD INJURY
(AMERICAN SPINAL INJURY ASSOCIATION)

(INTERNATIONAL SPINAL CORD SOCIETY)

Why standardise
examination?
• Confusion as regards the level of injury

• Confusion as regards definition of

completeness

• To simplify comparative assessment of

treatment and research
DEFINITIONS
• Tetraplegia (quadriplegia)

• Paraplegia

• Quadriparesis and paraparesis

• Dermatome – area of skin innervated by sensory

axons within each segmental nerve root

• Myotome – motor muscle fibres innervated by

segmental nerve root axons
Definitions (cont.)

• Neurological level – most caudal segment

with normal sensory and motor on both
sides. If they differ according to side of
body (possibly four different segments)
these must be recorded
• Key sensory points – 28 on each side
• Key motor points – 10 on each side
• Skeletal level – level at which the greatest
vertebral damage is found
Definitions (cont.)
• Sensory Scores
• Motor Scores
• Complete injury
• Zone of Partial Preservation (ZPP)
• Only in complete injuries
• Most caudal segment with some sensory/motor
function e.g.
• Incomplete injury
• Sacral sensation includes sensation at anal
mucocutaneous junction & deep anal sensation
• The initial examination is most important.
• Depending on the time post injury, it is
probably the best guide as regards future
prognosis.
• Remember the period of the maximal loss.
Frequent re-examination is therefore necessary.
• Often the patient or a region cannot be tested
accurately or at all. Record this as non testable
(NT) this will definitely affect the motor and/or
sensory score
 SENSORY EXAMINATION

• Both sides of the body to be tested

• Pinprick

• Light touch

• 28 key points
•
SENSORY EXAMINATION
(CONT)
• 0 = Absent

• 1 = Impaired (partial or altered appreciation.

This includes hyperaesthesia)

• 2 = Normal

• NT = not testable
SENSORY EXAMINATION (cont.)
Cervical
• C2 ……….occipital protuberance
• C3 ……….supraclavicular fossa
• C4 ……… top of acromioclavicular joint
• C5 ……… lateral side of the antecubital fossa
• C6 ……… thumb, dorsal surface proximal
phalanx
• C7 ……… middle finger, dorsal surface
proximal phalanx
• C8 ……… little finger, dorsal surface proximal
phalanx
 SENSORY EXAMINATION
THORACIC
• T1 ……Ulnar side cubital fossa
• T2 ……Apex axilla
• T3 ……3rd intercostal space (IS)
• T4 ……4th IS (nipple line)
BEWARE !!!!!!!!!!!!!!!!!!!
• T5 ……5th IS (midway between T4 & T6)
• T6 ……Xiphisternum
• T10 …..Umbilicus
• T12 …..Inguinal ligament at midpoint
 SENSORY EXAMINATION
Lumbar
• L1 ……Between T12 & L1
• L2 ……Mid anterior thigh
• L3 ……Medial Femoral Condyle
• L4 ……Medial Malleolus
• L5 ……Dorsum foot at 3rd metatarsal
phalangeal joint
 SENSORY EXAMINATION
Sacral
• S1 ……Lateral Heel
• S2 ……Midline popliteal fossa
• S3 ……Ischial Tuberosity
• S4-5 …Perianal area.
• This last examination is often best done
combined with a rectal examination.
• According to ASIA any sensation felt in this
area means that the patient is incomplete
 MOTOR EXAMINATION

• 5 Key muscles are assessed and

scored in each of the upper and
lower limbs
• Since the scoring system is from zero
to five the total in each limb is
therefore 25, with a grand total of
100.
•
 MOTOR EXAMINATION (cont.)
Scoring

Motor Power assessed on a Six Point scale

• 0 = Total paralysis
• 1 = palpable or visible contraction
• 2 = active movement, full ROM with gravity eliminated
• 3 = active movement full ROM against gravity
• 4 = active movement full ROM against moderate resistance
• 5 = normal – full active ROM against normal resistance !!!!!!!

• 5* = muscle able to exert, in examiner’s judgement,

sufficient resistance to be considered normal if identifiable
inhibiting factors were not present.
This has recently been added.
 MOTOR EXAMINATION
Scoring (cont.)
• Most muscles innervated by more than one nerve
segment
• Key muscles are therefore a simplification
• Presence of innervation by one segment and
absence of innervation by the other results in a
weakened muscle not 5/5
• If a muscle has grade 3/5, it has intact innervation
by most rostral (head end) of innervating
segments.
• Next most rostral muscle should test as 5/5, since
its two innervating segments will be intact.
• Motor Level is then C6
 MOTOR EXAMINATION
Scoring (cont.)
• Example:
• Extensor carpi radialis longus (C6 & C7) Motor Power 3/5
• Biceps (C5 & C6) Motor Power 5/5
• Triceps is completely paralysed C7 & C8 and one
presumes that C7 of Extensor carpi radialis longus is
also paralysed.
• However C6 of Extensor carpi radialis longus should be
functional and biceps (C5 & C6) is normal 5/5
• TRICEPS (C7 & C8) is completely paralysed
•Motor Level is then considered to be C6
provided that biceps is 5/5
 MOTOR EXAMINATION
Scoring (cont.)
• Not infrequently, a muscle tests less
than 5/5 but it may be fully innervated
but is inhibited due to factors
• Weakness due to disuse
• Pain
• Hypertonicity
• This muscle must be marked Non
Testable (NT)
 MOTOR EXAMINATION
Scoring (cont.)
If the above factors do not prevent the
patient performing a forceful
contraction and if the examiner feels
that the muscle would test normally,
were it not for these factors, it can
be graded as 5/5
 MOTOR EXAMINATION
Scoring (cont.)
• Myotomes not testable e.g.
• T2 – T12
• S2 – S5

Presumed to be the same as sensory

level
 MOTOR EXAMINATION
Scoring (cont.)
Key Muscle Groups
(can be tested in the supine position)would

• C5 – Elbow Flexors (biceps & brachialis)

• C6 – Wrist Extensors (ECRL & ECRB)
• C7 – Elbow Extensors (triceps)
• C8 – Finger Flexors (FD Profundus) to middle finger

• T1 – Small Finger Abductors (abductor digiti

minimi)
 MOTOR EXAMINATION
Key Muscle Groups

• L2 – Hip flexors (iliopsoas)

• L3 – Knee extensors (quadriceps)
• L4 – Ankle dorsiflexors (tibialis anterior)
• L5 – Long toe extensors (ext. Hallucis longus)

• S1 – Ankle plantarflexors(gastrocnemius &

Soleus)
 MOTOR EXAMINATION
The external anal sphincter should also be
tested.
If there is a voluntary movement the patient is
incomplete.
Other reasons for testing the anal sphincter by
rectal examination is to assess
• Tone of sphincter (patulous or not) Lower motor neurone
lesion or in spinal shock.
• Deep anal sensation. Present in an incomplete lesion
• Bulbocavernosis reflex. Presence means upper motor
neurone lesion and spinal shock disappearing.
 Rectal Examination

Other reasons for testing the anal

sphincter by rectal examination is to
assess
• Tone of sphincter (patulous or not) Lower
motor neurone lesion or in spinal shock.
• Deep anal sensation. Present in an
incomplete lesion
• Bulbocavernosis reflex. Presence means
upper motor neurone lesion and spinal shock
disappearing.
• The next step is to enter and total
the point score
•
 ASIA impairment scales
(modified from Frankel)

• A = Complete: no motor or function

in the sacral segments S4 – S5

• B = Incomplete: Sensory but not

motor function preserved below
neurological level & includes S4 -S5
 ASIA impairment scales
(modified from Frankel)

C = Incomplete: Motor function

preserved below the neurological
level, and more than half Key
muscles below neurological level,
muscle grade of less than 3/5.

In the original Frankel scale this was described as motor

useless
 ASIA impairment scales
(modified from Frankel)

D = Incomplete: Motor function is

preserved below the neurological
level and at least half of Key muscles
below the neurological level have
muscle grade of 3/5 or more

In the original Frankel scales this was described as or

 ASIA impairment scales
(modified from Frankel)

• E = Motor and sensory functions are

normal

• N.B. Sacral Sparing must be present

in B, C, D, E.