6. ⢠The injury carries a double threat: damage to the
vertebral column and damage to the neural tissues.
⢠Neurological injury is not always immediate and may
occur (or be aggravated) only if and when there is
movement.
⢠Fortunately, only 10% of spinal fractures are unstable
and less than 5% are associated with cord damage.
Spinal Injury
7. Stable Injury: injury of single column â normal daily
activity does not cause displacement of vertebral
components and no risk of neural tissue damage.
Unstable injury: injury of two or three columns â risk of
displacement of vertebral components:
⢠Risk of neural tissue damage
⢠Unacceptable deformity
Stability
8. Direct mechanism:
⢠Bullet (e.g gunshot)
⢠Blow
⢠Knife
Indirect mechanism (most cases):
⢠Road tra
ffi
c accidents
⢠Fall from height
⢠Sport injuries
⢠Head trauma
Mechanism and Causes
9. Spinal trauma is one of the few situations where
management starts before diagnosis.
⢠All trauma patients MUST be regarded as spinal injury UPO.
⢠The slightest possibility of spinal trauma should be treated by
immobilization until the patient has been resuscitated and
other life-threatening injuries have been identi
fi
ed and treated.
⢠Principles of ATLS applies to all (AcBCDE).
⢠The
fi
nding of a spinal injury makes it more (not less) likely that
there will be a second injury at another level (10-15%).
Approach
10. Hx:
⢠Mechanism of injury
⢠Pain
⢠Onset and duration of neurological symptoms
Ex (of entire spine using spinal log-roll)
⢠Look: penetrating wounds, swelling, ecchymosis
⢠Feel: tenderness, palpable steps or gaps
⢠Move: MUST be avoided.
⢠Neurology: ASIA
Approach
11. REV 04/19
Page 1/2 ISNCSCI Worksheet Š 2019 by ASIA is licensed under CC BY-NC-ND 4.0 (see http://creativecommons.org/licenses/by-nc-nd/4.0/).
Cite: Rupp et al.: ISNCSCI: Revised 2019.https://doi.org/10.46292/sci2702-1
NEUROLOGICAL
LEVELS
Steps 1- 6 for classification
as on reverse
1. SENSORY
2. MOTOR
R L 3. NEUROLOGICAL
LEVEL OF INJURY
(NLI)
4. COMPLETE OR INCOMPLETE?
Incomplete = Any sensory or motor function in S4-5
5. ASIA IMPAIRMENT SCALE (AIS)
(In injuries with absent motor OR sensory function in S4-5 only)
6. ZONE OF PARTIAL
PRESERVATION
Most caudal levels with any innervation
SENSORY
MOTOR
R L
MOTOR SUBSCORES SENSORY SUBSCORES
UER +UEL = UEMS TOTAL LER + LEL = LEMS TOTAL PPR + PPL = PP TOTAL
LTR + LTL = LT TOTAL
MAX (25) (25) (50) (25) (25) (50) (56) (56) (112)
MAX MAX (56) (56) (112)
MAX
(50) (56) (56)
RIGHT TOTALS
(MAXIMUM) (56) (56) (50)
LEFT TOTALS
(MAXIMUM)
(VAC) Voluntary Anal Contraction
(Yes/No)
(DAP) Deep Anal Pressure
(Yes/No)
C5
C6
C7
C8
T1
C5
C6
C7
C8
T1
L2
L3
L4
L5
S1
L2
L3
L4
L5
S1
C2
C3
C4
S2
S3
S4-5
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
L1
C2
C3
C4
S2
S3
S4-5
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
L1
RIGHT LEFT
UER
(Upper Extremity Right)
LER
(Lower Extremity Right)
UEL
(Upper Extremity Left)
LEL
(Lower Extremity Left)
Elbow flexors
Wrist extensors
Elbow extensors
Finger flexors
Finger abductors (little finger)
Hip flexors
Knee extensors
Ankle dorsiflexors
Long toe extensors
Ankle plantar flexors
Elbow flexors
Wrist extensors
Elbow extensors
Finger flexors
Finger abductors (little finger)
Hip flexors
Knee extensors
Ankle dorsiflexors
Long toe extensors
Ankle plantar flexors
0 = Absent
1 = Altered
2 = Normal
NT = Not testable
0*, 1*, NT* = Non-SCI
condition present
SENSORY
(SCORING ON REVERSE SIDE)
0 = Total paralysis
1 = Palpable or visible contraction
2 = Active movement, gravity eliminated
3 = Active movement, against gravity
4 = Active movement, against some resistance
5 = Active movement, against full resistance
NT = Not testable
0*, 1*, 2*, 3*, 4*, NT* = Non-SCI condition present
MOTOR
(SCORING ON REVERSE SIDE)
Comments (Non-key Muscle? Reason for NT? Pain?
Non-SCI condition?):
PinPrick(PPR)
LightTouch(LTR) PinPrick(PPL)
LightTouch(LTL)
SENSORY
KEY SENSORY POINTS
MOTOR
KEY MUSCLES
MOTOR
KEY MUSCLES
SENSORY
KEY SENSORY POINTS
C2
C3
C4
C6
T1
C5
L1
L2
L3
L4
L5
Palm
Key Sensory
Points
S4-5
S3
S2
S1
L5
L
4
L
3
L
2
C2
C3
C4
T3
T2
T4
T5
T6
T7
T8
T9
T10
T11
T12
C
8
C
7
C
6
Dorsum
INTERNATIONAL STANDARDS FOR NEUROLOGICAL
CLASSIFICATION OF SPINAL CORD INJURY
(ISNCSCI)
Patient Name Date/Time of Exam
Examiner Name Signature
12. Page 2/2
A = Complete. No sensory or motor function is preserved
in the sacral segments S4-5.
B = Sensory Incomplete. Sensory but not motor function
is preserved below the neurological level and includes the
sacral segments S4-5 (light touch or pin prick at S4-5 or
deep anal pressure) AND no motor function is preserved
more than three levels below the motor level on either side
of the body.
C = Motor Incomplete. Motor function is preserved at the
most caudal sacral segments for voluntary anal contraction
(VAC) OR the patient meets the criteria for sensory
incomplete status (sensory function preserved at the most
caudal sacral segments S4-5 by LT, PP or DAP), and has
some sparing of motor function more than three levels below
the ipsilateral motor level on either side of the body.
(This includes key or non-key muscle functions to determine
motor incomplete status.) For AIS C â less than half of key
muscle functions below the single NLI have a muscle
grade ⼠3.
D = Motor Incomplete. Motor incomplete status as
defined above, with at least half (half or more) of key muscle
functions below the single NLI having a muscle grade ⼠3.
E = Normal. If sensation and motor function as tested with
the ISNCSCI are graded as normal in all segments, and the
patient had prior deficits, then the AIS grade is E. Someone
without an initial SCI does not receive an AIS grade.
Using ND: To document the sensory, motor and NLI levels,
the ASIA Impairment Scale grade, and/or the zone of partial
preservation (ZPP) when they are unable to be determined
based on the examination results.
ASIA Impairment Scale (AIS) Steps in Classification
Muscle Function Grading
Sensory Grading
When to Test Non-Key Muscles:
0 = Total paralysis
1 = Palpable or visible contraction
2 = Active movement, full range of motion (ROM) with gravity eliminated
3 = Active movement, full ROM against gravity
4 = Active movement, full ROM against gravity and moderate resistance in a
muscle specific position
5 = (Normal) active movement, full ROM against gravity and full resistance in a
functional muscle position expected from an otherwise unimpaired person
NT = Not testable (i.e. due to immobilization, severe pain such that the patient
cannot be graded, amputation of limb, or contracture of > 50% of the normal ROM)
0*, 1*, 2*, 3*, 4*, NT* = Non-SCI condition present a
0 = Absent 1 = Altered, either decreased/impaired sensation or hypersensitivity
2 = Normal NT = Not testable
0*, 1*, NT* = Non-SCI condition present a
In a patient with an apparent AIS B classification, non-key muscle functions
more than 3 levels below the motor level on each side should be tested to
most accurately classify the injury (differentiate between AIS B and C).
The following order is recommended for determining the classification of
individuals with SCI.
INTERNATIONAL STANDARDS FOR NEUROLOGICAL
CLASSIFICATION OF SPINAL CORD INJURY
Movement
Shoulder: Flexion, extension, adbuction, 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 the index finger
Hip: Adduction
Hip: External rotation
Hallux and Toe: DIP and PIP flexion and abduction
Hallux: Adduction
Hip: Extension, abduction, internal rotation
Knee: Flexion
Ankle: Inversion and eversion
Toe: MP and IP extension
Root level
C5
C6
C7
C8
T1
L2
L3
L4
L5
S1
4. Determine whether the injury is Complete or Incomplete.
(i.e. absence or presence of sacral sparing)
If voluntary anal contraction = No AND all S4-5 sensory scores = 0
AND deep anal pressure = No, then injury is Complete.
Otherwise, injury is Incomplete.
6. Determine the zone of partial preservation (ZPP).
The ZPP is used only in injuries with absent motor (no VAC) OR sensory
function (no DAP, no LT and no PP sensation) in the lowest sacral segments
S4-5, and refers to those dermatomes and myotomes caudal to the sensory
and motor levels that remain partially innervated. With sacral sparing of
sensory function, the sensory ZPP is not applicable and therefore âNAâ is
recorded in the block of the worksheet. Accordingly, if VAC is present, the
motor ZPP is not applicable and is noted as âNAâ.
3. Determine the neurological level of injury (NLI).
This refers to the most caudal segment of the cord with intact sensation and
antigravity (3 or more) muscle function strength, provided that there is normal
(intact) sensory and motor function rostrally respectively.
The NLI is the most cephalad of the sensory and motor levels determined in
steps 1 and 2.
2. Determine motor levels for right and left sides.
Defined by the lowest key muscle function that has a grade of at least 3 (on
supine testing), providing the key muscle functions represented by segments
above that level are judged to be intact (graded as a 5).
Note: in regions where there is no myotome to test, the motor level is
presumed to be the same as the sensory level, if testable motor function
above that level is also normal.
1. Determine sensory levels for right and left sides.
The sensory level is the most caudal, intact dermatome for both pin prick
and light touch sensation.
a
Note: Abnormal motor and sensory scores should be tagged with a â*â to indicate an
impairment due to a non-SCI condition. The non-SCI condition should be explained
in the comments box together with information about how the score is rated for
classification purposes (at least normal / not normal for classification).
5. Determine ASIA Impairment Scale (AIS) Grade.
Is injury Complete? If YES, AIS=A
Is injury Motor Complete? If YES, AIS=B
Are at least half (half or more) of the key muscles below the
neurological level of injury graded 3 or better?
If sensation and motor function is normal in all segments, AIS=E
Note: AIS E is used in follow-up testing when an individual with a documented
SCI has recovered normal function. If at initial testing no deficits are found, the
individual is neurologically intact and the ASIA Impairment Scale does not apply.
(No=voluntary anal contraction OR motor
function more than three levels below the motor
level on a given side, if the patient has sensory
incomplete classification)
13. A: complete spinal cord injury
B: sensation present, motor absent
C: sensation present, motor present but not useful (MRC <3/5)
D: sensation present, motor useful (MRC âĽ3/5)
E: Normal function
This is modi
fi
ed from Frankel grading classi
fi
cation.
ASIA Impairment Scale (AIS)
14.
15. X-Ray (plain radiographs):
⢠Cervical: AP, lateral and open mouth views.
⢠Whole spine if cervical # con
fi
rmed or suggestive mechanism
⢠Assess
1. Prevertebral soft-tissue swelling (hematoma)
2. Sagittal alignment (three imaginary lines)
3. For instability:
- sagittal translation of 3.5 mm
- sagittal angulation of >11°
Imaging
22. CT:
⢠Remains the gold standard in spinal trauma and is indicated
for patients with suspected or visible injuries on X-Ray.
⢠Screening cervical CT in head trauma
⢠Usually CT of chest and abdomen done in polytrauma also
shows spine.
Imaging
23. Plain x-ray alone may be insuf
fi
cient to show the true state of incident. This x-ray showed the
fracture, but it needed a CT scan to reveal the large fragment encroaching on the spinal canal
26. MRI:
⢠Shows intervertebral discs, ligaments & neural structures.
⢠Indicated for all patients with neurological signs and those
who are considered for surgery.
Imaging
31. The objectives of treatment are:
â To preserve neurological function.
â To relieve any reversible neural compression.
â To restore alignment of the spine.
â To stabilize the spine.
â To rehabilitate the patient
Management
32. Realignment: traction, collar, halo jacket, braces.
Surgery: The indication is in
fl
uenced by the injury pattern,
level of pain, degree of instability and the presence of a
neurological de
fi
cit. The only absolute indication is
deteriorating neurological function.
⢠Stabilisation (ORIF)
⢠Decompression of neural elements (bony fragments,
hematoma)
Corticosteroids: although e
ff
ective for malignant cord
compression, they are not useful in traumatic cases.
Management
38. ⢠Survival decreases with older age of acquiring injury and more severe neurological injury.
⢠Survival is similar for those who survive
fi
rst 24 hours compared to those who survive
fi
rst
year post injury (except for ventilator dependent)
⢠Complete spinal cord injury has <5% chance of recovery, and it drops to basically zero if
does not recover in
fi
rst 72 hours.
Prognosis
