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5
NeurologicalAssessmentand
ClassificationofSpinalCordInjury
StevenKirshblumandRyanSolinsky
ASSESSMENTOFSPINALCORDINJURY
The most accurate way to neurologically assess apersonwho has sustained a
spinalcordinjury(SCI)istoperformastandardizedneurologicalexaminationas
endorsedbytheInternationalStandardsforNeurologicalClassificationofSpinal
Cord Injury (ISNCSCI) (1), also commonly referred to as the “International
Standards.”TheseStandardsprovidedefinitions(Table5.1)ofterminologyused
by clinicians as well as detailed instructions on examination techniques and
classificationrules.TheexaminationandclassificationofapersonwithSCIare
twodistinctskills,andthereforewillbedescribedseparately.
TheInternationalStandardsweredevelopedtodocumentselectedneurologic
parameters in a clinical setting (2). Although not the initial intention, these
Standards have been used for inclusion/exclusion criteria for research studies,
outcome measures for clinical trials, as well as for prognostication of
neurologicalrecoveryforspecificneurologicalcategoriesofSCI.
IntheStandards, the neurological examination of the person with SCI has
twomaincomponents,sensoryandmotor,withrequiredandoptionalelements
thatshouldberecordedonastandardizedworksheet(Figure5.1).Therequired
elementsallowthedeterminationofthesensory,motor,andsingleneurological
levels,aswellasgenerationofsensoryandmotorindexscores,determinationof
the completeness of the injury, and impairment classification. The rectal
examination, which tests for voluntary anal contraction (VAC) and deep anal
pressure(DAP),previouslyreferredtoas“deepanalsensation,” isalsopart of
the required components of the examination (1). Optional elements include
aspects of the neurological examination that may better describe the patients’
clinical condition (e.g., reflexes) but are not used for numerical scoring or
classification. To learn how to use the International Standards, a web-based
instructional course (InSTeP) is available through the American Spinal Injury
Association (ASIA) (www.asialearning.com). Themost recentrevisionsof the
International Standards were published in 2011 (3,4), with an update with
clarificationsin2015(1).
SensoryExamination
Thesensoryexamisperformedon28pointsonbothsidesofthebody(Figure
5.1)thataretermed“keysensorypoints.”Eachkeysensorypointistestedfor
pinpricksharp/dulldiscrimination and light touch (LT) appreciation aswellas
DAPaspartoftherectalexamination.Thesespecificpointswereadaptedfrom
Austin (5) and Foerster (6) with consensus amongst experienced spinal cord
physicians.Athree-pointgradingscale(0–2)isused,withthecheekoftheface
asthenormalcontrolpoint.Testingisperformedwiththepatients’eyesclosed
or vision blocked sothat the patient cannotidentify the site beingtested. For
lighttouch, atapered wispof cotton(i.e.,fromacotton tipapplicator) isused
andshouldbestrokedacrosstheskinmovingoveradistancenottoexceed1cm,
witha score of2(intact) being thesame touch sensationason the faceand1
(impaired) if felt different from the face. Hypo or hyperesthesia are both
classifiedasabnormalsensationandarescoredasa“1.”Ascoreof0(absent)is
usedifthereisnoappreciationofsensation.
Forthe pinexamination,a clean(and disposable) safetypin is used,and a
scoreof “2” is givenforsensationthat is perceived thesameas the face with
intact ability to differentiate sharp from dull. A score of “1” corresponds to
alteredsensation(hypoorhyperesthesia)relativetothefacewithintactabilityto
differentiatesharp(pinendofthesafetypin)fromdull(roundededgeofpin).A
scoreof“0”representsabsentsensation,butnotablyascoreof“0”isalsogiven
forinabilitytodifferentiatesharpfromdull.Ifaccuratesensorytestingisunable
tobeperformedatthekeysensorypointduetoextenuatingcircumstances(i.e.,
burns,casts,amputations,etc.),thelevelisdesignatedasnottestable,or“NT,”
ontheworksheet,oranalternatelocationwithin the dermatome can be tested
withanotationinthecommentboxthatanalternatesitewasused.Ifthereisa
questionwhetherthepatientcandefinitivelydiscriminatebetweenthesharpand
dull edges, 8/10 correct answers is considered accurate, as this reduces the
probabilityofcorrectguessingtolessthan5%.
WhentestingthedigitsforC6–C8keysensorypoints,thedorsalsurfaceof
the proximal phalanx should be tested. For the chest and abdomen, sensory
testing should be performed at the midclavicular line. A prominent pitfall in
performingsensorytestingisvariationinthecaudalextentoftheC4dermatome,
at times referred to as the C4 “cape” or “shelf.” Variably, this cervical
dermatomecan extend in closeproximityto the nippleline,makingit easy to
confuse it with the T3 dermatome. In accordance with the International
Standards,ifsensationatT1andT2keysensorypointsisabsentandT3appears
intact, T3 should be scored as absent if there is no sensation at T4 (thereby
assuminganextendedC4cape).
For persons in whom it may be difficult to identify the T3 and T4 key
sensorypoints(i.e.,patientswhoareobeseorhavelargebreasts),theT3andT4
intercostal spaces can be verified by palpation of the anterior ribs rather than
relyingonthe nippleline; forT3,theintercostalspace belowthe thirdrib.An
alternativemethodoflocatingT3ispalpatingthemanubriosternaljoint,whichis
atthelevelofthesecondrib.Atthatpoint,movingslightlylateraltopalpatethe
secondribandcontinuingtomoveinacaudaldirectionwilllocatethethirdrib
andthecorrespondingintercostalspacejustbelowit(2).
It is important to test the S4–S5 key sensory point (<1 cm lateral to the
mucocutaneous junction) for both sharp/dull discrimination and LT, as this
representsfunctionsofthemostcaudalaspectofthesacralspinalcord.Asingle
key sensory point is used to assess both S4 and S5 dermatomes. In addition,
DAPistestedbyinsertingalubricatedglovedfingerintotheanuswithpressure
applied to the anorectal wall. The patient is asked if they can appreciate this
digital pressure innervated by the somatosensory components of the pudendal
nerve (S4/S5). Consistently perceived pressure is recorded as either present
(YES) or absent (NO) on the worksheet. A recommended technique involves
pressureappliedusingthethumbtogentlysqueezetheanorectalwallagainstan
insertedindexfinger(7).Theterm“deepanalsensation”wasreplacedbyDAP
in the 2011 revisions, as the term “pressure” reinforced the technique as
described previously as opposed to more vigorous techniques that may relay
informationbyotherpathways(3).Ifapatienthasintactsensationtosharp/dull
discrimination or LT at S4/S5, DAP is not required for classification in the
current ISNCSCI exam. However, the motor portion of the anorectal exam
shouldstillbecompletedtoassessformotorsparing(describedlater).
Optional elements of the sensory examination include joint movement
appreciation and position sense and awareness of deep pressure/pain. Joint
movementappreciationandpositionsensecanbetestedintheupper(littlefinger
at the proximal interphalangeal joint,thumb, and wrist) andlower extremities
(greattoe,ankle,andknee).Scoringisasfollows:0(absent)—ifunabletoreport
jointmovementcorrectly,1 (impaired)—if consistently correct (8/10) on large
movementsofthejointsbutinconsistentonsmallmovementsofthejoints(10
°
or less), 2 (normal) if consistently correct on small movements of joints, and
“NT”ifthepatientisunabletounderstandandfollowdirectionsorifunableto
test the joint (i.e., cast or amputation). Deep pressure/pain appreciation of the
limbs is only tested if other sensory modalities are absent and performed by
applyingfirmpressurefor3to5secondsatdifferentlocations(wrist,nailbedof
thethumb,littlefinger,smallandgreattoe,orankle)afterestablishingabaseline
with the patient by applying pressure using the index finger or thumb on the
chin.Scoringis0(absent)ifnopressureisfeltperipherally,and1(present)if
feltreliablywhenpressureisapplied.Itisimportanttorecognizethattheseare
optionaltestswhosescoringhasnotbeenvalidatedandnotusedtoclassifythe
injury. If performed, they can be documented in the comments box on the
worksheet.
MotorExamination
The required elements of the motor examination consist of testing 10 key
muscles:5intheupperlimband5inthelowerlimbon eachsideof thebody
(Table 5.1). Other muscles are also clinically important, but are viewed as
optionalinthattheydonotcontributetothemotorindexscoresor levels.Itis
recommended that the muscles should be examined in a rostral to caudal
sequence,startingwiththeelbowflexors(C5testedmuscle)andfinishingwith
theankleplantarflexors(Slmuscle).Testingofallkeymusclesduringtheinitial
aswellasthefollow-upexaminationsisperformedwiththepatientinthesupine
position, to allow for a valid comparison (and reproducibility) of scores
throughoutthephasesofcare.Musclesaregradedandrecordedonthestandard
worksheet on a six-point scale from 0 to 5 (8). For purposes of inter-rater
reliability, it has been recommended that only whole numbers (not including
plusesand minuses)should beusedwhen comparingdata fromoneinstitution
withanother.
Althougheachofthekeymuscleshasonerootlisted,usuallytwosegments
innervatethesemuscles(i.e.,forbicepsC5andC6).Thekeymuscleshavebeen
chosen because of their consistency for being innervated primarily by the
segmentsindicatedandfortheireaseoftestinginthesupineposition.Inmost
circumstances,ifaparticularmusclehasagradeof3/5,itisconsideredforthe
purposesofthisclassificationtohavefullinnervationbyatleastthemorerostral
nerverootsegment andis consideredusefulforfunctionalactivities. Amuscle
initiallygraded as normal (5/5)wouldbeconsidered to be fullyinnervatedby
bothspinalrootsegments(Figure5.2).
Placing the joints in the proper position during manual muscle testing
(MMT)andstabilizingaboveandbelowthejointtestedisimportantforaccurate
grading, especially if the muscles may have less than antigravity strength (1).
Careful consideration toward muscle substitution masquerading as key muscle
movements must be considered. Common substitutions include forearm
supination mimicking wrist extension (C6), shoulder external rotation
substitutingforelbowextension(C7),wristextensionwithtenodesissubstituting
for long finger flexion (C8), and finger extension appearing as small finger
abduction(T1).Triggeringofco-contractingspasticity(e.g.,useofactiveelbow
flexiontotriggerelbowextension spasms) may also cause inaccuracies in the
motorexamifnotappreciated.Inthelowerextremities,abdominaloradductor
contractionsmayalsoappear(withorwithouttheadditionofspasticity)aship
flexion and ankle dorsiflexion may mimic long toe extension. The InSTeP
training videos are recommended to visualize all of these positions
(www.asialearning.com).
Patients’ clinical condition may prevent the completion of an accurate
examination.Limiting factors such aspainand deconditioning may bepresent
suchthatamuscleonlygradesa4/5.Iftheexaminerfeelsthatthepatientwould
otherwisehavenormalstrength,themuscleshouldbegradedasa5*toindicate
thatinhibitingfactorswerepresentanddocumentedinthecommentboxonthe
worksheet. When the patient is not fully testable for any reason, including
spasticity that prevents accurate stabilizationof the joint, uncontrolled clonus,
severe pain, a fracture present limiting the exam, the cognitivestatus impacts
participation,oracontracturelimitinggreaterthan50%offullrangeofmotion,
theexaminershouldrecordNTinsteadofanumericalscore.
In a patient with a potentially unstable spine, care must be taken when
performing MMT. When examining a newly injured individual with a lesion
below T8 vertebral level, the hip should not be flexed passively or actively
beyond90°,asthismayplacetoogreatakyphoticstressonthelumbarspine.In
thiscircumstance,isometricassessmentofhipflexionisappropriate.
VACistestedbyinsertingalubricatedglovedfingerandaskingthepatient
to “squeeze my finger as if to hold back a bowel movement” and graded as
either present (YES) or absent (NO) in theappropriatebox on the worksheet.
Care must be taken during this exam for patient modesty, as well as to
differentiatevolitionalcontractionfromanalspasmwhenthefingerisinsertedor
analcontractiontriggeredbyValsalva.
A number of optional muscles (diaphragm, deltoids, abdominal muscles,
medialhamstrings,andhipadductors)mayalsobetestedandmaybehelpfulin
determining motor sparing of certain regions of the spinal cord and motor
incompletenessbutare notused toobtainamotorindex score.The diaphragm
can be tested by measurement of the vital capacity or under fluoroscopy.
Movementofthehemidiaphragm two or more inter-spaces generally indicates
normal function. The deltoid, while important with respect to the function it
providesforreachoftheupperextremity,isnotusedformotorscoringbecause
it cannot properly be tested in the supine position. Beevor’s sign can test the
abdominalmuscles(innervatedbyT6–T12).Whileaskingthepatienttoflexthe
neckandtrunk(ahalfsit-upor crunch),ifthepatienthasalesionbetweenT9
andT11,theumbilicuswillmoverostrallybecausetheupperabdominalmuscles
areinnervatedatandaboveT10.AnegativeBeevor’ssign(nomovementofthe
umbilicus with trunk flexion) is present when the abdominals have full
innervationortotalabsenceofabdominalinnervation.Palpatingtheabdominal
muscles during the test helps distinguish between these, as no umbilical
movementwithoutanypalpablecontractionisasignofabsenceofinnervation.
This test should not be performed during the acute stages of thoracic/lumbar
injuries.Thehipadductormuscle,whilenotusedaspartofthemotorscore,is
animportantmuscletomonitor,asitisoftenthefirstmuscletorecoverinthe
lowerextremity.
Although not a part of the ISNCSCI, deep tendon reflex testing may be
usefultoregularlyassessalongwithanalwink andbulbocavernosus reflexfor
identifyingphases ofspinal shock(9)and identification ofupperversus lower
motorneurondysfunction.Spasticityandautonomic assessmentscan alsohelp
providers develop a more comprehensive understanding of an individual’s
deficitsandaredescribedelsewherewithinthistext.
CLASSIFICATIONOFSPINALCORDINJURY
Utilizing a standard method of neurological assessment is important to help
determinethecourseofrecoveryandtheeffectofinterventionsinthetreatment
ofSCI.
Therehavebeen manysystems developedfortheclassificationof SCIthat
havebeenbasedon bonypatterns ofinjury,mechanismofinjury,neurological
function, and functional outcome (10–16). Afull history of the classifications
usedinSCIisreviewedelsewhere(17,18).Inbrief,in1969,Frankeldescribeda
five-gradesystemofclassifyingtraumaticSCI,withadivisioninto“complete”
and“incomplete”injuries(19).In1982,theAmericanSpinalInjuryAssociation
(ASIA) published a booklet Standards for Neurological Classification of SCI
(20) that defined basic terms and examination in SCI, as well as described a
number of anatomically incomplete clinical syndromes. Other scales and
examination techniques have also been described (21–24), some that utilize
additionalmusclegroups,suchasusedintheNASCIStrials(2,24).ElMasryet
al., however, found that the ASIA and NASCIS motor scoring systems are
comparableinrepresentingmotordeficitsandrecovery(25).
Definitions and classifications over the years have changed with multiple
revisions of the Standards. This includes the muscles tested, areas of
dermatomes and key sensory points, terminology used, and the name of the
classification itself. In 1992, the ASIA Impairment Scale (26) replaced the
Frankelclassificationandwasfurtherrevisedin1996,2000,and2011(3)with
anupdate in2015(1). The 1992 standards were endorsed bytheInternational
MedicalSocietyofParaplegia(nownamedtheInternationalSpinalCordSociety
[ISCoS]),andatthattimetermedthe“InternationalStandardsforNeurological
andFunctionalClassificationofSpinalCordInjury.”In2000,whentheFIMwas
removedfromtheStandards(27),theterm“Functional”wasremovedfromthe
name.
FIGURE5.1 Worksheet for theuse of recordingsensory and motor
components.(continued)
Source: American Spinal Injury Association: International Standards for Neurological
Classification of Spinal Cord Injury; Atlanta, GA, Revised 2011, Updated 2015. With
permission.
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