Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6022_Библиотеки_им_академика_М_И_Перельмана
.pdf
FIGURE5.1(continued)Backsideofworksheet.
DEFINITIONSOFTERMSINSPINALCORD
INJURY
Tetraplegia,preferredtothetermquadriplegia,isdefinedasimpairmentorloss
ofmotorand/orsensoryfunctioninthecervicalsegmentsofthespinalcorddue
todamageofneuralelementswithinthespinalcord.Itdoesnotincludebrachial
plexus lesions or injury to the peripheral nerves outside the neural canal (1).
Tetraplegiaresultsinimpairmentoffunctioninthearmsaswellaspossiblythe
trunk, legs, and pelvic organs. Paraplegia refers to an impairment of motor
and/or sensory function in the thoracic, lumbar, or sacral (but not cervical)
segmentsofthespinalcordsecondarytodamageofneuralelementswithinthe
spinalcanal. Withparaplegia,armfunctioning isspared,but dependingonthe
levelofinjury,the trunk, legs, and pelvicorgansmay be involved. Paraplegia
can also refer to cauda equina (CE) and conus medullaris injuries, but not
lumbarsacral plexus lesions or injuries to peripheral nerves outside the neural
canal. The terms quadriparesis (tetraparesis) and paraparesis are discouraged
becausetheydescribeincompletelesionsimprecisely.
Thesensorylevelisthemostcaudaldermatometohavenormal(scoreof2)
sensation for both sharp/dull discrimination and LT. This is determined by a
gradeof 2(normal/intact) inalldermatomes beginningwith C2andextending
caudallytothefirstsegmentthathasascoreoflessthan2foreithersharp/dull
discriminationorLT.Theintactdermatomelevellocatedimmediatelyabovethe
first dermatome level with impaired or absent light touch or pin sensation is
designatedasthesensorylevel.Astherightandleftsidesmaydiffer,thesensory
levelshouldbedeterminedforeachside.For a single sensory level, the most
rostralofallistaken.
Ifsensationisabnormal atC2,thesensorylevelisdesignated asC1(1).If
sensationisintactthroughS4–S5,thesensorylevelshouldberecordedasintact
(“INT”) rather than as S4–S5. If the patient is unable to reliably appreciate
sensationwhentestedontheface,then“NT”shouldberecordedand“ND”(not
determinable) should be documented in theappropriatearea on the worksheet
withnosensorylevelgiven.Sensoryindexscoringiscalculatedbyaddingthe
scoresforalldermatomes,foratotalscorepossibleof112(56oneachside)for
sharp/dull discrimination and LT. If “NT” has been documented at any level,
thenasensoryscorecannotbecalculated.Thesensoryscoreprovidesameansof
numericallydocumentingchangesinsensoryfunction.
FIGURE5.2Muscleinnervationbylevelofinjury.
Source: American Spinal Injury Association: International Standards for Neurological
Classification of Spinal Cord Injury; Atlanta, GA, Revised 2011, Updated 2015. With
permission.
Themotor level is definedasthe lowest keymusclethat hasagrade of at
least3,providingallkeymusclesrepresentedbysegmentsrostraltothatlevel
are graded as 5 (1). The motorlevel maydifferby side ofthe body; a single
motorlevelwouldbethemorerostralofthetwo.If“NT”hasbeendocumented
aspartoftheexam,andthismuscleisrequiredfordeterminationofthemotor
level,thedesignationofthemotorlevelforthatsideshouldbedeferredandND
isdocumentedontheworksheet.
FormyotomesthatarenotclinicallytestablebyMMT(i.e.,aboveC5,T2–
L1,andS2–S5),theyareassumedtohavefullinnervationifsensoryinnervation
forsharp/dull discrimination and LTatthe corresponding level are also intact.
For example, if the sensory level is C4 and there is no C5 motor function
strength(orstrengthgradedas<3),themotorlevelisC4.Inthecasewherethe
C5motorfunctionisgradedatleast3onbothsidesofthebody,withasensory
levelontherightofC3andontheleftofC4,withimpairedsensationatC4on
theright,themotorlevelontherightwouldbeC3(andC5ontheleft).Sincethe
C4dermatomeonthe rightisimpaired,itispresumedthattheC4myotomeis
alsoimpaired.Therefore,themotorlevelisdesignatedasC3,sincethe patient
doesnotmeetthecriteriaofhavingakeymusclefunction(inthis casetheC5
muscle)≥3/5withalllevelsabove(inthiscaseincludingC4)scoringasnormal.
On the left side, the C4 dermatome is normal so that the C4 myotome is
considerednormal,andasaresulttheleftmotorlevelisC5.
If,forexample,allupperlimbkeymusclefunctionsarenormal,withintact
sensationtoT6,themotorleveldeferstothesensorylevelandisrecordedasT6.
Ifhowever,withaT6sensorylevel,theT1musclefunctionisgradeda3(ora4)
insteadofa5,whileT6isstillthesensorylevel,themotorlevelwouldbeT1,as
allthemusclelevelsabovetheT6levelarenotnormal.
Itisimportanttorecognizeanddocumentifneurologicdeficitisunrelatedto
SCI. For example, in a patient with a thoracic level injury who also has a
brachial plexus injury, a note should be made in the comment box on the
worksheettocorrectlyclassifythepatient’sspinallevelofinjury(thoraciclevel),
ratherthanassigningahigher(cervical)levelduetoanon-SCI-relatedinjury.
Motorindexscoringiscalculatedbyaddingthemusclescoresofeachkey
musclegroup.Inthepast,atotalmotorscoreof100(25foreachextremity)was
calculated, but it is no longer recommended to add the upper and lower limb
scores together.Rather it is recommended to separate the motor scores into 2
scores:one forthe upperlimbsand onefor thelowerlimbs(1,28).Themotor
scoresprovideameansofnumericallydocumentingchangesinmotorfunction.
If“NT”hasbeendocumentedforanymuscle,thenamotorindexscorecannot
becalculated.
Theneurologicallevelofinjury(NLI)referstothemostcaudalsegmentof
thespinalcordwithnormalsensoryandatleastantigravitymusclefunctionon
bothsidesofthebody,providedthatthereisnormal(intact)sensoryandmotor
functionrostrally. Motorandsensorylevelsarethesamein<50%ofcomplete
injuries,andthemotorlevelmaybemultiplelevelscaudaltothesensorylevelat
1yearpostinjury(29).
Thesingleneurologicallevelisthesinglemostcaudallevelsatwhichboth
motor and sensory modalities are intact on both sides of the body (i.e., the
highest of all the motor and sensory levels). If the motor level is C7 and the
sensorylevelisC8,theoverallsingleNLIisC7.The(single)NLIisusedwhen
determiningthe ASIAImpairmentScale (AIS)grade, especially differentiating
AISCfromD.
The motor level and upper extremity motor index score better reflect the
degreeoffunctionaswellastheseverityofimpairmentanddisability,relativeto
theNLI,aftermotorcompletetetraplegia(29).Thisisbecausethesensorylevel
mayplacetheneurologiclevelmorerostral,therebyincorrectlyimplyingpoorer
motorfunction.
The zone of partial preservation (ZPP) is defined as the dermatomes and
myotomes caudal to the sensory and motor levels that remain partially
innervatedinan individualwith aneurologicallycomplete(AISA) injury(see
the following section) (1). The ZPP should be recorded on the worksheet by
documentingthemostcaudalsegmentwithsomesensoryand/ormotorfunction.
AsinglesegmentforeachZPPratherthantheentirerangeofpartiallyinnervated
segments should be documented. For example, in an individual with AIS A
tetraplegia,iftherightsensorylevelisC5andsome sensation extends to C8,
then C8 is recorded as the right sensory ZPP. For ZPP description, motor
functiondoesnotfollowsensoryfunction(i.e.,inacaseofaT6levelofinjury,
impairedsensation(1/2)atT7doesnotimplythatthereisintact/impairedmotor
function at T7). If there is no ZPP (no partially innervated segments below a
motororsensorylevel),themotororsensorylevelshouldbeenteredastheZPP
(1).Withanincompleteinjury,theZPPisnotapplicable,and“NA”isrecorded.
A neurological complete injury is defined as the absence of sensory and
motor function in the lowest sacral segments (no sacral sparing), and an
incomplete injury as partial preservation of sensory and/or motor function as
determined by examination of the most caudal segment (S4–S5) (sacral
sparing).Sacralsparingistestedbysharp/dulldiscriminationandLTattheanal
mucocutaneous junction (S4/S5 dermatome) on both sides, as well as testing
VAC of the external anal sphincter (themotoraspect)and DAPaspart of the
rectal examination. If any of these are present (representing sacral sparing),
intact or impaired, even on one side, the individual has an incomplete injury.
Accordingto this definition, apatientwith cervical SCI canhavesensoryand
motor function in the trunkor even in the lowerextremities but unless sacral
sparingispresent,theinjuryisclassifiedas“complete”withalongZPP.When
sacral sparing is used to define incompleteness intheacute phase post injury,
motorrecoveryissignificantlymorelikelytooccurthanwhenitisnot(30).The
“sacralsparing”definitionofthecompletenessoftheinjurywasadoptedbythe
ASIAStandardsCommitteein1992(26).Priortothis,aninjurywasconsidered
“incomplete”ifmotororsensoryfunctionextended>3levelsbelowtheinjury.
The sacral sparing definition has been considered a more stable definition,
because fewer patients convert from incomplete to complete status during
neurologicrecoveryintheacuteandsubacuteperiod.
The ASIA Impairment Scale (AIS) has five grades, which are listed in
Table5.2.ThedeterminationoftheAISisdescribedinTable5.3.
AISA:Motorandsensorycomplete—nosacralsparingincludingsharp/dull
discriminationorLTsensationatanyoftheS4–S5dermatomes;noVACandno
DAP. In this case, a ZPP is documented on the worksheet. If the injury is
complete, the standardized worksheet will read “N-O-O-O-O-N” across the
bottom—“no”forVAC,thefour0’sfornoS4–S5sensationforLTorsharp/dull
discriminationmodalitiesoneithersideofthebody,and“no”forDAP(2).
AIS B: Motor complete and sensory incomplete. Sensory but not motor
functionispreservedatthemostcaudalsacralsegmentsS4–S5,ANDnomotor
functionispreservedgreaterthan3levelsbelowthemotorleveloneithersideof
thebody.
AISC: Motor incomplete: Motor function is preserved at the most caudal
sacralsegmentsonVACORthepatientmeetsthecriteriaforsensoryincomplete
status(sensoryfunctionpreservedatthemostcaudalsacralsegments(S4–S5)by
LT, sharp/dulldiscrimination,or DAP), with sparingofmotor function greater
than3 levelsbelowthe ipsilateral motorlevel on eithersideof thebody. This
includeskeyornon-keymusclefunctionstodeterminemotorincompletestatus.
(Theuseofnon-keymuscleswillbeexplainedinthefollowingsection.)ForAIS
C—less than half of the key muscle functions below the NLI have a muscle
gradeof≥3.
Ifapatienthasasensoryincompletelesionandabsenceofallthekeymuscle
groups below the level but has the presence of VAC, the appropriate
classificationisAISC.Ina caselikethis,however,oneshouldbecarefulthat
theyare feeling the anal sphincter volitionally contract rather than contracting
gluteal muscles or a reflex sphincter contraction (as noted earlier). When in
doubt,the patient should be scored as not having volitional contraction of the
analsphincter(31).
Once a patient is classified as having a motor incomplete injury, it is
importantto distinguishbetween anAIS CandD. Injuriesare classifiedas an
AISCifmorethanhalfofthekeymusclesbelowthesingleNLIofthepatient
aregradedaslessthan3/5.
AIS D: Motor incomplete status as mentioned earlier (specifically motor
functionispreservedbyVACORthepatientmeetsthecriteriaforsacralsensory
incompletestatus,withsparingofmotorfunctiongreaterthan3levelsbelowthe
ipsilateral motor level on either side of the body), with at least half (half or
more)ofthekeymusclesbelowthesingleNLIhavingamusclegradeof≥3.
ItisimportanttonotethattodistinguishanAISCversesD,themotorscores
belowthesingleNLIareused,whereastodistinguishbetweenanAISBversusa
C,themotor level on each side of the body isused. Thereason forusing the
motorleveltodistinguishanAISBversusCistoavoidthepossiblesituation
whenapatientmayregainsensationinasingleadditionalcaudallevel,changing
theAISfrom“C”toa“B.”Forexample,ifapatientinitiallyhadamotorlevel
ofC5andasensorylevelofC4withsensorysparingatS4/S5andsomemotor
sparingonlyin C6–C8,using theneurologicallevel,thispatient wouldqualify
forAISC(becauseC8motoris>3levelsbelowtheneurologicallevel[C4]).If
the patient regains normal sensation over time in the C5 dermatome (with no
otherchanges),theneurologicallevelbecomesC5,andthepatientwouldrevert
fromanAIS CtoaBbecauseC8isno longergreaterthan3levelsbelowthe
neurologiclevel,indicating“worsening” despiteneurologic improvement.This
isavoidedbyusingthemotorlevel,sincethedesignationisindependentofthe
sensorylevel.
AIS E: All components of the standardized neurological examination are
normal. The grade E is used in follow-up when testing an individual with a
previously documented SCI that has recovered normal function. If no
neurologicaldeficitsarefoundatinitialtesting,thentheAISdoesnotapply.
TABLE5.2ASIAImpairmentScale
A
Complete
NomotororsensoryfunctionispreservedinthesacralsegmentsS4–S5.
BSensory
Incomplete
SensorybutnotmotorfunctionispreservedatthemostcaudalsacralsegmentsS4–S5,ANDno
motorfunctionispreserved>3levelsbelowthemotorleveloneithersideofthebody.
CMotor
Incomplete
Motorfunctionispreservedatthemostcaudalsacralsegments(S4–S5)onVACORthepatient
meetsthecriteriaforsensoryincompletestatus(sensoryfunctionpreservedatthemostcaudal
sacralsegments[S4–S5]byLT,PP,orDAP),withsparingofmotorfunction>3levelsbelowthe
motorleveloneithersideofthebody.Thisincludeskeyornon-keymusclefunctions>3levels
belowthemotorleveltodeterminemotorincompletestatus.ForAISC—lessthanhalfofkey
musclefunctionsbelowthesingleNLIhaveamusclegrade≥3.
DMotor
Incomplete
Motorincompletestatusasdefinedabove,withatleasthalf(halformore)ofkeymuscle
functionsbelowthesingleNLIhavingamusclegrade≥3.
ENormal IfsensationandmotorfunctionastestedwiththeISNCSCIaregradedasnormalinall
segments,andthepatienthadpriordeficits,thentheAISgradeisE.SomeonewithoutaSCI
doesnotreceiveanAISgrade.
AIS,ASIAimpairmentscale;DAP,deepanalpressure;ISNCSCI,internationalstandardsforneurological
classificationofspinalcordinjury;LT,lighttouch;NLI,neurologiclevelofinjury;PP,partialpreservation;
SCI,spinalcordinjury;VAC,voluntaryanalcontraction.
Source:AmericanSpinalInjuryAssociation:InternationalStandardsforNeurologicalClassificationof
SpinalCordInjury;Atlanta,GA,Revised2011,Updated2015.Withpermission.
TABLE5.3StepsinClassifyingtheInjuryAccordingtotheAIS
a. Determinesensorylevelsforrightandleftsides.
• Startingfromthetopoftheflowsheetforsensoryfunction,godowntheworksheetuntilyouseea“1”or
“0.”
• Goingup1levelgivesyouthesensorylevel.
b. Determinemotorlevelsforrightandleftsides.
• Themotorlevelisthemostcaudalkeymusclegroupthatisgraded≥3/5withallsegmentsabovegraded
5/5strength.
• Inregionswherethereisnomyotometotest,themotorlevelispresumedtobethesameasthesensory
level,iftestablemotorfunctionabovethatlevelisalsonormal.
c. Determinetheneurologicallevelofinjury.
Themostrostralofthesensoryandmotorlevelsdeterminedinsteps1and2.
d. Determinewhethertheinjuryiscompleteorincomplete(sacralsparing).
Sacralsparing=sensoryormotorfunctioninthelowestsacralsegmentsthatincludesPPorLTatS4–
S5,VAC,orDAP.
e. DetermineAISgrade:
1. Isinjurycomplete(i.e.,nosacralsparing)?
Ifyes,AIS=A;andrecordZPPifpresent.
2. Ifincomplete,isinjurymotorincomplete?
• No:AIS=B.(AISBreferstoacasewherethereisnoVACORmotorfunction>3levelsbelowthe
motorlevelonagivenside,ifthepatienthassensoryincompleteclassification).
• Yes:presenceofVACORmotorfunction>3levelsbelowthemotorlevelonagivensideifthe
patienthassensoryincompleteclassification.
3. Ifmotorincomplete,are≥50%thekeymusclesbelowtheneurologicallevelgraded3orbetter?Ifno–
AIS=C.Ifyes–AIS=D.
4. Ifsensationandmotorfunctionisnormalinallsegments,AIS=E.
• Note:AISEisusedinfollow-uptestingwhenanindividualwithadocumentedSCIhasrecovered
normalfunction.Ifnodeficitsarefoundatinitialtesting,theindividualisconsideredtobe
neurologicallyintact,andtheASIAImpairmentScaledoesnotapply.
AIS,ASIAimpairmentscale;DAP,deepanalpressure;LT,lighttouch;PP,partialpreservation;SCI,spinal
cordinjury;VAC,voluntaryanalcontraction;ZPP,zoneofpartialpreservation.
When a component of the scoringand classification cannot be determined
(e.g., the sensory level, motor level NLI, AIS grade, or ZPP) based upon the
examination,“ND”(notdeterminable) should beappropriately documented on
theworksheet(1).Forexample,if“NT”(nottestable)isusedinthescoringfor
the examination, and the motor, sensory or NLI, or AIS grade cannot be
determined based upon this, then “ND” should be used for thedesignation of
these levels and AIS grade on the worksheet. The reason for the “NT” grade
shouldbedocumentedinthe“Commentsbox.”
Iftherearenon–SCI-relatedcausesofweakness,thisshouldbedocumented
and taken into account when classifying the injury (32). For example, in a
patientwithaT8fractureandcompleteparaplegiawhoalsohasaleftbrachial
plexusinjury,notationshouldbemadethatthesensoryandmotordeficitsinthe
leftarmareduetobrachialplexusinjury,notSCI,andthepatientmay stillbe
classifiedwithanNLIofT8.
Havingawell-definedclassificationofSCIallowscliniciansandresearchers
to study the effects of drug and rehabilitation interventions and determine
prognosis. The AIS is currently the most valid and reliable classification to
assess SPI and is used by the National Spinal Cord Injury Database.
Computerized classifications programs have been developed utilizing this
schema (33,34), and algorithms are available at www.ISNCSCIalgorithm.com
andhttp://ais.emsci.org. A number of articles have posed challengingcases as
wellassomepotentialimprovementstotheclassification(32,35–39);however,
theclassificationatthistimehasremainedunchangedsince2015.
Non-KeyMuscles
IncaseswhereanindividualappearstohaveaclassificationofAISB,non-key
muscles(seeTable5.4)greaterthan3levelsbelowthemotorleveloneachside
shouldbeadditionallytested(1).Asdiscussedpreviously,thepresenceofactive
non-keymusclesgreaterthan3levelsbelowthemotorlevelindicatesanAISC
injuryasopposedtoAISB(1).Non-keymusclesdonotneedtobeexaminedas
aroutinepartoftheISNCSCIexamination,butonlyinsuspectedcasesofAISB
versusAISC.Thepresenceofanymusclefunctioninthesemusclesshouldbe
documentedinthecommentssectionoftheworksheet.
RELIABILITYOFEXAMINATION
Theexaminationandclassification(useoftheISNCSCI)hasbeenfoundoverall
to be valid, reliable, and sensitive to change, most especially in patients with
neurologically complete injuries (39–46). The amount of training plays an
important role in understanding and performing the examination and
classificationschemaduetoimpactonreliability(40,45,46).
Cohenetal. foundhigh reliabilityoftheLT, sharp/dulldiscrimination,and
motorscores; inter-raterreliabilityvaluesranged from.96to.98,and intra-rater
reliabilityvalueswere .98to .99(40).Marinoetal. alsodemonstrated thatthe
motor and sensory examination is reliable, with inter-rater reliability of the
motorexamof.97,LT–.96,andsharp/dulldiscrimination.88,whenconducted
bytrainedexaminers.Sharp/dulldiscriminationscoreshadthelowestreliability,
possiblybecauseof thecomplexity ofdifferentiatingsharpfromdullsensation
(41).
TABLE5.4Non-KeyMusclesforISNCSCIClassificationofIndividualsasAIS
CVersusAISB
MOVEMENT ROOTLEVEL
Shoulder:Flexion,extension,adduction,internal,andexternalrotation
Elbow:Supination
C5
Elbow:Pronation
Wrist:Flexion
C6
Finger:Flexionatproximaljoint,extension
Thumb:Flexion,extension,andabductioninplaneofthumb
C7
Finger:FlexionatMCPjoint
Thumb:Opposition,adduction,andabductionperpendiculartopalm
C8
Finger:Abductionoftheindexfinger T1
Hip:Adduction L2
Hip:Externalrotation L3
Hip:Extension,abduction,internalrotation
Knee:Flexion
Ankle:Inversionandeversion
Toe:MPandIPextension
L4
HalluxandToe:DIPandPIPflexionandabduction L5
Hallux:Adduction S1
AIS,ASIAimpairmentscale;DIP,distalinterphalangeal;IP,interphalangeal;ISNCSCI,international
standardsforneurologicalclassificationofspinalcordinjury;MCP,metacarpophalangeal;MP,
metatarsalphalangeal;PIP,proximalinterphalangeal.
Source:AmericanSpinalInjuryAssociation:InternationalStandardsforNeurologicalClassificationof
SpinalCordInjury;Atlanta,GA,Revised2011,Updated2015.Withpermission.
Thereliabilityofindividualdermatomeandmyotomescoresislessthanthat
forsummedscores(42,43).DuetotheISNCSCIhavingnopalmarsensorytest
location, the GRASSPmay potentially be a more sensitive measure to assess
upper limb function following tetraplegia (47). Given that pin testing is the
principle assessment responsible for determining the level of injury (48), a
modifiedandshorterexaminationmaybeindicated.Furtherstudyisunderway.
PEDIATRICCONSIDERATIONS
The examination in the pediatric population is well described in the ASIA
learning center site as part of the WeeSTeP (http://www.asia-
spinalinjury.org/learning/). The comprehensive examination of the ISNCSCI is
reportedly too complex for the cognitive abilities and tolerance of children
youngerthan6yearsold(49,50),andsomepatientsasoldas8yearsmayhave
difficultywiththeexam(49,51).Althoughthereishighinter-raterreliabilityof
repeated ISNCSCI motor and sensory scores in children with chronic SCI in
thoseovertheageof6,forchildrenlessthan6yearsold,theirsensory,motor,
and neurological level of injury should be estimated by way of a clinical
examination and documented as estimates as opposed to documentation of
definitivelevelsbasedupontheISNCSCI.
Becausetheexamcanbetimeconsuming,bothforthepediatricpatientand
theexaminer,ashortenedexaminationwith16dermatomestested(asopposedto
56dermatomes)was studied and found to provide good correlationtothefull
examination (52). This shortened exam may be useful for evaluating children
withSCIwhocannottoleratethefullexam.
Vogeletal.reportedthattherewasgoodagreementonrepeatedpinprickand
lighttouch sensationat S4–5(anorectal)inthepediatric populationfor allage
groupsand typesof injury(tetra/paraplegia)(7). However,for DAPand VAC,
therewasweakeragreementinmanyoftheyoungeragegroups.Therefore,the
useoftheanorectalexaminallchildren/youthfordesignationofinjuryseverity
orclinicalresearchtrialsisnotnecessarilysupported(7).
Соседние файлы в папке Библиотека им академика М.И. Перельмана