Introduction[edit | edit source]Spinal Cord Injury can severely impair or cease the conduction of sensory and motor signals, as well as functions of the autonomic nervous system. A systematic examination of dermatomes and myotomes, thus, would allow a clinician to determine the affected segments of the spinal cord. Show
The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), commonly referred to as the ASIA Exam, was developed by the American Spinal Injury Association (ASIA) as a universal classification tool for spinal cord injuries based on a standardized sensory and motor assessment, with the most recent revision published in 2019.[1] It involves both a Motor and Sensory examination to determine the Sensory Level and Motor Level for each side of the body (Right and Left), the single Neurological Level of Injury (NLI) and whether the injury is Complete or Incomplete.[2] International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) ISNCSCI Scoring Outlines and ASIA Impairment Scale (AIS) Sensory Examination[edit | edit source]Key Sensory Points are readily located in relation to bony anatomical landmarks in the dermatomes C2 - S5. They are tested bilaterally using Light Touch (LT) and Pin-Prick (PP) [sharp-dull discrimination]. Equipment common to clinical settings are used, such as a cotton tip applicator for light touch and either a neuro-tip or safety pin for pin-prick. Appreciation of light touch and pin prick sensation at each of the key points is made in comparison to sensation on the patient’s cheek as a normal frame of reference.[2] A three-point scale is used for scoring:
Sensory Level[edit | edit source]It is defined as the most caudal, intact dermatome for both light touch and pin prick (sharp/dull discrimination) sensation. The sensory level is determined by performing an examination of the key sensory points within each of the 28 dermatomes on each side of the body, as above, and may be different for the right and left side. The Sensory Level is the intact dermatome level located immediately above the first dermatome level with impaired or absent light touch or pin-prick sensation, and should be determined for each side of the body as the right and left sides may differ. Up to four sensory levels may be generated for each dermatome: Right Pin-prick, Right Light Touch, Left Pin-prick and Left Light Touch. The overall single sensory level is the most rostral intact sensory point.[2] Sensory Score[edit | edit source]Sensory scores of each dermatome for pin-prick and light touch can be summed across dermatomes and sides of body, right and left, to generate two summary sensory scores: Pin-prick and Light Touch. Normal sensation for each modality is assigned a score of 2. A score of 2 for each of the 28 key sensory points for Light Touch on each side of the body would result in a maximum score of 56 for Light Touch. A score of 2 for each of the 28 key sensory points for Pin-Prick on each side of the body would result in a maximum score of 56 for Pin-Prick. The Total Maximum Sensory Score is 112. The Sensory Score provides a means of numerically documenting changes in sensory function, but cannot be calculated if any required key sensory point is Not Testable.[2] Motor Examination[edit | edit source]Key Motor Functions of the 10 Paired Myotomes C5 - T1 and L2 - S1 are tested bilaterally. Improper positioning and stabilization can lead to substitution by other muscles, and will not accurately reflect the muscle function being graded.[2] A Six-Point Scale is used for scoring:
Patient should be supine-lying for testing, except for the rectal examination that can be performed side-lying. This ensures consistency across tests to allow for a valid comparison from acute stage through to rehabilitation. Each key muscle function should be examined in a cephalo-caudal sequence. Ensure to stabilize both above and below the joint to prevent any muscle substitution during the testing. Move the joints through their full range of movement prior to completing manual muscle testing (MMT), as above, to rule out any pain, spasticity, or contracture which might impact the scores. The hip should not be allowed to actively or passively flex beyond 90° due to the increased kyphotic stress placed on the lumbar spine in any individual with a suspected acute traumatic injury below the T8 level. Instead unilateral, isometric exam should be completed to ensure the contralateral hip remains extended to stabilize the pelvis.[2] International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) Key Motor Function [2]
Motor Level[edit | edit source]The Motor Level is 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). The motor level is determined, as above, by examining the key muscle function within each of the 10 myotomes on each side of the body, and may be different for the right and left side. In regions where there is no myotome that are clinically testable i.e., C1 to C4, T2 to L1, and S2 to S5, the Motor Level is presumed to be the same as the Sensory Level, if testable motor function above that level is also normal.[2] Example 1: If the sensory level is C4, and there is no C5 motor function strength (or strength graded <3), the motor level is C4. Example 2: If the sensory level is C4, with C5 key muscle function strength graded as 4, the motor level would be C5 because the strength at C5 is at least 3 with the “muscle function” above considered normal: presumably if there was a C4 key muscle function it would be graded as normal since the sensation at C4 is intact. Motor Score[edit | edit source]Motor scores for each myotome can be summed across myotomes and sides of body, right and left, to generate a single motor score for each of the upper limbs and lower limbs. Normal strength is assigned a grade of 5 for each muscle function. A score of 5 for each of the five key muscle functions of the upper extremity would result in a maximum score of 25 for each extremity, totaling 50 for the upper limbs. A score of 5 for each of the five key muscle functions of the lower extremity would result in a maximum score of 25 for each extremity, totaling 50 for the lower limbs. In previous versions of a total motor score of 100 for all extremities was calculated but construct validity of the Motor Score as a measure of recovery following spinal cord injury and as an outcome measure for clinical trials is greater when Upper Extremity and Lower Extremity Motor Scores are scored independently and not summated together, therefore it is now recommended to consider Upper Extremity and Lower Extremity Scores separately. The Motor Score, provide a means of numerically documenting changes in motor function, but cannot be calculated if any required muscle function is Not Testable.[2] Determination of Neurological Level of Injury[edit | edit source]The Neurological Level of Injury is determined by identifying the most caudal segment of the cord with intact sensation and antigravity muscle function strength (Grade 3 or more) on both sides of the body, provided that there is normal, intact sensory and motor function rostrally (Grade 5). Sensory Level refers to the most caudal, intact dermatome for both light touch and pin-prick sensation (Score = 2). Motor Level refers to the most caudal myotome with a key muscle function of at least Grade 3 on Motor Examination. If there is a discrepancy between the most caudal intact section between the four possible levels of Right-Sensory Level, Left-Sensory Level, Right-Motor Level, or Left-Motor Level, the Neurological Level of Injury is considered the most cephalad segment of these four levels.[2] ASIA Impairment Scale (AIS)[edit | edit source]Spinal Cord Injuries are classified in general terms of being neurologically “Complete” or “Incomplete” based upon Sacral Sparing, which refers to the presence of Sensory or Motor Function in the most Caudal Sacral Segments i.e. preservation of light touch or pin prick sensation at S4-5 Dermatome, Deep Anal Pressure or Voluntary Anal Sphincter Contraction.[2]
The following ASIA Impairment Scale (AIS) designation is used in grading the degree of impairment: ASIA Impairment Scale (AIS) [2]
Incomplete injuries are further categorized under 5 types as per their clinical presentation. They are:
Zone of Partial Preservation[edit | edit source]Earlier, the Zone of Partial Preservation (ZPP) was only used with Complete Injuries ASIA Impairment Scale - Grade A (AIS A).[2] With the 2019 revision, the ZPP now applies to all cases regardless of the grades of AIS.[1] ZPP refers to the dermatomes and myotomes caudal to the sensory or motor level that remain partially innervated. The extent of the Sensory or Motor ZPP is determined by the most caudal segment with some sensory or motor function respectively, and should be recorded for both right and left sides and for sensory and motor function.[2] Example: If the left sensory level is C6, and some sensation extends from C7 through T1, then “T1” is recorded in the right sensory ZPP block on the worksheet. Motor ZPP is recorded in Incomplete injuries with absent VAC. Sensory ZPP is recorded in the absence of sensory function in S4-5 (LT and PP), as long as DAP is not present. In the presence of DAP, Sensory ZPP should be noted as “not applicable (NA)”. In the absence of DAP, Sensory ZPP can be recorded if there is absence of LT and PP sensation at S4-5, while it should be noted as “not applicable (NA)” if there is presence of LT or PP sensation at S4-5.[1]
Steps in Classification[edit | edit source]Psychometrics[edit | edit source]Reliability[edit | edit source]The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) Sensory and Motor examinations are reliable when conducted by a trained examiner.[5] Both interrater and intrarater reliability were found to be excellent.[6][7] Formal training in the administration of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) Standards has been shown to improve the accuracy of the examiner’s classification.[8] Use of the 2013 Worksheet Revision provides significantly better classification performance and a reduction in misclassification of Motor Level and Neurological Level of Injury since its introduction, except at C2 - 4 Level, which has been suggested may be linked to the body-side based grouping of myotomes and dermatomes on the same horizontal alignment. As such it is recommended that any future revision of the worksheet should maintain the same graphical aspect in the layout.[9] Validity[edit | edit source]The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) are validated for injury classification.[10] Construct validity of the ASIA Motor Score as a measure of recovery following spinal cord injury and as an outcome measure for clinical trials is greater when Upper Extremity and Lower Extremity Motor Scores are scored independently and not summated together.[10] Importance of Patient Explanation[edit | edit source]The ASIA Exam should be completed within 72 hours of the spinal cord injury to reliably predict recovery. The examination is extremely uncomfortable and confusing for individuals, particularly because they have recently gone through significant trauma. Explaining why we do the test and what is it entails is vital to make individuals more comfortable during the exam.[8] The clinician must inform subjects that this test will help us determine the location of injury to the spinal cord, its severity, and gauge prognosis through time.[2] Often, the International Standards for Neurological Classification of Spinal Cord Injury and ASIA Impairment Scale paint a different picture in comparison to what is seen on an MRI or CT scan. Resources[edit | edit source]International Standards for Neurological Classification of Spinal Cord Injury: Assessment Forms
International Standards for Neurological Classification of Spinal Cord Injury: Sensory and Motor Guides
ASIA E-Learning Centre InSTeP: International Standards
ASIA E-Learning Centre ASTeP: Autonomic Anatomy & Function
References[edit | edit source]
How would the nurse document normal muscle strength?A common method of evaluating muscle strength is the Medical Research Council Manual Muscle Testing Scale. This method involves testing key muscles from the upper and lower extremities against gravity and the examiner's resistance and grading the patient's strength on a 0 to 5 scale.
Which score on the muscle strength scale will the nurse document for a patient who can perform active movement against gravity and some resistance quizlet?Muscle rating 4 is given when the client is able to perform active motion against some resistance. When the client is able to perform active movements against gravity, the muscle strength is graded as 3. If the client is able to perform passive ROM, the muscle strength is rated as 2.
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