Neurological assessment for asia chart

How to assess neurological deficit in spinal cord injury patient? this slide will give u some of the information.

1. ASIA SCORING Syukran

2. Spinal Cord Conduit for motor and sensory between brain and body Spinal Cord Injury (SCI) affects conduction of Sensory & Motor signals

3. History AMERICAN SPINAL INJURY ASSOCIATION(ASIA) 1982 – First developed the International Standards for Neurological Classification of Spinal Cord Injury 1992 - Revised. Endorsed by International Medical Society of Paraplegia-Renamed International Standards for Neurological and Functional Classification of Spinal Cord injury. 1994 – first published reference manual 2000 - revised and the term “Functional” was deleted from the name 2011- the latest version of ISNCSCI had been published. Kirshblum et al

4. ASIA measures: NEUROLOGICAL LEVEL SENSORY LEVEL MOTOR LEVEL SENSORY SCORE (pin prick and light touch) MOTOR SCORE ZONE OF PARTIAL PRESERVATION

5. Definitions TETRAPLEGIA impairment or loss of sensory and/or motor function in cervical segments. impairment of function in the arms as well as the trunk, legs and pelvic organs. (four extremities) Does not include brachial plexus lesions or injury to peripheral nerves

6. PARAPLEGIA impairment or loss of motor and/or sensory function in the thoracic, lumbar or sacral Arm functioning is spared trunk, legs, pelvic organs may be involved depends on the level eg. Cauda equina and Conus medullaris

7. Myotome refers to the collection of muscle fibers innervated by the motor axons within each segmental nerve (root). Dermatome refers to the area of the skin innervated by the sensory axons within each segmental nerve (root).

8. Neurological level of injury (NLI) refers to the most caudal segment of the spinal cord with normal sensory and antigravity motor function on both sides of the body, provided that there is normal (intact) sensory and motor function rostrally.

9. Sensory level 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 (right and left) and is the most caudal, normally innervated dermatome for both pin prick (sharp/dull dis- crimination) and light touch sensation. This may be different for the right and left side of the body.

10. Motor level The motor level is determined by examining a key muscle function within each of 10 myotomes on each side of the body and is defined by the lowest key muscle function that has a grade of at least 3 providing the key muscle functions represented by segments above that level are judged to be intact. This may be different for the right and left side of the body.

11. Explaining the examination to your PATIENTS This is not a fun exam Uncomfotable Confusing Requires patience

12. 1) Help in determining where the level of Spinal Cord was injured 2) It might be different than what was seen on the MRI or CT Scan 3) This is the main test we use to determine what level the injury was, how severe it was, and a rough idea of what we could expect for recovery The importance of the Exam:

13. Timing of the Examination The initial examination should be done in EMERGENCY DEPARTMENT for Traumatic Spinal Cord Injury Attempt to determine motor level, sensory level, completeness of injury and AIS score However it is difficult to obtain a complete and reliable results in ED Traumatic Brain Injury Pain Respiratory Failure Shock Cognitive Changes Drugs

14. Sensory Key point in each of the 28 dermatomes (from C2 to S4-S5) on the right and left sides Two aspects of sensation are examined: light touch pin prick (sharp-dull discrimination)

15. LIGHT TOUCH wisp cotton applied lightly. Stroke across skin. Not exceed 1 cm Done with eyes close PIN PRICK standard safety pin pointed end for sharpness rounded end for dullness apply light pressure without moving pin after point of contact

16. Sensory Test of Anal Region S4-S5 dermatome Perianal Sensation Deep Anal Sensation

17. Sensory Grading 0 = absent 1   = impaired ( partial or altered appreciation including hyperesthesia) 2   = normal NT = not testable

18. Motor Key Muscles Functions 10 paired myotomes Upper Limb C5-T1 Lower Limb L2-S1 Represent each respective spinal cord segment

19. Manual Muscle Testing Grading Strength Grade Description 5/5 Full Strength, Full ROM 4/5 Provides some strength against resistance for full ROM 3/5 Can perform movement against gravity for full ROM 2/5 Can perform movement with gravity eliminated for full ROM 1/5 Some muscle activity (Palpable or Visible), but unable to move against gravity 0/5 No muscle activity detected

20. Other considerations: The grade must be achieved with FULL RANGE OF MOTION at the given resistance level Not Testable (NT) for limbs that you are not certain of 5/5 strength -could not be tested due to pain/ casting/fracture *NO PLUSES OR MINUSES !!!!!!

21. Positioning for motor examination Neutral position for Grade 3 testing Strategically eliminate gravity for Grade 2 testing When testing for Grade 4 and 5, the muscle is positioned in a manner that partially activates the muscles Patient is instructed to maintain that position C6 Wrist in full extension

22. C5 - Biceps

23. C6 – wrist extensor

24. C7 – triceps

25. C8 – Fingers flexors (DIP)

26. T1 - Small Finger Abductor

27. Its time to complete our asia chart!!!

28. ASIA Impairment Scale Classification 1. Determine sensory level for right and left side The lowest level with a 2 (normal) for both pinprick and light touch where every level higher is also 2 The sensory level may be different on the left and right sides

29. AIS Classification Determine motor levels for right and left sides The lowest level where the muscle grade is at least a 3, with all muscles above graded as a 5 In regions where there is no myotome to test, the motor level is presumed to be the same as the sensory level.

30. AIS Classification 3. Determine the neurological level of injury The highest level of the 4 individual levels

31. AIS Classification 4. Determine whether the injury is Complete or In complete. If complete AIS Grade = A Defined by presence/absence of sacral sparing If NO voluntary anal contraction AND all S4-5 sensory scores are 0 AND there NO deep anal pressure then the injury is complete NOOOON Sign N N O O O O

32. AIS Classification 5. Determine ASIA impairment Scale grade A = Complete. B = Sensory incomplete. C = Motor incomplete. D = Motor incomplete. E = Normal.

33. AIS Classification

34. AIS Classification

35. Zone of Partial Preservation Only defined for AIS A – COMPLETE lesions Lowest dermatome and myotome on either side with any preserved function (even if abnormal)

36. Steven C. Kirshblum et al. Reference for the 2011 revision of the international standards for neurological classification of spinal cord injury. J Spinal Cord Med . 2011 Nov ; 34(6): 547–554.