SCI (Spinal Cord Injury) (alternate).pdf

About types of SCI and classification of it

1. ASIA –A KEY GUIDE IN THE
CLINICAL ASSESSMENT AND
DIAGNOSIS OF SCI

2. To review the basics of SCI
To learn the ASIA classification for SCI
patients
To gain competence in SCI diagnosis and
management using ASIA classification.

8. Dorsal columns
Anterior and Lateral
Spinothalamic tract

12. SCI ETIOLOGY 2005

14. 24.9%
50.8%
4.9%
10.3%
2.7%1.6% 3.2% 0.0% 1.1% 0.5%
26.5%
54.1%
4.9%
11.4%
3.2%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
TransportationUnintentional
Fall
Sports
/Recreation
Assault Self-
Inflicted
Others
SCI Registry in January 2005 to December 2009,
Males Females Overall

17. Rates appear to be 40 new
cases /million population
10,000 cases per year
4 cases/ million population
Incident rate of fatal SCI
before hospitalization
(1989-1991)

18. 2 methods
Mathematic calculation
Average duration within
the geographic area
176,965 in 1988
As of June 2006:
253,000
Predicted prevalence in
2014 = 276,281
Trend towards increase:
results exclusively from
improved life expectancy

19. Age
47% 15-29 y/o
27% 30-44 y/o
12% 45-59 y/o
11% > 60 years old
3% < 15 years old
Most common age at injury : 19 years
NSCIS 1973-1999

21. The most common age affected is 17 years which is comparable
to the NSCISC Annual Report in 2007 that reports 19 years as
the most common age in cumulative frequency distribution of
age at injury.
Table 2: Patients Enrolled in the SCI Registry from Jan 2005 to April 2009,
by Age and Sex Distribution
Age Group Males Females Overall
0-15 11 8 19
16-30 87 10 97
31-45 70 14 84
46-60 47 3 50
61-75 10 2 12
76-98 0 0 0
225 37 262

22. Male Female
Before 1980 81.7% 18.2%
Since 2000 77.8% 22.2%

24. Majority of patients
are males
Consistent with
demographic study
of SCIs in other
countries
86%
14%
Figure 1. Sex Distribution of Patients
Enrolled in the SCI Registry from
January 2005 to April 2009
Male Female

25. Complete
Absent sensory and
motor function in
lowest sacral
segment

26. Incomplete
(+) Sensory and
Motor
Sacral sparing

28. Most common
Cervical injuries (mid
to lower segments)
Motor weakness
UE>LE, bladder
dysfunction, sensory
loss below the level of
the lesion
hyperextension injuries

29. hemisection of the
spinal cord
ipsilateral motor
paralysis
contralateral
sensory hypesthesia
penetrating lesion

30. anterior 2/3 of cord,
and is related to
vascular insufficiency,
sparing the posterior
columns
bony fragments or
retropulsed disk
complete motor
paralysis and sensory
anesthesia
worst prognosis of all
cord syndromes

31. Least common
Preservation of
pain, temperature
and touch
appreciation
Poor prognosis for
ambulation

32. Conus medullaris –
inferior aspect of L1
Epiconus – segment
above the conus
(L4-S1)

33. SYMPTOM CONUS
MEDULLARIS
CAUDA EQUINA
Pain
Bowel and bladder
reflexes
Anal and BC reflexes
Muscle tone
Muscle stretch reflexes
Symmetry of weakness
Sensation
Recovery prognosis
Uncommon
Absent
Absent
Depends
Depends
Yes
Absent in saddle dist.
And may be dissoc.
Limited
Very common and severe
Absent
Absent
Decreased
Decreased
No
In root distribution
Possible

34. Assessment of Spinal Cord Injury

35. Promote standards
of excellence of
health care in SCI
patients
Educate health
providers
Research and
development
Multidisciplinary
Approach

36. Evidence-based
Valid, reliable, consistent
Allow Prognosis
◦Neurological
◦Functional (Rehabilitation goals)
Allows study of interventions
◦Rehabilitation
◦Drugs

37. Motor Examination Sensory Examination

38. Other required elements:
Determination of Sensory level, Motor level &
Neurologic level
Sensory and motor index scores
Complete/Incomplete
Classification of the impairment

39. ❑Motor level
❑Motor index score
❑Sensory level
❑Sensory index score
❑Neurologic level of
injury
❑Complete injury
❑Incomplete injury
❑Skeletal level
❑Zone of partial
preservation (ZPP)

40. Sensory Exam
◦28 sensory “points”
◦Test pinprick/dull and
light touch
Importance of sacral
pin testing
◦3 point scale (0,1,2)
◦“optional”:
proprioception & deep
pressure to index and
great toe (“present vs
absent”)
◦deep anal sensation
recorded “present vs
absent”

42. 10 key muscles
Examined in a rostral
to caudal sequence
Testing of all the key
muscles
Graded from 0 to 5

43. Myotome Dermatome
C5 Biceps Lateralside of the antecubital fossa
C6 ECRL Thumb
C7 Triceps Middle finger
C8 FDP Little finger
T1 Abd. digiti minimiMedial side of the antecubital fossa
L2 Ilio-psoas Mid-anterior thigh
L3 Quadriceps femorisMedial femoral condyle
L4 Tibialis anterior Medial malleolus
L5 EHL Dorsum of thefoot 3
rd
MTP joint
S1 Gastroc-soleus Lateral heel

44. C2 Occipital protruberance
C3 Supraclavicular fossa
C4 Top ofthe acromio-clavicular joint
T2 Apex ofthe axilla
T4 Nipple line
T6 Xiphoid process
T10 Umbilicus
T12 Inguinal ligament
S2 Popliteal fossa in themidline
S3 Ischial tuberosity
S4-S5 Perianal area

45. 6 point scale (0-5) …..(avoid +/-’s)
◦0 = no active movement
◦1 = palpable muscle contraction
◦2 = movement thru ROM w/o gravity
◦3 = movement thru ROM against gravity
◦4 = movement against some resistance
◦5 = movement against full resistance

46. A = complete paralysis
B = sensory only
C = motor useless
D = motor useful
E = Recovery
❑ Replaced in 1992 by ASIA Impairment Scale
(AIS)

48. AIS-A: Complete; (-) Motor; (-) sensory
AIS-B: (+) Sensory; (-) Motor
AIS-C: (+) Motor; more than half of the key
muscles graded <3/5
AIS-D: (+) Motor; more than half of the key
muscles graded 3 or more
AIS-E: Normal Recovery

49. Determine
sensory
level for
right & left
side
Determine
motor level
for right &
left side
Determine
the single
neurological
level
Determine
whether the
injury is
complete or
incomplete
Determine
ASIA
impairment
scale grade

50. 1. Determine the sensory level for right and
left sides.
Eg. Thumb, right
 Middle finger, left

51. 2. Determine motor
levels for right and
left sides.
right left
C5 5 5
C6 5 4
C7 3 3
C8 3 2
T1 1 1

52. Determine the single neurological level
◦Same motor & Sensory levels both sides
Myotome right left
C5 5 5
C6 5 4
C7 3 3
C8 3 2
T1 1 1
dermatome right left
C2 2 2
C3 2 2
C4 2 2
C5 2 2
C6 2 2
C7 2 2
C8 1 1
T1 1 1

53. COMPLETE INCOMPLETE.

54. Is injury
complete?
Yes
AIS - A
Record
ZPP
No
Is injury
incomplete
AIS - B
Yes
Are at least half of the key
muscles below the
neurological level graded 3
or better?
AIS - D
AIS - CNo
If sensation and motor function is
normal in all segments →AIS -E

55. L
E
7- Complete Independence
6- Modified Independence
NO HELPER
V
E
L
S
Modified Dependence
5- Supervision (subject -
100%)
4- Min. Assist ( 76%+)
3- Mod. Assist (50%+)
Complete Dependence
2- Max. Assist (25%+)
1- Total assist (less 25%)
HELPER

56. Self Care:
A. Self Care
B. Grooming
C. Bathing
D. Dressing Upper body
E. Dressing lower body
F. Toileting
Sphincter Control
G. Bladder Management
H. Bowel Management
Transfer
I. Bed, Chair, W/C
J. Toilet
K. Tub, Shower
Locomotion
L. Walk/W/C
M. Stairs
Communication
N. Comprehension
O. Expression
Social Cognition
P. Social Interaction
Q. Problem Solving
R. Memory
Motor Subtotal Score Cognitive Subtotal Score

57. PREDICTING THE OUTCOME
ON TRAUMATIC SCI

58. “All subjects with cervical cord lesion would
improved one neurological level.”
Introduced prognosis of neurological
recovery in cervical lesions and walking based
on clinical syndromes
C5 C6; C6 C7
Stauffer ES. Diagnosis and prognosis of acute cervical spinal cord
injury. Clin Orthop 1975;112:9

59. “The accuracy, frequency thoroughness and
timing of the neurologic assessment during
the first week after injury is essential to
predicting the motor recovery of individuals
with SCI.”
Kirshblum SC et.al. Levels of spinal cord injury and predictors of
neurologic recovery. Phys Med Rehabil Clin North Am 2000

60. A 48 year old, male sought consult at the E.R.
after sustaining a spinal cord injury due to
fall from a roof top at the height of typhoon
“Ondoy” 3 weeks ago.
The motor and sensory examination are as
follows:

61. Right Left
C5 (Biceps) 5 5
C6 (ECRL) 5 5
C7(triceps) 3 3
C8(FDP) 1 1
T1 (AbdDM) 1 1
L2(iliopsoas) 0 0
L3(Quads) 0 0
L4(tibialis Ant.) 0 0
L5(EHL) 0 0
S1 (gastroc-soleus) 0 0

62. Right Left
C2-C7 2/2 2/2
C8-S3 0/2 0/2
S4-S5 1/2 1/2

63. A.C5
B.C6
C.C7
D.C8
Commentary: since C7 is the most caudal dermatomallevel
having an intact sensation
Right Left
C2-C72/2 2/2
C8-S30/2 0/2
S4-S51/2 1/2

64. A.28/112
B.30/112
C.56/112
D.70/112
Commentary: adding the sensory scores of all
dermatomes on both sides will give you a sum of 28

65. A.C5
B.C6
C.C7
D.C8
Commentary:
since C7 is the most caudal key muscle having a grade of 3 with a
muscle above it has a grade of 5 or normal
Right Left
C5 (Biceps) 5 5
C6 (ECRL) 5 5
C7(triceps) 3 3
C8(FDP) 1 1
T1 (AbdDM) 1 1
L2(iliopsoas) 0 0
L3(Quads) 0 0
L4(tibialis Ant.) 0 0
L5(EHL) 0 0
S1 (gastroc-
soleus)
0 0

66. A.25/100
B.30/100
C.40/100
D.50/100
COMMENTARY: adding the motor grade on both sides will give
you a score of 30

67. A.C5
B.C6
C.C7
D.C8
Commentary : since C7 is the most caudal level having both motor and
sensory modalities intact.
Motor
level
Right LeftSensory
level
Right Left
C5
(Biceps)
5 5 C2-C7** 2/2 2/2
C6 (
ECRL)
5 5 C8-S3 0/2 0/2
C7**
(triceps)
3 3 S4-S5 1/2 1/2
C8(FDP) 1 1
T1
(AbdDM)
1 1
L2
(iliopsoa
s)
0 0
L3
(Quads)
0 0
L4
(tibialis
Ant.)
0 0
L5(EHL) 0 0
S1
(gastroc-
soleus)
0 0

68. Incomplete
Commentary:
An Incomplete SCI is defined as preservation of motor or sensory
function below the neurologic level of injury that includes the lowest
sacral segments (Sacral sparing) since in our patient the sacral
segments were preserved.
De Lisa , Joel A.et.al Neurologic Assessment and Classification of Traumatic Spinal Cord
Injury. Spinal Cord Medicine 2002 p.87
Right Left
C2-C7 2/2 2/2
C8-S3 0/2 0/2
S4-S5 1/2 1/2

69. A.AIS-A
B.AIS-B
C.AIS-C
D.AIS-D
E.AIS-E
Commentary: the patient is classified as AIS-C
because half of the key muscles below the
neurologic level** is having a muscle grade of less than 3
Right Left
C5 (Biceps) 5 5
C6 (ECRL) 5 5
C7(triceps)** 3 3
C8(FDP) 1 1
T1 (AbdDM) 1 1
L2(iliopsoas) 0 0
L3(Quads) 0 0
L4(tibialis Ant.) 0 0
L5(EHL) 0 0
S1 (gastroc-
soleus)
0 0

70. ASCI, incomplete NL C7, secondary to fall;
AIS-C