d Z ] Á ] o o Z o µ u ] v Á Z Ç } µ workshop handout.pdf · ð l î ï l î ì í ó ó v o Æ...

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4/23/2017 1 International Standards for Neurological Classification of Spinal Cord Injury Michael Kryger, MD SCI Fellow Current Concepts in Spinal Cord Injury Medicine Conference April 29, 2017 “ASIA Exam” • The exam now referred to as the International Standards exam • Patients are classified according to the ASIA Impairment Scale (AIS) • Combined efforts from – ASIA: American Spinal Injury Association – ISCOS: International Spinal Cord Society International Standards • Last Revised booklet in 2011, 7 th edition • Worksheet revised 2013 The ASIA Form Components of the Test • Three Main Parts to the Exam: – Strength Testing – Light Touch Sensation – Pinprick Sensation • Lowest Level of motor control: – Voluntary Anal Contraction • Lowest Level of Sensation: – Deep Anal Pressure Explaining the exam to your Patients • This is NOT a fun exam- it is uncomfortable, confusing and requires patience • So explaining to the patient why we do it is important!

Transcript of d Z ] Á ] o o Z o µ u ] v Á Z Ç } µ workshop handout.pdf · ð l î ï l î ì í ó ó v o Æ...

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International Standards for Neurological Classification of Spinal

Cord InjuryMichael Kryger, MD

SCI Fellow

Current Concepts in Spinal Cord Injury Medicine Conference

April 29, 2017

“ASIA Exam”• The exam now referred to as the

International Standards exam• Patients are classified according to the ASIA

Impairment Scale (AIS)• Combined efforts from

– ASIA: American Spinal Injury Association– ISCOS: International Spinal Cord Society

International Standards

• Last Revised booklet in 2011, 7th edition

• Worksheet revised 2013

The ASIA Form

Components of the Test• Three Main Parts to the Exam:

– Strength Testing– Light Touch Sensation– Pinprick Sensation

• Lowest Level of motor control: – Voluntary Anal Contraction

• Lowest Level of Sensation:– Deep Anal Pressure

Explaining the exam to your Patients

• This is NOT a fun exam- it is uncomfortable, confusing and requires patience

• So explaining to the patient why we do it is important!

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What not to say:

• “Let’s do this test- it’s for a research database and makes the world a better place!”

• These patients have just gone through significant traumas- they may not care about helping the greater good.

Explaining the exam to your Patients• This test will help us determine where your

spinal cord was injured• It might be different than what was seen on

the MRI or CT Scan• This is the main test we use to determine

what level your injury was, how severe it was, and a rough idea of what we could expect for recovery

Explaining the exam to your Patients

• Plus, not only can we use past data to predict how you will do, if you would like, we can add your exam to a research database so that future people can benefit like you will

Timing of the Exam• Initial exam in ER documents traumatic SCI

– Apply appropriate interventions– Attempt to determine motor level, sensory level,

completeness of injury and AIS score• Difficult to obtain a complete and reliable exam in ER• Comorbidities: TBI, Respiratory failure, pain, illicit

drugs, shock, cognitive changes, etc• 72 hour exam may be better for prediction of recovery

Man

ual M

uscl

e Te

stin

g Manual Muscle Testing GradingStrength 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

1/5Some muscle activity (Palpable or visible), but

unable to move against gravity

0/5 No muscle activity detected

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Manual Muscle Testing: Other considerations

• The grade must be achieved with full range of motion at the given resistance level

– (ie moving 25% of ROM against gravity does not earn you a 3/5)

• 5* indicates that you would expect a muscle to be 5/5 strength if there was no SCI-related limiting factor (like a fracture, or pain limiting motion)

• NT for limbs that you are not certain of 5/5 strength, but could not be tested due to pain/casting/fracture etc.

• No pluses or minuses!

Positioning for Motor Exam• Neutral positioning for Grade 3 testing• Strategically eliminate gravity for Grade 2 testing

– Maintain that position for Grade 1 or 0 testing• When testing for grade 4 or 5, the muscle is positioned in a

manner that partially activates the muscle– Patient is instructed to maintain that position– Examples:

• C6 – wrist in full extension• L2 – Hip flexed to 90 degrees

• Refer to Motor exam guides on ASIA website for detailed positioning for each myotome

C5- Biceps

Gravity Eliminated

Against Gravity

Against Resistance

C6- Wrist Extensors

Against Gravity

Against ResistanceGravity Eliminated

C7- Triceps

Against Gravity

Against ResistanceGravity Eliminated

C8- Finger Flexors (FDP-DIP)

Against Gravity/ Against ResistanceGravity Eliminated

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T1- Finger Flexors (FDP-DIP)

Against Gravity/ Against ResistanceGravity Eliminated

L2- Hip Flexors

Against Gravity

Against ResistanceGravity Eliminated

L3- Quadriceps

Against Gravity

Against ResistanceGravity Eliminated

L4- Dorsiflexors

Against Gravity/ Against ResistanceGravity Eliminated

L5- Great Toe Extensor

Against Gravity/ Against ResistanceGravity Eliminated

S1- Plantarflexors

Against Gravity

Against ResistanceGravity Eliminated

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Motor Exams Pearls and Pitfalls• Patient must be supine for testing• Move the joints through ROM prior to MMT

to rule out any pain, spasticity , or contracture which might effect motor scores

• Stabilize above and below the join tested to prevent muscle substitution – Supination for Wrist extension– Elbow extension by external shoulder rotation

Motor Exams Pearls and Pitfalls• Beware compensatory muscle relaxation

– Elbow extension mimicked by biceps relaxation – Relaxation of great toe flexors– Palpate the muscle to verify contraction

• Consider substituting isometric muscle contractions in persons with unstable spine– Avoid hip flexion in persons with lesion T8 and below

as this may increase kyphotic stress on L-spine

Non-key Muscle Groups• Shoulder movement (C5) except shrug• Elbow Supination (C5)• Elbow pronation (C6)• Wrist Flexion (C6)

– Etc... See ASIA Form• These become important when assigning AIS

Grade Ligh

t-to

uch

Sens

atio

n

Light-touch Sensation

• Use a cotton swab with the top fluffed out• Use the face as comparison

Grade Description

2 Normal Sensation

1 Abnormal Sensation (hyper or hypo -esthesia)

0 Absent Sensation

NT Not Testable

Pinp

rick

Sens

atio

n

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Pinprick Sensation• Use a Safety Pin- cover = dull, pin =sharp • Use the face as comparison

Grade Description

2 Normal- can distinguish sharp/dull, and sharp is equivalent to face

1 Can distinguish sharp/dull, and sharp is less than or sharper than face

0 Cannot distinguish sharp/dull (<80%)

NT Not Testable

Sensation Pearls and Pitfalls• Eyes should be closed for sensory testing• Tell the patient not to guess• If a patient can not accurately distinguish

sharp/ dull on their face then the sensory exam is Not Testable

• If there is concern for guessing, each point should be tested 10 times. – An accurate response is required 8/10 times

Sensation Pearls and Pitfalls• If a patient has abnormal sensation at C2 but

intact sensation on the face, then the person is given a sensory level of C1

• Dermatomes can be graded as Not Testable if factors are present which inhibit normal testing– Hairy chest, burn, peripheral neuropathy,

wrapping, etc.

Brief Overview of Dermatomes

Brief Overview of Dermatomes Brief Overview of Dermatomes

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Anal Exam• Very Important Part to test!• Voluntary Anal Contraction-

– Insert finger into rectum, and ask patient to contract anus (like holding in a BM), and release. Repeat several times to confirm voluntary contraction

• Deep Anal Pressure-– With finger still in rectum, ask patient which direction you are

applying pressure- towards head, towards feet, towards right side or towards left side.

– Should show consistent differentiation between directions• Use Gloves and Lube

Anal Exam

• Don’t forget dermatomes at this point too:

1) Each vertical column is added for a column total for motor and sensory

Scoring the ASIA Exam2) Separate motor scores are calculated for the UE and LE

Scoring the ASIA Exam

3) Separate total scores are calculated for LT and PP

Scoring the ASIA ExamASIA Impairment Scale Classification

1. Determine sensory levels for right & left sides– The lowest level with a 2 (normal) for both pinprick

and light touch where every level higher is also 2

• The sensory levels may be different on the left and right sides

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AIS Classification

2. Determine motor levels for right and left sides.– The lowest level where the muscle grade is at least a

three, 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

AIS Classification

3. Determine the Neurological Level of Injury– The highest level of the four individual levels

AIS Classification

4. Determine whether the injury is Complete or Incomplete. If complete AIS Grade = A– Defined by presence/absence of sacral sparing– If NO voluntary anal contraction AND all S4-5 sensory

scores are O AND there is NO deep anal pressure then injury is COMPLETE

– NOOOON SignN O O O O N

AIS Classification

5. Determine ASIA Impairment Scale (AIS) GradeA = CompleteB = Sensory Incomplete (ie Motor Complete)C = Motor IncompleteD = Motor IncompleteE = Normal

AIS Classification6. If A is ruled out, is the injury Motor incomplete?

(Do they get out of “B”???)– Preservation of motor function is defined by

• Presence of voluntary anal contraction OR

• Motor movement greater than three levels below the motor level on that side of the body

– (may use non-key muscle groups)– If both of these are absent, AIS Grade = B

Non-key muscle groups

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AIS Classification

6. If B is ruled out, how incomplete is the motor function?

- Are at least half of the key muscles below the neurological level of injury graded 3 or better?

- If no, AIS Grade = C- If yes, AIS Grade = D

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)

You’re ready to do an ASIA Exam! References• American Spinal Injury Association. International Standards for

Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta GA.

• American Spinal Injury Association:http://www.asia-spinalinjury.org/

– ISNCSCI Exam Sheet– Motor Exam Guide– Sensory Exam Guide

• Online ASIA Exam calculator: http://isncscialgorithm.azurewebsites.net/

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