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![Page 1: Spinal Cord Injury: Neurological Exam, Classification and Prognosis William McKinley MD Director SCI Rehabilitation Medicine Associate Professor VCU Dept.](https://reader035.fdocuments.in/reader035/viewer/2022062619/5518c53c550346a61f8b5773/html5/thumbnails/1.jpg)
Spinal Cord Injury: Neurological Exam, Classification and Prognosis
William McKinley MD
Director SCI Rehabilitation Medicine
Associate Professor
VCU Dept PM&R
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Case Presentation
31 yo wm s/p MVATetraplegia
Questions… Neurological recovery? Functional Outcome? Ambulation?
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Case Study
M LT PP C5 5 2 2 C6 3 2 1 C7 2 1 1 C8 1 1 1 T1 0 0 0 T2-L1 0 0 L2 0 0 0 L3 0 0 0 L4 0 0 0 L5 0 0 0 S1 0 0 0
Motor Level ?Sensory Level ?NLI ?ASIA ?Neuro/Functional
prognosis ?
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Importance of Comprehensive Neurological Exam
Evidence-based valid, reliable, consistent
Better communication to patient, family, team
Allows for prognosis Neurological Functional (Rehabilitation goals)
Allows study of interventions(rehab, drugs)
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International Standards for Neurological Classification of Spinal Cord Injury
ASIA (American Spinal Injury Association)Two main components (motor & sensory)
motor & sensory level, neurological level, ASIA impairment classification
• 1982 ASIA standards use “Frankel Classification”
• 1992 “ASIA Impairment Scale” replaces Frankel
• 1996 & 2000 ASIA revisions
72 hour exam - reliable prognostic time
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Sensory Exam
28 sensory “points” (within derm’s) Test light touch & pin/pain **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”
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Sensory Exam (cont)
Sensory level (SLI) = most caudal segment with normal (2/2) LT & Pin sensation
Sensory index score (SIS) = addition of sensory points (total possible 112)
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Motor Exam10 “key” muscles (5 upper & 5 lower ext)
• C5-Elbow flexion L2-hip flexion
• C6-wrist extension L3-knee extension
• C7-elbow extension L4-ankle dorsiflexion
• C8-finger flexion L5-toe extension
• T1-finger abduction S1-ankle plantarflexion
Sacral exam: voluntary anal contraction (present/absent) “optional m’s: diaphragm (VC), abdominal (Beevors
test) , hip adductors
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Motor Grading Scale
6 point scale (0-5) …..(avoid +/-’s)
0 = no active movement 1 = 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
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Motor exam (cont)Motor level (MLI) = lowest normal level with
3/5 (& level above 5/5)
Each M has 2 root innervations, if 3/5 = full innervation by more rostral root level
(4/5 acceptable with pain, deconditioning) Motor Index Score (MIS) = total 100 pts
**Superiority of Motor level vs Sensory
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Neurological Level of Injury (NLOI)Lowest level with normal sensory & motor
can record as MLI & SLI and on each side:• (ie: Right C5 sensory & C6 motor, Left C6 sensory & C7
motor)• motor level = sensory levels , 50%• If no key muscle for MLI, than NLI = SLI
Zone of partial preservation (ZPP) - preserved segments below NLOI
• used only in complete SCI Zone of Injury (ZOI) - 2-3 levels below NLOI
• recovery may be better or worse in ZOI
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Case:
M LT PP C5 5 2 2 C6 3 2 1 C7 2 1 1 C8 0 0 0 T1 0 0 0 T2-L1 0 0 L2 0 0 0 L3 0 0 0 L4 0 0 0 L5 0 0 0 S1 0 0 0
Motor Level = C6
Sensory Level = C5
Neurological Level of Injury (NLOI) = C5
Zone of Injury = C6-8
Zone of Partial Preservation = C6-7
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ASIA Impairment Scale
A = Complete - no S/M sacral functionB = Sensory incomplete -sacral sensory
sparingC = Motor incomplete -motor sparing
below ZOI (strength < 3/5 in most m’s)D = Motor incomplete - “ ”(>3/5)E = Normal - Normal S/M exam
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Mechanisms for Neurological Recovery
1. Remyelination- neuropraxia (0-3 months)2. Hypertrophy of innervated muscles (3-6
months)3. Peripheral sprouting from intact nerves to
denervated muscle (3-6 months)4. Axonal regeneration (12-18 months)
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Central Cord Syndrome
Upper extremities weaker than LE’sseen with older age (Spondylosis) asso with
hyperextension injuries
“favorable” prognostic factors: LE > UE (proximal > distal), Bladder/bowel age < 50yr (vs > 50 yr): ambulation 90% (vs 35%),
bladder 80% (vs 30%), dressing 80% (vs 15%)
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Brown-Sequard Syndrome
Cord “hemi-section” incidence 2-4 %
ipsilateral motor & proprioceptive loss and contralateral pain/temperature loss P/T tracts cross at spinal cord level
“favorable” prognosis for ambulation (90%), ADL independence (70%), bladder (85%)
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Anterior/Posterior Cord Syndrome ACS
Anterior spinal art. to ventral 2/3 of SC
loss of motor, pain (sparing of proprioception)
poor prognosis for neuro recovery
PCS Posterior spinal art.to
posterior columns loss of proprioception
(sparing of motor & pain)
poor prognosis for ambulation
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Conus Medullaris/Cauda Equina Syndromes
Conus lies behind T-10-l-2
vertbrae S1-5 spinal cord bladder, bowel &
sexuality dysfunction more often complete poor prognosis
CES L/S nerve root injury spinal cord ends ot L1-2 more often asso with pain more often incomplete (+/-
recovery 12-18 mo) better prognosis
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Neurologic vs Functional OutcomeNeurological Outcome - degree of motor & sensory
recovery after SCIFunctional Outcome - degree of mobility and self-
care performance
Key factors patient motivation availability of services avoidance of complications (pain, spasticity, contractures)
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Functional Outcomes by Level of Injury
C1,2,3- power chair, ECU, ventilatorC5 - feeding C6 - tenodesis graspC7 ** independent w/ most ADL’s/mobility
- manual W/C, transfers, dressing
C8/T1 - bladder/bowel independenceL 2,3 - **Ambulation
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Neuro-testing & Neurological Prognosis
MRI better than CT for cord & soft tissue visualization Cord transection (rare) and hemorrhage correlate
with poor prognosis Edema (1-2 levels only) correlates with
incomplete injury & better prognosis
SSEP (may assist when assoc LOC) no more reliable than neuro exam
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Etiology and prognosis
Better spinal stenosis fall unilateral facet disloc.
Worse GSW flexion/rotation bilateral facet disloc.
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Medical Intervention & Prognosis
Methylprednisilone - greater motor recovery noted if given < 8 hrs (for 24 hrs)
Gangliosides - no difference at 1 yr
Surgery (decompression/stabilization) - no neurological differences, but decreased LOS
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Neurological Recovery
Incomplete injuries have better prognosis sparing of motor/sensory WITHIN or BELOW
the zone of injury (ZOI).
Key factors: incomplete > complete **motor & PIN sparing are “key” early recovery is better
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ASIA Classification & Outcome
Admit ASIA (at 72hr) ASIA D (at 1 year)
A 0-5%
B-1 20-25%
B-2 (sacral pin prick) 40-50%
C 60-75%
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Neurological Outcomes in ZOI
Most pts with complete injury recover one motor level
Recovery to 3/5 at one yr: 25-50% of 0/5 m’s 75-100% of 1-2/5 m’s
Most occurs during first 6 months with greatest rate of change in first 3 months
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Ambulation
Benefits: overcome barriers, self esteem, cardiopulmonary exercise
Prognostic Factors Age & Energy expenditure (3-9 X in para) NLOI
• Below T-11Para - good prognosis• L 2-3 para (pelvic control, hip flexion & knee ext with hip/knee
proprioception)– “community ambulators”
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Community Ambulation and Lower extremity motor strength (LEMS at 1 month)
0 1-9 10-19 20-29
Tetra-C 0% NA NA NA
Tatra-I 21% 63% 100%
Para-C 45% 100%
Para-I 33% 70% 100% 100%
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Case Study #1
M LT PP C5 5 2 2 C6 3 2 1 C7 2 1 1 C8 1 1 1 T1 0 0 0 T2-L1 0 0 L2 0 0 0 L3 0 0 0 L4 0 0 0 L5 0 0 0 S1 0 0 0
Motor Level = C6Sensory Level = C5NLI = C5ASIA = ANeuro/Functional
prognosis ZOI = good below ZOI = none Ambulation = none
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Case Study #2
M LT PP C5 5 2 2 C6 3 2 1 C7 0 1 0 C8 0 0 0 T1 0 0 0 T2-L1 0 0 L2 0 0 0 L3 0 0 0 L4 0 0 0 L5 0 1 0 S1 0 1 0
Motor Level = C6Sensory Level = C5NLI = C5ASIA = B-1 (no pin)Neuro/Functional
prognosis ZOI = poor below ZOI = poor Ambulation = poor
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Case Study #3
M LT PP C5 5 2 2 C6 3 2 1 C7 0 2 1 C8 0 1 1 T1 0 0 0 T-L 0 0 L2 0 0 0 L3 0 0 0 L4 0 0 0 L5 0 1 1 S1 0 1 1
Motor Level = C6Sensory Level = C5NLI = C5ASIA = B-2 (pin*)Neuro/Functional
prognosis ZOI = good below ZOI = good Ambulation = good
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Case Study #4
M LT PP C5 5 2 2 C6 3 2 1 C7 0 0 0 C8 0 0 0 T1 0 0 0 L2 1 0 0 L3 0 0 0 L4 0 0 0 L5 0 1 1 S1 1 1 1
Motor Level = C6Sensory Level = C5NLI = C5ASIA = CNeuro/Functional
prognosis ZOI = Poor below ZOI = good
Ambulation = good
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Future Considerations for Enhance Recovery
Basic science/clinical research Neuropharmacologic agents (4-AP) Nerve transplantation, stem cells BWS (body weight support)
• training of central pattern generator in inc SCI FES - (UE grasp, ambulation, bladder)
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Conclusions
Accurate neuro exam is imperative
Incompleteness in key for prognosis
Earlier recovery (1-3 months) is better
ZOI & below ZOI may have different prognosis
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