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The International Standards Booklet for Neurological and Functional Classification of Spinal Cord Injury*

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The International Standards Booklet for Neurological and Functional Classification of Spinal Cord Injury* Paraplegia 32 (1994) 70-80 © 1994 International Medical Society of Paraplegia The International Standards Booklet for Neurological and Functional Classification of Spinal Cord Injury* 1 F Ditunno lr MD,! W Young PhD MD,2 W H Donovan MD,3 G Creasey MD-+ 1 Department of Rehabilitation Medicine, Thomas Jefferson University Ho pital � : . Philadelphia, Pennsylvania; 2 Department of eurosurgery, New York Umverslty edlcal 3 ."! . � Center, New York; The Institute for RehabdltatlOn and Research, l!0u�ton, Texas, 4Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA. Introduction recognition of the need for greater accept­ ance, ASIA sought input from a broader For almost a quarter of a century the international community in spinal cord in­ array of experts representing. SCI res�a.rch jury (SCI) has advocated a unifor measure interests as well as from dIverse chlllcal � specialis s. The international Medical Soci­ of SCI severity. 1 Such agreement IS needed � ety of Paraplegia (IMSOP), as ell as ma y for the accurate communication between � � other organizations and professIOnal socie­ clinicians and for comparisons of research ties interested in classification, were repre­ results among investigators. The severity f ? sented by members on the committee the injury after SCI is primarily reflecte� III the extent of paralysis and loss of sensation formed in 1990. The international standards revised by the ASIA Committee in 1992 (impairment) and the inability to perform activities of daily living (disability). These were endorsed by IMSOP in Barcelona, in measurements of impairment and disability September 1992. The rationale for these standards evolved serve as the determinants of the clinical from two major influences. The first was the outcome in SCI. 2 The importance of clinical need to refine the definition of neurological outcome measures have been emphasized levels. For close to 30 years rehabilitation for purposes of cost justific tion in the � . and SCI clinicians used the neurological United States, in recent IllternatlOnal level to define function or disability. 8 Key neurotrauma research forums, and particu­ muscles and key sensory points were devel­ larly in multicenter clinical trials. mini­ � oped to determine these levels more pre­ mum data set which is both practical and cisely for the national database of the Model reliable is essential to multicenter trials. The SCI Centers' reporting purposes.9 The use of such measures in recent studies second influence was the need for agree­ includes the prognosis of motor recovery in ment between investigators on key muscles the upper extremities of tetraplegic subjects and key sensory points for use as endpoints based on an increase of muscle strength and in motor and sensory scores. Several of the motor levels;3 the effects of drug interven­ authors recognized this needlO and the tion in SCI based on improvement in motor opportunity to achieve it for use in clinical and sensory scores;4.5 and the efficiency of trials. The need for uniformity was partIcu­. rehabilitation in SCI based on improvement larly evident when it became apparent that of functional assessment measures.6 In re­ two of the largest study groups involved in sponse to this need, the A��r!can Spinal acute spinal cord injury, the National D�ta­ Injury Association (ASIA) IllitIally devel­ base of the Model Spinal Cord Injury oped standards for neurological classifica­ Centers, and the National Acute Spinal tion of spinal cord injury in 1982.7 In Cord Injury Study, II were using somewhat disparate methods for collecting neuro­ *This is published with the permission of the Ameri­ logical data. Because the key mus�les and can Spinal Injury Association (ASIA). their five grades are used to determllle both Paraplegia 32 (1994) 70-80 The international standards booklet for paraplegia 71 neurological levels and to calculate the Definitions motor score, lengthy discussions were re­ quired by the ASIA Committee to achieve Tetraplegia (preferred to 'quadriplegia') agreement. Each of the measures in the This term refers to impairment or loss of standards, however, has gone through a motor and/or sensory function in the cerv­ laborious process of discussion and ical segments of the spinal cord due to documentation during meetings, conference damage of neural elements within the spinal calls, input from national and international canal. Tetraplegia results in impairment of societies and organizations, and we shall function in the arms as well as in the trunk, continue to invite comments and recom­ legs and pelvic organs. It does not include mendations. Thus, the face validity of the brachial plexus lesions or injury to peri­ standards has been arrived at by this pro­ pheral nerves outside the neural canal. cess. Dr Wise Young assisted the primary author as co-chairman, and Dr William Paraplegia Donovan served as co-editor. Drs Paul This term refers to impairment or loss of Dollfus and Hans Frankel identified Dr motor and/or sensory function in the Graham Creasey to provide input from thoracic, lumbar or sacral (but not cervical) IMSOP. The remainder of the committee segments of the spinal cord, secondary to members include Drs Michael B Bracken, damage of neural elements within the spinal Margaret Brown, Thomas B Ducker, canal. With paraplegia, arm functioning is Frederick M Maynard Jr, Samuel L Stover, spared, but, depending on the level of Charles H Tator, Robert L Waters, and injury, the trunk, legs and pelvic organs may Jack E Wilberger. Further refinements of be involved. The term is used in referring to validity and precision will be accomplished cauda equina and conus medullaris injuries, by an annual review of research findings, but not to lumbosacral plexus lesions or comments and the booklet will be updated injury to peripheral nerves outside the as necessary. In an effort to increase the neural canal. accuracy and the reliability of the examina­ tion, a teaching package, which will provide a manual and video tapes demonstrating the Quadriparesis and paraparesis examination, scoring, scaling and rationale Use of these terms is discouraged, as they of the measures, is in preparation. The describe incomplete lesions imprecisely. In­ initial draft video of the examination has stead, the ASIA Impairment Scale (see been shown in North America, Asia, and below) provides a more precise approach. twice in Europe this spring and summer, and has been greeted with enthusiasm. It Dermatome should be available in 1994. These standards This term refers to the area of the skin represent the most valid, precise, and reli­ innervated by the sensory axons within each able minimum data set and currently are segmental nerve (root). being utilized by the National Spinal Cord Injury database and two large multicenter drug trials involving more than forty SCI Myotome centers in the United States and Canada. This term refers to the collection of muscle IMSOP is committed to promulgating these fibers innervated by the motor axons within standards for international use and is re­ each segmental nerve (root). sponsible for approving all translations of this booklet. 12 These standards are pub­ Neurological level, sensory level and motor lished with the permission of the American level (see summary chart) Spinal Injury Association and copies of the The first of these terms refers to the most booklet and training package can be ob­ caudal segment of the spinal cord with tained by contacting: Lesley M Hudson normal sensory and motor function on both MA, 2020 Peachtree Road, NW Atlanta, sides of the body. In fact, the segments at Georgia 30309, USA. which normal function is found often differ 72 Dill/nnO Paraplegia 32 (1994) 70-80 by side of body and in terms of sensory vs Zone of partial preservation (ZPP) motor testing. Thus, up to four different This term refers to those dermatomes and segments may be identified in determining myotomes caudal to the neurological level the neurological level, i.e., R-sensory, L­ that remain partially innervated. When sensory, R-motor, L-motor. In cases such as some impaired sensory and/or motor func­ this, it is strongly recommended that each of tion is found below the lowest normal these segments be separately recorded and segment. the exact number of segments so that a single 'level' not be used, as this can affected should be recorded for both sides as be misleading in such cases. When the term the ZPP. The term is used only with 'sensory level' is used, it refers to the most complete injuries. caudal segment of the spinal cord with normal sensory function on both sides of the body; the motor level is similarly defined Neurological examination with respect to motor function. These Introduction 'levels' are determined by neurological The neurological examination has two com­ examination of: (1) a key sensory point ponents (sensory and motor). which are within each of 28 dermatomes on the right separately described below. Further, the and 28 dermatomes on the left side of the neurological examination has both required body, and (2) a key muscle within each of 10 as well as optional, though recommended, myotomes on the right and 10 myotomes on elements. The required elements are used in the left side of the body. determining the sensory/motor/neurological levels, in generating scores to characterize sensory/motor functioning and in determin­ Skeletal level ing completeness of the injury. The optional This term refers to the level at which. by measures, though not used in scoring, may radiographic examination, the greatest ver­ add to a specific patient's clinical descrip­ tebral damage is found. tion. When the patient is not fully testable Sensory scores and motor scores (see When a key sensory point or key muscle is summary chart) not testable for any reason, the examiner Numerical summary scores that reflect the should record 'NT instead of a numeric degree of neurological impairment associ­ score.
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