INTERNATIONAL STANDARDS FOR NEUROLOGICAL Patient Name______Date/Time of Exam ______CLASSIFICATION OF SPINAL CORD INJURY Examiner Name ______Signature ______(ISNCSCI)

MOTOR SENSORY SENSORY MOTOR KEY SENSORY POINTS KEY SENSORY POINTS KEY MUSCLES KEY MUSCLES RIGHT Light Touch (LTR) Pin Prick (PPR) Light Touch (LTL) Pin Prick (PPL) LEFT Patient Name______Date/Time of Exam ______C2 INTERNATIONAL STANDARDS FOR NEUROLOGICAL C2 CLASSIFICATION OF SPINAL CORD INJURY C3 Examiner Name ______C3 Signature ______(ISNCSCI) C4 C2 C4 Elbow flexors C5 MOTOR SENSORYC3 SENSORYC5 Elbow flexors MOTOR KEY SENSORY POINTS KEY SENSORY POINTS UER Wrist extensors KEY MUSCLES C4 C6 Wrist extensors KEY MUSCLES RIGHTC6 Light Touch (LTR) Pin Prick (PPR) Patient Name______Light Touch (LTL) Pin Prick (PPL) Date/Time of UELExam ______LEFT (Upper Extremity Right) INTERNATIONAL STANDARDS FOR NEUROLOGICAL T2 (Upper Extremity Left) Elbow extensors C7 C2 T3 C7 Elbow extensors CLASSIFICATION OF SPINALC2 CORD INJURYT4 C5 C2 Finger flexors C8 Examiner Name ______C8 Finger flexors Signature ______0 = absent (ISNCSCI) T5 1 = altered C3 C3 Finger abductors (little finger) T6 Finger abductors (little finger) T1 2 = normal T1 C4 C2 C4 NT = not testable SENSORYT7 SENSORY T2 MOTOR C3 T2 MOTOR Comments (Non-key Muscle? Reason for NT? Pain?): Elbow flexors C5 KEY SENSORY T8POINTS C3 KEY SENSORY POINTS MOTOR C5 Elbow flexors RIGHTT3 KEY MUSCLES 0 = absent T9 T1 T3 (SCORING ON REVERSEKEY MUSCLES SIDE) LEFT Light Touch (LTR) Pin Prick (PPR) C4 Light Touch (LTL) Pin Prick (PPL) UER Wrist extensors C6 1 = altered C6 Wrist extensors UEL C4 T10 C6 (Upper Extremity Right) T4 2 = normal T2 T4 0 = total paralysis (Upper Extremity Left) Elbow extensors C7 C2 NT = not testable T11 C2 T3 1 = palpable or visible contractionC2 C7 Elbow extensors T5 C5 T5 T4 2 = active movement, gravity eliminated Finger flexors C8 0 = absentC3 T12 C3 C8 Finger flexors T5 3 = active movement, against gravity 0 = absent T6 1 = altered L1 T6 Finger abductors (little finger) Palm C2T6 C4 Finger abductors (little finger) 1 = altered T1 2 = normalC4 4 = active movement, against some resistanceT1 T7 T7 2 = normal T7 NT = not testable C3 5 = active movement, against full resistance Elbow flexors T2 C3 T2 C5 Elbow flexors NT = not testable Comments (Non-key Muscle? Reason for NT? Pain?):C5 T8 T8 5* = normal corrected for pain/disuse MOTOR T8 C4 UER Wrist extensors C6 T3 S3 0 = absent T9 T1 NT = not testable T3 C6 (SCORINGWrist extensors ON REVERSE SIDE) UEL 1Key = altered SensoryC4 T2 T9 (Upper Extremity Right) T9 L2 • T10 C6 (Upper Extremity Left) Elbow extensors T4 S4-5 2 = normalC2 T3 T4 0 = totalElbow paralysis extensors C7 NT Points= not testable T11 C7 T10 T4 C5 T10 SENSORY 1 = palpable or visible contraction Finger flexors T5 T5 C8 Finger flexors C8 0 = absent T5T12 T11 (SCORING ON REVERSE 2SIDE) = active movement, gravity eliminated T11 1 = altered T6 3 = active movement, against gravity Finger0 abductors= absent (little finger) T6 T6 L1 T1 Finger abductors (little finger) T1 2 = normal Palm 0 = absent 2 = normal T121 = altered T7 T12 4 = active movement, against some resistance NT = not T7testableS2 L3 1= altered T7 NT = not testable 2 = normal T2 C3 C8 C8 T8 T2 5 = active movement, against full resistance Comments (Non-key Muscle?NTL1 = not testableReason for NT? Pain?): C6 C6 L1 5* = normal correctedMOTOR for pain/disuse T8 0 = absentC7 C7 T9 T1 T8 T3 S3 T3 (SCORING ON REVERSE SIDE) 1 = alteredC4 NT = not testable Hip flexors L2 Dorsum Dorsum T10 KeyC6 Sensory L2 Hip flexors T9 T4T9 2 = normal L2 • T4 0 = total paralysis NT = not testableS4-5 T11 LER Knee extensors L3 T10T5 Points L3 Knee extensorsT5T10 1 = palpableLEL or SENSORYvisible contraction L4 T12 T11 2 = active(SCORING movement, ON gravity REVERSE eliminated SIDE) (Lower Extremity Right) Ankle dorsiflexors L4 T11T6 L1 L4 Ankle dorsiflexorsT6 (Lower 3 = active Extremity movement, Left) against gravity 0 = absent L5 0 = absent 2 = normal Long toe extensors 1 = altered T12 Palm T12 4 = active movement, against some resistance L5 T7 S2 L3 L5 Long toe extensorsT7 1= altered NT = not testable 2 = normal S1 C8 C8 5 = active movement, against full resistance Ankle plantar flexors NT = not testable L1 C6 C6 L1 5* = normal corrected for pain/disuse S1 T8L5 C7 C7 S1 Ankle plantar T8flexors S3 Key Sensory NT = not testable S2 Hip flexors L2 T9 L2 Dorsum• Dorsum S2 T9 L2 Hip flexors S4-5 Points S3 Knee extensors L3 T10 S3 T10 L3 Knee extensorsSENSORY (VAC) Voluntary anal contraction LER L4 (DAP) Deep anal pressure LEL S4-5 Ankle dorsiflexors L4 S4-5 T11 (SCORING ON REVERSE SIDE) (Yes/No) (Lower Extremity Right) T11 (Yes/No) L4 Ankle dorsiflexors (Lower Extremity Left) L5 0 = absent 2 = normal Long toe extensors L5 T12 L3 T12 S2 L51= alteredLong toe extensors NT = not testable RIGHT TOTALS S1 C8 C8 LEFT TOTALS Ankle plantar flexors S1 L1 L5 C6 C6 L1 S1 Ankle plantar flexors (MAXIMUM) C7 C7 (MAXIMUM) Hip flexors L2 S2 Dorsum Dorsum S2 L2 Hip flexors MOTOR SUBSCORES SENSORY SUBSCORES Knee extensors L3 S3 S3 L3 Knee extensors (VAC) Voluntary anal contraction L4 (DAP) Deep anal pressureLEL UER + UEL = UEMS TOTALLER LER + LEL S4-5= LEMS TOTAL LTR + LTL LT TOTAL PPR + PPL (Lower Extremity Right) (Yes/No) L4 = S4-5 = PP TOTAL (Lower Extremity Left) Ankle dorsiflexors L5 L4 Ankle dorsiflexors(Yes/No) MAX (25) (25) (50) MAX (25) (25) (50) MAX (56) (56) (112) MAX (56) (56) (112) Long toe extensors L5 L5LEFTLong TOTALS toe extensors RIGHT TOTALS S1 Ankle plantar flexors S1 L5 (In complete injuries only) Ankle plantar flexors NEUROLOGICAL R L 3. NEUROLOGICAL(MAXIMUM) 4. COMPLETE OR INCOMPLETE? S1(MAXIMUM) R L LEVELS 1. SENSORY S2 Incomplete = Any sensory or motor function in S4-5 ZONE OF PARTIAL S2SENSORY MOTOR SUBSCORES LEVEL OF INJURY SENSORY SUBSCORES Steps 1-5 for classification S3 PRESERVATION S3MOTOR as on reverse 2. MOTOR (NLI) 5. ASIA IMPAIRMENT SCALE (AIS) Most caudal level with any innervation (VAC)UER Voluntary + UELAnal Contraction= UEMS TOTAL S4-5LER + LEL = LEMS TOTAL LTR + LTL = LT TOTAL S4-5 PPR + PPL(DAP) Deep= AnalPP TOTAL Pressure (Yes/No) MAX (25)This (25) form may be copied freely(50) but shouldMAX not(25) be altered without (25) permission from the (50)American SpinalMAX Injury(56) Association. (56) (112) MAX (56)REV (Yes/No)02/13 (56) (112)

RIGHT TOTALS (In complete injuriesLEFT only) TOTALS NEUROLOGICAL R L 3. NEUROLOGICAL 4. COMPLETE OR INCOMPLETE? R L (MAXIMUM) ZONE OF PARTIAL(MAXIMUM) LEVELS 1. SENSORY LEVEL OF INJURY Incomplete = Any sensory or motor function in S4-5 SENSORY MOTORSteps 1-5 SUBSCORES for classification PRESERVATION MOTOR as on reverse 2. MOTOR (NLI) 5. ASIA SENSORYIMPAIRMENT SUBSCORES SCALE (AIS) Most caudal level with any innervation UER + UEL = UEMS TOTAL LER + LEL = LEMS TOTAL LTR + LTL = LT TOTAL PPR + PPL = PP TOTAL This form may be copied freely but should not be altered without permission from the American Spinal Injury Association. REV 02/13 MAX (25) (25) (50) MAX (25) (25) (50) MAX (56) (56) (112) MAX (56) (56) (112)

NEUROLOGICAL R L 4. COMPLETE OR INCOMPLETE? (In complete injuries only) R L 3. NEUROLOGICAL ZONE OF PARTIAL LEVELS 1. SENSORY LEVEL OF INJURY Incomplete = Any sensory or motor function in S4-5 SENSORY Steps 1-5 for classification PRESERVATION MOTOR as on reverse 2. MOTOR (NLI) 5. ASIA IMPAIRMENT SCALE (AIS) Most caudal level with any innervation

This form may be copied freely but should not be altered without permission from the American Spinal Injury Association. REV 11/15 Muscle Function Grading ASIA Impairment Scale (AIS) Steps in Classification 0 = total paralysis The following order is recommended for determining the classification of 1 = palpable or visible contraction individuals with SCI. No sensory or motor function is preserved in 2 = active movement, full range of motion (ROM) with gravity eliminated A = Complete. the sacral segments S4-5. 1. Determine sensory levels for right and left sides. 3 = active movement, full ROM against gravity The sensory level is the most caudal, intact dermatome for both pin prick and 4 = active movement, full ROM against gravity and moderate resistance in a muscle specific position B = Sensory Incomplete. Sensory but not motor function light touch sensation. is preserved below the neurological level and includes the sacral = (normal) active movement, full ROM against gravity and full resistance in a 5 segments S4-5 (light touch or pin prick at S4-5 or deep anal 2. Determine motor levels for right and left sides. functional muscle position expected from an otherwise unimpaired person pressure) AND no motor function is preserved more than three Defined by the lowest key muscle function that has a grade of at least 3 (on = (normal) active movement, full ROM against gravity and sufficient resistance to 5* levels below the motor level on either side of the body. supine testing), providing the key muscle functions represented by segments be considered normal if identified inhibiting factors (i.e. pain, disuse) were not present above that level are judged to be intact (graded as a 5). NT = not testable (i.e. due to immobilization, severe pain such that the patient Note: in regions where there is no myotome to test, the motor level is C = Motor Incomplete. Motor function is preserved at the cannot be graded, amputation of limb, or contracture of > 50% of the normal ROM) presumed to be the same as the sensory level, if testable motor function above most caudal sacral segments for voluntary anal contraction (VAC) that level is also normal. Sensory Grading OR the patient meets the criteria for sensory incomplete status (sensory function preserved at the most caudal sacral segments 0 = Absent 3. Determine the neurological level of injury (NLI) (S4-S5) by LT, PP or DAP), and has some sparing of motor = Altered, either decreased/impaired sensation or hypersensitivity This refers to the most caudal segment of the cord with intact sensation and 1 function more than three levels below the ipsilateral motor level antigravity (3 or more) muscle function strength, provided that there is normal 2 = Normal on either side of the body. NT = Not testable (intact) sensory and motor function rostrally respectively. (This includes key or non-key muscle functions to determine The NLI is the most cephalad of the sensory and motor levels determined in motor incomplete status.) For AIS C – less than half of key steps 1 and 2. When to Test Non-Key Muscles: muscle functions below the single NLI have a muscle grade ≥ 3. In a patient with an apparent AIS B classification, non-key muscle functions 4. Determine whether the injury is Complete or Incomplete. more than 3 levels below the motor level on each side should be tested to D = Motor Incomplete. Motor incomplete status as defined most accurately classify the injury (differentiate between AIS B and C). (i.e. absence or presence of sacral sparing) above, with at least half (half or more) of key muscle functions If voluntary anal contraction = No AND all S4-5 sensory scores = 0 Movement Root level below the single NLI having a muscle grade ≥ 3. AND deep anal pressure = No, then injury is Complete. Shoulder: Flexion, extension, abduction, adduction, internal C5 Otherwise, injury is Incomplete. and external rotation E = Normal. If sensation and motor function as tested with Elbow: Supination the ISNCSCI are graded as normal in all segments, and the 5. Determine ASIA Impairment Scale (AIS) Grade: Elbow: Pronation C6 patient had prior deficits, then the AIS grade is E. Someone Is injury Complete? If YES, AIS=A and can record without an initial SCI does not receive an AIS grade. ZPP (lowest dermatome or myotome Wrist: Flexion NO on each side with some preservation) Finger: Flexion at proximal joint, extension. C7 Using ND: To document the sensory, motor and NLI levels, Thumb: Flexion, extension and abduction in plane of thumb the ASIA Impairment Scale grade, and/or the zone of partial Is injury Motor Complete? If YES, AIS=B preservation (ZPP) when they are unable to be determined Finger: Flexion at MCP joint C8 (No=voluntary anal contraction OR motor function Thumb: Opposition, adduction and abduction perpendicular based on the examination results. NO more than three levels below the motor level on a to palm given side, if the patient has sensory incomplete Finger: Abduction of the index finger T1 classification)

Hip: Adduction L2 Are at least half (half or more) of the key muscles below the Hip: External rotation L3 neurological level of injury graded 3 or better? Hip: Extension, abduction, internal rotation L4 NO YES Knee: Flexion Ankle: Inversion and eversion INTERNATIONAL STANDARDS FOR NEUROLOGICAL AIS=C AIS=D Toe: MP and IP extension CLASSIFICATION OF SPINAL CORD INJURY If sensation and motor function is normal in all segments, AIS=E Hallux and Toe: DIP and PIP flexion and abduction L5 Note: AIS E is used in follow-up testing when an individual with a documented SCI has recovered normal function. If at initial testing no deficits are found, the Hallux: Adduction S1 individual is neurologically intact; the ASIA Impairment Scale does not apply.