This document provides information about the American Spinal Injury Association (ASIA) scale for classifying spinal cord injuries. It outlines the 5 steps for determining the ASIA grade: 1) determine sensory levels, 2) determine motor levels, 3) determine the neurological level of injury, 4) determine if the injury is complete or incomplete, and 5) determine the ASIA Impairment Scale grade (A-E). A 30-year-old man who fell 8 feet and had no motor function or voluntary anal contraction below his inguinal region is presented as a case example to demonstrate how to apply the ASIA scale.

1. American Spinal Injury
Association(ASIA) SCALE
Dr Awaneesh Katiyar

2. Case Report
• A 30 yrs. Man presented in ED with history of fall from height (8
feet), vitals were normal, complaining of inability to move his lower
limbs and severe backache Immediately after trauma.
• Motor lower limb – 0/5, upper limb - 5/5
• Sensory level – at the level of inguinal region.
• No voluntary anal contraction, DAP, but sensation over S4-S5 present.
• ASIA grade?

3. History
• Frankel five-grade system introduced - In 1969,
• Frankel scale was adapted by ASIA- In 1982.

4. Frankel classification 1969
Frankel Grade Motor Sensory
Grade A No motor function No sensory function.
Grade B No motor function detected below
level of lesion
Some sensory function below level of lesion
preserved
Grade C Preserved motor, Nonfunctional Sensation may or may not be preserved
Grade D Preserved motor, functional Normal Sensory
Grade E Normal motor Normal Sensory

7. STEPS OF CLASSIFICATION
1. Determine sensory levels for right and left sides.
2. Determine motor levels for right and left sides.
3. Determine the neurological level of injury (NLI)
4. Determine whether the injury is Complete or Incomplete
5. Determine ASIA Impairment Scale (AIS) Grade

8. Determine sensory levels for right and left sides.

10. Determine motor levels for right and left sides.
Lowest key muscle function that has a grade of at least 3 (on supine testing),
Key muscle functions represented by segments above that level are judged to be intact .
The motor level is presumed to be the same as the sensory level.

11. Key Muscles upper Extremity
Upper extremities
Elbow flexors C5
Wrist extensors C6
Elbow extensors C7
Finger flexors C8
Little finger abductor T1

12. Key Muscles lower extremities
Lower extremities
hip flexors L2
knee extensors L3
Ankle dorsiflesors L4
Long toe extensors L5
Ankle planter flexors S1

13. Determine the Neurological Level of Injury(NLI)
The most caudal segment of the cord with intact sensation and antigravity (3 or more)
muscle function strength,
There is normal (intact) sensory and motor function rostrally respectively. The NLI is the
most cephalad of the sensory and motor levels determined in steps 1 and 2.

14. Determine whether the injury is Complete or Incomplete
• If voluntary anal contraction = No AND all S4-5 sensory scores = 0
AND deep anal pressure = No, then injury is Complete.
• Otherwise, injury is Incomplete.

15. Determine ASIA Impairment Scale (AIS) Grade

16. ASIA IMPAIRMENT SCALE
ASIA Grade Motor Sensory
Grade A No motor function No sensory function included sacral sensation.
Grade B Not motor function is preserved Sensory function intact or altered, decreased or
hypersensitive
Grade C Motor Incomplete -single NLI have a
muscle grade ≥ 3.
Sensory function intact or altered, decreased or
hypersensitive
Grade D Motor Incomplete - the single NLI having
a muscle grade  3.
Sensory function intact or altered, decreased or
hypersensitive
Grade E Normal. Normal

17. Muscle Function Grading
0 = Total paralysis
1 = Palpable or visible contraction
2 = Active movement, full range of motion (ROM) with gravity eliminated.
3 = Active movement, full ROM against gravity
4 = Active movement, full ROM against gravity and moderate resistance in a muscle specific position
5 = (Normal) active movement, full ROM against gravity and full resistance in a functional muscle position expected from an
otherwise unimpaired person
5* = (Normal) active movement, full ROM against gravity and sufficient resistance to be considered normal if identified inhibiting
factors (i.e. pain, disuse) were not present.
NT = Not testable (i.e. due to immobilization, severe pain such that the patient cannot be graded, amputation of limb, or contracture
of > 50% of the normal ROM)

18. Sensory Grading
0 = Absent
1 = Altered, either decreased/impaired sensation or hypersensitivity
2 = Normal
NT = Not testable

19. Uses of ASIA chart
• Neurological assessment
• Daily evaluation and
neurological assessment
• Diagnosis – spinal shock
vs complete cord injury

21. Disability is not about nonfunctional limbs,
but its about nonfunctional mind.
Thank you ………
drawaneeshkatiyar@gmail.com