How to assess neurological deficit in spinal cord injury patient? this slide will give u some of the information.

1. ASIA SCORING
Syukran

2. Spinal Cord
• Conduit for motor and sensory between brain and body
• Spinal Cord Injury (SCI) affects conduction of Sensory & Motor
signals

3. History
AMERICAN SPINAL INJURY ASSOCIATION(ASIA)
• 1982 –First developed the International Standards for Neurological
Classification of Spinal Cord Injury
• 1992 - Revised. Endorsed by International Medical Society of Paraplegia-
Renamed International Standards for Neurological and Functional
Classification of Spinal Cord injury.
• 1994 – first published reference manual
• 2000 - revised and the term “Functional” was deleted from the name
• 2011- the latest version of ISNCSCI had been published.
Kirshblum et al

4. ASIA measures:
• NEUROLOGICAL LEVEL
• SENSORY LEVEL
• MOTOR LEVEL
• SENSORY SCORE (pin prick and light touch)
• MOTOR SCORE
• ZONE OF PARTIAL PRESERVATION

5. Definitions
TETRAPLEGIA
• impairment or loss of sensory and/or motor function in cervical
segments.
• impairment of function in the arms as well as the trunk, legs and
pelvic organs. (four extremities)
• Does not include brachial plexus lesions or injury to
peripheral nerves

6. PARAPLEGIA
• impairment or loss of motor and/or sensory function in the thoracic,
lumbar or sacral
• Arm functioning is spared
• trunk, legs, pelvic organs may be involved depends on the level
• eg. Cauda equina and Conus medullaris

7. Myotome
• refers to the collection of muscle fibers
innervated by the motor axons within each
segmental nerve (root).
Dermatome
•refers to the area of the skin innervated by
the sensory axons within each segmental
nerve (root).

8. Neurological level of injury (NLI)
•refers to the most caudal segment of the
spinal cord with normal sensory and
antigravity motor function on both sides of the
body, provided that there is normal (intact)
sensory and motor function rostrally.

9. Sensory level
• The sensory level is determined by performing
an examination of the key sensory points within
each of the 28 dermatomes on each side of the
body (right and left) and is the most caudal,
normally innervated dermatome for both pin
prick (sharp/dull dis- crimination) and light
touch sensation. This may be different for the
right and left side of the body.

10. Motor level
• The motor level is determined by examining a key
muscle function within each of 10 myotomes on
each side of the body and is defined by the lowest
key muscle function that has a grade of at least 3
providing the key muscle functions represented by
segments above that level are judged to be intact.
• This may be different for the right and left side of
the body.

11. Components of the Test
Main Parts of
Examination
1) Manual Muscle Power
Testing
2) Light Touch sensation
3) Pinprick Sensation
Lowest level of
Motor Control
- Voluntary Anal
Contraction
Lowest level of
Sensation
- Deep Anal Pressure

12. Explaining the examination to your PATIENTS
This is not a fun exam
•Uncomfotable
•Confusing
•Requires patience

13. 1) Help in determining where the level of Spinal Cord
was injured
2) It might be different than what was seen on the
MRI or CT Scan
3) This is the main test we use to determine what
level the injury was, how severe it was, and a
rough idea of what we could expect for recovery
The importance of the Exam:

14. Timing of the Examination
• The initial examination should be done in EMERGENCY DEPARTMENT for
Traumatic Spinal Cord Injury
• Attempt to determine motor level, sensory level, completeness of injury and AIS
score
• However it is difficult to obtain a complete and reliable results in ED
• Traumatic Brain Injury
• Pain
• Respiratory Failure
• Shock
• Cognitive Changes
• Drugs

15. Sensory
• Key point in each of the 28
dermatomes (from C2 to S4-
S5) on the right and left sides
• Two aspects of sensation are
examined:
• light touch
• pin prick (sharp-dull
discrimination)

16. LIGHT TOUCH
• wisp cotton
• applied lightly.
• Stroke across skin. Not
exceed 1 cm
• Done with eyes close
PIN PRICK
• standard safety pin
• pointed end for sharpness
• rounded end for dullness
• apply light pressure without
moving pin after point of
contact

17. Sensory Test of Anal Region
•S4-S5 dermatome
•Perianal Sensation
•Deep Anal Sensation

18. Sensory Grading
0 = absent
1 = impaired ( partial or altered appreciation
including hyperesthesia)
2 = normal
NT = not testable

24. Motor
• Key Muscles Functions
• 10 paired myotomes
• Upper Limb C5-T1
• Lower Limb L2-S1
• Represent each
respective spinal cord
segment

25. Manual Muscle Testing Grading
Strength
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
1/5 Some muscle activity (Palpable or Visible), but unable to move
against gravity
0/5 No muscle activity detected

26. Other considerations:
• The grade must be achieved with FULL RANGE OF
MOTION at the given resistance level
• Not Testable (NT) for limbs that you are not certain of
5/5 strength
-could not be tested due to pain/ casting/fracture
*NO PLUSES OR MINUSES !!!!!!

27. Positioning for motor examination
• Neutral position for Grade 3 testing
• Strategically eliminate gravity for Grade 2 testing
• When testing for Grade 4 and 5, the muscle is
positioned in a manner that partially activates
the muscles
• Patient is instructed to maintain that position
• C6 Wrist in full extension

28. C5 - Biceps

29. C6 – wrist extensor

30. C7 – triceps

31. C8 – Fingers flexors (DIP)

32. T1 - Small Finger Abductor

38. Its time to complete our asia
chart!!!

42. ASIA Impairment Scale Classification
1. Determine sensory level for right and left side
• The lowest level with a 2 (normal) for both pinprick
and light touch where every level higher is also 2
• The sensory level may be different on the left and
right sides

43. AIS Classification
• Determine motor levels for right and left sides
• The lowest level where the muscle grade is at least a
3, 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.

44. AIS Classification
3. Determine the neurological level of injury
• The highest level of the 4 individual levels

45. AIS Classification
• 4. Determine whether the injury is Complete or In
complete. If complete AIS Grade = A
• Defined by presence/absence of sacral sparing
• If NO voluntary anal contraction AND all S4-5 sensory
scores are 0 AND there NO deep anal pressure then
the injury is complete
• NOOOON Sign
N NO O O O

46. AIS Classification
5. Determine ASIA impairment Scale grade
• A = Complete.
• B = Sensory incomplete.
• C = Motor incomplete.
• D = Motor incomplete.
• E = Normal.

47. AIS Classification

50. AIS Classification

52. 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)

53. • Steven C. Kirshblum et al. Reference for the 2011 revision of the
international standards for neurological classification of spinal cord injury.
J Spinal Cord Med. 2011 Nov; 34(6): 547–554.