1. Spinal cord injuries have an annual incidence of 15-40 cases per million people, with motor vehicle accidents and falls being the most common causes. 2. The American Spinal Injury Association (ASIA) impairment scale is the most widely used classification system for spinal cord injuries, grading injuries as complete or incomplete. 3. Common spinal cord syndromes include anterior cord syndrome (involving motor and pain pathways), posterior cord syndrome (involving proprioception and touch), and Brown-Sequard syndrome (unilateral involvement of pathways on one side of the spinal cord).

1. Spinal Cord Injury
classification, Syndromes
Dr SANJOG CHANDANA

2. Annual incidence : 15-40 cases per million
Causes : RTA (50 %), Falls and work related
injuries( 30 %), violent crime (11%), sports
related (9%)
56 % occurs in cervical spine
Male : female – 4:1

3. • FOR Survivors with SCI – Pain , Bladder and bowel functions, Sexual
dysfunction and hand function are considered highest determinants
of QOL.

4. Phases of Spinal cord injury
• Primary – due to impact
• Secondary – delayed , progressive – period of tissue injury followed
by primary injury.

6. • SCI Classification systems are – for the diagnosis and management
• First widely accepted – 1967 – Frankel
• Frankel Classification:
• COMPLETE (A)
• SENSORY ONLY (B)
• MOTOR USELESS (C)
• MOTOR USEFULL (D)
• RECOVERY (E)

7. • considerable influence and its general framework lives on in
more modern classification schemes.
• it provided an easy scheme for classifying patients based on
obvious and easily assessed aspects of neurological
function.
• major short-coming of this scale, however, is the
subjectivity inherent in judging what constitutes “useful”.
• also fails to recognize laterality and the independence with
which motor and sensory function can be lost.
• scores of C and D have a ceiling effect, or discontinuity,
whereby disproportionately few patients improve beyond
these scores.
• This scale does, however, seem remarkably forward-
thinking when today’s emphasis on the functional
significance is considered.

8. Lucas Neuro Trauma Motor Index
• 1979 - Lucas and Ducker
• based on both the bony level of injury and
corresponding motor function.
• Their scale was unique in that it subdivided SCI into
two types of complete lesions (neurology consistent
with the bony level or caudal to it) and three types of
partial lesions.
• Not widely used largely because it ignores sensory
function.

9. Tator Sunnybrook Scale
• The Sunnybrook Scale -Charles Tator -1982, was the next
major attempt to classify neurological function following
SCI.
• To produce “a more comprehensive assessment of recovery
factors”,
• It was essentially a modification of the Frankel scale, which
subdivided C and D scores.
• It was thus a more sensitive ten point scale that facilitated
more independent scoring of motor and sensory deficits.
• It also emphasized that the level of injury should be defined
as the most distal level of intact neurological function as
opposed to the most proximal damaged level, or the bony
level of injury.

10. Definitions
• Tertraplegia : This term referes to impairment or loss of motor and/or
sensory functions in the cervical segments of spinal cord due to
damage of the neural elements within the spinal canal. It results In
impairment of functions in the arm as well as typically in the trunk,
legs and pelvic organs. ( brachial plexus /peripheral nerve should not
be included)

11. • Paraplegia : This term referes to impairment or loss of motor and/or
sensory function in the thoracic . Lumber or sacral ( but not cervical )
segments of spinal cord, secondary to damage of neural elements
within the canal. With paraplegia , arm functioning is spread , but
depending on the level of injury , the trunk, pelvic organ may be
involved. Does not involve lumbosacral plexus or peripheral nerves.
• Use of paresis – avoided.

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

13. •Sensory level: The sensory level is determined by
performing examination of key sensory points of
each side of body ( right and left ), and is the
most caudal , normally innervated for both pin
prick and light touch sensation. This may be
different for the right and left side of body.

14. • Motor level: The motor level is determined by examinaing a key
muscles function within each of 10 myotomes on each side of body
and is defined by the lowest key muscle function that has a grade of
atleast 3 ( in supine position), provided the key muscle functions
represented by segments above that level are judged to be intact.
• This may be different for right and left side of body.

15. Neurological level of injury
• The NLI refers to the most caudal segment of spinal cord with normal
sensory and antigravity motor function on both sides of body ,
provided that there is normal function rostrally.
• The segments at which normal function is found often differ by side
of the body.
• Upto four segments may be found.
• R/L, Sensory / Motor
• The NLI is most rostral to it.

16. Skeletal level
• This term is used to denote the level at which , by radiographic
examination, the greatest vertebral damage is found.

17. American Spinal Injury Association Score
• ICNCSCI – International Standard for Neurological Classification of SCI.
• First published in 1982
• Tests 5 key muscles in each extremity – each scoring 5 points – total
100
• Optional testing for diaphragm, deltoids, abdominalis, medial
hamstrings and hip adducters

18. • Sensory testing
• For light touch and pin prick
• Grades as Normal ( 2 points), decreased ( 1 points ) and Absent( 0)
• C2 – S5 – bilaterally.
• JPS and Deep pressure touch – optional
• Modification of Frankel’s scale

20. Motor function grading
• 0- Total paralysis
• 1- palpable or visible contraction
• 2- Active movement , full ROM with gravity eliminated
• 3- Active movement , full ROM against gravity
• 4- Active movements, 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.
• NT – not testable.

21. Sensory grading
• 0- absent
• 1- altered, either decreased / impaired or hypersensitivity.
• 2 – Normal
• NT – not testable

22. • A –COMPLETE
• No sensory or motor function is preserved in the sacral segments S4-
5

23. • B – SENSORY INCOMPLETE
• Sensory but motor function is preserved below the neurological level
and includes the sacral segments S4-5 ( Light touch or pin prick at S4-
5, or Deep anal pressure ) AND No motor function is preserved more
then three level below the motor level on either side of body.

24. • C – MOTOR INCOMPLETE
• Motor function is preserved at the most caudal sacral segments for
voluntary anal contraction ( VAC) , or the patient meets the criteria
for sensory incomplete status ( Sensory level preserved at the most
caudal sacral segments S4-5, By LT, PP, or DAP), and has some sparing
of motor functions more than three levels below the ipsilateral motor
level on either side of body.
• (this includes key or non key muscle functions to determine motor
incomplete status )
• For AIS C – less than half of the key ,muscle functions below the single
NLI have a muscle grade >= 3.

25. • D – MOTOR INCOMPLETE
• Motor incomplete status as define in C, with at least half ( half or
more ) of key muscles functions below the single NLI having muscle
grade >= 3.

26. • E = Normal
• If sensation and motor functions as tested with the ISNCSCI are
grades as normal in all segments.
• And the patient had prior deficits - , then graded as E.
• Someone with initial SCI does not receive an AIS grade.

27. ASIA impairment scale

32. Spinal cord syndromes
• Complete
• Incomplete

33. Complete
• All ascending tracts from
below and descending tracts
from above are interrupted.
• Affects motor , sensory and
autonomic functions.

34. Clinical Syndromes
• Anterior cord syndrome
• Posterior cord syndrome
• Brown Sequard Syndrome
• Conus Medullaris Syndrome
• Cauda equina syndrome
• Central cord Syndrome

35. Brown Sequard Syndrome
• Hemi section of spinal cord
• Unilateral involvement of Corticospinal ,
• Posterior column
• Contralateral Spinothalamic tract .
• Dissociated sensory loss : contralateral loss of pain and temperature (
lateral spinothalamic tract ), and preserved light or crude touch (anterior
spinothalamic tract)
• LMN signs at the level of lesion

37. Anterior cord
syndrome
• Syndrome involving the
anterior and lateral motor
corticospinal tracts ( motor
level )
• Spinothalamic tracts ( pain
and temperature )
• Sparing of Posterior column (
Two point discrimination ,
position sense , Deep
pressure sense).

38. Posterior cord
syndrome
• Minimal or no motor signs
• Proprioception , vibration, two
point discrimination and light
touch are lost below the level
of the lesion

40. Conus medullaris syndrome
• Located between D11- L1,L2
• Mostly at thoracolumbar fracture location
• Symmetrical weakness of the lower limbs
• Flaccid rectal tone
• Bladder involvement

41. Cauda equina syndrome
• Traumatic lesion below L2
• Asymmetric pain
• Sensory loss
• Bowel and bladder involvement

43. Management:
• Imaging : CT / MRI
• Critical care management – Airway , Hypotension, Respiratory and
Cardiac.
• Neurogenic shock – decreased systemic vascular resistance.
• Surgical decompression after stabilisation
• Role of MPSS ?