Spinal Cord Injury: Neurological Exam, Classification and Prognosis William McKinley MD Director SCI Rehabilitation Medicine Associate Professor VCU Dept PM&R

Case Presentation 31 yo wm s/p MVA Tetraplegia Questions… Neurological recovery? Functional Outcome? Ambulation?

Case Study M LT PP Motor Level ? Sensory Level ? NLI ? ASIA ? T2-L1 0 0 L2 0 0 0 L3 0 0 0 L4 0 0 0 L5 0 0 0 S1 0 0 0 Motor Level ? Sensory Level ? NLI ? ASIA ? Neuro/Functional prognosis ?

Importance of Comprehensive Neurological Exam Evidence-based valid, reliable, consistent Better communication to patient, family, team Allows for prognosis Neurological Functional (Rehabilitation goals) Allows study of interventions(rehab, drugs)

International Standards for Neurological Classification of Spinal Cord Injury ASIA (American Spinal Injury Association) Two main components (motor & sensory) motor & sensory level, neurological level, ASIA impairment classification 1982 ASIA standards use “Frankel Classification” 1992 “ASIA Impairment Scale” replaces Frankel 1996 & 2000 ASIA revisions 72 hour exam - reliable prognostic time

Sensory Exam 28 sensory “points” (within derm’s) 3 point scale (0,1,2) Test light touch & pin/pain **Importance of sacral pin testing 3 point scale (0,1,2) “optional”: proprioception & deep pressure to index and great toe (“present vs absent”) deep anal sensation recorded “present vs absent”

Sensory Exam (cont) Sensory level (SLI) = most caudal segment with normal (2/2) LT & Pin sensation Sensory index score (SIS) = addition of sensory points (total possible 112)

Motor Exam 10 “key” muscles (5 upper & 5 lower ext) C5-Elbow flexion L2-hip flexion C6-wrist extension L3-knee extension C7-elbow extension L4-ankle dorsiflexion C8-finger flexion L5-toe extension T1-finger abduction S1-ankle plantarflexion Sacral exam: voluntary anal contraction (present/absent) “optional m’s: diaphragm (VC), abdominal (Beevors test) , hip adductors

Motor Grading Scale 6 point scale (0-5) …..(avoid +/-’s) 0 = no active movement 1 = muscle contraction 2 = movement thru ROM w/o gravity 3 = movement thru ROM against gravity 4 = movement against some resistance 5 = movement against full resistance

Motor exam (cont) Motor level (MLI) = lowest normal level with 3/5 (& level above 5/5) Each M has 2 root innervations, if 3/5 = full innervation by more rostral root level (4/5 acceptable with pain, deconditioning) Motor Index Score (MIS) = total 100 pts **Superiority of Motor level vs Sensory

Neurological Level of Injury (NLOI) Lowest level with normal sensory & motor can record as MLI & SLI and on each side: (ie: Right C5 sensory & C6 motor, Left C6 sensory & C7 motor) motor level = sensory levels , 50% If no key muscle for MLI, than NLI = SLI Zone of partial preservation (ZPP) - preserved segments below NLOI used only in complete SCI Zone of Injury (ZOI) - 2-3 levels below NLOI recovery may be better or worse in ZOI

Case: Motor Level = C6 Sensory Level = C5 M LT PP Neurological Level of Injury (NLOI) = C5 Zone of Injury = C6-8 Zone of Partial Preservation = C6-7 M LT PP C5 5 2 2 C6 3 2 1 C7 2 1 1 C8 0 0 0 T1 0 0 0 T2-L1 0 0 L2 0 0 0 L3 0 0 0 L4 0 0 0 L5 0 0 0 S1 0 0 0

ASIA Impairment Scale A = Complete - no S/M sacral function B = Sensory incomplete -sacral sensory sparing C = Motor incomplete -motor sparing below ZOI (strength < 3/5 in most m’s) D = Motor incomplete - “ ”(>3/5) E = Normal - Normal S/M exam

Mechanisms for Neurological Recovery 1. Remyelination- neuropraxia (0-3 months) 2. Hypertrophy of innervated muscles (3-6 months) 3. Peripheral sprouting from intact nerves to denervated muscle (3-6 months) 4. Axonal regeneration (12-18 months)

Central Cord Syndrome Upper extremities weaker than LE’s seen with older age (Spondylosis) asso with hyperextension injuries “favorable” prognostic factors: LE > UE (proximal > distal), Bladder/bowel age < 50yr (vs > 50 yr): ambulation 90% (vs 35%), bladder 80% (vs 30%), dressing 80% (vs 15%)

Brown-Sequard Syndrome Cord “hemi-section” incidence 2-4 % ipsilateral motor & proprioceptive loss and contralateral pain/temperature loss P/T tracts cross at spinal cord level “favorable” prognosis for ambulation (90%), ADL independence (70%), bladder (85%)

Anterior/Posterior Cord Syndrome ACS Anterior spinal art. to ventral 2/3 of SC loss of motor, pain (sparing of proprioception) poor prognosis for neuro recovery PCS Posterior spinal art.to posterior columns loss of proprioception (sparing of motor & pain) poor prognosis for ambulation

Conus Medullaris/Cauda Equina Syndromes CES L/S nerve root injury spinal cord ends ot L1-2 more often asso with pain more often incomplete (+/-recovery 12-18 mo) better prognosis Conus lies behind T-10-l-2 vertbrae S1-5 spinal cord bladder, bowel & sexuality dysfunction more often complete poor prognosis

Neurologic vs Functional Outcome Neurological Outcome - degree of motor & sensory recovery after SCI Functional Outcome - degree of mobility and self-care performance Key factors patient motivation availability of services avoidance of complications (pain, spasticity, contractures)

Functional Outcomes by Level of Injury C1,2,3- power chair, ECU, ventilator C5 - feeding C6 - tenodesis grasp C7 ** independent w/ most ADL’s/mobility - manual W/C, transfers, dressing C8/T1 - bladder/bowel independence L 2,3 - **Ambulation

Neuro-testing & Neurological Prognosis MRI better than CT for cord & soft tissue visualization Cord transection (rare) and hemorrhage correlate with poor prognosis Edema (1-2 levels only) correlates with incomplete injury & better prognosis SSEP (may assist when assoc LOC) no more reliable than neuro exam

Etiology and prognosis Better spinal stenosis fall unilateral facet disloc. Worse GSW flexion/rotation bilateral facet disloc.

Medical Intervention & Prognosis Methylprednisilone - greater motor recovery noted if given < 8 hrs (for 24 hrs) Gangliosides - no difference at 1 yr Surgery (decompression/stabilization) - no neurological differences, but decreased LOS

Neurological Recovery Incomplete injuries have better prognosis sparing of motor/sensory WITHIN or BELOW the zone of injury (ZOI). Key factors: incomplete > complete **motor & PIN sparing are “key” early recovery is better

ASIA Classification & Outcome

Neurological Outcomes in ZOI Most pts with complete injury recover one motor level Recovery to 3/5 at one yr: 25-50% of 0/5 m’s 75-100% of 1-2/5 m’s Most occurs during first 6 months with greatest rate of change in first 3 months

Ambulation Benefits: overcome barriers, self esteem, cardiopulmonary exercise Prognostic Factors Age & Energy expenditure (3-9 X in para) NLOI Below T-11Para - good prognosis L 2-3 para (pelvic control, hip flexion & knee ext with hip/knee proprioception) “community ambulators”

Community Ambulation and Lower extremity motor strength (LEMS at 1 month)

Case Study #1 M LT PP Motor Level = C6 Sensory Level = C5 NLI = C5 T2-L1 0 0 L2 0 0 0 L3 0 0 0 L4 0 0 0 L5 0 0 0 S1 0 0 0 Motor Level = C6 Sensory Level = C5 NLI = C5 ASIA = A Neuro/Functional prognosis ZOI = good below ZOI = none Ambulation = none

Case Study #2 M LT PP Motor Level = C6 Sensory Level = C5 NLI = C5 T2-L1 0 0 L2 0 0 0 L3 0 0 0 L4 0 0 0 L5 0 1 0 S1 0 1 0 Motor Level = C6 Sensory Level = C5 NLI = C5 ASIA = B-1 (no pin) Neuro/Functional prognosis ZOI = poor below ZOI = poor Ambulation = poor

Case Study #3 M LT PP Motor Level = C6 Sensory Level = C5 NLI = C5 T-L 0 0 L2 0 0 0 L3 0 0 0 L4 0 0 0 L5 0 1 1 S1 0 1 1 Motor Level = C6 Sensory Level = C5 NLI = C5 ASIA = B-2 (pin*) Neuro/Functional prognosis ZOI = good below ZOI = good Ambulation = good

Case Study #4 M LT PP Motor Level = C6 Sensory Level = C5 NLI = C5 ASIA = C Neuro/Functional prognosis ZOI = Poor below ZOI = good Ambulation = good

Future Considerations for Enhance Recovery Basic science/clinical research Neuropharmacologic agents (4-AP) Nerve transplantation, stem cells BWS (body weight support) training of central pattern generator in inc SCI FES - (UE grasp, ambulation, bladder)

Conclusions Accurate neuro exam is imperative Incompleteness in key for prognosis Earlier recovery (1-3 months) is better ZOI & below ZOI may have different prognosis