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

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

3. Case Study M LT PP Motor Level ? Sensory Level ? NLI ? ASIA ?
T2-L L L L L S
Motor Level ?
Sensory Level ?
NLI ?
ASIA ?
Neuro/Functional prognosis ?

4. 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)

5. 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

6. 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”

7. 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)

8. 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

9. 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

10. 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

11. 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) levels below NLOI
recovery may be better or worse in ZOI

12. 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 C C C C T
T2-L L L L L S

13. 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

15. 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)

16. 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%)

17. 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%)

18. 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

19. 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 mo)
better prognosis
Conus
lies behind T-10-l-2 vertbrae
S1-5 spinal cord
bladder, bowel & sexuality dysfunction
more often complete
poor prognosis

20. 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)

21. 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

22. 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

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

24. 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

25. 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

26. ASIA Classification & Outcome

27. 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

28. 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”

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

30. Case Study #1 M LT PP Motor Level = C6 Sensory Level = C5 NLI = C5
T2-L L L L L S
Motor Level = C6
Sensory Level = C5
NLI = C5
ASIA = A
Neuro/Functional prognosis
ZOI = good
below ZOI = none
Ambulation = none

31. Case Study #2 M LT PP Motor Level = C6 Sensory Level = C5 NLI = C5
T2-L L L L L S
Motor Level = C6
Sensory Level = C5
NLI = C5
ASIA = B-1 (no pin)
Neuro/Functional prognosis
ZOI = poor
below ZOI = poor
Ambulation = poor

32. Case Study #3 M LT PP Motor Level = C6 Sensory Level = C5 NLI = C5
T-L L L L L S
Motor Level = C6
Sensory Level = C5
NLI = C5
ASIA = B-2 (pin*)
Neuro/Functional prognosis
ZOI = good
below ZOI = good
Ambulation = good

33. 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

34. 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)

35. 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