Development of Interview and Online Self-report Versions of Motor and Sensory Components of a Neurological Exam for Classifying Spinal Cord Injury (One-SCI).

Retrospective validation protocol. The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most comprehensive tool for classifying spinal cord injuries (SCI), but it is not adapted for the evaluation of trauma patients. The objective is to develop and validate a streamlined tool, the Montreal Acute Classification of Spinal Cord Injury (MAC-SCI) that can be integrated in the evaluation of trauma patients to detect and characterize traumatic SCI (tSCI). The completion rate of the ISCNSCI during initial evaluation after tSCI was estimated at a Level-1 trauma center specialized in SCI care. Using a modified Delphi technique, we designed the MAC-SCI, a new tool to detect and characterize the severity grade and level of SCI in the polytrauma patient. A cohort consisting of 35 consecutive tSCI patients with complete ISNCSCI documentation was used to validate the MAC-SCI. The severity grade and neurological level of injury (NLI) were assessed using the MAC-SCI, and compared to those obtained with the ISNCSCI. Only 33% of 148 patients admitted after a tSCI had a complete ISNCSCI performed at initial presentation. The MAC-SCI retains 53 of the 134 elements from the ISNCSCI. There was a 100% concordance in severity grade between the MAC-SCI and ISNCSCI. The NLI were within 2 levels between the MAC-SCI and ISNCSI for 100% of patients. The MAC-SCI is a streamlined tool that accurately detects and characterizes tSCI in the acute trauma setting. It could be implemented in trauma protocols to guide the management of SCI patients. Level III Diagnostic criteria.

IntroductionWe aim to evaluate the effects of injury-related factors and clinician training grades on the frequency, completion and accuracy of International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) charts in a tertiary care neurosurgery unit.Materials and methodsWe retrospectively analysed 96 ISNCSCI charts of 24 traumatic spinal cord-injured (SCI) patients and 26 controls (vertebral fracture but neurologically intact), written by 50 clinicians. Seven components of each ISNCSCI charts (motor scores, sensory scores, sensory levels, motor levels, neurological level of injury, SCI severity and AIS) were reviewed to evaluate the effect of injury factors and clinician grade on the completion and accuracy of the ISNCSCI components.ResultsThe ISNCSCI chart was used 1.9 times on average during admission. The number of ISNCSCI assessments was significant in those with isolated spinal injuries (p = 0.03). The overall completion and accuracy rates of the assessed ISNCSCI chart components were 39% and 78.1%, respectively. Motor levels and AIS had the lowest completion rates. Motor levels and sensory levels had the lowest accuracy rates. The completion rate was higher in the charts of male patients, tetraplegic patients, and in patients with isolated spinal injuries. The junior clinicians had a significantly greater ISNCSCI chart completion rate than their seniors. However, the senior clinicians were more accurate in completing the ISNCSCI chart components.ConclusionThe quality of ISNCSCI documentation remained poor regardless of the clinician training grade and injury factors. Clinicians should be educated on the ISNCSCI protocol and the importance of adequate documentation.

This article represents the content of the booklet, International Standards for Neurological Classification of Spinal Cord Injury, revised 2011, published by the American Spinal Injury Association (ASIA). For further explanation of the clarifications and changes in this revision, see the accompanying article (Kirshblum S., et al. J Spinal Cord Med. 2011:doi 10.1179/107902611X13186000420242 The spinal cord is the major conduit through which motor and sensory information travels between the brain and body. The spinal cord contains longitudinally oriented spinal tracts (white matter) surrounding central areas (gray matter) where most spinal neuronal cell bodies are located. The gray matter is organized into segments comprising sensory and motor neurons. Axons from spinal sensory neurons enter and axons from motor neurons leave the spinal cord via segmental nerves or roots. In the cervical spine, there are 8 nerve roots. Cervical roots of C1-C7 are named according to the vertebra above which they exit (i.e. C1 exits above the C1 vertebra, just below the skull and C6 nerve roots pass between the C5 and C6 vertebrae) whereas C8 exists between the C7 and T1 vertebra; as there is no C8 vertebra. The C1 nerve root does not have a sensory component that is tested on the International Standards Examination. The thoracic spine has 12 distinct nerve roots and the lumbar spine consists of 5 distinct nerve roots that are each named accordingly as they exit below the level of the respective vertebrae. The sacrum consists of 5 embryonic sections that have fused into one bony structure with 5 distinct nerve roots that exit via the sacral foramina. The spinal cord itself ends at approximately the L1-2 vertebral level. The distal most part of the spinal cord is called the conus medullaris. The cauda equina is a cluster of paired (right and left) lumbosacral nerve roots that originate in the region of the conus medullaris and travel down through the thecal sac and exit via the intervertebral foramen below their respective vertebral levels. There may be 0, 1, or 2 coccygeal nerves but they do not have a role with the International Standards examination in accordance with the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Each root receives sensory information from skin areas called dermatomes. Similarly each root innervates a group of muscles called a myotome. While a dermatome usually represents a discrete and contiguous skin area, most roots innervate more than one muscle, and most muscles are innervated by more than one root. Spinal cord injury (SCI) affects conduction of sensory and motor signals across the site(s) of lesion(s), as well as the autonomic nervous system. By systematically examining the dermatomes and myotomes, as described within this booklet, one can determine the cord segments affected by the SCI. From the International Standards examination several measures of neurological damage are generated, e.g., Sensory and Motor Levels (on right and left sides), NLI, Sensory Scores (Pin Prick and Light Touch), Motor Scores (upper and lower limb), and ZPP. This booklet also describes the ASIA (American Spinal Injury Association) Impairment Scale (AIS) to classify the severity (i.e. completeness) of injury. This booklet begins with basic definitions of common terms used herein. The section that follows describes the recommended International Standards examination, including both sensory and motor components. Subsequent sections cover sensory and motor scores, the AIS classification, and clinical syndromes associated with SCI. For ease of reference, a worksheet (Appendix 1) of the recommended examination is included, with a summary of steps used to classify the injury (Appendix 2). A full-size version for photocopying and use in patient records has been included as an enclosure and may also be downloaded from the ASIA website (www.asia-spinalinjury.org). Additional details regarding the examination and e-Learning training materials can also be obtained from the website15.

Study designCommittee consensus process including additional structured feedback from spinal cord injury (SCI) experts attending a focus group workshop.ObjectivesTo define a taxonomy for standardized documentation of non-SCI-related conditions in the International Standards for Neurological Classification of SCI (ISNCSCI).SettingAmerical Spinal Injury Association (ASIA) International Standards Committee with 16 international ISNCSCI experts.MethodsWith the new taxonomy, not-normal sensory or motor scores should be tagged with an asterisk (“*”), if they are impacted by a non-SCI condition such as burns, casts, joint contractures, peripheral nerve injuries, amputations, pain, or generalized weakness. The non-SCI condition and instructions on how to handle the “*”-tagged scores during classification should be detailed in the comments box. While sum scores are always calculated based on examined scores, classification variables such as the neurological level of injury (NLI) or the ASIA Impairment Scale (AIS) grades are tagged with an “*”, when they have been determined on the basis of clinical assumptions.ResultsWith the extended “*”-tag concept, sensory and motor examination results impacted by non-SCI conditions above, at, or below the NLI can be consistently documented, scored, and classified. Feedback from workshop participants confirms agreement on its clinical relevance, logic and soundness, easiness of understanding, communicability, and applicability in daily work.ConclusionsAfter multiple internal revisions, a taxonomy for structured documentation of conditions superimposed on the impairments caused by the SCI together with guidelines for consistent scoring and classification was released with the 2019 ISNCSCI revision. This taxonomy is intended to increase the accuracy of ISNCSCI classifications.

It is important to perform an accurate neurological assessment using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) to judge the prognosis of spinal cord injury patients. We can gauge the prognosis for upper extremity function or gait ability according to the ISNCSCI results. ISNCSCI involves both sensory and motor examination, and it is performed with the patient in the supine position to enable a comparison between the initial and follow-up exams. The sensory exam is performed on the 28 key sensory points of dermatomes for light touch and pinprick. The motor exam is performed on 10 key muscles on each side. The sensory and motor levels for the right and left sides are determined according to the sensory and motor exam results. The neurological level of injury is the most caudal level of the cord at which both the motor and sensory functions are intact. Finally, the American Spinal Injury Association Impairment Scale (AIS) is determined. AIS A indicates complete injury, and AIS B, C, and D indicate incomplete injuries. Once the sensory and motor levels, neurological level of injury, and AIS scale of a spinal cord injury patient are determined through ISNCSCI, the patient's prognosis can be predicted based on those results. Furthermore, ISNCSCI performed at 72 hours after an injury yields the most significant prognostic factors.

Sensorimotor function of patients with spinal cord injury (SCI) is commonly assessed according to the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). From the ISNCSCI segmental motor and sensory assessments, upper and lower extremity motor scores (UEMS and LEMS), sum scores of pinprick (PP) and light touch (LT) sensation, the neurological level of injury (NLI) and the classification of lesion severity according to the American Spinal Injury Association Impairment Scale (AIS) grade are derived. Changes of these parameters over time are used widely to evaluate neurological recovery. Evaluating recovery based on a single ISNCSCI scoring or classification variable, however, may misestimate overall recovery. Here, we propose an Integrated Neurological Change Score (INCS) based on the combination of normalized changes between two time points of UEMS, LEMS, and total PP and LT scores. To assess the agreement of INCS with clinical judgment of meaningfulness of neurological changes, changes of ISNCSCI variables between two time points of 88 patients from an independent cohort were rated by 20 clinical experts according to a five-categories Likert Scale. As for individual ISNCSCI variables, neurological change measured by INCS is associated with severity (AIS grade), age, and time since injury, but INCS better reflects clinical judgment about meaningfulness of neurological changes than individual ISNCSCI variables. In addition, INCS is related to changes in functional independence measured by the Spinal Cord Independence Measure (SCIM) in patients with tetraplegia. The INCS may be a useful measure of overall neurological change in clinical studies.

Context/Objective: To verify the hypothesis that motor levels (ML) inferred from sensory levels in the upper cervical segments C2–C4 according to the current version of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) are counterintuitive in cases where the most rostral myotomes C5 and C6 are graded as intact.Design: Prospective cohort study of ISNCSCI instructional course participants completing a post-test after the workshop to determine the MLs in two variants of a complete, high cervical spinal cord injury (SCI) case scenario. Both variants were based on the same ISNCSCI sensory and MLs of C2. In the first variant myotomes C5 and C6 were bilaterally graded as intact, while in variant 2 only active movements against gravity were possible (grade 3).Setting: Eight ISNCSCI instructional courses conducted during the study period from November 2012 until March 2015 in the framework of the European Multicenter Study on Human Spinal Cord Injury (EMSCI— http//emsci.org).Participants: Ninety-two clinicians from twenty-two SCI centers. Most of the attendees were physicians (58.7%) or physical therapists (33.7%) and had less than one year (44.6%) experience in SCI medicine.Interventions: Not applicable.Outcome Measure: The classification performance described as percentage of correctly determined MLs by the clinicians.Results: Variant 2 (89.13%) was significantly (P < 0.0001) better classified than variant 1 (65.76%). In variant 1 with intact myotomes at C5 and C6, C6 was incorrectly classified as the ML by the clinicians in 33.15% of all cases, whereas in variant 2 with non-intact C5 / C6 myotomes, C6 was rarely chosen (2.17%).Conclusions: Sensory level deferred MLs in the high cervical region of C2–C4 are counterintuitive whenever the most rostral cervical myotomes are intact. An adjustment of the ML definition in ISNCSCI may be needed.

Study designRetrospective review of ISNCSCI datasets.ObjectivesTo discuss the correct classification of ISNCSCI datasets considered as challenging.SettingInternational expert collaboration.MethodsThe International Standards Committee of the American Spinal Injury Association (ASIA) receives challenging case scenarios regarding the International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI). Among those cases received, sample cases representing different categories of typical classification difficulties were identified by members of the International Standards committee.ResultsFrom the cases received, five sample cases were identified as representative for publication. These cases are related to the correct classification in the presence of non-SCI related conditions, the determination of motor zones of partial preservation in regions with no myotomes to test, the classification of the ASIA Impairment Scale in patients with substantial motor function below the motor level but no sacral sparing, the inclusion of non-key muscle functions in the classification of sensory incomplete individuals, and the correct classification of individuals with an amputation.ConclusionPresenting cases with challenging classifications, along with responses and explanations, will serve spinal cord injury professionals to better understand and utilize the ISNCSCI classification. As the ISNCSCI endorsed by ASIA and the International Spinal Cord Society (ISCoS) evolves over time, such resources are important to clarify inquiries from the spinal cord injury community and to understand the rationale for revisions.

Descriptive comparison analysis. To evaluate whether five training cases of International Spinal Cord Injury Core Data Set (ISCICDS) are appropriate for testing the facts within the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) and could thus be used for testing its training effectiveness. The authors reviewed the five training cases from the ISCICDS and determined the sensory level (SL), motor level (ML) and American Spinal Injury Association Impairment Scale (AIS) for the training cases. The key points from the training cases were compared with our interpretation of the key aspects of the ISNCSCI. For determining SL, three principles of ML, sacral sparing, complete injury, classification of AIS A, B, C and D, determining motor incomplete status through sparing of motor function more than three levels below the ML, there are corresponding case scenarios in ISCICDS. However, no case scenario shows classification of AIS E and the use of voluntary anal sphincter contraction for determination of motor incomplete status. Neurological level of injury could be deduced from the SL and ML. Finally, none of the cases include information about zone of partial preservation, sensory score or motor score. Majority of the facts related to SL, ML and AIS are included in the five training cases of ISCICDS. Thus, using these training cases, it is feasible to test the above facts within the ISNCSCI. It is suggested that the missing fact should be included in an update of the training cases.

Objective: Assessment of spinal cord injuries (SCI) severity is usually done according to the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). However, a limitation of ISNCSCI has not been thoroughly evaluate; therefore, a systematic review was performed to gather current evidence on the limitations of the ISNCSCI for assessing SCI. Methods: An extensive literature search was performed using Medline, Embase, Web of Science, Cochrane library, and Scopus for all articles up until the end of 2017 and then was updated to the end of 2020. Data was summarized by two independent reviewers and limitations of the ISNCSCI was further categorized. Results: 31 studies were included in the analysis. The limitations of ISNCSCI were classified into 6 domains: 1) lack of assessment of autonomic nervous system; 2) low value in assessing severity of SCI severity in children; 3) confounding factors which impact outcome are not accounted for by ISNCSCI; 4) lack of an established optimal cut off time point for administering the ISNCSCI; 5) low predictive and diagnostic value for assessing incomplete motor injuries; 6) poor classification and predictive value of the ISNCSCI. Conclusion: Although the ISNCSCI is a commonly used tool to assess the severity of SCI, there are several limitations.

Physiological analysis reveals that during voluntary contraction Ia afferent input have a lesser facilitatory effect on motor neurons in humans with chronic incomplete spinal cord injury compared with control subjects.

Editor's evaluation: Altered regulation of Ia afferent input during voluntary contraction in humans with spinal cord injury

To describe the performance of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) examination in individuals with traumatic spinal cord injury (TSCI) and nontraumatic spinal cord injury (NTSCI) across Canadian acute and rehabilitation facilities, evaluating timing, completeness, and classification accuracy. Using the Rick Hansen Spinal Cord Injury Registry (2015-2022), participants were analyzed across 6 cohorts: (A) TSCI-acute-admission (n = 4461), (B) TSCI-acute-discharge (n = 972), (C) TSCI-rehabilitation-admission (n = 2673), (D) TSCI-rehabilitation-discharge (n = 2316), (E) NTSCI-rehabilitation-admission (n = 728), and (F) NTSCI-rehabilitation-discharge (n = 619). ISNCSCI data included performed (yes/no), timing (≤72 hours, ≤7 days, and >7 days of admission/discharge), completeness, missing items, and worksheet used (yes/no). Classification accuracy between the clinician-determined and algorithm-generated ASIA Impairment Scale and neurological level of injury classification was evaluated. Descriptive and bivariate statistics were used to analyze cohorts. Overall, 70% of participants had at least one examination performed, with 76% performed ≤72 hours, 91% ≤7 days, and 9% >7 days. However, 45% were partially complete, primarily missing sensory scores and rectal components ≤7 days. Comparison of TSCI and NTSCI during rehabilitation showed that NTSCI cohorts had significantly more exams at admission and fewer at discharge, with more complete exams. Moreover, age at injury, injury type, mechanism, severity, length of stay, and pain influenced examination performance. This study highlights the need for greater consistency in ISNCSCI examination performance and identifies patient-level barriers to completion. Determining the most effective standardized approach for ISNCSCI use across SCI care, addressing modifiable human/organizational factors, and ensuring comprehensive clinical training will improve the quality of this assessment.

Prospective, longitudinal cohort study. To quantify the effect of formal training in the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) on the classification accuracy and to identify the most difficult ISNCSCI rules. European Multicenter Study on Human Spinal Cord Injury (EMSCI). EMSCI participants rated five challenging cases of full sensory, motor and anorectal examinations before (pre-test) and after (post-test) an ISNCSCI instructional course. Classification variables included sensory and motor levels (ML), completeness, ASIA Impairment Scale (AIS) and the zones of partial preservation. 106 attendees were trained in 10 ISNCSCI workshops since 2006. The number of correct classifications increased significantly (P<0.00001) from 49.6% (2628 of 5300) in pre-testing to 91.5% (4849 of 5300) in post-testing. Every attendee improved, 12 (11.3%) achieved 100% correctness. Sensory levels (96.8%) and completeness (96.2%) are easiest to rate in post-testing, while ML (81.9%) and AIS (88.1%) are more difficult to determine. Most of the errors in ML determination arise from sensory levels in the high cervical region (C2-C4), where by convention the ML is presumed to be the same as the sensory level. The most difficult step in AIS classification is the determination of motor incompleteness. ISNCSCI training significantly improves the classification skills regardless of the experience in spinal cord injury medicine. These findings need to be considered for the appropriate preparation and interpretation of clinical trials in spinal cord injury.

ObjectivesSince their introduction, electronic International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) calculators have evolved to powerful tools providing error-free ISNCSCI classifications in education, research and clinical practice. For increased accessibility and dissemination, a multilingual support is mandatory. The aim of this work was to setup a general multilingual framework for the freely available ISNCSCI calculator (https://ais.emsci.org) of the European Multicenter Study about Spinal Cord Injury (EMSCI).MethodsThe graphical user interface (GUI) and PDF export of the ISNCSCI worksheet were adapted for multilingual implementations. Their language-dependent content was identified. These two steps called internationalization have to be performed by a programmer in preparation of the translations of the English terms into the target language. This step following the internationalization is called localization and needs input by a bi-lingual clinical expert. Two EMSCI partners provided Standard Mandarin Chinese and Czech translations. Finally, the translations are made available in the application.ResultsThe GUI and PDF export of the ISNCSCI worksheet were internationalized. The default language of the calculator is set according to the user’s preferences with the additional possibility for manual language selection. The Chinese as well as a Czech translation were provided freely to the SCI community.ConclusionsThe possibility of multilingual implementations independent from software developers opens the use of ISNCSCI computer algorithms as an efficient training tool on a larger scale.