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 MVATetraplegia

Questions… Neurological recovery? Functional Outcome? Ambulation?

Case Study

M LT PP C5 5 2 2 C6 3 2 1 C7 2 1 1 C8 1 1 1 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

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) 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 Exam10 “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:

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

Motor Level = C6

Sensory Level = C5

Neurological Level of Injury (NLOI) = C5

Zone of Injury = C6-8

Zone of Partial Preservation = C6-7

ASIA Impairment Scale

A = Complete - no S/M sacral functionB = Sensory incomplete -sacral sensory

sparingC = 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’sseen 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

Conus lies behind T-10-l-2

vertbrae S1-5 spinal cord bladder, bowel &

sexuality dysfunction more often complete poor prognosis

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

Neurologic vs Functional OutcomeNeurological Outcome - degree of motor & sensory

recovery after SCIFunctional 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, ventilatorC5 - feeding C6 - tenodesis graspC7 ** independent w/ most ADL’s/mobility

- manual W/C, transfers, dressing

C8/T1 - bladder/bowel independenceL 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

Admit ASIA (at 72hr) ASIA D (at 1 year)

A 0-5%

B-1 20-25%

B-2 (sacral pin prick) 40-50%

C 60-75%

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)

0 1-9 10-19 20-29

Tetra-C 0% NA NA NA

Tatra-I 21% 63% 100%

Para-C 45% 100%

Para-I 33% 70% 100% 100%

Case Study #1

M LT PP C5 5 2 2 C6 3 2 1 C7 2 1 1 C8 1 1 1 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

Motor Level = C6Sensory Level = C5NLI = C5ASIA = ANeuro/Functional

prognosis ZOI = good below ZOI = none Ambulation = none

Case Study #2

M LT PP C5 5 2 2 C6 3 2 1 C7 0 1 0 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 1 0 S1 0 1 0

Motor Level = C6Sensory Level = C5NLI = C5ASIA = B-1 (no pin)Neuro/Functional

prognosis ZOI = poor below ZOI = poor Ambulation = poor

Case Study #3

M LT PP C5 5 2 2 C6 3 2 1 C7 0 2 1 C8 0 1 1 T1 0 0 0 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 = C6Sensory Level = C5NLI = C5ASIA = B-2 (pin*)Neuro/Functional

prognosis ZOI = good below ZOI = good Ambulation = good

Case Study #4

M LT PP C5 5 2 2 C6 3 2 1 C7 0 0 0 C8 0 0 0 T1 0 0 0 L2 1 0 0 L3 0 0 0 L4 0 0 0 L5 0 1 1 S1 1 1 1

Motor Level = C6Sensory Level = C5NLI = C5ASIA = CNeuro/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