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

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
C5
C6
C7
C8
T1
T2-L1
L2
L3
L4
L5
S1
5
3
2
1
0
0
0
0
0
0
2
2
1
1
0
0
0
0
0
0
0
2
1
1
1
0
0
0
0
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 Exam
 10 “key” muscles (5 upper & 5 lower ext)
•
•
•
•
•


C5-Elbow flexion
C6-wrist extension
C7-elbow extension
C8-finger flexion
T1-finger abduction
L2-hip flexion
L3-knee extension
L4-ankle dorsiflexion
L5-toe extension
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
C5
C6
C7
C8
T1
T2-L1
L2
L3
L4
L5
S1
5
3
2
0
0
0
0
0
0
0
2
2
1
0
0
0
0
0
0
0
0
2
1
1
0
0
0
0
0
0
0
0
 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 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
 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
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
A dm it A S IA (at 7 2hr) A S IA D (at 1 year)
A
0 -5 %
B -1
2 0-25 %
B -2 (sacral p in p rick)
4 0-50 %
C
6 0-75 %
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
1 0-19
2 0-29
T etra-C 0 %
NA
NA
NA
T atra-I
21%
63%
1 00 %
P ara-C
45%
P ara-I
33%
70%
1 00 %
1 00 %
1 00 %
Case Study #1












M LT PP
C5
C6
C7
C8
T1
T2-L1
L2
L3
L4
L5
S1
5
3
2
1
0
0
0
0
0
0
2
2
1
1
0
0
0
0
0
0
0
2
1
1
1
0
0
0
0
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
C5
C6
C7
C8
T1
T2-L1
L2
L3
L4
L5
S1
5
3
0
0
0
0
0
0
0
0
2
2
1
0
0
0
0
0
0
1
1
2
1
0
0
0
0
0
0
0
0
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
C5
C6
C7
C8
T1
T-L
L2
L3
L4
L5
S1
5
3
0
0
0
0
0
0
0
0
2
2
2
1
0
0
0
0
0
1
1
2
1
1
1
0
0
0
0
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
C5
C6
C7
C8
T1
L2
L3
L4
L5
S1
5
3
0
0
0
1
0
0
0
1
2
2
0
0
0
0
0
0
1
1
2
1
0
0
0
0
0
0
1
1





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