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

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Presentation on theme: "Spinal Cord Injury: Neurological Exam, Classification and Prognosis William McKinley MD Director SCI Rehabilitation Medicine Associate Professor VCU Dept."— Presentation transcript:

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… l Neurological recovery? l Functional Outcome? l Ambulation?

3 Case Study § M LT PP §C §C §C §C §T §T2-L1 0 0 §L §L §L §L §S §Motor Level ? §Sensory Level ? §NLI ? §ASIA ? §Neuro/Functional prognosis ?

4 Importance of Comprehensive Neurological Exam §Evidence-based l valid, reliable, consistent §Better communication l to patient, family, team §Allows for prognosis l Neurological l 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) l 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 derms) l Test light touch & pin/pain l **Importance of sacral pin testing §3 point scale (0,1,2) l optional: proprioception & deep pressure to index and great toe (present vs absent) l 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 flexionL2-hip flexion C6-wrist extensionL3-knee extension C7-elbow extensionL4-ankle dorsiflexion C8-finger flexionL5-toe extension T1-finger abductionS1-ankle plantarflexion l Sacral exam: voluntary anal contraction (present/absent) l optional ms: diaphragm (VC), abdominal (Beevors test), hip adductors

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

10 Motor exam (cont) §Motor level (MLI) = lowest normal level with 3/5 (& level above 5/5) l Each M has 2 root innervations, if 3/5 = full innervation by more rostral root level l (4/5 acceptable with pain, deconditioning) l 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 l 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 l Zone of partial preservation (ZPP) - preserved segments below NLOI used only in complete SCI l Zone of Injury (ZOI) levels below NLOI recovery may be better or worse in ZOI

12 Case: § M LT PP §C §C §C §C §T §T2-L1 0 0 §L §L §L §L §S §Motor Level = C6 §Sensory Level = C5 §Neurological Level of Injury (NLOI) = C5 §Zone of Injury = C6-8 §Zone of Partial Preservation = C6-7

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 ms) §D = Motor incomplete - (>3/5) §E = Normal - Normal S/M exam

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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 LEs §seen with older age (Spondylosis) asso with hyperextension injuries §favorable prognostic factors: l LE > UE (proximal > distal), Bladder/bowel l age 50 yr): ambulation 90% (vs 35%), bladder 80% (vs 30%), dressing 80% (vs 15%)

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

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

19 Conus Medullaris/Cauda Equina Syndromes §Conus l lies behind T-10-l-2 vertbrae l S1-5 spinal cord l bladder, bowel & sexuality dysfunction l more often complete l poor prognosis §CES l L/S nerve root injury l spinal cord ends ot L1-2 l more often asso with pain l more often incomplete (+/- recovery mo) l better 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 l patient motivation l availability of services l 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 ADLs/mobility l - manual W/C, transfers, dressing §C8/T1 - bladder/bowel independence §L 2,3 - **Ambulation

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

23 Etiology and prognosis §Better l spinal stenosis l fall l unilateral facet disloc. §Worse l GSW l flexion/rotation l 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 l sparing of motor/sensory WITHIN or BELOW the zone of injury (ZOI). §Key factors: l incomplete > complete l **motor & PIN sparing are key l 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: l 25-50% of 0/5 ms l % of 1-2/5 ms §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 l Age & Energy expenditure (3-9 X in para) l 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 §C §C §C §C §T §T2-L1 0 0 §L §L §L §L §S §Motor Level = C6 §Sensory Level = C5 §NLI = C5 §ASIA = A §Neuro/Functional prognosis l ZOI = good l below ZOI = none l Ambulation = none

31 Case Study #2 § M LT PP §C §C §C §C §T §T2-L1 0 0 §L §L §L §L §S §Motor Level = C6 §Sensory Level = C5 §NLI = C5 §ASIA = B-1 (no pin) §Neuro/Functional prognosis l ZOI = poor l below ZOI = poor l Ambulation = poor

32 Case Study #3 § M LT PP §C §C §C §C §T §T-L 0 0 §L §L §L §L §S §Motor Level = C6 §Sensory Level = C5 §NLI = C5 §ASIA = B-2 (pin*) §Neuro/Functional prognosis l ZOI = good l below ZOI = good l Ambulation = good

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

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

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