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Spinal Cord Injury: Neurological Exam, Classification and Prognosis

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Presentation on theme: "Spinal Cord Injury: Neurological Exam, Classification and Prognosis"— 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…
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 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





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