1. Michael Keith MD Ann Bryden OTRL Cleveland Ohio USA

2. SCI Classification  An important component in determining potential interventions is the classification of the level of injury  Classification schemes provide a common platform for understanding the degree of function associated with the level of SCI

3. SCI Classification  International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) American Spinal Injury Association (ASIA) International Spinal Cord Society (ISCoS) Most commonly used  International Classification for Surgery of the Hand in Tetraplegia (ICSHT) For cervical level SCI only  Both classifications include a motor and sensory portion  The ICSHT is focused on the upper extremity

4. Who are the Stakeholders, and Why?  An increasing number of stakeholders International Tetraplegia Group – Therapists and Surgeons International Campaign for Cures of Spinal Cord Injury Paralysis (ICCP) American Spinal Injury Association (ASIA) / International Spinal Cord Society (ISCoS) – UE Basic Data Set  Why? Detect changes from natural recovery Better define incomplete lesions Measure the impact of interventions ○ Aimed at cure ○ Activity based therapy ○ Surgical reconstruction

5. NEW Version 2/2013

7. ASIA Update – Non Key Muscles MovementRoot Level Shoulder: Flexion, extension, abduction, internal and external rotation Elbow: Supination C5 Elbow: Pronation Wrist: Flexion C6 Finger: Flexion at proximal joint, extension Thumb: Flexion, extension and abduction in plane of thumb C7 Finger: Flexion at MP joint Thumb: Opposition, adduction and abduction perpendicular to palm C8 Finger: Abduction of the index fingerT1

8. Congruence with ICSHT? MovementRoot Level ICSHT Shoulder: Flexion, extension, abduction, internal and external rotation Elbow: Supination C5No Shoulder Elbow: Pronation Wrist: Flexion C64545 Finger: Flexion at proximal joint, extension Thumb: Flexion, extension and abduction in plane of thumb C7867867 Finger: Flexion at MP joint Thumb: Opposition, adduction and abduction perpendicular to palm C88 Finger: Abduction of the index finger T1

9. Current Classifications A classification should tell you what to do.  ASIA, ISCOS, AIS, ISNCSCI Work well with complete lesions, complicated - perhaps without predictive use for surgical treatment. Does not classify results or permit patient reported outcomes.

10. Current Classifications A classification should tell you what to do.  International Surgical Classification Work well with complete motor paralysis, voluntary (C5,C6), Group 0,1,2,3, 1/3 of cases. Many Patient choices, surgical variations in C7,C8 Does not report anatomic change or PRO. Can be used for equivalency of function.

11. . Functional Enhancement for Cervical SCI - 1990 Electrical Stimulation Tendon Transfers Finger, thumb flexion Finger, thumb extension C4 C5 C6 C7 C8 O:0 O:1 OCu:2 OCu:3 OCu:4 OCu:5 OCu:6 OCu:7 OCu:8 PD->Triceps FES ECRL->FDP PT->FPL Br->ECRB Br->FPL Br->EDC Thumb abduction Elbow extension Elbow flexion Wrist extension Shoulder abduction OCu:9

12. Where do the Classifications Fail? ASIA(arms)  C4 – 2  C5 – 5  C6 – 6  C7 – 3  NC - 2 ICSHT (arms)  Group 0 – 4  Group 1 – 3  Group 2 – 5  Group 5 – 3  NC - 3 Subject Characteristics (n=9, 18 Arms*) Specific Examples

13. Where do the Classifications Fail?  Incomplete Injuries  Spasticity  Characterizing Paralysis  Examples 77VC R: C5, -C6, C7, C8 / 5, -6, -7, 8 99VC R: C6 / 0, -1, 2, -3, 4, 5, 6, -7 99 VC L: C6, -C7, C8 / 2, -3, -4, 5, 6, -7, 8

14. “IC Exceptions” Partial Tetraplegia Asymmetrical lesions Recovered- Regenerated, Repaired Hyper-reflexive Contracted Bi-manual activities

15. Clinical Decision Support  Evidence Based Clinical Practice Guidelines  Appropriate Use Criteria  Cumulative experience without evidence  Informed Opinion

16. Clinical Practice Guidelines  Evidence based if outcome based.  Solve problems of clinical decision making.  Make Recommendations based on strong evidence.  Find directions for outcomes research.  Form the basis for national Performance Measures and Appropriate Use Criteria.  Search: www.guidelines.govwww.guidelines.gov

17. Appropriate Use Criteria RAND Methodology  Writing Group Classification Risk Adjustment Important Clinical Criteria Alternative Treatments

18. Appropriate Use Criteria  Review Group Refine credibility of application by experts  Voting Group Shareholders Rate for Appropriate, Maybe Appropriate, Rarely Appropriate

19. Examples of AUC- AAOS App.  www.aaos.org/auc www.aaos.org/auc

20. Examples of AUC- AAOS App.  http://aaos.webauthor.com/go/auc http://aaos.webauthor.com/go/auc

21. AAOS AUC App, Distal Radius Fx

22. Potential AUC writing table Scenarios for AUC on Tetraplegia Management Appropriate *, Maybe &, Not % Muscle Scores- Voluntary ICKey Muscle ASIA/AIS/ISN CSCI/ISCOSKey MuscleContracture release Osteotomy, HO resection Hyper-reflexia Botox, Chemo neuromodulation Tendon, Nerve Transfer, O:0A-C4 O:1DeltoidA-C5Elbow FlexorBi to Tri*Baclofen Pump& Radial Osteotomy- pronation 40* Ocu2ECBLECRBA-C6Wrist Extensor Ocu3BicepsBRA-C7Elbow Extensor Ocu4FDPFDSA-C8Finger FlexorFractional Lengthening* APBADQA-T15th Abductor etc These combinations include both.AND. And.OR.

23. Measuring Spasticity  Challenges in measuring spasticity Ashworth Tardieu Other  Distinguishing between measures of spasticity and spasms Penn spasm scale, others>

24. Lets write a AUC about Surgical Decision Making in Tetraplegia.  Review the literature for outcomes summary. CPG unlikely.  Writing group  Review Group  Voting Group