Daniel E. Graves

International standards for neurological classification of spinal cord injury (Revised 2011)

This article represents the content of the booklet, International Standards for Neurological Classification of Spinal Cord Injury, revised 2011, published by the American Spinal Injury Association (ASIA). For further explanation of the clarifications and changes in this revision, see the accompanying article (Kirshblum S., et al. J Spinal Cord Med. 2011:doi 10.1179/107902611X13186000420242 The spinal cord is the major conduit through which motor and sensory information travels between the brain and body. The spinal cord contains longitudinally oriented spinal tracts (white matter) surrounding central areas (gray matter) where most spinal neuronal cell bodies are located. The gray matter is organized into segments comprising sensory and motor neurons. Axons from spinal sensory neurons enter and axons from motor neurons leave the spinal cord via segmental nerves or roots. In the cervical spine, there are 8 nerve roots. Cervical roots of C1-C7 are named according to the vertebra above which they exit (i.e. C1 exits above the C1 vertebra, just below the skull and C6 nerve roots pass between the C5 and C6 vertebrae) whereas C8 exists between the C7 and T1 vertebra; as there is no C8 vertebra. The C1 nerve root does not have a sensory component that is tested on the International Standards Examination. The thoracic spine has 12 distinct nerve roots and the lumbar spine consists of 5 distinct nerve roots that are each named accordingly as they exit below the level of the respective vertebrae. The sacrum consists of 5 embryonic sections that have fused into one bony structure with 5 distinct nerve roots that exit via the sacral foramina. The spinal cord itself ends at approximately the L1-2 vertebral level. The distal most part of the spinal cord is called the conus medullaris. The cauda equina is a cluster of paired (right and left) lumbosacral nerve roots that originate in the region of the conus medullaris and travel down through the thecal sac and exit via the intervertebral foramen below their respective vertebral levels. There may be 0, 1, or 2 coccygeal nerves but they do not have a role with the International Standards examination in accordance with the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Each root receives sensory information from skin areas called dermatomes. Similarly each root innervates a group of muscles called a myotome. While a dermatome usually represents a discrete and contiguous skin area, most roots innervate more than one muscle, and most muscles are innervated by more than one root. Spinal cord injury (SCI) affects conduction of sensory and motor signals across the site(s) of lesion(s), as well as the autonomic nervous system. By systematically examining the dermatomes and myotomes, as described within this booklet, one can determine the cord segments affected by the SCI. From the International Standards examination several measures of neurological damage are generated, e.g., Sensory and Motor Levels (on right and left sides), NLI, Sensory Scores (Pin Prick and Light Touch), Motor Scores (upper and lower limb), and ZPP. This booklet also describes the ASIA (American Spinal Injury Association) Impairment Scale (AIS) to classify the severity (i.e. completeness) of injury. This booklet begins with basic definitions of common terms used herein. The section that follows describes the recommended International Standards examination, including both sensory and motor components. Subsequent sections cover sensory and motor scores, the AIS classification, and clinical syndromes associated with SCI. For ease of reference, a worksheet (Appendix 1) of the recommended examination is included, with a summary of steps used to classify the injury (Appendix 2). A full-size version for photocopying and use in patient records has been included as an enclosure and may also be downloaded from the ASIA website (www.asia-spinalinjury.org). Additional details regarding the examination and e-Learning training materials can also be obtained from the website15.

Reference for the 2011 revision of the international standards for neurological classification of spinal cord injury

Abstract The latest revision of the International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) was available in booklet format in June 2011, and is published in this issue of the Journal of Spinal Cord Medicine. The ISNCSCI were initially developed in 1982 to provide guidelines for the consistent classification of the neurological level and extent of the injury to achieve reliable data for clinical care and research studies. This revision was generated from the Standards Committee of the American Spinal Injury Association in collaboration with the International Spinal Cord Societys Education Committee. This article details and explains the updates and serves as a reference for these revisions and clarifications.

Brain immaturity is associated with brain injury before and after neonatal cardiac surgery with high-flow bypass and cerebral oxygenation monitoring

BACKGROUND New intraparenchymal brain injury on magnetic resonance imaging is observed in 36% to 73% of neonates after cardiac surgery with cardiopulmonary bypass. Brain immaturity in this population is common. We performed brain magnetic resonance imaging before and after neonatal cardiac surgery, using a high-flow cardiopulmonary bypass protocol, hypothesizing that brain injury on magnetic resonance imaging would be associated with brain immaturity. METHODS Cardiopulmonary bypass protocol included 150 mL . kg(-1) . min(-1) flows, pH stat management, hematocrit > 30%, and high-flow antegrade cerebral perfusion. Regional brain oxygen saturation was monitored, with a treatment protocol for regional brain oxygen saturation < 50%. Brain magnetic resonance imaging, consisting of T1-, T2-, and diffusion-weighted imaging, and magnetic resonance spectroscopy were performed preoperatively, 7 days postoperatively, and at age 3 to 6 months. RESULTS Twenty-four of 67 patients (36%) had new postoperative white matter injury, infarction, or hemorrhage, and 16% had new white matter injury. Associations with preoperative brain injury included low brain maturity score (P = .002). Postoperative white matter injury was associated with single-ventricle diagnosis (P = .02), preoperative white matter injury (P < .001), and low brain maturity score (P = .05). Low brain maturity score was also associated with more severe postoperative brain injury (P = .01). Forty-five patients had a third scan, with a 27% incidence of new minor lesions, but 58% of previous lesions had partially or completely resolved. CONCLUSIONS We observed a significant incidence of both pre- and postoperative magnetic resonance imaging abnormality and an association with brain immaturity. Many lesions resolved in the first 6 months after surgery. Timing of delivery and surgery with bypass could affect the risk of brain injury.

2009 Review and Revisions of the International Standards for the Neurological Classification of Spinal Cord Injury

Abstract Summary: The International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) were recently reviewed by the ASIAs Education and Standards Committees, in collaboration with the International Spinal Cord Societys Education Committee. Available educational materials for the ISNCSCI were also reviewed. The last citable reference for the ISNCSCIs methodology is the ISNCSCI Reference Manual, published in 2003 by ASIA. The Standards Committee recommended that the numerous items that were revised should be published and a precedent established for a routine published review of the ISNCSCI. The Standards Committee also noted that, although the 2008 reprint pocket booklet is current, the reference manual should be revised after proposals to modify/revise the ASIA Impairment Scale (AIS as modified from Frankel) are considered. In addition, the Standards Committee adopted a process for thorough and transparent review of requests to revise the ISNCSCI.

A Longitudinal Study of Depression From 1 to 5 Years After Spinal Cord Injury

OBJECTIVE To describe rates of probable major depression and the development and improvement of depression and to test predictors of depression in a cohort of participants with spinal cord injury (SCI) assessed at 1 and 5 years after injury. DESIGN Longitudinal cohort study. SETTING SCI Model System. PARTICIPANTS Participants (N=1035) who completed 1- and 5-year postinjury follow-up interviews from 2000 to 2009. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Probable major depression, defined as Physician Health Questionnaire-9 score of 10 or higher. RESULTS Probable major depression was found in 21% of participants at year 1 and 18% at year 5. Similar numbers of participants had improvement (25%) or worsening (20%) of symptoms over time, with 8.7% depressed at both 1 and 5 years. Increased pain (odds ratio [OR], 1.10), worsening health status (OR, 1.39), and decreasing unsafe use of alcohol (vs no unsafe use of alcohol; OR, 2.95) are risk factors for the development of depression at 5 years. No predictors of improvement in depression were found. CONCLUSION In this sample, probable major depression was found in 18% to 21% of participants 1 to 5 years after injury. To address this high prevalence, clinicians should use these risk factors and ongoing systematic screening to identify those at risk for depression. Worsening health problems and lack of effective depression treatment in participants with SCI may contribute to high rates of chronic or recurrent depression in this population.

Intermittent Catheterization With a Hydrophilic-Coated Catheter Delays Urinary Tract Infections in Acute Spinal Cord Injury: A Prospective, Randomized, Multicenter Trial

To investigate whether intermittent catheterization (IC) with a hydrophilic‐coated catheter delays the onset of the first symptomatic urinary tract infection (UTI) and reduces the number of symptomatic UTIs in patients with acute spinal cord injury (SCI) compared with IC with standard, uncoated catheters.

Effectiveness of gabapentin in controlling spasticity : a quantitative study

The purpose of this investigation was to study the effectiveness of gabapentin in controlling spasticity in persons with spinal cord injury (SCI) using a surface EMG-based quantitative assessment technique called the brain motor control assessment (BMCA). Six men from a Veterans Affairs Medical Center with spasticity due to traumatic SCI were studied as part of a multi-center, placebo-controlled, cross-over, clinical trial of gabapentin. Spasticity was evaluated using multi-channel surface EMG recordings of muscles in the lower extremities, abdomen and low back before and during treatment with oral gabapentin or placebo. Gabapentin or placebo was given orally in doses 400 mg three times daily for 48 h. Following a 10 day wash-out period subjects were crossed-over to receive the medication not received the first time. This was followed by an elective open-label extension. Group results during the controlled trial did not reach statistical significance at the dosage used. One subject demonstrated a dramatic improvement in spasticity that was apparent both clinically and with the BMCA. Other subjects demonstrated modest improvements which were seen in the BMCA but not recognized clinically. During the open label extension, the four subjects who participated experienced important clinical improvements with higher doses (to 3600 mg/day). These improvements were often in components of spasticity in which the BMCA had detected subclinical changes during the cross-over trial. A seventh subject was studied using the BMCA at doses of 1200 mg T.I.D. gabapentin, off gabapentin and 800 mg T.I.D. gabapentin and demonstrated quantitatively a dose-related effect with higher doses of gabapentin which matched clinical observations. Gabapentin at doses of 400 mg T.I.D. may be effective in controlling some features of spasticity in persons with SCI. Higher doses provide greater control of spasticity, and controlled studies using higher doses are needed to evaluate gabapentins efficacy.

Comparison of dalteparin and enoxaparin for deep venous thrombosis prophylaxis in patients with spinal cord injury

Chiou-Tan FY, Garza H, Chan KT, Parsons KC, Donovan WH, Robertson CS, Holmes SA, Graves DE, Rintala DH: Comparison of dalteparin and enoxaparin for deep venous thrombosis prophylaxis in patients with spinal cord injury. Am J Phys Med Rehabil 2003;82:678–685. Objective To determine differences between dalteparin and enoxaparin in patients with spinal cord injury. Design This prospective, randomized, open-label study was performed as a multiple hospital trial in a large urban setting. A total of 100 patients with acute (<3 mo) spinal cord injury were recruited. A total of 95 patients met all inclusion criteria. Fifty received enoxaparin, and 45 received dalteparin. Main outcome measures included deep venous thrombosis, bleeding, compliance, Short Form-12 Health Status Survey, satisfaction, and medication/labor costs. Patients were randomized to receive 30 mg of enoxaparin subcutaneously every 12 hr or 5000 IU of dalteparin subcutaneously once daily. Prophylaxis was continued for 3 mo for motor-complete and 2 mo for motor-incomplete patients. Results Six percent of the patients developed deep venous thrombosis while receiving enoxaparin and 4% while receiving dalteparin (&khgr;2 = 0.44, df = 1, P = 0.51). Four percent developed bleeding while receiving dalteparin and 2% while receiving enoxaparin (&khgr;2 = 0.13, df = 1, P = 0.72). No differences were noted in compliance, health status, or most of the satisfaction measures. It was, however, noted that after being discharged home, the patients receiving enoxaparin rated the shots significantly more inconvenient (two injections per day) compared with taking three pills per day, than those receiving dalteparin (one injection per day, P < 0.05). The cost of the medication was

Prevalence and outcomes of pediatric in-hospital cardiopulmonary resuscitation in the United States: an analysis of the Kids' Inpatient Database*.

1101/mo for enoxaparin (two injections per day) and

Upper- and Lower-Extremity Motor Recovery After Traumatic Cervical Spinal Cord Injury: An Update From the National Spinal Cord Injury Database

750/mo for dalteparin (one injection per day). Conclusion Similar compliance, health status, deep venous thrombosis, and bleeding rates were found between dalteparin and enoxaparin.