William H. Donovan

International standards for neurological and functional classification of spinal cord injury

International Standards for Neurological and Functional Classification of Spinal Cord Injury

The International Standards Booklet for Neurological and Functional Classification of Spinal Cord Injury

The International Standards Booklet for Neurological and Functional Classification of Spinal Cord Injury

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.

Epidemiologic Overview of Individuals with Upper-Limb Loss and Their Reported Research Priorities

More than 6,600 one-page surveys were sent to individuals throughout the country with upper-limb loss or absence. Of those surveys, 2,477 were returned, and demographic information was recorded. A more comprehensive seven-page survey was then sent to the respondents who agreed to participate. A total of 1,575 of these surveys were returned: 1,020 by body-powered users, 438 by electric users and 117 by bilateral users of prostheses. The results of the surveys indicate users of body-powered and electric prostheses identify surprisingly similar elements as necessary in the design of a better upper-limb prosthesis. These qualities include additional wrist movement, better control mechanisms that require less visual attention and the ability to make coordinated motions of two joints. Desired near-term improvements for body-powered prostheses include better cables and harness comfort, whereas those for electric prostheses include better gloving material, better batteries and charging units, and improved reliability for the hand and its electrodes. This article discusses the specific functions that various levels of upper-extremity amputees gain from their prostheses as well as the device features that aid or detract from their functions.

Neurologic recovery after traumatic spinal cord injury: data from the model spinal cord injury systems

OBJECTIVE To present data on neurologic recovery gathered by the Model Spinal Cord Injury (SCI) Systems over a 10-year period. DESIGN Case series. SETTING Twenty-one Model SCI Systems. PATIENTS A total of 3,585 individuals with traumatic SCI admitted between January 1, 1988 and December 31, 1997. MAIN OUTCOME MEASURES Neurologic impairment category; Frankel grade; American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade; motor score. RESULTS SCI caused by violence is more likely than SCI from nonviolent etiologies to result in a complete injury. Changes in severity of injury were similar using the older Frankel scale and the newer ASIA Impairment Scale. Individuals who were motor-complete with extended zones of sensory preservation but without sacral sparing were less likely to convert to motor-incomplete status than those with sacral sparing (13.3% vs 53.6%; p < .001). Motor score improvements at 1 year were related to severity of injury, with greater increases for better AIS grades except grade D, because of ceiling effects. Individuals with AIS grade B injuries have a mixed prognosis. CONCLUSION Neurologic recovery after SCI is influenced by etiology and severity of injury. Multicenter studies on prognostic features such as preserved pin sensation in grade B injuries may identify subgroups with similar recovery patterns. Identification of such groups would facilitate clinical trials for neurologic recovery in acute SCI.

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.

International standards to document remaining autonomic function after spinal cord injury.

Study design:Experts opinions consensus.Objective:To develop a common strategy to document remaining autonomic neurologic function following spinal cord injury (SCI).Background and Rationale:The impact of a specific SCI on a persons neurologic function is generally described through use of the International Standards for the Neurological Classification of SCI. These standards document the remaining motor and sensory function that a person may have; however, they do not provide information about the status of a persons autonomic function.Methods:Based on this deficiency, the American Spinal Injury Association (ASIA) and the International Spinal Cord Society (ISCoS) commissioned a group of international experts to develop a common strategy to document the remaining autonomic neurologic function.Results:Four subgroups were commissioned: bladder, bowel, sexual function and general autonomic function. On-line communication was followed by numerous face to face meetings. The information was then presented in a summary format at a course on Measurement in Spinal Cord Injury, held on June 24, 2006. Subsequent to this it was revised online by the committee members, posted on the websites of both ASIA and ISCoS for comment and re-revised through webcasts. Topics include an overview of autonomic anatomy, classification of cardiovascular, respiratory, sudomotor and thermoregulatory function, bladder, bowel and sexual function.Conclusion:This document describes a new system to document the impact of SCI on autonomic function. Based upon current knowledge of the neuroanatomy of autonomic function this paper provides a framework with which to communicate the effects of specific spinal cord injuries on cardiovascular, broncho-pulmonary, sudomotor, bladder, bowel and sexual function.

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.

Continuous Infusion of Intrathecal Baclofen: Long-term Effects on Spasticity in Spinal Cord Injury

The effects of intrathecal baclofen infusion were studied in 9 spinal cord injury patients whose spasticity had been refractory to oral medications. In a two stage, placebo controlled trial, baclofen was administered into the lumbar intrathecal space and subsequent clinical and neurophysiologic changes were assessed. In stage 1, 9 patients underwent a 5 day percutaneous infusion of baclofen and placebo via an external pump. Ashworth and reflex scores were assessed at time of enrollment, after infusion of that amount of baclofen which provided optimal spasticity control and after intrathecal infusion of placebo. The mean Ashworth grade decreased from 3.78 ± 1.34 to 1.16 ± 0.48 (p < 0.001) while mean reflex score decreased from 3.57 ± 1.05 to 0.64 ± 0.87 (p < 0.001). These values differed significantly from those associated with placebo therapy (Ashworth grade—2.54 ± 1.04, p < 0.001; reflex score—2.56 ± 1.04, p < 0.01). Objective improvements in functional abilities and independence were noted in 8 patients, while somatosensory and brainstem auditory evoked potentials were unchanged in all patients. Urodynamic evaluation revealed increased bladder capacity in 3 patients, while in 4 no change was observed.In Stage 2, permanent programmable infusion pumps were implanted in 7 patients who demonstrated a good response during Stage 1. In this group, mean Ashworth score decreased from 3.79 ± 0.69 to 2 ± 0.96 (p < 0.001) and mean reflex score decreased from 3.85 ± 0.62 to 2.18 ± 0.43 (p < 0.001). Baclofen dosage increased from 182 ± 135 to 528 ± 266 mcg/day over the 3-22 month follow-up period. Most of the dosage increase occurred within the initial 12 months following infusion pump implantation and tended to plateau thereafter.Minor complications such as catheter dislodgement/kinking and nausea occurred infrequently while no device related infections were observed. There was no clinical evidence of any significant baclofen neurotoxicity either in Stage 1 or 2. The only ambulatory patient developed marked lower extremity weakness during Stage 1 intrathecal baclofen infusion and was temporarily unable to walk.We conclude that continuous administration of intrathecal baclofen is an effective and safe modality for spasticity control in patients who are refractory to oral medications.

URINARY TRACT INFECTION PROPHYLAXIS USING ESCHERICHIA COLI 83972 IN SPINAL CORD INJURED PATIENTS

PURPOSE Escherichia coli 83972 was previously shown to establish bladder colonization in select patient groups. We evaluate the safety and feasibility of using bacterial interference with E. coli 83972 to prevent urinary tract infection in spinal cord injured patients. MATERIALS AND METHODS A total of 21 men and women with neurogenic bladder secondary to spinal cord injury underwent intravesical inoculation with E. coli 83972. Frequency of symptomatic urinary tract infection before and after colonization was compared. RESULTS Successful long-term bladder colonization was achieved in 13 study participants. Mean duration of colonization was 12.3 months (range 2 to 40). Subjects had no symptoms of urinary tract infection while colonized with E. coli 83972 (0 infection per 18.4 patient-years). Successfully colonized subjects had experienced a mean of 3.1 symptomatic urinary tract infections per year (range 2 to 7) before colonization. Symptomatic infection also occurred in 4 subjects who were not successfully colonized with E. coli 83972 and in 7 others after spontaneous loss of colonization. Colonized subjects reported subjective improvement in quality of life with respect to urinary tract infection while colonized. CONCLUSIONS E. coli 83972 may be safely used to establish long-term asymptomatic bladder colonization in spinal cord injured subjects. Preliminary findings suggest that colonization with E. coli 83972 may reduce the frequency of urinary tract infection in patients with neurogenic bladder secondary to spinal cord injury.